Every finding on record at Jefferson Healthcare Center

Based on interviews and record reviews, the facility failed to ensure annual influenza and pneumococcal immunizations were administered after consent was obtained for 2 (Resident #14, Resident #85) of 5 sampled residents investigated for immunization requirements. Findings:Review of the facility's Influenza and Pneumococcal Immunizations policy and procedure, dated 09/18/2017, revealed, in part, all residents shall be offered, and if consented, administered the annual influenza and pneumococcal vaccines. Further review revealed this information shall be documented in the resident's electronic immunization record. On 04/07/2026 at 12:15PM, S3Assistant Director of Nursing/Infection Preventionist (ADON/IP) was presented with a request for all Influenza and Pneumococcal immunization consents and administration records for Resident #14 and Resident #85. Resident #14Review of Resident #14's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/2026 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 01, which indicated Resident #14 was severely cognitively impaired. Review of Resident #14's signed annual influenza and pneumococcal immunization informed consent form, dated 09/17/2025, revealed Resident #14's responsible party selected that Resident #14 was to receive the annual influenza and pneumococcal vaccines. Review of Resident #14's Physician's Orders dated 10/06/2025 revealed an order indicating Resident #14 may receive the annual influenza and pneumococcal vaccines. Review of Resident #14's electronic record which included Resident #14's immunization record revealed no documentation the influenza and pneumococcal vaccines were administered to Resident #14 since consent was obtained on 11/24/2025 and/or no documentation as to why the immunizations were not administered. In an interview on 04/07/2026 at 12:33PM, S3ADON/IP confirmed Resident #14 had consented to receive the annual influenza and pneumococcal vaccines, but was not administered either and offered no explanation as to why the vaccines were not administered to Resident #14. Resident #85Review of Resident #85's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/2026 revealed, in part, a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #85 was cognitively intact. Review of Resident #85's signed annual influenza and pneumococcal immunization informed consent form, dated 11/24/2025, revealed Resident #85's responsible party selected that the resident was to receive the annual influenza and pneumococcal vaccines. Review of Resident #85's Physician's Orders dated 11/25/2025 revealed an order indicating Resident #85 may receive the annual influenza and pneumococcal vaccines. Review of Resident #85's electronic record which included Resident #85's immunization record revealed no documentation the influenza and pneumococcal vaccines were administered to Resident #85 since consent was obtained on 11/24/2025 and/or no documentation as to why the immunizations were not administered. In an interview on 04/07/2026 at 11:45AM, Resident #85 indicated he wanted the annual influenza and pneumococcal vaccines. Resident #85 further indicated he had not received any vaccines since being admitted to the facility. In an interview on 04/07/2026 at 12:33PM, S3ADON/IP indicated Resident #85 had consented to receive the annual influenza and pneumococcal vaccines, but was not administered either and offered no explanation as to why the vaccines were not administered to Resident #85. In an interview on 04/08/2026 at 12:05PM, S1Administrator was presented with the above mentioned findings and did not provide any additional evidence to dispute the above mentioned deficient practice.

Based on interviews and record reviews the facility failed to ensure a resident/responsible party was notified in advance of a care planning conference to enable resident to participate in care plan meeting for 1 (Resident #89) of 32 sample resident records reviewed for care plans.Findings:Review of Resident #89's medical records revealed, in part, Resident #89 had an initial admit date of 10/11/2024 and was identified in the medical record as being his own responsible party. Further review revealed, Resident #89 had the following diagnoses: Type II Diabetes, Chronic Obstructive Pulmonary Disease, and Schizoaffective Disorder. Review of Resident #89's Quarterly Minimum Data Se) with an Assessment Reference Date of 03/26/2026 revealed, in part, Resident #89 had a Brief Interview for Mental Status score of 15, indicating Resident #89 was cognitively intact.In an interview on 04/06/2026 at 12:43PM, Resident #89 indicated he was responsible for his own care. Resident #89 further indicated he was not aware of, and he had not been invited by the facility, to a meeting to discuss his plan of care.Review of Resident #89's Notice of Care Plan Meeting form dated 01/22/2026, revealed, in part, a note that an unsuccessful attempt was made to contact Resident #89's family member to schedule a care plan meeting. Further review revealed Resident #89 was not included or was made aware of an upcoming care plan meeting.In an interview on 04/07/2026 at 10:20AM, S2Social Worker indicated she could not provide any documented evidence that indicated Resident #89 had ever been invited and/or attended a care plan meeting. In an interview on 04/07/2028 at 11:03AM, S1Administrator indicated Resident #89 had not been invited to his quarterly care plan meetings to discuss his plan of care and should have been.

Based on observations, interviews, and record reviews, the facility failed to ensure staff were competent in mechanical lift operational procedures for 9(S5Certified Nursing Assistant [CNA] Supervisor, S7CNA, S8CNA, S9CNA, S15CNA, S16CNA, S17CNA, S18CNA, S19CNA) of 14 staff members investigated for staff competency with the operation of the facility's mechanical lift.Findings:Review of the facility's Transferring a Resident policy/procedure, dated 07/02/2019, revealed, in part, staff were to follow the manufacture's guidelines for mechanical lift transfer procedures.Review of the facility's mechanical lift Operating Manual, dated 03/2007, revealed, in part, the mechanical lift transfer procedure (from a bed) specified that the caster brakes of the mechanical lift should be left unlocked when a resident was raised from the bed during transfer. Further review revealed, leaving the mechanical lift caster brakes unlocked would allow the mechanical lift to walk forward to center itself over the resident's center of gravity as it was raised. Further review revealed, this procedure increased the stability of the mechanical lift.In an interview on 12/02/2025 at 9:51AM, S5CNA Supervisor indicated when using the facility's mechanical lift to transfer a resident from a bed, it was the facility's procedure to lock the brakes of the mechanical lift when the resident was raised using the mechanical lift, and to lock the brakes of the mechanical lift when resident was lowered using the mechanical lift.Observation on 12/02/2025 at 9:54AM revealed, after placing Resident #R5 in the mechanical lift sling and hooking the mechanical lift sling to the mechanical lift using its loops, S15CNA walked up to the mechanical lift and locked both of the mechanical lift's caster brakes. Further observation revealed S9CNA continued the procedure of transferring Resident #R5 with the mechanical lift and raised Resident #R5 approximately 2-3 inches off of the bed without unlocking the mechanical lift's caster brakes.In an interview on 12/02/2025 at 10:00AM, S15CNA indicated the caster brakes of the mechanical lift should have been locked when raising a resident from a bed or letting a resident back down using the mechanical lift.In an interview on 12/02/2025 at 10:15AM, S16CNA indicated when transferring a resident from a bed, she would lock the brakes of the mechanical lift while lifting a resident out of the bed with the mechanical lift, unlock the brakes to move the mechanical lift, and then lock the brakes when placing a resident lowering the resident back down into a chair using the mechanical lift.In an interview on 12/02/2025 at 10:24AM, S17CNA indicated she would lock the caster brakes of the mechanical lift when raising a resident off of the bed.In an interview on 12/02/2025 at 10:26AM, S18CNA indicated the mechanical lift's brakes should be down and locked when residents are lifted up from a bed using the mechanical lift, unlocked when the rolling the mechanical lift, and then relocked when lowering a resident back down in the bed or chair.In an interview on 12/02/2025 at 10:33AM, S9CNA confirmed S15CNA locked the caster brakes of the mechanical lift during the above mentioned observation of Resident #R5's transfer.In a telephone interview on 12/02/2025 at 12:26PM, S8CNA indicated she would lock the brakes of the mechanical lift when she lifted a resident up from a bed using a mechanical lift.In an interview on 12/02/2025 at 12:32PM S19CNA indicated the brakes of the mechanical lift were to be locked when lifting a resident up from a bed and lowering a resident down into the bed or chair using the mechanical lift.In an interview on 12/02/2025 at 1:46PM, S4CNA Supervisor indicated 9CNA and S15CNA should not have locked the caster brakes of the mechanical lift when transferring Resident #R5. S4CNA Supervisor further indicated the caster brake locks should not be locked when a resident was raised from the bed using the mechanical lift.In an interview on 12/04/2025 at 1:04PM, S2Corporate Nurse indicated the CNAs using the facility's mechanical lifts should be competent in the procedure on the proper usage of the facility's mechanical lift per the manufacturer's guidelines.

Based on observations, interviews, and record review, the facility failed to ensure a dependent resident was provided assistance with dressing/changing clothes for 1(Resident #3) of 3 sampled residents reviewed for activities of daily living needs. Findings: Review of Resident #3's Electronic Medical Record (EMR) revealed, in part, Resident #3 was admitted to the facility on [DATE]. Further review revealed Resident #3 had a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/2025 revealed, in part, Resident #3 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #3 was cognitively intact. Further review revealed Resident #3 required substantial/maximal assistance with upper and lower body dressing. Observation on 12/01/2025 at 9:15AM revealed Resident #3 was lying in bed wearing a hospital gown with a red stain noted to left upper corner of Resident #3's chest. Observation on 12/02/2025 at 9:35AM revealed Resident #3 was sleeping in her bed, wearing a hospital gown with the red stain noted to left upper corner of Resident #3's chest. Observation on 12/03/2025 at 8:58AM revealed Resident #3 was lying in her bed wearing a hospital gown with the red stain noted to left upper corner of Resident #3's chest In an interview on 12/03/2025 at 9:00AM, Resident #3 indicated no staff member had changed her clothes and Resident #3 had been wearing the same hospital gown since 12/01/2025. Resident #3 further indicated she was not changed yesterday and wanted her clothes to have been changed. In an interview on 12/03/2025 at 12:03PM, S13Certified Nursing Assistant indicated she gave Resident #3 a bed bath on 12/02/2025 and then dressed Resident #3 in the same hospital gown she had on prior to her bath. In an interview on 12/03/2025 at 12:09 PM, S2Corporate Nurse acknowledged a resident's clothes should have been changed daily and a resident should not have been dressed in the clothes they were wearing prior to a bath, after the resident received a bath.

Based on interviews and record reviews, the provider failed to ensure the accuracy of resident's records for 6 (Resident #2, Resident #3, Resident #R6, Resident #R7, Resident #R8, Resident #R9) of 9 residents reviewed for accurate records.Findings: Review of Resident #2's December 2025 Task Log documentation report revealed, in part, on 12/03/2025 at 11:55AM, S15CNA documented on Resident's #2 performance regarding bed mobility, toilet use, bowel elimination, that Resident #2 was turned and positioned, and that Resident #2 had eaten 51-75% of the 8:00AM meal. Further review revealed on 12/03/2025 at 11:56AM, S15CNA documented on Resident #2's performance regarding bladder elimination. Review of Resident #3's December 2025 Task Log documentation report revealed, in part, documentation a bed bath was completed for Resident #3 by S10CNA on 12/02/2025. Review of Resident #R6's December 2025 Task Log documentation report revealed, in part, on 12/03/2025 at 11:54AM, S15CNA documented on Resident's #R6 performance regarding bed mobility, toilet use, bowel elimination, bladder elimination, and that Resident #R6 had eaten 51-75% of the 8:00AM meal.Review of Resident #R7's December 2025 Task Log documentation report revealed, in part, on 12/03/2024 at 11:53AM, S15CNA documented on Resident's #R7 performance regarding bed mobility, toilet use, bowel elimination, bladder elimination, and that Resident #R7 was turned and positioned. Further review revealed on 12/03/2025 at 11:52AM, S15CNA documented that Resident #R7 had eaten 51-75% of the 8:00AM meal.Review of Resident #R8's December 2025 Task Log documentation report task revealed, in part, on 12/03/2025 at 11:57AM, S15CNA documented on Resident's #R8 performance regarding bed mobility, and that Resident #R8 had eaten 76-100% of the 8:00AM meal Further review revealed on 12/03/2025 at 11:58AM, S15CNA documented on Resident #R8's performance regarding toilet use, bowel elimination, and bladder elimination.Review of Resident #R9's December 2025 Task Log documentation report revealed, in part, on 12/03/2025 at 12:02PM, S15CNA documented on Resident's #R9 performance regarding bed mobility, toilet use, bowel elimination, bladder elimination, that Resident #2 was turned and positioned, and that Resident #R9 had eaten 0-25% of the 8:00AM meal.In an interview on 12/03/2025 at 11:40AM, S10CNA indicated she was not the person who documented Resident #3 had a bath on 12/02/2025, because she did not take care of Resident #3 on 12/02/2025. S10CNA further indicated she had shared her electronic medical record (EMR) credentials with S11CNA, S12CNA, and S13CNA, and they had used her credentials to document on residents' activities of daily living (ADLs) on 12/02/2025.In an interview on 12/03/2025 at 11:52AM S11CNA indicated she used S14CNA's credentials to document residents' ADLs on 12/02/2025, and had used S10CNA's credentials to document residents' ADLs on 12/01/2025.In an interview 12/03/2025 at 12:03PM S13CNA confirmed she had given Resident #3 a bed bath on 12/02/2025, and she had used S10CNA's credentials to document Resident #3's bed bath in Resident #3's electronic medical record (EMR) on 12/02/2025.In an interview on 12/03/2025 at 12:38PM, S20CNA indicated she provided care to Resident #2, Resident #R6, Resident #R7, Resident #R8, and Resident #R9 on 12/03/2025. S20CNA further indicated while she received her new EMR credentials on 12/02/2025, she forgot them at home, so instead, had used S15CNA's credentials to document Resident #2, Resident #R6, Resident #R7, Resident #R8, and Resident #R9's ADLs on 12/03/2025. In an interview on 12/03/2025 at 12:09PM, S2Corporate Nurse indicated staff's EMR credentials should be confidential. S2Corporate Nurse further indicated staff should not share their credential information nor document in residents' EMRs using another CNA's credentials.In an interview on 12/03/2025 at 12:22PM, S4CNA Supervisor indicated the facility's CNAs should not use each other's credentials to document in residents' EMRs.

Based on interview and record review, the facility failed to ensure the required members of the Quality Assessment and Assurance committee met at least quarterly. Findings: Review of the facility's Quality Assurance Policy and Procedure revealed, in part, the facility's Quality Assurance committee would meet at least quarterly to identify issues and develop, implement, and/or oversee implementation of appropriate plans of correction for identified quality deficiencies. Further review revealed the Quality Assurance committee would consist of the Medical Director (MD), the Administrator, the Director of Nursing (DON) and 3 other staff members designated by the facility. Review of the facility's Quarterly Quality Assurance (QQA) meeting minutes on 07/26/2024 revealed the sign-in sheet documented the staff that participated in the QQA meeting, validated by signatures, included the DON, the Administrator, Dietary Manager, and MD. Further review revealed no documented evidence, and the facility was unable to present any documented evidence, additional staff were present for the 07/26/2024 QQA meeting Review of the facility's QQA meeting minutes on 10/30/2024 revealed the sign-in sheet documented the staff that participated in the QQA meeting, validated by signatures, included the included the DON, the Assistant Director of Nursing, 3 Minimum Data Set Nurses, 2 Social Workers, the Dietary Manager, and the Nurse Educator. Further review revealed there was no documented evidence, and the facility was unable to present any documented evidence the MD and the Administrator were present for the 10/30/2024 QQA meeting. Review of the facility's QQA meeting minutes on 01/30/2025 revealed the sign-in sheet documented the staff that participated in the QA meeting, validated by signatures, included the DON, the Administrator, and the MD. Further review revealed no documented evidence, and the facility was unable to present any documented evidence additional staff were present for the QQA meeting on 01/30/2025. There was no documented evidence, and the facility was unable to present any documented evidence the facility's Quality Assessment and Assurance committee was composed of all required members on 07/26/2024, 10/30/2024, and 01/30/2025. In an interview on 05/01/2025 at 11:08AM, S2DON indicated she had no additional documented evidence to present to show the QQA meetings on 07/26/2024, 10/30/2024, and 01/30/2025 had the required members in attendance.

Based on interviews and record review, the facility failed to ensure the Quality Assurance Committee implemented a developed plan of action to correct identified quality deficiencies in monitoring their system for accurate narcotic count documentation. Findings: Cross Reference F755. Review of facility's Quality Assurance (QA) program revealed, in part, a Quality Assurance Performance Improvement (QAPI) plan created on 03/25/2025 which identified a problem with medication cart audit reports. Further review revealed a corrective action plan that included an initial audit would be performed on all medication carts by administrative nurses and weekly audits would be performed to ensure all required nurse signatures were documented. Further review revealed documentation on 04/01/2025, the narcotic book weekly audit was documented as a recurring problem with an intervention to discipline staff for noncompliance. In an interview on 05/01/2025 at 11:08AM, S2Director of Nursing (DON) confirmed the facility opened the QAPI for medication cart audits which included the narcotic book audits on 03/25/2025. S2DON further confirmed during the current survey, the survey team identified the narcotic reconciliation documentation which was missing nurse signatures and they were inaccurate. S2DON indicated that no disciplinary actions of nursing staff were performed regarding the recurring problems identified in the narcotic book audits. S2DON further indicated continued problems in the above area would indicate the facility's QA/QAPI process had been ineffective and had not been revised.

Based on interviews and record reviews, the facility failed to maintain a system to accurately reconcile controlled substances for 5 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e) of 5 (Medication Cart a, Medication Cart b, Medication Cart c, Medication Cart d, Medication Cart e) medication carts reviewed for the reconciliation documentation of controlled substances. Findings: Review of the facility's Medication Administration policy and procedure dated 10/04/2024 revealed, in part, at change of shift, the off going and oncoming nurses shall count the medications in the narcotic cabinet for any discrepancies utilizing the controlled drug package inventory form. Review of the facility's undated Controlled Drug Count Record and Package Inventory form revealed, in part, a signature acknowledged the nurse had counted the controlled drugs and had found the quantity of each medication was in agreement with the quantity stated on the Controlled Dug Administration Record. Further review revealed the nurse should have signed and had another nurse witness. Review of the facility's April 2025 Medication Cart a Controlled Drug Count Record and Package Inventory revealed, in part, there was no signature that indicated the oncoming nurse had reconciled Medication Cart a's controlled substances with the off going nurse on 04/06/2025 for the 11:00PM to 7:00AM shift. There was no documented evidence and the facility did not present any documented evidence the facility's nurses reconciled the controlled substances on Medication Cart a as required for the above mentioned date and times. Review of the facility's April 2025 Medication Cart b Controlled Drug Count Record and Package Inventory revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart b's controlled substances with the oncoming nurse on: - 04/03/2025 for the 11:00PM to 7:00AM shift; - 04/04/2025 for the 11:00PM to 7:00AM shift; - 04/07/2025 for the 11:00PM to 7:00AM shift; - 04/08/2025 for the 11:00PM to 7:00AM shift; - 04/13/2025 for the 11:00PM to 7:00AM shift; and, - 04/14/2025 for the 11:00PM to 7:00AM shift. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart b's controlled substances with the off going nurse on: - 04/08/2025 for the 11:00PM to 7:00AM shift; - 04/13/2025 for the 11:00PM to 7:00AM shift; - 04/14/2025 for the 11:00PM to 7:00AM shift; and - 04/28/2025 for the 7:00AM to 3:00PM shift. There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart b for the above mentioned dates and/or times. Review of the facility's April 2025 Medication Cart c Controlled Drug Count Record and Package Inventory revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart c's controlled substances with the oncoming nurse on: - 04/22/2025 for the 11:00PM to 7:00AM shift; and, - 04/29/2025 for the 7:00AM to 3:00PM shift. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart c's controlled substances with the off going nurse on: - 04/22/2025 for the 3:00PM to 11:00PM shift; and, - 04/23/2025 for the 11:00PM to 7:00AM shift. There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart c for the above mentioned dates and/or times. Review of the facility's April 2025 Medication Cart d Controlled Drug Count Record and Package Inventory revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart d's controlled substances with the oncoming nurse on: - 04/05/2025 for the 11:00PM to 7:00AM shift; and, - 04/28/2025 for the 11:00PM to 7:00AM shift. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart d's controlled substances with the off going nurse on: - 04/23/2025 for the 3:00PM to 11:00PM shift; and, - 04/29/2025 for the 7:00AM to 3:00PM shift. Further review revealed the oncoming nurse and off going nurse did not document the total number of controlled medication packages reconciled on the following dates: - 04/01/2025; - 04/12/2025; - 04/13/2025; - 04/14/2025; and, - 04/15/2025. There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart d for the above mentioned dates and/or times. Review of the facility's April 2025 Medication Cart e Controlled Drug Count Record and Package Inventory revealed, in part, there was no signature that indicated the off going nurse had reconciled Medication Cart e's controlled substances with the oncoming nurse on: - 04/01/2025 for the 3:00PM to 11:00PM shift; - 04/15/2025 for the 7:00AM to 3:00PM shift; - 04/16/2025 for the 7:00AM to 3:00PM shift; - 04/21/2025 for the 7:00AM to 3:00PM shift; - 04/22/2025 for the 7:00AM to 3:00PM shift; and, - 04/28/2025 for the 7:00AM to 3:00PM shift. Further review revealed there was no signature that indicated the oncoming nurse had reconciled Medication Cart e's controlled substances with the off going nurse on: - 04/01/2025 for the 3:00PM to 11:00PM shift; - 04/16/2025 for the 3:00PM to 11:00PM shift; and, - 04/29/2025 for the 7:00AM to 3:00PM shift. Further review revealed the oncoming nurse and off going nurse did not document the total number of controlled medication packages reconciled on 04/29/2025. There was no documented evidence and the facility did not present any documented evidence of having a record of receipt and disposition of all controlled drugs in Medication Cart e for the above mentioned dates and/or times. In an interview on 04/29/2025 at 9:15AM, S12Licensed Practical Nurse (LPN) indicated nurses were required to reconcile controlled substances with the off going nurse at the beginning of their shift and reconcile controlled substances with the oncoming nurse at the end of their shift. S12LPN further indicated the nurses should document that the controlled substance reconciliation was completed on the facility's Controlled Drug Count Record and Package Inventory form. S12LPN further indicated she did not sign the Medication Cart c Controlled Drug Count Record and Package Inventory with the off going nurse at the beginning of her above mentioned shift on 04/29/2025 and should have. In an interview on 04/29/2025 at 10:10AM, S17LPN indicated nurses were required to reconcile controlled substances with the off going nurse at the beginning of their shift and reconcile controlled substances with the oncoming nurse at the end of their shift. S17LPN further indicated the nurses should have documented that the controlled substance reconciliation was completed on the facility's Controlled Drug Count Record and Package Inventory form. S17LPN further indicated she did not sign the Medication Cart e Controlled Drug Count Record and Package Inventory with the off going nurse at the beginning of her above mentioned shift on 04/29/2025 and should have. There was no documented evidence and the facility did not present any documented evidence to dispute the above mentioned deficient practice. In an interview on 05/01/2025 at 12:20PM, S2Director of Nursing confirmed the above mentioned Controlled Drug Count Record and Package Inventory sheets were not completed with a nurse's signature at the beginning and/or at the end of the nurse's shift as required and should have been.

Based on interviews and record reviews, the facility failed to follow a physician's order to ensure daily wound care was provided for a resident with unhealed pressure ulcers for 1 (Resident #14) of 1 (Resident #14) sampled residents reviewed for pressure ulcers. Findings: Review of the May 2023 Louisiana Administrative Code, Title 46, Part XLVII revealed, in part: the registered nurse retained the accountability for the total nursing care of the individual and was responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she received, regardless of whether the care was provided solely by the registered nurse or by the registered nurse in conjunction with other licensed or unlicensed assistive personnel. Further review revealed, in part, the plan for nursing care was implemented according to the following criteria: nursing actions were consistent with the plan for nursing care and nursing actions were documented by written records. Review of the facility's Wound Care policy and procedure, dated 11/26/2014, revealed, in part, nursing interventions for the treatment of wounds included the cleansing and dressing of wounds as ordered. Review of Resident #14's medical record revealed, in part, Resident #14 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation (a disease that causes the heart to inefficiently pump blood), peripheral vascular disease, and unhealed pressure ulcers. Review of Resident #14's Braden Scale assessment dated [DATE] revealed, in part, a total score of 15.0, which indicated Resident #14 was at a risk for skin breakdown and/or developing a pressure ulcer. Review of Resident #14's March through April 2025 electronic Medication Administration Record (eMAR) revealed, in part, the following physician's orders were documented as not performed: - Clean Resident #14's left heel with normal saline, pat dry, apply santyl (a medication used to remove damaged skin tissue from wounds) to the wound bed, apply a moisture barrier to the peri wound, and cover with a dressing once a day by an unnamed agency nurse on 03/21/2025 and 04/16/2025, S16LPN/TN on 04/17/2025 and 04/21/2025, and no eMAR entry on 04/05/2025; - Paint distal aspect of left great toe with betadine and leave open to air once a day by an unnamed agency nurse on 03/21/2025, S16Licensed Practical Nurse (LPN)/Treatment Nurse (TN) on 04/17/2025 and 04/21/2025, and no eMAR entry on 04/05/2025; - Cleanse Resident #14's left hip Stage 3 (a wound that has broken through the top two layers of skin and into the fatty tissue below) pressure ulcer wound with wound cleanser, pat dry, apply santyl, and cover with a clean dry dressing by an unnamed agency nurse on 04/16/2025, S16LPN/TN on 04/17/2025 and 04/21/2025; and, - Clean Resident #14's Unstageable (a full-thickness tissue injury where the depth is obscured by eschar and/or slough) sacrum pressure ulcer wound with wound cleanser, apply santyl to wound bed and surrounding area, apply barrier of choice to the surrounding wound area, and cover with a dry dressing daily and as needed until healed once a day by S16LPN/TN on 04/23/2025. Review of Resident #14's progress notes from March 2025 through April 2025 revealed, in part, no documented evidence Resident #14 was provided wound care as ordered on the above mentioned dates. In an interview on 04/29/2025 at 3:40PM, Resident #14 indicated there were multiple days he did not receive wound care for his unhealed pressure ulcers when he left the facility for dialysis treatment. In an interview on 05/01/2025 at 11:45AM, S18Registered Nurse/Treatment Nurse (RN/TN) indicated Resident #14 should have received daily wound care for his unhealed pressure injuries as ordered. S18RN/TN further indicated she was unaware of any orders to hold Resident #14's wound care on the above mentioned dates related to Resident #14 attending dialysis appointments There was no documented evidence and the facility could not provide any documented evidence, Resident #14 refused or received wound care for his unhealed pressure injuries on the above mentioned dates. In an interview on 05/01/2025 at 12:20PM, S2Director of Nursing (DON) indicated Resident #14 should have received daily wound care as ordered. S2DON further indicated Resident #14 should have received wound care before or after his scheduled dialysis appointments.

Based on interviews and record reviews, the facility failed to ensure a resident's physician was notified of a resident's elevated blood glucose level for 1 (Resident #114) of 5 (Resident #36, Resident #67, Resident #104, Resident #105, Resident #114) sampled residents investigated for unnecessary medications. Findings: Review of Resident #114's April 2025 physician's orders revealed, in part, an order to administer Resident #114's Humalog Insulin Pen (a medication used to help control blood glucose levels) 100 units/milliliters as per a sliding scale before meals and at bedtime. Further review revealed, if Resident #114's blood glucose level was between [PHONE NUMBER] mg/dL (milligrams per deciliter), Resident #114's physician should be called. Review of Resident #114's April 2025 electronic Medication Administration Record (eMAR) revealed, in part: On 04/07/2025 at 4:00PM, Resident #114's blood glucose level was 433 mg/dL; On 04/11/2025 at 4:00PM, Resident #114's blood glucose level was 360 mg/dL; On 04/17/2025 at 4:00PM, Resident #114's blood glucose level was 389 mg/dL; On 04/22/2025 at 4:00PM, Resident #114's blood glucose level was 384 mg/dL; On 04/25/2025 at 4:00PM, Resident #114's blood glucose level was 394 mg/dL; On 04/30/2025 at 4:00PM, Resident #114's blood glucose level was 389 mg/dL; On 04/11/2025 at 8:00PM, Resident #114's blood glucose level was 398 mg/dL; On 04/13/2025 at 8:00PM, Resident #114's blood glucose level was 385 mg/dL; On 04/22/2025 at 8:00PM, Resident #114's blood glucose level was 361 mg/dL; On 04/24/2025 at 8:00PM, Resident #114's blood glucose level was 369 mg/dL; On 04/26/2025 at 8:00PM, Resident #114's blood glucose level was 394 mg/dL; On 04/28/2025 at 8:00PM, Resident #114's blood glucose level was 365 mg/dL; and, On 04/29/2025 at 8:00PM, Resident #114's blood glucose level was 389 mg/dL. There was no documented evidence, and the facility did not present any documented evidence Resident #114's physician was notified of the above mentioned blood glucose levels as ordered. In an interview on 05/01/2025 at 12:10PM, S2Director of Nursing (DON) indicated the nurses should have been notifying Resident #114's physician for any blood glucose level above 352. In an interview on 05/01/2025 at 1:15PM, S2DON indicated the facility had no documented evidence Resident #114's physician was notified of the above elevated blood glucose levels as ordered.

Based on interviews and record reviews, the facility failed to provide a resident with a 30-day notice prior to discharge for 1(Resident #174) of 1 (Resident #174) sampled residents reviewed for discharge. Findings: Review of Resident #174's electronic medical record revealed, in part, Resident #174 was discharged from the facility on 02/05/2025 at 3:33PM. Review of Resident #174's electronic medical record revealed, in part, that Resident #174 did not receive 30-day notice prior to discharge. The facility did not present any documented evidence that Resident #174 received a 30-day written notification of discharge as required. In an interview on 05/01/2025 at 12:30PM, S19Social Service Director indicated Resident #174 did not receive a 30-day notification prior to discharge. In an interview on 05/01/2025 at 2:30PM, S1Administrator confirmed Resident #174 did not receive a 30- day written notification prior to discharge.

Based on interviews and record reviews, the facility failed to ensure: 1. An injury of unknown origin was reported to the State Survey Agency as required after discovery of a bruise to a resident's right eye (Resident #146); and, 2. An allegation of resident to resident physical abuse was reported to the State Survey Agency as required (Resident #154). This deficient practice was identified for 2 (Resident #146, Resident #154) of 3 (Resident #56, Resident #146, Resident #154) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prevention and Prohibition policy and procedure, dated 09/30/2019, revealed, in part, the facility must ensure all alleged violations involving injuries of unknown origin and abuse were reported immediately, but no later than 2 hours after the allegation was made to the administrator of the facility and to other officials (including the State Survey Agency) in accordance with state law through established procedures. 1. Review of Resident #146's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/16/2025 revealed, in part, Resident #146 had a Brief Interview for Mental Status (BIMS) score of 02 (00-07 indicated Resident #146 had a severe cognitive impairment). Further review revealed Resident #146 required supervision for transfers and was independent for ambulation. Review of Resident #146's progress note dated 04/20/2025 at 10:48PM revealed, in part, Resident #146 was observed with a bruise of unknown origin to the right periorbital (area around the eye) area. Further review revealed the skin to the right periorbital area was reddish-blue in color. Review further revealed Resident #146 was unable to provide a history of the bruise. In an interview on 04/29/2025 at 5:34PM, S1Administrator indicated she was aware of Resident #146's right periorbital bruising with no witnessed falls reported around 04/20/2025. S1Administrator further indicated due to Resident #146 having a habit of picking things up off the floor the facility assumed he must have hit his eye on something or had a fall. S1Administrator indicated she did not submit a SIMS report to the State Survey Agency. In an interview on 04/29/2025 at 5:34PM, S29Regional Administrator indicated a SIMS report was not completed for Resident #146's right periorbital bruising. S29Regional Administrator acknowledged origin of Resident #146's right periorbital bruising was not identified. In an interview on 05/01/2025 at 1:23PM, S1Administrator indicated Resident #146 was unable to explain the reason for the bruising, and the facility had no documented evidence Resident #146 had a witnessed fall. S1Administrator further indicated the facility was unable to prove the origin of Resident #146's right periorbital injury; however she did not believe she needed to complete a SIMS report to notify the State Survey Agency of Resident #146's injury of unknown origin. S1Administrator did not offer any further explanation for the reason why the facility felt the injury of unknown origin was not reportable. 2. Review of Resident #154's medical record revealed Resident #154 was admitted to the facility on [DATE] with diagnoses, which included, vascular dementia and mood or anxiety disturbance. Review of Resident #154's MDS with an ARD of 01/22/2025 revealed, in part, Resident #154 had a BIMS of 03 (score of 00-07 indicated severe cognitive impairment). Review of the facility's Incident Log revealed, in part, on 03/24/2025 Resident #154 was listed as the recipient of physical aggression on 03/24/2025 at 12:00AM with Resident #91 listed as the aggressor. Review of Resident #154's nurse's note dated 03/24/2025 at 2:52PM revealed, in part, the staff was notified by a Certified Nursing Assistant (CNA) that Resident #91 grabbed Resident #154 out of his wheelchair. Further review revealed Resident #91 was hovering over and yelling at Resident #154. In an interview 04/30/2025 at 2:10PM, S2Director of Nursing (DON) indicated on 03/24/2025 Resident #91 pulled Resident #154 out of a wheelchair onto floor in response to Resident #154 extending his arm out to him. S2DON was unable to verify if the incident involving Resident #91 and Resident #154 on 03/24/2025 was an allegation of resident to resident abuse which required reporting to the State Survey Agency. There was no documented evidence, and the facility presented no documented evidence, of the allegation of resident to resident abuse involving Resident #91 and Resident #154's on 03/24/2025 had been reported to the State Survey Agency. In an interview on 04/30/2025 at 4:15PM, S1Administrator indicated the facility had not reported the allegation of a resident to resident altercation between Resident #91 and Resident #154 to the State Survey Agency. 40405

Based on observations, interviews, and record review, the facility failed to maintain a sanitary environment in a resident's room for 1 (Resident #36) of 1 (Resident #36) sampled residents investigated for environment. Findings: Review of Housekeeper Aide Job Description, dated 04/15/2015, revealed, in part, the primary purpose of the Housekeeper Aide was to perform the day-to day activities of the housekeeping department in accordance with current federal, state, and local standards. Further review revealed the housekeeper aide was responsible for cleaning walls by washing, wiping, dusting, spot cleaning, disinfecting, and deodorizing. Observation on 04/28/2025 at 10:25AM of Resident #36's room, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed. Observation on 04/29/2025 at 10:31AM of Resident #36's room, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed. Observation on 04/30/2035 at 10:42AM of Resident #36's room, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed. Observation on 05/01/2025 at 11:53AM of Resident #36's room, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed. In an interview on 05/01/2025 at 11:57AM, S8Housekeeper indicated she was responsible for ensuring she cleaned each resident's room. S8Housekeeper further indicated she had cleaned and wiped all unclean areas on Resident #36's wall. Observation with S8Houskeeper on 05/01/2025 at 12:02PM, revealed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed. In an interview on 05/01/2025 at 12:02PM, S8Housekeeper indicated she noticed there was an unknown dried brown substance on two areas of the wall next to Resident #36's bed. In an interview on 05/01/2025 at 12:05PM, S5Business Office Specialist confirmed Resident #36's wall was not maintained in a sanitary manner at this time, and should have been maintained in a sanitary manner. In an interview on 05/01/2025 at 1:43PM, S1Administrator acknowledged she was aware of the above findings and had nothing to present to dispute the above mentioned deficient practice.

Based on interviews and record reviews, the facility failed to ensure a resident with a facility initiated discharge with Medicare Part A skilled services days remaining was provided with a Notice of Medicare Non-Coverage (NOMNC) for 1 (Resident #227) of 3 (Resident #34, Resident #68, Resident #227) sampled residents reviewed for Beneficiary Notification requirements. Findings: Review of Resident #227's Skilled Nursing Facility (SNF) Beneficiary Notification Review revealed, in part, Resident #227 started Medicare Part A skilled services on 09/23/024 with the last covered day of Part A services on 11/03/2024. Further review revealed the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. Review of Resident #227's Social Service note dated 11/04/2024 revealed, in part, social services issued a local coverage of determination (LCD) for skilled services on 11/03/2024 with discharge home on 11/04/2024. Further review revealed no documented evidence a Notice of Medicare Non-Coverage (NOMNC) was provided to Resident #227 or Resident #227's responsible party prior to discharge and prior to non-covered days. There was no documented evidence, and the facility presented no documented evidence, Resident #227 was provided with a NOMNC notice prior to Medicare Part A services being discontinued. In an interview on 04/30/2025 at 10:09AM, S19Social Services Director indicated the facility had not been able to locate Resident #227's NOMNC that should have been completed by S21Prior Social Worker. In an interview on 05/01/2025 at 12:57PM, S1Administrator indicated the facility had identified a problem with beneficiary notices, but had not implemented a Quality Assurance and Perform Improvement (QAPI) at this time. S1Administrator further indicated the facility should have a NOMNC for the facility initiated discharge with skilled days remaining; however, the facility was unable to provide documented evidence Resident #227 or Resident #227's family was provided with a NOMNC prior to Medicare Part A services discontinuing.

Based on interviews and record reviews, the facility failed to ensure residents were able to access and manage their funds at all times for 3 (Resident #17, Resident #56, Resident #67) of 3 (Resident #17, Resident #56, and Resident #67) sampled residents reviewed for personal funds. Findings: Review of the facility's Resident Trust Fund policy and procedure, undated, revealed, in part, residents or family members may deposit funds into the resident trust fund account for resident's personal spending. Further review revealed just like a bank the facility had banking hours, and to please see the facility business office specialist for a listing of the resident's banking hours. Review of the facility's Resident Trust Fund Policy and Procedure, effective date of 01/23/2023, revealed, in part, residents who have authorized the facility to manage their personal funds must have reasonable access to those funds. Further review revealed the facility was expected to maintain amounts of petty cash on hand that may be required by the residents, and a request for fifty dollars or less would be honored the same day. Resident #17 Review of Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/2025 revealed a Brief Interview for Mental Status (BIMS) score of 14 (score of 13-15 indicated Resident #17 was cognitively intact). In an interview on 04/28/2025 at 10:21AM, Resident #17 indicated he could not access his funds on the weekends. Resident #56 Review of Resident #56's MDS with an ARD of 03/21/2025 revealed a BIMS score of 12 (score of 08-12 indicated Resident #56 had a moderate cognitive impairment). In an interview on 04/28/2025 at 10:46AM, Resident #56 indicated he could not access his funds on the weekends. Resident #67 Review of Resident #67's MDS with an ARD of 01/29/2025 revealed a BIMS score of 14 (score of 13-15 indicated Resident #67 was cognitively intact). In an interview on 04/28/2025 at 11:39AM, Resident #67 indicated she could not access her funds on the weekends. Resident #67 further indicated she was informed the money dispersal was closed on Saturdays and Sundays. In an interview on 04/29/2025 at 11:30AM, S26Business Office Specialist (BOS) indicated Resident #17, Resident #56, and Resident #67 had personal funds accounts with the facility. S26BOS further indicated the process for the residents to access their funds was the facility's bank was open from 1:00PM through 3:00PM Monday through Friday. S26BOS further indicated she only opened Monday through Friday, and on the weekends she would leave a petty cash box with the weekend registered nurse, usually S2Director of Nursing (DON). In an interview on 04/29/2025 at 11:47AM, S2DON indicated she was given a petty cash box on the weekends for residents with personal funds accounts. S2DON further indicated she can dispense funds, but she never publicized this information. S2DON further indicated the funds would only be available for the 8 hours she was working at the facility. In an interview on 05/01/2025 at 12:20PM, S26BOS indicated the facility did not have anything documented which identified the facility's banking hours. S26BOS further indicated the facility did not have documented evidence that residents were provided with banking hours or it was discussed with residents during care plan meetings and/or resident council meets as to how to access funds on the weekends. S26BOS further indicated the facility did not have any documented evidence that any resident had accessed their funds on the weekends. There was no documented evidence, and the facility presented no documented evidence, the facility had resident's personal funds available on the weekends and that residents were made aware that their personal funds could be accessed on weekends. In an interview on 05/01/2025 at 1:19PM, S1Administrator indicated personal funds were available to residents on the weekends; however, the facility had no documented evidence personal funds were available on weekends, that the facility had notified residents on how to access their funds on the weekends, and/or that residents were accessing funds on the weekends.

Based on interviews and record reviews, the facility failed to ensure: 1. A referral was made to the Louisiana Office of Behavioral Health's Preadmission Screening and Resident Review (PASRR) program for a resident with a onset of mental illness since admission (Resident #121); and, 2. A referral was made to the Louisiana Office of Behavioral Health's PASRR program for a resident identified with a mental illness upon admission (Resident #17). This deficient practice was identified for 2 (Resident #17, Resident #121 of 3 (Resident #17, Resident #57, Resident #121) sampled residents investigated for PASRR. Findings: 1. Review of Resident #121's Electronic Medical Record (EMR) revealed, in part, Resident #121 was admitted to the facility on [DATE]. Further review revealed Resident #121 had a diagnosis of moderate, recurrent, Major Depressive Disorder with an onset date on 09/02/2022. Further review revealed no documented evidence a PASRR Level II evaluation was completed for Resident #121 and/or a referral was made to the Louisiana Office of Behavioral Health's PASRR program for Resident #121 since admission. Review of facility's Quality Improvement Corrective Action Plan regarding the facility not appropriately submitting Level II reviews to the Louisiana Office of Behavioral Health's PASRR program revealed, in part, a Re-Admit Screening for New Psychiatric Diagnosis and/or Psychotropic Medication Changes form was completed for Resident #121 on 03/28/2025 as part of the facility's auditing for the Quality Improvement Corrective Action Plan. Review of Resident #121's Re-Admit Screening for New Psychiatric Diagnosis and/or Psychotropic Medication Changes form dated 03/28/2025 revealed, in part, no documentation staff identified a referral to the Louisiana Office of Behavioral Health's PASRR program needed to be completed due to Resident #121's diagnosis of Major Depressive Disorder since his admission. In an interview on 04/30/2025 at 1:25PM, S24Corporate Nurse acknowledged Resident #121's Major Depressive Disorder diagnosis occurred after his admission, and was a diagnosis that would have required a referral to the Louisiana Office of Behavioral Health's PASRR Program. S24Corportate Nurse further indicated the staff should have identified during the facility auditing on 03/28/2025 that Resident #121 required a referral to the Louisiana Office of Behavioral Health's PASRR program. There was no documented evidence, and the provider did not present any documented evidence, a referral was made to the Louisiana Office of Behavioral Health's PASRR program regarding Resident #121's diagnosis of Major Depressive Disorder that occurred after his admission. In an interview on 04/30/2025 at 1:30PM, S4Administrator Assistant indicated the facility's staff should have identified Resident #121 required a Level II PASRR evaluation during the facility's 03/28/2025 PASRR audit of Resident #121's record. 2. Review of Resident #17's EMR revealed, in part, Resident #17 was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder and Bipolar II Disorder. Further review revealed no documented evidence a PASRR Level II evaluation was completed for Resident #17 and/or a referral was made to the Louisiana Office of Behavioral Health's PASRR Program for Resident #17. In an interview on 04/30/2025 at 1:35PM, S4Administrator Assistant indicated Resident #17 was admitted with diagnoses of Major Depressive Disorder and Bipolar II Disorder. S4Administrator Assistant further indicated if a resident was admitted with a mental illness diagnosis, a referral for a Level II PASRR evaluation should have been submitted to the Louisiana Office of Behavioral Health's PASRR program. There was no documented evidence, and the provider did not present any documented evidence, a referral was made to the Louisiana Office of Behavioral Health's PASRR program regarding Resident #17's diagnoses of Major Depressive Disorder and Bipolar II Disorder. In an interview on 04/30/2025 at 1:39PM, S1Administrator confirmed a referral for a Level II PASRR evaluation should have been submitted to the Louisiana Office of Behavioral Health's PASRR program for a resident who was admitted with a mental illness diagnoses. 47487

Based on record reviews and interviews, the facility failed to ensure a Level I Pre-Admission Screening and Resident Review (PASRR) was accurately completed to reflect a resident's mental illness for 1 (Resident #17) of 3 (Resident #17, Resident #57, Resident #121) sampled residents investigated for PASRR requirements. Findings: Review of Resident #17's medical record revealed, in part, Resident #17 was admitted to the facility on [DATE] with diagnoses, which included, major depressive disorder and bipolar II disorder. Review of Resident #17's incomplete and undated Level I PASRR revealed, in part, Resident #17 was documented to not have been diagnosed with a mental illness. Further review revealed no psychiatric diagnosis was selected/identified on the above mentioned assessment. In an interview on 04/30/2025 at 1:35PM, S4Administrator Assistant (AA) indicated Resident #17 was admitted with diagnoses of major depressive disorder and bipolar II disorder. S4AA further indicated Resident #17's undated preadmission Level I PASRR indicated Resident #17 did not have a mental illness diagnosis, and was inaccurate and incomplete. There was no documented evidence, and the provider did not present any documented evidence a complete Level I PASRR was completed for Resident #17. In an interview on 04/30/2025 at 1:39PM, S1Administrator confirmed Resident #17's Level I PASRR was not verified for accuracy and completeness and should have been.

Based on observations, interviews, and record review, the facility failed to ensure a dependent resident received nail care for 1 (Resident #22) of 2 (Resident #21, Resident #22) sampled residents investigated for activities of daily living (ADLs). Findings: Review of Resident #22's April 2025 Care Task log revealed, in part, Resident #114's nail care task was documented as not applicable on 05/01/2025 at 5:59AM. Observation on 05/01/2025 at 8:28AM revealed all 10 of Resident #22's fingernails were yellowed and extended one-fourth to one-half of an inch above the tips of Resident #22's fingers. Further observation revealed an unknown gray substance was visible underneath Resident #22's nails where they extended above Resident #22's fingertips. In an interview on 05/01/2025 at 8:28AM, Resident #22 indicated that he would like his fingernails cut. In an interview on 05/01/2025 at 8:39AM, S25CNA indicated Resident #22 required total assistance with ADLs. Observation on 05/01/2025 at 10:40AM revealed all 10 of Resident #22's fingernails were yellowed and extended one-fourth to one-half of an inch above the tips of Resident #22's fingers. Further observation revealed an unknown gray substance was visible underneath Resident #22's nails where they extended above Resident #22's fingertips. Observation on 05/01/2025 at 12:47PM, revealed all 10 of Resident #22's fingernails were yellowed and extended one-fourth to one-half of an inch above the tips of Resident #22's fingers. Further observation revealed an unknown gray substance was visible underneath Resident #22's nails where they extended above Resident #22 finger tips. Further observation revealed, when Resident #22 turned his hands over to present his palms, the nails on the middle three fingers of Resident #22's left hand had an unknown gray substance packed beneath the nail area that extended above Resident #22's fingertips. In an interview on 05/01/2025 at 12:47PM, S9Assistant Director of Nursing (ADON) acknowledged Resident #22's nails needed to be cut, and staff should have cleaned the unknown gray substance from beneath Resident #22's fingernails.

Based on observation, interviews, and record review, the facility failed to ensure a carton of nutritional supplement was stored per a manufacturer's guideline and was not available for resident consumption. Findings: Review of Med Plus 2.0 nutritional supplement's directions revealed, in part, the product should be used within 4 hours of opening if not refrigerated. Observation on 05/01/2025 at 8:30AM revealed an opened unrefrigerated carton of Med Plus 2.0 nutritional supplement on Medication Cart d. Further observation revealed the above mentioned carton had an opened date of 04/30/2025. In an interview on 05/01/2025 at 8:45AM, S13Licensed Practical Nurse (LPN) confirmed the above mentioned supplement was opened on 04/30/2025, not refrigerated, and available for resident consumption. S13LPN further indicated he did not know the supplement should have been used within 4 hours of opening if not refrigerated. In an interview on 05/01/2025 at 11:00AM, S2Director of Nursing (DON) confirmed nursing staff should have ensured the carton of Med Plus 2.0 nutritional supplement was discarded 4 hours after being opened if not refrigerated. S2DON confirmed an opened and unrefrigerated Med Pass 2.0 nutritional supplement dated 04/30/2025 should not have been on Medication Cart d and available for use.

Based on interviews and record reviews, the facility failed to ensure an injury of unknown origin was thoroughly investigated for 1 (Resident #146) of 3 (Resident #56, Resident #146, Resident #154) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prevention and Prohibition policy and procedure dated 09/30/2019, revealed, in part, for an allegation of abuse, the administrator was to complete a thorough investigation, including interviews of employees who were working in the resident's room during the time in question, and obtaining signed statements from these employees. Further review revealed the investigator would interview the resident if the resident was cognitively able to answer questions, and if not able to interview, the investigator would interview the resident's roommate. Review of Resident #146's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 04/16/2025 revealed, in part, Resident #146 had a Brief Interview for Mental Status (BIMS) score of 02 (00-07 indicated Resident #146 had a severe cognitive impairment). Further review revealed Resident #146 required supervision for transfers and was independent for ambulation. Review of Resident #146's progress note dated 04/20/2025 at 10:48PM revealed, in part, Resident #146 was observed with a bruise of unknown origin to the right periorbital (area around the eye) area. Further review revealed the skin to the right periorbital area was reddish-blue in color. Review further revealed Resident #146 was unable to provide a history of the bruise. In an interview on 04/29/2025 at 5:34PM, S1Administrator indicated she was aware of Resident #146's right periorbital bruising with no witnessed falls reported around 04/20/2025. S1Administrator further indicated due to Resident #146 having a habit of picking things up off the floor the facility assumed Resident #146 may have hit his eye on something or had a fall. S1Administrator further indicated she had spot checked the security footage but did not have any documented evidence of the dates and times reviewed or what was seen, and she was still waiting on the written statements from the staff S30Certified Nursing Assistant (CNA) Supervisor had interviewed. In an interview on 04/29/2025 at 5:48PM, S30CNA Supervisor indicated she only conducted verbal interviews with staff regarding Resident #146's right periorbital bruising. S30CNA Supervisor further indicated she had only interviewed S31CNA and S32CNA. S30CNA Supervisor further indicated she did not have any documented evidence of S31CNA and S32CNA's verbal statements as she failed to write down their statements. In an interview on 04/29/2025 at 5:55pm S31CNA indicated none of the staff had ever interviewed her regarding Resident #146's right periorbital bruising. In an interview on 04/29/2025 at 5:59PM, S33Licensed Practical Nurse (LPN) indicated she had not been asked about the bruising to Resident #146's right eye. In an interview on 04/29/2025 at 6:09PM, S32CNA indicated she had notified S33LPN of the bruise to Resident #146's right periorbital area on a Thursday. S32CNA indicated the area under Resident #146's eye was reddish purple, then became black and red. S32CNA further indicated neither S30CNA Supervisor nor S1Administrator had interviewed her or asked her to write a statement regarding the bruising to Resident #146's right periorbital area. In an interview on 05/01/2025 at 1:23PM, S1Administrator indicated the facility had assumed Resident #146 had a fall which caused the bruising/discoloration to the right periorbital area; however, Resident #146 did not have any documented falls. S1Administrator further indicated she did not document the video surveillance footage review, nor did she interview any other shifts or staff other than S31CNA and S32CNA. S1Administrator further indicated she had no other documented evidence to present that the facility had completed a thorough investigation into the bruising on Resident #146's right periorbital area.

Based on record reviews, interviews, and observations, the facility failed to: 1. Ensure residents (Resident #143 and Resident #132), with a known history of unsafe, smoking were supervised while smoking; and, 2. Ensure residents who were identified as unsafe smokers, did not have access to smoking materials for 4 (Resident #41, Resident #109, Resident #132, Resident #143) of 4 unsafe smokers reviewed for safe smoking. The facility documented 13 residents that were unsafe smokers. The deficient practice resulted in an Immediate Jeopardy situation for Resident #143 on 05/21/2023 at 1:02pm when Resident #143, an unsafe smoker that required supervision, was sitting in her wheelchair in the smoking patio near the entrance of Dayroom Z smoking a cigarette without supervision of staff and without a smoker's apron in place. Resident #143 was observed smoking a cigarette with visible ashes noted falling on Resident #143's shirt and wheelchair. The immediate Jeopardy situation continued for the following: On 05/22/2023 at 2:48 p.m. when Resident #41, an unsafe smoker, was observed in his room lying across his bed with a red pack of cigarettes with 2 cigarettes in the pack, exposed out the bottom of his shorts. On 05/23/2023 at 5:54 a.m. Resident #132, an unsafe smoker that required supervision, was sitting outside on the smoking patio near the Hall Y entrance smoking a brown cigarette without staff supervision. On 05/23/2023 at 9:48 a.m. when Resident #109, an unsafe smoker, was observed rolling down Hall Y towards the smoking area with an unlit cigarette in his mouth. S1Administrator was notified of the Immediate Jeopardy on 05/23/2023 at 10:19 a.m. The Immediate Jeopardy was removed on 05/23/2023 at 4:40 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. Corrective actions were taken for residents (#143, #132, #41, and #109) for the deficient practice by: - The Director of Nursing (DON) in-serviced all staff who were currently in the facility on 05/23/2023 at 1:00 p.m. to ensure unsafe smokers were supervised and ensure their smoking materials/or cigarettes were not in their possession. An unsafe smokers list was placed at the nurse's station. Staff were given copies of the unsafe smokers list. Staff currently not at the facility would be in-serviced at the beginning of their next shift. All staff would be in-serviced by 05/25/2023. - Corporate nurse went to Resident #143's room on 05/23/2023 at 10:00 a.m. and removed smoking materials from resident's possession and educated on ensuring smoking materials were kept on the nurses cart. - DON, Assistant Director of Nursing(ADON) and Administrator removed smoking materials from Resident #132, #41, #109, and #143 on 05/23/2023 at 10:45 a.m. Residents were educated to ensure smoking materials were kept on the nurses cart. 2. All residents who resided in the facility had the potential to be affected by the deficient practice. The facility had a census of 173. 3. Measures put into place to ensure the deficient practice would not recur were: - DON in-serviced staff on 05/23/2023 at 1:00 p.m. to ensure unsafe smokers were supervised and ensured their smoking materials/or cigarettes were not in their possession. Staff in-serviced that an unsafe smokers list was placed at the nurse's station. Staff were also given a copy of the unsafe smokers list. Staff currently not at the facility would be in-serviced at the beginning of their next shift. All staff would be in-serviced by 05/25/2023. - A facility wide audit was performed by the DON, ADON, Administrator, and Corporate Nurse on 05/23/2023 at 10:45 a.m. to ensure all unsafe smokers were not in possession of smoking materials/cigarettes. - Starting on 05/23/2023 at 11:00 a.m. the facility would have a smoking aide assigned to the smoker's patio to supervise unsafe smokers from 7:00 a.m. - 10:00 p.m. During the times of 10:00 pm - 7:00 a.m. the charge nurse would make visual observations of the smoker's patio to ensure safety. If an unsafe smoker would like to smoke between the hours of 10:00 p.m. - 7:00 a.m., the charge nurse would perform supervision. - Starting on 05/23/2023 at 4:00 p.m. the DON or designee would provide direct supervision observations 2 times a week until 06/25/2023 to ensure the smoking aid or designated staff were supervised residents appropriately. - The facility performed a resident council meeting on 05/23/2023 at 2:00 p.m. to educate smoking resident on not sharing smoking materials with other residents. - On 05/23/2023 at 11:00 a.m. the facility placed a nursing intervention order on all unsafe smokers electronic record to be signed every shift to ensure staff were aware of which resides were considered unsafe smokers. - On 05/23/2023 at 12:30 p.m. the facility placed an unsafe smokers alert on the unsafe resident's task care plan in the resident's electronic chart to be signed off by certified nursing assistants (CNAs) every shift. 4. The facility planned to monitor its performance to ensure solutions were achieved and sustained by: - DON or designee would perform visual observation facility audits 2 times per week until 06/23/2023 to ensure unsafe smokers were appropriately supervised and were not in possession of smoking materials. 5. The likelihood of serious harm to resident #132, #41, #109, and #143 no longer existed after 2:00 p.m. on 05/23/2023. The deficient practice has the likelihood to cause serious harm to the remaining 9 residents identified as unsafe smokers by the facility. Findings: Review of the facility's Smoking Policy and Procedure revealed, in part, safe smoking assessment and/or Interdisciplinary (ID) Team will determine if resident is safe to smoke. Residents deemed unsafe will be discussed with ID Team to determine protocol to be implemented on individual basis (ex. smoking apron needed, cigarettes stored at nurses station, lighter removed from resident from resident possession, direct supervision needed, etc.). Safe smoking assessments will be completed on residents who smoke upon admission, re-smoking assessments will be completed on residents who smoke upon admission, readmission, quarterly, annually, significant changes, and as needed. Further review revealed no documented evidence for the protocol of when direct supervision was required for unsafe smokers. Resident #143 Review of Resident #143's face sheet revealed, in part, Resident #143 was admitted to the facility on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease and Nicotine Dependence Review of Resident #143's social services note dated 04/11/2023 revealed, in part, Resident #143's Brief Interview for Mental status Score was 15 which indicated Resident #143 was cognitively intact. Review of Resident #143's Comprehensive Care Plan revealed, in part, Resident #143 may be at risk for potential for injury related to her smoking habit and on 05/01/2023 Resident #143 was deemed an unsafe smoker. Further review revealed Resident #143 should have a smoker's apron when she smoked, be instructed to smoke in designated smoke areas, be instructed on safe measures to dispense smoking material, may need her cigarettes and lighter administered to her by staff when Resident #143 needed to smoke. Further review revealed, in part, Resident #143 may need supervision when she smoked. Review of Resident #143's nurses' notes revealed, in part, a nurse's note with a date of 05/01/2023 written by S2DirectorOfNursing which stated Resident #143 was reported to have smoked in her room over the weekend. Further review revealed, in part, all smoking paraphernalia was removed from Resident #143's room and was placed in the nurse's cart. Review of Resident #143's assessment for safe smoking date of completion: 05/31/2023 revealed, in part, Resident #143 was an unsafe smoker. Review of this assessment revealed Resident #143 had a history of smoking and had been considered an unsafe smoker since an episode of smoking in her room. Review of this assessment revealed Resident #143's smoking material was removed from her room and must be kept on the nurse's cart. Review of this assessment revealed Resident #143 must ask a nurse for her cigarettes and be supervised in the smoking area. Review of the facility's unsafe smoker list with a date of 05/18/2023 revealed Resident #143 was an unsafe smoker. Review revealed Resident #143 required her smoking items be kept on the cart, supervision while smoking, and assistance provided as needed while smoking. Observation on 05/21/2023 at 1:02 p.m. revealed, Resident #143, an unsafe smoker that required supervision, was sitting in her wheelchair in the smoking patio near the entrance of Dayroom Z. Observation revealed Resident #143 took a cigarette from Resident #13. Resident #13 then lit Resident #143's cigarette and the two residents began to smoke together. Observation revealed Resident #143 dropped ashes on her shirt. Observation further revealed Resident #143 discarded her cigarette in the sewage drain. At this time Resident #143 did not have a smoking apron on and no staff were present to supervise Resident #143. In an interview on 05/21/2023 at 1:28 p.m., Resident #143's son stated Resident #143 does smoke. In an interview on 05/21/2023 at 1:30 p.m., S14Certified Nursing Assistant (CNA) stated Resident #143 goes outside and smokes frequently on the smoking patio near Dayroom Z. S14CNA stated Resident #143 does not require supervision when smoking and she is allowed to keep her own cigarettes. Observation on 05/22/2023 at 12:31 p.m. revealed, Resident #143 in her room in her wheelchair with cigarette ashes on her green velvet pants and shirt. Observation revealed a half of a brown cigarette on Resident #143's bedside table. Observation on 05/22/2023 at 1:45 p.m. revealed Resident #143 was sitting at a table in Dayroom Z, playing cards with a gold and white pack of Marlboro cigarettes noted on the table. In an interview on 05/22/2023 at 1:48 p.m., Resident #143 stated the cigarettes on the table belong to her. Resident #143 stated she normally smokes right outside of the Dayroom Z doorway with Resident #13. Resident #143 further stated she does not wear an apron and she does not need staff to supervise her when she smokes. In an interview on 05/22/2023 at 1:58 p.m., Resident #13, a cognitively intact resident, stated him and Resident #143 smoke every day together in the smoking pavilion near Day Room Z door. Resident #13 stated Resident #143 usually has her own cigarettes and she does not have to be watched by staff or wear an apron. Resident #13 stated when they smoke they are usually by their self. Observation on 05/22/2023 at 4:25 p.m. circular piles of gray ash noted in Resident #143's wheelchair. Observation further revealed gray ash noted on Resident #143's floor near her bedside. In an interview on 05/22/2023 at 4:32 p.m., Resident #143 stated she has her Marlboro cigarettes in her drawer in her room. Resident #143 stated she hid the cigarettes in her drawer. Resident #143 stated when she gets ready to go outside, she is going to go with Resident #13 and get a light from him. Resident #143 stated she normally smokes with Resident #13 and she gets a light from him or any resident that is on the smoking patio. Resident #143 further stated if she doesn't have cigarettes she will get them from Resident #13. Resident #143 further stated she does not have to be supervised by staff when smoking. Observation on 05/23/2023 at 5:19 a.m. revealed, a half of a brown cigarette on Resident #143's bedside table. In an interview on 05/23/2023 at 5:21 a.m., S16Certified Nursing Assistant (CNA) stated Resident #143 keeps her smoking material on her person and she smokes all the time. S16CNA stated Resident #143 usually goes with Resident #13 or other residents to smoke at night, but she can smoke unsupervised if she wants. S16CNA stated Resident #143 is not an unsafe smoker to her knowledge. S16CNA stated Resident #143 was awake around 2:00 a.m. and went outside to smoke with Resident #13. S16CNA stated she had worked at the facility about 2 weeks and the facility had not informed her of any residents on her hall who were unsafe smokers or who needed to be supervised. In an interview on 05/23/2023 at 5:30 a.m., S23Licensed Practical Nurse (LPN) stated Resident #40, Resident #109, Resident #132, Resident #143 are all unsafe smokers, but none of them smoke at night. Observation on 05/23/2023 at 6:37 a.m. revealed half of a brown cigarette on Resident #143's bedside table. In an interview on 05/23/2023 at 8:09 a.m., S21MDSCoordinator stated Resident #143 should have had a smoking assessment done on 05/01/2023 when she was observed smoking in her room and she did not. S21MDSCoordinator stated unsafe smokers are communicated with staff and the IDT team in the morning meeting. S21MDSCoordinator stated Resident #143 was an unsafe smoker after smoking in her room and should have direct supervision of staff when she smoked. S21MDS Coordinator stated Resident #143 should not be allowed to have smoking materials at any time. S21MDS Coordinator stated the nurse on the hall or the front desk should keep her smoking material. Observation on 05/23/2023 at 8:30 a.m. revealed Resident #143 sitting at the table located in the middle of the smoking patio out of sight of S17Smoking Aide smoking a cigarette. Further observation revealed Resident #143 put the cigarette to her mouth, dropped ash onto her green felt shirt, wiped it off of her shirt, and then placed the lit cigarette into the table and twisted it. In an interview on 05/23/2023 at 8:35 a.m., Resident #143 stated she smoked last night between 1:00 a.m. and 2:00 a.m. with Resident #13, Resident #143 stated she did not have staff supervision while she was smoked. In an interview on 05/23/2023 at 10:00 a.m. S2Director of Nursing (DON) stated Resident #143 was caught smoking in her room over the weekend and Resident #143 was deemed an unsafe smoker after that incident. Observation on 05/23/2023 at 10:23 a.m. revealed half of a brown cigarette on her bedside table. In an interview on 05/23/2023 at 10:25 a.m. S7Coorporate Nurse confirmed Resident #143 had half of a brown cigarette on her bedside table. S7Cooporate Nurse further stated Resident #143 should not be in possession of smoking material. Resident #132 Review of Resident #132's face sheet revealed, in part, Resident #132 was admitted to the facility on [DATE] with diagnoses that included: Acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease, and Tobacco Use. Review of Resident #132's Minimal Data Set with an Assessment Reference Date of 05/10/2023 revealed, in part, Resident #132's Brief Interview for Mental status Score was 12 which indicated Resident #132 was cognitively intact. Review of Resident #132's Comprehensive Care Plan, with a start date of 11/16/2021, revealed, in part, Resident #132 may be at risk for potential for injury related to at times I am an unsafe smoker. Review revealed on 12/29/2022 Resident #132 had burns noted on his fingers and needed a smoker's apron. Review revealed Resident #132 should be instructed to smoke in designated smoking areas, be instructed on safe measures to dispense smoking material, and may need his cigarettes and lighter administered to him by staff when Resident #132 needed to smoke. Further review revealed, in part, Resident #132 may need supervision when he smoked. Review of Resident #132's assessment for safe smoking with a completion date of 03/13/2023 revealed, in part, Resident #132 was an unsafe smoker. Review of this assessment revealed Resident #132 was not able to understand smoking materials are for use only in designated areas, was not able to understand that sharing materials with other residents is considered an unsafe smoking behavior, was not observed not sharing smoking materials with other residents, and was not able to understand that all smoking material was to be stored and distributed by nursing staff. Review of the facility's unsafe smoker list with a date of 05/18/2023 revealed Resident #132 was an unsafe smoker. Review revealed Resident #132 required his smoking items be kept on the cart, supervision while smoking, and a smoking apron be worn while smoking. In an interview on 05/23/2023 at 5:30 a.m., S23Licensed Practical Nurse (LPN) stated Resident #40, Resident #109, Resident #132, Resident #143 are all unsafe smokers, but none of them smoke at night that she is aware of except Resident #132. S23LPN further stated Resident #132 did not have cigarettes at this time. Observation on 05/23/2023 at 5:45 a.m. revealed Resident #132 was observed walking down Hall X with a green lighter and a pack of cigarettes in his hand. Observation on 05/23/2023 at 5:54 a.m. revealed Resident #132 was outside on the smoking patio near the Hall Y entrance smoking a brown cigarette without staff supervision and without a smoker's apron. In an interview on 05/23/2023 at 6:02 a.m., Resident #132 stated he keeps his cigarettes and lighter on his person at all times. Resident #132 further stated he does not have to have staff supervision when he is smoking. In an interview on 05/23/2023 at 6:03 a.m., Resident #56, a cognitively intact resident, stated she is a safe smoker who frequently smokes every few hours. Resident #56 further stated Resident #132 smokes often at night with her. Resident #56 further stated the facility does not have a smoking aide after 7:00 p.m. Resident #56 stated the smoking aide usually worked 7:00 a.m. - 7:00p.m. and at night who ever smokes was not supervised by staff. Observation on 05/23/2023 at 6:40 a.m. revealed Resident #132 sitting outside on the smoking patio near the Hall Y entrance smoking a brown cigarette without staff supervision and without a smoker's apron. Observation revealed Resident #132 was in possession of a pack of cigarettes and a green lighter at this time. Further observation revealed Resident #132 used the green lighter to light a random resident's cigarette. In an interview on 05/23/2023 at 7:08 a.m., S17Smoking Aide stated she was a part time employee and worked 3 days a week. S17Smoking Aide stated her understanding of her job position was to ensure residents do not fight on the smoking patio and provide them a smoker's apron if they need it. S17Smoking Aide stated she was not sure who required a smoker's apron, but as far as she was aware there was only one female resident. S17Smoking Aide stated she does not administer the residents their cigarettes or monitor when they have cigarettes. Review of the facility's staffing schedules for 05/21/2023-05/23/2023 revealed the following staff were assigned to Smoking Aide: 05/21/2023-S28Smoking Aide; 05/22/2023-S28smoking Aide and S17Smoking Aide; 05/23/2023-S26Smoking Aide and S27Smoking Aide Review of S17Smoking Aide's time sheet revealed on 05/22/2023 S17Smoking Aide worked from 8:32 a.m. - 3:12 p.m. Review of S26Smoking Aide's time sheet revealed on 05/23/2023 S26Smoking Aide arrived at 7:03 a.m. Review of S27Smoking Aide's time sheet revealed on 05/23/2023 S27Smoking Aide arrived at 7:06 a.m. Review of S28Smoking Aide's time sheet revealed on 05/21/2023 S28Smoking Aide worked from 9:38 a.m.-6:55 p.m. and on 05/22/2023 S28Smoking Aide worked from 7:27 a.m.- 5:50 p.m. Resident #41 Review of Resident #41's face sheet revealed, in part, Resident #41 was admitted to the facility on [DATE] with diagnoses that included: Extrapyramidal and Movement Disorder, Alcohol Abuse, and Legal Blindness of the Left Eye. Review of Resident #41's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/2023 revealed, in part, a Brief Interview for Mental Status score of 8 which indicated moderately cognitive impaired. Further review revealed Resident #41 used tobacco use. Review of Resident #41's Comprehensive Care Plan with a start date of 05/03/2023 revealed, in part, Resident #41 may be at risk for potential for injury related to his smoking habit and Resident #41 was an unsafe smoker. Further review revealed, Resident #41 should have a smoking apron when he smoked, be instructed to smoke in designated smoke areas, be instructed on safe measures to dispense smoking material, may need his cigarettes and lighter administered to him by staff when Resident #41 needed to smoke. Further review revealed, in part, Resident #41 may need supervision when he smoked. Review of Resident #41's assessment for safe smoking dated 05/01/2023 revealed, in part, Resident #41 was an unsafe smoker. Review of this assessment revealed Resident #41 had a history of smoking and was observed sharing smoking materials with other residents. Further review of this assessment revealed Resident #41 remained an unsafe smoker and all smoking paraphernalia was to be kept in the nurse's care. Review of the facility's unsafe smoker list with a date of 05/18/2023 revealed Resident #41 was an unsafe smoker. Review revealed Resident #41 required his smoking items be kept on the cart, supervision while smoking, a smoking apron be worn while smoking, and assistance as needed. Observation on 05/22/2023 at 2:48 p.m. revealed, Resident #41 was lying across his bed on his left side with a red pack of cigarettes exposed out the bottom of his shorts on his right leg with 2 cigarettes in the pack. In an interview on 05/22/2023 at 2:48 p.m., Resident #41 stated the cigarettes observed in the previous observation belonged to him. Observation on 05/23/2023 at 10:21 a.m. revealed Resident #41 sitting in his wheelchair at the smoking area door on Hall Y with a red pack of cigarettes with 2 cigarettes tucked under his left leg. In an interview on 05/23/2023 at 10:32 a.m., Resident #41 stated he keeps his cigarettes in his possession. 4.) Resident #109 Review of Resident #109 face sheet revealed an admitted [DATE] with diagnoses, in part, that included Tobacco Use. Review of Resident #109 Minimal Data Set with an Assessment Reference Date of 03/22/2023 revealed, in part Resident #109 had a Brief Interview for Mental Status Score of 11 which indicated Resident #109 had moderate cognitive impairment. Review of Resident #109's Comprehensive Care Plan, with a start date of 03/27/2023, revealed, in part, Resident #109 may be at risk for potential for injury related to being an unsafe smoker. Further review revealed, Resident #109 should have a smoker's apron when he smoked, be instructed to smoke in designated smoking areas, be instructed on safe measures to dispense smoking material, and may need his cigarettes and lighter administered to him by staff when Resident #109 needed to smoke. Further review revealed, in part, Resident #109 may need supervision when he smoked. Review of Resident #109 Assessment for Safe Smoking with a completion date of 03/21/2023 revealed, in part, Resident #109 was not able to light and smoke a cigarette while demonstrating safe technique by putting out the lighter or matches and disposing of ash. Further review revealed, in part, Resident #109 was not able to communicate understanding that smoking materials were for use only in designated smoking areas and was not able to communicate his understanding that sharing smoking materials (cigarettes, matches, lighter, etc.) with other residents was considered an unsafe smoking behavior. Further review Resident #109's cigarettes must be kept on the nurse's cart. Review of the facility's unsafe smoker list with a date of 05/18/2023 revealed Resident #109 was an unsafe smoker. Review revealed Resident #109 required his smoking items be kept on the cart, supervision while smoking, and a smoking apron be worn while smoking. Observation on 05/21/2023 at 10:11 a.m., revealed Resident #109 on Hall X getting a cigarette from Resident #88. Observation on 05/23/2023 at 9:48 a.m., revealed Resident #109 rolled down Hall Y towards the smoking area with an unlit cigarette in his mouth. In an interview on 05/23/2023 at 10:05 a.m., S1Administrator stated the designated smoking area was the patio centrally located in the center of the building. S1Administrator stated residents who require assistance or are unsafe smokers have specific interventions specified on their careplan and smoking assessment that outlines the reason they are unsafe and the interventions the facility has put into place. S1Administrator stated Resident #40, Resident #109, Resident #132, and Resident #143 are all unsafe smokers. S1Adminstrator stated Resident #143 is an unsafe smoker because she was caught smoking in her room. S1Administrator stated she was not concerned Resident #143 would catch herself on fire. S1Adminsitrator stated unsafe smokers should not have their smoking material on their person in the facility at any time.

The facility failed to be administered in a manner that uses resources to effectively and efficiently meet the needs of the residents by failing to: 1. Ensure residents (Resident #143 and Resident #132), with a known history of unsafe, smoking were supervised while smoking; and, 2. Ensure residents who were identified as unsafe smokers, did not have access to smoking materials for 4 (Resident #41, Resident #109, Resident #132, Resident #143) of 4 unsafe smokers reviewed for safe smoking. The facility documented 13 residents that were unsafe smokers. The deficient practice resulted in an Immediate Jeopardy situation for Resident #143 on 05/21/2023 at 1:02pm when Resident #143, an unsafe smoker that required supervision, was sitting in her wheelchair in the smoking patio near the entrance of Dayroom Z smoking a cigarette without supervision of staff and without a smoker's apron in place. Resident #143 was observed smoking a cigarette with visible ashes noted falling on Resident #143's shirt and wheelchair. The immediate Jeopardy situation continued for the following: On 05/22/2023 at 2:48 p.m. when Resident #41, an unsafe smoker, was observed in his room lying across his bed with a red pack of cigarettes with 2 cigarettes in the pack, exposed out the bottom of his shorts. On 05/23/2023 at 5:54 a.m. Resident #132, an unsafe smoker that required supervision, was sitting outside on the smoking patio near the Hall Y entrance smoking a brown cigarette without staff supervision. On 05/23/2023 at 9:48 a.m. when Resident #109, an unsafe smoker, was observed rolling down Hall Y towards the smoking area with an unlit cigarette in his mouth. S1Administrator was notified of the Immediate Jeopardy on 05/23/2023 at 11:01 a.m. The Immediate Jeopardy was removed on 05/23/2023 at 4:40 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1. Corrective actions were taken for the residents (Resident #41, Resident #109, Resident #132 and Resident #143) affected by the deficient practice by: - Regional Director in-serviced the Administrator and Administrative staff on 05/23/2023 at 2:00 p.m. on ensuring the safety of unsafe smokers, - Facility audit performed on 05/23/2023 at 10:45 revealed that unsafe smokers did not have any smoking materials in their possession. 2. All residents who reside in the facility had the potential to be affected by the deficient practice. The facility had a census of 173. 3. Measures were put into place to ensure the deficient practice would not recur were: - Regional Director in-serviced the Administrator on 05/23/2023 at 2:00 p.m. on ensuring the safety of unsafe smokers. - Facility audit performed on 05/23/2023 at 10:45 revealed that unsafe smokers did not have any smoking materials in their possession. 4. The facility planned to monitor its performance to ensure solutions were achieved and sustained by: - Regional Director or designee would perform Quality Assurance (QA) administration audits 2 times per week until 06/23/2023 to ensure the facility was being administered in a manner that use its resources to effectively and efficiently meet the needs and safety of unsafe smokers. - Regional Quality Improvement Nurse or designee would perform QA administration nursing audits 2 times per week until 06/23/2023 to ensure the facility was being administered in a manner that use its resources to effectively and efficiently meet the needs and safety of unsafe smokers. 5. The likelihood of serious harm to Resident #41, Resident #109, Resident #132 and Resident #143 no longer existed after 2:00 p.m. on 05/23/2023. The deficient practice has the likelihood to cause serious harm to the remaining 9 residents identified as unsafe smokers by the facility. Findings: Cross Reference F689 In an interview on 05/23/2023 at 10:00 a.m., S2Director of Nursing (DON) stated Resident #143 was caught smoking in her room the weekend prior to 05/01/2023 and Resident #143 was deemed an unsafe smoker after that incident. In an interview on 05/23/2023 at 10:05 a.m., S1Administrator stated the designated smoking area was the patio centrally located in the center of the building. S1Administrator stated residents who require assistance or are unsafe smokers have specific interventions specified on their careplan and smoking assessment that outlined the reason they are unsafe and the interventions the facility has put into place. S1Administrator stated Resident #40, Resident #109, Resident #132, and Resident #143 are all unsafe smokers. S1Adminstrator stated Resident #143 is an unsafe smoker because she was caught smoking in her room. S1Administrator stated she was not concerned Resident #143 would catch herself on fire. S1Adminsitrator stated unsafe smokers should not have their smoking material on their person in the facility at any time. In an interview on 05/23/2023 at 10:25 a.m., S7Coorporate Nurse confirmed Resident #143 had half of a brown cigarette on her bedside table. S7Cooporate Nurse further stated Resident #143 should not be in possession of smoking material. In an interview on 05/23/2023 at 1:30 p.m., S30Regional Director stated he had in-serviced S1Adminsitrator on ensuring the safety of unsafe smokers. S30Regional Director further stated, S30Regional Director or designee would perform administrative audits 2 times per week until 06/23/2023 to ensure the facility is being administered in a manner that used its resources to effectively and efficiently meet the needs and safety of unsafe smokers. In an interview on 05/24/2023 at 10:30 a.m., S29Clinical Director of Operations stated the facility needed to ensure they had a better system in place for all of the smokers in the facility.

Based on record reviews, interviews, and observations, the facility failed to: 1.Ensure oxygen cylinders were stored and secured in a manner that prevented the potential for serious harm or injury for 4 residents (Resident #9, Resident #10, Resident #11, and Resident #12) out of the 34 residents that required oxygen as identified on the oxygen Physician Orders List and; 2. Ensure residents who were identified as unsafe smokers did not have access to smoking materials for 3 (Resident #6, Resident #7, and Resident #8) out of 9 unsafe smokers identified on the Unsafe Smoker List. The deficient practice resulted in an Immediate Jeopardy (IJ) situation on 01/23/2023 at 2:15 p.m. when Resident #9 knocked over one large oxygen cylinder in his room, and the large oxygen cylinder's valve opened and oxygen was inadvertently released with a hissing sound. On 01/23/2023 at 2:15 p.m., surveyor was standing with S6Treatment Nurse (TN) outside of Resident #9's room. A crash was heard followed by a hissing sound. S6TN and the surveyor ran into Resident #9's room to find Resident #9 had tangled up his oxygen tubing into his electric scooter wheel, and reversed backward into three large and one small free standing oxygen cylinder next to his bed. Further observation revealed, two large oxygen cylinders and one small oxygen cylinder were knocked over, and one large oxygen cylinder's valve was opened and oxygen was inadvertently released. Resident #9's oxygen tubing was disconnected from oxygen concentrator that he was supposed to be on, and Resident #9's room was cluttered with multiple oxygen cylinders unsecured, oxygen concentrators, multiple cords, and tubing lying on the floor causing the likelihood for the potential for severe harm or injury. The deficient practice resulted in an Immediate Jeopardy (IJ) situation on 01/23/2023 at 3:00 p.m., when Resident #8 was observed smoking a cigarette in his bed and stated you caught me smoking and extinguished his cigarette into a small bowl on his bedside table. Resident #8 stated that he asked to go outside and smoke, but that staff would never bring him outside, so he smoked in his room. Resident #8 stated that he was not able to get out of bed by himself and transfer to a wheelchair. Resident #8 had a red pack of cigarettes, a purple lighter, and one extinguished cigarette butt at his bedside. This deficient practice had the likelihood to potentially cause serious harm or injury to all 178 residents residing in the facility as identified on the Facility Census List. The facility submitted a plan of removal that consisted of the following: 1.Corrective actions were taken for Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 by the alleged deficient practice by: Registered Nurse (RN) Director of Nursing (DON) in-serviced nursing staff on 01/24/2023 on ensuring oxygen cylinders are secured in cylinder racks/cylinder stands and properly stored in designated areas, ensuring unsafe smokers are supervised and ensuring smoking materials and/or cigarettes are not in possession of any unsafe smokers and kept on the nurse's carts. The nursing staff will ensure unsafe smokers are not in possession of smoking material by observation every shift. Agency staff and new hires will be in-serviced on oxygen cylinders and unsafe smokers prior to working any shift. Regular staff will be in-serviced prior to the next shift. Facility wide audits performed by S2Directior of Nursing (DON), S7Assistant Director of Nursing (ADON), S1Administrator, and S3Corporate Nurse on 01/24/2023 to ensure all oxygen cylinders were stored and secured properly and to ensure unsafe smokers were not in possession of smoking materials/cigarettes. The facility will contact family members of unsafe smokers via phone call on 01/25/2023 to inform them that when delivering smoking materials they should give the materials to the resident's assigned nurse and not the resident. 2. All residents who reside in the facility have the potential to be affected by the alleged deficient practice. The facility had a census of 178. 3. Measures put in place to ensure the alleged deficient practice will not recur are: RN DON in-serviced nursing staff on 01/24/2023 on ensuring oxygen cylinders are secured in cylinder racks/cylinder stands and properly stored in designated areas, ensuring unsafe smokers are supervised and ensuring smoking materials and/or cigarettes are not in possession of any unsafe smokers and are kept on the nurse's carts. The nursing staff will ensure unsafe smokers are not in possession of smoking materials by observation every shift. Agency staff any new hires will be in-services on oxygen cylinders and unsafe smokers prior to working any shift. Facility wide audit performed by S2Directior of Nursing (DON), S7Assistant Director of Nursing (ADON), S1Administrator, and S3Corporate Nurse on 01/24/2023 to ensure all oxygen cylinders were stored and secured properly and to ensure unsafe smokers were not in possession of smoking material/cigarettes. The facility will contact family members of unsafe smokers via phone call on 01/15/2023 to inform them that when delivering smoking materials they should give the materials to the resident's assigned nurse and not the resident. The facility performed smoking assessments on all residents that smoke on 01/24/2023. Smoking binders identifying unsafe smokers were updated on 01/24/2023 and placed at each nurse's station. Cognitive unsafe smokers were counseled per S1DON and S7ADON on 01/24/2023 on smoking policy and ensuring smoking materials are given to their nurse. 4. The facility plans to monitor its performance to ensure solutions are achieved and sustained by: RN DON or designee to perform facility audits 2 times per week to ensure oxygen cylinders are properly secured, unsafe smokers are appropriately supervised and to ensure unsafe smokers are not in possession of smoking materials/cigarettes. Audits began on 01/24/2023. Audits will continue until 02/25/2023. 5. Corrective actions will be completed by: 01/25/2023. The Immediate Jeopardy was removed on 01/25/2023 at 2:32 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal. Findings: 1. Review of the facility's Oxygen Administration Policy and Procedure revealed, in part, oxygen cylinders should be secured on a stand with a safety strap or chain and appropriate oxygen sign should be placed per facility procedure. Resident #9 Review of Resident #9's electronic medical recorded (EMR) revealed Resident #9 was admitted to facility on 10/26/2022 with diagnoses which included, in part, pain, shortness of breath, anxiety, wheezing, and person history of malignant neoplasm of prostate. Review of Resident #9's MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 11/08/2022 revealed, in part, Resident #9 had a BIMS (brief interview mental status) score of 13 which indicated mild cognitive impairment, and Resident #9 required extensive two person physical assistance with bed mobility, transfer, and requires supervision with locomotion on hall with motorized scooter. Review of Resident #9's care plan revealed, in part, a goal of Resident #9 will exhibit no shortness of breath with interventions that include administer oxygen as ordered. Further review revealed, in part, no interventions or goals related to safe/unsafe smoking. Review of Resident #9's physician orders for January 2023 revealed, in part, an order for oxygen at 2-8 liters via nasal cannula continuous (may remove for ADL's). Review of Resident #9's Assessment for Safe Smoking dated 10/27/2022 revealed, in part, Resident #9 was a safe smoker. Observation on 01/23/2023 at 10:56 a.m., revealed one (1) oxygen cylinder unsecured and lying on the floor in Resident #9's room. On 01/23/2023 at 2:15 p.m., surveyor was standing with S6Treatment Nurse (TN) outside of Resident #9's room. A crash was heard followed by a hissing sound. S6TN and the surveyor ran into Resident #9's room to find Resident #9 had tangled up his oxygen tubing into his electric scooter wheel, and reversed backward into three large and one small free standing oxygen cylinder unsecured next to his bed. Further observation revealed, two large oxygen cylinders and one small oxygen cylinder were knocked over, and one large oxygen cylinder's valve was opened and oxygen was inadvertently released. Resident #9's room was cluttered with multiple oxygen cylinders, oxygen concentrators, multiple cords, and tubing lying on floor. Observation on 01/23/2023 at 2:16 p.m. of Resident #9's room revealed 3 large oxygen cylinders free standing, unsecured between the night stand and bed, 1 large oxygen cylinder lying on the floor under the sink, unsecured, 1 small oxygen cylinder standing unsecured by the bed. Further observation revealed Resident #9 in his motorized scooter without nasal cannula on his nose. Resident #9 oxygen tubing was unconnected from oxygen concentrator when tangled in motorized scooter wheels. On 01/23/2023 at 2:30 p.m., the survey team performed a facility wide audit of resident rooms and nurse's stations ensuring the safe storage of oxygen cylinders. Resident #10 Review of Resident #10's electronic medical recorded (EMR) revealed Resident #10 was admitted to facility on 01/15/2021 and readmitted to facility on 01/17/2022 with diagnoses which included, in part, Hereditary Spastic Paraplegia and Aspiration Pneumonia. Review of Resident #10's MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 11/08/2022 revealed, in part, Resident #10 required extensive to total assistance for all ADLs, with limited assistance for eating only. Review of Resident #10's Assessment for Safe Smoking dated 08/01/2022 revealed, in part, Resident #10 was a safe smoker. Observation on 01/23/2023 at 2:35 p.m., revealed one free standing oxygen cylinder unsecured in Resident #10's room. Resident #12 Review of Resident #12's electronic medical recorded (EMR) revealed Resident #12 was admitted to facility on 11/24/2021 with diagnoses which included, in part, Spinal Stenosis and Chronic Obstructive Pulmonary disease (COPD). Review of Resident #12's MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 01/04/2022 revealed, in part, Resident #12 had a BIMS (brief interview mental status) score of 13 which indicated mild cognitive impairment, and Resident #12 required extensive assistance with transfers, dressing, personal hygiene, and toilet use. Observation on 01/23/2023 at 2:50 p.m., revealed one free standing oxygen cylinder unsecured in Resident #12's room. Resident #11 Review of Resident #11's electronic medical recorded (EMR) revealed Resident #11 was admitted to facility on 03/24/2021 with diagnoses which included, in part, COPD, Tobacco use, and Obstructive Sleep Apnea. Review of Resident #11's MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 10/12/2022 revealed, in part, Resident #11 had a BIMS (brief interview mental status) score of 14 which indicated he was cognitively intact, and Resident #11 required limited assistance for all activities of daily living (ADLs). Observation on 01/23/2023 at 2:52 p.m., revealed one free standing oxygen cylinder unsecured in Resident #11's room. Observation on 01/23/2023 at 3:10 p.m. of Nurse' Station b revealed 6 large oxygen cylinders and 4 small oxygen cylinders on the floor not secured. Further observation revealed, 2 small oxygen cylinders on the counter not secured on the medication room counter. In an interview on 01/23/2023 at 3:11 p.m., S1Director of Nursing (DON) stated all oxygen cylinders should be properly stored when in residents rooms or in the medication rooms. S1DON further stated there should not be any oxygen cylinders free standing and not in a holder or stand. On 01/23/2023 at 3:30 pm, S3Corporate Nurse (CN) and S1Administrator were notified that oxygen cylinders were free standing and unsecured in multiple resident's rooms and nurse's station. S3CN and S1Administrator stated that staff would perform a facility wide audit to ensure no oxygen cylinders were free standing and unsecured. Observation on 01/24/2023 at 9:30 a.m., revealed one free standing oxygen cylinder unsecure in Resident #10's room. Observation on 01/24/2023 at 10:11 a.m., revealed one free standing oxygen cylinder unsecure in Resident #12's room. Observation on 01/24/2023 at 2:15 p.m. revealed the Nurse's Station b revealed 2 small oxygen cylinders and 1 large oxygen cylinder free standing and unsecured in Nurse's Station b. One small oxygen cylinder also placed on top of another small oxygen cylinder in the holder. In an interview on 01/24/2023 at 2:16 p.m., S11 Licensed Practical Nurse (LPN) stated that the two large and two small oxygen tanks in South Nursing Station are not secured and should be secured. Observation on 01/24/2023 at 2:20 p.m. of Nurse's Station a revealed one small oxygen tank improperly stored on its side on top of multiple other large oxygen tanks on the rack. In an interview on 01/24/2023 at 2:20 p.m., S12Licensed Practical Nurse (LPN) stated that 1 small oxygen tank was stored improperly in Nurse's Station a should be properly secured. Observation on 01/24/2023 at 2:45 p.m. did not reveal any oxygen safety signs on the doors of the oxygen storage area of the Nurse's Station a and the Nurse's Station b. In an interview on 01/24/2023 at 2:50 p.m., S3Corporate Nurse (CN) stated facility does not have oxygen safety signs in the designated areas where oxygen tanks are stored. 2. Review of facilities' smoking policy and procedure revealed, in part, a Safe Smoking Assessment and/or the Interdisciplinary Team will determine if a resident is safe to smoke. Further review revealed, in part, Safe Smoking Assessments will be completed on all resident who smoke upon admission, readmission, quarterly, annually, significant change, and as needed. Resident #8: Review of Resident #8's electronic medical recorded (EMR) revealed Resident #8 was admitted to facility on 06/03/2022 with diagnoses which included, in part, sequelae of cerebral infarction, schizophrenia primary insomnia, tobacco use, cerebral infarction, and hemiplegia affecting left non dominant side. Review of Resident #8's Quarterly MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 12/02/2022 revealed, in part, Resident #8 had a BIMS (brief interview mental status) score of 10 which indicated he was mildly cognitively impaired, and Resident #8 required extensive two person physical assistance with bed mobility, transfer, and one person limited physical assistance for locomotion. Review of Resident #8's care plan revealed, in part, goal of Resident #8 will have minimal to no injuries r/t smoking with interventions that include Resident #8 will be reminded to smoke in designated smoke areas, Resident #8 will be instructed on safe measures to dispense smoking material, Resident #8 may need his cigarettes and lighter administered to me when he needs to smoke, and Resident #8 may need supervision when he smokes. Review of the facility's Resident Unsafe Smoker List dated 12/29/2022 revealed, in part, Resident #8 was listed as needing smoking items kept on nurse's cart. Review of Resident #8's Assessment for Safe Smoking dated 09/05/2022 revealed, in part, Resident #8 had a memory problem, was observed sharing smoking materials with other residents, and was noted for smoking in his room. Further review revealed, in part, a summary that Resident #8 is an unsafe smoker. Review of Resident #8's nurse's note revealed, in part, note dated 06/14/2022 that noted that resident stated that he is a smoker, but has not smoked since he came into the facility because he doesn't have any cigarettes. Review of Resident #8's nurse's note revealed, in part, note dated 07/06/2022 revealed, in part, resident had half smoking cigarette sitting on end table by his bed. Review of Resident #8's nurse's note revealed, in part, a note dated 08/09/2022 that noted that Resident #8 was caught smoking by nurse in Resident #8's room. Observation on 01/23/2023 at 3:00 p.m., revealed Resident #8, who was identified as an unsafe smoker per the smoking assessment completed on 09/05/2022, was smoking a cigarette in his bed. Resident #8 stated you caught me smoking and extinguished cigarette in small bowl on his bedside table. Resident #8 stated that he requested to go out and smoke, but staff do not bring him outside, so he smokes in his room. Resident #8 stated that he is not able to get out of bed by himself and transfer to a wheelchair. Resident #8 had a red pack of cigarettes, a purple lighter, and one extinguished cigarette butt at his bedside. In an interview on 01/23/2023 at 3:15 p.m., S2Director of Nursing (DON) stated that Safe Smoking assessments are to be performed quarterly when MDS is completed. S2DON further stated that anyone who is an unsafe smoker should have smoking materials kept on nursing carts. On 01/23/2023 at 3:30 p.m., S3Corporate Nurse (CN) and S1Administrator were notified that Resident #8 was found smoking in his room. S3CN and S1Administrator stated staff would perform a facility wide audit to ensure smoking paraphernalia is stored appropriately. Resident #6 Review of Resident #6's Quarterly MDS (Minimum Data Sheet) with ARD (Assessment Reference Date) of 11/09/2022 revealed, in part, Resident #6 had a BIMS (brief interview mental status) score of 14 which indicated she was cognitively intact. Review of Resident #6's care plan with a target date of 03/31/2023 revealed, in part, Resident #6 was a smoker, and was caught smoking in room on 10/05/2022, 11/09/2022, and 11/15/2022. Further review revealed, in part, interventions that included Resident #6 cigarettes to be administered to her and that Resident #6 was to be directed to the authorized smoking areas. Review of Resident #6's assessment for safe smoking dated 11/07/2022 revealed, in part, unsafe smoker since episode of smoking in room and resident aware cigarettes are in the nurse's cart. Observation on 01/24/2023 at 10:50 a.m., revealed Resident #6 had an open pack of cigarettes and a purple lighter in her shirt pocket. In an interview on 01/24/2023 at 10:50 a.m., Resident #6 stated she was allowed to keep her cigarettes and lighter because she smoked by herself at night. Observation on 01/24/2023 at 11:10 a.m. with S1Administrator, S2DON, S3Corporate Nurse, S13Regional Director, revealed Resident #6 was in the possession of a lighter and cigarettes. In an interview on 01/24/2023 at 12:30 p.m., S1Administrator, S2DON, S3Corporate Nurse, S13Regional Director, all agreed and acknowledged residents who were assessed as unsafe smokers should not have had possession of a lighter and cigarettes without staff supervision. Resident #7 Review of Resident #7's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/28/2022 revealed, in part, Resident #7 had a BIMS (brief interview mental status) score of 14 which indicated she was cognitively intact, and Resident #7 required extensive assistance with transfers; and total dependence with dressing, personal hygiene, and toilet use. Review of Resident #7's smoking assessment completed on 11/07/2022 identified Resident #7 as an unsafe smoker. Observation on 01/24/2023 at 10:00 a.m., revealed Resident #7 had an open pack of cigarettes on his bed containing 5-6 cigarettes. In an interview on 01/24/2023 at 10:00 a.m., Resident #7 stated he had possession of cigarettes but did not have a lighter. Observation on 1/24/2023 at 10:28 a.m., revealed Resident #7 had an open pack of cigarettes on his bed containing 5-6 cigarettes. In an interview on 01/24/2023 at 11:15 a.m., S1Administrator stated Resident #7 did have a pack of cigarettes in his room, and she had removed a pack of cigarettes from Resident #7's room on 01/24/2023. In an interview on 01/24/2023 at 12:30 p.m., S2DON stated any residents identified as an unsafe smoker should not be in possession of any smoking materials. She further stated the ADONs checks every day the unsafe smoker's rooms for smoking materials but does not document their rounds unless there is an issue. Observation on 01/24/2023 at 1:00 p.m., revealed Unsafe Smokers List housed at the three nursing stations in the facility were last printed on 11/10/2022 and were not up to date.

Based on interviews the facility failed to administer its resources effectively and efficiently by failing to: 1. Ensure oxygen cylinders were stored and secured in a manner that prevented the potential for serious harm or injury for 4 residents (Resident #9, Resident #10, Resident #11, and Resident #12) out of the 34 residents that required oxygen as identified on the oxygen Physician Orders List and; 2. Ensure residents who were identified as unsafe smokers did not have access to smoking materials for 3 (Resident #6, Resident #7, and Resident #8) out of 9 unsafe smokers identified on the Unsafe Smoker List. This deficient practice resulted in an Immediate Jeopardy (IJ) on 01/23/2023 when the facility's administration failed to utilize resources to ensure the resident's environment was free of hazards for all residents residing in the facility due to the unsafe storage of unsecured oxygen cylinders, and due to the facilities' administrator failing to ensure the safety of unsafe smokers. On 01/23/2023 at 2:15 p.m, Resident #9 knocked over one large oxygen cylinder in his room, and the large oxygen cylinder's valve opened and oxygen was inadvertently released with a hissing sound. On 01/23/2023 at 2:15 p.m., surveyor was standing with S6Treatment Nurse (TN) outside of Resident #9's room. A crash was heard followed by a hissing sound. S6TN and the surveyor ran into Resident #9's room to find Resident #9 had tangled up his oxygen tubing into his electric scooter wheel, and reversed backward into three large and one small free standing oxygen cylinder next to his bed. Further observation revealed, two large oxygen cylinders and one small oxygen cylinder were knocked over, and one large oxygen cylinder's valve was opened and oxygen was inadvertently released. Resident #9's oxygen tubing was disconnected from oxygen concentrator that he was supposed to be on, and Resident #9's room was cluttered with multiple oxygen cylinders unsecured, oxygen concentrators, multiple cords, and tubing lying on the floor causing the likelihood for the potential for severe harm or injury. On 01/23/2023 at 3:00 p.m., Resident #8 was observed smoking a cigarette in his bed and stated you caught me smoking and extinguished his cigarette in a small bowl on his bedside table. Resident stated that he asked to go outside and smoke, but that staff would never bring him outside, so he smoked in his room. Resident #8 stated that he was not able to get out of bed by himself and transfer to a wheelchair. Resident #8 had a red pack of cigarettes, a purple lighter, and one extinguished cigarette butt at his bedside. This deficient practice had the likelihood to potentially cause serious harm or injury to all 178 residents residing in the facility as identified on the Facility Census List. The Immediate Jeopardy was removed on 01/25/2023 at 2:32 p.m., after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, which included: 1.Corrective actions were taken for the residents (Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #120 by the alleged deficient practice by: Regional Director in-services Administrator on 01/24/2023 on ensuring the safety of unsafe smokers and ensuring oxygen cylinders are secured and properly stored. Facility audit performed on 01/24/2023 and it is noted that there are no unsecured oxygen cylinders improperly stored. Audit also revealed that unsafe smokers had no smoking material in their possession. 2. All residents who reside in the facility have the potential to be affected by the alleged deficient practice. The facility has a census of 178. 3. Measures put in place to ensure the alleged deficient practice will not reoccur are: Regional Director in-serviced Administrator on 01/24/2023 on ensuring the safety of unsafe smokers and ensuring oxygen cylinders are secured and properly stored. Facility audit performed on 01/24/2023 which noted that there are no unsecured oxygen cylinders improperly stored. 4. The facility planned to monitor its performance to ensure solutions are achieved and sustained by: Regional Director or designee will perform quality assurance administration audits 2 times per week to ensure the safety of unsafe smokers and to ensure oxygen cylinders are secure and stored properly. Audits began on 01/25/2023. Rounds will continue until 02/25/2023. 5. Corrective actions will be completed by: The facility plans to have the alleged deficient practice completed by 01/25/2023. Findings: Cross reference F689. On 01/23/2023 at 3:30 pm, S3Corporate Nurse (CN) and S1Administrator were notified that oxygen cylinders were free standing and unsecured in multiple resident's rooms and nurse's station. S3CN and S1Administrator confirmed that oxygen cylinders were not secured and stored properly. S3CN and S1Administrator further stated that staff would perform a facility wide audit to ensure no oxygen cylinders were free standing and unsecured. On 01/23/2023 at 3:30 p.m., S3Corporate Nurse (CN) and S1Administrator were notified that Resident #8 was found smoking in his room. S3CN and S1Administrator confirmed that Resident #8 was an unsafe smoker and should not have access to smoking paraphernalia or be smoking in his room. S3CN and S1Administrator further stated staff would perform a facility wide audit to ensure smoking paraphernalia was stored appropriately. Observation on 01/24/2023 at 11:10 a.m. with S1Administrator, S2DON, S3Corporate Nurse, S13Regional Director, revealed Resident #6, who was an unsafe smoker, in the possession of a lighter and cigarettes In an interview on 01/24/2023 at 11:15 a.m., S1Administrator stated Resident #7, who was an unsafe smoker, did have a pack of cigarettes in his room, and she just had removed a pack of cigarettes from Resident #7's room on 01/24/2023. In an interview on 01/24/2023 at 2:50 p.m., S3Corporate Nurse (CN) stated the facility does not have oxygen safety signs in the designated areas where oxygen cylinders are stored. In an interview on 01/25/2023 at 1:30 p.m., S13Regional Director stated he had in-serviced facility's administrator on ensuring the safety of unsafe smokers and ensuring oxygen cylinders are secured and properly stored. S13Regional Director further stated, S13Regional Director or designee would perform administrative audits 2 times per week to ensure the safety of unsafe smokers and to ensure oxygen cylinders are secure and stored properly. S13Regional Director stated that audits began on 01/25/2023 and would continue until 02/25/2023.

Based on interviews, the facility failed to administer its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to; 1) Ensure the safety of an unsafe smoker (Resident #6) and, 2) Take steps to prevent transmission of COVID-19 by allowing COVID-19 positive staff to work with COVID-19 negative residents before completing Center for Disease Controls (CDC) Return to Work Criteria. This deficient practice resulted in an Immediate Jeopardy (IJ) on 08/03/2022 when the facility's Administrator failed to ensure resources were utilized to ensure the safety of an unsafe smoker and ensure steps were taken to prevent transmission of COVID-19 by allowing COVID-19 positive staff to work with COVID-19 negative residents before completing the CDC Return to Work Criteria. The Immediate Jeopardy was removed on 08/04/2022, after it was determined through interview, and record review, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1) Corrective actions were taken for the residents affected by the alleged deficient practice by: regional director in-serviced administrator on 08/04/2022 on the facility's return to work policy and procedure, regional director in serviced the administrator on 08/03/2022 on ensuring the safety of unsafe smokers and to ensure steps are taken to prevention transmission of COVID-19 by not allowing COVID-19 positive staff to work in the facility, facility audit performed on 08/03/2022 and it is noted that there are no current positive COVID-19 employees currently working in the facility, facility will follow the CDC return to work guidelines for employees who test positive for COVID-19, facility will not allow COVID-19 positive employees to return to work until CDC quarantine guidelines are met. 2) All residents who resident in the facility have the potential to be affected by the alleged deficient practice, the facility has a census of 196. 3) Measures put in place to ensure the alleged deficient practice will not recur are: regional director in serviced administrator on 08/04/2022 on the facility's return to work policy and procedure, regional director in-serviced the administrator on 08/03/2022 on ensuring the safety of unsafe smokers and to ensure steps are taken to prevent transmission of COVID-19 by not allowing COVID-19 positive staff to work in the facility, facility audit performed on 08/03/2022 and it is noted that there are no current positive COVID-19 employees currently working in the facility, facility will follow the CDC return to work guidelines for employees who test positive for COVID-19, facility will not allow COVID-19 positive employees to return to work until CDC quarantine guidelines are met. 4) The facility plans to monitor its performance to ensure solutions are achieved and sustained by: regional director or designee will perform QA audits two times per week to ensure the safety of unsafe smokers and ensure steps are taken to prevent transmission of COVID-19 by not allowing COVID-19 positive staff to work in the facility. 5) Corrective actions will be completed by: the facility plans to have the alleged deficient practice completed by 08/04/2022 Findings: Cross Reference F689 and F880 1. In an interview on 08/02/2022 at 12:55pm, S1Administrator stated the designated smoking area was right outside the door that was located directly across from the time clock and the vending machines. S1Administrator stated no resident at any time should be smoking in the facility, nor should the doors be open when the resident smokes. S1Administrator stated he was not able to be the police at his facility because he does not have enough staff to do that. S1Administrator stated Resident #6 was a problem resident. S1Administrator further stated Resident #6 takes cigarettes from other residents, and he has been an issue for a little while. 2. In an interview on 08/03/2022 at 9:56am, S1Administrator stated the facility was in a staffing shortage crisis and per the facility policy and the Center for Disease Controls Guidance any staff member who was positive for COVID-19 but has no symptoms can return to work without a 5 day isolation period at home, must wear a N95 mask, and sanitize hands. In an interview on 08/03/2022 at 1:13pm, S1Administrator stated the facility's plan for staffing shortage crisis was to use agency staff. S1Administrator stated he has not reported his staffing shortage to anyone except entering it on his Nation Health and Safety Network (NHSN) report which he fills out weekly. S1Administrator stated before using a COVID-19 positive staff member the facility will utilize the department head staff such as the ADONs and the Minimum Data Set (MDS) nurses to fill the shifts. S1Administrator stated there was an on call list for department heads that was used first to fill the shifts of COVID-19 positive staff. S1Administrator further stated he does not have documentation stating where he tried to get an agency staff to work a shift before letting a COVID-19 positive staff member work. S1Administrator further stated the COVID-19 positive staff members were allowed to work in any area of the facility. S1Administrator further stated that they did not let the residents know they were being cared for by a COVID-19 positive staff member. S1Administrator further stated he did not have an official written plan of what the facility does in a staff shortage crisis.

Based on record review and interview, the facility failed to take actions to help prevent the transmission of COVID-19 to 7 random (R1, R2, R3, R4, R5, R8, R9) sampled residents reviewed for COVID-19 infection control. The facility failed to; 1. Ensure staff who test positive for COVID-19 were immediately removed from the facility, and not allowed to work with COVID-19 negative residents; and, 2. Ensure that staff, who tested positive for COVID-19, did not return to work if they did not meet Centers for Disease Control and Prevention (CDC) return to work criteria. The deficinet practice had the likelihood to cause serious harm and/or death of other residents from being infected with COVID-19 due to staff members returning to work before a 5 day isolation at home period This failed practice resulted in an Immediate Jeopardy (IJ) on 08/03/2022 when the provider allowed COVID-19 positive staff to provide care to COVID-19 negative residents. Review of the facility's list of staff members who tested positive for COVID-19 in July 2022 revealed, in part, the following: -On 07/13/2022 S12CertifiedNursingAssistant (CNA) tested positive for COVID-19. Further review revealed S12CNA continued her shift on 07/13/2022 after testing positive for COVID-19 and provided direct care on 07/14/2022, 07/17/2022, and 07/18/2022 before S12CNA completed a 5 day isolation period at home. Further review revealed during those days S12CNA cared for residents on Hall W, Hall Y, and Hall Z. -On 07/14/2022 S9LiccencedPracticalNurse (LPN) tested positive for COVID-19. Further review revealed S9LPN continued her shift on 07/14/2022 after testing positive for COVID-19and provided direct care on 07/15/2022, 7/18/2022, and 07/19/2022 before completing a 5 day isolation period at home. Further review revealed during those days S9LPN cared for residents on Hall X. -On 07/14/2022 S11CNA tested positive for Covid-19. Further review revealed S11CNA continued her shift on 07/14/2022 after testing positive for COVID-19 and provided direct care to residents on 07/15/2022 and 07/16/2022 before completing a 5 day isolation period at home. Further review revealed during those shifts S11CNA cared for residents on Hall X and R5 tested positive for COVID-19 on 07/21/2020. -On 07/20/2022 S13CNA tested positive for COVID-19. Further review revealed S13CNA continued her shift on 07/20/2022 after testing positive for COVID-19 and provided direct care on 07/21/2022, 07/22/2022, 07/23/2022, and 07/24/2022 before completing a 5 day isolation period at home. Further review revealed during those days S13CNA cared for residents on Hall Z. -On 07/21/2022 S8LPN tested positive for COVID-19. Further review revealed S8LPN continued her shift on 07/21/2022 after testing positive for COVID-19 and worked on 07/26/2022 before completing a 5 day isolation period at home. Further review revealed during those days S8LPN cared for residents R1, R2, R3, R4, R5, R8, and R9 who resided on Hall W and Hall X tested positive for COVID-19 between 07/21/2022 through 07/29/2022. -On 07/27/2022 S10LPN tested positive for COVID-19. Further review revealed S10LPN provided direct care on 07/29/2022, 07/30/2022, and 07/31/2022 without completing a 5 day isolation period at home. Further review revealed during those days S10LPN cared for residents on Hall W, Hall X, and Hall Y. The administrator was notified of the Immediate Jeopardy on 08/03/2022 at 5:11 p.m. The Immediate Jeopardy was removed on 08/04/2022 at 3:02 pm, after it was determined through interview, and record review, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1) Corrective actions were taken for the residents affected by the alleged deficient practice by: administrator in serviced staff on 08/04/2022 on the facility's employee return to work policy and procedure; the facility reviewed its employee return to work policy and procedure and it will be updated on an as needed basis; Facility audit performed on 08/03/2022 and it is noted that there are no current positive COVID-19 employees currently working in the facility; facility will follow the CDC return to work guidelines for employees who test positive for COVID-19; facility will not allow covid-19 positive employees to return to work until CDC quarantine guidelines are met. 2) All residents who reside in the facility have the potential to be affected by the alleged deficient practice. The facility has a census of 196. 3) Measures put into place to ensure the alleged deficient practice will not recur are: facility audit performed on 08/03/2022 and it is noted that there are no current positive COVID-19 currently working in the facility; facility will follow the CDC return to work guidelines for employees who test positive for COVID-19; facility will not allow COVID-19 positive employees to return to work until CDC guidelines are met; administrator in serviced on 08/03/2022 by regional director to ensure steps are taken to prevent transmission of COVID-19 by not allowing COVID-19 positive staff to work in the facility 4) The facility plans to monitor its performance to ensure solutions are achieved and sustained by: regional RN or designee will perform QA audits 3 times per week to ensure that there are no current positive COVID-19 employees currently working in the facility 5) Corrective actions will be completed by: the facility plans to have the alleged deficient practice completed by 08/04/2022. The likelihood of serious harm and/or death of other residents from being infected with COVID-19 due to staff members returning to work before a 5 day isolation at home period, no longer existed as of 08/04/2022 at 3:02pm. Findings: Review of the facility's Surveillance: Infection Prevention and Control Program Policy revealed, in part, work restrictions for health care providers with COVID-19 per CDC. Further review revealed staff that test positive for COVID-19 should not to return to work for 5 days after a positive COVID-19 test. Review revealed, in part, during a staffing crisis, per the CDC guidelines there are no staff work restrictions. Review of the facility's list of residents who tested positive for COVID-19 in July 2022 and August 2022 revealed the following: R1 tested positive for COVID-19 on 07/28/2022 and was on isolation precautions from 07/28/2022 through 08/07/2022. R2 tested positive for COVID-19 on 07/28/2022 and was on isolation precautions from 07/28/2022 through 08/07/2022. R3 tested positive for COVID-19 on 07/29/2022 and was on isolation precautions from 07/29/2022 through 08/08/2022. R4 tested positive for COVID-19 on 07/29/2022 and was on isolation precautions from 07/29/2022 through 08/08/2022. R5 tested positive for COVID-19 on 07/21/2022 and was on isolation precautions from 07/21/2022 through 07/31/2022. R8 tested positive for COVID-19 on 07/24/2022 and was on isolation precautions from 07/24/2022 through 08/03/2022. R9 tested positive for COVID-19 on 07/23/2022 and was on isolation precautions from 07/23/2022 through 08/02/2022. In an interview on 08/01/2022 at 2:30pm, S20UnitCoordinator stated if a staff member tests positive for COVID-19 they have to stay out of work for 5 days if they have symptoms. S20UnitCoordinator further stated if a staff member is asymptomatic they can come back to work and must wear an N95. In an interview on 08/02/2022 at 10:20am S3InfectionPreventionist stated if a staff member tests positive for COVID-19 and is asymptomatic they can continue to work but have to wear an N95. S3InfectionPreventionist further stated if a staff member tests positive and is symptomatic the staff member must quarantine for 5 days. In an interview on 08/02/2022 at 3:17pm S4AssistantDirectorofNursing (ADON) stated she tested positive for COVID-19 at the facility on 07/28/2022. S4ADON stated she tested herself and when her result came back positive she told the S3IP and S1Administrator and was sent home. S4ADON stated she stayed home on 07/29/2022, 07/30/2022, and 07/31/2022. S4ADON further stated she returned to work before the end of her 5 day quarantine due to state surveyors entering for a survey. S4ADON further stated when she tested positive for COVID-19 none of her supervisors instructed her on how long she needed to be out of work. In an interview on 08/02/2022 at 3:32pm, S6HumanResources (HR) stated she tested positive for COVID-19 on 07/27/2022 without symptoms. H6HR further stated S3IP and S1Administrator authorized her to stay at work because she did not have any symptoms. In a telephone interview on 08/02/2022 at 3:41pm, S8LPN stated she tested positive for COVID-19 at the facility on 07/21/2022. S8LPN further stated she performed the test herself and when the result was positive she let S3IP know her results. S8LPN further stated she was authorized to stay at work for the rest of her shift with a N95 mask because she did not have any symptoms. S8LPN further stated when she got home that night she started to feel bad and stayed home the next few days. S8LPN further stated she returned to work on 07/26/2022 when she felt better. S8LPN further stated no supervisor gave her direction on how long to stay out of work. In an interview on 08/03/2022 at 9:22am, S3InfectionPreventionist stated there is no one in charge of tracking when positive staff members can return to work and if they completed their 5 day quarantine. S3InfectionPreventionist further stated the facility is in a staffing shortage. In an interview on 08/03/2022 at 9:46am, S2CoorporateQINurse (CQIN) stated if a staff member tests positive for COVID-19 and does not have any symptoms they are able to continue working but must wear an N95 mask the whole shift. S2CQIN stated the facility policy states when the facility is in a staff shortage crisis a positive staff member can work without symptoms and must wear a N95 mask. S2CQIN stated the facility has been in a staffing crisis for a month or more. S2CQIN further stated the interventions put into place by the facility to address the staffing shortage is using agency staff and shift incentives. In an interview on 08/03/2022 at 9:56am, S1Administrator stated the facility is in a staff shortage crisis and per the facility policy any staff member who is positive for COVID-19 but has no symptoms can return to work without a 5 day quarantine and must wear a N95 mask and sanitize hands. S1Administrator further stated due to the staffing shortage crisis the facility has used agency to staff to cover the shifts. S1Administrator further stated the facility continued to take in new admits throughout the staffing shortage crisis. Review of the CDC Strategies to Mitigate Healthcare Personnel Staffing Shortages which was updated on 01/21/2022 revealed, in part, the following must be completed prior to utilizing COVID-19 positive staff members to work with COVID-19 negative residents: -Healthcare facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate these shortages; -Healthcare facilities should inform patients and healthcare providers when the facility is utilizing these strategies; -Communicate with local healthcare coalitions and federal, state and local public health partners; -Adjust staff schedules; -Hire additional healthcare providers; and, -Rotate healthcare providers to positions that support patient care activities, and cancel all non-essential procedures. In an interview on 08/03/2022 at 1:13pm, S1Administrator stated the facility's plan for staffing shortage crisis was to use agency staff. S1Administrator stated he has not reported his staffing shortage to anyone except entering it on his Nation Health and Safety Network (NHSN) report he fills out weekly. S1Administrator stated before using a COVID-19 positive staff member the facility will utilize the department head staff such as the ADONs and the Minimum Data Set (MDS) nurses to fill the shifts. S1Administrator stated there was an on call list for department heads that was used first to fill the shifts of COVID-19 positive staff. S1Administrator further stated he does not have documentation stating where he tried to get an agency staff to work a shift before allowing a COVID-19 positive staff member work. S1Administrator further stated the COVID-19 positive staff members are allowed to work in any area of the facility. S1Administrator further stated that we did not let the COVID-19 negative residents know they were being cared for by a COVID-19 positive staff member. S1Administrator further stated he does not have an official written plan of what the facility does in a staff shortage crisis. In an interview on 08/03/2022 at 1:15pm, the S1Administrator confirmed that they were deficient on hours for 07/17/2022 for -24.60 hours. In an interview on 08/03/2022 at 1:36pm, S14MDSCoordinator (MDSC) stated she was not on an on call schedule to cover COVID-19 positive staff's shifts and was not asked to cover shifts for COVID-19 positive staff. In an interview on 08/03/2022 at 1:36pm, S15MDSC stated she was not on an on call schedule to cover COVID-19 positive staff member's shifts. In an interview on 08/03/2022 at 1:37pm, S16MDSC stated she was not on an on call schedule to cover COVID-19 positive staff member's shifts and was not pulled to cover shifts for COVID-19 positive staff. In a telephone interview on 08/03/2022 at 4:41pm, S10LPN stated she tested positive for COVID-19 at home on 07/27/2022. S10LPN stated she informed the facility of her positive test and was not informed of how long to stay out of work. S10LPN further stated she was not told she could not be at work upon returning 07/29/2022.

Based on interview and record review, the facility failed to ensure the Infection Preventionist maintained infection control measures to track and enforce the Center for Disease Control (CDC) Return to Work Criteria for COVID-19 positive staff members. This deficient practice resulted in an Immediate Jeopardy (IJ) on 08/03/2022 at 5:11pm when the facility failed to ensure the designated Infection Preventionist was performing ongoing involvement, oversight, monitoring and supervision of the facility's tracking and enforcing of the CDC Return to Work Criteria for COVID-19 positive staff members which resulted in 7 COVID-19 negative residents testing positive for COVID-19 after exposure to the COVID-19 positive staff member. The Immediate Jeopardy was removed on 08/04/2022 at 3:02 pm, after it was determined through interview, and record review, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: 1) Corrective actions were taken for the residents affected by the alleged deficient practice by: Facility audit performed on 08/03/2022 and it is noted that there are no current positive COVID-19 employees currently working in the facility, the facility reviewed the return to work policy for employees and will make updates as needed, regional RN in-serviced infection Preventionist on 08/04/2022 on the facility's return to work policy and procedure, regional RN in serviced infection Preventionist on ensuring the infection prevention and control program is maintained by not allowing COVID-19 positive staff to work in the facility, facility will following the CDC return to work guidelines for employees who test positive for COVID-19, facility will not allow COVID-19 employees to return to work until CDC quarantine guidelines are met. 2) All residents who resident in the facility have the potential to be affected by the alleged deficient practice, the facility has a census of 196. 3) Measures put in place to ensure the alleged deficient practice will not recur are: regional RN in serviced Infection Preventionist on ensuring the infection prevention and control program is maintained by not allowing COVID-19 positive staff to work in the facility, facility audit performed on 08/03/2022 and is noted that there are no current positive COVID-19 employees currently working in the facility, facility will follow the CDC return to work guidelines for employees who test positive for COVID-19, facility will not allow COVID-19 positive employees to return to work until CDC quarantine guidelines are met. 4) The facility plans to monitor its performance to ensure solutions are achieved and sustained by: regional RN or designee will perform QA audits two times per week to ensure the infection prevention and control program is established and maintained by not allowing COVID-19 positive employees work in the facility. 5) Corrective actions will be completed by: the facility plans to have the alleged deficient practice completed by 08/04/2022 Findings: Cross Reference F880 and F835 In an interview on 08/02/2022 at 10:20am S3Infection Preventionist (IP) stated if a staff member tests positive for COVID-19 and was asymptomatic they can continue to work but have to wear an N95 mask. S3IP further stated if a staff member tests positive and was symptomatic the staff member must complete a 5 day isolation period at home before returning to the facility. In an interview on 08/03/2022 at 9:22am, S3IP stated there is no one in charge of tracking when the positive staff members can return to work and if they completed their 5 day isolation period at home. In an interview on 08/04/2022 at 10:17am, S2Coorporate Quality Improvement Nurse confirmed that this was a deficient practice of not tracking and enforcing of the CDC Return to Work Criteria for COVID-19 positive staff members.

Based on record reviews, interviews, and observations, the facility failed to: 1. Ensure a resident (Resident #6), with a known history of unsafe smoking, with moderate cognitive impairment, was supervised while smoking; and, 2. Ensure residents who were identified as unsafe smokers, did not have access to smoking materials and were supervised while smoking for 1 (Resident #6) out of 5 (Resident #6, #7, #8, #9, and #10) unsafe smokers reviewed for safe smoking. The facility noted 8 residents that were unsafe smokers. The deficient practice resulted in an Immediate Jeopardy situation for Resident #6 on 08/02/2022 at 11:00am when Resident #6 was sitting in his wheelchair in the doorway of the hall W day room, with the door open, smoking a cigarette without facility staff providing supervision. Resident #6 was observed smoking with visible ashes noted falling to Resident #6's green shirt, pants, and blue wheelchair cushion. Further observation of Resident #6 revealed, two round pencil size holes with brown edges to the left upper corner of his blue wheelchair cushion. The deficient practice has the likelihood to cause serious harm to the remaining 7 residents identified as unsafe smokers by the facility. Observation on 08/02/2022 at 4:36pm revealed Resident #6 entered the smoking area through the hall W room entrance door. Observation revealed, Resident #6 exchanging money with an unidentified resident. Observation revealed Resident #6 then received a half a pack of cigarettes in red packaging. Observation revealed Resident #6 reached over with the cigarette in his mouth. Observation revealed an unidentified resident then lit Resident #6's cigarette with a lighter. Observation revealed Resident #6 began to smoke unsupervised. Observation revealed Resident #6 had both hands shaking while holding the cigarette and smoking. Observation further revealed Resident #6 was dropping ashes on his green shirt and blue and red plaid pants. S1Administrator was notified of the Immediate Jeopardy on 08/02/2022 at 4:15pm. The Immediate Jeopardy was removed on 08/04/2022 at 3:15pm, after it was determined through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit, which included: There are a total of 8 residents who have the potential to be affected by this alleged practice. 08/02/2022 at 5:00pm- Resident #6 was placed on one to one supervision until 08/05/2022. After 08/05/2022 the resident will be supervised along with the other smokers by the smoking supervisors. 08/02/2022 at 4:00pm- Staff development nurse in-services all smokers on not sharing smoking materials with other residents. 08/03/2022 at 7:00am- A nurse/designated employee was put in place to monitor smokers daily on the day shift, evening shift, and night shift in the designated smoking area. Day shift and evening shift will not have scheduled smoking times. From 10:00pm-6:00am, scheduled smoking times for unsafe smokers will be 11:00pm and 1:00am. 08/03/2022 at 8:00am- Director of Nursing (DON) or designee initiated an all staff in-service on the following that will be completed by 08/07/2022: The facility's smoking policy and procedure; All unsafe smokers must be supervised while smoking; All smoking materials of unsafe smokers will be kept on the nurse's medication cart; A list of unsafe smokers will be placed in a binder at each nurses station and will be updated as appropriate by the Minimal Data Set (MDS) department so that staff is aware of the unsafe smokers; MDS department in-serviced on completing a smoking assessment on all smokers at least quarterly and as appropriate. MDS department to update unsafe smokers list when changes are made and replace each list at all nurses stations. 08/03/2022 at 8:00am-Nursing Facility Administrator (NFA) or designee to spot check unsafe smokers weekly to ensure they are being supervised appropriately. 08/03/2022 at 8:00am-Director of Nursing (DON) or designee to spot check unsafe smokers list at each nurse's station to ensure compliance. The likelihood of serious harm to resident #6 and the other 7 residents no longer existed after 08/02/2022 at 5:00pm. Findings: Review of the facility's Smoking Policy and Procedure revealed, in part, safe smoking assessment and/or Interdisciplinary (ID) Team will determine if resident is safe to smoke. Residents deemed unsafe will be discussed with ID Team to determine protocol to be implemented on individual basis (ex. smoking apron needed, cigarettes stored at nurses station, lighter removed from resident from resident possession, direct supervision needed, etc.). Safe smoking assessments will be completed on residents who smoke upon admission, re-smoking assessments will be completed on residents who smoke upon admission, readmission, quarterly, annually, significant changes, and as needed. Further review revealed no documented evidence for the protocol of when direct supervision was required for unsafe smokers. Resident #6 Review of Resident #6's face sheet revealed, in part, Resident #6 was admitted to the facility on [DATE] with diagnoses that included: [CONDITION(S)], Lack of Coordination, Extrapyramidal and Movement Disorder, [CONDITION(S)], [CONDITION(S)] of the Left Eye Review of Resident #6's MDS with an assessment reference date of 05/11/2022 revealed, in part, Resident #6's Brief Interview for Mental status Score was an 8. Resident #6 had moderate cognitive impairment. Review of Resident #6's Comprehensive Care Plan revealed, in part, Resident #6 may be at risk for potential for injury related to his smoking habit and on 05/11/2022 Resident #6 was an unsafe smoker. Further review revealed Resident #6 should smoke in designated smoke areas, be instructed on safe smoking measures, may need his cigarettes and lighter given to him by staff when Resident #6 needs to smoke. Resident #6 may need supervision when he smokes and he may need his room searched for cigarettes, lighters, and/or ashes. Review of Resident #6's assessment for safe smoking date of completion: 05/09/2022 revealed, in part, Resident #6 was an unsafe smoker. Review of this assessment revealed Resident #6 has a history of smoking and has been considered an unsafe smoker since an episode of smoking in his room. Review of this assessment revealed Resident #6 was aware that he was considered an unsafe smoker and if the resident wanted to smoke he must do so at the supervised smoking sessions. Further review of this assessment revealed Resident #6 had [CONDITION(S)] reported on his clothing. Observation on 08/02/2022 at 11:00am revealed Resident #6 was noted sitting in his wheelchair in the doorway of the hall W day room, with the door open, smoking a cigarette without facility staff providing any direct supervision. Resident #6 observed smoking and visible ashes were noted falling to Resident #6's green shirt, pants, and blue wheelchair cushion. Observation revealed Resident #6 had both hands shaking while holding the cigarette and smoking. Further observation of Resident #6 revealed, two round pencil size bun holes to the wheelchair cushion. In an interview on 08/02/2022 at 11:10am, Resident #6 stated he smokes without supervision. Resident #6 further stated he keeps his own lighter and cigarettes. In an interview on 08/02/2022 at 12:08pm, S22Licensed Practical Nurse (LPN) stated Resident #6 goes out to the smoking area to smoke by himself because he is not an unsafe smoker. S22LPN stated Resident #6's cigarettes are kept on the cart and when Resident #6 is ready to smoke S22LPN gives Resident #6 his cigarettes and lighter, and Resident #6 goes outside to the patio and smokes without supervision. S22LPN stated Resident #6 did not need to be supervised during smoking sessions. S22 LPN further stated Resident #6 often will keep his lighter or get a lighter from other residents. In an interview on 08/02/2022 at 12:11pm, S21Certified Nursing Assistant (CNA) stated she has been working at the facility approximately 5 months and she is familiar with Resident #6. S21CNA stated Resident #6 goes out to the smoking area to smoke frequently throughout the day. S21CNA stated Resident #6 smokes unsupervised and Resident #6 does not have to wear a protective garment or be in a supervised smoking area. S21CNA further stated no education was provided to her regarding Resident #6 being an unsafe smoker. Observation on 08/02/2022 at 12:15pm, revealed a red lighter with a black top lying on Resident #6's roommate's bed. S22LPN removed the lighter and acknowledged it was for Resident #6. S22LPN further stated sometimes he will keep his lighter on his person after smoking. Observation on 08/02/2022 at 12:20pm, revealed S21CNA and S23CNA Supervisor inspecting Resident #6's clothing. Observation revealed a pair of blue pajama pants noted with a dime size hole with brown and white edges to the left front thigh area. Observation revealed light and dark grey powder like substance noted on the floor directly under Resident #6's bedside table located on the left side of Resident #6's bed. In an interview on 08/02/2022 at 12:22pm, S23CNA Supervisor stated the light and dark grey substance is ashes. She further stated it may have fell off of Resident #6's clothes because Resident #6 frequently has ashes on his clothes after smoking. In an interview on 08/02/2022 at 12:30pm, S23CNA Supervisor stated the activities department and S24Restorative CNA and S25Restorative CNA assist in supervising unsafe smokers. In an interview on 08/02/2022 at 12:40pm, S25Restorative CNA stated restorative CNA's do not supervise unsafe smokers. S25Restorative CNA stated the restorative CNA's job was to give fluids to the residents in the smoking area. S25Restorative CNA stated supervising a resident who was an unsafe smoker is the responsibility of the CNA assigned to the resident. In an interview on 08/02/2022 at 12:41pm, S24Restorative CNA stated Resident #6 does not require supervision with smoking. S24Restorative CNA stated Resident #6 is able to wheel himself around in his wheelchair and take himself out to smoke. S24Restorative CNA further stated Resident #6 does not require staff be present during smoking sessions. In an interview on 08/02/2022 at 12:43pm, S26Recreational Director stated the activities department does not oversee unsafe smokers. In an interview on 08/02/2022 at 12:45pm, S2Corporate Quality Improvement Nurse (CQIN) stated Resident #6 should be smoking in the designated smoking area across from the time clock near the administrative offices because that area has high traffic. S2CQIN Nurse further stated this was the area where the residents smoke because staff are frequently in the area. S2Corporate QI Nurse further stated the facility does not have assigned smoking times, designated personnel, or a binder to maintain unsafe smokers. In an interview on 08/02/2022 at 12:55pm, S1Administrator stated the designated smoking area was right outside the door that was located directly across from the time clock and the vending machines. S1Administrator stated no resident at any time should be smoking in the facility, nor should the doors be open when the resident is smoking. S1Administrator stated he was not able to be the police at his facility because he does not have enough staff to do that. S1Administrator stated Resident #6 was a problem resident. S1Administrator further stated Resident #6 takes cigarettes from other residents, and he has been an issue for a little while. In an interview on 8/2/2022 at 2:30pm S32Social Services Director stated she and her partner, the other social worker, are both new to the facility and were never informed of a smokers list, an unsafe smokers list, or how social services played a role in the process. S32 further stated she has not done anything with the smokers since working here. Observation on 08/02/2022 at 3:17pm revealed Resident #6 sitting in his wheelchair right outside of the hall W day room door, smoking a cigarette without facility staff providing supervision. Resident #6 was observed smoking and visible ashes were noted falling to Resident #6's red and blue plaid pajama pants on both the right and left thigh area. In an interview on 08/03/2022 at 9:18am, S16MDS Coordinator, LPN stated a resident who was designated an unsafe smoker should have a staff member present with them any time they are smoking. S16MDS Coordinator, LPN stated Resident #6 was an unsafe smoker and should have staff providing direct supervision when he was smoking. S16MDS Coordinator, LPN stated Resident #6 should not be allowed to have smoking materials at any time. S16MDS Coordinator, LPN stated the nurse on the hall should keep his smoking material and then directly hand it to the staff member taking him to smoke. S16MDS Coordinator, LPN stated the MDS department never received a report from staff that Resident #6 was borrowing, buying, or taking cigarettes and/or lighters from other residents or being noncompliant with unsafe smoking procedures. S16MDS Coordinator, LPN further stated when Resident #6 became an unsafe smoker all department heads were notified of Resident #6's smoking status and the interventions put into place. In an interview on 08/04/2022 at 9:30am, S30CNA stated she was in the day room, but she was not supervising Resident #6 on 08/02/2022. S30CNA stated she did not know who Resident #6 was and she did not do anything with smoking residents or residents who need to be supervised when smoking. S30CNA further stated she has never been trained on any of the unsafe smoking procedures prior to today when an in-service was presented. In an interview on 08/04/2022 at 10:24am, S2CQIN stated S1Administrator and himself watched the facility camera footage. S2CQIN stated Resident #6 was sitting in the doorway with half of his wheelchair in the facility while the door to the facility was open. S2CQIN stated no staff intervened at any point and they should have.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician and Responsible Party of a significant change in a resident's condition for 2 (Resident #1 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for a change in condition. This deficient practice resulted in actual harm for Resident #5 when the facility failed to notify the physician when a cognitively impaired resident had a deteriorating venous wound, new wounds, and not being able to obtain a urine specimen as ordered. The facility further failed to ensure nursing staff promptly notified the physician when Resident #5 was found to be lethargic, short of breath with an oxygen saturation of 69%. Resident #5 was admitted to the Intensive Care Unit (ICU) and diagnosed with [REDACTED]. Resident #5 was estimated to have a 9.4 Liter free water deficit. This deficient practice resulted in actual harm for Resident #1 when the facility failed to promptly notify they physician after he developed [MEDICAL CONDITION] to his lower extremities and three Stage 2 pressure ulcers to his mid-back area. The facility further failed to notify the physician when a physically impaired resident (Resident #1) with an indwelling foley catheter was noted with yellow discharge coming from his penis, had sediment in his urine, slurred speech, and had his medications held. The resident's physician was not immediately notified of these changes. On 12/26/16 at 06:24pm, Resident #1 had a change in mental status described as confusion, head turned to one side, slurred speech, and labored breathing. Resident #1 was sent to the hospital and diagnosed with [REDACTED]. Resident #1 was admitted to the Intensive Care Unit (ICU) and during this hospitalization , Resident #1 was placed on a ventilator. Findings: Resident #5 Review of Resident #5's clinical record revealed in part, that he was admitted to the facility on [DATE], was identified as being at risk for pressure ulcer development, urinary tract infections, and dehydration. Further review revealed he had the following diagnoses, in part: Mental [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] [MEDICAL CONDITION], History of [MEDICAL CONDITION], [DIAGNOSES REDACTED], Protein-Calorie Malnutrition, [MEDICAL CONDITION], Pressure and Venous Ulcers, Vitamin Deficiency, and a History of Dehydration, Urinary Tract Infections and Bacteremia. Review of Resident #5's Quarterly Minimum Data Set (MDS) with a reference date of 10/04/16, revealed in part that he was severely cognitively impaired, had no behavior problems, required extensive physical assistance of one Certified Nursing Assistant (CNA) with dressing, eating, and hygiene, and required extensive physical assistance of two CNAs with toilet use, bed mobility, and transfers. Further review revealed Resident #5 was incontinent of bowel and bladder, and was totally dependent on staff for bathing. Review of Resident #5's Care Plan revealed in part that a plan of care was developed for his impaired skin integrity which included to observe his skin when providing routine care and to monitor for changes in my skin status that may indicate worsening of my wound and notify Resident #5's Physician. A plan of care for Resident #5's [MEDICAL CONDITIONS] was developed which included that nursing staff were to monitor Resident #5's intake and output and to notify the Physician of [MEDICAL CONDITION]. A plan of care was also developed for Resident #5 for requiring extensive to total assistance from staff with his daily needs which included to assist with bed mobility, transfers, and feeding and that the registered dietician was to evaluate my diet as appropriate. Resident #5's Care Plan also revealed that Resident #5 was at risk for infection related to his incontinence and that Resident #5's labs were to be done as ordered by the physician, that fluids should be encouraged, and that the Physician was to be notified of any significant changes. Resident #5 Care Plan further revealed that a plan of care was developed for his urine incontinence with interventions to include observing Resident #5's skin daily for irritation and redness, and to evaluate Resident #5's fluid intake and hydration status. Review of Resident #5's Admission Wound Assessment Report conducted upon admission to the facility on [DATE] revealed in part, that he had [MEDICAL CONDITION] of the right lower extremity, infection, and [MEDICAL CONDITION] reaction due to internal fixation device. Further review revealed Resident #5 was admitted to the facility with a left lateral lower superior leg wound measuring 9.5centimeters (cm) x 4cm x 0.3cm with a 90% red 10% yellow wound bed with a small amount of bloody drainage and a 0.2cm macerated periwound area and no signs or symptoms of infection. A left lateral inferior lower leg wound measuring 5.5cm x 3cm x 0.3cm with a 100% red wound bed, small bloody wound drainage, and no signs or symptoms of infection. A right heel unstageable wound measuring 1.2cm x 3.3cm with a blackish brown color with a mushy intact skin texture, and no signs or symptoms of infection. Resident #5 also had a left upper inner gluteal Stage 2 pressure ulcer measuring 3.5cm x 3cm with 100% red wound bed and no signs or symptoms of infection. A left lateral ankle scar measuring 1cm x 1cm dark area at the medial aspect which could be a possible Suspected Deep Tissue Injury (SDTI) which will be monitored, and a right great toe SDTI measuring 1.3cm x 1.1cm black in color with no signs or symptoms of infection. Review of Resident #5's Wound Assessment Report dated 11/22/16 revealed in part, that a new unstageable pressure ulcer due to suspected deep tissue injury developed on Resident #5's left lateral malleolus that was not present upon admission which measured 4cm x 4cm. Further review revealed no documented evidence that the above mentioned wound had any signs or symptoms of infection and the wound bed and wound drainage documentation was blank. Further review revealed the Physician was notified of this wound on 11/23/16. Review of Resident #5's wound narrative notes for 11/22/16 revealed in part, that Resident #5's left malleolus and right heel had a new SDTI onset with both wounds having a dark red, soft and boggy wound bed with flat wound edges and soft and dark periwound areas with a small amount of sanguineous drainage seen on the gauze and inside of the sock. Further review revealed Resident #5's wounds had no signs or symptoms of infection and a sign at the head of the bed reminded staff and family members to keep boots on at all times. Review of #5's Wound Assessment Report dated 11/23/16 revealed in part, that Resident #5's venous ulcer to his left lateral upper and lower shin had deteriorated. Further review revealed the wound bed was 50% [MEDICATION NAME] tissue and 50% slough with normal surrounding skin and measured 2cm x 1cm x 0.10cm. The above mentioned wound documentation further revealed the venous ulcer had small sanguineous drainage and no signs or symptoms of infection. There was no documented evidence that Resident #5's Physician was notified of Resident #5's venous ulcer deterioration. Review of Resident #5's Departmental Notes dated 11/24/16 at 3:12pm, revealed in part, that Resident #5 had blood tinged urine at which time the Physician was notified with an order to catheterize Resident #5 to obtain a specimen for a urinary analysis (UA) with culture and sensitivity and give Bactrim DS (antibiotic medication used to treat infection) every 12 hours for seven days. There was no documented evidence and the facility did not present any documented evidence that a urine specimen was obtained as ordered or that Resident #5's Physician was notified that a urine specimen could not be obtained on 11/24/16 or on 11/25/16. Review of Resident #5's Department Notes dated 11/26/16 at 6:12am, revealed a second attempt to retrieve a urine specimen via in and out catheter was unsuccessful due to possible trauma as indicated by light active bleeding from the meatus which stopped after five minutes. Further review revealed Resident #5 showed no signs of pain or discomfort from the resident, and will report to on-coming nurse. There was no documented evidence and the facility did not present any documented evidence that a urine specimen was obtained as ordered or that Resident #5's Physician was notified of possible trauma or that a urine specimen could not be obtained on 11/26/16. Review of Resident #5's Departmental Notes dated 11/26/16 at 10:44am, revealed S7/LPN found Resident #5 unresponsive, with labored breathing and an oxygen saturation of 69%, a blood pressure of 89/43, a pulse of 112 beats per minute, 16 respirations per minute, and a temperature of 99.5*Fahrenheit. Further review revealed Resident #5's Physician was notified with an order to send Resident #5 to the hospital emergency room for evaluation. Review of Resident #5's hospital records revealed in part that he was seen in the emergency roiagnom on [DATE] at 11:32am, because of a change in mental status. Review of Resident #5's emergency department physical exam revealed a blood pressure of 153/128, a pulse of 136 beats per minute, a temperature of 101.5*Fahrenheit, and an oxygen saturation of 88%. Further review revealed Resident #5 was mildly sweating and had dry mucous membranes with white plaques noted to the back of the mouth, was moaning, had right sided rhonchi, a sacral ulcer to the left buttock without purulent drainage or surrounding redness, and a 3cm deep right heel ulcer with purulent, foul smelling drainage, left ankle ulcer with exposed hardware, and an ulcer to the lateral aspect of the left lower leg. Further review revealed Resident #5 was referred to podiatry because of his right heel ulcer and exposed hardware to the left ankle. Review of Resident #5's physical exam of his wounds performed by a Podiatrist revealed in part, that Resident #5 had an infected left lateral malleolus malodorous ulcer with serosanguineous drainage with exposed hardware which consisted of a plate and screw. Resident #5 also had a left lateral fibula ulcer which was proximal to the malleolus ulcer which had exposed fibular bone. Resident #5's exam further revealed Resident #5 also had an infected right posterior heel ulcer with a pungent odor, drainage, and exposed bone. Further review revealed that critical care was necessary to treat or prevent imminent or life-threatening deterioration [MEDICAL CONDITION] and right heel debridement. In interview on 12/14/16 at 10:00am, S7/LPN indicated Resident #5 was totally dependent on staff for water and that he could not hold a cup or get and drink anything independently. S7/LPN further indicated Saturday morning on 11/26/16 at 07:00am, she received a report from S23/LPN a urine specimen could not be obtained on Resident #5. S7/LPN further indicated while she was doing her 8:00am medication pass, which was done between 7:00am to 9:00am, she noticed that Resident #5 did not ask for water like he usually did. Resident #5 was lethargic, unresponsive, looked clammy, had a temperature, had labored breathing, and had an oxygen saturation of 69%. S7/LPN verified that she called Resident #5's Physician at around 10:45am, and was given an order to send Resident #5 to the hospital emergency room (ER) for an evaluation. S7/LPN was then asked why she didn't notify Resident #5's Physician earlier and S7/LPN indicated that she had a lot going on that day and had to get everything situated. There was no documented evidence and the facility did not present any documented evidence that Resident #5's Physician was notified of and/or Resident #5 being assessed as having an ulcer to buttock, or an ulcer with exposed bone, hardware, wound deterioration and/or foul smelling drainage. In interview on 12/14/16 at 1:50pm, S4/RN Treatment Nurse indicated Resident #5 did not have any breakdowns to his buttocks, only had ulcers on his shin, malleolus and his heel. Wounds were treated daily as ordered, with no changes since Resident #5's assessment conducted on 11/22/16 and 11/23/16. In interview on 12/14/16 at 2:30pm, S1/Administrator, S2/DON, and S3/Quality Assurance (QA)/Quality Improvement (QI) Nurse were informed of the above findings and were asked if they wanted to present anything to the surveyors to dispute the above mentioned findings and S3/QA/QI Nurse further indicated that as far as they knew, Resident #5 did not have a sacral ulcer, and that there have been changes in staff and they were in a transition; S1/Administrator offered no response. Resident #1: Review of Resident #1's clinical record revealed, in part, that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed Resident #1 had an indwelling foley catheter. Review of Resident #1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/16 revealed, in part, he was incontinent of bowel and bladder, had functional limitation in range of motion to upper and lower extremities, required extensive assistance of two Certified Nursing Assistants (CNAs) with bed mobility, transfers, toilet use, and totally dependent on staff for personal hygiene and bathing. Further review revealed Resident #1 was assessed for having one Stage 2 pressure ulcer which was present on admission, and Moisture Associated Skin Damage. Documentation did not reflect that Resident #1 had an infection of the foot, [MEDICAL CONDITION], and/or purulent drainage. Review of Resident #1's record revealed, in part, that a Care Plan was developed for urinary incontinence with approaches which included, in part, assist me with perineal cleaning as needed, observe me for behavioral changes that may indicate a Urinary Tract Infection, and evaluate my fluid intake and hydration status. A Care Plan was also developed for cognitive loss related to Stroke, with approaches which included, in part, report any changes to my Physician. Further review of Resident #1's record revealed a Care Plan was developed for multiple medications and approaches which included, in part, administer my medications as ordered and report significant changes to my Physician. Further review of Resident #1's Care Plan revealed in part, problem addressed with skin integrity to sacrum; gluteal cleft with Stage II pressure ulcer to gluteal cleft. Review of Progress Notes dated 12/05/16 and documented by S13/Licensed Practical Nurse (LPN) revealed a skin assessment was completed and Resident#1 was noted to have three blisters along the left side of his abdomen, two of which were open. Review of the progress note revealed the wound care nurse was informed and the dressing was clean, dry and intact to site. There was no documentation that the physician and responsible party were notified. Review of Resident #1's Wound Assessment Notes from 11/18/16 through 12/13/16 revealed discussion of a Stage 2 pressure ulcer to the right buttock only. There was no mention of [MEDICAL CONDITION] and blisters to both lower legs, nor was there mention of any dressings to Resident #1's leg or mid/lateral trunk. An observation was made on 12/09/16 at 10:40am of Resident #1 with S15/LPN. Resident#1 was noted to have a large reddened area to both anterior legs. Legs appeared to be [MEDICAL CONDITION]. Also noted were some blisters on the inflamed areas to the legs. Also noted were two 4x4 dressings to left mid back/side area. The dressings were not initialed and dated but had 4 J written on one of the dressings. The dressings were soiled with what appeared to be old drainage. In interview at this time, S15/LPN explained that Resident #1's dressings were from a past pain pump insertion site. Observation revealed Resident #1 had a Stage 2 pressure ulcer to the right buttock and a Stage 2 to the right buttock crease. Observation on 12/09/16 at 12:10pm revealed S4/Registered Nurse (RN) Treatment Nurse performed a skin assessment on Resident #1. When Resident #1's reddened, [MEDICAL CONDITION] and blistered legs were pointed out by the surveyor, S4/RN Treatment Nurse stated Resident #1 had [MEDICAL CONDITION] off and on. S4/RN Treatment Nurse was unaware of the blisters and the extent of the [MEDICAL CONDITION] to Resident #1's legs. S4/RN Treatment Nurse confirmed there was no treatment ordered for Resident #1's leg blisters. S4/RN Treatment Nurse was shown the two dressings on Resident #1's left mid-back. S4/RN Treatment Nurse confirmed that she did not know how long the dressings were there, nor what was under the dressings. The two dressings to left mid-back area were removed by S4/RN Treatment Nurse which revealed three Stage 2 open areas. S4/RN Treatment Nurse stated that she had no knowledge of the dressings and that any changes in wounds and skin condition should be reported to her by the assistant treatment nurse. In interview on 12/09/16 at 2:23pm S9/CNA stated she observed Resident #1 had boils on his left mid back where the dressings were. S9/CNA stated Resident #1 had the dressings when he returned from a doctor's visit, but she did not remember exactly when, but that it was a while ago. S9/CNA indicated she reported this to the nurse as she reports everything unusual about her residents. S9/CNA also disclosed that the nurses knew about the [MEDICAL CONDITION] on the resident's legs and stated everybody knew. Review of Resident #1's Departmental Notes dated 12/09/16 at 3:10pm, revealed Resident #1's Physician was notified of his bilateral lower extremities at which time an order was given to consult with wound care and an order was written for [MEDICATION NAME] 100mg (an antibiotic used to treat infection) was ordered twice a day for ten days for [MEDICAL CONDITION]. In interview on 12/13/16 at 12:20pm S4/RN Treatment Nurse indicated that the three open areas to Resident #1's left lateral/side were reported to S6/RN part time wound care nurse by S13/LPN. S4/RN Treatment Nurse indicated the condition of Resident #1's legs and three open areas to his left lateral side were not reported to S4/RN Treatment Nurse or to the physician. In a telephone interview on 12/13/16 at 12:36pm, S13/LPN indicated she was informed of Resident #1's blisters to his back area by the CNA. S13/LPN stated she reported the two open areas to the wound care nurse who dressed it. S13/LPN did not confirm that it was reported to the physician. In interview on 12/14/16 at 2:20pm S1/Administrator, S2/RN Director of Nursing (DON), and S3/RN Quality Assurance/Quality Improvement Nurse acknowledged staff should have identified and addressed [MEDICAL CONDITION] to Resident #1's leg and pressure ulcers to Resident#1's back, and the physician and Resident #1's responsible party should have been informed of the changes. Review of Resident #1's Nurse's Notes entry dated 12/25/16 at 11:15pm revealed Resident #1 was noted with a yellow discharge coming from his penis and sediment in his urine, and the nurse faxed Resident #1's change in condition to the doctor's office on 12/26/16 at 11:15pm. Review of a fax to a physician's office dated 12/26/16 at 2:29am revealed Resident #1 was noted with a cup and bottle with alcohol, speech slurred, red eyes, a yellow discharge from his penis, and sediment in his urine. Further review revealed the nurse withheld his medications. There was no documented evidence and the facility did not present any documented evidence that Resident #1's Physician was called at this time, that anyone responded that they received the fax at that time, or that Resident #1's Physician reviewed the above mentioned fax at that time. Review of Resident #1's Nurse's Notes entry dated 12/26/16 at 7:40am revealed, in part, an empty bottle of whiskey was found in Resident #1's room, and Resident #1 cried most of the shift and even called 911 twice. Review of Resident #1's December 2016 electronic Medication Administration Record [REDACTED] 2:00pm: [MEDICATION NAME] 10milligrams (mg) by mouth every 8 hours (a muscle relaxant); 05:00pm: Prostat 30milliliters (ml) by mouth twice daily (a protein supplement used to aid in wound healing); Potassium Chloride ER 10millliequivalent (meq) by mouth twice daily (a supplement used to treat low levels of potassium in the blood); [MEDICATION NAME] 300mg by mouth every evening (an antacid); and [MEDICATION NAME] 300mg by mouth three times a day (an anti-[MEDICAL CONDITION] medication, also used for nerve pain); 09:00pm: Tamsulosin [MEDICATION NAME] 0.4mg by mouth at bedtime (a medication used to treat the symptoms of [MEDICAL CONDITION] which is defined as prostate gland enlargement which can block the flow of urine out of the bladder and cause bladder, urinary tract or kidney problems); and 10:00pm: [MEDICATION NAME] 10mg by mouth every 8 hours (a muscle relaxant). Further review of Resident #1's December 2016 eMAR revealed the following medications were withheld on 12/26/16 at: 05:00pm: Potassium Chloride ER 10meq by mouth twice daily; Prostat 30ml by mouth twice daily; and [MEDICATION NAME] 300mg by mouth every evening. There was no documented evidence and the facility provided no documented evidence that Resident #1's Physician was notified of withheld medications. Review of Resident #1's Nurse's Notes entry dated 12/26/16 at 6:24pm revealed Resident #1 had a change in mental status described as confusion, head turned to one side, slurred speech, and labored breathing. An empty bottle of liquor was found in Resident #1's sheets. Resident #1 was found to have an oxygen saturation of 85%, a blood pressure of 138/67, a pulse of 101, and a temperature of 105.3*Fahrenheit. The Physician was notified and ordered Resident #1 to be sent out to the hospital. Review of Resident #1's hospital records revealed, in part, that he was seen in the emergency roiagnom on [DATE] at 6:29pm with [MEDICAL CONDITION] activity, gaze fixed to the left, unresponsive to pain, and cloudy urine in his foley bag, which was placed prior to arrival in the Emergency Department (ED). Review of Resident #1's emergency department physical exam revealed a blood pressure of 112/86, a pulse of 108 beats per minute, 20 respirations per minute, a temperature of 103*Fahrenheit, and an oxygen saturation of 98%. Further review revealed, in part, Resident #1 was actively seizing upon arrival to the ED, with dry mucous membranes, twitching appreciated with left gaze preference, [MEDICAL CONDITION](a resting heart rate of over 100 beats per minute), indwelling catheter with sediment appreciated in the foley bag. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Central Nervous System (CNS) failure or compromise,[MEDICAL CONDITION] (a life threatening condition when the body's response to infection injures its own tissues and organs), and [MEDICAL CONDITION]. Review of Resident #1's initial assessment by the ED Physician revealed, in part, Resident #1 was febrile, actively seizing, given Intravenous (IV) medications, remained lethargic (sluggish) with depressed respirations and periods of apnea (temporary cessation of breathing). Venous Blood Gas (VBG) showed mild hypercapnia (excessive carbon [MEDICATION NAME] in the bloodstream, typically caused by inadequate respiration). Resident #1 was reassessed after 1 hour of treatment and had worsening acidosis (a buildup of carbon [MEDICATION NAME] in the blood that results from poor lung function or depressed breathing), was less responsive, intubated for [MEDICAL CONDITION] and admitted to Intensive Care Unit. Further review revealed the Physician suspected presentation due [MEDICAL CONDITIONS], and Altered Mental Status (AMS). Review of Resident #1's laboratory results drawn in the emergency room revealed the following abnormal results, in part with the source of the general laboratory reference ranges via www.medscape.com: BUN: 36 (general reference range: 8-21) Creatinine: 1.8 (general reference range: 0.8-1.3) Urine Appearance: cloudy (general reference range: clear) Protein, UA: 3+ (general reference range: 0) Leukocytes, UA: 3+ (general reference range: negative) WBC, UA: 31 (general reference range: 2-5) Bacteria, UA: Moderate (general reference range: none). Resident #1 was diagnosed with [REDACTED]. Resident #1 was placed on a ventilator and admitted to the Intensive Care Unit. Further review revealed Resident #1's serum alcohol level was negative. In interview on 12/28/16 at 10:45am, S15/LPN stated she usually faxed communications to the physician's office, and would call only if a resident had a life or death situation occur. S15/LPN stated she was unsure how long it would take for the physician to read a faxed communication, but would usually find out on her next shift when checking for new physician's orders [REDACTED]. In interview on 12/28/16 at 11:00am, S2/DON reviewed Resident #1's nursing notes regarding penile discharge and urinary sediment and was asked if the nurse notified the physician of these findings. S2/DON stated the nurse faxed a communication to the physician's office. S2/DON reviewed and confirmed that the fax was sent on 12/26/16 at 2:29am. S2/DON was unable to verify if the physician received the faxed communication in a timely manner. There was no documented evidence and the facility provided no documented evidence that the faxed communication regarding a change in resident status was promptly received and reviewed by the Physician for recommendations of treatment.

Based on interview and record review the facility failed to ensure a resident was free from neglect by failing to adequately and timely assess skin conditions of a resident to prevent an avoidable pressure wounds and deteriorating venous wound (Resident #5). The facility failed to assess a resident and promptly notify the physician of a change of condition in a resident with decrease fluid intake and low urine output (Resident #1). This deficient practice affected 2 (Resident #1 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. This deficient practice resulted in an actual harm for Resident #1, a physically impaired resident with an indwelling foley catheter, was noted with yellow discharge coming from his penis, sediment in his urine, slurred speech, and had his medications held. The resident's physician was not immediately notified of these changes. On 12/26/16 at 6:24pm, Resident #1 had a change in mental status described as confusion, head turned to one side, slurred speech, and labored breathing. Resident #1 was sent to the hospital and diagnosed with [REDACTED]. Resident #1 was placed in the Intensive Care Unit (ICU) and placed on a ventilator. This deficient practice resulted in actual harm for Resident #5, a cognitively impaired resident, when the facility failed to identify new pressure wounds and deteriorating venous wound. The facility also failed to ensure nursing staff identified that the resident had low fluid intake and output. On 11/26/16 Resident #5 became unresponsive, with labored breathing. Resident #5 was sent to the hospital, admitted to ICU, was placed on a ventilator with [DIAGNOSES REDACTED]. Resident #5 was estimated to have a 9.4 Liter free water deficit. Findings: Review of the facility's Abuse Prevention and Prohibition Policy and Procedure revealed in part, that neglect was defined as a failure of the facility, its employees or service providers to provide adequate medical care or goods and services to a resident to avoid physical harm, pain, mental anguish, or emotional distress such as failing to feed a resident who needs physical assistance. Resident #1: Review of Resident #1's clinical record revealed, in part, that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #1's clinical record revealed he had a history of [REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/16 revealed, in part, he was incontinent of bowel and bladder, had functional limitation in range of motion to upper and lower extremities, required extensive assistance of two CNAs with bed mobility, transfers, toilet use, and totally dependent on staff for personal hygiene and bathing. Further review of the MDS revealed no documentation of an indwelling foley catheter for Resident #1. Review of a fax to a physician's office dated 12/26/16 at 2:29am revealed Resident #1 was noted with a cup and bottle with alcohol, speech slurred, red eyes, a yellow discharge from his penis, and sediment in his urine. Further review revealed the nurse withheld Resident #1's medications. There was no documented evidence and the facility did not present any documented evidence that Resident #1's Physician was called at this time, that his office was open to receive the fax and give the fax to Resident #1's Physician at this time, that anyone responded that they received the fax at that time, or that Resident #1's Physician reviewed the above mentioned fax at that time. Review of Resident #1's Nurse's Notes entry dated 12/26/16 at 7:40am revealed, in part, an empty bottle of whiskey was found in Resident #1's room, and Resident #1 cried most of the shift and even called 911 twice. Review of Resident #1's December 2016 electronic Medication Administration Record [REDACTED] 2:00pm: [MEDICATION NAME] 10milligrams (mg) by mouth every 8 hours (a muscle relaxant); 5:00pm: Prostat 30milliiters (ml) l by mouth twice daily (a protein supplement used to aid in wound healing); Potassium Chloride ER 10milliequivalent (meq) by mouth twice daily (a supplement used to treat low levels of potassium in the blood); [MEDICATION NAME] 300mg by mouth every evening (an antacid); [MEDICATION NAME] 300mg by mouth three times a day (an anti-[MEDICAL CONDITION] medication, also used for nerve pain); 09:00pm: Tamsulosin [MEDICATION NAME] 0.4mg by mouth at bedtime (a medication used to treat the symptoms of [MEDICAL CONDITION] which is defined as prostate gland enlargement which can block the flow of urine out of the bladder and cause bladder, urinary tract or kidney problems); and 10:00pm: [MEDICATION NAME] 10mg by mouth every 8 hours (a muscle relaxant). Further review of Resident #1's December 2016 eMAR revealed the following medications were withheld on 12/26/16 at: 05:00pm: Potassium Chloride ER 10meq by mouth twice daily; Prostat 30ml by mouth twice daily; and [MEDICATION NAME] 300mg by mouth every evening. There was no documented evidence and the facility provided no documented evidence that Resident #1's Physician was notified of the withheld medications. Review of Resident #1's Nurse's Notes entry dated 12/26/16 at 6:24pm revealed Resident #1 had a change in mental status described as confusion, head turned to one side, slurred speech, and labored breathing. An empty bottle of liquor was found in Resident #1's sheets. Resident #1 was found to have an oxygen saturation of 85%, a blood pressure of 138/67, a pulse of 101, and a temperature of 105.3*Fahrenheit. Further review revealed the Physician was notified and ordered Resident #1 to be sent out to the hospital. Review of Resident #1's hospital records revealed, in part, that he was seen in the emergency roiagnom on [DATE] at 6:29pm with [MEDICAL CONDITION] activity, gaze fixed to the left, unresponsive to pain, and cloudy urine in his foley bag placed prior to arrival in Emergency Department (ED). Review of Resident #1's emergency department physical exam revealed a blood pressure of 112/86, a pulse of 108 beats per minute, 20 respirations per minute, a temperature of 103*Fahrenheit, and an oxygen saturation of 98%. Further review revealed, in part, Resident #1 was actively seizing upon arrival to the ED, with dry mucous membranes, twitching appreciated with left gaze preference, [MEDICAL CONDITION](a resting heart rate of over 100 beats per minute), indwelling catheter with sediment appreciated in the foley bag. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Central Nervous System (CNS) failure or compromise,[MEDICAL CONDITION] (a life threatening condition when the body's response to infection injures its own tissues and organs), and [MEDICAL CONDITION]. Review of Resident #1's initial assessment by ED Physician revealed, in part, Resident #1 was febrile, actively seizing, given Intravenous (IV) medications, remained lethargic (sluggish) with depressed respirations and periods of apnea (temporary cessation of breathing). Venous Blood Gas (VBG) showed mild hypercapnia (excessive carbon [MEDICATION NAME] in the bloodstream, typically caused by inadequate respiration). Resident #1 was reassessed after 1 hour of treatment and had worsening acidosis (a buildup of carbon [MEDICATION NAME] in the blood that results from poor lung function or depressed breathing), was less responsive, intubated for [MEDICAL CONDITION] and admitted to ICU. Further review revealed the Physician suspected presentation due [MEDICAL CONDITIONS], and Altered Mental Status (AMS). Review of Resident #1's laboratory results drawn in the emergency room revealed the following abnormal results, in part with the source of the general laboratory reference ranges via www.medscape.com : Blood Urea Nitrogen (BUN): 36 (general reference range: 8-21) Creatinine: 1.8 (general reference range: 0.8-1.3) Urine Appearance: cloudy (general reference range: clear) Protein, UA: 3+ (general reference range: 0) Leukocytes, UA: 3+ (general reference range: negative) White Blood Cells (WBCs), UA: 31 (general reference range: 2-5) Bacteria, UA: Moderate (general reference range: none). Resident #1 was diagnosed with [REDACTED]. Resident #1 was placed on a ventilator and admitted to the Intensive Care Unit. Further review revealed Resident #1's serum alcohol level was negative. Review of Resident #1's record revealed a fax form for non-emergency communication dated 10/15/16 at 01:30pm which read, in part, Resident returned from a local hospital with a foley catheter for [MEDICAL CONDITION]. In interview on 12/27/16 at 3:08pm, S14/Licensed Practical Nurse (LPN)/MDS Coordinator stated she was unaware that Resident #1 had an indwelling foley catheter, and did not capture it on the significant change MDS with an ARD of 10/25/16, and therefore no plan of care to reduce the risk of urinary tract infections was developed for the use of a foley catheter for Resident #1. In interview on 12/28/16 at 11:00am, S2/Director of Nursing (DON) reviewed Resident #1's nursing notes regarding penile discharge and urinary sediment and was asked if the nurse notified the physician of these findings. S2/DON stated the nurse faxed a communication to the physician's office. S2/DON reviewed and confirmed that the fax was sent on 12/26/16 at 2:29am. S2/DON was unable to verify if the physician received the faxed communication in a timely manner. Upon review of the Nurse's Notes entry regarding resident calling 911 twice in one shift, S2/DON stated he had done this before, that he drank a lot of alcohol which clouded his judgment. When asked if S2/DON thought Resident #1 may have called 911 because he didn't feel well, S2/DON stated he was unsure. In interview on 12/28/16 at 12:30pm, S2/DON and S3/QA/QI Nurse were asked if the Physician's hours of operation included midnight, and both confirmed the Physician would not have received a faxed communication in the middle of the night. There was no documented evidence and the facility provided no documented evidence that the faxed communication regarding a change in resident status was promptly received and reviewed by the Physician for recommendations of treatment. Resident #5: Review of Resident #5's clinical record revealed in part, that he was admitted to the facility on [DATE], was identified as being at risk for pressure ulcer development, urinary tract infections, and dehydration. Further review revealed he had the following diagnoses, in part: Mental [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] [MEDICAL CONDITION], History of [MEDICAL CONDITION], [DIAGNOSES REDACTED], Protein-Calorie Malnutrition, [MEDICAL CONDITION], Pressure and Venous Ulcers, Vitamin Deficiency, and a History of Dehydration, Urinary Tract Infections and Bacteremia. Review of Resident #5's Quarterly Minimum Data Set (MDS) with a reference date of 10/04/16, revealed in part that he was severely cognitively impaired, had no behavior problems, required extensive physical assistance of one CNA with dressing, eating, and hygiene, and required extensive physical assistance of two CNAs with toilet use, bed mobility, and transfers. Further review revealed Resident #5 was incontinent of bowel and bladder, and was totally dependent on staff for bathing. Review of Resident #5's Wound Assessment Report dated 11/22/16 revealed in part, that a new unstageable pressure ulcer due to suspected deep tissue injury developed on Resident #5's heel that was not present upon admission which measured 8cm x 8cm. Further review revealed no documented evidence that the above mentioned wound had any signs or symptoms of infection and the wound bed and wound drainage documentation was blank. Review of Resident #5's Wound Assessment Report dated 11/22/16 revealed in part, that a new unstageable pressure ulcer due to suspected deep tissue injury developed on Resident #5's left lateral malleolus that was not present upon admission which measured 4cm x 4cm. Further review revealed no documented evidence that the above mentioned wound had any signs or symptoms of infection and the wound bed and wound drainage documentation was blank. Review of Resident #5's wound narrative notes for 11/22/16 revealed in part, that Resident #5's left malleolus and right heel had a new Suspected Deep Tissue Injury (SDTI) onset with both wounds having a dark red, soft and boggy wound bed with flat wound edges and soft and dark periwound areas with a small amount of sanguineous drainage seen on the gauze and inside of sock. Further review revealed Resident #5's wounds had no signs or symptoms of infection. and a sign at the head of the bed reminded staff and family members to keep boots on at all times. Review of #5's Wound Assessment Report dated 11/23/16 revealed in part, that Resident #5's venous ulcer to his left lateral upper and lower shin had deteriorated. Further review revealed the wound bed was 50% [MEDICATION NAME] tissue and 50% slough with normal surrounding skin and measured 2centimeters (cm) x 1cm x 0.10cm. The above mentioned wound documentation further revealed the venous ulcer had small sanguineous drainage and no signs or symptoms of infection. There was no documented evidence that Resident #5's Physician was notified of Resident #5's venous ulcer deterioration. Review of Resident #5's Registered Dietician assessment dated [DATE] revealed in part that Resident #5's intake of food and supplements was inadequate, and that he was to have 2200-2600cc of fluid per day with staff to monitor intake, labs, skin, and hydration. Review of Resident #5's Departmental Notes dated 11/24/16 at 3:12pm, revealed in part, that Resident #5 had blood tinged urine at which time the Physician was notified with an order to catheterize Resident #5 to obtain a specimen for a urinary analysis (UA) with culture and sensitivity and give Bactrim DS (antibiotic medication used to treat infection) every 12 hours for 7 days. Review of Resident #5's Department Notes dated 11/26/16 at 6:12am, revealed a second attempt to retrieve a urine specimen via in and out catheter was unsuccessful due to possible trauma as indicated by light active bleeding from the meatus which stopped after 5 minutes. Further review revealed Resident #5 showed no signs of pain or discomfort from resident, and will report to on-coming nurse. Review of Resident #5's Departmental Notes dated 11/26/16 at 10:44am, revealed S7/LPN found Resident #5 unresponsive, with labored breathing and an oxygen saturation of 69%, a blood pressure of 89/43, a pulse of 112 beats per minute, 16 respirations per minute, and a temperature of 99.5*Fahrenheit. Further review revealed Resident #5's Physician was notified with an order to send Resident #5 to the hospital emergency room for evaluation. Review of Resident #5's hospital records revealed in part that he was seen in the emergency roiagnom on [DATE] at 11:32am, because of a change in mental status. Review of Resident #5's emergency department physical exam revealed a blood pressure of 153/128, a pulse of 136 beats per minute, a temperature of 101.5*Fahrenheit, and an oxygen saturation of 88%. Further review revealed Resident #5 was mildly sweating and had dry mucous membranes with white plaques noted to the back of the mouth, was moaning, had right sided rhonchi, a sacral ulcer to the left buttock without purulent drainage or surrounding redness, and a 3cm deep right heel ulcer with purulent, foul smelling drainage, left ankle ulcer with exposed hardware, and an ulcer to the lateral aspect of the left lower leg. Further review revealed Resident #5 was referred to podiatry because of his right heel ulcer and exposed hardware to the left ankle. Review of Resident #5's physical exam of his wounds performed by a Podiatrist revealed in part, that Resident #5 had an infected left lateral malleolus malodorous ulcer with serosanguineous drainage with exposed hardware which consisted of a plate and screw. Resident #5 also had a left lateral fibula ulcer which was proximal to the malleolus ulcer which had exposed fibular bone. Resident #5's exam further revealed Resident #5 also had an infected right posterior heel ulcer with a pungent odor, drainage, and exposed bone. Further review revealed that critical care was necessary to treat or prevent imminent or life-threatening deterioration [MEDICAL CONDITION] and right heel debridement. Review of Resident #5's laboratory results drawn in the emergency room revealed the following abnormal results, in part with the source of the general laboratory reference ranges via www.medscape.com : White Blood Count (WBC): 23.26 (general reference range: 4-10) Hemoglobin: 10.9 (general reference range: 13-17) Hematocrit: 34.9 (general reference range: 40-52) Sodium: 167 (general reference range: 135-145) Chloride: 129 (general reference range: 95-105) Blood Urea Nitrogen (BUN): 34 (general reference range: 8-21) Total Protein: 8.9 (general reference range: 60-80) [MEDICATION NAME]: 1.6 (general reference range: 3.5-5.5) Urine Appearance: cloudy (general reference range: clear) Protein, UA: 2+ (general reference range: 0) Occult Blood, UA: 3+ (general reference range: negative) Leukocytes, UA: 2+ (general reference range: negative); and Bacteria, UA: Moderate (general reference range: none). Review of Resident #5's hospital records also revealed that his chest x-ray result showed bilateral [MEDICAL CONDITIONS], was admitted to the Intensive Care Unit (ICU) in serious condition, was hospitalized and placed on a ventilator, underwent wound debridement, and Percutaneous Endoscopic Gastrostomy (PEG) tube placement (a feeding tube). Review of Resident #5's Critical Care Medicine Physician's Progress Notes dated 11/26/16 revealed in part, that Resident #5 had recently experienced neglect, was admitted to the Intensive Care Unit (ICU) for severe dehydration, and for the treatment of [REDACTED]. Further review revealed Resident #5 was estimated to have a 9.4 Liter free water deficit. In interview on 12/14/16 at 10:00am with S7/LPN indicated Resident #5 was totally dependent on staff for water and that he could not hold a cup or get and drink anything independently. S7/LPN further indicated Saturday morning on 11/26/16 at 7:00am, she received a report from S23/LPN a urine specimen could not be obtained on Resident #5. S7/LPN further indicated while she was doing her 8:00am medication pass, which was done between 7:00am to 9:00am, she noticed that Resident #5 did not ask for water like he usually did. Resident #5 was lethargic, unresponsive, looked clammy, had a temperature, had labored breathing, and had an oxygen saturation of 69%. S7/LPN verified that she called Resident #5's Physician at around 10:45am, and was given an order to send to the ER for an evaluation. S7LPN was then asked why she didn't notify Resident #5's Physician earlier and S7/LPN indicated that she had a lot going on that day and had to get everything situated. S7/LPN was asked what total fluid intake amount for a day would cause her to become concerned and S7/LPN indicated that she wouldn't be concerned until a resident's total intake for a day was less than 100cc. Review of Resident #5's Fluid Intake and Output Roster for the month of November 2016 revealed in part: Fluid intake total for 11/2/16 was 360cubic centimeter (cc) ; Fluid intake total for 11/04/16 was 270cc; Fluid intake total for 11/07/16 was 120cc; Fluid intake total for 11/08/16 was 240cc; Fluid intake total for 11/10/16 was 120cc; Fluid intake total for 11/12/16 was 150cc; Fluid intake total for 11/13/16 was 240cc; Fluid intake total for 11/14/16 was 240cc; and Fluid intake total for 11/15/16 was 150cc. Further review revealed Resident #5's fluid intake was not monitored for the following dates from 11/01/16 through 11/26/16: 11/01/16, 11/03/16, 11/05/16, 11/06/16, 11/09/16, 11/11/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/23/16, 11/24/16, and 11/25/16. The facility was not able to present any other documentation which showed that Resident #5's fluid intake was monitored as required. Review of Resident #5's Dehydration Monitoring form which included signs and symptoms of dehydration which included in part: dry mucous membranes, decreased urine output, decreased skin turgor, confusion or change in mental status, lethargy, and fever. Further review revealed nursing staff assessed Resident #5 as having no signs or symptoms of dehydration from November 1, 2016 to November 26, 2016 at 2:07am. Review of Resident #5's clinical record revealed no documented evidence and the facility did not present any documented evidence that Resident #5's vital signs were taken between 10/18/16 through 11/26/16. There was no documented evidence and the facility did not present any documented evidence that Resident #5's Physician was notified of and/or Resident #5 being assessed as having an ulcer to buttock, or an ulcer with exposed bone, hardware, wound deterioration and/or foul smelling drainage. In interview on 12/14/16 at 1:50pm, S4/RN Treatment Nurse indicated she was not made aware that Resident #5's [MEDICATION NAME] level was low from his 10/3/16 lab, that none of the treatment nurses are informed of any lab results, but felt that it's important to know a resident's [MEDICATION NAME] level in order to use the information to prevent or improve a resident's skin condition. In interview on 12/14/16 at 10:10am, S22/Nurse Practitioner indicated it was difficult to follow the facility's charting on residents because half of the charting was done in the chart, and the other half in the electronic record, but stated it was important that the record be easy to go through for the continuity of care and to ensure nothing gets missed. In interview on 12/14/16 at 2:30pm, S1/Administrator, S2/DON, and S3/QA/QI Nurse indicated that residents have opportunities to get fluids with meals and during the medication pass, and staff only document accurate intake and outputs (I&Os) on residents on fluid restrictions; therefore, Resident #5's I&Os may be misleading, but given Resident #5's history, his I&Os should have been monitored more closely. S3/QA/QI Nurse further indicated that as far as they knew, Resident #5 did not have a sacral ulcer, and that there have been changes in staff and they were in a transition. S2/DON indicated that they had already been QAing vital signs, and S1/Administrator offered no response. In interview on 12/27/16 at 2:25pm, S8/LPN was asked why Resident #5's labs ordered on [DATE] weren't done as ordered and indicated that she thinks it was because labs are only done by the night nurse on Mondays, Wednesdays, and Fridays, and if the nurse couldn't get the UA on Friday, then they probably were going to wait until Monday to get it, but wasn't sure.

§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, . This requirement is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and/or psychosocial well-being for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to assess and identify blisters and redness to a Resident's lower extremities and mid-back area (Resident #1). This actual harm was discovered to have occurred to Resident #1 on 12/09/16 when an observation of the resident was conducted with the surveyor present. Resident #1 was noted to have a large reddened area to both anterior legs. Legs appeared to be [MEDICAL CONDITION]. Also noted were some blisters on the inflamed areas to the legs. Resident #1 ' s physician was notified by the wound care nurse and informed of the condition of his bilateral lower extremities, at which time an order was given to consult with wound care. An order was received and written for [MEDICATION NAME] 100mg (an antibiotic used to treat infection) was ordered twice a day for ten days for [MEDICAL CONDITION]. Findings: Resident #1 Review of Resident #1's clinical record revealed, in part, that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/16 revealed, in part, he was incontinent of bowel and bladder, had functional limitation in range of motion to upper and lower extremities, required extensive assistance of two Certified Nursing Assistants (CNAs) with bed mobility, transfers, toilet use, and totally dependent on staff for personal hygiene and bathing. Further review Resident #1 was assessed for having one Stage 2 pressure ulcer which was present on admission, and Moisture Associated Skin Damage and documentation did not reflect that Resident #1 had an infection of the foot (e.g. [MEDICAL CONDITION], and/or purulent drainage). Review of Resident #1's record revealed, in part, that a Care Plan was developed for cognitive loss related to a Stroke, with approaches which included, in part, report any changes to the Physician. Further review of Resident #1's Care Plan revealed in part, problem addressed with skin integrity to sacrum; gluteal cleft with Stage 2 pressure ulcer to gluteal cleft. Further review of Resident #1's Care Plan on 12/09/16 revealed no problems identified with non-pressure related skin integrity issues. Review of Progress Notes dated 12/05/16 and documented by S13/Licensed Practical Nurse (LPN) revealed skin assessment was completed and Resident#1 was noted to have three blisters along the left side of his abdomen, two of which were open. Review of the progress note revealed the wound care nurse was informed and the dressing was clean, dry and intact to site. No documentation that the physician and responsible party were notified. Review of Resident #1's Wound Assessment Notes from 11/18/16 through 12/13/16 revealed discussion of a Stage 2 pressure ulcer to right buttock only. There was no mention of [MEDICAL CONDITION] and blisters to both lower legs, nor was there mention of any dressings to Resident #1's leg or mid/lateral trunk. An observation was made on 12/09/16 at 10:40am of Resident #1 with S15/Licensed Practical Nurse (LPN). Resident#1 was noted to have a large reddened area to both anterior legs. Legs appeared to be [MEDICAL CONDITION]. Also noted were some blisters on the inflamed areas to the legs. Also noted were two 4x4 dressings to left mid back/side area. The dressings were not initialed and dated but had 4 J written on one of the dressings. The dressings were soiled with what appeared to be old drainage. In interview with S15/LPN who was changing the resident explained that the dressings were from a past pain pump insertion site. Observation revealed a Stage 2 pressure ulcer to right buttock and a Stage 2 pressure ulcer to the right buttock crease. Observation on 12/09/16 at 12:10pm revealed S4/Registered Nurse (RN) Treatment Nurse performed a skin assessment on Resident #1. When Resident #1's reddened, [MEDICAL CONDITION] and blistered legs were pointed out by the surveyor, S4/RN Treatment Nurse stated Resident #1 had [MEDICAL CONDITION] off and on. S4/RN Treatment Nurse was unaware of the blisters and the extent of the [MEDICAL CONDITION] to Resident #1's legs. S4/RN Treatment Nurse confirmed there was no treatment ordered for Resident #1's leg blisters. S4/RN Treatment Nurse was shown the two dressings on Resident #1's left mid-back. S4/RN Treatment Nurse confirmed that she did not know how long the dressings were there, nor what was under the dressings. The two dressings to left mid-back area were removed by S4/RN Treatment Nurse which revealed three Stage 2 open areas. S4/RN Treatment Nurse stated that she had no knowledge of the dressings and that any changes in wounds and skin condition should be reported to her by the assistant treatment nurse. In interview on 12/09/16 at 2:23pm S9/Certified Nursing Assistant (CNA) stated she observed Resident #1 had boils on Resident #1's left mid back where the dressings were. S9/CNA stated Resident #1 had the dressings when he returned from a doctor's visit, but she did not remember exactly when, but that it was a while ago. S9/CNA indicated she reported this to the nurse as she reports everything unusual about her residents. S9/CNA also disclosed that the nurses knew about the [MEDICAL CONDITION] on the resident's legs and stated everybody knew. Review of Resident #1's Departmental Notes dated 12/09/16 at 3:10pm, revealed Resident #1's Physician was notified of his bilateral lower extremities at which time an order was given to consult with wound care and an order was written for [MEDICATION NAME] 100 milligrams (mg) (an antibiotic used to treat infection) was ordered twice a day for ten days for [MEDICAL CONDITION]. In interview on 12/13/16 at 12:20pm S4/RN Treatment Nurse indicated antibiotics and dressings for Resident #1's lower legs were ordered on Friday (12/09/16) after noting the condition of the legs with the surveyor. S4/RN Treatment Nurse further revealed that the three open areas to Resident #1's left lateral/side were reported to S6/RN part time wound care nurse by S13/LPN. S4/RN Treatment Nurse indicated the condition of Resident #1's legs and three open areas to his left lateral side were not reported to S4/RN Treatment Nurse or to the physician. In a telephone interview on 12/13/16 at 12:36pm S13/LPN indicated she was informed of Resident #1's blisters to his back area by the CNA. S13/LPN stated she reported the two open areas to the wound care nurse who dressed it. S13/LPN did not confirm that it was reported to the physician. In interview on 12/14/16 at 2:20pm S1/ Administrator, S2/Director of Nursing, and S3/RN Quality Assurance/Quality Improvement Nurse acknowledged the deficient practice and stated staff should have identified and addressed [MEDICAL CONDITION] to Resident #1's leg and blisters to Resident#1's back, and the physician and residents' responsible party should have been informed of the changes.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 (Resident #3 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents by failing to: 1. Ensure a resident with a left heel Stage 3 pressure ulcer had legs elevated as ordered (Resident #3); 2. Ensure a resident with a left heel Stage 3 pressure ulcer had bilateral off-loading heel boots applied as ordered (Resident #3); and 3. Identify and inform the Physician of a new wound to a resident's buttocks, infected wounds, a left lateral fibula ulcer proximal to the malleolus which had exposed bone, and a left ankle ulcer with exposed hardware (Resident #5). Actual harm occurred for Resident #5, who was cognitively impaired, when the facility failed to identify and assess left lateral fibula ulcer which was proximal to the malleolus ulcer which had exposed fibular bone and a left ankle ulcer with exposed hardware. According to hospital records the resident was admitted to critical care and placed on a ventilator on 11/26/16 to treat or prevent imminent or life-threatening deterioration [MEDICAL CONDITION] and right heel debridement. Actual harm occurred for Resident #3, who was cognitively impaired, when facility staff did not elevate her legs and apply bilateral off-loading boots to prevent the worsening of an existing Stage III left heel ulcer. Findings: Resident #5 Review of Resident #5's clinical record revealed in part, that he was admitted to the facility on [DATE], was identified as being at risk for pressure ulcer development, urinary tract infections, and dehydration. Further review revealed he had the following diagnoses, in part: Mental [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], History of [MEDICAL CONDITION], [DIAGNOSES REDACTED], Protein-Calorie Malnutrition, [MEDICAL CONDITION], Pressure and Venous Ulcers, Vitamin Deficiency, and a History of Dehydration, Urinary Tract Infections, and Bacteremia. Review of Resident #5's Quarterly Minimum Data Set (MDS) with a reference date of 10/04/16, revealed in part that he was severely cognitively impaired, had no behavior problems, required extensive physical assistance of 1 CNA with dressing, eating, and hygiene, and required extensive physical assistance of two CNAs with toilet use, bed mobility, and transfers. Further review revealed Resident #5 was incontinent of bowel and bladder, and was totally dependent on staff for bathing. Review of Resident #5's Care Plan revealed in part that a plan of care was developed for his impaired skin integrity which included to observe his skin when providing routine care and to monitor for changes in my skin status that may indicate worsening of my wound and notify Resident #5's Physician. A plan of care was also developed for Resident #5 for requiring extensive to total assistance from staff with his daily needs which included to assist with bed mobility, transfers, and feeding and that the registered dietician was to evaluate my diet as appropriate. Resident #5's Care Plan also revealed that Resident #5 was at risk for infection related to his incontinence and that Resident #5's labs were to be done as ordered by the physician, that fluids should be encouraged, and that the Physician was to be notified of any significant changes. Resident #5 Care Plan further revealed that a plan of care was developed for his urine incontinence with interventions to include observing Resident #5's skin daily for irritation and redness, and to evaluate Resident #5's fluid intake and hydration status. Review of Resident #5's Wound Assessment Report dated 11/22/16 revealed in part, that a new unstageable pressure ulcer due to suspected deep tissue injury developed on Resident #5's heel that was not present upon admission which measured 8 centimeters (cm) x 8cm. Further review revealed no documented evidence that the above mentioned wound had any signs or symptoms of infection and the wound bed and wound drainage documentation was blank. Review of Resident #5's Wound Assessment Report dated 11/22/16 revealed in part, that a new unstageable pressure ulcer due to suspected deep tissue injury developed on Resident #5's left lateral malleolus that was not present upon admission which measured 4cm x 4cm. Further review revealed no documented evidence that the above mentioned wound had any signs or symptoms of infection and the wound bed and wound drainage documentation was blank. Review of Resident #5's Wound Narrative Notes for 11/22/16 revealed in part, that Resident #5's left malleolus and right heel had a new Suspected Deep Tissue Injury (SDTI) onset with both wounds having a dark red, soft and boggy wound bed with flat wound edges and soft and dark periwound areas with a small amount of sanguineous drainage seen on the gauze and inside of sock. Further review revealed Resident #5's wounds had no signs or symptoms of infection and a sign at the head of the bed reminded staff and family members to keep boots on at all times. Review of Resident #5's Departmental Notes dated 11/26/16 at 10:44am, revealed S7/LPN found Resident #5 unresponsive, with labored breathing and an oxygen saturation of 69%, a blood pressure of 89/43, a pulse of 112 beats per minute, 16 respirations per minute, and a temperature of 99.5*Fahrenheit. Further review revealed Resident #5's Physician was notified with an order to send Resident #5 to the hospital emergency room for evaluation. Review of Resident #5's hospital records revealed in part that he was seen in the emergency roiagnom on [DATE] at 11:32am, because of a change in mental status and had a sacral ulcer to the left buttock without purulent drainage or surrounding redness, and a 3cm deep right heel ulcer with purulent, foul smelling drainage, left ankle ulcer with exposed hardware, and an ulcer to the lateral aspect of the left lower leg. Further review revealed Resident #5 was referred to podiatry because of his right heel ulcer and exposed hardware to the left ankle. Review of Resident #5's physical exam of his wounds performed by a Podiatrist revealed in part, that Resident #5 had an infected left lateral malleolus malodorous ulcer with serosanguineous drainage with exposed hardware which consisted of a plate and screw. Resident #5 also had a left lateral fibula ulcer which was proximal to the malleolus ulcer which had exposed fibular bone. Resident #5's exam further revealed Resident #5 also had an infected right posterior heel ulcer with a pungent odor, drainage, and exposed bone. Further review revealed that critical care was necessary to treat or prevent imminent or life-threatening deterioration [MEDICAL CONDITION] and right heel debridement. Review of Resident #5's laboratory results drawn in the emergency room revealed the following abnormal results n part, with the source of the general laboratory reference ranges via www.medscape.com: White Blood Count (WBC): 23.26 (general reference range: 4-10) Hemoglobin: 10.9 (general reference range: 13-17) Hematocrit: 34.9 (general reference range: 40-52) Sodium: 167 (general reference range: 135-145) Chloride: 129 (general reference range: 95-105) Blood Urea Nitrogen (BUN): 34 (general reference range: 8-21) Total Protein: 8.9 (general reference range: 60-80) [MEDICATION NAME]: 1.6 (general reference range: 3.5-5.5) Urine Appearance: cloudy (general reference range: clear) Protein, UA: 2+ (general reference range: 0) Occult Blood, UA: 3+ (general reference range: negative) Leukocytes, UA: 2+ (general reference range: negative); and Bacteria, UA: Moderate (general reference range: none). Review of Resident #5's hospital records also revealed that his chest X-ray result showed bilateral [MEDICAL CONDITIONS], was admitted to the Intensive Care Unit (ICU) in serious condition, was hospitalized and placed on a ventilator, underwent wound debridement, and Percutaneous Endoscopic Gastrostomy (PEG) tube placement (a flexible tube placed through the abdominal wall and into the stomach which allows nutrition, fluids, and/or medications to be put directly into the stomach). Review of Resident #5's Critical Care Medicine Physician's Progress Notes dated 11/26/16 revealed in part, that Resident #5 had recently experienced neglect, was admitted to the ICU for Severe Dehydration, and for the treatment of [REDACTED]. There was no documented evidence and the facility did not present any documented evidence that Resident #5's Physician was notified of and/or Resident #5 being assessed as having an ulcer to buttock, or an ulcer with exposed bone, hardware, wound deterioration and/or foul smelling drainage. In interview on 12/14/16 at 1:50pm, S4/Registered Nurse (RN) Treatment Nurse indicated Resident #5 did not have any breakdowns to his buttocks, only had ulcers on his shin, malleolus and his heel. S4/RN/Treatment nurse stated Resident #5's wounds were treated daily as ordered, with no changes since Resident #5's assessment conducted on 11/22/16 and 11/23/16. In interview on 12/14/16 at 2:30pm, S1/Administrator, S2/Director of Nursing (DON), and S3/Quality Assurance (QA)/Quality Improvement (QI) Nurse were informed of the above findings and were asked if they wanted to present anything to the surveyors to dispute the above mentioned findings and S3/QA/QI Nurse further indicated that as far as they knew, Resident #5 did not have a sacral ulcer, and that there have been changes in staff and they were in a transition; S1/Administrator offered no response. Resident #3 Review of Resident #3's record revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3 admitted to Hospice services on 07/08/16. Review of Resident #3's Minimum Data Sheet with Assessment Reference Date of 10/18/16 revealed in part: Resident #3 had a Brief Interview for Mental Status score of 0 (00-07 severe cognitive impairment); Resident #3 required extensive assistance of one to two persons assistance for all activities of daily living, except for eating which the resident required limited assistance of one person; Resident #3 was at risk for developing pressure ulcers with one Stage 3 pressure ulcer measuring 2.5centimeters (cm) x 2.5cm x 0.3cm with slough present for the type of advanced wound. Review of Resident #3's care plan revealed in part, problem addressed for impaired skin integrity with a Stage 3 pressure ulcer to the left heel with approaches for wound care as ordered by physician, observe skin when providing routine care, monitor for changes and notify physician of any changes, pillows and supportive devices to assist with positioning, and off-loading boots to bilateral feet. Review of Resident #3 ' s weekly Wound Assessment Report dated 10/07/16 revealed the pressure ulcer to Resident's left heel was identified on 06/16/16 and was not present on admission. Further review of the Wound Assessment Report revealed the pressure ulcer to Resident #3 ' left heel had deteriorated and was identified as a Stage 3 pressure ulcer. Further review revealed the wound bed was 50% granulation tissue, 40% [MEDICATION NAME] tissue, and 10% slough and measured 2.5centimeters (cm) x 2.5cm x 0.30cm, with no infection and moderate amount of serosanguineous drainage; Physician and Responsible Party and Hospice nurse were notified. Review of Resident #3 ' s weekly Wound Assessment report dated 11/23/16 revealed improvement with Resident #3 ' s Stage 3 pressure ulcer to left heel. Further review revealed the wound bed was 50% granulation tissue, 40% [MEDICATION NAME] tissue, and 0% slough and 0% eschar and measured 2.5cm x 2.5cm x 0.20cm, with no infection and small amount of serosanguineous drainage; Physician and Responsible Party and Hospice nurse were notified. Review of Resident #3 ' s weekly Wound Assessment report dated 12/01/16 revealed improvement with Resident #3 ' s Stage 3 pressure ulcer to left heel. Further review revealed the wound bed was 30% granulation tissue, 70% [MEDICATION NAME] tissue, and 0% slough and 0% eschar anc measured 1.5cm x 1.5cm x 0.10cm, with no infection and small amount of serosanguineous drainage; Physician and Responsible Party and Hospice nurse were notified. Review of Resident #3 ' s weekly Wound Assessment report dated 12/08/16 revealed documentation of deterioration with Resident #3 ' s Stage 3 pressure ulcer to left heel. Further review revealed the wound bed was 40% granulation tissue, 30% [MEDICATION NAME] tissue, and 30% slough and 0% eschar and measured 3.5cm x 1.5cm x 0.10cm, with no infection and small amount of serosanguineous drainage; Physician and Responsible Party were notified on 10/28/16. Further review of the Wound Assessment report notes dated 12/08/16 revealed pressure reduction to include off-loading boot at all times, alternating air-loss mattress and turning/repositioning to reduce pressure/comfort. Observation on 12/09/16 at 11:14am sign above Resident #3's bed to please keep boots on at all times. Further observation revealed Resident #3's heel lift boot on left foot only and bilateral lower extremities not elevated with [MEDICAL CONDITION] bag and tubing on the floor. In interview on 12/09/16 at 12:06pm S12/Licensed Practical Nurse (LPN) stated Resident #3 was total care and required heel protectors on her at all times. Observation on 12/09/16 at 2:15pm Resident #3 had one heel lift boot to left foot only. In interview on 12/09/16 at 2:23pm S10/Certified Nursing Assistant (CNA) stated she observed Resident #3 with only one heel boot protector on her left foot. Observation with S17/CNA on 12/13/16 at 10:20am revealed Resident #3 lying in bed with foot of bed flat with bilateral heel lift boots noted to feet with no elevation of bilateral lower extremities. In interview on 12/13/16 at 10:23am S17/CNA stated Resident #3 should have her legs elevated. Observation with S18/CNA on 12/13/16 at 2:40pm Resident #3 lying on right side in bed, bed in the lowest position with foot of bed flat with bilateral lift boots on feet with no assistive device used to elevate legs. Observation with S10/CNA on 12/14/16 at 10:15am Resident #3 lying flat in bed with bed in lowest position with foot of bed flat with no heel lift boots noted on bilateral feet. Resident #3's legs were crossed with no assistive device used to elevate legs. In interview on 12/14/16 at 1:45pm S17/CNA stated she was aware that Resident #3 needed to have bilateral heel boots and legs elevated. S17/CNA stated sometimes Resident #3 had her bilateral heel boots on and sometimes she didn't. S17/CNA stated the Hospice CNA came today and she must have taken her heel boots off when she bathed Resident #3 and Hospice CNA didn't put them back on. S17/CNA stated she had to go look for her heel boots and put them back on Resident #3's feet. In interview on 12/14/16 at 11:35am reviewed above findings with S2/Director of Nursing and S3/Quality Assurance/Quality Improvement Nurse and facility did not have anything further to present.

Based on record review and interview, the facility failed to ensure residents were assisted with hydration and offered sufficient fluid intake to maintain proper hydration and health for 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5). The facility failed to: 1.) Ensure a resident dependent on staff for eating and drinking received enough fluids to prevent severe dehydration (Resident #5); 2.) Monitor a resident's fluid intake (Resident #5); and 3.) Ensure staff accurately assessed a resident's hydration status (Resident #5). This deficient practice resulted in an actual harm when Resident #5, a cognitively impaired resident requiring assistance from staff for all activities of daily living, became unresponsive, with labored breathing. Resident #5 was sent to the hospital on [DATE], was diagnosed with [REDACTED]. Further review revealed Resident #5 was estimated to have a 9.4 Liter free water deficit. Resident #5 was admitted to the Intensive Care Unit (ICU) and was placed on a ventilator. Findings: Review of Resident #5's clinical record revealed in part, that he was admitted to the facility on [DATE], was identified as being at risk for urinary tract infections, and dehydration. Further review revealed he had the following diagnoses, in part: Mental [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], History of [MEDICAL CONDITION], [DIAGNOSES REDACTED], Protein-Calorie Malnutrition, [MEDICAL CONDITION], Pressure and Venous Ulcers, Vitamin Deficiency, and a History of Dehydration, Urinary Tract Infections and Bacteremia. Review of Resident #5's Quarterly Minimum Data Set (MDS) with a reference date of 10/04/16, revealed in part that he was severely cognitively impaired, required extensive physical assistance of one Certified Nursing Assistant (CNA) with dressing, eating, and hygiene. Review of Resident #5's Care Plan revealed in part that a plan of care was developed for his [MEDICAL CONDITIONS] which included that nursing staff were to monitor Resident #5's intake and output and to notify the Physician of [MEDICAL CONDITION]. A plan of care was also developed for Resident #5 for requiring extensive to total assistance from staff with his daily needs which included to assist with bed mobility, transfers, and feeding and that the registered dietician was to evaluate my diet as appropriate. Resident #5's Care Plan also revealed that Resident #5 was at risk for infection related to his incontinence and that Resident #5's labs were to be done as ordered by the physician, that fluids should be encouraged, and that the Physician was to be notified of any significant changes. Resident #5 Care Plan further revealed that a plan of care was developed for his urine incontinence with interventions to include, in part, evaluate Resident #5's fluid intake and hydration status. Review of Resident #5's Registered Dietician assessment dated [DATE] revealed in part that Resident #5's intake of food and supplements was inadequate, and that he was to have 2200-2600 cubic centimeters (cc) of fluid per day with staff to monitor intake, labs, skin, and hydration. Review of Resident #5's Departmental Notes dated 11/24/16 at 3:12pm, revealed in part, that Resident #5 had blood tinged urine at which time the Physician was notified with an order to catheterize Resident #5 to obtain a specimen for a urinary analysis (UA) with culture and sensitivity, and to give Bactrim DS (antibiotic medication used to treat infection) every 12 hours for seven days. There was no documented evidence and the facility did not present any documented evidence that a urine specimen was obtained as ordered or that Resident #5's Physician was notified that a urine specimen could not be obtained on 11/24/16 or on 11/25/16. Review of Resident #5's Department Notes dated 11/26/16 at 6:12am, revealed a second attempt to retrieve a urine specimen via in and out catheter was unsuccessful due to possible trauma as indicated by light active bleeding from the meatus which stopped after five minutes. Further review revealed Resident #5 showed no signs of pain or discomfort from resident, and will report to on-coming nurse. There was no documented evidence and the facility did not present any documented evidence that a urine specimen was obtained as ordered or that Resident #5's Physician was notified of possible trauma or that a urine specimen could not be obtained on 11/26/16. Review of Resident #5's Departmental Notes dated 11/26/16 at 10:44am, revealed S7/LPN found Resident #5 unresponsive, with labored breathing and an oxygen saturation of 69%, a blood pressure of 89/43, a pulse of 112 beats per minute, 16 respirations per minute, and a temperature of 99.5*Fahrenheit. Further review revealed Resident #5's Physician was notified with an order to send Resident #5 to the hospital emergency room (ER) for evaluation. Review of Resident #5's hospital records revealed in part that he was seen in the emergency roiagnom on [DATE] at 11:32am, because of a change in mental status. Review of Resident #5's emergency department physical exam revealed a blood pressure of 153/128, a pulse of 136 beats per minute, a temperature of 101.5*Fahrenheit, and an oxygen saturation of 88%. Further review revealed Resident #5 was mildly sweating and had dry mucous membranes with white plaques noted to the back of the mouth, was moaning, and had right sided rhonchi. Further review revealed that critical care was necessary to treat or prevent imminent or life-threatening deterioration [MEDICAL CONDITION]. Review of Resident #5's laboratory results drawn in the emergency room revealed the following abnormal results, in part with the source of the general laboratory reference ranges via www.medscape.com: White Blood Count (WBC): 23.26 (general reference range: 4-10) Hemoglobin: 10.9 (general reference range: 13-17) Hematocrit: 34.9 (general reference range: 40-52) Sodium: 167 (general reference range: 135-145) Chloride: 129 (general reference range: 95-105) Blood Urea Nitrogen (BUN): 34 (general reference range: 8-21) Total Protein: 8.9 (general reference range: 60-80) [MEDICATION NAME]: 1.6 (general reference range: 3.5-5.5) Urine Appearance: cloudy (general reference range: clear) Protein, UA: 2+ (general reference range: 0) Occult Blood, UA: 3+ (general reference range: negative) Leukocytes, UA: 2+ (general reference range: negative); and Bacteria, UA: Moderate (general reference range: none). Review of Resident #5's Critical Care Medicine Physician's Progress Notes dated 11/26/16 revealed in part, that Resident #5 had recently experienced neglect, was admitted to ICU for [REDACTED]. Further review revealed Resident #5 was estimated to have a 9.4 Liter free water deficit. In interview on 12/14/16 at 10:00am with S7/Licensed Practical Nurse (LPN) indicated Resident #5 was totally dependent on staff for water and that he could not hold a cup or get and drink anything independently. S7/LPN further indicated Saturday morning on 11/26/16 at 7:00am, she received a report from S23/LPN a urine specimen could not be obtained on Resident #5. S7/LPN further indicated while she was doing her 8:00am medication pass, which was done between 7:00am to 9:00am, she noticed that Resident #5 did not ask for water like he usually did. Resident #5 was lethargic, unresponsive, looked clammy, had a temperature, had labored breathing, and had an oxygen saturation of 69%. S7/LPN verified that she called Resident #5's Physician at around 10:45am, and was given an order to send to the ER for an evaluation. S7/LPN was then asked why she didn't notify Resident #5's Physician earlier and S7/LPN indicated that she had a lot going on that day and had to get everything situated. S7/LPN indicated CNAs document fluid intake and the nurses look at the total fluid intakes at the end of every shift. S7/LPN was asked what total fluid intake amount for a day would cause her to become concerned and S7/LPN indicated that she wouldn't be concerned until a resident's total intake for a day was less than 100cc. Review of Resident #5's Fluid Intake and Output Roster for the month of November 2016 revealed in part: Fluid intake total for 11/2/16 was 360 cubic centimeters (cc); Fluid intake total for 11/04/16 was 270cc; Fluid intake total for 11/07/16 was 120cc; Fluid intake total for 11/08/16 was 240cc; Fluid intake total for 11/10/16 was 120cc; Fluid intake total for 11/12/16 was 150cc; Fluid intake total for 11/13/16 was 240cc; Fluid intake total for 11/14/16 was 240cc; and Fluid intake total for 11/15/16 was 150cc. Further review revealed Resident #5's fluid intake was not monitored for the following dates from 11/01/16 through 11/26/16: 11/01/16, 11/03/16, 11/05/16, 11/06/16, 11/09/16, 11/11/16, 11/16/16, 11/17/16, 11/18/16, 11/19/16, 11/20/16, 11/21/16, 11/22/16, 11/23/16, 11/24/16, and 11/25/16. The facility was not able to present any other documentation which showed that Resident #5's fluid intake was monitored as required. Review of Resident #5's Dehydration Monitoring form which included signs and symptoms of dehydration which included in part: dry mucous membranes, decreased urine output, decreased skin turgor, confusion or change in mental status, lethargy, and fever. Further review revealed nursing staff assessed Resident #5 as having no signs or symptoms of dehydration from 11/01/16 through 11/26/16 at 2:07am. Review of Resident #5's clinical record revealed no documented evidence and the facility did not present any documented evidence that Resident #5's vital signs were taken between 10/18/16 through 11/26/16. In interview on 12/14/16 at 10:10am, S22/Nurse Practitioner reviewed the above with the surveyor and did not dispute the hospital records or the above findings. S22/Nurse Practitioner further indicated that Resident #5's Percutaneous Endoscopic Gastrostomy tube (feeding tube) was a result of his hospitalization . In interview on 12/14/16 at 2:30pm, S1/Administrator, S2/Director of Nursing (DON), and S3/Quality Assurance (QA)/Quality Improvement (QI) Nurse were informed of the above findings and were asked if they wanted to present anything to the surveyors to dispute the above mentioned findings and S3/QA/QI Nurse indicated that residents have opportunities to get fluids with meals and during the medication pass, and staff only document accurate intake and outputs (I&Os) on residents with fluid restrictions; therefore, Resident #5's I&Os may be misleading but given Resident #5's history, his I&Os should have been monitored more closely. S2/DON indicated that they had already been QAing vital signs, and S1/Administrator offered no response.

Based on observation, interview and record review the facility failed to ensure they had nursing staff sufficient nursing staff with the appropriate competencies and skills sets in number which ensured each resident was provide services to assure resident safety and attain or maintain their highest practicable physical well-being for 2 (Resident #1 and Resident #5) of 5 sampled residents in a total sample of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5). The facility failed to: 1.) Identify and assess a left lateral fibula ulcer which was proximal to the malleolus ulcer which had exposed fibular bone and a left ankle ulcer with exposed hardware (Resident #5); 2.) Assess a resident and promptly notify the physician of a change of condition in a resident with decrease fluid intake and low urine output (Resident #1); 3.) Ensure that the nursing staff promptly notify the physician that Resident #1 was noted with yellow discharge coming from his penis, sediment in his urine, slurred speech on 12/26/16 at 2:29am (Resident #1); 4.) Ensure residents were assisted with hydration and offered sufficient fluid intake to maintain proper hydration and health (Resident #1); and 5.) Assess and identify blisters and redness to a Resident's lower extremities and mid-back area (Resident #1). Actual harm occurred for Resident #5, a cognitively impaired resident, when the facility failed to identify new pressure wounds and deteriorating venous wound. The facility also failed to ensure nursing staff identify that the resident had a low fluid intake and output. On 11/26/16 Resident #5 became unresponsive, with labored breathing. Resident #5 was sent to the hospital, admitted to the Intensive Care Unit (ICU), was placed on a ventilator with [DIAGNOSES REDACTED]. Resident #5 was estimated to have a 9.4 Liter free water deficit. Actual harm occurred for Resident #1,a physically impaired resident, with an indwelling foley catheter was noted with a yellow discharge coming from his penis, sediment in his urine, slurred speech on 12/26/16 at 2:29am. Further review of his medication revealed his medications were held. The resident's physician was not immediately notified of these changes. On 12/26/16 at 6:24pm, Resident #1 had a change in mental status described as confusion, head turned to one side, slurred speech, and labored breathing. Resident #1 was sent to the hospital and diagnosed with [REDACTED]. Resident #1 was placed in the Intensive Care Unit (ICU) placed on a ventilator. Findings: 1.) Cross reference to findings at tag F157; 2.) Cross reference to findings at tag F223; 3.) Cross reference to findings at tag F309: 4.) Cross reference to findings at tag F314; 5.) Cross reference to findings at tag F315; 6.) Cross reference to findings at tag F327; 7.) Cross reference to findings at tag F490; and 8.) Cross reference to findings at tag F502. Resident #5 Review of Resident #5's Departmental Notes dated 11/26/16 at 10:44am, revealed S7/LPN found Resident #5 unresponsive, with labored breathing and an oxygen saturation of 69%, a blood pressure of 89/43, a pulse of 112 beats per minute, 16 respirations per minute, and a temperature of 99.5*Fahrenheit. Further review revealed Resident #5's Physician was notified with an order to send Resident #5 to the hospital emergency room for evaluation. Review of Resident #5's hospital records revealed in part that he was seen in the emergency roiagnom on [DATE] at 11:32am, because of a change in mental status and had a sacral ulcer to the left buttock without purulent drainage or surrounding redness, and a 3 centimeter (cm) deep right heel ulcer with purulent, foul smelling drainage, left ankle ulcer with exposed hardware, and an ulcer to the lateral aspect of the left lower leg. Further review revealed Resident #5 was referred to podiatry because of his right heel ulcer and exposed hardware to the left ankle. Review of Resident #5's physical exam of his wounds performed by a Podiatrist revealed in part, that Resident #5 had an infected left lateral malleolus malodorous ulcer with serosanguineous drainage with exposed hardware which consisted of a plate and screw. Resident #5 also had a left lateral fibula ulcer which was proximal to the malleolus ulcer which had exposed fibular bone. Resident #5's exam further revealed Resident #5 also had an infected right posterior heel ulcer with a pungent odor, drainage, and exposed bone. Further review revealed that critical care was necessary to treat or prevent imminent or life-threatening deterioration [MEDICAL CONDITION] and right heel debridement. In interview on 12/14/16 at 10:00am with S7/LPN indicated while she was doing her 8:00am medication pass, which is done between 7:00am to 9:00am, she noticed that Resident #5 did not ask for water like he usually did. Resident #5 was lethargic, unresponsive, looked clammy, had a temperature, had labored breathing, and had an oxygen saturation of 69%. S7/LPN verified that she called Resident #5's Physician at around 10:45am, and was given an order to send to the hospital emergency room (ER) for an evaluation. S7/LPN was then asked why she didn't notify Resident #5's Physician earlier and S7/LPN indicated that she had a lot going on that day and had to get everything situated. S7/LPN indicated CNAs document fluid intake and the nurses look at the total fluid intakes at the end of every shift. S7/LPN was asked what total fluid intake amount for a day would cause her to become concerned and S7/LPN indicated that she wouldn't be concerned until a resident's total intake for a day was less than 100cc. In interview on 12/14/16 at 2:30pm, S1/Administrator, S2/DON, and S3/QA/QI Nurse were informed of the above findings and were asked if they wanted to present anything to the surveyors to dispute the above mentioned findings and S3/QA/QI Nurse indicated that residents have opportunities to get fluids with meals and during the medication pass, and staff only document accurate intake and outputs (I&Os) on residents with fluid restrictions; therefore, Resident #5's I&Os may be misleading but given Resident #5's history, his I&Os should have been monitored more closely. S2/DON indicated that they had already been QAing vital signs, and S1/Administrator offered no response. Resident #1 Review of Progress Notes dated 12/05/16 and documented by S13/Licensed Practical Nurse (LPN) revealed a skin assessment was completed and Resident#1 was noted to have three blisters along the left side of his abdomen, two of which were open. Review of the progress note revealed the wound care nurse was informed and the dressing was clean, dry and intact to site. There was no documentation that the physician and responsible party were notified. Review of Resident #1's Wound Assessment Notes from 11/18/16 through 12/13/16 revealed discussion of a Stage 2 pressure ulcer to the right buttock only. There was no mention of [MEDICAL CONDITION] and blisters to both lower legs, nor was there mention of any dressings to Resident #1's leg or mid/lateral trunk. An observation was made on 12/09/16 at 10:40am of Resident #1 with S15/LPN. Resident#1 was noted to have a large reddened area to both anterior legs. Legs appeared to be [MEDICAL CONDITION]. Also noted were some blisters on the inflamed areas to the legs. Also noted were two 4x4 dressings to left mid back/side area. The dressings were not initialed and dated but had 4 J written on one of the dressings. The dressings were soiled with what appeared to be old drainage. In interview at this time, S15/LPN explained that Resident #1's dressings were from a past pain pump insertion site. Observation revealed Resident #1 had a Stage 2 pressure ulcer to the right buttock and a Stage 2 to the right buttock crease. Observation on 12/09/16 at 12:10pm revealed S4/Registered Nurse (RN) Treatment Nurse performed a skin assessment on Resident #1. When Resident #1's reddened, [MEDICAL CONDITION] and blistered legs were pointed out by the surveyor, S4/RN Treatment Nurse stated Resident #1 had [MEDICAL CONDITION] off and on. S4/RN Treatment Nurse was unaware of the blisters and the extent of the [MEDICAL CONDITION] to Resident #1's legs. S4/RN Treatment Nurse confirmed there was no treatment ordered for Resident #1's leg blisters. S4/RN Treatment Nurse was shown the two dressings on Resident #1's left mid-back. S4/RN Treatment Nurse confirmed that she did not know how long the dressings were there, nor what was under the dressings. The two dressings to left mid-back area were removed by S4/RN Treatment Nurse which revealed three Stage 2 open areas. S4/RN Treatment Nurse stated that she had no knowledge of the dressings and that any changes in wounds and skin condition should be reported to her by the assistant treatment nurse. In interview on 12/13/16 at 12:20pm S4/RN Treatment Nurse indicated that the three open areas to Resident #1's left lateral/side were reported to S6/RN part time wound care nurse by S13/LPN. S4/RN Treatment Nurse indicated the condition of Resident #1's legs and three open areas to his left lateral side were not reported to S4/RN Treatment Nurse or to the physician. In a telephone interview on 12/13/16 at 12:36pm, S13/LPN indicated she was informed of Resident #1's blisters to his back area by the CNA. S13/LPN stated she reported the two open areas to the wound care nurse who dressed it. S13/LPN did not confirm that it was reported to the physician. In interview on 12/14/16 at 2:20pm S1/Administrator, S2/RN Director of Nursing (DON), and S3/RN Quality Assurance/Quality Improvement Nurse acknowledged staff should have identified and addressed [MEDICAL CONDITION] to Resident #1's leg and pressure ulcers to Resident#1's back, and the physician and Resident #1's responsible party should have been informed of the changes. Review of Resident #1's Nurse's Notes entry dated 12/25/16 at 11:15pm revealed Resident #1 was noted with a yellow discharge coming from his penis and sediment in his urine, and the nurse faxed Resident #1's change in condition to the doctor's office on 12/26/16 at 11:15pm. Review of a fax to a physician's office dated 12/26/16 at 2:29am revealed Resident #1 was noted with a cup and bottle with alcohol, speech slurred, red eyes, a yellow discharge from his penis, and sediment in his urine. Further review revealed the nurse withheld his medications. There was no documented evidence and the facility did not present any documented evidence that Resident #1's Physician was called at this time, that anyone responded that they received the fax at that time, or that Resident #1's Physician reviewed the above mentioned fax at that time. In interview on 12/14/16 at 2:20pm S1/ Administrator, S2/Director of Nursing (DON), and S3/RN Quality Assurance (QA)/Quality Improvement (QI) Nurse acknowledged the deficient practice and stated staff should have identified and addressed [MEDICAL CONDITION] to Resident #1's leg and blisters to Resident#1's back, and the physician and residents' responsible party should have been informed of the changes. In interview on 12/28/16 at 11:00am, S2/Director of Nurses (DON) reviewed Resident #1's nursing notes regarding penile discharge and urinary sediment and was asked if the nurse notified the physician of these findings. S2/DON stated the nurse faxed a communication to the physician's office. S2/DON reviewed and confirmed that the fax was sent on 12/26/16 at 02:29am. S2/DON was unable to verify if the physician received and/or reviewed the faxed communication in a timely manner. Upon review of Resident #1's care plan, S2/DON confirmed there was no plan of care developed for the use of a foley catheter for staff to follow and prevent possible urinary tract infections. In interview on 12/28/16 at 4:10pm, S1/Administrator, S2/DON, S3/QA/QI Nurse, and S26/Regional Director indicated that they realize they have a lot of work to do, and would work hard to address the above.

Based on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (Resident #1 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to: 1.) Implement its policies and procedures that prohibit and prevent abuse/neglect by failing to ensure an allegation of neglect related to a resident receiving necessary care and services from medical staff was thoroughly investigated (Resident #5). 2.) Ensure sufficient nursing staff with the appropriate competencies and skills sets to provide services to assure resident safety and attain or maintain their highest practicable physical, and mental well-being (Resident #1 and Resident #5). Actual harm occurred for Resident #5, a cognitively impaired resident, when the facility failed to identify new pressure wounds and deteriorating venous wound. The facility also failed to ensure nursing staff identify that the resident had a low fluid intake and output. On 11/26/16 Resident #5 became unresponsive, with labored breathing. Resident #5 was sent to the hospital, admitted to the Intensive Care Unit (ICU), was placed on a ventilator with [DIAGNOSES REDACTED]. Resident #5 was estimated to have a 9.4 Liter free water deficit. Actual harm occurred for Resident #1,a physically impaired resident, with an indwelling foley catheter was noted with a yellow discharge coming from his penis, sediment in his urine, slurred speech on 12/26/16 at 2:29am. Further review of his medication revealed his medications were held. The resident's physician was not immediately notified of these changes. On 12/26/16 at 6:24pm, Resident #1 had a change in mental status described as confusion, head turned to one side, slurred speech, and labored breathing. Resident #1 was sent to the hospital and diagnosed with [REDACTED]. Resident #1 was placed in the Intensive Care Unit (ICU) placed on a ventilator. Findings: 1.) Cross reference to findings at tag F157; 2.) Cross reference to findings at tag F223; 3.) Cross reference to findings at tag F226; 4.) Cross reference to findings at tag F309: 5.) Cross reference to findings at tag F314; 6.) Cross reference to findings at tag F315; 7.) Cross reference to findings at tag F327; 8.) Cross reference to findings at tag F353; 9.) Cross reference to findings at tag F502; and 10.) Cross reference to findings at tag F520 In interview on 12/28/16 at 4:10pm, S1/Administrator, S2/Director of Nursing, S3/Quality Assurance (QA)/Quality Improvement (QI) Nurse, and S26/Regional Director indicated they realized they had a lot of work to do, and would work hard to address the above.

Based on interview and record review the facility that is responsible for the quality and timeliness of laboratory services failed to provide or obtain laboratory services to meet the needs of its resident(s) by: 1,) failing to obtain a urinalysis (UA) (laboratory test to detect infection in urine) lab as ordered by the Physician (Resident #5); 2.) failing to obtain a urine culture (laboratory test to determine the presence of bacteria in urine) lab as ordered by the Physician (Resident #5); and 3.) failing to obtain a urine sensitivity (laboratory test which determines which antibiotic the bacteria is sensitive to in order to treat the infection) lab as ordered by the Physician (Resident #5). This deficient practice resulted in an actual harm when a physician's orders [REDACTED].#5. Resident #5 was a cognitively impaired resident requiring assistance from staff for all activities of daily living who became unresponsive on 11/26/16. Resident #5 also had labored breathing, an oxygen saturation of 69%, a blood pressure of 89/43, a pulse of 112 beats per minute, 16 respirations per minute, and a temperature of 99.5*Fahrenheit. Resident #5 was sent to the hospital, was diagnosed with [REDACTED]. Resident #5 was estimated to have a 9.4 Liter free water deficit. Resident #5 was admitted to the Intensive Care Unit (ICU), was placed on a ventilator, underwent wound debridement, and Percutaneous Endoscopic Gastrostomy (PEG) tube placement (a flexible tube placed through the abdominal wall and into the stomach which allows nutrition, fluids, and/or medications to be put directly into the stomach). This deficient practice was identified for 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents receiving care and services from the facility, but had the potential to affect any of the 173 residents who reside at the facility as documented on the facility's CMS Form-672 Resident Census and Conditions of Residents. Findings: Review of Resident #5's Departmental Notes dated 11/24/16 at 3:12pm, revealed in part, that Resident #5 had blood tinged urine at which time the Physician was notified with an order to catheterize Resident #5 to obtain a specimen for a urinalysis, and culture and sensitivity test. An order was also given to start Bactrim DS (antibiotic medication used to treat infection) every 12 hours for seven days. Review of Resident #5's Department Notes dated 11/26/16 at 6:12am, revealed a second attempt to retrieve a urine specimen via in and out catheter was unsuccessful due to possible trauma as indicated by light active bleeding from the meatus (the point where urine exits the urethra) which stopped after five minutes. Further review revealed Resident #5 showed no signs of pain or discomfort from resident, and would report to on-coming nurse. Review of Resident #5's Departmental Notes dated 11/26/16 at 10:44am, revealed S7/Licensed Practical Nurse (LPN) found Resident #5 unresponsive, with labored breathing and an oxygen saturation of 69%, a blood pressure of 89/43, a pulse of 112 beats per minute, 16 respirations per minute, and a temperature of 99.5*Fahrenheit. Further review revealed Resident #5's Physician was notified with an order to send Resident #5 to the hospital emergency room for evaluation. Review of Resident #5's hospital records revealed in part that he was seen in the emergency roiagnom on [DATE] at 11:32am, because of a change in mental status. Review of Resident #5's emergency department physical exam revealed a blood pressure of 153/128, a pulse of 136 beats per minute, a temperature of 101.5*Fahrenheit, 16 respirations per minute, and an oxygen saturation of 88%. Further review revealed Resident #5 was mildly sweating and had dry mucous membranes with white plaques noted to the back of the mouth, was moaning, had right sided rhonchi, a sacral ulcer to the left buttock without purulent drainage or surrounding redness, and a 3 centimeter (cm) deep right heel ulcer with purulent, foul smelling drainage, left ankle ulcer with exposed hardware, and an ulcer to the lateral aspect of the left lower leg. Further review revealed Resident #5 was referred to podiatry because of his right heel ulcer and exposed hardware to the left ankle. Review of Resident #5's physical exam of his wounds performed by a Podiatrist revealed in part, that Resident #5 had an infected left lateral malleolus malodorous ulcer with serosanguineous drainage with exposed hardware which consisted of a plate and screw. Resident #5 also had a left lateral fibula ulcer which was proximal to the malleolus ulcer which had exposed fibular bone. Resident #5's exam further revealed Resident #5 also had an infected right posterior heel ulcer with a pungent odor, drainage, and exposed bone. Further review revealed that critical care was necessary to treat or prevent imminent or life-threatening deterioration [MEDICAL CONDITION] and right heel debridement. Review of Resident #5's laboratory results drawn in the emergency room revealed the following abnormal results, in part: White Blood Count (WBC): 23.26 (general reference range: 4-10) Hemoglobin: 10.9 (general reference range: 13-17) Hematocrit: 34.9 (general reference range: 40-52) Sodium: 167 (general reference range: 135-145) Chloride: 129 (general reference range: 95-105) BUN: 34 (general reference range: 8-21) Total Protein: 8.9 (general reference range: 60-80) [MEDICATION NAME]: 1.6 (general reference range: 3.5-5.5) Urine Appearance: cloudy (general reference range: clear) Protein, UA: 2+ (general reference range: 0) Occult Blood, UA: 3+ (general reference range: negative) Leukocytes, UA: 2+ (general reference range: negative); and Bacteria, UA: Moderate (general reference range: none). Review of Resident #5's hospital records also revealed that his chest x-ray result showed bilateral [MEDICAL CONDITIONS], was admitted to the Intensive Care Unit (ICU) in serious condition, was hospitalized and placed on a ventilator, underwent wound debridement, and PEG tube placement. Review of Resident #5's Critical Care Medicine Physician's Progress Notes dated 11/26/16 revealed in part, that Resident #5 had recently experienced neglect, was admitted to ICU for [REDACTED]. Further review revealed Resident #5 was estimated to have a 9.4 Liter free water deficit. There was no documented evidence and the facility did not present any documented evidence that a urine specimen was ever obtained by the facility as ordered or that Resident #5's Physician was notified that a urine specimen could not be obtained by facility staff. In interview on 12/14/16 at 2:05pm, S8/LPN indicated the night nurses were responsible for obtaining urine specimens unless it was a stat order. In interview on 12/27/16 at 12:20pm, S2/Director of Nursing (DON) indicated the system for obtaining labs was that the ward clerk and medical records person was to manage and coordinate all scheduled labs. They look to make sure everything was updated and the ward clerk sends requisitions to the lab on who and what labs need to be drawn. S2/DON further indicated that the Nurses inform them of any new labs and/or stat lab orders. Labs are routinely drawn on Monday, Wednesday, and Friday mornings and the results come in by the afternoon which are obtained by the Assistant Director of Nursing (ADON), reviewed by a Registered Nurse (RN) who then gives them to the ward clerk (also known as the unit coordinator) who then sends the results to the Physician. S2/DON also indicated if stat labs are obtained, the nurses report off to the oncoming nurse if results were not obtained on their shift. In interview on 12/27/16 at 2:10pm, S23/Ward Clerk was asked about the system for obtaining labs, and indicated that she was notified by the nurse of an order for [REDACTED]. In interview on 12/27/16 at 2:25pm, S8/LPN was asked why Resident #5's labs ordered on [DATE] weren't done as ordered and indicated that she thought it was because labs are only done by the night nurse on Mondays, Wednesdays, and Fridays, and if the nurse couldn't get the UA on Friday, then they probably were going to wait until Monday to get it, but wasn't sure. In interview on 12/27/16 at 3:10pm with S2/DON and S3/Quality Assurance (QA)/Quality Improvement (QI) Nurse were informed of the above and indicated urine specimens should be obtained by facility nursing staff when the order is received then call the lab to come and pick up the specimen and that staff shouldn't wait for a Monday, Wednesday, or Friday to obtain a urine specimen. S2/DON and S3/QA/QI Nurse further indicated they had done in-services, but may have to re-educate nursing staff and be specific on what and when labs should be done. S2/DON and S3/QA/QI Nurse were asked why no one realized that the lab orders were not carried out, and S2/DON and S3/QA/QI Nurse indicated in this particular case they did not know why, that it should have been done, and it just fell through the cracks.

Based on observation, interview and record review the facility failed to maintain a quality assessment and assurance committee that developed and implemented appropriate plans of action to correct identified quality deficient practice for 2 (Resident #1 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to: 1.) Ensure sufficient nursing staff were equipped with appropriate competencies and skills sets to provide services to assure resident safety and attain or maintain their highest practicable physical and mental well-being (Resident #1 and Resident #5). 2.) Assess a resident and promptly notify the physician of a change of condition in a resident with decrease fluid intake and low urine output (Resident #1); 3.) Ensure a resident with an indwelling foley catheter received the appropriate treatment and services to prevent urinary tract infections (Resident #1); 4.) Implement its policies and procedures that prohibit and prevent abuse/neglect by failing to ensure an allegation of neglect related to a resident receiving necessary care and services from medical staff was thoroughly investigated (Resident #1); and 5.) Ensure residents were assisted with hydration and offered sufficient fluid intake to maintain proper hydration and health (Resident #5). Actual harm occurred for Resident #5 when the facility failed to notify the physician when a cognitively impaired resident had a deteriorating venous wound, new wounds, and not being able to obtain a urine specimen as ordered. The facility further failed to ensure nursing staff notified the physician when Resident #5 was found to be lethargic, short of breath with an oxygen saturation of 69%. The facility also failed to ensure nursing staff identified that the resident had a low fluid intake and output. On 11/26/16 Resident #5 became unresponsive, with labored breathing. Resident #5 was sent to the hospital, admitted to the Intensive Care Unit (ICU), was placed on a ventilator with [DIAGNOSES REDACTED]. Resident #5 was estimated to have a 9.4 Liter free water deficit. Actual harm occurred for Resident #1, a physically impaired resident, with an indwelling foley catheter was noted with a yellow discharge coming from his penis, sediment in his urine, slurred speech on 12/26/16 at 2:29am. Further review of his medication revealed his medications were held. The resident's physician was not immediately notified of these changes. On 12/26/16 at 6:24pm, Resident #1 had a change in mental status described as confusion, head turned to one side, slurred speech, and labored breathing. Resident #1 was sent to the hospital and diagnosed with [REDACTED]. Resident #1 was placed in the Intensive Care Unit (ICU) placed on a ventilator. Findings: 1.) Cross reference to findings at tag F223; 2.) Cross reference to findings at tag F314; 3.) Cross reference to findings at tag F315; 4.) Cross reference to findings at tag F327; and 5.) Cross reference to findings at tag F502. Review of the facility's census on 12/28/16, revealed a resident census of 173 residents. In interview on 12/28/16 at 9:45am, S3/Quality Assurance (QA)/Quality Improvement (QI) Nurse indicated the surveyors were provided all of the QA documentation that was completed since 12/14/16. Review of the facility's Continuous Quality Improvement Corrective Action Plan dated 12/15/16 for hydration revealed in part that hydration rounds were completed on three random resident rooms with one room being observed with an empty water pitcher which was refilled at the time of the observation. Further review revealed hydration rounds were completed on three random resident rooms on 12/21/16 with one room being observed with an empty water pitcher which was refilled at the time of the observation. Another hydration round was completed on 12/27/16 on three random resident rooms with one room being observed with an empty water pitcher which was refilled at the time of the observation. There was no documented evidence and the facility did not present any documented evidence that the residents identified with empty water pitchers were able to get hydration themselves or relied on staff for hydration. There was no documented evidence that residents were observed for dehydration and/or that any documented evidence which showed that the QA plan was changed to prevent the identified issue of residents having empty water pitchers in their room. Review of the facility's Continuous Quality Improvement Corrective Action Plan dated 11/30/16 revealed in part, that one of the identified problems was residents were started on antibiotic therapy for urinary tract infections and the infection report and task care plan was not initiated, but there was no documented evidence that a QA was developed to prevent Urosepsis. There was no documented evidence and the facility did not present any documented evidence which showed that the QA plan was changed to include any follow-up which acted upon the above observation(s). Review of the facility's Quality Assurance (QA) plan for ensuring vital signs revealed in part, three resident records were audited once a week beginning on 12/06/16, to check if vital signs were documented. Further review of the audit conducted for the week of 12/19/16 through 12/25/16 revealed vital signs were missing on one of the three charts reviewed. There was no documented evidence and the facility did not present any documented evidence that the resident with missing vital signs was assessed to see if he was stable, that the person who had not documented the vital signs was re-educated, that other resident's under that person's care had missing vital signs as well, and/or that the audit sample size was expanded, or that the QA plan was changed to include any follow-up which acted upon the above audit. In interview on 12/28/16 at 11:45am, S3/QA/QI Nurse was asked about the above and indicated he didn't think it was done. S3/QA/QI Nurse was then asked if anything was done or changes made to the QA after problems were noted during the audits, and indicated no, but would see if the Director of Nursing (DON) or Assistant Director of Nursing (ADON) had done anything, and would present the information to the surveyor if found. S3/QA/QI Nurse further indicated the QA plan may have not been the best, but would work on it, and realized how three audits done once a week with nothing done after problems were identified looked like, but realizes a lot needs to be done and would work hard to get it done. There was no additional information presented to the surveyors other than what was already provided. In interview on 12/28/16 at 4:10pm, S1/Administrator, S2/DON, S3/QA/QI Nurse, and S26/Regional Director indicated that they realize they have a lot of work to do, and would work hard to address the above.

Based on interview and record review, the facility failed to ensure a resident with an indwelling foley catheter received the appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. The facility failed to: 1.) Accurately assess a resident who was readmitted to the facility with an indwelling foley catheter; 2.) Develop a plan of care for a resident with an indwelling foley catheter; and 3.) Promptly notify a Physician of Resident #1 having a yellow discharge from his penis and sediment in his urine. This deficient practice resulted in an actual harm when Resident #1 was noted with a yellow discharge from his penis and sediment in his urine. The resident's Physician was not immediately notified of these changes. On 12/26/16 at 06:24pm, Resident #1 had a change in mental status described as confusion, head turned to one side, slurred speech, and labored breathing. Resident #1 was sent to the hospital and diagnosed with [REDACTED]. Resident #1 was admitted to the Intensive Care Unit (ICU) and during this hospitalization , Resident #1 was placed on a ventilator. Findings: Review of Resident #1's clinical record revealed, in part, that he was admitted to the facility 10/12/15, and readmitted on [DATE], with [DIAGNOSES REDACTED]. Further review of Resident #1's clinical record revealed he had a history of [REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/16 revealed, in part, he was incontinent of bowel and bladder, had functional limitation in range of motion to upper and lower extremities, required extensive assistance of two Certified Nursing Assistants (CNAs) with bed mobility, transfers, toilet use, and totally dependent on staff for personal hygiene and bathing. Further review of the MDS/ARD of 10/25/16, Section H, Bowel and Bladder, Subsection H0100 - Appliances - revealed a box checked as None of the above which indicated no documentation of an indwelling foley catheter for Resident #1. Review of Resident #1's record on 12/27/16 revealed, in part, that a Care Plan was developed for urinary incontinence with approaches which included, in part, for staff to assist Resident #1 with personal care cleaning as needed, observe for behavioral changes that may indicate a urinary tract infection, to evaluate his fluid intake and hydration status. A Care Plan was also developed for cognitive loss related to stroke, with approaches which included, in part, report any changes to my doctor. Further review revealed no Care Plan was developed for Resident #1's use of an indwelling foley catheter. Review of Resident #1's record revealed a Fax Form for Non-Emergency Communication dated 10/15/16 at 1:30pm which read, in part, Resident #1 returned to the facility with a foley catheter for [MEDICAL CONDITION]. Review of Resident #1's Nurse's Notes entry dated 12/25/16 at 11:15pm revealed Resident #1 was noted with a yellow discharge coming from his penis and sediment in his urine, and the nurse faxed Resident #1's change in condition to the doctor's office on 12/26/16 at 11:15pm. Review of a fax to a physician's office dated 12/26/16 at 2:29am revealed Resident #1 was noted with a cup and bottle with alcohol, speech slurred, red eyes, a yellow discharge from his penis, and sediment in his urine. Further review revealed the nurse withheld his medications. There was no documented evidence and the facility did not present any documented evidence that Resident #1's Physician responded that the fax was received at that time, or that Resident #1's Physician reviewed the above mentioned fax at that time. Review of Resident #1's Nurse's Notes entry dated 12/26/16 at 7:40am revealed, in part, an empty bottle of whiskey was found in Resident #1's room, and Resident #1 cried most of the shift and even called 911 twice. Review of Resident #1's December 2016 electronic Medication Administration Record [REDACTED] 2:00pm: [MEDICATION NAME] 10 milligrams (mg) by mouth every 8 hours (a muscle relaxant); 05:00pm: Prostat 30 milliliters (ml) by mouth twice daily (a protein supplement used to aid in wound healing); Potassium Chloride ER 10 milliequivalent (meq) by mouth twice daily (a supplement used to treat low levels of potassium in the blood); [MEDICATION NAME] 300mg by mouth every evening (an antacid); [MEDICATION NAME] 300mg by mouth three times a day (an anti-[MEDICAL CONDITION] medication, also used for nerve pain); 09:00pm: Tamsulosin [MEDICATION NAME] 0.4mg by mouth at bedtime (a medication used to treat the symptoms of [MEDICAL CONDITION] which is defined as prostate gland enlargement which can block the flow of urine out of the bladder and cause bladder, urinary tract or kidney problems); and 10:00pm: [MEDICATION NAME] 10mg by mouth every 8 hours (a muscle relaxant). Further review of Resident #1's December 2016 eMAR revealed the following medications were withheld on 12/26/16 at: 05:00pm: Potassium Chloride ER 10meq by mouth twice daily; Prostat 30ml by mouth twice daily; and [MEDICATION NAME] 300mg by mouth every evening. There was no documented evidence and the facility provided no documented evidence that Resident #1's Physician was notified of withheld medications. Review of Resident #1's Nurse's Notes entry dated 12/26/16 at 6:24pm revealed Resident #1 had a change in mental status described as confusion, head turned to one side, slurred speech, and labored breathing. An empty bottle of liquor was found in Resident #1's sheets. Resident #1 was found to have an oxygen saturation of 85%, a blood pressure of 138/67, a pulse of 101, and a temperature of 105.3*Fahrenheit. The Physician was notified and ordered Resident #1 to be sent out. Review of Resident #1's hospital records revealed, in part, that he was seen in the emergency roiagnom on [DATE] at 6:29pm with [MEDICAL CONDITION] activity, gaze fixed to the left, unresponsive to pain, and cloudy urine in his foley bag which was placed prior to his arrival in the Emergency Department (ED). Review of Resident #1's emergency department physical exam revealed a blood pressure of 112/86, a pulse of 108 beats per minute, 20 respirations per minute, a temperature of 103*Fahrenheit, and an oxygen saturation of 98%. Further review revealed, in part, Resident #1 was actively seizing upon arrival to the ED, with dry mucous membranes, twitching appreciated with left gaze preference, [MEDICAL CONDITION](a resting heart rate of over 100 beats per minute), indwelling catheter with sediment appreciated in the foley bag. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Central Nervous System (CNS) Failure or Compromise,[MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of Resident #1's initial assessment by ED Physician revealed, in part, Resident #1 was febrile, actively seizing, given Intravenous (IV) medications, remained lethargic (sluggish) with depressed respirations and periods of apnea (temporary cessation of breathing). Venous Blood Gas (VBG) showed mild hypercapnia (excessive carbon [MEDICATION NAME] in the bloodstream, typically caused by inadequate respiration). Resident #1 was reassessed after one hour of treatment and had worsening acidosis (a buildup of carbon [MEDICATION NAME] in the blood that results from poor lung function or depressed breathing), was less responsive, intubated for [MEDICAL CONDITION] and admitted to ICU. Further review revealed the Physician suspected presentation due [MEDICAL CONDITIONS], and Altered Mental Status (AMS). Review of Resident #1's laboratory results drawn in the emergency room revealed the following abnormal results, in part with the source of the general laboratory reference ranges via www.medscape.com: Blood Urea Nitrogen (BUN): 36 (general reference range: 8-21) Creatinine: 1.8 (general reference range: 0.8-1.3) Urine Appearance: cloudy (general reference range: clear) Protein, Urinalysis (UA): 3+ (general reference range: 0) Leukocytes, UA: 3+ (general reference range: negative) White Blood Cell (WBC), UA: 31 (general reference range: 2-5) Bacteria, UA: Moderate (general reference range: none). Resident #1 was diagnosed with [REDACTED]. Resident #1 was placed on a ventilator and admitted to the Intensive Care Unit. Further review revealed Resident #1's serum alcohol level was negative. In interview on 12/27/16 at 3:08pm, S14/Licensed Practical Nurse (LPN)/MDS Coordinator stated she was unaware that Resident #1 had an indwelling foley catheter, and did not capture it on the significant change MDS with an ARD of 10/25/16, and therefore no plan of care to reduce the risk of urinary tract infections was developed for the use of a foley catheter for Resident #1. In interview on 12/28/16 at 10:45am, S15/LPN stated she usually faxed communications to the physician's office, and would call only if a resident had a life or death situation occur. S15/LPN stated she was unsure how long it would take for the physician to read a faxed communication, but would usually find out on her next shift when checking for new physician's orders [REDACTED]. In interview on 12/28/16 at 11:00am, S2/Director of Nurses (DON) reviewed Resident #1's nursing notes regarding penile discharge and urinary sediment and was asked if the nurse notified the physician of these findings. S2/DON stated the nurse faxed a communication to the physician's office. S2/DON reviewed and confirmed that the fax was sent on 12/26/16 at 02:29am. S2/DON was unable to verify if the physician received and/or reviewed the faxed communication in a timely manner. Upon review of Resident #1's care plan, S2/DON confirmed there was no plan of care developed for the use of a foley catheter for staff to follow and prevent possible urinary tract infections. There was no documented evidence and the facility provided no documented evidence that the faxed communication regarding a change in resident status was promptly received and reviewed by the Physician for recommendations of treatment.

Based on observations, interviews and record reviews, the facility failed to be administered in a manner that used resources effectively and efficiently for 1 (#1) of 5 (#1, #2, #3, #4, #5) residents to maintain their highest physical well-being. S1Adm failed to ensure that residents were free of accident hazards during transport in the facility ' s transportation van. The facility administrator failed to develop policies and procedures regarding safety of residents in w/c ' s during transportation in the facility van including training transport drivers and ongoing monitoring of drivers to ensure policy was followed. An Immediate Jeopardy Situation began on 10/22/12, when Resident #1 was not properly secured in the facility van and during transportation , the resident ' s wheelchair (w/c) tilted backwards resulting in the resident hitting his head on the van ' s lift device and sustaining an injury. The Immediate Jeopardy Situation ended on 10/22/12 when the facility contracted ambulance service for transportation of their residents for the remainder of the day and thereafter. The deficiency continues at an actual harm for Resident #1 and a potential for more than minimal harm for any resident in the facility in w/c ' s who are transported per facility van. Findings: An interview on 10/29/12 at 9:00 a.m. was conducted with Resident #1. Resident #1 was asked about the incident on 10/22/12 that occurred in the facility s transportation van. Resident #1 indicated he was being transported back to the facility in his wheelchair after his [MEDICAL TREATMENT] appointment in the facility ' s transportation van by S2CNA. Resident #1 indicated that when the van made a turn and hit a bump, his wheelchair tilted backward and his head hit the lift device in the back of the van resulting in a " cut " on the back of his head. Resident #1 indicated he was not secured properly by S2CNA. Review of Resident #1 ' s medical record revealed the resident was sent to the emergency room for evaluation and treatment. A review of the emergency room record revealed Resident #1 sustained an abrasion and a scalp laceration that required staples to close the laceration and prevent further bleeding. An interview on 10/29/12 at 11:30 a.m. was conducted with S2CNA. S2CNA was asked about the incident on 10/22/12 when she was transporting residents in the facility ' s transportation van. S2CNA indicated on 10/22/12 she was assigned to transport residents to their appointments. S2CNA indicated Resident #1 was picked up from the [MEDICAL TREATMENT] center as a w/c transport. S2CNA indicated she secured Resident #1 and his wheelchair by putting the seat belt strap through the arms of the wheelchair until it clicked and then locked the wheels of the wheelchair. S2CNA indicated when she made a turn and hit a bump, Resident #1's w/c tilted backward and Resident #1 ' s head hit the lift device resulting in a laceration to the back of his head. S2CNA was asked about her training as a transport driver. S2CNA indicated she received one week of training as a transport driver from the previous CNA transport driver. An interview on 10/29/12 at 12:20 p.m. was conducted with S3Maint. S3Maint indicated he was the facility's maintenance supervisor. S3Maint was asked about the training of transport drivers. S3Maint indicated the training of transport drivers was the responsibility of the maintenance supervisor and indicated he did not train S2CNA as S2CNA was already a transport driver when he became the maintenance supervisor. S3Maint was asked if he had any in service record or performance checklist documenting S2CNA was trained by the previous maintenance supervisor or by any other facility staff. S3Maint indicated, " No " . S3Maint was asked for the policy on the training of transport drivers. S3Maint indicated the maintenance department did not have a policy on the training of transport drivers. S3Maint was asked for any training in services and/or any performance checklists used in training transport drivers. S3Maint indicated the maintenance department had neither written training in services nor any written performance checklists developed on the training of transport drivers. An interview on 10/29/12 at 2:30 p.m. was conducted with S1Adm. S1Adm was asked if the facility had any policy that addressed the training of transport drivers for the facility ' s transportation van. S1Adm indicated, " No " . S1Adm was asked if the facility had any policy that addressed the safe transporting of residents in the facility ' s transportation van. S1Adm indicated, " No " . S1Adm was asked if the facility had any documented staff in services on the safety of transporting residents in the facility ' s transportation van. S1Adm indicated, " No " . S1Adm was asked if the facility had developed any written training in services and/or any performance checklists used in training transport drivers. S1Adm indicated, " No " . S1Adm was asked if the facility ' s transportation van was still being used to transport residents. S1Adm indicated the transportation van had not been used since the incident with Resident #1 on 10/22/12. S1Adm indicated the facility had a contract with an ambulance service and she contacted them immediately to start transporting residents on 10/22/12 and thereafter. A review of the facility ' s investigative report of the transportation van incident on 10/22/12 revealed Resident #1 was being transported back to the facility from the [MEDICAL TREATMENT] center on 10/22/12 in the facility ' s transportation van when driver, S2CNA, made a turn that resulted in Resident #1 and his w/c tilting backward. Resident #1 hit his head on the lift device in the back of the van and sustained an abrasion and laceration. A further review of the facility ' s investigative report of the incident revealed the facility determined that Resident #1 ' s w/c had not been properly secured during transportation resulting in the resident sustaining an injury. The injury required the resident to be sent to the emergency room for repair of the laceration. A phone interview on 11/9/12 at 11:20 a.m. was conducted with S1Adm. S1Adm was informed of the Immediate Jeopardy Situation. S1Adm was asked if the facility had resumed the use of the transportation van in transporting residents. S1Adm indicated the facility continued to use their contract ambulance services for all resident transportation needs. S1Adm indicated there were no systems in place as of 11/9/12 and the facility continued to use the contracted ambulance service for all resident transportation needs since the incident on 10/22/12.

Based on observations, interviews and record reviews , the facility failed to ensure that 1 (#1) of 5 sampled residents ( #1, #2, #3, #4, #5) was free of accident hazards during transport in the facility's transportation van. The facility failed to: 1. Ensure that a resident's wheelchair (w/c) was properly secured in the facility van prior to moving the van on 10/22/12. 2. Have a policy and procedure for training of drivers of the facility's transportation van. 3. Have a policy and procedure for safe transporting of residents in the facility's transportation van. An Immediate Jeopardy Situation began on 10/22/12, when Resident #1 was not properly secured in the facility van and during transportation , the resident ' s wheelchair (w/c) tilted backwards resulting in the resident hitting his head on the van ' s lift device and sustaining an injury. The Immediate Jeopardy Situation ended on 10/22/12 when the facility contracted ambulance service for transportation of their residents for the remainder of the day and thereafter. The deficiency continues at an actual harm for Resident #1 and a potential for more than minimal harm for any resident in the facility in w/c ' s who are transported per facility van. Findings: An interview on 10/29/12 at 9:00 a.m. was conducted with Resident #1. Resident #1 was asked about the incident on 10/22/12 that occurred in the facility's transportation van. Resident #1 indicated he was being transported back to the facility in his w/c after his dialysis appointment in the facility ' s transportation van by S2CNA. Resident #1 indicated that when the van made a turn and hit a bump, his w/c tilted backward and his head hit the lift device in the back of the van resulting in a " cut " on the back of his head. Resident #1 indicated he was not secured properly by S2CNA. Review of Resident #1 ' s medical record revealed the resident was sent to the emergency room for evaluation and treatment. A review of the emergency room record revealed Resident #1 sustained an abrasion and a scalp laceration that required staples to close the laceration and prevent further bleeding. An interview on 10/29/12 at 11:30 a.m. was conducted with S2CNA. S2CNA was asked about the incident on 10/22/12 when she was transporting residents in the facility ' s transportation van. S2CNA indicated on 10/22/12 she was assigned to transport residents to their appointments. S2CNA indicated Resident #1 was picked up from the dialysis center as a w/c transport. S2CNA indicated she secured Resident #1 and his w/c by putting the seat belt strap through the arms of the w/c until it clicked and then locked the wheels of the w/c. S2CNA indicated when she made a turn and hit a bump, Resident #1's w/c tilted backward and Resident #1 ' s head hit the lift device resulting in a laceration to the back of his head. S2CNA was asked about her training as a transport driver. S2CNA indicated she received one week of training as a transport driver from the previous CNA transport driver. An interview on 10/29/12 at 12:20 p.m. was conducted with S3Maint. S3Maint indicated he was the facility's maintenance supervisor. S3Maint was asked about the training of transport drivers. S3Maint indicated the training of transport drivers was the responsibility of the maintenance supervisor and indicated he did not train S2CNA as S2CNA was already a transport driver when he became the maintenance supervisor. S3Maint was asked if he had any in service record or performance checklist documenting S2CNA was trained by the previous maintenance supervisor or by any other trained facility staff. S3Maint indicated, " No " . S3Maint was asked for the policy on the training of transport drivers. S3Maint indicated the maintenance department did not have a policy on the training of transport drivers. S3Maint was asked for any training in services and/or any performance checklists used in training transport drivers. S3Maint indicated the maintenance department had neither written training in services nor any written performance checklists developed on the training of transport drivers. An interview on 10/29/12 at 2:30 p.m. was conducted with S1Adm. S1Adm was asked if the facility had any policy that addressed the training of transport drivers for the facility ' s transportation van. S1Adm indicated, " No " . S1Adm was asked if the facility had any policy that addressed the safe transporting of residents in the facility ' s transportation van. S1Adm indicated, " No " . S1Adm was asked if the facility had any documented staff in services on the safety of transporting residents in the facility ' s transportation van. S1Adm indicated, " No " . S1Adm was asked if the facility had developed any written training in services and/or any performance checklists used in training transport drivers. S1Adm indicated, " No " . S1Adm was asked if the facility ' s transportation van was still being used to transport residents. S1Adm indicated the transportation van had not been used since the incident with Resident #1 on 10/22/12. S1Adm indicated the facility had a contract with an ambulance service and she contacted them immediately to start transporting residents on 10/22/12 and thereafter. A review of the facility ' s investigative report of the transportation van incident on 10/22/12 revealed Resident #1 was being transported back to the facility from the dialysis center on 10/22/12 in the facility ' s transportation van when driver, S2CNA, made a turn that resulted in Resident #1 and his w/c tilting backward. Resident #1 hit his head on the lift device in the back of the van and sustained an abrasion and laceration. A further review of the facility ' s investigative report of the incident revealed the facility determined that Resident #1 ' s w/c had not been properly secured during transportation resulting in the resident sustaining an injury. The injury required the resident to be sent to the emergency room for repair of the laceration. A phone interview on 11/9/12 at 11:20 a.m. was conducted with S1Adm. S1Adm was informed of the Immediate Jeopardy Situation. S1Adm was asked if the facility had resumed the use of the transportation van in transporting residents. S1Adm indicated the facility continued to use their contract ambulance services for all resident transportation needs. S1Adm indicated there were no facility based transportation systems in place as of 11/9/12 and the facility continued to use the contract ambulance service for all resident transportation needs since the incident on 10/22/12.