Every finding on record at Juniper Gardens Center for Nursing and Rehabilitat

Based on record review, and resident, staff, and family interviews, the facility failed to ensure residents' rights to maintain dignity for 3 of 3 residents reviewed for dignity (Resident #33, Resident #41, and Resident #24). The findings included: 1. Resident #33 was admitted to the facility on [DATE] with diagnoses that included chronic pain, muscle weakness, and reduced mobility. The 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #33 was cognitively intact with no behaviors, had adequate vision and no issues with communicating. The MDS documented Resident #33 was frequently incontinent of urine and bowel and required substantial to max assistance with toileting. On 11/18/25 at 11:56 AM an interview was conducted with Resident #33. She stated there was a night shift (11:00 PM to 7:00 AM) Nurse Aide (NA) #1 who made her lay wet when she was incontinent. Resident #33 stated when she called before first rounds on night shift and informed NA #1 she needed an incontinence change, NA #1 told her, No ma'am, not for 2 hours, that's what the regulations say and the previous shift (3:00 PM to 11:00 PM) should have provided incontinence care on their last round. Resident #33 shook her head and angrily stated her bladder was not on a schedule or timer, and she felt she was being caught in a battle between staff. Resident #33 stated the previous shift had done an incontinence round at approximately 10:00 PM but she had not been incontinent nor needed to use the bathroom at that time. Resident #33 stated this happened several times a week, but she had not reported it. She shared she used her cell phone (noted on overbed table) to track NA #1's response time. A follow up interview was conducted on 11/20/25 at 8:30 AM with Resident #33 to clarify NA #1 not addressing her incontinence care needs. Resident #33 shook her head and stated, while [NA #1] did come to the room to answer the call bell after change of shift she did not check or provide incontinence care at that time. Resident #33 stated she was aware of when she was incontinent and was made to lie wet until the next rounding on the 11:00 PM to 7:00 AM shift, sharing that lying there wet made her feel forgotten. Resident #33 stated this happened multiple times but did not provide exact number of times this has happened with NA #1. An interview was conducted on 11/20/25 at 6:00 AM with Nurse Aide (NA) #1 who was named by Resident #33 as the staff member who left her wet. NA #1 stated she had been working at the facility for 6 months. NA #1 explained she received hand off report and completed an initial walk-through on the rooms on her assignment beginning at 10:45 PM. NA #1 stated she began her first incontinence round between 12:30 and 1:00 AM with her second incontinent round beginning between 2:30 AM and 3:00 AM. NA #1 explained her final rounding began at approximately 5:30 AM. NA #1 stated she was usually assigned to 300 hall and split the 100 hall with the 2nd nurse aide on duty. NA #1 reported Resident #33 requested assistance between rounds stating, she was wet. NA #1 would inform Resident #33 the 3:00 PM to 11:00 PM shift should have changed you at 10:00 PM on their last round. NA #1 explained this happened several times a week and she has told Resident #33 the regulations say we round every 2 hours. When asked if she checked Resident #33 for incontinence and completed incontinence care when Resident #33 called for assistance before the first round on night shift, NA #1 stated, yes. Later in the interview, NA #1 shared Resident #33 was one of the two residents who regularly requested assistance between incontinence rounds on night shift and had to be reminded that rounds occur every 2 hours and requests for incontinence care made at the beginning of night shift should have been addressed by the 3:00 PM to 11:00 PM shift. Resident #33's weekly skin check was completed on 11/20/25. Review of the skin check revealed Resident #33's skin was intact with no redness or other issues. An observation of incontinence care for Resident #33 was completed on 11/21/25 at 9:30 AM. The observation revealed Resident #33's skin was intact with no redness, rash or other issues. On 11/20/25 at 5:35 AM an interview was conducted with Nurse #3. She stated she worked night and had no concerns with any of the nurse aides that worked that shift. She stated there were consistent staff that worked the night shift. Nurse #3 stated all the staff worked well together. Nurse #3 was not aware of Resident #33's concern regarding being informed to wait for incontinent care by NA #1. On 11/20/25 at 5:40 AM an interview was conducted with Nurse #4 who stated she worked night shift and she had no concerns with any of the nurse aides that worked night shift and had not received any resident concerns about the nurse aides. Nurse #4 was not aware of Resident #33's concern regarding being informed to wait for incontinent care by NA #1. An interview was conducted on 11/20/25 at 4:00 PM with the Administrator and Director of Nursing (DON). They both stated they were not aware of this issue and NA #1's behavior was unacceptable. The Administrator stated NA #1 would be taken off schedule immediately. An interview was conducted on 11/21/25 at 5:05 PM with the Administrator and Director of Nursing (DON). Both stated all residents should be responded to promptly. The DON stated a resident should never be told it was not time to provide care. NA #1 should have taken care of Resident #33's incontinence care needs regardless if incontinence rounds had just been completed on the previous shift. The Administrator stated the staff member should not have made those statements to Resident #33 and should have promptly responded to her request. The Administrator stated all residents should be treated in a dignified manner and this would not be considered treating a resident with dignity by making them wait for care. 2. Resident #41 was admitted on [DATE] with diagnoses including paraplegia, muscle weakness and depression. Resident #41's 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact, had functional impairment of both sides of his lower extremities, was dependent on staff for toileting hygiene, was always incontinent with bowel and bladder, had adequate vision. An interview occurred with Resident #41 on 11/18/2025 at 11:45 AM, Resident #41 stated on many occasions during the night shift (11:00 PM to &7:00 AM) his call light was answered with wait times for care between 1 to 1.5 hours. Resident #41 stated he always had his phone and checked the times he had to wait for care to be rendered. Resident #41 claimed Nurse Aide (NA) #1 deferred incontinence care and would tell him that state law says I only needed to change you every 2 hours. Resident #41 questioned, What would happen if something really bad happened like choking or falling or having a stroke and the aide wasn't coming for 2 hours? On 11/20/25 at 5:35 AM an interview was conducted with Nurse #3. Nurse #3 stated she worked night shift and had no concerns with any of the nurse aides that worked the night shift. She stated there were consistent staff that worked the night shift. Nurse #3 stated all the staff worked well together. Nurse #3 was not aware of Resident #41's concern regarding being informed to wait for incontinence care by NA #1. On 11/20/25 at 5:40 AM an interview was conducted with Nurse #4. Nurse #4 stated she worked night shift and she had no concerns with any of the nurse aides that worked the night shift and had not received any resident concerns about the nurse aides. Nurse #4 was not aware of Resident #41's concern regarding being informed he had to wait for incontinence care by NA #1. During an interview on 11/20/2025 at 6:06 AM NA #1 stated Resident #41 often used his call light for assistance, requesting incontinence care, snacks or drinks. NA #1 further stated she told Resident #41 that state law was you get changed every 2 hours. NA #1 explained when Resident #41 used his call light she would tell him she would come back when it was time. A follow up interview with Resident #41 on 11/20/2025 at 8:26 AM revealed he used his call light around 12 AM last night (11/20/2025) to request incontinence care. Resident #41 stated NA #1 entered his room and turned off his light. Resident #41 continued to state, NA #1 did not come back until 3 AM. Resident #41 revealed he used his phone to know what time it was. Resident #41 explained when NA #1 provided care NA #1 just took his wet brief off and put on a dry brief. Resident #41 said, no wipes, no towels, just the wet one off and a dry one on. During an observation of incontinence care on 11/20/2025 at 9:18 AM of Resident #41, NA #2 removed the soiled brief, cleaned Resident #41's groin area and buttocks with disposable wipes. Resident #41 complained to NA #2 of a rash and feeling itchy. NA #2 recleaned the groin area while looking for a rash. NA #2 stated she did not notice a rash. Resident #41 expressed relief after being cleaned again by NA #2. NA #2 provided a new brief and assisted Resident #41 with getting dressed for the day. Observation revealed Resident 41's skin on his groin and buttocks were intact, clean with no visible rash or reddened areas. During an interview with NA #2 on 11/20/2025 at 9:25 AM NA #2 she had not worked with NA #1 and had no knowledge of NA #1 withholding care. NA #2 stated Resident #41 had never expressed complaints of lack of care by night shift nurse aides to her. An interview was conducted on 11/21/25 at 5:05 PM with the Administrator and Director of Nursing (DON). Both stated all residents should be responded to promptly. The DON stated a resident should never be told it was not time to provide care. NA #1 should have taken care of Resident #41's incontinence needs regardless if incontinence rounds had just been completed on the previous shift. The Administrator stated the staff member should not have made those statements to Resident #41 and should have promptly responded to his request. The Administrator stated all residents should be treated in a dignified manner and this would not be considered treating a resident with dignity by making them wait for care. 3. Resident #24 was admitted on [DATE] with diagnoses of dysphasia, and cancer of the kidney, liver, lung, and brain. Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired with inattention and disorganized with his thinking. Resident #24 was noted to have some impairment and needed a minimum of set up assistance for meals and supervision or touch-assistance with oral and toileting hygiene, putting on his shoes, rolling left to right in bed, and showering. He had no behavioral symptoms indicated. Resident #24 was occasionally incontinent of bowel and bladder and required assistance with toileting hygiene. Resident #24's activities of daily living (ADL) deficit due to being hard of hearing care plan dated 03/27/2025 included interventions to speak on an adult level, speak clearly and slower than normal and to validate resident's message by repeating aloud. Review of the Facility Reported Entity report dated 06/05/2025 revealed the Director of Nursing (DON) interviewed Resident #24 on 06/05/2025. Resident #24 stated he was sitting on the edge of the bed when Nurse Aide #3 (NA) was aggressive with him during care. The Facility Reported Entity report stated, Resident #24 alleged NA #3 jerked him around like a rag doll and pushed him back onto the bed. Resident #24 stated NA #3 told him he could do it himself and threw a brief at him and stated, to quit being lazy. When asked if he felt safe at the facility, Resident #24 replied Yes, when that big gorilla isn't here. An observation and interview were conducted on 11/18/2025 at 12:00PM with Resident #24. He was observed in bed in a hospital gown, clean and odor free. Resident #24 had some trouble with his thoughts and communicating. His voice was very weak and barely a whisper. Resident #24 indicated he had been mistreated by NA #3 on the third shift (11:00PM to 7:00AM) as was described by Resident #24 as being big and black. Resident #24 was not able to verbalize how this incident with NA #3 made him feel before moving on to other non-related topics. Resident #24 could not recall or provide any additional information. A telephone interview on 11/19/2025 at 9:00AM with NA #3 stated she recalled the events of 06/05/2025 with Resident #24. During the last rounds at about 4:30AM Resident #24 had soiled the bed. She explained Resident #24 was hard of hearing. NA #3 stated she raised her voice and stated, 'Let's get you out of these wet clothes.' She further stated she repeated her request because Resident #24 kept saying 'what did you say, what did you say?' NA #3 explained she had not or did not touch him at that time. Resident #24 was able to put his incontinent product on himself with cueing. NA #3 communicated she assisted Resident #24 with taking off his shirt due to it being wet. NA #3 continued to communicate she washed him up and gave him an incontinent brief to put on. NA #3 verbalized this was the only time she physically touched or assisted Resident #24. During an interview on 11/20/2025 at 8:50PM NA #4 revealed she never saw NA #3 abuse or mistreat anyone. She indicated that Resident #24 didn't like NA #3 and Resident #24 called NA#3 some inappropriate names. NA #4 confirmed Resident #24 was hard of hearing and staff needed to take their time when communicating with him. A telephone interview was conducted on 11/20/2025 at 11:22AM with former Resident #54 who was roommates with Resident #24 while at the facility. Former Resident #54's MDS report, dated 04/15/2025 indicated he was cognitively intact. Former Resident #54 indicated he clearly watched the incident involving Resident #24 who he said was out of bed and incontinence care. Former Resident #54 said that NA #3 entered the room and turned the light on. Former Resident #54 stated that NA#3 was yelling at and pushed Resident #24 on to bed and threw the brief at him, which hit him in the stomach. Former Resident #54 stated NA #3 told Resident #24 could change himself. When asked, Former Resident #54 was not aware of any other incidents with NA #3 treating him or Resident #24 badly. During an interview on 11/21/2025 at 9:40AM the Administrator indicated that she found out about the allegation when the Assistant Director of Nursing (ADON) was doing a random customer service check with various residents. She did not indicate any residents by name except Resident #24 and Resident #54. The Administrator could not recall whether it was Resident #24 or #54 who was the one that reported the allegation. The Administrator recalled that the alleged NA #3 was rough with Resident #24. The Administrator questioned if NA #3 startled Resident #24 because it was nighttime and NA #3 was a very big statured person. She stated NA #3 was terminated. The Administrator stated it was never okay to treat any residents roughly or disrespectfully.

Based on observations, record review, staff and resident interviews the facility failed to ensure advance directive information was accurate throughout the medical record for 1 of 1 resident reviewed for advance directives (Resident #4).The findings included:Resident # 4 was admitted to the facility on [DATE] and readmitted to the facility on [DATE].Review of Resident #4's electronic health record (EHR) revealed an active physician order dated [DATE] that stated Do Not Resuscitate (DNR).Resident #4's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was cognitively intact.Further review of Resident #4's electronic health record revealed an active physician order dated [DATE] stated that he was a Full Code.Resident #4's advance directive care plan dated [DATE] revealed residents' code status to be Full Code.An observation conducted on [DATE] of the Advance Directives binder located at the nursing station revealed a yellow Do Not Resuscitate form dated [DATE] and indicated no expiration date that was signed by the physician. Further review of the binder revealed Resident #4 had a Medical Orders for Scope of Treatment (MOST) form dated [DATE] that was signed by the resident and the physician. The MOST form read Attempt to Resuscitate (Full Code).An observation and interview were conducted with the Social Worker on [DATE] at 4:21 PM After review and observation of the Advance Directives binder, the Social Worker stated Resident #4's face sheet indicated he was a Full Code and his MOST form dated [DATE] indicated he was a Full Code. The Social Worker further observed a yellow DNR form dated [DATE] that indicated no expiration date. The Social Worker stated the yellow DNR was no longer valid. The Social Worker was observed to place the yellow DNR form back into the Advance Directives binder along with the face sheet and MOST form. During an interview and observation with Nurse #1 on [DATE] at 1:37 PM she indicated she would initiate Cardiopulmonary Resuscitation (CPR) on Resident #4 if he was unresponsive with no respirations or heartbeat. Nurse #1's observation of the Advance Directive binder indicated she would disregard the DNR form dated [DATE]. The nurse was observed to place the yellow DNR form back in the Advance Directives binder. Nurse #1 stated she would check the EHR and MOST form to confirm a resident's code status.During an interview on [DATE] at 1:41 PM Resident #4 stated he was a DNR. Resident #4 stated a DNR meant the staff would not provide CPR if needed.An interview with the Director of Nursing (DON) on [DATE] at 3:45 PM stated the code status information in the Advance Directive binder and the EHR should match. The DON revealed she expected nurses to check the MOST form in the Advance Directives binder and the code status in the EHR.

Based on observations and staff interviews, the facility failed to post a list of names, addresses (mailing and email) and telephone numbers of all required state agencies and advocacy groups, such as the State Survey Agency, Department of Social Services, the State Long Term Care Ombudsman Program and the resident advocacy network. These observations occurred on 3 of the 4 days of the onsite recertification survey.The findings included:On 11/18/2025 at 1:00 PM, 11/19/2025 at 9:50 AM and 11/20/25 at 10:00 AM, an observation of the facility (inclusive of all hallways) revealed no postings of name or contact information for the following: the local Department of Social Services, the State Long Term Care Ombudsman, State Survey Agency or the resident advocacy network.During the Resident Council meeting on 11/20/2025 at 10:31 AM, Resident Council attendees (Resident #4, Resident # 23, Resident #42, and Resident #53) stated they did not know who the local Ombudsman was or how to contact them and did not know how to contact the State Agency to file a complaint or where that information would be found in the facility. During a walking tour of the facility and interview on 11/20/2025 at 11:02 AM with the Activities Director and the Director of Nursing, there were no postings of name or contact information for the local Department of Social Services, the State Long Term Care Ombudsman, State Survey Agency or the resident advocacy network. The Director of Nursing reported it was the Administrator's responsibility to ensure that postings were present. The Director of Nursing confirmed that all residents and their representatives should be informed of all available resources and that the postings be in a location easily visible and accessible if any resident or their representative needed them.On 11/21/2025 at 5:14 PM an interview was conducted with the Administrator who stated that contact information for the local Department of Social Services, the State Long Term Care Ombudsman, State Survey Agency or the resident advocacy network should be posted in a location easily visible and accessible should any resident or their representative need to access them. The Administrator stated she thought the Federal posting related to Medicare/Medicaid was adequate.

Based on observations, resident and staff interviews, the facility failed to display survey results in a location accessible to residents and the public. This deficient practice occurred for 4 out of 4 days of the survey.The findings included:During an initial tour of the facility on 11/18/25 at 1:00 PM, survey result signage was observed in a picture frame on a table behind the receptionist in the main lobby. The survey signage revealed the following statement: State Survey results are in the binder under this sign. Survey signage was not observed in any other area in the facility. No binder was observed under the signage.An observation on 11/19/25 at 11:00 AM revealed the survey results binder was not located in any other area of the facility. Further observation of the desk behind the receptionist continued to reveal no evidence of the survey results binder.An additional observation on 11/20/25 at 10:00 AM revealed the survey results binder was not located in any other area of the facility. Further observation of the desk behind the receptionist continued to reveal no evidence of the survey results binder.A Resident Council group meeting was conducted on 11/20/25 at 10:31 AM. During the meeting, the resident council attendees indicated they did not know where the survey results were located (Resident #4, Resident # 23, Resident #42, and Resident #53). The Resident Council President shared he had been at the facility for 3 years and did not know the location of the survey results. An interview and observation were completed with the Activities Director (AD) and the Director of Nursing (DON) on 11/20/25 at 11:02 AM. Both stated that the survey results binder would be located behind the receptionist desk in the front lobby. During the walking tour the AD and DON were unable to locate the survey results binder. The DON stated she was not sure where the binder was, but she would ask the Administrator. In an interview with the Administrator on 11/21/2025 at 5:14 PM, she explained the survey result binder should be behind the receptionist desk and a sign was posted there identifying the location of the survey results under this signage. The Administrator stated the survey results binder was located on 11/20/25 on the bookshelf in the main dining room and offered that perhaps a resident had removed it from the table behind the receptionist and placed it in this bookshelf. The Administrator stated that survey results should be available to all residents, their representatives, and visitors at all times.

Based on record review, resident, staff, physician and contract transport company interviews, the facility's contracted transport driver (Driver #1) failed to leave Resident #12 in place for a clinical assessment of injury after a fall that occurred during transport. Resident #12 was being transported back from a medical appointment in a contract transport van while unsecured in her wheelchair. Driver #1 made a sudden stop which caused Resident #12 to fall forward out of her wheelchair onto the van floor. Driver #1 pulled the van off to the side of the road and transferred Resident #12 off the van floor back into her wheelchair and continued back to the facility. Driver #1 was not qualified to provide a comprehensive physical assessment to determine if the resident sustained any injuries. Upon arrival at the facility, Driver #1 did not notify facility staff of the resident's fall. Resident #12 notified staff of the fall in the van and was assessed by nursing staff and noted to have swelling and a skin tear to her left knee. A hospital computed tomography (CT) scan revealed Resident #12 had suffered a distal (away from the center of the body) left fracture to the femur (break in bone above left knee joint) due to her fall in the van. This deficient practice occurred for 1 of 3 sampled residents reviewed for quality of care (Resident #12). The findings included: Resident #12 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis (MS), muscle weakness, contractures of the left knee, hip, wrist, and of the right knee and hip. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact, utilized a wheelchair for mobility, and dependent for assist with transfers. Resident #12 was also coded as having on-going pain and receiving scheduled pain medications. Review of a physician order dated 10/01/23 revealed Resident #12 received Gabapentin (used for pain) 300 milligrams (mg) 1 tablet by mouth every 8 hours as needed (prn) for pain. Review of a physician order dated 10/01/23 revealed Resident #12 received Acetaminophen (mild to moderate pain) 650 mg 1 tablet by mouth every 4 hours as needed for mild pain. Review of Resident #12's Medication Administration Record (MAR) from 10/1/23 through 10/5/23 revealed the following administrations of Resident #12's prn pain medications Gabapentin 300 mg and Acetaminophen 650 mg: - 10/1/23: Gabapentin at 10:44 AM (pain level 1) (on a scale of 1 to 10 with 10 being the worst pain possible) - 10/2/23: Acetaminophen at 8:08 AM (pain level 0), Acetaminophen at 3:27 PM (pain level 0) - 10/3/23: Gabapentin at 8:05 AM (pain level 7), Acetaminophen at 9:06 AM (pain level 7), Acetaminophen at 3:23 PM (pain level 8) - 10/4/23: Acetaminophen at 7:55 AM (pain level 1), Acetaminophen at 7:58 PM (pain level 0) - 10/5/23: Acetaminophen at 5:19 AM (pain level 0), Gabapentin at 3:01 PM (pain level 2) Review of facility van incident report dated 10/05/23 written by Unit Manager #1 read in part: [Resident #12] fell from chair after [Driver #1] pressed the brakes while out of facility being transported by outside services. [Resident #12] stated, he slammed on the brakes, and I fell on the floor, he picked me up and put me back in chair. Assessment completed, transport company owner notified, physician notified, vital signs taken, skin assessment completed. Review of Driver #1's statement dated 10/5/23 indicated, [Driver #1] was driving on my way through greenlight, suddenly had to brake, [Resident #12] went forward and hit her knee against driver seat chair. A phone interview was attempted with Driver #1, but he was unable to be reached. An interview was conducted with Resident #12 on 08/20/24 at 11:00 AM revealed on 10/05/23 she had been transported to an appointment by the transport company and on her way back to the facility, Driver #1 had secured her wheelchair in the van but forgot to secure her into her wheelchair, so when he had to make a sudden stop she fell out of her wheelchair onto the van floor. She stated Driver #1 pulled the van off the side of the road and assisted her back into her wheelchair and transported her back to the facility. Resident #12 revealed as soon as she got back to the facility, she notified the Director of Nursing (DON) and the Administrator about the fall and they asked her what happened, assessed her for injuries and at the time her left knee was swollen some and had a skin tear, but she was not in any real pain. Resident #12 revealed she believed Driver #1 should have either called 911 for help after the fall prior to putting her back into her chair or taken her to the hospital to be assessed. Review of a physician order dated 10/05/23 revealed an order for a mobile x-ray to be completed on Resident #12's left ankle, left foot, left knee, left tibia (located on inside of leg, below knee joint, and forms top of ankle joint), and left fibula (located on outside of leg, below knee joint, and forms top of ankle joint). Review of an on-call physician note dated 10/06/23 indicated on 10/05/23, Resident #12 had a fall from her wheelchair on transportation van. Resident #12's left knee was swollen, she complained of increased pain at a level 10 in her left knee and leg, and her x-ray results had not been received. Ibuprofen 400 mg twice daily for 3 days and Tylenol 500 mg three times daily for 3 days was ordered for Resident #12's acute pain post fall. Review of on-call physician orders for Resident #12 dated 10/06/23 indicated Ibuprofen 400 mg twice daily for 3 days for acute pain post fall and Tylenol 500 mg three times daily for 3 days for acute pain post fall. Review of a mobile x-ray dated 10/06/23 of Resident #12's left knee revealed a moderately displaced (more complex fracture because bones are out of alignment or in pieces) distal left fracture of the femur of indeterminate age (not able to determine how long-ago fracture occurred). Clinical follow-up was recommended. Review of an on-call physician note dated 10/06/23 revealed Resident #12's x-ray results were reviewed with no new treatment orders. The on-call physician indicated to continue to monitor and follow-up with the resident's primary care physician was recommended. Review of Resident #12's Medication Administration Record (MAR) from 10/6/23 through 10/8/23 revealed the following administrations of Resident #12's pain medications Tylenol 500 mg and Ibuprofen 400 mg and prn pain medication Gabapentin 300 mg: - 10/6/23: Gabapentin at 12:14 AM (pain level 2), Tylenol at 2:00 PM (pain level of 10), Ibuprofen at 8:00 PM (pain level 0), Tylenol 10:00 PM (pain level of 0), and Gabapentin at 11:24 PM (pain level 1) - 10/07/23 Tylenol at 6:00 AM (pain level 0), Gabapentin at 7:35 AM (pain level 1), Ibuprofen at 8:00 AM (pain level 0), Tylenol at 2:00 PM (pain level 0), Gabapentin at 3:24 PM (pain level 1), Ibuprofen at 8:00 PM (pain level 0), and Tylenol at 10:00 PM (pain level of 2) - 10/08/23 Tylenol at 6:00 AM (pain level 0), Ibuprofen at 8:00 AM (pain level 0), Gabapentin at 10:47 AM (pain level 1), and Tylenol at 2:00 PM (pain level of 0) Review of an on-call physician note dated 10/08/23 revealed Resident #12 complained of pain in her stomach area when inhaling and requested to be sent out to the hospital. Resident #12 was sent out from the facility to the hospital at 4:05 PM. Review of the hospital discharge summary dated 10/09/23 revealed Resident #12 was seen at emergency department (ED) for a fall and shortness of breath. Resident #12 had an abrasion and edema (swelling) to the left knee and a CT scan was obtained and revealed a distal femur fracture on the left and some possible bruising to the ribs as a result of the fall. The consulting ED provider did not recommend any emergency intervention given that Resident #12 was non-ambulatory, and wheelchair bound. Resident #12 was discharged back to the facility with an order for Naproxen (treat fever and pain) 375 mg by mouth twice daily and follow-up with orthopedics. During interview with Resident #12 on 8/20/24 at 11:00 AM she revealed on the day after the fall (10/06/23), her pain had gotten worse around her left knee and the facility administered her pain medications and completed an x-ray of her left side. She stated a couple of days later (10/08/23) she started having some trouble breathing and was sent out to the hospital where they confirmed she had broken her left leg and bruised her ribs because of the fall. Resident #12 revealed the hospital administered her some more pain medication, referred her to an orthopedist, and sent her back to the facility. An interview conducted with Director of Nursing (DON) on 8/21/24 at 12:06 PM revealed she was familiar with Resident #12. She stated on the afternoon of 10/05/23, Resident #12 had entered the facility by herself in her electric wheelchair after being transported to a medical appointment by their contract transport company. The resident stated that she had fallen on the van and Driver #1 picked her up and placed her back into her wheelchair after the fall and transported her back to the facility. She (the DON) revealed she immediately assessed Resident #12 for injury and noted a skin tear to her left knee with some swelling. The DON stated she notified the physician of Resident #12's fall on 10/05/23 and received an order for a mobile x-ray of the left knee. A mobile x-ray was completed on 10/06/23 and revealed a distal left leg fracture of the femur but was not able to determine the age of the fracture due to Resident #12's contractures and follow-up was recommended. She revealed the on-call physician was notified of the results and did not order any further treatment until reviewed by the facility physician. The DON stated on 10/08/23 Resident #12 was complaining of stomach pain when taking a deep breath and requested to be sent out to hospital. The on-call physician was notified, and orders were received for her to be sent out. She indicated a CT scan completed at the hospital on 10/08/23 revealed Resident #12 had suffered a left leg fracture of the femur and suspected bruised ribs from the fall in the van. Resident #12 returned to the facility with an order to follow-up with orthopedics outpatient. The DON also revealed after Resident #12 had fallen into the van floor, Driver #1 should have immediately contacted the facility and medical personnel to come and assess Resident #12 prior to moving her back into her wheelchair to keep from possibly causing further injury or trauma. A telephone interview conducted with the physician on 8/21/24 at 4:55 PM revealed he was familiar with Resident #12 and her fall on the van on 10/05/23. He stated he was notified on the day the accident had occurred and approved a mobile x-ray order for Resident #12's left side extremities due to her left knee showing signs of swelling. He revealed the mobile x-ray and the CT scan from the hospital both showed Resident #12 had suffered a left leg femur fracture due to the fall and recommended follow-up with outpatient orthopedic. The physician stated Resident #12 had MS which caused her to have contractures in all her extremities and suspected demineralization (loss of bone minerals faster than can be replaced) that made it easier for injury. He revealed he had been told by the DON that Driver #1 did not have her assessed by medical personnel prior to moving her after the fall. He indicated he would expect medical personnel to be notified immediately anytime a resident sustains a fall so an assessment of injury can be completed prior to them being moved. He stated moving a resident prior to them being assessed could cause further injury or trauma. An interview was conducted with the Administrator on 8/21/24 at 5:27 PM revealed she was familiar with Resident #12. She stated on 10/05/23, Resident #12 had been transported by their contract transport company to an appointment. She indicated when the resident arrived back at the facility, the resident reported that during her transport back to the facility she was not secured into her wheelchair and had fallen out of her wheelchair onto the van floor. Resident #12 stated Driver #1 had stopped the van and assisted her back into her chair and brought her back to the facility. The Administrator revealed while the DON was assessing Resident #12 for injury and contacting the physician, Driver #1 came into the facility and she attempted to interview him (Driver #1) about the incident, but he refused to give statement and left the facility. The Administrator indicated she contacted the Contract Transport Company Owner to notify them about the incident. She stated the owner of the transport company assisted her with receiving a written statement about the incident from Driver #1 and was able to view camera footage from the van to corroborate Resident #12's statement of how the fall occurred, that she had not been secured into her wheelchair, and Driver #1 did not contact medical personnel to assess her (Resident #12) after the fall prior to transporting her back to facility. The Administrator revealed Resident #12 had suffered a left leg femur fracture and bruised ribs from the fall. She stated according to the information received from the transport company, Driver #1 was no longer employed with the company and had received prior education on accident protocols which included notifying the facility and medical personnel when a resident had been involved in an accident prior to moving resident or proceeding forward with transport. A telephone interview conducted with the Contract Transport Company Owner on 8/22/24 at 9:29 AM indicated on 10/05/23, he was notified by the facility of the fall incident involving Driver #1 and Resident #12. He stated he received a written statement from Driver #1 and reviewed video footage from the van. Driver #1 failed to secure the lap belt and when he (Driver #1) had to stop suddenly Resident #12 fell out of her wheelchair onto the van floor. He revealed after the fall, Driver #1 pulled the van over, assisted Resident #12 back into her wheelchair and transported her back to the facility. He stated Driver #1 was no longer employed with the company and all drivers received training prior to transporting on van safety and the protocol on what to do if an accident occurred. The Contract Transport Company Owner stated Driver #1 should have pulled over, stopped the van, contacted 911 and the facility, and waited for Resident #12 to be assessed by medical personnel prior to her being moved to prevent any further injury to the resident. The facility was notified of immediate jeopardy on 8/22/24 at 5:50 PM. The facility provided the following corrective action plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; The identified resident (Resident #12) is still a current Resident at the facility. Resident #12 was picked up by a contract transportation driver from a scheduled neurology appointment for transport back to the facility. Prior to leaving the appointment, the contracted driver secured Resident #12 wheelchair, but failed to secure Resident #12 seatbelt leaving her unsecured. During transport, the contracted driver had to slam on brakes causing Resident #12 to fall forward from her wheelchair into the van floor. Contracted Driver pulled off road and assisted Resident #12 back into her wheelchair and then continued to transport Resident #12 back to the facility. Contracted Driver failed to contact 911 and/or facility prior to moving Resident #12 from van floor and prior to placing her back into wheelchair after fall. The following actions after this incident: On 10/5/23, the facility initiated immediate investigation on 10/5/23. On 10/5/23, Resident #12 medical director (MD) and responsible person (RP) made aware of incident. On 10/5/23, Order obtained for x-ray to the left ankle, left foot, left knee, left tibia and left fibula. On 10/6/23, Resident #12 complained of pain on a level of 10 on a level 0-10, MD notified, and new orders obtained for the following: Ibuprofen 400mg take 1 tablet by mouth twice daily x3 days for acute pain post fall and Tylenol 500mg take 1 tab by mouth three times daily x3 days for acute pain s/p fall. Pain medication effective with a pain scale of 0 noted. On 10/6/23, x-ray results were obtained and showed the following, Left tibia/fibula- No fracture or dislocation is identified, bony structures are osteoporotic. Left ankle-No acute fracture, dislocation or osseous lesion, bony structures are osteoporotic. Left Knee- moderately displaced fracture of the distal diaphysis of the femur of indeterminate age. No dislocation is identified. Left Foot-soft tissue swelling of the foot. Bony structures are osteoporotic. No acute fracture or dislocation is identified. There is moderate hallux valgus (bony bump that forms on joint at the base of big toe), mild degenerative change of the interphalangeal (hinge shaped joint in toe) joint, first metatarsophalangeal (joint that connects toes to foot bone) joint and midfoot is present. On 10/8/2023, Resident #12 complained of pain when she inhales in her stomach area especially the left upper quad. Resident and Daughter requested for Resident to be sent out to the Hospital for Evaluation and treatment. Vital signs at that time were as follows: BP 114/72, P 68, Resp. 18, Temp. 97.8. Resident transported via ambulance and MD was notified of the transport. On 10/8/23 hospital x-ray revealed an acute comminuted (break into three or more pieces) and mildly displaced distal femoral fracture with minimal angulation. Soft tissue swelling adjacent to the fracture. A left hip gamma nail (metal implant used to stabilize fractures) seen, no dislocation. No evidence of knee joint effusion (abnormal fluid accumulation within knee joint). On 10/9/23, Resident #12 returned back to the facility via stretcher accompanied by two emergency management technicians (EMT) attendants. Resident complained of pain and discomfort to the left femur upon assessment pain meds were administered and effective. New orders from emergency department (ED) for Naproxen 375mg PO BID. Ortho follow up appointment with Orthopedic surgery as soon as possible. On 10/9/23, Facility made Resident #12 an Ortho appointment on 10/10/23 at 2:15pm. RP and MD made aware of the appointment. On 10/10/23, Resident #12 was taken to Ortho via facility transport. Ortho plan on 10/10/23 state Resident is not a strong surgical candidate given knee contracture, would not recommend a long leg cast at that time. Instead recommended a knee immobilizer and limit range of motion of including weight-bearing. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; The Director of Nursing reviewed the accidents for the last three months and there were no other situations where licensed nurses did not assess the resident before the resident was moved. Review completed on 10/9/23. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; The van drivers were re-educated on 10/9/23 by the Administrator on the proper procedures if a resident was to have a fall/injury or abnormal event in the facility van, that 911 is to be called prior to moving the resident. The education was already a component of the Transportation Driver orientation given by Administrator/Designee. The Administrator notified the contract transportation company on 10/5/23 via phone, and stated that until proof of driver training to include wheelchair procedures and calling 911, then contracted transportation will not be utilized. Beginning 10/9/23, Any transportation from contract services was required to provide the driver's PASS (Passenger Assistance Safety and Sensitivity) training to the Administrator/Designee prior to transporting the facilities residents. These competencies are maintained by the Administrator/Designee. The contracted transportation supervisor who is PASS (Passenger Assistance Safety and Sensitivity) Certified completed education for contracted drivers on 10/12/23 and ongoing; prior to transporting facility residents. This education included both wheelchair patent procedures and to contact 911 immediately should any emergencies with patients occur during transport. 4. Address how the facility plans to monitor its performance to make sure that solutions are sustained. Beginning 10/9/23 Director of Nursing/Designee audited incident/accident logs to ensure no resident had a fall during transportation and 911 wasn't called. Director of Nursing/Designee reviewed incident/accident logs 5 days a week for 4 weeks, 3 days a week for 4 weeks and weekly for 4 weeks. On 10/9/23 Administrator made the decision to take audits to the monthly Quality Assurance meeting for tracking, trending, and recommendations from the IDT team. Alleged Date of Immediate Jeopardy Removal and corrective action plan completion: 10/13/23 The facility's corrective action plan was validated on 8/27/24 by the following: Interviews with facility transporters revealed they had received education on proper procedures if a resident was to have a fall, injury, or accident in the facility van, that 911 was to be called immediately, do not move resident until assessed by a medical professional, and call facility to notify of incident. The education was included as a component of the transportation orientation. Contract transport company re-education dated 10/12/23 verified staff were educated on passenger safety and sensitivity training, wheelchair procedures, and calling 911 immediately for any emergencies during transport. Review of the audit tool for the review of the incident/ accident logs was completed with no issues noted. Interviews were also conducted with alert and oriented residents who had been transported since October 2023 with no concerns, incidents, or accidents identified. Interview with the Administrator revealed she had educated facility transport drivers on proper procedures if a fall, injury, or accident occurred while transporting to include calling 911 immediately and not moving resident until assessed by medical personnel and notifying facility of the incident. The Administrator also verified the contract transport company had educated their drivers on the proper wheelchair procedures, calling 911 for any emergencies during transport, and safety and sensitivity training. The facility's immediate jeopardy removal date and the corrective action completion date was validated as 10/13/23.

Based on record review and interviews with resident, staff, physician and the contract transport company's owner, the facility's contracted transport driver (Driver #1) failed to provide safe transportation when Resident #12's lap belt was not applied leaving her unsecured in her wheelchair. Resident #12 was being transported back from a medical appointment when Driver #1 made a sudden stop resulting in Resident #12 falling forward out of her wheelchair onto the van floor on her left knee and rolling onto her left side. Driver #1 pulled the van off to the side of the road and transferred Resident #12 off the van floor back into her wheelchair and continued back to the facility. Resident #12 had swelling and a skin tear to her left knee. A hospital CT (computed tomography) scan revealed Resident #12 had suffered a distal (away from the center of the body) left fracture to the femur (break in bone above left knee joint) due to her fall in the van. This deficient practice occurred for 1 of 3 sampled residents reviewed for accidents (Resident #12). The findings included: Review of the contract van vehicle anchorages for the 4-point wheelchair securement systems manual dated 2007 read in part: The illustrated manual provided directions for securing wheelchairs for transport in the transportation van. Tracks on the floor of the van (L-track) where the pin connectors of the retractors locked in place and straps connected to the wheelchair by a J-hook (a J-shaped metal hook affixed to the fabric straps that were attached to the connector pins). The manual illustrated the position of the pin connectors indicated two rear connectors were directly behind the wheelchair and the two front pin connectors were secured to the front and side of each side of the wheelchair. The instructions directed to follow the tie down angles in the illustration and attached the J-hooks on the wheelchair frame in the proper locations and apply resident seatbelt. Resident #12 was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis (MS), muscle weakness, contractures of the left knee, hip, wrist, and of the right knee and hip. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact, utilized a wheelchair for mobility, and dependent for assist with transfers. Resident #12 was also coded as having on-going pain and receiving scheduled pain medications. Review of a physician order dated 10/01/23 revealed Resident #12 received Gabapentin 300 milligrams (mg) 1 tablet by mouth every 8 hours as needed (prn) for pain. Review of a physician order dated 10/01/23 revealed Resident #12 received Acetaminophen 650 mg 1 tablet by mouth every 4 hours as needed for mild pain. Review of Resident #12's Medication Administration Record (MAR) from 10/1/23 through 10/5/23 revealed the following administrations of Resident #12's prn pain medications Gabapentin 300 mg and Acetaminophen 650 mg: -10/1/23: Gabapentin at 10:44 AM (pain level 1) (on a scale of 1 to 10 with 10 being the worst pain possible) -10/2/23: Acetaminophen at 8:08 AM (pain level 0), Acetaminophen at 3:27 PM (pain level 0) -10/3/23: Gabapentin at 8:05 AM (pain level 7), Acetaminophen at 9:06 AM (pain level 7), Acetaminophen at 3:23 PM (pain level 8) -10/4/23: Acetaminophen at 7:55 AM (pain level 1), Acetaminophen at 7:58 PM (pain level 0) -10/5/23: Acetaminophen at 5:19 AM (pain level 0), Gabapentin at 3:01 PM (pain level 2) Review of facility van incident report dated 10/05/23 written by Unit Manager #1 read in part: [Resident #12] fell from chair after [Driver #1] pressed the brakes while out of facility being transported by outside services. [Resident #12] stated, he slammed on the brakes, and I fell on the floor, he picked me up and put me back in chair. Assessment completed, transport company owner notified, physician notified, vital signs taken, skin assessment completed. Review of Driver #1's statement dated 10/5/23 indicated, [Driver #1] was driving on my way through greenlight, suddenly had to brake, [Resident #12] went forward and hit her knee against driver seat chair. A phone interview was attempted with Driver #1, but he was unable to be reached. An interview was conducted with Resident #12 on 08/20/24 at 11:00 AM revealed on 10/05/23 she had been transported to an appointment by the transport company and on her way back to the facility, Driver #1 had secured her wheelchair in the van but forgot to secure her into her wheelchair, so when he had to make a sudden stop she fell out of her wheelchair onto the van floor. She stated Driver #1 pulled the van off the side of the road and assisted her back into her wheelchair and transported her back to the facility. Resident #12 revealed as soon as she got back to the facility, she notified the Director of Nursing (DON) and the Administrator about the fall and they asked her what happened, assessed her for injuries and at the time her left knee was swollen some and had a skin tear, but she was not in any real pain. Resident #12 revealed the fall in the van happened so fast that she didn't have time to feel scared or even think about what had happened, but she did feel that Driver #1 should have secured her into her chair especially since due to her MS diagnosis she was not able to secure herself. Review of physician order dated 10/05/23 revealed an order for a mobile x-ray to be completed on Resident #12's left ankle, left foot, left knee, left tibia (located on inside of leg, below knee joint, and forms top of ankle joint), and left fibula (located on outside of leg, below knee joint, and forms top of ankle joint). Review of on-call physician note dated 10/06/23 indicated on 10/05/23 Resident #12 had a fall from her wheelchair on transportation van. Resident #12's left knee was swollen, she complained of increased pain at a level 10 in her left knee and leg, and her x-ray results had not been received. Ibuprofen 400 mg twice daily for 3 days and Tylenol 500 mg three times daily for 3 days was ordered for Resident #12's acute pain post fall. Review of on-call physician orders for Resident #12 dated 10/06/23 indicated Ibuprofen 400 mg twice daily for 3 days for acute pain post fall and Tylenol 500 mg three times daily for 3 days for acute pain post fall. Review of a mobile x-ray dated 10/06/23 of Resident #12's left knee revealed a moderately displaced (more complex fracture because bones are out of alignment or in pieces) distal left fracture of the femur of indeterminate age (not able to determine how long-ago fracture occurred). Clinical follow-up was recommended. Review of an on-call physician note dated 10/06/23 revealed Resident #12's x-ray results were reviewed with no new treatment orders. The on-call physician indicated to continue to monitor and follow-up with the resident's primary care physician was recommended. Review of Resident #12's Medication Administration Record (MAR) from 10/6/23 through 10/8/23 revealed the following administrations of Resident #12's pain medications Tylenol 500 mg (three times daily), Ibuprofen 400 mg (twice daily), Gabapentin 300 mg (prn): -10/6/23: Gabapentin at 12:14 AM (pain level 2), Tylenol at 2:00 PM (pain level of 10), Ibuprofen at 8:00 PM (pain level 0), and Tylenol 10:00 PM (pain level of 0) -10/07/23: Tylenol at 6:00 AM (pain level 0), Gabapentin at 7:35 AM (pain level 1), Ibuprofen at 8:00 AM (pain level 0), Tylenol at 2:00 PM (pain level 0), Gabapentin at 3:24 PM (pain level 1), Ibuprofen at 8:00 PM (pain level 0), Tylenol at 10:00 PM (pain level of 2), and Gabapentin at 11:24 PM (pain level 1) -10/08/23 Tylenol at 6:00 AM (pain level 0), Ibuprofen at 8:00 AM (pain level 0), Gabapentin at 10:47 AM (pain level 1), and Tylenol at 2:00 PM (pain level of 0) Review of an on-call physician note dated 10/08/23 revealed Resident #12 complained of pain in her stomach area when inhaling and requested to be sent out to the hospital. Resident #12 was sent out from the facility to the hospital at 4:05 PM. Review of the hospital discharge summary dated 10/09/23 revealed Resident #12 was seen at emergency department (ED) for a fall and shortness of breath. Resident #12 had an abrasion and edema (swelling) to the left knee and a CT scan was obtained and revealed a distal femur fracture on the left and some possible bruising to the ribs as a result of the fall. The consulting ED provider did not recommend any emergency intervention given that Resident #12 was non-ambulatory, and wheelchair bound. Resident #12 was discharged back to the facility with an order for Naproxen (treat fever and pain) 375 mg by mouth twice daily and follow-up with orthopedics. During interview with Resident #12 on 8/20/24 at 11:00 AM she revealed on the day after the fall (10/06/23), her pain had gotten worse around her left knee and the facility administered her pain medications and completed an x-ray of her left side. She stated a couple of days later (10/08/23) she started having some trouble breathing and was sent out to the hospital where they confirmed she had broken her left leg and bruised her ribs because of the fall. Resident #12 revealed the hospital administered her some more pain medication, referred her to an orthopedist, and sent her back to the facility. An interview conducted with Director of Nursing (DON) on 8/21/24 at 12:06 PM revealed she was familiar with Resident #12. She stated on the afternoon of 10/05/23, Resident #12 had returned to the facility after being transported to a medical appointment by their contract transport company and stated that she had fallen on the van. She revealed she immediately assessed Resident #12 for injury and noted a skin tear to her left knee with some swelling. The DON stated she notified physician of Resident #12's fall on 10/05/23 and received an order for a mobile x-ray of left knee. A mobile x-ray was completed on 10/06/23 and revealed a distal left leg fracture of the femur but was not able to determine the age of the fracture due to Resident #12's contractures and follow-up was recommended. She revealed the on-call physician was notified of the results and did not order any further treatment until reviewed by the facility physician. The DON stated on 10/08/23 Resident #12 was complaining of stomach pain when taking a deep breath and requested to be sent out to hospital. The on-call physician was notified, and orders were received for her to be sent out. She indicated a CT scan completed at the hospital on 10/08/23 revealed Resident #12 had suffered a left leg fracture of the femur and suspected bruised ribs from the fall in the van, Resident #12 returned to the facility with an order to follow-up with orthopedics outpatient. A telephone interview conducted with the physician on 8/21/24 at 4:55 PM revealed he was familiar with Resident #12 and her fall on the van. He stated he was notified on the day the accident had occurred and approved a mobile x-ray order for Resident #12's left side extremities due to her left knee showing signs of swelling. He revealed the mobile x-ray and the CT scan from the hospital both showed Resident #12 had suffered a left leg femur fracture due to the fall and recommended follow-up with outpatient orthopedic. The physician stated Resident #12 did have MS which caused her to have contractures in all of her extremities and suspected demineralization (loss of bone minerals faster than can be replaced) making it easier for injury, Resident #12 would still have had to fallen hard onto a hard surface to sustain that type of injury. He revealed he had been told by the DON that Driver #1 did not secure Resident #12 into her wheelchair causing her to fall. He indicated he would expect that all residents be secured while being transported in their wheelchairs. An interview was conducted with the Administrator on 8/21/24 at 5:27 PM revealed she was familiar with Resident #12. She stated on 10/05/23, Resident #12 had been transported by their contract transport company to an appointment. She indicated when the resident arrived back at the facility, the resident reported that during her transport back to the facility she was not secured into her wheelchair and had fallen out of her wheelchair onto the van floor. Resident #12 stated Driver #1 had stopped the van and assisted her back into her chair and brought her back to the facility. The Administrator revealed while the DON was assessing Resident #12 for injury and contacting the physician, she attempted to interview Driver #1 about the incident, but he left the facility, so she contacted the Contract Transport Company Owner to notify them about the incident. She stated the Contract Transportation Company Owner assisted her with receiving a written statement about the incident from Driver #1 and was able to view camera footage from the van to corroborate Resident #12's statement of how the fall occurred and that she had not been secured into her wheelchair. The Administrator revealed Resident #12 had suffered a left leg femur fracture and bruised ribs from the fall. She stated according to the information received from the transport company, Driver #1 was no longer employed with the company and had received prior education on securing residents and their wheelchairs during transport. A telephone interview conducted with the Contract Transport Company Owner on 8/22/24 at 9:29 AM revealed on 10/05/23, he was notified by the facility of the fall incident involving Driver #1 and Resident #12. He also revealed he received a written statement from Driver #1 and reviewed video footage from the van to confirm Resident #12's statement about the fall. He stated according to the van video footage, Driver #1 was transporting Resident #12 from an appointment back to the facility and secured Resident #12's wheelchair into the van but failed to secure her into her wheelchair by using the lap belt. He stated during this transport, Driver #1 had to stop suddenly causing Resident #12 to fall out of her wheelchair onto the van floor. He revealed after the fall, Driver #1 pulled the van over, assisted Resident #12 back into her wheelchair and transported her back to the facility. He stated Driver #1 was no longer employed with the company and all drivers received training prior to transporting on van safety and proper ways to secure residents in wheelchairs in vans. The Contract Transport Company Owner stated Driver #1 should have secured Resident #12 lap belt in her wheelchair to keep her from falling forward out of her wheelchair and once the fall had occurred, he should have stopped the van, contacted 911 and the facility, and waited for Resident #12 to be assessed by medical personnel prior to her being moved. The facility was notified of immediate jeopardy on 8/22/24 at 5:50 PM. The facility provided the following corrective action plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; The identified resident (Resident #12) is still a current Resident at the facility. Resident #12 was picked up by a contract transportation driver from a scheduled neurology appointment for transport back to the facility. Prior to leaving the appointment, the contracted driver secured Resident #12 wheelchair, but failed to secure Resident #12 seatbelt leaving her unsecured. During transport, the contracted driver had to slam on brakes causing Resident #12 to fall forward from her wheelchair into the van floor. Contracted Driver pulled off road and assisted Resident #12 back into her wheelchair and then continued to transport Resident #12 back to the facility. Contracted Driver failed to contact 911 and/or facility prior to moving Resident #12 from van floor and prior to placing her back into wheelchair after fall. The following actions after this incident: On 10/5/23, Facility initiated immediate investigation on 10/5/23. On 10/5/23, Resident #12 medical director (MD) and responsible person (RP) made aware of incident. On 10/5/23, Order obtained for x-ray to the left ankle, left foot, left knee, left tibia and left fibula. On 10/6/23, Resident #12 complained of pain on a level of 10 on a level 0-10, MD notified, and new orders obtained for the following: Ibuprofen 400mg take 1 tablet by mouth twice daily x3 days for acute pain post fall and Tylenol 500mg take 1 tab by mouth three times daily x3 days for acute pain s/p fall. Pain medication effective with a pain scale of 0 noted. On 10/6/23, x-ray results were obtained and showed the following, Left tibia/fibula- No fracture or dislocation is identified, bony structures are osteoporotic. Left ankle-No acute fracture, dislocation or osseous lesion, bony structures are osteoporotic. Left Knee- moderately displaced fracture of the distal diaphysis of the femur of indeterminate age. No dislocation is identified. Left Foot-soft tissue swelling of the foot. Bony structures are osteoporotic. No acute fracture or dislocation is identified. There is moderate hallux valgus (bony bump that forms on joint at the base of big toe), mild degenerative change of the interphalangeal (hinge shaped joint in toe) joint, first metatarsophalangeal (joint that connects toes to foot bone) joint and midfoot is present. On 10/8/2023, Resident #12 complained of pain when she inhales in her stomach area especially the left upper quad. Resident and Daughter requested for Resident to be sent out to the Hospital for Evaluation and treatment. Vital signs at that time were as follows: BP 114/72, P 68, Resp. 18, Temp. 97.8. Resident transported via ambulance and MD was notified of the transport. On 10/8/23 hospital x-ray revealed an acute comminuted (break into three or more pieces) and mildly displaced distal femoral fracture with minimal angulation. Soft tissue swelling adjacent to the fracture. A left hip gamma nail (metal implant used to stabilize fractures) seen, no dislocation. No evidence of knee joint effusion (abnormal fluid accumulation within knee joint). On 10/9/23, Resident #12 returned back to the facility via stretcher accompanied by two emergency management technicians (EMT) attendants. Resident complained of pain and discomfort to the left femur upon assessment pain meds were administered and effective. New orders from emergency department (ED) for Naproxen 375mg PO BID. Ortho follow up appointment with Orthopedic surgery as soon as possible. On 10/9/23, Facility made Resident #12 an Ortho appointment on 10/10/23 at 2:15pm. RP and MD made aware of the appointment. On 10/10/23, Resident #12 was taken to Ortho via facility transport. Ortho plan on 10/10/23 state Resident is not a strong surgical candidate given knee contracture, would not recommend a long leg cast at that time. Instead recommended a knee immobilizer and limit range of motion of including weight-bearing. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; No other Residents have had a fall/accident/or injury during a transport due to not being properly secured during transportation. Director of Nursing reviewed last 3 months of accident/incidents to ensure no other falls occurred during transport to and from the facility due to not being properly secured. Audit was completed on 10/9/23. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; An immediate in-service initiated on 10/9/23 by Maintenance Director on Q-straint system in van and how to properly secure a resident in the van, for facility transportation drivers. This education consisted of hands on and return demonstration, and verbal education. Van Drivers were educated by Administrator on ensuring Driver Transport safety checklist to be completed for all transports completed by the facility van drivers prior to leaving the facility with the resident. Education completed on 10/9/23. On 10/6/23 the contracted transportation company had a safety meeting with all drivers re-educating them on ensuring Residents are properly secured in van prior to transports Education will be added to new Transportation Driver orientation and given by the Administrator. Administrator added education to new hire orientation on 10/9/23. 4. Address how the facility plans to monitor its performance to make sure that solutions are sustained; Beginning 10/9/23, Administrator/designee will review transportation book and ensure that Driver Transport Safety checklist for all transports completed by The Ivy van drivers Monday-Friday for 12 weeks. Beginning 10/9/23, someone from Administration observed Residents that were being transported via van to ensure Resident was properly secured in van prior to leaving the facility for transport, Administration observed 5 days a week for 4 weeks, 3 days a week for 4 weeks and weekly for 4 weeks. On 10/9/23 the Administrator made the decision to take the results of the observations to the monthly Quality Assurance meeting for tracking, trending, and recommendations from the IDT team. Alleged Date of Immediate Jeopardy Removal: 10/10/23 Alleged Date of Corrective Action Completion: 10/13/23 The facility's corrective action plan was validated on 8/27/24 by the following: Interviews with facility transporters revealed they had received education on restraint system in van and how to properly secure a resident in the van as well as the driver safety checklist that was to be completed prior to leaving facility with residents. The facility transporters also stated they had to verbalize their understanding of the education they had received and complete a demonstration showing they were capable of securing residents inside the van properly for transport. The facility transporters revealed they only transported residents in manual wheelchairs inside the facility vans and any resident that required a geriatric-chair (a padded chair with a wheeled base) for transport, would have to be transported by non-emergent EMS transport and any resident with an electric wheelchair would have to be transported by their contract transport company. Contract transport company re-education dated 10/06/23 verified staff were educated on ensuring residents are secured in vans according to the manufacturer's instructions prior to transport. Review of facility orientation education for new hire transport drivers verified the education included the driver safety checklist and educational and video material on van restraint system and securing residents properly into van prior to transport. Review of the audit tools and driver safety checklist was completed with no issues noted. An observation was made on 8/23/24 of facility transporter securing a resident in their wheelchair inside the van in accordance with the manufacturer's instructions prior to being transported. Interviews were also conducted with alert and oriented residents who had been transported since October 2023 with no concerns identified. No additional transportation incidents were identified since October 2023. Interview with the Administrator revealed she had educated facility transport drivers on properly securing residents into the vans, completing van safety checklist, hands-on observations of drivers securing residents into vans prior to transport, completed audits and reviews of driver safety checklist with no issues. The Administrator also stated the facility had only transported residents with manual wheelchairs in their facility vans, residents who required a geriatric chair were transported by non-emergent EMS transport and residents with an electric wheelchair were transported by contract transport. The facility's immediate jeopardy removal date was validated as 10/10/23 and the corrective action completion date was validated as 10/13/23.

Based on observations, record review and staff interviews the facility failed to post cautionary and safety signage outside of resident rooms that indicated the use of oxygen for 4 of 4 residents (Resident #1, #6, #8, and #42) reviewed for respiratory care. The findings included: a. Resident #1 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was not coded for receiving oxygen. A review of Resident #1's physician orders revealed an order dated 1/26/24 for oxygen to be administered continuously via nasal cannula at 3 liters per minute (l/min). An observation on 8/19/24 at 4:03 PM revealed Resident #1 was lying in bed wearing a nasal cannula with oxygen being administered at 3 l/min. There was no cautionary or safety signage posted at the entrance to Resident #1's room to indicate oxygen was in use. An observation of Resident #1 conducted on 8/20/24 at 11:00 AM revealed she was sitting on the side of her bed with oxygen being administered via nasal cannula at 3 l/min. There was no safety signage posted at the entrance to Resident #1's room to indicate oxygen was in use. b. Resident #6 was admitted to the facility on [DATE]. A review of the quarterly MDS dated [DATE] indicated Resident #6 was not coded for receiving oxygen. A review of Resident #6's physician orders revealed an order dated 5/20/24 for oxygen to be administered via nasal cannula at 2 l/min as needed. An observation on 8/20/24 at 11:00 AM revealed Resident #6 was sitting in her wheelchair wearing a nasal cannula with oxygen being administered at 2 l/min. There was no cautionary or safety signage posted at the entrance to Resident #6's room to indicate oxygen was in use. An observation on 8/22/24 at 9:45 AM revealed Resident #6 was lying in bed and wearing a nasal cannula with oxygen being administered at 2 l/min. There was no cautionary or safety signage posted at the entrance to Resident #6's room to indicate oxygen was in use. c. Resident #8 was admitted to the facility on [DATE]. A review of the admission MDS dated [DATE] indicated Resident #8 was not coded for receiving oxygen. A review of Resident #8's physician orders revealed an order dated 6/14/24 for oxygen to be administered via nasal cannula at 2 l/min as needed. An observation conducted on 8/19/24 at 12:21 PM revealed Resident #8 was lying in bed sleeping and wearing a nasal cannula with oxygen being administered at 2 l/min. There was no cautionary or safety signage posted at the entrance to Resident #8's room to indicate oxygen was in use. An observation conducted on 8/20/24 at 9:30 AM revealed Resident #8 was lying in bed sleeping and wearing a nasal cannula with oxygen being administered at 2 l/min. There was no safety signage posted at the entrance to Resident #8's room to indicate oxygen was in use. d. Resident #42 was admitted to the facility 8/13/24. A review of the admission MDS dated [DATE] revealed Resident #42 was coded for receiving oxygen therapy during the assessment period. A review of Resident #42's physician orders indicated an order dated 8/14/24 for oxygen to be administered via nasal cannula at 3 l/min continuously. An observation conducted on 8/19/24 at 4:43 PM revealed Resident #42 was lying in bed wearing a nasal cannula with oxygen being delivered at 3 l/min. There was no cautionary or safety signage posted at the entrance to Resident #42's room to indicate oxygen was in use. An observation of Resident #42 was conducted on 8/20/24 at 11:30 AM. Resident #42 was lying in bed wearing a nasal cannula with oxygen being delivered at 3 l/min. There was no safety signage posted at the entrance to Resident #42's room to indicate oxygen was in use. An observation conducted at the main entrance of the facility on 8/19/24 at 5:30 PM revealed there was no cautionary or safety signage posted to notify those entering the building that oxygen was in use. An interview was conducted with the Administrator on 8/22/24 at 3:10 PM. She stated she had not noticed there was no safety signage posted at the facility's main entrance to indicate oxygen was in use but that it should be posted. The Administrator further stated safety signage for oxygen use was not posted outside of resident rooms because she was not aware that was still a requirement. An interview was conducted with the Director of Nursing on 8/23/24 at 10:56 AM. She stated safety signage for the use of oxygen was not posted at the facility entrance or outside of resident rooms because they were not aware the signage was required.

Based on record review, resident, staff, Consultant Pharmacist, Nurse Practitioner, and Physician interviews, the facility failed to administer medications as ordered by the Physician that included Bosulif (medication for leukemia) and Olanzapine (an antipsychotic medication). This occurred for 2 of 5 residents (Resident #9 and Resident #13) reviewed for significant medication errors. Findings included: 1. Resident #9 was admitted to the facility 08/24/22 with a diagnosis including chronic myelocytic leukemia (cancer of white blood cells). Review of Resident #9's Physician orders revealed an order dated 01/20/23 for Bosulif 100 milligrams (mg) 2 tablets by mouth every day related to leukemia. Review of Resident #9's annual Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact with no behaviors. Review of Resident #9's Medication Administration Records (MARs) from December 2023 through August 2024 revealed Bosulif was initialed by nursing staff as being administered as ordered. An interview with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) on 08/21/24 at 11:53 AM revealed the facility became aware on 08/01/24 that Resident #9 had a surplus of Bosulif on the medication cart. She explained Bosulif was provided by an outside specialty pharmacy and the facility only received 60 pills a month so she was unsure why there would be leftover medication in the cart. The ADON/IP stated she checked the medication cart where Resident #9's Bosulif was stored, and she noted three opened bottles of Bosulif with varying amounts of pills in each bottle. She stated one bottle indicated it was dispensed in December 2023, one bottle indicated it was dispensed in January 2024, and the last bottle indicated it was dispensed in February 2024. The ADON/IP stated Resident #9 was a participant in an all-inclusive care program which provided her Bosulif. She stated the Physician at the all-inclusive care program was notified that Resident #9 did have a surplus of Bosulif medication and the facility was unable to determine why there would be a surplus of the medication. An interview with the Director of Nursing (DON) on 08/21/24 at 12:06 PM revealed the facility became aware of Resident #9 having a surplus of Bosulif on the medication cart on 08/01/24 and notified the Physician of the surplus. The DON stated the Bosulif was provided by a specialty pharmacy that was associated with the all-inclusive care program Resident #9 participated in. She stated the Physician for the all-inclusive care program came to the facility and she checked the medication cart with the Physician. The DON stated they found three bottles of Bosulif with varying amounts of medication in each bottle in the medication cart and one bottle indicated it was dispensed in December 2023, one bottle indicated it was dispensed in January 2024, and another bottle indicated it was dispensed in February 2024. She stated she wasn't sure why there would be a surplus of Bosulif. A telephone interview with the Physician at the all-inclusive care program on 08/21/24 at 2:49 PM revealed Resident #9 had been taking Bosulif for leukemia for approximately 2 years. He explained the medication was very expensive and was paid for by the all-inclusive care program in which Resident #9 was a member. The Physician stated Bosulif was prepared each month by a specialty pharmacy, was delivered to his office, and a nurse from his office delivered the medication to the facility. He stated that he received a telephone call from one of the nurses in his office around the first of August 2024, that delivered the Bosulif to the facility and she notified him there was a surplus of the medication in the medication cart. The Physician stated he came to the facility and found three bottles of Bosulif, each containing a differing amount of the medication, and there were 87 extra tablets. He stated the bottles indicated they were dispensed in January 2024, February 2024, and March 2024. The Physician stated the specialty pharmacy called his office every month to make sure Bosulif was still needed before they prepared the medication, and it was not possible they would send extra medication due to the cost. He stated there was no way to know for sure, but since Resident #9 had not been hospitalized in the past two years, it appeared there were days from January 2024 through March 2024 when she did not receive the two tablets of medication she was supposed to receive. The Physician stated the surplus of Resident #9's Bosulif on the medication cart would be considered a significant medication error. He stated he reached out to Resident #9's oncologist and explained the situation with Bosulif and he was informed that if her laboratory tests were unchanged, the resident did not suffer any harm. The Physician stated he checked Resident #9's laboratory work after the error occurred in August 2024, and her laboratory work was unchanged. An interview with the Administrator on 08/21/24 at 5:28 PM revealed she was aware of the concerns with Resident #9 not receiving her Bosulif as ordered. She stated she felt that since Resident #9 was alert and oriented she would have asked staff if her medication cup did not contain Bosulif and she felt that Resident #9 did receive her medication as ordered. An interview with Resident #9 on 08/22/24 at 9:25 AM revealed there was a time when she was not receiving her Bosulif as ordered (she was unsure of the time frame) and now she checked her medication cup each morning to make sure she received Bosulif. A telephone interview was conducted on 08/23/24 at 11:57 AM with Nurse Practitioner (NP) #2 from Resident #9's oncology office. NP #2 stated she was aware of concerns that Resident #9 had not received her Bosulif as ordered but her most recent laboratory work in August 2024 revealed she was almost in remission and did not suffer any harm from missing medication. 2. Resident #13 was admitted to the facility 04/10/19 with a diagnosis including schizophrenia. Review of Resident #13's Physician orders dated 02/24/24 revealed an order for Olanzapine 10 milligrams (mg) one tablet at bedtime for schizophrenia. Review of Resident #13's February 2024, Medication Administration Record (MAR) revealed nursing staff initialed the MAR as administering the Olanzapine as ordered. Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired and had other behaviors 4 to 6 days during the look back period. An interview with the Director of Nursing (DON) on 08/23/24 at 7:53 AM revealed the facility became aware on 02/16/24 of Resident #13 receiving Olanzapine 20 mg once daily instead of Olanzapine 10 mg daily. She stated Resident #13 received Olanzapine 20mg daily from 02/05/24 until 02/16/24. The DON stated she could not recall how the facility became aware of Resident #13 receiving the incorrect dose of Olanzapine, but when it was brought to her attention she notified the Nurse Practitioner (NP) and Responsible Party (RP), removed Olanzapine 20 mg from the medication cart, and ordered the correct dose of Olanzapine from the pharmacy. The DON stated she was not sure how the incorrect dose was able to be requested from pharmacy or why the error occurred. A telephone interview with the Consultant Pharmacist on 08/22/24 at 1:35 PM revealed Resident #13 had active orders for Olanzapine 20 mg and Olanzapine 10 mg in the computer and when staff requested a refill of Olanzapine in March 2024, they checked 20 mg needed to be refilled instead of 10 mg. She stated she was not sure why Resident #13 had two active orders in the computer for Olanzapine, but since the facility requested a 20 mg refill, they received a 20 mg refill. A telephone interview with Nurse Practitioner (NP) #3 on 08/23/24 at 12:13 PM revealed she was aware Resident #13 had received Olanzapine 20 mg daily for 11 days in February 2024, instead of the ordered Olanzapine 10 mg daily. She stated eleven days was a long time to receive the incorrect dose of Olanzapine and she considered that a significant medication error. NP #3 stated when she was notified of Resident #13 receiving the incorrect dose of Olanzapine, she wrote orders to gradually reduce the dose from 20 mg to 10mg. She stated Resident #13 had taken Olanzapine 20 mg in the past and did not suffer any harm.

Based on observations, record review, and staff interviews the facility failed to implement Special Droplet Contact Precautions when Nurse #1 and Nurse Aide (NA) #1 entered Resident #4's room without donning Personal Protective Equipment (PPE); failed to ensure staff implemented their infection control policy for hand hygiene when Nurse #2 failed to wear gloves during insulin administration and perform hand hygiene after insulin administration for Resident #28; and when Unit Manager #1 failed to perform hand hygiene after removing dirty gloves and before donning clean gloves during wound care for Resident #12. These failures occurred during a COVID-19 outbreak at the facility for 3 of 5 residents reviewed for infection control practices (Resident #4, Resident #28, Resident #12). Findings included: The Special Droplet Contact Precautions (SDCP) signage, with a revised date of 02/09/2022, noted staff should follow the instructions on the signage before entering the resident's room which included, All healthcare personnel must: 1) clean hands before entering and when leaving the room, 2) wear a gown when entering room and before leaving, 3) wear N-95 or higher level respirator before entering the room and remove after exiting, 4) wear protective eyewear (face shield or goggles), and 5) wear gloves when entering room and remove before leaving. The facility's policy titled, Hand Hygiene last revised 10/26/23 read in part as follows: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Hand hygiene is indicated and will be performed under the conditions listed in the hand hygiene table. Hand Hygiene Table: 1) before and after handling clean or soiled dressings, 2) before performing resident care procedures, 3) before applying and after removing PPE, including gloves, and 4) after handling items potentially contaminated with blood or body fluids. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 1.a. A continuous observation of Resident #4's room on 08/19/24 from 12:29 PM to 12:30 PM revealed SCDP signage posted and PPE supplies on the room door. NA #1 entered the room with a lunch meal tray wearing only a surgical mask without donning any PPE per the instructions on the signage. NA #1 placed the meal tray on the overbed table, sanitized her hands with ABHR, and exited the room. An interview with NA #1 on 08/19/24 at 1:06 PM revealed she did not realize Resident #4 was on SDCP until she was already in the room. She stated she had been trained to read and follow signage on resident room doors and it was an oversight. An interview with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) on 08/19/24 at 2:12 PM revealed she expected all nursing staff to follow posted signage on resident room doors by donning and doffing all PPE as instructed. An interview with the Director of Nursing (DON) on 08/23/24 at 7:53 AM revealed she expected staff to follow posted signage on resident room doors by using PPE as instructed. b. A continuous observation of Resident #4's room on 08/19/24 from 12:32 PM through 12:34 PM revealed SCDP signage posted and PPE supplies on the room door. Nurse #1 entered Resident #4's room wearing only a surgical mask without donning any PPE per the instructions on the signage. Nurse #1 checked Resident #4's blood glucose, removed her gloves, performed hand hygiene with (ABHR), picked up the glucometer, and exited the room. An interview with Nurse #1 on 08/19/24 at 12:34 PM revealed she did not don the PPE listed on the signage for Resident #4 because she thought the sign was for Enhanced Barrier Precautions (a type of TBP that doesn't require full PPE with each entry to a resident room). She stated she should have looked at the sign more closely and it was an oversight. An interview with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) on 08/19/24 at 2:12 PM revealed she expected all nursing staff to follow posted signage on resident room doors by donning and doffing all PPE as instructed. An interview with the DON on 08/23/24 at 7:53 AM revealed she expected staff to follow posted signage on resident room doors by using PPE as instructed. 2. A continuous observation of Nurse #2 on 08/20/24 from 8:16 AM through 8:18 AM revealed she gathered Resident #28's insulin pen and an alcohol swab, entered his room, opened the alcohol swab, swabbed his right upper arm with the alcohol swab, administered the insulin injection into his right upper arm, collected the insulin pen and exited the room. Nurse #2 did not apply gloves to administer Resident #28's insulin injection and did not perform hand hygiene after administering the insulin. An interview with Nurse #2 on 08/20/24 at 8:18 AM revealed she got in a hurry and that's why she did not wear gloves when she administered Resident #28's insulin injection and she should have performed hand hygiene after administering the insulin. An interview with the DON on 08/23/24 at 7:53 AM revealed she expected staff to wear gloves when administering insulin and perform hand hygiene after removing gloves. An interview with the ADON/IP on 08/23/24 at 10:59 AM revealed gloves should be worn when insulin was administered, and hand hygiene should be performed after removing gloves. 3. A continuous observation of Unit Manager #1 on 08/20/24 from 4:40 PM through 5:00 PM revealed with gloved hands she cleaned Resident #12's ischial (the curved bone forming the base of the pelvis) wound with wound cleanser, removed her gloves, opened a clean gauze dressing, applied clean gloves, measured the wound, applied calcium alginate (an absorbent dressing) and a dry dressing to the wound, removed her gloves, and sanitized her hands with ABHR. Unit Manager #1 did not perform hand hygiene after removing dirty gloves and before touching a clean dressing. An interview with Unit Manager #1 at 5:07 PM revealed she usually performed hand hygiene each time she removed her gloves and before touching other items and she did not when providing wound care for Resident #12 due to an oversight. An interview with the DON on 08/23/24 at 7:53 AM revealed hand hygiene should be performed after gloves were removed and before putting on clean gloves. An interview with the ADON/IP on 08/23/24 at 10:59 AM revealed hand hygiene should be performed each time gloves are removed and before putting on clean gloves.

Based on record reviews, staff, and responsible person (RP) interviews, the facility failed to notify the RP of a follow-up urologist appointment for a scheduled procedure for Resident #19. During Resident #19 urology appointment on 5/31/24, a follow-up recommendation for a cystoscopy (used to diagnose, monitor, and treat conditions affecting the bladder and urethra) procedure was recommended and scheduled for 6/04/24. Resident #19's RP was not notified of the recommendations for the scheduled cystoscopy on 6/04/24. This deficient practice affected 1 of 3 residents reviewed for notification (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses including obstructive and reflex uropathy (blockage preventing urine from draining properly and cause urine to back-up into kidneys), urinary retention, and use of indwelling catheter. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #19 was moderately cognitively impaired and assessed as having an indwelling catheter. Review of urology office note dated 5/31/24 revealed in part Resident #19 was seen on this date for urinary retention and previously failed voiding trials. Follow-up recommendation for treatment included a cystoscopy procedure in office, scheduled for 6/04/24 at 9:00 AM. Review of urology office note dated 6/04/24 revealed in part Resident #19 was seen at urology office on this date for a scheduled cystoscopy for urinary retention. Cystoscopy was completed, Resident #19 tolerated procedure well, and follow-up recommendations for treatment included a referral for a Urolift (small implants placed to lift or hold excess tissue out of the way and allowing urine to flow more freely) procedure to assist with longstanding urine retention. A telephone interview conducted with the RP on 8/21/24 at 9:28 AM revealed she was the legal guardian for Resident #19 and was responsible for reviewing all recommendations from medical appointments. She stated Resident #19 was seen by the urologist on 5/31/24 for urinary retention with recommendations for a scheduled cystoscopy on 6/04/24. She revealed the facility transported Resident #19 to his scheduled urology appointment on 6/04/24 for the cystoscopy procedure. Resident #19's RP stated she was not made aware of the recommendations from Resident #19 urology appointment on 5/31/24 for the cystoscopy procedure on 6/04/24 prior to his appointment. She revealed she was notified by the Director of Nursing (DON) on 6/05/24 of the outcome and follow-up recommendations from the urology appointment and procedure on 6/04/24, and she informed the DON that she had not been made aware of the recommendations from Resident #19 urology appointment on 5/31/24 or of the scheduled cystoscopy that was completed on 6/04/24. She stated the DON was not aware Resident #19's RP had not been notified of the recommendations from Resident #19 urology appointment on 5/31/24 or of the scheduled cystoscopy on 6/04/24 and assumed the urology office had notified Resident #19's RP of the recommended procedure. Resident #19's RP felt the facility should have contacted her about the recommendations from Resident #19 urology appointment on 5/31/24 and the scheduled cystoscopy on 6/04/24 to assure that she was made aware instead of assuming the urology office would contact her. An interview with the DON on 8/21/24 at revealed she was familiar with Resident #19 and his RP not being notified of follow-up recommendations for a urology procedure. She stated normally she would always notify a residents RP of any follow-up recommendations or scheduled procedures from appointments. She revealed in the case with Resident #19, she had received the follow-up recommendations from his urology appointment on 5/31/24 for a scheduled cystoscopy on 6/04/24 and assumed the urology office had contacted Resident #19's RP about the recommendations and procedure. The DON stated failing to notify Resident #19's RP about the follow-up recommendations and scheduled urology procedure was just an oversight or human error on her part. She revealed she was not made aware Resident # RP had not been made aware of the recommendations from his urology appointment on 5/31/24 for the scheduled cystoscopy on 6/04/24 until she contacted the RP on 6/05/24 to discuss the follow-up recommendations from the cystoscopy and realized Resident #19's RP had no knowledge of the follow-up recommendations or of the cystoscopy. She stated herself and nursing staff were responsible for making sure all RPs were notified of resident appointments, received recommendations from appointments, scheduled follow-up appointments and procedures, and were provided with any paperwork or consents to be completed and reviewed, and moving forward would ensure all resident RPs were notified of any follow-up recommendations or scheduled procedures from appointments. An interview with the Administrator on 8/21/24 at revealed she was familiar with Resident #19 and the incident with his RP not being notified of his urology appointment recommendations for a scheduled cystoscopy on 6/04/24. She stated although the DON and nursing staff typically do notify all resident RPs of any follow-up recommendations from appointments or scheduled procedures, medical offices would usually notify the RPs as well. She believed this incident was just an oversight or human error, the DON assumed the urology office had contacted Resident #19's RP and was not made aware until after the scheduled procedure the RP had not been notified. The Administrator stated the DON should have contacted Resident #19's RP about the follow-up recommendations from his urology appointment on 5/31/24 and his scheduled procedure on 6/04/24, moving forward the DON and nursing staff would be responsible for making sure all resident RPs were made aware of any follow-up recommendations or scheduled procedures from appointments.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set assessment (MDS) for oxygen use (Resident #1, #6, and #8) and hospice services (Resident #1 and Resident #4) for 4 of 5 residents reviewed for accuracy of assessments. The findings included: a. Resident #1 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD). A review of Resident #1's physician orders revealed an order dated 1/26/24 for oxygen to be administered continuously via nasal cannula at 3 liters per minute (lpm). A review of Resident #1's medical record indicated she was admitted to hospice services on 2/8/24. A review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] indicated Resident #1 was not coded for receiving hospice services or oxygen. b. Resident #6 was admitted to the facility on [DATE] with diagnoses that included COPD, emphysema, and chronic respiratory failure. A review of Resident #6's physician orders revealed an order dated 5/20/24 for oxygen to be administered via nasal cannula at 2 lpm as needed. A review of the quarterly MDS assessment dated [DATE] indicated Resident #6 was not coded for receiving oxygen. c. Resident #8 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracranial hemorrhage (stroke from brain bleeding not caused by trauma) and obstructive sleep apnea. A review of Resident #8's physician orders revealed an order dated 6/14/24 for oxygen delivered via nasal cannula at 2 lpm as needed. A review of the admission MDS dated [DATE] indicated Resident #8 was not coded for receiving oxygen. An interview was conducted with the MDS Coordinator on 8/22/24 at 1:25 PM. She stated Resident #6's and Resident #8's MDS assessments should have been coded to reflect they were receiving oxygen and Resident #1's MDS assessment should have been coded to reflect she was receiving hospice services and oxygen. She further stated the coding inaccuracies were an oversight on her part. An interview conducted with the Administrator on 8/22/24 at 3:10 PM revealed she expected the MDS assessment to be coded accurately. 39037 d. Resident #4 was admitted to the facility 01/09/24 with a diagnosis including non-Alzheimer's dementia. Review of Resident #4's medical record revealed she was admitted to hospice services on 08/01/24. A significant change in condition Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was not coded as receiving hospice services. An interview with the MDS Coordinator on 08/23/24 at 11:39 AM revealed Resident #4's significant change MDS should have been coded to reflect she was receiving hospice services, and it was an oversight. A telephone interview with the Director of Nursing (DON) on 08/26/24 at 10:29 AM revealed she expected MDS to be coded accurately.

Based on observations, record review, resident and staff interviews, the facility failed to administer pain medication to 1 of 1 resident (Resident #97) reviewed for pain management when she complained of pain at a level of 9 on a scale of 0 to 10. The findings included: Resident #97 was admitted to the facility on [DATE] with diagnoses which included hypertension, diabetes mellitus and end stage renal disease. Resident #97's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact, required extensive to total assistance of 1 staff member with all activities of daily living except eating. The assessment also revealed Resident #97 received as needed pain medication for pain and non-verbal sounds of pain related to stage IV pressure ulcer on the resident's sacral region. Review of Resident #97's care plan dated 4/24/23 revealed a focus area for chronic pain. The interventions included evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, identify and record previous pain history and management of that pain and impact on function, identify previous response to analgesia including pain relief, side effects and impact on function, identify, record and treat the resident's existing conditions which may increase pain and or discomfort, monitor/document for probable cause of each pain episode, remove/limit causes where possible, monitor/document for side effects of pain medication, observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls, report occurrences to the physician, monitor/record/report to nurse loss of appetite, refusal to eat and weight loss, monitor/record/report to nurse resident complaints of pain or requests for pain treatment and notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Observation during medication pass on 05/01/23 at 10:38 AM revealed Resident #97 getting her morning medications. Nurse #2 was administering her medications including Aspirin and asked the resident what her pain level was at that time and Resident #97 stated it was a 9 on a scale of 0 to 10. Nurse #2 administered the Aspirin and proceeded to the next resident without offering Resident #97 any pain medication. Review of Resident #97's Medication Administration Record, revealed she had Oxycodone Hydrochloride (HCl) Oral tablet 5 milligrams (mg) - give 5 mg by mouth every 6 hours as needed for pain ordered. The MAR indicated the resident had not received the Oxycodone within the last 6 hours and the resident could have received the medication for her pain level of 9. Observation and interview on 05/01/23 at 11:51 AM with Resident #97 revealed her sitting up in her wheelchair in her room and she was shifting in her wheelchair to try and get comfortable. Resident #97 stated she had not received anything for pain since yesterday and she guessed they were trying to extend the time between dosages since it was a narcotic. Resident #97 further stated her pain was still between an 8 and 9 and her face was grimaced and she stated she was going to put on her light and ask for pain medication. Interview on 05/01/23 at 3:45 PM with Resident #97 revealed she had put her call light on earlier and requested pain medication but stated she had not received any yet. She stated her pain was still between 8 and 9 and said it was only relieved some when she took pain medication. Interview and observation on 05/01/23 at 3:59 PM with Nurse #2 revealed she was taking care of Resident #97 from 7:00 AM to 7:00 PM and said she had not given her any pain medication because she had not asked for pain medication but said she had given her some Gabapentin at 2:00 PM. Nurse #2 stated she remembered Resident #97 had told her earlier in the day that her pain level was a 9 on a scale of 0 to 10 but said she had forgotten and had not given the resident pain medication. Nurse #2 stated she should have given her medication for pain when Resident #97 had said her pain level was a 9 but said she had forgotten and did not medicate the resident. Nurse #2 stated she was going to assess her pain level and get her something for pain if she needed it. An observation of her assessment revealed Resident #97 told Nurse #2 her pain level was an 8 and Nurse #2 stated she would get her medication for pain. Nurse #2 gave Resident #97 Oxycodone HCl 5 mg oral tablet by mouth at 4:05 PM. A follow up interview on 05/01/23 at 4:50 PM revealed Resident #97's pain level was now a 2 and she had some relief from the pain medication administered. Interview on 05/02/23 at 1:45 PM with Nurse Aide (NA) #3 revealed she was assigned to care for Resident #97 on 05/01/23 and 05/02/23 from 7:00 AM to 3:00 PM. NA #3 stated Resident #97 had complained about pain both days but had not asked her to tell the nurse that she needed pain medication. NA #3 further stated Resident #97 always complained about pain and had told NA #3 that her pain was constant. NA #3 stated she had been trained to let the nurse know when a resident requested pain medication but said she had not requested pain medication but had said she was having pain. NA #3 indicated she should have told the nurse Resident #97 was complaining of constant pain. Interview on 05/02/23 at 3:26 PM with the Director of Nursing (DON) revealed Nurse #2 should have medicated Resident #97 when she told the nurse her pain level was a 9 on a scale of 0 to 10. The DON stated Resident #97 had chronic pain and should not have gone that long without being medicated for pain. She further stated it might be beneficial for Resident #97 to be on scheduled pain medication instead of as needed and said they could discuss with the physician and get her medication adjusted.

Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of urinary catheter (Resident #97), discharge disposition (Resident #43), activities of daily living (Resident #29), and falls (Resident #24) for 4 of 18 residents reviewed for MDS accuracy. The findings included: 1. Resident #97 was admitted to the facility on [DATE] with diagnoses which included hypertension, end stage renal disease and diabetes mellitus. Resident #97 was observed on 04/30/23 at 1:09 PM sitting up in her wheelchair in her room and had an indwelling urinary catheter. Review of Resident #97's admission Minimum Data Set (MDS) assessment dated [DATE], under Section H. Bladder and Bowel, H100 Appliance, the assessment was marked at A. Indwelling catheter due to the resident's urinary catheter. Under Section H300 Urinary Continence, the assessment was marked at 3. Always incontinent (no episodes of continent voiding) instead of 9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy or no urine output for entire 7 days. Interview on 05/02/23 at 3:26 PM with the Director of Nursing (the MDS Nurse was out of the building and unavailable by phone) revealed she would have expected the MDS nurse to have marked the urinary catheter as not rated instead of always incontinent of urine. She stated it was an error in coding on the part of the MDS nurse. 2. Resident #43 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, malnutrition, and muscle weakness. According to her nursing discharge note, Resident #43 was discharged home on 02/23/23. Review of her discharge Minimum Data Set (MDS) assessment dated [DATE] under Section A. Identification Information, A2000, the assessment was marked with discharge date as 02/23/2023. Under Section A2100, Discharge Status, the assessment was marked 03. Acute Hospital instead of 01. Community. Interview on 05/02/23 at 3:26 PM with the Director of Nursing (the MDS Nurse was out of the building and unavailable by phone) revealed she would have expected the MDS nurse to have marked the discharge status as community instead of acute hospital. She stated it was an error in coding on the part of the MDS nurse. 40476 3.Resident #29 was admitted to the facility on [DATE] with diagnoses which included hypertension and diabetes mellitus. Review of Resident #29's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated dressing, eating, toilet use, personal hygiene and bathing did not occur or her family and/or non-facility staff had provided the care 100% of the time for those activities during the entire look back period. Resident #29 was observed on 05/01/23 at 2:29 PM sitting up in her wheelchair in her room. Resident #29 was dressed and well groomed. The MDS nurse was not available for an interview. An interview on 05/02/23 at 3:26 PM with the Director of Nursing revealed she would have expected the MDS nurse to have included the functional status of Resident #29 to reflect she required extensive assistance of two staff members for activities of daily living. She stated it was an error in coding on the part of the MDS nurse. 4. Resident #24 was admitted to the facility on [DATE] with diagnoses which included hypertension, coronary artery disease and renal insufficiency. Review of her quarterly Minimum Data Set (MDS) assessment dated [DATE] under Section J. Health Conditions, J1700C, the assessment was marked Resident #24 had experienced no falls resulting in a fracture in the last six months. Review of the facility incident log revealed Resident #24 had experienced falls on the dates of 10/18/22, 10/29/22, 2/26/23 and 3/13/23. The falls on the dates of 2/26/23 and 3/13/23 resulted in a major injury. Interview on 05/02/23 at 3:26 PM with the Director of Nursing (the MDS Nurse was out of the building and unavailable by phone) revealed she would have expected the MDS nurse to have marked Resident #29's falls on the MDS assessment. She stated it was an error in coding on the part of the MDS nurse.

Based on observations, staff interviews and record review, the facility failed to ensure leftover food items stored for use in the reach-in freezer were labeled, dated and sealed. The failure occurred in 1 of 3 cold storage units and had the potential to affect food served to residents. The findings included: An observation occurred on 04/30/23 at 12:10 PM with Dietary Aide #1, of the kitchen's reach-in freezer revealed the following leftover food items stored for use: - an opened undated bag half full of frozen chicken tenders - an opened undated bag half full of frozen diced chicken - two opened undated bags three-fourth full of frozen chicken breast - two opened undated bags half full of frozen chicken drumettes and wings An interview conducted with Dietary Aide #1 on 04/30/23 at 12:20 PM revealed all items in the reach in freezer should be sealed and have a label on them with the date the items were opened. An interview conducted with Cook #1 on 4/30/23 at 12:25 PM revealed all items in the reach in freezer should be sealed and have a label on them with the date the items were opened. An interview with the Dietary Manager (DM) on 04/30/23 at 1:00 PM revealed she expected staff to label foods after opening with the date opened and store in sealed containers. She stated that dietary staff were expected to round daily during their shift to monitor all cold storage units for unlabeled, undated foods. The DM also stated she believed the opened undated items found had been overlooked by staff. An interview with the Administrator on 05/02/23 at 3:40 PM revealed she expected dietary staff to label, date and seal all foods before storage.

Based on record reviews, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the complaint investigation survey of 06/23/22 and a recertification survey of 07/14/21. The repeated deficiency was in the area of accuracy of assessments. The facility's continued failure during three Federal surveys showed a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag was cross referenced to: F-641: Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of urinary catheter (Resident #97), discharge disposition (Resident #43), activities of daily living (Resident #29), falls (Resident #24) and antipsychotic medications (Resident #21) for 5 of 18 residents reviewed for MDS accuracy. During the complaint investigation of 6/23/22 the the facility failed to obtain a resident's weight within 30 days of the Minimum Data Set (MDS) Assessment Reference Date (ARD, the last day of the look back period) for 1 of 4 MDS assessments reviewed (Resident #10). During the recertification survey of 07/14/21 the facility failed to accurately code a Pre-Admission Screening and Resident Review (PASRR) Level II and failed to code a resident accurately in the area of diagnoses and range of motion. During the revisit and complaint investigation survey of 06/23/22 the facility failed to obtain and record a resident's weight within 30 days of the assessment. F-677: Based on observations, record review, family and staff interviews, the facility failed to provide shaving of resident's face and clipping of toenails for 1 of 4 residents (Resident #40) reviewed for assistance with activities of daily living. During the recertification and complaint survey of 2/7/20 the facility failed to provide incontinence care to keep residents clean and dry (Resident #20 and Resident #12) and failed to provide nail care (Resident #26) for 3 of 3 dependent residents reviewed for activities of daily living (ADL). An interview on 05/02/23 at 3:26 PM with the Director of Nursing and Administrator revealed they would have expected the Minimum Data Set (MDS) Nurse to have coded all assessments accurately and said it was an error in documentation on the part of the MDs Nurse. The Administrator felt like the failure of the QAA was due to the high rate of turnover in the position of the MDS Nurse and as the position stabilized so would the issues with the program.

Based on observation, record review and staff interviews, the facility failed to ensure a resident had been assessed to self-administer medications (Resident #8). This occurred for 1 out of 3 residents reviewed for medication administration. The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD and respiratory failure. Resident #8's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and required set up assistance of one staff member for most activities of daily living (ADL). On 05/02/23 at 9:16 AM an observation was conducted of Nurse #1 preparing Resident #8's medication from the medication cart and put them into a cup. Nurse #1 then went into the room with the medication cup and the resident's Cyclosporine (immunosuppressant, used to increase tear production) eye drops. Nurse #1 then handed the medication to Resident #8. Resident #8 stated, I have already administered my eye drops to myself this morning. Nurse #1 stated to the surveyor that Resident #8 self-administered her nebulizer treatments and her eye drops. Nurse #1 stated she had brought the nebulizer treatment into the room earlier in the morning and handed the solution to Resident #8 in which the resident poured the solution into the machine and started her own breathing treatment. Resident #8's physician orders from 01/02/23 through 05/02/23 were reviewed and did not reveal an order to self-administer medication. Review of the medical record did not reveal an assessment for Resident #8 to self-administer medication. An interview was conducted on 5/2/23 at 9:20 AM with Nurse #1. During the interview she stated she always allowed Resident #8 to self- administer her own eye drops and nebulizer treatment. She stated she was unsure if the resident had been assessed to administer her own medication by the facility. An interview was conducted on 5/2/23 at 10:23 AM with Resident #8. She stated she felt she could take care of herself and she was able to dress herself and required limited assistance from staff. The interview revealed facility staff had asked her if she wanted to self-administer her medication and some nurses would not allow her to do so. She stated Nurse #1 was one of the only staff that would allow her to administer her eye drops and nebulizer treatment. Resident #8 stated Nurse #1 had brought her Albuterol nebulizer solution into the room that morning and handed it to her for her to start her own nebulizer treatment. She stated she wanted to administer her eye drops but did not want to be responsible for her pill medication or the nebulizer solution. An interview conducted on 05/02/23 at 10:04 AM with the Director of Nursing (DON) revealed no residents in the facility had orders to self-administer their medication. She stated she expected nurses to administer the resident's medication and remain in the room with the resident until they took all of the medication that was ordered. The DON stated if a resident were to request to self-administer their medication, they would need to sign a form prior to doing so and be assessed.

Based on observations, record review, family and staff interviews, the facility failed to provide shaving of resident's face and clipping of toenails for 1 of 4 residents (Resident #40) reviewed for assistance with activities of daily living. The findings included: Resident #40 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. His diagnoses included hypertension and non-Alzheimer's dementia. Review of Resident #40's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired and required total assistance of 2 staff with bathing and extensive assistance of 1 staff with personal hygiene and had impairment of both sides of upper and lower extremities. Review of the shower schedule for Resident #40 revealed he received showers on Wednesday and Saturday on 1st shift (7:00 AM to 3:00 PM). Review of Resident #40's care plan dated 03/23/23 revealed a focus area for his inability to complete activities of daily living care related to his cognitive impairment. The interventions included assist with picking out and putting on clothes appropriate for season and comfort, explain all procedures and purposes in terms understood prior to performing tasks and encourage self-performance, praise efforts, not just successes, provide encouragement and praise daily, provide resident education and family support, report changes in ADL self-performance to nurse, and turn and reposition, shifting weight to enhance circulation as needed. Observation and interview with family member at bedside of Resident #40 on 04/30/23 at 3:11 PM revealed the resident resting in bed with covers pulled over him and his feet hanging out of the covers. The resident was noted to have 1/4 inch stubble on his face and his toes on each foot other than his big toes had nails that were 1/4 to 1/2 inch beyond the end of his toes. The family member at his bedside stated Resident #40 did not look like himself because he had always been clean shaven and did not typically have stubble on his face. She further stated he needed to be shaved and his toenails needed to be clipped because they were way too long. The family member indicated Resident #40 usually kept himself well groomed. Observation of Resident #40 on 05/01/23 at 8:48 AM revealed him lying in bed and he still had 1/4 inch stubble on his face and his toenails on each foot were 1/4 to 1/2 inch beyond the end of his toes. Interview on 05/01/23 at 2:08 PM with Nurse Aide (NA) #1 revealed Resident #40 had been going to the shower but since his decline he had been getting bed baths. NA #1 stated bed baths or showers usually included bathing resident from head to toe or assisting them, shaving men, and women with facial hair, shampooing their hair and clipping their fingernails unless they were diabetic and then the nurses clipped their nails. NA #1 further stated she didn't trim toenails but residents who needed their toenails trimmed were either done by the nurse or referred to the podiatrist for their nails to be trimmed. NA #1 stated she had not noticed Resident #40 had not been shaved or needed his toenails trimmed. Interview on 05/01/23 at 3:02 PM with NA #2 revealed she took Resident #40 on the shower bed to the shower on his bath days. She stated his shower included cleaning him from head to toe, shampooing his hair, shaving him if needed and clipping and cleaning his fingernails as needed. NA #2 further stated the NAs typically did not cut resident's toenails but referred them to the nurse to be trimmed or to the podiatrist as needed. NA #2 stated she had not noticed Resident #40's toenails and whether they needed trimming and had not noticed he needed to be shaved. Interview on 05/02/23 at 1:13 PM with Nurse #3 who was assigned to Resident #40 on 1st shift (7:00 AM to 7:00 PM) revealed she had not noticed his facial hair and that he needed to be shaved and had not noticed his toenails and said no one had reported to her they needed to be trimmed. Nurse #3 observed Resident #40's facial hair and agreed he needed to be shaved and observed his toenails and agreed they needed to be trimmed and said she would take care of shaving him and clipping his toenails today on her shift. Interview on 05/02/23 at 3:19 PM with the Director of Nursing (DON) revealed she expected the NAs and Nurses to observe the resident's full body when providing care, bathing them, and providing skin inspections. She said she would have expected the NAs and the Nurses to have noticed the resident's toenails needed to be trimmed and clipped prior to their getting so long. The DON indicated they would need to do education on assessing residents need for shaving and trimming nails.

Based on record reviews, and interviews with staff, and Medical Director, the facility failed to notify the Primary Care Provider of significant changes in a resident's condition (Resident #9) when he developed a new opened sacral pressure ulcer, when the pressure ulcer deteriorated and when he continued to have [CONDITION(S)] (low blood pressure) despite receiving intravenous fluids. The facility also failed to report results of a urinalysis and urine culture resulting in a delay in treating the resident (Resident #9) for [CONDITION(S)] (urinary tract infection). Resident #9 was hospitalized on [DATE] for severe [CONDITION(S)]/septic shock due to an infected stage 4 pressure ulcer to the sacrum. In addition, the facility failed to notify the Primary Care Provider when a resident had a severe unintended weight loss (Resident #10). Resident #10 had a cumulative weight loss of 24.4% from 1/19/22 through 4/6/22, was admitted to the hospital on 4/7/22 and had a feeding tube inserted in the stomach. These failures were for 2 of 3 residents reviewed for notification of changes (Resident #9 and Resident #10). Immediate Jeopardy began on 3/9/2022 when staff failed to identify a significant weight loss of 11.5% for Resident #10. Resident #10 continued to lose weight and had a cumulative weight loss of 24.4% since 1/19/2022. Immediate Jeopardy began on 3/26/22 for Resident #9 when the facility failed to follow up on urine culture results and provide the care and services required by Resident #9 resulting in a delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 continued to have confusion, altered mental status, [CONDITION(S)] (low blood pressure) and pressure ulcer deterioration which resulted in Resident #9 being sent out to the emergency room for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was removed on 6/18/22 when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #9's medical record indicated a faxed result from the laboratory dated 3/23/22 at 8:46 PM for a urinalysis with the following abnormal values: cloudy appearance, leukocytes 3+, protein 100, blood 3+, WBC (white blood cells) 3+ and bacteria 3+. A urine culture result reported by the laboratory on 3/26/22 at 11:22 AM indicated Resident #9's urine had a growth of Providencia stuartii of >100,000 cfu (colony-forming unit)/ml (milliliter). The report also outlined the different antibiotics that the organism was susceptible and resistant to. A phone interview with Nurse #2 on 6/13/22 at 2:12 PM revealed she had taken care of Resident #9 on the evening shift when he started to get sick on 3/21/22. Nurse #2 stated she noticed a change in his condition when he called her by another nurses' name, and he was getting more confused. She remembered him receiving intravenous fluids, but she had to hold his blood pressure medication on 3/22/22, 3/23/22, 3/24/22, 3/25/22 and 3/31/22 because his blood pressure was low. Nurse #2 stated at first the low blood pressure reading didn't alert her because Resident #9's blood pressure fluctuated all the time. Nurse #2 also stated she had thought about Resident #9 possibly having [CONDITION(S)], but she assumed he was being seen by the wound doctor for his pressure ulcer on his sacrum. Nurse #2 further stated she worked on 3/23/22 but didn't remember seeing Resident #9's urinalysis result and was not aware that he had [CONDITION(S)]. She couldn't remember if it was passed on during report that they were still waiting on Resident #9's urinalysis and urine culture results. Nurse #2 also stated she had done most of Resident #9's [MEDICATION(S)] dressing in March 2022 and she noticed that the open wound on his buttocks had gotten worse, but she didn't remember exactly when it started to get worse. Nurse #2 stated she remembered Resident #9's wound being slightly smaller than the size of a quarter when she started working with him but on 3/30/22 when she had changed his [MEDICATION(S)] dressing, she noticed that the wound had gotten bigger to the size of a baseball, and it was draining more. Nurse #2 did not notify the doctor of the worsening of Resident #9's pressure ulcer because she thought he was already being seen by the wound doctor. A phone interview with Nurse #7 on 6/13/22 at 12:18 PM revealed she took care of Resident #9 on 3/24/22 and 3/25/22 and had to change his [MEDICATION(S)] dressing on both days. Nurse #7 stated she first saw Resident #9's ulcer to his sacrum on 3/24/22. Nurse #7 stated she observed a quarter-sized open area on Resident #9's bottom that looked clean, pink and had no drainage and no foul odor. Nurse #7 did not report this observation to anyone as she thought this was normal for him. She also did not remember receiving on report that they were waiting on Resident #9's urinalysis and urine culture results. An interview with the Interim Director of Nursing (DON) on 6/13/22 at 10:43 PM revealed Resident #9 had intermittent confusion within the last 4 to 6 weeks when he was at the facility, but she noticed that Resident #9 was a lot more confused on 3/30/22. She stated she looked through Resident #9's medical record on 3/30/22 and discovered a urine culture report dated 3/26/22 that hadn't been addressed. She reported this to the Nurse Practitioner (NP) and requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Interim DON also stated she was not sure if she had received a report from the nurse before her that they were waiting on Resident #9's urinalysis and urine culture results. A phone interview with Nurse #8 on 6/14/22 at 11:03 AM revealed she took care of Resident #9 on the night shift from 7:00 PM on 3/30/22 to 7:00 AM on 3/31/22. Nurse #8 thought they were still waiting on his urine culture results and was not aware that it had been reported by the laboratory on 3/26/22. Nurse #8 stated things often got trickled down during report between the nurses and not everything got followed up on. She also noted that Resident #9's blood pressure was low, so she held his [MEDICATION(S)] dose for 8:00 PM. Nurse #8 stated she put a note in the provider's notebook about Resident #9's blood pressure so they could see it when they come the next day. Nurse #8 stated she didn't think it was something she had to report right then and didn't use the electronic message through the tablet to communicate with a provider. An interview with Nurse #4 on 6/13/22 at 4:01 PM revealed she took care of Resident #9 on 4/1/22 and had to hold his 8:00 AM [MEDICATION(S)] dose because his blood pressure was low. Nurse #4 stated Resident #9's low blood pressure didn't alert her because she thought he was receiving intravenous fluids because his blood pressure had been low. A phone interview with Nurse #3 on 6/13/22 at 10:20 AM revealed she took care of Resident #9 from 7:00 AM to 7:00 PM on 4/2/22 and 4/3/22. Nurse #3 recalled seeing the wound on his buttocks on 4/3/22 when she had to change the [MEDICATION(S)] dressing. Nurse #3 stated she was surprised to see how bad the wound looked and stated it was the worst-looking pressure ulcer she had ever seen. After Nurse #3 saw the wound, she called the former Director of Nursing (DON) into the room and the former DON placed an antiseptic dressing on the wound. Nurse #3 assumed that the former DON had notified the doctor of Resident #9's pressure ulcer and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A phone interview was attempted on 6/13/22 at 12:01 PM, 6/14/22 at 12:00 PM and 6/15/22 at 10:19 AM with the former DON with no return call. A NP note dated 4/5/22 indicated Resident #9 was seen by the NP for the wound to his buttocks. It was documented there was an unstageable wound to one-fourth area of the coccyx, eschar (dead tissue that eventually sloughs off healthy skin after an injury) present to the buttocks and there was also a 2 cm by 2 cm necrotic area to the right heel. Unable to stage wound, recommend he be sent to the hospital for wound evaluation. Multiple attempts were made to contact the NP, but they were unsuccessful. The NP no longer worked with the Medical Director's team. A follow-up interview with the Interim Director of Nursing (DON) on 6/13/22 at 3:00 PM revealed the nursing staff were only supposed to communicate with the providers through text messages through the tablet and the facility did not utilize a notebook for the providers. The Interim DON stated she did not see any documentation/communication regarding Resident #9's worsening condition from 3/22/22 to 4/5/22 except when she had notified the NP of his urine culture results on 3/30/22. The Interim DON also stated that she checked the nurse to physician documented communication text messages and there was no report to the medical staff that Resident #9's wound to his buttocks had opened, was large and black. A phone interview with the Medical Director (MD) on 6/14/22 at 4:22 PM revealed he was aware of open areas on Resident #9's buttocks that recurred due to his non-compliance with offloading and incontinence care, but he wasn't sure about the pressure ulcer that developed right before he was sent out to the hospital. The MD stated he had expected to be notified of any deterioration/decline in pressure ulcers even though they had expected Resident #9's ulcer to get worse due to his non-compliance. The MD also stated he didn't know that there was delay with starting Resident #9 on antibiotics for [CONDITION(S)], but he would have hoped the nursing staff had followed up on the urine culture result, so it was communicated to the NP who had ordered the urinalysis and urine culture. The MD stated he also expected the nurses to have assessed Resident #9 who was acutely ill and checked his vital signs at least once a day. He also expected the nursing staff to report any decline in condition especially the deterioration of Resident #9's pressure ulcer and continued low blood pressure readings even though he was receiving intravenous fluids. Resident #9's hospital admission notes dated 4/5/22 indicated Resident #9 was seen in the Emergency Department for altered mental status. Resident #9 was found to have severe [CONDITION(S)]/septic shock with acute organ dysfunction, an infected decubitus ulcer stage IV, a pressure injury of buttock stage IV, elevated white blood cells indicating an infection, metabolic [CONDITION(S)], acute [CONDITION(S)] superimposed on chronic kidney disease stage 3, intravascular volume depletion (dehydration), and low sodium. The surgical consult for decubitus sacral ulcer determined the ulcer was large, necrotic, and malodorous ulcer with only minimal [CONDITION(S)]. Plan was for surgical debridement and diverting [CONDITION(S)]. It was suspected the sacral ulcer was contaminated with stool. Resident #9 was critically ill and at risk for decompensation resulting in end-organ dysfunction. The resident's fevers were up to 103 Fahrenheit due to an infected sacral pressure ulcer. A CT (computed tomography) scan of the sacral pressure ulcer revealed extensive subcutaneous gas formation (deep seeded infection with gas forming organisms) and tunneling upward within the gluteal and above the gluteal tissues. Resident #9 also had a stage 4 pressure ulcer to the right plantar foot and a soft tissue ulcer to the great toe stump. An interview with the Director of Nursing (DON) on 6/13/22 at 5:34 PM revealed the nurses were supposed to complete weekly skin checks on each resident but if the resident had a pressure ulcer, the nurses were supposed to bring it to the doctor's attention. Any resident with a pressure ulcer should be referred to the wound doctor for proper treatment and evaluation. During a follow-up interview on 6/15/22 at 1:40 PM, the DON also stated that she expected the nurses to follow up on laboratory results and address them with the doctor. The DON further stated she expected the nurses to monitor acutely ill residents by obtaining a full set of vital signs at least once during their shift and to call the doctor about any acute issues or change in condition. The Administrator was notified of Immediate Jeopardy on 6/15/22 at 1:41 PM. 2. Resident #10 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was active on resident's discharge date of [DATE]. Resident #10 weighed 125.7 pounds on 1/19/2022 collected by mechanical lift. Review of January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The weight documented in vital signs revealed on 3/9/2022, Resident #10 weighed 111.2 pounds (representing an 11.5% weight loss since 1/19/2022) and documented on 3/23/2022 Resident #10 weighed 112.3 pounds. Resident #10 refused to be weighed on 3/16/2022 and 3/30/2022. Attempts were made to interview Nurse #1 who entered the weights for Resident #10 on 3/9/2022 and 3/23/2022, via telephone were unsuccessful. Nurse #1 was assigned Resident #10 on 3/16/2022 and 3/30/2022 when Resident #10 refused to be weighed. Review of Nursing Progress Notes for March 2022 revealed no documentation the physician was notified of Resident #10's weight change or Resident #10's refusals to be weighed. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Attempts were made to interview the Physician via telephone were unsuccessful. Resident #10 weighed 95 pounds on 4/6/2022, undocumented how the weight was collected. (representing a 24.4% weight loss since 1/19/2022). Review of Nursing Progress Notes for April 2022 revealed no documentation the physician was notified of Resident #10's weight loss. An interview was conducted on 6/8/2022 at 3:11 P.M. with the Unit Manager who entered Resident #10's weight into the electronic medical chart on 4/6/2022. During the interview the Unit Manager revealed when the weights were entered into the computer system, if the weight appeared inaccurate, she requested a reweigh be completed by the assigned nurse. If the reweigh came back with a significant weight change, the physician and the dietician were notified. Resident #10's chart was reviewed with the Unit Manager, the Unit Manager stated, it appeared a reweigh was not completed and the physician was not notified about Resident #10's weight change. Nurse Practitioner Progress note dated 4/7/2022 revealed the reason for the visit with Resident #10 was documented as chronic. The section Assessment and Plan in the progress note indicated Resident #10 had a 16-pound weight loss. The note reads in part Periods of agitation. Requires assistance with ADL's (activities of daily living). Monitor weight. Monitor consumption of meals. Attempts were made to interview Nurse Practitioner via telephone were unsuccessful. An interview was conducted on 6/11/2022 at 8:08 A.M. with Nurse#2. Nurse #2 revealed on 4/7/2022 at the start of her 7 P.M. to 7 A.M. shift, she entered Resident #10's room and told him Hello. She revealed when she spoke to Resident #10, he did not respond to her greeting. Nurse #2 stated this was not normal for Resident #10 and she went to his bedside to assess him. Nurse #2 stated she completed a set of vital signs which were within Resident #10's normal range. During the interview, Nurse #2 stated due to Resident #10's lack of a verbal response, she felt something was wrong. After talking to the physician and Resident #10's responsible party, Resident #10 was sent to the emergency department for evaluation. Resident #10 was admitted to the Hospital on 4/7/2022 with a chief complaint of altered mental status. The physician examination completed in the emergency department on 4/7/2022 at 8:50 P.M. revealed Resident #10 weighed 95 pounds. A nutrition consultation was ordered. Resident #10 was admitted to the hospital on 4/7/2022 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical records reviewed showed Resident #10 had a feeding tube inserted through his nose to his stomach (nasogastric tube). On 4/10/2022 an x-ray was ordered and completed for a tube check to verify placement of the nasogastric tube. The x-ray findings revealed a small bowel feeding tube ended in Resident #10's stomach. A review of the hospital course indicated the resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE] to another skilled nursing facility. Resident #10 had a discharge weight of 104 pounds. An interview was conducted on 6/11/2022 at 5:02PM with the Regional Nurse Consultant revealed expectations would be to monitor weights, provide interventions for weight loss and notify responsible parties to include the MD and RP. On 6/12/2022 at 1:55 P.M., the facility's Regional Nurse Consultant and Director of Nursing (DON) were informed of the immediate jeopardy. The facility provided the following acceptable credible allegation of Immediate Jeopardy removal. Credible Allegation of Immediate Jeopardy Removal for F580. 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The identified resident (Resident #10) is no longer a resident of the facility. Resident #10 had a 24.4% weight loss from January to April with no notification to Primary Care Provider. The other identified resident (Resident #9) is no longer a resident of the facility. Resident #9 had delay in treatment with failure to notify the physician of results of urinalysis, deterioration of pressure ulcer and continued decline in mental status and condition. All other residents have the potential to be affected by the deficient practice. Other residents were identified as having weight loss. We have had 1 resident refuse weight to be obtained. We will ask them again and will contact family to see if they can assist in encouraging them to be weighed. The Primary Care Provider will be notified by the DON or DON designee within 24 hours for those residents identified to have weight loss. All other residents have the potential to be affected by the deficient practice. Other residents were identified as having skin integrity issues. All resident charts will be audited to determine if any other outstanding labs. have not been addressed, initiating 6/15/2022 and completed by 6/15/2022. The Primary Care Provider will be notified by the DON or DON designee by 6/16/2022 with any identified residents with skin integrity issues that have not been previously identified and any outstanding labs. that have not been addressed. All residents' records were reviewed for change in condition that was not reported/change in wound or pressure sore that was not communicated and completed by 6/16/2022 by the DON and the DON Designee. 100 percent skin body audit of all residents was initiated on 6/14/22 and completed 6/15/2022. Any skin integrity issues identified will be reported to the Primary Care Provider by 6/15/2022. An audit of all residents' charts via Point Click Care system initiated 6/15/2022 conducted by the DON and/or the DON Designee to determine if any labs. have not been addressed and will be completed by 6/15/2022. The Primary Care Provider was notified of all labs. test results. 2. Actions taken to alter the process or system failure to prevent adverse outcome from occurring or recurring: Immediate in-service initiated 6/11/2022 and completed on 6/14/2022 for weight loss and immediate in-service initiated 6/14/2022 for observed skin integrity issues with completion on 6/15/2022 and any labs. not being addressed by the Director of Nursing (DON) and/or the Corporate Nurse Consultant to the Licensed nursing staff to ensure that they inform the DON or DON designee of any weight loss initiated 6/11/2022; skin integrity issues; or any labs. that have not been addressed initiated 6/15/2022 with completion of lab. in-servicing 6/16/2022. The in-service will be conducted in person, telephone, or text. Those nurses and nurse aides that will have in-service that was not able to be conducted in person, will be acknowledged on the sign in sheet in-service sheet as to the method of communication conveyed. The staff that received text will have to be provided 1:1 in-service when they report to work prior to caring for resident. Also, signage at the time clock will alert those named that received text to see the DON or DON Designee prior to taking care of the residents. Nursing staff will have evidence of in-service communication initiated by 6/15/2022 and will have the in-person in-service prior to their working shift with signatures on the sign-in sheet prior to them working their shift. The DON and/or DON designee will be responsible for tracking employees who aren't educated and ensuring they are educated prior to them working after 6/17/2022. All newly hired nurses along with any agency staff will receive the information contained in the in-service prior to working with residents. The DON and/or DON Designee initiated in-service on 6/15/2022 with the Licensed nurses and nurse aides to report any changes in a resident's skin integrity, eating habits or any observations that are not typical of the individual resident. Additional in-service training initiated for Nurse Aides on 6/17/2022 regarding any changes in vital signs, any change in habits and routines are to be reported to the nurse. The Nurse Aide should report to the Licensed Nurse and the Licensed Nurse should assess the resident and report and notify the Primary Care Provider of any abnormal findings. Education provided by the DON and/or DON designee and completed by 6/17/2022. The DON and/or DON designee will be responsible for tracking employees who aren't educated and ensuring they are educated prior to them working after 6/17/2022. This education will be given to all newly hired Licensed Nursing staff and agency staff prior to taking their resident assignment. Licensed nursing staff will be educated to notify the Primary Care Provider promptly if they observe a new pressure wound or open area, any signs of wound infection, any wound deterioration. This was initiated on 6/14/2022, by the DON and/or RN certified wound nurse and will be conducted to the nursing staff to include nurses, nurse aides, and agency nursing staff and will be completed by 6/16/2022. This education will be given to all newly hired Licensed Nursing staff and agency staff prior to taking their resident assignment. The Nurse Aides will be educated to notify the nurse with any changes in skin integrity promptly to the individual resident's nurse. Such changes as redness, rashes, any skin break, abrasions, or any unusual skin integrity observations that were not noted with skin observation during prior care provided. Nurse Aides will also be educated on signs and symptoms of [CONDITION(S)] to include: faster heart rate, reduced urine output, fever and chills, difficulty breathing, mental confusion and hyperventilation. In-service education initiated on 6/17/2022 by the DON and/or the DON designee to report to the nurse any changes from baseline for the residents. For example, any changes in vital signs, changes in eating habits, changes in habits or routine, any complaints of pain to the nurse promptly. The DON and/or DON designee is tracking and cross referencing the list posted at the time clock with that of current staff to include licensed nurses and nurse aides. The DON and/or DON designee will be responsible for tracking employees who aren't educated and ensuring they are educated prior to them working after 6/17/2022. This education will be given to all newly hired Licensed Nursing staff and agency staff prior to taking their resident assignment. If any residents are identified to have greater than 5-pound weight loss or greater, the MD will be notified by the DON and/or DON Designee and prompt interventions will be put in place to prevent further weight loss. If any residents are identified to have skin integrity issues or labs. that have not been addressed, the DON and/or DON designee will notify the Primary Care Provider promptly. The skin observation Report and Labs. will be reviewed during clinical meeting by the DON and/or DON Designee. The DON or DON Designee will also receive the skin integrity information from the licensed nurse. The Lab. calls the Licensed nurse of any critical labs, and the Nurse notifies the Primary Care Provider promptly. A Lab. book will be implemented and kept at the nurses' station that will reflect ordered labs. and notification of Primary Care Provider when lab. results have been obtained. The book will reflect the resident's name, the date of the lab. ordered, the ordered lab., the date results obtained and if critical labs. noted, the notification date and time the Primary Care Provider was notified. The Nurse receiving lab. order will place lab. in the lab. book. The Nurse who receives lab. results will notify Primary Care Provider of any Critical Lab. results and document in lab. book of doing notification. All critical labs. are called to the Nurse at the facility from the Lab. All Licensed Nursing staff to include agency to receive In-service education and was initiated on 6/16/2022 by DON and/or DON Designee and completed by 6/17/2022. The DON and/or DON designee will be responsible for tracking employees who aren't educated and ensuring they are educated prior to them working after 6/17/2022. This education will be given to all newly hired Licensed Nursing and agency staff prior to taking their resident assignment. The DON and/or Designee will review the lab. book every morning to determine if any labs. have not been addressed and/or Primary Care Provider notified. The DON and/or Weekend supervisor will check the lab. book on the weekend to ensure the same. If the DON and/or DON Designee find any issues, the DON or DON Designee will notify the Primary Care Provider. The weekend supervisor was educated 6/16/2022 and has been informed of her responsibility in this regard. The facility will conduct weekly Focus meetings with the Interdisciplinary team to discuss any resident weight losses, skin integrity issues, and any abnormal labs. or any issues with morning reviews of lab. book to determine if any trends and will discuss the interventions put in place and determine if the interventions are beneficial until the resident meets their or desired body weight; skin assessments, wound measurements with wound healing progress or issues with wound healing; and lab. issues noted in morning reviews by the DON or DON Designee. If interventions are not reflective of achieving desired results, the Primary Care Provider will be notified, and interventions will be re-addressed and potential to add or eliminate and replace interventions as appropriate to achieve weight gain goals; wound healing goals; notification of labs. Completion Date - 6/18/2022 The credible allegation for the immediate jeopardy removal was validated on 6/23/22 with a removal date of 6/18/22. A review of in-service education records from 6/11/22 to 6/17/22 revealed education was provided to nurses and nurse aides on topics that included reporting any weight loss to the nurse and the Unit Manager, reporting any changes in eating pattern and when a resident refused to eat and reporting any changes in the residents' baseline condition such change in vital signs, change in activity, smoking habits and change in daily habits to the nurse. Any new orders, changes in residents' conditions, reports, weight loss, skin integrity issues and laboratory results that have not been addressed need to be communicated timely to the physician, family, and the Director of Nursing. Interviews with the nursing staff revealed they had been educated on when to report a resident's change in condition as well as who to report the change in condition to. They also verbalized the different signs of changes including [CONDITION(S)] and what observations to look for while working with the residents at the facility. The nurses stated they had been educated on notifying the Primary Care Provider of changes such as a new pressure wound or open area, any signs of wound infection and any wound deterioration. This notification to the medical provider also included reporting weight loss and any changes in the residents' condition. The laboratory book was observed at the nurses' station, and it included an audit tool developed by the facility that included information on the resident's name, laboratory test order date, laboratory test ordered, date the results were obtained, any critical laboratory test results and the date and time the medical provider was notified. A weekly focus meeting was held on 6/17/22 which included the Administrator, the Director of Nursing, and the Infection Preventionist. They discussed the following areas: skin observations, wound reports, laboratory audit review/notification, weight loss, change of conditions and acute charting boards.

Based on record reviews, and interviews with staff, family member, Physician Assistant and Medical Director, the facility failed to identify the seriousness of significant changes in a resident's condition (Resident #9), complete and document on-going thorough assessments and identify the need for medical attention when the resident's medical condition continued to deteriorate. This resulted in a delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure was for 1 of 3 residents reviewed for quality of care (Resident #9). Immediate Jeopardy began on 3/26/22 when the facility failed to follow up on Resident #9's urine culture results and provide the care and services required by Resident #9 resulting in a delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 continued to have confusion, altered mental status, [CONDITION(S)] (low blood pressure) and pressure ulcer deterioration which resulted in Resident #9 being sent out to the emergency room for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy was removed on 6/18/22 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 3 half tablets if blood pressure is over 140/90. Resident #9's care plan revised on 4/18/21 indicated he had hypertension. Interventions included to give anti-hypertensive medications as ordered, monitor for side effects such as orthostatic [CONDITION(S)] (low blood pressure that happens when standing up from sitting or lying down) and increased heart rate and effectiveness and report significant changes to the physician. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 was cognitively intact, had no rejection of care behaviors, required extensive physical assistance with bed mobility, transfer and personal hygiene, and was totally dependent on staff assistance with toilet use. He had impairment to both sides of lower extremities and used a wheelchair. He was always incontinent of both urine and bowel. The MDS further indicated he was at risk of developing pressure ulcers/injuries, but he did not have any unhealed pressure ulcers/injuries. A progress note written by Nurse #1 on 3/21/22 at 6:18 PM indicated Resident #9 was little bit confused since morning. His vital signs were as follows: blood pressure (BP) at 139/60, pulse at 94, respiratory rate at 20, temperature at 97.9 and oxygen saturation at 97% on room air. Resident #9 denied pain, was diaphoretic and pale. Blood glucose was 225 mg/dL (milligrams per deciliter). He was refusing to go back to bed. He refused lunch and went out for smoke. BP was rechecked at 130/80 manually and pulse at 88. Nurse Practitioner (NP) was informed and ordered the following: CBC (complete blood count), CMP (comprehensive metabolic panel), CXR (chest x-ray) and UA (urinalysis). Resident #9 ate 40% of his supper. Resident #9's family member was notified regarding his present condition. A phone interview with Nurse #1 on 6/12/22 at 6:43 PM revealed she noticed Resident #9 had a decline on 3/21/22 because he was not eating and had to be assisted to eat. He was also diaphoretic, pale and had been having episodes of confusion which was not normal for him. Resident #9 was usually alert and oriented. Nurse #1 informed the NP who ordered bloodwork, chest x-ray and urinalysis with urine culture. Nurse #1 stated she obtained the urine specimen through straight catheterization and sent it to the laboratory on 3/21/22. Nurse #1 stated she noticed that Resident #9's urine was very concentrated when she obtained his urine sample, so she obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #1 stated she had suspected that Resident #9 might have a urinary tract infection given the new onset of confusion. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . He appeared to not feel well but no acute distress noted. Resident #9 ate breakfast and was drinking some but blood pressure low for him this morning (110/64). [MEDICATION(S)] was held. Resident #9's blood pressure normally ranged between 110/60 and 140/80. Skin tenting (skin abnormality indicative of dehydration) was present. Intravenous fluids ordered. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] *Dextrose-Sodium Chloride Solution 5-0.9% - use 75 ml (milliliters)/hour for 2 days x 3 liters for dehydration. *Insert an indwelling catheter and connect to urine bag for urinary retention. Further review of Resident #9's medical record indicated a faxed result from the laboratory dated 3/23/22 at 8:46 PM for a urinalysis with the following abnormal values: cloudy appearance, leukocytes 3+, protein 100, blood 3+, WBC (white blood cells) 3+ and bacteria 3+. A urine culture result reported by the laboratory on 3/26/22 at 11:22 AM indicated Resident #9's urine had a growth of Providencia stuartii of >100,000 cfu (colony-forming unit)/ml (milliliter). The report also outlined the different antibiotics that the organism was susceptible and resistant to. A review of Resident #9's medical record indicated no evidence that the urinalysis and urine culture results received on 3/26/22 were reported to the Nurse Practitioner or to the Medical Director. Resident #9's Vital Signs Record from 3/21/22 to 4/5/22 indicated his temperature and pulse were not checked on 3/26/22, 3/27/22, 3/28/22, 3/29/22, 3/30/22, 4/1/22, 4/2/22, 4/4/22 and 4/5/22. The progress notes and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 3/22/22 at 8:44 AM (BP-110/64), 3/23/22 at 8:54 AM (BP-109/54), 3/23/22 at 9:19 PM (BP-116/57), 3/24/22 at 9:44 PM (BP-105/43), 3/25/22 at 8:40 PM (BP-118/52), 3/30/22 at 8:38 PM (BP-96/50), 3/31/22 at 10:16 PM (BP-98/48) and 4/1/22 at 8:17 AM (BP-98/48). A phone interview with Nurse #2 on 6/13/22 at 2:12 PM revealed she had taken care of Resident #9 on the evening shift when he started to get sick on 3/21/22. Nurse #2 stated she noticed a change in his condition when he called her by another nurses' name, and he was getting more confused. She remembered him receiving intravenous fluids, but she had to hold his blood pressure medication on 3/22/22, 3/23/22, 3/24/22, 3/25/22 and 3/31/22 because his blood pressure was low. Nurse #2 stated at first the low blood pressure reading didn't alert her because Resident #9's blood pressure fluctuated all the time. Nurse #2 also stated she had thought about Resident #9 possibly having [CONDITION(S)], but she assumed he was being seen by the wound doctor for his pressure ulcer on his sacrum. Nurse #2 further stated she worked on 3/23/22 but didn't remember seeing Resident #9's urinalysis result and was not aware that he had [CONDITION(S)]. She couldn't remember if it was passed on during report that they were still waiting on Resident #9's urinalysis and urine culture results. Nurse #2 also stated she had done most of Resident #9's [MEDICATION(S)] dressing in March 2022 and she noticed that the open wound on his buttocks had gotten worse, but she didn't remember exactly when it started to get worse. Nurse #2 stated she remembered Resident #9's wound being slightly smaller than the size of a quarter when she started working with him but on 3/30/22 when she had changed his [MEDICATION(S)] dressing, she noticed that the wound had gotten bigger to the size of a baseball, and it was draining more. Nurse #2 did not notify the doctor of the worsening of Resident #9's pressure ulcer because she thought he was already being seen by the wound doctor. A phone interview with Nurse #7 on 6/13/22 at 12:18 PM revealed she took care of Resident #9 on 3/24/22 and 3/25/22 and had to change his [MEDICATION(S)] dressing on both days. Nurse #7 stated she first saw Resident #9's ulcer to his sacrum on 3/24/22. Nurse #7 stated she observed a quarter-sized open area on Resident #9's bottom that looked clean, pink and had no drainage and no foul odor. Nurse #7 did not report this observation to anyone as she thought this was normal for him. She also did not remember receiving on report that they were waiting on Resident #9's urinalysis and urine culture results. A phone interview with Nurse #5 on 6/13/22 at 11:06 AM revealed she worked with Resident #9 on the evening shift on 3/26/22 but she never received a report that they were waiting on Resident #9's urinalysis and urine culture results. She did not see Resident #9's urine culture result on the fax machine. Nurse #5 stated she also took care of Resident #9 on 3/27/22 and 3/28/22 and had only checked his blood pressure on those dates to determine if she could give his [MEDICATION(S)] dose. She did not check his temperature and was not aware that he had a [CONDITION(S)] at that time. A progress note written by the Interim Director of Nursing (DON) on 3/30/22 at 1:00 PM indicated she called Resident #9's family member for an update and informed him that Resident #9 was confused again today and had pulled his midline (intravenous catheter) out last night on third shift. Resident #9 appeared to be delirious as confusion comes and goes. Urinalysis came back indicating [CONDITION(S)] with >100,000 Providencia stuartii. The Interim DON notified the Nurse Practitioner through electronic message and an antibiotic was requested. An interview with the Interim DON (DON through 6/6/22) on 6/13/22 at 10:43 PM revealed Resident #9 had intermittent confusion within the last 4-6 weeks when he was at the facility, but she noticed that Resident #9 was a lot more confused on 3/30/22. She stated Resident #9 was talking out of his head and he was still in bed late that morning when he would usually be up before the first morning smoking time at 8:00 AM. The Interim DON remembered the Nurse Practitioner (NP) saying that Resident #9 was dehydrated which was why he was receiving intravenous fluids. She stated she looked through Resident #9's medical record on 3/30/22 and discovered a urine culture report dated 3/26/22 that hadn't been addressed. She reported this to the NP and requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Interim DON stated on the day the laboratory reported results to them, they would receive an alert directly in the electronic medical record to notify them of any new result. However, if a staff member opened up the alert, it would clear out, but that wouldn't necessarily mean that someone had followed up on it. The Interim DON also stated she was not sure if she had received a report from the nurse before her that they were waiting on Resident #9's urinalysis and urine culture results. A phone interview with Nurse #8 on 6/14/22 at 11:03 AM revealed she took care of Resident #9 on the night shift from 7:00 PM on 3/30/22 to 7:00 AM on 3/31/22. Nurse #8 gave Resident #9's first dose of antibiotic injection intramuscularly because he had pulled off his midline catheter. Nurse #8 thought they were still waiting on his urine culture results and was not aware that it had been reported by the laboratory on 3/26/22. Nurse #8 stated things often got trickled down during report between the nurses and not everything got followed up on. She also did not check his temperature and pulse but had noted that his blood pressure was low, so she held his [MEDICATION(S)] dose for 8:00 PM. Nurse #8 stated she put a note in the provider's notebook about Resident #9's blood pressure so they could see it when they come the next day. Nurse #8 stated she didn't think it was something she had to report right then and didn't use the electronic message through the tablet to communicate with a provider. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] is a cephalosporin antibiotic used to treat a wide variety of bacterial infections. It works by killing bacteria or preventing their growth. A Nurse Practitioner note dated 3/31/22 of Resident #9's general medical condition indicated he was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no assessment or mention of the buttocks wound. Multiple attempts were made to contact the NP, but they were unsuccessful. The NP no longer worked with the Medical Director's team. An interview with Nurse #4 on 6/13/22 at 4:01 PM revealed she took care of Resident #9 on 4/1/22 and had to hold his 8:00 AM [MEDICATION(S)] dose because his blood pressure was low. She didn't check the rest of his vital signs including his temperature and pulse because it wasn't indicated on the Medication Administration Record. Nurse #4 stated Resident #9's low blood pressure didn't alert her because she thought he was receiving intravenous fluids because his blood pressure had been low. A phone interview with Nurse #3 on 6/13/22 at 10:20 AM revealed she took care of Resident #9 from 7:00 AM to 7:00 PM on 4/2/22 and 4/3/22. Nurse #3 recalled seeing the wound on his buttocks on 4/3/22 when she had to change the [MEDICATION(S)] dressing. Nurse #3 stated she was surprised to see how bad the wound looked and stated it was the worst-looking pressure ulcer she had ever seen. Nurse #3 described the ulcer as unstageable and reported that it was black and red in some areas and had a foul odor. After Nurse #3 saw the wound, she called the former Director of Nursing (DON) into the room and the former DON placed an antiseptic dressing on the wound. Nurse #3 assumed that the former DON had notified the doctor of Resident #9's pressure ulcer and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A phone interview was attempted on 6/13/22 at 12:01 PM, 6/14/22 at 12:00 PM and 6/15/22 at 10:19 AM with the former DON with no return call. A phone interview with Resident #9's family member on 6/7/22 at 12:15 PM revealed he visited Resident #9 at the facility and often talked to him by phone. When he visited Resident #9 on 4/1/22, he noticed Resident #9 was out of it and then on 4/5/22, he didn't even recognize him. Resident #9's family member stated he was concerned that Resident #9 had developed a [CONDITION(S)], so he asked the staff to go ahead and send him to the hospital. At the ER (emergency room ), Resident #9 had a wound on his buttocks that was black and smelled of dead tissue. A follow-up interview with the Interim Director of Nursing (DON) on 6/13/22 at 3:00 PM revealed the nursing staff were only supposed to communicate with the providers through text messages through the tablet and the facility did not utilize a notebook for the providers. The Interim DON stated she did not see any documentation/communication regarding Resident #9's worsening condition from 3/22/22 to 4/5/22 except when she had notified the NP of his urine culture results on 3/30/22. The Interim DON also stated that she checked the nurse to physician documented communication text messages and there was no report to the medical staff that Resident #9's wound to his buttocks had opened, was large and black. An interview on 6/14/22 at 12:25 PM with the Physician Assistant (PA) currently working at the facility revealed the provider should have been keeping an eye out for laboratory results that they had ordered. Whenever laboratory results were ready, they automatically populated in the electronic medical record and the NP who had ordered Resident #9's urinalysis and urine culture should have followed up when it became available. The PA stated she would have expected the nurses to monitor Resident #9's vital signs because the blood pressure would typically go down as the infection worsened because of the fluids trying to get into the tissues to fight the infection. A phone interview with the Medical Director (MD) on 6/14/22 at 4:22 PM revealed he was familiar with Resident #9 and remembered him having a routine work-up for altered mental status which included CBC. CMP, CXR and UA. The MD stated he didn't know that there was delay with starting Resident #9 on antibiotics for [CONDITION(S)], but he would have hoped the nursing staff had followed up on the urine culture result, so it was communicated to the NP who had ordered the urinalysis and urine culture. The MD stated he also expected the nurses to have assessed Resident #9 who was acutely ill and checked his vital signs at least once a day. He also expected the nursing staff to report any decline in condition especially the deterioration of Resident #9's pressure ulcer and continued low blood pressure readings even though he was receiving intravenous fluids. Resident #9's hospital admission notes dated 4/5/22 indicated Resident #9 was seen in the Emergency Department for altered mental status. Resident #9 was found to have severe [CONDITION(S)]/septic shock with acute organ dysfunction, an infected decubitus ulcer stage IV, a pressure injury of buttock stage IV, elevated white blood cells indicating an infection, metabolic [CONDITION(S)], acute renal failure superimposed on chronic kidney disease stage 3, intravascular volume depletion (dehydration), and low sodium. The surgical consult for decubitus sacral ulcer determined the ulcer was large, necrotic, and malodorous ulcer with only minimal [CONDITION(S)]. Plan was for surgical debridement and diverting [CONDITION(S)]. It was suspected the sacral ulcer was contaminated with stool. Resident #9 was critically ill and at risk for decompensation resulting in end-organ dysfunction. The resident's fevers were up to 103 Fahrenheit due to an infected sacral pressure ulcer. A CT (computed tomography) scan of the sacral pressure ulcer revealed extensive subcutaneous gas formation (deep seeded infection with gas forming organisms) and tunneling upward within the gluteal and above the gluteal tissues. Resident #9 also had a stage 4 pressure ulcer to the right plantar foot and a soft tissue ulcer to the great toe stump. An interview with the Director of Nursing (DON) on 6/15/22 at 1:40 PM revealed she expected the nurses to follow up on laboratory results and address them with the doctor. While waiting on results from the laboratory, this information should be reported by the nurses to each other, so they knew to monitor for the laboratory result. The DON stated she expected the nurses to monitor acutely ill residents by obtaining a full set of vital signs at least once during their shift and to call the doctor about any acute issues or change in condition. The Administrator was notified of Immediate Jeopardy on 6/15/22 at 1:41 PM. The facility provided the following IJ Removal Plan with the correction date of 6/18/22. 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The identified resident (Resident #9) is no longer a resident of the facility. The facility failed to complete thorough and ongoing assessment of a resident after a significant change in condition and failed to report urinalysis results and deterioration of pressure ulcer to the Primary Care Provider. All other residents have the potential to be affected by the deficient practice. All resident charts were audited to determine if any other outstanding labs. have not been addressed, initiated on 6/15/2022 and completed on 6/15/2022. The Primary Care Provider was notified by the Director of Nursing (DON) or DON designee on 6/15/2022 with any identified residents with skin integrity issues that have not been previously identified. The Primary Care Provider will be notified by the DON or DON designee by 6/16/2022 with any identified residents with any outstanding labs. that have not been addressed. Licensed Nurses and Nurse Aides interviewed to determine if any current residents have had any significant changes of their conditions, if so DON and/or the DON designee will assess the resident to determine if a significant change has occurred and will notify the Primary Care Provider of change by 6/16/2022. An audit of all residents' charts via Point Click Care system was completed on 6/15/2022 by the DON and/or DON designee to determine if any labs. have not been addressed. 2. Actions taken to alter the process or system failure to prevent adverse outcome from occurring or recurring: Immediate in-service initiated 6/15/2022 for observed skin integrity issues and any labs not being addressed by the DON and/or the DON Designee to the Licensed nursing staff, Nurse Aides, and any agency staff regarding assessing residents with any change in condition and to report any deterioration of pressure ulcer to the Primary Care Provider immediately. The DON and/or DON Designee initiated in-service on 6/15/2022 with the Licensed nurses and nurse aides to report any changes in a resident's skin integrity, eating habits, altered mental status or any observations that are not typical of the individual resident. The Nurse aide should report to the Licensed Nurse and the Licensed Nurse should assess the resident and report and notify the Primary Care Provider of any abnormal findings. * Licensed nursing staff will be educated to notify the Primary Care Provider promptly if they observe a new pressure wound or open area, any signs of wound infection, any wound deterioration. This was initiated on 6/14/2022, by the DON and/or RN certified wound nurse will be conducted to the nursing staff to include nurses, nurse aides, and agency nursing staff and will be completed by 6/16/2022. The DON and/or DON designee will be responsible for tracking employees who aren't educated and ensuring they are educated prior to them working after 6/16/2022. This education will be given to all newly hired Licensed Nursing staff and agency staff prior to taking their resident assignment. * Licensed Nursing staff to included agency will be educated to notify the Primary Care Provider if a newly admitted resident is noted to have open wound/pressure sore. Any new resident with wound or open area will have orders to conduct weekly skin assessments and measurements on TAR. This education was initiated on 6/14/2022, by DON and/or RN certified wound nurse and will be completed by 6/16/2022. This education will be given to all newly hired Licensed Nursing staff and agency staff prior to taking their resident assignment. * Licensed Nursing staff to include agency will be educated on signs and symptoms of [CONDITION(S)] to include: faster heart rate, reduced urine output, fever and chills, difficulty breathing, mental confusion and hyperventilation. This education was initiated on 6/14/2022, by DON and/or RN certified wound nurse and will be completed by 6/16/2022. The DON and/or DON designee will be responsible for tracking employees who aren't educated and ensuring they are educated prior to them working after 6/16/2022. This education will be given to all newly hired Licensed Nursing staff and agency staff prior to taking their resident assignment. * The Nurse aides will be educated to notify the nurse with any changes in skin integrity immediately to the individual resident's nurse. Such changes as redness, rashes, any skin break, abrasions, or any unusual skin integrity observations that were not noted with skin observation during prior care provided. Nurse Aides will also be educated on signs and symptoms of [CONDITION(S)] to include: faster heart rate, reduced urine output, fever and chills, difficulty breathing, mental confusion and hyperventilation. This education was initiated on 6/14/2022, by DON and/or RN certified wound nurse and will completed by 6/16/2022. The DON and/or DON designee will be responsible for tracking employees who aren't educated and ensuring they are educated prior to them working after 6/16/2022. This education will be given to all newly hired Licensed Nursing staff and agency staff prior to taking their resident assignment. * Facility will implement Acute Charting Board that will be placed on each Medication cart for each Licensed Nurse to review and chart on each shift. Acute Charting Board will include any resident who is having an acute episode or event to alert the Licensed Nurse to chart a thorough assessment depending on the condition of the resident every shift i.e.: new onset antibiotic, fall with or without injuries, any new or worsening behaviors, altered mental status, change of condition, IV fluids. The Acute Charting Board will be updated by the Licensed Nurse taking care of the resident that has the acute change or event and the DON and/or Designee will ensure updates are addressed based on the 24-hour report and/or clinical meeting. This will be implemented on 6/16/2022. The Licensed Nurse will have to chart every shift their assessment until the Resident is stable and the Resident can only be removed from the Acute charting book by the Weekend Supervisor/DON and/or the DON Designee when the resident is no longer in need of acute charting. The residents in the acute charting will have a list of resident names on a list so the nurses will know who to chart on. The acute charting and any assessments or changes during the shift will be communicated with the oncoming shift. In-service education will be initiated on 6/16/2022 by DON and/or DON Designee and completed by 6/16/2022. The DON and/or DON designee will be responsible for tracking employees who aren't educated and ensuring they are educated prior to them working after 6/16/2022. This education will be given to all newly hired Licensed Nursing staff and agency staff prior to taking their resident assignment. * In-service education was initiated on 6/16/2022 by DON and/or DON Designee and completed by 6/16/2022. A thorough assessment includes aspects related to the individual resident's needs and monitoring. For example, the licensed nurses were in-serviced to monitor for signs and symptoms of [CONDITION(S)] and to notify the Primary Care Provider if the resident exhibits any signs or symptoms of [CONDITION(S)]. The licensed nurses were in-serviced on weight monitoring and if any weight loss greater than 5 pounds from previous weight, there will be notification of Primary Care Provider and RD. The licensed nurses were in-serviced on any resident with fall to determine if any injury and to send out to hospital if any change in resident cognitive status or complaints of pain or obvious injury as laceration requiring sutures, any pupillary changes, also observation for 72 hours after fall unwitnessed if no serious injury note with; the licensed nurses were in-serviced to notify if any change in the resident from their normal cognitive behavior baseline or typical habits, routines or any changes in food intake. The licensed nurses were in-serviced as to any change in vital signs such as increase or decrease in temperature, heart rate, blood pressure and respirations and any symptoms that are exhibited with change of vital signs to notify the Primary Care Provider. The licensed nurses were in-serviced as to any changes in wound size, changes in color, drainage, odor, or pain to be reported to the Primary Care Provider. Any resident on IV fluids will have vital signs taken every shift while on IV therapy. The DON and/or DON designee will be responsible for tracking employees who aren't educated and ensuring they are educated prior to them working after 6/17/2022. This education will be given to all newly hired Licensed Nursing staff and agency staff prior to taking their resident assignment. Facility will implement and keep at the nurses' station Interact Care Path Tools Workbook/SBARs (Situation, Background, Assessment, Recommendation). An education Tool and Reference for Guiding Evaluation of Specific Symptoms That Commonly Cause Acute Care Transfer. This tool guide provides clear instructions on what signs and symptoms needs to be reported immediately to the Primary Care Provider, what can wait until the following day and when a resident needs to be assessed by a Medical Provider, this will be implemented on 6/16/2022. In-service education will be initiated on 6/16/2022 by the DON and/or DON designee and completed by 6/17/2022. The DON and/or DON designee will be responsible for tracking employees who aren't educated and ensuring they are educated prior to them working after 6/16/2022. This education will be given to all newly Licensed Nurses and agency licensed nurses prior to taking their resident assignment. This education was provided to licensed nurses on 6/16/22 and 6/17/22. * The DON and/or DON designee will review all change of conditions in clinical meeting to ensure SBARs were completed along with Primary Care Physician and family notification (if they are responsible party). If the DON and/or DON designee find any issues, the DON or DON Designee will notify the Primary Care Provider. Clinical meetings will be held every weekday morning after the morning stand up meetings. The weekend RN or DON Designee will review the 24-hour report and will ensure any changes in the resident condition is addressed and proper notification to the Primary Care Provider and the responsible party. The needed documentation for the 24-hour report was included in the in-service training. * Lab. book will be implemented and kept at the nurses' station that will reflect ordered labs. and notification of Primary Care Provider when lab. results have been obtained. The book will reflect the resident's name, the date of the lab. ordered, the ordered lab., the date results obtained and if critical labs. noted, the notification date and time the Primary Care Provider was notified. The Nurse receiving lab. order will place lab. in the lab. book. The Nurse who receives lab. results will notify Primary Care Provider of any Critical Lab. results and document in the lab. book of doing notification. All critical labs. are called to the Nurse at the facility from the Lab. In-service education will be initiated on 6/16/2022 by DON and/or DON Designee and completed by 6/17/2022. The DON and/or DON designee will be responsible for tracking employees who aren't educated and ensuring they are educated prior to them working after 6/17/2022. This education will be given to all newly hired Licensed Nursing and agency staff prior to taking their resident assignment. * The DON and/or Designee will review the lab. book every morning to determine if any labs. have not been addressed and/or Primary Care Provider notified. The DON and/or Weekend supervisor will check the lab. book on the weekend to ensure the same. If the DON and/or DON Designee find any issues, the DON or DON Designee will notify the Primary Care Provider. The weekend supervisor was educated 6/16/2022 and has been informed of her responsibility in this regard. The in-service will be conducted in person, telephone, or text. Those Nurses and Nurse aides that have in-service that was not able to be conducted in person, will be acknowledged on the sign in in-service sheet as to the method of communication conveyed. The staff that received text will be provided 1:1 in-service when they report to

Based on observations, record reviews, and interviews with staff, Wound Physician, Physician Assistant, and Medical Director, the facility failed to complete skin assessments as ordered, effectively assess, and monitor a pressure ulcer, and ensure treatments/interventions were implemented and modified/adjusted according to resident's response (Resident #9). Resident #9 who was at high risk for pressure ulcers was hospitalized on [DATE] with an infected stage 4 pressure ulcer (full-thickness skin and tissue loss) with tunneling (passageway of tissue destruction under the skin surface). In addition, the facility failed to update physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures were for 2 or 3 residents reviewed for pressure ulcers (Resident #9 and Resident #6). Immediate jeopardy began on [DATE] when the facility failed to provide the necessary care and services for a pressure ulcer that deteriorated in condition. The facility failed to modify the treatment, implement interventions, monitor/evaluate the impact of the interventions, and adjust accordingly. This led to a high-risk resident (Resident #9) being hospitalized on [DATE] for [CONDITION(S)] due to an infected stage 4 sacral pressure ulcer. On [DATE], Resident #9's family decided on comfort-guided care with hospice. Resident #9 was transferred to the hospice house on [DATE] and died on [DATE] due to cerebral infarction. The Immediate Jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 was cited at a scope and severity level of E. The findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] - Weekly skin check/skin observation tool every Wednesday and Saturday on the evening shift. [DATE] - Mix [MEDICATION(S)] diaper relief cream with (brand name) moisture barrier ointment and apply to excoriation on buttocks, groin, and upper posterior thighs twice a day and as needed. Resident #9's care plan initiated on [DATE] indicated Resident #9 had a pressure area to the left ischium (curved bone forming the base of each half of the pelvis). He refused to be put back to bed due to him being a smoker and he only wanted to lie down once a day for incontinence care and then wanted right back up to smoke. He refused to see the wound doctor. Interventions included to administer treatments as ordered and monitor for effectiveness, encourage the resident to lie down during the day, if the resident refuses treatment, confer with the resident, interdisciplinary team, and family to determine why and try alternative methods to gain compliance and document alternative methods. The last Wound Evaluation and Management Summary completed by the wound physician on [DATE] indicated Resident #9 had a shear, full thickness wound to the left buttock which measured 3.2 cm (centimeters) in length, 1.3 cm in width and 0.1 cm in depth. He also had a shear, full thickness wound to the right buttock which measured 1.2 cm in length, 2 cm in width and 0.1 cm in depth. Both wounds had a light serous exudate. The wound physician applied a [MEDICATION(S)] dressing to each buttock. A phone interview with the Wound Physician on [DATE] at 11:30 AM revealed he had not seen Resident #9 for the past 6 months because Resident #9 had declined assessment at times. There was also no family involvement or team meeting to address non-compliance and Resident #9 was discharged from his service on [DATE] after his last visit. The facility had not informed him that Resident #9 had required his services due to his recent decline. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 was cognitively intact, had no rejection of care behaviors, required extensive physical assistance with bed mobility and personal hygiene, and was totally dependent on staff assistance with toilet use and bathing. He had impairment to both sides of his lower extremities and used a wheelchair. The MDS further indicated Resident #9 was always incontinent of both urine and bowel. Resident #9 was at risk of developing pressure ulcers/injuries, but he didn't have any unhealed pressure ulcers/injuries. He had a pressure reducing device for bed and received application of ointments/medications. A document entitled, Braden Scale for Predicting Pressure Ulcer Risk, dated [DATE] indicated Resident #9 was at high risk for developing a pressure ulcer due to very limited sensory perception, very moist skin, chairfast and very limited mobility. He also had a problem with friction and shear due to him requiring moderate to maximum assistance in moving and complete lifting without sliding against sheets was impossible. The most recent weekly skin check/skin observation tools in Resident #9's medical record were documented by Nurse #1 on [DATE] and [DATE]. On [DATE], Nurse #1 documented Resident #9 had redness to his buttocks and groin area. On [DATE], Nurse #1 documented Resident #9 had a rash to his bottom. Resident #9's care plan last revised on [DATE] indicated Resident #9 had a pressure ulcer to the coccyx. He had been in bed due to decline and refused to be turned off his back. Interventions included to administer treatments as ordered and monitor for effectiveness. If the resident refused treatment, confer with the resident, interdisciplinary team, and family to determine why, and try alternative methods to gain compliance and document alternative methods. A review of Resident #9's medical record indicated there was no evidence of any other weekly skin check/skin observation tool completed after [DATE]. The progress notes from [DATE] to [DATE] indicated no documented refusal from Resident #9 with wound care/treatment, skin checks and wound assessments. A phone interview with Nurse #1 on [DATE] at 6:43 PM revealed she completed a skin check on Resident #9 on [DATE] and observed no open areas on his buttocks. Nurse #1 stated Resident #9's bottom had always been red, but she did not note any open wound or ulcer. She applied barrier cream to his buttocks as ordered. Nurse #1 stated she couldn't remember if Resident #9's buttocks had a [MEDICATION(S)] dressing on when she did his skin check. On [DATE], Nurse #1 completed another skin check on Resident #9 and she observed rashes to his bottom, so she applied his prescribed barrier cream. Nurse #1 further stated she also couldn't remember if there was a [MEDICATION(S)] dressing on Resident #9's buttocks when she checked his skin on [DATE]. A phone interview with Nurse #5 on [DATE] at 11:06 AM revealed she was assigned to complete a skin check on [DATE] on Resident #9 but she couldn't remember what his skin looked like that day, and she failed to completely document his skin evaluation because of interruption during the shift. Further interview with Nurse #5 revealed she took care of Resident #9 on [DATE] and she noted a tremendous change on Resident #9's buttocks when she was about to change his [MEDICATION(S)] dressing on [DATE]. Nurse #5 stated she observed an open decubitus ulcer which measured approximately 8 cm in length and 8 cm in width with a ,d+[DATE] cm depth. The ulcer had a lot of drainage, and she noticed a foul odor, but she wasn't sure if all the odors came from the wound because she had to clean up urine and stool that had contaminated the wound. Nurse #5 said feces would often get on Resident #9's dressing and she had to change it a few times on her shift. Nurse #5 stated she was shocked at how much Resident #9's pressure ulcer had deteriorated, and she knew he needed to be referred to a wound doctor or the facility physician but didn't think he needed to be sent out to the hospital at that time. When the former Director of Nursing (DON) came in the next day to relieve Nurse #5 from the medication cart, Nurse #5 recalled telling the former DON that Resident #9 needed to see the wound doctor. The former DON assured her she would look at the wound and do whatever was necessary. A phone interview with Nurse #7 on [DATE] at 12:18 PM revealed she took care of Resident #9 on [DATE] and [DATE] and had to change his [MEDICATION(S)] dressing on both days. Nurse #7 stated she first saw Resident #9's ulcer to his sacrum on [DATE]. Nurse #7 stated she observed a quarter-sized open area on Resident #9's bottom that looked clean, pink and had no drainage and no foul odor. Nurse #7 did not report this observation to anyone as she thought this was normal for him. She also did not complete a wound assessment because she didn't think she had to. An interview with Nurse Aide (NA) #4 on [DATE] at 4:38 PM revealed she worked on the evening shift and often provided a bed bath to Resident #9. NA #1 stated when she started working with Resident #9 in [DATE], he only required one dressing to each buttock. But when she gave him a bed bath on [DATE], NA #4 observed a big wound on his bottom which smelled bad. NA #4 stated she was horrified at the sight of Resident #9's pressure ulcer that she didn't want to remember or even think about what it looked like. NA #4 stated she informed Nurse #8 who ended up placing at least 4 dressings to Resident #9's pressure ulcer. A phone interview with Nurse #8 on [DATE] at 11:03 AM revealed she had to change Resident #9's [MEDICATION(S)] dressing on [DATE] and he had several scattered open areas that were irregularly shaped on his buttocks and ischial (lower part of the hip bone) areas. Nurse #8 remembered having to apply 4 [MEDICATION(S)] dressings with one on each buttock and one on each ischial area. Nurse #8 described the wounds as red and beefy, and she recalled that she didn't have to pack any of the wounds. They drained a lot and had some odor, but she didn't think she had to report it to the doctor or complete a wound assessment. Nurse #8 couldn't give approximate measurements of the wounds but stated that the ulcer on the right buttock was smaller than the one on the left. She wasn't sure about the odor as well because they had to clean up Resident #9 and remove urine and stool off the wound. Nurse #8 stated the area where his ulcers were located were easily contaminated with stool and urine. Nurse #8 also stated that NA #4 probably thought the wounds looked bad because they were bleeding and had a lot more drainage than usual. A phone interview with Nurse #2 on [DATE] at 2:12 PM revealed she had done most of Resident #9's [MEDICATION(S)] dressing in [DATE] and she noticed that the open wound on his buttocks had gotten worse, but she didn't remember exactly when it started to get worse. Nurse #2 stated she remembered Resident #9's wound being slightly smaller than the size of a quarter when she started working with him but on [DATE] when she had changed his [MEDICATION(S)] dressing, she noticed that the wound had gotten bigger to the size of a baseball, and it was draining more. Nurse #2 did not notify the doctor of the worsening of Resident #9's pressure ulcer because she thought he was already being seen by the wound doctor. Nurse #2 also stated she didn't think about completing a wound assessment and didn't think his wound was that severe that she needed to send him to the hospital at that time. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #9's medical record indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] is a cephalosporin antibiotic used to treat a wide variety of bacterial infections. It works by killing bacteria or preventing their growth. An interview with the Unit Manager (UM) on [DATE] at 9:20 AM revealed she injected a prescribed antibiotic into Resident #9's buttock on [DATE] but could not recall whether or not Resident #9 had a dressing that covered his coccyx or buttocks at the time of the injection. The UM stated that she was focused on giving Resident #9 the shot that she didn't notice any abnormalities or open areas to his buttocks. She reported there was nothing that alarmed her or caused any concern, and she did not notice any odor. An interview with Nurse #9 on [DATE] at 11:05 AM revealed she was not usually assigned to take care of Resident #9 but had changed his wound dressing before whenever he complained to her that he was having a hard time getting the nurses to change his dressings. Nurse #9 stated she went ahead and did his dressing, but she couldn't remember what his buttocks looked like at that time. Nurse #9 stated this happened in [DATE] and had reported this to the former DON. A phone interview with NA #5 on [DATE] at 8:40 AM revealed she worked with Resident #9 from 7:00 PM to 7:00 AM and he was usually already in the bed whenever she came in to work. Resident #9 knew whenever he needed to have his brief changed and he used his call light whenever he needed something. NA #5 stated he was always compliant with her, and he always let her provide incontinence care to him. NA #5 stated Resident #9's bottom always had small, slashed areas whenever she started working with him. NA #5 noticed Resident #9's bottom starting to break down and that was when they started putting a dressing to the open areas and they would usually put one dressing to each buttock. She couldn't tell for sure when Resident #9's buttocks started to worsen but she said it had been open for at least a month before he was sent to the hospital. NA #5 stated the drainage from the wound increased and she noticed a foul odor coming from it. She remembered one time when his dressing had come off, she told Nurse #7 about it, and she was told by Nurse #7 that he would have to wait because the dressing change was not scheduled to be done on her shift. NA #5 could not remember when this had happened. A progress note dated [DATE] and written by Nurse #3 indicated Resident #9 had a huge unstageable ulcer on the buttocks. Ulcer was very large, approximately 8 centimeters (cm) by 8 cm unstageable. Cleaned ulcer on coccyx with wound cleanser and (antiseptic) dressing applied. A phone interview with Nurse #3 on [DATE] at 10:20 AM revealed she took care of Resident #9 from 7:00 AM to 7:00 PM on [DATE] and [DATE]. Nurse #3 recalled seeing the wound on his buttocks on [DATE] when she had to change the [MEDICATION(S)] dressing. Nurse #3 stated she was surprised to see how bad the wound looked and stated it was the worst-looking pressure ulcer she had ever seen. Nurse #3 described the ulcer as unstageable and reported that it was black and red in some areas and had a foul odor. After Nurse #3 saw the wound, she called the former Director of Nursing (DON) into the room and the former DON placed an antiseptic dressing on the wound. Nurse #3 assumed that the former DON had notified the doctor of Resident #9's pressure ulcer and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A phone interview with NA #6 on [DATE] at 7:15 PM revealed she took care of Resident #9 on the night shift and sometimes she came in at 7:00 PM. At first, Resident #9 had a red area that would open and to which they applied cream and ointment. The open area would heal and then re-open whenever he refused to lie down during the day. NA #6 couldn't remember when Resident #9's bottom first looked bad, but she stated that she reported it to Nurse #2 and Nurse #5. NA #6 stated Resident #9's ulcer continued to worsen and had a foul odor. It went from bad to worse in a short period of time, it became dark in color and the drainage was horrible. NA #6 also stated she thought the doctor was aware of Resident #9's pressure ulcer and that he was giving the nurses orders about the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A phone interview was attempted on [DATE] at 12:01 PM, [DATE] at 12:00 PM and [DATE] at 10:19 AM with the former DON with no return call. A nurse practitioner (NP) note dated [DATE] indicated Resident #9 was seen by the NP for wound to his buttocks. Unstageable wound to one-fourth area of the coccyx, eschar (dead tissue that eventually sloughs off healthy skin after an injury) present to the buttocks and there was also a 2 cm by 2 cm necrotic area to the right heel. Unable to stage wound, recommend he be sent to the hospital for wound evaluation. Multiple attempts were made to contact the NP, but they were unsuccessful. The NP no longer worked with the Medical Director's team. An interview on [DATE] at 12:25 PM with the Physician Assistant currently working at the facility revealed Resident #9's wound should have been assessed each week by medical staff or a nurse for the size, drainage, type of tissues, signs, and symptoms of infection, and need for debridement. With eschar tissue present, the wound could easily become infected, and she would have debrided the wound or sent Resident #9 out for evaluation. A phone interview with the Medical Director (MD) on [DATE] at 4:22 PM revealed he was aware of open areas on Resident #9's buttocks that recurred due to his non-compliance with offloading and incontinence care, but he wasn't sure about the pressure ulcer that developed right before he was sent out to the hospital. The MD stated Resident #9 had so many co-morbidities and he felt this was likely a terminal ulcer. The MD stated he wasn't surprised the ulcer developed fast, but he couldn't say how fast and to what extent the pressure ulcer had deteriorated. The MD further stated he had expected to be notified of any deterioration/decline in pressure ulcers even though they had expected Resident #9's ulcer to get worse due to his non-compliance. The MD also stated that with his smoking and low [MEDICATION(S)] level, the pressure ulcer could have opened up pretty readily. He said he didn't feel Resident #9's pressure ulcer progression was avoidable based on his past history, behaviors, and co-morbidities. Resident #9's hospital admission notes dated [DATE] indicated Resident #9 was seen in the Emergency Department for altered mental status. Resident #9 was found to have severe [CONDITION(S)]/septic shock with acute organ dysfunction, an infected decubitus ulcer stage IV, a pressure injury of buttock stage IV, elevated white blood cells indicating an infection, metabolic [CONDITION(S)], acute [CONDITION(S)] superimposed on chronic kidney disease stage 3, intravascular volume depletion (dehydration), and low sodium. The surgical consult for decubitus sacral ulcer determined the ulcer was large, necrotic, and malodorous ulcer with only minimal [CONDITION(S)]. Plan was for surgical debridement and diverting [CONDITION(S)]. It was suspected the sacral ulcer was contaminated with stool. Resident #9 was critically ill and at risk for decompensation resulting in end-organ dysfunction. The resident's fevers were up to 103 Fahrenheit due to an infected sacral pressure ulcer. A CT (computed tomography) scan of the sacral pressure ulcer revealed extensive subcutaneous gas formation (deep seeded infection with gas forming organisms) and tunneling upward within the gluteal and above the gluteal tissues. Resident #9 also had a stage 4 pressure ulcer to the right plantar foot and a soft tissue ulcer to the great toe stump. Resident #9's death certificate dated [DATE] indicated the immediate cause of death was cerebral infarction. An interview with the Director of Nursing (DON) on [DATE] at 5:34 PM revealed the nurses were supposed to complete weekly skin checks on each resident but if the resident had a pressure ulcer, the nurses were supposed to bring it to the doctor's attention. Any resident with a pressure ulcer should be referred to the wound doctor for proper treatment and evaluation. The Administrator was notified of Immediate Jeopardy on [DATE] at 12:57 PM. The facility provided the following IJ Removal Plan with the correction date of [DATE]. 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The identified resident (Resident #9) is no longer a resident of the facility. Resident #9 had a wound that increased in size and severity and the facility allegedly failed to identify changes for Resident #9 who was assessed as a high risk for pressure sores and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . All other residents have the potential to be affected by the deficient practice. * An immediate skin assessment/total body audit of all residents is being initiated today, [DATE], by the licensed nursing staff and will be completed by [DATE]. * The skin assessment/audit will consist of observation of the current status of the individual resident's skin integrity and compare to the last documented skin assessment for the resident and will be documented on the skin assessment sheet. * Any resident/s with newly developed wounds will be measured and staged by facility employed RN certified wound nurse. * Any resident with any newly developed wounds or worsening wounds, the resident's nurse will inform the DON or DON Designee. Primary Care Provider will be notified immediately by the DON or DON Designee. * Any resident that refuses to have skin assessment, will be asked again by their assigned licensed nurse, and will contact family to see if they can assist in encouraging them to allow us to conduct skin assessment. * If the resident continues to refuse and has a BIMS score of 12 or greater, will be provided with information by the DON or DON Designee regarding the risks of refusing skin assessment or wound care and will be care planned as such. The DON or DON Designee will update the care plan during the weekly Focus meeting if not updated on the care plan at the time of notification. * The Primary Care Provider will be notified by the DON or DON Designee regarding the refusal as well and will be documented in the Care Plan. After 3 separate attempts to encourage the resident to allow, the DON or DON Designee will notify the Primary Care Provider regarding the refusal and will document in the clinical record and the care plan. * All current residents will have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON or DON Designee will ensure the order is placed on the TAR. The current residents with wounds/pressure sores that need weekly assessment and/or measurements will be documented in Resident/s chart by [DATE]. The DON and/or the RN certified wound care nurse and/or DON designee will ensure the TAR will reflect the documentation of weekly assessment and/or measurements along with the order for the wound care for the individual resident on weekly basis. 2. Actions taken to alter the process or system failure to prevent adverse outcome from occurring or recurring: Immediate in-service initiated [DATE] by the Director of Nursing (DON) and/or RN certified wound nurse and/or DON Designee will be conducted to the nursing staff to include nurses and nurse aides. * The in-service will be conducted in person, telephone, or text. Those staff members that were unable to be contacted other than text, will have in person in-service training prior to taking an assignment and will have evidence of the in-service training with their signature on the in-service sign in sheet. Those staff members that were not available in person that received a text of highlighted information presented in the in-service will have to be provided 1:1 in-service when they report to work prior to caring for residents. Also, signage at the time clock will alert those named that received text to see the DON or DON Designee prior to taking care of the residents. All staff will have evidence of in-service communication initiated by [DATE] and will have the in-person in-service prior to their working shift with signatures on the sign-in sheet prior to them working their shift. All newly hired staff (nurses and nurse aides) along with any agency staff will receive the information contained in the in-service prior to working with residents. The DON and/or RN certified wound nurse and/or DON Designee will be responsible for tracking which staff need in person education and what day and shift they are scheduled to work. They will be notified that this is effective immediately beginning on [DATE]. A. The in-service will be presented by the Director of Nursing (DON) and/or RN certified wound nurse and/or DON Designee to all nursing staff regarding performing and documenting weekly wound assessments along with the weekly skin checks/evaluations for residents with identified wounds/pressure wounds on a weekly and as needed basis. An assignment sheet will be posted/available at the nurse's station to alert the nurse assigned to a particular resident/room number when the individual resident's weekly skin assessment, and documentation of wound/pressure sores measurements are due. This will be posted as of [DATE]. B. Director of Nursing (DON) and/or RN certified wound nurse and/or DON Designee will be responsible for creating the list for current residents in addition to updating as needed for new admissions or residents with changes in skin integrity. This list will be in addition to orders on TAR. If any resident refuses their wound care treatment or body skin assessment, this will be reflected on the TAR and a note in the resident record regarding the refusal along with the notification of Primary Care Provider. The nurse will also notify the DON or DON designee for refusal of any assessment and/or wound care. All weekly skin assessments and wound/pressure sore assessments and measurements will be on the individual resident's TAR. C. Any resident that refuses to have skin assessment or wound care will be asked again by their assigned licensed nurse and will contact family to see if they can assist in encouraging them to allow us to conduct skin assessment. D. If the resident continues to refuse that has a BIMS score of 12 or greater, will be provided with information by the DON or DON Designee regarding the risks of refusing skin assessment or wound care and will be care planned as such. Staff will be educated to notify the DON or DON Designee for refusals of weekly skin assessments, wound assessments, or wound care. E. The Primary Care Provider will be notified by the DON or DON Designee regarding the refusal as well and will be documented in the Care Plan. F. Although contracted wound providers conduct assessments, the licensed staff will continue to be expected to conduct weekly skin assessments and measurements regardless of other wound service providers. G. Licensed nursing staff will be educated to notify the Primary Care Provider if they observe a new pressure wound or open area, any signs of wound infection, any wound deterioration initiated [DATE] by the Director of Nursing (DON) and/or RN certified wound nurse will be conducted to the nursing staff to include nurses and nurse aides and will be completed by [DATE]. H. Licensed nursing staff will be educated to notify the Primary Care Provider if a newly admitted resident is noted to have open wound/pressure sore. The new resident with wound or open area will have orders to conduct weekly skin assessment and measurements on TAR. I. Signs and symptoms of [CONDITION(S)] to include: * Faster heart rate * Reduced urine output * Fever and chills * Difficulty in breathing * Mental confusion * Hyperventilation J. The Nurse Aides will be educated to notify the nurse with any changes in skin integrity immediately to the individual resident's nurse. Such changes as redness, rashes, any skin break, abrasions, or any unusual skin integrity observations that were not noted with skin observations during prior care provided. * The facility will conduct weekly Focus meetings with the Interdisciplinary team (IDT) to discuss any resident wounds and will discuss the interventions put in place and determine if the interventions are beneficial and if not, the DON or DON designee will notify the Primary Care Provider of the status of wound and need for additional wound treatment intervention. This is a process that was in place historically and will be re-implemented. The DON or DON Designee is responsible for ensuring the weekly Focus meetings occur. * The IDT include dietary manager, the registered dietician (when available) DON or DON designee, Administrator, Social Service Director, Activity Director, and nurse and/or nurse aide that are involved in the care of residents. The alleged date of IJ removal is [DATE]. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. On [DATE], the facility's credible allegation was validated through record reviews and staff interviews. The facility provided education documentation for all staff on identifying and reporting a change in condition especially in skin integrity. In addition, the facility provided signed education sheets on the new system for completing skin assessments. The education provided details on how all new admissions, readmissions would have an initial, weekly, and as needed skin assessments completed by the nurse. Interviews conducted with the nursing staff validated skin assessments were assigned to each resident and were flagged on the Treatment Administration Record (TAR) for the nurse to complete. The nurses interviewed were able to explain the new system implemented by the facility. The nursing aides were interviewed and described the different signs of changes in skin integrity to be reported to the nurse during provision of care. The Director of Nursing (DON) was interviewed and described the way the new system worked to ensure skin assessments were completed. She reported all skin assessments were assigned in the electronic medical record (EMR) on the Treatment Administrator Record (TAR) to be completed by the nurse based on an assignment sheet set up by the DON. She explained she or her designee were responsible for reviewing the assessments daily to ensure all skin assessments had been thoroughly completed. The DON explained she or her designee verified the sheets were completed in detail and not just checked as done. A weekly focus meeting was held on [DATE] which included the Administrator, the Director of Nursing, and the Infection Preventionist. They discussed the following areas: skin observations, wound reports, laboratory audit review/notification, weight loss, change of conditions and acute charting boards. 2. Resident #6 was readmitted from the hospital to the facility on [DATE]. Her cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS revealed the resident was cognitively able to make decisions for activities of daily living. Resident #6 required total assistance from one staff member with bed mobili [TRUNCATED]

Based on staff interviews and record reviews, the facility failed to monitor a resident's weight on a weekly basis as ordered by the physician, identify a severe unintended decline in his weight, and implement/adjust interventions. The resident was sent to the hospital on 4/7/2022 and had a feeding tube placed in the stomach for 1 of 1 resident (Resident #10) reviewed for maintain nutritional status. The facility also failed to provide a physician ordered nutritional supplement for 2 of 2 sample residents (Resident #11 and Resident #2). Immediate Jeopardy began on 3/9/2022 when staff failed to identify a significant weight loss of 11.5% for Resident #10. Resident #10 continued to lose weight and had a cumulative weight loss of 24.4% since 1/19/2022. Immediate Jeopardy was removed as of 6/14/2022 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level E (No actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education, ensure monitoring systems put into place are effective. The jeopardy tag is left out of compliance at a scope and severity E also for Resident #11 and #2. The findings included: 1. Resident #10 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10 was [AGE] years old. Resident #10's care plan last updated on included meal satisfaction and by mouth intake. Interventions included add Resident #10 to the meal list of residents needing additional assistance with feeding and weigh/monitor results weekly. Physician diet order initiated on 5/11/2020 read in part No Added Salt diet, dysphagia mechanically altered diet, thin consistency related to [CONDITION(S)]. The order was active on resident's discharge date of [DATE]. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was active on resident's discharge date of [DATE]. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was active on resident's discharge date of [DATE]. Resident #10's quarterly MDS dated [DATE] indicated resident was not cognitively intact for daily decision making. Resident #10's height was 61 inches and he weighed 124 pounds. Resident diet included therapeutic and mechanically altered diet. The MDS indicated Resident #10 was assessed for total dependence on one staff member for assistance with eating. Resident #10 had no weight loss or gain since the previous review. The MDS further indicated Resident #10 had limited range of motion on both sides of his upper and lower extremities. Nurse's progress note dated 1/5/2022 showed Resident #10 was diagnosed with COVID-19. Resident #10 remained in the facility. Resident #10's electronic medical record, on the vital sign tab which included weights showed his weight documented as 125.7 pounds on 1/19/2022, weight collected by mechanical lift. Review of January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review was conducted of Resident #10's meal intake records for January 2022 revealed his intake as resident refused on 11 occasions (15% of the meals documented), 0-25% of the meal was consumed on 31 occasions (44% of the meals documented), 26-50% of the meal was consumed on 13 occasions (18% of the meals documented), 51-75% of the meal was consumed on 12 occasions (17% of the meals documented), and 76-100% of the meal was consumed on 4 occasions (6% of the meals documented). Review of February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review was conducted of Resident #10's meal intake records for February 2022 revealed his intake as resident refused on 7 occasions (9% of the meals documented), 0-25% of the meal was consumed on 16 occasions (21% of the meals documented), 26-50% of the meal was consumed on 15 occasions 20(% of the meals documented), 51-75% of the meal was consumed on 24 occasions (32% of the meals documented), and 76-100% of the meal was consumed on 13 occasions (17% of the meals documented). Resident #10's care plan was updated on 3/3/2022 included an area of focus for difficulty swallowing related to dysphagia, [CONDITION(S)], and mental disorder. On review of the care plan history updates, there was no update completed on 3/3/2022, unable to identify staff who made the update to the care plan. Dietician note dated 3/3/2022 showed Resident #10 was stable with weight for greater than 6 months, he was fed by staff, and received a magic cup with lunch daily. The Dietician's documentation stated no acute nutrition concerns at this time. Will continue current diet/supplement regimen and will follow up as needed. A telephone interview was conducted on 6/8/2022 at 4:15PM with the facility's Consultant Registered Dietician (RD). During the interview, RD stated Resident #10 had a significant weight change from 1/19/2022 to 3/9/2022. The RD indicated she started working at the facility in January 2022 and at that time, she was contacted by facility staff through email, telephone, or text when a resident had a significant weight change. The RD further stated she had not received notifications from staff about Resident #10's weight change. During the interview the RD stated when she completed the dietary assessment in March, there was no documentation in Resident #10's medical record that stated he had a weight decrease. The RD further stated she ran a weight report at the beginning of each month and stated Resident #10 weight change would have showed on the report she ran when she returned to the facility on [DATE]. Resident #10 had been discharged on [DATE]. Resident #10's annual MDS dated [DATE] indicated Resident #10 had a weight of 126 pounds and was on a mechanical altered and therapeutic diet. The MDS further stated Resident #10 had not had a weight loss of 5% in the last month or a weight loss of 10% in the last 6 months. A follow up interview conducted on 6/13/2022 at 10:28 A.M. with the RD revealed she was responsible to complete the weight section on the MDS. During the interview she stated she used the last weight available in Resident #10's medical chart. The weight used for the March MDS was from January 2022 and was recorded as 125.7 pounds, which she rounded up to 126 pounds. Review of March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10 refused to be weighed on 3/16/2022 and 3/30/2022. Attempts were made to interview Nurse #1 who entered the weights for Resident #10 on 3/9/2022 and 3/23/2022, via telephone were unsuccessful. A review was conducted of Resident #10's meal intake records for March 2022 revealed his intake as resident refused on 7 occasions (11% of the meals documented), 0-25% of the meal was consumed on 11 occasions (17% of the meals documented), 26-50% of the meal was consumed on 13 occasions (20% of the meals documented), 51-75% of the meal was consumed on 15 occasions (23% of the meals documented), and 76-100% of the meal was consumed on 20 occasions (30% of the meals documented). Resident #10 weighed 111.2 pounds collected by mechanical lift on 3/9/2022. (representing an 11.5% weight loss since 1/19/2022). Resident #10 weighed 95 pounds on 4/6/2022, undocumented how the weight was collected. (representing a 24.4% weight loss since 1/19/2022). An interview was conducted on 6/8/2022 at 3:11 P.M. with the Unit Manager, who weighed Resident #6 on 4/6/2022. The Unit Manager stated she started working at the facility the end of March 2022 and had identified ordered weights missing for residents. The Unit Manager further stated the resident's assigned nurse was responsible to have the NA weigh residents on days the resident weights were ordered. She then revealed, the assigned nurse was responsible for either documenting the resident's weight or giving the information to the Unit Manager and she documented the resident's weight into the resident's medical record. During the interview the Unit Manager stated she ran a report each month to identify missing weights and followed up with the assigned nurse to ensure the resident weights were collected. After reviewing Resident #10's medical record, the Unit Manager stated she was unsure why there were so many missing weights for Resident #10. The Unit Manager then revealed maybe the weights had been collected and not documented in the system; however, she is unaware of any paperwork at the facility with resident weights listed that have not been entered. During the interview the Unit Manager revealed with the variation from one weight to the next, Resident #10 should have been reweighed. She further stated she was unsure if a reweigh was completed on Resident #10 but based off the medical record it appeared a reweigh was not completed and she was unsure why it was not done. During the interview the Unit Manager stated Resident #10 was a little guy, but she was not familiar enough with the resident to visually recognize he had lost weight. Lab test for Comprehensive Metabolic Panel (CMP) was ordered and collected on 3/11/22. The lab results were completed on 3/12/22 and there is a fax date stamp on the top of the lab results that reads Sat [DATE]:07:16 2022. The lab results revealed an abnormal level of potassium 6.1 millimoles per Liter (mmol/L) (normal range is 3.5-5.1 mmol/L) and [MEDICATION(S)] 3.2 grams per deciliter (g/dL) (normal range is 3.5-5.7g/dL). The lab results report was initiated and dated 3/17/22. Nurse Practitioner Progress note dated 4/7/2022 indicated Resident #10 had a 16-pound weight loss. Under Assessment and Plan for significant weight loss the note reads in part Periods of agitation. Requires assistance with ADL's (activities of daily living). Monitor weight. Monitor consumption of meals. Lab results dated 3/11/22 included in progress note. Attempts were made to interview Nurse Practitioner via telephone were unsuccessful. An interview conducted on 6/8/2022 at 3:19 P.M. with Nurse #10. During the interview, Nurse #10 stated nurses provided NAs with a list at the beginning of the shift with residents who had weights ordered for that day. The NAs weighed the residents and gave the information back to the nurse to document in the resident's medical record. She further stated the former unit manager completed reweighs for residents with weight alerts triggered by the medical chart. She stated the medical chart alerted the use of significant weight changes from the previous entry. When staff received this alert, they informed the former Unit Manager. The Unit Manager completed a reweigh to verify a weight change had occurred. The Physician and RD were made aware of weight changes alerted through the medical record computerized system when the reweigh confirmed a weight change. Nurse #10 stated she was familiar with the resident and had not observed him to have a weight loss. When she reviewed his medical chart, she stated Resident #10 had a significant weight loss and she was unsure what caused him to lose the weight. An interview was conducted on 6/10/2022 at 9:32 A.M. with Nurse #5. During the interview Nurse #5 stated she had provided care to Resident #10 in the months prior to him being discharged from the facility. She stated she had not noticed any change in his eating pattern or any change in his weight. An interview was conducted on 6/11/2022 at 6:57 A.M. with Nurse Aide (NA) #7. During the interview, NA #7 stated she was familiar with Resident #10. She stated Resident #10 was able to hold his food and feed himself finger foods that included cakes, half of a sandwich, and soda cans. An interview was conducted on 6/11/2022 at 7:19 A.M. with NA #6. During the interview NA #6 stated she stayed in the room and assisted Resident #10 with eating. When he was given something in his hand, he was able to hold the item and feed himself. She stated if Resident #10 wanted a snack offered to him, he took the snack from staff and ate it. When Resident #10 refused the snack, he threw the snack on the floor. NA #6 revealed Resident #10 ate most of the food provided to him. During the interview, NA #6 stated she had not observed any weight loss for Resident #10. An interview was conducted on 6/11/2022 at 8:08 A.M. with Nurse#2. During the interview, Nurse #2 stated Resident #10 looked different and appeared to have had a weight loss prior to his discharge to the hospital (on 4/7/22). Nurse #2 stated she was unsure how much Resident #10 ate for mealtime, however, stated he ate snacks on third shift. During the interview, Nurse #2 revealed on 4/7/2022 at the start of her 7 P.M. to 7 A.M. shift, she entered Resident #10's room and told him Hello. She revealed when she spoke to Resident #10, he did not respond to her greeting. Nurse #2 stated this was not normal for Resident #10 and she went to his bedside to assess him. Nurse #2 stated she completed a set of vital signs which were within Resident #10's normal range. During the interview, Nurse #2 stated due to Resident #10's lack of a verbal response, she felt something was wrong and had Resident #10 sent to the emergency department for evaluation. Resident #10 was admitted to the Hospital on 4/7/2022 with a chief complaint of altered mental status. The physician examination completed in the emergency department on 4/7/2022 at 8:50 P.M. revealed Resident #10 weighed 95 pounds. A nutrition consultation was ordered. Resident #10 was admitted to the hospital on 4/7/2022 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical records reviewed showed Resident #10 had a feeding tube inserted through his nose to his stomach (nasogastric tube). On 4/10/2022 an x-ray was ordered and completed for a tube check to verify placement of the nasogastric tube. The x-ray findings revealed a small bowel feeding tube ended in Resident #10's stomach. A review of the hospital course indicated the resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE] to another skilled nursing facility. Resident #10 had a discharge weight of 104 pounds. An interview was conducted on 6/11/2022 at 5:02PM with the Regional Nurse Consultant revealed expectations would be to monitor weights, provide interventions for weight loss and notify responsible parties to include the MD and Responsible Party. On 6/11/2022 at 5:55 P.M., the facility's Regional Nurse Consultant and Director of Nursing were informed of the immediate jeopardy. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 6/14/2022. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy Removal for F692 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The identified resident (Resident #10) is no longer a resident of the facility. Resident #10 had a 24.4 % weight loss from January to April with no identification or assessment of weight loss during time of his loss of weight to determine avoidability. All other residents have the potential to be affected by the deficient practice. There is question as to accuracy of weights, therefore the scale has now been recalibrated and all residents will be weighed today 6.12.2022. This will assist in identifying residents that have any weight loss and any discrepancies from last weight to today's weight will be addressed with MD and resident representative being notified today. Other residents were identified as having significant weight loss. We have had 3 residents refuse weight to be obtained. We will ask them again and will contact family to see if they can assist in encouraging them to be weighed. Their responsible representatives and MD are being notified. The Registered Dietician was on the IDT call today and will be reviewing each individual resident to determine appropriate interventions and the MD will be made aware of recommendation and the MD will determine if appropriate. The IDT team will meet again tomorrow, 6.13.2022 to review all the interventions. 2. Actions taken to alter the process or system failure to prevent adverse outcome from occurring or recurring: Immediate inservice initiated 6/11/2022 by the Director of Nursing (DON) and/or the Corporate Nurse Consultant to the nursing staff to include nurses and nurse aides to ensure that all residents are weighed on an at least monthly basis. The inservice will also include dietary staff and the interdisciplinary team, including the registered dietician, certified dietary manager and therapists that are involved in the care of the residents. The inservice will be conducted in person, telephone, email or text. Those staff members that will have inservice that was not able to be conducted in person, will be acknowledged on the sign in sheet inservice sheet as to the method of communication conveyed. All staff will have evidence of inservice communication by 6.12.2022 and will have the inperson inservice prior to their working shift with signatures on the sign in sheet prior to them working their shift. All newly hired staff ( nurses and nurse aides) along with any agency staff will receive the information contained in the inservice prior to working with residents. Any resident that has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If there is a weight discrepancy of 5 pounds greater or less than the previous weight obtained, the staff member will reweigh and inform the charge nurse. The charge nurse in turn will inform the Unit Manager or the DON or the DON designee of the weight discrepancy. The Unit Manager and/or the DON and/or the DON designee will notify the MD and responsible party of any weight loss and will put in place an immediate intervention to prevent further weight loss and to attain optimum weight gain based on the Registered Dietician and/or MD recommendations. The Registered Dietician will be contacted by phone and or email by the DON or DON designee with any identified weight changes to address and assist with the interventions and resolution. Audit of all residents' weights will be initiated 6/11/2022 by the (DON) and/or Certified Dietary Manager, and/or the Corporate Nurse Consultant and completed 6/12/2022 to determine if any residents have had any weight loss since last weight obtained. The audit will consist of review of documented weights from the last 2 months to determine if any weight discrepancies are identified. The weight scale was calibrated last evening 6.11.2022 by the Maintenance Director to ensure the accuracy of the scale prior to the new weights to be obtained. Any weights ordered by the MD more often than once a month will be addressed to ensure ongoing compliance with order for more frequent weights. A list will be updated an placed at the nurse's station for the nurses and nurse aides reference. The DON or DON designee will notify the RD within 24 hours or the next business day of any resident with identified weight loss. The RD will assist with interventions and recommendations for weight gain goals. If any residents are identified to have greater than 5 pound weight loss or greater, the MD and responsible party will be notified by the UM and/or DON and/or DON Designee and immediate interventions will be put in place to prevent further weight loss. Any resident with identified weight loss will be weighed weekly until they meet their weight goal based on their usual body weight or their individual desired weight with the RD and/or MD input are attained and maintained for 90 consecutive days. The determination of utilizing the individual resident weight gain goals will be based on their preference of desired weight goal, their usual body weight based on their preference with input from RD. If any resident is identified to have continued weight loss, the MD will be immediately notified by the Unit Manager and/or the DON and/or DON designee to determine if there were any underlying pathology that would contribute to continued weight loss. The facility will conduct weekly Focus meetings with the Interdisciplinary team to discuss any resident weight losses and will discuss the interventions put in place and determine if the interventions are beneficial until the resident meets their or desired body weight. If interventions are not reflective of achieving desired results, the interventions will be re-addressed and potential to add or eliminate and replace interventions as appropriate to achieve weight gain goals. Date of corrective action completion Immediate Jeopardy Removal date will be 6/14/2022 The facility's credible allegation of Immediate Jeopardy removal was validated on 6/16/2022. The validation was evidenced by staff interviews, record reviews and review of inservice attendance sheets to verify education had been provided to staff that addressed a new system of identifying and treating weight loss. The interventions included the weight scales and platform scales were recalculated to ensure weight accuracy, residents were weighed and residents with a significant weight loss were reweighed to ensure weight loss, the Registered Dietician will consult the weight loss and offer recommendations (more frequent weights, supplements and therapy screens) the Medical Director and Responsible Parties will be notified, residents medical records were reviewed to ensure interventions had been put in place, weekly weight meetings will be held by the IDT to discuss weight loss. The Administrator notified of the credible allegation for the removal of immediate jeopardy for the removal date of 06/14/22 was validated on 06/16/22. The Administrator stated she would be responsible to ensure the compliance would be maintained. 2. Resident #11 was admitted to the facility on [DATE] from a hospital. Her cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An [CONDITION(S)] refers to bleeding inside the skull, which can lead to rapid brain damage or death. The resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Her weight was reported to be 121.5 pounds (#) on 11/23/21. The facility's consultant Registered Dietitian (RD) completed a nutritional assessment on 11/29/21. Her comments included, Spoke with resident this morning. Resident reports not liking the food as it is flavorless and she refuses to eat anything until it tastes better. She reports liking Ensure and said she will drink that if it is brought to her. Recommend adding Ensure and liberalizing diet d/t (due to) poor PO (oral) intake. Calories are for maintenance. The RD recommendations also included liberalizing Resident #11 ' s diet due to her poor oral intake. On 12/14/21, the resident's physician ordered a Regular diet with regular textures to be provided. The order also indicated an Ensure shake (a high calorie, high protein nutritional supplement) should be added to all meal trays until the resident's intake at meal times was consistently greater than 75%. A review of Resident #11's care plan included an area of focus indicating the resident had a potential nutritional problem related to dementia and medication use (initiated on 12/19/21). The care plan interventions indicated the facility would provide her diet as ordered, monitor and record intake for every meal, and provide supplements as ordered. A verbal order was again received by the provider on 1/7/22 to provide Ensure with meals for poor to no meal intake. The order included a notation which read, Please ensure patient receives at meal time. Resident #11's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The resident was assessed to have intact cognitive skills and was reported to be independent with eating. She was noted to be 68 inches tall and 117#. The resident weights also included, in part: 119.0# on 5/1/22 and 121.0# on 6/6/22 (her most recent weight). A review was conducted of Resident #11's meal intake records from the past 30 days revealed her intake as: --0-25% of the meal was consumed on 3 occasions (4% of the meals documented); --26-50% of the meal was consumed on 6 occasions (8% of the meals documented); --51-75% of the meal was consumed on 36 occasions (48% of the meals documented); --76-100% of the meal was consumed on 30 occasions (40% of the meals documented). An observation was conducted on 6/8/22 at 8:40 AM of Resident #11 as she was sitting in her room with her breakfast meal tray placed on the tray table beside her. The top of her meal ticket read, add house shake with all meal trays. There was no House Shake nor any other nutritional supplement on her meal tray. Upon inquiry, the resident confirmed she did not receive a nutritional supplement with the meal. An observation was conducted on 6/8/22 at 12:35 PM as Resident #11 was sitting in her wheelchair eating a sub sandwich brought from outside the facility. No House Shake or nutritional supplement was seen at the time of the observation. When asked, the resident stated a nutritional supplement was neither brought into her room nor offered to her. An observation was conducted on 6/9/22 at 8:37 AM as Resident #11 was sitting in her room with her breakfast meal tray placed on the bedside tray table beside her. The top of her meal ticket read, add house shake with all meal trays. There was no House Shake nor any other nutritional supplement on her meal tray. Upon inquiry, the resident reported she loved the nutritional supplement but had not received one over the last 3 days. An observation was conducted on 6/9/22 at 12:15 PM as Resident #11's meal tray was delivered to her. There was no House Shake nor any other nutritional supplement observed on her meal tray. A review of Resident #11's June 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation showed Ensure was not provided with the last 7 consecutive meals served (beginning with lunch on 6/7/22 and through lunch on 6/9/22). An interview was conducted on 6/9/22 at 2:20 PM with the Dietary Manager. During the interview, the Dietary Manager reviewed the Dietary Department's list of nutritional supplements ordered for residents. She stated, I do not have anything for them (including a reference to Resident #11) they do not get supplements from me. Upon inquiry, the Dietary Manager indicated commercial nutritional supplements such as Ensure were provided from the Nursing Department. When asked what the House Shake would be, the Dietary Manager reported she was not sure and stated Resident #11's meal ticket was not correct because the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 6/9/22 at 5:11 PM with the facility's Unit Manager. During the interview, the Unit Manager was asked who was responsible for ensuring Resident #11 received a nutritional supplement such as Ensure. She stated the hall nurse was responsible for this and added that if the resident refused the supplement, the refusal needed to be documented in the resident's medical record and the physician notified. At that time, the Unit Manager was shown documentation on Resident #11's June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Accompanied by the Unit Manager on 6/9/22 at 5:15 PM, an observation was made of the contents of the nursing station refrigerator. The Unit Manager reported Ensure was typically stored in the refrigerator. However, no Ensure was found stored in the refrigerator; she then reported there was no Ensure in stock at the facility. The Unit Manager stated she knew Resident #11 loved this nutritional supplement and was not even particular about the flavor she received. When asked what needed to be done at this point, the Unit Manager reported the provider and consultant RD needed to be notified Ensure was out of stock to see if there was an appropriate alternative that could be offered to Resident #11 until the Ensure came in. An interview was conducted with the facility's interim Administrator on 6/9/22 at 5:45 PM. During the interview, concerns were expressed regarding failure of Resident #11 to receive a nutritional supplement prescribed three times daily. The interim Administrator stated he would expect a nutritional supplement to either be available in-house or the physician to be contacted for an acceptable, alternative supplement to be selected. 3. Resident #2 was admitted to the facility on [DATE]. His cumulative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nutrition Note dated 1/17/22 and authored by the facility's Registered Dietitian (RD) reported the resident received Magic Cup as a nutritional supplement. His most recent weight was noted as 142 pounds (#) on 1/12/22. Another Nutrition Note authored by the RD on 4/8/22 reported the resident's current weight was 144# and had remained stable over the past 6 months. This note also indicated Resident #2 received Magic Cup as a nutritional supplement. Resident #2's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The resident had moderately impaired cognitive skills for daily decision making. The assessment reported Resident #2 required extensive assistance from staff with one person physical assistance. He was 69 inches tall and weighed 144#. He received a therapeutic and mechanically altered diet. A review of the resident's care plan included an area of focus which indicated he was at nutrition risk related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent out to the hospital on 5/22/22 with re-entry to the facility on [DATE]. Resident #2 ' s re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . His current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent weight was recorded on 6/12/22 as 138.0#. An observation was conducted on 6/9/22 at 12:16 PM as Resident #2 was lying in bed with his head of bed raised and a lunch meal tray placed on the bedside tray table in front of him. The resident's meal ticket included a notation to send a frozen nutritional treat every day with lunch. No frozen nutritional cup/treat was on his meal tray. An interview was conducted on 6/9/22 at 2:20 PM with the Dietary Manager. During the interview, the Dietary Manager reviewed the Dietary Department's list of nutritional supplements ordered for residents. She stated, I do not have anything for them (including a reference to Resident #2)

Based on record reviews, and interviews with staff, family member, Physician Assistant and Medical Director, the facility failed to provide effective leadership and implement effective systems to manage unintended weight loss, change in condition, physician notification and pressure ulcers. This failure affected 5 of 5 residents reviewed for administration (Resident #2, Resident #6, Resident #9, Resident #10, and Resident #11). Immediate Jeopardy began on 3/9/2022 when when effective systems were not in place to ensure residents received necessary care and services. Immediate Jeopardy was removed as of 6/18/2022 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level E (No actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: This tag is cross referred to: F-580: Based on record reviews, and interviews with staff, and Medical Director, the facility failed to notify the Primary Care Provider of significant changes in a resident's condition (Resident #9) when he developed a new opened sacral pressure ulcer, when the pressure ulcer deteriorated and when he continued to have [CONDITION(S)] (low blood pressure) despite receiving intravenous fluids. The facility also failed to report results of a urinalysis and urine culture resulting in a delay in treating the resident (Resident #9) for [CONDITION(S)] (urinary tract infection). Resident #9 was hospitalized on [DATE] for severe [CONDITION(S)]/septic shock due to an infected stage 4 pressure ulcer to the sacrum. In addition, the facility failed to notify the Primary Care Provider when a resident had a severe unintended weight loss (Resident #10). Resident #10 had a cumulative weight loss of 24.4% from 1/19/22 through 4/6/22, was admitted to the hospital on 4/7/22 and had a feeding tube inserted in the stomach. These failures were for 2 of 3 residents reviewed for notification of changes (Resident #9 and Resident #10). F-684: Based on record reviews, and interviews with staff, family member, Physician Assistant and Medical Director, the facility failed to identify the seriousness of significant changes in a resident's condition (Resident #9), complete and document on-going thorough assessments and identify the need for medical attention when the resident's medical condition continued to deteriorate. This resulted in a delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure was for 1 of 3 residents reviewed for quality of care (Resident #9). F-686: Based on observations, record reviews, and interviews with staff, Wound Physician, Physician Assistant, and Medical Director, the facility failed to complete skin assessments as ordered, effectively assess, and monitor a pressure ulcer, and ensure treatments/interventions were implemented and modified/adjusted according to resident's response (Resident #9). Resident #9 who was at high risk for pressure ulcers was hospitalized on [DATE] with an infected stage 4 pressure ulcer (full-thickness skin and tissue loss) with tunneling (passageway of tissue destruction under the skin surface). In addition, the facility failed to update physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures were for 2 or 3 residents reviewed for pressure ulcers (Resident #9 and Resident #6). F-692: Based on staff interviews and record reviews, the facility failed to monitor a resident's weight on a weekly basis as ordered by the physician, identify a severe unintended decline in his weight, and implement/adjust interventions. The resident was sent to the hospital on 4/7/2022 and had a feeding tube placed in the stomach for 1 of 1 resident (Resident #10) reviewed for maintain nutritional status. The facility also failed to provide a physician ordered nutritional supplement for 2 of 2 sample residents (Resident #11 and Resident #2). An interview conducted with the Administrator and the Corporate Nurse Consultant on 6/15/22 at 2:09 PM revealed they were not aware of the severity of the wounds and weight loss experienced by the affected residents, and the former Director of Nursing and the former Administrator played an enormous part in the issue. They stated they needed to put effective systems in place, so the same issues don't happen again in the future. The Administrator was notified of Immediate Jeopardy on 6/15/22 at 1:28 PM. The facility provided the following IJ Removal Plan with the correction date of 6/18/22. All the following was covered with the New Administrator and Director of Nursing. * Nurse Consultant will be providing facility oversight to the administrative staff to ensure that action plans are being followed. * Nurse Consultant re-educated the Administrator and Director of Nursing on job descriptions with emphasis on the role and responsibilities in the oversight of resident care and services on 6/17/22. * Nurse Consultant re-educated the Administrator and Director of Nursing on regulation F-835 with emphasis on the role and responsibilities in the oversight of resident care and services on 6/17/22. * Nurse Consultant reviewed the role and responsibilities related to Quality Assurance with the Nursing Home Administrator and Director of Nursing. * Nurse Consultant re-educated the Administrator and Director of Nursing related to the findings outlined in the Immediate Jeopardy deficiencies to include corrective plan and ongoing process evaluation and monitoring. * Systematic changes: * Implemented daily clinical meeting to discuss weights, labs, pressure ulcers and change of conditions. * Implemented weekly resident risk meeting to discuss areas such as weight loss, critical labs, pressure ulcers and weight loss. * Implemented additional shift to shift communication collaterals related to acute changes in condition, high-risk events, and labs. * New Administrator and Director of Nursing have been introduced to employees during the process of education related to the corrective actions taken by the facility on the immediate jeopardies. * Decision was made on June 17th, 2022, to hold a Resident council meeting to introduce the administrative staff and expectations of care and staff moving forward. Quality Assurance/Performance Improvement On 6/17/22, an Ad hoc Quality Assurance Performance Improvement (QAPI) Meeting was convened to review the Credible Allegation of Compliance as written. All plans that have been put in place are effective and we respectfully request the removal of Immediate Jeopardy status as of 12:00 AM on 6/18/22. * The Corporate Nurse Consultant educated the Administrator and DON on the components of the regulations completed. Additionally, the systems and processes were reviewed for all deficient practices and were updated on 6/13/22 pertaining to: *F580 Notify of Changes *F684 Quality of Care *F686 Treatment/Services to Prevent/Heal Pressure Ulcers *F692 Nutrition/Hydration Status The Administrator is responsible for ensuring that the Focus Meetings are being held and the Administrator was informed of this responsibility on 6/15/22. * The facility will conduct weekly Focus meetings with the Interdisciplinary team to discuss any resident weight losses, skin integrity issues, and any abnormal labs. or any issues with morning reviews of lab. book to determine if any trends and will discuss the interventions put in place; skin assessments, wound measurements with wound healing progress or issues with wound healing; and lab. issues noted in morning reviewed by the DON or DON Designee. If interventions are not reflective of achieving desired results, the Primary Care Provider will be notified, and interventions will be re-addressed and potential to add or eliminate and replace interventions as appropriate to achieve wound healing goals; weight gain goals; notification of labs. and change of conditions. Date of alleged IJ removal - 6/18/22 The credible allegation for the immediate jeopardy removal was validated on 6/23/22 with a removal date of 6/18/22. On 6/17/22 at the daily clinical meeting, all areas of the immediate jeopardy citations were reviewed with the interdisciplinary team (IDT) and interventions put into place were discussed. This was validated by interviews with members of the IDT. A weekly focus meeting was held on 6/17/22 which included the Administrator, the Director of Nursing, and the Infection Preventionist. They discussed the following areas: skin observations, wound reports, laboratory audit review/notification, weight loss, change of conditions and acute charting boards. A review of the resident council meeting minute dated 6/22/22 indicated the new Administrator and Director of Nursing introduced themselves to the residents and reviewed with them their care expectations. The audit tools completed by the facility on skin status, laboratory results and weights were reviewed. The medical provider was notified of results from the audits for additional follow-up as needed. On 6/17/22, the Corporate Nurse Consultant provided education with the new Administrator and Director of Nursing on their job descriptions, roles, and responsibilities in the oversight of resident care and services. They were also educated on identifying issues with immediate jeopardy cited and discussed with them the components of the regulations for F-580, F-684, F-686, F-692 and F-835. The education also included QA roles and responsibilities, correction plans and monitoring processes. Interviews with nurses and nurse aides revealed they received education on identifying any changes in resident condition including skin issues, weight loss, changes in vital signs and daily habits and reporting these changes to the nurses and the medical providers.

Based on record review, observation and interviews with staff and the wound doctor, the facility failed to provide wound care to a venous ulcer per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #4 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 was severely cognitively impaired and was totally dependent on staff assistance with bed mobility. The MDS further indicated Resident #4 had a total of three venous ulcers and received application of nonsurgical dressings and ointments/medications other than to feet. Resident #4's care plan revised on 3/10/22 indicated Resident #4 had a venous ulcer to the left lower medial leg, a venous ulcer to the left lower lateral leg and a venous ulcer to the left lateral foot which was resolved on 3/10/22. Interventions included treatments as ordered. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ¼ (antiseptic) solution, apply (antifungal) cream, cover with oil emulsion dressings and abdominal pads, wrap site with a gauze bandage roll and change daily every day shift. A review of Resident #4's Treatment Administration Record (TAR) for March 2022 indicated the treatment order for Resident #4's left lower leg was marked as completed by Nurse #3 on 3/17/22 and 3/18/22, Nurse #5 on 3/19/22 and Nurse #4 on 3/20/22. During an observation of wound care on Resident #4 on 3/21/22 at 11:30 AM with Nurse #2, a dressing to Resident #4's left lower leg was noted with a date of 3/16/22. An interview with Nurse #2 on 3/21/22 at 2:13 PM revealed that when she did Resident #4's wound care she did not look at the date on the old dressing and did not notice that it had been dated 3/16/22 before she removed it. Nurse #2 stated that she was focused on the procedure and was thinking about what she needed to do while changing Resident #4's dressing. Nurse #2 stated that Resident #4's treatment to her left leg should have been done daily and she was not sure why it had not been changed since 3/16/22. Nurse #2 stated that she did notice that Resident #4's left leg wound looked drier than usual. A phone interview with Nurse #3 on 3/21/22 at 2:10 PM revealed she worked with Resident #4 on 3/17/22 and 3/18/22 on the day shift from 7:00 AM to 7:00 PM. Nurse #3 stated she knew she was supposed to do Resident #4's treatment to her left lower leg but she didn't do it because the wound doctor was scheduled to come to the facility on either 3/17/22 or 3/18/22 but she couldn't remember which day he was supposed to come. Nurse #3 also stated that she worked with Resident #4 on 3/19/22 from 7:00 AM to 11:30 AM but she didn't do Resident #4's wound care because she thought she was only supposed to pass medications during the four hours that she worked on 3/19/22. A phone interview with Nurse #5 on 3/21/22 at 12:35 PM revealed she came in at 1:00 PM on 3/19/22 and worked with Resident #4 until the night shift. Nurse #5 stated the Director of Nursing (DON) had the keys to her cart when she reported for work because Nurse #3 had already left at 11:30 AM. Nurse #5 stated she didn't do Resident #4's treatment to her left leg because she thought Nurse #3 had already done it on her shift and just forgot to mark it off on her TAR. Nurse #5 also stated she didn't think to check Resident #4's left leg dressing before she marked it off as completed on Resident #4's TAR on 3/19/22 because she usually worked on the night shift and treatments were usually scheduled to be done on the day shift. A phone interview with Nurse #4 on 3/21/22 at 12:41 PM revealed she worked with Resident #4 on 3/20/22 from 7:00 AM to 3:00 PM but she never got around to doing Resident #4's treatment to her left leg. Nurse #4 stated when she got ready to do it, Resident #4 had requested for her to come back later in the shift. But when she had gathered the supplies she needed to do Resident #4's wound care, Resident #4 had already gotten up in her wheelchair and it was difficult for her to do it while she was in her wheelchair. Nurse #4 stated she reported this to the oncoming shift, but she could not remember the name of the nurse. A phone interview with the wound doctor on 3/21/22 at 3:53 PM revealed he usually came to the facility on Thursday, but he did not do rounds on 3/17/22 so the last time he saw Resident #4 was on 3/10/22. The wound doctor stated he had requested for the nursing staff to do daily dressing changes to Resident #4 who had a venous ulcer to her left leg which had been a difficult wound to heal. The wound doctor stated he prescribed an antifungal cream to be applied to the wound to decrease inflammation and decrease the fungal load. He stated the medicated cream loses its effectiveness when Resident #4's dressing was not changed for several days and would not be as effective in eliminating the problem. He also stated that a new batch of antifungal cream and a new dressing should be applied daily to Resident #4's venous ulcer to her left leg. An interview with the Director of Nursing (DON) on 3/21/22 at 4:00 PM revealed she remembered telling the nursing staff that the wound doctor was not coming to the facility on [DATE] so she was not sure why Nurse #3 did not know about it. The DON also came in to work on 3/19/22 to relieve Nurse #3 when she left at 11:30 AM but she did not tell her that Resident #4's treatment to her leg had not been completed. The DON stated Nurse #3 told her that she had everything done and all the DON had to do was wait for Nurse #5 to come in at 1:00 PM. The DON stated there had been poor communication between the nurses which led to Resident #4 not receiving her wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on record reviews, observations and interviews with staff, and review of Centers for Disease Control and Prevention Center (CDC) guidelines for responding to COVID-19 in nursing homes and the facility's COVID-19 policy revealed the facility failed to implement CDC guidelines and facility COVID-19 policy when the facility failed to quarantine readmitted residents, require staff to wear all recommended Personal Protective Equipment (PPE) when caring for residents on enhanced droplet contact precautions, and post required transmission-based precaution signage for 2 of 5 readmitted residents reviewed for infection control (Resident #8 and Resident #9). These failures occurred during a COVID-19 pandemic. On 10/05/20 there were 14 residents in the facility who had tested positive for the [MEDICAL CONDITION]. Immediate Jeopardy began on 09/22/20 when the facility failed to quarantine a readmitted resident on enhanced droplet contact precautions and failed to follow their COVID-19 Policy/Plan for readmissions. Immediate jeopardy was removed on 10/11/20 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems in place are effective. The findings included: The CDC guideline entitled Responding to Coronavirus (COVID-19) In Nursing Homes last reviewed and updated on 04/30/20 indicated the following statements: * Place signage at the entrance to the COVID-19 unit that instructs healthcare personnel (HCP) they must wear eye protection and an N95 or higher-level respirator (or facemask if respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. * All recommended COVID-19 PPE should be worn during the care of residents under observation which includes use of an N95 or higher-level respirator (or facemask if respirator is not available), eye protection, (goggles or a disposable face shield that covers the front and sides of the face), gloves and gown. * A single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted resident should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. * New residents could be transferred out of the observation (quarantine) area or from a single to a multi-resident room if they remain afebrile and without symptoms for 14 days after their last exposure (e.g., date of admission). A review of the facility's COVID-19 Policy/Plan for Facilities updated 04/04/20 read in part: All resident will be isolated for a minimum of 14 days following admission or readmission in an area of the building designated for residents at high risk. Any resident placed in isolation for COVID-19 for a positive COVID result or as a person under investigation will be kept in Enhanced Droplet Isolation or Airborne precautions modified for available PPE until such time as the physician determines such isolation is no longer clinically appropriate. This isolation utilizes private room or cohort with approved roommate situation with surgical mask or N95 respirator if available, eye protection, gloves, and gown at all times when in the presence of the resident. The Infection Preventionist (IP) will establish and monitor any isolation required including proper PPE and required posting of the type of isolation to serve as notice to others. During the entrance conference on 10/05/20 at 8:45AM the Director of Nursing and Administrator indicated the 300 hall was the positive COVID-19 hall and the 100 hall was the quarantine hall for COVID-19 but also had negative residents on the hall. Residents on the 200 hall were residents that had tested negative at the facility. Prior to 09/26/20 all three halls were designated for skilled care, general population residents. 1. a. Resident #9 was readmitted to the facility from the hospital on [DATE] to a private room on the 300 hall but was moved 4 days later on 09/26/20 to a semi-private room on the 100 hall with a roommate. The roommate was not a new admission or readmission and did not require quarantine or transmission-based precautions. Resident #9 and the roommate were both tested for COVID-19 on 09/24/20 and 10/03/20 in the facility and their test results were negative. Observation on 10/05/20 at 9:00AM revealed Resident #9 was in a semi-private room on the 100 hall with no precautions posted. There was no signage on the door regarding enhanced droplet contact precautions and no PPE available outside the door to Resident #9's room. An interview on 10/05/20 at 10:00AM with Nurse #1 revealed this was her fourth day working at the facility. She stated she was responsible for all but two of the residents on the 100 hall including Resident #9. Nurse #1 indicated none of the residents under her care were on enhanced droplet contact precautions and none had been on these precautions for the last four days she had worked at the facility. Nurse #1 further indicated Resident #9 had not been on enhanced droplet contact precautions and stated there had been no PPE available outside her door. She stated she had not been offered a gown or protective eyewear when caring for any of the residents she had been assigned on the 100 hall including Resident #9. She stated she had not received education at the facility about COVID-19 but stated she had received education through her Agency. An interview on 10/05/20 at 2:30PM with NA #3 revealed this was her second day working at the facility and she was the nurse aide for both the 100 hall and the 200 hall. She stated she was not aware Resident #9 needed to be on isolation and stated she had not been on isolation the past two days she had worked. NA #3 indicated she had not worn any PPE except a mask and gloves when providing care to Resident #9. She stated she had not received education at the facility about COVID-19 but stated she had received education through her Agency. An interview on 10/05/20 at 4:01PM with the Director of Nursing (DON) revealed Resident #9 had originally been admitted to the facility from the hospital to a private room on the 300 hall on 09/22/20. She stated Resident #9 had been moved to a semi-private room on 09/26/20 (due to 300 hall being converted to COVID positive unit) and stated the resident was not placed on precautions when she was transferred to the 100 hall and had not been on Enhanced droplet contact precautions when she was on the 300 hall. The DON further stated she was not sure why Resident #9 had not been quarantined on enhanced droplet contact precautions for 14 days but stated the resident should have been since she was readmitted from the hospital. She indicated Resident #9 should have had available PPE for the staff outside her door and stated she would make sure the appropriate PPE was placed in a bin outside her door. A subsequent phone interview with the Director of Nursing (DON) on 10/06/20 at 12:21PM revealed the facility did testing of the residents and staff on 09/24/20 and received the results on 09/26/20 that 12 residents had tested positive for COVID-19. The DON further stated on 09/26/20 they had to convert the 300 hall to a COVID positive hall and move the 12 residents that had tested positive to that hall and move the residents on the 300 hall which included Resident #9 out to the other hallways. She indicated she had contacted the Health Department on 09/26/20 but there was no staff available to assist with the information regarding the positive residents. The DON stated she had since spoken with a nurse at the Health Department on 09/29/20 and had received multiple resources and guidance about testing, surveillance, CDC guidance and said she had briefly scanned the information but was not as familiar with the regulations or guidance as she needed to be to direct the staff and ensure the residents were appropriately quarantined. An interview on 10/05/20 at 4:12PM with the Administrator revealed he had only been at the facility for about a week. He stated he was not fully familiar with the COVID-19 regulations but stated they were not taking admissions to the facility due to their outbreak status. The Administrator indicated he was aware that readmissions should be isolated, and staff should be wearing full PPE as if they were COVID positive. He stated he was not aware Resident #9 was not placed on quarantine for 14 days with enhanced droplet contact precautions following her readmission. The Administrator further stated he was not aware PPE had not been placed outside her door and stated he would remedy that immediately. The Administrator explained they had just implemented a clinical meeting during their morning meeting last Friday (10/02/20) and stated today was supposed to be the first day of their full meeting to include clinical information. He stated he was aware of where to locate information regarding regulations of COVID-19 and had a corporate liaison to reach out to with questions. The Administrator further stated he had not spoken with anyone at the local county Health Department. b. Resident #8 was readmitted to the facility from the hospital on [DATE] to a private room on the 100 hall. A review of her medical record revealed she was tested for COVID-19 at the facility on 10/03/20 and her test result was negative. Observation of Resident #8 on 10/05/20 at 9:00AM revealed her room was covered in a zippered plastic barrier held up with black support poles that extended out into the hallway approximately 4 to 5 feet. There was a sign on the plastic barrier outside her room that read Contact Precautions. The sign indicated staff entering the room to provide patient care should perform hand hygiene, wear gloves when entering the room, wear isolation gown when entering the room and use patient-dedicated or single use disposable equipment or clean and disinfect equipment between patients. There was no available PPE on her door or in a bin outside of Resident #8 ' s room. An observation on 10/05/20 at 9:10AM of Nurse Aide (NA) #3 going in to assist Resident #8 revealed her wearing a mask, gown and gloves in the room but no protective eye wear or face shield. An interview on 10/05/20 at 2:30PM with NA #3 revealed this was her second day working at the facility and she was the nurse aide for both the 100 hall and the 200 hall. She stated she was not aware Resident #8 needed to be on enhanced droplet contact precautions and stated she had not been on isolation the past two days she had worked. NA #3 indicated she had not worn any PPE except a mask, gown and gloves when providing care to Resident #8. She further indicated she had not been offered protective eye wear or a face shield to wear while caring for Resident #8. NA #3 stated she had not received education at the facility about COVID-19 but stated she had received education through her Agency. An interview on 10/05/20 at 3:52PM with Nurse #4 revealed it was her second day working at the facility. She stated she had been told in report that Resident #8 was on contact precautions due to shingles. Nurse #4 indicated she and the nurse aide had worn a mask, gown and gloves into the room when providing care but stated neither of them had worn protective eye wear or a face shield and further indicated they were not aware they needed full PPE when going into Resident #8's room. Nurse #4 stated there had not been PPE available outside the door either of the days she had worked and stated she had to get gowns for she and NA #3 from the supply room when providing care to the resident. Nurse #4 further stated she did not know why available PPE had not been outside the resident's door. According to Nurse #4, she had not received education at the facility regarding COVID-19 but had received education through her Agency. An interview on 10/05/20 at 4:01PM with the Director of Nursing (DON) revealed Resident #8 was readmitted to the facility from the hospital to a private room on the 100 hall. She further stated Resident #8 had been placed under Contact Precautions for shingles. The DON stated Resident #8 had not been quarantined on enhanced droplet contact precautions but should have been since she was readmitted from the hospital. She further stated she must have misinterpreted the regulations but was not aware they needed to quarantine residents at the back of a hall or have a hall to quarantine residents readmitted from the hospital. A subsequent phone interview with the Director of Nursing (DON) on 10/06/20 at 12:21PM revealed the facility did testing of the residents and staff on 09/24/20 and received the results on 09/26/20 that 12 residents had tested positive for COVID-19. The DON further stated on 09/26/20 they had to convert the 300 hall to a COVID positive hall and move the 12 residents that had tested positive to that hall and move the residents on the 300 hall out to the other hallways. She indicated she had contacted the Health Department on 09/26/20 but there was no staff available to assist with the information regarding the positive residents. The DON stated she had since spoken with a nurse at the Health Department on 09/29/20 and had received multiple resources and guidance about testing, surveillance, CDC guidance and said she had briefly scanned the information but was not as familiar with the regulations or guidance as she needed to be to direct the staff and ensure the residents were appropriately quarantined. An interview on 10/05/20 at 4:12PM with the Administrator revealed he had only been at the facility for about a week. He stated he was not fully familiar with the COVID-19 regulations but stated they were not taking admissions to the facility due to their outbreak status. The Administrator indicated he was aware that readmissions should be isolated, and staff should be wearing full PPE as if they were COVID positive. He stated he was not aware Resident #8 was not placed on quarantine for 14 days with enhanced droplet contact precautions following her readmission. The Administrator further stated he was not aware PPE had not been placed outside her door and stated he would remedy that immediately. The Administrator explained they had just implemented a clinical meeting during their morning meeting last Friday (10/02/20) and stated today was supposed to be the first day of their full meeting to include clinical information. He stated he was aware of where to locate information regarding regulations of COVID-19 and had a corporate liaison to reach out to with questions. The Administrator further stated he had not spoken with anyone at the local county Health Department. 3. The 300 hall was identified by the Director of Nursing (DON) and Administrator as the designated COVID-19 hall for positive residents and was converted on 09/26/20. There were 14 positive COVID-19 residents on the 300 hall. a. On 10/05/20 at 9:20AM the Director of Nursing was observed talking with the 300 hall nurses in the nursing station on the COVID-19 positive hall and wearing a black cloth face mask. An observation and interview were conducted in the conference room on 10/05/20 at 10:22AM with the Director of Nursing (DON). She was observed to be wearing a black cloth mask on her face and stated she was currently serving as the Infection Preventionist. A second interview and observation were conducted with the Director of Nursing (DON) on 10/05/20 at 5:26PM in the conference room. The DON was observed wearing a black cloth mask. She revealed she had not donned her N95 mask because she had been assisting staff and had not taken the time to switch from her cloth mask she had been wearing since arrival to the facility this morning. The DON stated she was aware it was not appropriate and was not following the guidelines to wear a cloth mask in the facility and she would immediately go don her N95 mask. b. An interview with NA #4 on 10/05/20 at 5:37PM revealed she had worked at the facility for 2 weeks on the 100 hall and the 200 hall. She was dressed in scrubs and a cloth face mask during the interview. NA #4 stated she had been provided a cloth face mask when she had started working at the facility. She further stated she had a surgical mask over the cloth mask but had discarded the surgical mask. According to NA #4 she had not been told she could not wear the cloth mask when caring for the residents on the 100 and 200 halls but stated she had used the surgical mask over the cloth mask at times. A third interview was conducted with the DON on 10/05/20 at 6:00PM in the conference room. The DON was observed to be wearing an N95 mask and stated all staff caring for residents in the facility should be wearing an N95 mask and should not be wearing a cloth mask while taking care of the residents in the facility. The DON stated she would make sure NA #4 had an N95 mask to wear during her shift. The Administrator was notified of the immediate jeopardy on 10/07/20 at 6:49PM. On 10/10/20 at 7:12PM, the facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. All residents have the potential to suffer as a result of failure to implement Transmission Based Precautions for COVID 19 by not placing enhanced droplet contact precautions signs up and not ensuring staff are wearing all recommended Personal Protective Equipment to include gown and eye protection as well as gloves and N95 mask for Residents #8 and #9 when providing care. Residents were at increased risk due to not cohorting and quarantining residents whose COVID 19 status is unknown as well as dedicated staff not consistently assigned to the designed unit for admission of residents whose COVID 19 status is unknown. Residents #8 and #9 had enhanced droplet contract precaution signs placed on the door of their rooms and isolation carts placed outside of the rooms with correct PPE in the carts. The facility's COVID 19 policies were not updated to current Centers for Disease Control guidance and Centers for Medicare and Medicaid requirements. Date Completed: 10/7/2020 Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. 1. Facility halls have been redesigned into 4 different units: an isolation unit for active symptomatic COVID 19 positive residents (100 unit back of hall); a quarantine unit for newly admitted /returning residents for 14-day quarantine (100 unit front of hall). These are separated by a double wall barrier, and a second double wall barrier at the entrance of this unit into the main common space; a recovery unit (300 unit) and a person under investigation unit or general population unit (PUI) (200 unit). This design allows us to ensure that residents are placed in the appropriate area based on test results, symptoms and admission status. Date of Completion 10/9/2020 2. Enhanced droplet contact precautions signs have been placed on all resident rooms in the isolation unit, quarantine unit, and recovery unit at this time. Date of Completion 10/9/2020 3. All Staff assigned in the facility have been given full PERSONAL PROTECTIVE EQUIPMENT (gowns, gloves, mask, eye protection, face shields) and instructed on use of the PERSONAL PROTECTIVE EQUIPMENT for all residents in the facility at this time. The education was provided by the Administrator and Director of Nursing on 10/8/2020 and 10/9/2020. Completion of this education will be done by the Regional Director of Clinical Services on 10/11/2020 for those staff who were not able to be educated prior. This education included all nursing, dietary, housekeeping, and therapy staff. Date of Completion: 10/11/2020 4. Any staff member not present when the training was provided will be trained by the Director of Nursing, the Regional Director of Clinical Services, and the Administrator before being allowed to return to work as well as any new hires. All new hires will be educated by the DON or designee on the use of enhanced precautions and proper PPE before taking shifts on the units. This training will include all nursing, dietary, housekeeping and therapy staff. Completion Date: 10/11/2020. 5. As of 10/8/2020 staff will be designated and dedicated to the isolation unit. The isolation unit will now house COVID 19 Positive residents (3 remaining) on one end with a double wall barrier that leads to the quarantine area on the other end of the unit and then another double wall barrier leading out to the common open space. The PUI unit will now be for residents under investigation of possible exposure and the Recovery unit will be for residents who are coming off 14-day COVID 19 positive symptom. The policy of the facility going forward will be that the Director of Nursing and Environmental Services Supervisor will assign dedicated staff to the isolation unit when at all possible based upon current crisis staffing contingencies as relates to industry staffing shortages. Every effort will be made to have assigned and dedicated staff for the isolation unit. Date of Completion: 10/9/2020 6. The facility's COVID 19 admissions policies and procedures will be updated by Regional Director of Clinical Services to include the current Centers for Disease Control (CDC) guidance and Centers for Medicare and Medicaid (CMS) requirements for 14 day quarantine with enhanced droplet contact precautions of all newly admitted residents. The new policy states that for all residents admitted to the facility, they will be placed on the quarantine unit for a period of 14 days, enhanced droplet contact precautions will be followed by all staff assigned to the quarantine unit and designated staff will be assigned to the unit. Date of Completion: 10/11/2020 7. Beginning on 10/8/2020 all facility staff in all departments have been in-serviced on location of isolation rooms, enhanced droplet precaution contact signage and its meaning and proper PERSONAL PROTECTIVE EQUIPMENT usage when providing care for residents in rooms with enhanced droplet precautions and contact isolation by the Director of Nursing and the Administrator. Date of Completion:10/11/2020 8. The Admissions Coordinator have been instructed and educated by the Facility Administrator on the facility policy that ALL admissions from an outside facility must be admitted to the quarantine unit for 14-day isolation period. Date of Completion: 10/11/2020 9. CDC recommended Personal Protective Equipment (gloves, gowns, N95 Mask, eye protection and face shields) has been placed on the outside of the rooms on enhanced droplet contact precaution units (COVID 19 positive, quarantine and recovery units). Date of Completion: 10/9/2020 10. All residents and staff have been tested weekly as required under the current requirements of the Center for Medicare and Medicaid Services and guidelines of Center for Disease Control (CDC) for current surveillance testing requirements. The next scheduled round of testing starts on 10/7/2020 and 10/8/2020. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents will be tested , and all staff and residents that test negative will be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. Date of Completion: 10/8/2020 11. Beginning 10/8/2020 the Director of Nursing will make daily rounds Monday-Friday and the Assigned Charge Nurse on Saturday and Sunday to ensure that Enhanced Droplet Contact Precautions Signs are posted on the doors of residents that are under a 14 day isolation period and that staff are following enhanced droplet contact precautions. The night nurse will round on the isolation, quarantine, and recovery unit to ensure that precautions are being maintained by all staff and that proper PPE is always worn. The charge nurses and night shift nurses were educated regarding this monitoring 10/9/2020. 12. The Director of Nursing and Environmental Services Supervisor will review schedules and assignment sheets daily Monday thru Friday and Friday for Saturday and Sunday to ensure that staff dedicated to the enhanced droplet contact precaution unit are assigned to that unit only for their entire shift. Staff assigned to the enhanced droplet contact precaution unit will stay on that unit for the entirety of that shift. Date of Completion: 10/9/2020 13. The Medical Supply Clerk will inventory the Personal Protective Equipment in the facility daily Monday - Friday and the weekend nurse will replace any Personal Protective Equipment that is in low supply on the Personal Protective Equipment Supply carts. Education was provided to the Medical Supply Clerk and the weekend nurses on 10/9/2020. 14. The Admissions Coordinator must report to the Administrator and the Director of Nursing all individuals being considered for admission, the room assignment for the individual and the medical history of [REDACTED]. The Administrator and the Director of Nursing will ensure that all admissions are admitted to the quarantine unit for 14-day quarantine period. The Admissions Coordinator has been in-serviced on the procedure on 10/9/2020 by the facility Administrator. The Administrator and Director of Nursing will document on an Admission Acceptance Form, to be implemented by 10/11/2020 that the individual has been reviewed and will be admitted to the quarantine unit for the required 14-day quarantine period. Additionally, once admitted the Director of Nursing or designee will maintain a log of all admissions/readmissions to track and ensure that the new admit completes a 14-day quarantine period on the quarantine unit. 15. Regional Director of Clinical Services will update policies and procedures related to COVID 19 requirements to be current with CDC and CMS guidelines. Policies will include enhanced droplet contact precaution requirements with use of enhanced droplet PPE for use with residents on precautions with isolation and 14-day quarantine. THE TITLE OF THE PERSON RESPONSIBLE FOR IMPLEMENTING THE ACCEPTABLE PLAN OF CORRECTION: Administrator Regional Director of Clinical Services The Facility alleges the removal of the immediate jeopardy on 10/11/2020 On 10/13/20 the facility's plan for immediate jeopardy was validated by the following. Review of in-service training records revealed staff from all shifts and all disciplines had been in-serviced on 10/03/20, 10/06/20, 10/08/20 10/09/20 and 10/13/20 regarding designated area for residents admitted and readmitted and COVID-19 positive residents on the 300 hall and the back of the 100 hall with quarantined residents on the top of the 100 hall, all behind plastic zippered barriers clearly marked with signage indicating enhanced droplet contact precautions, appropriate PPE in plastic bins outside the doors, and signage for donning and doffing of full PPE. There were dedicated staff identified on both the 300 hall and the 100 hall. The 200 hall was now the COVID negative hall and residents on this hall were tested weekly as well as the other residents in the facility. Staff were being tested weekly as well. Residents admitted or readmitted were being quarantined on the top of the 100 hall for 14 days. The COVID negative residents were relocated to the 200 hall which was now the clean hall. The facility's COVID-19 Policy/Plan was reviewed, and revisions were noted. The facility's date of immediate jeopardy removal of 10/11/20 was validated.

Based on observations, record review, staff and resident interviews, the facility failed to treat one resident with dignity by leaving the resident lying in a large amount of urine and stool from 12:41 AM to 8:30 AM on 12/16/18 for 1 of 5 residents dependent on staff for incontinence care (Resident #13). Findings included: Resident #13 was readmitted to the facility on [DATE] with an original admission on 10/08/09 with the following Diagnoses: [REDACTED]. A review of Resident #13's Annual Minimum Data Set (MDS), dated [DATE], indicated he was cognitively intact and was totally dependent on staff for toileting. The MDS further indicated Resident #13 was always incontinent of bowel and bladder. The MDS revealed that he displayed verbal behaviors toward others but had no rejection of care. A review of the Activities of Daily Living (ADL) Rehabilitation Care Area Assessment (CAA) and Urinary Incontinence CAA associated with the 02/28/18 MDS noted Resident #13 needed assistance with toileting as the resident was incontinent of bowel and bladder and staff provided incontinent care routinely and as needed. The Behavior Symptom CAA revealed that he had verbal aggression directed toward staff. A review of Resident #13's care plan, dated 03/14/18, indicated the resident had an ADL self-care performance deficit and required extensive assistance from staff for toileting needs. The care plan further indicated that incontinence care was provided routinely and as needed for Resident #13 and that Resident #13 was encouraged to use bell to call for assistance. A review of the care plan for Resident #13 revealed that he had the potential to be verbally aggressive toward caregivers. The care plan, regarding the resident being verbally aggressive toward caregivers, further revealed staff were to assess and anticipate resident's toileting needs and comfortable level and the resident needed monitoring, reminding, assistance to turn or reposition at least every 2 hours and more often as needed or requested. An interview was conducted with Resident #13 on 12/18/18 at 10:30 AM. The resident provided the recordings of call bell unresponsiveness and lack of response on 12/16/18 that verified the resident's statements. He stated that on 12/16/18 at 12:41 AM, he was laying in urine and feces and he turned on his call light and pressed record on his personal computer voice recorder and someone came in to his room and turned the call light off without checking on him. He further stated that at 4:41 AM, he turned his call light on again and pressed record on his personal computer voice recorder and his call light was turned off by staff and no one responded to his needs. He indicated that at 5:51 AM, he turned on his call light and pressed record on his voice recorder and it took 30 minutes before NA #2 came to his room. With his recording pushed to the play button, the surveyor heard the statements made by the NA #2 and the response by the resident on 12/16/18 at 5:51 am. Upon entering his room, he further indicated that NA #2 asked Resident #13, You keep ringing the call bell? What do you need, huh? Resident #13 stated he responded, That should be obvious. I haven't been cleaned up all night. Resident #13 stated NA #2 did not change his brief, then left Resident #13's room and turned off his light. At 7:30 AM, Resident #13 indicated that he pressed his call light because he was soaked with urine and feces and had been laying there all night without being cleaned up and pressed record on his personal computer voice recorder. He further indicated that Nurse #1 came into his room and he told her that he had not been cleaned up and she stated that she was in the middle of sending someone to the hospital and can't make the NA's come in to help. Then, Nurse #1 left the resident's room and did not return to his room. At 8:30 AM, Resident #13 revealed that he rang his call light again and NA # 3 came into his room and cleaned him, and she washed his bed 3 times and the under pad was turned upside down and soaked up the urine and the pad looked like tobacco. Resident #13 tearfully reported he felt hurt because staff didn't clean him up. An interview was conducted with the Social Worker on 12/18/18 at 1:13 PM. She revealed there were no grievances filed for the month of (MONTH) (YEAR). An interview was conducted with NA #3 on 12/18/18 at 3:01 PM. She indicated that she went into Resident #13's room on 12/16/18 at 8:30 AM and had to change his whole bed because he was wet with urine from just below his shoulders to his knee cap. NA #3 stated she found Resident #13 soaked with urine and feces before but this was the worst she saw his bed that soaked. NA #3 stated that Resident #13 never refused incontinence care. NA #3 recalled the bed spread was wet all the way through and everything from the chux (disposable) pad to the washable pad was brown. In cleaning up the bed, NA #3 stated she took a chux (disposable) pad and placed the cotton side of the chux pad on mattress and the chux pad was soaked with urine. NA #3 stated that at the end of first shift, she notified Nurse #2 of the condition she found Resident #13 and what he reported regarding his need for assistance not being addressed from 12:41 AM to 8:30 AM. NA #3 further stated that Nurse #2 told Resident #13 that the social worker was the one who addressed the grievances and that Resident #13 mentioned something about writing a grievance regarding 3rd shift because he said it was not right how he was being treated. A phone interview was conducted with NA #4 on 12/19/18 at 8:00 pm. NA #4 stated she worked third shift and frequently worked with Resident #13. NA #4 stated Resident #13 typically received incontinence care at 1:30 am and 5:30 am, at a minimum and that was close to shift change. She indicated that Resident #13 had never saturated his bed due to his incontinence but that he got a little sweaty because he had computer equipment in his room that made the room hot. A phone interview was conducted with NA #2 on 12/19/18 at 8:21 PM. She stated that the nursing assistants who came in at 11:00 PM typically went to Resident #13's room at 1:30 AM and change him. She further stated that if Resident #13 was given a suppository, the NA's went to change the resident more often. She indicated that Resident #13 did not get a suppository during 2nd shift on 12/15/18. She further indicated that it was her perception that Resident #13 rang his call bell at 1:30 am and 5:30 am and both times went into his room, woke him up and changed him. She stated that Resident #13 had been telling 1st shift that he hadn't been changed, so the NAs woke him and changed him. She further stated that she reported any concerns to the oncoming shift. She did not mention that she reported any concerns to first shift regarding Resident #13 on 12/16/18. A phone interview was conducted with the DON on 12/20/18 at 6:50 AM. She indicated that she expected all residents would be treated with respect and dignity and care to be provided when requested. A phone interview was conducted with Nurse #2 on 12/20/18 at 9:13 AM. She indicated that she worked 7:00 am to 7:00 pm on 12/16/18 and that toward the end of her shift, Resident #13 told her he wanted to file a grievance because no one changed him for an extended time the early morning of 12/16/18. She stated that towards the end of first shift NA #3 confirmed Resident #13 was very wet. She further stated that she reported the information to the night shift Nurse #7. She indicated that she did not notify the social worker or file a grievance because the social worker checked on Resident #13 daily. An interview was conducted with the Social Worker on 12/20/18 at 9:39 AM. She indicated that she did not talk to Resident #13 during the week of (MONTH) 17th, (YEAR) and wasn't aware of any concerns involving Resident #13. She further indicated that in the past, Resident #13 complained about being soaked in urine when the previous Director of Nursing (DON) was working at the facility which was before (MONTH) (YEAR). She revealed that she didn't remember Resident #13 filing any recent grievances. An interview was conducted with the Administrator on 12/20/18 from 11:14 AM to 12:25 PM. She stated she expected all residents to be treated with dignity and respect and told this to every staff member when she started working at the facility on 11/26/18. She further stated she expected concerns to be reported so follow-up could be done. She indicated staff were supposed to care for residents and it was a problem of dignity if care was not given. She indicated again she should have been told about the incident, so she could fix the problem.

Based on observations, record review, staff and resident interviews, wound physician interview, and hospice nurse interview, the facility staff neglected to acknowledge a resident's call bell and failed to provide incontinence care for 8 an hour time frame from 12:41 AM to 8:30 AM for 1 of 5 residents dependent on staff for incontinence care (Resident #13); failed to provide treatments as scheduled and ensure wound care was done consistent with physician orders [REDACTED].#1); and failed to complete pressure ulcer treatment as ordered and scheduled for 3 days (Resident #7) for 1 of 3 residents reviewed for pressure ulcers Findings include: 1. Resident #13 was readmitted to the facility on [DATE] with an original admission on 10/08/09 with the following Diagnoses: [REDACTED]. A review of Resident #13's Annual Minimum Data Set (MDS), dated [DATE], indicated he was cognitively intact and was totally dependent on staff for toileting. The MDS further indicated Resident #13 was always incontinent of bowel and bladder. The MDS revealed that he displayed verbal behaviors toward others but had no rejection of care. A review of the Activities of Daily Living (ADL) Rehabilitation Care Area Assessment (CAA) and Urinary Incontinence CAA associated with the 02/28/18 MDS noted Resident #13 needed assistance with toileting as the resident was incontinent of bowel and bladder and staff provided incontinent care routinely and as needed. The Behavior Symptom CAA revealed that he had verbal aggression directed toward staff. A review of Resident #13's care plan, dated 03/14/18, indicated the resident had an ADL self-care performance deficit and required extensive assistance from staff for toileting needs. The care plan further indicated that incontinence care was provided routinely and as needed for Resident #13 and that Resident #13 was encouraged to use bell to call for assistance. A review of the care plan for Resident #13 revealed that he had the potential to be verbally aggressive toward caregivers. The care plan, regarding the resident being verbally aggressive toward caregivers, further revealed staff were to assess and anticipate resident's toileting needs and comfortable level and the resident needed monitoring, reminding, assistance to turn or reposition at least every 2 hours and more often as needed or requested. An interview was conducted with Resident #13 on 12/18/18 at 10:30 AM. The resident provided the recordings of call bell unresponsiveness and lack of response on 12/16/18 that verified the resident's statements. He stated that on 12/16/18 at 12:41 AM, he was laying in urine and feces and he turned on his call light and pressed record on his personal computer voice recorder and someone came in to his room and turned the call light off without checking on him. He further stated that at 4:41 AM, he turned his call light on again and pressed record on his personal computer voice recorder and his call light was turned off by staff and no one responded to his needs. He indicated that at 5:51 AM, he turned on his call light and pressed record on his voice recorder and it took 30 minutes before NA #2 came to his room. With his recording pushed to the play button, the surveyor heard the statements made by the NA #2 and the response by the resident on 12/16/18 at 5:51 am. Upon entering his room, he further indicated that NA #2 asked Resident #13, You keep ringing the call bell? What do you need, huh? Resident #13 stated he responded, That should be obvious. I haven't been cleaned up all night. Resident #13 stated NA #2 did not change his brief, then left Resident #13's room and turned off his light. At 7:30 AM, Resident #13 indicated that he pressed his call light because he was soaked with urine and feces and had been laying there all night without being cleaned up and pressed record on his personal computer voice recorder. He further indicated that Nurse #1 came into his room and he told her that he had not been cleaned up and she stated that she was in the middle of sending someone to the hospital and can't make the NA's come in to help. Then, Nurse #1 left the resident's room and did not return to his room. At 8:30 AM, Resident #13 revealed that he rang his call light again and NA # 3 came into his room and cleaned him, and she washed his bed 3 times and the under pad was turned upside down and soaked up the urine and the pad looked like tobacco. Resident #13 tearfully reported he felt hurt because staff didn't clean him up. An interview was conducted with the Social Worker on 12/18/18 at 1:13 PM. She revealed there were no grievances filed for the month of (MONTH) (YEAR). An interview was conducted with NA #3 on 12/18/18 at 3:01 PM. She indicated that she went into Resident #13's room on 12/16/18 at 8:30 AM and had to change his whole bed because he was wet with urine from just below his shoulders to his knee cap. NA #3 stated she found Resident #13 soaked with urine and feces before but this was the worst she saw his bed that soaked. NA #3 stated that Resident #13 never refused incontinence care. NA #3 recalled the bed spread was wet all the way through and everything from the chux (disposable) pad to the washable pad was brown. In cleaning up the bed, NA #3 stated she took a chux (disposable) pad and placed the cotton side of the chux pad on mattress and the chux pad was soaked with urine. NA #3 stated that at the end of first shift, she notified Nurse #2 of the condition she found Resident #13 and what he reported regarding his need for assistance not being addressed from 12:41 AM to 8:30 AM. NA #3 further stated that Nurse #2 told Resident #13 that the social worker was the one who addressed the grievances and that Resident #13 mentioned something about writing a grievance regarding 3rd shift because he said it was not right how he was being treated. A phone interview was conducted with NA #4 on 12/19/18 at 8:00 pm. NA #4 stated she worked third shift and frequently worked with Resident #13. NA #4 stated Resident #13 typically received incontinence care at 1:30 am and 5:30 am, at a minimum and that was close to shift change. She indicated that Resident #13 had never saturated his bed due to his incontinence but that he got a little sweaty because he had computer equipment in his room that made the room hot. A phone interview was conducted with NA #2 on 12/19/18 at 8:21 PM. She stated that the nursing assistants who came in at 11:00 PM typically went to Resident #13's room at 1:30 AM and changed him. She further stated that if Resident #13 was given a suppository, the NA's went to change the resident more often. She indicated that Resident #13 did not get a suppository during 2nd shift on 12/15/18. She further indicated that it was her perception that Resident #13 rang his call bell at 1:30 am and 5:30 am and both times went into his room, woke him up and changed him. She stated that Resident #13 had been telling 1st shift that he hadn't been changed, so the NAs woke him and changed him. She further stated that she reported any concerns to the oncoming shift. She did not mention that she reported any concerns to first shift regarding Resident #13 on 12/16/18. A phone interview was conducted with the DON on 12/20/18 at 6:50 AM. She indicated that she expected all residents would be treated with respect and dignity and care to be provided when requested. A phone interview was conducted with Nurse #2 on 12/20/18 at 9:13 AM. She indicated that she worked 7:00 am to 7:00 pm on 12/16/18 and that toward the end of her shift, Resident #13 told her he wanted to file a grievance because no one changed him for an extended time the early morning of 12/16/18. She stated that towards the end of first shift NA #3 confirm Resident #13 was very wet. She further stated that she reported the information to the night shift Nurse #7. She indicated that she did not notify the social worker or file a grievance because the social worker checked on Resident #13 daily. An interview was conducted with the Social Worker on 12/20/18 at 9:39 AM. She indicated that she did not talk to Resident #13 during the week of (MONTH) 17th, (YEAR) and wasn't aware of any concerns involving Resident #13. She further indicated that in the past, Resident #13 complained about being soaked in urine when the previous Director of Nursing (DON) was working at the facility which was before (MONTH) (YEAR). She revealed that she didn't remember Resident #13 filing any recent grievances. An interview was conducted with the Administrator on 12/20/18 from 11:14 AM to 12:25 PM. She stated Resident #13 only wanted to be changed 2 times at night and the administrator thought care was being provided but when he fell asleep she thought maybe he didn't know he was being changed after care was given. The administrator felt staff were going in the room and changing him and her expectations were for residents to be checked every 2 hours to ensure they were dry and to provide care if needed. The administrator stated she was coming in the building all shifts to check on care and expected care to be provided to all residents on all shifts and that she was in the building Saturday night during 3rd shift and arrived around midnight and left at 1:30 AM. Resident #13 could be difficult to please, but she expected staff to follow his care plan and do rounds to check on him and all residents throughout their shift. The administrator revealed she was not aware of the incident or that a grievance had been filed. Her expectation was that all residents were to be treated with dignity and respect and this was told to every staff member when she started working at the facility on 11/26/18. The administrator also expected concerns to be reported so follow-up could be done, and staff were supposed to care for residents and it was a problem of dignity if care was not given. The administrator indicated again she should have been told about the incident, so she could fix the problem. 2. Resident #1 was readmitted to the facility on [DATE] with an original admission on 01/10/17 with the following Diagnoses: [REDACTED]. A review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated she had severe cognitive impairment, she had behavioral symptoms of scratching herself, she was always incontinent of bowel and bladder and needed extensive assistance with 2 plus person physical assistance for transfers, bed mobility, toileting, and extensive assistance with 1-person physical assistance for personal hygiene. The MDS also indicated that she was at risk for pressure ulcer development but that she had no pressure ulcer. A review of the Pressure Ulcer Care Area Assessment (CAA) associated with the 01/08/18 MDS revealed Resident #1 was at risk for breakdown due to her incontinence and needed assistance with positioning. Resident #1 was also admitted with multiple areas of breakdown primarily to her legs and buttocks and had a history of [REDACTED]. A review of the Facility Skin Condition Record for Non-Pressure Ulcer Skin Conditions for Right Hip Wound Infection, dated 11/24/18, indicated the following wound measurements in centimeters (cm): 8.5 cm in length x 1.4 cm in width x 1.2 cm in depth and 8.1 cm undermining at 12 o'clock. A review of the Facility Skin Condition Record for Non-Pressure Ulcer Skin Conditions for Right Hip Wound Infection, dated 12/05/18, indicated the following wound measurements in centimeters (cm): 4.2 cm in length x 1.2 cm in width x 0.8 cm in depth and 8.0 cm undermining at 12 o'clock. A review of Resident #1's Physician Orders, dated 12/05/18, revealed the following: 1. Cleanse Right hip with wound cleanser, pat dry, pack with Dakins' soaked Kling gauze, and cover with dry dressing every day and as needed. 2. Cleanse Right hip periwound with wound cleanser, pat dry, apply [MEDICATION NAME] and cover with dry dressing every day and as needed. A review of the care plan for the nonstageable area to right hip or potential for pressure ulcer development, dated 12/6/18, indicated Resident #1's pressure ulcer would show signs of healing and would remain free from infection. The care plan further indicated the following interventions were in place for staff to administer treatments as ordered and were monitored for effectiveness, dressing was monitored to ensure it was intact and adhering and staff to report loose dressings to the treatment nurse, and the resident needed moisturizer applied to her skin. A review of the Facility Skin Condition Record for Non-Pressure Ulcer Skin Conditions for Right Hip Wound Infection, dated 12/12/18, indicated the following wound measurements in centimeters (cm): 5.1 cm in length x 1.1 cm in width x 2.0 cm in depth and 4.8 cm undermining at 3 o'clock (progress: improved). A review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the resident's right hip dressing change and periwound dressing change was not initialed as done on the following dates: 12/07/18; 12/08/18; 12/10/18; & 12/17/18. A review of (MONTH) (YEAR) TAR revealed the following treatments for Resident #1 were not initialed as done the following dates: 1. Apply zinc oxide to groin redness/area every day. (not initialed on 12/07/18; 12/08/18; 12/10/18; & 12/17/18) 2. [MEDICATION NAME] Cream 5%- apply to all body parts with abrasion every night on 3pm-11 pm until all areas are healed and then as needed. (not initialed on 12/07/18; 12/8/18; 12/11/18; 12/14/18; 12/15/18; 12/16/18; and 12/17/18) 3. [MEDICATION NAME] Cream- apply to Bilateral Lower Extremities twice daily for 7am-7 pm and 7pm to 7am (not initialed on 12/10/18 for 7am to 7 pm) 4. [MEDICATION NAME] Unscented Cream- apply to affected areas topically every day on upper extremities (not initialed on 12/07/18; 12/08/18; 12/10/18; & 12/17/18) 5. [MEDICATION NAME] Shampoo 2%- apply to scalp once a week for itch on 11 p-7p (not initialed on12/07/18 and 12/14/18) 6. Vitamin A+D ointment for [MEDICATION NAME] Clear with Vit A&D - apply topically to buttocks and thighs every day. (not initialed on 12/07/18; 12/08/18; 12/10/18; & 12/17/18) An observation of Resident #1 being assisted to bed via Hoyer Lift was conducted on 12/17/18 at 2:30 pm with Nurse #6 and NA #5 present. At the time of the transfer, Nurse #6 was performing a skin assessment on the resident. During continuing observation of Nurse #6 and NA #5 repositioning the resident, the nurse did not change the dressing, as the dressing was undated. An interview with Nurse #6 was conducted on 12/17/18 from 2:45 PM to 3:00 PM. Nurse #6 stated that the facility had a treatment nurse on Tuesdays, Wednesdays, and Thursdays during the week and a treatment nurse on Saturdays and Sundays every other weekend but there was no treatment nurse on Mondays and Fridays. Nurse #6 indicated that the wound on Resident #1's right hip started out as a bump about 2 weeks ago and the facility had a wound doctor. Nurse #6 further indicated the resident had undermining (destruction of tissue extending under the skin edges so that the pressure ulcer was larger at its base than at the skin surface) of the wound and it was a decubitus pressure ulcer. She indicated that the right hip wound treatment was for the wound to be packed and covered with a blue dry dressing. An interview was conducted with the Treatment Nurse on 12/18/18 at 8:52 AM. She stated that she knew nothing about Resident #1's right hip wound until Saturday; 11/24/18, which was the date she saw the wound for the first time. She further stated that the right hip wound had already popped open and was draining and developed undermining. She indicated that she documented information in the facility doctor's book about Resident #1's right hip wound. She further indicated that she initiated treatment to the right hip on 11/24/18. She stated that when she was not at work, the treatments on residents were not consistently getting done because she would find the same dressings that she placed on residents from when she last worked. She indicated that on 12/05/18, she completed the treatments on all the residents and, when she went back to work on Tuesday; 12/11/18 she checked Resident #1's dressing and the blue foam was saturated with drainage, had no date on it, and the wound was not packed as ordered. She said the wound packing was ordered because Resident #1 had undermining of the wound. An observation and interview were conducted with the Treatment Nurse on 12/18/18 from 1:15 PM to 1:35 PM. She was performing a dressing change on Resident #1's right hip. She stated that when the wound doctor first came to assess the resident's right hip wound after it opened up, he stated that the wound looked like a bad infection and he removed the dead tissue off of the top of the wound which revealed the undermining. She further stated that the undermining had decreased from 8 centimeters (cm) to 4 cm. During continued observation, the undated blue sponge was still noted on Resident #1's right hip and the periwound (skin surrounding the wound) was not covered with a dressing and had 4 small areas of thick yellow adherent tissue surrounding the dressing. Further observation indicated there was no odor noted from the old dressing or the wound itself. The Treatment Nurse stated that the dry dressing she removed from the wound should not have been there because the dressing did not follow the physician's orders [REDACTED]. She further stated that Resident #1 never refused care, but she did scratch her right hip and around the wound which caused the dressing to hang loosely off the wound. The Treatment Nurse stated that because the dressing may come off, she told the Na's to notify the hall nurses and they could change the dressing because the treatment order was as needed also. She also stated that all nurses were responsible for doing a weekly skin assessment. An interview was conducted with Nurse #6 on 12/18/18 at 2:04 PM. She stated that she did not change the dressing on 12/17/18 for Resident #1. She further stated that when the treatment nurse was not at the facility, the hall nurses were responsible for changing the dressing. She indicated that she notified oncoming 3rd shift, Nurse #8, on 12/17/18 that a treatment had not been done for Resident #1. A phone interview was conducted with Nurse #8 on 12/19/18 at 9:53 AM. She indicated that she did not do the treatments on Resident #1 on 12/17/18 because she was working by herself with only one NA. A phone interview was conducted with Nurse #4 on 12/19/18 at 10:07 AM. She indicated that on 12/08/18, she only performed a dressing change on another resident, not Resident #1. A phone interview was conducted with Nurse #7 on 12/19/18 at 10:27 AM. She stated that she worked with Resident #1 on 12/17/18, from 11:00 PM to 7:00 AM, and did not perform any treatments on Resident #1. An interview was conducted with the Wound Doctor on 12/19/18 at 11:14 AM. He indicated that when the regular treatment nurse was not working every day, there was an issue with treatments being completed as ordered. He stated he was not sure if Resident #1 scratching her skin caused the infection of her right hip. He further stated that Resident #1 needed wound packing wet to moist dressings once a day and that the periwound deteriorated (per the Wound Care notes, dated 12/12/18, due to [MEDICAL CONDITION]). He indicated that the [MEDICATION NAME] was ordered for the periwound abrasion and the key to successful wound healing was to protect the wound and that the dressing was supposed to be covering the wound. A phone interview was conducted with Nurse #2 on 12/19/18 at 11:55 AM. She stated she worked with Resident #1 on 12/08/18 and that no treatments were done. A telephone interview was conducted with the DON on 12/19/18 1:53 PM. She indicated her expectation was that treatment orders should be followed, and treatments completed as scheduled. An interview was conducted with the Administrator on 12/20/18 from 11:14 AM to 12:25 PM. The administrator indicated that she expected treatments to be done consistent with the physician orders. She further indicated she was not aware treatments were not being done as scheduled but expected all orders to be followed for type of treatment and schedule set for treatments. 3. Resident #7 admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].#7 read in part, skin prep (forms a film protecting skin) to bilateral top of foot and protect with foam dressing twice weekly and as needed. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 was moderately impaired for daily decision making and displayed no rejection of care during the 7-day assessment period. Further review of the MDS indicated Resident #7 required extensive assistance with activities of daily living and had 2 unhealed pressure ulcers. Review of a care plan, with a revised date of 10/25/18, revealed Resident #7 had the potential for pressure ulcer development related to needing assistance with mobility, incontinence and decreased oral intake with the goal she would be free from any signs or symptoms of infections related to altered skin integrity. The interventions included for staff to administer treatments as ordered and monitor for effectiveness. Review of a physician's orders [REDACTED].#7 read in part, cleanse right outer ankle with wound cleanser, pat dry, apply Polymen Dressing (type of dressing that contains a mild cleaning agent activated by moisture and gradually released into the wound area) 3 times a week. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed treatment for [REDACTED]. There were no initials on the TAR indicating the treatment to Resident #7's right outer ankle was completed on the scheduled days of 12/03/18, 12/07/18, 12/10/18 or 12/17/18. Further review of the TAR revealed no initials indicating the treatment for [REDACTED]. During an interview on 12/18/18 at 8:35 AM, the Wound Nurse (WN) explained she was responsible for completing wound treatments for residents on the days she worked, which were Tuesdays, Wednesdays and Thursdays each week, and the hall nurses were responsible for completing wound treatments the remaining days. The WN recalled changing the dressing on Resident #7's right outer ankle on 12/05/18 with the next dressing changes scheduled on 12/07/18 and 12/10/18. She stated when she returned to work on 12/11/18, the dressing in place was dated 12/05/18 with her initials, smelled and was hanging off the wound. The WN confirmed she did not work on 12/03/18, 12/07/18 or 12/10/18 and stated it was an ongoing issue that wound treatments were not being completed by the hall nurses on the days she was not scheduled to work. She added she completed treatments on the day she returned if she noticed they were not done by the hall nurses on the day scheduled. An observation was made of Resident #7's wound care on 12/18/18 at 10:40 AM. The WN washed her hands and as she was removing the old dressing from the top of Resident #7's left foot she stated the dressing that was in place was Polymen which was the wrong treatment. The dressing was dated 12/17/18 and initialed by Nurse #5. The skin on top of Resident #7's left foot was intact with no redness or inflammation noticed. The WN indicated the treatment ordered was preventative and the dressing would be replaced to protect the area. The WN washed her hands and as she removed the bunny boot (foot/heal protector) from Resident #7's right foot, there was no dressing covering the right outer ankle and the wound was exposed to air. The wound was red with a small amount of yellow slough (dead tissue) and the skin surrounding the wound bed was a dark reddish color. The WN cleaned the ankle with wound cleanser, patted the area dry and applied Polymen dressing as ordered. During a telephone interview on 12/18/18 at 1:23 PM, Nurse #1 confirmed she worked as a hall nurse on 12/07/18 and did not complete wound treatment to Resident #7's right outer ankle. She explained she was never shown how to complete wound treatments and only reapplied a resident's dressing when it fell off. Nurse #1 added she was never informed she needed to complete treatments on the days the WN was not scheduled. During an interview on 12/18/18 at 3:00 PM, Nurse #4 confirmed she was the nurse assigned to provide care to Resident #7 on 12/03/18. Nurse #4 stated she did not complete the wound treatment to Resident #7's right outer ankle or any other resident assigned because she was never trained to provide wound care. Nurse #4 explained the facility had a WN who completed the treatments for all residents and was never informed she needed to complete the treatments when the WN was not scheduled. During a telephone interview on 12/18/18 at 3:31 PM, Nurse #5 confirmed she provided wound treatment to Resident #7 on 12/17/18 and stated she must have forgotten to initial the TAR when completed. Nurse #5 added the Hospice Nurse (HN) was present during the wound treatment. Nurse #5 explained she put a 4 inch (in) by 4 in bandage on the top of Resident #7's left foot and applied [MEDICATION NAME] (transparent dressing used to cover and protect wound) and Polymen dressing to her right outer ankle. Nurse #5 added she reviewed the TAR prior to providing treatment and was unable to explain why there was no dressing on Resident #7's right outer ankle or why the wrong dressing was applied to the top of her left foot. During a telephone interview on 12/18/18 at 4:08 PM, the HN confirmed she was present when Nurse #5 provided wound treatment to Resident #7 on 12/17/18. The HN explained she only observed the treatment provided for the pressure ulcer on Resident #7's right outer ankle and was not familiar with the treatment ordered for the top of her foot. She stated Nurse #5 followed the wound treatment orders and applied [MEDICATION NAME] and a non-adhesive Polymen dressing to Resident #7's right outer ankle since Hospice was out of the adhesive Polymen dressing they normally used. She added it was possible the dressing had fallen off after treatment was provided. During an interview on 12/19/18 at 11:14 AM, the Wound Physician (WP) indicated he had only been providing wound care at the facility for the past 3 weeks and was not able to confirm if there was an issue with wound treatments not being completed as ordered or scheduled. He added if a resident was on Hospice he tried to limit the dressing changes to avoid causing them discomfort. The WP stated when he treated Resident #7's wound earlier that morning, it showed improvement with no signs of infection and no changes were made to the current treatment as ordered by Hospice. He was unaware a dressing was not observed on Resident #7's wound on 12/18/18 and stated a dressing should have been applied and the wound not left exposed. During a telephone interview on 12/19/18 at 2:03 PM the Director of Nursing (DON) explained nursing staff were informed upon hire that providing wound treatment was a part of their job description. The DON stated she would expect the hall nurses to complete wound treatments as ordered and scheduled when the WN was absent. During a telephone interview on 12/20/18 at 9:41 AM, Nurse #2 confirmed she was the nurse assigned to provide care to Resident #7 on 12/10/18. Nurse #2 stated she did not complete the wound treatment to Resident #7's right outer ankle because she received Hospice services and the HN provided wound care. During an interview on 12/20/18 at 11:14 AM, the Administrator was unaware wound treatments were not being completed by the hall nurses when the WN was not scheduled to work. She stated she was aware of all the training needs in the building and felt the nurses needed more training in wound care. She added it was her expectation wound treatments were completed as scheduled and consistent with the physician orders.

Based on observations, record review, resident interviews, staff interviews, and physician interviews, the facility failed to develop a care plan which accurately described the wounds for 2 of 4 residents reviewed for wounds (Residents #1 and #11); failed to implement the care plan for treating wounds for 2 of 4 residents reviewed for wounds (Residents #1 and #7); and failed to implement the care plan for activities of daily living (ADLs) for 2 of 5 residents reviewed for ADLs (Residents #1 and #13). The findings included: 1. Resident #13 was readmitted to the facility on [DATE] with an original admission on 10/08/09 with the following Diagnoses: [REDACTED]. A review of Resident #13's Annual Minimum Data Set (MDS), dated [DATE], indicated he was cognitively intact and was totally dependent on staff for toileting. The MDS further indicated Resident #13 was always incontinent of bowel and bladder. A review of the Activities of Daily Living (ADL) Rehabilitation Care Area Assessment (CAA) and Urinary Incontinence CAA associated with the 02/28/18 MDS noted Resident #13 needed assistance with toileting as the resident was incontinent of bowel and bladder and staff provided incontinent care routinely and as needed. A review of Resident #13's care plan, dated 03/14/18, indicated the resident had an ADL self-care performance deficit and required extensive assistance from staff for toileting needs. The care plan further indicated that incontinence care was provided routinely and as needed for Resident #13 and that Resident #13 was encouraged to use bell to call for assistance. An interview was conducted with Resident #13 on 12/18/18 at 10:30 AM. The resident provided the recordings of call bell unresponsiveness and lack of response on 12/16/18 that verified the resident's statements. He stated that on 12/16/18 at 12:41 AM, he was laying in urine and feces and he turned on his call light and pressed record on his personal computer voice recorder and someone came in to his room and turned the call light off without checking on him. He further stated that at 4:41 AM, he turned his call light on again and pressed record on his personal computer voice recorder and his call light was turned off by staff and no one responded to his needs. He indicated that at 5:51 AM, he turned on his call light and pressed record on his voice recorder and it took 30 minutes before NA #2 came to his room.With his recording pushed to the play button, the surveyor heard the statements made by the NA #2 and the response by the resident on 12/16/18 at 5:51 am. Upon entering his room, he further indicated that NA #2 asked Resident #13, You keep ringing the call bell? What do you need, huh? Resident #13 stated he responded, That should be obvious. I haven't been cleaned up all night. Resident #13 stated NA #2 did not change his brief, then left Resident #13's room and turned off his light. At 7:30 AM, Resident #13 indicated that he pressed his call light because he was soaked with urine and feces and had been laying there all night without being cleaned up and pressed record on his personal computer voice recorder. He further indicated that Nurse #1 came into his room and he told her that he had not been cleaned up and she stated that she was in the middle of sending someone to the hospital and can't make the NA's come in to help. Then, Nurse #1 left the resident's room and did not return to his room. At 8:30 AM, Resident #13 revealed that he rang his call light again and NA # 3 came into his room and cleaned him, and she washed his bed 3 times and the under pad was turned upside down and soaked up the urine and the pad looked like tobacco. Resident #13 tearfully reported he felt hurt because staff didn't clean him up. An interview was conducted with NA #3 on 12/18/18 at 3:01 PM. She indicated that she went into Resident #13's room on 12/16/18 at 8:30 AM and had to change his whole bed because he was wet with urine from just below his shoulders to his knee cap. NA #3 stated she found Resident #13 soaked with urine and feces before but this was the worst she saw his bed that soaked. NA #3 stated that Resident #13 never refused incontinence care. NA #3 recalled the bed spread was wet all the way through and everything from the chux (disposable) pad to the washable pad was brown. In cleaning up the bed, NA #3 stated she took a chux (disposable) pad and placed the cotton side of the chux pad on mattress and the chux pad was soaked with urine. NA #3 stated that at the end of first shift, she notified Nurse #2 of the condition she found Resident #13 and what he reported regarding his need for assistance not being addressed from 12:41 AM to 8:30 AM. NA #3 further stated that Nurse #2 told Resident #13 that the social worker was the one who addressed the grievances and that Resident #13 mentioned something about writing a grievance regarding 3rd shift because he said it was not right how he was being treated. A phone interview was conducted with the Director of Nursing (DON) on 12/19/18 at 1:53 PM. She stated that she expected all care plans for ADL's be followed. An interview was conducted with the Administrator on 12/20/18 from 11:14 AM to 12:25 PM. She stated she expected care plans to be accurate and expected interventions to be followed in terms of care whether it was care for treatments or ADLs. 2. Resident #1 was readmitted to the facility on [DATE] with an original admission on 01/10/17 with the following Diagnoses: [REDACTED]. 2a. A review of Resident #1's Physician Orders, dated 12/05/18, revealed the following: 1. Cleanse Right hip with wound cleanser, pat dry, pack with Dakins' soaked Kling gauze, and cover with dry dressing every day and as needed. 2. Cleanse Right hip periwound with wound cleanser, pat dry, apply [MEDICATION NAME] and cover with dry dressing every day and as needed. A review of the care plan for the nonstageable area to right hip or potential for pressure ulcer development, dated 12/6/18, indicated Resident #1's pressure ulcer would show signs of healing and would remain free from infection. The care plan further indicated the following interventions were in place for staff to administer treatments as ordered and were monitored for effectiveness, dressing was monitored to ensure it was intact and adhering and staff to report loose dressings to the treatment nurse, and the resident needed moisturizer applied to her skin. A review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated she had severe cognitive impairment, she had behavioral symptoms of scratching herself, she was always incontinent of bowel and bladder and needed extensive assistance with 2 plus person physical assistance for transfers, bed mobility, toileting, and extensive assistance with 1-person physical assistance for personal hygiene. The MDS also indicated that she was at risk for pressure ulcer development but that she had no pressure ulcer. A review of the Pressure Ulcer Care Area Assessment (CAA) associated with the 01/08/18 MDS revealed Resident #1 was at risk for breakdown due to her incontinence and needed assistance with positioning. Resident #1 was also admitted with multiple areas of breakdown primarily to her legs and buttocks with a history of chronic pruritis (itching). The CAA also revealed she was prone to self-inflict scratches. A review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the resident's Right hip dressing change and periwound dressing change was not initialed as done on the following dates:12/07/18; 12/08/18; 12/10/18; & 12/17/18. A review of (MONTH) (YEAR) TAR revealed the following treatments for Resident #1 were not initialed as done the following dates: 1. Apply zinc oxide to groin redness/area every day. (not initialed on 12/07/18; 12/08/18; 12/10/18; & 12/17/18) 2. [MEDICATION NAME] Cream 5%- apply to all body parts with abrasion every night on 3pm-11 pm until all areas are healed and then as needed. (not initialed on 12/07/18; 12/8/18; 12/11/18; 12/14/18; 12/15/18; 12/16/18; and 12/17/18) 3. [MEDICATION NAME] Cream- apply to Bilateral Lower Extremities twice daily for 7am-7 pm and 7pm to 7am (not initialed on 12/10/18 for 7am to 7 pm) 4. [MEDICATION NAME] Unscented Cream- apply to affected areas topically every day on upper extremities (not initialed on 12/07/18; 12/08/18; 12/10/18; & 12/17/18) 5. [MEDICATION NAME] Shampoo 2%- apply to scalp once a week for itch on 11 p-7p (not initialed on 12/07/18 and 12/14/18) 6. Vitamin A+D ointment for [MEDICATION NAME] Clear with Vit A&D - apply topically to buttocks and thighs every day. (not initialed on 12/07/18; 12/08/18; 12/10/18; & 12/17/18) An observation of Resident #1 being assisted to bed via Hoyer Lift was conducted on 12/17/18 at 2:30 pm with Nurse #6 and NA #5 present. At the time of the transfer, Nurse #6 was performing a skin assessment on the resident. During continuing observation of Nurse #6 and NA #5 repositioning the resident, the nurse did not change the dressing, as the dressing was undated. An interview with Nurse #6 was conducted on 12/17/18 from 2:45 PM to 3:00 PM. Nurse #6 stated that the facility had a treatment nurse on Tuesdays, Wednesdays, and Thursdays during the week and a treatment nurse on Saturdays and Sundays every other weekend but there was no treatment nurse on Mondays and Fridays. Nurse #6 indicated that the wound on Resident #1's right hip started out as a bump about 2 weeks ago and the facility had a wound doctor. Nurse #6 further indicated the resident had undermining (destruction of tissue extending under the skin edges so that the pressure ulcer was larger at its base than at the skin surface) of the wound and it was a decubitus pressure ulcer. She indicated that the right hip wound treatment was for the wound to be packed and covered with a blue dry dressing. An interview was conducted with the Treatment Nurse on 12/18/18 at 8:52 AM. She stated that she knew nothing about Resident #1's right hip wound until Saturday; 11/24/18, which was the date she saw the wound for the first time. She further stated that the right hip wound had already popped open and was draining and developed undermining. She indicated that she documented information in the facility doctor's book about Resident #1's right hip wound. She further indicated that she initiated treatment to the right hip on 11/24/18. She stated that when she was not at work, the treatments on residents were not consistently getting done because she would find the same dressings that she placed on residents from when she last worked. She indicated that on 12/05/18, she completed the treatments on all the residents and, when she went back to work on Tuesday; 12/11/18 she checked Resident #1's dressing and the blue foam was saturated with drainage, had no date on it, and the wound was not packed as ordered. She said the wound packing was ordered because Resident #1 had undermining of the wound. An observation and interview were conducted with the Treatment Nurse on 12/18/18 from 1:15 PM to 1:35 PM. She was performing a dressing change on Resident #1's right hip. She stated that when the wound doctor first came to assess the resident's right hip wound after it opened up, he stated that the wound looked like a bad infection and he removed the dead tissue off of the top of the wound which revealed the undermining. She further stated that the undermining had decreased from 8 centimeters (cm) to 4 cm. During continued observation, the undated blue sponge was still noted on Resident #1's right hip and the periwound (skin surrounding the wound) was not covered with a dressing and had 4 small areas of thick yellow adherent tissue surrounding the dressing. Further observation indicated there was no odor noted from the old dressing or the wound itself. The Treatment Nurse stated that the dry dressing she removed from the wound should not have been there because it the dressing did not follow the physician's orders [REDACTED]. She further stated that Resident #1 never refused care, but she did scratch her right hip and around the wound which caused the dressing to hang loosely off the wound. The Treatment Nurse stated that because the dressing may come off, she told the Na's to notify the hall nurses and they could change the dressing because the treatment order was as needed also. She also stated that all nurses were responsible for doing a weekly skin assessment. An interview was conducted with Nurse #6 on 12/18/18 at 2:04 PM. She stated that she did not change the dressing on 12/17/18 for Resident #1. She further stated that when the treatment nurse was not at the facility, the hall nurses were responsible for changing the dressing. She indicated that she notified oncoming 3rd shift, Nurse #8, on 12/17/18 that a treatment had not been done for Resident #1. A phone interview was conducted with Nurse #8 on 12/19/18 at 9:53 AM. She indicated that she did not do the treatments on Resident #1 on 12/17/18 because she was working by herself with only one NA. A phone interview was conducted with Nurse #4 on 12/19/18 at 10:07 AM. She indicated that on 12/08/18, she only performed a dressing change on another resident, not Resident #1. A phone interview was conducted with Nurse #7 on 12/19/18 at 10:27 AM. She stated that she worked with Resident #1 on 12/17/18, from 11:00 PM to 7:00 AM, and did not perform any treatments on Resident #1. An interview was conducted with the Wound Doctor on 12/19/18 at 11:14 AM. He indicated that when the regular treatment nurse was not working every day, there was an issue with treatments being completed as ordered. He stated he was not sure if Resident #1 scratching her skin caused the infection of her right hip. He further stated that Resident #1 needed wound packing wet to moist dressings once a day and that the periwound deteriorated (per the Wound Care notes, dated 12/12/18, due to [MEDICAL CONDITION]). He indicated that the [MEDICATION NAME] was ordered for the periwound abrasion and the key to successful wound healing was to protect the wound and that the dressing was supposed to be covering the wound. A phone interview was conducted with Nurse #2 on 12/19/18 at 11:55 AM. She stated that no treatments were done on Resident #1 on 12/08/18. She further stated that on 12/10/18, she only changed another resident's dressing, not Resident #1. A telephone interview was conducted with the DON on 12/19/18 1:53 PM. She stated that Resident #1's treatment orders should be followed, and treatments completed as scheduled. An interview was conducted with the Administrator on 12/20/18 from 11:14 AM to 12:25 PM. The administrator stated that treatment orders should be followed and completed as scheduled. 2b. A review of Care Kardex (the system in place at the facility for nursing assistants to know resident specific needs) for Resident #1 revealed she was supposed to get nail care daily and as needed. Review of the (MONTH) (YEAR) bed baths and nail care sheet for Resident #1 indicated no nail care was documented. A review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated she had severe cognitive impairment, she had behavioral symptoms of scratching herself, she was always incontinent of bowel and bladder and needed extensive assistance with 2 plus person physical assistance for transfers, bed mobility, toileting, and extensive assistance with 1-person physical assistance for personal hygiene. The MDS also indicated that she was at risk for pressure ulcer development but that she had no pressure ulcer. A review of the Pressure Ulcer Care Area Assessment (CAA) associated with the 01/08/18 MDS revealed Resident #1 was also admitted with multiple areas of breakdown primarily to her legs and buttocks with a history of chronic pruritis (itching). The CAA also revealed she was prone to self-inflict scratches. A review of ADL Functional/Potential CAA associated with the 01/08/18 MDS revealed Resident #1 had a [DIAGNOSES REDACTED]. A review of the care plan, dated 01/08/18, for the Potential for Pressure Ulcer Development indicated Resident #1's self-inflicted scratches and wound would show signs of healing and remain free from infection. The care plan also revealed the following interventions were in place for potential for pressure ulcer development: staff to make sure fingernails were clean, trimmed, and had no jagged edges and staff to administer treatments as ordered and treatments were monitored for effectiveness. An observation of Resident #1 being assisted to bed via Hoyer Lift was conducted on 12/17/18 at 2:30 pm with Nurse #6 and NA #5 present. Resident #1's nails on both hands were observed to be dirty with a brownish red colored substance under her fingernails and the nails were ¼ inch in length and the fingernail on the second digit of the right hand had a jagged edge. An interview with Nurse #6 was conducted on 12/17/18 from 2:45 PM to 3:00 PM. Nurse #6 stated that the resident definitely needed good nail care and NA's were supposed to cut her nails when they gave her a shower and also stated that Resident #1 did not refuse care. An interview with NA #5 was conducted on 12/17/18 at 3:00 PM. NA #5 indicated that Resident #1 was supposed to have her nails cut during her shower and that Resident #1 did not refuse care. An observation conducted of Resident #1 was conducted on 12/18/18 from 1:15 PM to 1:35 PM. The observation of the resident during the dressing changed revealed Resident #1's nails on both hands were still dirty with a brownish red colored substance under her fingernails and the nails were ¼ inch in length and the fingernail on the second digit of the right hand had a jagged edge. An interview was conducted with NA #4 on 12/19/18 at 8:55 AM. She stated that she worked 3rd shift and did not do nail care on Resident #1 because that was done on day shift. An observation of Resident #1 was conducted on 12/19/18 at 12:40 PM. During the observation, Resident #1's nails on both hands were still dirty with a brownish red colored substance under her fingernails and the nails were ¼ inch in length and the fingernail on the second digit of the right hand had a jagged edge and the resident put her right hand in her mouth. An interview was conducted with NA #5 on 12/19/18 at 12:45 PM. She stated that nail care should be done after Resident#1's shower. After looking at Resident #1's fingernail, NA #5 stated that the resident's nails needed to be cut. NA #5 then left the resident's room without performing nail care. An observation of Resident #1 in the Activity Room was conducted on 12/20/18 at 10:35 AM. Resident #1's nails on both hands were still dirty with a brownish red colored substance under her fingernails and the nails were ¼ inch in length and the fingernail on the second digit of the right hand had a jagged edge. A telephone interview was conducted with the DON on 12/19/18 1:53 PM. She stated that her expectation was that every time residents got a shower their nails should be checked and checked daily to determine if they needed to be cleaned or trimmed and the care plan should have been followed. An interview was conducted with the Administrator on 12/20/18 from 11:14 AM to 12:25 PM. The administrator stated that nail care should have been done consistent with the plan of care. 2c. A review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated she had severe cognitive impairment, she had behavioral symptoms of scratching herself, she was always incontinent of bowel and bladder and needed extensive assistance with 2 plus person physical assistance for transfers, bed mobility, toileting, and extensive assistance with 1-person physical assistance for personal hygiene. The MDS also indicated that she was at risk for pressure ulcer development but that she had no pressure ulcer. A review of the Pressure Ulcer Care Area Assessment (CAA) associated with the 01/08/18 MDS revealed Resident #1 was also admitted with multiple areas of breakdown primarily to her legs and buttocks with a history of chronic pruritis (itching). The CAA also revealed she was prone to self-inflict scratches. A review of the care plan for the nonstageable area to right hip or potential for pressure ulcer development, dated 12/6/18, indicated Resident #1's pressure ulcer would show signs of healing and would remain free from infection. An interview was conducted with the MDS nurse on 12/19/18 at 12:26 PM. She indicated that she had to clarify with the treatment nurse on 12/19/18 because she didn't know why she documented the right hip unstageable pressure ulcer on the 12/06/18 care plan other than on 11/28/18, it was marked Unstaged on the facility Wound Tracking Report and had an X through the wound stages portion of the report. A telephone interview was conducted with the DON on 12/19/18 1:53 PM. She stated that Resident #1's wound was not unstageable and was incorrectly staged on the Care Plan and her expectation was the wound should have been staged correctly. A follow-up interview was conducted with the MDS nurse on 12/19/18 at 3:52 pm. She revealed that the Unstageable Pressure Ulcer should not have been listed on Resident #1's 12/06/18 care plan because the wound was an infection, not a pressure ulcer. An interview was conducted with the Administrator on 12/20/18 from 11:14 AM to 12:25 PM. The administrator stated the care plan should be an accurate reflection of Resident #1's wound. 3. Resident #7 admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed Resident #7 was moderately impaired for daily decision making and displayed no rejection of care during the 7-day assessment period. Further review of the MDS indicated Resident #7 required extensive assistance with activities of daily living and had 2 unhealed pressure ulcers. Review of a care plan, with a revised date of 10/25/18, revealed Resident #7 had the potential for pressure ulcer development related to needing assistance with mobility, incontinence and decreased oral intake with the goal she would be free from any signs or symptoms of infections related to altered skin integrity. The interventions included for staff to administer treatments as ordered and monitor for effectiveness. Review of a physician's orders [REDACTED].#7 read in part, cleanse right outer ankle with wound cleanser, pat dry, apply Polymen Dressing (type of dressing that contains a mild cleaning agent activated by moisture and gradually released into the wound area) 3 times a week. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed treatment for [REDACTED]. There were no initials on the TAR indicating the treatment to Resident #7's right outer ankle was completed on the scheduled days of 12/03/18, 12/07/18 or 12/10/18. During an interview on 12/18/18 at 8:35 AM, the Wound Nurse (WN) explained she was responsible for completing wound treatments for residents on the days she worked, which were Tuesdays, Wednesdays and Thursdays each week, and the hall nurses were responsible for completing wound treatments the remaining days. The WN recalled changing the dressing on Resident #7's right outer ankle on 12/05/18 with the next dressing changes scheduled on 12/07/18 and 12/10/18. She stated when she returned to work on 12/11/18, the dressing in place was dated 12/05/18 with her initials, smelled and was hanging off the wound. The WN confirmed she did not work on 12/03/18, 12/07/18 or 12/10/18 and added it was an ongoing issue that wound treatments were not being completed on the days she was not scheduled to work. She added she completed treatments on the day she returned to work if she noticed they were not done by the hall nurses on the day scheduled. During a telephone interview on 12/18/18 at 1:23 PM, Nurse #1 confirmed she worked as a hall nurse on 12/07/18 and did not complete wound treatment to Resident #7's right outer ankle. She explained she was never shown how to complete wound treatments and only reapplied a resident's dressing when it fell off. Nurse #1 added she was never informed she needed to complete treatments on the days the WN was not scheduled. During an interview on 12/18/18 at 3:00 PM, Nurse #4 confirmed she was the nurse assigned to provide care to Resident #7 on 12/03/18. Nurse #4 stated she did not complete the wound treatment to Resident #7's right outer ankle or any other resident assigned because she was never trained to provide wound care. Nurse #4 explained the facility had a WN who completed the treatments for all residents and was never informed she needed to complete the treatments when the WN was not scheduled. During a telephone interview on 12/19/18 at 2:03 PM the Director of Nursing (DON) explained nursing staff were informed upon hire that providing wound treatment was a part of their job description. The DON stated it was her expectation nursing staff would follow Resident #7's care plan and provide wound treatment as scheduled and ordered. During a telephone interview on 12/20/18 at 9:41 AM, Nurse #2 confirmed she was the nurse assigned to provide care to Resident #7 on 12/10/18. Nurse #2 stated she did not complete the wound treatment to Resident #7's right outer ankle because she received Hospice services and the Hospice Nurse provided wound care. During an interview on 12/20/18 at 11:14 AM, the Administrator was unaware wound treatments were not being completed by the hall nurses when the WN was not scheduled to work. She stated she was aware of all the training needs in the building and felt the nurses needed more training in wound care. She stated it was her expectation wound treatments were completed as scheduled and ordered and staff provided care consistent with a resident's care plan. 4. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the care plan with an initiation date of 11/21/18 revealed an identified problem that Resident #11 had potential for pressure ulcer development related to immobility and incontinence and had a stage II pressure ulcer on his coccyx and left hip and had a stage III pressure ulcer on his right heel. The goal was Resident #11 would be free from any further pressure ulcer development. Interventions to address problem were as follows: Staff were to administer treatments as ordered and monitor for effectiveness. Staff were to monitor/document/report as needed any changes in skin status (appearance, color, wound healing, signs and symptoms of infection, wound size, and stage). A review of a wound physician's note dated 11/29/18 indicated Resident #11 had an unstageable pressure ulcer to coccyx, right hip, right heel, and right medial ankle. A review of hospital wound discharge sheet dated 12/07/18 indicated Resident #11 had stage I pressure ulcer to left heel and deep tissue injury right heel, pressure ulcer to right medial ankle that was not staged, pressure ulcer to sacrum, left knee, and right head that was unstageable, and pressure ulcer to right hip that was not staged. A review of the Admission Nursing Assessment (ANA) dated 12/07/18 revealed Resident #11 had an unstageable pressure ulcer to buttock, sacrum, right head, and left knee and a stage I pressure ulcer to left heel, and deep tissue injury to right heel. A review of a wound physician's note dated 12/12/2018 indicated Resident #11 had an unstageable pressure ulcer to coccyx, right hip, right heel, left heel, and a stage IV pressure ulcer to right medial ankle. On 12/19/18 at 10:36 AM an interview was conducted with the Minimum Data Set (MDS) nurse who stated she was responsible for updating the care plan to indicate pressure ulcer location and stage for Resident #11. The MDS nurse stated she was aware Resident #11 had pressure ulcers but had not reviewed the wound physician notes for 11/29/18 that indicated location and stage of Resident #11's pressure ulcers. She stated she had not reviewed the admission nursing assessment dated [DATE] and hospital discharge information dated 12/07/18 for pressure ulcer location and stage and had not reviewed the wound physician note dated 12/12/18 for pressure ulcer location and stage. The MDS nurse stated she did not update Resident #11's care plan to indicate pressure ulcer location and stage because she had been pulled from performing her duties as MDS nurse to administer medications and admit residents to the facility. On 12/19/18 at 10:53 AM an interview was conducted with the Administrator who stated the MDS nurse was responsible for updating Resident #11's care plan to indicate stage of pressure ulcers and location. She stated her expectation was that the MDS nurse would have updated the care plan to indicate Resident #11 had pressure ulcer areas. On 12/19/2018 at 2:35 PM a telephone interview was conducted with the Director of Nursing who stated it was her expectation that the MDS nurse would have updated the care plan to indicate stage and location of pressure ulcers for Resident #11.

Based on observations, record review, resident, and staff interviews, the facility failed to provide toileting assistance for 2 of 5 dependent residents reviewed for Activities of Daily Living (ADL) care (Resident #13) and failed to provide nail care for 2 of 5 dependent residents reviewed for ADL care (Resident #1). The findings included: 1. Resident #13 was readmitted to the facility on [DATE] with an original admission on 10/08/09 with the following Diagnoses: [REDACTED]. A review of Resident #13's Annual Minimum Data Set (MDS), dated [DATE], indicated he was cognitively intact and was totally dependent on staff for toileting. The MDS further indicated Resident #13 was always incontinent of bowel and bladder. The MDS revealed had no rejection of care. A review of the Activities of Daily Living (ADL) Rehabilitation Care Area Assessment (CAA) and Urinary Incontinence CAA associated with the 02/28/18 MDS noted Resident #13 needed assistance with toileting as the resident was incontinent of bowel and bladder and staff provided incontinent care routinely and as needed. A review of Resident #13's care plan, dated 03/14/18, indicated the resident had an ADL self-care performance deficit and required extensive assistance from staff for toileting needs. The care plan further indicated that incontinence care was provided routinely and as needed for Resident #13 and that Resident #13 was encouraged to use bell to call for assistance. A review of the care plan for Resident #13 revealed that he had the potential to be verbally aggressive toward caregivers. The care plan, regarding the resident being verbally aggressive toward caregivers, further revealed staff were to assess and anticipate resident's toileting needs . An interview was conducted with Resident #13 on 12/18/18 at 10:30 AM. The resident provided the recordings of call bell unresponsiveness and lack of response on 12/16/18 that verified the resident's statements. He stated that on 12/16/18 at 12:41 AM, he was laying in urine and feces and he turned on his call light and pressed record on his personal computer voice recorder and someone came in to his room and turned the call light off without checking on him. He further stated that at 4:41 AM, he turned his call light on again and pressed record on his personal computer voice recorder and his call light was turned off by staff and no one responded to his needs. He indicated that at 5:51 AM, he turned on his call light and pressed record on his voice recorder and it took 30 minutes before NA #2 came to his room. With his recording pushed to the play button, the surveyor heard the statements made by the NA #2 and the response by the resident on 12/16/18 at 5:51 am. Upon entering his room, he further indicated that NA #2 asked Resident #13, You keep ringing the call bell? What do you need, huh? Resident #13 stated he responded, That should be obvious. I haven't been cleaned up all night. Resident #13 stated NA #2 did not change his brief, then left Resident #13's room and turned off his light. At 7:30 AM, Resident #13 indicated that he pressed his call light because he was soaked with urine and feces and had been laying there all night without being cleaned up and pressed record on his personal computer voice recorder. He further indicated that Nurse #1 came into his room and he told her that he had not been cleaned up and she stated that she was in the middle of sending someone to the hospital and can't make the NA's come in to help. Then, Nurse #1 left the resident's room and did not return to his room. At 8:30 AM, Resident #13 revealed that he rang his call light again and NA # 3 came into his room and cleaned him, and she washed his bed 3 times and the under pad was turned upside down and soaked up the urine and the pad looked like tobacco. Resident #13 tearfully reported he felt hurt because staff didn't clean him up. An interview was conducted with the Social Worker on 12/18/18 at 1:13 PM. She revealed there were no grievances filed for the month of (MONTH) (YEAR). An interview was conducted with NA #3 on 12/18/18 at 3:01 PM. She indicated that she went into Resident #13's room on 12/16/18 at 8:30 AM and had to change his whole bed because he was wet with urine from just below his shoulders to his knee cap. NA #3 stated she found Resident #13 soaked with urine and feces before but this was the worst she saw his bed that soaked. NA #3 stated that Resident #13 never refused incontinence care. NA #3 recalled the bed spread was wet all the way through and everything from the chux (disposable) pad to the washable pad was brown. In cleaning up the bed, NA #3 stated she took a chux (disposable) pad and placed the cotton side of the chux pad on mattress and the chux pad was soaked with urine. NA #3 stated that at the end of first shift, she notified Nurse #2 of the condition she found Resident #13 and what he reported regarding his need for assistance not being addressed from 12:41 AM to 8:30 AM. NA #3 further stated that Nurse #2 told Resident #13 that the social worker was the one who addressed the grievances and that Resident #13 mentioned something about writing a grievance regarding 3rd shift because he said it was not right how he was being treated. A phone interview was conducted with NA #4 on 12/19/18 at 8:00 pm. NA #4 stated she worked third shift and frequently worked with Resident #13. NA #4 stated Resident #13 typically received incontinence care at 1:30 am and 5:30 am, at a minimum and that was close to shift change. She indicated that Resident #13 had never saturated his bed due to his incontinence but that he got a little sweaty because he had computer equipment in his room that made the room hot. A phone interview was conducted with NA #2 on 12/19/18 at 8:21 PM. She stated that the nursing assistants who came in at 11:00 PM typically went to Resident #13's room at 1:30 AM and change him. She further stated that if Resident #13 was given a suppository, the NA's went to change the resident more often. She indicated that Resident #13 did not get a suppository during 2nd shift on 12/15/18. She further indicated that it was her perception that Resident #13 rang his call bell at 1:30 am and 5:30 am and both times went into his room, woke him up and changed him. She stated that Resident #13 had been telling 1st shift that he hadn't been changed, so the NAs woke him and changed him. She further stated that she reported any concerns to the oncoming shift. She did not mention that she reported any concerns to first shift regarding Resident #13 on 12/16/18. A phone interview was conducted with the DON on 12/20/18 at 6:50 AM. She indicated that she expected all residents would be treated with respect and dignity and care to be provided when requested. A phone interview was conducted with Nurse #2 on 12/20/18 at 9:13 AM. She indicated that she worked 7:00 am to 7:00 pm on 12/16/18 and that toward the end of her shift, Resident #13 told her he wanted to file a grievance because no one changed him for an extended time the early morning of 12/16/18. She stated that towards the end of first shift NA #3 confirm Resident #13 was very wet. She further stated that she reported the information to the night shift Nurse #7. She indicated that she did not notify the social worker or file a grievance because the social worker checked on Resident #13 daily. An interview was conducted with the Social Worker on 12/20/18 at 9:39 AM. She indicated that she did not talk to Resident #13 during the week of (MONTH) 17th, (YEAR) and wasn't aware of any concerns involving Resident #13. She further indicated that in the past, Resident #13 complained about being soaked in urine when the previous Director of Nursing (DON) was working at the facility which was before (MONTH) (YEAR). She revealed that she didn't remember Resident #13 filing any recent grievances. An interview was conducted with the Administrator on 12/20/18 from 11:14 AM to 12:25 PM. She stated she expected all residents to be treated with dignity and respect and told this to every staff member when she started working at the facility on 11/26/18. She further stated she expected concerns to be reported so follow-up could be done. She indicated staff were supposed to care for residents and it was a problem of dignity if care was not given. She indicated again she should have been told about the incident, so she could fix the problem. 2. Resident #1 was readmitted to the facility on [DATE] with an original admission on 01/10/17 with the following Diagnoses: [REDACTED]. A review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated she had severe cognitive impairment, she had behavioral symptoms of scratching herself, she was always incontinent of bowel and bladder and needed extensive assistance with 2 plus person physical assistance for transfers, bed mobility, toileting, and extensive assistance with 1-person physical assistance for personal hygiene. The MDS also indicated that she was at risk for pressure ulcer development but that she had no pressure ulcer. A review of the Pressure Ulcer Care Area Assessment (CAA) revealed Resident #1 was at risk for breakdown due to her incontinence and needed assistance with positioning. Resident #1 was also admitted with multiple areas of breakdown primarily to her legs and buttocks and had a history of [REDACTED]. The CAA also revealed she was prone to self-inflict scratches. A review of ADL Functional/Potential CAA revealed Resident #1 had a [DIAGNOSES REDACTED]. Resident #1 also needed physical assistance with bathing or showering. A review of the care plan for the Potential for Pressure Ulcer Development indicated Resident #1's self-inflicted scratches. The care plan also revealed the following interventions were in place for potential for pressure ulcer development: staff to make sure fingernails were clean, trimmed, and had no jagged edges and staff to administer treatments as ordered and treatments were monitored for effectiveness. A review of Care Kardex for Resident #1 revealed she was supposed to get nail care daily and as needed and the (MONTH) (YEAR) bed baths and nail care sheet indicated no nail care was documented. An observation of Resident #1 being assisted to bed via Hoyer Lift was conducted on 12/17/18 at 2:30 pm with a nurse and nursing assistant present. Nurse #6 was performing a skin assessment on the resident. Resident #1's nails on both hands were dirty with a brownish red colored substance under her fingernails and the nails were ¼ inch in length and the fingernail on the second digit of the right hand had a jagged edge. An interview with Nurse #6 was conducted on 12/17/18 from 2:45 PM to 3:00 PM. Nurse #6 stated that the resident definitely needed good nail care and NA's were supposed to cut her nails when they give her a shower and also stated that Resident #1 was getting nail care and that Resident #1 did not refuse care. NA #5 concurred with Nurse #6 regarding Resident #1's nail care. An observation and interview were conducted with the Treatment Nurse on 12/18/18 from 1:15 PM to 1:35 PM. She was performing a dressing change on Resident #1's right hip. Further observation of the resident during the dressing changed revealed Resident #1's nails on both hands were still dirty with a brownish red colored substance under her fingernails and the nails were ¼ inch in length and the fingernail on the second digit of the right hand had a jagged edge. The Treatment Nurse stated that because the dressing may come off, she told the Na's to notify the hall nurses and they could change the dressing because the treatment order is as needed also. She also stated that all nurses were responsible for doing a weekly skin assessment. An interview was conducted with NA #4 on 12/19/18 at 8:55 AM. She stated that she did not do nail care on Resident #1 because that was done on day shift. An observation of Resident #1 was conducted on 12/19/18 at 12:40 PM. During the observation, Resident #1's nails on both hands were still dirty with a brownish red colored substance under her fingernails and the nails were ¼ inch in length and the fingernail on the second digit of the right hand had a jagged edge and the resident put her right hand in her mouth. An interview was conducted with NA #5 on 12/19/18 at 12:45 PM. She stated that nail care should be done after Resident#1's shower. After looking at Resident #1's fingernail, NA #5 stated that the resident's nails needed to be cut. NA #5 then left the resident's room without performing nail care. A telephone interview was conducted with the DON on 12/19/18 1:53 PM. She stated that her expectation was that every time residents get a shower their nails should be checked and checked daily to determine if they needed to be cleaned or trimmed and the care plan should have been followed. An observation of Resident #1 in the Activity Room was conducted on 12/20/18 at 10:35 AM. Resident #1's nails on both hands were still dirty with a brownish red colored substance under her fingernails and the nails were ¼ inch in length and the fingernail on the second digit of the right hand had a jagged edge. An interview was conducted with the Administrator on 12/20/18 from 11:14 AM to 12:25 PM. The administrator stated she expected nails to be cleaned every day by NAs. She further stated NAs should be able to do this and should have time to do this during AM care. She indicated that she talked with the NAs about nail care in particular for residents that had contractures. She further indicated that nail care should have been done consistent with the plan of care. The administrator stated she expected care plans to be accurate and expected interventions to be followed in terms of care whether it was care for treatments or ADLs.

Based on observations, record reviews and resident, staff and physician interviews, the facility failed to provide sufficient nursing staff to ensure residents received pressure ulcer and wound treatments and assistance with incontinence and nail care. This affected 4 of 12 sampled residents (Residents #1, #7, #11, and #13). Staff neglected to provide Resident #13 with incontinence care for nearly an 8-hour time span which resulted in the resident lying in a large amount of urine and feces. Findings included: This tag is cross-referenced to: 1a. F-550: Based on observations, record review, staff and resident interviews, the facility failed to treat one resident with dignity by leaving the resident lying in a large amount of urine and stool from 12:41 AM to 8:30 AM on 12/16/18 for 1 of 5 residents dependent on staff for incontinence care (Resident #13). b. F-600: Based on observations, record review, staff and resident interviews, wound physician interview, and hospice nurse interview, the facility staff neglected to acknowledge a resident's call bell and failed to provide incontinence care for 8 an hour time frame from 12:41 AM to 8:30 AM for 1 of 5 residents dependent on staff for incontinence care (Resident #13); failed to provide treatments as scheduled and ensure wound care was done consistent with physician orders [REDACTED].#1); and failed to complete pressure ulcer treatment as ordered and scheduled for 3 days (Resident #7) for 1 of 3 residents reviewed for pressure ulcers. c. F-677: Based on observations, record review, resident, and staff interviews, the facility failed to provide toileting assistance for 2 of 5 dependent residents reviewed for Activities of Daily Living (ADL) care (Resident #13) and failed to provide nail care for 2 of 5 dependent residents reviewed for ADL care (Resident #1). d. F-684: Based on observations, record review, staff interviews and physician interviews, the facility failed to provide treatments as scheduled and ensure wound care was done consistent with physician orders [REDACTED].#1). e. F-686: Based on observations, record review and Wound Physician, Hospice Nurse and staff interviews, the facility failed to initiate pressure ulcer treatment for 3 days to a resident admitted with pressure ulcers (Resident #11) and failed to complete pressure ulcer treatment as ordered and scheduled for 3 days (Resident #7) for 2 of 3 residents reviewed for pressure ulcers. During an interview on 12/18/18 at 11:30 PM Nurse #6 revealed she had been at the facility working as a hall nurse since 7:00 AM that morning. Nurse #6 explained she was scheduled to work the 7:00 AM to 7:00 PM shift but at 8:00 PM she was told to stay over and work the 7:00 PM to 7:00 AM shift due to a call-out. She added one of the 2 nurses scheduled to work the 7:00 PM to 7:00 AM shift called out and the other nurse wouldn't take the keys to her medication cart because she did not want to work by herself. Nurse #6 stated she felt that she could not leave and had to stay. During an interview on 12/18/18 at 12:30 AM Nurse Aide (NA) #6 confirmed there were times only one NA worked the 11:00 PM to 7:00 AM shift to provide resident care due to staff call-outs. She recalled being the only NA working the evening of 12/18/18. She added when short-staffed, it was difficult to get resident care provided such as early morning showers and getting residents up out of bed and ready for breakfast. During an interview on 12/18/18 at 6:40 AM Nurse #9 stated they had worked short-staffed a lot lately, sometimes with only one nurse and one NA for the entire building. Nurse #9 explained it was difficult for staff to get resident care provided when working short, such as getting residents up out of bed and ready for the day or showered and when working short, their main focus was to keep the residents safe and dry. During an interview on 12/20/18 at 11:14 AM, the Administrator stated she and the Director of Nursing, who was no longer employed, were both responsible for the scheduling of staff. She explained the number of staff scheduled per day was based on the current census and acuity level of the residents in the building. She added at the current census, her goal was to have 4 NAs scheduled to work on both the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts and 3 NAs scheduled to work the 11:00 PM to 7:00 AM shift. The Administrator stated since starting her employment on 11/26/18 one of the issues she dealt with was staff not giving sufficient notice when they called out of work which made it difficult to find replacements and contributed to the facility being short-staffed. The Administrator confirmed Nurse #6 worked 24 hours straight as a hall nurse on 12/18/18 to 12/19/18. She explained it happened due to staff call outs and although it was an unfortunate situation, Nurse #6 had agreed to stay. She added she has focused on filling open positions and the hiring process remained ongoing.

Based on observations, staff, resident and physician interviews and record reviews the facility's administration failed to provide oversight of processes and policies and effective leadership to ensure that residents were free from neglect, treated in a dignified manner, provided with basic nursing care, received pressure ulcer treatments as ordered, and were provided with sufficient nursing staff to meet their needs for 4 of 12 sampled residents reviewed for neglect, dignity, and provision of nursing care (Resident's #13, #7, #1 and #11). Facility administration also failed to develop a facility wide assessment to determine the necessary resources to care for the resident population. Staff neglected to provide Resident #13 with incontinence care for nearly an 8-hour time span which resulted in the resident lying in large amount of urine and feces. Findings included: This tag was cross referenced to: 1a. F-550: Based on observations, record review, staff and resident interviews, the facility failed to treat one resident with dignity by leaving the resident lying in a large amount of urine and stool from 12:41 AM to 8:30 AM on 12/16/18 for 1 of 5 residents dependent on staff for incontinence care (Resident #13). b. F-600: Based on observations, record review, staff and resident interviews, wound physician interview, and hospice nurse interview, the facility staff neglected to acknowledge a resident's call bell and failed to provide incontinence care for 8 an hour time frame from 12:41 AM to 8:30 AM for 1 of 5 residents dependent on staff for incontinence care (Resident #13); failed to provide treatments as scheduled and ensure wound care was done consistent with physician orders [REDACTED].#1); and failed to complete pressure ulcer treatment as ordered and scheduled for 3 days (Resident #7) for 1 of 3 residents reviewed for pressure ulcers. c. F-656: Based on observations, record review, resident interviews, staff interviews, and physician interviews, the facility failed to develop a care plan which accurately described the wounds for 2 of 4 residents reviewed for wounds (Residents #1 and #11); failed to implement the care plan for treating wounds for 2 of 4 residents reviewed for wounds (Residents #1 and #7); and failed to implement the care plan for activities of daily living (ADLs) for 2 of 5 residents reviewed for ADLs (Residents #1 and #13). d. F-677: Based on observations, record review, resident, and staff interviews, the facility failed to provide toileting assistance for 2 of 5 dependent residents reviewed for Activities of Daily Living (ADL) care (Resident #13) and failed to provide nail care for 2 of 5 dependent residents reviewed for ADL care (Resident #1). e. F-684: Based on observations, record review, staff interviews and physician interviews, the facility failed to provide treatments as scheduled and ensure wound care was done consistent with physician orders [REDACTED].#1). f. F-686: Based on observations, record review and Wound Physician, Hospice Nurse and staff interviews, the facility failed to initiate pressure ulcer treatment for 3 days to a resident admitted with pressure ulcers (Resident #11) and failed to complete pressure ulcer treatment as ordered and scheduled for 3 days (Resident #7) for 2 of 3 residents reviewed for pressure ulcers. g. F-725: Based on observations, record reviews and resident and staff interviews, the facility failed to provide sufficient nursing staff to ensure residents received pressure ulcer and wound treatments and assistance with incontinence and nail care. This affected 4 of 12 sampled residents (Residents #1, #7, #11, and #13). h. F-838: Based on record review and staff interview the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for the resident population competently during day to day operations and in an emergency situation. During an interview on 12/20/18 at 11:14 AM, the Administrator agreed there were still issues in the identified areas of concern and explained since starting her employment on 11/26/18 her focus had been on staffing. She added she planned to work on the rest once staffing was stable.

Based on observations, record review, family member, and staff interview the facility failed to treat a resident in a dignified manner by not placing a clean shirt on the resident after giving the resident a bed bath for 1 of 3 residents sampled for dignity (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive minimum data set ((MDS) dated [DATE] revealed that Resident #1 was severely impaired for daily decision making and had long/short term memory problems. The MDS further revealed that Resident #1 required extensive assistance of 1 staff member with dressing and was receiving hospice care. An observation was made of Resident #1 on 10/24/18 at 11:15 AM. Resident #1 was resting in bed with eyes closed and would not open them to verbal stimuli. He was cachexic (ill appearing) but appeared comfortable. He was dressed in a blue long sleeve thermal shirt and was covered with a sheet and comforter from the waist down. His family member was visiting at bedside and indicated that Resident #1 had on that same blue long sleeve thermal shirt yesterday when she visited. An observation of Resident #1 was made on 10/24/18 at 12:58 PM. Resident #1 was resting in bed with his eyes open. He was lethargic and non-verbal. Resident #1 was dressed in a blue long sleeve thermal shirt and was covered with a sheet and comforter from the waist down. An observation of Resident #1 was made on 10/24/18 at 5:50 PM. Resident #1 was resting in bed with his eyes open. He remained lethargic and non-verbal. Resident #1 remained dressed in a blue long sleeve thermal shirt and was covered with a sheet and comforter from the waist down. An observation of Resident #1 was made on 10/25/18 at 9:42 AM. Resident #1 was resting in bed with his eyes open and was non- verbal. Resident #1 remained dressed in a blue long sleeve thermal shirt. His family member was again at bedside and again indicated that Resident #1 now had been dressed in that same shirt for 3 days. The family member stated that Resident #1 was always dressed in khaki pants with a button up shirt and he always put on clean clothes each day. An observation of Resident #1's closet was made on 10/25/18 at 9:49 AM. The closet was full of approximately 10 button up shirts, 2 long sleeve thermal shirts one grey and one green, and 3 pair of pajamas bottoms, and 10 pair of khaki dress pants. An observation of Resident #1 was made on 10/25/18 at 2:50 PM. Resident #1 was resting in bed with his eyes closed and appeared comfortable. He remained dressed in a blue long sleeve thermal sheet and was covered with a sheet and comforter from the waist down. An interview was conducted with Nursing Assistant (NA) #1 on 10/25/18 at 2:54 PM. NA #1 confirmed that she was taking care of Resident #1. She stated that she had given him a very good bed bath earlier in the day and had put deodorant on him and applied a good amount of lotion to his skin. NA #1 confirmed that after she washed Resident #1 she had placed the same shirt back on him. She could not provide any reason why she had not changed the shirt after giving him his bed bath earlier in the day. NA #1 stated it was no problem and she would change the shirt immediately. An interview was conducted with Nurse #1 on 10/25/18 at 3:45 PM. Nurse #1 confirmed that she was responsible for Resident #1. She stated that she expected each resident to be treated in a dignified manner and placed in clean clothes each day or as needed. Nurse #1 stated that after a bed bath or shower was given to the resident they should definitely be placed in clean clothes. An interview was conducted with the Director of Nursing (DON) on 10/25/18 at 5:01 PM. The DON stated that when Resident #1 was able he was up each day and dressed in khaki pants and button up shirt and he never wavered from the that attire. The DON stated that she expected Resident #1 to be placed in clean clothes each day after he was provided a bed bath or shower and more often if the clothes were soiled.

Based on observations, record review, family, and staff interview the facility neglected to feed a dependent resident for 1 of 3 residents sampled for activities of daily living (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive minimum data set ((MDS) dated [DATE] revealed that Resident #1 was severely impaired for daily decision making and had long/short term memory problems. The MDS further revealed that Resident #1 required extensive assistance of 1 staff member with eating and was receiving hospice care. Review of a care plan dated 10/02/18 read in part, Resident #1 has an activity of daily living (ADL) deficit related to advanced dementia and received hospice services. The goal read, Resident #1 will have care needs met through the review date as evidence by his neat appearance. The interventions included, Resident #1 needed extensive assistance with all intake. Review of Resident #1's Kardex revealed that he required assistance with all intake. An interview was conducted with Resident #1's family member on 10/24/18 at 11:15 AM. The family stated she visited the facility multiple times a day and was very aware of Resident #1's condition. She stated that she did not believe that the staff were consistently feeding Resident #1 because she would come to visit and several times have found unopened snacks and meal trays with the cover still over them and food untouched on his bedside table. An observation was made on 10/24/18 at 5:50 PM, Nursing Assistant (NA) #2 was observed to deliver Resident #1 his supper tray. NA #2 placed the tray on Resident #1's bedside table removed the cover and set the tray up. NA #2 was then observed to exit Resident #1's room and return to the meal cart and continued to deliver trays to other residents on the unit. An observation was made of Resident #1 on 10/24/18 at 5:55 PM. The supper tray had been removed from Resident #1's bedside table. An observation was made of Resident #1 on 10/24/18 at 6:04 PM. A dietary staff was observed to deliver another tray to Resident #1 and set it on his bedside table remove the cover and exit the room. A continuous observation was made of Resident #1 on 10/24/18 from 6:04 PM to 6:20 PM. Resident #1's supper tray remained on his bedside table. The spoon had been placed in the mashed potatoes but had not disturbed the gravy on top of the potatoes. Resident #1 had attempted to reach his glass of tea and spilled it all over the food, tray, and comforter that was covering him. The supper tray remained untouched and at 6:20 PM the staff entered Resident #1's room picked up the supper tray and placed it on the cart and returned the cart to the dietary department. The staff did not offer to assist or feed Resident #1 his supper tray. An interview was made with NA #2 on 10/24/18 at 6:24 PM and again at 8:00 PM. NA #2 confirmed that she had delivered Resident #1 his supper tray. She also stated that this was her first time working on the unit where Resident #1 resided, and she was very unfamiliar with Resident #1. NA #2 was aware that Resident #1 needed to be assisted with his meals because she had been told by other staff members during report. NA #2 stated that when she delivered the tray to Resident #1 she placed the spoon in Resident #1's hand and he would not do anything, and she realized that food that was on the tray was the wrong consistency, so she returned the tray to the dietary department and they delivered the correct tray to Resident #1. NA #2 stated that when Resident #1 would not do anything with the spoon that she placed in his hand she assumed he did not want it and returned to the hall to deliver and assist the other residents on the unit. NA #2 stated she stayed in the room a few seconds and he would not accept any food so she moved on. An observation was made of Resident #1's supper tray on 10/24/18 at 6:36 PM. The tray was on the meal cart in the kitchen waiting to be cleaned off. The plate of food was covered with the tea that Resident #1 spilled when trying to pick up the glass and the spoon remained stuck in the mashed potatoes but again the gravy was not disturbed that was on top of the potatoes. The Administrator was made aware that Resident #1 was not offered or assisted with his supper meal on 10/24/18 at 6:45 PM. An interview was conducted with Nurse #1 on 10/25/18 at 3:45 PM. Nurse #1 confirmed that she was responsible for Resident #1. She stated that she expected each resident that needed assistance to be assisted with their meals. She stated it was unacceptable to not offer and assist Resident #1 with his supper meal. An interview was conducted with the Director of Nursing (DON) on 10/25/18 at 5:01 PM. The DON stated that she found it appalling and did not like that Resident #1 was not offered or assisted his supper meal on 10/24/18. The DON stated that NA #2 should have sat down with Resident #1 and attempted to feed him the correct supper tray and if he refused then she should have reported that to the nurse and documented it in the medical record. She added that she expected if NA #2 delivered the tray to Resident #1 then she should have stayed with him and attempted to feed him his supper. The DON stated that each resident had a Kardex that the NAs could review, and each NA also received report about their residents.

Based on observations, record review, and staff interview the facility failed to implement care plan interventions for feeding a resident (Resident #1) and failed to implement care plan interventions for wound dressing changes (Resident #3) this affected 2 of 3 residents sampled for activities of daily living. The findings included: 1.Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive minimum data set ((MDS) dated [DATE] revealed that Resident #1 was severely impaired for daily decision making and had long/short term memory problems. The MDS further revealed that Resident #1 required extensive assistance of 1 staff member with eating and was receiving hospice care. Review of a care plan dated 10/02/18 read in part, Resident #1 has an activity of daily living (ADL) deficit related to advanced dementia and receives hospice services. The goal read, Resident #1 will have care needs met through the review date as evidence by his neat appearance. The interventions included, Resident #1 needed extensive assistance with all intake. Review of Resident #1's Kardex revealed that he required assistance with all intake. An observation was made on 10/24/18 at 5:50 PM, Nursing Assistant (NA) #2 was observed to deliver Resident #1 his supper tray. NA #1 placed the tray on Resident #1's bedside table removed the cover and set the tray up. NA #1 was then observed to exit Resident #1's room without assisting him with the meal. A continuous observation was made of Resident #1 on 10/24/18 from 6:04 PM to 6:20 PM. Resident #1's supper tray remained on his bedside table. The supper tray remained untouched and at 6:20 PM the staff entered Resident #1's room picked up the supper tray and placed it on the cart and returned the cart to the dietary department. The staff did not offer to assist or feed Resident #1 his supper tray. An interview was made with NA #2 on 10/24/18 at 6:24 PM and again at 8:00 PM. NA #2 confirmed that she had delivered Resident #1 his supper tray. NA #2 stated that when she delivered the tray to Resident #1 she placed the spoon in Resident #1's hand and he would not do anything, she assumed he did not want it and returned to the hall to deliver and assist the other residents on the unit, without assisting Resident #1 with his meal tray. NA #2 confirmed that she was aware Resident #1 needed assistance with his meals because she had been told that by the other staff. An interview was conducted with the MDS Nurse on 10/25/18 at 3:04 PM. The MDS Nurse stated that she was responsible for initiating and updating Resident #1's care plan. She added that the NA ' s are expected to review and follow the Kardex each shift they work. Resident #1 was care planned to need assistance with all intake and the nursing staff were expected to follow that Kardex and plan of care. An interview was conducted with the Director of Nursing (DON) on 10/25/18 at 5:01 PM. The DON stated that she found it appalling and did not like that Resident #1 was not offered or assisted his supper meal on 10/24/18. The DON stated that NA #2 should have followed the Kardex and care plan for Resident #1 and assisted him with his intake. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed that Resident #3 was moderately impaired for daily decision making and had no behaviors during the reference period. The MDS further stated that Resident #3 required extensive assistance with activities of daily living and indicated that she had no pressure ulcers. Review of a care plan updated on 10/09/18 read in part, Resident #3 has the potential for pressure ulcer development related to needing assistance with mobility, incontinence, and poor intake. The goal read, Resident #1 would be free from any sign or symptoms of infection related to altered skin integrity and be free from any further pressure related skin issues. The interventions included: administer treatments as ordered and monitor for effectiveness. Review of a physician order [REDACTED]. Review of the treatment administration record (TAR) dated 10/01/18 through 10/31/18 revealed that on 10/22/18 and 10/23/18 there were no initials indicating the daily treatment to Resident #3's right outer ankle had not been completed. An interview was conducted with Nurse #1 on 10/24/18 at 6:00 PM. Nurse #1 confirmed that she was the nurse that was responsible for Resident #3 on 10/23/18. She stated that she did not complete the wound dressing to Resident #3's right outer ankle because there was a lot going on and she did not have time to complete the dressing change. She stated she was the only nurse on the units that day and there was just not enough time to do everything she needed to do. An interview was conducted with Nurse #3 on10/24/18 at 6:06 PM. Nurse #3 confirmed that she was responsible for Resident #3 on 10/22/18 and indicated that she was the only nurse on the units that day. Nurse #3 stated that she had not completed the dressing change to Resident #3's right outer ankle because she did not have time. Nurse #3 stated that when she was the only nurse on the units it was very hard to get everything completed and she had 2 readmissions that she had to work on in addition to her other duties and she just did have time to complete the dressing change as ordered. An interview was conducted with the MDS Nurse on 10/25/18 at 3:04 PM. The MDS Nurse stated that she was responsible for initiating and updating Resident #3's care plan. She added that the Nurses are expected to review and follow the care plan each shift they work. Resident #3 was care planned for wound care and the nurses should follow the care plan and provide the treatment as ordered. An interview was conducted with the DON on 10/25/18 at 5:01 PM. The DON stated that the Nurses were expected to follow the Resident #3 plan of care and provide wound care as ordered.

Based on observations, record review, family, and staff interview the facility failed to feed a dependent resident (Resident #1) and failed to provide showers as scheduled (Resident #4 and #8) this affected 3 of 3 residents sampled for activities of daily living. The findings included: 1.Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive minimum data set ((MDS) dated [DATE] revealed that Resident #1 was severely impaired for daily decision making and had long/short term memory problems. The MDS further revealed that Resident #1 required extensive assistance of 1 staff member with eating and was receiving hospice care. Review of a care plan dated 10/02/18 read in part, Resident #1 has an activity of daily living (ADL) deficit related to advanced dementia and receives hospice services. The goal read, Resident #1 will have care needs met through the review date as evidence by his neat appearance. The interventions included, Resident #1 needed extensive assistance with all intake. An interview was conducted with Resident #1's family member on 10/24/18 at 11:15 AM. The family stated she visited the facility multiple times a day and was very aware of Resident #1's condition. She stated that she did not believe that the staff were consistently feeding Resident #1 because she would come to visit and would find unopened snacks and meal trays with the cover still over them and food untouched on his bedside table. An observation was made on 10/24/18 at 5:50 PM, Nursing Assistant (NA) #2 was observed to deliver Resident #1 his supper tray. NA #1 placed the tray on Resident #1's bedside table removed the cover and set the tray up. NA #1 was then observed to exit Resident #1's room and return to the meal cart and continued to deliver trays to other residents on the unit. An observation was made of Resident #1 on 10/24/18 at 5:55 PM. The supper tray had been removed from Resident #1's bedside table. An observation was made of Resident #1 on 10/24/18 at 6:04 PM. A dietary staff was observed to deliver another tray to Resident #1 and set it on his bedside table remove the cover and exit the room. A continuous observation was made of Resident #1 on 10/24/18 from 6:04 PM to 6:20 PM. Resident #1's supper tray remained on his bedside table. The spoon had been placed in the mashed potatoes but had not disturbed the gravy on top of the potatoes. Resident #1 had attempted to reach his glass of tea and spilled it all over the food, tray, and comforter that was covering him. The supper tray remained untouched and at 6:20 PM the staff entered Resident #1's room picked up the supper tray and placed it on the cart and returned the cart to the dietary department. The staff did not offer to assist or feed Resident #1 his supper tray. An interview was made with NA #2 on 10/24/18 at 6:24 PM and again at 8:00 PM. NA #2 confirmed that she had delivered Resident #1 his supper tray. She also stated that this was her first time working on the unit where Resident #1 resided and she was very unfamiliar with Resident #1. NA #2 stated that when she delivered the tray to Resident #1 she placed the spoon in Resident #1's hand and he would not do anything, and she realized that food that was on the tray was the wrong consistency, so she returned the tray to the dietary department and they delivered the correct tray to Resident #1. NA #2 stated that when Resident #1 would not do anything with the spoon that she placed in his hand she assumed he did not want it and returned to the hall to deliver and assist the other residents on the unit. NA #2 stated she stayed in the room a few seconds and he would not accept any food so she moved on. An observation was made of Resident #1's supper tray on 10/24/18 at 6:36 PM. The tray was on the meal cart in the kitchen waiting to be cleaned off. The plate of food was covered with the tea that Resident #1 spilled when trying to pick up the glass and the spoon remained stuck in the mashed potatoes but again the gravy was not disturbed that was on top of the potatoes. The Administrator was made aware that Resident #1 was not offered or assisted with his supper meal on 10/24/18 at 6:45 PM. An interview was conducted with Nurse #1 on 10/25/18 at 3:45 PM. Nurse #1 confirmed that she was responsible for Resident #1. She stated that she expected each resident that needed assistance to be assisted with their meals. She stated it was unacceptable to not offer and assist Resident #1 with his supper meal. An interview was conducted with the Director of Nursing (DON) on 10/25/18 at 5:01 PM. The DON stated that she found it appalling and did not like that Resident #1 was not offered or assisted his supper meal on 10/24/18. The DON stated that NA #2 should have sat down with Resident #1 and attempted to feed him the correct supper tray and if he refused then she should have reported that to the nurse and documented it in the medical record. She added that she expected if NA #2 delivered the tray to Resident #1 then she should have stayed with him and attempted to feed him his supper. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed that Resident #4 was severely impaired for daily decision making and had long and short-term memory problems. The MDS also revealed that Resident #4 required total assistance of one staff member with bathing and had no rejection of care during the assessment reference period. Review of the shower schedule for Resident #4 revealed that her scheduled shower days were Monday and Thursday on 1st shift. Review of the facility's shower sheets for Resident #4 from 10/01/18 through 10/25/18 revealed the following: 10/01/18: No shower 10/02/18: Received a shower 10/04/18: Received a shower 10/08/18: No shower 10/11/18: Received a shower 10/15/18: No shower 10/18/18: Received a shower 10/22/18: No shower 10/25/18: Received a shower An observation was made of Resident #4 on 10/24/18 at 12:30 PM. Resident #4 was resting in bed with eyes open and was alert. Resident #4 was noted to have a slight body odor to her. Resident #4's family member was at bedside and had just provided incontinent care to her. An interview was conducted with Resident #4's family member on 10/24/18 at 12:44 PM. The family member stated that she visited the facility every day and most days multiple times during the day. She added that Resident #4 was scheduled to get a shower on Monday and Thursday on 1st shift and that was fine with her if she got those scheduled showers. The family member stated that Resident #4 was not consistently receiving her showers. The family member stated she has asked the staff to please take Resident #4 to the shower and just wash her real good and then return her to the bed and she would provide the rest of the personal care she needed so the staff could move on to the next resident but that was not happening either. The family member added that Resident #4 had not received her shower on Monday 10/22/18 so it had been a week and that was why she had the slight body odor to her. The family member stated she had asked the staff to please make sure that Resident #4 received her shower that was scheduled on 10/25/18. An interview was conducted with Nursing Assistant (NA) #3 on 10/25/18 at 3:26 PM. NA #3 stated that the shower scheduled was kept in a book at the nurse's station and each day she worked she would check the schedule to see which residents were scheduled for a shower on that day. NA #3 confirmed that she was taking care of Resident #4 on 10/08/18, 10/15/18, and 10/22/18 and confirmed that she had not showered Resident #4 because they were short staffed, and she did not have the time to do so. NA #3 stated that she reported to the nurse on the hall which she could not recall which nurse that she was unable to complete Resident #4's shower on those days. NA #3 stated that if she was unable to take Resident #4 to the shower she did try to give her a good bed bath but sometimes that was not possible. An interview was conducted with Nurse #1 on 10/25/18 at 3:45 PM. Nurse #3 stated that she did recall the NAs reporting to her that showers were not being completed but could not recall which specific residents. She added that when the NAs reported to her that they were unable to complete showers she would ask the next shift to complete them, but she was not sure if that was happening or not. An interview was conducted with the Director of Nursing (DON) on 10/25/18 at 5:01 PM. The DON stated that when she arrived at the facility a few months ago she quickly realized that showers were not being done and she had implemented the shower sheets and the nurses must sign off on the shower sheet after the shower had been completed. The DON stated that she was now holding both the NAs and the Nurses accountable when showers were not being completed as scheduled. She added that they have incorporated preferences into the shower schedule, so each resident was receiving what they wanted on the days that they wanted them. The DON further stated that she fully expected the staff to complete the showers for each resident as they were scheduled and to document the shower on the shower sheet and have the nurses sign off on them. 3. Resident #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #8 had moderate impairment in cognition and required extensive staff assistance with bathing. Further review revealed he displayed no rejection of care during the 7-day assessment period. Review of Resident #8's care plans, last revised on 05/18/18, revealed a plan in place to address his need for assistance with activities of daily living due to a self-care performance deficit related to dementia. Interventions included for staff to provide Resident #8 with extensive assistance with bathing/showering and use [MEDICATION NAME] blue shampoo to wash his hair on shower days. Review of the facility's bathing sheets for the period 09/05/18 to 10/25/18 revealed Resident #8 received 6 out of 16 scheduled showers on 09/05/18, 09/17/18, 09/27/18, 10/01/18, 10/15/18, and 10/18/18. On 10/25/18 at 10:12 AM Resident #8's Family Member (FM) voiced concerns he was not receiving his showers as scheduled. The FM explained Resident #8 was supposed to receive 2 showers per week on Monday and Thursday but had not received one in over a week. On 10/25/18 at 11:30 AM Resident #8 was observed up in his wheelchair sitting in the main dining room with a disheveled appearance and slight body odor. An interview with Nurse Aide (NA) #3 on 10/25/18 at 3:26 PM revealed the shower schedule was kept in a book at the nurse's station and each day she worked she would check the schedule to see which residents were scheduled for a shower. NA #3 confirmed she provided care to Resident #8 and if she was not able to provide him with a shower on his scheduled day it was because they were short staffed and she did not have the time to do so. NA #3 stated she reported to the nurse on the hall when she was unable to provide Resident #8 with shower on those days. NA #8 added when she was unable to take Resident #8 to the shower she did try to give him a bed bath but sometimes that was not possible. An interview was conducted with Nurse #1 on 10/25/18 at 3:45 PM. Nurse #3 stated that she did recall the NAs reporting to her that showers were not being completed but could not recall which specific residents. She added when the NAs reported to her that they were unable to complete showers she would ask the next shift to complete them, but she was not sure if that was happening or not. An interview was conducted with the Director of Nursing (DON) on 10/25/18 at 5:01 PM. The DON stated when she arrived at the facility a few months ago she quickly realized that showers were not being done and she had implemented the shower sheets and the nurses must sign off on the shower sheet after the shower had been completed. The DON stated she was now holding both the NAs and the Nurses accountable when showers were not being completed as scheduled. She added they have incorporated preferences into the shower schedule, so each resident was receiving what they wanted on the days that they wanted them. The DON further stated that she fully expected the staff to complete the showers for each resident as they were scheduled and to document the shower on the shower sheet and have the nurses sign off on them.

Based on observations, record reviews and resident and staff interviews, the facility failed to provide sufficient nursing staff to ensure residents received assistance with meals, bathing and wound care/treatments. This affected 5 of 8 sampled residents (Residents #1, #2, #3, #4, and #8). Findings included: This tag is cross-referenced to: 1. 483.12 (F600): Based on observations, record review, family, and staff interview the facility neglected to feed a dependent resident for 1 of 3 residents sampled for activities of daily living (Resident #1). 2. 483.24 (F677): Based on observations, record review, family, and staff interview the facility failed to feed a dependent resident (Resident #1) and failed to provide showers as scheduled (Resident #4 and #8) this affected 3 of 3 residents sampled for activities of daily living. 3. 483.25 (F686): Based on observations, record review, and staff interview the facility failed to apply the correct treatment to a pressure ulcer and failed to complete the pressure ulcer treatment as ordered (Resident #3) and failed to replace a dressing to a pressure ulcer when the dressing became dislodged (Resident #2) this affected 2 of 3 residents sampled for pressure ulcers. During an interview on 10/25/18 at 11:45 AM Nurse Aide (NA) #5 indicated she had only been employed for less than a week and they had worked short-staffed that entire time with only 3 to 4 NAs scheduled to provide resident care. NA #5 stated she often felt rushed and it wasn't always possible to get resident care provided as often as needed such as incontinence care or showers. During an interview on 01/25/18 at 1:52 PM the Wound Nurse (WN) stated staffing had been an issue since she started her employment and was often was pulled to work as a hall nurse instead of providing wound care for residents. She added when she was not scheduled to work or was pulled to cover a medication cart, it was not uncommon for wound treatments or dressing changes to not get done. During an interview on 10/25/18 at 5:01 PM the Director of Nursing (DON) confirmed she was responsible for the scheduling of staff. The DON acknowledged staffing was challenged due to not having enough staff and as a result, she was pulled to cover a medication cart on various shifts at least 3 to 4 days per week. She added they recently filled all available positions on the night shift (7:00 PM to 7:00 AM), hired a nurse for the day shift (7:00 AM to 7:00 PM) who would be starting orientation and planned to continue with the hiring process until all open positions were filled.

Based on observations, staff, resident and physician interviews and record reviews the facility's administration failed to provide oversight of processes and policies and effective leadership to ensure that residents were free from neglect, treated in a dignified manner, provided with basic nursing care, received pressure ulcer treatments as ordered, and were provided with sufficient nursing staff to meet their needs for 4 of 12 sampled residents reviewed for neglect, dignity, and provision of nursing care (Resident's #13, #7, #1 and #11). Facility administration also failed to develop a facility wide assessment to determine the necessary resources to care for the resident population. Staff neglected to provide Resident #13 with incontinence care for nearly an 8-hour time span which resulted in the resident lying in large amount of urine and feces. Findings included: This tag was cross referenced to: 1a. F-550: Based on observations, record review, staff and resident interviews, the facility failed to treat one resident with dignity by leaving the resident lying in a large amount of urine and stool from 12:41 AM to 8:30 AM on 12/16/18 for 1 of 5 residents dependent on staff for incontinence care (Resident #13). 1b. F-600: Based on observations, record review, staff and resident interviews, wound physician interview, and hospice nurse interview, the facility staff neglected to acknowledge a resident's call bell and failed to provide incontinence care for 8 an hour time frame from 12:41 AM to 8:30 AM for 1 of 5 residents dependent on staff for incontinence care (Resident #13); failed to provide treatments as scheduled and ensure wound care was done consistent with physician orders [REDACTED].#1); and failed to complete pressure ulcer treatment as ordered and scheduled for 3 days (Resident #7) for 1 of 3 residents reviewed for pressure ulcers. 1c. F-656: Based on observations, record review, resident interviews, staff interviews, and physician interviews, the facility failed to develop a care plan which accurately described the wounds for 2 of 4 residents reviewed for wounds (Residents #1 and #11); failed to implement the care plan for treating wounds for 2 of 4 residents reviewed for wounds (Residents #1 and #7); and failed to implement the care plan for activities of daily living (ADLs) for 2 of 5 residents reviewed for ADLs (Residents #1 and #13). 1d. F-677: Based on observations, record review, resident, and staff interviews, the facility failed to provide toileting assistance for 2 of 5 dependent residents reviewed for Activities of Daily Living (ADL) care (Resident #13) and failed to provide nail care for 2 of 5 dependent residents reviewed for ADL care (Resident #1). 1e. F-684: Based on observations, record review, staff interviews and physician interviews, the facility failed to provide treatments as scheduled and ensure wound care was done consistent with physician orders [REDACTED].#1). 1f. F-686: Based on observations, record review and Wound Physician, Hospice Nurse and staff interviews, the facility failed to initiate pressure ulcer treatment for 3 days to a resident admitted with pressure ulcers (Resident #11) and failed to complete pressure ulcer treatment as ordered and scheduled for 3 days (Resident #7) for 2 of 3 residents reviewed for pressure ulcers. 1g. F-725: Based on observations, record reviews and resident and staff interviews, the facility failed to provide sufficient nursing staff to ensure residents received pressure ulcer and wound treatments and assistance with incontinence and nail care. This affected 4 of 12 sampled residents (Residents #1, #7, #11, and #13). 1h. F-838: Based on record review and staff interview the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for the resident population competently during day to day operations and in an emergency situation. During an interview on 12/20/18 at 11:14 AM, the Administrator agreed there were still issues in the identified areas of concern and explained since starting her employment on 11/26/18 her focus had been on staffing. She added she planned to work on the rest once staffing was stable.

Based on staff interviews and record review the facility failed to notify the physician after a resident fell and developed a new onset of pain and the resident had a fractured femur for 1 of 1 sampled resident (Resident #48). The findings included: Resident #48 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Resident #48 died in the facility on [DATE]. The Minimum Data Set ((MDS) dated [DATE] specified the resident did not have impaired cognition, required limited assistance with activities of daily living and no history of falls. Review of Resident #48's medical record revealed a nurse's entry made by Nurse #2 dated [DATE] at 11:20 PM specified Resident #48 was found on the floor and no injury was noted but the resident complained of tenderness on her left side where she landed. Nurse #2 documented on the MAR that she administered as needed Tylenol (pain medication) 650mg (milligrams) for left hip pain. Nurse #2 did not document the time the medication was given and did not document if the pain medication was effective. There was no documentation in the medical record that the physician was notified of the fall or complaints of pain after the fall. The next nurse's entry made by Nurse #3 on [DATE] at 7:30 AM read in part that Resident #48's left hip was bruised, her left lower extremity was weaker than the right and the resident complained of tenderness in her left hip and leg. There was no documentation in the medical record of notification to the physician regarding pain or medication administration related to the Resident's complaint of pain. On [DATE] at 2:00 PM Nurse #3 documented in the medical record that Resident #48 complained of pain in her left hip and leg upon movement. Nurse #3 contacted the on-call physician and obtained orders for a mobile x-ray. Nurse #3 documented on [DATE] at 6:20 PM the x-ray had been performed and Resident #48 was comfortable as long as left leg wasn't moved. The Radiology Report dated [DATE] specified no fracture or dislocation was detected. A nurse's entry dated [DATE] at 10:00 AM specified Resident #48 continued to complain of pain to her left upper leg and hip. There was no documentation in the medical record that the physician was notified of the pain. On [DATE] at 1:00 PM the physician was notified and ordered a 2 view x-ray of the left femur and left hip. The Radiology Report dated [DATE] indicated Resident #48 had a left femoral fracture. Orders were obtained and Resident #48 was sent to the Emergency Department. On [DATE] at 4:30 PM the resident's physician was interviewed on the telephone and stated he expected nurses to notify him right away when a resident had new pain after a fall especially if it was hip pain because he didn't want a resident sitting on a fracture. The physician could not recall if he was notified on [DATE] when the resident fell or when the resident complained of pain on [DATE]. On [DATE] at 12:30 PM Nurse #3 was interviewed on the telephone and explained that she worked 7 AM to 7 PM on Friday, Saturday and Sunday. Nurse #3 explained that on [DATE] she was told in report that Resident #48 had fallen but nothing was different with the Resident. Nurse #3 stated on [DATE] that Resident #48 was weaker on the left side which was different for the resident but she did not attempt to contact the physician. Nurse #3 explained that later in the shift Resident #48 started to holler when her hip was touched and that was when she contacted the physician. On [DATE] at 2:00 PM the Director of Nursing (DON) was interviewed and explained that if Resident #48 had any pain after a fall the nurse should have contacted the physician right then. On [DATE] at 3:55 PM Nurse #2 was interviewed on the telephone and explained that she was not Resident #48's nurse on [DATE] when the resident fell but was called by a nurse aide who found the resident on the floor. Nurse #2 stated Resident #48 complained her butt hurt from the fall. Nurse #2 stated she did not contact the physician of the resident's fall or complaints of pain. A document titled Incident/Accident Report dated [DATE] completed by Nurse #2 specified the physician was contacted on [DATE] at 9:16 PM. Nurse #2 stated she did not call the physician and was not sure why she documented that the physician was notified of the fall.

Based on staff interviews and record review the facility failed to completely assess a resident for injury and respond to complaints of pain following a resident's fall which resulted in a fractured femur for 1 of 1 sampled resident (Resident #48). The findings included: Resident #48 was admitted to the facility on [DATE] diagnosed with [REDACTED]. Resident #48 died in the facility on [DATE]. The Minimum Data Set ((MDS) dated [DATE] specified the resident did not have impaired cognition, required limited assistance with activities of daily living and no history of falls. Resident #48's Medication Administration Record (MAR) was reviewed and revealed that on [DATE] at 8:00 AM Resident #48's blood pressure medications ([MEDICATION NAME] and [MEDICATION NAME]) and 2 diuretic medications ([MEDICATION NAME] and [MEDICATION NAME]) were held because the resident's blood pressure was ,[DATE] (low). Review of Resident #48's medical record revealed a nurse's entry made by Nurse #2 dated [DATE] at 11:20 PM specified Resident #48 was found in the floor and no injury was noted but the resident complained of tenderness on her left side where she landed. Vital signs were obtained and Resident #48's blood pressure was ,[DATE]. Neurological checks were started, the resident was given [MEDICATION NAME] (anti-anxiety medication) and put back to bed. Nurse #2 documented on the MAR that she administered as needed Tylenol (pain medication) 650mg (milligrams) for left hip pain. Nurse #2 did not document the time the medication was given and did not document if the pain medication was effective. There was no documentation in the medical record that the physician was notified of the fall or complaints of pain after the fall. The next nurse's entry made by Nurse #3 on [DATE] at 7:30 AM read in part that Resident #48's left hip was bruised, her left lower extremity was weaker than the right and the resident complained of tenderness in her left hip and leg. There was no documentation in the medical record of notification to the physician regarding pain or medication administration related to the Resident's complaint of pain. On [DATE] at 2:00 PM Nurse #3 documented in the medical record that Resident #48 complained of pain in her left hip and leg upon movement. Nurse #3 contacted the on-call physician and obtained orders for a mobile x-ray. Nurse #3 documented on [DATE] at 6:20 PM the x-ray had been performed and Resident #48 was comfortable as long as left leg wasn't moved. The Radiology Report dated [DATE] specified no fracture or dislocation was detected. A nurse's entry dated [DATE] at 10:00 AM specified Resident #48 continued to complain of pain to her left upper leg and hip. There was no documentation in the medical record that the physician was notified of the pain. On [DATE] at 1:00 PM the physician was notified and ordered a 2 view x-ray of the left femur and left hip. The Radiology Report dated [DATE] indicated Resident #48 had a left femoral fracture. Orders were obtained and Resident #48 was sent to the Emergency Department. On [DATE] at 4:30 PM the resident's physician was interviewed on the telephone and stated he expected nurses to notify him right away when a resident had new pain after a fall especially if it was hip pain because he didn't want a resident sitting on a fracture. The physician could not recall if he was notified on [DATE] when the resident fell or when the resident complained of pain on [DATE]. On [DATE] at 12:30 PM Nurse #3 was interviewed on the telephone and explained that she worked 7 AM to 7 PM on Friday, Saturday and Sunday. Nurse #3 explained that on [DATE] Resident #48 had refused to eat or drink anything and she was concerned the resident would become dehydrated. Nurse #3 stated that Resident #48's blood pressure was low (,[DATE]) and she decided to not administer blood pressure medications or diuretic medications. She stated on [DATE] she did not contact the physician because Resident #48 did not appear in acute distress. Nurse #3 explained that on [DATE] she was told in report that Resident #48 had fallen but nothing was different with the Resident. Nurse #3 added that on [DATE] she did not perform range of motion (ROM) on Resident #48 because she assumed the resident could move everything. Nurse #3 stated on [DATE] that Resident #48 was weaker on the left side which was different for the resident but she did not attempt to contact the physician. Nurse #3 explained that later in the shift Resident #48 started to holler when her hip was touched and that was when she contacted the physician. Nurse #3 did not recall if she administered pain medication to the resident on [DATE]. On [DATE] at 2:00 PM the Director of Nursing (DON) was interviewed and explained that she expected nurses to assess residents after a fall including range of motion before moving them and to call the physician if a resident had pain after a fall. The DON stated that if Resident #48 had any pain after a fall the nurses should have contacted the physician. On [DATE] at 3:55 PM Nurse #2 was interviewed on the telephone and explained that she was not Resident #48's nurse on [DATE] when the resident fell but was called by a nurse aide who found the resident in the floor. Nurse #2 added that she asked Resident #48 if she was okay and asked her if she could move all her extremities. Nurse #2 stated she did not perform ROM on Resident #48 but that the resident complained her butt hurt from the fall. Nurse #2 added that she and another staff person stood the resident up and transferred her to the wheelchair and then from the wheelchair to the bed. Nurse #2 explained that once the resident was back in bed she notified the nurse assigned to the resident of the incident, completed the incident report and continued on with her assignment. Nurse #2 stated she did not contact the physician of the resident's fall or complaints of pain. A document titled Incident/Accident Report dated [DATE] completed by Nurse #2 specified the physician was contacted on [DATE] at 9:16 PM. Nurse #2 stated she did not call the physician and was not sure why she documented that the physician was notified of the fall.

Based on record reviews and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in February 2015. This was for 5 recited deficiencies which were originally cited in February 2015 on a recertification and complaint survey and again on the current recertification survey. The deficiencies were in the areas to notify of a change in condition, provide dignity and respect, provide a safe, clean and comfortable homelike environment, provide care and services for highest well-being and to store, prepare and serve food under sanitary conditions. The facility's continued failure to implement and maintain procedures from a Quality Assessment and Assurance Committee, during two federal surveys of record, show a pattern of the facility's inability to sustain an effective Quality Assurance Program. The findings included: This tag is cross referenced to: 1. a. F157 Notification of changes in condition: Based on staff interviews and record review the facility failed to notify the physician after a resident fell and developed a new onset of pain and the resident had a fractured femur for 1 of 1 sampled resident (Resident #48). The facility was recited for F157 for failure to notify the physician after a resident fell and had pain and a fracture. F157 was originally cited during the February 5, 2015 recertification and complaint survey for failure to notify the physician after a resident fall for 1 of 2 residents reviewed for unwitnessed falls. (Resident # 31). b. F241 Dignity and respect: Based on observations and staff interviews the facility failed to maintain dignity during meals when staff stood over residents while they fed them and failed to engage them in conversation during 2 of 2 meal observations. (Resident #2, #32, and #30). During the recertification and complaint survey on 02/05/15 the facility failed to maintain and promote the dignity of 4 residents during 1 of 2 meals which were observed for tray delivery services. Residents #4, #8, #25, and #46 were not served at the same time as their tablemates and had to watch others eat prior to being served themselves. c. F253 Safe, clean, comfortable and homelike environment: Based on observations and staff interviews the facility failed to repair resident doors with broken and splintered laminate and wood on 17 of 26 resident doors (Resident room [ROOM NUMBER], #102, #104, #106, #109, #110, #201, #202, #204, #206, #207, #208, #302, #304, #305, #307 and #308) and failed to repair broken and splintered laminate and wood on 2 of 2 shower doors (shower door #1 and #2) and failed to repair smoke prevention doors with broken and splintered laminate and wood on 200 and 300 halls. During the recertification and complaint survey on 02/05/15 the facility failed to label bedpans and a urine hat stored in plastic bags from hooks and label an uncovered urine hat lying in the floor in resident bathrooms in 4 bathrooms on 2 of 3 halls. d. F309 Maintain well-being: Based on staff interviews and record review the facility failed to completely assess a resident for injury and respond to complaints of pain following a resident's fall which resulted in a fractured femur for 1 of 1 sampled resident (Resident #48). During the recertification and complaint survey on 02/05/15 the facility failed to assess and implement a bowel protocol for a resident who had not had a bowel movement for 9 days for 1 of 5 residents reviewed for unnecessary medications (Resident #17). e. F371 Based on observations, staff interviews and record review the facility failed to prevent the walk-in cooler floor from developing rust, keep the kitchen floor free from dirt build-up and repair cracked tiles in the kitchen floor. During the recertification and complaint survey on 02/05/15 the facility failed to 1) use proper hand hygiene when handling clean equipment and 2) air dry food trays and insulated domes before storing and 3) maintain the cleanliness of the exterior door panels of the reach-in refrigerator and freezer. During an interview on 11/19/15 at 4:23 PM the Administrator explained they evaluated quality assurance topics for review through monitoring tools and audits. She explained when they developed quality assurance plans for the deficiencies cited on 02/05/15 they monitored for the specific concerns that were cited. She explained dignity was monitored for a different issue than the current deficiency so now they would have to think out of the box and look at why there was deficient practice for different issues. She stated they needed to look at the whole regulatory area instead of just looking at the specific issues that were cited to prevent deficiencies on future surveys.

Based on observation, resident, staff and physician interview and record review, the facility failed to evaluate the risk of applying moist hot packs and follow the Occupational Plan of Care for one of three sampled residents. (Resident #1) The findings are: Review of the undated manufacturer recommendations for the moist hot pack heating unit included: The water temperature in the heating unit is approximately 160 degrees Fahrenheit. Do not apply over insensitive skin or in the presence of poor circulation. Review of the facility's Rehabilitation policy for using moist heat dated 9/1/2002 listed contraindications for use to include sensory loss. Under the heading, "Starting the Treatment" is listed check skin sensation."Use hot packs with EXTREME caution if sensation is lacking or diminished. Check the patient after a few minutes. More toweling may be needed between the pack and the patient." Resident #1 was admitted with [DIAGNOSES REDACTED]. Review of the current Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed with [REDACTED]. The resident had limited range of motion of both upper and lower extremities on one side of his body and required extensive assistance of one staff for the majority of his activities of daily living. Review of a physician's orders [REDACTED]. Apply resting hand splint to right hand. Monitor use of splint and instruct resident and staff in proper use of it. Review of the Occupational Therapy Evaluation completed on 12/15/11 revealed the resident had limited range of motion of the right shoulder and contractures of the right hand. The Occupational Therapist (OT) documented the resident was receiving gentle stretching exercises to the resident's right upper extremity and the hand splint was applied. The OT Therapy note dated 12/16/11 and signed by Certified Occupational Therapist Assistant (COTA) #1 stated the resident was found wearing the hand splint. The right hand splint was removed and gentle massaging and range of motion (ROM) to the right hand was provided. There was no documentation related to moist hot packs being applied to the resident's right hand. Review of a nurse's note dated 12/17/11 at 1:30 p.m. documented the resident showed the nurse supervisor the knuckles of his right hand. Two blisters without redness or swelling were noted. The resident communicated through gestures and yes/no answers that the blisters occurred during his therapy session on 12/16/11. The resident indicated that something hot had been placed on his hand. A fax was sent to the physician notifying him of the two blisters on the resident's hand. Treatment orders from the physician were received on 12/17/11 to apply skin prep to blisters on right hand every shift. "Blisters intact." On 12/26/11, the orders were changed to discontinue the skin prep and clean with normal saline. Apply a topical antibiotic ointment and cover with a clear, adhesive dressing which was to be changed every three days and whenever necessary. The last treatment order was received on 12/27/11 which stated to change the dressing from the clear dressing to an SS (silver sulfadiazine, a topical medication in the treatment of [REDACTED]. The dressing was to be changed every day and whenever necessary. Observation on 1/12/12 at 10:45 a.m. revealed Resident #1 sitting in the therapy room receiving passive range of motion by COTA #2. The resident had a dressing covering the back of his right hand. When asked, the resident pointed to the heating unit for moist hot packs and stated "hot, burn." COTA #2 then placed the splint on the resident's right hand showing that it did not rest against the dressing. During an observation and interview on 1/12/12 at 12:50 p.m. the Restorative Aide stated hot packs were only used with a physician's orders [REDACTED]. The wrapped hot pack was then placed inside a folded bath blanket. Prior to placing it against a resident, she stated a towel was used as another barrier between the resident and the hot pack. The aide also stated residents should not be left alone with a hot pack. A second observation of Resident #1 on 1/12/12 at 1:40 p.m. revealed he was sitting in his wheelchair without a dressing on the back of his right hand. The knuckle of the first finger had a circular scabbed area approximately .5 centimeter (cm) in diameter. The second knuckle had a circular superficial open area approximately 1 cm in diameter. During a telephone interview on 1/12/12 at 1:55 p.m., the Occupational Therapist stated she completed the evaluation on Resident #1 on 12/15/11. On 12/16/11, she returned and saw Resident #1 with the hot pack on his right hand. She stated that staff should not have placed a hot pack on Resident #1's hand because of the resident's "decreased sensation" in that extremity and there was not a physician's orders [REDACTED]. She stated that she told COTA #1 to remove the hot pack. She added that the pack was wrapped correctly and did "not think it had been on very long." Interview with the Director of Nurses (DON) on 1/12/12 at 2:35 p.m. revealed an investigation into the incident involving Resident #1 began on 12/17/11. Although the facility had been unable to contact COTA #1, the resident had previously indicated to her the blisters came after the hot packs were applied. During a telephone interview on 1/12/12 at 3:30 p.m., COTA #1 stated she put the moist heat on the resident's right hand because she thought she had verbal approval from the OT. She stated she did not have a physician's orders [REDACTED]. She added that after she applied the hot packs, she stepped outside the door to discuss the resident with the OT. There was other staff in the therapy room at this time, but no one was specifically with Resident #1. She stated the hot pack was on the resident's hand for approximately 5 minutes. She also stated when she removed the hot pack from the resident's hand, she did not see any blisters Telephone interview on 1/18/12 at 12:55 p.m. with the physician confirmed Resident #1 had decreased sensation on his right side which would have been more of a risk. He stated that generally, he did not have a problem with moist hot packs but expected staff to obtain an order from him prior to using them.

Based on observation, record review and staff interviews the facility failed to position mattresses and side rails in such a manner to maintain the safety for two (2) of ten (10) sampled residents who utilized side rails. (Resident #2 and Resident #8) Immediate jeopardy began on 03/07/11 when staff found Resident #2 with her head under the side rail and the rail resting on her neck. This accident occurred when the head of the bed was raised and the resident slid to the gap created between the mattress and side rail. Immediate jeopardy was removed on 07/08/11 when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring of systems put in place and completion of employee education. The findings are: 1. A review of the bed rail operating instructions from the bed and side rail manufacturer for lowering and raising the bed rail revealed "caution: there will be a gap between the bed rails and the mattress when the bed is in the semi Fowler position (head of bed elevated approximately 30 degrees). Put the bed rails in the "MID" position to eliminate the gap." These operating instructions applied to all beds in the facility with full side rails. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had short term and long term memory problems and severe impairment in cognition. The MDS also indicated Resident #2 required extensive assistance to move to and from a lying position in bed, turn from side to side, and position her body in bed. A review of a Siderail Utilization assessment dated [DATE] for Resident #2 stated side rails were indicated and served as an enabler to promote independence in position and bed mobility. In addition it stated Resident #2 was non-ambulatory, had alteration in safety awareness due to a cognitive decline, had a history of [REDACTED]. A review of the Care Area assessment dated [DATE] indicated side rails x (times) two (2) used to aid in turning and positioning while in bed. The Plan of Care related to behaviors dated 12/23/10 indicated Resident #2 was "resistive with care (combative) and exhibited restless behavior (banged on tables/doors with fist and fidgeted)." A review of an incident report dated 03/07/11 at 11:10 p.m. revealed Resident #2 "got her head under bed rail and rail was pressing down on resident's neck. A note was left in the maintenance request book to look at bed rail. Bed rails removed from bed and mat by bedside." The incident report was signed by Licensed Nurse (LN) #1. A review of the nurse's notes on 03/08/11 stated "at approximately 11:10 p.m. last night this nurse was informed that resident had somehow gotten head under left bedrail and it was resting on resident's neck on right side of neck with substantial pressure. No apparent injury found upon physical assessment. Responsible party notified via phone call. Also Nurse Practitioner notified via physicians fax and communication book" The nurse's note was also signed by LN #1. A review of the updated care plan dated 03/08/11 and nurse's notes dated 03/09/11 for Resident #2 stated the bed rails were removed as of 03/08/11. These documents were signed by the MDS Coordinator. A review of the Abnormal Involuntary Movement Scale (AIMS) dated 03/24/11 revealed Resident #2 had mild upper extremity movements and no lower extremity movements. An interview on 07/06/11 at 3:28 p.m. with the Minimum Data Set (MDS) Coordinator revealed she revised Resident #2's care plan on 03/08/11 by deleting the side rails as an intervention. An interview on 07/06/11 at 3:37 p.m. with the Maintenance Director revealed Resident #2 had full side rails on her bed prior to the incident on 03/07/11. He explained when he came to work on the morning of 03/08/11 the former Administrator and Director of Nursing told him to remove the side rails from Resident #2's bed. He stated he removed the rails and did not recall they were damaged or out of position. He explained he was also told to push one side of her bed up against the wall and put a mat on the floor by the opposite side of the bed. He confirmed that Resident #2 was still in the same bed as the one she had on 03/07/11 but the bed was in a low position with the side rails removed. An interview on 07/06/11 at 5:18 p.m. with LN #1 revealed on 03/07/11 he was at the nursing station when NA #9 told him the bed rail was down on Resident #2's neck. He stated he immediately went to Resident #2's room and observed the resident lying on her side with her neck under the bed rail. He explained he had to release the side rail and remove it off the resident's neck. LN #1 stated the resident was not in any respiratory distress. He stated he pulled the resident back over in bed and assessed her. He explained he looked at her neck, did not see any bruising and would have charted it in his nurse's note if he had seen anything unusual. He stated he documented "substantial pressure" in his nurse's note to mean the actual weight of the side rail itself. He verified Resident #2 had full length rails on both sides of her bed and the head of her bed was raised up approximately 20 to 30 degrees. LN #1 stated he did not call the physician because he did not see any injury and faxed a note to the doctor after the incident happened. He explained he did not remember anyone in administration talking with him about the incident after it occurred. He further explained the next time he came to work he noticed the rails had been removed from the resident's bed. Her bed was pushed up against the wall and a mat was on the floor on the opposite side of the bed. LN #1 stated he didn't recall Resident #2 ever attempting to get out of bed. When asked, LN #1 stated he was unaware who had cared for Resident #2 on the previous shift or how long the resident had been positioned with her head and neck under the side rail. During a telephone interview on 07/07/11 at 1:25 p.m. NA #9 revealed she was assigned to care for Resident #2 on 03/07/11 during the 11:00 p.m. to 7:00 a.m. shift. She explained she was walking up the hall on her first round and discovered the resident lying on her side facing out of the bed with the bottom of the full side rail resting on her neck. She further stated the resident's color was pink and she did not note any respiratory distress when she entered the room. An interview with the current Director of Nursing on 07/08/11 at 11:34 a.m. revealed she reviewed the Nurse Aide flow sheets for 3:00 p.m. to 11:00 p.m. on 03/07/11 and determined NA #6 was listed on the schedule to care for Resident #2. She further stated she was not working in the facility at that time and was unable to confirm who actually cared for the resident on 03/07/11. A telephone interview with NA # 6 on 07/08/11 at 12:11 p.m. revealed she worked from 3:00 p.m. to 11:00 p.m. on 03/07/11 but she did not care for Resident #2. She further stated she did not know who took care of Resident #2 during the evening of 03/07/11 and she did not go into Resident #2's room. Review of the audit document entitled "side rails" dated 04/01/11 was performed by LN #2. A review of the audit results revealed six beds were marked with a star as "large space with head of bed up." There was no documentation available indicating what if any changes or corrective actions were made by administrative staff. Interview on 07/07/11 at 9:50 a.m. with LN #2 revealed following the accident on 03/07/11 involving Resident #2, administration asked her to check all resident beds (spaces between the mattresses and side rails with the head of the beds rolled up). She stated she found four to six beds with what she considered "too large" a space between the rails and bed. She stated she gave the information to administrative staff, who no longer worked in the facility and was unaware of any follow-up or corrective actions that were performed based on the findings of the 04/01/11 audit. 2. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. The latest Minimum Data Set ((MDS) dated [DATE] indicated impaired cognition and extensive staff assistance for all care including bathing, grooming, dressing, toileting, and transfers. The MDS assessment review revealed impaired mobility of both lower extremities and no impairment of upper extremities. A review of Resident #8's care plan updated 04/28/11 revealed Resident #8 was at risk for skin breakdown due to immobility, [DIAGNOSES REDACTED]. Review of the Siderail Utilization Assessment forms dated 04/19/11 for Resident #8 revealed the resident was non-ambulatory, the resident had alteration in safety awareness due to cognitive decline, demonstrated poor bed mobility of difficulty moving to a sitting position on the side of the bed, the resident had difficulty with balance or poor trunk control, was on medication which would require increased safety precautions, and was currently using side rails to enable positioning or support. The resident expressed desire to have side rails raised while in bed. An observation on 07/05/11 at 11:58 a.m. revealed Resident #8 lying in her bed on her back with her head and shoulders positioned in the middle of the mattress. Full side rails were observed in the up position on each side of the bed. The entire left side rail and foot end of the right side rail were observed fitting flush with the bed frame. The right side rail was splayed outward at the head of the bed with the mattress shifted against that portion of the side rail. This position exposed the bed frame on the left side leaving a gap between the mattress and the head portion of the left side rail of approximately eight (8) inches. An observation on 07/05/11 at 3:15 p.m. revealed the positions of both side rails and mattress unchanged. Resident #8 remained with her head and shoulders in the middle of the mattress. An observation on 07/05/11 at 5:27 p.m. revealed Resident #8 in bed with head of bed in the up position eating her supper without assistance. The right and left side rails remained in the up position. The bed frame continued to be exposed at the head of the bed on the left side in the manner as described above. At 6:00 p.m. on 07/05/11 an observation of Resident #8's mattress and right side rail position was made with the Maintenance Director, Administrator, and Administrative Manager. The position of the side rails and mattress and the gap created at the head of the bed on the left side remained unchanged. The Maintenance Director explained the right side rail latch had become disengaged from the bed frame at the head of the bed causing the rail to stretch outward from the bed. The Administrator was observed unable to lower the right rail. The Maintenance Director stated he previously observed side rails in this facility to splay in this manner before, although, it was not a frequent occurrence. He was unable to explain why it happened. He continued he had no prior knowledge of the separation observed on Resident #8's bed. The Maintenance Director, Administrator, and Administrative Manager verified the resident could possibly place her head in the gap created on the left side of the bed and should be fixed immediately. They also acknowledged this situation should have been reported by nursing and direct care staffs. An interview on 07/05/11 at 6:10 p.m. with Licensed Nurse #2 revealed she had administered medications to Resident #8 throughout the day. She stated she did not observe the right side rail stretched out from the bed with the bed frame exposed at the left side of the head of the bed. An interview on 07/06/11 at 9:12 a.m. with Nursing Assistant (NA) #3 revealed she provided Resident #8 with care during the 7:00 a.m. to 3:00 p.m. shift on 07/05/11. She stated she did not notice the splayed position of the right side rail nor the exposed bed frame on the left side of the head of the bed. NA #3 added she did not attempt to lower the right side rail anytime on 07/05/11. The Administrator was informed of Immediate Jeopardy on July 7, 2011 at 4:35 p.m. for Resident #2 and Resident #8. The facility presented a credible allegation of compliance which included: For Resident #2: On 3/07/2011 the facility nursing staff raised the side rail, and pushed left side of the bed against the wall. The staff communicated the incident in the Maintenance book and faxed the physician. On 3/08/2011 The Maintenance Director at the facility removed the side rails and placed a protective bedside mat for Resident #2 as directed by the Administrator. On 3/16/2011 a personal alarm was placed on Resident #2 while in chair. To ensure that this alleged deficient practice does not currently exist, the facility has completed a side rail assessment on Resident #2 on 7/08/2011. The Kardex (information tool used by the nursing assistant to carry out approaches noted on the residents plan of care) and care plan of Resident #2 were reevaluated on 7/08/2011 by the MDS Coordinator and found all previous approaches (discontinuing side rails, using a low bed with bed side mat and bed alarm) are appropriate. Resident #8: On 7/06/ the splayed right hand rail was repaired. On 7/7/2011 the MDS Coordinator conducted a side rail assessment on Resident #8 using the side rail evaluation form. The form evaluates the need for side rails based on the following factors that include but are not limited to the resident's medical condition, bed safety, fall history, mobility, expressed desire and risk factors. Utilizing this assessment form, it was determined Resident #8 could safely use ? rails for turning and positioning. The Kardex and care plan was also updated to reflect this change. The Maintenance Director at the facility then removed the full length side rails, replaced with ? length side rails for Resident #8 and lowered the bed as directed by MDS Coordinator. Beginning 7/08/2011 Resident #8 will be monitored using a facility audit tool which consists of proper positioning of side rails, side rail locked in place, space between mattress and rail is less than four inches, side rail is securely fastened in position, and the locking mechanism is functioning . Resident #2 is assessed to ensure that her mats are properly placed at bedside. Each bed is assessed using the side rail audit tool at the beginning of every shift by the assigned nursing assistant. If the audit tool reflects interventions for Resident #2 and Resident #8 are needed corrective action will be taken immediately. The findings of these audits are reported immediately to the charge nurse, who in turn will call the DON. These immediate corrective actions can include but are not limited to repositioning of resident, placing a barrier such as pads or rolled up blankets to close any potentially dangerous gap(s), adjusting the side rail to a safe level and any mechanical failures reported to the Maintenance Director. The charge nurse will then inform the Administrator and/or DON. The Administrator and/or DON also reviews the side rails audits daily and will continue so for the next 30 days. They will then review them weekly for the next 60 days. Non-compliant issues will be addressed immediately by the Administrator and or DON and interventions put in place. In addition, all non-compliant findings will be addressed at monthly QA meetings. To ensure that other residents are not affected by non-complaint side rail issues, all residents with side rails will have a side rail assessment completed by the facility's MDS Coordinator on 7/08/2011. All resident care plans and Kardex were updated as of 7/08/2011. Each bed in the facility was assessed on 7/08/2011 by the Director of Maintenance to ensure that the side rails are in working condition, installed properly and do not impose an entrapment risk. The audit and assessment revealed 28 full side rails in use. Out of that 28, 8 side rails were removed and 14 changed to half rails. On 7/08/2011using the mentioned side rail audit tool, each resident was checked by the DON or Administrator to ensure his/her side rail does not impose any entrapment risk. No gaps larger than 4 inches between the mattress and side rails were found, all rails were fastened correctly and tightly and no evidence of potential entrapment found. The Maintenance Director or Nursing Supervisor will check each side rail daily for the next 30 days to ensure that side rails are securely fastened and no space greater than 4 inches exist. The Maintenance Director or Nursing Supervisor will then check each side rail weekly for the next 60 days to ensure that side rails are securely fastened and no space greater than 4 inches. Any non-compliant findings will be addressed immediately with corrective actions to ensure resident safety. Further actions and assessments will be evaluated at monthly QA meetings. All nurses certified nursing assistance, housekeepers, and department managers were in serviced by the facility Administrator, Facility Administrative Manager or DON on 7/07/2011 and 7/08/2011. Any individual who has not completed this in service by 7/08/2011 will not be allowed to work until completion is achieved. The in service included: proper positioning of full side rails when head of bed is elevated, side rails locked in place, checking for space of less than four inches between mattress and bed, side rail is securely fastened to the bed, and when raising and lowering the side rail the bed functions with no risk of entrapment. Each certified nursing assistant was instructed to complete a side rail tool by auditing the residents that they are assigned before the start of duty beginning second shift 7/08/2011. After the 3rd shift on 7/08/2011 the auditing will take place at the beginning and end of each shift. Any findings during the audit process that require corrective actions by the nursing assistant will be taken immediately to ensure resident safety, and these audit findings will be reported to the charge nurse. These immediate corrective actions include but are not limited to repositioning of resident, placing a barrier such as pads or rolled up blankets to close any potentially dangerous gap, adjusting the side rail to a safe level and any mechanical failures reported. The administrator is to be alerted immediately of any issues that can not be immediately resolved. The charge nurse informs the Administrator and/or DON of any issues reported. The Administrator and/or DON also reviews the side rails audits daily and will continue so for the next 30 days. They will then review them weekly for the next 60 days. Non-compliant issues will be addressed immediately by the Administrator and or DON and interventions put in place. In addition, all non-compliant findings and interventions as well as outcomes will be addressed at monthly QA meetings. To ensure that the system of preventing accidents of potential bed rail entrapment remains in place and that the facility remains in compliance; the DON or Administrator will audit daily the completed side rail tools completed by the nursing assistant daily for the first 30 days then weekly for the following 60 days. The Maintenance Director will complete an audit consisting of making sure all rails fit the bed properly and are in good working order weekly for 60 days. The Administrator will complete a report weekly of all identified issues that were non-compliant, and the corrective action, weekly. A copy of this report will be submitted to the facility IDT team, conduct a Patient at Risk Meeting and review appropriateness of interventions. The IDT Patient at Risk meeting will be attended by Administrator, DON, MDS Coordinator, Director of Therapy, Social Worker and Dietary Manger. The results of these audits will be compiled monthly and present to QA&A. The QA&A committee will address any finding of non compliance by educating individuals or using new interventions as necessary. Immediate Jeopardy was removed on July 8, 2011 at 7:55 p.m. with interviews of direct care and licensed nursing staff who confirmed they received in-service training on 07/08/11 prior to reporting on duty. Interviews with nursing staff revealed awareness of the monitoring tool to be completed at the beginning and end of every shift. Nursing staff was able to state actions to be taken if side rails were not fitting properly or presented a safety hazard. Staff also related knowledge of proper positioning of full side rails when the head of the bed was elevated. All resident beds were observed while accompanied by licensed and non licensed nursing staff. Observations revealed bed rails were securely attached to the bed frames and appropriate to resident needs.

Based on observation, record review and staff interview, the facility failed to properly transfer one (1) of three (3) residents with a mechanical lift. (Resident #1) The findings are: Resident #1 was most recently readmitted to the facility 11/08/07 with [DIAGNOSES REDACTED]. Review of Resident #1's current care plan revealed she was care planned for assist with activities of daily living. Care plan interventions were revised 04/11/11 to include use of Hoyer lift (mechanical patient lift) with transfers. Review of Resident #1's current care guide/kardex specified to transfer her using a mechanical lift with two person assist. On 05/05/11 at 9:15AM Nurse Aide (NA) #1 and NA #2 were observed transferring Resident #1 from the wheelchair to bed with mechanical lift. The resident was transferred safely with no complications. Interview with NA #1 and NA #2 at this time revealed they had the mechanical lift equipment for approximately two months. Interview with NA #1 and NA #2 stated they received training for use of the mechanical lift equipment and residents were transferred with two person assist. On 05/05/11 at 2:00PM NA #1 was observed at Resident #1's bedside. Resident #1 was observed lying in bed, alert, with no apparent sign of distress noted. Interview with NA #1 at this time revealed she had just attempted to transfer Resident #1 from wheelchair to bed using the mechanical lift without assistance. NA #1 stated she was aware that Resident #1 required two people to assist with transfers, but stated all other direct care staff were busy providing care to other residents and no one was available to assist so she performed the transfer by herself. NA #1 stated that she applied the sling and checked the side release hooks on each side of the sling to make sure the hooks were secure before she proceeded to transfer the resident. NA #1 stated the click mechanism on one of the hooks came apart as she began to lift the resident, the resident fell from the sling and hit her head on the floor. Observation of the sling at this time showed no sign of being torn or frayed; the side release hook on the left side of the sling was observed with prongs out of alignment. Licensed Nurse (LN) #1 was observed at Resident #1's bedside at this time assessing her condition. LN #1 stated the resident had no change in level of consciousness and her neurological status was stable. EMS arrived to the unit and transported Resident #1 to the hospital for evaluation. On 05/05/11 at 3:40PM an interview with the Administrator revealed that nursing and direct care staff were inserviced on two occasions on the use of the mechanical lift equipment. The Administrator was unable to provide the exact dates of training but provided one staff roster of an inservice dated 04/11/11. The Administrator was unable to provide an agenda of training content or validation of skills competency. Review of staff roster confirmed NA #1 attended the training session for use of the mechanical lift. The Administrator stated that she expected staff to follow Resident #1's care guide which specified two person assist was needed when transferring the resident with the mechanical lift. The Administrator stated she would expect staff to wait for assistance to transfer Resident #1 safely. On 05/05/11 at 5:00PM an interview with the Maintenance Director revealed the mechanical lift equipment was obtained from a sister facility a few months ago. The Maintenance Director stated that he checked all the slings for any signs of disrepair when the equipment was received. The Maintenance Director stated he identified and discarded one sling with this type of mechanism because it would not stay securely clasped. The Maintenance Director stated the grooves on the side release hook mechanism eventually wore down with repeated use over a period of time and would not be secure enough to transfer residents safely. The Maintenance Director stated he had observed staff transfer residents using the mechanical lift without assistance. On 05/05/11 at 7:30PM Resident #1 returned to the facility via EMS transport. Review of hospital discharge paperwork indicated Resident #1 sustained closed head trauma with a cervical (neck) sprain in otherwise stable condition.

Facility remains out of compliance. Refer to CMS 2567 (survey event id: 2QW011).