Every finding on record at Kulana Malama

Based on observations, interviews, and record reviews, the facility failed to implement infection prevention and control measures when providing care for residents. The facility did not ensure that staff was wearing applicable Personal Protective Equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions (EBP), changed gloves after performing a dirty task and before performing a clean task, and ensure connecting tubes for tube feeding were not exposed. This deficient practice placed the residents at risk for the potential spread of infections and communicable diseases. Findings Include: 1) On 09/23/25 at 09:35 AM, during an initial observation of Resident (R) 24, observed R24's feeding port disconnected from the feeding bag. The feeding bag was full of formula and the tube that connects from the feeding bag to the feeding port was exposed not covered. A purple cap connected to the tube was not covering the exposed tube as intended. At 09:44 AM, Registered Nurse (RN) 26 was observed entering R24's room to provide nursing care. RN26 was observed preparing R24's tube feeding and connecting the tube from the feeding bag to the resident's feeding port. During the connection process, it was noted that the tube was not covered with the designated purple cap. When asked about this, RN26 confirmed the cap had not been in place and acknowledged it should have been for infection control purposes. On 09/26/25 at 10:28 AM, an interview was conducted with Director of Nursing (DON). DON confirmed the designated purple cap should have been on, covering the connecting tubes, for infection control purposes. 2) On 09/25/25 at 12:28 PM, observed RN55 suction R18's tracheostomy tube without donning a gown. On 09/26/25 at 10:28 AM, an interview was conducted with DON. DON stated staff should be wearing gowns when suctioning residents. 3) On 09/23/25 at 09:42 AM, observed three staff members assisting R2 transfer out of bed and onto a gurney for transport to a doctor's appointment. Respiratory Therapist (RT)5 suctioned R2's tracheostomy tube (medical device inserted into the trachea or windpipe to establish or maintain an airway for breathing) while sitting up on the bed and was not wearing a gown. 4) On 09/24/25 at 09:18 AM, observed RN34 provide tracheostomy and gastrostomy tube (medical device inserted through the abdominal wall and into the stomach to provide a direct route for delivering nutrition, medications, and fluids to the stomach) care for R3. RN34 performed hand hygiene, donned gown and gloves and performed tracheostomy care. RN34 then removed her gloves, performed hand hygiene and performed gastrostomy tube care and proceeded to suction tracheostomy tube without changing her gloves and performing hand hygiene. 5) On 09/25/2025 at 8:03 AM observed RN19 during medication pass. RN19 performed a glucose check, suction, medication pass and started a tube feeding with R1. R1 is an [AGE] year-old resident. RN19 was observed using a hand sanitizer to clean her hands and put on clean gloves before performing the glucose check and disposed of the dirty gloves and performed hand hygiene before putting on a new set of clean gloves before suctioning R1. After suctioning was done RN19 disposed of dirty gloves, did hand hygiene and then put on clean gloves before giving R1 his medications through his gastrostomy tube. Afterwards RN19 connected R1's tube feeding to his gastrostomy tube and started R1's feeding. RN19 did not put on a gown prior to performing care with R1 who is on Enhanced Barrier Precautions. 6) On 09/25/25 at 08:11 AM, observed RN11 administer medications to R9. After administering the medications, RN11 suctioned R9's tracheostomy tube without donning a gown. 7) On 09/25/25 at 08:29 AM, observed RN11 suction R22's tracheostomy tube without donning a gown. On 09/26/25 at 11:16 AM, an interview was conducted with the Infection Preventionist (IP) at the seating area by the nurse's station. IP confirmed that the staff are to wear a gown when performing tracheostomy tube suctioning and change gloves and perform hand hygiene before suctioning the tracheostomy. Review of facility policy titled Enhanced Barrier Precautions stated, . Enhanced barrier precautions apply when . a resident has a wound or indwelling medical devices . include central lines, urinary catheters, feeding tubes and tracheostomies . EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities . Examples of high-contact resident care . device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) .

Based on record review and staff interview the facility failed to assure one of seven residents (R) 25, sampled for Respiratory Care, had documentation of two unplanned decannulations of her tracheostomy tube. The deficient practice does not reflect R25's health status when there was a change in her condition which required prompt staff intervention to maintain her airway. This deficient practice could affect all residents in the facility who have a tracheostomy tube and experience an unplanned decannulation that staff are not documenting a change with the resident in the resident's Electronic Health Record (EHR). Findings Include:On 09/25/25 lead surveyor requested and received a list of adverse events that occurred within the last six months from the Administrator. Review of the incident log provided revealed R25 had two unplanned decannulations on 06/18/25. Requested copies of incident reports and root cause analysis for decannulation that occurred with R25 on 06/18/25 from the administrator which she was able to provide on 09/25/25 at 05:05 PM. Review of the incident reports found the following: Facility incident report on 06/18/25 at 1430 (02:30 PM) stated R25 had been provided care by Certified Nurse Aide (CNA) 17 and CNA32 who witnessed R25's decannulation. CNA17 and CNA32 documented in the incident report After we changed her diaper, we were about to reposition her and she started laughing, she titted (sic.) her head back and her trach came out. Registered Nurse (RN) 17 documented on the same incident report R25 decannulated after her diaper was changed. She was laughing and her trach came out. Per CNA she called for help. RT (respiratory therapist) reinserted the trach w/o difficulty, no issues. SpO2 100% HR (heart rate) 80's, trach ties [NAME], not loose prior and during incident. Resident hyperextended neck and trach came out. Review of R25's progress notes in her EHR did not reveal a progress note written by a nurse or RT regarding this unplanned decannulation. Facility incident report for second decannulation with R25 stated the incident occurred on 06/18/25 at 22:45 (10:45 PM). CNA 29 and CNA15 documented the decannulation was witnessed and Changing brief leading to hyperextension of neck meanwhile holding trach tubing beeping of vent leading to decrease in respiration, looking/assessing what happened/why vent is beeping, call RN, Assess trach tube dressing and saw trach tubing out of trachea and trach tie was tied/ not loose. RN24 documented what was reported Saw trach out while performing care, beeping of vent was occurring, assessing and saw trach dressing, lifted trach dressing and saw trach tube of out trachea. Review of R25's progress notes did not reveal a progress note written by a nurse regarding this unplanned decannulation. On 09/26/2025 at 10:24 AM interviewed Respiratory Services Supervisor (RSS) in the conference room. Inquired of RSS about R25's two incidents of unplanned decannulation with her tracheostomy tube on 06/18/25. RSS reported R25 was refitted for a custom size trach which is longer and helps to prevent decannulation from occurring. RSS stated R25's trach was short and contributed to the decannulation when R25 hyperextended her neck. On 09/26/2025 at 10:58 AM interviewed Respiratory Therapist (RT) 16 in the conference room. Inquired about the incident with R25 that occurred on 06/18/25 when she had a decannulation of her tracheostomy tube. RT16 confirmed he was working this day and stated he believes he was assigned to R25. RT16 confirmed he helped when the decannulation occurred and he responded when staff yelled for help, and he put the trach back in. RT16 stated She (R25) was not in distress. Inquired if R25's O2 saturations decreased and RT16 stated he could not remember if she desated and stated there was no color change. She tolerates a quick decannulation okay. Inquired if he charted this incident in R25's EHR and he stated he did not believe it is expected of him to chart in the EHR this change that occurred with R25. On 09/26/2025 at 11:44 AM interviewed the Director of Nursing (DON) in the conference room. Inquired who would document an incident such as a decannulation of a resident's tracheostomy tube and he stated the nurse. DON confirmed the nurse who responded to the incident would document in the residents EHR about the incident. Requested a copy of the facility's documentation policy which the DON provided. Review of the facility policy Nursing Documentation in the Medical Record states Purpose: To provide a legal record of the nursing care that has been administered; to keep an accurate record of the resident's condition and course of stay; and to provide guidelines for documenting in the medical record. Policy: Nursing staff are required to document care provided to the resident in the medical record and to use the documentation as a means of communication and coordination of care with other healthcare providers. This includes Progress Notes, .

Based on observation, interview, and record review, the facility failed to ensure that stored food items at the off-site kitchen were discarded by their expiration or use-by dates. This failure created a potential risk of foodborne illness for two of two residents (Resident (R) 21 and R33) who received food for pleasure feeding and/or the introduction of solid foods from the off-site kitchen.Findings Include:On 09/23/2025 at 08:12 PM, during an initial tour of the off-site kitchen, observation and interview were conducted with the Lead [NAME] (LC). LC stated that meals are prepared at this off-site kitchen for a selective few residents, but does not know the specifics. When asked whether food designated for these residents was stored separately, such as on a designated shelf in the refrigerator or a separate area in the dry goods storage room, LC stated there was no separation in place.Concurrent observation in the walk-in refrigerator revealed cut and prepped onions stored in a large clear plastic container labeled with a discard date of 09/20/2025. Additionally, a tall clear plastic container of apples, identified by the LC as canned apples, was labeled with a discard date of 09/21/2025.Further observation in the dry goods storage room revealed 12 large cans of corned beef hash, each labeled with an expiration date of April 2025. LC confirmed that these items were past their use-by or expiration dates and acknowledged they should have been discarded.On 09/26/25 at 09:12 AM, an interview was conducted with Recreation Coordinator (RC). RC confirmed that two residents, R21 and R23, occasionally receive food prepared at the off-site kitchen. While both residents receive their primary nutrition via feeding tubes, they are offered opportunities to be introduced to solid foods. RC explained that a list of food preference, including likes and dislikes, was provided to the off-site kitchen. Dietary staff use this list to tailor meal preparation to the residents' preferences. In addition, new foods from the weekly menu are occasionally introduced for trial. The RC noted that R21 and R23 typically try these foods on weekends, when they are not attending school.Review of the facility's policy and procedure Food Receiving and Storage revised in 11/22, documented Refrigerated food are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on observation, interview, and record review, the facility failed to ensure staff members spoke amongst each other in a language understood by the resident they are providing care to, for one of two residents (Resident (R) 18) reviewed for dignity. This puts R18 at risk for feelings of exclusion, loss of dignity, and potential misunderstanding of care being provided. Findings Include: On 09/24/25 at 12:13 PM, during an observation outside of R18's room, observed his curtain drawn, at least two pairs of staff members feet can be seen around R18's bed and another staff member was observed to moving around the room. A Filipino language can be overheard from staff members outside of the room. After surveyor knocked on resident's room door, the staff members began disbursing except for the staff member administering medication. The three staff members quickly began speaking English and the staff member administering medication began talking to R18 in English to inform him of the medication she was administering. On 09/25/25 at 03:05 PM, an interview with a visitor (V1) of another resident (R7) reported staff members speak a different language other than English in front of the residents while providing care. V1 had informed the facility multiple times to speak English in front of R7 and does not feel it's appropriate to speak another language if it is not a resident's primary language. V1 has not only observed staff speaking a different language in front of R7 but other residents. Review of the employee handbook pages 57 and 58 date 01/25 provided be Administrator document under OTHER POLICIES Speak-English-Only Rule the document instructs In order to maximize the quality of residents care and to assure that the best interested of residents are served by employees .the facility] requires that employees speak only English while they are on duty attending to residents' needs or while they are in areas where resident care is delivered .

Based on interviews, medical record review and document review, the facility failed to assure that all nursing staff possessed the competencies and skill sets necessary to provide nursing care to meet residents' needs in a safe manner. Specifically, the licensed staff did not demonstrate 1) competency to perform and document neurological (neuro) assessments on a Resident whose baseline was neurologically impaired, 2) competency to identify a medical emergency that required timely response and transfer to a higher level of care, and 3) critical thinking to recognize the need to conduct and document a thorough physical and neurological assessment after a fall with potential head/neck injury, to determine if the Resident could be safely transferred from the floor to the bed. Due to the serious nature of this citation, and the fact that multiple licensed staff were involved, and did not demonstrate competency, this deficient practice was determined to be an immediate jeopardy (IJ). The survey team approved the facility abatement plan and validated it had been implemented. If nursing staff do not possess the competencies and skill sets for the population served, it could affect any resident and place them at risk of adverse events, harm or death. Findings include: 1) The facility is a 36 bed facility that cares for pediatric and adult residents that have complex medical issues. There is a high volume of residents that have cognitive and physical disabilities and require complex respiratory support due to various causes. This resident profile requires that all nursing staff have special skill sets to meet residents' medical needs. At the time of survey, the census was 33, nine adults and 24 pediatrics. Reviewed the Facility Assessment Tool last updated 03/05/2025. The document revealed the following: Part 1: Our Resident Profile included Diseases/conditions, physical and cognitive disabilities. These conditions included, Neurological Problems, which was further broken down to include but not limited to Traumatic Brain Injury, Minimal Consciousness, Vegetative State, Seizure disorder, Communication Difficulty and Anoxic Brain Damage. Part 2: Services and Care We Offer Based on our Residents' Needs, included Management of medical conditions. The Specific Care or Practices for Management of medical conditions read Assessment, early identification of problems/deterioration, management of medical symptoms and conditions . Part 3.4 Staff training/education and competencies, included staff training/education and competencies are necessary to provide the level and types of support and care for the residents.Staff competencies are monitored by department supervisors and nursing's scheduler. The assessment included Supplies, which listed respiratory, medical and nonmedical supplies. It was noted the list did not include a pen light, which should be used for neurological assessments. 2) R1 was a [AGE] year old male with history of traumatic brain injury (TBI) with subdural hematoma (bleeding inside the head). He had a decompression craniectomy (part of the skull is removed to reduce pressure on the brain and allow swelling). As a result of his injury, R1 was a quadriplegic (paralysis of all limbs), had a tracheostomy (hole in neck to breath), and a PEG (tube into the stomach through the abdominal wall for feeding). On 03/16/2025 at approximately 08:20 PM, R1 sustained a fall from bed; reported while being changed by a Certified Nurse Assistant (CNA). He had altered mental status (AMS), and was transferred to the hospital emergency room (ER) by ambulance for further evaluation on 03/17/2025 at 02:20 AM. R1's cat scan (x-ray of head) was negative at that time, for acute traumatic injury and he was discharged back to the facility, that same day (03/17/2025) at 12:10 PM. On arrival back to the facility, R1 was assessed to have altered mental status (AMS) from his baseline and was subsequently sent back to the hospital a second time on 03/18/2025 at 09:42 PM. That hospital transferred R1 to another facility (referral center) for further management, where he was admitted with primary diagnosis of subacute encephalopathy, multifactorial (disease affects the brain and leads to AMS). Despite treatment of the suspected causes of the encephalopathy, his mental status did not significantly improve and he was transitioned to comfort care and ultimately passed away on 04/05/2025. 3) Reviewed Nursing documentation that included [NAME]-Daily Assessment (template documentation format) notes as well as Health Status Notes (progress notes) after the fall, to the time R1 was initially transferred to the ER. These records included the following: 03/17/2025 Note entered at 08:52 AM: @2020 (03/16/2025, 08:20 PM), CNA assigned to the resident was changing the resident's diaper when the resident fell on the floor. Upon assessment found one linear redness to the right upper forehead measuring 2 cm (centimeter) x 0.5 cm, skin intact. No other visual injuries noted.CN (Charge Nurse) and this nurse @ bedside. @20:30 (08:30 PM on 03/16/2025) resident awake BP (blood pressure) 130/86. HR (heart rate) 62 T. (temperature) 35.5 (centigrade) RR (respiratory rate) 22 Awake, alert. @ 2035 (08:35 PM on 03/16/2025) BP 145/84 HR 60 O2 (oxygen saturation) RR 22. @ 2052 (08:51 PM on 03/16/2025) x 1 desat (desaturation (drop in oxygen level)) to 86% . RT (respiratory therapist) placed the resident on RC 28% BP 127/87 HR 59 O2 99 T 36.6. @ 2031 (08:31 PM) DON (Director of Nursing) made aware. @ 2112 (09:12 PM ) Attempted to call the doctor on .CN (Charge Nurse) phone, no answer. @ 2020 (08:30 PM) BP 127/87 HR 59 O2 99 T 36.6. @ 2128 (09:28 PM on 03/16/2025) sent Dr (MD1) a message regarding an update on resident's status and also called physician exchange @ 21:32 (09:32 PM). @ 2145 (09:45 PM) BP 134/87 HR 55 O2 100 T 36.5. @ 2217 (10:17 PM) BP130/87 HR 53 O2 100 RR 20. @ 2252 (10:52 PM) BP133/82 HR 51 O2 99. @ 2325 (11:25 PM) BP 124/72 HR 53 O2 100 RR 18. @ 0000 (00:00 AM on 03/17/2025) RT weaned the resident back to RN (room air), BP 109/63 HR 59 T 36.2 O2 98 RR 18. @ 0025 (00:25 AM on 03/17/2025 BP 103/69 HR 58 T 36.1. @ 0036 (00:35 AM on 03/17/2025) Called physician exchange again to follow up on not receiving a call back from the doctor. @ 0115 (01:15 AM on 03/17/2025) .during this assessment resident appeared more lethargic (drowsy, decrease in consciousness that affects mental status) than usual, no response to sternal rub (painful stimulus to test consciousness), and no response to yes or no questions . CN made aware again. Resident's baseline-responses yes or no to questions by blinking. @ 0153 (01:53 AM on 03/17/2025) MD1 called the facility back .Dr stated to send the resident out (to ER). @ 0206 Called 911. @ 0218 BP 134/86 O2 98 HR 61 RR 18. @ 0220 Resident transferred . 03/16/2025, 11:58 PM - 03/17/2025: [NAME]-Night Shift: Neurological LOC (level of consciousness): Alert. The areas on the form for Oriented, and Pupils were not completed. Although vital signs were documented and taken on a schedule that is standard for post fall with potential head injury, the nursing staff failed to do full neurological assessments, which should include LOC, and pupillary reaction. LOC for R1 would be if he could respond the way he usually did, blinking eyes to yes and no questions, smiling, response to suction and any sensation he may have (baseline could not be determined by documentation). Based on nursing notes, there was a significant change in condition at 01:15 AM, when R1 was not responsive to sternal rub and lethargic. With calls out to notify MD1, with no response, the nursing staff should have had the skill set to identify this as an emergency condition, called 911 and transferred R1 to the hospital. 4) Reviewed Nursing documentation from the time R1 returned to the facility prior to being transferred to ER for the second time. 03/17/2025 entered at 07:14 PM, Progress note: Resident back from QMC (hospital) @ 1210 (PM) .Noted L (left) cheek with redness and slightly swollen. Resident is less responsive, compared to his baseline. Does not blink eyes to questions asked. (Use to blink when talked to and if it's 2 x blink it means yes). Bilateral eyes constantly moving left to right or right to left side only. Able to clean his mouth using yankauer (suction tool) without difficulty. (Used to bite yankauer when doing oral care and smile at staff). Tongue constantly moving and deviated to the left. There is no evidence R1's physician was contacted to report R1's neuro status on return to the facility, which was not his baseline. 03/17/2025, 11:50 PM-03/18/2025 [NAME]-Night Shift: Neurological LOC: Alert. The areas on the form Oriented and Pupils, were not completed. Nursing note: .complete neuro (neurological) checks and vitals q 4 hr (every four hours). No blinking response to yes or no questions, bilateral eye movement continues to move left to right. Although complete neuro checks was documented to be done in the nursing note above, the entries were not found. 03/18/2025, 07:49 PM (Late Entry), Day shift Progress Note: .Received bedside report from NOC (night) RN. Per NOC RN Vitals are stable, but he seems lethargic and not at his baseline.RN called patient by their name and no response. RN opened patient's eyelid and flash a light to pupils. Non reactive and constricted, .RN made jokes to make the patient smile. Patient blinks as a form of communication.Patient was non-reactive, no smile and bilateral eyes were in horizontal nystagmus (involuntary rapid eye movements). RN assess eyes again and no change.Frequent checks made on patient through the night.No further neuro signs noted. Patient is nonreactive and eyes remain horizontal nystagmus.no smiling. 03/18/2025, 10:06 PM-03/19/2025 [NAME]-Night Shift: The neurological area on the form was not completed. Nursing Note: Pt (R1) was sent out to QMC (hospital) at 21:43 (09:43 PM). Pt had fall 3/17 (actual date was 03/16/2025), was sent to the ER for assessment, but was sent back to KM (facility) due to no abnormal findings. Pt's baseline is responsive. However, at BSSR (bedside shift report) and during med pass, pt noted to have a significant difference. Pt noted to also have pin-point pupils and increased lethargy. See Charge RN progress notes for further details . 03/18/2025, 10:26 PM, SBAR (Situation, Background, Assessment, Recommendations) report documented by NOC Charge RN: S: resident s/p (post) fall on 3/16, hx of TBI and VP shunt. Noted AMS upon starting shift and eye abnormalities. Concern that Resident needs reevaluation in ED for abnormal findings not consistent with baseline or expectations after a fall. B: resident p/fall on 3/16, returned to facility on 3/17 after having CT (cat scan) that showed no abnormal results. PMH (Past medical history) hx of TBI with VP shunt (tube that drains excess cerebrospinal fluid into abdomen), convulsions, quadriplegia. At baseline resident is responsive, laughs, tracks with eyes, no nystagmus, and blinks for yes and not blinking for no. A: resident with AMS, difficulty to arouse, lethargic, pupils pinpoint, nonreactive and fixed, noted to have constant horizontal nystagmus that is uncontrolled, unable to track, appears to have decreased facial muscle tone blinking. After awaking resident, noted that he was attempting to answer questions, however d/t (due to) facial tone he could not close his eyes while blinking. S: contacted MD1 (Provider) @ 2050 (08:50 PM), received orders to send resident to ER for revaluation.called 911 at 2120 (09:20 PM) and resident transferred .at 2145 (09:42 PM). In addition to the notes above, the staff initiated the Neurological Assessment Flow Sheet when R1 returned to facility 03/17/2025 at 12:10 PM. The flow sheet included instructions and area to document Level of Consciousness (LOC), Pupil Response, Motor functions-Hand grasps, Extremities, Pain Response and Vitals. It directed staff to use the Observation Column to note the presence or absence of specific resident conditions. Reviewed the flow sheet, which included the following: 03/17/2025 at 12:10 PM: Vital signs documented. 03/17/2025 at 01:47 PM: Vital signs documented. 03/17/2025 at 01:47 PM: Vital signs documented. 03/17/2025 at 01:47 PM: Vital signs documented. 03/17/2025 at 01:47 PM: Vital signs documented. 03/18/2025 at 12:00 PM: Vital signs documented. 03/18/2025 at 04:07 PM: Vital signs documented. There were no neurological assessments of LOC, Pupil response, or observations documented on this flowsheet. The Neurological assessment documented on return to the facility (03/17/2025, day shift) indicated R1 was not at his baseline. Assigned nursing staff night shift ( 03/17/2025 to 03/18/2025) and day shift 03/18/2025, continued to document he was not at baseline. In addition, the neuro exams did not consistently include pupillary response. It was not until 03/18/2025 at 08:50 PM, over 24 hours later, that the physician was notified for order to transfer to ER for reevaluation. 5) Review of Falls - Clinical Protocol policy and procedure, last revised March 2018. The policy included the following: .the nurse shall assess and document/report the following: .Change in condition or level of consciousness; . Neurological status; . The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved .signs of subdural hematoma or other intracranial bleeding could occur up to several weeks after a fall. This policy did not include any specifics as to how or when to do neuro checks. Reviewed the facility policy titled Neurological Assessment (Routine), last revised October 2023. The purpose statement was . to provide guidelines for conducting a routine neurological assessment (neuro checks). Equipment listed that was necessary when performing this procedure included a flashlight and documentation tool. The policy included: 1. Routine neurological assessment is conducted to evaluate the resident for small changes over time that may be indicative of neurological injury. 2. Routine neurological exams include assessing: a. mental status and level of consciousness; b. pupillary response; . Neurological Assessment/Evaluation included: 1. Mental Status: a. Determine the level of consciousness and alertness. b. Determine orientation to time, place and person. 2. Pupillary Response: a. Test both pupils to ensure they are equally reactive to light and accommodation. b. diameter of the pupils usually ranges from two to five millimeters, c. Test pupillary reaction to light. (1) Dim the lights of the room before performing this test (2) Using a penlight, approach the patient from the side. (3) Shine the penlight on one pupil. Observe the response of the lighted pupil. It should quickly constrict (direct reaction). The other pupil should constrict (consensual reaction). (4) Repeat with the other pupil. The policy included the expectation to document all assessment data obtained in the medical record, and Notify the physician of any changes in a residents neurological status. This policy was not specific regarding the frequency of neuro checks On 06/17/25, between 07:30 AM and 04:30 PM, multiple confidential interviews were done with facility staff. During an interview with Anonymous Staff Member (ASM)9, he/she reported that they had noticed after a review of the facility's policies and procedures that there was nothing found regarding conducting a neurological (neuro) assessment after a fall. Reviewed the facility policy titled Change in a Resident's Condition or Status, last revised February 2021. The policy statement was Our facility promptly notifies the resident, his or her attending physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. The policy included: 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an) a. accident or incident involving .; d. significant change in the resident's physical/emotional/mental condition; g. need to transfer the resident to a hospital/treatment center; . 2. A significant change of condition is major decline . in the resident's condition status that: a. will not normally resolve itself without intervention . 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (structured report for physician communication; Situation, Background, Assessment and Recommendation) Communication form. 7. The nurse will record in the resident's medical record information relative to changes in the resident's medical .condition or status. 6) On 06/16/2025 at 03:45 PM, interviewed ASM7. She said when R1 arrived back from the ER on [DATE], she assessed him right away. She said he had redness on left cheek, opened his eyes, but was not blinking. She said she reported it to the CN because he was not at baseline and worried about his eyes going left to right. ASM7 said she did not personally notify the physician, and did not know if the CN did. She said she used the neuro flow sheet and reported her concerns to the noc nurse at shift change. On 06/17/2025 at 07:47 AM, interviewed the ASM8, who was on at the time of the fall. Discussed the CN role and she said if something is going on, the staff will notify the CN, and they would call the doctor if needed. She went on to say they were trialing something new, and trying to have the assigned nurse be more involved and the CN would assist. The CN said she was in the next room and heard the fall, so was there quickly. She said from her recall, three staff moved R1 back to the bed. Inquired who assessed R1 when he was on the ground, before moving him, and she said she was not sure, but thought it was the nurse. She said R1 could not grasp (hand grasp is part of neuro check), so a neuro check for him would be if he can blink and checking his pupils. When asked if they did this prior to moving him, she said I think we never did. When asked if nursing could call 911, if there was an emergency, and then notify the physician after, she said yes. On 06/19/2025 at approximately 09:30 AM, conducted a telephone interview with ASM6, who entered R1's room after he was already in bed, about 15 minutes after the fall. He/she said the assigned Nurse was just starting the assessment, and he/she was unsure how much experience the Nurse had with neuro assessments, and a second set of eyes would be good who knows his (R1's) normal baseline. ASM6 said R1 had changes at that time, and his eyes were fluttering back and forth. He/she went on to say normally, R1 responds to jokes, bites down on the suction tube and you have to tell him to stop. He will look at you, and responds to your voice. ASM6 said R1 was not responding the way he normally was, his playfulness was gone. When they did the neuro check, they turned off the lights and checked pupils. When asked how they checked pupils, he/she said they used the cell phone flashlight. ASM6 said they looked for a form to document the ongoing neuro checks, but could not find it. On 06/17/2025, conducted a telephone interview with ASM9, who said on 03/18/2025 when he/she received report from the day shift, they reported some things about R1's behavior, which made him/her think R1 would probably need to be sent to the ER. ASM9 asked the day shift if they called the doctor, and reported his condition, but they had not. He/she said if the doctor was not called, he would assume R1 came back from the hospital at his baseline, which was not the case. ASM9 assessed R1, and said he looked panicky and fearful. He/she went on to say he was trying to answer, his pupils were moving crazy back and forth, and he wasn't blinking. ASM9 said it was like he had loss of muscle tone in his face, with one side reacting less than other side, trying to blink, but couldn't. He/she said R1 was very hard to wakeup. After the assessment, he/she called the physician and then sent him to the ER. ASM9 said he/she documented R1's baseline on the transfer form, and the ER doctor called about 03:00 AM, and wanted additional information regarding his usual behavior. He/she was unsure if the ER was aware of R1's baseline on the first visit. On 06/17/25 at 11:23 AM during a concurrent interview and review of R1's neuro assessments following his fall with the Director of Nursing (DON), DON agreed that at a minimum, nursing staff should have documented level of consciousness (LOC) and pupil response in addition to the vital signs that were documented. On 06/17/25 at 02:29 PM, an interview was done with the DON. When asked for the competency checklist for Certified Nurse Aide (CNA)1 (the staff member responsible for leaving the bed/safety rail down as she provided perineal care to R1 by herself, resulting in him falling out of bed), DON reported that he had been unable to locate a skills/competency checklist but was looking further into it. On 06/18/25 at 08:32 AM, an interview was done with the DON, at which time he confirmed he did not have a skills/competency checklist that was completed for CNA1. He agreed that it should have been done. On 06/18/25, during a confidential interview with ASM11, when asked if there had been any training on neuro assessments since R1's fall (when to conduct them, how to conduct a neuro assessment properly, how often to conduct them), he/she responded that he/she was not aware of any training on neuro assessments. When asked if he/she had a penlight to conduct a neuro assessment if he/she needed to, ASM11 responded that he/she did not have a penlight, and to his/her knowledge, the facility did not have any penlights available (for example, in the med cart). Concurrent inspection of the facility medication and treatments carts confirmed no penlights available to assess pupil response for a neuro assessment. 7) On 06/18/2025 at approximately 08:15 AM., observed the layout of R1's room with ASM8. R1's mechanism of injury was a fall from bed. The CNA was in the room, but could not see if he struck his head. There was redness observed on his R1's upper forehead, and he had a history of brain surgery with missing bone, and a shunt. There was high likelihood he struck his head on something. The standard of care post fall, would be to do a thorough head-to-toe assessment, full set of vitals and a neurological assessment, prior to moving him. The initial assessment would determine if he could be moved safely, or if EMS should be called (American Association of Post-Acute Care Nursing, Post-Fall Assessments, August 2021; American Nurse Journal 2023, The VIP treatment: A comprehensive post-fall assessment guideline). On 06/18/25 at 09:50 observations were done at the Nurses' Station. Review of the In-Service binder revealed no in-services had been conducted on how to perform a neuro assessment following R1's incident. 8) The facility documentation and interviews did not provide evidence that; 1) staff were knowledgeable of the importance to complete an thorough physical and neurological assessment, to determine if R1 could be moved safely; 2) the nursing staff understood what a complete neurological assessments was (i.e. pupils, eye movement, change from baseline), and how often they should be done, 3) the nursing staff understood the importance of timely transfer when neurological changes are noted, and 4) there was a structured approach to neurological assessments.

Based on interviews, medical record and document review, the facility failed to systematically analyze one Resident's (R1) adverse event (fall) and two unplanned hospitalizations for altered mental status. In addition, leadership received staff feedback regarding deficient practice related to this case and did not investigate the concerns. Due to this deficiency, system and process issues were not identified and addressed to ensure the nursing care met recognized standards of practice. Findings include: 1) Cross Reference F689 Free of Accident Hazards Despite being completely dependent on staff for all activities of daily living (ADLs), including toileting, bed mobility, and transfer, staff failed to ensure Resident (R)1's safety rails were secure and in place before walking away from his bed. As a result of this deficient practice, R1 experienced an avoidable fall. Reviewed the facility Incident Event report for the fall. The report was to be completed by Charge Nurse/Designee on Duty, and included The purpose of this report is to track and monitor patterns of incidents and to analyze the need for corrective action plans. The report was a template format to encourage thorough documentation, and was to be completed within 24 hours of occurrence and sent to the Director of Nursing (DON). The Nursing Care section included if the Care Plan (CP) was followed and if it met the Resident's needs and if Appropriate transfer technique was used. This area was left blank. Hand written on the form was Staff Huddle completed on same shift. Reviewed fall prevention policy/ All staff to be educated on fall prevention. Agency staff terminated effective immediately. This was an accident. Abuse & Neglect has been ruled out. The form had four places for signatures; Charge Nurse/Designee, DON, Medical Director and Administrator. The Medical Director was the only person that had not signed the report. The facility does a Root Cause Analysis on events and provides a fishbone diagram to prompt review of Staff/People, Rules/Policies/Process, Equipment/Supplies, Environment, Materials and Other Processes to facilitate identifying opportunities to improve. The DON wrote on the form CNA needed more wipes located @ the other side of the bed on the shelves, during care, then resident fell. This was determined to be an accident . There was no evaluation, or identification that the incontinence care was provided by one staff rather than two as indicated in R1's CP. There was no reminder to staff of the need for two person assist. Reviewed R1's CP , which included Always use 2-person assist and use mechanical devices d/t weigh over 50 pounds, which was initiated on 04/14/2022. On 06/18/2025 , during a confidential interview with ASM10, he/she reported that R1 was pretty heavy. ASM10 reported he/she would never change R1's adult incontinence brief by him/herself, he is always a 2-person brief change. On 06/17/2025 and 06/18/2025, between 07:30 AM and 04:30 PM, as well as off site phone interviews 06/19/2025, multiple confidential interviews were done with facility staff. During interviews with Anonymous Staff Members, there were inconsistencies of specifics related to the fall. There were no interviews, or written statements post fall of the staff on duty that evening, with the exception of the CNA involved, so survey interviews were from recall months later. ASM3, ASM4 and ASM8 said R1 was found flat on his back. During a confidential interview, ASM2, said he/she walked into the room, saw empty bed, upper rail on left side was down, lower rail was still up, right leg was stuck in the left lower rail, body was on ground. ASM2 did not stay in the room, as there were already several staff attending the situation. On 06/17/2025 at 08:15 AM, observed the layout of R1's room with ASM8, and concurrently conducted interview. At that time noted a cabinet in front of the window and placement of the bed. ASM8 pointed out where he/she was was in the next room, when the fall occurred, and said he/she heard the noise, but was unable to see if R1 struck his head, or how he landed. Attempted to reenact the mechanism of injury, and determine how he was moved back to the bed. ASM8's recall was that three staff members lifted him back in bed. 2) Cross Reference 713- Physician For Emergency Care Available 24 Hrs The facility failed to ensure 24 hours a day availability of a physician for emergency care, when MD1 could not be reached for over four hours after R1 fell and had a condition change. The staff failed to transport R1 to the emergency room (ER) in a timely manner to obtain physician evaluation when they were unable to reach MD1. Due to the lack of review of the unplanned transfers, and follow up on staff feedback, QAPI did not identify the delays of this physicians availability and response. 3) Cross Reference 726-Competent Nursing Staff The facility failed to ensue that all nursing staff possessed the competencies and skill sets necessary to provide nursing care to meet the residents' needs in a safe manner. Specifically, the licensed staff did not demonstrate competency when an adult resident (R)1 with traumatic brain injury (TBI) fell out of bed. Issues of competency included 1) performing and documenting neurological (neuro) assessments, 2) identifying a medical emergency that required timely response and transfer to a higher level of care on two separate occasions, 3) notification of Provider regarding baseline condition change after R1 returned to the facility from the ER, and 4) lack of knowledge regarding importance of a comprehensive physical and neurological assessment after a fall, to determine if Resident could be safely transferred from the floor to the bed 4) Reviewed the facility Fall Prevention Program, dated 10/2018. The program included Resident's fall events will be monitored as part of the facility-wide QI (Quality Improvement) program to identify trends and opportunities for improvement. Reviewed the Facility Quality Assurance and Performance Improvement (QAPI) Program, last revised date February 2020. The Policy Statement was This facility will develop, implement, and maintain an ongoing, facility wide, data driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. The program implementation included 2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: .C. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systemic quality deficiencies. Reviewed the QAPI minutes for the meeting dated 05/14/2/25. Noted the Standard Meeting Agenda items for all committees included Review data elements and document areas of concern or identified improvement opportunities. One of the data elements listed was ACTS/Rehospitalization, with the bullet point Identify any Trends or Action items for Quality Improvement Opportunities. This data element was marked N/A (not applicable) - Compliant. Another data element was Medical Record Audits where Transfers/Discharges was listed Medical Record audit done for discharge/transfers compliance. The minutes did not include any information regarding R1's fall. 6) The Director of Nursing (DON) was made aware of an anonymous staff member's (ASM) concerns by email, regarding R1's fall and unplanned transfers to the ER. The concerns included; 1) delay in initial neurological assessment, 2) reportedly R1 had nystagmus immediately after the fall, but was not documented 3) lack of thorough ongoing neuro assessments, 4) no documentation on day shift 03/18/2025 (ASM advised Assigned RN to document, 5) lack of provider notification of R1's AMS on return from the hospital, and 5) delay in transferring R1 to the ER twice, once after the fall, and again after return to the facility. 7) On 06/17/2025 during an interview with the Director of Nursing (DON), he said he had been made aware of the fall shortly after it occurred. He said We do not have falls at this facility, so this was very unusual. The DON said he had been told the CNA left the siderail down and R1 fell out of the bed. Inquired if anything had been discussed at QAPI or if any other opportunities had been identified, he said no. The DON said they provided an inservice and reminder to staff to keep rails up and supplies readily available. The DON said he did not personally investigate the fall, as it had been delegated to the Charge Nurse. He said he had not reviewed the medical record for nursing care and post fall documentation, and stated he was not aware of any specific staff concerns. Discussed how staff are trained to transfer residents, and he said PT had trained some staff to do a three man transfer for some Residents, but that R1 was not one of them. On 06/18/2025, conducted a second interview with the DON, after became aware that an ASM brought concerns to his attention. At that time, he confirmed receipt of the email. When inquired if there had been any investigation to validate the concerns or develop and implement action plans if needed, he said no. On 06/18/2025 during an interview with the Administrator (ADM) in the conference room, she said the focus of the Medical Record Audits for transfers referred to in the QAPI plan were to monitor compliance with providing the appropriate notices at time of discharge. She said they did not routinely review charts of the unplanned discharges (transfers to acute care) of adult residents for opportunities for improvement as it relates to medical and nursing care, or process issues (e.g. ambulance delay, MD response)., nursing or medical care. The ADM went on to say that the physician that has oversight of the pediatric population, reviews the unplanned discharges. When asked the ADM had been made aware of any concerns related to R1's two unplanned transfers to the ER, she said no.

The facility failed to ensure availability of a physician for emergency care for one Resident (R)1 of a sample size of three. R1 had a fall with a change of condition, and the facility was unable to reach the physician (MD)1 for over four and a half hours. In addition, the staff failed to transport R1 to the emergency room (ER) in a timely manner to obtain physician evaluation when they were unable to reach MD1. As a result of this deficient practice, there was a delay in transferring R1 to a higher level of care. Not having a physician available 24 hours a day could affect any resident who had an emergency, which could put them at risk of negative outcomes. Findings include: 1) R1 was a [AGE] year old male with history of traumatic brain injury (TBI) with subdural hematoma (bleeding inside the head). He had a decompression craniotomy (part of the skull is removed to reduce pressure on the brain and allow swelling), with post traumatic hydrocephalus (too much cerebrospinal fluid) that requires a shunt (catheter) to remove excess fluid. R1 had a tracheostomy (hole in neck for airway to breathe), PEG (tube into the stomach through the abdominal wall to provide means of feeding), and was a quadriplegic (permanent paralysis of all limbs from the neck down). On 03/16/2025, R1 sustained a fall from bed. 2) Reviewed the Progress Notes entered on 03/17/2025 at 08:52 AM. The notes included, but not limited to the following: @ (at) 2020 (08:20 PM on 03/16/2025) CNA (Certified Nurse Assistant) assigned to the resident (R1) was changing the resident's diaper when the resident fell on the floor. @ 2051 (08:51 PM on 03/16/2025 x1 desat (desaturation-drop in oxygen level) to 86% . @ 2112 (09:12 PM on 03/16/2025) Attempted to call the doctor on .CN (Charge Nurse) phone, no answer. @ 2128 (09:28 PM on 03/16/2025) sent Dr (MD1) a message regarding an update on resident's status and also called physician exchange (answering service) @ 21:32 (09:32 PM) @ 0036 (00:36 AM on 03/17/2025) Called physician exchange again to follow up on not receiving a call back from the doctor. @ 0115 (01:15 AM on 03/17/2025) .during this assessment resident appeared more lethargic (drowsy, decrease in consciousness) than usual, no response to sternal rub (painful stimulus to test consciousness level), and no response to yes or no questions . @ 0153 (01:53 AM on 03/17/2025) MD1 called the facility back . Dr stated to send the resident out (to ER). @ 0206 Called 911. @ 0220 Resident transferred . The facility was unable to reach MD1 for over four and a half hours. 3) On 06/17/2025 at 11:30 AM, interviewed the Director of Nursing, who said MD1 is the provider assigned to all the adult residents. He went on to say the nursing staff call him directly, and if they have any problem reaching him, they would call physicians exchange (answering service). When asked what they would do if unable to reach MD1, the DON said they would contact him, could call 911, or contact the Medical Director. On 06/17/2025 at 02:30 PM during a phone interview with Anonymous Staff Member (ASM)10, he/she confirmed the progress notes above and validated the multiple calls to reach MD1. On 06/19/2025 at approximately 09:15 AM, interviewed ASM6, who assisted ASM10 with R1's initial neurological assessment after his fall. He/she said R1 was not responding the way he normally does. ASM6 said ASM10 monitored R1 and was finally able to reach the physician after 4 1/2 hours. He/she said the practice is to call MD1 directly, and if he can't be reached, they will then call physicians exchange. ASM6 said it was his/her understanding that MD1 was out of the country. He/She was unsure what they would do if MD1 did not respond.

Based on interview and record review, the facility failed to ensure 1 of 6 residents sampled (Resident 1) was free from accident hazards. Despite being completely dependent on staff for all activities of daily living (ADLs), including toileting, bed mobility, and transfer, staff failed to ensure Resident (R)1's safety rails were secure and in place before walking away from his bed. As a result of this deficient practice, R1 experienced an avoidable fall. This deficient practice has the potential to affect all residents at the facility who are dependent on staff for ADLs and safety. Findings include: Resident (R)1 was a [AGE] year-old male admitted to the facility on [DATE] with a history of traumatic brain injury (TBI). R1's admitting diagnoses include, but are not limited to, quadriplegia (loss of motor and/or sensory function in all four limbs and the torso) and contractures (a permanent tightening of muscles, tendons, skin, and other tissues around a joint, leading to stiffness and reduced range of motion). In addition, R1 was nonverbal. A review of R1's electronic health record noted the following progress note on 03/17/2025 at 08:52 AM: .@2020 (at 08:20 PM the previous night) CNA (Certified Nurse Aide) assigned to the resident (R1) was changing the resident's diaper when the resident fell on the floor. A review of the facility incident report revealed the following description of R1's fall, that occurred on 03/16/2025, by CNA1, who was caring for him at that time: I was changing the Resident .he was turned on his Right side .I went to the other side of the bed as soon as I turned around the Resident was falling . The same incident report documents the CNA answering the question Explain the precautions to be taken to prevent event . with use lighting, make sure bed rails are up, make sure bed is locked . CNA1 was unavailable for interview by the State Agency (SA). On 06/17/2025, between 07:30 AM and 04:30 PM, multiple confidential interviews were done with facility staff. During an interview with Anonymous Staff Member (ASM)8, he/she confirmed from his/her observations that R1's room was poorly lit at the time of the incident, the bed was unlocked, the upper bed/safety rail on the side closest to the window (the side R1 fell off of) was lowered, and CNA1 reported she was on the opposite side of the bed when R1 fell. On 06/17/25 at 11:23 AM, interview was done with the Director of Nursing (DON). DON confirmed that R1 had fallen off the bed following CNA1 leaving at least one bed/safety rail down while she moved to the other side of the bed to obtain supplies for perineal care. DON confirmed he was notified by phone by one of the charge nurses about the fall and that he instructed her to make sure she discussed fall prevention at the change of shift huddle (meeting) and to have all staff in attendance sign that they received that education. DON reported that after conducting an investigation, it was determined that the incident was an accident. DON agreed that the accident was avoidable. Review of the facility policy and procedure, Fall Prevention Program, dated 10/2018, revealed the following: Resident's side rails will be kept in the raised up position when resident is in bed. Further review of the facility incident report noted the following documentation by the DON of actions taken as a result of the accident: Staff Huddle completed on same shift. Reviewed Fall Prevention policy. All staff to be educated on Fall prevention. Agency staff terminated effective immediately . DON provided evidence that all staff had completed the fall prevention training.

Based on interviews, medical record review and document review, the facility failed to develop a person-centered comprehensive care plan (CP) to meet the needs of one Resident (R)1 of a sample size of six. R1 had cognitive impairment and was nonverbal. His CP did not include how to communicate with him. As a result of this deficient practice, there was the potential not all staff were aware of how to communicate with him in a consistent manner. If Resident Care Plans are not comprehensive, Residents may not reach their highest medical, mental and psychosocial potential. Findings include: 1) R1 was a [AGE] year old male admitted to the facility on [DATE] after a traumatic brain injury (TBI). He had a tracheostomy (hole in neck to breathe), and a PEG (tube into the stomach through the abdominal wall for feeding). R1 had cognitive impairment (deficit from head injury, i.e. memory, understanding), quadriplegic (permanent paralysis of all limbs from the neck down) and nonverbal. 2) Review of R1's medical record revealed the following entry related to his cognition and communication: 03/18/2025 at 09:59 PM, Progress Notes: . At baseline resident is responsive, laughs, tracks with eyes, no nystagmus (roving eye movements), can respond by blinking for yes and not blinking for no. 03/18/2025 at 07:02 PM Late Entry, Progress notes: .(Patient blinks as form of communication. 1 blink for no and 2 blinks for yes). 3) On 06/17/2025 at 09:00 AM, during a phone interview with Anonymous Staff Member (ASM)9, he/she said R1's baseline was that he would blink, and laugh at jokes. ASM9 said he would blink several times for Yes, and once or not at all for No. 4) Reviewed R1's CP, which initiated the a plan for Altered communication/cognition r/t (related to) tracheostomy, traumatic brain injury, on 04/14/2022. The Goal was for Staff to anticipate needs and wants based on resident non-verbal responses. Interventions/Tasks included assess for signs and symptoms of pain and discomfort using the [NAME] pain scale (measurement of pain in people with cognitive impairment). There were no interventions of how staff communicated with R1, which was blinking his eyes to answer yes or no questions. In addition there was no documentation that he tracked with his eyes, laughed, or smiled. This information was important to establish communication with R1 and his baseline for cognition.

Based on observations, interview and record review, the facility failed to accurately document a medication order in the narcotic medication record for one resident (R)20, of 28 medication administration observations in the sample. The dosage was documented to give Lacosamide oral solution 10 milligram (mg) per milliliters (ml); give eight ml via Jejunostomy tube (J-Tube) two times a day. The Registered Nurse (RN) 23 verified the order should read give 12 ml via J-Tube two times a day. Findings include: On 06/05/24 at 09:00 AM a concurrent interview and observation during a medication administration for R20 revealed that the narcotic medication record for Lacosamide Oral Solution 10 MG/ML give 8 ml via J-Tube two times a day was handwritten with the incorrect dosage. The surveyor questioned RN23 about the dosage, and she verified with the electronic medical record, medication administration record (MAR) states give 12 ml. The bottle of the medication had small labels that stated the dosage has been changed in the medical record. The RN said, the narcotic form should have been updated, and removed it from the binder. A Medication Administration General Guidelines 2007 PharMerica Corp reviewed. Page 4, 9. Verify medication is correct three times before administering the medication .c. before dose is administered.

Based on observation, interview, and record review, the facility failed to ensure residents had routine dental care for two residents (R10 and R5) sampled. R10's most recent dental consult was conducted on 11/27/20. R5's most recent dental consult was conducted on 11/11/21. Findings include: 1) On 06/06/24 at 11:17 AM during record review of R10's Electronic Health Record (EHR) found resident had a dental consult filled out from 2020. Record review found R10 has a care plan in place for facility staff to arrange for dental consult yearly and PRN which was initiated on 01/10/2020. At this time inquired of Assistant Director of Nursing (ADON) if R10 was seen by the dentist within the past year. ADON stated she would check on this. On 06/06/24 at 11:59 AM during interview with Administrator she stated she had Director of Nursing schedule upcoming dental appointments for all residents in the facility for June and July 2024. Administrator stated dentists were not coming to facilities during the pandemic and just returned in 2023. ADON was unable to find any documentation at this time that R10 was seen in 2023. 42160 2) On 06/03/24 at 03:50 PM, conducted an observation of R5 lying in bed. R5's mouth was open and saw that the resident's teeth were yellow, appeared dirty, and had white reside on the inside of the resident's mouth to include his tongue. Conducted a record review of R5's Electronic Health Record (EHR). Review of the physician orders documented an order for, . f. May be seen by facility Dentist for examination, treatment, medications twice a year and as needed . Review of the resident's care plan documented R5 has self-care deficits for all personal needs related to cognitive impairment, contractures, immobility, and inability to make purposeful movements and has spastic quadriparesis with an intervention to .Provide oral hygiene BID (twice daily) and PRN (as needed) . Review of the task list, oral hygiene had been provided once on 06/02/24 (at 07:19 PM) and once on 06/03/24 (at 09:48 PM). On 06/05/24 at 10:32 AM, conducted a concurrent record review and interview with Unit Clerk (UC) and Administrator. UC stated the dentist comes to the facility on ce a year and reviewed a binder with the dental appointment summaries. Reviewed R5's dental summaries and it documented the resident's last dental check-up was on 11/11/21 (dental consults were documented as completed in 2016, 2017, and 2018). A review of R5's EHR did not contain documentation under the miscellaneous tab, assessments, physician orders, and progress notes of any other dental exam conducted after 11/11/21. UC stated R5 had been seen in 2023 and would get the dental consult summary from the dentist's office. UC reported the dentist's office was closed on 06/05/24 and 06/06/24 but would continue to follow-up for the requested dental consult summary. Administrator was unable to provide additional documentation of any other dental consult conducted after 11/11/21.

Based on record review and interview the facility failed to assure Resident (R) 15's insulin was held when his blood glucose level was less than 80 as ordered by the physician. The facility was not in compliance for significant medication error at the time the significant medication error occurred, the noncompliance happened after the last survey and prior to this survey. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey related to significant medication errors. Findings Include: On 06/06/24 at 09:30 AM during record review of R15's Electronic Health Record (EHR) found R15 was given Lantus Solostar Solution Peninjector 100 unit/ml (insulin Glargine) 55 units subcutaneously on 01/04/24 which is ordered to be given two times a day for R15's Type 2 Diabetes Mellitus with an order to hold (do not give the medication) for blood glucose (BG) less than 80. R15 had his blood glucose checked on 01/04/24 at 0730 (07:30 AM) and was documented at 79 mg/dl. Registered Nurse (RN) 25 gave R15 his 0900 (09:00 AM) dose of Lanstus Solostar 55 units of insulin instead of holding this medication as ordered by the physician with the hold parameter for blood glucose (BG) less than 80. On 06/06/24 at 09:51 AM interviewed Assistant Director of Nursing (ADON) and Administrator who were able to provide a copy of the incident event report for this medication error. Medication error was found after the fact by facility staff who reported the error to the charge nurse on the same day this incident occurred, 01/04/24. R15's doctor was notified of medication error on 01/04/24 at 1455 (02:55 PM) with no orders given at that time. R15's son was also notified of the medication error on 01/04/24 at 15:44 (03:44 PM). On 01/04/24 R15's blood glucose was rechecked at 02:45 PM and documented at 81 mg/dl. Later that same day at 1930 (07:30 PM) R15's blood glucose was documented at 69 mg/dl, which is a critical level requiring staff intervention. R15 was given glucose tablets as ordered for BG less than 70 mg/dl. R15's 2100 (9:00 PM) dose of Lanstus Solostar 55 units of insulin was held per physician ordered parameters. R15's physician was notified of critical BG level of 69 mg/dl and order given to decrease R15's Lantus Solostar insulin from 55 unit to 50 units twice a day with the same hold parameters. Review of incident report found Director of Nursing (DON) re-educated staff to read instructions/parameters carefully and cosign with another staff to double check. Root cause analysis was completed for the medication error on 01/04/24 at 0900 which resulted in the critical BG level later that evening at 1930. Facility is found to be in past non-compliance for this citation, facility found the medication error the day it occurred on 01/04/24, reported it to the charge nurse, DON, physician and R15's son and corrected it that day which included monitoring of R15, administration and holding of medication, staff interviews were conducted and staff were reeducated to review medication carefully before administering, to use the 5Rs. No POC is required for this citation.

Based on observation, interviews, and record review, the facility failed to ensure a resident's environment remains free of accident hazards for one resident (R27) sampled. Past non-compliance was determined for an incident on 03/01/24, R27 had an unwitnessed fall from the crib. The facility was not in compliance for accident hazard at the time the fall occurred, the noncompliance happened after the last survey date and prior to this survey, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey related to falls. However, in response to the fall, the facility installed a crib canopy, but did not conduct a safety assessment or assess for potential accident hazards for R27 after the canopy was implemented. As a result of this deficient practice, residents with newly implemented equipment are at a potential risk of harm resulting from an accident hazard. Findings include: 1) Past non-compliance was determined for an unwitnessed fall R27 sustained on 03/01/24. Review of the facility's investigation documented at approximately 03:30 PM- 03:40 PM, staff suctioned the resident's tracheotomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill into the lungs, a tube is inserted through it to provide an airway and to remove secretions from the lungs) and brought the railing up and left the room. At approximately 04:00 PM, staff went into R27's room and found the resident on the ground. The resident's gastro-jejunal (GJ) tube balloon was dislodged, and the stoma was open and completely exposed. A ST button (a low-profile tube) was inserted into the stoma and notified the physician. Post fall, the facility completed a root cause analysis of the fall, staff training (Fall Prevention and Safety, Locking Crib Rails, and Raising Side Rails), completed a physical therapy assessment of R27 functional abilities, revised the care plan with interventions which included implementing a canopy for the crib. 2) R27 is a 2-year-old female who was admitted to the facility on [DATE] with diagnosis which include George's syndrome, paralysis of vocal cords and larynx, chronic respiratory failure, tracheostomy, gastrostomy, dysphagia, pulmonary hypertension, dependence of respirator (ventilator), hypoxic ischemic encephalopathy (a type of brain injury that occurs when the brain experiences a decrease in oxygen or blood flow before, during, or after birth). R27 has a Preadmission Screening and Resident Review (PASRR) Level 2 condition of mental retardation and is totally dependent on staff for all care and needs. As a result of the fall on 03/01/24, the facility implemented the use of a canopy for R27's crib. On 06/03/24 at 09:50 AM, conducted an observation of R27 in the crib with a canopy over the top of the crib. The canopy was observed to be a heavy-duty plastic covering which covered the top of the crib. R27 was able to reach up and touch the canopy. R27 was observed watching a television through the canopy which distorted the images on the television (located above the front of the crib). Conducted a review of R27's Electronic Health Record (EHR) on 06/06/24 at 10:12 AM. Review of the care plan documented a safety intervention for the crib rails/side rails/padding: a. Raise side-rails and close canopy of crib to prevent falls secondary to motor disabilities, immature/impaired cognitive development/ abilities. Review of the progress notes documented a note physical therapy which documented an assessment of R27's functional ability and the potential need for R27 to be reassessed if implementation of the canopy was delayed for several months but did not include an assessment of R27 after the canopy was implemented. This surveyor was unable to find a safety assessment after the canopy was implemented or evaluation of the use of the canopy for R27. On 06/06/24 at 10:46 AM, conducted an interview and concurrent record review of R27's EHR with Registered Nurse (RN)33. Inquired if the facility completed a safety assessment of the implementation of the canopy after it was installed on R27's crib. RN33 confirmed a safety assessment or evaluation of the canopy was not done after the canopy was installed. RN33 also confirmed the facility did not identify that the canopy distorts the images on the television and did not consider how that would/could influence R27's development. On 06/06/24 at 09:10 AM, during an interview with the Administrator confirmed the facility did not conduct a safety assessment or an evaluation for the use of the canopy after the equipment was installed.

Based on record review and interview, the facility failed to ensure the following at the time of the resident's discharge for one resident (R) 32 of four in the sample: Communication of necessary information to one resident and the residents care giver; document a concise summary from the physician of the residents stay and course of treatment in the facility; and reconciliation of medications. Findings include: On 06/04/24 at 2:36 PM, Electronic Medical Record (EMR) reviewed. R32 is a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. Diagnosis includes spastic diplegic cerebral palsy, localization related (focal partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, acute respiratory failure with hypoxia, and tracheostomy. Physicians discharge summary dated 04/29/24 reviewed. The Physician hand wrote a note that stated Had stable course. On 06/04/24 at 3:03 PM, confirmed with the Social Services Director (SSD) that R32 was a voluntary discharge. The surveyor requested the discharge summary, post discharge plan of care and the last care conference meeting notes. Received and reviewed the discharge summary for R32. Summary: had stable course signed by Primary physician, and dated 05/02/24. Admission care conference summary dated 01/11/24 reviewed. Social work report.The family anticipates that he will reside at the facility for three to four months. Care conference summary discharge date d 04/12/24 reviewed. Social work follow up. No follow-up needed. Patient discharging on Monday 04/29/24. Care plan for R32 reviewed. Anticipated discharge to be within the next three to four months. The decision makers overall goal established in initial assessment is to have R32 return to the community once in home, nursing can be provided once again. Requested a copy of the discharge orders from the physician and the discharge instructions form from the Administrator on 06/06/24 at 10:45AM. At 11:25AM, the Administrator and the Registered Nurse (RN)23, who was assigned charge nurse on the day of discharge, discussed the discharge with the surveyor. RN23 verified with the surveyor that she verbally went over the checklist with R32's caregiver at the time of the discharge, and did not complete a discharge instruction form or document the discussion in the EMR. Orders reviewed. No discharge orders from the physician were found and the surveyor verified with the Administrator on 06/06/24 at 11:45 AM. Transfer of resident policy 10/2018 reviewed. Discharge of resident (nursing). Procedure: 1. All discharges require a physician order . 6. If the resident is being discharged to home, the assigned nurse must complete the discharge instructions form and review the following with the resident and responsible party: a. Medication .c. Equipment if any . e. Follow up physician visits . A copy of the discharge instructions is given to the resident/responsible party. The original is left in the chart.

Based on observation, interview and record review, the facility failed to enhance one Resident (R)6 of 12 residents in the sample's quality of life while in her room in bed. Music, television, or other auditory stimulating activities were not provided to the resident. The deficient practice dishonored the residents right to a dignified existence. Findings include: Random observations of Resident (R)6 on the following dates and times: 06/03/24 at 08:35 AM and 3:00 PM; 06/04/24 at 09:35 AM and 2:35 PM; and 06/05/24 at 08:35 AM. Observed R6 in bed awake with eyes closed or sleeping. The room was quiet without television or music playing. On 06/04/24 at 11:26 AM a telephone interview was conducted with R6 family member (FM). During the interview, the FM said, it really bothers me that her room is so quiet, they need to put the television on with cartoons or something. I have spoken to them several times about it and half the time they turn the television on. On 06/05/24 at 2:46 PM, interviewed the Recreation Coordinator (RC). When asked when the residents are in their room in bed why some rooms have a television on or music playing, and others don't. The RC replied, it depends on the resident's level, the more active ones might have an IPAD or a cell phone, toys, or a hanging mobile. For the others who aren't, and they are dependent, they should have a television unless it's time to go to sleep. Electronic medical record reviewed. Minimum data set annual dated 03/24/2024. R6 is Comatose and in a persistent vegetative state. Care plan dated 09/20/22 reviewed. Activities interventions: Sensory stimulation activities auditory, visual, tactile. TV/Movies. On 06/06/24 at 08:20 AM, observation in R6's room. Noted the room was quiet without any television or music playing. The Registered Nurse (RN)25 was repositioning R6's bed. The surveyor asked RN25 why the room doesn't have any television or music playing. RN25 stated, well it is dayshift, so activities will be coming in and later. RN25 turned on the television to a channel with sporting activities. Activity programs policy MED-PASS, Inc. revised June 2018 reviewed.4. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive, or emotional health .

Based on observation and interviews, the facility failed to ensure staff implemented infection control practices for infection prevention and and prevention of communicable diseases. Observed Registered Nurse (RN) 26 take off dirty gloves and put on clean gloves without performing hand hygiene. Observed Direct Care Staff (DCS)1 provide suctioning to a resident then enter another resident's room all while the staff's face mask was pulled under his/her chin, exposing the staff's mouth and nose. Findings include: 1) On 06/05/24 at 09:37 AM observed RN 26 prepare and administer Resident (R) 16's medications via their gastromy tube. After the task was completed RN26 took off her gloves, threw away the dirty gloves and put on a new pair of clean gloves. RN26 then suctioned R16's mouth and cleaned their mouth with a swab and prescribed medication. Afterwards interviewed RN26 and asked if she is to do anything after taking off her dirty gloves before putting on new clean gloves and she stated no my hands weren't dirty. On 06/05/24 at 11:10 AM interviewed Assistant Director of Nursing who confirmed staff are to do hand hygiene between glove use. Requested a copy of facility policy on hand hygiene. On 06/05/24 at 15:00 PM Administrator provided a copy of facility policy titled Handwashing/Hand Hygiene which states Indications for Hand Hygiene 1. Hand Hygiene is indicated g. immediately after glove removal. 42160 2) On 06/03/24 at approximately 03:05 PM, observed DCS1 providing suctioning to a resident, then entered the adjacent room. While in the adjacent room, DCS1 was at another resident's bedside observing the resident with his/her mask still down under the chin, which exposed DCS1's mouth and nose. On 06/05/24 at 12:40 PM, conducted an interview with the Infection Control Physician (ICP). During the interview, inquired as to what type of personal protective equipment (PPEs) staff should wear while in the resident's room and while providing care. ICP confirmed during suctioning and while in the resident's room, staff should have a face mask on and it should be properly worn to cover staff's mouth and nose.

Based on observations and interview, the facility failed to ensure a clean environment for one resident ((R)12) sampled. The mesh netting on the inside of R12's crib became soiled during care and staff did not change or clean the mesh. R12 regularly puts her legs vertically on the mesh which increases the resident's likelihood of encountering the soiled mesh. As a result of this deficient practice, residents with mesh on the inside of the crib have an increased potential for exposure to an unsanitary environment. Findings include: On 06/03/24 at 08:45 AM, conducted an observation of Certified Nurse Aide (CNA)25 and Registered Nurse (RN)99 providing peri-care for Resident R12. The resident had a large bowel movement (liquid consistency). Staff lowered the right bedrail and the mesh netting on the inside of the crib was in direct contact with the soiled bedsheet, which then soiled the mesh. Observations of R12 lying horizontally on the bed with her legs up against the mesh on 06/03/24 at 08:45 AM and 02:23 PM, 06/04/24 at 03:12 PM, 06/05/24 at 09:43 AM and 01:50 PM. On 06/06/24 at 11:25 AM, conducted a concurrent interview and record review with RN25. RN25 reviewed the resident's bowel movement log located in the resident's room and confirmed on 06/03/24, R12 had a large watery bowel movement. RN25 visually inspected the mesh netting and confirmed the mesh on the inside of R12's crib was soiled and needed to be changed. Staff changed the mesh and cleaned R12's mattress/bedding.

Based on record review and staff interview, the facility failed to maintain an infection prevention and control program (IPCP) to provide a safe environment to help prevent the transmission of communicable diseases and infections. The facility did not ensure that the IPCP was reviewed annually and updated as national standards change. As a result of this deficient practice, all the residents in the facility were placed at potential risk for developing communicable diseases and infections. Findings Include: On 06/22/23, review of the facility's Infection Control Policy and Procedure manual was conducted. Noted the first page in the inside cover titled, Kulana Malama - IP (infection prevention) Manual Approval Signature Sheet did not have any signatures on it. At 01:46 PM, a concurrent interview and record review was conducted with the Director of Nursing (DON) in his office. Asked DON when was the last time the Infection Control Policy and Procedure manual was reviewed. DON said it was reviewed last year and proceeded to show a copy of the manual that was in his office with the Approval Signature Sheet dated, 06/14/22. When asked if the manual was reviewed for 2023, DON responded, Not yet, but we have it scheduled this month. DON did not provide a date for when the manual will be reviewed. On 06/23/23 at 11:15 AM, the DON provided a meeting agenda dated 06/12/23. The agenda included, . III. Discuss any changes to Infection Control Policy and Procedure manual. Asked DON if minutes were taken for the meeting. DON responded, No, the meeting did not happen because something came up.

Based on observations, staff interview and review of the Ventec Life Systems User Manual, the facility failed to clean the VOCSN (Ventilator) Air Intake Filter every two weeks as recommended by the Manufacturer. As a result of this deficiency, the facility put the residents at risk for further complications. Findings include: On 06/21/23 at 10:45 AM, an observation of the VOCSN Air Intake Filter showed dust/dirt appearing build up on the surface of the filter. Concurrent staff interview with Respiratory Services Director (Resp Dir) revealed that the facility would only clean the filter once a month. During staff interview on 06/21/23 at 11:00 AM, Resp Dir acknowledged that the facility was not aware of the filter cleaning recommendation for every two weeks. Resp Dir said they would make the necessary change for filter cleaning to follow the Manufacturer's recommendation. Review of the Ventec Life Systems User Manual read the following: Cleaning and Maintenance, the organization responsible for the use and maintenance of VOCSN should perform all adjustments, cleaning, and disinfection of VOCSN. Follow all instructions provided in this Clinical and Technical manual to prevent damage to VOCSN during cleaning and maintenance procedures . Cleaning the Air and Fan Filters, clean the air and fan filters every two weeks to ensure VOCSN internal components are protected from dirt and dust .

Based on observations, interviews, and record review. The facility failed to implement interventions in a care plan to provide effective and person-centered care that meet professional standards of quality care for one of the three residents sampled (Resident (R) 2). Findings Include: Cross tag with F693. The facility failed to provide appropriate treatment and services to prevent complications for a resident who receives enteral feeding. R2 was admitted to the facility on [DATE]. R2's diagnosis included dysphagia, respiratory disorder, and gastroesophageal reflux disease without esophagitis. Observation was conducted on 06/20/23 at 01:50 PM in R2's room. R2 was lying flat in bed on his left side. Enteral feeding bag was attached and infusing. Observation was conducted on 06/21/23 at 01:21 PM in R2's room. R2 was observed lying flat in bed on his left side. R2's enteral feeding bag was attached and infusing. Interview with Registered Nurse (RN) 1 was conducted in R2's room on 06/21/23 at 01:27 PM. RN1 was asked about R2's flat position during enteral feedings. RN1 replied, supposed to be elevated to prevent aspiration but because he is on a special bed, you can't elevate him. On 06/20/23 at 02:20 PM an Electronic Health Record (EHR) review of R2's care plan, dated 04/18/23, indicated that R2 was, at risk for respiratory distress/ineffective breathing/airway and infections r/t: tracheostomy placed . One of the interventions listed for this focus area was, POSITIONING .Keep HOB [head of bed] raised at least 30 degrees to facilitate optimum breathing pattern and during tube feeding up to 1 hour after to prevent aspiration. A second focus area in R2's care plan indicated, altered GI [gastrointestinal] function/difficulties r/t [related to] gastrostomy dependence .chewing and swallowing difficulties requiring total GT [gastrostomy tube] feed, altered GI function, GERD, possible emesis. One of the interventions for this focus area indicated elevate HOB at least 30 degrees during TF and1 hour after TF to prevent aspiration. Concurrent observation and interview were conducted with the Director of Nursing (DON) on 06/22/23 at 01:27 PM in R2's room. R2 was observed lying flat in bed slightly on his stomach receiving his scheduled tube feeding. DON was questioned about R2's flat position in bed during enteral feedings. DON answered, he is okay he can tolerate that. His trust bought this bed, and it doesn't go up. But we did get him a new bed. DON was informed of R2's care plan indicating elevating R2's head of the bed at least 30 degrees during feeding. DON replied, just got to update the care plan. An interview was conducted with the DON on 06/23/23 at 11:08 AM at the nurse's station. DON was asked if there was a nursing assessment, MD assessment, or MD order that supported R2's position of lying flat during his enteral feedings. DON answered, that just comes from the daily nursing assessment charting and there is no MD order.

Based on observation, interview and record review, one Resident (R)5 acquired a stage four pressure injury while residing in the facility. In spite of the appropriate and timely wound treatment, and dietary interventions to address the wound, progressed to a stage four pressure ulcer of the coccyx. Surveyor made multiple observations from 03/16/21 to 03/18/21 and noted that R5 was lying in the same position for a minimum of three to three and one half hours. Timely turning and repositioning of the resident is crucial to promote wound healing and avoid continuous pressure on the existing injury. The deficient practice resulted in poor healing and worsening of the stage four coccyx injury and R5 was subjected to painful treatment and acquired infections that exacerbated the treatment outcome. The deficient practice failed to provide R5 with the highest practicable physical well being while residing in the facility. Findings include: Surveyor reviewed the electronic medical record (EMR) on 03/16/21 at 4:54 PM. Per the wound weekly observation tool dated 03/12/21 at 15:02, resident has a stage four pressure injury to the coccyx that is facility acquired. 1.8 cm L X 1.0 cm wide X 1.5 cm deep. Undermining from two to three o'clock position, with pink tissue. Current treatment and dressing provided. R5 is a disabled, male adult resident totally dependent on staff for bed mobility. Surveyor reviewed the EMR on 03/17/21 at 11:49 AM. Progress notes dated 09/02/20 17:42. Skin: Skin warm & dry, resident has current skin issues. Pressure Ulcer/ Injury. Skin issue Location: Coccyx Pressure Ulcer / injury Stage IV full thickness tissue loss. Wound Bed: Granulation. Wound Exudate: Serosanguineous. Peri Wound Condition: Fragile. Dressing saturation: Minimal (<25%). No wound odor. Tunneling present. Undermining noted. Clinical suggestions: Evaluated for pain, discomfort. Dressing changes/treatments performed as ordered. Resident is turned, ambulated, moved at least every 2 hours. Surveyor observed R5 in his hospital bed in the primary activity area on 03/17/21 at 12:47 PM. Noted head and shoulders facing to the right, on his back. The Registered Nurse (RN) 1 stated that she will do his dressing change around 2 PM after she give's his suppository and he has his bowel movement (BM). 03/17/21 at 01:25 PM R5 was in his bed in his room head and shoulders facing to the left side. Per RN, she just gave the suppository, and will change the dressing after his BM. Surveyor made the following additional observations on 03/17/21: 2:30 PM, same position, facing to his left side. 3:07 PM, same position, facing left side. 3:40 PM same position, facing left side. 430 PM facing left side. Surveyor received and reviewed thinned paper progress notes on 03/17/21 at 12:50 PM. 11/09/19. Daily skilled nurse's note. Coccyx wound closed with pinpoint scab. 11/29/19. Coccyx wound dressing changed after bath. Scant amount of purulent drainage noted to old dressing, no odor, no s/s infection. 12/05/19. No change to care of pressure ulcer coccyx wound, dressing changed, wound culture ordered and sent, pending results. 12/09/19. New order for [MEDICATION(S)] via GT BID x 14 days, diagnosis (DX): Coccyx wound infection. 03/19/20. Coccyx wound bed continues pink, no drainage, no signs symptoms of infection. Per wound consultant, coccyx wound closed with fragile scar tissue. 04/23/20. Seen by wound consultant (WC) measured 0.4 cm X 0.2 CM 0 0.2 cm with signs of improvement. 05/14/20. WC, coccyx wound perimeter with maceration, wound bed is with dark pink tissue, wound measurement 0.5 cm x 0.2 cm depth 0.3 cm, mom was updated with new order of the coccyx wound treatment. 06/04/20. New order for new coccyx wound treatment (tx) due to (d/t) worsening. New measurements 1.1 cm L x 0.4 cm w X 0.3 cm D. 06/18/20: Wound consultant came by today, coccyx wound measures 1.1 x 0.6 cm. 07/09/20: Coccyx wound continues with slight opening, blood noted to old packing strip, New order for [MEDICATION(S)], & intravenous (IV) [MEDICATION(S)]. and [MEDICATION(S)] for debridement. Coccyx wound measures 0.9 cm x 0.8 cm x 0.4 cm. with undermining. 07/30/20: Debridement to coccyx wound. remove dead tissue. 08/06/20: Coccyx wound with soft eeschar noted. wound bed 1.4 cm X 1.2 cm. Depth 0.5 cm. underminined with 3 o ' clock 0.2 cm. 08/15/20: Coccyx wound was debrided by WC, measured 2.7 cm X 1.5 cm X 0.7 CM x 0.6 cm underming to 2 o ' clock. New order for coccyx wound. 08/17/20: WC came to debride residents coccyx wound, measurements 2.9 cm x 2.8 cm x 0.8 cm. Labs ordered DX: Chronic wound. Surveyor reviewed the Registered Dietician (RD) notes on 03/17/21 at 2:52 PM. 11/29/20 nutrition/dietary note. Resident is at risk for poor wound healing his nutrition needs to be maximized without causing excessive weight gain. Goal to provide appropriate nutrition and hydration for optimal health with total G-Tube (GT) feeds. Maintain weight between 58-61 kilograms (kg). P: Continue with [MEDICATION(S)] 1.0 at 250 milliliters (ml) x 4 day at 125/ml per hour. Continue with [MEDICATION(S)] 1 packet day continue with [MEDICATION(S)] 2 packets continue with multivitamin. 12/19/20 Nutrition/dietary note. Recommendation. Start 1 packet of Juven/day. 02/27/21 Nutrition/ Dietary Note: Resident appears stable in weight. He has been stooling 1-2 x day no loose stools noted. Continue current plan. Surveyor observed R5 on 03/18/21 at 07:06 AM lying on his left side with pillows propped on his side and between his knees. Surveyor made the following additional observations on 03/18/21: 08:00 AM, R5 facing to the left looking toward the window with his neck hyperextended. 08:40 AM R5 in same position facing to the left looking toward the window with his neck hyperextended. 09:33 AM R5 in same position facing to the left looking toward the window with his neck hyperextended. 10:21 AM R5 in same position facing to the left looking toward the window. Surveyor observed a dressing change on 03/18/21 at 10:29 AM Present were RN2 [NAME], Director of Nursing (DON), and the wound care nurse consultant by cell phone face time so she was able to watch and assess the wound while RN2 did the dressing change. Surveyor asked RN2 what are the interventions nursing staff are doing to prevent worsening of the pressure ulcer, she replied that the wound nurse sees him weekly and the RN and certified nurse aide (CNA) are turning him every two hours The DON added that R5 also has a pressure relieving mattress. We are turning him side to side at least every two hours. he is also on Juven (a formula to promote wound healing). Surveyor asked if the resident has pain, if so, how is it being treated. The RN2 replied that he isn't having any pain now. The WC stated when we debride the wound he receives pain medicine via the G-tube and [MEDICATION(S)] topically. Surveyor asked the WC when did the current pressure ulcer (PU) develop and what caused the PU. The WC replied it started In August of 2019. R5 has been challenged because of bacteria that enters the wound during his frequent bowel movements. He has been on a few different antibiotics for infection. The area on the coccyx was open previously. Every week I'm doing a sharp debridement of the wound that seems to be helping, then thought we had some problems with protein issues. He is now on a vitamin D supplement. A big issue is he has quite a few BM's in a day. The staff are doing a good job putting that dressing on, and are able to keep the feces out of the wound. Surveyor asked what are the interventions to prevent the wound from worsening and improve. The WC replied, no shearing, when the nursing staff are rolling him they need to avoid pulling him up on that wound. Keep the dressing clean and no feces in the wound bed. We did get the Dietary consult and the RD adjusted his nutrients to include more protein and vitamin D. Keep him clean and dry, making sure the dressing is intact. If staff notice a sign of infection they are to report it to the DON and Wound nurse immediately. Surveyor asked how important it is to turn R5 every two hours, she stated that it is very important. Surveyor asked if the pressure ulcer is preventable and she said yes I would say it is. In this case very challenging to do but preventable. Surveyor asked what interventions were in place before the PU developed. The WC replied turning him regularly and keeping him clean. Surveyor noted at 10:40 AM R5 was turned onto his right side for the dressing change. At 11:57 AM, noted staff brought R5's bed out to the activity area, where he was facing to the right side. Surveyor made the following additional observations on 03/18/21: 12:45 PM R5 in same position in his bed facing the right side. 1:34 PM R5 in same position facing to the right side. 1:53 PM R5 is back in his room, same position facing to the right side.

Based on observations, record reviews, interviews and review of the facility's policies and procedures, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies/skills sets to provide nursing and related services to ensure each resident received care that was safe, and able to maintain their highest practicable physical, mental, and psychosocial well-being. It was found there was an insufficient number of licensed staff with a lack of competency training required to provide quality care for their residents who were all ventilatory dependent and required total care by staff. As a result, an immediate jeopardy (IJ) was identified for the systemic problems and potential for serious harm to occur to all their residents. Findings include: Cross-reference to findings from F550, F645, F656, F657, F726, F759, F760, F835, F837, F841, F851. 1) On 12/19/17 at 08:25 AM, during the initial tour of the facility, surveyor observed Staff#42 and Staff#8 flushing R#24's peripherally inserted central catheter (PICC) line. Staff#42 was assisting Staff#8 who held 2 syringes filled with liquid, and asked, Which syringe do I use first? Do I flush it with all (syringes)? After the nurses completed the task, they were queried whether it took 2 nurses to flush R#24's PICC line. Staff#42 stated that she worked the night shift (N(NAME)) and was supposed to have flushed R#24's PICC line but was too busy, so assisted the day shift nurse with the PICC line flush before going home because this resident was more complicated. Staff#42 further stated there were only 2 nurses working the night shift (N(NAME)) and the day shift nurse had to work until 2300 to provide residents [MEDICAL CONDITION]. The nurses reported that on 12/18/17 from 2300-0400 there were only 2 nurses on duty and a respiratory therapist on duty from 2100-0700. Staff#8 reported that since she started working with the facility as an agency nurse, 2 charge nurses have resigned and they were short staffed. On 12/22/17 at 07:12 AM, observed Staff#120 flushing R#24's PICC line with 10 mls of normal saline, and then 0.4 mls of [MEDICATION NAME] to lock the line, as the resident slept comfortably. Staff#120 said she was not sure who she was handing over care to for R#24, as her N(NAME) shift ended. Staff#120 voiced concern over R#24's care as he was the only resident in the facility with a PICC line for which he received total [MEDICATION NAME] nutrition (TPN). Staff#120 related on 12/18/17, she was the only permanent nurse staff on day shift and an agency nurse was assigned to R#24. The agency nurse was not familiar with R#24's care, and Staff#120 had to perform the dressing change to the resident's PICC line and guide the agency nurse to flush and start R#24's special TPN formula. The agency nurse also did not know how to start the portable TPN pump used in order for the resident to attend outside activities. Staff#120 said she could not understand why an agency nurse was assigned, who was not familiar with R#24 and had no orientation on his care. Staff#120 stated the DON made the nursing assignments, and that R#24 was the only one receiving TPN in the facility. 2) On 12/22/17 at 07:25 AM, observed Staff#117 providing a bed bath to R#18. Upon entering through the privacy curtains observed that R#18 was naked on the bed with damp skin and visibly shaking his arms and legs. Staff#117 was removing a tub of water from the bed and queried her whether R#18 was feeling cold. Staff#117 replied, He's always like that, as she stepped away from the bed to get a towel. Staff#117 then covered R#18 with a towel and wiped the resident dry. When Staff#117 removed the towel to dress the resident, his hands were still visibly shaking. Staff#117 covered R#18 with a blanket after dressing him and went to turn on a fan that blew directly onto the resident. Queried Staff#117 why the fan was turned on and she replied that they always leave the fan on for the resident. The room was cool and surveyor and other staff had sweaters on. Staff#117 looked at surveyor, then decided to turn the fan off. After the bed bath, Staff#117 reconnected R#18's gastrostomy tube feeding (TF) and restarted the TF pump. The TF bag was dated 12/21/17; 0600; with 100 ml of formula in the bag. The TF pump was running at 40 ml/hr; volume delivered /dose limit read 736 mls. On 12/22/17 at 07:37 AM, queried Staff#119 about R#18's TF bag and when the formula was poured in. Staff#119 replied she did not know this facility's staff routine, but at other places the TF bags were changed at 12 midnight. The DON was not in and Staff#119 then asked the N(NAME) shift nurse before she went home. The N(NAME) shift nurse did not care for R#18 on her shift and had to ask another N(NAME) shift nurse. Staff#119 then reported that the resident's formula was made and stored in the refrigerator and staff were to follow their feeding schedules and all residents had their TF bags changed at 0600, but sometimes it was done at 0800. On 12/22/17 at 07:49 AM, Staff#119 then went into R#18's room to turn off the feeding pump and stated, Because we don't know. Staff #119 looked at R#18's MAR and found that the N(NAME) shift nurse, Staff#19, administered the TF formula at 0600 on 12/22/17. Staff#119 stated this agency nurse probably used the 12/21/17 feeding bag instead of the new TF bag dated 12/22/17, that was also hanging on the TF pole, when she poured the 0600 TF formula. The N(NAME) nurse used the wrong, outdated TF bag. 3) On 12/21/17 at 11:01 AM, observed Staff#72 administer [MEDICATION NAME] powder to R#16. Staff#72 got a new container of [MEDICATION NAME], used a plastic spoon to get the scooper out, measured out 2 scoops of powder and placed the scooper back into container before closing it. The licensed staff did not know to remove the scooper and keep it out of the container to prevent contamination. 4) On 12/29/17 at 06:59 AM, interviewed Staff#8, an agency nurse, as to why R#16 had missing doses of meds. According to Staff#8, the meds were usually ordered by the charge nurse (CN) II position but currently all nurses were responsible. The med blister packs were delivered by the pharmacy and marked as 1 of 3 (1/3), 2/3, 3/3 (usually 3 blister packs for each med). The nurse who opened the blister pack and marked 3/3 should order a refill from the pharmacy. She said previously it was the CN II's responsibility. Since 12/14/17 all the CN II positions have been vacant, and Staff#91 taught nursing staff how to order meds on 12/13/17. Staff#8 further stated that she received her nursing orientation on 10/29/17, and had experience in GT [MEDICAL CONDITION] but not vents. 5) During the course of the recertification survey, interviews were conducted with staff, administration and family members. Various individuals approached and asked this surveyor to speak with them on matters and concerns that were related to resident care in the facility: 5a) On 12/19/17 at 08:30 AM, interviewed staff #33 who stated, All the RNs are agency except for one RN. Last night there were only two nurses. They mandated the three aides yesterday to stay. They always mandate. Last night one nurse from Kulana stayed back again because they were short .We work 12 hours, then we are mandated. Nowadays, people just pass when the call light goes on. I don't know what is going on. I've been here ten years and this is the worst that it has ever been. 5b) On 12/20/2017 at 10:30 AM, interviewed staff #118 who stated, We have lost a lot of caring and conscientious nurses and aides too. Within the past year, the majority of people left because of management on the nursing side. We don't have any charge nurses anymore. We don't have a code nurse. If we have a code, the agency nurse may not be able to help, especially at night time .The patient workload for the nurses - alarms would be going off all the time. The nurses are going, going, going and no lunch. The nurses paid time off (PTO's) got denied and so they couldn't take any time off. My main concern is the safety. The norm is seven nurses. I know at one point, getting agency nurses increased our medical errors. 5c) On 12/19/17 at 11:25 AM, interviewed staff #20 who stated regarding her workload, four (residents) is good. If anything else, I have to do like urinary tests, etc., then it becomes challenging. She stated, I have seven residents--these four and two kids in the other room. 5d) On 12/20/17 at 09:20 AM, interviewed staff #39 who stated, We are supposed to be five RNs and five CNAs. If you go below 25, the aides can go to four. Staff #66 is working on the floor today to make the five and assumes charge roles. This was confirmed on the nursing daily assignment sheet as well. 5e) On 12/20/17 R#25's family member (FM) requested to speak to this surveyor. Resident #25's FM stated, I am worried about (R#25's) safety. I went by chain of command and I went up to the RNs and stated some of the issues. For example, they repeatedly will take the blood pressure on the same side of (R#25's) arm and not with just one person but others. They would leave her and others' bed rails down. If it's left down and they are doing other things, like turning around, she could fall because she is fast .I came every day, every night and every evening because they are short staffed and I'm worried. How do I know if she fell , how do I know if I'm not here? She holds onto me when somebody not good. She cries when someone is mistreating her. They are short staffed. Every night they are short staffed. When I need help, there is no charge nurse. I have to stand around and look for someone. A lot of times, the roommate'[MEDICAL CONDITION] is off and the other families don't come and these kids cannot call for themselves. (R#25) has butt rash because of neglect and she has had dodo (poop) in her diaper that needs to be cleaned. Why did all these nurses leave here? The RNs here are doing a lot. Two nights ago, I asked the nurse to help clean my daughter up but she said she could not because she had ten patients and we are short staffed. Later on, someone told her to do it. I brought it to the director of nursing and administrator but they said 'there are changes and there have been bad apples'. I brought it to the owner and he told me that staffing when they leave because they have more experience and they move on but others stay because they live close by. I asked him how come he cannot hold on to the oldies and the newbies. People are rushing to get things done here .My main concern is that they lack safety protocol, and management training. I feel if I vocalize, I feel there will be retaliation. I feel like they know because the way they look at me and the way communication has changed. They don't wash their hands and come and take care of my daughter. I talked to the administrator and asked to talk with the doctor and she said I cannot talk with the doctor and she said to talk with the director of nursing because she has all the answers. The last time I talked to him when he told me that she is losing weight and it is good for her body--it was September. 5f) On 12/20/17 at 01:49 PM, observation was made at the nursing station where a monitor at the nursing station displays oxygen saturation and pulse. It was observed that the alarms were sounding for 20 minutes and this surveyor did not see any nurse, management or ward clerk address this. Queried Staff #32 regarding who looked at the alarms and she stated, I do or any immediate nurse or I go to the director of nursing. Queried Staff #110 who stated, I am not trained for the monitors, mostly the CNAs and nurses. If it's red, I call somebody for a sound. There is no unit clerk at night and at night we don't have a charge nurse. The charge nurse would usually help everyone here and monitor the screen too. But, not enough nurses, mostly agencies .Worked here almost 8 years. Sometimes I help them answer the call light and there's no one to answer because they don't have enough staff. When there is a delivery, I go to the back too. Observation on 12/20/17 at 03:00 PM revealed a red alarm with a heart rate that went down to 39 beats per minute and an oxygen saturation level of 91%. Staff #32 was sitting at the nurses station and did not show an urgency for a red alarm. 5g) On 12/21/17 at 07:50 AM, interviewed staff #34. She said, Because of what is going on, I decided to work the minimum. I feel that with the whole staffing issues, my license is on the line. Last night was four staff, me and the other nurse--had a total of 9 patients. There was no charge nurse and the last charge nurse left. The night shift, we don't have support for anyone to come in if one of us is sick. If there was a storm to come, I don't know where the back up generator is. I know that the management is back up but I don't feel that they are there for us. I feel like the patient safety and care is being compromised. For instance, repositioning, especially when the aides are short and changing them when they (residents) are soiled.[MEDICAL CONDITION] and catheter care is compromised. There are times when we were short and the management has said not to do [MEDICAL CONDITION] .With the new agency staff coming in, they don't know the patients like we do and the agency nurse actually passed one of her narcotics which was scheduled for 10:00 P.M. at midnight (two hours late). Because there is no charge nurse, there is no one to oversee. With the agency nurses, their expectations are probably higher than what it actually is. For instance, the agency nurse did a straight cath into the chucks. The agency nurses are asking their aide's to do the work instead of them doing it. There are a lot of med passes. If there is a med pass error, who is accountable for it? For example missing the dose or doubling the dose and this happens mainly because we are short staffed. 5h) On 12/22/17 at 07:45 AM, interviewed Staff #120 who stated, I have worked here for four years. The other night, there were only two nurses. I was supposed to get off at 7:30 PM and I stayed to 11:30 PM. I was mandated. Two nurses were new and I was the third person. I stayed to do care and pass meds. We only had three nurses for 25 from 11:30 pm to 7:00 am. There was only two for 25 and I don't think the agency carried a load. It's been like this for one year, staffing has been an issue. Easter there was just two. We told management we cannot accept this. Management told us that we can accept the assignment or we can leave but suffer consequences. Management said to focus on the care, airway, meds, feeding. Although we have a respiratory therapist, suctioning gets pushed to the side. The things that would not get done is [MEDICAL CONDITION], [DEVICE] care and urinary catheter care. I am able to get my care done but I am rushed. The agency nurses are not able to get everything done or they don't know how to do it. The charge nurses were slowly leaving and they weren't replaced. I put my name down and I never got trained. I'm leaving because it is too unsafe and I may come in and I may have the whole building to myself. Last night, there were four of us, then one nurse was sick and she went home. That left us with three nurse. There is two of us that have nine patients and the other one has seven. 5i) Interview with Staff #88 on 12/29/17 at 08:36 AM revealed that, The family had asked staff to take R#14 out on shower days and there were six aides and they didn't bring her out. Staff #88 stated that it's because we have agency aides and they don't bring the adult residents out of their rooms. Cross-reference to findings at F656. 5j) The SA also confirmed the RN staffing based on these interviews to the nursing daily assignment sheets from 12/20/17 and found it to be accurate to what the staff were reporting. Although the 12/18/17 staffing assignment was requested by a surveyor, it was not produced. However, Staff #66 affirmed during an interview on 12/22/17 that, we are still having problems with staffing and she worked that night shift when they only had 2 RNs for their 25 residents. 6) During the observation of Res #1 on 12/21/17 at 9:12 AM, Staff #98 stated the nurse aides usually are assigned to care for five residents each. Only when we get 7 or 9, it's very hard. Yesterday we had 7 each, because 1 CNA called out. Since recent, because people leave, we're getting help from agency, but we have a lot of staff turnover. You just feel overburdened and and tired, and can't take your break on time and extra exhausted and then they (administration) will mandate you, like when they only have 3 CNAs at night. They mandate you to stay until 11:30 PM if they are short on night CNAs. And then when you are working 12 hours, you feel so exhausted already and have to work extra. Yes, I feel that way. I will tell my charge nurse--but now we don't no more (have a charge nurse). Now I have to call (DON) to talk to her. I think the first time I was mandated, I told her I worked 2 days straight and mandated to stay over and then working the next day, so for me to work I'm not going to be able to focus and they should get somebody else. She said they are currently using 2 or 3 agency CNAs at this time as well and she is training Staff #15. 7) Interview with Staff #82 on 12/22/17 at 12:39 PM confirmed their nurse staffing had been affected by a large number of staff who resigned within the past several months. On 12/27/17, Staff #82 also produced the first printout of their payroll based journal (PBJ). She acknowledged the difference of 3,575.75 staff hours from the previous quarter ending 9/30/17 compared to the one ending 12/27/17. Cross-reference to findings at F838 and F851. 8) On 12/22/17 at 8:16 AM, interview of Staff #34 was done. Staff #34 said a couple of months ago, the nurse staffing ratio to resident care was either 7, 8 or 9 residents to a nurse, and the census was more than 25. Staff #34 believed due to poor care, some residents had to be sent to the hospital such as Res #28. With the current census at 25, Staff #34 did not feel like the residents were receiving the proper care they deserved such as checking the residents hourly, especially when they are hypotensive and bradycardic. Staff #34 said the respiratory therapists (RTs) come in at 10:00 AM and they do the ventilator checks every 4 hours. The new nurses and the agency nurses don't know what to do about the vent settings, and you have to check it on the log. Some of the new hires are more task oriented, so they surpass that because 'it's the RTs job', but it's not the RTs job. I feel the CNAs should have vent competency too, but it hasn't been scheduled by the DON. For medication administration, Staff #34 said she was trained by two nurses no longer at the facility. She was taught to put two tablets into separate medication cups to crush. Staff #34 said the water flushes for the medications were only given before and after the administration. She said, No annual competency check that I know of. Staff #34 said the agency nurses were trained on 3 night shifts and 3 day shifts. The recent ones have experience, but the first ones, like (Staff #16), had no experience. 9) On 12/22/17 at 8:50 AM, interview of Staff #119 was done. Staff #119 said she told Staff #66 of the medication (med) errors that there were a lot of them, this is a lot of errors. so the ones making errors, they had to re-read. Staff #119 stated the med errors had to do with a dot system and symbols. If the nurse put a med into a med cup, they would put a dot on it. But she said some would give it, or they would forget, or they gave a double dose, and they don't count how much meds. Staff #119 said, old nurses say its the new ones doing this, but something is wrong with the system. They're not doing it right, they sign the MARs (Medication Administration Record) late, and they making their own symbols. Staff #119 said the orientation for new nurses is 3 days of training. Staff #119 stated she recognized the procrastination in every area. For the medication errors, she told the administration they will have to answer to it because they were not keeping track of it. She also said the night shift staffing on 12/21/17--everyone called in sick and I told (DON) if you don't have a staff member coming in, then you have to come. You're getting rid of these people but you also gotta train them. Staff #119 further confirmed the nurses were not having their skills competency checked with their orientation. 10) On 12/22/17 at 10:10 AM, interview of Staff #65 was done. Staff #65 stated it has been escalating to the point where he has asked the night shift RTs to do their first rounds at 10 pm by checking airway clearance, do assessments and complete any night treatments. By morning, we prepare the children for school and told them (RTs) to mainly concentrate on if these residents are being suctioned--that's the most important thing, because if they let them settle into their secretions, you don't want it to settle into their lungs. Staff #65 was asked about the licensed nurse's role in conjunction with the respiratory therapists. He replied, It's more frequent with the agency nurses. The therapists asked me about it too, and we're not picking on them, but they seem to be overwhelmed with their work and they think that tracheal suctioning is like second priority. We notice they seem to be overwhelmed with passing meds. Staff #65 stated as a result, the nurses will rely on the RTs to suction because they are behind on passing medications. Staff #65 was asked who did the ventilator training competencies, and replied, The turnover has been so fast and furious we cannot keep up with who has done it and who didn't do it yet. I approached (DON) about vent competency and to give me an hour or so, but she can't even pull them off the floors. I don't think the agency is done because I don't remember doing any of them. When they (new hires) first come on, we do the suctioning with them, and if find they're not doing it competently, like there's tracheal bleeding due to trauma, we identify that nurse who shouldn't be doing it until we do their competency again and we deem them competent. Staff #65 stated as for the health and safety of the residents at this time, it's like something is going to happen--I hope not, but it's just when. You cannot depend on luck. 11) On 12/22/17 at 3:35 PM, interview of Staff #72 was done. She stated they were all hired on as a charge nurse. She said she was not trained as a charge nurse however, and questioned how could fulfill this duty if they were not trained for it. Staff #72 said, We're always short (staffed). I did Tuesday night, 7pm to 7am, but didn't leave then. She stated because they are constantly short of staff, they are mandated to stay. She had seven residents to care for during her day shift today including orienting a new nurse. So you just juggle, and our load is normally like 7 or 8 (residents) and when they hire, they tell you it's 6. The DON has ultimately the end say. It's just frustrating. We haven't had a monthly nursing meeting forever, and now two more long term staff are leaving. She stated she did not know where their current nursing policies and procedures were but that another agency nurse had asked her about it as well. Staff #72 said, for tonight's shift, one scheduled RN called in sick, so the 7-7 (night shift) will only have 3 RNs. They're probably going to mandate one of us to stay back or the DON will have to.

Based on observations, record reviews, interviews and review of the facility's policies and procedures, the facility failed to ensure there was sufficient nursing staff with the specific competencies and skill sets necessary to safely care for each residents' needs, as identified through resident assessments, and described in the plan of care. It was found there was an insufficient number of licensed staff with a lack of competency training required to provide adequate and safe nursing care for the capacity of residents who were all ventilatory dependent and required total care by staff. As a result, an immediate jeopardy (IJ) was identified as the potential for serious harm to occur for all their residents existed. Findings include: Cross reference to findings at F550, F645, F656, F657, F725, F759, F760, F835, F837, F841. 1) On 12/22/17 at 10:10 AM, Staff #65 stated for the ventilator competency training, it has been difficult to track which staff completed their training due to the rapid turnover of staff. Staff #65 stated he did not think the all of the current nursing staff had completed the ventilator competency training. He was uncertain if Staff #66 had initiated any of the same training but if so, he was unaware of it. 2) During an interview with Staff #119 on 12/22/17, she verified the nursing staff was not being competently trained. The SA found evidence of this by a) a 92% medication error rate found during their medication review task, b) incomplete documentation and monitoring without corrective measures of the facility's high rate of medication errors/omissions, c) missing documentation of ventilator competencies of 8 regular licensed staff and an unknown number of the agency staff without ventilatory competencies and d) missing documentation of the staff's annual [MEDICAL CONDITION] suctioning competencies. Staff #119 confirmed she told Staff #66 and Staff #82 about these issues since she knew she needed to complete her competencies for the nursing IVs by October 2017, but had been unable to do so. Staff #119 stated the systemic problem in this facility in every area has been procrastination. Staff #119 also verified for the medication error tracking, Staff #91 developed the handwritten notes given to the SA on 12/22/17 two days ago. She said they have not been tracking nor monitoring it, although the MAR and their medication error reports showed there were many errors. The SA's initial attempt to reconcile Staff #91's report found a discrepancy between Staff #91's count and the SA's (more were found). On 12/22/17, Staff #82 stated she would have it re-done by Staff #91. However, by 12/28/17, Staff #66 was asked by Staff #82 to re-do it, instead of Staff #91. Staff #66 initially said from January to May of 2017, there was no tracking for the medication errors/events. Staff #66 produced a 2017 Medication Event Report Summary, and it revealed a trend of missed doses, improper med administration, etc. For the month of October 2017 alone, there were 29 extra doses or overdoses administered by licensed staff as well as 5 missed doses. In addition, record review found extra, unaccounted missed doses of an antibiotic in September 2017 for Res #28, as well as one extra dose given to Res #21 (i.e., given 25 milligrams of Dantrolene instead of 12.5 mg) in the facility's event report. This was verified by Staff #82 on 12/28/17 at 4:35 PM. Staff #82 stated Staff #66 was not trained to track these things and the medication errors were more than what was documented on the summary reports given to the SA. 3) On 12/22/17 at 3:25 PM, interview with Staff #18 was done. She stated as an agency nurse, her skills were checked through the facility's recruiting agency. She had 3-4 days of floor orientation once employed at this facility with a verbal review of their policies. She did not recall having a written skills competency checklist as part of her orientation and signing off on it. She also said she did not know where to access the facility's current policies and procedures, but they're probably in one of the binders. Staff #18 said, I wish we had a charge nurse, after she asked Staff #72 about what to do with the ordered labs. 4) As part of the identified IJ, and during a 12/22/17 meeting at 12:39 PM with Staff #82, #119, #65 and #66, it was revealed the ventilator training was not being done. Staff #119 also queried to everyone, Can we learn these vents in one hour? Staff #82 agreed they would have to provide training and said, we have to deem them (their staff) competent. Part of the IJ abatement plan accepted by the SA on 12/22/17 at 7:00 PM was to ensure starting on 12/22/17, that all staff's competencies were reviewed and would include: 1) tracheal suctioning for the licensed nurses, respiratory therapists, nursing CNAs and activity CNAs, 2) [DEVICE] flushing for the licensed nurses and CNAs, 3) medication administration for [DEVICE] and J-tube for licensed nurses only and 4) ventilatory use for licensed nurses, respiratory therapists, nursing CNAs and Activity CNAs. As a result, the facility provided various skills documentation checklists as part of their initial plan to ensure all their staff were going to be deemed competent in their scope of work. 5) On 12/28/17 at 8:57 AM, Staff #119 verified a physician's orders [REDACTED].#119 was further asked what nursing standards of practice were used at this facility and she said, I actually don't know. I read some of their policies, but they're kinda old. We followed the policies from (pharmacy). Staff #119 also said for the use of the Bair Hugger, the licensed nurses were to apply it and not the CNAs. She said the CNAs however, are doing it and for one resident, once applied, they have to take a temp every 15 minutes, otherwise they can heat up. For Res #1, record review found when the Bair Hugger was applied, there was no order as to the frequency of monitoring his temperature and his December vital signs log sheet showed his temperatures were only recorded hourly, yet, missing documentation of when the Bair Hugger was applied or not. Staff #119 confirmed there was no policy for the staff to follow regarding the application of the Bair Hugger. The facility failed to ensure all of their staff were competently trained in their respective disciplines of practice.

Based on observations, record reviews, interviews and review of the facility's policy and procedure, the facility failed to ensure the facility's medication error rates are not 5 percent or greater for 4 of 16 residents (Residents #25, #14, #16, and #23 ) in the survey sample. In addition, the facility's practice of medication administration was not based on current standards of practice as evidenced by the actions observed of the licensed staff and others who were interviewed. As a result, there existed a high potential for harm to the health and safety of all their residents and an immediate jeopardy (IJ) was identified on 12/22/17. Findings includes: Cross-reference to findings at F725, F726, F760, F835, F837, F841. 1) On 12/21/17 at 09:28 AM, surveyor observed Staff#109 administering medications (meds) via R#25's gastrostomy tube (GT). Staff#109 opened the [MEDICATION NAME] capsule and mixed it with distilled water, used a 1 ml (milliliter) syringe for the multi-vitamins, a syringe of 0.3 ml [MEDICATION NAME], and syringe of 2.5 ml [MEDICATION NAME]. Staff #109 stated that for R#25, she used 5 ml of distilled water before and after her med administration. After administering each syringe of med one after the other via the GT, Staff#109 flushed the resident's GT with 5 ml distilled water at the end. Staff#109 stated that she had her nursing education and training in California and was taught to flush between meds when administering via the GT. When Staff #109 was hired at this facility however, she was told the facility protocol was to just flush before and after med administration. On 12/21/17 at 09:02 AM, the MRR for R# 25 noted on the December 2017 physician order [REDACTED]. 2) A medication pass observation of Staff #20 on 12/20/17 at 9:28 A.M. for R#14 revealed the following meds administered via the [DEVICE]: 1) Multi-vitamin tab, 1 tab. 2) Potassium 15 ml (20 MEQ) poured. 3) Senna 8.6 mg tab, 2 tabs. 4) [MEDICATION NAME] Immunity caps, 1 cap. 5) [MEDICATION NAME] 20 mg tab, 1 tab. 6) Fludrocortisone 0.1 mg tab, 1.5 tabs. 7) Levetiracetam 100 mg/ml solution, [MEDICATION NAME] 7.5 ml (750 mg) poured. The liquid meds were poured together into a 60 ml syringe in which they were administered via [DEVICE] and mixed with 30 ml of water, pushed in by a syringe. The medication tabs as above, multi-vitamin, Senna, [MEDICATION NAME] and Fludrocortisone were all crushed in a baggie and placed in a 30 ml cup, then poured into a 60 ml syringe. Staff #20 stated that physician orders [REDACTED]. 3) On 12/22/17 at 9:35 AM, a medication pass observation was done for R#16. Staff #20 administered the following medications to her: 1) Dantrolene 25 mg cap, 1 cap. 2) [MEDICATION NAME] 20 mg tab, 1 tab. 3) Multi-vitamin tabs, 1 tab. 4) Polyeth Glyco Powder 3350 NF, 1 capsule (17 gms). The nurse stated, Now I am going to crush meds and place it into the same cup with other meds. I like to pour it into one cup. Meds were poured into a 60 ml syringe and pushed through the [DEVICE] with no flushes in between. The physician orders [REDACTED].#16 were: 1) After tube feedings: 185 ml distilled water. 2) Before tube medications: [REDACTED] 3) After tube medications: [REDACTED] There were no orders for the crushing or mixing of these medications. 4) On 12/21/17 at 9:39 AM, Staff #12 was observed during the medication administration for Res #23. Staff #12 was observed to open and place the capsule contents of [MEDICATION NAME] 50 mg in a medication cup and added the [MEDICATION NAME] to it. He then drew up 10 ml of [MEDICATION NAME] Sodium into a syringe and left it on the side. In another medication cup, Staff #12 added the following medications into it: Atorvastatin 10 mg tablet, [MEDICATION NAME] 1000 mg tablet, [MEDICATION NAME] HCL 5 mg 1 tablet, Multivitamin 1 tab, Senna 8.6 mg 1 tablet and Vitamin C 500 mg 1 tablet, crushing all these medications together. He then added it into the med cup with the [MEDICATION NAME] and [MEDICATION NAME] to equal one med cup containing all the medications mixed together. Then he added the contents of the [MEDICATION NAME] 20 mg packet into a small plastic solo cup, added 15 ml of water and stirred it. Staff #12 also had cranberry juice to give the resident. At 9:51 AM, Staff #12 then added 5 mls of distilled water into one 10 ml syringe after removing the plunger, added half of the crushed medications into it, added more water and then replaced the plunger before shaking the syringe to mix the contents. He repeated the same method by taking another 10 ml syringe and added the rest of the crushed medications into it. At the end, Staff #12 had two 10 ml syringes, both with contents of a brownish color and pointed out that one syringe had 10 mls and the other measured 8.5 mls because he added a little more water to it. He then placed the syringes in a plastic cup to take to the bedside. The CNAs were providing care at the time, so the medication administration to the resident occurred at 10:06 AM. Staff #12 drew up the preflush of 60 mls of distilled water and administered it via Res #23's [DEVICE]. The first medication he administered thereafter was the [MEDICATION NAME], then the first syringe with the mixed medications, the second syringe of medications and last, the [MEDICATION NAME] drawn up in a separate syringe. After the [MEDICATION NAME], Staff #12 flushed it with an additional 15 ml of water. Next, Staff #12 opened the cranberry juice, drew up 30 mls and administered it to the resident via the [DEVICE]. Staff #12 then flushed the [DEVICE] with 60 ml of water. During the medication administration, Staff #12 was observed to only flush before and after the medications were administered via the [DEVICE] and after the [MEDICATION NAME] as per the physician's orders [REDACTED]. The licensed staff who were observed during medication administration was found to crush all medications together and administer them via the residents' gastrostomy tubes ([DEVICE]s) after mixing the crushed medications with distilled water in random amounts using syringes. As the medication pills/tablets were all crushed and mixed together, the water flushes between each medication did not occur, even when interspersed with the liquid medications (or juice) that was given. The only water flushes given were before and after the medications were administered. There also were no orders to crush medications. The SA's calculated total medication error rate was found to be 92%. The SA team had a combined total of 25 medication administration observations or opportunities for errors and 23 medication errors identified based on the facility having 1) no orders to crush the medications, 2) the licensed staff were crushing and combining the crushed meds to administer in syringes with random amounts of distilled water to mix it with, 3) crushed medications as well as liquid medications (i.e., [MEDICATION NAME]), and administered one after the other without any flushing between each medication, and 4) there was no current clinical standard of practice for the staff to follow as the facility's nursing policy and procedure, [DEVICE]/Pe[DEVICE] Feeding/Medications referenced 1996 clinical standards of practice. Staff #66 confirmed on 12/27/17 at 3:30 PM that the last time they reviewed their policy was in 2012. 5) On 12/27/17 at 1:40 PM, during an interview with Staff #66, she stated for medication errors, the general is to aim for less than 5%. Given the SA's observations and the identification of the IJ on 12/22/17, she stated she started off by tracking the medication errors but at some point, started to get behind. She also attributed to the fact that staff were not completing their forms correctly. She said, I do recognize that the med errors are happening and since (Staff #119) has joined us, she's happening to tackle all that too, maybe the way we do our MARs. We did recognize this is happening, and we have a lot of new faces. Staff #66 acknowledged she has not been keeping up with the log. The SA had to wait for Staff #66 to compose the medication error summary sheet as there was none except for the handwritten one produced on 12/22/17. Staff #66 stated no one taught her about QAPI either and she replied, No, when queried if there was anything she could show as to what changes she has made, identified or captured. On 12/28/17 at 3:56 PM, Staff #66 brought in a revised medication event report summary and said she was told by Staff #82 to put the tracking log together for January to May 2017. Of note, Staff #66 initially stated there was no tracking for January through May 2017. When the SA queried what Staff #66 was tracking, she identified the number of event reports instead of the actual number of medication errors. Staff #66 stated she did not know what the SA was asking for and then stated she could re-do it. Staff #66 however, failed to identify the trends and the actual number of medication errors as the critical components to be monitoring and improving. 6) On 12/28/17 at 5:00 PM, Staff #82 affirmed they had to find a new tracking system and more training for Staff #66 to track the medication errors. Staff #82 also acknowledged the reports were only being developed once the SA began asking for them from the beginning of the survey and recognized there was no system in place as the SA found it was being developed during the survey.

Based on observations, record reviews, interviews and review of the facility's policy and procedure, the facility failed to ensure that its residents are free of any significant medication errors for 4 of 16 residents (Residents #25, #14, #16, and #23 ) in the survey sample. As a result, there was a failure to protect from potential adverse medication consequences, a failure to have concise physician's orders [REDACTED]. In addition, it was found there were insufficient numbers of licensed staff who lacked the training for medication administration to adequately provide safe, competent nursing care for these residents who were all ventilatory dependent and required total care by staff. Further, the facility's practice of medication administration was not based on current standards of practice as evidenced by the actions observed of the licensed staff and others who were interviewed. As a result, there existed a high potential for harm to the health and safety of all their residents and an immediate jeopardy (IJ) was identified on [DATE]. Findings includes: Cross-reference to findings at F725, F726, F759, F835, F837, F841. 1) On [DATE] at 12:39 PM, the SA met with Staff #82, #66, #65 and #119. The facility staff was informed of the IJ based on the SA's medication error rate at 92%. Staff #119 stated she recognized the flushing of the medications was an issue, and it was not being done when the nurses were passing their medications to the residents. Staff #119 said this is the standard protocol to follow but that their previous medical director did not think it was necessary. She stated the administrative staff were all aware of this practice of not flushing between medications and it has been taught this way. Staff #119 concurred the standard of practice was to also ensure crushed medications administered via the [DEVICE] were not to be given all mixed together. The SA observed during the medication administration observation of various licensed staff that they were also drawing up random amounts of distilled water to dilute the combined medications. There were no resident specific orders to crush all the medications, nor orders to mix all the medications together, nor how much water to mix or dilute the medications with, and/or what the specific flush amounts were between the medications. The facility had 20 pediatric residents and 5 adult residents, however, there were no specific, individualized orders based on each resident's medical history and condition. 2) During an interview with the consultant pharmacist on [DATE] at 9:29 AM, she said they mostly have residents on fluid restriction in this facility. She was asked whether she observed the nurses performing medication administration at this facility, and she said no. Thus, when she was informed by the SA how the nurses were observed randomly drawing up free amounts of distilled water to dilute all of their crushed medications together, that if their residents were on fluid restriction, it would make it worse (fluid overload with no parameters). She then stated, we will need to tighten it up. The consultant pharmacist also said her recommendation was to get a physician's orders [REDACTED]. She said it was to be available in December and thought they would have a policy in time. She acknowledged their policies and procedures were yet to be revised although she was aware of the Phase 2 implementation of the federal regulations for long term care facilities. 3) Staff #82 verified the policies and procedures had not been reviewed/revised by the end of the extended survey. Staff #82 stated, No, in all honesty, no, as her response. She had been discussing it with their interim medical director and re-did the abuse type policy as well as creating a binder for the administrative policies. She confirmed the facility's existing policies and procedures have not been reviewed/revised for a long time. (Staff #66 had confirmed it was last done in 2012). Staff #82 also stated there was a loss of their regular licensed staff with the largest exit of staff starting around ,[DATE] weeks ago. She said these were the nurses who were at the facility ,[DATE] years, and currently, there was almost no licensed staff with this many years of experience. She also stated their facility assessment is going to the QA committee. 4) The facility's IJ abatement plan was accepted on [DATE] at 7:00 PM. It included the facility's corrective measures for 1) medication administration which a review of their current policy and procedure and and all resident orders to be reviewed. This included immediate training/orientation starting with shift huddles on the evening of [DATE]. The plan included the crushing of individual pills to mix with 5 ml of distilled water to dissolve it, flushing the [DEVICE] and/or J-tube with 5 ml of distilled water before giving the med, followed with a 1 ml flush of distilled water between each medication, unless ordered differently, and after giving the medication to follow with 5 ml of distilled water flush. It also included staff competency reviews at the start of each shift to ensure all staff were signed off for [DEVICE] flushing (licensed nurses and CNAs) and medication administration for [DEVICE] and J-tube (licensed staff only). It was revealed during the observations and interviews of many staff, that licensed staff were learning how to administer medications based on who previously taught them, and were not following clear physician/NP orders or have updated and current policies and procedures to follow. 5) On [DATE] at 11:01 AM, observed Staff#72 administer [MEDICATION NAME] powder to R#16. Staff#72 then crushed a multi-vitamin tab and mixed it with distilled water to administer through R#16's gastrostomy tube (GT). Staff#72 then mentioned the medication for R#16's [DIAGNOSES REDACTED] was not given at 1000 because it was not available. In addition, on the medication administration record (MAR), the resident had Dantrolene 25 mg cap, take 1 cap per GT 4 times daily (0500; 1000; 1700; 2200) DX: [DIAGNOSES REDACTED]. However, according to Staff#72 the med was last given by the N(NAME) shift nurse at 0500 and that the order from the pharmacy was not in yet. Staff #72 failed to administer this routine dose. Staff#72 stated that R#16 received 30 mls of distilled water flush through her GT before and after med administration. Staff#72 said she received her nursing education and training at a Hawaii university and was taught to flush between meds but was told this facility's protocol was to flush before and after all meds were administered. On [DATE] at 06:59 AM, based on review of R#16's MAR and documentation for Dantrolene 25 mg caps per GT 4 times daily (DX: [DIAGNOSES REDACTED]); it was found the med was not given at 1000 on [DATE], but also at 1700 with not available, written in the date/time blocks. 6) On [DATE] at 02:43 PM, observed Staff#72 administer meds to R#2. The resident had just returned to the facility from school. The resident's mouth was full of secretions with drool dripping from both sides of his mouth. Staff#72 stated that a portable suction was brought to school with R#2, and a school nurse rides home in the bus with the resident. Staff#72 did not know why school nurse did not suction R#2 as needed. Staff#72 then administered meds for R#2's secretion management. Staff#72 stated she was giving the resident his 1100 dosage of [MEDICATION NAME] 1 mg tabs 2.5 tab (2.5 mgs) per GT, because the school nurse won't administer the med at school via his GT. Thus, it was only on weekends and holidays which R#2 received the 1100 dose of glycopryrrolate at the facility. On [DATE] at 02:23 PM, the MRR on R#2 found noted on a physician order [REDACTED].#30; Hold [MEDICATION NAME] 40 mg doses until medication comes in from pharmacy. The [DATE]-31, 2017 MAR documented First [MEDICATION NAME] 2mg/ml had missed doses written on the date/time blocks for: ,[DATE] at 1700; ,[DATE] at 0500 & 1700; and ,[DATE] at 0500. The PO dated [DATE], included: First [MEDICATION NAME] 2mg/ml; take 20 ml (40 mg) per [DEVICE] twice daily (DX: [MEDICAL CONDITION], recurrent GI bleeding) [DATE]; and [MEDICATION NAME] 1 mg tabs 2.5 tab (2.5 mgs) per G - tube 4 times daily (DX: secretions management); 0500; 1100, 1700, 2300. Yet, on a [DATE] Medication Event Report it was noted, ,[DATE]-,[DATE] (0500); Medication [MEDICATION NAME]; Explanation of what happened: Medication was noted to be expired [DATE], medication was still given while expired. Describe effect/adverse reactions as a result of incident: No adverse effects to patient. Staff nurse notified Staff#30 and TORB given to hold until medication comes in from pharmacy. 7) On [DATE] at 10:34 AM, a closed MRR was done for R#28 who was discharged from the facility on [DATE]. The resident was emergently discharged on [DATE] due to a sudden change in status, and noted by nursing staff to be unresponsive, hypotensive and with [MEDICAL CONDITION]. The discharge summary dated [DATE] gave the reason for discharge as, acute decompensation; [MEDICAL CONDITION] and unresponsive. On the facility's form, Events During ___Stay, there was documentation on: [DATE] continued abscess + [MEDICAL CONDITION] - Therapy Results: PICC line 4 Fr. (hospital); Meropenum 1 g IV q 8 x 14 days; Pus culture ,[DATE]: no growth - ,[DATE]: extend Meropenem add'l 6 days; [DATE] neck Abscesses [MEDICAL CONDITION] L submandibular Therapy Results: Linezolid for abscesses + [MEDICAL CONDITION]; cult of serosang drainage+ . On [DATE] 2025 a shift note (,[DATE]) documented .Trach stoma pink moist with open abscess to L side above trach, [MEDICATION NAME] cream applied as ordered. Neckline intact .New orders: Start Linezolid 600 mg tab per [DEVICE] BID x 6 months. Orders documented & carried out . Upon further review of R#28's medical record, it was noted on a physician order [REDACTED]. Skip the doses for ,[DATE] (1000 & 2220), ,[DATE] (1000). Resume Linezolid ,[DATE] at 2200; Signature of Physician: former medical director ; Date: [DATE]. Linezolid is an antibiotic and was originally prescribed to be given twice daily for six months. The facility's practice was to discontinue medications when they were not available and the quality assurance oversight for nursing and pharmacy services failed to track and monitor this, including the concomittant rates/trends of medication errors.

Based on observation, record review, staff interviews and a review of the policies and procedures, the facility failed to ensure its residents are free from unplanned decannulations for 5 of 17 residents (Res #2, #7, #20, #24, #25). As a result, there was a failure to protect these residents from respiratory trauma/complications due to the number of unplanned decannulations. Residents who experience these unplanned decannulations suffer from oxygen desaturation, trauma and even the likelihood of death. An immediate jeopardy (IJ) was identified as the facility failed to recognize the serious nature of the decannulations, failed to track the incidence and rate of decannulations occurring in the facility, failed to identify the root cause(s) of the decannulations, failed to develop and implement care plan interventions to prevent the recurrence of decannulations, and failed to train or in-service staff about the decannulation risk for all residents in the facility. Finding includes: During the revisit survey, the SA observed an unplanned decannulation (removal of the [MEDICAL CONDITION]) on 2/28/18 at 11:10 AM for Res #20. This happened while she was attending her in-facility school program. Three respiratory therapists responded to a call for help and worked on the resident to re-insert the tube and re-establish her airway. The pediatric resident, was observed gasping with tears as her oxygen saturation level dropped to 69%, with a pulse of 164. Review of the facility's incident report found the cause of decannulation was due to the resident's [MEDICAL CONDITION] ties being extremely loose. Then the next day on 3/1/18 at 8:15 PM, another pediatric resident, Res #7, experienced a decannulation during his bed bath. Separate interviews of Staff #25, Staff #124, and Staff #98 were done, and it was found that Res #20 and Res #7 were known to decannulate frequently, but that it was not being addressed. The SA's manual tally taken from the facility's nursing 24-hour daily shift reports, found a total of 7 decannulations accounted for in (MONTH) (YEAR). In addition, the SA found a total of 8 decannulations which included the (MONTH) 28th decannulation of Res #7. This was compared to Staff #1's tracking report which noted her total for (MONTH) (YEAR) was the same (7 decannulations), but for (MONTH) (YEAR), she had recorded only 3 decannulations through (MONTH) 27th. Interview of Staff #124 on 3/1/18 at 8:35 AM found that during a decannulation, the primary goal was to re-establish the airway for oxygenation and to stabilize the resident. Staff #124 said previously, the decannulations were tracked by the previous director of nursing and the previous medical director, but currently, the Administrator signed off on the incident reports. Staff #124 stated, When the critical questions are asked, who witnessed this, who is going to write the report, no one wants to do the reporting. Staff #124 stated the decannulations were not discussed in the QA meeting and did not know if there was a critical number being reported, as the Incident Event Reports and Initial Investigative Findings were not routed to the respiratory therapy (RT) department. Staff #124 also stated there was no head charge nurse to complete these reports as well. Interview of Staff #25 on 3/1/18 at 10:12 AM revealed that licensed staff were aware that Res #20 decannulates because she was very active and often got wrapped up in her pulse oximetry tubing along with the ventilator tubing. Staff #25 said Res #20 desats so much and decannulates and once she goes down, she goes down fast because this girl has a lot of [MEDICAL CONDITION] too. Staff #25 said they have to check her almost every half hour when she was put into her crib. She said they're supposed to check [MEDICAL CONDITION], but was not certain if everybody did this. Interview Staff #1 on 3/1/18 at 10:53 AM revealed for the decannulations, she wanted to see what was happening with the numbers. The SA queried what Staff #1 has done about the occurrence and recurrence of decannulations. Staff #1 stated she was going to have to ask Staff #30 what she has done about it in her huddles and this was new data since their meeting three weeks ago. She further stated, We noticed these things (decannulations) going on and we need to get the numbers down. We need to find out what's going on with it. Big red flag. Staff #1 stated she was going to ask Staff #30 to pull everything about the decannulations and provide it to the S[NAME] During Staff #30's interview on 3/2/18 at 8:48 AM, she stated, We have a high rate of decannulation so we need to monitor them more closely and adequately do [MEDICAL CONDITION], like (Res #20), so we don't want them to pop out. (Res #2) does it frequently. But, I think monitoring more closely. This is the first time I've seen loose ties on her (Res #20). Staff #1 stated she did not know the reason for the loose ties. Regarding the discrepancy in the number of decannulations which the SA counted versus what Staff #30 had tracked and whether she was tracking the frequency/occurrences of it, Staff #30 stated, I don't think so, I think we just started in January. I don't think there's any actual running log of what was being done. When Staff #30 was made aware the SA's manual count taken from nursing's 24 hour daily shift reports totaled 8 decannulations in (MONTH) versus the 3 she had, she stated, Eleven decannulations (her total of 7 in (MONTH) plus her count of 3 in February) is very high, but when you look at three days, to me, in a pediatric population, I don't know if it's very high. The SA clarified if she meant one decannulation every three days and she said, Yes, I don't know if it's really high or not. Staff #30 was further queried whether she had implemented anything with the identification of the 7 decannulations she tracked in the month of (MONTH) alone. She stated, No, I haven't started anything. I have not done a breakdown, no, (i.e., which nurses, which shift, etc.). Interview of Staff #98 on 3/2/18 at 9:09 AM revealed there was an under reporting of the incidence of decannulations. Staff #98 stated for the decannulation which occurred for Res #7 at night on 3/1/18, There's no charge nurse, and usually it would be the charge nurse. The nurse who had the patient--she wasn't even aware she was supposed to write it up. So I told her I would show her how to write it up and what needs to be done. I showed her where in drawer and I called the doctor and then I asked the nurse to call the family .The nurse said she's had several decannulations and that she has had several decannulations but no one has ever told her about this. So I'm wondering if I didn't initiate writing a report, would they have wrote the report, called the doctor and family? Staff #98 said it was important to address decannulations because, Some of the residents they don't have any reserve, they desat so quickly . so our one resident, (Res #20), she's had quite a few decannulations so she's one of them where she desats very quickly. She's active in her bed, so oftentime, when she's alarming, she's all caught in her tubing, and she's just very active, and for one, they need to make sure the ties are tight enough. We've been physically checking and sometimes we can fit our whole hand in it. I can't pinpoint, it's all these new staff, because it's all new staff for us. We address it if we know who the nurse is, and we'll just let them know--I just let them know. I did that with the nurse for 2B one time and said I can fit my whole hand in there. I believe it was an agency nurse, but at night time, what do you do--call 911, but by that time, the kid is dead. So are they going to know what to do? This is coming from (Staff #1), that the new nurses should be able to jump onto the floor. But they're not paying attention to the desats, [MEDICAL CONDITION], and right after they leave the room after [MEDICAL CONDITION], they leave the room, but the secretions often loosen and they need suction and desat right after doing [MEDICAL CONDITION]. It's okay to be afraid, but if people are offering to be with you, you should try to do it because we're there if something goes wrong. So if you bring in [MEDICATION NAME], they should know how to do it. The SA found for the month of (MONTH) (YEAR), there were 4 decannulations which were not reported: Res #20 on 2/12/18; Res #21 on 2/16/18; Res #18 on 2/27/18 and Res #7 on 2/28/18. This data showed there were other residents who had decannulated and had not been identified as one of the high risk residents. This information substantiated some of the facility's staff's concerns related to the under reporting of such events. In addition, although the facility staff and management were aware of the decannulations, the incidence rate, accurate reporting procedure, staff education, review of the comprehensive care plans to prevent future decannulations, and quality performance improvement measures with a root cause analysis for each prior occurrence, were not being done. All of the facility's residents have a [MEDICAL CONDITION], are ventilatory dependent and dependent on staff for their airway management/life support. On 3/2/18 at 2:33 PM, per Staff #30, she said she could not find any inservice on decannulation, nor was there a policy available for it. On 3/2/18 at 7:05 AM, Staff #120 stated she could not find a current policy and procedure on unplanned decannulation. She also stated if it occurred, she would check the treatment for [REDACTED]. On 3/2/18 at 3:40 PM, an IJ was identified by the SA and the facility's management team was notified of it. The facility's abatement plan was accepted on 3/2/18 at 5:18 PM.

Based on observation, record review, staff interviews and a review of the policies and procedures, the facility failed to ensure its residents are free from unplanned decannulations for 5 of 17 residents (Res #2, #7, #20, #24, #25). As a result, there was a failure to protect these residents from respiratory trauma/complications due to the number of unplanned decannulations. Residents who experience these unplanned decannulations suffer from oxygen desaturation, trauma and even the likelihood of death. An immediate jeopardy (IJ) was identified as the facility failed to recognize the serious nature of the decannulations, failed to track the incidence and rate of decannulations occurring in the facility, failed to identify the root cause(s) of the decannulations, failed to develop and implement care plan interventions to prevent the recurrence of decannulations, and failed to train or in-service staff about the decannulation risk for all residents in the facility. Finding includes: During the revisit survey, the SA observed an unplanned decannulation (removal of the [MEDICAL CONDITION]) on 2/28/18 at 11:10 AM for Res #20. This happened while she was attending her in-facility school program. Three respiratory therapists responded to a call for help and worked on the resident to re-insert the tube and re-establish her airway. The pediatric resident, was observed gasping with tears as her oxygen saturation level dropped to 69%, with a pulse of 164. Review of the facility's incident report found the cause of decannulation was due to the resident's [MEDICAL CONDITION] ties being extremely loose. Then the next day on 3/1/18 at 8:15 PM, another pediatric resident, Res #7, experienced a decannulation during his bed bath. Separate interviews of Staff #25, Staff #124, and Staff #98 were done, and it was found that Res #20 and Res #7 were known to decannulate frequently, but that it was not being addressed. The SA's manual tally taken from the facility's nursing 24-hour daily shift reports, found a total of 7 decannulations accounted for in (MONTH) (YEAR). In addition, the SA found a total of 8 decannulations which included the (MONTH) 28th decannulation of Res #7. This was compared to Staff #1's tracking report which noted her total for (MONTH) (YEAR) was the same (7 decannulations), but for (MONTH) (YEAR), she had recorded only 3 decannulations through (MONTH) 27th. Interview of Staff #124 on 3/1/18 at 8:35 AM found that during a decannulation, the primary goal was to re-establish the airway for oxygenation and to stabilize the resident. Staff #124 said previously, the decannulations were tracked by the previous director of nursing and the previous medical director, but currently, the Administrator signed off on the incident reports. Staff #124 stated, When the critical questions are asked, who witnessed this, who is going to write the report, no one wants to do the reporting. Staff #124 stated the decannulations were not discussed in the QA meeting and did not know if there was a critical number being reported, as the Incident Event Reports and Initial Investigative Findings were not routed to the respiratory therapy (RT) department. Staff #124 also stated there was no head charge nurse to complete these reports as well. Interview of Staff #25 on 3/1/18 at 10:12 AM revealed that licensed staff were aware that Res #20 decannulates because she was very active and often got wrapped up in her pulse oximetry tubing along with the ventilator tubing. Staff #25 said Res #20 desats so much and decannulates and once she goes down, she goes down fast because this girl has a lot of [MEDICAL CONDITION] too. Staff #25 said they have to check her almost every half hour when she was put into her crib. She said they're supposed to check [MEDICAL CONDITION], but was not certain if everybody did this. Interview Staff #1 on 3/1/18 at 10:53 AM revealed for the decannulations, she wanted to see what was happening with the numbers. The SA queried what Staff #1 has done about the occurrence and recurrence of decannulations. Staff #1 stated she was going to have to ask Staff #30 what she has done about it in her huddles and this was new data since their meeting three weeks ago. She further stated, We noticed these things (decannulations) going on and we need to get the numbers down. We need to find out what's going on with it. Big red flag. Staff #1 stated she was going to ask Staff #30 to pull everything about the decannulations and provide it to the SA. During Staff #30's interview on 3/2/18 at 8:48 AM, she stated, We have a high rate of decannulation so we need to monitor them more closely and adequately do [MEDICAL CONDITION], like (Res #20), so we don't want them to pop out. (Res #2) does it frequently. But, I think monitoring more closely. This is the first time I've seen loose ties on her (Res #20). Staff #1 stated she did not know the reason for the loose ties. Regarding the discrepancy in the number of decannulations which the SA counted versus what Staff #30 had tracked and whether she was tracking the frequency/occurrences of it, Staff #30 stated, I don't think so, I think we just started in January. I don't think there's any actual running log of what was being done. When Staff #30 was made aware the SA's manual count taken from nursing's 24 hour daily shift reports totaled 8 decannulations in (MONTH) versus the 3 she had, she stated, Eleven decannulations (her total of 7 in (MONTH) plus her count of 3 in February) is very high, but when you look at three days, to me, in a pediatric population, I don't know if it's very high. The SA clarified if she meant one decannulation every three days and she said, Yes, I don't know if it's really high or not. Staff #30 was further queried whether she had implemented anything with the identification of the 7 decannulations she tracked in the month of (MONTH) alone. She stated, No, I haven't started anything. I have not done a breakdown, no, (i.e., which nurses, which shift, etc.). Interview of Staff #98 on 3/2/18 at 9:09 AM revealed there was an under reporting of the incidence of decannulations. Staff #98 stated for the decannulation which occurred for Res #7 at night on 3/1/18, There's no charge nurse, and usually it would be the charge nurse. The nurse who had the patient--she wasn't even aware she was supposed to write it up. So I told her I would show her how to write it up and what needs to be done. I showed her where in drawer and I called the doctor and then I asked the nurse to call the family .The nurse said she's had several decannulations and that she has had several decannulations but no one has ever told her about this. So I'm wondering if I didn't initiate writing a report, would they have wrote the report, called the doctor and family? Staff #98 said it was important to address decannulations because, Some of the residents they don't have any reserve, they desat so quickly . so our one resident, (Res #20), she's had quite a few decannulations so she's one of them where she desats very quickly. She's active in her bed, so oftentime, when she's alarming, she's all caught in her tubing, and she's just very active, and for one, they need to make sure the ties are tight enough. We've been physically checking and sometimes we can fit our whole hand in it. I can't pinpoint, it's all these new staff, because it's all new staff for us. We address it if we know who the nurse is, and we'll just let them know--I just let them know. I did that with the nurse for 2B one time and said I can fit my whole hand in there. I believe it was an agency nurse, but at night time, what do you do--call 911, but by that time, the kid is dead. So are they going to know what to do? This is coming from (Staff #1), that the new nurses should be able to jump onto the floor. But they're not paying attention to the desats, [MEDICAL CONDITION], and right after they leave the room after [MEDICAL CONDITION], they leave the room, but the secretions often loosen and they need suction and desat right after doing [MEDICAL CONDITION]. It's okay to be afraid, but if people are offering to be with you, you should try to do it because we're there if something goes wrong. So if you bring in [MEDICATION NAME], they should know how to do it. The SA found for the month of (MONTH) (YEAR), there were 4 decannulations which were not reported: Res #20 on 2/12/18; Res #21 on 2/16/18; Res #18 on 2/27/18 and Res #7 on 2/28/18. This data showed there were other residents who had decannulated and had not been identified as one of the high risk residents. This information substantiated some of the facility's staff's concerns related to the under reporting of such events. In addition, although the facility staff and management were aware of the decannulations, the incidence rate, accurate reporting procedure, staff education, review of the comprehensive care plans to prevent future decannulations, and quality performance improvement measures with a root cause analysis for each prior occurrence, were not being done. All of the facility's residents have a [MEDICAL CONDITION], are ventilatory dependent and dependent on staff for their airway management/life support. On 3/2/18 at 2:33 PM, per Staff #30, she said she could not find any inservice on decannulation, nor was there a policy available for it. On 3/2/18 at 7:05 AM, Staff #120 stated she could not find a current policy and procedure on unplanned decannulation. She also stated if it occurred, she would check the treatment for [REDACTED]. On 3/2/18 at 3:40 PM, an IJ was identified by the SA and the facility's management team was notified of it. The facility's abatement plan was accepted on 3/2/18 at 5:18 PM.

Based on observation, record review and staff interviews, the facility failed to ensure that a resident with a facility acquired pressure ulcer receives the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent the wound from worsening for 1 of 17 residents (Res #8) in the revisit sample. Finding includes: On 2/28/18 at 12:25 PM, the SA observed Res #8's coccyx wound with Staff #55 during wound care. Staff #55's knowledge was the resident's wound developed in the facility and it was determined to be an unstageable wound. Staff #55 measured the wound to be 3.0 cm (length) x 2.0 cm (width) x 1.8 cm (depth). She said, he does have undermining and measured it to be 4 cm at 12 o'clock spot. She also measured the wound at the 1:00 o'clock to 3 o'clock areas with a swab and noted 2 cm of undermining there, and 2 cm at the 7 o'clock to 12 o'clock areas. She said at the 6 o'clock spot, there was no undermining, some serosanguinous drainage, but no odor. Staff #55 said although the wound had been improving with less slough, the measurements were smaller prior to the dressing change, and surprised there was 4 cm of undermining found. The resident's right and left buttocks showed intact, pinkish white scar tissue, but the coccyx wound itself presented as a deep, circular coccyx wound with minimal slough. She stated there was no bone, but just tissue. She packed it with several dry woven gauze and applied absorptive dressing over it per the physician's orders [REDACTED]. Record review found this resident had a history of [REDACTED]. However, the first entry for the observed sacral/coccyx wound was found on a weekly skin assessment diagram of 12/11/17 which noted a general 3 x 2.5 cm open area. Then there were additional entries which noted the following: 12/18/17 - coccyx open wound measured 2.8 x 3 cm; 12/25/17 - Buttock with pink moist wound inferior to coccyx approx. 2.5 x 3.0 x 1.1 cm; 1/22/18 - See TAR; 1/29/18 - See TAR; 2/5/18 - coccyx wound 3 x 2.5 x 2.5. Of note, for each weekly skin assessment, licensed staff were charting Decubitus as None. Yet, the facility's wound care skin integrity evaluation report based on a DME nurse's assessment, documented Res #8 developed a sacral wound, full thickness, unstageable pressure ulcer with an onset date of 12/17/17. The wound measured 2.5 x 3.0 cm (L x W) with a 1.0 cm depth with no tunneling or undermining, was facility acquired, with the wound bed showing brown slough, 70% yellow adherent [MEDICATION NAME] slough, 5% tendon/muscle/ bone and 25% red, pink/red healthy granulation. A second assessment by the same DME nurse, and submitted as the facility's 1/19/18 wound care skin integrity evaluation, showed the wound remained a full thickness, unstageable sacral pressure ulcer with an increase in size to 3.0 x 2.5 x 1.7 cm (L x W x D). The wound bed was noted with 100% yellow adherent [MEDICATION NAME] slough with no tunneling or undermining and minimum exudate. Within the resident's record, various interdisciplinary (IDT) progress notes by licensed staff were found to be inconsistent about the sacral/coccyx wound they were treating, and failed to identify when the wound increased in diameter/size although daily measurements were being done, and failed to document whether the physician was notified when changes were found. Res #8's coccyx wound included the following documentation: 1/2/18 - 3 cm x 3 cm x 1 cm coccyx wound with slough; 1/12/18 - unstageable wound to coccyx measuring 3 cm x 2.5 cm x 1.5 cm; 1/14/18 - unstageable coccyx measured 3 cm L x 2.5 cm W x 2 cm D. Noted developing undermining at 3 (degrees) and 11 (degrees) positions. Noted with moderate amount slough and small amount pink granulation tissue. By 2/3/18, a nursing entry in the Treatment Administration Record (TAR) noted, Unstageable wound to coccyx noted with slough to perimeter and mid-wound. Also noted with moist pink tissue. No s/s infection. Noted with moderate amount of sero-sanguineous drainage. Measures 3 cm L x 2.5 cm W x 2.5 cm D. Undermining noted to 9 (degree) position measuring 2.7 cm. Treatment done as ordered .Continue to monitor. There was no documentation in the clinical record that any action was taken by licensed staff related to the developing undermining (no measurements found) on 1/14/18 with increase to the depth of the wound. The failure to notify and document treatment changes or perform a reassessment of the wound was similarly found for the 2/3/18 entry. The licensed staff were also found to document continue to monitor, but the on-going daily wound entries were not being reviewed by anyone. The monthly nursing notes and TAR entries found varied and inconsistent documentation which included the following: Monthly Nursing Notes: - 12/15/17 Section for Skin condition: Buttock wound - MASD; Other - Drsg and powered collagen, turning/repositioning. - 1/29/18 Section for Skin condition: Unstageable buttock wound, drsg with oints, pressure relieving devices, turning/ repositioning. - 2/16/18 Section for Skin condition: Ulcers: Stage III, coccyx pressure ulcer, pressure relieving devices, nutrition or hydration, turning/repositioning, ulcer care, Medications within past 30 days: Santyl. Daily Pressure Ulcer Documentation from the TAR: - 2/14/18 Stage IV to coccyx with loose slough to perimeter 3.75 cm x 3 cm x 2.5 cm. Wound improving with pink moist tissue. No odors, no s/s infection. Scant amount serosanguinous drainage on drsg. Treatment done as ordered .Will continue to monitor. - 2/15/18 PRN dressing change done for soiling .Undermining present to entire perimeter. - Another 2/15/18 nursing entry: .Measured 3 cm L x 2.5 cm W x 3 cm depth. Undermining to perimeter. Deepest at 12 (degree) at 3 cm undermining .absorptive dressing . - 2/16/18 Stage IV to coccyx with slough to perimeter, 3 cm x 3 cm x 2.5 cm, undermining 12 (degree) . - 2/21/18 Wound measures 3 cm L x 2.5 cm W x 2.5 cm D with undermining from 12-3 (degrees) position measuring 2.5 cm . - 2/27/18 Coccyx wound is unstageable measures 3 cm x 1.8 cm x 2.1 cm with undermining and slough to perimeter. Moderate amount of yellow serous drainage with slight odor to dressing . Then the attending physician's entry of 2/15/18 documented the coccyx wound as Stage IV wound. Cross-reference to findings at F710. The facility failed to track the progress of the wound, which was facility acquired and which increased in size. As a result of the wound not being monitored by licensed staff and the physician, coupled with the failure of the licensed staff to report changes and accurately identify the wound (proper wound staging), the potential for harm existed. Interview with Staff #55 on 3/1/18 at 3:31 PM revealed she was uncertain whether she could stage the wound. She stated her training to classify wounds was to go by the recommendation of the wound nurse. She confirmed if there was a change to the appearance of the wound, she would notify the physician and consult with the wound nurse. However, there was no documentation to evidence this. She said Staff #30 informed her it was unstageable. Staff #55 stated, I'm not sure in response to the query of what the facility's clinical guidelines were for wounds and staging of wounds. She also stated she saw the inconsistency with the clinical documentation with the nurses charting different things about the coccyx wound. Her rationale as to why the wound got bigger, was, looks like it got debrided and that's why it got bigger. Yet, the tunneling was significantly greater at 4 cm per her wound measurement on 2/28/18, and for the past two months, licensed staff failed to recognize and consistently monitor/document the changes to the wound. On 3/2/18 at 7:35 AM, interview with Staff #35 was done. Staff #35 stated she knew the wound was getting bigger, but was uncertain whether we can stage the ulcer. On 3/1/18 at 5:08 PM, interview with Staff #30 revealed she had not seen the wound for some time and acknowledged she was not tracking Res #8's wound status. Staff #30 and Staff #1 also were not aware their wound care consultant was not a consultant, but in fact a nurse certified in wound care that was employed by a DME supply company the facility contracted with. Staff #30 stated it was always a struggle to determine what the MASD was. Coupled to the lack of a comprehensive care plan for the unstageable sacral pressure ulcer and the failure of the physician's involvement related to the progression of the wound, there was a failure to provide this resident with the necessary treatment to prevent and heal a facility acquired pressure ulcer. Cross reference to findings at F726, F867.

Based on observation, record review and staff interviews, the facility failed to ensure that a resident with a facility acquired pressure ulcer receives the necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent the wound from worsening for 1 of 17 residents (Res #8) in the revisit sample. Finding includes: On 2/28/18 at 12:25 PM, the SA observed Res #8's coccyx wound with Staff #55 during wound care. Staff #55's knowledge was the resident's wound developed in the facility and it was determined to be an unstageable wound. Staff #55 measured the wound to be 3.0 cm (length) x 2.0 cm (width) x 1.8 cm (depth). She said, he does have undermining and measured it to be 4 cm at 12 o'clock spot. She also measured the wound at the 1:00 o'clock to 3 o'clock areas with a swab and noted 2 cm of undermining there, and 2 cm at the 7 o'clock to 12 o'clock areas. She said at the 6 o'clock spot, there was no undermining, some serosanguinous drainage, but no odor. Staff #55 said although the wound had been improving with less slough, the measurements were smaller prior to the dressing change, and surprised there was 4 cm of undermining found. The resident's right and left buttocks showed intact, pinkish white scar tissue, but the coccyx wound itself presented as a deep, circular coccyx wound with minimal slough. She stated there was no bone, but just tissue. She packed it with several dry woven gauze and applied absorptive dressing over it per the physician's orders [REDACTED]. Record review found this resident had a history of [REDACTED]. However, the first entry for the observed sacral/coccyx wound was found on a weekly skin assessment diagram of 12/11/17 which noted a general 3 x 2.5 cm open area. Then there were additional entries which noted the following: 12/18/17 - coccyx open wound measured 2.8 x 3 cm; 12/25/17 - Buttock with pink moist wound inferior to coccyx approx. 2.5 x 3.0 x 1.1 cm; 1/22/18 - See TAR; 1/29/18 - See TAR; 2/5/18 - coccyx wound 3 x 2.5 x 2.5. Of note, for each weekly skin assessment, licensed staff were charting Decubitus as None. Yet, the facility's wound care skin integrity evaluation report based on a DME nurse's assessment, documented Res #8 developed a sacral wound, full thickness, unstageable pressure ulcer with an onset date of 12/17/17. The wound measured 2.5 x 3.0 cm (L x W) with a 1.0 cm depth with no tunneling or undermining, was facility acquired, with the wound bed showing brown slough, 70% yellow adherent [MEDICATION NAME] slough, 5% tendon/muscle/ bone and 25% red, pink/red healthy granulation. A second assessment by the same DME nurse, and submitted as the facility's 1/19/18 wound care skin integrity evaluation, showed the wound remained a full thickness, unstageable sacral pressure ulcer with an increase in size to 3.0 x 2.5 x 1.7 cm (L x W x D). The wound bed was noted with 100% yellow adherent [MEDICATION NAME] slough with no tunneling or undermining and minimum exudate. Within the resident's record, various interdisciplinary (IDT) progress notes by licensed staff were found to be inconsistent about the sacral/coccyx wound they were treating, and failed to identify when the wound increased in diameter/size although daily measurements were being done, and failed to document whether the physician was notified when changes were found. Res #8's coccyx wound included the following documentation: 1/2/18 - 3 cm x 3 cm x 1 cm coccyx wound with slough; 1/12/18 - unstageable wound to coccyx measuring 3 cm x 2.5 cm x 1.5 cm; 1/14/18 - unstageable coccyx measured 3 cm L x 2.5 cm W x 2 cm D. Noted developing undermining at 3 (degrees) and 11 (degrees) positions. Noted with moderate amount slough and small amount pink granulation tissue. By 2/3/18, a nursing entry in the Treatment Administration Record (TAR) noted, Unstageable wound to coccyx noted with slough to perimeter and mid-wound. Also noted with moist pink tissue. No s/s infection. Noted with moderate amount of sero-sanguineous drainage. Measures 3 cm L x 2.5 cm W x 2.5 cm D. Undermining noted to 9 (degree) position measuring 2.7 cm. Treatment done as ordered .Continue to monitor. There was no documentation in the clinical record that any action was taken by licensed staff related to the developing undermining (no measurements found) on 1/14/18 with increase to the depth of the wound. The failure to notify and document treatment changes or perform a reassessment of the wound was similarly found for the 2/3/18 entry. The licensed staff were also found to document continue to monitor, but the on-going daily wound entries were not being reviewed by anyone. The monthly nursing notes and TAR entries found varied and inconsistent documentation which included the following: Monthly Nursing Notes: - 12/15/17 Section for Skin condition: Buttock wound - MASD; Other - Drsg and powered collagen, turning/repositioning. - 1/29/18 Section for Skin condition: Unstageable buttock wound, drsg with oints, pressure relieving devices, turning/ repositioning. - 2/16/18 Section for Skin condition: Ulcers: Stage III, coccyx pressure ulcer, pressure relieving devices, nutrition or hydration, turning/repositioning, ulcer care, Medications within past 30 days: Santyl. Daily Pressure Ulcer Documentation from the TAR: - 2/14/18 Stage IV to coccyx with loose slough to perimeter 3.75 cm x 3 cm x 2.5 cm. Wound improving with pink moist tissue. No odors, no s/s infection. Scant amount serosanguinous drainage on drsg. Treatment done as ordered .Will continue to monitor. - 2/15/18 PRN dressing change done for soiling .Undermining present to entire perimeter. - Another 2/15/18 nursing entry: .Measured 3 cm L x 2.5 cm W x 3 cm depth. Undermining to perimeter. Deepest at 12 (degree) at 3 cm undermining .absorptive dressing . - 2/16/18 Stage IV to coccyx with slough to perimeter, 3 cm x 3 cm x 2.5 cm, undermining 12 (degree) . - 2/21/18 Wound measures 3 cm L x 2.5 cm W x 2.5 cm D with undermining from 12-3 (degrees) position measuring 2.5 cm . - 2/27/18 Coccyx wound is unstageable measures 3 cm x 1.8 cm x 2.1 cm with undermining and slough to perimeter. Moderate amount of yellow serous drainage with slight odor to dressing . Then the attending physician's entry of 2/15/18 documented the coccyx wound as Stage IV wound. Cross-reference to findings at F710. The facility failed to track the progress of the wound, which was facility acquired and which increased in size. As a result of the wound not being monitored by licensed staff and the physician, coupled with the failure of the licensed staff to report changes and accurately identify the wound (proper wound staging), the potential for harm existed. Interview with Staff #55 on 3/1/18 at 3:31 PM revealed she was uncertain whether she could stage the wound. She stated her training to classify wounds was to go by the recommendation of the wound nurse. She confirmed if there was a change to the appearance of the wound, she would notify the physician and consult with the wound nurse. However, there was no documentation to evidence this. She said Staff #30 informed her it was unstageable. Staff #55 stated, I'm not sure in response to the query of what the facility's clinical guidelines were for wounds and staging of wounds. She also stated she saw the inconsistency with the clinical documentation with the nurses charting different things about the coccyx wound. Her rationale as to why the wound got bigger, was, looks like it got debrided and that's why it got bigger. Yet, the tunneling was significantly greater at 4 cm per her wound measurement on 2/28/18, and for the past two months, licensed staff failed to recognize and consistently monitor/document the changes to the wound. On 3/2/18 at 7:35 AM, interview with Staff #35 was done. Staff #35 stated she knew the wound was getting bigger, but was uncertain whether we can stage the ulcer. On 3/1/18 at 5:08 PM, interview with Staff #30 revealed she had not seen the wound for some time and acknowledged she was not tracking Res #8's wound status. Staff #30 and Staff #1 also were not aware their wound care consultant was not a consultant, but in fact a nurse certified in wound care that was employed by a DME supply company the facility contracted with. Staff #30 stated it was always a struggle to determine what the MASD was. Coupled to the lack of a comprehensive care plan for the unstageable sacral pressure ulcer and the failure of the physician's involvement related to the progression of the wound, there was a failure to provide this resident with the necessary treatment to prevent and heal a facility acquired pressure ulcer. Cross reference to findings at F726, F867.