Every finding on record at Ladera Center

Based on record review and interviews, the facility failed to ensure 1 (R #13) of 2 (R #13 and R #14) residents was free from verbal abuse, when R #13 was verbally abused by R #14 multiple times without consistent facility interventions to prevent the verbal abuse from occurring. This deficient practice is likely to cause the resident to feel disrespected and frustrated in their home. The findings are:A. Record review of R #13's quarterly Minimum Data Set (MDS a federally mandated assessment instrument completed by facility staff) revealed an admission date of 01/13/22 and a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 15, indicating R #13 was cognitively intact. R #13 had diagnoses of type 2 diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and obesity (overweight). B. Record review of R #14's quarterly MDS indicated an admission date of 09/24/24 and a BIMS score of 13, indicating R #14 was cognitively intact. R #14 had diagnoses of DM2, Alzheimer's (a disease which causes irreversible changes in memory, thinking, and behavior), dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), mild cognitive impairment (MCI; refers to a measurable decline in at least one cognitive area), and anxiety (feelings of fear or apprehension). C. Record review of R #14's care plan, dated 08/10/26, revealed R #14 was at risk of harm to self or directed at others and exhibited, or had the potential to exhibit, verbal behaviors such as cussing (the act of using offensive or vulgar language, commonly known as swearing or profanity) at a roommate, cussing at staff, and calling residents' names. Staff were directed to provide verbal feedback to R #14 regarding behavior, re orient R #14 to the situation, utilize diversion techniques as needed, evaluate the circumstances or triggers of the verbal behavior, and remove R #14 from the environment if needed. D. Record review of R #13's grievance, dated 08/13/26, revealed R #13 filed a grievance regarding name calling in the dayroom. R #13 stated R #14 said inappropriate things to her. R #14 was interviewed and stated he does say things to R #13 and does not want to be there with the other residents. E. On 08/18/26 at 3:11 pm, during an interview, R #13 stated R #14 would call her names when they passed each other in the hall. R #13 stated she sat in the back of the dayroom, so she did not have to move constantly to allow people to pass. R #13 stated she did not want to move and should not have to move because R #14 was calling her names. She stated the latest incident occurred when she was going to the front to get her coffee. R #13 stated R #14 was sitting with another resident, and R #14 stated, Here comes the fat cow, and mooed at her. R #13 stated she had written three grievances about these issues with R #14, but facility staff had not done anything about it. R #13 stated other residents and staff had overheard him saying these things to her, and it continued to happen, which she did not like. F. On 08/18/26 3:32 pm, during an interview, the Activities Director (AD) stated R #14 had been known to become very angry and would say or do things that were inappropriate. The AD stated when R #13 entered the dayroom, R #14 stopped arguing with another resident and stated, Look everyone, the hogs have arrived. The AD stated he intervened and told R #14 how inappropriate the comment was and that his behavior would not be accepted. G. On 08/18/26 at 3:45 pm, during an interview, the Activities Assistant (AA) stated she had heard R #14 insult and verbally abuse R #13 many times. She stated she attempted to redirect R #14 when this occurred, but it happened often. H. On 08/18/26 at 4:00 pm, during an interview, the Social Services Director (SSD) stated she spoke with R #14, who admitted to calling R #13 names and stated he did not like anyone at the facility. The SSD stated she filed a grievance for R #13 after this incident occurred.

Based on record review and interviews, the facility failed to ensure residents were treated with dignity and respect for 2 (R #2 and R #3) of 2 (R #2 and R #3) residents, when nursing staff and nursing students did not promote dignity and respect during a shower. This deficient practice is likely to result in residents feeling unimportant to facility staff and may negatively affect their quality of life.The findings are:R #2:A. Record review of the facility's Activities of Daily Living (ADLs; routine self-care tasks such as bathing, dressing, eating, toileting, and personal hygiene) policy, revised on 05/01/23 and reviewed 03/20/26, revealed the facility will provide the necessary care and services to ensure residents maintain or improve their ability to perform activities of daily consistent with the resident's needs, care plan, and accepted standards of practice. The policy identified bathing as an activity of daily living and stated residents who are unable to perform ADLs independently will receive the assistance necessary to maintain personal hygiene. B. Record review of R #2's Quarterly Minimum Data Set (MDS; a federally required assessment used to evaluate a resident's functional capabilities and care needs), dated 05/04/26, revealed the following:R #2 was admitted to the facility on [DATE].R #2 had a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 13, cognitively intact.R #2 made herself understood and understood others.R #2 had adequate hearing and adequate vision with corrective lenses. C. Record review of R #2's grievance, dated 06/05/26, revealed R #2 stated a Certified Nursing Assistant (CNA) allowed a male resident to enter the shower while she was showering. The grievance documentation indicated the incident occurred and showed a resolution date of 06/09/26. D. On 07/08/26 at 1:30 PM, during an interview, R #2 stated she was receiving a shower while CNA #1 assisted her on 06/05/26. CNA #2 brought a male resident into the shower room. R #2 stated CNA #1 informed CNA #2 that she was showering a female resident (R #2), but CNA #2 continued to bring the male resident into the shower room. R #2 stated she heard the male resident's voice while she was showering and became upset. R #2 stated she filed a grievance regarding the incident because she felt her privacy was not respected. E. On 07/10/26 at 10:12 AM, during an interview, the Director of Nursing (DON) stated she became aware of R #2's incident after staff reported a grievance. The DON stated the facility's investigation showed a CNA brought a male resident into the shower room while another CNA assisted R #2 with a shower. The DON stated the shower curtains remained closed throughout the incident, and staff removed the male resident from the shower room once they became aware of the situation. The DON stated the Administrator met with R #2 and her sister after the incident because R #2 was upset. The DON stated the facility expected staff to maintain resident privacy during bathing. F. On 07/10/26 at 1:00 PM, during an interview, the Administrator stated R #2 was receiving a shower when a male resident entered the shower room. The Administrator stated R #2 felt violated by the incident and was angry because staff allowed a male resident to enter the shower room while she was showering. The Administrator stated the shower curtains remained closed during the incident, but R #2 became aware of the male resident's presence after hearing his voice. The Administrator stated his expectation was to maintain residents' dignity and privacy during bathing. R #3:G. Record review of R #3's quarterly MDS, dated [DATE], revealed R #3 was admitted to the facility on [DATE] with the following diagnoses:Multiple sclerosis (MS; a disease that affects the brain and spinal cord and can cause weakness, numbness, balance problems, and difficulty with movement).Stage 4 pressure ulcer of the sacral region (a full-thickness wound extending through tissue over the tailbone).Chronic pain syndrome (persistent pain lasting longer than expected for normal healing).Gastroesophageal reflux disease (GERD; stomach acid flowing back into the esophagus causing irritation).Colostomy status (a surgically created opening of the colon through the abdominal wall to allow stool to leave the body).R #3 had a BIMS score of 15, cognitively intact. H. Record review of R #3's grievance, dated 06/21/26, revealed R #3 submitted a grievance because a nursing student brought a male resident into the shower room while she was bathing. I. Record review of the facility's nursing student educational agreement, dated 07/10/26, revealed nursing students were permitted to participate in clinical experiences at the facility. The agreement indicated nursing students would provide resident care under the supervision of a faculty member, and the facility would provide a supervised clinical experience. J. On 07/08/26 at 2:15 PM, during an interview, R #3 stated she was receiving a shower on 06/21/26 with assistance from Nursing Student #1 when Nursing Student #2 brought a male resident into the shower room. R #3 stated Nursing Student #2 asked Nursing Student #1 to watch the male resident while she left to retrieve an item. R #3 stated she was fully undressed and became uncomfortable knowing a male resident was present in the shower room with her. R #3 stated she later learned the male resident was blind, but she remained uncomfortable because a male resident had been brought into the shower room while she was showering. R #3 stated both shower curtains were closed. R #3 stated she told the nursing students a male resident should not have been brought into the shower room. R #3 stated she filed a grievance regarding the incident, and no one apologized to her afterward. K. On 07/10/26 at 9:30 AM, during an interview, the Nursing Student Instructor stated she became aware of the incident involving R #3 after facility leadership notified her that a resident reported a male resident had been brought into the shower room while a female resident was receiving a shower. The Nursing Student Instructor stated she interviewed Nursing Student #1 and Nursing Student #2 regarding the incident. The Nursing Student Instructor stated Nursing Student #2 brought the male resident into the shower room while Nursing Student #1 assisted R #3 with a shower. The Nursing Student Instructor stated the nursing students did not realize a resident was already in the shower room until R #3 asked if a male was in the shower room. She stated her expectation was that this would never occur. L. On 07/10/26 at 10:12 AM, during an interview, the DON stated she became aware of R #3's shower incident after R #3 filed a grievance. The DON stated the facility's investigation showed Nursing Student #2 brought a male resident into the shower room while Nursing Student #1 assisted R #3 with a shower. The DON stated the shower curtains remained closed throughout the incident. The DON stated the facility expected staff to maintain resident privacy and dignity during bathing. M. On 07/10/26 at 1:00 PM, during an interview, the Administrator stated R #3 was receiving a shower when Nursing Student #2 brought a male resident into the shower room. The Administrator stated R #3 became aware the male resident was in the shower room after hearing his voice. The Administrator stated R #3 expressed concerns regarding the incident. The Administrator stated his expectation was to maintain residents' dignity and privacy during bathing.

Based on observations and interviews, the facility failed to maintain a safe, clean, and sanitary environment by allowing fecal matter to remain on the floor of a common resident area and by failing to ensure proper separation between soiled laundry and clean linens. These deficient practices has the potential to affect residents, staff, and visitors by increasing the risk of healthcare-associated infections.The findings are:A. On 01/26/26 at 2:01 pm during an observation of the south shower room, brown fecal matter was on the floor, the shower chair, and the shower curtain. A pungent (strong, unpleasant smell), offensive odor was immediately detectable upon entering the space.B. On 01/26/26 at 2:02 pm during an interview with the environmental services regional manager (EVSR), she confirmed that the brown fecal matter was found on the shower chair, shower floor and shower curtain. EVSR stated that this is unsanitary and should have been addressed as soon as a staff is done helping a resident using the shower room and it did not happen.C. On 01/26/26 at 2:12 pm during an observation of the north shower room, a used facility gown was noted next to an uncovered clean towel rack.D. On 01/26/26 at 2:13 pm during an interview with the EVSR, she confirmed that the used facility gown should have been placed in the soiled clothing container as soon as possible to prevent cross contamination. She also confirmed that the clean towel rack should have been covered and it did not happen.

Based on record review and interview, the facility failed to make prompt (done without delay; immediate) efforts to resolve resident's grievances for 10 (R #'s 4, 6, 8, 39, 41, 48, 56, 72, 74 and 107) of 10 (R #'s 4, 6, 8, 39, 41, 48, 56, 72, 74 and 107) residents reviewed by:1.Not responding/following-up to grievances that involved missing personal items and smoking.2.Not responding to grievances that involved allegations of neglect for several days after the grievance was reported. 3. Failing to educate all nursing staff, including the nursing staff involved, for grievances with allegations of neglect. If the facility is not ensuring that grievances are responded to and without delay, then residents are likely at risk of continued/repeat concerns and feeling as though their concerns are unimportant to the facility.The findings are: A. On 01/21/26 at 12:35 PM during a telephone interview with R #41's family member, he stated that he had brought his aunt a TV on 04/07/24 and it was taken from her room, he further stated that he had contacted the facility to let them know that the TV was gone, and he has not gotten a response from the facility as of this date (01/21/26).B. On 01/22/26 at 12:12 pm during an interview with the Social Service Assistant (SSA), she stated she had gotten an email but did not recall the date from R #41's nephew that R #41's TV was missing and she had not written a grievance report and she did not follow-up on what had happened with R #41'a TV and she should have.C. On 01/22/26 at 12:54 PM during an interview with Maintenance Director (MD) he stated R #41's family had purchased a TV for her (R #41's) the facility was unable to connect it to the cable available in the room. The MD removed the TV from the room and replaced it with a facility TV on 10/23/24 and left R #41's TV in the R #41's room and it disappeared and he does not know where it went. MD confirmed R #41's TV is missing and he confirmed he did not notify the family that the TV was missing. MD stated that he should have followed -up with the family and let them know that the TV had been replaced with a facility purchased TV.D. On 01/21/26 through 01/22/26 during interview withs R #'s 4, 6, 8,39,48, 56, 72,74 and 107 they all stated that they had missing personal clothing and had filed grievances on the missing items and the items have not been found nor have they been replaced. All nine residents stated they have not gotten a response after filing a grievance report and they would like to know if their items will be replaced.E. On 01/22/26 at 11:35 am during an interview with the Social Services Director (SSD) she stated that follow-up with any grievance should be seven days to gather information if they are unable to be found then it could be communicated to the Administrator. F. Record review of facility's grievances dated 01/07/26 through 01/08/26 revealed that missing person item grievances had not been acted upon. G. On 01/22/26 at 1:37 pm during an interview with the facility Administrator, he stated, that the reason there was no response on the grievance form is because they have not been resolved and the facility is still looking for the missing items. H. On 01/28/26 at 10:00 am during an interview with Laundry Director, she stated that she has not responded to about two months of grievances because her department is short staffed and has not had the time to go through the grievances. I. On 01/22/26 at 11:00 am during an interview with residents at the resident council meeting R #79 stated that they would like more smoke breaks, she further stated that the Administrator had stated there was no one to watch the residents outside while smoking. She stated that previous to the present Administrator the residents allowed the residents six smoke breaks during the day and current Administrator had cut it down to three smoke breaks a day and had not talked to the residents about making those changes and she thought it should have been brought to resident council to discuss. R #79 also stated that Administrator had discussed with her about being a volunteer to watch the smokers during break and she was willing to do that. Administrator had to give her a test to confirm she was a safe smoker and capable of watching other residents during smoke breaks. He also was going to purchase a walkie talkie (form of communication with staff) set so she would be able to communicate with facility staff should any issues arise. R #79 stated that it has been several months since that conversation and the Administrator had not contacted her again about being the volunteer. R #79 stated issues of smoking have been brought up several times and has not gotten a response. J. Record review of current facility smoking times reveals 9:00 am, 2:00 pm and 7:30 pm.K. Record review ow Resident council minutes dated 10/21/26 revealed, Smoking is allowed only during smoking times. L. On 01/27/26 at 1:42 pm during an interview with the facility Administrator, he stated that he had changed the smoking times and the frequency. He further stated that he had spoken to R #79 about being the volunteer and she had declined. He stated residents that are evaluated as safe smokers are allowed to sign themselves out of the facility can go to the sidewalk in front of the facility to smoke. Administrator further stated that he did not document when he spoke to the resident council nor when he spoke to R #79 about taking the test to become a volunteer. M. Record review of the facility's grievance form dated 01/06/26 revealed R #107 's family member had voiced a concern during a care conference (meeting to discuss residents care), family member voiced that her sister R #107 had stated to her that on Monday, January 5th, 2026 she had been put to bet between 2:00 and 3:00 pm and the Certified Nurse Aide (CNA) that put her to bed expressed to her that she would help her change into night clothes by never came back to change her. and she had had to sleep in her clothing and her shoes on the entire night .N. On 01/22/26 at 12:12 pm during an interview with the Social Services Assistant (SSA) she stated that she had written the grievance during the care conference and had handed it to nursing and did not feel that she had to follow up with nursing about the response of the grievance. SSA further stated that she was not aware that there was no follow-up with the family either. SSA stated she should have followed up on the grievance since she is the one that wrote the grievance for the family.

Based on record review and interview, the facility failed to provide the required transfer information to the residents' and the residents' representatives in writing for 2 (R #118, and 131) of 2 (R #118, and 131) residents sampled for hospitalizations when staff failed to: 1. Notify the residents and resident representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand. 2. Send a written copy of the Transfer Notice to the Ombudsman (is a government official who investigates and tries to resolve complaints). 3. Ensure resident or their representative received a written notice of the bed hold policy which indicated the duration the bed would be held. These deficient practices could likely result in the residents and/or their representative not knowing the reason for the transfer, the location of the transfer or discharge, their rights to advocate and make informed decisions regarding the residents' healthcare. The findings are: R #118 A. Record review of the facility's Transfer and Discharge policy, dated 06/11/25, revealed the facility must ensure documentation is complete, involve the physician in the decision, notify the residents and/or their representative, issue a written notice, and assist with safe and appropriate discharge planning. The policy also stated residents must be informed of their right to appeal, and staff must notify the Ombudsman. B. Record review of R #118's admission record revealed he was admitted to the facility on [DATE]. C. Record of R #118's progress note dated 09/06/25 revealed resident was sent to the hospital due to abnormal other lab value or study,resident on cancer medication treatment, peg tube feeding, (is the use of a percutaneous endoscopic gastrostomy (PEG) tube to provide nutrition directly to the stomach for individuals who cannot eat or drink enough by mouth the use of a percutaneous endoscopic gastrostomy (PEG) tube to provide nutrition directly to the stomach for individuals who cannot eat or drink enough by mouth) bed bound, and tested positive for COVID. D. Record review of R #118's medical record, no date revealed staff did not document a transfer notice or a bed hold notification for R #118's transfer to the hospital on [DATE]. E. On 01/22/2026 at 10:00 AM, during an interview, the Social Service Director (SSD) stated R #118 was sent to the hospital due to a positive COVID test, his blood count was low and he was declining rapidly. SSD stated there are no notes in R #118's record of why R #118 did not return to the facility. SSD stated she didn't contact the ombudsman to inform the ombudsman when R #118 was discharged from the facility. SSD stated she does not see any nurses' notes regarding resident's transfer, discharge, and bed hold notice. R #131 F. Record review of R #131's face sheet revealed he was admitted to the facility on [DATE]. G. Record of R #131's progress note dated 01/12/26 revealed resident was sent to the hospital due to behavioral symptoms (agitation, psychosis). H. Record review of R #131's medical record, no date revealed staff did not document a transfer notice or a bed hold notification for R #131's transfer to the hospital on [DATE]. I. On 01/22/2026 at 10:03 AM, during an interview with SSD, she stated R #131 was discharged to the hospital due to his behavior. The psychiatric physician from the hospital informed the facility he was not safe to return to the facility and wrote an order to send resident to a psychiatric hospital. SSD stated she does notify the ombudsman of discharges; however, she has not notified ombudsman in a while. SSD stated she does not see any nurses' notes regarding resident's transfer, discharge, and bed hold notice. J. On 01/22/26 at 4:40 PM, during an interview with the Director of Nursing (DON) stated she did not realize that nursing was to do the transfer and bed hold notice process. DON's expectation is that the nurses and the business office send out the transfer, discharge, and bed hold notices within 24 hours.

Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 3 (R #39, #47, and #122) of 3 (R #39, #47, and #122) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: R #39:A. Record review of R #39's facesheet revealed he was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Nondisplaced fracture (nondisplaced fractures are often closed and do not move out of alignment) of right ulna (longer of the two bones in the forearm) styloid process (a slender projection of bone at the lower end of the ulna), subsequent encounter for closed fracture with routine healing. 2. Muscle weakness (generalized) 3. Other abnormalities (deviation from the normal) of gait (walking) and mobilityB. Record review of R #39's electronic health record revealed R #39's baseline care plan dated 12/27/25 did not include: 1. Use of right wrist brace 2. Use of oxygen C. On 01/21/26 at 1:58 pm during an interview with the Director of Nursing (DON), she confirmed R #39's baseline care plan was dated 12/27/25. The DON also confirmed that the baseline care plan omitted required information, such as use of wrist brace and oxygen use.R #47:D. Record review of R #47's facesheet revealed he was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Chronic idiopathic constipation (is a condition with constipation symptoms but no identifiable cause). 2. Personal history of other diseases of the digestive system. 3. Cerebral Palsy (a neurological condition that affects muscle movement and development due to brain damage).E. Record review of R #47's physician's order revealed an order dated 01/10/26 for Lactulose oral solution 10 (grams) gm / 15 (milliliters) ml, give 30 ml by mouth one time a day for constipation. F. Record review of R #47's care plan dated 01/20/26 revealed the following: 1. R #47 requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: cerebral palsy. 2. R #47 is at risk for falls due to impaired mobility. 3. R #47 exhibits or is at risk for alterations in comfort related to chronic pain. 4. R #47 is at risk for skin breakdown related to decreased activity. 5. Chronic idiopathic constipation is not addressed in this care plan.G. On 01/22/26 at 3:15 pm during an interview with the Unit Manager (UM), she confirmed that R #47's care plan does not meet her expectations because it does not include R #47's chronic idiopathic constipation or the care and support he needs.R #122H. Record review of R #122's facesheet revealed she was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Displaced intertrochanteric (a fracture type of broken hip) fracture of left femur (the bone of the thigh). 2. Displaced comminuted (reduced to minute particles or fragments) fracture of shaft of radius (one of the bones in the forearm), left arm. 3. Difficulty walking. 4. Age-related osteoporosis (bones to become weak and brittle).I. Record review of R #122's care plan dated 01/02/26 revealed the following: 1. R #122 requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to recent fall, left femur and left wrist fracture. 2. R #122 has a diagnosis of diabetes. 3. R #122 has potential for discharge or is expected to be discharged home. 4. R #122 is at risk for falls. 5. R #122 exhibits or is at risk for alterations in comfort related to fracture of left femur, and left wrist. 6. R #122 is at risk for complications related to the use of psychotropic drugs. 7. R #122 is at risk for skin breakdown related to decreased activity, incontinence, and limited mobility. 8. Wound care is not addressed in this baseline care plan.J. On 01/27/26 at 1:13 pm during an interview with the UM, she confirmed that R #122 arrived at the facility with a surgical wound related to hip surgery. She also confirmed that R #122's care plan did not address wound care related to hip surgery. The UM expects the wound care to the right hip should be added to the baseline care plan on admission and it did not happen.

Based on record review and interview, the facility failed to ensure staff revised the care plan for 3 (R #41, R #47 and R #122) of 8 (R #11, R #12, R #41, R #47, R #48, #118, R#122 and R #131) residents reviewed when staff failed to: 1. Revise the care plan after R #41 developed hand contractures. 2. Revise the care plan after R #47 was diagnosed with chronic idiopathic constipation (condition with constipation symptoms but no identifiable cause). 3. Ensure the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participated in the care plan meeting for R #122. These deficient practices could result in residents' care and needs not being addressed. The findings are: R #41 A. Record review of R #41's facesheet revealed she was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (also known as ischemic stroke, occurs when the blood supply to part of the brain is blocked or reduced) affecting right dominant side.** 2. Aphasia (is a language disorder that affects your ability to speak and understand what others say) following cerebral infarction.** 3. Dysphagia (difficulty swallowing) following cerebral infarction.** B. Record review of R #41's care plan, last updated on 12/29/25 revealed the care plan did not contain any goals or interventions in place for R #41's bilateral hand contractures and support she needs. C. On 01/22/26 at 3:15 pm during an interview with the Unit Manager (UM), she confirmed R #41's care plan does not meet her expectations because it does not include her bilateral hand contractures or the care and support she needs. R #47D. Record review of R #47's facesheet revealed he was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Chronic idiopathic constipation. 2. Personal history of other diseases of the digestive system. 3. Cerebral Palsy (a neurological condition that affects muscle movement and development due to brain damage). E. Record review of E #47's physician's order revealed: 1. 01/10/26: Lactulose oral solution 10 (grams) gm / 15 (milliliters) ml, give 30 ml by mouth one time a day for constipation. F. Record review of R #47's care plan dated 01/20/26 and revealed the following: 1. R #47 requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: cerebral palsy. 2. R #47 is at risk for falls due to impaired mobility. 3. R #47 exhibits or is at risk for alterations in comfort related to chronic pain. 4. R #47 is at risk for skin breakdown related to decreased activity. 5. Chronic idiopathic constipation is not addressed in this care plan. G. On 01/22/26 at 3:15 pm during an interview with the Unit Manager (UM), she confirmed that R #47's care plan does not meet her expectations because it does not include R #47's chronic idiopathic constipation or the care and support he needs. H. Record review of R #122's Care Plan Conference form, dated 01/05/26, revealed the following: 1. Staff documented the individuals that were present at the meeting were R #122's representative, Nurse, Rehab, R #122 and the Social Services Director (SSD). 2. Staff that were not documented to be in attendance were R #122's certified nurse aide (CNA), and physician. I. On 01/22/26 at 09:47 AM, during an interview, the SSD stated that for care plan meeting dates for R #122 occurred on 01/05/26 and 01/13/26. SSD state R #122 and her family members (FM) were in attendance. The Interdisciplinary Team (IDT) present including rehab, nurse, and director of social services. SSD stated the provider and the CNA are not included in the IDT meetings. SSD stated she didn't know that CNA, and the provider had to be in attendance.

Based on record review, observation and interview, the facility failed to provide quality care that meets professional standards for 6 (R #5, #39, #56, #90, #93, and #104) of 6 (R #5, #39, #56, #90, #93, and #104) residents reviewed when the staff failed to:-Follow physician orders.-Obtain physician ordersThese deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are: R #39: A. Record review of R #39's facesheet revealed he was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Nondisplaced fracture (nondisplaced fractures are often closed and do not move out of alignment) of right ulna (longer of the two bones in the forearm) styloid process (a slender projection of bone at the lower end of the ulna), subsequent encounter for closed fracture with routine healing. 2. Muscle weakness (generalized) 3. Other abnormalities of gait (is the pattern or manner of walking) and mobility 4. Influenza A virus with other respiratory manifestations (a respiratory illness). B. On 01/21/26 at 09:52 am during an observation inside R #39's room, R #39 was sitting on his wheelchair with his daughter at his side. R #39 had a brace to his right wrist and is receiving oxygen therapy via nasal cannula at 2 liters per minute (LPM). C. On 01/21/26 at 09:53 am during an interview with R #39, he stated his right wrist brace came from the hospital after he fell from home. R #39 stated he fell and broke his right wrist but does not require surgery. R #39 also stated that he does know why he is receiving oxygen at this facility. D. Record review of R #39's physician's order revealed R #39's does not have an order for oxygen therapy and right wrist brace. E. On 01/21/26 at 10:03 am during an interview with the Director of Nursing (DON), she confirmed R #39 has a right wrist brace and is receiving oxygen therapy with no orders in the electronic medical records. The DON stated that this should have been addressed by the nurses and received an order from the providers, but it did not happen. R #56 F. Record review of R #56's facesheet revealed she was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Type 2 diabetes mellitus (the body [NAME] use insulin correctly and sugar builds up in the blood) with hyperglycemia (happens when there's too much sugar in the blood). 2. Body mass index (BMI) 60.0 to 69.9, adult. 3. Long term use of insulin (natural hormone that turns food into energy and manages blood sugar level). 4. Long term use of injectable non-insulin antidiabetic drugs. G. Record review of R #56's physician's order revealed the following: 1. 08/13/24: Mounjaro (prescription once weekly injectable medication for type 2 diabetes) pen-injector 2.5 MG (milligrams) / (per) 0.5 (milliliters) ML, inject 0.5 ml subcutaneously (applied under the skin) every Wednesday. Discontinued 08/14/25. 2. 08/14/24: Mounjaro pen-injector 2.5 MG / 0.5 ML inject 0.5 ml subcutaneously one time a day every Wednesday. Discontinued 01/29/25. 3. 01/29/25: Mounjaro auto-injector 2.5 MG / 0.5 ML inject 0.5 ml subcutaneously at bedtime every Thursday. Discontinued 04/22/25. 4. 04/22/25: Mounjaro auto-injector 5 MG / 0.5 ML inject 0.5 ml subcutaneously at bedtime every Thursday. Discontinued 05/07/25. 5. 05/07/25: Mounjaro auto-injector 2.5 MG / 0.5 ML inject 2.5 mg subcutaneously one time a day every Thursday. Discontinued 07/09/25. 6. 07/09/25: Mounjaro auto-injector 5 MG / 0.5 ML inject 0.5 ml subcutaneously at bedtime every Thursday. Discontinued 08/01/25. 7. 08/01/25: Mounjaro auto-injector 5 MG / 0.5 ML inject 0.5 ml subcutaneously at bedtime every Saturday. Discontinued 08/04/25. 8. 08/04/25: Mounjaro auto-injector 5 MG / 0.5 ML inject 0.5 ml subcutaneously at bedtime every Thursday. Discontinued 09/19/25. 9. 09/19/25: Mounjaro auto-injector 5 MG / 0.5 ML inject 0.5 ml subcutaneously one time a day every Thursday. Discontinued 10/03/25. 10. 10/03/25: Mounjaro auto-injector 5 MG / 0.5ML inject 0.5 ml subcutaneously one time a day every Thursday. (current active order) H. Record review of R #56's medication administration record (MAR) revealed R #56 missed her mounjaro injectable medications on 04/17/25, 07/31/25, and 08/21/25. I. On 01/26/26 at 9:31 am during an interview with R #56, she stated the facility is not consistently giving her mounjaro medications. R #56 stated she is to receive the injection once a week, some weeks the medication is not available, and we just skip that dose. J. On 01/26/25 at 09:50 am during an interview with the Assistant Director of Nursing (ADON), she stated they were having a hard time getting medications from the pharmacy due to insurance pre-authorization. ADON confirmed R #56's missed her mounjaro injectable medications; The medication was not available on 04/17/25, and 08/21/25 doses, and for the 07/31/25 dose, the medication arrived on 08/04/25 and R #56 refused the medication because it was too close to her next dose. The ADON also stated that the nurses should be able to request the medication from the pharmacy as soon as they found out it was not available and it did not happen. R #90 K. Record review of R #90's facesheet revealed she was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following unspecified cerebrovascular disease (various medical conditions that impact the blood vessels in the brain) affecting right dominant side. 2. Vascular dementia (a type of cognitive impairment cause by reduced blood flow to the brain, leading to memory loss, confusion and changes in behavior), unspecified severity, with other behavioral disturbance 3. Aphasia (disorder that affects language abilities due to brain damage) following cerebral infarction. 4. Dysphagia (difficulty swallowing) following cerebral infarction. L. Record review of R #90's physician's order revealed a dietary order dated 01/08/25 for a scoop plate (a specialized plate designed to assist individuals who have difficulty using regular plates) and sippy cup for hot beverages. M. On 01/27/26 at 12:35 pm during an observation in the dining room, R #90 was served hot coffee in a regular cup. Further observation revealed the dietary meal slip indicated sippy cup for hot beverages. N. On 01/27/26 at 12:36 pm during an interview with admission's coordinator (AC), she confirmed the hot coffee was served in a regular cup. AC stated that per R #90's dietary order all hot beverages should be served in a sippy cup and it did not happen. R #5: O. Record review of R #5's face sheet revealed he was admitted on [DATE] with the following diagnoses (including but not limited to): -Multiple Sclerosis (is a chronic neurological disorder), Unspecified. -Type 2 Diabetes Mellitus without complications. -Muscle Weakness (Generalized) -Unspecified rotator cuff tear or rupture (is a common cause of shoulder pain and disability among adults) of right shoulder, no specified at traumatic. P. Record review of R #5's care plan dated 07/03/25, revealed Built -Up-Utensils for all meals. Q. Record review of R #5's physician's order did not reveal an order for Built-Up-Utensils. R. On 1/26/26 at 12:34 pm, during an interview with Occupational Therapist (OT), he stated he does an evaluation for built-up-utensils and will notify dietitian and dietary and they will put it on the computer for their meal tickets. He further stated, ultimately if a resident needs built-up-utensils for a long period of time a physician's order is needed for it. R #93: S. Record review of R #93's face sheet revealed he was admitted on [DATE] with the following diagnoses (including but not limited to): -Alzheimer's Disease (is the most common form of dementia, a brain disorder that slowly destroys a person's memory and thinking skills) with late onset. -Vascular Dementia (is a type of dementia caused by reduced or blocked blood flow to the brain, leading to brain cell damage and cognitive decline), Unspecified severity, without behavioral disturbance, mood disturbance, and anxiety (mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). -Psychophysiologic Insomnia (is a chronic sleep disorder where heightened mental, emotional, or physical arousal and learned sleep-preventing associations make it difficult to fall or stay asleep). -Unspecified hearing loss (is the partial or complete inability to hear sounds in one or both ears, which can significantly impact communication and quality of life), unspecified ear. T. Record review of R #93's care plan dated 11/19/25, revealed rehab eating devices, scoop plate during meals. U. Record review of R #93's physician's order dated 03/20/23 did not reveal an order for scoop plate during meals. V. On 1/26/26 at 12:34 pm, during an interview with Occupational Therapist (OT), he stated he does an evaluation for built-up-utensils and will notify dietitian and dietary and they will put it on the computer for their meal tickets. He further stated, ultimately if a resident needs built-up-utensils for a long period of time a physician's order is needed for it. R #104: W. Record review of R #104's face sheet revealed he was admitted on [DATE] with the following diagnoses (including but not limited to): -Contracture (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching), left hand. -Orthostatic Hypotension (blood pressure fall when standing from the supine [lying flat] to the erect [upright] position). -Restless Legs syndrome (is a condition that causes a very strong urge to move the legs). -Presence of Neurostimulator (An implantable neurostimulator is a surgically placed device about the size of a stopwatch. It delivers mild electrical signals to the epidural space near your spine through one or more thin wires, called leads). X. Record review of R #104's care plan dated 02/24/24, revealed Built -Up-Utensils for all meals. Y. Record review of R #104's physician's order did not reveal an order for Built-Up-Utensils. Z. On 1/26/26 at 12:34 pm, during an interview with Occupational Therapist (OT), he stated he does an evaluation for built-up-utensils and will notify dietitian and dietary and they will put it on the computer for their meal tickets. He further stated, ultimately if a resident needs built-up-utensils for a long period of time a physician's order is needed for it.

Based on record reviews, observations, and interviews, the facility failed to ensure that activities of daily living (ADL) are being provided to 2 (R #39, and #41) of 2 (R #39, and #41) residents reviewed, who were dependent on staff for necessary nail care. This deficient practice resulted in residents having long, jagged, and unclean fingernails, which poses a risk for the transmission of infection.The findings are:R #39A. Record review of R #39's facesheet revealed he was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Nondisplaced fracture (nondisplaced fractures are often closed and do not move out of alignment) of right ulna (longer of the two bones in the forearm) styloid process (a slender projection of bone at the lower end of the ulna), subsequent encounter for closed fracture with routine healing. 2. Muscle weakness (generalized). 3. Other abnormalities of gait (is the pattern or manner of walking) and mobility.B. On 01/21/26 at 9:52 am, during an observation of R #39's room with his daughter, R #39's fingernails on both hands were long, and contained a dark, brown substance underneath the nail beds. R #39 stated no one has addressed his fingernails since his admission to this facility.C. On 01/21/26 at 10:01 am during an interview with Certified Nursing Aide (CNA) #1, she confirmed R #39's fingernails are long and dirty. CNA #1 stated that nail care is done regularly but it did not happen.R #41D. Record review of R #41's facesheet revealed she was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (also known as ischemic stroke, occurs when the blood supply to part of the brain is blocked or reduced) affecting right dominant side. 2. Aphasia (is a language disorder that affects your ability to speak and understand what others say) following cerebral infarction. 3. Dysphagia (difficulty swallowing) following cerebral infarction.E. The following observations revealed: 1. On 01/20/26 at 1:30pm, R #41 appeared to be sleeping in bed, R #41's fingernails on both hands were long, and contained a dark, brown substance underneath the nail beds. 2. On 01/21/26 at 2:58pm, R #41's fingernails on both hands were long, and contained a dark, brown substance underneath the nail beds. 3. On 01/22/26 at 2:57pm, R #41's fingernails on both hands were long, and contained a dark, brown substance underneath the nail beds.F. The following interviews revealed the following: 1. On 01/20/26 at 1:32pm interview with CNA #1, she confirmed that R #41's fingernails are long and dirty. CNA #1 stated that nail care is done regularly but it did not happen. 2. On 01/21/26 at 2:59pm interview with CNA #2, she confirmed that R #41's fingernails are long and dirty. CNA #2 stated that R #41 received a shower yesterday and R #41's fingernails should have been addressed, and it did not happen. 3. On 01/22/26 at 2:58pm interview with Certified Medication Aide (CMA) #1, she confirmed that R #41's fingernails are still long and dirty. 4. On 01/22/26 at 3:15pm interview with the Unit Manager (UM), she stated that CNAs are expected to provide nail care during shower days (and as needed) and it did not happen.

Based on observations, and interviews, the facility failed to properly store medications and medical supplies located in the facility medication carts and medication storage room when the staff failed to ensure:-Treatment carts are not left unlocked and unattended.-Medical supplies are not opened or used.-An expired insulin (a hormone that regulates the amount of glucose in the blood) pen was properly discarded.These deficient practices are likely to result in medications and medical supplies being used in resident care resulting in residents being at risk of possible infections, and medication error.The findings are:A. On [DATE] at 8:06 am, during an observation of the south station, a treatment cart with prescription topical ointments, powders, and wound cleaning supplies was left unlocked and unattended.B. On [DATE] at 8:08 am during an interview with the Director of Nursing (DON), she confirmed the south station treatment cart was left unlocked and unattended. The DON stated that all treatment carts are expected to be locked and did not happen.C. On [DATE] at 08:09 am, during an observation of the north station treatment cart, two opened suture removal kit (pre-packaged collections of tools designed for the safe and efficient removal of sutures once a wound has healed) was found on the top drawer. D. On [DATE] at 8:10 am during an interview with Licensed Practical Nurse (LPN) #3, she confirmed that the two suture removal kits were open and left on the top drawer. LPN #3 stated that any medical supplies should be discarded appropriately and it did not happen.E. On [DATE] at 8:12 am, during an observation of the south front medication cart, an insulin pen with a discard date of [DATE] was found. F. On [DATE] at 8:14 am during an interview with LPN #4, she confirmed that the insulin pen was dated [DATE]. LPN #4 stated the insulin pen is considered expired and should be discarded appropriately and it did not happen.

Based on observations, and interviews, the facility failed to implement and follow an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by ensuring: -staff follow the established hand hygiene protocols to prevent the potential spread of infection residents observed during meal assistance. -a system of surveillance is in placed to identify environmental hazards before they could spread to residents and staff.These deficient practices are places the residents and staff at risk of contracting infections. The findings are:A. On 01/27/26 at 12:40 pm, during an observation in the dining room, Certified Nursing Aide (CNA) #3 assisted R #20 and R #42 with their meals. The residents were seated at the same table, CNA #3 performed the following sequence of actions: 1. CNA #3 used her bare right hand, touched R #20's spoon, scooped a spoon full of food and placed the same spoon in R #20's right hand. CNA #3 instruction R #20 to place the spoon in her mouth and eat. 2. Without performing hand hygiene, CNA #3 then turned to R #42, picked up R #42's spoon with her bare hands, scooped a spoon full of food, and then placed the spoon in R #42's hand and instructed R #42 to eat. 3. CNA #3 then returned to R #20 and continued assisting without any hand hygiene interventions.B. On 01/27/26 at 12:46 pm interview with the Director of Nursing (DON) confirmed that CNA #3 did not perform hand hygiene between helping residents during this meal time. The DON stated that hand hygiene should be performed between resident care and it did not happen.C. Refer to F0584 for related findings.

Based on observations and interviews, the facility failed to ensure that the resident call system was accessible for 2 (R #8, and #41) of 2 (R #8, and #41) residents reviewed. This deficient practice had the potential of placing the resident at risk for inability to summon health care workers as needed to receive assistance that may include urgent care to meet their medical, physical, mental, and psychosocial needs.The findings are:A. On 01/20/26 at 4:18 pm, during an observation, R #8 was found in bed with her call light button on the side of the bed nearly touching the floor. R #8 stated that she uses her call light button to call for help, but she does not know where her call light button went.B. On 01/20/26 at 4:20 pm interview with Licensed Practical Nurse #1, she confirmed the call light button is on the side of the bed and is not within reach of R #8. LPN #1 stated that call light buttons must be within reach at all times and it did not happen.C. On 01/21/26 at 9:44 am, during an observation, R #41 was found in bed with her call light button draped over the headboard and is not within reach. D. On 01/21/26 at 4:21 pm interview with Certified Nursing Aide #1, she confirmed the call light button is draped over the headboard and is not within reach of R #41. CNA #1 stated that call light buttons must be within reach at all times and it did not happen.

Based on record review and interview, the facility failed to ensure 1 (R #107) of 1 (R #107) resident was treated with respect and dignity when the facility failed to ensure that R #107 was not put to bed at night with her shoes on and fully clothed.This deficient practice is likely to result in residents feeling as if they were unimportant and that their preferences do not matter. The findings are: A. On 01/21/23 at 12:40 pm during an interview with R #107's sister (FM) #1, she stated she had been told by her sister (R #107) that she had been put to bed a fully clothed and with her shoes on and she had been upset about it. FM #1 stated that her sister (R #107) likes to be put to bed in her pajamas every night. FM #1 thought this was a concern and her sister was upset that is why she brought it to the facilities attention. B. Record review of R #107's care plan dated 10/02/24 revealed: it is important that she (R #107) has the opportunity to engage in daily routines that are meaningful relative to her preferences. Intervention: It is important for me to choose what clothing to wear.C. On 01/22/26 at 12:59 pm during an interview with Assistant Director of Nursing (ADON), she stated she was familiar with the incident that occurred with R #107 about putting her to bed without changing her into her bed clothing and with her shoes on. ADON further stated that the staff should have changed the resident into her preferred clothing and should not have left her shoes on. D. On 01/23/26 at 10:02 am during an interview with the Social Services Assistant (SSA), she stated R #107 (being put to bed with her fully clothed and her shoes on) was not right and the family had concerns about it and let her know at a care conference that the incident had happened and R #107 was unhappy about being left with her clothing and shoes on. E. On 01/27/26 at 9:18 AM during an interview with Certified Nurse Aide (CNA) #3, she stated, when she came in the morning after the incident (she cannot recall the date) R #107 was upset because another aide had put her to bed and did not put her pajamas on her and she had slept with her shoes on as well. R #107 stated to CNA #3 that the aide had told her she would return to change her and never returned, CNA #3 further stated that that R #107 needs assistance with changing her clothing she is unable to utilize her arm. CNA #3 confirmed that when she came in that morning that R #107 was still wearing her clothing and had not been changed into her pajamas, which she likes to wear every night. CNA #3 did not report the incident to any facility staff and she stated she should have let someone know being that R #107 was very upset.

Based on record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #132) of 1 (R #132) resident reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.The findings are:A. Record review of R #132's facesheet revealed she was admitted on [DATE] and discharged to community on 04/15/23 with the following diagnoses (including but not limited to): 1. Unspecified intracapsular fracture of right femur (a type of bone fracture that occurs within the joint capsule, often affecting the hip). 2. Type 2 diabetes mellitus (condition in which the body [NAME] use insulin correctly and sugar builds up in the blood) without complications. 3. Systemic lupus erythematosus (an autoimmune disease in which the body's immune system mistakenly attacks its own healthy cells and tissues, leading to inflammation and damage in various organs and systems), unspecified. 4. Age-related osteoporosis (causes bones to become weak and brittle). 5. Unspecified dementia (is the loss of cognitive functioning that interferes with daily life and activities), unspecified severity, without behavioral disturbance. 6. Muscle weakness (generalized).B. Record review of R #132's progress notes revealed the following: 1. 03/25/23 Nursing notes: skin check completed: right hip dressing. Clean, dry, and intact. 2. 03/27/23 Nursing notes: skin check completed: right hip. 3. 03/28/23 Nursing notes: skin check completed: right hip. 4. 03/31/23 Nursing notes: a skin check was performed: right lower extremity (hands and feet). 5. 04/01/23 Nursing notes: a new pressure wound unstageable due to slough and or eschar in-house acquired. Location: Coccyx was assessed today. 6. 04/15/23 Nursing notes: R #132 family present for wound care and teaching regarding unstageable pressure injury to coccyx (small bone at the bottom of the spine) area.C. Record review of R #132's weekly skin check revealed the following: 1. 03/31/23 : no pressure injury. 2. 04/10/23 : pressure injury to sacrum (bone in lower spine), unstageable due to presence of slough. 3. 04/13/23: unstageable pressure injury to coccyx area, in-house acquired. Record review of R #132's Minimum Data Set revealed (MDS; a federally mandated assessment instrument completed by facility staff) revealed the following: 1. MDS dated [DATE] section M0210: no unhealed pressure ulcers or injuries.E. On 01/27/26 at 11:30am during an interview with the MDS Coordinator, she confirmed R #132's MDS assessment dated [DATE] did not accurately document the unstageable pressure injury to the coccyx area.

Based on record review and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 1 (R #11) of 6 (R #11, R #12, R #48, R #118, R #122, and R #131) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meet their interests, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: A. Record review of R #11's admission record, no date revealed an admission date of 10/02/25 with the following diagnoses: 1. Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominant side (is a symptom that involves one-sided paralysis. A left-sided stroke is a stroke that damages the left side of the brain). 2. Essential (primary) Hypertension (high blood pressure, is a common condition where the force of blood against the artery walls is consistently too high). 3. Depression, unspecified (is a mood disorder that causes a persistent feeling of sadness and loss of interest). 4.Type 1 diabetes Mellitus with Hyperglycemia (high blood sugar, also called hyperglycemia, affects people who have diabetes). B. Record review of R #11's admission Minimum Data Set (MDS) assessment dated [DATE] revealed R #11's personal preferences for activities for the following: 1. Listen to music, 2. Pet visits, 3. Groups, 4. Religious Services. C. Record review of R #11's care plan revision dated 12/23/25 revealed R #11's care plan did include her personal preferences, and staff did not follow care plan to provide personal preference activities for R #11. D. Record review of R #11's entire record revealed no documentation for Recreation Participation Record, revealed staff did not follow care plan and show documentation of personal preference activities that occurred for the following personal preferences: 1. Pet visits. 2. Listening to music, 3. Religious Services E. Record review of R #11's entire record revealed no progress notes for recreation individual participation, revealed that no progress notes were completed by staff that activities occurred. F. On 01/22/2026 at 1:03 PM, during an interview with Activities Director (AD), he stated R #11 doesn't speak and is now in isolation. Sensory items putting block in and beads will be offered to her now. AD stated the Regional Activities Director was at the facility at the time R #11 was admitted . AD stated his expectation is that the activities assistants log in the participation sheets, and progress notes, and provide activities to residents in groups and one to ones. G. On 01/22/2026 at 1:12 PM, during an interview, the Regional Activities Director (RAD) stated R #11 was put on one-to-one programs when she was admitted to the facility on [DATE]. RAD stated activities staff are now focusing on one-to-one programs. RAD stated that the AD is learning his job, and RAD will be working with the activity aides providing one-to-one programs. The RAD stated the activities program was not very solid during October 2025-December 2025. R #11 is currently on one-to-one programs, and the RAD stated she completed R #11 admission activity assessment. The RAD's expectation is that she expects the activities staff to do one-to-one activity program with R #11. The RAD stated that the activity staff will be receiving training for activities, and she will work on one-to-one programs moving forward.

Based on record review, and interview, the facility failed to meet the professional standards of practice required to prevent skin breakdown for 1 (R #132) of 1 (R #132) resident reviewed for skin assessments when the facility failed to:Ensure a Braden Scale assessment was completed upon admission-Accurately utilize standardized tools such as the Braden Scale (nursing assessment tool used to estimate a patient's risk of developing pressure injuries (pressure ulcers)).-The lack of documented off-loading (Offloading is crucial for preventing pressure ulcers, particularly in individuals with limited mobility or those confined to a bed or wheelchair. By redistributing pressure away from vulnerable areas, offloading helps mitigate the risk of pressure ulcer development) coccyx (tailbone, the last bone at the end of the spine) directly contributed to the tissue necrosis (death of body tissue).These deficient practices led to the development of pressure injury to the coccyx area.The findings are:A. Refer to F0641 for related findings.B. Record review of R #132's Electronic Medical Records (EMR) revealed the following: 1. Braden Scale (a nursing assessment tool used to estimate a patient's risk of developing pressure injuries (pressure ulcers) were done on 04/01/23, 04/08/23, and 04/14/23. Further review of the facility Braden scale instructions was to be completed on resident move-in. 2. No Braden scale assessment was done on R #132 move-in date.C. Record review of R #132's careplan dated 04/28/23 revealed R #132 is at risk for skin breakdown related to decreased activity, impaired cognition, limited mobility, poor safety awareness, incontinence, sheer or friction, informed refusals of care, and recent surgery to the right hip was identified on 03/28/23. Intervention of turn and reposition every 1 to 2 hours was added only 04/01/23. D. On 01/27/26 at 09:02 am during an interview with the Assistant Director of Nursing (ADON), she stated that Braden Scale assessments are done on admission and it did not happen for R #132.

Based on observation, interview, and record review, the facility failed to ensure that resident preferences were honored for 1 (R #104) of 1 (R #104) resident reviewed when:-the facility served green peas despite the resident's dietary profile indicating a preference for no peas.The findings are: A. Record review of R #41's facesheet revealed she was admitted on [DATE] with the following diagnoses (including but not limited to): 1. Parkinson's Disease (progressive neurodegenerative disorder that primarily affects movement and is characterized by symptoms such as tremors, stiffness, and balance difficulties) with dyskinesia (involuntary or uncontrolled movements of the body, which can range from mild tremors to severe, erratic motions). 2. Presence of intraocular lens (artificial lens implanted in the eye to replace the natural lens). 3. Presbyopia (the gradual loss of your eyes' ability to focus on nearby objects). B. On 01/27/26 at 12:40 pm, during on observation in the dining room, R #104 was served beef chili corn chip casserole, flour tortilla, green peas, grapes and hot coffee for lunch with Licensed Practical Nurse (LPN) #5 assisting R #104 with meal. R #104's meal ticket clearly stated, no sides of peas or spinach. Further observation revealed R #104 ate half of the green peas that was served. C. On 01/27/26 at 12:41 pm during an interview with LPN #5, she confirmed that R #104 received a side of green peas on her lunch tray. LPN #5 stated that per R #104's preferences she should not have any peas on her meals and it did not happen. D. On 01/27/26 at 2:22 pm during an interview with the Dietary Manager (DM), he confirmed R #104's dietary preference during lunch and dinner is no sides of peas or spinach, and it did not happen.

Based on observation and interview, the facility failed to :Ensure stored foods are not left open to air.Ensure staff wore beard nets in the kitchen. These deficient practices are likely to affect all 107 residents listed on the census provided by the Administrator on 05/12/25 and may lead to foodborne illnesses in residents if proper food storage and safe food handling practices are not adhered to.The findings are: A. On 01/20/26 at 12:13 pm during an observation of the kitchen revealed one ten-pound box of frozen hamburger patties stored in freezer open to air.B. On 01/20/26 at 12:15 pm during an interview, Dietary Manager (DM) confirmed the ten-pound box of frozen hamburgers was open to air and should not have been left open.C. On 01/27/2026 12:27 pm during an observation of the kitchen revealed that Dietary Aide (DA) #1 was not wearing a beard guard and was serving lunch.D. On 01/27/26 at 12:38 am during an interview, the DM confirmed that DA #1 was not wearing a beard guard and stated that he should have been.

Based on observation and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all 110 residents who resided in the facility when staff failed to: 1. Offer baths or showers to the residents as scheduled and per residents' preference. 2. Offer substantial/maximal eating assistance for residents that require activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance. 3. Maintain fingernail length and cleanliness for residents who are dependent on the facility for ADL's. 4. Maintain dignity of residents who are dependent on the facility for ADLs. These deficient practices are likely to affect the comfort, dignity and health of the residents. The findings are: A. Refer to F0658 and F0677 for related findings. B. On 05/01/25 at 3:44 pm during an interview with Certified Nursing Assistant (CNA) #1, she stated the facility needs extra staff to complete daily tasks. She stated there isn't always enough staff to help with the Hoyer (resident moving device) lift which requires 2 staff to use safely. CNA #1 confirmed Hoyer residents must wait longer for transfers. CNA #1 confirmed she doesn't have enough time in her shift to complete all her work. C. On 05/01/25 at 4:33 pm during an interview with CNA #2, she confirmed that she cannot finish all of her duties during a regular shift. CNA # 2 confirmed short staffing affects quality of care. D. On 05/02/25 at 4:37 pm during an interview with CNA #3, she stated that she has 11 scheduled showers and only 3 have been completed (on the day of the interview). CNA #3 confirmed resident care is missed or late due to being short staffed. CNA #3 stated We are stretched too thin, for the amount of work the facility want her to do. CNA #3 stated she has too many residents and she cannot perform the level of care she would like to. Showers E. On 05/01/25 at 10:06 am during an interview with R #13, she stated that often she is told she cannot have a shower because they do not have the staffing to sit with the residents. R #13 stated bed baths won't happen either if the facility is short staffed. F. On 05/01/25 at 10:31 am during an interview with R #11, He stated there is not enough staff to meet his daily needs. R #5 stated the facility is short staffed and the CNA's do not always answer the call lights quickly. He confirmed staff tell him there are not enough staff, often due to staff calling off work. G. On 05/01/25 at 12:54 pm during an interview with R #9, she stated she is supposed to be bathed 3 times per week. R #9 confirms she only gets 2 showers per week. R #9 stated she is not allowed more than 2 showers per week. R #9 stated she doesn't think they have enough staff to cover more than 2 baths. R #9 confirmed she would love more than 2 baths per week. R #9 stated her biggest complaint is waiting for call light to be answered. H. On 05/01/25 at 2:50 pm during an interview with R #5, he stated he has maybe been showered twice in the last month. R #5 confirmed the facility is not showering him as often as they should. R #5 confirmed he never denies showers from staff, and he only changes his clothes when he gets a shower. I. On 05/01/25 at 3:10 pm during an interview with R #12, he stated that he is missing showers and is supposed to be getting 3 per week. R #12 stated he wants a shower every day. R #12 stated Grouchy is how I feel. It makes me feel terrible. Angry, it makes me frustrated. That I don't get showers. J. On 05/02/25 at 2:21 pm during an interview with R #10, he stated he gets 1 shower per month, but what can I do? R #10 stated there is no point in asking for anything because the staff will say, yeah yeah, and then he won't get anything. R #10 stated they (the facility) don't have enough staff to give me 3 showers per week. Eating Assistance K. On 05/01/25 at 12:40 pm during a dining room observation at lunch time, R #5 wore a clothing protector, sat at a table with other residents, and waited for his meal. After the meal arrived, R #5 tried to eat by himself. R #5's plate was half gone when he stopped eating. R #5's clothing protector was soiled with food and drink from his eating attempts. Staff never offered to assist R #5. L. On 05/01/25 at 2:50 pm during an interview with R #5, he stated Nurse Practitioner (NP) #1 told him he needs maximal eating assistance. R #5 stated he has to ask staff for help eating or it won't happen. M. On 05/02/25 at 1:02 pm during an observation at lunch time, R #14 sat at the table with a clothing protector on and a full plate of food in front of her. R #14 stated I need help, as she pointed to her plate of food. R #14 then placed her hands over her face and lowered her head N. On 05/02/25 at 1:03 pm during an interview, CNA #4 stated there are 10 residents in the dining area who need assistance eating and 4 staff members who can assist. CNA #4 stated We try to keep our eye on the feeders (humiliating term for residents requiring eating assistance), and he will remove resident food tray after it was served to them until he has time to assist them. CNA #4 confirmed the residents must wait to eat with their food right in front of them. CNA #4 confirmed the term feeders is a common term in the facility. Resident Grooming O. On 05/01/25 at 3:10 pm during an observation and interview, R #12's finger nails were uncut with dirt or grime underneath the nails on both hands. R #12 stated he dosen't know his nailed aren't clipped. He stated the nurse or CNA will cut his nails once in a while. P. On 05/02/2025 at 10:23 am during an observation, R #12's fingernails were in the same condition as the day prior. Q. On 05/01/25 at 2:50 pm during an observation and interview, R #5's fingernails were uncut with dirt or grime underneath the nail. R #5 stated that the facility does not cut his fingernails regularly. R. On 05/02/25 at 3:34 pm during an observation, R #5's fingernails in the same condition as the day prior. Resident Dignity R. On 05/02/25 at 1:03 pm during an interview with CNA #4, he used the term feeders at a full table of residents while assisting R #5 with his meal. CNA #4 confirmed the term feeders was used in reference to residents who need assistance with eating. CNA #4 confirmed this is a common term used in the facility. S. On 05/05/25 at 11:48 am during an interview with LPN #3, she used the term feeders when asked about residents who need assistance with eating. T. On 05/05/25 at 11:48 am during an interview with Nurse Manager, she stated I am not familiar with staffing schedule, It's not what I do here. U. On 05/05/25 at 10:26 am during an interview with the administrator, he stated, it's easy to assume that showers aren't being completed. V. On 05/05/25 at 12:14 pm, during an interview with DON, she stated CNAs have so many showers to do per day other staff should be helping. She stated the expectation is that showers are documented daily in the resident documentation software. The DON confirmed CNA complaints of night shift not helping with showers. The DON confirmed staffing needs are adjusted according to resident census and budget.

Based on observation and interview the facility failed to ensure that meals were served to residents at the posted serving times (Breakfast 7:30 am, Lunch 12:30 pm and Dinner 5:30 pm). This deficient practice is likely to result in the disruption of residents' dining experience. The findings are: A. On 05/01/25 at 9:49 am during initial walkthrough of the dining room and kitchen, lunch time was posted to be served at 12:30 pm. B. On 05/01/25 at 10:06 am during an interview with R #13, she stated that breakfast, lunch and dinner trays are always late. C. On 05/01/25 at 11:03 am during an interview, R #13 stated breakfast comes out late, sometimes at 9:00 am. Lunch comes to the rooms at 1:45 pm and dinner comes to the rooms at 6:45 pm. D. On 05/01/25 at 12:36 pm during an observation of lunch time in the dining room, the first resident meal tray was served at 12:51 pm. The last resident meal tray was served at 1:11 pm. E. On 05/01/25 at 1:15 pm during an observation of lunch time, the first lunch trays were delivered to north hall from kitchen. The Certified Nurse Aid (CNA)'s started to deliver the lunch trays to the resident rooms. F. On 05/01/25 at 1:27 pm during an observation of lunch time, the first lunch trays were delivered to south hall from kitchen. The CNAs started to deliver the lunch trays to the resident rooms. G. On 05/01/25 at 3:44 pm during an interview with CNA #1, she confirmed residents get upset because staff never know when the food trays are going to come out. H. On 05/02/25 at 12:45 pm during an observation of lunch time in the dining room, the first resident meal tray was served. I. On 05/02/25 at 1:03 pm during an observation of lunch time in the dining room, the last resident meal tray was served. J. On 05/02/25 at 1:23 pm during an observation of lunch time, the first lunch trays were delivered to north hall from the kitchen. The CNAs started to deliver the lunch trays to the resident rooms. K. On 05/02/25 at 1:44 Pm during an observation of lunch time, the first lunch trays were delivered to south hall from kitchen. The CNAs started to deliver the lunch trays to the resident rooms. L. On 05/02/25 at 3:03 pm during an interview with Dietary Manager (DM), he stated the kitchen starts plating the food at 12:30 pm. He confirmed the posted lunch time is 12:30 pm. DM stated by 1:30 pm, the kitchen should be done dropping trays off in the halls.

Based on record review and interview, the facility failed to notify the medical provider (Physicians and Nurse Practitioners) of a change in condition in which a resident with a history of myocardial infarction (MI; heart attack) reported chest pain for 1 (R #112) of 1 (R #112) residents reviewed for provider notification. If the facility fails to notify the provider of intermittent (not continuous) chest pain for a resident with prior history of MI (a major risk factor for having another MI), then it could likely delay the resident receiving necessary testing to determine if the resident requires life-saving medical intervention. This deficient practice likely contributed to the passing of R #1. The findings are: A. Record review of R #112's facesheet revealed R #112 admitted to the facility on [DATE] with the following list of diagnoses (not all-inclusive): - Diabetes mellitus (a chronic disease that occurs when the body is unable to control blood sugar levels). - Sepsis (a life-threatening extreme immune system response to infection or injury which can cause inflammation, blood clots, and damaged blood vessels reducing the blood flow and oxygen delivered to the body's organs). - Acute respiratory failure (inability to maintain adequate oxygenation in the body). - Atrial fibrillation (a type of irregular heartbeat that occurs when the electrical signals in the heart's upper chambers fire quickly and out of rhythm). - Myocardial infarction type 2 (a type of heart attack that occurs when the supply of oxygen to the heart does not meet the heart's demand). - Hypertension (high blood pressure). - Congestive heart failure (a serious long term condition that occurs when the heart cannot pump enough blood to the meet the body's needs). B. Record review of R #112's admission Minimum Data Set assessment (MDS; a federally mandated comprehensive assessment of each resident's functional capabilities that helps nursing home staff identify health problems), dated [DATE], revealed staff documented the following for the look back period (The time period over which staff observe a resident to capture the resident's condition or status for the MDS assessment. Unless otherwise stated, the look back period is seven days, and only those occurrences during the look back period will be captured on the MDS.): - Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 14, cognitively intact. - Active diagnoses of atrial fibrillation, heart failure, and hypertension. - R 112's pain was rare or non-existent. - R 112's ability to express ideas and wants was usually understood. Resident had difficulty communicating some words or finishing thoughts but was able if prompted or given time. - R 112's was able to understand others. Resident missed some part/intent of the message but comprehended most conversation. - No behaviors. - R 112's prognosis (life expectancy) was greater than 6 months. C. On [DATE] at 4:20 PM during an interview, CNA #2 stated that on [DATE] she checked on R #112 around 4 PM when he reported to her that his chest was hurting. CNA #2 immediately notified the nurse (LPN #1) who assessed the resident and took vital sign measurements. D. Record review R #112's nursing progress note, dated [DATE] at 4:01 PM and authored by Licensed Practical Nurse (LPN) #1, revealed the Certified Nursing Assistant (CNA) reported the resident complained of chest pain. Staff obtained the resident's vital signs as follows: ,d+[DATE] (blood pressure should be ,d+[DATE] or lower); 88 (normal pulse for adults is between 60 and 100); 22 (normal respiratory rate for a resting adult is between 12 and 20); 98.6 (the usual body temperature is generally considered to be between 97 and 99 degrees fahrenheit); on 2.5 liters (L) of oxygen. Staff assessed the resident, and he did not have any complaints at the time. R #112's color was pale, skin was cool, no diaphoresis (sweating). The resident answered questions appropriately. E. On [DATE] at 2:04 PM and 4:02 PM during an interview, LPN #1 stated the medical provider was not notified about R #112's initial report of chest pain, because he was at his baseline when she assessed him. LPN #1 stated she did not ask R #112 about his chest pain (type, duration, frequency), because he was not actively experiencing it. She stated she could not recall whether she considered his cardiovascular history when she decided not to notify the medical provider. F. On [DATE] at 1:40 PM during an interview, CNP (Certified Nurse Practitioner) #1 stated he expected to be notified if a resident complained of chest pain, even if the pain was not constant. CNP #1 stated staff should always take chest pains seriously, because residents may need diagnostics, such as an electrocardiogram (EKG; a test that checks for problems with the electrical activity of the heart) or blood tests to rule out a heart attack. He stated a resident with significant cardiovascular history such as R #112 was especially at risk and should be sent to the emergency room (ER) if they experienced chest pain in order to be evaluated by a provider. G. On [DATE] at 1:53 PM during an interview, LPN #2 stated residents who experienced any chest pain or other signs of a heart attack or stroke should be sent to out to the ER, and staff should notify the provider of the change in condition. H. Record review of R 112's nursing progress note, dated [DATE] at 5:00 PM and authored by LPN #1, revealed nursing staff found R #112 in bed without signs of life. Staff initiated cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken. EMS (Emergency Medical Service) arrived and continued life-saving measures which were ultimately unsuccessful and discontinued CPR at 5:34 PM. The family, facility administrator, nursing unit manager, and on-call provider were notified. Based on interview and record review, Immediate Jeopardy (IJ) was identified on [DATE] at 11:17 AM to the Administrator and the Director of Nursing, in person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 4:05 PM. Implementation of the POR was verified onsite on [DATE] with ongoing trainings for staff regarding change in condition and assessment of chest pains, and the facility completed a full sweep of all residents to identify any other resident who may be experiencing a change in condition and required provider notification. After verification of POR on [DATE] at 2:11 PM, the scope and severity was reduced to D. Plan of Removal: Identification/Correction:All residents have the potential to be affected by this alleged deficient practice, if the facility fails to monitor and notify the provider of residents for a change in condition related to chest pain. The following identification/corrections will be completed by [DATE]: Licensed nurses will complete head to toe assessments on current residents residing in the center to determine presence of a medical change in condition. Concentration on residents with the potential for cardiac complications (history of MI, CHF, etc) will be assessed for recent history of chest pain or other signs and symptoms of cardiovascular complications. Identified issues will be reported to the provider for further direction and medical orders. Systematic Measures: The Director of Nursing/designee will educate current staff regarding policy for resident change in condition. The education includes: - Change in condition is a sudden, clinically important deviation from a resident's baseline including physical, mental, or psychosocial status. Nursing assessment should have included description of chest pain, severity and how long pain had lasted. In addition, nurse should have considered the resident's heart history when assessing for chest pain. - All nurses must notify the provider, family and a nurse manager/nurse manager on-call immediately when they identify any change in condition, when the change occurs. If unsure that the residents are having a change, the nurse will consult with the nurse manager or the provider immediately once they have fully assessed the situation and have the information they need. - Nurses will be educated on nurse to nurse shift report that includes any pertinent diagnosis that could put the resident at risk for complications (i.e.: history of MI). The Director of Nursing/designee will begin education [DATE]. As of [DATE], 100% of currently scheduled staff have been educated on this policy. Any staff member that is not on the current schedule as of [DATE], is on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. New hires/agency staff will be educated on the above during orientation. Current agency staff are being educated on the above information, and will continue to be educated by the facility human resources and mentor as part of the orientation process, prior to their first shift. The Director of Nursing/designee will review resident progress notes, orders and nursing dashboard during the morning clinical meeting to determine if residents noted change in condition identified, process followed, and monitoring occurred. Quality Assurance and Monitoring the Director of Nursing/designee will audit progress notes 5 days per week in morning clinical meeting to monitor for timely notification of change in conditions. Administrator and/or designee will bring results of audits to QAPI committee for further recommendations based on tracking and trending presented monthly for the next 3 months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator.

Based on record review and interview, the facility failed to provide quality care to 1 (R #112) of 1 (R #112) residents when they failed to properly assess a resident with history of myocardial infarction (MI; heart attack) ) after the resident reported chest pains. If the facility fails to properly assess a resident who reports chest pains, then the resident may experience unidentified life-threatening conditions such as a heart attack. This deficient practice likely contributed to the passing of R #1 within the hour of reporting chest pain. The findings are: A. Record review of R #112's facesheet revealed that R #112 admitted to the facility on [DATE] with the following list of diagnoses (not all-inclusive): -Diabetes mellitus (a chronic disease in that occurs when the body is unable to control blood sugar levels). -Sepsis (a life-threatening extreme immune system response to infection or injury which can cause inflammation, blood clots, and damaged blood vessels reducing the blood flow and oxygen delivered to the body's organs). -Acute respiratory failure (inability to maintain adequate oxygenation in the body). -Atrial fibrillation (AFIB; a type of irregular heartbeat that occurs when the electrical signals in the heart's upper chambers fire quickly and out of rhythm). -Myocardial infarction type 2 (a type of heart attack that occurs when the supply of oxygen to the heart does not meet the heart's demand). -Hypertension (high blood pressure). -Congestive heart failure (a serious long term condition that occurs when the heart cannot pump enough blood to the meet the body's needs). -Full Code (a medical directive that tells a person's health care team to perform all possible life-saving measures if their heart or lungs stop working). B. Record review of R #112's admission Minimum Data Set assessment (MDS; a federally mandated comprehensive assessment of each resident's functional capabilities that helps nursing home staff identify health problems) dated [DATE] revealed staff documented the following for the look back period (The time period over which staff observe a resident to capture the resident's condition or status for the MDS assessment. Unless otherwise stated, the look back period is seven days, and only those occurrences during the look back period will be captured on the MDS.): - Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 14, cognitively intact. -Active diagnoses of atrial fibrillation, heart failure, and hypertension. -R #112 rated his pain as rare or non-existent -R #112's ability to express ideas and wants was usually understood. Resident had difficulty communicating some words or finishing thoughts but is able if prompted or given time. -R #112 was able to understand others. Resident missed some part/intent of the message but comprehends most conversation. -No behaviors are indicated on the MDS assessment. -R #112's prognosis (life expectancy) was greater than 6 months. C. On [DATE] at 4:20 PM during an interview, CNA #2 stated that on [DATE] she checked on R #112 around 4 PM when he reported to her that his chest was hurting. CNA #2 immediately notified the nurse (LPN #1) who assessed the resident and took vital sign measurements. CNA #2 stated she went to check on R #112 again approximately 45 to 60 minutes later and he was gone (deceased ). D. Record review of the National Institutes of Health article titled, Chest Pain, dated [DATE], revealed an assessment for chest pain should include the following components to help rule out serious, life-threatening causes: -Onset: In addition to when the pain started, ask what the patient was doing when the pain started. Was the pain brought on by exertion, or were they at rest? -Location: Can the patient localize the pain with one finger, or is it diffuse? -Duration: How long did the pain last? -Character: Let the patient describe the pain in his or her own words. -Aggravation/alleviating factors: It is very important to find out what makes the pain worse. Is there an exertion component, is it associated with eating or breathing? Is there a positional component? Don't forget to ask about new workout routines, sports, and lifting. Ask what medications they have tried. -Radiation: This may clue you into visceral pain. -Timing: How many times do they experience this pain? For how long does it let up? -Risk factors including: prior myocardial infarction (MI), family history of cardiac disease, smoking, hypertension (HTN), hyperlipidemia (HLD; high cholesterol), and diabetes. E. Record review of R #112's nursing progress note, dated [DATE] at 4:01 PM and authored by Licensed Practical Nurse (LPN) #1, revealed the Certified Nursing Assistant (CNA) reported the resident complained of chest pain. Staff obtained the resident's vital signs as follows: ,d+[DATE] (blood pressure should be ,d+[DATE] or lower); 88 (normal pulse for adults is between 60 and 100); 22 (normal respiratory rate for a resting adult is between 12 and 20); 98.6 (the usual body temperature is generally considered to be between 97 and 99 degrees fahrenheit); on 2.5 liters (L) of oxygen. Staff assessed the resident, and he did not have any complaints at the time. R #112's color was pale, skin was cool, no diaphoresis (sweating). The resident answered questions appropriately. - The record did not contain any other information regarding the resident assessment conducted by LPN #1 or what questions the resident answered appropriately. F. On [DATE] at 2:04 PM and 4:02 PM during an interview, LPN #1 stated the resident was at his baseline when she assessed him. LPN #1 stated she did not ask R #112 about his chest pain (type, duration, frequency), because he was not actively experiencing it. LPN #1 confirmed she did not notify the doctor of R #112's chest pain. She stated she could not recall whether she considered the resident's cardiovascular history when she assessed R #112 on [DATE]. G. On [DATE] at 1:40 PM during an interview, Certified Nurse Practitioner (CNP) #1 stated staff should always take chest pains seriously, because residents may need diagnostics, such as an electrocardiogram (EKG; a test that checks for problems with the electrical activity of the heart) or blood tests to rule out a heart attack. He stated a resident with significant cardiovascular history, such as R #112, was especially at risk and should be sent to the emergency room (ER) if they experienced chest pain in order to be evaluated by a provider. The CNP stated it was expected for staff to notify him if a resident had chest pain, but staff did not notify him of R #112's chest pain. H. On [DATE] at 1:53 PM during an interview, LPN #2 stated residents who experienced any chest pain or other signs of a heart attack or stroke should be sent to out to the ER to determine if a life-threatening condition exists. I. Record review of R #112's nursing progress note, dated [DATE] at 5:00 PM and authored by LPN #1, nursing staff found R #112 in bed without signs of life. Staff initiated cardiopulmonary resuscitation (CPR; an emergency procedure that combines chest compression with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken). EMS (Emergency Medical Service) arrived and took over life-saving efforts which were ultimately unsuccessful. EMS discontinued CPR at 5:34 PM. The family, facility administrator, nursing unit manager, and on-call provider were notified. J. Record review of R #112's nursing progress note, dated [DATE] at 8:02 PM and authored by Registered Nurse (RN) #1, revealed R #112 was pronounced deceased at 7:23 PM on [DATE]. Based on interview and record review, Immediate Jeopardy (IJ) was identified on [DATE] at 11:17 AM to the Administrator and the Director of Nursing, in person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 4:05 PM. Implementation of the POR was verified onsite on [DATE] with ongoing trainings for staff regarding change in condition and assessment of chest pains, and the facility completed a full sweep of all residents was completed to identify any other resident who may be experiencing a change in condition and required provider notification. After verification of POR on [DATE] at 2:11 PM, the scope and severity was reduced to D. Plan of Removal: Identification/Correction: All residents have the potential to be affected by this alleged deficient practice, if the facility fails to monitor and notify the provider of residents for a change in condition related to chest pain. The following identification/corrections will be completed by [DATE]: Licensed nurses will complete head to toe assessments on current residents residing in the center to determine presence of a medical change in condition. Concentration on residents with the potential for cardiac complications (history of MI, CHF, etc) will be assessed for recent history of chest pain or other signs and symptoms of cardiovascular complications. Identified issues will be reported to the provider for further direction and medical orders. Systematic Measures: The Director of Nursing/designee will educate current staff regarding policy for resident change in condition. The education includes: -Change in condition is a sudden, clinically important deviation from a resident's baseline including physical, mental, or psychosocial status. Nursing assessment should have included description of chest pain, severity and how long pain had lasted. In addition, nurse should have considered the resident's heart history when assessing for chest pain. -All nurses must notify the provider, family and a nurse manager/nurse manager on-call immediately when they identify any change in condition, when the change occurs. If unsure that the residents are having a change, the nurse will consult with the nurse manager or the provider immediately once they have fully assessed the situation and have the information they need. A full head-to-toe assessment needs to be completed by the nurse. The eInteract change in condition documentation needs to be completed specific to the change (ie: chest pain, fall, etc), with the notification noted. The assessment for the eInteract will trigger a specific assessment for chest pain that asks for a description, severity, length of time and if shortness of breath is occurring. This assessment will pull over a resident diagnosis list into the eInteract, change in condition form. It also needs to include all abnormal findings in each system within the form, vital signs, neurological status, chest pain with a history, blood glucose etc. The nurse needs to include a narrative note about what happened before, during and after the event, and the provider orders and interventions that were put into place. Monitoring needs to occur per the change in condition UDA (user defined assessment), and in progress notes as needed, to ensure that if further change occurs, the process is repeated and documented. If the change in condition is an immediate emergency, a nurse should stay with the resident to monitor until EMS arrives. The eInteract UDA, after the initial eInteract change in condition has been completed, triggers continued monitoring of the identified concern. If it is the same concern, continue with the UDA documentation. If it is a different concern, begin another eInteract change in condition assessment. When communicating with the doctor, the nurse must include all information pertinent (including diagnosis pertaining to the change in condition ie: cardiac related diagnosis for chest pain) to the change in condition, and should have it available when calling the doctor. -Nurses will be educated on nurse to nurse shift report that includes resident assessment and any pertinent diagnosis that could put the resident at risk for complications (ie: history of MI). The Director of Nursing/designee will begin education [DATE]. As of [DATE], 100% of currently scheduled staff have been educated on this policy. Any staff member that is not on the current schedule as of [DATE], is on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. New hires/agency staff will be educated on the above during orientation. Current agency staff are being educated on the above information, and will continue to be educated by the facility human resources and mentor as part of the orientation process, prior to their first shift. The Director of Nursing/designee will review resident progress notes, orders and nursing dashboard during the morning clinical meeting to determine if residents noted change in condition identified, process followed, and monitoring occurred. Quality Assurance and Monitoring The Director of Nursing/designee will audit progress notes 5 days per week in morning clinical meeting to monitor for timely notification of change in conditions. Administrator and/or designee will bring results of audits to QAPI committee for further recommendations based on tracking and trending presented monthly for the next 3 months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator.

Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (R #11) of 3 (R # 11, 12, 13) resident reviewed for medications. This deficient practice resulted in R#11's pulmonary embolism [blood clots in the lungs (PE)] getting worse since the last CT scan (medical imaging technique used to obtain detailed internal images of the body) on 09/08/23 putting resident at increased risk for stroke and blockage of blood flow to the heart which could result in death. The findings are: A. Record review of R #11's face sheet revealed she was admitted to the facility on [DATE] with a diagnosis of a dislocated (disturb the normal arrangement or position) right knee, broken right ankle, and pulmonary embolism [blood clots in the lungs (PE)] resulting from a fall at home on 09/08/23. B. Record review of R #11's transfer orders from the hospital, dated 09/15/23, revealed Eliquis (blood thinner), 5 mg (milligrams), 1 tablet twice daily was ordered to treat and prevent the blood clots in her lungs from getting worse. C. Record review of R #11's Program of All-Inclusive Care for the Elderly (PACE) orders sent to the facility, dated 09/15/23, did not include an order for Eliquis or include a diagnosis of pulmonary embolism. D. Record review of R #11's hospital transfer orders and the PACE orders revealed both were uploaded to R #11's Electronic Medical Record (EMR) on 09/14/23. E. Record review of R #11's PACE progress note, dated 09/22/23, revealed R #11 was sent by emergency medical ambulance to the hospital from the facility because the PACE provider found out R #11 had not been receiving Eliquis since her admission on 09/15/23. F. Record review of R #11's hospital CT scan (medical imaging technique used to obtain detailed internal images of the body) of her lungs, dated 09/23/23, revealed R #11's PE had gotten worse by increasing the burden (causing the lungs to work harder to oxygenate the blood) in the left lower lobe since CT chest 9/8/2023. G. On 10/30/23 at 9:47 am during an interview with the Director of Nursing (DON), he stated all orders, medications, and diagnosis for residents upon admission must be reconciled for accuracy. The DON further stated he did not identify R #11's order for Eliquis upon R #11's admission and confirmed that he should have. H. On 10/31/23 at 1:30 pm during an interview with the daughter (D) of R #11, she stated on 09/22/23 she visited R #11 and found her lying in bed, unable to be woken up. She made the facility aware of R #11's condition and called the PACE provider. R#11 was put on 5 liters per minute of oxygen via nasal canula (tube providing oxygen into the nose) and became more alert. She stated when the PACE provider got to the facility, she became aware R #11 was never started on Eliquis and immediately had R #11 transported to the hospital. The PACE provider told R #11's daughter that because R #11 had not been on Eliquis for almost 7 days, she was in danger of forming more blood clots, which could cause a stroke, myocardial infarction (blockage of blood flow to heart), and or death. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J which was announced on 10/30/23 at approximately 12:40 pm to the Administrator, in-person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 10/31/23 at 9:30 am. Implementation of the POR was verified onsite 10/31/23 by conducting record reviews and staff interviews. Scope and severity was lowered to level 2, D. Plan of Removal: On 10/30/23 the nursing team (Director of Nursing responsible) initiated a 30-day audit on all admissions to ensure all orders, diagnosis, and medications were reconciled and entered into the MAR as ordered. Any discrepancies will include a provider notification and review to ensure accurate medication orders are in place. On 10/30/23 the nursing team (Director of Nursing responsible) initiated an audit of all residents currently receiving anticoagulant medications to ensure medications are being given as ordered. Any identified concerns will include a change in condition documentation and notification to the provider and family. Any new orders will be followed.

Based on observation, interview, and record review the facility failed to provide quality care for 5 (R #29, 38, 61, 65 and 81) of 5 (R #s 29, 38, 61, 65 and 81) residents reviewed by not monitoring and treatment of wounds. This deficient practices could likely cause a decline in residents' health and well-being if physician orders are not followed, wounds could likely become infected causing sepsis (blood infection), osteomyelitis (bone infection) and/or other medical conditions could likely worsen.The findings are: A. Record review of R #81's facesheet revealed the following diagnoses: Type II diabetes (means that your body doesn't use insulin properly), chronic kidney disease (impaires kidney function), osteomyelitis diagnosed during stay at facility (inflammation of one or more joints), methicillin resistant staphylococcus aureus infection (Infections caused by specific bacteria that are resistant to commonly used antibiotics), peripheral vascular disease (is a slow and progressive circulation disorder), acquired absence of left toes diagnosed during stay at facility (amputation of left toes). This is not a complete listing of R #81's diagnoses. R #81 was initially admitted on [DATE] and was readmitted on [DATE]. B. Record review of hospital admission description indicated that R #81 had a laceration on his toe and was seeing podiatrist. It was noted on 06/20/23 in a podaitrist note that the laceration was healing. On 07/07/23 the podiatrist noted that R #81's left fifth digit was infected and disarticulated (seperation of two bones at their joint). R #81 was admitted to the hopsital on 07/05/23 for left toe gangrene (death of body tissue due to a lack of blood) and osteomyelitis. Left toe amputation was completed on 07/05/23. Resident was readmitted to the facility on [DATE]. C. Record review of the physician orders indicated an order dated 07/26/23 for wound care to be provided every day and as needed. D. On 08/27/23 at 7:18 pm, during an observation and interview, R #81 had two preventive boots (helps to prevent skin breakdown). One boot was on his right foot, and the other boot was not on his left foot. The dressing on his left foot was dirty and very bloody (both wet and dry blood) and was not a clean dressing. The dressing did not have a date or initials on it indicating when the dressing was last changed and who changed it. R #81 stated he did not know when the dressing was last changed. E. On 08/28/23 at 8:00 am, during an observation, R #81 was asleep in bed, and staff had not changed his dressing. The dressing was observed to be the same dressing as the day prior, with no date or initials. F. Record review of the Treatment Administration Record (TAR) for the month of August 2023 indicated that no wound care was completed on 08/27/23. G. On 08/28/23 at 2:25 pm, during an observation and interview, Family Member #1 (R #81's wife) was in the room while staff provided care to R #81. The dressing on R #81's left foot was the same dressing as previously observed this morning 08/28/23 at 8:00 am and on 08/27/23 at 7:18 pm, and the wife pointed at the wound dressing. She stated it (the dressing) had not been changed, and she had just asked staff to change the dressing. H. Record review of R #81's nursing progress notes, dated 07/05/23 at 8:49 am, indicated R #81 went to a podiatry (foot doctor) appointment and was sent to the hospital due to progression (worsening) of wounds. R #81 had a deteriorating venous wound (can be shallow, irregularly shaped sores and skin surrounding the stasis ulcer may be hard and discolored) on his left foot. I. Record review of R #81's wound care note dated 07/28/23 at 16:47 (4:47 pm), indicated wound care to the left 5th toe amputation (surgical removal of a body part): clean w (with) wound cleaner. Fill hole loosely with maxorb absorbent dressing. Paint heel dti (deep tissue injury) w betadine swab (impregnated with 10% povidone-iodine solution). Cover both w/ abd pads and wrap w entire roll kerlix. May use net stocking to secure, no compression. Change q day and PRN if soiled or off, everyday shift. Necrotic (dead tissue) areas to proximal (closer to the main part of body) aspects of wound are increasing. Distal (further away from the main part of body) wound end is black and soggy. No granulation (new tissue on surface of healing wounds) visible in wound, yellow thin slough (dead tissue) present, suspicious for more extensive depth. Awaiting provider input, rsd (resident) does have podiatry appt (appointment) on Monday [07/31/23] but might need to be seen in ER (emergency room ) prior. J. Record review of R #81's nursing progress note, dated 08/01/23 at 11:57 am, indicated Rsd returned from (name of clinic) podiatry appt yesterday (07/31/23) w no paperwork. Writer spoke w Chief of Podiatry (name of) about rsd's foot wound (left toe amputation). Goals of care discusses (discussed) (name of physician) reports they recommended a BKA (below the knee amputation on left leg), but family at that point did not want to go that route. Wound worsening, tendon and bone exposed and tunnels 8 cm (centimeters) up towards the ankle at this time. Slough and eschar (type of necrotic tissue that is secondary to cell death following tissue injury) to the edges. (name of physician) reports that goal is to dessicate (to dry up) the wound and dry it out, to possibly provide a stable dry gangrene (is a condition where body tissues die due to lack of blood supply or infection) bed that could be left alone. Goal is to attempt to prevent sepsis r/t (related to) wound on his left foot and toe amputation. They are going to discuss palliative care w family at next visit. (name of physician) to fax visit notes from 7/31 to facility. K. Record review of R #81's nursing progress note, dated 08/07/23 at 17:34 (5:34 pm), indicated the following, Per VA Hospital per appointment: - Left foot wound vacuum (vacuum assisted closure for wound therapy). - Dressing changes: Change x (times) 2, weekly (Wed, Fri). - VA podiatry will see every Monday. - Black foam with plastic wrap. - Make sure vacc running at 125 mmHg (pressure setting) continuous pressure. - Dress foot with 4 x 4 gauze,abd pad around vacc hose to ensure no pressure wounds, kerlix and or loose dressings around foot. - No weight bearing to left foot. L. Record review of R #81's Treatment Administration Record (TAR), for August 2023 and Nursing progress notes, indicated the following: - The TAR did not contain orders for the wound vac. - The wound order in place on the TAR was wound care, left 5th toe amputation: clean w wound cleaner. Saturate 4 x 4 gauze and wrap w entire roll kerlix. may use net stocking or ace to secure, no compression. Change q date and PRN if soiled or off every day shift start on 08/05/23. - The staff documented the following in the TAR for wound care: - August 5th indicated to see nursing note. Nursing note indicated that family requested wound care to be done later due to family visiting. - August 6th wound care was done. - August 7th and 8th indicated hold see nursing notes. Nursing notes indicated a wound vac was in place. - August 9th nothing was documented. - August 10th and 11th indicated to see nursing notes. Nursing notes indicated a wound vac was in place. - August 12th and 13th wound care was documented as being completed. - August 14th nothing was documented. - August 15th indicated to see nursing notes. Note Text: wound vac not present at time of wound care. No new orders returned from (name of hopsital) after visit. Contacting (name of hospital) for current plan of treatment for foot wound. Wound has worsened, increased eschar and slough areas r/t (due to) circulation issues . - August 16th -20th wound care was documented as being completed. - August 21st nothing was documented. - August 22nd -26th wound care was documented as being completed. - August 27th nothing was documented. - August 28th-31st wound care was documented as being completed. M. Record review of R #81's podiatry follow up note, dated 08/14/23 [Monday], indicated, Follow up on delayed primary closure of the left fourth and fifth ray (toe) amputation [refers to the ablation (removal of body tissue) of digital (fingers and toes) elements] date of service on 07/05/23 and 07/07/23. Patient has been in SNF (Skilled Nursing Home) for wound management. Presents to clinic with wife and daughter who states the vac last changed on Wednesday. Today, wound vac and dressings intact, however vac was not on and low battery. Patient endorses pain to the area. Removed wound vac, confirmed it has not been on since August 9th, 2023, while patient was at (name of) SNF. N. On 08/28/23 at 12:49 pm, during an interview, Family Member #2 stated the wound on her father's left foot had not been healing. She had taken him to a podiatry When her father went to a podiatry appoinment on 08/07 /23 he stated that the wound wasn't healing and ordered a wound vacuum. R #81 came back to the facility on [DATE] with the wound vacuum. She stated that when she (FM #2) got back to the facility from the 08/07/23 appointment, she gave the orders and supplies to Licensed Pracitcal Nurse (LPN) #3. FM #2 told LPN #3 that If they (the facility), were not able to change the wound vac, then they should send him back to the clinic and the clinic would change it. LPN #3 told her that they do it all the time, and it would not be a problem. She took her father (R #81) back to the podiatrist on Monday 08/14/23 and at that time the podiatrist realized that the wound vac was not turned on and the dressing had not been changed. The Podiatrist took the wound vac off at that point. They were discussing the BKA with the family, but the family decided not at this time.She stated that when she took him back on 08/14/23 the Podiatrist stated that the wound wasn't healing O. On 08/29/23 at 4:09 pm, during an interview with LPN #3, she stated that she was familiar with R #81's wound, and she remembers when he came back with a wound vac [08/07/23]. She stated she was the one who put in the progress note for his wound vac. LPN #3 stated that she did not put it in as an order, but she did let the Unit Manager know about the wound vac order. She thought the Wound Care nurse would enter the order into the electronic medical record. She stated that if there were no wound orders then it would not have triggered the nurses to have completed wound care for the wound vac. She stated I did not ever do any wound care while R #81 had the wound vac. She has been R #81's nurse and was at the time he had a wound vac. P. On 08/29/23 at 4:19 pm, during an interview, Director of Nursing (DON) stated she was not aware of the situation with the wound vac. She was aware R #81 had one, but she was unaware staff did not put the orders for the wound vac in R #81's medical record. The DON confirmed there was not an order for the wound vac, only a progress note. The DON stated the wound nurse would have entered in the orders for the wound vacc in this case; however, the wound nurse was off on Mondays, and she was on vacation sometime the beginning of August. The DON stated the Unit Manager would have put the orders in since the wound nurse was not available to do it. She stated if the nurse was familiar with the orders then the nurse could enter the orders into the resident's medical record. Q. On 08/30/23 at 4:55 pm, during an interview, DON stated the wound nurse was out last week, this week, and earlier in the month. The DON stated there was not a particular staff responsible for the oversight of wound care or to provide wound care in the absence of the wound nurse. The nursing staff should do the wound care if the wound care nurse was out. The DON wasn't aware that the wound vac for R #81 was never put in as an order. 40671 Resident #29 R. Record review of Face Sheet dated 11/15/22 for R #29 revealed this as an initial admitted and included the following diagnoses: Morbid Obesity, Venous Insufficiency (condition in which blood pools in veins, straining the walls of the vein), Stage 2 Pressure Ulcer of Right Buttock, Chronic Pain syndrome, Peripheral Vascular Disease (narrowing of blood vessels which reduces blood flow to the arms or legs), and Muscle Weakness. S. Record review of Physicians Orders for R #29 revealed the following: - Wound care, left buttock . change QD (every day) and PRN (as needed) if soiled (dirty) or off, every day shift. Start date: 06/07/23. D/C date: 06/08/23. - Wound care, bilat (bilateral - both sides) buttocks/posterior (back side) thighs . Q (every) change and PRN every day and night shift. Start date: 12/29/22. D/C date: 06/01/23. - Clean wounds to BLE (bilateral lower extremities - both legs) . change Tuesday (Tuesday), Fri (Friday), and PRN if soiled or off. Every day shift Tue, Fri. Start date: 02/14/23. D/C date: 06/09/23. - Wound care BLE . change QD and PRN if soiled or off, every day shift . Start date: 09/02/23. [no D/C date] - Weekly skin check . every day shift every Sun (Sunday) . Start date 02/06/23. [no D/C date] - Wound care, right scapula (shoulder) . change q day and PRN if soiled or off, every day shift. Start date: 03/09/23. D/C date: 03/31/23. - Wound care, LLE (left lower extremity - leg) . change QD and PRN if soiled or off, every day shift every Tue, Fri. Start date: 06/13/23. D/C date: 08/31/23. - Wound care, right posterior thigh change q day and PRN if soiled or off, every day shift. Start date: 07/12/23. [No D/C date] T. Record review of Treatment Administration Records (TAR), dated June 2023, for R #29, revealed the following: - Cleanse wounds to BLE . change Tue Fri Day Shift and PRN if soiled or off. Start date: 02/14/23. D/C date: 06/09/23. - 06/09/23 (Friday) - No documentation - Weekly skin check . every Monday night. Start date: 02/06/23. 06/26/23 (Monday) - No documentation - Wound care, bilat buttocks . q change and PRN every day shift. Start date: 06/07/23 D/C date: 06/08/23. 06/07/23 and 06/08/23 - No documentation - Wound care, LLE . change Tue, Fri Day Shift and PRN if soiled or off. Start date: 06/13/23. D/C date: 08/31/23. 06/16/23 - Documented as NN (See Nursing Notes) 06/20/23 (Tuesday) - No documentation 06/30/23 (Friday) - No documentation -Wound care, right posterior thigh . change q day and PRN if soiled or off. Start date: 06/28/23. D/C date: 07/11/23. 06/28/23 and 06/30/23 - No documentation - Wound care, right posterior thigh . change q day and PRN if soiled or off. Start date: 06/02/23. D/C date: 06/27/23. 06/06/23, 06/08/23, 06/09/23, 06/12/23, 06/13/23, 06/19/23, and 06/21/23 - Documented as R (refusal) 06/05, 06/07, 06/10 - 06/11, 06/14 - 06/15, 06/17 - 06/18, 06/20, 06/25 and 06/27 - No documentation U. Record review of TAR, dated July 2023, for R #29, revealed the following: - Wound care, LLE. Change Tuesday and Friday. Day Shift and PRN if soiled or off. Start date: 06/13/23. D/C date: 08/31/23. - 07/04/23 (Tuesday) - No documentation - 07/14/23 (Friday) - Documented as NN - 07/21/23 (Friday) - No documentation - 07/25/23 (Tuesday) - Documented as NN - Wound care, right posterior thigh. Change q day and PRN if soiled or off. Start date: 07/12/23. 07/15/23 - No documentation 07/20/23 - 07/22/23 - No documentation 07/24/23 - No documentation 07/29/23 - No documentation 07/30/23 - Documented as NN 07/31/23 - No documentation - Wound care, right posterior thigh. Change q day and PRN if soiled or off. Start date 06/28/23. D/C date: 07/11/23. 07/02/23 - No documentation 07/04/23 -07/05/23 - No documentation 07/10/23 - Documented as R (Refused) 07/11/23 - No documentation V. Record review of R #29's TAR, dated August 2023, for R #29, revealed the following: - Weekly skin check . every Monday Night. Start date: 02/06/23. [No D/C date] 08/14/23 (Monday) - Documented as R - Wound care, LLE . change Tue, Fri Day Shift and PRN if soiled or off. Start date: 06/13/23. D/C date: 08/31/23. 08/01/23 (Tuesday) - Documented as NN 08/04/23 (Friday) and 08/08/23 (Tuesday) - Documented as R 08/15/23 (Tuesday) - Documented as NN 08/18/23 (Friday) - Documented as R - Wound care, right posterior thigh . change q day and PRN if soiled or off. Start date: 07/12/23. Documented as NN on 08/01. 08/02/23 - Documented as R 08/04/23 - Documented as R 08/05/23 - No documentation 08/07/23 - Documented as NN 08/09/23 - Documented as R 08/10/23 - No documentation 08/14/23 - No documentation 08/15/23 - Documented as NN 08/16/23 - 08/18/23 - Documented as R 08/20/23 - Documented as NN 08/27/23 - No documentation W. Record review of TAR, dated September 1 - 6, 2023, for R #29, revealed the following: - Wound care, BLE . change QD and PRN if soiled or off. Start date: 09/02/23. 09/03/23 - Documented as NN 09/04/23 - No documentation - Wound care, LLE . change QD and PRN if soiled or off. Start date: 09/01/23. D/C date: 09/01/23. 09/01/23 - No documentation - Wound care, right posterior thigh . change q day and PRN if soiled or off. Start date: 07/12/23. 09/03/23 - Documented as NN 09/04/23 - No documentation X. Record review of nursing progress notes (referenced above as see nurse notes for wound care) revealed no nursing notes identifying that wound care was provided for 07/14/23, 07/25/23, 07/30/23, 08/01/23, 08/07/23, 08/15/23, 08/20/23 or 09/03/23. Y. Record review of nursing progress notes dated 06/06/23 at 10:01 am for R #29 revealed, IDT (interdisciplinary team) review for new pressure wound on 6/5/23. Resident has new wound to L (left) buttock . Z. Record review of nursing progress notes dated 06/07/23 at 12:33 pm for R #29 revealed, Wound documents as a new PI (pressure ulcer) is the same one that has been present since admission. Tx (treatment) orders remain in place for it and others . AA. Record review of nursing progress notes dated 06/16/23 at 16:59 (4:59 pm) for R #29 revealed, . Rsd (resident) denies refusing care . Rsd stated during care plan meeting that he did not receive wound care for 3 (three) weeks at one point . BB. Record review of nursing progress notes dated 07/08/23 at 12:13 pm for R #29 revealed, . Left post calf deteriorated sharply (to become worse quickly), r/t (related to) rsd refusals of care. New open areas where thick plaques (when dead skin and white blood cells can't shed fast enough, they build up and create thick, scaly surfaces of the skin.) have come free. Area macerated (softening and breaking down) . balls of both feet red but blanching (skin becomes pale or white), rsd does not believe he has irritated areas to balls of feet . CC. Record review of nursing progress notes dated 08/28/23 at 23:18 (11:18 pm) for R #29 revealed, . Skin breakdown on buttocks . DD. On 08/30/23 at 9:48 am, during an observation and interview, prior to Licensed Practical Nurse (LPN) #2 providing wound care for R #29's right leg, she appeared to have difficulty locating the wound care supplies. LPN #2 stated she was just cleaning and wrapping the leg, but that there were no orders for treating the wound. 45426 Findings for R #65 EE. Record review of R #65's admissions facesheet revealed R #65 was admitted to the facility on [DATE] with a diagnoses of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (area located below the lumbar spine and above the tailbone), unstageable (when the stage of the ulcer is not clear because the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black and the doctor cannot see the base of the wound to determine the stage). FF. On 08/28/23 at 11:22 am, during an interview, R #65 stated the wound on his butt (buttock) was hurting due to the dressing sticking. He stated the dressing was supposed to be changed daily, but it was not getting changed daily. GG. Record review of R #65's weekly wound evaluation revealed R #65 diagnosed with the following skin injuries: - 08/03/23 Pressure - Unstageable (Slough and/or eschar) Body location: coccyx (commonly known as the tailbone). New - 1 month old. Acquired: In-House (a pressure injury acquired while residing at the facility) - 08/03/23 Pressure - Deep Tissue Injury Body Location: Right heel. New - 7 days old. Acquired: Present on admission. HH. Record review of the physician orders for R #65 revealed the following orders: - Order, dated 08/4/23: Wound care, right buttock: clean with wound with wound cleaner. Apply generous layer of medhoney (a brand name wound and burn gel made from 100% Leptospermum (Manuka) honey) to slough and cover with foam dressing. Fold dressing flat into buttock cleft to secure. Change each day and as needed if soiled or off. - Order dated 08/04/23: Wound care, bilateral heels: paint heels with betadine (a topical antiseptic that provides infection protection against a variety of germs to help prevent infection and promote healing in skin wounds, pressure sores, or surgical incisions) each day every shift. II. Record review of R # 65's Treatment Administration Record (TAR), dated August, 2023, revealed the following for wound treatment: - Order with start date of 08/04/23, Wound care, right buttock: clean with wound with wound cleaner. Apply generous layer of medhoney to slough and cover with foam dressing. Fold dressing flat into buttock cleft to secure. Change each day and as needed if soiled or off. - Staff did not document wound care treatment for the dates of 08/05/23, 08/07/23, 08/09/23, 08/14/23, 08/17/23, 08/19/23, 08/21/23, and 08/24/23. - Order with start date of 08/04/23, Wound care, bilateral heels: pain heels with betadine each day every shift. - Staff did not document wound care treatment for the dates of 08/05/23, 08/07/23, 08/09/23, 08/14/23, 08/17/23, 08/19/23, 08/21/23, and 08/24/23. HH. Record review of R #65's wound evaluations revealed the following: - Coccyx wound evaluations: - Weekly wound evaluations were completed for R #65 on the dates of: 08/03/23 , 08/15/23, and 08/31/23. - 16 days passed between the assessment of 08/15/23 and 08/31/23. - Photos indicate the wound is on the left buttock and not the right buttock as identified in the physician's orders and the TAR for wound care. - Right heel: - Weekly wound evaluations were completed for R #65 on the dates of: 08/03/23 , 08/15/23, and 08/31/23. - 16 days passed between the assessment of 08/15/23 and 08/31/23. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of K which was announced on 08/30/23 at approximately 6:28 pm to the administrator, in-person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 08/31/23 at 12:11 pm. Implementation of the POR was verified onsite 08/31/23 by conducting record reviews and staff interviews. Plan of Removal: On 08/30/23 -08/31/23 the nursing team initiated a whole house resident skin sweep to identify all current wounds in the facility, and assess for correct identification and treatment. Any identified concerns, including refusals of wound care/assessment and worsening wounds will include change in condition documentation and notification to the provider and family. Any new orders will be followed. 47899

Based on record review, observation, and interview, the facility failed to prevent resident to resident sexual abuse and to protect multiple residents from observing ongoing sexual behaviors and verbal abuse for 6 (R #3, 29, 31, 45, 87 and 109) of 6 (R #3, 29, 31, 45, 87 and 109) residents reviewed for abuse. This deficient practice likely resulted in psychosocial distress (unpleasant emotions associated with a highly stressful environment) for the residents who observed the behavior; and for R #3 being uncomfortable around R #104. The findings are. A. On 08/27/23 at 4:45 pm, an observation revealed R #104 sat in the dayroom with a staff member next to him. B. On 08/28/23 at 8:00 am, during an interview, Unit Manager (UM) #1 stated the staff sat with R #104 in a one-to-one situation (staff to resident continuous care situation for at risk residents or those who pose a risk to others) after he was the identified as the perpetrator in a sexual assault allegation made on 08/21/23. C. Record review of a Social Services note dated 8/21/2023 at 9:26 am, indicated Another Resident (initials of R #31) filed a grievance due to a sexual assault by (name of R #104) towards (initials of R #3). (initials of R #31) stated this is making him (R #31) feel very uncomfortable and stated other women are negative affected by this (the inappropriate sexual behavior by R #104) and they don't like it happening, especially in the dayroom! D. Record review of R #104's Social Services note dated 8/21/23 at 9:27 am, indicated After further investigation, at approximately 8:00 AM today, 8/21/2023, this resident (R #104) sexually assaulted another resident (initials of R #3). SSD (Social Services Director) investigated the Sexually Maladaptive Behavior (actions that prevent people from adapting, adjusting, or participating in different aspects of life) reported 1 hour ago. (Initials of R #3) stated that this other Resident (R #104) assaulted him, it was unwelcome, and not appreciated. (initials of R #3) (name of) is scared, fearful that (initials of R #104) would touch him again. The victim reported he felt embarrassed and ashamed that (initials of R #104) revealed his penis in the present (presence) of others. (initials of R #3) stated he feels 'he was attacked by him.' E. Record review of R #104's a nursing progress note dated 8/21/23 at 16:39 (4:39 pm), indicated Resident (R #104) was sitting in day room masturbating (touching or rubbing your own private parts for sexual pleasure) with other residents present when staff informed resident that this was an activity that should be done in private. Resident stated, well he wants to see it, indicating another resident. Resident was removed from day room and assisted to his room. Received report that another male resident stated that this resident (R #104) had touched him inappropriately. Provider was notified and order to send to ER (emergency room ) for eval (evaluation) was received. Ambulance was called and staff were notified that (name of Police Department) needed to clear resident for transport. (Initials of the police dept) was notified and arrived on scene and remained on scene until resident was transported from the facility to the hospital for eval. Resident's behavior of masturbating in public has not been directed towards others until today. F. Record review of R #104's physician orders indicated an order on 08/21/23 Send resident to ER for further evaluation of sexually assaulting another resident. Increased sexual behaviors, masturbating in front of others. Increased vulgarity (being rude or gross) with masturbation, touching of others. Resident not to return until after a complete psychological evaluation (helps determine the cause of mental health symptoms or disorders). G. Record review of R #104's nursing progress notes, dated 8/21/23 at 14:22 (2:22 pm), (name of) ambulance called so he can be taken to the emergency for psych evaluation, but I was told that they must involve the cops before the transfer. The cops came, and resident was transferred to the emergency room along with the police officer. Resident was transported at 2:20 pm. H. Record review of a discharge note from (name of hospital) psychiatric emergency services (care center that helps individuals manage mental health crises) saw R #104 on 08/21/23 and prescribed him a new medication, Citalopram 10 milligrams once daily for anxiety (mental health disorder in which individuals experience frequent worry and fear about everyday situations) and depression (a mental health disorder in which individuals experience sadness and loss of interest in everyday activities). I. Record review of R #104's nursing progress note, dated 8/21/23 at 18:33 (6:33 pm), Resident was wheeled back from the hospital in a stable state. Citalopram 10 mg was prescribed at the hospital. J. Record review of R #104's physician orders indicated an order dated on 08/21/23. Resident to be one on one for every shift until evaluated by provider every day and night shift. K. On 08/28/23 at 9:42 am, during an interview, R # 29, (R #104's roommate) stated he (R #29) did not touch him physically or sexually, but he (R #104) masturbated and sat in his wheelchair naked in their room where R #29 could see him. He stated that he (R #104) also cussed at other residents. L. On 08/28/23 at 2:20 pm, during an interview, R #45 stated that R #104 called her a fucking bitch all the time for no reason. She stated she does not know him. She stated one-on-one staff attention has kept him in line, and he has had a one-to-one (supervision) for a couple of weeks now. M. On 08/29/23 at 11:07 am, during an interview, R #3 stated R #104 inappropriately touched him. He stated he (R #3) was in the dayroom on 08/21/23 (time unknown) when R #104 jacked off (slang for when a male releases semen from his penis) into his hand and put it in his (R #3) face. He told a staff member (unidentified staff member) about it. He stated this only happened one time, but earlier today (08/29/23) R #104 motioned to him with an open mouth and his hand moving up and down (indicating oral sex). He stated R #104 made him feel uncomfortable, and he does not like him being here in the facility. N. On 08/29/23 at 11:29 am, during an interview, Certified Nursing Assistant (CNA) #11 stated R #104 always calls R #109 and R #45 names when he see's them. She stated R #104 called them (R #109 and R #45) names all the time. She stated she did observe earlier today R #104 motioning to R #3 with an open mouth and his hand moving up and down [simulating oral sex]. She stated that when there is a behavior they will tell him to stop and take him out of the area. CNA #11 did not identify any intervention when providing one to one supervision to prevent occurrences from happening, only to respond after the fact. O. On 08/30/23 at 12:14 pm, during an observation and interview, R #104 was lying in his bed asleep; the unidentified sitter, stated that she was brought in today to just sit (provide one to one) with R #104, stated she was told to watch him, document on a log sheet what he is doing, and document if there are any (mental health related) behaviors. The sitter did not identify any intervention when providing one to one supervision to prevent occurrences from happening, only to respond after the fact. P. On 08/30/23 at 9:44 am, during an observation and interview, CNA #9 sat with R #104 during a one-to-one. CNA #9 stated she has observed R #104 yelling at other residents before. She stated that R #104 had seen him target R #3. CNA #9 had not observed R #104 display any sexual behavior. She stated if anything occurred with R #104, she is supposed to document it and tell the nurse and they will take him out of that area. CNA #9 did not identify any intervention when providing one to one supervision to prevent occurrences from happening, only to respond after the fact. Q. On 08/30/23 at 12:36 pm, during an interview, Social Services Director (SSD) stated R #104 has schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and depression, and he does not have a filter for what he expresses. He stated staff initially re-directed him to his room when he would start masturbating, and they tried to involve him in activities. He stated, after the incident with R #3 on 08/21/23, they put R #104 on a one-to-one for the residents' safety. The SSD stated R #104's behaviors are pretty extreme. The facility is not equipped to handle him here in the facility, but other facilities will not take him. He stated initially R #104 was disruptive verbally (calling out to others, cursing and calling other residents names) but then his sexual behaviors started to escalate. The SSD stated that in Resident Council meetings the residents voiced being uncomfortable around R #104. The SSD stated R #104 admitted to the police he ejaculated and then put his hand into R #3's mouth. R. On 09/05/23 at 10:02 am, during an interview, R #87 stated she observed R #104 masturbate five times and put it in his mouth. She stated seeing this made her feel just grossed out and disgusted. R #87 stated she frequently felt like he is not appropriate for this facility. She stated he caused disruptions and cussed people out. She stated she saw R #104 call R #45 a fucking bitch. She stated the day (08/21/23) he touched R #3, she observed R #104 proposition (make a offensive suggestion) R #3 by motioning to him with his arm and hand going up and down towards his mouth R #104 said, suck my dick to R #3. She stated after R #104 was put on a one-to-one his behavior improved. S. On 09/05/23 at 11:18 am, during an interview, the Center Executive Director (CED) stated staff and residents informed him countless times about R #104's sexually inappropriate behavior. He stated they reported R #104 yelled out at other residents and masturbated in public. The CED said R #31 filed two grievances about R #104. The CED stated he heard about R #104's behavior of masturbating about three weeks ago. The CED stated R #104 masturbated in public, and staff re-directed him to his room. The staff told R #104 that he needed to be someplace private if he was going to do that. He stated when he heard (08/21/23) that R #104 touched R #3 that is when they called police, requested SANE (sexual abuse nurse examiner) nurse to come to the facility, and they put R #104 on a one-to-one. The CED stated after the incident on 08/21/23, when they sent R #104 out to the hospital, they started him on another medication and did an evaluation on him. The CED stated they have one-to-one monitoring of R #104 and are documenting on a log of what is happening throughout the day.

Based on record review and interview, the facility failed to notify the physician of 1. Signs and symptoms of constipation (a condition in which stools may not pass for an extended period of time resulting in dry or lumpy stools that are painful to pass) and pain 2. Results of the xray ordered on 02/04/22 due to R #1 experiencing abdominal pain for 6 days 3. Delay is starting ordered [MEDICATION(S)] for 2 days and that R #1 had been refusing as needed laxatives This deficient practice likely resulted in 1 (R #1) of 4 (R #'s 1, 2, 3, and 4) residents reviewed for constipation to have worsening constipation resulting in a fecal impaction that likely resulted in pain for R #1. The findings are: A. Record review of facility policy titled Physician/Advanced Practice Provider (APP) Notification, last review date 12/01/21, revealed that Upon identification of a patient who has a change in condition, abnormal laboratory values, or abnormal diagnostics, a licensed nurse will: Perform appropriate clinical observations, collect pertinent patient information. Report to physician/advanced practice provider. If unable to contact attending physician/APP, the Medical Director will be contacted. B. Record review of R #1's face sheet, indicated that R #1 is an [AGE] year-old female, who was admitted to the facility on [DATE], following an admission from a local hospital. R #1 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] of anticoagulants (the use of medications to thin the blood), and hearing loss. C. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] E. Record review of nurse's notes, dated 02/01/22, revealed that the resident was feeling upset, and during a shower, she was observed to be constipated with a stool at her anal sphincter (rings of muscle at the opening of the anus). The resident refused help from staff and the daughter of the resident was notified of the observation and behavior of the resident. The daughter then informed the nurse that R #1 often refuses laxatives. The nurse then documented I was able to convince her to take a Senna Plus [a [MEDICATION(S)] and stool softener used to promote bowel movement] she was more friendly . F. Record review of the ADL's (Activities of Daily Living) documentation revealed that documentation of bowel movements was not documented for the following days: 1. December of 2021: 12/16/21, 12/19/21, 12/23/21 through 12/27/21 and 12/31/21. 2. January of 2022: 01/01/22 through 01/14/22, 01/16/22 and 01/18/22 through 01/21/22. 3. From February 1st through 10th, R #1 was documented as having small/medium bowels every day except on 02/03/22 (no bowels). The approximate size, color, consistency was not documented. G. Record review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #1's grandaughter] who reported [Name of R #1] is in pain from stooling. She had been having loose stools and I ordered metamucil fiber. Now [Name of R #1's grandaughter] reports she is constipated and c/o (complains of) pain to her anus. She has scheduled preparation H (hemmrhoid medication) and I will order lidocain cream (pain medication) for one week to the anus. Also, ordered daily [MEDICATION(S)] . Upon exam, she is tender to palpation of her RLQ (Right lower quadrent), discussed abdominal XR (xray) and she agrees. Reminded her to ask for her hemorrhoidal cream when she needs it. H. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . I. Record review of R #1's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . J. Record review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP ordered the xray as routine, not As soon as possible (ASAP) or STAT (immediately). The abdominal xray was conducted on 02/08/22. K. On 03/01/22 at 2:00 pm, during an interview, CNA #1 (Certified Nurse Assistant), when asked if R #1 displayed signs of constipation she replied, Before [her hospitalization on [DATE]], I would let the nurse know that she was impacted [experiencing a hardened stool stuck in the rectum or lower colon as a result of chronic constipation]. [Name of R #1] would tell me that she was hurting and that she is trying to poop. When asked what response she received after informing the nurse of signs of constipation, she replied, The nurse would say that she was refusing her stool softener. She then explained, [on the day of her disimpaction (the manual removal of a stool at the anal spincter), on 02/10/22] I told [name of NP (Nurse Practitioner)] that she was impacted and that the nurses say that she refuses the stool softeners. [Name of NP] wasn't aware that she [R #1] was refusing [stool softner] and that she was impacted. L. On 03/01/22 at 3:56 pm, during an interview, CNA #2 when asked to recall when she worked with R #1 she replied, I worked with her when she was in the AOU [Admission Observation Unit, from 12/14/21 through 01/18/22, she said she was having a hard time going to the bathroom [having a bowel movement]. When in the AOU, I didn't see if she had something protruding [sticking out], she didn't want me to help. So, I just told the nurse that her stomach was hurting. When asked if this was documented she said, The nurses are really busy with the meds [medications] and they don't document. M. Record review of the NP Progress Notes dated 02/10/22, revealed the following: Issues I am meeting with the granddaughter, following discussions from the RN/UM [Registered Nurse/Unit Manager] and the DON [Director of Nursing] that she wanted to see me urgently. [Name of granddaughter] reports that R #1 is having rectal pain, was found with feces in her room, and that the [MEDICATION(S)] cream (a cream that causes a loss of feeling in the skin and surrounding tissue) is not available. I informed her that I was not aware of the [MEDICATION(S)] cream was not available or that R #1 was in pain. Granddaughter requested a GI (Gastrointestinal) consult. During my last exam on 02/04/22, I ordered an abdominal X-ray for reports of new constipation and tenderness on palpation (with gentle pressure placing a hand or fingers on the surface of the body to identify the size, shape, firmness or location of pain) of abdomen .X-ray has not been uploaded to EHR (electronic health record). The [Name of RN/UM] informs me, he looked up results which show constipation The note continue to describe efforts to manually disimapct R #1. N. On 03/03/22 at 10:24 am, during an interview, the CNP (Certified Nurse Practitioner) stated, I think what led to it [the impaction] was unreported constipation. When I first met R #1, she was reporting loose stools. I asked a CNA to show me her stools and they were loose and dark, apparent of her GI (gastrointestinal) bleed. She stopped complaining of loose stools and constipation. Her abdomen was always flat and non-tender. Her daughter noticed constipation [on 02/04/22]. So, I started her on the Sennosides-Ducosate Sodium tablet [with a start date of 02/04/22]. When asked if she was notified of R #1's constipation that was noted by nursing on 02/01/22, she replied, No . I did not know if she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . O. On 3/03/22 at 12:33 pm, during an interview with the Center Nurse Executive (CNE), she confirmed that the order for an x-ray of her abdomen should have been ordered STAT (immediatly). P. On 03/04/22 at 10:07 am, during an interview, the RN (Registered Nurse)/Unit Manager (UM) #1, when asked what to recognize when a change in bowel movements should be reported, he replied, It would depend on the circumstances, if it's within 72 hours with a hard stool with constipation there is no immediate concern. If outside the 72 hours, then contact with the doctor would be required. With [name of R #1], they [her bowel movements and consistency] weren't being identified or reported. He then stated We didn't have reference orders [standing orders- a set of orders or instructions on how to handle certain circumstances] back then [before the occurrence of the incident on 02/11/22] so the nurses would of needed to have laid eyes on the person, and call the on-call provider to report. When asked what should occur if the resident was refusing medication or treatment, he replied, If she was refusing it, we need to call the provider to seek an alternative. When asked if the nursing staff was notifying the physician of refusals, he replied No, I don't think they were notifying her of the refusals. When asked what type of alternative treatment would of been considered, he replied, [the CNP] was thinking that she had hemorrhoids on 02/10/22. During her [CNP] visit on 02/04/22, this would have been the day when an exam would have been warranted. There was hemorrhoid ointment ordered on 12/31/21, it was effective until 02/11/22, however; it should have been reevaluated. Q. On 03/07/22 at 12:10 pm, during an interview with RN #2, when asked to review the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R. On 03/07/22 at 1:30 pm, during an interview with LPN #3 (Licensed Practical Nurse), when asked to recall the stool in the shower as explained in her nurses notes dated 02/01/22, she explained, Yes, I remember. The granddaughter said that she wouldn't take a [MEDICATION(S)] but she would take it if she thought it was a multivitamin. I told her [R #1] it was a medicine for her stomach. She [granddaughter] told me that the patient will not take meds, she doesn't like to take them at all, especially laxatives. I don't know why. It seems like I didn't have time to follow-up on her bowel movement. I only received a report from the CNA about the stool at orifice (opening). I then received word from the daughter about episodes of constipation due to refusals When asked if she received an order from the physician to administer the [MEDICATION(S)], she replied, It seems like I was going to put the order for the Senna [a [MEDICATION(S)]] in but I didn't get a chance to. With her, this [02/01/22] was the first time I was aware of bowel movement issues. She then confirmed that the physician was not notified of the event. When asked if the physician should of been notified, she replied yes and that she thought that the physician would of wanted her to administer a [MEDICATION(S)].

This is a repeat deficiency from a complaint survey completed on 12/10/21. Based on record review and interviews, the facility failed to ensure that 1 (R #1) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for constipation (when a person passes less than three bowel movements in a week, or has difficult bowel movements) were free from neglect, indicated by the following: 1) There was little to no documentation that nursing was assessing/monitoring the resident's bowels, following the initial administration of an antidepressant ordered for her depression (feelings of sadness). The medication was ordered on 01/10/22, which has a side effect of causing constipation. R #1 was also receiving Metamucil (to add bulk to her stool, because she had been having diarrhea); 2) Notifying the physician between 01/20/22 to 02/04/22, that R #1 was having small to no bowel movements (BM's) for 16 days; 3) Ordering a medication of Preparation H (Brand name of hemmoroidal cream), ordered on 12/31/21, used to decrease swelling and discomfort caused by hemorrhoids [swollen and inflamed veins in the rectum and anus]) a topical ointment when informed that R #1 was constipated and having pain, without a visual assessment of the rectum, to ensure: a) R #1 had hemorrhoids (which can either be both internal or external of the rectum); b) Rule out constipation or a fecal impaction (the act of a hard bowel movement that was stuck- no movement or flow); c) Understanding the reason why she was having pain on defecation (the act of having a BM); and 4. Not getting timely results of abdominal X-ray ordered for R #1 due to abdominal pain (ordered on 02/04/22, and not receiving the results until 02/10/22) which would have identified that R #1 was experiencing constipation/fecal impaction sooner. 5. Not starting an ordered [MEDICATION(S)] for 2 days and not notifying the Physician that R #1 had been refusing as needed laxatives. These deficient practices likely resulted in R #1 being neglected concerning her constipation, which led to a severe fecal impaction (hardened stool that's stuck in the rectum or lower colon) that needed a manual disimpaction (extracting or the act of removing visible hard stool expelling from the anus) likely causing severe pain. The findings are: Cross reference findings from F580: Notify of Changes and F697: Pain Management A. Record review of R #1's Admission Record, indicated that R #1 is an [AGE] year-old female, who was admitted to the facility on [DATE], following an previous admission from a local hospital. R #1 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] condition that is present at birth that is an absence of one or both kidneys), hypertension (having high blood pressure), and hearing loss. B. Record review of R #1's Admission MDS (Minimum Data Set) dated 12/20/21, indicated that R #1 was always continent (had control of) her bowels, under section H. Bowel Continence (the ability to control movements of the bowels). C. Record review of the Nurse Practitioner's (NP) Progress Note dated 01/10/22, revealed that the reported reason for the visit was R #1 was having depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The NP indicated the following: Treatment: Diarrhea (a condition in which feces are discharged from the bowels frequently and in a liquid form) - Continue mineral oil/[MEDICATION(S)]/[MEDICATION(S)] (Brand name of Preparation H, ordered on 12/31/21, used to decrease swelling and discomfort caused by hemorrhoids [swollen and inflamed veins in the rectum and anus]) a topical ointment, 14%-74.9%-0.25%, 1 app (application), rectally, once a day; Continue Metamucil (ordered on 12/22/21, increases the bulk of the stool) powder, ---, 1 pckt (packet) orally, once a day; Notes: Loose stools admission without watery stools resolved. Monitor for recurrence, hematochezia (the passage of fresh blood in the feces), melena (the passage of old dark blood in the feces), Pain with defecation was attributed to hemorrhoids Family requesting palliative approach to care (optimizing quality of life and minimizing suffering among people with serious, complex illnesses) and colonoscopy (a flexible tube inserted through the anus, that can visualize the large bowel and the far end of the small bowel) was declined . D. Record review of R #1's Initial Psychiatric Evaluation conducted on 01/10/22, indicated the following: Pt (Patient) states she is doing well today, states that she wants to go home. She has been independent for most of her life, and is having trouble adjusting to being taken care of. She notes that she has not been eating or sleeping well since arriving. Following the psychiatric evaluation visit, the Psychiatrist ordered [MEDICATION(S)] ([MEDICATION(S)], an antidepressant medication) medication at bedtime for depression (a mood disorder of feeling of sadness or loss of interest). E. Record review of R #1's Nursing Notes dated 01/04/22 through 01/27/22, indicated a lack of documentation in assessing R #1 by the nursing staff, as indicated by the following: 1. On 01/04/22 - A note indicated that a family member would like R #1 to have pastoral care (providing an emotional, social and spiritual support), as the family member stated that R #1 is a very spiritual person. 2. On 01/04/22 - A Braden Scale Assessment (an assessment tool used for predicting pressure sore [areas of damaged skin caused by staying in one position for too long] risks); 3. On 01/13/22 - A skin check assessment was performed; 4. On 01/20/22 - A skin check assessment was performed; and 5. On 01/27/22 - A skin check assessment was performed. There was no further documentation in R #1's chart, to indicate that other nursing assessments were being conducted during the month of January 2022. F. Record review of R #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. The mineral oil/[MEDICATION(S)]/[MEDICATION(S)] (Brand name of Preparation H, ordered on 12/31/21) on 01/04/22, R #1 was sleeping, medication was not administered as ordered; On 01/05/22, 01/10/22 and 01/17/22, it was documented that R #1 refused the medication. 2. Metamucil Fiber Packet (ordered on 12/23/21), indicated that R #1 refused the medication on 01/09/22, 01/13/22, 01/17/22, 01/23/22, 01/24/22 and 01/25/22. G. Record review of R #1's POC (Plan of Care) Response History dated for the month of January 2022, indicated by the facility as the Certified Nursing Assistants (CNA) documentation on the resident's Activities of Daily Living (ADL) during their shift. This included how the resident's shower, using a toilet, using a brief, having a BM (indicating the size of the BM), if the resident was continent or incontinent (the inability to control movements of the bowel). The POC Response History revealed the following: 1. On 01/20/22, CNAs documented that R #1 was continent of having a small BM; 2. On 01/21/22, CNAs documented that R #1 did not have a BM that day; 3. On 01/22/22, there was no documentation to either confirm or deny that R #1 had BM that day; 4. On 01/23/22, CNAs documented that R #1 was continent of having a medium BM; 5. On 01/24/22, CNAs documented that R #1 did not have a BM that day; 6. On 01/25/22, CNAs documented that R #1 did not have a BM that day; 7. On 01/26/22, there was no documentation to either confirm or deny that R #1 had BM that day; 8. On 01/27/22, CNAs documented that R #1 did not have a BM that day; 9. On 01/28/22, CNAs documented that R #1 was incontinent of a medium BM that day; 10. On 01/29/22, CNAs documented that R #1 did not have a BM that day; 11. On 01/30/22, CNAs documented that R #1 was incontinent of a medium BM that day; 12. On 01/31/22, CNAs documented that R #1 was incontinent of a small BM that day; 13. On 02/01/22, CNAs documented that R #1 was incontinent two times that day of having a small BM; 14. On 02/02/22, CNAs documented that R #1 was continent of a small BM at 2:04 am, and incontinent of a small BM at 12:59 pm; 15. On 02/03/22, CNAs documented that R #1 was continent of a medium BM at 8:52 pm. 16. On 02/04/22, CNAs documented that R #1 was incontinent of a small BM at 12:18 pm. The above documentation indicated how R #1's bowel movements were being monitored by the CNAs. There was no indication if the CNAs were communicating to the nurses or to the oncoming shift as to the day of R #1's last bowel movement. H. Record review of the ADL's (Activities of Daily Living) documentation revealed that documentation of bowel movements was not documented for the following days: 1. December of 2021: 12/16/21, 12/19/21, 12/23/21 through 12/27/21 and 12/31/21. 2. January of 2022: 01/01/22 through 01/14/22, 01/16/22 and 01/18/22 through 01/21/22. 3. From February 1st through 10th, R #1 was documented as having small/medium bowels every day except on 02/03/22 (no bowels). The approximate size, color, consistency was not documented. I. Record review of nurse's notes, dated 02/01/22, revealed that R #1 was wanting to leave the facility. R #1's daughter stated that while her mom was being showered, R #1 was noted as having a hard bowel movement coming out of her anus. The nurse documented that R #1 did not want the nursing staff to help her defecate (discharge feces from the body). R #1 stated to the nursing staff that her mom refuses laxatives (medication to help loosen stools). During the day, the nurse was able to convince R #1 to take a Senna Plus [a [MEDICATION(S)] and stool softener used to promote bowel movement]. J. Record review of the NP (Nurse Practitioner) Progress Notes dated 02/04/22, revealed the following: .I am seeing granddaughter [Name of granddaughter] who reports [Name of R #1] is in pain from stooling (the act of having a bowel movement). She had been having loose stools and I ordered Metamucil fiber [ordered on 12/22/21, with a stop date of 02/04/22, a product that increases bulk to the stool, that helps to cause bowel movements). Now [R #1] reports she is constipated and c/o [complains of] pain to her anus. She has scheduled Preparation H [that was ordered 12/31/22] and I will order [MEDICATION(S)] cream (for one week to the anus. Also, ordered daily [MEDICATION(S)]. DDX (differential diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Her weight has increased from 80 to 86 lbs (pounds) .However, it (the [MEDICATION(S)], an antidepressant) may cause constipation, and daily laxatives might help her stay regular. R #1 is seen sitting in bed. She denies abdominal pain, nausea, vomiting. Upon exam, she is tender to palpation of her RLQ (right lower quadrant), discussed abdominal XR (X-ray) and she agrees (the X-ray was not ordered immediately that day, it was ordered routine). Encouraged her to drink an extra glass of water with her laxatives. She has no further health complaints .Examination: .Back bony protuberances (a thing that protrudes [stick out] from something else) along spine .Gastrointestinal Abdomen flat, soft & tender to light palpation RLQ, non-distended, normoactive bowel sounds (the sounds of clicks or gurgles from the stomach) in all 4 quadrants, no masses palpated .calm, cooperative, smiles, euthymic (tranquil mental state or mood), full affect, no evidence of depression or anxiety. Judgement and insight appear intact . K. Record review of R #1's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. There was no documentation indicating if the resident had received, refused or if not available, the sennosides-ducosate sodium tablet [a [MEDICATION(S)] and stool softener used to promote bowel movement], which was ordered on 02/04/22 two times a day. The [MEDICATION(S)]/stool softner was not administered until 02/06/22; 2. R #1 had Acetaminophen (Tylenol, used for mild pain, ordered on 12/31/21, on a scheduled basis as to be administered three times a day (8 am, 12 pm and 8 pm) for pain. On 02/09/22, the pain level (being 0 is no pain and a 10 is having severe pain) for the 8:00 am dose was a 8 level, for the 12 pm dose a 8 level and for the 8 pm dose a 8 level. There was no documentation in the chart to indicate that the nurse had notified the NP of R #1's pain level for that day. L. Record review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP ordered the xray as routine, not As soon as possible (ASAP) or STAT (immediately). The abdominal xray was conducted on 02/08/22. M. Record review of the NP Progress Notes dated 02/10/22, revealed the following: Issues I am meeting with the granddaughter, following discussions from the RN/UM [Registered Nurse/Unit Manager] and the DON [Director of Nursing] that she wanted to see me urgently. [Name of granddaughter] reports that R #1 is having rectal pain, was found with feces in her room, and that the [MEDICATION(S)] cream is not available. I informed her that I was not aware of the [MEDICATION(S)] cream was not available or that R #1 was in pain .Granddaughter requested a GI (Gastrointestinal) consult. During my last exam, I ordered an abdominal X-ray for reports of new constipation and tenderness on palpation of abdomen .X-ray has not been uploaded to EHR (electronic health record). The [Name of RN/UM] informs me, he looked up results which show constipation . [Name of R #1] is seen lying in bed on her right hip grimacing. She is deaf but reads and answers to my voice recognition to text on my cell. Upon exam, her anus is open 6-7 cm (centimeters) in diameter with a visible stool [BM] ball protruding from the anus by 1-2 cm without bleeding, lesion [a region or piece of tissue which has suffered damage through injury or disease], or skin tone changes. [Name of CNA #1] reports that nurse was notified of this yesterday, however, I was not. Asked [Name of R #1] if I could send her to the ER (emergency room ), but she declines stating, No, I'll be Okay. Offered narcotic [used for severe pain] pain reliever and she declines stating, No, I don't want to get addicted. I ask CNA #1 if she could get the RN/UM. The RN/UM stated that he could not enter room because [Name of R #1] declines care from men, he brought the [MEDICATION(S)] gel (a gel that causes a loss of feeling in the skin and surrounding tissues). I offered [Name of R #1] help [the manual disimpaction] and she agreed. I did not feel confident delegating fecal disimpaction to the floor nurse. She does not tolerate pressure on the stool ball and I am unable to break off a piece due to it being-clay-like and hard. It will not be possible to insert the tip of the enema [a disposable squeeze bottle with soft, pre-lubricated tip, to squeeze the solution into the rectum] to help with stool passage either. I rub Vaseline [helps to soften and moisturize the skin] and [MEDICATION(S)] gel around the borders (skin around the anus) she attempts to push it out but is unable to. I let the Vaseline and [MEDICATION(S)] soothe her and look an instrument to help chip away the external stool. I consider a tongue blade but I'm afraid it could splinter and find a more appropriate unused plastic fork on her table that has a small hollow square handle tip and use the end of the handle to lightly chip away at the outside center of the stool ball. She tolerates the chipping and as small clumps fall off tension releases from the borders and the stool ball come out, I show it to [Name of R #1] and she is surprised and reports feeling better. I offer to help disimpact her and she nods yes. Upon rectal digital exam, I feel more stool in rectum. She reaches behind her as if to move my hands away. I encourage her to say the word stop when needs a break and does periodically say stop and I stop. I am able to digitally disimpact with [MEDICATION(S)] and Vaseline. Three smaller ball are removed and shown to her. No bleeding or anal tears are observed and her resting pulse is 74. More stool is felt but not in the immediate rectum and she is able to sit without discomfort. She requests a long break. I notify [Name of physician] who advises me to encourage [Name of R #1] to accept a narcotic pain reliever which she does. Checked on her later and she is eating dinner, still sitting on her bottom, denies pain, and reports feeling much better. Later that evening, I examine her digitally and felt stool that has not yet descended [moved down] near the anus. There is no observed bleeding on her diaper or on my gloved finger . N. On 03/01/22 at 2:00 pm, during an interview, CNA #1 when asked if R #1 displayed any signs of constipation, she replied, Prior to R #1's hospitalization [on 02/11/22], I was letting the nurse know that R #1 was telling me that she was hurting [pointing to her abdomen] and that she is trying to poop. When asked what response did she receive after informing the nurse of R #1's complaints of pain, she replied, The nurse would say that she was refusing her stool softener. She then explained, On 02/10/22, the day of her disimpaction, I told the [name of NP] that she was impacted and that the nurses tell me that R #1 has been refusing the stool softeners. She stated that [Name of NP] acknowledged that she wasn't aware that R #1 had been refusing her stool softeners nor was she aware of the results of the abdominal X-ray, which she had ordered on 02/04/22 (six days ago) and that for 16 days R #1 had either been having a small or no BMs in a couple of days in a row . O. On 03/02/22 at 1:10 pm, during an interview, R #1's granddaughter stated, Around the first [02/01/22], she [R #1] started telling me that she had pain and was uncomfortable. I started talking to the NP on the 4th. I started to tell her that [Name of R #1] extreme pain, major pain. She brought me hemorrhoid cream. She can't sit up cause her anus hurts. I try to get [Name of NP] to address the situation. I think it was just before the first that she was having pain on her bottom. [Name of NP] was saying that she had hemorrhoids. Then she would say they were getting worse. She wouldn't eat, she would just lay there and she was in extreme pain. [Name of NP] never examined her. It was never really hemorrhoids .[Name of NP] never changed her treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] P. On 03/03/22 at 10:24 am, during an interview, the CNP (Certified Nurse Practitioner) stated, I think what led to it [the impaction] was unreported constipation. When I first met R #1, she was reporting loose stools. I asked a CNA to show me her stools and they were loose and dark, apparent of her GI (gastrointestinal) bleed. She stopped complaining of loose stools and constipation. Her abdomen was always flat and non-tender. Her daughter noticed constipation [on 02/04/22]. So, I started her on the Sennosides-Ducosate Sodium tablet [with a start date of 02/04/22]. When asked if she was notified of R #1's constipation that was noted by nursing on 02/01/22, she replied, No . I did not know if she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Q. On 3/03/22 at 12:33 pm, during an interview with the Center Nurse Executive (CNE), she confirmed that the order for an x-ray of her abdomen should have been ordered STAT (immediately). R. On 03/04/22 at 10:07 am, during an interview, RN/UM (Registered Nurse/Unit Manager) #1, when asked what to recognize when a change in bowel movements should be reported, he replied, It would depend on the circumstances, if it's within 72 hours with a hard stool with constipation there is no immediate concern. If outside the 72 hours, then contact with the doctor would be required. With [name of R #1], they [her bowel movements and consistency] weren't being identified or reported. He then stated, We didn't have reference orders or standing orders (are written protocols that authorize nurses to complete certain clinical tasks without having to first obtain a physician order) back then [before the occurrence of the incident on 02/11/22] so the nurses would of needed to have laid eyes on the person, and call the on-call provider to report [the lack of BMs]. During the interview, the RN/UM when asked what should have occurred if the resident was refusing medication or treatments, and what should have the nursing staff been monitoring or assessing for this resident. He replied, If she [R #1] was refusing it [the medications], we need to call the provider to seek an alternative. When asked if the nursing staff was notifying the physician of refusals, he replied No, I don't think they were notifying her of the refusals. When asked what type of alternative treatment would have been considered. He replied, [the NP] was thinking that she [R #1] had hemorrhoids [although R #1 did not have a history of hemorrhoids], she did have a history of pain with defecation, based on a family discussion from 12/31/21, which was the reason for ordering the Preparation H ointment. The RN/UM stated that on 02/04/22, during the NP's visit this would have been the day when an examination or a visual assessment would have been warranted. There was a hemorrhoidal ointment ordered on 12/31/21, with an effective date until 02/11/22, however; it should have been reevaluated. The RN/UM confirmed that there was a lack of documentation/assessments by the nursing staff during the month of January 2022. When asked about the communication between the CNAs and the nursing staff, he replied that during the shift was when there should be communication between the CNAs and the licensed staff. He also stated that there should be communication between shift changes between the CNAs and the licensed staff who are coming onto their shifts. S. On 03/07/22 at 12:10 pm, during an interview with RN #2, when asked to review the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . T. On 03/07/22 at 1:30 pm, during an interview, LPN (Licensed Practical Nurse) #2, when asked to recall the stool in the shower as explained in her nurses notes dated 02/01/22, she stated, Yes, I remember. The granddaughter said that she wouldn't take a [MEDICATION(S)] (products that promote bowel movements), but she would take it if she thought it was a multivitamin. I told her [R #1] it was a medicine for her stomach. She [granddaughter] told me that the patient will not take meds, she doesn't like to take them at all, especially laxatives. I don't know why. It seems like I didn't have time to follow-up on her bowel movement. I only received a report from the CNA about the stool at the orifice (an opening e.g. mouth, rectum). I then received word from the daughter about episodes of constipation due to refusals. When asked if she received an order from the physician to administer the [MEDICATION(S)], she replied, It seems like I was going to put the order in for the Senna but I didn't get a chance to. With her, this was the first time I was aware of bowel movement issues. When asked if the physician should have been notified, she replied, Yes. She thought that the physician would of wanted her to administer a [MEDICATION(S)].

Based on record review and interview, the facility failed to provide effective pain management for 1 (R #1) of 1 (R #1, R #2, R #3, and R #4) residents reviewed for pain when they failed to: 1. Follow up on the results of the Xray ordered for R #1 on 02/04/22 for 6 days when there was noted abdominal pain, delaying identification of constipation/fecal impaction. 2. Notify the Physician when R #1 was experiencing severe pain on 02/09/22 and pain medication administered was ineffective. 3. Examine R #1 for the presence of hemorrhoids (swollen or inflamed veins in the rectum and anus that cause discomfort and bleeding) prior to prescribing hemorrhoid cream to treat anus pain. This deficient practice likely resulted in a delay in identifying R #1's fecal impaction, causing severe rectal pain and stress. The findings are: A. Record review of the facility's policy titled Pain Management, revision date 06/01/21, indicated the following: .Purpose: To maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain .The nurse will notify the physician/advanced practice provider (APP) as appropriate and obtain treatment orders as indicated .Center staff will report any observation or communication of pain to the nurse responsible for that patient. If a patient has a change in pain status, complete a pain evaluation .Patients receiving interventions for pain will be monitored for the effectiveness and side effects (e.g. constipation, sedation) in providing pain relief. Document: Non-pharmacological interventions and effectiveness; Effectiveness of PRN (as needed) medications; Ineffectiveness of routine or PRN medications including interventions, follow-up, and physician/APP notification; and Side effects, if present, and indication of physician/APP . B. Record review of R #1's face sheet, indicated that R #1 is an [AGE] year-old female, who was admitted to the facility on [DATE], following an admission from a local hospital. R #1 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] of anticoagulants (the use of medications to thin the blood), and hearing loss. C. Record review of the Nursing Progress notes dated 02/04/22 revealed, Daughter and I spoke and [Name of R #1] stated she was having too much pain and did not want to shower today. No additional notes included pain relief interventions. D. Record review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #1's granddaughter] who reported [Name of R #1] is in pain from stooling. She had been having loose stools and I ordered metamucil fiber. Now [Name of R #1's granddaughter] reports she is constipated and c/o (complains of) pain to her anus. She has scheduled preparation H and I will order [MEDICATION(S)] cream for one week to the anus. Also, ordered daily [MEDICATION(S)] . Upon exam, she is tender to palpation of her RLQ (Right lower quadrant), discussed abdominal XR (xray) and she agrees. E. Record review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP ordered the xray as routine, not As soon as possible (ASAP) or STAT (immediately). The abdominal xray was conducted on 02/08/22. F. On 03/03/22 at 10:24 am, during an interview, the CNP (Certified Nurse Practitioner) stated, I think what led to it [the impaction] was unreported constipation. When I first met R #1, she was reporting loose stools. I asked a CNA to show me her stools and they were loose and dark, apparent of her GI (gastrointestinal) bleed. She stopped complaining of loose stools and constipation. Her abdomen was always flat and non-tender. Her daughter noticed constipation [on 02/04/22]. So, I started her on the Sennosides-Ducosate Sodium tablet [with a start date of 02/04/22]. When asked if she was notified of R #1's constipation that was noted by nursing on 02/01/22, she replied, No . I did not know if she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . G. Record review of R #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. [MEDICATION(S)] Cream 4% started 02/04/22 at 12:00 pm apply to anus topically three times a day for pain with defecation for 7 days. 3. On 02/09/22, R #1 indicated to the nurse administering the scheduled dose of medication, that her pain level (on a scale of 0 to 10, and 10 being the most severe pain) as an 8 out of 10 that day during the 8:00 am, 12:00 pm and 8:00 pm doses. There was no indication by the nurse, that indicated where R #1's pain was located (either or back or somewhere else). 4. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . H. On 03/01/22 at 2:00 pm, during an interview, CNA #1 when asked if R #1 displayed any signs of constipation, she replied, Prior to [Name of R #1's] hospitalization [on 02/11/22], I was letting the nurse know that [Name of R #1] was telling me that she was hurting [pointing to her abdomen] and that she is trying to poop. When asked what response did she receive after informing the nurse of R #1's complaints of pain, she replied, The nurse would say that she was refusing her stool softener. She then explained, On 02/10/22, the day of her disimpaction, I told the [name of NP] that she was impacted and that the nurses tell me that [Name of R #1] has been refusing the stool softeners. She stated that NP acknowledged that she wasn't aware that R #1 had been refusing her stool softeners nor was she aware of the results of the abdominal X-ray, which she had ordered on 02/04/22 (six days ago) and that for 16 days R #1 had either been having a small or no BMs in a couple of days in a row. I. On 03/07/22 at 12:45 pm, during an interview, Registered Nurse (RN) #1 stated that on the day shift (7:00 am to 7:30 pm) on 02/09/22, it was her first day on the floor taking care of R #1. She stated that she did not remember the mood or behaviors that R #1 may have been experiencing that day. RN #1 stated that if she was more aware of what R #1 was experiencing with rectal pain, she would have contacted the physician to obtain a stronger pain medication for her. She was only aware that R #1 had the scheduled Acetaminophen order, and had no other stronger pain medications that were ordered by the physician. When asked if any other staff member had come up to her to say that R #1 was in pain that day. She stated that she did not remember that. J. Record review of R #1's medical record did not identify that the NP or the Medical Director was not contacted regarding R #1's pain on 02/09/22. K. Record review of the NP (Nurse Practitioner) Progress Notes dated 02/10/22, revealed the following: Issues I am meeting with the granddaughter, following discussions from the RN/UM [Registered Nurse/Unit Manager] and the DON [Director of Nursing] that she wanted to see me urgently. [Name of granddaughter] reports that R #1 is having rectal pain, was found with feces in her room, and that the [MEDICATION(S)] cream (a cream that causes a loss of feeling in the skin and surrounding tissue) is not available. I informed her that I was not aware of the [MEDICATION(S)] cream was not available or that R #1 was in pain. Granddaughter requested a GI (Gastrointestinal) consult. During my last exam on 02/04/22, I ordered an abdominal X-ray for reports of new constipation and tenderness on palpation (with gentle pressure placing a hand or fingers on the surface of the body to identify the size, shape, firmness or location of pain) of abdomen .X-ray has not been uploaded to EHR (electronic health record). The [Name of RN/UM] informs me, he looked up results which show constipation. [Name of R #1] is seen lying in bed on her right hip grimacing. She is deaf but reads and answers to my voice recognition to text on my cell. Upon exam, her anus is open 6-7 cm (centimeters) in diameter with a visible stool [BM] ball protruding from the anus by 1-2 cm without bleeding, lesion [a region or piece of tissue which has suffered damage through injury or disease], or skin tone changes. [Name of CNA (Certified Nursing Assistant) #1] reports that the nurse was notified of this yesterday [02/09/22], however, I was not. Asked [Name of R #1] if I could send her to the ER (emergency room ), but she declines stating, No, I'll be Okay. Offered narcotic [pain medication used for severe pain] pain reliever and she declines stating, No, I don't want to get addicted. I ask CNA #1 if she could get the RN/UM. The RN/UM stated that he could not enter the room because [Name of R #1] declines care from men, he brought the [MEDICATION(S)] gel (a gel that causes a loss of feeling in the skin and surrounding tissues). I offered [Name of R #1] help [the manual disimpaction (the removal of stool from the rectum using a gloved finger)] and she agreed .[Name of R #1] is seen lying in bed on her right hip grimacing. She is deaf but reads and answers to my voice recognition to text on my cell. Upon exam, her anus is open 6-7 cm (centimeters) in diameter with a visible stool [BM] ball protruding from the anus by 1-2 cm without bleeding, lesion [a region or piece of tissue which has suffered damage through injury or disease], or skin tone changes. [Name of CNA #1] reports that nurse was notified of this yesterday, however, I was not. The note continues to describe that the NP manually disimpacts R #1. L. On 03/02/22 at 1:10 pm, during an interview, R #1's granddaughter stated, Around the first [02/01/22], she [R #1] started telling me that she had pain and was uncomfortable. I started talking to the NP on the 4th. I started to tell her that [Name of R #1] extreme pain, major pain. She brought me hemorrhoid cream. She can't sit up cause her anus hurts. I try to get [Name of NP] to address the situation. I think it was just before the first that she was having pain on her bottom. [Name of NP] was saying that she had hemorrhoids. Then she would say they were getting worse. She wouldn't eat, she would just lay there and she was in extreme pain. [Name of NP] never examined her. It was never really hemorrhoids .[Name of NP] never changed her treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . M. On 03/04/22 at 1:35 pm, during an interview, the Emergency Medical Technicians (EMT) stated that on the evening of 02/11/22, when R #1 was being transferred to the local hospital, she was awake, alert and oriented to name and surroundings. She stated that enroute to the hospital that R #1 complained of rectal pain, that her rectum was hurting and bleeding. The EMT stated that R #1 was very distressed and distraught. The EMT stated that R #1 kept on saying Please don't hurt me. The EMT stated that the granddaughter had met the EMT's at the facility's door, and that R #1 had been sitting in a wheelchair. The Nurse Supervisor in charge provided very little information as to the situation regarding R #1. The EMT stated that the other EMT that she was with, lifted R #1 from the wheelchair to the gurney, stating that R #1 was very weak. The EMT stated that R #1 seemed terrified. The EMT stated, that R #1 kept saying Thank you. N. Record review of R #1's Progress Notes dated 02/12/22 at 10:13 am revelaed I went to check on pt (patient) in the ER at [name of local hospital]. G-daughter [Name of R #1's granddaughter] stated pt is very constipated. She said they did a CT scan and it show constipation. G-daughter [name of R #1's granddaughter] stated that in ER not find any damage from the nurse practitioner from disimpaction just constipation .

Based on interview and record review the facility failed to recognize and respond timely to a change in condition involving muscle weakness, numbness and slurred speech for 1 (R #7) of 3 (R #2, 5 and 7) residents reviewed for delay in treatment. This deficient practice likely resulted in R #7 to have newly developed persistent left sided arm and leg weakness that resulted in her inabliity to stand and walk as she had previously done. The findings are: A. Record review of admission record revealed R #7 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of the care plan for R #7 revealed that on 07/07/21 (R #7) required, limited assist of 1 [person] for transfers [moving from bed to chair and vice versa] [and] using a rolling walker [walking device used to help support a person while walking]. C. Record review of nursing progress notes dated 08/29/21 at 8:48 am revealed, late entry from 8/27/2021 Ms. [last name of R #7]was not able to work with therapy do to weakness on lower extremities [part of the body from the hips to the toes], this was report by therapy staff before lunch around 11:30 am. Daughters was here and report that Ms. [last name of R #7] was having weakness and numbness on left upper extremities [body parts including shoulder, arm, forearm, wrist, and hand] and lower extremities [leg, foot]. This was reported around 3:40 pm. Physician was at the facility at this time and was informed of Ms. [last name of R #7] complain of L [left] side weakness and numbness, Physician assess her and inform daughter about the citation [situation] and recommend daughter to have Ms. [last name of R #7] [be] check [ed] out at the hospital to rule out any cardiac [heart] issues, daughter agree and transportation was arrange immediately. Patient was send to [name of local hospital] with all necessary paper work. She was transfer on stretcher via ambulance around 5:15 pm. D. On 12/07/21 at 8:15 am during telephone interview with Licensed Practical Nurse #3 she revealed, that on 08/27/21 regarding R #7, She did have a complaint I do remember, therapy said she was weak. I check vitals and they were normal and I did tell my supervisor. I asked [R #7] Do you have pain? [and R #7 revealed] No, I feel weak I wasn't too concerned. [later in the day, she believes about 4:00 pm], R #7's daughter came to visit and said R #7 had weakness and numbness. I called the doctor and the doctor said to transport her [to the hospital]. E. On 12/07/21 at 11:10 am during interview with the R #7's daughter she revealed, the first time she visited her mother on 08/27/21 was in the morning about 10:30 am and her mom had been seen by the nurse because she had not felt good enough to go for a walk and she [the daughter] was told she was okay by the nurse. The next time she saw her mom was in the late afternoon of 08/27/21 at about 4:00 pm and her mom had slurred speech [mumbling, unable to speak clearly] and left sided weakness and that she was the person who alerted the staff to this change. She revealed, The hospital said she had a stroke. Since then she has more difficulty with the left side of her body. F. On 12/08/21 at approximately 1:15 pm, during interview with the Nurse Practitioner (NP) #1 she revealed, I remember the event [that occurred on 08/27/21 with R #7] because I was just leaving [when she was called to see R #7] it must have been around 4:00 pm because that is when I usually leave [the facility for the day] and I went to take a look at her, [R #7]. That was the first I was notified that, I can recall. I can't remember what I was told but remember going [to assess R #7] because it might be something neurological [having to do with the brain and or spine]. My notes say it was because of diminished sensation [decreased or lost ability to feel something over part of the body] to light and sharp touch. I guess, I would say I should have been notified of unusual weakness. Just the pain or just tingling in her shoulder would not have alerted me [that there was possibly a new neurological problem] because it is often from a pinched nerve or using their arms to push up in the wheelchair. G. On 12/08/21 at 2:34 pm, during a telephone interview with Restorative Aide (RA #1) she revealed, regarding R #7 on 08/27/21 [she remembers it being approximately 9:30 am], I was the one [therapy person] who went and told the nurse [that R #7], was feeling too weak to walk and was dizzy] [LPN #3], that morning. I had worked with her for awhile [in the past], we had her on restorative [therapy designed to regain or maintain a function or skill] before, for ambulation [walking] and for eating. That day she told me she was dizzy and a little weak, it was unusual for her. H. Record review of emergency room provider note for R #7 dated 08/27/21 at 6:09 pm revealed exam [of R #7] had improved momentarily but reverted back to left UE [upper extremity/arm] and lower extremity [leg] to be weak. I. Record review of, ADL [Activities of Daily Living, such as bathing turing in bed, walking] Record for August of 2021 prior to R #7's hospitalization , she was documented as walking in her room and as able to do this with supervision [watching but not physically assisting] of one person. When she returned from the hospital, her October 2021 the ADL record documented, that the activity did not occur [she was no longer able to perform this activity].

Based on record review and interview, the facility failed to ensure that residents received care needed to identify and treat Pressure Ulcers (PUs) [bed sore, skin, and underlying tissue such as fat, muscle and bone, damage due to excess pressure, friction, or shear to the area] for 2 (R #21 and 22) of 2 (R #21 and 22) residents reviewed for facility acquired pressure ulcers, due to not ensuring systems were implemented to prevent the development of facility acquired PU, quickly recognize the development of a pressure related injury, assess it accurately and obtain treatment care orders from the appropriate providers. This deficient practice likely resulted in R #21 and R #22 developing unstageable pressure wounds (full thickness skin [all layers of skin is gone and the damage extends into fat tissue and often into muscle and bone below the fat layer]) and may have contributed to their deaths. The findings are: Findings for R #21: A. Record review of the Admission Record revealed, she was admitted on [DATE], with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of the Nursing Documentation revealed: 1. On [DATE] at 3:50 pm, movement in bed, Very limited- unable to make significant changes in position independently, and for activity, cannot bear own weight, must be assisted into chair. 2. On [DATE] at 10:40 am, incontinent [unable to voluntarily control] of b/b [bowel and bladder], needs total care [another person must help with all] for all ADLs [activities of daily living such as, bathing brushing hair] and bed mobility, C. Record review of care plan revealed: 1. On [DATE], Skin tear present on admission on sacrum [a large triangular shaped bone at the base of the spine/just above the tail bone] . D. Record review of the following nursing skin checks revealed: 1. On [DATE] at 3:48 pm, The following New skin injury/wound(s) were identified: Bruise(s) (blood or bleeding under the skin): Description: bruising to bilateral [both] arms. There was no documentation of the skin tear that was present on the sacrum area. 2. On [DATE] at 8:00 pm, The following skin injury/wound(s) were previously identified and were evaluated as follows: Bruise(s): Description: Lt [light] bruises bilateral arms. There was no documentation of the skin tear that was present on the sacrum. 3. On [DATE] at 8:00 pm, No skin injury/wound were noted. There was no documentation of the skin tear that was present on the sacrum. 4. On [DATE] at 3:20 am, No skin injury/wound(s) were noted. There was no documentation of the skin tear that was present on the sacrum. E. Record review of Change in Condition Evaluation, dated [DATE] at 10:57 am, revealed, open area to sacrum. F. Record review of the Braden Assessments [a scale used to estimate the risk of an individual for pressure ulcer development with ratings from less than or equal to 9 to as high as 23]. The lower the number, the higher the risk for developing an acquired ulcer/injury. Six risk factors for PU development are rated from 1 - 4: 1. Sensory Perception, The ability to respond meaningfully to pressure related discomfort. 2. Moisture, the degree to which the skin is exposed to moisture. 3. Activity, the degree of physical activity. 4. Mobility, the ability to change and control body position. 5. Nutrition, usual food intake pattern. 6. Friction and Shear, the extent to which the body is subjected to these forces. [,d+[DATE] = no risk. ,d+[DATE] = mild risk. ,d+[DATE] = moderate risk, ,d+[DATE] is high risk and below 9 is very high risk], dated [DATE], [DATE] and [DATE] revealed a score of 13 (moderate risk) on all three assessments. G. Record review of care plan revealed: 1. On [DATE], MASD [Moisture Associated Skin Damage, skin damage caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or [MEDICATION(S)]], next to skin tear on sacrum. H. Record review of Skin and Wound Evaluation dated [DATE] at 2:49 pm revealed, a sacral wound measuring 6.2 by 4 cm (centimeters) without any depth [unstageable pressure wound: slough (yellow, tan, green, brown in color that may be moist, loose and stringy) and/or eschar (dry, thick leathery tissue), deep tissue injury] and identified as MASD. I. On [DATE] at 10:40 am, during an interview, UM (Unit Manager) #2 (who was responsible for the initial and ongoing wound assessments in the facility), when asked regarding the photo of the wound assessment, he had completed on [DATE], he confirmed it was a photograph taken during the evaluation which was completed after the change of condition report, documented on [DATE]. UM #2 stated that he now sees it was necrotic tissue [death or cells or tissue, either as eschar or slough] not MASD, as it indicates. He revealed that he has overseen the wound assessments since [DATE]. He does wound assessments weekly on every PU. He is notified of new skin injury or wounds, by the nurses and sometimes the Certified Nursing Assistants (CNAs). As soon as he was aware of a PU, he would begin at least weekly wound assessments, however the floor nurses as responsible for providing wound care. He explained, that when a new skin injury was identified, the process includes the nurse completing an e-interact Change in Condition Evaluation, notifying the residents' medical provider and the residents family or other contact. If that [e-interact Change in Condition Evaluation] does not occur, then the resident, medical provider, and family may not know of the new injury or wound. UM #2 confirmed the facility now has a designated Wound Care Nurse. J. Record review of the provider orders revealed the following: 1. [DATE]; orders for a specialty mattress to reduce pressure and a wound dressing to apply to the sacral wound, Cleanse wound with wound cleaner, apply skin prep [protects skin from tape stripping and moisture] to periwound [skin around the wound] skin, apply [MEDICATION(S)] [absorbant dressing] AG [silver] to wound bed and cover with foam dressing. 2. [DATE]; order amended to Wound Care: Sacrum: Cleanse wound with wound cleaner, apply skin prep to periwound skin, apply [MEDICATION(S)] AG to wound bed and cover with foam dressing. every day shift for Moisture associated injury to sacrum. 3. No other wound care orders were in the record prior to [DATE]. K. On [DATE] at 11:55 am, during an interview, CNA #1, who worked with the resident at the facility, stated that when R #21 needed to be turned, the nursing staff would try to turn her, R #21 would get mad at the staff. CNA #1 stated, We always told her she needed to be turned. I don't remember that wound. L. On [DATE] at 12:20 pm, during an interview, the Licensed Practical Nurse (LPN) #1 who worked with R #21 and would have been responsible for providing wound care stated after reviewing R #21's medical record stated, I don't remember [name of R #21]. I don't see any orders until the 4th in the month of May [2021] for wound treatments. I see she had a skin tear there [her sacrum] on [DATE]. The only order that I see is to turn her side to side. Heel suspension device [to reduce pressure to heels by elevating them off bed] and brand name of ProMattress [specialty mattress to reduce pressure and friction to a persons' skin] were ordered on the 4th [of May]. M. On [DATE] at 10:35 am, during an interview, the Shower Aide (SA) stated that recalled the resident and that she had told the nurse that the resident had a wound to her sacral area, she did not recall the date when this incident occurred. She has no documentation to support her account and cannot remember the name of the nurse she spoke with about the wound. She revealed she usually writes it down on her shower sheet when she sees any wound, but she cannot find the shower sheet for R #21. N. On [DATE] at 11:10 am, during an interview, the Human Resources/Medical Records Manager (HR/MR) stated that when an SA or CNA finds a new wound they would fill out a paper form and give it to the nurse, they don't keep those forms so they are never scanned into the record. During the month of May of this year (2021), the nursing staff, including licensed nurses and CNAs, were mostly agency staff [employees of another company that can be hired for temporary or long term work]. The HR/MR stated, The facility tried to get the agency nurses to chart [document] but for some reason, they just didn't. There was no charting on R #21 by the CNAs for May of 2021. O. On [DATE] at 11:58 am, during an interview, R #21's daughter, revealed, I picked her (the resident) up on Saturday [[DATE]], they (the resident and facility staff) were waiting outside when I got there, they (the facility staff) just put her (the resident) in the car and that was it. She revealed being aware that her mother had a wound, does not remember what date the facility told her about it, but that the wound was much worse than she thought. She reported, It (the wound) was the size of your hand with a big hole in the middle of it and it smelled bad. She (the resident) wasn't the way she used to be, she was in a lot of pain, she was drinking one glass after the other of water. How can those workers (the facility staff) do that to her (the resident)? I knew she (the resident) wasn't herself. I took her (the resident) to the hospital the next day. P. Record review of documentation from the residents' admission to acute care hospital after discharge from facility revealed: 1. On [DATE] at 10:45 pm, Emergency Department (ED) admission revealed, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was admitted from the ED into the Intensive Care Unit. 2. On [DATE] at 3:23 am, provider admission History and Physical revealed Septic shock likely due to the sacral decubitus wound [PU]. 3. On [DATE] at 4:45 pm, provider progress note revealed, [AGE] year-old woman presenting with .severe decubitus ulcer [PU], septic shock .Discussed with daughters, who have agreed that patient had suffered enough and would like to allow her to pass comfortably. 4. On [DATE] at 6:14 pm, discharge documentation revealed, Resident was declared deceased on [DATE] at 6:11 pm. Findings for R #22: Q. Record review of Admission Record revealed she was initially admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R. Record review of progress note by PACE [a healthcare and social engagement program for older adults that case manages all health care for the individual] provider dated [DATE] revealed a telehealth visit [a health care encounter, primarily online with Internet access on your computer, tablet, or smart phone using video and audio] was completed with the resident by the provider with the resident's PACE case manager and caregiver also participating remotely. Nurse Practitioner (NP) #2 revealed, [PACE- NPs note from the telehealth visit] When she arrived there in July [2020], she had wounds at her coccyx and her left heel; these have healed a long time ago and no new wounds. S. Record review of Skin and Wound Care nursing documentation dated [DATE] at 8:00 am revealed, a skin check was performed. No skin injury/wound(s) were noted. T. Review of Skin and Wound assessment dated [DATE] at 8:41 am revealed a sacral wound, Deep Tissue Injury (DTI): Persistent non-blanchable [when pressure applied, does not return to former color when pressure deep red, maroon or purple discoloration .4.3 by 2.4 centimeters (CM) without depth and 100 % eschar [hard dead tissue] .Patient has DTI with no opening in skin; wound cleansed with wound cleaner; skin prep to periwound [around the wound] skin; barrier cream to area of DTI, covered with optigentle foam dressing [a soft absorbent cover dressing]. Provider Notified. The following order was found, Wound Care:Coccyx - Cleanse DTI with wound cleaner, apply triad paste [a [MEDICATION(S)] based wound care product], skin prep to periwound skin, apply sacral optigentle foam dressing. every day shift for DTI to sacrum. U. Review of Skin and Wound assessment dated [DATE] at 8:41 am revealed a sacral wound, Deep Tissue Injury (DTI): Persistent non-blanchable deep red, maroon or purple discoloration .4.3 by 2.4 centimeters (cm) without depth and 100 % eschar [hard dead tissue] .Patient has DTI with no opening in skin; wound cleansed with wound cleaner; skin prep to periwound [around the wound] skin; barrier cream to area of DTI, covered with optigentle foam dressing [a soft absorbent cover dressing]. Provider Notified. V. Review of Skin and Wound assessment dated [DATE] at 4:21 pm revealed, sacral wound 3.8 by 3.1 cm without depth, 100 eschar .Wound cleansed with wound cleaner. [MEDICATION(S)] AG [a silver containing absorptive dressing] applied to wound; skin prep [a protective barrier product] to periwound skin and foam dressing to cover. Provider Notified. W. Record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [DATE]; Wound Prevention: Please turn resident q,d+[DATE] [every 2 to 3 hours]. 2. [DATE]; Wound Care: Coccyx - Cleanse DTI with wound cleaner, apply [MEDICATION(S)] AG to wound bed, skin prep to periwound skin, apply sacral optigentle foam dressing. every day shift for Stage III [a full thickness wound that extends into the fatty tissue underlying the skin layers] to sacrum 3. [DATE]; Wound Prevention Turn patient q,d+[DATE] hours every shift for Patient unable to turn self in bed, has PU. X. Record review of Order Recap [recapitulation, restating something] for dates [DATE] to [DATE] revealed, 1. On [DATE] the first topical care [procedures/products to use on the outside of the wound] order for the sacral ulcer, this was ordered by the Nurse Practitioner (NP #1) who sees wound care residents for the facility. 2. On [DATE] an updated topical care order for the sacral ulcer by NP #1. Wound Care: Coccyx - Cleanse DTI with wound cleaner, apply [MEDICATION(S)] AG to wound bed, skin prep to periwound skin, apply sacral optigentle foam [an absorptive wound dressing made to avoid damage to delicate skin around the wound] dressing every day shift for Stage III [a full thickness wound that extends into the fatty tissue underlying the skin layers] to sacrum 3. On [DATE] Promatt (foam & static air) Mattress.[a brand of mattress to decrease pressure on the body]. Y. On [DATE] at 12:20 pm during interview with Licensed Practical Nurse (LPN #1) he revealed, I don't remember the sacral wound [for R #22] [I see] the order for coccyx [tailbone] or sacral [wound] was [DATE]rd [2021]. Z. On [DATE] at 10:20 am during an interview with UM #2, he confirmed that first he knew of the resident's sacral wound was when he did her wound assessment on it on [DATE]. UM #2 confirmed he was not notified of any wound for R #22 prior to [DATE]. AA. On [DATE] at 3:05 pm, during an interview with CNA #2 she revealed, before the resident went to the hospital she had a wound on her butt just by the crack [gluteal fold] for a couple of months. It was really small [she used her fingers to show a circle about the size of a 50 cent piece] and we were putting that cream on it [20 % [MEDICATION(S)] oxide] and a patch the peach one [a foam cover dressing for wounds]. She was incontinent [unintentional loss of urine or stool], and we had to put something on it so it didn't get BM [bowel movement, stool] on it and all wet. We would tell the nurse [whatever nurse was working with them that day] but she didn't come. [first name of another CNA #3] and I found it [the sacral wound] and we told our nurse. She was an agency nurse. She is gone now. We work three, 12 hour shifts, are off for four days and then they [other CNAs] don't get them [residents] up or change them. I told the nurse [the agency nurse who was working with her that day]. BB. On [DATE] at 3:30 pm during an interview with CNA #3 she revealed, that R #22 was pleasant and was total assist [needed assistance with all activities of daily living such as moving in bed, personal hygiene]. She understood and spoke back to you. The resident wore a diaper [brief] and she fed herself, but then she started to need help and towards the end of her stay at the facility, she stopped eating. She rang her light when she wanted to be turned or wanted her TV on or off. She always wanted to be in bed. She was always saying 'lay me down, lay me down.' I'm not sure when she got it [the sacral wound]. When the resident left the facility, the wound was about like this [she indicates with two hands a wound about 5 X 6 inches] and the nurses were healing it with their treatment. The wound was there a couple of weeks. CC. Record review of census revealed R #22 was hospitalized from [DATE] until [DATE]. DD. Record review of hospital provider note dated [DATE] at 9:40 pm revealed, [AGE] year-old female with developmental delay and superimposed [over laid or on top of] dementia [symptoms that affect memory, thinking and interferes with daily life], along with multiple other co morbidities [medical conditions] who resides in a long-term care facility [nursing home]. She was admitted with altered mental status decreased P.O. [oral] intake and failure to thrive. Evaluation revealed multiple SIRS [Systemic [CONDITION(S)] response syndrome, is an exaggerated defense response of the body to a stressor] criteria which after infectious workup . seems to be related to infected decubitus (PU) sacral ulceration. EE. On [DATE] at 11:10 am, during an interview, the Human Resources/Medical Records Manager (HR/MR) stated that when an SA or CNA finds a new wound they would fill out a paper form and give it to the nurse, they don't keep those forms so they are never scanned into the record. During the month of May of this year (2021), the nursing staff, including licensed nurses and CNAs, were mostly agency staff [employees of another company that can be hired for temporary or long term work]. The HR/MR stated, The facility tried to get the agency nurses to chart [document] but for some reason, they just didn't. FF. On [DATE] at 12:05 pm during an interview with Nurse Practitioner (NP) #2 who works for the PACE program, We were notified of the sacral wound on [DATE]th [2021] just before 4:00 pm. NP #2 confirmed that PACE staff were not providing care for or assessing the wound prior to becoming aware of the wound on [DATE]. GG. Record review of nursing progress notes dated [DATE] at 5:00 am revealed, Called in to the Resd [resident] room to change dressing however on entering the room the Resd appears more pale than usual called her name with no response, shook the patient with no response the Code status checked, . Resd was pronounced dead at 0500 [5:00 am] hrs [hours].

Based on record review and interview, the facility failed to provide care and services to prevent the development of an avoidable pressure injury, for 1 (R #1) of 4 (R #s 1, 2, 3 and 4) residents that were reviewed for pressure ulcers. This deficient practice caused harm to R #1 by creating a Deep Tissue Injury (DTI) due to facility staff not monitoring the residents air mattress. The findings are: A. Record review of R #1's medical record revealed of the following Diagnoses: [REDACTED]. The resident is non-verbal and responds only to painful stimuli (a thing or event that evokes a specific functional reaction in an organ or tissue) and severe contractures (deformity restricts normal movement. It develops when your usually flexible connective tissues become less flexible) to arms, head, and neck. B. Record review of R #1's skin integrity report dated 04/05/19 revealed the resident's pressure wound of the coccyx was resolved. C. Record review of R #1's skin integrity report (undated) revealed an in house acquired pressure wound of the coccyx reopened on 05/16/19. The measurements were the following: Length 2.5 cm (centimeters), Width 1.0 cm, and the Depth was 0.1 cm. D. Record review of R #1's skin integrity report dated 06/04/19 revealed the resident had a new in house acquired pressure wound/deep tissue injury (DTI) of the coccyx and had the following measurements: Length 7.0 cm, Width 16.0 cm, and no depth recorded. E. Record review of R #1's skin integrity report dated 06/07/19, revealed the resident's in house acquired pressure wound of the coccyx (06/04/19) was now a part of the re-opened (05/16/19) coccyx wound that was in house acquired. F. Record review of R #1's skin integrity report dated 6/20/19 revealed the resident's in house acquired pressure wounds were combined. The first measurement of the combined wounds were as follows: Length 7.2cm, Width 4.5cm, and no depth measurement was recorded. G. Record review of R #1's change in condition progress note dated 06/04/19 indicated that the resident had a change in condition, skin discoloration on the coccyx (tail bone) secondary to pressure from inoperable air mattress. The resident was additionally noted with new black DTI (deep tissue injury is a pressure-related injury to subcutaneous tissues under intact skin) extending over left and right upper buttock areas. No open areas yet but the left buttock has a blister, mushy area adjacent to sacrum. The area of involvement is 7 cm X 16 cm, with a red and slowly blanchable area at the left edge. The resident is responsive to pain and sometimes touch, this is baseline for her. H. Record review of R #1's pressure ulcer investigation summary started on 06/04/19 at 2:00 pm, revealed a note stating, aware of conditions but did not monitor equipment in use successfully. I. Record review of R #1's progress note dated 06/07/19 indicated the following, Sacrum: clean coccyx area and apply powder collagen. Cover entire coccyx/sacral area w (with) large Opti gentle (a foam wound dressing that is made with a silicone adhesive border) dressing. Change q (every) day and PRN (as needed) if soiled or off every shift. Sacrum and coccyx wound are now one wound. Area appears sloughy and the dark area of SDTI (Suspected Deep Tissue Injury) will likely open further. J. On 08/19/19 at 3:42 pm, during an interview, LPN (Licensed Practical Nurse) #1 stated R #1's wound was a deep tissue injury on 06/03/19. She stated it was discovered when she turned her (R #1) on 06/03/19 and a blackened area had spread over her buttock area. The LPN stated she discovered this doing wound care on her other re-opened pressure wound. The LPN stated the bed malfunction from the afternoon of Sunday (06/02/19 until Monday morning (06/03/19) contributed to the DTI. She stated the Promat mattress should have been checked to make sure it was plugged in and turned on. She also stated it was off for about a day. The LPN stated the Certified Nursing Assistants (CNAs) and nurses are supposed to be making sure the machine is functioning and working. The LPN stated the mattress moving up and down possibly bumped the cord off the wall. K. On 08/20/19 at 11:03 am, during an interview, LPN #2 stated when he came in on 06/03/19 in the morning, it was discovered that the bed had malfunctioned for R #1. He stated the bed the resident had was deflated and was not working the way it usually does. LPN #2 stated the reason the bed malfunctioned is that it was unplugged. The LPN stated prior to this incident, there were no orders to check the mattress to make sure it was on, but that checking to make sure the air mattress is working is something that he indirectly listens for. LPN #2 stated that the bed made a humming noise that he would listen for.

The facility failed to ensure that residents received adequate supervision to prevent elopements. Resident #83, who was an elopement risk, was found to have wandered out of the facility on 06/08/17, a day when the outside temperature was above 90 degrees, and into a neighboring apartment complex where she was found by a bystander near a pool, covered in her own vomit, with blood shot eyes and breathing heavily. Another resident (Resident #86) was found to have wandered into the facility parking lot a few hours after R #83 had eloped on the same day and the wander guard on her wheelchair had not triggered the alarm. During the survey, Resident #99 was observed eloping. R #99 self-propelled her wheelchair in the facility parking lot and attempted to leave the premises by trying to go over the ledge at the edge of the parking lot. This deficient practice resulted in an Immediate Jeopardy at a Scope and Severity of K being identified on 07/27/17 at 3:30 pm. The Administrator and Director of Nursing (DON) were notified at this time and a Plan of Removal was requested. The facility took corrective action by providing an acceptable Plan of Removal on 07/28/17 at 9:56 am. The Plan of Removal included the following: 1. R #83- June 9, 2017 Care plan was updated with interventions to decrease risk of elopement including monitoring conditions that may contribute to elopement behavior. A wander guard was placed on resident. R #99- July 27, 2107 Care plan was updated with interventions to decrease risk of elopement including monitoring conditions that may contribute to elopement behavior. A wander guard was placed on resident. Resident will be redirected to inside courtyard when resident goes to front door and attempts to go outside. Wander guard will remain in place for 30 days then will be re-evaluated by IDT (interdisciplinary team). 2. An audit of residents with a BIMS (brief interview for mental status) score of 12 and under, who are mobile, was conducted to identify other residents with the potential to be at risk was completed on July 27, 2017. Those residents found to be at risk had care plans updated and will be reassessed on an elopement evaluation tool, with care plans updated, Medical Doctor notification and orders to place wander guard as indicated to be completed by 07/29/17. One on one initiated at front door July 26, 2017 and will continue for the next 4 days to establish consistent functioning of alarm system. 3. Licensed staff and CNAs (certified nursing assistants) will be educated on monitoring change of conditions and reporting them to their supervisor was initiated on July 27, 2017 and will continue until current staff have received this education. Clinical morning meeting will be held 5 times a week and review of changes in condition that would indicate a potential for elopement will be reviewed by IDT and an elopement assessment will be conducted to identify risk. Care plans will be updated and MD/Family notification will be completed as indicated. New admissions will be reviewed for risk on admission and interventions implemented as indicated with MD/Family notification. Elopement assessments will be completed quarterly and with changes of condition ongoing for residents with BIMS of 12 or below. 4. Results will be brought to QAPI (quality assurance and performance improvement) for review and follow up and review for 3 months. Based on the Plan of Removal, the IJ was lifted on 07/28/17 at 9:56 am. This resulted in the scope and severity being reduced from level K to level H. Based on observation, record review and interview, the facility failed to ensure residents were adequately supervised for 3 (R #s 83, 86 and 99) of 4 (R #s 58, 83, 86 and 99) residents reviewed during a complaint investigation for being an elopement risk. This deficient practice resulted in the residents' elopements from the facility and subsequently put them at risk for severe injury or death. The findings are: Findings Related to R # 83: A. Record review of R #83's electronic medical record revealed she was [AGE] years old and some of her [DIAGNOSES REDACTED]., essential hypertension (high blood pressure), st elevation myocardial infarction of unspecified site (heart attack), shortness of breath, dizziness and giddiness, [DIAGNOSES REDACTED] (a potassium deficiency), and history of falling. B. Record review of R #83's nurse's note dated 09/19/16 stated (Name of R #83) slept quietly this shift, unlike the previous night when she tried to leave facility through side door and was up all night ambulating, confused and refused to sit down. Awaiting labs and UA (urine analysis) results. C. Record review of R #83's progress note completed by a physician's assistant dated 09/19/16 stated, She does not remember becoming agitated or attempting to leave the facility last weekend. We discuss the possibility of getting her a wandergard (sic) and she says 'that sounds like a good idea' for her own safety. D. Record review of R #83's nurse's note dated 09/21/16 stated, Found resident sitting on roommates bed shaking her to wake her. Resident had no pants on and was accusing roommate of taking them. Pants were found in bathroom waste basket wet with urine. Tried to direct resident back to bed. Resident became very agitated. Resident hit certified nursing assistant and nurse and threw a box of gloves at nurse. RSD (resident) was given 0.5 mg of Ativan (an anti-anxiety medication) PO (by mouth). Resident continued to be confused and was confrontational with staff. At one point resident tried to leave unit through North West exit. When stopped by staff resident started screaming and was combative. Notified MD. Resident was given an additional does of Ativan 0.5mg PO. Resident eventually calmed down. E. On 07/26/17 at 1:58 pm, during an interview with the Director of Nursing, she stated the initial trigger for R #83's behaviors exhibited during September 2016 was the time her family took her outside the facility to go visit her great grandchild. The DON stated that after she came back, R #83 would be looking for a baby that she thought was in danger and her behaviors escalated from there. She stated that R #83 was sent to a behavioral health facility on 09/21/16 due to these sundowning behaviors (behaviors that may get worse in the late afternoon and evening) and she was readmitted to the facility on [DATE]. The DON stated that after returning, R #83's behaviors improved and she was at her cognitive baseline from when she was admitted . The DON stated R #83 was never put on a wander guard and the physician's assistant never communicated with her regarding a possible wander guard for R #83. F. Record review of R #83's elopement assessment dated [DATE] indicated R #83 had a history of [REDACTED]. G. Record review of R #83's most recent elopement assessment prior to the elopement on 06/08/17, dated 03/21/17, indicated R #83 did not have a history of actual elopement or attempted elopement. It indicated she did not have a history of wandering that places her at significant risk of getting to a potentially dangerous place or a history of wandering that significantly intrudes on the privacy or activity of others. It also indicated she was able to locate significant landmarks without assistance. H. Record review of R #83's care plan revealed that prior to 06/08/17, it did not address her history of attempted elopements or her risk of elopement. The care plan did have a focus related to increased agitation/sundowning behaviors (wandering around unit, verbal aggressive to neighbors) related to: cognitive loss/dementia dated 09/19/16. I. On 07/27/17 at 9:15 am, during an interview with the DON, she verified that R #83 did not have a care plan focus or interventions specific to elopement prior to 06/08/17. The DON stated that she does not know why a care plan was not completed to address the elopement risk. The DON stated that the elopement assessments are done quarterly and the scope of the questions only intended to cover the previous quarter. The DON verified that the elopement assessment dated [DATE] should have indicated that R #83's wandering did intrude on the privacy of others since she was wandering into other resident's rooms in February 2017. The DON stated that the purpose of the assessments is to identify residents that are at risk for elopement and then provide appropriate interventions based on those risks. J. Record review of a nurse's note dated 02/06/17 stated .Resident (R #83) alert. Confused. Wandering into other resident's rooms at beginning of shift. Redirected easily. Verbally upset at people who were supposed to give her a dog. Denies pain. K. Record review of R #83's urinalysis laboratory results dated [DATE] indicated the urine was collected on 01/31/17 and verified an infection in the urinary tract. L. Record review of a nurse's note dated 05/08/17 stated, Resident (R #83) with increase confusion thru shift. Alert. Wandering up and down D/E hall and to nurse's station before and after supper. Easily agitated . M. Record review of R #83's urinalysis laboratory results dated [DATE] indicated the urine was collected on 05/09/17 and verified an infection in the urinary tract. N. On 07/27/17 at 10:37 am, during an interview with the DON, she verified that historically there has been a correlation between R #83's UTI's (urinary tract infections) and her increased confusion and wandering throughout the facility. She stated that in the time leading up to her elopement on 06/08/17 the facility staff did not observe any signs or symptoms of a UTI, however she was diagnosed with [REDACTED]. O. Record review of the facility's 5-day investigation report regarding R #83's elopement on 06/08/17 stated, The facility was unable to use video surveillance to verify exact time of her departure. However, per staff interviews and timelines, it was approximately 40 minutes from the last time she was seen, until she was located. The report stated the date of incident as 05/11/18. The report's conclusion stated, At this time, we consider this to be an isolated incident. In the almost 4 years that (Name of R #83) has lived here, she has not eloped from the campus. As such, we do not believe (Name of R #83) is being neglected, abused or otherwise having her resident rights violated. P. On 07/26/17 at 3:26 pm, during an interview with the Administrator (ADM), he stated that at the time he reviewed the video, the monitor was broken. The ADM stated that once the monitor was replaced he did not go back and verify the time R #83 had eloped because he believed he already had a good estimate of the time of elopement based on his interviews with staff which he believed to be 3:30pm on 06/08/17. The ADM stated he could probably find that video tape footage if it had not been erased. Q. On 07/26/17 at 4:31 pm, during observation of the facility's video surveillance footage, R #83 was observed ambulating independently along the side walk near the front entrance with the help of her front facing walker. She was observed to step onto the facility parking at 3:15 pm on 06/08/17 and then proceeded to walk across the parking lot and left the premises at 3:17 pm on 06/08/17. R #83 disappeared from the view of the camera after leaving the edge of the parking lot. R. Record review of the fire department's Patient Care Report dated 06/15/17 regarding the EMS (emergency medical service) call for R #83's elopement stated they received the first call alerting them of R #83 at 4:29 pm on 06/08/17, they arrived on scene at 4:30 pm and R #83's vital signs were first taken at 4:39 pm. S. On 07/28/17 at 9:56 am, during an interview with the ADM, he acknowledged that his investigative report was incorrect in claiming approximately 40 minutes had elapsed since she was last seen and found since the actual time was 75 minutes (3:15 pm to 4:30 pm). The ADM also verified that he failed to interview R #83's roommate as part of his investigation. He stated the interview with the roommate only came about after a meeting with the ombudsman and R #83's daughter. The ADM also acknowledged the date of incident on the investigative report was incorrect as it was entered as a future date, 05/11/18. When asked about the conclusion of his investigation the ADM stated that he was looking at the bigger picture during the entire stay of the resident over 4 years. The ADM acknowledged that during the small window of time during which R #83 eloped, neglect may have occurred. The ADM verified that the investigation did not look into whether R #83's frequent UTI's (urinary tract infection) were a possible cause of the elopement. T. On 07/27/17 at 2:05 pm, during an interview with the Ombudsman, she stated that herself and the daughter of R #83 had several meetings with the ADM and other facility staff after the elopement on 06/08/17. She stated that during these meetings the ADM stated he was not aware the facility had cameras and that they were unable to retrieve the footage from the cameras. During these meetings, the daughter also expressed frustration that nobody had interviewed R #83's roommate (R #2) as part of the investigation. The Ombudsman stated the staff knew that R #2 was very close to R #83 and acted as her guardian angel by constantly looking out for her well-being. U. Record review of R #83's daughter's complaint letter dated 07/10/17 stated (Name of R #2) is Mom's guardian angel. She is a blessing to our family because she looks out for Mom. I don't think my Mom would've fared as well with any other roommate. The same letter also states, (Name of ADM) stated he didn't even know the cameras were there. He also stated that the camera probably recorded, but they are unable to retrieve the recording. V. On 07/27/17 at 3:20 pm, during an interview with R #2 (R #83's roommate), she stated that while she was playing bingo in the main dining area sometime after 3:00pm on 06/08/17 she saw R #83's walking around the front entrance of the facility. She stated that she found it odd since she knew R #83 never would go outside on her own. R #2 stated that when she got back to her room around 4:00pm she could not find R #83 in the room or bathroom which is when she alerted the nurse. R #2 stated the nurse told her that R #83 was probably in her room or bathroom. R #2 stated that she let the nurse know R #83 was not in her room or bathroom that was when the nurse started to alert others to help find R #83. W. On 07/27/2017 at 3:11 pm, during a telephone interview with Bystander #1, she stated that she was walking her dog that day (06/08/17) when she came across R #83 who was sitting on her walker, had vomit all over her, had bloodshot eyes and was breathing heavily. She stated R #83 was very confused and thought she lived at the apartment complex. She also stated that someone else had already called for an ambulance but she waited with R #83 until the fire department and an ambulance showed up. Bystander #1 stated that it was very hot that day with the temperature being somewhere in the 90's. Bystander #1 stated she works as a Certified Nursing Assistant (not at the facility) and so she knew that with the high temperature and R #83 having vomited that she would be dehydrated. X. On 07/26/2017 at 1:58 pm, during an interview with the DON, she stated that the front desk receptionist left early that day (06/08/17) for an appointment. The DON stated the receptionist usually works until 4:00pm and she does not recall how early she left that day. Y. On 07/26/17 at 2:49 pm, during an interview with the Front Desk Receptionist, she stated she did leave work early on 06/08/17 to take her mother to an appointment. After checking her electronic paystub she stated that she left work at 1:04 pm on 06/08/17. The Receptionist verified she was not working at the time of R #83's elopement but that she did hear about it afterwards. She stated that although it is not one of her official job duties she does keep an eye out for residents who try to elope. She stated she is very familiar with two residents (R #58 and R #86) who have wander guards that try to elope frequently. She stated R #86 has been discharged but when she was a resident she would try to elope through the front entrance about every 20 minutes. She stated she redirected those residents before they got near the door so the alarm wouldn't go off. The Receptionist stated she is also familiar with residents who tend to wander but don't have wander guards. She stated that she redirects those residents as well. The Receptionist stated that if she noticed a resident leaving that she wasn't familiar with she would call the nurse's station, speak with nurse and make sure the resident was allowed to leave. The Receptionist stated that if she saw R #83 leave the facility by herself she would have called the nurse's station since she had never previously seen R #83 leave by herself. She stated the only times she saw R #83 leave was with her family. Z. On 07/26/17 at 4:32 pm, during an interview with the Administrator, he stated that the front desk receptionist's main duties are to answer the phone and to track and assist visitors. He stated that one of her other duties not specified is to keep an eye out for residents who try to elope. The ADM stated that after the receptionist left on 06/08/17 she did not have a replacement that physically sat at the front desk reception area. The ADM stated that if the Receptionist had been working her full work day on 06/08/17 or if she had a replacement, the elopements of R #83 and R #86 on that day may have been prevented. AA. Record review of R #83's After Visit Summary from the hospital dated 06/08/17 stated Your [DIAGNOSES REDACTED].= + (test used to detect white blood cells in urine). Findings Related to R #86 BB. Record review of R #86's nurse's note dated 06/08/17 stated, On leaving the building, writer found rsd (resident) sitting in wheelchair in the parking lot, near the building but heading towards (Name of Adjacent Road) Rsd confused, states 'I'm going home.' Allowed writer to return her to the building without fuss. Nurse/DON notified and new wanderguard placed. CC. On 07/27/17 at 9:03 am, during with Licence Practical Nurse #1, she stated she found R #86 in the parking sometime between 5:30 pm and 6:00 pm on 06/08/17. She stated the resident was still in her wheelchair but was pointed toward the street. LPN #1 stated she did not noted any injuries on the resident and escorted her back into the facility. DD. Record review of R #86's care plan dated 04/06/17 revealed a focus related to her risk for elopement related to cognitive loss/dementia. One of the interventions in that care plan was to Utilize and monitor security bracelet per protocol. Wander guard in place at all times. One to rsd (resident) wrist, second to rsd w/c (wheelchair). EE. On 07/28/17 at 2:13 pm, during an interview with the DON, she stated R #86 had cut off the wander guard on her wrist but that the wander guard attached to her wheelchair was still attached when she was found in the parking lot. The DON verified the alarm did not trigger when R #86 eloped. The DON stated that she tested the wander system with R #86's wander guard that was still attached to her wheelchair. She stated that when the wander guard was placed on the bottom of the wheelchair (where it had been placed prior to the elopement) it did not trigger the alarm however when it was moved higher up to the arm of the wheelchair, it did trigger the alarm. FF. Record review of the facility's 5-day follow up Investigation Report regarding R #86's elopement on 06/08/17 revealed there was no reference to R #86's second wander guard that was attached to her wheelchair. The report only addressed the wander guard that was attached to the resident's wrist which she cut off prior to eloping. The report stated that a new wander guard was added to her person as well as one on her wheelchair. The report also stated there is no indication that our current wander guard system isn't working properly . GG. On 07/28/17 at 2:18 pm, during an interview with the Administrator, he stated that he did not do a thorough investigation since he failed to note that the resident had a second wander guard on her wheelchair. He also verified that the system was not working properly since a resident with a wander guard on her wheelchair was able to exit through the front doors without triggering the alarm. The ADM stated that the alarm did not trigger if the wander guard was below a certain height. Findings related to R #99 HH. On 07/27/17 at 1:06 pm, R #99 was observed self-propelling herself in her wheelchair in the parking lot in between two parked cars trying to make her way over the ledge toward the adjacent street. After several attempts to get over the ledge, R #99 turned around and began self-propelling toward the front entrance of the facility. During this time a Transport CNA (certified nursing assistant) was loading another resident into a van. The Transport CNA saw R #99, walked over to her and wheeled her to the front patio area where she had a short conversation with the resident in Navajo language. The Transport CNA wheeled the resident back into the facility and notified a nurse about what had happened. II. On 07/27/17 at 1:10pm, during an interview with the Transport CNA, she stated that R #99 told her that she was trying to get to the intersection to catch a ride on the bus. JJ. Record review of a note dated 07/27/17 stated Review of elopement 7/27/2017. Rsd (R #99) found in parking lot by facility driver. Rsd stating she was going to find a bus stop. Rsd frequently sits on facility front porch per her desire and has not previously demonstrated any exit seeking behavior while doing so. Staff noted that resident was out of her chewing tobacco and snacks and was waiting for family to provide. Facility staff contacted family to inform them that rsd was in need of these items and they will provide. Wandergaurd placed on resident x 30 days and will reassess rsd behavior and potential exit seeking behavior. Rsd will be redirected to center courtyard when she desires to be outdoors.

§483.25 Quality of care F309 Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: Based on interview and record review, the facility failed to seek out a more immediate medical opinion and/or medical care by not identifying and acting on an infection for one resident (R # 157) of one (R #157) looked at for quality of care issues. This deficient practice resulted in R #157 being diagnosed with [REDACTED]. The findings are: A. Record review of a progress note on 06/08/17, indicated that R #157 began complaining of her right leg being swollen. There was a change in condition noted at that time. Progress note indicated that the nurse had looked at her swollen leg and had an appointment on 06/14/17. B. Record review of the E-Interact Change in Condition Note indicated that on 6/8/17, a change in condition had been noted. The symptoms included [MEDICAL CONDITION] (new or worsening) skin wound or ulcer. C. Record review of a General Progress Note dated 6/08/17, indicated that R #157's right lower leg, where she had surgery before, was red, swollen and itching. Also her right 2nd toe is red and swollen. D. Record review of a General Progress Note dated 6/08/17, indicated that right foot was found with 2nd and 3rd toes red and macerated skin (this occurs when the skin is exposed to fluid for an extended period of time, like when a wound is covered with a bandage for too long) at distal end (the farthest from a point of origin or attachment), foot is swollen and surgical incision to left shin was also red and swollen. E. Record review of a General Progress Note dated 6/09/17, indicated that R #157 was voicing concerns about her shin and toe. It remained swollen and red around the old surgical incision and R #157 had complaints of pain when affected toe was touched. The right foot remained swollen and red, warm, pain upon touch, drainage from toe was scabbed over. F. Record review of the Change in Condition Follow Up Note dated 06/10/17, indicated that the lower extremity remained swollen and there had not been any change. G. Record review of the General Progress Note dated 06/12/17, indicated that the right foot was assessed and it was found that the 2nd/3rd toes continued to be red and macerated. H. Record review of a General Progress Note dated 6/14/17, indicated that R #157 had an appointment with hospital orthopedics and the findings were: right 2nd and 3rd toe bone infection, exposed bone, ulcers and [MEDICAL CONDITION]. New orders included wound care, surgery on 6/21/17 for 2nd and 3rd toe amputation. [MEDICATION NAME] BID (twice per day) and [MEDICATION NAME] BID antibiotics were ordered. I. On 07/28/17 at 8:02 am, during an interview with R #157, she stated that she had two toes amputated since being at this facility. She stated that she felt like this was due to a lack of communication with her, staff and with the doctors. She stated that she never felt like the information was relayed to the doctor of the facility and the doctor never came in to take a look at her toes and her shin this last time. J. On 07/28/17 at 2:29 pm, during an interview with the wound nurse, she stated that she looked at her toes and shin on Monday June 12th. She told her to keep her shoes and socks off as much as possible to let the area dry out. She was aware that R #157 had an appointment with a doctor on June 14th which was later that week. She stated that R #157 had become very sick, very quickly in the past and had become septic. She stated that if R #157 had any signs and symptoms of an infection, it should be addressed immediately. K. On 07/31/17 at 8:35 am, during an interview with the Unit Manager, she stated that they called R #157's surgeon and made an appointment for June 14th. The Unit Manager stated that maybe they should have called the Nurse Practioner or on call doctor to let them know about R #157's syptoms. She stated that if R #157 had an infection at the time the nurse looked at it, it would have been a delay in treatment. If it is red and warm then it might be an infection and the doctor would be notified. L. On 07/31/17 at 10:46 am, during an interview with R #157, she stated that she felt like they dropped the ball. She stated that in June she saw her foot getting red and swollen and she knew what was going on. She stated that she let them (staff) know but she did not feel like they were listening to her. R #157 stated that she pitched a fit and they started to dig around and found an as needed order for her surgeon. Staff made an appointment for her on June 14th. She stated that she felt like a week was too long for her to wait to see a doctor. J. Record review of the Resident Council Minutes indicated that in June 2017 R #157 spoke up during the meeting and stated that she had a complaint about the nursing staff. She stated that they don't listen to her, and that in the past she had shared information from a recent doctor's visit to nursing staff and they weren't listening to her.

Based on record review and interview, the facility failed to provide the necessary care and services for residents to attain their highest practicable physical well being, for 1 resident (R #1) of five residents (R #s 1, 2, 3, 4 and 5) reviewed during a complaint survey. The facility response to the resident's reports of symptoms of a urinary tract infection [MEDICAL CONDITION] was delayed several days in both April and May 2017. Attempts to obtain a urine sample for laboratory work were delayed until late in the evening, when the resident had already emptied her bladder or was disinclined to have her rest disturbed by the procedure. This deficient practice likely caused the resident's infections to worsen, resulting in two hospitalization s for [MEDICAL CONDITION] (a life-threatening infection of the blood). The findings are: Findings related to R #1's 03/29/17 to 04/21/17 stay at the facility A. Record review of R #1's facility medical record indicated that she was originally admitted to the facility on [DATE], and that she was currently [AGE] years old. Following a hospitalization in late March, she was readmitted to the facility on [DATE], and discharged to the hospital again on 04/21/17. Her [DIAGNOSES REDACTED]. B. Record review of R #1's facility History & Physical document, dated 03/31/17, found the statements: 1. (R #1) was admitted to (name of hospital) from 03/27/17 to 03/29/17 for a fall from her bed, worsening confusion, and altered mental status. 2. According to the surgical residents who spoke to (name of R #1's Family Member (FM) #1), patient had c/o (complained of) 5 days of dysuria (painful urination), change in urine habits and color, and chief complaint she thinks she has a UTI. She also had some intermittent fever and chills. 3. In ED (Emergency Department), patient is septic with a white count of 30K (an elevated white blood cell count of 30,000, indicative of infection), evaluated by general surgery who don't think the source is infected open wound and is most likely UTI. Patient admitted to medicine service for IV antibiotics. 4. Pt (patient) had [MEDICAL CONDITION] secondary to UTI. Pt to finish ertapenem (an antibiotic medication), EOT (end-of-treatment) 03/31/17. Continue to monitor for recurrence of UTI. C. Record review of facility progress notes for R #1 found: 1. a skilled nursing note dated 04/15/17 stating Resident has refused two days in a row to get out of bed, stating, 'I need antibiotics for a UTI. Until I get those, I'm not getting out of bed.' Advised resident that her vitals are stable and urinalysis (analysis of urine) via dipstick method (an on-the-spot means of assessing urine, considered less reliable than a laboratory urinalysis) was within normal limits. Rsd (resident) still refusing to get out of bed or work with restorative therapy . 2. a skilled nursing note dated 04/17/17 (11:18 am) stating, Per resident, having painful urination. New order for UA (urinalysis) and C&S (culture and sensitivity, a check for specific bacteria in the urine) if indicated. 3. a skilled nursing note dated 04/17/17 (2:09 pm) stating . Rsd refusing to get OOB (out of bed), refused food all day, did drink protein supplement with much encouragement . 4. a general note dated 04/21/17 (11:03 am) stating . Rsd very lethargic, has been ongoing. Got OOB yesterday for a shower, had to use hoyer (a mechanical lift device), rsd afraid her legs wouldn't hold her. Today rsd is confused at times during wound care, asking 'so what's going on out there? Are they going to auction those dogs?' 5. a change-in-condition note dated 04/21/17 (12:26 pm) stating . The symptoms include: Abnormal vital signs . Altered mental status 04/21/17 in the morning. Vitals BP (blood pressure) 83/66 (a reading that is below normal) 04/21/17 12:28 (pm) . Orders obtained include: Send to ER (emergency room ). D. Record review of R #1's physician orders [REDACTED]. E. Record review of R #1's laboratory results during this stay found that a urine sample was collected on 04/17/17, received by the laboratory on 04/18/17, and resulted back to the facility on [DATE] (day of the resident's discharge to a hospital). The laboratory result indicated that the resident's urine contained 3 organisms, and listed appropriate antibiotic therapy to combat each. F. Record review of R #1's hospital emergency department provider note, dated 04/21/17, found the statement Per report, patient was found to be altered and hypotensive (with low blood pressure) earlier today at SNF (skilled nursing facility). Hx (history) somewhat limited due to patient's mental status, however she indicates that she has been 'sick' for about a week, endorses diffuse (general) weakness, dysuria, malodorous (foul-smelling) urine . G. Record review of R #1's hospital history and physical document, dated 04/21/17, found: 1. a History of Present Illness section with statements indicating . She has a history of . frequent MDRO (multi-drug resistant organism) UTIs who presents from her SNF, due to concerns of (FM #1), for increasing lethargy, confusion and anorexia (failure to eat) that patient has had over the last week. He states that these are the symptoms that (R #1) gets when she has UTIs . 2. an Assessment and Plan by Problem section stating, [MEDICAL CONDITION], due to urinary tract infection: The patient presents [MEDICAL CONDITION] (with an abnormally rapid heart rate) with significant leukocytosis (elevated white blood cell count), as well as elevated [MEDICATION NAME] (an indicator [MEDICAL CONDITION]). Her urinalysis is cloudy, showing moderate leukocyte esterase (an indicator of UTI), greater than 150 white cells, many bacteria. This is her most likely diagnosis . H. Record review of R #1's hospital inpatient provider progress note, dated 04/28/17, found statements indicating .[MEDICAL CONDITION] 2/2 (resulting from) MDRO proteus and e coli (types of bacteria) UTI:[MEDICAL CONDITION] has resolved. Less likely septic from wound infections since it is improved on CT (an imaging scan) and there is no spreading erythemia, tracking (signs of wound infection), etc . Findings related to R #1's 05/01/17 to 05/14/17 stay at the facility I. Record review of facility progress notes for R #1 found: 1. a skilled nursing note dated 05/01/17 stating . readmission post (following) hospitalization [MEDICAL CONDITION] . 2. a general note dated 05/08/17 stating, Resident states concern that she is scared that UTI may have returned, verbalized understanding, informed resident that PA (physician's assistant) will be notified to see patient and see about further interventions. Pt expressed thanks and verbalized understanding. Will leave note for PA. 3. a general note dated 05/09/17 stating Rsd cont (continues) to refuse to get OOB, very resistant to even raising head of bed. Prefers to lay flat on back, in dim room. Encouragement given at each interaction to get OOB even for a little while. Rsd has no medical reason for being bed ridden in the flat laying position. Rsd worried that UTI has returned. 4. a general note dated 05/10/17 (9:00 pm) stating Upon entering room to perform straight cath (passage of a tube into the bladder to collect urine) procedure, (R #1) was sleeping and awoke upon hearing name. Inquired with (R #1) if she wished to proceed with straight cath procedure that was discussed earlier in the shift or wait until the following day due to fatigue. (R #1) appeared to stop and think for a moment and then stated, 'Yea, I guess wait until tomorrow. I'm a little tired.' Verbalized understanding and will inform oncoming shift. 5. a general note dated 05/11/17 (3:20 pm) stating . (FM #1) inquired about if staff was aware of (R #1's) c/o possible infection, informed (FM #1) that this writer will be obtaining UA sample this shift via straight cath method . 6. a general note dated 05/11/17 (9:40 pm) stating Upon entering (R #1's) room to perform straight cath procedure, (R #1's) brief noted being recently soiled with urine, will not attempt to straight cath due to recently emptied bladder, will inform oncoming shift. 7. a general note dated 05/12/17 (11:28 am) stating went into room to collect urine for UA, resident refused, stating will do it later. 8. a general note dated 05/13/17 stating Obtained UA via straight cath, called into lab for stat (expedited) pickup, (FM #1) aware. 9. a general note dated 05/14/17 (5:30 pm) stating . (R #1) appears weak and responds weakly to questions and does not appear at mental baseline. Asked CNA (Certified Nurse Aide) to obtain vital signs, temp (temperature) is elevated to 100.4, resp (respirations) normal, HR (heart rate) 74 and irregular, difficulty in obtaining BP (blood pressure) observed. fell ow nurse examined (R #1) and determined same previous assessment of AMS (acute mental status change, or confusion). Called 911 to transport (R #1) to (name of hospital) . 10. a general note dated 05/14/17 (10:20 pm) stating Called (name of hospital) and spoke to ICU (Intensive Care Unit) nurse (name) to receive update on (R #1), informed that (R #1) is in ER and admitted for [MEDICAL CONDITION] . J. Record review of R #1's physician's orders [REDACTED]. an order for [REDACTED]. K. Record review of a laboratory result for R #1 dated 05/16/17 found that the sample had been collected on 05/13/17, delivered to the laboratory on 05/14/17 (date of the resident's discharge to the hospital), and resulted back to the facility on [DATE]. The laboratory indicated that multiple infectious organisms were found, leading to the conclusion that the sample had been contaminated. Findings related to both stays of R #1 at the facility L. On 05/19/17 at 9:15 am, during interview with FM #1, he stated that he believed that there had been unreasonable delays in responding to R #1's UTI symptoms. He indicated that, both in April and in May, he had alerted facility staff to her symptoms, and it has taken a few days or a week for a urine sample to be sent for analysis. He stated that R #1 has had many UTIs, and he is familiar with her symptoms: pain with urination, refusal to get out of bed, lethargy, and confusion. He stated, There was definitely a big delay in care. When I told them, they assured me that they would check her, but they didn't think it was urgent, like they'd do it when they got around to it. There is definitely a lag in time between the request and getting the job done. He stated that R #1 remained in the Intensive Care Unit at present, though there was a chance she might be transferred to a regular unit that day. M. On 05/19/17 at 10:58 am, during interview with the Director of Nursing, she indicated that she had reviewed R #1's medical record. She confirmed that the resident had first reported UTI symptoms on 04/14/17, and that a urine sample was obtained for urinalysis on 04/17/17. The final report from the laboratory was not received until 04/30/17, 9 days after the resident was discharged to the hospital. She indicated that a delay of 13 days from sample collection to result was unusual. She stated that the facility's physicians would not order antibiotics without having received the laboratory's culture and sensitivity report, and confirmed that in both cases, the resident's condition deteriorated and she was hospitalized prior to receiving antibiotic orders in the facility. Regarding the reasonableness of waiting until the resident required emergency transport and placement in an intensive care unit before treating a UTI, the Director of Nursing expressed an opinion that the hospital reports were incorrect, and that the resident'[MEDICAL CONDITION] was the result of her wound, rather than her urinary tract infection.

Based on record review and interview the facility failed to ensure that 1 (R #1) of 4 (R #s 1, 2, 3, 4) residents reviewed for unnecessary medication did not receive excessive doses of pain medication. This deficient practice caused R #1 to: 1. Become unresponsive and had to be administered [MEDICATION NAME] (a medication used to block the effects of opioids/narcotics, especially in overdose) two times while at the facility. 2. To be taken by ambulance to the Emergency Department due to the over sedation of [MEDICATION NAME] (a narcotic pain medication). The findings are: A. Record review of the MAR (medication administration record) for July 2016 indicated that R (resident) #1 was taking [MEDICATION NAME] (a narcotic pain medication) Solution 20 MG/ML (milligram/milliliter). Give 0.5 ml (milliliter) by mouth every 1 hour as needed for pain/SOB (shortness of breath). B. Record review of the MAR for July 2016 indicated that R #1 was taking [MEDICATION NAME] HCI ([MEDICATION NAME]) Tablet 10 mg. Give 10 mg by mouth three times a day for pain. C. Record review of the physician's orders [REDACTED]. D. Record review of the physician's orders [REDACTED]. E. Record review of the MAR for July 2016 indicated that R #1 began receiving 40 mg of [MEDICATION NAME] on 07/20/16 three times per day. F. Record review of the MAR for July 2016 indicated that on 07/22/16, R #1 refused AM dose of [MEDICATION NAME]. G. Record review of the MAR for July 2016, indicated that a note was written on 07/23/16 resident request 3 [MEDICATION NAME] instead of 4 stated 4 was too much nurse not (notified). H. Record review of the nursing progress note dated 07/25/16 indicated: rsd (resident) sedated, slurring words, unable to hold head up, eyes droopy and sometimes shut with head bobbing downward, and lethargic, rsd states, 'that is too much, I don't want it all'. PA (Physician Assistant) notified. Orders obtained to give [MEDICATION NAME] 30 mg x1 dose this 0800 am dose. Will f/u (follow up) with provider regarding sedation of resident, will continue to monitor rsd for safety and status changes. I. Record review of the nursing progress note dated 07/25/16 indicated a new order for [MEDICATION NAME] HCl Tablet 10 MG; Give 30 mg by mouth one time only for pain until 07/25/2016 23:59 (11:59 pm) give 30 mg this am only. J. Record review of the nursing progress note dated 07/25/16 at 8:00 am, indicated that nurse notified of rsd. slurring words and apparent look of sedation. K. Record review of the nursing progress note dated 07/25/16 at 13:14 (1:14 pm). The note indicated that at 12:49 pm too lethargic to take meds nurse notified. L. Record review of a progress note dated 07/25/16 at 15:01 (3:01 pm), (Nurse) was called to resident's room. Resident lying on floor on stomach. Resident stated she leaned over in wheelchair and fell to floor. No new open or discolored areas noted at this time. ROM (range of motion) completed WNL (within normal limits). Neuro checks started, WNL. Doctor made aware via NP (nurse practioner), sister made aware. At present no complaints of pain or discomfort. Presently lying in bed. Alert, verbal, pupils equal and reactive, skin warm and dry, resp (respirations) even and unlabored. Will continue to monitor. M. Record review of the physician's progress note dated 07/27/16 stated that R #1 was sent to the ED (emergency department) on 07/25/16 for over sedation due to her scheduled [MEDICATION NAME]. [MEDICATION NAME] was given x 2 at the facility and patient remained unresponsive, so she was sent to the ED. In the hospital she was found to have a CBG (blood glucose) of 48 (Normal range of 80-110), she stated she hadn't eaten all day. She returned yesterday morning and [MEDICATION NAME] dose was decreased from 40 mg TID (three times per day) to 10 mg TID. N. On 10/26/16 at 10:57 am during an interview with Medication Technician #1, she stated that when she saw R #1 on 07/25/16 she was slouched over in her chair. It was very difficult to get her awake. She was almost comatose. PA (Physician's Assistant) #1 was made aware of the situation and had us watching and monitoring R #1. The medication was decreased from 40 mg to 30 mg three times per day. O. On 10/26/16 at 11:50 am, during an interview with RN (Registered Nurse) #1, she stated that on 07/25/16 she found R #1 in the hallway in her wheelchair slouched over. She stated that she was always drowsy but on this day it was particularly bad. Later, she saw R #1 lying flat in bed and she was very hard to wake. RN #1 did an sternal rub (rubbing the chest bone to arouse) on her and she did arouse a bit. RN #1 then reported this to PA #1. She stated that they were tapering her off [MEDICATION NAME] to the [MEDICATION NAME] at this time and she was worried that the [MEDICATION NAME] was building up in her system. She was told to monitor R #1 and when she was still very lethargic and hard to arouse the decision was made by the medical doctor to administer [MEDICATION NAME]. RN #1 stated that this worked and R #1 was sitting up and talking. Around 15 to 30 minutes later she was starting to get groggy again and the second dose of [MEDICATION NAME] was given and she was sent out to the hospital. P. On 10/26/16 at 2:40 pm, during an interview with PA #1 she stated that [MEDICATION NAME] is a stronger narcotic than [MEDICATION NAME]. She stated that the calculation for [MEDICATION NAME] to [MEDICATION NAME] was anywhere from 2:1 [MEDICATION NAME] to [MEDICATION NAME] to 4:1 [MEDICATION NAME] to [MEDICATION NAME] depending on how much [MEDICATION NAME] a person had been getting.

The facility failed to maintain an effective Infection Control Program to ensure a safe, sanitary and comfortable environment to help prevent the spread and transmission of contagious disease and infections by: Isolation Issues: 1) having 1 (R #162) resident with chronic Clostridium Difficile (C Diff) (a highly contagious bacterium infection that can cause symptoms such as diarrhea, abdominal pain, fever, intestinal damage and severe fluid loss) and active loose stools in a Contact Isolation room living with another resident (R #138) who does not have [DIAGNOSES REDACTED], 2) 3 residents (R #s 67, 80 and 138) sharing the same bathroom with R #162, 3) staff not wearing the proper Personal Protective Equipment (PPE) to include gowns and gloves prior to entering the isolation room, 4) staff not washing or sanitizing their hands after touching equipment and after leaving the isolation room, treatment of [REDACTED].>5) staff not properly containing soiled linen in the appropriate biohazard bags, 6) staff carrying soiled linens from isolation room with no gloves on and in clear plastic bags, 7) not maintaining proper temperature in the washing machines to effectively sanitize soiled linens. Storing of the IV pole: 8) having an IV (intravenous) pole with a bag of .9% of Sodium Chloride Solution still attached with two sharp needles exposed sitting in the hallway (which belonged to a resident who was discharged to the hospital two days prior) accessible to residents,This deficient practice has the potential to affect all 104 residents as identified on the Resident Census List provided by the Administrator on 06/22/15. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 06/26/15 at 10:05 am. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included: 1) Removing the IV pole Solution bag and attached needles, and placing it in appropriate receptacle for disposal, 2) mechanical equipment was cleaned with bleach solution by end of day, 3) education was started with staff on proper isolation techniques, PPE, and usage, sharps disposal and [DIAGNOSES REDACTED], 4) Identified soiled linens in resident rooms will be bagged within the room and transported to the soiled utility room, 5) Hand washing to be completed prior to returning to room, 6) attached protocol for contaminated isolation room cleaning, 7) Identified washing machine temperatures were adjusted by Maintenance, and 8) Complete inspection of facility. Based on the Plan of Removal and observations, the IJ was lifted on 06/26/15 at 4:41 pm. This resulted in the scope and severity being reduced from a scope and severity of L to Level 2, scope and severity F. Based on observation, record review, and interview, the facility failed to maintain an effective Infection Control Program to ensure a safe and sanitary environment to prevent the spread of bacteria and infectious organisms as evidenced by: 1. Failing to ensure that appropriate infection control and isolation practices were being followed for R #162 by not following federal guidelines for isolation practices and appropriate use of PPE. 2. Failing to clean and disinfect shared resident equipment. 3. Failing to properly dispose of contaminated linens and waste from residents who are on contact isolation. 4. Failing to identify the potential spread of Blood Borne Pathogens (bacteria and viruses spread by exposure to blood) by failing to properly dispose of used IV (intravenous) tubing that had two exposed sharps (needles) attached. This deficient practice has the potential to expose all 104 residents identified on the Resident Census List provided by the Administrator on 06/22/15 to infectious bacteria and viruses by not maintaining an effective Infection Control Program. The findings are: A. Record review of Contact Precautions Policy revised on 10/01/13, revealed Contact precautions will be used in addition to Standard Precautions when caring for a patient who is colonized or infected with epidemiologically important microorganisms that can be transmitted by direct contact (hand or skin to skin) or indirect contact with environmental surfaces in patient care environment. State regulations will be followed when applicable.Place patient in private room, if possible.Patient may cohort with an individual who has the same organism.Staff must use barrier precautions when entering the room, Wear gown and gloves, wear eye protection if splashing of infectious material is likely. B. Record review of Medical Record for R #162 indicated he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. diff (a highly contagious bacterium infection that can cause symptoms such as diarrhea, abdominal pain, fever, intestinal damage, and severe fluid loss). C. Record review of Care Plan revised on 04/21/15, revealed resident exhibits or is at risk for complications of infection related to [DIAGNOSES REDACTED]. Interventions include: Administer PO (by mouth) ABT (antibiotic) medication as ordered, educate (Name of R #162)/health care decision maker on good hand washing and prevention of spread of infection, Provide level 2 precautions (contact) (Contact precautions level 2 is defined as gown & gloves upon entering patient's room, Stop sign gets posted outside door to alert staff and visitors to see nurse before entering room. Level 2 is included in the Infectious Disease Management Policy dated 10/01/13). D. Record review of Physician order [REDACTED]. diff for 14 days. The order date is 04/26/15. E. Record review of Progress Note dated 04/30/15, revealed History of present illness: He (R #162) reports he is having diarrhea and needs to have his diaper changed. Progress note further revealed Stool culture is positive for [DIAGNOSES REDACTED]. F. Record review of the Interdisciplinary Progress Notes indicated the following: 1. 04/14/15, indicated Rd (resident) continues on ABT for [DIAGNOSES REDACTED]. Several loose watery stools noted. 2. 04/15/15, Continues with loose watery stools. 3. 04/24/15, Collected stool, sent to lab to r/o (rule out) [DIAGNOSES REDACTED]. 4. 04/26/15, Stool sample positive [DIAGNOSES REDACTED]. 5. 04/30/15, Rsd had 2 loose bms (bowel movements) tonight. 6. 05/07/15, Rsd had 2 xlg (extra-large) loose BMs this shift. 7. 05/08/15, Rsd had one diarrhea stool this shift. 8. 05/27/15, Rsd with x2 (two) large episodes of diarrhea this shift. Foul odor with mucus. 9. 06/22/15, Rsd had one liquid stool. 10. 06/24/15, Rsd had two large loose stools. 11. Progress notes dated 04/07/15 through 06/25/15 indicated R #162 was actively being treated with antibiotics for [DIAGNOSES REDACTED], he also had several episodes of loose/watery/liquid stools. G. Record review of the Recreation Activity Log dated April (sic), revealed on 04/22/15, 04/23/15, 04/24/15, and 04/25/15, R #162 was out of his room for Active games, bingo/cards/games, and trivia/word games. The log is coded with 1 which is Actively involved/observed/listened. During this time R #162 was still demonstrating signs of active [DIAGNOSES REDACTED]. H. Record review of Recreation Activity Log dated May (sic), revealed on 05/18/15 resident actively involved/observed/listened for active games. During this time R #162 was still demonstrating signs of active [DIAGNOSES REDACTED]. I. Record review of Interdisciplinary Progress Notes dated 06/03/15, revealed Up w/c (wheelchair). Attended activities. During this time R #162 was still demonstrating signs of active [DIAGNOSES REDACTED]. J. Record review of Interdisciplinary Progress Notes dated 06/09/15, revealed Resident up in w/c part of the evening, in day room, continue on Abx for [DIAGNOSES REDACTED]. K. On 06/22/15 at 8:15 am, during Initial Tour of North Unit, observation of room [ROOM NUMBER] revealed a 'Stop, see nurse' sign posted on the door and an isolation cart outside the room. At this time, there was not a red biohazard container observed in the room or outside the room. L. On 06/22/15 at 8:17 am, during interview Registered Nurse (RN) #1 stated that R #162 is on isolation for [DIAGNOSES REDACTED]. M. On 06/22/15 at 8:24 am, during observation of North Unit, the name plate posted outside room [ROOM NUMBER] revealed R #138 is assigned to bed B in the same room as R #162, who is on isolation for [DIAGNOSES REDACTED]. N. On 06/22/15 at 10:28 am, during observation of North Unit, R #138 (R #162's roommate) was observed to be participating in activities. R #138 was observed sitting in a merri-walker (a walker/chair combination that encourage a resident who would normally be placed in a wheelchair to get up and walk independently) at a table in the day room. O. On 06/22/15 at 12:09 pm, during observation of lunch, R #138 was observed sitting at a table in the main dining room waiting for his meal. R #138 was sitting at the table in a regular dining chair, his merri-walker was next to him. At this time, staff were not observed providing hand hygiene education or reminding R #138 to wash his hands. P. On 06/23/15 at 8:50 am, during interview RN #3 confirmed R #162 was on contact isolation due to having chronic [DIAGNOSES REDACTED]. She stated He (R #162) has had chronic [DIAGNOSES REDACTED] for a long time. He is on antibiotics now, they are going to stop on the 29th of June. RN #3 also confirmed R #138 and R #162 share a room, stating It's fine if they share a room. We don't put them with an immuno-compromised person. Q. On 06/23/15 at 9:30 am, during observation of room [ROOM NUMBER] (R #138 and R #162's room) revealed there was no red biohazard container in the room or outside the room to properly dispose of PPE (Personal Protective Equipment). R. On 06/23/15 at 9:34 am, during interview both R #67 and R #80 confirmed they share an adjoining bathroom with room [ROOM NUMBER], which is the room identified with [DIAGNOSES REDACTED]. S. On 06/23/15 at 11:13 am, during observation Housekeeping Aide #1 was observed entering R #162's room to clean. He did not put any PPE on before entering the room. Housekeeping Aide #1 was emptying R #138's trash. T. On 06/23/15 at 11:55 am, during interview RN #1 was asked who needs to wear PPE when entering R #162's room, she stated Everyone except the roommate. When asked if Housekeeping should have to wear PPE when cleaning or entering the room, she stated I would think. I would (referring to wearing PPE). U. On 06/24/15 at 7:55 am, during observation Certified Medication Aide (CMA) #2 was observed entering R #162's room. She did not put on any PPE before entering the room. V. On 06/24/15 at 1:33 pm, during observation Certified Nursing Assistant (CNA) #6 was observed entering R #162's room with no PPE. CNA #6 did not put a gown or any PPE on before entering the room. Further observation revealed there was no red biohazard container in or outside the room to properly dispose of PPE. W. On 06/24/15 at 1:37 pm, during observation CNA #6 came out of R #162's room holding a clear trash bag not identifiable as a biohazard bag with soiled items and then walked down the hall to the soiled utility room. X. On 06/24/15 at 5:17 pm, during observation the Weekend Receptionist #1 was observed going into R #162's room without putting any PPE on, then walking into room [ROOM NUMBER] across the hall. She was observed going into each room on the North front and middle units. Y. On 06/24/15 at 5:23 pm, during interview Weekend Receptionist #1 stated, The call lights in the bathrooms are not functioning, so I'm just checking to see if anybody needs anything. She also stated that she has to check every single room with a resident in it. Z. On 06/25/15 at 9:45 am, during observation of North Unit, CMA #1 was observed going into R #162's room with no PPE on. AA. On 06/25/15 at 10:25 am, during observation Licensed Practical Nurse (LPN) #4 was seen coming out of R #162's room. LPN #4 was observed to be touching R #162's feeding bottle with no gloves on. She was then observed walking into the nourishment room down the hall and coming out holding a small cup of soda, then she walked into the day room. LPN #4 was not observed washing or sanitizing her hands between exiting R #162's room and entering the nourishment room. BB. On 06/25/15 at 10:52 am, during interview RN #3 confirmed she does the education for all newly hired staff, which includes hand washing, infection control practices, and isolation protocols. Excluding housekeeping and laundry staff. With regards to isolation, she stated We don't keep them (residents on isolation) in their rooms. They can still go to therapy. When asked about residents with [DIAGNOSES REDACTED], she stated, Residents with [DIAGNOSES REDACTED] are not isolated to their rooms. If they have [DIAGNOSES REDACTED] and they are going to therapy they have to make sure they wash and clean their hands. We don't put a gown on them if they go out or anything. If it was just a little diarrhea not spilling out then, yes, they would go out. RN #3 confirmed staff follow the CDC guidelines for isolation practices. RN #3 was asked her expectations regarding PPE, she stated I expect staff to be using it. They know if they are doing direct care with a patient, for example [DIAGNOSES REDACTED] staff would need to gown and glove. During interview RN #3 was unsure if R #162 does or does not use the bathroom (that is shared between three residents as previously noted), she stated If he was to use the bathroom, he would only wash his hands. She confirmed that CNAs know they should put on a gown before walking into an isolation room. CC. On 06/25/15 at 2:50 pm, during interview regarding disposal of PPE CNA #5 stated We don't have red bags here (referring to biohazard bags). It's a regular clear plastic waste basket liner. She confirmed she entered R #162's room and didn't put any PPE on, she stated I didn't do anything (referring to putting on PPE). I just walked in and checked the bathroom and walked out. DD. On 06/25/15 at 3:09 pm, during observation of the dirty utility room on the North Unit, revealed eight large barrels, three of those were biohazard barrels with red lids and bags. The sink that staff are supposed to wash their hands is on the other side of the room, behind all eight barrels. The sink is not easily accessible for staff to wash their hands. EE. On 06/25/15 at 3:31 pm, during interview RN #3 was shown a spot that was cleaned by the surveyor on the hoyer lift on the North Unit. She confirmed that the hoyer lifts were dirty and the sink was not easily accessible. FF. On 06/25/15 at 3:40 pm, during observation of the dirty utility room on the South Unit, just outside the door, there was an IV pole with a 0.9% Solution bag with IV tubing and two exposed sharps at the end. The IV bag had the date 06/23/15 written on it. The pole was in a location that could be accessed by residents or visitors walking on the unit. The IV bag with solution was used for a resident that had been discharged to the hospital on [DATE]. There were two hoyer lifts outside the dirty utility room, they were visibly dirty. Inside the room there were seven barrels, one biohazard barrel was stacked on top of another. The room was crowded with barrels, and the sink was on the other side of the room. The sink was not easily accessible for staff to wash their hands. GG. On 06/25/15 at 3:43 pm, during interview RN #3 she stated I wasn't aware it was there, referring to the IV pole with two exposed sharps. She also stated it is not appropriate, it needs to be broken down and properly disposed. HH. On 06/25/15 at 4:30 pm, during interview, CNA #8 stated You would take it (soiled linen) and put it in a trash can, like a red soiled trash can that should be in the room. That is just basic knowledge. II. On 06/25/15 at 4:40 pm, during interview LPN #7 stated, The standard protocol for anybody in isolation regardless of what kind, is to always use hand sanitizer before entering the room, then gown up. When I have to give meds through R #162's [DEVICE], I gown up and put gloves on before I enter the room and then dispose of them when I come out of room. I would disrobe my gown and gloves and dispose of it in our soiled utility room in the red barrel containers. All we have in the resident rooms is just the small waste baskets that is it. Anything that has blood or especially someone with [DIAGNOSES REDACTED] should be disposed of in the red barrels. LPN #7 also stated, Well I don't think they (R#138 & R#162) share a bathroom and once R #162 starts getting up, we will probably put a commode chair in there. But anybody including visitors and staff should gown up regardless when they enter the room with gowns and gloves. JJ. On 06/25/15 at 4:33 pm, during interview the Housekeeping Supervisor stated she educates her own staff on isolation practices and the use of PPE. The Housekeeping Supervisor also stated her expectations for staff going to clean an isolation room, I expect them to cover with the gown and gloves on. They put their PPE on, they put it (referring to the isolation cart) right in front of the door. The Housekeeping Supervisor confirmed housekeeping staff should at a minimum have gown and gloves when entering an isolation room, she stated We want to cover their hands and clothes. When asked what the process of cleaning and disinfecting an isolation room with one ambulatory resident and one bed bound resident, she stated We would clean as much as we could on one side. If we can't get the nurse to get them out of bed we will still clean the bed rails. If it's somebody who is bed bound, when they change the sheets we will sanitize the mattress. KK. On 06/26/15 at 8:51 am, during interview the Activities Director stated that R #162 came out of his room, attended and was involved in activities in April 2015 and May 2015. With regards to R #162 she stated, I know he was isolated for [DIAGNOSES REDACTED]. I know that's a spore but it's contained in his brief. The Activities Director was asked if staff did anything to protect the resident while out of his room, she stated I don't think so. That's a resident right, if I had to go out and wear all kinds of stuff I would feel bad. We just did the three feet thing. The Activities Director was asked about the procedure of going into an isolation room, she stated If the cart was out there we would put PPE on. Then take it off before you leave the room and set it in the trash inside the door. The trash can they (facility) provide for the PPE. LL. On 06/26/15 at 9:22 am, during interview the Director of Nursing (DON) was asked her expectation for staff and rooms on isolation, she stated They (staff) should follow the rules for whatever isolation it is. If it's contact, wear gown and gloves. The DON was asked what her expectation is for a partially used IV bag with intravenous fluid with exposed sharps at the end of the IV tubing, she stated They would take the IV equipment down and put the pole back in the dirty utility to be cleaned. The DON was asked her expectation regarding equipment being disinfected, she stated They (equipment) should be wiped down in between each use, with bleach wipes. The DON was asked if wheelchairs (that are currently used by residents) are cleaned, she stated Yes, It's primarily the night time staff's responsibility to clean it if it needs to be cleaned. The DON failed to provide evidence that resident equipment was being disinfected as stated above. MM. On 06/26/15 at 9:42 am, during interview with the Administrator regarding PPE she stated My understanding is that if there is going to be any resident treatment, meaning changing of attends (disposable brief) or any kind of exposure to any potentially infected material, that's when they gown up. If they don't have contact with residents it's my understanding they don't have to. NN. On 06/26/15 at 10:25 am, during interview with Laundry Aide #1 she stated Isolation has different bags. [DIAGNOSES REDACTED] is in a yellow bag, and gets washed separately and anything with blood on it is in a red bag. She stated Sometimes the CNAs will tell me its (soiled linens) come from an isolation room. Laundry Aide #1 confirmed there are no yellow bags, CNAs put soiled linens in regular clear plastic bags. OO. On 06/26/15 at 12:34 pm, during interview the DON confirmed R #162 is still being treated for [REDACTED]. At this time, R #162 was taken off isolation and the isolation cart outside the room was removed. R #162 was still receiving the antibiotic [MEDICATION NAME] for [DIAGNOSES REDACTED]. PP. On 06/26/15 at 12:36 pm, during interview RN #3 stated she was unclear if the CNAs know how to chart (on the Activities of daily living (ADL) record) the differences between the types of stool. The term loose and watery is used interchangeably. QQ. On 06/26/15 at 2:48 pm, during telephone interview regarding washing machine temperatures the (Name of contracted company) Representative confirmed he was at the facility on 06/24/15. The last two months read out reports for the washing machines were discussed. After review the Representative stated he was not aware 130 degrees was not effective against bacteria as stated in the Infection Control Disinfection in the Laundry Process policy. He stated They (the facility) control the temperature of the water, I don't do that. If they need to raise the temperature that would be something they need to do. RR. On 06/26/15 at 3:00 pm, during interview with the Housekeeping Supervisor regarding the water temperature in the washing machines, she stated It should be higher. She confirmed the water was not hot enough to kill bacteria. SS. On 06/26/15 at 3:12 pm, during interview the Maintenance Supervisor confirmed he monitors the water temperatures for the washing machines in the facility. The Maintenance Supervisor was unaware of the discrepancy between (Names of contracted company) reports and his log book. TT. Record review of (Name of Maintenance Company) Service Detail Report-Laundry revealed the following: 1. 05/07/15 Linen pH (pH scale measures how acidic or basic a substance is) 6.5 and a Wash temp (temperature) of 130 deg (degrees) F (Fahrenheit). 2. 06/23/15 Linen pH 6.5 and a Wash temp of 130 deg F. UU. On 06/30/15 at 11:41 am, during interview with the Housekeeping Supervisor when asked how her department is notified of a resident who has been released from isolation? The Housekeeping Supervisor stated, I would be told in the morning managers meeting. Someone was taken off [DIAGNOSES REDACTED] last week I think. My staff would have done a 'Deep Clean' of the room. When asked to explain what 'Deep Clean meant', the Housekeeping Supervisor stated, the room would be cleaned with a bleach solution, curtains changed and the bed frame disinfected and mattresses wiped down front and back. When asked where the deep cleaning would be documented, the Housekeeping Supervisor stated that it would not be added to the Deep Cleaning calendar but that there would just be a note on her morning report sheet noting the room number and isolation status of that resident. When asked if she could produce this document she stated, I don't have it, I shred them at the end of the same day. VV. On 06/30/15 at 12:09 pm, during interview RN #3 stated, we let the housekeeping director know when a resident is taken off isolation. When asked how she would know the room was properly disinfected, RN #3 stated, The room was cleaned because (name of person) the housekeeping director told us. When question if anything was done with R #162, RN #3 asked for clarification. When asked if any care was given to R #162 specifically to ensure that R #162 was no longer harboring any [DIAGNOSES REDACTED] spores, she stated You mean clean him. I would have to check with the staff. When RN #3 was made aware there was no documentation proving R #162's was bathed or that the room had been 'Deep Cleaned', she had no response. RN #3 could not confirm if R #162 has been bathed or his room has been deep cleaned. R #162 was taken off contact isolation precautions on 06/26/15. WW. Record Review of Infection Control Disinfection in the Laundry Process Policy dated 01/01/00, revealed Most detergent and bleach cycles call for 140 F. to 160 F., which is far above the comfort zone for bacteria. In addition to the water temperature in the wash cycles, the temperature in the dryers provides substantial sanitation.Bacteria cannot exist beyond a pH of 8. A heavy alkali wash will raise the linens to a pH of 11 or 12 and will destroy any living organism in the wash. XX. Record review of Clostridium Difficile Procedure dated 07/01/14, indicated Contact Environmental Services to perform turnover/discharge cleaning when Precautions are discontinued. YY. Record review of Discontinuing Transmission Based Precautions revised on 10/01/13, indicated Inform the Housekeeping Department to perform discharge/turnover cleaning. ZZ. Record review of Discharge/turnover Room Cleaning revised on 11/01/12, indicated Resident/Patient rooms are cleaned and disinfected after discharge/turnover. Turnover is defined as discontinuation of Transmission Based Precautions. AAA. Record review of Personal Protective Equipment revised on 03/01/12, indicated Gloves will be worn when it is reasonably anticipated that the employee: Handles or touches contaminated items or surfaces. BBB. Record review of Standard Precautions Policy revised on 10/01/13, states Prevent transmission of microorganisms from used equipment .Do not use reusable equipment for the care of another individual until it has been cleaned and disinfected appropriately. CCC. Record review of the facilities Infection Control Nursing Principles and Practices PowerPoint dated May 2014, page 38 indicates that staff should consider all equipment including the residents environment is contaminated when dealing with a resident with [DIAGNOSES REDACTED]. DDD. Record review of CDC (Centers for Disease Control & Prevention) Guidelines for Management of Multidrug-Resistant Organisms in Healthcare Settings dated 2006, stated Clostridium Difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs) that becomes contaminated with feces may serve as a reservoir for the Clostridium Difficile spores. Clostridium Difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item .Use Contact Precautions: for patients with known or suspected Clostridium Difficile infection.Place these patients in private rooms. If private rooms are not available, these patients can be placed in rooms (cohorted) with other patients with Clostridium Difficile infection .Use gloves when entering patients' rooms and during patient care .Perform Hand Hygiene after removing gloves .Use gowns when entering patients' rooms and during patient care .Dedicate or perform cleaning of any shared medical equipment .Implement an environmental cleaning and disinfection strategy: Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. EEE. Record review of Association for Professionals in Infection Control and Epidemiology (APIC) Guide to Preventing Clostridium Difficile Infections dated 2013, review under Section 8: Special Considerations in Skilled Nursing Facilities regarding ambulation and socialization while in contact precautions stated, Have the resident perform hand hygiene, place a clean gown over the resident's clothing, and disinfect assistive devices (walkers, canes, wheelchairs) before leaving the room. FFF. Record review of CDC and Prevention Guideline for Environmental Infection control in Health-Care Facilities dated 2003, stated Most patients remain asymptomatic (not having symptoms) after infection, but the organism continues to be shed in their stools .the capacity to form spores (C. diff is a spore forming bacteria) enables the organism to persist in the environment (in soil or dry surfaces) for extended periods of time .high touch surfaces if patients bathroom, such as light switches, have been implicated as sources of infection .The proper use of gloves helps to minimize transfer of this pathogen from one surface to another .Colonized patients may also serve as a source of contamination.

A. On 06/23/15 at 8:57 am, during interview R #60 was asked if staff treat him with dignity and respect, he stated There is one skinny black nurse, I call her the black (explicative). She acts like I am poison. She acts and thinks she owns this place. I haven't told anyone because I don't know what would happen. She (Registered Nurse (RN #1) has a rotten attitude. One time I asked for a pain pill. I asked (name of RN #1) the nurse and she said 'I don't have to get you anything.' B. On 06/29/15 at 11:40 am, during interview with the DON she stated, Mainly my concerns with (name of RN #1) have been when she is asked to do something, I have heard from staff that she will say 'I don't have time to do it.' I have addressed this with her before and I've told her this is what you need to do, and if she doesn't know something, then she needs to go to the chart to find out. If something needs to be done for a resident, then she has to take the time to do it. The DON also stated, If I was going to be truthful, I think she could be (rude) at times, because I think they (staff) get a little stressed out on the North side because they don't have a med tech (medication technician) to pass medications and it is a heavy med (medication) pass over there. C. On 06/29/15 at 1:00 pm, during interview, the Administrator stated, I would hear from a lot of staff that her (RN #1) attitude and demeanor is lacking at times. D. On 06/29/15 at 1:35 pm, during interview CNA #1 stated There have been times when I have told her (RN #1) that a patient is in pain, and her (RN #1) response has been 'I'm too busy, or they will have to wait because I'm too busy.' CNA #1 then stated, at times, I'm afraid to approach her (RN #1) because she will say things like 'I don't want to hear it.' E. On 06/30/15 at 4:00 pm, during interview R #60 stated She (RN #1) treats me like (explicative) to tell you the truth. Let me give you an example, here a while back I gave this lady some money to get me some cigarettes, and she made the mistake of giving them to (Name of RN #1) and she (RN #1) acted like she owned them. She would only give me one at a time, and I had to ask her for my cigarettes. We (residents) go out to smoke break at ten thirty and we (residents) smoke more than one, and she would only give me one. They are my cigarettes. She acts like she owns this place. She is nothing but a stupid nurse. That's what I call her. R #60 stated that he had told another nurse, but telling anybody here is like telling the wind. R #60 does not remember who he told. R #60 was asked how long has this been going on, he stated It's been awhile. It started a long time ago. I was hurting one day, and I asked the head nurse (Name of Licensed Practical Nurse (LPN) #4) I for some pain pills and she told me to ask (Name of RN #1). She (RN #1) told me 'I don't have your pain pills, and I don't have to give you any.' From that day, I hated her guts. They (nurses) are here to make us feel better and she acts like she owns the place. When you're hurting, you ask for pain pills, they (nurses) are supposed to be here to help us. It makes me feel like she (RN #1) doesn't give a (explicative) about anybody here but herself. If I ask her for something nicely, she tells me 'I don't have to do anything.' She's here for a job and she doesn't do it. R #60 stated that he does not feel comfortable to ask for pain medications, I hate to be refused. Some of the older nurses are nice, but that black (explicative), I hate her guts. R #60 stated he has had pain in the past, but didn't ask for pain medication because she was his nurse. He stated I hate to even talk to her at all. She has a rotten attitude, like whatever she says goes. It makes me feel like she's here to help us, but she has an attitude.