Every finding on record at Las Cruces Village Nursing & Rehabilitation LLC

Based on observation, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for all 89 resident in the facility (residents were identified by the census list provided by the Administrator on 04/29/26) randomly sampled residents, when they failed to ensure a floor drain sink in the [NAME] Janitors room was in operable working condition after the drain became clogged. This deficient practice could likely result in residents living in an environment that puts them at risk of waterborne pathogens such as Legionella contamination microorganisms, bacteria and fungi, which could grow in stagnate accumulating water. The findings are: A. On 04/30/26 at 8:45 AM, during an observation of the 400 Unit revealed the following: 1. Water was coming from the [NAME] Janitor room out into the hallway floor. 2. When Houskeeper #24 opened the door there was a clogged floor drain roughly 10 inches full of black dirty water. B. On 04/30/26 at 8:48 AM, during an interview with Housekeeper #24 stated the following: 1. She spilt some water in the hall in front of the janitor room when she was dumping out her mop bucket in the floor drain sink. 2. She mopped it up. 3. She stated that the drain is clogged. 4. The floor drain sink is where they dispose of their cleaning chemicals from their mop buckets. 5. She told her supervisor, but it hasn't been fixed it. 6. She stated it's been a while. C. On 04/30/26 at 10:10 AM, during an interview with the Housekeeping Supervisor (HS) stated she has made several work orders regarding the [NAME] Janitor room and the water overflow. Maintenance has not fixed it. The HS stated she and her staff have been unclogging the drain on their own for months. D. On 04/30/26 at 10:16 AM, during an interview the Maintenance Director (MD) stated the following: 1. Housekeeping takes care of their department, and if anything is needed, the supervisor will let him know. 2. He had no active orders regarding water overflow. 3. Housekeeping should have done a work order for the [NAME] Janitor room. 4. This type of black water can carry diseases such as: bacteria, mold, e coli, salmonella, that cause skin infections and could possibly cause Legionella in the water. E. On 04/30/26 at 10:30 AM, during an interview, the Administrator stated he expects the staff to place work orders as soon as they find issues in the facility. He stated he expects staff to report issues immediately so the facility can take care of the issue right away.

Based on observation and interview, the facility failed to secure a treatment cart for all 27 residents on the 500 and 600 unit (residents were identified by the census list provided by the Administrator on 04/29/26). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are:A. On 04/29/26 at 8:40 am, during an observation, the nurses station revealed staff failed to secure a treatment cart on the 500/600 Unit. Staff were not present. B. On 04/29/26 at 8:44 am, during an interview, LPN #3 stated the treatment cart was unlocked. LPN #3 stated the treatment cart was the Treatment Nurse's (TN) cart. The TN was not on the unit. C. On 04/30/26 at 2:06 pm, during an interview, the [NAME] Consultant Nurse stated the treatment carts are supposed to be locked when not in use.

Based on interview and record review, the facility failed to provide the right to access personal and medical records pertaining to him or herself upon an oral or written request 1 (R #1) of 3 (R #1, R #2, and R #3) residents sampled for residents rights, when the facility failed to allow R #1's POA (the legally appointed person (the agent or attorney-in-fact) to make decisions or act on their behalf regarding financial, legal, or medical matters) [because R #1 did not have the capacity to on her own] to obtain R #1's medical record. If residents or their representatives acting on their behalf are not able to access their medical record, then they may not have the information needed to make healthcare decisions. The findings are:A. Record review of the State Agency Complaint Intake dated 03/24/26 revealed the following:R #1 had designated Family Member (FM) #1 as her POA.FM #1 was concerned about the care R #1 was receiving.FM #1 requested R #1's medical records before R #1 passed away.The facility never provided R #1's medical record. B. Record review of R #1's admission Record no date, revealed R 31 was admitted to the facility on [DATE]. C. Record review of R #1's care plan dated 03/10/25 revealed the following:1. R #1 had impaired cognitive function or impaired thought processes2. R #1 had a BIMS score of 5. D. Record review of R #1 POA form revealed the foolwoing:1. An effective date of 12/24/24.2. FM #1 had the authority to make decisions to: a. Long-term placement. b. Health care. c. Mental health including medications. d. Hospitalizations. E. Record review of the nursing progress notes dated 12/29/25 at 11:00 am, revealed the following note: .RP [FM #1] returned out of room with Resident while writer was speaking to ADON and approached ADON and writer stating, I am still waiting on medical records so I can sign whatever I need to sign to get my Mom's medical records. She is too busy on the phone. This is totally unacceptable. Look at my Mom. F. On 04/29/26 at 11:18 am, during an interview LPN #1 stated that if family members want to request medical records they had to go to see Medical Records (MR). G. On 04/30/26 at 10:50 am, during an interview MR confirmed the following:FM #1 did request to see R #1's medical records.MR gave her paperwork to fill out in order to get R #1 medical records twice.The first time FM #1 filled out the paperwork incorrectly.MR informed FM #1 that she needed to fill it out again. FM #1 did not give back the paperwork until after R #1 passed away.After a resident passes away the facility requests additional paperwork to release medical records.MR was aware FM #1 was R #1's POA and was able to act on her behalf.R #1 did not have the compacity to request medical records on her own.If it was a resident requested to have their medical record, they do not need to fill out paperwork. An oral request is sufficient.FM #1 never got R #1 medical records. H. Record review of the Determining Validity of Authorization for Release PHI (protected health information) facility policy revised date August 2020 revealed the following: I. The facility will use or disclose PHI pursuant to a valid authorization.II. The use or disclosure of PHI will be in a manner which is consistent with the authorization. I. Determining Which Disclosures Require an Authorization A. All requests from third party for release of PHI will go to the Medical Record Director. B. The Medical Records Director or his or her designee will determine whether the use or disclosure requires an Authorization from the resident.

Based on record review and interview, the facility failed to allow the resident the right to designate a representative and allow that representative the right to exercise the resident's rights to the extent those rights are delegated to the representative for 1 (R #1) of 3 (R #1, R #2, and R #3) residents sampled for residents rights, when the facility failed to allow R #1's POA (the legally appointed person (the agent or attorney-in-fact) to make decisions or act on their behalf regarding financial, legal, or medical matters) to obtain R #1's medical records. If resident representatives' decisions are not treated as that of a resident, then residents that do not have ability to make decisions for themselves are left with no one to advocate for their rights. The findings are:A. Record review of the State Agency Complaint Intake dated 03/24/26 revealed the following:R #1 had designated Family Member (FM) #1 as her POA.FM #1 was concerned about the care R #1 was receiving.FM #1 requested R #1's medical records before R #1 passed away.The facility never provided R #1's medical record. B. Record review of R #1's admission Record no date, revealed R #1 was admitted to the facility on [DATE]. C. Record review of R #1's care plan dated 03/10/25 revealed the following:1. R #1 had impaired cognitive function or impaired thought processes2. R #1 had a BIMS score of 5. D. Record review of R #1 POA form revealed the following:1. An effective date of 12/24/24.2. FM #1 had the authority to make decisions to: a. Long-term placement. b. Health care. c. Mental health including medications. d. Hospitalizations. E. Record review of R #1's nursing progress note dated 12/29/25 at 11:00 AM, revealed the following note: .RP [FM #1] returned out of room with Resident [R #1] while writer was speaking to ADON and approached ADON and writer stating, I am still waiting on medical records so I can sign whatever I need to sign to get my Mom's medical records. She is too busy on the phone. This is totally unacceptable. Look at my Mom. F. On 04/29/26 at 11:18 AM, during an interview LPN #1 stated that if family members want to request medical records they had to go to see Medical Records (MR). G. On 04/30/26 at 10:50 AM, during an interview MR confirmed the following:FM #1 did request to see R #1's medical records.MR gave her paperwork to fill out in order to get R #1 medical records twice.The first time FM #1 filled out the paperwork incorrectly.MR informed FM #1 that she needed to fill it out again. FM #1 did not give back the paperwork until after R #1 passed away.After a resident passes away the facility requests additional paperwork to release medical records.MR was aware FM #1 was R #1's POA and was able to act on her behalf.R #1 did not have the compacity to request medical records on her own.If it was a resident requested to have their medical records, they do not need to fill out paperwork. An oral request is sufficient.FM #1 never got R #1 medical records.

Based on record review, and interview, the facility failed to ensure care plan revisions were completed for 1 (R #24) of 3 (R #24, R #25, and R #26) residents reviewed for care plans, when the staff failed to revise the care plan with the most current resident information for R #24. This deficient practice could likely result in care plans not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care being provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. Record review of R #24's admission record, no dated revealed R#24 was admitted to the facility on [DATE]. B. On 04/29/26 at 11:20 AM, during an interview, with R #24's Family Member (FM) stated the following: 1. Housekeeper #26 caused R #24 to fall in her room. 2. Housekeeper #26 should not have assisted R #24 because she's not a CNA in the Secure Unit. 3. FM did not want Housekeeper #26 to work in the Secure Unit around R #24. 4. The pervious Administrator and DON informed FM on 12/10/26 that Housekeeper #26 would not work in the Secure Unit anymore. 5. This was told to the current Administrator and DON when they started to work and the facility. C. Record review of R #24's care plan revision date 06/26/25, revealed staff did not document a revision that included R #24's FM request to keep Housekeeper #26 from contact or care with R #24 in the Secure Unit. D. On 04/29/26 at 12:52 PM, during an interview, the Housekeeping Supervisor (HS) stated Housekeeper #26 does not work in the Secure Unit due to R #24's FM not wanting Houskeeper #26 working in the Secure Unit around R #24. E. On 04/29/26 at 2:42 PM, during an interview Housekeeper #26 stated that she is no longer working in the Secure Unit. Houskeeper #26 stated she is not to be in contact or care for R #24. F. On 04/30/26 at 10:04 AM, during an interview with MDS Nurse stated she is the person that inputs information into the residents' care plans. The staff did not let her know about R #24's FM, not wanting Housekeeper #26 to be in contact with or care for R #24 in the Secure Unit. MDS nurse stated that any changes to resident's care should be inputted into the care plan. R #24's care plan was not updated with this information. G. On 04/30/26 at 12:30 PM, during an interview, the ADON stated she did not see anything in R #24's care plan regarding FM's wishes to keep Housekeeper #26 from contact or care with R #24 in the Secure Unit. The ADON stated it should have been in R #24's care plan.

Based on observation and interview, the facility failed to post the Ombudsman contact information in areas accessible to residents and their representatives this could affect all 89 residents in the facility (residents were identified by the census list provided by the Administrator on 04/29/26). If residents and their representatives are not aware of how to contact the Ombudsman, then they would not be aware of how contact the Ombudsman about concerns they have. The findings are:A. On 04/29/26 at 9:35 AM, during an observation of the facility, revealed staff did not have the Ombudsman information posted. B. On 04/29/26 at 10:00 AM, during an observation of the Activities Room, revealed staff placed an 8.5 x 11-inch paper roughly at eye level on the side refrigerator with the Ombudsman information on it. C. On 04/30/26 at 12:47 PM, during an interview, the Administrator confirmed that the facility took down the Ombudsman's posters so the facility could paint. The Administrator confirmed staff failed to put the Ombudsman's posters back up after completion.

Based on observation and interview, the facility failed to retain 18 months of records for the posted nurse staff information, this could affect all 89 residents in the facility (residents were identified by the census list provided by the Administrator on 04/29/26). If the facility does not retain 18 months of posted staffing, then residents or the public would have access to review. The findings are:A. On 04/29/26 at 8:54 AM, during an observation of the front lobby revealed the posted nursing staff information for the day. B. On 04/29/26 at 8:58 AM, during an interview, the DON stated she was new. She stated she was not sure the facility had 18 months of posted nursing staff information. C. On 04/30/26 at 12:47 PM, during an interview, the Administrator stated the facility was trying to get access to the posted nursing staff information but was unable to.

Based on observation and interview, the facility failed to secure a medication cart for all 25 residents on the 500 and 600 units (residents were identified by the census list provided by the Administrator on 09/16/25). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are: A. On 09/16/25 at 8:45 AM, during an observation of the nurses' station on the 500/600 unit revealed a medication cart was in a central location near halls 500 and 600. Insulin pen needles (is an injection device that you can use to deliver preloaded insulin) and lancets (a single-use sharp pointed two-edged device that collects whole liquid blood sample) were on top of the medication cart that was left unattended. B. On 09/16/25 at 8:48 AM, during an interview LPN #28, confirmed that the insulin pens and lancets were on top of the medication cart. C. On 09/16/25 at 8:48 AM, during an interview with the ADON, she confirmed that medications and lancets should be locked inside the medication cart.

Based on observation, record review and interview, the facility failed to revise the care plan for 2 (R #8, and R #10) of 3 (R #8, R #9, and R #10) residents reviewed for neglect when they failed to revise the care plan for the resident's need for the following: 1. R #8 and R #10's briefs and approaches (any action, treatment, or strategy intentionally undertaken to prevent, treat, or improve an individual's health, functioning, or well-being). 2. R #8 and R #10's beds in lowest position and fall mats in place for fall risk. 3. R #8 no longer being an elopement (the unauthorized departure of a resident from the facility without the knowledge or supervision of staff) risk. This deficient practice could likely result in staff being unaware of changes in care being provided and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:R #8 A. On 09/08/25 at 3:17 PM, during an observation of R #8's room, revealed R #8's bed was in the lowest position and there was a fall mat by her bed. R #8 was wearing a brief. B. Record review of R #8's care plan, dated 12/24/24, revealed the following: 1. R #8 is a high risk for falls. 2. The care plan did not contain any documentation of the bed being in the lowest position and a fall mat or approaches for the bed positioning and mat. 3. R #8 is incontinent of bowel and bladder (experiencing a loss of control over when you urinate and defecate). 4. The care plan did not contain any documentation of R #8's briefs and approaches. C. Record review of R #8's care plan, dated 07/10/25, revealed R #8 is at risk for elopement. D. Record review of R #8's quarterly minimum data set (MDS a standardized collection of essential clinical and demographic information about an individual or service, designed to create a comprehensive understanding of their condition, needs, or performance) revealed R #8 is dependent (helper does all effort, resident does none of the effort) for activities of daily living care (ADL basic self-care tasks). E. On 09/09/25 at 3:21 PM, during an interview, the DON stated care plans should document if a resident needs the bed in the lowest position and if a fall mat is needed. The DON confirmed R #8's care plan did not contain any documentation that R #8 requires the bed to be in the lowest position, a fall mat and the interventions for them. The DON confirmed R #8's care plan documents that R #8 is an elopement risk. The DON said that the resident is not able to get out of bed on her own and is not able to elope. The DON stated R #8's care plan should be updated to document that R #8 is not at risk for elopement. R #10 F. On 09/09/25 at 3:13 PM, during an observation of R #10's room revealed R #10's bed was in the lowest position and that there was a fall mat in her room. G. On 09/09/25 at 3:15 PM, during an interview, CNA #9 confirmed R #10's bed is in the lowest position and when R #10 is in bed, they put the fall mat down. CNA #9 said R #10 has a history of falls. H. Record review of R #10's care plan dated 06/19/25, revealed the following. 1. R #10 is a high risk for falls. 2. The care plan did not contain any documentation of the bed being in the lowest position, a fall mat and interventions for the bed positioning and fall mat.3. R #10 is incontinent of bowel and bladder. 4. The care plan did not contain any documentation of R #10's briefs and interventions. I. On 09/09/25 at 3:21 PM, during an interview, the DON confirmed R #10's care plan did not contain any documentation that R #10's requires fall mat and bed to be in the lowest position. The DON stated the approaches should be documented. The DON confirmed R #10 is incontinent of bowel and bladder. The DON stated that if a resident uses briefs, they should be care planned. The DON confirmed R #10's care plan did not contain any documentation R #10 wears briefs and the approaches for the briefs.

Based on record review, and interview, the facility failed to meet professional standards of quality care for 11 of 19 residents on the 400 Unit (residents were identified by the resident matrix provided by the Administrator on 09/08/25) when staff failed to round on residents (regularly check on residents to assess needs, safety and comfort). This deficient practice could likely lead to the residents' needs and care not being met. The findings are: A. Record review of the state agency's complaint intake dated 07/29/25 revealed R #8 had fallen out of bed and was left on the floor for approximately three hours without staff rounding. B. Record review of a video from the facility's camera of the 400 unit on 06/14/25 at 11:00 PM until 06/15/25 at 3:23 AM revealed staff did not round on the following rooms: 1. 401 with 2 residents. 2. 402 with 2 residents. 3. 404 with 2 residents. 4. 405 with 2 residents. 5. 406 with 1 residents. 6. 410 with 2 resident. C. On 09/09/25 at 9:40 AM, during an interview, the Administrator stated staff did not round as is expected. The administrator said that standard practice is that residents are rounded on at least every 2 hours. The Administrator confirmed the facility video revealed staff did not round on rooms 401, 402, 404, 405, 406, and 410 between 11:00 PM and 3:23 PM.

Based on record review and interview, the facility failed to provide evidence for the alleged violations of neglect and exploitation were thoroughly investigated for 2 (R #8 and R #16) of 6 (R #8, R #9, R #10, R #16, R #17, and R #18) residents reviewed for allegations of neglect and misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent). If the facility does not keep evidence of investigations, then the state agency is unable to determine if a thorough investigation was completed and determine if the facility implemented appropriate actions to protect residents. The findings are: R #8 A. Record review of R #8's admission record, no date, revealed R #8 was admitted to the facility on [DATE]. B. Record review of R #8's quarterly MDS assessment, dated 07/10/25, revealed he had a Brief Interview for Mental Status (BIMS a number between 0 and 15 that indicates a person's cognitive functioning) score of 0 (Severe Impairment 0-7). C. Record review of the state agency's complaint intake dated 07/29/25 revealed R #8 had fallen out of bed and was left on the floor for approximately three hours without staff rounding (intentionally and regularly visit patients to assess their needs, discuss their care, and address potential issues proactively). D. Record review of the facility's incident report dated 06/15/25, revealed the Administrator did not document that she interviewed all staff that worked the night of 06/14/25 and 06/15/25 when R #8 fell and was on the floor. The Administrator did not document that she spoke with R #8's family. The incident report did not contain any documentation that the facility's video was reviewed or the findings of the video. E. On 09/09/25 at 12:18 PM, during an interview, the Administrator stated she did not have documentation of the interviews she did with the other staff and family of R #8. The Administrator stated she did view the facility's video, but she does not have documentation of the findings. R #16 F. Record review of R #16's admission documents, no date, revealed resident was admitted to the facility on [DATE]. G. Record review of R #16's quarterly MDS, dated [DATE], revealed he had a BIMS score of 15. H. Record review of R #16's grievance report, dated 07/31/25, revealed the following: 1. R #16 and the transportation worker met with SSD after returning from the bank. 2. R #16 reported there were many unauthorized transactions on his bank statement. 3. R #16 reported that $60 cash was missing from his wallet. 4. R #16 kept his wallet wrapped in towels and Velcro. 5. The document had half a sentence and an arrow to turn the page over, however, there was no documentation on the back of the page or any other pages attached. I. On 09/09/25 at 12:58 PM, during an interview, the Administrator stated the following: 1. She completed the investigation of R #16's allegation of misappropriation of property and was unable to determine who took R #16's money and the purchases with his card were not within the United States. 2. She did not have evidence to prove that the allegation of misappropriation of property was thoroughly investigated. J. On 09/10/25 at 11:47 AM, during an interview, the corporate nurse confirmed the following: 1. Administrators are expected to document interviews that are conducted regarding investigations. 2. Administrators are expected to keep all documents related to an investigation.

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 1 (R #24) of 3 (R #24, R #26 and R #27) 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: A. On 09/15/25 at 9:04 AM, during an interview with R #24's family member, she stated R #24 did not have a plan of care in place. B. Record review of R #24's admission Record, no date revealed R #24 was admitted into the facility on [DATE]. C. Record review of R #24's physician orders dated 08/25/25, revealed wound care to the sacrum (a large triangular-shaped bone located at the base of the vertebral column) area cleanse with wound cleanser and pat dry apply Collagen powder (a type of protein that forms the connective tissues in our bodies), and Barrier cream (a cream used to protect the skin from damage or infection) and cover with silicone dressing (a type of wound care product made from silicone gel or silicone-based materials) daily and PRN (as needed). D. Record review of R #24's progress notes dated 08/22/25 revealed staff documented R #24 had a small shallow sacral ulcer that was present on admission. E. Record review of R #24's admission MDS dated [DATE], revealed the following: 1. Staff documented R #24 had one-stage 2 pressure ulcer/injury (stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis) that was present upon admission. 2. Staff documented R #24's need for pressure ulcer/injury care. F. Record review of R #24's baseline care plan, dated 08/22/25, revealed the following: 1. Staff did not document R #24's pressure ulcer. 2. Staff did not document R #24 need for wound care. G. On 09/16/25 at 1:31 PM during an interview with the DON, he confirmed R #24's baseline care plan did not indicate R #24 had a pressure ulcer. The DON also confirmed R #24's baseline care plan did not include the need for wound care. The DON stated his expectation is that the nurses should care plan the needs of residents within the first 48 hours of admission.

Based on interview, and record review the facility failed to keep the resident free from neglect for 1 (R #8) of 3 (R #8, R #9, and R #10) residents reviewed for neglect when staff failed to conduct rounds (check on) on a resident and was left on the floor after a fall for 3 hours and 10 mins. This deficient practice could likely result in the resident suffering from lack of care, having anger, fear, and anxiety as a result of their neglect, and not getting the help she needs in a timely manner. The findings are: A. Record review of R #8's admission record, no date, revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8 has the following diagnosis: a. Parkinson's disease with dyskinesia, with fluctuations (a condition where a person experiences the typical symptoms of Parkinson's disease, such as tremors, rigidity, and slow movements, along with involuntary, writhing movements). b. Repeated falls. c. Muscle weakness (generalized). d. Need for assistance with personal care. e. Dependence on a wheelchair. f. Disorientation (the condition of having lost one's sense of direction), unspecified. g. Unspecified abnormalities of gait and mobility (difficulty walking or moving that has no clearly identified cause or specific type). B. Record review of a video from the motion activated camera in R #8's room, revealed the following: 1. On 06/15/25 at 12:50 AM, R #8 was on the floor beside her bed. 2. On 06/15/25 at 3:59 AM, R #8 was heard shrieking and moaning. 3. On 06/15/25 at 4:01 AM, CNA #8 was seen entering R #8's room and finds R #8 on the floor. C. Record review of a video from the facility's camera revealed the following: 1. Staff entered R #8's room on 09/14/25 at 9:46 PM. 2. Staff did not reenter R #8's room again until 09/15/25 at 4:01 AM. D. On 09/08/25 at 2:31 PM, during an interview, R #8's daughter stated the facility called her and told her R #8 had fallen out of bed on the morning of 09/15/25. R #8's daughter stated she called her brother and asked him to review the video from R #8's room. R #8's daughter stated that is when they saw R #8 had fallen out of bed and been on the floor for 3 hours. R #8's daughter stated R #8 is not able to use the call light. R #8's daughter stated R #8 is nonverbal and not able to call out for help because she has Parkinson's disease. R #8's daughter stated R #8 is not able to ambulate (walk; move about) on her own. E. On 09/09/25 at 9:40 AM, during an interview, the Administrator stated that she had viewed the facility's video and confirmed staff did not go into R #8's room from 06/14/25 at 11:00 pm until 06/15/25 at 4:00 AM. The Administrator stated her expectation and the standard practice are for staff to conduct rounds on residents every two hours and more often if the resident is not able to call for help on their own. The Administrator confirmed R #8 could have been on the floor for 5 hours and that R #8 is not able to push the call light, call out for help, or get up on her own.

Based on record review and interview, the facility failed to provide treatment and services specialized in managing and healing wounds that do not heal properly for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time) for 1 (R #24) of 3 (R #8, R #24 and R #25) residents reviewed for pressure ulcers, when staff failed to: Obtain wound care orders for R #24's pressure ulcer until three days after admission, Perform wound care for one day of the six days R #24 was in the facility. These deficient practices could likely result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of pressure ulcers. The findings are:A. On 09/15/25 at 9:04 AM, during an interview with R #24's family member, she stated R #24 had a wound when he got to the facility and did not receive wound care on 08/21/25 (day of admission). R #24 received wound care on 08/25/25. B. Record review of R #24's face sheet no date, revealed R #24 was admitted to the facility on [DATE]. C. Record review of R #24's MDS dated [DATE], revealed the following: 1. Staff documented R #24 had one-stage 2 ulcer/injury (stage 2 pressure ulcers are characterized by partial-thickness skin loss into but no deeper than the dermis) pressure ulcer/injury that was present upon admission. 2. Staff documented a clinical assessment (a formal assessment instrument/tool (e.g., Braden, [NAME], or other) was completed for the pressure ulcer. D. Record review of R #24's physician orders dated 08/25/25, revealed wound care to the sacrum (a large triangular-shaped bone located at the base of the vertebral column) area cleanse with wound cleanser and pat dry apply Collagen powder (a type of protein that forms the connective tissues in our bodies), and Barrier cream (a cream used to protect the skin from damage or infection) and cover with silicone dressing (a type of wound care product made from silicone gel or silicone-based materials) daily and PRN (as needed). E. Record review of R #24's Treatment Administration Record (TAR, electronic document where facility staff document wound care was completed) for August 2025 revealed staff did not document any wound care provided to R #24 upon admission to the facility on [DATE] for the following dates: 1. 08/21/25, 2. 08/22/25, 3. 08/23/25, 4. 08/25/25, 5. 08/26/25, 6. 08/27/25. F. Record review of R #24's progress notes for August 2025 revealed staff did not document that wound care was not completed for R #24. G. On 09/16/25 at 10:32 AM, during an interview with the Wound Care Nurse (WCN), he stated he was off when R #24 was admitted on [DATE]. He did a skin assessment on 08/24/25 when he returned. The WCN noted a stage 2 pressure ulcer/injury to R #24's sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hip bones of the pelvis). The WCN stated his expectation is that the floor nurses use their nursing education and obtain orders to perform treatment on residents. H. On 09/16/25 at 1:31 PM, during an interview with the DON, he confirmed his expectation for the nurses is within the first 48 hours of admission to do the following: 1. Obtain basic care orders with the in-house provider, 2. Provide wound care, and 3. Follow-up with Wound Care Nurse.

Based on observation, interview, and record review, the facility failed to store and serve food under sanitary conditions by professional standards of food service safety, this could affect all 78 residents living in the facility (residents were identified by the Resident Matrix provided by the Administrator on 06/22/25). When they failed to ensure staff maintain refrigerator temperatures in the dietary west wing kitchen. This deficient practice could expose residents to foodborne illnesses, which includes failing to maintain safe food temperatures. This can lead to a range of health risks, such as foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins), affecting residents and requiring immediate attention to ensure their safety.The findings are:A. On 06/23/25 at 7:15 AM, during an observation of the west wing kitchen the refrigerator temperature log temperatures were not documented for 06/21/25 and for 06/22/25.B. Record review of the refrigerator temperature log revealed the temperature log did not contain any records of temperatures for 06/21/25 and 06/22/25.C. On 06/25/25 at 11:22 AM, during an interview, the Dietary Director (DD) confirmed there were no temperatures logged for 06/21/25 and 06/22/25. The DD stated her expectations is that refrigerator temps are done daily by the dietary staff.

A. On 06/26/25 at 10:41 AM, during an interview, ADON #2 confirmed that she is the current IP and confirmed that she has started but has not completed the required IP training and does not have the training certificate yet.B. On 06/27/25 at 10:12 AM, during an interview, the Director of Clinical Services confirmed that ADON #2 had not completed the required IP training to receive her certification.

Based on the record review and interview, the facility failed to ensure RN coverage was provided for 8 consecutive hours a day and for 7 days a week. This failure could potentially affect all 79 residents who lived in the facility (residents were identified by the Resident Matrix provided by the Administrator on 06/23/25. This deficient practice is likely to result in residents not receiving the services they require. The findings are:A. Record review of the Payroll Base Journal (PBJ) Staffing Data Report (report from the data base of the federal agency overseeing certification for long term care facilities) dated Quarter #1 (October 1 through December 31) 2025 revealed no RN coverage for at least 8 consecutive hours on 10/19/24, 10/20/24, 10/26/24, and 10/27/24.B. On 06/27/25 at 3:40 PM during an interview, the corporate nurse stated they were unable to provide proof of RN coverage for 10/19/24, 10/20/24, 10/26/24, and 10/27/24.

Based on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections when they failed to have a water management program to minimize the risk of Legionella [a bacteria that can grow in parts of building water systems that are continually wet (e.g., pipes, faucets, water storage tanks, decorative fountains) and cause a serious type of pneumonia] and other opportunistic pathogens (bacteria that do not usually cause diseases in healthy people but may become extremely injurious to unhealthy individuals) in the building's water system. This failure could potentially affect all 79 residents who lived in the facility (residents were identified by the Resident Matrix provided by the Administrator on 06/23/25). If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are:A. Record review of the facility's Legionnaires' Disease and Water Management Program Policy and Procedure, dated 06/01/19, revealed the following: 1. The facility will annually identify where legionella could grow. 2. Documentation of control measures to prevent growth of legionella and other waterborne pathogens. B. On 06/27/25 at 11:42 AM, during an interview, the Maintenance Supervisor (MS) said that he did not have a map or diagram of the water system and potential sources for the growth of waterborne pathogens. The MS said that he does not have measures in place to prevent the growth of legionella and other waterborne pathogens in the building water system. The MS said that if there is a problem he calls the city or the people they contract with if they have problems.

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 3 (R #12, R #17, R #44,) of 6 (R #1, R #7, R #12, R #17, R #44, and R #75) residents reviewed for unnecessary medications, when staff failed to ensure: 1. Psychotropic medications for R #12 were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. A gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) was carried out for R #44. 3. Psychotropic medications ordered to be given as needed (PRN) for R #17 were not prescribed for longer than 14 days without documentation of the rationale to extend beyond 14 days in the resident's medical record including an indication for the duration of the PRN order. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are:Diagnosis R #12 A. Record review of R #12's admission record, no date, revealed the following: 1. R #12 was admitted to the facility on [DATE]. 2. R #12 did not have a psychiatric diagnosis. B. Record review of R #12's physician's order dated 04/15/25, revealed an order for sertraline (an antidepressant medication) 25 mg, give half a tablet in the morning for anxiety (intense, excessive, and persistent worry and fear about everyday situations). C. Record review of R #12's MAR dated June 2025, revealed the following regarding sertraline administration: 1. 06/01/25, medication refused (code 2). 2. 06/02/25, code 2. 3. 06/03/25 through 06/27/25, medication administered as ordered. D. On 06/27/25 at 11:54 AM, during an interview, the corporate nurse confirmed the following: 1. R #12 was taking sertraline for anxiety. 2. R #12 did not have a diagnosis of anxiety. 3. Staff are expected to ensure there is a psychiatric diagnosis for the psychotropic medications that are ordered. Gradual Dose Reduction R #44 E. Record review of R #44's admission record, no date, revealed the following: 1. R #44 was admitted to the facility on [DATE]. 2. With the following diagnoses: a. Dementia with other behavioral disturbance (refers to the non-cognitive symptoms that frequently accompany dementia, significantly impacting the individual's quality of life and the burden on caregivers. These disturbances can manifest as changes in mood, perception, and behavior, often appearing in the middle to later stages of the disease). b. Recurrent depressive disorder (multiple episodes of major depressive disorder, where symptoms last for at least two weeks. Each episode involves a period of depressed mood and loss of interest or pleasure in activities, along with other symptoms like changes in appetite, sleep, energy, and concentration). c. Anxiety Disorder. F. Record review of R #44's physician's orders multiple dates, revealed an order dated 11/30/23, for venlafaxine (antidepressant medication) 75 mg three times a day for depression. G. Record review of R #44's MAR dated June 2025, revealed R #44 received venlafaxine as ordered from 06/01/25 through 06/27/25. H. Record review of the pharmacist's recommendation dated 04/10/25, revealed the following: 1. The pharmacist recommended a dose reduction for venlafaxine. 2. The provider selected resident had a good response (no specifics as to what good response means) and wanted to continue the current dose. 3. The provider's rationale was no, depression - stable. I. Record review of R #44's entire medical record, no date, revealed the following: 1. R #44 had not had a dose reduction for venlafaxine since it was ordered on 11/30/23. 2. The provider did not document a rationale for why a dose reduction was contraindicated for R #44. J. On 06/27/25 at 11:44 AM, during an interview, the corporate nurse confirmed the following: 1. R #44 was taking venlafaxine 75 mg three times a day since 11/30/23. 2. Resident's should undergo a dose reduction periodically unless there is a documented reason why the dose should not be decreased. 3. R #44's medical record did not have documentation of a rationale for why R #44 should not have a dose reduction for venlafaxine. PRN Psychotropics R #17 L. Record review of R #17's admission record (no date) revealed the following: 1. R #17 was admitted to the facility on [DATE]. 2. R #17's diagnosis; Generalized anxiety disorder (mental health condition that causes excessive, frequent and unrealistic worry about everyday situations). M. Record review of R #17's physician's orders revealed the following: 1. Order date 05/14/25, lorazepam (benzodiazepine medication primarily used to treat anxiety disorders) 2 mg/ml, give 0.25 mg by mouth every four hours as needed for anxiety. 2. Lorazepam order did not include a duration. N. Record review of R #17's MAR dated MAY 2025, revealed the following: 1. R #17 received lorazepam on 05/18/25 at 9:04 PM. 2. R #17 received lorazepam on 05/21/25 at 8:13 PM. 3. R #17 received lorazepam on 05/22/25 at 6:50 AM. O. Record review of R #17's MAR dated JUNE 2025, revealed the following: 1. R #17 received lorazepam on 06/18/25 at 8:56 PM. 2. R #17 received lorazepam on 06/19/25 at 10:21 PM. P. Record review of R #17's provider progress note dated 06/21/25 revealed no documentation regarding the continued need for lorazepam. Q. On 06/27/25 at 3:35 PM, during an interview, the corporate nurse confirmed the following: 1. R #17 was taking lorazepam as needed since 05/14/25. 2. R #17 PRN lorazepam was ordered for greater than 14 days and the order did not have a duration of use.

Based on interview, observation, and record review, the facility failed to provide a safe, comfortable, and homelike environment for 2 (R #47 and R #61) of 4 (R #27, R #30, R #47 and R #61) residents reviewed for missing property, when staff failed to ensure that that resident property was free from loss or theft. This deficient practice could likely cause residents to feel like they are not living in a safe, comfortable, and home-like environment and like they are not valued. The findings are:R #47 A. On 06/23/25 at 11:37 AM, during an interview, R #47 stated the following: 1. A couple of months ago (unsure of date), two of his hats went missing. 2. He notified a CNA or nurse (unsure of staff name). 3. He had not heard anything else about his missing hats. B. Record review of the facility's grievance log, dated 03/01/25 through 06/25/25, revealed there were no grievances regarding R #47's missing hats. C. Record review of R #47's entire medical record, no date, revealed staff did not document an inventory of R #47's belongings. D. On 06/25/25 at 11:22 AM, during an interview, LPN #16 stated the following: 1. She was not aware R #47 was missing two hats. 2. When resident's have missing property, staff will try to find it. 3. If she does not find the missing property, she will notify the administrator when she sees her. 4. She stated the facility does not have a list of items that residents are missing so staff know to look for them. 5. She stated that resident's should have an inventory sheet with all the resident's belongings. 6. She confirmed R #47's medical record did not have an inventory sheet. E. On 06/25/25 at 11:27 AM, during an interview, ADON #1 stated the following: 1. He was not aware R #47 was missing two hats. 2. If a resident is missing property, staff were expected to look for the missing property. 3. If staff were unable to find the missing property, they were expected to notify direct supervisor about resident's missing property. 4. The social services director (SSD) should have completed a grievance form for any missing property. 5. If a resident's property is not found, the administrator will replace the property if it was on the resident's inventory sheet. 6. He confirmed R #47's medical record did not have an inventory sheet. 7. Staff were expected to update resident's inventory sheet with any new property. F. On 06/25/25 11:33 AM, during an interview, the SSD confirmed the following: 1. She was not aware R #47 was missing two hats. 2. She did not have a grievance form for R #47's missing hats. 3. When staff are notified that a resident is missing property, staff are expected to fill out a grievance form and give it to her. 4. Staff are expected to try to find the resident's missing property. 5. If resident's property is not found, the facility will replace the item. R #61 G. On 06/23/25 at 10:23 AM, during an interview, R #61's sister stated the following: 1. R #1's elbow brace has been missing for a couple of months (unsure of exact date). 2. R #1's sister notified a CNA (unsure of staff name) that the brace was missing. 3. R #1's sister has not heard anything regarding the missing brace. H. Record review of the facility's grievances log, dated 03/01/25 through 06/25/25, revealed there were no grievances regarding R #61's missing brace. I. On 06/27/25 at 1:46 PM, during an observation of R #61's room and interview, CNA #1 stated the following: 1. R #61 did have a brace. 2. CNA #1 looked in R #61's room and confirmed that the brace was not in the room. J. On 06/27/25 at 2:20 PM, during an interview, ADON #1 stated the following: 1. R #61 did have a brace. 2. R #61 stopped wearing the brace due to it rubbing her arm. K. On 06/27/25 at 2:27 PM, during an interview with occupational therapy assistant #1 (OTA; healthcare professional who works under the supervision of an occupational therapist to help patients develop, recover, and improve the skills needed for daily living and working) the following was revealed: 1. R #61 did have a brace. 2. OTA is not sure what happened to R #61's brace. L. On 06/25/25 at 11:40 AM, during an interview, the corporate social services worker confirmed the following: 1. Staff are expected to complete a grievance form for any missing property.

During a complaint and Covid 19 investigation the following was discovered: 1) Interviews and observations with staff revealed that staff were not aware of the isolation/quarantine zones within the building and what PPE requirements apply to each area including the area in which they were assigned. 2) Interviews and observations revealed staff were not compliant with PPE requirements both willing and unknowingly: a. CNA #4, CNA #5, and RN #3 confirm that there was no sign indicating that R #6 was on droplet precautions or PPE outside of her room for staff to use. R #6 had tested positive for Covid-19 but had not been moved from her unit to the Hot Unit/Red Zone (the unit that was set up for covid-19 positive residents.) b. CNA #5 entered R #6's room wearing N95 mask, face shield and gloves (no gown was worn). c. CNA #4 and CNA #5 did not remove their gowns (CNA #5 did not have a gown) upon exiting R #6's room where they provide care. d. CNA #4 and CNA #5 transported R #6 from her room in Yellow Zone (for suspected exposure without positive Covid-19 test results) into the Hot Unit. CNA #4 and CNA #5 entered the Hot Unit in same fashion, CNA #4 wearing the same gown and CNA #5 not wearing a gown. CNA #4 and CNA #5 continue to work until the end of their shift. e. RN #3 enter R #6's room (before CNA #4 and CNA #5 transferred her to the Hot unit) wearing a gown but did not change gown after entering the R #6. RN #3 continued to provide care to other residents on that unit which was a non-Covid positive unit. f. SM #3, who later tested Covid-19 positive, willingly did not wear proper PPE inside the isolation zones on two separate occasions. SM #7 also willing did not wear proper PPE. 3) During interviews and observations revealed disinfecting of high touch surface areas (i.e. door knobs, and hand rails) were not being disinfected. Also, disinfecting supplies were only available during housekeeping hours: 8:00 am -4:30 pm. Nursing staff are unable to disinfect high touch surfaces between the hours of 4:30 pm -8:00 am. This resulted in an Immediate Jeopardy that was called on 07/24/20 at 2:04 pm. A plan of removal was submitted on 07/24/20 at 6:00 pm, and was rejected. A final plan of removal was approved on 07/24/20 at 11:30 pm. Plan of Removal Plan of Removal of IJ Component This plan is to remove the level of severity of the alleged failed practice that resulted in the infection control .: Facility staff are not aware of the isolation/quarantine units within the building and what PPE requirements apply: 1. No visible signage in the units/outside resident doors indicating to precautions staff should be taking, 2. Staff not compliant with PPE requirements as evidenced by observation of staff entering a Covid positive room without proper PPE or removal of PPE upon exiting room. 3. Nurse enter (sic) Covid positive resident's room without (sic) with only a surgical mask (no N95) face shield, gown and gloves and did not remove gown upon exiting room and continued to provide care to other residents on a non-Covid positive unit with potentially contaminated PPE still on. 4. CNA's provided care and transferred a Covid positive resident to the Covid positive unit wearing N95 mask, face shield and gloves (no gown was worn). 5. Disinfecting supplies are available only during housekeeping hours: 8 am - 4:30 pm. Nursing staff are unable to disinfect high touch surfaces between the hours of 4:30 pm - 8:00 am. 1. Residents on Wing 400 could be affected by the deficient practice. Nurse and CNA identified as being potentially negatively affected by a failure to follow infection control and wearing proper PPE supplies. The facility recognizes that residents have the potential to be affected by the RN's and CNA's alleged deficient practice. 2. Immediate Actions to Remove Risk: A. Actions to change immediacy of the failed practice: · Education and competency verification has been provided for nursing staff currently working on the floor 07/24/2020 Putting on and Taking Off Personal Protective Equipment. · Education and competency verification will be provided for nursing staff on Putting on and Taking Off PPE prior to working their next scheduled shift. · Education provided for staff currently working on the floor 07/24/2020 about isolation zones and appropriate PPE to be worn. · Education will be provided for staff about isolation zones and appropriate PPE to be worn prior to them working their next shift. · Education has been provided for housekeeping and nursing staff currently working on the floor 07/24/2020 about responsibilities for cleaning/disinfecting High touch surfaces (sic) areas. · Education will be provided for housekeeping and nursing staff about responsibilities for cleaning/disinfecting high touch surfaces areas prior to working their next scheduled shift. · Access to cleaning supplies are available for nursing staff 24 hours a day, 7 days a week. Education has been provided to nursing staff on how to access cleaning supplies after housekeeping hours. · Appropriate Signs are posted on patient doors for isolation/quarantine precautions and appropriate PPE. · Infection Control compliance: Facility will monitor and audit appropriate PPE use, cleaning/disinfecting high touch areas and appropriate isolation/quarantine zone signage. 3. Addition: Plan of Removal of IJ Component: · Zone Color Description and Precautions please see attachments: PPE Equipment is identified in each Zone description. Appropriate PPE were provide (sic) to staff in each Zone. · Red Zone (Isolation Zone) All residents that have tested positive for COVID-19. · Yellow (Quarantine Zone) All Asymptomatic residents who may have been exposed to Covid-19 · Green Zone (Covid-Free Naïve Zone) All asymptomatic residents who are not considered to be exposed to Covid-19 · Gray zone (Transitional Zone) All asymptomatic residents without known COVID exposure who are (re) admitted to nursing home · Education has been provided for housekeeping and nursing staff currently working on the floor 07/24/2020 about responsibilities for cleaning/disinfecting high touch surfaces (sic) areas. Housekeeping and nursing created audits to monitor cleaning of high touch surfaces (sic) areas such as handrails, medication carts, walls and surfaces (sic) areas, high touch surfaces will be cleaned twice a shift or as needed. Audits will be conducted by Housekeeping Supervisor, Staff Development Coordinator/QAPI, or assigned designees. Upon verification of the Plan of Removal implemention, the Immediate Jeopardy was lifted 07/25/20 at 3:03 pm. This resulted in the scope and severity being reduced from a level 4, L to level 2, F. Based on observation, interview, and record review, the facility failed to implement proper infection control practices for CoVID-19, when the facility failed to: 1) ensure staff were knowledgeable of the different isolation/quarantine zones, 2) ensure staff were wearing proper PPE, and 3) ensure staff were cleaning high touch surface areas and had cleaning supplies available between 4:30 pm- 8:00 am. This has the potential to affect all 54 residents at the facility (residents were identified by the census list provided by the Executive Director on 07/21/20). This deficient practice resulted in 13 residents contracting COVID-19. The findings are: A. On 07/21/20 at 12:10 pm, during an interview, the DON confirmed that the facility had 5 (R #1, R #2, R #3, R #4, & R #5) positive residents for Covid-19, but that none of those residents were in the facility at that time. B. On 07/22/20 at 12:40 pm, during an interview, the DON confirmed that the facility had received 8 (R #6, R #7, R #8, R #9, R #10, R #11, R #12, & R #13) more positive test results for residents. Seven residents were in the facility at that time. R #13 had passed away over the previous weekend (07/18/20 to 07/19/20). C. On 07/22/20 at 3:50 pm, during an interview, the DON stated that the facility has three zones of isolation; the Red zone for residents who tested positive, Grey zone for new admissions, and the yellow zone for suspected exposure without positive Covid-19 test results. Findings related to Yellow Zone: D. Record review of the Isolation Zone Document no title dated 07/24/20 revealed Yellow Isolation zone PPE needed gloves, gown, N-95 mask and eye protection. E. On 07/23/20 at 1:25 pm, during an observation of the area designated as the Yellow Zone revealed two closed double doors to enter the Yellow Zone. No hand sanitizer stations were set up on any of the 3 hallways at that time. At the nurses' station that the hallways split off from had some hand sanitizer. Each of the 3 hallways did have one sink with soap just outside of the shower rooms. F. On 07/23/20 at 1:30 pm, during an interview, Staff Member (SM) #1 stated that she had not been given any guidance on how long to wear PPE or when to change it. SM #1 was not familiar with what zone of isolation she was in. SM #1 confirmed that she had been providing care to residents. G. On 07/23/20 at 1:35 pm, during an interview, SM #2 stated that she had not received guidance on PPE with respect to how long she could wear it, when did the face shields need to be disinfected, and what PPE was needed in the zone she was on. SM #2 stated that another staff member just handed the gown to her with no instruction other than to wear it. SM #2 confirmed that she had been providing care to residents. H. On 07/23/20 at 1:42 pm, during an interview, SM #3 was not wearing a gown. She stated that she was only given a hospital gown and stated, It would not protect me. So, I took it off. SM #3 confirmed that she had been providing care to residents. I. On 07/23/20 at 1:55 pm, during an interview, the Infection Preventionist stated that the facility had three zones of isolation: Red Zone, Grey Zone, and Yellow Zone. She confirmed that SM #1, SM #2, SM #3 were all working in the Yellow Zone. The IP confirmed that SM #3 should have been wearing a gown, face shield/goggles, and N-95 mask. The IP confirmed that she has not provided education to all staff about the zones of isolation and donning and doffing of PPE. J. On 07/23/20 at 2:45 pm, during an interview with SM #7 in the yellow zone, SM # 7 was not wearing a gown. SM #7 did not know what zone her unit was designated as. She stated she was given a cloth hospital gown with no instructions on how to use it or when to change it. SM #7 stated It has short sleeves it's made of cloth and it won't protect me so I'm not wearing it. SM #7 confirmed that she had been providing care to residents. K. On 07/23/20 at 3:45 pm, during an interview with SM #4 in the yellow zone, SM #4 stated that she was issued a N-95 mask but not given guidance as to when to use it. SM #4 was wearing a gown, face shield, and surgical mask. SM #4 confirmed that she had been providing care to residents. L. On 07/24/20 at 8:25 am, during an interview with SM #6 in the yellow zone, SM #6 stated that some staff were non-compliant with wearing PPE. SM #6 stated that some staff would pull their masks down at the nurses station and when they would talk to other staff members. M. On 07/24/20 at 1:20 pm, during an interview with SM #3 in the yellow zone, SM #3 stated that she was issued a N-95 mask but that it was hard for her to breathe through the shift with it on, so she was currently not wearing it. SM #3 was observed wearing googles, surgical mask, and gown. SM #3 confirmed that she had been providing care to residents. N. On 07/28/20 at 12:30 pm, during an interview the DON reported a list of residents and staff members who tested positive for CoVID-19. The DON stated that eight staff members had tested positive from late June 2020 to 07/28/20. The DON confirmed that SM #3 and SM #4 were among those that had tested positive for Covid-19 upon notification of their positive results today, they had been working daily at the facility. Findings related to Social Distancing: O. On 07/23/20 at 2:40 pm, during an observation of the lobby area revealed that the facility had a local government agency in the facility to provide fit testing for the N-95 masks. Staff were observed not social distancing themselves (at least 6 feet from another person) with about 20-25 staff members in the lobby area waiting to be fit tested . When brought to the Executive Director and DON's attention, they asked that staff socially distance outside of the facility. Observation of the area in front of the building revealed staff sitting in shade in groups of 4-5 and SM #8 and SM #9 have their face masks pulled down below their chin talking to one another. No one was 6 feet or great apart. During an interview at that time, the DON confirmed that staff were still not socially distancing, and that SM #8 and SM #9 were not wearing their masks. Findings related to R #6: P. On 07/23/20 at 3:45 pm, during an interview, SM #4 confirmed that R #6 had not been moved from the Yellow Zone to the Red Zone (Hot Zone) until early that afternoon. SM #4 confirmed that there had not been a sign on R #6 door in the Yellow Zone indicating what PPE was needed or that R #6 was on precautions. (Reminder: Per finding B, the facilty had received notification that R #6 was CoVID positive on 07/22/20.) Q. On 07/23/20 at 3:51 pm, during an interview, CNA #4 revealed that she and CNA #5 went into R #6's room to get R #6 ready to be transferred from the Yellow Zone into the Red Zone. CNA #4 stated that they gave R #6 care and packed some belongings. CNA #4 stated that she was wearing a N-95 mask, face shield, gown, and gloves. CNA #4 confirmed that CNA #5 was not wearing a gown but had on a N-95 mask, face shield, and gloves. CNA #4 stated that they took R #6 from her room in Yellow Zone through the lobby and to the Red Zone without changing any PPE, only changing their gloves. CNA #4 stated that they entered the Red Zone and transferred the resident into the bed of her new room. CNA #4 stated that upon leaving the Red Zone they were stopped and told to wash their hands up to their elbows and given new yellow gowns to wear. CNA #4 confirmed that she worked until the end of her shift. R. On 07/23/20 at 3:56 pm, during an interview, RN #3 stated that she had gone into R #6 room before she was transferred to the Red Zone. RN #3 stated that she wore only a surgical mask (no N95 mask), face shield, gown and gloves. RN #3 was asked if she had changed her gown when she had exited R #6's room. She stated that she had not and was still wearing the same gown she had worn when she entered R #6 room earlier in the day. RN #3 was asked if she gone into any other resident's rooms, and she confirmed that she had. S. On 07/23/20 at 4:01 pm, during an interview, the DON stated that R #6 had not been moved to the Red Zone because she was on hospice and was not expected to last the night and also the weather had been so bad they did not want to move her (as they would have had to take R #6 outside the building to enter the Red Zone). The DON confirmed that there was no signage posted outside of R #6's room when she was in the Yellow Zone to indicate she was on precautions. The DON confirmed that there was no PPE outside R #6's room for staff to use. The DON confirmed that the staff should have been wearing Face shield/googles, gown, N-95 mask, and gloves. The DON confirmed that the CNA's should not have gone into the Red Zone. The DON also confirmed that RN #3 should have changed her gown after entering R #6's room. T. On 07/24/20 at 12:00 pm during an interview, CNA #5 confirmed that she and CNA #4 went into R #6's room to get her ready to be transferred from the Yellow Zone into the Red Zone. CNA #5 stated that they gave R #6 care before the moved her. CNA #5 stated that she was not wearing a gown, just a N-95, face shield, and gloves. CNA #5 continued to state that CNA #4 had a N-95 mask, face shield, gown, and gloves. CNA #5 confirmed that R #6 was taken from her room in Yellow Zone through the lobby and into the Red Zone. CNA #5 confirmed that neither her or CNA #4 changed PPE, except for their gloves after giving care. CNA #5 stated that once in the Red Zone, they transferred R #6 in to her bed. CNA #5 confirmed that upon leaving the Red Zone they were stopped and told to wash their hands up to their elbows and issued new yellow gowns to wear. CNA #5 confirmed that she worked until the end of her shift. Findings related to High Touch Surface Areas: U. On 07/22/20 at 12:10 pm, during an interview, SM #6 stated that Housekeeping staff were not cleaning high touch surface areas (i.e. door knobs, and hand rails). V. On 07/22/20 at 3:35 pm, during an interview, SM #4 stated that Housekeeping staff had not been disinfecting high touch surface areas. SM #4 also stated that cleaning supplies were not always available; and that housekeeping had the disinfecting supplies. W. On 07/23/20 at 1:35 pm, during an interview, SM #2 stated that Housekeeping was not disinfecting high touch surface areas. SM #2 confirmed that disinfecting supplies were not readily available for staff to use; becuase Housekeeping kept them. X. On 07/23/20 at 2:48 pm, during an interview and observation, the Housekeeping Supervisor (HS) stated that her staff had been educated to wipe down high touch surface areas while they were on shift from 8:00 am to 4:30 pm. Observation of the housekeeping closet located near the nurses station revealed 2 bottles of disinfectant spray. HS was asked who continues with disinfecting high touch surface areas after housekeeping leaves and she stated I wouldn't know. HS confirmed that the closet is locked when housekeeping leaves for the day. Y. On 07/23/20 at 3:20 pm, during an interview and observation, SM # 8 stated and pointed out that there was no disinfectant spray or wipes available at the nurses station. She stated that she had not been informed/educated to wipe down any areas, she had not been shown where the disinfectant spray is kept and she proceeded to state that once housekeeping leaves she doesn't know who wipes down the high touch surface areas. Z. On 7/23/20 at 3:35 pm, during an interview, the Infection Preventionist (IP), stated that nursing staff had been educated on the need to disinfect high touch surface areas. The IP stated she did not have any documentation for the education provided and she had not completed process surveillance on wiping down surface areas. AA. No observations of facility staff disinfecting of high touch surface areas were made by surveyors during the course of the survey.

During a complaint investigation the following was discovered: 1) R #1 was readmitted to the facility after a fracture hip without any pressure ulcers on 02/20/18 it was document in the Wound RN Assessment that R #1 had developed 2 stage 2 pressure wounds (Partial thickness skin loss involving the epidermis and/or dermis) one on his left buttock, one on his right buttock, and a Suspected Deep Tissue Injury (a type of pressure injury) to R #1's left heel. 2) R #1's left buttock pressure ulcer healed, however R #1's right buttock developed into a stage 4 pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle). 3) After admission, residents were only getting skin observations by CNA's during resident showers (unless the resident already had wounds then the wound nurse would do skin assessments, nursing staff were not performing skin assessments for residents at risk for pressure ulcers), if a CNA noticed something during the skin observation then they would alert the nurse who would refer the resident to the wound nurse. 4) CNA documentation for repositioning was blank in several areas, and CNA documentation of wounds during shower was inaccurate. 5) Observation of R #1 revealed interventions ordered and on care plan not in place or being implemented. R #1 was observed in the same position upon several observations. R #1 heels were not elevated with pillow or Spenco boots (boot used to help protect R #1's heel) 6) R #1's CNA and Nurse were unfamiliar with his Care Plan 7) Concerns identified by the Wound Nurse #1 like CNA being unable to identify worn or improper pressure relieving devices, CNA needing retraining on repositioning residents, and documentation by CNAs and Nurses did not get reported to administration for actionable interventions. This resulted in an Immediate Jeopardy that was called on 05/17/18 at 4:00 pm. A plan of removal was submitted on 05/18/18 at 9:22 am, 1:15 pm, 2:40 pm and were rejected. A final plan of removal was approved on 05/18/18 at 3:00 pm. This plan is to remove the level of severity of the alleged failed practice of pressure ulcer identification, assessment, documentation. 1. Total number of residents at risk of the failed practice: This has the potential to affect all residents at risk for breakdown. 2. Immediate Actions to Remove Risk: A. Actions to change immediacy of the failed practice i. Immediately following confirmation of the alleged failed practice by State Surveyor at approximately 4:30 pm on 5/17/18, resident #1's care plan was reviewed by DON, Administrator and Wound Care Nurse. Interventions were updated to clarify resident's continence status, brief type. Education was provided to nursing staff on duty during the evening of (MONTH) 17th, (YEAR) regarding pressure ulcer practice guidelines including skin observation/assessments, repositioning. This education includes information about assessment and evaluation of skin both initially and ongoing, prevention strategies to mitigate skin breakdown, evaluating current interventions for continued effectiveness, and following pans of care which includes where to identify skin breakdown prevention interventions and repositioning schedules. Understanding will be evaluated via quiz. ii. All residents were assessed for skin integrity on 5/17/2018-5/18/2018. All care plans for residents with Braden scores of 18 or below were reviewed and updated on 5/17/18 - 5/18/2018 if to ensure appropriateness. All residents with Braden scores of 18 or less were reviewed on 5/17/2018-5/18/2018. All residents with Braden Scores 18 or less will have weekly skin observations by charge nurse or designee. B. Actions taken to prevent recurrence of the failed practice i. Audits on positioning will be conducted on Resident #1 and 2 additional residents at risk for skin breakdown daily x 10 days, then weekly x 2 then monthly x 6. Weekly nutrition risk/pressure ulcer committee will monitor high risk resident's status for potential and actual skin breakdown and report any trends to monthly QAPI committee. These audits include identifying care plan interventions for skin breakdown prevention, repositioning schedules, staff knowledge regarding intervention and observations of resident skin documentation completed by nurse and CAN to ensure accuracy. Results will be brought to monthly QAPI meeting for review and further recommendations. Documentation will be reviewed by DON or designee. ii. All Nursing staff members will be educated by Staff Development Director or designee before they are allowed to work again regarding pressure ulcer practice guidelines including skin observation/assessment, repositioning. This education includes information about assessment and evaluation of skin both initially and ongoing, prevention strategies to mitigate skin breakdown, evaluating current interventions for continued effectiveness, and following plans of care which includes where to identity skin breakdown prevention interventions and repositioning schedules. Understanding will be evaluated via quiz. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted 05/18/18 at 3:01 pm. This resulted in the scope and severity being reduced from a K to an E. Based on observation, interview, and record review, the facility failed to develop/implement Care Plans for 3 (R #1, R #2, and R #3) of 4 (R #1, R #2, R #3, and R #4) residents review for wounds, diet, infections, and foley catheters, when the facility failed to 1) implement R #1 Care Plan for his pressure wounds, 2) R #1's CNA and Nurse were unfamiliar with his Care Plan, 3) failed to update R #2's care plan for her diet, and 4) failed to follow Physician order [REDACTED].#1, and R #3. This deficient practice help contribute R #1's pressure wounds. The findings are: History and Records of R #1's Pressure Wounds A.Record review of the Convalescence Orders from the Hospital dated 02/05/18 revealed R #1 returned form the hospital on [DATE]. No documentation of any pressure wounds were found. B. Record review of the Multi-Disciplinary Note Wound Care Consultation from the hospital stay from 03/31/18 to 04/05/18, dated 04/02/18, revealed R #1 to have a stage 4 pressure ulcer on coccyx. C. Record review of the Wound RN Assessments revealed: 1. 02/20/18 revealed 2 new (one on the left and one on the right buttock) stage 2 pressure ulcers for R #1 that were not present upon admission. 2. 03/05/18 - 03/28/18 - right buttock unstageable pressure ulcer. 3. 04/06/18 - right buttock stage 4 D. Record review of the Wound Data Collection Left Buttock revealed the following: 1. Initial finding not present on admission; 02/20/18 - length (L) 5.0 cm, Width (W) 1.5 cm, Depth (D) blank 2. 02/27/18 - L 6.0 cm, W 3.0 cm, D 0.1 cm 3. 03/05/18 - L 5.8 cm, W 3.0 cm, D blank 4. 03/14/18 - wound closed 5. 03/21/18 - wound closed E. Record review of the Wound Data Collection Right Buttock revealed: 1. Initial finding not present on admission; 02/20/18 - L 6.1 cm, W 3.9 cm, D 0.1 cm 2. 02/27/18 - L7 cm, W 3.9 cm, D 0.1 cm 3. 03/05/18 - L 6.7 cm, W 3.1 cm, D blank 4. 03/14/18 - L 3.6 cm, W 2.1 cm, D blank 5. 03/21/18 - L 3.0 cm, W 2.6 cm, D 0.5 cm 6. 03/28/18 - L 3.5 cm, W 2.5 cm, D 2.0 cm 7. 04/06/18 - L 3.5 cm, W 3.0 cm, D 2.0 cm 8. 04/16/18 - L 3.5 cm, W 3.0 cm, D blank 9. 04/24/18 - L 3.6 cm, W 2.8 cm, D 1.5 cm 10. 05/01/18 - L 3.5 cm, W 2.0 cm, D 2.0 cm 11. 05/08/18 - L 2.0 cm, W 3.5 cm, D 1.0 cm 12. 05/15/18 - L 3.0 cm, W 2.0 cm, D 2.0 cm F. Record review of R #1's physician's orders [REDACTED]. G. Record review of the Wound Data Collection Left Heel revealed the following: 1. Initial finding not present on admission 02/26/18 L 4.1 cm, W 5.5, D blank Resident has a fluid filled blister to the lateral side of his Left heel. It is very tight & filled; does seem to be deep D/T how the tissues to this area feel. At this time it does not appear like he has any S/S of infection to this heel blister . Float heels off of his bed when he is in his bed; protect his heel with Spenco Boot. 2. 04/24/18 - L 1.5 cm, W 1.4 cm, D blank Airflow mattress & continues to be turned and repositioned Q 2 hours. Float his heels off of the bed when he is in his bed & keep Spenco boot on him at all times & keep heels elevated off of the bed. 3. 05/08/18 - L 1.0 cm, W 1.0 cm, D blank 4. 05/15/18 - L 1.0 cm, W 1.0 cm, D blank H. On 05/16/18 at 12:07 pm, during an interview the WN (Wound Nurse) #1 confirmed that R #2's pressure wounds were facility acquired pressure wounds (pressure wound developed in the facility). WN #1 stated that R #1 had been in the secure unit due to wondering. The WN #1 stated that R #1 had fallen and fractured his hip in (MONTH) (YEAR) and was sent out to the hospital for treatment/surgery. She continued to state that when he returned he was not able to walk around like he did before. The WN #1 stated R #1 had a hard time adjusting to not being able to walk and his new room/unit. The WN #1 stated R #1 would have a behavior of rocking back and forth and that WN #1 thought that had contributed to his pressure wounds on heels and buttocks. The WN #1 stated He never had wounds because he was mobile before his fall. I. Record review of R #1's Care Plan dated revealed the following: 1. 04/06/18 - The resident has actual impairment to skin integrity R/T (related to) hospitalization [MEDICAL CONDITION] (life threatening complication of an infection); Aspiration Pneumonia (occurs when food, saliva, liquids, or vomit in breathed into the lungs causing an infection); UTI (urinary tract infection); Stage 4 Pressure Injury; S/P Fall with Left Hip fx (fracture) and ORIF surgical repair; Dementia, [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION]; Depression .; Sleep Disorder; chronic [MEDICAL CONDITION] E/B (evidenced by) bruising to his upper extremities; extremely dry heels with pressure injury to left heel; hx SDTI [MEDICAL CONDITION] (suspected deep tissue injury). o Monitor location, size and treatment of [REDACTED]. to health care provider. o Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. o Keep skin clean and dry. Use lotion on dry skin. Do not apply on site of injury. o Assist Resident to turn and reposition in bed ~Q (every) 2 hours and PRN (as needed) Right to Left only. o Turn and reposition in chair Q 1 hour and PRN. o Elevate heels off bed; especially his Left one. o PT, OT, & ST to Evaluate & Treat. o Weekly skin observation by licensed nurse. o Keep skin clean and dry. Use topical cream, powder and liquid sealants to prevent or treat skin conditions. Do not apply on site of injury. o PT/OT referral if ordered. o Resident needs pressure relieving/reducing mattress, and chair cushion to protect the skin while in bed and while up in his W/C (wheelchair). 2. 04/24/18 - o The resident has 1 Stage 4 pressure ulcer & 1 SDTI to Left Heel R/T S/P hospitalization from [MEDICAL CONDITION]/Aspiration Pneumonia, UTI, S/P fall with left hip fx and ORIF surgical repair(nailing), [MEDICAL CONDITIONS], depression, anxiety, [MEDICAL CONDITION] E/B Open pressure area to his upper Right buttock area with depth of 2.0 & under tunneling & Hx of pressure area to his Left heel. Formation of another blister to his Left Lateral heel; 04/09/2018. Another open area to Left heel on 04/24/2018; long thin shallow open area; healing Stage 2. o Assess/record/monitor wound healing Daily. Report improvements and declines to the health care provider. o Provide supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. o Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. Documentation of Repositioning R #1 J. Record review of the Activities of Daily Living Sheets for (MONTH) (YEAR) revealed the following: 1. Assist Resident to turn and reposition in bed~Q 2 hours and PRN Right to Left only. The evening shift 2:00 pm -10:00 pm was blank on (MONTH) 26 and 27. 2. Turn and reposition in chair Q 1 hour and PRN. The evening shift 2:00 pm -10:00 pm was blank on (MONTH) 26 and 27. K. Record review of the Activities of Daily Living Sheets for (MONTH) (YEAR) revealed the following: 1. Assist Resident to turn and reposition in bed~Q 2 hours and PRN Right to Left only. The evening shift 2:00 pm -10:00 pm was blank on (MONTH) 2 and 4. The day shift 6:00 am -2:00 pm was blank on (MONTH) 4 and 8. 2. Turn and reposition in chair Q 1 hour and PRN The day shift 6:00 am -2:00 pm was blank on (MONTH) 8. 3. Turn and reposition in bed q 2 hours. On 04/13/18 was blank 12:00 am. On 04/13/18 at 2:00 am, 4:00 am, and 6:00 am, 04/16/18 12:00 am, 04/19/18 12:00 am, 04/21/18 12:00 am, 04/23/18 12:00 am, 04/25/18 12:00 am, 04/30/18 12:00 am were all marked with an X. 4. Turn and reposition in bed q 2 hours. 04/12/18 at 8:00 pm and 10:00 pm, 04/13/18 at 10:00 pm, 04/16/18 at 10:00pm, 04/19/18 at 10:00 pm, 04/21/18 at 10:00 pm, 04/23/18 at 10:00 pm, 04/25/17 at 10:00 pm were all blank. L. On 05/22/18 at 10:40 am, during an interview the MDSC stated that if there are blank spots on the ADL Sheets then CNAs are not documenting. The MDSC was not sure what the X marks were on the ADL Sheet as there was no X on the response key. Observations R #1 M. On 05/16/18 at 8:30 am, 9:23 am, 10:45 am, 2:54 pm, 4:04 pm; 05/17/18 at 8:09 am, 9:00 am, 10:23 am, 3:07 pm, and 4:03 pm revealed resident to be in his bed laying on his left side for all observations. N. Record review of the orders dated 04/06/18 revealed Turn & Reposition Q (every) 2 hours & PRN (as needed); Left To Right Only Position heels Off of his bed, use pillows & Spenco boots to protect them. Every shift for Stage 4 Pressure Wound & Preventative. O. On 05/17/18 at 10:23 am, during an observation of R #1's room and interview with LPN #3 confirmed that R #1's heels did not have the pressure relieving devices; no Spenco boots or pillow in place for him to use. P. On 05/17/18 at 4:03 pm, during an observation of R #1's room and interview with CNA #1 confirmed that R #1 had only the Spenco boots on. The pillow for R #1's feet was at the foot of bed, not in use. CNA #1 was asked what R #1's Care Plan stated intervention for his wounds were. CNA #1 stated she was not sure. Q. On 05/17/18 at 4:07 pm, during an observation of R #1's room and interview with LPN #4 confirmed that R #1 had only the Spenco boots on. The pillow for R #1's feet was at the foot of bed, not in use. LPN #4 was asked what R #1's Care Plan stated intervention for his wounds were LPN #1 stated I have to look it up. I know where it is but have to look it up. R #1 Diet R. Record review of R #1 physician's orders [REDACTED]. S. Record review of R #1 Diet Card no date revealed thin puree to nectar thick consistency, so it can be served in cups no straws ensure plus with all meals. T. On 05/21/18 at 12:27 pm, during an interview The Dietary Supervisor confirmed that R #1's order did not match his card for it was missing the no salt added. The DS confirmed that R #1 was not recieving the diet as ordered for his meals. R #2 Diet U. Record review of R #2's physician's orders [REDACTED]. V. Record review of R 32's Care Plan dated 03/16/2018 revealed the following: The resident has potential nutritional Problem . regular diet, chopped meats with gravy, regular thin liquids at meals. W. Record review of the R #2's Diet Card dated 05/08/18 revealed Cardiac diet X. Record review of the Patient Discharge Instructions 05/08/18 revealed Regular diet, regular texture, regular fluid consistency. Y. On 05/21/18 at 11:58 am, during an interview the MDSC confirmed the R #2's care plan was not revised to reflect her new diet order. She also confirmed that the order was not the same as the meal card. She was upgraded but no one told me or brought that paper work. We check at the Nutrition at Risk meeting but that has not happened because (Name of DON) is out. R #3 Diet Z. Record review of R #3's Physician's or dated 05/14/18 revealed Heart Healthy level 2-mechanical texture, regular fluid consistency. AA. Record review of the Patient Discharge Instructions dated 05/14/18 revealed Cardiac diet mechanical soft texture. BB. Record review of R #3's Diet Card dated 05/14/18 revealed no salt added diet mechanical soft texture. CC. On 05/21/18 at 12:27 pm, during an interview The Dietary Supervisor confirmed that R #3's order did not match his card for heart healthy diet it was written for NAS. The DS confirmed that R #3 was not recieving the diet as ordered for his meals. They are not the same heart healthy is low fast healthy oil, and low salt ect. No salt added is no salt added, we can liberalize this diet to no salt added but need an order. DD. On 05/21/18 at 1:01 pm during an interview the WN #1 stated that there needs to be some education on what a cardiac diet means, the nurses think it means no added salt.

During a complaint investigation the following was discovered: 1) R #1 was readmitted to the facility after a fracture hip without any pressure ulcers on 02/20/18. It was document in the Wound RN Assessment that R #1 had developed 2 Stage 2 pressure wounds (Partial thickness skin loss involving the epidermis and/or dermis (skin)) one on his left buttock, one on his right buttock, and a Suspected Deep Tissue Injury (a type of pressure injury) to R #1's left heel. 2) R #1's left buttock pressure ulcer healed, however R #1's right buttock developed into a Stage 4 pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle). 3) After admission, residents were only getting skin observations by CNA's during resident showers (unless the resident already had wounds then the wound nurse would do skin assessments, nursing staff were not performing skin assessments for residents at risk for pressure ulcers). If a CNA noticed something during the skin observation, then they would alert the nurse who would refer the resident to the wound nurse. 4) CNA documentation for repositioning was blank in several areas, and CNA documentation of wounds during shower was inaccurate. 5) Observation of R #1 revealed interventions ordered and on care plan not in place or being implemented. R #1 was observed in the same position upon several observations. R #1 heels were not elevated with pillow or in Spenco boots (boot used to help protect R #1's heel). 6) R #1's CNA and Nurse were unfamiliar with his Care Plan. 7) Concerns identified by the Wound Nurse #1 like CNA being unable to identify worn or improper pressure relieving devices, CNA needing retraining on repositioning residents, and documentation by CNAs and Nurses did not get reported to administration for actionable interventions. This resulted in an Immediate Jeopardy that was called on 05/17/18 at 4:00 pm. A plan of removal was submitted on 05/18/18 at 9:22 am, 1:15 pm, 2:40 pm and were rejected. A final plan of removal was approved on 05/18/18 at 3:00 pm. This plan is to remove the level of severity of the alleged failed practice of pressure ulcer identification, assessment, documentation. 1. Total number of residents at risk of the failed practice: This has the potential to affect all residents at risk for breakdown. 2. Immediate Actions to Remove Risk: A. Actions to change immediacy of the failed practice i. Immediately following confirmation of the alleged failed practice by State Surveyor at approximately 4:30 pm on 5/17/18, Resident #1's care plan was reviewed by DON, Administrator and Wound Care Nurse. Interventions were updated to clarify resident's continence status, brief type. Education was provided to nursing staff on duty during the evening of (MONTH) 17th, (YEAR) regarding pressure ulcer practice guidelines including skin observation/assessments, repositioning. This education includes information about assessment and evaluation of skin both initially and ongoing, prevention strategies to mitigate skin breakdown, evaluating current interventions for continued effectiveness, and following pans of care which includes where to identify skin breakdown prevention interventions and repositioning schedules. Understanding will be evaluated via quiz. ii. All residents were assessed for skin integrity on 5/17/2018-5/18/2018. All care plans for residents with Braden scores of 18 or below were reviewed and updated on 5/17/18 - 5/18/2018 if to ensure appropriateness. All residents with Braden scores of 18 or less were reviewed on 5/17/2018-5/18/2018. All residents with Braden Scores 18 or less will have weekly skin observations by charge nurse or designee. B. Actions taken to prevent recurrence of the failed practice i. Audits on positioning will be conducted on Resident #1 and #2, additional residents at risk for skin breakdown daily x 10 days, then weekly x 2 then monthly x 6. Weekly nutrition risk/pressure ulcer committee will monitor high risk resident's status for potential and actual skin breakdown and report any trends to monthly QAPI committee. These audits include identifying care plan interventions for skin breakdown prevention, repositioning schedules, staff knowledge regarding intervention and observations of resident skin documentation completed by nurse and CAN to ensure accuracy. Results will be brought to monthly QAPI meeting for review and further recommendations. Documentation will be reviewed by DON or designee. ii. All Nursing staff members will be educated by Staff Development Director or designee before they are allowed to work again regarding pressure ulcer practice guidelines including skin observation/assessment, repositioning. This education includes information about assessment and evaluation of skin both initially and ongoing, prevention strategies to mitigate skin breakdown, evaluating current interventions for continued effectiveness, and following plans of care which includes where to identity skin breakdown prevention interventions and repositioning schedules. Understanding will be evaluated via quiz. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted 05/18/18 at 3:01 pm. This resulted in the scope and severity being reduced from a K to an E. Based on observation, interview, and record review, the facility failed to prevent residents at risk for pressure ulcers from obtaining pressure ulcers, when the facility failed to 1) prevent R #1's pressure ulcers: one that healed, one that progressed to a stage 4 pressure ulcer, and one suspected deep tissue injury, 2) have nursing staff assess resident skin, 3) ensure CNA documentation for repositioning was complete (it was blank in several areas), and CNA documentation of wounds during shower was inaccurate, 4) Observation of R #1 revealed interventions ordered and on care plan not in place or being implemented. R #1 was observed in the same position upon several observations. R #1 heels were not elevated with pillow or in Spenco boots (boot used to help protect R #1's heel), 5) R #1's CNA and Nurse were unfamiliar with his Care Plan, 6) Concerns identified by the Wound Nurse #1. For example, CNA being unable to identify worn or improper pressure relieving devises, CNA needing retraining on repositions residents, and documentation by CNAs and Nurses did not result in any interventions. This has the potential to affect all 35 resident at risk for pressure ulcers Braden Score of less than 18 (residents were identified by the list provided by the administrator on 05/18/18). The findings are: History and Records of R #1's Pressure Wounds A. Record review of the Convalescence Orders from the Hospital dated 02/05/18 revealed R #1 returned form the hospital on [DATE]. No documentation of any pressure wounds. B. Record review of the Multi-Disciplinary Note Wound Care Consultation from the hospital stay from 03/31/18 to 04/05/18, dated 04/02/18, revealed R #1 to have a Stage 4 pressure ulcer on coccyx. C. Record review of R #1's Care Plan dated revealed the following: 1. 04/06/18 - The resident has actual impairment to skin integrity R/T (related to) hospitalization [MEDICAL CONDITION] (life threatening complication of an infection); Aspiration Pneumonia (occurs when food, saliva, liquids, or vomit in breathed into the lungs causing an infection); UTI (urinary tract infection); Stage 4 Pressure Injury; S/P Fall with Left Hip fx (fracture) and ORIF surgical repair; Dementia; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION]; Depression .; Sleep Disorder; chronic [MEDICAL CONDITION] E/B (evidenced by) bruising to his upper extremities; extremely dry heels with pressure injury to Left heel, and history of SDTI [MEDICAL CONDITION] (suspected deep tissue injury). o Monitor location, size and treatment of [REDACTED]. to health care provider. o Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. o Keep skin clean and dry. Use lotion on dry skin. Do not apply on site of injury. o Assist Resident to turn and reposition in bed ~Q (every) 2 hours and PRN (as needed) Right to Left only. o Turn and reposition in chair Q 1 hour and PRN. o Elevate heels off bed; especially his Left one. o PT, OT, & ST to Evaluate & Treat. o Weekly skin observation by licensed nurse. o Keep skin clean and dry. Use topical cream, powder and liquid sealants to prevent or treat skin conditions. Do not apply on site of injury. o PT/OT referral if ordered. o Resident needs pressure relieving/reducing mattress, and chair cushion to protect the skin while in bed and while up in his W/C (wheelchair). 2. 04/24/18 - o The resident has 1 Stage 4 pressure ulcer & 1 SDTI to Left Heel R/T S/P hospitalization [MEDICAL CONDITION]/Aspiration Pneumonia, UTI, S/P fall with left hip fx and ORIF surgical repair(nailing), [MEDICAL CONDITIONS], depression, anxiety, [MEDICAL CONDITION] E/B Open pressure area to his upper Right buttock area with depth of 2.0 & under tunneling & Hx of pressure area to his Left heel. Formation of another blister to his Left Lateral heel; 04/09/2018. Another open area to Left heel on 04/24/2018; long thin shallow open area; healing Stage 2. o Assess/record/monitor wound healing Daily. Report improvements and declines to the health care provider. o Provide supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. o Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration, etc. noted during bath or daily care. D. Record review of the Wound RN Assessments revealed: 1. 02/20/18 - revealed 2 new (one on the left and one on the right buttock) Stage 2 pressure ulcers for R #1 that were not present upon admission. 2. 03/05/18 - 03/28/18 right buttock: unstageable pressure ulcer. 3. 04/06/18 - right buttock: Stage 4 E. Record review of the Wound Data Collection Left Buttock revealed the following: 1. Initial finding not present on admission: 02/20/18 - length (L) 5.0 cm, Width (W) 1.5, Depth (D) blank 2. 02/27/18 - L 6.0 cm, W 3.0 cm, D 0.1 cm 3. 03/05/18 - L 5.8 cm, W 3.0 cm, D blank 4. 03/14/18 - wound closed 5. 03/21/18 - wound closed F. Record review of the Wound Data Collection Right Buttock revealed: 1. Initial finding not present on admission: 02/20/18 - L 6.1 cm, W 3.9 cm, D 0.1 cm 2. 02/27/18 - L7 cm, W 3.9 cm, D 0.1 cm 3. 03/05/18 - L 6.7 cm, W 3.1 cm, D blank 4. 03/14/18 - L 3.6 cm, W 2.1 cm, D blank 5. 03/21/18 - L 3.0 cm, W 2.6 cm, D 0.5 cm 6. 03/28/18 - L 3.5 cm, W 2.5 cm, D 2.0 cm 7. 04/06/18 - L 3.5 cm, W 3.0 cm, D 2.0 cm 8. 04/16/18 - L 3.5 cm, W 3.0 cm, D blank 9. 04/24/18 - L 3.6 cm, W 2.8 cm, D 1.5 cm 10. 05/01/18 - L 3.5 cm, W 2.0 cm, D 2.0 cm 11. 05/08/18 - L 2.0 cm, W 3.5 cm, D 1.0 cm 12. 05/15/18 - L 3.0 cm, W 2.0 cm, D 2.0 cm G. Record review of R #1's physician's orders [REDACTED]. H. Record review of the Wound Data Collection Left Heel revealed the following: 1. Initial finding not present on admission; 02/26/18 - L 4.1 cm, W 5.5, D blank Resident has a fluid filled blister to the lateral side of his Left heel. It is very tight & filled; does seem to be deep D/T how the tissues to this area feel. At this time it does not appear like he has any S/S of infection to this heel blister . Float heels off of his bed when he is in his bed; protect his heel with Spenco Boot. 2. 04/24/18 - L 1.5 cm, W 1.4 cm, D blank. Airflow mattress & continues to be turned and repositioned Q 2 hours. Float his heels off of the bed when he is in his bed & keep Spenco boot on him at all times & keep heels elevated off of the bed. 3. 05/08/18 - L 1.0 cm, W 1.0 cm, D blank 4. 05/15/18 - L 1.0 cm, W 1.0 cm, D blank Documentation and Assessment I. On 05/16/18 at 12:07 pm, during an interview the WN (Wound Nurse) #1 confirmed that R #1's pressure wounds were facility acquired pressure wounds (pressure wound developed in the facility). WN #1 stated that R #1 had been in the secure unit due to wondering. The WN #1 stated that R #1 had fallen and fractured his hip in (MONTH) (YEAR) and was sent out to the hospital for treatment/surgery. She continued to state that when he returned he was not able to walk around like he did before. The WN #1 stated R #1 had a hard time adjusting to not being able to walk and his new room/unit. The WN #1 stated R #1 had a behavior of rocking back and forth and that WN #1 thought that had contributed to his pressure wounds on heels and buttocks. The WN #1 stated He never had wounds because he was mobile before his fall. J. On 05/16/18 at 4:02 pm, during an interview CNA #1 was asked if R #1 had a hard time adjusting to his new room/unit on 400 hallway, CNA #1 state not that she could recall, He did not get up due to the sling (mechanical lift used to aid staff in lift residents). CNA #1 was asked if R #1 ever rocked back and forth or had any behaviors that cause friction on his skin from rubbing; CNA #1 stated, No, not that I saw. He slept a lot and could not move much. This did not correspond to the rocking back and forth behavior WN #1 stated. K. Record review of the Activities of Daily Living Sheets for (MONTH) (YEAR) revealed the following: 1. Assist Resident to turn and reposition in bed~Q 2 hours and PRN Right to Left only. The evening shift 2:00 pm -10:00 pm was blank on (MONTH) 26 and 27. 2. CNA skin check 02/06/18, 02/09/18, 02/13/18, 02/16/18, 02/20/18, 02/23/18 were all documented as 5 with the key response key being 0 - Scratched 1 - Red Area 2 - Discoloration 3 - Skin Tear 4 - Open Area 5 - None of the above observed 3. Turn and reposition in chair Q 1 hour and PRN. The evening shift 2:00 pm -10:00 pm was blank on (MONTH) 26 and 27. L. Record review of the Activities of Daily Living Sheets for (MONTH) (YEAR) revealed the following: 1. CNA skin check 03/02/18, 03/06/18, 03/13/18, 03/23/18, 03/30/18 were all documented as 5. 2. 03/09/18 was coded as a red area on the leg not being new. 3. 03/16/18 - red area on shoulder not new. 4. 03/20/18 coded as red area on foot not new. 5. 03/27/18 - open area to the buttock not new. M. Record review of the Activities of Daily Living Sheets for (MONTH) (YEAR) revealed the following: 1. Assist Resident to turn and reposition in bed~Q 2 hours and PRN Right to Left only. The evening shift 2:00 pm -10:00 pm was blank on (MONTH) 2 and 4. The day shift 6:00 am -2:00 pm was blank on (MONTH) 4 and 8. 2. CNA skin check 04/06/18, 04/10/18, 04/13/18, 04/17/18, 04/20/18, 04/27/18 were all documented as 5 with the key response key being 0 - Scratched 1 - Red Area 2 - Discoloration 3 - Skin Tear 4 - Open Area 5 - None of the above observed 04/24/18 red area to buttock not new. 3. Turn and reposition in chair Q 1 hour and PRN The day shift 6:00 am -2:00 pm was blank on (MONTH) 8. 4. Turn and reposition in bed q 2 hours. On 04/13/18 was blank 12:00 am. On 04/13/18 at 2:00 am, 4:00 am, and 6:00 am, 04/16/18 12:00 am, 04/19/18 12:00 am, 04/21/18 12:00 am, 04/23/18 12:00 am, 04/25/18 12:00 am, 04/30/18 12:00 am were all marked with an X. 5. Turn and reposition in bed q 2 hours. 04/12/18 at 8:00 pm and 10:00 pm, 04/13/18 at 10:00 pm, 04/16/18 at 10:00pm, 04/19/18 at 10:00 pm, 04/21/18 at 10:00 pm, 04/23/18 at 10:00 pm, 04/25/17 at 10:00 pm were all blank. N. On 05/17/18 at 8:41 am, during an interview, WN #1 confirmed that she could not find any documentation related to R #1 behavior of rocking back and forth. WN #1 stated that she had some concerns nurses were not documenting things in progress notes like the behaviors of residents. This included R #1's behavior of rocking back and forth. WN #1 stated that the CNAs have told her they told their nurse about residents refusing to be repositioned and the nurses are not documenting. She continued We have traveling nurses that are new and other nurses that are not documenting. WN #1 confirmed that the CNA Skin check did not correspond to the wounds that R #1's had on 02/20/18. O. On 05/17/18 at 9:04 am, during an interview, LPN #3 was asked if R #1 had a hard time adjusting to his new room/unit on 400 hallway, LPN #3 stated, No. LPN #3 was asked if R #1 ever rocked back and forth or had any behaviors that cause friction on his skin from rubbing, She stated I never saw that, he was pretty drowsy due to his medication when he got back from the hospital, and couldn't move much. This did not correspond to the rocking back and forth behavior WN #1 stated. P. On 05/22/18 at 10:40 am, during an interview, the MDS Coordinator (MDSC) stated that if there are blank spots on the ADL Sheets then CNAs are not documenting. The MDSC was not sure what the X marks were on the ADL Sheet as there was no X on the response key. Q. On 05/17/18 at 3:04 pm, during an interview, the MDSC stated that CNAs do skin observations during shower days. If they have any concerns, then they call the nurse. The Wound Nurse will be asked to assess the resident. Nurses do not perform skin assessment for resident at risk for pressure ulcers. R. On 05/18/18 at 1:20 pm, during an interview with the Administrator and Director of Nursing, they confirmed the nurses do not perform skin assessment for resident at risk for pressure ulcers. Our policy has CNA's doing skin observations and alerting the nurse of their concerns; it recommends we do weekly skin assessment. WN #1's Issues identified S. On 05/17/18 at 8:41 am, during an interview, WN #1 had identified some concerns related to pressure wound care and prevention: 1. CNAs needed training on identifying worn clarify or improper pressure relieving devises, 2. retraining repositioning residents, and 3. documentation by both CNAs and Nurses. We need work on documenting. WN #1 was asked if the facility was working on any of these concerns she had, she stated We are work on getting a class together with staff development. I don't think they have had any dates yet. T. On 05/17/18 at 8:52 am, during an interview, the Staff Development stated that the facility had some consultants recommend that they do retraining on documentation; but the facility has no set any dates yet. U. On 05/18/18 at 1:20 pm, an interview with the Administrator and Director of Nursing revealed that WN #1 had not been notified about concerns she had identified. Administrator confirmed that there were no dates for documentation in-services. Observations and Care Plan Issues V. On 05/16/18 at 8:30 am, 9:23 am, 10:45 am, 2:54 pm, 4:04 pm; 05/17/18 at 8:09 am, 9:00 am, 10:23 am, 3:07 pm, and 4:03 pm revealed resident to be in his bed laying on his left side for all observations. W. Record review of the orders dated 04/06/18 revealed Turn & Reposition Q (every) 2 hours & PRN (as needed); Left To Right Only Position heels Off of his bed, use pillows & Spenco boots to protect them. Every shift for Stage 4 Pressure Wound & Preventative. X. On 05/17/18 at 10:23 am, during an observation of R #1's room and interview with LPN #3 confirmed that R #1's heels did not have the pressure relieving devices, the Spenco boots or pillow, in place for him to use. Y. On 05/17/18 at 4:03 pm, during an observation of R #1's room and interview with CNA #1 confirmed that R #1 had only the Spenco boots on. The pillow for R #1's feet was at the foot of bed, not in use. CNA #1 was asked what R #1's Care Plan stated intervention for his wounds were. CNA #1 stated she was not sure. Z. On 05/17/18 at 4:07 pm, during an observation of R #1's room and interview with LPN #4 confirmed that R #1 had only the Spenco boots on. The pillow for R #1's feet was at the foot of bed, not in use. LPN #4 was asked what R #1's Care Plan stated intervention for his wounds were LPN #1 stated I have to look it up. I know where it is but have to look it up. AA. On 05/22/18 at 10:35 am during observation of WN #1 performed wound care for R #1, the following was observed: WN #1 opened a clean Chux (disposable underpad) on the overbed table and placed several items for wound care on the table. The WN #1 performed hand hygiene and gloved, then opened the package of Triple Helix Collagen Powder (a protein commonly used for wound healing) and poured it into the package of Derma Girate/AG (calcium alginate-a product used for wounds with heavy exudate to absorb fluid and fill dead space, and AG (silver-for anti-infective properties). The WN #1 went to the bedside table and opened the drawer and removed a handful of 4 x 4 gauze pads and an Allevyn (a type of hydrofoam dressing) dressing. The WN #1 opened the Alleyyn dressing and wrote the date on the exterior side of the dressing with a marker. The WCN the removed the old dressing from the resident. She did not perform hand hygiene or change her gloves after handling the packages, writing the date on the dressing, or opening a drawer and removing other supplies, some of which were not wrapped (the 4x4 gauze pads). The WN #1 removed the packing which was saturated with serous (bodily) fluid, then cleansed the wound with a spray bottle of normal saline (salt water) and the 4x4 gauze sponges. The WN #1 cleaned the resident as he began having a bowel movement and changed to a fresh brief underneath. The WN #1 performed hand hygiene and gloved and peeled the hydrofoam dressing back off and as the cover was being removed she placed her entire thumb and part of her palm in the middle of the dressing. After the dressing change, the WN #1 lowered the electric bed and the foley bag was then resting completely on the floor. BB. On 05/22/18 at 11:10 am, during an interview with the WN #1, when asked about her actions when she perform the dressing change; she affirmed, What I should have done was washed and changed my gloves after opening the packages and before I touched the resident. It was an infection risk. I should not have touched the part of the dressing that comes in contact with the wound and I should have repositioned the foley bag so it was not on the floor. It is an infection risk. Policies and Procedures CC. Record review of the Skin Assessment, Pressure Ulcer Prevention and Documentation Requirements revised date of (MONTH) (YEAR) revealed the following: All residents will have a comprehensive skin inspection done by the licensed nurse on admission/readmission to identify any skin issues present . A systematic skin inspection will be made daily by the nursing assistant assigned to those residents at risk for skin break down. The nursing assistants responsible for this will report any abnormal findings or signs of skin impairment to the licensed nurse . DD. Record review of the Pressure Ulcer Practice Guidelines revised date of (MONTH) (YEAR) revealed the following: Weekly skin checks are recommended to be performed on all residents but especially those identified as 'at risk,' . All significant abnormal findings/changes should be reported to the resident's primary care provider by the licensed nurse . As part of the process of managing in-house-acquired pressure ulcers, it is recommended that there be a quality assurance/performance improvement process designed to identify potential problems at their source, where there is greater potential for correcting skin break down. Identifying the root cause of pressure ulcer development though evaluation of potential causative factors should be a component of the quality assurance process . Once the investigation is completed, the information should be analyzed to determine why the pressure ulcer/sore developed . The nurse aide is an important team member in the management and prevention of pressure ulcers. It is recommended that there be a communication process between the nurse and the nurse aide for concerns that the nurse aide may identify during care delivery .

Based on record review and interview, the facility failed to 1) ensure a resident did not aspirate (inhale solid matter) on his stomach contents on [DATE] for 1 (R #1) of 3 (R #1, R #2, and R #3) sampled residents receiving tube feedings, and 2) ensure that a resident with Type 2 diabetes mellitus with complications was monitored to ensure normal blood sugars were maintained for 1 (R #1) of 3 (R #1, R #6, and R #7) sampled residents with Type 2 diabetes mellitus. On [DATE] at about 3:00 am, R #1 was found to have difficulty breathing and had dried vomitus (partially digested food) around his mouth. The facility sent him to the ER, and once there, he was placed on a ventilator to help his breathing. These failed practices could have contributed to his death on [DATE]. The findings are: Aspiration A. Record review of R #1's Nurse's Notes dated [DATE] at 5:51 am, revealed R #1 was sent to the ER at 1:35 am due to Severe hypoxemia (low oxygen level in the blood), labored breathing, . Respirations - 26 (breaths per minute), P (pulse) 107, O2 sats (oxygen saturation in the blood) 76% on 2 L/M (liters per minute), 83% on 4 L/M . B. Record review of R #1's Physicians' Orders revealed, [MEDICATION NAME] (sic) (nutritional substitute) at 50 cc (cubic centimeters; same as milliliters) per hour for 20 hours via pump per PEG tube (feeding tube that goes into the stomach) . Resident to be taken off at 1200 (noon) and restarted at 1600 (4:00 pm). C. Record review of R #1's ER visit notes, dated [DATE] at 3:05 am, revealed R #1 was, found with a mouth full of dried vomitus, per EMS (the ambulance service); patient has a peg (tube) and the presumption was that the patient had been overfed and then vomited and aspirated . Further review of the ER visit notes revealed that at 4:45 am, R #1 was placed on a ventilator to assist with his breathing. D. Record review of R #1's Laboratory results for [DATE] at 3:00 am revealed his White Blood Count (WBC) at 18.53. (Normal range is between 4.23 to 9.07; This could indicate an acute infection.) E. Record review of R #1's History and Physical dated [DATE] revealed the probable [DIAGNOSES REDACTED]. F. Record review of R #1's Physician's Consultative Notes from a pulmonologist (a doctor specializing in the lungs) dated [DATE] at 12:30 pm, revealed, Chest x-rays revealed . there are some bilateral opacities (areas that had someing going on) in both lung fields, this could be . active infection process. Further review revealed, Sepsis (a life-threatening illness caused by your body's response to an infection), source for infection is most likely the lungs . G. Record review of the Procedure Report from the [MEDICATION NAME] (visual scoping of the lungs) done on [DATE] revealed, There is significant amount of purulent (containing pus) respiratory secretions coming out from the right and left main bronchi (air tubes in the lungs). There is significant amount of respiratory secretions occluding (blocking) the left main bronchi. Impression: 1. Acute [MEDICAL CONDITION]. 2. Bacterial pneumonia. H. Record review of the Laboratory Report from the secretions collected from the [MEDICATION NAME] completed on [DATE] revealed, There is degenerated skeletal muscle and plant material present in this . sample. This finding raises the possibility of aspiration. I. Record review of the final Laboratory Results from the secretions collected from the [MEDICATION NAME] completed on [DATE] revealed R #1 had [MEDICAL CONDITION] (MRSA) (a contagious and antibiotic-resistant staph bacteria that leads to potentially dangerous infection) in the lungs. J. Review of R #1's hospital medical record revealed R #1 died on [DATE] at 4:47 pm. K. On [DATE] at 3:00 pm, during an interview, the Chief Nursing Officer, at the local hospital that R #1 was transferred to, stated he died from, Septic shock secondary to bacterial pneumonia. Type 2 Diabetes L. Record review of R #1's face sheet dated [DATE] revealed the [DIAGNOSES REDACTED]. M. Record review of R #1's physician's orders [REDACTED]. N. Record review of R #1's emergency room visit, dated [DATE] at 3:21 am, revealed a blood sugar level of 1041 milligrams per deciliter (mg/dl). (Normal range is between 70 to 100 mg/dl.) O. On [DATE] at 3:30 pm, during an interview, the DON stated that neither she nor the Administrator read in his clinical record or knew that the resident was a diabetic. O. On [DATE] at 11:35 am, during an interview, the DON stated the Health Information Management (HIM) Director sifts through other medical records for other diagnoses. She stated, In the past, she (the HIM Director) has not notified nursing services of additional diagnoses. It is not our protocol. She further explained that the nutritional replacement that R #1 was receiving had 44 grams of carbohydrates.

Based on record review and interview the facility failed to adequately supervise one (#110) of four residents (#89, 110, 113,and 125) sampled for increased falls and injury. This failure likely caused Resident #110 to sustain a fall that resulted in a left hip fracture. The finding are: A. Review of Resident #110's medical record indicated the following: 1. 10/01/13 at 7:30 pm a loud thump heard, found resident laying on floor in restroom, resident assisted to sitting position, resident rubbing head, a 4 centimeter (cm) contusion noted to right lower side of scalp. Ice pack applied. 2. 12/14/13 at 1:15 pm found resident on floor in sitting position next to chair, no apparent injury. 3. 01/14/14 at 5:00 pm resident found on floor, no injury noted. 4. 02/01/14 at 6:15 pm resident attempted to sit down in armchair, missed the chair and landed on carpeted floor, no injury noted. 5. 02/01/2014 at 9:30 pm resident went into another residents room and went to sit on the side of the bed, missed and sat on the floor, no injuries noted. 6. 02/02/14 1:06 pm attempted to sit in chair and missed the seat. No injuries noted. 7. 02/10/14 5:57 pm found on floor in sitting position. no injury noted. 8. 02/18/14 at 8:55 am resident found on floor in the common area with Certified Nursing Assistant (cna) at her side. No injuries noted. 9. 03/22/14 5:00 pm resident found on the floor after hearing a thud sound, moaning when pelvis palpated, especially on the right side, transferred to local Emergency Department (ED) for evaluation. 10. 04/12/14 at 4:50 pm found lying on right side in patio area. Resident trying to hold left knee and that it hurts. Resident sent to local ED for assessment. B. Review of the Face Sheet for Resident #110 indicated the resident was re-admitted to the facility on [DATE] after surgical repair for the left hip fracture sustained as a result of the fall on 04/12/14. C. Review of Resident #110's care plan dated 02/05/13 indicated Resident #110 was at risk for falls related to advanced dementia. There was no documentation to indicate Resident #110's care plan was revised before, during or after the nine episodes of falling and/or being found on the floor from 10/01/13 until 04/12/14. D. On 05/22/14 at 8:30 am, an interview was conducted with the DON concerning incident report and updating care plan. The DON stated that the incident reports are reviewed and there is if necessary information put in the Kardex area for the CNA's (Certified Nurse Assistant). When asked if there is a way to document the fall event and new interventions if necessary, on the care plan, the DON stated, "There is only a limited amount of information we can put in the care plans and I don't think we can document the new information or interventions on the care plan."

Based on record review and interview, the facility failed to ensure that the comprehensive care plan was updated and revised with specific goals and objectives for a resident identified at risk for falls for three (#89, #110, and 125) of four sampled residents (#89, 110, 113,and 125). This deficient practice is likely to cause residents who were identified and assessed at risk for falls to continue to fall. The findings are: A. Review of Resident #110's medical record indicated the following: 1. 10/01/13 at 7:30 pm a loud thump heard, found resident laying on floor in restroom, resident assisted to sitting position, resident rubbing head, a 4 centimeter (cm) contusion noted to right lower side of scalp. Ice pack applied. 2. 12/14/13 at 1:15 pm found resident on floor in sitting position next to chair, no apparent injury. 3. 01/14/14 at 5:00 pm resident found on floor, no injury noted. 4. 02/01/14 at 6:15 pm resident attempted to sit down in armchair, missed the chair and landed on carpeted floor, no injury noted. 5. 02/01/2014 at 9:30 pm resident went into another residents room and went to sit on the side of the bed, missed and sat on the floor, no injuries noted. 6. 02/02/14 1:06 pm attempted to sit in chair and missed the seat. No injuries noted. 7. 02/10/14 5:57 pm found on floor in sitting position. no injury noted. 8. 02/18/14 at 8:55 am resident found on floor in the common area with Certified Nursing Assistant (cna) at her side. No injuries noted. 9. 03/22/14 5:00 pm resident found on the floor after hearing a thud sound, moaning when pelvis palpated, especially on the right side, transferred to local Emergency Department (ED) for evaluation. 10. 04/12/14 at 4:50 pm found lying on right side in patio area. Resident trying to hold left knee and that it hurts. Resident sent to local ED for assessment. B. Review of the Face Sheet for Resident #110 indicated the resident was re-admitted to the facility on [DATE] after surgical repair for the left [MEDICAL CONDITION] sustained as a result of the fall on 04/12/14. C. Review of Resident #110's care plan dated 02/05/13 indicated Resident #110 was at risk for falls related to advanced dementia. There is no documentation to indicate Resident #110's care plan was revised before, during or after the nine episodes of falling and/or being found on the floor from 10/01/13 until 04/12/14. D. Review of the facility's incident reports revealed Resident #89 had fallen on 04/07/14. E. Review of Resident #89's clinical record revealed a fall care plan initiated 02/02/13 with Focus Areas, Goals and interventions for falls. There was no documentation on the care plan for the 04/07/14 fall or new interventions related to the fall. F. On 05/22/14 at 1:45 pm, an interview was conducted with the Director Of Nursing (DON) concerning interventions related to Resident 89's 04/07/14 fall. When asked if there were new interventions listed for the resident after the 04/07/14 fall the DON stated, "There is not any new interventions listed for that fall." G. Review of the facility's incident reports revealed Resident #125 had fallen on 04/19/14. H. Review of Resident #125's clinical record revealed a fall care plan initiated 04/10/14 with Focus Areas, Goals and interventions for falls. There was no documentation on the care plan for the 04/19/14 fall or new interventions related to the fall. I. On 05/22/14 at 8:30 am, an interview was conducted with the DON concerning incident report and updating care plan. The DON stated that the incident reports are reviewed and there is if necessary information put in the Kardex area for the CNA's (Certified Nurse Assistant). When asked if there is a way to document the fall event and new interventions if necessary, on the care plan, the DON stated, "There is only a limited amount of information we can put in the care plans and I don't think we can document the new information or interventions on the care plan."