Every finding on record at Lawrenceville Health & Rehabilitation

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to dispose of refuse properly. The facility staff failed to maintain clean dumpster area during the facility task- kitchen observation 3/17/25 at 10:30 AM. The findings include: On 3/17/25 at 10:30 AM, an observation was conducted in the dumpster area outside of the main kitchen, with OSM (other staff member) #1, the dietary manager. Dumpster #1 had an open seam on the front bottom of the dumpster. Tin foil with food debris and a white paper/trash bag were hanging out of the seam. In front of the dumpster was a half sandwich and citrus peel. Dumpster #2 had a bifold lid. The right side of the bifold lid was open all the way back. An interview was conducted on 3/17/24 at 10:40 AM with OSM #1, the dietary manager. When asked about the findings, OSM #1 stated, they just picked the trash up this morning, and we have not had a chance to come out and clean this area. We communicated with the county about a new trash dumpster last week. When asked who was responsible for the dumpster area, OSM #1 stated, maintenance and dietary. On 3/18/25 at 7:30 AM, ASM (administrative staff member) #1, the executive director stated, we have been calling the county about a new dumpster, and they finally brought a new one this morning. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. The facility's Waste Disposal policy revealed the following, Prior to disposal, all waste shall be kept in leak-proof, non-absorbent containers that are kept covered when not in use. Trash will be deposited into a sealed container outside the premises. No further information was provided prior to exit.

Based on resident / staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of the frequency of physician visits at least every 60 days for five of 29 residents in the survey sample, R48, R9, R59, R28 and R56. The findings include: 1. R48 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute respiratory failure, COPD (chronic obstructive pulmonary disease) and CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 12/19/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring supervision for mobility/transfers/bathing/dressing and eating. A review of the comprehensive care plan dated 1/7/25 revealed, FOCUS: the resident is a long-term care resident and requires assistance with their ADL's related to chronic health conditions, muscle weakness. INTERVENTIONS: Encourage the resident to participate to the fullest extent possible with each interaction. Supervision or touching assistance with bed mobility and transfers. A review of the Physician / NP (nurse practitioner) notes, revealed, physician notes: 9/25/24, 11/16/24, 2/5/25. A period of 81 days between physician visits on 11/16/24 to 2/5/25. An interview was conducted on 3/17/25 at approximately 2:00 PM with R48. When asked if she had any concerns, R48 asked, can I get another doctor. I do not see this doctor and he does not seem to be doing much for me. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. On 3/19/25 at 2:00 PM, ASM (administrative staff member) #3, the regional director of clinical services, stated, we do not have any additional evidence to provide. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/19/25 at 12:45 PM. A review of the facility's Physician Visits policy revealed, The Attending Physician and Non-physician practitioner will make visits in accordance with applicable state and federal regulations. The Attending Physician / designee must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit. 2. R9 was admitted to the facility on [DATE] with diagnosis that included but were not limited to MS (multiple sclerosis), DM (diabetes mellitus) and respiratory failure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/16/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and supervision for eating. A review of the comprehensive care plan dated 11/15/24 revealed, FOCUS: CARDIAC: the resident is at risk for cardiac complications secondary to hypertension. INTERVENTIONS: observe for signs and symptoms of fluid overload including pulmonary or lower extremity edema and shortness of breath and notify MD as indicated. A review of the Physician / NP (nurse practitioner) notes, revealed, physician notes: 12/11/24, no January 2025, February 2025 or March 2025 physician notes. As of 3/19/25, 98 days since 12/11/24 note. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. On 3/19/25 at 2:00 PM, ASM (administrative staff member) #3, the regional director of clinical services, stated, we do not have any additional evidence to provide. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/19/25 at 12:45 PM. A review of the facility's Physician Visits policy revealed, The Attending Physician and Non-physician practitioner will make visits in accordance with applicable state and federal regulations. The Attending Physician / designee must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit. 3. R59 was admitted to the facility on [DATE] with diagnosis that included but were not limited to encephalopathy, dysphagia and respiratory failure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 3/6/25, coded the resident as scoring a 02 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and supervision for eating. A review of the comprehensive care plan dated 12/17/24 revealed, FOCUS: ANTICOVULSANTS: the resident is at risk for adverse reactions related to requiring anticonvulsants for treatment of Mood Disorder Stabilization. INTERVENTIONS: Observe for signs and symptoms of convulsive activity and notify MD as indicated. observe for increased sedation, drowsiness, dizziness, and report to MD as indicated. A review of the Physician / NP (nurse practitioner) notes, revealed, physician notes: 11/23/24, 11/27/24 and 2/15/25. No December 2024 or January 2025 physician notes. 80 days between 11/27/24 and 2/15/25 physician notes. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. On 3/19/25 at 2:00 PM, ASM (administrative staff member) #3, the regional director of clinical services, stated, we do not have any additional evidence to provide. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/19/25 at 12:45 PM. A review of the facility's Physician Visits policy revealed, The Attending Physician and Non-physician practitioner will make visits in accordance with applicable state and federal regulations. The Attending Physician / designee must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit. 4. R28 was admitted to the facility on [DATE] with diagnosis that included but were not limited to CVA (cerebrovascular infarction), hemiplegia/hemiparesis and COPD (chronic obstructive pulmonary disease). The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 3/11/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximum assist for mobility/transfers/bathing/dressing and supervision for eating. A review of the comprehensive care plan dated 1/29/25 revealed, FOCUS: CONVULSIVE DISORDER: The resident has a risk for complications secondary to epilepsy. INTERVENTIONS: Observe for convulsive activity and notify MD as indicated. Administer meds as ordered. A review of the Physician / NP (nurse practitioner) notes, revealed, physician notes: 11/27/24, no additional physician notes from 11/27/24 to 3/19/25 a period of 112 days. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. On 3/19/25 at 2:00 PM, ASM (administrative staff member) #3, the regional director of clinical services, stated, we do not have any additional evidence to provide. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/19/25 at 12:45 PM. A review of the facility's Physician Visits policy revealed, The Attending Physician and Non-physician practitioner will make visits in accordance with applicable state and federal regulations. The Attending Physician / designee must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit. 5. R56 was admitted to the facility on [DATE] with diagnosis that included but were not limited to metabolic encephalopathy, CHF (congestive heart failure) and Alzheimer's. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/25/25, coded the resident as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and supervision for eating. A review of the comprehensive care plan dated 12/15/24 revealed, FOCUS: CARDIAC: the resident is at risk for cardiac complications secondary to congestive heart failure. INTERVENTIONS: observe for signs and symptoms of fluid overload including pulmonary or lower extremity edema and shortness of breath and notify MD as indicated. Administer medications as ordered. A review of the Physician / NP (nurse practitioner) notes, revealed, physician notes: 8/21/24, 11/20/24 and 2/21/25. No additional notes from 8/21/24 to 11/20/24 a period of 91 days and no additional notes from 11/20/24 to 2/21`/25 a period of 93 days. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. On 3/19/25 at 2:00 PM, ASM (administrative staff member) #3, the regional director of clinical services, stated, we do not have any additional evidence to provide. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/19/25 at 12:45 PM. A review of the facility's Physician Visits policy revealed, The Attending Physician and Non-physician practitioner will make visits in accordance with applicable state and federal regulations. The Attending Physician / designee must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every sixty (60) days thereafter. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit.

Based on observation, resident interview, facility staff interview, facility document review, and clinical record review, the facility staff failed to serve food in a form to meet resident needs for five of 29 residents in the survey sample, Residents #17, #19, #13, #1, and #20. The findings include: 1. For Resident #17 (R17), the facility staff failed to serve a mechanical soft diet on 3/17/25 at both the lunch and dinner meals. On 3/17/25 at 12:48 p.m., R17 was observed sitting up in bed eating lunch. The resident's lunch tray contained one regular roll and peach cobbler (peach slices and cobbler crust). The resident's tray also contained an empty Mountain Dew can with a straw. R17 stated his sister had brought the Mountain Dew earlier in the day and he had consumed the whole can using a straw. He stated the Mountain Dew was not thickened. A review of R17's meal ticket revealed, in part: Dysphagia mechanical soft, nectar thick liquid .moistened white cake with chopped peaches .no straws. At 1:00 p.m., OSM (other staff member) #4, a speech therapist, also observed R17's meal tray. She confirmed that the regular roll and peach cobbler did not conform with a mechanical soft diet. She also confirmed that the resident should not have a can of unthickened Mountain Dew on his overbed table and should not have consumed the Mountain Dew using a straw. On 3/17/24 at 5:53 p.m., R17 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R17's meal ticket revealed, in part: Dysphagia mechanical soft .ground chicken nuggets with barbecue sauce. A review of R17's prescribers' orders revealed the following order, dated 9/27/24: Mechanical Soft texture, Nectar liquids consistency, for oropharyngeal dysphasia; high aspiration risk. NO STRAWS. A review of R17's care plan revealed no information regarding the resident's altered diet. On 3/18/25 at 3:46 p.m., OSM #4 was interviewed. She stated a resident who has orders for a mechanical soft diet should always receive pureed bread, ground meat (consistency of ground hamburger), soft vegetables, and soft fruit that is chopped. She stated residents who eat food that is not the correct consistency run the risk of choking, aspirating food, and potentially developing complications like pneumonia. On 3/19/25 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated CNAs play a role in assuring that the food on a resident's tray matches what is on the meal ticket. She stated before she lifts the lid on a resident's plate, she looks at the meal ticket. She stated she does this to make sure the food served to the resident is at the correct consistency. On 3/19/25 at 8:49 a.m., OSM #1, the dietary manager, was interviewed. She stated the nursing staff sends her information regarding the consistency of resident diets. She enters that information into her software system and generates a meal ticket for each resident for every meal. She stated the meal ticket should contain the most up-to-date information regarding residents' food needs. She stated anyone on a mechanical soft diet should receive ground meat, soft (cooked) vegetables, chopped cold side dishes, mashed potatoes, chopped desserts, pureed bread, and chopped fruit. She stated mechanical soft meat should be the consistency of ground beef. She stated R17's 3/17 lunch potato salad should have been chopped. She stated she did not check the cobbler before it left the kitchen, and the cobbler should have been cut into smaller pieces. She stated R17 should not have been given a regular roll at any time. She stated R17's dinner meat should have been ground, not cubed. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Texture and Consistency-Modified Diets, revealed, in part: Texture and consistency-modified diets will be individualized with modifications made by the speech-language pathologist and physician in conjunction with the registered dietician-nutritionist and director of food and nutrition services. A written order is needed .The food and nutrition services department will be responsible for preparing and serving the diet texture and fluid consistency as ordered .Diets should be adjusted to meet individual needs. No additional information was provided prior to exit. 2. For Resident #19 (R19), the facility staff failed to serve a mechanical soft diet on 3/17/25 at both the lunch and dinner meals. On 3/17/25 at 1:09 p.m., R19 was observed sitting up in bed eating lunch. The resident's lunch tray contained one regular roll and peach cobbler (peach slices and cobbler crust). A review of R19's meal ticket revealed, in part: Dysphagia mechanical soft .pureed bread .moistened white cake with chopped peaches. On 3/17/24 at 5:49 p.m., R19 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed) and canned pineapple slices. A review of R19's meal ticket revealed, in part: Dysphagia mechanical soft .ground chicken nuggets with barbecue sauce .choice of soft, canned, chopped fruit. A review of R19's prescribers' orders revealed the following order, dated 5/14/24: Mechanical Soft texture, Regular/Thin consistency [for liquids]. A review of R19's care plan revealed no information regarding the resident's altered diet. On 3/18/25 at 3:46 p.m., OSM (other staff member) #4, a speech therapist, was interviewed. She stated a resident who has orders for a mechanical soft diet should always receive pureed bread, ground meat (consistency of ground hamburger), soft vegetables, and soft fruit that is chopped. She stated residents who eat food that is not the correct consistency run the risk of choking, aspirating food, and potentially developing complications like pneumonia. On 3/19/25 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated CNAs play a role in assuring that the food on a resident's tray matches what is on the meal ticket. She stated before she lifts the lid on a resident's plate, she looks at the meal ticket. She stated she does this to make sure the food served to the resident is at the correct consistency. On 3/19/25 at 8:49 a.m., OSM #1, the dietary manager, was interviewed. She stated the nursing staff sends her information regarding the consistency of resident diets. She enters that information into her software system and generates a meal ticket for each resident for every meal. She stated the meal ticket should contain the most up-to-date information regarding residents' food needs. She stated anyone on a mechanical soft diet should receive ground meat, soft (cooked) vegetables, chopped cold side dishes, mashed potatoes, chopped desserts, pureed bread, and chopped fruit. She stated mechanical soft meat should be the consistency of ground beef. She stated R19's 3/17 lunch potato salad should have been chopped. She stated she did not check the cobbler before it left the kitchen, and the cobbler should have been cut into smaller pieces. She stated R19's dinner meat should have been ground, not cubed, and the resident should have been given crushed or chopped pineapple, not a whole pineapple slice. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 3. For Resident #13 (R13), the facility staff failed to serve an advanced dysphagia diet on 3/17/25 at both the lunch and dinner meals. On 3/17/25 at 12:55 p.m., R13 was observed sitting up in bed eating lunch. The resident's lunch tray contained regular consistency potato salad and peach cobbler (peach slices and cobbler crust). A review of R13's meal ticket revealed, in part: Dysphagia advanced .peaches and cream cake. On 3/17/24 at 5:55 p.m., R13 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R13's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R13's prescribers' orders revealed the following order, dated 2/11/25: Dysphagia - Advanced texture. A review of R13's care plan revealed no information regarding the resident's altered diet. On 3/18/25 at 3:46 p.m., OSM (other staff member) #4, a speech therapist, was interviewed. She stated a resident who has orders for a dysphagia advanced diet should always receive ground meat, soft vegetables, and soft fruit. She stated residents who eat food that is not the correct consistency run the risk of choking, aspirating food, and potentially developing complications like pneumonia. On 3/19/25 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated CNAs play a role in assuring that the food on a resident's tray matches what is on the meal ticket. She stated before she lifts the lid on a resident's plate, she looks at the meal ticket. She stated she does this to make sure the food served to the resident is at the correct consistency. On 3/19/25 at 8:49 a.m., OSM #1, the dietary manager, was interviewed. She stated the nursing staff sends her information regarding the consistency of resident diets. She enters that information into her software system and generates a meal ticket for each resident for every meal. She stated the meal ticket should contain the most up-to-date information regarding residents' food needs. She stated anyone on an advanced dysphagia diet should receive chopped meat. She stated R1's dinner meat should have been ground, not cubed. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 4. For Resident #1 (R1), the facility staff failed to serve an advanced dysphagia diet on 3/17/25 at dinner. On 3/17/24 at 6:00 p.m., R1 was observed sitting in the day room being fed dinner by a OSM (other staff member) #5, the business office manager. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R1's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R1's prescribers' orders revealed the following order, dated 4/30/24: Dysphagia - Advanced texture. A review of R1's care plan revealed no information regarding the resident's altered diet. On 3/18/25 at 3:46 p.m., OSM (other staff member) #4, a speech therapist, was interviewed. She stated a resident who has orders for a dysphagia advanced diet should always receive ground meat, soft vegetables, and soft fruit. She stated residents who eat food that is not the correct consistency run the risk of choking, aspirating food, and potentially developing complications like pneumonia. On 3/19/25 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated CNAs play a role in assuring that the food on a resident's tray matches what is on the meal ticket. She stated before she lifts the lid on a resident's plate, she looks at the meal ticket. She stated she does this to make sure the food served to the resident is at the correct consistency. On 3/19/25 at 8:49 a.m., OSM #1, the dietary manager, was interviewed. She stated the nursing staff sends her information regarding the consistency of resident diets. She enters that information into her software system and generates a meal ticket for each resident for every meal. She stated the meal ticket should contain the most up-to-date information regarding residents' food needs. She stated anyone on an advanced dysphagia diet should receive chopped meat. She stated R13's dinner meat should have been ground, not cubed. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 5. For Resident #20 (R20), the facility staff failed to serve an advanced dysphagia diet on 3/17/25 at dinner. On 3/17/24 at 5:50 p.m., R20 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R20's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R20's prescribers' orders revealed the following order, dated 10/10/24: Dysphagia - Advanced texture. A review of R20's care plan revealed no information regarding the resident's altered diet. On 3/18/25 at 3:46 p.m., OSM (other staff member) #4, a speech therapist, was interviewed. She stated a resident who has orders for a dysphagia advanced diet should always receive ground meat, soft vegetables, and soft fruit. She stated residents who eat food that is not the correct consistency run the risk of choking, aspirating food, and potentially developing complications like pneumonia. On 3/19/25 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated CNAs play a role in assuring that the food on a resident's tray matches what is on the meal ticket. She stated before she lifts the lid on a resident's plate, she looks at the meal ticket. She stated she does this to make sure the food served to the resident is at the correct consistency. On 3/19/25 at 8:49 a.m., OSM #1, the dietary manager, was interviewed. She stated the nursing staff sends her information regarding the consistency of resident diets. She enters that information into her software system and generates a meal ticket for each resident for every meal. She stated the meal ticket should contain the most up-to-date information regarding residents' food needs. She stated anyone on an advanced dysphagia diet should receive chopped meat. She stated R20's dinner meat should have been ground, not cubed. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The findings include: On 3/17/25 at 10:20 AM, an observation was conducted in the main kitchen. In the refrigerator, there was found one large five-pound bag of shredded sharp cheese that was opened and not dated. OSM (other staff member) #1, the dietary manager was observed with the back of her hair without a hair net covering. An interview was conducted on 3/17/24 at 10:40 AM with OSM (other staff member) #1, the dietary manager. When asked to review the five-pound bag of shredded sharp cheese, OSM #1 stated, that should be dated, we just opened it for breakfast. When asked about the back of her hair not having a covering, OSM #1 stated, there was one on my hair, I do not know where it went. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. The facility's Food Safety and Sanitation policy revealed the following, Food Storage: When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. Employees: Are required to have their hair styled so that it does not touch the collar. Hair restraints are required and should cover all hair on the head. No further information was provided prior to exit.

3. For Resident #13 (R13) the facility staff failed to review and revise the care plan with a specialized diet order. On 3/17/25 at 12:55 p.m., R13 was observed sitting up in bed eating lunch. The resident's lunch tray contained regular consistency potato salad and peach cobbler (peach slices and cobbler crust). A review of R13's meal ticket revealed, in part: Dysphagia advanced .peaches and cream cake. On 3/17/24 at 5:55 p.m., R13 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R13's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R13's prescribers' orders revealed the following order, dated 2/11/25: Dysphagia - Advanced texture. A review of R13's care plan revealed no information regarding the resident's altered diet. On 3/19/25 at 7:52 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated floor nurses have the ability to update a resident's care plan, but generally the floor nurses tell members of management when care plans need to be updated. The management team usually review and revise the care plans based on nurse input. On 3/19/25 at 8:24 a.m., LPN #6, the MDS (minimum data set) coordinator was interviewed. She stated she reviews care plans daily for accuracy, and particularly focuses on new orders or items contained in the 24 hour report. She stated she does not put specific diets on the care plan because these can change. She stated if a resident has a modified diet, she indicates it in the care plan as, Diet as ordered. She stated floor nurses have the ability to update care plans, but generally they do not. She stated comprehensive care plan reviews include all orders and interventions a resident requires. On 3/19/25 at 9:08 a.m., LPN #6 stated that she had not been able to locate information related to resident diets on any of the care plans, and this is something she would need to correct. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 4. For Resident #20 (R20), the facility staff failed to review and revise the care plan with a specialized diet order. On 3/17/24 at 5:50 p.m., R20 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R20's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R20's prescribers' orders revealed the following order, dated 10/10/24: Dysphagia - Advanced texture. A review of R20's care plan revealed no information regarding the resident's altered diet. On 3/19/25 at 7:52 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated floor nurses have the ability to update a resident's care plan, but generally the floor nurses tell members of management when care plans need to be updated. The management team usually review and revise the care plans based on nurse input. On 3/19/25 at 8:24 a.m., LPN #6, the MDS (minimum data set) coordinator was interviewed. She stated she reviews care plans daily for accuracy, and particularly focuses on new orders or items contained in the 24 hour report. She stated she does not put specific diets on the care plan because these can change. She stated if a resident has a modified diet, she indicates it in the care plan as, Diet as ordered. She stated floor nurses have the ability to update care plans, but generally they do not. She stated comprehensive care plan reviews include all orders and interventions a resident requires. On 3/19/25 at 9:08 a.m., LPN #6 stated that she had not been able to locate information related to resident diets on any of the care plans, and this is something she would need to correct. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. Based on observation, clinical record review, staff interview, and facility document review, it was determined the facility staff failed to revise the comprehensive care plan for four of 29 residents in the survey sample, Resident #37, #39, #13, and #20. The findings include: 1. For Resident #37 (R37), the facility staff failed to revise the comprehensive care plan to include the use of a divided plate at meals. Observation of R37 on 3/17/25 at 1:24 p.m. revealed the resident sitting in bed eating lunch. The lunch was observed to be served with each portion in separate bowls on a tray. On 3/18/25 at 1:14 p.m., an observation of R37's lunch revealed it served on a regular plate. The physician orders for R37 documented in part, Divided/sectional plate at all meals. Order Date: 10/24/2024. The comprehensive care plan for R37 documented in part, Nutritional Status: the resident is at risk for weight loss, malnutrition or poor hydration status related to chronic disease, cognitive impairment, GERD (gastrointestinal reflux disease). Date Initiated: 01/29/2025. The comprehensive care plan failed to evidence documentation of the use of assistive devices during meals. On 3/18/25 at 3:42 p.m., an interview was conducted with LPN (licensed practical nurse) #5 who stated that the staff supervised R37 when eating and queued them to eat. She stated that R37 used their hands and fingers to eat a lot. She stated that she did not recall the resident using a divided plate during meals but may had seen one used in the past. She stated that the purpose of the care plan was to show the care that they were to give the patient, and it was a tool to follow. On 3/18/25 at 4:13 p.m., an interview was conducted with OSM (other staff member) #4, speech language pathologist. OSM #4 stated that they had not worked with R37 since May of 2024, but they placed the order for the divided plate on 10/24/2024. She stated that it was probably from a recommendation that was made from a routine screening, and she would check her files. On 3/18/25 at approximately 4:35 p.m., OSM #4 provided a handwritten therapy evaluation for R37 dated 10/24/24 which documented recommendations of .Recommend divided/sectional plate at all meals to (decrease) spillage from plate, thereby increasing po (by mouth) intake. On 3/19/25 at 8:24 a.m., an interview was conducted with LPN #6, the MDS (minimum data set) coordinator. She stated that she reviewed care plans daily for accuracy, and particularly focused on new orders or items contained in the 24-hour report. She stated floor nurses had the ability to update care plans, but generally they did not. She stated that the comprehensive care plan reviews included all orders and interventions a resident required. LPN #6 stated that the divided plate was an intervention that should have been included on R37's care plan and she had updated the care plan on 3/18/24. The facility policy Care Planning-Comprehensive Person Centered documented in part, . Each resident's comprehensive care plan will describe the following: a. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 13. The comprehensive care plan will: a. Incorporate identified problem areas; b. incorporate risk factors associated with identified problems . e. Reflect treatment goals, timetables and objectives in measurable outcomes . On 3/19/25 at 12:38 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit. 2. The facility failed to revise the comprehensive care plan for oxygen administration for R39. R39 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute respiratory failure, COPD (chronic obstructive pulmonary disease) and MI (myocardial infarction). The most recent MDS (minimum data set) assessment, a 5-day assessment, with an ARD (assessment reference date) of 2/13/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 2/10/25 revealed, FOCUS: RESPIRATORY: the resident is at risk for respiratory complications secondary to COPD, supplementary oxygen requirement. INTERVENTIONS: Administer oxygen as ordered. Administer medications as ordered. Care Plan revised 2/11/25. A review of the physician's order dated 2/12/25 revealed, Oxygen 4 liters via NC (specify continuous) DUE TO RESP FAILURE. every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. Oxygen Therapy @ 2 LM continuous every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. A review of the February and March 2025 MAR (medication administration record), oxygen 2lnc and oxygen 4lnc are both documented as administered. An interview was conducted on 3/18/25 at 8:45 AM with LPN (licensed practical nurse) #1. When asked to review the oxygen rate of R39, LPN #1 stated, it is on 2 liters nasal cannula. When asked to review the orders, LPN #1 stated, there are two conflicting orders for oxygen administration, one for 2 lnc and one for 4 lnc. When asked where oxygen administration would be evidenced, LPN #1 stated on the MAR. When asked to review R39's MAR, LPN #1 stated, oxygen 2lnc and oxygen 4lnc are both documented as administered. When asked what the professional standard of practice would be in this situation, LPN #1 stated, we should have called to clarify the physician's order and not documented that both rates were administered. When asked if the care plan should have been reviewed and revised with oxygen setting, LPN #1 stated, yes, it should have been reviewed. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. A review of the facility's Care Planning-Comprehensive Centered policy, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement interventions to prevent unnecessary medication administration for two of 29 residents in the survey sample, Residents #15 and #39. The findings include: 1. For Resident #15 (R15), the facility staff failed to respond to a pharmacist's recommendation to reduce the dose of Protonix (to treat esophageal reflux) and Trileptal (to prevent seizures). A review of R15's clinical record revealed a 4/19/22 order for Protonix (to treat esophageal reflux) 40 mg (milligrams) daily, an 8/4/22 order for Lorazepam (to treat anxiety) 1 mg twice daily, and a 4/25/24 order for Trileptal (to prevent seizures) 150 mg twice daily. In May and October 2024, the pharmacist recommended a dose reduction of the Protonix to 20 mg twice daily. In September 2024, the pharmacist recommended a dose reduction of Trileptal to 75 mg in the morning and 150 mg in the evening. R15's clinical record revealed no evidence that the facility physician considered and responded to these recommendations in a timely manner. On 3/18/25 at 12:47 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were interviewed. ASM #2 stated for each resident, the pharmacist reviews residents whom he/she deems necessary. The pharmacist lets ASM #2 know of any urgent concerns prior to leaving the building, then emails the remainder of the reports and recommendations to her. ASM #2 stated she distributes the documents to the appropriate attending physicians, and the physicians respond to the recommendations. She stated she has not regularly been scanning the physician recommendations into the residents' electronic medical record. She did not identify a process for follow up to make sure the physician responds to the pharmacist's recommendations. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Medication Regimen Review, revealed, in part: Medication regime reviews will be conducted with the intent to ensure that each resident's entire drug/medication regimen will be managed and monitored to achieve the following goals .Each resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed conditions .The consulting pharmacist will provide a copy of recommendations to the attending physician, medical director, and director of nursing within 5 working days of completion of the review .The director of nursing or designee will review the recommendations and the attending physicians will be contacted for review and response .If the attending physician does not respond within 30 days, the medical director will be asked to review the recommendations and/or contact the attending physician .The attending physician or medical director will document in the resident's medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it .If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. No additional information was provided prior to exit. 2. The facility staff failed to ensure R39 was free of unnecessary medications by monitoring anticoagulant as ordered. R39 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute respiratory failure, COPD (chronic obstructive pulmonary disease) and MI (myocardial infarction). The most recent MDS (minimum data set) assessment, a 5-day assessment, with an ARD (assessment reference date) of 2/13/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 2/11/25 revealed, FOCUS: ANTICOAGULANTS: the resident is at risk for bleeding and bruising related to use of an anticoagulant for diagnosis of history of heart disease. INTERVENTIONS: Observe for s/s of abnormal bleeding or bruising and or black tarry stools and report to MD as indicated. A review of the physician's order dated 2/10/25 revealed, Eliquis Oral Tablet 5 MG (Apixaban) Give 5 mg by mouth two times a day for heart health and physician order dated 3/17/25 ANTICOAGULANT MEDICATION - MONITOR FOR DISCOLORED URINE, BLACK TARRY STOOLS, SUDDEN SEVERE HEADACHE, N&V, DIARRHEA, MUSCLE JOINT PAIN, LETHARGY, BRUISING, SUDDEN CHANGES IN MENTAL STATUS AND/ OR V/S, SOB, NOSE BLEEDS. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every shift -Start Date03/17/2025 2300. R39's MAR (medication administration record) does not evidence any monitoring of anticoagulation monitoring till night shift on 3/17/25 after we entered on day shift 3/17/25. On 3/18/25 at 8:30 AM, an interview was conducted with LPN (licensed practical nurse) #1. When asked what monitoring is provided for anticoagulation, LPN #1 stated, we monitor for bruising, bleeding and blood in the urine or stool. When asked where this would be evidenced, LPN #1 stated, we document this on the MAR. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. A review of the facility's Medication and Treatment Orders policy, revealed, Orders for anti-coagulants will be prescribed only with appropriate clinical and laboratory monitoring. No further information was provided prior to exit.

Based on observations, staff /resident interviews facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care services for one of 29 residents, R39. The findings include: The facility staff failed to provide respiratory therapy per physician orders for R39. R39 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute respiratory failure, COPD (chronic obstructive pulmonary disease) and MI (myocardial infarction). The most recent MDS (minimum data set) assessment, a 5-day assessment, with an ARD (assessment reference date) of 2/13/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 2/10/25 revealed, FOCUS: RESPIRATORY: the resident is at risk for respiratory complications secondary to COPD, supplementary oxygen requirement. INTERVENTIONS: Administer oxygen as ordered. Administer medications as ordered. A review of the physician's order dated 2/12/25 revealed, Oxygen 4 liters via NC (specify continuous) DUE TO RESP FAILURE. every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. Oxygen Therapy @ 2 LM continuous every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. A review of the February and March 2025 MAR (medication administration record), oxygen 2lnc and oxygen 4lnc are both documented as administered. An interview was conducted on 3/18/25 at 8:45 AM with LPN (licensed practical nurse) #1. When asked to review the oxygen rate of R39, LPN #1 stated, it is on 2 liters nasal cannula. When asked to review the orders, LPN #1 stated, there are two conflicting orders for oxygen administration, one for 2 lnc and one for 4 lnc. When asked where oxygen administration would be evidenced, LPN #1 stated on the MAR. When asked to review R39's MAR, LPN #1 stated, oxygen 2lnc and oxygen 4lnc are both documented as administered. When asked what the professional standard of practice would be in this situation, LPN #1 stated, we should have called to clarify the physician's order and not documented that both rates were administered. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. A review of the facility's Oxygen Administration policy, revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Turn on the oxygen at the number of liters / minutes as ordered by the physician/practitioner. Report other information in accordance with facility policy and professional standards of practice. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide a complete pain management program including implementation of non-pharmacological interventions prior to the administration of as needed pain medications for one of 29 residents in the survey sample, Resident #58. The findings include: For Resident #58 (R58), the facility staff failed to evidence implementation of non-pharmacological interventions prior to administration of as needed pain medications on multiple dates in January, February and March of 2025. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/21/2025, the resident scored 11 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. Section J documented R58 having almost constant pain and receiving as needed pain medications. Section J further documented not receiving non-medication interventions for pain. On 3/17/25 at 1:06 p.m., an interview was conducted with R58 who stated that they had pain from a gout flare up and from a recent fall at home with a broken hip. R58 stated that the nurses gave them medications when they asked for it. When asked about non-pharmacological interventions prior to medication administration, R58 stated that they were not sure. The physician order's for R58 documented in part, - Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 3 tablet by mouth every 8 hours as needed for pain related to Pain in Unspecified Joint. Order Date: 01/17/2025. - Oxycodone HCl Oral Capsule 5 MG (Oxycodone HCl) Give 5 mg by mouth every 4 hours as needed for moderate pain related to Pain in Unspecified Joint. Order Date: 01/17/2025. The eMAR (electronic medication administration record) dated 1/1/25-1/31/25 documented the Oxycodone administered to R58 a total of 8 times for pain levels ranging from 3-9. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the Oxycodone. The eMAR dated 2/1/25-2/28/25 documented the Oxycodone administered to R58 a total of 4 times for pain levels ranging from 4-5. The eMAR documented the Acetaminophen administered to R58 once for a pain level of 5. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the Oxycodone or Acetaminophen. The eMAR dated 3/1/25-3/31/25 documented the Acetaminophen administered to R58 once for a pain level of 7. The eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of the Acetaminophen. The progress notes for R58 failed to evidence documentation of non-pharmacological interventions attempted prior to the administration of the as needed pain medication documented on the eMARs. On 3/18/25 at 3:42 p.m., an interview was conducted with LPN (licensed practical nurse) #5 who stated that prior to administering as needed pain medications she assessed the resident, asked them the pain level and how long the pain had been going on. LPN #5 stated that she attempted to reposition the resident and offer non-pharmacological interventions first and if that did not work, she administered the pain medication. She stated that the non-pharmacological interventions should be attempted prior to medication administration unless refused and they were documented on the eMAR or in the progress notes. The facility policy Pain Management documented in part, . 9. Various strategies and modalities may be utilized to assist the resident in achieving optimal comfort. Such strategies and modalities may include, but are not limited to: a. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: i. Environmental - adjusting the room temperature, smoothing the linens, providing a pressure-reducing mattress, repositioning, etc.; ii. Physical - ice packs, cool or warm compresses, baths, transcutaneous electrical nerve stimulation (TENS), massage, acupuncture, etc.; iii. Exercise - range of motion exercises to prevent muscle stiffness and contractures; iv. Cognitive or Behavioral - relaxation, music, diversions, activities, etc . On 3/18/25 at 4:42 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, and facility document review, the facility staff failed to ensure the DON (director of nursing) did not serve as a charge nurse for one of 30 days reviewed. The findings include: The facility staff failed to ensure the DON did not serve as a charge nurse on 3/1/25. A review of facility staffing data revealed the resident census was 72 residents on 3/1/25. A daily nursing assignment form dated 3/1/25 revealed ASM (administrative staff member) #2 (the director of nursing) was documented as the nurse working on the west wing. On 3/18/25 at 4:47 p.m., an interview was conducted with ASM #2. ASM #2 stated she worked as a charge nurse on the floor and medication cart on 3/1/25. On 3/19/25 at approximately 12:15 p.m., ASM #1 (the executive director) and ASM #2 were made aware of the above concern. A specific policy regarding this concern was not provided. No further information was presented prior to exit.

2. For Resident #15 (R15), the facility pharmacist failed to perform a medication regimen review in June and December of 2024. The attending physician failed to respond to the pharmacist's recommendations in June, September, and October 2024. A review of R15's clinical record revealed a 4/19/22 order for Protonix (to treat esophageal reflux) 40 mg (milligrams) daily, an 8/4/22 order for Lorazepam (to treat anxiety) 1 mg twice daily, and a 4/25/24 order for Trileptal (to prevent seizures) 150 mg twice daily. Further review of R15's clinical record revealed no evidence of a monthly medication regimen review by the pharmacist in June and December 2024. This review also revealed the following recommendations by the pharmacist: In May and October 2024, the pharmacist recommended a dose reduction of the Protonix to 20 mg twice daily. In September 2024, the pharmacist recommended a dose reduction of the Lorazepam to 0.5 mg in the morning and 1 mg in the evening. The pharmacist also recommended a dose reduction of Trileptal to 75 mg in the morning and 150 mg in the evening. R15's clinical record revealed no evidence that the facility physician considered and responded to these recommendations in a timely manner. On 3/18/25 at 12:47 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were interviewed. ASM #2 stated for each resident, the pharmacist reviews residents whom he/she deems necessary. The pharmacist lets ASM #2 know of any urgent concerns prior to leaving the building, then emails the remainder of the reports and recommendations to her. ASM #2 stated she distributes the documents to the appropriate attending physicians, and the physicians respond to the recommendations. She stated she has not regularly been scanning the physician recommendations into the residents' electronic medical record. She did not identify a process for follow up to make sure the medication regimen reviews are completed as required, or for physician response to the pharmacist's recommendations. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 3. For Resident #17 (R17), the facility pharmacist failed to perform a medication regimen review in April and November of 2024. A review of R17's clinical record revealed no evidence of a monthly medication regimen review by the pharmacist in April and November 2024. On 3/18/25 at 12:47 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were interviewed. ASM #2 stated for each resident, the pharmacist reviews residents whom he/she deems necessary. The pharmacist lets ASM #2 know of any urgent concerns prior to leaving the building, then emails the remainder of the reports and recommendations to her. She did not identify a process for follow up to make sure the medication regimen reviews are completed as required. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to complete and/or act upon monthly pharmacy medication regimen reviews for three of 29 residents in the survey sample, Residents #27, #15 and #17. The findings include: 1. For Resident #27 (R27), the facility staff failed to act upon pharmacy recommendations. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/21/24, the resident was documented as taking an antianxiety and an anticonvulsant medication. The physician orders for R27 documented in part, - Depakote Oral Tablet Delayed Release 125 MG (milligram) (Divalproex Sodium) Give 2 tablet by mouth one time a day for anxiety. Order Date: 03/09/2024. - Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day for anxiety. Order Date: 10/11/2022. The comprehensive care plan for R27 documented in part, - Anticonvulsants: the resident is at risk for adverse reactions related to requiring anticonvulsants for treatment of Mood Disorder Stabilization. Date Initiated: 12/27/2024. - Psychoactive Medications: the resident is at risk for complications related to psychoactive (antidepressant, anxiolytic or hypnotic) medications use secondary to diagnoses of: anxiety disorder. Date Initiated: 12/27/2024. The clinical record for R27 failed to evidence documentation of monthly pharmacy medication regimen reviews completed for the past 12 months. On 3/18/25 at 12:48 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that the pharmacist did a review of residents medications monthly and gave her a report upon their exit of any immediate concerns. She stated that he sent her an email with all the reviews and recommendations which she printed out and reviewed. She stated that she completed any nursing recommendations and sent any recommendations for the physician to their offices or contacted them for review. She stated that after the physician reviewed the recommendations, she put in any orders for any medication changes as needed. ASM #2 stated that some of the recommendations were not in the medical record. At that time, a request was made to ASM #1, the executive director, ASM #2 and ASM #3, the regional director of clinical services for evidence of monthly medication regimen reviews for R27 with evidence of physician response for any recommendations made. Review of the facility provided pharmacist medication regimen reviews for the past 12 months for R27 revealed the following recommendations: - A recommendation dated 9/29/24 which documented in part, .The resident has been taking Depakote DR 125mg, 2 tablets (250mg) once daily since (3/10/2024) without a GDR (gradual dose reduction). Could we attempt a dose reduction at this time to perhaps Depakote DR 125mg once daily to verify this resident is on the lowest possible dose? If not, please indicate the response below . The recommendation was observed to be blank with an attached psychiatric progress note for R27 dated 8/7/24 which documented a review of current medications with no changes recommended at that time. The progress note was observed to be dated 8/7/24 which was prior to the pharmacy recommendation for the GDR on 9/29/24. - A recommendation dated 12/16/24 which documented in part, .The resident has been taking Lorazepam 0.5mg once daily since (10/12/2022) without a GDR. Could we attempt a dose reduction at this time to perhaps Lorazepam 0.25mg once daily to verify this resident is on the lowest possible dose? If not, please indicate the response below . The recommendation was observed to be blank with an attached psychiatric progress note for R27 dated 12/10/24 which documented a review of current medications with no changes recommended at that time. The progress note was observed to be dated 12/10/24 which was prior to the pharmacy recommendation for the GDR on 12/16/24. The facility policy Medication Regimen Review documented in part, .The Consultant Pharmacist with perform a medication regimen review (MRR) for every resident in the facility. Routine reviews will be done monthly . The pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon . The attending physician or medical director will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record . On 3/19/25 at 12:38 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of required physician documentation after a resident is transferred to the hospital for one of 29 residents in the survey sample, R24. The findings include: The facility staff failed to evidence required physician documentation after a resident is transferred to the hospital for R24. R24 was transferred to the hospital on [DATE]. R24 was admitted to the facility on [DATE] with diagnosis that included but were not limited to TIA (transient ischemic attack), dysphagia and cognitive communication deficit. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/28/25, coded the resident as scoring a 08 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers/bathing/dressing and supervision for eating. A review of the comprehensive care plan dated 12/9/24 revealed, FOCUS: Resident has had an actual fall related to Confusion, Gait/balance problems, mild visual impairment, and HTN (hypertension). INTERVENTIONS: Bed lowest position. Re-educate resident on the importance of using call light for assistance and not transferring himself with no assistance. Call light is within reach and encourage the resident to use it for assistance as needed. He needs prompt response to all requests for assistance. A review of the nursing progress note dated 11/29/24 at 4:39 PM revealed, This nurse was contacted by another nurse r/t resident being in the bed. Resident was assessed, but denied any pain at the time, and no signs of external rotation at this time. Resident was assisted back to bed via staff and transfer lift device. Upon getting resident in the bed, he had c/o of R hip pain, while attempting to do VS. Area assessed further and noticed that R hip bone has a bulge, and it could be seen. MD was contacted to have resident sent out to hospital but left message with receptionist. RP was contacted and informed that resident would be sent to the hospital. EMS contacted for resident transfer. Resident left facility approximately 4:00 PM to hospital. Physician notes were dated 11/16/24 and 12/18/24 with no post hospital physician/NP transfer note evidenced. An interview was conducted on 3/19/25 at 7:25 AM with LPN (licensed practical nurse) #2. When asked when physicians write their notes after a resident is transferred to the hospital, LPN #2 stated, their notes are in PCC (point click care), but I do not know when they write them. There is one book on the [NAME] unit that we document what residents; the physician needs to see. An interview was conducted on 3/19/25 at 12:22 PM with ASM (administrative staff member) #4, the physician. When asked about timing of his resident visits and notes, ASM #4 stated, every Wednesday and extra Friday or Saturday, about six times per month. I did not have remote access for about six months to document. The nursing staff give me a shopping list of the people who are due to be seen. I started doing this in December. I run a whole list of my own, so I do not miss anyone. I use PCC to document my progress notes. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. A review of the facility's Physician/Practitioner Progress Notes policy revealed, Physician progress notes must be maintained for each resident. Physician/practitioner progress notes reflect the resident's progress and response to his or her care plan, medications, etc. Physician/practitioner documentation will be accurate, made timely, and signed/dated by the physician/practitioner. No further information was provided prior to exit.

Based on observation, clinical record review, staff interview, and facility document review, it was determined the facility staff failed to provide assistive devices during meals for one of 29 residents in the survey sample, Resident #37. The findings include: For Resident #37 (R37), the facility staff failed to provide a divided plate as ordered during meals. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/24, the resident scored three out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were severely impaired for making daily decisions. Section K documented no weight loss or swallowing difficulty. Observation of R37 on 3/17/25 at 1:24 p.m. revealed the resident sitting in bed eating lunch. The lunch was observed to be served with each portion in separate bowls on a tray. On 3/18/25 at 1:14 p.m., an observation of R37's lunch revealed it served on a regular plate. The physician orders for R37 documented in part, Divided/sectional plate at all meals. Order Date: 10/24/2024. The comprehensive care plan for R37 documented in part, Nutritional Status: the resident is at risk for weight loss, malnutrition or poor hydration status related to chronic disease, cognitive impairment, GERD (gastrointestinal reflux disease). Date Initiated: 01/29/2025. The care plan failed to evidence documentation of the use of assistive devices during meals. On 3/18/25 at 3:42 p.m., an interview was conducted with LPN (licensed practical nurse) #5 who stated that they supervised R37 when eating and queued them to eat. She stated that R37 used their hands and fingers to eat a lot. She stated that she did not recall the resident using a divided plate during meals but may had seen one used in the past. On 3/18/25 at 4:13 p.m., an interview was conducted with OSM (other staff member) #4, speech language pathologist. OSM #4 stated that they had not worked with R37 since May of 2024, but they placed the order for the divided plate on 10/24/2024. She stated that it was probably from a recommendation that was made from a routine screening, and she would check her files. On 3/18/25 at approximately 4:35 p.m., OSM #4 provided a handwritten therapy evaluation for R37 dated 10/24/24 which documented recommendations of .Recommend divided/sectional plate at all meals to (decrease) spillage from plate, thereby increasing po (by mouth) intake. The facility policy Assistance with meals documented in part, .Residents will receive assistance with meals in a manner that meets the individual needs of each resident . 2. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups. 3. Assistance will be provided to ensure that residents can use and benefit from special eating equipment and utensils . On 3/18/25 at 4:42 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, the facility staff failed to treat a resident with dignity for one of 29 residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to provide feeding assistance in a dignified manner at breakfast on 3/18/25. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/13/24, R1 was coded as being severely impaired for making daily decisions, having scored three out of 15 on the BIMS (brief interview for mental status). She was coded as requiring supervision or touching assistance for eating. On 3/18/25 at 8:44 a.m., R1 was observed sitting up in chair in the day room. She was being fed breakfast by OSM (other staff member) #5, the business office manager. OSM #5 was observed standing beside and over R1 as she fed the resident. On 3/19/24 at 7:43 a.m., CNA (certified nursing assistant) #1 was interviewed. She stated when she feeds or partially assists a resident with eating, she sits down beside the resident. She stated: I like to have eye contact. Standing on top of someone is not good. It is [NAME] important to face them and have eye contact with them. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Assistance with Meals, revealed, in part: Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. No additional information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to develop a comprehensive care plan for three of 29 residents in the survey sample, Residents #17, #19, and #1. The findings include: 1. For Resident #17 (R17), the facility staff failed to develop a care plan for the resident's dietary needs. On 3/17/25 at 12:48 p.m., R17 was observed sitting up in bed eating lunch. The resident's lunch tray contained one regular roll and peach cobbler (peach slices and cobbler crust). A review of R17's meal ticket revealed, in part: Dysphagia mechanical soft, nectar thick liquid .moistened white cake with chopped peaches .no straws. At 1:00 p.m., OSM (other staff member) #4, a speech therapist, also observed R17's meal tray. She confirmed that the regular roll and peach cobbler did not conform with a mechanical soft diet. On 3/17/24 at 5:53 p.m., R17 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R17's meal ticket revealed, in part: Dysphagia mechanical soft .ground chicken nuggets with barbecue sauce. A review of R17's prescribers' orders revealed the following order, dated 9/27/24: Mechanical Soft texture, Nectar liquids consistency, for oropharyngeal dysphasia; high aspiration risk. NO STRAWS. A review of R17's care plan revealed no information regarding the resident's altered diet. On 3/19/25 at 7:52 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated care plans are developed so the residents may have a more productive lifestyle, to do as much as possible independently, and to determine those things with which residents need help. On 3/19/25 at 8:24 a.m., LPN #6, the MDS (minimum data set) coordinator was interviewed. She stated she reviews care plans daily for accuracy, and particularly focuses on new orders or items contained in the 24 hour report. She stated she does not put specific diets on the care plan because these can change. She stated if a resident has a modified diet, she indicates it in the care plan as, Diet as ordered. She stated floor nurses have the ability to update care plans, but generally they do not. She stated comprehensive care plan reviews include all orders and interventions a resident requires. On 3/19/25 at 9:08 a.m., LPN #6 stated that she had not been able to locate information related to resident diets on any of the care plans, and this is something she would need to correct. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Care Planning - Comprehensive Person-Centered, revealed, in part: A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident .the resident will receive the services and/or items included in the plan of care .Each resident's comprehensive care plan will describe .services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. No additional information was provided prior to exit. 2. For Resident #19 (R19), the facility staff failed to develop a care plan for the resident's dietary needs. On 3/17/25 at 1:09 p.m., R19 was observed sitting up in bed eating lunch. The resident's lunch tray contained one regular roll and peach cobbler (peach slices and cobbler crust). A review of R19's meal ticket revealed, in part: Dysphagia mechanical soft .pureed bread .moistened white cake with chopped peaches. On 3/17/24 at 5:49 p.m., R19 was observed sitting up in bed eating dinner. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed) and canned pineapple slices. A review of R19's meal ticket revealed, in part: Dysphagia mechanical soft .ground chicken nuggets with barbecue sauce .choice of soft, canned, chopped fruit. A review of R19's prescribers' orders revealed the following order, dated 5/14/24: Mechanical Soft texture, Regular/Thin consistency [for liquids]. A review of R19's care plan revealed no information regarding the resident's altered diet. On 3/19/25 at 7:52 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated care plans are developed so the residents may have a more productive lifestyle, to do as much as possible independently, and to determine those things with which residents need help. On 3/19/25 at 8:24 a.m., LPN #6, the MDS (minimum data set) coordinator was interviewed. She stated she reviews care plans daily for accuracy, and particularly focuses on new orders or items contained in the 24 hour report. She stated she does not put specific diets on the care plan because these can change. She stated if a resident has a modified diet, she indicates it in the care plan as, Diet as ordered. She stated floor nurses have the ability to update care plans, but generally they do not. She stated comprehensive care plan reviews include all orders and interventions a resident requires. On 3/19/25 at 9:08 a.m., LPN #6 stated that she had not been able to locate information related to resident diets on any of the care plans, and this is something she would need to correct. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit. 3. For Resident #1 (R1), the facility staff failed to develop a care plan for the resident's dietary needs. On 3/17/24 at 6:00 p.m., R1 was observed sitting in the day room being fed dinner by a OSM (other staff member) #5, the business office manager. The dinner tray contained cubed chicken (approximately 1.5 centimeters cubed). A review of R1's meal ticket revealed, in part: Dysphagia advanced .ground chicken nuggets with barbecue sauce. A review of R1's prescribers' orders revealed the following order, dated 4/30/24: Dysphagia - Advanced texture. A review of R1's care plan revealed no information regarding the resident's altered diet. On 3/19/25 at 7:52 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated care plans are developed so the residents may have a more productive lifestyle, to do as much as possible independently, and to determine those things with which residents need help. On 3/19/25 at 8:24 a.m., LPN #6, the MDS (minimum data set) coordinator was interviewed. She stated she reviews care plans daily for accuracy, and particularly focuses on new orders or items contained in the 24 hour report. She stated she does not put specific diets on the care plan because these can change. She stated if a resident has a modified diet, she indicates it in the care plan as, Diet as ordered. She stated floor nurses have the ability to update care plans, but generally they do not. She stated comprehensive care plan reviews include all orders and interventions a resident requires. On 3/19/25 at 9:08 a.m., LPN #6 stated that she had not been able to locate information related to resident diets on any of the care plans, and this is something she would need to correct. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. No additional information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to meet professional standards for one of 29 residents, R39. The findings include: The facility staff failed to meet professional standards by clarifying the oxygen order for R39. R39 was admitted to the facility on [DATE] with diagnosis that included but were not limited to acute respiratory failure, COPD (chronic obstructive pulmonary disease) and MI (myocardial infarction). The most recent MDS (minimum data set) assessment, a 5-day assessment, with an ARD (assessment reference date) of 2/13/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers/bathing/dressing and set-up for eating. A review of the comprehensive care plan dated 2/10/25 revealed, FOCUS: RESPIRATORY: the resident is at risk for respiratory complications secondary to COPD, supplementary oxygen requirement. INTERVENTIONS: Administer oxygen as ordered. Administer medications as ordered. A review of the physician's order dated 2/12/25 revealed, Oxygen 4 liters via NC (specify continuous) DUE TO RESP FAILURE. every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. Oxygen Therapy @ 2 LM continuous every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. A review of the February and March 2025 MAR (medication administration record), oxygen 2lnc and oxygen 4lnc are both documented as administered. An interview was conducted on 3/18/25 at 8:45 AM with LPN (licensed practical nurse) #1. When asked to review the oxygen rate of R39, LPN #1 stated, it is on 2 liters nasal cannula. When asked to review the orders, LPN #1 stated, there are two conflicting orders for oxygen administration, one for 2 lnc and one for 4 lnc. When asked where oxygen administration would be evidenced, LPN #1 stated on the MAR. When asked to review R39's MAR, LPN #1 stated, oxygen 2lnc and oxygen 4lnc are both documented as administered. When asked what the professional standard of practice would be in this situation, LPN #1 stated, we should have called to clarify the physician's order and not documented that both rates were administered. The ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services was made aware of the finding on 3/18/25 at 4:45 PM. A review of the facility's Daily Work Assignments policy, revealed, All nursing service personnel shall follow daily work assignments and perform assigned duties in accordance with professional standards of practice and facility policy. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to complete an accurate MDS (minimum data set) for one of 29 residents in the survey sample, Resident #51. The findings include: For Resident #51 (R51), the facility staff failed to complete an accurate 12/31/24 MDS. On R51's most recent MDS, an annual assessment with an ARD (assessment reference date) of 12/31/24, the resident was coded as having no cognitive impairment. He was coded as being physically restrained when in a chair or out of bed. Observations of R51 occurred at the following dates and times: 3/17/25 at 1:00 p.m. and 4:40 p.m.; and 3/18/25 at 8:51 a.m. At none of these observations was R51 physically restrained. On 3/17/25 at 1:00 p.m., R51 stated he had never been physically restrained, and had always had free and independent movement in the bed and in a chair. On 3/19/25 at 8:24 a.m., LPN (licensed practical nurse) #6, the MDS coordinator, was interviewed. She stated she had originally coded R51 as being physically restrained because he used a seatbelt when he was out of bed in a wheelchair. She stated she had recently learned that the seatbelt was not considered a restraint because the resident could release the seatbelt independently, and the seatbelt did not restrict his movement in any way. She stated the process to correct the 12/31/24 MDS was underway, but the modified MDS has not yet been submitted. She did not know why the MDS was not yet submitted. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, MDS Correction, revealed, in part: If an error is discovered in a record that has already been accepted by the [Centers for Medicare and Medicaid Services], implement procedures for either Modification or Inactivation of the information in the system within 14 days of the discovery of the error. No additional information was submitted prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement interventions to prevent unnecessary psychoactive medication administration for two of 29 residents in the survey sample, Residents #15 and #39. The findings include: 1. For Resident #15 (R15), the facility staff failed to respond to a pharmacist's recommendation to reduce the dose of Lorazepam (to treat anxiety). A review of R15's clinical record revealed an 8/4/22 order for Lorazepam (to treat anxiety) 1 mg twice daily. In September 2024, the pharmacist recommended a dose reduction of the Lorazepam to 0.5 mg in the morning and 1 mg in the evening R15's clinical record revealed no evidence that the facility physician considered and responded to this recommendations in a timely manner. On 3/18/25 at 12:47 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were interviewed. ASM #2 stated for each resident, the pharmacist reviews residents whom he/she deems necessary. The pharmacist lets ASM #2 know of any urgent concerns prior to leaving the building, then emails the remainder of the reports and recommendations to her. ASM #2 stated she distributes the documents to the appropriate attending physicians, and the physicians respond to the recommendations. She stated she has not regularly been scanning the physician recommendations into the residents' electronic medical record. She did not identify a process for follow up to make sure the physician responds to the pharmacist's recommendations. On 3/19/25 at 12:37 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and ASM #3, the regional director of clinical services, were informed of these concerns. A review of the facility policy, Medication Regimen Review, revealed, in part: Medication regime reviews will be conducted with the intent to ensure that each resident's entire drug/medication regimen will be managed and monitored to achieve the following goals .Each resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed conditions .The consulting pharmacist will provide a copy of recommendations to the attending physician, medical director, and director of nursing within 5 working days of completion of the review .The director of nursing or designee will review the recommendations and the attending physicians will be contacted for review and response .If the attending physician does not respond within 30 days, the medical director will be asked to review the recommendations and/or contact the attending physician .The attending physician or medical director will document in the resident's medical record that the identified irregularity has been reviewed and what, if any action has been taken to address it .If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. No additional information was provided prior to exit. 2. For Resident #27 (R27), the facility staff failed to respond to pharmacy recommendations to prevent potential unnecessary psychotropic medications. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/21/24, the resident was documented as taking an antianxiety and an anticonvulsant medication. The physician orders for R27 documented in part, - Depakote Oral Tablet Delayed Release 125 MG (milligram) (Divalproex Sodium) Give 2 tablet by mouth one time a day for anxiety. Order Date: 03/09/2024. - Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day for anxiety. Order Date: 10/11/2022. The comprehensive care plan for R27 documented in part, - Anticonvulsants: the resident is at risk for adverse reactions related to requiring anticonvulsants for treatment of Mood Disorder Stabilization. Date Initiated: 12/27/2024. - Psychoactive Medications: the resident is at risk for complications related to psychoactive (antidepressant, anxiolytic or hypnotic) medications use secondary to diagnoses of: anxiety disorder. Date Initiated: 12/27/2024. The clinical record for R27 failed to evidence documentation of monthly pharmacy medication regimen reviews completed for the past 12 months. On 3/18/25 at 12:48 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that the pharmacist did a review of residents monthly and gave her a report upon their exit of any immediate concerns. She stated that he sent her an email with all the reviews and recommendations which she printed out and reviewed. She stated that she completed any nursing recommendations and sent any recommendations for the physician to their offices or contacted them for review. She stated that after the physician reviewed the recommendations, she put in any orders for any medication changes as needed. ASM #2 stated that some of the recommendations were not in the medical record. At that time, a request was made to ASM #1, the executive director, ASM #2 and ASM #3, the regional director of clinical services for evidence of monthly medication regimen reviews for R27 with evidence of physician response for any recommendations made. Review of the facility provided pharmacist medication regimen reviews for R27 documented the following recommendations: - A recommendation dated 9/29/24 which documented in part, .The resident has been taking Depakote DR 125mg, 2 tablets (250mg) once daily since (3/10/2024) without a GDR (gradual dose reduction). Could we attempt a dose reduction at this time to perhaps Depakote DR 125mg once daily to verify this resident is on the lowest possible dose? If not, please indicate the response below . The recommendation was observed to be blank with an attached psychiatric progress note for R27 dated 8/7/24 which documented a review of current medications with no changes recommended at that time. The progress note was observed to be dated 8/7/24 which was prior to the pharmacy recommendation for the GDR on 9/29/24. - A recommendation dated 12/16/24 which documented in part, .The resident has been taking Lorazepam 0.5mg once daily since (10/12/2022) without a GDR. Could we attempt a dose reduction at this time to perhaps Lorazepam 0.25mg once daily to verify this resident is on the lowest possible dose? If not, please indicate the response below . The recommendation was observed to be blank with an attached psychiatric progress note for R27 dated 12/10/24 which documented a review of current medications with no changes recommended at that time. The progress note was observed to be dated 12/10/24 which was prior to the pharmacy recommendation for the GDR on 12/16/24. On 3/19/25 at 12:38 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure professional standards of practice for medication administration for one of 18 residents in the survey sample, Resident #40. Findings include: Resident #40 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a significant change assessment dated [DATE]. Resident #40 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/15/22 at 8:55 AM, a medication pass and pour observation was conducted with LPN (licensed practical nurse) #1. As LPN #1 prepared medications for administration, LPN #1 stated that she did not have the medication [MEDICATION(S)] 0.4 mg (milligrams) for Resident #40 to administer. LPN #1 stated that she would call the pharmacy and have the medication delivered and would administer it upon arrival. At approximately 10:00 AM, a medication reconciliation for Resident #40 was completed. The resident's current orders were reviewed and included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/15/22 at 11:15 AM, LPN #1 was asked if the [MEDICATION(S)] 0.4 mg for Resident #40 had arrived from the pharmacy and if the medication had been administered. LPN #1 stated that the medication had not arrived. LPN #1 stated that she had called the pharmacy and the pharmacy told her that they did not have a current order for the [MEDICATION(S)] 0.4 mg for Resident #40. At 11:30 AM, LPN #1 called the pharmacy again. LPN #1 asked the pharmacy when the medication was last filled/dispensed and when it was sent to the facility. LPN #1 stated there was a current order for the [MEDICATION(S)] in Resident #40's record. The pharmacy stated that a 30 day supply was last sent on 12/30/21 and stated that the medication had been discontinued on 01/19/22. LPN #1 stated then that Resident #40 had gone out to the hospital on January 19th and was readmitted on [DATE], and that was probably why the medication was discontinued. LPN #1 stated that someone may have put the order back in the system. The resident's CCP (comprehensive care plan) was reviewed and documented, .alteration in bladder incontinence (date initiated: 09/16/21) .[CONDITION(S)] disorder .encourage fluids .monitor for signs/symptoms of [CONDITION(S)] (urinary tract infection) .monitor/document/report as needed possible causes of incontinence . Resident #40's MAR (medication administration record) was reviewed and revealed that the resident had not received the [MEDICATION(S)] 0.4 mg on March 7th, 9th, 10th, 14th and 15th (day of medication pass observation) due to the medication not being available for administration. On 03/15/22 at 3:15 PM, LPN #4 was interviewed regarding the [MEDICATION(S)] for Resident #40. LPN #4 stated that she did not give the medication to Resident #40 because it was not there to give. LPN #4 stated that Resident #40 did not get the medicine on March 7th, 8th, and 9th from her (the days she worked). LPN #4 was made aware that she had signed her initials on 03/08/22 indicating the medication had been given. LPN #4 stated that must have been accidental and stated that Resident #40 did not receive [MEDICATION(S)] on the three days that she worked (March 7th, 8th or 9th). On 03/16/22 at approximately 10:00 AM, the consultant pharmacist was interviewed regarding Resident #40's [MEDICATION(S)] order. The pharmacist stated that medications are automatically discontinued when a resident goes to the hospital and could not explain why Resident #40 still had a current order showing in the clinical record. The pharmacist stated that the facility may have had some medication ([MEDICATION(S)]) left or a slight overage from ordering early, but stated that there is no way the facility had enough medication to get them all the way through March 15th. The pharmacist stated that there are two [MEDICATION(S)] 0.4 mg pills in the stat box, but that is all. On 03/16/22 at approximately 3:30 PM, LPN #1 was interviewed again regarding Resident #40's [MEDICATION(S)]. LPN #1 was made aware of the discrepancy between when the pharmacy last delivered a 30 day supply of the medication on 12/30/22, that it was being documented that Resident #40 was getting the medication, when the resident's 30 day supply should have been exhausted. LPN #1 had documented multiple times that the medication was given and was asked how a medication can be administered when the medication is not available to give. LPN #1 stated, I would have borrowed it, I know that's illegal, but if I signed I gave it, I gave it. LPN #1 was asked how many days she borrowed medication. LPN #1 could not provide an answer. LPN #1 stated that she did not take the time to call the pharmacy or pull a sticker to reorder the medication for Resident #40. On 03/16/22 at approximately 4:00 PM, the administrator and DON were made aware of the above information in a meeting with the survey team. The DON stated that staff are not supposed to borrow medications from other residents. A policy was requested on administering medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A policy titled, Administering Medications was presented and reviewed. The policy documented, .Medications are administered in accordance with the prescriber orders .medications ordered for a particular resident may not be administered to another resident . No further information and/or documentation was presented prior to the exit conference on 03/17/22.

Based on observation, staff interview, and clinical record review, the facility staff failed to follow physician's orders for two of 18 residents in the survey sample, Resident #40 and Resident #212. Resident #40 was not administered medication ([MEDICATION(S)]) as ordered by the physician. Resident #212 was on a physician ordered fluid restriction, but there were no fluid intake records for this resident. Findings include: 1. Resident #40 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a significant change assessment dated [DATE]. Resident #40 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/15/22 at 8:55 AM, a medication pass and pour observation was conducted with LPN (licensed practical nurse) #1. As LPN #1 prepared medications for administration, LPN #1 stated that she did not have the medication [MEDICATION(S)] 0.4 mg (milligrams) for Resident #40 to administer. LPN #1 stated that she would call the pharmacy and have the medication delivered and would administer it upon arrival. At approximately 10:00 AM, a medication reconciliation for Resident #40 was completed. The resident's current orders were reviewed and included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/15/22 at 11:15 AM, LPN #1 was asked if the [MEDICATION(S)] 0.4 mg for Resident #40 had arrived from the pharmacy and if the medication had been administered. LPN #1 stated that the medication had not arrived. LPN #1 stated that she had called the pharmacy and the pharmacy told her that they did not have a current order for the [MEDICATION(S)] 0.4 mg for Resident #40. At 11:30 AM, LPN #1 called the pharmacy again. LPN #1 asked the pharmacy when the medication was last filled/dispensed and when it was sent to the facility. LPN #1 stated there was a current order for the [MEDICATION(S)] in Resident #40's record. The pharmacy stated that a 30 day supply was last sent on 12/30/21 and stated that the medication had been discontinued on 01/19/22. LPN #1 stated then that Resident #40 had gone out to the hospital on January 19th and was readmitted on [DATE], and that was probably why the medication was discontinued. LPN #1 stated that someone may have put the order back in the system. The resident's CCP (comprehensive care plan) was reviewed and documented, .alteration in bladder incontinence (date initiated: 09/16/21) .[CONDITION(S)] disorder .encourage fluids .monitor for signs/symptoms of [CONDITION(S)] (urinary tract infection) .monitor/document/report as needed possible causes of incontinence . Resident #40's MAR (medication administration record) was reviewed and revealed that the resident had not received the [MEDICATION(S)] 0.4 mg on March 7th, 9th, 10th, 14th and 15th (day of medication pass observation) due to the medication not being available for administration. On 03/15/22 at 3:15 PM, LPN #4 was interviewed regarding the [MEDICATION(S)] for Resident #40. LPN #4 stated that she did not give the medication to Resident #40 because it was not there to give. LPN #4 stated that Resident #40 did not get the medicine on March 7th, 8th, and 9th from her (the days she worked). LPN #4 was made aware that she had signed her initials on 03/08/22 indicating the medication had been given. LPN #4 stated that must have been accidental and stated that Resident #40 did not receive [MEDICATION(S)] on the three days that she worked (March 7th, 8th or 9th). On 03/16/22 at approximately 3:30 PM, LPN #1 was interviewed again regarding Resident #40's [MEDICATION(S)]. LPN #1 was made aware of the discrepancy between when the pharmacy last delivered a 30 day supply of the medication on 12/30/22, that it was being documented that Resident #40 was getting the medication, when the resident's 30 day supply should have been exhausted. LPN #1 had documented multiple times that the medication was given and was asked how a medication can be administered when the medication is not available to give. LPN #1 stated, I would have borrowed it, I know that's illegal, but if I signed I gave it, I gave it. LPN #1 was asked how many days she borrowed medication. LPN #1 could not provide an answer. LPN #1 stated that she did not take the time to call the pharmacy or pull a sticker to reorder the medication for Resident #40. On 03/16/22 at approximately 4:00 PM, the administrator and director of nursing (DON) were made aware of the above information in a meeting with the survey team. A policy was requested on administering medications per the physician's order. A policy titled, Administering Medications documented, .Medications are administered in accordance with the prescriber orders .medications ordered for a particular resident may not be administered to another resident . On 03/16/22 at approximately 5:00 PM, the DON and administrator were again made aware of the above information and concerns regarding Resident #40 not receiving his physician ordered [MEDICATION(S)] from March 7th through March 10th and on March 14th and 15th. No further information and/or documentation was presented prior to the exit conference on 03/17/22. 2. Resident #212 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13 indicating the resident was intact for daily decision making skills. Resident #212's physician's orders were reviewed. The resident had an order dated 10/26/21 for, 1 Liter fluid restriction daily related to CHF . The resident's MARs/TARs (medication administration records/treatment administration records) were reviewed. No fluid intake records were located. Resident #212's CNA (certified nursing assistant) documentation was reviewed for fluid intake. No records were found to evidence that the resident's fluid intake was being documented. The resident's CCP (comprehensive care plan) documented, .has potential fluid volume overload related to heart failure (date initiated: 11/03/21) .administer medications as ordered .diet as ordered .ensure all snacks and beverages offered .comply with diet and fluid restrictions .Monitor/document/report as needed any signs/symptoms of fluid overload . On 03/16/22 at approximately 5:00 PM, the administrator and director of nursing (DON) were made aware of the above concerns regarding Resident #212 having CHF, being ordered a fluid restriction on admission, and that no fluid intake records were found. The DON stated that she would look for them. The DON stated that they normally get an order and it will carry over to the MAR/TAR and they will document each shift the amount of fluid taken by the resident. The DON stated that it is usually divided out for a certain amount of fluid for each shift. On 03/17/22 at 10:55 AM, the DON stated that they did not have any intake records for Resident #212. No further information and/or documetnation was presented prior to the exit conference on 03/17/22.

Based on medication pass and pour observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. The total number of opportunities were 35, with a total of 4 medication errors, which resulted in a medication error rate of 11.43 percent. Findings include: 1. On 03/15/22 at 8:56 AM, LPN (Licensed Practical Nurse) #1 prepared medications for Resident #40. LPN #1 pulled the resident's medications and put them into a plastic medication cup. The medications were documented and then counted for accuracy. The count did not match. The medications in the cup were 12 pills; the number of pills documented was 10. LPN #1 was asked to pull each medication pill card/bottle from the medication cart. The pill cards/bottles were compared to the pills in the cup, as well as, what was documented. Each pill card had the pill's identifying characteristics listed. LPN #1 stated that she had pulled two of the famotidine pills (20 mg each) and stated the resident is ordered 40 mg. This made the count 11. LPN #1 stated that she also pulled a [MEDICATION(S)] pill, which would then make the count 12. As a result of the above information, each medication in the cup was verified with the pill identifying characteristics listed on the medication card or bottle. All were correct except one white pill. LPN #1 stated that the last pill in the cup was the [MEDICATION(S)] 5 mg tablet. The pill in the cup did not match the pill in the [MEDICATION(S)] 5 mg card and did not match the identifying characteristics listed on the card for [MEDICATION(S)] 5 mg. LPN #1 then stated that she did not know, but felt certain the pill should be the [MEDICATION(S)] 5 mg tablet. The pill in the cup was again compared to the pill in the [MEDICATION(S)] 5 mg card. LPN #1 then stated, That isn't the same pill. The pill in the cup was white, scored on one side, and had the imprint PLIVA 434. This pill was identified as a Trazadone 100 mg tablet. LPN #1 had pulled the incorrect mediation for administration. The [MEDICATION(S)] 5 mg pill that was ordered to be given at this time was not put in the cup for administration. LPN #1 was asked what she thought may have happened. LPN #1 stated that the Trazadone is a night time medication and she didn't pull any of those cards out. LPN #1 then stated that when she pulled the [MEDICATION(S)] 5 mg card out of the drawer, the first one was empty and the one behind it must have been the Trazadone card. LPN #1 stated, I must not have paid attention to that. LPN #1 had another card of the [MEDICATION(S)] 5 mg tablets, but no pills had been removed from the card, it was full. LPN #1 stated that Resident #40 was also supposed to get a tamsulosin ([MEDICATION(S)]) 0.4 mg capsule, but that the medication was not available, and she would have to call the pharmacy and have it delivered and would administer it when it arrived. LPN #1 stated, .That's a med error. LPN #1 was made aware that the omission of the [MEDICATION(S)] 5 mg tablet and the addition of the Trazadone 100 mg tablet would count as two medication errors. A medication reconciliation was completed for Resident #40. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] ([MEDICATION(S)]) tablet 5 mg give one tablet by mouth one time a day (9:00 AM) .Trazadone 100 mg give one tablet by mouth one time a day (9:00 PM) . On 03/15/22 at 11:30 AM, LPN #1 was asked about the [MEDICATION(S)] medication. LPN #1 stated that she had called the pharmacy and that they told her that the medication was not showing up as an active order in the system. LPN #1 was made aware that the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #40 to be administered at 9:00 AM. LPN #1 stated that when she called the pharmacy they told her that they did not have a current order for the Floxmax 0.4 mg for Resident #40, but she knew it was a current order. At approximately 12:00 PM, LPN #1 was made aware that the due to the medication [MEDICATION(S)] not being administered per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/16/22 at 5:00 PM, the administrator and DON were made aware of the above medication errors. No further information and/or documetnation was presented prior to the exit conference on 03/17/22. 2. A medication pass was conducted on 3/15/22 at 8:34 a.m. with licensed practical nurse (LPN) #4 administering medications to Resident #32. Included in medications administered to Resident #32 was [MEDICATION(S)] 25 mg (milligrams). Resident #32's clinical record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/15/22 at 10:00 a.m., LPN #4 was interviewed about the lorsartan potassium 25 mg administered to Resident #32. LPN #4 reviewed the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #4 pulled the pharmacy supply card of [MEDICATION(S)] used during the medication pass. The pharmacy label indicated the lorsartan potassium was 25 mg. LPN #4 looked through the medication cart and stated she did not see a supply card for a 50 mg dose. On 3/15/22 at 3:45 p.m., the unit manager (LPN #5) was interviewed about the medication error observed with Resident #32. LPN #5 looked through the medication cart and located a supply card with [MEDICATION(S)] 50 mg tablets. LPN #5 stated the 50 mg dose was available and should have been given as ordered. The policy titled, .general dose preparation of medication administration documented, .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time for the correct resident . This finding was reviewed with the administrator and director of nursing during a meeting on 3/15/22 at 4:30 p.m.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure one of 22 residents (Resident #1) was assessed and provided care and services for the prevention of urethral trauma related to the prolonged use of an indwelling Foley catheter. As a result the resident developed trauma to the urethra (urethral tear/erosion) constituting harm to the resident. Findings include: Resident #1 admitted to the facility originally on 02/28/18. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 03/06/18. This MDS documented the resident with a cognitive score of 6, indicating the resident had severe impairment in daily decision making skills. The resident was also assessed as requiring extensive assistance with most ADL's (activities of daily living) with assistance of at least one staff person for bed mobility, transfers, dressing, toileting and personal hygiene. The resident was totally dependent upon one staff person for bathing. The resident was assessed as having an indwelling catheter on this MDS and triggered in the CAAS (care area assessment summary) section of this MDS for cognition, urinary, falls and nutrition. The resident additionally triggered for pressure in the CAAS area of this MDS, but it was not marked to address this area in the careplan. During clinical record review, a consult from the urologist dated 04/03/18 documented, .This patient had incomplete voiding with + (positive) UA (urinalysis), decreased renal function and negative UC (urine culture) 2/18. Foley passed in ER (emergency room ) and has had hematuria and urethral trauma twice since then. [MEDICATION NAME] d/c'd (discontinued) but on [MEDICATION NAME] AODM (adult onset diabetes mellitus), [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Paraphimosis* reduced 1. atonic [MEDICAL CONDITION] bladder with incomplete voiding and trauma to urethra secondary to catheter manipulation. 2. paraphimosis Recommendations: D/C Foley catheter Intermittent cath BID (twice daily) if RU (residual urine) < (less than) 250 ml (milliliters) then intermittent cath QD (every day) RT (refer to) urology PRN (as needed) .signature of urologist. Paraphimosis occurs when the foreskin of an uncircumcised male cannot be pulled back over the head of the penis. Website: https://medlineplus.gov/ency/article/ 1.htm The resident's physician's orders were reviewed for (MONTH) (YEAR) and included an order to: .d/c Foley catheter (04/03/18) .intermittent catheterization, if urine output is less than 250 ml two times a day for urine retention .May D/C intermittent catheterization if urine output is 250 ml or more consistently . A physician's progress note dated 04/04/18 at 10:08 p.m. documented, .[MEDICAL CONDITION] and history of falling; at baseline .stable .agree with plan of care . The note made no mention of the resident's Foley catheter or care of the catheter. Nursing notes were reviewed and documented the following: 04/03/18 at 3:00 p.m., .resident back in facility .new order to D/C Foley catheter, intermittent catheterization BID if residual urine 250 ml then intermittent cath QD .called doctors office for clarification on how long to cath BID . Awaiting call back from doctors office . 04/04/18, .Foley d/c'd per MD (medical doctor) orders. Voiding without difficulty. Saturated three brief (sic) on this shift . On 04/06/18 the resident was admitted to the hospital and returned on 04/11/18. Resident #1 was readmitted with an indwelling catheter in place. The resident's physician's orders did not reveal a physician's order was in place for the indwelling catheter present on readmission of 04/11/18; physician's orders documented an order for [REDACTED]. On 06/27/18 nursing notes documented that [MEDICATION NAME] was ordered for penis irritation/scrotum and that the attending physician was in the facility (06/27/18) and had been made aware, and wanted to continue with the treatment as ordered and the resident required a follow up of condition. No information was found in the resident's clinical record regarding any follow up for the above condition. No physician's progress notes were found regarding concerns related to the resident's indwelling catheter. On 07/09/18 a nursing note documented, Irritated area on tip of penis has small amount of improvement, treatment to area is continued .scrotum is completely healed .Catheter strap is needed on catheter/leg at all times to prevent pulling on catheter . The resident's MARs/TARs (Medication Administration Records/treatment administration records) were reviewed from admission 02/28/18 through 09/20/18 and did not reveal any documentation that a leg strap was implemented or being tracked or monitored for placement, to ensure tension was not being placed on the catheter. On 07/14/18 a nursing note documented that the irritation to the resident's penis had improved. No other documentation, skin records, or wound records were located to indicate that the area had been assessed by nursing or the physician, or that the area of concern was being followed and monitored to evidence actual improvement or deterioration. On 07/20/18 a nursing note documented, Spoke with (name of attending physician) and he is aware of meatus tearing, I advised him of interventions in place and he wanted to know when resident was scheduled for next urologist appointment, if he has none scheduled appointment (sic). Spoke with wife while she was in facility and made aware of reeducation to staff and needing to check on next urologist appointment. On 07/25/18 a physician's progress note documented, pain with movement of patient; Foley catheter .Foley repositioning alleviates discomfort . There was no documentation in the physician progress notes [REDACTED]. Further review of the nursing notes revealed the following: 07/29/18, .treatment of [REDACTED].area has improved .skin at insertion site of resident's penis is pink in color, with no drainage or blood noted .(name of attending physician) in facility 07/25/18 and did see this resident no new orders given, would like this treatment to continue. 07/30/18, Continues with [MEDICATION NAME] cream to .penis .no drainage/bleeding noted. Instructed resident not pull on catheter. Pain upon manipulation or movement of catheter . 08/01/18, Some excoriation noted at Foley catheter insertion site. (Name of physician) in to see resident . 08/08/18 , .improvement at Foley catheter site .Another leg strap placed on resident Foley catheter tubing for stability. (Name of physician) in tonight, no new orders given. 08/24/18, Very little progress to penile meatus site, will ask for reevaluation of site R/T (related to) treatment. 08/25/18, Very little progress noted to penile meatus. Treatment continue (sic) as ordered. There were no physician progress notes [REDACTED]. A urology consult dated 08/28/18 documented, Report Requested Regarding: catheter problem .Findings: atrophic urethral necrosis at the distal phallus from chronic indwelling Foley, no significant acute [MEDICAL CONDITION], being treated with topical creams, patient also manipulating the Foley, atrophic distal penile necrosis secondary to chronic indwelling Foley. Recommendations: 1. continue lubricating penile meatus with KY jelly BID. 2. avoid excess catheter tension. These are the problems that occur with chronic indwelling Foley and why I recommended intermittent catheter on 04/18 See Note .signature of physician. A physician's order documented to, Discontinue Foley catheter (08/29/18) . On 09/02/18 a nursing note documented, d/c Foley catheter, intermittently catheterize twice daily if his residual urine are less than 250 cc he then can be catheterized once a day. Indwelling catheter should be avoided due to high likelihood of urethral trauma two times a day for urine retention. Intermittently catheterize twice daily If residual urine are less than 250 cc then he can be catheterized once a day. Indwelling Foley catheter should be avoided due to high likelihood of urethral trauma. Foley catheter in place (sic). On 09/03/18 the resident was admitted to the hospital and returned on 09/10/18. Resident #1 was readmitted with a Foley catheter in place. Resident #1's current CCP (comprehensive care plan) was reviewed and documented, .has impaired cognition .assist with decision making .has altered bladder elimination related to bladder neck obstruction with intermittent catheterization (date initiated: 02/28/18) (Revision on: 09/04/18) .interventions in place to minimize risk of complications from intermittent catheter use through next review .intermittent catheter as ordered (date initiated: 08/29/18) .Monitor and report to MD (medical doctor) any signs/symptoms of UTI (urinary tract infection) .obtain and monitor lab/diagnostic work as ordered .apply barrier cream .Observe catheter for tension during transfers and repositioning (date initiated: 07/24/18) .observe and report to nurse any skin impairments noted during care (date initiated: 03/22/18) .Observe skin areas around F/C (Foley catheter) strap and remove as needed to check skin condition (date initiated: 05/31/18 .check (name of Resident #1) for incontinence and assist with toileting as needed .has impaired skin integrity to the left gluteal area related to impaired mobility .apply barrier cream .assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .(dated initiated: 09/14/18) . The CCP did not address Resident # 1's current Foley catheter, did not address the resident's penile erosion/urethral tear and did not include any type of interventions for the prevention of complications related to the use of a Foley catheter. On 09/19/18 at 11:00 AM, the DON (director of nursing) was made aware of concerns regarding Resident # 1's indwelling catheter and possible complications and was asked to observe care of the resident's catheter. The DON stated that she would get the Unit Manager, LPN (Licensed Practical Nurse) # 1, to assist with the observation. The DON was asked for skin and/or wound assessment records for Resident #1. On 09/19/18 at 11:10 AM, LPN #1 took Resident #1 to his room via wheelchair. The LPN explained to the resident concerns regarding the catheter and was asked if an observation could take place. The resident agreed. The resident was sitting in his wheelchair. The LPN had a flashlight for observation and applied gloves. The LPN pulled the front of the resident's sweat pants down, exposing his genital area. The resident had an indwelling catheter in place. The resident's tip of the penis (glans penis) was red and raw. The LPN moved the penis to view the underside, the resident's penis was torn/ripped from the tip of the penis (the urethral opening) to the bottom of the glans penis (below the frenulum), the entire underside of the penis is open and raw. The resident had a leg strap on the left leg upper thigh. The LPN stated, It didn't look like that the last time I seen it. The LPN was asked when was the last time she had seen it. The LPN stated, The last time I seen it was, well I've been gone for three weeks. The LPN did not provide a date of when the resident's penis was last observed or any other information regarding the condition of the resident's penis. The resident stated, Tell my wife. The LPN stated that the resident's wife makes his appointments for him and that the resident has one coming up, but she (LPN) was not aware of when it was. The LPN was made aware that the resident just had an appointment on 08/31/18. The LPN stated, What did they say, what did they order? The resident was asked if the area hurt or was painful. The resident stated, Sometimes [MEDICAL CONDITION] hurts all the time. The LPN was asked when was the resident's next urology appointment. The LPN stated that she wasn't sure, but would find out. On 09/19/18 at approximately 4:00 p.m., the survey team met with the administrator and DON and informed of concerns regarding Resident #1. The DON was asked when a resident has a catheter, are the nurses supposed to be providing Foley catheter care and tracking output of the resident's catheter. The DON stated, Yes, anytime anyone has a catheter they (the nurses) should be documenting. The DON further stated that resident's with Foley catheters have an order set for care. The DON was asked if that was a standing order set or was the order set individualized. The DON stated that it was individualized for each resident. The DON was asked for a copy of Resident #1's urinary catheter order set regarding care and instructions, along with any policies and procedures for catheter care, the resident's kardex, and any voiding trials attempted with documentation. Admission assessments and skin assessments/wound records were presented and reviewed for Resident #1 from admission to present. An admission assessment dated [DATE] documented the resident had a indwelling catheter and with no skin impairments to any area of the body. An admission assessment dated [DATE] documented no skin impairments to any area of the body. An admission assessment dated [DATE] documented the resident had a catheter (did not specify type), and that the resident had penile, meatus tear from Foley catheter; no measurements or any other description was documented for this area. Skin assessments were located in the clinical record dated 04/18/18, 04/25/18, 05/02/18, 05/09/18, 05/16/18, 05/23/18, 05/30/18, 06/06/18, and 06/20/18. Each skin assessment documented the resident's skin was intact without any impairments to any area of the body. A skin assessment dated [DATE] documented that the resident had excoriation on penile meatus, treatment progress (sic); no other information or details were found. On 09/20/18 at approximately 9:40 a.m., the DON was interviewed regarding skin and/or wound records for Resident #1's penis. The DON stated that she has looked and seen the same thing as the surveyor. The DON stated that was all the assessment information for Resident #1 regarding skin/wound assessments. On 09/20/18 at 10:50 a.m., the unit manger, LPN # 1 was interviewed regarding Resident #1 and the observation of the resident's penis on 09/19/18. LPN # 1 was asked if she called the attending physician. The LPN stated, No, I didn't call (name of attending physician). The LPN was asked, who is responsibly for skin/wound assessments. The LPN stated that the nurse's do their own skin and wound assessments. The LPN was then asked if she thought a skin or wound assessment should have been done on Resident #1 based on the observation on 09/19/18. The LPN stated that the nurse assigned on that shift should have done some type of skin assessment, because the nurse's are providing catheter care. The LPN was asked if she thought a skin assessment or some documentation should have been completed for Resident #1 based on the findings of the observation on 09/19/18. The LPN stated, I guess I should have probably did it since I was the one who seen it. The LPN stated that it should have been completed on a nonpressure skin/wound assessment and that she was going to do it now. The LPN stated that she would include measurements. On 09/20/18 at 11:45 a.m., LPN #1 presented a non pressure skin assessment, which documented, .09/20/18 10:57 a.m present upon admission: yes penis meatus tear from prolonged use of catheter, red, no drainage, denies pain, measurements done . No measurements were included on this assessment. An attached nursing note dated 09/20/18 at 11:29 a.m .penis remains tor (sic) measurements done w-4, l-3, d-.5 .area that is beefy red and some areas are pink. He does exhibit some discomfort, it appears inflamed, (name of attending physician) office called and made aware of appearance. On 09/20/18 at approximately 12:00 p.m. noon, the DON and administrator were made aware of the serious concerns regarding Resident #1 in meeting with the survey team. The DON was asked if LPN #1 was qualified to do wound assessments and complete measurements and provide staging for wounds. The DON stated yes and went on to say that the ADON (assistant director of nursing), RN (registered nurse) #1 completed the assessment with the LPN. The DON was made aware that the LPN completed the assessment as non pressure, that the area was documented by the LPN as being present upon admission, and that the measurements were not included on the actual assessment. The DON was informed that clarification was needed regarding the measurements and if the area was present upon admission, where was that documentation. The DON presented a policy titled, Catheter care, urinary, which documented the care of a catheter for cleaning and did not provide interventions regarding concerns and/or complications. The current kardex for Resident #1 was presented and documented, .check for incontinence and assist with toileting as needed .provide peri care after each incontinent episode .observe skin areas around F/C strap and remove as needed to check for skin condition . At approximately 1:20 p.m. a pressure ulcer wound assessment dated [DATE] and timed 1:10 p.m. documented, that the area was not present upon admission and .site: groin (did not identify the penis as the wound site) type: pressure: 3 cm (centimeters) length 4 cm width .5 cm depth Stage: 2 .red .pain around penile meatus . The DON and administrator were again informed in a meeting with the survey team on 09/20/18 at approximately 1:30 p.m. of the serious concerns with Resident #1 including the lack of physician's orders for the indwelling catheter, lack of assessment by the nursing staff, not developing a CCP for the indwelling catheter and the lack of interventions for the care and maintenance of the indwelling catheter. A indwelling Foley catheter order set was never presented for Resident #1. An order set was presented for another resident, but not Resident #1. The DON stated that the order sets were basically the same, but one was not provided for Resident #1. No documentation and/or information regarding any type of voiding trials/bladder retraining and/or toileting program was presented for Resident #1. No further information and/or documentation was presented prior to the exit conference on 09/20/18 to evidence the facility staff provided appropriate care and services for the prevention of complications related to the prolonged use of a Foley catheter, which resulted in actual harm to the resident.

Based on staff interview, facility documentation and clinical record review, and in the course of a complaint investigation, the facility staff failed to for one resident (Resident #5) of five residents in the survey sample, to develop a care plan for the prevention of pressure ulcers. Resident #5 acquired a pressure ulcer to the sacrum, which progressed to a stage 4 wound, as well as unable to stage wounds on both heels, requiring hospitalization for [MEDICAL CONDITION] due to the sacral wound. Resident #5 did not have a care plan developed for prevention of skin breakdown. The findings included: Resident #5 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #5's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 2/14/18 coded Resident #5 with both short and long term memory loss with severe cognitive impairment. The MDS was completed as a significant change in status assessment. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of one staff member. The resident was incontinent of bowel and bladder. The resident was coded as having unplanned, non physician prescribed weight loss. There were no wounds documented on the MDS, and the resident was coded as being at risk for skin breakdown. On 3/2/18, a dietary note revealed: Per nursing staff at weekly wound meeting, resident has a stage 2 sacral ulcer and wound between right great toe and 1st toe. Review of the resident's care plan dated 12/6/17 revealed the resident did not address the resident's potential for skin breakdown. There were no interventions for the prevention of pressure wounds. On 3/5/18 (after development of the acquired pressure wound), the care plan had been updated to include interventions for prevention, but was not updated to include the sacral wound or the wounds on the toes. On 3/11/18 at 11:52 AM, the ER physician documented: The patient presents with decubitus ulcers. The onset was unknown. The course/duration of symptoms is worsening. Location, sacral. The character of symptoms is pain, redness, drainage and warmth. The degree of symptoms is severe. per nh (nursing home) increased lethargy over the last 3 days with worsening sacral ulcer . nursing home resident, concerns of neglect. Skin: warm, dirty, undated sacral dressing removed, a large stage 4 sacral decubitus measuring 6 cm by 4 cm with large eschar, inferior edge of eschar is open and draining purulent drainage. Ulcer tracks under the skin bilaterally and inferiorly, + malodor, no bleeding. 2 cm by 1 cm eschar on right shin no fluctuance, no drainage. Ulceration with purulent drainage noted between right first and second toes. Bilateral heel eschars noted no fluctuance, no drainage. Impression and Plan: Dehydration,[MEDICAL CONDITION], Stage 4 decubitus ulcer, [MEDICAL CONDITION] (high sodium). On 4/5/18, an interview with the MDS coordinator (RN-registered nurse A). When asked to identify prevention for skin breakdown on the care plan, RN(A) stated, No prevention, just care planned for pain. She went on to state that the resident should be care planned for pressure ulcer prevention. On 4/5/18, at approximately 10:00 AM, the Administrator and Corporate Consultant were notified of above findings.

Based on observation, staff interview, facility documentation and clinical record review, and in the course of a complaint investigation, the facility staff failed to prevent, assess appropriately, treat and monitor a pressure ulcer of the sacrum for one Resident, Resident #5 (closed record) in a survey sample of 5 residents, resulting in a stage 4 pressure ulcer of the sacrum and bilateral unable to stage pressure wounds to the heels. The resident required hospitalization for [MEDICAL CONDITION] due to wound infection. In addition, the resident's first and second toes on the right foot had to be amputated due to lack of treatment to the toes. For Resident #2, the facility failed to treat an acquired stage II pressure wound on the sacrum resulting in harm 1. Resident #5 sustained a sacral wound that was not treated, was inaccurately assessed by the wound nurse, which progressed to a stage 4, requiring hospitalization for [MEDICAL CONDITION] of the wound. The resident's first and second toes on the right foot had to be amputated. The resident also had eschar on both heels which the facility did not identify or treat. This resulting in harm. 2. Resident #2 acquires a stage II sacral wound that did not receive treatment. The findings included: Resident #5 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #5's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 2/14/18 coded Resident #5 with both short and long term memory loss with severe cognitive impairment. The MDS was completed as a significant change in status assessment. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of one staff member. The resident was incontinent of bowel and bladder. The resident was coded as having unplanned, non physician prescribed weight loss. There were no wounds documented on the MDS, and the resident was coded as being at risk for skin breakdown. Review of the clinical record revealed a nurses note dated 2/23/18 which read: IDT (interdisciplinary team) held, Resident triggered for 14.3% weight loss over a six month period. Recommended med pass 60 ml (milliliters) three times daily to increase daily kcal (kilocalories) intake. Continue to monitor weight per facility protocol. The weights were documented as followed: 10/6/17: 160 # (pounds) 11/6/17: 156# 12/17/18: 155# 1/7/18: 150# 2/7/18: 138 # On 3/2/18, a dietary note revealed: Per nursing staff at weekly wound meeting, resident has a stage 2 sacral ulcer and wound between right great toe and 1st toe. Recommend addition of multivitamin and Prostat 30 cc (cubic centimeters) to promote skin integrity and wound healing. The Prostat (protein supplement) was initiated on 3/6/18, but the multivitamin was not on the MAR (medication administration record); there was no documentation the multivitamin was given. Review of the resident's care plan dated 12/6/17 revealed the resident did not address the resident's potential for skin breakdown. There were no interventions for the prevention of pressure wounds. On 3/5/18 (after development of the acquired pressure wound), the care plan had been updated to include interventions for prevention, but was not updated to include the sacral wound or the wounds on the toes. On 4/5/18, an interview with the MDS coordinator (RN-registered nurse A). When asked to identify prevention for skin breakdown on the care plan, RN(A) stated, No prevention, just care planned for pain. She went on to state that the resident should be care planned for pressure ulcer prevention. On 3/5/18, a nurses note documented the following: Resident noted to have a 5 cm by 3 cm (centimeter) stage 2 sacral ulcer covered with slough, green foul smelling drainage noted. Resident also has an elevated temperature of 100.2 (degrees). Notified (name of physician) of resident's condition, new orders were given to start Keflex 250 mg twice a day for 10 days and to refer resident to the wound care clinic. Review of the TAR (treatment administration record) for March, (YEAR), revealed no treatment orders for this wound, or for treatment of [REDACTED]. The NPUAP (national pressure ulcer advisory panel) describes a stage 2 as, Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Slough is defined as yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed. This wound bed has both yellow stringy slough as well as thick adherent slough. Slough on a wound bed should be surgically debrided to allow for ingrowth of healthy granulation tissue. On 3/9/18 revealed the following nurse's note: Reassessment of wound 3/9/18 of sacral region. Stage 3 wound pink with some slough. Hydrogel applied with dressing. MD notified and RP (responsible party) notified of treatment regimen. Further review of the MAR indicated [REDACTED]. The NPUAP describes a stage 3 ulcer as a Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. On 3/10/18 at 12:44 PM, the nurse's note read: Resident on ABT (antibiotic therapy). Temperature of 102.1 Attempted to administer po (by mouth) Tylenol 650 mg. Resident having trouble swallowing. medication. Notified FNP (family nurse practitioner). New orders given for Tylenol suppositories 650 mg prn (as needed) every 6 hours for elevated temperature and pain. On 3/11/18 at 3:10 AM, the nurse's note read: Resident remains on ABT. She is running a temperature of 101.0 pushed fluids gave Tylenol bring down temperature. will check again. On 3/11/18 at 9:15 AM, the nurse's notes read: Upon assessing resident noticed residents (sic) condition had worsened since yesterday. Left sided facial drooping remains, resident lethargic and only moans/responds to painful stimuli. Unable to swallow any fluids or food. Attempted to offer resident medication and water unsuccessful. Resident has a temperature of 101.4. FNP in facility at this time and evaluated resident upon request. New orders were given to send resident to (name of hospital). On 3/11/18, the FNP note read: Asked by staff to see resident . Was called yesterday because she had a fever. Is on [MEDICATION NAME] at present. She was less active yesterday, not eating, drooling and not as responsive as usual. She is lying in bed turned towards left. She clenched eyes shut but PERLA (pupils equal and responsive to light, accommodation). Her mouth drooped left side. She has legs drawn up towards chest. No [MEDICAL CONDITION]. She has a sacral wound with a very foul odor. Her lungs remain clear. A/P (assessment /plan): Fever obtunded : DM (diabetes); dysphagia, sacral decubitus. She is full code. I advised to send her to hospital for evaluation due to worsening condition. Review of the hospital records revealed on 3/11/18 at 11:50 AM note by the receiving nurse documented, Pt (patient) with gown on that had dried food on it. On 3/11/18, the emergency department nursing note documented a call from the DON (director of nursing) from the discharging facility which read: I just want you all to know, this patient has an awful wound,and it has been treated. She is sick and dying. We have been treating with antibiotics. I just want you to know this is not neglect on our parts. It has not been neglected. On 3/11/18 at 11:32 AM, the ER nurse documented, Has a sacral wound that smells awful and the staff at (name of facility) has not changed it. On 3/11/18 at 11:52 AM, the ER physician documented: The patient presents with decubitus ulcers. The onset was unknown. The course/duration of symptoms is worsening. Location, sacral. The character of symptoms is pain, redness, drainage and warmth. The degree of symptoms is severe. per nh (nursing home) increased lethargy over the last 3 days with worsening sacral ulcer . nursing home resident, concerns of neglect. Skin: warm, dirty, undated sacral dressing removed, a large stage 4 sacral decubitus measuring 6 cm by 4 cm with large eschar, inferior edge of eschar is open and draining purulent drainage. Ulcer tracks under the skin bilaterally and inferiorly, + malodor, no bleeding. 2 cm by 1 cm eschar on right shin no fluctuance, no drainage. Ulceration with purulent drainage noted between right first and second toes. Bilateral heel eschars noted no fluctuance, no drainage. Impression and Plan: Dehydration,[MEDICAL CONDITION], Stage 4 decubitus ulcer, [MEDICAL CONDITION] (high sodium). NPUAP describes a stage 4 ulcer as a Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable On 3/13/18, the resident underwent [REDACTED]. The sacral wound was surgically debrided. A PEG (percutaneous endogastric) tube was placed for feeding and hydration. On 3/21/18, the discharge summary read, Discharge Diagnosis: [REDACTED]. secondary to multiple [MEDICAL CONDITION]. 2. Stage 4 sacral decubitus status [REDACTED]. 3. Right 1-2 toe gangrene status [REDACTED]. Advanced dementia. 5. Chronic issues. At time of discharge she was stable and afebrile. The resident was not discharged back to the discharging facility. On 4/4/18 at approximately 9:30 AM, the DSS (department of social services) was notified that surveyor was on site for the complaint. She stated, I want you to see my notes. A copy of the notes was received. The following notes were recorded from the DSS SW (social worker) of her conversation with the DON: 3/6/18: Documented as a stage 2, patient not eating (could not get anything in her). Nurse informed worker that patient not taking in nutrients wound were not going to heal, but the wounds were being treated. Husband was notified of about what was going on with his wife. 3/9/18: (Name of resident) health declined. She is a full code (if stop breathing full code) wanted husband to change from full code. He would not agree. Wound was measured and it had increased in size. She had no nutrients to feed the body. Worker asked the question several times, how many days does a person not eat before it is determined to seek medical attention outside of the nursing home and if wound care was not working when do you seek medical attention outside of the nursing home. Nurse (name of DON) response was skin breakdown happens fast when a patient is not eating . worker never received a direct answer to the question. Review of the nurse's notes written by the wound care nurse WCN (C) were written as late entries on 3/19/18 (after the 3/11/18 discharge note): 3/19/18 for 3/1/18: Stage 2 to sacral region. Wound pink with drainage noted. size 1 by 1. Odor noted. Hydrogel dressing ordered every day to sacral ulcer. MD notified and received order. No order for this treatment was written, nor was the order written on the TAR. 3/19/18 for 3/1/18: Necrotic tissue noted to toes on right foot with ulcer stage 1 between great toe and second toe. Order for Hydrogel and gauze dressing ordered per MD and RP (responsible party was notified. No order for this treatment was written or documented on the TAR. 3/19/18 for 3/1/18: Wound noted on the right lower leg stage 2, 3 by 1. No drainage, redness noted. Sureprep ordered. MD and RP contacted. No order was written nor documented on the TAR. 3/19/187 for 3/1/18: Wound noted to right second toe, 2 by 2. Stage 2 with yellowish drainage. Sureprep and gauze dressing ordered. MD contacted and RP notified. Again, no treatment order was written, nor was treatment documented on the TAR. 3/19/18 for 3/1/18: Wound noted between great toe and 2nd toe. Slough drainage sureprep administered. MD and RP notified. No treatment order was written nor were any treatments documented on the TAR. 3/19/18 for 2/28/18: Sacral wound observed. 1 by 1. Stage 2 wound bed pink with exudate, odor noted. Hydrogel and dressing applied. MD notified and RP notified. No treatment order was written, nor were any treatments documented on the TAR. Review of the wound tracking notes revealed hand written notes with an entry for 2/28/18 (on tracking the documentation stated it was first observed 3/1/18) for 1 by 1 cm stage 2 sacral wound) and a stage 1 right toes with necrotic tissue right toes. The next tracking note dated 3/9/18 which has the notation on the bottom of the record, late entry shows a 7 cm by 4.0 cm by 1cm depth,stage 3. On 4/3/18 at 2:00 PM, a brief interview was conducted with the wound care nurse, WCN (C). When asked who was responsible for the wound tracking, she stated, I guess I am; I didn't know that I was supposed to. On 4/4/18 at 9:00 AM, the Divisional Executive Director stated, (name of WCN (C)) will not be in today; we told her to take care of things at home. 4/4/18 at 3:40 PM, an interview with the DON (director of nursing) was conducted. She stated, It is a hot mess. I was doing wounds and I showed the ADON (assistant director of nursing- WCN (C)) how to. The DON went on to state that there were no treatments documented. 4/4/18 at 3:40 PM, the Administrator was present for above interview. She stated, We thought she had a lot of experience- we were told she was a certified wound nurse; she was not. On 4/5/18 at 9:30 AM, an interview was conducted with LPN (B). She stated, It was brought to my attention there was a dark spot on her sacrum. She went on to state that the CNA (certified nursing assistant) was told to keep cream on it. It (sacral area) opened up on Monday. I never heard anything else about it. She went on to say that two days later, it had an odor and the CNA thought it looked funny. I measured it myself, it was 5 cm by 3 cm, open with green drainage. She stated that she called the physician who said to start antibiotics and refer to the wound clinic. She denied knowledge if lab work was ordered, and stated, It was all on (name of wound nurse, WCN (C)). On 4/5/18 at 11:40 AM, CNA (A) was interviewed. She stated she was familiar with Resident #5. She stated that the resident fed herself, ate very slowly, and that she pocketed food. She stated, I would massage her throat. She also stated she had stopped eating for two weeks, that she ate less and less. She said that she reported this to WCN (C). The CNA reported that the wound on her back had greenish discharge and a very strong odor. She went on to state that for a couple of days before (resident was sent out) her diaper (sic) had no urine. She also stated, She literally was not eating in the last two days and would moan when she was turned. On 4/5/18 at 11:55 AM, a telephone interview was conducted with the resident's physician. He stated, I was following her for her feet and sacrum, she had ups and downs. The physician was asked if he had observed the wounds. He stated, I don't recall. The physician was asked if the family had been offered the option of a feeding tube, as the resident was a full code. He stated, I think we did a couple of years ago. He was asked if he had been aware the wound had progressed to a stage 3 with odor, fever, would he have sent her out earlier, he stated, I think I would. The physician was asked if he had ordered labs, he stated, Sometimes I get a CBC (complete blood count). Apparently she had not been eating or drinking. The facility presented the following when asked for their policy and procedure for pressure ulcers: Best Practices_ Skin & Wound: Under skin observation: Re-evaluate wound/skin treatment within two weeks of start date and every 2 weeks thereafter. Skin Health: Relieve and protect heel pressure. Provide pressure redistribution cushions for residents in wheelchairs, evaluate for adaptive equipment/positioning devices/specialty mattress. Therapy screen/evaluation as indicated. Nutrition: Monitor lab values to include, but not limited to CBC, [MEDICATION NAME] levels. Monitor weight trends. Review and update care plan reflecting interventions. It is to be noted that the family was not offered a PEG tube for nutrition, no labs were drawn to measure degree of infection and there were no preventative interventions in place to prevent the skin breakdown such as cushions or a specialty mattress, or heel pressure cushions/boots. 2. Resident #2 acquired a stage II sacral wound that did not receive treatment. Resident #2 was admitted to the facility on [DATE] and discharged to the hospital on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 3/29/18 coded Resident #2 with a BIMS (brief interview of mental status) of 9 out of a possible 15, or moderate cognitive impairment. The MDS was completed as a 14 day assessment. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of one staff member. The resident was incontinent of bowel and bladder. The resident was coded as having unplanned, non physician prescribed weight loss. The resident was coded as having a stage 4 pressure ulcer on readmission. On 2/23/18, the nurse's notes contain the following entry: Wound assessment performed. Stage 2 to sacral area region. Measurements obtained. No odor noted. Treatment as ordered. Review of the February, (YEAR) MAR (medication administration record) revealed there were no orders written or treatments documented for the sacral wound through the entire month of February. Review of the wound care tracking records for 2/28/18 revealed: Measurements of 1 cm by 2 cm with no depth recorded, as a stage II. On 3/9/18, documented as a late entry , the measurements were 1.5 cm by 2 cm, with no depth recorded, stage II. The resident was sent to the hospital on [DATE] and returned on 3/15/18 with a stage 4 sacral ulcer. There was no wound description from the hospital. Review of the March, (YEAR) TAR revealed the return treatment for [REDACTED]. The wound was documented as being treated on 3/20/18, no documentation for 3/21/18 to 3/23/18, 3/26/18 and 3/30/18. On 4/4/18 at 2:10 PM, wound treatment was done by LPN (A). The wound dressing was not in place; the CNA had told LPN (A) and she told the CNA to take it off. There were two wounds, one on the right and one on the left. The wound on the right buttock was approximately 3 by 5 cm with scattered slough. The wound on the left was approximately 2-3 cm in diameter with granulation tissue. Hydrogel was applied to the wound bed, sure prep applied around the wounds and a foam dressing was applied. The dressing was dated by the LPN. The LPN was asked to take off the heel boots. On the right heel, it had a dry, dark blister, which was treated with sure prep. The left heel was intact, sure prep was applied. The heel boots were re-applied. LPN(A) washed her hands appropriately. The resident showed no signs of pain or discomfort during the treatment. The resident was on a Low air loss mattress. Review of the care plan dated 4/3/18 revealed the resident was care planned for risk of skin impairment and had been revised to include the sacral and heel wound. The facility presented the following Plan of Correction (does not have an A[NAME] (allegation of compliance date) dated 3-11-18: 1. NP (nurse practitioner) in facility to assess resident for wound infection. Resident presented with temp, wound increase, exudate. Family and DON notified. Nurse had not yet changed treatment to sacral wound. DON notified hospital of patient condition. 2. All other residents were assessed by facility nurse to ensure there were no signs of wound infection. Facility sweep was initiated (completed 3/14/18). 3. DON provided re-education of nurses regarding skin assessments, notification of family and physician and wound formulary. (3-12-18). Contacted EMT for wound nurse to provide additional wound care education. CNA education if any skin alteration is noted to inform nurse immediately (need to complete Stop and Watch). Any new skin alteration will be discussed during the clinical meeting to ensure notification and treatments are in place. UDA weekly skin assessments will be monitored daily during the clinical meeting. 4. DON/Designee will complete Quality Monitoring Tool 5 times weekly x 4 weeks. This information will be presented by DON at monthly QAPI (quality assessment performance improvement) to assess the need for ongoing education and need for further monitoring. The DON stated there had been no QA meeting since the P[NAME].

Based on staff interview, facility documentation and clinical record review, and in the course of a complaint investigation, the facility staff failed for one resident (Resident #5) in a survey sample of 5 residents, to provide food and fluids to prevent significant weight loss and dehydration requiring hospitalization resulting in harm. Resident #5 had a 14.3 % weight loss in six months. The resident had documented difficultly with swallowing, pocketing food and fever from infected wounds. The facility failed to offer alternative sources of hydration and/or nutrition, resulting in dehydration. This resulted in harm. The findings included: Resident #5 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #5's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 2/14/18 coded Resident #5 with both short and long term memory loss with severe cognitive impairment. The MDS was completed as a significant change in status assessment. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of one staff member. The resident was incontinent of bowel and bladder. The resident was coded as having unplanned, non physician prescribed weight loss. There were no wounds documented on the MDS, and the resident was coded as being at risk for skin breakdown. Review of the clinical record revealed a nurses note dated 2/23/18 which read: IDT (interdisciplinary team) held, Resident triggered for 14.3% weight loss over a six month period. Recommended med pass 60 ml (milliliters) three times daily to increase daily kcal (kilocalories) intake. Continue to monitor weight per facility protocol. The weights were documented as followed: 10/6/17: 160 # (pounds) 11/6/17: 156# 12/17/18: 155# 1/7/18: 150# 2/7/18: 138 # No weights were obtained after 2/7/18. There were no weekly weights documented. On 3/2/18, a dietary note revealed: Per nursing staff at weekly wound meeting, resident has a stage 2 sacral ulcer and wound between right great toe and 1st toe. Recommend addition of multivitamin and Prostat 30 cc (cubic centimeters) to promote skin integrity and wound healing. The Prostat (protein supplement) was initiated on 3/6/18, but the multivitamin was not on the MAR (medication administration record); there was no documentation the multivitamin was given. On 3/5/18, a nurses note documented the following: Resident noted to have a 5 cm by 3 cm (centimeter) stage 2 sacral ulcer covered with slough, green foul smelling drainage noted. Resident also has an elevated temperature of 100.2 (degrees). Notified (name of physician) of resident's condition, new orders were given to start Keflex 250 mg twice a day for 10 days and to refer resident to the wound care clinic. Review of the TAR (treatment administration record) for March, (YEAR), revealed no treatment orders for this wound, or for treatment of [REDACTED]. On 3/9/18, a dietary note read: Per nursing staff at weekly wound meeting, Resident has a stage 2 sacral ulcer and wound between right great and 1st toe. Continue multivitamin and prostat (multivitamin order was not on the (MONTH) MAR-medication administration record) 30 cc (cubic centimeters) twice daily to promote skin integrity and wound healing, per MD order. On 3/10/18 at 12:44 PM, the nurse's note read: Resident on ABT (antibiotic therapy). Temperature of 102.1 Attempted to administer po (by mouth) Tylenol 650 mg. Resident having trouble swallowing. medication. Notified FNP (family nurse practitioner). New orders given for Tylenol suppositories 650 mg prn (as needed) every 6 hours for elevated temperature and pain. No further assessments were documented until 3:10 AM. On 3/11/18 at 3:10 AM, the nurse's note read: Resident remains on ABT. She is running a temperature of 101.0 pushed fluids gave Tylenol bring down temperature. will check again. No further assessment until 9:15 AM the next morning. On 3/11/18 at 9:15 AM, the nurse's notes read: Upon assessing resident noticed residents (sic) condition had worsened since yesterday. Left sided facial drooping remains, resident lethargic and only moans/responds to painful stimuli. Unable to swallow any fluids or food. Attempted to offer resident medication and water unsuccessful. Resident has a temperature of 101.4. FNP in facility at this time and evaluated resident upon request. New orders were given to send resident to (name of hospital). On 3/11/18, the FNP note read: Asked by staff to see resident . Was called yesterday because she had a fever. Is on [MEDICATION NAME] at present. She was less active yesterday, not eating, drooling and not as responsive as usual. She is lying in bed turned towards left. She clenched eyes shut but PERLA (pupils equal and responsive to light, accommodation). Her mouth drooped left side. She has legs drawn up towards chest. No [MEDICAL CONDITION]. She has a sacral wound with a very foul odor. Her lungs remain clear. A/P (assessment /plan): Fever obtunded : DM (diabetes); dysphagia, sacral decubitus. She is full code. I advised to send her to hospital for evaluation due to worsening condition. On 3/11/18 at 11:52 AM, the ER physician documented: The patient presents with decubitus ulcers. The onset was unknown. The course/duration of symptoms is worsening. Location, sacral. The character of symptoms is pain, redness, drainage and warmth. The degree of symptoms is severe. per nh (nursing home) increased lethargy over the last 3 days with worsening sacral ulcer . nursing home resident, concerns of neglect. Skin: warm, dirty, undated sacral dressing removed, a large stage 4 sacral decubitus measuring 6 cm by 4 cm with large eschar, inferior edge of eschar is open and draining purulent drainage. Ulcer tracks under the skin bilaterally and inferiorly, + malodor, no bleeding. 2 cm by 1 cm eschar on right shin no fluctuance, no drainage. Ulceration with purulent drainage noted between right first and second toes. Bilateral heel eschars noted no fluctuance, no drainage. Mouth: Dry mucous membranes. Impression and Plan: Dehydration,[MEDICAL CONDITION], Stage 4 decubitus ulcer, [MEDICAL CONDITION] (high sodium). Review of the labs done 3/11/18 at the hospital revealed: Sodium 157 (Critical) Normal 134-149 Chloride 117 (high) Normal 95-108 Glucose 298 (high) Normal less than 120 BUN 52 (high) Normal 7-20 Creatinine (1.01 (high) Normal 0.5-1.4 White blood count 21.8 (high) Normal 4.5-10 On 4/4/18 at approximately 9:30 AM, the DSS (department of social services) was notified that surveyor was on site for the complaint. She stated, I want you to see my notes. A copy of the notes was received. The following notes were recorded from the DSS SW (social worker) of her conversation with the DON (director of nursing): 3/6/18: Documented as a stage 2, patient not eating (could not get anything in her). Nurse informed worker that patient not taking in nutrients wounds were not going to heal, but the wounds were being treated. Husband was notified of about what was going on with his wife. 3/9/18: (Name of resident) health declined. She is a full code (if stop breathing full code) wanted husband to change from full code. He would not agree. Wound was measured and it had increased in size. She had no nutrients to feed the body. Worker asked the question several times, how many days does a person not eat before it is determined to seek medical attention outside of the nursing home and if wound care was not working when do you seek medical attention outside of the nursing home. Nurse (name of DON) response was skin breakdown happens fast when a patient is not eating . worker never received a direct answer to the question. On 4/5/18 at 11:40 AM, CNA (A) was interviewed. She stated she was familiar with Resident #5. She stated that the resident fed herself, ate very slowly, and that she pocketed food. She stated, I would massage her throat. She also stated she had stopped eating for two weeks, that she ate less and less. She said that she reported this to WCN (C). The CNA reported that the wound on her back had greenish discharge and a very strong odor. She went on to state that for a couple of days before (resident was sent out) her diaper (sic) had no urine. She also stated, She literally was not eating in the last two days and would moan when she was turned. On 4/5/18 at 11:55 AM, a telephone interview was conducted with the resident's physician. He stated, I was following her for her feet and sacrum, she had ups and downs. The physician was asked if he had observed the wounds. He stated, I don't recall. The physician was asked if the family had been offered the option of a feeding tube, as the resident was a full code. He stated, I think we did a couple of years ago. He was asked if he had been aware the wound had progressed to a stage 3 with odor, fever, would he have sent her out earlier, he stated, I think I would. The physician was asked if he had ordered labs, he stated, Sometimes I get a CBC (complete blood count). Apparently she had not been eating or drinking. Review of the care plan dated 2/7/18 revealed there were no new interventions for risk of malnutrition since 2/13/17. Interventions included: Monitor and report to MD for signs and symptoms of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat appears concerned during meals. Another intervention was obtain and monitor lab work and monitor weight per facility protocol. The policy and procedure for weekly weights included the following: weekly weights for new admissions, weight losses (5%, 7.5% and 10%) and stage III and IV pressure sores. On 4/4/18 at 3:25 PM, the FSM (food service manager) was asked about weekly weights. She stated, weekly times 4 weeks for wounds, weight loss and tube feeding. She also stated, The dietician may recommend tube feeding for weight loss. Review of the dietary notes revealed no documentation that the family was offered a feeding tube due to dysphagia, weight loss and pressure wounds. On 4/4/18 at 3:30 PM, the DON stated, I do not know when questioned if the family was offered a feeding tube. The resident's family had recently (3-9-18) refused to have the advance directive changed to no code. She remained a full code by request of the family. On 4/5/18, at approximately 10:00 AM, the Administrator and Corporate Consultant were notified of above findings.

Based on staff interview, facility documentation and clinical record review, and in the course of a complaint investigation, the facility failed to ensure one staff member, Wound Care Nurse C (WCN (C)), was competent to provide wound care and tracking for Resident #5, resulting in an acquired sacral wound deteriorating to a stage 4 wound with [MEDICAL CONDITION] resulting in hospitalization ; nor did WCN (C) document the presence of bilateral unable to stage heel wounds. WCN (C) failed to document treatment and accurate assessments of pressure wounds resulting in deterioration of the resident's condition, requiring hospitalization for treatment of [REDACTED]. The findings included: Resident #5 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #5's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 2/14/18 coded Resident #5 with both short and long term memory loss with severe cognitive impairment. The MDS was completed as a significant change in status assessment. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of one staff member. The resident was incontinent of bowel and bladder. The resident was coded as having unplanned, non physician prescribed weight loss. There were no wounds documented on the MDS, and the resident was coded as being at risk for skin breakdown. Review of the clinical record revealed a nurses note dated 2/23/18 which read: IDT (interdisciplinary team) held, Resident triggered for 14.3% weight loss over a six month period. Recommended med pass 60 ml (milliliters) three times daily to increase daily kcal (kilocalories) intake. Continue to monitor weight per facility protocol. The weights were documented as followed: 10/6/17: 160 # (pounds) 11/6/17: 156# 12/17/18: 155# 1/7/18: 150# 2/7/18: 138 # On 3/2/18, a dietary note revealed: Per nursing staff at weekly wound meeting, resident has a stage 2 sacral ulcer and wound between right great toe and 1st toe. Recommend addition of multivitamin and Prostat 30 cc (cubic centimeters) to promote skin integrity and wound healing. The Prostat (protein supplement) was initiated on 3/6/18, but the multivitamin was not on the MAR (medication administration record); there was no documentation the multivitamin was given. On 3/5/18, a nurses note documented the following: Resident noted to have a 5 cm by 3 cm (centimeter) stage 2 sacral ulcer covered with slough, green foul smelling drainage noted. Resident also has an elevated temperature of 100.2 (degrees). Notified (name of physician) of resident's condition, new orders were given to start Keflex 250 mg twice a day for 10 days and to refer resident to the wound care clinic. Review of the TAR (treatment administration record) for March, (YEAR), revealed no treatment orders for this wound, or for treatment of [REDACTED]. The NPUAP (national pressure ulcer advisory panel) describes a stage 2 as, Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Slough is defined as yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed. This wound bed has both yellow stringy slough as well as thick adherent slough. Slough on a wound bed should be surgically debrided to allow for ingrowth of healthy granulation tissue. On 3/9/18 revealed the following nurse's note: Reassessment of wound 3/9/18 of sacral region. Stage 3 wound pink with some slough. Hydrogel applied with dressing. MD notified and RP (responsible party) notified of treatment regimen. Further review of the MAR indicated [REDACTED]. The NPUAP describes a stage 3 ulcer as a Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. On 3/10/18 at 12:44 PM, the nurse's note read: Resident on ABT (antibiotic therapy). Temperature of 102.1 Attempted to administer po (by mouth) Tylenol 650 mg. Resident having trouble swallowing. medication. Notified FNP (family nurse practitioner). New orders given for Tylenol suppositories 650 mg prn (as needed) every 6 hours for elevated temperature and pain. On 3/11/18 at 3:10 AM, the nurse's note read: Resident remains on ABT. She is running a temperature of 101.0 pushed fluids gave Tylenol bring down temperature. will check again. On 3/11/18 at 9:15 AM, the nurse's notes read: Upon assessing resident noticed residents (sic) condition had worsened since yesterday. Left sided facial drooping remains, resident lethargic and only moans/responds to painful stimuli. Unable to swallow any fluids or food. Attempted to offer resident medication and water unsuccessful. Resident has a temperature of 101.4. FNP in facility at this time and evaluated resident upon request. New orders were given to send resident to (name of hospital). On 3/11/18, the FNP note read: Asked by staff to see resident . Was called yesterday because she had a fever. Is on [MEDICATION NAME] at present. She was less active yesterday, not eating, drooling and not as responsive as usual. She is lying in bed turned towards left. She clenched eyes shut but PERLA (pupils equal and responsive to light, accommodation). Her mouth drooped left side. She has legs drawn up towards chest. No [MEDICAL CONDITION]. She has a sacral wound with a very foul odor. Her lungs remain clear. A/P (assessment /plan): Fever obtunded : DM (diabetes); dysphagia, sacral decubitus. She is full code. I advised to send her to hospital for evaluation due to worsening condition. Review of the hospital records revealed on 3/11/18 at 11:50 AM note by the receiving nurse documented, Pt (patient) with gown on that had dried food on it. On 3/11/18, the emergency department nursing note documented a call from the DON (director of nursing) from the discharging facility which read: I just want you all to know, this patient has an awful wound,and it has been treated. She is sick and dying. We have been treating with antibiotics. I just want you to know this is not neglect on our parts. It has not been neglected. On 3/11/18 at 11:32 AM, the ER nurse documented, Has a sacral wound that smells awful and the staff at (name of facility) has not changed it. On 3/11/18 at 11:52 AM, the ER physician documented: The patient presents with decubitus ulcers. The onset was unknown. The course/duration of symptoms is worsening. Location, sacral. The character of symptoms is pain, redness, drainage and warmth. The degree of symptoms is severe. per nh (nursing home) increased lethargy over the last 3 days with worsening sacral ulcer . nursing home resident, concerns of neglect. Skin: warm, dirty, undated sacral dressing removed, a large stage 4 sacral decubitus measuring 6 cm by 4 cm with large eschar, inferior edge of eschar is open and draining purulent drainage. Ulcer tracks under the skin bilaterally and inferiorly, + malodor, no bleeding. 2 cm by 1 cm eschar on right shin no fluctuance, no drainage. Ulceration with purulent drainage noted between right first and second toes. Bilateral heel eschars noted no fluctuance, no drainage. Impression and Plan: Dehydration,[MEDICAL CONDITION], Stage 4 decubitus ulcer, [MEDICAL CONDITION] (high sodium). NPUAP describes a stage 4 ulcer as a Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable On 3/13/18, the resident underwent [REDACTED]. The sacral wound was surgically debrided. A PEG (percutaneous endogastric) tube was placed for feeding and hydration. On 3/21/18, the discharge summary read, Discharge Diagnosis: [REDACTED]. secondary to multiple [MEDICAL CONDITION]. 2. Stage 4 sacral decubitus status [REDACTED]. 3. Right 1-2 toe gangrene status [REDACTED]. Advanced dementia. 5. Chronic issues. At time of discharge she was stable and afebrile. The resident was not discharged back to the discharging facility. On 4/4/18 at approximately 9:30 AM, the DSS (department of social services) was notified that surveyor was on site for the complaint. She stated, I want you to see my notes. A copy of the notes was received. The following notes were recorded from the DSS SW (social worker) of her conversation with the DON: 3/6/18: Documented as a stage 2, patient not eating (could not get anything in her). Nurse informed worker that patient not taking in nutrients wound were not going to heal, but the wounds were being treated. Husband was notified of about what was going on with his wife. 3/9/18: (Name of resident) health declined. She is a full code (if stop breathing full code) wanted husband to change from full code. He would not agree. Wound was measured and it had increased in size. She had no nutrients to feed the body. Worker asked the question several times, how many days does a person not eat before it is determined to seek medical attention outside of the nursing home and if wound care was not working when do you seek medical attention outside of the nursing home. Nurse (name of DON) response was skin breakdown happens fast when a patient is not eating . worker never received a direct answer to the question. Review of the nurse's notes written by the wound care nurse WCN (C) were written as late entries on 3/19/18 (after the 3/11/18 discharge note): 3/19/18 for 3/1/18: Stage 2 to sacral region. Wound pink with drainage noted. size 1 by 1. Odor noted. Hydrogel dressing ordered every day to sacral ulcer. MD notified and received order. No order for this treatment was written, nor was the order written on the TAR. 3/19/18 for 3/1/18: Necrotic tissue noted to toes on right foot with ulcer stage 1 between great toe and second toe. Order for Hydrogel and gauze dressing ordered per MD and RP (responsible party was notified. No order for this treatment was written or documented on the TAR. 3/19/18 for 3/1/18: Wound noted on the right lower leg stage 2, 3 by 1. No drainage, redness noted. Sureprep ordered. MD and RP contacted. No order was written nor documented on the TAR. 3/19/187 for 3/1/18: Wound noted to right second toe, 2 by 2. Stage 2 with yellowish drainage. Sureprep and gauze dressing ordered. MD contacted and RP notified. Again, no treatment order was written, nor was treatment documented on the TAR. 3/19/18 for 3/1/18: Wound noted between great toe and 2nd toe. Slough drainage sureprep administered. MD and RP notified. No treatment order was written nor were any treatments documented on the TAR. 3/19/18 for 2/28/18: Sacral wound observed. 1 by 1. Stage 2 wound bed pink with exudate, odor noted. Hydrogel and dressing applied. MD notified and RP notified. No treatment order was written, nor were any treatments documented on the TAR. Review of the wound tracking notes revealed hand written notes with an entry for 2/28/18 (on tracking the documentation stated it was first observed 3/1/18) for 1 by 1 cm stage 2 sacral wound) and a stage 1 right toes with necrotic tissue right toes. The next tracking note dated 3/9/18 which has the notation on the bottom of the record, late entry shows a 7 cm by 4.0 cm by 1cm depth,stage 3. On 4/3/18 at 2:00 PM, a brief interview was conducted with the wound care nurse, WCN (C). When asked who was responsible for the wound tracking, she stated, I guess I am; I didn't know that I was supposed to. On 4/4/18 at 9:00 AM, the Divisional Executive Director stated, (name of WCN (C)) will not be in today; we told her to take care of things at home. 4/4/18 at 3:40 PM, an interview with the DON (director of nursing) was conducted. She stated, It is a hot mess. I was doing wounds and I showed the ADON (assistant director of nursing- WCN (C)) how to. The DON went on to state that there were no treatments documented. 4/4/18 at 3:40 PM, the Administrator was present for above interview. She stated, We thought she had a lot of experience- we were told she was a certified wound nurse; she was not. On 4/5/18 at 9:30 AM, an interview was conducted with LPN (B). She stated, It was brought to my attention there was a dark spot on her sacrum. She went on to state that the CNA (certified nursing assistant) was told to keep cream on it. It (sacral area) opened up on Monday. I never heard anything else about it. She went on to say that two days later, it had an odor and the CNA thought it looked funny. I measured it myself, it was 5 cm by 3 cm, open with green drainage. She stated that she called the physician who said to start antibiotics and refer to the wound clinic. She denied knowledge if lab work was ordered, and stated, It was all on (name of wound nurse, WCN (C)). On 4/5/18 at 11:40 AM, CNA (A) was interviewed. She stated she was familiar with Resident #5. She stated that the resident fed herself, ate very slowly, and that she pocketed food. She stated, I would massage her throat. She also stated she had stopped eating for two weeks, that she ate less and less. She said that she reported this to WCN (C). The CNA reported that the wound on her back had greenish discharge and a very strong odor. She went on to state that for a couple of days before (resident was sent out) her diaper (sic) had no urine. She also stated, She literally was not eating in the last two days and would moan when she was turned. On 4/5/18 at 11:55 AM, a telephone interview was conducted with the resident's physician. He stated, I was following her for her feet and sacrum, she had ups and downs. The physician was asked if he had observed the wounds. He stated, I don't recall. The physician was asked if the family had been offered the option of a feeding tube, as the resident was a full code. He stated, I think we did a couple of years ago. He was asked if he had been aware the wound had progressed to a stage 3 with odor, fever, would he have sent her out earlier, he stated, I think I would. The physician was asked if he had ordered labs, he stated, Sometimes I get a CBC (complete blood count). Apparently she had not been eating or drinking. The facility presented the following when asked for their policy and procedure for pressure ulcers: Best Practices_ Skin & Wound: Under skin observation: Re-evaluate wound/skin treatment within two weeks of start date and every 2 weeks thereafter. Skin Health: Relieve and protect heel pressure. Provide pressure redistribution cushions for residents in wheelchairs, evaluate for adaptive equipment/positioning devices/specialty mattress. Therapy screen/evaluation as indicated. Nutrition: Monitor lab values to include, but not limited to CBC, [MEDICATION NAME] levels. Monitor weight trends. Review and update care plan reflecting interventions. It is to be noted that the family was not offered a PEG tube for nutrition or an IV (intravenous) fluids for hydration, no labs were drawn to measure degree of infection and there were no preventative interventions in place to prevent the skin breakdown such as cushions or a specialty mattress, or heel pressure cushions/boots. The facility presented the following Plan of Correction (does not have an A[NAME] (allegation of compliance date) dated 3-11-18: 1. NP (nurse practitioner) in facility to assess resident for wound infection. Resident presented with temp, wound increase, exudate. Family and DON notified. Nurse had not yet changed treatment to sacral wound. DON notified hospital of patient condition. 2. All other residents were assessed by facility nurse to ensure there were no signs of wound infection. Facility sweep was initiated (completed 3/14/18). 3. DON provided re-education of nurses regarding skin assessments, notification of family and physician and wound formulary. (3-12-18). Contacted EMT for wound nurse to provide additional wound care education. CNA education if any skin alteration is noted to inform nurse immediately (need to complete Stop and Watch). Any new skin alteration will be discussed during the clinical meeting to ensure notification and treatments are in place. UDA weekly skin assessments will be monitored daily during the clinical meeting. 4. DON/Designee will complete Quality Monitoring Tool 5 times weekly x 4 weeks. This information will be presented by DON at monthly QAPI (quality assessment performance improvement) to assess the need for ongoing education and need for further monitoring. The DON stated there had been no QA meeting since the P[NAME].

Based on staff interview, facility documentation and clinical record review, and in the course of a complaint investigation, the facility failed for one resident (Resident #5) in a survey sample of five residents, to be free from neglect, requiring hospitalization for [MEDICAL CONDITION] due to failure to assess and treat an acquired sacral wound, dehydration, amputation of the first and second toes on the right foot due to gangrene and bilateral unable to stage pressure wounds on the heels resulting in harm. Resident #2 did not receive treatment for [REDACTED]. 1. Resident #5's acquired sacral wound, heel pressure wounds were not treated and the resident suffered dehydration from lack of appropriate interventions, such as IV (intravenous fluids) or placement of a tube for feeding resulting in harm. 2. Resident #2 acquired a stage II sacral wound that did not receive treatment. The findings included: 1. Resident #5's acquired sacral wound, heel pressure wounds were not treated and the resident suffered dehydration from lack of appropriate interventions, such as IV (intravenous fluids) or placement of a tube for feeding resulting in harm. Resident #5 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. [DIAGNOSES REDACTED]. Resident #5's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 2/14/18 coded Resident #5 with both short and long term memory loss with severe cognitive impairment. The MDS was completed as a significant change in status assessment. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of one staff member. The resident was incontinent of bowel and bladder. The resident was coded as having unplanned, non physician prescribed weight loss. There were no wounds documented on the MDS, and the resident was coded as being at risk for skin breakdown. Review of the clinical record revealed a nurses note dated 2/23/18 which read: IDT (interdisciplinary team) held, Resident triggered for 14.3% weight loss over a six month period. Recommended med pass 60 ml (milliliters) three times daily to increase daily kcal (kilocalories) intake. Continue to monitor weight per facility protocol. The weights were documented as followed: 10/6/17: 160 # (Pounds) 11/6/17: 156# 12/17/18: 155# 1/7/18: 150# 2/7/18: 138 # On 3/2/18, a dietary note revealed: Per nursing staff at weekly wound meeting, resident has a stage 2 sacral ulcer and wound between right great toe and 1st toe. Recommend addition of multivitamin and Prostat 30 cc (cubic centimeters) to promote skin integrity and wound healing. The Prostat (protein supplement) was initiated on 3/6/18, but the multivitamin was not on the MAR (medication administration record); there was no documentation the multivitamin was given. Review of the resident's care plan dated 12/6/17 revealed the resident did not address the resident's potential for skin breakdown. There were no interventions for the prevention of pressure wounds. On 3/5/18 (after development of the acquired pressure wound), the care plan had been updated to include interventions for prevention, but was not updated to include the sacral wound or the wounds on the toes. On 4/5/18, an interview with the MDS coordinator (RN-registered nurse A). When asked to identify prevention for skin breakdown on the care plan, RN(A) stated, No prevention, just care planned for pain. She went on to state that the resident should be care planned for pressure ulcer prevention. On 3/5/18, a nurses note documented the following: Resident noted to have a 5 cm by 3 cm (centimeter) stage 2 sacral ulcer covered with slough, green foul smelling drainage noted. Resident also has an elevated temperature of 100.2 (degrees). Notified (name of physician) of resident's condition, new orders were given to start Keflex 250 mg twice a day for 10 days and to refer resident to the wound care clinic. Review of the TAR (treatment administration record) for March, (YEAR), revealed no treatment orders for this wound, or for treatment of [REDACTED]. The NPUAP (national pressure ulcer advisory panel) describes a stage 2 as, Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Slough is defined as yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed. This wound bed has both yellow stringy slough as well as thick adherent slough. Slough on a wound bed should be surgically debrided to allow for ingrowth of healthy granulation tissue. On 3/9/18 revealed the following nurse's note: Reassessment of wound 3/9/18 of sacral region. Stage 3 wound pink with some slough. Hydrogel applied with dressing. MD notified and RP (responsible party) notified of treatment regimen. Further review of the MAR indicated [REDACTED]. The NPUAP describes a stage 3 ulcer as a Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. On 3/10/18 at 12:44 PM, the nurse's note read: Resident on ABT (antibiotic therapy). Temperature of 102.1 Attempted to administer po (by mouth) Tylenol 650 mg. Resident having trouble swallowing. medication. Notified FNP (family nurse practitioner). New orders given for Tylenol suppositories 650 mg prn (as needed) every 6 hours for elevated temperature and pain. On 3/11/18 at 3:10 AM, the nurse's note read: Resident remains on ABT. She is running a temperature of 101.0 pushed fluids gave Tylenol bring down temperature. will check again. On 3/11/18 at 9:15 AM, the nurse's notes read: Upon assessing resident noticed residents (sic) condition had worsened since yesterday. Left sided facial drooping remains, resident lethargic and only moans/responds to painful stimuli. Unable to swallow any fluids or food. Attempted to offer resident medication and water unsuccessful. Resident has a temperature of 101.4. FNP in facility at this time and evaluated resident upon request. New orders were given to send resident to (name of hospital). On 3/11/18, the FNP note read: Asked by staff to see resident . Was called yesterday because she had a fever. Is on [MEDICATION NAME] at present. She was less active yesterday, not eating, drooling and not as responsive as usual. She is lying in bed turned towards left. She clenched eyes shut but PERLA (pupils equal and responsive to light, accommodation). Her mouth drooped left side. She has legs drawn up towards chest. No [MEDICAL CONDITION]. She has a sacral wound with a very foul odor. Her lungs remain clear. A/P (assessment /plan): Fever obtunded : DM (diabetes); dysphagia, sacral decubitus. She is full code. I advised to send her to hospital for evaluation due to worsening condition. Review of the hospital records revealed on 3/11/18 at 11:50 AM note by the receiving nurse documented, Pt (patient) with gown on that had dried food on it. On 3/11/18, the emergency department nursing note documented a call from the DON (director of nursing) from the discharging facility which read: I just want you all to know, this patient has an awful wound, and it has been treated. She is sick and dying. We have been treating with antibiotics. I just want you to know this is not neglect on our parts. It has not been neglected. On 3/11/18 at 11:32 AM, the ER nurse documented, Has a sacral wound that smells awful and the staff at (name of facility) has not changed it. On 3/11/18 at 11:52 AM, the ER physician documented: The patient presents with decubitus ulcers. The onset was unknown. The course/duration of symptoms is worsening. Location, sacral. The character of symptoms is pain, redness, drainage and warmth. The degree of symptoms is severe. per nh (nursing home) increased lethargy over the last 3 days with worsening sacral ulcer . nursing home resident, concerns of neglect. Skin: warm, dirty, undated sacral dressing removed, a large stage 4 sacral decubitus measuring 6 cm by 4 cm with large eschar, inferior edge of eschar is open and draining purulent drainage. Ulcer tracks under the skin bilaterally and inferiorly, + malodor, no bleeding. 2 cm by 1 cm eschar on right shin no fluctuance, no drainage. Ulceration with purulent drainage noted between right first and second toes. Bilateral heel eschars noted no fluctuance, no drainage. Impression and Plan: Dehydration,[MEDICAL CONDITION], Stage 4 decubitus ulcer, [MEDICAL CONDITION] (high sodium). Review of the labs done 3/11/18 at the hospital revealed: Sodium 157 (Critical) Normal 134-149 Chloride 117 (high) Normal 95-108 Glucose 298 (high) Normal less than 120 BUN 52 (high) Normal 7-20 Creatinine (1.01 (high) Normal 0.5-1.4 White blood count 21.8 (high) Normal 4.5-10 NPUAP describes a stage 4 ulcer as a Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable On 3/13/18, the resident underwent [REDACTED]. The sacral wound was surgically debrided. A PEG (percutaneous endogastric) tube was placed for feeding and hydration. On 3/21/18, the discharge summary read, Discharge Diagnosis: [REDACTED]. secondary to multiple [MEDICAL CONDITION]. 2. Stage 4 sacral decubitus status [REDACTED]. 3. Right 1-2 toe gangrene status [REDACTED]. Advanced dementia. 5. Chronic issues. At time of discharge she was stable and afebrile. The resident was not discharged back to the discharging facility. On 4/4/18 at approximately 9:30 AM, the DSS (department of social services) was notified that surveyor was on site for the complaint. She stated, I want you to see my notes. A copy of the notes was received. The following notes were recorded from the DSS SW (social worker) of her conversation with the DON: 3/6/18: Documented as a stage 2, patient not eating (could not get anything in her). Nurse informed worker that patient not taking in nutrients wound were not going to heal, but the wounds were being treated. Husband was notified of about what was going on with his wife. 3/9/18: (Name of resident) health declined. She is a full code (if stop breathing full code) wanted husband to change from full code. He would not agree. Wound was measured and it had increased in size. She had no nutrients to feed the body. Worker asked the question several times, how many days does a person not eat before it is determined to seek medical attention outside of the nursing home and if wound care was not working when do you seek medical attention outside of the nursing home. Nurse (name of DON) response was skin breakdown happens fast when a patient is not eating . worker never received a direct answer to the question. Review of the nurse's notes written by the wound care nurse, (WCN C) were written as late entries on 3/19/18 (after the 3/11/18 discharge note): 3/19/18 for 3/1/18: Stage 2 to sacral region. Wound pink with drainage noted. size 1 by 1. Odor noted. Hydrogel dressing ordered every day to sacral ulcer. MD notified and received order. No order for this treatment was written, nor was the order written on the TAR. 3/19/18 for 3/1/18: Necrotic tissue noted to toes on right foot with ulcer stage 1 between great toe and second toe. Order for Hydrogel and gauze dressing ordered per MD and RP (responsible party was notified. No order for this treatment was written or documented on the TAR. 3/19/18 for 3/1/18: Wound noted on the right lower leg stage 2, 3 by 1. No drainage, redness noted. Sureprep ordered. MD and RP contacted. No order was written nor documented on the TAR. 3/19/18 for 3/1/18: Wound noted to right second toe, 2 by 2. Stage 2 with yellowish drainage. Sureprep and gauze dressing ordered. MD contacted and RP notified. Again, no treatment order was written, nor was treatment documented on the TAR. 3/19/18 for 3/1/18: Wound noted between great toe and 2nd toe. Slough drainage sureprep administered. MD and RP notified. No treatment order was written nor were any treatments documented on the TAR. 3/19/18 for 2/28/18: Sacral wound observed. 1 by 1. Stage 2 wound bed pink with exudate, odor noted. Hydrogel and dressing applied. MD notified and RP notified. No treatment order was written, nor were any treatments documented on the TAR. Review of the wound tracking notes revealed hand written notes with an entry for 2/28/18 (on tracking the documentation stated it was first observed 3/1/18) for 1 by 1 cm stage 2 sacral wound) and a stage 1 right toes with necrotic tissue right toes. The next tracking note dated 3/9/18 which has the notation on the bottom of the record, late entry shows a 7 cm by 4.0 cm by 1cm depth,stage 3. On 4/3/18 at 2:00 PM, a brief interview was conducted with the wound care nurse, WCN (C). When asked who was responsible for the wound tracking, she stated, I guess I am; I didn't know that I was supposed to. On 4/4/18 at 9:00 AM, the Divisional Executive Director stated, (name of WCN C) will not be in today; we told her to take care of things at home. 4/4/18 at 3:40 PM, an interview with the DON (director of nursing) was conducted. She stated, It is a hot mess. I was doing wounds and I showed the ADON (assistant director of nursing-WCN (C)) how to. The DON went on to state that there were no treatments documented. 4/4/18 at 3:40 PM, the Administrator was present for above interview. She stated, We thought she had a lot of experience- we were told she was a certified wound nurse; she was not. On 4/5/18 at 9:30 AM, an interview was conducted with LPN (B). She stated, It was brought to my attention there was a dark spot on her sacrum. She went on to state that the CNA (certified nursing assistant) was told to keep cream on it. It (sacral area) opened up on Monday. I never heard anything else about it. She went on to say that two days later, it had an odor and the CNA thought it looked funny. I measured it myself, it was 5 cm by 3 cm, open with green drainage. She stated that she called the physician who said to start antibiotics and refer to the wound clinic. She denied knowledge if lab work was ordered, and stated, It was all on (name of wound nurse,WCN (C)). On 4/5/18 at 11:40 AM, CNA (A) was interviewed. She stated she was familiar with Resident #5. She stated that the resident fed herself, ate very slowly, and that she pocketed food. She stated, I would massage her throat. She also stated she had stopped eating for two weeks, that she ate less and less. She said that she reported this toWCN (C). The CNA reported that the wound on her back had greenish discharge and a very strong odor. She went on to state that for a couple of days before (resident was sent out) her diaper (sic) had no urine. She also stated, She literally was not eating in the last two days and would moan when she was turned. On 4/5/18 at 11:55 AM, a telephone interview was conducted with the resident's physician. He stated, I was following her for her feet and sacrum, she had ups and downs. The physician was asked if he had observed the wounds. He stated, I don't recall. The physician was asked if the family had been offered the option of a feeding tube, as the resident was a full code. He stated, I think we did a couple of years ago. He was asked if he had been aware the wound had progressed to a stage 3 with odor, fever, would he have sent her out earlier, he stated, I think I would. The physician was asked if he had ordered labs, he stated, Sometimes I get a CBC (complete blood count). Apparently she had not been eating or drinking. The facility presented the following when asked for their policy and procedure for pressure ulcers: Best Practices_ Skin & Wound: Under skin observation: Re-evaluate wound/skin treatment within two weeks of start date and every 2 weeks thereafter. Skin Health: Relieve and protect heel pressure. Provide pressure redistribution cushions for residents in wheelchairs, evaluate for adaptive equipment/positioning devices/specialty mattress. Therapy screen/evaluation as indicated. Nutrition: Monitor lab values to include, but not limited to CBC, [MEDICATION NAME] levels. Monitor weight trends. Review and update care plan reflecting interventions. It is to be noted that the family was not offered a PEG tube for nutrition, no labs were drawn to measure degree of infection and there were no preventative interventions in place to prevent the skin breakdown such as cushions or a specialty mattress, or heel pressure cushions/boots. 2. Resident #2 acquired a stage II sacral wound that did not receive treatment. Resident #2 was admitted to the facility on [DATE] and discharged to the hospital on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Resident #2's Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 3/29/18 coded Resident #2 with a BIMS (brief interview of mental status) of 9 out of a possible 15, or moderate cognitive impairment. The MDS was completed as a 14 day assessment. The resident required extensive care with all ADL's (activities of daily living such as bed mobility and toileting) of one staff member. The resident was incontinent of bowel and bladder. The resident was coded as having unplanned, non physician prescribed weight loss. The resident was coded as having a stage 4 pressure ulcer on readmission. On 2/23/18, the nurse's notes contain the following entry: Wound assessment performed. Stage 2 to sacral area region. Measurements obtained. No odor noted. Treatment as ordered. Review of the February, (YEAR) MAR (medication administration record) revealed there were no orders written or treatments documented for the sacral wound through the entire month of February. Review of the wound care tracking records for 2/28/18 revealed: Measurements of 1 cm by 2 cm with no depth recorded, as a stage II. On 3/9/18, documented as a late entry , the measurements were 1.5 cm by 2 cm, with no depth recorded, stage II. The resident was sent to the hospital on [DATE] and returned on 3/15/18 with a stage 4 sacral ulcer. There was no wound description from the hospital. Review of the March, (YEAR) TAR revealed the return treatment for [REDACTED]. The wound was documented as being treated on 3/20/18, no documentation for 3/21/18 to 3/23/18, 3/26/18 and 3/30/18. On 4/4/18 at 2:10 PM, wound treatment was done by LPN (A). The wound dressing was not in place; the CNA had told LPN (A) and she told the CNA to take it off. There were two wounds, one on the right and one on the left. The wound on the right buttock was approximately 3 by 5 cm with scattered slough. The wound on the left was approximately 2-3 cm in diameter with granulation tissue. Hydrogel was applied to the wound bed, sure prep applied around the wounds and a foam dressing was applied. The dressing was dated by the LPN. The LPN was asked to take off the heel boots. On the right heel, it had a dry, dark blister, which was treated with sure prep. The left heel was intact, sure prep was applied. The heel boots were re-applied. LPN(A) washed her hands appropriately. The resident showed no signs of pain or discomfort during the treatment. The resident was on a Low air loss mattress. Review of the care plan dated 4/3/18 revealed the resident was care planned for risk of skin impairment and had been revised to include the sacral and heel wound. The facility presented the following Plan of Correction (does not have an A[NAME] (allegation of compliance date) dated 3-11-18: 1. NP (nurse practitioner) in facility to assess resident for wound infection. Resident presented with temp, wound increase, exudate. Family and DON notified. Nurse had not yet changed treatment to sacral wound. DON notified hospital of patient condition. 2. All other residents were assessed by facility nurse to ensure there were no signs of wound infection. Facility sweep was initiated (completed 3/14/18). 3. DON provided re-education of nurses regarding skin assessments, notification of family and physician and wound formulary. (3-12-18). Contacted EMT for wound nurse to provide additional wound care education. CNA education if any skin alteration is noted to inform nurse immediately (need to complete Stop and Watch). Any new skin alteration will be discussed during the clinical meeting to ensure notification and treatments are in place. UDA weekly skin assessments will be monitored daily during the clinical meeting. 4. DON/Designee will complete Quality Monitoring Tool 5 times weekly x 4 weeks. This information will be presented by DON at monthly QAPI (quality assessment performance improvement) to assess the need for ongoing education and need for further monitoring. The DON stated there had been no QA meeting since the P[NAME].

Based on observation, staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined that the facility staff failed to provide adequate supervision and safety devices to prevent accidents for two of 11 residents; Resident #110 and Resident #111. 1. Resident #110 and fell and broke his hip. 2 . Resident #111 fell out of his wheelchair. The findings include: 1. Resident #110 was not provided adequate supervision or assistive devices and fell and broke his hip. Resident #110 was originally admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an admission assessment with an ARD (assessment reference date ) of 07/15/2011. Resident #110 was assessed as having a cognitive summary score of 11, indicating that he was moderately impaired in his cognitive status. In section G0110, the resident was coded as needing extensive assistance for walking in the room and corridor with one person physical assist. He was also coded as needing limited assistance for locomotion on the unit and extensive assistance for locomotion off the unit, both with one person physical assist. The clinical record was reviewed on 09/08/2011 at approximately 9:15 a.m. Observed within the clinical record was a "Resident Transfer Form." The form was dated 11/27/1926 (Resident #110's birth date). The area which asked, "Reason For Transfer" was completed with "fell on floor." The nurse's notes revealed an entry for 08/31/2011 at 10:50 p.m., which read: "Resident found on floor in hallway witness (sic) by nurse. Resident lay (sic) on left hip moaning...called EMT (emergency transport)." The next entry, also dated 08/31/2011 at 2300 (11:00 p.m.) stated: "Resident sent to (initials of local hospital) E. (emergency) room..." The DON (director of nursing), who was standing at the nurse's station when the clinical record was being reviewed, was asked if the "Resident Transfer Form" was referring to the fall on 08/31/2011 and she stated, "Yes." A copy of the fall investigation was requested at that time. Other notes reviewed in the nurse's note section included the following: ? 08/02/2011 1430 (2:30 p.m.) "Noted on floor in hallway on (Lt) (left) side of body..." ? 08/14/2011 10:30 a.m. "Noted on floor in hallway by nurse, on knees was in the w/c (wheelchair) Stated trying to get out of here..." ? 08/26/2011 9:30 a.m. "Res (resident) found lying on floor saying 'I'm not lying on the floor, I'm lying on my bed.'...Assisted res to bed..." ? 08/29/2011 11:00 a.m. "...continues to be confused much of the time...able to ambulate but needs supervision since gait is unsteady at times." The next nurse's note in the clinical record was written 09/03/2011 at 1615 (4:15 p.m.) and stated: "Res arrived via stretcher escorted by 2 patient transport attendants. readmitted to (room number) with a [DIAGNOSES REDACTED]. The care plan was reviewed. The problem list included: Self care deficit related to ambulation, and Fall prevention. The care plan contained a page titled "Self Care Deficit Care Plan Ambulation/Locomotion." The Problem listed was: "Self Care Deficit Ambulation-Related To...Unaware of Safety" was checked as the reason for the deficit. Implementation date of this problem was 07/12/2011. Approaches and Interventions included: ? Provide assistance as needed with ambulation; ? Positive feedback for efforts and accomplishments; ? Assistive devices as indicated-Specify "walker" was handwritten in as the device. ? Monitor and report decline in abilities ? Use task segmentation: the following were handwritten in: "remind to put on shoes, remind to use walker, remind to use call bell for assistance" ? Use verbal cues ? Use simple direct communication ? Keep needed items in easy reach ? Physical Therapy screen as indicated ? Occupational Therapy screen as indicated ? Hands on Assist, handwritten under this was staff X 1 (one staff member assist) ? Utilize gait belt ? Restorative program The care plan also contained a page titled, "Fall Prevention Care Plan", also dated 7/12/11. The problem listed was, "At Risk for falls related to: Fall risk > (greater than) 10, Cognitive status, and history of falls." Approaches/Interventions included many of the same interventions listed above as well as the following: ? change in cognitive status ? change in functional status ? assess resident's ability to comprehend instructions ? assess resident's ability to follow directions ? Assure assistive devices are within reach Other problems listed on the care plan were: ? "Recent fall" handwritten underneath this was "per family." Interventions/approaches listed included, but were not limited to: "Keep in area where staff can monitor." ? "Weakness/Tiredness At risk for: "falls and injury" R/T (related to) "...dementia, general weakness." There were no new fall interventions listed on the care plan prior to the fall resulting in the broken hip on 08/31/2011. Physical therapy notes were reviewed. The weekly note for 08/07/2011 through 08/13/2011 stated that Resident #110 was, "Still very confused..." The summary of progress for that week stated, "..has had a slight setback and he is not using his w/c (wheelchair) as much and has gone back to his walker at times for use in the hallways as he needs CGA (contact guard assistance) at times for safe gait processes esp'ly (especially) in his turning and encountering of others." The summary note for 08/14/2011 through 08/20/2011 stated, "..is not making good progress as he is gets to a certain point and he will become distracted and get off the task at hand.." Occupational Therapy notes for the week of 08/24/2011 through 08/30/2011 stated, "Pt (patient) has made significant ? (decrease) c (with) progress this week due to ? (increase) weakness, confusion, & and ? lethargic behavior. However pt is less agitated and ? cooperation c therapeutic activities. Pt had required continuous orientation to place and memory with ? response with redirection." Also written on this weekly summary under the section "Identify remaining functional areas, impairments limiting progress and barriers to improvement" were the following: "? cognition, ? dynamic balance, ? activity tolerance." Precautions listed were "Fall risk, poor safety awareness." On 09/08/2011 LPN (licensed practical nurse) #3 was interviewed regarding Resident #110's fall on 08/31/2011. LPN #3 had written the note regarding the fall. She stated that she was giving medications the night of the fall. She stated that she did not witness the fall. She stated she never saw him until he was on the floor. She stated that one of the other nurses working told her she had witnessed the fall that was why she had documented that the fall was "witnessed by nurse." LPN #3 stated that when there is a fall there is a fall investigation that is started that is "like 15 pages of information." The other nurse (who although contacted by the facility was not available for interview) was going to complete that packet. Per LPN #3, the packet is completed and put on a clipboard for the DON or ADON (assistant director of nursing) or (name of another staff member) to pick up and complete their part. LPN #3 stated that she did not know if the packet was completed or not. She stated, "It was crazy here that night, we had one resident who was unresponsive, we had to call the cops for another resident and then (name of Resident #110) fell and had to go to the hospital." LPN #3 was asked if Resident #110 was using an assistive device when he fell . She stated, "I don't think so, he had a walker, a wheelchair and a cane. I didn't see any of those around him when he was laying on the floor." The DON was present during the interview with LPN #3. The DON stated that she and the ADON had been off when Resident #110 had fallen. The DON stated that she was not able to locate the investigation, and couldn't remember if she had ever seen it or not. The physical therapist, other staff #1 was interviewed during the afternoon of 09/08/2011. He was asked what type of assistive device Resident #110 was using during the time he fell and broke his hip. Other staff #1 stated that Resident #110 was suppose to be using his walker but the VA (veteran's administration) had given him a wheelchair and he was using that as well. Other staff #1 stated that Resident #110 was only suppose to be up with an assistive device but that he (Resident #110) didn't always remember that. Other staff #1 was asked about the note that stated, "CGA (contact guard assistance) at times for safe gait processes esp'ly (especially) in his turning and encountering of others." Other staff #1 stated that Resident #110 needed someone "standing by" in case he lost his balance. Other Staff #1 was asked if information such as the CGA and the resident not always remembering to use his assistive device was communicated to the nurse's and he stated, "Yes, we communicate that information." The DON and the administrator were notified of the above findings during an afternoon meeting on 09/08/2011. No further information was obtained prior to the exit conference on 09/08/0211. 2. Resident # 111 did not have adequate safety interventions/devices in place to prevent accidents. Resident # 111 was admitted to the facility on [DATE], with the most current readmission on 08/18/11. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a 14 day (admission) assessment, which assessed the resident as having a cognitive score of 14 (cognitively intact). Resident # 111 was also assessed as requiring extensive assistance from staff for all ADL's (activities of daily living). In Section G0300. of the MDS, Resident # 111 was assessed as "Not steady, only able to stabilize with human assistance" for A. through E. The resident was also assessed as using assistive devices (a walker and a wheelchair). Resident # 111 was observed on 09/08/11 at 9:25 a.m., sitting in his w/c (wheelchair) in his doorway. The resident was observed to be leaning slightly forward. LPN (licensed practical nurse) # 2 was also observed in the hallway, in close proximity passing out medications. At 9:30 a.m., LPN # 2 yelled out and it was observed that Resident # 111 had fallen from his w/c into the floor. The DON (director of nursing) appeared and attempted to assist the resident up. Resident # 111 was observed to be partially flaccid and unable to assist in getting back in the w/c. The resident was laid back down on the floor. Additional staff were called; it took a total of 4 staff to assist the resident back to the w/c from the floor. During this time, no safety alarm was heard. On 09/08/11 at approximatley 10:15 a.m., Resident # 111 was observed in the "living room" in his w/c; the resident was observed to have both feet in the bilateral foot rest attached to the w/c and was sitting upright. The w/c did not have a safety alarm attached or present. Resident # 111 was observed again, at approximately 11:30 a.m. in his room. The resident was sitting in his w/c leaning forward; a CNA (certified nursing assistant) was with the resident. The CNA was attempting to have the resident lie down in bed, but the resident was verbally resistive and continued to lean forward. The resident was observed to be confused and had his eyes closed, while saying "No" to the CNA. The resident's w/c was observed again to have no safety alarm device attached. The CNA was asked regarding the alarm and voiced that it was just transferred to the bed. The CNA was made aware at this time that the resident was observed in the living room without a safety device attached to the chair. No further information was provided by the CNA. At approximatley 11:45 a.m., the clinical record for Resident # 111 was reviewed. The most current POS (physician's orders [REDACTED]. The POS included an order for [REDACTED]. Resident # 111's admission assessment dated [DATE]. The fall risk section assessed Resident # 111 as a "15", which indicates the resident is a high fall risk. Nursing notes were then observed and documented that the resident had some confusion, but was not specific. Resident # 111's comprehensive care plan (CCP) was requested from staff for review. On 09/08/11 at approximatley 2:30 p.m. The administrator and DON (director of nursing) were made aware of the above and were asked if Resident # 111 had a chair safety device in place. The DON voiced that the resident did have a chair safety alarm and that it was in place that morning when the resident fell out into the floor. The administrative staff were made aware of the surveyors observation and that no alarms were heard sounding. The DON stated that the resident had the alarm on and it was functioning. The DON was asked why the alarm was not sounding if in fact, it was functioning. The DON stated, "I honestly don't know." Resident # 111's comprehensive care plan (CCP) was presented and reviewed. The CCP documented, "... immobility requires assist to transfer & ambulate...confusion & weakness...At risk for falls related to fall risk > (greater than) 10...assess change in cognitive/functional status...medication review... 9-8-11 chair & bed alarm..." The DON was interviewed again at approximately 4:45 p.m. and was asked about the CCP and the documentation added to the care plan on 09/08/11. The DON voiced that the resident had a chair and bed alarm, but it just wasn't on the care plan and it was added today. No further information or documentation was provided prior to the exit conference on 09/08/11.

Based on observation, clinical record review and facility document review, the facility staff failed to ensure safety devices were in place for 1 of 15 Resident. (Resident #1) The findings include: Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS) with an assessment reference date (ARD) of 7/14/11 assessed that Resident #1 had both short and long term memory loss and needing minimal assistance with decision making. On 7/26/11 at 4:10 p.m., Resident #1 was observed in bed with a fall mat on the side of the bed closest to the door of the room and the bed in a regular position, with the head of the bed elevated. The clinical record was reviewed. The 7/11 physician's orders [REDACTED].@ (at) bedside d/t (due to) hx (history) of falls. ? (check) placement and function every shift." The 6/11 POS documented "5/18/11 - Low bed with mats d/t hx of falls. ? Placement and function every week." Resident #1's care plan included the following: ? "Problem - At Risk for falls related to Fall risk > 10, Cognitive Status, Unsteady Gait" ? "Interventions/Approaches - ...Floor mat, Motion detectors Bed/wc ? placement functioning q shift, low bed, ? rails for ncrease mobility and safe turning...intentially get on pillow in floor @ bedside observed by staff doing this." A skilled nursing progress note dated 7/14/11 at 9:00 p.m. stated "Resident found lying on pillows placed on the floor next to the bed. Wheelchair noted to be turned over backwards on the floor. No injuries noted to resident and resident stated she was okay." On 7/27/11 at 3:45 p.m., the administrator, assistant director of clinical services (ADCS), regional clinical consultant, regional case mix coordinator and unit manager were advised of the findings during a meeting with the survey team. The ADCS was asked what the order "low bed with mats" meant. The ADCS stated that "there were to be mats on each side of the bed and that a low bed is to be used and in the low position when she (the resident) is in the bed."