Every finding on record at Los Alamos Wellness & Rehabilitation

Based on observation, and interview, the facility failed to ensure the results of the most recent state surveys were posted in areas of the facility that was readily accessible to residents and the public without having to ask for them. This could affect all 57 residents in the facility (residents were identified by the census report provided by the Administrator on 03/23/26). If residents, representatives, and/or visitors are unable to locate the most recent survey information, then they are unable to make informed decisions regarding residents' care. The findings are: A. On 03/25/26 at 2:00 PM, during an observation of the front lobby, revealed a survey results binder was located behind the receptionist desk in the front lobby area. The survey results binder was not readily accessible and visible for residents, family, or visitors. The survey results binder was in the middle of other binders. The survey results binder did not have any spine information on it to distinguish the binder from several other binders in the same area. B. On 03/25/26 at 1:54 PM, during an interview the Receptionist stated she was new working at the facility for about month and a half. She did not know if residents had access to the survey result binder. She stated that the survey results had been behind the reception desk since she had been working at the facility. C. On 03/26/26 at 3:52 PM, during an interview the Administrator stated that the survey result binder is located behind the receptionist's desk. The Administrator stated her expectation was that the survey result binder should be available to the residents, and the residents should know the location of the binder.

Based on record review and interview, the facility failed to provide the required transfer information for 3 (R #8, R #26, and R #43) of 4 (R #8, R #26, R #43, and R #59) residents reviewed for hospitalizations when staff failed to: 1. Notify R #8, R #26, R #43, and their representative(s) of the residents' transfer to the hospital in writing and in a language and manner they understand. 2. Ensure the transfer notices for R #8, R #26, and R #43 included: a. A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. b. The name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman (an advocate for residents in nursing homes and assisted living facilities).3. Send a written copy of R #8, R #26, and R #43 transfer notices to the Ombudsman. 4. Ensure R #8, R #26, and R #43 and their representative(s) receive a written notice of the bed hold policy which indicated the duration the bed would be held. These deficient practices could likely result in the residents and/or their representatives not knowing the reason for the transfer, the location of the transfer, and their rights to advocate and make informed decisions regarding the residents' healthcare. The findings are: R #8 A. Record review of R #8's admission Record, no date, revealed R #8 was admitted to the facility on [DATE]. B. Record review of R #8's nursing progress note, dated 01/31/26, revealed R #8 was transferred to the hospital following a fall. C. Record review of R #8's medical record, no date, revealed staff did not document a written transfer notice or written bed hold notice for R #8's transfer to the hospital on [DATE]. R #26 D. Record review of R #26's admission Record, no date, revealed R #26 was admitted to the facility on [DATE]. E. Record review of R #26's nursing progress notes revealed the following: 1. On 02/27/26, R #26 was transferred to the hospital for nausea, vomiting, and bleeding. 2. On 03/05/26, R #26 was readmitted from the hospital after an episode of vomiting with blood. F. Record review of R #26's medical record, no date, revealed the following: 1. Staff did not document a written transfer notification that included information regarding how R #26 or her representative could appeal a transfer or how to contact the Ombudsman for her transfer to the hospital on [DATE]. 2. Staff did not document a written bed hold notification for her transfer to the hospital on [DATE]. R #43 G. Record review of R #43's admission Record, no date, revealed R #43 was admitted to the facility on [DATE]. H. Record review of R #43's nursing progress notes revealed the following: 1. On 01/29/26, R #43 was transferred to the hospital after a fall with laceration to forehead. 2. On 03/17/26, R #43 was transferred to the hospital due to unresponsiveness. I. Record review of R #43's medical record, no date, revealed staff did not document a written transfer notice or written bed hold notice for her transfers to the hospital on [DATE] or 03/17/26. J. On 03/27/26 at 10:12 AM, during an interview, the SSD stated the following: 1. Staff did not document a transfer notice or a bed hold notice for R #26's transfer to the hospital on [DATE]. 2. She does not notify the Ombudsman about transfers to the hospital. 3. She emails a list of all residents who were discharged from the facility to the Ombudsman monthly. 4. She does not send a written copy of the transfer or discharge notices to the Ombudsman.

Based on record review and interview, the facility failed to ensure care plan revisions occurred for 4 (R #3, R #5, R #9, and R #14) of 10 (R #1, R #3, R #4, R #5, R #6, R #9, R #10, R #14, R #54, and R #64) residents reviewed for care plan accuracy, when staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #3 A. Record review of R #3's admission Record, no date, revealed the following: 1. R #3 was admitted to the facility on [DATE]. 2. R #3 had the following diagnoses: a. Alzheimer's Disease (a progressive, irreversible brain disorder that causes cognitive decline, memory loss, and behavior changes). b. Unsteadiness on feet (a lack of balance, stability, or coordination while standing or walking, often resulting in stumbling, staggering, or frequent falls). c. Repeat Falls d. Unspecified abnormalities of gait and mobility (general, undefined difficulties with walking or movement, such as unsteadiness or improper movement patterns). e. Unspecified lack of coordination (a general inability to control or coordinate muscle movements, that cannot be linked to a specific underlying diagnosis). B. On 03/24/26 at 1:48 PM, during an interview, R #3's Family Member (FM) stated that R #3 had fallen on 03/17/26. C. Record review of R #3's nursing progress note, dated 03/17/26, revealed R #3 was behind the secure unit door. R #3 fell when a staff member opened the door. D. Record review of R #3's IDT meeting note, dated 03/18/26, revealed the following: 1. R #3 fell due to an external force, causing R #3 to lose her balance. 2. The IDT recommended a referral for therapy to evaluate R #3. 3. Staff were to be mindful when entering and exiting the Secure Unit. 4. Staff were to redirect residents away from the doors. E. On 03/25/26 at 1:56 PM, during an interview, Physical Therapy Assistant (PTA) #16 stated the following: 1. R #3 was assessed by PT staff on 03/19/26 after she had fallen on 03/17/26. 2. After R #3 was assessed, she was started on PT services. 3. R #3 was not receiving PT services at the time of her fall on 03/17/26. F. Record review of R #3's care plan, revised 02/03/26, revealed staff did not revise R #3's care plan after R #3's fall on 03/17/26. G. On 03/25/26 at 1:12 PM, during an interview, the Regional Nurse Consultant (RNC) confirmed the following: 1. Staff did not revise R #3's care plan after her fall on 03/17/26. 2. Staff were expected to revise care plans when the IDT met and determined what interventions would be implemented to prevent future falls. R #5 H. Record review of R #5's admission record, no date, revealed R #5 was admitted to the facility on [DATE]. I. On 03/26/26 at 2:35 PM, during a random observation of the Secure Unit revealed R #5 was seated in the common area watching television. His lips were dry and chapped. J. On 03/26/26 at 2:47 PM, during an interview, R #5 stated he puts ChapStick on his lips all the time. He stated he knows they are dry, but it does not bother him. He does not need or want anything other than the Chapstick for his dry lips. He stated he thinks he drinks enough water because he drinks water all throughout the day. He stated that staff treat him well and remind him to drink water and use his Chapstick. K. On 03/26/26 at 2:51 PM, during an interview, CNA #1 stated R #5 does apply Chapstick to his dry lips throughout the day, however he is always licking or biting his lips therefore they stay dry and chapped. She stated R #5 does not complain about or report that his dry lips bother him. L. Record review of R #5's care plan dated 01/06/25 revealed R #5 is at risk for dehydration due to a diagnosis of traumatic brain injury. Care plan approaches included assessing R #5 for dehydration (.dry cracked lips.). Staff did not document revisions to R #5's care plan since 01/06/25. Staff did not document R #5's dry chapped lips. M. On 03/27/26 at 12:37 PM, during an interview, LPN #1 confirmed there was no documented review or revision for R #5's care plan related to dry, chapped lips since 01/06/25. R #9 N. Record review of R #9's admission Record, no date, revealed the following: 1. R #9 was readmitted to the facility on [DATE]. 2. R #9 had the following diagnoses: a. Unspecified dementia, unspecified severity, with agitation (a type of dementia characterized by cognitive decline and behavioral disturbances, including agitation, which can significantly impact daily functioning and quality of life. The specific type and cause of dementia have not been identified) b. Pathological fracture of the hip unspecified (when an unspecified bone in the hip breaks due to an underlying condition that weakens the bone, rather than from a traumatic injury). c. Unsteadiness on feet (lack of balance, stability, or coordination while standing or walking, often resulting in stumbling, staggering, or frequent falls). d. Repeated falls (when an individual experiences repeated falls in a specific time frame). e. Unspecified abnormalities of gait and mobility (general, undefined difficulties with walking or movement, such as unsteadiness or improper movement patterns). f. Unspecified lack of coordination (a general inability to control or coordinate muscle movements, that cannot be linked to a specific underlying diagnosis). O. Record review of R #9's nursing progress note, dated 03/09/26, revealed R #9 was found on the floor after reportedly falling out of bed. P. Record review of R #9's care plan revised on 02/11/26 revealed staff were to encourage R #9 to use environmental devices such as hand grips, handrails, etc. Q. On 03/27/26 at 12:37 PM, during an interview, LPN #2 confirmed the following: 1. R #9 fell on [DATE]. 2. Staff did not document that the IDT met to discuss R #9's fall. 3. R #9's care plan was not revised after her fall on 03/09/26. R #14 R. Record review of R #14's admission Record, no date, revealed the following: 1. R #14 was admitted to the facility on [DATE]. 2. R #14 had the diagnosis of unspecified systolic congestive heart failure (condition where the left ventricle of the heart [chamber that pumps oxygenated blood to the body] cannot pump blood effectively, leading to fluid buildup and reduced cardiac output [occurs when the heart cannot pump enough blood to meet the body's oxygen and nutrient demands]). S. Record review of R #14's physician's orders revealed an order dated 01/31/26: Lasix oral tablet (diuretic medication that helps eliminate fluid buildup) give 20 mg by mouth one time a day related to unspecified systolic congestive heart failure. T. Record review of R #14's care plan revealed the following: 1. The care plan for congestive heart failure was initiated on 12/14/25. 2. Staff did not document the use of Lasix for congestive heart failure. U. On 03/27/26 at 11:15 AM, during an interview, LPN #1 confirmed the following: 1. R #14 was taking Lasix for the diagnosis of congestive heart failure. 2. Staff did not revise R #14's care plan to include that R #14 was taking Lasix. 3. Staff should have revised R #14's care plan to include the high-risk medication Lasix and the interventions for monitoring potential side effects.

Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity for 1 (R #54) of 2 (R #54, and R #64) residents sampled for dignity, when the facility failed to wake R #54 while asleep in the dining room and/or ask if R #54 wanted to join the activity that was taking place in the dining room. This deficient practice is likely to result in residents feeling unimportant, embarrassed, undervalued, and could diminish their self-worth. The findings are: A. Record Review of R #54's admission Record, no date, revealed resident was admitted on [DATE]. B. Record review of R #54's quarterly MDS dated [DATE] revealed a BIMS score of 12. C. On 03/24/26 at 2:32 PM - 2:54 PM, during an observation of the tea social activity in the resident dining room revealed the following: 1. R #54 was asleep in the center of the dining room surrounded by other residents. 2. There were four staff present (activity director, activity assistant, dietary aide, and a volunteer). 3. Staff did not attempt to wake R #54 up. 4. R #54 was not offered tea during this time of the social. D. On 03/24/26 at 2:54 PM, during an interview with the Activity Assistant (AA), AA was asked if she had attempted to wake R #54, she stated Oh, I will try right now. AA attempted to wake R #54. R #54 was not fully awakened. AA poured R #54 a cup of hot water. AA placed the cup on the table in front of R #54 and walked away. E. On 03/24/26 at 3:10 PM, during an observation of the tea social activity in the resident dining room revealed the following: 1. R #54 was still asleep. 2. AA observed Surveyor returning to the dining room, she attempted to wake R #54. AA shook R #54's shoulder. She stated, [Name of R #54], wake up, please make me look good. F. On 03/24/2026 at 4:07 PM, during an interview with R #54 he stated the staff don't care, and they won't do anything to assist. Sometimes there's good or bad depending on the staff. G. On 03/24/26 at 3:15 PM, during an interview the Activity Director (AD) stated when residents are sleeping during activities, staff are expected to attempt to wake residents to determine if they want to participate or go to their room. AD stated that it should not take staff thirty minutes to wake R #54.

Based on interview and record review, the facility failed to keep residents free from neglect for 2 (R #8 and R #43) of 4 (R #8, R #26, R #43 and R #59) residents reviewed for hospitalization, when they failed to provide transportation from the hospital to the facility after being discharged from the emergency room (ER). If residents are left at the hospital after discharge, then they could likely feel confused, angry, fearful, and anxious. The findings are:R #8 A. Record review of the Intake Report (consumer complaint from the public to the state agency), dated 02/20/26, revealed residents that were transported to the ER at the local hospital were being left there for extended periods of time after being discharged . B. Record review of R #8's admission record, no date, revealed the following: 1. An admission date of 10/13/25. 2. R #8 had the following diagnoses: a. Alzheimer's disease (progressive, incurable neurodegenerative disease and the most common cause of dementia, causing severe memory, thinking, and behavior problems), unspecified. b. Vascular dementia, unspecified severity, with agitation (cognitive decline from vascular disease accompanied by behaviors like restlessness, pacing, shouting, or aggression). c. Vascular dementia, unspecified severity, with other behavioral disturbance d. Mild cognitive impairment of uncertain or unknown etiology (a slight, noticeable decline in cognitive functions-such as memory or reasoning-that is more significant than normal aging but not severe enough to interfere with daily independence). e. Cognitive communication deficit (communication impairments resulting from underlying cognitive disruptions-such as memory, attention, or executive function issues-rather than primary language deficits). f. Restlessness and agitation. C. Record review of R #8's change of condition MDS, dated [DATE], revealed the following:1. A BIMS score of 1.2. Resident was frequently incontinent of urine and bowel movements. D. Record review of R #8's nursing progress notes revealed the following: 1. On 01/31/26 at 3:00 AM, 911 was called. R #8 was transferred to the ER after a fall. 2. On 01/31/36 at 8:37 AM, R #8 returned from the hospital. E. Record review of R #8's medical record, no date, revealed R #8 was not discharged from the facility on 01/31/26. F. Record review of hospital discharge instructions, dated [DATE], revealed R #8 was discharged from the hospital at 5:21 AM. G. On 04/01/26 at 2:38 PM, during an interview with the local ER Nurse (ERN), she stated that R #8 was discharged on 01/31/26 at approximately 5:30 AM. She stated that she called the facility numerous times and was unable to reach anyone. The ERN stated that R #8 was very disoriented. The ER didn't have enough staff to sit with R #8 1-on-1. The ERN stated when she finally reached the Administrator, she was told the facility would send staff to pick R #8 up as soon as possible. The ERN stated that R #8 was picked up by facility staff at approximately 8:30 AM on 01/31/26. R #43H. Record review of R #43's admission record, no date, revealed the following: 1. An admission date of 11/25/25. 2. R #43 had the following diagnosis: a. Alzheimer's disease, unspecified. b. Dementia, unspecified severity with other behavioral disturbance. c. Bipolar disorder, current episode depressed, severe with psychotic features (a serious psychiatric emergency characterized by severe depression combined with hallucinations or delusions). d. Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). e. Anxiety disorder (mental health conditions characterized by excessive, uncontrollable fear or worry that interferes with daily life). I. Record review of R #43's admission MDS, dated [DATE], revealed the following:1. Staff documented a BIMS score of 2.2. Staff documented R #43 is frequently incontinent of urine.3. Staff documented R #43 is always incontinent of bowel movements.2. Staff documented that R #43 requires substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for toileting hygiene. J. Record review of R #43's nursing progress notes revealed the following: a. On 01/29/26 at 7:44 PM, R #43 was sent to the ER for evaluation after a fall. b. On 01/30/26 at 9:30 AM, R #43 returned from the hospital. K. Record review of R #43's medical record, no date, revealed R #43 was not discharged from the facility on 01/29/26. L. Record review of hospital discharge instructions, dated [DATE], revealed R #43 was discharged from the hospital at 10:16 PM. M. On 03/26/26 at 3:31 PM, during an interview, the Administrator confirmed that R #43 was transferred to the hospital on [DATE]. The Administrator stated that she was notified that R #43 was discharged on 01/29/26 at approximately 10:30 PM. The Administrator stated the facility always attempts to pick up residents as soon as possible after discharge from the hospital. The Administrator stated that the facility does not have 24-hour transportation. The Administrator confirmed that R #43 was not picked up from the hospital until 01/30/26 at approximately 9:00 AM. The Administrator stated that the hospital is responsible for the residents until the facility can pick them up, even after they have been discharged from the hospital. N. On 03/26/26 at 4:04 PM, during an interview with the ERN, she stated that R #43 arrived at the hospital on [DATE] at approximately 7:30 PM. She stated that R #43 was discharged at approximately 10:16 PM on 01/29/26. ERN stated she made several calls to the facility. The calls went to voicemail. The ERN stated that she was finally able to reach the Administrator on the Administrator's cell phone. The Administrator assured the ERN facility staff was on their way to pick R #43 up. The ERN stated that she talked to the Administrator approximately 3 more times after the initial contact. The ERN stated the Administrator stopped answering calls. Facility staff did not pick R #43 up until 01/30/26 at approximately 9:00 AM. The ERN stated that through the 11 hour wait, R #43 was confused and was trying to get up out of bed. The ERN stated that R #43 became more confused as the night progressed.

Based on observation, interview, and record review, the facility failed to keep residents free from involuntary seclusion (separation of a resident or patient from others, or from their room, against their will or the will of their legal representative) for 1 (R #7) of 1 (R #7) residents reviewed for physical restraints, when they failed to implement and document the following:1. The clinical criteria (rules or standards on which a decision or judgment is made to determine medical necessity) R #7 met for placement in the secured/locked area by the resident's physician along with information provided by members of the interdisciplinary team. 2. Whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect R #7 and assure her health and safety. 3. The IDT consideration of the impact and/or reaction of R #7, if any, regarding placement on the unit.4. Ongoing review and revision of R #7's care plan as necessary, including whether she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of R #7. These deficient practices could likely cause anxiety and depression due to residents being placed in an environment that restricts their freedom of movement throughout the facility. The findings are:A. On 03/24/26 at 4:38 PM, during an observation of the secured unit, it revealed R #7 was in the secured unit. B. Record review of R #7's admission record, no date, revealed an admission date of 06/25/24. C. Record review of R #7's Consent for Placement in Dementia Secure Unit form, revealed that R #7 signed on 02/13/26. D. Record review of R #7's Electronic Medical Record (EMR) revealed: 1. The physician and IDT did not document clinical rationale for R #7's placement in the secure unit. 2. Staff did not document that placement in secured unit was the least restrictive approach for R #7. 3. Staff did not document that the IDT assessed the impact or reaction of R #7 being placed in secured unit. 4. Staff did not document the ongoing review to indicate whether R #7 continued to meet the criteria to remain in the secured unit.5. Staff did not document a diagnosis of dementia. E. Record review or R #7's quarterly MDS, dated [DATE], revealed a BIMS score of 6. F. Record review of R #7's NM Elopement Risk Evaluation, dated 02/06/26, revealed R #7 is no risk of elopement. G. On 03/26/26 at 5:27 PM, during an interview, R #7 stated she did not know why she was in the secured unit. H. On 03/26/26 at 10:34 AM, during an interview with the SSD, she confirmed that the required documentation for placement in the secured unit was not completed. I. Record review of the facility's Secure Unit Policy, revision date July 2024, revealed that the criteria for the secured unit is a cognitive deficit and a high risk for elopement.

Based on observation and interview, the facility failed to provide an ongoing program of activities designed to meet the interests of the residents for 2 (R #8 and R #43) of 3 (R #8, R #43, and R #54) residents reviewed for activities, when staff failed to provide meaningful activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meet their interests, they are likely to experience an increase in boredom, isolation, and depression. The findings are:R #8A. On 03/24/26 at 10:17 AM, during an interview, R #8's Family Member stated he never sees residents doing any activities in the Secure Unit. B. On 03/24/26 at 3:08 PM, during an observation of the secured unit, there is an activity calendar posted in the commons area on the wall by the television. It was observed that the activity calendars are hanging in the resident's rooms also. C. On 03/24/26 at 2:18 PM, during an interview, CNA #8 stated activities are not scheduled in the Secured Unit. CNA #8 stated that the activities calendar posted was for the Main Unit. CNA #8 stated that at one time there was a table in the tv area for activities. CNA's were able to put out coloring sheets and other activities for the residents. CNA #8 stated that the table was removed about two months ago. She did not know why. R #43 D. On 03/24/26 at 2:43 PM, during an interview with R #43's Guardian, she stated the following:1. She had not observed any activities in the Secured Unit. 2. R #43 has had a decline in health. 3. R #43 was unable to get out of bed. 4. She did not think staff were providing one-on-one visits or activities for R #43. E. On 03/25/26 at 4:51 PM, during an interview, the Activities Director (AD) confirmed the following:1. The activities calendar posted in the Secured Unit was not for the Secured Unit. It was for residents in the main unit. 2. He did not have an activities calendar for the Secured Unit. 3. He does random non-scheduled activities throughout the day for the Secured Unit. 4. He did not have an activity aide until recently (AD did not give a specific time frame). 5. He had not been able to provide scheduled activities in the Secured Unit. 6. He could not leave things out for the residents in the Secured Unit because they disappear. 7. He currently does not have a consistent activity program for the Secured Unit.

Based on record review and interview, the facility failed to provide quality of care for 1 (R #3) of 1 (R #3) residents reviewed for hospice services when staff failed to: 1. Ensure care coordination occurred between hospice staff and facility staff.2. Ensure R #3's visit notes from hospice were in her medical record. 3. Ensure R #3's orders from the hospice provider were in her medical record. These deficient practices are likely to result in staff not being aware of residents' care needs, staff not providing ordered medications, and worsening of the residents' medical conditions. The findings are:A. Record review of R #3's admission Record, no date, revealed R #3 was admitted to the facility on [DATE]. B. On 03/24/26 at 2:06 PM, during an interview, R #3's Family Member (FM) stated the following:1. R #3 had fallen on 03/17/26.2. The hospice provider had ordered R #3 scheduled pain medication for hip pain.3. R #3 was diagnosed with pneumonia (a serious lung infection caused by bacteria, viruses, or fungi) and was started on antibiotics (powerful medications that treat bacterial infections by killing bacteria or preventing them from reproducing) on 03/19/26. C. Record review of R #3's hospice physician's orders, dated 03/19/26, revealed the following: 1. An order for doxycycline (antibiotic medication to treat infections) 100 mg twice a day for seven (7) days for upper respiratory infection (URI, a contagious viral or bacterial illness affecting the nose, throat, and sinuses, commonly causing cough, congestion, sore throat, and low-grade fever). 2. An order for prednisone (a potent synthetic corticosteroid used to treat severe inflammation, allergies, autoimmune diseases (like lupus and rheumatoid arthritis), asthma, and to prevent organ rejection) 20 mg daily for five (5) days for upper respiratory infection. 3. An order for acetaminophen (medication to treat mild-to-moderate pain and reduce fevers) 500 mg every eight (8) hours as needed for fever. D. Record review of R #3's physician's orders revealed the following: Record review of R #3's physician's orders revealed the following: 1. An order dated 03/19/26, for doxycycline 100 mg every 12 hours for infection (incorrect diagnosis, hospice order was for URI) until 03/28/26 at 11:59 PM (Order conflicts with the hospice order finding C. Seven days from 03/19/26 would have ended the morning of 03/26/26). 2. An order dated 03/19/26, for prednisone 5 mg (incorrect dose, hospice order was for 20 mg) once a day for pain (incorrect diagnosis, hospice order was for URI) with no end date (Order conflicts with the hospice order finding C. Hospice physicians ordered 20 mg for 5 days). 3. An order dated 03/19/26, for acetaminophen 500 mg every eight (8) hours as needed for pain (Order conflicts with the hospice order finding C. The hospice diagnosis was for fever). E. Record review of R #3's nursing progress notes revealed the following: 1. On 03/19/26 staff documented that R #3 had an elevated temperature of 100.8 degrees and had been looking ill since the morning. The hospice nurse assessed R #3 and medications were ordered. Acetaminophen 500 mg was administered to lower R #3's temperature. 2. On 03/23/26 staff documented hospice staff reported R #3 had pain to her left hip. R #3's hip appeared to be swollen. R #3's FM did not want diagnostic testing for R #3. R #3 was being treated for pneumonia. The hospice nurse was going to discuss R #3's pain regimen with the hospice provider to start R #3 on scheduled pain medication. F. Record review of R #3's medical record, no date, revealed no documentation of the following:1. Hospice nurse's assessment of R #3 on 03/19/262. Medication orders from the hospice provider on 03/19/26. G. Record review of R #3's hospice note, dated 03/23/26, revealed the following: 1. R #3 had moderate hip pain. 2. Hospice nurse discussed treatment options with R #3's FM. 3. R #3's FM decided on pain management for R #3.4. R #3 was on antibiotics for pneumonia. 5. R #3 had a productive cough. 6. R #3 had crackles (a lung sound often heard through a stethoscope as clicking or rattling, typically signify underlying conditions like pneumonia, heart failure (pulmonary edema), or chronic lung diseases) in the base (lower part) of her left lung. H. On 03/25/26 at 2:32 PM, during an interview, Hospice Nurse (HN) #16 stated the following: 1. Another hospice nurse assessed R #3 on 03/19/26. R #3 had crackles in her lower lungs and pain in her hip. 2. She assessed R #3 on 03/23/26. R #3 had pain in her hip. R #3's FM did not want diagnostic testing but wanted to focus on pain management. 3. She said that she delivered Toradol (a powerful, non-opioid, non-steroidal anti-inflammatory drug (NSAID) used for short-term (maximum 5 days) treatment of moderate-to-severe acute pain) pills and an order from the hospice provider for Toradol to the DON on 03/24/26. 4. She stated that the DON signed a form when she delivered the Toradol. I. On 03/25/26 at 3:14 PM, during an interview, the DON stated the following:1. HN #16 dropped off medication with her on 03/24/26.2. HN #16 did not give her an order for the medication that she delivered on 03/24/26.3. She was not sure what medication HN #16 gave her or what resident the medication was for. 4. She thought the medications HN #16 gave her was a refill for a resident and didn't require a new order.5. She gave the medication to RN #16 to log in the controlled drug log. J. On 03/25/26 at 3:26 PM, during an interview, RN #16 stated the following: 1. He was the nurse working with R #3 on 03/23/26. 2. The HN #16 did not tell him on 03/23/26 that the hospice provider was going to order scheduled pain medication for R #3. 3. The HN #16 did not provide him with a visit note or any hospice orders for R #3 on 03/23/26.4. The DON gave him a bottle of Tramadol (a prescription-only synthetic opioid analgesic used to treat moderate to severe pain in adults) [This contradicts HN #16 statement that she gave Toradol to the DON] 50 mg on 03/24/26 for R #3. 5. The DON did not give him a physician's order for Tramadol 50 mg for R #3. 6. The label on the bottle of Tramadol 50 mg had directions to administer one tablet to R #3 every eight (8) hours as needed for pain (This contradicts HN #16 statement that the medication was ordered as a scheduled medication). 7. He confirmed that R #3 did not have an order in her medical record for Tramadol 50 mg. K. On 03/27/26 at 10:03 AM, during an interview, the Medical Records Clerk (MRC) stated the following:1. Hospice staff were expected to complete a note after each visit. They should leave a copy with the nurse and a copy for her to upload in the medical record.2. R #3's medical record did not have any notes or orders from hospice staff on 03/19/26.3. R #3's medical record did not have any hospice orders from 03/23/26 or 03/24/26.4. She did not have any documentation from hospice staff that needed to be uploaded into R #3's medical record. L. On 03/27/26 at 11:09 AM, during an interview, the DON confirmed the following: 1. Hospice staff were expected to communicate with the nurse caring for residents regarding their assessment of residents and any orders that needed to be added for residents.2. Hospice staff were expected to provide documentation of hospice physician's orders and visit notes to the nurse taking care of the resident. They should also give another copy of the order to the MRC to scan into the resident's medical record. 3. Facility staff were expected to review hospice visit notes and enter any orders that were received from the hospice staff. 4. The MRC was expected to scan all hospice visit notes and hospice orders into the residents' medical records. 5. She was unable to find documentation of the visit note from the hospice nurse who assessed R #3 on 03/19/26. 6. Facility staff were expected to verify there was an order from the hospice provider for any medication that was received from hospice staff. They should ensure the orders were accurately entered into the resident's medical record.

Based on record review and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #3) of 3 (R #2, R #3, and R #14) residents reviewed for respiratory care when the staff failed to:1. Order medications for the correct dose and the correct length of time for R #3's respiratory infection. 2. Assess vital signs and respiratory status after R #3 was diagnosed with an upper respiratory infection.These deficient practices are likely to result in staff not being aware of residents' respiratory status and worsening of their condition. The findings are: A. Record review of R #3's admission Record, no date, revealed R #3 was admitted to the facility on [DATE]. B. On 03/24/26 at 2:06 PM, during an interview, R #3's Family Member (FM) stated that R #3 was diagnosed with pneumonia (a serious lung infection caused by bacteria, viruses, or fungi) and was started on antibiotics (powerful medications that treat bacterial infections by killing bacteria or preventing them from reproducing) on 03/19/26. C. Record review of R #3's hospice physician's orders, dated 03/19/26, revealed the following: 1. An order for doxycycline (antibiotic medication to treat infections) 100 mg twice a day for seven (7) days for upper respiratory infection (URI, a contagious viral or bacterial illness affecting the nose, throat, and sinuses, commonly causing cough, congestion, sore throat, and low-grade fever). 2. An order for prednisone (a potent synthetic corticosteroid used to treat severe inflammation, allergies, autoimmune diseases, asthma, and to prevent organ rejection) 20 mg daily for five (5) days for upper respiratory infection. 3. An order for acetaminophen (medication to treat mild-to-moderate pain and reduce fevers) 500 mg every eight (8) hours as needed for fever. D. Record review of R #3's physician's orders revealed the following: 1. An order dated 03/19/26, for doxycycline 100 mg every 12 hours for infection until 03/28/26 at 11:59 PM (Order conflicts with the hospice order finding C. Seven days from 03/19/26 would have ended the morning of 03/26/26). 2. An order dated 03/19/26, for prednisone 5 mg once a day for pain with no end date (Order conflicts with the hospice order finding C. Hospice physicians ordered 20 mg for 5 days). 3. An order dated 03/19/26, for acetaminophen 500 mg every eight (8) hours as needed for pain. (Order conflicts with the hospice order finding C. The hospice diagnosis was for fever.) E. Record review of R #3's MAR, dated March 2026, revealed the following: 1. Staff documented doxycycline 100 mg was administered on the following dates and times: a. 03/19/26 at 8:00 PM b. 03/20/26 at 8:00 AM and 8:00 PM. c. 03/21/26 at 8:00 AM and 8:00 PM. d. 03/22/26 at 8:00 AM and 8:00 PM. e. 03/23/26 at 8:00 AM and 8:00 PM. f. 03/24/26 at 8:00 AM and 8:00 PM. g. 03/25/26 at 8:00 AM and 8:00 PM. h. 03/26/26 at 8:00 AM and 8:00 PM. i. 03/27/26 at 8:00 AM and 8:00 PM. j. 03/28/26 at 8:00 AM and 8:00 PM.2. Staff documented prednisone 5 mg was administered on the following dates and times: a. 03/20/26 at 8:00 AM b. 03/21/26 at 8:00 AM c. 03/22/26 at 8:00 AM d. 03/23/26 at 8:00 AM e. 03/24/26 at 8:00 AM f. 03/25/26 at 8:00 AM g. 03/26/26 at 8:00 AM h. 03/27/26 at 8:00 AM i. 03/28/26 at 8:00 AM j. 03/29/26 at 8:00 AM k. 03/30/26 at 8:00 AM 3. Staff documented acetaminophen 500 mg was administered on the following dates: a. 03/20/26 b. 03/23/26 F. Record review of R #3's nursing progress notes revealed the following: 1. On 03/19/26 at 3:14 PM, staff documented that R #3 had an elevated temperature of 100.8* F. She had been looking ill since the morning. The hospice nurse assessed R #3 and medications were ordered. Acetaminophen 500 mg was administered to lower R #3's temperature. 2. On 03/19/26 at 3:28 PM, staff documented that R #3's temperature was rechecked and was 98.1* F. Staff would continue to closely monitor R #3. 3. On 03/23/26 staff documented that R #3 was being treated for pneumonia. G. Record review of R #3's hospice note, dated 03/23/26, revealed the following: 1. R #3 was on antibiotics for pneumonia. 2. R #3 had a productive cough. 3. R #3 had crackles (a lung sound often heard through a stethoscope as clicking or rattling, typically signify underlying conditions like pneumonia, heart failure (pulmonary edema), or chronic lung diseases) in the base (lower part) of her left lung. H. Record review of R #3's vital sign assessments, dated 03/01/26 to 03/30/26, revealed the following:1. Staff did not document R #3's blood pressure, temperature, or pulse between 03/20/26 and 03/24/26.2. Staff did not document R #3's blood pressure, temperature, or pulse 3 between 03/26/26 and 03/30/26. I. Record review of R #3's medical record, no date, revealed facility staff did not document a respiratory assessment (evaluates a patient's breathing and lung function through a systematic approach: inspection, palpation, percussion, and auscultation. Key steps include observing breathing effort and rate, checking oxygen saturation, evaluating chest symmetry, and listening for lung sounds) after medications were ordered for R #3 on 03/19/26 for an upper respiratory infection. J. On 03/27/26 at 11:09 AM, during an interview, the DON confirmed the following: 1. R #3 was receiving doxycycline and prednisone for an upper respiratory infection since 03/19/26. 2. Facility staff (staff that worked at the nursing home) did not document assessing R #3's respiratory status between 03/19/26 and 03/27/26. 3. Facility staff were expected to assess residents' respiratory status including lung sounds and breathing effort at least every shift for residents who had a diagnosis or a suspected diagnosis of a respiratory infection or pneumonia. 4. Facility staff were expected to document the respiratory assessment in the residents' progress notes. 5. Facility staff documented that R #3 had a fever on 03/19/26 and administered acetaminophen for the fever.6. Facility staff did not document R #3's temperature between 03/20/26 and 03/24/26 or between 03/26/26 and 03/27/26.7. Facility staff were expected to assess all of the residents' vital signs at least every shift when they had an infection. K. On 03/31/26 at 11:18 AM, during an interview, the DON confirmed the following: 1. The hospice provider ordered doxycycline 100 mg to be administered to R #3 twice a day for 7 days, totaling 14 doses. 2. R #3 received 19 doses of doxycycline 100 mg. Five doses more than hospice provider had ordered. 3. The hospice provider ordered prednisone 20 mg to be administered to R #3 once a day for 5 days, totaling 5 doses. 4. The order in R #3's medical record was for prednisone 5 mg once a day and had no end date. 5. The order for prednisone 5 mg in R #3's medical record did not match the order for prednisone 20 mg that the hospice provider had ordered. 6. R #3 received 11 doses of prednisone 5 mg. R #3 should have received 5 doses of prednisone 20 mg.

Based on record review and interview, the facility failed to effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 1 (R #63) of 1 (R #63) residents reviewed for pain, when the facility failed to:Administer scheduled pain medications.Offer PRN pain medication. This deficient practice could likely result in residents experiencing unnecessary pain causing residents to experience a decline in physical and emotional health. The findings are:A. Record review of R #63's admission Record (no date) revealed the following:1. R #63 was admitted to the facility on [DATE]. 2. R #63 diagnoses included: a. Post-polio syndrome (condition that affects some individuals who have previously had polio, leading to muscle weakness, fatigue, joint pain and other symptoms many years after the initial infection). b. Polyneuropathy (condition in which multiple peripheral nerves throughout the body are damaged disrupting communication between the brain and the rest of the body leading to pain, numbness and weakness). c. Other chronic pain (pain that lasts over three months and can affect several parts of the body). B. On 03/24/26 at 10:06 AM, during an interview, R #63 stated the following:1. She has generalized pain (diffuse, persistent or recurring pain that can involve muscles, joints and soft tissue throughout the body) that comes and goes. 2. She had to go to the emergency room (ER) three days ago due to uncontrolled nerve pain (also known as neuropathic pain occurs due to damage or dysfunction of the nerves that send pain signals to the brain). 3. She was prescribed hydrocodone (narcotic medication used to treat severe pain) and another medication (R #63 was unsure of name of medication). 4. She had not received the other medication. 5. She was concerned that the pain would return. 6. She thought she was supposed to see the facility provider yesterday (03/23/26) to follow up on her pain and medications.7. She had not seen a provider as of that time. C. Record review of R #63's medical record revealed the following: 1. After hours call note, dated 03/21/26, revealed at approximately 1439 (2:39 PM) I received a request for this patient (R #63) to go to the emergency room. The patient has complained of generalized pain and states that she requires an ER visit when this happens. Other solutions in house were offered and the patient refused. She was sent to the emergency room. 2. R #63 was sent to the local ER on [DATE] due to uncontrolled pain. 3. R #63 was discharged from the ER and back at the facility at 9:30 PM. 4. The ER diagnosed R #63 with neuropathic pain. 5. The ER prescribed the following medications: a. Hydrocodone-Acetaminophen 5-325 mg oral tablet (prescription combination medication used to relieve moderate to severe pain, combining a narcotic analgesic with over-the-counter analgesic for enhanced pain control.), take 1 tablet by mouth every eight to twelve hours for three days as needed for pain. b. Amitriptyline (antidepressant medication primarily used to treat major depression and a variety of pain syndromes such as neuropathic pain) 25 mg oral tablet, take half-tablet by mouth at bedtime as needed for insomnia (common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and not being able to return to sleep). D. Record review of R #63's physician's orders revealed the following: 1. Order start date 03/21/26, Order end date 03/24/26: amitriptyline HCl oral tablet 25 mg, give 1 tablet by mouth every twenty-four hours as needed for insomnia. 2. An order dated 03/24/26: amitriptyline HCl oral tablet 10 mg, give 1 tablet by at bedtime for neuropathic pain for 14 days. 3. An order dated 03/21/26: hydrocodone-acetaminophen oral tablet 5-325 mg, give 1 tablet by mouth every 8 hours as needed for pain until 03/25/2026. E. On 03/25/26 at 10:35 AM, during an interview, R #63 stated the following: 1. She finally saw the facility provider on 03/24/26. 2. The facility provider prescribed the same medication the ER did for two weeks, and she was told that it should help control the pain fluctuations. 3. The provider told her that she would not have to ask for the medication. She would get it every night. 4. She did not receive the medication on 03/24/26. 5. She confirmed the medication that the provider ordered for her was amitriptyline but stated she could not remember the name until it was mentioned to her. 6. Her pain could be at zero then jump to eight or nine (pain scale where zero is no pain and 10 is the most severe pain an individual has had). F. Record review of R #63's MAR for March 2026 revealed the following: 1. R #63 was not given any doses of her amitriptyline 25 mg PRN medication. 2. R #63 did not receive any doses of her amitriptyline 10 mg bedtime dose until 03/26/26 (two days after seeing the facility provider). G. On 03/25/26 at 4:19 PM, during an interview with the DON and LPN #3 the following was confirmed: 1. R #63 did not receive amitriptyline 25 mg PRN. 2. R #63 did not receive amitriptyline 10 mg at bedtime because the medication had not been received from the pharmacy yet.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #3 and R #7) of 2 (R #3 and R #7) residents reviewed for accuracy of documentation, when staff failed to: 1. Ensure R #3's medications were ordered for the correct diagnoses or symptom. 2. Clarify what type of respiratory illness R #3 was being treated for. 3. Ensure that R #7's care plan documented accurate diagnosis.These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are: R #3 A. Record review of R #3's admission Record, no date, revealed the following: 1. R #3 was admitted to the facility on [DATE]. 2. R #3's diagnoses did not include a respiratory illness. B. On 03/24/26 at 2:06 PM, during an interview, R #3's Family Member (FM) stated that R #3 was diagnosed with pneumonia (a serious lung infection caused by bacteria, viruses, or fungi) and was started on antibiotics (powerful medications that treat bacterial infections by killing bacteria or preventing them from reproducing) on 03/19/26. C. Record review of R #3's hospice physician's orders, dated 03/19/26, revealed the following: 1. An order for doxycycline (antibiotic medication to treat infections) 100 mg twice a day for seven (7) days for upper respiratory infection (URI, a contagious viral or bacterial illness affecting the nose, throat, and sinuses, commonly causing cough, congestion, sore throat, and low-grade fever). 2. An order for prednisone (a potent synthetic corticosteroid used to treat severe inflammation, allergies, autoimmune diseases (like lupus and rheumatoid arthritis), asthma, and to prevent organ rejection) 20 mg daily for five (5) days for upper respiratory infection. 3. An order for acetaminophen (medication to treat mild-to-moderate pain and reduce fevers) 500 mg every eight (8) hours as needed for fever. D. Record review of R #3's physician's orders revealed the following: 1. An order dated 03/19/26, for doxycycline 100 mg every 12 hours for infection (incorrect diagnosis, hospice order was for URI) until 03/28/26 at 11:59 PM (Order conflicts with the hospice order finding C. Seven days from 03/19/26 would have ended the morning of 03/26/26). 2. An order dated 03/19/26, for prednisone 5 mg (incorrect dose, hospice order was for 20 mg) once a day for pain (incorrect diagnosis, hospice order was for URI) with no end date (Order conflicts with the hospice order finding C. Hospice physicians ordered 20 mg for 5 days). 3. An order dated 03/19/26, for acetaminophen 500 mg every eight (8) hours as needed for pain (Order conflicts with the hospice order finding C. The hospice diagnosis was for fever). E. Record review of R #3's hospice progress note, dated 03/23/26, revealed the following: 1. R #3 was on antibiotics for pneumonia. 2. R #3 had a productive cough. 3. R #3 had crackles (a lung sound often heard through a stethoscope as clicking or rattling, typically signify underlying conditions like pneumonia, heart failure (pulmonary edema), or chronic lung diseases) in the base (lower part) of her left lung. F. On 03/27/26 at 11:09 AM, during an interview, the DON confirmed the following: 1. R #3's hospice order for doxycycline 100 mg was for a diagnosis of URI. 2. Staff documented the order for doxycycline 100 mg was for a diagnosis of infection. 3. R #3's hospice order for prednisone 20 mg was for a diagnosis of URI. 4. Staff documented the order for prednisone 5 mg was for a diagnosis of pain. 5. R #3's hospice order for acetaminophen 500 mg was for fever. 6. Staff documented the order for acetaminophen 500 mg was for pain. 7. Staff were expected to ensure orders were entered in the medical record for the correct dose, the correct duration, and the correct diagnosis. 8. R #3's medical record was not revised to include a respiratory illness. 9. Staff were expected to update residents' diagnoses when a resident had a new diagnosis. R #7 G. Record review of R #7's care plan, dated 07/03/24, revealed that R #7 had bladder incontinence related to neurogenic disorder. H. Record review of R #7's medical record, no date, revealed R #7 staff did not document R #7 had a diagnosis of neurogenic disorder. I. On 03/27/26 at 9:25 AM, during an interview, the MDS Coordinator (MDSC) confirmed that R #7 did not have a diagnosis of neurogenic disorder. The MDSC stated that she must have entered the diagnosis of neurogenic disorder by mistake.

Based on record reviews, observation and interviews, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds ( damage which results from unrelieved pressure on the body) for 2 (R #s 2 and 4) of 4 (R #s 1, 2, 3 and 4) residents reviewed for wounds when staff failed to: Follow Physician treatment orders for R #2 and 4.Document and monitor wound progress (that includes measurements; to track effectiveness of wound care treatments and to prevent the progression of pressure ulcers) for R #2. These deficient practices likely resulted in the worsening of R #2's and R #4's pressure wounds. The findings are: R #2: A. Record review of R #2's admission assessment revealed R #2 was admitted into the facility on [DATE] from the local hospital with stage 2 (some of the outer surface of the skin is damaged) pressure ulcer to his coccyx (tailbone) measuring 2.3x4.2 centimeters. B. Record review of R #2's face sheet medical diagnoses revealed the following (including but not limited to): -Type 2 diabetes mellitus (condition when the body cannot use insulin correctly and sugar build up in the blood), onset: 09/03/25. -Pressure ulcer (Bedsores are injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) of other site, unstageable (Unstageable pressure ulcers are wounds characterized by obscured depth due to the presence of necrotic tissue or eschar), onset: 09/03/25. -Muscle wasting and atrophy (loss of muscle mass), not elsewhere classified, multiple sites, onset 09/03/25. -Unspecified severe protein-calorie malnutrition (as a condition characterized by a weight loss of more than 10% within the past 6 months), onset 08/25/25. C. Record review of R #2's nursing admission evaluation dated 09/04/25 revealed: Integrity (part of admission documentation that verifies skin condition present on admission to the facility R #2 has a sacral pressure 11 (sacral pressure sore stage 2, when clarified by Registered Nurse (RN) #2 2.3 cm (centimeter) x 4.2 cm. One-person physical assist for bed mobility, dressing and personal hygiene. Two person assist with transfers, Toilet use, bathing. Wheelchair use for mobility. Full weight bearing D. Record review of R #2's weekly wound report (tracking system the facility utilizes to tract and trend all residents skin concerns) dated 09/03/25 through 10/15/25 revealed the following: - 09/03/25 - 09/10/25 = Date last assessed 09/05/25 Coccyx, Deep Tissue Pressure Injury, Length (L) = 6.00, Width (W) = 6.60, Depth (D) = 0.00, Deep Maroon=75%, Bright Beefy Red=25%. - 09/11/25 - 09/17/25 = No weekly skin assessment documentation found. - 09/17/25 - 09/24/25 = Date last assessed: 09/23/25 Coccyx, Unstageable (wound with full thickness tissue loss), L = 7.00, W = 7.00, D = N/A, Deep Maroon=25%, Bright Beefy Red=50%, slough (dead tissue that separates from the living tissue) white fibrinous (layer of tissue on its surface) =25%, Scant Exudate (fluid that drains from the wound) - serosanguineous (fluid that contains both clear water fluid and blood). - 09/24/25 - 10/01/25 = last assessed: 10/01/25 Coccyx, Unstageable, L = 7.00, W = 7.00, D = N/A, Bright Beefy Red=75%, slough white fibrinous=25%, Erythema (redness of the skin), Scant Exudate - serosanguineous. - 10/01/25 - 10/08/25 = No weekly skin assessment documentation found. - 10/08/25 - 10/15/25 = Date last assessed: 10/10/25 Coccyx, Unstageable, L = 7.00, W = 2.00, D = N/A, slough white fibrinous=100%, Erythema, moderate Exudate - serosanguineous. E. Record review of Care plan dated 09/03/25 revealed: [name of R #2] has 1 pressure ulcer or potential for pressure ulcer development r/t (related to) immobility. Approach- Administer treatments as ordered and monitor for effectiveness. Educate [name of R #2]/family/caregivers as to causes of skin breakdown, including, transfer/positioning/requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Inform [name of R #2]/family/caregivers of any new area of skin breakdown. The care plan did not identify any order for pressure relieving mattress, wheelchair cushion or requirement for staff to reposition the resident. F. Record review of R #2's physician orders revealed the - 09-05-25: stage 2 Pressure ulcer (localized damage to the skin typically occurs over bony prominent area) to coccyx (tailbone area): cleanse with wound cleanser or NS (Normal following: Saline, a solution used to clean wounds), pat dry, apply collagen (a type of special dressing) to wound bed, cover with bordered gauze QD (once daily) and PRN (as needed) Discontinued 09/06/25 - 09-06-25: SKIN TRAUMA (damage to skin and underlying tissue fur to mechanical force) to coccyx: cleanse with wound cleanser or NS, pat dry, apply collagen to wound bed, cover with bordered gauze QD and PRN Discontinued 09/26/25 - 09-24-25: Moisture barrier cream to peri area (part of the body that involves the genitals and anal area) and coccyx - 09-26-25: Unstageable to coccyx: cleanse with wound cleanser or ns, pat dry, apply calcium alginate (a topical medication) to wound bed, cover with bordered gauze qd (every day) and PRN Discontinue 10/10/25 - 10-06-25: Refer to wound care clinic to eval and treat as indicated - 10-10-25: Unstageable to coccyx: cleanse with wound cleanser or ns, pat dry, apply medi honey (a topical medication), apply calcium alginate to wound bed, cover with bordered gauze qd and PRN everyday shift AND as needed every day shift AND as needed every day shift AND as needed every day shift AND as needed. Wound Clinic Appointment 10-15-25. G. Record review of Treatment Administration Records revealed orders: Cleanse with wound cleanser or ns, pat dry, apply collagen to wound bed, cover with bordered gauze qd (each day) and PRN (as needed) every day shift dated 09/06/25 to 09/26/25 did not identify wound care was provided 09/15/25, 09/16/25, 09/17/25 and 09/24/25. Moisture barrier cream to peri area and coccyx every shift dated 09/04/25 to 09/24/25 was documented as conducted twice daily. H. On 10/14/25 at 2:51 PM, during an interview with Licensed Practical Nurse (LPN) #2, she stated R #2 wound is getting worse everyday (not improving). She confirmed that the previous wound treatment nurse was providing wound care treatments without an order from a provider (using wound treatment not ordered by the physician). I. On 11/18/25 at 12:57 pm during an interview with DON #2 she stated that on 09/25/25 LPN # 1 did a dressing change for R #2 that was not appropriate she put a dressing on that was not according to the order. J. Record review of corrective action memo dated 09/25/25 revealed: on 09/23/25 during wound rounds it was noted that [initial for R #2]'s dressing was not the ordered dressing for the wound. [initial for R #2] informed nurse that his dressing had been changed earlier and was told by [Initial of LPN #1] that she was going to change his dressing to one that only had to be changed every 3 days. This nurse removed dressing that had [Initial of LPN #1] initials dated 09/23/25 and observed a declination [worsening] in the state of the wound. Which presented 20% slough, 20% DTI and 60% beefy red tissue. K. On 10/15/25 at 11:10 am during an interview with Family (FM) #1, she stated that R #2 has a wound to his bottom, and LPN #2 told them that the wound is really bad and suggested we take him to the hospital. R #2 was admitted to the facility with the wound on his bottom it was the size of a quarter and it was getting bigger and blue all around the open sore and at the time he went to the hospital it was now the size of a business card. R #2 was transferred to [name of hospital in another city] the wound care team saw R #2 on 10/14/25 and they were told that they wanted to take all the dead skin off the wound. He complained of a lot of pain to his bottom. FM #1 further stated that the Treatment Nurse at the facility told her (FM#1) that the dressing orders had been changed and that they would not have to change the dressing as often and it would be done every 3 days so changing it less often would help with R #2 not having so much pain when it was not changed. L. Record review of R #2'sMinimum Data Set (MDS) assessment dated [DATE] revealed that R #2 is partial/moderate assistance (helper does less than half the effort) with Activities of Daily Living (ADL's dressing, transfers, bathing). M. On 10/15/25 at 2:52 during an interview with Nurse Practitioner, she stated that when she saw the wound it was unstageable, redness around the wound, small wound opening and she relied on treatment nurse's judgement to give an update on a regular basis. She stated she would expect that her orders were followed and that she would be notified of changes to the wound. NP confirmed that she had not been notified of R #2's worsening wound and would have liked to be notified as soon as there was any change to the wound, N. Record review of R #2's nursing note dated 10/12/25 revealed R #2 was discharged from facility to the hospital per family request due to R #2's unstageable wound. O. Record review of [name of local hospital] admission assessment dated [DATE] revealed: large Sacral (tailbone) decubitus ulcer, stage III or IV (three or four) Patient (R #2] was noted to have worsening of the sacral decubitus ulcer.When he [R #2] left the hospital in September, the wound was documented as stage II and the size of a quarter. R #4 P. Record review of R #4' face sheet revealed admission date of 01/29/24. Q. Record review of care plan initiated 10/29/24 reveals [name of R #4] has pressure ulcer or potential for pressure ulcer development r/t (related to) Hx (history) of ulcers. No additional updates to the care plan related to wound or treatment interventions as of 11/18/25. R. Record review of progress note dated 10/23/25 revealed Redness coccyx. S. Record review of R #4 progress note dated 11/04/25 revealed pressure ulcer stage 3 (full thickness tissue loss) wound that is measured at 1cm x 1cm x 0.1 cm located on the upper coccyx. T. Record review of Treatment Administration Record dated 09/29/25 through 10/16/25 revealed Stage 2 to coccyx, Cleanse with NS (normal saline), pat dry, apply duoderm q (every) 3 days and prn (as needed) every day shift every 3 days. U. Record review of R #4's provider orders dated 11/05/25 revealed an order remove the dressing, clean with normal saline or wound wash, place collagen sheet over the wound then cover the wound with dry dressing. Dressing is to be changed daily and as needed. V. Record review of R #4's Treatment Administration Record (TAR) revealed order Wounds care to stage 2 PI (pressure injury) to coccyx: Cleanse with wound cleanser or NS, pat dry, apply collagen sheet, cover with dry dressing. Change daily and PRN for dislodgment and soiling. Every day shift dated 11/05/25 to 11/19/25. Wound care was documented as being completed, 11/05/25, 11/07/25, 11/10/25 and 11/12/25 through 11/19/25. W. On 11/18/25 at 11:50 am during an observation of R #4's wound care treatment and an interview with DON #2, she confirmed the date on the dressing was 11/12/25, she confirmed the dressing was 6 days old and this would indicate R #4 had not been provided wound care since 11/12/25. DON #2 further stated that the documentation of wound care being completed on the TAR from 11/13/25 through 11/17/25 would be false documentation by RN #4. X. On 11/18/25 at 2:20 pm during interview with Medical Director, he stated if a wound does not improve then he would expect to be notified and he would consider changes to his wound care orders. MD confirmed that he had not been notified that the wound was not improving. MD confirmed that he would expect the nursing staff to keep him informed of all changes so that he could monitor and direct wound care. He stated the facility had a wound care nurse and this nurse should have noted any changes and concerns and then notified him of those changes and concerns. On 11/18/25 at approximately 6:15 pm the facility was notified of a finding of Immediate Jeopardy (IJ). On 11/19/25 at 2:24 pm an acceptable plan of removal was submitted with the following evidence: Plan of Removal 1. Immediate Actions Resident #2 is no longer a resident of the facility. Resident #4 wound was assessed and treated on 11/18/2025 by interim DON. Woundpresents in an improving condition. MD was notified of inaccurate documentation. Charge nurse alleged falsifying documentation suspended pending investigation on11/18/25. Interim DON completed an audit of all residents with wounds to ensure all orders werecarried out correctly on 11/18/2025. All other dressings were found to be dated correctlywith correct ordered treatment in place.2. System CorrectionsRe-educate all licensed nurses on:Wound care policyIdentification of wound progression: Proper wound assessment and monitoringtechniques to recognize signs of wound decline or wound not progressing.How to document completed wound care correctly.When and how to notify the provider related to change in worsening wound status toensure any new orders are provided as needed.Completing wound treatments exactly as ordered.Zero-tolerance policy for falsifying documentation.Nurses to complete competency related to completing wound dressing correctly.Nurse re-education and competency to be completed by interim DON or appropriatedesignee prior to completing any wound care for residents. Re-education/competencyobservation began on 11/18/25. Agency nurses will be educated prior to their shiftbeginning by interim DON/designee.Facility will consult with wound provider for consenting residents.3. Monitoring / QA Interim DON or designee will conduct weekly wound audits of current residents withwounds for two weeks, including wound assessment, documentation, notifications, andtreatments. Thereafter, 5 random residents will be selected to be reviewed weekly.4. Completion Date: 11/21/2025 The Plan of Removal was approved on 11/19/25. The Immediate Jeopardy was removed as of 11/19/25 and the scope and severity was reduced from J to D. The POR was verified as follows: Record review confirmed full house audit of all residents to identify any wounds. On 11/05/25 at 3:30 pm the Plan of Removal was verified when LPN #1, 2, 3 and Registered Nurse (RN) #1 each interviewed and stated they had been provided training on 11/18/25 which included reviewing all orders for all residents, verifying the orders with the facility provider, and entering the orders in each resident's EMR. All four nurses confirmed their training included monitoring all residents for daily wound care orders completing wound care orders and then documenting wound care. The Interim DON reported she had been provided training on 11/18/25 to monitor all residents with wounds review all resident's wound care orders and document all wound care provided. The facility administrator was interviewed and confirmed that the plan of removal had been reviewed by the facility Quality Assurance and Performance Improvement (QAPI) (a group of facility leaders who review the performance of the facility and staff and determine areas that could be improved) team on 11/18/25 and the changes were now included in the QAPI review.

Based on record review and interviews, the facility failed to notify the provider timely of any skin condition changes for 1 (R #1) of 1 (R #1) resident reviewed when the facility's treatment nurse (TN) did not notify the provider of the worsening wound and lack of healing progress. This deficient practice is likely to result in a delay in treatment or inadequate treatment. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] and discharged to the emergency room [DATE]. B. Record review of R #1's medical diagnoses on face sheet dated 10/14/25 revealed the following (including but not limited to): -Muscle wasting and atrophy (waste away), not elsewhere classified, multiple sites. -Morbid (SEVERE) obesity (substantial accumulation of body fat) due to excess calories. -Developmental disorder of scholastic skills (a persons ability to learn core academic skills).-Disorder of adrenal (endocrine gland located on top of each kidney) gland.-Hypopituitary (condition where pituitary gland does not produce one or more of its hormones)-Mild cognitive impairment C. Record review of nursing note dated revealed: 06/10/25 revealed R #1, stated that she had bumped her lower left leg on the door. RN (Registered Nurse) assessed and finding were top fine layer [skin] was broken and somewhat rolled up. Nurse did unroll what was able but steri-strips were applied area cleaned with NS (normal saline) and Optifoam adhesive applied wound measured 3.2cm by 2.6cm (cm=centimeters). 06/20/25 revealed, wound dressing changed done on LLE, wound sited cleansed with NS and povidone. Redness of skin surrounding the wound was noted no purulent smell or drainage was observed ABD pad applied over wound and securely wrap with kerlix. 06/26/26 revealed, wound to lower left leg, cleanse with normal saline or wound cleanser, pat dry, apply Santyl ointment to wound and cover with ABD pad. Chief complaint/cellulitis of left lower leg.No other notes from 06/28/26 to 08/14/26 identify that the physician was notified of wound progress. D. Record review of Care plan dated 06/10/26 and revised on 07/16/25 revealed, [name of R #1] has a non healing skin tear. Goal [name of R #1]'s skin tear will be healed by review dated. Target date 07/21/25. Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or had surface. E. Record review of R #1's Weekly Skin Checks dated 06/05/25 through 09/03/25 revealed the following: - 06/05/25: No wounds identified. - 06/10/25: Left lower leg (front) Skin tear 3.6x (by) 2.8 centimeters (cm) superficial (on the surface). - 06/17/25: Left lower leg (front) skin tear. No measurement provided. - 07/10/25 through 08/29/25: Left lower leg (front) open lesion (damaged tissue on the body) to mid front LLE, 5+PITTING EDEMA. No measurements of the wound were available during this time. F. Record review of R #1's wound report dated 06/07/25 through 09/01/25 revealed the following: - 06/07/25 - 06/14/25 = Date Identified 06/10/25 left lower leg front, Length (L) = N/A, Width (W) = N/A, Depth (D) = N/A). - 06/15/25 - 06/22/25 = (No weekly skin assessment documentation found) - 07/01/25 - 07/02/25 = (No weekly skin assessment documentation found) - 07/19/25 - 07/20/25 = (No weekly skin assessment documentation found) - 07/21/25 - 08/02/25 = Last assessed: 08/02/25 = Skin Tear left lower leg front, L=4.00 cm, W=4.50 cm, D=0.10 cm - 08/03/25 - 08/11/25 = (No weekly skin assessment documentation found) - 08/12/25 - 08/25/25 = Last assessed: 08/14/25 = Skin Tear left lower leg front, L=3.70 cm, W=5.00 cm, D=0.10 cm G. Record review of R #1's physician orders revealed the following: - 06/10/25: Clean LLE skin tear with NS (normal saline, a solution for cleaning skin) and top with optifoam (a specialty dressing brand) adhesive, one time a day for skin tear. Order discontinued on 06/11/25. - 06/23/25: Wound care: Monitor steri-strips (thin sticky bandages) on LLE for placement and S&S (signs and symptoms) of infection. Apply NAD (a specialty dressing use for wounds) over steri-strips and until drainage has decreased, apply abd (a type of dressing) pad over NAD. Wrap with Kerlix (type of bandage). Order discontinued on 06/25/25. - 06/27/25: Wound care to Left lower leg: Cleanse with NS or wound cleanser, pat dry, apply xeroform (a type of dressing) and cover with ABD pad and wrap with kerlix every day shift for skin tear. Order discontinued on 06/28/25. - 06/28/25: Wound care to left lower leg: cleanse with NS or wound cleanser, pat dry. apply Santyl (a topical medication) ointment, to wound, cover with ABD pad and wrap with kerlix. Ever yday shift for wound change dressing as needed if soiled, dislodged, and if resident persistence, of dressing change. Order discontinued on 08/14/25. - 08/14/25: Wound care to left lower leg: cleanse with NS or wound cleanser, pat dry. apply Santyl ointment to wound bed, apply collagen (a topical medication) to wound, cover with ABD (a type of dressing) pad and wrap with kerlix, everyday shift for wound change dressing as needed if soiled, dislodged, and if resident persistence, of dressing change. Order discontinued on 08/29/25. H. On 10/15/25 at 1:40 PM, during an interview with the Director of Nursing (DON), she stated all changes in wound status should be addressed immediately by notifying the provider to request any new orders. She confirmed the wound on R #1's left leg was not improving and was at a standstill and that the provider should have been notified by the facility nurses that the wound was not improving. She confirmed that there were no change in treatment order from 06/28/25 to 08/14/25 and that should be brought up to the provider's attention. She also confirmed that the treatment nurse and the provider did not have any communication regarding the wound on R #1's leg between 06/28/25 to 08/14/25. I. On 10/15/25 at 2:34 PM, during an interview with the Nurse Practitioner (NP), she stated, [name of R #1] will not let me look at her leg, so I rely on the nurses to tell her about the condition of her skin. She stated that she did not know R #1's leg wound was not improving and had not been informed by the facility of any changes.

Based on record review and interview the facility failed to ensure the wound was monitored weekly and order to refer to wound clinic was followed for 1(R #1) of 4(R #1-4) residents reviewed for wounds. This deficient practice likely resulted in the worsening of the wound. The findings are:Cross reference to findings in F580 A. Record review of R #1's wound report dated 06/07/25 through 09/01/25 revealed the following: - 06/07/25 - 06/14/25 = Date Identified 06/10/25 left lower leg front, Length (L) = N/A, Width (W) = N/A, Depth (D) = N/A). - 06/15/25 - 06/22/25 = (No weekly skin assessment documentation found) - 07/01/25 - 07/02/25 = (No weekly skin assessment documentation found) - 07/19/25 - 07/20/25 = (No weekly skin assessment documentation found) - 07/21/25 - 08/02/25 = Last assessed: 08/02/25 = Skin Tear left lower leg front, L=4.00 cm, W=4.50 cm, D=0.10 cm - 08/03/25 - 08/11/25 = (No weekly skin assessment documentation found) - 08/12/25 - 08/25/25 = Last assessed: 08/14/25 = Skin Tear left lower leg front, L=3.70 cm, W=5.00 cm, D=0.10 cm B. Record review of R #1's physician orders dated 07/23/25 revealed REFER RESIDENT TO (name of hospital) WOUND CARE CLINIC FOR FRONT LEFT LOWER EXTREMITY WOUND one time only for LLE WOUND for 7 Days. C. Record review of R #1's physician's order revealed an order dated 07/23/25 refer resident to [name of hospital] wound care clinic for front left lower extremity wound was placed by Licensed Practical Nurse (LPN) #1. D. Record review of R #1's progress notes revealed the following: - On 08/09/25 at 1:00 am, Nurse Practitioner (NP) made a referral to [name of hospital] wound clinic. - On 08/15/25 at 1:00 am, Medical Director (MD) made a referral to [name of hospital] wound clinic. E. On 10/15/25 at 1:40 pm, during an interview with the Director of Nursing (DON) she stated she oversees the entire nursing staff and that includes wound treatments. She expects the nurses to give a copy of any referrals and appointments to their scheduler/medical records personnel (MR). F. Record review of progress notes from July 2025 through October 2025 did not identify that an appointment for the wound clinic was made of that R #1 attended any wound clinic appointments. G. On 10/15/25 at 2:34 pm, during an interview, the NP revealed she made a referral for R #1 to go to the [name of hospital] Wound Care Clinic. She stated she gave a verbal order to LPN #1 on 08/09/25. She stated her expectations is that the facility would set up appointments and transportation. H. On 10/15/25 at 4:27 pm, during an interview, MR stated she never received this referral, and the resident was not seen for wound care at [name of Wound Care Clinic] as ordered. She stated nurses are expected to give her a copy of any referrals including any pertinent documents. She stated that once she has all of the information she can then proceed with faxing and calling the third party and getting a date for that referral or appointment. She stated she processes those referrals and appointments within hours of receipt of the referral. I. On 10/15/25 at 4:12 PM, during an interview with the DON, she confirmed that they [nurses] missed four weekly skin assessments (including description and measurements) for R #1. DON further stated that thorough skin assessments of wounds are used to monitor the wounds and assessments are expected to be completed and documented weekly.

Based on observation and interview, the facility failed to: ensure medications were stored properly, medication carts were locked and secured when not in use. This deficient practice is likely to result in resident injury, through dosing with medications that have been improperly stored, having access to medications not prescribed for them, and possible overdose. A. On 11/18/25 at 2:00 pm, during random observation of the memory care unit and interview the medication cart was unlocked. Medication cart was in the back of the unit and standing next to the medication cart was R #5 and walking back and forth was R #6. Medication cart was unlocked from 2:00 pm to 2:33. Housekeeping Director was asked medication cart should be left unlocked and he stated No and proceeded to go look for Director of Nursing (DON) #2, and left cart unlocked. Certified Nurse Aide (CNA) #1 was asked if medication cart should be unlocked, she stated it should not be she also walked away to look for the Nurse. CNA #1 came back a few minutes later and locked the medication cart. B. On 11/18/25 at 2:32 pm, during an interview with the Director of Nursing she confirmed the medication cart was unlocked and she stated that the medication carts should be locked when not in use.

Based on record review, observation and interview, the facility failed to ensure medical records were accurate for 2(R #2 and 4) of 4(R #104) residents reviewed. If the facility is not ensuring accurate medical records, then residents are likely at risk of not receiving the care needed to achieve optimal wellness. The findings are:R #2:A. Record review of R #2's admission assessment revealed R #2 was admitted into the facility on [DATE] from the local hospital with stage 2 (some of the outer surface of the skin is damaged) pressure ulcer to his coccyx (tailbone) measuring 2.3x4.2 centimeters. B. Record review of R #2's weekly wound report (tracking system the facility utilizes to tract and trend all residents skin concerns) dated 09/03/25 through 10/15/25 revealed the following: - 09/03/25 - 09/10/25 = Date last assessed 09/05/25 Coccyx, Deep Tissue Pressure Injury, Length (L) = 6.00, Width (W) = 6.60, Depth (D) = 0.00, Deep Maroon=75%, Bright Beefy Red=25%. - 09/11/25 - 09/17/25 = No weekly skin assessment documentation found. - 09/17/25 - 09/24/25 = Date last assessed: 09/23/25 Coccyx, Unstageable (wound with full thickness tissue loss), L = 7.00, W = 7.00, D = N/A, Deep Maroon=25%, Bright Beefy Red=50%, slough (dead tissue that separates from the living tissue) white fibrinous (layer of tissue on its surface) =25%, Scant Exudate (fluid that drains from the wound) - serosanguineous (fluid that contains both clear water fluid and blood). - 09/24/25 - 10/01/25 = last assessed: 10/01/25 Coccyx, Unstageable, L = 7.00, W = 7.00, D = N/A, Bright Beefy Red=75%, slough white fibrinous=25%, Erythema (redness of the skin), Scant Exudate - serosanguineous. C. Record review of Weekly Skin Check for R #2 dated 09/29/25 revealed No is response to question Does the resident have any skin impairment? The assessment also identified The assessment was completed using direct observation and communication with the resident, as well as communication with licensed and non licensed direct care staff member. R #4D. Record review of R #4' face sheet revealed admission date of 01/29/24. E. Record review of care plan initiated 10/29/24 reveals [name of R #4] has pressure ulcer or potential for pressure ulcer development r/t (related to) Hx (history) of ulcers. No additional updates to the care plan related to wound or treatment interventions as of 11/18/25. F. Record review of R #4's Treatment Administration Record (TAR) revealed order Wounds care to stage 2 PI (pressure injury) to coccyx: Cleanse with wound cleanser or NS, pat dry, apply collagen sheet, cover with dry dressing. Change daily and PRN for dislodgment and soiling. Every day shift dated 11/05/25 to 11/19/25. Wound care was documented as being completed, 11/05/25, 11/07/25, 11/10/25 and 11/12/25 through 11/19/25. G. On 11/18/25 at 11:50 am during an observation of R #4's wound care treatment and an interview with DON #2, she confirmed the date on the dressing was 11/12/25, she confirmed the dressing was 6 days old and this would indicate R #4 had not been provided wound care since 11/12/25. DON #2 further stated that the documentation of wound care being completed on the TAR from 11/13/25 through 11/17/25 would be false documentation by RN #4.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. All items were labeled and dated in the locked unit and room [ROOM NUMBER] refrigerators. 2. Daily temperatures of the locked unit and room [ROOM NUMBER] refrigerators were documented. These deficient practices are likely to affect all 20 residents in the locked unit, 2 residents in room [ROOM NUMBER] and is likely to cause foodborne illnesses in residents. The findings are: A. On 06/16/25 at 9:33 AM, during the initial walk through of the facility's locked unit, a refrigerator in the dining area and room [ROOM NUMBER]. The refrigerator contained the following food items and snacks for the residents. 1. Two containers of punch/juice, two containers of nutritional supplements, one container of salsa, all items were unlabeled and undated. 2. One uncovered container of punch/juice, dated 06/11/25, was expired and improperly stored. 3. Packaged frozen food items in the freezer that were unlabeled and undated. 4. room [ROOM NUMBER] refrigerator temperature log was not available for review. B. On 06/16/25 at 9:44 AM, during an interview, Certified Nursing Assistant (CNA) #1 confirmed the food items in the locked unit refrigerator belonged to the residents, all items should be labeled and dated and they were not. C. On 06/16/25 at 9:44 AM, during an interview, the Housekeeping Supervisor confirmed that the refrigerator in room [ROOM NUMBER] contained food items that were not labeled or dated, as required. D. On 06/16/25 at 9:44 AM, during an interview, Housekeeping Supervisor (HS) verified food items in room [ROOM NUMBER], all items should be labeled and dated and they were not. HS further confirmed that there was not a refrigerator temperature log available for review and there should be a temperature log.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. All items were labeled and dated in the locked unit refrigerator. 2. Daily temperatures of the locked unit refrigerator were documented. These deficient practices are likely to affect all 20 residents in the locked unit and could lead to foodborne illnesses in residents. The findings are: A. On 03/18/25 at 10:33 AM, during the initial walk through of the facility's locked unit, a refrigerator was in the dining area. The refrigerator contained food items and snacks for the residents. The refrigerator contained the following: 1. Two containers of punch/juice, one package of cheese, one head of lettuce, one package of turkey sandwich meat, one container of salsa, a partial loaf of bread, all items were unlabeled and undated. 2. One uncovered container of punch/juice dated 03/11/25. 3. Packaged frozen food items in the freezer that were unlabeled and undated. 4. Refrigerator temperature log was not available for review. B. On 03/18/25 at 10:44 AM, Certified Nursing Assistant (CNA) #1 verified the food items in the unit refrigerator belonged to the residents, all items should be labeled and dated and they were not. C. On 03/18/25 at 10:45 AM, Registered Nurse (RN) #1 verified that there was not a refrigerator temperature log available for review. She further stated that nursing staff was not responsible for the temperature log. That was done by kitchen staff. 34439

Based on observation and interview the facility failed to safeguard clinical record information by leaving Private Health Information (PHI) where unauthorized persons had access to the PHI for 1 (R #4) of 1 (R #4) resident reviewed during random observation. If resident's clinical information is not safe guarded, resident's PHI is likely to be viewed by unauthorized residents, visitors and staff. The findings are: A. On 03/19/25 at 5:40 PM during a random observation, the Admissions Coordinator (AC) left a clipboard with R #4's PHI face up and unattended in the facility lobby, visible to unauthorized residents, visitors and staff. B. On 03/19/25 at 5:42 PM, during an interview, the Human Resources Director (HR) confirmed the clipboard with R #4's PHI was left faced up and unattended in the facility lobby and PHI should not have been visible. 34439

Based on interview and record review, the facility failed to keep residents free from abuse for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for abuse when the facility failed to protect a resident. This deficient practice is likely to result in residents continuing to be at risk for abuse. The findings are: A. Record review of a complaint report for R #1 revealed on 12/30/24 an alleged incident of abuse had occurred as follows: a Certified Nurse Aide and another staff had witnessed a Registered Nurse (RN) #1 yell and push R #1. The incident had been reported to the Administrator. The unidentified reporter had not witnessed an investigation, and the nurse remained in the unit and the residents in the unit were at risk for further abuse by the accused nurse (RN) #1. B. Record review of R #1's face sheet, dated 03/18/25, revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: - Personal history of Traumatic Brain Injury. - Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. - Psychotic disorder with delusions due to known physiological condition. - Mild neurocognitive disorder due to known physiological condition with behavioral disturbance. C. On 03/18/25 at 12:31 PM during an interview with Laundry Aide (LA) #1, she stated she was in the memory care unit and she heard RN #1 yelling and saw R #1 push RN #1's medication cart towards her (RN #1) and the wall. Then RN #1 came around the medication cart and pushed R #1 into a room and R #1 fell down. LA #1 stated there was a resident (R #3) in the room and R #3 stated Oh my gosh what is happening. RN #1 proceeded to close the door, after she closed the door LA #1 spoke with Certified Nurse Aide (CNA) #1 that was also present and had also witnessed the incident and they went to talk to the Administrator and wrote statements. The incident occurred on 12/30/24 between 9:00-9:30 am and was reported approximately and hour and a half later RN #1 continued to work in the unit with the residents. LA #1 did notice that there was a cut on R #1's nose after the incident. D. On 03/18/25 at 1:33 PM during an interview with Certified Nursing Assistant (CNA) #1, she stated she had witnessed an incident between RN #1 and R #1 on 12/30/24. CNA #1 stated she was in the TV room area when she heard arguing, she got up from where she was sitting and she proceeded to walk towards RN #1 and R #1. R #1 push RN #1's medication cart and RN #1 came around the medication cart and RN #1 pushed R #1. R #1 fell on the floor in the room and hit his head on the footboard of the bed. RN #1 picked him up by the shirt. CNA #1 was going towards the room to check on R #1 and RN #1 closed the door. CNA #1 stated she heard R #3 yell to both RN #1 and R #1. Stop, Stop, oh my goodness what is happening, please stop. A few minutes later R #1 walked out of the room and went to his room, he had a cut on his nose that had not been there earlier when she saw him for breakfast. CNA #1 stated she heard [name of R #3] tell them to stop over and over again. CNA #1 along with LA #1 reported incident to Administrator and wrote a statement. CNA #1 then was asked to return back to the unit. CNA #1 stated she did witness RN #1 put her hands on R #, so she knew she had to report it. CNA #1 was told by the Administrator about an hour later that the incident had been investigated and everything was ok and just to continue to work in the unit with RN #1. E. On 03/18/25 at 1:50 PM during an interview with RN #1, she stated she remembered that R #1 was having aggressive behaviors the day of the incident (12/30/24). RN #1 was at the nurses station and R #1 approached her and was using foul language with her. She was passing medications and proceeded to head to the TV room when R #1 pushed her against the wall with the medication cart, she stated she came around the medication cart and and put her arms around him and lowered him to the ground, after she lowered him to the ground he got up and that was it, he walked back to his room. RN #1 stated she just kept telling him to relax and calm down. RN #1 further stated there was no injury to R #1. RN #1 reported the incident to Administrator and wrote a statement on 12/30/24. RN #1 stated she was not removed from patient care that day. Administrator was able to view the tape later that day and cleared her to continue working. F. Record review of the witness statement provided by LA #1 to the Administrator (ADM) on 12/30/24 revealed: About 9:30 am, I heard [name of R #1] and [name of RN #1] arguing in hall then [name of R #1] pushed [name of RN #1] against the wall. So [name of RN #1] came around from med (medication) cart and pushed [name of R #1] on the floor in the room and [name of R #1] fell to the floor. [name of R #1] has a cut on his face, and his lip a little swollen. I don't now [sic] what [name of R #1] hit in the room but he did hit the floor. [name of R #3] was telling them not to fight and she was screaming. G. Record review of the witness statement provided by CNA # 1 to ADM dated 12/30/25 revealed: Around 9:30 am I heard people arguing while I was combing residents hair. I walked toward the hallway on [NAME] (memory care unit), I then saw [name of RN #1 and R #1 arguing. I walked toward the window and where another employee LA #1 was. Then I heard yelling and foul language between the two [RN#1 and R #1] then the arguing continued into the room. I then saw RN #1 and R #1 with physical fighting, where she pushed him down fell on .bed and picked him (R #1) upwards with his shirt. I have noticed a scratch on his L (left) face and a swollen lip and he stated his mouth hurts. H. On 03/19/25 at 3:10 PM during an interview with the ADM, she provided a written account of the incident as she could recall. Written statement was generated earlier on this day (03/19/25) per her recollection of incident. ADM stated she had looked for handwritten notes she may have taken regarding the incident and could not located them. ADM stated family had not been called, the only thing that she had done was interview the three staff that were present on the day of the incident (12/30/24) and interviewed R #1. ADM confirmed that she felt a thorough investigation had been conducted and there was no need to remove staff from the area and she (ADM) believed that abuse had not occurred.

Based on record review and interview, the facility failed to ensure that resident received appropriate transfer assistance (Mechanical assistive devices for transfer include, but are not limited to, portable and stationary total body lifts, sit-to-stand devices, and transfer or gait belts) for 5 (R #1, 2, 3, 9, 10) of 6 (R #1, 2, 3, 7, 9, 10) resident reviewed for transfer assistance by: 1. Not utilizing the appropriate assistive device and technique for transfers for R #1, 3, 9 and 10 2. Not clearly communicating with staff the transfer assistance needed for residents, including R #2. If the facility is not clearly communicating the staff assistance needed to transfer a resident and not utilizing the ordered devices to ensure a safe transfer, then residents are likely to fall or sustain bodily injury. This deficient practice likely resulted in R #1 sustaining additional fracture in her arm and shoulder when staff pulled on her arm and brief when transferring the resident from her bed to the chair. The findings are: Findings related to R #1: A. Record review of R#1 admission orders dated 05/25/21, from (hospital) to (Rehabilitation Center) identified: 1. Diagnosis of fracture to left superior (upper) and inferior (lower) ramus (pelvic bone) of the pelvis and left distal (farthest from the trunk) clavicle (collar bone) 2. Nursing orders for ambulation (walk; move about) with assistance as needed B. Record review of R#1 Care Plan dated 05/25/21 identified assistance for bathing, bed mobility, dressing, grooming, locomotion, toileting, transfers, and walking from one CNA (Certified Nursing Assistant). C. Record review of R#1 Admission Functional Abilities assessment dated [DATE], by Registered Nurse (RN) #1, identified R#1 requiring substantial/maximal assistance with toileting, shower/bathing, upper body dressing, lower body dressing, rolling from left to right, sitting to lying down, lying to sitting on side of bed, standing up from a sitting position, chair to bed or bed to chair, and toilet transfer. D. Record review of Resident transfer guide observation for R #1 dated 05/26/21, completed by RN #1, identified the following: 1. Resident unable to transfer and ambulate independently. 2. Resident requires transfer assistance of one E. On 09/22/21 at 10:47 am during interview with R #1, she stated that she had fallen and broke her pelvic bone and collar bone and was released from the hospital to the facility for therapy. R #1 confirmed that she did not have surgery for her fractures. She stated I couldn't get out of bed. The only thing I could move was my left arm from elbow up. I had difficulty getting them to take me to the bathroom. They [staff] would put me on the side of the bed and pick me up. They would hold onto me with my diaper [brief] so I could stand. R #1 reported that the therapist used her to train staff on transfers since staff were not using the [gait] belts. R #1 reported that after the training one or two CNAs used the gait belt but not everyone. R #1 reported that she began to have an increase in pain before she was at the facility before she was transferred to the hospital. They [hospital] took X-rays and determined that I had additional broken bones. The way they [facility staff] were picking me up and dropping me, it cracked the bone around my rods [in shoulder]. F. Record review of the Medication Administration Record (MAR) dated 05/25/21 to 05/29/21 revealed that pain medication was administered on the following days: 1. 05/26/21; Oxycodone (pain medication) 5 mg (milligram) was administered. No pain scale noted. 2. 05/27/21; Acetaminophen (Tylenol) 650 mg was administered with pain scale 6 (0-10 pain scale) at 9:29 am and then again at 7:05 pm with pain scale 5. 3. 05/28/21; Acetaminophen (Tylenol) 650 mg was administered with pain scale 7 at 9:25 am 4. 05/29/21; Acetaminophen (Tylenol) 650 mg was administered with pain scale 8 at 1:31 pm G. Record review of R#1 (hospital) Admission note identified dated 05/29/21, displaced fracture of the distal humerus (bone of upper arm) and nondisplaced fracture involving the superior (upper) aspect of the scapula (shoulder blade). H. Record review of R#1 progress note dated 05/28/21, by SSD (Social Services Director), noted the following: SSD went into resident's room to do some assessments when she (R #1) let me know that she had had some concerns about her stay here so far. She (R #1) had said that on 05/26/21, there was a CNA from day shift who was rude to her and was transferring her incorrectly She was very upset about what had happened. These issues got addressed by PT (Physical Therapist) doing education with the CNA's working with her on how to transfer her safely and correctly . I. Record review of PT progress note for R #1 dated 05/27/21 identified a note by Physical Therapist (PT) #1 that he provided transfer training to CNA staff including how to aid patient with supine (laying flat on back) to sitting assistance with sitting up upper body and guarding Left lower extremity; educated staff on proper use of gait belts (assistive device which is used to help safely transfer a person from a bed to wheelchair, standing and sitting, and walking around) and how to assist with to stand and pivot transfers (person bears at least some weight on one or both legs and spins to move their bottom from one surface to another). Emphasized gait belt placement above pelvic injury and not under shoulder, along with having patient stand and pivot to her right side. J. On 09/23/21 at 12:22 pm during interview with PT #1, regarding R #1, he stated The week before Memorial day weekend, I evaluated her. She had a walker and could be weight bearing as tolerated. When I was leaving that night I got called. She [R #1] told me that someone had tried to lift her broken arm. I was told they grabbed on her arm. I spoke to the CNAs that night and went through how to safely transfer her and showed them using her [R #1]. PT #1 confirmed he was told by R #1 that they had pulled on her brief to balance her. PT #1 stated that staff should have used a gait belt. K. On 09/23/21 at 3:08 pm during interview with the Social Services Director (SSD), she confirmed that she wrote down R #1's grievance regarding transfers. SSD confirmed that she had given the grievance to Physical Therapy and they did transfer training with the staff. L. Record review of the Inservice Record dated 05/27/21 revealed a lecture and demonstration was conducted by PT #1 for Proper gait belt usage and transfer technique utilizing belt just above waist due to pelvic injury and to never transfer by UE (upper extremity, ie arm) due to injury. The inservice record was signed by 5 staff (CNA #3, 4, 5, 6 and CMA (Certified medication Aide) #2. M. On 09/28/21 at 2:58 pm during interview with the Administrator, she confirmed that she did see the grievance for R #1. PT was involved and training had been rendered. Training was done. As far as I know, he did training with all the CNAs. *Request for staff training on transfers was requested. On 09/29/21 at 4:52 pm, Administrator confirmed that no other staff competency on transfers (other than Inservice dated 05/27/21) was found. Findings related to R #2: N. On 09/23/21 at 12:22 pm during interview with PT #1 regarding R #2, he stated [Name of R #2] came in with a fracture. All bones in her ankle. She was deemed not weight bearing .she was not strong with gait (balance) Physically she might have been able to [bear weight] but she couldn't do it safety. O. Record review of Progress Notes for R #2 revealed the following: 1. 04/22/21: Resident admitted to the facility. Boot on right foot/ankle related to fracture Resident is non weight bearing to right lower extremity. 2. 04/27/21: Requires 1[person] assist for transfers to and from toilet. 3. 04/28/21: Requires minimal assist with transfer to and from bed and to and from toilet. 4. 05/01/21: Extensive assistance needed with ADLs (Activities of Daily Living) of one CNA. 5. 05/11/21: Non weight bearing continues to right lower extremity related to fracture. 6. 05/17/21: It was also recommended that due to her limited mobility at this time she have supervision with ambulation. 7. 05/22/21: limited assistance needed with ADLs of one CNA, able to transfer self for [from] bed to chair. P. On 09/28/21 at 9:22 am during interview with CNA #1 regarding R #2, she stated [Name of R #2] could normally transfer herself and as long as you use the gait belt and hop and take time turning slowly. Findings related to R #3: Q. Record review of R #3 (hospital) discharge notes dated 07/13/21, identified R #3 requiring maximum assistance (staff provide weight bearing support) with transfers. R. Record review of R #3 Resident transfer guide dated 07/14/21, by RN (Register Nurse) #2, identified resident as unable to transfer and ambulate independently or bear any weight, requiring assistance of two people with a Hoyer (resident lift). S. Record review of R #3 Care Plan dated 07/16/21, noted R #3 as having generalized weakness and at risk for falls and provide resident with safety device/appliance. T. Record review of R #3 Progress note dated 07/29/21, by RN#2, identified R #3 having a need for a hoyer lift to help transfer. U. Record review of Client Coordination Note Report dated 08/13/21, from hospice, indicated that R #3 Is a Hoyer lift transfer. V. Record review of R #3 Hospice Plan of Care dated 08/27/21, identified resident as requiring a Hoyer lift for transfers. W. On 09/22/21 at 2:32 pm during interview with R #3, he stated that recently during a transfer 2 people were holding on to his arms and legs and he could not stand and slid to ground. R #3 reported that usually they use the machine [hoyer] to transfer him but they didn't this time. X. Record review of the Grievance Complaint form dated 09/08/21 revealed [Name of R #3] pulled SSD and DOR (Director of Rehab/PT #1) aside to tell them about an incident that happened last week. He stated that [name of CNA #7] told him he could stand up and transfer to the shower chair. He knows that he is too weak to and he also is a hoyer lift, he ended up sliding to the ground.He said that there were two people on his arm and two [staff] on his legs trying to lift him and they dropped him again. They finally got a sling under him and got him up with the hoyer lift. Y. Record review of Employee Teachable Moment identified education was provided to CNA #7 on 09/10/21 that a resident with orders for hoyer lift must be transferred per orders at all times. No other staff members were identified as receiving training. Finding related to R #9 and R #10 and staff communication about transfer needs: Z. On 09/28/21 at 9:00 am during interview with R #10, he reported that staff assist him in transferring from bed to his chair and sometimes they grab onto his pants to keep him balanced during the transfer. AA. On 09/28/21 at 9:17 am during interview with CNA #1, she confirmed that staff should not be grabbing resident's clothes to help transfer them. She reported that this would be dangerous for the resident and the resident could fall. When asked how would a CNA know a resident's transfer needs, she reported Sometimes they won't tell us about new residents; to see if they are hoyer lift. I will go to nurse and DON and ask about transfers. I ask family lots of questions too. CNA #1 stated that she also reviews the care plan and asks Therapy but this information is not shared in any other ways with the CNAs. Per CNA #1 It's a safety thing and liability. CNA reported that they pass on what they learned to the next CNA on shift. BB. On 09/28/21 at 12:16 pm during interview with R #9, she reported that she had surgery in the beginning of September and when she first arrived, she required assistance from staff to go to the restroom. R #9 confirmed that staff do use the Gait belt to help transfer her but at times they grab her clothes and pants to help support her during the transfer. CC. On 09/28/21 at 2:09 pm during interview with CNA #2 when asked how does a CNA know what transfer assistance to provide a resident, she stated I ask the RN on duty, especially if we get a new resident. The nurse or the PT therapist. I always have to ask. There is no communication. We don't have a meeting in the morning [to discuss resident needs]. DD. On 09/28/21 at 2:42 pm during interview with CMA #1 when asked how do staff know what level of assistance a resident needs with transfers, she stated Therapy will automatically tell us. When we do shift change, we let the next shift know. After Therapy conducts their assessment, they let the staff know. Staff can then go into the ADLs [section in computer]. It will show resident history. It is inputted by therapy. EE. On 09/28/21 at 4:14 pm during interview with Nurse #1, when asked how do staff know what kind of assistance a resident needs, Nurse #1 reported Therapy. When they do their assessment, they will let us know. Sometimes therapy doesn't come until the next day after admission. Usually we won't transfer [the resident] until Therapy assess them, unless it's obvious what's [level of assistance] needed.

Based on observation, record review and interview, the facility failed to Provide ADL (activities of daily living) for 1 (R #37) of 1 (R#37) resident reviewed when they were unable to change her soiled brief (adult diaper) for over 2 hours leaving her sitting in her bowel movement. This deficient practice likely resulted in psychosocial harm to include frustration, humiliation and sadness to the resident when she is dependent upon staff's assistance to be cleaned following a bowel movement and is instead required to wait. The findings are: A. Record review of Face Sheet dated 04/23/21 for R #37 revealed this as an initial admitted and included the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of Minimum Data Set (MDS) Section G - Functional Status, dated 04/28/21 for R #37 revealed that R #37 requires Extensive Assistance with Bed Mobility, Transfer, Dressing, Toilet Use, Personal Hygiene and requires 2+ (more than two people) person assistance support for these activities; requires Extensive Assistance with Locomotion (movement from one place to another) and Eating; and requires Total Dependence with 2+ person assistance for Bathing. C. Record review of MDS Section C - Cognitive Patterns, dated 04/28/21 for R #37 revealed that she has a Brief Interview Mental Status (BIMS - a structured evaluation aimed at evaluating aspects of cognition ) of 15 (range of 0 - 15 with 15 being high level of cognition). D. Record review of Care Plans dated 04/28/21 for R #37 revealed, Problem: Category: ADL Functional/Rehabilitation Potential - Resident is totally dependent on staff for all ADLS. Goal: ADL approaches will meet resident's needs. Approach: TRANSFERS: R #37 requires mechanical lift (a device used to move those who are unable to stand or move on their own) for transfers. Resident is at risk for presssure injuries R/T related to) impaired mobility. Bowel Bladder incontinent R/T incomplete [CONDITION(S)] (partial damage to the spinal cord and some connections between the brain and areas below the level of injry exist). E. On 05/05/21 at 5:03 pm during an observation and interview with R #37 stated she is very frustrated and very upset because she has been sitting in a dirty depends (adult diaper) with poop for about two hours. She stated they (staff) told her that the batteries for the hoyer lift were dead. She further stated that she asked to be changed at about 3:00 pm but that she has been waiting now for a couple of hours to be changed. R #37 appeared to be visibly upset and frustrated at the time of the interview. F. On 05/05/21 at 5:19 pm during an interview, Certified Nurses Aide (CNA) #1 stated the hoyer lift wasn't working at about 3:30 pm and that she was aware that R #37 had been waiting to have her depends changed. She stated R #37 should not have to wait to be changed but because the batteries on the hoyer lift were dead she had to wait to be changed. G. On 05/05/21 at 5:33 pm during observation R #37 was observed in her bed. R #37 was transferred from her wheelchair to her bed with the assist of 3 staff due to Hoyer Lift not able to be used due to battery was not charged. Staff members who transferred R #37 were CNA #1, CNA #3 , and PT(physical Therapist) #1. CNA #3 confirmed R #37 had a medium size bowel movement and was changed at this time out of her soiled brief.

Based on record review and interview, the facility failed to ensure that residents were free from neglect for 1 (R #1) of 3 (R #1, 2, and 3) residents reviewed for falls. This is indicated by nursing staff not following physicians orders by not providing 1:1 supervision. This deficient practice likely resulted in R #1 being admitted to the hospital with [REDACTED]. The finding are: A. Record review of the admission orders [REDACTED].Ambulates (walks) with assist and independently (but falls) . B. Record review of the Care Plan dated 02/11/20 for R #1 revealed, Problem Category: Falls. (Name of R #1) is at risk for falls r/t (related to) increased cognitive decline (when your brain doesn't work as well as it used to) . Goal: (Name of R #1) will remain free from injury with this POC (Plan of Care) thru next review. Approach: 1) Give (name of R #1) verbal reminders not to ambulate/transfer without assistance. 2) Provide (name of R #1) an environment free of clutter. C. Record review of the Care Plan dated 02/11/20 for R #1 revealed, Problem Category: ADL (Activities of Daily Living)/Rehabilitation Potential . Goal: ADL approaches to meet resident's needs. Approach: .Walking Ability: Requires cane and supervision. D. Record review of the (Name of hospital) admission documentation dated 05/17/20 for R #1 revealed, Diagnosis: [REDACTED]. Presenting complaint: EMS (Emergency Medical Services) states: pt (patient) fell from standing position, sustaining contusion (bruise) to right brow, c/o (complains of) pain to left hip . Fall Risk .The patient has a history of falls . Assessment: 8:47 pm . Derm (dermatological - skin): Bruising that is on right side of forehead swelling. Injury description: Head injury sustained to right side of forehead is closed, did not have loss of consciousness (alertness), was sustained 30-60 minutes ago . 5/18 ED (Emergency Department) course . the CT (computerized tomography - type of x-ray) scan of the brain, as read by the radiologist (specialist in medical imaging) showed . trace right subdural (collection of blood on the brain surface) measuring 3 cm (centimeters) . E. Record review of the (Name of hospital) admission documentation dated 05/18/20 for R #1 revealed, Chief Complaint: Fall. History of Present Illness: .She was transferred today from (name of hospital) emergency room to (name of hospital) downtown on account of traumatic subdural hemorrhage (bleeding between the brain cover and the brain caused by injury) from a fall . Active Hospital Problems - Diagnosis: [REDACTED]. Repeat CT showed subdural hematoma measuring up to 7 mm (millimeters), likely stable . (name of physician) consulted this morning again on 05/18, he does not think that patient needs intervention at this point . F. Record review of the Facility Incident Investigation dated 05/17/20 for R #1 revealed, Incident type: Fall . unwitnessed fall. Resident found laying on right side . List interventions in place to prevent incident: 1:1 (one to one) when resident returns from hospital . List interventions to attempt to prevent reoccurrence: Other (is marked) Care Plan Initiated/Modified (is marked). Specify: 1:1 G. Record review fo the (Name of hospital) admission documentation dated 05/19/20 for R #1 revealed, History of Present Illness . This [AGE] year old white female, transported by paramedic (emergency medical provider) ambulance from skilled nursing facility, (name of facility), was found on the floor after an unwitnessed fall this evening. The patient was treated by me 2 nights earlier for a similar episode of fall which resulted in a small subdural hematoma to the right side . and has now suffered another fall causing laceration to her right forehead, significant bruising on her entire right face . ED course . sent to CT for CT scan of head and cervical spine (neck) . the CT scan was read by the radiologist as showing subacute (recent onset) 6 mm right subdural hematoma with mild mass effect on cerebral sulci (grooves on the surface of the brain). Small subdural blood along the right tentorium (membrane that covers the brain). Focal hemorrhagic contusion (damaged brain tissue) in anterior (front) aspect of right temporal (bottom) lobe. 3 mm midline shift to left . Fracture to anterior wall and lateral (side) wall of right maxillary sinus (sinus bone). Fracture of floor of right orbit (bones of the eye socket) . H. Record review of the Facility Incident Investigation dated 05/19/20 for R #1 revealed, Incident type: Other: Fall . found on floor . Potential contributing factor(s) related to the occurrence . lack of 1:1 coverage during fall . I. Record review of the Physicians Orders dated 05/19/20 for R #1 revealed, Start date: 05/19/20. Order Description: One on one care following a fall with injury. J. Record review of the Progress Notes dated 05/19/20 at 2:32 pm for R #1 revealed, Resident had just returned to facility. Resident had slid off her wheelchair but the Certified Nurses Assistant (CNA) who was helping nurse transfer resident was able to catch her. It was a witnessed incident no injuries occurred. K. Record review of the Progress Notes dated 05/19/20 at 3:40 pm for R #1 revealed, .is a 1:1 . L. Record review of the Progress Notes dated 05/19/20 at 5:46 pm for R #1 revealed, .I called the on call to get an order for [REDACTED]. M. Record review of the Progress Notes dated 05/19/20 at 10:27 pm for R #1 revealed, This nurse was getting report from day nurse (name of nurse) when was called by (name of) CNA that resident was on the floor . this nurse and (name of nurse) went to the residents room and found resident lying on her right side with a puddle of blood noted by resident's right side of head . N. Record review of the Progress Notes dated 05/20/20 at 12:09 am for R #1 revealed, When this nurse and (name of nurse) went to resident's room when called by (name of) CNA resident was in room alone, with no one on one sitter, CNA (name of) had no one to replace. O. Record review of the Progress Notes dated 05/20/20 at 12:16 am for R #1 revealed, Called ER and spoke to (name of registered nurse) that resident had a possible bleed to the right side of residents head and a fracture to right arm . P. On 06/03/20 at 4:40 pm during an interview with the Assistant Director of Nursing (ADON) she stated that R #1 was sent to theER on ,[DATE] due to a fall and was transferred out to (name of hospital) due to subdural hematoma. She stated that when R #1 came back from the hospital on May 19th she was very confused. She stated that R #1 was sent out to the ER again on 05/19 for another fall and that R #1 received fractures to her face following this fall and was sent out to (name of hospital) on 05/20. ADON stated that R #1 was housed on the West Wing of the facility and that normally there would be one Certified Nurse Assistant (CNA) for the night shift on the West Wing, but that if any resident required 1:1 services there would then be the regular CNA and also the CNA for 1:1 services. ADON stated that on May 19th that the CNA whose shift was ending left before the CNA whose shift was starting was physically in R #1's room and that the nurse on duty that night was aware of this. ADON stated that she was in the process of calling in agency staff because there were two call ins that night and there was no one to relieve the 1:1 CNA. She stated that R #1 was alone in her room for about three minutes and that is when she fell .

The facility self reported an injury of unknown origin, regarding a resident that was found unresponsive in her room, with the lower part of her body on the floor and the left side of her neck pressed up against the bed rail. The resident had a laceration/discoloration to the left side of her neck. The resident had shallow breathing and shortly thereafter, passed away. The facility replaced all the air mattresses the following day. Based on observation, record review and interviews, the following was discovered: 1. Multiple residents had problems with the air mattresses pushing them around in the bed prior to this incident. 2. Not all residents were being assessed for the use of bed rails prior to being used. 3. Staff was not provided adequate training on entrapment risk and how and when to adjust the air pressure in the air mattresses. 4. Between when the resident expired and the air mattresses were replaced, another resident got caught between the air mattress and bed rail, resulting in injury. This resulted in Immediate Jeopardy being called on [DATE] at 11:55 am. A Plan of Removal was received and and rejected on [DATE] at 10:56 am. A second Plan of Removal was received and approved on [DATE] at 1:07 pm. The Plan of Removal Included: 1. Immediate education on safety risk of enablers (bed rails) that may result in entrapment. 2. Interdisciplinary assessment of residents with side rails to be done monthly and identify all residents for entrapment risks on-going and upon admission. 3. DON (Director of Nursing) to contact the manufacturer of the beds and air mattresses for their recommendations. Immediate and on-going staff education on bed safety and risks that would jeopardize the resident's safety, including entrapment. 4. Immediately implementing a bed safety program to include: gaps within the bed system, ensure bed rails are properly installed and identifying additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment. 5. Quality Assurance (QA) committee to review bed safety reports on a monthly basis and PRN (as needed) for appropriate action. Based upon the Plan of Removal, the scope and severity was decreased from a K, to a H, Level 3. Based upon observation, record review and interview, the facility failed to ensure that resident were free from accidents and hazards by: 1. Not assessing residents for the use of bed rails prior to being used. 2. Not identifying that there was evidence that the air mattresses (Brand:Invacare MicroAir MA65 Alternating Pressure with Low Air Loss System) were pushing residents (R #3 and R #4) off/around their beds, which along with side rails, could pose a risk for entrapment. 3. Not educating staff on how and when to adjust the air pressure, especially for the use of max inflate (inflating the air mattress to firm for purposes of providing personal care). 4. Not immediately intervening when a concern with the mattresses was identified. This deficient practice likely resulted in R #1 becoming entrapped between her air mattress and the bed rails causing her death, and R #2 becoming entrapped between the air mattress and bed rail which likely resulted in bruising. If the facility is not appropriately assessing residents for risks of accidents, then residents, especially those residents that have air mattresses and bed rails are likely to experience physical injury and/or death. The findings are: A. Record review of R #1's care plan dated [DATE] revealed (Name of R #1) is at risk for skin impairment r/t (related to) decreased mobility, incont. (incontinent) of b/b (bowel and bladder), MASD (Moisture Associated Skin Damage) to bottom. Interventions included Use pressure reducing mattress on bed. B. Record review of the Micro Air User Manual for MA65 dated 2011 revealed 5.2 Entrapment May Occur. Warning: Patient entrapment with bed side rails may cause injury or death. Mattress must fit bed frame and side rails snugly to prevent patient entrapment. Monitor patient frequently. Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimension, and mattress thickness, size or density could increase the risk of entrapment. C. Record review of R #1's Progress Notes dated [DATE] revealed resident was checked on during reg (regular) rounds at midnight resident was resting comfortably, attend (brief) was changed and bed was in lowest position. 0030 (12:30 am) client was in bed with her eyes closed although she was very restless 0125 (1:25 am) the CNA (certified nurse aid) on shift checked on the client and found her laying on the floor on top of her bed mat (floor) with her bed in the low position, the client feet and torso were on the floor and her neck was pressed up against the quarter bed railing, resident also had a 2 cm (centimeter)* (by) 0.7 cm *0.1 cm laceration to the midline of her neck 0126 (1:26 am) the resident was placed in her bed oxygen was placed on the client all pillows were removed from the bed and sternal rub (pain stimulus applied in an attempt to arouse) was performed with no response although the client was still breathing. 0129 (1:29 am) (Name of medical clinic) was called and emergency transport was dispatched 0135 (1:35 am) on call for (Name of Physician #1) was notified of the clients death as well as the Director of Nursing D. On [DATE] at 9:37 am during an interview with Social Services Director (SSD) regarding R #1, he said She had been stable, no real changes. Baseline very confused. Was not capable of walking on her own. Needed maximum assistance with transfers. She ambulated in her wheel chair. She could propel it on her own but she needed cues on which direction to go and how. She could communicate. She'd nonsensical answer. E. Record review of the Minimum Data Set for R #1 dated [DATE] revealed that R #1'scognitive skills and decision making abilities were severly impaired and she needed extensive assistance with bed mobility and transfers, and total dependence for toilet use and personal hygiene. F. On [DATE] at 9:58 am, during interview with Central Supply, when asked what happened when the R #1 passed, she replied I really don't know. Something with her (air) mattress (MA65) was over inflated. I don't get that. How she would have slid. When asked if the resident was expected to pass, she replied No. She wasn't Hospice or anything. G. Record review of pick-up/Service Ticket from Medical Supply Company dated [DATE] revealed that the MA65 mattresses were picked up and AirDyne Mattresses were delivered/exchanged for R #2, 4, 7, 11, 25 and 26. H. On [DATE] at 10:09 am, during an interview with CNA #1, she said that following R #1's death, We had a meeting and they told about the air mattresses, they told a little bit about that some people don't know how to use them properly, and they told us that they were going to switch them. The ones they switched out for are more flat (AirDyne), level and the old ones (MA65) were a little more bulky. When asked if there were any problems with the old mattresses (MA65), she said I never did. I know people had problems inflating them. Like when you change people the old mattresses (MA65) would bulk up on one side, if they were turned. If some (staff) forgot to inflate or fill it up, a resident could fall out. I. On [DATE] at 10:15 am during interview with R #1's daughter she stated I have to be honest, I don't know a whole lot. They called me at 3:30 (am) in the morning. I was told by the nurse/DON that they found my mom on the floor, and she seemed to be panicked and couldn't communicate, she was breathing when 911 came, and she passed when they were there. I went there, and I saw my mom. I noticed she had a mark on her neck, it looked weird. The nurse that found her, at 10:30 pm said she found that her legs were off the bed, she was restless but she usually is not, she changed her and got her in bed. At 1:10 (am) she found my mom, and her neck got caught in the railing, she was convulsing and got caught on the rail. She wasn't communicating, her dementia is too advanced. Her body was moving and she got caught. J. On [DATE] at 10:16 am during interview with Registered Nurse (RN) #1, when asked what happened when the resident passed, she replied I wasn't here. I didn't get here until a couple days after. When I got here, we did get all the mattress changed out to the Airdyne mattress. Foam in the middle. The one she had (before) was all air (MA65). Regarding her air mattress, the RN replied It couldn ' t have been more that 2 months (old). She had some sheering on the back. So we wanted to make sure it didn't get any worse. When asked if the air mattress helped, she replied Yes, she healed pretty fast. When asked if there were any problems with the old mattresses (MA65), she replied Not that I was aware of. RN #1 explained that They weigh the person, to adjust the setting (air). The people that bring the mattress to set them up (make the adjustments). No one should touch that once its sets up. K. On [DATE] at 10:43 am during an interview with Licensed Practical Nurse (LPN) #1 regarding what happened that night that R #1 passed, he said Resident was laying next to her bed, the bed rail was up she was lateral to her bed, facing away from the bed. The bed was in the low position, her feet and torso was on her left side of her neck, little bit of her face but more so her neck was pressed up against the bed rail. When asked what he thinks happened, he said What I think might have happened, she got up on her own, got caught in the bed rail, then the air mattress (MA65) inflated behind her. Those mattresses would deflate on one side, and probably entrapped. That's the only reason I say that. L. On [DATE] at 11:20 am during an interview with the DON, when asked what she thought happened to R #1, she said I don't know, I honestly do not know. When asked if there was a problem with the bed, she said I don't know if there was or not. I don't know. It is kinda out of my realm. Usually we change them (air mattresses) out when they heal (from wound). She was almost healed out. Probably at that time, it may have been time for a regular mattress. When asked what happened after she passed, she said We decided to go back to the Airdyne mattress. We weren't sure if the mattress was malfunctioning. Not pressuring right, pushing up on one side. We don't know. We called (Name of Supplier), we were nervous because we had a few people in those mattresses. When asked how long it took to get the new mattresses, she said Maybe 24 hours. New mattresses came and everyone's mattress (air mattress) was replaced. When asked if anyone had gotten caught in the old mattresses, she said No. Never. Never had a complaint, or incident that I am aware of or saw. DON confirmed that she conducted the investigation following R #1's passing, which included witness statements from the nurse (Name of LPN #1) and the 2 CNAs, (Name of CNA #2 and CNA #3). They all said the same thing. We talked about the mattresses and we were worried that it could have been the mattresses that could have flung her. When asked how the new mattresses are being monitored, she said They are all set by resident weights by Central Supply or wound care nurse. DON stated that the inflate settings are locked and the Aides do not know how to adjust the settings. When asked if there would ever be a reason to inflate or deflate the mattress after it has been set she said Sometimes you can do a max inflate for resident care. From my understanding they go back to original setting after 30 minutes. I don't know if that happened (with R #1). DON stated that she didn't think the CNAs are using the max inflate. M. Record review of the Micro Air User Manual for the MA65 dated 2011 revealed on page 25 Press the Max Inflate/low air loss button to select the max inflate mode or the low air loss mode. Max Inflate Mode- in this mode, the mattress inflates rapidly to maximum firmness. A series of beeps sound every three minutes as a reminder that the Max Inflate mode is active. After 30 minutes, the Max Inflate mode deactivates and the control until defaults to the previous setting. N. On [DATE] at 2:38 pm during interview with CNA #4 when asked if there is a difference with the new mattresses, he responded During the day time, yes. The other ones (MA65) seemed more soft, cause it was all air. There was a chance you could accidentally unplug it. It had alternating pressure every 15 minutes. There was a max inflate. That was for transfers or changes in bed. Push button to max inflate and then 30 minutes it would go back. Max inflate feels like a regular mattress. When asked if he had been provided training on the mattresses, he responded That company came by and showed us how to use them and the settings have to be a certain weight. When asked if he had any concerns with the old mattress, he stated I didn't. When asked why the mattresses were replaced then, he stated There were concerns of the mattress pushing residents over (to one side). I never got to see that. When asked if he had ever heard of any residents getting caught in the bed, he responded I heard of (Name of R #1) from staff (her getting caught). CNA #4 was unable to provide any more details. O. On [DATE] at 8:08 pm during an interview with CNA #2 she was asked to recall the events when she found R #1 on [DATE]. She stated, Well her legs were hanging off the bed, around 10:30 or 11:00 pm, so I put her back in bed and changed her, and I checked on her once or twice and she was still in bed, then I went in again and her legs were out of the bed again. Her legs were down on the ground and she was facing the rail. On the rail, her face was resting on it. Regarding R #1's functional status, she said Alzheimer's. She couldn't do much. P. Record review of the Nursing Services Policy and Procedures Manual: Bed Safety revised [DATE] revealed 2. To try and prevent deaths/injuries from the beds and related equipment, the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. review the gaps within the bed system are within the dimensions established by the FDA (food and drug Administration) e. identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). Staff Training 4. The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. Side rail Use Interdisciplinary Assessment 5. if side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. Q. On [DATE] at 10:10 am, during interview with the Acting Administrator, she confirmed that the facility was not doing bed rail assessments prior to what happened to R #1. She explained that the beds came with bed rails and they were just being used. R. On [DATE] at 11:23 am, during interview with Certified Medication Aide (CMA) #1 when asked if she had received any education or in services regarding bed rails, gaps or entrapment, she stated Not that I can remember, not recently any way. S. On [DATE] at 1:26 pm, during an interview with RN #2, she confirmed that she had never received any training on entrapment. T. On [DATE] at 1:29 pm, during an interview with CNA #5, when asked if she had any trainings or in-services recently on how to use the air mattresses and when to adjust them, she said No, not recently. There was a training they had recently at a church, it was an all day thing, but I couldn't make it. Usually they (facility management) will catch me up on the in-services, but I haven't had anything recently. U. On [DATE] at 1:30 pm, during interview with RN #3, when asked if R #1 ever complained about the mattress, she stated She couldn't talk. She could say random things. When asked if any training was provided to staff after the incident (with R #1), she stated They had a meeting. I was too busy on the floor and I didn't go. When asked if CNAs ever use the max inflate setting for the air mattresses, she replied I don't think that would be appropriate. I have never seen a CNA max inflate. V. On [DATE] at 1:45 pm, during interview with CNA #6, when asked if R #1 moved around in bed, she replied No, if you put her in one position she stays in that position. W. On [DATE] between approximately 10:00 am and 12:00 pm, all 54 residents' beds were observed for bed rails. Bed rails were observed to be on 20 out of the 54 beds (R #,[DATE]). The DON was asked for bed rail assessments for all 20 residents, and provided assessments for 9 out of 22 residents (R #5- R #13). X. On [DATE] at 2:15 pm, during interview with the DON, she confirmed that not all residents that have bed rails have been assessed for the use of bed rails. She stated that they had planned to complete all the assessments by today ([DATE]) however that did not happen. The DON confirmed assessments for the use of side rails were not done prior to the incident with R #1. When asked when did she start to have a concern with the air mattresses (MA65), she stated Probably on the 16th ([DATE]). She stated that the new mattresses (Airdyne) came on the 17th. DON confirmed that residents continued to sleep on the air mattresses on the evening of the 16th after R #1 has passed away. When asked if staff adjust the air, she stated They are not supposed to. When asked if she had ever heard of that happening, she stated No, I don't think they know how. We did an in-service on this back about 9 months ago. Because they (air mattresses) were new to the facility, the settings and how they worked and the appropriateness of them. She confirmed the in service on [DATE] talked about adjusting the air pressure. To my knowledge they (staff) hadn't (adjusted the air pressure). I was on the floor when we got these mattresses. I know to max inflate when providing care and wound care and you put it back to the setting when you're done or I believe that it (air mattress) deflates after 15 or 30 minutes. When asked why the training agenda ([DATE]) include Air mattress setting to be ONLY set by nursing staff she responded In case they were inflating or deflecting those (air mattresses). We address that in that meeting. Most of the CNAs said they don't know how to do that. They (air mattress) are set by weight before they (mattresses) came in. When asked if any training was provided after R #1 passed, she responded No. They (staff) acted appropriately and they did what they were supposed to do. Let the charge nurse know and stay with the resident. When asked if they have provided any training regarding entrapment risk, she stated Not since I've been DON. Previous, I don't know. When asked if there had been any concerns with the old mattresses, she stated No, not until this incident. When asked if she is aware of the measurements between the bed rail and mattress that can pose a risk for entrapment, she said After this incident, I did ask (Name of Central Supply) to provide measurements of what constitutes as a quarter rail or half rail. The DON conformed that she is unaware of entrapment risk measurements. Y. Record review of the All Staff Meeting Agenda dated [DATE] revealed the agenda item, Air mattress settings to be ONLY set by nursing staff. Of the 56 staff members names, only 34 staff had signed in to the training. Z. On [DATE] at 2:17 pm, during an interview with CNA #7, when asked if there were any incidences with the previous mattresses (MA65), she stated, The ones we had before, (Name of R #4) was not happy with it and when we would put her in, she would just sink. She would just be sunken in there. I wouldn't change the setting, I would just take her out of bed and allowed it to inflate again. When asked if she has heard of anyone falling out of them, she stated, No, just her, she is the only one I had a problem with. When asked if she has received any In-services or education on air mattresses, bed rails or entrapment, she confirmed that she hadn't recently. AA. On [DATE] at 10:25 am, during observation of R #4's air mattress and interview with CNA #4 when asked if he could demonstrate how the air mattresses work, he stated This is a regular mattress (Air Dyne) so it doesn't deflate all the way. The pressure is assigned to their weight. Observation made that the air mattress was unplugged. CNA plugged in the mattress and stated There wasn't alternating pressure. It doesn't deflate. The other mattress (MA65) would have been deflated all the way to the bottom (if it had been unplugged). CNA #4 confirmed that regarding the old air mattresses, You would need to max inflate to provide care. The old one it would go back to the original setting after 30 minutes to its original setting. CNA #4 confirmed that he would not deflate the mattress after using max inflate. When asked about training, he confirmed that the Supply Company showed the staff how to inflate or deflate the mattresses. He also confirmed that he learned about the AirDyne mattresses in that original training ([DATE]). When asked if he received any training after R #1 passed away, he stated No. We were told not to touch it (the settings) besides auto firm. BB. On [DATE] at 10:36 am, during interview with Central Supply, she stated that they removed the old mattresses (MA65) when the new mattresses (AirDyne)came. Those ones were actually a lot different cause it would blow up the mattress. If the power went out, it would just deflate and be on the frame. The old ones would alternate the pressure, alternate the weight. Regarding staff changing the air pressure, she stated When they were doing transfers they would do max inflate and when they sat up it would be at fowler (upright position). Max inflate; it would harden the old mattresses. When asked if the old mattresses needed to be set back (deflate back to original setting), she stated I think it would automatically go off and go back to its original setting. She confirmed that during the training provided by the company, they didn't discuss entrapment risk or how the mattress fit within the bed rails. She stated that the training was only provided to whatever staff were here. She also confirmed that the training was provided before the old air mattresses were delivered on [DATE]. CC. On [DATE] at 11:20 am, during an interview with CNA #8, she confirmed that she did not receive any training on how to use the new air mattresses. No, I'd like some training on it because I'm not sure about how to use the buttons on it, I don't really know how to use them. DD. On [DATE] at 1:59 pm, during an interview with CNA #3 she was asked to recall the events regarding R #1 on [DATE], she said I was working as a med tech (Medication Technician) that night, (Name of CNA #2) had come out of the room and asked for my help. I saw her (R #1) on the floor with her face between the rail and the mattress. When asked for clarification of R #1's position, she said It was in between the rail and the mattress, her head was caught between the two. It was right in between, right in the middle, I had to stick my hand between the side trail and mattress and move her head out. When asked if R #1 could reposition herself or grab the rail, she said No we had to do it for her, she could help, but not by herself. Only with her left side though, she couldn't do it if it was on her right side, not sure why. When asked if there were any complaints about the old mattresses, she said All the residents complained about the mattresses (MA65). They're hard to turn people in. She stated that after the incident, they took a lot of the side rails off the beds. EE. On [DATE] at 2:56 pm, during interview with the Acting Administrator (AA), when asked at what point was there a concern with the mattress, she stated that the DON's concerns were with some marks on R #1's neck. So we had our nurse consultant in town, and I believe that (Name of DON) and the nurse consultant rallied to assess the mattress. Regarding her level of involvement, she stated The nurse consultant kind of took over. Once we realized that we didn't have an order for [REDACTED]. The side rails anyway. The whole thing happened so fast. OMI (Office of Medical Investigator) was called and they said they didn't need to (investigate) because her (R #1) advanced dementia and history of smoking. It wasn't unusual for her to pass. We suggested reporting it to the state. Nurse consultant thought that since it was a usual death. It wasn't unintended. She was of age and there wasn't anything unusual. That it didn't need to be reported. Regarding concerns with the bed, she said I am not sure where the problem with the bed came up. That was not something that I came up with. I don't know who made the suggestion. FF. On [DATE] at 11:21 am, during interview with the DON, regarding the training provided by the mattress/bed company ([DATE]), she confirmed that it was only offered to those staff that were working that day, It wasn't a great in service. They just talked about both beds. Regarding if CNAs adjust the air pressure on the mattresses, she said I believe that the CNAs do not. They have never been trained to do a max inflate. The in service a couple months ago, they talked about max inflate. But it was never like, this is how you do it. It was basically just how the bed works. When asked how does she know that her staff aren't using the max inflate, she said I don't know that staff aren't using max inflate. I can almost guarantee that the night staff doesn't touch those settings cause they don't know how to work them. There may be a few aids that know how to work those beds but they should not be adjusting the settings cause it is based on weight. GG. On [DATE] at 12:17 pm ,during interview with CNA #2 (Night shift CNA), she confirmed that she uses the max inflate button to provide care to residents, and she used max inflate when she provided care to R #1 the evening she passed. HH. On [DATE] at 2:32 pm, during interview with the DON, she confirmed that she did interview CNA #3 however she did not write it down. She stated, that CNA #3 said the same thing as CNA #2 about that evening. When asked what CNA #3 said about R #1's position, the DON said She said that her neck was pressed up against the bed rail, torso and bottom half on the floor. Besides interviewing the initial witnesses, the DON confirmed that there was nothing else she did for her investigation. Findings related to R #2: II. On [DATE] at 10:43 am, during an interview with LPN #1 he stated The very next day (after R #1 passed), (Name of R #2) got his arm caught (between the bed rail and air mattress). It was weird. JJ. On [DATE] at 1:30 pm, during interview with RN #2 when asked if anyone had ever gotten stuck between the air mattress and bed rail, she stated Here? Yes. We had (Name of R #2). I was the nurse that came in the morning to relieve the night nurse. I didn't see anything that happened. I heard there was an issue with his mattress. He was IV (Intravenous) and I went to check on him and do rounds and when I went, he was really a swollen man. He didn't want to go to the hospital. He said that he got caught and rubbed on his left chest up to the neck. Three weeks ago or over. I got him out of bed and we cleaned him up. I did a quick assessment and I noticed his swelling was still pretty bad. I wanted to send him out and I called the doctor cause of the swelling. The part about being stuck in the area. It was no longer an issue. He was laughing about it and saying that he got stuck in Spanish. Left side of neck, chest and shoulder. Sent him (to the hospital) cause of the swelling. When asked if anything happened to the resident's bed after he got stuck, she replied He never came back (from the hospital). When asked if she told anyone about him getting stuck, she stated I told the DON and CNAs. I replaced the mattress, He never came back. KK. Record review of Progress Notes for R #2 dated [DATE] revealed 0330 (3:30 am) Staff herd (sic) the resident asking for help form his room 0330 staff entered the clients room and found the resident trapped with his head and Lt (left) forearm in the quarter bed rail. The clients was facing the bathroom wall with his neck and Lt forearm entangled in the Lt bed railing 0331 (3:31 am) staff immediately deflated the air mattress released the resident from the bedrail and assessed the clients airway. 0333 Nursing staff completed ABCs measures, ran a full head to toe assessment, completed ROM (Range of Motion) and neurological cheeks (sic) were started. The client was asked about information regarding the occurrence the resident stated I was in bed reached for my water pitcher on my bedside table, the mattress deflated on the Lt (left) side inflated on the rt (right) side and forced me off the bed, it then inflated on the flat side and forced my head and arm between the mattress and the railing this is when I began asking for help. 0400 (4:00 am) on call for the facility was informed of the incident via telephone 0410 (4:10 am) on call for (Name of Medical Doctor) was called with no response. 0530 (5:30 am) POA (Power of Attorney) for the client was called and informed of the occurrence, POA stated that he would be arriving in the facility sometime in the morning or early afternoon. LL. On [DATE] at 2:15 pm, during interview with the DON, when asked if any other residents had been caught between the bed rail and mattress before, she said No. When asked if she was aware of the incident involving R #2, she said Yes. I heard that he had fallen on the floor and he was reaching over to get a glass of water and his mattress moved him one way or another and he had his feet hanging over the bed. We were gonna send him out for his cardiac issues. We ended up sending him out that day because of the concerns his son had with the cardiac issues. When asked if she had any concern regarding R #2's bed or bed rails, she said No. He had a fall and was sent shortly thereafter. DON confirmed that this incident happened after R #1 passed. When asked if she had any new insight into what happened to R #1 after hearing about what happened to R #2, she said Not really. Maybe a little with the mattress concerns. We didn't have a whole lot of time to investigate him cause he was sent out so quickly. He did yell for help. I know that. DON confirmed that she did not report this incident to the state. MM. On [DATE] at 2:56 pm during interview with the Acting Administrator (AA), she denied being aware of any problems with the bed. When asked if she would be informed of bed problems, she said I believe so. I hope so. When asked if she was informed that resident, R #2 got caught in his bed, she said No. I knew he went out that day but I was told that it was for heart related. The son told me that he wanted him to go out. He had trouble getting out of bed because of the mattress. When asked again if she was aware that R #2 got caught between the air mattress and bed rail, she said I believe that I was. Findings related to R #3: NN. On [DATE] at 2:27 pm during observation and interview, R #3's bed had no bed rail. R #3's Roommate, R #10 stated that the facility has recently changed the resident 's air mattress. He stated He fell off (the bed) three times in one night. A week ago, more than that. When asked about the bed rails, he stated They (staff) took them off. He would slide right off (the bed), arou

The facility self reported an injury of unknown origin, regarding a resident that was found unresponsive in her room, with the lower part of her body on the floor and the left side of her neck pressed up against the bed rail. The resident had a laceration/discoloration to the left side of her neck. The resident had shallow breathing and shortly thereafter, passed away. The facility replaced all the air mattresses the following day. Based on observation, record review and interviews, the following was discovered: 1. Multiple residents had problems with the air mattresses pushing them around/out of bed prior to this incident. 2. Not all residents were being assessed for the use of bed rails prior to being used. 3. Staff was not provided adequate training on entrapment risk and how and when to adjust the air pressure in the air mattresses. 4. Between when the resident expired and the air mattresses were replaced, another resident got caught between the air mattress and bed rail, resulting in injury. This resulted in Immediate Jeopardy being called on [DATE] at 11:55 am. A Plan of Removal was received and and rejected on [DATE] at 10:56 am. A second Plan of Removal was received and approved on [DATE] at 1:07 pm. The Plan of Removal Included: 1. Immediate education on safety risk of enablers (bed rails) that may result in entrapment. 2. Interdisciplinary assessment of residents with side rails to be done monthly and identify all residents for entrapment risks on-going and upon admission. 3. DON (Director of Nursing) to contact the manufacturer of the beds and air mattresses for their recommendations. Immediate and on-going staff education on bed safety and risks that would jeopardize the resident's safety, including entrapment. 4. Immediately implementing a bed safety program to include: gaps within the bed system, ensure bed rails are properly installed and identifying additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment. 5. Quality Assurance (QA) committee to review bed safety reports on a monthly basis and PRN (as needed) for appropriate action. Based upon the Plan of Removal, the scope and severity was decreased from a K, to a H, Level 3. Based upon observation, record review and interview, the facility failed to be administered in a manner that enables it to maintain the highest practicable physical, mental and psychosocial well-being of each resident by: 1. Not assessing residents for the use of bed rails prior to being used. 2. Not monitoring the air mattresses and identifying that there was evidence that the air mattresses (Brand:Invacare MicroAir MA65 Alternating Pressure with Low Air Loss System) were pushing residents (R #3 and R #4) off/around their beds, which along with side rails, could pose a risk for entrapment. 3. Not educating staff on how and when to adjust the air pressure, especially for the use of max inflate (inflating the air mattress to firm for purposes of providing personal care). 4. Not immediately intervening when a concern with the mattresses was identified, allowing residents to continue to sleep on the MA65 beds while waiting for the bed replacement. 5. Not conducting a thorough investigation to determine a likely cause of R #1's demise, to then identify appropriate interventions to prevent it from reoccurring. 6. Not immediately implementing interventions to decrease the risk for entrapment for other residents, after R #1 expired. This deficient practice likely resulted in R #1 becoming entrapped between her air mattress and the bed rails causing her death, and R #2 becoming entrapped between the air mattress and bed rail which likely resulted in bruising. If the facility Administration is not monitoring for hazards, assessing the risk of assisted devices, and not intervening immediately when problems are identified, then residents are likely to experience preventable physical injury and/or death. The findings are: A. Record review of R #1's care plan dated [DATE] revealed (Name of R #1) is at risk for skin impairment r/t (related to) decreased mobility, incont. (incontinent) of b/b (bowel and bladder), MASD (Moisture Associated Skin Damage) to bottom. Interventions included Use pressure reducing mattress on bed. B. Record review of the Micro Air User Manual for MA65 dated 2011 revealed 5.2 Entrapment May Occur. Warning: Patient entrapment with bed side rails may cause injury or death. Mattress must fit bed frame and side rails snugly to prevent patient entrapment. Monitor patient frequently. Proper patient assessment and monitoring, and proper maintenance and use of equipment is required to reduce the risk of entrapment. Variations in bed rail dimension, and mattress thickness, size or density could increase the risk of entrapment. C. Record review of R #1's Progress Notes dated [DATE] revealed resident was checked on during reg (regular) rounds at midnight resident was resting comfortably, attend (brief) was changed and bed was in lowest position. 0030 (12:30 am) client was in bed with her eyes closed although she was very restless 0125 (1:25 am) the CNA (certified nurse aid) on shift checked on the client and found her laying on the floor on top of her bed mat (floor) with her bed in the low position, the client feet and torso were on the floor and her neck was pressed up against the quarter bed railing, resident also had a 2 cm (centimeter)* (by) 0.7 cm *0.1 cm laceration to the midline of her neck 0126 (1:26 am) the resident was placed in her bed oxygen was placed on the client all pillows were removed from the bed and sternal rub (pain stimulus applied in an attempt to arouse) was performed with no response although the client was still breathing. 0129 (1:29 am) (Name of medical clinic) was called and emergency transport was dispatched 0135 (1:35 am) on call for (Name of Physician #1) was notified of the clients death as well as the Director of Nursing D. On [DATE] at 9:37 am during an interview with Social Services Director (SSD) regarding R #1, he said She had been stable, no real changes. Baseline very confused. Was not capable of walking on her own. Needed maximum assistance with transfers. She ambulated in her wheel chair. She could propel it on her own but she needed cues on which direction to go and how. She could communicate. She'd nonsensical answer. E. Record review of the Minimum Data Set for R #1 dated [DATE] revealed that R #1'scognitive skills and decision making abilities were severly impaired and she needed extensive assistance with bed mobility and transfers, and total dependence for toilet use and personal hygiene. F. On [DATE] at 9:58 am, during interview with Central Supply, when asked what happened when the R #1 passed, she replied I really don't know. Something with her (air) mattress (MA65) was over inflated. I don't get that. How she would have slid. When asked if the resident was expected to pass, she replied No. She wasn't Hospice or anything. G. Record review of pick-up/Service Ticket from Medical Supply Company dated [DATE] revealed that the MA65 mattresses were picked up and AirDyne Mattresses were delivered/exchanged for R #2, 4, 7, 11, 25 and 26. H. On [DATE] at 10:09 am, during an interview with CNA #1, she said that following R #1's death, We had a meeting and they told about the air mattresses, they told a little bit about that some people don't know how to use them properly, and they told us that they were going to switch them. The ones they switched out for are more flat (AirDyne), level and the old ones (MA65) were a little more bulky. When asked if there were any problems with the old mattresses (MA65), she said I never did. I know people had problems inflating them. Like when you change people the old mattresses (MA65) would bulk up on one side, if they were turned. If some (staff) forgot to inflate or fill it up, a resident could fall out. I. On [DATE] at 10:15 am during interview with R #1's daughter she stated I have to be honest, I don't know a whole lot. They called me at 3:30 (am) in the morning. I was told by the nurse/DON that they found my mom on the floor, and she seemed to be panicked and couldn't communicate, she was breathing when 911 came, and she passed when they were there. I went there, and I saw my mom. I noticed she had a mark on her neck, it looked weird. The nurse that found her, at 10:30 pm said she found that her legs were off the bed, she was restless but she usually is not, she changed her and got her in bed. At 1:10 (am) she found my mom, and her neck got caught in the railing, she was convulsing and got caught on the rail. She wasn't communicating, her dementia is too advanced. Her body was moving and she got caught. J. On [DATE] at 10:16 am during interview with Registered Nurse (RN) #1, when asked what happened when the resident passed, she replied I wasn't here. I didn't get here until a couple days after. When I got here, we did get all the mattress changed out to the Airdyne mattress. Foam in the middle. The one she had (before) was all air (MA65). Regarding her air mattress, the RN replied It couldn ' t have been more that 2 months (old). She had some sheering on the back. So we wanted to make sure it didn't get any worse. When asked if the air mattress helped, she replied Yes, she healed pretty fast. When asked if there were any problems with the old mattresses (MA65), she replied Not that I was aware of. RN #1 explained that They weigh the person, to adjust the setting (air). The people that bring the mattress to set them up (make the adjustments). No one should touch that once its sets up. K. On [DATE] at 10:43 am during an interview with Licensed Practical Nurse (LPN) #1 regarding what happened that night that R #1 passed, he said Resident was laying next to her bed, the bed rail was up she was lateral to her bed, facing away from the bed. The bed was in the low position, her feet and torso was on her left side of her neck, little bit of her face but more so her neck was pressed up against the bed rail. When asked what he thinks happened, he said What I think might have happened, she got up on her own, got caught in the bed rail, then the air mattress (MA65) inflated behind her. Those mattresses would deflate on one side, and probably entrapped. That's the only reason I say that. L. On [DATE] at 11:20 am during an interview with the DON, when asked what she thought happened to R #1, she said I don't know, I honestly do not know. When asked if there was a problem with the bed, she said I don't know if there was or not. I don't know. It is kinda out of my realm. Usually we change them (air mattresses) out when they heal (from wound). She was almost healed out. Probably at that time, it may have been time for a regular mattress. When asked what happened after she passed, she said We decided to go back to the Airdyne mattress. We weren't sure if the mattress was malfunctioning. Not pressuring right, pushing up on one side. We don't know. We called (Name of Supplier), we were nervous because we had a few people in those mattresses. When asked how long it took to get the new mattresses, she said Maybe 24 hours. New mattresses came and everyone's mattress (air mattress) was replaced. When asked if anyone had gotten caught in the old mattresses, she said No. Never. Never had a complaint, or incident that I am aware of or saw. DON confirmed that she conducted the investigation following R #1's passing, which included witness statements from the nurse (Name of LPN #1) and the 2 CNAs, (Name of CNA #2 and CNA #3). They all said the same thing. We talked about the mattresses and we were worried that it could have been the mattresses that could have flung her. When asked how the new mattresses are being monitored, she said They are all set by resident weights by Central Supply or wound care nurse. DON stated that the inflate settings are locked and the Aides do not know how to adjust the settings. When asked if there would ever be a reason to inflate or deflate the mattress after it has been set she said Sometimes you can do a max inflate for resident care. From my understanding they go back to original setting after 30 minutes. I don't know if that happened (with R #1). DON stated that she didn't think the CNAs are using the max inflate. M. Record review of the Micro Air User Manual for the MA65 dated 2011 revealed on page 25 Press the Max Inflate/low air loss button to select the max inflate mode or the low air loss mode. Max Inflate Mode- in this mode, the mattress inflates rapidly to maximum firmness. A series of beeps sound every three minutes as a reminder that the Max Inflate mode is active. After 30 minutes, the Max Inflate mode deactivates and the control until defaults to the previous setting. N. On [DATE] at 2:38 pm during interview with CNA #4 when asked if there is a difference with the new mattresses, he responded During the day time, yes. The other ones (MA65) seemed more soft, cause it was all air. There was a chance you could accidentally unplug it. It had alternating pressure every 15 minutes. There was a max inflate. That was for transfers or changes in bed. Push button to max inflate and then 30 minutes it would go back. Max inflate feels like a regular mattress. When asked if he had been provided training on the mattresses, he responded That company came by and showed us how to use them and the settings have to be a certain weight. When asked if he had any concerns with the old mattress, he stated I didn't. When asked why the mattresses were replaced then, he stated There were concerns of the mattress pushing residents over (to one side). I never got to see that. When asked if he had ever heard of any residents getting caught in the bed, he responded I heard of (Name of R #1) from staff (her getting caught). CNA #4 was unable to provide any more details. O. On [DATE] at 8:08 pm during an interview with CNA #2 she was asked to recall the events when she found R #1 on [DATE]. She stated, Well her legs were hanging off the bed, around 10:30 or 11:00 pm, so I put her back in bed and changed her, and I checked on her once or twice and she was still in bed, then I went in again and her legs were out of the bed again. Her legs were down on the ground and she was facing the rail. On the rail, her face was resting on it. Regarding R #1's functional status, she said Alzheimer's. She couldn't do much. P. Record review of the Nursing Services Policy and Procedures Manual: Bed Safety revised [DATE] revealed 2. To try and prevent deaths/injuries from the beds and related equipment, the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. review the gaps within the bed system are within the dimensions established by the FDA (food and drug Administration) e. identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). Staff Training 4. The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. Side rail Use Interdisciplinary Assessment 5. if side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. Q. On [DATE] at 10:10 am, during interview with the Acting Administrator, she confirmed that the facility was not doing bed rail assessments prior to what happened to R #1. She explained that the beds came with bed rails and they were just being used. R. On [DATE] at 11:23 am, during interview with Certified Medication Aide (CMA) #1 when asked if she had received any education or in services regarding bed rails, gaps or entrapment, she stated Not that I can remember, not recently any way. S. On [DATE] at 1:26 pm, during an interview with RN #2, she confirmed that she had never received any training on entrapment. T. On [DATE] at 1:29 pm, during an interview with CNA #5, when asked if she had any trainings or in-services recently on how to use the air mattresses and when to adjust them, she said No, not recently. There was a training they had recently at a church, it was an all day thing, but I couldn't make it. Usually they (facility management) will catch me up on the in-services, but I haven't had anything recently. U. On [DATE] at 1:30 pm, during interview with RN #3, when asked if R #1 ever complained about the mattress, she stated She couldn't talk. She could say random things. When asked if any training was provided to staff after the incident (with R #1), she stated They had a meeting. I was too busy on the floor and I didn't go. When asked if CNAs ever use the max inflate setting for the air mattresses, she replied I don't think that would be appropriate. I have never seen a CNA max inflate. V. On [DATE] at 1:45 pm, during interview with CNA #6, when asked if R #1 moved around in bed, she replied No, if you put her in one position she stays in that position. W. On [DATE] between approximately 10:00 am and 12:00 pm, all 54 residents' beds were observed for bed rails. Bed rails were observed to be on 20 out of the 54 beds (R #,[DATE]). The DON was asked for bed rail assessments for all 20 residents, and provided assessments for 9 out of 22 residents (R #5- R #13). X. On [DATE] at 2:15 pm, during interview with the DON, she confirmed that not all residents that have bed rails have been assessed for the use of bed rails. She stated that they had planned to complete all the assessments by today ([DATE]) however that did not happen. The DON confirmed assessments for the use of side rails were not done prior to the incident with R #1. When asked when did she start to have a concern with the air mattresses (MA65), she stated Probably on the 16th ([DATE]). She stated that the new mattresses (Airdyne) came on the 17th. DON confirmed that residents continued to sleep on the air mattresses (MA65) on the evening of the 16th after R #1 has passed away. When asked if staff adjust the air, she stated They are not supposed to. When asked if she had ever heard of that happening, she stated No, I don't think they know how. We did an in-service on this back about 9 months ago. Because they (air mattresses) were new to the facility, the settings and how they worked and the appropriateness of them. She confirmed the in service on [DATE] talked about adjusting the air pressure. To my knowledge they (staff) hadn't (adjusted the air pressure). I was on the floor when we got these mattresses. I know to max inflate when providing care and wound care and you put it back to the setting when you're done or I believe that it (air mattress) deflates after 15 or 30 minutes. When asked why the training agenda ([DATE]) include Air mattress setting to be ONLY set by nursing staff she responded In case they were inflating or deflecting those (air mattresses). We address that in that meeting. Most of the CNAs said they don't know how to do that. They (air mattress) are set by weight before they (mattresses) came in. When asked if any training was provided after R #1 passed, she responded No. They (staff) acted appropriately and they did what they were supposed to do. Let the charge nurse know and stay with the resident. When asked if they have provided any training regarding entrapment risk, she stated Not since I've been DON. Previous, I don't know. When asked if there had been any concerns with the old mattresses, she stated No, not until this incident. When asked if she is aware of the measurements between the bed rail and mattress that can pose a risk for entrapment, she said After this incident, I did ask (Name of Central Supply) to provide measurements of what constitutes as a quarter rail or half rail. The DON conformed that she is unaware of entrapment risk measurements. Y. Record review of the All Staff Meeting Agenda dated [DATE] revealed the agenda item, Air mattress settings to be ONLY set by nursing staff. Of the 56 staff members names, only 34 staff had signed in to the training. Z. On [DATE] at 2:17 pm, during an interview with CNA #7, when asked if there were any incidences with the previous mattresses (MA65), she stated, The ones we had before, (Name of R #4) was not happy with it and when we would put her in, she would just sink. She would just be sunken in there. I wouldn't change the setting, I would just take her out of bed and allowed it to inflate again. When asked if she has heard of anyone falling out of them, she stated, No, just her, she is the only one I had a problem with. When asked if she has received any In-services or education on air mattresses, bed rails or entrapment, she confirmed that she hadn't recently. AA. On [DATE] at 10:25 am, during observation of R #4's air mattress and interview with CNA #4 when asked if he could demonstrate how the air mattresses work, he stated This is a regular mattress (Air Dyne) so it doesn't deflate all the way. The pressure is assigned to their weight. Observation made that the air mattress was unplugged. CNA plugged in the mattress and stated There wasn't alternating pressure. It doesn't deflate. The other mattress (MA65) would have been deflated all the way to the bottom (if it had been unplugged). CNA #4 confirmed that regarding the old air mattresses, You would need to max inflate to provide care. The old one it would go back to the original setting after 30 minutes to its original setting. CNA #4 confirmed that he would not deflate the mattress after using max inflate. When asked about training, he confirmed that the Supply Company showed the staff how to inflate or deflate the mattresses. He also confirmed that he learned about the AirDyne mattresses in that original training ([DATE]). When asked if he received any training after R #1 passed away, he stated No. We were told not to touch it (the settings on the air mattresses) besides auto firm. BB. On [DATE] at 10:36 am, during interview with Central Supply, she stated that they removed the old mattresses (MA65) when the new mattresses (AirDyne)came. Those ones were actually a lot different cause it would blow up the mattress. If the power went out, it would just deflate and be on the frame. The old ones would alternate the pressure, alternate the weight. Regarding staff changing the air pressure, she stated When they were doing transfers they would do max inflate and when they sat up it would be at fowler (upright position). Max inflate; it would harden the old mattresses. When asked if the old mattresses needed to be set back (deflate back to original setting), she stated I think it would automatically go off and go back to its original setting. She confirmed that during the training provided by the company, they didn't discuss entrapment risk or how the mattress fit within the bed rails. She stated that the training was only provided to whatever staff were here. She also confirmed that the training was provided before the old air mattresses were delivered on [DATE]. CC. On [DATE] at 11:20 am, during an interview with CNA #8, she confirmed that she did not receive any training on how to use the new air mattresses. No, I'd like some training on it because I'm not sure about how to use the buttons on it, I don't really know how to use them. DD. On [DATE] at 1:59 pm, during an interview with CNA #3 she was asked to recall the events regarding R #1 on [DATE], she said I was working as a med tech (Medication Technician) that night, (Name of CNA #2) had come out of the room and asked for my help. I saw her (R #1) on the floor with her face between the rail and the mattress. When asked for clarification of R #1's position, she said It was in between the rail and the mattress, her head was caught between the two. It was right in between, right in the middle, I had to stick my hand between the side rail and mattress and move her head out. When asked if R #1 could reposition herself or grab the rail, she said No we had to do it for her, she could help, but not by herself. Only with her left side though, she couldn't do it if it was on her right side, not sure why. When asked if there were any complaints about the old mattresses, she said All the residents complained about the mattresses (MA65). They're hard to turn people in. She stated that after the incident, they took a lot of the side rails off the beds. EE. On [DATE] at 2:56 pm, during interview with the Acting Administrator (AA), when asked at what point was there a concern with the mattress, she stated that the DON's concerns were with some marks on R #1's neck. So we had our nurse consultant in town, and I believe that (Name of DON) and the nurse consultant rallied to assess the mattress. Regarding her level of involvement, she stated The nurse consultant kind of took over. Once we realized that we didn't have an order for [REDACTED]. The whole thing happened so fast. OMI (Office of Medical Investigator) was called and they said they didn't need to (investigate) because her (R #1) advanced dementia and history of smoking. It wasn't unusual for her to pass. We suggested reporting it to the state. Nurse consultant thought that since it was a usual death. It wasn't unintended. She was of age and there wasn't anything unusual. That it didn't need to be reported. Regarding concerns with the bed, she said I am not sure where the problem with the bed came up. That was not something that I came up with. I don't know who made the suggestion. FF. On [DATE] at 11:21 am, during interview with the DON, regarding the training provided by the mattress/bed company ([DATE]), she confirmed that it was only offered to those staff that were working that day, It wasn't a great in service. They just talked about both beds. Regarding if CNAs adjust the air pressure on the mattresses, she said I believe that the CNAs do not. They have never been trained to do a max inflate. The in service a couple months ago, they talked about max inflate. But it was never like, this is how you do it. It was basically just how the bed works. When asked how does she know that her staff aren't using the max inflate, she said I don't know that staff aren't using max inflate. I can almost guarantee that the night staff doesn't touch those settings cause they don't know how to work them. There may be a few aids that know how to work those beds but they should not be adjusting the settings cause it is based on weight. GG. On [DATE] at 12:17 pm ,during interview with CNA #2 (Night shift CNA), she confirmed that she uses the max inflate button to provide care to residents. HH. On [DATE] at 2:32 pm, during interview with the DON, she confirmed that she did interview CNA #3 however she did not write it down. She stated, that CNA #3 said the same thing as CNA #2 about that evening. When asked what CNA #3 said about R #1's position, the DON said She said that her neck was pressed up against the bed rail, torso and bottom half on the floor. Besides interviewing the initial witnesses, the DON confirmed that there was nothing else she did for her investigation. II. Record review of Department of Health Incident Report identifying the incident as an injury of unknown origin was signed by the DON on [DATE] at 1:15 pm. The cover sheet was dated [DATE] and the fax stamp identified that the Incident Report and Investigation was faxed on [DATE]. The Investigation Conclusion stated The facility does not substantiate abuse or neglect related to this occurrence, and believe (Name of R #1) was attempting to exit her bed and expired. After a thorough investigation, it is noted that staff responded timely and appropriately to the occurrence and acted accordingly. There was no docummentation of any post incident interventions identified or implemented. Findings related to R #2: JJ. On [DATE] at 10:43 am, during an interview with LPN #1 he stated The very next day (after R #1 passed), (Name of R #2) got his arm caught (between the bed rail and air mattress). It was weird. KK. On [DATE] at 1:30 pm, during interview with RN #2 when asked if anyone had ever gotten stuck between the air mattress and bed rail, she stated Here? Yes. We had (Name of R #2). I was the nurse that came in the morning to relieve the night nurse. I didn't see anything that happened. I heard there was an issue with his mattress. He was IV (Intravenous) and I went to check on him and do rounds and when I went, he was really a swollen man. He didn't want to go to the hospital. He said that he got caught and rubbed on his left chest up to the neck. Three weeks ago or over. I got him out of bed and we cleaned him up. I did a quick assessment and I noticed his swelling was still pretty bad. I wanted to send him out and I called the doctor cause of the swelling. The part about being stuck in the area. It was no longer an issue. He was laughing about it and saying that he got stuck in Spanish. Left side of neck, chest and shoulder. Sent him (to the hospital) cause of the swelling. When asked if anything happened to the resident's bed after he got stuck, she replied He never came back (from the hospital). When asked if she told anyone about him getting stuck, she stated I told the DON and CNAs. I replaced the mattress, He never came back. LL. Record review of Progress Notes for R #2 dated [DATE] revealed 0330 (3:30 am) Staff herd (sic) the resident asking for help form his room [ROOM NUMBER] staff entered the clients room and found the resident trapped with his head and Lt (left) forearm in the quarter bed rail. The clients was facing the bathroom wall with his neck and Lt forearm entangled in the Lt bed railing 0331 (3:31 am) staff immediately deflated the air mattress released the resident from the bedrail and assessed the clients airway. 0333 Nursing staff completed ABCs measures, ran a full head to toe assessment, completed ROM (Range of Motion) and neurological cheeks (sic) were started. The client was asked about information regarding the occurrence the resident stated I was in bed reached for my water pitcher on my bedside table, the mattress deflated on the Lt (left) side inflated on the rt (right) side and forced me off the bed, it then inflated on the flat side and forced my head and arm between the mattress and the railing this is when I began asking for help. 0400 (4:00 am) on call for the facility was informed of the incident via telephone 0410 (4:10 am) on call for (Name of Medical Doctor) was called with no response. 0530 (5:30 am) POA (Power of Attorney) for the client was called and informed of the occurrence, POA stated that he would be arriving in the facility sometime in the morning or early afternoon. MM. On [DATE] at 2:15 pm, during interview with the DON, when asked if any other residents had been caught between the bed rail and mattress before, she said No. When asked if she was aware of the incident involving R #2, she said Yes. I heard that he had fallen on the floor and he was reaching over to get a glass of water and his mattress moved him one way or another and he had his feet hanging over the bed. We were gonna send him out for his cardiac issues. We ended up sending him out that day because of the concerns his son had with the cardiac issues. When asked if she had any concern regarding R #2's bed or bed rails, she said No. He had a fall and was sent shortly thereafter. DON confirmed that this incident happened after R #1 passed. When asked if she had any new insight into what happened to R #1 after hearing about what happened to R #2, she said Not really. Maybe a little with the mattress concerns. We didn't have a whole lot of time to investigate him ca

During resident room observation and restroom water checks, water temperatures appeared to be very hot to the touch. Further investigation of water temperature checks in resident rooms on all Wings revealed temperatures ranging from 117.4 degrees to 132.1 degrees Fahrenheit. The Administrator was informed of the Immediate Jeopardy on 05/18/15 at 3:49 pm. A plan of Removal was accepted 05/18/15 at 6:02 pm, which included: 1. Immediate adjustment of the temperatures on the water heaters, 2. Draining existing hot water for the system and checking temperatures again, 3. Facility will monitor water temperatures throughout the evening to ensure water temperatures are between 100 and 105 degrees, and Facility Maintenance Supervisor will checks water temperatures every hour at random locations on 05/19/15, 4. Maintenance Supervisor was educated on how to calibrate non-digital thermometers, and the facility will replace all thermometers with digital thermometers, 5. All facility staff will be oriented to the safe temperature range between 100-119 degrees, and discrepancies will be reported to the Maintenance Supervisor and Administrator, 6. Digital temperature gauges will be installed in each shower, 7. All laundry will be washed at the laundry mat until a consultant can verify that the hot water and laundry chemicals will ensure proper infections control and sanitization, 8. Water temperatures will be monitored daily and then once stable, 3 times each week at random locations to ensure safe ranges. Based on observation, record review and interview, the facility failed to ensure residents were free of accidents and hazards by: 1. Not ensuring that water temperatures were within a safe range to prevent burns for bathing and Activities of Daily Living (ADL)s. 2. Not identifying likely causes or implementing new interventions after R #48 has sustained 4 falls in the early morning. 3. Not ensuring that Resident #3 received adequate supervision and assistive devices to prevent falls. The resident experienced multiple falls with a fracture and skin tears. This deficient practice has the potential to affect all 52 residents, identified on the Facility Census List provided by the Administrator on 05/18/15. The findings are: Findings related to water temperatures: A. On 05/18/15 at 10:43 am during observation of R #48's restroom (Room 207), the water temperature in the restroom sink was hot to the touch. At 11:49 am the water temperature in the restroom sink was measured at 123.3 degrees B. On 05/18/15 at 11:38 am during observation of Room 204, the water temperature in the restroom sink was hot to the touch, and measured at 125.1 degrees. C. On 05/18/15 at 12:47 pm during observation of random room restroom sink water temperatures revealed the following temperatures: Room 210 125.4 degrees Room 209 130.1 degrees Room 107 128.5 degrees Room 109 132.1 degrees Room 114 130.1 degrees Room 202 123.8 degrees Room 203 130.3 degrees Room 204 125.1 degrees Room 206 130.1 degrees D. On 05/18/15 at 1:38 pm during interview with the Maintenance Supervisor (MS), he stated that he checks the water temperatures of 4 random rooms on Thursday of every week. He stated I put it downstream for about 2 minutes until it taps out. They've been about 110-118 (degrees Fahrenheit). When asked what is an acceptable water temperature, he stated 115 (degrees). E. On 05/18/2015 at 1:38 pm during interview with Certified Nurse Aide (CNA) #7 she stated that some residents like hot showers and for those residents, she moves the dial towards the hot side and looks at the temperature gauge on the wall to ensure it was not too hot or cold. F. On 05/18/15 at approximately 2:00 pm during observation of the shower rooms, revealed the following temperatures (Fahrenheit): 1. Memory Unit Shower Room: Shower #1 temperature gauge on the wall read 100 degrees, however the temperature through the thermometer probe read 122.4 degrees. Shower #2 temperature gauge on the wall read 100 degrees, however the temperature through the thermometer probe read 118.8 degrees. 2. East Shower Room: Shower #1 temperature gauge on the wall read 100 degrees, however the temperature through the thermometer probe read 110.2 degrees and a second time checked the wall gauge read 105 degrees and the temperature through the thermometer probe read 111.1 degrees. Shower #2 temperature gauge on the wall read 100 degrees, however the temperature through the thermometer probe read 123.3 degrees. G. On 05/18/15 at 1:58 pm during interview with R #9 when asked if the water ever gets too hot for her, she responded It gets too hot for the 'help' but not for me. H. Record review of the Water Temperature Logs revealed the following temperatures (degrees Fahrenheit): 12/18/14: Rooms 101, 106, 202 and 205 were 120 degrees 12/25/15: Rooms 201 and 203 were 120 degrees 01/08/15: Room 203 was 122 degrees 01/22/15: Rooms 103, 107, 201 and 205 were 120 degrees 01/29/15: Rooms 104, 106 and 201 were 120 degrees 02/05/15: Rooms 104, 106 and 202 were 120 degrees 02/12/15: Rooms 102, 106 and 203 were 120 degrees 02/19/15: Rooms 106 ad 205 were 120 degrees 02/26/15: Rooms 103, 106, 204 were 120 degrees 03/05/15: Rooms 101, 106 and 204 were 120 degrees 03/12/15: Rooms 102, 106 and 201 were 120 degrees 03/19/15: Room 204 was 120 degrees 03/26/15: Room 203 was 120 degrees 04/02/15: Room 202 was 120 degrees 04/09/15: Rooms 106 and 202 were 120 degrees 04/16/15: Rooms 104, 122 and 207 were 122 degrees, and Rooms 210 and 215 were 120 degrees. 04/23/15: Rooms 101, 214 and 217 were 20 degrees, and Room 204 and 207 were 122 degrees 04/30/15: Rooms 203 and 204 were 122 degrees, and Room 120 and 210 were 120 degrees 05/07/15: Rooms 201 and 212 were 120 degrees and Room 206 was 122 degrees. 05/14/15: Rooms 203 and 206 were 122 degrees and Room 211 was 120 degrees. I. On 05/18/15 at 2:02 pm during interview with the MS, when asked about the temperatures documented on the Water temperature logs, he stated No one has an answer for what the temps (temperature) should be. 120-122 (degrees Fahrenheit) seems like it's within range. The Maintenance Supervisor stated that if the temperatures were 125-130 degrees, I'd call somebody (to adjust them). J. On 05/18/15 at 2:09 pm during observation and interview, the MS was asked to check the temperatures of several rooms. He checked the temperature for Room 209 (previously measured at 130.1 degrees) and left his thermometer under the running water for 58 seconds. The temperature on his thermometer read 118 degrees. For Room 206 (previously measured at 130.1 degrees), he left his thermometer under the running water for 56 seconds and the temperature it read was 122 degrees. When asked how often he calibrates his thermometer, he stated, I have a few of these, so I use it for a couple months and then replace it. MS confirmed that he does not calibrate his thermometers, stating I just buy them and replace them. The MS was asked to calibrate his thermometer and he confirmed that he didn't know how. K. On 05/18/15 at 2:23 pm during observation and interview with the MS, he had his thermometer in a cup of ice water, and he confirmed that the thermometer read 22 degrees Fahrenheit (ice water is 32 degrees Fahrenheit). L. On 05/18/15 at 3:13 pm during observation and interview with the Administrator, the hot water heater temperatures were checked. The Laundry/Kitchen hot water heater was set to 130 degrees (Fahrenheit) and the restroom hot water heater was set to 138 degrees (Fahrenheit). The Administrator confirmed these temperatures. Findings related to R #48: M. Record review of Progress Notes for R #48 revealed: 02/22/15 CNA entered room at 0300 (3:00 am) to provide care and found resident laying on the floor beside the bed. resident was laying with her legs and abd (abdomen) on the floor mat, while her chest, arms and head were on the floor. 03/07/15 at approx. (approximately) 0500 (5:30 am), resident was found by staff with the lower half of her body on the floor mat and upper half of her body on the bed. resident was naked. She was disoriented. It's possible that resident attempted to get out of bed, trying to sit at the side of the bed when the event occurred. 04/24/15 found on floor at approx. (Approximately) 0630 (6:30 am) assisted by cna from floor to toilet. 05/19/15 Resident was found sitting on her floor mat this morning. resident states she was trying to get in her w/c (wheelchair). N. Record review of the Care Plan for R #48 dated 04/29/15 revealed (Name of R #48) is at risk for falls r/t (related to) DX: (diagnosis) stroke and previous falls prior to admission, hx of fall and recent fall 04/24/2015. Interventions included: fall leaf program, side mattress, low bed, pin alarm to bed and in w/c (wheelchair), assist with mobility needs, encourage use of assistive device for locomotion+ wheelchair, leave night light on in room, keep call light in reach and respond promptly, keep personal items and frequently used items within reach, provide an (sic) safe environment free of clutter, glare, foreign objects, appropriately lit for time of day. O. Record review of the Falls and Fall Risk Management Policy and Procedure dated 04/05/15 revealed Procedure 15. If falling occurs despite intial interventions, staff will implement additional or different interventions. 16. Within 24 hours of the first business day following a fall occurrence the interdisciplinary team will identify possible or likely causes of the fall using resident specific evidence including medical history, known functional impairments, etc. 17. The IDT will evaluate chain of events or circumstances preceding a fall including but not limited to: Time of day. P. On 05/26/15 at 2:21 pm during interview with Social Services (SS) #1, he confirmed that he is on the Falls Committee and there have been no new concerns regarding R #48. Q. On 05/26/15 at 4:17 pm during interview with the Director of Nursing (DON) she confirmed that R #48 is a risk for falls and requires transfer assistance. When asked what interventions have been implemented since her last fall (05/19/15), she said 72 hour monitoring for bruising and change in mental status. When asked if any new preventative measures were implemented, she responded Just the current ones were continued. When asked if the Fall Committee had considered that all R #48's falls happen in the early morning, she looked through the Progress Notes and said On 3/28/15, it was reviewed but there was no change in the orders. Findings related to R #3: R. Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. S. The MDS dated [DATE] indicated the resident had a fall with fracture in the last 2-6 months. The resident had two or more falls, one with injury and one with a major injury. The resident's BIMS score was coded as 9. The resident required extensive assistance with transfers, bed mobility, and toilet use. The resident was frequently incontinent of bowel and bladder. T. The care plan dated 3/18/15 indicated the resident was at a risk for falls due to impaired cognitive ability and impaired decision-making ability related to dementia, decreased vision, mobility and balance. The approaches included, in pertinent part, to check every shift that the self-releasing seat belt (SRSB) and pressure alarm to wheelchair and bed were on and functioning properly, to monitor the residents ability to self-release the belt, and to use an anti-rollback system in the wheelchair. The care plan indicated the resident removed the pressure sensitive wheelchair alarm at times. Additional approaches included to keep the call light in reach and respond promptly and to toilet every 2-3 hours. U. On 5/18/15 at 10:30 AM, the resident was observed in his wheelchair. The resident removed his SRSB, stood and then sat back down; however, the SRSB did not sound. In addition, there was no pressure alarm in the wheelchair and the left anti-roll back and anti-tippers were missing. Staff were observed in the area but no one intervened. V. On 5/19/15 at 8:24 AM, the resident was observed in his wheelchair in the area outside of the dining room. There was no pressure alarm in his wheelchair and the left anti-roll back and anti-tippers were missing. The resident was observed releasing the seatbelt, however, the alarm did not sound. Then the resident reattached the seatbelt. Staff were observed in the area but no one intervened. W. On 5/19/15 at 9:18 AM, the resident was observed in his room in bed. The resident's call light was not in reach. The call light was behind the resident along the wall. There was no pressure alarm in the resident ' s bed. The resident was trying to stand up but was unable to so he laid sideways on the bed. X. On 5/21/15 the resident was observed continuously from 7:44 AM through 10:15 AM. At 7:44 AM, the resident was observed seated in his wheelchair in the dining room. There was no pressure alarm on the wheelchair and the left anti-roll back and anti-tippers were missing. At 8:13 AM, staff took the resident directly from the dining room to the area by the nurse ' s station. At 8:20 AM, the resident removed and then reattached his seatbelt; however, the alarm did not sound. Staff were observed in the area but no one intervened. At 8:55 AM, the resident was taken directly from the nurse's station area to the activity room. At 10:15 AM, the resident was taken directly from the activity room to the area near the nurse ' s station. The surveyor requested to observe incontinence care; however, the aides provided the care without getting the surveyor. At 5/22/15 at 8:15 AM, the CNA who worked with the resident stated the resident has been in the dining room since before 7:30 AM. The resident was not provided incontinence care for almost three hours. Y. Review of event reports and nursing progress notes revealed the resident experienced 15 falls since 9/2014 and sustained one rib fracture, an abrasion, and skin tear. Concerns with the assessment or interventions selected following the resident ' s fall: - 9/11/14 - The resident was found in the bathroom. The alarm did not sound. - 9/16/14 - The resident was found sitting in the bathroom leaning backwards. There was no information documented regarding whether the alarms were on and functioning. - 9/19/14 - The resident removed his wheelchair alarm, self-transferred, and was found in the bathroom. Staff failed to reassess the effectiveness of using a personal alarm for a resident who could remove it. - 10/8/14 - The resident attempted to self-transfer from his wheelchair to bed and fell . The fall was witnessed. The assessment indicated the alarms were in place; however, there was no mention of whether the wheelchair alarm sounded. - 11/13/14 - The resident fell in the hall. There was no documentation of the circumstances surrounding the fall or whether the alarm was used. In addition, there was no evidence therapy screened the resident after 10/14/14. - 1/10/15 - The resident was yelling for help and was found lying on his right side on the floor by the heater. The floor and the resident ' s shirt were wet from the toilet overflowing. The resident was sent to the emergency room for complaints of right elbow pain, increased lethargy and confusion. There was no documentation of the circumstances surrounding the fall or whether the bed alarm was in place and functioning prior to the fall. - 1/18/15 - The resident was yelling for help and was found lying on the floor in his room. The resident had removed his personal alarm to look for something in his dresser. The resident said he fell over backwards. Again, the staff failed to reassess the effectiveness of using a personal alarm for a resident who could remove it. - 3/11/15 - The resident was yelling for help and was found in the bathroom. The resident said he was standing, washing his face and fell down. The resident removed his personal alarm. The resident sustained [REDACTED]. - 3/25/15 - The resident was found on his back on the floor in the bedroom. There was no documentation whether the alarm sounded prior to the fall. There was a new intervention for an activity consult; however, there was no activity consult found. - 3/27/15 - The resident was found in the bathroom on his knees with his pants down. The resident sustained [REDACTED]. - 4/3/15 - The resident was found sitting in trashcan in the bathroom. The resident had removed the SRSB and attempted to self-transfer. There was no indication whether the SRSB or alarm sounded. Staff failed to reassess the effectiveness of using a SRSB for a resident who could remove it. - 4/11/15 - The resident fell in his room. The fall was witnessed. The resident attempted to stand up from his wheelchair but the wheelchair rolled back out from behind the resident. The resident sustained [REDACTED]. Again, the staff failed to reassess the effectiveness of using a personal alarm and SRSB for a resident who could remove it. - 4/25/15 - The resident was found sitting in front of his dresser. The resident removed his SRSB. There was no indication whether the SRSB or alarm sounded. Again, the staff failed to reassess the effectiveness of using a personal alarm and SRSB for a resident who could remove it. - 5/1/15 - The resident was found sitting on the floor near his bed. There was no documentation of the circumstances surrounding the fall or whether the alarm or SRSB was used or sounded. - 5/10/15 - The resident was found on the floor with his back against the bed. There was no documentation of the circumstances surrounding the fall or whether the alarm was used or sounded. Z. The fall prevention policy indicated, in pertinent part, that staff should ensure that all device alarms and equipment are in good repair and in working order prior to using them on the resident. If the item is not in good repair and working order, it is not to be used and the item should be reported to the charge nurse and an item that is working should be used instead. The charge nurse is responsible for checking alarms on a weekly basis and monitoring the devices to ensure they are applied correctly daily during their routine observations of care. Documentation of battery checks will be noted in the Treatment Administration Record (TAR). AA. The 2015 TAR was reviewed and there were no specific treatments for testing or monitoring alarms or batteries according to the policy. BB. The resident's family member was interviewed on 5/19/15 at 11:00 AM and stated the resident had fallen many times in the bathroom because staff did not help the resident right way. The family stated when any alarm sounded staff did not always come right away. The family said there were times when the resident removed the SB and pressure alarms. CC. On 5/22/15 at 8:22 AM, the CNA who worked with resident was interviewed. The CNA said the resident required extensive assistance with toileting. The CNA said the resident needed supervision when seated in his wheelchair since he had fallen a lot. The CNA said the resident was checked for incontinence every two hours or sooner. The CNA said the resident was on a toileting program every two hours because he became anxious. The aide said if they did not help him to the bathroom, the resident would transfer on his own to go to the bathroom. The aide said the resident did not use his call light. The CNAs make sure he has his alarms on at all the times, in the bed and chair. The aide said he knew how to take his alarms off. The CNA said when he gets up he will not call for help. The aide said the bed alarm used to be on the right side of the bed but must have fallen because he can take the alarm off. DD. On 5/22/15 at 8:38 AM, the LPN was interviewed. The LPN said the aides should check the resident every two hours for incontinence. The LPN said the resident can use the call light. The LPN was not sure where the alarms were documented. She thought the aides checked the alarms. The LPN said she would follow up. EE. On 5/22/15 at 11:06 AM, the LPN was interviewed again. The LPN said the nurses were supposed to check the alarms every shift and document it on the TAR. The LPN confirmed the resident ' s SRSB was alarmed and he used both a wheelchair and bed pressure alarm. FF. The Director of Nursing (DON) was interviewed on 5/22/15 at 8:56 AM. The DON said the resident is checked every two to three hours for incontinence. The DON said the resident would attempt to self-toilet multiple times throughout the day. The resident was provided education all the time and he was very independent. He was encouraged to use the call light and wait for assistance. The DON said toilet assessments and elimination status were completed every day in the daily charting, then quarterly and annually. The DON said she would follow up with the toileting assessments. However, no toileting assessments or voiding trials were provided. The DON said the resident was on the falling leaf program, so if staff were to see him stand up they should jump in and help. The DON confirmed the resident also had anti-roll back and anti-tippers on his wheelchair. The DON indicated the resident could remove the SRSB and alarms. The DON was unable to explain how staff would check the SRSB to ensure it sounded when it was released. The DON said the assessment of the fall was in the event report charting. GG. On 5/22/15 at 12:01 PM, the Physical Therapist (PT) was interviewed. The PT said nursing would ask when a screen was needed. The PT was not sure if they had done a screen after every fall since he fell a lot. The PT confirmed he had an anti-roll back system on his wheelchair. Therapy was responsible for putting the anti-roll backs on. The PT said the resident could take the wheelchair apart. The PT said the administrator asked me to put a left anti-roll back on not long ago. The PT was unaware the anti-tippers were not on the wheelchair. The PT agreed there was no system in place to monitor the anti-roll back breaks. HH. The Occupational Therapist was interviewed on 5/22/2015 at 4:15 PM. The OT said the resident ' s anti roll back breaks were fixed and anti-tippers where applied.

Based on record review and interview, the facility failed to provide necessary pain relief for 1 (R #1) of 4 (R #1, 2, 3, 4) residents reviewed for pain management by not providing R #1 with available pain medication on 11/21/13 after staff noted resident was having 8/10 (0 is no pain, 10 is worst pain) pain. This deficient practice likely resulted in R #1 experiencing unnecessary discomfort affecting her appetite, ability to get out of bed and fully particpate in therapy sesions. The findings are: A. Record review of Observation Report for R #1 dated 11/21/13 to 11/22/13 and 11/24/13 to 11/25/13 revealed that resident confirmed that she had frequently experienced pain or hurting during the last 5 days. Resident was documented as having facial expressions, protective body movements or postures, indicators of pain on 11/21/13 and 11/24/13, 11/25/13 and vocal complaints of pain on 11/21/13 and 11/24/13. B. Record review of Occupational Therapy Plan of treatment for [REDACTED]." C. Record review of Resident Progress Notes on 11/21/13 revealed "Pt (patient) declined getting out of bed. She c/o (complained of) hip pain. OT (Occupational Therapist) notified nursing staff." D. Record review of Medication Administration Record [REDACTED]. E. On 05/28/14 at 3:06 pm, during interview with Registered Nurse (RN) #1, she stated "She (R #1) came in black and blue from a fall. She was weak." When asked if the resident had any pain, she responded "I know that she did have pain. It was pretty uncomfortable for her. She was so black and blue all down the right side." F. On 05/29/14 at 1:51 pm, during interview with Family Member (FM) #1, when asked if she believed R #1's pain was being managed, she responded "I don't. I don't think she heard that she had to ask for pain medication. She told me every time- 'I hurt so bad.' She didn't eat cause she hurt. When they moved her, it hurt." When asked if she would have asked for pain medication, she responded "Probably not, unless she was asked if she needed a pain pill. (Name of R #1) was English and didn't want to make waves. She was usually always in pain. I would be there for hours. When I would ask for pain meds, she'd get it. When she'd get it, it seemed to help and she would just sleep. She'd say, 'I hurt so bad, I don't feel like eating.' She ate very little. She'd ask if she could go back to bed. She was so weak, she couldn't move. I hurt just watching her face- she would turn white and not breathe." G. On 05/29/14 at 2:47 pm, during interview with Certified Occupational Therapy Assistant #1, he stated "I remember there being a certain level of pain that made it difficult for her to do exercises at a functional level. I remember there being possible nausea. She was having a difficult time. The Nurse was monitoring her for pain and nausea." When asked about R #1's pain listed in evaluation on 11/21/14, he responded "8/10, that is pretty bad pain. With that kind of pain rating, I would have gone straight to nursing." When asked if he treats pain, he responded "Pain meds before therapy: it is one of our strategies and therapy techniques to make sure residents are medicated a half hour before hand so it's not unbearable. It's usually pretty standard." H. On 05/30/14 at 11:51 am, during interview with the Director of Nursing, she stated "The 21st there is no record that she was given anything (for pain)." I. Record review of Nursing Service Policy and Procedure Manual regarding Pain Assessment and Management dated 2001, revised October 2010 revealed: 1. General Guidelines: Pain management is a multidisciplinary care process that included the following: Assessing the potential for pain. 2. Recognizing Pain: Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the term "pain" and use other descriptors such as throbbing, aching, hurting, cramping, numbness and tingling. Review the Medication Administration Record [REDACTED]. 3. Monitoring and Modifying Approaches: Re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Based on record review and interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well being for 1 (R #1) of 2 (R #1 and 5) residents reviewed for potential delay in treatment by failing to ensure the physician was promptly notified regarding a significant change in condition. This deficient practice presents a risk that the resident will not receive necessary medical treatment in a timely manner to prevent further decline. The findings are. A. On 05/29/14 at 10:15 am, during interview with Physician's Assistant (PA) #1, she confirmed that she was not informed by staff prior to her initial assessment on 11/26/13 that Family Member (FM) #1 had mentioned that resident was having left sided weakness or that COTA #1 also noted R #1 was unable to move her left arm. B. On 05/30/14 at 1:07 pm, PA #1 was interviewed. When asked if the resident was having weakness with her arm in the morning is that something as a provider she would want to be notified about, she stated, "It would depend. If it was flaccid (limp), yes, but if it was weakness because she was sleeping on it, probably no, but if it was persistent, or getting worse, or she had complaints of numbness, yes." C. On 05/28/14 at 3:06 pm, during interview with RN #1, she stated, "The daughter told me about 11 ish that she was having left side weakness." D. On 05/28/14 at 3:39 pm, during interview with the Assistant Director of Nursing (ADON), she stated that her and PA #1 were in her office when "One of the therapists came in and said 'You need to look at (name of R #1).' They already had her out here (lobby) in the wheelchair and at that time she did have significant weakness at that time on the left side. There was a significant change in status. It was about 4:00 (pm)." When asked if RN #1 had previously communicated any concerns about the resident to PA #1, she responded "Usually they (nurses) write notes about what's going on with the resident. None were stated at the time." The ADON confirmed that she was not aware that FM #1 had complained to RN #1 earlier that day about R #1 having left sided weakness. E. On 05/29/14 at 1:51 pm, during interview with FM #1, she stated "It was about 10 (am) when I showed up and I'm sitting there with her and they were trying to get her up. She'd usually grab my hand and she couldn't reach out. I raised it (her arm) up and let it go and it flopped. I spoke to the nurse, (name of RN #1) and she said she'd check on her. I came back at 3:30 pm. She was no longer speaking. She was just in a daze. I'm lifting it (her arm) up and it's dropping." F. On 05/29/14 at 2:47 pm, during interview with COTA #1, he stated "There was one occasion when she had either left or right side diminishing functioning." When asked when that occurred, he responded "Early pm. Maybe around 12:30 pm or lunch time." When asked if he informed anyone about the weakness, he responded "The CNAs (Certified Nursing Assitants) and nurses were all in communication about what's going on. There might have been a mini stroke or something going on. Like an onset, there might have been some facial droop and weakness and inability to move against gravity. It looks like there was some pretty obvious features going on." G. On 05/30/14 at 11:49 am, during interview with COTA #1, he confirmed that he had a therapy session with the resident around lunch time at which time he informed the nurse of his concerns regarding the resident's arm. H. On 06/03/14 at 2:12 pm, RN #1 was interviewed. When asked if COTA #1 informed her that R #1 had left sided weakness, she stated, "He did, and I let him know that I assessed her." I. Record review of Resident Progress Notes revealed: 1. "11/26/2013 12:03 pm (Recorded as Late Entry on 11/27/2013 12:04 PM) Pt c/o (complained of) inability to move LUE (left upper extremity). Pt (patient) was assessed by therapist and was unable to provide resistance with RUE (right upper extremity), no ability to raise RUE against gravity. W (West) nurse was notified, stated pt will be monitored." 2. "11/26/2013 16:24 (4:24 pm) Per (name of Physician Assistant #1) resident to ER (emergency room ) for evaluation d/t (due to) left sided weakness. Resident transported via EMS (Emergency Medical Services)." 3. "11/26/2013 5:50 pm. Later in the day, COTA was able to get pt into WC (wheelchair) and out of her room. And noticed decreased use of her LUE, decreased grip using thumb and forefinger only, no response to drop. Consult c (with) (name of PA #1) about new concern."

Based on record review and interview, the facility failed to implement the care plans for 3 (R# 2, 3, 4) of 5 (R# 1, 2, 3, 4, 5) residents reviewed for pressure ulcers by not ensuring that residents were being repositioned every 2-3 hours. This deficient practice likely resulted in the development of Stage 2 pressure ulcers to the buttocks and right hip for R #2, Stage 2 pressure ulcer to the left hip and an unstageable pressure ulcer to the coccyx (tailbone) for R #4, and a stage 2 pressure ulcer to the coccyx and a Stage 3 pressure ulcer to the mid lower back for R #3. The findings are: Findings for R#2 A. Record review of R #2's Progress Notes dated 05/31/13 to 10/13/13, 10/20/13 to 10/26/14, 10/28/13, and 10/30/13 to 11/29/30 revealed no reference that R #2 was repositioned or offered to reposition every 2-3 hours. B. Record review of Care Plan for R #2 dated 05/29/13 revealed "(Name of R #2) is at risk for skin impairment r/t (related to) decreased mobility, incont. (Incontinent) of b/b (bowel and bladder). she has hx (history) of pressure ulcer. Approach: assist with repositioning q (every) 2-3 hours and prn (as needed) for decreased pressure and increased comfort." C. Record review of Resident Progress Notes for R #2 revealed: 1. 10/13/13 "New Stage II Pressures to right and left buttocks. Right buttocks with pink beefy tissue present. Left buttocks smaller in size with pink beefy tissue wound bed." 2. 11/30/13 "New Stage II to right hip." D. On 04/22/14 at 1:09 pm, during interview with Certified Nurse Aid (CNA) #1, when asked where he documents repositioning, he responded "There is no where for us to document it on our computer, but we let the nurse know and they document it. They should." E. On 04/23/14 at 10:28 am, during interview with Registered Nurse (RN) #1, when asked how often R #2 is repositioned, she responded, "As needed. There is not a general order for it." When asked who documents repositioning, she responded "(name of R #2) doesn't have an order- if it's an order we document. It wouldn't be nursing." F. On 04/23/14 at 3:15 pm, during interview with the Director of Nursing (DON), she confirmed that there was no repositioning documentation for R #2 until there was a Physician order [REDACTED]. Finding s for R #4: G. Record review of R #4's Progress Notes dated 07/24/13 to 09/28/13 and 09/30/13 to 11/24/13 revealed no reference that the R #4 was repositioned or offered to reposition every 2-3 hours. H. Record review of Care Plan for R #4 dated 04/10/13 revealed "(Name of R #4) is at risk for skin impairments r/t decreased mobility, incont. of b/b. Approach: Assist with repositioning q 2 hours and prn for decreased pressure and increased comfort." I. Record review of Resident Progress Notes for R #4 revealed: 1. 11/07/13 "During skin assessment, discovered a stage 2 area of skin breakdown to left hip over the bony process." 2. 11/25/13 "During skin check, noted new unstageable to coccyx measuring 3.0 x 1.5 cm. Left hip pressure sore re-open. Wound stage II with pink beefy tissue." J. On 04/23/14 at 3:15 pm, during interview with the DON, she confirmed that there was no repositioning documentation for R #4 until there was a Physician order [REDACTED]. Findings for R #3: K. Record review of R #3's Progress Notes dated 08/25/13 to 09/14/13, 09/16/13 to 10/17/13, 10/19/13 to 10/20/13, 10/22/13 to 11/03/13, 11/05/13 to 11/16/13, and 11/18/13 revealed no reference that R #3 was repositioned or offered to reposition every 2-3 hours. L. Record review of Care Plan for R #3 dated 07/26/13 revealed "(Name of R #3) is at risk for skin impairments r/t decreased mobility, incont. of b/b. Approach: Assist with repositioning q 2 hours and prn for decreased pressure and increased comfort." M. Record review of Resident Progress Notes for R #3 revealed: 1. 08/30/13 "Stage II with dressing to mid lower back clean, dry, and intact." 2. 10/01/13 "Stage II wound to mid lower back now bigger in size." 3. 10/09/13 "Wound now unstageable, with slough present, peri wound red." 4. 11/15/13 "Noted re-open stage 2 to mid lower back. Noted new stage 2 to coccyx area." 5. 11/19/13 " Mid lower back now bigger in size. Wound now stage 3 per wound specialist." N. On 04/23/14 at 3:15 pm, during interview with the DON, she confirmed that there was no repositioning documentation for R #3 until there was a Physician order [REDACTED]. O. On 04/24/14 at 3:05 pm during interview with the DON, when asked if the resident is not on the program but repositioning is in the care plan, would it be documented, she responded "It's expected of them so it's not documented. It's just cause we have such a high risk population, so we don't require them to document unless it's there (physician order)." P. On 04/23/14 at 3:29 pm, during interview with Licensed Practical Nurse (LPN) #1, she stated "Everyone is care planned for (repositioning) every 2-3 hours and prn (as needed) on their care plan." When asked where repositioning is documented, she responded "Besides doing your rounds and making sure your people are being repositioned. Unless there is an order, we don't have documentation because it's part of the care plan. The care plan is nursing interventions. If it's care planned and part of her care, it's expected that it's happening. It's a guideline for them to use dependent upon that resident and their specific needs."

Based on record review and interview, the facility failed to prevent the development of avoidable pressure ulcers for 3 (R# 2, 3, 4) of 5 (R# 1, 2, 3, 4, 5) residents reviewed for pressure ulcers by not ensuring that residents were being repositioned. This deficient practice likely resulted in the development of Stage 2 pressure ulcers to the buttocks and right hip for R #2, a Stage 2 pressure ulcer to the left hip and an unstagebale pressure ulcer to the coccyx (tailbone) for R #4, a stage 2 pressure ulcer to the coccyx and a Stage 3 pressure ulcer to the mid lower back for R #3. The findings are: Findings for R #2 A. Record review of R #2's Progress Notes revealed: 1. 10/13/13 "New Stage 2 Pressures to right and left buttocks. Right buttocks with pink beefy tissue present. Left buttocks smaller in size with pink beefy tissue wound bed." 2. 11/11/13 "Weekly Skin Report: Both Stage 2 wounds to buttocks resolved. Noted blanchable area to left (sic) hip." 3. 11/30/13 "New Stage 2 to right hip." B. Record review of Care Plan for R #2 dated 05/29/13 revealed "(Name of R #2) is at risk for skin impairment r/t (related to) decreased mobility, incont. (Incontinent) of b/b (bowel and bladder). she has hx (history) of pressure ulcer. Approach: assist with repositioning q (every) 2-3 hours and prn (as needed) for decreased pressure and increased comfort." C. Record review of Resident Progress Notes dated 05/31/13 to 10/13/13, 10/20/13 to 10/26/14, 10/28/13, and 10/30/13 to 11/29/30 revealed no reference that R #2 was repositioned or offered to reposition every 2-3 hours. D. On 04/22/14 at 1:09 pm, during interview with Certified Nurse Aid (CNA) #1, when asked where he documents repositioning, he responded "There is no where for us to document it on our computer, but we let the nurse know and they document it. They should." E. On 04/23/14 at 10:28 am, during interview with Registered Nurse (RN) #1, when asked how often R #2 is repositioned, she responded, "As needed, there is not a general order for it." When asked who documents repositioning, she responded "(Name of R #2) doesn't have an order- if it's an order we document. It wouldn't be nursing." F. On 04/23/14 at 3:15 pm, during interview with the Director of Nursing (DON), she confirmed that there was no respositioning documentation for R #2 until there was a Physician order [REDACTED]. G. On 04/24/14 at 3:05 pm, during interview with the DON, when asked what pressure sore preventive measures were put in place for R #2, she responded "She had an APP (Alternating Pressure Pad), we did put in all the precautions but we didn't document the repositioning." Findings for R #4: H. Record review of R #4's Progress Notes revealed: 1. 11/07/13 "During skin assessment, discovered a stage 2 area of skin breakdown to left hip over the bony process." 2. 11/18/13 "Weekly skin report: Left hip stage 2 resolved." 3. 11/25/13 "During skin check, noted new unstageable to coccyx." and "Left hip pressure sore re-open. Wound stage 2 with pink beefy tissue." I. Record review of Care Plan for R #4 dated 04/10/13 revealed "(Name of R #4) is at risk for skin impairments r/t decreased mobility, incont. of b/b. Approach: Assist with repositioning q 2 hours and prn for decreased pressure and increased comfort." J. Record review of R #4's Progress Notes dated 07/24/13 to 09/28/13 and 09/30/13 to 11/24/13 revealed no reference that R #4 was repositioned or offered to reposition every 2-3 hours. K. On 04/23/14 at 3:15 pm, during interview with the DON, she confirmed that there was no respositioning documentation for R #4 until there was a Physician order [REDACTED]. L. On 04/24/14 at 2:34 pm, during interview with RN #1, when asked if R #4 could lift herself, she responded "She could move a little bit but not too much, not enough to change positions." Findings for R #3 M. Record review of R #3's Progress Notes revealed: 1. 08/24/13 "Midback decubitus dressing c/d/I (clean/dry/intact)." 2. 10/01/13 "Stage 2 wound to mid lower back now bigger in size." 3. 10/09/13 "Wound now unstageable, with slough present, peri (area between the vagina and anus) wound red." 4. 10/21/13 "Unstageable wound resolved." 5. 11/15/13 "Noted re-open stage 2 to mid lower back. Noted new stage 2 to coccyx area." 6. 11/19/13 "Mid lower back now bigger in size. Wound now stage 3 per wound specialist." N. Record review of Care Plan for R #3 dated 07/26/13 revealed "(Name of R #3) is at risk for skin impairments r/t decreased mobility, incont. of b/b. Approach: Assist with repositioning q 2 hours and prn for decreased pressure and increased comfort." O. Record review of R #3's Progress Notes dated 08/25/13 to 09/14/13, 09/16/13 to 10/17/13, 10/19/13 to 10/20/13, 10/22/13 to 11/03/13, 11/05/13 to 11/16/13, and 11/18/13 revealed no reference that R #3 was repositioned or offered to reposition every 2-3 hours. P. On 04/23/14 at 3:15 pm, during interview with the DON, she confirmed that there was no respositioning documentation for R #3 until there was a Physician order [REDACTED]. Q. Record review of Nursing Services Policy and Procedure Manual on Repositioning revised 10/2010 revealed: 1. General Guidelines: Positioning residents on existing ulcer should be avoided since it puts additional pressure on the tissue that is already compromised and may impede healing. 2. Interventions/Care Strategies: Turning/repositioning program includes a continuous consistent program for changing the residents position in realigning the body. The program is defines as a specific approach that is organized, planned, documented, monitored and evaluated. a. Residents who are in bed should be on a q 2hour turning program. b. For residents with a stage I or above pressure ulcer, q2 hour turning is inadequate. c. For residents who are in a chair should be on a q 1 hour repositioning program. d. If ineffective, the turning and repositioning frequency will be increased. e. Avoid placing resident on the greater trochanter (outer hip area) for more than momentary placement. 3. Repositioning the resident in the chair: a. Encourage the chair fast resident who is able to move to change positions or shift weight at least every 15 minutes or as often as possible. 4. Documentation: The following information should be recorded in the resident's medical record: a. The position in which the resident is placed. This may be on a flow sheet. b. The name and title of the individual who gave the care. c. If the resident refused the care and the reason(s) why. d. The signature and title of the person recording the data. R. On 04/24/14 at 3:05 pm, during interview with the DON, when asked to describe the repositioning program, she responded "For those who are on pressure sores, they are repositioned every two hours or prn; showing any signs of discomfort or sliding in the chair." When asked how someone is referred to the program, she responded "Usually, if they are at risk when they first come into the facility or come in with a pressure sore, they will usually be on the program." When asked if repositioning is documented, she responded "CNA's no. Nursing will document once a shift that they are being repositioned by staff. "When asked if the resident is not on the program, but repositioning is in the care plan, would it be documented, she responded " It's expected of them so it's not documented. It's just cause we have such a high risk population, so we don't require them to document unless it's (physician order) there." S. On 04/23/14 at 3:29 pm, during interview with Licensed Practical Nurse (LPN) #1, she stated "Everyone is care planned for (repositioning) every 2-3 hours and prn on their care plan." When asked where repositioning is documented, she responded "Besides doing your rounds and making sure your people are being repositioned. Unless there is an order, we don't have documentation because it's part of the care plan. The care plan is nursing interventions. If it's care planned and part of her care, it's expected that it's happening. It's a guideline for them to use dependent upon that resident and their specific needs."

Based on interview and record review the facility failed to implement their policy and procedure for preventing neglect for 1 (R #1) of 1 (R #1) residents reviewed related to the investigation of residents with potential injuries of unknown source. This deficient practice likely led to the death of R #1 as a result of the facility neglecting to provide a prompt emergency medical evaluation after the resident's neurological status began to deteriorate because of an internal brain bleed. If residents are not provided with prompt medical services when medical emergencies occur the underlying cause of the emergency can worsen, resulting in further injury. The findings are: A. On 02/27/13 at 11:16 am, during an interview with Certified Nursing Assistant (CNA) #1, he confirmed working on 01/30/13 during the day shift. CNA #1 confirmed that after he came on shift, he and CNA #3 changed R #1's undergarments between 7:00 am to 7:30 am. CNA #1 stated, "(R #1) was asleep during the entire process, he was limp, not normal, I told (Licensed Practical Nurse (LPN) #1), I'm not sure what happened after that." B. On 02/27/13 at 11:53 am, during an interview with LPN #1, LPN #1 confirmed he was the nurse responsible for R #1 during the day shift on 01/30/13 between the hours of 6:30 am and 7:00 pm. LPN #1 stated, "(CNA #1) had came and told me (R #1) didn't want to get up for breakfast and that (R #1) wasn't looking too good, I first saw (R #1) at 8:00 am. I was on the phone then, about 10 minutes, and then I went into the room. I told (CNA #1) to sit (R #1) up in the bed." LPN #1confirmed that when R #1 was asked if he had any pain, R #1 didn't speak but shook his head. LPN #1 stated, "This resident was new for me, I didn't know anything about him, I didn't know what was normal for him. I thought he was fine. I didn't take his vital signs because he seemed fine, wasn't pale or anything." C. On 02/27/13 at 1:58 pm, during an interview with LPN #1, LPN #1 confirmed that R #1's vital signs on the neurological function check list form were performed by a CNA. LPN #1 stated, "I was written up and suspended." LPN #1 was asked, 'Why?' LPN #1 stated, "They (the facility) said I didn't get down there fast enough." D. On 02/28/13 at 11:05 am, during an interview with Maintenance Director (DOM), he confirmed that on 01/30/13 at 10:00 am, Family Member (FM) #1 had found R #1 unconscious in his bed. DOM stated, "(FM #1) had found (R #1) was yelling for help because (R #1) wasn't breathing or something." E. On 02/28/13 at 3:15 pm, during an interview with LPN #3, LPN #3 confirmed she was the nurse responsible for R #1 during the night shift on 01/29/13 between the hours of 6:30 pm and 7:00 am. LPN #3 stated, "(R #1) was up most of the night. In the late PM (sic) (01/29/13) (R #1) could understand what I was saying. I gave (R #1) his early morning medications around 5:30 am - 6:00 am." LPN #3 was asked, 'How did (R #1) look when you gave him his morning medications?' LPN #3 stated, "He didn't say anything. (R #1) was verbal in the late PM (sic) (01/29/13) but he didn't say anything when I gave him his medications, he didn't respond appropriately." LPN #3 was asked, 'Was this normal for (R #1)?' LPN #3 stated, "I don't know, that was the first time I had worked with (R #1)." LPN #3 was asked, 'Did you know much about (R #1)'s base-line (normal level of functioning) or history?' LPN #3 stated, "Not really. It was the first time I had worked with him." F. On 02/28/13 at 4:15 pm, during an interview with CNA #3, CNA #3 confirmed that they worked with R #1 on the night shift of 01/29/13 to the morning of 01/30/13. CNA #3 stated, "(R #1) was restless all night, he really wanted to get out of bed and go sit in the chair at the nurses' station. I didn't want him to fall so we got (R #1) in his wheel chair and he followed me around most of the night, then we put him to bed around 3:00 am (01/30/13). In the morning, close to 7:00 am, (CNA #1) and I changed (R #1)'s undergarments, (R #1) looked very tired and he was mumbling something but I couldn't understand." G. On 02/28/13 at 4:33 pm, during an interview with CNA #1, CNA #1 was asked, 'What exactly did you report to (LPN #1) on the morning of the incident?' CNA #1 stated, "I told (LPN #1) that (R #1) really didn't look good, his breathing was rough and he was gurgling." CNA #1 pointed to his throat while describing the gurgling sound. H. On 02/27/13 at 11:34 am, during an interview with LPN #2, she confirmed working during the day shift on 01/30/13. LPN #2 confirmed that she had provided nursing care for R #1 when he was admitted to the facility on [DATE] from a local hospital. LPN #2 stated, "He (R #1) came here with numerous bruises and skin tears. He was alert oriented and could make his needs known. I was working the West side that morning (01/30/13) until 10:00 am when I went to do treatments. I was called to his (R #1)'s room at that time. (R #1) was in bed, the head of the bed was up and he had his oxygen on. He was un-arousable to loud direct verbal stimuli (speaking loudly to wake a person) and sternal rub (applying pressure to the mid chest to wake a person). His skin was pink and his respirations were regular. Then I asked a CNA to get me equipment to take (R #1)'s vital signs and then (LPN #1) entered the room." I. On 03/01/13 at 11:05 am, during an interview with the Director of Nursing (DON), she was asked to give a description of the incident that occurred with R #1 on 01/30/13. DON confirmed that R #1 was evaluated by Physician's Assistant #1, at approximately 10:00 am and that subsequently EMS was requested between 10:05 am and 10:10 am. During the interview DON was asked, 'Why was (LPN #1) suspended/written up?' DON stated, "(LPN #1) was suspended pending our investigation. (LPN #1) was slow to respond to the emergency." During the interview DON was informed that LPN #3 had previously confirmed that on 01/30/13, R #1 had begun to not respond appropriately while being given his early morning medications. DON was asked, 'What do you expect of your nurses when a resident has a change in condition?' DON stated, "With any change in condition I would expect the nurse to call the physician." J. Record review of the facility's Policies and Procedures on 'Reporting Abuse to Facility Management' revealed a notation that read, "1. Condemnation of Resident Abuse: Our facility does not condone resident abuse by anyone, including staff members, physicians, consults, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. 2. To help with recognition of incidents of abuse, the following definitions of abuse are provided: (f) 'Neglect' is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." K. Record review of 'Employee Notice of Disciplinary Action' dated 01/30/13 a notation that read, "On 01/30/13 (LPN #1) was told twice by (CNA #1) that (R #1) was unresponsive and unable to be awaken since night shift, (LPN #1) did not evaluate or assess resident and stated to DON that resident was responsive to (LPN #1) in the morning." L. Record review of 'Skilled Daily Nurses Notes' date 01/30/13 at 8:30 am revealed a notation made by LPN #1 that read, "Resident was non-verbal with eyes open looking down." M. Record review of Hospital (HOSP) #1's Radiology-CT brain scan report for R #1, dated 01/30/13 at 11:28 am, revealed that the resident was identified as having a subdural collection (bleeding of the brain) and a cerebral herniation (squeezing of the brain outside of its normal position in the head). N. Record review of HOSP #2's Progress Notes, dated 01/30/13 revealed a notation that stated R #1 had, "No hope of a meaningful survival." On 02/01/13 at 9:17 am a notation was made that R #1 was pronounced dead.

Based on record review and interview the facility failed to ensure 1 (R #1) of 1 (R #1) reviewed residents regarding neglectful treatment received prompt Emergency Medical Services (EMS) in order to prevent further [MEDICAL CONDITION] as the result of the resident's change in neurological condition. This deficient practice was likely to have caused harm as a result of delaying prompt medical care after nursing staff noted a change in neurological status. If residents do not receive emergency services when needed they are unable to maintain their highest practicable level of well-being. The findings are: A. On 02/27/13 at 11:16 am, during an interview with Certified Nursing Assistant (CNA) #1, he confirmed working on 01/30/13 during the day shift. CNA #1 confirmed that after he came on shift, he and CNA #3 changed R #1's undergarments between 7:00 am to 7:30 am. CNA #1 stated, "(R #1) was asleep during the entire process, he was limp, not normal, I told (Licensed Practical Nurse (LPN) #1), I'm not sure what happened after that." B. On 02/27/13 at 11:53 am, during an interview with LPN #1, LPN #1 confirmed he was the nurse responsible for R #1 during the day shift on 01/30/13 between the hours of 6:30 am and 7:00 pm. LPN #1 stated, "(CNA #1) had came and told me (R #1) didn't want to get up for breakfast and that (R #1) wasn't looking too good, I first saw (R #1) at 8:00 am. I was on the phone then, about 10 minutes, and then I went into the room. I told (CNA #1) to sit (R #1) up in the bed." LPN #1confirmed that when R #1 was asked if he had any pain, R #1 didn't speak but shook his head. LPN #1 stated, "This resident was new for me, I didn't know anything about him, I didn't know what was normal for him. I thought he was fine. I didn't take his vital signs because he seemed fine, wasn't pale or anything." C. On 02/28/13 at 3:15 pm, during an interview with LPN #3, LPN #3 confirmed she was the nurse responsible for R #1 during the night shift on 01/29/13 between the hours of 6:30 pm and 7:00 am. LPN #3 stated, "(R #1) was up most of the night. In the late PM (sic) (01/29/13) (R #1) could understand what I was saying. I gave (R #1) his early morning medications around 5:30 am - 6:00 am." LPN #3 was asked, 'How did (R #1) look when you gave him his morning medications?' LPN #3 stated, "He didn't say anything. (R #1) was verbal in the late PM (sic) (01/29/13) but he didn't say anything when I gave him his medications, he didn't respond appropriately." LPN #3 was asked, 'Was this normal for (R #1)?' LPN #3 stated, "I don't know, that was the first time I had worked with (R #1)." LPN #3 was asked, 'Did you know much about (R #1)'s base-line (normal level of functioning) or history?' LPN #3 stated, "Not really. It was the first time I had worked with him." D. On 02/28/13 at 4:33 pm, during an interview with CNA #1, CNA #1 was asked, 'What exactly did you report to (LPN #1) on the morning of the incident?' CNA #1 stated, "I told (LPN #1) that (R #1) really didn't look good, his breathing was rough and he was gurgling." CNA #1 pointed to his throat while describing the gurgling sound. E. On 02/27/13 at 11:34 am, during an interview with LPN #2, she confirmed working during the day shift on 01/30/13. LPN #2 confirmed that she had provided nursing care for R #1 when he was admitted to the facility on [DATE] from a local hospital. LPN #2 stated, "He (R #1) came here with numerous bruises and skin tears. He was alert oriented and could make his needs known. I was working the West side that morning (01/30/13) until 10:00 am when I went to do treatments. I was called to his (R #1)'s room at that time. (R #1) was in bed, the head of the bed was up and he had his oxygen on. He was un-arousable to loud direct verbal stimuli (speaking loudly to wake a person) and sternal rub (applying pressure to the mid chest to wake a person). His skin was pink and his respirations were regular. Then I asked a CNA to get me equipment to take (R #1)'s vital signs and then (LPN #1) entered the room." F. On 03/01/13 at 11:05 am, during an interview with the Director of Nursing (DON), she was asked to give a description of the incident that occurred with R #1 on 01/30/13. DON confirmed that R #1 was evaluated by Physician's Assistant #1, at approximately 10:00 am and that subsequently EMS was requested between 10:05 am and 10:10 am. During the interview DON was asked, 'Why was (LPN #1) suspended/written up?' DON stated, "(LPN #1) was suspended pending our investigation. (LPN #1) was slow to respond to the emergency." During the interview DON was informed that LPN #3 had previously confirmed that on 01/30/13, R #1 had begun to not respond appropriately while being given his early morning medications. DON was asked, 'What do you expect of your nurses when a resident has a change in condition?' DON stated, "With any change in condition I would expect the nurse to call the physician." G. Record review of 'Employee Notice of Disciplinary Action' dated 01/30/13 a notation that read, "On 01/30/13 (LPN #1) was told twice by (CNA #1) that (R #1) was unresponsive and unable to be awaken since night shift, (LPN #1) did not evaluate or assess resident and stated to DON that resident was responsive to (LPN #1) in the morning." H. Record review of 'Skilled Daily Nurses Notes' date 01/30/13 at 8:30 am revealed a notation made by LPN #1 that read, "Resident was non-verbal with eyes open looking down." I. Record review of Hospital (HOSP) #1's Radiology-CT brain scan report for R #1, dated 01/30/13 at 11:28 am, revealed that the resident was identified as having a subdural collection (bleeding of the brain) and a cerebral herniation (squeezing of the brain outside of its normal position in the head). J. Record review of HOSP #2's Progress Notes, dated 01/30/13 revealed a notation that stated R #1 had, "No hope of a meaningful survival." On 02/01/13 at 9:17 am a notation was made that R #1 was pronounced dead.

The facility failed to ensure that R #67 did not develop avoidable pressure sores, received the necessary treatment and care to promote healing, prevent infection and to prevent new sores from developing. R #67 was readmitted to the facility with a pressure ulcer to the left heel. This pressure ulcer increased in stage and size, became infected and then developed maggots. This resulted in an Immediate Jeopardy (IJ) being identified on 08/05/11 at 2:00 pm. The Administrator was notified of the findings for the IJ on 08/05/11 at 3:20 pm. The scope and severity was lowered to a scope and severity of G after the facility submitted their Plan of Removal. The facility took corrective action by providing an acceptable Plan of Removal on 08/05/11 at 6:10 pm. The Plan of Removal indicated that the facility action plan was to: 1. Immediately complete a skin sweep on all residents identified with wounds by midnight 08/05/11. 2. Immediately review all physician orders [REDACTED]. 3. Begin room checks of identified resident for visual signs of insects, provide fly-swatter for immediate removal of such, and daily visual inspection of wounds for maggots. 4. Immediately notify the New Mexico Department of Health Incident Management regarding resident involved with change of condition. 5. Immediately investigate the significant change in resident condition. 6. Re-educate all licensed staff regarding facility policy related to physician notification of change in condition, documentation, wound care, transcription of physician orders [REDACTED]. 7. Facility to do a facility wide skin sweep, verify physician orders [REDACTED]. 8. Assign a designee for the responsibility of wound care, on-going monitoring for insects, specifically flies, 9. Review physician orders [REDACTED]. All to be completed by 08/08/11 at noon. Based on observation, interview and record review the facility failed to ensure that 1 (#67) of 6 residents (#81, 66, 29, 99 & 96) was provided with routine preventative skin care and wound care per physician's orders [REDACTED]. This deficient practice caused actual harm to R #67 and is likely to cause harm for other residents at risk for pressure ulcers. The findings are: A. Record Review of admission orders [REDACTED] 1. [DIAGNOSES REDACTED]. 2. [MEDICATION NAME] to both heels daily. B. Record Review of facilities nursing notes revealed: 1. Entry by Registered Nurse (RN) #2 dated 03/22/11, "Stage III to left heel [MEDICATION NAME] in place with protective padding to both heels." 2. Entry by Licensed Practical Nurse (LPN) #3 dated 03/30/11 revealed a note "[MEDICATION NAME] to left lower buttock to open area, change every 2-3 days and as needed. 3. Entry by RN #1 dated 07/31/11 documented "dressing change by LPN #1 and CNA, upon removing old dressing larvae maggot fell out of left heel wound site into Chux, larvae was alive, did not see any more on surface of wound bed, foul smell, wound is black. Resident was pre-medicated for pain and Hospice notified by phone of larvae and elevated temp 99.0, continue to monitor." 4. Entry by Director of Nursing (DON) dated 08/01/11 revealed "DON met with resident's husband/Power of Attorney (POA) to inform him of condition of her wound and finding of maggots in her left heel wound bed related to him that hospice nurse and MD #1 had been notified on 07/31/11." "He wants to see what MD #1 wanted to do medically." "Call to Speciality hospital for their medical advice." 5. Entry by RN #1 dated 08/02/11 documented "New stage II pressure ulcer to right buttocks." C. Record Review of wound care log for R #67 for Left heel pressure ulcer, which was acquired in the hospital, revealed the following decline while at the facility: 1. Report dated 04/01/11- Left heel ulcer, date of onset 03/22/11, treatment, skin prep. Site eschar/necrotic 2. Report dated 04/08/11-Left heel ulcer 3.2 cm X 6.2 cm, treatment, skin prep. Site eschar/necrotic. 3. Report dated 04/15/11- Left heel ulcer 3.0 cm X 2.4 cm, eschar/necrotic, treatment, skin prep. 4. Report dated 04/22/11- Left heel 3.0 cm X 2.4 cm, eschar/necrotic tissue, treatment, skin prep. 5. Report dated 04/28/11- Left heel 3.0 cm X 2.4 cm, eschar/necrotic tissue, treatment, skin prep. 6. Report dated 05/06/11- left heel 3.0 cm X 4.0 cm, treatment, skin prep 7. Report dated 05/13/11- Left heel 3.0 cm X 4.0 cm, eschar/necrotic tissue, treatment, skin prep. 8. Report dated 05/20/11- Left heel 3.0 cm X 4.0 cm, treatment, skin prep. 9. Report dated 05/27/11- Left heel, 3.0 cm X 4.0 cm, eschar/necrotic tissue, treatment, skin prep. 10. Report dated 06/03/11-Left heel 3.2 cm X 4.2 cm, no exudate, no tunneling, wound bed is black/eschar, progress not changed. 11. Report dated 06/18/11- Left heel 4.3 cm X 6.3 cm, unable to detect depth, no exudate, slight odor, wound bed black/eschar, progress deteriorated, odor noted to heel, edges separating and lifting, treatment changed. 12. Report dated 06/23/11- Left heel 4.3 cm X 6.2 cm, slight odor, stronger pain med needed, progress not changed. 13. Report dated 07/06/11- Left heel 5.6 cm X 8.6 cm, depth 4.2 cm, exudate purulent and copious, tunneling 4 cm, foul odor, wound bed slough, black/eschar, surrounding tissue maceration, hospice in to evaluate, progress deteriorated, continue treatment. 14. Report dated 07/14/11- Left heel 5.6 cm X 8.6 cm, 4.2 cm in depth, tunneling 4 cm, foul odor, copious purulent exudate. 15. Report dated 07/20/11- Left heel 6.1 cm X 9.0 cm, 5.0 cm in depth, copious amount of purulent exudate, 4 cm tunneling, foul odor, wound bed slough. treatment changed. 16. Report dated 07/28/11- Left heel 10 cm X 12 cm, serosanguineous large amount of exudate, foul odor, wound bed black/eschar. 17. Report dated 08/03/11- Left heel 10 cm X 12. 7 cm, serous scant exudate, foul odor, black/eschar wound bed, not changed, treatment changed. D. Record Review of wound care log for R #67 for the in house acquired pressure ulcer revealed the following: 1. Left buttock - Date of onset 08/02/11, Stage II, 3.1 cm X 1. 3 cm, depth 0.1 cm, no odor, no exudate. E. Record Review of the facilities clinical protocol for pressure ulcers and skin breakdown revised 07/2010 states "The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration. F. On 08/04/11 at 2:42 pm, during an interview with the DON, she said the last DON, RN #5 was a certified wound care specialist and she was the person who determined if wounds were pressure, arterial or venous. The DON said she heard RN #5 and the Physician's Assistant argue whether or not the heel was a pressure ulcer. The Physician's Assistant said that was it was a pressure ulcer and RN #5 was saying it was not. The DON confirmed that RN #5 classified the wound types without the help of the physician and that the facility did not follow it's own protocol. G. On 08/04/11 at 3:30 pm, during an interview with the Assistant Director of Nursing (ADON), she stated "All wounds are recent with the exception of the left heel, she acquired that when she was hospitalized ." The ADON confirmed that R #67 had seven ulcerations to her skin. The wound care logs indicated 2 out of the 7 ulcers were categorized as pressure ulcers. The ADON confirmed that the last DON, RN #5 classified all the wounds and that the Physician's Assistant did not agree with her. The ADON confirmed that RN #5 classified the wound types without the help of the physician and that the facility did not follow it's own protocol. The ADON said R #67's heel and buttock areas were the only two pressure ulcers. H. On 08/08/11 at 4:46 pm, during an interview with the Wound Care Consultant (WCC) she stated, "I am a wound care specialist and I supply the facility with wound care products. I am not the wound care consultant for the facility." When asked about her "Wound Care Skin Integrity Evaluation" dated 08/05/11 she stated, "I document what the facility nurses wrote about the wounds for the purpose of ordering supplies. I simply placed a supply order. I did not assess the wound on 08/05/11. I discuss products only for a wound. I did not know anything about the maggots until Thursday, August 4th." I. On 08/08/11 at 10:48 am, during an interview with RN #1, she confirmed being present when the maggot was found in R #67's wound. RN #1 confirmed this was a significant change in the resident's condition. RN #1 stated, "It was a worm. It was moving and it looked like a larvae maggot." RN #1 said she was not comfortable with the DON not being involved and said the DON did not assess the wound when she was alerted. RN #1 said after finding the maggot, R #67 went to see MD #1 and the resident returned from the physician's office with the same dressing to her foot. RN #1 said (Name of MD #1) didn't even look at her wounds. J. On 08/08/11 at 10:48 am, during an interview with LPN #1, he confirmed being present when the maggot was found in R #67's wound. He said he thought it was a significant change in condition and that the DON and the ADM should have come to the building to check the resident that day. LPN #1 confirmed that the DON did not assess R #67's wound. LPN #1 confirmed it was a white worm and it was alive and moving. LPN #1 said he was not comfortable with the lack of involvement from his DON regarding their findings. K. Record Review revealed of an e-mail to R #67's physician, MD#1 revealed the following: with the following: 1. 08/01/11 st 10:19 am " (Name of RN #1) would like to update you on (Name of R #67) wound care". 2. 08/01/11 at 2:37 pm," (Name of RN #1) wants you to know that they have found some maggots in her wounds and they are doing the best they can with care". 3. 08/01/11 at 5:55 pm, MD #1 responded, "I understand that this is going to lead to her death, and that is very difficult, do the best they can do." L. On 08/05/11 at 11:45 am, during interview and record review, the Director Of Nursing (DON), Assistant Director of Nursing (ADON) and the Clinical Coordinator (CC) confirmed that the following physician orders [REDACTED]. 1. Medication Administration Record (MAR) for the month of March 2011, wound care orders for R #67's left heel obtained on 03/25/11 for treatment twice a day was missing 2 opportunities out of 10. a. Physician orders [REDACTED]. b. Physician order [REDACTED]. c. Physician orders [REDACTED]. 2. MAR for the month of April 2011 with wound care orders for R #67's left heel obtained on 03/25/11 for treatment twice a day was missing 24 opportunities out of 60. A physician's orders [REDACTED]. 3. MAR for the month of June with date 03/25/11 to left heel, for skin prep twice daily was missing 12 opportunities out of 60. a. Order with origination date of 12/14/10 to apply moisturizer to both legs every day was confirmed that the nurses did not document this treatment for [REDACTED]. b. Order with origination date of 12/14/10 to apply gauze/foam padding to bilateral heels was confirmed that the nurses did not document this treatment for [REDACTED]. c. Orders all dated 06/28/11 for wound care treatments were not documented by nurses for 3 days. d. It was also confirmed with the DON, ADON and the CC that new orders received on 06/17/11 and 6/22/11 were not transcribed onto the June MAR until 06/28/11 and were not signed off from then through the end of the month. 4. MAR for the month of July 2011 for an order dated 07/06/11 for [MEDICATION NAME] silver to left heel, change every 3-7 days. Cleanse wounds with wound cleaner and secure with [MEDICATION NAME]. The MAR contained nurses signatures for this treatment on the following dates: July 13, 14, 15, 16, 19,20, 21, 22, 23, 24, 25 26 th. a. An order originating on 07/21/11 to left heel, cleanse with normal saline, apply 4 X 4 moistened with 0.5% Dakins solution, cover with dressing 4 X 4 and secure with Kerlix, change daily. The order was not carried out by nursing on July 28th. b. Orders with origination date of 12/14/10 to apply moisturizer to both legs every day was missing 3 out of 31 opportunities. 5. MAR for the month of August 2011 with the following wound care orders originated on 07/06/11, [MEDICATION NAME] silver to left heel change every 3-7 days, cleanse with wound cleaner and secure with [MEDICATION NAME] were still on the MAR and the wound care had changed to left heel on 07/21/11. The treatments were not signed off at all when checked on 08/05/11. a. New orders were received by the physician on 08/03/11 to flush wound with Dakins solution 35ml with 18 gauge catheter, flush well, Iodosorb or hydrogel daily, cover with Opti-foam, charcoal dressing and abdominal pad daily. The treatments were not carried out or transcribed onto R #67's MAR until 08/05/11. b. New order dated 08/03/11 for left buttock wound, wash with normal saline, pat dry, skin prep periwound, hydrogel to wound bed and cover every morning daily and as needed till resolved. This order not transcribed until 08/05/11 when pointed error out to ADON. M. On 08/05/11 at 1:15 pm observed R #67 laying in bed on her back with weight shifted to her left side. Both feet were against her footboard. No supportive devices present for relieving pressure points. N. On 08/05/11 at 1:45 pm, during an interview with LPN #2, she confirmed that she was unaware of the wound care order change for R #67's left heel dated 08/03/11. LPN #2 also confirmed that the facility did not have the needed supplies in order to follow the physicians orders. O. On 08/05/11 at 1:47 pm, during an interview with hospice nurse RN #7, she said she was the substitute nurse and the RN who normally cares for R #67 was on vacation. (Name of RN #6) had done wound care in the past but the facility took over since daily dressing changes for the wound were needed. RN #7 said that RN #6 had concerns about R #67's care because they never elevated her legs and lots of issues with her left leg. P. Review of the facilities policy on wound care dated 07/2010 contained the following protocol: "Use disposable cloth to establish clean field on resident's over-bed table if used. Wash and dry your hands thoroughly. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. Put on gloves. Be certain all clean items are on clean field. Discard all soiled laundry, linen, towels, and washcloths into soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. Clean the area used as a field for dressing supplies." Q. On 08/05/11 at 2:05 pm during an observation of wound care to R #67's left heel, LPN #2 opened all bandages and supplies and laid them on R #67's over-bed table without a barrier. The table was dirty and contained ring marks from beverage glasses left over from lunch time. LPN #2 and the ADON confirmed that the table was dirty and that LPN #2 did not clean the over-bed table prior to setting up her wound care supplies. It was also confirmed by both LPN #2 and the ADON that R #67 has meals in her room on the over-bed table and is fed by her husband. During the wound care observation, LPN #2 removed the soiled dressing and carried it over the over-bed table where the clean dressings were opened and laying uncovered in their containers. LPN #2 then tossed the dirty dressing into the garbage can lined with a red isolation bag placed approximately 3 feet away from the bed. LPN #2 was irrigating the wound with a syringe and needle containing Dakins solution and the ADON was holding R #67's leg up when suddenly the ADON said "OH" and turned her face to the right, away from LPN #2 to avoid being splashed again. LPN #2 asked the ADON: "Did I get you" and the ADON did not reply. After removing the soiled dressing, LPN #2 did not change gloves and wash hands before applying clean dressings. After completing the dressing, LPN #2 removed her gloves and tied up the red isolation bag touching the inside liner with bare hands and carried it down the hall to dispose in proper container. After the completion of wound care, the breaks in infection control technique were discussed with LPN #2 and the ADON who agreed that aseptic (preventing infection) technique was broken. R. Based on observation of wound care on 08/05/11 at 2:05 pm, LPN #2 did not follow the facilities policy and procedure for wound care. S. On 08/05/11 at 4:00 pm observed R #67 in same position since wound care at 1:30pm. T. On 08/05/11 at 4:36 pm, observed R #67 was up in wheelchair and husband was feeding her dinner. Observed a fly inside the room in R #67's window sill and that was confirmed by R #67's husband. He said he used mosquito [MEDICATION NAME] when he takes her outdoors. U. Record review of the incident report submitted to the state agency dated 08/05/11 revealed the following: "Resident was being treated for [REDACTED]. LPN notified RN on duty of same, also notifying DON and ADON." Report indicated that R #67's husband was notified of the incident on 08/01/11 at 11:00am by the DON. R #67's physician, MD #1 was notified on 08/01/11 at 10:00am by RN #1. The date of the incident was 07/31/11. V. On 08/08/11, between 1:30 pm and 4:00 pm, observed R #67 in bed flat on back in the same position. No supportive devices were present for relieving pressure points. W. On 08/09/11, between 11:00 am and 2:11 pm, observed R #67 in her wheelchair. At 2:11 pm, R #67 was in her wheelchair outside with her foot wrapped in Kerlix bandage and a fly was observed on her left leg thigh area. When asked if any staff had repositioned his wife since this morning, R #67's husband stated, "once." When asked if staff regularly repositioned R #67, R #67's husband stated, "No, I know they should do it more often." X. On 08/18/11 at 3:27 pm, during an interview with the hospice nurse RN #6 she state, "(Name of R #67) was admitted on hospice with a stage II on her coccyx and a blackened area to her left heel. I had numerous care concerns with the nursing care and they still didn't follow up after communicating my concerns to them. (Name of R #67) didn't have a pressure relieving mattress, no padding to her heels and her legs were never elevated when I observed her on visits. I was seeing her three times a week and now I go twice a week. I discussed my concerns mainly with LPN #1, LPN #2 and the ADON. I requested pressure relieving devices and finally instructed her husband, who stays at her bedside, to use a pillow and even the teddy bear in her room to relieve pressure areas. (Name of R #67) didn't even have wings (foot pedals) on her wheelchair. Her buttock finally was resolved and the heel was the same for awhile and then it got real bad. The smell was horrible. That wound is one of the worst things I have seen and I have been a nurse for [AGE] years. She then developed a bunch of pressure area wounds and the buttock went from a stage II to now it's necrotic (dead) tissue. That was only in a period of 2-3 weeks. Every time I visit she is siting up in her wheelchair. She has lots of skin tears and (Name of R #67) can't scratch or tear her skin. Her nails are very short and I ask them to put her protective sleeves on for protection but they don't. I have witnessed her dressings not being changed for several days." When asked how long were the same dressings in place, RN #6 stated, "I have witnessed bandages dated three days old when I was present and witnessed the wound care. I suggested to wrap the foot in a plastic bag when they take her outdoors but they didn't. LPN #2 uses the same supplies for (Name of R #67) that she uses for the other residents. I recommended that all supplies be bagged specifically for (Name of R #67)'s wound care. They still don't do that. I witnessed dressing changes when the drainage was not always contained and that worries me from the infection control stand point. I was notified of the maggots the following Monday when they discovered them over the weekend. The care is scattered and no follow up." When asked if the maggot infestation could have been avoided, RN #6 stated, "Yes, the infestation of maggots could have been prevented if they would follow good technique and change the dressings daily as instructed by the physician." Y. On 08/19/11 at 9:15 am, during observation and interview, R #67 sitting in wheelchair in room alone. Dressing to left heel soaked through with drainage and foul odor in room. R #67 did not have any heel protectors on, just Kerlix gauze soaked with drainage. R #67 did not have legs elevated and no protective sleeves were in place. This observation was confirmed with CNA #2 and CNA #3 at 9:25 am. Z. On 08/19/11 at 9:28 am, during an interview with CNA #3, she was asked to explain what routine care she gave to R #67 and to include any special instructions about her skin. CNA #3 stated, "We give her showers twice a week, on Thursdays and Saturdays. I showered her yesterday. We put lotion on her skin on shower days. She is total care. We feed her breakfast in the mornings in the dining room and her husband feeds her lunch and dinner in her room." CNA #3 expressed her concern about the large amount of drainage seeping through the bandage from the resident's foot and the impact on other residents. Observed a bag of charcoal hanging under R #67's wheelchair and CNA #3 did not know why it was placed there. CNA #3 never mentioned applying lotion to R #67's skin daily, turning and repositioning her or relieving pressure points. AA. On 08/19/11 at 9:43 am, during an interview with CNA #2, he confirmed he was present on 07/31/11 with RN #1 and LPN #1 when the maggot was discovered. CNA #2 said he assisted with R #67's dressing changes as often as possible since he is in nursing school. He stated, "I helped the nurses, (Name of RN #1) and (Name of LPN #1) by holding up her leg while the nurses changed the bandages. LPN #1 removed the old dressing and RN #1 put the new dressing on. The wound was dead flesh and it was much smaller than it is now. (Name of R #67) really declined over the last month or so. When the nurse unwrapped the dressing there was one maggot. The maggot fell on to the Chux pad. We double bagged it and put it into the biohazard bag. The center of the wound was black and edges were white with a real foul smell. I didn't see the DON here that day at all." When asked if the maggot was alive, CNA #2 stated, "Yes it was wiggling around." BB. On 08/19/11 at 10:50 am, after a wound care observation with LPN #2, CNA #2 and CNA #3, R #67 was left laying in bed on her back after the treatment. R #67's left leg was bent at the knee and her foot was on the bed leaving pressure to her left heel. R #67's husband was at her side and he said he would put a pillow there for her comfort. No pressure relieving devices were used to position R #67.

Based on interview and record review the facility failed to re-assess 1 (#67) of 6 ( #81, 66, 67, 29, 99 & 96) residents with wounds after a significant change regarding a decline in condition. R #67 had multiple ulcers that increased in size and she also developed an infection to the pressure ulcer on her left heel which later lead to the development of maggots in her wound. The findings are: A. Record Review of admission orders [REDACTED] 1. [DIAGNOSES REDACTED]. 2. [MEDICATION NAME] to both heels daily. B. Record Review of facilities nursing notes revealed the following: 1. Entry by Registered Nurse (RN) #2 dated 03/22/11 revealed, "Stage III to left heel [MEDICATION NAME] in place with protective padding to both heels." 2. Entry by Licensed Practical Nurse (LPN) #3 dated 03/30/11 revealed "[MEDICATION NAME] to left lower buttock to open area, change every 2-3 days and as needed. 3. Entry by LPN #2 dated 05/23/11 revealed "Left great toe, red ulcer." 4. Entry by RN #4 dated 07/10/11 revealed " foul odor to left great toe." Entry by RN #4 dated 07/10/11 revealed "left heel large amount of black moist drainage. "Tissue soggy and foul smelling." 5. Entry by RN #1 dated 07/31/11 revealed "dressing change by LPN #1 and Certified Nursing Assistant (CNA) #2, upon removing old dressing larvae maggot fell out of left heel wound site into Chux, larvae was alive, did not see any more on surface of wound bed, foul smell, wound is black." 6. Entry by Director of Nursing (DON) dated 08/01/11 revealed "DON met with resident's husband/POA (Power of Attorney) to inform him of condition of her wound and finding of maggots in her left heel wound bed." 7. Entry by RN #1 dated 08/02/11 revealed "New stage II pressure ulcer to right buttocks." C. Record Review of wound care log for R #67 for the left heel pressure ulcer, which was acquired in the hospital, revealed the following decline while at the facility: 1. Report dated 04/01/11- Left heel ulcer, date of onset 03/22/11, treatment, skin prep. Site eschar/necrotic 2. Report dated 04/08/11-Left heel ulcer 3.2 cm X 6.2 cm, treatment, skin prep. Site eschar/necrotic. 3. Report dated 04/15/11- Left heel ulcer 3.0 cm X 2.4 cm, eschar/necrotic, treatment, skin prep. 4. Report dated 04/22/11- Left heel 3.0 cm X 2.4 cm, eschar/necrotic tissue, treatment, skin prep. 5. Report dated 04/28/11- Left heel 3.0 cm X 2.4 cm, eschar/necrotic tissue, treatment, skin prep. 6. Report dated 05/06/11- left heel 3.0 cm X 4.0 cm, treatment, skin prep 7. Report dated 05/13/11- Left heel 3.0 cm X 4.0 cm, eschar/necrotic tissue, treatment, skin prep. 8. Report dated 05/20/11- Left heel 3.0 cm X 4.0 cm, treatment, skin prep. 9. Report dated 05/27/11- Left heel, 3.0 cm X 4.0 cm, eschar/necrotic tissue, treatment, skin prep. 10. Report dated 06/03/11-Left heel 3.2 cm X 4.2 cm, no exudate, no tunneling, wound bed is black/eschar, progress not changed. 11. Report dated 06/18/11- Left heel 4.3 cm X 6.3 cm, unable to detect depth, no exudate, slight odor, wound bed black/eschar, progress deteriorated, odor noted to heel, edges separating and lifting, treatment changed. 12. Report dated 06/23/11- Left heel 4.3 cm X 6.2 cm, slight odor, stronger pain med needed, progress not changed. 13. Report dated 07/06/11- Left heel 5.6 cm X 8.6 cm, depth 4.2 cm, exudate purulent and copious, tunneling 4 cm, foul odor, wound bed slough, black/eschar, surrounding tissue maceration, hospice in to evaluate, progress deteriorated, continue treatment. 14. Report dated 07/14/11- Left heel 5.6 cm X 8.6 cm, 4.2 cm in depth, tunneling 4 cm, foul odor, copious purulent exudate. 15. Report dated 07/20/11- Left heel 6.1 cm X 9.0 cm, 5.0 cm in depth, copious amount of purulent exudate, 4 cm tunneling, foul odor, wound bed slough. treatment changed. 16. Report dated 07/28/11- Left heel 10 cm X 12 cm, serosanguineous large amount of exudate, foul odor, wound bed black/eschar. 17. Report dated 08/03/11- Left heel 10 cm X 12. 7 cm, serous scant exudate, foul odor, black/eschar wound bed, not changed, treatment changed. D. Record Review of wound care log for R #67 for all other in house acquired ulcerations revealed the following: 1. Left great toe - Date of onset 05/23/11 a. Report for week of 06/03/11 Unstageable, 1.1 cm X 1. 6 cm, slight odor, wound bed black/eschar. b. Report for week of 06/23/11 Unstageable, 1.3 cm X 2. 6 cm, serous exudate, moderate odor, wound bed slough, pain scale 4, hospice notified. c. Report for week of 07/06/11 Unstageable, 1. 3 cm X 2. 6 cm, slight odor, black/eschar wound bed pain scale 4, hospice notified. d. Report for week of 07/14/11 Unstageable, 1.3 cm X 2. 6 cm, black/eschar wound bed, pain scale 4, no change to treatment. e. Report for week of 07/20/11, Unstageable, 1. 4 cm X 3.1 cm, Serosanguineous exudate, depth 0.1 cm, scant amount of exudate, slight odor, wound bed slough, pain scale 2. f. Report for week of 07/28/11 1.7 cm X 1.0 cm. 2. Left buttock - Date of onset 08/02/11, Stage II, 3.1 cm X 1. 3 cm, depth 0.1 cm, no odor, no exudate. 3. Left lateral upper calf - Date of onset 07/28/11, 1.3 cm X 1.1 cm, wound bed slough, categorized as a venous ulcer by RN #5. a. Report for week of 08/03/11 1.2 cm X 1. 0 cm, 0.1 cm in depth, wound bed granulation tissue, progress not changed. 4. Left lateral malleolus, date of onset 07/28/11, categorized as a venous ulcer by RN #5. 2.0 cm X 3. 0 cm, no exudate, wound bed black/eschar. a. Report for week of 08/03/11 3.2 cm X 3. 0 cm, foul odor, black/eschar wound bed, treatment changed. 5. Left lateral foot - Date of onset 07/28/11, categorized as a venous ulcer by RN #5. 8.0 cm X 2.5 cm, no exudate, wound bed purple. a. Report for week of 08/03/11 9.2 cm X 2.5 cm, serous small amount of exudate with foul odor, wound bed black/eschar, progress deteriorated, treatment changed. 6. Left knee - Date of onset 07/28/11, 2.4 cm X 1.4 cm, scant exudate, wound bed slough. a. Report for week of 08/03/11 2.4 cm X 1.9 cm, depth 0.1 cm, scant exudate, wound bed granulation tissue, progress is deteriorated. E. Review of the facilities policy on "Significant change in condition revised on 07/2010 " it defines that as a decline or improvement in the resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. 2. Impacts more than one area of the resident's health status and; 3. Requires interdisciplinary review and or revision to the care plan. 4. The final decision regarding what constitutes a significant change in status is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20(b)(ii). 5. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS 2.0 RAI Instruction Manual. F. On 08/04/11 at 2:42 pm, during an interview with the DON she stated that the last DON, RN #5 was a certified wound care specialist and she was the person who determined if wounds were pressure, arterial or venous. The DON stated she heard RN#5 and the Physician's Assistant argue over the heel and the Physician's Assistant stated that it was a pressure ulcer. G. On 08/04/11 at 3:30 pm, during an interview with the Assistant Director of Nursing (ADON) she stated, "All wounds are recent with the exception of the left heel, she acquired that when she was hospitalized ." The ADON confirmed that R #67 had seven ulcerations to her skin. The ADON confirmed that R #67 was not re-assessed for a significant change in condition. The ADON confirmed there was not a new MDS for a significant change in condition nor a nursing assessment. The ADON confirmed the last DON, RN #5 classified all the wounds and the Physician's Assistant did not agree with her. The ADON confirmed R#67 had a significant decline in condition. H. On 08/05/11 at 12:07 pm, during an interview with the Administrator (ADM) she stated she did not believe this was a significant change in condition. The ADM said "Because of the progressive decline in her wound, maggots are not normal in wounds unless some sort of contamination was present." The Clinical Coordinator (CC) was present and agreed she did not think R #67 had a significant change in condition. The CC and the DON both confirmed there was no change in wound care after the maggots were discovered. The DON also confirmed the resident was not re-assessed for a change in condition. I. On 08/08/11 at 9:30 am, during an interview, the DON confirmed the facility did not follow their policy for a significant change in condition. J. On 08/08/11 at 10:48 am, during an interview with RN #1 she confirmed being present when the maggot was found in R #67's wound. RN #1 confirmed this was a significant change in the resident's condition. RN #1 stated the DON did not assess the wound when she was alerted. K. On 08/08/11 at 10:48 am, during an interview with LPN #1 he confirmed being present when the maggot was found in R #67's wound. LPN #1 stated that he thought it was a significant change in condition and that the DON and the ADM should have come to the building to check the resident that day. LPN #1 stated that the DON did not assess R #67's wound. L. Record Review of an e-mail from R #67's physician, Medical Doctor (MD) #1 revealed the following: 1. 08/01/11 at 10:19 am " (Name of RN #1) would like to update you on (Name of R #67). 2. 08/01/11 at 2:37 pm, " (Name of RN #1) wants you to know that they have found some maggots in her wounds and they are doing the best they can with care." 3. 08/01/11 at 5:55 pm, MD #1 responded, "I understand that this is going to lead to her death, and that is very difficult, do the best they can do." M. On 08/19/11 at 9:43 am, during an interview with CNA #2, he stated, "(Name of R #67) really declined over the last month or so."

Based on observation, interview and record review the facility failed to follow physician's orders for 1 (#67) of 6 (#81,66, 29, 99 & 96) residents for skin and wound care. This deficient practice is likely to have caused a significant decline in condition by R #67. R #67 was admitted with 1 skin ulcer and had 6 facility acquired skin ulcers, all of which increased in size. The findings are: A. On 08/05/11 at 11:45 am, during an interview, the Director Of Nursing (DON), Assistant Director of Nursing (ADON) and the Clinical Coordinator (CC) confirmed that the following physician orders were not followed: 1. Medication Administration Record (MAR) for the month of March 2011, wound care orders for R #67's left heel obtained on 03/25/11 for treatment twice a day was missing 2 opportunities out of 10. a. Physician orders with origination date of 12/14/10 to apply moisturizer to both legs every day was missing 60 opportunities out of 60. b. Physician order with origination date of 12/14/10 for gauze/foam padding to bilateral heels daily was missing 60 opportunities out of 60. c. Physician orders for left foot lesion with origination date of 02/25/11 to complete treatment every 3 days was blank for the entire month of March 2011. 2. MAR for the month of April 2011 with wound care orders for R #67's left heel obtained on 03/25/11 for treatment twice a day was missing 24 opportunities out of 60. A physician's order for skin tear treatment with origination date of 03/30/11 to complete every 3 days was missing 4 opportunities out of 8. 3. MAR for the month of June with date 03/25/11 to left heel, for skin prep twice daily was missing 12 opportunities out of 60. a. Physician's order with origination date of 03/30/11, left shin skin tear wash with normal saline, pat dry, skin prep apply hydrogel to wound bed, cover with op site dressing, change every 3 days. confirmed that the nurses omitted this care and did not document it at all for the entire month of June 2011. b. Order with origination date of 05/21/11 for right lower extremity anterior lateral aspect, cleanse wound with normal saline, apply oil [MEDICATION NAME] gauze to wound bed, secure with gauze wrap and tape, change daily and as needed, monitor for infection. Confirmed that the nurses did not document this wound care for the entire month of June 2011. c. Order with origination date of 12/14/10 to apply moisturizer to both legs every day was confirmed that the nurses did not document this treatment for [REDACTED]. d. Order with origination date of 12/14/10 to apply gauze/foam padding to bilateral heels was confirmed that the nurses did not document this treatment for [REDACTED]. e. Orders all dated 06/28/11 for wound care treatments were not documented by nurses for 3 days. f. It was also confirmed with the DON, ADON and the CC that new orders received on 06/17/11 and 6/22/11 were not transcribed onto the June MAR until 06/28/11 and were not signed off from then through the end of the month. g. Physician orders dated 06/17/11,"Left elbow wound wash with normal saline, pat dry, skin prep periwound, apply hydrogel to wound bed, cover with op- site, change every day and as needed till healed. Confirmed order never transcribed onto R #67's MAR. 4. MAR for the month of July 2011 for an order dated 07/06/11 for [MEDICATION NAME] silver to left great toe and left heel, change every 3-7 days. Cleanse wounds with wound cleaner and secure with [MEDICATION NAME]. The MAR contained nurses signatures for this treatment on the following dates: July 13, 14, 15, 16, 19,20, 21, 22, 23, 24, 25 26th. a. An order originating on 07/21/11 to left heel, cleanse with normal saline, apply 4 X 4 moistened with 0.5% Dakins solution, cover with dressing 4 X 4 and secure with Kerlix, change daily. The order was not carried out by nursing on July 28th. b. An order originating on 05/31/11 for left great toe wound to cleanse with normal saline, apply Idosorb to wound bed daily and cover with foam dressing, wrap with Kerlix and change daily was in place until order changed on 07/06/11. Nursing did not complete this wound care on July 5 th and then after receiving new orders proceeded to sign off this treatment which was discontinued on 07/06/11 on the following dates: July 13, 14, 15, 18, 19, 20, 21 and 22nd. c. Orders with origination date of 12/14/10 to apply moisturizer to both legs every day was missing 3 out of 31 opportunities. 5. MAR for the month of August 2011 with the following wound care orders originated on 07/06/11, [MEDICATION NAME] silver to left great toe and left heel change every 3-7 days, cleanse with wound cleaner and secure with [MEDICATION NAME] were still on the MAR and the wound care had changed to left heel on 07/21/11. The treatments were not signed off at all when checked on 08/05/11. a. New orders were received by the physician on 08/03/11 to flush wound with Dakins solution 35ml with 18 gauge catheter, flush well, Iodosorb or hydrogel daily, cover with Opti-foam, charcoal dressing and abdominal pad daily. The treatments were not carried out or transcribed onto R #67's MAR until 08/05/11. b. New order dated 08/03/11 for left buttock wound, wash with normal saline, pat dry, skin prep periwound, hydrogel to wound bed and cover every morning daily and as needed till resolved. This order not transcribed until 08/05/11 when pointed error out to ADON. B. On 08/05/11 at 1:45 pm, during an interview with LPN #2, she confirmed that she was unaware of the wound care order change for R #67's left heel dated 08/03/11. LPN #2 also confirmed that the facility did not have the needed supplies in order to follow the physicians orders. C. Record Review of wound care log for R #67 for Left heel pressure ulcer, which was acquired in the hospital, revealed the following decline while at the facility: 1. Report dated 04/01/11- Left heel ulcer, date of onset 03/22/11, treatment, skin prep. Site eschar/necrotic 2. Report dated 04/08/11-Left heel ulcer 3.2 cm X 6.2 cm, treatment, skin prep. Site eschar/necrotic. 3. Report dated 04/15/11- Left heel ulcer 3.0 cm X 2.4 cm, eschar/necrotic, treatment, skin prep. 4. Report dated 04/22/11- Left heel 3.0 cm X 2.4 cm, eschar/necrotic tissue, treatment, skin prep. 5. Report dated 04/28/11- Left heel 3.0 cm X 2.4 cm, eschar/necrotic tissue, treatment, skin prep. 6. Report dated 05/06/11- left heel 3.0 cm X 4.0 cm, treatment, skin prep 7. Report dated 05/13/11- Left heel 3.0 cm X 4.0 cm, eschar/necrotic tissue, treatment, skin prep. 8. Report dated 05/20/11- Left heel 3.0 cm X 4.0 cm, treatment, skin prep. 9. Report dated 05/27/11- Left heel, 3.0 cm X 4.0 cm, eschar/necrotic tissue, treatment, skin prep. 10. Report dated 06/03/11-Left heel 3.2 cm X 4.2 cm, no exudate, no tunneling, wound bed is black/eschar, progress not changed. 11. Report dated 06/18/11- Left heel 4.3 cm X 6.3 cm, unable to detect depth, no exudate, slight odor, wound bed black/eschar, progress deteriorated, odor noted to heel, edges separating and lifting, treatment changed. 12. Report dated 06/23/11- Left heel 4.3 cm X 6.2 cm, slight odor, stronger pain med needed, progress not changed. 13. Report dated 07/06/11- Left heel 5.6 cm X 8.6 cm, depth 4.2 cm, exudate purulent and copious, tunneling 4 cm, foul odor, wound bed slough, black/eschar, surrounding tissue maceration, hospice in to evaluate, progress deteriorated, continue treatment. 14. Report dated 07/14/11- Left heel 5.6 cm X 8.6 cm, 4.2 cm in depth, tunneling 4 cm, foul odor, copious purulent exudate. 15. Report dated 07/20/11- Left heel 6.1 cm X 9.0 cm, 5.0 cm in depth, copious amount of purulent exudate, 4 cm tunneling, foul odor, wound bed slough. treatment changed. 16. Report dated 07/28/11- Left heel 10 cm X 12 cm, serosanguineous large amount of exudate, foul odor, wound bed black/eschar. 17. Report dated 08/03/11- Left heel 10 cm X 12. 7 cm, serous scant exudate, foul odor, black/eschar wound bed, not changed, treatment changed. D. Record Review of wound care log for R#67 for all other in house acquired ulcerations revealed the following: 1. Left great toe- Date of onset 05/23/11 a. Report for week of 06/03/11 Unstageable, 1.1 cm X 1. 6 cm, slight odor, wound bed black/eschar. b. Report for week of 06/23/11 Unstageable, 1.3 cm X 2. 6 cm, serous exudate, moderate odor, wound bed slough, pain scale 4, hospice notified. c. Report for week of 07/06/11 Unstageable, 1. 3 cm X 2. 6 cm, slight odor, black/eschar wound bed pain scale 4, hospice notified. d. Report for week of 07/14/11 Unstageable, 1.3 cm X 2. 6 cm, black/eschar wound bed, pain scale 4, no change to treatment. Report for week of 07/20/11, Unstageable, 1. 4 cm X 3.1 cm, Serosanguineous exudate, depth 0.1 cm, scant amount of exudate, slight odor, wound bed slough, pain scale 2. Report for week of 07/28/11 1.7 cm X 1.0 cm. 2. Left buttock, date of onset 08/02/11, Stage II, 3.1 cm X 1. 3 cm, depth 0.1 cm, no odor, no exudate, pressure ulcer. 3. Left lateral upper calf-date of onset 07/28/11, 1.3 cm X 1.1 cm, wound bed slough, categorized as a venous ulcer by RN#5. a.Report date on 08/03/11 1.2 cm X 1. 0 cm, 0.1 cm in depth, wound bed granulation tissue, progress not changed. 4. Left lateral malleolus, date of onset 07/28/11, categorized as a venous ulcer by RN#5. 2.0 cm X 3. 0 cm, no exudate, wound bed black/eschar. a. Report for week of 08/03/11 3.2 cm X 3. 0 cm, foul odor, black/eschar wound bed, treatment changed. 5. Left lateral foot, date of onset 07/28/11, categorized as a venous ulcer by RN #5. 8.0 cm X 2.5 cm, no exudate, wound bed purple. a.Report for week of 08/03/11 9.2 cm X 2.5 cm, serous small amount of exudate with foul odor, wound bed black/eschar, progress deteriorated, treatment changed. 6. Left knee, date of onset 07/28/11 2.4 cm X 1.4 cm, scant exudate, wound bed slough. a.Report for week of 08/03/11 2.4 cm X 1.9 cm, depth 0.1 cm, scant exudate, wound bed granulation tissue, progress is deteriorated. E. On 08/04/11 at 3:30 pm, during an interview with the ADON she said, "All wounds are recent with the exception of the left heel, she acquired that when she was hospitalized ." The ADON confirmed that R #67 had seven ulcerations to her skin. F. On 08/18/11 at 3:27 pm, during an interview with the hospice nurse RN #6 "I have witnessed her dressings not being changed for several days." When asked how long were the same dressings in place RN #6 stated, "I have witnessed bandages dated three days old when I was present and witnessed the wound care. The care is scattered and no follow up." G. On 08/19/11 at 9:28 am, when asked to explain what routine care she gave to R #67 and to include any special instructions about her skin CNA #3 stated, "We give her showers twice a week, on Thursdays and Saturdays. I showered her yesterday. We put lotion on her skin on shower days." CNA #3 never mentioned applying lotion to R #67's skin daily, turning and repositioning her or the use of devices to relieve pressure points. H. On 08/19/11 at 10:50 am, during a wound care observation with LPN #2, CNA #2 and CNA #3, R #67 was left laying in bed on her back after the treatment. R #67's left leg was bent at the knee and her foot was on the bed leaving pressure to her left heel. No pressure relieving devices were used to position R #67. O. Review of R #67's care plan contained the following approaches to her risk of skin breakdown. Assist with repositioning every 2-3 hours and as needed (prn). Notify physician and family of change in condition in relation to skin. Toilet per facility plan and prn. Provide preventative care such as lotion, barrier cream daily and prn. Provide pressure reducing devices such as pillow support for comfort. Provide treatment per orders. Notify Physician if no improvement at end of 2 weeks of current treatment. Consult with wound specialist with regards to maggots in wound.

Based on observation, interview and record review the facility failed to ensure that 1 (#67) of 6 residents (#81,#66,#29,#99, & #96) was provided with the necessary care and services for routine preventative skin care and wound care in order to maintain the highest practicable well being. This deficient practice resulted in actual harm to R #67, who developed 4 skin ulcerations which progressively worsened. The findings are: A. Record Review of admission orders [REDACTED] 1. [DIAGNOSES REDACTED]. 2. [MEDICATION NAME] to both heels daily. B. Record Review of facilities nursing notes revealed the following: 1. Entry by Licensed Practical Nurse (LPN) #2 dated 05/23/11 "Left great toe, red ulcer." 2. Entry by Registered Nurse (RN) #4 indicated" foul odor to left great toe." C. Record Review of wound care log for R #67 for all in house acquired skin ulcerations revealed the following: 1. Left great toe - Date of onset 05/23/11 a. Report for week of 06/03/11 Unstageable, 1.1 cm X 1. 6 cm, slight odor, wound bed black/eschar. b. Report for week of 06/23/11 Unstageable, 1.3 cm X 2. 6 cm, serous exudate, moderate odor, wound bed slough, pain scale 4, hospice notified. c. Report for week of 07/06/11 Unstageable, 1. 3 cm X 2. 6 cm, slight odor, black/eschar wound bed pain scale 4, hospice notified. d. Report for week of 07/14/11 Unstageable, 1.3 cm X 2. 6 cm, black/eschar wound bed, pain scale 4, no change to treatment. e. Report for week of 07/20/11, Unstageable, 1. 4 cm X 3.1 cm, Serosanguineous exudate, depth 0.1 cm, scant amount of exudate, slight odor, wound bed slough, pain scale 2. f. Report for week of 07/28/11 1.7 cm X 1.0 cm. 2. Left lateral upper calf - Date of onset 07/28/11, 1.3 cm X 1.1 cm, wound bed slough, categorized as a venous ulcer by RN #5. a. Report for week of 08/03/11 1.2 cm X 1. 0 cm, 0.1 cm in depth, wound bed granulation tissue, progress not changed. 3. Left lateral malleolus, date of onset 07/28/11, categorized as a venous ulcer by RN #5. 2.0 cm X 3. 0 cm, no exudate, wound bed black/eschar. a. Report for week of 08/03/11 3.2 cm X 3. 0 cm, foul odor, black/eschar wound bed, treatment changed. 5. Left lateral foot - Date of onset 07/28/11, categorized as a venous ulcer by RN #5. 8.0 cm X 2.5 cm, no exudate, wound bed purple. a. Report for week of 08/03/11 9.2 cm X 2.5 cm, serous small amount of exudate with foul odor, wound bed black/eschar, progress deteriorated, treatment changed. 6. Left knee - Date of onset 07/28/11, 2.4 cm X 1.4 cm, scant exudate, wound bed slough. a. Report for week of 08/03/11 2.4 cm X 1.9 cm, depth 0.1 cm, scant exudate, wound bed granulation tissue, progress is deteriorated. D. On 08/04/11 at 2:42 pm, during an interview with the DON she said the last DON, RN #5 was a certified wound care specialist and she was the person who determined if wounds were pressure, arterial or venous. The DON said she heard RN #5 and the Physician's Assistant argue over the heel and the Physician's Assistant said that was a pressure ulcer. E. On 08/04/11 at 3:30 pm, during an interview with the Assistant Director of Nursing (ADON) she said, "All wounds are recent with the exception of the left heel, she acquired that when she was hospitalized ." The ADON confirmed that R #67 had seven ulcerations to her skin. The wound care logs indicated out of 7 ulcers, 2 were pressure ulcers, 3 were venous ulcers and 2 were arterial ulcers. The ADON confirmed the only place in R #67's medical record of [MEDICAL CONDITIONS] was on a telephone order generated by the facility to clarify one ulcer as venous due to [MEDICAL CONDITION]. The ADON confirmed the last DON, RN #5 classified all the wounds and the Physician's Assistant did not agree with her. The ADON said R #67's heel and buttock areas were the only two pressure ulcers. F. Record Review of the facilities clinical protocol for pressure ulcers and skin breakdown revised 07/2010 states: "The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration. The ADON and the DON both confirmed that RN #5 classified the wound types and not the physician. The facility did not follow it's own protocol. G. On 08/08/11 at 4:46 pm, during an interview with the Wound Care Consultant (WCC) she said, "I am a wound care specialist and supply the facility with wound care products. "I am not their wound care consultant for the facility." Read copy of her notes dated 08/05/11 and she responded, "I document what the facilities nurses wrote about the wounds for the purpose of ordering supplies." "I simply placed a supply order." "I did not assess the wound on 08/05/11. " I discuss products only for a wound. "I did not know anything about the maggots until Thursday, August 4th." H. On 08/05/11 at 11:45 am with 6 months of Medication Administration Records (MAR) in hand, months March through August 2011 it was confirmed by the Director Of Nursing (DON), Assistant Director of Nursing (ADON) and the Clinical Coordinator (CC) the following physician orders [REDACTED]. 1. MAR for the month of March 2011, wound care orders for R #67's left heel obtained on 03/25/11 for treatment twice a day was missing 2 opportunities out of 10. Physician orders [REDACTED]. Physician order [REDACTED]. Physician orders [REDACTED]. 2. MAR for the month of April 2011 with wound care orders for R #67's left heel obtained on 03/25/11 for treatment twice a day was missing 24 opportunities out of 60. A physician's orders [REDACTED]. 3. MAR for the month of June with date 03/25/11 to left heel,for skin prep twice daily was missing 12 opportunities out of 60. physician's orders [REDACTED]. confirmed that the nurses omitted this care and did not document it at all for the entire month of June 2011. Order with origination date of 05/21/11 for right lower extremity anterior lateral aspect, cleanse wound with normal saline, apply oil [MEDICATION NAME] gauze to wound bed, secure with gauze wrap and tape, change daily and as needed, monitor for infection. Confirmed that the nurses did not document this wound care for the entire month of June 2011. Order with origination date of 12/14/10 to apply moisturizer to both legs every day was confirmed that the nurses did not document this treatment for [REDACTED]. Order with origination date of 12/14/10 to apply gauze/foam padding to bilateral heels was confirmed that the nurses did not document this treatment for [REDACTED]. Orders all dated 06/28/11 for wound care treatments were not documented by nurses for 3 days. It was also confirmed with the DON, ADON and the CC that new orders received on 06/17/11 and 6/22/11 were not transcribed onto the June MAR until 06/28/11 and were not signed off from then through the end of the month. Physician orders [REDACTED]. Confirmed order never transcribed onto R #67's MAR. 4. MAR for the month of July 2011 for an order dated 07/06/11 for [MEDICATION NAME] silver to left great toe and left heel, change every 3-7 days. Cleanse wounds with wound cleaner and secure with [MEDICATION NAME]. The MAR contained nurses signatures for this treatment on the following dates: July 13, 14, 15, 16, 19,20, 21, 22, 23, 24, 25 26th. An order originating on 07/21/11 to left heel, cleanse with normal saline, apply 4 X 4 moistened with 0.5% Dakins solution, cover with dressing 4 X 4 and secure with Kerlix, change daily. The order was not carried out by nursing on July 28th. An order originating on 05/31/11 for left great toe wound to cleanse with normal saline, apply Idosorb to wound bed daily and cover with foam dressing, wrap with Kerlix and change daily was in place until order changed on 07/06/11. Nursing did not complete this wound care on July 5th and then after receiving new orders proceeded to sign off this treatment which was discontinued on 07/06/11 on the following dates: July 13, 14, 15, 18, 19, 20, 21 and 22nd. Orders with origination date of 12/14/10 to apply moisturizer to both legs every day was missing 3 out of 31 opportunities. 5. MAR for the month of August 2011 with the following wound care orders originated on 07/06/11, [MEDICATION NAME] silver to left great toe and left heel change every 3-7 days, cleanse with wound cleaner and secure with [MEDICATION NAME] were still on the MAR and the wound care had changed to left heel on 07/21/11. The treatments were not signed off at all when checked on 08/05/11. New orders were received by the physician on 08/03/11 to flush wound with Dakins solution 35ml with 18 gauge catheter, flush well, Iodosorb or hydrogel daily, cover with Opti-foam, charcoal dressing and abdominal pad daily. The treatments were not carried out or transcribed onto R #67's MAR until 08/05/11. New order dated 08/03/11 for left buttock wound, wash with normal saline, pat dry, skin prep periwound, hydrogel to wound bed and cover every morning daily and as needed till resolved. This order not transcribed until 08/05/11 when pointed error out to ADON. I. On 08/05/11 at 1:15 pm observed R #67 laying in bed on her back with weight shifted to her left side. Both feet were against her footboard. No supportive devices such as pillow were present for relieving pressure points. J. On 08/05/11 at 1:45 pm, during an interview with LPN #2, she confirmed that she was reading new wound care orders for R #67. The orders referenced were changed on 08/03/11. LPN #2 confirmed that prior to this change in order the facility was still following orders obtained on 07/21/11.LPN #2 confirmed the facility did not have the needed supplies for the new order to include charcoal dressings at this time. K. On 08/05/11 at 1:47 pm, during an interview with the hospice nurse RN #7 she said she was the substitute nurse and the RN who normally cares for R #67 was on vacation. RN #7 confirmed that R #67 was admitted to hospice on 03/23/11 with admission [DIAGNOSES REDACTED]. She denied any medical history of [REDACTED].#67 got the call about the maggots on 08/01/11. (Name of RN #6) had done wound care in the past but the facility took over since daily dressing changes for the wound were needed. RN #7 said that RN #6 had concerns about R #67's care because they never elevated her legs and lots of issues with her left leg. L. On 08/05/11 at 2:05 pm during an observation of wound care to R #67's left heel, LPN #2 opened all bandages and supplies and laid them on R #67's over-bed table without a barrier. The table was dirty and contained ring marks from beverage glasses left over from lunch time. This was confirmed by LPN#2 with ADON that she did not clean the over-bed table prior to setting up her wound care supplies. LPN #2 and the ADON confirmed that the table was in fact dirty and there were visible marks from beverage cups. It was also confirmed by both LPN #2 and the ADON that R #67 has meals in her room on the over-bed table and is fed by her husband. During the observation. LPN #2 removed the soiled dressing and carried it over the over-bed table where the clean dressing were opened and laying uncovered in their containers. LPN #2 then tossed the dirty dressing into the garbage can lined with a red isolation bag placed approximately 3 feet away from the bed. LPN #2 was irrigating the wound with a syringe and needle containing Dakins solution and the ADON was holding R #67's leg up when suddenly the ADON said "OH" and turned her face to the right, away from LPN #2 to avoid being splashed again. LPN #2 asked the ADON: "Did I get you" and the ADON did not reply. After removing the soiled dressing LPN #2 did not change gloves and wash hands before applying clean dressings. After completing the dressing, LPN #2 removed her gloves and tied up the red isolation bag touching the inside liner with bare hands and carried it down the hall to dispose in proper container. After the completion of wound care the breaks in infection control technique were discussed with LPN #2 and the ADON who agreed that aseptic technique was broken. M. Review of the facilities policy on wound care dated 07/2010 contained the following protocol: "Use disposable cloth to establish clean field on resident's over-bed table if used." "Wash and dry your hands thoroughly." "Pull glove over dressing and discard into appropriate receptacle." "Wash and dry your hands thoroughly." "Put on gloves." "Be certain all clean items are on clean field." "Discard all soiled laundry, linen, towels, and washcloths into soiled laundry container." "Remove disposable gloves and discard into designated container." Wash and dry your hands thoroughly." "Clean the area used as a field for dressing supplies." N. Based on observation of wound care on 08/05/11 at 2:05 pm LPN #2 did not follow the facilities policy and procedure for wound care. O. On 08/05/11 at 4:00 pm observed R #67 in same position since wound care at 1:30pm. At 4:36pm R #67 was up in wheelchair and husband was feeding her dinner. Observed a fly inside the room in R #67's window sill and that was confirmed by R #67's husband. He said he used mosquito [MEDICATION NAME] when he takes her outdoors. P. On 08/08/11 observed R #67 in bed flat on back between the hours of 1:30pm to 4:00 pm in the same position. No supportive devices such as pillows were present for relieving pressure points. Q. On 08/09/11 at 11:00 am observed R #67 in wheelchair until 2:11pm observed R #67 still sitting in wheelchair. R #67 was outside with foot wrapped in Kerlix bandage and observed a fly on her left leg thigh area. A physical therapy aide walked by and adjusted her foot pedals since they were not positioned correctly. Asked R #67's husband if any staff had repositioned his wife since this morning and he said, "once" Asked if staff regularly repositioned R #67 and he said, "No, I know they should do it more often." R. On 08/18/11 at 3:27 pm, during an interview with the hospice nurse RN #6 she state, "(Name of R #67) was admitted on hospice with a stage II on her coccyx and a blackened area to her left heel. I had numerous care concerns with the nursing care and they still didn't follow up after communicating my concerns to them. (Name of R#67) didn't have a pressure relieving mattress, no padding to her heels and her legs were never elevated when I observed her on visits. I was seeing her three times a week and now I go twice a week. I discussed my concerns mainly with LPN #1, LPN #2 and the ADON. I requested pressure relieving devices and finally instructed her husband, who stays at her bedside, to use a pillow and even the teddy bear in her room to relieve pressure areas. (Name of R #67) didn't even have wings (foot pedals) on her wheelchair. Her buttock finally was resolved and the heel was the same for awhile and then it got real bad. The smell was horrible. That wound is one of the worst things I have seen and I have been a nurse for [AGE] years. She then developed a bunch of pressure area wounds and the buttock went from a stage II to now it's necrotic (dead) tissue. That was only in a period of 2-3 weeks. Every time I visit she is siting up in her wheelchair. She has lots of skin tears and (Name of R #67) can't scratch or tear her skin. Her nails are very short and I ask them to put her protective sleeves on for protection but they don't. I have witnessed her dressings not being changed for several days." When asked how long were the same dressings in place, RN #6 stated, "I have witnessed bandages dated three days old when I was present and witnessed the wound care. I suggested to wrap the foot in a plastic bag when they take her outdoors but they didn't. LPN #2 uses the same supplies for (Name of R #67) that she uses for the other residents. I recommended that all supplies be bagged specifically for (Name of R #67)'s wound care. They still don't do that. I witnessed dressing changes when the drainage was not always contained and that worries me from the infection control stand point. I was notified of the maggots the following Monday when they discovered them over the weekend. The care is scattered and no follow up." When asked if the maggot infestation could have been avoided, RN #6 stated, "Yes, the infestation of maggots could have been prevented if they would follow good technique and change the dressings daily as instructed by the physician." S. On 08/19/11 at 9:15 am observed R #67 sitting in wheelchair in room alone. Dressing to left heel soaked through with drainage and foul odor in room. R #67 did not have any heel protectors on just Kerlix gauze soaked with drainage. R #67 did not have legs elevated and no protective sleeves were in place. R #67 was not able to reach her call bell. This observation was confirmed with CNA #2 and CNA #3 at 9:25am. T. On 08/19/11 at 9:28 am, during an interview with CNA #3 she was asked to explain what routine care she gave to R #67 and to include any special instructions about her skin. CNA #3 said, "We give her showers twice a week, on Thursdays and Saturdays." "I showered her yesterday." "We put lotion on her skin on shower days." "She is total care, I brush her teeth, change her and use the Hoya to transfer her." "We feed her breakfast in the mornings in the dining room and her husband feeds her lunch and dinner in her room." CNA #3 expressed her concern about the large amount of drainage seeping through the bandage to the resident's foot and the impact on other residents. Observed a bag of charcoal hanging under R #67's wheelchair and neither CNA #2 or CNA #3 knew why it was placed there. CNA #3 never mentioned applying lotion to R #67's skin daily, turning and repositioning her or relieving pressure points. Observed CNA #3 place protective sleeves on R #67 at this time. U. On 08/19/11 at 9:43 am, during an interview with CNA #2 he confirmed he was present on 07/31/11 with RN #1 and LPN #1 when the maggot was discovered. CNA #2 said he assist with R #67's dressing changes as often as possible since he is in nursing school. "I helped the nurses, RN #1 and LPN #1 out by holding up her leg while the nurses changed the bandages." "LPN #1 removed the old dressing and RN #1 put the new dressing on." "The wound was dead flesh, it was much smaller than it is now." "(Name of R #67) really declined over the last month or so." "When the nurse unwrapped the dressing there was one maggot." "The maggot fell on to the Chux pad," "We double bagged it and put it into the biohazard bag." "The center of the wound was black and edges were white with a real foul smell." "I didn't see the DON here that day at all." Asked CNA #2 if the maggot was alive and he said, "Yes it was wiggling around." V. On 08/19/11 at 10:50 am, during a wound care observation with LPN #2, CNA #2 and CNA #3, R #67 was left laying in bed on her back after the treatment. R #67's left leg was bent at the knee and her foot was on the bed leaving pressure to her left heel. R #67's husband was at her side and he said he would put a pillow there for her comfort. No pressure relieving devices were used to position R #67 such as an ankle do-nut sitting on her dresser to relieve pressure to her heels. W. Review of R #67's care plan contained the following approaches to her risk of skin breakdown. Assist with repositioning every 2-3 hours and as needed (prn). Notify physician and family of change in condition in relation to skin. Toilet per facility plan and prn. Provide preventative care such as lotion, barrier cream daily and prn. Provide pressure reducing devices such as pillow support for comfort. Provide treatment per orders. Notify Physician if no improvement at end of 2 weeks of current treatment. Consult with wound specialist with regards to maggots in wound.

Based on observation and interview, the facility failed to ensure that the main entrance doors were maintained to prevent accidents. This deficient practice caused actual harm to 1 (#8) of 1 (#8) residents who obtained a skin tear and bruise. The findings are: A. On 08/02/11 at 11:18 am, during observation and interview, R #8 was observed with a large skin tear and a large bruise to his right forearm. He also had a scabbed area to his right elbow. When asked how it happened, R #8 said that the front doors of this building are very heavy and hard to manipulate. He caught the door with his arm (blocked it) and obtained a skin tear and bruise. He requested for the doors to be lighter or automatic for himself and other residents at the facility. B. On 08/04/11 at 4:24 pm, during an interview, when asked if a work order was submitted to the maintenance department to check if the doors were in safe operating condition, the Director of Nursing stated "No." C. On 08/04/11 at 4:55 pm, during an interview, the Director of Maintenance said that he has made some calls to get some ideas on fixing the pressure of the front doors. The Director of Maintenance also stated that the doors were old and that he oiled and greased them hoping that would make the doors lighter. He stated "I have not received any orders to address the doors as of today."