Every finding on record at Macgregor Downs Health Center by Harborview

Based on record review, staff and resident interviews, the facility failed to honor a resident's right to attend care plan meetings for 1 of 28 residents reviewed for care planning (Resident #53).Findings included:Resident #53 was admitted to the facility on [DATE].The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #53 was moderately cognitively impaired. The care plan for Resident #53 was initiated on 2/12/24 and last revised on 3/26/26.Record review revealed a late entry note written by Social Worker #1 on 3/31/26 stated a care plan meeting was held with only the Interdisciplinary Team (IDT) (the facility Social Worker and the MDS Nurse) in attendance. The Responsible Party (RP) was invited but did not attend. The record also revealed advanced directives and code status were reviewed. An interview with Resident #53 was conducted on 4/27/26 at 11:26 AM. Resident #53 stated she did not get invited to care planning meetings. She went on to say she feels her RP is not acting in her best interest and attending care plan meetings would help her better understand her current situation.During an interview with Social Worker (SW) #1 on 4/28/26 at 3:43 PM, she said Resident #53 was not listed as her own responsible party (RP) and therefore would not have been invited to attend care plan meetings. She stated she only invited the individual listed as a RP to the care plan meetings. SW #1 indicated the only time a resident would be invited to attend was if a resident was listed as their own RP. SW #1 added that Resident #53's RP had been invited to attend care plan meetings, but she did not recall a time when the RP had attended. During an interview on 4/29/26 at 2:06 PM, the Administrator said he expected staff to send care plan meeting invitations to residents who had the cognitive ability to participate and for whom participation would have been meaningful.

Based on observations, record review, and staff interviews, the facility failed to clean and maintain window curtains, the flooring underneath medical equipment, and the packaged terminal air conditioner (PTAC) in a resident's room for 1 of 28 resident rooms (Resident #6) on 1 of 6 halls observed for environment. The findings included: Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that she was severely cognitively impaired. An observation of Resident #6's room on 4/27/26 at 1:45 PM revealed both (two in total) window curtains had scattered red stains on them. There were also two pools of brown liquid underneath the tube feeding pole to the right of the head of the bed. It was also observed that dust like black bits, fragments, and pieces were on top of and inside the PTAC near the insertion site of the filter. Additional observations of Resident #6's room were conducted on 4/28/26 at 8:13 AM and 4/29/26 at 9:07 AM both observations revealed the two window curtains had scattered red stains on them. There were also 2 pools of brown liquid underneath the tube feeding pole to the right of the head of the bed. It was also observed that dust like black bits, fragments, and pieces were on top of and inside the PTAC near the insertion site of the filter. An interview with Housekeeper #1 was conducted on 4/29/26 at 9:47 AM. She revealed she was hired in August 2025 and mainly was assigned to Resident #6's hall. She was assigned to Resident #6's room on 4/27/26 and 4/29/26. Housekeeper #1 stated Housekeeper #2 was assigned to Resident #6's room on 4/28/26. When cleaning a resident's room, housekeepers were expected to take out the trash, sweep the floor, mop the floor only if there was a spill, clean the bathroom, change the hand sanitizer, and replenish bathroom supplies. Housekeeper #1 stated that she checked behind the beds every day because residents ate in their rooms. She indicated that housekeeping was responsible for seeing if the window curtains needed to be replaced or cleaned. If there was an issue or the window curtains displayed any stains, she would notify the Housekeeping Manager/Maintenance Director. The PTAC units were also cleaned by housekeeping. An observation of Resident #6's room was conducted during an interview with Housekeeper #1 on 4/29/26 at 9:56 AM. Housekeeper #1 confirmed that the window curtains had red stains on them, there were two pools of dried brown liquid under the tube feeding pole, and there was a dusty black substance on top of the PTAC and inside the vents. Housekeeper #1 stated she tried to get the two pools of brown liquid up off the floor by wiping and scraping but was unsuccessful because the floor wax caused the brown liquid to become stuck. She further stated that she was never instructed to inspect the window curtains, only the privacy curtains and did not know the protocol for window curtains. Housekeeper #1 indicated that when interviewed earlier, she thought the window curtains were the same as the privacy curtain. She could not explain why the PTAC unit was not cleaned earlier, but it was her responsibility. Housekeeper #2 was interviewed on 4/29/26 at 10:07 AM. She revealed that she only focused on the trash and flooring in Resident #6's room on 4/28/26. Housekeeper #2 stated that everything looked fine to her. The Housekeeping Manager/Maintenance Director was interviewed on 4/29/26 at 10:11 AM. He revealed that the previous Housekeeping Manager ended their employment on 4/24/26. The Housekeeping Manager/Maintenance Director stated that all cleanliness concerns in Resident #6's room should have been identified and cleaned. When trying to scrape up the hardened brown liquid, it often brought up the wax; however, Housekeeper #1 could have sprayed it and let it sit multiple times and then it would come up within a few days. Housekeeper #1 should have notified the Housekeeping Manager/Maintenance Director about the stained window curtains. They would have been washed in the washing machine and hung up wet because they would melt in the dryer. However, the facility was in the process of replacing all window curtains and the valances on top of the curtains because the window curtains were more than [AGE] years old. The interview further revealed replacing the window curtains was first spoken about 1.5 years ago, but other urgent matters have come up since then. The Administrator was interviewed on 4/29/26 at 2:54 PM. He revealed he was awaiting a final decision from the facility's interior designer about the window treatment replacements. Although no upright chairs were observed in Resident #6's room, the Administrator indicated that the bottom of the upright chairs produced a black substance that disintegrated when touched and could have contributed toward the PTAC dusty black substance. He stated that the brown pools of liquid underneath the tube feeding pole should have been cleaned as soon as they were identified.

Based on record review and interviews with staff, Nurse Practitioner, Physician, Responsible Party (RP), and Hospital Case Manager, the facility failed to allow Resident #129 to return the facility after being transferred to the hospital for evaluation for 1 of 4 residents reviewed for discharge (Resident #129).Finding included:Resident #129 was admitted to the facility on [DATE]. His active diagnoses included Parkinson's disease, bilateral sensorineural hearing loss (a permanent type of hearing loss caused by inner ear damage), bilateral unqualified visual loss (significant vision reduction in both eyes that has not been specifically categorized as either low vision or blindness), hypertension, diabetes mellitus, hyperlipidemia, dementia, anxiety disorder, depression, and asthma.Medical record review from admission on [DATE] through 4/18/26 revealed no evidence of behaviors for Resident #129. A late entry progress note dated 4/20/26 completed by Nurse #1 revealed Resident #129 was observed kneeling on the floor over his roommate. He was very aggressive and appeared to intend harm to his roommate. The two were separated, assessed with no injuries noted, and the provider and RPs were notified. Resident #129 was sent to the hospital for evaluation.During an interview on 4/29/26 at 2:08 PM Nurse Aide #3 stated she was the nurse aide on the hall when the incident happened between Resident #129 and his roommate. She indicated she had just finished caring for another resident and left that room when she heard Nurse #1 shout for help from Resident #129's room. She entered and the nurse had already separated the two residents. The roommate had a small laceration to his left eye that healed within two days. She stated Resident #129 had been on her assignment previously but had never presented with any signs of aggression towards other residents and rarely became upset with staff. She explained that when he became upset with staff he would yell at them and make them leave but he had never been physically threatening that she was aware of. She indicated it was a surprise for him to behave this way toward another resident. Law enforcement was notified and Resident #129 was sent to the hospital. Upon discharge on [DATE], a transfer/discharge notice was provided to Resident #129. The reason for the transfer/discharge was documented to be necessary for Resident #129's welfare, his needs could not be met in the facility, and the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident. The hospital record from 4/19/26 through 4/21/26 indicated Resident #129 was sent to the Emergency Department (ED) for evaluation of agitation. A Psychiatry and Behavioral Medicine ED consultation note indicated the resident was noted with a history of Parkinson's disease with worsening confusion and no prior psychiatric history of aggression/agitation. The resident reported he had left his room and when he came back someone was in his bed and he got upset with them. The resident had no acute concerns for psychiatric illness and did not meet inpatient criteria. The ED's history of present illness indicated Resident #129 was blind and hard of hearing. ED Case Management notes indicated that initially the facility indicated the resident could return on 4/20/26 when a private room was available; and subsequently the facility indicated the resident could not return to the facility at all. The resident was discharged home with his spouse on 4/21/26 with home health services.During a phone interview on 4/29/26 at 3:46 PM the ED/Behavioral Health Case Manager stated the resident was sent to the hospital on 4/19/26 and was assessed and cleared to return to the facility for Skilled Nursing Facility (SNF) level of care by the providers in the ED that evening. She notified the Hospital Liaison for the facility who said Resident #129 could go back to the facility the following day (4/20/26) because they needed to prepare and admit Resident #129 into a private room. The ED/Behavioral Health Case Manager told the Hospital Liaison Resident #129 did not need to stay overnight in the hospital and questioned what the difference was between staying one more night or not. The ED was having capacity issues, and Resident #129 who was deemed appropriate for SNF care was taking up a bed needed for someone who had an actual reason to be in the hospital. The facility's Hospital Liaison said she would speak with the Administrator. That evening (4/19/26) around 5:00 PM, the facility's Hospital Liaison then notified the ED/Behavioral Health Case Manager that Resident #129 would not be allowed to return to the facility. She attempted to find Resident #129 placement in a SNF elsewhere but was unsuccessful. The RP came to the hospital and took him home 4/20/26. The ED/Behavioral Health Case Manager set up home health and ensured safety of the discharge, Resident #129's RP just wanted him to get therapy first before returning home. Resident #129 did not return to the facility.During a phone interview on 4/29/26 at 4:05 PM Resident #129's RP (his spouse) stated she was called by Resident #129's nurse on a Sunday (4/19/26) and was told he needed to be sent to the hospital due to confusion and delusions and needed the hospital to evaluate him. The nurse also indicated he had become very angry with his roommate and they had to be separated. He went to the hospital on Sunday 4/19/26 around 11:00 AM. The facility had asked for a psychiatric examination. The hospital did not identify any psychiatric illness, and a case manager from the hospital whose name she could not remember called and said Resident #129 needed to wait 24 hours for a private bed to open according to the facility. Then the hospital case manager called again and said the facility was not taking Resident #129 back and she would try to find another facility for him to go to. She was later told via phone by the ED/Behavioral Health Case Manager that other facilities were not accepting Resident #129, and it was late in the night on 4/19/26 when the hospital informed her the resident had to go home with her. She told them he could not return home that night. She was called at about 10:00 AM in the morning on 4/20/26 and she told them she was not sure it was safe for him to be discharged this way. She was then told by the hospital that he had to go home. She stated she spoke with the Director of Nursing at the facility and was told she had no appeal or recourse. When asked, she concluded she did not think Resident #129 had any psychosocial harm because he was a very resilient fellow. Resident #129 was currently living at home and being seen by home health. She reported that things were going okay but hated that Resident #129 did not receive a little more therapy before returning home. During an interview on 4/29/26 at 1:45 PM Nurse Aide #1 indicated she was familiar with Resident #129. She stated she was not involved in the incident in which Resident #129 became hostile to his roommate. She stated she had not observed any aggressive or violent behaviors toward other residents. She indicated that the resident could get irritable and yell at a staff member to leave the room at times but if he was given fifteen minutes and he would apologize to the staff. Nurse Aide #1 reported she was surprised to learn he had been aggressive toward his roommate, as he had never exhibited such behavior in the past when she took care of him on her assignment. During an interview on 4/29/26 at 1:48 PM Nurse Aide #2 stated she was familiar with Resident #129. She further stated she was not involved in the incident with Resident #129 and his roommate. She reported she had not had any indication of him being aggressive or violent to other residents and was surprised to hear he had been aggressive towards his roommate as he had never done anything like that in the past. During an interview on 4/28/26 at 10:46 AM, Social Worker #1 and Social Worker #2 stated they were not involved with any decision regarding whether a resident was allowed to return to the facility or not. They stated that decision was handled by the Admissions Department and the Director of Nursing if needed.During an interview on 4/28/26 at 10:50 AM the Admissions Director and the Admissions Ambassador stated they did not have any say on whether a resident was allowed to return to the facility or not. The decision in question was handled by the Administrator and Director of Nursing. The admission Director stated the admissions department did not have any involvement in the decision. During an interview on 4/29/26 at 12:14 PM Nurse Practitioner #1 stated she arrived at the facility the morning after the incident happened (4/20/26) and she was informed Resident #129 had been uncharacteristically aggressive towards his roommate. She stated she was not involved in the decision not to allow Resident #129 back in the facility; however, she did agree they were unable to provide the level of care he needed at that time. Prior to this incident, Resident #129 did not display this level of cognitive decline and had not displayed similar behaviors. With this in mind, and his visual impairment, she believed he could have attacked someone else if he thought something was abnormal or believed he was under attack. She indicated in an environment where it could not be ensured that an individual would not approach, speak to, or touch Resident #129 without first explaining what they were doing, such as a roommate, visitor, or other resident as he was ambulatory and would walk the hall, she felt the facility could not ensure the safety of Resident #129 or the other residents in the facility who might not approach him as a medical professional would. During an interview on 4/29/26 at 1:09 PM Physician #1 stated he was familiar with Resident #129. He further stated the decision to not allow the resident to return was made by the Director of Nursing and Administrator without him and then after that decision had been made, he was updated on the status of the resident and agreed with the decision. The Physician stated that given Resident #129's visual and hearing impairment, he could have attacked another individual if he perceived something as abnormal or was under the impression he was under attack as happened with his roommate on 4/19/26. Physician #1 verbalized he was surprised when he heard about this incident as Resident #129 had not displayed this type of behavior previously. He concluded that while he agreed with the decision to not take the resident back, he was not involved in the decision and did not document anything regarding the facility not being able to care for Resident #129. During an interview on 4/28/26 at 11:03 AM the Administrator stated the decision not to allow Resident #129 back into the facility was made as a result of the incident on 4/19/26 and hospital records following the incident. She explained that the hospital records did not indicate the hospital had done anything for Resident #129 besides completing a psychiatric assessment and deeming him fit to return to the facility that same day. The Administrator felt the facility could not guarantee the safety of other residents if they allowed Resident #129 back into the facility. Nurse Practitioner #1 was made aware of the incident and the decision not to allow Resident #129 to return to the facility during a conversation with the Director of Nursing and the Administrator and she (Nurse Practitioner #1) agreed with the decision. The Medical Director was not involved in the decision but was informed later and agreed. The facility's Hospital Liaison informed the hospital Resident #129 would not be returning to the facility and Resident #129's RP was notified by the hospital. The Administrator stated he had not seen any behaviors of aggression towards other residents displayed by Resident #129 prior to 4/19/26.

Based on observations and staff interviews, the facility failed to store a sugar scoop in a manner that prevented the potential for cross contamination by storing the scoop in the bulk sugar bin with the scoop handle touching the sugar. This was for 1 of 3 pantry's observed. This had the potential to affect food served to residents. Findings included: On 2/11/25 at 4:05 PM an observation of the bulk sugar bin in Hall 2 pantry revealed the sugar scoop was stored directly in the bulk sugar bin with the handle of the scoop in contact with the sugar. In an interview with Dietary Aide #1 at that time she stated she was assigned to the Hall 2 pantry that day. She reported that when she had gone on her break a little after 3:00 PM that day the scoop had not been in the sugar. She stated the sugar scoop should always be stored separately and not in contact with the sugar in the bin for sanitary reasons to prevent the potential for cross contamination. She reported this had probably been done by [NAME] #1. On 2/11/25 at 4:13 PM an interview with the Dietary Manager indicated a scoop should never be stored directly in the bulk sugar bin. She reported this was to prevent the potential cross contamination of the sugar by the scoop. In an interview on 2/11/25 at 4:15 PM [NAME] #1 stated he recently used the sugar from the bulk sugar bin in Hall 2 pantry to make sweet tea for the resident's supper meal. He reported he knew that after using the scoop it should not be stored directly in the sugar to prevent cross contamination of the sugar by the scoop. He stated he accidentally left the scoop in the sugar after he used it. On 2/13/25 at 9:44 AM an interview with the Administrator indicated a scoop should never be stored directly in the bulk sugar bin after it was used. He stated [NAME] #1 knew better than to do this.

Based on observations, record reviews and staff interviews, the facility failed to implement their infection control policies and procedures when Housekeeper #1 failed to wear an isolation gown while cleaning the room of two residents on droplet contact precautions and the Director of Nursing (DON) failed to wear personal protective equipment (PPE) before entering the room of a resident on droplet contact precautions. In addition, Nurse #3 and the Administrative Ambassador failed to wear PPE and perform hand hygiene before entering the room of two residents on droplet contact precautions and Nurse #1 failed to perform hand hygiene before putting on clean gloves and after removing soiled gloves. This deficient practice occurred for 5 of 24 staff (Housekeeper #1, Administrative Ambassador, Director or Nursing, Nurse #3 and Nurse #1) observed for infection control practices. The findings included: 1. The facility policy implemented on 3/1/22 and reviewed/revised on 7/1/24 titled Transmission-Based (Isolation) Precautions read in part It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. During continuous hall observation on 2/9/25 at 12:15 PM it was observed that a sign was posted on the door to room [ROOM NUMBER] in which Residents #16 and #122 were residing. Both residents had been diagnosed with Influenza A and were on droplet precautions for infection control. The signage stated in part: Droplet Contact Precautions, everyone must 1. Clean hands before entering and when leaving, 2. Wear a gown when entering the room and remove before leaving, 3. Wear a surgical/procedure mask when entering, 4. Wear gloves when entering. Housekeeper #1 was observed wearing only gloves and a surgical mask while wet mopping the floor. In an interview with Housekeeper #1 on 2/9/25 at 12:30 PM he revealed he should have worn a gown into the room, he went on to say he didn't realize the sign on the door showed he needed to wear an isolation gown. An interview was conducted on 2/10/25 at 1:50 PM with the Director of Facility Services. He stated his expectation would have been that his staff wear gowns, masks and gloves when a droplet contact precaution sign is posted on the door. An interview with the Director of Nursing (DON) was held on 2/10/25 at 2:15 PM. The DON stated she revealed her expectation would have been the housekeepers wear a gown, mask, and gloves when working in a droplet precaution room. In an interview with the Administrator on 2/11/25 at 11:58 AM, he stated there had been extensive training regarding precautions, there were signs on the doors that told the staff what PPE they should wear. The staff should wear gowns, gloves, and masks when entering a droplet precaution room as the residents may cough or sneeze and spread infection. 37468 2. Resident #57 active diagnoses included influenza. Review of the signage on the door to Resident #57's room read in part, Droplet Contact Precautions. Everyone must: Clean hands before entering and when leaving room. Wear a gown when entering the room and remove before leaving. Wear surgical/procedure mask when entering the room. Remove immediately before leaving room. Wear gloves when entering room. Perform hand hygiene after removing gloves. During observation on 2/9/25 at 10:56 AM the Director of Nursing entered Resident #57's room with no gown or gloves and a surgical/procedure mask, touched the privacy curtain while speaking with Resident #57, washed her hands, and left the room. During an interview on 2/9/25 at 10:57 AM the Director of Nursing, upon looking at the signage on the door, stated she thought it was enhanced barrier precautions room instead of droplet precautions room and she should have put on a gown and gloves prior to entering the room. During an interview on 2/9/25 at 11:03 AM the Administrator stated infection prevention protocols must be followed at all times. 48230 3. During an observation on 2/9/25 at 12:50 PM Nurse #3 and the Administrative Ambassador entered the room of Residents #286 and Resident #287 (room [ROOM NUMBER]). Both residents had been diagnosed with Influenza A and were on droplet precautions for infection control. There were two signs on the door entitled droplet precautions describing what personal protective equipment (PPE) must be worn if entering the room. The required PPE was a gown, gloves and mask in addition to performing hand hygiene before donning PPE. Both Nurse #3 and the Administrative Ambassador walked into the room to investigate a beeping noise without performing hand hygiene or donning the required PPE. In an interview with Nurse #3 on 2/9/25 at 12:54 PM she stated she was worried the beeping noise was an oxygen concentrator and didn't think about donning PPE or performing hand hygiene before entering the room. Nurse #3 further stated she should have performed hand hygiene and donned the proper PPE to enter the room as both residents tested positive for influenza A and were on droplet precautions to prevent the spread of virus. In an interview with the Administrative Ambassador on 2/9/25 at 12:56 PM he stated he was aware of the droplet precautions signage and policy and he should have stopped to don PPE before entering the room. The Director of Nursing (DON) stated in an interview on 2/10/25 at 2:53 PM that all staff were trained on infection control practices such as donning PPE before entering a room with droplet precaution signage. An interview with the Administrator was conducted on 2/11/25 at 11:58 AM. He stated all staff were provided with education on infection prevention and control practices upon hire. He further stated all residents on droplet precautions have a sign attached to their door so staff can easily know what precautions are required and for which tasks. 4. A review of the facility policy titled Hand Hygiene dated 7/1/2023 stated in part: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 6. (a.) the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves. An observation of a blood glucose check was conducted on 2/11/25 at 9:49 AM. During the observation, Nurse #1 failed to perform hand hygiene before putting on gloves. She carried the gloves into the resident's room with her. Nurse #1 set down the blood glucose monitoring supplies and subsequently dropped one of the gloves on the floor at the resident's bedside. The Nurse then picked up the dropped glove and put it on, put on the other glove and proceeded to check the residents blood sugar. Nurse #1 then failed to perform hand hygiene after removing the gloves and returning to her medication cart where she opened the cart and proceeded to begin pouring medications for the next resident. During an interview, Nurse #1 stated she should have performed hand hygiene before putting on gloves and after taking them off. She further stated using the glove she dropped was a breach in infection control as the floor is considered dirty and it should not have been used on the resident. Nurse #1 indicated she was aware hand hygiene should be performed before donning and after doffing gloves. Nurse #1 indicated she had been educated about infection control upon hire. In an interview on 2/11/25 at 9:59 AM the Director of Nursing (DON) stated hand hygiene such as using hand sanitizer or washing with soap and water should be performed before putting on gloves and after removing them. She further stated anything dropped on the floor is considered contaminated and should be thrown away instead of being used on a resident. This is to avoid introducing infection to the resident. The DON indicated all staff were trained in infection control procedures. An interview with the Administrator was conducted on 2/11/25 at 11:58 AM. He stated all staff were provided with education on infection prevention and control practices upon hire. He further stated that hand hygiene is the frontline defense against the spread of infection and should be performed both before putting on gloves and after removing them. In an interview with the Regional Director of Operations on 2/13/25 at 9:02 AM she revealed that the facility was unable to find documentation that Nurse #1 was educated on infection control at any time since hired on 10/15/24.

Based on observation and staff and resident interviews, the facility failed to assess the ability of a resident to self-administer medications and vitamins for 1 of 1 resident with medications observed at bedside (Resident #42). Findings included: Resident #42 was admitted to the facility on [DATE]. Her active diagnoses included anemia, heart failure, hypertension, diabetes, and respiratory failure. Review of Resident #42's Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. Review of Resident #42's electronic health record on 2/10/25 at 1:06 PM revealed there was no physician's order for self-administration of medications and no self-administration of medication assessment. During observation on 2/9/25 at 11:24 AM two medication cups with pills were observed in Resident #42's room on the resident's bedside table. There were no facility staff members in the resident's room. Resident #42 was in bed and the bedside table with the medication placed in front of her. Review of the Medication Administration Record on 2/10/25 at 8:04 AM revealed Resident #42's morning medications were signed as given by Nurse #2 on 2/9/25 were Amiodarone HCl Oral Tablet 200 milligrams (MG), Ascorbic Acid Tablet 250 MG, Citalopram Hydrobromide Oral Tablet 20 MG, Clopidogrel Bisulfate Oral Tablet 75 MG, Cyanocobalamin Tablet 250 micrograms (MCG), Decubi-Vite Oral Capsule (Multiple Vitamins with Minerals) 1 tablet, Ferrous Sulfate Oral Tablet Delayed Release 1 tablet, Potassium Chloride Extended Release 10 milliequivalents (MEQ), Prednisone Oral Tablet 10 MG, Apixaban Oral Tablet 2.5 MG, Carvedilol Oral Tablet 12.5 MG, and Glucosamine-Chondroitin DS Oral Tablet 500-400 MG. During an interview on 2/9/25 at 11:25 AM Resident #42 stated the nurse left the medications for her on the bedside table and had told her one medication cup contained regular meds and the other contained Vitamins but she did not know which medication cup was which. She concluded she had not taken the medications yet because she did not know which was which. During an interview on 2/9/25 at 11:29 AM Nurse #2 stated she did not intentionally leave the medications in Resident #42's room but now that the surveyor was asking, she remembered she did leave them in the room. She stated the medications cups contained Resident #42's morning medications and when she arrived in the room to administer them that morning, she could not recall the exact time, but the breakfast tray was arriving. She helped other staff pull Resident #42 up in bed and then was pulled to another room to assist another resident. She stated she put the medication cups down on Resident #42's bedside table and told the resident she would be right back. She forgot and did not return to administer the morning medications. She stated she was trained to put non-administered medications back in the locked medication cart if leaving a resident's room to assist another resident. She stated the reason she left them in the room was because she thought she was coming right back. She stated the medication cups contained her scheduled morning medications. During an interview on 2/10/25 at 2:26 PM the Director of Nursing stated medication should not be left at the bedside for Resident #42. Nurse #2 should administer the medications and ensure the medications were taken by the resident before leaving the room. If the nurse needed to leave the room prior to the resident taking all medications, the nurse should lock the remaining medications in her cart after identifying the medication cup with the resident's name.

Based on record review, and resident, family and staff interviews, the facility failed to ensure a copy of the resident's advanced directive was included in the resident's record and failed to provide written advance directive information and/or an opportunity to formulate an advance directive (Residents #105 and #114). This was for 2 of 4 residents reviewed for advance directive. The findings included: A review of the facility's policy titled Residents' rights Regarding Treatment and Advance Directives dated 3/1/22 and reviewed/revised on 3/1/24 revealed it is the policy of this facility to support and facilitate a residents' right to formulate an advance directive. On admission the facility will determine if the resident has executed an advance directive, and if not determine whether the resident would like to formulate an advance directive. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. 1. Resident # 105 was admitted to the facility on [DATE]. A review of Resident #105's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Resident #105's care plan last revised on 12/3/24 indicated the resident's code status was full code. There was no documentation in the record for education regarding the formulation of advanced directives and /or an opportunity to formulate advanced directives. An interview was held with Social Worker #3 on 2/10/25 at 11:35 AM and she revealed she did not discuss advance directives. She stated the admission nurse or Social Worker # 2 would have been responsible for that task. In an interview with Social Worker #2 on 2/10/25 at 11:45 AM, she stated she had only been employed at the facility for two months and did not have to deal with advance directives. If there was a request for help with advance directives she would help them. She further stated the admission nurse was responsible for advance directives. An interview with Admission Nurse #1 on 2/11/25 at 3:45 PM who admitted Resident #105 revealed if a resident had advance directives in place upon admission, the document was downloaded into the system by the Administrative Ambassador. If a resident did not have advance directives in place she did not initiate a conversation to educate or formulate advance directives. She went on to state she thought the Admissions Director was responsible for that task. An interview with the Admissions Director was conducted on 2/11/25 at 4:00 PM at which time she stated she did not discuss advance directives with families or residents. She indicated that would be the admission nurse's responsibility. An interview was completed with the Administrator and the Director of Nursing on 2/11/25 at 4:10 PM. The DON indicated the social worker assigned to each resident was tasked to speak with and educate the resident and the resident's responsible party about advance directives. 41009 2. Resident #114 was admitted to the facility on [DATE] with a diagnosis of left leg fracture. A review of Resident #114's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. A review of Resident #114's medical record did not reveal any documentation of a discussion to determine whether or not Resident #114 had formulated any advanced directives such as a living will or a health care power of attorney or would like to formulate one. Additionally, there were no copies of such documents in Resident #114's medical record. On 2/12/25 at 8:33 AM in a telephone interview Resident #114's family member stated she did not recall anyone at the facility having a conversation with her regarding the formulation of advanced directives. She stated Resident #114 had both living will and a health care power of attorney documents. She reported she could not recall anyone from the facility asking her to bring copies of the documents to the facility, and she had not done so. On 2/12/25 at 9:42 AM an interview with Admissions Nurse #2 indicated she did not have conversations with residents or their family regarding advanced directives such as a living will or a heath care power of attorney during her admissions process. She stated she only discussed code status. On 2/12/25 at 9:52 AM an interview with the Admissions Director indicated she spoke with resident's and their family members regarding advanced directives such as living wills or health care powers of attorney during the admissions process and asked them to bring copies of any documents they had already formulated. She stated she did not document these conversations anywhere, and she could not recall whether Resident #114 or his family member reported having a living will or a health care power of attorney to her. The Admissions Director stated she didn't see anything in his medical record. On 2/12/25 at 11:28 AM an interview with Social Worker #2 indicated she did not recall ever having a conversation with Resident #114 or his family member regarding advanced directives such as a living will or a health care power of attorney. She stated typically if a resident had a living will or a health care power of attorney the resident or a family member would bring her a copy. She stated she did not see either of these documents in Resident #114's medical record. On 2/12/25 at 11:33 AM an interview with Social Worker #3 indicated she did not know whether or not Resident #114 had a living will or a health care power of attorney. She stated typically if a resident had either of these documents, they would bring a copy in for the medical record. She reported the only thing with regards to advanced directives she could see in Resident #114's medical record was the desire to be a full code status. Social Worker #3 stated if a resident or a family member brought up the desire to formulate other advanced directives at the care plan meeting, she would have a discussion with them at that time, but Resident #114 had not had a long-term care plan meeting yet. On 2/13/25 at 8:09 AM an interview with the Director of Nursing indicated that when a resident was admitted to the facility, the Admissions Director would get any copies of advanced directive paperwork such as a living will or a health care power of attorney a resident had. She reported if someone needed assistance with formulating an advanced directive, the SW would assist with this. On 2/13/25 at 9:44 AM an interview with the Administrator indicated the facility should have a process in place for determining whether a resident had or would like to formulate advanced directives such as a living will or a health care power of attorney.

Based on record review and staff interviews, the facility failed to provide a CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF/ABN) for 1 of 3 residents reviewed for beneficiary notices (Resident #89). Findings included: Resident #89 was admitted to the facility on [DATE]. Review of Resident #89's electronic health record revealed Medicare part A services began on 1/6/25. The resident's last covered day of Medicare Part A was 1/19/25. Resident #89 remained in the facility following her discharge from Medicare Part A. There was no evidence a SNF/ABN form was provided to the resident or resident representative. During an interview on 2/11/25 at 11:19 AM Social Worker #3 stated Resident #89's last covered date was 1/19/25 for Medicare part A. A SNF/ABN was missed and not provided to Resident #89 and it should have been. The SNF/ABN was used to provide the resident or representative information regarding what costs they would be responsible to pay out of pocket should they continue the services which were no longer covered by insurance. During an interview on 2/11/25 at 11:45 AM the Administrator stated Resident #89 should have received a SNF/ABN.

Based on record review and staff interviews, the facility failed to develop the comprehensive care plan in the area of pain for 1 of 28 residents (Resident #114) whose comprehensive care plans were reviewed. Findings included: Resident #114 was admitted to the facility on [DATE] with a diagnosis of left leg fracture. A review of Resident #114's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He had been on a scheduled pain medication regime. He had pain almost constantly. His pain affected his sleep and interfered with his daily activities almost constantly. Resident #114 rated his pain as a 10 on a zero to 10 scale with zero being no pain and 10 being the greatest pain. The Care Area Assessment (CAA) for pain was triggered. A review of Resident #114's comprehensive care plan dated as initiated on 1/27/25 did not reveal a focus area for pain. On 2/11/25 at 10:11 AM in an interview the MDS Director stated Resident #114's comprehensive care plan should have been developed by 1/27/25 based on his comprehensive admission MDS assessment date of 1/14/25. She stated the MDS Coordinator completing Resident #144's comprehensive MDS assessment dated [DATE] would have been responsible for ensuring the CAA for pain which was triggered on the assessment was developed on this comprehensive care plan. On 2/11/25 at 10:20 AM an interview with the MDS Coordinator indicated she completed Resident #114's MDS assessment dated [DATE]. She stated the presence of Resident #114's pain during this assessment was something that triggered the CAA for pain. She went on to say this should have been reflected on Resident #114's comprehensive care plan when it was developed, and it was not. She reported this was an oversight on her part. On 2/13/25 at 8:09 AM an interview with the Director of Nursing indicated Resident #144's pain was something that should have been included on his comprehensive care plan.

Based on observations, record review, and staff and physician interviews, the facility failed to follow a physician's order for placement of a lidocaine (topical pain medication) patch on a resident's left hip when the patch was applied to the resident's back. This was for 1 of 2 residents (Resident #114) reviewed for professional standards of practice. Findings included: Resident #114 was admitted to the facility on [DATE] with a diagnosis of left leg fracture. A review of Resident #114's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He had been on a scheduled pain medication regime. He had pain almost constantly. His pain affected his sleep and interfered with his daily activities almost constantly. Resident #114 rated his pain as a 10 on a zero to 10 scale with zero being no pain and 10 being the greatest pain. Resident #114's active physician's orders as of 2/10/25 revealed a physician's order dated 1/16/25 for a lidocaine (topical pain medication) 5 percent (%) patch to be applied topically to Resident #114's left hip in the morning and at bedtime for pain. There was no physician's order for a lidocaine patch to be applied to Resident #114's back. Resident #114's February 2025 Medication Administration Record (MAR) revealed documentation indicating Nurse #10 applied a lidocaine 5% patch topically to Resident #114's lower back on at 9:00 AM on 2/10/25. On 2/11/25 at 8:09 AM an observation of bathing activity was conducted for Resident #114 with Nurse Aide #3. During the activity, a topical pain patch was observed on Resident #114's mid-back dated 2/10/25 with the initials that corresponded to Nurse #10. On 2/11/25 at 8:39 AM in an interview Nurse #10 stated she applied a lidocaine 5 % patch topically to Resident #114's back in the morning on 2/10/25. She stated that when she went in to administer Resident #114's medication that morning, he refused for her to put the patch on his left hip and asked her to place the patch on his back, so she had. She reported she should not have applied a lidocaine patch on Resident #114's back without a physician's order to do so. Nurse #10 stated she should have gotten a physician's order first. On 2/11/25 at 8:50 AM an interview with the Director of Nursing indicated Nurse #10 should not have applied a lidocaine patch to Resident #144's back without a physician's order to do so. She stated if Resident #114 had been requesting to have a lidocaine patch for his back, Nurse #10 should have contacted the physician. On 2/11/25 at 11:47 AM in an interview Resident #114's Physician stated Nurse #10 should not have applied a lidocaine patch to a body part she did not have an order for. The Physician stated she was present in the facility on 2/10/25, and Nurse #10 should have spoken to her and gotten an order before she did this. On 2/13/24 at 9:44 AM in an interview the Administrator stated Nurse #10 should not have applied a lidocaine patch to Resident #114's back without a physician's order to do so.

Based on record review, staff, resident and physician interview, the facility failed to clarify orders for blood sugar monitoring and insulin administration for short and long-acting insulins (insulin is a medication injected into the skin to control blood sugar) from the hospital discharge summary for a resident with a diagnosis of diabetes (Resident #81). This was for 1 of 2 residents reviewed for professional standards of practice. The findings included: The hospital discharge summary for Resident #281 dated 2/7/25 stated in part: - Monitor blood sugars closely - Sliding scale insulin (short acting insulin) - Continue Lantus (long-acting insulin) The hospital discharge summary revealed that upon Resident #281's arrival in the emergency department on 1/17/25 he told hospital staff that he had not been taking his diabetic medication for some time as he did not believe it would help him. Resident #281 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus II, osteomyelitis (bone infection) and sepsis (blood infection from osteomyelitis) and surgical removal of last two toes on left foot due to gangrene caused by Diabetes Mellitus II. Review of physician orders for Resident #281 revealed there were no orders for blood sugar monitoring, sliding scale insulin or Lantus insulin. Resident #281's Medication Administration Record (MAR) for February 2025 did not include blood sugar monitoring, Lantus insulin or short-acting insulin. Further review of the MAR revealed that Resident #281 had not received blood sugar monitoring or insulin administration since admission. A review of Resident #281's medical record did not reveal documentation of blood sugar monitoring since admission on 2/7/25. Resident #281's Admission Minimum Data Set (MDS) was not yet available. An interview was conducted on 2/10/25 at 9:04 AM with Resident #281. The resident stated he was diabetic and was admitted to the facility after having two toes removed on his left foot due to diabetes. He further stated he was supposed to be on insulin at home before the operation to remove his toes. Resident #281 revealed he did not believe that insulin or blood sugar monitoring would help him in any way and that was why he had two toes removed. In an interview with Admissions Nurse #1 on 2/11/25 at 2:25 PM she revealed she was the Nurse that completed the admission orders for Resident #281 on 2/7/25. Admissions Nurse #1 stated she was unaware Resident #281 was to have orders for Diabetes Mellitus II monitoring and management including blood sugar checks, short-acting insulin and long-acting insulin. She further stated the resident was admitted in the evening on a Friday (2/7/25) and she overlooked the text box that gave instructions for blood sugars to be monitored closely and for short-acting and long-acting insulin to be administered, as this was written above the medication orders section in the hospital discharge summary. The nurse added, had she seen these instructions, she would have contacted the on-call physician or Nurse Practitioner for specific orders regarding a schedule for blood sugar monitoring and administration of insulin. Nurse #1 indicated she did call the on-call Nurse Practitioner to sign off on the admission orders. Resident #281's Physician (Medical Director) was interviewed on 2/11/25 at 3:01 PM. She stated she was just made aware Resident #281 needed orders to check his blood sugars and for short acting and Lantus insulin. She further stated she wrote orders for blood sugar checks, short acting insulin and Lantus insulin starting the evening of 2/11/25. She further stated Resident #281 just had his blood sugar checked at 2:55 PM and was within normal limits at 135 milligrams per deciliter. The Physician indicated that Resident #281 could have had adverse effects to an extremely high or extremely low blood sugar while it was not monitored or treated. Some effects included changes in mental status, kidney damage or unconsciousness. Resident #281 had not received oral diabetic medications or insulin prior to the blood sugar check at 2:55 PM. In an interview with the Director of Nursing (DON) on 2/11/25 at 3:10 PM she stated that Admissions Nurse #1 should have read the discharge summary in its entirety. She further stated the admissions order process was for the Admissions Nurse to transcribe the orders from the hospital discharge summary, have a second Nurse review the discharge summary and orders and then have them signed off on by a provider. A review of the orders with the DON during the interview revealed that Admissions Nurse #1 signed off on the orders as both the first and second check. In an interview with the Administrator on 2/11/25 at 3:17 PM he stated he was not aware of the admissions process from the point of the nursing process.

Based on record review, and resident, staff, and physician interviews, the facility failed to provide care in a safe manner when Resident #42 rolled out of bed during care and sustained a skin tear to the left forearm, skin tear to the right upper arm, and hematoma (bruise) to the left hip and when Resident # 92 was rolled out of bed during care and sustained a right arm skin tear this was for 2 of 6 residents reviewed for accidents. (Resident #42 and Resident #92) Findings included: 1. Resident #42 was admitted to the facility on [DATE]. Her active diagnoses included anemia, heart failure, hypertension, diabetes, and respiratory failure. Review of the care guide posted in Resident #42's closet door dated 1/7/25 revealed she was extensive 1 person assistance with transfers and activities of daily living. Review of Resident #42's Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. She required partial/moderate assistance with the ability to roll from lying on back to left and right side, and returning to lying on back on the bed. Resident #42 was on blood thinner medication. Review of Resident #42's care plan dated 1/9/25 revealed Resident #42 was care planned to be at risk for falls related to deconditioning, back pain, history of falls, impaired balance, gait, and mobility. The interventions included to anticipate and meet the resident's needs, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. She was care planned to require assistance by staff to turn and reposition in bed as necessary. Review of a progress note dated 1/13/25 noted as a fall note written by Nurse #1 revealed Resident #42 was being changed by the Nurse Aide #2 and slid to the floor. Upon assessment, Resident #42 had a skin tear on her right upper arm and a small skin tear on her left forearm. She also had a bruise on her left hip on the backside that was blackish blue. She was transported to the emergency department. During an interview on 2/10/25 at 3:06 PM Nurse Aide #2 stated she was changing Resident #42 and standing on the side of the bed towards the door changing her brief. She unstrapped the brief and then went to the window side and using the draw sheet, pulled towards herself to turn the resident to face the door. The resident kept rolling which was not something she normally did and her bottom half slid off the side of the bed. When she saw this, she lowered the bed and the resident slid down to a sitting position on the floor with her back against the bed. She stated the resident did not hit the ground hard as she had been able to lower the bed as she was sliding out of it. Her skin would easily bruise and bleed and she was on a blood thinner. She immediately got Nurse #1 and the nurse assessed the resident and it was decided to send the resident to the hospital. She stated she stayed with Resident #42 until the ambulance came to the facility to take her to the hospital. She stated she had been trained when turning a resident to turn them towards herself instead of facing away from herself. She stated she did not know why she turned the resident away from herself that day. She concluded after the resident left in the ambulance, Nurse #1 reeducated her in regards to turning residents towards herself so that her body would be in front of the resident and prevent the resident from continuing to roll. During an interview on 2/10/25 at 11:33 AM Nurse #1 stated she usually worked with Resident #42 and knew her well. She required limited assistance with dressing and one person assistance with turning and repositioning as well as transfers. Nurse #1 stated Resident #42 was at this functioning level since she started working at the facility the beginning of November 2024. She stated Nurse Aide #2 was trying to change Resident #42's brief and instead of rolling the resident towards herself she rolled the resident in the opposite way (the other side of the bed from where the nurse aide was standing) and Resident #42 continued to roll, and her legs fell off the side of the bed. This caused Resident #42 to begin to slide off the bed. Nurse Aide #2 started lowering the bed as the resident slid to the floor. The nurse aide then came and got the nurse who did an assessment. She saw that Resident #42's right leg was bent oddly, and she had two skin tears. One skin tear on each forearm. It wasn't fast or heavy bleeding but it was enough they had to hold pressure to her arms. She also had a bruise on her left hip that was blackish blue. From there she got Admission Nurse #1 (who was the unit manager at the time) and they got an order to send the resident to the hospital. Resident #42 did not want to go but the Responsible Party wanted her to go to the hospital and because the Responsible Party wanted her to go to the hospital she agreed to go. The resident was sent directly to the hospital, and she did not provide the resident with any pain medication at that time as Resident #42 had indicated to her she did not want pain medication. The resident stated she had pain but kept stating she was fine and did not want to go to the hospital until the nurse informed the resident that her Responsible Party wanted her to go to the hospital. She stated she then reeducated Nurse Aide #2 to ensure she turned residents towards herself and not away from herself when providing activities of daily living care. Review of the hospital discharge summary dated 1/30/25 revealed Resident #42 had sustained an accidental fall which resulted in a left hip hematoma. A CT (Computed Tomography) scan of the head and a CT scan of the cervical spine for Resident #42 were negative for acute intracranial abnormality. A CT scan of the abdomen and pelvis were noted to have hematoma within the subcutaneous tissues of the left lateral lower abdominal wall and hip. Resident #42 was hospitalized for unrelated health concerns. During an interview on 2/9/25 at 11:44 AM Resident #42 stated two weeks ago she fell in her room but did not really remember the details. Resident #42 stated her left hip had pain, and she sustained a large bruise as a result of the fall. Resident #42 stated a nurse aide was providing care to her at the time but did not remember the nurse aide's name or the time of day. Resident #42 stated the nurse aide placed her on the edge of the bed, and she fell to the floor. The nurse aide was upset and got a nurse. The nurse told the resident she should go to the hospital. Resident #42 stated she told the staff she was fine and did not need any pain medications and just needed to be put back in bed, but they worried her Responsible Party, and he wanted her to go to the hospital. She stated she was in pain following her bottom hitting the floor and estimated the pain was an 8 out of 10 and did not remember if she got pain medication. The pain did not last long and got much better before she arrived at the hospital. She could not remember what all happened at the hospital or how long she was there. She stated it was an accident and did not have anything else to add about the fall. During an interview on 2/12/25 at 7:53 AM Admission Nurse #1 stated she was the unit manager at the time of Resident #42's fall. Staff yelled for help and when she arrived, Nurse #1 was concerned the resident might have broken her hip, but Resident #42 kept stating she was okay, did not want to go to the hospital, and was not in pain. The physician was called, and the Responsible Party was called, and they were trying to convince the resident to go to the hospital, which she did finally agree to when they told her that her Responsible Party wanted her to go as well as the physician. Because the resident was stating she did not have pain and just asking staff to put her back in bed, they did not provide any pain medication at that time. Emergency Medical Services arrived quickly, and they took her out to the hospital, and she did not have any fractures, just a large bruise on her left hip and skin tear to both arms. She stated she then spoke to Nurse Aide #2 separately and re-educated the nurse aide to always turn residents towards herself instead of away from herself to prevent accidents like this. During an interview on 2/11/25 at 11:01 AM the Physician stated it sounded like Nurse Aide #2 thought she was providing care correctly and then was educated later after the incident by nursing how to appropriately turn residents. The nurse aide should have turned the resident towards herself in order for the nurse aide's body to prevent the resident from continuing to roll off the bed so the reeducation was appropriate. She stated the outcome for Resident #42 was a skin tear to each forearm and a hematoma to the left hip. She stated the resident did not hit her head so she felt there were no other outcomes that could have resulted from this incident for the resident or other residents. During an interview on 2/10/25 at 3:28 PM the Director of Nursing stated a resident should never sustain a fall during care and she was notified when Resident #42 sustained her fall. She stated Nurse Aide #2 should have turned the resident towards herself in order for her body to prevent the resident from rolling further. She stated this was how staff were trained to turn and reposition residents. During a follow up interview on 2/13/24 at 8:10 AM the Director of Nursing stated upon review of the documentation regarding Resident #42's fall, the facility did not complete 100% in-services of all nurses and nurse aides in the facility following the fall. She further stated they reviewed three residents following the incident and did not complete a 100% audit of all residents who could have been affected. 41009 2. Resident #92 was admitted to the facility on [DATE] with a diagnosis of heart failure. A review of Resident #92's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She had functional impairment in range of motion on one side of her upper extremities and both sides of her lower extremities. She required substantial assistance to roll from left to right in bed. She was always incontinent of bladder. She had no falls since her prior assessment. A review of a nursing progress note for Resident #92 dated 12/5/24 at 8:11 PM written by Nurse #1 indicated Resident #92 experienced a fall from bed at 6:00 PM that day. Nurse Aide (NA) #1 was present during the fall and provided Nurse #1 with a full statement of the incident. NA #1 had been attempting to change Resident #92's bed sheets, turned Resident #92 away from herself, pulled on the bed sheets, and Resident #92 fell off the bed onto her right side. Resident #92 had not hit her head. A full body assessment and vital signs were done. Resident #92 any pain. Resident #92 had a right arm skin tear which was cleaned, and a dry dressing was applied. Her family member and physician were notified. A review of a written statement by Nurse #1 dated 12/5/24 revealed NA #1 had been educated on how to change a resident with one assist. NA #1 was instructed that when changing a resident with one assist, she should turn the resident towards herself and not away from herself. When using a turn sheet, she should be mindful of how light or heavy the resident was and how fast or slow she was pulling the sheet with consideration to where the resident's body was positioned in bed. On 2/12/25 at 3:43 PM an interview with NA #1 indicated she recalled Resident #92's fall on 12/5/24. She stated when she went into Resident #92's room that day, Resident #92's sheets had been wet. She went on to say Resident #92 had been positioned more toward the right side of her bed and when she pulled on the draw sheet to bring Resident #92 closer to herself to turn Resident #92, instead of coming towards her, Resident #92 had rolled off the right side of her bed. She reported Resident #92's bed had been approximately 3 feet from the floor at the time, and Resident #92's upper body had gone off the bed first followed by Resident #92's legs. She stated Resident #92 had not said anything, and she could see that Resident #92 did not hit her head during the fall. NA #1 went on to say she immediately called for Nurse #1 who came to assess Resident #92. She stated although Resident #92 needed only one person to assist with bed mobility, she thought because her bed had been wet the use of the draw sheet had not gone as planned. She reported she had received education after the incident, and in the future would get another person to assist her if a resident's bed was wet. On 2/12/25 at 8:02 AM an interview with Nurse #1 indicated she recalled Resident #92's fall on 12/5/24. She stated when NA #1 notified her she immediately went to assess Resident #92. She reported Resident #92's bed had been positioned approximately 2 feet from the floor and Resident #92 had been lying on the floor beside her bed on her right side. Nurse #1 went on to say she completed a full body assessment of Resident #92 and took her vital signs. She stated Resident #92 had denied any pain, denied hitting her head during the incident and had not seemed upset at the time but was just asking them to get her up. She reported Resident #92 had a skin tear to her right arm which she cleaned and dressed. She went on to say she had notified Resident #92's family member and physician of the fall, and after getting a full statement of the event from NA #1, had notified Admission Nurse #1 who had been her supervisor at the time. Nurse #1 stated she provided immediate education to NA #1 after the incident that NA #1 should always roll residents towards herself when turning them in bed. A physician's order for Resident #92 dated 12/6/24 indicated to clean her right arm skin tear with normal saline and apply a non-adherent gauze dressing every Monday and Friday for skin tear. On 2/12/25 at 7:56 AM an interview with Resident #92 indicated she did not recall ever having fallen from bed during care. She stated she had no concerns with the way NAs provided care to her, and she always felt safe during care. On 2/12/25 at 8:15 AM an interview with Admissions Nurse #1 indicated she did not think she had been present in the facility when Nurse #1 notified her of Resident #92's fall on 12/5/24, and after Nurse #1 notified her by telephone, she notified the Director of Nursing (DON). On 2/12/25 at 8:22 AM an interview with the DON indicated she had been notified of the circumstances of Resident #92's fall on 12/5/24 and immediate education had been provided to NA #1 regarding always turning residents towards herself when turning them in bed. She went on to say she thought an in-service had also been provided to all staff regarding this after the incident. On 2/13/25 at 8:09 AM a follow-up interview with the DON indicated 100 percent staff education had not been completed after Resident #92's fall on 12/5/24. On 2/12/25 at 12:28 PM a telephone interview with Resident #92's Physician indicated Resident #92 had not experienced any major injury as a result of the fall that occurred on 12/5/24. She reported Resident #92 would have been at risk for any injury that could occur as a result of a fall. She stated a fall from bed would not be an anticipated outcome during the provision of care and it must have been a frightening experience for both Resident #92 and NA #1. On 2/13/25 at 9:44 AM an interview with the Administrator indicated Resident #92 should not have sustained a fall during the provision of care. On 2/12/25 a review of an in-service training record dated 12/11/24 provided by the Staff Development Coordinator (SDC) revealed the attached procedure titled: Turning a Resident on His/her Side Away From You which included in part the following: Steps in the Procedure: 5. Slide both your arms under the resident's back to his/her far shoulder. 6. Slide the resident's shoulders towards you on your arms. 7. Slide both your arms (as far as you can) under the resident's buttocks. 8. Slide the resident's buttocks towards you. 9. Slide both arms under the resident's feet and ankles. 10. Slide the resident's feet towards you. On 2/12/25 at 10:44 in an interview the SDC stated she provided an in-service training on the proper procedure for turning a resident on their side away from you in bed to nurses and nurse aides on 12/11/24 in response to Resident #92's fall from bed during care on 12/5/24. She reported that while the in-service did not specifically address the use of a draw sheet, it was standard practice to use a draw sheet when repositioning residents.

Based on observations, record review, and staff and family interviews, the facility failed to attempt alternatives to bed rail use and document how these alternatives failed to meet the resident's needs prior to the installation of bed rails. This was for 1 of 6 residents (Resident #114) reviewed for accidents. Findings included: Resident #114 was admitted to the facility on [DATE] with a diagnosis of left leg fracture. A review of Resident #114's medical record revealed an informed consent for the use of bed rails dated 1/7/25 that indicated the risks versus the benefits of bed rail use. This was signed by Resident #114's family member indicating she consented to the use of bed rails for Resident #114. A review of Resident #114's nursing admission assessment dated [DATE] at 4:51 PM completed by Admissions Nurse #2 revealed Resident #114 would have quarter (1/4) length rails on his bed to assist with bed mobility and positioning and to provide a handhold area for support by staff. Resident #114's family member requested to keep side rails on the bed for assistance with positioning and mobility. A review of a side rail/entrapment risk evaluation for Resident #114 dated 1/7/25 at 5:26 PM completed by Admissions Nurse #2 revealed Resident #114 wanted side rails in place and used them for positioning and mobility. The side rails did not inhibit Resident #114's mobility or freedom and were not a restraint. He would have 1/4 length rails on both sides of his bed. The entrapment risk section of the evaluation indicated because Resident #114 had dementia, was able to notify staff of his needs, and had trouble sleeping at night that alternatives to bed rail use should be considered. A review of Resident #114's medical record did not reveal a physician's order for bed rails or any documentation that alternatives to bed rail use were attempted. A review of Resident #114's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He had no impairment in range of motion of his upper or lower extremities. He required moderate assistance (helper does less than half the effort) to roll from left to right in bed, go from sitting on the side of the bed to lying in bed, and to go from lying on the bed to sitting on the side of the bed. He required maximal assistance (helper does more than half the effort) to safely come to a standing position from sitting on the side of the bed. He did not walk. He did not use restraints. On 2/9/25 at 2:09 PM Resident #114 was observed his room. He had 1/4 length bed rails in the raised position on both the left and right side of his bed. On 2/11/25 at 8:01 AM Resident #114 was observed in bed. He had 1/4 length bed rails in the raised position on both the left and right side of his bed. He did not indicate he knew what the bed rails were for. On 2/11/25 at 4:27 PM an interview with Resident #114's family member indicated she had signed a consent form for bed rail use when Resident #114 was admitted to the facility. She stated she felt he could use these for help with repositioning. She reported she did not recall anyone ever discussing alternatives to bed rail use with her. On 2/12/25 at 9:42 AM an interview with Admissions Nurse #2 indicated she did not ever discuss or attempt any alternatives to bed rail use with residents or their family. She stated she just explained what they were and what they were for. She reported bed rails were already on most of the beds, and if a resident or family member didn't want them, they could be taken off. On 2/12/25 at 1:15 PM an interview with the Director of Nursing indicated she was not aware of any alternatives to bed rail use used by the facility. On 2/13/25 at 9:44 AM an interview with the Administrator indicated he did not know what alternatives to bed rails were attempted prior to their use. He stated he would need to discuss that with the therapy team.

Based on record review, staff and resident interviews the facility failed to assess for food preferences for 1 of 1 resident reviewed for food preferences (Resident #280). Findings included: Resident #280 was admitted to the facility on [DATE]. Resident #280's 5-day Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired. An interview with Resident #280 was conducted on 2/9/25 at 12:41 PM. Resident #280 stated she wished the kitchen would stop sending pork products on her tray because she doesn't like pork. She further stated no one had asked her about her food preferences. An interview was conducted on 2/10/25 at 11:18 AM with the Dietary Manager. The Dietary Manager stated food preference assessments were conducted upon admission. A record review by the Dietary Manager was observed at this time that revealed no food preferences had been documented in the computer for Resident #280 and the Dietary Manager was not able to locate the paper assessment for the resident's food preferences. She stated that up until two weeks ago she had an assistant that completed the resident food preferences assessments. An interview was conducted on 2/10/25 at 11:43 AM with the Administrator. The Administrator stated he expected the Kitchen Manager to ensure newly admitted residents are assessed for food preferences upon admission.

Based on record review and staff interviews, the facility failed to have a complete and accurate Medication Administration Record (MAR) for 1 of 2 residents who received enteral formula (a method of providing nutrition directly into the gastrointestinal tract through a tube) who were reviewed for medical record accuracy (Resident #333). Findings included: Resident #333 was admitted to the facility on [DATE]. Resident #333 Physician's orders included an order dated 11/12/24 for enteral formula Osmolite 1.5, 237 milliliters (ml) to be administered every 6 hours. In a telephone interview with Nurse #4 on 2/11/24 at 8:20 AM she revealed when she started to pour the enteral formula into the tube Resident #333 stated he did not want the formula, she then stopped pouring the enteral formula. She went on to say Resident #333 had not refused his enteral formula to her in times past. Attempts made to reach Nurse #4 for further investigation were not successful. Review of the MAR for 11/27/24 revealed the midnight dose of enteral formula was given as prescribed by Nurse #4. An interview with Nurse #6 was held on 2/11/24 at 12:30 PM at which time she revealed that if a resident refused an enteral formula, she would document the refusal on the MAR as refused. An interview with Nurse #8 was held on 2/11/25, she revealed if a resident refused an enteral formula after she started pouring, she would stop and document on the MAR the resident had refused. In an interview with the Director of Nursing on 2/12/25 at 9:40 AM, she revealed if a resident refused the enteral formula after the start of pouring the enteral formula she would mark refused on the MAR. An interview with the Administrator was held on 2/13/25 at 9:30 AM, he stated the staff should document what happened. He would expect the documentation would state the administration of the enteral formula was incomplete and the resident refused.

Based on observation, record review and interviews with pest control staff, resident and facility staff, the facility failed to maintain an effective pest control program to prevent an infestation of mice and to protect a vulnerable resident from mice. On 7/1/24 Resident #18 was in bed when she felt something touch her foot. She pressed her call bell for assistance and when Nurse Aide (NA) #7 responded the NA pulled the blankets off the bed and a mouse jumped out of the bed and onto the floor. On 7/7/24 Resident #18 was in bed when NA #7 pulled the covers down to provide care and a mouse jumped out of the bed and onto the floor. On 7/26/24 Resident #18 saw a mouse running across the floor of her room. Resident #18 was shocked when the mouse was in her bed, and she was afraid of being bitten by a mouse. Mice are known to carry multiple diseases that can be life threatening. Diseases can spread by rodent bites and contact with their feces, urine, and saliva. This deficient practice affected 1 of 3 residents and had a high likelihood of affecting other vulnerable residents in the facility. Immediate jeopardy began on 7/1/24 when the facility failed to maintain an effective pest control program. The immediate jeopardy was removed on 8/2/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower level and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. Findings included: The Centers for Disease Control and Prevention's website indicates rodents such as mice are known to carry many diseases that can spread directly to people through: contact with rodent feces, urine, and saliva; rodent bites; and the handling of rodents. Rodent feces, urine, and saliva can spread by breathing in air or eating food that is contaminated with rodent waste. Rodents can spread bacterial and viral diseases that can be life threatening. Review of facility Pest Control Treatment Logs from Pest Control Company #1 dated 6/25/24 indicated Pest Control Technician #1 inspected and treated all offices, restrooms, pantries, dining rooms, medical offices, and nurses' stations. The exterior bait boxes were cleaned and rebaited. No mice were found in the facility or the bait stations. In an interview with the Maintenance Director on 7/18/24 at 10:07 am, he stated he had been in this position for approximately two years. He explained construction began in the field beside the facility on 1/11/24. He stated shortly after the construction began he started receiving reports of rodent activity in the facility but cannot recall who reported it and the exact dates. The facility had a contract with Pest Control Company #1 and they came weekly to service the facility. This weekly service was in place prior to the identification of rodent activity. The pest control service included treating the interior and exterior of the facility. The facility had rodent bait stations placed every 20 feet around the facility. The facility had a total of 44 black exterior rodent bait stations around the entire facility. The rodent bait stations were serviced monthly on 5/28/24 and 6/25/24. A review of Resident #18's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. She required assistance from one staff member to turn and reposition her in the bed. She also required a mechanical lift with two staff members for transfers. She had limited physical mobility on her left side related to a stroke. In a phone interview with Nurse Aide (NA) #7 on 7/18/24 at 9:17 am, she stated she worked with Resident #18 on night shift that began at 11:00 pm on 6/30/24 and ended at 7:00 am on 7/1/24. She further stated she answered the call light for Resident #18 on 7/1/24 within 5 minutes of activation. Resident #18 reported she felt something on her foot and when NA# 7 pulled the blankets off the bed, a mouse jumped out of the bed onto the floor. She stated Resident #18 was surprised it was a mouse. Resident #18 did not have any bite marks noted on her. She reported the event to Nurse #3. Nurse #3 did not assess Resident #18. No crumbs were noted in the room and Resident #18's food/snacks were in plastic containers. NA #7 was unaware that mice could carry diseases. She indicated she had seen mice throughout the facility in the past two months. NA #7 explained maintenance was not available during her shift to report the pest activity. She reported to the nursing staff about pest activity. It was her understanding that the nursing staff would contact maintenance about the pest activity during day shift (7:00 am until 3:00 pm). The facility educated the staff and the residents after reports of mice activity about keeping food/snacks in enclosed containers in the residents' rooms. NA #7 was unable to recall the exact date of this training. During a phone interview with Nurse #3 on 7/18/24 at 9:17 am, she stated she was working on Resident #18's hall on night shift that began at 11:00 pm on 6/30/24 and ended at 7:00 am on 7/1/24. She remembered hearing about a mouse from NA #7 during her shift on 7/1/24. She indicated NA #7 did not state the mouse was in a resident's bed. She indicated she had not seen any mouse activity in the facility. Nurse #3 further stated she reported the mouse activity to Nurse #6 for day shift. She did not report it to maintenance because maintenance was not in the building during night shift. She explained she did a verbal report to the oncoming shift in the morning of what happened during her shift. She did not know if it was reported to maintenance or anyone in administration. Attempts were made to interview Nurse #6 via phone with messages left on 7/31/24 with no return phone call received. Nurse #6 was the day shift supervisor scheduled to work on 7/1/24. Attempts were made to interview NA #8 (Medication Aide) via phone with messages left on 7/31/24 with no return call received. NA #8 was scheduled to work on Hall 4 (the hall where Resident #18's resided) on 7/2/24 for day shift (6:45 am until 3:15 pm on 7/2/24). The pest control treatment log from Pest Control Company #1 dated 7/2/24 revealed, Pest Control Technician #1 treated the interior and exterior of the facility. The dining rooms, pantries, and the main kitchen were all treated and inspected. The 44 exterior bait boxes around the exterior of the facility were cleaned and rebaited. No mice were identified on this visit. In a phone interview with NA #7 on 7/18/24 at 9:17 am, she stated she worked with Resident #18 on night shift that began at 11:00 pm on 7/6/24 and ended at 7:00 am on 7/7/24. On 7/7/24 Resident #18 was in bed when NA #7 came to the room to provide incontinence care. NA #7 reported she pulled the covers down to provide care and a mouse jumped out of the bed and onto the floor. She stated Resident #18 was shocked because it was another mouse found in her bed. Resident #18 did not have any bite marks noted on her. She reported the event to Nurse #3. Nurse #3 did not assess Resident #18. No crumbs were noted in the room and Resident #18's food/snacks were in plastic containers. During a phone interview with Nurse #3 on 7/18/24 at 9:17 am, she stated she was working on Resident #18's hall on night shift that began at 11:00 pm from 7/6/24 and ended at 7:00 am on 7/7/24. She remembered hearing about a mouse from NA #7 during her shift 7/7/24. She indicated NA #7 did not state the mouse was in a resident's bed. She further stated she reported the mouse activity to the oncoming nurse for day shift (Nurse #4). She did not know if it was reported to maintenance or anyone in administration. In a phone interview with Nurse #4 on 7/31/24 at 10:39 am, she stated she was the day shift nurse (6:45 am until 7:15 pm) on 7/7/24 on Resident #18's hall. She further stated she was not given a report from Nurse #3 related to a mouse being found in Resident #18's bed. She indicated she had seen mice in Nurses' Station 1 running under the chairs on the floor but could not recall the dates the mice were seen. Attempts were made to interview Nurse #6 via phone with messages left on 7/31/24 with no return phone call received. Nurse #6 was the day shift supervisor scheduled to work on 7/7/24. The pest control treatment log from Pest Control Company #1 dated 7/9/24 revealed Pest Control Technician #1 treated and inspected all the rooms in Hall 4, all dining rooms, pantries, and the kitchen area. No mice were found during this inspection. The previous DON was interviewed via phone on 7/18/24 at 9:43 am. Her last day of employment in the facility was 7/10/24. She stated she recalled being told about a mouse in Resident #18's room by the ADON but did not recall the exact date. She was unaware the mouse was found in the bed. She explained she informed the Maintenance Director and the Housekeeping Supervisor about the mouse activity. She indicated Resident #18's room was cleaned by housekeeping staff immediately. She was unaware of the second incident involving a mouse in Resident #18's bed. In an interview with the Maintenance Director on 7/18/24 at 10:07 am he explained he had the pest control company come again and rebaited the exterior rodent bait stations on 7/2/24 and 7/9/24 after reports of mice. He explained he would receive texts via his cell phone from the staff about the mice and where the mice were located. He was unaware of a mouse being found in a resident's bed. He indicated the pest control company donated glue traps in addition to the exterior rodent bait stations and explained how to use these traps. He placed glue traps when he received a text message. The glue traps were small boxes with a sticky substance on the inside. The mice would go into the trap and get stuck on the glue in the box. He did not have a log of when and where he placed the glue traps. He checked the glue traps daily. He reported a significant amount of mice had been caught with the glue traps throughout the facility. He stated the mice could enter in deceivingly small places. He could not determine any specific entry point in the facility. He indicated he contacted another pest control company in June with a rodent specialist for more options to treat the rodent issue. This meeting was scheduled for later this day (7/18/24). The facility educated the staff and the residents after reports of mice activity about keeping food/snacks in enclosed containers in the residents' rooms. During an interview with the Housekeeping Supervisor on 7/17/24 at 5:01pm, he stated he was called about mouse activity by the previous DON in Resident #18's room. He could not recall the exact date. He was unaware of the second incident. He reported Resident #18's room was cleaned immediately. No crumbs were noted and all Resident #18's snacks/food were in sealed plastic containers. He further stated Resident #18's room was deep cleaned last Thursday (7/11/24). (The process of deep cleaning a room involved moving every dresser and nightstand, cleaning along the walls of the room, cleaning every vent in the room, and everything in the bathroom.) Resident #18 was interviewed on 7/17/24 at 4:26 pm and stated the facility had a problem with mice and has had the problem for the past 3 to 4 months. She indicated last week she felt something on her foot, and she pushed her call bell for assistance. Within 5 minutes the NA came into her room and pulled the blankets off her bed, a mouse jumped off the bed onto the floor. She explained this happened twice in the last week but could not recall exact dates. She stated there was no injury or harm from the mice. The NA reported this incident to the floor nurse. She also stated after this happened, she had seen several mice in her room and on the dresser beside the bed. She stated she reported this to the staff. She further stated she did not want mice in her room and was afraid of getting bitten. During an observation of Resident #18's room on 7/17/24 at 4:45 pm, the facility had placed a glue trap on the floor (date unknown) beside the air conditioning (AC) unit on the wall. No cracks or holes were noted around the AC unit. The glue trap was a small white box approximately 7 inches in height by 3 and 1/2 inches in width. A sticky substance was located on the inside of the box. Small black pellets were observed around and on inside of the glue trap. Resident #18 gave permission to look in the dresser's top drawer and there was no evidence of mice activity observed. No food or crumbs were noted in Resident #18's room. The service inspection report from Pest Control Company #2 dated 7/23/24 control on the first Thursday of each month and the interior of the facility on the third Friday of each month. Pest Control Technician #2 installed 50 rodent bait stations spaced 20 feet apart on the exterior of the facility (replacing the existing rodent bait stations), 3 boxes of glue boards, and installation of 60 metal rodent traps placed in the following locations: - 2 metal rodent traps at each exit of nursing stations - 2 metal rodent traps in each dining room - 1 metal rodent trap in each pantry - 5 metal rodent traps in the main kitchen Attempts were made to interview Pest Control Technician #2 via phone with messages left on 7/31/24 with no return phone call received. In an interview with Resident #18 on 7/30/24 at 3:19 pm, she stated she had seen one mouse in her room since 7/18/24. She further stated the mouse ran from under her bureau out into the hall on 7/26/24. Resident #18 revealed she reported the sighting to the Social Worker and to someone in Housekeeping. On 7/30/24 at 4:15 pm an interview was conducted with Floor Technician #1. He stated Resident #18 reported to him that she had seen a mouse on 7/26/24. The Floor Technician further stated he checked the traps in her room, finding one with a mouse in it. He revealed he disposed of the trap and replaced it with a new one the same day. He reported this to the Maintenance Director and asked for another glue trap. An interview was conducted on 7/30/24 at 4:25 pm with the Social Worker (SW). She stated Resident #18 reported on 7/26/24 she saw a mouse in her room the same day. The SW indicated she looked for the mouse and did not find it but later heard that Floor Technician #1 had found it in a trap in her room and disposed of it. During a text conversation with the Maintenance Director on 7/30/24, he indicated texting was the quickest and easier way of communication. He stated the facility met with another Pest Control Company in July but did not provide the date of this meeting. He further indicated he had found a few possible entries for mice (did not indicate locations) and he had sealed them. He stated he was still currently looking for points of entry. He further stated he checked the glue traps in the room Resident #18 resided in yesterday (7/30/24) and no mouse was found. (The Maintenance Director identified the room by room number and did not use resident specific information in the text messages.) A phone interview with a contracted Pest Control Account Manager for Pest Control Company #1 on 7/18/24 at 12:45 pm revealed they provided pest control services to the facility and treated the facility. He stated the facility had 44 exterior rodent bait stations with poison placed around the building to help prevent mice from entering the building. He indicated mice could enter the building through small holes. He confirmed the pest control company donated glue traps during the visits in July to the Maintenance Director for the interior of the facility. During a phone interview with the Pest Control Technician #1 on 7/30/24 at 2:19 pm, he stated he treated the facility weekly interiorly and exteriorly. No mice were found on the interior of the facility. He did find a couple of dead mice on his visits in July outside around the bait boxes and he disposed of them. He indicated he was made aware of the mice problem by the Maintenance Director. In an interview with the previous administrator, Administrator #1, on 7/17/24 at 3:56 pm she stated she was aware the facility had a problem with mice and connected it to the construction which began in January 2024. The facility sent out notification flyers to the family members. The flyer asked the family members to help decrease the clutter in the residents' rooms and ensure all food items were in plastic containers. She indicated the facility had contracted with a pest control company and they came to the facility weekly and as needed. She further indicated she was not aware of a mouse being found in a resident's bed. In an interview with the current administrator, Administrator #2, on 7/30/24 at 5:24 pm, she revealed she had visited Resident #18 on 7/29/24 and the resident reported she had not seen any mice recently. The Administrator stated Resident #18 asked her to spray peppermint spray around her bed as she had seen mice in the past. Peppermint spray is one of the interventions they have added. She further stated she has added a new intervention each week; the first week was to change poisons, this week was to add the peppermint spray as a deterrent and next week she would add high frequency noise plug-ins. During a follow up phone interview with Administrator #2 on 7/31/24 at 4:44 pm, she stated mice had been seen throughout the facility and in the attic. She indicated the flyers were placed in all resident rooms on Station 2 on 6/27/24. The facility held a family council meeting on 7/16/24 to inform the family members about the mice activity. The flyers were mailed to the family members on 7/25/24 as a reminder. She also stated that she thinks the interventions from Pest Control Company #2 have shown improvement with the rodent activity. The maintenance department was responsible for disposing of the mice. She further stated the facility had a manager on the weekends who checked the traps and housekeeping staff also checked the traps during the weekends. In a phone interview with the Physician on 7/31/24 at 5:03 pm, she stated she was made aware of the mice in the facility today. She further stated her concern was mice carry germs and diseases. She stated she had never heard of a mouse biting a human, but it was possible. The resident would be exposed to the germs and diseases the mice carried. She explained she has worked in the facility for 5 years and has never seen any insects, roaches, or mice. Administrator #2 was notified of immediate jeopardy on 7/31/24 at 10:58 am. The facility provided the following credible allegation of immediate jeopardy removal: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: - On 7/1/24 Resident #18 was in bed when she felt something touch her foot. She pressed the call bell for assistance and NA #7 responded. NA #7 pulled the blankets off the bed and a mouse jumped out of the bed and onto the floor. - On 7/7/24 Resident #18 was in bed when NA #7 came to the room to provide routine incontinence care. NA #7 pulled the covers down to provide care and a mouse jumped out of the bed and onto the floor. - On 7/26/24 Resident #18 saw a mouse run out from under her bureau in the room and out of the door to her room. She reported to staff who checked an interior mouse trap and the mouse was there. - Resident #18 was unable to get out of bed without staff assistance to protect herself. - On 7/31/24 the DON notified Resident #18's responsible party about the Pest Control problem. She voiced understanding. - On 7/31/24 NHA and DON also offered room change to Resident #18 and Resident #18's roommate and both said they did not want to move. - The Administrator reviewed grievances for the last 30 days with no concerns regarding mice in resident rooms on 8/1/24 - The wound nurse will complete skin checks on 8/1/24 to ensure cognitively impaired residents with Brief Interview for Mental Status (BIMS) of 12 or less do not have any evidence of mouse bites. - Resident #18 was provided with education by the Administrator regarding room decluttering for prevention of pests on 8/1/24 and was educated regarding facility pest control program, education about mice of why to be concerned inclusive of bite wounds, consumption of food/water for breathing dust contaminated by rodent droppings and other waste products, what you can do to prevent rodents by keeping living spaces clean, clutter free eliminating potential nesting areas, sealing up access points and reporting to staff when rodent is seen. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: - Facility provided education to Responsible Parties by sending out a mailer regarding decluttering of resident rooms on 7/25/24. Residents and Responsible Parties were sent another mailer with a letter on 8/1/24 regarding education about mice of why to be concerned inclusive of bite wounds, consumption of food/water for breathing dust contaminated by rodent droppings and other waste products, what you can do to prevent rodents by keeping living spaces clean, clutter free eliminating potential nesting areas, sealing up access points and reporting to staff when rodent a is seen. - Social Workers also went to every resident room on 8/1/24 and reviewed the mailer that went out responsible parties and education about mice of why to be concerned inclusive of bite wounds, consumption of food/water for breathing dust contaminated by rodent droppings and other waste products, what you can do to prevent rodents by keeping living spaces clean, clutter free eliminating potential nesting areas, sealing up access points and reporting to staff when rodent a is seen. For residents that were not interviewable, a copy was left in the room for education for visitors. There are 2 different exterminator companies (Pest Control Company #1 and Pest Control Company #2) working on their common practices of rounding the facility and inspecting for entry points for mice removal in the building along with re-baiting the outside traps. Pest Control Company #1 was at the facility on 7/2/24 and 7/9/24. Pest Control Company #1 and Pest Control Company #2 were both at facility on 7/23/24. - Glue traps provided by the exterminators were placed approximately every 10 feet within the attic space on 7/31/24 by the Maintenance Director and Maintenance Assistant. The traps will be checked Monday through Friday by the Maintenance Director and/or Maintenance Assistant and replaced if necessary and designated housekeeping and manager on duty will complete task on the weekend. Additional traps will be placed 8/1/24 in many outlying areas such as closets and break rooms etc. by the Maintenance Director. These will be mapped out and checked Monday through Friday by the Maintenance Director and/or Maintenance Assistant and designated housekeeping and manager on duty will complete tasks on the weekend. The staff who are responsible for this on the weekend were educated by the Administrator on this responsibility on 8/1/24. - The facility's policy and procedures for Pest Control Program was reviewed on 7/31/24 at approximately 1pm by the Director of Nursing, Administrator, Infection Preventionist, Environmental Services Supervisor, Maintenance Director and Corporate Maintenance Director. The Corporate Maintenance Director inserviced the participants on the Pest Control Program policy and the importance ensuring all residents are kept safe from household pests and rodents. - All staff from all departments will be 100% educated on facility Pest Control Policy, education regarding mice, what to be concerned about, what we can do to prevent and eliminate rodents and will understand the diseases mice can carry. Education included reporting any sightings or droppings to their supervisor. Supervisors who receive reports of mice sightings or droppings will then call Maintenance Director who will advise on how to trap the mouse/mice and if that is unsuccessful Maintenance Director will come to the facility to ensure the process was successful. Inservice began on 7/31/24 at approximately 3pm by the Administrator, DON and/or Maintenance Director. Effective 8/2/24, no Staff shall work without having gone through the inservice training. This will include agency and new staff. The Director of Nursing and/or Maintenance Director were educated by the Administrator on the pest control policy, mice, reasons to be concerned, what to do to prevent rodents and the process for trapping on 8/1/24. The Director of Nursing/Maintenance Director will be responsible for keeping up the list of staff training completion. - The Medical Director was informed by the Director of Nursing services on 7/31/24 of the Immediate Jeopardy related to Pest Control. The Medical Director had no recommendations. Alleged Date of Immediate Jeopardy Removal: 8/2/24 Onsite validation of the immediate jeopardy removal plan was conducted on 8/2/24. The following was verified: Resident #18's responsible party was informed of the pest control problem. A room change was offered to Resident #18 and Resident #18's roommate and the residents declined. Resident #18 was provided with education that included the pest control program, education about mice, and pest prevention. Grievances were reviewed by the Administrator with no additional concerns and skin checks were conducted with all residents with a BIMS of 12 or less. Education via mailers was confirmed for responsible parties. Residents were provided with mailers and residents who were interviewable had education completed by the Social Worker. Interventions by Pest Control Company #1 and Pest Control Company #2 were verified to be completed as indicated via interview and observations. The policy and procedure were reviewed for the Pest Control Program as indicated. Staff interviews with staff from various departments confirmed education was completed on the Pest Control Policy, education regarding mice, what to be concerned about, prevention and elimination techniques, and the dangers of mice to include the diseases that they can carry. The facility's immediate jeopardy removal date of 8/2/24 was verified.

Based on observation, record review, and staff interviews the facility failed to maintain an indwelling urinary catheter drainage tubing from touching the floor for 1 of 1 resident reviewed for indwelling urinary catheter use (Resident #14). This deficient practice placed the resident at increased risk for infection of the urinary system. The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (a condition in which the flow of urine is blocked and can cause urine to back up and injure one or both kidneys). Review of the care plan dated 6/17/24 indicated Resident #14 was at risk for alteration of elimination of bladder with a goal of no complications related to indwelling urinary catheter use. Interventions included to check catheter tubing for proper drainage and positioning. A review of Resident #14's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact. He required partial to moderate assistance for toileting. The MDS assessment indicated Resident #14 had an indwelling urinary catheter. An observation was conducted of Resident #14 's urinary catheter drainage collection system on 7/18/24 at 9:30 am. Resident #14 was noted to be sitting in a wheelchair in his room. He was observed to have an indwelling urinary drainage catheter system in place. The urinary drainage bag was noted to have a privacy cover in place. The bag had been secured to the framework of Resident #14's wheelchair beside the seat. The urinary drainage tubing was noted to be partially lying on the floor of the resident's room underneath his wheelchair. In an interview with Nurse #1 on 7/18/24 at 9:49 am she stated she had been assigned to Resident #14 on 7/18/24 and was not aware that Resident #14's urinary catheter drainage tubing was in contact with the floor. She stated the drainage bag should have been attached to a metal bar on the wheelchair frame so that it was situated lower than the bladder to ensure proper drainage, but no parts of the urinary catheter drainage system, to include the drainage tubing should have been in contact with the floor. She indicated there was a concern for infection for the resident if the drainage tubing touched the floor. She further indicated the Nursing Assistant (NA) should have known how to position the tubing to keep it off the floor. During an interview with NA #1 on 7/18/24 at 9:51 am it was revealed that NA's complete urinary catheter care and that the urinary catheter drainage tubing should not touch the floor. She stated that she had not assisted Resident #14 with his morning care on 7/18/24. She further indicated that care for a resident with an indwelling urinary catheter care included hanging the urinary catheter drainage bag on the metal frame of the wheelchair and clipping the tubing to a metal bar under the wheelchair so that the drainage tubing did not touch the floor. She stated that if the tubing touched the floor, it was unsanitary and created a risk for infection for the resident. During an interview with NA #2 on 7/18/24 at 9:58 am it was revealed that she was assigned to care for Resident #14 on 7/18/24 after she had been called in because the facility was short of staff. She stated she arrived at work late on 7/18/24. She stated she did not check on Resident #14 when she first arrived to work because he was already up in his wheelchair and breakfast trays were already on the hall, so she immediately assisted with serving breakfast trays. She stated when she checked on him after breakfast she did not look to see if the tubing touched the floor. She stated that if the urinary tubing touched the floor, it created a risk of infection for the resident. The interview further revealed that NA #2 received training on indwelling urinary catheter care and maintenance at least once a year by the facility and the training included to keep the urinary catheter drainage tubing straight so it would drain properly and to keep it off the floor. In an interview with the Director of Nursing (DON) on 7/18/24 at 1:19 pm she stated Resident #14's indwelling urinary catheter drainage tubing should not have been in contact with the floor. She stated that Resident #14's urinary catheter drainage tubing should have been secured underneath the wheelchair seat so that it did not touch the floor. She stated the tubing on the floor was an infection control concern. She further indicated that staff received training when hired and annually in a skills fair on how to maintain a urinary catheter that included tubing placement. She stated that the skills fair included firsthand practice with indwelling urinary catheter care and maintenance. In a follow-up interview with the DON on 7/18/24 at 2:59 pm she stated that the facility had a policy on urinary catheter care and the facility further followed the urinary catheter manufacturer recommendations on catheter use and maintenance. The interview further revealed that the facility's infection preventionist/staff development coordinator was on vacation and unavailable for interview. In an interview with the facility Administrator on 7/18/24 at 3:18 pm she stated the urinary drainage bag tubing for Resident #14 should not have been on the floor.

Based on observations and staff interviews the facility failed to prevent the potential for cross-contamination by storing plastic scoops inside dry ingredient bins allowing the handles to touch the dry ingredients for 2 of 2 observations. Findings included: During an observation of the kitchen on 12/17/23 at 10:35 AM the flour and sugar scoops were observed in the flour and sugar bins and the handles were visibly touching the flower and sugar. During observation of the kitchen on 12/18/23 at 12:43 PM the flour and sugar scoops were again observed in the flour and sugar bins and the handles were visibly touching the flower and sugar. During an interview on 12/18/23 at 12:46 PM the Kitchen Supervisor stated scoops were not to be stored inside the storage bin due to sanitation concerns with the handle. The scoops would normally be put on a container on top of the storage bin. He concluded he was unsure why they were all stored in the storage bins, and they should not have been stored in that way. During an interview on 12/18/23 at 10:55 AM the Dietary Manager stated the scoops for the flour and sugar bins were to be stored outside of the flour and sugar bins to prevent contamination of the product by the scoop handle.

Based on observation and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place. This was for one repeat deficiency in the area of Food Procurement, Store/Prepare/Serve-Sanitary (F812) originally cited on [DATE] during a recertification and complaint investigation survey and subsequently cited on [DATE] during the recertification and complaint investigation survey. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. This tag is cross referenced to: F812: Based on observations and staff interviews the facility failed to prevent the potential for cross-contamination by storing plastic scoops inside dry ingredient bins allowing the handles to touch the dry ingredients for 2 of 2 observations. During the recertification and complaint investigation survey of [DATE] the facility was cited for failing to keep food on the tray line at a safe temperature, to discard expired foods, and to label food from outside of the food. In an interview with the Administrator on [DATE] at 1:45 PM she stated she was not employed by the facility during the 2021 survey and she was unsure of what the performance improvement plan was for that deficiency. She further stated that there was a lot of staff turnover in the kitchen which may have contributed to the repeat concern.

Based on observation, record review and staff, resident, nurse practitioner, and podiatrist interviews, the facility failed to notify the resident's physician of a change in condition for 1 of 1 resident (Resident #118) reviewed for Notification of Changes. Resident #118 experienced bleeding following the debridement of her right great toenail. This change in condition was not reported to the resident's attending Physician or the Podiatrist. Findings included: Resident # 118 was admitted to the facility on [DATE] with a diagnosis that included type 2 diabetes with neuropathy, and chronic kidney disease (CKD) stage 3. Review of podiatry visit summary and progress notes dated 12/6/23 revealed that Resident #118 had a podiatric diagnosis of atherosclerosis (a thickening or hardening of the arteries) of the extremities, onychomycosis (fungal infection of the nail unit); type 2 diabetes mellitus with peripheral circulation disorders. Resident #118 was evaluated, examined, and treated at bedside. The note further the toenails were debrided without incident. No signs of infection were noted. The nails were debrided by manual method. On 12/17/23 at 1:57 PM an interview with Resident #118 revealed she was concerned about a wound on her right great toe from where the Podiatrist cut her toenails recently. She stated she was diabetic and was concerned it would get infected. Resident #118 stated that she did not notice the wound right away because she had no feeling in her feet, so it did not hurt. Resident #118 stated it was a family member that first noticed blood on her sock over the right great toe when she visited the following day (12/7/23) and notified staff and they cleaned it and put an adhesive bandage on her toe. She did not recall the name of the staff that was notified. In a phone interview with Nurse #2 on 12/19/23 at 8:43 AM it was revealed that Nurse #2 was familiar with and assigned to Resident #118 when on duty. Nurse #2 indicated that the podiatry clinic was held on Tuesday 12/5/23 or Wednesday 12/6/23 and she next saw the resident on Thursday 12/7/23 or Friday 12/8/23. She further indicated that when she saw Resident #118 that there was an adhesive bandage on her right great toe that had residual dried blood on it, so she cleaned it and left it open to air, so it would not get infected. She stated there was also dried blood noted on the right great toe of Resident #118 and you could see the indentation of where the cut toenail had previously been, but the tissue looked healthy. Nurse #2 indicated that when the family member of Resident #118 came and asked about her toe on 12/7/23 or 12/8/23 that she went to the room with the family member, looked at the toe together and removed the adhesive bandage and showed her that it was clean and there was no swelling or odor, but the nail was noticeably cut too short. On 12/21/23 at 9:58 AM in a phone interview with the facility contract Podiatrist it was revealed that he recalled providing podiatry services of toenail debridement (trimming) to Resident #118 on 12/6/23 at the facility. He reported that Resident #118 was a poorly controlled diabetic with poor circulation and had weak pulses to the lower extremities, had chronic kidney disease, fungal toenails and a poor immune system placing her at high risk for infection. The Podiatrist further indicated Resident #118 had on blue nail polish and that nail polish can harbor infection further increasing her risk for infection. He did not recall cutting her nails too short and did not notice blood at the time. The interview further revealed that bleeding can occur later after nail debridement, and it was not uncommon for a patient with her diagnosis. He stated that she was on low dose aspirin and that would cause bleeding to be present longer. He indicated that when the nurse noted that the area had bled that she should have cleaned the toe, applied antibiotic ointment, and covered it with a band aid and then should have notified the on-call podiatrist for further instructions.

Based on observation, physician interview, physician assistant interview, staff interview, and record review the facility failed to avoid delays in obtaining an order to test for [MEDICAL CONDITION] (C. diff), in changing pressure sore treatments for wounds which were not healing, in providing protein supplementation to promote healing, in scheduling a consult with the wound clinic for debridement, in re-culturing for [DIAGNOSES REDACTED], and in addressing leakage around a rectal tube for 1 of 2 sampled residents (Resident #346) reviewed for pressure ulcers. Before the facility provided Resident #346 with wound clinic consultation/debridement on 01/15/16 the resident's sacral pressure ulcer deteriorated from a stage I to a stage IV pressure ulcer, and the resident's gluteal crease/buttock deep tissue injury (DTI) opened and deteriorated/enlarged into two stage III pressure ulcers to the bilateral buttocks. Findings included: A hospital Discharge Summary documented Resident #346 was hospitalized from [DATE] until 12/11/15. The reported noted, Pt (patient) has persistent leukocytosis (an increase in the number of white cells in the blood, frequently a sign of inflammation and/or infection). Remained elevated despite receiving 7 days of empiric Meropenem (broad spectrum antibiotic that can treat both Gram-positive and Gram-negative bacteria). Afebrile (without elevated temperature) throughout. Urine culture negative, CXR (chest x-ray) normal. Blood cultures from outside hospital (11/25) negative. Labs drawn on 11/27/15 documented Resident #346 had low total protein (at 5.6 grams per deciliter with normal being 6.2 - 8.3) and [MEDICATION NAME] (at 3.1 grams per deciliter with normal being 3.4 - 4.9) levels. Resident #346 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. diff. A 12/11/15 Clinical Health Status documented the resident had blanchable redness to the sacrum, and redness to the gluteal folds. The registered dietitian's (RD's) 12/11/15 Nutrition Assessment documented the resident's total calorie needs were 1468 - 1615, her protein needs were 74 - 89 grams, and her fluid needs were 2220 cubic centimeters (cc) per day. A 12/11/15 RD progress note documented the resident was admitted to facility receiving [MEDICATION NAME] 1.5, a low-residue formula, at 45 cc/hour providing 1620 calories and 2130 cc of total fluid including flushes. The formula also provided 68 grams of protein. A 12/15/15 RD progress note documented, Receiving ST (speech therapy) services w (with)/trials of puree, NTL (nectar thick liquid) diet. To facilitate participation in therapy and provide fiber recommend change .feedings to [MEDICATION NAME] 1.5 ,a fiber blend formula, 237 cc QID (four times daily) .to provide 1422 kcal (calories) and 2048 cc (to) total fluid including flushes. This formula also provided 60 grams of protein. A 12/15/15 4:40 PM nursing progress note documented the resident's pleasure feedings by mouth were discontinued, and the resident was made NPO (nothing by mouth) by ST. A 12/17/15 Wound Evaluation Flow Sheet documented Resident #346 had a 4 x 4 centimeter (cm) suspected deep tissue injury (DTI) to her lower gluteal crease/buttocks. The wound bed was described as red. It was documented on 12/17/15 the Treatment Nurse ordered soap and water zinc oxide cream bid (twice daily) for the ulcers to the sacrum and gluteal crease. A 12/17/15 10:21 PM nursing progress note documented the resident had an episode of vomiting and diarrhea during the shift. A 12/18/15 7:38 AM nursing progress note documented, resident is noted having loose stools after feeding is administered . A 12/18/15 physician order [REDACTED].#346. The resident's 12/18/15 admission minimum data set (MDS) documented her short and long term memory could not be assessed, she was severely impaired in decision making, she was dependent on one or staff members for her activities of daily living, she was always incontinent of bowel and bladder, she had a feeding tube, she had one stage I pressure ulcer and one deep tissue injury, and she had pressure relieving devices for her chair and bed. The care plan generated by the 12/18/15 assessment identified, Pressure ulcer actual: Pressure Ulcer Present - admitted with stage I on sacrum and unstageable (suspect deep tissue injury) on inner lower gluteal crease as a problem. Interventions to this problem included weekly skin inspection, weekly wound assessments, consults as needed, air mattress as order--monitor proper placement and functioning each shift and PRN (as needed), pressure reducing wheelchair cushion, provide thorough skin care after incontinent episodes and apply barrier cream, and turning and repositioning. The resident's Bowel and Bladder Detail Report documented she had five episodes of diarrhea on 12/19/15 and six episodes of diarrhea on 12/20/15. Progress notes on 12/21/15 - 12/23/15 documented the resident was having loose watery stools and watery diarrhea. 12/22/15 Wound Evaluation Flow Sheets documented Resident #346 had a 2 x 2 cm stage I red area to her sacrum and a 3 x 3 cm suspected DTI to her lower gluteal crease/buttocks. The resident's Bowel and Bladder Detail Report documented she had two episodes of diarrhea on 12/22/15 and four episodes of diarrhea on 12/23/15. A 12/23/15 RD progress note documented the resident's formula was being changed back to [MEDICATION NAME] 1.5 at 45 cc/hour. The resident's Bowel and Bladder Detail Report documented she had three episodes of diarrhea on 12/24/15 and 12/25/15, four episodes on 12/26/15, and three episodes on 12/27/15, one episode on 12/28/15, and three episodes on 12/29/15. In a 12/29/15 8:41 AM progress note the Treatment Nurse documented, . noted with wound care that area on inner gluteal crease has increased in size and extends to both rt (right) and lt (left) inner buttock dark red in color and dark pink in middle of wound. Upper area on sacrum has opened and is a dark pink .Primary nurse also aware and stated she noted the difference on the 24th of this month. All interventions in place for pressure relief, air matt(ress), pillows . In her 12/29/15 assessment Resident #346's primary physician documented, Buttox .appears to be 2 large red and violaceous (violet in color) areas seen on left sacral and right sacral regions. Left is larger than right at approximately 2 x 2 inches and inferior portion of the left wound is open Inner gluteal fold, buttox and inner thigh posteriorly and anteriorly have coalescing redness and satellite [MEDICAL CONDITION]. A 12/29/15 physician order [REDACTED]. A 12/29/15 physician order [REDACTED]. diff as soon as possible. A 12/29/15 physician order [REDACTED]. 12/30/15 Wound Evaluation Flow Sheets documented Resident #346's sacral pressure measured 2 x 2 x 2 cm and declined to a stage III wound with dark red tissue and scant red drainage. It was documented the resident's gluteal/buttock DTI now measured 9 x 8 x 0.1 cm with scant serous exudate. The treatment for [REDACTED]. Per surveyor calculation, this decline in the resident's wounds increased her protein needs to 87 - 109 grams of protein daily. 12/30/15 lab results documented Resident #346's total protein and [MEDICATION NAME] levels were now lower than when hospital labs were drawn on 11/27/15. On 12/30/15 the resident's total protein was 5.0 grams per deciliter (g/dL), with normal being 6.2 - 8.3 g/dL, and her [MEDICATION NAME] was 2.7 g/dL, with normal being 3.4 - 4.9 g/dL. The resident's Bowel and Bladder Detail Report documented she had three episodes of diarrhea on 12/30/15 and two episodes on 12/31/15. A 12/31/15 10:49 PM nursing progress note documented when entering Resident #346's room the nurse noted for the first time a smell associated with [DIAGNOSES REDACTED], and observed loose stool which was mustard yellow with a mucous film. A 01/01/16 9:35 AM nursing progress noted documented, .Buttocks area color changing from red to grayish appearance . A 01/01/16 8:06 PM nursing progress note documented, Stool specimen was obtained by this shift and taken to the hospital at 5 pm. The resident's Bowel and Bladder Detail Report documented she had three episodes of diarrhea on 01/01/16. A 01/02/16 11:37 AM nursing progress note documented lab results revealed Resident #346 was positive for [DIAGNOSES REDACTED], placed on contact isolation, and was started on [MEDICATION NAME] 500 mg TID (milligrams three times daily) x 14 days. The resident's Bowel and Bladder Detail Report documented she had three episodes of diarrhea on 01/02/16. A 01/03/16 2:34 PM nursing progress note documented, .pt's buttock showing very little signs of healing, wound bed noted to have large amount yellowish, gray, tan tissue. Will have day shift treatment nurse to reevaluate on tomorrow. The resident's Bowel and Bladder Detail Report documented she had two episodes of diarrhea on 01/03/16. A 01/04/16 physician order [REDACTED]. A 01/04/16 1:33 PM nursing progress documented, Resident bottom area viewed by the ADON (assistant director of nursing). Patient buttocks raw and open in two areas. Greenish/brown layer visible in the open area. Patient receiving barrier cream around the open wound daily . The resident's Bowel and Bladder Detail Report documented she had one episode of diarrhea on 01/04/16. A 01/05/16 RD progress note documented with the possibility of malabsorption Resident #346's formula was being changed to Vital 1.5, a peptide-based formula, 55 cc/hour with one scoop of [MEDICATION NAME] protein supplement TID providing 2070 calories, 107 grams of protein, and 2670 cc of fluid including water flushes. A 01/05/16 1:42 PM nursing progress note documented, Unit receptionist made contact with the Wound Clinic by phone to schedule appt. The office stated they would call the facility back with the date and time by the end of this week Greenish and grayish appearance to the two open wounds. Barrier cream applied around the open areas A 01/05/15 Wound Evaluation Flow Sheet documented the resident's stage III sacral pressure ulcer measured 2.5 x 2 x 1.2 cm with scant serous drainage and pungent odor. The wound bed was described as 100% slough. A 01/05/15 physician order [REDACTED]. The resident's Bowel and Bladder Detail Report documented she had two episodes of diarrhea on 01/05/16, 01/06/16, and 01/07/16. In a 01/07/16 12:34 PM progress note the Treatment Nurse documented, Wound below sacrum increased in size to cover gluteal crease and extends to both rt and left buttocks. No dressing can stay in place for this area due to resident's incontinence. Writer (Treatment Nurse) suspected both wounds may be infected due to the worsening condition of both wounds and has voiced this to ____ (name of physician's assistant) A 01/07/16 Wound Evaluation Flow Sheet documented the resident's gluteal/buttock stage III ulcer measured 9 x 3 x 0.2 cm with pungent odor. The wound bed was described as 10% granulation tissue and 90% slough. The current treatment was documented as soap and water zinc oxide barrier cream bid and prn. Wound continues to worsen despite interventions, resident continues to have constant loose watery foul stools, was documented under the current wound status. The resident's Bowel and Bladder Detail Report documented she had one episode of diarrhea on 01/08/16, three episodes on 01/09/16, one episode of diarrhea on both 01/10/16 and 01/11/16, no episodes on 01/12/16, and two episodes on 01/13/16. A 01/13/16 6:34 PM nursing progress note documented, Resident is incontinent of bladder and has a rectal tube in place this shift and brown watery stool is passing in the tubing. 01/14/16 Wound Evaluation Flow Sheets documented the resident's sacral pressure ulcer had declined to a stage IV wound measuring 4 x 2 x 1.8 cm. The wound had minimal sanguineous exudate with strong odor, and the wound bed was described as 100% slough. Santyl was the treatment being utilized for the sacral wound. It was documented that the resident's gluteal/buttocks pressure ulcer had declined to a stage IV wound measuring 9 x 6 x 0.3 cm. The wound had minimal sanguineous exudate with strong odor, and the wound bed was described as 60% granulation tissue and 40% slough. Current treatment for [REDACTED]. A 01/14/16 2:42 PM progress note written by the Treatment Nurse documented, .Rectal tube placed late yesterday and is in place however resident continues to have stool seep out around tubing getting into wound The resident's Bowel and Bladder Detail Report documented she had two episodes of diarrhea on 01/14/16. Review of consults revealed Resident #346 was first seen at the wound clinic on 01/15/16. Consult notes documented, The wounds on her buttock area were 3 separate wounds. The wound on the sacrum measured 3.1 x 1.6 x 2.4 cm. Undermining was present. At the 3 o'clock position the undermining was 0.6 cm. at the 6 o'clock position the undermining was 0.8 cm, and at the 9 o'clock position undermining was 1.6 cm. The base of this ulcer was covered with [MEDICATION NAME] exudate and necrotic fat that needed removal. The sacral ulcer initially appeared to be a stage III, but with debridement we found these sacral ligaments to be exposed making it actually a stage IV. The right buttock ulcer measured 4 x 5.3 x 0.7 cm. It was fairly clean and did not need debridement. The stage III ulcer on the left buttock measured 5 x 4.7 x 0.7 cm. It was covered with [MEDICATION NAME] exudate and did need debridement The wounds should be treated with topical Santyl changed on a daily basis (this meant changing the treatment to the gluteal crease/buttocks from zinc oxide to Santyl and continuing Santyl to the sacrum) There was no evidence of infection in the wounds A 01/15/16 physician order [REDACTED]. diff (results were not available during the survey). The resident's Bowel and Bladder Detail Report documented she had one episode of diarrhea on 01/15/16, two episodes on 01/16/16 and 01/17/16, one episode on 01/18/16, two episodes on 01/19/16, and five episodes on 01/20/16. 01/20/16 Wound Evaluation Flow Sheets documented Resident #346's stage IV sacral wound measured 4 x 2.2 x 3 cm with undermining of 1.3 cm at 12 and 2 cm at 6:00 PM. There was thin watery serous exudate with a strong odor, and the wound bed was described as 60% granulation tissue and 40% slough. The resident's gluteal/buttocks stage IV pressure ulcer measured 8.5 x 6 x .3 cm with thin watery serous exudate with a strong odor. The wound bed was described as 80% granulation tissue and 20% slough. In a 01/21/16 2:43 PM progress note the Treatment Nurse documented, .Anal tube in place for loose stools however stool continues to seep around tubing and gets into wound bed The resident's Bowel and Bladder Detail Report documented she had two episodes of diarrhea on 01/21/16. A 01/22/16 Wound Clinic consult documented, She has 3 decubitus ulcers. The sacral ulcer today measured 5.5 x 2 x 2.6 cm. There was [MEDICATION NAME] around the full circumference of the wound to a depth of 3.8 cm. The right buttock wound measured 4.5 x 4 x 0.8 cm and the left buttock wound measured 5.2 x 4.5 x 0.7 cm. All 3 of these ulcers were covered with [MEDICATION NAME] exudate that needed removal There was no evidence of infection in the wounds The resident's Bowel and Bladder Detail Report documented she had two episodes of diarrhea on 01/22/16, three episodes on 01/23/16, four episodes on 01/24/16, two episodes on 01/25/16, one episode on 01/26/16, and four episodes on 01/27/16. During observation of Resident #346's wound care on 01/27/16 at 8:48 AM the Treatment Nurse removed dressings with scant serous drainage. The Treatment Nurse stated the wound dressing required frequent changes because of numerous loose stools the resident continued to experience. A rectal tube was draining liquid stool, but there was also liquid stool oozing around the tube. The Treatment Nurse reported the resident usually oozed bowel movement around the rectal tube but today seemed worse than usual. The nurse asked a nursing assistant (NA) to alert the unit manager that the resident needed a new rectal tube. The sacral wound was approximately a half dollar in size, slightly oval shaped, approximately 1/2 inch deep, red with an area of yellow slough with white edges. The wound was irrigated with normal saline (NS), Santyl was applied, NS-moistened gauze was packed into the wound, and a dry dressing was applied. The intergluteal cleft wound on the right and left buttocks was approximately a dollar bill size altogether, being irregularly shaped (like a butterfly with a wing on each buttock), 1/4 inch deep, and beefy red with white edges. The wound was irrigated with NS, Santyl was applied, NS-moistened gauze was packed into the wound, and a dry dressing was applied. 01/27/16 lab results documented Resident #346's white blood count rose to 19.40 k/uL (thousands of cells per microliter of blood) from 11.90 k/uL on 01/13/16, with normal being 4.5 - 11.0 k/uL. At 11:07 AM on 01/28/15 the Treatment Nurse stated Resident #346 had diarrhea and loose stools from admission forward. However, she reported it was not until the end of December 2015 that an odor indicative of [DIAGNOSES REDACTED] was noted (and still persisted). She commented the rectal tube leaked a little bit since it was inserted, but that seepage had worsened recently. She stated dressings would not stay on the resident's wounds because of all the diarrhea. For example, she reported that a [MEDICATION NAME]/[MEDICATION NAME] dressing would bunch up and make the wounds worse. According the Treatment Nurse, she used zinc oxide on stage II and a lot of stage III wounds with minimal depth. She stated the zinc oxide was frequently rubbed off Resident #346's wounds because of the constant incontinent care that had to be provided. This nurse also commented she had products such as wound gel, [MEDICATION NAME] spray, [MEDICATION NAME], and [MEDICATION NAME] available for use, but had not tried any of those for Resident #346. She reported the wounds continually had minimal exudate, but this exudate did not smell of infection. However, the nurse explained she suspected underlying infection due to the rapid decline of the wounds. According to the Treatment Nurse, once wounds had yellow, tan, or brown slough in them she began to use Santyl to try and clean out the wound beds. However, she stated if the zinc content of barrier cream was high enough, and the resident was eating well, sometimes she did not change treatments even if the wounds were not healing. The Treatment Nurse commented that if she needed their help the director on nursing (DON) and physician assistant (PA) would view wounds with her, and she stated they both would sometimes ask to see certain wounds if they had concerns, residents had concerns, or family members had concerns. She stated she was primarily responsible for determining the treatment products used on wounds. At 2:45 PM on 01/28/16 Nurse #6, who cared for Resident #346 on first shift, stated the resident was nonverbal. She reported the resident, from admission to now, would usually have two to four episodes of diarrhea or at least loose stools on first shift. She commented at first the facility thought formula toleration was causing the gastrointestinal problem, but when tube feeding adjustment did not work, the resident was checked for and eventually treated for [REDACTED]. She reported on first shift the Treatment Nurse did all prn dressing changes so she had not seen the resident's wounds herself. According to Nurse #6, to try and keep stool out of the wounds a rectal tube was inserted, but stool would seep around the tube. At 2:50 PM on 01/28/16 NA #3, who cared for Resident #346 on first shift, stated the resident had two or three episodes of diarrhea or very loose stools about two or three times on first shift daily. She commented the stools and diarrhea always had foul odor, but more so toward the end of December 2015. She reported prior to wound clinic visits, she thought the resident was receiving [MEDICATION NAME] in the front perineum, zinc barrier cream to the buttocks, and zinc barrier cream and then Santyl to the sacrum. Before getting the rectal tube, NA #3 stated the Treatment Nurse averaged doing a couple of prn dressing changes daily on first shift. At 4:48 PM on 01/28/16 Resident #346's PA stated she probably viewed Resident #346's wounds with the Treatment Nurse five or six times during the resident's stay. She reported the wounds declined rapidly with the sacrum presenting as a stage I and declining to a Stage IV, and the gluteal crease/buttocks presenting as a DTI (deep purple but not black in color). She remarked even though the wound on the buttocks was not truly over a bony prominence, she considered the wound to be a DTI due to its coloring. The PA commented treatment options for wound care were not her area of expertise so she left those decisions up to the Treatment Nurse. However, the PA stated zinc barrier cream was only appropriate for stage I ulcers or intact skin. Once a pressure wound opened, she reported the treatment product should change. She commented the time period for changing treatments when there was no healing progress varied greatly from resident to resident depending on their nutritional status and co-morbidities. In addition, the PA reported adequate caloric and protein intake played an important role in wound healing. She stated odor was not the definitive criteria in testing for [DIAGNOSES REDACTED]. The PA explained after a couple of days of having three and four episodes of diarrhea or very loose stools she would expect to see a resident checked for [DIAGNOSES REDACTED]. She commented if green tissue was noted in the wound bed, she would expect the facility to check for infection. The PA also commented Resident #364 was sent out to the wound clinic because no progress was being made by the facility in healing the wounds, even with the use of Santyl. According to the PA, she was never approached about helping to get the resident in to the wound clinic more quickly. She reported there were larger sizes of rectal tubes available than the one inserted into Resident #346, but then comfort became an issue. The PA stated a follow-up stool culture to check for [DIAGNOSES REDACTED] was desirable for this resident because she was continuing to experience diarrhea with foul odor. She explained another round of [MEDICATION NAME] would be possible for the resident. At 5:24 PM on 01/28/16 the Treatment Nurse clarified that on Thursdays she communicated to the DON whose wounds she might want to look at, but the DON did not routinely go with her on wound rounds. She stated occasionally the DON or PA would ask to see the wounds of particular residents, especially certain stage III and IV wounds. A 01/28/16 physician order [REDACTED]. A hospital Discharge Summary documented Resident #346 was hospitalized from [DATE] until 02/04/16. Her primary discharge [DIAGNOSES REDACTED]. diff [MEDICAL CONDITION]), sacral decubitus stage IV with exposed sacral ligaments, and stage III pressure ulcers to the right and left buttocks. 01/28/16 testing revealed the resident's stool sample was negative for [DIAGNOSES REDACTED], and her [MEDICATION NAME] and total protein levels were within normal limits. At 11:30 AM on 01/29/16 the Medical Director (MD), and Resident #346's primary physician, stated she observed the resident's wounds on 12/29/15 and found the sacral wound to have opened and a DTI to the gluteal crease/buttocks. She explained the DTI was disturbing because there was no way of knowing what lay beneath. The MD stated zinc barrier cream was appropriate for treating moist areas, small stage II ulcers, and opened blisters. However, she reported she expected the wound beds of stage III and IV ulcers to be packed with absorbent dressings or enzymatic agents/dressings. The MD also commented odor was not the only criteria for testing to determine the presence of [DIAGNOSES REDACTED]. She explained that testing for [DIAGNOSES REDACTED] was a good idea if residents were experiencing watery stools and had received antibiotic therapy in the last 30 days. According to the MD, the resident was referred to the wound clinic for debridement of her wounds, especially with documentation of green tissue in the wound beds to determine whether infection was present. However, she reported she was not approached to help get Resident #346 into the wound clinic more quickly. She also stated she had one contact at the wound clinic who would even make facility visits if residents were too compromised to make the trip to the clinic. According to the MD, follow-up stool cultures for [DIAGNOSES REDACTED] were not always recommended because there could be false positive results due to [MEDICATION NAME] that had built up. The MD reported Resident #346 was sent to the hospital on [DATE] due to an elevated white blood cell count. She explained the resident might need strong intravenous (IV) antibiotics, IV fluids, and blood cultures, and the hospital needed to rule [MEDICAL CONDITION] and [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) bacteria. At 12:23 PM on 01/29/16 the facility's RD stated Resident #346 was just started on tube feeding in the hospital on [DATE], and was admitted to the facility on [DATE]. Even though she reported she did review hospital discharge documents which contained information about low protein and total [MEDICATION NAME] levels, the RD commented the primary consideration of the facility was to make sure the resident's formula toleration improved and to stop the diarrhea. She explained [MEDICATION NAME] levels could be lowered and greatly influenced by infection and inflammation both of which Resident #346 suffered from. The RD also added that when completing her initial nutrition assessment on 12/15/15 the resident did not have any open wounds so the need to increase protein intake was not yet paramount. According to the RD , the plan was to gradually increase the rate of the tube feeding after the diarrhea was controlled. At 1:57 PM on 01/29/16 the DON reported she observed all wounds greater than a stage II weekly even though it might not be with the Treatment Nurse. She stated there was a quick decline in Resident #346's wounds. According to the DON, zinc barrier cream to the edges and surrounding tissue of stage III and IV wounds would be appropriate, but if there was slough in the wound bed, she would expect there to be a [MEDICATION NAME] agent used on it. She stated even though she observed Resident #346's wounds she had not observed the Treatment Nurse perform wound care on the resident. The DON also commented even though it was unusual to find DTIs to the buttocks, they could form anywhere. The DON reported she could not explain why it took so long to collect a stool sample and check for [DIAGNOSES REDACTED] or why a stool re-culture was not collected as ordered on [DATE] . She commented the referral was made to the wound clinic because Resident #346's wounds were not healing. She remarked when a physician order [REDACTED]. She stated she was not notified that there was any trouble getting the resident an appointment at the wound clinic. The DON reported every wound was different so it could be two days to two weeks before changing treatments if wounds were not healing. According to the DON, she was not notified that the rectal tube was leaking/seeping until 01/27/16 when the surveyor was making her wound treatment observation. At 2:30 PM on 01/29/16 the Treatment Nurse stated she thought there was a mistake in her documentation because she thought she changed the treatment to Resident #346's gluteal crease/buttocks to Santyl on 01/07/16. However, she was unable to explain why her Wound Evaluation Flow Sheets and the Treatment Administration Record (TAR) documented only zinc barrier cream was used on the buttocks wound until after the resident returned from her first wound consult on 01/15/16. At 2:45 PM on 01/29/15 the Administrator, after meeting with an interdisciplinary team, stated Resident #346 had a persistent leukocytosis [DIAGNOSES REDACTED]. He commented the Treatment Nurse diagnosed a DTI to the gluteal crease/buttocks on admission, and the physician confirmed the DTI during her 12/29/15 assessment. He explained the rapid decline of the DTI might have been caused by all this infection underneath. The Adminsitrator stated, if this was the case, the outcome would not have been good for the resident's wounds no matter how proactive the facility was in it's treatment of [REDACTED]. At 4:08 PM on 01/29/18, during at telephone interview with the Wound Center Director, she stated it was not apparent what the nursing home was treating Resident #346's wounds with upon her 01/15/16 initial assessment, but the resident did have dressings on both wounds when she was first seen. She reported the clinic recommended continued use of Santyl to the wounds because the clinic had the best success utilizing this [MEDICATION NAME] agent. According to the director, no signs and symptoms of infection were noted in the wound beds, and the wounds were clean (not contaminated with fecal matter). According to the Wound Center Director, it was not apparent that the nursing home had done anything wrong in the treatment of [REDACTED]. Once the wound beds were cleaned through the debridement process, she reported the wound center wanted Resident #346 placed on wound vac therapy. At 5:04 PM on 01/29/16 Nurse #8, who cared for Resident #346 on second shift, stated the resident received high powered antibiotics in the hospital which probably contributed to the development of [DIAGNOSES REDACTED]. This nurse commented the resident had watery stools with odor since admission and through the evening of 01/28/16 when she was discharged to the hospital. During the prn dressing changes she had to make due to soilage, Nurse #8 stated the treatment ordered for the gluteal crease/buttocks was zinc barrier cream around the edges of the wounds, even when the wound was staged as III with slough. She commented she was told that the Treatment Nurse had consulted with the PA about this treatment. According to the nurse, Resident #346 usually had a couple of loose stools/diarrhea nightly on second shift. She reported she heard third shift complaining that the rectal tube was leaking, but she thought the tube did cut down on fecal contamination of the wounds. The nurse stated no product would stay on the buttocks well due to the diarrhea, but this changed after the wound clinic ordered Santyl dressings on the buttocks. At 5:15 PM NA # 4, who sometimes cared for Resident #346 on second shift, stated no NA was permanently assigned to this resident on second shift. However, she reported when she worked