Every finding on record at Madison Health and Rehabilitation Center

Based on interview, record review, review of facility policies, and review of [NAME] 9th edition - Standard of Practice for Nursing Assessment of Change in Condition information which the facility followed as its standard of practice, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident (R) 1) of eight sampled residents.The facility identified a change in condition for R1 on [DATE] and notified the physician of the change in condition. However, the physician ordered labs were not obtained promptly. Additionally, staff had no evidence of ongoing monitoring of the resident for a period of 12 hours, until they documented R1 had decreased blood pressure. Staff notified the Licensed Practical Nurse (LPN) of additional changes in condition and the need to send R1 out to the hospital; however, this did not promptly occur. R1 was ultimately found without respiration or heartbeat, was administered cardiopulmonary resuscitation (CPR) and transferred to the hospital where he was pronounced dead on [DATE].The findings include: Review of the facility's policy, Quality of Care, reviewed 03/2026, revealed quality of care was a fundamental principle that applied to all treatment and care provided to facility residents. Further review revealed the facility must ensure residents receive treatment and care in accordance with professional standards of practice. The policy noted the need to provide needed care and services for the resident's physical well-being; recognize and/or assess risk factors for specific conditions/problems; implement resident specific care and treatment consistent with the physician's orders and professional standards of practice; and monitor and evaluate the resident's response to interventions, and/or revise as appropriate.Review of the facility's policy, Change of Condition Standard of Practice, reviewed 03/2026, revealed the facility would immediately (as soon as possible/no longer than 24 hours) inform the resident, consult the resident's physician, and the resident representative when there was a significant change in the resident's physical or a need to alter treatment significantly (depending on the nursing assessment, appropriate notification could range from immediate to 48 hours). Further review revealed nursing judgement was an integral part of the skilled care provided at the facility; therefore, such judgement was applied on a case-by-case basis in keeping with acceptable nursing practice. Further review of the policy revealed that it did not address frequency or content of nursing assessments or monitoring of residents after a change in condition was noted.Review of the facility's policy, Lab and Diagnostics Standard of Practice, revised 04/2025, revealed the facility would provide or obtain laboratory services when ordered by a physician. Further review of the policy revealed that it did not address timeframes in which ordered labs were to be obtained.Review of a 2023 [NAME] 9th Edition - Standard of Practice for Nursing Assessment of Change in Condition, provided by the (Corporate) Chief Nursing Officer revealed the core elements of the standard of practice for change in condition included recognition of change, rapid assessment, collaboration, documentation, resident safety, and continuity of care. Further review revealed recognition of change included nurses must be vigilant for deviations from baseline vital signs, mental status, pain levels, or functional status. This included both sudden and gradual changes and should be documented promptly. Continued review revealed rapid assessment used the nursing process to determine the cause, severity, and urgency of the change. Additionally, collaboration included notifying the provider immediately if the change was unexpected, life-threatening, or outside expected parameters. Documentation included recording the time, nature, and context of the change, along with interventions and provider responses. Further review revealed continuity of care included reassessing frequently, especially in unstable residents. Review of R1's admission Face Sheet revealed the facility admitted R1 on [DATE] with diagnoses which included cellulitis of the right lower limb and multiple sclerosis. R!1's Comprehensive Care Plan included a Discharge Planning Care Plan that R1 wanted to receive short term rehab and discharge to home. R1 was not on hospice services (with no indication of expected or imminent death) and was a Full Code status (indicating the resident wanted all live saving measures taken in the event his heart stopped).Review of R1's medical records revealed no concerns with a change of condition between admission on [DATE] until [DATE] at 3:32 PM. Review of monitoring prior to this time revealed R1's blood pressure on [DATE] at 7:00 AM was 118/65 millimeters of mercury (mmHg).Review of R1's Progress Notes, dated [DATE] at 3:32 PM by Licensed Practical Nurse (LPN) 2, revealed a change in condition. Per the Note, R1 presented with slight confusion this shift (7:00 AM to 7:00 PM) and moderate jerking movements of his bilateral hands. Further review revealed LPN2 notified the Medical Director (R1's physician) of the resident's change in condition with a new order obtained for a urinalysis, complete blood count (CBC), comprehensive metabolic panel (CMP), Covid swab, and a 2-view chest x-ray. Continued review revealed the facility would obtain new orders on the resident and observe the resident's chart for finalized results.Review of R1's chest x-ray report, obtained on [DATE] at 4:03 PM and signed on [DATE] at 5:56 PM, revealed no acute cardiopulmonary disease.Further review of R1's record revealed no evidence that the labs which were ordered (urinalysis, CBC, CMP, and Covid swab) were completed.Review of R1's clinical record revealed no further progress notes from [DATE] at 3:32 PM until [DATE] at 11:51 AM, after R1 was found without pulse or respiration, CPR was initiated, and EMS transported the resident to the hospital where he was ultimately pronounced dead. Review of the facility's 24-Hour Report/Change of Condition Report form revealed that both [DATE] and [DATE] noted that R1 had new orders for lab work. However, further review of the clinical record revealed that the only evidence that staff monitored R1 after the change in condition was first identified on [DATE] at 3:32 PM was blood pressure readings at 7:00 PM (126/80), and on [DATE] at 7:00 AM (90/54). Review of R1's Progress Note, dated [DATE] at 11:51 AM, documented by LPN1, revealed that staff notified LPN1 that R1 was not acting normal this shift (7:00 AM to 7:00 PM). R1's vital signs included blood pressure of 79/54, heart rate (HR) 64, respirations (R) 22 and labored, and oxygen saturation (O2) of 94%. R1 was alert and oriented times one (indicating awake but only aware of one standard marker of orientation, such as person/name) and responded to his name being called; however, when asked questions to gauge consciousness, R1 would not respond. LPN1 got an order to call 911 to send R1 to the emergency room (ER) for evaluation; however, while awaiting transport, R1 became pale, and was not breathing with no detectable pulse and a code (CPR) was initiated. Further review of LPN1's 11:51 AM Progress Note revealed that it was written after Emergency Medical Services (EMS) documented they transported R1 to the hospital at 11:47 AM, per review of the [DATE] EMS run sheet. LPN1's 11:51 AM Progress Note did not indicate at what time each of the above listed facility actions (staff identification of change in resident condition on [DATE], physician notification, or 911 call) actually occurred on the morning of [DATE].Further review of the EMS run sheet, dated [DATE], revealed EMS received the call at 11:21 AM that the resident had a decline in condition and needed transfer to the hospital and arrived on scene at 11:27 AM. Further review revealed EMS was with the patient at 11:32 AM and departed the scene at 11:47 AM. Per the run sheet, EMS found the resident did not have a heartbeat, provided CPR, and intubated R1 prior to leaving the scene.Review of R1's untimed ER Encounter Note, dated [DATE], revealed R1 presented to the ED in cardiac arrest, was noted to be asystole (no heart rhythm), and CPR was in progress for approximately 25 to 30 minutes. Further review revealed EMS stated R1 had been in asystole since they arrived at the facility and had no shockable rhythm. R1 was pronounced dead at the hospital on [DATE] at 12:08 PM.Further review of R1's record revealed that staff documented R1 had a blood pressure of 90/54 on [DATE] at 12:17 PM, 30 minutes after R1 was transported from the facility and nine minutes after his death.Interview, on [DATE] at 11:05 AM, with LPN2 revealed she worked on [DATE] from 7:00 AM to 7:00 PM. She stated she noticed a change in R1 about an hour before she called the doctor, saying he was shaky, wasn't his normal self. She related that she notified the Medical Director (who was also R1's primary physician), and received orders to obtain labs, a chest x-ray and a Covid swab. LPN2 stated she entered the labs to be drawn routinely with the next lab draw on [DATE] and the lab was also to obtain the Covid swab. LPN2 added that any time a physician was notified of a change in condition, vital signs and nursing assessments should be done every four hours to make sure the resident was not getting worse until they received the lab results. She further stated that was the physician's expectation, as she had heard him say if it was important enough to call him, they should be monitoring the patient every four hours.Interview on [DATE] at 11:20 AM with LPN3 revealed she worked on [DATE] at 7:00 PM until [DATE] at 7:00 AM. LPN3 stated LPN2 gave her report on [DATE] at 7:00 PM and told her that R1 had orders for labs and wasn't feeling good. LPN3 stated she checked on R1 and gave him his scheduled 7:00 PM pain medication (Gabapentin) early in her shift and he went back to sleep. LPN3 added that she checked on R1 throughout the night and checked his vitals but failed to document the assessments and could not recall specifics to validate her contention that R1 was stable throughout the night. She stated it was the expectation that any time a physician was notified of a resident's change in condition, the staff provided increased assessments and vital signs, but the facility did not designate how often to do the increased assessments or vital signs. LPN3 further stated she verbally notified LPN 1 at shift change on [DATE] at 7:00 AM that she had given R1 a pain pill during the shift and told LPN1 the information regarding R1's change in condition and pending lab orders.During an interview, on [DATE] at 1:45 PM, Kentucky Medication Aide (KMA) 2 stated she passed medication on R1's hall on [DATE] day shift. She further stated that she gave R1's medication around 8:00 AM or 8:30 AM on [DATE] and R1 stated he didn't feel good. KMA2 noted that later, staff got LPN1 in the room because R1 was not doing well; however, she was not involved after she gave R1 his morning medications. Further interview with KMA2 revealed she did not inform the nurse (LPN1) that R1 was not feeling well because she thought he was already aware of the concern and saw him in R1's room at an unidentified time. Review of a timeline provided by the Unit Manager revealed that although KMA2 thought she gave R1 his medication 8:00 - 8:30 AM, R1's medication was documented as administered at 10:01 AM.During an interview on [DATE] at 3:00 PM, State Registered Nurse Aide (SRNA) 2 stated she and SRNA3 were assigned to R1 on [DATE] day shift. She further stated R1 was shaking at the beginning of the 7:00 AM - 7:00 PM shift and could not hold his drink and did not eat breakfast. SRNA2 noted that she checked on him again after she passed all breakfast trays and offered to feed R1, but he said he did not feel like eating. SRNA2 stated she and SRNA3 notified LPN1 of R1's change in condition and stated that the resident needed to be transported to the hospital at that time. SRNA2 noted that she then returned to R1's room at approximately 10:00 AM for the resident's every two-hour check and change round and found that R1 was still shaking and continued to not feel well. She stated LPN1 obtained R1's vital signs at some time during that morning, but she was not sure what time this occurred or what the vital signs were. During an interview, on [DATE] at 3:39 PM, SRNA3 stated she was working with SRNA2 on [DATE] day shift. She further stated she went with SRNA2 to take R1, his breakfast tray and R1 was very shaky. She stated she notified LPN1 and asked him to send R1 to the ER around 7:30 AM and LPN1 stated to keep an eye on him. SRNA3 stated she again notified LPN1 that R1 was shaky after breakfast trays were picked up. SRNA3 stated LPN1 took R1's vitals sometime around 10:00 AM and she again asked LPN1 if he could send R1 to the ER. She stated LPN1 stated he could not send R1 to the hospital without getting approval from The Boss. SRNA3 stated that sometime around 11:00 AM, she was taking a break when SRNA2 came to the break room to get her, stating LPN 1 had said R1 was going to the hospital and she needed assistance to clean him up. She further stated she left the break room and saw LPN1 at the nurse's station when SRNA2 came down the hall, stating R1 was gone. SRNA3 added that in response, nurses began CPR and EMS were already in the building when LPN1 ran into the room.Interview on [DATE] at 3:30 PM with LPN1 revealed he was taking care of R1 on [DATE] day shift (7:00 AM to 7:00 PM). Although LPN3 stated that she passed on information about R1's pending labs and not feeling well, LPN1 denied he received any information from the nurse on the prior shift about R1 other than she had given R1 pain medication. LPN1 also denied that two direct care staff (SRNA2 and SRNA3) asked him to send the resident out to the hospital as early as 7:30 AM. Further interview with LPN1 revealed that R1 seemed fine at the beginning of the shift, even though R1's documented blood pressure for 7:00 AM was low at 90/54. Further interview with LPN1on [DATE] at 4:00PM, revealed that later that morning, staff reported to him that R1 did not feel well and was shaking. He stated that he assessed R1 and notified the Unit Manager (UM) of R1's change in condition and was told to notify the physician. He then called the Medical Director and obtained an order for R1 to be transported to the ER, then he called EMS. He stated prior to EMS arrival, R1 coded and he performed CPR for about 5-10 minutes before EMS arrived and continued to code R1. However, further interview with LPN1 revealed that he could not provide approximate times of when any of these listed actions occurred, or the intervals of time between each action. Interview with LPN1 revealed he could not explain the apparent time delay until 11:21 AM when LPN1 finally called for an ambulance in response to R1's change in condition, adding that he should have documented the actions when they occurred.During a follow-up interview on [DATE] at 4:00 PM, LPN1 stated he was told R1 wasn't acting right during morning med pass, but he looked at R1 and got his vital signs and was not concerned. However, he acknowledged he had no evidence this occurred, as the only vitals that were charted on [DATE] prior to R1's transfer from the facility was the low blood pressure that the KMA charted at 7:00 AM shift change. LPN1 stated he told the SRNAs to keep an eye on R1, and staff told him a little later in the morning R1 was not doing well and he assessed R1 to have a low blood pressure. He stated he called Unit Manager (UM) 1 who gave him permission to send R1 out to the hospital, then called the Medical Director for the order, then called 911. LPN1 further stated he told the SRNA's to clean him [R1] up before he made the phone calls and he was not sure where they were or if anyone was with R1 while he (LPN1) was at the nurse's station. He added that SRNA 2 then came running down the hall, stating R1 was not breathing, He walked to R1's room, while LPN4, who was coming down the hall, grabbed the crash cart. He stated EMS arrived 5-10 minutes later and continued CPR. Attempts to clarify on [DATE] at 4:00 PM, possible concerns with lack of monitoring and/or delays in in care with LPN1 were unsuccessful. When asked for a timeline (due to discrepancies with staff statements, lack of evidence of timely vital signs and monitoring, and the failure to call for an ambulance until 11:21 AM), LPN1 stated he was unable to recall time frames or specifics such as vitals or monitoring. LPN1 noted that it was the facility's procedure to get approval from the Administrative Nurse on call prior to sending out residents to the hospital. LPN1 reported that he had no delay in getting approval to send R1 out to the hospital and was unable to provide a rationale for the apparent delay in services. Additionally, LPN 1 added that he should have accurately documented the resident's status and actions the facility took that day. During an interview, on [DATE] at 12:02 PM, UM1 stated LPN1 called her the morning of [DATE] and said R1 wasn't acting right with low vital signs. She further stated she told LPN1 to call the physician, and the next thing she knew, LPN1 called her back to state that R1 coded. UM1 noted the protocol stated to provide an assessment every 4 hours, but as a nurse she would check on the resident way more often. During an interview on [DATE] at 2:32 PM, the Medical Director stated he was notified on [DATE] in the afternoon that R1 had a change in condition and he gave orders for labs to be drawn. He further stated that it was his expectation staff would have obtained labs at that time for a sick resident, but he failed to state the labs were to be performed stat (immediate) as he thought it was understood. He stated it was his expectation that staff would assess the resident and obtain vital signs every two hours following a change in condition that warranted a phone call to him. Further interview with the Medical Director confirmed that when he was called again on [DATE] and was told R1 had declined, he ordered R1 sent to the hospital at that time. During an interview on [DATE] at 3:50 PM, the Director of Nursing (DON) stated it was his expectation if a physician was notified of a resident's change in condition and ordered labs that the labs would be obtained stat. He further stated 24-hour acute charting should be completed every shift for 72 hours for residents with a change in condition. He added that his expectation was that nurses usually remained in the room with the resident if the resident's condition required them to be sent to the hospital unless the nurse was printing paperwork. Further interview with the DON revealed that he was unaware of the facility's nursing standard of practice.During an interview, on [DATE] at 4:23 PM, the Administrator stated the facility followed [NAME] for nursing standard of practice. He further stated he believed staff did everything correctly except they should have documented their assessments and vital signs. During this interview, the Administrator referenced a facility-created timeline, which, he stated, indicated that nursing staff had been in R1's room several times during the morning, (i.e. to apply an anti-fungal treatment). However, review of this timeline revealed no evidence to indicate that staff were actively monitoring or assessing the resident's change in condition, including obtaining and recording vital signs and other changes in status to determine what further steps (if any) were needed.

Based on observation, interview, record review and facility policy review, the facility failed to ensure timely dental referral and appropriate follow-up for a resident with missing dentures for one of four sampled residents(R) (R3). In April of 2025, R3's lower dentures were reported missing. There was no documented evidence that the facility initiated a timely dental referral or offered prompt replacement of the missing dentures.Review of the facility's policy titled Dental Services Standard of Practice dated 10/2020 and last reviewed 4/2025, indicated the facility was responsible for assisting residents in obtaining routine and emergency dental services. Further review of the policy revealed residents with lost or damaged dentures should receive prompt dental referrals, and if the facility was responsible for the loss, the facility would incur replacement costs.Review of R3's admission Record revealed she was admitted to the facility on [DATE] with diagnoses of Alzheimer's, cerebral infarction, hemiplegia, and hypertension.Review of R3's Quarterly Minimum Data Set (MDS) with Reason for Assessment (RFA) date of 04/02/2025 revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 10, which indicated R3 was severely cognitively impaired.Review of R3's progress note dated 4/22/2025 at 3:40 PM by RN2 revealed R3 was noted to have missing lower dentures per R3's Responsible Party (RP). The Social Services Director (SSD) was notified, and a Speech therapy evaluation request was placed. Per the progress note, R3 voiced no difficulties experienced with chewing or swallowing at that time.Review of R3's progress note dated 04/23/2026 at 10:47 AM revealed the Interdisciplinary Team (IDT) met to discuss R3 was noted to have missing lower dentures per RP, SSD was notified and Speech therapy request was placed. R3 voiced no difficulties experienced when chewing or swallowing at that time.Review of R3's progress note dated 4/28/2025 at 5:46 PM by the SSD revealed on 04/24/2026, the SSD called R3's responsible party and discussed R3's missing lower dentures. R3 was pending Medicaid, and the contracted dental provider would require full payment prior to replacement of dentures. SSD discussed the situation with Administration and indicated follow-up would occur regarding Medicaid status and cost estimates. Further review of the note revealed the SSD completed a missing item form; however, there was no documentation of a dental referral or that the facility offered to assume financial responsibility.Review of the Grievance/Concern Form dated 04/25/2026 completed by the SSD revealed the SSD had informed R3's RP that the cost of the lower denture replacement would be $1200.00. The SSD further documented the RP agreed to wait for the Medicaid approval before proceeding. However, there is no documentation the RP was informed the facility may be responsible for the replacement costs.During an interview on 04/08/2026 at 10:36 AM with R33's responsible party, she stated she was never informed that the facility would cover any of the cost for the denture replacement. She further stated she was made aware of the cost of the lower denture replacement being $1200.00. She further stated R3 experienced difficulty eating requiring small bites and soft foods after the loss of the lower dentures. Also, the RP did inform the facility that R3 would probably need a full set of dentures after waiting so long for a replacement lower denture.During an interview with the SSD on 04/08/2026 at 2:32 PM she stated she was informed of R3's missing dentures and herself, and other staff searched the room for the dentures. The SSD stated she had a discussion with R3's responsible party and since R3 was private pay and Medicaid was pending the responsible party wanted to wait until Medicaid was approved before getting dental services. SSD further stated she did not inform R3's daughter that the facility could be responsible for the costs for dental services. The SSD further stated the daughter never requested the facility to pay for replacement dentures.During an interview on 04/08/2026 at 5:00 PM with the Administrator, he stated he replaced missing items on a case-by-case basis and acknowledged it would have been best practice to cover the costs of the replacement dentures for R3. The Administrator stated he was unsure if the offer was made to cover the cost of the replacement dentures. He further stated if the family had requested the facility pay for the dentures he would have. Furthermore, the Administrator stated the facility should have offered to cover the cost of R3's dentures.During an interview on 04/08/2026 at 6:00PM with the Senior Administrator, she stated she was made aware of R3's missing dentures. She stated the family or R3 had not made any insinuation that the facility was at fault for the missing dentures. She further stated she felt the facility did what the family wanted as far as waiting for the Medicaid approval so R3 could get a full set. She further stated the inventory sheet on R3, that was normally done on admission with all residents could not be located for R3. Furthermore, the Senior Administrator stated the facility probably should have offered to cover the cost of the dentures.

Based on observation, interview, and record review, it was determined the facility failed to provide the residents with a right to a safe, clean, comfortable, and homelike environment for five of 28 sampled residents (Resident (R)6, R7, R64, R37and R48) on one of three hallways.The findings include:Review of the facility policy titled, Resident Rights undated, revealed the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living. On 07/23/2025 at 10:50 AM, observation of Resident (R)6's room revealed a black substance was on the floor around the baseboard. Continued observation of R6's room revealed three tiles were observed to be cracked in R6's bathroom floor.On 07/24/2025 at 10:48 AM observation of R7's room revealed a black substance on the baseboard of the bathroom. Parts of the baseboard was missing in R7's room around the air condition unit. On 07/24/2025 at 10:54 AM observation of R64's room revealed a black substance on the baseboards of the room. Continued observation revealed baseboards were missing underneath the air condition unit along with a hole in the wall under the bottom of the unit.On 07/24/2025 at 11:08 AM observation of R37's room revealed the wall had a crack in it behind R37's bed along with no baseboard behind the bed. Continued observation revealed a hole in the top of the tub near the faucet. On 07/24/2025 at 11:14 AM observation of the oxygen storage entrance revealed a black substance around the bottom of the door. In an interview with the Maintenance Director on 07/24/2025 at 11:42 AM, he stated When we get a work order, we try to prioritize how important they are, and we try to get them completed within 24 hours. According to the Maintenance Director, all staff had been educated to report any physical plant issues to maintenance, and he was responsible for ensuring that any physical plant issues were repaired. Further, he stated that anyone in the facility could submit a work order for repairs. The Maintenance Director stated that he checks every morning when he comes to work for new work orders. The Maintenance Director stated that he had not received any new work orders and was not aware of any broken or missing tiles, but added it was important to complete needed repairs to keep the residents from falling or getting hurt. During an interview with the Director of Nursing (DON) on 07/24/2025 at 12:13 PM, the DON stated that she was unaware of any black substance on the walls or baseboards of any of the resident rooms. The DON further stated that if there was something like that growing on the walls and baseboards, housekeeping should notify her, and they would have someone come in and look at it to determine what the black substance was and how to treat it. She stated the facility attempts to repair items as quick as possible, adding, We never want any kind of fall or incident to happen due to something we could have prevented. The DON stated her expectation was for staff was to observe for possible dangers within the facility and complete a work order for maintenance to resolve the environmental concerns. The Administrator stated in interview on 07/24/2025 at 12:42 PM that it was his expectation that anytime someone saw anything wrong with the building, they would complete a work order for maintenance to repair concerns identified. The Administrator further stated that residents should always have a clean and safe environment.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five of 28 residents on three of three separate hallways.The findings include: Review of the facility's policy titled, Residents Rights Standards of Practice, origination date 04/2024, revealed the facility would ensure each resident was treated with respect and dignity, and cared for in a manner that promoted maintenance or enhancement of their quality of life. Review of the facility's policy titled, Infection Control, Revised 10/2018, revealed the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage the transmission of diseases and infections. Review of the facility's policy titled, Isolation – Categories of Transmission-Based Precautions, undated, revealed standard precautions were to be used when caring for residents at all times regardless of their suspected or confirmed infection status. Continued review revealed appropriate notification was to be placed on the room entrance door and in the front of the chart so that personnel and visitors were aware of the need for and the type of precaution to be utilized. The signage informed the staff of the type of CDC precaution(s), instructions for use of Personal Protective Equipment (PPE), and/or instructions to see a nurse before entering the room. Review of the facility's policy titled, Hand Hygiene, undated, revealed hand hygiene was required to be performed by staff at medication preparation areas and after contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. Review of the facility's policy titled, Cleaning and Disinfection of Resident Care items and Equipment, revision date 04/2025, revealed resident-care equipment, including reusable items and durable medical equipment, would be cleaned and disinfected to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupation Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. Continued review revealed objects that enter sterile tissue (e.g. urinary catheters), or the vascular system (e.g. intravenous catheters) were considered critical items and must be sterile. Further review revealed respiratory therapy equipment should be free from all microorganisms, although small numbers of bacterial spores were permissible. Review of the Lippincott procedure Manual Nineth Edition revealed maintaining a closed drainage system was essential to minimize the risk of infection. Furthermore, wipe all connecting junctions with alcohol prior to reconnecting tubing. Review of the Enhanced Barrier Precautions signage posted outside of the residents' rooms throughout the survey stated the following: Everyone must clean their hands, including before entering and when leaving the room. 1a. Observation on 07/22/2025 at 8:30 AM revealed oxygen tubing unbagged and, on the floor, and a second oxygen tubing unbagged on a sink in a resident's room. b. Observation, on 07/22/2025 at 9:15 AM, revealed Licensed Practical Nurse (LPN) 1 removed medications from the packet and placed the medications in his/her ungloved hands before placing the medications into a container to administer the medications to a resident. In an interview with LPN1, on 07/23/2025 at 8:16 AM, LPN1 stated she should not have placed medications into her ungloved hands, adding, that was an accident. LPN1 continued to state not following proper infection control protocols could spread infections that could make residents sick, cause them to be hospitalized , or die. c. Review of R7's admission Face Sheet revealed resident was admitted on 0611/2025 with corticobasal deterioration, dementia, and urinary tract infection (UTI). Review of R7's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/2025, revealed a Brief Interview for Mental Status (BIMS) score of 3 of 15, which indicated moderately impaired cognition. Review of R7'2 Physician order dated 07/07/2025 revealed R7 was on contact precautions due to a UTI. During observation on 07/22/2025 at 9:25 AM, with Licensed Practical Nurse (LPN)4 and State Registered Nurse Aide (SRNA) 5, entered the room of R7 due to R7 partially sliding out of bed onto fall mat. R7 was noted to have enhanced barrier precaution signage outside the room door. LPN4 and SRNA 5 entered the room with gloves only. R7 was also noted to have had a bowel movement and had pulled brief partially off. Both LPN4 and SRNA5 continued to provide care with gloves only. Further observation revealed R7 had pulled the foley catheter from the drainage tubing. The foley was still in place to R7, the disconnected end was lying in the bed under the resident. LPN4 was noted to pick up the drainage tubing, and catheter end and reconnect without cleaning ends. During an interview on 07/23/2025 at 8:13 AM with LPN4 she stated she was aware she should have followed the Enhanced Barrier Precautions that included handwashing prior to entering the room, donning gown, and then handwashing following care. LPN 4 further stated she was in a pressing matter and needed to rush due to R7 sliding out of bed. Further interview with LPN4 she stated she should not have reconnected the foley catheter back to drainage tubing prior to cleaning. LPN4 stated not following the infection control precautions could cause infection to spread others. She further stated she had been educated on infection control. During an interview on 07/23/3035 at 2:40 PM with SRNA5, she stated she was aware she needed to use appropriate Personal Protection Equipment (PPE) and follow the enhanced barrier precautions as indicted on the signage but felt the resident safety was most important at the time she entered the room, and he was sliding out of the bed. She stated not donning appropriate PPE could cause spread of infection to other residents. During an interview on 07/24/2025 at 11:48 AM with the Director of Nursing (DON) she stated the facility followed the Lippincott Manual guidelines for foley catheter care and did not have a policy for urinary catheter change and care. She further stated she expected staff to follow aseptic technique with d. Observation, on 07/22/2025 at 11:37 AM, revealed Respiratory Therapist (RT) 1 entered resident rooms with Enhanced Barrier Precaution signage posted on the entrance door and changed residents' oxygen tubing without washing their hands before entering or after exiting the resident room. During an interview, on 07/23/2025 at 3:20 PM, RT1 stated when he changed oxygen tubing, he did not wash his hands before entry or after exiting the room, regardless of whether the room had contact precaution signage or enhanced barrier precaution signage. RT1 stated not following proper infection control policies could lead to the spread of viruses to residents. RT1 stated he was not aware of the facility's infection control policies. e. Observation and interview, on 07/23/2025 at 5:35 AM, revealed Certified Nursing Assistant (CNA) 1 exited a resident's room with Enhanced Barrier Precautions signage on the door while wearing an isolation gown. During an interview, CNA1 stated she should have removed her isolation gown prior to exiting the resident's room. CNA1 further stated she had received education on infection control and not removing her gown in the resident's room could spread germs to other residents. During an interview, on 07/23/2025 at 6:20 AM, LPN2 stated staff were in a hurry this morning, and she would not be surprised that staff were not wearing PPE when performing resident care in a room marked with Enhanced Barrier Precautions. LPN2 continued to state that not following proper infection control policies could allow infections to spread between residents and staff, leading to sickness or death. The Regional Quality Nurse 1 stated in interview on 07/23/2025 at 10:00 AM, she had not performed staff training at the facility. Further, the Regional Quality Nurse 1 stated she would not have expected staff entering or exiting an enhanced barrier precaution room to wash their hands if they did not have direct contact with a resident, even though the facility signage stated everyone should wash their hands before entry and after exiting the resident's room. During an interview, on 07/23/2025 at 1:53 PM, the Wounds Nurse 1 stated medications should never be touched with bare hands as it could lead to widespread infection issues that could result in sickness, hospitalization, and death. The Infection Preventionist stated in interview, on 07/23/2025 at 2:47 PM, it was his expectation for staff to wash their hands before and after changing oxygen tubing, to prevent infections, such as pneumonia, which could happen if staff did not follow correct infection control protocols. The Infection Preventionist stated it was his expectation for all staff to follow infection control protocols to ensure the safety of residents. During an interview, on 07/24/2025 at 11:48 AM, the Director of Nursing (DON) stated she conducted walkthroughs of the facility to ensure staff were following infection control policies and she had seen staff being noncompliant with protocols, such as proper hand hygiene. The DON continued to state proper infection control protocols not being followed could lead to mass infection outbreaks that could lead to the death of residents. The DON stated she expected all facility staff to follow all policies and protocols. The Administrator stated in interview, on 07/24/2025 at 11:31 AM, that if staff did not follow proper infection control protocols, it could lead to a global transmission of infection that could spread to residents, staff, or visitors, and depending on the resident's comorbidities, could lead to any number of negative outcomes. The Administrator stated it was his expectation for all staff to follow all policies and protocols set forth by the facility.

44974 47852 Based on observation, interview, and record review, it was determined the facility failed to ensure the residents were given the appropriate treatment and services to maintain personal hygiene-bathing for five of 27 sampled residents, Resident (R) 36, Resident 55, Resident 64, Resident 79, Resident 84. Review of a facility policy, titled Activities of Daily Living (ADLs), dated 10/2020, revealed the facility would provide care and services for the following ADLs: hygiene (bathing, dressing, grooming, oral care). According to the policy, any resident who was unable to carry out ADLs would receive the necessary services to maintain good nutrition, grooming, and personal/oral hygiene. The policy failed to include specifics related to the provision of these services. Review of an undated Shower List revealed each resident was scheduled to receive two showers per week. Further review of the schedule revealed that the determination of the schedule was based on the resident's room number. 1.Review of (Resident (R)79's) Admission Face Sheet revealed the facility admitted the resident on 05/10/2024 with the diagnoses including cerebral infarction due to embolism of unspecified precerebral artery, mood disorder due to known physiological condition, secondary hypertension, and weakness. Review of R79's Minimum Data Set with an Assessment Reference Date (ARD) of 05/15/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS documented that it was very important for the resident to choose between baths and showers, and that the resident needed partial/moderate assistance from staff for bathing. Review of the resident's care plan revealed a goal with a target date of 11/19/2024 for the resident to be clean, dry and odor free through the next review. The care plan further documented that hygiene care would be provided daily and as needed with a 5/28/2024 start date. Review of the facility's undated Shower Schedule AB Unit provided by the Senior Administrator on 10/07/2024, revealed R79 was supposed to receive a shower twice a week (during day shift on Mondays/Thursdays). Review of the shower sheet in the Electronic Medical Record (EMR) revealed staff were to document each day that either a bath was given, a shower was given, the activity did not occur, or the resident refused care. Review of R79's shower sheets from 09/01/2024 through 10/08/2024 revealed no evidence of showers or baths between 09/01/2024 - 09/18/2024, or 09/30/2024 - 10/08/2024. Review of the shower sheets revealed that R79 had refused a shower on 09/02/2024 and 10/03/2024. During an interview with R79 on 10/07/2024 at 3:21 PM, R79 stated he refused his shower after staff woke him up at midnight to shower. R79 further stated that staff marked his shower as a refusal and did not offer to reschedule it the next day. Observation of R79 on 10/07/2024 at 3:21 PM revealed the resident had a noticeable body odor. The resident's hair was flattened to the back of his head and appeared to be oily. An interview with R79 during this observation revealed that showers were not routinely offered twice a week per shower schedule, or during the scheduled shift of 7AM -7PM. R79 stated staff frequently wake him after midnight for his shower and that made him very upset. R79 further stated that he did not want family or friends to visit him when he couldn't get a shower because he knew how bad he smelled. R79 added that he is not a nasty person and liked to be clean. Observation of R79 on 10/08/2024 at 09:15 AM revealed the resident had a noticeable body odor. The resident's hair was flattened to the back of his head and appeared to be oily. During an interview with R79 during this observation he stated he still had not had a shower since 09/30/2024 and I can smell myself. Observation of R79 on 10/09/2024 at 5:05 PM revealed the resident had a noticeable body odor. The resident's hair was flattened to the back of his head and appeared to be oily. During an interview with R79 during observation he stated that he felt nasty when he didn't get a shower and liked to be clean every day. R79 added that he thought the facility should at least offer him a bed bath if they couldn't assist him with a shower. R79 further stated he had missed activities before because he felt too nasty to attend. 2. Review of R36's Admission Face Sheet revealed the facility admitted the resident on 07/06/2023 with diagnoses including multiple sclerosis, quadriplegia, contracture to the left elbow, muscle weakness, major depressive disorder, pressure ulcer to the left hip and sacral area, anxiety disorder, psychophysiologic insomnia, and a neuromuscular dysfunction of the bladder. Review of R36's Minimum Data Set with an Assessment Reference Date (ARD) of 09/15/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS documented that it was somewhat important for the resident to choose between baths and showers, and that the resident was dependent on staff for bathing. Review of the resident's care plan revealed an intervention for resident to use the shower bed for all baths with a 4/30/2024 start date. Review of the facility's undated Shower Schedule CDE Unit provided by the Senior Administrator on 10/07/2024, revealed R36 was supposed to receive a shower twice a week (during day shift on Tuesdays/Fridays). Review of the shower sheet in the Electronic Medical Record (EMR) revealed staff were to document each day that either a bath was given, a shower was given, the activity did not occur, or the resident refused care. Review of R36's shower sheets from 09/01/2024 through 10/08/2024 revealed no evidence of showers or baths between 09/10/2024-09/15/2024, and 09/24/2024-10/09/2024. Review of these shower sheets revealed that for each day when no shower/bath was provided, staff documented that the activity did not occur. Review of R36's Nurse Progress Note dated 10/01/2024 at 4:05 AM revealed resident refused bed bath and said, I don't like a bed bath, I'm not taking a bed bath until all my antibiotics are done then I will start taking my showers again. Observation of R36 on 10/07/2024 at 1:15 PM revealed the resident had a noticeable body odor. The resident's hair was flattened to the back of his head and appeared to be oily. Observation of R36 on 10/08/2024 at 3:50 PM revealed the resident had a noticeable body odor. The resident's hair was flattened to the back of his head and appeared to be oily. During an interview with R36 during this observation he stated that I have to make them shower me. R36 further stated that the staff only wants to give him a bed bath because it takes two people to shower me, and they don't always have enough staff to do it. During an interview with R36 on 10/09/2024 he stated that the staff had been refusing to shower him because he was in isolation due to a urinary tract infection. R36 further stated that staff told him he could not go to the shower room until he completed his antibiotics. R36 added that he had felt gross and dirty this week. R36 also stated that he did not feel clean after taking a bed bath and that is why he preferred a shower. 3. Review of R64's Admission Face Sheet revealed the facility admitted the resident on 11/02/2022 with diagnoses including listerial sepsis, nicotine dependence, alcohol abuse, type 2 diabetes mellitus, depression, congestive heart failure, chronic atrial fibrillation, and chronic obstructive pulmonary disease. Review of 64's Minimum Data Set with an Assessment Reference Date (ARD) of 09/04/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS documented that it was somewhat important for the resident to choose between baths and showers, and that the resident required partial/moderate assistance from staff for bathing. Review of the facility's undated Shower Schedule CDE Unit provided by the Senior Administrator on 10/07/2024, revealed R64 was supposed to receive a shower twice a week (during night shift on Tuesdays/Fridays). Per the shower sheet in the Electronic Medical Record (EMR), staff were to document each day that either a bath was given, a shower was given, the activity did not occur, or the resident refused care. Review of R64's shower sheets from 09/01/2024 through 10/04/2024 revealed no evidence of showers or baths between 09/06/2024 - 09/23/2024. Review of the shower sheets revealed that R64 had a partial bath on 09/07/2024, and 09/13/2024. During an interview with R64 on 10/09/2024 at 8:40 AM he stated he had gone four weeks without a shower in the past due to staff waking him up after midnight to shower. R64 further stated that staff marked his shower as a refusal and did not offer to reschedule it the next day. Observation of R64 on 10/08/2024 at 8:56 AM and 10/09/2024 at 8:40 AM revealed a strong body odor scent. R64 stated during the observation that neither him nor his roommate had not been offered a shower in days. During an interview with R64 on 10/09/2024 at 5:18 PM R64 stated that he did not like being dirty or smelling bad. R64 further stated that this embarrassed him when he was around other residents. During an interview with Certified Nursing Aide (CNA) 8 on 10/10/2024 at 10:13 AM a partial bath was marked when staff cleaned the resident's face, arm pits, and peri area of the body. Review of the facility's undated Partial Bed Bath (assisting resident with bath) form it revealed that a partial bath was the cleaning of the entire body except the resident's hair, applying deodorant and lotion, and providing the resident with clean clothes. During an interview with CNA 12 on 10/11/2024 at 12:50 AM she stated that the facility does not always have enough staff to do all the scheduled showers. CNA 12 further stated that the facility had to have at least six CNAs on night shift to complete all their task and showers. 4. Review of R 84's Admission Face Sheet revealed R84 was admitted on [DATE] with diagnoses of Hemiplegia and hemiparesis following intracerebral hemorrhage affecting the left side, Atherosclerotic heart disease, and central pain syndrome. Review of R84's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/10/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R84 was cognitively intact. Further review of the MDS section GG-Functional Abilities and Goals, revealed R84 was dependent with shower/bathing self, and toileting hygiene. Review of R84's Comprehensive Care Plan (CCP) dated 09/16/2024 revealed a self-care deficit as evidenced by the need for total assist with bathing, dressing lower body, mobility, related to left hemiplegia and additional risk for decline, and additionally R84 preferred no male caregivers. Interventions included grooming/dressing, and oral care, and incontinent care as needed. Goals were that R84 would be washed, dressed and free from symptoms of pain times 90 days. There was no documentation of resident centered goals for shower/bath or frequency. Further review of the CCP, dated 09/16/2024, revealed a behavior related to declination of showers and refusal of therapy with interventions of allowing the resident time to verbalize feelings, social worker to visit and encourage resident to follow physician orders. During an interview, on 10/08/2024 at 4:49 PM with R84, he stated he was supposed to get a shower or bed bath at least twice weekly, but only got one when he really needed a bath. R84 further stated the staff have come into his room late at night, not sure of time, asked if he wanted a shower, and he told staff it was too late. R84 stated if he refused a shower or bath, he had to sign a paper saying he refused. R84 further stated I don't refuse a shower or bath unless its late at night. During an interview, on 10/09/2024 at 8:52 AM with R84, he stated when staff came into the room, they would not listen to him when he requested assistance. R84 further stated when the Certified Nursing Assistant (CNA) (unknown) brought his breakfast tray in, just minutes before State Surveyor Agent (SSA) entered the room, R84 had told CNA he was soiled and needed his brief changed. R84 stated she just said OKAY and left the room. R84 pressed his call light for assistance at 8:53 AM. The SSA observed the Registered Nurse (RN) 1, on 10/09/2024 at 8:54 AM, step into R84's room, spoke with him briefly and turned off the call light. Continued observation, on 10/09/2024 at 8:57 AM, revealed the Infection Preventionist (IP) 1 (male), coming down hallway. The IP1 stated I thought a call light needed answered. LPN 4 stated No. I don't see a light on. RN1 did not say anything, and, as the IP started to walk away, the SSA informed him R84 needed assistance. The IP1 was then informed by RN1 that R84 needed assistance. The IP1 stated R84 would not let him provide care. Continued observation on 10/09/2024 at 9:01 AM revealed IP2 at R84's doorway. R84 informed IP2 he needed changed. IP2 went down hallway to get someone to assist R84. Continue observation on 10/09/2024 at 9:06 AM revealed CNA 7 came to R84's room, and IP2 also went into the room and closed the door to change R84. During an interview on 10/09/2024 at 9:25 AM, R84 stated he felt much better, and he didn't have to lay all day in a wet brief. R84 further stated sometimes it was 3-4 hours before someone came to change him. During an interview on 10/10/2024 at 3:54 PM, R84 stated he was informed his shower day was changed and he did not know what days he was supposed to have a shower. R84 stated the last shower he remembered was approximately 2 weeks ago when he was on another hallway. During an interview on 10/11/2024 at 6:30 AM, R84 stated he was not offered a shower yesterday or last night. R84 further stated CNA5 told him on 10/10/2024 that she was off on 10/11/2024, but would try to get him on the shower list for yesterday. During an interview on 10/11/2024 at 9:30 AM, R84 stated he was not offered a shower/bath last night and did not receive a bed bath. R84 further stated CNA11 had came in and changed his brief and cleaned him after he had a bowel movement. R84 further stated if they said I refused that is not true, I do not like being lied on, I did not refuse a shower. During an interview on 10/11/2024 at 2:54 PM, R84 stated his roommate had just been brought back from getting a shower. R84 stated he asked the CNA(unknown) if he was getting a shower next and she stated to him she wasn't sure that someone else had been added to the list. 5. Review of R55's Admission Face Sheet revealed the facility admitted the resident on 05/03/2024 with diagnoses which included right femur and spine fractures, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF). Review of R55's Quarterly MDS assessment, dated 09/13/2024, revealed a BIMS score of 15 out of 15, which indicated R55 was cognitively intact. Further review of the MDS section GG-Functional Abilities and Goals revealed the facility assessed R55 to require substantial/maximal assistance with showering or bathing self and toileting hygiene. Review of R55's CCP, dated 12/21/2021, revealed the facility assessed R55 to have a self care deficit as evidenced by diagnoses of respiratory failure, COPD and CHF. Interventions included for staff to provide assistance with the Activities of Daily Living (ADL) and oral mouth care every shift and as needed. Further review revealed no documentation of resident centered goals for shower/bath or frequency for R55. Review of the CCP dated 07/25/2022 revealed a behavior related to declination of showers with interventions to encourage the resident to follow physician orders and allow personal hygiene. During an interview, on 10/11/2024 at 9:30 AM, R55 stated she did not receive her scheduled bath/shower on 10/10/2024 because staff came in about 10:00 PM to offer the shower, she had already gone to bed for the evening and I wasn't getting up once I went to bed. R55 further stated staff often try to bathe/shower her after she has gone to bed for the night and, if she refuses, staff do not offer to bathe/shower her at other times and she loses one (1) of her weekly showers. During an interview on 10/11/2024 at 3:30 PM, the Director of Nursing (DON) stated she conducted random shower/bath audits. The DON stated her expectation was for showers/bathing to be provided to residents to maintain hygiene. The DON further stated a new shower sheet was provided to her on Monday from either the Wound Care nurse or the Unit Manager and the DON was told it was initiated by the Administrator. The DON stated she preferred the resident sign the shower sheets, so she knew they did refuse. The DON further stated the process they follow was, if a resident refused 1-2 times, a note was put in by the nurse on the floor. The note would be pulled by the DON and taken to the Interdisciplinary team meeting (IDT) every morning. The DON would then add the resident back to the list to see if maybe the time the bath was offered was wrong. The DON stated staff had not been documenting why a resident refused a shower until the past week or so. The DON further stated it was the responsibility of the IDT to talk to the Resident to see why a shower was refused. The DON stated she followed up to see why the shower was refused. According to the DON, shower sheets should have the reason why a shower was refused and the nurse should sign the document. The DON stated the process for refusal of the shower was the nurse was required to confirm the refusal with the resident, then document the findings in a progress note. The IDT then reviewed and added interventions to the care plan. During an interview 10/07/2024 at 11:40 AM with the Senior Administrator she said showers were literally given all day. The Administrator further stated that the facility was in the process of adjusting shower schedule to avoid late hour showers. Additional interview with the Senior Administrator and Administrator on 10/10/2024 at 4:05 PM revealed that the Senior Administrator had worked on a new shower schedule yesterday and instructed staff to start it today. She stated that currently the new shower schedule was based off the room number but would be tweaked in the upcoming days to reflect the resident's shower preference. Both Administrators stated that it was not their expectation for residents to be woke up for showers after 11 PM or marked as a refusal if this occurred. During an interview on 10/11/2024 at 6:45 PM, the Interim Administrator stated her expectation was for residents to receive hygiene/showers as scheduled and should be clean and neat without odor. The Interim Administrator stated any refusals should be addressed as a team to discern a reason for the refusals. The Interim Administrator further stated R84 had been offered a schedule change in September, and the facility did a Performance Improvement Plan (PIP) for the shower process. The Interim Administrator stated several residents did not want a shower at night. During an interview on 10/11/2024 at 7:12 PM, the Medical Director stated his expectation was that residents receive regular showers/baths and be kept clean. The Medical Director further stated if a resident was refusing care, then there should be documented evidence and follow up to find reason for refusal of personal care and the resident should be accommodated as much as possible.

44974 The facility failed to have an effective system to ensure that all resident care plans were updated and revised to include individualized interventions for four of 27 sampled residents (Resident #36, Resident #64, Resident #79, and Resident #84). Review of Comprehensive Care Plans Standard of Practice dated 10/2020 revealed that each resident's comprehensive care plan is designed to identify problem areas, incorporate risk factors associated with identified problems, build on the resident's strengths, reflect the resident's expressed wishes regarding care and treatment goals, reflect treatment goals, timetables, and objectives in measurable outcomes. 1.Review of (Resident (R)79's) Admission Face Sheet revealed the facility admitted the resident on 05/10/2024 with the diagnoses including cerebral infarction due to embolism of unspecified precerebral artery, mood disorder due to known physiological condition, secondary hypertension, and weakness. Review of R79's Minimum Data Set with an Assessment Reference Date (ARD) of 05/15/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS documented that it was very important for the resident to choose between baths and showers, and that the resident needed partial/moderate assistance from staff for bathing. Review of R79's Comprehensive Care Plan (CCP) revealed that R79 has a goal to have his ADL needs met through the next review on 11/19/2024. Review of R79's CCP interventions further revealed to adjust R79's daily routine as needed to promote independence, encourage resident to participate to his ability, incontinent care as needed, resident may have personal items at bedside, to notify the MD, family/responsible party of changes as needed, PT and OT as needed, and resident may use upright walker for assistance. There is no evidence that the facility created a person-centered care plan that addressed the resident's shower time preference, assistance needed by staff, or that the resident prefers a female staff member to bath him. Observation of R79 on 10/07/2024 at 3:21 PM revealed the resident had a noticeable body odor. The resident's hair was flattened to the back of his head and appeared to be oily. An interview with R79 during this observation revealed that showers were not routinely offered twice a week per shower schedule, or during the shift he prefers. R79 stated staff frequently wake him after midnight for his shower and that made him very upset. R79 further stated that he did not want to get out of his warm bed during the night for a shower. Observation of R79 on 10/08/2024 at 09:15 AM revealed the resident had a noticeable body odor. During an interview with R79 during this observation he stated he had refused showers in the past due to the sex of the CNA performing the shower. R79 added that on admission he requested to only have females assist with his bathing. Observation of R79 on 10/09/2024 at 5:05 PM revealed the resident had a noticeable body odor. The resident's hair was flattened to the back of his head and appeared to be oily. During an interview with R79 during observation he stated that he felt nasty when he didn't get a shower and liked to be clean every day. R79 added that he thought the facility should at least offer him a bed bath if they couldn't assist him with a shower. R79 further stated he had missed activities before because he felt too nasty to attend. 2. Review of R36's Admission Face Sheet revealed the facility admitted the resident n 07/06/2023 with diagnoses including multiple sclerosis, quadriplegia, contracture to the left elbow, muscle weakness, major depressive disorder, pressure ulcer to the left hip and sacral area, anxiety disorder, psychophysiologic insomnia, and a neuromuscular dysfunction of the bladder. Review of R36's Minimum Data Set with an Assessment Reference Date (ARD) of 09/15/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS documented that it was somewhat important for the resident to choose between baths and showers, and that the resident was dependent on staff for bathing. Review of the resident's care plan revealed an intervention for resident to use the shower bed for all baths with a 4/30/2024 start date. Review of R36's Nurse Progress Note dated 10/01/2024 at 4:05 AM revealed resident refused bed bath and said, I don't like a bed bath, I'm not taking a bed bath until all my antibiotics are done then I will start taking my showers again. Observation of R36 on 10/07/2024 at 1:15 PM revealed the resident had a noticeable body odor. The resident's hair was flattened to the back of his head and appeared to be oily. Observation of R36 on 10/08/2024 at 3:50 PM revealed the resident had a noticeable body odor. The resident's hair was flattened to the back of his head and appeared to be oily. During an interview with R36 during this observation he stated that I have to make them shower me. R36 further stated that the staff only wants to give him a bed bath because it takes two people to shower me, and they don't always have enough staff to do it. Review of R36's Comprehensive Care Plan (CCP) revealed that R36 has a goal to remain free from any unidentified ADL changes through the next review on 12/22/2024. Review of R36's CCP interventions further revealed to provide incontinent care as needed, to notify the MD, family/responsible party of changes as needed, PT and OT as needed, and for resident to use shower bed for all baths. There is no evidence that the facility created a person-centered care plan that addressed the resident's shower time preference, assistance needed by staff for transferring to shower bed, or the assistance needed for bathing. 3. Review of R64's Admission Face Sheet revealed the facility admitted the resident on 11/02/2022 with diagnoses including listerial sepsis, nicotine dependence, alcohol abuse, type 2 diabetes mellitus, depression, congestive heart failure, chronic atrial fibrillation, and chronic obstructive pulmonary disease. Review of 64's Minimum Data Set with an Assessment Reference Date (ARD) of 09/04/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. The MDS documented that it was somewhat important for the resident to choose between baths and showers, and that the resident required partial/moderate assistance from staff for bathing. Review of the facility's undated Shower Schedule CDE Unit provided by the Senior Administrator on 10/07/2024, revealed R64 was supposed to receive a shower twice a week (during night shift on Tuesdays/Fridays). Per the shower sheet in the Electronic Medical Record (EMR), staff were to document each day that either a bath was given, a shower was given, the activity did not occur, or the resident refused care. During an interview with R64 on 10/09/2024 at 8:40 AM he stated he had gone four weeks without a shower in the past due to staff waking him up after midnight to shower. R64 further stated that he does not like to take late showers. During an interview 10/07/2024 at 11:40 AM with the Senior Administrator she stated that the residents plan of care should reflect the resident's shower schedule, time preferences, assistance needed for bathing and transferring to the shower bed or chair, and if the resident has a male or female preference. 4. Review of Resident(R) 84's Admission Face Sheet revealed R84 was admitted on [DATE] with diagnoses of Hemiplegia and hemiparesis following intracerebral hemorrhage affecting left side, Atherosclerotic heart disease, and central pain syndrome. Review of R84's Admission Minimum Data Set (MDS) assessment with a Assessment Reference Date (ARD) of 09/10/2024 revealed a Brief Interview for Mental Status (BIMS) score of fifteen of fifteen, which indicated R84 was cognitively intact. Further review of the MDS section GG-Functional Abilities and Goals, revealed R84 was dependent with shower/bathing self, and toileting hygiene. Review of section GG-further revealed R84 was dependent with transferring from bed to chair, and required assist of 2. Review of R84's Comprehensive Care Plan (CCP) dated 09/16/2024 revealed a self-care deficit as evidenced by the need for total assist with bathing, dressing lower body, mobility, related to left hemiplegia and additional risk for decline, and additionally R84 preferred no male caregivers. Interventions included grooming/dressing, and oral care, and incontinent care as needed. Goals were that R84 would be washed, dressed and free from symptoms of pain times ninety days. However, there was no documented evidence of resident centered goals for shower/bath or frequency. Further review of R84's care plan revealed there was no documented evidence that resident required assist of 2 persons and a hoyer lift for transfers. Further review of the CCP dated 09/16/2024 revealed a behavior as related to declination of showers and refusal of therapy with interventions of allowing resident time to verbalize feelings, social worker to visit and encourage resident to follow physician orders. During an interview on 10/08/2024 at 4:49 PM with R84, he stated he is supposed to get a shower or bed bath at least twice weekly, but only gets one when he really needs a bath. He further stated the staff have come into his room late at night, not sure of time and asked if he wanted a shower and he told staff it was too late. He stated if he refused a shower or bath, he had to sign a paper saying he refused. R84 further stated I don't refuse a shower or bath unless its late at night. During an interview on 10/11/2024 at 6:45 PM with the Interim Administrator stated the Care Plans should be person centered. She further stated Care plans could be updated by any nurse or administrative discipline. In September department managers started asking residents their preferences. As far as showers being specific on the Care Plan the facility had not addressed that area yet. During an interview on 10/11/2024 at 7:12 PM with the Medical Director he stated he expected the resident care plans be resident centered with their preferences to give the resident as much control possible with their choices.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Review of the undated facility's policy, titled Hand Hygiene, revealed hand hygiene was described as cleaning your hands by using either handwashing, antiseptic hand wash, or antiseptic hand rub and was to be performed before and after glove use in the facility. Review of the facility's policy, titled Policies and Practices-Infection Control, revised October 2018, revealed the policy was intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Continued review of the policy revealed two of the objectives were to prevent, detect, investigate, and control infections in the facility and to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. 1. On 10/08/2024 at 8:15 AM, observation of LPN3 revealed she did not clean her hands before putting on gloves after touching a doorknob on the supply room door. During an interview with LPN3 on 10/08/2024 at 8:24 AM, LPN3 stated she knew she was supposed to clean her hands before putting on her gloves after touching the supply room doorknob but got nervous and forgot. LPN3 stated the risk for not performing good hand hygiene was spreading germs to residents and potentially giving herself an infection as she couldn't say who else had touched the doorknob. 2. On 10/11/2024 at 6:15 AM, during a tour of the facility, one pack of unopened briefs was observed lying on the floor in room [ROOM NUMBER]. During an interview with Certified Nursing Assistant (CNA) 12, on 10/11/2024 at 6:25 AM, CNA12 stated she was not sure who passed the briefs and they should have been put in the resident's closet, not lying in the floor. CNA12 further stated the briefs were contaminated and an infection control issue and should not be used on a resident. During an interview with Kentucky Medication Aide (KMA) 1, on 10/11/2024 at 6:25 AM, KMA1 stated the briefs were a fall risk for anyone entering or exiting room [ROOM NUMBER]. KMA1 further stated she was not sure who passed the briefs, but they should not be lying in the floor. During an interview with the Infection Preventionist (IP) on 10/11/2024 at 12:05 PM, the IP stated all staff should be using hand hygiene before and after putting on gloves as it was in the policy and all staff should follow the policies. The IP stated the risk for not using proper hand hygiene was the spread of infection, which could cause both residents and staff to get sick. The IP stated that briefs should never be left on the floor, whether they were opened or unopened, as it was not sanitary and could spread germs and bacteria throughout the facility. During an interview with the Director of Nursing (DON) on 10/11/2024 at 3:28 PM, the DON stated she expected her nursing staff to follow the facility policies, especially during direct care with the residents. The DON stated briefs should never be left on the floor even if unopened because of possible germs on the floor. The DON stated all of these infection control issues were discussed during the infection control training, which was just done on 09/23/2024. The DON stated the risk of anybody in the facility not utilizing good hand hygiene was the spread of infection, which could cause sickness to both staff and residents. The DON stated she made rounds daily on the hallways and if she saw an issue with infection control, then she educated either the staff or resident on good hand hygiene and the importance of washing hands. During an interview with the Administrator on 10/11/2024 at 6:45 PM, the Administrator stated she expected all staff to follow the policies and procedures of the facility. The Administrator stated if staff didn't use hand hygiene, then infection could spread and harm residents and staff. The Administrator stated she expected when briefs were passed to store them properly and not just put them on the floor as that went against the facility's infection control policy. The Administrator stated staff were educated on infection control during orientation and at least annually thereafter. The Administrator stated infection control had just been reviewed for all staff recently on 09/23/2024. The Administrator stated disciplinary action would occur if a staff member continued to be noncompliant with the policy.

Based on observation, interview, and record review, the facility failed to ensure all residents with gastrostomy tubes had their nutritional needs met and the administration of enteral nutrition was consistent with and followed the practitioner's orders for one (1) of 27 sampled residents, Resident (R) 74. Review of the facility's policy, Nutrition/Hydration Status Maintenance, dated 10/2020, revealed the facility would ensure, based on a resident's comprehensive assessment, a resident who demonstrated sufficient intake alone or with assistance was not fed by enteral methods unless the resident's clinical condition demonstrated enteral feeding was clinically indicated. Review of the facility's policy, Weight Process Standard of Practice, dated 07/2020, revealed the facility would provide nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment. The findings include: Observation, on 10/08/2024 at 3:05 PM, revealed R74 up in his wheelchair, with tube feeding disconnected. Further observation revealed a 1000 milliliter (ml) bottle of formula, dated 10/07/2024 at 10:00 PM, with 480 ml remaining in the bottle. Observation, on 10/09/2024 at 3:52 PM, revealed R74 out of his room with tube feeding disconnected and pump, tubing and bottle of formula hanging to bedside. Observation, on 10/09/2024 at 5:20 PM, revealed R74 up in his wheelchair, with tube feeding disconnected. Further observation revealed a 1000 milliliter (ml) bottle of formula, dated 10/09/2024 at 6:00 AM, with 500 ml remaining in the bottle. Observation, on 10/10/2024 at 1:38 PM, revealed R74 out of his room with tube feeding disconnected and pump, tubing and bottle of formula hanging to bedside. Review of R74's Admission Face Sheet revealed the facility admitted the resident on 09/19/2023 with diagnoses which included esophageal obstruction, gastro-esophageal reflux disease with esophagitis, and acute kidney failure. Review of R74's Physician's Orders, dated 06/26/2024, revealed an order for water per gastrostomy tube (GT) at 53 ml/hour for 22 hours per day. Review of R74's Physician's Orders, dated 08/09/2024, revealed an order for pureed diet with nectar thick liquids comfort foods and thin water and ice chips. Review of R74's Physician's Orders, dated 08/26/2024, revealed an order for formula per tube at 75 ml/hour for 22 hours a day. In an interview with R74, on 10/08/2024 at 3:05 PM, he stated when staff assisted him from his bed to his wheelchair in the morning, they disconnected his tube feeding and it was typically not reconnected until bedtime when he went back to bed. He further stated some days he went without his tube feeding connected from 7:00 AM to 9:00 PM or 10:00 PM. He continued to state he wasn't sure how much of his nutritional needs were being met, and he did eat food by mouth some days, but not every day. In an interview with Licensed Practical Nurse (LPN) 8, on 10/09/2024 at 5:15 PM, she stated she did not normally work on that hall and believed R74's tube feeding was bolus and he unhooked himself from the feeding often. She further stated she was responsible for R74's care during that shift, but she did not work on his unit often. She continued to state she was unaware R74 had a physician's order for a continuous G-tube feeding instead of a bolus. In an interview with the Dietician, on 10/11/2024 at 2:35 PM, she stated she started as the facility Dietician in August 2024. She further stated she ran reports for the weekly weight meetings which triggered for significant weight changes but did not keep a calorie count on R74. She continued to state she was unsure how many calories R74 received each day and based her recommendation for formula of 75 ml/hour for 22 hours a day on the resident's nutritional needs. Additionally, she stated she was not sure how much of the feeding the resident received and she was aware he unhooked himself from the feeding periodically. She stated she had not completed any calorie counts for residents since she started as the Dietician. She further stated she was responsible for completing the Swallowing/Nutritional Status section of the resident's Minimum Data Set, which required a percentage of nutrition the resident received from tube feeding in relationship to overall nutrition. In an interview with the Director of Nursing (DON), on 10/11/2024 at 3:28 PM, she stated the facility did not complete calorie counts and used resident weights to determine resident's nutritional status. She continued to state residents who received tube feedings were discussed in the weekly weight meetings and R74's weight was stable. In an interview with the Administrator, on 10/11/2024 at 6:45 PM, she stated she expected staff to follow physician orders and to report to the physician if orders could not be followed so the physician could change the orders if needed. In an interview with the Medical Director, on 10/11/2024 at 7:12 PM, he stated it was his expectation for staff to follow all physician orders and notify him if they had trouble following the orders so treatment could be changed if necessary. He continued to state residents' health conditions could be negatively affected if physician orders were not followed, he treated residents based upon the current orders, and needed to be aware of any deviation from those orders to give the best care possible.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure an accurate assessment for one (1 ) of 27 sampled residents, Resident (R) 74. The facility assessed R74, on a Quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/17/2024, to have received 51% or more of proportion of total calories the resident received through parenteral or tube feeding. However, there was no evidence the facility completed a calorie count to determine the amount of nutrition the resident received from either tube feeding or intake by mouth. The findings include: Review of the RAI manual, dated 10/2024, revealed the steps for assessment of proportion of total calories the resident received through parenteral or tube feeding included review of intake records within the last 7 days to determine actual intake through parenteral or tube feeding routes and calculate the proportion of total calories received through these routes; if the resident had more substantial oral intake than sips of fluids, consult with the dietician who totaled their calories per day. The MDS was coded for a proportion of total calories the resident received through parenteral or tube feeding. Observation, on 10/08/2024 at 3:05 PM, revealed R74 up in his wheelchair, with tube feeding disconnected. Observation, on 10/09/2024 at 3:52 PM, revealed R74 out of his room with tube feeding disconnected and pump, tubing and bottle of formula hanging to bedside. Observation, on 10/09/2024 at 5:20 PM, revealed R74 up in his wheelchair, with tube feeding disconnected. Observation, on 10/10/2024 at 1:38 PM, revealed R74 out of his room with tube feeding disconnected and pump, tubing and bottle of formula hanging to bedside. Review of R74's Admission Face Sheet revealed the facility admitted the resident on 09/19/2023 with diagnoses which included esophageal obstruction, gastro-esophageal reflux disease with esophagitis, and acute kidney failure. Review of R74's Physician's Orders, dated 06/26/2024, revealed an order for water per gastrostomy tube (GT) at 53 ml/hour for 22 hours per day. Review of R74's Physician's Orders, dated 08/09/2024, revealed an order for pureed diet with nectar thick liquids comfort foods and thin water and ice chips. Review of R74's Physician's Orders, dated 08/26/2024, revealed an order for formula per tube at 75 ml/hour for 22 hours a day. Review of R74's Quarterly MDS, with an ARD of 07/17/2024, revealed the Swallowing/Nutritional Status section of the MDS was marked as 51% or more of proportion of total calories the resident received through parenteral or tube feeding. In an interview with Licensed Practical Nurse (LPN) 8, on 10/09/2024 at 5:15 PM, she stated R74's tube feeding was bolus and he unhooked himself from the feeding often. She further stated she was unfamiliar with R74 and didn't realize he had a physician order for continuous tube feedings and not bolus feedings. In an interview with the Dietician, on 10/11/2024 at 2:35 PM, she stated she started as the facility Dietician in August 2024. She further stated she was unaware of the facility completing any calorie counts and she relied on nursing services to provide any reports such as calorie counts. She continued to state the reports she ran for the weekly weight meetings were triggered by significant weight changes. Additionally, she stated she had not completed R74's previous MDS since she was new to the facility, and she was unaware of who completed the calorie counts. She stated she was responsible for completing the Swallowing/Nutritional Status section of the MDS. She further stated she monitored residents for significant weight changes and R74 had been stable with weight. In an interview with the Director of Nursing (DON), on 10/11/2024 at 3:28 PM, she stated the facility did not complete calorie counts and used resident weights to determine resident's nutritional status. In an interview with the LPN MDS Nurse, on 10/11/2024 at 4:08 PM, she stated it was the policy of the facility to complete the MDS per the RAI manual. She further stated she did not complete the Swallowing/Nutritional Status section of the MDS, and it was completed by the Dietician or the Dietary Manager. In an interview with the Account Manager of Healthcare Services Group, on 10/11/2024 at 4:38 PM, she stated she did not complete any calorie counts and the Dietician was responsible for gathering calorie counts for the MDS. In an interview with the District Manager of Healthcare Services Group, on 10/11/2024 at 4:40 PM, he stated it was the Dietician's responsibility to obtain calorie counts and complete that portion of the MDS.

Based on observation, interview, and record review, it was determined the facility failed to implement an effective infection control training program that included the written standards, policies, and procedures for infection control. Observation of staff members revealed they were not wearing appropriate personal protective equipment (PPE), and not disinfecting multi-use equipment (a Hoyer lift) after each use in a contact precaution room. Additionally, staff were unable to explain the differences between types of transmission-based precautions (TBP) and when PPE was to be worn, based on signage. The findings include: Review of the facility assessment, dated 10/17/2023, revealed the facility listed Prevention of Infections and Identification of infections, prevention of infections as services that the facility provided for residents. Further review revealed the facility listed infection control, including hand hygiene, use of PPE, and disease specific precautions, as mandatory training for all staff. Review of staff education binders from 06/2023 through 11/2023, revealed only one (1) of the six (6) months reviewed contained evidence of staff education on donning/doffing PPE. Further review of the binders revealed no evidence of staff education on the different types of TBP during that timeframe. Observation on 11/16/2023 at 3:30 PM, revealed two (2) Certified Nursing Assistants (CNA) were taking a mechanical lift into Resident #3's room. Continued observation revealed the CNA's asked Resident #3 to confirm whether he/she wanted to go back to bed, after returning from therapy and activities. Further observation revealed the CNAs saw Resident #3 was receiving an intravenous (IV) antibiotic at that time and decided to wait until the infusion was completed before transferring the resident back to bed. Additional observation revealed CNA #7 doffed (took off) the PPE, washed his/her hands, then pushed the mechanical lift into the hallway, placing it along the opposite wall, then began to walk away without cleaning the lift. During an immediate interview with CNA #7, on 11/16/2023 at the time of observation, she stated the facility's expectation was for staff to clean the lift as soon as they finished using it. She stated it was important to clean the lift immediately after use to prevent cross-contamination, and ensure the lift was clean for the next user. CNA #7 stated she had not cleaned the lift after taking it into Resident #3's as she had not really used for the resident. She further stated she was not sure whether it was necessary to clean the lift after removing it from Resident #3's room, since it had been in a room with contact precautions. The CNA additionally stated she would clean it right then. In further interview with CNA #7, on 11/17/2023 at 1:30 PM, she stated she had gone to the Infection Preventionist/Education and Training Director (IP/ETD) person to ask about the cleaning for the mechanical lift, and was provided education that the mechanical lift had to be cleaned with antibacterial wipes. She further stated her education was that two (2) staff using the lift, for one (1) staff member to doff his/her PPE and sanitize his/her hands. The CNA was informed after doffing and sanitizing his/her hands, to exit the resident's room, then take the sanitizing wipes back to the second staff member in the resident's room who would use the wipes to clean the lift. She further stated after the second staff member cleaned the lift, the first staff member would move the lift out for storage or use it with the next resident. In an interview on 11/15/2023 at 5:38 AM, CNA #1 was unable to describe what enhanced barrier precautions meant and when to wear PPE for contact precautions and enhanced barrier precautions. In an interview on 11/17/2023 at 8:28 AM, Licensed Practical Nurse (LPN) #20 stated she had to re-educate aides several times on wearing PPE in contact precaution rooms. She further stated she did not believe the facility's education was effective and most of what she had learned on infection control was from another facility. In an interview with Registered Nurse (RN) #1 on 11/16/2023 at 5:59 PM, she stated the infection control at the facility was a mess. She stated the IP/ETD was a brand new nurse, and no in-services were being done with return demonstrations done. The RN stated they just come around with the sign in sheet for infection control. She stated there was not adequate training provided, and orientation should include a large part of that type education. She further stated none of us do it (infection control measures) on a regular basis and often it was because the facility did not provide the PPE supplies. In an interview on 11/15/2023 at 11:27 AM, the IP/ETD stated he provided education to staff on TBP and donning/doffing PPE during routine monthly education sessions. He stated he also observed staff practices on the floor to ensure infection control practices were in use, and he provided one-on-one (1:1) education to staff members who failed to follow the infection control policies. In continued interview, the IP/ETD stated he observed for compliance with PPE every day and had not noted a pattern of staff non-compliance. He stated that staff gave various reasons for not wearing PPE, including not seeing the signage, and feeling like they had too much to do to take the time to put on the PPE. In an interview on 11/16/2023 at 2:13 PM, the Medical Director stated the facility had experienced a lot of staff turnover which presented challenges with ensuring consistency in staff compliance with infection control practices. The Medical Director stated the IP/ETD had to provide frequent reminders to staff about wearing PPE and if there continued to be breaks in infection control measures, the facility needed to consider changing their education program to improve compliance. In an interview on 11/17/2023 at 1:37 PM, the Director of Nursing (DON) stated she was unable to provide details on what staff were trained on because that was the role of the IP/ETD. In further interview, the DON stated she had been trained on donning/doffing PPE, handwashing, and the types of TBP. She further stated she was also certified as an infection preventionist. In an interview on 11/17/2023 at 5:47 PM, the Administrator stated the IP/ETD trained each employee during their orientation on the facility's infection control program, including handwashing and donning/doffing PPE. She stated the management team conducted daily visual rounds to observe for compliance with infection control measures and provided re-education to staff as needed. The Administrator further stated that based on the instances of breaks in infection control the State Survey Agency (SSA) Surveyors identified, the facility needed to provide staff with re-education on infection control. 44396

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure drugs and biological's were labeled in accordance with currently accepted professional principles for one (1) of two (2) Medication Room observation. Review of the Manufacturer's recommendation for the insulin pens revealed the insulin pens were good for twenty-eight (28) days after opening. Observation of the A/B Unit Medication Room revealed seven (7) insulin pens were lying on the counter in ZipLoc bags, without an open and/or used by date, recorded on the label. As a result, the expiration date for the medication could not be determined. The findings include: Review of the facility policy titled, Label/Store Drugs & Biologicals Standard of Practice, dated 10/2020, revealed the purpose was for drugs and biologicals to be labeled in accordance with currently accepted professional principles, and include the expiration date when applicable. Further review revealed if a multi-dose vial had been opened or accessed, the vial was to be dated and discarded within twenty-eight (28) days unless the manufacturer specified a different date for that particular vial. Review of the Insulin Glargine injection prescribe's information revealed the pens, once opened, were to be stored at room temperature for up to twenty-eight (28) days. Review of the Admelog insulin pen instructions revealed after there first use, the pens were to be stored at room temperature up to twenty-eight (28) days, then to be discarded even if it still had insulin left in it. Review of the Humalog insulin pen instructions for use revealed the pens were to be stored at room temperature and discarded after twenty-eight (28) days, even if it still had insulin left in it. Review of the manufacturer's recommendation revealed the medications were only good for twenty-eight (28) days. Observation of the Unit A/B medication storage room on 11/17/2023 at 9:10 AM, by the State Survey Agency (SSA) Surveyor, and Licensed Practical Nurse (LPN) #8 and the Assistant Director of Nursing (ADON) revealed the following insulin pens stored on the counter in storage bags without an opened date and/or a use by date on the label: Insulin Glargine pen, 100 units/milliliter (u/ml) labeled for Resident # 2; Humalog Pen, 100 u/ml labeled for Resident #2; Insulin Glargine 100 u/ml labeled for Resident # 282; Insulin Glargine 100 u/ml labeled for Resident # 131; Insulin Glargine 100 u/ml labeled for Resident # 136 on the pen only with no label on the bag; Insulin Lispro 100 u/ml labeled for Resident # 56; Admelog 100 u/ml in a zipped bag with a label showing it was delivered on 11/16/2023, and to refrigerate; however, had no opened date and was located in the medication storage room. Review of the audit sheet for the Medication Cart for the A Hall on Unit A/B, dated 11/12/2023, revealed an open breathing treatment medication that was undated and not labeled with a resident's name. Further review revealed two (2) open insulin pens undated. Review of the audit sheet for the B Hall Medication Cart on the A/B unit, dated 11/12/2023, revealed open breathing treatment medication not labeled with a resident's name or the date. Further review revealed two (2) insulin pens unlabeled with no resident's name on it. Review of the audit sheet for the E Hall Medication Cart on the C/D/E unit, dated 11/12/2023, revealed open breathing treatment medications which were not dated or labeled with a resident's name. Further review revealed one (1) resident (unnamed) had no insulin at all in his/her medicine box container. During an interview with LPN #9 on 11/17/2023 at 9:10 AM, she stated the nurses were responsible for receiving resident's medication from Pharmacy, and for ensuring the medication was stored appropriately. She stated nurses were also responsible for labeling the insulin pens and/or storage bags with the date the medication was opened and the date it must be used by. During interview with Certified Nursing Assistant (CNA) #8 on 11/17/2023 1:14 PM, she stated she audited the medication carts and storage rooms every weekend. She stated she used a form for audits that was provided by the Pharmacy. The CNA stated the audit form included things a Surveyor would look for like dates on water, applesauce or pudding, spoons available and placed handle side up, pill crusher available, opened dates on insulin, and whether the medications were stored properly. She stated she then gave the audit forms, once completed, to the Unit Managers, the Director of Nursing (DON) and the Infection Preventionist nurse. She stated she had noted undated insulin pens during her audits and those which had been turned in, and provided copies. During interview with LPN #9 on 11/17/2023 at 1:27 PM, regarding insulin storage, she stated when the resident's insulin was removed from the refrigerator, the medication must be marked with the date it was opened and the use by date should also be recorded within twenty-eight (28) days after opening the medication. She stated the outcome of not dating a resident's medication after opening was nurses or Kentucky Medication Aides (KMA) would not know if the insulin was still safe to use. During interview with the ADON on 11/17/2023 at 9:35 AM, she stated the nurses were responsible for receiving medications from the Pharmacy. She stated the shipping list of medications indicated the need for refrigeration of the medications. The ADON stated nurses were expected to place a date on the label for insulin pens when opening. She stated the pens observed in the medication storage room should have been dated upon being opened and she would discard the pens immediately and reorder. Additionally, the ADON stated besides her stating she would discard and reorder the pens, the Pharmacy sent the pens the provider ordered and the pens were stored in the other storage room, where the refrigerator was. She further stated she got subsequent pens from there. During an interview with the Director of Nursing (DON) on 11/17/2023 at 2:20 PM, she stated insulin pens were to be dated when removed from the refrigerator for resident use because the insulin was to be used within twenty-eight (28) days. She stated she expected the staff to follow the facility's policy as required. During an interview with the Administrator on 11/17/2023 at 5:48 PM, she stated her expectation was for staff to follow the facility's policy to date insulins when they were opened. She stated she also expected staff to document the use by date on the insulin.

Based on observation, interview, record review, review of the facility's Assessment and policies, and review of the Centers for Disease Control and Prevention (CDC) Multidrug Resistant Organism (MDRO) Guides for Personal Protective Equipment (PPE) Use in Nursing Homes, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to maintain proper infection control practices for two (2) of six (6) residents in contact precautions, Resident #3 and #4, and one (1) of thirty-four (34) residents in Enhanced Barrier Precautions, Resident #36. Observation revealed staff members failed to don the appropriate personal protective equipment (PPE) prior to entering residents' contact and/or enhanced barrier precaution isolation rooms. Additionally, observation revealed staff failed to clean and disinfect shared resident equipment. Interview with multiple staff revealed lapses in their education and communication regarding standards of practice and the facility's policies related to Infection Prevention Control (IPC). The findings include: Review of the facility's assessment dated [DATE], revealed the facility listed Prevention of Infections and Identification of infections, prevention of infections as services that the facility provided for residents. Further review revealed the facility listed infection control, including hand hygiene, use of PPE, and disease specific precautions, as mandatory training for all staff. Review of the facility's policy titled, Infection Control, dated 10/2018, revealed the facility's infection control practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment to prevent and manage transmission of diseases and infections. Further review revealed the facility provided training to all staff appropriate to the employee's job responsibilities. Review of the facility's policy titled, Enhanced Barrier Precautions Standard of Practice, dated 07/2022, revealed the facility required staff to wear gown and gloves when performing high-contact care for residents at risk for multi-drug resistant organisms (MDROs), such as residents with wounds or with an indwelling medical device. Further review revealed high-contact care activities included: dressing, providing hygiene, transferring, changing linens, and changing briefs. Review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions, undated, revealed contact precautions were implemented for residents known to be infected with microorganisms that could be transmitted by direct contact with resident or indirect contact with environmental surfaces or resident care items. Continued review revealed staff members were to wear gloves and gowns upon entry into a resident's room with contact precautions in place. Further review revealed if equipment was to be shared with a resident in contact precautions and other residents, the equipment was to be disinfected before use on another resident. Review of the Centers for Disease Control and Prevention (CDC) Multidrug Resistant Organism (MDRO) Guides for PPE Use in Nursing Homes website: https://www.cdc.gov/hai/containment/faqs.html revealed contact precautions required the use of gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident. Per review of the document, the resident was given dedicated equipment (e.g., stethoscope and blood pressure cuff) and was to be placed in a private room. Continued review revealed when private rooms were not available, some residents (e.g., residents with the same pathogen) might be roomed together. Further review revealed the document stated residents on contact precautions were recommended to be restricted to their rooms except for medically necessary care, including restriction from participation in group activities. 1. Review of Resident #4's Face Sheet revealed the facility admitted the resident on 11/09/2021. Continued review revealed Resident #4's diagnoses, at the start of the survey on 11/13/2023, included a Stage 4 Pressure Ulcer to his/her back, Generalized Anxiety Disorder, and presence of methicillin-resistant Staphylococcus aureus (MRSA). Review of Resident #4's Care Plan dated 11/16/2023, revealed the facility included contact precautions as an intervention for the resident due to the presence of MRSA. Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. a. Observation on 10/15/2023 at 10:19 AM, of Resident #4 with the Wound Care Nurse revealed she reached under her PPE into her pocket for a marker. Further observation revealed she used the marker to date the resident's dressing and reached back under her gown to place the marker back in her pocket. In an interview on 10/15/2023 at 10:25 AM, the Wound Care Nurse stated she had not considered that reaching under her PPE for the marker and then using the marker for other residents' dressings was a failure in infection control practices. She further stated she would consult with the facility's Infection Control Nurse to determine if she needed to go home to change her scrub top. b. Observation of the signage posted for Resident #4 revealed the resident was in contact precautions and staff members were to don (put on) PPE, including gowns and gloves, before entering the resident's room. Further observation revealed the signage instructed staff to use dedicated equipment and to clean and disinfect reusable equipment before use on another resident. In an interview on 11/14/23 at 11:56 AM, Resident #4 stated staff did not wear gowns into his/her room unless State Survey Agency (SSA) Surveyors were present. Observation on 11/15/2023 at 10:45 AM, revealed State Registered Nursing Assistant (SRNA) #2 failed to disinfect a Hoyer lift (a mechanical lift used to transfer residents from one surface to another) after using it to transfer Resident #4. In interview on 11/15/2023 at 10:47 AM, CNA #2 stated she did not disinfect the Hoyer lift because it was not visibly soiled. She stated she only cleaned the lifts if a resident had something contagious, which she did not believe applied to Resident #4. She stated she used alcohol wipes to clean equipment. CNA #2 further stated she did not recall what training the facility provided about disinfecting lifts or the different kinds of precautions. 2. Review of Resident #3's electronic health record (EHR) revealed the facility admitted him/her on 11/25/2023, with diagnoses including unspecified fracture of right distal femur, subsequent encounter for closed fracture with routine healing, multiple sclerosis, and Type 2 Diabetes Mellitus. Further review revealed Resident #3 was under contact precautions due to a urinary tract infection (UTI) caused by Escherichia coli (E. coli). a. Observation, during an interview with Resident #3 at his/her room door on 11/14/2023 at 3:40 PM, revealed the Facility Scheduler walked into the resident's room without donning PPE despite the signage at the door which indicated the resident was on contact precautions. During interview with the Facility Scheduler on 11/14/2023 at 4:05 PM, she stated she had gone into Resident #3's room only to turn off the call light and not to perform any personal care. She stated she thought this was appropriate and also stated she had received infection control training from the Infection Preventionist (IP) Nurse. Further interview revealed she stated she did not know whether she should avoid entering other resident rooms or not for the day. During interview with the Infection Preventionist (IP) Nurse on 11/14/2023 at 4:32 PM, he stated the Facility Scheduler had come to him to inform him that she feared she had made an error. He further stated he had provided re-education about using PPE with contact precautions for staff. b. Observation on 11/16/2023 at 3:30 PM, revealed two (2) nursing assistants entered Resident #3's room with a mechanical lift. They asked the resident to confirm whether he/she wanted to go back to bed since returning from therapy and activities. Continued observation revealed the nursing assistants saw Resident #3 was receiving an intravenous (IV) antibiotic at that time, and waited until it was completed prior to transferring him/her back to bed. Observation revealed CNA #7 doffed (removed) her PPE, washed her hands then pushed the mechanical lift into the hallway, placing it along the opposite wall, and began to walk away. During an immediate interview with CNA #7, she stated the expectation was staff would clean the lift as soon as the resident finished using it. She stated it was important to clean the lift immediately after use to prevent cross contamination, so it would be clean for the next user. CNA #7 stated she had not cleaned the lift at that time because she had not really used it with Resident #3. She further stated she was not sure whether it was necessary to clean the lift since it had, in fact, been in a room with contact precautions; however, she would clean it right then. During interview with Licensed Practical Nurse (LPN) #1 on 11/14/2023 at 3:50 PM, she stated that everyone was expected to don (put on) PPE in accordance with the contact precautions until the resident was cleared with antibiotics. She stated she thought the timeframe was seven (7) days of receiving antibiotics. During another interview with CNA #7 on 11/17/2023 at 1:30 PM, she stated she had gone to the IP Nurse who provided education that the mechanical lift had to be cleaned with antibacterial wipes. She stated her education was when two (2) people used the lift, one (1) could doff his/her PPE and sanitize their hands, exit the room, then bring the wipes back to the partner who would clean the lift. The CNA further stated the first partner (who sanitized his/her hands and obtained the sanitizing wipes) could move the lift out for storage or use with the next resident. During interview with the IP Nurse on 11/15/2023 at 11:27 AM, he stated the only shared equipment for a resident in contact precautions was the mechanical lift, vital sign measuring equipment, and glucometers. He stated those were cleaned with Virex (Wipes which delivered fast, effective cleaning) wipes. The IP Nurse stated Resident #3 was to remain on contact precautions until 11/20/2023. He stated the IP Nurse education provided to staff was to use the indicated PPE with contact precautions no matter the purpose of being in the room, and doff the PPE just prior to exiting room. The IP Nurse further stated staff must exit residents' rooms who were under precautions, and use hand sanitizer immediately, unless visibly soiled, then they were to wash hands with soap and water. During interview with the DON on 11/17/2023 at 2:22 PM, she stated multi-use equipment was to be cleaned with the purple top wipes (Micro Kill germicidal wipes) immediately after every use. The DON was unable to state the process for cleaning a mechanical lift after use even though she stated she received infection control education as well as other staff. 3. Review of Resident #36's Face Sheet revealed the facility admitted the resident on 12/20/2021, with the resident's diagnoses, as of 11/16/2023, included Stage 4 Pressure Ulcer of the right buttock, Polyneuropathy, and Unspecified Dementia. Observation on 11/16/2023 at 5:34 AM, revealed signage outside Resident #36's door that indicated the resident was in Enhanced Barrier Precautions. Continued review of the signage revealed staff were to wear gowns and gloves when providing high contact care such as changing linens. Observation on 11/16/2023 at 5:34 AM, revealed CNA #1 and LPN #4 failed to wear protective gowns while changing the bed linens for Resident #36, who was in Enhanced Barrier Precautions. In an interview on 11/15/2023 at 9:34 AM, Resident #36's family member stated staff members did not wear PPE when changing the linens or providing other high contact care for Resident #36. In an interview on 11/15/2023 at 5:38 AM, CNA #1 stated she should have worn a gown while changing Resident #36's linens; however, she was not paying attention when she entered the resident's room. Interview with CNA #1 further revealed she was unable to describe what Enhanced Barrier Precautions meant and when to wear PPE for contact precautions and Enhanced Barrier Precautions. In an interview on 11/15/2023 at 11:27 AM, the IP Nurse/Education and Training Director (IP/ETD) stated he provided education to staff on transmission-based precautions (TBP) and donning/doffing PPE during the routine monthly education sessions. He stated he also observed staff practices on the floor and provided one-on-one (1:1) education to staff members who failed to follow the facility's infection control policies. The IP/ETD stated he observed for compliance with PPE every day and had not noted a pattern of staff not being compliant. He further stated staff members gave various reasons for not wearing PPE, including not seeing the signage and feeling like they had too much to do to take the time to put on the PPE. Review of the staff education binders from 06/2023 to 11/2023, revealed only one (1) month of the six (6) months reviewed, contained evidence of staff education on donning/doffing PPE. Further review revealed no evidence of staff education on the different types of transmission-based precautions during that time period. In an interview on 11/16/2023 at 2:13 PM, the Medical Director stated there had been a lot of staff turnover at the facility. The Medical Director further stated the turnover presented challenges with ensuring consistency in staff compliance with infection control practices. In an interview on 11/17/2023 at 1:37 PM, the DON stated she expected staff to follow infection control guidelines to prevent the transmission of infections. She further stated staff were to disinfect multi-use equipment, such as lifts with the approved wipes immediately after use. In an interview on 11/17/2023 at 5:47 PM, the Administrator stated she expected staff to follow the facility's transmission based precaution protocols, including wearing PPE and cleaning multi-use equipment. 44396

Based on observation and interview, it was determined the facility failed to provide the residents with a right to a safe, clean, comfortable, and homelike environment. Observation on 11/16/2023, of the Unit E shower room revealed a soiled brief and a glove on the floor, with many cracked or missing tiles in the floor, and an open area in the wall behind the toilet. Further observation on 11/16/2023, revealed the Unit C shower room had many cracked or missing titles in the floor and base board area. The findings include: Review of the facility policy titled, Resident Rights undated, with listed regulatory reference to 483.10 Resident Rights, revealed the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living. Observation of the Unit E shower room, on 11/16/2023 at 5:34 AM, revealed the shower door was propped open with a clothing protector. Observation of the Unit E shower room door from the hallway revealed the door wainscoting was broken, loose, and pulling away from the lower front left-hand corner of the door. Observation facing inside the shower room toward the door, revealed in the lower right corner by the door frame, the baseboard had two (2) broken tiles and one (1) broken tile above exposed an open area in the wall, next to the door frame at the floor level. Further observation of the door revealed the door frame was rough from the floor to above the latch area. Continued observation in the Unit E shower room, of the former tub room area, revealed several broken tiles around the baseboard with an open concrete area, with no tiles in an approximately 2 1/2 feet wide by 5 feet long area. Observation further revealed a 1/2 inch wood board covering an area of the drain in the tub removal area, with the appearance of possible water damage and peeling. In addition, observation revealed a white brief left on the floor near the back wall and the wood board, with the appearance of being left there for several days. Further observation revealed a clear vinyl glove on the floor, to the left of the brief, near the shower. Observation facing the shower room revealed a baseboard tile cracked in the left corner, chipped, and mid-center, under the shower head, of the same wall. Observation of the opposite wall revealed a chip between two (2) chipped tiles in the baseboard. Observation of the back shower wall revealed five (5) tiles broken in the base board. Observation of the toilet room, in the shower room area, revealed behind the toilet, three (3) loose tiles, one (1) tile missing in the baseboard behind the toilet, and two (2) tiles above the baseboard in the left corner were loose from the wall. Observation in the Unit C shower room on 11/16/2023 at 6:00 AM, revealed on the wall with a shower head, near the baseboard, two (2) tiles were missing. Continued observation of the floor throughout the shower area revealed missing tiles. In additional observation the wood board covering the opening from the removed tub area revealed a 1/2 inch broken area of tile to the left of the board in the baseboard area. In an interview with the Maintenance Director on 11/17/2023 at 8:47 AM, he stated the facility's TELS (A computer program system for tracking and recording scheduled or requested maintenance performed and completed in the facility) system was used for staff to request repairs or when residents made requests for repairs. He stated the Units C and E had a budget request for shower room repairs; however, those requests had not been approved. He stated breaks in the tile could lead to water leaking and open areas would allow pests to enter. The Maintenance Director further stated staff had been rough with opening the Unit E shower room door and did not always have the code. In an interview with the Director of Nursing (DON) on 11/17/2023 at 1:23 PM, she stated she was not aware the Unit E shower room door was propped open. She stated there was an infection control concern for a used brief and a glove being left in the shower room on the floor. The DON stated missing tiles would allow water, air, and pests to enter the shower room. She further stated the shower rooms on Unit C and Unit E were not a homelike environment with the broken tiles or a brief left on the floor, and residents would not want to take a shower. In an interview with the Administrator on 11/17/2023 at 5:48 PM, she stated the repairs to the shower rooms would be completed and addressed by using a preventive maintenance log. She further stated that missing tiles would allow for pests to enter the facility.

Based on interview and review of the facility's policy, it was determined the facility failed to provide an ongoing program to support residents in their choice of activities, designed to support the psychosocial well-being of each resident and to encourage both independence and interaction in the community. The resident group expressed a desire to go on outings into the local community; however, that had not been provided by the facility, as the Administrator expressed there were insufficient staff to provide adequate supervision to residents if out on community outings. Residents #4, #33, #45, #54, #56, and #60 all expressed a desire to go on outings into the community. The findings include: Review of the facility's policy titled, Activities Standard of Practice, dated 07/2021, revealed the facility provided, based on assessment, care plan, and resident preferences, an ongoing program to support residents in their choice of activities. The policy stated activities were designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and social interaction. 1. Review of Resident #4's Face Sheet revealed the facility admitted the resident on 11/09/2021, with diagnoses to include Acute Kidney Failure Unspecified, Generalized Anxiety Disorder, and Insomnia Unspecified. Continued review revealed the facility assessed Resident #4 in an 08/30/2023, Quarterly Minimum Data Set (MDS) Assessment to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating no cognitive impairment. In an interview with Resident #4 on 11/17/2023 at 1:12 PM, the resident stated he/she had discussed in Resident Council about residents going on outings into the community, and tried to discuss that request with the previous Administrator. Resident #4 stated however, the previous Administrator told him/her residents could not go out as the bus needed repairs and he did not want to get the repairs done. Resident #4 further stated the current Administrator canceled all outside of the facility activities. Resident #4 additionally stated the Administrator sold the bus that used to take the residents places because it required too much upkeep, but facility management had not been letting the residents use the bus anyway. 2. Review of Resident #33's Face Sheet revealed the facility admitted the resident on 11/09/2019, with diagnoses to include Hemiplegia Unspecified Affecting Right Dominant Side, Acquired Absence of Right Leg Above Knee, and Cerebral Infarction Unspecified. Continued review revealed the facility assessed Resident #33 in an 11/06/2023 Annual MDS Assessment to have a BIMS score of nine (9) out of fifteen (15), indicating moderate cognitive impairment. In an interview with Resident #33 on 11/16/2023 at 3:30 PM, the resident stated it did not do any good to talk about going on outings, as it had been brought up multiple times in Resident Council. Resident #33 stated the former Activities Director would take residents out all the time, sometimes just to ride around in the community. Resident #33, who had been at the facility longer than most in resident council, stated in the past they had outings scheduled frequently, and he/she felt more like a part of the community. Resident #33 further stated he/she did not like just sitting around and playing bingo. Resident #33 concluded by stating it felt like we [the residents] were just waiting to die for facility management. 3. Review of Resident #45's Face Sheet revealed the facility admitted the resident on 07/28/2021, with diagnoses to include Major Depressive Disorder, Paraplegia Unspecified, and Obstructive Sleep Apnea. Review of Resident #45's Annual MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), indicating no cognitive impairment. In an interview with Resident #45 on 11/16/2023 at 3:40 PM, the resident stated he/she had talked to the Activities Director and the Administrator about going on outings, although nothing had been done by them to facilitate outings. Resident #45 stated he/she did not think the facility had a bus anymore, although he/she was not told this directly. Per Resident #45, residents used to go on outings before COVID-19 hit. Resident #45 stated he/she knew in another facility, residents went out to eat at local restaurants, and even went to an aquarium. The resident further stated at this facility, he/she understood residents used to go to restaurants and shopping, even out to the lake, although this had not been the case since he/she had been residing at the facility. 4. Review of Resident #54's Face Sheet revealed the facility admitted the resident on 01/15/2021, with diagnoses to include Type 2 Diabetes Mellitus Without Complications, Anxiety Disorder due to Known Physiological Condition, and Cerebral Infarction Unspecified. Review revealed of Resident #54's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) out of fifteen (15), indicating no cognitive impairment. In an interview with Resident #54 on 11/14/2023 at 2:10 PM, the resident stated the facility had a bus that was parked at a sister facility; however, none of the residents residing in the current facility had not been out shopping or on any trips. Resident #54 stated he/she did not want to be a Latch Key person. The resident stated he/she would like to go on outings for Christmas carols, out shopping to the grocery, or would love to go to the local department store or out to get something to eat. Resident #54 further stated the facility used to have activities where residents would go outside and use the slip and slide and we had so much fun, but facility staff would not let residents do anything outside now. 5. Review of Resident #56's Face Sheet revealed the facility admitted the resident on 06/18/2021 with diagnoses to include Type 2 Diabetes Mellitus Without Complications, Acute Kidney Failure Unspecified, and Chronic Kidney Disease Unspecified. The facility assessed Resident #56 in a 09/08/2023 Quarterly MDS as a fifteen (15) out of fifteen (15) on a BIMS, indicating no cognitive impairment. In an interview with Resident #56 on 11/16/2023 at 3:30 PM, the resident stated he/she had been told the facility did not have a bus to take residents on outings. Resident #56 stated the Resident Council had expressed interest in going on outings numerous times, and would like to go out to eat, go to the park, go to the movies, see Christmas lights, or just drive around the neighborhood. The resident stated however, the Administrator told residents they could not ride on the bus, as it would be a safety issue. 6. Review of Resident #60's Face Sheet revealed the facility admitted the resident on 12/22/2021, with diagnoses which included Generalized Anxiety Disorder, Unspecified Diastolic (Congestive) Heart Failure, and Retention of Urine Unspecified. Review of Resident #60's Annual MDS assessment dated [DATE], revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15), indicating no cognitive impairment. In an interview with Resident #60 on 11/16/2023 at 3:30 PM, the resident stated his/her desire to go on outings had been brought up numerous times in Resident Council. Resident #60 stated the facility had provided numerous excuses why that could not happen, to include: the bus was broken; they had no one who could drive the bus; and the facility did not have insurance on the bus. The resident stated the Administrator's door was not open to talk to residents, and she was not willing to listen to residents regarding outings. Resident #60 further stated residents were stuck in the facility playing bingo instead of getting outside for activities or going out into the community. In an interview with the Ombudsman on 11/16/2023 at 2:00 PM, she stated there were a lot of younger residents that do not want to just sit here and die, they wanted to do things, they wanted to go on outings. She stated residents had asked and asked and asked about outings, and had been told that the facility's corporation would not pay insurance and would not pay for someone to drive the vehicle on outings. The Ombudsman stated the bus only serviced residents at the sister facility according to the Administrator. She stated the Administrator told her she (the Administrator) had been in long-term care for thirty-eight (38) years, and never had a facility in which she took residents on outings, and would not start doing that now. The Ombudsman stated outings had been brought up, and she had written grievances; however, they (the facility) did not change things. She stated she saw other facilities go into the community, either in facility buses or through a local transportation service, but was told by the Administrator the facility did not have the finances and the facility's corporation said they could not do that. The Ombudsman concluded by stating there were means and ways the facility was not utilizing to facilitate outings for the residents. In an interview with the Activities Director (AD) on 11/16/2023 at 12:03 PM, she stated she had been in that role since February of 2023, and had been the Activities Assistant (AA) prior to that. She stated although multiple residents had expressed an interest in going on outings, the facility had no way to accommodate outings at the moment. The AD stated she had not scheduled any outings since she had been the AD, as she had not been able to take residents on outings. She stated not too long ago, she asked several residents if they had suggestions for the activities calendar, as she wanted them to be involved in planning activities that they wanted to do. The AD stated residents had expressed interest in having activities outside of facility. She stated the closest she could get to going out was to get something catered in from a local restaurant for some residents, which she did once a month. The AD further stated when she conveyed residents' interest in going on outings to the Administrator, she was told the facility did not have enough staff to resident ratio to facilitate outings. In an interview with the Director of Nursing (DON) on 11/17/2023 at 1:46 PM, she stated she had only been in that role for two (2) months; however, had been part of the facility's staff on and off since 2010. She stated no one had expressed any desire to her personally, to go on outings. The DON stated the facility had previously went on outings, and shared a bus with their sister facility. The DON stated the AD, the AA, and a nursing team member had previously gone and did all kinds of different things in the community with residents. She stated they went to the park, bowling, out to eat, and to the movies. Per the DON, she was not sure what caused all those activities to stop, and was not sure if the bus was available any longer or not. She stated it had been a couple of years ago at least, pre COVID-19, since any outings had taken place as far as she could remember. The DON further stated residents did enjoy outings, and she absolutely thought it could be a quality of life issue for residents to be able to go out into the community. In an interview with the Administrator on 11/16/2023 at 1:21 PM, she stated we just don't do outings. She stated she did not have staff to take residents on outings, and she had never had a building that did outings for residents. The Administrator stated that would take staff off the floor that they did not have to be able to do outings. The Administrator stated it had come up in Resident Council meetings that residents were interested in going on outings; however, it would not be feasible to take everyone everyplace they possibly wanted to go. She stated if residents needed items, the facility performed the shopping for them. According to the Administrator, to her residents would almost need one to one (1:1) supervision if they were taken to a store, because the facility was responsible for the residents' safety. She stated a resident could fall, or something else could happen to them while on outings. The Administrator stated if residents slipped and fell , that was not a question she wanted to talk to an attorney about. The Administrator further stated she looked at resident outings as a major safety issue, and the facility could not leave residents unattended. In addition, she concluded by stating she could look into outings like going to see Christmas lights, but could not commit to doing that.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary services for its residents to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being for one (1) of forty-five (45) sampled residents (Resident #7). The facility failed to arrange for Resident #7 to receive styling services for his/her hair according to his/her preferences, resulting in the resident having a decreased self-image. The facility failed to provide previously provided beauty services, and there was no evidence the facility attempted to arrange outside services per Resident #7's preferences. The findings include: Review of Resident #7's Face Sheet revealed the facility admitted the resident on 05/27/2022, with diagnoses to include Major Depressive Disorder, Chronic Obstructive Pulmonary Disease (COPD), and Dysphagia. Review of Resident #7's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15), indicating moderate cognitive impairment. Review of Resident #7's Care Plan dated 09/29/2022, revealed the facility included interventions for the resident's mood which included encouraging the resident to express his/her feelings and encourage participation in activities of his/her choice. Observation on 11/13/2023 at 6:45 PM, revealed Resident #7 lying on his/her bed with his/her hair past shoulder length. Continued observation revealed Resident #7's hair was unkempt, with uneven ends. In an interview with Resident #7 on 11/13/2023 at 6:45 PM, the resident stated he/she did not feel like himself/herself as he/she had not been provided with the opportunity to have his/her hair cut and permed in longer than he/she could remember. Resident #7 further stated he/she used to get those services, and did not know why that had stopped. In an interview with the Activities Director (AD) on 11/17/2023 at 2:59 PM, she stated several residents, including Resident #7, had reported to her that they would like to have their hair professionally cut and styled. She stated the facility's beauty shop closed due to Coronavirus Disease 2019 (COVID-19) and it had not re-opened due to not having a state license for the beauty shop or a licensed beautician available. The AD stated she mentioned the residents wanting hair services provided to the Administrator, who told her that the facility was not able to accommodate the request. She stated she was not aware of a policy outlining the process for obtaining hair services for residents. She stated that taking residents to an outside beauty shop for hair services was not an option due to not having anyone trained to drive the facility's bus, which was shared with a sister facility. Additionally, the AD stated she would have decreased self-image if she was not able to maintain her preferred grooming routine and thought it was reasonable for Resident #7 to feel the same way. In an interview with the Director of Nursing (DON) on 11/17/2023 at 1:37 PM, she stated residents had been getting haircuts from family members since the beauty shop closed during the pandemic. She stated it would be the role of the AD to keep track of hair appointments for residents if that was a service the facility offered. The DON stated she would have decreased self-esteem if she could not get her hair cut and/or styled according to her preferences. In an interview with the Administrator on 11/17/2023 at 5:47 PM, she stated she did not know anything about residents wanting beauty services. She stated the facility had not made Resident #7's preference a priority due to emphasizing other aspects of care while it was under special focus. The Administrator further stated she would have to look into arrangements for residents to go to an outside beauty salon because the facility's beauty shop was not in good repair, and a stylist was not available to come provide beauty services.

Based on interview and record review, it was determined the facility failed to treat each resident with respect, and dignity and provide care for each resident in a manner and environment that promoted dignity or enhancement of quality of life for one (1) of forty-five (45) sampled residents (Resident #51). The facility failed to ensure Resident #51 was ensured dignity by not providing adequate and timely supplies for personal hygiene, specifically adult pull-up garments. The findings include: Review of the facility policy titled, Resident Rights undated, with regulatory reference to 483.10 Resident Rights, revealed residents had the right to receive the services and or items included in the plan of care. Review of Resident #51's Face Sheet revealed the facility admitted the resident on 06/22/2022, with diagnoses to include Unspecified Dementia with Unspecified Severity, Respiratory Failure, Disorder of the Skin and Subcutaneous Tissue, and a History of Falling. Review of the Quarterly Minimum Data Set, dated dated dated [DATE] revealed the facility assessed Resident #51 to have a Brief Interview for Mental Status score of thirteen (13) out of fifteen (15), indicating he/she was cognitively intact. Continued review of the Quarterly MDS Assessment, section H, revealed the facility also assessed Resident #51 as frequently incontinent of bowel and occasionally incontinent of bladder. During interview with Resident #51 on 11/14/2023 at 4:02 PM, the resident stated he/she had not had any adult pull-ups (disposable underwear) for three (3) days. Resident #51 stated he/she had asked someone from each shift to find pull-ups for him/her. The resident stated he/she was very upset about not having the pull-ups because he/she did not like having to wear the same underwear for so long. During further interview with Resident #51 on 11/15/2023 at 1:30 PM, the resident stated pull-ups had been delivered to him/her earlier that day. Resident #51 expressed relief to have clean underwear and stated that he/she had been so upset because he/she could smell himself/herself and felt unclean. Resident #51 stated he/she felt embarrassed and undignified without having clean pull-ups to wear, and further stated he/she was lucky he/she had not had a bowel movement accident. During interview with State Registered Nursing Aide (SRNA) #9 on 11/17/2023 at 3:41 PM, she stated Resident #51 had told her he/she was out of pull-ups on 11/14/2023, and she reported that information to the nurse. SRNA #9 stated the nurse had sent her to look for pull-ups for the resident; however, she did not find any in the regular storage area, which was in the conference room cabinets, or anywhere else. She stated the nurse also looked for pull-ups and could not find any for Resident #51. SRNA #9 stated Resident #51 was offered a brief, but he/she did not want to wear a brief as it was uncomfortable. She stated she looked for pull-ups to borrow from another resident, but nobody wore Resident #51's size, so a pull-up was not able to be acquired in that manner either. SRNA #9 further stated it was understandable that Resident #51 had been upset, because she would not want to wear a pull-up longer than they were supposed to be used. During interview with Licensed Practical Nurse (LPN) #1 on 11/17/2023 on 03:29 PM, she stated SRNA #9 reported to her on 11/15/2023, that Resident # 51 was out of pull-ups and had been out for several days. She stated she sent SRNA #9 to find pull-ups for Resident #51; however, the SRNA reported back that she had been unable to find the pull-ups in the normal storage places. LPN #1 stated she subsequently searched for pull-ups herself, without success. LPN #1 further stated there were pull-ups in a shipment received on the following day and they were delivered to Resident #51 at that time. In addition, she stated she understood Resident #51 feeling upset about wearing the same pull-up for multiple days, because a person might feel like they were not clean or might smell. During interview with the Director of Nursing (DON) on 11/17/2023 at 2:20 PM, she stated she was unaware of issues with supplies such as pull-ups. She stated the facility ordered stock and staff had access to those supplies. The DON further stated she understood a person would be uncomfortable with wearing the same underwear for four (4) days in a row. During interview with the Administrator on 11/17/2023 at 5:38 PM, she stated she was currently doing the ordering for the facility. She stated nursing staff gave her a list of what was needed, then she went back to review the prior orders to determine the volume needed. The Administrator stated she made out an order every week on Mondays, as the deadline was on Tuesday, and a shipment arrived on Wednesdays. She further stated she could understand someone feeling unclean and undignified with wearing the same pull-up for an extended time.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to review and update comprehensive care plans as indicated for one (1) of thirty-four (34) sampled residents (Resident #15). Resident #15's care plan was not revised to included increased supervision and monitoring after a change in cognition, resulting in a fall with significant injury. The findings include: Review of the facility's policy titled, Comprehensive Care Plans Standard of Practice, dated 10/2020, revealed the purpose of the policy was to ensure an individualized Comprehensive Care Plan (CCP) that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs would be developed for each resident. Further review revealed the facility's care planning/Interdisciplinary Team (IDT), in coordination with the resident, family and/or representative, developed and maintained a CCP for each resident that identified the highest level of functioning the resident might be expected to attain. Continued review revealed that a CCP was based on a thorough assessment that included, but was not limited to, the Minimum Data Set (MDS) assessments. Additional review revealed each resident's care plan was designed to identify problem areas; incorporate risk factors associated with the problems, built on the resident's strengths; and reflected the resident's wishes regarding treatment goals, timetables, and outcomes. Per the policy, a resident's care plan identified the professional services responsible for each element of care and should aid in preventing or reducing declines in the resident's functional status and/or functional levels. Further review revealed resident assessments were ongoing and care plans were revised as information about the resident and the resident's condition changed. Per the policy, care plans were reviewed and updated when there was a significant change in the resident's condition, when the desired outcome was not met, when the resident had been readmitted to the facility from a hospital stay, and at least quarterly. Review of the facility's policy, Falls Standard of Practice, dated 07/2020, revealed a resident's care plan was to be updated with implemented interventions after a fall. Additional review revealed the Clinical Quality Assurance (QA) Interdisciplinary Team (IDT) would review and discuss any fall during the morning clinical meeting with the care plan updated to reflect any changes to risk factors or needed interventions. The facility's policy for Interdisciplinary Team (IDT) was requested and was not provided. The Director of Nursing (DON) furnished a written list of the IDT Members which included the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Unit Manager (UM), the Wound Nurse, the Minimum Data Set Nurse (MDS), the Staff Development Coordinator (SDC), the Director of Rehabilitation Services and the Social Services Director (SSD). Review of Resident #15's medical record revealed the facility admitted the resident, on 02/20/2020, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Oxygen Dependence, Congestive Heart Failure (CHF), and Obstructive Sleep Apnea. Review of Resident #15's Quarterly Minimum Data Set (MDS) Assessment, dated 08/15/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), which indicated he/she was cognitively intact. Review of Resident #15's Progress Notes, dated 08/09/2022 and 08/11/2022, revealed the facility assessed Resident #15 as having confusion on 08/09/2022, and again on 08/11/2022, when staff notified the physician, who ordered laboratory tests. Further review revealed on 08/22/2022, the resident was very confused and disoriented, hallucinated, and attempted to climb out of bed. Further review of Resident #15's Progress Notes, revealed on 08/27/2022 at 2:57 AM, Resident #15 called out for help and was found sitting on his/her bottom with his/her back resting against the bed. Resident #15 was transferred to a local hospital Emergency Department (ED) for evaluation related to the fall and decline in his/her level of consciousness. Review of the IDT Note, dated 08/29/2022 at 10:46 AM, revealed Resident #15 had been admitted to the hospital because of his/her critical CO2 (carbon dioxide) level. Review of the Progress Notes revealed on 09/05/2022, the resident was diagnosed with a broken right tibia (leg) from the previous fall found after completing a Computed Tomography (CT) scan and X-ray. Review of the Progress Notes revealed Resident #15 returned to the facility on [DATE] after hospital care. Review of Resident #15's Comprehensive Care Plan (CCP) revealed a fall care plan initiated on 03/05/2020. Further review revealed the contributing problem was risk for injury as evidenced by need for assistance with Activities of Daily Living (ADL) related to COPD, CHF, morbid obesity, Hypertension, incontinence, and medications. Continued review revealed the interventions initiated on 03/05/2020 included a bariatric bed with the assistance of two (2) staff and use of a mechanical lift, medications/treatments and laboratory tests as ordered, monitor for side effects, and Physical Therapy evaluation/treatment as indicated. An additional intervention was added on 03/23/2020, which was half side rails times two (2) to aid with bed mobility. With additional review, no other interventions were noted. Continued review of Resident #15's CCP revealed a plan for Cognitive Loss, dated 03/03/2020 revealed interventions to include: 1) approach resident warmly and positively, explain all procedures to resident before doing care, etc.; 2) attempt to establish a comfortable daily routine; 3) elicit support of family/friends as needed to assist resident with more difficult or complex decisions; 4) encourage resident to reminisce to help keep long term memory intact; 5) notify physician, family, responsible party of changes as needed; and 6) provide cueing, prompting, and assist for personal care as needed. Further review of the cognitive loss care plan revealed no revisions and no added interventions for increased monitoring following new onset confusion. In a telephone interview with Resident #15's Daughter on 06/29/2023 at 12:10 PM, she stated Resident #15 was normally alert and oriented, but had asked the facility about placing a bed alarm because the resident became confused if his/her O2 was too low. She also stated a bed alarm would alert the staff if Resident #15 was attempting to get out of bed unassisted and that, if an alarm was not possible, the facility should put someone in the room with him/her until the resident was no longer confused. She further stated she was not aware of any fall prevention strategies the facility had attempted. In an interview with State Registered Nursing Assistant (SRNA) #7 on 06/30/2023 at 4:10 PM, she stated Resident #15 was disoriented the day he/she fell out of bed. She stated Resident #15's confusion seemed intermittent; specifically, he/she would be speaking normally then say something off the wall. She also stated the disorientation was not Resident #15's baseline and was a new onset problem before the fall on 08/27/2022. In an interview with the MDS Nurse on 07/01/2023 at 5:43 PM, she stated she did not do cognitive care plans, and this would fall into the responsibility of the Social Services Director (SSD). In an interview with the SSD on 07/01/2023 at 6:22 PM, she stated upon notification of a resident having cognitive changes, she was responsible for care planning and revising the care plan. She stated with cognitive changes, there would be increased supervision, the care plan would be updated accordingly, and documented in a Progress Note. The SSD stated she slightly remembered Resident #15's incident. She stated the resident was confused, and this was not normal for Resident #15. The SSD stated as she remembered, Resident #15 was confused and was trying to get out of the bed when he/she had the fall. However, review of the current CCP for Resident #15 revealed no documented evidence it had been revised to include interventions for increased supervision after the onset of cognitive changes on 08/22/2022. In an interview with the Director of Nursing (DON) on 07/01/2023 at 5:51 PM, he stated, after a change in condition, the nurse would notify the physician, increase monitoring, as evidenced by charting on every shift for seventy-two (72) hours. He stated this was just the standard of practice for nursing. The DON stated his expectation was for staff to carry out the best nursing practice. He further stated increased monitoring, by every fifteen (15) minutes or every thirty (30) minute checks, was an intervention which required a Physician's Order and should be on the care plan. He stated his expectation for a resident's change in condition was to notify the physician, the resident's family, carry out any new orders, and increase monitoring for seventy-two (72) hours, documented with a progress note on every shift. During an interview with the Administrator on 07/01/2023 at 6:40 PM, with the [NAME] President of Operations in attendance per the Administrator's permission, she stated she was not the Administrator at the time of Resident #15's fall and did not have a clinical background. But in this type of situation, she stated she would expect the staff to notify the physician and act on the physician's orders. She stated if it was not noted in a care plan, a nurse caring for a resident in this situation would learn in report of any changes in condition and the need for increased monitoring. 46651

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were as free of accident hazards as possible and failed to provide the necessary supervision to prevent accidents for one (1) of thirty-four (34) sampled residents (Resident #15). On 08/27/2022, Resident #15 sustained a fall after being observed to have confusion and hallucinations. Resident #15 was transferred and admitted to the hospital on 08/27/2022 and returned on 09/01/2022. Additionally, Resident #15 returned to the hospital where a transverse fracture to the right tibia (leg) from the previous fall was found. The findings include: Review of the facility's policy, Falls Standard of Practice, dated 07/2020, revealed the facility would ensure compliance with the regulatory intent of F689, that (i) the residents' environment remained as free of accident hazards as possibly, and (ii) each resident received adequate supervision and assistance devices to prevent accidents. Further review revealed each resident would have a Falls Risk Assessment completed by a licensed nurse, with immediate reasonable interventions initiated to reduce risk of falls. Continued review revealed a resident's care plan was to be updated with implemented interventions after a fall. Additional review revealed the Clinical Quality Assurance (QA) Interdisciplinary Team (IDT) would review and discuss any fall during the morning clinical meeting with the care plan updated to reflect any changes to risk factors or needed interventions. Subsequent review revealed residents experiencing a fall were reviewed to determine the effectiveness of current interventions or to identify potential new approaches. Review of Resident #15's medical record revealed the facility admitted the resident, on 02/20/2020, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Oxygen Dependence, Congestive Heart Failure (CHF), and Obstructive Sleep Apnea. Review of Resident #15's Quarterly Minimum Data Set (MDS) Assessment, dated 08/15/2022, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15). This score indicated Resident #15 was cognitively intact. Review of Resident #15's Progress Notes revealed the first evidence that Resident #15 was having confusion was documented on 08/09/2022, and again on 08/11/2022. At that time, staff notified the physician, who ordered laboratory tests. Further review revealed the confusion recurred, as noted on 08/22/2022. Review of the Progress Note revealed the resident was very confused and disoriented, had hallucinations, attempted to climb out of bed. Record review revealed labs were ordered related to the new confusion. Review of the Progress Note, dated 08/23/2022 at 6:26 PM, revealed staff received critical labs related to Resident #15's CO2 (carbon dioxide) level. Review of the Progress Note, dated 08/27/2022, revealed Resident #15 called out for help and was found sitting on his/her bottom with his/her back resting against the bed. Further review of the Note revealed Resident #15 was transferred to a local hospital Emergency Department (ED) for evaluation related to the fall and notable decline in his/her level of consciousness. Review of the Interdisciplinary Team (IDT) Note, dated 08/29/2023 at 10:46 AM, revealed Resident #15 had been admitted to the hospital because of his/her critical CO2 level. Continued review of the Progress Notes revealed the facility readmitted Resident #15, on 09/01/2022, with added diagnoses of Hypercapnic Encephalopathy and Acute Kidney Injury. Review of Resident #15's ED records, dated 08/27/2022, revealed the facility assessed the resident and found him/her to be lethargic and was placed on a BiPAP machine (Bilevel positive airway pressure known as BPAP, or more commonly under the trade name, BiPAP, a machine that helps you breathe). Further review revealed Resident #15 was seen in the ED due to confusion with hallucinations over the past few days. Continued review of the ED record revealed Resident #15 was admitted to the hospital and received a CT scan, which was labeled tibia/fibula, but the study performed was of the femur, which revealed no fracture. Review of the Nursing Note, dated 09/05/2022, and the hospital ED record revealed Resident #15 was transferred to a local hospital ED, on 09/05/2022, for evaluation of a possible infection. Further review revealed the resident was diagnosed with a broken right tibia (leg) from the previous fall found after completing a Computed Tomography (CT) scan and X-ray. The Note also revealed Resident #15 was then transferred to a different acute care hospital related to the fracture. Review of the Progress Notes revealed Resident #15 returned to the facility on [DATE] after hospital care. Review of Resident #15's hospital records from the second admission on 09/05/2022 at Hospital #2, revealed he/she was admitted for treatment of the acute, traumatic, closed, right distal tibia/fibula fracture of the right lower extremity. Further review revealed the right lower extremity was splinted in the operating room. Continued review revealed no surgical intervention for the fracture was planned. The facility readmitted Resident #15 on 09/18/2022. Review of Resident #15's Comprehensive Care Plan, revealed a Fall Plan was initiated on 03/05/2020. The contributing problem was risk for injury as evidenced by need for assistance with Activities of Daily Living (ADL) related to COPD, CHF, morbid obesity, Hypertension, incontinency, and medications. Continued review revealed interventions were initiated on 03/05/2020 with one more added on 03/23/2023 and none added after the fall on 08/27/2022. Review of the fall care plan revealed interventions, dated 03/05/2020, included laboratory tests as ordered, monitor for side effects of medications every shift, notify Medical Doctor as needed, O2 and bipap per orders, PT evaluation/tx as indicated. Observation of Resident #15, on 06/27/2023 at 11:04 AM, revealed the resident was resting comfortably, with no signs of distress, and oxygen (O2) in place per nasal cannula at four (4) L per minute. In a telephone interview with Resident #15's Daughter on 06/29/2023 at 12:10 PM, she stated the resident became confused if his/her O2 was too low and that she had asked the facility about adding an alarm to Resident #15's bed. She stated the facility's staff had discussed several options about fall prevention, but her suggestions were met with reasons why they could not be done. Resident #15's Daughter stated the facility had not tried any fall prevention interventions of which she was aware. She stated she could not remember if her parent's leg was broken when he/she fell out of bed in August 2022. In a continued interview with Resident #15's Daughter, on 06/29/2023 at 12:10 PM, she stated she understood that staff members were busy, but if Resident #15 became confused and an alarm could not be on his/her bed, the facility needed to put someone in the room with him/her until he/she got back to normal. She also stated Resident #15 was normally alert and without confusion. The Daughter stated Resident #15 would not wear his/her Continuous Positive Airway Pressure (CPAP, only provided one level of airway pressure) machine and got carbon dioxide (CO2) buildup, which made him/her confused. In an interview with Resident #15 on 06/29/2023 at 4:30 PM, he/she stated that he/she was hallucinating when he/she fell out of bed. The resident stated he/she did not recall the date of that fall. Resident #15 further stated he/she had a CPAP, but did not wear it because he/she hated it. Resident #15 stated he/she did not recall subsequent incidents of hallucinating, and he/she had not fallen again. Resident #15 stated he/she did not have surgery to repair the fracture due to his/her CHF. In an interview with the State Registered Nursing Assistant (SRNA) #7 on 06/30/2023 at 4:10 PM, she stated Resident #15 was disoriented the day he/she fell out of bed. She stated Resident #15's confusion seemed intermittent; namely, he/she would be speaking normally then say something off the wall. She also stated the disorientation was not Resident #15's baseline. In an interview with Licensed Practical Nurse #7 on 06/30/2023 at 3:47 PM, she stated she recalled when Resident #15 fell out of bed because she worked that hallway the following shift. She stated Resident #15 was transferred to the hospital for evaluation after the fall. In an interview with the Social Services Director (SSD) on 07/01/2023 at 6:22 PM, she stated she was responsible for care planning with cognitive loss or changes. She stated with a notification of a resident having cognitive changes, there would be increased supervision, the care plan would be updated accordingly, and documented in a Progress Note. She stated care plan reviews occurred in the IDT meeting, where the team updated the care plan depending on the reason for the change. With cognitive changes, she stated it could be a nursing care plan if the cause of the confusion was medical, such as a urinary tract infection or O2 issues. She stated she slightly remembered Resident #15's incident. The SSD stated as she remembered, Resident #15 was confused and was trying to get out of the bed. She stated, in a situation like that, the physician was normally notified and labs requested to determine the cause of the confusion. In an interview with the Director of Nursing (DON) on 07/01/2023 at 5:51 PM, he stated, after a change in condition, the nurse would notify the physician, increase monitoring, and chart on every shift for seventy-two (72) hours. The DON stated this was just the standard of practice for nursing. He stated per this standard of practice, there were increased progress notes for those days. The DON stated actions after a resident's change in condition were based on the Physician's Orders. He stated his expectation was for staff to carry out the best nursing practice. The DON stated he expected the nursing staff to make prudent decisions and notify the physician. He stated staff might not notify the DON necessarily, but he preferred to be notified for a resident's fall. The DON stated increased monitoring, by every fifteen (15) or every thirty (30) minute checks, was an intervention requiring a Physician's Order and would be on the care plan. He also stated that currently there was only one (1) resident on a bed alarm or chair alarm because the facility was limited on those. During continued interview, the DON stated Resident #15 did not currently have a bed alarm, but he was not sure whether the resident had ever had an alarm intervention. He stated his expectation for a resident's change in condition was to notify the physician, the resident's family, carry out any new orders, and increase monitoring for seventy-two (72) hours, documented with a Progress Note on every shift. The DON stated actions taken following new onset confusion would depend on the Physician's Orders. During an interview with the Administrator on 07/01/2023 at 6:40 PM, with the [NAME] President of Operations in attendance, she stated she was not the Administrator at the time of Resident #15's fall and did not have a clinical background. But in this type of situation, she would expect the staff to notify the physician and act on the Physician's Orders. She further stated staff called the doctor and did what he ordered in response to Resident #15's fall. She stated the physician ordered laboratory tests, vital signs, and increased documentation. The Administrator and the DON both emphasized increased supervision and defined it as the staff charted on the resident on each shift, and did not define it as every 15 or 30 minute checks. She stated she was not sure of the frequency of supervision, and that was dependent on the situation. The Administrator stated she did not know if Resident #15 was close to the nurse's station, but the staff was checking on him/her more frequently after. If not in a care plan, she stated a nurse caring for a resident in this situation would learn in report of any changes in condition and the need for increased monitoring. She additionally stated the IDT met two (2) days after the fall, when the resident was admitted to the hospital. She stated IDT notes documented the care plan was changed, and the intervention noted was medical workup at the hospital.

Based on observations, interviews, and record review, it was determined the facility failed to ensure menus were posted and/or followed as posted. Review of the menus posted for the 06/27/2023 lunch meal did not match the foods observed to be served to the residents. This deficiency affected sixty-four (64) of sixty-five (65) current residents; one (1) resident was receiving tube feedings and did not receive meal trays. The findings include: Observation of the posted lunch menu for 06/27/2023 at 9:10 AM, and review of the facility's menus for week two revealed the facility menu listed hamburger on a bun with lettuce, tomato, ketchup, pickle spear, confetti coleslaw, french fries, and chocolate chip cookies were to be served to the residents for lunch. However, observation of the tray line, on 06/27/2023 at 12:00 PM, revealed the residents' meal being prepared consisted of hot dogs, mashed potatoes, fried potatoes and cole slaw. Review of the facility's menu for week one (1), for the Saturday 06/24/2023 lunch meal, revealed the lunch menu listed roast turkey with gravy, steamed broccoli florets with lemon, rice pilaf, dinner roll and cherry cheesecake bar. Interviews with Residents #38, #48, and #2, during the Resident Council Meeting on 06/28/2023 at 2:00 PM, the Council members stated the facility served hotdogs on 06/24/2023 and 06/27/2023. The Members stated the menus were not always posted and or followed. 1. Record review revealed the facility admitted Resident #2 on 11/09/2021 with diagnoses which included Hypertension, Pressure Ulcer, Unspecified Stage, and Depression. Review of Quarterly Minimum Data Set (MDS) Assessment, dated 06/12/2023, revealed the facility assessed Resident #2 with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen, which indicated Resident #2 was cognitively intact. During an interview with Resident #2 on 06/28/2023 at 10:38 AM, he/she stated that most of the time the menu that was posted was not the meal that would actually be served. 2. Record review revealed the facility admitted Resident #38 on 07/28/2021, with diagnoses which included Congestive Heart Failure, Hypertension and Cardiovascular Accident. Review of the Quarterly MDS Assessment, dated 06/16/2023, revealed the facility assessed Resident #38 with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) which indicated Resident #38 was cognitively intact. During an interview with Resident #38 on 06/28/2023 at 2:30 PM, he/she stated he/she had worked thirty years in the food service industry. Resident #38 stated menus were not usually posted and sometimes the facility served food that was not on the menu. During interview with Dietary Aide #1 on 07/01/2023 at 2:20 PM, she stated she had been with the facility for approximately one (1) year, and received training during her orientation and received periodic inservices related to food handling and storage. She stated if they ran out of supplies they must find a substitute item and obtain permission from their supervisor before they can use it. Dietary #1 stated that alternate meals were mandatory and that they would do special requests if they were given advanced notice. In an interview with Dietary Cook #1 on 07/01/2023 at 4:17 PM, he stated he was new to the facility. He stated he tried to prepare alternate food selections as soon as he was made aware of the need for them. Dietary Cook #1 stated he would consult with his manager if a substitution was needed. During an interview with the Certified Dietary Manager (CDM) on 06/29/2023 at 11:46 AM, she stated menus were seasonal and were changed out monthly. The CDM stated she was aware that the menu had been changed. She stated on 06/24/2023, hot dogs had been served but she could not recall why the menu had not been followed. The CDM further stated the lunch menu on 06/27/2023 had been changed as the facility's vendor had not delivered the hamburger patties, so hot dogs were served instead. She stated the residents were made aware of the changes while in the dining room. During an interview with the Registered Dietician (RD) on 07/01/2023 at 10:13 AM, she stated she had been the facility's RD for about three (3) weeks. She stated she was not aware the facility had changed the menus. The RD stated the CDM should made her aware when a product was not available in order to decide what substitute could be made. In an interview with the Administrator on 07/01/2023 at 6:01 PM, she stated the Dietary Manager was responsible for ensuring menus were posted and followed as indicated. She stated if menu items were not available that was to be communicated to the Registered Dietician for changes that needed to occur. She stated the Dietary Manager made her aware when items were not available. 47567

Based on observation, interview and facility policy review it was determined the facility failed to provide food and drink that was palatable and attractive for six (6) of thirty-four (34) sampled residents (Residents #2, #23, #27, #36, #38 and #54). The findings include: Review of the facility's policy, Food: Quality and Palatability, revised 09/2017, revealed food would be palatable, attractive, and prepared and served in a manner, form, and texture to meet resident's needs. Observation during lunch tray line, on 06/27/2023 from 12:00 PM through 12:30 PM, of the steam table, revealed the pureed hotdog and the mashed potatoes were of a soupy consistency. Continued observation revealed the hotdogs soaking in water were discolored. 1) Record review revealed the facility admitted Resident #54 on 09/20/2021 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, and Hypertension. Review of Resident #54's Quarterly Minimum Data Set (MDS) Assessment, dated 05/14/2023, revealed the facility assessed Resident #54 with a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen, which indicated Resident #54 was cognitively intact. In an interview with Resident #54 on 06/28/2023 at 8:32 AM, Resident #54 stated, the food quality was not the greatest because most of the time it did not taste good and sometimes it looked bad. Resident #54 showed the State Survey Agency (SSA) Surveyor a video of a pancake that was served to him/her for breakfast on or around the morning of 12/15/2022. The pancake appeared to be hard when hit against the table. Additionally, Resident #54 provided pictures of banana slices that were turning brown and were wrapped in plastic wrap. Resident #54 stated, they were given out for snack the other day and he/she was unable to eat them. 2) Record review revealed the facility admitted Resident #2 on 11/09/2021 with diagnoses which included hypertension, pressure ulcer, unspecified stage, and depression. Review of Resident #2's Quarterly MDS Assessment, dated 06/12/2023, revealed the facility assessed Resident #2 with a Brief Interview for Mental Status (BIMS) score of fifteen of fifteen, which indicated Resident #2 was cognitively intact. In an interview with Resident #2 on 06/28/2023 at 10:38 AM, the resident showed the Surveyor pictures of a previous meal that was served to him/her on 02/03/2023. In the picture the meal ticket read, Regular Diet- Double Meat protein, Smothered Steak, roasted green beans, Spaghetti Noodles, Herbed dinner roll, tropical fruit salad, and tea. However, Resident #2's meal tray in the photograph showed he/she was served a dinner roll, green beans, and macaroni noodles. No meat protein item was noted on the dinner tray. Resident #2 stated that often times the food was not palatable. 3) Record review revealed the facility admitted Resident #23 on 01/10/2023 with diagnoses which included End Stage Renal Disease, Hypertension, and Diabetes Mellitus Type 2. Review of Resident #23's Quarterly MDS Assessment, dated 05/02/2023, revealed the facility assessed Resident #23 with Brief Interview for Mental Status (BIMS) score of fifteen of fifteen, which indicated Resident #23 was cognitively intact. In an interview with Resident #23 on 06/27/2023 at 3:40 PM, the resident stated the food temperatures were okay but the food did not taste well. 4) Record review revealed the facility admitted Resident #36 on 12/13/2022 with diagnoses which included Type 2 Diabetes Mellitus, Chronic Congestive Heart Failure, and Hypertension. Review of Resident #36's MDS Assessment, dated 04/25/2023, revealed the facility assessed Resident #36 with a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), which indicated no cognitive impairment. In an interview with Resident #36 on 06/27/2023 at 11:45 AM, he/she stated the food was awful and he/she would notfeed it to a dog. Resident #36 stated the meat was hard and tough. 5.) Record review revealed the facility admitted Resident #27 on 02/08/2021, with diagnoses which included Type 2 Diabetes Mellitus, Morbid Obesity (severe) due to excess calories, and fluid overload. Review of Resident #27's Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #27 with a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. During interview with Resident #27 on 06/27/2023 at 9:55 AM, the resident stated he/she had been at the facility for almost two (2) year. Resident #27 stated he/she had diabetes and had complained that the food served, was not enough and was not palatable. The resident stated there had been times that dinner was not served until after 7:30 PM. Resident #27 stated the food would be cold, and portions were small. He/she stated, It's not good, it's nasty. The resident stated, For instance, today for breakfast he/she was served eggs and hash browns, no meat. Additionally, Resident #27 stated the food was usually cold and late when served. He/she stated he/she would get served peas yet, he/she had told staff and dietary many times that he/she did not like peas. Resident #27 stated one night he/she was served mashed potatoes, potato wedges, and macaroni and cheese. The Resident stated that was too many carbohydrates, and the portions were too small. Resident #27 stated he/she was served what looked like tomato soup with rice, might have been two (2) spoonfuls; not enough to say it was a serving. In an interview with Dietary Cook #1 on 07/01/2023 at 4:17 PM, he stated he was new to the facility. He stated he tries to accommodate resident preferences the best he could by preparing alternate selections when the need arose. He stated, he tried to dress the plates to make the food look more appealing. In an interview with the Registered Dietician (RD) on 07/01/2023 at 10:13 AM, she stated she was new to the facility as of three (3) weeks ago. She stated she was unaware of any resident concerns with food but would be following up with the Certified Dietary Manager (CDM). In an interview with the Administrator on 07/01/2023 at 6:01 PM, she stated she expected food to be palatable for the residents to eat. She stated the Dietary Manager was responsible for oversight of the kitchen. The Administrator stated she had received test trays on multiple occasions and if any concerns were noted they would be addressed with the CDM and RD. 45113 46651 47567

Based on interview, record review, and review of the facility's Administrator's and Director of Nursing's Job Descriptions, it was determined the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to maintain substantial compliance, after the 05/21/2020, Abbreviated Survey, in the areas of 42 CFR 483.10 Notification of Change (F580); 42 CFR 483.25 Quality of Care (F684); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657); and 42 CFR 483.70 Resident Records-Identifiable Information (F842). During the 05/21/2020 survey, F580, F657 and F684 were cited at the Immediate Jeopardy level. Observations, interview, and record review revealed the facility's administration failed to use its resources to provide quality care and services to meet the needs of the residents. (Refer to F580, F656, F657, F684, F686, F692, F842, F867, F880, and F886) In addition, the facility's administration failed to ensure the facility maintained the standard levels of care and services for its residents. (Refer to F658, F695, F761 and F812). The facility's failure to be administered in a manner that enabled the effective use of its resources has caused or is likely to cause harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/25/2022 and was determined to exist on 09/12/2021, 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) at the highest scope and severity (s/s) of a J, 42 CFR 483.25 Quality of Care (F686) at an s/s of a J, 42 CFR 483.70 Administration (F835 and F837), at the highest s/s of an L; and F842 at an s/s of a J, 42 CFR 483.75 Quality Assurance and Performance Improvement (F867) at an s/s of an L, and 483.80 Infection Control (F880) at an s/s of an L. The facility was notified of Immediate Jeopardy on 02/25/2022. An acceptable Immediate Jeopardy Removal Plan was received on 03/03/2022, which alleged removal of the Immediate Jeopardy effective 03/03/2022. However, the State Survey Agency was unable to validate the removal of the Immediate Jeopardy prior to exit on 03/04/2022. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's, Job Description for the Administrator, undated, revealed the Administrator's operational responsibilities included the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that governed nursing facilities to assure the highest degree of quality of care would be provided to residents at all times. Continued review revealed the Administrator's essential functions included facility and compliance management, and facility staffing and retention. The Administrator was responsible to ensure excellent care for residents was maintained by overseeing and monitoring resident care services delivered. Per review of the Job Description, the Administrator worked with and supervised personnel in the facility to provide opportunity for instruction, guidance, and counsel as necessary to ensure a complete understanding of responsibilities. Further review revealed the Administrator would ensure the maintenance of accurate medical records for auditing and regulatory compliance within appropriate approved guidelines. Review of the facility's Job Description for the Director of Nursing (DON), undated, revealed the DON's responsibilities were to plan, organize, develop, and direct the overall operation of the facility's nursing department, in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities, as directed by the Administrator, to assure the highest degree of quality of care was provided for residents at all times. Continued review revealed the essential functions of the DON position included supervision and evaluation of all nursing services provided in the facility. The DON was responsible for ensuring that the medical records and reports concerning resident care were maintained. Further review revealed the responsibility of the DON included determining staffing needs and to ensure orientation and training of nursing services personnel. In addition, the DON was also responsible for communicating to the Administrator, nursing concerns and identified problem areas with the developed plans of action to address the concerns/problem areas. Interview with the facility's Vice President of Operations (VPO), on 02/25/2022 at 10:30 AM, revealed there was not a job description for the Regional Quality Manager (RQM) position. Interview with the Regional Quality Manager (RQM), on 02/24/2022 at 12:22 PM, revealed she provided oversight of the clinical processes in the facility. She stated she provided clinical resources and support for the Director of Nursing (DON) and the Administrator through Quality Assurance (QA) review. Review of the 05/21/2020 Abbreviated Survey's Plan of Correction, and the 03/04/2022 findings revealed the facility failed to maintain compliance and be administrated in a manner to provide quality care and services. The facility was cited at actual harm and Immediate Jeopardy on both surveys. The facility was previously cited deficiencies, on 05/21/2020 related to notification to the provider secondary to a change in a resident's conditions; providing care to residents per standards of practice; revisions to the care plan with changes in a resident and their necessary care; pain management with a resident's change in condition; and maintaining accurate and consistent medical documentation/records. The same areas of deficient practice were identified on the 03/04/2022 survey. Interview with Director of Nursing (DON) #1, on 02/25/2022 at 1:00 PM, revealed she had been the DON at the facility from the spring of 2020 until mid-November 2021. Continued interview revealed her job was to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently. She stated the Regional Quality Manager (RQM) had been present in the building weekly and provided resources and education directly for her. Further interview revealed, she was uncertain if her job description or responsibilities had been reviewed with her upon hire. DON #1 further stated the RQM's involvement in Quality Assurance (QA) reviews in the facility was how deficient practices were identified. Per interview, the DON was responsible for addressing deficient practices identified by the RQM. Interview with the Regional Quality Manager (RQM), on 02/24/2022 at 12:22 PM, revealed she had been the RQM for one (1) and a half years at the facility and had been the acting DON #2, from December 23, 2021, until January 24, 2022. However, she had been out of the facility most of December 2021. Per interview, she was not part of the administration of the facility while acting as the DON, or as the RQM. Continued interview revealed she had no power in the facility for making changes in either role. However, she started her job was to provide clinical resources and support to the DON and the Administrator through the ongoing QA review. Further interview revealed she had gone over the DON #1's job responsibilities with her and had also discussed with her the state and federal regulations. Interview with DON #3, on 02/16/2022 at 2:15 PM, revealed he had been in the DON role for only one (1) month, from January 24, 2022, until February 18, 2022. Per interview, the Administrator had reviewed his DON job description and responsibilities with him upon hire, and he was considered part of the facility's Administration. Continued interview revealed he had been responsible for the overall operations of the facility's nursing department while in the DON role. However, he stated he had no long-term care background experience and had not received training from the facility related to the responsibilities of the DON role. Continued interview revealed he was told upon hire he would receive training from another DON at a sister facility; however, he had not been provided that training. In addition, he stated he was not familiar with the state and federal regulations for long-term care. He further stated he had been responsible for the care needs of the facility's residents and the supervision of its nursing staff. DON #3 stated that he ensured residents received the necessary care and services and provided the supervision of nursing staff as required through the department's morning clinical meeting. He stated that in the meetings orders, change in condition, incidents, admissions/transfers/discharges, etc., that occurred within the last twenty-four (24) hours were reviewed. Interview with the Administrator, on 02/25/2022 at 1:00 PM, revealed she had been in the role for four (4) months and had a temporary license. She stated she was responsible for ensuring the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Continued interview revealed her job description was reviewed with her by the VPO when she was hired into the Administrator role. Per interview, she had the State Operational Manual in her office to use as a resource. The Administrator stated she was responsible for the care needs of the facility's residents and for the supervision of its staff. She stated she was the DON's direct supervisor. The Administrator revealed she believed the facility addressed the identified 05/21/2020 Survey concerns through its Quality Assurance (QA) program. Further interview revealed she was not aware of any continued audits related to the notification of change, care plans, quality of care, and resident records. The Administrator further revealed she had not reviewed the facility's previous survey results, nor the QA documents prior to accepting the role of Administrator. She stated that she had not reviewed the previous survey results because it occurred when she was a social worker and not an Administrator at the facility. Further interview revealed she ensured her responsibilities were accomplished through ongoing quality reviews completed by the RQM and DON. She stated that she talked with the VP of Ops, RQM and DON daily about what was going on in the facility. Continued interview revealed she relied on the RQM's and DON's oversight of clinical processes in the facility to ensure all clinical staff and processes were in place, per the Policy and Procedure. In addition, interview on 02/25/2022 at 1:00 PM, with the Administrator revealed she was not aware of any of the deficiencies cited during the current survey having been addressed in the facility's QA Committee meetings: Interview with the former VPO, on 02/25/2022 at 2:51 PM, revealed her current role was to provide support for the facility's Administrator. Continued interview revealed she was unaware of concerns that had been identified within the facility, prior to the State Survey Agency's (SSA) arrival in the facility for the current survey. She stated she had been the VPO for six (6) years and had provided oversight for the Administrator. The VPO revealed she was in contact with the Administrator daily and was present in the facility twice a month to provide support and resources. Per the VPO, the facility had experienced changes in leadership, specifically the Administrator, and the DON. Further interview revealed she had worked with the Administrator to help her understand the Administrator role as she transitioned into the new role. The VPO further stated she would continue to provide oversight of the Administrator and would be watching over the daily operations of the facility.

Based on observation, interview, record review, review of facility policy, and review of the facility's Plan of Correction submitted for 05/21/2020 survey, it was determined the facility failed to have effective processes in place to address system failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) meetings. As a result, the facility failed to identify quality of care deficiencies, failed to develop and implement plans of action to correct identified quality of care deficiencies, and failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. This was evidenced by deficient practice cited at F580, F657, F684, and F842, which had previously been cited on 05/21/2020. During the 05/21/2020 survey, Immediate Jeopardy was identified at 42.CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657); 42 CFR 483.25 Quality of Care (F684); and 42 CFR 483.70 Resident Records-Identifiable Information (F842). The facility submitted an acceptable Plan of Correction (POC) alleging compliance as of 05/13/2020. However, the facility failed to maintain substantial compliance resulting in current deficient practice being cited at the Immediate Jeopardy level in the same areas. The facility's failure to have an effective Quality Assusrance Program in place has caused or is likely to cause harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/25/2022 and was determined to exist on 09/12/2021, 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) at the highest scope and severity (s/s) of a J, 42 CFR 483.25 Quality of Care (F686) at an s/s of a J, 42 CFR 483.70 Administration (F835 and F837), at the highest s/s of an L; and F842 at an s/s of a J, 42 CFR 483.75 Quality Assurance and Performance Improvement (F867) at an s/s of an L, and 483.80 Infection Control (F880) at an s/s of an L. The facility was notified of Immediate Jeopardy on 02/25/2022. An acceptable Immediate Jeopardy Removal Plan was received on 03/03/2022, which alleged removal of the Immediate Jeopardy effective 03/03/2022. However, the State Survey Agency was unable to validate the removal of the Immediate Jeopardy prior to exit on 03/04/2022. The Immediate Jeopardy is ongoing. Refer to F580, F657, F684, and F842 The findings include: Review of the facility's policy titled, QAPI Plan Standard of Practice, dated 06/2020, revealed the purpose of the Quality Assurance and Performance Improvement (QAPI) program was to provide overall guidance to the facility, to provide excellence in quality of care and support quality of life through patient centered care. Continued review revealed the facility conducted an annual Facility Assessment review, systematic performance evaluation, problem analysis and implementation of improvement strategies to achieve its quality goals. Further review revealed the scope of the facility's QAPI activities was to include all service areas and be supported by the facility's QAPI Interdisciplinary Team (IDT) members. Review of the Job Description for the Administrator, undated, revealed the Administrator was responsible for the facility's day-to-day functions in accordance with current federal, state, and local standards, guidelines, and regulation that governed nursing facilities to assure the highest degree of quality of care was provided at all times for residents. Continued review revealed the essential functions of the Administrator position included facility and compliance management, and facility staffing and retention. Review revealed the Administrator was responsible for ensuring excellent care of facility residents which was maintained through the overseeing and monitoring of patient care services being delivered. Further review revealed the Administrator was to work with and supervise facility personnel in order to provide opportunity for instruction, guidance, and counseling as necessary to ensure personnel had complete understanding of their responsibilities. Review further revealed the Administrator ensured the maintenance of accurate medical records for auditing and regulatory compliance within appropriate approved guidelines. Review of the Acceptable Plan of Correction (POC), for the Abbreviated Survey dated 05/21/2020, revealed for the deficient practice which had been cited at F580, the facility had provided education for licensed nurses regarding physician notification with changes of condition in residents, and the documentation required for physician notifications. Continued review of the POC revealed for the deficient practice cited at F684, the facility implemented resident skin inspections to include new/undocumented skin impairments and pain assessment. Further review of the POC revealed for the deficient practice cited at F842, residents' care plans were updated with new interventions related to a change in resident status in the electronic medical record. The POC review revealed for the deficient practice cited at F657, the facility provided education for licensed nurses related to the regulatory requirement that resident care plans were to be updated when a change of condition occurred for a resident. Further review of the Plan of Correction (POC), for the survey dated 05/21/2020, revealed the DON, Unit Manager or Wound Nurse, or weekend Registered Nurse (RN) supervisor would review the audits initiated on 05/08/2020 on a daily basis for Physician orders. Review of the POC further revealed for the audits which had been initiated for validating updated care plan and skin/wound assessments, the DON, Unit Manager or Wound Nurse, or weekend Registered Nurse (RN) supervisor would review the audits until the facility achieved regulatory compliance. In addition, the POC review additionally revealed the results of the facility's monitoring/auditing would be reviewed a minimum of weekly in the facility's QAPI meetings being held to track the facility's progress toward regulatory compliance. Finally, review of the POC for the 05/21/2020 survey revealed the QAPI meetings included, but were not limited to the: Administrator, Director of Nursing, Unit Managers, Human Resources, Business Office Manager, Social Services Director, Activities Director, Dietary Manager, Minimum Data Set (MDS) Coordinator and Medical Records. Review of the facility's Quality Assurance (QA) Committee meeting documentation revealed meetings held on 05/05/2021, 05/26/2021, which were concerning mock surveys results and actions, with the attendees noted as former Administrator #1, Medical Director, Director of Nursing (DON) #1 and current Administrator (#2), who had been the former Social Services Director (SSD). The same attendees were noted for the 06/12/2021, and 07/30/2021 meetings, and for the 08/03/2021, and 08/26/2021 meetings the attendees included former Administrator #1, DON #1 and current Administrator #2 (former SSD). Continued review revealed for the 09/17/2021, and 10/15/2021 meetings the attendees included Administrator #2 and former Registered Nurse (RN)/Education Training Director #2. Review of the 11/23/2021, and 11/30/2021 meetings revealed the attendees included Administrator #2, and DON #1. Further review revealed Administrator #2, DON #2 were noted as attending the 12/30/2021 meeting, and the Medical Director noted as attending by phone. Interview on 02/22/2022 at 5:18 PM, with former Wound Nurse #1 revealed she had informed the Administrator in November 2021, that there were issues with the facility's wound care and treatment and documentation. Continued interview revealed at that time the facility implemented changes to its weekly skin assessment protocol and direct care nurses were provided a schedule for skin assessments and responsibility to complete the assessments weekly. According to the Wound Nurse, she had worked as a direct care nurse, Unit Manager and the Wound Nurse in the months of November 2021 and December 2021. She revealed; however, she was responsible for weekly wound assessments and wound care for residents who had wounds. Further interview with the former Wound Nurse #1, on 02/22/2022 at 5:18 PM, revealed she had been working one hundred and twenty (120) to one hundred and fifty (150) hours per week in November and December 2021 and had not been able to complete her Wound Nurse care duties. She stated she had informed the Administrator #2, at that time, that she could not do what needed to be done with residents' wounds. The Wound Nurse stated she had also informed Administrator #2 at the same time that she had identified direct care nurses were not completing the documentation for things such as assessment and treatment administration records. Further interview revealed the Administrator #2 asked her to complete a skin sweep of all residents' skin status in the facility in January 2022, which she had completed and documented. The Wound Nurse stated she provided the hand-written reports to the Administrator after completing the skin sweep. She further revealed she had become frustrated with the situation and no longer worked as a full-time nurse at the facility. Continued interview revealed she had not worked at the facility since 01/24/2022. In addition, the Wound Nurse revealed she attended the Daily Clinical Reports (DCR) meetings, to discuss and review anything new with residents in the past twenty-four (24) hours and check to see if everything had been done related to the resident's care. She further stated she could not attend every DCR meeting due to working on the units as assigned. Interview with the Assistant Minimum Data Set (MDS) Coordinator #1, on 02/24/2022 at 8:55 AM, revealed Monday through Friday, she attended the DCR meetings. Continued interview revealed in the DCR meetings Physicians' orders, labs, residents' skin assessment progress notes were reviewed, and residents' care plans updated. The MDS Coordinator revealed she attended the facility's monthly QAPI meetings, where she made changes to residents' care plans. Further interview revealed she had not identified any issues concerning the care plans. Interview with Registered Nurse (RN) #1, the Director of Nursing (DON) on 02/25/2022 at 12:21 PM, revealed she was responsible for completing the facility's Quarterly review of residents' falls. She revealed her responsibilities also included: attending weekly resident falls meetings; performing audits of residents' laboratory (lab) results; and reviewing new and discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the DON's position was to assist in ensuring the facility was administered in a manner which enabled it to use its resources effectively and efficiently. The DON further revealed she took part in the facility's monthly QAPI meetings, QAPI Committee members, including herself, had not identified any issues with the residents' wounds. Interview on 02/25/2022 at 1:00 PM, 02/25/2022 at 4:56 PM and 02/25/2022 at 6:09 PM, with Administrator #2 revealed around the time of the 05/21/2020 Abbreviated Survey she had participated in the facility's Quality Assurance (QA) program as the Social Services Director (SSD). Interview revealed; however, she could not recall what had been audited at that time, or when the facility had achieved compliance as she had not been a clinical person for the deficient practice cited at F580, F657, F684, and F842. She stated the POC dated 05/21/2020 had been reviewed in the facility's QA Committee meetings. Continued interview revealed when she had been hired as the Administrator, in November 2021, she was not made aware of any ongoing audits regarding the facility's previous POCs. An additional interview with the Administrator on 02/25/2022 at 1:00 PM; 4:56 PM, and 6:09 PM, revealed she assumed the ongoing audits that were discussed in the QA Committee meetings, and that the facility had achieved regulatory compliance. She revealed the facility's QA Committee had not identified concerns in those areas since she had become the Administrator. The Administrator revealed she relied on the clinical leads, the DON and Regional Quality Manager (RQM), to bring any concerns to the QA Committee's and her attention. Further interview revealed; however, she was not aware of any concerns with the clinical practices within the facility. She further stated she was not familiar with the facility's Governing Body or that the Governing Body was responsible for establishing and implementing policies regarding the management and operation of the facility. In addition, the Administrator revealed it was her responsibility to ensure all facility processes established by the Vice President of Operations (VPO) were maintained including the facility's Quality Assessment and Assurance (QAA) and QAPI programs. Interview with the Regional Quality Manager (RQM) on 02/24/2022 at 12:22 PM, revealed she was aware of the concerns regarding residents' wounds, weights, and clinical documentation within the facility and had informed the Administrator of the concerns. Interview revealed the RQM stated she reviewed the facility's systems, processes, Quality Indicators, and made recommendations to the Administrator and DON. Per interview, the RQM reviewed documentation for quality indicators and the nursing departments process, such as falls, skin, weights, labs, etc. She then compiled the review into a report she provided to the DON and the Administrator, per email or verbal report, weekly. Continued interview revealed if concerns were identified in her review, she would discuss her findings with the DON and the Administrator and strongly recommended a process on how to make change; but it was ultimately up to the Administrator and the DON to implement the change. In January, 2022, she identified wound/skin assessment were not documented/completed weekly in the medical record. Further interview with the RQM, on 02/24/2022 at 12:22 PM, revealed; however, any changes that would be made, after discussing the concerns with the Administrator, were ultimately up to the Administrator and the DON. Continued interview revealed the facility's resident wound system was broken due to the lack of documentation by nursing staff. She stated she had informed the Administrator of identified concerns regarding the lack of documentation for residents' wounds and wound care. Further interview revealed for the facility's QA, the DON was supposed to audit resident's labs to ensure none were missed, and audit residents' skin and wounds weekly. The RQM revealed; however, the facility had no documented evidence of audit sheets for 05/21/2020 through 12/2021. She further revealed due to the high turnover of facility DON's from 12/23/2021 to 02/24/2022, the audits had not been completed and had not been available for review in the DCR meetings. Interview on 02/25/22 at 3:00 PM, with the Vice President of Operations (VPO), revealed she had worked in her role since 2016 and she provided oversight and support for the Administrator. The VPO stated the RQM notified the Administrator of any clinical areas of concern for the facility. Continued interview revealed the RQM audited the facility's QA processes through use of a clinical score card, which had been conducted on 05/2021. The VPO revealed if any issues were identified by the RQM, the issues were worked through in the facility's QA process. She stated the RQM visited the building weekly and reported any identified concerns from the visits to her (VPO). Further interview revealed the RQM had not communicated any identified concerns regarding residents' wounds or the facility's wound process. She further revealed the facility had a process in place to audit residents' wounds weekly and determine if wound treatment had been completed as per the facility's policy. In addition, the VPO further stated the RQM reviewed the documentation in residents' electronic medical record for any omissions and reported any documentation issues or other identified issues to the DON. Interview on 02/24/2022 at 1:30 PM, with the facility's Medical Director revealed she participated with the Administration and DON and other leadership personnel to oversee any clinical issues regarding medical care. Continued interview revealed she took part in the facility's regular QA meetings and had provided her input during that process. The Medical Director revealed there had not been any routine QA meetings for 01/2022 and 02/2022 until the occurrence of the facility's standard survey. She stated the facility's Administration was responsible for the oversight of its resources to ensure and maintain best care practices for residents. Further interview revealed the Medical Director had identified lapses in the facility's documentation of residents' wound assessments which were to be documented in order to know if a resident's wound had improved or worsened. In addition, the Medical Director stated she had identified the inconsistent documentation in residents' Medication Administration Records (MARs) and Treatment Administration Records (TARs) and had informed the Administrator of that information.

Based on interview, record review, and review of the facility's policy, it was determined the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility. The Governing Body failed to ensure compliance in the areas of 42 CFR 483.10 Resident Rights,F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657; 42 CFR 483.25 Quality of Care, F684 and F697; and 42 CFR 483.70 Administration, F842 during the 05/21/2020 Abbreviated Survey. Continued non-compliance was cited during this Survey at 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657; 42 CFR 483.25 Quality of Care, F684 and F697; and 42 CFR 483.70 Administration, F842. The facility's failure to ensure the Governing Body implemented policies has caused or is likely to cause harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/25/2022 and was determined to exist on 09/12/2021, 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) at the highest scope and severity (s/s) of a J, 42 CFR 483.25 Quality of Care (F686) at an s/s of a J, 42 CFR 483.70 Administration (F835 and F837), at the highest s/s of an L; and F842 at an s/s of a J, 42 CFR 483.75 Quality Assurance and Performance Improvement (F867) at an s/s of an L, and 483.80 Infection Control (F880) at an s/s of an L. The facility was notified of Immediate Jeopardy on 02/25/2022. An acceptable Immediate Jeopardy Removal Plan was received on 03/03/2022, which alleged removal of the Immediate Jeopardy effective 03/03/2022. However, the State Survey Agency was unable to validate the removal of the Immediate Jeopardy prior to exit on 03/04/2022. The Immediate Jeopardy is ongoing. Refer to F580, F656, F657, F684, F686, F692, F697, F726, F835, F837, F842, F867 and F880 The findings include: Review of the facility's policy titled, Governing Body, undated, revealed the Governing Body consists of the Vice President of Operations (VP of Ops), the Regional Quality Manager (RQM), the Administrator and the Director of Nursing (DON). Per policy, the VP of Ops would be notified of state reportable events, falls with injury and unusual event/occurrences, and Statement of Deficiency/Plan of Correction status. Additionally, the VP of Ops, the RQM, and the DON would conduct routine follow up to include staffing, reportable events, Statement of Deficiency/Plan of Correction (SOD/POC) status, and policy and procedure. Continued review revealed the RQM and the DON would review general clinical issues such as risks, acute readmissions, interventions, systems, tracking/trending, and SOD/POC status. The Governing body would review the facility operational status including Regulatory Compliance, Quality Measure Improvement, Staff Development, and Census Development. Further, the Governing body would review the Clinical Score Card including evaluation of Quality Assurance (QA), infection, tracking/trending, investigations, outcomes, and hospital readmissions. The Governing body would also schedule meetings for all the Regional, Administrators, and the DONs to review education, policy/procedure updates and annual mock surveys. Review of the Statements of Deficiencies (SOD) for the Abbreviated Survey dated 05/21/2020, revealed Immediate Jeopardy was cited at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657), and 42 CFR 483.25 Quality of Care (F684) all at a S/S of a J. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F684). Deficient practice was also cited at 42 CFR 483.25, F697 at a S/S of a G and 42 CFR 483.70 Administration, F842 at a S/S of a D. An acceptable Allegation of Compliance was received on 05/13/2020, which alleged removal of Immediate Jeopardy on 05/13/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 05/13/2020 as alleged. However, the Governing Body failed to ensure compliance was maintained. During this Survey, repeat deficiencies from the Abbreviated Survey dated 05/21/2020 include 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657; 42 CFR 483.25 Quality of Care, F684 and F697; and 42 CFR 483.70 Administration, F842. Immediate Jeopardy (IJ) was cited at 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656 and F657; 42 CFR 483.25 Quality of Care, F684, F686 and F692; all a Scope and Severity (S/S) of a J. Additionally, Immediate Jeopardy (IJ) was cited at 42 CFR 483.70 Administration, F835 and F837 at a S/S of an L, and F842 at a S/S of a J; 42 CFR 483.75 Quality Assurance and Performance Improvement, F867, at a S/S of an L; and 42 CFR 483.80 Infection Control, F880, at a S/S of an L. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F684, F686, F692) and 42 CFR 483.45 Pharmacy Services (F760), at a s/s of an F. Interview with the Vice President of Operations, on 02/23/2022 at 11:56 AM, and 02/25/2022 at 10:30 AM, revealed when the company ownership changed in 2018, she no longer had a job description. Further interview revealed there was not a job description for the Regional Quality Manager (RQM). Review of the facility's, Job Description for the Administrator, undated, revealed the Administrator's operational responsibilities included the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulation that governed nursing facilities to assure the highest degree of quality of care would be provided to residents at all times. Continued review revealed the Administrator's essential functions included facility and compliance management, and facility staffing and retention. Review revealed the Administrator was responsible to ensure excellent care for residents was maintained by overseeing and monitoring resident care services delivered. Per review of the Job Description, the Administrator worked with and supervised personnel in the facility to provide opportunity for instruction, guidance, and counsel as necessary to ensure complete understanding of responsibilities. Further review revealed the Administrator would ensure the maintenance of accurate medical records for auditing and regulatory compliance within appropriate approved guidelines. Review of the the facility's, Job Description for the Director of Nursing (DON), undated, revealed the DON's responsibilities were to plan, organize, develop, and direct the overall operation of the facility's nursing department, in accordance with current federal, state, and local standards, guidelines, and regulation that govern nursing facilities, as directed by the Administrator, to assure the highest degree of quality of care was provided for residents at all times. Continued review revealed the essential functions of the DON position included supervision and evaluation of all nursing services provided in the facility. Per review of the DON's Job Description, the DON was responsible for ensuring the medical records and reports concerning resident care were maintained. Further review revealed the responsibility of the DON included determining staffing needs and to ensure orientation and training of nursing services personnel. In addition, review revealed the DON was also responsible for communicating to the Administrator, nursing concerns and identified problem areas with the developed plans of action to address the concerns/problem areas. Interview with Director of Nursing (DON) #1, on 02/25/2022 at 1:00 PM, revealed she was the DON at the facility from the spring of 2020 until mid-November 2021. Additionally, the Governing Body would include the Administrator and the RQM as she reported to them. Further, DON #1 revealed she was aware of the deficiencies cited during the Abbreviated Survey, on 05/21/2020. However, she was not aware of continued audits related to those deficient areas. Further she relied on the RQM to identify clinical areas of deficiency and to give direction to achieve regulatory compliance. Interview with the Regional Quality Manager (RQM), on 02/25/2022 at 12:45 PM, revealed she had been the RQM for one and a half years at the facility and was the acting DON #2, from December 23, 2021 until January 24, 2022. Additionally, she was part of the Governing Body, as per the facility's policy. Per interview, she audited clinical systems, Quality Indicators and reviewed the overall operational status of the nursing department. She stated she also provided weekly clinical support and Quality Assurance (QA) reports to the DON and the Administrator. Further, she reviewed regulatory compliance with the DON and the Administrator. Continued interview revealed she was aware of the deficiencies cited during the last Abbreviated Survey dated 05/21/2020. However, she was not fully aware of the extent of clinical systemic issues that were currently occurring in the facility. Interview with the Administrator, on 02/25/2022 at 1:00 PM, revealed she had worked at the facility in her role, for four (4) months and had a temporary license. Per interview, she was unfamiliar with who the Governing Body was and their responsibilities. However, she stated it was her responsibility as the Administrator, to ensure all processes established in the facility were maintained, to include the Quality Assurance and Assessment/ Quality Assessment Performance Improvement (QAA/QAPI) program. Continued interview revealed the Administrator was not aware of the previous Plan of Correction for the Abbreviated Survey in May of 2020, which occurred prior to her role at the facility as the Administrator. Further, she was not aware of clinical systemic issues at the facility and stated she was not clinical as she was a social worker until she became the Administrator. Interview with the Vice President of Operations (VP of Ops), on 02/25/2022 at 2:50 PM, revealed she had been in the role since 2016. Per interview, as VP of Ops she was part of the Governing Body, as per the facility's policy. She stated her current role was to provide support to the Administrator. Continued interview revealed the facility was required to maintain their own policies and procedures to meet regulatory requirement. Per interview, the facility's policies and procedures were from the previous company. She stated she provided resources and help getting these policies and procedures implemented, but did not make clinical decisions. Further interview with the VP of Ops, revealed she was unaware of the concerns identified within the facility, but would offer support and resources as needed. Continued interview with the Vice President of Operations, on 02/25/2022 at 2:50 PM, revealed she was not involved in the monthly Quality Assurance (QA) meetings and did not give the facility direction on their QA. However, she was aware of the QA action plans and any concerns discussed in QA, as she reviewed the facility's QA on a shared drive and also discussed QA with the Administrator. Additionally, neither the Administrator or the RQM communicated the concerns related to deficient practices which were identified by the State Survey Agency (SSA), prior to the SSA arrival into the facility. Per interview, the facility should have had systems/audits in place to identify issues with clinical practices and reported them to her to ensure follow up review and correction. The VP of Ops stated she would provide oversight to the Administrator and monitor the facility's daily operations with routine visits.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. The facility further failed to implement recommended interventions as per the Centers for Medicare and Medicaid Services (CMS), the Center for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19, which affected all residents. Observations, on 02/15/2022 through 02/25/2022, of multiple areas of the facility, and multiple facility personnel revealed the facility failed to ensure staff fully and consistently implemented their infection control processes and followed the facility's policies and the CDC's guidelines for infection prevention and control (IPC). Staff failed to wear the appropriate personal protective equipment (PPE) in droplet precaution isolation rooms, and observations revealed staff failed to clean and disinfect shared resident equipment. Additionally, facility staff failed to ensure visitors observed social distancing and wore appropriate source control, such as masks, in accordance with national standards while in the facility. Interviews with multiple staff revealed lapses in education and communication regarding standards of practice, facility policies and current CDC recommendations related to IPC. Furthermore, the facility failed to establish and maintain an effectiveinfection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19 routine audits for IPC compliance were performed, and failed to ensure all facility staff received current, evidence-based education on IPC practices to prevent the spread of COVID-19. The facility failed to ensure the continual oversight by a qualified Infection Preventionist. Additionally, the facility failed to ensure an ongoing system of infection surveillance designed to detect, investigate the source, evaluate the impact of interventions, educate on the spread of infectious disease, and report communicable diseases. The facility's failure to establish and maintain an infection prevention and control program has caused or is likely to cause harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/25/2022 and was determined to exist on 09/12/2021, 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) at the highest scope and severity (s/s) of a J, 42 CFR 483.25 Quality of Care (F686) at an s/s of a J, 42 CFR 483.70 Administration (F835 and F837), at the highest s/s of an L; and F842 at an s/s of a J, 42 CFR 483.75 Quality Assurance and Performance Improvement (F867) at an s/s of an L, and 483.80 Infection Control (F880) at an s/s of an L. The facility was notified of Immediate Jeopardy on 02/25/2022. An acceptable Immediate Jeopardy Removal Plan was received on 03/03/2022, which alleged removal of the Immediate Jeopardy effective 03/03/2022. However, the State Survey Agency was unable to validate the removal of the Immediate Jeopardy prior to exit on 03/04/2022. The Immediate Jeopardy is ongoing. Refer to F882 and F886 The findings include: Review of the CDC's COVID-19 Nursing Homes and Long-Term Care Facilities, updated 11/09/2021, revealed healthcare settings should continue to use community transmission rates and continue to follow CDC's infection prevention and control recommendations for healthcare settings. Review of the CDC's COVID-19 Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes Nursing Homes & Long-Term Care Facilities, updated 02/02/2022, revealed older adults living in congregate settings were at high risk of being affected by [CONDITION(S)]-CoV-2. Continued review revealed a strong IPC program was critical to protect residents. Further review revealed even as nursing homes resumed normal practices, they must sustain core IPC practices and remain vigilant in order to prevent the spread of [CONDITION(S)]-CoV-2, and protect residents from severe infections, hospitalization s, and death. Continued review of the CDC's document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 02/02/2022, revealed dedicated medical equipment was to be used when caring for a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection. Further review revealed all non-dedicated, non-disposable medical equipment used for for a patient suspected or confirmed to have the [CONDITION(S)]-CoV-2 virus, should be cleaned and disinfected according to the manufacturer's instructions and facility policies before use on another patient. Review of the CDC's Clean Hands Count for Healthcare Providers, reviewed 01/08/2021, revealed hand hygiene reduces the spread of infection and disease to patients. Alcohol-based hand rub (ABHR) and washing hands with soap and water were the two (2) methods for hand hygiene. Continued review revealed multiple opportunities for hand hygiene to occur during a single care episode. Further examination revealed the clinical indications for the use of hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, when staff has visibly soiled hands, and before preparing or handling medications or food. Review of the facility's policy titled, Infection Prevention and Control Policy and Procedures: Novel Coronavirus (2020-nCoV), revised 03/19/2021, revealed the purpose of the policy was to establish and maintain an infection prevention and control program, which incorporated education and surveillance, to reduce the risk of transmission of COVID-19. Per policy review, the facility was to implement actions according to the CDC, CMS, and the State Cabinet for Health and Family Services (CHFS) recommendations. Review of the facility's policy titled, Policies and Practices - Infection Control, undated, revealed the purpose of the policy was to maintain a safe, sanitary, and comfortable environment, and to help prevent and manage transmission of diseases and infections. Per the policy review, the facility was to prevent, detect, investigate, and control infections, and maintain a safe environment for personnel, residents, and visitors. Continued review revealed additional purposes of the policy noted it was to establish guidelines for implementing transmission-based isolation precautions (TBP); and maintain records of incidents and corrective actions related to infections. Review of the policy revealed the facility's Quality Assurance and Performance Improvement (QAPI) Committee, through the facility's Infection Control Committee, was to help departments and managers ensure IPC practices were implemented and followed. Further review revealed all facility personnel were to be trained on IPC policies and practices upon hire and periodically thereafter, to the appropriate degree of direct resident contact and job responsibilities. Review of the policy further revealed the Director of Nursing Services (DNS) and the Infection Preventionist (IP) were responsible for disseminating information about IPC policies and practices to facility personnel. 1. Review of the facility's Hand Washing handout, undated, revealed training for how to conduct hand hygiene. Continued review revealed however, the handout did not instruct staff on when hand hygiene was required to be performed while providing resident care. Review of the facility's, In-Service Training Record, dated 04/2021, revealed seventy-three (73) staff members were trained on donning and doffing personal protective equipment (PPE) and hand-hygiene. Review of the facility's, In-Service Training Record, date 07/29/2021, revealed seven (7) out of twenty (20) nurses had been trained on hand-hygiene, wearing gloves, and donning and doffing of PPE. 2. Review of the CMS, Center for Clinical Standards and Quality/Survey and Certification Group QSO-20-38-NH Memo titled, Testing of Staff and Residents During an Outbreak Investigation, revised 09/10/2021, revealed a new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident, triggered an outbreak investigation. Continued review revealed upon identification of a single new case of COVID-19 infection in any staff or residents, testing was to begin immediately. Per the Memo, facilities were to use their community transmission level as the trigger for staff testing frequency, and communities with a high (red) rate of transmission, twice weekly testing of staff was required. Further review revealed facilities were to monitor their level of community transmission every other week, and adjust the frequency of performing staff testing accordingly. In addition, the QSO-20-38-NH Memo, revealed the guidance represented the minimum testing expected. Review of the State Department for Public Health's Long-Term Care Facility COVID-19 County Indicator Map for transmission level from 01/25/2022 to 02/25/2022, revealed the facility's county community activity rate was noted as high (red zone), which required the facility to test staff and residents two (2) times a week for COVID-19. Review of the facility's Infection Surveillance program documentation, provided by the Administrator on 02/17/2022, revealed it was a map of the facility. Continued review revealed the COVID-19 Isolation rooms were highlighted in yellow, with no other rooms of residents with infections highlighted. Review of the map revealed there was no corresponding documentation or legend on the map to explain how to read the map. Review of the facility's COVID-19 employee testing records revealed all staff had been tested weekly on the following dates: 01/25/2022, 02/01/2022, 02/08/2022, 02/15/2022, despite the fact the county community COVID-19 activity map was in the red zone, and the facility was experiencing an outbreak, which required twice weekly testing. Further review of COVID-19 employee teasing results revealed the facility identified two (2) staff were positive on 12/31/2021; one (1) staff was positive on 01/07/2022; one (1) staff was positive on 01/09/2022; one (1) staff was positive on 01/11/2022; two (2) staff were positive 01/12/2022; and one (1) staff on 01/13/2022; one (1) staff was positive on 01/30/2022; one (1) staff was positive on 01/31/2022; one (1) staff was positive on 02/02/2022; one (1) staff was positive on 02/03/2022; two (2) staff were positive 02/04/2022; one (1) staff was positive on 02/06/2022; two (2) staff were positive on 02/07/2022; and two (2) staff were positive 02/09/2022. However, there was no documented evidence the facility conducted COVID-19 testing twice per week despite the fact the county community COVID-19 activity map was in the red zone, and the facility was experiencing an outbreak, which required twice weekly testing. Review of the facility's, Resident Vaccination List, undated, revealed the facility had seventy-seven (77) residents. Continued review revealed sixty-four (64) fully vaccinated residents; three (3) residents who had received only one (1) dose of the vaccine; and nine (9) residents who had refused vaccination. Review of the facility's documentation for resident's COVID-19 exposure and positive cases as of 02/07/2022, revealed fifteen (15) residents had tested positive for the COVID-19 virus and twelve (12) residents had experienced direct exposure to COVID-19. The SSA requested resident testing results for December 2021, January 2022 and February 2022, however, December 2021 and January 2022 results were not received. Review of the facility's resident testing results, from 02/02/2022 to 02/25/2022, revealed the following results for COVID-19 testing: thirteen (13) residents tested positive on 02/02/2022; two (2) residents tested positive on 02/03/2022; four (4) residents tested positive on 02/15/2022; and one (1) additional resident tested positive on 02/21/2022. 3. Observation of the facility, on 02/15/2022 at 10:30 AM, revealed there was no sign posted on the facility's entrance door alerting visitors to the presence of COVID-19 in the building. Observation revealed no sign posted on or near the entrance door leading to the COVID-19 Unit. Continued observation revealed no observation of educational signage posted regarding hand hygiene practices. Observation of the facility's B, C, D, and E Halls revealed no visible signage posted related to IPC practices. Further observation of Hall B revealed no visible IPC signs posted, except for resident rooms [ROOM NUMBERS], which were Droplet Precautions isolation rooms. 4. Interview with the Administrator, on 02/22/2022 at 3:12 PM, revealed the facility did not have a policy related hand hygiene. Observation of Hall D during meal service, on 02/15/2022 at 12:30 PM, revealed State Registered Nurse Aide (SRNA) #23 failed to perform hand hygiene after serving meals to residents in rooms [ROOM NUMBERS], and before placing a meal tray down in room [ROOM NUMBER]. Observation revealed SRNA #23 take a meal tray into room [ROOM NUMBER]. She came out of the room and did not perform hand hygiene. She pulled another tray from the meal cart and entered room [ROOM NUMBER]. She placed Resident #37's tray on the bedside table, moved the table, removed the plate cover, set up the place settings, and took the lid off the resident's coffee cup. Before leaving room [ROOM NUMBER], SRNA #23 touched the end of Resident #37's bed and bed lines. She exited the room without performing hand hygiene. After leaving room [ROOM NUMBER], SRNA #23 obtained another meal tray and entered room [ROOM NUMBER], placing the meal tray on the bedside table. SRNA did not set up the meal tray. SRNA #23 exited room [ROOM NUMBER] and performed hand hygiene using ABHR from the wall dispenser in the hall. Interview with SRNA #23, on 02/15/2022 at 12:35 PM, revealed she only delivered the meal trays and had not provided care for residents. Interview further revealed she was not aware she should use alcohol-based hand rub (ABHR) after each meal tray passed. Furthermore, SRNA #23 stated there was no risk of cross contamination because she did not provide care to the residents when passing out trays. 5. Review of the CDC's COVID-19 Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes Nursing Homes & Long-Term Care Facilities, updated 02/02/2022, revealed that health care personnel in areas with moderate to substantial community transmission should wear eye protection in addition to N95 or equivalent masks while in resident care areas and while providing resident care. 5(a). Observation on 02/18/2022 at 3:19 PM, of Licensed Practical Nurse (LPN) #8 revealed while the facility had COVID-19 positive residents in the facility, LPN #8 was wearing a surgical mask pulled down below his nose while administering medications to residents. Interview with LPN #8, on 02/18/2022 at 3:19 PM, revealed it was difficult to see when wearing a face shield or goggles LPN #8 stated he realized however, that was not an excuse, and should have been wearing the appropriate PPE correctly according to the facility's policy during the ongoing COVID-19 outbreak. He stated knew wearing the appropriate PPE prevented the spread of infection. LPN #8 stated further that he had not received recent education on IPC policies or practices. 5(b). Observation of SRNA #10, on 02/24/2022 at 12:59 PM revealed she was in a patient care area, near the nursing station. Continue observation revealed she had her mask pulled down below her nose. Additional observation of SRNA #10 on 03/03/2022 at 5:17 PM, revealed she had her mask pulled below her chin while standing at the computer in a resident care area. Interview on 03/02/2022 at 12:59 PM, with SRNA #10 revealed she had not realized she was not wearing her mask correctly. She stated she had difficulty breathing when the mask covered her nose. According to SRNA #10, she had not received education and training on IPC practices and PPE for several months. Additional interview with SRNA #10 on 03/04/2022 at 5:17 PM, revealed she was unaware she had not been wearing her mask correctly. 5(c). Observation on 03/04/2022 at 1:01 PM, of SRNA #25 revealed she was wearing her mask pulled down below her nose while providing care in room [ROOM NUMBER]. Continued observation revealed SRNA #25 came out of resident room [ROOM NUMBER] and without performing hand hygiene, proceeded to the clean linen cart where she was observed to remove linen. She then walked into resident room [ROOM NUMBER]. Further observation revealed SRNA #25 did not perform hand hygiene before entering room [ROOM NUMBER]. The Surveyor attempted interview with SRNA #25, on 03/04/2022 at 1:01 PM, at the time of observation; however, SRNA #25 stated I am too busy. I have to get these residents back to bed, and walked into resident room [ROOM NUMBER] closing the door. Interview with LPN #1, on 02/22/2022 at 9:30 AM, revealed as part of the facility's IPC program and facility policy, all staff were required to wear a KN95 masks while in the facility while there was a current outbreak of COVID-19. She further stated all PPE was to be worn appropriately. The KN95 should fit well, covering the mouth and nose at all times. 6. Review of the manufacturer's instructions for the Point-of-Care COVID-19 test kit, utilized by the facility, revealed the testing instructions required the specimen be an anterior nasal swab obtained from both nostrils. Observation of the Minimum Data Set (MDS) Nurse, on 02/20/22 at 10:22 AM, revealed she was performing a Point-of-Care (POC) COVID-19 test on Resident #17. Continued observation revealed the MDS Nurse swabbed only one (1) of Resident #17's nostrils when performing the test and not both nostrils per the manufacturer's recommendations and instructions. Interview, on 02/20/22 at 10:50 AM, with the MDS Nurse revealed she routinely performed COVID-19 testing on the facility's residents and staff. She stated she received training on COVID-19 Rapid Testing in Point-of-Care Settings; however, she could not recall the specific training program she had completed. The MDS Nurse stated per the manufacturer's instructions, she should have swabbed both of Resident #17's nostrils when performing the COVID-19 AG testing to ensure that a false-negative result was not obtained. She stated normally she swabbed both the nostrils, but when she reviewed the procedure prior to performing the testing with the Regional Quality Manager (RQM), the RQM instructed her to only swab one (1) nostril. Interview, on 02/20/22 at 10:50 AM, with the RQM revealed she had instructed the MDS Nurse to swab only one (1) nostril when performing the test. Further interview revealed she had also received training on completing COVID-19 Rapid Testing in Point-of-Care Settings. 7. Interview with the Administrator, on 02/22/2022 at 3:12 PM, revealed the facility did not have a respiratory policy or an Infection Control policy related to respiratory use and/or equipment. 7(a). Observation of Resident #26, on 02/16/2022 at 5:20 PM, revealed the resident was receiving oxygen at five (5) liters per minute (LPM) via a nasal cannula (NC) without humidification. Further observation revealed there was no date on the oxygen tubing to indicate when it had been placed in use. Observation further revealed the oxygen tubing was stretched from Resident #26's oxygen concentrator and lying on the floor leading to the resident's bed. 7(b). Observation of Resident #50, on 02/23/22 at 12:07 PM, revealed he/she was receiving oxygen at two (2) LPM via a NC. Continued observation revealed the oxygen tubing was not dated, and was lying on the floor. Observation revealed Resident #50 had an oral suctioning catheter lying uncovered on his/her bedside table. Observation of the suction canister revealed it was overfilled and undated. Further observation revealed Resident #50's nebulizer (breathing treatment) machine with dust on it, and a build up of a crusty substance on the mouthpiece. In addition, observation revealed the nebulizer mouthpiece had what appeared to be food particles on the mouthpiece reservoir with the mouthpiece lying on the bedside table, and the tubing, which was not dated, lying across the floor. 7(c). Observation of Resident #8, on 02/23/22 at 12:28 PM, revealed the resident was receiving oxygen at two (2) LPM via a NC. Continued observation revealed the undated oxygen tubing was lying on the floor. Additional observation revealed Resident #8's nasal cannula was crusted with sinus debris. Interview with LPN #1, on 02/22/2022 at 9:30 AM, revealed it was the responsibility of the Respiratory Specialist (RS) to manage residents' oxygen concentrators and tubing. She stated the facility did not have that position staffed, and as a result, the nursing staff was responsible for changing residents' oxygen tubing weekly. LPN #1 further stated all oxygen tubing should have been dated with date it was changed. Interview with RN #1, on 02/22/2022 at 9:30 AM, revealed it was the Respiratory Specialist's (RS) responsibility to manage residents' oxygen concentrators and tubing. According to RN #1, if the facility did not have the position staffed, nursing staff was responsible for changing residents' oxygen tubing weekly. Continued interview revealed the RS position was not filled and nursing was responsible. Further interview revealed oxygen tubing was to be dated with the date it was changed. 8. Interview with the Administrator, on 02/22/2022 at 3:12 PM, revealed the facility did not have a policy related to emptying, cleaning, storage or Infection Control of bedpans and urinals. 8(a). Observation of Resident #50's room, on 02/16/2022 at 8:46 AM, revealed two (2) urinals, one (1) of which contained an amber color liquid, located on the floor near the resident's bed. Observation revealed one (1) urinal appeared empty; however, looked as if it had not been rinsed out. Further observation revealed neither urinal had been dated or marked with the resident's name. Interview with Resident #50, on 02/16/2022 at 8:46 AM, revealed staff did not routinely empty his/her urinals when they came into the resident's room. Resident #50 further stated when he/she finished using the urinal, the staff often just placed the urinal on the floor if it was not full of urine. 8(b). Observation of Resident #17's room, on 02/20/2022 at 10:30 AM, revealed two (2) urinals located on the resident's bedside table. Observation revealed one (1) urinal was half-filled with amber colored liquid, and the second urinal had a small amount amber colored liquid in the bottom of the urinal, with drops of amber colored liquid substance on the outside of the urinal. In addition, observation revealed the urinals were not dated or labeled with the resident's name. Interview with Resident #17, on 02/20/2022 at 11:30 AM, revealed staff did not empty his/her urinals unless he/she asked them to do so. Continued interview revealed staff often put his/her meal tray on the bedside table right beside the urinals. Resident #17 further stated when that happened, he/she lost his/her appetite from smelling the urine. Further interview revealed Resident #17 would move his/her meal tray off the bedside table and place the tray on his/her bed. Interview with SRNA #1, on 02/20/2022 at 3:14 PM, revealed urinals were emptied on a regular basis and as requested by the residents. She stated she could not explain why Resident #17's urinals had not been emptied for several hours. SRNA #1 further stated Resident #17's meal trays were placed on his/her bed and not on the bedside table because the resident liked having the tray on the bed. 9. Review of the facility's policy, Visitation Guidance Protocol, revised 11/12/2021, revealed the purpose of the policy was to ensure safe visitation by adhering to the core principles of COVID-19 infection prevention and control practices to mitigate the risk of infection spread. Further review revealed hand-hygiene, use of face masks that covered the mouth and the nose, and social distancing were to be requested of all visitors. Additionally, visitors were to wear source control (the use of respirators or well-fitting a facemask to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing) while around other residents or health care personnel regardless of vaccination status. Observation on the facility's Hall E, on 02/19/2021 at approximately 4:10 PM, revealed four (4) visitors, one (1) adult and three (3) children entering resident room [ROOM NUMBER]. Observation revealed the adult visitor stayed in room [ROOM NUMBER] with the door closed; however, the three (3) children remained outside of the room in Hall E. Continued observation revealed one (1) of the children appeared under the age of two (2) years and would not be required to wear a mask. However, the two (2) other children appeared as over two (2) years of age and were required to wear a mask. Observation revealed the two (2) older children were wearing masks; however, their masks were not covering their noses. Further observation revealed the three (3) children were sitting and/or lying on the floor or walking up and down Hall E. Observation further revealed the nursing staff present on the hall were not actively redirecting and educating visitors to follow the facility's current IPC processes. When the State Survey Agency (SSA) Surveyor notified Kentucky Medication Aide (KMA) #2 that visitors were not wearing their masks appropriately, and several children were sitting/lying on the floor outside of the room [ROOM NUMBER], she shrugged her shoulders. In addition, observation revealed KMA #2 failed to educate or redirect the visitors on the facility's IPC practices while the visitors were present within the facility. Interview with KMA #2, on 02/19/2022 at approximately 4:15 PM, revealed staff could not tell residents' family members what to do. She further stated visitors were given IPC education material when they checked into the facility. 10. Observation of resident room [ROOM NUMBER] on, 02/21/2022 at 8:45 AM, revealed signage on the door alerting staff and visitors Resident #36, who resided in the room, was on Droplet Precautions. Continued observation revealed Resident #36's room door also had signage instructing staff and visitors to see the nurse before entering room [ROOM NUMBER]. Observations throughout the day on 02/21/2022 and 02/22/2022 revealed the door to room [ROOM NUMBER] remained open. Further observation throughout the day on 02/21/2022 and 02/22/2022, revealed no PPE storage container was set up outside of room [ROOM NUMBER] for staff to obtain the appropriate PPE to don prior to entering the room, and no biohazard receptacles for contaminated linen and trash observed inside room [ROOM NUMBER]. 10(a). Observation of SRNA #14, on 02/21/2022 at 1:33 PM, revealed she was inside resident room [ROOM NUMBER] gathering resident belongings. Continued observation revealed the signage on the resident's door indicated the resident was in Droplet Precaution Isolation. Further observation revealed SRNA #14 was not wearing PPE for the Droplet Precautions. SRNA #14 exited room [ROOM NUMBER], a Droplet Precautions isolation room, carrying items held against her uniform. Observation revealed SRNA #14, without performing hand hygiene, exited resident room [ROOM NUMBER] and walked through the community hallway to another unit. Further observation revealed room [ROOM NUMBER]'s door remained wide open with Droplet Precaution signage present; however, no PPE cart was observed outside of the door. Interview with SRNA #14, on 02/21/2022 at 1:33 PM, revealed she had been taking personal items from resident room [ROOM NUMBER] to the COVID-19 isolation unit because a resident had just tested positive for COVID-19. Per the interview, Resident #36 in room [ROOM NUMBER], was not COVID-19 positive, but had been placed on Droplet Precautions after his/her roommate tested positive for COVID-19. Continued interview revealed she did not touch the resident's belongings. Further, SRNA #14 stated she was a contract agency employee and she had not received IPC training while working at the facility. 10(b). Observation of Housekeeper #2, on 02/21/2022 at 2:24 PM, revealed he entered resident room [ROOM NUMBER], a Droplet Isolation precautions room without donning appropriate PPE. Continued observation revealed no PPE container or supplies was observed outside the room door. Continued observation revealed Housekeeper #2 checked a waste receptacle for trash, and moved the receptacle closer to the resident. When the Housekeeper exited the room, he failed to perform hand hygiene. Interview with Housekeeper #2, on 02/21/2022 at 2:30 PM, revealed he had worked at the facility for two (2) years. Housekeeper #2 stated he had not noticed the Droplet Precaution signage on the door when he entered room [ROOM NUMBER] without wearing the appropriate PPE. Continued interview revealed he did not recall hearing that room [ROOM NUMBER] had been transitioned into a Transmission Based Precaution (TBP) room due Resident #36 having been exposed to COVID-19. He stated he had entered room [ROOM NUMBER] to check for trash, did not realize he had not performed hand hygiene upon exiting the room. Per interview, Housekeeper #2 stated he did not know were to find the appropriate PPE to don prior to entering room [ROOM NUMBER], as there was no PPE container located outside of the room. Further interview revealed he had IPC in-service training last month, which had included handwashing, the use of PPE, and donning and doffing of PPE procedures. Interview with the Housekeeping/Laundry Supervisor, on 02/23/2022 at 4:35 PM, revealed it was her expectation laundry and housekeeping staff wore masks at all times while in the facility. She stated it was important for staff to follow the facility's IPC practices to prevent the spread of infection. 10(c). Observation of SRNA #13, on 02/22/2022 at 10:06 AM, revealed she entered resident room [ROOM NUMBER], a Droplet Isolation precautions room without donning appropriate PPE, and no PPE container or PPE supplies were observed outside the room. Continued observation revealed when SRNA #13 exited room [ROOM NUMBER], she failed to perform hand hygiene. Interview with SRNA #13, on 02/22/2022 at 10:10 AM, revealed she had no idea Resident #36 in room [ROOM NUMBER] had been placed on Droplet Precautions, even though signage on the room door stated Droplet Precautions. She stated, after learning that information, she should have donned full PPE before entering and used ABHR prior to exiting the room. Continued interview revealed she had not been made aware Resident #36 was on Droplet Precautions during morning report. Further interview revealed SRNA #13 was a contract agency employee and she stated she had not received IPC training while working at the facility. 10(d). Observation of SRNA #12, on 02/22/2022 at 10:31 AM, revealed she entered resident room [ROOM NUMBER], a Droplet Precaution room without donning the appropriate PPE. Observation revealed no PPE container located outside room [ROOM NUMBER]'s door. Further observation revealed when SRNA #12 exited room [ROOM NUMBER], she failed to perform hand hygiene. Interview with SRNA #12, on 02/22/2022 at 10:35 AM, revealed she had not been aware Resident #36 in room [ROOM NUMBER] was placed on Droplet Precautions, even though the room door had Droplet Precaution signage on it. She stated she had not provided resident care; however, she should have donned full PPE before entering, after she learned of the Droplet Precautions. Further interview revealed she should have performed hand hygiene before entering and upon exiting the room. SRNA #12 further revealed she was also assigned to pe

Based on interview and record review it was determined the facility failed to ensure one (1) of thirty-three (33) sampled residents (Resident #428) maintained sufficient fluid and nutritional intake to maintain proper hydration, nutrition, and health. Resident #428 did not meet estimated fluid needs in September of 2019, from [DATE] through [DATE]. Interviews with staff revealed the resident ate five (5) times in eight (8) days. Additionally, staff had not documented the resident's intake on [DATE], [DATE], and [DATE]. There was no evidence that any action was taken to address the resident's poor intake. Subsequently, the facility failed to identify the resident was at risk for dehydration and was malnourished. On [DATE], the resident was transferred to the hospital for a change of condition. Upon admission to the hospital, the resident was diagnosed with Severe Dehydration and Malnutrition. The facility's failure to intervene when the resident declined in his/her fluid and meal intake presented and immediate jeopardy to residents. The facility's failure to ensure residents received sufficient fluid and nutritional intake to maintain proper hydration, nutrition, and health has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.10 Resident Rights (F580) at the highest scope and severity (s/s) of a J, 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657) at the highest s/s of a J, and 42 CFR 483.25 Quality of Care (F684 and F692) at the highest s/s of a J. The facility was notified of Immediate Jeopardy on [DATE]. An acceptable Immediate Jeopardy Removal Plan was received on [DATE], which alleged removal of the Immediate Jeopardy effective [DATE]. However, the State Survey Agency was unable to validate the removal of the Immediate Jeopardy prior to exit on [DATE]. The Immediate Jeopardy is ongoing. Refer to F580 and F657 The findings include: Interview with the Administrator, on [DATE] at 3:12 PM, revealed the facility did not have a policy for nutrition and hydration. Review of a closed medical record for Resident #428 revealed the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #428's laboratory results from, [DATE], revealed the resident's Blood Urea Nitrogen (BUN) level was 39 milligrams per deciliter (mg/dL), [DATE] revealed the resident's BUN was 36 mg/dL, and in [DATE], the resident's BUN was 36 mg/dL (normal range ,d+[DATE] mg/dL). Review of Resident #428's Nutritional Care Plan, dated [DATE], revealed the facility developed a care plan that stated Resident #428 had problems chewing and swallowing. The care plan further revealed the facility identified that the resident was at risk for nutrition and hydration. The goal was for the resident to remain free of signs and symptoms of dehydration for ninety (90) days and to maintain a consistent body weight. Further review of Resident #428's care plan revealed the resident had interventions that included allowing for the resident's likes/dislikes, providing follow-up education/encouragement if preferences were in compliance with prescribed diet, monitoring the resident's weight, providing snacks and supplements as ordered, and provide nutritional counseling as needed. Further review of the resident's care plan revealed it was not revised to reflect concerns identified with the resident's decrease in meal and fluid intake. Review of Resident #428's nutritional assessment completed by the Dietitian, dated [DATE], revealed the facility assessed the resident to require 1475 to 1770 milliliters (ml) of fluid daily. Further, the resident was on a regular consistency, thin liquids diet for fortified foods at all meals. The resident was assessed to weigh one-hundred and thirty point six (130.6) pounds. Continued review revealed the resident received peanut butter sandwiches and ice cream at lunch and dinner. Further, the assessment stated the resident was stable at the time for nutritional and hydration status. Review of Resident #428's weight, dated [DATE], revealed the resident weighed one-hundred and thirty (130) pounds; however, the resident refused to be weighed in [DATE]. A review of Resident #428's Quarterly Minimum Data Set (MDS) Assessment, completed [DATE], revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident to have severely impaired cognition. The assessment indicated the resident required extensive assistance of one (1) staff for eating. Further review of the MDS revealed the resident was assessed to weigh one-hundred and thirty (130) pounds with no loss or gain in the past month or six (6) months. Review of Resident #428's meal intake documentation from [DATE] through [DATE], revealed on [DATE]; the resident refused all meals and ate less than twenty five (25%) percent; on [DATE], the resident had no food intake documented; on [DATE], the resident ate seventy five to one-hundred (,d+[DATE]%) percent of breakfast, but refused lunch and dinner; on [DATE], the resident had no documented intake at breakfast and refused lunch and dinner eating less than twenty five (25%) percent; on [DATE], the resident refused breakfast, ate lunch at fifty to seventy-five (,d+[DATE]%) percent and refused dinner; on [DATE], the resident had no breakfast intake documented, refused lunch, ate less than twenty five (25%) percent and ate twenty-five to fifty (,d+[DATE]%) percent for dinner; on [DATE], the resident ate fair with fifty to seventy-five (,d+[DATE]%) percent for breakfast; no documented intake for lunch, and ate poor for dinner, eating twenty-five to fifty (,d+[DATE]%) percent; on [DATE] and [DATE], the resident had no documented intake. Further, there was no evidence found in the resident's medical record to indicate staff notified the physician that the resident had decreased food intake. Further review of Resident's #428's average daily food and fluid intake report, dated [DATE], revealed the facility documented the resident's average fluid intake was 240.50 milliliters (ml), which was less than the resident's estimated fluid needs of 1475 to 1770 milliliters (ml) per day. Review of Resident #428's laboratory results, dated [DATE], revealed a Comprehensive Metabolic Panel (CMP) was drawn and had hemolyzed (an indication that the red blood cells in that sample were destroyed in some way). The results were contaminated; however, there was no evidence the labs were redrawn. Interview with Registered Nurse RN(#4), on [DATE] at 11:34 AM, revealed she documented she received the resident ' s labs, on [DATE] and contacted the physician. However, she stated she could not recall the CMP not being able to be completed because of its contamination. According to RN #4, she was agency and was new to the facility. The RN stated she did not have computer access to reorder labs in the computer and could not recall if she notified the physician about reordering the CMP. Further review of Resident #428's closed medical record revealed the resident tested positive for COVID-19, on [DATE], and was transferred to the facility's designated COVID unit. Review of the Nursing Progress Notes, dated [DATE] at 10:25 AM, revealed the resident appeared lethargic and the resident's fingers and toes on the right side and three (3) fingers on the left hand were purple in color. However, there was no documented evidence the resident's physician was notified the resident consumed less than twenty-five (25%) percent of his/her average food intake since [DATE], and that the resident had not met his/her fluid needs. Further review of Resident #428's closed medical record revealed, on [DATE] at 2:33 PM, Resident #428's physician conducted a telehealth visit with the resident. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no documented evidence the physician was notified the resident was failing to meet his/her fluid needs and had only consumed twenty-five (25%) percent of his/her meals since [DATE]. Review of Resident #428's Nurses' Progress Notes, dated [DATE] at 8:59 AM, signed by Registered Nurse (RN)#2, revealed Resident #428 continued to have purple fingers and toes. However, there was no documentation that the resident's physician was notified that the resident's fingers and toes remained discolored. Further, there was no documented evidence the physician was notified of the resident's refusal of his/her meals and fluids. Further review of Resident #428's Nurses' Progress Notes, dated [DATE] at 11:00 AM, revealed the resident vomited a large amount of dark black colored emesis, and the resident's oxygen saturation was not able to be obtained. The staff notified the resident's physician, who instructed staff to transfer the resident to the hospital for further evaluation and treatment. Review of Resident #428's hospital record, dated [DATE], revealed the hospital admitted the resident with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the hospital record revealed the resident weighed one-hundred- and twenty-two-point eight (122.8) pounds, approximately an eight (8) pound weight loss since August. Further review of the hospital record revealed Resident #428's condition declined, he/she was placed on comfort measures and expired at the hospital on [DATE]. An interview with Registered Nurse (RN) #2, on [DATE] at 10:31 AM, revealed she had cared for the resident, on [DATE], and remembered the resident's fingers being discolored and thought, the resident had a medical condition. Further, she stated the resident's purple fingers would not have been considered a change of condition for the resident. According to the RN, she was able to obtain oxygen saturations for the resident and did not recall any concerns. Per interview, she stated she used her personal phone for the resident's telehealth visit. She stated the resident's physician was aware of his/her purple fingers. RN #2 revealed she was unaware of the resident's refusals with his/her fluids and meals. She further revealed that had she been made aware of the resident's refusals, she would have reported the resident's change in fluid/meal intake to the physician. An interview with State Registered Nurse Aide (SRNA) #4, on [DATE] at 2:14 PM, revealed he cared for Resident #428 the night before the resident was sent to the hospital on [DATE]. SRNA #4 stated at approximately 5:00 AM on [DATE], he could not obtain an oxygen saturation on the resident and could not get the resident to take in any fluids. The SRNA stated the resident's breathing was labored and he/she was drenched in sweat. SRNA #4 stated, I thought (the resident) was going to die. Further interview revealed he notified Licensed Practical Nurse (LPN) #6 of the resident's condition multiple times during the night, but the LPN did not notify the resident's physician. Interview with Licensed Practical Nurse (LPN) #6, on [DATE] at 2:58 PM, revealed she had provided care to Resident #428 on the night shift from 7 PM-7 AM, [DATE] through [DATE]. However, LPN #6 denied any staff reported a change in Resident #428's condition to her. She stated if staff told her of the resident ' s change in condition, she would have notified the resident's physician. Interview with the Unit Manager, on [DATE] at 3:36 PM, revealed she attended the Daily Clinical Review (DCR) meetings. Per interview, she stated residents' labs, new physician orders, bowel reports, and food and fluid intake reports, were reviewed in the clinical meetings for any concerns. The Unit Manager revealed she did not recall concerns discussed in the clinical meetings related to Resident #428's decrease in fluid and meal intake. Further interview with the Unit Manager revealed she could not explain why Resident #428's Comprehensive Metabolic Panel (CMP) was not obtained after his/her report came back contaminated. Further, she stated it was important to obtain the CMP for Resident #428 to monitor for his/her metabolic status. Further interview with the Unit Manager, on [DATE] at 3:36 PM, revealed that during the month of September, she worked the floor, providing nursing coverage, as many of the staff were off sick due to COVID. She further stated staff were unable to work, however, the facility utilized agency staff. Per interview, she stated she had not noticed Resident #428's decline. Continued interview with the Unit Manager revealed the Director of Nursing (DON) would have picked up her duties in the Daily Clinical Review (DCR) meetings and would have referred the resident to the Interdisciplinary Team (IDT) with the resident's identified concerns. Interview with Dietitian #1, on [DATE] at 2:47 PM, revealed she was responsible for revising the nutritional services plan of care for Resident #428. According to the Dietitian, she was not aware the resident was not eating and/or drinking. Per interview, staff did not alert her when the resident was not meeting his/her estimated fluid needs. The Dietitian revealed she met with the IDT weekly to review concerns with the residents' nutrition and hydration needs. Further, she stated the resident had improved from the previous month, thus changed the resident's weights from weekly weights to monthly weights. Per interview, it was for this reason, Resident #428 was not discussed in the IDT meetings. Further, she revealed she was unaware of the resident's decline in [DATE]; however, added she should have been made aware by staff. Interview with the Former Director of Nursing (DON) #1, on [DATE] at 12:29 PM, revealed the facility's procedure for ensuring the residents' hydration and nutrition were addressed was to provide the residents with food and fluids at meals; offer snacks, and staff were to pass water/ice to the residents on each shift. Further, the DON stated she conducted the daily clinical review (DCR) meetings with the members of the interdisciplinary team (IDT) and reviewed any concerns that had developed. According to the DON, if staff failed to document rather or not a resident ate or drank, the IDT might not have known when a resident refused his/her fluid and/or meal intakes. Per interview, the IDT would not have addressed the residents' concerns with hydration/nutrition if the residents' did not trigger for these concerns. DON #1 stated Resident #428 was monitored by the IDT, prior to September, but had improved. Additionally, she stated the Unit Managers and the nurses were responsible for reviewing the residents' lab values when received. Further interview with the Former Director of Nursing (DON) #1, on [DATE], revealed the average daily intake reports were printed by the resident's Unit Manager or the DON, if the unit manager was working the floor. Continued interview revealed the report was then reviewed weekly in the IDT meetings. According to the DON, she was not aware of any concerns with Resident #428 not meeting his/her estimated fluid needs. Further, DON #1 stated that if the IDT was made aware of the resident's concerns, the Dietitian would have revised the resident ' s plan of care with interventions to address his/her poor nutrition and hydration. Per interview, she stated that if the Interdisciplinary Team (IDT) was made aware of the resident's decline and his/her decreased estimated meal/fluid intakes, the physician would have been notified and orders would have been obtained from the physician for intravenous fluids, or the resident would have been sent to the hospital. Interview on [DATE] at 1:05 PM, with the Former Administrator, who was the Administrator in September of 2021, revealed she was not aware of any concerns with Resident #428 not eating and drinking on the COVID unit. Further interview with the Former Administrator revealed it would have been her expectation that staff would take action and try to increase the resident's fluid/food intake and notify the physician if a resident refused his/her hydration and nutritional needs. Interview with Physician #1, on [DATE] at 2:25 PM, revealed he was made aware of Resident #428's discolored fingers and toes during the telehealth visit on [DATE]. Continued interview revealed the physician stated that he expected to be notified if the resident's condition continued or worsened, as it would indicate further oxygenation problems. According to the physician, he was never made aware that Resident #428's refusals of fluid and meal intake. Per interview, staff had not alerted him the resident was not meeting his/her estimated fluid needs. According to the physician, he would have expected the contaminated CMP results to be redrawn for Resident #428 to monitor the resident's metabolic status. Further interview with Physician #1, on [DATE] at 2:25 PM, revealed he visited Resident #428 in the hospital and the resident's condition had declined since the telehealth visit on [DATE]. Physician #1 stated he had not been notified of Resident #428's decline prior to the resident's hospitalization . Further interview with the physician revealed if he had been made aware that the resident was not eating and drinking, he would have ordered labs, intravenous (IV) fluids, and may have sent the resident to the hospital sooner.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the physician for one (1) of thirty-three (33) sampled residents (Resident #428) when the resident experienced a change of condition and there was a need to alter treatment. Resident #428 had experienced a decrease in food and fluid intake since [DATE], which continued after the resident was diagnosed with COVID-19 on [DATE] and moved to the facility's COVID unit. However, there was no evidence the resident's physician was notified of the resident's decrease in food/fluid intake. In addition, although the resident's physician was notified in a telehealth visit on [DATE], that the resident's fingers and toes were discolored, there was no evidence the physician was notified the resident's extremities remained discolored until [DATE], when the resident was transferred to the hospital and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #428 expired at the hospital on [DATE]. The facility's failure to ensure the resident's physician(s) were notified when the resident experienced a change in condition and/or need to alter treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.10 Resident Rights (F580) at the highest scope and severity (s/s) of a J, 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657) at the highest s/s of a J, and 42 CFR 483.25 Quality of Care (F684 and F692) at the highest s/s of a J. The facility was notified of Immediate Jeopardy on [DATE]. An acceptable Immediate Jeopardy Removal Plan was received on [DATE], which alleged removal of the Immediate Jeopardy effective [DATE]. However, the State Survey Agency was unable to validate the removal of the Immediate Jeopardy prior to exit on [DATE]. The Immediate Jeopardy is ongoing. Refer to F657 and F692 The findings include: A review of the facility's policy, Change of Condition Standard of Practice, dated [DATE], revealed the facility would immediately (as soon as possible/no longer than 24 hours) inform/consult with the resident's physician when there was any significant change in the resident's status. Review of Resident #428's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #428's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was cognitively severely impaired. Review of Resident #428's nutritional assessment completed by the Dietitian dated [DATE], revealed the facility assessed the resident to require between 1475 milliliters (ml) to 1770 (ml) of fluid daily. Further review of Resident #428's average daily food and fluid intake report, dated [DATE], revealed the resident consumed an average of 240 ml daily, which was less than the fluid needs the resident was assessed to have, between 1475 to 1770 ml. However, there was no evidence the facility staff contacted the resident's physician when he/she decreased his/her fluid intake. Review of Resident #428's meal intake documentation from [DATE] through [DATE], revealed on [DATE]; the resident refused all meals and ate less than twenty five (25%) percent; on [DATE], the resident had no food intake documented; on [DATE], the resident ate seventy-five to one-hundred (,d+[DATE]%) percent of breakfast, but refused lunch and dinner; on [DATE], the resident had no documented intake at breakfast and refused lunch and dinner eating less than twenty-five (25%) percent; on [DATE], the resident refused breakfast, ate lunch at fifty to seventy-five (,d+[DATE]%) percent and refused dinner; on [DATE], the resident had no breakfast intake documented, refused lunch, ate less than twenty-five (25%) percent and ate twenty-five to fifty(,d+[DATE]%) percent for dinner; on [DATE], the resident ate fair with fifty to seventy-five (,d+[DATE]%) percent for breakfast; no documented intake for lunch, and ate poor for dinner, eating twenty-five to fifty (,d+[DATE]%) percent; on [DATE] and [DATE], the resident had no documented intake. However, there was no evidence found in the resident's medical record to indicate staff notified the resident's physician when he/she refused his/her meals and when the resident was documented to have eaten fair topoor for most of his/her meals, during the period of [DATE] through [DATE]. Continued review of Resident #428's closed medical record revealed on [DATE], Resident #428 tested positive for COVID-19 and was transferred to the facility's designated COVID unit. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress Notes, dated [DATE] at 10:25 AM, completed by, Registered Nurse (RN) #2 revealed the resident appeared lethargic and the resident's fingers and toes on the right side and three (3) fingers on the left hand were purple in color. However, there was no documented evidence the resident's physician was notified that the resident had not met his/her fluid needs or had consumed less than twenty-five (25%) percent of his/her average food intake since [DATE]. Further review of Resident #428's medical record revealed, on [DATE] at 2:33 PM, Resident #428's physician conducted a telehealth visit with the resident. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were advised to offer the resident fluids to maintain adequate hydration. However, there was no evidence that the physician was notified that the resident failed to meet his/her fluid needs and had only consumed twenty-five (25%) percent of meals since [DATE]. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A continued review of Resident #428's medical record revealed Nurses' Progress Notes dated [DATE] at 08:59 AM, completed by RN #2, revealed the Resident #428 continued to have purple fingers and toes. However, there was no documentation that the resident's physician was notified that the resident's fingers and toes remained discolored, and the resident continued to not eat or drink adequately. An interview with State Registered Nurse Aide (SRNA) #4, on [DATE] at 2:14 PM, revealed he cared for Resident #428 the night before the resident was sent to the hospital on [DATE]. SRNA #4 stated at approximately 5:00 AM on [DATE], he could not obtain an oxygen saturation on the resident and could not get the resident to take in any fluids. The SRNA stated the resident's breathing was labored and he/she was drenched in sweat. SRNA #4 stated, I thought (the resident) was going to die. Further interview revealed he notified Licensed Practical Nurse (LPN) #6 of the resident's condition multiple times during the night; however, LPN #6 did not notify the resident's physician. SRNA #4 stated LPN #6 revealed, day shift would take care of the resident when they came on shift. The SRNA #4 stated LPN #6 did not do anything to assist the resident. Interview with Licensed Practical Nurse (LPN) #6, on [DATE] at 2:58 PM, revealed she provided care to Resident #428, located on the COVID unit, during the night shift from [DATE] through [DATE], 7 PM to 7 AM. LPN #6 revealed that when she last checked on the resident, the resident was in no distress, which she could recall. Further interview revealed staff had not notified her of the resident's change in condition. She further stated that if staff had, she would have notified the resident's physician. Review of the Nurses' Progress Notes signed by Licensed Practical Nurse (LPN) #5, on [DATE] at 11:00 AM, revealed Resident #428 had vomited a large amount of dark black colored emesis, and the resident's oxygen saturation were not able to be obtained. The staff notified the resident's physician, who instructed staff to transfer the resident to the hospital for further evaluation and treatment. Review of Resident #428's hospital record dated [DATE], revealed the hospital admitted the resident with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical record revealed Resident #428's condition declined, he/she was placed on comfort measures and expired at the hospital on [DATE]. Interview with Physician #1, on [DATE] at 2:25 PM, revealed he was made aware of Resident #428's discolored fingers and toes during the telehealth visit on [DATE]. However, further interview revealed he was unaware of the resident's change in condition in which staff were unable to obtain the resident's oxygen saturation and of the resident's decreased food/fluids intake. Continued interview revealed he expected to be notified when a resident's condition worsened, as it would indicate further oxygenation problems. According to the physician, he was never made aware of Resident #428's refusal of meals/fluids nor was he aware the resident was not meeting his/her estimated fluid needs. Further interview revealed he had visited Resident #428 in the hospital and the resident's condition had declined since the telehealth visit on [DATE]. Physician #1 stated he had not been notified of Resident #428's decline prior to the resident's hospitalization . Further interview with the physician revealed if he had been made aware that the resident was not eating or drinking, he would have ordered labs, intravenous (IV) fluids, and would have sent the resident to the hospital sooner. Interview with the Former Director of Nursing (DON), on [DATE] at 12:29 PM, revealed she was not aware of any concern with Resident #428 not eating or meeting his/her estimated fluid needs. The DON stated she did not recall any concerns with the resident having discolored fingers, but she would have expected staff to report such concerns to the resident's physician, as a change of condition and for staff to provide increased monitoring of the resident. Further interview revealed if the Interdisciplinary Team (IDT) had been aware of the resident's decline, the physician would have been notified and orders would have been obtained from the physician for intravenous (IV) fluids, or the resident would have been sent to the hospital. Interview on [DATE] at 1:05 PM, with the Former Administrator, who was the Administrator in September of 2021, revealed she was not aware of any concerns with Resident #428. She stated she was not aware that State Registered Nurse Aide (SRNA) #4 reported Resident #428's concerns to Licensed Practical Nurse (LPN) #6, which were not addressed. The former Administrator stated daily conference calls were made during the morning meetings by the Administrator or the DON to the nursing staff working on the COVID unit. Per the interview, this call was made to discuss any concerns the floor nurse might have had while working the unit; however, there were no concerns identified related to Resident #428.

Based on observation, interview, record review and review of the Resident Assessment Instrument (RAI), Version 3.0, dated 10/2019, it was determined the facility failed to implement the Comprehensive Plan of Care related to pressure ulcers for four (4) of thirty-three (33) sampled residents (Residents #19, #39, #47, #63). Review of the Comprehensive Care Plan for Resident #47 revealed the Comprehensive Care Plan (CCP) interventions included: assess the skin and report skin breakdown; treatments as ordered; treatment to the Deep Tissue Injury (DTI) to right outer foot and monitor until resolved; treatment to the left heel as ordered; and treatment to the left outer foot as ordered. However, there was no documented evidence the facility was monitoring the resident's wounds, as there was no Wound Assessment completed from 01/13/2020 until 02/16/2022, after Surveyor intervention. Further, there was no documented evidence treatments were performed as ordered. The resident's pressure ulcers deteriorated and he/she developed [CONDITION(S)] (a bone Infection). Review of the Comprehensive Care Plan for Resident #19 revealed the Comprehensive Care Plan (CCP) interventions included: assess skin and report redness, rashes, bruises, abrasions or skin breakdown; provide wound care as ordered by the physician; and provide medications and treatments as per orders. However, there was no documented evidence the facility was monitoring the resident's wounds nor was there documented evidence physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no initial Wound Assessment until until 12/07/2021, twenty-eight (28) days after admission. Additionally, there was no documented evidence of a Wound Assessment from 12/07/2021, until the surveyor requested to observe a skin assessment on 02/16/2022, seventy-one (71) days later, when the resident's wounds were noted to be larger and unidentified wounds were noted. Review of the Comprehensive Care Plan for Resident #39 revealed the Comprehensive Care Plan (CCP) interventions included: Staff were to assess skin and report redness, rashes, bruises, abrasion or skin breakdown; pressure reduction mattress; provide incontinent care as needed; provide wound care as ordered by the MD. However, there was no documented evidence the facility was monitoring the resident's wounds nor was there documented evidence physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No documented evidence of a wound assessment from 01/11/2022 until the surveyor requested to observe skin assessment on to 02/16/2022, thirty-six (36) days later, the wound has worsened with a tunneling noted at 6.5 cm. Review of the Comprehensive Care Plan for Resident #63 revealed the Comprehensive Care Plan (CCP) interventions included: Staff were to assess skin and report redness, rashes, bruises, abrasion or skin breakdown; pressure reduction mattress; provide incontinent care as needed; provide wound care as ordered by the MD; treatment to stump per order. Review of Care Plan dated 02/04/2022 revealed new treatments for Resident #63's stage II coccyx and Left AKA was not updated on the care plan until 02/07/2022. No documented evidence of wound assessment for residents left AKA until the surveyor requested to observe skin assessment on to 02/16/2022. The facility's failure to ensure Resident's Comprehensive care palns were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/25/2022 and was determined to exist on 09/12/2021, 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) at the highest scope and severity (s/s) of a J, 42 CFR 483.25 Quality of Care (F686) at an s/s of a J, 42 CFR 483.70 Administration (F835 and F837), at the highest s/s of an L; and F842 at an s/s of a J, 42 CFR 483.75 Quality Assurance and Performance Improvement (F867) at an s/s of an L, and 483.80 Infection Control (F880) at an s/s of an L. The facility was notified of Immediate Jeopardy on 02/25/2022. An acceptable Immediate Jeopardy Removal Plan was received on 03/03/2022, which alleged removal of the Immediate Jeopardy effective 03/03/2022. However, the State Survey Agency was unable to validate the removal of the Immediate Jeopardy prior to exit on 03/04/2022. The Immediate Jeopardy is ongoing. The findings include: Interview with the Administrator on 02/21/2022 at 3:12 PM revealed the facility did not have a policy related to implementation of the Comprehensive Care Plan. According to the Administrator, the facility followed the Resident Assessment Instrument (RAI) process for developing, and implementing the plan of care. Review of the facility's copy of the RAI, Version 3.0, dated 10/2019, revealed the Minimum Data Set (MDS) views the resident in distinct functional areas to gain knowledge of the resident's functional status. Per the RAI, the facility should develop and implement an interdisciplinary care plan based on assessment information gathered throughout the RAI process. Further RAI review revealed, facility should re-evaluate the resident's status at prescribed intervals and modify the individualized care plan as appropriate. Review of the facility's Skin Care Standard of Practice Policy, dated 07/2020, revealed the facility would assess all residents on admission, readmission, and quarterly and with each change in condition that would compromise the skin. Per policy, the baseline skin assessment would be completed within twenty-four (24) hours of admission and documented in the medical record. Additionally, the Comprehensive Care Plan (CCP) initiated upon admission with the Baseline Care Plan and the development process for the CCP. Continued review revealed the CCP would reflect skin care needs, ADLs, nutrition, and activity level that would impact skin integrity risk. The Braden Risk Assessment would be completed on Admission, weekly for 4 weeks, with changes of condition, and on a quarterly basis. A skin assessment would be completed by a licensed nurse on admission/readmission, and on a minimum of weekly thereafter. 1. Review of the medical record for Resident #47, revealed the facility admitted the resident on 03/18/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's Quarterly Minimum Data Set (MDS) Assessment, dated 12/24/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating severe cognitive impairment. Additional review revealed the facility assessed the resident as at risk for developing a pressure ulcer and as having one (1) Stage IV pressure ulcer and three (3) suspected Deep Tissue Injuries (DTIs). Review of Resident #47's Comprehensive Care Plan (CCP), dated 01/04/2022, revealed the resident had a problem with impaired skin integrity including a Deep Tissue Injury (DTI) to the left heel, an unstageable pressure ulcer to the right outer foot, and a DTI to the left outer foot. The goal with a target date of 04/04/2022, revealed the resident would have no unidentified skin issues through the next review. Interventions included: assess the skin and report skin breakdown; perform treatments as ordered; treatment to the DTI to right outer foot and monitor until resolved; treatment to the left heel as ordered; and treatment to the left outer foot as ordered. Review of Resident #47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's Wound Evaluation Form, dated 01/13/2022, revealed the resident had a facility acquired pressure ulcer to the left outer foot which measured 2.9 centimeters (cm) long by 2.0 cm wide; and a facility acquired Stage IV pressure ulcer to the left heel classified as a Deep Tissue Injury (DTI) which measured 6.0 cm long by 4.1 cm wide by 1.4 cm deep. Continued review revealed there were no other Wound Evaluations documented in the Electronic Medical Record, indicating the CCP was not implemented related to assessing and monitoring skin. Review of Resident #47's January 2022 Treatment Administration Record (TAR) revealed wound treatments were not documented as being completed on 01/04/2022, 01/16/2022, 01/23/2022, 01/28/2022, and 01/29/2022, indicating the CCP was not implemented related to performing treatments as ordered. Review of Resident #47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's Physician's Note, dated 02/11/2022, revealed there were recent skin changes to the left heel, and x-ray imaging was obtained. Imaging concerning for [CONDITION(S)] and C-reactive protein (a blood test used to check for inflammation) elevated at 120.4 mg/l (milligrams per liter) (normal range is considered less than 10 mg/l). Further, the resident was to continue on antibiotic coverage in the form of [MEDICATION(S)] and [MEDICATION(S)] (antibiotic medication). Review of Resident #47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's February 2022 TAR, revealed the ordered wound treatments were not documented as being completed on 02/04/2022, 02/06/2022, 02/11/2022, 02/12/2022, 02/13/2022, and 02/15/2022 indicating the CCP was not implemented related to assessing and monitoring skin. Record review revealed there was no documented evidence of monitoring Resident #47's wounds as per the CCP. There was no documented evidence of Wound Evaluations for Resident #47 from 01/13/2022 until 02/16/2022, when the State Survey Agency (SSA) Representative asked to observe a skin assessment. Observation of a skin assessment, performed on 02/16/2022 at 3:07 PM, by Registered Nurse (RN) #1, revealed Resident #47's Deep Tissue Injury to the left outer foot had opened and increased in size to 4.0 cm long by 3.5 cm wide by 0.2 cm deep. The Stage IV pressure ulcer to the resident's left heel had increased in size to 6.0 cm long by 2.0 cm wide by 0.2 cm deep. Additionally, the resident was noted to have an area of brown eschar to the right lateral foot measuring 2.0 cm long by 1.5 cm wide with no depth. Review of the medical record revealed the brown eschar to the right lateral foot was an unidentified area until this skin assessment. Interview with Director of Nursing (DON) #3, on 02/21/2022 at 4:44 PM, revealed he had started at the facility in January 2022, and was unaware Resident #47 had pressure ulcers. Further, he was unaware skin assessments and wound measurements for Resident #47 were not being completed as per the CCP. According to the DON, a resident's pressure ulcers/wound could get worse or become infected if not being monitored and treated. Per interview, it was his expectation Resident #47's CCP would have been implemented related to monitoring skin, completing Wound Assessments and treatments as ordered. Interview with the Medical Director, on 02/24/20 at 1:27 PM, revealed she was the primary care physician for Resident #47. Per interview, the resident was diagnosed with a left heel deep tissue injury and was started on [MEDICATION(S)] for a Stage IV pressure ulcer. She further stated the resident was later diagnosed with [CONDITION(S)] and a Peripherally Inserted Central Catheter (PICC) line was placed for intravenous antibiotics related to the pressure ulcers. Per interview, two (2) of the resident's wounds had deteriorated. Continued interview revealed it was her expectation treatments were completed as ordered and skin was monitored consistently in order to identify new skin breakdown and to note the progress of pressure ulcers. 2. Review of Resident #19's medical record revealed the facility admitted the resident on 11/09/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's Admission Minimum Data Set (MDS) Assessment, with a reference date of 11/15/2021, revealed the facility assessed the resident as at risk for pressure ulcers and as having two (2) Stage III pressure ulcers that were present at admission on 11/09/2021. Further, the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating intact cognition. Record review revealed there was no documented evidence of a Wound Assessment for Resident #19 on admission. Review of Resident #19's Comprehensive Care Plan, dated established 11/09/2021 and implemented 12/08/2021, revealed the resident was assessed to have two (2) Stage III pressure ulcers on the outside of the right foot; a wound to the right outer leg on the side of the knee; a wound to the mid back spine and a wound to the right outer leg. The goal with a target date of 03/08/2022 stated the resident would remain free from any unidentified skin issues through next review. The interventions included: assess skin and report redness, rashes, bruises, abrasions or skin breakdown; pressure reduction mattress; provide wound care as ordered by the physician; and provide medications and treatments as per orders. Review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no documented evidence of treatment orders for Resident #19's wounds. Review of Resident #19's Initial Wound Assessment, completed 12/07/2021, twenty-eight (28) days after admission revealed the resident had the following wounds: 1) Wound to the right gluteal cleft resolved, scar tissue present. 2) Right outer knee wound measured Length-2.0 centimeters (cm) x Width-1.5 cm x Depth-unable to be determined (UTD), no odor, slough covering wound bed, small amount of bloody drainage noted when wound cleaned. However, the description did not indicate the type of wound or stage of wound. 3) Mid back wound measured Length-2.0 cm x Width-1.0 cm with no Depth recorded, no odor but large amount of bloody drainage when cleaned. However, the description did not indicate the type of wound or stage of wound. 4) Right outer calf wound measured Length-15 cm x Width-4.0 cm x Depth-0.2 cm, area of wound close to 12 o ' clock position was noted to have a small area of slough noted, bright red epithelization and granulation present. The wound was described as a Stage III pressure ulcer. 5) Right outer foot wound at base of fifth toe measured Length-2.5 cm x Width-2.0 cm x Depth-0.1 cm, small amount of bloody drainage noted when cleaned, granulation and epithelization present, no odor. The description did not indicate the type of wound or stage of wound. 6) Right outer foot measured Length-1.5 cm x Width-1.5 cm x Depth-0.2 cm, small amount of bloody drainage noted when cleaned. The description did not indicate the type of wound or stage of wound. Review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's January 2022 Treatment Administration Record (TAR), revealed the intervention to clean the two (2) Stage III Pressure ulcers on the outside of the right foot with wound cleanser, pat dry, and apply Santyl and cover with border gauze daily at 7:00 AM. However, the treatment was not signed to indicate the treatment was completed on 01/01/2022 and 01/02/2022, indicating the CCP was not implemented related to treatments as ordered. Review of Resident #19's Physician orders, dated 01/14/2022, revealed orders for Iodosorb External Gel 0.9% (Cadexomer Iodine), one (1) application to the back daily between 7:00 AM and 6:59 PM. Cleanse wound to back with wound cleanser, pat dry, and apply Iodosorb to wound, and cover with dry dressing. Change dressing daily and PRN (as needed). Review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's February 2022 TAR, revealed the intervention for wound treatment to apply skin prep to scar tissue at right gluteal cleft daily for prevention of breakdown, was not signed to indicate the treatments were completed for thirteen (13) days including 02/01/2022,02/02/2022, 02/03/2022, 02/04/2022, 02/05/2022, 02/08/2022, 02/09/2022, 02/11/2022, 02/12/2022, 02/13/2022, 02/14/2022, 02/15/2022, and 02/18/2022, indicating the CCP was not implemented related to treatments as ordered. Review of Resident #19's February 2022 TAR, revealed the intervention to monitor the wound on the resident's mid back was not signed to indicate monitoring at 7:00 AM for seven (7) days including 02/02/2022, 02/04/2022, 02/04/2022, 02/05/2022, 02/11/2022, 02/12/2022, 02/13/2022, and 02/15/2022, indicating the CCP was not implemented related to treatments as ordered. Review of Resident #19's February 2022 TAR, revealed the intervention for wound treatment air mattress was not signed at 7:00 AM for six (6) days including 02/02/2022, 02/04/2022, 02/05/2022, 02/11/2022, 02/12/2022, and 02/13/2022, indicating the CCP was not implemented related to treatments as ordered. Observation of Resident #19, on 02/14/2022 at 9:41 AM, revealed the resident was sitting up in bed. Resident #19 reported there was no bandage on his/her back. The resident's right leg was wrapped in gauze, dated 02/10/2022. Per the TAR, Resident #19's bandage to the right leg was to be changed on 02/12/2022, two (2) days prior, indicating the CCP was not implemented related to treatments as ordered. Observation on 02/16/2022 at 9:41 AM, of a skin assessment for Resident #19 performed by the Education Director, revealed the resident's mid back wound measured Length-7.0 cm x Width-7.0 cm with an open area in the center which measured 1.0 cm x 1.0 cm x 0.5 cm with purulent drainage; the resident's right calf wound measured Length-22 cm x Width-7.0 cm x Depth-0.25 cm ; right great toe wound measured Length-2.0 cm x Width-3.5 cm x (no depth) and was scabbed; right inner ankle wound measured 2.5 cm x 4.5 cm x (no depth) and was scabbed. This Wound Assessment was completed seventy-one (71) days after the last wound assessment, after Surveyor intervention, indicating the CCP was not implemented related to assessing the resident's skin. Observation and record review revealed from 12/07/2021 until 02/16/2022, the wound to Resident #19's mid back became larger; the area to the right outer calf became larger and increased in depth; and new unidentified areas were found on the resident's right great toe and right inner ankle. The unidentified areas revealed the CCP was not implemented related to assessing skin. Interview, on 02/16/2022 at 1:40 PM, with the Education Director, revealed the nurses were responsible for the skin assessments and wound treatments at this time. She was unaware skin assessments and wound treatments were not being completed as ordered and revealed the CCP was to be implemented related to skin breakdown. Interview with Registered Nurse (RN) #1, on 02/19/2022 at 2:42 PM, revealed she had not been completing Wound Assessments. She further stated the nurses had not been trained to do Wound Assessments and she was not sure which staff member was responsible for completing them. Interview with Resident #19's Physician, on 02/24/2022 at 1:27 PM, revealed she was aware the resident sometimes refused care, especially wound treatments. However, she stated it was her expectation for staff to try to perform wound treatments, and to ensure wound measurements, staging and description of wounds were documented weekly. Further, it was her expectation that all wounds have a treatment in place, and Resident #19 should have had a treatment in place from admission related to pressure ulcers. 3. Record review revealed the facility admitted Resident #39 on 12/20/2021 with Essential (primary) Hypertension, other chronic pain, Polyneuropathy, unspecified, Pressure Ulcer of Right Buttock, Stage 3, Adult Failure to Thrive, [CONDITION(S)], [CONDITION(S)], unspecified, [CONDITION(S)], unspecified, Pressure Ulcer of Right Buttock/unstageable and Acute Kidney Failure, unspecified. Review of Resident #39's Admission MDS Assessment, dated 12/24/2021, revealed the facility had assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating cognitive impairment. Continued review revealed Resident #39 was assessed to be at risk for pressure ulcers and had one unstageable deep tissue injury present on admission on 12/21/2021 and a care plan was developed. Review of Braden Scale for Predicting Pressure Sore Risk, dated 01/31/2022, revealed Resident #39 was at high risk with a total score of twelve (12). Review of Resident #39's Comprehensive Care Plan, dated 12/20/2021, revealed the resident had a Stage III Pressure to right buttock. Staff were to assess skin and report redness, rashes, bruises, abrasion or skin breakdown; pressure reduction cushion; provide incontinence care as needed; provide wound care as ordered by the MD; air mattress as ordered; treatment to buttocks per order. Review of Resident #39's initial Wound Assessment, dated 12/21/2022 revealed the resident had a wound measuring 12.2 cm in length x 7 cm in width x 0 cm depth. The wound was dry; black in color; with macerated tissue; no drainage, odor or pain. There was no documented evidence of the wound Stage or where the wound was located. Review of Resident # 39's Physician orders, dated 01/07/2022, revealed Santyl External Ointment 250 unit/gm ([MEDICATION(S)]) apply to buttock daily between 7:00 AM and 6:59 PM. Cleanse wound to right buttock with wound cleanser, pat dry and apply [MEDICATION(S)] to the outer perimeter of wound. Apply Santyl to eschar on wound, to cover with border gauze and to change daily and PRN. Review of Resident # 39's EMR revealed the next documented Wound Assessment was eighteen (18) days later, on an MD Note, dated 01/07/2022. Per Note the visit was a telehealth wellness visit. The resident had an Unstageable (US) Wound on his/her sacral, which was worse, deeper getting bigger; the wound had no tunneling, no eschar. The wound measurements were 4 cm in length x 2 cm in width. There was no documented evidence of the wound depth or color. Additional review of Resident #39's EMR revealed a Wound Assessment four (4) days later, dated 01/11/2022 at 5:03 PM. Continued review of the Wound Assessment revealed the resident's wound measurements were 11 cm in length x 6.8 cm in width x o cm in depth, the wound was black in color, necrotic, with discolored tissue, small/minimal drainage, no odor, no pain. The wound was documented as not worse. There was no documented evidence of the wound location or Stage. However, continued review of Resident #39's EMR, on 01/11/2022 at 5:10 PM, revealed a Wound Assessment where the wound was measured at 12.4 cm in length x 7.4 cm in width x 0 cm in depth. Per this Assessment the tissue was broken, with moderate serosanguineous drainage, an odor was present, there was no pain and the wound was not worse. However, the measurements were greater, and the wound now had drainage and odor. Further, the Assessment did not include the location of the wound or the Stage of the wound. Review of Resident #39's February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed blanks areas for seven days on 02/02/2022, 02/04/2022, 02/05/2022, 02/11/2022, 02/12/2022, 02/13/2021 and 02/15/2022, indicating the CCP was not implemented. Review of Resident #39's February 2022 TAR revealed no documented evidence that wound care treatments had been completed for a twice per day coccyx treatment to cleans the wound and appy [MEDICATION(S)] and oil emulsion with a wet to dry gauze dressing for the 9:00 AM treatment dates of 02/11/2022, 02/12/2022, 02/13/2022, 02/14/2022 and 02/15/2022 and the 9:00 PM treatment dates of 02/09/2022, 02/11/2022, 02/12/2022 and 02/13/2022, indicating the CCP was not implemented. Interview with Resident #39, on 02/16/2022 at 11:25 AM, revealed the resident felt bad. The resident additionally stated he/she had sores on his/her bottom, and they hurt. The resident was unable to state when the wounds were acquired. The resident further stated the nurses looked at the sore but not daily. Observation of Resident #39 during care provided by Agency SRNA #1, on 02/16/2022 at 11: 30 AM, revealed the resident had two (2) dressings on his/her buttock. One dressing (the top one) was dated 02/14/2022; however, orders revealed the dressing would be changed daily, indicating the CCP was not implemented. Interview with Agency SRNA #1, on 02/16/2022 at 11:30 AM, revealed she had worked at the facility for nine (9) months on day shift. She was assigned to the resident Resident #39 on 02/16/2022. Per interview, the resident was total care for all Activities of Daily Living . Additionally, the resident had a really big bed sore on his/her buttock since the resident was admitted to the facility. Continued interview revealed the resident was incontinent of bowel and bladder and wore briefs. The resident needed to be changed every two (2) hours; however, it was common practice for the aides to not complete the first round (check and change for peri-care) until after breakfast due to their assignments of vitals and passing trays. Per interview the first round could be after 10:00 AM. Further, the resident had a wound infection earlier in the year and the wound looked a better now. Further review of the EMR revealed Resident #39's wound was assessed on 01/11/2022 and not assessed again until 02/16/2022 at 12:12 PM, thirty-six (36) days between assessments. Per the Wound Assessment, dated 02/16/2022, the wound measurement was 12 cm in length x 7 cm in width x 2.5 cm in depth, to the left wound. The wound was moist, with intact tissue, small/minimal sanguineous drainage, no odor, mild pain and undermining to the left of the wound at the 9:00 o'clock position. Per the Assessment the wound was not worse; however, the wound measurements were greater since the 01/11/2022 assessment, the wound now had pain and undermining. Further, the Assessment did not include the wound location or Stage. Interview, on 02/16/2022 at 1:35 PM, with LPN #7 who was agency staff, revealed she had been to the facility eight (8) times and had not received any training from her agency or the facility on wound care, wound assessment, or documentation of wounds. Additionally, she did not know what the order for treatment was for Resident #39. Further, she told the Director of Nursing (DON) who was present with the Education Director Nurse, she did not feel comfortable performing wound care on the resident. Interview, on 02/16/2022 at 1:40 PM, with the Education Director Nurse, revealed she had worked at the facility since May of 2021 however had been in her current role since February 2022. Per interview, Resident #39 was admitted to the facility with the coccyx wound, at that time it was completely covered with eschar and the treatment was to cover with Santyl. She stated when the border came off, there was a huge wound with tunneling under it. Additionally, she had rounded with the Medical Director on 02/09/2022 for the major wounds in the facility because the wound nurse was no longer at the facility at that point. When she rounded with the physician, the physician told her the resident's wound was Unstageable. Continued interview revealed the wound nurse, prior to leaving the facility, was responsible for all skin and wound assessment and documentation as well as rounding with the physician for wounds. Additional interview revealed after completion of treatment or assessment, the primary nurse was now responsible to documented on the TAR/MAR in the EMR. Observation of wound care performed for Resident #39, on 02/16/2022 at 1:45 PM with the Education Director Nurse, the DON and the Agency LPN #7, revealed there were two (2) adhesive border dressings intact to the mid buttock. The top dressing was dated 02/16/2022 with initials, there were two dime size bright red blood spots on the top right corner of the dressing. The bottom dressing had two (2) nickel size bright red blood spots on the distal end of the dressing, it was dated 02/16/2022 and initialed. Continued observation revealed the Education Director Nurse removed the dressing revealing a large, irregular shaped wound that was moist with a beefy red wound bed with scattered yellow slough throughout the wound bed. No drainage noted. No odor noted. No eschar. Peri wound skin was pink but blanchable. The edges of the wound were thick and rolled. At the top of the wound a large hole was noted which tunneled upward and slightly towards the right. The wound was cleaned with wound cleanser on a 4x4 gauze and patted dry. The wound measurements were 11 cm length x 5.5 cm width x no depth measured. Tunneling of the wound was measured at 6.5 cm with Q-tip and the nurse stated the tunneling was from 12:00 -1:00 o'clock positions. Two 4x4 gauze pads were saturated with normal saline and laid over the tunneling hole. An oil emulsion was laid over remaining wound bed and [MEDICATION(S)] was thinly applied around the wound edges. No eschar was noted and no Santyl was used. One (1) adhesive border gauze was placed over the treatment, initialed and dated. Interview with the Regional Quality RN, on 02/16/2022 at 3:00 PM, revealed she had completed a wound assessment for the resident on 02/16/2022 because she heard the SSA wanted to watch wound care. She stated she used the National Pressure Injury Advisory Panel (NPIAP) as a resource for wound assessment. She staged the wound as a Stage III because there was no tendon or muscle showing only deep tissue. Continued interview revealed she measured the wound to be 12 cm length x 7 cm width (at widest across) x 2.5 cm with tunneling. She stated she did not measure tunneling because she did not have a Q-TIP and knew someone else was going to be measuring it with the SSA observing. Additionally, she stated the tunnelling appeared to go upward towards the left and that is why she documented it as at the 9:00 o'clock position to show it went towards the left. Further, she stated p [TR

Based on interview, record review, the facility's policy and the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, revised October 2019, it was determined the facility failed to revise the Comprehensive Care Plan with interventions to prevent malnutrition and dehydration for one (1) of thirty-three (33) sampled residents (Resident #428). In September 2021, Resident #248 was not meeting his/her estimated fluid needs and not eating. Resident #428 was later diagnosed with COVID-19. Resident #248 was transferred to the hospital and diagnosed with Severe Dehydration, Malnutrition, and Acute [CONDITION(S)]. In addition, the facility failed to revise the Comprehensive Care Plan with interventions to treat pressure ulcers and prevent worsening of the pressure ulcers for three (3) of thirty-three (33) sampled residents (Residents #19, #39 and #63). The facility's failure to ensure resident Comprehensive Care Plans were revised as indicated has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/18/2022 and was determined to exist on 09/12/2021, in the areas of 42 CFR 483.10 Resident Rights (F580) at the highest scope and severity (s/s) of a J, 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657) at the highest s/s of a J, and 42 CFR 483.25 Quality of Care (F684 and F692) at the highest s/s of a J. The facility was notified of Immediate Jeopardy on 02/18/2022. An acceptable Immediate Jeopardy Removal Plan was received on 03/03/2022, which alleged removal of the Immediate Jeopardy effective 03/03/2022. However, the State Survey Agency was unable to validate the removal of the Immediate Jeopardy prior to exit on 03/04/2022. The Immediate Jeopardy is ongoing. An Acceptable Immediate Jeopardy Removal Plan was received on 03/03/2022, which alleged removal of the Immediate Jeopardy effective 03/03/2022. However, the State Survey Agency was unable to remove the Immediate Jeopardy prior to exit on 03/04/2022. The Immediate Jeopardy is ongoing. The findings include: 1. Interview on 02/21/2022 at 3:12 PM, with the Administrator, revealed the facility did not have a policy for revision of residents' care plans. According to the Administrator, the facility followed the Resident Assessment Instrument (RAI) process for developing, revising, and following the plan of care. Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, revised October 2019, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, 4.7 revealed the care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care. Further review revealed facilities were to use the past fifteen (15) months of assessments results to develop, review, and revise the resident's comprehensive plan of care. Further review revealed the resident's care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. Review of Resident #428's closed medical record revealed the facility admitted him/her on 05/18/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #428's Quarterly Minimum Data Set (MDS) Assessment, dated 08/03/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident was cognitively impaired. The facility assessed the resident to require the extensive assistance of staff for eating and weighed one hundred and thirty (130) pounds. Further review of the assessment revealed the resident had no weight loss or gain in the past month or six (6) months, and had no assessed concerns for nutrition and hydration. Review of Resident #428's Comprehensive Care Plan revealed a nutritional services care plan for the resident dated 06/11/2021. Review of the nutritional services care plan revealed Resident #428 had problems noted of difficulty swallowing/chewing, and weight gain of 6.9% in one (1) month. Continued review revealed goals had been developed for Resident #428 which included the resident to maintain a consistent body weight plus or minus five (5) percent for ninety (90) days, and remain free of signs and symptoms of dehydration for ninety (90) days. Further review revealed the interventions developed included: staff to allow for the resident's likes/dislikes; provide his/her diet, snacks and supplements as ordered; provide follow up diet education/encouragement if preferences were not in compliance with prescribed diet; monitor his/her weight; and provide nutritional counseling as needed. In addition, review of the care plan further revealed no documented evidence of any revisions made to Resident #428's Comprehensive Care Plan after the date of 06/11/2021. Review of a nutrition assessment completed for Resident #428 by the dietitian, dated 07/29/2021, revealed the facility assessed the resident's estimated fluid need was 1475 to 1770 milliliters (ml) per day. In addition, Resident #428's documented food intake from 09/12/2021 until 09/20/21, revealed Resident #428 had only consumed meals five (5) times in the eight (8) day period. Further review revealed no documented evidence of any food intake for Resident #428 for the dates of 09/13/2021, 09/15/2021, and 09/19/2021. Review of Resident #428's closed medical record revealed the resident was diagnosed with the COVID-19 virus on 09/15/2021. Further review revealed five (5) days later, on 09/20/2021, the resident was transferred to the hospital following a change of condition. The resident was noted to vomit a dark black substance. Review of the hospital record for Resident #428 revealed the resident was admitted to the hospital on 09/20/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Emergency Department Physician documented Resident #428 was thin and cachetic (extreme weight loss and loss of muscle mass). According to the hospital Dietitian's assessment of Resident #428, on 09/21/2021, the resident was severely malnourished with a Body Mass Index (BMI) of 17.52. The Hospital dietetic also documented the resident had severe loss of muscle mass, prominent protrusion of bones, and pronounced hollowness/depression of the eyes. Resident #428 passed away at the hospital on 09/26/2021. Interview with the MDS Nurse, on 02/24/2022 at 8:56 AM, revealed she did not develop or revise Resident #428's plan of care for nutrition/hydration when the resident had a decline in food/fluid intake. Further interview revealed the Dietitian was responsible for developing and revising the resident's plan of care for nutrition and hydration. Interview with Dietitian #1, on 02/18/2022 at 2:47 PM, revealed she was responsible for revising the nutritional services care plan for Resident #428. According to the Dietitian, she had not been made aware that Resident #428 had not been eating and drinking, and not meeting his/her estimated fluid needs. The Dietitian stated she came to the facility and met with the Interdisciplinary Team (IDT) weekly. She stated during her weekly visit she reviewed any resident identified as having a nutritional concern. The Dietician stated she mainly focused on weight loss or, on residents whom the facility had identified as nutritionally at risk. However, the Dietician stated she was never notified of a concern regarding Resident #428, and she had not assessed the resident. Further the Dietician stated in the previous month (August 2021) Resident #428 had improved as far as his/her weight and nutrition. She stated since the improvement, the IDT had determined Resident #428's weekly weights could be changed to monthly weights. Dietician #1 further stated she could not recall any concerns being discussed in the IDT meetings related to Resident #428's nutrition and hydration. Interview with the former Director of Nursing (DON) #1 on 02/19/2022 at 12:29 PM, revealed the DON had conducted the daily clinical review (DCR) meetings with members of the IDT. She stated in the DCR meetings, she and the IDT members reviewed any concerns that had developed regarding residents. According to former DON #1, if a resident was not eating and drinking and that information had not been noted, she and the other IDT members might not become aware. Former DON #1 stated average daily intake reports for residents were printed by the Unit Manager, or the DON if the Unit Manager was working the floor. She stated the report was reviewed weekly in the facility's IDT meetings. Further interview revealed the former DON had not been made aware of any concern regarding Resident #428 not eating or meeting his/her estimated fluid needs. She further stated if the IDT had been made aware of any concerns regarding Resident #428's nutritional or fluid deficits, the Dietitian would have revised the resident's care plan with interventions to address those issues. 2. Review of Resident #19's medical record revealed the facility admitted the resident on 11/09/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's Admission MDS Assessment, dated 11/15/2021, revealed the facility assessed the resident to be at risk for pressure ulcers with two (2) Stage III pressure ulcers present on admission on 11/09/2021. A care plan was developed. Continued review revealed the facility assessed Resident #19 with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's Admission Care Plan dated 12/08/2021, revealed the facility had noted and care planned the resident for the following skin issues: two (2) Stage III pressure ulcers on the outside of the right foot; wound to right outer leg on side of knee; wound to mid-back spine; and wound to the right outer leg. Continued review revealed interventions which included: staff to assess Resident #19's skin and report redness, rashes, bruises, abrasion or skin breakdown. Record review revealed additional interventions included: a pressure reduction mattress; provide wound care, treatments and medications as ordered by the Physician. Further review revealed Resident #19's care plan was not revised/updated with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, further review revealed Resident #19's care plan had not been updated/revised to include the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of Resident #19's medical record and care plan revealed the resident was noted as a left above the knee [CONDITION(S)] (AKA). Further review revealed Resident #19 was a left AKA and the pressure reduction boot was ordered for the wrong leg. Review of the facility's, Initial Wound Assessment note for Resident #19 dated 12/07/2021, which was completed twenty-eight (28) days after admission, documented the following wounds and measurements: wound to right gluteal cleft resolved; wound to right outer knee measured 2 cm (centimeters) x 1.5 cm x UTD (unstageable depth of a wound); wound to mid back measured 2 cm x 1 cm x UTD; wound to the right outer calf measured 15.0 cm x 4 cm x 0.2 cm; wound to right outer foot at base of pinky toe measured 2.5 cm x 2 cm x 0.1 cm; and the wound to his/her right outer foot measured 1.5 cm x 1.5 cm x 0.2 cm. Further review revealed no evidence of other Wound Assessment Notes or wound measurements present in Resident #19's medical record until 02/16/2022. Review of the care plan revealed the facility failed to update the care plan with interventions to treat pressure ulcers and prevent worsening of the pressure ulcers Observation on 02/16/2022 at 9:41 AM with the Education Director revealed measurements were completed of Resident #19's wounds. Observation revealed the right calf wound measured: Length-22 cm x Width-7 cm x Depth-0.25 cm; right great toe wound measured Length-2 cm x Width-3.5 cm x scab (no depth); right inner ankle wound measured Length-2.5 cm x Width-4.5 cm x scab (no depth); and mid back wound measured 7 x 7 cm with open area in the center that was 1 cm x 1 cm, with purulent drainage. Review of Resident #19's skin assessments and Progress Notes revealed it had been seventy-one (71) days since the last assessment was documented. The facility failed to complete skin assessments and revise Resident #19's care plan to ensure appropriate care was provided. 3. Review of Resident #39's medical record revealed the facility admitted the resident on 12/20/2021. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's Admission MDS Assessment, dated 12/24/2021, revealed the facility assessed the resident as at risk for pressure ulcers. Continued review of the MDS revealed the facility had assessed the resident with one (1) unstageable pressure injury which presented as a deep tissue injury which was present on the resident's admission. Further review revealed the facility assessed Resident #39 with a BIMS' score of six (6), which indicated the resident was moderately cognitively impaired. Review of the facility's IDT Notes dated 12/20/2021, revealed on admission, the facility assessed Resident #39 to have a large unstageable deep tissue injury (DTI) that was covered in black tissue with varying degrees of redness surrounding it. Review of Resident #39's admission Care Plan, dated 12/20/2021, revealed the facility documented and care planned the resident for a Stage 3 pressure ulcer to the right buttock. Continued review of the care plan revealed no interventions were implemented until 01/07/2022, seventeen (17) days later. Interventions noted on 01/07/2022 included for staff to assess the resident's skin and report any redness, rashes, bruises, abrasion or skin breakdown. Further review revealed the 01/07/2022 interventions additionally included a pressure reduction mattress, and staff to provide wound care as ordered by the Physician, and provide incontinent care as needed. Continued review of Resident #39's medical record revealed the resident was sent to a Wound Care Physician on 02/09/2022 for evaluation of his/her right buttock pressure ulcer. The evaluation revealed a note from the Wound Physician dated 02/09/2022, which documented Resident #39's wound as worse with Santyl ointment ([MEDICATION(S)] agent) currently being used. Continued review of the Progress Note revealed Resident #39 had been documented as bed bound and wound was deep and getting bigger. Further review revealed the Plan for Resident #39's right buttock pressure ulcer was to discontinue the Santyl ointment; start [MEDICATION(S)] to the center of the ulcer with a dressing twice a day. Review of the Plan further revealed avoid direct pressure to the pressure ulcer with an air mattress and side to side position changes for the resident. Further review of Resident #39's care plan revealed no documented evidence of updates/revisions to the care plan regarding the new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's Initial Wound Assessment note for Resident #39 dated 12/21/2021, revealed the resident had been noted to have an unstageable pressure ulcer on his/her right buttock. Continued review of the Wound Assessment note revealed the wound measurements were documented as 12.0 cm length x 7 cm width x depth 0. Further review revealed the unstageable pressure ulcer on Resident #39's right buttock was noted as dark purple/black in color and feels boggy. In addition, further review revealed Resident #39's skin around the unstageable pressure ulcer on the right buttock was macerated (condition occurring when skin remains in contact with moisture for too long) and had moisture-associated skin damage (MASD) noted. Observation of wound care and measurements performed on 02/16/2022 at 1:45 PM, by Licensed Practical Nurse (LPN) #4, with the facility's Regional Quality Manager (RQM) and DON also present, during LPN# 4 conducted wound care and measurements. Observation revealed the measurements of Resident #39's right buttock unstageable pressure ulcer revealed LPN #4's measurements were 11 cm length x 5.5 cm width; however, the depth of the wound was not documented. Further observation revealed LPN #4 observed tunneling (occurs when a pressure ulcer progresses causing passageways underneath the surface of the skin) was measured as 6.5 cm with a cotton swab and the RQM stated the tunneling was from 12:00-1:00 o'clock (a clock format used to describe location). 4. Review of Resident #63's medical record revealed the facility admitted him/her on 01/14/2022, with [CONDITION(S)], unspecified, Acquired absence of left leg above knee (AKA), Asthma, Chronic Pulmonary Embolism, and Acute Respiratory Failure with [CONDITION(S)]. Review of the Admission MDS Assessment, dated 01/19/2022, revealed the facility assessed Resident #63 as at risk for pressure ulcers, with one (1) Stage II Pressure Ulcer and a surgical wound present on admission. Record review revealed a care plan was developed to address Resident #63's skin issues. Further review revealed the facility had assessed Resident #63 with a BIMS' score of fifteen (15), which indicated the resident was cognitively intact. Review of the facility's IDT's notes dated 01/14/2022, revealed the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, further review revealed no documentation that the IDT addressed the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #63's Admission Care Plan, dated 01/14/2022, revealed the resident was noted to have a Stage II Pressure to his/her coccyx and a left AKA which had been care planned. Continued review revealed Resident #63 had new wound orders related to the left AKA dehiscence; however, the facility failed to revise the care plan until 02/07/2022. Continued review revealed interventions included staff to assess skin and report redness, rashes, bruises, or skin breakdown; pressure reduction mattress to bed; provide incontinent care as necessary; and provide wound care and treatment to stump (left AKA wound) as ordered. However, review of Resident #63's Comprehensive Care Plan dated 02/04/2022, revealed new treatments for Resident #63's Stage II coccyx and left AKA were not updated on the care plan until 02/07/2022. Review of the facility's Initial Wound Assessment note for Resident #63, dated 02/16/2022, revealed the resident had a deep wound from dehiscence (partial or total separation of previously approximated surgical wound edges). Continued review revealed the wound measurements were documented as 6 cm in length x 5 cm in width x 1 cm depth. Further review revealed the wound was noted as red flesh, with a small amount of yellow drainage. Review further revealed Resident #63 had complained of pain with the packing of the wound. In addition, record review revealed no documented evidence of the wound tissue or location of the wound. Observation on 02/21/2022 at 1:30 PM, with State Registered Nurse Aide (SRNA) # 17 and Kentucky Medication Aide (KMA) #2 revealed Resident #63 had an open hole on his/her coccyx between the gluteal fold. Observation of wound care and interview on 02/21/2022 at 1:50 PM, with LPN #13 revealed the open hole observed on Resident #63's coccyx wound was circular but irregular in shape; the peri skin was blanchable; and there was no drainage or odor. Continued observation revealed LPN #13 measured the coccyx wound and the wound measurements obtained were 1 cm length x 0.9 cm width x 0.4 cm depth, which was the first documented evidence of the coccyx wound assessment since the resident was admitted , thirty-eight days prior. LPN #13 stated she was uncertain of the stage of the coccyx wound, and this had been the first time she had seen the wound or provided care for the resident. Interview with LPN #4 on 02/20/2022 at 4:00 PM, revealed residents' wound changes and treatments were to be updated/revised on their care plans. LPN #4 stated nursing staff used residents' care plans to provide the appropriate care and treatments. Interview with LPN #12 on 02/20/2022 at 4:15 PM, revealed she used residents' care plans to know how to care for the residents. LPN #12 stated she knew residents' care plans needed to be updated or revised when changes occurred with a resident. Interview with the MDS Nurse on 02/24/2022 at 8:55 AM, revealed the facility had no audits in place to ensure residents' care plans were an accurate reflection of the residents. She stated all residents had a baseline care plan when admitted . Interview revealed she relied on the staffs' documentation to know when changes occurred, and she updated/revised the residents' care plans with more specific interventions, after the changes. Continued interview revealed residents' care plans were to be revised and updated to ensure they were accurate. She stated the care should be revised timely to reflect each resident's needs to ensure staff knew how to care for them. The MDS Nurse stated, everyone (all staff) used the residents' care plans as it told them how to take care of each resident. According to the MDS Nurse, the potential problems of residents having an incomplete or inaccurate care plan was that a resident might not receive the care they needed, or the resident might develop a wound which might not be cared for as needed. She stated the floor nurse could tell her or the DON, if the care was not accurate for a resident, and she or the DON would make the necessary changes. Further interview revealed on a resident's admission, the nurses did the face-to-face assessment of the new resident. The MDS Nurse stated she did not normally do a head to toe assessment even on a resident's admission. She further stated she relied on the documentation that was discussed and reviewed in the facility's daily clinical meeting to know when to revise residents' care plans. In addition, she stated all new treatment orders and wound changes should have been placed on the residents' care plans to ensure the care plan was revised timely. The MDS Nurse stated if a resident's care plan was not updated or revised timely it could be harmful for the resident. Interview with the Administrator on 02/24/2022 at 12:58 PM, revealed her expectations were for facility staff to update and revise residents' care plans. Continued interview revealed with any new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the residents' care plans were the way staff knew what care the residents needed; therefore, the care plans needed to be updated timely. The Administrator stated she was not aware the residents' care plans were not being updated or revised as required. Interview with the facility's Medical Director on 02/24/2022 at 1:27 PM, revealed residents' care plans were to be revised timely to show changes with residents in order to ensure and maintain the continuity of care for the residents. The Medical Director stated ensuring residents' care plans were revised was for best practices.

Based on observation, interview, record review and review of the facility's policy, the Lippincott Manual of Nursing Practice, Ninth Edition, it was determined the facility failed to ensure one (1) of thirty-three (33) sampled residents (Resident #428) received the necessary quality of care and treatment services in accordance with professional standard of practices. State Registered Nurse Aides (SRNAs #3 and #4) observed a change of condition for Resident #428. Staff were not able to obtain the resident's oxygen saturation level due to the resident being drenched in sweat. The resident's fingers were purple almost black in color. The facility had no documented evidence staff conducted a thorough assessment of Resident #428's physical condition including his/her respiratory status, nor documented evidence of staff's inability to obtain the resident's oxygen saturation level. Resident #428 was transported to the hospital and according to the hospital record he/she required eight (8) liters of supplemental oxygen per minute to maintain his/her oxygen saturation levels. In addition, Resident #428 was diagnosed with [CONDITION(S)] (medical emergency caused by the body's response to an infection which could be life-threatening) due to Pneumonia and Acute Respiratory Failure due to [CONDITION(S)] (lack of adequate oxygenation). The facility's failure to ensure residents received quality of care and treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/18/2022 and was determined to exist on 09/12/2021, in the areas of 42 CFR 483.10 Resident Rights (F580) at the highest scope and severity (s/s) of a J, 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657) at the highest s/s of a J, and 42 CFR 483.25 Quality of Care (F684 and F692) at the highest s/s of a J. The facility was notified of Immediate Jeopardy on 02/18/2022. An acceptable Immediate Jeopardy Removal Plan was received on 03/03/2022, which alleged removal of the Immediate Jeopardy effective 03/03/2022. However, the State Survey Agency was unable to validate the removal of the Immediate Jeopardy prior to exit on 03/04/2022. The Immediate Jeopardy is ongoing. The findings include: Interview with Director of Nursing (DON) #5, on 03/04/2021 at 5:36 PM, revealed the facility did not have a policy regarding professional standard of practice. However, the facility utilized, the Lippincott Manual of Nursing Practice, Ninth Edition, to guide its nursing staff's practice to meet professional standards. Review of the Lippincott Manual of Nursing Practice, Ninth Edition, page 284, revealed for acute respiratory disorders the standards of care guidelines for respiratory compromise was for the nurse to perform a thorough systematic assessment. Continued review revealed the thorough systematic assessment was to include assessment of: mental status; vital signs; cardiovascular status and respiratory status. Further review revealed the nurse should evaluate for signs of [CONDITION(S)] (low level of oxygen in the blood) when anxiety, restlessness, confusion, or aggression of new onset were noted. Further review revealed the nurse was to document the patient's condition to provide a record for continuity of care and notify the appropriate health care provider of significant findings of [CONDITION(S)]; cyanosis, rapid and shallow respirations, abnormal breath sounds, change in behavior or level of consciousness (LOC). Review of Resident #428's closed medical record revealed the facility admitted the resident on 05/18/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Quarterly Minimum Data Set (MDS) assessment completed for Resident #428 with a date of 08/03/2021 revealed the facility assessed the resident to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of five (5). Further review revealed the facility assessed the resident to require the extensive assistance of two (2) staff for transfers, bed mobility, and toileting. Continued review revealed the facility assessed the resident as always incontinent of bowel and bladder. Review of Resident #428's Comprehensive Care Plan revealed the facility had revised the plan of care for Resident #428 with a positive COVID status on 09/14/2021. Interventions included to place the resident in transmission based precautions, per the facility's COVID 19 protocol and administer medications as ordered. Review of the Nursing Progress Notes for Resident #428, dated 09/20/2021 at 11:34 AM, revealed thirty minutes earlier on 09/20/2021 at 11:00 AM, the resident was documented to have had a large emesis (vomit) which was dark black in color. Continued review of the 09/20/2021 Nursing Progress Note, revealed Resident #428's vital signs were noted as: blood pressure 173/83; pulse of 85; respirations of 18; and the resident's oxygen saturation was not able to be obtained. According to the Note, the physician was contacted and orders were received to send the resident to the hospital for evaluation and treatment. Further review of the Nursing Progress Notes for Resident #428 revealed no documented evidence of assessment of the resident's respiratory status from 6:00 AM until 11:00 AM on 09/20/2021 when the resident was sent out to the hospital. Review of the hospital's medical record for Resident #428 revealed when the resident arrived at the emergency room (ER) on 09/20/2021, the resident required oxygen at eight (8) liters per minute (LPM) to maintain his/her oxygen saturation Continued review revealed Resident #428 was noted to have crepitus (palpable or audible popping, crackling, grating, or a crunching sensation) lung sounds and had been diagnosed with [CONDITION(S)] due to Pneumonia and Acute Respiratory Failure due to [CONDITION(S)]. Further review revealed Resident #428's fingers and toes were assessed as cyanotic (bluish or purplish discoloration of the skin due to lack of adequate oxygen) and the resident's lower extremities were mottled (blotches or spots indicating abnormal flood flow). Review of the hospital records revealed Resident #428 was placed on comfort measure at the hospital. Resident #428 passed away at the hospital six (6) days later on 09/26/2021. Interview on 02/08/2022 at 4:06 PM, with State Registered Nurse Aide (SRNA) #3 revealed on the morning of 09/20/2021 at approximately 5:00 AM, Resident #428 would not take a drink for her. The SRNA stated they had checked on the resident every two hours. Continued interview revealed Resident #428's fingers had been purple almost black and she and SRNA #4 reported the changes to Licensed Practical Nurse (LPN) #6. SRNA #3 stated LPN #6 had not done anything for Resident #428. Further interview revealed due to LPN #6's not doing anything, she had decided to report her concerns regarding Resident #428 to the oncoming day shift nurse. The SRNAs stated there was no night shift supervisor on duty. However, she had not been able to report to the day shift nurse because LPN #6 had been with the day shift nurse at shift change for shift report. Further interview with SRNA #3 revealed since she couldn't talk to LPN #6, she attempted to notify the Director of Nursing (DON) and the Administrator, but they did not answer their phone. Interview on 02/08/2022 at 2:14 PM, with SRNA #4 revealed the SRNA had been working the night before the resident was sent to the hospital on 09/20/2021. SRNA #4 stated around 5:00 AM, Resident #428 had a change of condition and wasn't eating and drinking. Continued interview revealed the SRNA had been unable to obtain an oxygen saturation on Resident #428, and the resident's breathing was labored. He stated Resident #428 had been drenched in sweat and he thought the resident was going to die. Further interview revealed he and SRNA #3 reported everything regarding Resident #428's condition to LPN #6 multiple times. SRNA #4 stated LPN #6 told him that the resident was not going to die in the next two hours and day shift would take care of Resident #428 when they came in to work. Interview on 02/18/2022 at 2:58 PM, with LPN #6 revealed she had provided care for Resident #428 on the night shift on 09/19/2021 from 7:00 PM to 7:00 AM on the morning of 09/20/2021. LPN #6 stated she checked on the resident every hour. According to the LPN, she could not remember any concerns regarding Resident #428 not eating or drinking and had not been made aware of any changes in the resident's condition. Continued interview revealed LPN #6 denied any knowledge of SRNA #3 and SRNA #4 reporting concerns of Resident #428's fingers being purple/black and not being able to get an oxygen saturation level on the resident. LPN #6 stated if she had known of that information, she would have assessed Resident #428, and reported any changes of condition to the Physician and resident's family. Further interview revealed LPN #6 could not recall why she had not documented any Progress Notes on her shift for Resident #428 on 09/19/2021 through 09/20/2021. Interview on 02/18/2022 at 11:55 AM, with LPN #5 revealed the LPN could not recall very much about Resident #428, other than sending the resident to the hospital. LPN #5 stated sometimes the SRNAs got residents' vital signs and sometime she would get the vital signs. She stated she was not aware why vital signs for Resident #428 were not documented from 6:00 AM to 11:00 AM, or why there was no assessment documented either. Continued interview revealed residents were checked on every hour. However, she might have been busy and forgot to put Resident #428's vital signs in the computer. LPN #5 stated that might also have been why she had not made any notes for Resident #428 in the computer. Further interview revealed she could not recall Resident #428's fingers being blue, nor not being able to obtain an oxygen saturation level for the resident. LPN #5 further stated Resident #428 had experienced a change of condition, vomiting a large black emesis, and she called the Physician and sent the resident out to the hospital as she documented in his/her record. An interview with SRNA #8 on 02/19/2022 at 10:13 AM revealed he often provided care for Resident #428 on the COVID Unit from 09/15-20/2021. SRNA #8 stated the resident did not eat and drink well. However, he stated he could not document the resident's food and fluid intake because he was an agency staff and did not have computer access to chart care in the electronic medical record. Further interview revealed Resident #428 did not eat and drink very much and he thought it was normal for the resident and didn't report anything to the nurse. Interview on 02/19/2022 at 12:29 PM, with former Director of Nursing (DON) #1 revealed if a resident had a change of condition the nurse was supposed to assess the resident. Continued interview revealed the nurse assessing a resident's change in condition was also to document the findings of the assessment in the resident's electronic medical record, notify the Physician and document the notification and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment should include: checking oxygen saturation levels, and if warranted, assessment of the resident's lung sounds because they were on the COVID Unit. The DON stated they reviewed residents' electronic medical records in the morning meeting, but she did not recall any concerns with Resident #428. Continued interview revealed former DON #1 was not aware assessments of the oxygen saturation level for Resident #428 had not been documented from 6:00 AM to 11:00 AM as required. The DON stated she did not recall any concerns with Resident #428 having had discolored fingers. However, she stated she expected this information to have been reported to the Physician as a change of condition for the resident. She stated she also expected Resident #428 to have been monitored by nursing staff. Further interview revealed she was not aware of any concerns regarding LPN #6 not assessing Resident #428 after SRNAs #3 and SRNA #4 reported to her they had not been able to obtain the resident's oxygen saturation level, and the resident was drenched in sweat with his/her fingers purple almost black. The DON stated she was not aware of any concerns with LPN #6 not assessing residents. She stated staff should have came to her and reported concerns of a nurse not checking on residents. Interview on 02/19/2022 at 1:05 PM, with the former Administrator #1 (who was the Administrator of record in September 2021) revealed she was not aware SRNA #3 and SRNA #4 had reported concerns regarding Resident #428 to LPN #6. She was not aware the LPN took no action to assess the resident and document her findings in accordance with professional standards of practice. The Administrator stated she was also not aware that LPN #6 had not assessed Resident #428 from 6:00 AM to 11:00 AM, prior to the resident being sent to the hospital. According to the Administrator, she monitored care provided for residents on the COVID Unit by having a daily conference call with the nurse assigned to work on the COVID Unit. Further interview revealed the Administrator also stated she monitored residents' care on the COVID Unit by reviewing the status of each resident. However, she could not recall any concerns regarding Resident #428. In addition, the Administrator stated the nurses should provide care in accordance with professional standards to ensure residents received the quality care necessary. She stated she was not aware that SRNAs #3 and #4 had any concerns with LPN #6. She stated they if the nurse was not checking on a resident for a change of condition, the staff should have reported the incident to her.

Based on observation, interview, record review and a review of the facility policy, it was determined the facility failed to have an effective system in place to ensure residents wounds were assessed and received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for four (4) of thirty-three (33) sampled residents (Residents #47, 19, #39, and #63). Record review and interview revealed the facility's Wound Nurse resigned from the facility in January 2022, and although the Administrator became aware that same month the Wound Assessments were not being completed consistently, there was no documented evidence of a skin sweep of all residents in order to identify any new pressure ulcers or identify if pressure ulcers were deteriorating. Wound Assessments were left for the staff nurses to complete. However, interview with the staff nurses revealed they were unaware they were to complete the Wound Assessments, had not had training related to measuring and staging of wounds, and were not comfortable completing this type of wound assessment. Review of the facility's Skin Care Standard of Practice revealed a skin assessment would be completed weekly by a licensed nurse and staging and measuring would be completed by the assigned nurse to maintain continuity in documentation of progression of wound healing. However, record review revealed these assessments were not consistently completed and there was no documented evidence of consistent monitoring of the progress of the residents' wounds. As a result, observation of skin assessments performed revealed there was deterioration of residents wounds and unidentified wounds. The facility's failure to ensure resident wounds were assessed and received necessary treatment and services has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/25/2022 and was determined to exist on 09/12/2021, 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) at the highest scope and severity (s/s) of a J, 42 CFR 483.25 Quality of Care (F686) at an s/s of a J, 42 CFR 483.70 Administration (F835 and F837), at the highest s/s of an L; and F842 at an s/s of a J, 42 CFR 483.75 Quality Assurance and Performance Improvement (F867) at an s/s of an L, and 483.80 Infection Control (F880) at an s/s of an L. The facility was notified of Immediate Jeopardy on 02/25/2022. An acceptable Immediate Jeopardy Removal Plan was received on 03/03/2022, which alleged removal of the Immediate Jeopardy effective 03/03/2022. However, the State Survey Agency was unable to validate the removal of the Immediate Jeopardy prior to exit on 03/04/2022. The Immediate Jeopardy is ongoing. Refer to F656 and F657 The findings include: Review of the facility policy, titled Skin Care Standard of Practice dated July 2020, revealed the facility would ensure residents with pressure ulcers receive necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection. Further review of the policy revealed a skin assessment would be completed weekly by a licensed nurse and staging and measuring would be completed by the assigned nurse to maintain continuity in documentation of progression of wound healing. Further review of the policy, revealed weekly documentation of wound status and response to healing including need to alter treatment would be included in the medical record. 1. Review of Resident #47's closed medical record revealed the facility admitted the resident on 03/18/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's Physician's orders, dated 10/12/2020, revealed orders for weekly skin inspections. Review of Resident #47's Quarterly Minimum Data Set (MDS) Assessment, dated 12/24/2021, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance of two (2) staff for bed mobility, and extensive assistance of two (2) staff for transfers. Continued review revealed the resident was assessed as always incontinent of bowel and bladder. Additional review revealed the facility assessed the resident as at risk for developing a pressure ulcer and as having one Stage IV pressure ulcer and three (3) suspected Deep Tissue Injuries (DTIs). Review of Resident #47's Comprehensive Care Plan (CCP), dated 01/04/2022, revealed the resident had a problem with impaired skin integrity including a Deep Tissue Injury (DTI) to the left heel, an unstageable pressure ulcer to the right outer foot, and a DTI to the left outer foot. The goal, with a target date of 04/04/2022, revealed the resident would have no unidentified skin issues through next review. The interventions included: assess the skin and report skin breakdown; treatments as ordered; treatment to the DTI to right outer foot and monitor until resolved; treatment to the left heel as ordered; and treatment to the left outer foot as ordered. However, the facility failed to revise the CCP with interventions to treat pressure ulcers. Further, the facility failed to ensure the CCP was followed. (Refer to F656 and F657). Review of Resident #47's Physician's orders, dated 01/07/2022, revealed orders for [MEDICATION(S)] 100 mg (antibiotic medication) twice daily for a wound infection. Review of Resident #47's Physician's orders, dated 01/11/2022, revealed orders for treatment to clean the wound to the left outer foot with wound cleanser, pat dry, apply Santyl (a medicated ointment that removes dead tissues from wounds) and cover the wound with a foam dressing daily and as needed. Review of Resident #47's Physician's orders, dated 01/11/2022, revealed orders for left heel to be cleaned with Dakins solution, pat dry apply, Santyl (a medicated ointment that removes dead tissues from wounds) to the wound bed, cover with petroleum gauze cover with calcium alginate and cover with a foam dressing, change daily and as needed. Review of Resident #47's Wound Evaluation Form, dated 01/13/2022, revealed the resident had a facility acquired pressure ulcer to the left outer foot measuring 2.9 centimeters (cm) long by 2.0 cm wide; and a facility acquired Stage IV pressure ulcer to the left heel classified as a Deep Tissue Injury (DTI) measuring 6.0 cm long by 4.1 cm wide by 1.4 cm deep. Resident #47 did not have any other Wound Evaluations documented in the Electronic Medical Record. Review of Resident #47's January 2022 Treatment Administration Record (TAR) revealed the resident's ordered wound treatments were not documented as being completed on 01/04/2022, 01/16/2022, 01/23/2022, 01/28/2022, and 01/29/2022. Review of Resident #47's Physician's orders, dated 01/31/2022, revealed orders to clean the wound to the right foot with wound cleanser, apply Santyl and cover with a nonstick foam dressing. However, there was no documented evidence of a wound to the right foot during this timeframe. Review of Resident #47's Physician's orders, dated 02/05/2022, revealed orders for Santyl to be applied daily to pressure ulcer other site stage IV; however, there was no wound site was identified in the order. Review of Resident #47's Physician's orders, dated 02/08/2022, revealed orders for intravenous [MEDICATION(S)] (antibiotic) one (1) Gram every eight (8) hours and [MEDICATION(S)] one (1) Gram every six (6) hours for six (6) weeks for [CONDITION(S)] (bone infection). Review of Resident #47's Physician's Note, dated 02/11/2022, revealed there were recent skin changes to the left heel, and x-ray imaging was obtained. Imaging concerning for [CONDITION(S)] and C-reactive protein (a blood test used to check for inflammation) elevated at 120.4 mg/l (milligrams per liter) (normal range is considered less than 10 mg/l). Per the Note, the resident was to continue on antibiotic coverage in the form of [MEDICATION(S)] and [MEDICATION(S)] (antibiotic medication). Review of Resident #47's Physician's orders dated 02/14/2022, revealed orders for skin inspection to be completed on Tuesdays on the evening shift. Review of Resident #47's February 2022 TAR, revealed the ordered wound treatments were not documented as being completed on 02/04/2022, 02/06/2022, 02/11/2022, 02/12/2022, 02/13/2022, and 02/15/2022. There was no documented evidence of weekly skin assessments or Wound Evaluations for measurements/staging documented from 01/13/2022 until 02/16/2022, over a month later, when the State Survey Agency (SSA) Representative asked to observe a skin assessment for Resident #47. Observation of a skin assessment for Resident #47, conducted on 02/16/2022 at 3:07 PM, by Registered Nurse (RN) #1, revealed the resident's Deep Tissue Injury to the left outer foot had opened and increased in size to 4.0 cm long by 3.5 cm wide by 0.2 cm deep. The Stage IV pressure ulcer to the left heel had increased in size to 6.0 cm long by 2.0 cm wide by 0.2 cm deep. Additionally, the resident was noted to have an area of brown eschar to the right lateral foot measuring 2.0 cm long by 1.5 cm wide with no depth. Per record review, the brown eschar to the right lateral foot was an unidentified area until this skin assessment. The area to the right lateral foot was observed without a dressing in place prior to this skin assessment. Interview with Registered Nurse (RN) #1, on 02/16/2022 at 3:10 PM, revealed the wound on Resident #47's right foot should have been covered with a dressing and she was not aware the wound was not covered. According to the nurse the area to the resident's right lateral foot was not new, but she was not aware of when the area developed. Per interview, the area was supposed to have a treatment to be cleaned with 1/2 strength Dakins ( a wound cleanser) and Santyl (an ointment to remove dead tissue from a wound) and covered with a foam dressing. However, there was no documented evidence of a Physician's order for 1/2 strength Dakins and Santyl. Interview with Licensed Practical Nurse (LPN) #LPN #7, on 02/22/2022 at 8:35 AM revealed she was an Agency nurse and was often assigned to Resident #47. Per interview, she did not receive any training on wounds during her orientation. When the LPN was questioned if she completed skin assessments and wound treatments, she stated she was unable to perform wound treatments/ or wound assessments as she was not comfortable with this and would pass the treatments/assessments off to the next shift to complete. However, she did not know if the next shift was completing the treatments/assessments that she did not complete. Interview with Licensed Practical Nurse (LPN) #5, on 02/22/2022 at 5:18 PM, revealed she was the former wound nurse and assessed and measured wounds weekly and made wound rounds with the physician. Per interview, it was her responsibility to complete weekly skin assessments as well as complete wound assessments weekly. Further, she left the facility in January of 2022 and the floor nurses were supposed to take over measuring the wounds weekly and document wound assessments in the Electronic Medical Record (EMR) system. According to the wound nurse she documented the wound assessments on paper because of problems with the computer system deleting information, and then handed the assessments and measurements to the Administrator. Per interview she started back at the facility as the wound nurse on 03/02/2022. Interview with Director of Nursing (DON) #3, on 02/21/2022 at 4:44 PM, revealed he had started at the facility in January 2022. Further interview revealed he was not aware Resident #47 had pressure ulcers, nor was he aware skin assessments and wound measurements for Resident #47 were not being completed. According to the DON, he was new to long term care and was in training and was monitoring residents by making rounds in the facility, but was still trying to learn and did not monitor for anything specific. Further interview revealed a resident's pressure ulcers/wound could get worse or become infected if not being monitored and treated, or if the correct treatment was not ordered. Interview with the Medical Director, on 02/24/2022 at 1:27 PM, revealed she was also the primary care physician for Resident #47 and stated the resident had declined and was more debilitated in recent months due to Cancer. Per interview, the resident was diagnosed with a left heel deep tissue injury. Further, the resident was started on [MEDICATION(S)] for a Stage IV pressure ulcer, but the resident was frail and the wound wouldn't heal. She stated the resident was later diagnosed with [CONDITION(S)] and a Peripherally Inserted Central Catheter (PICC) line was placed for intravenous antibiotics. According to the Physician, she did look at notes and tried to track down a time line for Resident #47's wounds and noted two (2) of the resident's wounds had deteriorated. Further interview revealed some of the treatment orders were incorrect as there was confusion related to the wounds on the right and left lower extremities. Per interview, the order dated 01/31/2022, to clean the wound to the right foot with wound cleanser, apply Santyl and cover with nonstick foam dressing should not have been ordered. 2. Review of Resident #19's medical record revealed the facility admitted the resident on 11/09/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #19's medical record revealed no skin assessments were completed on admission. Review of Resident #19's Braden Scale for Predicting Pressure Sore Risk, dated 11/09/2021, revealed Resident #19 was at mild risk for pressure ulcers with a total score of fifteen (15). Review of Resident #19's Physician's orders, dated 11/10/2021, revealed orders to monitor wound on mid back for signs and symptoms of worsening or non healing every shift until resolved. Resident #19's Physician's orders dated 11/16/2021, revealed orders to monitor wounds on right outer foot for signs and symptoms (s/s) of worsening or non healing every shift until resolved, and monitor wounds on right outer leg for s/s of worsening or non healing every shift until resolved. However, there was no documented evidence of treatment orders for Resident #19's wounds. Review of Resident #19's Admission Minimum Data Set (MDS) Assessment, with a reference date of 11/15/2021, revealed the facility assessed the resident as at risk for pressure ulcers and also as having two (2) Stage III pressure ulcers that were present at admission on 11/09/2021. Further review revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating intact cognition. Continued review revealed the facility assessed the resident as requiring extensive assistance of two (2) persons for transfers. There was no documented evidence of a Wound Assessment until 12/07/2021, which was twenty-eight (28) days after admission. Review of Resident #19's Initial Wound Assessment Note, dated 12/07/2021, revealed the following: 1) Wound to the right gluteal cleft resolved, scar tissue present. 2) Wound to the right outer knee measured Length-2.0 centimeters (cm) x Width-1.5 cm x Depth-unable to be determined (UTD), no odor, slough covering wound bed, small amount of bloody drainage noted when wound cleaned. This description did not indicate the type of wound or stage of wound. 3) Wound to mid back measured Length-2.0 cm x Width-1.0 cm with no Depth recorded, no odor but large amount of bloody drainage when cleaned. This description did not indicate the type of wound or stage of wound. 4) Wound to right outer calf measured Length-15 cm x Width-4.0 cm x Depth-0.2 cm, area of wound close to 12 O'clock noted to have small area of slough noted, bright red epithelization and granulation present. This wound was described as a Stage III pressure ulcer. 5) Wound to right outer foot at base of fifth toe measured Length-2.5 cm x Width-2.0 cm x Depth-0.1 cm, small amount of bloody drainage noted when cleaned, granulation and epithelization present, no odor. This description did not indicate the type of wound or stage of wound. 6) Wound to right outer foot measured Length-1.5 cm x Width-1.5 cm x Depth-0.2 cm, small amount of bloody drainage noted when cleaned. This description did not indicate the type of wound or stage of wound. Review of the Resident #19's Comprehensive Care Plan, dated 12/08/2021, revealed the resident had two (2) Stage III pressure ulcers on the outside of the right foot; a wound to the right outer leg on the side of the knee; a wound to the mid back spine and a wound to the right outer leg. The goal with a target date of 03/08/2022 revealed the resident would remain free from any unidentified skin issues through next review. Interventions included: assess skin and report redness, rashes, bruises, abrasions or skin breakdown; pressure reduction mattress; provide wound care as ordered by the physician; and provide medications and treatments as per orders. However, there was no documented evidence the CCP was implemented, nor was the CCP revised with interventions to treat the resident's wounds. (Refer to F656 and F657) Review of Resident #19's Physician's orders, dated 12/08/2021, revealed orders to apply skin prep to scar tissue at right gluteal cleft daily for prevention of breakdown. Review of Resident #19's January 2022 Treatment Administration Record (TAR), revealed the intervention for wound treatment to the two (2) Stage III Pressure ulcer on the outside of the right foot with wound cleanser and pat dry. Apply Santyl and cover with border gauze daily at 7:00 AM. However, the treatment was not signed to indicate the treatment was completed at 7:00 AM on 01/01/2022 and 01/02/2022. There was no Physician's order found in the medical record for intervention. Resident #19's Physician orders, dated 01/14/2022, revealed orders for Iodosorb External Gel 0.9% (Cadexomer Iodine), one (1) application to back daily between 7:00 AM and 6:59 PM. Cleanse wound to back with wound cleanser, pat dry, and apply Iodosorb to wound, cover with dry dressing. Change daily and PRN (as needed). Review of Resident #19's Physician's orders, dated 02/05/2022, revealed orders for Vaseline gauze to right leg and foot an wrap with Gauze every three (3) days. Review of Resident #19's February 2022 TAR, revealed the intervention for wound treatment to apply skin prep to scar tissue at right gluteal cleft daily for prevention of breakdown at 7:00 AM, was not signed to indicate the treatments were completed for thirteen (13) days including 02/01/2022, 02/02/2022, 02/03/2022, 02/04/2022, 02/05/2022, 02/08/2022, 02/09/2022, 02/11/2022, 02/12/2022, 02/13/2022, 02/14/2022, 02/15/2022, and 02/18/2022. Interview with Registered Nurse (RN) #1, on 02/19/2022 at 11:20 AM, revealed she did wound care for Resident #19 on 02/18/2022, but had no explanation as to why this treatment was not charted. Review of Resident #19's February 2022 TAR, revealed the intervention to monitor the wound on the resident's mid back was not signed to indicate monitoring at 7:00 AM for seven (7) days including 02/02/2022, 02/04/2022, 02/04/2022, 02/05/2022, 02/11/2022, 02/1/ , 02/13/2022, and 02/15/2022. Review of Resident #19's February 2022 TAR, revealed the intervention for wound treatment air mattress was not signed at 7:00 AM for six (6) days including 02/02/2022, 02/04/2022, 02/05/2022, 02/11/2022, 02/12/2022, and 02/13/2022. Interview with Resident #19, on 02/10/2022 at 9:41 AM, revealed he/she did not receive the wound care treatment like the doctor ordered. The resident stated he/she did not currently have a bandage on his/her back. Interview with Licensed Practical Nurse (LPN) #4, on 02/10/2022 at 10:15 AM, revealed she was assigned to Resident #19, but had not checked on Resident #19's bandages today. She further stated she had no knowledge if the resident had his/her bandages on or when they were changed last . Further interview with LPN #4, on 02/10/2022 at 10:45 AM, revealed the resident's dressing to the mid back was not in place and the dressing to the resident's right leg should have been changed a few days ago and she would change the dressings. Observation on 02/14/2022 at 9:41 AM, revealed there was no bandage on Resident #19's resident's back. The resident's right leg was wrapped in gauze, dated 02/10/2022. Per the TAR, Resident #19's bandage to the right leg was to be changed on 02/12/2022, two (2) days prior. Interview with LPN #4, on 02/20/2022 at 4:00 PM, revealed she did change Resident #19's right leg bandage on 02/12/2022 and she had no explanation as to how the bandage was dated 02/10/2022. Continued interview revealed she could see how it could be a concern if wound bandages were not changed timely. Further, she did not perform Wound Assessments and she did not know who was responsible for performing Wound Assessments and she had never been instructed to do this. Observation on 02/16/2022 at 9:41 AM, of a skin assessment for Resident #19 performed by the Education Director, revealed the mid back wound measured Length-7.0 cm x Width-7.0 cm with an open area in the center which measured 1.0 cm x 1.0 cm x 0.5 cm with purulent drainage; the resident's right calf wound measured Length-22 cm x Width-7.0 cm x Depth-0.25 cm ; right great toe wound measured Length-2.0 cm x Width-3.5 cm x (no depth) and was scabbed; right inner ankle wound measured 2.5 cm x 4.5 cm x (no depth) and was scabbed. The Education Director did not stage the wounds during this skin assessment. This Wound Assessment was completed seventy-one (71) days after the last wound assessment, after Surveyor intervention. Interview, on 02/16/2022 at 1:40 PM, with the Education Director Nurse, revealed until January 2022 the wound nurse was responsible for all skin and wound assessment and documentation as well as rounding with the Physician to view the wounds. Additional interview revealed the nurses were responsible for the skin assessments and wound treatments at this time. She was unaware skin assessments and wound treatments were not being completed as ordered. She stated after the nurse completed a treatment or assessment, the nurse was responsible to document on the Treatment Administration Record (TAR) in the Electronic Medical Record. The following is a comparison of Resident #19's wounds noted in the Electronic Medical Record (EMR) for the Initial Wound assessment dated [DATE], which was completed 28 days after admission, and the next Wound Assessment, dated 02/16/2022, completed seventy-one (71) days after the last documented assessment, and after Surveyor intervention. Wound Assessment on 12/07/2021: 1. right gluteal cleft resolved on 12/7 2. right outer knee 2.0 cm x 1.5 cm x UTD 3. mid back 2.0 cm x 1.0 cm x depth was left blank 4. right outer calf 15 cm x 4.0 cm x 0.2 cm 5. right outer foot pinky 2.5 cm x 2.0 cm x 0.1 cm 6. right outer foot 1.5 x 1.5 x 0.2 Wound Assessment on 02/16/2022: 1. right gluteal cleft resolved 12/7 2. right outer knee nothing observed 3. mid back 7 cm x 7 cm x 0.5 cm, larger 4. right outer calf 22 cm x 1.0 cm x 2.5 cm larger and had increased depth appearance moist, pink-color, drainage-moderate serous (Clear). Surrounding tissue-discolored 5. right outer foot pinky dark spot observed 6. right outer foot dark spot observed 7. right great toe with scab 2.0 cm x 3.5 cm, NEW AREA 8. right inner ankle with scab 2.5 cm x 4.5 cm NEW AREA Continued review of the Wound Assessment revealed from 12/07/2021 until 02/16/2022, the wound to Resident #19's mid back became larger; the area to the right outer calf became larger and increased in depth; and new unidentified areas were found on the resident's Right great toe and Right inner ankle. Interview with Registered Nurse (RN) #1 on 02/19/2022 at 2:42 PM, revealed she was often assigned to Resident #19 and was unaware of any deterioration of the resident's wounds as she had not been completing Wound Assessments. She stated the nurses had not been trained to do Wound Assessments and she was not sure which staff member was responsible for completing them. Interview with Resident #19's Physician, on 02/24/2022 at 1:27 PM, revealed she was aware the resident sometimes refused care, especially wound treatments. However, she stated it was her expectation for staff to try to perform wound treatments, and to ensure wound measurements, staging and description of wounds were documented weekly. Further, it was her expectation that all wounds have a treatment in place, and Resident #19 should have had a treatment in place from admission related to pressure ulcers. 3. Record review revealed the facility admitted Resident #39 on 12/20/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's Admission MDS assessment dated , 12/24/2021 revealed the facility assessed the resident as at risk for pressure ulcers, and with one (1) unstageable deep tissue injury (DTI) which were present on his/her admission on 12/21/2021. Continued review of the Admission MDS revealed a care plan had been developed for Resident #39's admission wounds. Further review revealed the facility assessed Resident #39 to have a BIMS score of six (6), indicating he/she was severely impaired in cognition. Review of the Braden Scale for Predicting Pressure Sore Risk for Resident #39, dated 01/31/2022, revealed the facility had assessed the resident as at high risk for pressure ulcers, as indicated by the total score of twelve (12). Review of the facility's initial Wound Assessment for Resident #39, dated 12/21/2022, revealed the resident had a wound measuring 12.2 cm in length x 7 cm in width x 0 cm depth. Continued review revealed the wound was noted as dry, black in color, and with macerated (skin exposed to moisture for too long which appears as soggy, soft, or whiter than usual). Further review the documentation noted no drainage, odor or pain had been present at the wound site. Review further revealed no documented evidence of the wound having been Staged or the location of the wound. Review of Resident #39's Comprehensive Care Plan, dated 12/21/2021, revealed the facility had care planned the resident for a Stage III Pressure Ulcer to the right buttock. Review revealed the interventions included for staff to assess the resident's skin and report redness, rashes, bruises, abrasion or skin breakdown. Continued review revealed the interventions also included: a pressure reduction cushion; air mattress as ordered; provide incontinence care as needed; provide wound care as ordered by the Physician; and treatment to the resident's buttocks as ordered. Review of the Physician's order, dated 01/07/2022, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #39's buttock daily between 7:00 AM and 6:59 PM. Continued review of the 01/07/2022 Physician's order revealed the order also included to cleanse the wound to the right buttock with wound cleanser, pat dry, apply [MEDICATION(S)] cream (topical antimicrobial drug used as an adjunct for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the 01/07/2022 Physician's order revealed the wound was to be covered with border gauze and change the dressing daily and as needed (prn). Continued review of Resident #39's medical record revealed the next documented Wound Assessment was eighteen (18) days later, was noted on a Physician's Note, dated 01/07/2022. Review of the Physician's Note revealed Resident #39 a telehealth wellness visit had been completed for the resident. Review of the Physician's Note revealed Resident #39 had an Unstageable (US) Wound on his/her sacral area, which was worse, deeper, and getting bigger with no tunneling or eschar. Further review of the Note revealed wound measurements documented as 4 cm in length x 2 cm in width. Review further revealed no documented evidence of the wound depth or color of the wound. Further review of Resident #39's medical record revealed a Wound assessment dated on 01/11/2022 at 5:03 PM by an unknown author, (four [4] days after the telehealth visit), which noted the resident's wound measurements where 11.8 cm in length x 6.8 cm in width x o cm in depth, and the wound was black in color, necrotic, with discolored tissue. Further review of the Wound Assessment revealed the wound had small/minimal drainage, no odor, and no pain, and the wound was not worse. Review further revealed no documented evidence of the wound's location or the Stage of the wound. In addition, review of Resident #39's medical record revealed a Wound assessment dated [DATE] at 5:10 PM by an unknown author, which noted the wound as measuring 12.4 cm in length x 7.4 cm in width x 0 cm in depth. Continued review of the Wound Assessment revealed the tissue was broken, with moderate serosanguineous drainage, with an odor present, no pain and the wound noted as not worse. Further review revealed the Wound Assessment did not have the location of the wound or Stage of the wound documented. Review of the February 2022 MAR for Resident #39 revealed no documentation noting the [MEDICATION(S)] wound treatment as having been completed as ordered for the dates of the 2nd, 4th, 5th,11th,12th,13th, and 15th of that month, a total of seven (7) days. Further review revealed staff were to initial the time and date on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2022 TAR for Resident #39 revealed no documentation noting the ordered wound treatment, (cleanse wound, apply [MEDICATION(S)] and oil emulsion, wet to dry gauze twice daily on coccyx every 12 hours) had been completed at 9:00 AM for the dates of the 01/11/2022, 02/12/2022, 02/13/2022, 02/ 2, and 02/15/2022, a total of five (5) days. Continued review of the February 2022 TAR revealed no documentation noting the ordered wound treatment had been completed at 9:00 PM for the dates of the 9th, 11th, 12th and 13th, a total of four (4) days. Further review revealed staff were to initial the time and date on the TAR after completing application of the ordered wound treatment; however, the area for staff's initials for those dates was blank. Interview with Resident #39, on 02/16/2022 at 11:30 AM, revealed the resident felt bad. Resident #39 stated he/she had sores on his/her bottom, and the areas hurt. Further interview revealed the resident was unable to state when the sores (wounds) were acquired; however, stated the nurses looked at the sores, just not daily. Observation, on 02/16/2022 at 11: 30 AM during care provided by Agency SRNA #1, revealed Resident #39 had two (2) dressings on his/her buttock. One (1) dressing (the top one) was dated 02/14/2022 (two [2] days previously); however, orders revealed the dressing was to have been changed daily. Interview with Agency SRNA #1 on 02/16/2022 at 11:30 AM, revealed she had worked at the facility for nine (9) months on the day shift, from 7:00 AM to 7:00 PM. She revealed she was assigned to Resident #39's care that day. Per interview, Resident #39 was total care for all his/her ADLS. Continued interview revealed Resident #39 had a really big bed sore on his/her [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure resident records were complete, and staff accurately documented care and services provided for six (6) of thirty-three (33) sampled residents (Residents #19, #28, #39, #47, #63, and #428). The facility admitted Resident #19, on [DATE], with two (2) Stage III Pressure Ulcers to the outside of the right foot; a wound to the right outer leg on the side of the knee; a wound to the mid spinal area; and, a wound to the right outer leg. However, at times, the facility failed to consistently document the care and assessment of the ulcers, as orders. The resident's wounds were not documented on from [DATE] until [DATE] (28 day). The facility admitted Resident #39 on [DATE] with a Stage III Pressure Ulcer to the right buttock. Documentation revealed a lapse in weekly wound assessments with no documented evidence that the facility conducted the resident's wound assessments until [DATE] (18 days later). Record review revealed the facility admitted Resident #47 on [DATE]. Resident #47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no documentation that the facility conducted the skin assessments including measurements and the progression of the resident's pressure areas from [DATE] until [DATE]. Assessment on [DATE], revealed the ulcers had declined and the resident had developed [CONDITION(S)] (a bone Infection). The facility admitted Resident #63 on [DATE] with a Stage II Pressure Ulcer to the coccyx and staples to the left above the knee amputation. However, the facility failed to document assessments of the resident's areas until [DATE], thirty-four (34) days after admission to the facility, at which time the wounds had declined. The facility failed to ensure Resident #428's food and fluid intake was completely and accurately documented for seventeen (17) days, from [DATE] until [DATE]. Resident #428 was admitted to an acute care hospital on [DATE]. Resident #428's admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Resident #28 did not have accurate documentation concerning administration of [MEDICATION(S)] (a Schedule V pain medication given for the resident's Diabetic [CONDITION(S)]) on the Medication Administration Record (MAR). The MAR revealed documentation that the resident received [MEDICATION(S)] for thirteen (13) days when he/she did not because the facility had failed to obtain the medication. The resident's medication was not in the facility. The facility's failure to ensure medical records were accurately maintained has caused or is likely to cause harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) at the highest scope and severity (s/s) of a J, 42 CFR 483.25 Quality of Care (F686) at an s/s of a J, 42 CFR 483.70 Administration (F835 and F837), at the highest s/s of an L; and F842 at an s/s of a J, 42 CFR 483.75 Quality Assurance and Performance Improvement (F867) at an s/s of an L, and 483.80 Infection Control (F880) at an s/s of an L. The facility was notified of Immediate Jeopardy on [DATE]. An acceptable Immediate Jeopardy Removal Plan was received on [DATE], which alleged removal of the Immediate Jeopardy effective [DATE]. However, the State Survey Agency was unable to validate the removal of the Immediate Jeopardy prior to exit on [DATE]. The Immediate Jeopardy is ongoing. Refer to F692, F697 and F761. The findings include: Review of the facility's,Skin Care Standard of Practice Policy, dated ,d+[DATE], revealed the facility would assess all residents on admission, readmission, quarterly, and with each change in condition that would compromise the skin. Per the policy, the baseline skin assessment would be completed within 24 hours of admission and documented in the medical record. Staging and measuring of the wound would be completed by the assigned nurse to maintain continuity in documentation of progression of would healing. 1. Review of Resident #19's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility admitted Resident #19 with Pressure Ulcers to his/her back and right leg. Review of Resident #19's Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident to be at risk for pressure ulcers. Resident #19 had two (2) Stage III pressure ulcers that were present on admission on [DATE]. In addition, Resident #19's Brief Interview for Mental Status' (BIMS) score was fifteen (15) of fifteen (15), which indicated the resident's cognition was intact. Review of Resident #19's Care Plan, dated [DATE], revealed the resident had two (2) Stage III pressure ulcers on the outside of the right foot; one (1) on the right outer leg by the side of the knee; one (1) on the mid-back spine; and, one (1) on the right outer leg. Staff were to provide wound care and treatments as ordered by the physician. Review of Resident #19's [DATE] Treatment Administration Record (TAR) revealed inconsistency (did not document) in documentation for the intervention of wound treatment to the two (2) Stage III Pressure Ulcers on the outside of the right foot. The treatment consisted of using wound cleanser, pat dry, apply Santyl (a topical medication to promote wound healing) and cover with border gauze daily at 7:00 AM. However, the treatment was not signed (blank) to indicate the treatments were completed at 7:00 AM on [DATE] and [DATE]. Review of Resident #19's February 2022 TAR, revealed inconsistency (blanks) in documentation for the intervention of wound treatment to apply skin prep to scar tissue at the right gluteal cleft for prevention of breakdown (daily) at 7:00 AM, However, the treatment was not signed (blank) to indicate the treatments were completed for fourteen (14) days including [DATE] - [DATE]; [DATE] - [DATE]; [DATE]; [DATE]; [DATE] - [DATE]; and [DATE]. Review of Resident #19's February 2022 TAR revealed inconsistency in documentation for monitoring of the resident's wound and wound treatment on his/her mid back. The TAR was not signed (blank) to indicate this monitoring/treatment was done at 7:00 AM for seven (7) days including [DATE], [DATE], [DATE], [DATE] - [DATE], and [DATE]. Review of Resident #19's February 2022 TAR revealed inconsistency in documentation for wound treatment with an air mattress. Further review revealed this intervention was not signed (blank) at 7:00 AM for six (6) days, including [DATE], [DATE], [DATE] and [DATE] - [DATE], to indicate the resident had an air mattress. Interview with Resident #19, on [DATE] at 9:41 AM, revealed he/she did not receive the wound care treatment like the doctor had ordered. The resident stated he/she did not have a bandage on his/her back. An observation, during the interview, revealed there was no bandage on the resident's back, and the resident's leg was wrapped in [MEDICATION(S)] dated [DATE]. Per the TAR, Resident #19's bandage was to be changed on [DATE]. Record review revealed the dressing change was documented as changed on [DATE]. However, an observation made on [DATE] revealed the bandage had not been changed since [DATE]. Interview with Licensed Practical Nurse (LPN) #4, on [DATE] at 3:26 PM, revealed she did not think Resident #19 had any treatments. She stated she thought the resident might have a treatment on his/her foot two (2) times a week or every three (3) days. She stated if the resident refused, she just charted it and told the Administrator. Interview with Registered Nurse (RN) #1, on [DATE] at 11:20 AM, revealed she did wound care on Resident #19, on [DATE], but she had no explanation why it was not charted. 2. Review of Resident #39's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #39's Admission MDS Assessment, dated [DATE], revealed the facility assessed Resident #39 to be at risk for pressure ulcers. The resident had one (1) unstageable deep tissue injury that was present on admission on [DATE]. A care plan was developed. In addition, Resident #39 had a BIMS' score of six (6) of fifteen (15), indicating severe cognitive impairment. Review of Resident #39's Care Plan, dated [DATE], revealed the resident had a Stage III pressure ulcer of the right buttock. Staff was to provide wound care as ordered by the physician; air mattress as ordered; and treatment to buttocks. Review of the February 2022 Medication Administration Record (MAR) for Resident #39 revealed no documentation noting the [MEDICATION(S)] wound treatment as having been completed as ordered for the 2nd, 4th, 5th, 11th, 12th, 13th, and 15th of that month, a total of seven (7) days. Further review revealed staff were to initial the time and date on the MAR after completing application of the [MEDICATION(S)] wound treatment. However, the area for staff's initials for those dates was blank. Review of the February 2022 TAR for Resident #39 revealed no documentation noting the ordered wound treatment (cleanse wound, apply [MEDICATION(S)] and oil emulsion, wet to dry gauze twice daily on coccyx every 12 hours) had been completed at 9:00 AM for the dates of the 11th, 12th, 13th, 14th, and 15th, a total of five (5) days. Continued review of the February 2022 TAR revealed no documentation noting the ordered wound treatment had been completed at 9:00 PM for the 9th, 11th, 12th and 13th, a total of four (4) days. Further review revealed staff were to initial the time and date on the TAR after completing application of the ordered wound treatment; however, the area for staff's initials for those dates was blank. Interview with Resident #39, on [DATE] at 11:25 AM revealed the resident felt bad. The resident additionally stated he/she had sores on his/her bottom, and they hurt. Resident #39 stated the nurses looked at the sores, but not daily. Interview with LPN #7 (an agency nurse), on [DATE] at 1:35 PM, revealed she had been to the facility eight (8) times and had not received any training from her agency or the facility on wound care, wound assessment, or documentation of wounds. Additionally, she did not know the treatment order for Resident #39's wounds. 3. Review of Resident #63's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #63's Admission MDS Assessment, dated [DATE], revealed the facility assessed Resident #63 to be at risk for pressure ulcers. Resident #63 had one Stage II Pressure Ulcer on the coccyx and a surgical wound that was present on admission on [DATE]. In addition, the facility assessed Resident #63 with a BIMS' score of fifteen (15) of fifteen (15), which indicated intact cognition. Review of Resident #63's Baseline Care Plan, dated [DATE], revealed the resident had a Stage II Pressure Ulcer to his/her coccyx and an above the knee (AKA) amputation to the left lower extremity. Continued review revealed staff were to provide wound care and treatment as ordered by the Physician; and, provide a pressure reduction mattress. Review of Resident #63's [DATE] TAR revealed no documented evidence of staff's initials to indicate Resident #63's coccyx wound treatment had been provided on the 14th, 15th, 16th, 18th, 20th, 24th, 25th, and on the 28th, for a total of eight (8) days. Review of Resident #63's [DATE] TAR revealed no documented evidence of staff's initial to indicate wound monitoring of Resident #63's left AKA had been provided on the 18th, 20th, 24th, and 28th, a total of four (4) days. Review of Resident #63's February 2022 TAR revealed no documented evidence of staff's initials to indicate the wound treatment ordered for Resident #63's coccyx had been provided on the 1st, 2nd, 3rd, 4th, 5th, 8th, 12th, 13th, 15th, 16th and 18th, a total of eleven (11) days. Review of the February 2022 TAR revealed no documented evidence of staff's initials to indicate Resident #63's wound treatment/monitoring for his/her left AKA had been provided as ordered for the 1st, 2nd, 3rd, 4th, 5th, 8th, 12th, 13th, 15th, 16th, 18th, a total of eleven (11) days. Interview with Resident #63, on [DATE] at 1:25 PM, revealed his/her wound care at the facility had been irregular. Resident #63 stated, that it was supposed to be done to his/her stump twice daily and his/her coccyx daily. However, Yesterday the resident's wound treatments had been missed. Resident #63 stated his/her stump treatment was a daytime treatment, but the stump treatment was not done until 2:00 AM that morning. Interview with Licensed Practical Nurse (LPN) #12, on [DATE] at 4:15 PM, revealed there was no reason why the MAR/TAR's were incomplete. She stated if the wound treatments were done, they needed to be documented. 4. Review of Resident #47's closed medical record revealed the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's Quarterly MDS Assessment, dated [DATE], revealed the facility assessed the resident as having a BIMS' score of five (5) of fifteen (15), which indicated severe cognitive impairment. Additional review revealed the facility assessed the resident as at risk for developing a pressure ulcer and as having one (1) Stage IV pressure ulcer and three (3) suspected Deep Tissue Injuries (DTIs) on his/her feet. Review of Resident #47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #47's Care Plan, dated [DATE], revealed the resident had a problem with impaired skin integrity including a DTI to the left heel, an unstageable pressure ulcer to the right outer foot, and a DTI to the left outer foot. Interventions included: treatments as ordered; treatment to the DTI to the right outer foot and monitor until resolved; treatment to the left heel as ordered; and, treatment to the left outer foot as ordered. Review of the [DATE] TAR for Resident #47's wound care revealed the resident's ordered wound treatments were not documented as being completed on [DATE], [DATE], [DATE], [DATE], and [DATE], a total of five (5) days. Review of the February 2022 TAR for Resident #47's wound care revealed the resident's ordered wound treatments were not documented as being completed on [DATE] - [DATE]; [DATE] - [DATE], and [DATE], a total of seven (7) days. In addition, there was no documented evidence of weekly skin assessments or Wound Evaluations for measurements/staging documented from [DATE] until [DATE], over a month later, when the State Survey Agency (SSA) Surveyor asked to observe a skin assessment for Resident #47. Review of Resident #47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no documented evidence of a wound to the right foot during this timeframe. Interview with LPN #4, on [DATE] at 9:45 AM, revealed when she was assigned to Resident #47 she might not have done the resident's treatments. She stated she could not remember and was not aware of the resident's wounds getting worse. Also, she stated sometimes treatments would be documented and deleted out of the electronic medical record (EMR) because the computer system had problems. 5. Review of Resident #428's closed medical record revealed the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #428's most recent Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident to be severely cognitively impaired with a BIMS' score of five (5) of fifteen. Further review revealed the facility assessed the resident to require the extensive assistance of two (2) staff for transfers, bed mobility, and toileting. Continued review revealed the facility assessed the resident as always incontinent of bowel and bladder. Review of Resident #428's Food and Fluid intake documentation for [DATE] revealed the resident's food and fluid intake was not documented on [DATE]. The lunch meal was not documented on [DATE]; lunch and supper meal not documented on [DATE]; lunch and supper were not documented on [DATE]; lunch and supper not documented on [DATE]; no meal intakes were documented on [DATE], [DATE]; no meal intakes were documented, for breakfast and lunch was not documented on [DATE], no meal intake was documented on [DATE]; breakfast and lunch were not documented on [DATE], breakfast and lunch was not documented on [DATE]; no meal intake was documented on [DATE]; breakfast was not documented on [DATE]; breakfast was not documented on [DATE]; and lunch was not documented on [DATE]. No meal intake was documented on [DATE]; and, breakfast was not documented on [DATE]. Review of the Hospital Record for Resident #428 revealed the resident was transferred to an acute care hospital on [DATE] and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #428 died at the hospital on [DATE]. Interview with State Registered Nurse Aide (SRNA #4) on [DATE] at 2:14 PM revealed he could remember being told to push fluids for Resident #428 but could not remember who told him. SRNA #4 stated all the residents on the Covid Unit were being encouraged to eat and drink but, he could not recall documenting the extra fluids in the system. Interview with SRNA #5 on [DATE] at 2:35 PM revealed Resident #428 required assistance with feeding. SRNA #5 stated she had problems charting intakes in the system. She stated she worked with a lot of agency SRNAs, who did not have a log in to document food and fluid intakes in the electronic medical record system. An interview with SRNA #7 on [DATE] at 10:30 AM revealed she worked on the floor at times and documented meals intakes for Resident #428. She stated at times the computer would not allow her to document. SRNA #7 stated when information was entered on the computer it would be deleted out. Interview with SRNA #8, on [DATE] at 10:13 AM, revealed the SRNA often took care of Resident #428. However, he did not have a computer log in PASSWORD?to document food and fluid intake. 6. Review of the medical record for Resident #28 revealed the facility admitted the resident on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #28's Medication Administration Record (MAR) for [DATE] and February 2022 revealed the resident's [MEDICATION(S)] was documented as being administered on [DATE] -[DATE]; [DATE]-[DATE]; and, on [DATE]-[DATE]. However, the resident did not have [MEDICATION(S)] available at the facility to be administered during this time. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 4:41 PM revealed if she had marked the medication as being administered on [DATE]-[DATE] for Resident #28 it would have been an oversight. She stated the medication was not available. Interview with Licensed Practical Nurse LPN #4 on [DATE] at 9:45 AM revealed if she was working with only a KMA to assist she may not get all medications documented. She further stated if she had documented a medication as given that was not available it was by accident. Interview with Licensed Practical Nurse (LPN) LPN #7, on [DATE] at 8:35 AM revealed she was an agency nurse and if she didn't document medications as being administered, she may have given the medications and did not document it. LPN #7 stated if the medication was not available, she may have not documented in the medical record or forgot to make a note. Interview with Director of Nursing (DON) #3, on [DATE] at 4:44 PM, revealed he had started at the facility in [DATE]. Further interview revealed he was not aware Resident #47 had pressure ulcers, nor was he aware skin assessments and wound measurements for Resident #47 were not being completed or documented. According to the DON, he was new to long term care, was in training, and was monitoring residents by making rounds in the facility, but was still trying to learn and did not monitor for anything specific. Interview with the Director of Education, on [DATE] at 10:19 AM, revealed she had made rounds with the Physician, on [DATE], and transcribed treatment orders for Resident #47's wound care. She stated she mistakenly got the left foot wound and the right foot wound mixed up and was not aware why Santyl was ordered for a wound to the right foot when the Physician wanted skin prep only applied to the wound. The Director of Education stated she could not explain why the treatment order was not specific or accurate to which wound and the location of the wound. Interview with the Medical Director, on [DATE] at 1:27 PM, revealed she was concerned that wound care and measurements were not getting completed and documented in the medical record. Further interview revealed she intended for the unstageable wound to Resident #47's right foot to be treated with skin prep to keep the wound closed. Per interview, the order dated [DATE], to clean the wound to the right foot with wound cleanser, apply Santyl, and cover with a nonstick foam dressing should not have been ordered. The Medical Director stated she did look at the notes and tried to track down a time line for Resident #47's wounds and noted two (2) of the resident's wounds had deteriorated. Interview with the Director of Education, on [DATE] at 1:40 PM, revealed she had worked at the facility since [DATE]. However, she had been in her current role since February 2022. Per the interview, she stated the wound nurse, when she was at the facility, was responsible for all skin and wound assessments and documentation as well as rounding with the physician for wounds. She stated, after completion of a wound treatment or assessment, the nurse was responsible to document it on the TAR and MAR in the electronic medical record (EMR). Interview with the Regional Quality Manager (RQM), who was a Registered Nurse (RN), on [DATE] at 3:00 PM, revealed documentation of wound treatments on the TAR and the MAR and wound assessments was essential to determine the effectiveness of skin/wound care the residents received. Additional interview with the Regional Quality Manager, on [DATE] at 12:22 PM, revealed there were no excuses for the wound treatments not being completed and documented on the TAR. Interview with Director of Nursing (DON) #4, on [DATE] at 2:15 PM, revealed skin and wound assessments should be accurately and thoroughly completed and documented weekly in the EMR, by the assigned nurse responsible for the resident. Continued interview with the Medical Director, on [DATE] at 1:27 PM, revealed she noticed a change in the quality of documentation after the wound nurse left, as agency nurses were not invested in providing the best care possible. According to the Medical Director many of the residents' wounds got worse. The Medical Director stated it was unsafe to practice in such an environment with wound treatments not being done or documented, and she could not defend the facility for any of this. Interview with the Administrator, on [DATE] at 12:58 PM, revealed if a nurse did not follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she would expect staff to complete the wound treatments and document it. She stated she expected nursing to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to ensure one (1) of three (3) resident's care plans (Resident #1) was reviewed and/or revised when a significant change in condition occurred. On 04/08/2020, Resident #1 developed a red, tender area to the top of his/her left foot; and, on 04/10/2020, the resident developed bruising and pain to the foot that required scheduled pain medication for pain is out of control. The facility revised the resident's care plan on 04/10/2020 with an intervention to administer pain medication as ordered and on 04/14/2020 to monitor the bruising. However, the facility failed to revise the resident's care plan with individualized, measurable interventions that could evaluate the care plan's effectiveness as required by the RAI Manual. In addition, the facility failed to revise the resident's care plan with interventions to address the resident's care when the resident's foot/leg became cold, mottled (mottling is blotchy, red-purplish marbling of the skin can be a symptom of a serious underlying condition, such as vascular disease), with thready pulses (pulse is not easily felt and commonly rapid) on 04/14/2020; nor when the resident's pain was not managed with medication that was prescribed on 04/10/2020. On 04/24/2020, at approximately 4:00 AM, Resident #1's left foot was cold and mottled with necrotic (dead) tissue to the resident's foot and the resident had no pulses at the left knee or left foot. Resident #1 was transferred to a local hospital on [DATE], where the resident was diagnosed with [REDACTED]. The resident was then transferred to a large medical center where Resident #1's left leg was amputated (surgically removed) above his/her knee on 04/25/2020 related to Profound ischemia (restricted blood flow) and cadaveric (corpse like) left lower extremity. The facility's failure to revise resident care plans when a significant change in condition occurred has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/06/2020, and was determined to exist on 04/14/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657), and 42 CFR 483.25 Quality of Care (F684). The facility was notified of the Immediate Jeopardy on 05/06/2020. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F684). An acceptable Allegation of Compliance was received on 05/13/2020, which alleged removal of Immediate Jeopardy on 05/13/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 05/13/2020, prior to exit on 05/21/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657), and 42 CFR 483.25 Quality of Care (F684), while the facility monitors the effectiveness of systemic changes and quality assurance -activities. The findings include: Email correspondence with the Administrator on 05/05/2020 at 10:14 AM revealed the facility did not have a care plan policy. The Administrator stated the facility followed the Resident Assessment Instrument (RAI) Manual for care plans. Review of the RAI Manual, Section 4.7, revealed the care plan must include measurable objectives and timeframes, and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review of the RAI, Section JO100 Pain Management, revealed planning for care must utilize identification of pain management interventions, review the effectiveness of pain management, and revise the plan if goals are not met. The Manual further revealed that residents would need a comprehensive, individualized management regimen. Review of Section M, Skin Conditions, revealed planning for care of skin changes should be accounted for in the interdisciplinary care plan. According to the RAI Manual, the care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident was receiving. Review of Resident #1's medical record revealed the facility admitted the resident on 01/23/2020, with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set Assessment ((MDS) dated [DATE], revealed the resident required extensive assistance of two (2) staff members with transfers/toileting, personal hygiene, and bed mobility; and could ambulate (walk) with the assistance of one person. According to the MDS, Resident #1 had no venous or arterial ulcers (wounds on the leg or ankle caused by poor circulation), and no other ulcers, wounds, or skin problems of the foot. The MDS also indicated Resident #1 had no pain and was not on a scheduled pain medication regimen during the assessment period. Review of Resident #1's care plan also revealed he/she had problems of hypertension, incontinence of urine/bowels, and limited mobility on 01/31/2020 and the care plan stated the goals for the resident were to be free of signs/symptoms of cardiac distress (shortness of breath, complaints of chest pain and abnormal vital signs, etc.) and maintain intact skin integrity. Interventions implemented on Resident #1's care plan dated 01/31/2020, included that staff were to assess and report redness, rashes, bruises, abrasions, or skin breakdown. The care plan also indicated staff were to monitor for [MEDICAL CONDITION] and elevate the resident's legs, as needed; and turn and reposition the resident every two (2) hours and as needed. Review of Resident #1's Nurse's Notes revealed at 5:10 PM on 04/08/2020, the resident's left foot was slightly red and tender to touch. On 04/10/2020, at 1:53 PM, the resident's left foot was swollen, red, a small bruise was observed to the left great toe and the top of the resident's left foot, and the resident complained of pain. Review of Resident #1's care plan revealed the facility revised the care plan on 04/10/2020 to include the resident's left leg and foot pain concern and an intervention was added three (3) days later on 04/13/2020 that stated meds (medications) per orders see mars (Medication Administration Record). The care plan did not address an individualized pain management regimen for Resident #1 as required by the RAI Manual, nor did the care plan facilitate review of the effectiveness of the pain management. Further review of Resident #1's medical record revealed on 04/13/2020, three (3) days after the bruising was identified to the resident's foot, the facility revised the resident's Medication Administration Record [REDACTED]. Further review revealed this was discontinued on 04/14/2020 when non-drug treatment monitoring of the bruise twice daily was added. Staff documented each shift from 04/14/2020 through 04/23/2020 that the bruise was monitored. However, further review of Resident #1's care plan revealed no documented evidence that the facility revised the resident's care plan when the resident developed bruising, redness, or swelling to the left foot/toe with time-frames and a description of the services that were required to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for Resident #1 as required by the RAI Manual. Further review of Resident #1's Nurse's Notes revealed on 04/14/2020 at 4:07 AM, the resident's left foot was cold, mottled, pulses were thready, and capillary refill (time for color to return to normal after pressure has been applied. A prolonged capillary refill time may indicate decreased peripheral perfusion or peripheral artery disease) was abnormal. Continued review of Resident #1's care plan revealed the facility revised the care plan on 04/14/2020 and directed staff to monitor discolorations to left foot until resolved. However, the care plan did not address the resident's foot being cold and/or mottled, nor did it address the resident's pulses being thready. Subsequently, the care plan did not include measurable objectives with established timeframes; specific interventions; items needing additional assessment, testing, and review/notification of the physician; nor, items that may require additional monitoring. Continued review of the Nurse's Notes revealed the circulation to Resident #1's foot/leg continued to worsen. On 04/17/2020 and 04/21/2020, staff documented that the resident's left leg/foot was cool/cold, had discoloration/bruising, and/or had faint/thready pulses. In addition, review of the resident's Physical Therapy Notes for 04/17/2020 and 04/21/2020 revealed the resident had decreased weight bearing and was unable to bear weight to the left foot/leg by 04/23/2020. Again, the resident's care plan was not revised with timeframes and a description of the services that were required to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident #1's Nurse's Notes dated 04/24/2020 at 8:35 AM, revealed the resident's foot had developed necrotic (dead tissue) and/or black areas to the foot, toes, and heel. The left knee had a red/purple area covering most of the knee and was cool and tender to touch. The nurse also documented that the resident had pain, no palpable pedal pulses nor popliteal pulses (pulses in the foot and knee), and the skin between the knee and foot was cold and mottling. Review of Resident #1's medical record from Hospital #1 revealed he/she arrived at the hospital on [DATE] at approximately 12:30 PM. Further review revealed after diagnostic tests were completed and with the results at 3:43 PM on 04/24/2020, it was determined the resident had a Critical lower limb ischemia (restricted blood supply to tissue) and Occlusion of the mid left superficial femoral artery distally. The resident was transferred to a larger medical center (Hospital #2) for further evaluation/treatment on 04/24/2020, where the resident's left leg was amputated (surgically removed) above his/her knee on 04/25/2020 related to Profound ischemia (restricted blood flow) and cadaveric (corpse like) left lower extremity. Interview with Licensed Practical Nurse (LPN) #1 at 3:50 PM on 05/04/2020 revealed she assessed Resident #1 on 04/17/2020 and determined that Resident #1's pedal pulses were faint, and his/her left leg was discolored from the shin to the toes. According to LPN #1 nursing staff did not review/revise the care plans, to include developing interventions to address the resident's concerns/problems. Interview with Registered Nurse (RN) #1 at 8:15 AM on 05/05/2020 revealed she assessed Resident #1 on 04/14/2020 and 04/21/2020, and determined that the resident's foot/leg was cold, mottled, and the resident's pulses were thready. However, according to RN #1, she did not review/revise the resident's care plan when she identified changes in the resident's condition because she was not responsible to review/revise care plans at the facility. Interview with the MDS Nurse on 05/05/2020 at 1:45 PM revealed care plans were reviewed/revised during a morning meeting Monday through Friday. The MDS Nurse stated that during the meetings, she reviewed new physician's orders [REDACTED]. gets to the care plan. The MDS Nurse stated if she had been aware of the ongoing change in Resident #1's condition, she would have revised the resident's care plan. Interview with the DON on 05/05/2020 at 5:00 PM revealed residents' care plans were reviewed/revised during the Interdisciplinary Team (IDT) Meeting held Monday through Friday. The DON stated that she and other members of the IDT reviewed documentation to ensure care plans were reviewed/revised when changes in a resident's condition occurred. The DON stated she did not recall reviewing nursing documentation related to Resident #1's ongoing change in condition, which included the notes that the resident's left foot/leg was cold and mottled and his/her pulses were thready. However, according to the DON, the assessment findings would not trigger a care plan revision for Resident #1 because it was not a permanent change for the resident. Interview with the Administrator on 05/05/2020 at 5:40 PM revealed she did not attend IDT Meetings regularly. She stated she had no process to ensure resident care plans were reviewed/revised as required. ***The facility implemented the following actions to remove Immediate Jeopardy effective 05/13/2020: 1. Resident #1 no longer resides at the facility. 2. The facility held an ad hoc QAPI (Quality Assurance and Performance Improvement) committee meeting on 05/07/2020 to review the Immediate Jeopardy findings and discuss the development of the action items to be completed. 3. Members of the clinical leadership team conducted head-to-toe skin inspections on 05/08/2020, which included checking pedal pulses and capillary refill for all residents. No new circulatory concerns were identified. 4. On 05/08/2020, the Director of Nursing (DON) selected a sample of three (3) completed skin inspection forms from each hall (15 in total), as a second review. The DON identified no concerns. 5. Beginning on 05/12/2020, the DON, Unit Manager, Wound Nurse, and/or Nurse Supervisor will assess five (5) residents per unit daily to assess circulatory changes, capillary refill, and pedal pulses, comparing to the documented baseline from 05/07/2020. Staff completing the assessments will immediately address any concerns. The monitoring will continue until the facility meets regulatory compliance. The QAPI team will review the results at least weekly to track the facility's progress toward regulatory compliance. 6. The Minimum Data Set (MDS) Coordinator provided education to the Education Training Director (ETD) regarding updating resident care plans when a resident's change in condition occurs. The ETD then provided this education to all licensed nurses by 05/08/2020. Each nurse was required to verbalize the process to update the care plan in the Electronic Medical Record to ensure competency. 7. The Director of Nursing and ETD educated all licensed nurses on physician notification, change in condition and Medical Director Notification on 05/07/2020 through 05/09/2020. The education also included documentation requirements for physician notifications in the medical record. Resident skin inspections to include, but not limited to, circulatory indicators of capillary refill, pedal pulses, and vital signs. Any new/undocumented skin impairments or signs/symptoms of circulatory problems require immediate physician notification and documentation in the medical record in the nursing progress notes. In addition, staff will update care plans with the new interventions related to a change in a resident's status. 8. On 05/07/2020 through 05/08/2020, all licensed nurses were required to complete a post-test to verify training competency related to physician notification, change in condition and Medical Director Notification. The nurses were required to receive a score of 100% before resuming duties. Licensed nurses on leave will be required to have this education and pass a posttest prior to returning to work. Any newly hired licensed nurse will receive this education/testing from the ETD and/or DON prior to assuming duties. 9. On 05/08/2020 the Director of Nursing, MDS Coordinator, Wound Nurse, and Nurse Managers completed a review of the last thirty days of Interdisciplinary Team (IDT) notes and physician's orders [REDACTED]. The review included ensuring staff had updated resident care plans to reflect the change of condition and any associated interventions. The Director of Nursing, MDS Coordinator, Wound Nurse, and Nurse Managers identified no concerns. 10. On 05/08/2020, the Director of Nursing, Unit Manager and/or Weekend Supervisor, initiated an on-going audit of the prior 24- hour nursing notes and physician's orders [REDACTED]. Nursing leadership will address any concerns when discovered. 11. On 05/08/2020, the QAPI team held a second ad hoc meeting to review the initial skin/circulatory audits, physician notifications and care plan updates, as well as the status of the licensed nurse's education initiated on 05/07/2020. The Administrator reviewed the results with the Medical Director on 05/08/2020. ***The State Survey Agency verified the facility implemented the following actions to remove Immediate Jeopardy on 05/13/2020, as alleged: 1. Review of the medical record revealed the facility transferred Resident #1 to the hospital on [DATE] and the resident did not return to the facility. 2. A review of QAPI Committee meeting minutes dated 05/07/2020 revealed the committee reviewed the Immediate Jeopardy notifications and the action plans for facility compliance. Review of the meeting sign in sheet dated 05/07/2020, revealed the facility's department heads attended. Interviews, conducted on 05/21/2020, with the Administrator, Medical Director, Director of Nursing (DON), the Unit Managers, and the Minimum Data Set (MDS) Coordinator revealed the facility had conducted a QAPI meeting on 05/07/2020 to discuss the immediate jeopardy and to initiate the development of a plan of action for compliance. 3. A review of skin assessments conducted from 05/06/2020 through 05/08/2020 revealed all residents had a head to toe skin assessment performed to include evaluation of pedal pulses and capillary refill. Review of skin assessments completed for Resident #4, Resident #5, Resident #6 and Resident #7 revealed the assessments were completed with no concerns identified. Observation of skin assessments for Resident #6 and Resident #7 conducted on 05/20/2020, included evaluation of pedal pulses and capillary refill with no concerns identified. Interviews with the DON, Unit Manager #1, and Unit Manager #2 on 05/21/2020 revealed all residents' skin, pedal pulses, and capillary refill status was assessed by 05/08/2020. 4. A review of skin assessment audits completed by the DON on 05/08/2020 revealed the DON had audited a sample of fifteen (15) completed skin assessments with no issues identified. Review of the May 2020 skin assessments completed for Resident #4, Resident #5, Resident #6, and Resident #7 revealed no concerns with the completion or accuracy of the assessments. Interview with the DON on 05/21/2020 at 2:38 PM revealed she had conducted audits of the skin assessments performed on 05/08/2020, of three (3) residents from each hallway with no new issues or changes of condition found. 5. A review of daily audits completed from 05/12/2020 through 05/20/2020 by the DON, Unit Managers, Wound Nurse, and the Weekend Supervisor revealed five (5) residents from each unit were assessed daily for circulatory changes, capillary refill, and pedal pulses. The assessments were compared with assessments completed on 05/08/2020 with no concerns identified. Interviews with the DON, Unit Manager #1, Unit Manager #2, the Wound Nurse, and the Weekend supervisor conducted on 05/21/2020 revealed they were assessing a sample of residents daily on each unit for circulatory concerns to ensure any changes in a resident's condition was identified. 6. A review of an in service education sign in sheet dated 05/07/2020 revealed the MDS Nurse had educated the EDT on updating resident care plans when a change in condition occurred. Interview with the MDS Nurse on 05/21/2020 at 1:42 PM revealed she had trained the EDT on the requirement to update the plan of care when a resident had a change of condition. Interview with the EDT Nurse on 05/21/2020 at 1:57 PM, revealed the MDS Nurse had educated her on updating resident care plans on 05/07/2020. The EDT stated she educated all licensed nurses except employees who were on leave regarding the requirement by 05/08/2020. Further interview with the EDT revealed employees who were on leave could not work until the training was completed. Review of employee in-service education sign in sheets revealed all licensed employees were educated on updating resident care plans when a change in condition occurred on 05/08/2020 by the EDT Nurse. Interviews conducted with LPN #3, LPN #4, Unit Manager #1, Unit Manager #2, and the Weekend Supervisor on 05/21/2020 revealed they received education on 05/08/2020 by the EDT on updating care plans when a resident had a change of condition. 7. A review of Education Sign in Sheets dated 05/07/2020 through 05/09/2020 revealed all nurses were educated by the DON and EDT on physician notification, change of condition, Medical Director Notification if the physician could not be reached and documentation requirements for physician notifications in the medical record. The education referenced resident skin inspections, circulatory indicators of capillary refill, pedal pulses, and vital signs. Any new/undocumented skin impairments or signs/symptoms of circulatory problems required immediate physician notification and documentation in the medical record and updating the plan of care with the new interventions related to a change in resident's status. Interviews with the DON at 2:38 PM and the EDT Nurse at 1:57 PM on 05/21/2020, revealed they had in serviced all nursing staff from 05/07/2020 through 05/08/2020 regarding physician notification, change of condition, conducting assessments for circulatory issues, updating the plan of care and documenting in the medical record. Interviews on 05/21/2020 conducted with LPN #3, LPN #4, Unit Manager #1, Unit Manager #2, the MDS Nurse and the Weekend Supervisor revealed the EDT and the DON had in serviced them related to the process for physician notification of change of condition, conducting skin assessments to identify circulatory concerns, updating the resident's plan of care and documenting in the resident's medical record. 8. A review of post-tests completed by licensed nursing staff on 05/07/2020 and 05/08/2020 revealed all nursing staff had completed a post-test with a satisfactory score. Interviews with LPN #1, LPN #2, Unit Manager #1, Unit Manager #2, the MDS Nurse, and the Weekend supervisor on 05/21/2020 revealed they completed a post-test after the education provided by the EDT and the DON on 05/07/2020 or 05/08/2020. 9. Review of the past thirty days Progress Notes and Physician order [REDACTED]. Observations conducted on 05/20/20 for Resident #4, Resident #5, Resident #6, and Resident #7 revealed no concerns with change of condition. Record reviews conducted for Resident #4, Resident #5, Resident #6, and Resident #7's May 2020 Nurse's Notes, physicians orders, skin assessments, and the plan of care revealed no concerns with change of condition, updating the plan of care or physician notification. Interviews with the DON, Unit Manager #1, and Unit Manager #2, on 05/21/2020 revealed they had reviewed thirty days of progress notes, physician orders, and residents' care plans to ensure changes of condition had been identified, physicians were notified, and the resident's care plan was updated with new interventions on 05/08/2020 with no issues identified. 10. A review of daily nursing note audits and physician's orders [REDACTED]. A review of the medical records for Resident #4, Resident #5, Resident #6, and Resident #7 to include May 2020 Progress Notes, Physicians Orders, and the Plan of Care revealed no concerns with physician notification of change of condition or with updates to the plan of care for the residents. Interviews with the DON, Unit Manager #1, Unit Manager #2 and the Weekend Supervisor on 05/21/2020 revealed they had reviewed the previous twenty-four hour nursing notes and physician's orders [REDACTED]. 11. A review of the QAPI Committee meeting minutes dated 05/08/2020 revealed the QAPI Committee reviewed audit findings of skin assessments, physician notifications, care plan updates, and the status of licensed nurse's education initiated on 05/07/2020. A review of QAPI Committee Meeting Minutes for 05/12/2020 and 05/19/2020 revealed the QAPI Committee was meeting weekly to review audit findings and to monitor the facility's plan of action. An interview with the Medical Director on 05/21/2020 at 2:49 PM reveled the Medical Director attended the QAPI meeting on 05/07/2020 by phone to review the Immediate Jeopardy Notification and the Plan of Action. Further interview with the Medical Director revealed she attended the QAPI meeting on 05/08/2020 in person to review the facility's audits and education progress. The Medical Director stated staff would contact her within thirty minutes if they were not able to reach a resident's physician when the resident had a change of condition. The Medical Director stated she had been attending weekly QAPI meetings to monitor the facility's compliance. An interview with the Administrator on 05/21/2020 at 3:05 PM revealed she had been monitoring the QAPI process for compliance daily by conducting the morning meetings to ensure daily audits were completed and any identified concerns were addressed. In addition, the Administrator had conducted weekly QAPI Meetings for continued review of audit findings and monitoring the facility's compliance and Immediate Jeopardy removal.

Based on interview, record review, and review of the Merck Manual (medical information resource manual), it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received necessary care and treatment in accordance with professional standards. On 04/08/2020, Resident #1 developed a small, red area on the top of his/her left foot which progressively declined until 04/24/2020, when the resident's foot and leg were cold, mottled (Mottling is blotchy, red-purplish marbling of the skin can be a symptom of a serious underlying condition, such as vascular disease), had necrotic (dead) tissue and staff could not palpate a pulse in the resident's foot or at the knee. Although staff notified Resident #1's physician on several occasions from 04/08/2020 through 04/17/2020, regarding the resident's left extremity, the staff failed to recognize, identify, and act upon clinical indications that the resident's circulatory status was continuing to decline from 04/08/2020 through 04/23/2020. Subsequently, the facility took no action to contact the resident's physician and/or ensure further diagnostic testing was conducted. On 04/24/2020, Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. Continued review of hospital records revealed on 04/25/2020, Resident #1's left leg was surgically removed above the left knee due to Profound ischemia (restricted blood flow) and cadaveric (corpse like) left lower extremity. The facility's failure to ensure residents received care and treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/06/2020, and was determined to exist on 04/14/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657), and 42 CFR 483.25 Quality of Care (F684). The facility was notified of the Immediate Jeopardy on 05/06/2020. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F684). An acceptable Allegation of Compliance was received on 05/13/2020, which alleged removal of Immediate Jeopardy on 05/13/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 05/13/2020, as alleged, prior to exit on 05/21/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657), and 42 CFR 483.25 Quality of Care (F684), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Administrator on 04/30/2020 at 1:00 PM revealed the facility had no policy related to Nursing Assessment. Email correspondence with the Administrator on 05/05/2020 also revealed the facility had no policy related to Professional Standards of Practice. However, interview with the Administrator on 05/05/2020 at 5:40 PM, revealed if a resident experienced a change in condition, she expected staff to reassess the resident, and if the change in condition continued, staff should notify the resident's physician. According to the Merck Manual, modified July 2019, symptoms of occlusive [MEDICAL CONDITION] varied; however, when an artery narrows, the part of the body it supplies may not receive enough blood resulting in ischemia (lack of blood flow/oxygen). Ischemia is a severe condition that can cause tissue damage and loss of limbs. This condition will not improve on its own and requires appropriate medical attention. In the limbs, early symptoms of ischemia may include claudication (pain, burning, or cramping in the muscles with exercise that goes away with rest). This can progress over time to critical limb threatening ischemia, the reduction of blood flow to the affected extremity that results in severe pain or tissue loss. If the tissue of the limb has been affected, a non-healing sore or even gangrene may occur and the skin turns black; this requires immediate attention. Further review of the Merck Manual revealed when the blood supply is severely reduced, the foot may be cold, and special equipment may be needed to detect pulses in the foot. As the artery is narrowed further, a person may develop sores that do not easily heal, typically on the toes or heel and occasionally on the lower leg, especially after an injury. Continued review of the Merck Manual revealed sudden, complete blockage of an artery in a leg or an arm may cause severe pain, coldness, and numbness in the affected limb. The person's leg or arm is either pale or bluish (cyanotic). No pulse can be felt below the blockage. The sudden, drastic decrease in blood flow to the limb is a medical emergency. The absence of blood flow can quickly result in loss of sensation in or paralysis of a limb. If blood flow is absent for too long, tissue may die, and the limb may need to be amputated. Review of Resident #1's medical record revealed the facility admitted the resident on 01/23/2020 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set Assessment ((MDS) dated [DATE], revealed the resident required extensive assistance of two (2) staff members with transfers/toileting, personal hygiene, and bed mobility. Further review revealed the resident could ambulate (walk) with the assistance of one person. The MDS also revealed Resident #1 was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of five (5). According to the MDS, Resident #1 had no venous or arterial ulcers (wounds on the leg or ankle caused by poor circulation); and no other ulcers, wounds, or skin problems of the foot. Review of a Skin Ulcer/Injury Form for Resident #1, revealed on 04/08/2020 at 5:00 PM, the resident's physician was notified because a red spot was observed on the top of Resident #1's left foot. According to the documentation, the resident told staff that he/she bumped his/her foot. Review of Nurse's Notes revealed on 04/10/2020, at 1:53 PM staff documented that Resident #1's left foot was now swollen, red, a small bruise was noted to the top of the left foot and left great toe, and the resident complained of pain. Staff documented that the resident's physician was contacted to request scheduled pain medication because Resident #1 was not alert enough to ask for pain medication, until his/her pain is out of control. Resident #1's medical record also revealed on 04/10/2020 at 2:24 PM that therapy staff would be asked to screen the resident. Review of Resident #1's Therapy Notes revealed Physical Therapy evaluated the resident on 04/13/2020 and noted that the resident complained of pain with weight bearing to the left foot/ankle. Continued review of the Nurse's Notes revealed on 04/13/2020 at 4:13 PM, therapy staff reported to nursing that Resident #1 would not bear weight to the left lower extremity and the resident's physician was notified. an order for [REDACTED]. Further review of Resident #1's Nurse's Notes revealed the next day, on 04/14/2020 at 4:07 AM, Registered Nurse (RN) #1 documented that the resident's left foot was cold, mottled, pulses were thready (pulse is not easily felt and commonly rapid), and the resident's capillary refill was abnormal (time taken for color to return normal after pressure has been applied. A prolonged capillary refill time may indicate decreased peripheral perfusion or peripheral artery disease). There was no documented evidence that the facility identified this as an acute change in the resident's condition; subsequently, no action was taken to address the resident's circulatory compromise to the resident's foot. Continued review of the Nurse's Notes for Resident #1, revealed on 04/15/2020, staff documented the resident's bruises had improved, and that the resident had pedal pulses and no pain. However, review of the resident's Physical Therapy Notes for 04/15/2020 revealed the resident was only able to take one step with a rolling walker with significant complaints of left foot pain. Further review of Resident #1's Nurse's Notes revealed on 04/16/2020, at 8:36 PM, Resident #1's left lower extremity was discolored and capillary refill was slow. According to the Note, the resident's physician was notified and an order for [REDACTED]. Continued review of the Nurse's Notes revealed on 04/17/2020 at 4:51 PM, Resident #1's left leg had become cold to the touch from the resident's knee to the toes, had discoloration from the shin to the toes, the left foot was swollen, had bruising to the top of the foot and the top of all toes, and the resident's pedal pulses were faint. In addition, despite being on scheduled pain medication, the Note also stated that the resident continued to voice pain with movement of his/her left leg/foot. According to the Note, a Doppler study had been completed and the facility was awaiting the results. In addition, Resident #1's Physical Therapy Notes also indicated on 04/17/2020 that the resident continues to have pain in left foot/ankle and was unable to bear weight on his/her left lower extremity due to pain. The Notes stated an ultrasound had been ordered and staff were awaiting results of the test. Again, there was no documented evidence the facility identified this acute change in the resident's condition and no action was taken to address the worsening condition of the resident's foot/leg. Review of Resident #1's Venous Doppler test results revealed the test was conducted on 04/17/2020 and no abnormal findings were indicated. Review of Nurse's Notes dated 04/17/2020 at 7:06 PM, revealed the physician was notified of the results of the test. However, continued review of Resident #1's Nurse's Notes revealed on 04/18/2020, 04/19/2020, and 04/20/2020, staff continued to document that the resident's left foot/left extremity continued to be cool to touch and was discolored. In addition, the resident's Physical Therapy (PT) Notes revealed that the resident had difficulty bearing weight to the left lower extremity on 04/20/2020. Further review revealed there was no documented evidence that staff took any action to ensure Resident #1 received care and treatment to address the signs/symptoms of decreased blood flow to his/her foot and leg. On 04/21/2020 at 2:08 AM, staff documented that Resident #1's feet were cold despite wearing socks, his/her feet were mottling, pulses were thready, capillary refill was abnormal, and had bruising to the left foot and to the great and second toe. In addition, PT Notes for 04/21/2020 revealed the resident had decreased weight bearing because of pain in the left foot, the notes also indicated, X-ray and Doppler were negative. Further review of Resident #1's medical record revealed there was no documented assessment of the resident's foot/leg on 04/22/2020. On 04/23/2020 at 1:35 PM, review of Nurse's Notes revealed that Resident #1's left lower extremity continued to be cool to touch with discoloration from the knee to the toes, [MEDICAL CONDITION] to the foot and lower leg, and pulses were noted in the resident's foot. In addition, Resident #1's Physical Therapy Notes for 04/23/2020 revealed the resident continued to bear weight on his/her right lower extremity only, and the therapist documented short wave diathermy is contraindicated due to possible blood flow impairment and cognitive deficits. Again, no action was taken to address Resident #1's circulatory compromise to the left leg/foot. Review of Nurse's Notes revealed on 04/24/2020 at 8:35 AM, RN #1 documented that the bruises that had appeared on 04/08/2020 to the ventral side of Resident #1's foot had become dry, necrotic areas. In addition, the resident's toes, lateral, ventral, and plantar surfaces of the foot, and the heel were deep purple with black areas. The left knee had a red/purple area covering most of the proximal aspect of the patella (knee), and was cool and tender to touch. The RN also documented that the resident had pain, no palpable pedal pulses nor popliteal pulses (pulses in the foot and knee), and the skin between the knee and foot was cold and mottling. According to the Nurse's Note, the resident's physician's office was contacted and a staff member at the physician's office was going to have the physician make a tele call (tele medicine/video) to view the resident's foot when the physician arrived at the office. Continued review of Resident #1's medical record revealed staff documented on 04/24/2020 at 1:10 PM that the resident was transferred to the hospital. Review of Resident #1's Emergency Medical Services (EMS) transportation sheet revealed EMS was notified of the need to transport the resident to the hospital on [DATE] at 11:53 AM. Continued review of the EMS sheet revealed the resident arrived at the hospital for evaluation and treatment at 12:30 PM on 04/24/2020. Review of Resident #1's medical record from Hospital #1 revealed the resident was diagnosed with [REDACTED]. Resident #1 was transferred to a larger medical center (Hospital #2) for further care/treatment on 04/24/2020. Review of Resident #1's medical record from Hospital #2 revealed Resident #1's left leg was amputated (surgically removed) above his/her knee on 04/25/2020 related to Profound ischemia (restricted blood flow) and cadaveric (corpse like) left lower extremity. Interview with State Registered Nurse Aide (SRNA) #4 on 05/03/2020 at 2:40 PM revealed she frequently cared for Resident #1 and nursing staff had told her that an ultrasound had been completed on the resident's leg and was normal. However, according to SRNA #4, the discoloration and area to the resident's foot just kept getting worse. The SRNA stated the resident would be moaning and complaining of pain whether we moved (him/her) or not. SRNA #1 stated she reported to nursing staff the changes she observed to the resident's leg and foot; however, she stated, It continually got progressively worse. Interview with SRNA #2 on 05/03/2020 at 6:35 PM revealed she frequently cared for Resident #1 and had observed bruising to the resident's left foot around 04/09/2020. SRNA #2 stated she was on leave from work, and when she returned the week of April 15, 2020 (unable to recall the exact date), the resident's left leg was purple in appearance and the resident moaned with pain when staff moved his/her leg. SRNA #2 stated she reported the changes in the resident's leg to nursing staff, who stated they were aware of the change in Resident #1's condition. Interview with SRNA #3 on 05/04/2020 at 12:20 PM revealed she also frequently provided care for Resident #1. She stated around the time the facility received the Venous Doppler results (approximately 04/17/2020) bruising was observed to Resident #1's big toe on his/her left foot. She stated days later the bruising started going up the resident's leg. SRNA #3 also stated Resident #1's left leg was colder to touch than the right leg and remained that way for approximately two (2) weeks before he/she went to the hospital. In addition, SRNA #3 stated the resident just hurt, period. She stated, Anything to do with that leg from the time the bruising started, hurt. The SRNA also stated she reported the changes in the resident's condition to facility nurses, including LPN #1. Interview with SRNA #1 on 05/02/2020 at 6:00 PM revealed Resident #1 had a lot of pain to the left foot. He stated the last few times he cared for the resident, the resident required more assistance with bed mobility because of the pain. He further stated that he cared for Resident #1 during the night shift (7 PM-7 AM) on 04/23-24/2020. SRNA #1 stated the resident's leg was cold and looked bad during his shift. He stated the facility nurses were aware and were also concerned. SRNA #1 stated he observed them (the nurses) Googling information on their phones regarding the resident's leg. He stated the nurses thought it was dry gangrene. The SRNA was unable to recall exactly what time the change in the resident's leg was observed, but stated, It was early morning, on 04/24/2020. Interview with the Physical Therapist on 05/04/2020 at 2:30 PM revealed Resident #1's left foot was really painful and the resident didn't want to put weight on it. He stated he notified Nursing of the resident's complaints of pain and inability to bear weight. In addition, the Therapist stated Resident #1's left leg was cooler to touch than his/her right leg; however, he did not assess the resident's pulses in his/her lower extremities. Interview with LPN #1 at 3:50 PM on 05/04/2020 revealed she documented Resident #1's assessment findings on 04/17/2020 and observed that the resident's pedal pulses were faint, and his/her left leg was discolored from the shin to the resident's toes. LPN #1 acknowledged the resident's leg never improved after the diagnostic test results were negative for a venous blood flow problem on 04/17/2020. She acknowledged that nursing assessments should guide care. LPN #1 stated the resident's physician should have been notified so other diagnostic tests could have been conducted. LPN #1 stated that contacting the physician when the resident did not improve could have made a difference in the outcome for the resident, especially since his/her concern was later determined to be arterial. Interview with RN #1 at 8:15 AM on 05/05/2020 revealed she assessed Resident #1 on 04/14/2020 and 04/21/2020. RN #1 stated, Looking back, I would have been more persistent with physician notification after the Doppler results. She stated, My gut was telling me something was wrong. On 04/24/2020 at approximately 4:00 AM, the RN stated she observed dry, necrotic (dead) tissue to the resident's toes, lateral/ventral aspects of his/her foot, and his/her heel. RN #1 stated the resident's left knee also had a red/purple area covering most of the proximal aspect (front center) of his/her knee, and she was unable to obtain pulses to Resident #1's left foot or behind his/her knee. Further interview with RN #1 revealed she paged the resident's physician at approximately 6:30 AM on 04/24/2020 to notify him of the change in the resident's condition; however, the physician did not return the call at that time. She stated she waited until the physician's office was open, around 8:00 AM, and notified office staff; however, she was informed the physician was at the hospital. According to the RN, she was not able to document the resident's assessment until 8:35 AM on 04/24/2020. RN #1 stated once she completed resident documentation, and was able to leave the facility, she went to the physician's office (around 9:00 AM approximately five (5) hours after the assessment of the decline in the resident's condition) and notified Resident #1's physician of the change in his/her condition. RN #1 stated the physician directed his office staff to arrange for Resident #1 to be directly admitted to the hospital for further evaluation and treatment. RN #1 stated that although it was the facility's practice to notify the physician at the time a change in condition was identified to have occurred, she had been unsuccessful in contacting Resident #1's physician prior to going to the physician's office. Interview with the Director of Nursing (DON) on 05/05/2020 at 5:00 PM revealed residents' condition was monitored daily, Monday-Friday, during an Interdisciplinary Team (IDT) meeting. The DON stated nursing documentation, twenty-four (24) report sheets, laboratory results, and physician orders [REDACTED]. However, the DON stated she did not recall identifying that Resident #1 had an ongoing change in condition, nor any documentation that indicated the resident's foot/leg was cold/mottled or his/her pulses were thready. The DON stated she was notified of the resident's change in condition the morning of 04/24/2020 when she arrived at the facility. Interview with LPN #2 on 05/20/2020 at 1:15 PM revealed staff had not been trained on signs/symptoms of vascular or arterial issues until this happened to this resident in reference to Resident #1. Email correspondence with the Administrator on 05/06/2020 at 1:59 PM revealed the facility had provided no education related to the signs and/or symptoms of arterial ulcers to direct care nursing staff. Interview with Physician #1 on 05/05/2020 at 12:50 PM revealed staff had not informed him that Resident #1's pulses were thready in his/her left foot, or that the resident's leg/foot was cold to touch until 04/24/2020. He stated staff were required to notify him when changes in a resident's condition occurred. However, the physician confirmed he received no calls from the facility related to Resident #1's condition, after he was notified of the normal Venous Doppler results on 04/17/2020. He stated if staff had informed him of the ongoing change in the resident's condition, after the Venous Doppler ultrasound was conducted, he would have ordered an Arterial Doppler and Resident #1 could have potentially had a different outcome. Interview with Physician #2 on 05/14/2020 at 4:00 PM revealed he evaluated Resident #1 on 04/24/2020 at Hospital #1. He stated when he evaluated the resident his thought was that the resident could have had blockages for a while. Physician #2 stated lower extremities being cool to touch and thready pulses were definitely a sign that was when the problem started for Resident #1. He also stated those assessment findings were telltale signs that something was wrong and he would expect licensed nurses to inform a physician of those findings when they were identified. Interview with Physician #3 on 05/18/2020 at 11:10 AM revealed he evaluated Resident #1 at Hospital #2. He stated he conducted the surgical removal of the resident's left lower extremity above the knee on 04/25/2020, because the resident's leg had been without blood supply. Physician #3 stated Resident #1 also had full thick necrosis on multiple areas of the foot and toes. He stated the resident appeared to have two weeks' worth of ischemia before the resident got to the hospital and stated, It definitely didn't just happen. ***The facility implemented the following actions to remove Immediate Jeopardy effective 05/13/2020: 1. Resident #1 no longer resides at the facility. 2. The facility held an ad hoc QAPI (Quality Assurance and Performance Improvement) committee meeting on 05/07/2020 to review the Immediate Jeopardy findings and discuss the development of the action items to be completed. 3. Members of the clinical leadership team conducted head-to-toe skin inspections on 05/08/2020, which included checking pedal pulses and capillary refill for all residents. No new circulatory concerns were identified. 4. On 05/08/2020, the Director of Nursing (DON) selected a sample of three (3) completed skin inspection forms from each hall (15 in total), as a second review. The DON identified no concerns. 5. Beginning on 05/12/2020, the DON, Unit Manager, Wound Nurse, and/or Nurse Supervisor will assess five (5) residents per unit daily to assess circulatory changes, capillary refill, and pedal pulses, comparing to the documented baseline from 05/07/2020. Staff completing the assessments will immediately address any concerns. The monitoring will continue until the facility meets regulatory compliance. The QAPI team will review the results at least weekly to track the facility's progress toward regulatory compliance. 6. The Minimum Data Set (MDS) Coordinator provided education to the Education Training Director (ETD) regarding updating resident care plans when a resident's change in condition occurs. The ETD then provided this education to all licensed nurses by 05/08/2020. Each nurse was required to verbalize the process to update the care plan in the Electronic Medical Record to ensure competency. 7. The Director of Nursing and ETD educated all licensed nurses on physician notification, change in condition and Medical Director Notification on 05/07/2020 through 05/09/2020. The education also included documentation requirements for physician notifications in the medical record. Resident skin inspections to include, but not limited to, circulatory indicators of capillary refill, pedal pulses, and vital signs. Any new/undocumented skin impairments or signs/symptoms of circulatory problems require immediate physician notification and documentation in the medical record in the nursing progress notes. In addition, staff will update care plans with the new interventions related to a change in a resident's status. 8. On 05/07/2020 through 05/08/2020, all licensed nurses were required to complete a post-test to verify training competency related to physician notification, change in condition and Medical Director Notification. The nurses were required to receive a score of 100% before resuming duties. Licensed nurses on leave will be required to have this education and pass a posttest prior to returning to work. Any newly hired licensed nurse will receive this education/testing from the ETD and/or DON prior to assuming duties. 9. On 05/08/2020 the Director of Nursing, MDS Coordinator, Wound Nurse, and Nurse Managers completed a review of the last thirty days of Interdisciplinary Team (IDT) notes and physician's orders [REDACTED]. The review included ensuring staff had updated resident care plans to reflect the change of condition and any associated interventions. The Director of Nursing, MDS Coordinator, Wound Nurse, and Nurse Managers identified no concerns. 10. On 05/08/2020, the Director of Nursing, Unit Manager and/or Weekend Supervisor, initiated an on-going audit of the prior 24- hour nursing notes and physician's orders [REDACTED]. Nursing leadership will address any concerns when discovered. 11. On 05/08/2020, the QAPI team held a second ad hoc meeting to review the initial skin/circulatory audits, physician notifications and care plan updates, as well as the status of the licensed nurse's education initiated on 05/07/2020. The Administrator reviewed the results with the Medical Director on 05/08/2020. ***The State Survey Agency verified the facility implemented the following actions to remove Immediate Jeopardy on 05/13/2020, as alleged: 1. Review of the medical record revealed the facility transferred Resident #1 to the hospital on [DATE] and the resident did not return to the facility. 2. A review of QAPI Committee meeting minutes dated 05/07/2020 revealed the committee reviewed the Immediate Jeopardy notifications and the action plans for facility compliance. Review of the meeting sign in sheet dated 05/07/2020, revealed the facility's department heads attended. Interviews, conducted on 05/21/2020, with the Administrator, Medical Director, Director of Nursing (DON), the Unit Managers, and the Minimum Data Set (MDS) Coordinator revealed the facility had conducted a QAPI meeting on 05/07/2020 to discuss the immediate jeopardy and to initiate the development of a plan of action for compliance. 3. A review of skin assessments conducted from 05/06/2020 through 05/08/2020 revealed all residents had a head to toe skin assessment performed to include evaluation of pedal pulses and capillary refill. Review of skin assessments completed for Resident #4, Resident #5, Resident #6 and Resident #7 revealed the assessments were completed with no concerns identified. Observation of skin assessments for Resident #6 and Resident #7 conducted on 05/20/2020, included evaluation of pedal pulses and capillary refill with no concerns identified. Interviews with the DON, Unit Manager #1, and Unit Manager #2 on 05/21/2020 revealed all residents' skin, pedal pulses, and capillary refill status was assessed by 05/08/2020. 4. A review of skin assessment audits completed by the DON on 05/08/2020 revealed the DON had audited a sample of fifteen (15) completed skin assessments with no issues identified. Review of the May 2020 skin assessments completed for Resident #4, Resident #5, Resident #6, and Resident #7 revealed no concerns with the completion or accuracy of the assessments. Interview with the DON on 05/21/2020 at 2:38 PM revealed she had conducted audits of the skin assessments performed on 05/08/2020, of three (3) residents from each hallway with no new issues or changes of condition found. 5. A review of daily audits completed from 05/12/2020 through 05/20/2020 by the DON, Unit Managers, Wound Nurse, and the Weekend Supervisor revealed five (5) residents from each unit were assessed daily for circulatory changes, capillary refill, and pedal pulses. The assessments were compared with assessments completed on 05/08/2020 with no concerns identified. Interviews with the DON, Unit Manager #1, Unit Manager #2, the Wound Nurse, and the Weekend supervisor conducted on 05/21/2020 revealed they were assessing a sample of residents daily on each unit for circulatory concerns to ensure any changes in a resident's condition was identified. 6. A review of an in service education sign in sheet dated 05/07/2020 revealed the MDS Nurse had educated the EDT on updating resident care plans when a change in condition occurred. Interview with the MDS Nurse on 05/21/2020 at 1:42 PM revealed she had trained the EDT on the requirement to update the plan of care when a resident had a change of condition. Interview with the EDT Nurse on 05/21/2020 at 1:57 PM, revealed the MDS Nurse had educated her on updating resident care plans on 05/07/2020. The EDT stated she educated all licensed nurses except employees who were on leave regarding the requirement by 05/08/2020. Further interview with the EDT revealed employees who were on leave could not work until the training was completed. Review of employee in-service education sign in sheets revealed all licensed employees were educated on updating resident care plans when a change in condition occurred on 05/08/2020 by the EDT Nurse. Interviews conducted with LPN #3, LPN #4, Unit Manager #1, Unit Manager #2, and the Weekend Supervisor on 05/21/2020 revealed they received education on 05/08/2020 by the EDT on updating care plans when a resident had a change of condition. 7. A review of Education Sign in Sheets dated 05/07/2020 through 05/09/2020 revealed all nurses were educated by the DON and EDT on physician notification, change of condition, Medical Director Notification if the physician could not be reached and documentation requirements for physician notifications in the medical record. The education referenced resident skin inspections, circulatory indicators of capillary refill, pedal pulses, and vital signs. Any new/undocumented skin impairments or signs/symptoms of circulatory problems required immediate physician notification and documentation in the medical record and updating the plan of care with the new interventions related to a change in resident's status. Interviews with the DON at 2:38 PM and the EDT Nurse at 1:57 PM on 05/21/2020, revealed they had in serviced all nursing staff from 05/07/2020 through 05/08/2020 regarding physician notification, change of condition, conducting assessments for circulatory issues, updating the plan of care and documenting in the medical record. Interviews on 05/21/2020 conducted with LPN #3, LPN #4, Unit Manager #1, (TRUNCATED)

Based on observation, interview, record review, and review of the facility's policy it was determined the facility failed to immediately inform the physician and the responsible party when a significant change in condition occurred for one (1) of three (3) sampled residents (Resident #1). Resident #1's physician was notified on 04/08/2020 that the resident had developed a red area to the top of the left foot. The facility made subsequent physician notifications when the resident was having pain to the foot on 04/10/2020; when the resident was unable to bear weight on 04/13/2020; and, on 04/16/2020, when the resident's capillary refill (time taken for color to return normal after pressure has been applied. A prolonged capillary refill time may indicate decreased peripheral perfusion or peripheral artery disease) was abnormal and the left lower extremity was discolored. However, staff also documented beginning 04/14/2020, that the resident had thready pulses (pulse that is not easily felt and commonly rapid) and the left foot was cold and mottled (mottling is blotchy, red-purplish marbling of the skin which can be a symptom of a serious underlying condition, such as vascular disease). However, there was no documented evidence the physician was made aware. Further review of Resident #1's medical record revealed the resident's foot/leg continued to decline; however, the resident's physician was not notified. On 04/24/2020 at approximately 4:00 AM, the resident had no pulses at the knee or foot, and the left, lower leg was cold and mottled. Interview with the resident's daughter revealed she was not aware that the resident's foot was injured until the resident's roommate told her of the injury through a window on 04/10/2020. She further stated she was not aware how serious the resident's condition was until she saw the resident after the resident was transferred to the hospital. Resident #1 was transferred to a local hospital on [DATE] and diagnosed with [REDACTED]. Resident #1 was then transferred to a larger medical center where the resident's left leg was amputated (surgically removed) above his/her knee on 04/25/2020 related to Profound ischemia (restricted blood flow) and cadaveric (corpse like) left lower extremity. The facility's failure to notify the resident's physician of a change in condition and need to alter treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/06/2020, and was determined to exist on 04/14/2020 at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657), and 42 CFR 483.25 Quality of Care (F684). The facility was notified of the Immediate Jeopardy on 05/06/2020. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F684). An acceptable Allegation of Compliance was received on 05/13/2020, which alleged removal of Immediate Jeopardy on 05/13/2020. The State Survey Agency determined the Immediate Jeopardy was removed on 05/13/2020 as alleged, prior to exit on 05/21/2020, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F657), and 42 CFR 483.25 Quality of Care (F684), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Administrator on 05/05/2020 at 5:40 PM revealed if residents experienced a change in condition, she expected staff to reassess the resident, and if the change in condition continued, staff should notify the resident's physician. However, review of the facility's policy titled Change in a Resident's Condition or Status, last revised November 2016, revealed the facility would promptly notify the resident, his/her physician and a resident representative based on the resident's cognition, of changes in the resident's medical/mental condition and or status. The policy defined a significant change of condition as a decline or improvement in a resident's status that would not normally resolve itself without intervention by staff or by standard disease-related clinical interventions being implemented (is not self-limiting). The policy also stated a significant change was something that impacted more than one area of the resident's health status, and required interdisciplinary review and/or revision to the care plan. Review of Resident #1's medical record revealed the facility admitted the resident on 01/23/2020 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set Assessment ((MDS) dated [DATE], revealed the facility assessed Resident #1 to be cognitively impaired with a Brief Interview for Mental Status (BIMS) score of five (5). Further review revealed the facility assessed the resident to require extensive assistance of two (2) staff members with toileting, transfers, and bed mobility; and, he/she could ambulate (walk) with the assistance of one person. According to the MDS, Resident #1 had no venous or arterial ulcers (wounds on the leg or ankle caused by poor circulation), and no other ulcers, wounds, or skin problems of the foot. Review of Nurses' Notes revealed on 04/08/2020 at 5:10 PM, Resident #1's left foot was slightly red and tender to touch. Review of a Skin Ulcer/Injury Form for Resident #1, revealed on 04/08/2020 at 5:00 PM, the resident's physician was notified of a red spot on the top of Resident #1's left foot. Continued review of Nurse's Notes revealed on 04/10/2020 at 1:53 PM, staff documented that Resident #1's left foot was swollen, red, a small bruise was noted to the top of the left foot and to the left great toe, and the resident had pain. According to the documentation, the resident's physician was contacted to request scheduled pain medication because Resident #1 was not alert enough to ask for pain medication, until the resident's pain is out of control. Interview with Resident #1's daughter on 05/18/2020 at 10:00 AM revealed the facility did not notify her of the resident's injury/pain. She stated she was not aware of any change in the resident's condition until she visited the resident's window on 04/10/2020 and was informed by the resident's roommate that the resident had injured his/her foot (the daughter was unable to visit inside the facility due to COVID-19 restrictions). She stated she called the facility and spoke with the facility's Social Worker, who told her that she checked on the resident and the injury was not a big deal. Further review of the Nurse's Notes revealed on 04/13/2020 at 4:13 PM, a nurse documented that therapy notified nursing staff that Resident #1 would not bear weight to the left lower extremity. According to the Note, the resident's physician was notified and an order for [REDACTED]. Review of Resident #1's x-ray report revealed the left foot x-ray was completed on 04/13/2020 and showed that the resident had diffuse osteopenia (low bone mineral density), mild osteoarthritic (joint disease) changes, and a small posterior heel spur (a foot condition created by calcium deposits). No acute fracture or dislocation was identified. Further review of Resident #1's Nurse's Notes revealed on 04/14/2020 at 4:07 AM, Registered Nurse (RN) #1 documented that the resident's left foot was now cold, mottled, (his/her) pulses were thready, and the resident's capillary refill was abnormal. However, there was no documented evidence the resident's physician was notified when the change in the resident's condition was identified. Interview with RN #1 on 05/05/2020 at 8:15 AM revealed that she did not notify Resident #1's physician that the resident's foot had become cold and mottled with thready pulses. She stated the resident's x-ray results had returned with no acute findings during her shift, so she reported the change in the resident's condition to the oncoming shift. According to the RN, Resident #1's physician may not answer the phone at night, or say this could have waited. Review of Resident #1's Nurse's Notes dated 04/16/2020, at 8:36 PM, two (2) days later, revealed Licensed Practical Nurse (LPN) #2 documented that Resident #1's left lower extremity was discolored, and his/her capillary refill was slow. According to the Note, the resident's physician was notified and an order for [REDACTED]. Interview with LPN #2 on 05/04/2020 at 4:50 PM confirmed that she only informed Resident #1's physician that the resident's left lower extremity and foot in general was discolored and his/her capillary refill was slow. Further interview revealed LPN #2 did not notify the resident's physician of the thready pulses. Further review of Resident #1's Nurse's Notes for 04/17/2020 at 4:51 PM, revealed LPN #1 documented the resident's left leg had become cold to touch from the knee down to the toes, discoloration was observed from his/her shin to the toes, the left foot was swollen, and the resident's pedal pulses were faint. The Nurse's Note stated the Venous Doppler study had been completed and they were awaiting the results. Further review revealed there was no documented evidence that the resident's physician was notified that the coldness and discoloration had worsened and was affecting the resident's leg. Interview with LPN #1 on 05/04/2020 at 3:50 PM confirmed that on 04/17/2020, Resident #1's pedal pulses were faint, and the resident's left leg was discolored from the shin to his/her toes. However, the LPN stated she did not inform the resident's physician, but stated that looking back, she should have notified the physician. Review of Resident #1's Venous Doppler study/test results revealed the test was conducted on 04/17/2020 and no abnormal findings were indicated. Review of Nurse's Notes revealed the physician was notified of the test results on 04/17/2020 at 7:06 PM. Continued review of Resident #1's Nurse's Notes revealed on 04/18/2020, 04/19/2020, 04/21/2020 and 04/23/2020, LPN #1 and RN #1 continued to document that the resident's left foot and/or left extremity was cool to touch and was discolored. However, there was no documented evidence that the resident's physician was made aware that the resident's foot had become cool. Review of LPN #1's documentation for 04/23/2020 at 1:35 PM, revealed the LPN documented that Resident #1's Left lower extremity continues to be cool to touch, with discoloration noted from toes to knee. The LPN also documented [MEDICAL CONDITION] was also observed to the resident's left lower foot and leg and the resident's pedal pulses were positive. Continued interview with LPN #1 on 05/04/2020 at 3:50 PM, with RN #1 on 05/05/2020 at 8:15 AM, revealed they never notified Resident #1's physician that the resident's foot/leg was cold, nor that the resident's leg had become discolored from the knee to the toes. LPN #1 stated she should have notified Resident #1's physician when she identified the change in the resident's condition. The LPN stated, We could have done other diagnostic tests, got the resident out sooner, and a different outcome could have occurred for the resident. RN #1 stated looking back she would have been more persistent with notifying the resident's physician about the resident's leg/foot after the Venous Doppler study. RN #1 stated, My gut was telling me something was wrong. However, she stated she did not notify Resident #1's physician when she assessed the resident's leg to be cold and mottled with thready pulses. Interview with the Director of Nursing (DON) on 05/05/2020 at 5:00 PM revealed Monday through Friday the facility held an Interdisciplinary Team (IDT) meeting to ensure physicians were notified timely when a change in a resident's condition was identified. She stated the team reviewed resident medical records, which included Nurse's Notes, in attempts to ensure physician notification occurred as required. The DON stated the facility conducted an investigation related to care/treatment, which included physician notification for Resident #1, and no concerns were identified. Continued review of Resident #1's Nurse's Notes revealed on 04/24/2020 at 8:35 AM, RN #1 documented that the bruises that had appeared on 04/08/2020 to the ventral side of foot were now dry necrotic areas. The resident's toes; lateral, ventral, and plantar surfaces of the foot; and the heel were deep purple with black areas. The left knee had a red/purple area covering most of the proximal aspect of the patella (knee), and was cool and tender to touch. The RN also documented that the resident had pain, no palpable pedal pulses nor popliteal pulses (pulses in the foot and knee), and the skin between the knee and foot was cold and mottling. According to the Nurse's Note, the resident's physician's office was contacted and a staff member at the physician's office was going to have the physician make a tele call to view the resident's foot when the physician arrived at the office. Continued interview with RN #1 on 05/05/2020 at 8:15 AM, revealed she cared for Resident #1 on 04/24/2020 and at approximately 4:00 AM, she identified that the resident's foot/leg had worsened. She stated the resident had necrotic (dead tissue) to the toes, purple/black areas to the lateral/ventral aspects of his/her foot, and to his/her heel; and had a new red/purple area covering most of the proximal aspect (front center) of his/her knee. In addition, the RN stated that she was unable to obtain pulses to Resident #1's left foot or behind his/her knee. According to the RN, she paged the resident's physician at approximately 6:30 AM on 04/24/2020 in an attempt to notify him of the change in the resident's condition; however, the physician did not return the call at that time. She stated she waited until the physician's office opened at approximately 8:00 AM and called the physician's office; however, office staff stated the physician was at the hospital. RN #1 stated she completed her shift documentation and went to the physician's office at approximately 9:00 AM and notified the physician of the change in Resident #1's condition. RN #1 stated the physician directed his office staff to contact the hospital of the need for Resident #1 to be directly admitted to the hospital for further evaluation and treatment. Interview with Physician #1 on 05/05/2020 at 12:50 PM revealed staff informed him that Resident #1 complained of pain and that he/she had a small bruise and swelling to his/her left leg. However, staff did not inform him that Resident #1's pulses were thready in his/her left foot, or that the resident's leg/foot was cold to touch until 04/24/2020 at approximately 9:15 AM (unable to recall exact time) when RN #1(she attempted to page the physician at approximately 6:30 AM and when he returned call to the facility, time unknown, the nurse had already left the facility) however, the RN came to his office and showed him photographs of the resident's leg/foot. The physician stated staff were required to inform him when changes in a resident's condition occurred, and if staff would have informed him of the ongoing changes in the resident's condition, after the Venous Doppler ultrasound was conducted on 04/17/2020, he would have ordered an Arterial Doppler study and the resident could have potentially had a different outcome. Review of Resident #1's medical record from Hospital #1 revealed he/she arrived to the hospital at approximately 12:30 PM. After diagnostic tests were completed at 3:43 PM on 04/24/2020, Resident #1's [DIAGNOSES REDACTED]. Resident #1 was later transferred to a larger medical center (Hospital #2) for further care/treatment on 04/24/2020. Review of Resident #1's medical record from Hospital #2 revealed the resident's left leg was amputated (surgically removed) above his/her knee on 04/25/2020 related to Profound ischemia (restricted blood flow) and cadaveric (corpse like) left lower extremity. Continued interview with Resident #1's Daughter on 05/18/2020 at 10:00 AM revealed after she learned of the resident's injury on 04/10/2020, the facility notified her several times about testing that was being conducted. However, she stated the facility did not relay how bad the resident's condition was and, she had not been able to visit to see the resident because of visitation restrictions due to COVID-19. She stated she was not aware how bad the resident's leg was until she saw the resident on 04/24/2020 after the resident had been taken to the hospital. She stated when she saw the resident's leg it was mottled and the resident's toes were black. She stated the resident's leg had gotten progressively worse since the amputation on 04/25/2020, had since required another surgery to remove more of that leg. Resident #1's Daughter stated the resident was [AGE] years old, and should not be spending the last part of his/her life like this. The daughter stated the facility . should have gotten (the resident) help sooner, before it went that far and got that bad. ***The facility implemented the following actions to remove Immediate Jeopardy effective 05/13/2020: 1. Resident #1 no longer resides at the facility. 2. The facility held an ad hoc QAPI (Quality Assurance and Performance Improvement) committee meeting on 05/07/2020 to review the Immediate Jeopardy findings and discuss the development of the action items to be completed. 3. Members of the clinical leadership team conducted head-to-toe skin inspections on 05/08/2020, which included checking pedal pulses and capillary refill for all residents. No new circulatory concerns were identified. 4. On 05/08/2020, the Director of Nursing (DON) selected a sample of three (3) completed skin inspection forms from each hall (15 in total), as a second review. The DON identified no concerns. 5. Beginning on 05/12/2020, the DON, Unit Manager, Wound Nurse, and/or Nurse Supervisor will assess five (5) residents per unit daily to assess circulatory changes, capillary refill, and pedal pulses, comparing to the documented baseline from 05/07/2020. Staff completing the assessments will immediately address any concerns. The monitoring will continue until the facility meets regulatory compliance. The QAPI team will review the results at least weekly to track the facility's progress toward regulatory compliance. 6. The Minimum Data Set (MDS) Coordinator provided education to the Education Training Director (ETD) regarding updating resident care plans when a resident's change in condition occurs. The ETD then provided this education to all licensed nurses by 05/08/2020. Each nurse was required to verbalize the process to update the care plan in the Electronic Medical Record to ensure competency. 7. The Director of Nursing and ETD educated all licensed nurses on physician notification, change in condition and Medical Director Notification on 05/07/2020 through 05/09/2020. The education also included documentation requirements for physician notifications in the medical record. Resident skin inspections to include, but not limited to, circulatory indicators of capillary refill, pedal pulses, and vital signs. Any new/undocumented skin impairments or signs/symptoms of circulatory problems require immediate physician notification and documentation in the medical record in the nursing progress notes. In addition, staff will update care plans with the new interventions related to a change in a resident's status. 8. On 05/07/2020 through 05/08/2020, all licensed nurses were required to complete a post-test to verify training competency related to physician notification, change in condition and Medical Director Notification. The nurses were required to receive a score of 100% before resuming duties. Licensed nurses on leave will be required to have this education and pass a posttest prior to returning to work. Any newly hired licensed nurse will receive this education/testing from the ETD and/or DON prior to assuming duties. 9. On 05/08/2020 the Director of Nursing, MDS Coordinator, Wound Nurse, and Nurse Managers completed a review of the last thirty days of Interdisciplinary Team (IDT) notes and physician's orders [REDACTED]. The review included ensuring staff had updated resident care plans to reflect the change of condition and any associated interventions. The Director of Nursing, MDS Coordinator, Wound Nurse, and Nurse Managers identified no concerns. 10. On 05/08/2020, the Director of Nursing, Unit Manager and/or Weekend Supervisor, initiated an on-going audit of the prior 24- hour nursing notes and physician's orders [REDACTED]. Nursing leadership will address any concerns when discovered. 11. On 05/08/2020, the QAPI team held a second ad hoc meeting to review the initial skin/circulatory audits, physician notifications and care plan updates, as well as the status of the licensed nurse's education initiated on 05/07/2020. The Administrator reviewed the results with the Medical Director on 05/08/2020. ***The State Survey Agency verified the facility implemented the following actions to remove Immediate Jeopardy on 05/13/2020, as alleged: 1. Review of the medical record revealed the facility transferred Resident #1 to the hospital on [DATE] and the resident did not return to the facility. 2. A review of QAPI Committee meeting minutes dated 05/07/2020 revealed the committee reviewed the Immediate Jeopardy notifications and the action plans for facility compliance. Review of the meeting sign in sheet dated 05/07/2020, revealed the facility's department heads attended. Interviews, conducted on 05/21/2020, with the Administrator, Medical Director, Director of Nursing (DON), the Unit Managers, and the Minimum Data Set (MDS) Coordinator revealed the facility had conducted a QAPI meeting on 05/07/2020 to discuss the immediate jeopardy and to initiate the development of a plan of action for compliance. 3. A review of skin assessments conducted from 05/06/2020 through 05/08/2020 revealed all residents had a head to toe skin assessment performed to include evaluation of pedal pulses and capillary refill. Review of skin assessments completed for Resident #4, Resident #5, Resident #6 and Resident #7 revealed the assessments were completed with no concerns identified. Observation of skin assessments for Resident #6 and Resident #7 conducted on 05/20/2020, included evaluation of pedal pulses and capillary refill with no concerns identified. Interviews with the DON, Unit Manager #1, and Unit Manager #2 on 05/21/2020 revealed all residents' skin, pedal pulses, and capillary refill status was assessed by 05/08/2020. 4. A review of skin assessment audits completed by the DON on 05/08/2020 revealed the DON had audited a sample of fifteen (15) completed skin assessments with no issues identified. Review of the May 2020 skin assessments completed for Resident #4, Resident #5, Resident #6, and Resident #7 revealed no concerns with the completion or accuracy of the assessments. Interview with the DON on 05/21/2020 at 2:38 PM revealed she had conducted audits of the skin assessments performed on 05/08/2020, of three (3) residents from each hallway with no new issues or changes of condition found. 5. A review of daily audits completed from 05/12/2020 through 05/20/2020 by the DON, Unit Managers, Wound Nurse, and the Weekend Supervisor revealed five (5) residents from each unit were assessed daily for circulatory changes, capillary refill, and pedal pulses. The assessments were compared with assessments completed on 05/08/2020 with no concerns identified. Interviews with the DON, Unit Manager #1, Unit Manager #2, the Wound Nurse, and the Weekend supervisor conducted on 05/21/2020 revealed they were assessing a sample of residents daily on each unit for circulatory concerns to ensure any changes in a resident's condition was identified. 6. A review of an in service education sign in sheet dated 05/07/2020 revealed the MDS Nurse had educated the EDT on updating resident care plans when a change in condition occurred. Interview with the MDS Nurse on 05/21/2020 at 1:42 PM revealed she had trained the EDT on the requirement to update the plan of care when a resident had a change of condition. Interview with the EDT Nurse on 05/21/2020 at 1:57 PM, revealed the MDS Nurse had educated her on updating resident care plans on 05/07/2020. The EDT stated she educated all licensed nurses except employees who were on leave regarding the requirement by 05/08/2020. Further interview with the EDT revealed employees who were on leave could not work until the training was completed. Review of employee in-service education sign in sheets revealed all licensed employees were educated on updating resident care plans when a change in condition occurred on 05/08/2020 by the EDT Nurse. Interviews conducted with LPN #3, LPN #4, Unit Manager #1, Unit Manager #2, and the Weekend Supervisor on 05/21/2020 revealed they received education on 05/08/2020 by the EDT on updating care plans when a resident had a change of condition. 7. A review of Education Sign in Sheets dated 05/07/2020 through 05/09/2020 revealed all nurses were educated by the DON and EDT on physician notification, change of condition, Medical Director Notification if the physician could not be reached and documentation requirements for physician notifications in the medical record. The education referenced resident skin inspections, circulatory indicators of capillary refill, pedal pulses, and vital signs. Any new/undocumented skin impairments or signs/symptoms of circulatory problems required immediate physician notification and documentation in the medical record and updating the plan of care with the new interventions related to a change in resident's status. Interviews with the DON at 2:38 PM and the EDT Nurse at 1:57 PM on 05/21/2020, revealed they had in serviced all nursing staff from 05/07/2020 through 05/08/2020 regarding physician notification, change of condition, conducting assessments for circulatory issues, updating the plan of care and documenting in the medical record. Interviews on 05/21/2020 conducted with LPN #3, LPN #4, Unit Manager #1, Unit Manager #2, the MDS Nurse and the Weekend Supervisor revealed the EDT and the DON had in serviced them related to the process for physician notification of change of condition, conducting skin assessments to identify circulatory concerns, updating the resident's plan of care and documenting in the resident's medical record. 8. A review of post-tests completed by licensed nursing staff on 05/07/2020 and 05/08/2020 revealed all nursing staff had completed a post-test with a satisfactory score. Interviews with LPN #1, LPN #2, Unit Manager #1, Unit Manager #2, the MDS Nurse, and the Weekend supervisor on 05/21/2020 revealed they completed a post-test after the education provided by the EDT and the DON on 05/07/2020 or 05/08/2020. 9. Review of the past thirty days Progress Notes and Physician order [REDACTED]. Observations conducted on 05/20/20 for Resident #4, Resident #5, Resident #6, and Resident #7 revealed no concerns with change of condition. Record reviews conducted for Resident #4, Resident #5, Resident #6, and Resident #7's May 2020 Nurse's Notes, physicians orders, skin assessments, and the plan of care revealed no concerns with change of condition, updating the plan of care or physician notification. Interviews with the DON, Unit Manager #1, and Unit Manager #2, on 05/21/2020 revealed they had reviewed thirty days of progress notes, physician orders, and residents' care plans to ensure changes of condition had been identified, physicians were notified, and the resident's care plan was updated with new interventions on 05/08/2020 with no issues identified. 10. A review of daily nursing note audits and physician's orders [REDACTED]. A review of the medical records for Resident #4, Resident #5, Resident #6, and Resident #7 to include May 2020 Progress Notes, Physicians Orders, and the Plan of Care revealed no concerns with physician notification of change of condition or with updates to the plan of care for the residents. Interviews with the DON, Unit Manager #1, Unit Manager #2 and the Weekend Supervisor on 05/21/2020 revealed they had reviewed the previous twenty-four hour nursing notes and physician's orders [REDACTED]. 11. A review of the QAPI Committee meeting minutes dated 05/08/2020 revealed the QAPI Committee reviewed audit findings of skin assessments, physician notifications, care plan updates, and the status of licensed nurse's education initiated on 05/07/2020. A review of QAPI Committee Meeting Minutes for 05/12/2020 and 05/19/2020 revealed the QAPI Committee was meeting weekly to review audit findings and to monitor the facility's plan of action. An interview with the Medical Director on 05/21/2020 at 2:49 PM reveled the Medical Director attended the QAPI meeting on 05/07/2020 by phone to review the Immediate Jeopardy Notification and the Plan of Action. Further interview with the Medical Director revealed she attended the QAPI meeting on 05/08/2020 in person to review the facility's audits and education progress. The Medical Director stated staff would contact her within thirty minutes if they were not able to reach a resident's physician when the resident had a change of condition. The Medical Director stated she had been attending weekly QAPI meetings to monitor the facility's compliance. An interview with the Administrator on 05/21/2020 at 3:05 PM revealed she had been monitoring the QAPI process for compliance daily by conducting the morning meetings to ensure daily audits were completed and any identified concerns were addressed. In addition, the Administrator had conducted weekly QAPI Meetings for continued review of audit findings and monitoring the facility's compliance and Immediate Jeopardy removal.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice for one (1) of three (3) sampled residents (Resident #1). Review of Resident #1's Nursing Notes dated 04/08/2020, revealed the resident complained of pain in his/her left foot. The Nurses Notes indicated Tylenol (pain medication) was administered to the resident however, review of the Medication Administration Record (MAR) revealed no documented evidence the medication was given. Continued review of Resident #1's Nursing Notes revealed on 04/10/2020, Resident #1's physician ordered scheduled Tylenol and [MEDICATION NAME] [MEDICATION]) be administered. However, medical record review and staff interviews revealed the resident continued to complain of pain until 04/24/2020, when the facility transferred the resident to the hospital. Resident #1 was diagnosed with [REDACTED]. There was no documented evidence the facility re-assessed the resident's pain or attempted to manage the resident's ongoing complaints of pain when the ordered medication was not effective. The findings include: Review of the facility's policy Pain Management Process, dated October 2015, revealed the facility's goal was to ensure all residents received appropriate pain relief measures to ensure a resident's pain does not affect their ability to function within their designated goals. The policy also stated the facility would meet the resident's goals for pain control by the use of medications and alternative methods to reduce pain. In addition, the policy stated necessary intervention, evaluation, and re-evaluation would be a standard of care practice for licensed nurses. Review of Resident #1's medical record revealed the facility admitted the resident on 01/23/2020 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the staff assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) indicating the resident was cognitively impaired and required extensive assistance of two (2) staff members with transfers, toileting and bed mobility. In addition, staff assessed Resident #1 to have no pain and was not on a scheduled pain medication regimen. Review of a Skin Ulcer/Injury Form dated 04/08/2020 at 5:00 PM, revealed staff assessed Resident #1 to have a red area on top of the left foot, caused by the resident bumping his/her foot. Review of Resident #1's Nursing Notes dated 04/08/2020 at 5:10 PM, revealed the resident's left foot was slightly red, tender to touch, and the resident complained of pain to the area. The nurse documented in the nursing notes that she administered Tylenol 650 mg (milligrams) to Resident #1 which the resident had ordered on an as needed basis. However, review of Resident #1's MARS for 04/08/2020 revealed no documented evidence the nurse administered the medication to Resident #1. Interview with Licensed Practical Nurse (LPN) #3 on 05/20/2020 at 1:50 PM, revealed the LPN stated she administered the resident's Tylenol on 04/08/2020 as indicated in her nurses notes. However, she stated the system has a glitch in it and sometimes it will remove documentation that as needed medication had been administered. Interview with Resident #1's Daughter on 04/30/2020 at 4:15 PM revealed she went to the facility to visit Resident #1 through the window on 04/10/2020. She stated while at the window, Resident #1's roommate (unsampled Resident #8) yelled through the window and asked her if she was aware that Resident #1's leg was hurt and that Resident #1 had been yelling out in pain. The daughter stated that was the first time she had heard about a problem with the resident's lower extremity; she stated the facility had not notified her of any concerns. An interview with Unsampled Resident #8, whom the facility assessed to have a BIMS' score of fourteen (14), indicating the resident was cognitively intact, was conducted on 04/30/2020 at approximately 11:30 AM. The roommate was unaware of what had happened to Resident #1's leg, but stated, I just know it hurt (him/her) really bad. The roommate stated Resident #1 yelled out and moaned in pain, but I couldn't help (him/her). Unsampled Resident #8 stated he/she was glad to see Resident #1's Daughter at the window so I could try and get help for Resident #1. Review of Nursing Notes dated 04/10/2020 at 1:53 PM, revealed Resident #1 was complaining of pain to the left foot/leg. Further review of the Nursing Note revealed staff contacted Resident #1's physician of the assessment and the resident's complaints of pain. Further review revealed the staff requested a scheduled pain medication be ordered, due to the resident's cognitive status and not being alert enough to request pain medication until the pain is out of control. Continued review of Resident #1's Nursing Notes, revealed the resident's physician called the facility on 04/10/2020 at 3:38 PM and ordered the resident to receive scheduled Tylenol (pain reliever) 650 milligrams (mg) three times a day at 7 AM, 1 PM and 7 PM and [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION] medication) 75 mg twice a day at 7 AM and 7 PM. In addition, review of Resident #1's MAR revealed the resident also had a previous order for Tylenol 650 mg four times daily as needed, with the maximum dose of Tylenol not to exceed 3000 mg from all sources daily. Continued review of Resident #1's Medication Administration Record revealed from 04/09/2020 through 04/24/2020 Resident #1 complained of pain on 04/09/2020, 04/10/2020, 04/11/2020, 04/13/2020, 04/17/2020, 04/18/2020, 04/19/2020, 04/20/2020, 04/23/2020, and 04/24/2020, despite receiving the scheduled Tylenol and [MEDICATION NAME]. In addition, the MARS revealed Resident #1 was administered as needed Tylenol, in addition to the scheduled Tylenol and [MEDICATION NAME] on 04/10/2020 at 1:56 PM and 10:20 PM, on 04/16/2020 at 7:23 PM and on 04/22/2020 at 10:45 PM. However, there was no documented evidence found to indicate that the facility ever re-evaluated the resident's on-going pain or notified the physician to obtain a more effective pain management regimen. Review of Physical Therapy Notes for Resident #1, dated 04/14/2020, revealed therapy staff documented Resident #1 complained of pain when attempting to bear weight; and, on 04/15/2020, the resident had significant complaints of left foot pain. On 04/17/2020, the Therapy Notes stated that Resident #1 remained unable to bear weight on the left extremity due to pain. Interview with the Physical Therapist on 05/04/2020 at 2:30 PM, revealed the therapist described Resident #1's lower extremity to be really painful. The therapist stated he notified nursing of the resident's visible signs of pain. Interview with State Registered Nurse Aide (SRNA) #1 on 05/02/2020 at 6:00 PM revealed he cared for Resident #1 during the night shift on 04/23/2020. SRNA #1 stated Resident #1 would exhibit facial grimace and had a lot of pain. SRNA #1 stated the last few times he had cared for Resident #1, the resident required the assistance of two (2) staff due to the amount of pain the resident was experiencing. Interview with SRNA #4 on 05/03/2020 at 2:40 PM revealed Resident #1 would be moaning and complain of pain whether care was being provided or not. The SRNA stated, she reported the resident's complaints of pain to the nurses. Interview with SRNA #2 on 05/03/2020 at 6:35 PM and SRNA #5 on 05/04/2020 at 1:00 PM, revealed both staff stated Resident #1 moaned when the left lower extremity was moved. The staff stated they notified the nursing staff of the resident's complaints of pain when care was provided. Interview with SRNA #3 on 05/04/2020 at 12:20 PM revealed she frequently cared for Resident #1 and stated the resident just hurt, period. SRNA #3 stated anything to do with that leg from the time the bruising started caused Resident #1 to be in pain. Interview with Registered Nurse (RN) #1 at 8:15 AM on 05/05/2020 revealed she was assigned to care for Resident #1 on 04/24/2020. RN #1 stated when she touched the resident's left lower extremity, the resident was yelping in pain. RN #1 stated the resident's leg only hurt if you touched or moved it. Interview with Licensed Practical Nurse (LPN) #2 on 05/20/2020 at 1:15 PM revealed if a resident complained of pain their pain level should be assessed and documented on the MAR and later re-evaluated to ensure that the measures taken were effective to relieve the resident's pain. Interview with LPN #3 on 05/20/2020 at 1:50 PM revealed if a resident complained of pain staff were required to re-evaluate the pain after administering medication or a pain relieving intervention to evaluate effectiveness. However, LPN #3 stated even though staff had informed her that Resident #1 had complained of pain, (unsure of specific dates) she failed to conduct a pain assessment for the resident as required. Interview with Unit Manager (UM) #1 on 05/21/2020 at 12:38 PM revealed staff were required to conduct pain assessments for facility residents once a shift. The UM also stated when Resident #1 voiced complaints of pain, staff should have assessed the resident's pain and documented a follow up assessment to ensure interventions to manage the pain were effective. Interview with the DON on 05/05/2020 at 5:00 PM revealed she expected staff to assess a resident's complaints of pain when voiced and to assess the effectiveness of pain medication that was ordered to ensure its effectiveness. The DON also stated she was not made aware that Resident #1 had ongoing complaints of pain from 04/10/2020 through 04/24/2020. Interview with Physician #1 on 05/05/2020 at 12:50 PM revealed staff had not informed him that Resident #1 had ongoing complaints of pain after he ordered Tylenol and [MEDICATION NAME] to be administered routinely on 04/10/2020. The Physician stated staff should have informed him of Resident #1's ongoing complaints of pain. Review of Hospital records for Resident #1 revealed the resident arrived to the hospital on [DATE] at 12:30 PM and diagnostic tests performed revealed the resident had a critical lower limb schema (restricted blood supply to tissue) and occlusion of the mid left superficial femoral artery distally. Subsequently, on 04/25/2020, Resident #1 underwent amputation of the left lower extremity.

Based on interview, record review, review of the facility's policies, and review of the Administrator's Job Description, it was determined the facility failed to be administered in a manner that enabled its resources to be used effectively to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Immediate Jeopardy (IJ) was identified on 12/19/18 and the facility submitted an Allegation of Compliance (A[NAME]) alleging that the IJ was removed on 12/23/18. Although the facility conducted monitoring as alleged in the A[NAME], the Administrator failed to provide oversight to ensure monitoring was accurately completed in order to identify concerns. Subsequently, the facility failed to identify that Resident #5's admission orders [REDACTED]. The facility's failure to ensure the Administrator used its resources effectively has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/19/18, and determined to exist on 12/10/18 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F658) and 42 CFR 483.45 Pharmacy Services (F760). The facility was notified of the Immediate Jeopardy on 12/19/18. An acceptable Allegation of Compliance was received on 12/27/18, which alleged removal of the Immediate Jeopardy on 12/23/18. A partial extended survey conducted on 01/02/19 through 01/08/19 revealed the Immediate Jeopardy was not removed and further Immediate Jeopardy was identified at 42 CFR 483.70 Administration (F835) and 42 CFR 483.75 Quality Assessment and Performance Improvement (F867). The facility was notified of the Immediate Jeopardy on 01/08/19. The Immediate Jeopardy is ongoing (Refer to F658, F760, F842, and F867). The findings include: Review of the Administrator's Job Description dated 12/12/16, revealed the Administrator's purpose was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to residents at all times. Further review of the policy revealed that the responsibility of the Administrator included facility management, compliance management, facility staffing/retention, and directing committees and meetings. Immediate Jeopardy was identified on 12/19/18, and the facility was notified on 12/19/18. The facility submitted an A[NAME] on 12/27/18, which alleged Immediate Jeopardy was removed as of 12/23/18. The A[NAME] stated the facility would fax resident histories and physicals/discharge summaries, which included treatments, medications, and [DIAGNOSES REDACTED]. Then, upon the resident's admission to the facility, the admitting nurse would make verbal contact with the physician to verify and validate the physician's orders [REDACTED]. 1. Review of Resident #5's medical record revealed the facility admitted the resident on 12/26/18 at 2:30 PM, from an acute care hospital. Review of Resident #5's Hospital Discharge Summary dated 12/26/18, revealed the hospital physician documented several medications which the resident was to continue to receive at the facility. However, review of physician's orders [REDACTED].'s orders [REDACTED]. Further review of the physician's orders [REDACTED]. Interview with the Assistant Director of Nursing (ADON) on 01/07/19 at 12:35 PM, revealed she identified on the morning of 12/27/18, that staff had failed to verify the physician's orders [REDACTED]. In addition, review of facility audits being conducted as part of the A[NAME] revealed no documented evidence that the facility identified that staff failed to follow the A[NAME], and administered medications to Resident #5 without a physician's orders [REDACTED].>2. Review of Resident #2's medical record revealed the facility admitted the resident on 12/21/18, after an acute care hospital stay. Review of a Discharge Summary from the acute care hospital dated 12/21/18, revealed the resident was to continue to receive [MEDICATION NAME] (a diuretic) and Potassium Chloride (a potassium replacement given in conjunction with a diuretic) every other day. However, review of Resident #2's physician's orders [REDACTED]. [REDACTED].#2's [MEDICATION NAME] was transcribed to the MAR indicated [REDACTED]. Review of Resident #2's MARs revealed the MAR indicated [REDACTED]. Review of the A[NAME] audits revealed the DON had audited Resident #2's Admission process and documented that Resident #2's physician's orders [REDACTED]. However, there was no documentation in the audit notes or the QA Meeting Minutes that any concerns with the transcription of Resident #2's medications were identified. Interview with the Administrator, who was also the QA Coordinator, on 01/05/19 at 1:30 PM revealed she routinely led QA meetings and was present in the recent weekly Quality Assurance (QA) Meetings (12/21/18, 12/28/18, and 01/04/19) when the monitoring included in the A[NAME] was discussed. The Administrator stated no problems were discussed related to the monitoring and no changes to the A[NAME] actions plan have been made/implemented.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the medical records for nine (9) of seventeen (17) sampled residents (Resident #1, Resident #2, Resident #3, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #15) were accurate. Review of MARs for Resident #1, Resident #2, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #15 revealed no documentation that staff had administered the residents' medications at 8:00 PM and 9:00 PM. Staff interviews and review of the facility's video surveillance footage revealed the facility administered the residents' medications early (one to two hours), but failed to document that they were administered. However, after the State Survey Agency discovered the medications were not documented, but given early, the facility documented that the medications were administered late. In addition, review of facility video surveillance footage and interviews with staff revealed on 12/28/18, the facility failed to ensure evening medications were administered timely (were one to two hours late) to Resident #1 and Resident #2. However, review of the facility's documentation revealed the medications were administered on time. Observation of medication administration on 01/02/19 and review of Medication Error Reports revealed staff administered 0.5 mg of [MEDICATION NAME] to Resident #3 from 12/28/18 through 01/02/19. However, staff documented that 0.25 mg was administered, as ordered by the resident's physician. In addition, on 01/03/19 staff documented that Resident #3's [MEDICATION NAME] was administered as ordered; however, the medication was not available for administration. The facility's failure to ensure medical records were accurate has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/19/18, and determined to exist on 12/10/18 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F658) and 42 CFR 483.45 Pharmacy Services (F760). The facility was notified of the Immediate Jeopardy on 12/19/18. An acceptable Allegation of Compliance was received on 12/27/18, which alleged removal of the Immediate Jeopardy on 12/23/18. A partial extended survey conducted on 01/02/19 through 01/08/19 revealed the Immediate Jeopardy was not removed and further Immediate Jeopardy was identified at 42 CFR 483.70 Administration (F835) and 42 CFR 483.75 Quality Assessment and Performance Improvement (F867). The facility was notified of the Immediate Jeopardy on 01/08/19. The Immediate Jeopardy is ongoing. The findings include: Review of the facility's Medication Administration General Guidelines Policy dated (MONTH) (YEAR) revealed the individual who administered a medication dose was required to document that the medication was administered on the resident's MAR. The policy stated that in no case should the individual who administered the medications report off-duty without first recording the administration of any medications. 1. Review of MARs for Resident #1, Resident #2, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #15 (who resided on the [NAME] Hall) on 01/02/19 revealed the residents' evening medications for 8:00 PM and 9:00 PM for 01/01/19 were not documented as administered. The medications included: [MEDICATION NAME] (anti-diabetic medication) for Resident #15 and Resident #12; Eliquis (anti-coagulant) for Resident #9 and Resident #10; and [MEDICATION NAME] (used to treat high blood pressure) for Resident #1, Resident #2, Resident #10, and Resident #15. Interview with Licensed Practical Nurse (LPN) #4 on 01/03/19 at 11:41 AM revealed she administered medications to the residents on the [NAME] Hall on 01/01/19, but she did not document that the medications were given because of computer problems. According to LPN #4, the computerized MAR would not permit staff to document that medications were administered unless it was within the timeframe to be given, e.g., one hour before or after the due time. LPN #4 stated she came back to the facility last evening (01/02/19) after the facility staff contacted her, and documented that all medications were administered. According to the LPN, she documented that the medications were administered to the residents late. However, review of the facility's video surveillance footage of the [NAME] Hall for the evening shift on 01/01/19 with the Payroll Clerk revealed LPN #4 entered the [NAME] Hall with the medication cart at approximately 4:15 PM and at approximately 6:15 PM, and at 7:50 PM, the LPN left the [NAME] Hall and did not return, which was approximately one hour and ten minutes to two hours before the residents' 9:00 PM medications were due. An additional interview with LPN #4 was conducted at 4:32 PM on 01/03/19. Although the LPN stated in her previous interview that she documented a late entry that the medications were administered late, during this interview LPN #4 stated she had given the residents' evening medications on 01/01/19 before they were scheduled to be administered. The LPN stated the electronic MAR would not allow her to document that the medications were administered and it was probably because it was too early to give them. Interview with the Director of Nursing (DON) on 01/03/19 at 9:52 AM confirmed that LPN #4 did not document that medications were administered to approximately twenty-one (21) residents on 01/01/19. The DON stated the LPN documented late entries in the residents' medical records that the medications were administered. 2. Review of the facility's video surveillance footage of the [NAME] Hall with the Payroll Clerk on 01/03/19 at 2:20 PM, revealed on 12/28/18 Licensed Practical Nurse (LPN) #4 was observed on the [NAME] Hall at approximately 3:00 PM with the medication cart. At approximately 6:20 PM on 12/28/18, LPN #4 left the [NAME] Hall with the medication cart and was not seen on the hallway again on 12/28/18. The Payroll Clerk confirmed that staff were not observed on the [NAME] Hall again administering medications until 10:10 PM on 12/28/18, when LPN #9 entered the Hallway with a medication cart. Review of the MARs for Resident #1 and Resident #2 revealed LPN #9 documented that she administered medication to the residents at 8:00 PM and 9:00 PM, one to two hours before the LPN was observed passing medication. On 01/07/19 at 2:50 PM and 3:10 PM, and on 01/08/19 at 2:38 PM and 3:39 PM, attempts to reach LPN #9 were unsuccessful. Interview with the Regional Director of Operations on 01/08/19 at 4:52 PM revealed she reviewed the video footage for the evening of 12/28/18 and confirmed that LPN did not administer medications to residents until after 10:00 PM. 3. Observation of Medication Administration on 01/02/19 at 8:15 PM revealed Licensed Practical Nurse (LPN) #8 administered [MEDICATION NAME] 0.5 mg to Resident #3. However, review of the resident's physician's orders [REDACTED]. Review of Resident #3's MAR revealed the facility revised the MAR when the [MEDICATION NAME] dosage was decreased on 12/28/18, and the MAR stated 0.25 mg should be administered to the resident. Further review revealed LPN #8 documented on the MAR that she administered 0.25 mg on 01/02/19 at 8:15 PM, even though observation revealed she administered 0.5 mg. Further review of Resident #3's (MONTH) (YEAR) and (MONTH) 2019 MARs revealed staff had documented that 0.25 mg of [MEDICATION NAME] had been administered to the resident since 12/28/18. However, review of Medication Error Reports revealed LPN #6, LPN #8, and LPN #10 had received verbal disciplinary counseling related to administering the incorrect dose of [MEDICATION NAME] to Resident #3 between 12/28/18 and 01/02/19. Interview with LPN #8 on 01/03/19 at 4:58 PM revealed she did not identify that the resident's order for [MEDICATION NAME] had been changed and she administered the medication that was available, which was 0.5 mg. 4. Observation of Medication Administration on 01/02/19 at 8:15 PM revealed Licensed Practical Nurse (LPN) #8 did not administer [MEDICATION NAME] to Resident #3. The LPN stated the medication was not available. Review of Resident #3's MAR revealed LPN #8 did not document that the medication was administered to the resident on 01/02/19, but documented that the medication was administered on 01/03/19. However, interview with LPN #8 on 01/04/19 at 4:30 PM revealed she did not administer [MEDICATION NAME] on 01/03/19 because Pharmacy did not deliver the medication until 01/04/19 at 4:00 AM. Interview with Registered Nurse (RN) #3 on 01/07/19 at 12:50 PM revealed the label on medication packages should be removed, placed on a reorder sheet, and faxed to the pharmacy before the resident ran out of the medication. The RN stated if the resident had no medication available, staff were required to call the pharmacy and reorder the medication. Interview with LPN #4 on 01/07/19 at 12:18 PM revealed medication packages had a reorder by date and staff tried to reorder medications before or on that date by removing the package label, placing it on a reorder sheet, and faxing the reorder sheet to the pharmacy. Review of the Nursing Monthly Meeting notes dated 08/02/18 revealed nurses were reminded to Sign your meds off as you give them. If you wait to sign out at the end of the med pass then they shoe (show) late, (this can be an IJ) so don't do it, if for any reason you give the med on time but sign it out late you need to do a nurses note stating it was give at the correct time and why it was signed out late! Review of the minutes for the 09/20/18 Nursing Monthly Meeting revealed Red in MAR'S - make sure you sign you MARs-TARs. A lot of Red Again! Interview with the Administrator on 01/08/19 at 3:50 PM revealed she was not aware there was an issue with inaccurate medical records and no action had been taken to address documentation on MARs.

Based on interview, record review, review of facility policies, and review of Kentucky Board of Nursing Advisory Opinion Statements #14, it was determined the facility failed to provide services that met professional standards of quality for twelve (12) of seventeen (17) sampled residents (Resident #1, Resident #2, Resident #3, Resident #5, Resident #6, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #15). On 12/10/18, the facility admitted Resident #1 from his/her home. The Primary Care Provider (PCP) that the patient utilized while living in the community faxed a summary of the patient's condition and a medication list to the facility on [DATE]. The facility failed to identify that the fax contained two pages of medications that had another person's name on them (another patient of the PCP), and failed to identify that the resident did not have [DIAGNOSES REDACTED].#1 at the facility. Registered Nurse (RN) #1 transcribed all the medications from the list, including the medications from the pages that had another patient's name, onto physician orders [REDACTED].#1. The facility administered the medications to Resident #1 on 12/11/18 and/or 12/12/18. Subsequently, Resident #1 received 19 different medications, including anti-psychotic, anti-depressant, diabetic, and [MEDICAL CONDITION] medications that were not required to treat the resident's condition. Resident #1 experienced a change in condition on 12/12/18 and was transferred to the local hospital. The resident's [DIAGNOSES REDACTED]. Review of MARs for Resident #1, Resident #2, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #15 revealed no documentation that staff administered the residents' medications at 8:00 PM and 9:00 PM. Staff interviews and review of the facility's video surveillance footage revealed the facility failed to administer medications timely (one to two hours early) for approximately 21 residents; however, the facility documented that the medications were administered late. In addition, review of the facility's video surveillance footage and interviews with staff revealed on 12/28/18 the facility failed to ensure evening medications were administered on the [NAME] Hall timely. Review of the MARs for residents that resided on the [NAME] Hall revealed staff documented that the residents' medications were administered at 8:00 PM and 9:00 PM timely. However, review of the facility's video footage and staff interviews revealed these medications were one to two hours late (after 10:00 PM). The facility admitted Resident #5 on 12/26/18 from an acute care hospital. The hospital sent discharge instructions for the resident's medications to the facility. The facility transcribed the medications onto physician's orders [REDACTED].#5 on 12/27/18 at 8:00 AM and 12:27 PM. The facility admitted Resident #2 on 12/21/18. The resident had physician's orders [REDACTED]. The facility failed to transcribe the physician's orders [REDACTED]. On 12/22/18, the pharmacy sent Resident #2's [MEDICATION NAME] to the facility with instructions on the label to administer daily, and instructions on the potassium label to administer twice daily. A count of Resident #2's medications on 01/03/19 at 11:00 AM revealed 13 doses of [MEDICATION NAME] and 19 doses of Potassium Chloride had been removed from the resident's medication supply. However, if administered as ordered, only six (6) doses of the medications should have been missing from the resident's medication. Further, on 12/28/18, Resident #3's physician decreased the resident's [MEDICATION NAME] (anti-anxiety medication) from 0.5 milligrams (mg) to 0.25 mg. The facility revised the resident's MAR to reflect the order change and documented that 0.25 mg was administered to the resident from 12/28/18 through 01/02/19. However, observation of medication administration on 01/02/19 and review of Medication Error Reports revealed staff administered 0.5 mg of [MEDICATION NAME] to the resident from 12/28/18 through 01/02/19. Staff documented that ten (10) doses of Resident #8's [MEDICATION NAME] (blood thinner) were unavailable/not administered; however, the pharmacy had delivered the medication to the facility. There was no documented evidence that staff attempted to determine why the medication was not available or obtain the medication. Resident #6 had a physician's orders [REDACTED]. However, the facility failed to transcribe the order for the medication to the resident's MAR accurately and the resident only received Keflex twice daily. The facility's failure to provide services that met professional standards has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/19/18, and determined to exist on 12/10/18 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F658) and 42 CFR 483.45 Pharmacy Services (F760). The facility was notified of the Immediate Jeopardy on 12/19/18. An acceptable Allegation of Compliance was received on 12/27/18, which alleged removal of the Immediate Jeopardy on 12/23/18. A partial extended survey conducted on 01/02/19 through 01/08/19 revealed the Immediate Jeopardy was not removed and further Immediate Jeopardy was identified at 42 CFR 483.70 Administration (F35), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F867). The facility was notified of the Immediate Jeopardy on 01/08/19. The Immediate Jeopardy is ongoing. The findings include: Review of the Kentucky Board of Nursing Advisory Opinion Statement #14 titled Roles of Nurses in the Implementation of Patient Care Orders, editorial revision (MONTH) (YEAR), revealed Nurses are held responsible and accountable for their decisions regarding the receipt and implementation of patient care orders based upon the individuals' educational preparation and clinical competence in nursing .It is the responsibility and the obligation of a nurse to question a patient care order that is deemed inappropriate by a nurse according to his/her educational preparation and clinical experience. In any situation where an order is unclear, or a nurse questions the appropriateness, accuracy, or completeness of an order, the nurse should not implement the order until it is verified for accuracy with the qualified provider. Interview with the Director of Nursing (DON) on 12/18/18 at 5:30 PM and 12/19/18 at 2:25 PM revealed the facility did not have a policy related to transcribing medications or obtaining verbal or phone orders, but had an admission process form. Review of the Admission Process Form in place on 12/10-12/18 revealed the form had a space to add the resident's name, the date, and the nurse completing the form. There were also spaces for the nurse to document with his/her initials that items of the admission process were completed. The admission process items included directions for the nurse to Write OUT Physician orders [REDACTED]. Review of the facility's Medication Administration General Guidelines policy, dated (MONTH) (YEAR), revealed medications would be administered by authorized personnel as prescribed by the physician. The policy also stated that medications would be given in accordance with good nursing principles/practices and authorized personnel would familiarize themselves with a medication before administering it. In addition, the policy stated Medications are administered in accordance with written orders of the prescriber. If any ordered medication appeared to be excessive considering the resident's age and condition, or if a medication order appeared to be unrelated to the resident's [DIAGNOSES REDACTED]. According to the policy, prior to administering a medication, staff should review and confirm the medication order for each individual resident on the MAR and compare the medication and dosage schedule on the resident's MAR with the medication label. The policy stated if the label and MAR were different, and the container was not flagged indicating a change in directions, or if there was any other reason to question the dosage or directions, the prescriber's orders were required to be checked for the correct dosage schedule, and a direction change sticker applied to the label if directions had changed from the current label. Continued review of the Medication Administration Guidelines Policy revealed medications were required to be administered within 60 minutes of the scheduled time, except before or after meal orders, which were administered based on mealtimes. According to the policy, the individual who administered the medication dose was required to record the administration on the resident's MAR immediately following the medication being given. The policy stated that in no case should the individual who administered the medication report off-duty without first recording the administration of any medications. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 12/10/18 from home with [DIAGNOSES REDACTED]. Review of Resident #1's admission orders [REDACTED]. However, review of the fax dated 11/30/18 revealed two pages of the fax contained a medication list that belonged to another patient of the PCP. Further review of Resident #1's MAR revealed on 12/11/18 and/or 12/12/18, the facility administered the resident all the medications that were listed on the fax from the PCP, including the medications that were listed for the other PCP patient, prior to obtaining orders from the resident's attending physician. The medications that were administered to Resident #1 in error were: [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] (used to treat [MEDICAL CONDITION]/[MEDICAL CONDITION] mania), [MEDICATION NAME] (used to treat diabetes), [MEDICATION NAME] (anti-ulcer medication), [MEDICATION NAME] (used to treat functional or irritable bowel syndrome), [MEDICATION NAME] (anti-depressant, anti-anxiety), [MEDICATION NAME] (Iron supplement), [MEDICATION NAME] (used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disease), [MEDICATION NAME] (used to treat diabetes), [MEDICATION NAME] Insulin (used to treat diabetes), [MEDICATION NAME] (anti-psychotic), Trazadone (anti-depressant), Atorvastatin (used to lower cholesterol and triglyceride levels in the blood), [MEDICATION NAME] (used to treat diabetes), [MEDICATION NAME] (used to treat high blood pressure), [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] XL (used to treat high blood pressure and prevent chest pain), [MEDICATION NAME] (used to treat asthma and allergies [REDACTED]. Interview with Registered Nurse (RN) #1 on 12/18/18 at 2:45 PM, revealed she transcribed Resident #1's medications from the fax that the facility received from the PCP to the admission physician orders [REDACTED]. While transcribing the medications, RN #1 stated she did not notice that the fax from the PCP office contained another patient's medication list or that some of the medications were used to treat conditions that Resident #1 did not have. RN #1 stated she entered the medications that were listed on the fax into the facility's computer system as physician orders [REDACTED].#1. RN #1 stated she sent a copy of the orders to the attending physician's office, but she did not contact the physician to obtain verbal/written orders to administer the medications. According to RN #1, she was also caring for Resident #1 on 12/12/18, when Resident #1 had a change in condition. RN #1 stated after speaking with the family about the resident's condition, it was discovered the facility had administered the wrong medications to the resident. Interview on 12/18/18 with Licensed Practical Nurse (LPN) #1 at 3:20 PM, LPN #2 at 11:35 AM, and LPN #3 at 12:12 PM revealed the process when admitting a resident to the facility from home included reviewing the resident's home medication list with the physician. The LPNs stated they would call the physician who was caring for the resident at the facility and review each medication with the attending physician and obtain orders to administer the resident's medications. Interview with Resident #1's Attending Physician on 12/18/18 at 2:25 PM revealed Resident #1 was a new resident/patient and the physician had not cared for the resident previously. The physician stated it was common practice to continue home medications, but he had not reviewed a list of Resident #1's medications and the facility had not contacted him to obtain orders, or to verify that the medications on the medication list could be administered to the resident. Interview with the Administrator on 12/18/18 at 4:40 PM, and the Director of Nursing (DON) on 12/18/18 at 10:22 AM, 12:00 PM, and 5:30 PM, and on 12/19/18 at 12:40 PM and 2:25 PM revealed the previous process for obtaining physician's orders [REDACTED]. Review of Resident #1's History and Physical (H&P) from the hospital admission on 12/12/18 revealed the resident had a history of [REDACTED]. The report stated the patient was reportedly given [MEDICATION NAME], Mentoring, Ypres doses even though (the resident) not on these medications .(The resident's) blood sugar was also noted to be in the low 30s . Further review of the hospital record revealed a discharge summary dated 12/14/18. According to the summary, Resident #1's discharge [DIAGNOSES REDACTED]. The discharge summary mentioned the medications given in error at the facility and that the medications had been stopped. 2. Review of the MARs for Resident #1, Resident #2, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #15 on 01/02/19 revealed the residents' evening medications for 8:00 PM and 9:00 PM for 01/01/19 were not documented as administered. The medications not documented as given included: [MEDICATION NAME] (anti-diabetic medication) for Resident #15 and Resident #12; Eliquis (anti-coagulant) for Resident #9 and Resident #10; and [MEDICATION NAME] (used to treat high blood pressure) for Resident #1, Resident #2, Resident #10, and Resident #15. Interview with LPN #4 on 01/03/19 at 11:41 AM revealed she worked on the evening of 01/01/19 and was responsible for administering the evening medications to residents who resided on the [NAME] Hall. LPN #4 stated that she often had problems with the MAR computer system and that she was unable to document that the residents' medications were given on the evening of 01/01/19. The LPN stated she did not report the computer problem of 01/01/19. Per LPN #4, the computer MAR system would not permit staff to sign medications as administered unless it was within the timeframe to be given, e.g., one hour before or after due time. According to LPN #4, she gave the medications, but forgot to go back and sign the medications in the MAR computer system as given at the end of the shift. The LPN stated the process for giving medications was to pull the medication, check the medication with the MAR, and sign the MAR after the medication was given. LPN #4 stated she came back to the facility last evening after facility staff contacted her, and documented that all medications were administered to the residents on the [NAME] Hall. She stated she added documentation that the medications were administered late. On 01/03/19 at 2:20 PM, video footage of the [NAME] Hall for the evening shift on 01/01/19 was requested from the Administrator. The Administrator had the Payroll Clerk assist with viewing the video footage. According to the Payroll Clerk, the video footage was not accurately dated and time stamped, but it was able to show footage for 01/01/19 beginning at approximately 3:00 PM. The Payroll Clerk was able to identify staff on the video and assisted with viewing the video. Further review of the video footage revealed LPN #4 entered the [NAME] Hall with the medication cart at approximately 4:15 PM. The LPN was on and off the unit several times between 4:15 PM and 5:45 PM and was observed to help nursing assistants pass evening meals to residents on the unit. At approximately 6:15 PM, LPN #4 was observed at the medication cart taking medications out of the cart and going into resident rooms. The LPN left the [NAME] Hall with the medication cart at approximately 7:50 PM. According to the Payroll Clerk, there were no other staff who administer medications visible on the unit until 9:53 PM, when LPN #1 was seen entering the hall with the medication cart. LPN #1 entered a resident's room and later EMS (Emergency Medical Staff) was observed transporting a resident off the unit via stretcher. LPN #1 was observed to start administering medications at approximately 11:00 PM. An additional interview with LPN #4 was conducted at 4:32 PM on 01/03/19. During this interview, LPN #4 stated she had given the residents' evening medications on the [NAME] Hall on 01/01/19, but had given them before they were scheduled to be administered. The LPN stated the electronic MAR would not allow her to document that the medications were administered and it was probably because it was too early to give them. Further interview with the DON on 01/03/19 at 9:52 AM revealed she had talked to LPN #4 on 01/02/19, and the LPN documented late entries that the medications were administered on 01/01/19. The DON stated LPN #4 received written disciplinary action for not documenting that the medications were administered to residents on the [NAME] Wing/Hall for the evening of 01/01/19, which involved approximately 21 residents. Review of the Disciplinary Report for LPN #4 dated 01/03/19 revealed on 01/01/19, the LPN failed to comply with the Standards of Conduct per page 43 of the employee handbook, which included completing all documents and records accurately. The form indicated the LPN was responsible for administering the evening medications for residents on the [NAME] Hall. Continued review revealed, Review of the Medication Administration Records for the evening medications for the unit revealed you did not sign any resident medications off for the PM pass. 3. Review of the facility's video footage for 12/28/18 with the facility's Payroll Clerk revealed LPN #4 was observed on the [NAME] Hall at approximately 3:00 PM with the medication cart. LPN #4 was observed entering and exiting the hallway several times and at approximately 5:12 PM, the LPN was observed passing medications to residents on the [NAME] Hall. At approximately 6:20 PM, LPN #4 left the [NAME] Hall with the medication cart and was not seen on the hallway again on 12/28/18. At 10:10 PM on 12/28/18, LPN #9 was observed entering the [NAME] Hall with the medication cart. The Payroll Clerk confirmed that there was no nurse or Medication Aide on the [NAME] Hall administering medications to residents between 6:20 PM and 10:10 PM on 12/28/18. A review of staff time sheets on 01/08/19, confirmed that LPN #4 worked on 12/28/18 from 7:36 AM until 8:10 PM and LPN #9 worked from 7:07 PM until 8:00 AM. Even though video footage revealed LPN #9 was not on the [NAME] Hall until approximately 10:10 PM, review of the MARs for Resident #1 and Resident #2 revealed LPN #9 documented that she administered medications to the residents at 8:00 PM and 9:00 PM on 12/28/18. Attempts to reach LPN #9 on 01/07/19 at 2:50 PM and 3:10 PM, and on 01/08/19 at 2:38 PM and 3:39 PM, were unsuccessful. Interview with the Regional Director of Operations on 01/08/19 at 4:52 PM revealed the facility had not identified that LPN #9 did not administer medications to Resident #1 or Resident #2 timely. She stated she reviewed the video footage for the evening shift on 12/28/18 and confirmed she did not see anyone administer medications to residents from approximately 6:00 PM to 10:00 PM. The Director stated she saw LPN #9 on the hallway after 10:00 PM giving residents medications. 4. Review of Resident #5's medical record revealed the facility admitted the resident on 12/26/18 at 2:30 PM, from an acute care hospital, with [DIAGNOSES REDACTED]. Review of Resident #5's Hospital Discharge Summary dated 12/26/18, revealed the following medications should be continued: [MEDICATION NAME] every twelve (12) hours (treats irregular heart beat); [MEDICATION NAME] daily (treats constipation); [MEDICATION NAME] every 24 hours (treats blood clots in the legs or lungs); [MEDICATION NAME] every four (4) hours as needed (treats and prevents wheezing and shortness of breath); [MEDICATION NAME] CQ every 24 hours (assists with smoking cessation); [MEDICATION NAME] every four (4) hours as needed (narcotic pain medication); [MEDICATION NAME] daily (treats acid reflux); [MEDICATION NAME] every six (6) hours (treats and prevents ulcers in the intestines); [MEDICATION NAME] twice daily (treats [MEDICAL CONDITIONS] Disorder); [MEDICATION NAME] daily (for diabetes management); [MEDICATION NAME] every night (treats high blood pressure); [MEDICATION NAME] daily (treats mood disorders); [MEDICATION NAME] twice daily (treats high blood pressure and heart failure); [MEDICATION NAME] twice daily as needed (treats high blood pressure); [MEDICATION NAME] every night (treats enlarged prostate); [MEDICATION NAME] on Monday, Wednesday, and Friday (for fluid retention); [MEDICATION NAME] daily ([MEDICAL CONDITION] medication); Multivitamin daily; [MEDICATION NAME] every eight (8) hours as needed (treats nausea, vomiting); [MEDICATION NAME] every night (treats depression and mood disorders); [MEDICATION NAME] daily with breakfast (treats enlarged prostate); and Vitamin D daily (vitamin supplement). A review of physician's orders [REDACTED]. According to a Nurse's Note dated 12/26/18 at 5:07 PM, the facility left a voicemail with the on-call physician with a request to review Resident #5's admission medication orders. Further review of Resident #5's Nurses' Notes dated 12/26/18 at 5:10 PM, revealed the resident's orders were entered into the facility's computer system and the facility was awaiting a return call from the physician. At 2:11 AM on 12/27/18, LPN #9 documented that the resident's medications had been checked in the computer for accuracy; however, the physician had not returned their call for medication verification. Further review of Resident #5's Hospital Discharge Summary revealed on 12/26/18 (no time) two (2) nurses documented that the resident's orders were verified in the computer system and were correct. Continued review of Resident #5's medical record revealed no documented evidence that the facility obtained verbal orders from the resident's physician to administer the medications that were transcribed from the discharge summary until 12/27/18 at 4:38 PM. Review of a Nurse's Note dated 12/27/18 at 4:38 PM, revealed the ADON (Assistant Director of Nursing) contacted the physician and verified Resident #5's physician orders [REDACTED]. Continued review of the Hospital Discharge Summary dated 12/27/18 (no time), revealed the Assistant Director of Nursing documented that the orders were faxed for the second time. However, review of the resident's MAR revealed the facility administered the following medications to Resident #5 on 12/27/18 at 8:00 AM prior to obtaining a physician's orders [REDACTED]. In addition, the facility administered [MEDICATION NAME] at 12:27 PM on 12/27/18. Interview with the ADON on 01/07/19 at 12:35 PM and 3:05 PM, revealed nursing staff were required to contact the resident's physician upon admission to the facility. The ADON stated if the physician could not be reached, staff should notify the Medical Director. She further stated that if the nurse could not reach either physician, staff should notify the DON for further instructions. The ADON stated on the morning of 12/27/18, she discovered that verbal orders to administer Resident #5's medications had not been obtained. Even though the ADON's note stated the physician was contacted at 4:38 PM on 12/27/18, the ADON stated she contacted the physician and verified the resident's medication orders at approximately 8:00 or 8:30 AM. However, interview with Physician #1 on 01/07/19 at 2:40 PM revealed the facility did not contact him regarding physician orders [REDACTED]. 5. Review of Resident #2's medical record revealed the facility admitted the resident on 12/21/18, after an acute care hospital stay for a left humerus (arm) fracture, anxiety, hypertension, and presence of a coronary bypass graft. Review of Resident #2's annual assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 14, indicating the resident was cognitively intact. Review of the Discharge Summary from the acute care hospital dated 12/21/18, revealed the resident was required to continue [MEDICATION NAME] 20 mg every other day and potassium chloride 20 meq packet (the medication is mixed with water, juice, etc. and taken by mouth) every other day. According to the discharge summary, the resident last received [MEDICATION NAME] at the hospital on [DATE]. A review of Resident #2's Physician order [REDACTED]. [REDACTED]. However, review of the resident's MAR revealed the resident's order for [MEDICATION NAME] was transcribed to the MAR to be given every day, not every other day as ordered by the physician. Further review of the MAR revealed the resident's potassium medication was transcribed to the MAR as twice daily, not every other day as ordered by the resident's physician. Review of Resident #2's MARs revealed the MAR was revised due to a new physician's orders [REDACTED]. Observation and interview with Resident #2 on 01/04/19 at 1:01 PM, revealed staff administered the resident's medications daily in a white medication cup. The resident could not recall whether [MEDICATION NAME] was in the medication cup every day, but stated he/she drank the potassium medication daily. Observation of Resident #2's [MEDICATION NAME] medication package on 01/08/19 at 2:45 PM revealed the medication label also had the incorrect prescribing information, and stated the medication should be administered daily, not every other day as it was ordered by the physician. Interview with the facility pharmacist on 01/08/19 at 2:50 PM, revealed the order the facility sent to the pharmacy on 12/21/18, was for [MEDICATION NAME] 20 mg every day, not every other day. Interview with the Pharmacy Director on 01/09/19 at 3:00 PM revealed the facility sent an order to Pharmacy on 12/21/18 that stated Resident #2's potassium should be administered twice daily, not every other day. Subsequently, the pharmacy sent thirty (30) of each of the medications for Resident #2 on 12/22/18, with the incorrect instructions for use. The Pharmacy Director stated on 12/23/18 that the facility sent a new order to change the potassium to every other day; and on 12/25/18, they sent an order for [REDACTED]. According to the Pharmacy Director, the pharmacy did not change the medication labels when the order changed; the facility generated their own MARs. Review of Resident #2's MAR for (MONTH) (YEAR) and (MONTH) 2019 revealed staff documented that six (6) doses of [MEDICATION NAME] and five (5) doses of potassium were administered to the resident from 12/22/18 through 01/03/19. However, on 01/03/19 at 11:00 AM a reconciliation of Resident #2's medications with RN #2 revealed thirteen (13) tablets of [MEDICATION NAME] had been removed from the package of thirty (30) that Pharmacy delivered on 12/22/18, twelve days earlier. Further observation revealed nineteen (19) packets of potassium had been removed from the supply of thirty (30) that were also delivered by the pharmacy on 12/22/18. Interview with RN #2 on 01/04/19 at 11:50 AM revealed she confirmed that Resident #2's medication count was not accurate and stated she could not speak as to what happened with the medication. RN #2 stated she would notify the resident's physician of the incorrect count. Interviews with Kentucky Medication Aide (KMA) #2 on 01/04/19 at 11:13 AM, and Registered Nurse (RN) #1 on 01/04/19 at 11:35 AM, who had documented that they administered medications to Resident #2, revealed they did not recall what medications they administered to the resident. Interview with KMA #1 on 01/04/19 at 3:05 PM revealed she recalled administering medications to Resident #2 and believed she administered [MEDICATION NAME] to the resident daily. Interview with the Director of Nursing (DON) on 01/04/19 at 10:55 AM revealed she was not aware there was a discrepancy in Resident #2's [MEDICATION NAME] and potassium. Interview with Physician #1 on 01/04/19 at 10:40 AM revealed [MEDICATION NAME] was ordered for Resident #2 due to increased [MEDICAL CONDITION] and congestion. The physician stated the resident's symptoms had improved and he had decreased the dosage to every other day prior to admission to the facility. The physician stated if the resident had received too much [MEDICATION NAME], the resident was at risk for dehydration. According to the physician, receiving too much potassium was not really a danger if the resident was receiving the potassium with [MEDICATION NAME]. 6. Review of Resident #3's medical record revealed the facility admitted the resident on 12/05/17. The resident had [DIAGNOSES REDACTED]. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of four (4), indicating the resident was cognitively impaired. Review of Resident #3's physician's orders [REDACTED]. However, observation of the medication administration on 01/02/19 at 8:15 PM for Resident #3 revealed the [MEDICATION NAME] package present in the resident's medication drawer was still labeled with instructions to administer 0.5 mg to the resident. Subsequently, observation revealed Licensed Practical Nurse (LPN) #8 administered Resident #3 [MEDICATION NAME] 0.5 mg, instead of [MEDICATION NAME] 0.25 mg as ordered. Interview with LPN #8 on 01/03/19 revealed she was not aware the resident's order

Based on interview, record review, and review of facility processes, it was determined the facility failed to ensure three (3) of seventeen (17) sampled residents (Resident #1, Resident #6, and Resident #8) were free from significant medication errors. The facility admitted Resident #1 from home on 12/10/18, and utilized a facsimile (fax) provided by the resident's community Primary Care Provider (PCP) to order medication for the resident. However, the fax also included another PCP patient's medication list. Although the other patient's name and identifying information were clearly labeled on the medication list, the facility did not identify that the medications were not Resident #1's, and subsequently the resident was administered nineteen (19) medications in error at the facility on 12/11/18 and 12/12/18. The medications administered in error to Resident #1 included anti-psychotics, anti-depressants, and medications used to treat diabetes and [MEDICAL CONDITION]. The resident experienced a change in condition on 12/12/18 and was transferred to the hospital and diagnosed with [REDACTED]. In addition, the resident was also diagnosed with [REDACTED]. On 12/22/18, Resident #6 was readmitted to the facility with physician orders [REDACTED]. However, the order was transcribed incorrectly to the resident's MAR and subsequently, the resident was administered only twenty (20) doses of Keflex instead of the physician ordered (30) thirty doses of Keflex. On 12/10/18, Resident #8 was readmitted to the facility with orders to receive [MEDICATION NAME] (a blood thinning medication) until 01/03/19, to prevent [MEDICAL CONDITION]. However, the facility failed to administer the medication to Resident #8 on 12/18/18, 12/19/18, 12/20/18, 12/21/18, 12/23/18, 12/24/18, 12/25/18, 12/28/18, 12/29/18, and 12/30/18, resulting in ten (10) doses of missed medication. The facility's failure to ensure residents were free of significant medication errors has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/19/18, and determined to exist on 12/10/18 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F658) and 42 CFR 483.45 Pharmacy Services (F760). The facility was notified of the Immediate Jeopardy on 12/19/18. An acceptable Allegation of Compliance was received on 12/27/18, which alleged removal of the Immediate Jeopardy on 12/23/18. A partial extended survey conducted on 01/02/19 through 01/08/19 revealed the Immediate Jeopardy was not removed and further Immediate Jeopardy was identified at 42 CFR 483.70 Administration (F835) and 42 CFR 483.75 Quality Assessment and Performance Improvement (F867). The facility was notified of the Immediate Jeopardy on 01/08/19. The Immediate Jeopardy is ongoing. The findings include: Interview with the Director of Nursing (DON) on 12/18/18 at 5:30 PM and 12/19/18 at 2:25 PM revealed the facility did not have written policies related to medication errors or the transcription of physician orders. Review of the facility's Medication Administration General Guidelines policy, dated (MONTH) (YEAR), revealed medications would be administered by authorized personnel as prescribed by the physician. The policy also stated that medications would be given in accordance with the manufacturers' specifications and good nursing principles/practices. Further, the policy stated that authorized personnel would familiarize themselves with a medication before administering it. In addition, the policy stated that if any ordered medication appeared to be excessive considering the resident's age and condition, or if a medication order appeared to be unrelated to the resident's [DIAGNOSES REDACTED]. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 12/10/18 with diagnoses of [MEDICAL CONDITION] with Lower Urinary Tract Symptoms, [MEDICAL CONDITION], Dementia, and Essential Hypertension. Further review of the medical record revealed that prior to admission to the facility the resident was residing in a different city than where the facility was located. Therefore, upon admission to the facility, the resident would be utilizing a new primary care provider, and the resident's past medical history was obtained from the resident's previous primary care provider that he/she utilized while living in the community. Continued review of Resident #1's medical record revealed that prior to the resident arriving at the facility on 12/10/18, the facility had obtained a facsimile (fax) from the resident's primary care provider on 11/30/18, which included a summary of the care Resident #1 required and a list of medications prescribed for Resident #1. Subsequently, that list of medications was utilized by facility staff on 12/10/18, to transcribe medications onto a physician's orders [REDACTED].#1. However, review of the fax containing Resident #1's information and medications revealed it also contained five (5) pages of information and medications which were clearly labeled with another patient's name and identifying information. Review of Resident #1's Medication Administration Record (MAR) initiated on 12/10/18, revealed the other patient's medications were also transcribed onto Resident #1's MAR. Further review of Resident #1's MAR initiated on 12/10/18, revealed Resident #1 had been administered nineteen (19) medications on 12/11/18 and 12/12/18 that were not listed on Resident #1's medication list and included medications that the resident had no [DIAGNOSES REDACTED].#1 included [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] (used to treat [MEDICAL CONDITION]/[MEDICAL CONDITION] mania), [MEDICATION NAME] (used to treat diabetes), [MEDICATION NAME] (anti-ulcer medication), [MEDICATION NAME] (used to treat functional or irritable bowel syndrome), [MEDICATION NAME] (anti-depressant, anti-anxiety), [MEDICATION NAME] (Iron supplement), [MEDICATION NAME] (used to treat [MEDICAL CONDITION] and bi-polar disease), [MEDICATION NAME] (used to treat diabetes), [MEDICATION NAME] Insulin (used to treat diabetes), [MEDICATION NAME] (anti-psychotic), Trazadone (anti-depressant), Atorvastatin (used to lower cholesterol and triglyceride levels in the blood), [MEDICATION NAME] (used to treat diabetes), [MEDICATION NAME] (used to treat high blood pressure), [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] XL (to treat high blood pressure and prevent chest pain), [MEDICATION NAME] (used to treat asthma and allergies [REDACTED]. Further review of the physician's orders [REDACTED].#1 dated 12/10/18, revealed facility staff had utilized the faxed list from the PCP, which contained the other patient's medications, to generate physician orders [REDACTED]. However, further review of the Physician order [REDACTED].#1. Review of Resident #1's Baseline Care Plan dated 12/10/18, revealed the facility had assessed the resident to be independent with transfers, walking, and toileting and required setup help only for meals. In addition, the care plan stated the resident was confused at times. Review of a Stop and Watch Form (form used to notify the nurse of a change in a resident's condition) dated 12/12/18 at 1:45 PM, revealed Therapy staff had completed the form because Resident #1 appeared to have experienced a change in condition and seemed different than usual. The form indicated the resident was weak and drowsy. Review of Nurse's Notes for Resident #1 dated 12/12/18 at 5:18 PM, revealed staff documented Resident appearing lethargic and not responding as well. The Note also stated that Resident #1's family was at the resident's bedside stating that Resident #1 was not acting right. Further review of the nursing documentation revealed the resident's blood glucose level was 55 mg/dl (normal level is 80-130). Resident #1's Physician was notified and ordered the staff to administer the resident [MEDICATION NAME] (given to raise blood glucose levels) from the emergency drug box, and to send the resident to the hospital for further evaluation and treatment. Interview with Registered Nurse (RN) #1 on 12/18/18 at 2:45 PM, revealed she was working when Resident #1 was admitted to the facility. RN #1 said the resident was alert with confusion upon admission. The RN stated Resident #1 was admitted from home and the resident's PCP had sent documentation regarding the resident's medical history including mediations the resident had been prescribed prior to being admitted to the facility. RN #1 stated she did not notice that the fax contained another patient's medication list, despite the resident's name and identifying information being clearly visible on the documentation. The RN stated she completed a physician's orders [REDACTED]. However, RN #1 stated she did not speak to the resident's attending physician or take any further action to verify the accuracy of the orders for Resident #1. RN #1 stated she then entered the resident's medications into the facility's electronic system, and faxed the physician's orders [REDACTED]. Continued interview with RN #1 on 12/18/18, at 2:45 PM, revealed she was working on 12/12/18 when Resident #1 experienced a change in condition. The RN stated the resident's family was present at the facility on the afternoon of 12/12/18, and was complaining that the resident was acting different and appeared to be much more drowsy than usual. The RN stated that due to the resident being a new admission to the facility and still unfamiliar to staff, she was asking the family questions regarding the resident's usual condition in an attempt to figure out what might be causing the change in the resident. RN #1 stated it was when the resident's medications were being reviewed with the family that the family stated that Resident #1 was not supposed to be receiving several of the medications that she was listing. Subsequently, RN #1 stated it was discovered that Resident #1 had been administered several wrong medications, and the resident was sent to the hospital for further evaluation and treatment. Interview with Resident #1's Attending Physician on 12/18/18 at 2:25 PM revealed the resident was a new patient for him, and he had not previously cared for the resident. The physician stated the facility had faxed the Physician order [REDACTED].#1 to his office on 12/10/18. However, the physician stated that he had not reviewed the orders or given the facility verification to initiate the orders prior to the resident being administered the medications. During further interview, the physician stated it was usual practice to continue home medications. Further interview with the physician confirmed Resident #1 had received incorrect medications at the facility and was subsequently admitted to the hospital for treatment. Review of Resident #1's hospital record dated 12/12/18, revealed the resident had been admitted to the hospital on [DATE] after being administered several wrong medications at the facility on 12/11/18 and 12/12/18. Further review of the hospital documentation revealed the resident was diagnosed with [REDACTED]. In addition, the resident was also diagnosed with [REDACTED]. Interview with the Administrator on 12/18/18 at 4:40 PM and the Director of Nursing (DON) on 12/18/18 at 10:22 AM, 12:00 PM, and 5:30 PM, and on 12/19/18 at 12:40 PM and 2:25 PM, revealed Resident #1's PCP had faxed another patient's medications to the facility along with Resident #1's medications on 11/30/18, which had resulted in the facility administering the resident several medications in error. Both the Administrator and DON stated the facility initiated an investigation once the medication errors were discovered, but it had not been completed. 2. Review of Resident #6's medical record revealed the facility admitted the resident on 09/20/18, with diagnosed including: [DIAGNOSES REDACTED]. Review of Resident #6's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was cognitively intact. Review of Nurse's Notes for Resident #6 dated 12/22/18 at 4:30 PM, revealed the resident was readmitted to the facility after an acute hospital stay with physician orders [REDACTED]. Review of Resident #6's Medication Administration Record (MAR) dated (MONTH) (YEAR), revealed the order for Keflex was transcribed onto the resident's MAR to be administered twice per day, instead of three (3) times per day as ordered by the physician. Further review of Resident #6's MAR revealed the antibiotic had only been administered to the resident twice daily from 12/23/18 through 01/01/19. Interview with Resident #6 on 01/04/19 at 3:15 PM, revealed the resident recalled he/she had been on antibiotics recently to treat a urinary tract infection, but was unsure how many times a day he/she received the antibiotic. Interview with Licensed Practical Nurse (LPN) #3 on 01/04/19 at 4:00 PM, revealed Resident #6's order for Keflex had been transcribed incorrectly to the resident's MAR, and the resident had received twenty (20) doses of Keflex, instead of thirty (30) doses as ordered. LPN #3 stated she relied on the resident's MAR for administering medications. Review of Resident #6's Nurse's Notes dated 01/06/19, revealed on 01/04/19 at 2:44 PM the resident's physician was contacted regarding the medication error and no further orders were received. Interview with the Director of Nursing (DON) on 01/06/19 at 1:40 PM, revealed she was not aware that Resident #6's Keflex medication had been transcribed incorrectly to the resident's MAR. 3. Review of Federal Food and Drug Administration Guidelines revealed [MEDICATION NAME] was classified as a medication with a narrow therapeutic index, which is defined as a medication that when the dose is adjusted, even in small amounts, may lead to a significant change in blood concentration, which could result in serious therapeutic failures or adverse drug reactions. Review of Resident #8's medical record revealed the facility admitted the resident on 12/10/18, with diagnoses of Unspecified [MEDICAL CONDITION] Hip, Fracture of Right Distal Humerus, Dysphagia, Severe Intellectual Disabilities, Long-Term Use of Anticoagulants, Unspecified Convulsions, and Hypertension. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be severely cognitively impaired. Review of a Hospital Discharge Summary for Resident #8 dated 12/10/18, revealed the resident had surgical repair of a right [MEDICAL CONDITION] on 11/29/18, and was readmitted to the facility on [DATE], with orders to receive [MEDICATION NAME] (a blood thinning medication) until 01/03/19, to prevent [MEDICAL CONDITION]. However, review of Resident #8's MAR for (MONTH) (YEAR) revealed the facility failed to administer the [MEDICATION NAME] to Resident #8 on 12/18/18, 12/19/18, 12/20/18, 12/21/18, 12/23/18, 12/24/18, 12/25/18, 12/28/18, 12/29/18, and 12/30/18, resulting in ten (10) doses of missed medication. Further review of Resident #8's (MONTH) (YEAR) MAR revealed documentation made by Nursing on 12/18/18 and 12/19/18 that the medication was not available to be administered. Documentation on 12/21/18 at 1:05 PM revealed the medication was not administered with no reason cited; and on 12/24/18 and 12/29/18, it was documented that the medication was not administered due to being discontinued. However, review of Resident #8's medical record revealed no documented evidence that the [MEDICATION NAME] medication had been discontinued by Resident #8's physician. Interview with Registered Nurse (RN) #1 on 01/07/19 at 2:45 PM revealed she did not administer Resident #8's [MEDICATION NAME] on 12/18/18, because the medication was not available. The RN stated she could not remember calling the pharmacy to inquire about the medication, but thinks she asked someone about the medication and was told it was coming. Interview with LPN #6 on 01/07/19, at 11:45 AM, revealed she did not administer Resident #8 [MEDICATION NAME] on 12/19/18 and 12/24/18 because it was not available for administration. Interview on 01/06/19 at 1:40 PM and 01/07/19 at 3:45 PM, with the DON revealed she was aware that Resident #8 had not been administered several doses of [MEDICATION NAME] as ordered, but was unaware of why. The DON stated she intended to initiate an investigation of the incident. The DON stated the facility had not conducted any monitoring of medications to ensure accuracy of administration in the last three (3) months. However, the DON stated that the facility's pharmacy also conducted medication administration observations, but she was unable to locate any documentation of monitoring conducted by the pharmacy.

Based on interview, record review, review of facility policy, and review of the Allegation of Compliance submitted on 12/27/18, the facility failed to have an effective system in place to identify quality issues and/or develop and implement an effective plan to correct identified deficiencies through the Quality Assurance Performance Improvement (QAPI) Program. The facility failed to identify quality deficiencies related to significant medications errors, accurate documentation, standards of nursing practice, and other concerns related to resident clinical care. The facility further failed to develop action plans and/or re-evaluate to determine if the problem(s) was resolved. The facility failed to ensure orders were verified with the physician upon admission for Resident #5 as alleged in the Allegation of Compliance (A[NAME]), the facility failed to ensure orders were transcribed accurately for Resident #2, and repeat medications errors with Resident #3. In addition, the facility failed to identify problems with medication administration documentation and other clinical problems in the Quality Assurance Performance Improvement (QAPI) process, implement actions to address the identified concern, and/or follow up on actions implemented. The facility's failure to ensure an effective QAPI Program is in place has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/19/18, and determined to exist on 12/10/18 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F658) and 42 CFR 483.45 Pharmacy Services (F760). The facility was notified of the Immediate Jeopardy on 12/19/18. An acceptable Allegation of Compliance was received on 12/27/18, which alleged removal of the Immediate Jeopardy on 12/23/18. A partial extended survey conducted on 01/02/19 through 01/08/19 revealed the Immediate Jeopardy was not removed and further Immediate Jeopardy was identified at 42 CFR 483.70 Administration (F835) and 42 CFR 483.75 Quality Assessment and Performance Improvement (F867). The facility was notified of the Immediate Jeopardy on 01/08/19. The Immediate Jeopardy is ongoing. Findings include: Review of the facility's Quality Review and QAPI Plan Standard of Practice revealed Standard of Practice: Our Quality Assurance and Performance Improvement Program represents our facility's committee to continuous quality improvement. In addition to the Facility Assessment review, our program ensures an ongoing systematic performance evaluation, problem analysis and implementation of improvement strategies to achieve our quality goals .QAA Meetings: In addition to the QAA Meeting, the facility conducts Quality Reviews daily, weekly and periodically throughout the month. The Interdisciplinary Team (IDT) will report their findings to the QAA Committee for review. The QAA Committee may assign the Quality Assurance and Performance Improvement (QAPI) Sub-Committee(s) to address specify as needed. Quality Review Areas include but are not limited to: Abuse, Behavior and Psychoactive Medication Reviews, Care Plan Meetings, Catheter Use, Census, Changes of Condition, Customer Service, Falls, Grievances, Human Resources/Staffing, Incident and Accidents, Infection Prevention and Control, Antibiotic Stewardship, Memory Care/Dementia Care, Weights, Nutrition, Eternal Nutrition, Dietary Recommendations, Rehospitalization s, Resident Assessment Process/Minimum Data Set, Restorative Care, Restraints, Safety Reviews, Skin/Wound, Survey Activity, Training/Competency, and Work Plan Development .QAPI Plan Follow-up and Oversight: The Facility QAA Committee under the direction of the Administrator is responsible to verify Action Plans and Performance Improvement Plans are in place for areas that require improvement . 1. Interview with the Administrator on 01/05/19 at 1:30 PM revealed QAPI meetings are held monthly and as needed. The Medical Director attends the Quarterly QAPI Meetings. Per the Administrator, she is the Quality Assurance (QA) Coordinator. The Administrator stated the facility identifies problems through resident or staff voiced concerns, and via clinical meetings. The Administrator stated she could not remember or find any problems with medication administration or medication errors in the QAPI minutes for the year of (YEAR). The Administrator stated infection control data was presented in the QAPI Meeting in March, April, and (MONTH) (YEAR) and Fall data was presented in (MONTH) and (MONTH) (YEAR); however, the Administrator was unable to describe how this data was utilized or if there were problems identified/addressed related to the data on infection control and falls. Per the Administrator, the facility did not have other routine monitoring or audits included in the QAPI minutes for (YEAR) except for the falls and infection control data collection. The Administrator was asked to relay a problem the QAPI Committee had identified and she stated that in (MONTH) (YEAR) Therapy had brought up the need to complete an audit of resident wheelchairs with anti-rollback bars to ensure the wheelchairs were functional. The Audit was completed and four (4) chairs were identified as needing repair and two (2) as needing to be removed/not used by residents. The Administrator stated she gave these results to the Maintenance Director. When asked what the Maintenance Director did with the information, the Administrator stated she did not know but assumed he had fixed the chairs. Per the Administrator, the QA minutes did not include a follow-up on this identified concern. Further, the QAPI Committee had identified in (MONTH) (YEAR) that the [MEDICATION NAME] (TB) Screening form was not in place in the resident medical records. The QAPI Committee's action plan was to screen all residents upon admission and annually (not specific as to who was to complete the screening) and to follow up in (MONTH) (YEAR). The Administrator looked at the QAPI Minutes for (MONTH) and there was no mention of the TB screenings follow-up. In addition, per the Administrator, in (MONTH) (YEAR), the QAPI Committee minutes included a problem of intake and outputs not being documented and the system being broken. The Administrator stated the QAPI Committee developed a plan to in-service night shift nurses between 08/15/18 and 08/31/18 and to monitor on a daily basis. The Administrator stated the person(s) responsible for monitoring was not listed and there was no follow-up listed in the minutes for this identified problem. The Quality Review Areas (e.g., Catheter Use, Abuse, Changes in Condition, Restraints, etc.) listed in the Facility Standard of Practice noted above were not reviewed in the QAPI (YEAR) Meetings, per interview with the Administrator. 2. Interview with the DON on 01/08/19 at 3:00 PM revealed the only training in the past year she could find on medication administration was documented in the monthly nurse's meeting. The DON provided notes from three monthly meetings dated 08/02/18, 09/20/18, and 10/11/18. Review of the Nursing Monthly Meeting notes revealed on 08/02/18 under Documentation nurses were reminded to Sign your meds off as you give them. If you wait to sign out at the end of the med pass then they shoe (show) late, (this can be an IJ) so don't do it, if for any reason you give the med on time but sign it out late you need to do a nurses note stating it was give at the correct time and why it was signed out late!. The minutes for the 09/20/18 meeting included Red in MAR'S - make sure you sign you MARs-TARs. A lot of Red Again! The 10/11/18 meeting was on Drug Regimen Reviews. Interview with the Administrator on 01/08/19 at 3:50 PM revealed she did not remember the problems identified in the (MONTH) (YEAR) or (MONTH) (YEAR) nursing meetings being brought to any QAPI meeting. The Administrator stated the facility would have had an extra meeting to discuss the problems if these problems had been brought to QA. The Administrator stated that before being told today by the Assistant Director of Nursing, she was not aware that the nurse competency skills checklists (including nurse competencies in administering medications) were not being completed per the facility assessment plan. 3. Review of the Allegation of Compliance (A[NAME]) received on 12/27/18 which alleged compliance as of 12/23/18 revealed an update was added on 12/19/18 by the DON which added the following process: The process is as follows: The facility will fax H&P/Discharge summary which includes treatments, medication and [DIAGNOSES REDACTED]. Then upon admission, the admitting nurse will call the physician to verify and validate orders that were faxed which include verification of treatments, medications, and diagnosis. (a) Review of Resident #5's medical record revealed the facility admitted the resident on 12/26/18 at 2:30 PM, from an acute care hospital. Review of Resident #5's Hospital Discharge Summary dated 12/26/18, revealed the hospital physician documented several medications that should be continued for Resident #5. A review of physician orders [REDACTED]. Although the nurse's notes for 12/26/18 at 5:07 PM revealed staff attempted to reach the physician to verify Resident #5's orders, the orders were not verified until the next day, 12/27/18, which was in conflict with the A[NAME] that stated order verification/validation would be completed upon admission. Review of the A[NAME] information revealed no mention of this concern in the monitoring notes. The audit for checking order verification was checked as completed with no concern documented. (b) Review of Resident #2's medical record revealed the facility admitted the resident on 12/21/18, after an acute care hospital stay. Review of the Discharge Summary from the acute care hospital dated 12/21/18 revealed the resident was required to continue [MEDICATION NAME] 20 mg tablet (commonly known as [MEDICATION NAME], a diuretic) every other day and potassium chloride 20 milliequivalents (meq) packet (a potassium replacement given with a diuretic). A review of Resident #2's Physician order [REDACTED]. [REDACTED]. However, a review of the resident's Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Further review of Resident #2's MARs revealed the MAR indicated [REDACTED]. Review of the A[NAME] audits revealed the DON had audited Resident #2's admission process and that the resident's physician's orders [REDACTED].#2's medications being transcribed incorrectly to the MAR. 4. Review of Resident #3's medical record revealed the facility admitted the resident on 12/05/17. Review of Resident #3's physician's orders [REDACTED]. However, during observation of medication administration on 01/02/19 at 8:15 PM for Resident #3, the [MEDICATION NAME] package present in the resident's medication drawer was still labeled with instructions to administer 0.5 mg to the resident. Subsequently, observation revealed that Licensed Practical Nurse (LPN) #8 administered Resident #3 [MEDICATION NAME] 0.5 mg instead of [MEDICATION NAME] 0.25 mg as ordered. Interview with the Director of Nursing (DON) on 01/03/19 at 12:55 PM revealed she initiated an investigation on 01/03/19 and determined that staff had administered 0.5 mg of [MEDICATION NAME] since the order changed on 12/28/18, and not the newly prescribed dose of 0.25 mg. The DON stated she would be completing Medication Error Reports on the nurses who gave this medication at the incorrect dose. Review of the QAPI Meeting Minutes for 01/04/19 revealed the notes included the A[NAME]/follow-up survey and that concerns were identified regarding holes in the EMAR/TAR. However, the notes did not mention the medication errors with Resident #3's [MEDICATION NAME].