Every finding on record at Middleton Village Nursing and Rehab

Number of residents sampled:5Number of residents cited:5Based on observation, interview, and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect all residents who resident at the facility. Residents (R45, R18, R76, R15, R65, R3, R58, R74, R34, R54) on 5 of 5 hallways voiced concerns regarding food temperatures and palatability of food served. Surveyor received a test tray, and hot foods were served cold. Evidenced by: The facility policy, Food Preparation and Service, dated 7/14, states, in part;.Food service employees shall prepare and serve food in a manner that complies with safe food handling practices.3. The temperature of foods held in steam tables will be monitored by food service staff. Example 1: On 3/3/26 at 9:50 AM, R45 indicated she eats her meals in her bedroom and hot foods are served cold. R45 indicated she will ask for other items on the menu but does not always get what she has ordered. At 12:45 PM, Surveyor followed back up with R45 to see how her lunch was. R45 indicated the pork chop was cold and difficult to eat. Example 2: On 3/3/26 at 12:21 PM, Surveyor received a lunch test tray. The Pork chop temped at 120 F (Fahrenheit), rice at 123.9 F, and spinach at 128 F. The pork chop was chewy and not palatable. Example 3: On 3/3/26 at 12:03 PM, surveyor interviewed R18 about how the food is in the facility. R18 stated that the food is cold all the time. Example 4: On 3/3/26 at 9:24 AM, Surveyor interviewed R76 asked how the food is in the facility. R76 reported everything is cold. The food comes down on big trays and sits in hallway. Very rare that you get something hot. Example 5: On 3/3/26 at 1:45 PM, Surveyor interviewed R15 about the food in the facility. R15 states the food is terrible; cold sometimes, not palatable at all. Example 6: On 3/3/26 at 9:24 AM. Surveyor interviewed R65 about how the food is in the facility. R65 states sometimes the food is cold. Not good at all. Example 7 On 3/3/26 at 12:24 PM, Surveyor interviewed R3 regarding his meals. R3 indicated the meat the facility provides is tough to chew and the food is often cold. Example 8 On 3/3/26 at 10:40 AM, Surveyor interviewed R58 regarding her meals. R58 stated the food is never at the right temperature. R58 stated the food is served cold and the portions are small. R58 stated the meat is too tough to eat. Example 9 On 3/4/26 at 8:30 AM, Surveyor interviewed R74 regarding meals. R74 stated he eats in his room. R74 stated the food is bland and cold. Example10 On 3/4/26 at 9:43 AM, Surveyor interviewed R34. R34 stated the food she receives arrives cold, particularly in the morning. R34 also noted the plates are ice cold when they arrive. Example 11 On 3/3/26 at 9:40 AM, Surveyor interviewed R54. R54 stated the food at the facility tastes terrible. On 3/3/26 at 1:51 PM, DM Q (Dietary Manager) indicated hot foods should be served hot and cold foods served cold. DM Q indicated understanding of the above concern. On 3/326 at 4:09 PM, NHA A (Nursing Home Administrator) indicated hot foods should be served hot and cold foods served cold. NHA A indicated understanding of the above concern. The facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature.]

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 73 residents who reside in the facility.Surveyor observed dietary aide directly touching food with dirty gloves.Evidenced by:The facility policy, Food Preparation and Service, 7/14, states, in part.Food service employees shall prepare and serve food in a manner that complies with safe food handling practices.5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food borne illness.6. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use.On 3/3/26 at 12:06 PM, Surveyor was observing staff plate food for lunch. Surveyor observed DA W (Dietary Aide) wash hands, put on gloves, touch the counter, lunch tickets and the tray cart, and then directly touch the pork chops while wearing the same gloves. DA W indicated you should have clean gloves on when handling food.On 3/3/26 at 1:57 PM, DM Q (Dietary Manager) indicated staff should use tongs or clean gloves when handling food. DM Q indicated staff should wash hands, put a clean pair of gloves on, and then directly handle food. At 2:48 PM, DM Q indicated staff were educated and an in-service was provided to all staff regarding safe food handling.On 3/3/26 at 4:09 PM, NHA A (Nursing Home Administrator) indicated understanding of the above concern.The facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed.

Based on interview and record review, the facility did not ensure the facility wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 73 residents residing in the facility.The facility assessment does not include information on staffing levels needed for specific shifts.This is evidenced by:Surveyor requested a facility assessment policy; however, staff reported to Surveyor that the facility does not have a facility assessment policy.Surveyor reviewed the facility assessment, last updated 2/26/26, as part of a resident investigation. Surveyor found that the facility assessment does not contain information on staffing levels needed for specific shifts.The facility assessment states, in part: .PurposeThe purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility.The intent of the facility is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require.Staffing plan.*This is building specific. The facility uses the staffing ladders method to ensure appropriate staffing is being followed per mandatory federal regulation.Example 1. Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs. Enter number of staff needed or an average or range.Direct care staffDirect care staff is calculated based upon acuity of resident needs and ADL (Activities of Daily Living) index scores; flexibility is allowed due to the nature of admissions and discharges for short term and long term care resident needs reflected in the activities of daily living index reflected on the MDS (Minimum Data Set). Staffing is adjusted based upon resident clinical needs.Licensed Nurses, LPN (Licensed Practical Nurse), and RN (Registered Nurse).*Of note: staffing levels needed for specific shifts are not indicated.On 3/5/26 at 2:52 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A what is the yearly workflow process for facility assessments. NHA A indicates facility assessment reviews occur yearly with additional reviews conducted more frequently for needed changes. NHA A also indicates concerns or changes can be identified by any staff member. These concerns are then brought to the IDT (Interdisciplinary Team) for review and to make changes to the facility assessment. Surveyor asked NHA A which staff members are involved in the facility assessment review process. NHA A indicates the IDT and any staff member who identifies a need. Surveyor asked NHA A if facility staffing levels for each shift should be included in the facility assessment. NHA A indicates she needs to review her policies and procedures and will let the Surveyor know.Of note: The listed names for review include NHA A, DON B (Director of Nursing), a Governing Body Representative from the facility's corporate organization, and the facility Medical Director. Additionally, NHA A did not further respond to the question if staffing levels for each shift should be included on the facility assessment.

Based on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 5 of 23 sampled Residents (R3, R14, R29, R48, and R58). R3 refuses his showers because the showers are too cold. R58 has not showered in 3 months because the shower does not have hot water. R29 did not receive all showers as scheduled. R14 did not receive all showers as scheduled. R48 did not receive all showers as scheduled and has not been shaved. This is evidenced by: The facility's policy Activities of Daily Living (ADLs), dated 5/7/20, includes: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, our facility provides necessary care and services to ensure that a resident's activities of daily living. In accordance with the comprehensive assessment, together with respect for individual resident needs and choices our facility provides care and services for the following activities: *Hygiene: Bathing, dressing, grooming and oral care *Mobility: Transfer and ambulation, including walking *Elimination: Toileting *Dining: Eating, including meals and snacks. Monitor and evaluate the resident's response to care plan interventions and treatment. On 3/3/26 at 12:40 PM, CNA V (Certified Nursing Assistant) indicated the water temps in the shower rooms have been an issue for a few weeks. CNA V indicated it has been reported to maintenance. Example 1 R3 admitted to the facility on [DATE] with diagnoses including morbid obesity, limitation of activities due to disability, unspecified fall, reduced mobility, and muscle weakness. R3's Brief Interview for Mental Status (BIMS), on 12/15/25, has a score of 15, indicating R3 is cognitively intact. On 3/3/26 at 12:24 PM, Surveyor interviewed R3 regarding his showers. R3 stated he is supposed to get a shower twice a week. R3 stated he looks forward to his showers. R3 stated sometimes they (the facility) run out of hot water then he has to refuse the shower. R3's shower schedule is twice a week on day shift, Tuesdays and Fridays. R3's February CNA documentation for showers indicate R3 did not receive a shower in the month of February. R3 did receive a bed bath on 2/10/26. Example 2 R58 admitted to the facility on [DATE] with diagnoses including diabetes type 2 and arthritis. R58's BIMS, on 2/19/26, has a score of 14, indicating R58 is cognitively intact. On 3/3/26 at 10:40 AM, Surveyor interviewed R58. R58 indicated she has not had a shower in at least 3 months because they (the facility staff) tell me there is no hot water and then ask if I want a shower. R58 stated she refuses her showers because there is no hot water and R58 does not want to shower in cold water. R58's shower schedule is twice a week on the evening shift, Wednesdays and Saturdays. R58's February CNA documentation for showers indicate R58 did not receive a shower in the month of February. R58 did receive 3 bed baths in the month February on 2/4/26, 2/25/26, and 2/28/26. Example 3 On 3/3/26 at 12:35 PM, HN X (Hospice Nurse) indicated the water in the shower rooms are cold and that it's been going on for a few weeks now. HN X indicated she just assisted R29 with a shower and she screamed. On 3/3/26 at 12:45 PM, R29 indicated her shower was cold. R29's showers are scheduled on Sunday and Thursday AM (day shift). Documentation shows the following: Sunday dates for the past month are: 2/1/26, 2/8/26, 2/15/26, 2/22/26, and 3/1/26. Thursday dates for the past month are: 2/5/26, 2/12/26, 2/19/26, and 2/26/26. Bed baths were documented on: 2/5/26, 2/8/26, 2/12/26, 2/15/26, 2/22/26, 2/26/26, and 3/1/26. NA (not applicable) was documented on: 2/19/26. No shower/bath documentation for: 2/1/26 and 2/19/26. Example 4 On 3/5/26 at 10:48 AM, Surveyor interviewed R14. Surveyor asked R14 when you have a bed bath, does your hair get washed; R14 said yes. Surveyor asked R14 how they wash his hair, R14 said with washcloths. Surveyor asked R14 if nail care is completed with shower/bath(s), R14 replied usually. R14's showers are scheduled on Tuesday and Friday AM. Documentation shows the following: Tuesday dates for past month: 2/3/26, 2/10/26, 2/17/26, 2/24/26, and 3/3/26. Friday dates for past month: 2/6/26, 2/13/26, 2/20/26, and 2/27/26. Bed baths documented on: 2/13/26, 2/20/26, 2/24/26, and 2/27/26. NA (not applicable) was documented- 2/10/26. No shower/bath documentation for: 2/3/26, 2/6/26, 2/10/26, 2/17/26, and 3/3/26. Example 5 R48's showers are scheduled on Monday AM and Thursday PM. Monday dates for past month: 2/2/26, 2/9/26, 2/16/26, 2/23/26, and 3/2/26. Thursday dates for past month: 2/5/26, 2/12/26, 2/19/26, and 2/26/26. Bed baths documented on: 2/3/26, 2/12/26, 2/16/26, 2/23/26, and 2/26/26. Resident refusal documented- 2/7/26, 2/10/26, and 2/19/26. No shower/bath documentation for: 2/2/26, 2/9/26, and 3/2/26. On 3/5/26 at 8:57 AM, Surveyor interviewed R48. It is important to note that R48 continues to have long, approximately 0.5-inch-long facial hair still present to her chin. Surveyor asked R48 if she wanted to shower or if the bed bath was ok, R48 replied that she used to go to the shower but hasn't in a long time they do a bed bath which is OK, but they don't wash her hair. Surveyor asked R48 in the past when she received bed baths, how did they wash her hair; R48 stated they used to have those netting-like caps, but they haven't had them in a long while; I would just like to feel clean, and I don't. On 3/4/26 at 2:20 PM, Surveyor interviewed CNA D (Certified Nursing Assistant) regarding the shower room water temperature. CNA D indicated that the water is too cold to give residents a shower. CNA D stated the water temperature has been too cold for at least 3 weeks. CNA D indicated staff may offer a bed bath if the resident does not want to shower. On 3/4/26 at 2:59 PM, Surveyor interviewed DON B (Directory of Nursing) regarding showers and ADLs. DON B indicated she was not aware residents were refusing showers because of cold water. DON B indicated staff should notify DON B when residents do not receive a shower. DON B indicated shaving and nail care is part of ADLs and staff should be offering and providing those services to residents as that is part of the ADL routine. On 3/5/26 at 10:51 AM, Surveyor interviewed CNA N (Certified Nursing Assistant). Surveyor asked CNA N if a shower/bath were documented as NA in the computer, what does that mean or what would be the reason someone would have their shower/bath marked like that, CNA N indicated she does not know why you would document as NA. Surveyor asked CNA N if a bed bath is given, does the resident's hair get washed, CNA N said yes if they want it washed. Surveyor asked CNA N how they wash someone's hair when a bed bath is given; CNA N said they could take them to the beauty shop but not many do that, they used to have caps to wash, or they wash their hair with washcloths.

Based on observation, interview, and record review, the facility did not ensure each resident had the right to a safe, clean, comfortable, and homelike environment for 3 of 3 shower rooms, in use, affecting a pattern of residents who use the shower rooms and 3 (R3, R51, and R58) of 23 sampled residents. R3 refuses his showers because the showers are too cold.R51 stated the shower is cold.R58 has not showered in 3 months because the shower does not have hot water.The water temperature in 3 shower rooms that are in use, did not have adequate hot water.This is evidenced by:The facility policy Water Temperatures, Safety of, dated 12/09, includes: Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperature in a safety log.Example 1R3 admitted to the facility on [DATE] with diagnoses including morbid obesity, limitation of activities due to disability, unspecified fall, reduced mobility, and muscle weakness. R3's Brief Interview for Mental Status (BIMS) on 12/15/25 has a score of 15, indicating R3 is cognitively intact.On 3/3/26 at 12:24 PM, Surveyor interviewed R3 regarding his showers. R3 stated he is supposed to get a shower twice a week. R3 stated sometimes they (the facility) run out of hot water then he has to refuse the shower.Example 2R51 admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a chronic autoimmune disease that disrupts the signal transmission between the brain and spinal cord) and need for assistance with personal care.R51's Brief Interview for Mental Status (BIMS) on 1/2/26 has a score of 12, indicating R51 has cognitive impairment.On 3/3/26 at 9:34 AM, Surveyor interviewed R51. R51 stated when she takes a shower it is on the colder side. R51 stated the water gets colder later in the day and prefers her showers in the morning. R51 stated by the end of the shower when she is getting rinsed off, she has to grit my teeth because the water is cold.Example 3R58 admitted to the facility on [DATE] with diagnoses including diabetes type 2 and arthritis.R58's Brief Interview for Mental Status (BIMS) on 2/19/26 has a score of 14, indicating R58 is cognitively intact.On 3/3/26 at 10:40 AM, Surveyor interviewed R58. R58 indicated she has not had a shower in at least 3 months because they (the facility staff) tell me there is no hot water and then ask if I want a shower. R58 stated she refuses her showers because there is no hot water and does not want to shower in cold water.Example 4 The facility provided Surveyor with Grievance forms related to the cold-water temperature in the shower rooms.On 2/10/26, a grievance was filed. The concern on the grievance form states: .several resident/staff complaints about water in shower room being cold. The resolution states, hot water heater temping appropriate at site of heater. Maintenance aware of ongoing concern and continue to remedy situation.On 3/5/26 at 9:01 AM, Surveyor interviewed MT C (Maintenance). MT C indicated he does water temperature checks in resident rooms. MT C stated he does not check the water temperature in the shower rooms. MT C indicated when he checks the water temperature in the resident rooms, he is looking for at least 100 degrees Fahrenheit.MT C provided surveyor with the temperature logs obtained from resident rooms. On 1/9/26, MT C obtained water temperatures from a sample of resident rooms on each hallway. A total of 15 rooms were sampled. The water temperature ranged from 108.4 - 113.6 degrees Fahrenheit. On 1/16/26, MT C obtained water temperatures from a sample of resident rooms on each hallway. A total of 15 rooms were sampled. The water temperature ranged from 108.6 - 115.2 degrees Fahrenheit. On 1/23/26, MT C obtained water temperatures from a sample of resident rooms on each hallway. A total of 15 rooms were sampled. The water temperature ranged from 80.2 - 111.6 degrees Fahrenheit.On 1/26/26, MT C obtained water temperatures from a sample of resident rooms on each hallway. A total of 15 rooms were sampled. The water temperature ranged from 87.8 - 93 degrees Fahrenheit. On 2/3/26, MT C obtained water temperatures from a sample of resident rooms on each hallway. A total of 15 rooms were sampled. The water temperature ranged from 91.2 - 98.7 degrees Fahrenheit. On 2/12/26, MT C obtained water temperatures from a sample of resident rooms on each hallway. A total of 15 rooms were sampled. The water temperature ranged from 89.8 - 110.5 degrees Fahrenheit. On 2/20/26, MT C obtained water temperatures from a sample of resident rooms on each hallway. A total of 15 rooms were sampled. The water temperature ranged from 71.7 - 83.1 degrees Fahrenheit. On 2/27/26, MT C obtained water temperatures from a sample of resident rooms on each hallway. A total of 15 rooms were sampled. The water temperature ranged from 92.3 - 102.6 degrees Fahrenheit. On 3/4/36 at 1:07 PM, Surveyor observed the water temperature in the shower room on hallway 4. Surveyor turned the shower on full hot water. After 5 minutes, the water temperature was 91.2 degrees Fahrenheit. On 3/4/36 at 1:13 PM, Surveyor observed the water temperature in the shower room on hallway 3. Surveyor turned the shower on full hot water. After 5 minutes, the water temperature was 78.9 degrees Fahrenheit. On 3/4/36 at 1:20 PM, Surveyor observed the water temperature in the shower room on hallway 2. Surveyor turned the shower on full hot water. After 5 minutes, the water temperature was 84.3 degrees Fahrenheit. While taking the temperature, Surveyor noted the water temperature felt colder. The water temperature was fluctuating down to 78.9. On 3/5/26 at 9:01 AM, Surveyor interviewed MT C. MT C indicated he contacted two plumbers. MT C provided an email he sent to one plumber. The email was dated 2/23/26 at 8:08 AM. Email subject line: Estimate for mixing valve. Body of the email: Hello, we have not had adequate hot water in our facility for several weeks and think this must be the issue. The plumber came out on 2/24/26 and gave an estimate for a mixing valve replacement. A different plumbing service came out on 3/3/36 for another estimate.On 3/4/26 at 2:20 PM, Surveyor interviewed CNA D (Certified Nursing Assistant) regarding the shower room water temperature. CNA D indicated that the water is too cold to give residents a shower. CNA D stated the water temperature has been too cold for at least 3 weeks.On 3/4/26 at 3:08 PM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A indicated she became aware of the cold-water temperature in the shower rooms on 2/5/26. NHA A indicated MT C was adjusting water temperatures and the facility received another concern from residents and staff that the water was still cold. NHA A stated they have had two plumbers come to the facility and give estimates, but the facility is trying to figure out what needs to be fixed before moving on with a plumber.

Based on observation, interview, and record review the facility did not ensure drugs and biologicals are labeled in accordance with currently accepted professional standards for 3 of 3 out of 5 medication carts reviewed for medication storage.The Harbor Hall medication cart had an undated open insulin pen for R36. Additionally, Surveyor located a box of 3 warm, undated GLP-1 pens without a resident label fixed to the box or the pens.The St. [NAME] Hall medication cart had an illegible date on R67 inhaler.The Depot Hall medication cart had an open and undated ophthalmic solution (eye drops) for R62. Additionally, there was an undated, open insulin pen for R19 and an open, undated inhaler for R17.As evidenced by:The facility policy entitled, Storage of Medications, dated 4/2007, states, in part: Policy StatementThe facility shall store all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation.3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing.4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location.Example 1:On 3/3/26 at 10:19 AM, Surveyor observed the Harbor Hall medication cart with RN P (Registered Nurse). Surveyor found a Humalog 100 insulin pen with no open date, belonging to R36. In the bottom, right drawer, Surveyor found a box of 3 Mounjaro (GLP-1 medication) pens. The box and the pens did not contain resident identifiers. The box and pens were also warm to the touch.Of note: According to the Food and Drug Administration Medication Guide, Mounjaro single-patient single-dose and multi-dose pens should be stored in the refrigerator between 36 F to 46 F or at room temperature. Single-dose pens should only be kept at room temperature for up to 21 days. Multi-dose pens should only be kept at room temperature for up to 30 days. Source: https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/215866s009lbl.pdf#page=25Example 2:On 3/3/26 at 10:34 AM, Surveyor observed the St. [NAME] medication cart with RN P (Registered Nurse). Surveyor found an inhaler in a box labeled Breya (medication that opens airways to help with breathing) belonging to R67. The inhaler had an illegible open date written on the inhaler.On 3/3/26 at 10:46 AM, Surveyor interviewed RN P. Surveyor asked RN P if she could read the open date written on the inhaler. RN P states, no.Example 3:On 3/3/26 at 11:17 AM, Surveyor observed the Depot Hall medication cart with ADON O (Assistant Director of Nursing). Surveyor found a ketorolac ophthalmic solution (Anti-inflammatory and pain medication eye drops) belonging to R62 with no open date. Surveyor also found an Advair inhaler (reduces airway inflammation and relaxes airway muscles) belonging to R17 with no open date. Additionally, Surveyor found an Lispro insulin pen belonging to R19 with no open date.(Of note: Advair should be used within 30 days after opening the foil pouch or protective packaging due to the medication begins to degrade due to exposure to air and moisture.)On 3/3/26 at 11:20 AM, Surveyor interviewed ADON O. Surveyor asked ADON if medications such as ophthalmic solutions, inhalers, and insulin pens should be labeled with an open date. ADON O indicates, yes, everything should be dated.On 3/3/26 at 4:16 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if there is a process or procedure for checking medication carts for things like expired or unused medications. DON B indicates the facility does routine medication cart audits and they use a first-in first-out system for rotation. DON B also expects staff to check dates while administering medications, and medications should be removed from the cart if they are expired. Surveyor asked DON B what the expectation is for staff who identify medications or insulin that is unlabeled or have no open dates. DON B indicates she would expect these medications to be labeled with an open date if they are open. Surveyor asked DON B if inhalant medications should have an open date. DON B indicates she would expect these medications to be labeled with an open date if they are open. Surveyor asked DON B if ophthalmic solutions should have an open date. DON B indicates she would expect these medications to be labeled with an open date if they are open. Surveyor asked DON B if open dates should be legible. DON B indicates, yes, however legibility is subjective.

Based on interview and record review, the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 1 resident (R11) reviewed for hospice.R11's current hospice plan of care and visit notes were not available to facility staff.As evidenced by:R11 was administered to the facility on 2/13/25 with diagnoses including end stage renal disease (kidney failure in which the kidney's no longer function well enough to sustain life), type 2 diabetes mellitus, infection and inflammatory reaction due to indwelling urethral catheter, obstructive and reflux uropathy (urine flow is blocked and backs up into the kidneys), and retention of urine.R11's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 12/22/25 indicates a Brief Interview for Mental Status score of 10 out of 15, indicating R11 has a moderate cognitive impairment. Section H indicates R11 has an indwelling catheter. Section O indicates R11 is receiving hospice care.R11's Physician Orders include:[Organization Name] hospice services in place d/t (due to) diagnosis of End Stage Renal Disease. Start date: 2/14/25. Active order.R11's Comprehensive Care Plan indicates:Focus: R11 has a terminal/end stage prognosis r/t (related to) dx (diagnosis) of end stage renal disease. Date initiated: 3/28/25.Interventions:Hospice and facility will coordinate plans of care to manage symptoms such as nausea, agitation, pain, uncomfortable breathing, pressure ulcer prevention interventions, nutrition and hydration needs, and psychosocial interventions. Date initiated: 3/28/25.Hospice case manager will collaborate with wound care nurse r/t (related to) skin integrity issues. Date initiated: 3/28/25.Notify [Organization Name] hospice of changes in condition. Date initiated: 3/28/25.Resident will be communicated with by the hospice case manager for routine updates. Facility will contact Hospice as needed. Date initiated: 3/28/25.Encourage R11 to express feelings, listen with non-judgmental acceptance, compassion. Date initiated: 3/28/25.Encourage support system of family and friends. Date initiated: 3/28/25.On 3/4/26, Surveyor reviewed the facility hospice binders. No hospice binder was able to be located for R11. Surveyor also reviewed the facility's electronic medical record and did not find any hospice notes. On 3/4/26, Surveyor requested all R11's hospice notes. The facility provided hospice notes printed off an outside electronic medical record. The date printed is indicated to be 3/4/26.On 3/5/36 at 9:37 AM, Surveyor interviewed RN F (Registered Nurse). Surveyor asked RN P where she would look for hospice notes. RN P indicates the electronic medical record, and sometimes the notes are in the binder. Surveyor asks RN P if she has access to the outside electronic medical record. RN P states, no.On 3/5/26 at 9:51 AM, Surveyor interviewed LPN L (Licensed Practical Nurse). Surveyor asked LPN L where he would look for hospice notes. LPN L indicates the hospice binders and sometimes they get scanned into the facility's electronic medical record. Surveyor asked LPN L if he has access to the outside electronic medical record. LPN L states, no.On 3/5/26 at 2:52 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the process is for communicating with hospice providers. DON B indicates hospice nurses send their notes via email to the facility's clinical management team. Additionally, hospice providers will give in-person reports to facility staff. Surveyor asked DON B where hospice notes are kept. DON B indicates hospice notes are all in the outside electronic medical record. DON B also notes that notations or important notes are faxed to the facility. These would include important information such as resident monitoring. Surveyor asked DON B if all direct care licensed nursing staff have access to the outside electronic medical record. DON B indicates, no. Surveyor asked DON B if direct care licensed nursing staff should have access to residents' hospice notes. DON B indicates that she would not say they need access to the outside electronic medical record since the important notes are getting faxed directly from hospice. Surveyor asked DON B if R11 has a hospice binder. DON B indicates she knows hospice nurses weren't putting notes in there because they are emailed. DON B also indicates some documents are uploaded to the facility's electronic medical record such as the important notes, orders, and care plans.R11's hospice visit notes were not available to the facility's direct care licensed nursing staff.

Based on interview and record review, the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized in accordance with accepted professional standards and practices for 1 resident (R18) of 23 residents sampled. R18 experienced an incident involving a transfer and sustained a fracture. Staff did not document this incident in the medical record. Evidenced by:The Facility Policy titled, Charting and Documentation includes, in part:Policy Statement: Any changes to the residents' medical or mental condition shall be documented in the residents' medical chart. All incidents, accidents, or changes in the residents' condition must be recorded. R18 was admitted to the facility on [DATE] with diagnoses that include Type II diabetes (a condition where your body has trouble turning the food you eat into energy), anemia with chronic kidney disease (your blood doesn't have enough healthy red blood cells to carry oxygen through your body), age-related osteoporosis (age related bone degeneration), and hemarthrosis, right knee (bleeding into a joint). On 3/4/26 at 2:50 PM, Surveyor interviewed R18, who reported that on 2/6/26 she was being transferred from her wheelchair to the bed and her leg got caught in the wheelchair. R18 states she did not fall and the CNA was able to get her over to the bed. R18 also states she had a lot of pain, but she couldn't get staff to send her to the emergency room. Surveyor reviewed R18's medical record and found no indication related to the details of R18's leg becoming caught between her wheelchair and the bed.The first note related to this incident in the medical record was on 2/7/26 at 3:05 PM, in a progress note with the heading E Mar general note stating Resident complained of her right knee hurting this morning, ringing the call light repeatedly and stating she wants to go to the hospital. Assessment completed. She was given her morning medications (acetaminophen) to help her discomfort. Used non pharmalogical interventions (ice pack) which gave her relief, and she was able to sleep.The next progress note for R18 was on 2/8/26 when she was complaining of pain and the facility called her son, her power of attorney, at 7:00 AM and he didn't return the call until 10:00 AM and gave the ok for R18 to go to the hospital. She returned from the hospital at approximately 10:45 PM with a diagnosis of Right Tibial Plateau fracture.On 3/5/26 at 4:55 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked would you have expected staff to write progress notes about what happened. DON B indicates the facility completed risk management paperwork, which DON B indicates is an internal document. DON B also indicates R18's notes discuss R18's pain and being sent out to the hospital. Additionally, R18 was already being monitored daily for pain. A Risk Management form was filled out by DON B on 2/8/26. (Of note: The Risk Management form is not a part of the medical record.)There is no documentation regarding an incident or monitoring of R18 after an event occurred within R18's medical record.

Based on interview and record review, the facility did not ensure the residents' right to formulate an advanced directive in 1 of 23 sampled residents reviewed (R76) for advanced directives. R76 is a full code with corresponding paperwork in the medical chart. She has no advanced directive in the medical chart. No evidence of discussions regarding advanced care planning, other than code status, was noted to be in R76's medical record. This is evidenced by: The facility policy Advance Directives revised 4/2013 states in part: The interdisciplinary team will review annually with the resident his or her advance directive to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). R76 had an initial admission date of [DATE] and a current code status of Cardiopulmonary Resuscitation (CPR). R76's Minimum Data Sheet (MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) summary score of 14, cognitively intact. On [DATE] at 9:12 AM, Surveyor asked R76 have you ever talked with anyone regarding advanced directives. R76 indicated no, I wanted to see a social worker, but no one ever came. Surveyor asked have you ever had a care conference. R76 indicated she had one with therapy but never talked about advance directives. On [DATE] at 11:43 AM, Surveyor interviewed SSD M (Social Services Director) Surveyor asked SSD M How often do you have care conferences. SSD M replied care conferences-as often as I can. I (SSD M) try to do them quarterly but with me being the only one it's hard. Surveyor asked what is covered in care conferences. SSD M stated overall sense of how they are doing, medication changes, code status, falls, psych services, wounds, skin issues if they have them, and health drive services. Surveyor asked if they would discuss advanced directives. SSD M stated we do talk about POA's (Power of Attorney) at each care conference. Surveyor asked if SSD M has documentation about each care conference. SSD M stated that she would look for it. On [DATE] at 2:23 PM SSD M stated that she was unable to find any documentation for care conferences or discussion regarding advanced directives. Surveyor asked if she had talked with R76. SSD M stated no, but I am going to follow up with her. On [DATE] at 3:45 PM Surveyor asked NHA A (Nursing Home Administrator) would you expect the social worker to have a conversation with residents about advance directives? NHA A replied I think it could be a conversation. Surveyor asked NHA A if she would expect there to be documentation of this discussion, NHA A replied, yes, I would expect there to be documentation.

Based on observation, interview, and record review, the facility did not ensure each resident has the right to be fully informed in a language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition for 1 of 23 sampled residents (R84).The Facility does not ensure R84 is receiving communication in a language he can understand.As evidenced by:On 3/3/26 at 3:27 PM, Surveyor interviewed R84. Surveyor asks R84 if he is concerned about anything. R84 indicated he has trouble communicating with staff and wants them to speak with him in Spanish. R84 also indicated he only speaks a little English.(Of note: Surveyor observed R84 using hand signals when trying to converse with Surveyor along with having word-finding difficulty for the word pain.)The facility policy titled, Translation and/or Interpretation of Facility Services, dated 3/2012, states, in part: Policy StatementThis facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility.Policy Interpretation and Implementation.3. The coordinator of this facility's language access program is the Director of Social Services, or his/her designee.4. All LEP persons shall receive a written notice in their primary language of their rights to obtain competent oral translation services free of charge. If written notice is not possible, such notice shall be given orally.7. Written translation of vital information is available in the following languages at this time.(Of note: List is blank)R84 was admitted to the facility on [DATE] with diagnoses including traumatic hemothorax (blood collects in the space between the lung and chest wall), multiple fractures of ribs of left side, paranoid schizophrenia (schizophrenia characterized by prominent paranoia and delusions), chronic diastolic (congestive) heart failure (CHF; failure of heart to pump blood adequately), anxiety disorder, developmental disorder of scholastic skills.R84's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/4/26, indicates R84 has a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating R84 is moderately cognitively impaired. Section A indicates R84's preferred language is Spanish and that he needs or wants an interpreter to communicate with a doctor or health care staff. Section E indicates R84 experienced behavioral symptoms such as verbal behavioral symptoms directed towards others (examples: threatening, screaming, or cursing at others) and other behavioral symptoms not directed at others (examples: throwing objects, hitting or scratching self, or disruptive sounds) for 1-3 days during the assessment period.R84's Comprehensive Care Plan indicates a Focus for a communication problem related to a language barrier. R84's primary language is indicated to be Spanish and the date initiated is 3/3/26. The goal for this focus is for R84 to be able to make basic needs known by utilizing the translation line on a daily basis through the review date. The date initiated for this goal is 3/3/26 and the target date is 3/9/26. The only intervention listed states: COMMUNICATION: [R84's Name] prefers to communicate in Spanish. Utilize translation service. This intervention was initiated on 3/3/26.R84's Certified Nursing Assistant (CNA) Kardex (documentation system to summarize and organize key resident information) states, in part: COMMUNICATION: [R84's Name] prefers to communicate in Spanish. Utilize translation service.On 2/19/26 at 4:10 PM, a Progress Note is written that states, in part: . Language: Spanish [sic]. Resident does need or want an interpreter to communicate with a doctor or health care staff.On 3/5/26 at 9:39 AM, Surveyor observed the outside of the closet door in R84's room. A sign was present that directed staff to download a translator app onto their phones and the log-in information for the facility's account.On 3/5/26 at 9:45 AM, Surveyor interviewed CNA V (Certified Nursing Assistant). Surveyor asked CNA V how long she has been working at the facility. CNA V indicated a little over a year. Surveyor asked CNA V which hall she usually works on when at the facility. CNA V indicated she usually works in R84's hall. Surveyor asked CNA V if R84 speaks English. CNA V indicated R84 speaks very little English, but he can tell you if he is wet or what he wants to drink. CNA V also noted R84's sister comes often to help translate, but for the most part the communication from R84 is not the greatest.On 3/5/26 at 9:51 AM, Surveyor interviewed LPN L (Licensed Practical Nurse). Surveyor asked LPN L how long he has worked at the facility. LPN L indicated since 2021. Surveyor asked LPN L which hall he usually works in when at the facility. LPN L indicated he moves around between the halls. Surveyor asked LPN L if R84 speaks English. LPN L indicated he would say no. LPN L also indicated R84 mostly points when he wants something. LPN L then demonstrated when R84 wants to be boosted up in bed. LPN L held both thumbs up and made an upward motion with both hands. Surveyor asked LPN L if the facility has a translator or translator line available for staff. LPN L indicated the facility has a translator line, but they only use it if they need to communicate more.On 3/5/26 at 10:50 AM, Surveyor interviewed COTA T (Certified Occupational Therapy Assistant) and PTA U (Physical Therapy Assistant). Surveyor asked COTA T and PTA U if R84 can speak English. COTA T and PTA U indicated R84 can speak broken English and can answer basic yes or no questions. PTA U also indicated they know some basic Spanish, then demonstrated by speaking several basic terms Surveyor understood to be in the Spanish language. COTA T and PTA U also indicated they believe R84 understands most things they say or ask. Additionally, R84's sister visits frequently and can help translate. Surveyor asked COTA T and PTA U if the facility has a translator available to staff. COTA T and PTA U stated yes.On 3/5/26 at 10:55 AM, Surveyor interviewed OT S (Occupational Therapist). Surveyor asked OT S if she has worked with R84. OT S indicated she only completed R84's initial evaluation. Surveyor asked OT S if she utilized a Spanish translator when she completed R84's initial evaluation. OT S indicated no. Surveyor asked OT S if R84's sister was present for the evaluation. OT S indicated no.Surveyor reviewed R84's admission occupational therapy evaluation dated 2/19/26. This evaluation includes functional assessments such as eating, dressing, toileting hygiene, and bathing. The evaluation also includes assessment of extremity range of motion, balance, pain, and sensory processing.On 3/5/26 at 10:59 AM, Surveyor interviewed AD R (Activity Director). Surveyor asked AD R if R84 participates in activities. AD R indicated he mostly listens to music and doesn't really participate in group activities. AD R also noted R84 prefers to be in his room sleeping or resting. Surveyor asked AD R if R84 speaks English. AD R indicated yes, but otherwise staff use a translator.On 3/5/26 at 11:01 AM, Surveyor interviewed SW M (Social Worker). Surveyor asked SW M if R84's sister attends his care conferences. SW M indicated she does and usually translates for staff. Surveyor asked SW M if she completed admission assessments with a translator. SW M indicated she completed those assessments with the language line (translator). Surveyor asked SW M if R84 ever reported concerns to her that staff were not using Spanish translators to communicate with him. SW M stated no.On 3/5/26 at 2:52 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R84 speaks English. DON B indicated R84 does have the ability to communicate basic needs and has the ability to be understood and understand English. Surveyor asked DON B if she expects staff to use the language line (Translator) for communication with R84. DON B indicated, yes, for more extensive conversation and less so for basic needs. Surveyor asked DON B if she has personally been made aware of any grievances from R84 or his Healthcare Power of Attorney regarding his communication with staff. DON B stated no. Facility staff are aware R84 needs a translator as R84 speaks Spanish. The facility did not ensure R84 receives communication in his preferred language or a language R84 is able to understand.

Based on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated and did not report the results of all investigations to officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 of 1 allegations of abuse involving 1 of 3 residents reviewed for abuse (R1).An allegation of sexual abuse was made in which a staff member was accused of inappropriately touching R1's genitals and the facility did not conduct a thorough investigation and report the results to the state survey agency.Based on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated and did not report the results of all investigations to officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 of 1 allegations of abuse involving 1 of 3 residents reviewed for abuse (R1).An allegation of sexual abuse was made in which a staff member was accused of inappropriately touching R1's genitals and the facility did not conduct a thorough investigation and report the results to the state survey agency.Evidenced by:The facility's abuse policy states, The facility will have written procedures that include: Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a.) Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b.) not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. the administrator will follow up with government agencies to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Additionally, The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to:* Responding immediately to protect the alleged victim and integrity of the investigation* Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed.* Increased supervision of the alleged victim and residents.*Room or staffing changes to protect the residents from the alleged perpetrator.* Protection from retaliation. R1 was admitted to the facility on [DATE].On 9/15/25, a family member of R1 expressed a care concern to NHA A (Nursing Home Administrator), which was documented as a grievance. Facility grievance documentation states R1's family expressed concern with peri care on R1 as CNA C (Certified Nursing Assistant) was not wearing gloves when conducting care on 9/14/25. NHA A resolved the complaint by care planning that no males would work with R1 any longer. Additionally, the facility interviewed staff and residents, asking the following questions:1. Has a staff member ever made you feel uncomfortable during personal care?2. If so, did you report it?3. Who do you report concerns about staff to? On 9/23/25, the facility became aware of an allegation of sexual abuse regarding R1. The family member of R1 who made the 9/15/25 grievance had elevated their complaint, saying that on 9/14/25 CNA C inappropriately touched R1's vaginal area during routine care. The facility conducted an investigation including interviews and education with staff regarding the facility's abuse policy, which concluded on 9/30/25. As of 10/8/25, a report was still not submitted to the state agency, nor did the facility report its findings to the state agency at the conclusion of the investigation.The following should be noted:*CNA C continued working with residents during the investigation, despite the sexual abuse allegation. Education on abuse policies did not conclude at the facility until 9/30/25. Facility records indicate CNA C worked on 9/25, 9/26, 9/27, and 9/28. This was confirmed on 10/8/25 at 2:20 PM in an interview with Surveyor. CNA C stated that he gave a statement to the facility but continued working the floor and was not suspended or removed from resident care. When the grievance became elevated to include a sexual nature on 9/23/25, the facility did not conduct any additional interviews or ask any additional questions of staff or residents. On 10/8/25 at 2:50 PM, Surveyor interviewed NHA A who stated that the incident should have been submitted to the state on 9/23/25 when the grievance was elevated. NHA A stated that she had received education on the abuse policy and indicated that she should have then submitted a report to the state regarding the 9/23/25 allegation, including findings report, given that the education of the abuse policy had included timely reporting to the state agency.

Based on interview and record review the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 reportable incidents involving 1 of 3 residents reviewed for abuse (R1).An allegation of abuse was made involving facility staff inappropriately touching R1, this was not reported to the State Agency.Evidenced by:The facility's abuse policy states, The facility will have written procedures that include: Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a.) Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b.) not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.R1 was admitted to the facility on [DATE].On 9/23/25, the facility became aware of an allegation of sexual abuse regarding R1. A family member of R1 reported to NHA A (Nursing Home Administrator) that a CNA had inappropriately touched R1's private area during routine care. The facility conducted an investigation including interviews and education with staff regarding the facility's abuse policy, which concluded on 9/30/25. As of 10/8/25, a report was still not submitted to the state agency.On 10/8/25 at 2:50 PM, Surveyor interviewed NHA A who stated that that the incident should have been submitted to the state on 9/23/25. NHA A stated that she had received education on the abuse policy and indicated that she should have then submitted a report to the state regarding the 9/23/25 allegation, given that the education of the abuse policy had included timely reporting to the state agency.

Based on observation, interview, and record review, the facility did not ensure the preparation, storage, and serving of food in a clean and sanitary environment. This has the potential to affect all 67 residents in the facility. Surveyor observed partially eaten meal trays from the previous meal sitting on tables in the dining room while residents were eating breakfast. Surveyor observed 3 wall dispensers of hand sanitizer in the dining room to not be in working order. Surveyor observed a table in the dish room to be covered with stacked boxes mixed with a tray of glasses, a dirty towel, dirty coffee pots, and a fleece jacket laying on top of a metal pot which was inside of a box of white aprons. Surveyor observed a microwave in the kitchen which was covered with multi-colored splatters all over the inside walls. Surveyor observed an opened package of butter with half of the wrapper removed and butter was sitting on a cart by the stove exposed to air, not covered. Surveyor observed multi-colored stains on the wall to the right and left of the dish room entrance and stains on the curtain by the garbage. Evidenced by: Facility policy, entitled Safe Storage of Food, revised 1/1/25, states in part: .All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination .Storage areas will be neat, arranged for easy identification . Example - Dirty meal trays on tables in dining room On 5/5/25 at 8:25 AM, Surveyor was in dining room observing breakfast. Surveyor observed 4 meal trays with dirty plates, bowls, and cups on the table under the wall clock in the dining room. Surveyor observed a scoop of rice on one of the plates, dried piece of tomato on another plate, melted Jello with strawberry pieces and oranges in 3 of the bowls, and some coffee in 2 of the cups. Surveyor checked the menu from Sunday 5/4/25; the supper menu was Salisbury steak, rice pilaf, seasoned squash, and mandarin orange gelatin. Example - Empty hand sanitizer dispensers On 5/5/25 at 8:40 AM, Surveyor tested the hand sanitizer dispensers outside and inside of the main dining room. All 3 of the dispensers on the inside of the dining room were not working. Example - Dish room table Facility policy, entitled Safe Storage of Food, revised 1/1/25, states in part: .All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination .Storage areas will be neat, arranged for easy identification . Facility Kitchen AM Dietary Aide Cleaning Schedule states, in part: .Thursday - Move tables and drying rack in dish room. Sweep and mop underneath. Pickup any kitchen ware; cups, silverware, bowls, lids, etc. On 5/5/25 at 8:45 AM, Surveyor and DM E (Dietary Manager) observed a metal table in the dish room to have stacks of cardboard boxes, a tray of clear plastic glasses to be sitting on top of a cardboard box, a metal basket sitting on top of a cardboard box containing a soiled towel and 2 coffee pots with brown residue in them, a large black tub was sitting on top of the metal basket, a fleece jacket was laying on top of a metal pot which was sitting on a opened cardboard box containing white aprons. Surveyor interviewed DM E about these items. DM E indicated she needed to take those items to storage and hasn't gotten them to the basement yet, said she would take care of it. Example - Microwave Facility Kitchen AM [NAME] Cleaning Schedule states, in part: .Thursday - Wipe down inside and outside of microwave . On 5/5/25 at 9:55 AM, Surveyor and DM E observed the inside of the microwave. On all walls on the inside, there were several multi-colored splatters dried on the surfaces. Surveyor interviewed DM E about the cleaning of the microwave and DM E indicated the microwave should be getting wiped out after every meal and stated she would have someone clean it. Example - Opened package of butter Facility policy, entitled Safe Storage of Food, revised 1/1/25, states in part: .All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination .Storage areas will be neat, arranged for easy identification . On 5/5/25 at 9:55 AM, Surveyor and DM E observed an opened package of butter sitting on a cart by the stove in the kitchen. The wrapper was half torn off and the butter wasn't covered, wrapped or dated. DM E indicated the butter should be covered, labeled and put away. Example - Splatters on the wall On 5/6/25 at 12:32 PM, Surveyor, DA F (Dietary Aide), and DM E observed several multi-colored dried on splatters on the wall to the right and left of dish room entrance and observed dried on splatters on the curtain in the dining room by the garbage. Surveyor interviewed DA F and DM E who both indicated the PM kitchen staff are supposed to be cleaning the walls daily. DM E stated she would have someone clean the walls and find out who should be cleaning the curtains. On 5/7/25 at 4:04 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who indicated she would expect kitchen staff to follow their policies and procedures and cleaning schedules.

Based on observation, interview, and record review, the facility did not ensure each resident had the right to a safe, clean, comfortable, and homelike environment for 3 of 9 sampled Residents (R5, R7 and R8), 3 of 3 shower rooms, and 1 of 1 kitchen. Surveyor observed a kitchen door to be detached from the hinges and leaning against the kitchen sink. Surveyor observed meal trays for R7 and R8 to be in their rooms without R7 and R8 present. R5 voiced concerns regarding cleanliness of shower room. [NAME], Harbor, and Depot shower rooms were observed to be cluttered with equipment/shower chairs, unclean, and not homelike. Depot Shower room was observed to have mechanical concerns with the shower and dripping water from the ceiling. This is evidenced by: The facility policy, Quality of Life - Homelike Environment, revised April 2014, includes, in part: Policy Statement: Residents are provided with a safe, clean comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: .2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order . Example 1 On 5/5/25 at 11:05 AM, Surveyor made a visit to the kitchen and observed the kitchen door which connects the dish room and main dining room to be detached from the side hinges and only attached by a hydraulic hinge at the very top of the door. This door was leaning up against the kitchen sink. Of note, when Surveyor made a follow up visit to the kitchen on 5/7/25 around 11:15 AM, Surveyor observed the door to be completely unattached from the top hinge as well, and being held upright by the kitchen sink. On 5/5/25 at 11:08 AM, Surveyor interviewed DC C (Dietary Cook) and asked how long the door has been unattached to the hinges and propped up against the sink. DC C indicated the door has been hanging like this for about a week and maintenance is working on fixing it. On 5/6/25 at 8:41 AM, Surveyor interviewed MD D (Maintenance Director) about the kitchen door. MD D told Surveyor he was made aware of the door not being attached to the hinges a few months ago. MD D indicated regional management is trying to find a new door, regional management is supposed to be handling this, unsure of the status of the door. MD D told Surveyor he thinks there is risk for cross-contamination from the water spraying and the mist going into the dining room, potentially containing food particles or bacteria. He stated he has expressed his concerns to the owner and regional manager. Following the interview, MD D showed Surveyor two email threads/conversations relating to the kitchen door needing to be replaced and these conversations go back to January and February of 2025. The first email thread is between MD D and a third-party company the facility uses for ordering items. The emails are from 1/3/25 to 1/8/25 and there is discussion of verifying receiving the request, verifying measurements, hinge and latch type, fire rating needed. The second email thread is between MD D, NHA A (Nursing Home Administrator), ordering company, and regional director. The emails are from 1/22/25 to 2/13/25 and there is discussion about door quotes, getting additional quotes. On 2/13/25 at 12:24 PM, there is an email from NHA A to regional director and ordering company stating the following: We've attempted to repair but are unable to do so because the doors are rotted from water damage. What are you recommending we do now as the doors should be in place for sanitation purposes in relation to life safety code. The ordering company replied back on 2/13/25 at 1:02 PM stating they have reached out to a company in [NAME] for a third quote. (of note, that was the last email in the thread.) On 5/7/25 at 12:01 PM, Surveyor interviewed NHA A regarding the kitchen door. NHA A indicated during the interview she was made aware of the kitchen door not being on the hinges about a week and a half ago. NHA A stated she believes the door is ordered. Of note, Surveyor observed email correspondence indicating NHA A was a recipient and sender of emails with knowledge of the door needing to be replaced as early as January 2025. Surveyor asked NHA A if there's been any other follow up with the door since the email last sent on 2/13/25. NHA A indicated the door getting ordered is the follow up. NHA A is unable to recall exactly when the door was ordered. Example 2 On 5/5/25 at 2:16 PM, Surveyor was making resident observations throughout the building. R8's meal tray was observed sitting in resident's room on over bed table when R8 was not in the room. On 5/5/25 at 2:52 PM, Surveyor observed R7's meal tray to be sitting in resident's room on over bed table and resident was not in the room. On 5/7/25 at 9:34 AM, Surveyor interviewed R7 and asked how she feels when a meal tray gets left in her room after she's done eating. R7 indicated it bothers her. R8 refused an interview with Surveyor. On 5/7/25 at 4:15 PM, Surveyor interviewed CNA G (Certified Nursing Assistant) and asked when staff would take a meal tray out of someone's room. CNA G indicated she would take the tray out when resident was done eating, when they are ready. On 5/7/25 at 4:20 PM, Surveyor interviewed DON B (Director of Nursing) about expectation for taking meal trays out of resident rooms. DON B indicated it's based on resident preference and when resident is fully finished with their meal. 39849 Example 3 On 5/5/25 at 2:49 PM Surveyors interviewed R5 who indicated she had a shower that morning and that she feels the shower room is cluttered, congested, not clean, and does not feel homelike. R5 indicated she does not always get her shower on Depot and sometimes is taken to [NAME] hall. R5 indicated last week was the last time she had been to the one on [NAME] and indicated it is more homelike than depot but still cluttered and indicated they need to take some of that stuff down to the basement. Example 4 On 5/5/25 at approximately 8:15 AM Surveyors began observations of the facility shower rooms and completed staff interviews regarding the shower rooms which included the following: [NAME] Hall shower room: 1) Two lifts and Multiple shower chairs were present with some shower chairs being stacked on top of each other. 2) Wet white paper like substance on the tile by the shower as well as other white substance noted on floor. 3) A shelving unit containing the following: Multiple bottles of open, unlabeled skin and hair cleanser, dust present on shelves, a pair of gripper socks noted to be stained with a used bar of soap sitting directly on top of them, a pair of glasses. 4) Open bottles of skin and hair cleanser on the metal rail in the shower. On 5/5/25 at 8:40 AM Surveyors interviewed CNA H (Certified Nursing Assistant) in the [NAME] Hall shower room. During the observation and interview CNA H indicated that the bottles of skin and hair cleanser should either be taken back to the room with the resident or tossed. CNA H indicated some residents bring their own soaps and things and they should always be taken back out with the resident. Surveyors asked CNA H how she would know whose bottles belong to whom and she indicated they do not label them because they are supposed to stay with the resident and go back with them or get tossed. CNA H was not able to identify who the glasses belong to, who's bar of soap was on the gripper socks and indicated this should be in a container, agreed the floor and shelving unit were not clean and indicated if she was a resident she would not want to shower in this room. Depot Hall shower room: 1) Sign on half tile wall with the handwritten message, Caution 116 (on low) in spa room. 2) Tub: dead insect, tannish/brown colored streaks at front of tub, wheelchair foot pedals in the tub. 3) Multiple shower chairs with one having a brown substance noted on the seat portion. 4) Handheld shower head on floor and running. 5) Ceiling tile above shower dripping water. 6) A black substance in and around the grout on the shower side of the half tile wall. 7) No shower handle was noted for adjusting water. The portion of the shower where the handle should be had a towel over it and the towel was saturated and water was leaking from the area where the handle would attach. There is a yellow discoloration of the tile where the water runs down. 8) A white substance on the metal plate where the shower handle should be connected. On 5/5/25 at 8:30 AM Surveyors interviewed CNA J in the Depot shower room. During the observation and interview CNA J indicated the following: She thought the brown substance on the shower chair was BM (Bowel Movement) and not considered clean, the tub is not used, however, would still not be considered clean and supplies should not be stored in the tub, the shower head should not be left on the ground, she did not know why the ceiling was leaking and indicated if something like this is happening a maintenance form should be completed. CNA J indicated she did not consider the shower room to be a homelike environment and suggested we speak with CNA I who had showered a resident in this room that morning. On 5/5/25 at 2:10 PM Surveyors interviewed CNA I about the Depot shower room. CNA I indicated she is the only one who knows how to use that shower. There is no handle and she uses a towel to grip the part you can still turn. CNA I indicated she did not know when the Caution sign was put on the half tile wall. CNA I indicated she has seen the ceiling dripping and indicated it does this all the time not just when the shower is in use. CNA I indicated the depot shower never shuts off and that she puts a towel over where the handle should be because that knob shoots water directly out, so the towel has to be there during showers. CNA I indicated this would not be considered a homelike environment. On 5/6/25 at 2:35 PM Surveyors interviewed CNA I who indicated the ceiling had been dripping in the Depot shower room for a month or two and doesn't feel it is truly a functioning shower. On 5/7/25 at 8:27 AM Surveyors interviewed DON B and NHA A and reviewed the above observations of the shower rooms. DON B and NHA A agreed the shower rooms were neither clean nor homelike. 49436 Example 5 On 5/5/25 at 8:25 AM, Surveyor observed the following in the shower room on Harbor Hall. 1) The toilet had brown and black matter on the walls of the interior of the toilet bowl. 2) There was a commode bucket next to the toilet. Approximately 50% of the bottom of the inside of the commode bucket was covered with a dry, crusted, yellow substance. 3) There was no hand sanitizer in the wall sanitizer unit. 4) On the sink, there was a pair of scissors, a hairbrush, and an opened canister of shaving cream. 5) The tall trash can was full of trash with no lid. 6) There was a 3 drawer stand next to the shower. There was a towel placed over top of the stand. The towel was wet and discolored with a yellow substance. 7) On top of the towel was a basin, 2 open bottles of soap and a wet loofa sponge. On 5/7/25 at 8:30 AM, Surveyors interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator) regarding the shower rooms. Surveyor described the scene of the shower room on Harbor Hall to DON B and NHA A. DON B and NHA A both indicated the shower room is not tidy, clean or homelike for the residents.

Based on interview and record review, the facility did not ensure that they provided pharmaceutical services (including procedures that assures the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This affected 1 (R2) of 6 residents reviewed for medication administration. R2 had 2 dates in May 2025 that were blank for his thyroid medication. This is evidenced by: The Facilities Administering Medications Policy and Procedure dated 12/24 documents, in part: .3. Medications must be administered in accordance with the orders, including any required time frame .19. The individual administering the medication must initial the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones . R2 is short term resident of the facility. R2 has the following diagnoses: cerebral infarction, nontraumatic intracerebral hemorrhage in cerebellum, psychosis not due to a substance or known physiological condition, hypothyroidism (thyroid gland doesn't produce enough thyroid hormone), mood disorder, alcohol dependence with unspecified alcohol-induced disorder, psychoactive substance abuse, anxiety disorder, personality disorder, and encephalopathy (disease in which the functioning of the brain is affected by some agent or condition. R2's Physician Order include: Levothyroxine Sodium Oral Tablet 100 mcg (micrograms) (Levothyroxine Sodium) Give 1 tablet by mouth one time a day related to Hypothyroidism. R2's MAR (Medication Administration Record) includes: Levothyroxine Sodium Oral Tablet 100 mcg (micrograms) (Levothyroxine Sodium) Give 1 tablet by mouth one time a day related to Hypothyroidism is scheduled at 0600 (6:00 AM). R2's medication was not signed out on 5/2/25 and 5/3/25. On 5/7/25 at 11:32 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if there is a blank box in the MAR was the medication given, DON B explained it could indicate that it was not checked and saved. Surveyor asked DON B if there is any way to know if the medication was given if the box is blank, DON B replied that it can't be verified, no. Surveyor asked DON B would you expect all medications to be given as ordered, DON B stated yes. On 5/6/25 at 11:48 AM, Surveyor interviewed IP P (Infection Preventionist). Surveyor asked IP P what a blank box on the MAR (Medication Administration Record) would indicate, IP P replied she couldn't answer that now, she would have to find out who worked to figure out why it was blank. On 5/6/25 at 1:12 PM, Surveyor interviewed LPN S (Licensed Practical Nurse). Surveyor asked LPN S what a blank box on the MAR would indicate, LPN S replied that they might not have given the med, or sometimes people give the med but forget to mark it off. On 5/7/25 at 3:20 PM, Surveyor interviewed LPN T. Surveyor asked LPN T what a blank box on the MAR would indicate? LPN T replied that she had not seen a MAR before, it didn't look like that on her screen. Surveyor asked LPN T to bring up the MAR on her computer. After seeing the MAR, LPN T replied that someone didn't sign or give a code. On 5/6/25 at 3:25 PM, Surveyor interviewed LPN Q. Surveyor asked LPN Q what a blank box on the MAR would indicate, LPN Q replied nothing was done. The facility submitted additional documentation. This documentation was reviewed but does not change the citation.

Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R2) reviewed for elopement. R2 did not have an order to check the function of his elopement device. This is evidenced by: The Facilities Elopement/Unsafe Wandering Policy and Procedure dated 1/4/24 does not speak to monitoring the function of the elopement device. R2 is short-term resident of the facility. R2 has the following diagnoses: cerebral infarction, nontraumatic intracerebral hemorrhage in cerebellum, psychosis not due to a substance or known physiological condition, mood disorder, alcohol dependence with unspecified alcohol-induced disorder, psychoactive substance abuse, anxiety disorder, personality disorder, and encephalopathy (disease in which the functioning of the brain is affected by some agent or condition). R2's Physician Orders include: Wander Device, Check placement and location on right ankle dated 4/28/25. It is important to note that R2's TAR (treatment authorization request) does not include to check the function of his wander device. On 5/5/25 at 3:11 PM, Surveyor interviewed RN M (Registered Nurse). Surveyor asked RN M how she checks placement of the wander device, RN M said a visual check. Surveyor asked RN M how she checks the function of the wander device, RN M stated she hasn't done that yet. Surveyor asked RN M what she meant by she hasn't done that yet, RN M explained that she is new and hasn't learned how to check the function of the wander device yet. Surveyor asked RN M if there was anything she was going to do regarding checking the function of wander devices today, RN M said I'm going to ask someone how to do that. On 5/7/25 at 11:32 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how often should the function of the wander devices be checked, DON B stated every shift. Surveyor asked DON B how the function of the wander device is checked, DON B explained that there is a box that you point at the device, green light means its functioning, red light means it's not functioning. Surveyor asked DON B if all nurses should know how to check the function of the wander device, DON B stated yes. On 5/5/25 at 12:00 PM, Surveyor interviewed LPN N (Licensed Practical Nurse). Surveyor asked LPN N how the function of the wander guard is checked, LPN N replied she takes the resident for a walk in the hall to the door and gets close enough for the alarm to go off. She also reports that you can use the brown box and check, but she doesn't like to use that so much. Surveyor asked LPN N how often the wander guard should be checked, LPN N replied every day. On 5/6/25 at 9:20 AM, Surveyor interviewed RN R (Registered Nurse). Surveyor asked RN R how the function of the wander guard is checked, RN R replied that she didn't know, she was just an agency nurse and hadn't done that yet. Surveyor asked RN R how often the wander guard should be checked. RN R replied she didn't know and would have to check. RN R returned and replied that it should be checked every shift, but she also had not done that yet. On 5/6/25 at 11:05 AM, Surveyor interviewed LPN S. Surveyor asked LPN S how the function of the wander guard is checked, LPN S replied that she uses the brown box that is at the nurses' station, she holds it to the wander guard and if it beeps and turns green it is working. LPN S showed Surveyor the brown box at the nurses' station. Surveyor asked LPN S how often the wander guard should be checked, LPN S replied every shift. On 5/6/25 at 11:46 AM, Surveyor interviewed IP P (Infection Preventionist). Surveyor asked IP P how the function of the wander guard checked, IP P replied that there is a grey box at the nurses' station to check the wander guard, or you can take the resident up to a door and see if the alarm sounds. Surveyor asked IP P how often the function of the wander guard should be checked, IP P replied on the NOC shift. On 5/6/25 at 3:15 PM, Surveyor interviewed RN T. Surveyor asked RN T how the function of the wander guard is checked, RN T replied when the resident gets too close to the receptionist it should go off. Surveyor asked RN T if there was any equipment used to check the function, RN T replied she didn't know of any equipment to use. Surveyor asked RN T how often the wander guard should be checked, RN T replied she did not know how often. On 5/7/25 at 4:03 PM, DON B handed Surveyor Elopement/Unsafe Wandering Policy and Procedure and said that this doesn't speak directly to checking function of the device but protocol here is to check every shift.

Based on interview and record review the facility did not thoroughly investigate an allegation of abuse this has the potential to affect 1 of 6 investigations reviewed affecting resident (R5). R5 reported an allegation of abuse that was not thoroughly investigated by the facility. R5's most recent Minimum Data Set (MDS), target date 3/8/25, indicates a Brief Interview of Mental Status (BIMS) of 13. Indicating that R5 is cognitively intact. On 5/5/25 at 2:49PM Surveyors interviewed R5 who indicated last week when she was in activities R9 said to her If I had a gun, I'd shoot you. R5 indicated she did not believe any staff witnessed the event. R5 indicated she did not tell anyone until the next day when she reported it during her therapy session to OT K (Occupational Therapist) who told her she would report it to NHA A (Nursing Home Administrator). R5 indicated it makes her feel anxious. On 5/5/25 at 3:42PM Surveyors interviewed OT K who indicated that R5 did report to her that R9 had said to her If I had a gun, I would shoot you. At 3:50PM PT L (Physical Therapist) joined the interview and indicated she was present when R5 reported this. OT K and PT L both indicated they had not been interviewed or asked to complete a statement by anyone. On 5/7/25 at 9:35AM Surveyors interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing) and asked what the process is when a resident reports an allegation of abuse. NHA A indicated first intervene and make sure the resident is safe. NHA A indicated ideally it would be reported to her immediately and they would begin an investigation right away. NHA A indicated they would complete the following: Interview the resident; If the resident is able to identify staff or give a description - take steps to identify; If identified staff, suspend if necessary; if not identified they would try to identify the person through other staff and resident interviews; conduct further resident interviews to ask if they have experienced the issue; talk to staff, have they witnessed anything; resident assessments if needed. Surveyor asked if anyone had reported that R5 told staff that R9 said to her, If I had a gun I'd shoot you. NHA A indicated she would have to double check. Surveyors requested any information regarding an investigation. On 5/7/25 at 10:15AM NHA A provided a Grievance Form with a Date occurred of 5/2/25 for R5. The form includes, in part: Describe the concern: Another resident made a comment that made R5 uncomfortable. Surveyors verified with NHA A that the grievance form is referring to the comment that R9 made to R5 that if she had a gun, she would shoot her. Of note, the form does not contain the name of the resident that made the comment, the name of the staff member(s) who reported the allegation, or information regarding interviews with staff or other residents. Surveyor asked NHA A if she considered this an allegation of abuse when therapy reported it to her. NHA A indicated, yes, and that they began the investigation process immediately. Surveyors asked NHA A if she interviewed other staff or residents to see if anyone else had information or concerns about R9 making threats to other residents. NHA A indicated, no, and that they should have seen if it happened to others. Surveyors asked NHA A how they protected R5 and other residents. NHA A indicated that R5 reported she wheeled herself away when it happened and there was no one else around. R9 was in her room when she met with her and that R9 had indicated staff had wheeled her in there. NHA A indicated she spoke with R9, and she indicated she would never do this and doesn't have the means and that she knew she shouldn't have made the comment. NHA A indicated she also searched R9's room. NHA A indicated this would not be considered a thorough investigation.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made for 2 of 6 residents (R2 and R5) reviewed for abuse. R2's POA (Power of Attorney) reported an alleged sexual abuse allegation and did not report this to the State Agency or Law Enforcement. R5 reported an allegation of abuse that was not reported to other officials (including to the State Survey Agency) within two hours of discovery. This is evidenced by: The Facilities Policy and Procedure entitled Abuse, Neglect, and Exploitation dated 1/5/24 documents, in part: .Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Sexual Abuse is non-consensual sexual contact of any type with a resident .VII. Reporting/Response .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) . On 5/5/25 at 9:48 AM, Surveyor interviewed POA O (Power of Attorney). Surveyor asked POA O if there was any additional concerns or information she wanted to share, POA O stated The Administrator, NHA A (Nursing Home Administrator) still has not gotten back to me about the staff member that went in his room and touched him, she just said they viewed the cameras and that no males cared for him. The Facility had a documented grievance form dated 4/29/25, Describe the concern: Resident told POA that he did not like the male caregiver 4/29/25 morning .Action taken: Schedule reviewed, and resident had female CNA (Certified Nursing Assistant) and nurse. Camera reviewed . On 5/7/25 at 11:44 AM, Surveyor interviewed NHA A. Surveyor gave NHA A the grievance form filed on 4/29/25 and asked, what did POA O say to you regarding this document (grievance form), NHA A replied first it was that he didn't like his caregiver and then it was a male caregiver touched his (private area). Surveyor asked NHA A if this allegation should have been more than a grievance, NHA A said they did a full investigation on it. On 5/7/25 at 4:08 PM, Surveyor interviewed NHA A. Surveyor gave NHA A the Abuse, Neglect and Misappropriation Policy and Procedure and asked, does this allegation meet the definition of sexual abuse, NHA A stated yes. Surveyor asked NHA A if allegations of sexual abuse are reportable incidents, NHA A stated yes. It is important to note that this allegation while investigated thoroughly, was not reported to the State Agency or Law Enforcement. 39849 Example 2 R5's most recent Minimum Data Set (MDS), target date 3/8/25, indicates a Brief Interview of Mental Status (BIMS) of 13. Indicating that R5 is cognitively intact. On 5/5/25 at 2:49PM Surveyors interviewed R5 who indicated last week when she was in activities R9 said to her If I had a gun I'd shoot you. R5 indicated she did not believe any staff witnessed the event. R5 indicated she did not tell anyone until the next day when she reported it during her therapy session to OT K (Occupational Therapist) who told her she would report it to NHA A (Nursing Home Administrator). R5 indicated it makes her feel anxious. On 5/5/25 at 3:42PM Surveyors interviewed OT K who indicated that R5 did report to her that R9 had said to her If I had a gun I would shoot you. OT K could not recall if it was Thursday or Friday of last week as R5 was on the schedule for both days, but indicated she reported this to NHA A right away. At 3:50PM PT L (Physical Therapist) joined the interview and indicated she was present when R5 reported this and that she went with OT K to report the incident to NHA A. On 5/7/25 at approximately 9:35AM Surveyors interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing) and asked what the process is when a resident reports an allegation of abuse. NHA A indicated first intervene and make sure the resident is safe. NHA A indicated ideally it would be reported to her immediately, if she can't be reached, then to DON B. They would begin an investigation right away and if it needed to be reported they would report it to the state and call police if needed. Surveyor asked if anyone had reported that R5 told staff that R9 said to her, If I had a gun I'd shoot you. NHA A indicated she would have to double check. Surveyors asked NHA A if that would warrant a self-report. NHA A indicated, yes. On 5/7/25 at 10:15AM NHA A provided a Grievance Form with a Date occurred of 5/2/25 for R5. The form includes, in part: Describe the concern: Another resident made a comment that made R5 uncomfortable. Surveyors verified with NHA A that the grievance form is referring to the comment that R9 made to R5 that if she had a gun she would shoot her. Surveyors asked NHA A if she considered what R9 had said to R5 a threat. NHA A indicated, yes. Surveyor asked NHA A if she considered this an allegation of abuse when therapy reported it to her. NHA A indicated, yes. Of note, there is no information on the form to indicate the time the allegation was reported. Surveyors read the definition of verbal abuse from the facility abuse policy and asked NHA A if the statement made by R9 to R5 would be considered verbal abuse and therefore a reportable incident. NHA A indicated, yes and that it was not reported.

Based on interview and record review, the facility did not ensure each resident receives care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 1 of 2 sampled residents (R41). R41 developed an in house acquired, stage 3 pressure injury on her coccyx. Surveyor observed R41 to be lying directly on her wound and to have her heels directly on the mattress/not floating several times during survey. The facility delayed changing out R41's bed to a mattress designed to treat pressure injuries stage 3 or higher. The facility did not perform wound care per physician orders. Evidenced by: Facility policy, titled Pressure Injury/Skin Integrity, review date 10/21/24, includes: It is the policy of the facility to enable nursing staff to manage wounds and select appropriate interventions according to the National Pressure Ulcer Advisory Panel . The facility will ensure a resident receives care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing . Interventions will be used to mitigate the risk for skin breakdown, based on individual risk factors, and may include, but are not limited to: the use of pressure redistribution devices such as mattresses or cushions; devices to eliminate or reduce friction and shearing; or the implementation of individualized turning and repositioning schedules. Interventions should be documented in the electronic medical record, including the residents individualized resident-centered plan of care . It is important that each pressure ulcer or non-pressure ulcer wound be identified. Identification of factors that may have influenced development of the wound/root cause analysis, the potential for development of additional wounds, or for the deterioration of the pressure ulcers should be recognized and may include: the type of wound: pressure versus non pressure related . the wound stage . describe and monitor the wounds characteristics . monitor the progress toward healing and for potential complications . determine if infection is present . assess, treat, and monitor pain . mind your dressings and treatments . wound documentation is more detailed than routine skin documentation and shall include information related to the wound based on a clinical assessment . wound documentation guidelines: document size: length times width times depth . document any undermining tunneling sinus tract . describe any exudate: type, amount, and/or odor . describe the various types/characteristics of tissue in wound bed . describe wound edges . describe surrounding tissue . R41 admitted to the facility on [DATE] with the following diagnoses: morbid obesity, muscle weakness, asthma, metabolic encephalopathy, heart disease, and age-related osteoporosis. Her most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 8/21/24 indicates R41's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. R41's Comprehensive Care Plan, initiated 12/22/18, includes: The resident has potential for skin impairment related to incontinence, limited mobility . Goal: 12/22/18 The resident will remain free of new skin impairment through the review date. Interventions: 12/22/18 Apply barrier cream per facility protocol to help protect skin from excess moisture. 1/3/19 ensure heels are elevated while resident is lying in bed. 12/22/18 change bedding/clothing if moist. Determine cause of moisture and eliminate if possible. 12/22/18 Monitor skin when providing cares, notify nurse of any changes in skin appearance. 4/23/23 Apply barrier cream per orders as needed with episodes of incontinence. R41's TAR (Treatment Administration Record) for September 2024, includes Order: Barrier cream to buttocks/coccyx every shift and as needed. Start date: 12/27/18: This is signed out as completed on all three shifts 9/1/24-9/30/24, except for on the following dates where each date on one of the shifts is left blank or not signed off as completed: 9/3 PM shift not completed, 9/6 PM shift not completed, 9/7 NOC shift not completed, 9/10 PM shift not completed, 9/15 AM shift not completed, 9/27 AM shift not completed. Order: Start date: 1/14/20 Resident may wear double briefs every shift for FYI (For Your Information) this is signed out as completed on 85 of 90 shifts. Order: Float heels using pillows while in bed every shift. Start date: 12/27/18. This is signed out as completed all but 3 shifts. (It is important to note double briefing is not a current SOP, double briefing adds another layer between R41 and her pressure reducing mattress and it can significantly increase the risk of developing pressure injuries due to excessive moisture trapped against the skin, creating a hot and humid environment that can break down skin integrity.) R41's Braden Scale for Predicting Pressure Sore Risk, dated 9/4/24, indicates R41 is at risk for pressure injury development with a score of 15. R41's Comprehensive Care Plan entry, added on 9/12/24, includes the following: 9/12/24 The resident has an actual skin impairment to sacrum. Goal: 9/12/24 Resident's skin impairment will improve by review date. Intervention: 9/12/24 evaluate and treat per physician orders. (It is important to note R41's Medical Record does not contain any measurements or character description of this skin impairment. There is no evidence that the facility contacted R41's MD regarding this skin impairment.) R41's Nurse Note, dated 9/18/24, includes Enabler bar/assist bar: Resident has been assessed for risk of entrapment . Observed that there is proper fit to the bed frame. Bed dimensions are appropriate for the resident's size and weight . Resident is able to safely utilize grab bar . R41's Skin Observation Tool, dated 9/23/24, indicates R41 has redness under her breasts, but no other skin concerns. (It is important to note there is no mention of R41's skin impairment that is mentioned on R41's comprehensive care plan.) R41's Nurse Notes, dated 9/29/24, include CNA (Certified Nursing Assistant) informed this writer that resident had small amount of blood and was not sure where it was from when doing cares. This writer observed small amount of vaginal bleeding when wiping. Also, a small skin impairment noted to coccyx. Area cleaned and Mepilex applied. PCP (Primary Care Physician) notified via fax due to not using facility provider. (It is important to note there is no description of this skin impairment in R41's medical record. There is no evidence the wound is stable, if it is worsening, or if it is improving. It is also important to note R41's care plan was not updated with this new skin impairment.) An email correspondence with R41's physician group, dated 10/2/24, includes, in part: . I will be sure to add (R41's name) to NP F's (Nurse Practitioner) wound schedule for tomorrow. R41's Skin Observation Tool, dated 10/3/24, includes: No new skin issues observed. (It is important to note R41's Skin Observation Tool does not reflect her skin impairment while her medical record indicates in two separate documents she has a skin impairment, on 9/12/24 in her care plan and on 9/29/24 in her nurses notes. There are no measurements, no description of characteristics, no monitoring of the impairment to compare if the impairment is stable, worsening, or improving. It is important to note there is no root cause analysis completed in R41's medical record to indicate what could have been the cause of this skin impairment.) R41's TAR, October 2024, includes Order: Sacrum: Apply bordered foam dressing to prevent further skin breakdown in the morning for wound care Start date: 10/2/24. End date: 10/10/24 . This treatment is signed as completed on all days, except for on 10/3/24 and 10/9/24. These boxes are blank. Order: Sacrum: Apply Medi honey followed by bordered foam. To be done daily in the morning for wound care. Start date 10/10/24. End date 10/17/24 . This treatment is signed out as completed all days except for 10/12/24. This box is blank. Order: Sacrum: Cleanse with normal saline. Fit collagen to wound bed followed by duoderm. To be done Monday, Wednesday, and Friday for wound care. Start date: 10/17/24. These treatments were signed out as completed on all days. Order: Float heels using pillows while in bed every shift. Start date: 12/27/18. This is signed out as completed all but 3 shifts. Order: Air mattress for wound care. Check function every shift for wound healing. Start date: 10/16/14. These are all signed as completed. Order: May wear double briefs every shift for FYI. Order date: 1/14/20. These are signed off as completed all but 3 shifts. (It is important to note R41's medical record had no evidence in it of R41's treatment being completed or R41 refusing wound care on 10/9 or 10/12.) R41's Nurse Practitioner Note, dated 10/10/24, includes: Patient seen today for initial evaluation of coccyx wound. Wound has been open for greater than 2 weeks however she declined assessment last week. She is lying in bed, no acute distress. She denies any pain, fever, or chills. Wound examined with full assessment and plan . Stage 3 pressure injury to coccyx, measuring 1.0cm x 0.6cm x unable to determine . 100% slough with scant serous drainage . Plan: cleanse wound, apply Medi honey to wound bed followed by bordered foam to be changed daily . Continue offloading measures per facility protocol, continue nutritional support, continue medical management of multiple comorbidities, continue wound assessment weekly with treatment plan as directed . R41's Nurse Practitioner Note, dated 10/17/24, includes: Patient seen today for follow up of coccyx wound. Wound appears improved with decrease in slough. No current signs and symptoms of infection. Patient reports pain with any palpation to area is 7 out of 10. She is now on offloading mattress . Stage 3 pressure injury to coccyx, measuring 1.2cm x 0.6cm x 0.2cm, 10% slough, 90% granulation tissue with scant serous drainage . Plan: Continue offloading measures per facility protocol, continue nutritional support, continue medical management of multiple comorbidities, continue wound assessment weekly with treatment plan as directed . Cleanse wound, apply collagen followed by duoderm to be changed 3 times a week and as needed . R41's Skin Observation Tool, dated 10/17/24 includes: No new skin issues observed. (It is important to note R41 has a stage 3 pressure injury that is not captured on her skin observation tool.) R41's Nurse Practitioner Note, dated 10/24/24, includes chief complaint - evaluation to coccyx . Patient seen today for reevaluation of coccyx wound. She is lying in bed. No acute distress. Denies pain at rest. She has mild pain with any pressure to coccyx. Wound without signs and symptoms of infection . Stage 3 pressure injury to coccyx, measuring 0.6cm x 0.5cm x 0.1cm, 100% smooth red with scant serous drainage . Plan: Continue offloading measures per facility protocol, continue nutritional support, continue medical management of multiple comorbidities, continue wound assessment weekly with treatment plan as directed . Cleanse wound, apply collagen followed by duoderm to be changed 3 times a week and as needed . On 10/23/24 at 9:44 AM, Surveyor observed R41 to be lying on her back, directly on her pressure injury with her heels in direct contact with her mattress. R41 indicated staff did not offer to put pillows or other offloading device under her feet but that she should have them up on pillows. R41 indicated she had a concern that the facility did not give her an air mattress until a few days ago. (It is important to note on or before 10/10/24, R41 developed a stage 3 pressure ulcer, and an air mattress was not placed until 10/16/24.) On 10/23/24 at 2:39 PM, Surveyor observed R41 to be lying on her back, directly on her pressure injury with her heels in direct contact with her mattress. R41 stated, They do sometimes put my feet up on pillows, but they didn't today. On 10/23/24 at 2:40 PM, CNA KK stated, R41's heels should be floated with pillows. I don't know why the first shift did not float them. Surveyor asked if R41 should be lying directly on her wound. CNA KK indicated she should not be. CNA KK indicated R41 was on a regular foam, bariatric mattress before she received this air mattress. On 10/23/24 AT 9:46 AM, DON B (Director of Nursing) indicated R41 was on a bariatric foam mattress until 10/16/24. Then R41 was given a bariatric air mattress. On 10/23/24, NHA A (Nursing Home Administrator) indicated R41 was on a Medline bariatric foam mattress until 10/16/24 when she was given a Proactive Protekt Aire, air mattress. Medline Bariatric Foam Mattress manufacturer recommendations for use, Medline.com, includes, in part: Three-layer foam mattresses helps prevent formation of pressure injuries . pressure injury risk level: high risk stage 1 and 2 . Proactive Protekt Aire Mattress 8000BA42 manufacturer's recommendations for use, undated, includes: 10x20 cells . prevention and treatment for pressure ulcers stage 1 to stage 4 On 10/23/24 at 4:34 PM, ADON X (Assistant Director of Nursing) indicated R41's heels should be floated. ADON X indicated R41's skin was fragile looking but there was no open area on 9/29/24. ADON X indicated she should have described the skin impairment in R41's medical record. ADON X indicated it was not open until the facility had her added to NP F's list to be seen. (It is important to note the facility sent an email on 10/2/24 asking that R41 be added to the list for NP F's wound rounds.) On 10/24/24 at 7:44 AM, CNA CC indicated she never saw the wound uncovered after initially finding it on 9/29/24. At the time she found it, it was not opened but was reddened and fragile looking. On 10/24/24 at 9:02 AM, NP F (Nurse Practitioner) indicated she has only seen R41's wound three times. NP F indicated the wound had 100% slough over the wound bed the first time she saw it and it was a stage 3 caused by pressure. NP F stated, It had been present for greater than a week when I first saw it. She refused to let me see it the week before. NP F indicated she expects the facility to follow SOP(Standard of Practice) for wound care including description and measurements to be completed weekly. NP F stated, I would expect them to be monitoring it. I don't know exactly what day it opened. They should have notified me when it opened or changed. I expect the facility to follow physician orders for wound care and heels floated. It was open for a week when I saw it, because the first time we went in on October 3rd, she refused to allow me to see it. She (R41) kicked us out of her room. (Of note, a wound with 100% slough should be classified as unstageable.) On 10/24/24 at 9:48 AM, Surveyor observed R41 to be lying directly on her wound with her heels in direct contact with her mattress. Surveyor observed R41's wound to be bright red without slough present. Facility staff had already completed wound care and did not inform Surveyor to be able to observe the wound care. During an interview, LPN C (Licensed Practical Nurse) indicated she and NP F did wound rounds together this morning. LPN C indicated NP F debrided the wound during wound rounds. LPN C described the debridement to Surveyor, stating, She took a q tip and roughed it up a little to remove the biofilm and to increase blood flow. LPN C indicated on 10/3/24, she was on vacation when NP F came to do wound rounds and R41 refused to allow NP F to assess the wound. LPN C stated, We don't usually reapproach for wound assessment. If NP F doesn't get it done or if R41 doesn't let NP F complete wound care, we wait until the next week. Surveyor asked how often wounds should be assessed. LPN C indicated she was not sure. LPN C indicated she added the air mattress on 10/16/24, stating, I asked (R41) if she wanted an air mattress and she did so I got her one on the 16th. After wound observation, Surveyor observed LPN C assist R41 back to lying directly on her wound and with her feet in contact with her mattress. LPN C exited the room. Surveyor asked LPN C if R41 should be lying directly on her wound and if her heels should be in direct contact with R41's mattress. LPN C began to walk down the hallway, Surveyor asked if LPN C was able to assist R41 with positioning off her wound and getting her heels floated. LPN C indicated she was, and she went back into R41's room and assisted R41 off her wound and positioned her heels to be floating. On 10/24/24 at 4:05 PM during an interview, DON B (Director of Nursing) and NHA A (Nursing Home Administrator) indicated R41 should not be positioned directly on her wound and her heels should be floated, not in direct contact with her mattress. DON B indicated R41's mattress should have been changed when her wound was staged at a stage 3 pressure injury, on 10/10/24. DON B and NHA A indicated when R41 refuses to be assessed by NP F another staff should attempt to complete the wound assessment, because the standard of practice and facility policy is to assess wounds weekly. DON B indicated a description should have been recorded in R41's medical record of R41's skin impairment when it was noted on 9/12/24 and on 9/29/24. DON B indicated she is unsure how the staff are monitoring the skin impairment without measurements or a description. NHA A and DON B indicated wound care should be completed as ordered and refusals should be charted in resident's medical record. DON B indicated a blank box on the TAR indicates the wound care was not completed.

Based on observation, interviews, and record review, facility staff did not ensure that each resident who required pain management received such services according to the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 2 residents (R26) reviewed for pain management resulting in R26 experiencing uncontrolled pain. R26 was experiencing breakthrough pain at 9 out of 10 severity and the facility staff did not provide her with pain medication over a period of 5 hours on 10/22/24. The facility had R26's as needed pain medication in contingency stock, however R26 was told the facility was out of her medication. R26's comprehensive care plan does not include individualized non-pharmacological interventions, and the medical record does not indicate any of these interventions being performed. This is evidenced by: The facility policy titled, Pain Management, dated 11/28/17, states in part: Purpose . Residents are observed for pain regularly during daily care and interactions. The facility clinicians use standardized pain scales when caring for residents that are able to assist in determining the severity of pain and effectiveness of interventions . The Interdisciplinary team (IDT), together with the resident and/or resident representative develop a Care Plan that will address the individual goals of comfort and individualized interventions to [NAME] those goals . General Guidelines . The resident experience of pain is highly individual and subjective. Pain is what the resident says it is . Be familiar with the physiological and behavioral signs of pain . Acute pain should be assessed every 30-60 minutes after the onset and reassessed as indicated after analgesic relief is obtained. Pain observation consists of gathering both subjective and objective data .Observation . Pain in our residents will be evaluated and/or observed as needed and: . before and after PRN analgesics . Suggestive Signs and Symptoms of Pain: . sighs, groans, crying, labored breathing .facial grimacing . Documentation: The resident's clinical record will include documentation on pain, pain medications and their effects. Specific areas include: -Each pain observation -Pharmacological and non-pharmacological interventions and their effects. Documentation should be recorded on the pain monitoring tool provided each residents individual Medication Administration Record (MAR) and should including the following, with regard to observation, evaluation and/or report of pain: Date, Time, Pain Rating, Pain Location, Pain Quality, Pain Duration, Non-Pharmacological Interventions, PRN Analgesics if provided and initial, Follow up Pain Rating, Time and Initial . Follow Up: Pain will be assessed regularly, Follow Up: . The resident's response to interventions and comfort level will be monitored. Side effects of pain medications will be monitored . If an acceptable comfort range is not met the interdisciplinary team, along with the physician shall reconsider approaches and make adjustments as indicated. R26 was admitted to the facility on [DATE] with diagnoses that include in part: Acute on Chronic Diastolic (Congestive) Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Infection, and Inflammatory Reaction due to Internal Right Hip Prosthesis, and Presence of Right Artificial Hip Joint. R26's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/24/24 indicates R26 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates R26 is cognitively intact. Section J indicates R26 is on a scheduled pain regimen, is receiving PRN (As Needed) pain medication, and receives non-medication pain intervention. Section J also indicates R26 occasionally has pain and that her pain occasionally affects sleep, therapy activities, and day-to-day activities. R26's Comprehensive Care Plan states, in part: Residents Acceptable Level of Pain is 1 on a 0-10 scale. Focus: The resident is on pain medication therapy per orders. Date Initiated: 9/27/24. Goal: The resident will be free of any discomfort or adverse side effects from pain medication through the review date. Date Initiated: 9/27/24. Target Date: 12/19/24. Interventions: Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT (every shift). Date Initiated: 9/27/24. Focus: The resident has the potential for pain. Date Initiated: 9/19/24. Goal: The resident will not have an interruption in normal activities due to pain through the review date. Date Initiated: 9/19/24. Target date: 12/19/24. The resident will not have discomfort related to side effects of analgesia through the review date. Date Initiated: 9/19/24. Target Date: 12/19/24. Interventions: Provide the following non-pharmacological pain interventions: (specify: Heat/Ice as ordered/tolerated, Distraction/Quiet Room, Repositioning). Date Initiated: 9/19/24. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 9/19/24. R26's Physician Orders state in part: Acetaminophen Capsule 500 MG (Milligrams) Give 2 capsule by mouth three times a day for pain Not to exceed 4000 MG APAP (Acetaminophen)/24 Hours. Start date: 9/25/24. Tramadol HCL Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for moderate and severe pain. Start date: 9/25/24. Tylenol Extra Strength Oral Tablet 500MG (Acetaminophen) Give 2 tablet by mouth at bedtime for pain Not to exceed 4000MG APAP/24 hours. Start date: 9/25/24. R26's Medication Administration Record (MAR), from October 2024, indicates, in part: 10/21/24: 12:03 AM- Tramadol 500MG x1 tablet administered for pain . Pain rating: 4 out of 10. Medication indicated to be effective. 8:00 PM- Acetaminophen 500MG x2 capsules administered as scheduled for pain . Pain rating: 0 out of 10. 8:00 PM- Tylenol Extra Strength 500MG x2 tablet administered as scheduled for pain . Pain rating 0 out of 10. 10/22/24: 8:00 AM- Acetaminophen 500MG x2 capsules administered as scheduled for pain . Pain rating: 4 out of 10. 1:00 PM- Acetaminophen 500MG x2 capsules administered as scheduled for pain . Pain rating: 4 out of 10. 1:55 PM- Tramadol 500MG x1 tablet administered for pain . Pain rating: 4 out of 10. No indication provided at time document was printed on 10/22/24 at 17:59:33 (5:59 PM) On 10/22/24 at 8:55 AM, Surveyor observed R26 tell a facility CNA (Certified Nursing Assistant) that she wanted her pain medication. CNA acknowledged R26 then went directly to speak to LPN HH (Licensed Practical Nurse). On 10/22/24 at 8:56 AM, Surveyor interviewed R26. R26 was seated in a wheelchair during the interview. Surveyor observed R26 to be tremorous and visibly winced whenever she moved. R26 stated that she noticed her pain start to become worse when they started to reduce her prednisone (steroid). R26 confirmed that she had just requested her pain medication from the CNA. On 10/22/24 at 11:44 AM, Surveyor was in the process of interviewing LPN HH, when Surveyor and LPN HH were approached by RN LL (Registered Nurse). RN LL is employed by an outside agency. RN LL advised LPN HH that R26 was in severe pain and was requesting pain medication. LPN HH stated that R26 had already received her scheduled pain medication. RN LL asked LPN HH if R26 had any PRN (as needed) pain medications available. LPN HH stated the resident is out of her PRN pain medication. RN LL asked if maybe a provider should be called then so that R26's pain can be treated. LPN HH stated, I was just getting to that. RN LL provided LPN HH her business card and requested a phone call once R26's pain medication was provided. LPN HH indicated she would call RN LL. On 10/22/24 at 11:55 AM, Surveyor interviewed R26. R26 appeared visibly upset. Surveyor observed R26 to be teary-eyed and wincing with movement. Surveyor asked R26 if she had received her pain medication as she requested. R26 stated she had not. R26 also stated that she can't bend down due to the pain and was crying before her (Agency Nurse's Name) arrival because she was in so much pain. R26 stated, I've just been sitting here suffering. On 10/22/24 at 3:19 PM, Surveyor interviewed R26. R26 confirmed that facility staff did come in and administer her pain medication. Surveyor advised R26 that the MAR (Medication Administration Report) indicates she reported a pain level of 4 out of 10 today to facility staff, Surveyor asked R26 if this is correct. R26 appeared visibly angry and stated If I'm crying you know I'm in pain. I don't cry over a 4. R26's Medication Administration Record (MAR), from October 2024, indicates, in part: 10/22/24: 1:55 PM- Tramadol 500MG x1 tablet administered for pain . Pain rating: 4 out of 10. (Of note, R26 waited 5 hours for pain medication for breakthrough pain. It should be noted the pain medication was available in the facility contingency.) On 10/22/24 at 4:34 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B to show Surveyor how the contingency stock worked. DON B led Surveyor to the medication room and to a machine containing a variety of medications. While DON B was accessing R26's contingency stock, Surveyor asked DON B what she what the expectation is for staff prior to administering pain medication. DON B states, she would expect a resident assessment and based off assessment findings, appropriate interventions would be decided, either non-pharmacological or pharmacological interventions. Surveyor asked DON B how soon an assessment or treatment should be provided to the resident following a complaint of pain. DON B states as soon as possible. DON B demonstrated that the facility has a machine that is stocked with R26's PRN pain medication. Surveyor asked DON B which staff members in the facility have a code for the contingency stock. DON B stated all licensed nurses who are directly employed by the facility staff along with some agency nurses. DON B also states that per diem nurses who are not regularly on the schedule do not have a contingency code and should seek assistance from facility nurses. Surveyor asked DON B what the process is for pulling medication from the contingency stock. DON B states, nurses are expected to call the pharmacy for a contingency code, and once they have the code the medication should be pulled from the machine and administered to the resident. Surveyor asked DON B if the medication is available in contingency stock, would she expect it to be administered to the resident if no stock is available in the medication cart. DON B states, yes. Surveyor asked DON B if she would expect agency staff without contingency codes to seek assistance from other staff members to obtain contingency stock medication. DON B states, yes. On 10/23/24 at 11:35 AM, Surveyor interviewed RN LL. RN LL is employed by an outside agency. Surveyor asked RN LL if R26 told her she was in pain during her visit on 10/22/24. RN LL stated that she was told the resident asked for her pain medication, but that facility staff told her they had nothing to give R26. RN LL also stated that R26 told her that her pain was at 9 out of 10 severity. Surveyor asked RN LL if she made any visible observations of the resident's status. RN LL stated that she could visibly see that the resident was in pain. Surveyor asked if the facility ever returned the call that RN LL had requested. RN LL stated they did not, so she called R26 directly to check on her. R26 was admitted with diagnosis including Acute on Chronic Diastolic (Congestive) Heart Failure and Infection and Inflammatory Reaction due to Internal Right Hip Prosthesis. R26 was in severe, breakthrough pain and the facility did not provide R26 with her prescribed PRN pain medication or document non-pharmacological pain management causing the resident to experience severe pain for 5 hours.

Based on interview and record review, the facility did not ensure that each resident received, and the facility provided, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 7 of 27 residents (R58, R13, R66, R76, R79, R80 and R42 .) reviewed for change of condition. R58 and R13 are being cited at severity level 3 (actual harm). R66, R76, R79, R80 and R42 are being cited at severity level 2 (potential for more than minimal harm). R58 had an infection in his tooth (abscess) and the facility did not follow up with orders to obtain the antibiotic, did not initiate antibiotic therapy and did not monitor R58's mouth pain and oral condition. R58 was seen on 9/4/24 by a dentist and prescribed Amoxicillin for swelling in his gums this ordered was not followed by the facility and R58 did not receive the prescribed antibiotic. On 9/24/24 as part of a follow-up visit, an RDH (Registered Dental Hygienist) observed pus coming from the same area noted by the dentist on 9/4/24 and an antibiotic was re-prescribed 20 days later. The facility did not monitor or assess R58's oral status during this time (9/4 to 9/24). R13 had a blister develop on her right breast on 9/24/24, there was no initial measurement completed, staff did not complete treatments on 9/26/24 and 10/7/24. Staff document the blisters were no longer present on 9/30/24. On 10/3/24 the blisters are documented as open areas and have deteriorated necessitating a new order added for Santyl (used to remove damaged tissue) with a bordered foam dressing. No assessments/measurements of the wound were completed from 10/3 - 10/7/24. On 10/5/24 a new order was added for doxycycline (an antibiotic) for a wound infection. The facility failed to implement aggressive preventative measures to prevent R13's wound from deteriorating/worsening and to prevent additional wounds from developing. R66 presented to the facility at high risk for infection due to her immunocompromised status related to actively receiving chemotherapy and renal stent (a thin, flexible tube that's placed in the ureter to help urine pass from the kidney to the bladder.) At no point in this time period did R66 have a care plan related to her chemotherapy. A full set of vital signs, including temperature, were only taken in September on 9/10/24, 9/19/24, 9/20/24, and upon readmission to the facility on [DATE]. Facility staff did not complete a full nursing assessment to monitor any adverse effects that may occur as the result of R66's chemotherapy treatment and increased risk of infection. R76 did not have wound care documented that it was completed as ordered. R79 did not have wound care documented that it was completed as ordered. R80 did not have an assessment documented prior to being sent to the ER (emergency room ). The facility failed to assess and document R42's change in condition prior to sending R42 to the hospital. The facility failed to monitor and observe R42 for a minimum of 72 hours after R42's fall on 10/19/24. Example 1 According to the Cleveland Clinic, if left untreated, a tooth abscess (infection in the root of a tooth) can spread to your jawbone, the soft tissues of your face and neck, and beyond. In extremely rare cases, the infection can travel to your heart (endocarditis) and brain (bacterial meningitis). Abscesses are caused by broken, chipped or cracked teeth. Bacteria can then seep into any opening in a tooth and spread to the pulp. Signs of a tooth abscess include gum redness and swelling and open draining sore on the side of your gums. (https://my.clevelandclinic.org/health/diseases/10943-abscessed-tooth) According to the Mayo Clinic, leaving a tooth abscess untreated can lead to serious, even life-threatening, complications. Treatment of a tooth abscess include extraction, root canal, draining and antibiotics. R58 was admitted to the facility on [DATE] and has diagnoses that include Type 2 diabetes, atherosclerotic heart disease, respiratory failure, chronic pain syndrome and a history of MRSA (Methicillin-resistant Staphylococcus aureus). His most recent MDS (Minimum Data Set), dated 8/13/24, shows a BIMS score (Brief Interview for Mental Status) of 15, indicating R58 is cognitively intact. R58 is independent with oral cares. His care plan states, Focus: Resident has dental/oral problems .Goal: The resident will comply with mouth care .Interventions: Resident has no teeth/dentures. Of note, R58 does have a few remaining teeth. On 9/4/24, a DDS (Doctor of Dental Science) came to see R58 at the facility. DDS's post visit summary stated, Patient scheduled for initial exam by hygienist for draining broken tooth. Patient is edentulous upper arch with 4 lower teeth and root #27 present. Gingival swelling present, on facial of root #27. Patient reports no symptoms. Patient is very afraid of dentists and is unsure about oral surgery referral for extraction. Will advise staff on RX (prescription) Amoxicillin 500 mg x 30 tabs. Take 1-tab 3x/day until gone. Will follow-up at next visit for eval/consult. Patient understood and is satisfied. R58 was visited by RDH (Registered Dental Hygienst) on 9/24/24 as part of a regular cleaning and follow-up visit. RDH's post visit note states, Heavy plaque present, brushed patient's teeth first to remove prior to scaling moderate calculus (calcified dental plaque); scaled to patient's tolerance; toothette used to rinse and control bleeding; instructed patient to brush teeth/tongue; patient is still in a lot of pain and said that he has not received antibiotic yet-I did send a message to dentist to see if we still need this RX sent over. Patient is miserable; oral hygiene is not good at all, heavy bleeding, heavy plaque, moderate/heavy calculus, patient is not cooperative. On 10/28/24 at 9:56 AM, Surveyor interviewed RN Q (Registered Nurse) who stated that about a month or so ago R58 stated to her that his teeth hurt and she observed that R58 had a swollen area on his gums. RN Q stated that she then contacted the nurse practitioner. A nurse practitioner progress note on 9/24/24, with a noted time of service of 2:15 PM states, Patient complaining of increased pain to his right lower gum, noted small dental carry (cavity) on right gum with inflammation and redness, at this time we will treat for tooth abscess and recommending patient to follow-up with insurance coverage and to be seen by an oral surgeon. No reported chest pain, dyspnea, constipation, diarrhea, nausea, vomiting Chart reviewed. Care discussed with nursing staff offer no new concerns. Periapical abscess without sinus. Augmentin ordered for 7 days, follow up with oral surgeon It should be noted that R58's pain is evaluated each shift (3 times daily) at the facility and his self-described acceptable level of pain is 1 on a scale of 1 to 10. This evaluation does not indicate where his pain is, and there is no documentation showing the facility was specifically monitoring R58's oral pain or checking R58's oral status. Between 9/4/24 and 9/24/24, R58 rated his general pain at 5 or higher on 26 occasions. Additionally it should be noted that the facility weighed R58 only twice during the time period of 9/4/24 and 9/24/24. On 8/21/24, the facility logged R58's weight at 292.1 lbs. and on 9/9/24 registered him at 279.6 lbs. On 10/24/24 at 2:55 PM, Surveyor interviewed DON B (Director of Nursing), who provided Surveyor with an email that she received on 9/4/24 at 11:56 PM from the dental office with the attached after visit summary and order for Amoxicillin. DON B stated she just missed it. When asked what the process is for getting such orders from an outside provider such as the dentist, DON B stated that after-visit summaries are emailed within a few days of visits to her, the social services director and the assistant director of nursing. DON B stated that each person needs to open all emails and that she (DON B) looks at all emails and would be responsible for making sure orders are filled timely. Additionally, DON B stated that she was unaware that R58 did not get this antibiotic timely until it was brought to her attention by Surveyors. On 10/28/24 at 2:49 PM, Surveyor interviewed DDS O (Doctor of Dental Surgery) who stated that during his visit on 9/4/24, he could see swelling on the gums of R58, but he could not see any pus or drainage at that time and felt that an antibiotic was the best course of action as R58 did not want any surgical intervention and was afraid of dentists. On 10/28/24 at 11:56 AM, Surveyor interviewed RDH P (Registered Dental Hygienist) who stated that she was at the facility on 9/24/24 between 10:00 AM and 1:00 PM and she observed pus coming from R58's broken tooth and that R58 absolutely had a tooth abscess. RDH P described the gum area as red and swollen. RDH P stated that when she pushed on the inflamed gum tissue near the tooth, pus continued to ooze out. RDH P stated that R58 told her that he had not yet received the antibiotic prescribed by DDS O, so she contacted DDS O and confirmed that the order had been sent over to the facility. RDH P stated that she did not speak with a nurse at the facility. RDH P stated that when she sees an infection, she personally sends a message to her office to notify them. RDH P also stated that R58 told her that he couldn't eat, it was keeping him up at night, and that it was a throbbing pain that was making his face throb and making him miserable. RDH P stated what she observed was absolutely clear to me that it was infected. Additionally, RDH P stated that in her over [AGE] years as an RDH, she has seen abscesses spread to the neck of patients, which required emergency drainage. R58 was started on Amoxicillin on 9/25/24 with a first dose noted on his MAR (Medication Administration Record) at 9:00 PM. This course of antibiotics was concluded on 10/2/24. The facility was made aware by DDS O through his after-visit summary (emailed on 9/4/24) that R58 had a potential infection (abscess) on 9/4/24 with orders to treat with an antibiotic. The facility did not act on these orders and did not monitor/reassess R58 and on 9/24/24 RDH P observed the same area to be infected and emanating pus. 30992 Example 2 The facility policy, Pressure Injury/Skin Integrity, reviewed 10/21/24, documents, in part, as follows: It is the policy of this facility to enable nursing staff to manage wounds and select appropriate interventions according to the National Pressure Ulcer Advisory Panel (NPUAP). Procedure Wound Care Team - Wound Care Team will include the participation of the Wound Care Nurse, Director of Nursing, Therapy Representative, Dietician, Director of Clinical Services, and the Medical Director as needed. The wound care team committee will meet at least monthly to review current wounds, change of conditions, and overall plan of care. The wound team will submit a report to be discussed at the quarterly QAPI (Quality Assurance and Performance Improvement) meeting. Wound rounds will be completed weekly by a licensed nurse and overseen by the Director of Nursing. Weekly documentation of wounds is completed by a licensed nurse. The goal for wound care is to prevent or manage the cause, provide a moist wound healing environment, avoid further trauma, protect surrounding skin, manage exudate, avoid infection, ensure adequate pain control. Interventions: Interventions will be implemented to mitigate the risk for skin breakdown, based on individual risk factors, and may include, but are not limited to: .devices to eliminate or reduce friction and shearing .Interventions should be documented in the residents' EMR (Electronic Medical Record), including the residents individualized resident-centered plan of care. Wound Identification: It is important that each pressure ulcer, or non-pressure wound be identified. Identification of factors that may have influenced development of the wound (root cause analysis), the potential for development of additional wounds, or for the deterioration of the pressure ulcer(s) should be recognized and may include Differentiate the type of wound (pressure-related versus non-pressure related); Describe and monitor the wound's characteristics. Monitor the progress toward healing and for potential complications. Determine if infection is present. Assess, treat, and monitor pain, if present, and Monitor dressings and treatments. Treatment/Management: Residents with risk for or who have a loss of skin integrity will receive the appropriate treatment/services which may include Specific physician ordered medication/treatment, rehabilitation services, assessments/care to prevent infections. Interventions and treatments should be routinely evaluated for efficacy and modified/changed as needed. Documentation: Routine ongoing documentation should be conducted related to the resident's skin condition and the resident's response to the care and treatment of the skin. The frequency of documentation shall be determined based on the resident's individual needs in accordance with accepted standards of practice. Wound documentation is more detailed than routine skin documentation and shall include information related to the wound based on a clinical assessment. R13 was admitted to the facility on [DATE] with diagnoses including, but not limited to, displaced bimalleolar fracture, acute kidney failure stage 2 (mild), hepatitis C, cocaine and alcohol abuse, intervertebral disc degeneration, and osteoarthritis. Of note, R13 is not diabetic. R13's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R13 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 14. R13's MDS indicates she is at risk for skin impairment. R13 was admitted with no skin impairment. R13's Certified Nursing Assistant (CNA) Visual/Bedside Kardex, dated 10/23/24, documents the following: Skin: Apply barrier cream per orders as needed with episodes of incontinence. Encourage and assist with frequent repositioning while in bed an ensure to document refusals. Provide pericare after each incontinent episode. On 9/11/24, R13's Braden Score is 17, indicating she is at risk of skin breakdown. On 9/13/24, PTA/DOR D (Physical Therapy Assistant/Director of Rehab) documented the following note: .WC (wheelchair) switched out for one same size but easier to propel. Pt (patient) can propel x 66 ft (feet) and states she likes better. Note, PTA/DOR D is currently on leave and unavailable for interview. On 9/16/24, R13's Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review: CNA & RN J (Registered Nurse) signed - No concerns documented. On 9/22/24, R13's Skin Check documents Redness under L (left) breast. On 9/23/24, R13's Skin Check documents Redness under L (left) breast. On 9/23/24, R13's Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review: CNA & RN J (Registered Nurse) signed - No further skin issues. On 9/24/24 at 4:54 PM, RN I (Registered Nurse) documented the following progress note: *Skin Observation Note Text: Resident has NEW skin issue(s) observed. 1 Other (specify) - two big blisters to top of left [SIC] breast, states she has no idea where it came from, filled with fluid. Skin turgor with good elasticity. Skin color is normal for ethnic group. Skin temperature is warm (normal). Skin moisture is normal. Skin condition is normal. No other issues noted. Note, initially the facility has no documentation that the Physician/NP (Nurse Practitioner) was notified until Surveyor was investigating and asking questions related to Physician/NP notification. As a result, the following note (late entry) was entered by Physician E: On 9/24/24 at 5:15 PM, Physician E documented the following note (late entry): Chief Complaint: Skin blister Subjective: RN informed me of the patient's skin irritation underneath R (right) breast. Blister-like lesion as per report is not open, not weeping. Recommend applying skin prep on the affected area BID (two times daily) and reassess patient in 1 week or sooner. Consider wound RN consult. Physical Examination: N/A (Not Applicable) Assessment and Plan 1. Skin irritation/blister-apply skin prep BID. This note was electronically entered and signed by Physician E on 10/28/24 at 8:28 AM. On 9/24/24, R13's TAR (Treatment Administration Record) documents the following treatment order: Wound care: R (Right) breast, skin prep BID (twice daily) to blister - two times a day for wound care. Order Date: 9/24/24; D/C (Discontinue Date): 10/2/24. The facility scheduled the treatments at 8:00 AM and 8:00 PM daily. On 9/26/24, the facility did not complete R13's 8:00 PM treatment per Physician orders. R13's TAR (Treatment Assessment Record) documents the facility continued the skin prep treatment from 9/24/24 - 10/2/24. On 9/30/24, RN J (Registered Nurse) documented the following: No new skin issues and blisters are no longer present to right breast. Note, on 10/10/24 NP F (Nurses Practitioner) documents R13's wound Developed from ruptured blister. On 10/28/24 at 9:05 AM, Surveyor spoke with RN J (Registered Nurse). Surveyor showed RN J her documentation from 9/30/24 and asked what she observed. RN J stated the blisters were flat with no fluid. RN J stated, They weren't popped, they were absorbed. On 10/1/24, there is no documented assessment or measurement of R13's blister. On 10/2/24, there is no documented assessment or measurement of R13's blister. On 10/3/24, Physician E ordered the following: Wound care R breast; cleanse area dry apply Santyl apply bordered foam dressing. To be done DAILY in the morning for wound care start on pm shift 10/3/24. Of note, there is no assessment/measurement of R13's wound. On 10/3/24, R13's TAR documents the following: Wound care: R (Right) breast: Cleanse area dry apply Santyl. Apply bordered foam dressing. To be done daily in the morning for wound care start on PM shift 10/3/24. On 10/3/24, handwritten Wound Rounds documents R13, refused stated she's using cocoa butter. Note, this was not provided to Surveyor until 10/28/24 after the facility was notified of serious concerns related to this wound. In addition, this information is not documented in R13's medical record. Also of note, R13 stated to Surveyor that she has not put cocoa butter or any lotion on the blisters when they were intact or open. On 10/5/24, NP F (Nurse Practitioner) documented the following order for R13: Doxycycline hyclate 100 mg tablet Route: by mouth two times a day for wound infection for 7 days. On 10/7/24, the facility did not complete R13's Santyl treatment and dressing change. On 10/4/24, 10/5/24, and 10/6/24, RN J completed R13's treatment to the right breast. There is no documented assessment, measurement, or description of the wound bed to R13's right breast. On 10/7/24, the facility did not complete R13's treatment per Physician orders. On 10/7/24 at 2:35 PM, RN J (Registered Nurse) documented the following progress note: Resident has no new skin issues observed. It is important to note, because R13's treatment was not completed staff did not visualize R13's wound on this date. On 10/8/24, the facility documented the following assessment and measurement of R13's right breast: 4.71 x 1.87 - 70% slough, 30% epithelial. No evidence of infection. Santyl, silicone dressing. Blister that opened. In house acquired. On 10/8/24, MDS RN G (Minimum Data Set Registered Nurse) updated R13's comprehensive care plan documents the following: The resident has actual skin impairment to R (right) breast. (Date Initiated: 10/8/24) Goal: Resident skin impairment will improve by review date. (Date Initiated: 10/8/24) (Target Date: 11/17/24) Interventions: Evaluate and treat per physicians orders. (Date Initiated: 10/8/24) On 10/10/24, R13's Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review: CNA and RN J - Shower given, hair washed, sheets changed, wound cleaned and dressing changed; circled 9. Blisters. RN J documented Wound care in place. On 10/10/24, NP F (Nurse Practitioner) documented the following: Chief Complaint: Initial evaluation of breast Initial evaluation ruptured blister R (right) breast wound necrotic tissue, slough to majority of wound bed, no warmth or purulent drainage. Subjective: Patient seen today for initial evaluation of ruptured blister to right breast. Wound examined and noted to have necrotic tissue, slough to majority of wound bed. Patient reports tenderness to right breast. No warmth or purulent drainage. No current S/SX (signs/symptoms) of infection. Full assessment and plan as below. Diagnosis that could affect wound healing: CKD (Chronic Kidney Disease), hep C (hepatitis), obesity, tobacco use. Interventions in place: Continue nutritional support, continue hygiene care, continue weekly wound assessment with treatment plan as directed. Plan: Cleanse wound apply Santyl over areas of slough followed by bordered foam to be changed daily. Orders given for lidocaine 5% ointment for potential debridement next week. Assessment: Unspecified open wound of right breast, initial encounter. Developed from ruptured blister now with necrotic tissue covering majority of wound bed. No erythema or warmth to periwound. There is some tenderness to right breast. It does not appear to have active infection to wound. Full assessment and plan as above. On 10/14/24, R13's Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review: CNA and RN J (Registered Nurse) signed (Circled both breasts.) On 10/15/24, NP F (Nurse Practitioner) documented the following assessment: 4.71 x 1.87 80% epithelial. 20% granulation. Santyl, silicone. Blister opened. On 10/21/24 at approximately 11:15 AM, Surveyor spoke with R13. Surveyor asked R13 if she has any open areas on her skin. R13 stated yes and pointed to the side of her right breast. R13 asked Surveyor if she would like to see a photo of her open area. R13 showed Surveyor a photo of the open area on her right breast. On 10/21/24 at approximately 11:30 AM, Surveyor asked DON B (Director of Nursing) what caused the wound to R13's right breast. DON B stated she will check and find out. On 10/21/24 at 12:05 PM, DON B stated R13's wound to her right breast was caused by, Ruptured blisters from new wheelchair so she can propel. On 10/21/24, R13's Skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review: CNA & RN J (Registered Nurse) Right breast circled, wound care in place, bandage. On 10/22/24, NP F (Nurse Practitioner) documented the following assessment: 1.22 x 1.01 Santyl, silicone. Ruptured blister in house acquired. On 10/22/24, MDS RN G (Minimum Data Set Registered Nurse) updated R13's comprehensive care plan with the following intervention: Resident encouraged to choose clothing that avoids skin on skin friction and encouraged to store personal belongings in bag rather than undergarments. (10/22/24) It is important to note, this intervention related to friction was not added to the care plan until survey was in process and Surveyor was asking questions regarding the root cause of R13's wound to her right breast. On 10/23/24 at 3:04 PM, Surveyor spoke with OT/Acting DOR U (Occupational Therapist/Acting Director of Rehab). OT/Acting DOR U stated, R13 is currently receiving PT (Physical Therapy) and works with PTA/DOR D (Physical Therapy Assistant/Director of Rehab) and PT H (Physical Therapist). Surveyor asked OT/Acting DOR U what R13 was receiving PT for. OT/Acting DOR U stated, R13 was originally seen for a fracture of her leg and has been long term care since that point. OT/Acting DOR U stated, R13 would like to transition to a lower level of care however, right now she is still a Hoyer (total body lift for transfers). Her insurance has only approved so many days or only approved for OT (Occupational Therapy), so we have been seeing her on and off. OT/Acting DOR U stated, R13 is working with PT for strengthening and eventually for her to stand. Surveyor asked OT/Acting DOR U, is therapy working with R13 on her positioning. OT/Acting DOR U stated, we might have switched out her wheelchair as she had trouble propelling her wheelchair a few months ago. OT/Acting DOR U added, R13 had trouble pushing the wheelchair with her arm. Surveyor reviewed therapy documentation with OT/Acting DOR U. OT/Acting DOR U stated, she thinks R13 has always had a good size (correct fit) for her width. Surveyor asked OT/Acting DOR U, since R13 got her new wheelchair have you seen her since. OT/Acting DOR U stated, no, most of our work with R13 has been on strengthening. OT/Acting DOR U added, R13 also worked on wheelchair propulsion. After reviewing R13's therapy notes, OT/Acting DOR U stated, No, there's nothing related to positioning. OT/Acting DOR U stated, on 9/13/24 PTA/DOR D (Physical Therapy Assistant/Director of Rehab) documented the following note: .WC (wheelchair) switched out for one same size but easier to propel. Pt (patient) can propel x 66 ft (feet) and states she likes better. Note, PTA/DOR D is currently on leave and unavailable for interview. OT/Acting DOR U stated, R13 is not currently receiving OT but is receiving PT. OT/Acting DOR U stated, PT H (Physical Therapist) just saw R13 today. Surveyor asked OT/Acting DOR U, has the facility made therapy staff aware of a wound to R13's breast. OT/Acting DOR U stated no. Surveyor asked OT/Acting DOR U, has the facility made therapy aware that R13 puts items in her bra, tops or under her arm. OT/Acting DOR U stated, I am not. Surveyor asked OT/Acting DOR U, could friction from items in her bra, top, or under her arm cause an open area to the side of her right breast. OT/Acting DOR U stated, Potentially. OT/Acting DOR U stated, If something large was there it could, I guess it would depend on the amount of pressure or time it's placed there. On 10/23/24 at 3:48 PM, Surveyor spoke with MDS RN G (Minimum Data Set Registered Nurse). Surveyor asked MDS RN G about the following care plan intervention: Resident encouraged to choose clothing that avoids skin on skin friction and encouraged to store personal belongings in bag rather that undergarments, dated 10/22/24. MDS RN G stated, over the summer when R13 was outside in the smoking area R13's phone fell on to the ground. MDS RN G stated, she was wrongly under the impression it fell off R13's lap until R13 stated it fell out of her shirt. MDS RN G stated, R13 got a wheelchair upgrade so she can propel more. MDS RN G stated, sometimes there was rubbing as she was self-propelling more. MDS RN G stated R13 would often keep her cell phone and other things in her bra. MDS RN G stated, now R13 has a purple backpack on the back of her wheelchair to carry belongings (added 10/22/24). MDS RN G stated, she got the backpack, she was proud and showing off where she puts her phone. Surveyor asked MDS RN G, did you have conversations with R13 regarding not storing her phone in her bra, top, under her arm. MDS RN G stated, yes, she had ongoing conversations with R13 especially during the summer. MDS RN G stated, I have a feeling she didn't change her behavior for me. MDS RN G stated when R13 is outside smoking, she has a pack of cigarettes in her bra or under her arm. MDS RN G stated she has not seen R13 put anything else besides her phone or cigarettes in her bra, top, or under her arm. Surveyor asked MDS RN G, did you document, or care plan this concern. MDS RN G stated No. MDS RN G stated now that it's cooler, R13 wears a hoodie with pockets and stores her phone there. MDS RN G stated she just heard R13 has an open area. MDS RN G stated, this past summer was the last time MDS RN G could tell R13 had something in her bra or inside her top because it fell out. MDS RN G stated she was worried about R13's hygiene and moisture trapped in there. MDS RN G stated, I didn't think about the fact it could cause issues. MDS RN G stated R13 is sweaty, and moisture accumulates in folds. MDS RN G stated it is her expectation that R13 not put stuff in her bra, top, and under her arm. Surveyor asked MDS RN G, when was this care plan intervention added to R13's care plan. MDS RN G stated, we talked about it the evening of 10/21/24 and she added it to R13's care plan on 10/22/24. (Note, this intervention was added after survey was in process and Surveyor was asking questions related to R13's wound.) On 10/23/24 at 4:08 PM, Surveyor spoke with PT H (Physical Therapist). PT H stated PTA/DOR D (Physical Therapy Assistant/Director of Rehab) has been working with R13 and he is currently on leave. PT H stated she has worked with R13 the last few weeks on lower extremity strength, ankle weights, and stand lift. PT H stated PTA/DOR D has been working with R13 doing a lot of standing exercises. PT H stated she saw R13 today and together they made a plan to work on standing exercises on 11/1/24. PT H reviewed R13's therapy documentation indicating PTA/DOR D switched R13's wheelchair on 9/13/24. Surveyor asked PT H, has the facility made you aware of a wound on R13's right breast due to propelling in her wheelchair. PT H stated, I was not aware of that, no. PT H stated she worked with R13 today and neither staff nor R13 mentioned anything to her regarding a wound. It is important to note, the facility did not talk with therapy regarding other possible options related to positioning or padding the armrest that may prevent the wound from worsening and prevent further skin breakdown and wounds. PT H added, as it gets cold R13 is wearing more layers, maybe it could be with the layers. PT H stated nursing address the treatments, but therapy may be able to assist with positioning. On 10/24/24 at 8:50 AM, Surveyor contacted RN I (Registered Nurse), the staff member that R13 reported the open area to. Surveyor did not receive a return phone call. On 10/24/24 at 9:08 AM and 10/28/24 at 11:53 AM, Surveyor spoke with NP F (Nurse Practitioner). Surveyor asked NP F, would you have expected an initial measurement of R13's wound to her right breast. NP F stated usually she measures the wounds, the facility brings them to her attention. NP F stated it would need to be an RN (Registered Nurse) who measures typically when a resident has an open wound. NP F stated she would not expect the facility to measure intact blisters. NP F stated she expects the facility to notify her. NP F stated she doesn't ask the facility what the measurement is, she just goes and does her own assessment. Surveyor asked NP F, on 9/30/24 when R13's blisters were noted to be no longer present would you expect staff to continue to assess the area. NP F stated, not if it was resolved, they would then just proceed with their normal skin checks. Surveyor shared documentation with NP F from 9/24/24 that reads as follows: On 9/24, staff noted two big blisters to top of left breast, states she has no idea where it came from, filled with fluid. Surveyor asked NP F, when did the facility notify you regarding the blisters. NP F stated, I can just go off when I saw them, they notified me at some point because I started seeing her on 10/10/24. NP F stated sometime the week prior to 10/10/24 she was notified and her initial assessment of R13's wound was on 10/10/24. NP F stated maybe the other provider for Internal Medicine was notified before. NP F stated the clinic has a record of when the facility notified them. Surveyor asked NP F, how often should staff assess and measure the wound. NP F stated, At least weekly and I'll do the measurements weekly with LPN C (Licensed Practical Nurse). Surveyor asked NP F, would you expect staff to describe the wound bed during the assessments. NP F stated, that's what I do and then they have a report too. NP F stated LPN C writes it down and puts it in their system (electronic medical record). Surveyor asked NP F, do you know what caused R13's open area to her right breast. NP F stated, Honestly I don't. NP F added, R13 has no history of blisters, I don't know if it [TRUNCATED]

Based on staff interview, record review, document review, and policy review, the facility did not ensure staff responded appropriately to an alarm and provided adequate supervision to 1 of 2 (R5) residents reviewed for elopement. R5 was assessed by the facility to be at risk for elopement. He did wear a WanderGuard. On 12/18/23, R5 eloped from the facility and was found on facility grounds by staff. On 02/25/24, at approximately 04:26am, R5 eloped from the facility through an alarmed door. Staff responded to the alarm but did not look outside the door to determine if anyone was outside. Staff did not begin a room-by-room search until approximately 30 minutes later when it was noted R5 was not in the building. Law Enforcement was not notified of the missing resident for 2 hours. R5 was found at a gas station approximately 1.5 miles from the facility around 07:32am and returned him to the facility at 08:06am. The facility's failure to implement appropriate safety measures and provide adequate supervision to R5 created a finding of Immediate Jeopardy that began on 02/25/24. The Administrator, Director of Nursing (DON), and Nurse Consultant were informed of Immediate Jeopardy on 4/11/24 at 11:30 AM. The immediate jeopardy was removed and corrected on 02/25/24. Findings include: The facility's policy titled; Elopement/Unsafe Wandering dated 01/04/24 contains the following information: .4. Procedure for Locating Missing Resident. a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g., intimal alert code). b. Quickly determine if the resident is out on leave or pass. c. Initiate a rapid search of the building and the grounds. d. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department . The policy does not address how quickly to notify the police after a resident elopes from the facility and does not address to not turn off the door alarm until the resident is found. On 04/29/24 at 10:53am, the DON confirmed with Surveyor that this was the facility's policy prior to R5's elopement on 2/25/24 and that this is still the facility's policy. She said the policy was reviewed by Quality Assurance and Performance Improvement (QAPI) and the facility's corporate office and no changes were made to the policy. R5 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to occlusion or stenosis of right carotid arteries, dementia with agitation, cognitive communication deficit, muscle weakness, difficulty in walking, congestive heart failure, blindness of one eye, and hearing loss. R5 was ambulatory with the use of a rolling walker. R5 was mostly supervision or touching assistance with activities of daily living (ADLs). R5's annual Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 10/05/23, contained a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 was cognitively intact. Upon a readmission on 10/23/23, R5 was assessed to be an elopement risk due to impaired safety awareness. R5's quarterly MDS assessment with an ARD of 01/05/24, indicated R5 had a decline in his cognition with a BIMS score of 8 out of 15 which indicated R5 was moderately cognitively impaired. The MDS indicated R5 had a history of wandering and exit seeking, wore a WanderGuard, had impaired balance and limited mobility, required a walker to ambulate, and was at risk for falls. R5's care plan included a problem of Elopement risk/wanderer due to impaired safety awareness initiated on 09/26/23, which indicated the following interventions: Staff aware of resident's wander risk, check WanderGuard placement and functionality every shift, encourage and assist resident to call his daughter from his room telephone, wander alert personal safety device on right ankle, offer food and fluids, resident enjoys coffee, engage in therapeutic conversation and encourage resident to visit/converse with other residents. R5's Visual/Kardex Report (Certified Nursing Assistant care card) dated 12/20/23 and provided by the DON (Director of Nursing) listed safety interventions of: check WanderGuard placement and functionality every shift, encourage and assist resident to call his daughter from his room telephone, ensure appropriate visual aids, glasses, are available, safety device wander guard to right ankle and mobility indicates uses walker. R5's Wander/Elopement Risk Evaluation dated 01/11/24 and provided by the DON indicated a score of 29. The document indicated, a score equal or greater than 6 is at risk. The document indicated R5 was physically able to leave the building on his own; R5 was independent with mobility; and his mode of locomotion was marked ambulatory. R5's EMR (electronic medical record) and investigative file provided by the DON contained the following attempted elopements: On 12/18/23, R5 eloped from the facility around 1:50 AM through the Harbor Hall dining room door which sounded an alarm. Staff responded to the door alarm sounding, looked outside the door, and located R5 and brought him back into the building. Following the 12/18/23 elopement, staff were educated and R5's care plan was updated to include approaches to offer food and coffee, encourage resident to visit with other residents, and engage in therapeutic conversation. Review of a facility investigation revealed that R5 had a second elopement on 2/25/24. On 02/25/24, R5 eloped from the facility's front doors triggering the alarm at 4:26 AM. According to Registered Nurse (RN) 3, on 02/25/24 he heard the alarm and went to the front door where Certified Nurse Aide (CNA) 3 was resetting the door alarm and told him everything was fine and that all the residents were in their beds. At approximately 5:00AM, CNA3 came up to him and said R5 was not in his room. RN3 got the other night nurse, LPN4, and they started doing a room-by-room search. RN3 stated that he called DON at 5:35AM. DON instructed RN3 to do a more thorough search of the facility. The facility notified the [NAME] Police at 7:05am. Surveyor reviewed the police report from the [NAME] Police and interviewed [NAME] Police Officer 1. The report revealed R5 was found at the Kwik Trip gas station approximately 1.5 miles from the facility at 7:32 AM. The police returned R5 to the facility at 8:06 AM. Interview with Police Officer 1 on 04/10/24 at 12:04 AM, confirmed the police station received the call from the facility at 7:02 AM and she took the call at 7:05AM. Police Officer1 confirmed that according to their records R5 was found at 7:32 AM and returned to the facility at 8:06AM. Surveyor reviewed the previous Administrator's five-day report dated 03/01/24, which indicates that based on camera footage, the resident left the facility via the front door at 4:26 AM. Surveyor interviewed the DON and the Maintenance Director on 04/09/24 at 9:54 AM, which revealed that the front entrance of the facility consisted of two sets of doors. The inner set of doors used to have WanderGuard sensors attached to the metal frame of the door. Above this set of doors is a motion detector. The Maintenance Director stated that he reviewed the camera footage for 02/25/24, which showed R5 coming down the hallway and prior to getting to the first set of doors, the motion detector detected the walker and opened the door. Once R5 went through this set of doors, the WanderGuard on R5's ankle triggered the alarm. The inner set of doors opens to a vestibule which then opens to the outer doors (external doors), which the Maintenance Director stated were unlocked at all times. During this interview, the DON and Maintenance Director stated that when the receptionist leaves at 8:00 PM, she locks the inner set of doors. The morning that R5 eloped, even though the motion sensor detected R5's walker, this set of doors should have been locked, the motion detector would not have been able to open the doors, and that a staff must have unlocked this set of doors and forgot to relock the doors and that was how R5 was able to exit the building. Both the DON and Maintenance Director stated that the first set of doors are locked at 8:00 PM and if a family member wanted to exit the building, a staff person would have to unlock the doors. They both stated that staff have the code to unlock the doors and they are to relock the doors until the receptionist arrives the next morning at 7:30 AM. On 04/09/24 at 2:13PM, the DON confirmed with Surveyor that the facility did not save the camera footage, the facility did not have a backup system to save the camera footage, and it was not uploaded onto the internet. Surveyor interviewed RN3 on 03/27/24 at 10:11 AM. RN3 stated that when the alarm went off on 02/25/24, he immediately went to the front door and when he got there, CNA3 had disabled the code by entering the door code and told him everything was fine and that all the residents were in their beds. He said not even 5 minutes later, CNA3 came up to him and said R5 was not in his room. He got the other night nurse, and they started doing a room-by-room search. RN3 stated that he called the DON at 5:35 AM. The DON instructed RN3 to do a more thorough search of the facility. On 04/09/24 at 9:54 AM, Surveyor asked DON why there was a delay in contacting the police from 5:35AM to 7:05AM? DON stated that she wanted to exhaust all possibilities that they would find R5 in the facility. DON stated that she told RN3 to do a more thorough search of every room, locked closets, etc. to be sure that they searched everywhere. On 04/09/24 at 3:25PM, Surveyor interviewed LPN4 who stated that at midnight on 02/25/24, R5 came to the nurses' station and wanted to know if the man came with the money to pay for the steel. LPN4 stated she walked R5 back to his room and observed his room from the nurses' station until she started to pass medications. LPN4 stated that when the alarm went off, she went to the back door however, it was not alarming. LPN4 stated that she went to the front door, and no one was there. The door was not alarming. On 04/09/24 at 1:04PM, Surveyor interviewed R11 (R5's resident friend who lives in the facility) who stated on 02/25/24 at 4:07 AM, R5 came to her room and said he was leaving. R11 looked at her cell phone and told R5 that it was 38 degrees Fahrenheit (F) outside. R5 said he was going home. R11 stated that he was wearing two hooded sweatshirts, khaki pants, socks, and shoes. She said R5 had the hooded sweatshirt pulled over his head. R11 said that when RN3 came to talk to her on 2/25/24 at 5:15AM, she told RN3 that you better get out there and look, because R5 said he was going home. R11 said that he had a white bag and his rolling walker and that she could not convince him to stay in the facility. Review of a Nurse's Note, in the EMR, indicated: late entry for 02/25/24 at 6:30 AM, resident wandering out of facility and staff and law enforcement were actively looking for resident. During an interview on 03/26/24 at 10:29 AM, CNA1 said R5 wore a WanderGuard and would tell staff that he was going to work or to the store but could be easily redirected by staff. CNA1 stated she never observed him exit seeking or trying to get out of a door. She received a call while she was at home around 5:40 AM on the morning of 02/25/24 from the DON letting her know that R5 was missing. She drove to the facility along with another staff member and assisted staff in searching the inside and outside of the facility along with nearby streets and side roads. Sometime between 7 AM and 8 AM she heard that police had located R5 at a nearby gas station a few miles away from the facility. He had his walker with him. Upon return to the facility, R5 was placed on 1:1 supervision until he was discharged a few days later to another facility with a secure unit as per the Power of Attorney's wishes. During an interview on 03/26/24 at 11:15 AM, RN1 said R5 would usually walk around the facility with his walker stating he was going to work, and she would tell him that it was his day off and redirect him to something else. He was very receptive to redirection. She never saw him exit seeking but she thinks it was probably because he walked in circles around the wagon wheel (nurse station) and most likely did not know where the exits were located. On the morning of 02/25/24, she arrived at the facility about 5:15 AM through the main front door. As she was walking in another nurse asked her if she had seen R5, but she told them she had not. She did not remember seeing anyone outside or along the long driveway. She was informed that staff had been unable to locate R5. Law enforcement was contacted at some point. A little later in the morning staff were told police had found him about a mile or a mile and a half away. She did see him after he returned, and he was wearing winter wear that included pants and a jacket. There were no injuries, and he was placed on 1:1 supervision until he was discharged . During an interview on 03/26/24 at 12:35 PM, LPN 1 said R5 wore a WanderGuard and was always stating that he needed to go to work. R5 wandered around but he did not walk up to doors or try to open them. LPN 1 stated in the early morning of 02/25/24, around 5:35 AM, she received a phone call from the DON that R5 was missing. She immediately went to the facility and arrived at 5:50 AM to 5:55 AM and saw RN3 and RN1 outside. LPN1 stated that she assessed R5 when he was returned to the facility and that R5 had no new skin issues noted from incident. LPN1 confirmed that R5 was wearing a hooded sweatshirt, a sweatshirt underneath, khaki pants, socks, and shoes. During an interview on 04/09/24 at 4:45 PM, the DON stated that the Administrator told her to have LPN1 call the police at 6:45 AM. LPN1 confirmed that she called the police by using the facility's phone and dialing 911. LPN1 provided no evidence of what time she made the 911 call. During an interview on 03/26/24 at 12:35 PM, LPN2 said on 02/25/24 around 5:30 AM, he received a call from DON that R5 was missing and requested that he come to the facility. When he arrived, he assisted in searching for R5 both inside and outside the facility. Staff were in their cars driving around the area looking up and down streets. He and another staff reviewed the cameras and discovered R5 exited through the front lobby sliding doors. They were able to see R5 walking towards the dumpsters with his walker, and he had on pants, two sweatshirts, and a bag. At some point he walked out of range of the camera view, and they lost sight of him. During an interview on 04/09/24 at 10:00 AM, the Maintenance Director stated that he monitored the WanderGuard system weekly. The Maintenance Director showed documentation which indicated that the two doors with WanderGuard devices were functioning. The last time the two doors' WanderGuards were checked prior to R5's elopement was on 02/22/24. The Maintenance Director showed documentation that he evaluated all the other doors in the facility to ensure that they had a 15 second delay before releasing and sounding the alarm. The documentation showed the other doors were all functioning. Tour of the facility on 04/09/24 at 10:00 AM revealed the two doors' WanderGuard devices were functioning, and the other doors had a 15 second delay before they released, the door opened, and the alarm sounded. The Maintenance Director stated that after R5 was returned to the facility on [DATE], he moved the WanderGuard sensors that were attached to the door frame to the wall area before the first set of doors. With the WanderGuard sensor device in hand, he demonstrated that the first set of doors locked when the WanderGuard was nine feet from the door. The DON provided documentation that she had conducted in-service training on the facility's Wandering and Elopement Policy and Procedure starting on 02/25/24 daily times one week, then weekly times four week. Interview with nurses, CNAs, Rehabilitation Director, housekeeping, laundry, Business Office, and Activities Director revealed staff stated that they had attended an in-service training or completed the Relias training, and they were able to verbally state what to do when the door alarm goes off. Each stated that they would not turn off the alarm, would go outside and conduct a search of the property, search inside the facility and conduct a count of the residents. Review of RN3 and CNA3's personnel records revealed documentation that both had participated in elopement training on 01/31/24 which was prior to R5's 02/25/24 elopement. CNA3's file indicated that she was terminated as of 03/01/24. Review of CNA3's timesheet revealed the last day CNA3 worked at the facility was 02/25/24 at 6:05 AM. Currently there is one resident (R7) with a history of wandering but no active wandering or exit seeking behavior residing at the facility. R7's care plan had updated interventions in place to include wearing a WanderGuard. Review of the Wander/Elopement book revealed R7 was listed in the book. There was a book in the laundry, nurses' station, and rehab. The failure to supervise a resident who was able to elope from the facility created a reasonable likelihood for serious harm which created a finding of Immediate Jeopardy. The facility removed and corrected the immediate jeopardy on 02/25/24 when it completed the following: 1. Resident's WanderGuard device was checked and was functioning properly. 2. All WanderGuards and WanderGuard/alarm doors were checked for functionality. No adverse findings noted. 3. Education of ALL staff on Wandering and Elopement Policy and Procedure was completed before next scheduled day of work. 4. Elopement Drills were conducted every shift for seven days, once a week on every shift for four weeks, then once a week every month for two months. 5. WanderGuard sensor was adjusted on the front doors. 6. All residents were reassessed for wandering and elopement risk. 7. All residents at risk for wandering and elopement were reviewed and reassessed by DON/designee to ensure accurate, appropriate plan of care was in place. 8. Elopement and wandering binders were reviewed and updated as needed. 9. WanderGuard sensors were relocated to capture a bigger radius. 10. Staff were educated and able to describe when doors are to be locked and how to lock and unlock the doors. DON or designee conducted Elopement drills once a week on every shift for four weeks after initial seven days, then once a week every month for two months. All results were brought to QAPI and readdressed and tweaked as needed. Ad hoc education was provided when indicated. Audits were reviewed at the monthly QAPI meeting to determine trends or patterns of concern and/or if further education were needed and would continue until substantial compliance had been achieved.

Based on interview and record review, the facility did not promptly consult with the physician for 3 of 24 (R2, R6, and R7) sampled residents when they experienced significant changes in condition or met parameters set by the physician to be notified. R2 has a significant cardiac history with previous myocardial infarction. The facility failed to promptly consult with R2's physician when R2 presented with chest pain and numbness in the arm and face and a noted respiratory rate of 32 on [DATE]. R2 was later sent to the hospital and found to have an acute myocardial infarction (MI). The facility's failure to immediately consult with R2's physician when she was experiencing chest pain and numbness in the arm and face created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. DON B (Director of Nursing) was informed of the IJ on [DATE] at 3:46 PM. The IJ was removed and corrected on [DATE]. Evidenced by: INTERACT: Change of Condition: Signs and Symptoms: Chest pain, pressure, or tightness. Immediate (Notify the attending or on-call MD, NP, or PA on call as soon as possible). New or abrupt onset, unrelieved by current medications, OR accompanied by diaphoresis, change in vital signs or new EKG changes. Note: Hospital record dated [DATE] indicates that R2 presented with shortness of breath that has been chronic (~4 years) since her shoulder surgery. R2 presented with chest pain that was located on her left side and radiated down her left arm. She felt lightheaded. She also notes having had palpitations during this episode. INTERACT: Change of Condition: Vital Signs: Respiratory Rate. Immediate. Respirations > 28, < 10/minute. Note: Facility Health Status Note, dated [DATE] at 3:16 AM indicates R2 had a respiratory rate of 32. According to cdc.gov, A heart attack, also called a myocardial infarction, happens when a part of the heart muscle doesn't get enough blood. The more time that passes without treatment to restore blood flow, the greater the damage to the heart muscle. The Facility policy titled, Notification of Changes Guideline, states in part . Purpose: It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician). All pertinent information will be made available to the provider by the facility staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. OVERVIEW OF COMPONENTS OF THE GUIDELINE 1. Requirements for notification of resident, the resident representative, and their physician: 2) A significant change in the resident's physical, mental and psychosocial status. (i) A significant change includes deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. 3) A need to alter treatment significantly. (i) A significant treatment alteration includes the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. R2 was admitted to the facility on [DATE]. R2 has diagnoses that include: cerebral infarction, hemiplegia, acute embolism and thrombosis, Type 2 diabetes mellitus, major depressive disorder, essential hypertension, atherosclerotic heart disease, heart failure, and chronic obstructive pulmonary disease (COPD). R2 is [AGE] years old. R2 is a full code (indicating R2 would like CPR (cardiopulmonary resuscitation) performed in the event her heart would stop). R2's most recent Minimum Data Set (MDS), dated [DATE], indicates R2 is supervision of one staff member for bed mobility, dressing, hygiene, and toileting. R2 requires limited assistance of one staff member for transfers. R2 has a Brief Interview of Mental Status (BIMS) of 12 indicating moderate cognitive impairment. On [DATE] at 3:16 AM, Health Status Note states, Resident woke up in a state of panic stating she was having chest pain and that her heart was going to stop, that she couldn't feel her arms, they were going numb and that her mouth was also going numb. Assessed resident, her BP (blood pressure) was ,d+[DATE], pulse 69, R (respirations) 32, T (temperature) 98.3, and pulse ox (oxygen) 100% on room air. Heart rhythm strong and regular with an apical pulse of 70. She states her chest hurts when I pushed on it lightly. She kept repeating and crying stating, I don't want to die! I don't want to die! Spoke with her about anxiety, she states she used to take something but that she didn't know what it is and should be 'in my charts.' Will pass along in report to see if we can get something ordered for anxiety for this resident. Note: RN J (Registered Nurse) did not promptly update the provider on R2's change of condition which included presenting with chest pain, numbness, and elevated respiratory rate in a resident with known cardiac history. On [DATE] at 4:00 AM, electronic medication administration record (eMAR) - Medication Administration Note states, Hydrocodone-Acetaminophen ,d+[DATE] MG (milligram), give 1 tablet by mouth every 4 hours as needed for pain. Pain in her chest/muscle/skeletal. On [DATE] at 5:00 AM, eMAR - Medication Administration Note states, Hydrocodone-Acetaminophen ,d+[DATE] MG (milligram), give 1 tablet by mouth every 4 hours as needed (PRN)for pain. Follow-up Pain Scale was: 7. PRN (as needed) Administration was: Effective, somewhat effective according to resident. (Of note, resident continues to have pain of 7 1 hour after pain medication given). On [DATE] at 6:51 AM, eMAR - Medication Administration Note states, Acetaminophen Tablet 650 MG, give 1 tablet by mouth every 8 hours as needed for Pain. Do not exceed 4000mg APAP (Acetaminophen)/24 hrs. (hours). Requested, crying. (Note, resident was given pain medication and continued crying despite receiving pain medication 3 hours earlier. It should be noted the MD was still not consulted despite continued pain and crying). On [DATE] at 11:02 AM, eMAR - Medication Administration Note states, Acetaminophen Tablet 650 MG, give 1 tablet by mouth every 8 hours as needed for Pain. Do not exceed 4000mg APAP (Acetaminophen)/24 hrs. (hours). PRN Administration was: Ineffective. Follow-up Pain Scale was: 10. On [DATE] at 13:06 (1:06 PM), Health Status Note states, Received report that resident began to experience discomfort in chest around 01:00 (1:00 AM) and that resident had received PRN Hydrocodone-Acetaminophen Tablet ,d+[DATE] MG at 04:00 (4:00 AM). NOC (night) RN (registered nurse) reporting attributing discomfort to resident history of feeling anxious. Suggested writer speak with NP (Nurse Practitioner) about PRN anxiety prescription. NOC RN reported VSS (vital signs stable). Writer went to assess resident and confirmed VSS. Encouraged resident to take deep breaths and resident reported lessening of discomfort a little. Resident asking for pain medication that writer administered acetaminophen 650 mg at 06:51 (6:51 AM). Ineffective. Spoke to NP when arrived at 09:20 (9:20 AM) and was asked to give resident Tums (administered at 09:37 (9:37 AM)). NP visited with resident and asked writer to call 911 and transfer to ER (emergency room ). Resident transferred at 09:50 (9:50 AM). Note: The oncoming shift Nurse did not update the physician or NP of R2's change of condition until the NP was in the building approximately 8 hours later. Note: The oncoming Nurse notes state the nurse completed an assessment and vitals signs on R2, but there is no documentation in R2's medical record to indicate this was completed. Hospital notes include in part . Hospital Encounter: H&P (History and Physical) dated [DATE] states in part . Recent admission [DATE] for partially occlusive thrombus at the left carotid terminus (blood clot in the artery) as well as chronic right ICA (internal carotid artery) occlusion who presents with chest pain, found to have anterior STEMI (ST elevated myocardial infarction/heart attack). On presentation to the cardiology team, she endorses that she began having symptoms last night (chest pain). She noted shortness of breath that has been chronic (4 years) since her shoulder injury. She notes that the chest pain was located on her left side and radiated down her left arm. She denies and LOS (loss of sensation). She felt lightheaded. She also notes having had palpitations during this episode. Ejection Fraction: 65% on [DATE]. Ejection Fraction: [DATE], left ventricular ejection fraction, by visual estimation is, 35%. ECG (Echocardiogram) [DATE], post Cath (catheterization) Anterior infarct (cited on or before 03-FEB (February)-2023 ECG [DATE], per Cath (catheterization) Anteroseptal infarct, possibly acute Lateral injury pattern ** ** ACUTE MI/STEMI ** ** Assessment and Plan: She is presenting following a STEMI s/p (status post) stenting to LAD (left anterior descending) #Anterior STEMI ,d+[DATE] (secondary to) possible embolus -TTE (transesophageal echo) to evaluate heart function post MI (myocardial infarction) Disposition: Patient with STEMI in need of medical optimization. Cardiovascular Medicine Attending Addendum: In addition, I note the following: R2 was admitted after an anterior STEMI s/p what appeared angiographically more like embolic occlusion of the mLAD (mid left anterior descending) (minimal underlying CAD (coronary artery disease) by IVUS (intravascular ultrasound)). Patient has had systemic symptoms (night sweats, chills, weight loss) and does have elevated inflammatory markers. Hospital Encounter: PT (Physical Therapy), from [DATE], states in part . Medical Diagnosis: STEMI involving left anterior descending coronary artery. Medical Diagnosis: STEMI involving left anterior descending coronary artery Patient Active Problem List: Stroke, acute, embolic Acute on chronic CHF Aortic valve stenosis STEMI involving left anterior descending coronary artery Resident was admitted to [hospital name] on ,d+[DATE] with chest pain, found to have anterior STEMI. She underwent cardiac Cath (catheterization) with PCI (percutaneous intervention into coronary artery) and DES (drug eluding stent) to LAD (anterior descending), IVUS (intervascular US), and aspiration of thrombectomy of LAD on ,d+[DATE]. On ,d+[DATE], she had a stroke, code called due to blurred vision and left sided weakness. CT (CAT Scan/x-ray) revealed no hemorrhage, early ischemic change, large vessel occlusion or perfusion deficit. It does show hypoattenuation in the left lentiform nucleus into the left caudate and appearance is suggestive of chronic vs subacute injury. Hospital Encounter: Discharge Summary, from [DATE] states in part . Inpatient Discharge Summary: Briefly, R2 was admitted to [Hospital Name] for STEMI s/p stenting to LAD. She was also found to have severe aortic stenosis on TTE (transesophageal echo) with reduced LVED (left ventricular ejection fraction) 35%. She suffered a PEA (pulseless electrical activity) arrest on [DATE] and passed away at 16:03 (4:03 PM). Hospital Course: #Anterior STEMI #Concern for Hypercoagulable state She was found to have 100% occlusion on mid LAD. DES (drug eluding stent) x1 placed in the mid LAD. IVUS (intervascular US) of LAD showed findings consistent with embolic. TEE ,d+[DATE] with valvular etiology for her embolic lesion and atrial thrombus. Given her history of DVT (deep vein thrombosis/ blood clot) and stroke, hematology was consulted and started hypercoagulable work up, with results pending at the time of PEA arrest. She was started on DAPT (aspirin, Plavix) and apixaban. Patient developed another episode of chest pain in the early AM of ,d+[DATE], with ECG showing ongoing ST elevation in the anterior leads. She was brought emergently to the Cath lab, with LHC (left heart catheterization) showing patent LAD stent and new obstructive disease. #Aortic Stenosis TTE ,d+[DATE] demonstrated severe aortic stenosis in low output state. Interventional Cardiology and Cardiac surgery were consulted for TAVR/SAVR (Transaortic valve replacement/surgical aortic valve replacement-heart valve replacement) work up. #Concern for TIA History of L MCA stroke Patient demonstrated weakness and left sided sensory changes on ,d+[DATE] so a stroke code was called. Symptoms resolved. #PEA Arrest Patient developed sudden onset dyspnea (shortness of breath) and diaphoresis (sweating) in the afternoon of ,d+[DATE] after getting out of bed for a bowel movement. Code Blue was called. She was found to be in PEA (pulseless electrical arrest/no heartbeat) arrest CPR was performed for 30 minutes. Patient pronounced dead at 16:03 (4:03 PM). On [DATE] at 2:49 PM, Surveyor interviewed NP I (Nurse Practitioner). Surveyor asked NP I about R2's hospitalization and her expectations for notification. NP I stated, I would have expected a provider to be notified, especially in this situation. From what I remember, the resident complained of chest pain in the middle of the night. When I got to the facility, staff began to tell me about it. I went down to R2's room and I found her hysterical, complaining of pain and numbness. I felt she needed to be evaluated in the ER. R2 had a MI and was in the ICU (intensive care unit) and passed away on [DATE]. I don't know the specifics of the cause of death. Even with vital signs stable, I would have expected the on-call physician to be notified of this change of condition. On [DATE] at 3:33 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B about R2's hospitalization and expectations for change of condition for a resident. DON B stated, Any review or documentation for that resident I can say I don't remember but I will look. Absolute notification. I would not expect staff to continue to monitor the resident. I would expect she be sent out. Surveyor requested a copy of any education or auditing done related to the change of condition for R2. Note: Surveyor did not receive any documentation of education. On [DATE] at 4:43 PM, Surveyor interviewed LPN N (Licensed Practical Nurse). Surveyor asked LPN N what the facility used for a standard of practice of change of condition (COC). LPN N stated, We use Interact for change of condition. Surveyor asked LPN N if she could find the eInteract that was completed for R2's change of condition on [DATE]. LPN N stated, There was no eInteract completed in the computer. The eInteract should be completed each time there is a COC. On [DATE] at 8:22 AM, Surveyor interviewed NP I. Surveyor asked NP I about R2's change in EF (ejection fraction) from October to February and if delay and STEMI could have caused this to occur. NP I stated, It is definitely possible that it could have contributed to that. An MI could cause decreased EF as the heart muscle is dying. It is pretty safe to assume the [DATE] MI contributed to the decrease in EF. On [DATE] at 11:55 AM, Surveyor spoke with DON B. During this phone call DON B indicated that she had information that she was going to be sending to Surveyor. DON B also stated, I educated the Nurse who was caring for R2 the same day and I also completed audits of staff. All staff knew what to do for a change of condition, so I did not complete any education. On [DATE] at 12:21 PM, Surveyor received an email from DON B including what appears to be a handwritten note out of a notebook that states, RN J interview for R2 incident on 2.3.23. LM (left message) 2.3, 12:38 ([DATE] at 12:38 PM). Vitals/listened to HR (heart rate). Appeared muscular skeletal, fine when we weren't in room. Education given on COC (change of condition). Note in facility electronic charting system verifies s/s (signs and symptoms) that should have been reported. RN J v/u [sic] statement above. Attached is a copy of a handwritten audit indicating it was completed on [DATE] with 10 Nurses names. Handwritten answers to question, If a resident presented with chest pain, what would you do? Column indicating if they passed or failed. Form indicates all staff involved in the audit passed. There is no indication of education provided. The last item included in the email was a typed note stating, This writer asked RN J to give description of the R2 condition on [DATE]. RN J stated that the resident complain [sic] of chest pain, and was very anxious, but resident has anxiety episodes before. RN J stated that when staff left the room her anxiety was less, and resident was calm with no complaints. RN J stated that she checked her vitals and listened to HR (heart rate), and all was WNL (within normal limits), and RN J noted no irregularities. RN J felt that it was muscular skeletal. As she said she lightly pushed on the area and residents stated that she could feel pain. Education provided to RN J on COC. This writer educated that per RN J's note in electronic charting system it verified that signs and symptoms should have been reported. Education provided to RN J regarding Chest pain and to ALWAYS update NP or MD (medical doctor) regarding chest pain. RN J verbalized understanding and stated, I feel so bad, I just thought she was having anxiety as she had in the past. This writer again stated that even if she thought it was anxiety, it is always best and safest practice to update NP for any COC and follow their orders/guidance. Nurses are not able to diagnose. RN J stated, No, I know that I should have called. (Note: There is no signature on this document to indicate what time interview and education was conducted or who wrote the note. The document also is not signed by RN J that she acknowledged and agreed with what was written.) The facility's failure to notify the physician timely with an acute change of condition resulted in a finding of immediate jeopardy which was removed on [DATE], when the facility implemented the following action plan: Immediate Corrective Action for R2 (affected resident) Beginning on [DATE] DON B provided education to nursing staff on recognition of change of condition and the need to notify the physician immediately with change of condition including chest pain. On [DATE] DON B provided education to the nursing staff on the facility's policy regarding notification of the physician. On [DATE] DON B audited nursing staff regarding chest pain. Nurses were able to verbalize the following: 1. Identifying chest pain as a possible cardiac event. 2. Immediately notify physician 3.Follow MD/NP orders 4. If unable to contact MD/NP, to send resident out for emergent evaluation. Audits on change of condition continued through quality assurance process. 42038 R6 experienced a 16-pound weight loss and the facility failed to update the physician. R7 experienced a 16-pound weight gain and the facility failed to update the physician. These are a level 2 example no actual harm. Example 2 The facility's policy titled Weight Monitoring Guideline revised [DATE], states in part: .Residents will be weighed; documentation will be recorded in PCC (Point Click Care): *Upon admission and re-admission .* Daily for three days .* As prescribed by the physician or mid-level practitioner .The Licensed Nurse: *Will verify the accuracy of the weight by comparing the weight with the mist recently recorded weight. *Direct a re-weight for variances < or > 5 pounds. *Consult the physician and dietian [sic]/ designee with a confirmed 5% weight variances in 30 days and 10% in 6 months and/ or as ordered by the physician with weight parameters. *For residents on daily weights for fluid volume overload prevention and monitoring weight notification parameters should be discussed with the physician and at minimum consultation should be completed with a 5-pound weight change in 1 week for residents with heart failure or fluid volume overload . R6 was admitted to the facility on [DATE] with diagnoses that include s/p (status post) coronary artery bypass graft x 3, congestive heart failure, type 2 diabetes mellitus, muscle weakness, anxiety disorder, and major depressive disorder. R6's most recent Minimum Data Set (MDS) dated [DATE] states that R6 had a Brief Interview of Mental Status (BIMS) of ,d+[DATE], indicating that R6 is cognitively intact. R6's hospital discharge orders dated [DATE] stated: Daily weights, call if gain 3# in one day or 3# in one week. Fluid Restriction- 2000 cc (cubic centimeters)/ per day. The facility's physician orders dated [DATE] state: Daily weights every day shift Notify DM (Dietary Manager) if weight increases by 3 pounds in one day or 3 pounds in 1 week. Fluid Restriction- 2000 cc (cubic centimeters)/ per day. R6's weights are as follows: ,d+[DATE]: 214.2 lbs. (pounds) ,d+[DATE]: no weight obtained ,d+[DATE]: no weight obtained ,d+[DATE]: no weight obtained ,d+[DATE]: 215 lbs. ,d+[DATE]: 206.4 lbs. ,d+[DATE]: 206.8 lbs. ,d+[DATE]: 202.7 lbs. ,d+[DATE]: no weight obtained ,d+[DATE]: 202.6 lbs. ,d+[DATE]: 202.6 lbs. ,d+[DATE]: 204.4 lbs. ,d+[DATE]: 203 lbs. ,d+[DATE]: no weight obtained ,d+[DATE]: 202.1 lbs. ,d+[DATE]: 203.6 lbs. ,d+[DATE]: 205.1 lbs. ,d+[DATE]: 198 lbs. ,d+[DATE]: 198.6 lbs. ,d+[DATE]: 197.8 lbs. ,d+[DATE]: 198.2 lbs. It is important to note that there is no documentation that the facility notified the physician that weights were not obtained on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Example 3 R7 was admitted to the facility on [DATE] with diagnoses that include: right above the knee amputation, sepsis, type 2 diabetes mellitus, toxic encephalopathy, and malignant neoplasm of the bladder. R7's most recent Minimum Data Set (MDS) dated [DATE] states that R7 has a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating that R7 is cognitively intact. R7's MDS also indicates that he required extensive assistance of 2 people for bed mobility and transfers. R7's physician orders dated [DATE] state: Weights every day shift for 3 days. Weights every day shift every 7 days for 3 weeks. Weights every day shift starting on the 1st and ending on the 7th every month. R7's weights are as follows: ,d+[DATE]: no weight obtained ,d+[DATE]: 138.5 lbs. ,d+[DATE]: no weight obtained ,d+[DATE]: 136.6 lbs. ,d+[DATE]: 142.4 lbs. ,d+[DATE]: 153 lbs. ,d+[DATE]: 145.2 lbs. It is important to note that there is no documentation indicating that the facility updated the physician when the weights were not obtained. Additionally, there is no documentation indicating that the facility updated the physician when R7 gained 14.5 lbs. from ,d+[DATE] to ,d+[DATE], as well as when he lost 7.8 lbs. from ,d+[DATE] to ,d+[DATE]. No re-weights were documented. On [DATE] at 5:22 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she would expect facility staff to obtain re-weights if there is a discrepancy with a resident's weight, DON B stated yes, Surveyor asked DON B if she would expect that nursing staff updated the physician when there is a significant weight loss or gain, DON B stated yes.

Based on observation, interview and record review, the facility did not ensure each resident receives adequate supervision and assistive devices for 1 of 2 residents (R20) reviewed for supervision and accidents out of a total sample of 18. R20 fell 10 times from 3/2/22 to 8/17/22 and fractured her nose and shoulder during two separate falls. Root cause analysis was not complete for each fall and R20 was not assessed for possible bladder and bowel changes as a potential root cause to the falls. Evidenced by: The facility's Fall Evaluation Safety Guideline dated 11/28/2017, includes: -Multiple Falls: *Trend falls for the resident-time of day, reason for fall location of fall, etc; *Refer to Therapy; *Restorative Nursing Programming. R20 was admitted to the facility on [DATE] with diagnoses that include [CONDITION(S)], general muscle weakness, [CONDITION(S)], polyneuropathy, [CONDITION(S)], history of falls and difficulty walking. R20's Care Plan documents: - Difficult breathing due to history of COVID 19 and [CONDITION(S)]; - Impaired visual function; -Bladder incontinence; -Communication problem related to [CONDITION(S)]; -Requires physical assistance of two staff to transfer; -Potential for constipation; -Risk for falls includes ensure footwear fits properly, non skid socks/footwear, anticipate and meet resident's needs. R20's MDS (Minimum Data Set) dated 6/2/22 measures R20's BIMS (Brief Interview for Mental Status) as 3 which is cognitively severely impaired. R20 requires limited assistance for bed mobility and transfers. She requires extensive assistance with toileting and scores occasionally incontinent for bladder and bowel. R20's Post Fall Evaluations include: -3/2/22 6:20 AM (Fall with major injury) On 3/2/22 at 6:20 AM, R20 was found on the floor of her room with a bloody nose. The fall incident report indicated R20 was wearing gripper socks at the time of the fall. The Root Cause analysis indicated R20 has history of forgetfulness and did not ask for assistance to get out of bed. Resident was attempting to self transfer. The Intervention for the fall was leave the resident's door open, make sure the floor mat is on floor by her bed and keep bed in low position. Hospital radiology report dated 3/2/22, documents R20 has bilateral comminuted nasal bone fractures with slight displacement. There also seems to be a minimally displaced fracture of the ossified anterior cartilaginous nasal septum. On 8/18/22 at 1:00 PM, Surveyor spoke with LPN D (Licensed Practical Nurse). LPN D said he did not know what the root cause of the fall was; he found her on the floor with a bloody nose and sent her out. LPN D said the fall committee does the fall interventions. -4/3/22 6: 15 AM-fell on her buttocks-no injury. No Root Cause defined. The Intervention for the fall was keep wheelchair at bedside. -4/9/22-7:00 AM (Injury)-no description of how resident found-no Root Cause defined-R20 had a scalp laceration on left temporal side of head 1.5 centimeters-The Intervention for the fall was mat to floor, door open, wheelchair away from bed (out of reach), call bell within reach and educate on using call bell with every interaction. Note, R20 has cognitive impairment with a BIMS of 3; educating R20 would not be an effective intervention. -5/12/22 2:00 PM-Found resident on floor-wedged between the bed and her wheelchair-Root Cause -is resident may have attempted to transfer and slipped to the floor-and wheel chair may not have been locked-stated she hit the floor with her head but there was no bump or bruise-after neurological check she was lifted back to bed with a hoyer lift-The Intervention for the fall was mat, call bed instruction and keeping wheelchair out of sight initiated. -5/23/22-9:45 AM-Found resident lying on floor trying to get up-lying in her room between her bed and wheelchair-no injury-Root Cause- is it appears resident may have attempted to self transfer-the Intervention for the fall was discussed relocating resident closer to nurses station-all other fall interventions in place. -6/5/22 4:00 AM-(Fall with major injury)-nurse heard noise-resident was sitting in bathroom floor leaning to the left holding her shoulder-unsupervised fall-skin tear to back upper deltoid-assisted resident to wheelchair-ice applied to (guarded area) left shoulder-Hospice, physician and son notified and sent to emergency room -interventions in place-Root Cause -is resident self ambulated to bathroom, did not call for assistance, may be used to getting up early or needed to use the restroom, poor safety awareness-no new Interventions put in place.The hospital radiology report dated 6/5/22 documents R20 had a comminuted fracture involving the surgical neck of the left proximal humerus with posterior angulation of the humeral head with respect to the humeral shaft. On 8/18/22 at 2:00 PM, Surveyor spoke with RN C (Registered Nurse). RN C said she thinks R20 was in the wheelchair and going to the bathroom. RN C did not know the root cause of the fall -7/6/22 5:00 PM-Found on floor on mat beside bed-resident said she was trying to get out of bed-small skin tear to lower leg-Root Cause -is resident attempted to self transfer-resident unable to state why she was trying to get out of bed-it was around dinner time, resident may have been hungry-bed remains in lowest position with fall mat-and call light in place; -7/25/22 8:05 AM-Found on floor at bedside-resident said she was trying to go to the bathroom, crawled/rolled out of bed-Root Cause - it appears resident rolled out of bed-resident stated she needed to use the restroom-resident unable to use call call related to dementia. -8/10/22 3:00 PM-(Injury)-Nurse summoned to resident's room-received report resident had fallen and head was bleeding-sent to emergency room for evaluation-Root Cause-resident appears to have dozed off in her chair and fallen forward-no new Interventions put in place; -8/17/22 4:49 PM-(Injury)-Found in front of her wheelchair lying on the floor on her left side-new laceration of scalp and opening of old laceration of scalp. It's important to note the facility did not have the resident on a toileting program, did not assess her bowel and bladder status with a bowel and bladder diary and did not have the resident on a restorative nursing program to help prevent falls. On 8/18/22 at 2:30 PM, Surveyor spoke to HA E (Hospice Aide). HA E said she always toilets R20 when she is here and does not resist to be toileted. HA E said R20 should be toileted regularly. On 8/18/22 at 2:45 PM, Surveyor spoke to CNA F (Certified Nurse Assistant). CNA F said she offers to toilet R20, but R20 will say no. Surveyor asked CNA F if R20 understands her when she verbally offers R20 to go to the bathroom. CNA F said she was not sure. On 8/18/22 at 3:00 PM, Surveyor spoke to DON B (Director of Nursing). DON B said R20 has many interventions in place and that R20 is very independent. DON B said they have not completed a bowel and bladder diary. DON B said she completes the root cause analysis of each fall. DON B said the root cause analysis and intervention for R20's fall on 8/17/22 has not been completed yet. DON B said they have tried the intervention of toileting R20 every two hours, and that intervention agitated her. Surveyor asked for documentation about R20 being toileted every two and how it agitated her. Surveyor has not received any documentation on the intervention of toileting R20 every two hours and that it agitated her.

Based on observation, interview and record review, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, prevent new ulcers from developing, and a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable in 1 of 3 residents reviewed for pressure injury concerns (R32) out of a total sample of 18. R32 was at risk for PI (Pressure Injury) development due to his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Evidenced by: According to the NPUAP's (National Pressure Ulcer Advisory Panel), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Risk Factors and Risk Assessment 1.1 Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries . 1.3 Consider the potential impact of an existing pressure injury of any Category/Stage on development of additional pressure injuries . 1.7 Consider the impact of diabetes mellitus on the risk of pressure injuries. 1.8 Consider the impact of perfusion and circulation deficits on the risk of pressure injuries . 1.10 Consider at the impact of impaired nutritional status on the risk of pressure injuries . 1.17 Consider the impact of time spent immobilized before surgery, the duration of surgery and the American Society of Anesthesiologists (ASA) Physical Status Classification on surgery-related pressure injury risk . 1.24 When conducting a pressure injury risk assessment: o Use a structured approach o Include a comprehensive skin assessment o Supplement use of a risk assessment tool with assessment of additional risk factors o Interpret the assessment outcomes using clinical judgment . According to the www.npuap.org <http://www.npuap.org> the NPUAP (National Pressure Ulcer Advisory Panel): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe Moisture Associated Skin Damage (MASD) including Incontinence Associated [CONDITION(S)] (IAD), Intertriginous [CONDITION(S)] (ITD), Medical Adhesive Related Skin Injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. The Facility's Policy and Procedure titled, Skin Management Guideline, with an effective date of 11/28/17, indicates, in part: Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care .Procedure: I. Prevention of Pressure Ulcers * All residents admitted to the facility will be evaluated for actual and potential skin integrity issues . An individualized plan of care will be developed upon admission, reviewed, and updated quarterly and with a change in condition as needed. The plan of care will identify impairment and predicting factors. Interventions for prevention, removing and reducing predicting factors and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] * Pressure redistribution surface for bed and seating surfaces: Specified through clinical evaluation and determination * Adaptive equipment and seating to support and encourage correct anatomical alignment . *Specified turning and repositioning . *Pressure, friction, shear reduction . B. Monitoring of Skin Integrity . *The Care Plan for Skin Integrity is to be evaluated and revised based on response, outcomes, and needs of resident . II. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review the wound formulary for guidance 2. Consult with the Physician/NP and Resident Representative .6. Re-evaluate turning and repositioning interventions 7. Initiate Braden Scale and initiate investigation process if new onset .10. Initiate the Wound Initial Documentation Observation in PCC (Point Click Care) .The Weekly Wound Documentation Observation in PCC should only have ONE WOUND per observation . The Facility's Policy and Procedure titled, Skin Protection Guideline, with an effective date of 7/7/21, indicates, in part: Purpose: To provide evidenced based practice standards for the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Evaluation .The process includes evaluating: *Specific risk factors and changes in the resident's condition that may impact the development and/or healing of a PU/PI (Pressure Ulcer/Pressure Injury) *Implementing, monitoring, and modifying interventions to stabilize, reduce or remove underlying risk factors *If a PU/PI is present, provide treatment to heal and prevent the development of additional PU/PIs . The NPIAP (National Pressure Injury Advisory Panel) outlines the following (this list is not all inclusive and each resident must be reviewed for potential, individualized risk factors). Some factors are modifiable [NAME] [sic] others are not: *Limited mobility and activity *Friction *Shearing *Presence of current injuries: Risk for worsening and / [sic] or additional development *Alterations in skin status over pressure points *Diabetes *Disease or condition that alters perfusion and create circulatory deficits . *Alterations in sensory perceptions *Immobilization before a surgery, the duration of surgery and related impacts on skin including: -Duration of crucial care stay -Mechanical ventilation -Use of vasopressors . An admission evaluation helps identify residents at risk of developing a PU/PI, and residents with existing PU/PIs. Because a resident at risk can develop PU/PI within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI . The admission evaluation helps define those initial care approaches. In addition, the admission evaluation may identify pre-existing signs suggesting that tissue damage has already occurred, and additional tissue loss may occur . Some situations, which may have contributed to this tissue damage prior to admission, include pressure resulting from immobility during hospitalization or surgical procedures, during prolonged ambulance transport, or while waiting to be assisted after a debilitating event, such as a fall or a [CONDITION(S)] . Interventions Interventions for prevention, removing and reducing predicting factors and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] *Selection of an individualized support surfaces (A specialized device for pressure re-distribution designed for management of tissue loads, micro-climate and / or [sic] other therapeutic functions) for bed and seating to enhance pressure re-distribution *Specified through clinical evaluation and determination *Adaptive equipment and seating to support and encourage correct anatomical alignment . *Specified turning and repositioning . *Pressure, friction, shear reduction . R32 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's most recent MDS (Minimum Data Set) with a target date of 6/12/22, documents a BIMS (Brief Interview of Mental Status) score of 7, which indicates, a severe cognitive impairment. R32's Adult Hospital Medicine Admission History and Physical Note, with a date of service of 5/24/22, indicates, Pt reports having fallen four days ago in his kitchen after losing his balance. He landed on his right hip, crawled back into bed and has been there since. He had some food and drink near his bed, but that is all he has had since then. He did take his medications. The pt. endorses that he was urinating into bottles because he was unable to get up due to the pain . R32's Physician Transfer Order Report, indicates, in part: Active Problems: Acute deep vein [CONDITION(S)] (DVT) of right lower extremity . It is important to note R32's report of decreased mobility while in bed for a 4-day period, decreased perfusion due to an acute DVT of the right lower extremity, decrease nutrient intake and the potential for friction and shear while crawling back to bed would increase R32's risk for developing PIs. R32's Physician Transfer Order Report, indicates, in part. Discharge Orders: Admit to: Skilled Nursing Facility . Dressing and Wound Orders: -Minimize pressure with frequent repositioning, scheduled turning every 2 hours with a 30-degree tilt -Therapeutic support surface (low air loss mattress). -Minimize friction and shear by keeping skin clean and moisturized (use lift sheet or TAPS (Turning and positioning system) system. -Incontinence management Current wound care recommendations include: Location: Left posterior thigh Frequency: Every 3 days and as needed if soiled, saturated, or loose. Cleanse wound gently with normal saline and gauze - Apply a thin layer of the [MEDICATION(S)] directly to the wound bed (approximately a nickel thickness) or onto a dressing. Additional Dressing and Wound Instructions: -Minimize pressure with frequent repositioning, scheduled turning every 2 hours with a 30-degree tilt. -Therapeutic support surface (low air loss mattress) -Minimize friction and shear by keeping skin clean and moisturized (use of lift sheet or TAPS system) Expected Discharge & Plan (recommendations) Discharge cares as follows: Same as above. Manufacturer's recommendations were requested for R32's wheelchair cushion, mattress on admission, and current air mattress. On 8/17/22 at 2:49 PM Recommendations were provided for Direct Supply Panacea Immerse Mattress. The documentation does not note what stage PI the mattress is rated for. DOO R (Director of Operations) indicated she is still working on finding more information. The following information was provided to the Surveyor by the facility: -R32's mattress, on admission to the facility, is noted to be a Direct Supply Panacea Immerse Mattress with the following information noted on the manufacturer documents provided to Surveyor: *The mattress manufacturer has tested the technology used in the Panacea Immerse mattress to assess its comfort and pressure redistribution properties. A full study, entitled A prospective Study of a Unique Open-Cell Foam Mattress with a Modified Top Layer in hospitalized General Medical-Surgical Patients, is included for your convenience. The findings show that, when used properly as part of a comprehensive care program, the Panacea Immerse technology did not lead to skin breakdown in patients with intact skin at the time of admission, and improved existing skin integrity in over 75% of patients with existing decubitus ulcers . The facility also provided the Surveyor with information for Direct Supply Panacea ImmersaGel Mattress and highlighted the following information: These pressure redistribution support surfaces are appropriate for use as part of an overall care plan to prevent and treat decubitus ulcers. Resident-specific assessment could alter your usage of these mattresses. It is unclear based on the differing mattress information documents received from the facility, which mattress the resident was using on admission. The facility failed to implement physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Of note, there was no information regarding pressure injury prevention/treatment rating in the manufacturer's recommendations obtained from the facility. There is no evidence that the mattress R32 was using on admission was appropriate for his PI present on admission or to prevent future injury. Of note, R32's Hospital Physician Transfer Report indicates Dressing and Wound orders for Left Posterior Thigh Wound, indicating a wound was present on discharge from the hospital. R32's Facility wound evaluation, dated 6/7/22, denotes an area of 5.53 cm x 4.07 cm to Left Thigh Lateral, with the wound bed documented as 100% eschar. Of note, a wound described as 100% eschar under current standards of practice would be categorized as an unstageable PI. -R32's current mattress, implemented on 6/22/22, is noted to be an Integra Healthcare Equipment True LAL (Low Air Loss Mattress) System. Product Description: Our True Low Air Loss System with Pulsation offers an extraordinary therapeutic mattress system for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Of note, R32 did not receive the LAL until 6/22/22, 10 days after the first documentation, on 6/12/22, of the left and right buttock pressure ulcers starting and 7 days after the coccyx wound can be seen on the June 15, 2022, Wound Evaluation picture. According to the NPUAP's (National Pressure Ulcer Advisory Panel), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Support Surfaces 7.1 Select a support surface that meets the individual's need for pressure redistribution based on the following factors: o Level of immobility and inactivity o Need to influence microclimate control and shear reduction o Size and weight of the individual o Number, severity, and location of existing pressure injuries o Risk for developing new pressure injuries . 7.4 Use a high specification reactive single layer foam mattress or overlay in preference to a foam mattress without high specification qualities for individuals at risk of developing pressure injuries. 7.5 Consider using a reactive air mattress or overlay for individuals at risk for developing pressure injuries . 7.7 Assess the relative benefits of using an alternating pressure air mattress or overlay for individuals at risk of pressure injuries . 7.9 For individuals with a pressure injury, consider changing to a specialty support surface when the individual: o Cannot be positioned off the existing pressure injury o Has pressure injuries on two or more turning surfaces (e.g., the sacrum and trochanter) that limit repositioning options o Has a pressure injury that fails to heal or the pressure injury deteriorates despite appropriate comprehensive care o Is at high risk for additional pressure injuries o Has undergone flap or graft surgery o Is uncomfortable o 'Bottoms out' on the current support surface . R32's Skin and Wound Evaluation with an effective date of 6/7/22 indicates the following: A. Describe 1. Type 5. Bruise .22. Location Right Antecubital Space 23. Acquired .2. Present on Admission 24. How long has the wound been present? 2. Exact Date .24a. Exact Date: 6/6/22 .I. Progress .3. Notes: Bruising noted to Right Antecubital Space. No open measurable areas noted. No concerns noted. Resolved on admission assessment . Of note: No other Skin or Wound areas are noted on this evaluation. R32's Braden scale evaluations (an evidenced-based tool that predicts the risk for developing a pressure injury) noted the following: *Effective date of 6/6/22, noted a score of 17 (at risk) *Effective date of 6/13/22, noted a score of 16 (at risk) *Effective date of 6/20/22, noted a score of 16 (at risk) R32's care plan documents the following, in part: Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) fx. (fracture) of right femur, malnutrition, wedge compression fx. of thoracic spine, falls, malaise, [CONDITION(S)], [CONDITION(S)] and weakness. Date Initiated 6/6/22. Interventions/Tasks: Bed Mobility: Physical Assist x 2. Date Initiated 6/11/22. Transfers: Resident requires: 1 assist stand-pivot with 2ww (wheeled walker) to/from WC (wheelchair) to/from edge of bed . Focus: The resident has limited physical mobility r/t fx. of right femur, malnutrition, wedge compression fx. of thoracic spine, falls, malaise, [CONDITION(S)], [CONDITION(S)] and weakness. Date Initiated: 6/6/22. Interventions/Tasks: * Resident has a weight bearing restriction (NWB (non-weight bearing) to Right leg r/t hip fx.) Date Initiated: 6/6/22. *Uses Wheelchair (ensure foot pedals are in place). *Provide supportive care, assistance with mobility as needed. Document assistance as needed. Date Initiated: 6/6/22 . Focus: The resident has potential for impairment to skin integrity r/t limited mobility. Date Initiated: 6/6/22. Interventions/Tasks: *-Monitor skin when providing cares, notify nurse of any changes in skin appearance. Date Initiated: 6/6/22 . Focus: The resident has actual impairment to skin integrity to left and right buttocks and Right Thigh (Lateral) r/t abrasions and surgical incision. Date Initiated: 6/30/22. Interventions/Tasks: * Evaluate and treat per physicians' orders. Date Initiated: 6/6/22 . * 6/22/22: The resident needs pressure relieving/reducing mattress i.e.: air mattress while in bed and continued use of cushion in wc. Date Initiated: 6/30/22 . * The resident needs assistance and reminding to reposition every 2-3 hours while in bed or in wheelchair. Date Initiated: 6/22/22 . Focus: The resident has bladder incontinence r/t limited mobility. Date Initiated: 6/6/22. Interventions/Tasks: * Clean peri-area with each incontinence episode. Date Initiated 6/6/22 . R32's CNA (Certified Nursing Assistant) care plan, documents the following in part: Skin: * 6/22/22: The resident needs pressure relieving/reducing mattress i.e.: air mattress while in bed, and continued use of cushion in the wc .Bed Mobility: * Bed Mobility: Physical Assist x 2 .Resident Care: *The resident needs assistance and reminding to reposition every 2-3 hours [NAME] in bed or in wheelchair . R32's Progress Notes document the following: 6/6/22 3:52PM Nursing Evaluation: (Admit, Readmit, Qtly, Annual Sig Change) . Resident admitted from: (Hospital Name) Skin Integrity: The resident has skin integrity concerns. 0 .Musculoskeletal: Resident has weakness. Location: Left hand and legs Resident has weight bearing restriction. Location: Weight bearing as tolerated right lower extremity. No ROM (Range of Motion) impairment to upper extremities. ROM impairment to RLE (Right Lower Extremity). The resident needs assistance with ADL's. Resident uses assistive device/s: Wheelchair . 6/12/22 5:55 PM (Created Date) Health Status Note (nurses note): Placed dressing to buttocks, pressure ulcers starting to bilateral buttocks, cleansed, and dressed with bordered gauze. Blanchable purple discoloration to buttocks/coccyx area. Educated resident to reposition q2hours (every), placed pillow under left side. Reported to oncoming nurse to reposition resident q2hours. Unstageable pressure ulcer to left gluteal fold noted, cleansed and Medahoney [sic] applied with bordered gauze. It is important to note the wound evaluation notes for the right and left buttock denote wound evaluation dates of 6/13/22 and note minutes old. 6/23/22 1:01 PM Health Status Note (nurses note). Note Text: Roho cushion ordered today for resident to use while in wheelchair. New wound care orders were obtained per discussion with provider .Re-education given to resident on importance of repositioning every two-three hours to promote healing and prevent further breakdown, resident was able to verbalize and understanding and repeat back education . Of note, Information obtained from the facility regarding R32's wheelchair cushion notes it is a Direct Supply Foam Cushion, not a Roho. Surveyor also observed R32's wheelchair with staff and noted a Foam Cushion with Direct Supply Label. 6/27/22 3:25PM Health Status Note (nurses note) Note Text: During dressing change to left and right buttocks and coccyx, it was noted that wound continues to deteriorate. Slough noted to wound bed on coccyx with opening noted to center. Increased depth noted and tunneling at 12 o'clock of 3.8cm. Wound bed with foul smell. Moderate serosanguineous drainage. Provider, NP contacted. NP ordered to have resident sent out for further wound evaluation due to rapid deterioration . Of note, R32 declined to be interviewed or allow Surveyor to observe wound care. R32's Wound Evaluations documents include the following, in part: ---Left Thigh Lateral Evaluated on 6/7/22 #3 Abrasion Body Location: Left Thigh Lateral New - 1 day old Acquired: Present on Admission Dimensions: Length: 5.53cm Width 4.07cm Deepest Point 0cm Wound Bed: % Eschar 100% . Periwound: Edges - Epithelialization; Surrounding Tissue - Intact; Induration - None Present; [CONDITION(S)] - No swelling or [CONDITION(S)]; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: New Notes: Wound noted to Left Thigh (Lateral) with complete eschar to wound bed. Small amount of old serosanguineous drainage noted to old dressing. No s/s of infection. Wound cleansed with wound cleanser, pat dried. [MEDICATION(S)] applied to eschar, covered with foam border, resident tolerated well. Provider updated . Of note, a wound described as 100% eschar, under current standards of practice, would be categorized as an unstageable PI. Evaluated on 6/8/22 #3 Abrasion Body Location: Left Thigh Lateral Stable - 2 days old Acquired: Present on Admission Dimensions Length: 3.89cm Width 3.88cm Deepest Point 0cm Wound Bed: % Slough 10%; % Eschar 90% Periwound: Edges - Epithelialization; Surrounding Tissue - Intact; Induration - None Present; [CONDITION(S)] - No swelling or [CONDITION(S)]; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Stable Notes: Eschar noted to wound bed. Small amount of slough noted around the outer edges of wound bed. Small amount of serosanguineous drainage noted to old dressing. No s/s of infection. Wound care provided per order; resident tolerated it well. Evaluated on 6/15/22 #3 Abrasion Body Location: Left Thigh Lateral Stable - 9 days old Acquired: Present on Admission Dimensions: Length: 4.88cm Width 3.39cm Deepest Point 0.2cm Wound Bed: % Slough 10%; % Eschar 90% . Periwound: Edges - Epithelialization; Surrounding Tissue - Intact; Induration - None Present; [CONDITION(S)] - No swelling or [CONDITION(S)]; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Stable Notes: Wound bed with eschar and slough. Small amount of drainage noted. No s/s of infection. Wound care provided per order. Resident tolerated it well. Evaluated on 6/22/22 #3 Abrasion Body Location: Left Thigh Lateral Stable - 16 days old Acquired: Present on Admission Dimensions: Length: 4.2cm Width 3.84cm Deepest Point 0.4cm Wound Bed: %Granulation 10%; % Slough 60%; % Eschar 30% . Periwound: Edges - Epithelialization; Surrounding Tissue - [CONDITION(S)]; Induration - None Present; [CONDITION(S)] - No swelling or [CONDITION(S)]; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Stable Notes: Wound bed with eschar and slough. Heavy serosanguineous drainage noted. Foul smell noted to wound bed. Wound care provided per order; resident tolerated well. Provider updated. It is important to note the following: R32's Physician Transfer Order Report, which includes a picture of R32's left posterior thigh, indicates under the picture: Large open wound, appears as this may have been a caused by traumatic injury. This is a typical for a pressure related injury. Measures 7.5cm x 7.5cm partial thickness wound. Further documentation notes: .Appraisal: -R32 with anasarca. -Wound to the posterior left upper posterior thigh appears as a possible skin tear with full flap loss. There is no surrounding tissue [CONDITION(S)] and is a typical for pressure related injury . -Low air loss mattress in place d/t R32's low mobility status . Based on Surveyor review of wound care documentation and pictures (Best seen on June 22, 2022, documentation) provided by the facility, along with review of The Physician Transfer Report documentation, the body location appears to be the same posterior aspect of the left thigh versus the lateral thigh description given in facility wound evaluations. R32's Physician order, dated 6/6/22, includes in part: Left Posterior thigh. Cleanse wound with normal saline and gauze. Apply thin layer of [MEDICATION(S)] directly to wound bed. Use [MEDICATION(S)] sacral dressing . ---Left Buttock Evaluated on 6/13/22 #5 Abrasion Body Location: Left Buttock New - Minutes old Acquired: In-House Acquired Dimensions: Length: 2.8cm Width 2.8cm Wound Bed: %Granulation 100% . Periwound: Edges - Attached; Surrounding Tissue - [CONDITION(S)] Fragile; Induration - None Present; [CONDITION(S)] - No swelling or [CONDITION(S)]; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: New Notes: Abrasion noted to left buttock. Open area with granulation tissue. Peri-wound very fragile, [CONDITION(S)] noted, area non-blanchable. Wound cleansed with wound cleanser, pat dried. Covered with foam border. Provider updated. Evaluated on 6/15/22 #5 Abrasion Body Location: Left Buttock Stable - 2 days old Acquired: In-House Acquired Dimensions: Length: 3.74cm Width 3.91cm Wound Bed: %Granulation 100% .Other - Pink or red . Periwound: Edges - Attached; Surrounding Tissue - [CONDITION(S)]; Induration - None Present; [CONDITION(S)] - No swelling or [CONDITION(S)]; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Stable Notes: Wound bed with granulation tissue. Peri-wound with [CONDITION(S)]. Moderate amount of drainage noted. No s/s of infection. Wound care provided per order; resident tolerated it well. Education: Educated resident on the importance of repositioning every 2-3 hours to promote healing, resident verbalized an understanding . Evaluated on 6/22/22 #5 Abrasion Body Location: Left Buttock Stable - 9 days old Acquired: In-House Acquired Dimensions: Length: 3.5cm Width 3.23cm Wound Bed: %Epithelial 10% .%Granulation 10% .%Slough 80% .Other - Pink or red . Periwound: Edges - Epithelialization; Surrounding Tissue - [CONDITION(S)]; Induration - None Present; [CONDITION(S)] - No swelling or [CONDITION(S)]; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Stable Notes: Wound bed with slough, granulation tissue and epithelial tissue. Moderate amount of serosanguineous drainage noted. No s/s of infection. Wound care provided per order; resident tolerated it well. Provider contacted with update on wound . Of note, a wound described as 80% slough, 10% Epithelial, and 10% Granulation, under current standards of practice, would be categorized, at a minimum, as a stage III PI. This would be considered a deterioration in this wound. It is important to note that on Surveyor review of the different wound evaluation pictures provided of Left Buttock, there are areas of dark purple discoloration noted to right and left buttock. ---Right Buttock Evaluated on 6/13/22 #6 Abrasion Body Location: Right Buttock New - Minutes old Acquired: In-House Acquired Dimensions: Length: 1.49cm Width 1.79cm Deepest Point 0cm Wound Bed: %Granulation 100% .Other - Pink or red. Periwound: Edges - Attached; Surrounding Tissue - [CONDITION(S)] Fragile; Induration - None Present; [CONDITION(S)] - No swelling or [CONDITION(S)]; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal. Progress: New Notes: Abrasion noted to right buttock. Open area with granulation tissue. Peri-wound with [CONDITION(S)], blistering and fragile skin. Small amount of serosanguineous drainage noted. No s/s of infection. Wound cleansed with wound cleanser, pat dry. Covered with foam border dressing. Provider updated. Of note, a wound described as 100% Granulation, under current standards of practice, would be categorized as a stage III PI. It is important to note that on Surveyor review of the picture provided for the 6/13/22 wound evaluation documentation, it appears there is an area dark purple/red discoloration noted on right buttock, sacral/coccyx area, and left buttock. Evaluated on 6/15/22 #6 Abrasion Body Location: Right Buttock Deteriorating - 2 days old Acquired: In-House Acquired Dimensions: Length: 6.5cm Width 3.44cm Deepest Point 0.1cm Wound Bed: %Epithelial 40% .%Granulation 50% .%Slough 10% .Other - Pink or red . Periwound: Edges - Attached; Surrounding Tissue - Blister Fragile; Induration - None Present; [CONDITION(S)] - No swelling or [CONDITION(S)]; Change in Temperature (Degrees) - 0; Periwound Temperature - Normal . Progress: Deteriorating Notes: No dressing in place upon assessment. New open areas noted to coccyx area, granulation tissue noted. Epithelial and granulation tissue noted to other areas. Periwound with [CONDITION(S)], blister, and fragile skin. Moderate amount of serosanguineous drainage noted. No s/s of infection. Wound care provided per order; resident tolerated it well. Provider updated. It is important to note that on Surveyor review of the picture provided for th

Based on interview and record review, the facility did not ensure that each resident received needed supervision to prevent accidents for 1 of 3 residents (R1) reviewed for falls from a total sample of 19. R1, who is on an antiplatelet medication and may bruise and bleed more easily, was transferred via a Hoyer lift with assist of 1, instead of 2 as care planned. R1 fell out of the Hoyer lift and struck his head on the floor. The likelihood for harm was then exacerbated when the certified nursing assistant (CNA) moved R1 into bed by himself without waiting for a nursing assessment. The fall caused a hematoma to his posterior head and fractured C6 osteophyte (is the sixth cervical (neck) vertebra from the top; bone spurs often form where bones meet each other - this is typically caused by [CONDITION(S)]) and created a likelihood for more serious injury. Facility failure to ensure each resident is transferred safely created a finding of immediate jeopardy that began on 5/23/22. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on 5/26/22 at 3:12 PM. The immediate jeopardy was removed on 5/26/22. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The Facility's Policy and Procedure entitled Fall Evaluation Safety Guideline with an effective date of 11/28/17 documents, in part: .Fall Evaluation- A fall evaluation is used to identify individuals who have predicting factors for falls. This evaluation is completed upon admission, quarterly, annually and with a significant change in condition .Procedure .3. Initiate, review and revise the fall care plan as appropriate, with new or discontinued interventions . The Facility's Policy and Procedure entitled Guideline on Sara (stand lift) and Maxi (full body lift), undated, documents the following, in part: .Maxi-lift .It is intended to be used in hospitals, nursing homes or other health care facilities where the patient: Sits in a wheelchair, Has no capacity to support himself/herself, Cannot stand unsupported and is not able to bear weight; not even partially, Is dependent on the caregiver in most situations OR where the patient: is passive, might almost be bedridden, is often stiff or has contracted joints, is totally dependent on caregiver . The Manufacturer's Manual documents the following, in part, on page 19: .Preparing the Lift for Use NOTE: Although .recommends that two assistants be used for all lifting preparation, transferring from, and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case . R1 is a long-term resident of the facility. R1 has the following diagnoses: ataxia following nontraumatic intracerebral hemorrhage (impaired coordination), limitation of activities due to disability, muscle weakness (generalized), cerebral infarction (stroke), weakness, other lack of coordination, unspecified lack of coordination, other muscle spasm, cramp and spasm, [CONDITION(S)] unspecified affecting right dominant side (paralysis of one side of body (right)), [CONDITION(S)] (muscle jerks), acquired absence of right leg above knee, extrapyramidal and movement disorder, and [CONDITION(S)]. It is important to note that R1 has many diagnoses that indicate he is unable to support himself and/or move or not move with intention. R1's care plan documents the following, in part: R1 requires assist for ADL self-care performance deficit r/t [related to] spasms and contractures .Transfers: Resident requires Total/Hoyer mechanical lift . This care plan is dated 10/26/20. R1 has limited physical mobility r/t Stroke and RBKA [right below knee amputation] .Right upper extremity positioned on lap with carrot or rolled up wash cloth in hand. Offer V shaped pillow behind head, tilt in space feature to help from sliding out of chair, recline slightly when resting .Transfers: R1 requires use of a Hoyer lift for all transfers . This care plan is dated 10/26/20. Resident is at risk of falls due to limited mobility, [CONDITION(S)] [stroke] and RBKA . This care plan is dated 10/26/20. R1 is at risk for falls r/t comprehension, Gait/balance problems, Incontinence, H/O (history of) Falls, H/O [CONDITION(S)], H/O LBKA, Use of Psychotropics . This care plan is dated 10/26/20. The resident has an amputation of RLE [right lower extremity] . This care plan is dated 1/31/20. R1 has potential chronic pain r/t involuntary movement and loss of limb [surgical amputation] right below the knee amputation . This care plan is dated 10/26/20. R1's CNA care plan documents the following, in part: .Safety, 5/24/22: Resident is to have 2 staff to assist with Hoyer transfers for all transfers . .Transferring, Transfers: Resident requires Total/Hoyer mechanical lift; Transfers: R1 requires use of a Hoyer lift for all transfers . R1's Transfer Ability Tool dated 6/9/21 documents Transfers: Resident requires Total/Hoyer mechanical lift. It is important to note that this tool does not indicate that R1 could safely be transferred with the Hoyer lift and 1 assist. R1's Minimum Data Set's (MDS) document the following, in part: MDS dated [DATE]- .Transfer, total dependence of two persons physical assist . MDS dated [DATE]- .Transfers, total dependence of two persons physical assist . R1's Physician Orders contain: [MEDICATION(S)] 75 mg QD (daily) with a start date of 6/10/21. Antiplatelet medications are used to prevent the formation of blood clots that can lead to [CONDITION(S)] and stroke. Common side effects include bleeding, bruising, etc. R1's Nurses' Notes document the following, in part: 5/23/22 at 9:19 PM- Situation: R1 .Resident had a fall. The fall was witnessed. Resident slipped from Hoyer lift pad during transfer Background: Resident is NOT on Anticoagulant or Antiplatelet medication .History or current complaint is: None Assessment: BP [blood pressure] 145/72 - 5/23/2022 17:40 [5:40 PM] Position: Lying l[left]/arm P [pulse] 59 - 5/23/2022 17:40 Pulse Type: Regular R [respirations] 20 - 5/23/2022 17:40 T [temperature] 97.5 - 5/23/2022 17:22 [5:22 PM] Route: Temporal Artery O2 [oxygen saturation] 94 % - 5/23/2022 17:40 Method: Room Air BS [blood sugar] 174.0 - 7/15/2021 11:08 [11:08 AM] Pnl [pain level] 0 - 5/23/2022 19:25 Pain scale: Numerical Resident has NO injury. No pain is noted. Neurological changes are NOT noted. Recommendation/Response: Neuro Evaluation form Facility fall protocol. It is important to note that R1 is on an antiplatelet medication, [MEDICATION(S)]. 5/23/22 at 9:25 PM- Post-Fall: Total Fall Risk Score is: 11 Fall risk scored above 5, resident is at a HIGH risk for falls. BP 145/72 - 5/23/2022 17:40 Position: Lying l/arm T 97.5 - 5/23/2022 17:22 Route: Temporal Artery P 59 - 5/23/2022 17:40 Pulse Type: Regular R 20.0 - 5/23/2022 17:40 O2 94.0 % - 5/23/2022 17:40 Method: Room Air Pnl 0 - 5/23/2022 19:25 Pain scale: Numerical Resident is receiving anti-coagulant medication. The resident does not receive anti-diabetic medications. Resident is receiving [CONDITION(S)] medication. Resident is receiving anti-hypertensive medication. There have not been any changes in the medication. There is no new pain, post fall. There is not a noted pattern to falls. The resident does not have any injury noted. New interventions for this fall that are being implemented: Proper use of h/l [Hoyer lift] Pain Eval: Pain Scale is at: 0. Location is: Pain Score is: Satisfactory pain management / Continue with current plan of care. Skin Observation: Resident does not have a new skin issue. Slight redness and swelling to top of head. Neuro Observation: Resident is alert. Resident is NOT oriented x4; oriented to person, Pupils: PERRLA [pupil, equal, round, reactive to light and accommodation]. Eye evaluation is at resident baseline. Speech is clear. Responds to simple commands. Verbalizes appropriately. There are no noted changes in baseline speech clarity. Right side hand grasp has weakness. There are no changes to the baseline hand grasp strength. Movement and sensation intact in left arm. Movement and sensation intact in left leg. Resident has right side weakness r/t [CONDITION(S)] Evaluation indicates no changes from baseline. It is important to note that the Facility indicates Proper use of Hoyer lift as new intervention for this fall and it is important to note that resident did have an injury post fall of hematoma to posterior head. 5/23/22 at 9:50 PM- Note Text: This evaluation is being completed related to post fall Fall Risk Score is: 11 Fall risk scored above 5, resident is at a HIGH risk for falls. Only Fall Risk Evaluation in R1's medical record is dated 5/23/22 (which was completed post fall from Hoyer). It is important to note that the first question on this evaluation is Has the resident had a recent known fall? This question is answered no. This document is not accurately completed which gives R1 a lower fall risk score. 5/23/22 at 10:22 PM- Note Text: resident slipped from Hoyer lift while being transferred from chair to bed. Fall was witnessed. Resident hit his head on the floor. Denied pain, no non-verbal indicators of pain noted. Assisted to bed. Remain alert and verbally responsive. Able to move left arm and leg. Right side weakness in place r/t [CONDITION(S)] along w/ [with] right side aka. Neuros initiated and wnl [within normal limits]. Slight swelling and redness noted to top of head. Md [Physician], family and DON notified. 5/24/22 at 1:48 PM- Note Text: Resident complained of pain of 9 today and said he just didn't feel right. Applied ice pack to bump on top/back of head from fall the night before but was not effective in relieving pain per resident. Called .NP [Nurse Practitioner] regarding resident's pain. Advised that his BP was 179/83, P 55 and pain level was 9. She said she was coming to the Facility in about an hour and to call her if things changed .NP assessed resident and advised that he be sent to the ER [emergency room ]. EMS [Emergency Medical Services] arrived about 1030 and took him . EMS report dated 5/24/22 documents the following, in part: .a [AGE] year-old male that had fallen the previous night and was now experiencing high blood pressure and head pain .The pt. [patient] states that he is experiencing pain in his head and neck. Facility staff reports that the pt. was being transferred last night using a Hoyer lift at around 2125 [9:25 PM] when there was a mechanical failure with the lift and the pt. fell approximately 3 feet .The staff reports that the pt. has had a previous stroke and he suffers from stroke deficits which includes slurred speech and [CONDITION(S)]. EMS asks staff if the pt. is presenting at his baseline and staff responds with yes however, they report that the pt. is answering questions slightly slower than normal. EMS asks questions of staff regarding the pts [patient's] medication usage and preferred hospital destination, but staff is unable to answer those questions. EMS is given a packet from staff containing that information .It is noted that the pt. does take a blood thinner. A report regarding the fall last night is also given to EMS from staff. In the report, staff indicated that proper fall protocol was followed and that the pt. was not taking a blood thinner . ER report dated 5/24/22 documents the following, in part: .1. Fracture of an osteophyte from the C6 inferior endplate .follow up in 2 weeks .Clinical Impressions: Fall from ground level, Osteophyte of cervical spine, and Acute traumatic injury of cervical spine .Risk of Complications, Morbidity, and/or Mortality- Presenting problems: high, Diagnostic procedures: high, and Management options: high .Neurosurgery Brief Consult Note- Was called about his patient regarding C6 anterior osteophyte fracture sustained after being dropped from Hoyer lift .Viewed imaging that demonstrated non-displaced anterior inferior C6 osteophyte fracture .Recommendations as follows: 1. Please place patient in rigid collar to be worn at all times. 2. Please obtain upright cervical spine x-rays (AP and lateral) in the collar. 3. Can follow up in Neurosurgery clinic .in 2 weeks with upright cervical spine x-rays to be completed at that visit . 5/24/22 at 6:58 PM- Note Text: Return from .ER @ 1515 [3:15 PM]. Resident was sent to ER for c/o [complaints of] pain r/t fall on 5/23/22. Return w/neck brace in place due to fracture. No other orders noted. Will continue to observe. On 5/25/22 at 4:22 PM, Surveyor interviewed CNA E. Surveyor asked CNA E if he could explain how R1 fell ; CNA E explained that he was putting R1 to bed with the Hoyer lift, it was a freak accident that the strap came undone; CNA E further explained that he couldn't get the legs of the lift under the bed so he pulled with the lift toward him and that caused him to rock back and forth in the sling and then he fell . CNA E stated I tried my best to catch him when he hit the floor he was screaming. Surveyor asked CNA E what happened next, CNA E said he moved the lift, ran to get another CNA, looked for the nurse, then returned to R1's room and put him back to bed. Surveyor asked CNA E if he was aware that he should not have moved R1 before the nurse could see him. CNA E stated, I just wasn't thinking about it, I just wanted to get him up off the floor. Surveyor asked CNA E if he was alone transferring R1. CNA E stated the other CNA was feeding residents so I thought I could get him in bed. Surveyor asked CNA E what strap came undone causing R1 to fall. CNA E said the left side by his head. Surveyor asked CNA E if R1 was supposed to be transferred with 1 assist. CNA E said he doesn't work down that hall much. When Surveyor asked CNA E if residents that use the Hoyer lift are supposed to be transferred with 1 or 2 assist, CNA E stated always with two. Surveyor asked CNA E if he transferred R1 alone back to bed from the floor after fall, CNA E said yes. Surveyor asked CNA E how R1 was after he was back in bed, CNA E replied he was his normal self, he did have a bump on the back of his head but had not C/O pain. CNA E further explained that he worked the NOC shift that night and R1 slept fine and was laughing and joking with me. Surveyor asked CNA E if he had received education regarding this incident, CNA E stated no, DON B had called and discussed what happened with him, but he had not received any education. On 5/25/22 at 3:35 PM, Surveyor interviewed LPN D (Licensed Practical Nurse). Surveyor asked LPN D to explain the events surrounding R1's fall from 5/23/22; LPN D explained that she was on break. CNA E came to her upon her return and told her R1 had slipped out of the sling of the Hoyer lift; LPN D further explained that upon entering R1's room he was already back in bed. R1 was alert, talking and denied pain, he did have a lump to posterior head. Surveyor asked LPN D if CNA E transferred R1 by himself. LPN D said through conversation with CNA E, yes, that was the case, he was alone with R1 during transfer. Surveyor asked LPN D if she had any other contact with R1 after the fall, LPN D said yes, she was here when he returned from theER on [DATE]. Surveyor asked LPN D what R1's condition was upon return, LPN D stated he had a hard collar on, she gave him some Tylenol, he was drowsy, he seemed comfortable but didn't eat as well as he usually does. Surveyor asked LPN D if the neuro checks had been resumed upon R1's return. LPN D said no. On 5/25/22 at 2:09 PM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C to explain R1's condition prior to being sent to theER on [DATE]; RN C explained that she knew he had fallen and hit his head the night prior (5/23/22). She completed his neuro check noting his BP to be a little high and R1 C/O pain to his head rating it 9 (on a 1-10 pain scale); RN C further explained that she applied ice to the lump on the back of his head and called the NP. Surveyor asked RN C if it was unusual for R1 to C/O head pain, RN C stated yes. Surveyor asked RN C what the NP said when she called her. RN C said NP said she would be in the facility within an hour and would assess R1 at that time and to call her if anything changed. Surveyor asked RN C what transpired after the NP assessed R1. RN C stated she told me to send him to the ER. On 5/26/22 at 8:40 AM, Surveyor interviewed RN F. Surveyor asked RN F what occurs after a resident falls. RN F explained they are asked about pain, there is a complete assessment (head to toe) including ROM to all extremities, shoulder shrugs, move legs independently, see if legs have any external or internal rotation, begin neuro checks; if going to ER leave on floor and have 911 called otherwise back to bed, administer Tylenol or other pain medication, call Provider, DON B and residents' representative. Surveyor asked RN F how many staff should transfer a resident that uses the Hoyer lift, RN F said all residents that transfer with a Hoyer lift are 2 assist. On 5/26/22 at 10:05 AM, Surveyor interviewed CNA G after observing her and another CNA perform a Hoyer lift transfer. Surveyor asked CNA G how many staff should transfer a resident that uses the Hoyer lift. CNA G stated always 2 staff with Hoyer lift transfers. Surveyor asked CNA G if there is anything else that should always be done when using a Hoyer lift. CNA G said cross the straps at the legs, unless they are the short ones that are used for residents with amputations. Transferring a resident with a full body mechanical lift without an assessment indicating it was safe to complete such transfer with one staff resulted in a fall with fracture and created a reasonable likelihood for serious harm occurring. This led to a finding of Immediate Jeopardy (IJ). The IJ was removed on 5/26/22 as the facility implemented the following action plan: Resident was evaluated at the hospital on 5/24/22. After extensive testing, the only finding was fracture of a C6 osteophyte. A cervical collar was placed. No further treatment was ordered. The resident returned from the hospital on 5/24. The resident's care plan was updated to reflect two-person assist for Hoyer transfers. Residents requiring a Hoyer lift transfer have the potential to be affected. The facility has reviewed the care plans for any residents requiring a Hoyer lift transfer to ensure that the care plan states two-person assist. Re-education and Hoyer lift competencies have been completed with the facility nursing staff. Education also included the facility post fall guidelines. Any remaining nursing employees will be required to complete education and competencies prior to working on their assigned unit. Lift competencies will include new staff on hire and annual competencies. Audits will be completed by the DON or designee on varying shifts, including observations of transfers for residents requiring a Hoyer lift. Transfer audits will be done 3 times per week, one on each shift, for 4 weeks, then results taken to QAPI [Quality Assurance Plan Improvement]. The DON is notified of all falls in the facility. She will provide assessment, instruction, and guidance to licensed nurses following a fall as needed. The DON will review fall incidents daily Monday through Friday to ensure that the resident's care plan was followed, and established facility post-fall guidelines were implemented. This will be done for 4 weeks, and results brought to QAPI. Audits will be discussed during the IDT [interdisciplinary team] QAPI monthly meetings. The IDT team will determine when consistent compliance has been met and audits can be discontinued. The NHA is responsible for this task.

Based on interview and medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 1 of 3 sampled residents (R1). R1 was admitted to the facility on [DATE] status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's hospital discharge orders indicate: Wound Care Instructions: Incision care: Cleanse daily. The facility has no documentation that staff were assessing and cleansing R1's surgical incision until 5/25/21 when NP D (Nurse Practitioner) noted R1's surgical incision was erythemic with an elevated fluctuant abscess on 5/24/21. On 5/25/21 R1 was started on [MEDICATION(S)], a broad-spectrum antibiotic, for an infection. R1 was re-hospitalized from 5/28/21 - 6/11/21 requiring additional IV (intravenous) antibiotic, abscess drainage, and surgical revision of the wound. In addition, the facility has no documentation of R1's surgical incision in his Admission Skin Assessment, MDS (Minimum Data Set) or Care Plan. This is evidenced by: The facility policy, Skin Management Guideline, revised 11/28/17, indicates in part, the following: Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care. A comprehensive individual evaluation guides the: .Identification of the presence of skin impairment; Provides an ability for the facility to develop and implement a care plan that reflects each resident's identified needs; Identify interventions to stabilize, reduce or remove underlying risk factors An individualized plan of care will be developed upon admission, reviewed and updated quarterly and with a change in condition as needed. The plan of care will identify impairment and predicting factors; Inspection of skin daily with cares and weekly by a licensed nurse; Skin Care 13. Consult with the Physician/NP if the wound is deteriorating or increases in size. Re-evaluate plan of care as appropriate. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's 5/18/21 hospital record indicates the following: Post cerv (cervical) incision: Clean, dry, intact, flat, no SQ (subcutaneous - meaning occurring under the skin) fluid collection/induration. R1's 5/19/21 hospital record prior to discharge indicate Incision: Edges well approximated R1's MDS (Minimum Data Set) assessment dated [DATE] notes a BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. Section M (Skin), Surgical wound is blank. R1 is his own person. R1's Comprehensive Care Plan includes in part: The resident has an alteration in neurological status (SPECIFY) (This is blank) r/t (related to) Date Initiated: 5/19/2. Goal: The resident will be able to function at the fullest potential possible as outlined by the interdisciplinary team through the review date. Interventions: Notify MD (Medical Doctor)/Responsible party of changes in neurological status. On 5/19/21 R1's hospital discharge instructions indicate: Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound Care Instructions: Incision care: Cleanse daily As documented below, through interview, the facility did not add the order to cleanse daily to the Treatment Administration Record until 5/25/21. R1's Admission Skin assessment dated [DATE] indicates: 3. Skin Integrity: a. Does the resident have skin integrity concerns: No (Note, there is no indication of R1's surgical incision.) On 5/24/21, 5 days following R1's admission to the facility, NP D (Nurse Practitioner) assessed R1 during an inpatient visit. Chief Complaint: Laminectomy, surgical site infection Patient seen today for routine f/u (follow up), medication and disease management. His cervical incision is noted to be erythemic with elevated fluctuant abscess at superior aspect and [CONDITION(S)] surrounding to inferior aspect. He reports some mild tenderness. He is afebrile. Skin comments: Neck surgical wound Surgical site infection: nursing made aware of appearance and instructed to contact surgeon for sooner f/u and treatment, surgeon deferred initiating treatment change until evaluation in AM. On 5/25/21 R1's McGeers Infection Symptom Tracking indicates the following: 1. Date symptoms observed: 5/25/21 2. Name of Physician notified: NP D (Nurse Practitioner) 3. Date and Time Physician Notified: 5/25/21 7:00 PM 4. Responsible Part Notified: Yes 5. Daughter 6. Date and Time Party Notified: 5/25/21 at 7:17 PM E. [CONDITION(S)]/Soft Tissue/Wound Infection: Yes 2a. [CONDITION(S)], Soft Tissue Wound, Decubiti (Pressure Ulcer): a. Presence of Pus at the wound, skin, or soft tissue site 2b. If not pus present - must have four of the following: (Indicated all of the following) Redness at the site, Swelling at the site, Tenderness or pain at site I. Any other infections: 1. Yes; 2. Describe: admitted to facility with noted oozing abscess to nape of neck; area reddened, tender to touch, painful to palpation with center core opened draining a yellowish thick fluid. ABT (antibiotics) initiated for noted abscess which has not subsided since admission which appears to have declined. There is no prior documentation that indicates R1 had an abscess upon admission or that it was draining a yellowish thick fluid. The facility's first assessment of R1's surgical incision is 5/25/21, six (6) days after admission. On 5/25/21 R1 had an appointment with PA E (Physician Assistant) at the clinic for a wound check. On physical exam today BP (blood pressure) 136/70, Temp (temperature) 97.3 F (Fahrenheit) (Axillary) he is seated in a wheelchair, but he is able to stand and takes a few shuffling steps with a stooped forward posture. Upper extremity strength testing does reveal 5/5 strength throughout. He does have some pain in his neck with deltoid testing. Incision overall appears to be healing well other than an area of the superior aspect of the incision that is approximately 2 cm (centimeters) across with a fluctuant fluid collection just below the surface of the skin. There is also an adhesive crust over the incision and that was peeled away carefully after being cleaned with iodine. A small opening was identified and clear serous fluid was expressed with gentle massage. No purulence was noted. A culture swab was obtained. Assessment and Plan: status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound does not appear overtly infected although there was a small amount of fluid expressed from the most superior portion of the incision. Give the small opening and fluid collection, I will treat the patient with [MEDICATION(S)] 500 twice a day for 5 days.He will follow-up as scheduled in neurosurgery clinic in about one month, but if any worsening symptoms were to occur in regards to his wound or he has any questions or concerns I encouraged him to contact neurosurgery office. He was here in clinic today with his daughter. On 5/25/21 at 7:14 PM, R1's progress notes indicate the following: [MEDICATION(S)] Ointment 500 units/gram - Apply to cervical wound topically two times a day for wound care wash gently with soap and water, rinse, pat dry then apply [MEDICATION(S)] and cover with dressing. On 5/25/21 at 9:33 PM, R1's progress notes indicate the following: Resident started [MEDICATION(S)] 500 mg, BID (twice a day). On 5/26/21 the facility assessed and measured R1's surgical incision for the first time. Wound Information: Status: Active, Type: Surgical, Classification: Incision, Source: Present on admission, Date identified: 5/19/21 Size: 1.50 x 1.30 x 0, Tissue Type: Pale Pink Non-granulating=100% (Note, the picture contained in this assessment demonstrates the surgical incision is reddened [CONDITION(S)] surrounding the wound.) On 5/28/21 NP D assessed R1 during an inpatient visit. Chief Complaint: Discharge Planning Subjective: HPI: 70 y/o (year old) male patient with PMH (primary medical history) including stenosis of cervical spine with [CONDITION(S)], DM2 (diabetes mellitus type 2), dementia, [CONDITION(S)] (hypertension), [CONDITION(S)] (chronic obstructive pulmonary disease) recently hospitalized s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . He was felt stable for discharge to SNF (skilled nursing facility) for (Sub-Acute Rehabilitation) on 5/19/21. During his stay he developed an infection to cervical incision site requiring I&D (incision and drainage) and initiation of antibiotic by surgeon on 5/25/21 with improvement. He was seen today for discharge planning at his request. His daughter is reportedly planning to stay with him at this time. He is recommended to discharge home with home health services for PT/OT/Nursing (Physical Therapy/Occupational Therapy). Skin Comments: Post neck incision well approximated with mild soft [CONDITION(S)] and [CONDITION(S)] Assessment: Spinal stenosis: S/P C4-7 laminectomy. PT/OT eval and treat as indicated. [MEDICATION(S)] PRN (as needed) for pain. Seen by surgeon 5/25/21 d/t (due to) concern of infection, [MEDICATION(S)] until 5/30/21 . On 5/29/21 at 2:27 AM, R1's H&P (History and Physical) indicate the following: .He followed up with NS (Neurosurgeon) on 5/25/21 and had fluid expressed out of his wound, was started on [MEDICATION(S)] and went back to the facility for further rehab. ER workup revealed AKI (acute kidney injury) with a normal creatinine 2 weeks ago, now greater than 8. The patient was also hypotensive (72/50) in the ER. WBC (white blood cell count) is elevated along with procalcitonin, [MEDICATION(S)]. Assessment and Plan: AKI (Acute kidney injury)-normal creatinine 2 weeks ago, now 8.78; likely multifactorial including: prerenal, [CONDITION(S)], medication related ([MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)]). -Aggressive IVF (intravenous fluids), recheck in the am -Consider Nephrology consult if creatinine continues to worsen -Renal dose medications -UA (urinalysis) unremarkable [CONDITION(S)] - improving with IVF, continue at 125 cc/hr. (hour) Elevated [MEDICATION(S)]-likely secondary to [CONDITION(S)], recheck R1's Emergency Department orders are as follows: .0.9% NaCl injection 3ml - 0.9% NaCl injection 1-10ml -- Followed by -0.9% Nacl IV bolus -0.9% Nacl infusion -0.9% NaCl injection 3ml -0.9% NaCl injection 1-10ml -0.9% NaCl IV Bolus -[MEDICATION(S)] ([MEDICATION(S)]) 600 mg in 50 ml NACL IVPB (Intravenous piggyback setup) (This means medication is administered via secondary IV tubing connected to the primary tubing). S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Will not continue antibiotics at this time, but with any change in condition would empirically treat . R1 was hospitalized from 5/29/21 - 6/11/21. R1's hospital noted dated 6/10/21 indicates the following: Procedure: Posterior cervical washout with re-approximation of fascia and drain placement. Pre-Op Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] R1's hospital records dated 6/11/21 indicate the following: .His wound worsened with [CONDITION(S)], but still no fever or pain. It was opened at the bedside on 6/9/21 with copious serous drainage. On 6/9/21 R1 was taken to the operating room and underwent wound revision with closure of facial dehiscence. Following surgery, he continued to do fairly well, tolerating pain. We will plan on SNF (skilled nursing facility) transfer on POD#1(post-op day number 1) with drains in place and close follow up in clinic on Monday with Physician for wound check and likely drain removal. On 10/25/21 at 4:22 PM, DON B (Director of Nursing) indicated there is no Admission Skin Assessment for R1's surgical incision. On 10/25/21 at 5:00 PM, Surveyor spoke with DON B and DSS C (Director of Clinical Services). Surveyor asked DON B and DSS C if there is documentation for the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . DSS C stated there is no documentation to cleanse the surgical incision until orders were entered with [MEDICATION(S)] on 5/25/21. Surveyor asked DON B and DSS C would you expect this to be documented and done. DSS C stated, Yes. Surveyor asked DON B why is it important to follow Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/2/21 at 9:14 AM, Surveyor spoke with NP D. Surveyor asked NP D if she recalls R1. NP D stated, yes. NP D stated on 5/24/21 she went to the facility to see R1 for a routine visit. NP D stated the visit was routine and the facility did not notify of her of any concerns related to R1's surgical incision. NP D stated when she saw R1's surgical incision, It was clear it needed an antibiotic and I&D (incision and draining). NP D stated she remembers pushing hard for the nurse to call R1's Surgeon and she was not willing to take no for an answer. NP D stated R1's infected surgical incision should have been noticed by the staff and staff should have been monitoring and cleansing R1's incision. NP D stated she is a Wound Consultant and she can tell how long a wound/infection has been present and this infection was there for a couple of days prior to her visit. NP D stated this infection did not appear suddenly and if it had R1 likely would have gone septic quickly. NP D stated the fluid under R1's surgical incision needed to come out which required the I&D.

Based on observation, interview, medical record review, and facility policy and procedure review, the facility did not implement professional standards of practice to prevent PIs (pressure injuries) from developing, worsening, or to promote healing of PIs. Assessments of PIs were not consistently being completed by an RN (Registered Nurse), for 2 of 3 residents (R1, R2) reviewed for PIs out of a sample of 5 residents. On [DATE] a CNA (Certified Nursing Assistant) discovered a stage 3 PI on R1's coccyx measuring 10.0 cm x 10.0 cm and a stage 3 PI on R1's left heel measuring 8.0 cm x 7.0 cm. The heel PI was malodorous. R1 was hospitalized [DATE] where both PIs were identified as being infected. R1 received four (4) IV (intravenous) antibiotics during his 1 week hospitalization . Staff identified a stage 3 PI on R2's left heel on [DATE] that measured 1.7 x 3.2 x 0.10 cm; the wound bed is documented as 75% Pink or red non-granulating and 25% slough loosely adherent. From ,d+[DATE] - [DATE] the wound bed was documented as 75% non-blanchable [CONDITION(S)] and 25% non-granulated tissue. This PI remained stable and about the same size until [DATE] when there was undermining and 100% slough. The facility did not consult with R1's Physician or NP (Nurse Practitioner) on this date and no change in treatments or in R2's care plan. On [DATE] R2's PI was 3.5 x 5.0 x 0.1 cm and was 90% necrotic and 10% beefy red. There was no consultation with a Physician and no change in treatment. The facility did not assess or measure the PI the following week, and there is no documentation of an assessment or measurement until [DATE]. At that time, the PI was significantly larger, measuring 10.5 x 9.0 x 0.30 cm and remained 90% necrotic. The facility notified NP H (Nurse Practitioner), who ordered [MEDICATION(S)], an antibiotic. The facility did not assess the wound again until [DATE], 13 days later. The PI was 10.0 x 6.0 x 0 and was 100% necrotic. R2 went on hospice on [DATE] and expired on [DATE]. R1 and R2 developed new pressure injuries (PI) that worsened. Staff failed to identify, measure, and assess R1 and R2's wounds weekly, failed to contact a Physician/NP timely, or implement preventative measures timely to prevent R2's PI from deteriorating /worsening. This created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA A (Nursing Home Administrator), DON B (Director of Nursing) and DOCO G (Director of Clinical Operations) of the immediate jeopardy on [DATE] at 3:08 PM. The immediate jeopardy was removed on [DATE] and continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility implements its action plan. As evidenced by The facility's policy, Skin Management Guideline, dated [DATE], indicates in part, the following: Purpose: to ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown . Inspection of skin with daily cares and weekly by a licensed nurse. Specified turning and repositioning Pressure, friction, shear reduction A. Turning and Repositioning Observation - For those residents that are immobile, or need assistance with mobility evaluate turning and repositioning needs: Upon admission, Re-admission, with a change of condition and annually II. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review the wound formulary guidance 2. Consult with the Physician/NP and Resident Representative 3. Notify Supervisor/Designee as assigned 4. Notify Dietary for nutritional interventions 5. Notify Therapy Department for seating surface evaluation and possible treatment interventions and other interdisciplinary team members as appropriate. 6. Re-evaluate turning and repositioning interventions 7. Initiate Braden Scale and initiate investigation process if new onset 8. Evaluate interventions per risk factors identified and re-evaluate and modify the plan of care based on root cause analysis for new skin alterations . 9. Update the Care Plan for Skin Integrity and nursing assistant care cards with skin concern, appropriate risk factors, turning intervals and interventions as appropriate. 11. When a pressure ulcer is present, daily wound monitoring should include: An evaluation of the ulcer, if no drainage is present; An evaluation of the status of the dressing, if present; The status of the area surrounding the ulcer (that can be observed without removing the dressing); The presence of the possible complication, such as signs of infections; Whether pain, if present, is being adequately controlled 12. Consult with a Physician/NP, Family and Supervisor/Designee if the ulcer(s) has not shown progress in two weeks. 13. Consult with the Physician/NP if the wound is deteriorating or increases in size. Re-evaluate plan of care as appropriate. Resident Choice - In order for a resident to exercise his or her right to appropriately make informed choices about care and treatment or to refuse treatment, the facility and the resident (or the Resident Representative) will discuss the resident's condition, treatment options, expected outcomes, and consequences of refusing treatment. The facility will address the resident's concerns and offer relevant alternatives if the resident has refused treatments/interventions. This will be documented in PCC using the Risk versus Benefits to provide an opportunity to make an informed decision . The NPIAP classifies a pressure injuries as follows: Stage 3: Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and [MEDICATION(S)] tracts may be associated with Stage 4 pressure ulcers. Example 1 R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 has an APOAHC (Activated Power of Attorney for Health Care). Surveyor requested R1's Braden Assessment scores (a measure of pressure injury risk) from DON B. DON B did not provide any documentation. R1's Admission MDS (Minimum Data Set) dated [DATE] indicates R1 is cognitively intact with a BIMS (Brief Interview for Mental Status) of 13 and requires extensive assistance of 2 for bed mobility, and extensive assist of 1 for transferring, walking on and off the unit, dressing and toileting. R1's MDS indicates he is at risk for PI development and he was admitted with no PIs. R1's Quarterly MDS dated [DATE] indicates R1 is cognitively intact with a BIMS of 12 and requires limited assist of 2 for bed mobility and transfers, and extensive assist of 1 for walking on the unit, toileting and extensive assist of 2 for dressing. R1's Visual /Bedside Kardex, dated [DATE], indicates the following for Skin: Ensure that heels are elevated while resident is lying in bed; use foam offloading heel float-if refused use pillows to float heels; Keep HOB (head of bed) at or below 30 degrees. When elevating HOB, [NAME] knees or place pillow under knees; Assess fingers and toes for warmth and color PRN (as needed); avoid positioning the resident on back. Position side to side. Maintain both heels in a floating position using heel floater; Ensure that R1's shoes fit well and do not place pressure on his bunion. R1's comprehensive care plan indicates the following: R1 has the potential for impairment to skin integrity r/t (related to) age related changes to skin, hallux valgus (bunion), incontinence, limited mobility (Date Initiated [DATE]) - Apply barrier cream per facility protocol to help protect skin from excess moisture (Date Initiated [DATE]); Ensure that heels are elevated while resident is lying in bed (Date Initiated [DATE]), use foam offloading heel float - if refused use pillows to float heels; Keep HOB (head of bed) at or below 30 degrees (Date Initiated [DATE]). When elevating HOB, [NAME] knees (this means to place a pillow under the knee/knees so it/they are at an angle or either comfort or to take the pressure of the lower back) or place pillow under knees (Date Initiated [DATE]); Pressure reduction bed mattress (Date Initiated [DATE]); Wheelchair pressure reduction cushion (Date Initiated [DATE]); Educate resident/family/caregivers of causative factors and measure to prevent skin injury (Date Initiated [DATE]); Ensure that R1's shoes fit well and do not place pressure on his bunion (Date Initiated [DATE]) Surveyor requested information from DON B regarding R1's mattress. DON B did not provide the requested information. R1's medical record does not note any pressure injuries until [DATE]. On that date R1's Coccyx Wound Assessment Details Report indicates the following measurements in centimeters (cm): [DATE] - 10.0 cm x 10.0 cm x Unknown *Source: Facility-acquired Date Identified: [DATE] Identified by: DON B (Director of Nursing) Assessment Information: [DATE] at 8:51 AM *Clinical Stage: 3 Exudate: None Periwound Criteria: [CONDITION(S)] Wound Edge: Separate from base Odor: No Sings of Infection Present: Unable to determine Is patient on antibiotics: No Dressing Present: Yes Dressing Date & Initialed: Yes Undermining: Unknown Tunneling: Unknown R1's Left Heel Wound Assessment Details Report indicates the following: [DATE] - 8.00 cm x 7.00 cm x Unknown Type: Pressure *Source: Facility-acquired Date Identified: [DATE] Identified by: DON B (Director of Nursing) Assessment Information: [DATE] at 8:44 AM *Clinical Stage: 3 Exudate: None Periwound Criteria: [CONDITION(S)] Wound Edge: Separate from base *Odor: Yes Sings of Infection Present: No Is patient on antibiotics: No Dressing Present: Yes Dressing Date & Initialed: Yes Undermining: None Tunneling: None On [DATE] NP H (Nurse Practitioner) documents the following note: SNF (Skilled Nursing Facility) nurse calling to report patient with DTI (Deep Tissue Injury) to left heel and pressure ulcer to coccyx. Did not have measurements or stage of pressure injury, believes coccyx was a stage 2 or 3 probably stage 3. Discussed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Discussed having DON B assess wounds, coccyx likely will apply skin prep to peri wound intact skin and [MEDICATION(S)] to open area; but final plan pending more thorough assessment. Nurse to call NP H back with measurements of both wound and stage of pressure injury to coccyx. NP H also placed call to DON B with update on wound and request further assessment. NP H has not heard back from DON B or floor nurse; message left again for DON B to follow-up. NP H has not received return call from DON B and attempted again to reach without answer. Reiterated NP H has not heard of wound assessments and yesterday was the first time NP H was made aware of any wounds. Per SNF EHR (Electronic Health Record): Stage 3 facility acquired pressure injury to coccyx measuring 10.0 cm x 10.0 cm. No odor or drainage per documentation. (Note, photos of R1's heel and coccyx are included in NP H's note). Plan: Refer to wound care, XR (x-ray) L (left) heel 2 view stat, Start Prosource 30ml (milliliters) daily, CBC no diff (differential) to r/o (rule out) infection, reiterated to staff must keep pressure off heel and coccyx, discussed trying to get air mattress. On [DATE] R1's Radiology Report, signed by the Radiologist at 7:27 PM, indicates the following: Results: Oblique and lateral projections. Markedly suboptimal x-ray beam penetration. Calcaneal enthesophytes noted. No gross acute fracture, osseous lesion or dislocation. Conclusion: No gross acute bony abnormality given the limitations of the study. Repeat as needed. On [DATE], the NP covering for NP H noted the following: NP called the facility and requested a fax number to send radiology report back with signature and orders to continue current wound care; referral already made to hospital Burn and Wound Clinic-refer to telephone encounter [DATE] for further details of referral. R1's Coccyx Wound Assessment Details Report: indicates the following: [DATE]- 10 cm x 10.0 cm x Unknown (Note, based on the facility's photographic documentation, this PI has visibly increased in size from two days prior with more necrotic tissue.) Source: Facility-acquired Date Identified: [DATE] Identified by: DON B (Director of Nursing) Assessment Information: [DATE] at 8:51 AM *Clinical Stage: 3 Exudate: None Periwound Criteria: [CONDITION(S)] Wound Edge: Separate from base Odor: No Sings of Infection Present: Unable to determine Is patient on antibiotics: No Dressing Present: Yes Dressing Date & Initialed: Yes Undermining: Unknown Tunneling: Unknown R1's Left Heel Wound Assessment Details Report indicates the following: [DATE] - 8.00 cm x 7.00 cm x 0.00 Type: Pressure Source: Facility-Acquired Clinical Stage: Unstageable Periwound Criteria: [CONDITION(S)] Wound Edge: Distinct and attached *Odor: Yes Sings of Infection Present: No Is patient on antibiotics: No Dressing Present: Yes Dressing Date & Initialed: Yes Undermining: None Tunneling: None General: Tissue Type: Purple Ecchymosis-100% On [DATE] at 6:39 PM, the hospital report indicates R1 arrived to the ED (emergency department). Admission Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], hospital documentation indicates R1's APOAHC (Activated Power of Attorney for Health Care) requests / agrees to: 1. Immediate transition to COMFORT CARE ONLY. -no further surgical debridement -no further IV abx (antibiotics) -no further testing (MRI, bone scan, labs, etc.) 2. DNR (Code Status: Do Not Resuscitate) - COMFORT 3. Liberal use of comfort medications 4. NO [MEDICATION(S)] tube artificial hydration/nutrition 5. Palliative feeds for comfort 6. Discharge to 24 hour facility with hospice - no hospice preference 7. NO rehospitalization Hospice consult ordered. Hospice Eligibility / Certification of a Terminal Illness - Given the patient's [CONDITION(S)], heart failure with reduced ejection fraction, chronic [CONDITION(S)], Parkinsonism, [CONDITION(S)] and [CONDITION(S)] disorders, severe dysphasia, bedbound status, [CONDITION(S)] bacteremia, infected pressure ulcers of the left calcaneus (heel) and sacral areas, and family decision against further aggressive medical intervention, it is my medical judgement that his prognosis, should his diseases progress as expected, is less than 6 months and eligible for hospice services. R1's wound cultures at the hospital are as follows: Left Heel: [DATE] Proteus mirabilis, MSSA ([CONDITION(S)]-susceptible staphylococcus aureus) Coccyx: [MEDICATION(S)] gram negative and gram positive rods On [DATE] at 12:22 AM, R1's ED (emergency department) H&P (History and Physical) indicates, in part, the following: .with a history significant for CAD ([CONDITION(S)]), HFrEF (heart failure with reduced ejection fraction), heart flutter on [MEDICATION(S)], [CONDITION(S)] (hypertension), [CONDITION(S)] disorder, [CONDITION(S)] disorder, parkinsonism, tardive dyskinesia, chronic headache, hyperthyroid, polyneuropathy, sleep-disordered breathing, history of substance abuse with alcohol and cocaine with presents with coccygeal wound and fatigue. [CONDITION(S)] likely secondary to coccygeal wound, foul smelling draining wound on coccyx, stage 3 per nursing notes and measuring 10 x 10 cm, dressed in ER. Lactic acid 2.4, procal 0.18, s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . S/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Critical Care Documentation: R1 was critically ill, with a high risk of imminent or life-threatening deterioration in condition; Risk for severe [CONDITION(S)] requiring fluid resuscitation (Circulatory failure) History: Chief Complaint - Lethargy - R1 sent from facility for lethargy, hasn't been eating/drinking or ambulating as normal x2 days. On [DATE], R1's hospital discharge summary indicates the following: 1. Coccyx wound: Stage 3 wound at admission with foul smelling drainage. Wound care followed for dressing of wound. Started on antibiotics [MEDICATION(S)] and [MEDICATION(S)] in the ED. Antibiotics were escalated throughout admission to [MEDICATION(S)] and [MEDICATION(S)] per Infectious Disease. Wound cultures and blood cultures were drawn. Nuclear imaging via tagged white blood cell scan was attempted to assess for [CONDITION(S)], but was ultimately inconclusive. This prompted conversations with family and patient re: comfort care. See below for further detail. 2. Left Heel wound: Similar management as above in terms of antibiotic courses and attempts at imaging to determine [CONDITION(S)]. Decision ultimately made to forego further surgical debridement. 3. Patient and family were engaged with conversations with palliative care towards middle of hospitalization . Decision was made to pursue comfort care and hospice given advanced staging of wounds and other chronic co-morbid conditions. Because of this, [MEDICATION(S)] was discontinued. No further debridement of the wounds is warranted. Escalation, liberally, of pain medication is appropriate . On [DATE] upon re-admission to the facility, R1's Nursing Evaluation indicates R1 has skin impairments: 50. Left Heel and 23. Coccyx. Note, there is no assessment or measurements of R1's PIs upon readmission. R1 declined for Surveyor to observe cares and PI treatments. On [DATE] at 2:04 PM, Surveyor spoke with NP H (Nurse Practitioner). Surveyor asked NP H when the facility first notified her of R1's PI to his coccyx and left heel. NP H stated the facility notified her on [DATE]. NP H stated she was not available to come to the facility and reviewed the wound documentation and pictures in R1's EHR (electronic health record). NP H stated R1 had a huge unstageable PI to his left heel and coccyx that were both black. Surveyor asked NP H what stage are R1's PI's. NP H stated, stated without seeing the PI's in person, NP H stated, Probably a stage 3. Surveyor asked NP H when you would expect to be notified of a PI (pressure injury). NP H stated, I would expect to be notified immediately when a PI is found. NP H indicated she was never notified when these PI's were a Stage 1 or 2, and they were both Stage 3 when discovered. NP H stated usually PIs are noted on shower days or with cares, however, these PIs were not noted prior to being discovered at a stage 3. NP H stated since the prior WCC (Wound Care Certified) RN (Registered Nurse) left (her last day was [DATE]), I am rarely getting notified of a change in wound. Surveyor asked NP H if R1's PI's to his coccyx and heel were avoidable or unavoidable. NP H stated R1's PI's are avoidable. Surveyor asked NP H were R1's PI's infected. NP H stated, yes, R1's coccyx wound was very foul smelling with a lot of drainage. NP H added, R1 received multiple IV (intravenous) antibiotics while hospitalized for 1 week. Surveyor asked NP H the results of R1's cultures. NP H stated R1's blood culture was positive for streptococcus, R1's left heel culture indicated Proteus Mirabalis and MSSA; R1's coccyx culture indicated [MEDICATION(S)] gram negative and positive rods. NP K stated that on [DATE] the facility transitioned R1's care to their Medical Director. On [DATE] at 10:10 AM, Surveyor spoke with CNA E (Certified Nursing Assistant). Surveyor asked CNA E if R1 refuses care. CNA E stated R1 does not refuse care, however, he will move his feet so they're not floated because he keeps moving. CNA E stated we use Heelz Up and pillows to float R1's feet. On [DATE] at 10:12 AM, Surveyor spoke with CNA J, (Certified Nursing Assistant). CNA J stated she tried to float R1's feet this morning, however, he kept putting his feet down. CNA J stated she told CNA E who in turn told LPN L (Licensed Practical Nurses). Note, there is no documentation or evidence that staff followed up regarding this. Surveyor requested documentation from DON B. DON B did not provide any additional documentation. On [DATE] at 12:25 PM and 3:08 PM, Surveyor spoke with DON B (Director of Nursing) and DOCO G (Director of Clinical Operations). Surveyor asked DON B and DOCO G what standard of practice the facility follows for PIs. DOCO G stated the facility follows the NPIAP (National Pressure Injury Advisory Panel). Surveyor asked DON B when the previous WCC (Wound Care Certified) RN left. DON B indicated she left [DATE]. Surveyor asked DON B who is your wound care nurse. DON B stated she is the wound care nurse. Surveyor stated RN F documented wound care notes. DON B stated she is no longer assigned to wound care. Surveyor asked DON B if RN F is wound care certified. DON B stated, no. Surveyor asked DON B, are you wound care certified. DON B stated, yes. Surveyor asked DON B how often are PIs to be measured. DON B stated, Weekly or with changes. Surveyor asked DON B, when should the Physician/NP be notified of a PI. DON B stated, on discovery, with any changes, if doing a treatment for 2 weeks with no change (improvement), and any decline in the wound. Surveyor asked DON B is there any documentation of R1's PI's at a Stage 1 or 2. DON B stated, no. Surveyor asked DON B do you have any concerns regarding the stage that R1's coccyx and left heel PI's were discovered. DON B stated, Yes. DON B stated, she noted a decline in R1's condition. Surveyor asked DON B what date she noted the decline in R1's condition. DON B stated, It was gradual, it wasn't any specific date. Surveyor asked DON B, what is the root cause of R1's PI to his coccyx and left heel. DON B stated, Lying in bed, refusals to move around. Surveyor asked DON B if R1's refusals are documented. DON B stated she will check. The facility did not provide further information. Surveyor asked DON B did the facility provide risks and benefits to R1 and his APOAHC related to his refusals to reposition. DON B stated, I don't think so, no. Note, no additional information was provided. It is important to note that NP H contacted DON B to discuss PIs. DON B stated they identified this as an issue and took immediate steps to put this in PNC (past non-compliance) on [DATE]. However, DON B stated on [DATE] all weekly PIs measurements and assessments for all residents in house were lost. Surveyor asked DON B if she repeated the assessments and measurements. DON B stated, no. Subsequently, the deficient practices related to PIs are in current non-compliance. Example 2 R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 has an APOAHC (Activated Power of Attorney for Health Care). R2's Braden Assessment Scores are as follows: ,d+[DATE]: 15 (High Risk), ,d+[DATE]: 15 (High Risk), ,d+[DATE]: 15 (High Risk), ,d+[DATE]: 15 (High Risk), ,d+[DATE]: 12 (High Risk), ,d+[DATE]:12 (High Risk), ,d+[DATE]: 13(Moderate Risk), ,d+[DATE]: 13 (Moderate Risk) Braden Risk Levels: ,d+[DATE] At Risk, ,d+[DATE] Moderate Risk, ,d+[DATE] High Risk, ,d+[DATE] Very High Risk R2's Admission MDS (Minimum Data Set) dated [DATE], indicates R1 is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) of 5 and requires extensive assistance of 2 for bed mobility, transfers, and toileting. R2 requires extensive assist of 1 for dressing and hygiene. R2's MDS indicates she is at risk for PI development and was admitted to the facility without any PIs. R2's Quarterly MDS dated [DATE], indicates R2 is moderately cognitively impaired with a BIMS of 9 and requires extensive assist of 2 for bed mobility, transfers, toileting, dressing and hygiene. R2 is an extensive assist of 1 for eating. R2's Visual /Bedside Kardex, dated [DATE], indicates the following for Skin: Ensure that heels are elevated while resident is lying in bed; use offloading boots while in bed; R2 encouraged to lay down between meals; Pressure relieving mattress/air mattress as ordered R2's comprehensive care plan indicates the following: (Date Initiated [DATE]) R2 has unstageable pressure injury to sacrum and stage 3 pressure injury to L (left) heel and potential for impairment to skin integrity and is at high risk for pressure injury development r/t (related t) incontinence limited mobility, decrease in nutritional intake, DM 2 (diabetes mellitus type 2) *sacrum is closed* dressing is for preventative measure (Date Initiated: [DATE]); Goal: R2's pressure ulcers [sic] will show improvement by next review period unless comorbidities cause unavoidable decline (Date Initiated [DATE], Target Date: [DATE]); Interventions: Ensure that heels are elevated while resident is lying in bed; use offloading boots while in bed; Change bedding/clothing if moist; Dietary Consult as needed; Encourage/assist R2 reposition when in wheelchair every ,d+[DATE] hours; Encourage/assist with turning and repositioning every ,d+[DATE] hours; Wheelchair pressure reduction cushion; Administer pain medication as ordered; Alternating air mattress to bed; Educate resident/family/caregivers of causative factors and measures to prevent skin injury; Weekly skin evaluation / report significant changes / evaluate every 7 days per policy; R2 encouraged to lay down between meals (All interventions implemented [DATE] with the exception of this last intervention Initiated [DATE]) On [DATE], R2's TAR (Treatment Administration Record) the following intervention was added: Offloading boots to bilateral feet while in bed. This is being signed out. On [DATE] R2's TAR the following intervention was added: Reposition q (every) 2 hours while in bed every shift. This being signed out. R2 developed a Stage 3 PI to her Left Heel on [DATE]. Measurements (in centimeters) are as follows: [DATE]: 1.7 x 3.20 x 0.10 Pink or red non-granulating 75%, Slough loosely adherent 25% [DATE]: 1.0 x 2.90 x 0.10 Pink or red non-granulating 75%, Slough loosely adherent 25% [DATE]: 1.0 x 1.50 x 0.10 Pink or red non-granulating 75%, Slough loosely adherent 25% [DATE]: 1.0 x 1.5 x 0.10 Pink or red non-granulating 75%, Slough loosely adherent 25% [DATE]: 0.50 x 1.00 x 0.10 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25% [DATE]: 0.50 x 0.50 x 0.10 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25% ,d+[DATE]: 0.50 x 0.50 x 0.10 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25% [DATE]: 0.40 x 0.40 x 0.10 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25% [DATE]: 0.30 x 0.40 x 0.10 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25% [DATE]: 0.30 x 0.40 x 0.10 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25% [DATE]: 1.70 x 2.5 x 0 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25% Area has a clear fluid filled blister around some of site [DATE]: 1.70 x 2.5 x 0 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25% [DATE]: 1.70 x 2.5 x 0 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25% [DATE]: 1.70 x 2.5 x 0 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25%% [DATE]: 1.50 x 1.50 x 0 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25% [DATE]: 1.50 x 1.50 x 0 Non-blanchable [CONDITION(S)] 75%, Pink or red non-granulating 25% *[DATE]: 1.0 x 1.0 x 0.10 - Slough non-adherent 100%; Note, this is a change of condition for R2 as the PI is 100% slough and there is undermining. The facility did not consult with R2's Physician/NP. *[DATE]: 1.5 x 1.5 x 0.10 - Slough non-adherent 100% - R2's PI increased in size; the facility did not consult with R2's Physician/NP. *[DATE]: 3.50 x 5.0 x 0.10 - NECROTIC 90%, bright pink or beefy red 10% - Note, from ,d+[DATE] - [DATE] is 15 days in between measurements and the PI worsened. The facility did not consult with R2's Physician/NP. *[DATE]: 10.50 x 9.0 x 0.30 - NECROTIC 90%; Odor: Yes. The facility contacts NP H to notify her of R2's worsening Left Heel PI thirty (30) days after the change in condition of R2's PI. Under RN Review Comments RN F documented the following note: [DATE] 12:18 PM - Call made the NP (NP H) to make aware that area has spread larger on heel. New treatment order was given for [MEDICATION(S)] and change daily. NP (NP H) will have resident seen at wound clinic. R2's family called and made aware of changed [sic] of site. New order for Prosource. [DATE]: 10.0 x 11.0 - Eschar, boggy, mild odor - Note, this is PA K's (Physician Assistant) assessment and measurement which is a 5.0 cm discrepancy from the facility's measurements the following day (below). ,d+[DATE] is 12 days in between PI measurements and assessments and the PI worsened from [DATE]. *[DATE]: 10.0 x 6.0 x 0 - NECROTIC 100% - Note, from ,d+[DATE] - ,d+[DATE] is 13 days in between PI measurements and assessments and the PI worsened from 90% necrotic to 100% necrotic. Note, on [DATE] R2's PA K (Physician Assistant) assessed and measured R2's PI to her Left Heel: 10.0 x 11.0 cm eschar, boggy, mild odor. Note, this is a 5.0 cm difference in measurements. On [DATE] R2's PA K had an initial visit with R2, documenting the following PIs: Left Inferior Ischium 5.0 x 6.0 cm 75% necrotic tissue and 25% yellow slough, malodorous (The facility has no documentation of this PI prior to PA K discovering the PI on ,d+[DATE]) Superior Right Buttock 2.0 x 2.75 cm with mild necrotic tissue Left Foot (Heel): 10.0 x 11.0 cm eschar, boggy, mild odor Great Plantar Toe with Eschar Right Foot (Heel): DTI (Deep Tissue Injury) Pressure Ulcer of Left Heel: Unstageable s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] It is important to note, on [DATE] the facility documented R2's Left Heel PI with 100% slough. On [DATE] the facility again documented the PI with 100% slough. On [DATE] the facility documented R2's PI as 90% necrotic. The facility went two (2) weeks without measuring and assessing R2's PI. The current standard of practice indicates PIs are to be measured weekly. It was not until [DATE] when R2's PI increased significantly in size that the facility contacted NP H. NP H updated R2's treatment when she was notified. The facility did not identify the change in condition of R2's PI for thirty (30) days (from ,d+[DATE]-,d+[DATE]). From [DATE] to [DATE] the facility went thirteen (13) days without measuring and assessing R2's PI and the PI worsened from 90% eschar to 100% eschar. T

Based on observation, interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents in 2 of 3 residents (R5 and R3) reviewed for fall concerns. Staff did not implement the appropriate fall interventions when providing care for R5. R5 required staples to the back of her head after falling from bed. R3 did not have fall interventions in place when he fell from bed and hit his head, loosening his teeth. Surveyor observed fall interventions were not in place, and staff was not aware that R3 was a fall risk. This is evidenced by the following: Example 1 R5 is a long term care resident that was admitted to the facility on [DATE]. R5's diagnoses include cognitive delay and [CONDITION(S)]. R5's most recent MDS (Minimum Data Set) dated 6/7/21 states that R5 has a BIMS (Brief Interview for Mental Status) of 0/15 indicating severe cognitive impairment. R5 also requires extensive assistance for bed mobility, transfers, and toilet use. R5's CNA Kardex states, in part: Provide bariatric air mattress with wedges under to create wingtip type mattress for boundary identification, frequent checks to ensure proper positioning with R5 centered in her bed, .floor mat beside bed. Bed mobility: Physical Assist, Bathing: Physical Assist, Dressing: Physical Assist. R5's care plan dated 12/30/20 states, in part, The resident has a communication problem r/t (related to) [CONDITION(S)]. The staff will anticipate needs for this resident .Ensure/ provide a safe environment: Soft call light in reach .Bed in lowest position and wheels locked. R5 had a fall on 8/13/21 at 7:15 PM. The Report of Resident Fall states, Summoned by CNA (Certified Nursing Assistant) to residents [sic] room. Resident was lying on her back with a pool of blood. Assessed resident laceration on to the back of her head. Placed her in bed with help of the CNA. CNA stated he had left the resident unattended for less than a minute to grab a towel. R5 was sent to the ER (emergency room ) for evaluation and treatment. R5 returned to the facility after receiving staples to the back of her head. It is important to note that the facility was unable to provide R5's ER notes. On 8/17/21, Surveyor interviewed LPN C (Licensed Practical Nurse). Surveyor asked LPN C to explain the details of R5's fall on 8/13/21. LPN C stated she was at the nurse's station when the CNA asked her to come assess R5. The CNA reported to her R5 had fallen out of bed. The CNA stated he had put her to bed, left the room to get a towel, and R5 rolled out of bed on to the floor. Surveyor asked if R5's bed was in the low position, LPN C stated it was not in the low position and it was just below waist height. Surveyor asked LPN C if the fall mat was in place, LPN C stated no. Surveyor asked LPN C if the wedge wings were in place, LPN C stated R5 has them but they were not in place at that time due to the CNA getting her ready for bed. On 8/17/21 at 2:34 PM, Surveyor observed R5 sitting in her room, in her Broda chair with her call light on the bed, not within her reach. On 8/17/21 at 2:35 PM Surveyor interviewed CNA D. Surveyor asked CNA D if he thought that R5 could reach her call light, CNA D stated no, I do not. On 8/18/21, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectation is for staff regarding the implementation of fall interventions, DON B stated she expects staff will follow those interventions. Surveyor asked DON B how she ensures staff are aware of fall interventions, DON B stated they are on the CNA Kardex and they are documented in the care plan. Surveyor asked DON B if she would have expected R5's fall interventions to be in place prior to her fall, DON B stated yes. Example 2 R3 was admitted to the facility on [DATE] with diagnoses of CHF ([CONDITION(S)]), Type 2 Diabetes, stroke, and [CONDITION(S)] (paralysis to one side of the body). R3' most recent MDS dated [DATE] documents a BIMS of 10/15 indicating moderate cognitive impairment. R3 also requires extensive assist for bed mobility, transfers, and toilet use. R3''s care plan dated 11/27/19 states, in part: R3 is a high risk for falls r/t weakness, history of falls, impulsivity, incontinence, polypharmacy, and vision. Interventions .Dycem added to (underneath) wheelchair cushion, bed in low position, CB to be assessed and changed out for soft touch call light, gripper socks to be in place at all times, assure gripper socks are on feet and encourage use when not in place as resident tolerates, landing strip on open side of bed to prevent injury. R3's CNA Kardex states, in part: CB (call bell) to be assessed and changed out for a soft touch call light, assure gripper socks are on feet and encourage use when not in place as resident tolerates, landing strip on open side of bed to prevent injury. Nurse's notes on 8/6/21 state Summoned to room per CNA, resident noted on floor lying in front of bed on back. R3 had an unwitnessed fall on 8/6/21. The facility's Report of Resident Fall does not give a summary of events. It does state R3 sustained minor injury; his front teeth were loose and R3 stated he hit his head on the floor. R3 was sent to the ER for evaluation. The ER notes the facility reported R3 had an approx. [sic] 4 foot fall from a hospital bed that was elevated in the air A small lac (laceration) noted on the upper gums. R3's bed was not in the low position, as directed in the plan of care, at the time of this fall. On 8/17/21 at 9:40 AM, Surveyor observed CNA E perform incontinence cares with R3. Upon entering R3's room, Surveyor observed the bed was not in low position, R3 had on regular socks, and there was no landing strip on the open side of the bed, and the call light is not a soft touch call light. Surveyor also looked in R3's wheelchair, no Dycem found under wheelchair cushion. On 8/17/21, Surveyor interviewed CNA E. Surveyor asked CNA E how she knows what residents are fall risks, CNA E stated the information is in the care plans, computer system, and sometimes the nurse will let them know. Surveyor asked CNA E how she knows what interventions have been put into place, CNA E stated if it's in the room, it should be being used. Surveyor asked CNA E what fall interventions are in place for R3, CNA E stated she was unsure and she didn't believe R3 was a fall risk. CNA E stated R3 doesn't have a fall mat and she has never seen one in R3's room.

Based on interview and record review, the facility did not assure bowel elimination and implement interventions to prevent constipation and fecal impaction for 4 of 4 residents (R1, R2, R3, and R4). The facility does not have a bowel and bladder policy, did not monitor or assess bowel movements, did not develop and implement a care plan related to constipation, R1 did not have documentation of a bowel movement for 5 days (5/11-5/15/21) and was taking narcotics. R1 was hospitalized on [DATE] for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 experienced a fecal impaction requiring intervention and the facility did not have a record for her bowel movements for 10 days prior. R3 did not have documentation of bowel movements for 8 days and R3 did not have documentation of bowel movements for 8 days. R4 did not have documentation of a bowel movement multiple days in May. Findings Include: Example 1 Surveyor requested a copy of the facility Bowel and Bladder Policy and Bowel Training Policy. The facility was unable to provide Surveyor with copy of policies prior to leaving the facility. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual for the definition of constipation reads, If the resident has two or fewer bowel movements during the 7-day look-back period or if for most bowel movements their stool is hard and difficult for them to pass (no matter what the frequency of bowel movements). Surveyor reviewed R1's medical record. R1 was admitted to the facility 5/11/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge MDS (Minimum Data Set) dated 5/16/21 indicates that R1 is frequently incontinent of bowel and bladder. A staff assessment of cognition indicates R1 is independent - decisions consistent/reasonable. R1 requires limited assistance with bed mobility and transfers, is independent with eating and requires extensive assistance with toileting. MDS assessments under H0600 Constipation present state, No. Note: An admission MDS was not completed as R1 was not in the facility long enough for one to be completed. Surveyor reviewed R1's Admission record which did not indicate a date for R1's last bowel movement. Surveyor reviewed Certified Nursing Assistant (CNA) bowel charting from 5/11/21 to 5/16/21. There are no Bowel Movements charted from 5/11/21 to 5/15/21. On 5/16/21, AM (Morning), NOC (Night) and PM (Evening) shifts all charted M (Medium), 3 (Constipated/Hard). There is no documentation that a nurse was updated. Surveyor reviewed Nurse's Notes for R1 for entire stay in the facility. Daily Skilled Notes do not show that bowel or GI (Gastrointestinal) assessments were documented or completed between 5/11/21 and 5/16/21. Surveyor reviewed Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet by mouth every 4 hours as needed for pain. No more than 6 in a day, Sennosides tablet 8.6 mg. Give 2 tablets by mouth as needed for constipation. Take two tablets PO (by mouth) BID (twice a day) PRN (as needed) for constipation. Note: Surveyor requested a copy of the facility's standing orders. DON (Director of Nursing) indicates that the facility does not have standing orders. Surveyor reviewed Medication Administration Record (MAR) from 5/11/21 to 5/16/21. Sennosides are not documented as being given. Oxycodone was taken as follows: 5/11/21: None 5/12/21: taken at 4:22 PM for pain 5/10 and taken at 8:54 PM for pain 6/10. 5/13/21: taken at 4:06 PM for pain 5/10 and taken at 8:54 PM for pain 5/10. 5/14/21: taken at 4:50 AM for pain 5/10 and taken at 7:05 PM for pain 5/10. 5/15/21: taken at 7:37 AM for pain 9/10, taken at 11:38 AM for pain 8/10, and taken at 5:41 PM for pain 5/10. 5/16/21: taken at 8:50 AM for pain 9/10. Surveyor reviewed R1's Controlled Drug Use Record for Oxycodone 10 mg. Log indicates R1 took Oxycodone on the following occasions . 5/12/21: 4:16 PM and 9:00 PM 5/13/21: 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM (The 8:00 AM dose and the 12:00 PM dose are not noted in the Nurse's Notes and there is no pain rating for these times.) 5/14/21: 4:45 AM, 9:00 AM, 1:00 PM, 7:00 PM (The 9:00 AM and the 1:00 PM doses are not noted in the Nurse's Notes and there is no pain rating for these times.) 5/15/21: 7:37 AM, 11:38 AM, and 5:35 PM 5/16/21: 8:50 AM Surveyor reviewed Nurse's Notes from 5/11/21 to 5/16/21. There are no notes related to bowel assessments completed, bowel movements charted, PRN medications administered, physician notification of lack of bowel movement, medication effectiveness assessments or interventions completed. R1 called 911 on her own behalf on 5/16/21. Nurse's Note from 5/16/21 at 7:01 PM, states Resident called 911, she was having bowel impaction, though she had medium formed bowel movement on AM and PM shift today. Resident's PCP (Primary Care Provider) was called and updated. Voice message left for her N/P (Nurse Practitioner) and DON was also updated. Surveyor reviewed the comprehensive plan of care for R1 dated 5/11/21. There is no focus area related to constipation, bowel management or monitoring. On 6/01/21 at 11:18 AM, Surveyor interviewed R1. Surveyor asked R1 to tell her about her recent hospitalization from the facility. R1 stated, I reported to numerous CNAs (Certified Nursing Assistance) and I also spoke with a Nurse who did not speak very good English that I was constipated and having pain related to constipation. On the day I was hospitalized staff kept telling me I had a bowel movement but I didn't. I was in so much pain that I started picking the bowel movement out myself. I told the CNA and Nurse I thought I needed to go to the hospital but no one did anything, so I called them myself. I ended up in the hospital for a week due to a fecal impaction. I am currently no longer in the hospital and back at an Assisted Living Facility. I refused to go back to the facility after my hospitalization . On 5/17/21 at 12:30 PM, DON B conducted an interview with CNA C. Surveyor reviewed CNA C's statement which states the following, I took care of R1 on 5/16/21 on both shifts. R1 slept most of both shifts. Call light put on but I answered (sic) (she) the resident requested pain medication. I informed the Nurse, Nurse went right in. The resident did have 2 medium bowel movements one on day shift and one right before she left. Before 911 came I was in the room cleaning up R1 because she had a BM (bowel movement). I had the water running and resident turned on her side. I let her know I was going to get a gown and I would be right back. When I came back I seen 911 coming towards door and a co-worker and I cleaned her up. On 6/01/21 at 12:09 PM, Surveyor interviewed CNA C. CNA C stated, I worked with R1 on 5/16/21. R1 refused both her morning and afternoon meals and stated she was impacted and thought she needed to go to the hospital, which I reported to both the day shift and PM shift Nurses. R1 complained of being constipated but I told her she had a bowel movement. R1 had stool on her hands and fingers and I thought she was playing with her stool. I told the Nurse R1 stated she was constipated but she had a bowel movement. Surveyor asked if it was possible R1 was trying to digitally remove stool and didn't actually have a bowel movement. CNA C stated, Yes, I just thought she was a digger. She told me she was in pain and wanted to go to the hospital and I reported that to the Nurse. Note: CNA reported to the Nurse on both the day shift and PM shift that R1 thought she needed to go to the hospital for what she believed to be a fecal impaction. On 6/01/21 at 2:32 PM, Surveyor interviewed DON B. DON B stated, I am aware of the concerns with R1 and R2 that is why I started a QA (Quality Assurance) and educated staff on documentation of bowel movements. I completed interviews with staff working at the time. I am not aware of any current noncompliance. Audits are randomly being done to monitor documentation. Surveyor asked DON B if it is an expectation that bowel movements are documented daily and reviewed by the Nurses. DON B stated, Yes, that is why I started the QA. On 5/17/21 at 3:00 PM, DON B conducted an interview with LPN D. Surveyor reviewed LPN D's statement which states the following, Resident informed nurse she had a medium BM and she felt as if it should have been more. Nurse went to med (medication) cart and CNA went to her room, before I can make it back around the next thing I knew 911 was in his (sic) room. During the shift resident only requested pain medication never stated or informed nurse she wanted to go to the hospital. On 6/01/21 at 2:40 PM, Surveyor interviewed LPN D. Surveyor asked LPN D about R1 and her hospitalization . LPN D stated, I didn't fill out the interview. I informed the DON of what happened and she wrote it and I signed it. I did review what she wrote prior to signing and it was accurate. R1 called and said she needed me. She stated she felt she should have more of a bowel movement. I informed R1 I would come and assess her but before I could do that CNA C reported R1 had another medium bowel movement that was formed. The person that gave me report also stated stool was formed. The person giving me report did not indicate stool was constipated or hard. R1 did not report pain for that day to me. LPN D also states staff are to report bowel movements to the next shift, sometimes it is missed and then we should look in the charting. Surveyor asked LPN D if CNA C reported R1 had stool on her hands and fingers. LPN D stated, No. I offered R1 a stool softener but the EMS (Emergency Medical Service) was already here and she refused and wanted to go to the hospital. The CNA should have let me know R1 had stool on her hands and fingers as that would be new for this resident and indicate something was wrong. Surveyor asked if CNA C reported R1 wanted to go to the hospital. LPN D stated, No, she never told me that. On 6/01/21 at 3:39 PM, Surveyor conducted an interview with NHA A. Surveyor asked NHA A who was in charge of QA (Quality Assurance) and if aware of QA done for R1 and R2. NHA A stated, I think there was just constipation stuff not impaction. The QA Plan will be ongoing without an end date but we would like to see improvement within a month. Last week we had an in-service on documentation in POC (point click care). On 6/01/21 at 4:45 PM Surveyor interviewed MDS Coordinator (MDS Coor) F. Surveyor asked MDS Coor F where the information is gathered from that is entered into the MDS, and specifically Section H: Bowel and Bladder, question H0600, if constipation was present. MDS Coor F stated he would use the 7 day look back period. The assessment date of 5/16/21 would mean information would be gathered from 5/11/21 to 5/16/21 otherwise known as the rule of 7. Information is gathered from ECS including nursing notes and assessments. Surveyor asked what other methods would are used to gather information to make this assessment. There was no documentation provided to support H0600 marked No for constipation present. MDS Coor F also stated that she was hospitalized herself during this time and was completing the MDS from the hospital. Note: R1 was only in the facility for 6 days so a true 7 day look back period was not available to MDS Coor F. Note: Surveyor called hospital on 12 separate occasions to request R1's records but was unable to reach anyone and a return call was never received. Surveyor also attempted to call EMS (Emergency Medical Services) and a call was also not received back from them. The DON also attempted to get records for Surveyors without success. On 5/17/21 an in-service was completed and 23 CNA's and Nurses attended. The in-service form indicates the following Topic: Understanding the importance of reporting and recording residents Bowel Movement. Nurses should view the dash board Q (every) shift to ensure alerts are noted and documented. CNA's should document in the POC and report any abnormal findings to the nurse. Describe Information Provided: Understanding constipation and Fecal Impaction. See attached. Regular monitoring with stool charting prevents constipation, [CONDITION(S)] and [CONDITION(S)] in elderly patients. Note: There are no forms that would have been provided during this in-service in the facility QA folder. Note: There are 52 CNA's and Nurses listed on the facility staff listing. DON B provided Surveyor with a copy of what she indicates staff were educated on 5/17/21. This document states in part . Alerts are intended to show when they are truly important to resident well-being and care. Too often we see them due to inaccurate documentation or lack of documentation. Do's: 1. Document on all scheduled or times tasks every shift. PRN bricks are only to be documented on if that task was completed. They should remain white if not utilized. 2. Check with each resident toward the end of shift that you did not already chart on to ensure if they had a BM. 3. Document Resident Not Available only at end of shift if the resident was truly not available for your entire shift and therefore the only answer you could give. DON'T: 1. Do not document on PRN (as needed) task brick unless you did the task and need to chart it - these DO NOT have to 'go-green.' Staying white will not affect your compliance and is the correct thing to do so you do not trigger alerts. 2. Do not use N/A (not applicable) unless that is truly the answer. Very rarely would that be the correct answer. 3. Do not document 'Resident Not Available' or 'Activity did not occur' at the beginning of a shift as the proper time to indicate these is (sic) at the end of a shift if not able to observe or complete that task. The facility has audits dated 5/18, 5/19 and 5/25/21. These audits indicate the following: 5/18/21, Clinical Dashboard Reviewed, No. Any resident's alerts triggering for NO BM'S, NO. QA/QI review completed by: (Surveyor unable to read initials or what initials are written). 5/19/21, Clinical Dashboard Reviewed, Yes. Any resident's alerts triggering for NO BM'S, yes. FB flagged on 5/19 but had to BM. QA/QI review completed by . (Surveyor unable to read initials or what initials are written). 5/25/21, Clinical Dashboard Reviewed, Yes. Any resident's alerts triggering for NO BM'S, yes. FB flagged on 5/25 but had BM 5/25. QA/QI review completed by . (Surveyor unable to read initials or what initials are written). Example 2 R2 was admitted to the facility on [DATE]. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MAR (Medication Administration Record) shows R2 was given the [MEDICATION(S)] and Senna as ordered since her admission to the facility. Surveyors attempted to speak with R2 on 6/1/21, but she was unable to provide any information regarding her bowel regimen or history of constipation. Facility documents resident bowel movements on both its POC (Point of Care) system and the MAR. R2 was documented as having no bowel movements on both the POC and MAR between 5/4/21 and 5/14/21. A facility progress note, dated 5/14/21, states Therapy approached stating that the resident isn't feeling well. She is having weakness and unable to stand and also altered mental status change. Resident states she is tired and would like to go home. The facility notified R2's physician who gave the facility orders to send to the hospital for evaluation. R2 was admitted to the hospital on 5/14/21 and was discharged on [DATE]. The discharge summary report from the ED (Emergency Department) states, Abdominal CT revealed large colonic/rectal stool burden and very distended urinary bladder with possible bladder outlet obstruction. Patient was manually disimpacted (removal of stool from the rectum) in ED and a Foley catheter was inserted. Upon return to the facility on [DATE], the facility incorporated a bowel regimen as prescribed by the hospital and bowel movements have been tracked indicating R2 has had a bowel movement at least every other day through 6/1/21. On 6/1/21 at 4:30 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated the bowel movements for R2 would only appear in the MAR and POC and there is no other record of bowel movements. DON B also stated the facility had identified concerns with charting bowel movements and conducted in-service training with nursing staff on 5/17/21. DON B stated she had no way of verifying if, in fact, bowel movements were taking place prior to 5/17/21 and not being documented or if residents were truly constipated for long periods of time. Example 1 and Example 2 deficiences are being cited at Actual Harm. Example 3 R4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 5-day MDS (Minimum Data Set) dated 5/11/21 indicates that R4 has a BIMS (Brief Interview of Mental Status) score of 10, indicating that R4 has moderate cognitive impairment. R4 is occasionally incontinent of bladder and always continent of bowel. R4 requires extensive assistance of one with bed mobility, limited assistance of two staff for transfers and toileting and independent after set-up for eating. MDS assessments under H0600 Constipation present is not completed. Surveyor reviewed Certified Nursing Assistant (CNA) bowel charting from 5/22/21 to 5/31/21. There is no Bowel Movements charted from 5/22/21 to 5/26/21 and 5/29/21 to 5/31/21. On 5/28/21 it is charted that R4 had M (Medium), 1 (Formed/Normal). There is no other documentation indicating that a Nurse was notified on any occasion that R4 had went multiple days without having a BM or without BM charting. Surveyor reviewed R4's eMAR (Electronic Medication Administration Record). Surveyor noted Senna Tablet 8.6 mg (Sennosides), Give 1 tablet by mouth one time a day for constipation, ordered 5/05/21. Surveyor reviewed the comprehensive plan of care for R4 dated 3/17/21. There is no focus area related to constipation, bowel management or monitoring. Example 4 R3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS (Minimum Data Set), a comprehensive assessment of R3's functional status and capabilities completed on April 2, 2021 indicates he was continent of bowel and bladder and had a BIMS (Brief Interview of Mental Status) score of 15. BIMS scores of 13-15 indicate an intact cognitive response. R3's health record indicates in the documentation form entitled, 'Survey report for bowel and bladder care' that during the period of May 23-May 31, 2021 (9 days), R3 did not have a bowel movement (BM). Per the instructions on this recording tool, which was initiated on 11/25/15, staff are supposed to record every shift (shift being 8 hours) whether a resident had a BM or not. Staff are also supposed to document size, consistency and number of BM's every shift. Of the 93 opportunities in May to record this information, staff failed to document anything 21 times or 21.4% of the time for R3. On 6/1/21 at 1:30 PM, Surveyor asked DON B, for the facility policy regarding bowel regimes, standards of care and/or standing orders for constipation? DON B replied, We don't have a policy on bowel regimes or standing orders for constipation. Surveyor asked DON B, how do you know when someone is developing constipation? DON B answered, It comes up as an alert on our electronic health record (EHR). Surveyor was unable to locate the 'alert' indicating R3 had not had a BM in R3's health record. On 6/2/21 at 3:15 PM, Surveyor asked DON B, regarding the facility process that alerts the nurses a resident has not had a BM? DON B indicated, The CNA's (certified nursing assistants) record the BM's. If it has been more than three days, the EHR sends an alert to the nurse. The nurse should then follow up. Surveyor stated an alert on R3's record was not found and R3 has went 10 days without a BM. Surveyor showed DON B the BM tracking record within R3's record. DON B replied, Sometimes, R3 transfers himself to the toilet and has a BM, therefore, nothing is charted. Surveyor asked DON B, what the expectation is for CNA's regarding BM documentation. DON B answered Part of the education I am providing is to document BM's but it is hard to get everyone on board. Surveyor asked DON B, do you expect staff to chart per the instructions on the documentation form that includes size, number and consistency of BM every shift? DON B replied, Yes. Surveyor asked DON B, regarding the alert for R3's record that there has not been a BM. DON B indicated, she did not see the alert for R3. Surveyor asked, can indicate in R3's health record where the nurses interviewed the resident to determine if R3 had a BM in the last 9 days? DON B answered, No. Surveyor asked DON B, per the facility's tracking, should an alert have been generated in the EHR? DON B answered, Yes. Surveyor asked, if R3 did or did not have a BM, should this have been charted? DON B replied, Yes. Surveyor asked DON B, if the resident did not have a BM, should the nurses have followed up, interviewed, assessed the resident and informed the physician? DON B, indicated Yes. Surveyor asked DON B, what policy or standard of care does the facility use if a resident hasn't had a BM or is developing constipation? DON B replied, We don't have a standard of care or policy, we use the alert on the EHR. The CNA is supposed to ask the resident and chart, not just leave it blank. R3 takes himself to the bathroom so I know he is not constipated. Surveyor asked DON B, what about nonverbal residents, how would you determine they are constipated or impacted without accurate charting, without the resident's self-report, without a facility process for follow up, assessment or physician notification? DON B replied, I am doing education so there is better charting. Surveyor asked DON B, if the record was accurate, what standard of care or process would a nurse follow to assist R3 who hasn't had a BM in 9 days? DON B answered, We don't have a standard of practice or policy regarding this; we have the alert in the EHR. On 6/1/21 at 3:30 PM, Surveyor interviewed R3 if he is bothered with constipation. Surveyor asked R3, has constipation been an issue for you? R3 replied, I don't have constipation. I use [MEDICATION(S)] (an [MEDICATION(S)] which pulls water into the colon to make stools softer and easier to pass) about every third day and don't have any trouble at all. Surveyor asked R3, have you had any periods of time when you didn't have a BM for 5-8 days? R3 stated, Never, never gone that long without a BM. Surveyor asked R3, about his medications in particular the narcotics ordered for pain and they can cause constipation; do the narcotics control your pain? R3 answered, I rarely have pain, and I don't use the narcotics. Surveyor asked R3, but you do use the [MEDICATION(S)]? R3 replied, Yes, about every 3 days, I'm on water pills and not moving around as much as I should, it slows me down in that department. Of note, Surveyor reviewed R3's medication administration record (MAR) for May 2021. [MEDICATION(S)] was recorded as given one time, on 5/3/21 at 07:49 AM. R3 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview and record review, the facility did not follow proper sanitation and food handling practices in accordance with professional standards for food service safety. This has the potential to affect all 62 residents. The facility failed to check surface temperatures of dishes and utensils in a high temperature ware dish machine and failed to [MEDICATION(S)] when temperatures were below the established guidelines for wash and rinse temperatures. Additionally on [DATE], the external dishwasher temperature gauge indicated the dishwasher was not reaching the required wash or rinse temperature and (Agency) CNA I (Certified Nursing Assistant) continued to use the dish machine. (Agency) CNA I and (Agency) CNA H were pulled to work as Dietary Aides in the kitchen. CNA I and CNA H are not trained to monitor the external temperature gauge on the dish machine's wash and rinse cycles or to check the dish and utensil surface temperature with heat sensitive test strips or a non-regressing thermometer. Subsequently, dishware and utensils were not properly sanitized. Surveyor observed CNA I (Certified Nursing Assistant) repeatedly move from dirty to clean dishes without washing her hands. Note, even if dishes and utensils were being properly sanitized they could have been contaminated by a worker going back and forth between dirty and clean dishes. Surveyor observed CNA I wet stack plates, lids and cups. Surveyor observed a fan covered in dust and debris blowing directly on clean dishes. Failure to ensure systems were in place to ensure wash and rinse temperatures met the identified standard for properly sanitizing dishes and utensils created a finding of Immediate Jeopardy (IJ). The IJ began on [DATE] at the beginning of the facility's Sunday start survey. NHA A (Nursing Home Administrator) and Director of Operations J were notified of the IJ on [DATE] at 2:12 PM. The facility removed the IJ on [DATE]; however, the deficient practice continues at a scope/severity level F (potential for more than minimal harm/widespread) as the facility continues to implement its removal plan and as evidenced by the following: No one was monitoring the holding temperature of foods, which may have been infected in the kitchen, to ensure foods were held and served at a temperature where bacteria would not multiply. No one was monitoring the chilling temperatures and times of chilled food KS G (Kitchen Supervisor) was preparing food in a dirty kitchen. Food was served cold; There were multiple complaints from residents that food is cold when served. The Surveyor observed four food trays sitting on a cart for 49 minutes before being served. One of the trays was not covered, but staff brought it back to the kitchen and got a different tray. There are no logs indicating staff have monitored any food temperatures at any meal. Review of the facility's menu indicates the facility has served potentially hazardous foods. These include scrambled eggs, sausages, sausage patties, pork roast, beef roast, breaded fish sandwiches, egg salad, beef and macaroni casserole, and barbecue riblets. Surveyor observed two (2) garbage bins with 3 out of 4 lids open. Surveyor observed multiple open food items, with no open or thaw date including PHF (potentially hazardous foods). Findings include: Dish machine The facility uses the US Food Code as their kitchen's operational standards of practice. 2017 Food and Drug Administration (FDA) Food Code states: ,d+[DATE].13 Temperature Measuring Devices, Manual and Mechanical ware washing (B) in hot water mechanical ware washing operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL, surface temperature. ,d+[DATE].112 .When surface temperatures of utensils passing through ware washing machines using hot water for sanitizing do not reach the required 160 degrees (F) Fahrenheit, it is important to understand the factors affecting the decreased surface temperature. A comparison should be made between the machine manufacturer's operating instructions and the machine's actual wash and rinse temperatures and final rinse pressure. The actual temperatures and rinse pressure should be consistent with the machine manufacturer's operating instructions and within limits specified in sections ,d+[DATE].112 and ,d+[DATE].113. If either the temperature or pressure of the final rinse spray is higher than the specified upper limit, spray droplets may disperse and begin to vaporize resulting in less heat delivery to utensil surfaces. Temperatures below the specified limit will not convey the needed heat to surfaces. Ecolab's manufacturer guidelines for the ES-2000HT (high temperature) hot water sanitizing dish machine states, in part, as follows: Operating Temperatures: Wash (minimum) 150 degrees F. and Sanitizing Rinse (minimum) 180 degrees F. To effectively clean and sanitize dishes and utensils, the wash (minimum) temperature should reach 150 degrees F. and the rinse (minimum) temperature should reach 180 degrees F. The facility policy, Mechanical Cleaning and Sanitizing, dated 2010, states, in part, as follows: Dish machines will be operated in accordance with manufacturer's instructions. High Temperature Dishwasher: Dish machine's using hot water for sanitizing may be used if the temperature of the wash water is no less than that specified by the manufacturer, which may vary from 150 degrees F. to 165 degrees F., depending on the type of machine, and if the final rinse temperature is no less than 180 degrees F. According to Why a Dish Needs to Hit 160 Degrees to Really be Clean, Because most bacteria are killed at a temperatures between 140°-150°, 160° is considered a safe industry standard to assure a dish or utensil has been properly sanitized. Common bacteria that may be spread include: Norovirus is a common bacteria which is easy to contract and quite contagious . Salmonella is perhaps the best known of bacterial infections and is present on many raw foods. Although cooking removes the bacteria assuming the inner portion of the food reaches a temperature of 150°, any utensils or surfaces used to prep the food remains infected. Listeria can be a particularly dangerous bacteria as it is able to grow even in refrigeration. Poisoning via Listeria typically resembles a mild flu condition, but can be lethal for small children or the elderly. Staphylococcus aureus (S. aureus) is the typical bacterial variant in foods which are prepared after cooking, such as salads, especially the mayonnaise varieties such as potato or chicken salad. Preventing an outbreak requires diligent hand washing before and after handling each component of the recipe along with proper refrigeration of the food and of course, cleaning the dishes used during storage and serving. [CONDITION(S)] botulinum, commonly known as [CONDITION(S)], is one of the rarer bacteria but is more likely to be a fatal infection rather than causing simple stomach problems for a few days. It's important to properly sanitize everything used for [NAME] foods, and boil the food well before serving after the seal is broken. https://paperthermometer.com/blogs/posts/why-a-dish-needs-to-hit-160-degrees-to-really-be-clean On [DATE] at 9:10 AM, Surveyor observed (Agency) CNA H and (Agency) CNA I doing dishes. CNA H and CNA I stated they are both agency CNA's that were pulled to work in the kitchen today and they have worked in the facility's kitchen on multiple occasions prior to today. Surveyor explained to CNA H and CNA I that Surveyor will be observing their process for washing dishes. Surveyor observed manufacturer guidelines for the dish machine printed on the external Wash (150 degrees) and Rinse (180 degrees) gauges. Surveyor observed an Ecolab poster to the right of the dish machine that also indicated the manufacture guidelines for the wash and rinse cycles. As the CNAs were running the dish machine, Surveyor made four (4) separate observations of the dish machine: Wash at 130 degrees F. and the Rinse at 160 degrees F., with a fifth rinse at 165. Surveyor observed CNA I repeatedly going from dirty to clean while doing dishes without washing her hands. CNA H left the dish room to collect dishes in the dining room. Surveyor observed CNA I pull 15 clean plates from the dish machine. CNA I pushed dirty plates into the dish machine. CNA I took the 15 clean plates and wet stacked them on top of one another. CNA I went to the sink of dirty dishes, pulled the sprayer down with her bare hands, sprayed 9 dirty bowls, loaded them onto the rack, and pushed them in the dish machine. CNA I grabbed clean bottoms (that hold plates during meals service) and put them on the drying rack. CNA I then pulled 9 clean bowls from the dishwasher. CNA I then grabbed the sprayer with bare hands and started spraying dirty breakfast plates. CNA I then pulled 11 clean lids from the dishwasher and went back to spraying dirty dishes. CNA I started the dish machine and started putting away clean lids. Agency CNA then pulled 16 clean plate warmers out of the dishwasher and stacked them on top of one another. On [DATE] at 9:12 AM, Surveyor observed a dusty and dirty fan blowing on the clean dishes. While observing CNA H and CNA I doing dishes, Surveyor made four (4) separate observations of the dish machine's wash an rinse cycle not meeting the minimum wash temp of 150 degrees F. and the minimum sanitizing rinse temperature of 180 degrees F. Surveyor observed 4 occasions where the dish machine Wash is 130 degrees F. and the Sanitizing Rinse is 160 degrees F, with a fifth rinse at 165 degrees F. Surveyor observed CNA H and CNA I did not check the temperature of the dish machine. On [DATE] at 9:25 AM, Surveyor asked CNA H and CNA I if they received training to monitor the temperature of the dish machine. Both CNA H and CNA I stated, No. CNA H stated, They didn't teach us anything in detail. Surveyor asked CNA H and CNA I were you trained to not go from dirty to clean. Both CNA H and CNA I stated, yes, they were trained to not go from dirty to clean. Surveyor asked CNA I if she should wash her hands when going from dirty to clean. CNA I stated, Yes. Surveyor asked CNA I if she washed her hands when going from dirty to clean. CNA I stated, No. CNA I added, You saw that I didn't wash my hands. Surveyor asked CNA I should you have washed your hands when going from dirty to clean. CNA I stated, Yes. Surveyor asked CNA H and CNA I do you know what temperature the dish machine is supposed to be at for the wash & rinse cycles. Both CNA H and CNA I stated, no and they were not trained to monitor the temperature of the dish machine. Surveyor asked CNA H and CNA I do you check the internal temp of the dish machine. Both CNA H and CNA I stated no, they know nothing about a non-regressing thermometer or running a test strip through the dish machine. Note, even if dishes and utensils were being properly sanitized they could have been infected by a worker going back and forth between dirty and clean dishes. On [DATE] at 9:28 AM, Surveyor spoke with KS G. Surveyor asked KS G what the wash/rinse should be on the dish machine. KS G stated 155 wash & 185 rinse. Surveyor shared the manufacturer guidelines on wall of 150 degrees F (minimum) & 180 degrees F. (minimum). Surveyor asked KS G is that accurate. KS G stated, Yes. Surveyor asked KS G should the dish machine reach the required wash and sanitizing rinse temperatures. KS G stated, I would think so. Surveyor asked KS G, do staff check the temperature of the dish machine. KS G stated, Other than outside (external) temp not that I'm aware of. Surveyor asked KS G, do staff check the internal temperature of the dish machine. KS G stated, Not that I'm aware of. Surveyor asked KS G, do staff use any test strips to check the internal temperature of the dish machine. KS G stated, No. Surveyor asked KS G, do you know when Ecolab last serviced the dish machine. KS G stated, No. Surveyor asked KS G should the fan in the dish room be clean. KS G stated, I don't know. KS G stated when he started as a Cook at the facility he was trained for 2 days as a Cook and to do inventory. KS G added, I'm teaching myself, I don't have any training on dishes. KS G stated the kitchen is extremely short staffed and he has complained to the facility, however, they have job postings/ads to hire more Cooks, however, there are no applicants. KS G stated he quit complaining because the situation doesn't change. Surveyor informed KS G of Surveyor's observations that the dish machine running under the manufacturer guidelines for the Wash and Sanitizing Rinse cycles. Surveyor shared with KS G he will need to make an alternate plan for dishware for lunch as the dish machine is not working properly. Surveyor also shared observations with KS G of CNA I going from clean to dirty dishes repeatedly without washing her hands, therefore, the dishes are not clean and will need to be rewashed once the dish machine is repaired. On [DATE] at 10:33 AM, Surveyor observed CNA H and CNA I bringing beverage carts down multiple halls together with plastic cups and mugs that were not properly sanitized due to the dish machine not meeting temperature criteria. On [DATE] at 10:35 AM, Surveyor informed NHA A (Nursing Home Administrator) Surveyor shared observation of CNA H and CNA I bringing beverage carts down multiple halls with cups that were to not be used. NHA A stated, he will take care of this. On [DATE] at 12:35 PM, NHA A stated Ecolab checked out dish machine and found no issue with the wash or rinse temperatures. ER N (Ecolab Territory Representative) stated he just ran the dish machine and the Wash temp was 150 degrees F. and the Sanitizing Rinse temperatures were 180, 184, and 185. ER N stated, I found no issues, I ran it once and it hit 180. ER N added, the second time it hit 184 & 185. Ecolab Territory Representative stated, I don't have a logical explanation. Surveyor suggested we go to kitchen & run the dish machine together. Surveyor, NHA A, ER N, and DM O (Director of Maintenance) went to the kitchen's dish machine. Ecolab Territory Representative ran the dish machine. The first time the dish machine was run, the wash and rinse temperatures reached the manufacturer guidelines. Surveyor requested to run the dish machine multiple times and asked ER N to read the gauge as Surveyor observed the gauge. On the 2nd, 3rd and 4th attempts, ER N stated, The rinse was 175, 170 and 165. Surveyor observed a wash cycle at 140 degrees F. After these observations, ER N replaced the sensor on the dish machine. On [DATE] at 1:00 PM, DM O ran a Food Grade TStick that indicates 170 degrees for 10 seconds through the dish machine and stated there's some brown on the TStick which means it's reaching at least 170 degrees F. On [DATE] at 2:12 PM, Surveyors spoke with NHA A, NHA A stated the sensor doesn't affect anything but the gauge. NHA A stated, it was temping out right. NHA A added, there was nothing wrong with the machine. Director of Operations J stated, there was calcification on the tip (of the sensor) and it wouldn't pick up sensitivity of the temperature. Surveyor asked NHA A if the facility has a non-regressing thermometer. NHA A stated, he thinks DM O has one. Surveyor asked if he has started educating staff and has a sign in sheet to document staff training. NHA A stated, Not yet. NHA A stated, he gave KS G a log to document food temperatures. Surveyor requested KS G, CNA H and CNA I's training. Note, no further documentation was provided to Surveyor. On [DATE] at 11:59 AM, Ecolab's Extra Service Request indicates the following: Machine temp (temperature) off. Replaced gauges and got 185 on rinse and 151 on wash. Note, this was before Surveyor and staff returned to the dish machine at 12:35 PM for additional observations. On [DATE] at 3:23 PM, Surveyor spoke with NHA A. NHA A informed Surveyor since Ecolab came in [DATE] for the service call the dish machine has not been in use since as it's not reaching the minimum manufacturer guidelines for the wash and rinse temperature. NHA A stated, It's the element, so it's not producing the steam to sanitize the dishes. NHA A added, if the dish machine sits for a little bit (not being used) it reaches the required temperatures. If the dish machine is being run a lot it doesn't temp. Note, during Surveyor's observation the dish machine was being run many times. NHA A added, the dish machine is not currently in use and Ecolab is coming today or tomorrow. Surveyor asked NHA A when was the dish machine last used. NHA A stated it was last used yesterday [DATE], before the IJ (immediate jeopardy) call. On [DATE] at 11:57 AM, Ecolab's Extra Service Request indicates the following: Replaced element gasket thermostat and vacuum breaker float. Found a lot of scale buildup on element and thermostat and vacuum breaker float. Pictures on the report include the old element and sediment from the booster tank. Failure to ensure systems were in place to ensure wash and rinse temperatures met the identified standard for properly sanitizing dishes and utensils created a finding of Immediate Jeopardy (IJ). The facility removed the IJ on [DATE] when it implemented the following plan: All facility Dietary or staff working in the dietary department will be educated prior to their next working shift on: *The policies and procedures of completing internal temperature of the dishware machine *Monitoring and documentation of temperatures upon the start of dishwashing after each meal *Education will include corrective actions if temperatures are not within desired temp guidelines and immediate corrective actions will be implemented Education for all dietary staff or staff working in the dietary department will be prior to their next working shift and include the following: * No food shall be served on dishes that have not reached a surface temperature of wash: 150 degrees F - 170 degrees F wash cycle and ,d+[DATE] degrees rinse cycle. The facility will create a policy to ensure dishware service temperatures are completed at each meal and documented on an appropriate log all staff will receive education regarding the policy. * If desired temperature parameters are not met, staff will immediately switch to disposable products for all meals. The staff will immediately notify the Supervisor or Dietary Manager for further investigation. The Dietary manager will then immediately notify the Administrator. Staff will continue to use disposable dishes and utensils until notified by the Administrator to resume dishware. * If for any reason, staff believe the dishwasher is not reaching desired parameters for surface temperatures, they will switch to disposable dishes immediately and notify the Dietary Manager, who will then notify the Administrator. * Documentation of surface temperatures and/or rinsing range on logs for dishwasher at each meal will be audited for completion and accuracy by the Administrator / designee Staff will follow the process/procedure if temperatures are out of range. Temperature logs for dish machine and audits will begin immediately. * The cook/s will immediately begin completing temperature logs prior to meal service and periodically during meal service to prevent foodborne illness. Administrator / designee will audit logs to ensure completion and food temperatures remain in a safe service range. * The facility will develop a policy and procedure for completing food temperatures, holding temperatures and cooling of food to prevent foodborne illness. All dietary staff will be educated on the facility policy. * QAPI (Quality Assurance and Performance Improvement) Monitoring Plan: Auditing will be completed to ensure food temperatures are completed and within safe temperature range. Auditing will be completed to ensure dish surface temperatures are being completed and accurate. Auditing will occur daily for one month, 3 times/wk. for two weeks and then weekly and as needed by the DM (Dietary Manager), Maintenance Supervisor (or designees). * Routine audits will be completed randomly ongoing. On [DATE] at 1:40 PM, Surveyor spoke with CNA H. Surveyor asked CNA H did the facility provide education to you over the past day. CNA H stated, yes, yesterday after Surveyors left the building (note, this is after 5:,d+[DATE]:30 PM) and this morning. CNA H stated the facility educated him regarding dish machine temperatures, temperature logs, food temperatures, and cleaning the kitchen. On [DATE] at 1:41 PM, Surveyor spoke with KS G. Surveyor asked KS G if the facility provided any education to him. KS G stated, yes the facility started educating him yesterday and today regarding taking temperatures of foods and the dish machine and recording temp logs. On [DATE] at 3:57 PM, Surveyor spoke with Admissions Director BB and Cook CC who is Spanish speaking. Admissions Director BB assisted with translating the conversation for Cook CC. Cook CC, who is normally the Dietary Assistant is the Cook for the PM shift tonight. Surveyor asked Cook CC have you received training from the facility over the last day. Cook CC stated, yes, he received training last night regarding to check the check the food temperatures when he's cooking, when it's in the table, make sure the steam table is hot, and to check the temperature of the food when he puts it on the carts. Surveyor asked Cook CC, if food is left over from a meal what do you do with it. Cook CC stated, when he's done serving everything gets thrown away. Surveyor asked Cook CC if he has received education regarding the dish machine. Cook CC stated, yes. Surveyor asked Cook CC what education he received. Cook CC stated to make sure the temperature of the dish machine is correct first. Surveyor asked Cook CC how do you do this. Cook CC stated the dish machine has a thermostat on it tonight. Surveyor asked have you received any training regarding temperatures of the dish machine besides checking the outside temperature gauge. Cook CC stated, yes, they gave him temperature papers to put in the machine, take it out and see how warm it is. Surveyor asked Cook CC, what if it's not within the required temperatures. Cook CC stated, he will call the Supervisor. Surveyor asked Cook CC what temperature is the dish machine supposed to be at. Cook CC stated, Wash 150 degrees and Rinse 180 degrees. On [DATE] at 4:09 PM, Surveyor spoke with CNA DD. CNA DD stated she is a CNA (Certified Nursing Assistant) but she has been helping in out as a Dietary Aide; my role tonight is Dietary Aide. Surveyor asked CNA DD have you receive any education over the past day. CNA DD stated, yes, she was trained regarding the temperature gauge on dishwasher. CNA DD stated, they showed us how to read it; It should be at 150 for the wash & 180 for the rinse. Surveyor asked CNA DD, did they talk to you about logging the temperatures? CNA DD stated, They did, there's a paper in there. CNA DD added, they also educated me on not going from dirty to clean while in the kitchen and doing dishes. On [DATE] at 3:23 PM Surveyor spoke with NHA A. Surveyor asked NHA A, how staff should check the internal temperature of the dishwasher. NHA A showed Surveyor two (2) new thermometers, Temp Rite Dishwasher Plate Thermometer, still in the packaging. NHA A stated, that's a temporary solution for now. NHA A stated, we're going to move to something digital. Surveyor asked NHA A, how staff should do this. NHA A stated, staff are going to put the new thermometer in (FDA Food compliant for sanitization) through the dish machine; staff will be checking the internal temperature of the dish machine three times per day (breakfast, lunch and dinner). Surveyor asked NHA A, Should staff document that they are checking the internal temperature of the dish machine. NHA A stated, yes, we created log for staff to document this. Surveyor asked NHA A should staff wash their hands when going from dirty to clean. NHA A stated, Yes. Surveyor asked NHA A, should a dirty fan be blowing on the clean dishes. NHA A stated no, we're going to be doing a deep clean on the fan. Surveyor asked NHA A, should it be clean. NHA A stated, Yes The deficient practice continues at a scope/severity level F (potential for more than minimal harm/widespread) as the facility continues to implement its removal plan. Outdoor Garbage Bins On [DATE] at 9:40 AM, Surveyor completed the initial kitchen tour with KS G. KS G stated the Dietary Manager has been out for about 3 weeks due to a health condition. KS G stated the kitchen is intensely short staffed. There's no Cooks, just a Dietary Assistant on the PM shift tonight. KS G stated he is working from 5:00 AM - 1:30 PM and stated I get everything ready. Dietary Manager G added, I know there are things that are not being done appropriately due to short staffing. Surveyor and KS G walked outside to the dumpsters. Surveyor observed dumpster #1 (inside fence) with 1 lid open. Surveyor observed dumpster #2 (outside the fence) with both lids open. There were bags of garbage in each bin. Surveyor observed two (2) recliners next to dumpster #2. Surveyor observed a mauve recliner with a remote with grass and leaves on the seat and a tan broken tan recliner with no back. On [DATE] at 9:42 AM, Surveyor asked KS G, should the lids be closed on the dumpsters. KS G stated, Yes. Surveyor asked KS G should recliners be outside by the dumpsters. KS G stated, he doesn't know what the recliners are doing out here, they're not from the kitchen. Surveyor asked KS G should the recliners be left out by the dumpsters. KS G stated, No. Surveyor asked KS G how long the recliners have been outside. KS G stated he is unsure. [MEDICATION(S)] fish in Dirty Food Prep Sink On [DATE] at 9:45 AM, Surveyor observed a large stainless tray of [MEDICATION(S)] fish sitting in the dirty food prep sink covered with food particles and debris. KS G stated he needs to cover the [MEDICATION(S)] and put it in the refrigerator as he was mixing up the [MEDICATION(S)] salad when Surveyor walked in the kitchen. KS G stated he drained the liquid from the can of [MEDICATION(S)] and set the stainless tray in the sink so he didn't spill [MEDICATION(S)] juice. On [DATE] at 9:45 AM, Surveyor asked KS G if the sink should be clean. KS G stated, yes. Undated open items The facility policy, Labeling and Dating Foods, dated 2010, states, in part, as follows: Prepared and packaged food will be labeled and rotated to decrease the risk of foodborne illnesses, provide the highest quality product for the residents and minimize waster. Dry stores: Bagged or boxed food once removed from the original package will be placed in an ingredient bin that is labeled with the common name of the food and the date the item is placed in the bin. Examples of these items include oatmeal, cereals, flour sugar and thickeners. Refrigerated stores: Foods prepared on the premises to be held cold will be labeled with the date of preparation and time as required for cooling purposes. This food will also be labeled with the date to discard or use by. The discard/use by date will be a maximum of 6 days after preparation. For example, food prepared on [DATE]th will be labeled to discard on, or use by, [DATE]th. A manufacturer's expiration date will be honored first. On [DATE] at 9:46 AM, Surveyor observed eleven (11) bowls of diced peaches, covered and undated. On [DATE] at 9:46 AM, Surveyor asked KS G, should the peaches be dated. KS G stated, yes. KS G added, They need to be thrown away, they were not thrown out at the end of meal service yesterday. On [DATE] at 9:47 AM, Surveyor observed three (3) 2 gallon containers of Kool-aid (1) Fruit punch (1) Lemonade (1) Orange. On [DATE] at 9:47 AM, Surveyor asked KS G should the Kool-aid be labeled the date it was made. KS G stated, Probably yes, I would think so. On [DATE] at 9:48 AM, Surveyor observed Gordon's Choice small curd cottage cheese (open) with no open date. The Best by date is [DATE]. On [DATE] at 9:48 AM, KS G stated the cottage cheese was delivered on [DATE], with no open date, and a Best by date of [DATE]. Surveyor asked KS G should the cottage cheese be dated when it's opened? KS G stated, Yes, it should be. On [DATE] at 9:49 AM, Surveyor observed a red substance on the inside bottom of the cooler. On [DATE] at 9:49 AM, Surveyor asked KS G what is the red substance. KS G stated, he thinks it is Kool aid. Surveyor asked KS G when was the refrigerator last cleaned out. KS G stated the refrigerator is cleaned, As needed. Surveyor asked KS G is the refrigerator dirty. KS G stated, Yes. Surveyor asked KS G do you document when the refrigerator is cleaned. KS G stated, there is no cleaning schedule/documentation of cleaning. On [DATE] at 9:50 AM, Surveyor observed the outside of the refrigerator contained food particles and debris. On [DATE] at 9:50 AM, Surveyor asked KS G is there a schedule to clean the outside of the refrigerator. KS G stated, the refrigerator is cleaned As needed. KS G added, there is no cleaning schedule/documentation of cleaning. On [DATE] at 9:51 AM, Surveyor observed twelve (12) pitchers of Kool Aid - (4) lemonade, (4) fruit punch, (4) orange. On [DATE] at 9:51 AM, Surveyor asked KS G should these be dated when they were made. KS G stated, I believe so. KS G added he thinks they may have been mixed last night. On [DATE] at 9:52 AM, Surveyor observed a box of Hormel Thick & Easy Clear Thick Apple Juice (open) with no open date- 46 oz. (ounces) - Expiration date [DATE]. On [DATE] at 9:52 AM, Surveyor asked KS G, should this apple juice be dated when opened? KS G stated, Yes. On [DATE] at 9:55 AM, Surveyor observed the juice machine with Apple Juice (manufactured date of [DATE]) and an Orange Blend Juice (manufactured [DATE]). There is no open date on the juices. On [DATE] at 9:55 AM, Surveyor asked KS G, should juices in the juice machine be dated when opened. KS G stated, I'm sure it should. On [DATE] at 9:51 AM, Surveyor observed Cheerios, Corn Flakes, Rice Krispies, and Raisin Bran in bins. A sticker on each bin indicates Prepared Open/Use by [DATE]. On [DATE] at 9:51 AM, Surveyor asked KS G is the cereal expired. KS G stated, we refill these about one time per week. KS G stated he thinks the labels were not changed out when the cereal was added. Surveyor asked KS G, should the cereals be dated when opened. KS G stated, Yes. On [DATE] at 10:01 AM, Surveyor observed the walk in cooler. Surveyor observed approximately 4 pounds of ground beef thawed with no open date/date pulled from the freezer. Surveyor observed 8 packages of chicken breasts thawed with no open date/date pulled from freezer. On [DATE] at 10:01 AM, Surveyor asked KS G when the ground beef and chicken was pulled from the freezer. KS G stated he pulled these items from the freezer on Thursday ([DATE]). Surveyor asked KS G should the meat be dated when it's pulled from the freezer to thaw in the refrigerator. KS G stated, Yes. Microwave/Countertops/Appliances The facility policy, undated, states as follows: General Sanitation: All users of the kitchen are expected to use good hygienic practices at all times and to follow all established cleaning and sanitation procedures. Cleaning and Sanitation: Cleaning is necessary to protect against microorganisms. Food-contact surfaces shall be cleaned in this sequence. Cleaning should be performed before, during and after food preparation. Each user must properly clean and sanitize the kitchen after their shift and ensure that the kitchen is read for the next user. Sanitizing Food Surfaces: Cleaning and sanitation should be performed as frequently as necessary before, during and after food preparation to prevent contamination. Cleaning & Kitchen Equipment: .Remove food and soil from under and around the equipment; Remove any detachable parts; Manually wash, rinse and sanitize detachable parts, or run them through the dishwashing machine; Wash and rinse all other food-contact surfaces that you cannot remove and then w [TRUNCATED]

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 (R227) of 24 sampled residents and 1 (R44) of 9 supplemental residents. The facility failed to complete comprehensive assessment for R44 when R44 presented with changes in mobility and had a known past history of hip dislocation. A Physical Therapist reported changes in R44's mobility which were suspicious of hip dislocation. The nurse failed to report this to an RN thus a timely nursing assessment was not completed delaying treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R44 went four days before an x-ray was ordered, during which time R44 had increased pain and mental status changes. R227 has follow up appointment orders from admission that the facility was not aware of, and the facility failed to set up this appointment. Evidenced by: According to Chapter N6 of the Wisconsin Nurse Practice Act, An RN (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment: Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient, which includes goals and priorities derived from the nursing diagnosis . According to mayoclinic.com a dislocation is an injury to a joint - a place where two or more bones come together - in which the ends of your bones are forced from their normal position. This painful injury temporarily deforms and immobilizes the joint. Dislocation is most common in shoulders and fingers. Other sites include elbows, knees and hips. If you suspect a dislocation, seek prompt medical attention to return your bones to their proper positions. A dislocated joint can be: Visibly deformed or out of place; Swollen or discolored; intensely painful; immovable. It can be difficult to tell a broken bone from a dislocated bone. For either type of injury, get medical help right away. If possible, ice the joint and keep it immobile while you're waiting to be seen. According to an article in PubMed, late dislocations after total hip arthroplasty (THA) are challenging for the hip surgeon because the cause is often not evident and recurrence is common. Example 1 R44 admitted to facility on [DATE] following hospitalization for left hip fracture repair. R44 is a DNR (does not want CPR (cardio-pulmonary resuscitation). R44 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R44 has an AHCPOA (Activated Healthcare Power of Attorney) and is not his own decision maker. Per R44's care plan, notes the following: Initiated [DATE] . Focus: The resident has limited physical mobility r/t (related to) left hip replacement with chronic dislocations. Interventions: Resident has weight bearing restriction (specify). Self-Propels Wheel Chair (Does not use foot pedals, ask resident to lift feet if pushing w/c (wheelchair). Provide supportive care, assistance with mobility as needed . Initiated [DATE] . Focus: The resident has actual chronic pain r/t left hip fracture with surgical fixation and chronic dislocations of same. Interventions: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor/record/report to Nurse and s/sx (signs and symptoms) of non-verbal pain: Changes in breathing, Mood/behavior, etc. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. R44's Admission MDS (Minimum Data Set) dated [DATE] states in part . R44 requires extensive assistance of two staff members for bed mobility, transfers, toileting and hygiene. R44 also requires extensive assistance of one staff member for locomotion on and off the unit. BIMS (Brief Interview of Mental Status) score of 10, indicating moderate cognitive impairment. Nurses Notes dated [DATE] at 6:36 PM document in part . Resident is able to feed self, transfer x1 (times) assist with reminders to use call light, dsg (dressing) and other adls (activities of daily living) is assist x (does not indicate number of people used for assist) with resident able to participate. Nurses Notes dated [DATE] at 8:53 AM document in part . Resident s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R44 had orders for Tylenol 1000mg (milligrams) by mouth TID (three times a day) for pain. Oxycodone 2.5mg by mouth every 8 hours as needed for acute pain. ASA (Aspirin) 81mg chew tab. Note: R44 had not used Oxycodone since [DATE], while hospitalized . R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: NOC (night) shift, ,d+[DATE]. [DATE]: AM (morning) shift ,d+[DATE], PM (afternoon) shift ,d+[DATE], and NOC shift ,d+[DATE] Nurses Notes dated [DATE] at 10:39 AM document in part . Cognition: Orientation: Person, place and time. The resident does not require supervision for safety. There has not been a change in the resident's baseline cognition. ADL Function: Resident requires partial/moderate assistance with walking, transferring, bed mobility, dressing, toileting and hygiene. R44's Physician's Note from [DATE] with APNP C (Advanced Practice Nurse Prescriber) states in part . Primary Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . States feels 'just fine.' He reports 'mild' pain to left femur/hip area. Pain is localized. Denies any numbness or tingling. Denies any calf pain. Just prior to visit he was independently ambulating down hallway, telling staff he wanted to leave facility. RN staff orientated. He was pleasant, cooperative and sat back in his chair without issues. Full ROS (review of systems) completed with patient and staff d/t (due to) cognition. Physical Exam: Extremities: LLE: Left hip abduction brace in place. LLE nonpitting [CONDITION(S)] 2+ (plus) from knee down to foot. DP (dorsalis pedis) pulse 2+. [NAME] sign negative. Neuro: Disoriented to situation. Moves all extremities spontaneously. Denies numbness and tingling. Assessment/Plan: Left cemented THA (total hip arthroplasty)-dislocated [DATE]. Last dose of oxycodone ,d+[DATE]. LLE 2+ nonpitting [CONDITION(S)] noted on exam today. LLE venous Doppler to r/o (rule out) DVT (deep vein thrombosis). Activity instructions per discharge summary: WBAT (weight bear as tolerated) TEDS (compression stockings used to reduce the risk of DVT) x2 weeks, hip abductor brace on at all times, maintain hip precautions. Pain thought to be contributing with behaviors at night while inpatient. No issues last night with pain. On [DATE] at 5:01 PM nurses note documents in part . New order taken for a venous Doppler study of LLE DX (diagnosis) [CONDITION(S)] on arrival to facility. Hx (history) of fx and dislocation to r/o DVT. Nurses Notes dated [DATE] at 10:31 AM document in part . Resident up in w/c, denied pain or discomfort, expressed to family he was in pain. Used PRN Oxycodone as ordered, when asking resident about pain he states, 'I don't know' but visual s/s (signs and symptoms) of pain present w/ (with) movement of LLE, working w/ therapy as well as transfers. L hip - surgical drsg (dressing) remains intact w/o striking present. R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: AM shift ,d+[DATE], PM shift ,d+[DATE], and NOC shift ,d+[DATE] Note: R44 had not used Oxycodone prior to this since [DATE] while still hospitalized . Pain was managed with TID Tylenol 1000mg. The Nurse did not identify the change in resident need for pain medication and did not physically observe the resident or contact an RN to do an assessment. Nurses Notes dated [DATE] at 3:30 PM document: Resident had Doppler completed on LLE. R44's Physical Therapy note dated [DATE] states in part . During transfer from WC (Wheelchair) to bed, pt (patient) was unable to stand, painful during weight shifting and need max A (maximum assist) for sit to stand and for stand pivot transfer. Pt was able to do all transfer and ambulation with CGA/min A (Contact Guard Assist with minimum assist) for safety yesterday during evaluation. Today, pt was unable to lift his Lt (left) leg and was complaining of pain and left leg was mildly internally rotated. Notified the same change to assigned nurse and recommended for Lt Hip x-ray to rule out dislocation. CNA (Certified Nursing Assistant) was educated on hip abduction brace and explained all hip precaution. Instructed to keep brace on all the time except during hygiene. Note: The Nurse working did not assess R44 or find an RN (Registered Nurse) to complete one. R44's Occupational Therapy note dated [DATE] states in part . OT (Occupational Therapy) noted patient was in WC and appeared stuck in the doorway; patient was asking for help. When OT asked what was the matter, patient indicated he 'couldn't move out of here because his L LE (left lower extremity) was 'stuck'. OT noted patient did not have foot pedals on WC or in room and patient was having difficulty picking up L LE to assist with propulsion (the action of driving or pushing forward). OT picked up patient's L LE to help him into the room, went to find elevating leg rests and fit to patient's L LE and had patient show her that he could propel in room with L LE slightly elevated. R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: AM shift ,d+[DATE], PM shift ,d+[DATE], and NOC shift ,d+[DATE] Nurse Notes dated [DATE] at 7:46 AM document in part . Resident L hip-surgical, great bruising present to peri wound as expected, [CONDITION(S)] 2+ pitting, s/s of pain to LLE, resident denies pain verbally but shows pain w/movement, LLE r/o DVT [DATE], per radiology report good blood flow present w/o signs of DVT present, NP (Nurse Practitioner) notified. Note: During an interview with NP D she states that a message with Doppler results were left on her office voicemail and she did not receive it until [DATE]. This voicemail was left on a Saturday when the NP's was not in work status and the on call Physician was not notified of the results. Nurse Notes dated [DATE] at 4:23 PM it documents in part . Medication Administration Note: Oxycodone HCL Capsule 5mg give 0.5mg by mouth every 8 hours as needed for acute pain. Pain rating ,d+[DATE]. R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: AM shift NA (not applicable), PM shift ,d+[DATE], and NOC shift ,d+[DATE] Nurses Notes dated [DATE] at 4:41 AM document in part . Medication Administration Note: Oxycodone HCL Capsule 5mg give 0.5mg by mouth every 8 hours as needed for acute pain. Pain rating ,d+[DATE]. Nurses Notes dated ,d+[DATE] at 4:16 PM document in part . Medication Administration Note: Oxycodone HCL Capsule 5mg give 0.5mg by mouth every 8 hours as needed for acute pain. Pain rating ,d+[DATE]. R44's Physical Therapy note dated [DATE] states in part . Attempted several times to initiate PT today. Pt displayed increased confusion and unable/refuses to follow directions. Abductor brace not on, provided pt education that he needs to be wearing it. R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: AM shift ,d+[DATE], PM shift ,d+[DATE], and NOC shift ,d+[DATE] R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: AM shift ,d+[DATE], PM shift ,d+[DATE], and NOC shift ,d+[DATE]. Note: R44 received Oxycodone for pain on ,d+[DATE], ,d+[DATE] and twice on ,d+[DATE]. Nurses Notes dated [DATE] at 2:01 AM document, Resident asleep in bed, no s/s of c/o pain, L Hip surgical, bruising continues, swelling noted as LLE is larger than RLE (right lower extremity), floating heels as resident will allow. R44's Physical Therapy note dated [DATE] states in part . Assisted pt with placing abductor brace on L hip. Pt instructed on transfers and bed mobility wheelchair to bed. Provided continued pt education on needing to wear his L brace at all times. Discussed with PT about possible hip dislocation. Nursing states they will be ordering x-rays. Nurse Notes dated [DATE] at 9:10 AM document in part . SBAR-General: Situation: STAT (immediately) x-ray, 2-view XR (x-ray) left hip. Dx (Diagnosis): Internal rotation S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Signs and Symptoms: Left leg inverted upon assessment. Assessment: Left leg inverted with non-pitting [CONDITION(S)] to left foot. Returned to bed per therapist. Left leg splinted utilizing two pillows. Educated resident and staff on the importance of keeping left leg splinted. Recommendation/Response: STAT x-ray, 2-view XR left hip. Dx: Internal rotation S/P left hip surgery per NP D. Educated resident on orders received from NP for STAT x-ray of left hip. Denies pain/discomfort. On [DATE] at 9:25 AM, a nursing note documents, Writer spoke w/ therapy, request for XRAY OF L Hip, resident unable to BWAT (bear weight as tolerated), and call placed to NP D, notified of therapy findings, request for XRAY. Note: On [DATE] therapy noted a change in condition in R44 as resident was unable to lift his left leg, was complaining of pain and left leg was mildly internally rotated. Therapy appropriately notified the nurse and requested left hip x-ray to rule out dislocation in a resident with a history of dislocation. R44's clinical presentation warranted a physical assessment. The nurse did not complete data collection or notify a RN to complete an assessment this resulted in a delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses Notes dated [DATE] at 12:58 PM, R44's x-ray report states in part . Results: Femoral hardware with superior dislocation. Soft tissue swelling. No fracture. Conclusion: Acute left femoral head dislocation. Nurse Notes dated [DATE] at 3:48 PM document in part . Left hip/pelvis x ray results received. Acute left femoral head dislocation. Orders per NP D to send to Hospital ER (emergency room ) for closed reduction. Resident denies pain or discomfort at this time. Rates pain ,d+[DATE] at present. Nurse Note dated [DATE] at 4:37 PM documents in part . Writer asked if resident had any falls recently. Resident stated, 'No.' Physical Therapy noted in the am (AM) that the resident was having difficulties with PT not able to bear weight on to left lower extremity. PT reported this to staff. R44's Ambulance Transport Notes dated [DATE] at 4:30 PM document in part . As the crew arrived, the patient's airway was patent, breathing was normal at room air, and the patient's hands were cold with oxygen saturation of 94%. The patient was oriented at A&OX3 (Alert and oriented to person, place and time) but did not have trouble communicating with the crew and the staff. According to the staff, the patient has left femoral hip dislocation and the patient was having a bracelet (sic) on the left hip. The patient was stable, and the patient was administered with Tylenol 3 times a day and one other pain medication. Pain is ,d+[DATE] in pain scale. R44's Hospital Notes dated [DATE] document in part . Dislocation, Hip - W/ Procedural Sedation. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications given: [MEDICATION(S)] 10mg/mL IV BOLUS last given at 8:36 PM. Activity: Weight bear as tolerated left lower extremity. Hip abduction brace on at all times restricting hip flexion to a maximum of 40 degrees. No rotation, adduction, or abduction. When in bed must have ,d+[DATE] pillows between legs to prevent adduction. On [DATE], it is documented in part . Altered Mental Status, Resolved. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications Given: Oxycodone HCL tab 5mg, last given at 6:35 AM. You have been seen for 'Altered Mental Status.' Altered mental status has many causes. Come more common causes are: Reaction to medicine (this can happen if too much pain or sedative medicine is taken). Your symptoms have gotten better or gone away completely. Nurses Notes dated [DATE] at 1:25 AM document in part . Patient came back from the hospital via ambulance approx. (approximately) 2215 (10:15 PM). Patient denies pain. The patient and staff were reminded to use extra caution during transfers due to the anesthesia medication that was given during the procedure. He does have a full immobilizer cast that he is to wear until [DATE] at follow up apt (appointment). As a result of this incident the facility had the following nurse's statements: A statement was written by LPN F on [DATE] and states, On [DATE], post AM shift; writer was approached by therapy asked if resident was 'having' x-ray, at that time I stated he was in the process of having a Doppler completed, no further interaction on this day. On [DATE] AM shift same therapist approached and asked where x-ray report was, writer then stated he had a Doppler completed not an x-ray. Then the therapist began to speak of changes, I then spoke with NP whom we both went to therapy to get a full assessment. The therapist never expressed any changes to LLE to writer. A statement was written by LPN E, it was undated and states, PT approached me on Friday, [DATE]th, 2021 in regards to a patient. I started my shift and had not gotten report. PT stated that a patient who used to walk with both legs was unable to walk now and would like an x-ray order. PT did not specify which patient or any additional details pertaining to the order however PT mentioned it was LPN F's patient. I went to find LPN F and tell her the message that the PT relayed to me. LPN F told me she knew you (sic) which PT was talking about and that an X-ray was already ordered for that patient. After that I went back to doing my duties. Note: When therapy reported this to the Nurse she did not complete any data collection of the resident or contact an RN to complete an assessment. The nurse did not contact the physician, which resulted in a delay of treatment and increased pain. R44 had not taken any pain medication prior to [DATE] since his hospitalization on [DATE]. R44 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Note: Though the facility did education with Therapy on updating Nurse Management with a resident change of condition on [DATE], and also completed education to nursing staff on [DATE] on change of condition,. The facility failed to identify this particular resident as a concern and did not educate all nursing staff on the need to complete an RN assessment with a resident's change of condition. On [DATE] at 1:19 PM, Surveyor interviewed DON B. Surveyor asked DON B to describe what happened between [DATE] and [DATE] with R44. DON B stated, LPN E told me that something was said in passing from therapy. She thought they were talking about the Doppler when PT said x-ray because they were already here doing the Doppler. Education was done with therapy because an in-service was already completed with Nursing. We looked at this as a communication problem with therapy and staff. A QAPI Plan was completed in which we educated all therapy staff on bringing any concerns to a Nurse Manager. I did not educate Nursing because I thought it was a therapy communication issue. When I interviewed LPN E and LPN F they stated that therapy did not specify information and that it was provided in passing. R44 was seen by the NP that day and she didn't identify a concern so I thought the Doppler was what was wanted. Surveyor asked DON B if an RN assessed R44. DON B stated, No, I thought since he had been seen by the NP she would have noted any concerns. Note: R44 was not seen on [DATE] but on [DATE], the day prior to therapy reporting concerns and changes in R44's mobility. On [DATE] at 2:22 PM, Surveyor interviewed NP D. Surveyor asked NP D about Doppler. NP D stated, When R44 was admitted he was seen by NP C. She noted increased [CONDITION(S)] with abduction brace in place and ordered a Doppler. I was not notified until [DATE] about the therapists concerns. The facility left me a message about the Doppler results on my office voicemail on Saturday and I didn't get them until Monday ([DATE]). On [DATE] at 2:32 PM, Surveyor interviewed LPN E. Surveyor asked LPN E about concerns brought to her by therapy on [DATE] regarding R44. LPN E stated, When they came they were looking for LPN F. I told LPN F he needed an x-ray. LPN F told me she knew which patient and that an x-ray was already ordered. I had just started on [DATE] and was new to the facility. I thought it was already getting done, LPN F told me that. Note: Surveyor attempted to contact LPN F who no longer works in the facility on [DATE]. No return call received. On [DATE] at 2:36 PM, Surveyor interviewed PT K (Physical Therapist). Surveyor asked PT K to tell her about [DATE] and R44. PT K stated, I signed my note at the end of the shift but it was written earlier in the day. I reported to the assigned Nurse. When I saw the changes around 2:00 PM, I couldn't find anyone but when I saw LPN E I told her what I saw and that R44 needed an x-ray. She asked me what to do because she was new. I told her I didn't know and she should ask another Nurse. LPN E said 'okay.' That was on Friday and I don't work on Saturday and Sunday. R44 was not on my schedule on Monday but on Tuesday when I saw him I asked the Nurse about the x-ray. That Nurse told me that they had done a Doppler. I then went and talked with DON B and asked her why an x-ray was not done. DON B said they got mixed up and did a Doppler. I then asked that they get an x-ray. The main thing with R44 was that he was not able to bear the weight that he had previously been able to do. The x-ray then showed a dislocation. The facility failed to have a system in place that ensured care and treatment were sought when there was a noted change in R44's mobility reported to them by Therapy. An RN assessment was not completed and the physician was not notified of Therapy concerns and request for x-ray. The resident began using Oxycodone for pain on [DATE] and had not been using any pain medication other than Tylenol since he was in the hospital on [DATE]. The facility was aware of R44's history of dislocation and these changes should have been an indication for follow up and assessment. Example 2 R227 was admitted to the facility [DATE] for skilled nursing care. R227 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility did not have a policy for appointment set up. R227's Hospital Discharge Summary includes the following orders: follow up with plastics in 1 month, urology consult, [MEDICATION(S)] Urethral/Mucosal Gel Prefilled Syringe 2%, Apply to Urethral topically every 6 hours for bladder relief Use before straight cath, and Straight cath q 6 hours (every), Use [MEDICATION(S)] 2% (UROJET) BEFORE each straight cath. R227's Hospital Discharge Summary includes the following notation, in part: urology consult ordered, unable to void without straight cath, await urology appointment for recommendations . Of note there is no urology appointment pending in R227's medical record. On [DATE] at 8:40 AM, Surveyor interviewed R227. Surveyor asked R227 if he had any concerns with the facility thus far, R227 said he's supposed to be straight cathed three times a day and they aren't always on top of that. Surveyor asked R227 if he could explain why the straight cathing was needed, R227 explained he had a catheter at the first hospital he was at, they removed it and he could pee for 2 days then it had to be re-inserted because he couldn't pee; same thing at second hospital he was at, this time they did not replace, instead they ordered the straight caths. Surveyor asked R227 if he had any concerns with the procedure itself of straight cathing, R227 stated sometimes this is painful, because of the frequency, it is tender, I tell them but it's hard to understand some of the staff here. On [DATE] at 10:05 AM, Surveyor interviewed RN, UM T, Registered Nurse, Unit Manager). Surveyor asked RN, UM T if R227 had any follow up orders for appointments in his Discharge paperwork, RN, UM T said there was for plastics. Surveyor asked RN, UM T how appointments get set up, RN, UM T said if we have documentation on admission we make a copy of it and give it to Medical Records to set up appointment and transportation. Surveyor asked RN, UM T if she recalled seeing a urology consult ordered for R227, RN, UM T said I don't remember urology consult in paperwork, just plastics. On [DATE] at 10:08 AM, Surveyor interviewed MR HH (Medical Records). Surveyor asked MR HH if she had any appointments to set up for R227, MR HH said I don't have any for R227. Surveyor asked MR HH how appointments get set up, MR HH explained if the admission nurse notes appointments then they make a copy and give to her; MR HH also goes through Discharge Summary to see if any appointments are needed, if they admit on a Friday, she will look on Monday. On [DATE] at 1:34 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how the appointment process works, DON B explained if there are appointments set-up already or are seen on admission, the admission nurse will copy and give to MR HH; then 2 nurses check the orders so they should be looking then too, and the ADON (Assistant Director of Nursing) reviews all new admission charts, if they admit on a Friday, they are reviewed on Monday. R227 has pain with the straight cath procedure due to its frequency. The facility was unaware of the urology consult ordered and did not set up the appointment, R227 continues to have pain with this procedure. The facility failed to note a needed urology consult and failed to set up the needed appointment for R227.

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 (R44) of 24 sampled residents. R44 had a change of condition on [DATE] and therapy requested an x-ray; the LPN (Licensed Practical Nurse) working did not consult R44's physician when alerted to the change in R44's condition and R44 did not get an x-ray until [DATE]. X-ray revealed an acute left femoral head dislocation. Resident went four days (,d+[DATE] to [DATE]) without consultation with a physician, during which time R44 had increased pain and altered mental status. This is evidenced by: The facility's policy and procedure entitled Notification of Change Guidelines, effective [DATE], states, in part: .Purpose: It is the practice of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident. Objective of the Notification of Change Guideline: The objective of the notification is to ensure that the facility staff makes appropriate notification to the physician and delegated Non-Physician Practitioner and immediate notification to the resident and/or the resident representative when there is a change in the resident's condition. 3. Tool for contacting Physician regarding a change in condition (CIC). (i). SBAR Evaluation - Situation, Background, Assessment, Response/Recommendation. (ii). Prepare the Evaluation through SBAR sections. (iii). Make recommendations you may have to the Physician. (iv). Document in the Response/Recommendations section the approved recommendations as well as any Orders received from the Physician. Notification is provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatment. Procedure for Notification of Changes for Resident. Procedure: 1.The nurse will immediately notify the resident, resident's physician and the resident representative(s) for the following (list in not all inclusive). If the resident's physician is not available contact the Medical Director. b .A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication. d. A need to alter treatment significantly. Per AMDA (American Medical Directors Association) guidelines, it states, in part: .an ACOC (acute change of condition) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death .When reporting information to a practitioner about a patient's condition, a nurse should not assume that the practitioner knows the patient well or can remember relevant details such as previous lab abnormalities or the patient's current medication regimen .Examples of Staff Roles and Responsibilities in Monitoring Patients With ACOCs .Staff nurse *Recognize condition change early, *Assess the patient's symptoms and physical function and document detailed descriptions of observations and symptoms, *Update the charge nurse or supervisor if patient's condition deteriorates or patient fails to improve within expected time frame, *Report patient status to practitioner as appropriate . Example 1 R44 admitted to facility, on [DATE], following hospitalization for left [CONDITION(S)] repair. R44 is a DNR (does not want CPR (cardio-pulmonary resuscitation). R44 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R44 has an AHCPOA (Activated Healthcare Power of Attorney) and is not his own decision maker. Per R44's care plan, notes the following: Initiated [DATE] . Focus: The resident has limited physical mobility r/t (related to) left hip replacement with chronic dislocations. Interventions: Resident has weight bearing restriction (specify). Self-Propels Wheel Chair (Does not use foot pedals, ask resident to lift feet if pushing w/c (wheelchair). Provide supportive care, assistance with mobility as needed . Initiated [DATE] . Focus: The resident has actual chronic pain r/t left [CONDITION(S)] with surgical fixation and chronic dislocations of same. Interventions: Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor/record/report to Nurse and s/sx (signs and symptoms) of non-verbal pain: Changes in breathing, Mood/behavior, etc. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. R44's Admission MDS (Minimum Data Set) dated [DATE] states in part . R44 requires extensive assistance of two staff members for bed mobility, transfers, toileting and hygiene. R44 also requires extensive assistance of one staff member for locomotion on and off the unit. BIMS (Brief Interview of Mental Status) score of 10, indicating moderate cognitive impairment. Nurses Notes dated [DATE] at 6:36 PM, it document in part . Resident is able to feed self, transfer x1 (times) assist with reminders to use call light, dsg (dressing) and other adls (activities of daily living) is assist x (does not indicate number of people used for assist) with resident able to participate. Nurses Notes dated [DATE] at 8:53 AM document in part . Resident s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident is calm and pleasant able to voice needs and concerns, denies pain, has call light in reach. R44 had orders for Tylenol 1000mg (milligrams) by mouth TID (three times a day) for pain. Oxycodone 2.5mg by mouth every 8 hours as needed for acute pain. ASA (Aspirin) 81mg chew tab. Note: R44 had not used Oxycodone since [DATE], while hospitalized . R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: NOC (night) shift, ,d+[DATE]. [DATE]: AM (morning) shift ,d+[DATE], PM (afternoon) shift ,d+[DATE], and NOC shift ,d+[DATE] Nurses Notes dated [DATE] at 10:39 AM, it document in part . Cognition: Orientation: Person, place and time. The resident does not require supervision for safety. There has not been a change in the resident's baseline cognition. ADL Function: Resident requires partial/moderate assistance with walking, transferring, bed mobility, dressing, toileting and hygiene. R44's Physician's Note from [DATE] with APNP C (Advanced Practice Nurse Prescriber) states in part . Primary Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . States feels 'just fine.' He reports 'mild' pain to left femur/hip area. Pain is localized. Denies any numbness or tingling. Denies any calf pain. Just prior to visit he was independently ambulating down hallway, telling staff he wanted to leave facility. RN staff orientated. He was pleasant, cooperative and sat back in his chair without issues. Full ROS (review of systems) completed with patient and staff d/t (due to) cognition. Physical Exam: Extremities: LLE: Left hip abduction brace in place. LLE nonpitting [CONDITION(S)] 2+ (plus) from knee down to foot. DP (dorsalis pedis) pulse 2+. [NAME] sign negative. Neuro: Disoriented to situation. Moves all extremities spontaneously. Denies numbness and tingling. Assessment/Plan: Left cemented THA (total hip arthroplasty)-dislocated [DATE]. Last dose of oxycodone ,d+[DATE]. LLE 2+ nonpitting [CONDITION(S)] noted on exam today. LLE venous Doppler to r/o (rule out) DVT (deep vein thrombosis). Activity instructions per discharge summary: WBAT (weight bear as tolerated) TEDS (compression stockings used to reduce the risk of DVT) x2 weeks, hip abductor brace on at all times, maintain hip precautions. Pain thought to be contributing with behaviors at night while inpatient. No issues last night with pain. On [DATE] at 5:01 PM, it documents in part . New order taken for a venous Doppler study of LLE DX (diagnosis) [CONDITION(S)] on arrival to facility. Hx (history) of fx and dislocation to r/o DVT. Nurses Notes dated [DATE] at 10:31 AM document in part . Resident up in w/c, denied pain or discomfort, expressed to family he was in pain. Used PRN Oxycodone as ordered, when asking resident about pain he states, 'I don't know' but visual s/s (signs and symptoms) of pain present w/ (with) movement of LLE, working w/ therapy as well as transfers. L hip - surgical drsg (dressing) remains intact w/o striking present. R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: AM shift ,d+[DATE], PM shift ,d+[DATE], and NOC shift ,d+[DATE] Note: R44 had not used Oxycodone prior to this since [DATE] while still hospitalized . Pain was managed with TID Tylenol 1000mg. The physician was not consulted in regards to R44's increase in pain and nonverbal indicators of pain. Nurses Notes dated [DATE] at 3:30 PM document: Resident had Doppler completed on LLE. R44's Physical Therapy note dated [DATE] states in part . During transfer from WC (Wheelchair) to bed, pt (patient) was unable to stand, painful during weight shifting and need max A (maximum assist) for sit to stand and for stand pivot transfer. Pt was able to do all transfer and ambulation with CGA/min A (Contact Guard Assist with minimum assist) for safety yesterday during evaluation. Today, pt was unable to lift his Lt (left) leg and was complaining of pain and left leg was mildly internally rotated. Notified the same change to assigned nurse and recommended for Lt Hip x-ray to rule out dislocation. CNA (Certified Nursing Assistant) was educated on hip abduction brace and explained all hip precaution. Instructed to keep brace on all the time except during hygiene. Note: The Nurse working did not follow through on contacting the physician per PT recommendations to rule out a dislocation in a resident with a known history of dislocation. The x-ray was not ordered as requested by the therapist resulting in a delay of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R44's Occupational Therapy note dated [DATE] states in part . OT (Occupational Therapy) noted patient was in WC and appeared stuck in the doorway; patient was asking for help. When OT asked what was the matter, patient indicated he 'couldn't move out of here because his L LE (left lower extremity) was 'stuck'. OT noted patient did not have foot pedals on WC or in room and patient was having difficulty picking up L LE to assist with propulsion (the action of driving or pushing forward). OT picked up patient's L LE to help him into the room, went to find elevating leg rests and fit to patient's L LE and had patient show her that he could propel in room with L LE slightly elevated. R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: AM shift ,d+[DATE], PM shift ,d+[DATE], and NOC shift ,d+[DATE] Nurse Notes dated [DATE] at 7:46 AM documents in part . Resident L hip-surgical, great bruising present to peri wound as expected, [CONDITION(S)] 2+ pitting, s/s of pain to LLE, resident denies pain verbally but shows pain w/movement, LLE r/o DVT [DATE], per radiology report good blood flow present w/o signs of DVT present, NP (Nurse Practitioner) notified. Note: During an interview with NP D she states that a message with Doppler results were left on her office voicemail and she did not receive it until [DATE]. This voicemail was left on a Saturday when the NP's was not in work status and the on call Physician was not notified of the results. Nurse Notes dated [DATE] at 4:23 PM document in part . Medication Administration Note: Oxycodone HCL Capsule 5mg give 0.5mg by mouth every 8 hours as needed for acute pain. Pain rating ,d+[DATE]. R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: AM shift NA (not applicable), PM shift ,d+[DATE], and NOC shift ,d+[DATE] Nurses Notes dated [DATE] at 4:41 AM document in part . Medication Administration Note: Oxycodone HCL Capsule 5mg give 0.5mg by mouth every 8 hours as needed for acute pain. Pain rating ,d+[DATE]. Nurses Notes dated ,d+[DATE] at 4:16 PM document in part . Medication Administration Note: Oxycodone HCL Capsule 5mg give 0.5mg by mouth every 8 hours as needed for acute pain. Pain rating ,d+[DATE]. R44's Physical Therapy note dated [DATE] states in part . Attempted several times to initiate PT today. Pt displayed increased confusion and unable/refuses to follow directions. Abductor brace not on, provided pt education that he needs to be wearing it. R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: AM shift ,d+[DATE], PM shift ,d+[DATE], and NOC shift ,d+[DATE] R44's eMAR (electronic Medication Administration Record) pain evaluation every shift indicates the following: [DATE]: AM shift ,d+[DATE], PM shift ,d+[DATE], and NOC shift ,d+[DATE]. Note: R44 received Oxycodone for pain on ,d+[DATE], ,d+[DATE] and twice on ,d+[DATE]. Nurses Notes dated [DATE] at 2:01 AM document, Resident asleep in bed, no s/s of c/o pain, L Hip surgical, bruising continues, swelling noted as LLE is larger than RLE (right lower extremity), floating heels as resident will allow. R44's Physical Therapy note dated [DATE] states in part . Assisted pt with placing abductor brace on L hip. Pt instructed on transfers and bed mobility wheelchair to bed. Provided continued pt education on needing to wear his L brace at all times. Discussed with PT about possible hip dislocation. Nursing states they will be ordering x-rays. Nurse Notes dated [DATE] at 9:10 AM document in part . SBAR-General: Situation: STAT (immediately) x-ray, 2-view XR (x-ray) left hip. Dx (Diagnosis): Internal rotation S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Signs and Symptoms: Left leg inverted upon assessment. Assessment: Left leg inverted with non-pitting [CONDITION(S)] to left foot. Returned to bed per therapist. Left leg splinted utilizing two pillows. Educated resident and staff on the importance of keeping left leg splinted. Recommendation/Response: STAT x-ray, 2-view XR left hip. Dx: Internal rotation S/P left hip surgery per NP D. Educated resident on orders received from NP for STAT x-ray of left hip. Denies pain/discomfort. On [DATE] at 9:25 AM documents, Writer spoke w/ therapy, request for XRAY OF L Hip, resident unable to BWAT (bear weight as tolerated), and call placed to NP D, notified of therapy findings, request for XRAY. Note: On [DATE] therapy noted a change in condition in R44 as resident was unable to lift his left leg, was complaining of pain and left leg was mildly internally rotated. Therapy appropriately notified the nurse and requested left hip x-ray to rule out dislocation in a resident with a history of dislocation the nurse failed to notify the physician. R44's clinical presentation and known history of dislocation warranted an immediate physician notification. The nurse did not notify the physician which delayed R44's treatment. The physician was not notified of R44's change of condition for 4 days. Nurses Notes dated [DATE] at 12:58 PM, R44's x-ray report states in part . Results: Femoral hardware with superior dislocation. Soft tissue swelling. No fracture. Conclusion: Acute left femoral head dislocation. Nurse Notes dated [DATE] at 3:48 PM document in part . Left hip/pelvis x ray results received. Acute left femoral head dislocation. Orders per NP D to send to Hospital ER (emergency room ) for closed reduction. Resident denies pain or discomfort at this time. Rates pain ,d+[DATE] at present. Nurse Notes dated [DATE] at 4:37 PM document in part . Writer asked if resident had any falls recently. Resident stated, 'No.' Physical Therapy noted in the am (AM) that the resident was having difficulties with PT not able to bear weight on to left lower extremity. PT reported this to staff. R44's Ambulance Transport Notes dated [DATE] at 4:30 PM document in part . As the crew arrived, the patient's airway was patent, breathing was normal at room air, and the patient's hands were cold with oxygen saturation of 94%. The patient was oriented at A&OX3 (Alert and oriented to person, place and time) but did not have trouble communicating with the crew and the staff. According to the staff, the patient has left femoral hip dislocation and the patient was having a bracelet (sic) on the left hip. The patient was stable, and the patient was administered with Tylenol 3 times a day and one other pain medication. Pain is ,d+[DATE] in pain scale. R44's Hospital Notes dated [DATE] document in part . Dislocation, Hip - W/ Procedural Sedation. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications given: [MEDICATION(S)] 10mg/mL IV BOLUS last given at 8:36 PM. Activity: Weight bear as tolerated left lower extremity. Hip abduction brace on at all times restricting hip flexion to a maximum of 40 degrees. No rotation, adduction, or abduction. When in bed must have ,d+[DATE] pillows between legs to prevent adduction. On [DATE], it is documented in part . Altered Mental Status, Resolved. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications Given: Oxycodone HCL tab 5mg, last given at 6:35 AM. You have been seen for 'Altered Mental Status.' Altered mental status has many causes. Come more common causes are: Reaction to medicine (this can happen if too much pain or sedative medicine is taken). Your symptoms have gotten better or gone away completely. Nurses Notes dated [DATE] at 1:25 AM document in part . Patient came back from the hospital via ambulance approx. (approximately) 2215 (10:15 PM). Patient denies pain. The patient and staff were reminded to use extra caution during transfers due to the anesthesia medication that was given during the procedure. He does have a full immobilizer cast that he is to wear until [DATE] at follow up apt (appointment). As a result of this incident the facility had the following nurse's statements: A statement was written by LPN F on [DATE] and states, On [DATE], post AM shift; writer was approached by therapy asked if resident was 'having' x-ray, at that time I stated he was in the process of having a Doppler completed, no further interaction on this day. On [DATE] AM shift same therapist approached and asked where x-ray report was, writer then stated he had a Doppler completed not an x-ray. Then the therapist began to speak of changes, I then spoke with NP whom we both went to therapy to get a full assessment. The therapist never expressed any changes to LLE to writer. A statement was written by LPN E, it was undated and states, PT approached me on Friday, [DATE]th, 2021 in regards to a patient. I started my shift and had not gotten report. PT stated that a patient who used to walk with both legs was unable to walk now and would like an x-ray order. PT did not specify which patient or any additional details pertaining to the order however PT mentioned it was LPN F's patient. I went to find LPN F and tell her the message that the PT relayed to me. LPN F told me she knew you (sic) which PT was talking about and that an X-ray was already ordered for that patient. After that I went back to doing my duties. Note: When therapy reported this to the Nurse she did not contact the physician, which resulted in a delay of treatment and increased pain for R44. R44 had not taken any pain medication prior to [DATE] since his hospitalization on [DATE]. R44 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Note: Though the facility did education with Therapy on updating Nurse Management with a resident change of condition on [DATE], and also completed education to nursing staff on [DATE] on change of condition, the facility failed to identify this particular resident as a concern and did not educate all nursing staff on the need to contact the MD with a change of condition. On [DATE] at 1:19 PM, Surveyor interviewed DON B. Surveyor asked DON B to describe what happened between [DATE] and [DATE] with R44. DON B stated, LPN E told me that something was said in passing from therapy. She thought they were talking about the Doppler when PT said x-ray because they were already here doing the Doppler. Education was done with therapy because an in-service was already completed with Nursing. We looked at this as a communication problem with therapy and staff. A QAPI Plan was completed in which we educated all therapy staff on bringing any concerns to a Nurse Manager. I did not educate Nursing because I thought it was a therapy communication issue. When I interviewed LPN E and LPN F they stated that therapy did not specify information and that it was provided in passing. R44 was seen by the NP that day and she didn't identify a concern so I thought the Doppler was what was wanted. Surveyor asked DON B if an RN assessed R44. DON B stated, No, I thought since he had been seen by the NP she would have noted any concerns. Note: R44 was not seen on [DATE] but on [DATE], the day prior to therapy reporting concerns and changes in R44's mobility. On [DATE] at 2:22 PM, Surveyor interviewed NP D. Surveyor asked NP D about Doppler. NP D stated, When R44 was admitted he was seen by NP C. She noted increased [CONDITION(S)] with abduction brace in place and ordered a Doppler. I was not notified until [DATE] about the therapist's concerns. The facility left me a message about the Doppler results on my office voicemail on Saturday and I didn't get them until Monday ([DATE]). On [DATE] at 2:32 PM, Surveyor interviewed LPN E. Surveyor asked LPN E about concerns brought to her by therapy on [DATE] regarding R44. LPN E stated, When they came they were looking for LPN F. I told LPN F he needed an x-ray. LPN F told me she knew which patient and that an x-ray was already ordered. I had just started on [DATE] and was new to the facility. I thought it was already getting done, LPN F told me that. Note: Surveyor attempted to contact LPN F who no longer works in the facility on [DATE]. No return call received. On [DATE] at 2:36 PM, Surveyor interviewed PT K (Physical Therapist). Surveyor asked PT K to tell her about [DATE] and R44. PT K stated, I signed my note at the end of the shift but it was written earlier in the day. I reported to the assigned Nurse. When I saw the changes around 2:00 PM, I couldn't find anyone but when I saw LPN E I told her what I saw and that R44 needed an x-ray. She asked me what to do because she was new. I told her I didn't know and she should ask another Nurse. LPN E said 'okay.' That was on Friday and I don't work on Saturday and Sunday. R44 was not on my schedule on Monday but on Tuesday when I saw him I asked the Nurse about the x-ray. That Nurse told me that they had done a Doppler. I then went and talked with DON B and asked her why an x-ray was not done. DON B said they got mixed up and did a Doppler. I then asked that they get an x-ray. The main thing with R44 was that he was not able to bear the weight that he had previously been able to do. The x-ray then showed a dislocation. R44 had a change of condition this was reported to Nursing by Therapy who requested an x-ray be completed. The physician was not notified of Therapy concerns and request for x-ray. R44 had a change of condition and the facility failed to immediately notify the physician with the concerns.

Based on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 3 of 5 residents reviewed (R1, R5 and R12) of a total sample of 13 residents. The facility failed to do the following: 1. R1 is African-American man, has asthma, [MEDICAL CONDITIONS], a pacemaker, and resides in a facility with an active COVID-19 outbreak. R1 experienced a change in condition on [DATE] at 6:42 PM when R1's temperature was 99.2 degrees F (Fahrenheit), two degrees above his baseline temperature. R1 complained of being chilled, and staff turned his thermostat to 85 degrees. At 11:00 PM R1 complained of SOB (Shortness of Breath) and abdominal pain. RN C did not complete a full nursing assessment, including respiratory assessments, abdominal assessments, obtain vital signs, and notify the Physician. Subsequently, on [DATE] at 2:14 AM, R1 called 911 due to shortness of breath. R1 was transported to the ED (Emergency Department) via EMS (Emergency Medical Services). R1 was diagnosed at the ED with COVID-19+, fever, dyspnea, and pneumonia. R1 was admitted to the hospital, where he remained until dying from COVID-related complications on [DATE]. The facility did not implement isolation precautions for R1 when his temperature alerted as a warning on [DATE] at 6:42 PM and he was experiencing chills. 2. On [DATE], R5 presented with a significant change in altered mental status. Staff reported the resident was lethargic and gurgling. He required 4.5 liters of oxygen. The facility failed to immediately complete a full nursing assessment of R5's condition, or consult with a physician, which delayed in R5 receiving needed emergency medical services. R5 died at the facility before paramedics arrived. The facility's failure to assess R1 and R5 when they were experiencing significant changes in condition created a finding of IJ (Immediate Jeopardy) beginning on [DATE]. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ on [DATE] at 11:52 AM. The IJ was removed on [DATE]; however, the deficient practice continues at a scope and severity of a G (actual harm/isolated) as the facility continues to implement its action plan and as evidenced by: On [DATE] at 1:00 PM, R12 presented with a significant change in level of consciousness which consisted of R12 having a blank stare and non-responsive to commands. There is no documented assessment of the resident in the record and no evidence staff notified the physician. He had another episode three days later. R12's weight log documents he was 172 pounds when he was admitted on [DATE] and on [DATE], his weight was documented at 151.2. The facility did not reweigh R12 to determine if this was an accurate weight and did not inform the physician. R12 was admitted to the hospital with [REDACTED]. Evidenced by: According to Chapter N6 of the Wisconsin Nurse Practice Act, An RN (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment: Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient, which includes goals and priorities derived from the nursing diagnosis . Example 1 On [DATE] R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's Admission MDS (Minimum Data Set) demonstrates his BIMS (Brief Interview for Mental Status is 14, indicating he is cognitively intact, and requires extensive assistance of two for transferring and toileting. R1 is incontinent of bowel and bladder. R1 is his own person. R1 is a DNR (do not resuscitate if respirations or heartbeat cease). R1's CNA Care Card, dated [DATE], indicates the following: Bed Mobility: R1 requires extensive assistance by 1 staff to turn and reposition in bed. Toilet Use: R1 requires extensive assistance by 1 staff for toileting. Hygiene: R1 requires limited assistance (x1) (1 assist) staff with personal hygiene and oral care. Transfers: R1 requires extensive assistance by 1 staff to move between surfaces. Dressing: R1 requires extensive assistance by 1 staff to dress. R1's comprehensive Care Plan, dated [DATE], includes the following focus areas: Focus: R1 has (potential) Respiratory Infection r/t COVID-19, dated [DATE]. Goal: R1 will be free from s/sx of infection by review date. Interventions: Isolation measure will be implemented in accordance with the CDC requirements. Monitor for symptoms to condition change and report to provider: (Changes in vital signs, changes in respiratory status such as increased dyspnea, hemoptysis, decreased o2-oxygen sats, tachypnea). R1 must wear a mask if there is a need to exit the room. R1 should don (put on) a mask/cover mouth, if able, when staff are present in the room. Focus: R1 has a defibrillator r/t hx (history of) cardiac issues. Goal: R1 will remain free from s/sx (signs and symptoms) of pacemaker malfunction or failure through the review date. Interventions: Monitor/document/report PRN (as needed) any s/sx of altered cardiac output or pacemaker malfunction: dizziness, [MEDICAL CONDITION], difficulty breathing (dyspnea), pulse rate lower than programmed rate, lower than baseline b/p (blood pressure). On [DATE] at 6:42 PM, RN C documented R1's vitals: Temperature: 99.2 (!) (! indicates warning), Respirations: 20, Oxygen Saturation: 94% RA (room air) Blood Pressure: ,[DATE], and Pulse: 71. It is important to note that R1's temperature was 99.2 degrees F (Fahrenheit), two degrees above his baseline temperature. R1 also complained of being chilled, and staff turned his thermostat to 85 degrees. On [DATE] at 11:00 PM, R1 complained of shortness of breath for 5 hours, vomiting, and abdominal pain. RN C did not complete a full nursing assessment, including respiratory assessments, abdominal assessments, and notify the Physician. Of note, the facility was in the midst of a COVID-19 outbreak ([DATE] - [DATE]) at this time. There is no evidence that R1 was put on contact and droplet isolation precautions upon symptom onset. On [DATE] at 2:14 AM, R1 called 911 from his personal phone. On [DATE] at 2:14 AM, the EMS (Emergency Medical Services) report indicates PSAP (Pubic-Safety Answering Point) R1's call to 911 is received. EMS arrived at the scene at 2:25 AM. Complaint Reported: Breathing problem. The Resident Care Report Narrative reads as follows: EMS was called by a male with shortness of breath. Upon location to this nursing facility EMS is met at the nursing station by two staff members (based on written staff statements this is RN C and LPN H (Licensed Practical Nurse.) The nurse states that our pt (patient) was taken by a different ambulance and we are no longer needed. EMS crew questioned this statement and asked the nurse to make sure and check the room we were dispatched to. The nurse went down to the room and came out and states that The pt (patient) is just mad that I didn't go in there right when he called. The nurse again states that EMS is not needed and we can leave. EMS crew told the nurse that we need to make contact with the pt. The pt is a [AGE] year old male that is found sitting upright on the end of his bed. The pt is naked with a dirty Depends around his knees. The nurse was also in the room with us was very short and rude to the pt when she was speaking to him. The pt asked the nurse to leave the room as she wasn't there to help anything. The pt states that he has been short of breath for ,[DATE] hours and when he pressers the call light for help the nurse won't come quickly or offer any help. The pt states he has had the chills as well all day and the nurse gave him a warm blanket and turned the thermostat up to 85 degrees which we notice that is still at 85 degrees at this time. Pt had to use his personal cell phone to call 911 as he thought the nursing staff wasn't doing anything for him. The pt requests transport to the hospital. The pt is given a new Depend and placed on the cot. The pt is taken to the ambulance and transport is started to the hospital (at [DATE] at 2:50 AM). The pts vitals are taken and monitored. The pt has a temperature of 98.4 orally. The pt states he has asthma but this breathing issue feels different. The pt continued to talk about that nurse at the facility and how he isn't treated equally and he feels like she is very mean to him. A radio report is called to the hospital with no further questions or comments given in return. Transport is done without incident and pt care is turned over to hospital staff in room [ROOM NUMBER]. The ER nurse was informed of the situation and she said she would follow up with the facility. On [DATE] at 2:55 AM, RN C documented the following NN (Nurses Notes) in R1's medical record: Res called 911 from room. When EMS (Emergency Medical Services) showed up he told writer that he called 911 because he had been waiting for a CNA for 5 hours. When EMS interviewed him he said he was SOB (short of breath) x 5 hrs (hours) and has been throwing up. Res c/o (complained of) sob (shortness of breath) around 2300 (11:00 PM) and was offered his inhaler but declined saying he didn't need it because he was sob because his belly hurt. Res did not appear to be in any distress. Writer checked on res 15 minutes later and he was sleeping. Res did not appear in any respiratory distress when EMS was here. He was anxious and swung at writer and began swearing at writer when writer informed EMS that he declined inhaler and was sleeping. EMS took res to hospital since they were already here. On [DATE] at 3:29 AM, emergency room (ER) Notes, includes, in part: Patient feeling short of breath worsening over the past day. Subjective Fever, chills, cough. Coughing so hard that he felt like he was choking earlier tonight. Apparently, nurse at the nursing home did not help him, so he himself called 911. Patient states there is COVID at the nursing home but not in his wing. Vitals in ER: Blood Pressure ,[DATE], Pulse 71, Temp 101.0 (!), Respirations 16, Oxygen Saturation 96%. Note (!) indicates an alert for a reading that is out of normal range and requires further follow up. Assessment Febrile, temp 101 [MEDICAL CONDITION]: Crackles in the bases. Pulse ox okay. Chest x-ray : Similar appearance of patchy opacities at the left lung base, possibly representing atelectasis through superimposed infectious process is not excluded. On [DATE] at 5:22 AM, emergency room (ER) Notes, includes, in part: 71 yo (year old) male h/o (history of) afib with pacer (pacemaker), DM (diabetes mellitus),[MEDICAL CONDITION](hypertension), [MEDICAL CONDITIONS], asthma, multiple [MEDICAL CONDITION]'s (strokes) - approximately 8. Came from SNF (Skilled Nursing Facility). +COVID going around at his SNF. He had COVID testing done last week which was negative. C/o (complained of) terrible sore throat, cough, sob, fever, chills, and rigors which began Sat am. He ask his nurse at the SNF to call EMS, but he states she refused, and yelled at him, and told him he was fine. So he called EMS himself. He has also had some mild rhinorrhea and nasal congestion .COVID 19 came back + (positive). Will start [MEDICATION NAME] 6mg IV daily. Will continue antibiotic for possible superimposed bacterial pneumonia, as procalcitonin is elevated, and pneumonia is unilateral. ED work-up remarkable for electrocardiogram (EKG) showing ventricular paced rhythm, normal complete blood count (CBC), chemistry (labs) reflects acute on chronic [MEDICAL CONDITION] with creatinine 2.3 which is a little worse than his baseline, troponin negative. BNP, procalcitonin, D-dimer all elevated. (Lab values) Urinalysis negative. Chest x-ray read as patchy opacities left lung base possibly infectious process. Diagnosis: [REDACTED]. Disposition: Admit On [DATE] at 4:23 AM, R1's x-ray report was signed electronically, indicates: Similar appearance of patchy opacities at the left lung base, possibly representing atelectasis though superimposed infectious process is not excluded. Assessment Plan: CXR (chest x-ray) shows LLL (left lower lobe) infiltrate. COVID-19 test came back positive. Will start [MEDICATION NAME] (steriod) 6mg via intravenous (IV) daily Will continue antibiotics for possible superimposed bacterial pneumonia, as procalcitonin is elevated, and pneumonia is unilateral. R1's ED Physician ordered the following IV (intravenous antibiotics): [MEDICATION NAME] HCL ([MEDICATION NAME]) 750 mg in sodium chloride 0.9% 250 ml IVPB 750 mg. Intravenous 250 ml/hr, every 12 hours and [MEDICATION NAME]-tazobactam ([MEDICATION NAME]) 4.5g syringe 4.5 g intravenous, every 8 hours. R1 was admitted to the hospital, where he remained until dying from COVID-related complications on [DATE]. R1's Death Certificate indicates R1's immediate cause of death was acute hypoxemic [MEDICAL CONDITION] due to COVID-19. On [DATE] the former NHA interviewed R1 via phone while she investigated a complaint filed by the EMT. R1 reported he told the nurse (RN C) that he couldn't breathe, and she didn't believe him. R1 said that he got tired of arguing with her, so he called 911 himself. R1 states when he told the nurse he didn't feel well and felt he had a fever, she responded that she took his temperature 5 hours ago and he didn't have a fever. R1 states that the nurse also yelled at him for calling 911 and told him he was not allowed to do that. R1 states when the paramedics arrived, the nurse was also arguing with them and stating that R1 did not have a fever. R1 states when the paramedics took his temperature, he did have a fever and they took him to the hospital. On [DATE] at 2:30 PM, DON B interviewed RN C and documented an Interview/Statement Record and document a hand written statement on a NN. It is important to note, this information is not part of R1's medical record. The hand written notes read as follows: Res put on call light around 11:00 PM. Writer went to check on him. He c/o (complained of) SOB. He was offered his inhaler but declined stating he was SOB because his belly hurt. Res lips and finger nails were pink. Face was flushed due to being upset. A&Ox3 (alert to person, place and time). neurological faculties WNL (within normal limits) for res. LS (lung sounds) clear to auscultation. (Note, this is inconsistent with the lung assessment at the ED) Breathing steady and unlabored at 20. O2 (oxygen saturation) 96% RA (room air). Bowel sounds present. Belly non-tender. Soft and round belly. Res HOB (head of bed) was ,[DATE] degrees. Res complained of emesis 5 min (minutes) before but no signs of emesis found. Res said emesis was in trash. Writer reassured res that lung sounds and belly are ok and his breathing appears normal. Informed him writer would be back in 15 min to check on him. At 11:20 PM res was sleeping. Appeared to be sleeping until 2:30 AM when EMS showed up. When res checked on res he said he called 911 because he had been waiting for the CNA for 5 hrs (hours). When paramedics interviewed him she said he had been SOB x 5 hrs and vomiting. No signs of emesis. Res face was flushed from being agitated. Fingers and lips pink. Resp (respirations) regular even and unlabored at 20. When writer informed res that writer had been in there at 11:00 PM and offered inhaler but he declined and he has appeared to be sleeping since 11:20 PM he took a swing in writer's general direction and started swearing. Writer stepped out in hall with one EMS and explained situation and res background. EMS decided to take res to ER because they were here. DON updated. None of the above assessment is documented in the record, and portions of it conflict with findings found at the emergency room . On [DATE] at 2:10 PM, Surveyor spoke with RN C. RN C stated R1 complained of SOB at on [DATE] at 11:00 PM. RN C stated she offered R1 his inhaler, completed an assessment, listened to his lungs, and checked his oxygen saturation which was around 90%. RN C stated she told R1 she would be back in ,[DATE] minutes and when she returned he was sleeping. RN C stated she didn't hear another peep until the ambulance showed up. RN C stated he told me he called 911 because he didn't have a CNA. Surveyor asked RN C if she noticed the temperature she had documented in R1's medical record at 6:42 PM alerted as a warning. RN C stated, I was unaware it came up as a warning. Surveyor asked RN C when does a temperature alert as a warning? RN C stated temperatures alert with a warning when it is below 97.0 or above 100.0 degrees. Note, R1's temperature alerted as it is 2 degrees above his baseline temperature. Did you contact R1's physician? RN C stated, No. Surveyor asked RN C, did you take R1's vitals at or after 11:00 PM when R1 was complaining of SOB? RN C stated, Don't ask me what those vitals were I cannot recall! Surveyor asked RN C did you document the vitals? RN C stated, I did not. Surveyor asked should have documented R1's vitals? RN C stated, I should have. Surveyor asked RN C did you contact R1's NP (Nurse Practitioner) or Physician? I called the NP and left a message after R1 went to the hospital. Surveyor asked RN C did you document this? RN C stated I think so. Surveyor asked RN C when you notify an NP or Physician where do you document the notification? RN C stated, in the Nurses Notes. It is important to note there is no evidence that RN C notified the NP or Physician before R1 called 911 himself due to SOB. RN C stated the she was frustrated by the whole situation and R1 was very rude to her. RN C stated she was tired from being on a long shift (2nd and 3rd shift). Surveyor asked RN C what assessments did you complete related to R1's report of SOB? RN C stated she assessed R1's lung sounds, pulse oximeter (oxygen saturation), and checked to see if the resident's breathing is labored. RN C stated R1 said his stomach hurt so I did an abdominal assessment and that came back unremarkable. RN C stated if a resident is complaining of SOB, I would call the Physician to see if I could get a nebulizer or inhaler ordered or send the resident to the ED. Surveyor asked RN C how soon would you do that if a resident is complaining of SOB? RN C stated, Almost immediately, depending on how short of breath they were. It is important to note that the last set of vitals for R1 is on [DATE] at 6:42 PM and there are no assessments documented either. RN C stated, I did a very poor job documenting that night. On [DATE] at approximately 4:15 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B if a resident states they are SOB what do you expect staff to do? DON B stated she expects staff to assess the resident's respiratory status, see if they can stabilize the resident, check if there is an order for [REDACTED].? DON B stated, I don't believe she documented anything. DON B added, I would expect her to assess the resident, take vital signs, check if the resident has PRN (as needed) medication available for respiratory management, assess skin turgor, and respiratory lung sounds. If a nurse is unable to stabilize a resident he/she should call 911, follow up with the resident's Physician and family. Surveyor asked DON B did RN C document her actions on [DATE] and [DATE] related to R1? DON B stated, I don't think she documented it. Surveyor asked DON B when was the last time a CNA/Nurse provided care to R1 on ,[DATE] or [DATE]? DON B stated CNA J was agency. DON B added she has made multiple attempts to contact the CNA, with no return call, and she has since quit the agency. DON B stated there is no documentation whatsoever from the CNA assigned to work with R1. Surveyor asked DON B did RN C go back and check on R1 after she noted he was sleeping? DON B stated she asked RN C that question. RN C stated she did but there was no proof in R1's medical record. RN C stated to DON B that she asked the CNA to check on R1. RN C could not remember the CNA's name or what she looked like. Surveyor asked DON B what would you have expected RN C to do? DON B stated depending on the scenario and if the resident is stable I would expect her to go back periodically, at least every ,[DATE] minutes. DON B added if a resident is in acute distress I would expect the nurse to institute care right away - immediately. Surveyor asked DON B did you notice that the ED's respiratory assessment documents crackles in the bases of R1's lungs and does not concur with RN C's assessment that she documented as part of your investigation. DON B stated, yes, Hence the reason why I educated on SBAR, cephalocaudal (head to toe) assessment, PCC (PointClickCare) SBAR. Surveyor stated on [DATE] at 6:42 PM, RN C documented R1's vitals. R1's temp is documented as 99.2 (Warning high of 99.0 exceeded!) degrees F. Surveyor asked DON B what would you have expected RN C to do? DON B stated, she would have expected RN C to check for PRN (as needed) order for Tylenol, notify R1's Physician and monitor accordingly. Surveyor asked DON B do you feel RN C and/or other facility staff monitored accordingly? DON B stated, Based on what I told you, no. Surveyor asked DON B if R1 should have been put on isolation when experiencing a temperature and chills. DON B stated, yes. Surveyor asked DON B if there is evidence that R1 was put on isolation precautions when experiencing symptoms of COVID. DON B stated, no. The facility failed to assess R1 when he was noted to be experiencing a change in condition, exhibiting a temperature of 2 degrees above his baseline and complained of being chilled. R1 then complained of being short of breath and having abdominal pain. There is no evidence that RN C completed a full nursing assessment, including respiratory assessments, abdominal assessments, and obtained vital signs. There is no evidence that staff quarantined R1 when his temperature was 2 degrees above baseline and he complained of being chilled on [DATE] at 6:42 PM, There is no evidence that staff continued to monitor and assess R1's condition. Example 2 R5 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. R5's MDS (Minimum Data Set) dated [DATE] documented R5 was cognitively impaired with a BIMS (Brief Interview for Mental Status) of 6 and required extensive assistance with mobility, transfers, hygiene and toileting. R5's Care Plan documents behavior approaches and personal care assistance. DON investigated the care of R5 on ,[DATE] and [DATE]. Per this investigation: LPN D (Licensed Practical Nurse) wrote on [DATE] she took care of this resident for the [DATE] to [DATE] night shift. The resident wanted to stay up and told the nurse to turn sports on please-resident was asleep from 3:00 AM to 6:00 AM. Vital signs were stable during the night ,[DATE]/-[DATE]. On [DATE] at 5:30 PM, Surveyor spoke with DON B. DON B said she had completed oral care on R5 that morning ([DATE]) before breakfast. DON B said she had performed oral care because the CNA on R5's assignment said R5 had refused oral care done by her. DON B said R5 was not in respiratory distress or lethargic at that time. In her statement to the DON, LPN E wrote on [DATE] that R5 was under my care for the day shift (on [DATE]). During the shift resident was easily aroused, took meds in applesauce. Resident had been sleeping but was aroused and took most of his meds .resident did not seem to be in any distress or discomfort any time during this shift . R5's [DATE] Progress/Nursing notes document: -2:42 PM-critical INR (international normalized ratio) (blood test for blood thinning medication) 9.4 result received-spoke with physician at anti-coagulant clinic-physician stated to hold [MEDICATION NAME] (blood thinning medication) until [DATE] and redraw blood work on [DATE]. Physician stated not to give [MEDICATION NAME] until labs have been reported to the clinic. Late entry written at 10:47 PM for the afternoon of [DATE] - R5 was on O2 (oxygen) at 4.5 liters at start of shift. He was lethargic and gurgling. CNA (Certified Nurse Assistant) said he had been like this all day and it was reported he was like this last night as well. R5's daughter came for window visit and had many questions about res. condition. Writer reported she would investigate and contact daughter when writer knew more. Vital signs blood pressure (BP) ,[DATE] temperature (T) 97.1 heart rate (HR) 85 respirations (R) 22 and oxygen saturation (O2 Sat) (measurement of oxygen in the blood) 68% on 4.5 liters of oxygen per nasal cannula. 911 contacted and EMS dispatched. By the time EMS arrived at 4:20 PM, res. was expired. Res. daughter was updated at 6:30 PM and questions answered as best as possible. Resident physician on call was contacted at 6:45 PM and he pronounced res. expired and released body to funeral home. Voice mail left for NP. Questions answered by staff for (name of police force) police. Body released to funeral home at 9:00 PM. Of note: this nursing note indicates it was documented at 10:47 PM, however the change of condition for R5 occurred prior to 4 PM and R5 expired at 4:20 PM. On [DATE] at 2:10 PM, Surveyor spoke with RN C (Registered Nurse). RN C said she does not recall the CNA that told her the resident was lethargic and gurgling all day. He was lethargic when she came on shift. (There was no documented assessment of R5's lethargy.) When the resident daughter was at the window visit at 3:00 PM, he seemed improved. RN C said the report she received from LPN E was that LPN E did not know the resident. RN C said she thinks she did vital signs-they were stable. RN C said she thinks she called the physician. RN C said she did not document calling the physician, completing an assessment or the vital signs. On [DATE] at 4:00 PM, Surveyor spoke to R5's (dtr) daughter. R5's dtr. said she had not spoken to R5 in a couple of days, which was usual for them. R5's dtr. said she wanted to do a window visit with R5, so she called the facility and requested a time for a window visit. R5's dtr. said she would arrive between 3:30 and 4:00 PM. R5's dtr. waited 20 minutes after arriving at the facility for R5. She asked a women passing by to check on R5 to see why he had not come to the window yet. The women reported back to R5's dtr. They are having trouble with his oxygen. R5's dtr said she thought this was wrong, because R5 never used oxygen. RN C brought R5 to the window. R5's dtr. said he was non-responsive and breathing heavily and that he had oxygen on. R5's dtr. said to RN C, What is wrong with him? RN C told R5's dtr. He's sleepy. R5's dtr. said to wake him up. RN C touched R5 on the shoulder and spoke to him. R5's dtr. said he did not respond. R5's dtr. told RN C to find out what was wrong with R5 and call her back within an hour. RN C took R5 away from the window. R5's dtr. said RN C called 45 minutes to one hour later to say R5 expired. On [DATE] at 3:15 PM, Surveyor spoke with MD F (Medical Doctor). MD F said he was not aware that the resident had a change of condition. MD F said he was not aware the resident had expired until he received the death certificate to sign. MD F said the cause of death was complications of [MEDICAL CONDITION] (a heart condition). MD F said if he had been contacted that the resident had a high INR and/or a change of condition he would have ordered the resident be sent to the emergency room . R5 presented with a significant change of condition, lethargic and gurgling per R5's nursing note and staff report, however there is no indication RN C completed a nursing assessment and called the physician to report R5's significant change of condition. In fact R5 was brought to a window visit vs. receiving emergency care to sustain life. R5 expired secondary to an acute change of condition and complications of [MEDICAL CONDITION] Fibrillation. Facility failure to assess and monitor R1 and R5 after they experienced significant changes in condition, and failure to intervene as needed based on these assessments created a finding of IJ (Immediate Jeopardy) beginning on [DATE] at 6:42 PM. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ on [DATE] at 11:52 AM. The IJ was removed on [DATE] when the facility implemented the following: The 2 identified residents, R1 and R5 no longer reside at the facility. On [DATE], Licensed Nurses and Certified Nursing Assistants were educated on the following: 1. Change in Condition 2. Nursing Assessments 3. Physicians' Notification of Condition Changes (of Residents) 4. Proper Documentation and Timely Follow-up of Changes in Condition. 5. Notification of Resident and/or Responsible Party of Changes in Condition 6. POC Documentation for CNAs CarePlan and Kardex Review. 7. How to Use a Stop-and-Watch Tool. Education to be continued with all Licensed Nurses and Certified Nursing Assistants prior to start of their shifts. In Summary: On [DATE], a full house 'sweep' was completed per facility rounds by licensed nurses to determine if there were any residents who presented with evidence of any change of condition, that would require implementation of resident assessments, change of condition notification to physician/provider, resident and/or resident's responsible party, and requiring documentation of immediate follow-up. On [DATE], there were no residents noted to have a change in condition requiring these specific parameters indicated. On [DATE], Stop-and-Watch tools have been made readily accessible for Certified Nursing Assistants and Licensed Nursing Staffs' access. [DATE] Licensed Nurses and Certified Nursing Staff received education on the proper use of the Stop-and-Watch Tools. All Nursing Staff and CNAs will be educated on the use of Stop-and-Watch Tools and it's use prior to their shift worked. On [DATE] Certified Nursing Assistants were provided education on the following: Documenting in POC, Accessing the Resident's CarePlan and Kardex review, and (notifying a licensed nurse when the Kardex Needs Revised/Updated). All Certified Nursing Assistants will receive education regarding this prior to starting their shift until all CNAs receive the education prior to their shift worked. On [DATE], a (24) Hour PointClickCare report was extrapolated via the facility's computer system and reviewed. Contents of nursing documentation of all resident's statuses was reviewed to recognize/identify any areas of concern requiring immediate follow-up, any concerns requiring implementation of a resident assessment, any change of condition requiring immediate follow-up reporting/notifying physician and/or provider, resident and/or responsible party of changes in condition. On [DATE], no findings were observed. On [DATE], the 24 Hour Report Sheet was reviewed to recognize any areas of concern requiring immediate follow-up, any concerns requiring implementation of a resident assessment, any change of condition requiring immediate follow-up reporting/notifying physician and/or provider or resident and/or responsible party of changes in condition. No areas of concern related to changes in condition of residents were observed. On [DATE], a m (TRUNCATED)

Based on record review and interview, the facility did not immediately notify and consult with the resident's physician when a significant change in the resident's physical status occurred for 3 of 5 residents reviewed (R1, R5 and R12) of a total sample of 13 residents. In [DATE] the facility was in the midst of a COVID-19 outbreak. R1 experienced a Change in Condition on [DATE] at 6:42 PM when R1's temperature was 99.2 degrees F (Fahrenheit), two degrees above his baseline temperature. R1 complained of being chilled, and staff turned his thermostat to 85 degrees. On [DATE] at 11:00 PM R1 complained of SOB (shortness of breath) and abdominal pain. RN C did not notify and consult with the Physician. Subsequently, on [DATE] at 2:14 AM, R1 called 911 due to shortness of breath. R1 was transported to the ED (Emergency Department) via EMS (Emergency Medical Services). R1 was diagnosed at the ED with COVID-19+, fever, dyspnea, and pneumonia. R1 was admitted to the hospital, where he remained until dying from COVID-related complications on [DATE]. On [DATE], R5 presented with a significant change in altered mental status, reportedly was gurgling all shift, and was requiring oxygen at 4.5 liters/minute. The facility failed to immediately complete a full nursing assessment of R5's condition, or consult with a physician, which delayed in R5 receiving needed emergency medical services. The facility's failure to immediately notify the physician for R1 and R5's significant change of condition created a finding of IJ (Immediate Jeopardy) beginning on [DATE]. On [DATE] at 11:52 AM, NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ. The IJ was removed on [DATE]; however, the deficient practice continues at a scope and severity of a G (actual harm/isolated) as the facility continues to implement its action plan and as evidenced by the following: On [DATE] at 1:00 PM, R12 presented with a significant change in level of consciousness which consisted of R12 having a blank stare and non-responsive to commands. The physcian was not notified. R12 had another episode three days later. R12's weight log documents he was 172 pounds when he was admitted on [DATE] and on [DATE], his weight was documented at 151.2. The facility did not immediately consult with R12's physician regarding this significant change. R12 was admitted to the hospital with [REDACTED]. Evidenced by: AMDA (American Medical Directors Association) definition of Acute Change of Condition (ACOC): An ACOC is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral or functional domains. Clinically important means a deviation that, without intervention, may result in complication or death. AMDA (American Medical Directors Association) Protocols for Physician Notification includes, in part: Condition: Temperature - A range of 98.2 degrees F (Fahrenheit) (36.8 degrees Celsius) oral temperature is considered normal. A patient's normal temperature will vary by up to 0.9 degrees Fahrenheit (0.5 degrees Celsius) daily. As quickly as possible after admission, try to establish the patient's normal temperature range. A sudden or rapid change from normal temperature may suggest an ACOC. One temperature reading above 100 degrees Fahrenheit, two readings above 99 degrees Fahrenheit or an increase of 2 degrees above the upper end of the patient's normal range may indicate an ACOC. The facility was unable to provide a policy and procedure for ACOC. Example 1 On [DATE] R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's Admission MDS (Minimum Data Set) demonstrates his BIMS (Brief Interview for Mental Status) is 14, indicating he is cognitively intact, and requires extensive assistance of two for transferring and toileting. R1 is incontinent of bowel and bladder. R1 is his own person. On [DATE] at 6:42 PM, RN C documented R1's vitals: Temperature: 99.2 (!) (! indicates warning), Respirations: 20, Oxygen Saturation: 94% RA (room air) Blood Pressure: ,[DATE], and Pulse: 71. It is important to note that R1's temperature was 99.2 degrees F (Fahrenheit), two degrees above his baseline temperature. R1 also complained of being chilled, and staff turned his thermostat to 85 degrees. On [DATE] at 11:00 PM, R1 complained of shortness of breath for 5 hours, vomiting, and abdominal pain. RN C did not complete a full nursing assessment, including respiratory assessments, abdominal assessments, obtain vital signs, and notify and consult with the Physician. Subsequently, on [DATE] at 2:14 AM, R1 called 911 from his personal phone due to shortness of breath. R1 was transported to the ED (Emergency Department) via EMS (Emergency Medical Services). R1 was diagnosed at the emergency room with COVID-19+, fever, dyspnea, and pneumonia. R1 was admitted to the hospital, where he remained until dying from COVID-related complications on [DATE]. On [DATE] at 2:14 AM, the EMS report indicates PSAP (Pubic-Safety Answering Point) R1's call to 911 is received. EMS arrived at the scene at 2:25 AM. Complaint Reported: Breathing problem. The Resident Care Report Narrative reads as follows: EMS was called by a male with shortness of breath. Upon location to this nursing facility EMS is met at the nursing station by two staff members (based on written staff statements this is RN C and LPN H (Licensed Practical Nurse.) The nurse states that our pt (patient) was taken by a different ambulance and we are no longer needed. EMS crew questioned this statement and asked the nurse to make sure and check the room we were dispatched to. The nurse went down to the room and came out and states that The pt (patient) is just mad that I didn't go in there right when he called. The nurse again states that EMS is not needed and we can leave. EMS crew told the nurse that we need to make contact with the pt. The pt is a [AGE] year old male that is found sitting upright on the end of his bed. The pt is naked with a dirty Depends around his knees. The nurse was also in the room with us was very short and rude to the pt when she was speaking to him. The pt asked the nurse to leave the room as she wasn't there to help anything. The pt states that he has been short of breath for ,[DATE] hours and when he presses the call light for help the nurse won't come quickly or offer any help. The pt states he has had the chills as well all day and the nurse gave him a warm blanket and turned the thermostat up to 85 degrees which we notice that is still at 85 degrees at this time. Pt had to use his personal cell phone to call 911 as he thought the nursing staff wasn't doing anything for him. The pt requests transport to the hospital. The pt is given a new Depend and placed on the cot. The pt is taken to the ambulance and transport is started to the hospital (at [DATE] at 2:50 AM). The pt's vitals are taken and monitored. The pt has a temperature of 98.4 orally. The pt states he has asthma but this breathing issue feels different. The pt continued to talk about that nurse at the facility and how he isn't treated equally and he feels like she is very mean to him. A radio report is called to the hospital with no further questions or comments given in return. Transport is done without incident and pt care is turned over to hospital staff in room [ROOM NUMBER]. The emergency room (ER) nurse was informed of the situation and she said she would follow up with the facility. On [DATE] at 2:55 AM, RN C documented the following NN (Nurses Notes) in R1's medical record: Res called 911 from room. When EMS (Emergency Medical Services) showed up he told writer he called 911 because he had been waiting for a Certified Nursing Assistant (CNA) for 5 hours. When EMS interviewed him he said he was SOB (short of breath) x 5 hrs (hours) and has been throwing up. Res c/o (complained of) sob (shortness of breath) around 2300 (11:00 PM) and was offered his inhaler but declined saying he didn't need it because he was sob because his belly hurt. Res did not appear to be in any distress. Writer checked on res 15 minutes later and he was sleeping. Res did not appear in any respiratory distress when EMS was here. He was anxious and swung at writer and began swearing at writer when writer informed EMS that he declined inhaler and was sleeping. EMS took res to hospital since they were already here. On [DATE] at 3:29 AM, emergency room Notes, includes, in part: Patient feeling short of breath worsening over the past day. Subjective Fever, chills, cough. Coughing so hard that he felt like he was choking earlier tonight. Apparently, nurse at the nursing home did not help him, so he himself called 911. Patient states there is COVID at the nursing home but not in his wing. Vitals in ER: Blood Pressure ,[DATE], Pulse 71, Temp 101.0 (!), Respirations 16, Oxygen Saturation 96%. Note (!) indicates an alert for a reading that is out of normal range and requires further follow up. Assessment Febrile, temp 101 [MEDICAL CONDITION]: Crackles in the bases. Pulse ox okay. Chest x-ray: Similar appearance of patchy opacities at the left lung base, possibly representing atelectasis through superimposed infectious process is not excluded. On [DATE] at 5:22 AM, emergency room (ER) Notes, includes, in part: 71 yo (year old) male h/o (history of) afib with pacer (pacemaker), DM (diabetes mellitus),[MEDICAL CONDITION](hypertension), [MEDICAL CONDITIONS], asthma, multiple [MEDICAL CONDITION]'s (strokes) - approximately 8. Came from SNF (skilled nursing facility). +COVID going around at his SNF. He had COVID testing done last week which was negative. C/o (complained of) terrible sore throat, cough, sob, fever, chills, and rigors which began Sat AM. He asked his nurse at the SNF to call EMS, but he states she refused, and yelled at him, and told him he was fine. So he called EMS himself. He has also had some mild rhinorrhea and nasal congestion .COVID 19 came back + (positive). Will start [MEDICATION NAME] 6mg intravenous (IV) daily. Will continue antibiotic for possible superimposed bacterial pneumonia, as procalcitonin is elevated, and pneumonia is unilateral. ED work-up remarkable for electrocardiogram (EKG) showing ventricular paced rhythm, normal CBC, chemistry reflects acute on chronic [MEDICAL CONDITION] with creatinine 2.3 which is a little worse than his baseline, troponin negative. BNP, procalcitonin, D-dimer all elevated. Urinalysis negative. Chest x-ray read as patchy opacities left lung base possibly infectious process. Diagnosis: [REDACTED]. Disposition: Admit On [DATE] at 4:23 AM, R1's x-ray report was signed electronically, indicates: Similar appearance of patchy opacities at the left lung base, possibly representing atelectasis though superimposed infectious process is not excluded. Assessment Plan: CXR (chest x-ray) shows LLL (left lower lobe) infiltrate. COVID-19 test came back positive. Will start [MEDICATION NAME] 6mg via IV daily Will continue antibiotics for possible superimposed bacterial pneumonia, as procalcitonin is elevated, and pneumonia is unilateral. R1's ED Physician ordered the following IV (intravenous antibiotics): [MEDICATION NAME] HCL ([MEDICATION NAME]) 750 mg in sodium chloride 0.9% 250 ml IVPB 750 mg. Intravenous 250 ml/hr, every 12 hours and [MEDICATION NAME]-tazobactam ([MEDICATION NAME]) 4.5g syringe 4.5 g intravenous, every 8 hours. R1 was admitted to the hospital, where he remained until dying from COVID-related complications on [DATE]. R1's Death Certificate indicates R1's immediate cause of death was acute hypoxemic [MEDICAL CONDITION] due to COVID-19. On [DATE] while investigating a complaint filed by the EMT, the former NHA interviewed R1 via phone. R1 reported he told the nurse (RN C) that he couldn't breathe, and she didn't believe him. R1 said that he got tired of arguing with her, so he called 911 himself. R1 states when he told the nurse he didn't feel well and felt he had a fever, she responded that she took his temperature 5 hours ago and he didn't have a fever. R1 states that the nurse also yelled at him for calling 911 and told him he was not allowed to do that. R1 states when the paramedics arrived, the nurse was also arguing with them and stating that R1 did not have a fever. R1 states when the paramedics took his temperature, he did have a fever and they took him to the hospital. On [DATE] at 2:30 PM, DON B interviewed RN C and documented an Interview/Statement Record and document a hand written statement on a NN. It is important to note, this information is not part of R1's medical record. The hand written notes read as follows: Res put on call light around 11:00 PM. Writer went to check on him. He c/o (complained of) SOB. He was offered his inhaler but declined stating he was SOB because his belly hurt. Res lips and finger nails were pink. Face was flushed due to being upset. A&Ox3 (alert to person, place and time). neurological faculties WNL (within normal limits) for res. LS (lung sounds) clear to auscultation. (Note, this is inconsistent with the lung assessment at the ED) Breathing steady and unlabored at 20. O2 (oxygen saturation) 96% RA (room air). Bowel sounds present. Belly non-tender. Soft and round belly. Res HOB (head of bed) was ,[DATE] degrees. Res complained of emesis 5 min (minutes) before but no signs of emesis found. Res said emesis was in trash. Writer reassured res that lung sounds and belly are ok and his breathing appears normal. Informed him writer would be back in 15 min to check on him. At 11:20 PM res was sleeping. Appeared to be sleeping until 2:30 AM when EMS showed up. When nurse checked on res he said he called 911 because he had been waiting for the CNA for 5 hrs (hours). When paramedics interviewed him he said he had been SOB x 5 hrs and vomiting. No signs of emesis. Res face was flushed from being agitated. Fingers and lips pink. Resp (respirations) regular even and unlabored at 20. When writer informed res that writer had been in there at 11:00 PM and offered inhaler but he declined and he has appeared to be sleeping since 11:20 PM he took a swing in writer's general direction and started swearing. Writer stepped out in hall with one EMS and explained situation and res background. EMS decided to take res to ER because they were here. DON updated. On [DATE] at 2:10 PM, Surveyor spoke with RN C. RN C stated R1 complained of SOB on [DATE] at 11:00 PM. RN C stated she offered R1 his inhaler, completed an assessment, listened to his lungs, and checked his oxygen saturation which was around 90%. RN C stated she told R1 she would be back in ,[DATE] minutes and when she returned he was sleeping. RN C stated she didn't hear another peep until the ambulance showed up. RN C stated he told me he called 911 because he didn't have a CNA. Surveyor asked RN C did you notice the temperature you documented in R1's medical record at 6:42 PM alerted as a warning? RN C stated, I was unaware it came up as a warning. Surveyor asked RN C when does a temperature alert as a warning? RN C stated temperatures alert with a warning when it is below 97.0 or above 100.0 degrees. Note, R1's temperature alerted as it is 2 degrees above his baseline temperature. Did you contact R1's physician? RN C stated, No. Surveyor asked RN C, did you take R1's vitals at or after 11:00 PM when R1 was complaining of SOB? RN C stated, Don't ask me what those vitals were I cannot recall! Surveyor asked RN C did you document the vitals? RN C stated, I did not. Surveyor asked should you have documented R1's vitals? RN C stated, I should have. Surveyor asked RN C did you contact R1's NP (Nurse Practitioner) or Physician? I called the NP and left a message after R1 went to the hospital. Surveyor asked RN C did you document this? RN C stated I think so. Surveyor asked RN C when you notify an NP or Physician where do you document the notification? RN C stated, in the Nurses Notes. It is important to note there is no evidence that RN C notified the NP or Physician before R1 called 911 himself due to SOB. RN C stated the she was frustrated by the whole situation and R1 was very rude to her. RN C stated she was tired from being on a long shift (2nd and 3rd shift). RN C stated if a resident is complaining of SOB, I would call the Physician to see if I could get a nebulizer or inhaler ordered or send the resident to the ED. Surveyor asked RN C how soon would you do that if a resident is complaining of SOB? RN C stated, Almost immediately, depending on how short of breath they were. On [DATE] at approximately 4:15 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B if a resident states they are SOB what do you expect staff to do? DON B stated she expects staff to assess the resident's respiratory status, see if they can stabilize the resident, check if there is an order for [REDACTED].? DON B stated, I don't believe she documented anything. DON B added, I would expect her to assess the resident, take vital signs, check if the resident has PRN (as needed) medication available for respiratory management, assess skin turgor, and respiratory lung sounds. If a nurse is unable to stabilize a resident he/she should call 911, follow up with the resident's Physician and family. Surveyor asked DON B did RN C document her actions on [DATE] and [DATE] related to R1? DON B stated, I don't think she documented it. DON B added if a resident is in acute distress I would expect the nurse to institute care right away - immediately. Surveyor asked DON B did you notice that the ED's respiratory assessment documents crackles in the bases of R1's lungs and does not concur with RN C's assessment that she documented as part of your investigation. DON B stated, yes, Hence the reason why I educated on SBAR, cephalocaudal (head to toe) assessment, PCC (PointClick Care) SBAR. Surveyor stated on [DATE] at 6:42 PM, RN C documented R1's vitals. R1's temp is documented as 99.2 (Warning high of 99.0 exceeded!) degrees F. Surveyor asked DON B what would you have expected RN C to do? DON B stated, she would have expected RN C to check for PRN (as needed) order for Tylenol, notify R1's Physician and monitor accordingly. Surveyor asked DON B do you feel RN C and/or other facility staff monitored accordingly? DON B stated, Based on what I told you, no. Example 2 R5 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. R5's MDS (Minimum Data Set) dated [DATE] documented R5 was cognitively impaired with a BIMS (Brief Interview for Mental Status) of 6 and required extensive assistance with mobility, transfers, hygiene and toileting. R5's Care Plan documents behavior approaches and personal care assistance. R5's [DATE] Progress/Nursing notes document: -2:42 PM-critical INR (international normalized ratio) (blood test for blood thinning medication) 9.4 result received-spoke with physician at anti-coagulant clinic-physician stated to hold [MEDICATION NAME] (blood thinning medication) until [DATE] and redraw blood work on [DATE]. Physician stated not to give [MEDICATION NAME] until labs have been reported to the clinic. It is important to note that the nurse documenting the [MEDICATION NAME] order did not document if she told the physician about a change of condition for R5, who had been lethargic and gurgling all shift per a nurse's note at 10:47 PM. There is no evidence that staff told the physician that R5 was requiring 4.5 liters of oxygen. -10:46 PM -call received from NP (Nurse Practitioner) with orders for fluid goal two liters per day, night shift to total daily fluid intake and blood work [DATE]. There is no evidence that nursing told the NP that R5 had been lethargic and gurgling all shift per a nurse's note at 10:47 PM. There is no evidence that staff told the NP that R5 was requiring 4.5 liters of oxygen. It's important to note the nurse did not document the time the NP called with the order or if the nurse reported R5's change of condition to the NP. -10:47 PM-R5 was on O2 (oxygen) at 4.5 liters at start of shift. He was lethargic and gurgling. CNA (Certified Nurse Assistant) said he had been like this all day and it was reported he was like this last night as well. R5's daughter came for window visit and had many questions about res. condition. Writer reported she would investigate and contact daughter when writer knew more. Vital signs blood pressure (BP) ,[DATE] temperature (T) 97.1 heart rate (HR) 85 respirations (R) 22 and oxygen saturation (O2 Sat) (measurement of oxygen in the blood) 68% on 4.5 liters of oxygen per nasal cannula. 911 contacted and EMS dispatched. By the time EMS arrived at 4:20 PM, res. was expired. Res. daughter was updated at 6:30 PM and questions answered as best as possible. Resident physician on call was contacted at 6:45 PM and he pronounced res. expired and released body to funeral home. Voice mail left for NP. Questions answered by staff for (name of police force) police. Body released to funeral home at 9:00 PM. On [DATE] at 4:00 PM, Surveyor spoke to R5's (dtr) daughter. R5's dtr. said she had not spoken to R5 in a couple of days, which was usual for them. R5's dtr. said she wanted to do a window visit with R5, so she called the facility and requested a time for a window visit. R5's dtr. said she would arrive between 3:30 and 4:00 PM. R5's dtr. waited 20 minutes after arriving at the facility for R5. She asked a women passing by to check on R5 to see why he had not come to the window yet. The women reported back to R5's dtr. They are having trouble with his oxygen. R5's dtr said she thought this was wrong, because R5 never used oxygen. RN C brought R5 to the window. R5's dtr. said he was non-responsive and breathing heavily and that he had oxygen on. R5's dtr. said to RN C, What is wrong with him? RN C told R5's dtr. He's sleepy. R5's dtr. said to wake him up. RN C touched R5 on the shoulder and spoke to him. R5's dtr. said he did not respond. R5's dtr. told RN C to find out what was wrong with R5 and call her back within an hour. RN C took R5 away from the window. R5's dtr. said RN C called 45 minutes to one hour later to say R5 expired. On [DATE] at 2:10 PM, Surveyor spoke with RN C (Registered Nurse). RN C said she does not recall the CNA that told her the resident was lethargic and gurgling all day. He was lethargic when she came on shift. When the resident daughter was at the window visit at 3:00 PM, he seemed improved. RN C said the report she received from LPN E was that LPN E did not know the resident. RN C said she thinks she did vital signs-they were stable. RN C said she thinks she called the physician. RN C said she did not document calling the physician or the vital signs. On [DATE] at 3:15 PM, Surveyor spoke with MD F (Medical Doctor). MD F said he was not aware that the resident had a change of condition. MD F said he was not aware the resident had expired until he received the death certificate to sign. MD F said the cause of death was complications of [MEDICAL CONDITION] (a heart condition). MD F said if he had been contacted that the resident had a high INR and/or a change of condition he would have ordered the resident be sent to the emergency room . On [DATE] at 10:30 AM, Surveyor spoke to NP G. NP G said when she spoke to RN C on [DATE], RN C did not report a change of condition on R5. R5 presented with a significant change of condition, lethargic and gurgling per staff report however there is no indication RN C called the physician to report R5's significant change of condition. In fact R5 was brought to a window visit vs. an immediate call to the physician. R5 expired secondary to an acute change of condition and complications of [MEDICAL CONDITION] Fibrillation. The facility's failure to complete a full nursing assessment and notify and consult with the Physician as R1 and R5's conditions changed prevented staff from getting a comprehensive picture of R1and R5's clinical conditions and, thus, prevented them from taking appropriate follow-up action, such as prompt consultation with the physician, with complete information about the resident's condition. This failure created a situation of Immediate Jeopardy, which was removed on [DATE] when the facility implemented the following action plan. The 2 identified residents, R1 and R5 no longer reside at the facility. On [DATE], Licensed Nurses and Certified Nursing Assistants were educated on the following: 1. Change in Condition 2. Nursing Assessments 3. Physicians' Notification of Condition Changes (of Residents) 4. Proper Documentation and Timely Follow-up of Changes in Condition. 5. Notification of Resident and/or Responsible Party of Changes in Condition 6. POC Documentation for CNAs CarePlan and Kardex Review. 7. How to Use a Stop-and-Watch Tool. Education to be continued with all Licensed Nurses and Certified Nursing Assistants prior to start of their shifts. In Summary: On [DATE], a full house 'sweep' was completed per facility rounds by licensed nurses to determine if there were any residents who presented with evidence of any change of condition, that would require implementation of resident assessments, change of condition notification to physician/provider, resident and/or resident's responsible party, and requiring documentation of immediate follow-up. On [DATE], there were no residents noted to have a change in condition requiring these specific parameters indicated. On [DATE], Stop-and-Watch tools have been made readily accessible for Certified Nursing Assistants and Licensed Nursing Staffs' access. [DATE] Licensed Nurses and Certified Nursing Staff received education on the proper use of the Stop-and-Watch Tools. All Nursing Staff and CNAs will be educated on the use of Stop-and-Watch Tools and its use prior to their shift worked. On [DATE] Certified Nursing Assistants were provided education on the following: Documenting in POC, Accessing the Resident's CarePlan and Kardex review, and (notifying a licensed nurse when the Kardex Needs Revised/Updated). All Certified Nursing Assistants will receive education regarding this prior to starting their shift until all CNAs receive the education prior to their shift worked. On [DATE], a (24) Hour PointClickCare report was extrapolated via the facility's computer system and reviewed. Contents of nursing documentation of all resident's statuses was reviewed to recognize/identify any areas of concern requiring immediate follow-up, any concerns requiring implementation of a resident assessment, any change of condition requiring immediate follow-up reporting/notifying physician and/or provider, resident and/or responsible party of changes in condition. On [DATE], no findings were observed. On [DATE], the 24 Hour Report Sheet was reviewed to recognize any areas of concern requiring immediate follow-up, any concerns requiring implementation of a resident assessment, any change of condition requiring immediate follow-up reporting/notifying physician and/or provider or resident and/or responsible party of changes in condition. No areas of concern related to changes in condition of residents were observed. On [DATE], a medical record review was completed on all residents in the facility per (48) Hour Look-back period under resident alerts in charting. Specific charting data that flag sections in PointClickCare System, which is documented by Licensed Nurses. This section of resident alerts in the facility's computer system was reviewed (on all residents) to determine any areas of concern requiring immediate follow-up, any concerns requiring implementation of a resident assessment, any change of condition requiring immediate follow-up reporting/notifying physician and/or provider or resident and/or responsible party of changes in condition. No areas of concern related to changes in condition of residents were observed. On [DATE], resident Change-of-Condition binders have been placed at each nurse's station/cart. The facility's Licensed Nurses and Certified Nursing Assistant Staff were educated on the placement of Change-of-Condition Binders. The policy on Notification of Changes (in Condition) Guidelines and STOP-and-WATCH Tools were placed in those specific binders for Licensed Nurses and Certified Nursing Assistants staff's use and ready access. On [DATE] Computer inputted Vital Signs, Blood Glucose Report were audited/completed on all resident who had documented vitals and blood sugar readings to determine any issues identified to determine any areas of concern requiring immediate follow-up, any concerns requiring implementation of a resident assessment, any change of condition requiring immediate follow-up reporting/notifying physician and/or provider or resident and/or responsible party of changes in condition. No areas of concern related to changes in condition of residents were observed. On [DATE], all physician's orders [REDACTED]. No areas of concern related to changes in condition of residents were observed. On [DATE] Audits on the following: 1. Change in Condition 2. Nursing Assessments 3. Physicians' Notification of Condition Changes (of Residents) 4. Proper Documentation and Timely Follow-up of Changes in Condition. 5. Notification of Resident and/or Responsible Party of Changes in Condition were completed to determine any issues requiring any areas of concern requiring immediate follow-up, any concerns requiring implementation of a resident assessment, any change of condition requiring immediate follow-up reporting/notifying physician and/or provider or resident and/or responsible party of changes in condition. No areas of concern related to changes in condition of residents were observed. Audits will continue for compliance monitoring for the following summarized occurrences: (10) residents daily for (1) month, then (3) residents weekly for (2) weeks, then (3) residents (2) times monthly for (1) month, then (3) residents monthly for(1) month. Monthly Random audits will be instituted thereafter. Results of audits to be brought to Quality Assurance/Performance Improvement (QAPI) for review to determine results of specified audits, thus to validate substantial compliance. Licensed Nurses will be educated by Nurse Manager/Designee on how to complete a full head-to-toe assessment. Return Demonstrations by Licensed Nursing Staff (monitored by Nurse Manager/Designee) to validate competency will be performed. Certified Nursing Assistants will be educated by Nurse Manager/Designee on how to properly document in POC and how to appropriately report changes in condition (of residents) to the Licensed Nurses. Certified Nursing Assistants will be evaluated via post-test to determine competency. Cross Reference F684 J The deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by the following example: Example 3 R12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R12's MDS admission (Minimum Data Set) indicates mild cognitive impairment, set up with food but independent in eating, extensive assistance requiring (TRUNCATED)

Based on observation, interview, and record review the facility did not ensure the residents' environment remained as free of accident hazards as possible for 1 of 9 residents reviewed (R7), who experienced an electrical shock when a light switch shorted out in her room, An RN never assessed R7 for injuries. R7's Medical Doctor was not notified of the incident, and the short was never repaired so R7 continued to be at risk for a similar incident occurring. Since being shocked, R7 has experienced more pain in her hand and complains of her hand falling asleep. The facility's failure to ensure a safe environment in R7's room created a finding of immediate jeopardy that began on [DATE]. The Nursing Home Administrator (NHA A) and Director of Nursing (DON B) were notified of the immediate jeopardy on 2/5/20 at 9:55 AM. The immediate jeopardy was removed on 2/4/20. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its plan of correction. This is evidenced by: According to https://ehs.princeton.edu/book/export/html/[AGE], The major hazards associated with electricity are electrical shock, fire and arc flash. Electrical shock occurs when the body becomes part of the electric circuit, either when an individual comes in contact with both wires of an electrical circuit, one wire of an energized circuit and the ground, or a metallic part that has become energized by contact with an electrical conductor. The severity and effects of an electrical shock depend on a number of factors, such as the pathway through the body, the amount of current, the length of time of the exposure, and whether the skin is wet or dry. Water is a great conductor of electricity, allowing current to flow more easily in wet conditions and through wet skin. The effect of the shock may range from a slight tingle to [MEDICAL CONDITIONS]. The chart below shows the general relationship between the degree of injury and amount of current for a [AGE]-cycle hand-to-foot path of one second's duration of shock. While reading this chart, keep in mind that most electrical circuits can provide, under normal conditions, up to 20,000 milliamperes of current flow. Current Reaction 1 Milliampere Perception level 5 Milliamperes Slight shock felt; not painful but disturbing 6-30 Milliamperes Painful shock; let-go range 50-150 Milliamperes Extreme pain, respiratory arrest, severe muscular contraction 1000-4,300 Milliamperes Ventricular fibrillation 10,000+ Milliamperes [MEDICAL CONDITIONS] probable death According to OSHA,[MEDICAL CONDITION] the most common shock-related injury. An electrical accident can result in an electrical burn, arc burn, thermal contact burn, or a combination of burns. Of these, [MEDICAL CONDITION] the most [MEDICAL CONDITION] require immediate medical attention. They occur when electric current flows through tissues or bone, generating heat that causes tissue damage. R8 lives across the hall from R7. R8 is cognitively intact with a Brief Interview for Mental Status (BI[CONDITION]) score of 14 out of 15. On 2/4/20 at 9:56 AM, during initial tour of the facility, R8 indicated there is an electrical problem in R7's room that has not been addressed or reported. R8 indicated R7 is visually impaired and while R7 was reaching for something that was plugged in, she was electrocuted and burned on her left hand. R8 indicated R7's hand was covered in a black soot.R8 said R7 came to her after this happened and R8 is the one who called LPN J (Licensed Practical Nurse). R8 pointed towards her nightstand that had several outlets built into the left side panel. R8 also pointed to a beaded metal cord light switch on the wall above the nightstand that hung down and the end of it was lying on the nightstand. Approximately 4 inches to the right of the light switch cord was the call light cancel button. R8 concluded the conversation stating, I ask staff about this. LPN J told me it doesn't concern me. It does concern me if the [MEDICAL CONDITION]. It worries me. R7 was admitted to the facility on [DATE] with diagnoses, including: chronic pain, [MEDICAL CONDITION] of bilateral knees, [MEDICAL CONDITION] in one eye, and Diabetic Retinopathy. Her most recent MDS, with ARD of 1/15/2020, indicates R7 is cognitively intact with a Brief Interview for Mental Status (BI[CONDITION]) score of 14 out of 15. On 2/4/20 at 10:05 AM, during an interview R7, indicated that she received an electric shock from a switch in her room and has a sore on her left hand. Surveyor observed a moon shaped scab approximately a quarter of an inch long on the outside, back of R7's left hand. R7 was in the middle of therapy and made arrangements with Surveyor to meet later in the day. On 2/4/20 at 3:12 PM, Surveyor brought a second Surveyor to observe R7's scab on her hand. Surveyor asked R7 if she was blind all of her life. R7 stated, No. I can see shapes, colors, and shadows still. I can see enough to know you are wearing a white sweater with black stripes. I just can't make out the details of your face. (It is important to note Surveyor was wearing a white sweater with black stripes.) R7 pointed at the beaded metal switch cord that hung down and laid resting on her nightstand. She indicated the cord broke when she received the shock that sent her backwards in a hurry. Surveyors observed the broken off piece of the metal cord under R7's bed, on the floor. R7 stated, I saw blue, red, and orange flash across the wall at the same time I felt the shock run right through my hand and arm. R7 said she let go immediately of the metal cord then. R7 indicated since the incident she has experienced more pain at night, her hand has been falling asleep and she can't wake it up, and today (2/4/20) she had trouble holding her bingo chips. R7 also indicated she had not seen her MD for this and she would like to. Surveyor asked if the cord was for just one light above R7's bed or both. R7 indicated she thought both, but was not sure. Surveyor reached her hand out to pull cord and as soon as her hand touched cord, Surveyor felt a sudden painful shock in her hand and arm. Surveyor jolted backwards away from the cord. Surveyor also heard a snap sound when this happened. Second Surveyor and R7 both voiced that they heard the pop sound when Surveyor moved back rapidly. Second Surveyor observed R7's hand with a moon shaped scab on it and R7 stated it was a flash burn. On 2/4/20 at 3:02 PM, during an interview LPN J, indicated R8 and R7 called her. She noticed R7 had black soot or black dust on her left hand and R7 indicated to her that she was electrocuted on her hand and she saw a light go through the wall, all while messing with her charging cord and metal pull cord. LPN J stated, She is blind. I was like how could you see anything? She didn't see nothing. I used a wet washcloth and soap to wipe the black dust, soot stuff off her hand. Her skin was dry, intact, and clean. Her vitals were fine. I knew she didn't see nothing. No shock. No pain. I was not concerned. LPN J indicated she did tell RN K (Registered Nurse) and MM E (Maintenance Man). R7's nurse note, dated [DATE] at 6:42 PM, includes: Resident in room. Denied pain or discomfort to hands. Black dust like sud present to left hand. Vital signs stable. Skin clean, dry, and intact. On 2/4/20 at 3:06 PM, during an interview, RN K indicated LPN J did report the incident to her. RN K indicated she asked LPN J what she did about it to which LPN J replied she checked R7's skin, the environment, R7's vitals. RN K stated, No injury was noted. No residual pain. Surveyor then asked RN K if she assessed R7. RN K stated, I did not go look at (R7) or assess her. On 2/4/20 at 3:15 PM, Surveyor went to find MM E. During an interview MM E indicated he was unaware that a resident reported she had been shocked by an electrical switch in her room. MM E indicated he expects staff to notify him immediately of a concern like this because he would drop everything he is doing to fix it because this is a resident safety concern. MM E indicated to R7 he could get her a different room while he works or has someone work on her switch. R7 stated she has been avoiding the night stand altogether, especially the metal light cord and the call light cord. She indicated she worries about the house starting on fire. MM E took the face plate off of the switch and indicated that he will not touch this and he is going to call an electrician to come in. MM E stated, I know better than to touch this. Too many wires going into here for me. On 2/4/20 at 4:30 PM, during an interview, DON B indicated LPNs do not assess residents and she was unaware R7 reported that she received an electrical shock. DON B indicated it is her expectation when any staff member is made aware of a safety concern they report it to her, have an RN assess resident, notify resident's medical doctor (MD), and have MM E ensure environment is safe. DON B indicated RN K should have assessed R7 for injury, notified R7's MD, and reported the incident to DON B and/or NHA A. DON B indicated MM E should have also been notified by LPN J and/or RN K. NHA A entered room and joined conversation, stating that she was unaware R7 reported this incident until now and RN K should have assessed resident, R7's MD should have been notified R7 should have been offered a different room, and MM E should have been involved. On 2/4/20 at 5:10 PM, R7 stated her pain is normally at a 6 out of 10 due to her arthritis, but since the event it has been between 7-9 out of 10 at night and her sleep has been interrupted due to the pain. R7 also indicated she struggled to hold her bingo chips today. R7 stated, It feels like it is tingling or shutting off circulation. It is very, very painful, like the hand and arm are going to sleep. You keep trying to wake it up but can't. The facility's failure to ensure a safe environment in R7's room created a finding of immediate jeopardy, which was removed on 2/4/20, when the facility implemented the following plan: Immediate Corrective Action of Resident Affected: Upon notification of event: 2/4/20 RN assessment MD notification Electrician called immediately and onsite to assess outlet in room Electrician to assess all like outlets or receptacle Resident moved to another room Identifying other residents with potential for being affected and interventions to prevent this from occurring in the future. All residents in a private room have the potential to be affected Measures put in place to prevent reoccurrence. System revision. Policy to be reviewed regarding reporting incidents/accidents to DON/NHA Education to be completed immediately on 2/4/20 and prior to clinical staff's next scheduled shift regarding the following: immediate reporting of incidents to DON/NHA, notification to MD/NP and POA if applicable, incident report requirements. Education regarding usage of TELS to communicate needs to Maintenance Educate staff on fire safety procedure (fire extinguisher usage (PASS) in event of electrical fire. How facility will monitor system and corrective action: Evaluation of electrical safety to be completed during safety rounds weekly for one month and monthly for three months by Maintenance or designee and report to QAPI. Pain assessment completed every shift for (R7) to monitor for changes in condition All audit results will be reviewed by the facility Quality Assurance Committee to determine if any further staff education or facility policy changes are needed. Any deficiencies will be corrected immediately and reviewed again by the Quality Assurance Committee monthly. All above measures will be subject to review, assessment, and modification. Electrician Invoice # , dated 2/6/20, includes, in part: Emergency Service Call: Need to check over light switch that shocked a resident- please repair . Troubleshoot light for why it would give a resident a shock . Found damage to HOT wire causing box and cover plate to transfer electricity which could cause a shock to someone when touched. Made repairs and tested and have it working properly. Needs . to inspect all resident rooms with lights that are on pull chains for potential problems . (Total of 16 units mentioned in report) - 12 units: no damage to wires and/or device . working properly - 1 unit: resident was too ill to have electrician enter unit - 1 unit: replaced wire nut on the ground wire - 1 unit: replaced pull string - 1 unit: (R7's room) found in this unit the device had gone bad. Replaced with a new device that was supplied by others and tested . Found no further issues with wiring.

Based on record review and interview, the facility did not ensure that 1 of 3 sampled residents (R1) received treatment and care in accordance with professional standards of practice for foot care. LPN [NAME] (Licensed Practical Nurse) falsely documented that she completed R1's diabetic foot checks on the following dates: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. R1 was noted to have an extensive full thickness wound on [DATE]. LPN [NAME] did not document the wound on the foot, consult the physician regarding the development of the foot wound, or any areas of impaired skin integrity. On [DATE], R1 was noted to have an extensive full-thickness gangrene wound on his right foot. R1 was hospitalized for [REDACTED]. R1 went on hospice on [DATE] and expired on [DATE]. On [DATE], when the facility began investigating this incident, they interviewed R1. When R1 was asked if staff remove his socks daily, he replied, I don't know. I don't think so. When staff asked when was the last time he had his socks off, R1 replied, I don't know. It's been awhile I guess. On [DATE], the facility interviewed LPN E. LPN [NAME] admitted she did not complete R1's daily diabetic foot checks or weekly skin assessment that she documented as completed. Other staff indicated R1 would refuse to allow them to take off his socks so they could check his feet. The facility did not provide any Risks and Benefits to R1, regarding refusing skin checks and refusing to have his socks removed, to allow him the right to make an informed decision. The facility's failure to complete diabetic foot checks created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. On [DATE] at 4:10 PM, NHA A (Nursing Home Administrator) was informed of the I[NAME] The IJ was removed and corrected on [DATE]. This is evidenced by: The facility policy, Skin Management Guideline, dated [DATE], states, as follows: It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards. Guideline, Procedure: I. Prevention of Pressure Ulcers Inspection of skin daily with cares and weekly by a Licensed Nurse B. Monitoring of Skin Integrity Skin will be observed daily during cares by the nursing assistants. If any skin concerns are noted, they are to be reported to the licensed nurse. Weekly skin observations on the bath/shower daily will be performed by a Licensed Nurse. If a skin concern is noted, refer to the skin and wound care formulary. The Care Plan for Skin Integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. The Physician will be consulted with changes suggesting impairment in skin integrity. According to AMDA (American Medical Doctors Association) - The Society for Post-Acute and Long-Term Care Medicine - Pressure Ulcers - Clinical Practice Guideline - http:// www.amda.com/ tools/ guideline.cfm#pressureulcer .to the extent feasible, caregivers should educate patients about daily foot care (e.g., washing, moisturizing), nail care, and about the importance of avoiding walking barefoot, avoiding foot trauma, and promptly telling a caregiver about foot pain or changes in the appearance of the feet . treatment of [REDACTED]. Risk Category: At-risk foot (patients who smoke; have vascular insufficiency, [MEDICAL CONDITION], retinopathy, [MEDICAL CONDITION], history of ulcers or amputations, structural deformities, infections, skin/nail abnormality; are on anticoagulation therapy; cannot see, feel, or reach their feet.) treatment plan: [REDACTED] · Refer for podiatric care at least annually and as needed for specific foot problems · Train caregivers to perform daily foot care and inspection · To the extent feasible, train patients to perform daily foot care and inspection . R1 was admitted to the facility, [DATE], with [DIAGNOSES REDACTED]. R1's Quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated that R1's BIMS (Brief Interview for Mental Status) is 14, indicating he is cognitively intact and requires assist of 1 for bed mobility, transfers, toileting, and dressing. This MDS indicates no skin impairment. This MDS indicates no foot problems were present. R1's TAR (Treatment Administration Record) Skin check weekly. Use 'Skin Observation' under evaluations tab every evening shift every Saturday. Order Date [DATE]. R1's TAR Skin check to bilateral feet q (every) HS (bedtime) d/t (due to) DM (Diabetes Mellitus) every evening shift. Order Date: [DATE]. CNA J (Certified Nursing Assistant) provided a bed bath to R1 on [DATE]; however, per statement, He (R1) always has to have the socks on his feet. CNA J did not remove his socks or look at his feet. LPN [NAME] documented on R1's TAR that she completed R1's diabetic foot checks on the following dates: ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. LPN [NAME] did not document wounds, areas of concerns or any refusals. On [DATE], LPN [NAME] documented on R1's TAR that she completed R1's skin observation. LPN [NAME] did not document wounds, areas of concerns or any refusals. R1's NN (Nurses Notes) are as follows: On [DATE] at 2:07 PM, Call placed to NP (Nurse Practitioner), request treatment orders for R (right) foot-2nd, 3rd, 4th, 5th digit, foul smell present, cleansed site without issue, resident denied pain or discomfort, denied feeling to digits during palpation, pending return call from NP with new orders. On [DATE] at 5:29 PM, (SBAR (Situation, Background, Assessment and Recommendation)) S (Situation): R (Right) foot, 2nd, 3rd, 4th, and 5th digit discoloration, planter foot with discoloration and peeling skin; B (Background): DM (Diabetes Mellitus), [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]), [MEDICAL TREATMENT]; A (Assessment): Resident stated unable to feel digits with palpation, foot cleaned with NS (Normal Saline), pat dry lambs wool between digits, wrapped with kerlix; R (Response) Keep current treatment in place until seen via (by) wound nurse. Request: f/u (follow up) with wound nurse for treatment orders. - On [DATE] at 7:00 AM, RN F (Registered Nurse), who is WCC (Wound Care Certified), assessed R1 together with NP (Nurse Practitioner), and documented the following NN: Assessed resident's R foot/toes. See wound rounds for full assessment. Resident is unsure when wound may have began d/t lack of sensation to area. Resident is unsure of any prior injury to area. Hx (history of) diabetic [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Pedal pulse + (positive) with Doppler. NP in facility to assess. Ordered for resident to go to ED (Emergency Department) for further evaluation. Area dressed as NP ordered. Paramedics called and resident left for ED around 7:00 AM. Resident refused any family or friends to be updated. RN F documented the following Wound Assessment Detail Report - Wound: R plantar foot D2 and D3 (digit/toe 2 and 3); Type: Diabetic/Ulcer; Source: Facility Acquired; Date Identified: [DATE]; Clinical Stage: Full thickness; Non-removable device or dressing: No: PUSH (Pressure Ulcer Scale for Healing) Score: 16; General: Tissue Type: Necrotic Soft, Adherent 100 ; Has been debrided: No; Outcome: Probable improvement; Exudate: Amount - moderate, Type - Bloody; Periwound criteria: Callous Wound Edge: Distinct and attached; Pain Scale: 0; Odor: Yes; Signs of Infection Present: Yes; Is Patient on Antibiotics: No; Dressing Present: Yes; Dressing Date and Initiated: Yes; Measurements: 12.0 cm (centimeters) x (by) 10.0 cm x Unknown (Length x Width x Depth) Area: 120 cm; Undermining: Unknown; Tunneling: Unknown; Pulses D.P. (Dorsalis Pedia) 3+ (Normal), P.T. (Posterior Tibial): 3+ (Normal). Pulses demonstrate that R1 has normal circulation to his feet. On [DATE], R1's NP documented the following Progress Note: R1 is a [AGE] year old male who is seen today for urgent follow-up of right foot injury/wound. Report yesterday from SNF (Skilled Nursing Facility) nurse that toes ,[DATE] were bruised, unknown injury. Overnoc (overnight) nurse reports it looked and smelled like gangrene. Hx (history) of diabetic [MEDICAL CONDITION]. Unknown onset despite daily diabetic foot checks at facility. Today on exam, R1 is found in bed with RLE (Right Lower Extremity) elevated on pillow. Denies fever/chills. Occas (Occasional) upset stomach. R1 reports no pain d/t lack of sensation in feet. Examined with SNF wound nurse, (RN F) . Exam: General: Chronically ill-appearing, pleasant male, in no acute distress; Heart: Irregular rhythm, ,[DATE] murmur; Extremities: + pedal pulses are 2+ and symmetric; Skin: Right foot as noted above in photos - with necrotic area on distal plantar aspect into D,[DATE], macerated toes, +foul odor, [MEDICAL TREATMENT] cath (catheter) intact w/o (without) s/s (signs/symptoms) of infection; Neuro: Alert & oriented x 3 (person place and time) with fluent speech; Psych: Calm and appropriate. A (Assessment) Right foot ulcer, Diabetic [MEDICAL CONDITION]; Comment: New necrotic area on right foot/toes, foul odor, likely vascular compromise; Plan: Pt (Patient) agreeable to transfer to emergency department for further evaluation - likely needing debridement, IV (intravenous) abx (antibiotics), and vasc (vascular) consult, Hand off given to ED. On [DATE] at 8:56 AM, the ED Physician documented, in part, the following note: R1 is a [AGE] year old male with a history of depression,[MEDICAL CONDITION](hypertension), [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]), chronic [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] who presents with necrosis for R foot. Pt currently living in a SNF. Pt states he and staff noticed a change in his foot yesterday. He has no feeling in his feet due to chronic [MEDICAL CONDITION] and therefore this has not caused him any pain. Physical Exam (Extremities): R 2nd-4th toe necrosis, forefoot with necrotic tissue. Foul smelling (see pictures below). Assessment/Plan: R foot necrosis/gangrene/[MEDICAL CONDITION]: Resident at SNF and presents today with R 2nd, 3rd, and forefoot necrosis. Unclear when this started. XR (x-ray) obtained and does show evidence of soft tissue gas, no evidence of osteo[DIAGNOSES REDACTED]. Discussed with Vascular Surgery will evaluate with an angiogram but foot is likely not salvageable. No fevers but WBC ([NAME] Blood Cell) is 19. ESR (Erythrocyte Sedimentation Rate, a blood test that detects and monitors inflammation) 101. (Normal range is ,[DATE] millimeters with slightly increased range in the elderly.) Vitals are stable. On [DATE] at 1:13 PM, R1's Physician Assistant documented the following note, in part: Patient is a [AGE] year old male who is seen in the ER (emergency room ) non-healing ulcerations of the right foot/toes with gangrene/necrosis. I am consulted for evaluation of his [MEDICAL CONDITION] and arterial flow. Patient resides in a SNF. Patient has no idea how long his toes have been necrotic. He feels this is neglect. Apparently staff at the SNF noticed the necrosis and was referred to the ED. He has no previous workup for [MEDICAL CONDITION]. He denies recent injury. He has a history of diabetes. [MEDICAL CONDITION] on [MEDICAL TREATMENT], diabetic peripheral [MEDICAL CONDITIONS] not on anticoagulation secondary to numerous falls as well as GI (gastrointestinal) bleeding in (MONTH) of this year, felt to be due to NSAID (Non-Steroidal Anti-[MEDICAL CONDITION]) use. Was treated with EGD (an endoscopic procedure that allows your doctor to examine your esophagus, stomach and duodenum (part of your small intestine)) and cauterization as well as PPI (Proton Pump Inhibitors (medicines that reduce stomach acid)). He denies any recurrence of bleeding since. He denies any pain in his foot. He does ambulate with assist devices. He has been started on IV antibiotics. Xray of the right foot showed soft tissue ulceration along the mid plantar foot. Prominent underlying soft tissue gas. No radiographic evidence of osteo[DIAGNOSES REDACTED] Plan: Patient with active foot infection with severe gangrene. He is at high risk for limb loss. Xray shows gas in soft tissue. Necrotic/gangrenous toes 2, 3 on right extending past web space. There is purpura and [DIAGNOSES REDACTED] in the right forefoot. There is a large necrotic area/ulceration extending from toes 2, 3 to the plantar surface. There is significant odor. There is not drainage on plantar surface but the toes are soupy. On [DATE] at 9:29 AM, R1's Physician Assistant documented wound cultures growing heavy gram + cocci, moderate gram - bacilli (R1 has an infection in his toes). Continue IV antibiotics. On [DATE], R1's hospital document indicates: .R foot gangrene, BKA (Below Knee Amputation) [DATE]. R1 returned to the facility on [DATE], started on Hospice on ,[DATE], and expired on [DATE]. On [DATE], the facility filed a self-report with the state agency. In its investigation the facility noted that Staff who had worked with resident were interviewed. Statements showed that resident regularly chooses to not have his socks removed, not have his feet checked and declines his showers. He will agree to bed baths, but states he does not like to have his socks removed. Like residents were interviewed with no additional concerns noted. Statements taken by the facility noted: On [DATE], R1's statement: R1 states he does not know how long his toes have been discolored. He states he does not know how long he has had the wound on the bottom of his foot and states he did not know it was draining fluid. R1 stated he has no pain in his feet and has no feeling in his feet. When asked when the last time he had his socks off, he replied I don't know. It's been a while I guess. When asked if the CNAs assist him with daily cares, dressing and bathing, he replied, Yes. When asked if the staff remove his socks daily, he replied, I don't know, I don't think so. On [DATE], LPN E's statement obtained via phone: This Writer asked LPN [NAME] what R1's feet looked like when she looked at them the previous nights when performing daily diabetic foot checks. She stated, I didn't really see his feet. I wanted to look at his feet. He complains of back pain, so I medicated him and reapproached and he still did not want me to take his socks off. I told the aide to wash him up for bed and to get me to look at his feet when he was ready and he declined to take his socks off. LPN [NAME] went on to say this is a regular occurrence with R1. I asked if she completed a full skin observation on [DATE] which she signed out with no abnormalities noted. She stated she did, but did not look at his feet. On [DATE], CNA H's statement stated, as follows: She has only worked with R1 a couple of times. She stated, the other morning, I think Sunday or Monday, I got him ready for [MEDICAL TREATMENT]. I emptied his catheter bag, washed him up a bit, pericare. I helped him with his pants, shirt and shoes. She stated he already had socks on, so she did not remove them. She stated she has not seen R1's feet. She noted this morning ([DATE]) he had a bandage on his foot. She also stated she had noticed a foul odor in his room. She stated she noticed it the other morning (Sunday or Monday) as well. She said she emptied his garbage, checked his drawers for something rotten and changed his bed, to identify the cause of the smell. She did not know it was coming from a wound. On [DATE], CNA I's statement stated, as follows: CNA I stated lately when she has worked with R1, he has been up and dressed already for [MEDICAL TREATMENT] in the morning. When he returns in the afternoon, she empties his foley catheter bag, sets him up for lunch, assists him to the bathroom if needed. When she has performed cares, it is not his shower day. She provides pericare and washes his armpits. CNA I stated she has not seen his feet in a long time, a couple of months. She states he is always wearing socks. He likes his socks on his feet and does not like staff to remove them. On [DATE], CNA J's statement stated, as follows: CNA J states R1 always refuses showers. He does accept bed baths. He asks for staff to wash his periarea and bottom, and will ask for lotion to be put on his buttocks, then he will perform the rest. CNA J states she has not seen his feet, he always has socks on. CNA J stated, He always has to have the socks on his feet. She did not notice any drainage on his socks when performing cares for him. She has not noted any odor from his body. He uses his call light appropriately for needs. On [DATE] at 6:40 PM, NHA A (Nursing Home Administrator) stated to Surveyor that the facility did not provide any Risks and Benefits to R1 regarding refusing skin checks and refusing to have his socks removed. NHA A stated there is no documentation to this effect. Surveyor explained the benefits of providing Risk and Benefits to residents so that they may make an informed decision. NHA A voiced understanding. In summary, LPN [NAME] documented that she completed R1's daily diabetic foot checks and weekly skin assessments, when she did not. LPN [NAME] did not document wounds, areas of concerns or any refusals. The facility did not provide any Risks and Benefits to R1, regarding refusing skin checks and refusing to have his socks removed, to allow him the right to make an informed decision. The facility's failure to complete daily foot checks created a finding of IJ which was removed, on [DATE], when the facility implemented the following action plan: Immediate Corrective Action of R1 (affected resident) [DATE] Skin alteration observed by nurse, DON (Director of Nursing) immediately notified, DON assessed skin alteration NP notified of new skin alteration New treatment orders obtained and administered [DATE] NP and facility wound nurse assessed R1's foot NP wrote order to send R1 to ED for evaluation and treatment Resident admitted to the hospital Appropriate notifications made to family/friends Appropriate notifications made to facility/corporate leadership Resident's clinical documentation and shower sheets reviewed Investigation initiated Care plan updated upon return from hospital [DATE] Identifying other residents with potential for being affected and interventions to prevent this from occurring in the future. Wound nurse lead a house wide skin sweep performed on all residents. No new skin alterations noted. All resident Braden assessments reviewed Residents identified as high risk were reviewed Interventions implemented and care plans updated as identified ,[DATE] & [DATE] Measures put in place to prevent reoccurrence. System revision. Education was completed for appropriate nursing staff which includes: Skin management guideline Prevention of pressure ulcers Turning and repositioning Monitoring of skin integrity Nutrition Reporting of new skin alterations Reporting of resident refusals of showers and skin observations Daily diabetic foot checks Notification of skin alterations to Wound Nurse Proper and required documentation [DATE] How Facility will Monitor System and Corrective Action: Two QA (Quality Assurance) tools were developed: Foot check audit: to assure residents receive diabetic foot checks as ordered; Shower sheet audit: to assure residents shower sheets are complete and accurate. Audits being completed by the facility wound nurse and reviewed with DON or designee. Complete random audits of foot checks weekly for 3 months. Administrator responsible for the process. Findings of this QA tool will be submitted to the facilities QAPI (Quality Assurance and Performance Improvement) committee for review and corrective action. [DATE] Upon returning to the facility, Nurse identified (LPN E) received disciplinary action, counseling and education on the completion of required skin observations and proper documentation. QAPI - All audit results will be reviewed by the facility Quality Assurance Committee to determine if any further staff education or facility policy changes are needed. Any deficiencies will be corrected immediately and reviewed again by the Quality Assurance Committee monthly. On [DATE] at 12:20 PM, Surveyor spoke with NHA A and RN F (Registered Nurse). Surveyor asked NHA A what did you do when you were notified of the necrotic wound on R1's foot. NHA A stated we did audits and made sure skin checks were being completed, interviewed staff, interviewed residents to see if they had any concerns regarding their care. NHA A stated we did a full house skin sweep. We noted diabetic residents in house and did foot checks on all diabetic residents. NHA A stated this started, [DATE], and is ongoing (documentation shows this began [DATE]). NHA A stated the facility started auditing shower sheets and it is ongoing. We are assuring that resident Skin Assessments are being done weekly and diabetic residents feet are to be checked daily at bedtime. RN F is the Nurse assigned to complete these audits. NHA A stated that LPN [NAME] is currently out of the country and will return in 6 weeks. On [DATE], from 1:35 PM - 1:50 PM, Surveyor interviewed multiple staff members that confirmed they did receive training as indicated by facility.

The facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion (ROM) and/or to prevent further decrease in range of motion for 1 of 2 residents (R42) reviewed for Restorative Nursing Programming. R42 was discharged from Physical Therapy on 7/20/18 and no Restorative Nursing Program was put in place. On 9/27/18, ten weeks later, R42 developed a contracture in the LUE (Left Upper Extremity). The facility did not update R42's Comprehensive Care Plan or CNA (Certified Nursing Assistant) Care Card with the new physician's orders [REDACTED]. The facility did not provide documentation to Surveyor to demonstrate that ROM is currently being provided to R42. This is evidenced by: The facility's policy, Restorative Nursing Program Guideline, undated, states, as follows: The facility will provide a Restorative Nursing Program with interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. The program is consistent with the Center for Medicare and Medicaid Services (CMS) regulations as documented in the Resident Assessment Instrument (RAI) Manual. The program is overseen by the Director of Nursing (DON) and is managed by the Restorative Nursing Program Manager (RNPM) or designee. The RNPM and/or designee must be a licensed nurse. 1. Resident Identification a. Decisions to admit or discharge residents from the program are made by the RNPM with input from nursing, therapy, and other Interdisciplinary Team Members (IDT) as appropriate. b. Residents identified as requiring Restorative Nursing services demonstrate the clinical need for the intensity, complexity and focus of a structured program that is not typically provided in the course of a usual and customary nursing plan of care. 2. Delivery of Restorative Treatment a. CNA's, Restorative Nursing Staff and Activities Staff are trained in restorative programs by the RNPM which may, but not necessarily, include therapy participation. b. Treatment is delivered by CNA's, Restorative Nursing Staff, and Activities Staff. R42 admitted to the facility, on 5/17/18, with [DIAGNOSES REDACTED]. R42's Hospital H&P (History & Physical), dated 5/17/18, documents a [DIAGNOSES REDACTED]. (It is important to note that R42 did not have any contractures upon admission.) R42's BIMS (Brief Interview for Mental Status), on 12/20/19, is 2, indicating severe cognitive impairment. R42's spouse is the APOAHC (Activated Power of Attorney for Healthcare). R42's ROM in Section G, of the MDS, indicate 2:2 (two out of two) for the following assessments: Upper and lower body impaired ROM: 5/24/18, 10/16/18, 12/20/18, and 3/6/19. R42's Comprehensive Care Plan states: Focus: The resident has actual ADL (Activities of Daily Living), dated 5/17/18, self-care performance deficit r/t (related to) limited mobility, hematoma on brain. Goal: The resident will maintain current level of function in ADLs through the review date. Date Initiated: 5/27/18. Target Date: 4/9/19. Interventions: .Nursing Restorative: Palm protector to be worn during day and PM (evening), please remove at bedtime for L (Left) hand. Date Initiated: 6/18/18. Monitor/document /report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Dated Initiated: 8/9/18. R42's Comprehensive Care Plan states, in part: Focus: The resident has limited physical mobility r/t neurological deficits, stroke, weakness . Date Initiated: 10/3/18. Goal: The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Interventions: Nursing Rehab/Restorative: Active ROM (AROM) Program: Resident will receive AROM to bilateral upper extremities to tolerance with supervison to improve strength and functional ROM and allow participation in ADLs by 2/28/19. (It is important to note that by the time the facility implemented a Restorative/ROM program for R42, resident had already developed a contracture to the LUE.) R42's CNA Care Card states: Hoyer, wheelchair; General mechanical soft/nectar thick liquids Assisted Diner; Incontinent, prefers bed bath; Minimal verbal, 1A (assist), reposition q2h (every two hours), Prevalon boots in place when in and out of bed; wedge/pillows between knees; Air mattress; Abductor to LE; L hand splint. R42 received Physical Therapy from 5/18 - 7/20/18. After R42 was discharged from Physical Therapy, no Restorative Nursing Program (ROM) was put in place. Ten weeks later, R42 developed a contracture to the LUE. On 9/27/18, R42's physician first diagnosed R42 with a contracture. The Physician's Note indicates: [MEDICAL CONDITION] - with contracture LUE - wheelchair for ambulation, boots to cushion legs/ankles. On 11/1/18, while hospitalized , a second physician documented the contracture to the LUE in the following note: Neuro: A&Ox1 (alert to either person place or time), full ROM of right extremities, contracted LUE with no voluntary movement noted. R42's Telephone Order, signed 3/20/19, states Pt (Patient) is to be wearing left hand guard to prevent contracture - on in AM, off in PM. (It is important to note, as of 4/9/19, the Comprehensive Care Plan and CNA Card Card do not reflect this updated order.) (It is also important to note that Surveyor requested a copy of R42's ROM documentation for the last 3 months or to view it on the computer to confirm that it is being done. This information was not provided to Surveyor.) On 4/9/19 at 5:45 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, from 7/20/18 (when PT ended) - 10/3/18, (when a restorative plan was put in place), what was being done to prevent R42 from developing a contracture. DON B stated she was aware that R42's hand protector was in place, but not aware of any other interventions. DON B stated it is her expectation that once a resident's PT (physical therapy) ends that PROM (Passive Range of Motion) or AROM is put in place for the resident to prevent contractures. DON B stated it is her expectation that R42's hand protector be worn per the physician's orders [REDACTED]. DON B stated, 11/13/18, an Education In-Service was provided to staff regarding splint usage. This was prompted following a different survey; however, the sign-in sheets do not reflect that all staff listed received the education. R42 was discharged from Physical Therapy, on 7/20/18, and no Restorative Nursing Program was put in place. On 9/27/18, ten weeks later, R42 developed a contracture in the LUE. The facility did not update R42's Comprehensive Care Plan or CNA Care Card with the new physician's orders [REDACTED]. The facility did not provide documentation to Surveyor to demonstrate that ROM is currently being provided to R42. The facility is in current non-compliance for R42's development of a contracture to the LUE.

Based on observation, interview, and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent ulcers from developing and receive necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 4 residents (R30) reviewed for pressure injuries (PI) out of a total sample of 67 residents. R30 developed a PI in the facility which is currently unstageable. R30 was observed with feet in shoes and heels on bed. R30's air mattress was observed three times at an incorrect setting. This is evidenced by: According to the www.npuap.org <http://www.npuap.org> the NPUAP (National Pressure Ulcer Advisory Panel): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (break in skin). The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead skin). If slough or eschar is removed, a Stage 3 or Stage 4 PI will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Risk factors for heel PIs: Extrinsic factors: pressure, friction, shear. [MEDICATION NAME] Factors: age (decreased cushioning), decreased mobility and activity, malnutrition/dehydration, decreased sensation, decreased L[NAME] (Level of Consciousness), vascular disease, fragile skin/[MEDICAL CONDITION], underlying comorbidities, contractures and hammocking of mattress . Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure - a state sometimes called 'floating heels.' 1.1. Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon . The facility's policy entitled Skin Management Guidelines, with an effective date of 11/28/17, states, in part: Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualize interventions to prevent, reduce and treat skin breakdown .Procedure: I. Prevention of Pressure Ulcers: All residents admitted to the facility will be evaluated for actual and potential skin integrity issues. The Admission evaluation will be completed upon admission .within 2 hours .Interventions for prevention, removing and reducing predicting factors and treatment for [REDACTED].Elevating heels: for residents that cannot turn and reposition themselves; For residents that have diminished sensory perceptions of the lower extremities that may affect and independent ability to turn, reposition and off load pressure; Offloading devices may vary, may include pillows and should be selected based on resident comfort and positioning needs .II. treatment of [REDACTED]. Review the wound formulary for guidance. 2. Consult with the Physician/NP (Nurse Practitioner) and Resident Representative. 3. Notify Supervisor/Designee as assigned. 4. Notify Dietary for nutritional interventions . The facility uses a Primatech AiroDyne Alternating Pressure/Low Air Loss System mattress for R30. The manufacturer's guidelines state, in part: The AiroDyne is a portable alternating pressure mattress with low air loss designed to treat and/or prevent pressure ulcers, otherwise known as bed sores. The AiroDyne consists of a power unit, a mattress, and a cover .provide optimal comfort levels and therapy to patients according to their weight .Features: Control Dial: Patient weight knob is used to adjust pressure of mattress according to patient's weight . (It is important to note that Surveyor observed mattress set at 325 pounds on 3 separate occasions during survey. R30's last weight, on 4/8/2019, was 106.8 pounds. Also, the air mattress is not listed as an intervention on care plan.) R30 was admitted to the facility on [DATE]. R30 had a hospitalization , on 1/21/19, and was readmitted on [DATE]. R30 has the following Diagnoses: [REDACTED]. R30's Skin Risk Assessment, upon readmission to facility, with Braden Scale dated 1/27/19, indicated R30 scored a 15, indicating R30 was at risk. (It is important to note that this Skin Risk Assessment is dated 1/27/19, which is 2 days after R30 was readmitted on [DATE], which does not follow the facility's policy and procedure to complete within 2 hours. Also, R30's Braden Scale scores have been at a 17 (at risk) since 12/19/17, until the assessment on 1/27/19.) R30's physician's orders [REDACTED]. Skin check to heels every shift for skin redness .Check air mattress and pump every shift for inflation, pump should be on alternating option if available (not on static), if pump has weight setting, have setting closest to residents current weight. Every shift .Offloading boots to bilateral feet on while in bed and in w/c (wheelchair) (if res (resident) wishes to have them on in w/c) every shift for pressure relief. (It is important to note R30's TAR (Treatment Administration Record) for April, for these orders, indicates that this has been checked every shift, except on day shift of 4/7/19.) Order obtained, on 4/3/19, for Santyl Ointment 250 unit/gm (gram) ([MEDICATION NAME]) apply to R (right) heel topically every day shift for wound. Cleanse with NS (normal saline), pat dry. Apply skin prep to periwound. Apply Santyl to wound base and cover with silicone foam border. Change daily and PRN (as needed). (It is important to note this procedure was not documented as being done on 4/5/19 and 4/7/19.) R30's Skin Care Plan that was initiated on 12/12/17, that was in place upon R30's return to facility, on 1/25/19, includes, in part: The resident has potential for impairment to skin integrity r/t (related to) limited mobility, incontinence with a goal that the resident will remain free of new skin impairment through the review date. Interventions include, in part: Ensure that heels are elevated while resident is lying in bed, use offloading boots .encourage/assist with turning and repositioning every 2-3 hours . On 2/1/19, the facility identified that R30 had an unstageable PI to right heel measuring 4.0 x 5.0 cm (centimeter). In Progress Note, dated 2/1/19, it states, in part: .Resident has decrease in nutritional intake when res returned home from hospital .Offloading boots to bilateral feet, repositioning q2 (every 2) hours, skin prep to heels, prostat, offloading with pillows up until 1/29, then offloading boots to feet, repositioning q2hours, skin prep to heels .On 1/19 res c/o (complained of) pain to heels and it was noted that heels were red. Boots and skin prep were implemented at this time . (Please note, R30 was care planned to have heels elevated using offloading boots since 12/12/17, so this is not a new intervention. Also, current observation, on 4/7/19, of offloading boots not in place.) On 4/7/19 at 8:55 AM, Surveyor interviewed R30 who said there was an open area on one's right heel. R30 was observed wearing tennis shoes bilateral. Surveyor observed R30 has Primatech AiroDyne air mattress, which was set at 325 pounds (should be set for resident's weight which is 106.8#). On 4/7/19 at 2:57 PM, Surveyor observed R30 with feet in tennis shoes resting with heels on bed. Surveyor observed blue boots on the bed beside resident, not on feet. R30 should have them on, but staff didn't put them on. Surveyor also observed air mattress still set at 325 pounds. On 4/8/19 at 8:52 AM, Surveyor observed R30 lying in bed with blue boots on. Surveyor observed air mattress was still set at 325 pounds. On 4/8/19 at 9:02 AM, Surveyor observed RN C (Registered Nurse) perform dressing change to right heel. RN C indicated that area is unstageable and in-house acquired, with approximately 95% to the wound bed. Dressing includes cleaning and applying Santyl and foam dressing daily. Surveyor asked RN C if R30 should be lying in bed with tennis shoes on. RN C indicated it was incorrect for R30 to have shoes on in bed; R30 should have the offloading boots on when in bed. Surveyor had RN C observe the knob that controls the mattress based on weight. RN C stated it was set at 325 pounds. RN C stated it should not be set that high, it should be set on R30's weight, which was not 325 pounds. RN C will go check R30's weight and then adjust it. On 4/8/19 at 4:01 PM, Surveyor interviewed DON B (Director of Nursing) about Surveyor's observations. DON B indicated when R30 is in bed, one should have offloading boots on and air mattress should be set for R30's weight, not 325 pounds. R30 developed avoidable PI to right heel. R30 was identified as at risk for PI development and interventions were put into place; however, current observations of non-compliance of not wearing offloading boots in bed and incorrect air mattress usage were noted.

Based on interview and record review, the facility did not provide timely basic life support; including CPR (Cardiopulmonary Resuscitation), for 1 of 9 residents (R1) reviewed, in accordance with the resident's directives. On [DATE], upon admission to the facility, R1 designated that they would like CPR if R1's heart stopped beating or R1 would stop breathing. On [DATE], R1 was found pulseless and not breathing. Nursing staff did not initiate CPR despite R1's directives to be provided CPR in accordance with the wishes until approximately 50 minutes after R1 was found pulseless and not breathing. The facility's failure to ensure R1 received basic life support, including CPR, in accordance with their wishes, per R1's signed CPR Preference form and facility policy, created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the IJ finding on [DATE] at 1:30 PM. On [DATE], the facility recognized the deficient practice by the facility nursing staff and took steps to correct the deficient practice and ensure compliance at the time of the complaint survey. Based upon this determination, the IJ was removed and corrected on [DATE]. This is evidenced by: Facility policy entitled 'CPR- Cardiopulmonary Resuscitation,' dated [DATE], states, in part: Nursing staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: A valid Do Not Resuscitate (DNR) order is in place. Resident presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition) are present. Initiating CPR could cause injury or peril to the rescuer. CPR certified staff will be available at all times .The objective of the CPR guideline is to provide basic life support based (sic) until emergency medical services arrives, consistent with the resident Advance Directives, in the absence of an Advance Directive or DNR order and if the resident does not show signs of clinical death. Prompt initiation of CPR is essential as brain death begins four to six minutes following [MEDICAL CONDITION] if CPR is not initiated within that time . If no DNR order/Advance Directive exists or if Advance Directive does not indicate Do Not Resuscitate, begin resuscitation efforts . Example 1 R1 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. R1's Significant Change Minimum Data Set (MDS), dated [DATE], indicates R1 has a BIMS (Brief Interview of Mental Status) of 10 out of 15, which indicated moderate cognitive impairment. R1's chart indicates that R1 is their own person, no evidence of activation or incapacitation. R1's CPR form, dated [DATE], states, in part: I (R1's Name) understand that a FULL CODE STATUS means that if my heart stops beating or if I stop breathing, Cardiopulmonary Resuscitation (attempt to restart the heart and/or breathing which may include artificial airways and mechanical ventilator) will be used. I understand that I may revoke this decision at any time. I give permission to share this information with the necessary healthcare providers, doctors, nurses or healthcare personnel to implement this directive. I hereby request a FULL CODE order to be obtained from my physician. This form was initialed by R1 on [DATE]. R1's Hospital Discharge Summary, dated [DATE], states, in part: Code status at Discharge: Full Code. R1's care plan, dated [DATE], states, in part: Focus: Resident has elected Full Code status. Intervention: Nursing staff will provide CPR. [DATE] R1 elected and was signed onto Hospice. [DATE] a Telephone Order was written for a DNR. (Please note there is no indication in R1's chart that R1 elected/wished to be a DNR.) R1's (MONTH) (YEAR) Order Summary Report, signed by the physician on [DATE], states, in part: DNR and Full Code. R1's Progress Note, dated [DATE] at 11:00 PM, signed by DON B, states: Patient noted without pulse and respirations. Hospice notified. Code status noted and chest compressions started, AED (Automated External Defibrillator) applied and 911 called. EMS (Emergency Medical Service) and Police arrived on scene to assist. Police Report, dated [DATE], showed emergency services was dispatched at 10:57 PM on [DATE]. On [DATE] at 10:20 AM, Surveyor interviewed DON B regarding [DATE] situation with R1. DON B indicated, at approximately 9 PM, R1 was having discomfort and DON B gave R1 medication per R1's Medication Administration Record [REDACTED]. DON B indicated, at approximately 10PM, DON B found R1 pulseless and non-breathing. DON B indicated, based on previous Hospice discussions, they thought R1 was a DNR. DON B indicated they contacted Hospice at this time and it wasn't until approximately 45 to 50 minutes later they noticed R1 had a signed Full Code and called a code at that time. DON B indicated they were doing a chart review on R1 when they noted R1 was a Full Code. DON B indicated they went down to room, AED grabbed and backboard placed, CPR initiated and 911 called. DON B indicated a police officer assisted with CPR upon their arrival. DON B indicated that Hospice Social Worker indicated to DON B that R1's DNR order was invalid. DON B indicated that nothing was signed by R1 indicating they wanted to be a DNR. On [DATE] at 11:40 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) regarding R1's death. LPN C indicated to Surveyor that they arrived to the facility around 10:15 PM and that DON B was the Floor Nurse for R1. DON B gave LPN C report indicating that R1 received pain medication around 9 PM and was last checked at 10 PM, when R1 was found pulseless and non-breathing. LPN C indicated Hospice was contacted at that time and would be out. LPN C indicated, about an hour later, they were approached due to DON B calling a code on R1 and LPN C went to R1's room with the AED. LPN C indicated that DON B started compressions and was on the phone with 911 and rescue breathing was provided via Ambu Bag (bag valve mask). LPN C indicated paramedics took over once they arrived. LPN C indicated that Hospice agency was unsure of R1's code status and was to call back. LPN C indicated they would look under the Advance Directive tab in the chart to find a code status. On [DATE], Surveyor was conducting chart review and noted that R1's Electronic Health Record states, in part: Code status: DNR) Full Code. (Photographic evidence of this was provided to Surveyor by DON B on [DATE].) The facility's failure to ensure R1 received CPR, following their wishes, as stated on the CPR Preference form, signed [DATE], created a situation of IJ on [DATE] when R1 was found pulseless and not breathing and CPR was not provided to R1 immediately by nursing staff. The facility recognized the deficient practice and took the following corrective steps to ensure that deficient practice does not occur again: (,[DATE]-[DATE]) 1) The facility conducted an in-house chart audit of all patients signed code status. 34 residents are noted to be DNR with proper documentation in place and 20 were noted as Full Code. 2) CPR certification audits of all RNs (Registered Nurse) and LPNs on staff. CPR education was provided. 3) Crash cart audits completed with supplies in place. 4) Regional Director of Clinical Services in-serviced the DON on the following: - Identification of code status: Full Code vs. DNR - Admission Advance Directive requirements - Medical Emergency protocol - CPR - Notification of Changes in Condition 5) DON/Designee is responsible to educate nursing staff on the following measures: - Notification of Change in Condition policy - Admission Advance Directive requirements -Medical Emergency protocol - CPR 6) Integrated into staff orientation: - Notification of Change in Condition policy - Admission Advance Directive requirements - Medical Emergency protocol - CPR 7) Integrated into Staff annual training: - Notification of Change in Condition policy - Admission Advance Directive requirements - Medical Emergency Protocol - CPR 8) DON/Designee to complete competency and/or skill check validation through: - Conduct mock code blue drills every shift starting [DATE] x (times) 24 hours, daily x 1 day, and quarterly moving forward. - Validation of CPR certification to be completed upon employment and annually upon license verification; to be completed by HR (Human Resources) or designee. 9) DON or Designee is responsible to complete QA (Quality Assurance) tool on: - Change of Condition - daily x 1 week, 3x/week x 3 weeks, and weekly x 1 month. Change of Conditions to be discussed during management clinical review - Code status audits of new admits daily x 1 week, 3x/week x 3 weeks, and weekly x 1 month. Code status then reviewed with quarterly care plan review and at the time of Hospice service admission. - Summation of audit tool presented quarterly to QAPI (Quality Assurance and Performance Improvement) Committee.

Based on observation, interview and recordreview, the facility did not ensure that each resident received adequate supervision and assistance to prevent accidents by identifying, evaluating and implementing interventions for 2 of 4 residents (R7 and R10) reviewed for falls and smoking, out of a total sample of 13. The facility did not get R10 the type of wheelchair that Occupational Therapy had assessed him as needing. Subsequently, R10 fell from his wheelchair and fractured his nose. The facility did not complete a thorough fall investigation when R10 fell and fractured his nose; additionally, R10's call light was observed to not be placed within his reach. R7 was assessed by the facility to be a potentially unsafe smoker on two separate occasions and the facility did not ensure she stayed safe. R7 acquired a burn while smoking a cigarette. R7 was known to staff to not follow facility procedures for smoking in designated areas, known to have [MEDICAL CONDITION] her clothing, and to not keep smoking materials secured by staff and the facility did not take action to ensure she followed the facility policy and thus keep her safe. Example 1 The facility's Fall Evaluation Safety Guideline policy, dated 11/28/17, includes, in part: . The intent of this guideline is the (sic) ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident . Post Fall Action: Team Huddle-a post fall gathering to review a fall. Post Fall Investigation (Review recent medication, vital signs, toileting schedule, changes in mood or behavior, sign/symptoms of infection, increased assistance with ADL's (Activity of Daily Living, environment, etc.). Root Cause Analysis-determine casual factors of fall. Evaluate resident and re-evaluate risk. Evaluate effectiveness of interventions. R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. attack, dementia with behaviors and history of falls. R10's annual MDS (Minimum Data Set) Assessment, dated 7/8/18, notes a BIMS (Brief Interview for Mental Status) Score of 7 out of 15, indicating severe cognitive impairment. R10 is non-ambulatory and is transferred with a Hoyer lift. R10's Fall Risk Evaluation, dated 5/21/18, notes a score of 43, which indicates that R10 is at high risk for falls (scale notes score of 16 or higher equals high risk to fall). R10's Comprehensive Care Plan includes, in part: Focus - (R10) is at risk for fall related to immobility, incontinence, vision and communication deficit, cognitive impaired, uses of diuretics and [MEDICAL CONDITION] drugs, history of falls, date initiated 5/14/14, Goal - will not sustain serious injury through review date 10/14/18. Interventions - Anticipate and meet resident's needs, date initiated 5/14/14. Assess risk for falls . Assist resident to activity or into bed between meals, dated 5/14/14. Be sure call light is within reach and encourage to use it for assistance as needed. Needs prompt response to all requests for assistance, dated 5/14/14. Educate/remind to request assistance prior to transfer, dated 5/14/14. Follow facility fall protocol, dated 5/14/14 . OT (Occupational Therapy) eval (evaluation) for w/c positioning and size, date initiated 5/21/18 . Lay resident down in bed between meals, date initiated 6/11/18 . On 5/21/18 at 9:00 AM, R10 had a witnessed fall from his w/c (wheelchair) to the floor in his room. R10's Fall Event Report notes that R10 was found yelling, while grabbing the footboard of his bed, while in his room after breakfast. Witness then tried to help (R10) get back into w/c, but (R10) slipped from w/c and onto the floor landing on left side. This fall resulted in a skin tear to R10's left hand. A written witness statement was completed for this fall. On 5/21/18, a new intervention was added to R10's care plan to prevent further falls, was to have OT evaluate and treat R10 for fall from w/c. Under Possible Causative Factors, call bell not in reach was checked. On 5/21/18, the facility completed an Interdisciplinary Review for R10's fall. A Fishbone Diagram (cause and effect diagram) on R10's fall has handwritten notes including: mobility device, position, foot pedals, questions for behaviors and OT eval for w/c as interventions. OT saw R10 from 5/23/18-6/8/18 for the fall from his w/c, which occurred on 5/21/18. On 5/23/18, OT Notes, includes, in part: (R10) is a long term resident of this facility and has a history of falling from his w/c. (R10) has been previously assessed by this department with recommendations made for purchase of alternative w/c to prevent further falls (12/16). (R10) is non-ambulatory, transferred via EZ Stand. On 6/5/18, OT wrote a note to the (former) Nursing Home Administrator that R10 was referred to OT due to a fall from his w/c. This issue has been addressed in the past and a new w/c was requested for him (R10). This note also states in part that R10 is unsafe in the w/c that we have in stock, due to his unique body type. (R10) is very long waisted and heavy from the waist up making him too heavy in all w/cs we have tried . (OT) . suggesting that we purchase the attached w/c for this patient to ensure comfort and safety going forward. Attachment has 3 different w/cs pictured. On 6/7/18, OT Notes, includes, in part: (R10) continues to have functional deficits including limited strength, limited trunk stability . poor pt. (patient) cooperation, limited cognitive abilities prevent the patient from achieving all established goal. Precautions: low endurance-needs frequent rests . On 6/9/18, at about 11:45 AM, Nurses Notes show that R10 was found face down on the floor in the dining room. The facility called 911 and transported R10 to the emergency room for evaluation. R10's CT scan (x-ray) in the emergency room on 6/9/18 showed a non-displaced minimally comminuted bilateral nasal bone fracture. The facility's Fall Packet for R10, notes, in part, that R10 had a witnessed fall on 6/9/18. -The checklist for the Fall Packet includes a space for Statement, this line is unchecked, and under Witness Statement, manager diet is written, Name is left blank and there are no witness statements included with the fall packet. -Fall Event Notes include R10 had a witnessed fall from his w/c to the floor, in the dining room while eating lunch, slid out of chair. R10 was not attended by an employee and was found on the floor face down. -Preventative measures in place (check list): Call light - encouraged and taught use of, Pain medication: Assessed for need, Toileting plan, Call light: Kept within reach, Non-skid shoes -Severity of Injury Notes: Minor injury abrasion, face and both hands, which is inaccurate as R10 suffered a fracture of his nose during this fall. -Possible Causative Factors (check list): Other - Resident fell forward from the chair. R10's fall investigation was incomplete, for example: there is no documentation or indication of where in the dining room R10 fell , who witnessed the fall, what staff were in the dining room at the time of the fall, what type of w/c R10 was using, what devices, if any, were placed in his w/c, what R10 was doing at the time of the fall, when was the last time that staff had contact with R10 before the fall and there were no witness statements obtained. On 6/11/18, the facility completed an Interdisciplinary Review for R10's fall of 6/9/18. A Fishbone Diagram on R10's fall has handwritten notes, including: w/c right fit, rent until purchase, and lay down between meals as interventions. On 9/17/18 at 2:40 PM, Surveyor interviewed DON B about R10's fall on 6/9/18, reviewing the R10's fall packet. Surveyor noted that the facility determined that this was a witnessed fall. Surveyor asked if the facility had obtained witness statements from R10's fall on 6/9/18. DON B indicated that there were no witness statements and there should have been. DON B stated that CNA H was present at the fall and would have her talk to Surveyor. No further documentation was provided. On 9/17/18 at 3:30 PM, Surveyor interviewed RN E about R10's fall on 6/9/18. RN E stated that CNA H came to get her, because R10 had fallen; RN E stated that she did not witness the fall. RN E stated that she immediately went into the dining room and assessed R10, instructed staff to call 911 and provided first aid to R10. Surveyor asked RN E if she completed the fall investigation for R10. RN E stated no, that the primary nurse should have completed all the details that day. On 9/17/18 at 4:30 PM, Surveyor observed R10 in bed with 1/4 side rails raised on each side of his upper bed and a trapeze above his bed. Surveyor observed that R10's call light was out of his view, hanging on the outside of his side rail, hanging below the frame of the bed. Surveyor asked R10 if he could reach his call light, R10 stated no. Surveyor saw CNA J in the hall and asked CNA J if R10's call light was positioned so that he could reach it. CNA J went into R10's room and asked R10 if he could reach his call light, R10 said no, R10 stated to hang the call light on his trapeze so he could reach it easier which CNA J did. R10's call light should have been placed in R10's reach, and was not. On 9/17/18 at 5:30 PM Surveyor interviewed CNA H, who stated that on 6/9/18 someone came down the hall and said that R10 was on the floor, he was on his stomach with his arm underneath him and a gash on his face, his glasses were bent. CNA H stated that there were other residents in the dining room, CNA H did not see nursing staff in the dining room, and there were kitchen staff in the dining room. CNA H stated that the nurse came in and assessed R10, instructing staff not to move him and to call 911, ice was applied to R10's head. On 9/24/18, Surveyor called DON B asking when R10 received a new w/c as was recommended by OT on 6/5/18 and what interventions the facility put in place for R10's safety after the fall on 5/21/18 besides the OT evaluation. DON B stated that she would provide that information as soon as possible. No further information was received. On 9/25/18 Surveyor received additional information from the facility indicating the facility rented a new w/c for R10 on 6/12/18. R10 had 2 falls within 20 days, the second fall resulting in a fracture to his nose. The second fall was not thoroughly investigated. R10 had a recommendation from OT to have a larger w/c purchased due to R10's body type. The facility failed to immediately act on this recommendation and R10 suffered a fall with a nasal fracture. During survey, R10 was observed in bed with his call light out of his reach. Example 2 The facility Smoking Policy, dated 11/28/18, states, in part: Residents who want to smoke are evaluated and assessed for smoking safety . Each resident will be informed prior to, or upon admission. Residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Procedure: #5. Residents . will be informed of the need to comply with the smoking policy, as well as any precautionary measure as determined necessary following evaluation. #6. Interventions for safe smoking, such as a smoking apron, will be included in the resident individualized smoking care plan. #7. Any resident with restrictions will have direct supervision during smoking unless contraindicated within the facility smoking policy. #8. Residents, who do not comply with the smoking policy and do not adhere to their safety interventions, will be addressed according to policy and resident bill of rights. #9. Smoking materials including lighters and cigarettes will be securely stored. R7 was admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) for her MDS (Minimum Data Set) was a 15, meaning she was cognitively intact on her Admission MDS, dated 5/30/18, Significant Change MDS on 7/16/18, and Quarterly MDS, dated [DATE]. Her Admission Evaluation included Skin Impairments that include only an incision to groin area to her right thigh. The facility Smoking Risk Observation, dated 5/23/18, states that she scored a 0, indicating she was a safe smoker. The facility Smoking Risk Observation, dated 5/26/18, states that she scored a 2, indicating she was a potentially unsafe smoker. It has marked that she smokes in unauthorized areas and smokes cigarette butts from ash trays. It also did not have marked yes or no to whether she begs or steals smoking materials from others. The facility Smoking Risk Observation, dated 7/2/18, states that she scored a 1, indicating she was a potentially unsafe smoker. It has marked that she smokes in unauthorized areas. R7's Progress Note, on 8/13/18 at 10:38 AM, states: Resident is a smoker, Resident smokes cigarettes. Resident carries matches or lighter. Resident smokes less than hourly. Resident is careless with smoking materials (Drops cigarette butts or matches on the floor, furniture, self or others;[MEDICAL CONDITION] tips; Smokes near oxygen). Resident begs or steals smoking materials from others. Resident Risk Score is 4.0, Unsafe Smoker - follow facility policy. It does not specifically include why or how R7 was burned while smoking on this date. The facility Wound Assessment Details report, dated 8/14/18, states: R7's wound was a burn to her front right thigh with stage full thickness measuring 1.5 by 1.5 by 0.1 cm (centimeter). It shows a picture with a burn area and two scars that look like [MEDICAL CONDITION]- circular and the same size as the open burn area. In the Plan/Comments area of the assessment it states: 8/14/18 .Burns from res (resident) (R7) smoking cigarettes. Smoking eval (evaluation) has been completed with res needing to be a supervised smoker. NP (Nurse Practioner) updated. Treatment orders in place. (sic) There was no evidence that the NP was notified the day that the burn occurred on 8/13/18 when documented at 10:38 AM. The facility Smoking Risk Observation, dated 9/7/18, states that she scored a 0, indicating she was a safe smoker. Surveyor initially reviewed R7's care plan in the electronic record at approximately 10:45 AM, prior to attempting to interview R7. The electronic record included in her Care Plan for Smoking, created 6/13/18, stating: Resident can smoke unsupervised. It also did not include that she had been burned while smoking. When the facility gave a printed copy of R7's care plan later that afternoon it included: 6/13/18 - Resident's smoking materials to be secured by facility staff 6/13/18 - Notify Charge Nurse immediately if it is suspected resident has violated facility smoking policy 8/13/18 - Observe clothing and skin for signs of cigarette burns. 8/13/18 - The resident requires supervision while smoking. (Note that this is different from what was viewed by Surveyor earlier in the day.) On 9/17/18 at 2:25 PM, Surveyor interviewed CNA D (Certified Nursing Assistant) who was working on R7's Unit. Surveyor asked if R7 smokes and CNA D stated she goes out various times a day and agreed she smokes at least hourly. CNA D looked at his Care Sheet, Surveyor viewed it as well, and it did not include that R7 smokes or any information regarding her smoking. Surveyor asked if she had ever been burned while she was smoking, he stated that he did not believe she had. CNA D explained that she goes out a lot and she'll be so zonked at 3:00 AM that I don't know how she stays sitting up. CNA D did not know how she obtained her smoking materials or where she kept them. CNA D explained that she goes out with family and they visit her, so that could be where she gets the smoking materials. On 9/17/18 at 2:30 PM, Surveyor interviewed RN E (Registered Nurse). Surveyor aske RN E if R7 smokes and she explained that she herself did not smoke and did not know if R7 smoked. RN G was also at the Nurses' Station and Surveyor asked her if R7 smoked. RN G stated that R7 smokes independently. Surveyor asked if R7 had ever been injured or burned while smoking. RN G stated R7 had not been injured or hurt smoking. RN G explained that residents are not supposed to keep smoking materials in their rooms. RN E had opened an unlocked drawer with 8 packs of cigarettes with various brands and none were labeled as RN E looked at each box for indication of which resident they belonged to. LPN F (Licensed Practical Nurse) was also sitting at the Nurses' Station and explained that R7 won't hand over her smoking materials and keeps them in her room somewhere. On 9/17/18 at 3:05 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated that R7 was burned by her cigarette and self-reported it to staff on 8/13/18. DON B stated it was her understanding that R7 had dozed off not paying attention to her cigarette on 8/13/18. DON B stated they had done education to R7 regarding her smoking and changed her to be a supervised smoker and it was her expectation that staff keep R7 alert while she smoked. DON B stated it was not investigated as it was not known how R7 had gotten burned. DON B stated R7 had received [MEDICATION NAME], and since that medication had been discontinued completely as of 9/7/18, she had been reassessed to be an independent smoker as of 9/7/18. At 4:15 PM, Surveyor asked DON B if any new interventions had been added after R7's smoking evaluations, on 5/26/18 or 7/2/18, when R7 had been assessed as being a Potentially Unsafe Smoker. DON B stated that no new interventions had been put in place and, that in her opinion, R7 had not ever needed to have a smoking apron to keep her safe from burns. Surveyor also asked if the other 2 scars on R7's right thigh [MEDICAL CONDITION] occurred at the facility. DON B was not aware of the scars and Surveyor requested any further information regarding the scars. The Initial Skin Assessment was provided with no evidence of the scars being present on admission and no other information was given about how they occurred. On 9/17/18 at 4:30 PM, Surveyor interviewed CNA D who stated he had not known that R7 had ever needed assistance/supervision to smoke. At 4:50 PM, Surveyor interviewed RN G who stated she also did not know that R7 had ever needed assistance or supervision to smoke. She also stated that she had seen a couple of burn holes in R7's clothing, but could not remember when she had seen them.

Based on interview and record review the facility did not ensure Residents are free of significant mediation errors for 3 of 6 total sampled residents (Resident 1, 2 and 3). Resident 1 had an order for [REDACTED]. On 5/25/16 Resident 3 was given the wrong narcotic medication; [MEDICATION NAME] SR 15 MG (milligrams) was given instead of prescribed [MEDICATION NAME] SR MG. The facility did not place preventative measures to ensure that a like error did not re-occur. Resident 2 did not receive physician ordered [MEDICATION NAME] 2 mg (milligrams) for 3 consecutive days upon admit. The facility did not place preventative measures to ensure that a like error did not re-occur. This is evidenced by: Example 1 Resident 1 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Telephone order dated 10/03 (no year or time) states in part: [MEDICATION NAME] ER 30mg by mouth every 12 hours. 10/03/2016 at 9:36PM, progress note states in part: writer did phone DOC (doctor) regarding no script for new medication orders of AM. DOC was not able to fax pharmacy the needed scripts. (Nurse Practitioner name) did phone back and was made aware of scripts and (pharmacy name) did fax the needed codes to retrieve medications from contingency. (Nurse Practitioner name) was aware of the lateness of new medications to be given. Pharmacy narcotic sign out form on 10/03/2016 (no time) states in part: Medication: 30mg SR (sustained release) quantity: 3 Nurse: (initials of RN C and RN D). Occurrence report dated 10/03/2016 at 10:15PM states in part: Type: Medication Error, Reported by: RN D .ambulance called on 10/3/2016 11pm and used on 10/3/2016 11:24pm Immediate actions taken: non-emergency transfer, transfer to hospital, on call doctor gave order to administer [MEDICATION NAME] 0.4mg dose subQ .Nurses note of what happened written by (RN D) entered by (RN D) on 10/4/2016 12:21AM. Writer gave medication late as the DOC was not able to fax script for new orders from AM, (nurse practitioner) did fax pharmacy and the codes were faxed to the facility. MSO4 ([MEDICATION NAME]) was given at 10:30pm. Write gave 3 tabs -90mg- MSO4 30 mg tablet SR. went back and noted all meds were indeed swallowed. See PCC (point click care) for further information Medication as ordered MSO4 30mg SR (by mouth) 5PM Medication as administered MSO4 90mg (by mouth) 10:15PM .10/3/2016 10:15PM effect on resident none at the time with SR dose. Telephone order: (no date) at 10:30PM states: may give 1 dose [MEDICATION NAME] 0.4mg subcutaneous sustained release now. May send to ER if approved by family. If family not sending, not approved. Phone DOC for further orders. Family approved sending to ER. 10/03/2016 at 11:35pm, Progress note states in part: Authorization codes received from (pharmacy) to obtain newly ordered from this AM to pull narcotics from contingency. Writer gave 90mg MSO4 ([MEDICATION NAME]) SR (by mouth) at 2215 (10:15pm). DOC (physician name) aware and gave orders to give administer [MEDICATION NAME] 0.4mg sustained release subcutaneous right arm at 10:30PM with order to send to ER (emergency room ) with family approval. Family approved sending to ER at 10:30PM for evaluation. (Ambulance service) transport called and left facility with patient at 11:24PM. Resident was alert and verbal as leaving. Please note there is no evidence of an assessment for Resident 1 between the time the inaccurate dose of medication was given to Resident 1 and the time EMS arrives at the facility. EMS report for 10/03/2016 issued on: 10/04/8:23am for Resident 1 states in part: Chief complaint: Overdose-[MEDICATION NAME] Call information: Dispatch Urgency: EMERGENCY Mode to scene: Lights and Sirens mode from scene: lights and sirens Dispatch reason: Poisoning or Drug ingestion .Pertinent Findings .Primary signs and symptoms: Poisoning or Drug ingestion Other signs and symptoms: Altered LOC or unresponsive .patient was found lying in bed alert to self. Nurse confirms this is baseline .oxygen noted to be low she was placed on 2lpm (liters per minute) via cannula .once in the ambulance .at 2328 {11:28PM) the patient began having a decrease in level of consciousness and a slowing respiratory rate. [MEDICATION NAME] was drawn up. At 2330 (11:30pm) the patients respiratory rate noted to be 5-6/min. she was given 0.5mg [MEDICATION NAME] via (intravenous) without complication . Time: 23:28 (11:28pm), 10/3/16 event: leave scene time . 11:30PM event: vital sign assessment SBP/DBP: 88/35 Pulse 60 Resp: 4 .Time: 11:40PM 10/3/16 event: at destination . Emergency Department (ED) REPORT for Resident 1 dated 10/3/2016 at 11:44pm states in part: presents to the ED via EMS with chief complaint of a [MEDICATION NAME] overdose .she was supposed to receive 30mg extended release [MEDICATION NAME] at 2200 (10PM) hours today, but was mistakenly given 90mg extended release [MEDICATION NAME]. She was given 0.4mg [MEDICATION NAME] at her living facility and another 0.5mg [MEDICATION NAME] by EMS due to bradypnea (low respirations). Patient did also receive 0.25mg [MEDICATION NAME] today. Of note, she is not normally on oxygen Final diagnostic impressions: (age) brought to the emergency from her nursing facility when she was found hypoxic (depravation of adequate oxygen) and apneic (suspension of/without breathing) after receiving an overdose of extended release [MEDICATION NAME] .agreed to admit . 10/04/2016 at 1:00AM, progress note states in part: Hospice nurse called back at this time. Patient being admitted to (Hospital Name) no admitting [DIAGNOSES REDACTED]. 10/04/2016 at 1:33AM Hospitalist admission note states in part: .She became lethargic and hypotensive and required [MEDICATION NAME] 0.4 x1 at facility and repeat 0.5mg dose by EMS. Unfortunately no one is willing to take her back until she has been observed at the hospital .Assessment/Plan: .Presented with iatrogenic narcotic overdose .Iatrogenic narcotic overdose in setting of chronic pain (due to) spinal stenosis, [MEDICAL CONDITION], and hip pain. Hold all narcotics/benzo's/[MEDICATION NAME]. Suspect she will wake up in the next few hours and will likely be able to be (discharged ) back to her facility later today . 10/04/2016 at 10:33AM Hospitalist Discharge Summary states in part: .Principal Diagnosis: [REDACTED]. On 10/13/2016 at 12:27pm Surveyor interviewed Certified Nursing Assistant E regarding Resident 1. CNA E indicated Resident 1's a little spacey and is coming back to normal since hospitalization . CNA E indicated since Resident 1 was back from the Hospital her talking did decrease but would increase as the day went on. On 10/13/2016 at 12:31PM Surveyor interviewed Registered Nurse (RN) F regarding Resident 1. RN F indicated she works with Resident 1 often. RN F indicated Resident 1 is currently where she was prior to hospitalization , but that Resident 1 was drowsy upon return. On 10/13/2016 at 1:20PM Surveyor Interviewed DON B regarding 10/03/2016 medication error. DON B indicated that two nurses have to pull from contingency and that RN C and RN D pulled together. RN C and RN D pulled 3 [MEDICATION NAME] ER 30mg tablets and RN C gave the 3 tablets of 30mg ER [MEDICATION NAME]. DON B indicated that a medication error is a change of condition. DON B stated yes indicating the need for a Registered Nurse assessment. DON B indicated to Surveyor that she would expect vitals, head to toe assessment or an assessment to be done between the time the medication error occurred and emergency medical service arrival. DON B indicated that its pharmacy policy to pull 24 hours' worth of medications with one pharmacy code. DON B stated No, its verbal indicating there is no evidence of education after medication error occurred to nursing staff or nursing staff involved. On 10/03/2016 at 2:32pm Surveyor interviewed Registered Nurse (RN) C regarding 10/03/2016 medication error and assessment. RN C indicated to Surveyor that she worked that day and remembered she made an error. RN C indicated her and RN D went in to pull out medication with code and they pulled 30mg tablets of [MEDICATION NAME], pulled 3 of them. RN C indicated she went to her cart and looked at medex (medication administration record) and that she was thinking it was three tablets of 10 mg of [MEDICATION NAME]. RN C indicated she went down to check and check that the pills weren't pocketed. RN C indicated that she did not chart a head to toe assessment and that an assessment should have been charted. RN C sated I forgot what I grabbed after doing all those codes, I did do it, I made the error. RN C stated yes indicated she should have checked the 5 rights (right resident, drug, dose, time and route). On 5/25/16 Resident 3 was given the wrong narcotic medication; [MEDICATION NAME] SR 15 MG (milligrams) was given instead of prescribed [MEDICATION NAME] SR MG. The facility did not implement preventative measures to ensure that a like error did not re-occur. Example 2 Resident 3 was admitted to the facility with [DIAGNOSES REDACTED]. Resident 3's physician orders [REDACTED]. Review of the facility's Medication Error Details Report for Resident 3 notes that on 5/25/16 (at 4:00 PM), RN (Registered Nurse) G, inadvertently gave Resident 3 another residents medication, [MEDICATION NAME] SR 15 MG was given instead of Resident 3's prescribed [MEDICATION NAME] SR 15 MG. This error was not discovered until 10:00 PM when the nurses completed the end of shift narcotic count. The Medication Error Details Report document, which is not part of Resident 3's medical record, also notes that the physician was notified at 11:20 PM. It is important to note that there no documentation in Resident 3's medical record that he was assessed or monitored for any potential adverse effects from receiving the wrong narcotic medication (such as vital signs, pain assessment). On 10/13/16 at 12:30 PM Surveyor telephoned RN G asking about Resident 3 receiving [MEDICATION NAME] SR 15 MG instead of prescribed [MEDICATION NAME] SR 15 MG on 5/25/16 at 4:00 PM. RN G stated that she had given Resident 3 the wrong medication because the resident's medication cards were right next to each other in the medication drawer. RN G stated that she did not discover the error until she was completing narcotic count at the end of the shift. Surveyor asked if RN G had received education from the facility regarding the prevention of a future error of this kind, RN G stated she had not, but that she should have checked for the 5 rights of medication administration, right resident, medication, dose, time and route and did not check for the 5 rights before administering the wrong medication to Resident 3. On 10/13/16 at 2:30 PM Surveyor interviewed DON B asking if she had provided education to staff about Resident 3's medication error on 5/25/16, DON B indicated she thought this was discussed with RN G but did not have evidence of education being provided and that there should have been. Example 3 Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Medication Error Report for Resident 2 notes that Resident 2 was admitted to the facility on [DATE] with a valid script in hand for [MEDICATION NAME] 2MG dose scheduled to be administered at HS (Hours of Sleep). Resident 2 did not receive his dose of [MEDICATION NAME] on 9/12/16 and 9/13/16. On 9/14/16 during the evening medication pass, Licensed Practical Nurse (LPN) H reported that Resident 2 had not received his [MEDICATION NAME] and that they did not have the medication on hand in the facility. The pharmacy was notified on 9/14/16 at 9:45PM and the facility was notified the medication was not sent due to an invalid script. ADON (Assistant Director of Nursing) I was notified and called the pharmacy at 11:15PM and spoke to the pharmacy technician to have the [MEDICATION NAME] sent to the facility stat. Resident 2 was notified of the situation and asked for the medication to be administered when it arrived to the facility. The [MEDICATION NAME] was sent to the facility stat and it arrived at the facility at 9/15/16 at 3:00AM. Per the Progress Notes Resident 2 received his [MEDICATION NAME] on 9/15/16 at 3:00AM. The Medication Error Report notes in conclusion the IDT (interdisciplinary team) reviewed the medication error. The IDT determined that multiple issues caused the error. The nursing staff did not fax the prescription to pharmacy and the nursing staff did not give the medication and did not follow up for 2 days. The pharmacy had the order for the medication and did not communicate that the prescription was not faxed and that they would not be sending the medication. The IDT conclusion is the DON (Director of Nursing) will be providing disciplinary action with nursing staff involved and they will be following up with pharmacy to resolve the issue on their end. On 10/13/16 at 9:55AM Surveyor interviewed ADON I and DON B. ADON I noted that with medication errors they will determine the cause after they complete an investigation. ADON I felt her conclusion was that this was a pharmacy error and no discipline was needed or given. DON B notes that she would expect that if no medication was sent that the staff would call that pharmacy to get a code for the contingency and if pharmacy refuses to release from the contingency medications to notify the doctor. DON B stated that the nurses followed what they should have done but that it should have been done on Day 1. The facility failed to recognize Resident 2 did not have his prescribed [MEDICATION NAME] in the facility and failed to notify the pharmacy that Resident 2 was missing his prescribed [MEDICATION NAME] thus Resident 2 missed 2 doses of prescribed [MEDICATION NAME].

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer for 4 of 9 residents (Residents 15, 5, 3, and 13). Resident 15 was admitted to the facility without a pressure ulcer (PU) and was identified to be at high risk for PU development. Resident 15 developed 2 avoidable Stage 3 pressure ulcers while in the facility. Resident 5's heels were not floated and were observed to have developed red and purple discoloration on both heels. Resident 3 was identified to be at risk for PU development. Resident 3 was identified by the facility as having incontinence associated [MEDICAL CONDITION] (IAD). The Hospice nurse identified the area as a Stage 2 PU however the facility continued to classify the area as IAD. Observation of Resident 3's coccyx revealed Resident 3 has a facility acquired unstageable pressure ulcer to his coccyx. The facility failed to identify Resident 3's impaired skin integrity as an unstageable PU. Resident 13 had large non blanchable areas to her buttocks. The facility did not ensure the areas were monitored for healing per her care plan. This is evidenced by the following: The Quick Reference Guide entitled Pressure Ulcer Prevention published by the National Pressure Ulcer Advisory Panel (NPUAP) in 2009 indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Ensure the heels are free of the surface of the bed. Using a pillow under the calves so the heels are elevated (i.e., floating) will accomplish reduction of pressure on heels. The facility's Skin Management Program with a revision date of 7/14 states in part; Purpose: To ensure that all residents who are admitted to the facility are assessed and evaluated per the skin program in order to determine appropriate measures to be taken by the facility staff, to prevent, reduce, and treat pressure ulcers (PU). Procedure 1; b. Daily skin checks by nursing assistants during the provision of care. c. Weekly skin checks by licensed staff. d. Weekly checks completed by nursing assistants and documented on shower sheets. 2; f. Skin condition and overall condition. g. Re-evaluation, assessment, and care planning. 3. a. Identify the resident at risk of developing PU's, the level and nature of risks. b. Identify the presence of PU's. d. The care process should include efforts to stabilize, reduce or remove underlying risk factors. f. Modify interventions as appropriate. 7. The facility should have a system/procedure to assure: assessments are timely and appropriate interventions are implemented, monitored, and revised as appropriate; and changes in condition are recognized, evaluated, reported to the practitioner, and addressed. On 9/17/15 at 10:45 AM, Surveyor interviewed Registered Nurse WCC (RN Wound Care Certified) E who is the facility wound care nurse, regarding the standard of practice the facility follows for wound care. RN E stated, I don't know. I think we have a policy. On 9/22/15 at 9:55 AM, Surveyor interviewed Registered Nurse Consultant (RN) U and Director of Nursing (DON) B regarding the standard of practice the facility follows for wound care. RN U indicated that it is the corporate policy to investigate any PU right away. RN U indicated that the RN should assess the resident's body on shower day and any skin breakdown should be reported to the nurse as soon as possible. Surveyor again asked RN U what standard of practice the facility follows for wound care. RN U indicated they follow the NPUAP guidelines. Example 1 area 1 Resident 15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 15's admission Braden assessment, dated 9/13/14 indicates Resident 15 scored a 9 indicating Resident 15 was at very high risk for PU development. The facility's Braden risk score indications are as follows: At Risk: 15 -18, Moderate Risk: 13-14, High Risk: 10-12, Very High Risk: 9 or below. The Braden assessment was again completed on 3/17/15 with a score of 13 moderate Risk, 7/22/15 with a score of 12 High Risk. Resident 15's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/3/15, indicates A Brief Interview for Mental Status (BIMS) could not be completed. The Staff Assessment for Mental Status indicated severe cognitive impairment. Section M0150 of the MDS indicates Resident 5 is at risk for developing a PU. Section M0210 Unhealed Pressure Ulcers Section indicated 0. G0110, Activities of Daily Living (ADL's) indicates Resident 15 requires 2 staff and extensive assistance for bed mobility and transfers. Resident 15's comprehensive care plan Potential for impairment to skin integrity of the r/t (related to) immobility, tube feedings, via GTube, bowel incontinence, hx (history) of fall, and abrasion to toes, dated 9/16/14, states in part, Apply barrier cream, Ensure heels are elevated, Identify/document potential causative factors and eliminate/resolve where possible, wear socks at all times except during cares, low air loss mattress. Resident 15's comprehensive care plan The resident has an actual ADL (Activities of Daily Living) self-care performance deficit r/t Dementia dated 9/12/14, states in part,7 # (Pound) weights to both ankles when up in chair- weights off when in bed. Resident 15's comprehensive care plan The resident has unstageable pressure ulcer to right lateral malleolus r/t immobility and severe flexure contracture dated 5/14/15, Interventions include: Turn/ reposition at least every two hours, More often as needed or as requested, position on left side when in bed. Prevalon boots when in bed. Nursing notes dated 5/9/15 1:37 PM, (Late Entry noted on documentation) state in part, Reported by CNA, prior to resident transferring into wheelchair, that resident had redness to R (Right) lateral ankle. Observed by writer and noted blanchable redness. Resident was then transferred into w/c (Wheel chair). On 5/13/15 without a time stamp, Nurse Practitioner (NP) Q gave a telephone order that includes, Clean R lateral ankle with NS (Normal Saline), apply Santyl, and 3x (Triple) Abx (Antibiotic) oint.(Ointment) to slough, cover with foam dressing daily. It should be noted that there is no documentation as to why the order for Santyl was requested from NP Q. Nursing notes dated 5/14/15 at 4:06 AM, states in part, Reposition side to side q (Every) 2 hours during the night, no s/s (Signs or Symptoms) of pain or discomfort. Nursing notes dated 5/14/15 at 1:11 PM, states in part, Prevalon boot was off right foot when writer went in room at 7:30 AM, placed back on foot. Dressing not in place. Treatment completed without incident. Wound bed dry and tan. Santyl placed on slough, triple antibiotic ointment to surrounding intact skin. Foam dressing applied. Resident was on left side while in bed today. Nursing notes dated 5/14/15 at10:38 PM, state in part, New orders received from Nurse Practitioner (NP) Q for pro stat once daily. Drsg. (Dressing) intact to R lateral ankle. Skin/Wound Notes dated 5/14/15 at 10:31 AM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring 1.2 x 1.7 x >0.1 cm (Centimeter). Base of wound is 100% covered in dry adherent yellow slough. Wound is oval, distinct rounded edges. No drainage noted. Peri-wound is red non blanchable. Res. (Resident) is immobile and has severe contractures to BLE (Bilateral Lower Extremities). Res. has restless legs which may have caused a friction to the area. Bilateral ankle weights are also applied while res. Is up in w/c. Res. Has 3 + [MEDICAL CONDITION] to RLE (Right Lower Extremity). Ankle wts were removed and res. (Resident) is tolerating this change. Skin/Wound Notes dated 5/20/15 at 12:54 PM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring1.0 x1.5 x>0.1cm. Base of wound is 100% covered in dry adherent tan/yellow slough. Wound is oval, distinct rounded edges. Scant serous drainage. Peri-wound is red and blanchable. Ankle wts continued to be d/c'd (Discontinued) and res, tolerating this change. Skin/Wound Notes dated 5/27/15 at 9:53 AM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring1.0 x1.0 x>0.1cm. Base of wound is 100% covered in moist yellow slough that is beginning to loosen. Wound is round, with distinct rounded edges. Scant serous drainage. Peri-wound is pink and blanchable. Ankle wts continued to be d/c'd and res, tolerating this change. Skin/Wound Notes dated 6/315 at 9:35 AM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring1.1 x 0.8 x >0.1cm. Slough is receding evenly around all edges of wound exposing pink granulation tissue. 70% adherent yellow slough remains to the center of the wound base. Wound is round, with distinct rounded edges. Small serous drainage. Peri-wound is pink and blanchable. Ankle wts continued to be d/c'd and res, tolerating this change. Skin/Wound Notes dated 6/10/15 at 12:45 PM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring1.0 x 0.8 x 0.1cm Slough is receding evenly around all edges of wound exposing pink granulation tissue. 25% yellow loose slough remains to center of wound base. Slough is loose enough to notice pink granular tissue underneath. Wound is round, with distinct rounded edges. Small serous drainage. Peri-wound is pink and blanchable. Tolerating no ankle wts. Skin/Wound Notes dated 6/17/15 at10:26 AM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring1.0 x 0.6 x 0.1cm. Slough is receding evenly around all edges of wound exposing pink granulation tissue. 25% yellow adherent slough remains to wound base. Wound is oval, with distinct rounded edges. Small serous drainage. Peri-wound is pink and blanchable. Tolerating no ankle wts. Skin/Wound Notes dated 6/24/15 at 1:05 PM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring 0.7 x 0.6 x <0.1cm. 25% yellow adherent slough remains to wound base with 75% pink granulation tissue. Wound is round, with distinct rounded edges. Small serous drainage. Peri-wound is pink and blanchable. Tolerating no ankle wts. Skin/Wound Notes dated7/1/15 at 6:31 PM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring 0.7 x 0.6 x <0.1cm. 50% yellow adherent slough remains to wound base with 50% pink granulation tissue. Wound is round, with distinct rounded edges. No drainage. Peri-wound is pink and blanchable. Tolerating no ankle wts. Skin/Wound Notes dated7/8/15 at 10:49 AM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring 0.3 x 0.4 x 0 cm. Area is covered with adherent brown crust. No drainage. Peri-wound is pink and blanchable. Tolerating no ankle wts. Skin/Wound Notes dated7/15/15 at 12:12 PM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring 0.6 x 0.5 x <0.1 cm. Area is 100% pink moist granulation tissue. Scant serous drainage. Peri-wound is pink and blanchable. Tolerating no ankle wts. Skin/Wound Notes dated7/22/15 at 11:32 AM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring 0.3 x 0.3 x <0.1 cm. Area is 100% pink moist granulation tissue. Scant serous drainage. Peri-wound is pink and blanchable. Tolerating no ankle wts. Skin/Wound Notes dated7/29/15 at 12:27 PM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring 0.4 x 0.4 x <0.1 cm. Area is 100%yellow crust. Scant serous drainage. Peri-wound is pink/yellow and blanchable. Tolerating no ankle wts. Skin/Wound Notes dated 8/5/15 at 5:35 AM, states in part, Unstageable pressure ulcer to (R) lateral malleolus measuring 0.7 x 0.6 x <0.1 cm. Base has 25% yellow slough and 75% pink moist tissue. Scant serous drainage. Peri-wound is pink/yellow and blanchable. Tolerating no ankle wts. On 8/8/15 at 7:30 AM, Resident 15 was transferred to the hospital via ambulance for an unrelated illness. On 8/19/15 at approximately 4:30 PM Resident 15 was readmitted to the facility. [DIAGNOSES REDACTED]. On 9/22/15 at 10:00, AM, Surveyor interviewed Licensed Practical Nurse (LPN) G regarding Resident 15's PU that developed on his right malleolus when interventions were in place. LPN G stated, The PU was caused by the weights on his ankles. LPN G indicated that Resident 15's wife used weights on his ankles when he was at home too. On 9/2215 at 10:10 AM, Surveyor interviewed RN Consultant U regarding Resident 15's PU that developed. RN U indicated that Resident 15 had Dementia, some [MEDICAL CONDITION] and a Peg tube so he was not absorbing all the nutrients. RN U indicated that Resident 15 had RLS (Restless Leg Syndrome) and all the movement of his ankles in bed may have caused it. Review of Rehabilitation Screen dated 5/28/15 states, Recommend weights on B ankles with sitting Broda chair. (Chair that reclines.) Positioning in chair looks appropriate but most importantly, comfortable for the patient. This assessment was signed by Physical Therapist (PT) II. On 9/22/15 at 3:00 PM, Surveyor interviewed PT HH regarding the Rehabilitation Screen dated 5/28/15. PT HH indicated that PT II was not in the building at this time. PT HH indicated that this is not a new recommendation for this resident as he has used the weights in the past. Example 1 area 2 Skin/Wound Note dated 7/29/15 at 12:27PM, states in part, Two partial thickness skin tears noted to coccyx area. Proximal measures 1.5 cm x 1.0 x< 0.1 and distal 2.0 x 0.5 x <0.1cm. [MEDICATION NAME] tissue noted to be peeled from site and remains on wound edges. Area and peri- wound are blanchable. Base is red and moist. Small amount of bloody drainage. Education provided to floor staff to use draw sheet when repositioning. Physician's Telephone Order dated 7/29/15, without a time stamp includes, Clean skin tear to coccyx with NS, pat dry, apply dry foam dressing QD (Every day) till healed. Nursing notes dated 8/4/15 at 4:40 PM, state in part, Informed by staff nurse of resident previous friction area to coccyx as open with slough present. Area to coccyx measures 3.5 x 1.7 cm. Wound is unstageable due to presence of slough to 80% of wound bed. Scant sanguinous drainage present. Wife informed of pressure ulcer development. Physician's Telephone Order dated 8/4/15, without a time stamp includes, New tx (treatment) order to coccyx- clean with NS, apply Santyl with triple abx oint to wound base , cover with foam dressing QD till healed. Skin/Wound Note dated 8/5/15 at 5:35 AM, states in part, Stage 3 pressure ulcer to coccyx measures 3.4 x 1.6 x0.1. Base of wound is 50%black loose moist slough and 50% red, moist tissue. Edges are irregular. Peri wound is pink per normal skin hue. Moderate amount of sero sanguineous drainage. Resident 15 developed 2 avoidable, stage 3 PU's and was identified as high risk for PU development upon admit, however the facility failed to implement interventions to prevent PU development when the reddened area was noted on the R malleolus and when the skin tears were noted on the coccyx. Example 2 Resident 5 was admitted to the facility on [DATE] with a re admission date of [DATE]. [DIAGNOSES REDACTED]. Resident 5's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/20/15, indicates A Brief Interview for Mental Status (BIMS) was not completed. Section M0150 of the MDS indicates Resident 5 is at risk for developing a PU. Section M0210 Unhealed Pressure Ulcers Section indicated 0. G0110. Activities of Daily Living (ADL's) indicate Resident 15 requires 2 staff and extensive assistance for bed mobility and transfers. Resident 15's comprehensive care plan, regarding ADL Self Care Performance Deficit r/t stroke dated11/25/12, states, in part, Skin Inspection: Resident name requires Skin inspection BID (Twice daily) with cares. Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. On 9/16/15 at 1:45 PM, Surveyor observed Resident 5 lying in bed with bilateral off-loading boots on and a bed cradle. Nursing Notes dated 9/20/15 at 10:24 AM, states in part, Writer noted her R heel is bright red and the L heel is purple, both blanchable, skins intact. Review of physician's orders [REDACTED]. Float heels while in bed. Have wound nurse assess next week. On 9/21/15 at 7:20 AM, Surveyor observed Resident 5 asleep in bed with her heels on the mattress. On 9/21/15 at 8:55 AM, Surveyor observed Resident 5 lying in bed with gripper socks on and bilateral heels on the bed. On 9/21/15 at 9:15 AM, Surveyor interviewed Certified Nursing Assistant (CNA) O regarding the gripper socks for Resident 5. CNA O indicated that overnights dressed Resident 5 and she is to wear gripper socks in bed, On 9/21/15 at 10:00 AM, Surveyor observed Resident 5 asleep in bed with her heels on the mattress. On 9/21/15 at 10:05 AM, Surveyor observed Resident 5's heels with LPN G. LPN G removed the gripper socks and indicated she already put the skin prep on Resident 5's heels. Surveyor observed Resident 5's left heel to be light purple in color. LPN G applied pressure to the heel and indicated it was spongy. Surveyor observed Resident 5's right heel to be red in color. LPN G applied pressure to the heel and indicated it was spongy but blanchable. Surveyor asked LPN G if Resident 5 wears off loading boots and LPN G indicated she does not wear off loading boot. LPN G placed the gripper socks back on Resident 5 and left her positioned on her back with her heels on the mattress. LPN G asked CNA O to apply some ointment on Resident 5's bottom with the next cares that area provided. On 9/21/15 at 10:50 AM, Surveyor interviewed DON B regarding Resident 5 and her heels being floated. DON B stated, I don't know her and if it is ordered they should be. I am not aware of any breakdown. I have not looked at her. On 9/21/15 at 10:55 AM, Surveyor interviewed RN E regarding the process if a concern with skin occurs what is the process. RN E indicated that she has a mailbox. The facility has pressure and non-pressure sheets. That is how I find out or they just tell me. The floor gets a treatment order and the person who found it should be measuring it. RN E stated, I am not aware of any new skin issues. On 9/21/15 at 11:00 AM, Surveyor observed Resident 5 asleep in bed on her back with her heels on the mattress. On 9/21/15 at 12:05 AM, Surveyor observed Resident 5 sitting in her w/c in the dining room with gripper socks on and both heels on the foot pedals. On 9/21/15 at 1:30 PM, Surveyor observed Resident 5 sitting in her w/c in her room with gripper socks on and both heels on the foot pedals. On 9/21/15 at 2:10 PM, Surveyor observed Resident 5 sitting in her w/c in the dining room with gripper socks on and both heels on the foot pedals. On 9/21/15 at 3:30 PM, Surveyor observed Resident 5 sitting in her w/c in the dining room with gripper socks on and both heels on the foot pedals. Resident 5 was asleep in her w/c. On 9/21/15 at 3:40 PM, Surveyor asked CNA M when Resident 5 will be going back to bed as she is asleep in her w/c. CNA M indicated that she will lay Resident 5 down after she eats supper. On 9/21/15 at 4:45 PM, Surveyor observed Resident 5 sitting in her w/c in her room with gripper socks on and both heels on the foot pedals. Resident 5 was asleep. On 9/22/15 at 7:20 AM, Surveyor observed Resident 5 in bed with her eyes closed. Resident 5 had bilateral pressure off - boots on. On 9/22/15 at 8:10 Surveyor observed cares for Resident 5 that CNA N was providing. Resident 5 stated, My heels hurt yesterday. Not so much today. Surveyor observed Resident 5's L heel, Resident 5's L heel was noted to be red in color with the skin intact. Resident 5 stated it felt tender when CNA N applied pressure. Surveyor observed Resident 5's R heel and noted the center of heel was light purple and the skin appears to be peeling away. CNA N pointed out to Surveyor that the tip of the left 2nd digit has a red area. CNA N put gripper socks and off -loading boots on Resident 5. CNA N repositioned Resident 5 to her left side. It should be noted, there are no documented measurements indicating the size of the discolored areas on Resident 5's heels or in her chart. According to the Wound Care Education Institute Blog <http://blog.wcei.net/wp-content/uploads/2011/09/A-Question.jpg> dated Monday, November 24th, 2014 states in part; Incontinent Associated [MEDICAL CONDITION] (IAD) Identifying Incontinence Associated [MEDICAL CONDITION] or IAD can be a challenge for wound care clinicians as often it is confused and mislabeled as a pressure ulcer. We need to get good at identifying the true root cause of what has caused the skin breakdown. This IAD skin damage is damage that occurs from the top layers of the skin down where the pressure ulcer damage starts down deep when vessels are occluded from pressure. IAD is an inflammation of the perineal skin that has come into contact with urine or stool for an extended period of time and this has lead to skin damage. IAD may present as an area of [DIAGNOSES REDACTED], blistered, [MEDICAL CONDITION] and or a denuded area, but it will be free of necrosis. There may be [MEDICATION NAME] loss and the skin damage will always remain partial thickness in nature. The patient may experience pain and complain of itching or burning as well. Example 3 Resident 3's [DIAGNOSES REDACTED]. Resident 3's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/5/15, indicates A Brief Interview for Mental Status (BIMS) was not completed by the facility. Section M0150 of the MDS indicates Resident 3 is at risk for developing a PU. Section G0110, Activities of Daily Living (ADL's) indicates Resident 3 requires 2 staff and extensive assistance for bed mobility and transfers. The facility has a PU Avoidability assessment dated [DATE] which states in part; Date noted: 5/21/15 - right gluteal (glute) excoriation 7/1/15 - Stage 2 and 6/3/15 - left glute excoriation; reopen was prior Stage 2 Risk factors: terminally ill, [MEDICAL CONDITION] and chronic bowel incontinence Interventions: low air loss mattress, heels floated, reposition every 2 hours, wheel chair cushion Resident was admitted to the facility with Stage 2 PU to left glute and Stage 1 to right glute. Areas have resolved and re-opened. Nursing notes dated 9/2/15 at 11:50 AM state in part; Incontinence excoriation noted over a previous PU area. Open area (OA) to bilateral glutes and coccyx measures 5.5cm x 4.0 cm x<0.1 cm. Tissue is moist, red and purple with small amount of sanguineous (bloody) exudate. Wound is blanchable; periwound red and blanching with areas of purple tissue. Resident 3 has a history of PU to glutes and coccyx. On air mattress and wheelchair (w/c) cushion. Repositioned every 2 hours. Will limit time up in w/c to 2-3 hours. Continue with [MEDICATION NAME] and foam dressing. Resident 3 has a Hospice Progress note dated 9/8/15 a Braden scale was completed with this note and lists Resident 3's Braden score as 8 indicating Resident 3 is at high risk for skin impairment. In addition, this note lists Resident 3 as having a Stage 2 to left buttocks measuring 6 centimeters (cm) x 3.5 cm. Wound to sacrum appears worse than last week. Excoriated area is now a Stage 2 PU with localized, small deeper wound located within the Stage 2 wound. Minor slough noted. Positive redness noted circumferentially around wound site. Spouse at bedside during assessment also looked at sacral wound and corroborates that wound is looking worse. Spoke with facility Registered Nurse (RN) MM about current wound care regimen. Hospice nurse expressed concern with facility RN MM regarding possible stool getting into wound. Facility RN MM states many different attempts at different wound care for Resident 3 and current one has seemed to benefit Resident 3 the best. Of note, the Hospice nurse noted the wound worsening on 9/8/15 and discussed the appearance and worsening of the wound - now a PU with RN MM. The facility RN MM failed to notify the physician of the worsening of Resident 3's wound now being assessed as a Stage 2 PU. The facility did not make a change in Resident 3's treatment for [REDACTED]. Nursing notes dated 9/9/15 at 11:28 AM states in part; Incontinence excoriation noted over a previous PU area. Open area (OA) to bilateral glutes and coccyx measures 4.5cm x4.0cmx<0.1cm. Base has 80% yellow/tan adherent slough. Outer edge of base is moist red and purple with small amount of sanguineous exudate. Wound is blanchable. Periwound is red and blanching with areas of light purple macerated tissue. Nurse practitioner (NP) updated and treatment changed to skin prep and Santyl. Of note, the wound is now 80% slough the PU should have been considered unstageable. The facility continues to classify the PU as IAD. Nursing notes dated 9/16/15 at 11:48 AM states in part; Incontinence excoriation noted over a previous PU area. OA to coccyx measures 3.2cmx3.2cmx0.1. Base has 50 % yellow/tan adherent slough and 50 % red moist tissue. Wound is blanchable. Edges are irregular. Periwound is red/purple and blanchable. On 9/17/15 at 10:50 AM Surveyor observed wound care being provided to Resident 3. Upon entering the room Registered Nurse (RN) E the facility's wound care nurse stated Resident 3 has incontinent associated excoriation Resident 3's buttocks was not a PU. On 9/17/15 at 10:50 AM Surveyor noted Resident 3 to have a dinner plate size area of red, denuded excoriation extending across both buttocks. Surveyor identified this area as IAD. On 9/17/15, at 11:15 AM Surveyor interviewed Registered Nurse (RN) E regarding Resident 3's impaired skin integrity and the facility skin/wound care policy and procedures. RN E is wound care certified and the facility's wound care nurse. Surveyor asked RN E regarding Resident 3's impaired skin integrity. RN E stated Resident 3 has IAD and excoriation from incontinence. Surveyor asked RN E if she would expect to see slough and eschar (necrotic tissue) with IAD. RN E stated it's blanchable, slough started last week. Surveyor asked RN E what standard of practice (SOP) the facility follows for wound care. RN E was not aware of a facility SOP for wound care. Surveyor asked RN E if slough and eschar would be present in IAD. RN E stated she doubted it now, RN E stated she felt she was previously misguided by facility staff. Surveyor asked RN E based on how the wound appeared on 9/17/15, day Surveyor observed wound care, how she would classify the wound. RN E stated based on what I see today the wound is unstageable. RN E stated she would be documenting Resident 3 as having a facility acquired unstageable PU. On 9/22/15 at 2:05 PM Surveyor interviewed Director of Nursing (DON) B regarding the facility's standard of practice for wound care DON B stated the facility uses or will use the National Pressure Ulcer Advisory Panel (NPUAP) and Wound Care Education Institute (WCEI) as a SOP. DON B is also wound care certified stated she would be assisting RN E with wound care assessments as needed. Resident 3 had a previous history of PU's. Resident 3 developed a facility acquired unstageable PU on his coccyx. Resident 3 was identified as having worsening skin integrity and a development of a PU; however the facility failed to notify the physician implement treatment interventions until the following day when Resident 3 was assessed by the facility wound care nurse. However, the facility failed to classify this area as a PU. Resident 3's wound was not classified as a PU by the facility until the PU was observed by the survey team. Example 4 Resident 13 has [DIAGNOSES REDACTED]. Resident 13's Minimum Data Set, completed 4/8/15, indicates she is cognitively intact. Resident 13'd care plan started 4/2/15 states, The resident has actual impairment to skin integrity buttock r/t (due to) immobility. The goal is she will have no complications due to non blanchable area of the buttock and interventions to monitor/document, size and treatment of [REDACTED]. to the physician. On 9/22/15 at 10:35 Surveyor observed Resident 13 cares. Surveyor observed a large purple area to her right ischial area approximately saucer size and her left ischial area to be dark purple approximately the size of a 50 cent piece. Resident 13 told Surveyor that she has had them since her stroke at the hospital and that they were big blisters at the hospital. On 9/22/15 Surveyor requested facility documentation of Resident 13's skin being monitored specifically her non blanchable areas to her buttocks. The facility did not provide any evidence of monitoring.

Based on observation, interview and record review the facility did not ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 8 residents (Residents 1 and 5) Resident 1 was assisted with cares in bed without the adequate number of staff. Resident 1 fell out of the bed and suffered a hip fracture. Resident 5 had recent falls on 6/22, 6/28 and 7/12 and is assessed as being at risk for falls. The facility implemented an intervention of a bed and wheelchair alarm for Resident 5. Resident 5 was observed in bed when the pad alarm was in the off position. Resident 5 was observed in his wheelchair in the dining room with no alarm on his wheelchair. Resident 5 had a fall on 6/28/15. The fall investigation states, Bed alarm was not sounding. There is no evidence that the facility investigated why the alarm was not sounding. This is evidenced by the following: Example 1 Resident 1's [DIAGNOSES REDACTED]. Resident 1's care plan for ADL (Activities of Daily Living) deficit includes the intervention of Bed Mobility- Resident 1 requires 2 assist for participation to reposition and turn in bed. Date initiated: 4/8/14. On 4/7/15 Resident 1 had a fall out of bed. Per the facility incident report Resident 1 was transferred to bed with the assistance of 3 staff at 11:30 PM. Two of the staff left the room, leaving 1 staff to provide cares. The report indicates that Resident 1 was receiving cares when she moved her left leg which then started to slide off the bed. Resident 1 and the CNA (Certified Nursing Assistant) were not able to maintain her balance on the bed. Resident 1 slid off the bed opposite from the CNA onto her knees. Resident 1 complained of leg pain and was transferred to the emergency department and admitted with suspicion of a hip fracture. Upon readmission Resident 1 will be care planned as a two assist with all cares. Resident 1's hospital discharge summary, dated 4/13/15 indicates Resident 1 sustained a right subtrochanteric hip fracture. Orthopedic surgery decided on non-operative management of the hip fracture. Resident 1's physical therapy discharge summary, dated 4/7/15, indicates the current level of functioning as of 3/20/15 is able to roll with maximum assist of 2 staff. On 7/13/15, at 2:57 PM, Surveyor interviewed Registered Nurse Consultant (RN) C and Assistant Director of Nursing (ADON) D. RN C stated prior to the fall Resident 1's care plan was 1-2 assist with cares. RN C stated the amount of staff depends on if it is safe with 1 or they need 2. RN C stated the CNAs determine at the time how many staff they need to use to assist Resident 1. Resident 1's care plan indicates for the past year, as of 4/8/14, Resident 1 was to have 2 staff assist with bed mobility. There was no education of follow up with the staff regarding not following the plan of care. On 7/14/15, at 12:28 PM, Surveyor interviewed Physical Therapist (PT) M. PT M confirmed she wrote the therapy discharge summary on 4/7/15. PT M stated they were working on bed mobility as Resident 1 was demonstrating some increased leg movements and so they were working to see if there could be a decrease in the level of assistance needed. PT M stated to her knowledge she believed Resident 1's plan of care was still 2 people to assist with bed mobility. PT M stated she has not recommended a change to the care plan as Resident 1's level of assistance depended on how tired she was and she was not ready for less assistance with bed mobility. The facility allowed CNAs to determine if 1 or 2 staff should be used when assisting Resident 1 in bed. Resident 1's care plan and physical therapy notes indicate there should be 2 CNAs. Example 2 Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's care plan for falls states as follows: Focus: The resident is high risk for falls and has had multiple falls related to confusion, lack of insight, non compliance with call light use, and multiple attempts at self transfer. Interventions: Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. The resident uses chair and bed electronic alarm. Ensure the device is in place and working. On 7/13/15 at 10:55 AM, Surveyor observed Resident 5 lying in a low bed on his back with a fall mat on the right side of his bed. The alarm was not turned on. On 7/13/15 at 11:00 AM, Surveyor entered Resident 5's room with Licensed Practical Nurse (LPN) H. Resident 5 was laying on his back in a low bed with a fall mat on the right side of the bed. Surveyor asked LPN H if Resident 5's pad alarm in bed was turned on. LPN H stated, no. When LPN H turned the pad alarm on it began beeping (chirping) continuously. LPN H removed the pad alarm from Resident 5's bed and stated that the batteries must be low. LPN H took the pad alarm off of Resident 5's wheelchair and placed it under Resident 5 in bed. LPN H stated she was going to replace the batteries in the other pad alarm. The manufacturer guidelines for the Smart alarm state as follows: If the monitor is Chirping (similar to a smoke alarm), the battery needs to be replaced. Remove battery cover and insert new battery. On 7/13/15 at 11:40 AM, Surveyor entered Resident 5's room with Certified Nursing Assistant (CNA) F and Certified Nursing Assistant (CNA) G to observe a transfer. Surveyor observed Resident 5 lying in a low bed on his back with a fall mat on the right side of his bed, pad alarm on. CNA F and CNA G transferred Resident 5 into his wheelchair. CNA F noted there was no alarm on Resident 5's wheelchair and stated, That's weird, I'm going to ask the nurse, there was an alarm there and now it's gone. On 7/13/15 at 11:54 AM, Surveyor observed Resident 5 in his wheelchair in the dining room. There was no pressure pad alarm on his wheelchair and staff was not with Resident 5. On 7/13/15 at 11:55 AM, Surveyor asked CNA F if Resident 5 has an alarm on his wheelchair. CNA F stated he does not have an alarm on his wheelchair but he should and she is working on it. Resident 5 was left unattended in the dining room. Example 3 Resident 5 had a fall on 6/28/15. The fall investigation states, Bed alarm was not sounding. There is no evidence that the facility investigated why the alarm was not sounding. On 7/13/15 at 4:10 PM, Surveyor spoke with Registered Nurse - Assistant Director of Nursing (ADON) D. Surveyor showed ADON D the fall investigation for Resident 5's fall on 6/28/15. Surveyor asked ADON D if she could tell me why Resident 5's bed alarm was not sounding. ADON D stated, I can make an assumption, but I don't know if it was turned on or not functioning. ADON D stated, I can't say either way. Surveyor encouraged ADON D to check for any information related to why the alarm did not sound. No further information was provided to Surveyor . On 7/3/15 at 3:50 PM, Surveyor spoke with ADON D. Surveyor asked ADON D if care plans are to be followed. ADON D stated, yes. Surveyor asked ADON D if a resident has a care plan for a pad alarm in their bed and chair do you expect them to be in place, turned on and functioning. ADON D stated, yes. ADON D stated the pad alarm should have been on Resident 5's bed and wheelchair and should be functioning. ADON D stated staff should be checking to ensure the pad alarms are working each time they transfer a resident.

Based on interviews and record review, the facility did not ensure that 2 of 2 residents (Residents 1 and 5) with [MEDICAL CONDITION] received proper treatment and care for [MEDICAL CONDITION]. The facility admitted Resident 1, who breathed through a [MEDICAL CONDITION], without ensuring that all nurses were trained in caring for a resident with a [MEDICAL CONDITION], without developing an emergency plan, and without the proper equipment in the room to be used in an emergency. When Resident 1's [MEDICAL CONDITION] became dislodged from Resident 1's stoma, nursing staff incorrectly attempted to reinsert the outer [MEDICAL CONDITION] (without lying the resident down and without using an obturator to guide the tube) and, in doing so, created a false passage and bleeding. Resident 1 remained without her breathing device or attempts to place an alternative device to keep her airway open for 1 hour and 45 minutes. The facility contacted a transportation ambulance to transport Resident 1 to the hospital instead of calling 911. Resident 1's stoma was not adequately kept open to ensure Resident 1's air passage was not blocked. Resident 1 passed away at the emergency room . Resident 5 is a current resident at the facility who has a [MEDICAL CONDITION]. Licensed Practical Nurse (LPN) E, who was the nurse in charge of Resident 5, stated she was not trained by the facility for [MEDICAL CONDITION] care. LPN E stated she was newly hired and did not work in the nursing homes prior to coming to the facility. LPN E stated she was trained in nursing school for basic [MEDICAL CONDITION] care, but no training was provided by the facility prior to her being responsible for Resident 5. The facility's failure to ensure that staff had the appropriate equipment readily available to respond to an emergency and knew how to respond in an emergency and its failure to ensure that Resident 1 received appropriate nursing care when Resident 1's mode of breathing, her [MEDICAL CONDITION], became dislodged created a finding of immediate jeopardy. Immediate jeopardy began on [DATE], the date that Resident 1 was admitted to the facility. The NHA was notified on [DATE] that immediate jeopardy existed. The immediate jeopardy had been removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as all portions of the corrective actions have not been fully implemented. This is evidenced by: The University of Pittsburgh Medical Center's guide for [MEDICAL CONDITION] care, dated 2007, If your [MEDICAL CONDITION] comes out or becomes blocked, you need to have a plan to deal with the emergency situation quickly. If you are unable to solve the problem quickly, call 911. If the [MEDICAL CONDITION] comes out and another tube is not available. The stoma (neck opening) may stay open for a short period of time. 1. If possible, reinsert the old [MEDICAL CONDITION]. 2. If you cannot insert the old one, insert a hold a hollow tube such as a straw, suction catheter, or inner cannula into the stoma. Sometimes the smaller inner cannula can be inserted until emergency help arrives. 3. If using a straw, suction catheter, or inner cannula, replace with a new [MEDICAL CONDITION] or old [MEDICAL CONDITION] as soon as possible. Emergency kit should include the following supplies: A clean [MEDICAL CONDITION] set with obturator, water soluble lubricant, such as [MEDICATION NAME], suction catheter, syringe, if you have a cuffed [MEDICAL CONDITION], sterile saline bullets, gloves, [MEDICAL CONDITION] ties, a smaller size [MEDICAL CONDITION] set with obturator. Remember to make an emergency plan. Standard of Practice: John Hopkins titled difficulty inserting the New [MEDICAL CONDITION], dated [DATE]: 1. If the patient normally requires oxygen, place oxygen over the stoma site. 2. Gather the equipment needed for [MEDICAL CONDITION] (trach) tube change. 3. Always have a [MEDICAL CONDITION] and ties available at all times. 4. Wash hands if you have time. 5. Put the Obturator in the [MEDICAL CONDITION] and put a few drops of water on the end. 6. Remove [MEDICAL CONDITION] if it is around the neck. If it is partially in the stoma, you can try to gently reinsert the [MEDICAL CONDITION]. If you cannot insert the old tube, go to the 7th step. 7. Insert the [MEDICAL CONDITION] and quickly remove the Obturator. 8. Re-insert the inner cannula. 9. [MEDICAL CONDITION]. Difficulty inserting the New [MEDICAL CONDITION]: 1. Check to make sure the patient is positioned with chin pointing toward the ceiling and neck is extended. 2. Try to reinsert [MEDICAL CONDITION]. Do not force the trach. 3. If it still does not enter, try to reinsert the old tube. Since this tube was in before, it should pass into the stoma without difficulty again. 4. If the [MEDICAL CONDITION] does not fit try [MEDICAL CONDITION] that is a smaller than the size the patient normally uses. Always keep a [MEDICAL CONDITION] available when changing the rube. 5. If this measure is unsuccessful, take a suction catheter and put it in the stoma. Hold in place and cut approximately 5 cm or 2 inches from the stoma. The catheter will keep the stoma open. 6. Try to insert the [MEDICAL CONDITION] over the suction catheter. Always hold the catheter to prevent migration into the trachea. 7. If the above measures fail, administer oxygen if the patient normally requires oxygen. If it is evident the patient is able to breath via her mouth, the Ambu bag can be used and placed over the mouth; otherwise just direct the oxygen toward the stoma. 8. Call 911. The facility policy titled [MEDICAL CONDITION] (An artificial opening into the neck into the windpipe (trachea) allowing air to go in and out of the lungs.) care, dated [DATE], the purpose of this procedure is to guide tracheotomy care and the cleaning and sterilization of reusable metal tracheotomy tubes. Procedure guidelines: [MEDICAL CONDITION] care in part: 1. Check Physician order. 5. Inspect skin and stoma for signs or symptoms of infection, leakage or dislodge tube. 6. Remove old dressing and ties. 11. Change disposable [MEDICAL CONDITION] in accordance with established policy. On [DATE] at approximately 2:30 PM Surveyor spoke with Registered Nurse Consultant (RNC) G regarding an established policy for disposable tracheotomy tubes as written in the tracheotomy care policy. RNC G stated the facility does not have separate written policy for disposable [MEDICAL CONDITION] care. RNC G stated the facility would follow the booklet provided inside the [MEDICAL CONDITION] care box. RNC G provided Surveyor with the [MEDICAL CONDITION] booklet. The facility manufacturer guide booklet: Shiley [MEDICAL CONDITION]: The Shiley disposable [MEDICAL CONDITION] are double cannula [MEDICAL CONDITION] with disposable inner cannula and snap lock connector. The [MEDICAL CONDITION] have a radiopaque, biocompatible outer cannula constructed of [MEDICATION NAME] chloride. A swivel neck plate allows conformity to individual neck anatomies. The disposable inner cannula with 15 millimeters snap lock connector is translucent for easy inspection and can be used with standard respiratory equipment. The smooth rounded tip obturator (a pointed tube that guides [MEDICAL CONDITION] into place) facilitates insertion. Insertion: Insert the Obturator into the outer cannula. The Obturator should be fully seated before the tube is inserted into the patient. Cautions: The Obturator should be cleaned and then stored in an accessible location near the patient should it be needed for an unscheduled re-incubation. On [DATE] at 11:30 AM, DON B stated the facility does not have a policy for what to do if a [MEDICAL CONDITION] dislodges and comes out. DON B stated the only policy is for the cleaning of a metal trach. DON B stated the nurses would not have had access to an emergency policy of how to reinsert a [MEDICAL CONDITION] at the time Resident 1's [MEDICAL CONDITION] dislodged and came fully out of her neck. Example 1 Resident 1 was a [AGE] year old female admitted to the facility on [DATE]. Resident 1 had a [MEDICAL CONDITION] secondary to her metastatic squamous cell [MEDICAL CONDITION]. Resident 1 had a total glossectomy (surgical removal of the tongue) and radical dissection due to metastatic squamous [MEDICAL CONDITION] of the tongue on [DATE]. Resident 1's hospital note, dated [DATE] at 12:40 PM: Resident 1 is unable to speak, but is still quite sharp and able to communicate through writing. She has difficulty with neck flexion since her previous treatment and has an ongoing trach. On [DATE] Resident 1 had a new #4 Shiley cuffless tube [MEDICAL CONDITION] placed without difficulty after hip surgery. Cleansed with peroxide and sterile mixture, new gauze applied to site. Inner cannula also cleansed. Peri-orbital [MEDICAL CONDITION] noted to right eye and cheeks are ruddy color. Physician order [REDACTED]. Suction PRN -[MEDICAL CONDITION] instill 3 ml NS. 2. Humidified air. 3.[MEDICAL CONDITION]: change suction canister every shift and PRN. 4. [MEDICAL CONDITION] every day. 7. Change disposable inner cannula daily. Resident 1's Admission respiratory assessment in part, dated [DATE], Respiratory rate is regular, no cough and breath sounds are clear in bilateral lungs. Equipment section list the following equipment: Oxygen and rate of oxygen, Via [MEDICAL CONDITION] with cuff inflated yes or no. (It is important to note the equipment section of the assessment was not completed. There are no visible areas marked to indicate Resident 1 used any respiratory equipment to include her [MEDICAL CONDITION].) Resident 1's admission minimum data set (MDS), dated [DATE], indicated Resident 1's short and long term memory are intact. Resident 1 needs extensive assist of 1 person with transfers. Resident 1 was provided oxygen, suctioning and a [MEDICAL CONDITION] (trach) while a resident at the facility. Surveyor reviewed Resident 1's comprehensive care plans. During the review Surveyor was unable to locate a care plan for Resident 1 related to her need for the [MEDICAL CONDITION], or a care plan for the care of the tracheotomy. There was no emergency plan. On [DATE] at 8:30 AM, Surveyor spoke with Registered Nurse Consultant (RNC) G regarding a comprehensive care plan for Resident 1. RNC G stated she reviewed Resident 1's care plan and could not locate a care plan for Resident 1's [MEDICAL CONDITION]. RN C G stated there should have been a comprehensive care plan for Resident 1's [MEDICAL CONDITION] for the use and care of the [MEDICAL CONDITION]. On the morning of [DATE], Resident 1 developed respiratory wheezing, some shortness of breath, a low-grade fever, and was coughing up yellow sputum. The physician saw the resident and gave orders for Muxinex, Ablbuterol nebulizer treatment and an immediate chest x-ray. He directed staff to monitor and continue [MEDICATION NAME] but at a higher dose due to change in respiratory status. The chest X-ray, dated [DATE] at 6:15 PM, noted Right lower lobe atelectasis, but no infiltrate or congestion. That evening at 9:15 PM, RN F went into Resident 1's room to do [MEDICAL CONDITION] care, according to an interview on [DATE] at 3:40 PM with Surveyor . RN F stated she lifted Resident 1's chin and [MEDICAL CONDITION] was part way out onto the neck when she lifted Resident 1's chin. She released the one side of [MEDICAL CONDITION] by releasing the velcro strap. RN F stated she attempted to reinsert [MEDICAL CONDITION] by just pushing it back into Resident 1's stoma. She attempted several times and then left the room to go get RN C to help reinsert the [MEDICAL CONDITION]. RN F stated did not use an Obturator to attempt to reinsert [MEDICAL CONDITION] into Resident 1's stoma. RN F also stated she does not know what an Obturator is or why she would use the obturator. RN F stated she could not remember when her [MEDICAL CONDITION] was completed in the facility, but did know it was over a year ago. Surveyor asked RN F on [DATE] at 3:40 PM where Resident 1 was located when the [MEDICAL CONDITION] was being reinserted. RN F stated Resident 1 was up in her chair. RN F also stated Resident 1's head is always down toward her chest and hard to lift up. The other Nurse had to pull her head and shoulders up to try to reinsert [MEDICAL CONDITION]. RN F stated she did not attempt to lay Resident 1 in the bed to reinsert [MEDICAL CONDITION]; they left her up in the chair. RN F stated it was really hard to see the Stoma area to try to reinsert the tube no matter how hard we tried to lift her head and pull her shoulders back. While nursing was attempting to reinsert [MEDICAL CONDITION], Resident 1 wrote the following note: Bad More Kleenex Is Shirley here? This was removed incorrectly. The more time you waste now the faster the whole thing closes. Getting tight! Do you have a way to keep it moist? Puzzled Surveyor asked RN F if she remembers Resident 1 writing a note while she was trying to reinsert the [MEDICAL CONDITION]. She stated she does remember Resident 1 writing a note while she was working with the [MEDICAL CONDITION]. She stated she did read the notes and she did remember she asked for Shirley, but Shirley was not working that night. RN F stated she does not remember what else was on the written note. RN F stated Resident 1 communicates with everyone by a written note. Surveyor spoke with Registered Nurse (RN) C on [DATE] at 12:45 PM. RN C stated she entered the room on [DATE] and the [MEDICAL CONDITION] was completely out. RN C looked through the [MEDICAL CONDITION] to ensure there was not blockage. RN F pulled back on Resident 1's head so RN C could locate the stoma. RN C tried to push in the old [MEDICAL CONDITION] but it would not go. RN C stated the stoma was much smaller than the [MEDICAL CONDITION]. On [DATE] at 12:50 PM Surveyor asked RN C is she knew what an obturator was used for when reinserting a [MEDICAL CONDITION]. RN C stated she had never heard of an Obturator and did not use one to reinsert the [MEDICAL CONDITION]. RN F stated she then went to get RN D to help. RN C stated she could not remember the last time she was trained on [MEDICAL CONDITION] care but she did know it was over a year ago or so. RN C stated Resident 1 was up in her chair and the stoma was very difficult to locate. On [DATE] at 3:30 PM Surveyor spoke with RN C regarding keeping Resident 1 ' s stoma open and patent. RN C stated they only tried the outer portion of the [MEDICAL CONDITION] when attempting to reinsert the [MEDICAL CONDITION] back into Resident 1's stoma. RN C stated they did not attempt to place the inner cannula (a small tube) into Resident 1's stoma. RN C also stated they did not insert any other device into the stoma to keep the stoma open for Resident 1. RN C stated they only used the [MEDICAL CONDITION] that fell out of Resident 1 during all of the attempts to reinsert the stoma. RN C stated she was notified at 9:25 PM (10 minutes after the [MEDICAL CONDITION] was already out of Resident 1's stoma.) that Resident 1 [MEDICAL CONDITION] was out and she went directly to her room. On [DATE] at 2:25 PM, Surveyor spoke with RN D regarding Resident 1's [MEDICAL CONDITION] dislodgement. RN D stated RN F came to her and stated Resident 1's [MEDICAL CONDITION] came fully out of Resident 1's stoma and asked RN D to come and help assist to get it back in. RN D stated this was after 9:30 PM that RN F came to get me to go see Resident 1. RN D stated she was not familiar with Resident 1 and had worked with her only once before. RN D stated she looked at Resident 1's stoma and it was very constricted and quite small. RN D stated she knew trying to put the tracheotomy tube in was not going to work because the hole was way too small to fit the tracheotomy tube. RN D stated she placed the [MEDICAL CONDITION] up to the stoma. She stated she did not attempt to push in the [MEDICAL CONDITION] because when she placed it by the stoma she knew it was not going to go in. RN D stated she did not use an Obturator. She stated she does not remember the [MEDICAL CONDITION] and believes it was over a year ago. RN D stated she did observe Resident 1 writing in her tablet, but does not know what she was writing. RN D stated she remained with Resident 1 for a few minutes and did do an oxygen saturation level on her, which read in the 90 percentiles. RN D stated Resident 1 was up in her chair when she entered the room. RN D stated there was no extra equipment in the room. There was not an obturator on the wall or by the bed. Resident 1 did have oxygen on when RN D left the room to finish her work, After 93 minutes the facility contacted Paratech for transport to the emergency room (no lights/no siren). On [DATE] at 3:30 PM Surveyor spoke with RN C regarding calling Paratech versus 911. RN C stated she bases the decision of when to call 911 depending on if the situation is emergent or not. RN C stated she did not believe Resident 1 was in distress and thought Paratech was ok to call. Resident 1's nursing note dated [DATE] at 10:45 PM indicates that her O2 sat was 96% prior to leaving facility. Resident 1's nursing note dated [DATE] at 5:59 AM, at beginning of shift author received report from PM Nurse that Resident was being sent to ER via ambulance because [MEDICAL CONDITION] not be re-inserted. At about 10:22 PM Author asked how Resident was doing and Resident wiggled her hand in a gesture meaning so-so. Author asked if she was ok waiting for the ambulance which would be there soon. Resident gave a thumbs up sign. Resident had a soft touch call light in lap and Author told her to hit that if she needed anything at all or started feeling different. Resident again gave a thumbs up. Author exited the room and ran into an Aide and told Aide to use walkie talkie to contact Author immediately if Resident call light went on which it did not. Author saw Resident off with Paratech transport. She transferred herself with minimal assist to gurney and did not appear to be in any distress. Face was reddish in color as noted in previous ,[DATE] progress note. Resident 1's emergency room (ER) physician progress notes [REDACTED]. They reported attempted to put it back multiple times unsuccessfully. Vitals Temp: 98.8, Pulse 95, Respiratory 24. BP ,[DATE] oxygen saturation 95%. Physical exam: Constitutional: She appears well-developed and well nourished. Acutely ill appearing with [MEDICAL CONDITION] and decreased responsiveness. Cushingoid face secondary to chronic steroid use. Neck: No tracheal deviation present. Scarring right side of neck from [MEDICAL CONDITION]. [DIAGNOSES REDACTED]tous anterior neck with stoma. Neck contracted. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes. Neurological: She is alert. She exhibits normal muscle tone. Skin: Skin is warm and dry. Medical decision: Have reviewed the previous chart, nursing notes and vitals. Patient presents with complaints of tracheotomy change. MD walked in to the room the patient is in respiratory distress with [MEDICAL CONDITION] and decreased responsiveness. Emergently attempted to place [MEDICAL CONDITION] the stoma. Unclear false passage was created or irregularity been created from nursing home staff attempting a placed trach. Large amount of blood was seen from the stoma.[MEDICAL CONDITION] removed. Unfortunately ET tube was full of blood. Unable to suction to clear. Did confirm the patient is a Do not resuscitate (DNR). Therefore, no CPR was given. Patient was pronounced dead. Final Diagnostic impression: Respiratory arrest. [MEDICAL CONDITION]. On [DATE]/5 at 2:11 PM, Surveyor spoke with Resident 1's Ears Nose and Throat (ENT) Physician (MD) I. MD I was scheduled to replace Resident 1's [MEDICAL CONDITION] on [DATE]/15. MD I stated he would have expected any nursing facility that was going to admit a [MEDICAL CONDITION] resident to have recent training for all nurses related to [MEDICAL CONDITION] care and what to do if the [MEDICAL CONDITION] fully comes out. MD I stated you must use an Obturator to reinsert any [MEDICAL CONDITION] and must have one available in the room of all [MEDICAL CONDITION] patients. Basic [MEDICAL CONDITION] training discusses the use of the Obturator and if they would of had the training they would have known what an Obturator was and how to reinsert the [MEDICAL CONDITION] properly. MD I also stated the resident should have been laid in a bed to extend her neck to get full vision of the stoma and keep the tracheal tube expanded. MD I continued to state the lack of training left this resident and other [MEDICAL CONDITION] patients at risk. On [DATE] at 10:55 AM Surveyor spoke with ENT Physician (MD) L regarding Resident 1's dislodgement of the [MEDICAL CONDITION]. MD L replaced Resident 1's cuffless #4 Shiley [MEDICAL CONDITION] on [DATE] prior to Resident 1's admission to the facility. MD L stated he was familiar with Resident 1 due to assisting in surgery with her [MEDICAL CONDITION] insertion. MD L stated the nurse should have had basic [MEDICAL CONDITION] knowledge even before Resident 1 was admitted to the facility. MD L stated Resident 1 had extensive [MEDICAL CONDITION] and [MEDICAL CONDITION], which had created the need for the [MEDICAL CONDITION]. MD L stated the Nurses should have immediately called the physician when Resident 1's [MEDICAL CONDITION] came out of her neck. An Obturator should have been readily available for the nurses to attempt to reinsert the [MEDICAL CONDITION]. MD L also stated after a few short minutes of not getting the [MEDICAL CONDITION] back in staff should have called 911 so emergency help could have been given timely. On [DATE] at 10:55 AM Surveyor asked MD L what complications could have happened to Resident 1 while the nurses were trying to place the old [MEDICAL CONDITION] into her smaller, hard-to-visualize stoma. MD L stated they could create a false passage into the neck which would also resemble a stoma but would still not allow the [MEDICAL CONDITION] to pass. The second concern would be they could cause bleeding into the tracheal area of the neck and down. MD L stated the facility should meet the standards and get their staff trained prior to accepting any [MEDICAL CONDITION] residents. On [DATE] at approximately 10:00 AM Surveyor spoke with Director of Nursing (DON) B regarding the investigation completed by DON B related to Resident 1's dislodgement of her [MEDICAL CONDITION]. DON B stated she spoke to the nurse involved in the incident regarding the dislodgement of the [MEDICAL CONDITION]. DON B stated there has not been any training since the event on [DATE]. On [DATE] at 9:25 AM, Surveyor spoke with Licensed Practical Nurse (LPN) E. LPN E was working the skilled hall in the facility. LPN E advised Surveyor she had 1 resident (Resident 5) that currently had a [MEDICAL CONDITION]. Surveyor asked LPN E if she was trained by the facility regarding [MEDICAL CONDITION] care and what to do in an emergency of a [MEDICAL CONDITION] dislodges from the stoma. LPN E stated she was not trained by the facility for [MEDICAL CONDITION] care. LPN E stated she was newly hired and did not work in the nursing homes prior to coming to the facility. LPN E stated she was trained in nursing school for basic [MEDICAL CONDITION] care, but no training was provided by the facility prior to her being responsible for Resident 5. The facility's failure to provide to have trained professional nurse in the facility with readily available equipment to be used in an emergency and its failure to provide Resident 1 with appropriate emergency medical assistance when her mode of breathing, her [MEDICAL CONDITION], became dislodged from her stoma created an immediate jeopardy situation. The facility removed the immediate jeopardy on [DATE] by taking the following actions: Facility policy in relation to [MEDICAL CONDITION] emergent care in the event of dislodgement/compromised airway, and cardiopulmonary resuscitation were reviewed and revised on [DATE]. Facility policy includes that an additional [MEDICAL CONDITION] with cannula be available at bedside taped above the bed in a sealed bag device. An Obturator will be included for use in the event of dislodgement of the [MEDICAL CONDITION]. Licensed nursing staff education will be initiated [DATE] by Regional Nurse Consultant/DON related to [MEDICAL CONDITION] care and Emergency Management to include. 1. [MEDICAL CONDITION] care per facility policy and procedure. Copy provided to staff during education session. 2. Proper use of an obturator during insertion of an inner cannula. 3. Emergent intervention in the event of dislodgement or accidental removal of [MEDICAL CONDITION] device (cannula). 4. Cardio-pulmonary resuscitation procedure in relation to residents requiring [MEDICAL CONDITION]. The education will be completed by [DATE]. Licensed nurses including new employees hired on or after [DATE] will be educated prior to returning to work. Education and competency checklist related to [MEDICAL CONDITION] care/emergency management will be completed annually for licensed nursing staff to ensure continued competence in skilled care. Compliance will be ensured by competency skills checklist performed by Northwest Therapy and Regional Nurse Consultant for licensed nurses by returned demonstration of skilled related to education. Audit of skills checklist and education will be completed by Administrator/Regional Nurse consultant to ensure that the services provided by qualified licensed nursing staff in relation to [MEDICAL CONDITION] care and emergency management of same. Cross reference F281 Example 2 Resident 5 was admitted to the facility [DATE]. MDS [DATE], BIMS = 15 indicating no cognitive impairment. Resident 5's [DIAGNOSES REDACTED]. On [DATE] at 1:35 PM Surveyor interviewed Resident 5 about her [MEDICAL CONDITION]. Resident 5 has independently completed her own [MEDICAL CONDITION] cares for over 2 years. Resident 5 and has been assessed by the facility and has physician orders [REDACTED]. Resident 5 informed Surveyor that she has an extra [MEDICAL CONDITION] kit that she brought from home in her room. Surveyor asked Resident 5 if she ever received education as to what to do if the outer cannula of her [MEDICAL CONDITION] would come out, Resident 5 said she had, when she first had the [MEDICAL CONDITION] 2 years ago. Surveyor asked Resident 5 if the outer cannula of her [MEDICAL CONDITION] had ever come out, Resident 5 said it had come out only one time (when she was at home) and she simply put it back in. On [DATE] at 3:30 PM Surveyor interviewed ADON (Assistant Director of Nursing) H if there was an obturator available to staff for Resident 5's [MEDICAL CONDITION] care. ADON H stated that she did not know what an obturator was but that she would look it up. Surveyor requested that ADON H come to Resident 5's room to look for [MEDICAL CONDITION] supplies. Surveyor received Resident 5's permission to look at the [MEDICAL CONDITION] kit which she had brought to the facility from home, to examine the contents with ADON H. Surveyor and ADON H observed that the kit contained one [MEDICAL CONDITION] outer cannula, 2 inner cannulas and one obturator. It is important to note that Resident 5 had [MEDICAL CONDITION] supplies at her bedside, including the obturator, but it was not because the facility assessed the need for it, planned for it or obtained it. The [MEDICAL CONDITION] supplies were present because Resident 5 had happened to bring the supplies with her from home, and the facility was unaware of this.

Based on interviews and record review, the facility did not ensure that 2 of 2 residents with [MEDICAL CONDITION] (Residents 1 and 5) received services in accordance with professional standards of practice concerning the treatment and care of [MEDICAL CONDITION]. Professional standards of practice indicate that when caring for an individual with a trachestomy tube: ~ staff must be trained in [MEDICAL CONDITION] care ~ an emergency plan must be developed ~ emergency equipment must be in the room ~ the individual be lying down when the [MEDICAL CONDITION] is replaced ~ an obturator be immediately available and be used to guide the tube into place ~ a smaller tube be immediately available and be used if the original tube cannot be replaced ~ 911 be called if the tube cannot be replaced in minutes The facility admitted Resident 1, who breathed through a [MEDICAL CONDITION], without ensuring that all nurses were trained in caring for a resident with a [MEDICAL CONDITION], without developing an emergency plan, and without the proper equipment in the room to be used in an emergency. When Resident 1's [MEDICAL CONDITION] became dislodged from Resident 1's stoma, nursing staff incorrectly attempted to reinsert the outer [MEDICAL CONDITION] (without lying the resident down, without using an obturator to guide the tube, and without trying a smaller tube) and, in doing so, created a false passage and bleeding. Resident 1 remained without her breathing device or attempts to place an alternative device to keep her airway open for 1 hour and 45 minutes. The facility contacted a transportation ambulance to transport Resident 1 to the hospital instead of calling 911. Resident 1's stoma was not adequately kept open to ensure Resident 1's air passage was not blocked. Resident 1 passed away at the emergency room . Licensed Practical Nurse (LPN) E, who was working the skilled hall in the facility, stated that she had 1 resident (Resident 5) who currently had a [MEDICAL CONDITION]. When asked if she was trained by the facility regarding [MEDICAL CONDITION] care and what to do in an emergency of a [MEDICAL CONDITION] dislodges from the stoma, LPN E stated she was not trained by the facility for [MEDICAL CONDITION] care. LPN E stated she was newly hired; she stated she was trained in nursing school for basic [MEDICAL CONDITION] care, but no training was provided by the facility prior to her being responsible for Resident 5. The facility's failure to ensure that the care provided to Residents 1 and 5 met professional standards of practice created a finding of immediate jeopardy. Immediate jeopardy began on [DATE], the date that Resident 1 was admitted to the facility. The NHA was notified on [DATE] that immediate jeopardy existed. The immediate jeopardy had been removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as all portions of the corrective actions have not been fully implemented. This is evidenced by: The University of Pittsburgh Medical Center's guide for [MEDICAL CONDITION] care, dated 2007, If your [MEDICAL CONDITION] comes out or becomes blocked, you need to have a plan to deal with the emergency situation quickly. If you are unable to solve the problem quickly, call 911. If the [MEDICAL CONDITION] comes out and another tube is not available. The stoma (neck opening) may stay open for a short period of time. 1. If possible, reinsert the old [MEDICAL CONDITION]. 2. If you cannot insert the old one, insert a hold a hollow tube such as a straw, suction catheter, or inner cannula into the stoma. Sometimes the smaller inner cannula can be inserted until emergency help arrives. 3. If using a straw, suction catheter, or inner cannula, replace with a new [MEDICAL CONDITION] or old [MEDICAL CONDITION] as soon as possible. Emergency kit should include the following supplies: A clean [MEDICAL CONDITION] set with obturator, water soluble lubricant, such as [MEDICATION NAME], suction catheter, syringe, if you have a cuffed [MEDICAL CONDITION], sterile saline bullets, gloves, [MEDICAL CONDITION] ties, a smaller size [MEDICAL CONDITION] set with obturator. Remember to make an emergency plan. Standard of Practice: John Hopkins titled difficulty inserting the New [MEDICAL CONDITION], dated [DATE]: 1. If the patient normally requires oxygen, place oxygen over the stoma site. 2. Gather the equipment needed for [MEDICAL CONDITION] (trach) tube change. 3. Always have a [MEDICAL CONDITION] and ties available at all times. 4. Wash hands if you have time. 5. Put the Obturator in the [MEDICAL CONDITION] and put a few drops of water on the end. 6. Remove [MEDICAL CONDITION] if it is around the neck. If it is partially in the stoma, you can try to gently reinsert the [MEDICAL CONDITION]. If you cannot insert the old tube, go to the 7th step. 7. Insert the [MEDICAL CONDITION] and quickly remove the Obturator. 8. Re-insert the inner cannula. 9. [MEDICAL CONDITION]. Difficulty inserting the New [MEDICAL CONDITION]: 1. Check to make sure the patient is positioned with chin pointing toward the ceiling and neck is extended. 2. Try to reinsert [MEDICAL CONDITION]. Do not force the tract. 3. If it still does not enter, try to reinsert the ole tube. Since this tube was in before, it should pass into the stoma without difficulty again. 4. If the [MEDICAL CONDITION] does not fit try [MEDICAL CONDITION] that is a smaller than the size the patient normally uses. Always keep a [MEDICAL CONDITION] available when changing the rube. 5. If this measure is unsuccessful, take a suction catheter and put it in the stoma. Hold in place and cut approximately 5 cm or 2 inches from the stoma. The catheter will keep the stoma open. 6. Try to insert the [MEDICAL CONDITION] over the suction catheter. Always hold the catheter to prevent migration into the trachea. 7. If the above measures fail, administer oxygen if the patient normally requires oxygen. If it is evident the patient is able to breath via her mouth, the Ambu bag can be used and placed over the mouth; otherwise just direct the oxygen toward the stoma. 8. Call 911. Example 1 Resident 1 was a [AGE] year old female admitted to the facility on [DATE]. Resident 1 had a [MEDICAL CONDITION] secondary to her metastatic squamous cell [MEDICAL CONDITION]. Resident 1 had a total glossectomy (surgical removal of the tongue) and radical dissection due to metastatic squamous [MEDICAL CONDITION] of the tongue on [DATE]. Resident 1's hospital note, dated [DATE] at 12:40 PM: Resident 1 is unable to speak, but is still quite sharp and able to communicate through writing. She has difficulty with neck flexion since her previous treatment and has an ongoing trach. On [DATE] at 3:15 PM. Light green sputum noted from [MEDICAL CONDITION]. Cleansed with peroxide and sterile mixture, new gauze applied to site. Inner cannula also cleansed. Does have complaint of mild Shortness of breath (SOB)., Peri-orbital [MEDICAL CONDITION] noted to right eye and cheeks are ruddy color. Physician order [REDACTED]. Suction PRN -[MEDICAL CONDITION] instill 3 ml NS. 2. Humidified air. 3.[MEDICAL CONDITION]: change suction canister every shift and PRN. 4. [MEDICAL CONDITION] every day. 7. Change disposable inner cannula daily. Resident 1's Admission respiratory assessment in part, dated [DATE], Respiratory rate is regular, no cough and breath sounds are clear in bilateral lungs. Equipment section list the following equipment: Oxygen and rate of oxygen, Via [MEDICAL CONDITION] with cuff inflated yes or no. (It is important to note the equipment section of the assessment was not completed. There are no visible areas marked to indicate Resident 1 used any respiratory equipment to include her [MEDICAL CONDITION].) Resident 1's admission minimum data set (MDS), dated [DATE], indicated Resident 1's short and long term memory are intact. Resident 1 needs extensive assist of 1 person with transfers. Resident 1 was provided oxygen, suctioning and a [MEDICAL CONDITION] (trach) while a resident at the facility. Surveyor reviewed Resident 1's comprehensive care plans. During the review Surveyor was unable to locate a care plan for Resident 1 related to her need for the [MEDICAL CONDITION], or a care plan for the care of the tracheotomy. There was no emergency plan. On [DATE] at 8:30 AM, Surveyor spoke with Registered Nurse Consultant (RNC) G regarding a comprehensive care plan for Resident 1. RNC G stated she reviewed Resident 1's care plan and could not locate a care plan for Resident 1's [MEDICAL CONDITION]. RNC G stated there should have been a comprehensive care plan for Resident 1's [MEDICAL CONDITION] for the use and care of the [MEDICAL CONDITION]. On the morning of [DATE], Resident 1 developed respiratory wheezing, some shortness of breath, a low-grade fever, and was coughing up yellow sputum. The physician saw the resident and gave orders for Muxinex, Ablbuterol nebulizer treatment and an immediate chest x-ray. He directed staff to monitor and continue [MEDICATION NAME] but at a higher dose due to change in respiratory status. The chest X-ray, dated [DATE] at 6:15 PM, noted Right lower lobe atelectasis, but no infiltrate or congestion. Surveyor spoke with RN F on [DATE] at 3:40 PM. RN F stated she went into Resident 1's room to do [MEDICAL CONDITION] care at 9:15 PM on [DATE]. RN F stated she lifted Resident 1's chin and [MEDICAL CONDITION] was part way out onto the neck when she lifted Resident 1's chin. She released the one side of [MEDICAL CONDITION] by releasing the velcro strap. RN F stated she attempted to reinsert [MEDICAL CONDITION] by just pushing it back into Resident 1's stoma. She attempted several times and then left the room to go get RN C to help reinsert the [MEDICAL CONDITION]. RN F stated did not use an Obturator to attempt to reinsert [MEDICAL CONDITION] into Resident 1's stoma. RN F also stated she does not know what an Obturator is or why she would use the obturator. RN F stated she could not remember when her [MEDICAL CONDITION] was completed in the facility, but she did know it was over a year ago. Surveyor asked RN F on [DATE] at 3:40 PM where Resident 1 was located when the [MEDICAL CONDITION] was being reinserted. RN F stated Resident 1 was up in her chair. RN F also stated Resident 1's head is always down toward her chest and hard to lift up. The other Nurse had to pull her head and shoulders up to try to reinsert [MEDICAL CONDITION]. RN F stated she did not attempt to lay Resident 1 in the bed to reinsert [MEDICAL CONDITION]; they left her up in the chair. RN F stated it was really hard to see the Stoma area to try to reinsert the tube no matter how hard we tried to lift her head and pull her shoulders back. While nursing was attempting to reinsert [MEDICAL CONDITION], Resident 1 wrote the following note: Bad More Kleenex Is Shirley here? This was removed incorrectly. The more time you waste now the faster the whole thing closes. Getting tight! Do you have a way to keep it moist? Puzzled Surveyor asked RN F if she remembers Resident 1 writing a note while she was trying to reinsert the [MEDICAL CONDITION]. She stated she does remember Resident 1 writing a note while she was working with the [MEDICAL CONDITION]. She stated she did read the notes and she did remember she asked for Shirley, but Shirley was not working that night. RN F stated she does not remember what else was on the written note. RN F stated Resident 1 communicates with everyone by a written note. Surveyor spoke with Registered Nurse (RN) C on [DATE] at 12:45 PM. RN C stated she entered the room on [DATE] and the [MEDICAL CONDITION] was completely out. RN C looked through the [MEDICAL CONDITION] to ensure there was not blockage. RN F pulled back on Resident 1's head so RN C could locate the stoma. RN C tried to push in the old [MEDICAL CONDITION] but it would not go. RN C stated the stoma was much smaller than the [MEDICAL CONDITION]. On [DATE] at 12:50 PM Surveyor asked RN C is she knew what an obturator was used for when reinserting a [MEDICAL CONDITION]. RN C stated she had never heard of an Obturator and did not use one to reinsert the [MEDICAL CONDITION]. RN F stated she then went to get RN D to help. RN C stated she could not remember the last time she was trained on [MEDICAL CONDITION] care, but she did know it was over a year ago or so. RN C stated Resident 1 was up in her chair and the stoma was very difficult to locate. On [DATE] at 3:30 PM Surveyor spoke with RN C regarding keeping Resident 1 ' s stoma open and patent. RN C stated they only tried the outer portion of the [MEDICAL CONDITION] when attempting to reinsert the [MEDICAL CONDITION] back into Resident 1's stoma. RN C stated they did not attempt to place the inner cannula (a small tube) into Resident 1's stoma. RN C also stated they did not insert any other device into the stoma to keep the stoma open for Resident 1. RN C stated they only used the [MEDICAL CONDITION] that fell out of Resident 1 during all of the attempts to reinsert the stoma. RN C stated she was notified at 9:25 PM (10 minutes after the [MEDICAL CONDITION] was already out of Resident 1's stoma.) that Resident 1 [MEDICAL CONDITION] was out and she went directly to her room. On [DATE] at 2:25 PM, Surveyor spoke with RN D regarding Resident 1's [MEDICAL CONDITION] dislodgement. RN D stated RN F came to her and stated Resident 1's [MEDICAL CONDITION] came fully out of Resident 1's stoma and asked RN D to come and help assist to get it back in. RN D stated this was after 9:30 PM that RN F came to get me to go see Resident 1. RN D stated she was not familiar with Resident 1 and had worked with her only once before. RN D stated she looked at Resident 1's stoma and it was very constricted and quite small. RN D stated she knew trying to put the tracheotomy tube in was not going to work because the hole was way too small to fit the tracheotomy tube. RN D stated she placed the [MEDICAL CONDITION] up to the stoma. She stated she did not attempt to push in the [MEDICAL CONDITION] because when she placed it by the stoma she knew it was not going to go in. RN D stated she did not use an Obturator. She stated she does not remember the [MEDICAL CONDITION] and believes it was over a year ago. RN D stated she did observe Resident 1 writing in her tablet, but does not know what she was writing. RN D stated she remained with Resident 1 for a few minutes and did do an oxygen saturation level on her, which read in the 90 percentiles. RN D stated Resident 1 was up in her chair when she entered the room. RN D stated there was no extra equipment in the room. There was not an obturator on the wall or by the bed. Resident 1 did have oxygen on when RN D left the room to finish her work, After 93 minutes the facility contacted Paratech for transport to the emergency room (no lights/no siren). On [DATE] at 3:30 PM Surveyor spoke with RN C regarding calling Paratech versus 911. RN C stated she bases the decision of when to call 911 depending on if the situation is emergent or not. RN C stated she did not believe Resident 1 was in distress and thought Paratech was ok to call. Resident 1's nursing note dated [DATE] at 10:45 PM indicates that her O2 sat was 96% prior to leaving facility. Resident 1's nursing note dated [DATE] at 5:59 AM, at beginning of shift author received report from PM Nurse that Resident was being sent to ER via ambulance because [MEDICAL CONDITION] not be re-inserted. At about 10:22 PM Author asked how Resident was doing and Resident wiggled her hand in a gesture meaning so-so. Author asked if she was ok waiting for the ambulance which would be there soon. Resident gave a thumbs up sign. Resident had a soft touch call light in lap and Author told her to hit that if she needed anything at all or started feeling different. Resident again gave a thumbs up. Author exited the room and ran into an Aide and told Aide to use walkie talkie to contact Author immediately if Resident call light went on which it did not. Author saw Resident off with Paratech transport. She transferred herself with minimal assist to gurney and did not appear to be in any distress. Face was reddish in color as noted in previous ,[DATE] progress note. Resident 1's emergency room (ER) physician progress notes [REDACTED]. They reported attempted to put it back multiple times unsuccessfully. Vitals Temp: 98.8, Pulse 95, Respiratory 24. BP ,[DATE] oxygen saturation 95%. Physical exam: Constitutional: She appears well-developed and well nourished. Acutely ill appearing with [MEDICAL CONDITION] and decreased responsiveness. Cushingoid face secondary to chronic steroid use. Neck: No tracheal deviation present. Scarring right side of neck from [MEDICAL CONDITION]. [DIAGNOSES REDACTED]tous anterior neck with stoma. Neck contracted. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes. Neurological: She is alert. She exhibits normal muscle tone. Skin: Skin is warm and dry. Medical decision: Have reviewed the previous chart, nursing notes and vitals. Patient presents with complaints of tracheotomy change. MD walked in to the room the patient is in respiratory distress with [MEDICAL CONDITION] and decreased responsiveness. Emergently attempted to place [MEDICAL CONDITION] the stoma. Unclear false passage was created or irregularity been created from nursing home staff attempting a placed trach. Large amount of blood was seen from the stoma.[MEDICAL CONDITION] removed. Unfortunately ET tube was full of blood. Unable to suction to clear. Did confirm the patient is a Do not resuscitate (DNR). Therefore, no CPR was given. Patient was pronounced dead. Final Diagnostic impression: Respiratory arrest. [MEDICAL CONDITION]. On [DATE]/5 at 2:11 PM, Surveyor spoke with Resident 1's Ears Nose and Throat (ENT) Physician (MD) I. MD I was scheduled to replace Resident 1's [MEDICAL CONDITION] on [DATE]/15. MD I stated he would have expected any nursing facility that was going to admit a [MEDICAL CONDITION] resident to have recent training for all nurses related to [MEDICAL CONDITION] care and what to do if the [MEDICAL CONDITION] fully comes out. MD I stated you must use an Obturator to reinsert any [MEDICAL CONDITION] and must have one available in the room of all [MEDICAL CONDITION] patients. Basic [MEDICAL CONDITION] training discusses the use of the Obturator and if they would of had the training they would have known what an Obturator was and how to reinsert the [MEDICAL CONDITION] properly. MD I also stated the resident should have been laid in a bed to extend her neck to get full vision of the stoma and keep the tracheal tube expanded. MD I continued to state the lack of training left this resident and other [MEDICAL CONDITION] patients at risk. On [DATE] at 10:55 AM Surveyor spoke with ENT Physician (MD) L regarding Resident 1's dislodgement of the [MEDICAL CONDITION]. MD L replaced Resident 1's cuffless #4 Shiley [MEDICAL CONDITION] on [DATE] prior to Resident 1's admission to the facility. MD L stated he was familiar with Resident 1 due to assisting in surgery with her [MEDICAL CONDITION] insertion. MD L stated the nurse should have basic [MEDICAL CONDITION] knowledge even before Resident 1 was admitted to the facility. MD L stated Resident 1 had extensive [MEDICAL CONDITION] and [MEDICAL CONDITION] which created the need for the [MEDICAL CONDITION]. MD L stated the Nurses should have immediately called the physician when Resident 1's [MEDICAL CONDITION] came out of her neck. An Obturator should have been readily available for the nurses to attempt to reinsert the [MEDICAL CONDITION]. MD L also stated after a few short minutes of not getting the [MEDICAL CONDITION] back in, staff should have called 911 so emergency help could have been given timely. On [DATE] at 10:55 AM Surveyor asked MD L what complications could have happened to Resident 1 while the nurses were trying to place the old [MEDICAL CONDITION] into her smaller, hard-to-visualize stoma. MD L stated they could create a false passage into the neck which would also resemble a stoma but would still not allow the [MEDICAL CONDITION] to pass. The second concern would be they could cause bleeding into the tracheal area of the neck and down. MD L stated the facility should meet the standards and get their staff trained prior to accepting any [MEDICAL CONDITION] residents. On [DATE] at approximately 10:00 AM Surveyor spoke with Director of Nursing (DON) B regarding the investigation completed by DON B related to Resident 1's dislodgement of her [MEDICAL CONDITION]. DON B stated she spoke to the nurse involved in the incident regarding the dislodgement of the [MEDICAL CONDITION]. DON B stated there has not been any training since the event for the nurse related to [MEDICAL CONDITION] care or for what to do when a [MEDICAL CONDITION] comes out of a resident. On [DATE] at 9:25 AM, Surveyor spoke with Licensed Practical Nurse (LPN) E. LPN E was working the skilled hall in the facility. LPN E advised Surveyor she had 1 resident (Resident 5) that currently had a [MEDICAL CONDITION]. Surveyor asked LPN E if she was trained by the facility regarding [MEDICAL CONDITION] care and what to do in an emergency of a [MEDICAL CONDITION] dislodges from the stoma. LPN E stated she was not trained by the facility for [MEDICAL CONDITION] care. LPN E stated she was newly hired and did not work in the nursing homes prior to coming to the facility. LPN E stated she was trained in nursing school for basic [MEDICAL CONDITION] care, but no training was provided by the facility prior to her being responsible for Resident 5. The facility's failure to provide to have trained professional nurse in the facility and to provide Resident 1 with emergency medical assistance in accordance with professional standards of practice when her mode of breathing, her [MEDICAL CONDITION], was dislodged from her stoma created an immediate jeopardy situation. The facility removed the immediate jeopardy on [DATE] by taking the following actions: Facility policy in relation to [MEDICAL CONDITION] emergent care in the event of dislodgement/compromised airway, and cardiopulmonary resuscitation were reviewed and revised on [DATE]. Facility policy includes that an additional [MEDICAL CONDITION] with cannula be available at bedside taped above the bed in a sealed bag device. An Obturator will be included for use in the event of dislodgement of the [MEDICAL CONDITION]. Licensed nursing staff education will be initiated [DATE] by Regional Nurse Consultant/DON related to [MEDICAL CONDITION] care and Emergency Management to include. 1. [MEDICAL CONDITION] care per facility policy and procedure. Copy provided to staff during education session. 2. Proper use of an obturator during insertion of an inner cannula. 3. Emergent intervention in the event of dislodgement or accidental removal of [MEDICAL CONDITION] device (cannula). 4. Cardio-pulmonary resuscitation procedure in relation to residents requiring [MEDICAL CONDITION]. The education will be completed by [DATE]. Licensed nurses including new employees hired on or after [DATE] will be educated prior to returning to work. Education and competency checklist related to [MEDICAL CONDITION] care/emergency management will be completed annually for licensed nursing staff to ensure continued competence in skilled care. Compliance will be ensured by competency skills checklist performed by Northwest Therapy and Regional Nurse Consultant for licensed nurses by returned demonstration of skilled related to education. Audit of skills checklist and education will be completed by Administrator/Regional Nurse consultant to ensure that the services provided by qualified licensed nursing staff in relation to [MEDICAL CONDITION] care and emergency management of same. Cross reference F 328 Example 2 Resident 5 was admitted to the facility [DATE]. MDS [DATE], BIMS = 15 indicating no cognitive impairment. Resident 5's [DIAGNOSES REDACTED]. On [DATE] at 1:35 PM Surveyor interviewed Resident 5 about her [MEDICAL CONDITION]. Resident 5 has independently completed her own [MEDICAL CONDITION] cares for over 2 years. Resident 5 and has been assessed by the facility and has physician orders [REDACTED]. Resident 5 informed Surveyor that she has an extra [MEDICAL CONDITION] kit that she brought from home in her room. Surveyor asked Resident 5 if she ever received education as to what to do if the outer cannula of her [MEDICAL CONDITION] would come out, Resident 5 said she had, when she first had the [MEDICAL CONDITION] 2 years ago. Surveyor asked Resident 5 if the outer cannula of her [MEDICAL CONDITION] had ever come out, Resident 5 said it had come out only one time (when she was at home) and she simply put it back in. On [DATE] at 3:30 PM Surveyor interviewed RN (Registered Nurse) C if there was an obturator available to staff for Resident 5's [MEDICAL CONDITION] care. RN C stated that she did not know what an obturator was but that she would look it up. Surveyor requested that RN C come to Resident 5's room to look for [MEDICAL CONDITION] supplies. Surveyor received Resident 5's permission to look at the [MEDICAL CONDITION] kit which she had brought to the facility from home, to examine the contents with RN C. Surveyor and RN C observed that the kit contained one [MEDICAL CONDITION] outer cannula, 2 inner cannulas and one obturator. It is important to note that Resident 5 had [MEDICAL CONDITION] supplies at her bedside, including the obturator, but it was not because the facility assessed the need for it, planned for it or obtained it. The [MEDICAL CONDITION] supplies were present because Resident 5 had happened to bring the supplies with her from home, and the facility was unaware of this.

Based on interview and record review, the facility did not ensure that each resident was provided with sufficient fluid intake to maintain proper hydration and health for 5 of 5 residents reviewed (Residents 5, 2, 3, 4 and 1). Resident 5 was admitted to the facility 8/22/14 after an [MEDICAL CONDITION] was placed. Resident 5 had orders for intake and output monitoring. The facility did not conduct fluid intake monitoring and did not analyze data collected from the [MEDICAL CONDITION] output. Resident 5 was hosptalized on [DATE] with [DIAGNOSES REDACTED]. The facility did not complete assessments for signs of dehydration. Resident 5 was again hospitalized with [MEDICAL CONDITION] and evidence of dehydration on 9/16/14 and returned to the facility on [DATE]. The facility did not complete fluid intake requirements calculations and did not initiate a comprehensive care plan, which included dehydration risk interventions, for Resident 5 until the day of the survey, 9/22/14. The facility did not compute fluid intake requirements during the hydration assessments for Residents 2, 3, 4, and 1. The first example rises to a level G and the additional examples are at an E level. This is evidenced by: The facility's policy titled "Hydration Risk and/or Dehydration" dated 4/28/07 states, "A resident who demonstrates a risk for dehydration and/or is identified, as having dehydration or hydration problems will have appropriate interventions established and implemented to improve or maintain hydration status ...1. Identify residents newly admitted or readmitted with a risk for hydration concerns ...a. impaired decision-making ability, b. Comprehension/communication problems. c. Body control problems. d. Hand dexterity problems. e. bowel problems f. swallowing problems ...i. abnormal lab tests ...3. Calculate estimated fluid needs ..." According to the AMDA Clinical Practice Guideline titled "Dehydration and Fluid Maintenance in the Long-Term Care Setting", "Ordinarily, about 100 ml per day is lost through feces. However, gastrointestinal water loss can increase significantly in the presence of diarrhea, vomiting, or other gastrointestinal conditions, which may in turn cause severe dehydration...Early detection of acute illness, followed by objective estimation of hydration status, is key to preventing significant dehydration. Nursing assistants should be trained to systematically observe patients for early signs and symptoms of acute illness. In the absence of definitive signs, staff and practitioners must recognize and report risk factors for dehydration such as diarrhea, use of diuretics, and adverse medication effects on eating and drinking." Example 1 Resident 5 was admitted to the facility on [DATE]. According to "[DIAGNOSES REDACTED]. The above [DIAGNOSES REDACTED]. The facility completed an initial Minimum Data Set (MDS) assessment, dated 8/29/14. Section C of this assessment notes that Resident 5 scored 13 points on the Brief Interview for Mental Status, indicating that Resident 5 is cognitively intact. Section D, Mood, notes that Resident 5 exhibited the symptom of having poor appetite or overeating nearly every day. Section G, Functional Status, notes that Resident 5 needs supervision or oversight with eating and has no limitation of upper extremity range of motion. Section H, Bladder and Bowel indicates that Resident 5 has an ostomy and an indwelling catheter. Section K, Swallowing/Nutritional Status indicates that Resident 5 weighs 221 pounds and has had weight loss. Section N notes that Resident 5 received a diuretic each of the last seven days since admission. Resident 5's Care Area Assessment (CAA) for Dehydration/Fluid Maintenance triggered resultant of this assessment and it was decided to address this via a care plan. The facility initiated the following care plans for Resident 5 upon admission: "Focus: The resident is on diuretic therapy ([MEDICATION NAME]) r/t (related to) fluid retention/[MEDICAL CONDITION]. Date initiated 8/23/14. Goals: The resident will be free of any discomfort or adverse side effects of diuretic therapy through the review date ...Interventions: Administer DIURETIC medications as ordered by physician. Monitor for side effects and effectiveness Q-shift (each shift). Monitor/document report prn (as needed) adverse reactions to DIURETIC therapy: dizziness, postural [MEDICAL CONDITION], fatigue, and an increased risk for falls. Date Initiated 8/23/14. Focus: The resident has a nutritional problem or potential nutritional problem: predicted suboptimal energy intake r/t decreased appetite & recent hospitalization aeb (as evidenced by) resident consumes 50% of 2 meals per day. Resident reported significant unintentional weight loss of about 25# (UBW (usual body weight) of 245#) during hospitalization . Date initiated 8/25/14; Goals: Resident will maintain hydration status as evidenced by good skin turgor and pink/moist mucus membranes.(No interventions are included for Resident 5's risk for dehydration) Date initiated 8/25/14 ...Interventions: Provide and serve supplements as ordered. Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide, serve diet as ordered. Monitor intake and record q meal ...date initiated 8/25/14." The facility nursing department completed "Hydration Risk Screener" on 8/23/14. This document notes that Resident 5 has 1-2 predisposing risk factors (Urinary Tract Infection [MEDICAL CONDITION], infection, fever, dx (diagnosis) of depression, dementia, pschiatic (SIC) disorders, Diabetes, [MEDICAL CONDITION]/Failure, pressure ulcer/wound) present and takes 1-2 of listed medications (Diuretics, [MEDICAL CONDITION], antidepressants, hypnotics-sedatives). Section I of this screen includes a section for fluid requirements. This section is noted to be blank. The facility dietary department completed "Nutritional & Dietary Profile" for Resident 5 on 8/25/14. This assessment indicates that Resident 5 weighs 221 pounds and is 69 inches tall, is obese, on a regular diet, has an incision in the abdomen, is tolerating the general textured diet and denies chewing or swallowing issues. Section A of this assessment notes an area for "Nutritional Requirements." This section is blank. Section C of this assessment, "Fluid" states that Resident 5 receives thin liquids. Section G notes that Resident 5 has a poor appetite. Resident 5's "admission orders [REDACTED]." This document is signed by a physician. The facility did not initiate intake measurements for Resident 5. Resident 5's "Comprehensive Intake-Output Record" for August, 2014 includes a large line through the Intake section. Urine output is measured via the Foley catheter and [MEDICAL CONDITION] output is measured. [MEDICAL CONDITION] output ranges from 600 mL to 1250 milliliters per day. It is important to note that the facility did not consistently described [MEDICAL CONDITION] output numerically, but also used "Big" and "lg (large)" for output measurements. Resident 5's September, 2014 "Physician Orders" state, "I&O for Foley & drains." Please note on 8/29/14 the nurse practitionar saw Resident 5 and noted increased trace [MEDICAL CONDITION] in his bilateral lower extremities and ordered his [MEDICATION NAME] 20 mg to be increased to 40 mg a day. "Progress Notes" dated 9/2/14 state, "(Resident 5) took am meds with thin liquids today, vs (vital signs) recorded. After he had his [MEDICAL CONDITION] changed and was transferred to the w/c (wheel chair) he had a syncopial episode with BP (blood pressure) 76/53, pulse 112, eyes not focused and unresponsive. (NP C) was present with this event. New orders noted for mediation adjustments and vs will be monitored as per D.O. (doctor's orders) ...Staff reminded to empty [MEDICAL CONDITION] frequently, fluids encouraged." "Nursing Facility Acute Visit" written by Nurse Practitioner (NP) C, dated 9/2/14 states, "[MEDICAL CONDITION]: Comment: Multifactorial: known a-fib with RVR (rapid ventricular response), bundle branch block; pain from ostomy; suspect dehydration; weakness; [MEDICAL CONDITION] improving...attending physician notified..." The facility "Progress Notes" for Resident 5 do not include physical assessment by nursing staff for signs and symptoms of dehydration despite Resident 5's high output of stool. The facility did not have data that would suggest that Resident 5 took in adequate fluids to offset the amounts of fluid stools eliminated per the [MEDICAL CONDITION]. On 9/2/14 Resident 5's received an order to hold [MEDICATION NAME], on 9/3/14 and begin [MEDICATION NAME] to 20 mg daily on 9/4/14. "Progress Notes" dated 9/4/14 state, "Resident alert and oriented X 4, pleasant & cooperative. Up today working with therapy. Upon arrival back to room, resident stated that he got blurred vision and felt weak. Writer arrived and took VS and notified NP that was here at the time. Got resident back in bed and encouraged resident to drink additional fluids, he accepted 240 mL (milliliters) of Gatorade at the time. NP arrived to see him and labs were ordered at change of shift. PM nurse aware and will continue to monitor and report labs as they become available. Resident is resting in bed at the time writer left ....Labs returned from Meriter. Critical low sodium at 120. GNP notified of critical low lab values. BP 68/47 at 1640 (4:40 PM). Ordered to send to...ER as is not comfortable with [MEDICAL CONDITION], chills, sweats and [MEDICAL CONDITION]." Hospital "Admission H&P" dated 9/4/14 states, "Per patient he was feeling his usual self today when during therapy at the nursing home he felt light headed and so the nurses took his blood pressure and it was low. Per nurse at (facility) who was called, patient over the past week has been having increasingly low blood pressures, they have been around the 90s/50s for 1 week now. The patient has also been complaining of some headaches and lightheadedness, but was alert and oriented and seemed like otherwise his normal self. Patient's blood pressure was taken today and SPB (systolic blood pressure) was noted to be in the 60s. The NP had visited the patient recently also and performed a BMP (basic metabolic panel) and was found to be quite hyponatremic so he was advised to be taken to the ED (emergency department). Of note also, nursing notes that patient's ostomy output has been quite high ranging from 1.5 L (liters)-2L a day ...Was discharged 2 weeks ago after prolonged hospital stay that resulted in bowel resection with end [MEDICAL CONDITION] and wound vac placement. In the ED the patient received 2 L boluses and BPs remained around 80s/50s. Problem list: Principal Problem: [MEDICAL CONDITION]. Active Problems: [MEDICAL CONDITIONS], AKI (acute kidney injury) ....Recent Labs: Sodium (Normal Sodium is 135-145 mmol/liter): 8/22/14: 134*), 8/26/14: 131, 9/4/14: 123* ...BUN (blood urea nitrogen) (Normal BUN is 8-23 mg/dL.): 8/22/14: 11, 8/26/14: 13, 9/4/14: 53*. Creatinine (Normal Creatinine is 0.50-1.20.): 8/22/14: 0.8, 8/26/14: 0.80, 9/4/14: 1.7* [MEDICAL CONDITION] is believed to be related to dehydration due to poor intake and blood pressure medications ...Has had increased ostomy output with poor PO (by mouth) intake ...Renal: AKI with creatinine elevated to 1.7. Baseline creatinine at 0.7-0.8. High BUN/Cr ratio likely due to prerenal etiology, likely from dehydration ...Assessment and Plan: [MEDICAL CONDITION]-improved with smaller cuff in the MICU and after fluids. This is likely related to his bp meds and diuretic use as well as I (intake)<< (less than) O (output) for days with poor po intake and significant ostomy drainage ..." "Discharge Summary" from Resident 5's hospital stay (9/4/14 to 9/9/14) states, "Admission Diagnosis: [REDACTED]. Resident 5 was readmitted to the facility on [DATE]. The facility completed "Hydration Risk Screener" on 9/9/14. Resident 5 scored four points on this screen. It is important to note that, interviews with staff indicated that they are not aware of what the scores mean. This assessment notes that Resident 5 has a history of dehydration. Section I states, "Nursing Considerations 2 (box checked) I&O per facility protocol. Section J states, "Monitor I&O for dehydration." The facility did not have evidence that Resident 5's fluid intakes were monitored or that output values were analyzed. Resident 5's "Comprehensive Intake-Output Record" for September 9, 2014 to September, 16, 2014 includes a large line through the Intake section. Urine output is measured via the Foley catheter and [MEDICAL CONDITION] output is measured. [MEDICAL CONDITION] output ranges from 1200 mL to 3300 milliliters per day. NP C wrote an "Encounter Note" dated 9/15/14 which states, "[MEDICAL CONDITION]: Comment: unclear if this is secondary to stool output vs. SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) as pt is no longer on diuretic. Plan: add Sodium 1 gm (gram) TID (three times per day) with meals. Watch labs. Check for SIADH..." The facility did not assess for signs and symptoms of dehydration despite the addition of sodium to Resident 5's medication regime and recent history and [DIAGNOSES REDACTED]. "Progress Notes" dated 9/16/14 at 10:52 AM state, "Critical labs called to (NP C). Eval of resident=Syncopal episode when transferred from the bed to the w/c by therapy. He was not responding to voice or shaking. Left arm was noted with tremor. VS taken 96/64, 97.1, 111, 22, 96% on ra (room air). Order received to transfer to ER (hospital name) for eval ...." "Internal Medicine Hospitalist History and Physical" dated 9/16/14 states, "(Resident 5) is a [AGE] year old male admitted after single episode of weakness and near [MEDICAL CONDITION] that occurred during physical therapy today. Near [MEDICAL CONDITION]/weakness, likely due to [MEDICAL CONDITION] secondary to hypovolemia, but [MEDICAL CONDITION] and a-fib could be contributing factors. No SOB (shortness of breath), chest pain to suggest ACS (acute coronary syndrome) ...will hydrate aggressively. [MEDICAL CONDITION]: Suspect chronic hypovolemic [MEDICAL CONDITION] based on dry exam, possible related to new ostomy and poor PO intake. No evidence of [MEDICAL CONDITION] ...IVF (intravenous fluids) stop fluids if Na (sodium) increasing too fast. Q6H (every six hours) BMP. [MEDICAL CONDITION]-given [MEDICATION NAME], insulin, [MEDICATION NAME] in ED. On IVF, Q6H BMPs overnight to monitor. Will give one dose [MEDICATION NAME] as well. AKI-Cr (creatinine) 2.0 on admit with normal baseline. Suspect prerenal (nephrotoxins, dehydration, hx [MEDICAL CONDITIONS]), though patient has known kidney stones and hx [MEDICAL CONDITION] ...Physical exam ...In general well appearing [AGE] year old male, pleasant and cooperative ...mucous membranes appear dry ...Laboratory Studies on Admission ...Sodium: 121* ...Potassium 6.0*(Normal potassium is 3.4-4.8.) ...BUN: 47*, Creatinine: 2.0* ...GFR (Glomerular Filtration Rate): 30* ...Unfortunately 81 yowm (year old white male) with recurrent admissions for dehydration, severe [MEDICAL CONDITION] following [MEDICAL CONDITION]. He returns today with copious ostomy output, [MEDICAL CONDITION] and lightheadedness. He did not lose consciousness. He has not chest pain or sob. No palpation, no focal neuro sx (symptoms). On exam he has decreased skin turgor, dry MM (mucous membranes) ..." "Physician Discharge Summary" dated 9/19/14 states indicates lab values collected on 9/19/14 as "Sodium: 133*, Potassium 4.2 ...BUN: 14 ...creatinine 0.9, GFR: 80." Resident 5 was readmitted to the facility on [DATE]. The facility completed "Hydration Risk Screener" on 9/19/14. This assessment states that Resident 5 scored five points. Section J states, "I&O per facility policy." Resident 5's "Comprehensive Intake-Output Record" for September 19, 2014 to the day of the survey (9/22/14) includes a large line through the Intake section. Urine output is measured via the Foley catheter and [MEDICAL CONDITION] output is measured. [MEDICAL CONDITION] output ranges from 500 milliliters on 9/19/14 to 2950 milliliters on 9/21/14. "Progress Notes" for Resident 5 from his readmission on 9/19/14 to the time of survey do not include physical assessments for signs and symptoms of dehydration. an order for [REDACTED]. (Check mark) BMP weekly q Thursday" was written on 9/22/14 by NP C. The facility initiated a care plan for Resident 5 dated 9/22/14 (day of survey) which states the following: "Focus: The resident has dehydration or potential fluid deficit r/t poor intake, diuretic use, nausea, vomiting. Date initiated 9/22/14. Goals: The resident will remain free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor....Interventions; Description: Administer medications as ordered. Monitor/document for side effects and effectiveness. Educate the resident/family/caregivers on importance of fluid intake. Monitor vital signs as ordered/per facility protocol and record. Notify MD of significant abnormalities. Monitor/document bowel sounds and frequency of BM: provide medication as ordered. Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Notify Physician if: persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours, persistent output exceeding intake past 48 hours, abnormal lab. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Administer extra fluids between meals and medication times." It is important to note that this is the first care plan for Resident 5 that includes intervetions related to the management of Resident 5's history of and potention for continued dehydration. Surveyor spoke with Registered Dietician (RD) D on 9/22/14 at 12:11 PM. RD D stated that the nurses do the hydration screen and that she does not know what the scoring means. Surveyor asked RD D when she recommends for intake and output measurements to be measured. RD D stated that when someone has a [MEDICAL CONDITION] or [MEDICAL CONDITION], is on tube feeding or TPN (total [MEDICATION NAME] nutrition). RD D stated that the CNAs document this on the I&O record or possibly by the nurses on the MAR (medication administration record) as well. Surveyor asked RD D about calculating fluid needs. RD D stated that they are calculated and she usually uses the 30 mL/kg formula. RD D stated that this was part of the nutrition assessment. Surveyor asked RD D about hydration care plans for those residents at risk. RD D stated that this is dependent on cognitive status and she does educate those residents who can manage their fluids on their own. Surveyor requested fluids needs assessment for Resident 5. Surveyor spoke with NP C on 9/22/14 at 12:30 PM. NP C stated that intakes would have been helpful as she would have known there was a negative balance. NP C stated that (Resident 5's) sodium kept trending down. NP C stated that (Resident 5) needed to be in a more monitored environment, so the decision was made to send him out. NP C stated that the facility was clearly not able to maintain him here (at the facility) and that (Resident 5) had increased output through the [MEDICAL CONDITION] as well. NP C stated she usually does ask about fluid intake. NP C stated that she just wrote an order now for intakes. Surveyor spoke with RD D on 9/22/14 at 12:44 PM. RD D stated that the facility's new form does not have a spot for a fluid needs assessment. RD D stated that, per protocol, the residents need 1 milliliter of fluid per kilo calorie per day. Surveyor and RD D reviewed Resident 5's nutrition assessment and noted that area for a fluid intake and nutritional requirements. RD D agreed that this was blank. RD D stated that this should have been calculated. Using a standard 30 mL/kg of body weight calculation, Resident 5 would require approximately 3007 mL of fluid intake per day. Surveyor spoke with Certified Nursing Assistant (CNA) E on 9/22/14 at 1:50 PM. CNA E stated that (Resident 5) does well with feeding himself. CNA E stated that intakes and outputs are recorded on the sheet. CNA E stated that (Resident 5) was on I&O as of today. Surveyor spoke with Director of Nursing (DON) B on 9/22/14 at 1:00 PM. DON B stated that she was not sure what the scores for the Hydration Risk Screener meant, that she would have to look at Point Click Care. Surveyor asked DON B about the order for "Intake and Output for Foley and Drains" on the September Physician order [REDACTED]. DON B stated that this was not necessarily something that would be done. Surveyor asked for evidence that this was discussed and basis for which the decision was made to not complete them. Surveyor asked DON B about care planning for monitoring intakes as well as outputs for Resident 5. DON B stated that a care plan should have been initiated after (Resident 5) returned from the 9/4/14 hospital admit. The facility did not complete physical assessments for signs of dehydration despite the triggering of the Hydration CAA, variable and large amounts of liquid stool eliminated through a newly placed [MEDICAL CONDITION], and an unknown fluid intake requirement for Resident 5. The facility did not analyze data for output, in attempt to ensure that output did not far exceed fluid intake. A care plan addressing hydration and fluids was not implemented until after Resident 5 was hospitalized twice due to insufficient fluids. The facility provided a timeline regarding Resident 5's hydration status and hospitalization s on 9/24/14. This timeline states, "Facts: 1. Frequent hydration status monitoring via BMP labs." The facility completed labs on Resident 5, but did not ensure that physical assessments for signs of dehydration were completed and intakes were monitored. In addition, the timeline states, "3. No orders for strick I&O were given at the time of hospital discharges..." This statement is correct, however orders that included "I&Os for Foley & drains" were signed by a physician in August and September, while Resident 5 resided in the facility. The facility's nursing department also established an intervention of I&O via their "Hydration Risk Screener." The following examples are cited at the "D" level: Example 2 Resident 2 has [DIAGNOSES REDACTED]. The facility completed a "Hydration Risk Screener" dated 7/17/14 in which Resident 2 was noted to have risk factors related to [DIAGNOSES REDACTED]. This section is noted to be blank. The facility completed "Nutritional and Dietary Profile" dated 7/8/14. This assessment notes that Resident 2 receives thin liquids. Section A of this assessment notes that protein and calorie needs are calculate, but fluid intake needs are not. Section J of this assessment includes an area for fluid intake requirements to be calculated. This section is incomplete. The facility did not have evidence that fluid intake requirements were calculated for Resident 2. Example 3 Resident 3 has [DIAGNOSES REDACTED]. The facility completed a "Hydration Risk Screener" dated 8/14/14 in which Resident 3 was noted to have risk factors related to mobility. This assessment includes, in Section I, an area where a fluid requirement calculation is to be completed. This section is noted to be blank. The facility completed "Nutritional and Dietary Profile" dated 8/15/14. This assessment notes that Resident 3 receives thin liquids. Section A notes that protein and calorie needs are calculated but that fluid needs are not. Section J of this assessment includes an area for fluid intake requirements to be calculated. This section is incomplete. The facility did not have evidence that fluid intake requirements were calculated for Resident 3. Example 4 Resident 4 has [DIAGNOSES REDACTED]. The facility completed a "Hydration Risk Screener" dated 9/12/14 in which Resident 4 was noted to have risk factors related to mobility and diagnoses. This assessment includes, in Section I, an area where a fluid requirement calculation is to be completed. This section is noted to be blank. The facility completed "Nutritional and Dietary Profile" dated 9/19/14. This assessment notes that Resident 4 receives thin liquids. Section A notes that protein and calorie needs are calculated but that fluid needs are not. Section J of this assessment includes an area for fluid intake requirements to be calculated. This section is incomplete. The facility did not have evidence that fluid intake requirements were calculated for Resident 4. Example 5 Resident 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The facility completed a "Hydration Risk Screener" dated 8/13/14 in which Resident 1 was noted to have risk factors related toswallowing difficulties, more than 3 lbs. weight loss in one month. This assessment includes, in Section I, an area where a fluid requirement calculation is to be completed. This section is noted to be blank. The facility completed "Nutritional and Dietary Profile" dated 8/14/14. This assessment notes that Resident 1 receives nectar thick liquids. Section A of this assessment notes that protein and calorie needs are calculate, but fluid intake needs are not. Section J of this assessment includes an area for fluid intake requirements to be calculated. This section is incomplete. The facility did not have evidence that fluid intake requirements were calculated for Resident 1.

Based on observation, record review and interview the facility did not immediately consult with a physician when a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications) occurred with a need to alter treatment significantly in 2 of 8 total residents reviewed (Residents 8 and 1). Resident 8 had complaints of severe left arm/wrist pain and swelling at 3:50 AM a pain medication was given but no physician was called until 8:50 AM and the physician did not respond to the request for an X-ray until 1:13 PM. An X-ray at 4:30 PM revealed a fractured wrist. Resident 8 also had confusion and increased temperature (102 degrees Fahrenheit) at 11:30 AM and the physician was not called immediately to report the condition change. In addition the Physician had ordered Occupational Therapy (OT) to see Resident 8 to assess for a splint or a sling for her new left wrist fracture. OT had already left the building on 2/1/13 and the facility did not call the physician back to find out the plan of care for Resident 8's fractured wrist until the OT consult could be conducted. Resident 1 complained of pain and experienced hematuria. Resident 1 requested to be transported to the hospital. A physician was not informed of these conditions and Resident 1's request to be hospitalized per request. This is evidenced by the following: The American Medical Directors Association, Acute Changes of Condition in Long term Care settings a Clinical Practice Guideline indicates the following timelines in calling the physician in the following areas: *Musculoskeletal pain: marked localized bruising, swelling, or pain over a joint or bone with or without a recent fall. Is to be called to the physician immediately to notify of a change in condition. *Weakness of arm or leg: abrupt onset of noticeable changes in strength or use. This indicates immediate reporting to the physician. *Fractures and dislocations: any suspected fracture or dislocation should be called to the physician immediately. *Fever: New onset of a temperature of over 104 regardless of any symptoms OR T over 101 with other symptoms (unless under treatments already or physician already known) requires immediate notification to a physician. *Medical Complaint by family or resident; A demand to speak to a physician or have a medical assessment without delay requires an immediate notification to the physician. Example 1 Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 8's care plan for the problem titled "[MEDICAL CONDITION]" first initiated 1/16/13 indicates that resident will remain free of injuries or complications related to [MEDICAL CONDITION]. Interventions listed include the following: ...Monitor/document/report to MD PRN signs or symptoms or complications related to [MEDICAL CONDITION]; acute fracture/ compression Fractures...Obtain and monitor lab/diagnostic work as ordered and report to MD... A nursing note on 2/1/13 at 6:55 AM states, "Res. woke at about 3:50 A, c/o (complaints of) L arm being very sore, guarding/tenderness w/only (with only) light touch, is visibly slightly swollen but no evidence of skin discoloration, difficult to tell if pain is localized as she's guarding the entire arm and doesn't want it touched or moved, facial grimacing and almost tearful with amount of pain that she feels in it, given [MEDICATION NAME] 10 mg at 4 am; temp 100 F auxiliary at the time, BP and P elevated but probably r/t pain level, discussed w/ am nurse who will f/up (follow up) on VS (vital signs) and arm c/o." This note was written by RN G (Registered Nurse). This significant change of condition was not called immediately to Resident 8's physician. A nursing note on 2/1/13 at 7:18 AM states, "Patient participating 5x/wk in therapy; recning (receiving) pain mgmt (management), nutritional services and anticoagulation therapy; continues on PO ATB (by mouth antibiotic) for UTI (Urinary Tract Infection), per nursing has had a new onset of pain and are F/U with PCP...(Primary Care Physician)" This note written by Unit Manager RN E. This note states that the PCP will be called but there is no updated assessment for Resident 1's new significant arm pain. A nursing note dated 2/1/13 at 11:25 AM states, "Resident confused this am. Very warm to touch. looks dry. Fluids offered and encouraged. Did have a temp of 102.1. Lung sound clear. No cough or congestion. No nausea or emesis. left arm in a lot of pain. Unable to lift the arm. Swollen and the shoulder area. Stated that her shoulder and arm have been hurting her a few days. resting in bed...Unable to give Tylenol due to allergy. Placed call to PCP and did receive new orders. Will wait for results and follow up at that time. Continue to push fluids." It should be noted that orders received at this time were to draw labs, no orders were received to deal with her wrist pain, and there was no consulting with a physician as the orders were given by an assistant. A nursing note on 2/1/13 at 6:43 PM states, "Writer went to pick up left wrist and resident yelled and was in pain. Swelling noted to the wrist area. Complains of shoulder hurting her most of the week...Therapy had been working with her. Call placed with PCP with concerns and x-rays were taken. Also UA was collected and positive for UTI...Results were called to PCP and received new orders. Resident is unaware of how she hurt her wrist. Confusion noted due to her UTI. Not able to express words as she would have before. DON aware of results. Will continue to monitor." A nursing note on 2/1/13 at 8:18 PM states, "Due meds given, pt complained of pain and due pain meds given. no other issues, call lights within reach. left wrist fx noted per report." A nursing note on 2/2/13 at 3:02 AM states, "Swelling noted on left hand. Elevated left hand, afebrile call light within reached. no other issues will continue to monitor." A nursing note on 2/2/13, no time noted, indicated "late entry" states, "Night nurse reported to writer on Friday am resident had some swelling in her left arm. Night CNA (Certified Nursing Assistant) had told night nurse this information. Writer assessed in early am and called the PCP. On Thursday resident was toileted by writer and cna there was no sign of pain and swelling at that time. Was able to move her left arm like her usual. No information from therapy regarding the wrist issue except therapy had reported shoulders hurting her more. There was not a new issue. Resident has [MEDICAL CONDITION] changes in her shoulder." A physician's clinic patient call note (documented phone call from the facility to the clinic and their response) dated 2/1/13 indicates that LPN F (Licensed Practical Nurse) called the primary care physician at 8:53 AM requesting the following orders: (1) CBC, UA/Culture and Sensitivity, because pt has a temp of 102.1 this morning. She has been treated for [REDACTED]. (2) x-ray of Left shoulder and arm and wrist b/c (because) per therapy, pt has been c/o worsening left should pain all week. This morning (LPN F) can't even touch her wrist without pt yelling in pain. They can do x-rays there. Please call back with verbal OK's." A physician's clinic patient call note dated 2/1/13 indicates that at 10:00 AM (LPN F) called back to check on status of orders and she states that lab is coming out to draw another pt for stat labs and would like to know if pt should have labs done too." C-MA responded, "I have given the verbal to go ahead with the CBC, UA/Culture and Sensitivity" (Please note that this is not a consultation with a physician.) A physicians clinic patient call note dated 2/1/13 indicates at 1:13 PM a note from the physician states, "OK to do xr's(X-rays)-please let them know." Resident 8's X-Ray Radiology Report dated 2/1/13 indicates that at 4:30 PM the findings report was faxed to the facility. The results are as stated: The left wrist demonstrates a [MEDICAL CONDITION] aspect of the left triquetral bone with minimal displacement. Modes soft tissue swelling is present. Osteopenia is present. Modest [MEDICAL CONDITION] change of the left wrist. Conclusion: Left triquetral fracture as described." A physician's orders [REDACTED]. Use splint or sling. Ice or heat..." Please note that OT did not see Resident 8 on Friday 2/1/13. There is no documentation in Resident 8's medical record as to the plan of care that was used to treat her fractured wrist. No physician was called back to request treatment orders for her new fracture when OT did not see resident to provide a sling or splint treatment. Resident 8 received the pain medication [MEDICATION NAME] 5 mg 2 tabs (10 mg total) twice on 2/1/13, three times on 2/2/13, three times on 2/3/13, one time on 2/5/13 and once on 2/6/13 for verbal complaints of pain in her wrist. On 2/7/13 at 3:00 PM Surveyor interviewed NHA A (Nursing Home Administrator) regarding calling the physician when there is a change of condition. NHA A read the nursing note of Resident 8 at 6:55 AM on 2/1/13. NHA A stated, "We are working on a self-report for an injury of unknown origin on her wrist fracture. I read the note and (RN G) should have called the physician at 3:50 AM when the (RN G) noted a change of condition in (Resident 8). If the nurses do not get the physician to call back timely they are to call the physician again if no response the Medical Director is to be contacted which they have done before. I was not aware that this had occurred. We will be working on a solution to this. We follow the AMDA guidelines for physician notification." The facility failed to consult with Resident 8's physician when she had a significant change of condition related to significant pain in her arm, increased temp, and new confusion. Orders were not received for her wrist until 1:30 PM. At 4:30 PM a fracture was noted and the physician gave orders to have OT assess for a splint or a sling. OT did not see Resident 8 and no call back to the physician to receive an alternate plan of care for Resident 8's fractured wrist. Example 2 Resident 1's [DIAGNOSES REDACTED]. Resident 1 has an indwelling Foley Catheter. Resident 1 is his own decision maker. Resident 1's most current MDS (Minimum Data Set) with an observation look behind date of 1/23/13 documents Resident 1's BIMS (Brief Interview for Mental Status) score is 15 out of 15. Resident 1's Nurses Notes contain the following documentation: 11/18/12 - 07:25 (7:25 am): "Res (resident) c/o (complains of) abdominal pain w/ (with) gas and bloating; assessed situation: BS (bowel sounds) + (positive) x 4, abdomen soft and non tender in RUQ (right upper quadrant) & RLQ (right lower quadrant), soft but some tenderness in LLQ (left lower quadrant), taut & tender in LUQ (left upper quadrant). Percussion in LUQ suggestive of a large tympanic gas bubble; discussed assessment aspects & findings w/ (with) res, res agreed to try [MEDICATION NAME] and geri mox as anti gas measures & give treatment some time to work. Medications given at 12:05 am. Res continued to call staff, provided caring and reassurance, res wanted to go to ER (emergency room ) but discussed that situation did not warrant that given that we had orders that could deal w/ situation. When situation not resolved almost 2 hours later, res agreed to take one [MEDICATION NAME] for the pain, given at 1:50 am which did allow him to relax and he appeared to fall asleep within about 30 min (minutes) and he stopped calling for assistance from staff." 11/18/12 - 16:43 (4:43 pm): - "Pt had his cath (catheter) changed. His (sic) had kidney stones that had blocked the indwelling one and a result he was having leakage all over. No other issues or concerns noted. New cath intact no leakage." 11/19/12 - 01:38 (1:38 am): - PM nurse and noc (night) RN (Register Nurse) have spent better part of 1 - 1/2 hours with (Resident 1). He had numerous complaints all ending in wanting to go to (hospital). A - new Foley isn't right. B - my stomach is going to explode all over. C - is there blood leaking out of my butt? D - my penis has leakage. E - I want a shot for pain. Refused offer of pain pills. Eventually asked for and took pills. A - D were found to have no validation." 11/19/13 - 05:58 (5:58 am): "(Resident 1) slept until 0400 (4:00 am) he wanted up in w/c (wheelchair) as he was still having pain. Refused more pain meds. He wants to go to (hospital) for a shot." 11/19/12 6:14 (6:14 am): "Res had c/o penis and rectal pain at beg (beginning) of shift, discussed situation w/ res, noted dried blood around meatus. Turned res per his request and saw no evidence of bleeding on sheets beneath him. Res agreed to try pain pills to see if he was able to get sleep overnight. Two [MEDICATION NAME] given at 12:30 am. LPN (Licensed Practical Nurse) and RN both observed res asleep an hr (hour) and 2 - 3 hours after med (medication) given. Light red urine in Foley bag at beg of shift, this AM only pink tinged urine in catheter tubing above bag. No further dried or fresh blood at meatus this morning." 11/19/12 - 06:15 (6:15 am): "Aide reported to writer that Pt (Patient) c/o exreme (sic) pain from "caterer that's too big" and requesting to go out to hospital "if something's not done". Writer informed Pt that night shift RN would be consulted... Writer informed RN that Pt is demanding a new smaller catheter ... Pt demanding to go to hospital if nurse doesn't put new Foley in. RN reported to writer that she would insert a new catheter. Writer will inform (Hospital) Urology of 22 g (gauge) Foley inserted and hematureia." 11/19/12 06:54: "Writer noted RN going in to see pt. Pt demanding to have catheter out or go to (hospital). RN had Urology supplies with her and asked Pt if he wanted a new catheter or go to hospital. Pt said he's in a lot of pain and has been all night and requested to go to hospital instead of having RN try a new catheter. Pt is own POA (Power of Attorney). Writer called (two ambulances) who both reported soonest arrival could be in 40 - 60 min... Administrator notified." Resident 1's progress Notes from the ER dated 11/19/12 document the following: "Arrives per EMS (Emergency Medical Service), awake, alert, strong smelling urine and thick blody (sic) drainage from Foley catheter... elevated temp of 99.8 ... UA positive for LE (leukocyte esterase), [MEDICATION NAME], WBCs (White Blood Cells) and bacteria. Patient received 1G (Gram) [MEDICATION NAME] IV (intravenous) in house and discharged home on 500 mg (milligrams) BID (twice a day) [MEDICATION NAME] for presumed E coli UTI (Urinary Tract Infection) (most recent culture) but today's culture will need to be followed and antibiotics adjusted accordingly... Diagnoses: [REDACTED]. On 2/8/13 at 2:25 pm Surveyor spoke with NHA (Nursing Home Administrator) A regarding Resident 1's ER visit on 11/19/12. NHA A confirmed that Resident 1 should have been sent to the ER as soon as he requesting, or at least a physician should have been notified stating "If he wants to go, he goes, even if we don't see anything."