Every finding on record at Midtown Center for Health and Rehabilitation

Based on policy review, medical record review, and interview, the facility failed to ensure residents were accurately assessed for smoking for 2 of 2 (Resident #15 and #62) sampled residents reviewed. The findings include: 1.Review of the facility's policy titled, RAI (Resident Assessment Instrument) -MDS 3.0 Completion dated 1/1/2023, revealed .Residents are assessed using a comprehensive assessment process, in order to identify care needs . 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Atrial Fibrillation, Bronchopneumonia, Chronic Obstructive Pulmonary Disease, Hypertension, Wheezing, Dyspnea, and Nicotine Dependence. Review of the Care Plan dated 6/10/2025 confirmed Resident #15 was care planned for smoking. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had a Brief Interview for Mental Status score of 9, which indicated the resident was moderately cognitively impaired and was not coded for the use of tobacco. 3.Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Diabetes and Emphysema. Review of the annual MDS assessment dated [DATE], revealed Resident #62 had a BIMs score of 9, which indicated Resident #62 was moderately cognitively impaired and the resident was not assessed for the use of tobacco. 4.Review of the facility's Smoking List revealed Residents #15 and #62 were on the facility smoking list. 5. Observation in the facility's designated smoking area on 9/3/2025 at 9:39 AM, revealed Residents #15 and #62 smoking in the facility designated smoking area. During an Interview on 9/4/2025 at 3:41 PM, the MDS Director confirmed that the use of tobacco should have been captured on Resident #15's admission MDS assessment and Resident #62's annual MDS assessment.

Based on medical record review and interview, the facility failed to ensure residents were free from accident hazards for 1 of 5 (Resident #15) reviewed. The findings include: 1. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Arial Fibrillation, Cerebrovascular Disease, Cognitive Communication Deficit, Bronchopneumonia, Congestive Heart Failure, Hypertension, and Seizures. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact, dependent on staff for Activities of Daily Living skills, and the use of oxygen therapy. Review of the Physician order dated 3/5/2025 revealed Resident #15 received oxygen 2 liters/minute, binasal cannula (tubing used to deliver oxygen through the nose). Observation in Resident #15's room on 9/3/2025 at 8:13 AM, revealed Resident #15 in bed with binasal cannula tubing intact in nose and connected to an unsecured oxygen tank cylinder sitting at the resident's bedside. The oxygen cylinder was not secured to prevent from falling or causing injury or harm. During an interview on 9/3/2025 at 8:19 AM, Licensed Practical Nurse (LPN) A confirmed the oxygen tank should be secured to prevent injury or harm, and that it was hazardous if it fell over

Based on policy review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 5 of 9 residents (Resident #4, #64, #65, #77, #161) receiving enteral tube feeding (nutrition provided through a tube inserted into the gastrointestinal tract). The findings include: 1. Review of the facility policy titled, Safe and Homelike Environment . revised 1/2025, revealed .the facility will provide a safe, clean, comfortable and homelike environment.services will be provided as necessary to maintain a sanitary, orderly and comfortable environment . Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 6/12/2025, revealed .Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection.Cleaning is the removal of visible soil from objects and surfaces and normally is accomplished manually or mechanically using water with detergents or enzymatic products.Examples include .feeding tube pumps .Each user is responsible for routine cleaning and disinfection of multi-resident items after each use.Direct care staff are responsible for cleaning single-resident equipment when visible soiled.Most equipment may be cleaned /disinfected in the areas in which the equipment is used.For durable medical equipment such as feeding pumps, staff shall store used/dirty equipment in soiled utility room . 2. Review of the medical record revealed Resident #4 admitted on [DATE], with diagnoses including Cerebral Infraction, Dysphagia, and Aphasia. Review of the physician order dated 2/21/2025, revealed Resident #4 received named enteral tube feeding at 70 milliliters(ml) per hour through a feeding tube pump. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicated Resident #4 had severely impaired cognition, was dependent upon staff for eating, and received enteral feeding. Observations in Resident #4's room on 9/2/2025 at 10:35 AM, 4:37 PM and on 9/3/2025 at 8:06 AM, and 12:20 PM, revealed the enteral feeding pump was infusing and had dried, tan, unknown substances on the base of the enteral feeding pole. During an observation and interview in Resident #4's room on 9/3/2025 at 5:15 PM, the Director of Nurses (DON) confirmed the base of the resident's enteral feeding pole was splattered with dried enteral feeding and needed to be cleaned. The DON confirmed the enteral feeding pole should be cleaned at the time the feeding is dropped or leaked onto the pole. 3. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Seizures, and Hemiplegia. Review of the physician order dated 2/21/2025 revealed Resident #64 received named enteral feeding at 65 ml per hour and water at 55 ml per hour through a feeding tube pump. Review of the quarterly MDS assessment dated [DATE], revealed Resident #64 was severely cognitively impaired. Observations in Resident #64's room on 9/2/2025 at 10:20 AM, 11:33 AM, and 4:19 PM, and on 9/3/2025 at 7:48 AM, 12:06 PM, and 4:39 PM, revealed a dry, light brown colored substance on the enteral feeding pump and a dark brown colored substance resembling rust on the enteral feeding pole and on the base of enteral feeding pole. During observation and interview in Resident #64's room on 9/3/2025 at 5:28 PM, the Administrator and the DON confirmed resident's enteral feeding poles should not have dry substance or rust and should be cleaned. 4. Review of the medical record revealed Resident #65 was admitted on [DATE], with diagnoses including Cerebral Infraction, Dysphagia, Convulsions, and Aphasia. Review of the Physician Order dated 2/21/2025, revealed Resident #65 received named enteral tube feeding at 65 milliliters per hour through a feeding tube pump. Review of the quarterly MDS assessment dated [DATE], revealed Resident #65 was rarely/never understood and had severely impaired cognitive skills. Resident #65 was dependent upon staff for activities of daily living and received an enteral feeding nutrition. Observation in Resident #65's room on 9/2/2025 at 11:13 AM and 4:47 PM and on 9/3/2025 at 7:57 AM and 12:12PM, revealed the resident's enteral feeding pump infusing and had dried, tan, unknown substances splattered on the base of the enteral feeding pole. During and observation and interview in Resident # 65's room on 9/03/2025 at 5:24 PM, the DON confirmed the base of the resident's enteral feeding pole was splattered with dried enteral feeding and needed to be cleaned. 5. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Hemiplegia, Dysphagia, Gastrostomy, and Disorder of Thyroid. Review of the Physician Orders dated 4/30/2025, revealed Resident #77 received named enteral tube feeding at 80 ml per hour through a feeding tube pump. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicated severe cognitive impairment. Resident was dependent for all activities of daily living and received enteral feeding nutrition. Observations in Resident #77's room on 9/2/2025 at 10:30 AM and 4:44 PM, and on 9/3/2025 at 4:40 PM, revealed the enteral feeding pump infusing, and dried, tan, unknown substances splattered on the enteral feeding pump and on the base of the enteral feeding pole, and brown colored areas that appeared to be rust on the enteral pump pole. During and observation and interview in Resident # 77's room on 9/03/2025 at 5:28 PM, the DON confirmed the base of the resident's enteral feeding pump and pole was splattered with dried enteral feeding, should have been cleaned and the pole should be replaced. 5. Review of the medical record revealed Resident #161 admitted on [DATE], with diagnoses including Cerebral Infraction, Dysphagia, and Gastrostomy (insertion site of feeding tube). Review of the Physician Order dated 2/21/2025 revealed Resident #161 received named enteral tube feeding at 75 ml per hour through a feeding tube pump. Review of the quarterly MDS assessment dated [DATE], revealed the Resident #161 was rarely/never understood and had severely impaired cognitive skills. Resident #161 was dependent on staff for activities of daily living and received enteral feeding nutrition. Observations in Resident #161's room on 9/2/2025 at 11:15 AM and 4:50 PM, and on 9/3/2025 at 7:56 AM and 12:15 PM, revealed the enteral feeding pump infusing and dried, tan, unknown substances were splattered on the base of the enteral feeding pole. During an observation and interview in Resident #161's room on 9/03/2025 at 5:22 PM, the Administrator and DON confirmed the base of the enteral feeding pole was covered with dried enteral feeding. The DON confirmed the enteral feeding pole should be replaced with a clean pole

Based on policy review, medical record review, observation and interview, the facility failed to follow physician orders for 1 of 5 nurses (Licensed Practical Nurse (LPN) A) observed during medication administration. The findings include: 1. Review of the facility policy titled, Medication Administration, dated 2/20/2024, revealed .Compare medication source .with MAR [medication administration record] to verify resident name, medication name . 2. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE], and with a readmitted [DATE], with diagnoses including Cerebral Infarction, Hemiplegia, Wheezing, Shortness of Breath and Pneumonia. Review of the of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #48 was severely cognitively impaired. Review of the Medical Regimen Review Report dated 3/1/2025 - 3/20/2025, revealed .albuterol sulfate solution [for wheezing] for nebulization; 2.5 mg [milligrams]/3 ml [milliliters] .Every 6 Hours - PRN [as needed] . arformoterol solution [used for wheezing] for nebulization; 15 mcg [micrograms] .Twice A Day; 07:00AM - 11:00 AM . Observation on 3/19/2025 at 9:32 AM, revealed LPN A administered Albuterol Sulfate 25mg/3ml per nebulizer to Resident #48. Review of the Medication Administration Record (MAR) dated March 2025, revealed LPN A signed out that Arformoterol was administered, and Albuterol was not signed out as administered. During an interview on 3/19/2025 at 2:40 PM, the 3rd floor Assistant Director of Nursing (ADON) confirmed that this was a medication error. During an interview on 3/19/2025 at 2:50 PM, LPN A confirmed that she administered the Albuterol Sulfate and not the Arformoterol. During an interview on 03/20/2025 at 3:34 PM, the Director of Nursing (DON) confirmed that medications should be compared to the MAR for verification that the correct medication is being given.

Based on policy review, observation and interview, the facility failed to ensure infection control practices to prevent the spread of infection were used when 3 of 5 (Licensed Practical Nurses (LPN) A, B and C) nurses failed to do hand hygiene during medication administration. The findings include: 1. Review of the facility policy titled, Medication Administration, dated 2/20/2024, revealed .Wash hands prior to administering medications per facility protocol .Administer medication as ordered .Wash hands using facility protocol . Review of the facility policy titled, Hand Hygiene, dated 1/2024, revealed .If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . 2. Observation during medication administration on 3/19/2025 at 8:55 AM, revealed LPN B cleaned the blood pressure cuff with a Sani cloth and did not perform hand hygiene prior to preparing medications, administering medications or after administering medications to the Resident. 3. Observation during medication administration on 3/19/2025 at 9:32 AM, revealed LPN A did not perform hand hygiene prior to donning personal protective equipment (PPE). LPN A entered the Resident's room and had to return to the medication, LPN A doffed the PPE and did not perform hand hygiene, LPN A donned new PPE and did not perform hand hygiene. 4. Observation during medication administration on 3/19/2025 at 1:14 PM, LPN C did not perform hand hygiene prior to donning PPE. During an interview on 3/20/2025 at 3:34 PM the Director of Nursing (DON) was asked if staff should wash hands prior to donning and after doffing gloves. She stated, yes .

Based on policy review, medical record review, observation, and interview the facility failed to provide care and services consistent with professional standards of practice to appropriately identify pressure ulcers/pressure injuries (PU/PIs), to prevent pressure ulcers/injuries, and promote healing of existing PU/PIs, and failed to prevent the development of additional PU/PIs for 6 of 10 (Residents #27, #78, #151, #171, #478, and #479) sampled residents for pressure ulcers/injury. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #27 who was at risk of developing PU/PIs, had contractures to upper and lower extremities, and was dependent on staff for preventative interventions, repositioning and turning, developed an open pressure ulcer/injury to the palm of left hand from having long fingernails embedded into the skin and developed a stage 3 PU/PI to the right buttock that was identified as a stage 3, when Resident #78 with a Left Lateral Ankle Stage 4 PU/PI wound that was not consistent with the characteristics of staging, when Resident #151, who was dependent on staff for repositioning and turning and who was at risk for developing PU/PIs, developed pressure wounds to the right foot due to pressure from the foot board, when Resident #171, a resident at risk for developing pressure ulcers, developed a Stage 3 PU/PI to the coccyx that was identified as a stage 3, and when the facility failed to administer prescribed PU/PI treatments for Residents #478 and #479, and when Resident #478's wound was inconsistent with staging. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-686 on 9/5/2024 at 11:52 AM, and on 9/5/2024 at 12:24 PM of the amended IJ, in the Chapel. The facility was cited Immediate Jeopardy at F-686 at a scope and severity of J which is Substandard Quality of Care. The IJ was effective from 10/19/2023 and is ongoing. The findings include: 1. Review of the National Pressure Injury Advisory Panel 2019 Guidelines, revealed .Skin and soft tissue assessment is the basis of pressure injury prevention and treatment. Skin and tissue assessment is an essential component of any pressure injury risk assessment and should be conducted as soon as possible after admission, as a component of a full risk assessment .Each time the individual's clinical condition changes, a comprehensive skin and tissue assessment should be conducted to identify any alterations to skin characteristics or integrity, and to identify any new pressure injury risk factors . In addition to comprehensive skin assessment, a brief skin assessment of the pressure points should be undertaken during repositioning .Presence of persistent erythema can indicate a need to increase frequency of repositioning. Check pressure points onto which the individual will be repositioned to ensure that the skin and tissue has fully recovered from previous loading .Ongoing skin assessment is necessary to detect early signs of pressure injury . 2. Review of the facility's policy titled, Pressure Injury and Management, revised 8/30/2022, revealed .The facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Definitions: 'Pressure Ulcer/Injury' refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. 'Avoidable' means the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate . Policy Explanation and Compliance Guidelines .2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .3. Assessment of Pressure Injury Risk .Licensed nurses will conduct a pressure injury risk assessment .upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly . 4. Interventions for Prevention and to Promote Healing .After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management .Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics) .Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to .Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) .Minimize exposure to moisture and keep skin clean .Provide appropriate, pressure-redistributing mattresses for all residents .Maintain or improve nutrition and hydration status .Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present .Pressure injuries will be differentiated from non-pressure injuries .Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection, wound bed, wound edge and surrounding tissue characteristics .Interventions will be documented in the care plan and communicated to all relevant staff .Compliance with interventions will be documented in the weekly summary charting .5. Monitoring .The nurse will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of the findings in the medical record .The attending physician (or designee) will be notified of .The presence of a new pressure injury upon identification .The progression towards healing, or lack of healing, of any pressure injuries weekly .Any complications (such as infection, development of a sinus tract, etc.) as needed .A Focused Incident review will be performed on each pressure injury that develops in the facility. Findings will be reported in the monthly QAA [Quality Assessment and Assurance] Committee Meeting .The effectiveness of current preventative and treatment modalities and processes will be discussed in accordance with the QAA Committee Schedule, and as needed when actual or potential problems are identified .6. Modification of Interventions .Interventions on a resident's plan of care will be modified as needed .Changes in resident's degree of risk for developing a pressure injury .New onset or recurrent pressure injury development .Lack of progression towards healing .Resident non-compliance .Changes in the resident's goals . Review of the facility's policy titled Skin Assessment, dated 5/2023, revealed .It is our policy to perform a full body assessment as part of or systematic approach to pressure injury prevention and management .Policy Explanation and Compliance Guidelines .1. A skin assessment will be conducted by a licensed or registered nurse upon admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 2. Procedure .Begin head to toe, thoroughly examining the resident's skin for conditions. Pay close attention to pressure points [can include sacrum, heels, greater trochanter (upper hip area) ischial area (lower hip area), back of the head, ears, shoulders, elbows, inner knees and malleoli (ankle bones)], bony prominences, and underneath medical devices .Remove any special garments or devices .Remove any dressings, using clean technique .and note findings . Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, ad lesions .3. Consider the general status of the resident's skin .Color .Temperature .Moisture status .Skin texture/turgor .Perfusion. 4. Considerations for a resident with darkly pigmented skin .Localized heat .Edema .Bogginess .Induration .Temperature differences of surrounding skin .Skin discoloration. 5. Considerations for a bariatric resident .Perform assessment with at least one other staff member to assist with mobility ad positioning of body parts .Thoroughly inspect each surface skin fold .6. Differentiating the extent of redness .Blanchable erythema (redness) loses its redness when a finger is pressed on the erythema for 3 seconds and released. Blanching is assessed following the removal of the finger .Non-blanchable erythema (redness) persists when touched. Review of the facility's policy titled, Skin Integrity- Foot Care, reviewed/revised on 4/1/2024, revealed .Policy: It is the policy of this facility to ensure residents receive proper treatment and care .to maintain mobility and good foot health .Policy Explanation and Compliance Guidelines: 1. This facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications from the resident's medical conditions .The facility will utilize a systematic approach for the prevention and management of foot ulcers, including efforts to identify risk; stabilize, reduce, or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as appropriate .2. Assessment of risk .Licensed nurses will conduct pressure injury risk assessments and skin assessments in accordance with facility policy for those assessments .The comprehensive assessment process will be utilized for identifying additional risk factors or conditions that increase risk for impaired skin integrity of the foot. Examples include, but are not limited to .diabetes, peripheral vascular disease, peripheral arterial disease, venous insufficiency, peripheral neuropathy, and lack of sensation in the feet .Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after task. 3. Interventions for preventions and to Promote healing .Interventions will based on specific factors identified in the risk assessment, skin assessment, and assessment of any foot ulcers .Appropriate offloading or orthopedic devise, diabetic shoes, or pressure-relieving devices will be utilized .referrals to podiatrists, vascular or orthopedic surgeons, or wound care physicians will be made when appropriate. The facility will arrange for transportation to and from any appointments .Medical conditions will be managed and interventions will be implemented in accordance with professional standards of practice to prevent complications from medical conditions .Evidence-based treatments will be provided for all residents who have a foot ulcer .Pressure injuries will be differentiated from non-pressure ulcers . 4. Monitoring .The attending physician will assume responsibility for overall care and treatment of the resident's medical conditions .RNs [Registered Nurses] and LPNs [Licensed Practical Nurses] will participate in the management of medical conditions by following physician orders, assessment of residents, and reporting changes in condition .Interventions will be modified in a resident's plan of care as needed. Considerations for needed modifications include .Changes in medical condition or degree of risk for developing foot ulcers .New onset or recurrent foot ulcer .lack of progression towards healing .Resident non-compliance .Changes in the resident's goals and preferences. 6 .The facility will follow proper infection prevention practices for foot care equipment/devices, including but not limited to nail clippers .reusable medical devices .must be cleaned and reprocessed . 3. The facility's Pressure Injury Staging and Care Plan Consideration and Pressure Injury Management Guidelines documents (from The Named Company dated 2019) were provided to the survey team on 9/4/2024, when the facility was asked for the source used by the facility to identify and stage pressure ulcers/injuries. The documents are as follows: a. Review of the facility's Pressure Injury Staging and Care Plan Consideration document revealed, .Stage 1 Pressure Injury: Non-blanchable erythema of intact skin .Intact skin with a localized area of non-blanchable erythema [a skin discoloration that doesn't run white when pressed], which may appear differently in darkly pigmented skin Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis [middle layer of skin] .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 [healing process for deep pressure ulcers], slough [dead tissue], and eschar [dead dark tissue] are not present. These injuries commonly result from adverse microclimate [temperature, humidity airflow near the skin] and shear in the skin over the pelvis and shear [pressure and friction exerted] in the heel . Stage 3 Pressure Injury . Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible .Undermining and tunneling [tunneling and separation in a wound that occurs under the skin] may occur .If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury .Stage 4 Pressure Injury .Full-thickness skin and tissue loss with exposed or directly palpable fascia [tissue, tendons, etc. that are exposed and can be felt in a stage 4 pressure ulcer/injury], muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible, Epibole (rolled edges), undermining and/or tunneling often occur .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 .in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar .Deep Tissue Pressure Injury [DTPI]: .Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface .Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions . b. Review of the facility's Pressure Injury Management Guidelines document revealed, .Stage 1 .Off Load .Manage Moisture Cover/Protect .Strategies to Protect: Choose Moisture Barrier to match type and level of incontinence. Assess repositioning interval. Assess support surfaces. Assess wheel chair positioning .Stage 2 Partial Thickness .Off Load .Manage Exudate Cover/Protect .Cleanse with normal saline or Wound Cleanser. Light Exudate: Apply Hydrogel, Hydrogel Ag [silver], Honey Hydrogel, Xeroform or Petrolatum Gauze. Change Daily. Minimal/Moderate Exudate: Apply Hydrocolloid Dressing. Change Q3D [every 3 days] .Stage 3 Full Thickness . Off Load .Manage Exudate Fill cavity Cover/Protect .Cleanse with normal saline or Wound Cleanser. Light Exudate: Apply Hydrogel, Hydrogel Ag, Honey Hydrogel or Collagen. Moderate Exudate: Apply Collagen, Calcium Alginate, Honey Alginate or Super Absorbent Dressing. Heavy Exudate: Apply Calcium Alginate, Honey Alginate or Super Absorbent Dressing. Change QD [every day] or QOD [every other day] .Stage 4 Full Thickness .Off Load .Manage Exudate . Debride if needed .Fill cavity Cover/Protect .Cleanse with normal saline or Wound Cleanser. Light Exudate: Apply Hydrogel, Hydrogel Ag, Honey Hydrogel or Collagen. Moderate Exudate: Apply Collagen, Calcium Alginate, Honey Alginate or Super Absorbent Dressing. Heavy Exudate: Apply Calcium Alginate, Honey Alginate or Super Absorbent Dressing. Change QD or QOD .Unstageable 100 % [percent] Eschar Full Thickness .Off Load . Manage Exudate . Debride . Fill Cavity .Cover/Protect . Cleanse with normal saline or Wound Cleanser. Chose a debridement: Autolytic, enzymatic or sharp debridement. Light Exudate: Apply Hydrogel, Hydrogel Ag, Honey Hydrogel dressing. Moderate Exudate: Apply Collagen, Calcium Alginate, Honey Alginate or Super Absorbent Dressing. Heavy Exudate: Apply Calcium Alginate, Honey Alginate or Super Absorbent, Change Dressing QD or QOD . Unstageable .Off Load .Keep Dry .Cover/Protect .Assess Support Surfaces .Decrease Friction/Shear .Stable Eschar: Keep area dry. Keep area intact. Assess wheelchair positioning and seating. Stable Eschar on heels: (dry, no erythema, no exudate, fluctuance [Sign of pus that has accumulated beneath the surface of the skin])- area does not need to be debrided. Paint with skin prep or betadine. Off load heels. No shoes . Deep Tissue Injury [DTI] .Off Load .Keep Dry .Cover/Protect .Assess Support Surfaces .Decrease Friction/Shear . Strategies to protect: DTI on heels: Suspend heels with pillows, specialty cushions, boots. DTI sacral/gluteal: Use moisture barrier to match type and amount of incontinence. Assess repositioning interval. Assess support surfaces. Assess wheelchair positioning and seating .Medical Device Related Pressure Injuries .Pressure injuries that result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant ulcer generally conforms to the pattern or shape of the device. Should be staged to the most severe tissue damaged depth .Off Load .Manage Exudate .Debride if needed .Fill cavity . Cover/Protect .Removal, padding or repositioning of device causing injury is of utmost importance to allow and/or prevention. Residents with any type of medical device in place should be assessed at least twice a day for possible skin injury. 4. Review of medical record revealed Resident #27 was admitted on [DATE], with diagnoses including Cerebral Infarction, Hemiplegia, Diabetes, Contracture, Dysphagia, Dementia and Aphasia. Review of the Braden Scale assessment completed on 12/30/2022 revealed Resident #27 was at high risk of developing a pressure ulcer. The facility failed to provide Resident #27's Braden Scale Assessment since the admission assessment on 12/30/2022 after requesting. Review of Resident #27's care plan revealed .Approach Start Date 4/20/2023 CONTRACTURES: The resident has contractures of the LUE [left upper extremity], bilateral hands). Provide skin care to keep clean and prevent skin breakdown . Review of Resident #27's care plan revealed .Approach date 11/22/2023 . Resident is at risk for skin breakdown R/T [related to] immobility . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #27 was rarely/never understood with cognitive skills for daily decision making severely impaired. The resident did not have a Brief Interview for Mental Status (BIMS) score. Further review revealed Resident #27 had impaired Range of motion (ROM) to upper left side extremity and a ROM impairment to both lower extremities. Resident #27 was dependent on staff for all activities of daily living (ADL's). Review of Resident #27's Medication Administration Record (MAR) dated 8/1/2024 through 8/31/2024 revealed: Cleanse area to palm of left hand with wound cleanser, pat dry, apply calcium alginate with a dry 4 x (by) 4, on Monday, Wednesday, and Friday. Cleanse stage 3 (III) to right buttock with wound cleanser pat dry, apply silver alginate and cover with border foam 3 times weekly and as needed. Review of Resident #27's care plan revealed .Approach Start Date: 8/6/2024 Rolled wash cloth inside left hand . Review of Resident #27's Wound Event Note dated 8/7/2024, revealed laceration to palm of left hand, caused by fingernails embedded into left hand, with measurements, in centimeters (cm) by (x) length x width x depth (L x W x D), of 2.2 cm x 2.0 cm x 0.2 cm. The facility failed to provide signed physician orders for the pressure ulcer/injury treatment to Resident #27's left hand palm. Review of Resident #27's care plan revealed .Approach Start Date: 8/7/2024 Resident has skin tears or cuts palm of left hand .Record location, size (length, width, depth), color, surrounding skin, presence/absence of drainage/pain/signs of healing every week .Treat area per MD [Medical Doctor] orders . Review of Resident #27's progress note dated 8/13/2024, revealed .laceration measures 0.2 cm x 0.2 cm x 0.1 cm left palm . Review of the INTEGRATED WOUND CARE Follow-up Progress Note dated 8/16/2024, revealed a stage 3 pressure injury/ulcer was identified on Resident #27's right buttock as a pressure injury with moderate serosanguinous exudate and tissue type documented with 100% granulation. The wound measured 1.1 cm x 0.9 cm x 0.3 cm. Review of the medical record revealed Resident #27's stage 3 to right buttock pressure injury was identified on 8/16/2024 with measurements of 1.1 cm x 0.9 cm x 0.3 cm. Review of Resident #27's MARS dated 8/1/2024 -8/31/2024, revealed no wound treatment documentation for right buttock stage 3 pressure injury on 8/16/2024. The facility failed to provide signed physician orders for treatment of Resident #27's stage 3 pressure injury. Review of Resident #27's care plan revealed .Approach Start [NO DATE] Resident with stage 3 to right buttock .provide treatments as ordered .assess wounds and skin weekly for changes .keep clean and dry as possible .Minimize skin exposure to moisture .keep linen clean and dry and wrinkle free . The care plan was not revised/updated to reflect the date the Stage 3 was identified. Observation on 8/19/2024 at 9:30 AM and 2:45 PM, and on 8/20/2024 at 8:09 AM and 2:23 PM, revealed Resident #27's fingernails appeared trimmed with jagged edges, bilateral hands without hand rolls, and with a foul odor. The resident's legs were observed to be contracted. The facility failed to follow the care plan for bilateral hand rolls for Resident #27. During an interview on 8/20/2024 at 2:30 PM, CNA O was asked how many staff are supposed to turn and reposition Resident #27. CNA O stated, We try to use 2 staff to turn and repo [reposition]. CNA O was asked if she smelled an odor from Resident #27's hands. CNA O stated, They are sweaty and needs cleaning I will get someone to help me wash them. CNA O was asked when Resident #27's hands are washed. CNA O states, She is bathed daily, but we ask the nurse to help open her hands at times . CNA O was asked what she would do if she observed an injury or a wound on a resident. CNA O stated, I would need to tell my nurse. CNA O was asked if Resident #27 was supposed to have anything in her hands. CNA O stated, I think so, I will get some washcloths . CNA O was asked why she didn't have hand rolls in her hands. CNA O stated, .guess we forgot .we should have had them there in her hands when we came on shift this morning . CNA O was asked how often Resident #27's nails are trimmed. CNA O stated, I don't know the nurse takes care of that . CNA O was asked if Resident #27 can open her hands on her own. CNA O stated, .no she cannot do anything she had a stroke .we do all her care, she's totally dependent on staff . During an interview on 8/20/2024 at 3:15 PM, LPN N was asked who trims Resident #27's nails. LPN N stated, The CNA trims her nails weekly . LPN was asked who cleans her hands. LPN N stated, .the CNA cleans her hands daily . LPN N was asked if Resident #27 had a wound inside her left hand. LPN N stated, I think she does but the wound nurse takes care of the wounds . LPN N was asked would Resident #27 have interventions in place for her hand contractures. LPN N stated, She needs hand rolls for that . Observation on 8/20/2024 at 3:45 PM, revealed Resident #27 did not have hand rolls in her hands in accordance with the resident's care plan. The resident's legs were observed to be contracted. Observation and interview in Resident's room on 8/21/2024 at 10:30 AM, with LPN A revealed Resident #27's bilateral hands did not have hand rolls. LPN A was asked when Resident #27 should have hand rolls. LPN A stated, She should have hand rolls each shift, I will do that now. LPN A opened Resident #27's left contracted hand, removed the dressing from her left palmed hand. Observation of Resident #27's palm of left-hand revealed a round open wound. The round edge of the wound appeared white with a moist edge surrounding the wound. The wound bed was red. The dressing had light brown drainage, with a slight odor. The wound measured (L length x [by] width x Depth) 2.0 cm x 2.0 cm x 0.2 cm. LPN A was asked what caused the wound and what stage was the wound. LPN A stated, I originally found the wound on 8/7 [2024] during her weekly skin assessment. My wound event note was documented as a laceration .the injury was caused by her fingernails embedded into her left palm of her hand. LPN A was asked if the wound was caused by pressure to the left palm from her nails embedded into her hand. LPN A stated, Yes, it was . LPN A was asked if the laceration she documented was actually a pressure injury. LPN A stated, I can't say . LPN A was asked if she can stage a wound. LPN A stated .Yes I am certified, but the Wound Nurse Practitioner stages the wounds . LPN A was asked if the wound should be staged as a pressure injury. LPN A stated, .the nails were pressed into her skin by her contracted hand, and pressure was applied, I would say it could be a pressure injury . LPN A was asked who trims her fingernails and how often are they trimmed. LPN A stated, The charge nurse usually trims them .I can't say when the last time they were trimmed . LPN A was asked how long her fingernails were on the day the wound was found. LPN A stated, Her nails were very long .that's why they cut into her hand and why I documented a laceration . LPN A was asked how often Resident #27's hands are cleaned. LPN A stated, Staff should clean her hands everyday but the nurses may have to assist with opening her hands. LPN A was asked if Resident #27 can open her hands or position herself in bed. LPN A stated, No she's total dependence [on staff] with her care. LPN A was asked what interventions are in place for Resident #27's hand contractures. LPN A stated, She is supposed to have a hand roll or rolled wash cloths in her hands. LPN A was asked if Resident #27's hand had a foul odor and why she doesn't have hand rolls in place. LPN A stated, Yes, her hands have an odor and need to be cleaned .she needs hand rolls in her hands as well . LPN A was asked how often the dressing is changed. LPN A stated, 3 times a week. LPN A was asked why the laceration was changed to a skin tear on 8/23/2024. LPN A stated .I probably would not have changed the wound to a skin tear, but the wound NP documented that . LPN A was asked if the wound could have been prevented. LPN A stated, I believe so. LPN A was asked if the resident's left palm wound was larger than the last measurement. LPN A stated .I believe so, it's almost the same size as the day it was initially found . The resident's legs were observed to be contracted. The 8/21/2024 measurements were not documented in the medical record, and the 8/21/2024 measurements had increased in size from the 8/13/2024 measurements. Observation on 8/22/2024 at 7:30 AM, revealed Resident #27 did not have hand rolls in her hands in accordance with the care plan. Observation and interview in the resident's room on 8/22/2024 at 10:30 AM, revealed LPN C described Resident #27's right buttock as a stage 3 pressure injury. LPN C stated, .the wound appears as a full thickness tissue loss with the wound bed red with granulation tissue measuring 0.5 cm x 0.5 cm x 0.3 cm. LPN C was asked when the wound was found and at what stage was the wound when it was first documented. LPN C stated, The right buttock [pressure ulcer/injury] was found on 8/16/2024 at a Stage 3. LPN C was asked how Resident #27 developed a wound at a stage 3. LPN stated, .her comorbidities . LPN C was asked if a wound should initially start at a stage 3. LPN C stated, No, it should not start as a stage 3 pressure injury. Review of Resident #27's progress note dated 8/23/2024, revealed .skin tear to left hand measures 0.4 cm x 0.4 cmx 0.1 cm . Resident #27's left palm pressure injury healed on 8/24/2024. Review of the INTEGRATED WOUND CARE Follow-up Progress Note dated 8/23/2024, revealed Resident #27's .pressure ulcer stage 3 to right buttock was .documented as a pressure injury with moderate serosanguinous exudate and tissue type with 50% granulation and 50% dermis. The wound measured 0.5 cm x 0.5 cm x 0.3 cm . Review of Resident #27's shower/bath sheets dated 8/2/2024, 8/6/2024, 8/9/2024, 8/13/2024 revealed no documentation the resident had any skin integrity issues or open area to the right buttock. Review of the INTEGRATED WOUND CARE Follow-up Progress Note dated 8/26/2024, revealed Resident #27's pressure ulcer stage 3 to the right buttock was documented as a pressure injury with no exudate, with tissue type 100% epithelial, and measured 0.5 cm x 0.5 cm x 0.3 cm. The facility was asked for signed MD orders on 8/27/2024. The facility did not provide requested signed MD on 8/27/2024. The facility was asked for signed MD orders on 8/28/2024. The facility did not provide requested signed MD orders on 8/28/2024. The facility provided signed MD orders on 8/29/2024, but the orders did not include Resident #27's treatments to pressure injury to palm of left hand or stage 3 right buttock. During an interview on 8/29/2024 at 2:30 PM, the DON was asked if the Medical Regimen Review Report dated 8/1/2024 through 8/28/2024 included the complete signed physician orders August 2024 for Resident #27. The DON stated Yes. The DON was asked if she can see treatment orders on the report. The DON stated No, but I will check on that . The DON was asked if the treatment orders should be signed by the physician. The DON stated Yes. The DON was asked if a treatment isn't signed on the MAR or Treatment Administration Record (TAR), was the wound treatment completed. The DON stated, .if it's not documented it's not completed. Review of the INTEGRATED WOUND CARE Follow-up Progress Note dated 9/2/2024, revealed .Pressure ulcer Buttock right .Resolved 9/2/2024 .PLAN .MASD [moisture- associated skin damage] right Buttock .Cleanse with wound cleanser, pat dry. Apply collagen, border gauze. QD [every day]/ [and] prn [as needed] . The facility failed to reassess and implement interventions for the change in wound classification to a MASD. Review Resident #27's progress notes dated 9/2/2024, revealed .Resident was seen by wound NP today per her observation stage 3 to right buttock .resolved . During an interview on 9/4/2024 at 9:30 AM, the Wound Nurse Practitioner (NP) was asked how a wound in the palm of a contracted left hand caused by long fingernails, could be identified initially as a laceration on 8/7/2024, then on 8/23/2024 be changed to a skin tear, and not be identified as a pressure injury to the palm of her left han [TRUNCATED]

Based on policy review, medical record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) was provided nail care for 1 of 4 (Resident #105) sampled residents reviewed for activities of daily living. The facility's failure to ensure toenail care was provided resulted in Actual Harm when Resident #105's skin was adhered to a long toenail, causing the resident pain. The findings include: 1. Review of the facility policy titled, Activities of Daily Living (ADLs), dated 2/2024, revealed .Care and services will be provided for the following activities of daily living .grooming .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain .grooming and personal hygiene . Review of the facility policy titled, Nailcare, dated 4/1/2024, revealed .Assessments of resident nails will be conducted on admission .to determine the resident's nail condition, needs .Routine cleaning and inspection of nail will be provided during ADL care on an ongoing basis .Routine nail care .will be provided at regular intervals . Review of the Admission Packet Document titled, Resident Rights, revealed .The resident has the right to a dignified existence .inside and outside the facility . 2. Review of the medical record revealed Resident #105 was admitted to the facility on [DATE], with diagnoses including Muscle Weakness, Pain, and Need for assistance with Personal Care. Review of the physician orders revealed .Start Date .4/7/2024 .Consultation for Podiatry .as needed for patient health and comfort . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #105 was cognitively intact and dependent on staff for personal hygiene. Review of the care plan dated 6/24/2024, revealed Resident #105 had a self care deficient and was dependent on staff for ADLs. During an interview on 8/18/2024 at 4:31 PM, Resident #105 stated, I need my toenails cut, they have not been cut since I have been here. They look like a freak show. Observation in the resident's room on 8/20/2024 at 10:21 AM, revealed Resident #105 asked the surveyor when she was going to get her toenails cut. The toenails were making the socks poke out due to their length. LPN K was asked to Resident 105's room by the surveyor and asked to remove Resident #105's socks. Resident #105 told LPN K that she was hurting her while she was moving her toes and looking at the nails. Resident #105's toenails on the left foot were thick, long and extended past the tips of the toes about 1/4 of an inch. The right foot toenails were thin and extended past the tips of the toes. LPN K didn't want to trim the right foot big toenail because she felt the skin was attached to the nail. She stated she was going to try to trim the other nails. LPN K confirmed the Resident was on the podiatry list for the week. Review of the progress notes revealed, 08/21/2024 03:09 PM [Named Resident #105] .informed that podiatry has cancelled and has been rescheduled for 9/5/24 [2024], 9/12/24 and 9/24/24, though [Named Resident #105] was scheduled for outside podiatry visit today . During an interview on 8/21/24 at 10:28 AM, the Social Work Director confirmed podiatry cancelled visit today and won't be back until September. Resident #105 was on the list to be seen by the onsite Podiatry Company, that had cancelled the 8/21/2024 facility onsite visit. The facility scheduled an outside appointment after the facility onsite podiatry company cancelled. During an interview on 8/22/24 at 8:24 AM, Resident #105 stated she went to the podiatrist (outside of the facility) yesterday [8/21/2024] and had her toenails cut. She stated, .my toes feel a lot better. They don't hurt anymore . During an interview on 8/22/2024 at 12:20 PM, Resident #105 was asked if her toenails hurt before they were cut. Resident #105 stated, Yes, my toenails were painful. During an interview on 9/3/2024 at 10:35 AM, the 3rd floor Assistant Director of Nursing (ADON) confirmed nails should be assessed two times a week and staff should have noticed the nail length before 8/18/2024, when the surveyor brought the resident's long and painful toenails to the facility's attention. During an interview on 9/3/2024 at 4:54 PM, Resident #105 was asked how her toenails were, she stated, .feels like I have new feet . Resident #105 was admitted to the facility on [DATE] and there was a physician's order for a podiatry consult dated 4/7/2024. The facility failed to provide podiatry services until 8/21/2024 when Resident #105's toenails were long, painful, and the right big toenail was attached to the skin, which caused pain to the resident.

Based on policy review, medical record review, and interview, the facility failed to provide education for Advance Directives to residents or resident's responsible parties for 33 of 34 sample residents (Resident #12, #22, #23, #27, #29, #30, #43, #50, #51, #58, #71, #86, #91, #92, #95, #97, #98, #105, #107, #112, #123, #124, #127, #137, #150, #151, #153, #154, #156, #157, #171, #174, and #229) reviewed for Advanced Directives. The findings include: 1. Review of the facility's policy titled Advance Directives Policy, dated 2/20/2024, revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Advanced directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated .The facility will provide the resident or resident representative information about the right to refuse medical or surgical treatment and formulate an advance directive . 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Neurogenic Bladder, Dysphagia, Rheumatoid Arthritis, Psychosis, and Hypothyroidism. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated cognitive intact. 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Anxiety, Atrial Fibrillation, and Psychosis. Review of the significant change MDS dated [DATE] revealed Resident #22 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. 4. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Anxiety, Diabetes, Cerebral Infarction, Cancer of Kidney, and Schizophrenia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #23 had a BIMS score of 14, which indicated the Resident was cognitively intact. 5. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Diabetes, Gastrostomy, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #27 had severe cognitive impairment. The facility was unable to perform a BIMS test. 6. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, Aphasia, and Dysphagia. Review of the quarterly MDS dated [DATE], revealed Resident #29 had a BIMS of 9, which indicated the Resident had moderate cognitive impaired. 7. Review of the medical record revealed resident #30 was admitted to the facility on [DATE], with diagnosis including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Dementia, and Thyrotoxicosis. Review of the quarterly MDS dated [DATE] revealed Resident #30 had a BIMS score of 11, which indicated the Resident had moderate cognitive impairment. 8. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease, Glaucoma, Coronary Artery Disease, and Anxiety. Review of the annual MDS dated [DATE] revealed Resident #43 had a BIMS score of 12, which indicated the Resident had moderate cognitive impairment. 9. Review of the medical record revealed Resident #50 was admitted to the facility on [DATE], with diagnoses including Chronic Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Cerebral Infarction, Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed Resident #50 had a BIMS score of 15, which indicated the Resident was cognitively intact. 10. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Diverticulosis, Pulmonary Edema, Diabetes, and Sepsis. Review of the quarterly MDS dated [DATE], revealed Resident #51 had a BIMS of 11, which indicated the Resident had moderate cognitive impairment. 11. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE], with diagnoses including Atherosclerotic Heart Disease, Anxiety, Hypertension, and Heart Failure. Review of the Quarterly MDS dated [DATE], revealed Resident #58 had a BIMS score of 9, which indicated the Resident had moderate cognitive impairment. 12. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Urinary Retention, Congestive Heart Failure, Chronic Respiratory Failure, and Cardiomyopathy. Review of the annual MDS dated [DATE], revealed Resident #71 had a BIMS score of 15, which indicated the Resident was cognitively intact. 13. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Diabetes, Heart Failure, Psychotic Disorder, and Anxiety. Review of the quarterly MDS dated [DATE], revealed Resident #86 had a BIMS score of 00, which indicated the Resident had severe cognitive impairment. 14. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE], with diagnoses including Dysphagia, End Stage Renal Disease, Breast and Colon Cancer, Muscle Weakness, Metabolic Encephalopathy, Hypertension, Pressure Ulcer Stage 3 of Right Buttocks and Left Buttocks, and Severe Protein Malnutrition. Review of the admission MDS dated [DATE], revealed Resident #91 had a BIMS of 4, which indicated the Resident had severe cognitive impairment. 15. Review of the medical record revealed Resident #92 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Depression, and Atrial Fibrillation. Review of the annual MDS dated [DATE] revealed Resident #92 had a BIMS score of 6, which indicated the Resident had severe cognitive impairment. 16. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE], with diagnoses including Bipolar Disorder, Anxiety, Dementia, and Rheumatoid Arthritis. Review of the quarterly MDS dated [DATE] revealed Resident #95 had a BIMS score of 13, which indicated the resident was cognitively intact. 17. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease, Diabetes, and Vitamin D Deficiency. Review of the quarterly MDS dated [DATE] revealed Resident #97 had a BIMS score of 13, which indicated the Resident was cognitively intact. 18. Review of the medical record revealed Resident #98 was admitted to the facility on [DATE], with diagnoses including Senile Degeneration of Brain, Diabetes, Functional Quadriplegia, Benign Prostatic Hyperplasia, Cerebral infarction, and Hypothyroidism. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 00, which indicated Resident #98 was severely cognitively impaired. 19. Review of the medical record revealed Resident #105 was admitted to the facility on [DATE], with diagnoses including Complete Intestinal Obstruction, Morbid Obesity, Dyspnea, and Cellulitis. Review of the quarterly MDS dated [DATE],4 revealed Resident #105 had a BIMS score of 13, which indicated the Resident was cognitively intact. 20. Review of the medical record revealed Resident #107 was admitted to the facility on [DATE], with diagnoses including Fusion of Spine, Spondylosis, Spinal Stenosis, Pain, and Sleep Apnea. Review of the quarterly MDS dated [DATE], revealed Resident #107 had a BIMS of 15, which indicated the Resident was cognitively intact. 21. Review of the medical record revealed Resident #112 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure, Nontraumatic Intracerebral Hemorrhage, Cocaine Abuse, and Diabetes. Review of the quarterly MDS dated [DATE] revealed Resident #112 had a BIMS of 12, which indicated the Resident was moderately cognitively impaired. 22. Review of the medical record revealed Resident #123 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease, Chronic Kidney Disease, Diabetes, and Anemia. Review of the quarterly MDS dated [DATE] revealed Resident #123 had BIMS of 5, which indicated the resident was severe cognitive impaired. 23. Review of the medical record revealed Resident #124 was admitted to the facility on [DATE], with diagnoses including Systemic Lupus Erythematosus, Diabetes, and Pressure Ulcers. Review of the quarterly MDS dated [DATE] revealed Resident #124 had a BIMS of 12, which indicated the resident was cognitively intact. 24. Review of the medical record revealed Resident #127 was admitted to the facility on [DATE], with diagnoses including Benign Neoplasm of Meninges, Chronic Obstructive Pulmonary Disease, Psychosis, Diabetes, and Seizures. Review of the quarterly MDS dated [DATE] revealed Resident #127 had a BIMS score of 5, which indicated the Resident had severe cognitive impairment. 25. Review of the medical record revealed Resident #137 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Depression, Anemia, and Aphasia. Review of the quarterly MDS dated [DATE], revealed Resident #137 had severe cognitive impairment. The facility was unable to perform a BIMS test. 26. Review of the medical record revealed Resident #150 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory Failure, Adult Failure to Thrive, and Insomnia. Review of the quarterly MDS dated [DATE], revealed Resident #150 had a BIMS of 13, which indicated the Resident was cognitively intact. 27. Review of the medical record revealed Resident #151 was admitted to the facility on [DATE], with diagnoses including Spondylosis, Anxiety, Spinal Stenosis, and Pressure Ulcer of Sacral Region. Review of the quarterly MDS dated [DATE], revealed Resident #151 had a BIMS of 12, which indicated the Resident was cognitively intact. 28. Review of the medical record revealed Resident #153 was admitted to the facility on [DATE], with diagnoses including Nontraumatic Intracerebral Hemorrhage, Diabetes, Cerebral Infarction, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #153 had a BIMs of 8, which indicated the resident had moderate cognitive impairment. 29. Review of the medical record revealed Resident #154 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, End Stage Renal Disease, Seizures, Anemia, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #154 had a BIMS score of 11, which indicated the Resident had moderate cognitive impairment. 30. Review of the medical record revealed Resident #156 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease, Congestive Heart Failure, Diabetes, and Atrial Fibrillation. Review of the quarterly MDS dated [DATE], revealed Resident #156 had a BIMS score of 11, which indicated the Resident had moderate cognitive impairment. 31. Review of the medical record revealed Resident #157 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Esophageal Cancer, Hypertension, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed Resident #157 had a BIMS score of 14, which indicated the Resident was cognitively intact. 32. Review of the medical record revealed Resident #171 was admitted to the facility on [DATE], with diagnoses including Anemia, Colon Cancer, Dysphagia, Atelectasis, and Altered Mental Status. Review of the quarterly MDS dated revealed Resident #171 had a BIMS of 7, which indicated the Resident had severe cognitive impairment. 33. Review of the medical record revealed Resident #174 was admitted to the facility on [DATE], with diagnoses including Encephalopathy, Diabetes, Dementia, Hypokalemia, and Systemic Lupus Erythematosus. Review of the admission MDS dated [DATE], revealed Resident #174 had a BIMS score of 6, which indicated the Resident had severe cognitive impairment. 34. Review of the medical record revealed Resident #229 was admitted to the facility on [DATE], with diagnoses including Nontraumatic Intracerebral Hemorrhage, Vitamin B12 Deficiency, Cerebral Infarction, Bacteremia, and Schizophrenia. Review of the admission MDS dated [DATE], revealed Resident #229 had a BIMS score of 5, which indicated the Resident had severe cognitive impairment. 35. During an interview on 8/26/2024 at 11:34 AM, the Administrator was asked who was responsible for the Advance Directive. The Administrator stated, .on admission it's the Admission Director .and then Social Services does it 48 hours after admission . The Administrator was asked should residents be offered advance Directive, educated and given opportunity to formulate on admission. The Administrator stated, Yes, Ma'am. The Administrator confirmed the facility had done a 100% audit of advance directive since the survey team had made her aware of the advance directives. The Administrator confirmed advance directive should be done on admission. The facility was unable to provide documentation that the Advance Directives had been offered to Resident #12, #22, #23, #27, #29, #30, #43, #50, #51, #58, #71, #86, #91, #92, #95, #97, #98, #105, #107, #112, #123, #124, #127, #137, #150, #151, #153, #154, #156, #157, #171, #174, and #229.

Based on policy review, medical record review, and interview, the facility failed to report allegations of abuse for 4 of 12 residents (Residents #35, #43, #107 and #157) sampled for abuse. The findings include: 1. Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 4/3/2024, revealed .It is the policy of the facility to provide protections for the .welfare and rights of each resident .that prohibit and prevent abuse .Abuse .includes verbal abuse .willfully includes .derogatory terms to residents .within hearing distance .Reporting of all alleged violations to the Administrator, state agency .and to all other required agencies .within a specified timeframes .Not later than 24 hours if the events .do not result in serious bodily injury . 2. Review of the medical record revealed Resident #157 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Malignant Neoplasm of Esophagus, Anxiety, and Depression. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated Resident #157 was cognitively intact. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental (BIMS) score of 14 which indicated Resident #157 was cognitively intact. Review of the Investigation Staff to Resident Allegation, dated 8/21/2024, revealed .Notifications (complete all that apply) .Physician .[Named Physician] .8/21/24 1530 .Family .[Named Family Member] .8/21/24 1545 .What happened .CNA [certified nursing assistant] .constantly asking her [resident] when she was going home and that she did not need to be here. [Resident] voiced .made her feel nervous and upset . Review of the facility investigation provided, revealed the allegation of verbal abuse was not reported. During an interview on 9/3/2024 at 2:00 PM the Director of Nursing (DON) was asked if the allegation of abuse was reported to the state agency. She stated that after talking to the resident they didn't feel it was abuse and did not report the allegation. 3. Review of the medical record revealed Resident #107 was admitted to the facility on [DATE], with diagnoses including Cerebral Infraction and Schizoaffective Disorder. Review of the quarterly MDS assessment dated [DATE], revealed Resident #107 had BIMS score of 15, which indicated cognitively intact. Review of a named police department Incident Report dated 8/26/2024 at 8:44 AM, revealed Resident #35 alleged that Resident #107 had been physically aggressive toward Resident #107. 4. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Anxiety and Hypertension. Review of the annual MDS dated [DATE], revealed Resident #43 had a BIMSs score of 12, which indicated moderately cognitively impaired. Review of a named police department Incident Report dated 8/26/2024 at 8:44 AM, revealed Resident #43 alleged that Resident #107 had been physically aggressive toward Resident #107. During an interview on 8/27/2024 at 3:45 PM, the Administrator confirmed she was made aware on 8/26/2024, of an allegation that Resident #107 had been physically aggressive with Resident #43 on 8/23/2024. 5. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis and Cerebral Infraction. Review of the quarterly MDS dated [DATE], revealed Resident #35 had a BIMS score of 12, which indicated moderately cognitively impaired. Review of a named police department Incident Report dated 8/26/2024 at 8:44 AM, revealed Resident #35 alleged that Resident #107 had been verbally aggressive toward her. Review of the Incident Reporting System sheet revealed Resident #35's allegation of verbal abuse was not reported to the state until 8/27/2024 at 5:30 PM. The facility failed to report an allegation of resident-to-resident abuse in a timely matter.

Based on policy review, medical record review, facility investigation, named Police Department Incident Report, and interview, the facility failed to thoroughly investigate alleged incidents of resident-to-resident abuse for 3 of 12 sampled residents (Resident #35, #43 and #107) reviewed for abuse and failed to submit a 5-day follow up report to the state in a timely matter for 2 of 5 sampled residents (Resident #58 and #98) reviewed for abuse. The findings include: 1.Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 4/3/2024, revealed .It is the policy of this facility to .An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur .Provide complete and thorough documentation of the investigation .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include .Responding immediately to protect the alleged victim .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) 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, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies . 2. Review of the medical record revealed Resident #107 was admitted to the facility on [DATE], with diagnoses including Cerebral Infraction, Spinal Stenosis, Schizoaffective Disorder, and Hemiplegia and Hemiparesis following cerebral infraction affecting left non-dominant side Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #107 had Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. 3. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE], with diagnoses including Anxiety and Hypertension, Review of the annual MDS assessment dated [DATE], revealed resident #43 had a BIMS score of 12, which indicated moderately impaired cognition. Review of a [named police department] Incident Report dated 8/26/2024 at 8:44 AM, revealed Resident #35 alleged Resident #107 was physically aggressive toward Resident #107. The facility failed to present a thorough investigation of the allegation Resident #107 was physically abusive toward Resident #43. 4. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Cerebral Infraction, and Pain in Right Knee. Review of the quarterly MDS assessment dated [DATE] revealed a Brief interview for Mental Status BIMS score of 12, which indicated Resident #35 was moderately cognitively impaired. Review of a [named police department] Incident Report dated 8/26/2024 at 8:44 AM, revealed Resident #35 alleged that Resident #107 was verbally aggressive toward her. Review of the facilities investigation revealed after the facility became aware on 8/26/2026 of Resident #35's allegation of verbal abuse, there were no statements from witness', nor from the perpetrator, or alleged victim until 8/27/2024. There were no interventions to prevent the verbal abuse, until 8/27/2027 at 5:00 PM for Resident #35 and until 8/27/2024 at 3:00 PM for Resident #107. The facility failed to provide dates for the Staggered Smoking Breaks for Resident #35 and Resident #107. There were no in-services related to verbal abuse until 8/27/2024. The facility failed to present a thorough investigation of Resident #35's allegation of verbal abuse. During an interview on 8/27/2024 at 3:45 PM, the Administrator confirmed verbal aggression is a form of abuse and she was not made aware of Resident #35's allegation of verbal abuse on 8/26/2024 until 8/27/2024. During an interview on 8/28/2024 at 11:49 AM, the Social Worker confirmed on Monday Morning, 8/26/2024, she was informed by Resident #35 that during a smoke break on 8/25/2024, Resident #107 used profane language to address Resident #35. The facility failed to thoroughly investigate allegations of abuse. 5. Review of the medical record revealed Resident #58 was admitted on [DATE] with diagnoses including Atherosclerotic Heart Disease, Anxiety, Hypertension, and Heart Failure. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #58 was moderately cognitively impaired. Review of the Facility Reported Incident revealed, .Date and time of occurrence: 2/8/2024 10:55:00 AM .became aware of the incident on 2/8/2024 10:55:00 AM .facility reported .Physical Abuse .Employee was immediately removed from the hall and placed on suspension pending investigation .heard resident holler out you are smothering me .stop hitting me .Social Services, MD [medical doctor] and family made aware. Abuse in-service immediately initiated . Review of the Incident Reporting System sheet revealed Resident #58's allegation of staff to resident abuse 5-day follow up was not submitted to the state until 9/5/2024. During an interview on 9/4/2024 at 9:21 AM, the Administrator was asked who is responsible to report the 5 day follow up to the state. The Administrator stated, .the 5 day is myself or the DON . The Administrator confirmed she didn't see that the 5 day follow up had been done. 6. Review of the medical record revealed Resident #98 was admitted to the facility on [DATE] with diagnoses including Senile Degeneration of Brain, Diabetes, Functional Quadriplegia, Benign Prostatic Hyperplasia, Cerebral Infarction, and Hypothyroidism. Review of the Annual MDS assessment dated [DATE], revealed a BIMS score of 00, which indicated Resident #98 was severely cognitively impaired and was not coded for behaviors. Review of the Facility Reported Incident revealed, .Date and time of occurrence: 1/29/2024 4:15:00 AM .The facility reported the following [Named Resident # [NAME]] .hit [Named Resident #98] on the face on left side, discoloration noted to left side face .aggressor placed on 1:1 .Law enforcement and Ombudsman notified .5 day follow up report not submitted . Review of the Incident Reporting System sheet revealed Resident #98's allegation of resident-to-resident abuse 5-day follow up was not submitted to the state until 9/5/2024. During an interview on 9/4/2024 at 9:30 AM, the Administrator confirmed that she could not find the 5 day follow up to the state and stated, .I'm honest .didn't do it .

Based on job description, facility employee file, medical record review, and interview, the facility failed to ensure the licensed practical nurses (LPN) who performed wound care had the competencies and skill sets necessary to perform the care and services for pressure ulcers for 3 of 3 LPNs (LPN A, LPN B, and LPN C) who performed wound care for pressure ulcers for 7 of 10 sampled (Resident #27, #78, #123, #151, #171, #478, and #479) residents who received wound care for pressure ulcers. The findings include: 1. Review of the Treatment Nurse Job Description updated 12/2018, revealed .Provide nursing care to residents as prescribed by the physician and in accordance with standards of nursing practice and regulations .assess and document resident progress in the medial record. Perform all preventative skin care, dressing changes and wound care. Monitor turning and positioning of residents. Monitor the treatment of decubitus ulcers with appropriate documentation and communication to the physician .notify physician of new skin problems, changes of condition .Communicate pertinent information about resident condition and progress . 2. Review of the Clean Wound Dressing Change competency form for LPN A revealed the skills documentation section was incomplete. The competency form was not dated or signed by a Reviewer. Review of the Clean Wound Dressing Change competency form for LPN C revealed the skills documentation section was incomplete. The competency form was not dated or signed by a Reviewer. 3. Review of the medical record revealed Resident #27 was admitted on [DATE], with diagnoses including Hemiplegia, Diabetes, Contracture, Dysphagia, Cerebral Infarction, Atrial Fibrillation, and Gastrostomy Status. Resident #27 developed a facility acquired pressure ulcer to the hand due to the Resident's long fingernails being embedded into the Resident's skin. A Stage 3 facility acquired pressure ulcer to the Resident's right buttock was discovered by staff on 8/16/2024. There was no documentation the Resident had a Stage 3 pressure ulcer to the right buttock prior to 8/16/2024. There were no signed physician's orders for treatments to the Resident's hand and buttocks pressure ulcers. LPN C was Resident #27's wound/treatment nurse. 4. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnosis including Cerebral Infarction with Hemiplegia, Dysphagia, Diabetes, Seizures, Major Depressive Disorder, Cardiac Pacemaker, and Gastrostomy. Resident #78 developed a facility acquired pressure ulcer to Left Lateral Ankle area which was identified as a Stage 4 pressure ulcer. LPN B inconsistently assessed the staging of the pressure ulcer. LPN B was Resident' 78's wound/treatment nurse. LPN B had competencies and skills for providing and assessing wounds. 5. Review of the medical record revealed Resident #123 was admitted on [DATE], with diagnoses including Peripheral Vascular, Diabetes, Neuropathy, and Chronic Kidney Disease. Resident #123 developed a vascular wound to the right heel on 7/30/2024. On 8/26/2024, LPN C documented the wound drainage with a foul order at which time the NP ordered antibiotics. There was no documentation LPN C had identified the worsening of the wound prior to 8/26/204. LPN C was Resident #123's wound/treatment nurse. 6. Review of the medical record revealed Resident #151 was admitted to the facility on [DATE], with diagnoses including Benign Prostatic Hypertrophy, Difficulty Walking, Anxiety, Spinal Stenosis, Tobacco Use, Moderate Protein Calorie Malnutrition, Polyneuropathy and Stage 3 Pressure Ulcer. Resident #151 developed a facility acquired pressure ulcer to the right foot described as a fluid filled blister on 8/6/2024from the foot resting on the foot board. On 8/16/2024, the pressure ulcer to the right foot was reclassified as a Stage 3 measuring 7 by 2 by 0.2. LPN C was Resident #151's wound/treatment nurse. 7. Review of the medical record revealed Resident #171 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Colon, Abnormalities of Plasma Protein, Dysphagia, Atelectasis, Hypertension, Altered Mental Status, Anemia in Neoplastic Disease, and Open Wound, Left Lower Leg. Resident #171 was identified as being at risk for pressure ulcers on admission. Resident #171 developed a facility acquired pressure ulcer to the coccyx area on 8/19/2024 measuring 5 by 1.3 by 0.3 assessed as a Stage 3. LPN C was Resident #171's wound/treatment nurse. 8. Review of the medical record revealed Resident #478 was admitted on [DATE], with diagnoses including Anoxic Brain Injury, Encephalopathy, Decubitus Ulcers, Pneumonia, Urinary Tract Infection, Peripheral Vascular Disease, Gastrostomy, Acute Respiratory Failure with Hypoxia, Epilepsy, Dementia, Alcohol Abuse, Pulmonary Edema, Quadriplegia. Resident #478 developed a facility acquired pressure ulcer assessed as a Stage 3 to the sacral area on 9/13/2023. Wound care treatments were ordered for every Monday, Wednesday and Friday. The wound care treatments to the sacral pressure ulcer were not performed every Monday, Wednesday and Friday from 10/1/2023 - 10/31/2023 as ordered. Resident #478 developed a facility acquired pressure ulcer assessed as a State 3 to the umbilicus area on 10/19/2023. Daily wound dressings/care was ordered. There was no documentation wound care was performed on 10/19/2023, 10/28/2023, 10/29/2023, 10/30/2023 and 10/31/2023. LPN C was Resident #478's wound/treatment nurse. 9. Review of the medical record revealed Resident #479 was admitted on [DATE] with diagnoses including End Stage Renal Disease, Hemodialysis, Pulmonary Embolism, Heart Failure, Type 2 Diabetes Mellitus, Rheumatoid Arthritis, Morbid Obesity, Polyneuropathy, Unspecified Psychosis, Essential Hypertension, and Sarcoidosis. Review of LPN H's admission note for Resident #479 dated 8/11/2023 revealed the Resident was admitted with a State 3 pressure ulcer to the buttock and ischial area. Review of the NP's note for Resident #479 dated 8/14/2023 revealed the NP documented, .No reported impaired skin integrity concerns . Review of the Physicians note dated 8/14/2023 revealed to perform wound care to the buttock and ischial pressure ulcers once per day every Monday, Wednesday and Friday. Review of the treatment records for Resident #479 revealed the pressure ulcer wound care was not performed once per day every Monday, Wednesday and Friday as ordered form 8/14/2023 - 9/1/2023. LPN C assessed Resident #479/2 pressure ulcers inconsistently. LPN C was Resident #479's wound/treatment nurse. 10. During an interview on 9/5/2024 at 11:00 AM, the Director of Nursing (DON) was asked if she was aware that some of the pressure ulcers had been identified once the pressure ulcers had reached a Stage 3. The DON stated, Yes . The DON was asked should the development of pressure ulcers be identified sooner. The DON confirmed if residents' skin was being checked and weekly nurse's assessments were being completed, she would expect the development of pressure ulcers to be identified before they reached a Stage 3. The DON was asked should pressure ulcer care/treatment be missed and not followed per physician orders. During an interview on 9/5/2024 at 4:55 PM, the Area Director of Clinical services confirmed this facility has had prior issues with pressure ulcers. Refer to F-686

Based on policy review, observation, and interview, the facility failed to ensure appropriate infection control prevention and practices during medication administration when 1of 7 nurses (Licensed Practical Nurse (LPN)) G observed failed to clean the rubber seal of the insulin pen before attaching the needle, when 4 of 7 nurses (LPN G, LPN I, LPN L and Registered Nurse (RN) F observed failed to implement appropriate hand hygiene, and when 1 of 7 nurses (LPN H) failed to clean reusable equipment between residents. The findings include: 1. Review of the facilities policy titled, Insulin Pen dated 11/1/2023, revealed It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing .and serve as a teaching aid to prepare residents for self administration of insulin therapy upon discharge .Procedure .Gather supplies .Perform hand hygiene .Don gloves .Attach pen needle .Remove the pen cap from the insulin pen .Wipe the rubber seal with alcohol pad .Prime .Set the insulin dose .Injecting the insulin .Remove gloves and perform hand hygiene . Review of the facility's policy, Medication Administration dated 2/20/2024, revealed .Wash hands prior to administering medication per facility protocol .Wash hands using facility protocol and product . Review of the facility's policy titled, Hand Hygiene dated 3/22/2024, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection .using proper technique .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing the gloves . 2. During an observation on 8/21/2024 at 3:40 PM, RN F went to medication room, came back to the medication cart and prepared medications, went to Resident room and administered medications. RN F failed to perform hand hygiene. Observation on 8/22/2024 at 9:32 AM, revealed LPN G took the blood pressure of Resident, went to medication cart to write the blood pressure results, took medications to the Resident's room and administered the medications. LPN G failed to perform hand hygiene. Observation on 8/22/2024 at 9:32 AM, revealed LPN H took a blood pressure cuff from the medication cart, took Resident #45's blood pressure, went back to the medication cart, prepared medications, administered medications, returned to medication cart, put supplies away and did not clean the blood pressure cuff before putting it away. LPN H failed to clean reusable equipment. Observation on 8/22/2024 at 11:17 AM, revealed LPN I prepared medications, entered Resident #159's room and donned gloves. LPN I failed to perform hand hygiene. Observation on 8/26/2024 at 2:21 PM, revealed LPN G gathered Resident #91's insulin pen and needle, placed the needle on the insulin pen and failed to clean the rubber seal of the insulin pen before attaching the needle. During an interview on 8/26/2024 at 2:57 PM, LPN G confirmed she failed to wipe the rubber seal of the insulin pen with an alcohol pad before attaching the needle. Observation in Resident #144's room on 8/27/2024 at 9:29 AM, revealed LPN G entered Resident room, administered the Resident's inhaler, removed her gloves, and failed to perform hand hygiene. Observation on 8/29/2024 at 10:18 AM, revealed LPN L failed to perform hand hygiene before dispensing Resident #173's medication. During an interview on 9/5/2024 at 3:20 PM, the DON confirmed the blood pressure cuff should be cleaned between use on Residents and hand hygiene should be performed during medication administration.

Based on policy review, observation and interview, the facility failed to ensure medications were stored appropriately when Licensed Practical Nurse (LPN) I left one (1) of 9 medication storage areas (2nd floor Split Cart) unlocked, unattended, and out of line of site and when 3 of 7 nurses (LPN H, LPN L and Registered Nurse (RN)) F left medications unattended at the bedside. The findings include: 1. Review of the facility policy titled, Medication Storage dated 9/2023, revealed .All drugs .will be stored in locked compartments .medication carts, cabinets, drawers .During a medication pass, medications must be under the direct observation of the person administering the medications or locked in the mediation storage area/cart . 2. Observation on 8/21/2024 at 2:31 PM, revealed RN F in Resident #157's room. The RN placed a medication cup containing medications on the overbed table and went to the bathroom to wash their hands. The medication was left out of sight and unattended during this time. Observation on 8/22/2024 at 9:32 AM, revealed LPN H in Resident #45's room. The LPN placed the tray containing medications on the overbed table and went to bathroom to wash their hands. The medications were left out of sight and unattended during this time. During an interview on 8/22/2024 at 10:05 AM, LPN H stated, I should have taken the meds [medications] with me. Observation on 8/22/2024 at 11:10 AM, LPN I walked away from the 2nd floor Split Cart medication cart leaving the medication cart unlocked, unattended and out of the line of sight. Observation of the medication cart revealed a tube of Diclofenac Sodium Gel 1% was in the drawer with no label with Resident's name on it. LPN I stated it was Resident #379's medication. During an interview on 8/22/2024 at 11:14 AM, LPN I confirmed she should not have left the medication cart unlocked and out of the line of sight and medications should be labeled with the Resident's name. During an interview on 8/22/2024 the 2nd floor Assistant Director of Nursing stated, Cart [medication carts] should be locked and medications should be labeled with the resident name. Observation on 8/29/2024 at 10:18 AM, revealed LPN L entered Resident #173's room, placed the Resident's medications on the overbed table, walked away from the medications, went into the bathroom and left the Resident's medication out of her sight and unattended. During an interview on 8/29/2024 at 10:18, LPN L confirmed she should not have walked away and left Resident #173's medication out of sight and unattended. During an interview on 9/5/2024 at 3:20 PM, the Director of Nursing confirmed nurses should not walk away from the medications, leave medications out of sight of staff, medication carts should be locked when unattended and out of sight and medications in the medication cart should be labeled with the Resident's name.

Based on policy review, observation, and interview, the facility failed to ensure food was stored properly when unlabeled, undated, and expired items were in 2 of 3 (200 hall and 400 hall) nourishment refrigerators observed. The findings include: 1. The facility's policy titled, Use and Storage of Food Brought in by Family or Visitors revised [DATE], revealed .All food items .by the family or visitor brought in must be labeled .and dated .The facility may refrigerate labeled and dated .items in the nourishment refrigerator .If not consumed within 3 days, food will be thrown away by the facility staff . 2. Observation in the 200 Hall Nutrition Room on [DATE] at 8:40 AM, revealed the following in the residents' nourishment refrigerator: A bottle of tea unlabeled and undated. A plastic container with a sandwich unlabeled and undated. A bag with a water bottle and container of watermelon, unlabeled and undated. During an interview on [DATE] at 8:49 AM, the 2nd floor Assistant Director of Nursing (ADON) confirmed that staff and residents share the same nourishment refrigerator, and foods should be dated and labeled. 3. Observation in the 400 Hall Nutrition Room on [DATE] at 9:06 AM, revealed the following in the residents' nourishment refrigerator: A container with a Mexican meal unlabeled and undated. A jar of chunky salsa unlabeled and undated. A bottle of Jungle punch unlabeled and undated. A snicker ice-cream bar unlabeled and undated. During an interview on [DATE] at 9:07 AM, Licensed Practical Nurse (LPN) E confirmed that items in the nourishment refrigerator should be dated and labeled. During an interview on [DATE] at 12:07 PM, the Administrator confirmed items in the nutritional refrigerators should be labeled and dated. During an interview on [DATE] at 12:23 PM, the ADON was asked were the nutritional refrigerators on the halls for both the residents and staff. The ADON stated, For residents only . The ADON confirmed items in the refrigerator should be labeled and dated . During an interview on [DATE] at 2:33 PM, the Dietary Manager (DM) confirmed the kitchen wasn't responsible for the nourishment refrigerators and stated, .on Fridays the housekeepers throw out everything that is not labeled and dated .and clean them out . The DM confirmed everything in the nourishment refrigerators should be labeled and dated.

Based on policy review, job description review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure a QAPI program that identified issues, implemented appropriate actions, and monitored the actions for residents with pressure ulcer/injuries and nail care for 7 of 10 (#27, #78, #123, #151, #171, #478, and #479) sampled residents reviewed for pressure ulcers, and 1 of 4 (Resident #105) sampled residents reviewed for activities of daily living. The findings include: 1. Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI), reviewed and revised 2/3/2024, revealed It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data- driven QAPI program that focuses on indicators of the outcomes of care and quality life and addresses all of the care and unique services that facility provides .The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan .The QAA Committee shall be interdisciplinary and shall .Consist at a minimum of .The Director of Nursing Services [DON], The Medical Director or his/her designee, at least three other members of the facility's staff .The Infection Preventionist .Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary .Develop and implement appropriate plans of action to correct identified quality deficiencies .Regularly review and analyze data, including collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements .The QAA committee must sign to verify approval of all plans of correction written .The QAPI plan will address the following elements .Tracking and measuring performances . Establishing goals and thresholds for performance improvements .Identifying and prioritizing quality deficiencies .Systematically analyzing underlying causes of systemic quality deficiencies .Developing and implementing corrective action or performances improvement activities .Monitoring and evaluating the effectiveness of corrective action/performances improvement activities and revising as needed .A prioritization of program activities that focus on resident safety, health outcomes .The facility must also consider the incidence, prevalence, and severity of problems or potential problems identified .The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program .The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility .The governing body and /or executive leadership is responsible and accountable for the QAPI program .The facility maintains procedures for feedback, data collection systems, and monitoring, including adverse event monitoring .The facility draws data from multiple sources, including input from all staff, residents, families, and others as appropriate .Data is collected from all departments and is used to develop and monitor performances indicators .All identified problems will be addressed and prioritize, whether by frequency of data collection/monitoring or by the establishment of sub-committees .Considerations include .High-risk, high-volume, or problem-prone areas .Incidence, prevalence, and severity of problems in those areas .PIPs [Performance Improvement Projects] shall be designed to achieve and sustain performance improvement over time and to have an expected favorable outcome .Upon conclusion of the PIP, the sub-committee shall provide the QAA Committee with a report, which contains a summary and analysis of activities and recommendations for improvement .To ensure improvements are sustained, the effectiveness of performance improvement activities will be monitored in QAA Committee meetings in accordance with the QAPI plan, but no less than annually . 2. Review of the signed Administrator's job description signed 10/1/2023, revealed .Lead and Direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintain excellent care for the residents .Duties and Responsibilities .Monitor each department activities, communicate policies, evaluate performance, provide feedback and assist observe, coach .Oversee regular rounds to monitor deliver of nursing care, operation of support departments .ensure resident needs are being addressed .Responsible for the QA (Quality Assurance) program .Maintain a working knowledge of and confirm compliance with all governmental regulations . Review of the signed Director of Nursing (DON)'s job description signed 1/1/2024, revealed .To manage the overall operations of the Nursing Department in accordance with company policies, standards of nursing practices, and governmental regulations so as to maintain excellent care of all residents' needs .Management duties including .training and developing .In the absence of the Administrator and the Assistant Administrator .Monitor the Weekly Level of Care Report .and take appropriate action .Plan, develop, organize, implement, evaluate and direct the nursing services department as well as its programs .in accordance with current rules, regulations, guidelines that govern the long-term care facility .Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department .Organize, develop, and direct the administration and resident care of the nursing service department .Participate in Department Supervisor Meetings, Resident Care Plan Meetings, Quality Assessment and Assurance Committee Meetings, In Service Education .Participate in coordination of resident services .Meet monthly with nursing staff regarding Chart Audit and Physician's orders .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with .State and Federal guidelines .Inform state of any reportable incidents within appropriate time frames .Complete investigative analysis .Make rounds with physicians as necessary .Schedule daily rounds to observe residents and to determine if nursing needs are being met .Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations .Review and verify that documentation procedures for nursing are met according to .state and federal guidelines .Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care .Review Quality Indicator reports . 3. Review of a Performance Improvement Plan for the allegation of compliance for pressure ulcers put into place to address any citation and to prevent residents from suffering any adverse outcome and to prevent occurrence and reoccurrences from May 16, 2024 to June 2024, was as followed: a. Identification of residents affected or likely to be affected b. All residents had an updated Braden Assessment completed between 5/16/2024 and 5/23/2024 c. Ensure initial skin assessments were completed d. Facility policies and procedures related to skin care, wound care, and pressure injury prevention were reviewed and revised e. Provided education to all licensed nurses on the completion of the Braden Score Assessment policy, and completed treatments on all new admissions f. Daily audit of the Treatment Administration Record to ensure accurate and complete documentation of skin related treatments as ordered g. Daily audits of skin related treatments including documentation, Braden Assessments, and orders. h. PIP initiated to report on above monitoring and will continue for 3 months. 4. The facility failed to ensure staff provided care and services consistent with professional standards of practice to appropriately identify PU/PIs, to prevent the development of PU/PIs, and to promote the healing of existing PU/PIs for at risk and vulnerable residents. Refer to F686. 5. The facility failed to ensure, vulnerable residents who depended on staff for ADL care and services, was given toenail care which resulted in Actual Harm for Resident #105, when the resident's toenails adhere to the resident's skin that caused pain. Refer to F677. 6. During an interview on 9/5/24 at 11:00 AM, with the Administrator and the Director of Nursing (DON), the Administrator confirmed that a Quality Assurance Performance Improvement meeting is held quarterly with the last meeting held on July 29,2024. The Administrator confirmed that all department heads along with Medical Director attends the meeting. The Administrator confirmed that the facility is currently working on falls, accident/incidents, the environment, and enhanced barrier precautions. The Administrator confirmed that a weekly wound meeting is held and she does not attend. The Administrator confirmed that she relies on the DON to keep her informed of pressure wounds, the number of pressure wounds and their progress. The Administrator confirmed she does not attend pressure wound meetings. The DON confirmed she was aware that pressure wounds were being found at a Stage 3. The DON confirmed that if resident's skin is being checked daily by CNAs (certified nursing assistants) and weekly by the wound nurses that no wound should be found at a Stage 3. The DON confirmed that the wound nurses should do their own assessments and should not use the assessment of the Wound Nurse Practitioner as their own assessments. The DON confirmed that she expects treatments for wounds to be completed as ordered and documented on the TAR (Treatment Administration Record). The Administrator confirmed she was unaware that pressure wounds were being found at a Stage 3 and that she should have been informed. The Administrator confirmed that the licensed nurses, including the wound nurses, are given yearly skills assessments with return demonstration. The DON confirmed that the 3 wound nurses were LPNs (licensed practical nurses). The DON confirmed that LPNs must be certified to stage pressure wounds. The DON confirmed that she was unaware that LPN H was not certified to stage pressure wounds and she should have been. The DON confirmed that she was the one who keeps the Medical Director informed of the wounds and their progress along with the wound nurses. The DON confirmed that the Medical Director is informed when he writes new orders for any change in treatments or supplements but no formal meeting given to the Medical Director other than in the QAPI meeting held quarterly. The DON confirmed she does not make rounds with the wound nurses unless they have a question about a wound. During an interview on 9/5/2024 at 4:20 PM, the Medical Director confirmed he was not aware that pressure wounds were being found at Stage 3 or higher in the facility and that the facility has protocols that should catch wounds before they get to a Stage 3 or higher. The Medical Director confirmed that the wound nurses should be able to stage pressure wounds and may need a higher level of degree. During an interview on 9/5/2024 at 5:46 PM, the DON confirmed that the facility had a PIP in place for pressure ulcers that started 5/16/2024 and ended 6/24/2024. The DON confirmed the PIP was put into place because of the history of the facility to have large amounts of pressure wounds, the identification of Stage 3 pressure wounds, facility acquired pressure wounds and previous survey results related to wounds. The DON confirmed that the PIP consisted of full body assessments on all residents, turning and repositioning of residents, the Braden Scale assessment and completing treatments and documentation of the completion of treatments. The DON confirmed that identifying, assessment, staging, and documentation was not part of the PIP. The DON confirmed that she in serviced staff on the Pressure Wound policy dated 8/20/2022 and should have used the newly revised Pressure Ulcer policy dated 4/2024. The DON was asked was your PIP effective if there are wounds found at Stage 3, treatments that have not been documented as complete, and inconsistency of staging of wounds. The DON stated, Yes, I would day it was. The DON was asked with pressure ulcers being so important in the wellbeing of a resident how did 30 days of monitoring put you in compliance. The DON confirmed the PIP is ongoing and the monitoring for compliance has continued. The DON was asked if it is ongoing, how were wounds found at a Stage 3, treatments not documented on the TARs, and inconsistent staging found. The DON confirmed that only treatment documentations was part of the PIP.

Based on policy review, medical record review, observation and interview the facility failed to provide appropriate care and services for residents with an indwelling catheter (a tube in the bladder that drains urine) for 2 of 4 (Resident #71 and #91) sampled residents reviewed for indwelling catheters. The findings include: 1. Review of the facility policy titled, Indwelling Catheter and Removal, dated 3/15/2023, revealed .Indwelling urinary catheters are catheters that remain in the bladder to assist with urinary elimination .increase the risk of urinary tract infections .If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures . Review of the facility policy titled, Catheter Care, dated 2/20/2024, revealed .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use .Catheter care will be performed every shift and as needed by nursing personnel . 2. Review of the Hospital Progress Note for Resident #71 dated 11/10/2022, prior to admission to the nursing home facility, revealed .Chief Complaint .abd [abdominal] pain and unable to urinate. Abd [abdomen] firm and distended on arrival. Pt [Patient] unable to state when he last urinated .Foley catheter was placed .impression .Acute urinary retention due to bladder outlet obstruction .Acute renal failure .UTI [urinary tract infection] . Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Atrial Fibrillation, Retention of Urine, Dysuria, Diabetes, Congestive Heart failure and Chronic Obstructive Pulmonary Disease. Review of the January 2023 Physician's Orders for Resident #71 revealed, .Provide [named indwelling urinary catheter] .care with soap and water every shift and PRN [as needed] .Order Date .11/14/2022 .Change [named indwelling urinary catheter] .bag Q [every] 2 weeks on the first and 15th of every month . Review of the October 2023 Medication Administration Record (MAR) revealed there was no documentation Resident #71's catheter bag was changed in the month of October. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #71 was cognitively intact and had an indwelling urinary catheter. Review of the November 2023 MAR revealed there was no documentation Resident #71's catheter bag was changed in the month of November. Review of the December 2023 MAR revealed there was no documentation Resident #71's catheter bag was changed in the month of December. Review of the medical regimen review report dated 7/1/2023 - 12/31/2023, revealed .Change .[named indwelling urinary catheter] Bag every 2 weeks on night shift and as needed .Start Date 09/18/2023 . The facility was unable to provide documentation that Resident #71's catheter bag was changed every 2 weeks as ordered for the months of October, November and December of 2023. The facility failed to provide catheter care and ensure resident #71's catheter bag was changed in accordance with the physician's orders and their policy to prevent potential catheter related problems such as UTIs. Review of the progress notes revealed, .1/23/2024 .The nurse assessed the resident [#71] having dark red blood and sediments in urine in his 16 Fr [French] . [named indwelling urinary catheter] .BP [blood pressure] 101/67 P [pulse] 105 T [temperature] 101.9. The resident verbally states that his catheter has not pulled/tugged .The nurse contacted .MD [Medical Doctor] gave orders to collect UA [urinalysis], & [and] to create orders for lab [laboratory] to draw CBC [Complete Blood Count], BMP [Basic Metabolic Profile]. The nurse collected urine and the urine had a foul strong odor .The nurse performed catheter care and changed the resident's foley bag . Review of the URINE CULTURE dated 1/23/2024, revealed > [greater than] 100,000 cfu [colony forming unit]/mL [milliliter] Multiple bacterial morphotypes [group of organisms in urinary sediment that can be a valuable tool for diagnosis] present; no predominant pathogen . Review of the January 2024 MAR revealed Resident #71's catheter bag was not signed as being changed till the resident complained of pain on 1/25/2024. Review of the progress note revealed, .1/25/2024 .Resident [#71] complained of pain to lower abdomen and perineal area. He has decreased urine output and c/o [complaint of] pain 5/10. Attempted to remove foley and reinsert and resident refused. Patient stated he wanted to be transferred to the hospital . Review of the progress notes revealed, .1/25/2024 .c/o of bladder pain and no urinary output .head to toe assessment completed with bladder distention noted. resident [#71] refused to allow this nurse to change foley out did allow to flush with 60cc of normal saline. NP [Nurse Practitioner] was notified and gave new order for lab and bladder scan but resident refused and asked to be transported to hospital .resident .transferred to [Named Hospital] . Review of the Hospital ED (Emergency Department) records dated 1/25/2024 and 1/26/2024 revealed Resident #71 presented to the ED and was discharged back to the nursing facility on 1/26/2024. Review of ED Physician Documentation dated 1/25/2024, revealed .Presented today with abdominal distention, and with a malfunctioning Foley which was not draining. Urology was consulted, and they removed the Foley. It was apparently encrusted and difficult to remove, somewhat traumatic .Foley has been replaced .shows mild leukocytosis [a high white blood cell count that can be caused from infections, inflammation, injury or immune disorder] .Follow up with Urology .Take the antibiotic .for urinary tract infection .The patient presents with urinary retention .from the nursing home .States he has had his foley in place for over a year w/o [without] it being changed. He is coming from a nursing home and nursing home reports it hasn't been exchanged since November 2022. Attempted to deflate balloon, which only removed 3L [liter] of a yellow-brown liquid. When attempting to remove unable to withdraw and patient is in extreme pain. Cut the catheter balloon port off w/o further drainage or deflation .Spoke with urology .asked for patient to be able to urinate prior to discharge. If patient is unable to do so, advised giving him a couple of hours before replacing the foley .Unable to urinate will require foley placement prior to discharge .patient is tachycardic and diaphoretic. Likely due to bladder distention with unable to void .Impression and Plan .Condition: Stable .was given the following educational materials: FOLEY CATHETER CARE, URINARY RETENTION . Review of the 1/26/2024 ED Discharge Instructions revealed, .Be sure to follow up with your regular physician or specialist as instructed at discharge as this is the best way to ensure that you receive the very best of care . Review of the progress note revealed, .1/26/2024 .Resident [#71] arrived via [by way of] stretcher x [times] 2 assist .16 Fr .catheter .Dark red urine, medium amount of urine in bag .1/29/2024 .Resident continues ABT [antibiotic] therapy for UTI . Review of the progress notes revealed, .3/5/2024 .Attempted to change resident's foley catheter and resident refused, stating You are not changing my catheter, I only want the bag changed and I told you that.Foley bag changed, resident tolerated well . Review of the March 2024 MAR revealed Resident #71's catheter bag was not signed as being changed as ordered for the month of March. Review of the lab results dated 4/15/2024, revealed .URINALYSIS .NITRITE POSITIVE .LEUKOCYTES 3+ [plus] RBC [red blood cells] 0-2 .WBC [white blood cells] 20-30 .BACTERIA MANY .URINE CULTURE .> [greater than] 100,000 CFU [colony-forming unit] [a count to measure the number of bacteria in a urine sample] .ML [milliliter] PROVIDENCIA RETTGERI [is a bacteria primarily associated with complicated urinary tract infections from patients that have long term catheter] . Review of the progress notes revealed, . 4/27/2024 .Resident completes Macrobid therapy for UTI . Review of the progress notes revealed, . 4/29/2024 .nurse spoke to resident and asked resident why he refuses to let staff provide foley catheter exchanges. Resident stated, No, I am not going to let them touch my foley, and you all can just get ready to send me to the hospital whenever it needs to be changed. Review of the April 2024, May 2024, June 2024, and July 2024 MARs revealed there was no documentation Resident #71's catheter bag was changed each month as ordered. Review of the August 2024 Physician Orders revealed, .Change [named indwelling urinary catheter] .Bag every 2 weeks on night shift and as needed .Start Date 09/18/2023 . Observation in the resident's room on 8/27/2024 at 3:04 PM, revealed Resident #71 dressed, lying in the bed with an indwelling urinary catheter hanging on the right side of the bed, a privacy bag covering the drainage bag. During an interview on 8/29/2024 at 2:10 PM, Licensed Practical Nurse (LPN) I confirmed she took care of Resident #71, he was compliant with catheter care and let staff change his catheter bag. Review of the Urology Consult dated 8/30/2024, revealed .I explained to the patient today .that it [indwelling catheter] definitely needs to be changed every month .Infection in a patient with a catheter, is only when the patient has bacteria in the urine and they are having symptoms or very foul-smelling urine . During a telephone interview on 9/3/2024 at 10:05 AM, Previous Nurse Practitioner (NP) R was asked about Resident #71's catheter and how often catheters should be changed. NP R stated, .didn't [facility] share with me any policies and one of those was catheter change .I was hoping it was not true .about not being changed in a year .catheter should be changed out every 3 months .but has to be done routine and catheter care daily .that should come with standard of care with the facility .a part of the protocol that is missing . During an interview on 9/4/2024 at 9:01 AM, the Director of Nursing (DON) confirmed physician orders should be followed, Resident #71's catheter bag should have been changed every 2 weeks, and there should be no blanks left on the MAR, if he had refused, should be signed and clicked refused. During an interview on 9/4/2024 at 9:36 AM, the Administrator confirmed Physician orders should be followed and stated, .we don't change the catheter .he [Referring to Resident #71] goes to the ER [emergency room ] or urologist, what we do is change the catheter bag . The Administrator confirmed catheter care should be provide, there should be no blanks on the MAR and if the resident refused it should have been documented. During a telephone interview on 9/4/2024 at 3:59 PM, Previously Employed NP Q confirmed she provided care to Resident #71 and was asked how often catheters should be changed. NP Q stated, .I don't know what the policy was at that time .asked numerous times .when I did ask people no one could give me an answer .I asked the physician .administration and nurse's staff .standard practice every month . NP Q confirmed the catheter bags should be changed every 2 weeks and not changing the bag every 2 weeks could cause a urinary tract infection and stated, .due to the sediment build up . NP Q was asked do you feel like residents are receiving quality care at the facility. NP Q stated, No. During a telephone interview on 9/5/2024 at 8:35 AM, LPN M confirmed Resident #71 allowed staff to perform catheter care and change out the catheter bag, but he wanted to be sent to the hospital to have the catheter exchanged. During an interview on 9/5/2024 at 4:01 PM, the DON confirmed that she was unable to provide the UA that was ordered on 1/23/2024. During a telephone interview on 9/5/2024 at 4:32 PM, the Medical Director confirmed he provided Resident #71's care. The Medical Director was asked how often catheters should be changed. The Medical Director stated, . I've been Director here .just over a year .my protocol case to case . change every month . The Medical Director confirmed catheter bags should be changed every 2 weeks and stated, .that is the protocol to avoid uti . The Medical Director was asked should physician orders be followed. The Medical Director stated, Definitely. During an interview on 9/5/2024 at 6:09 PM, the DON was asked did the facility do an assessment or put anything in place for why Resident #71 didn't want the staff to change out his catheter. The DON stated, .we sent him to urologist .and try to encourage him . 3. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Malignant Neoplasm of the Breast and Colon, History of Breast Cancer, Need Assistance with Personal Care, Diabetes, Acute Kidney Failure, Severe Protein Malnutrition, Pressure Ulcer of Left and Right Buttocks Stage 3, and Obstructive Reflux Uropathy. Review of the admission MDS dated [DATE] revealed Resident #91 had a BIMS of 4, which indicated severe cognitive impairment, incontinent of bowel, the use of an indwelling urinary catheter, and the use of a feeding tube. Review of the Care Plan revised 7/30/2024, revealed .Problem Start Date .7/3/2024 .Indwelling Catheter .Resident requires an indwelling urinary catheter r/t [related to] obstruction .Provide catheter care . Review of a Physician Order dated 7/3/2024 to 7/29/2024, revealed Foley 16 FR with 10 cc balloon to bedside straight drainage for diagnosis / Hx [history of] need .every shift . Review of the facility's Treatment Administration Record (TAR) for July 2024 revealed staff documented the use of a 16 Fr 10cc [NAME] indwelling catheter every shift from 7/3/2024 to 7/16/2024. Review of the medical record revealed no order for indwelling catheter care for the use of an indwelling urinary catheter for August 2024. Review of the August 2024 TAR revealed Resident #91 had no order for urinary catheter care. Review of a Physician Progress Note dated 8/9/2024 revealed, .Foley catheter with sediment looking urine . Observations in the resident's room on 8/19/2024 at 10:56 AM and 3:01 PM, and 8/20/2024 at 8:25 AM, revealed an indwelling urinary catheter tube with cloudy yellow urine in tubing, catheter bag elevated and contained in a privacy bag. Observation in the resident's room on 8/21/2024 at 8:44 AM and 9:27 AM, revealed an indwelling urinary catheter bag contained in a privacy bag and elevated with clear yellow urine in tubing. Observation in the resident's room on 8/26/2024 at 11:04 AM and 2:26 PM, revealed an indwelling urinary catheter bag contained in a privacy bag and elevated at bedside. Observation in the resident's room on 8/28/2024 at 11:29 AM and 3:32 PM, and 8/29/2024 at 11:33 AM, revealed an indwelling urinary catheter bag contained in a privacy bag and elevated with yellow urine in the tubing. During an interview on 8/29/2024 at 2:23 PM, the DON was asked if a resident has an indwelling urinary catheter should they have written physician orders for the use. The DON confirmed that residents should have physician orders for the use of an indwelling urinary catheter. The DON confirmed that residents should receive catheter care at least every shift. The DON confirmed that Resident #91 was admitted with an indwelling urinary catheter.

Based on medical record review, and interview the facility failed to provide appropriate care and services for wounds (non-pressure ulcer/injury wounds) for 2 of 10 (Residents #123 and #479) reviewed for wounds. The findings include: 1. Review of medical record revealed Resident #123 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease (PVD), Diabetes, Neuropathy, Chronic Kidney Disease, Acquired Absence of Left Leg Below Knee, and Metabolic Encephalopathy. Review of Resident #123's Right Lower Extremity Arterial Duplex Ultrasound dated 3/19/2024, revealed .Mild to moderate PAD [Peripheral Artery Disease]. Below-knee monophasic [one phase] flow consistent with distal trifurcation [the act of splitting or dividing into three branches] disease . Review of the quarterly MDS dated [DATE], revealed Resident #123 had a BIMS score of 5, which indicated Resident #123 had severe impaired cognition. Functional status was coded to reveal the resident was totally dependent on others for ADL's. Review of Resident #123's care plan effective date 7/30/2024, revealed .Resident has vascular/multifactorial -Right Heel [identified on 2/20/2024 as a pressure ulcer/injury] -Right Ankle [identified on 5/7/2024] vascular/multifactorial: Resident is at risk for further skin breakdown . Review of Resident #123's care plan with effective date of 8/5/2024, revealed . Wound-NP reclassified all pressure ulcers above to Vascular Ulcer .has Peripheral Vascular Disease [PVD] with potential for complications aeb [as evidenced by] Previous Pressure Ulcers reclassified .on (8/5/24) as Vascular Ulcer-Right Heel, Vascular Ulcer-Right Ankle, and Vascular Ulcer-Right Lateral Midfoot resolved .Observe PRN [as needed] any s/sx [signs and symptoms] of skin problems related to PVD: Redness, Edema, Blistering, Itching, Burning, Bruises, Cuts, other skin lesions . Review of Resident #123's INTEGRATED WOUND CARE Follow-up Progress Note dated 8/05/2024, revealed .vascular and diabetic right ankle was observed and documented with moderate serosanguinous exudate with 60% slough and 40% dermis .the wound measured 2.2 cm x 2.5 cm x 0.3 cm .Cleanse with dakins [topical antiseptic to treat and prevent infections], pat dry, apply honey followed by xeroform then gauze wrap QD [every day]/[and] prn [as needed] . Review of Resident #123's Wound Detail Report dated 8/7/2024, revealed .arterial ulcer right ankle wound 0.6 cmx 1.2 cm x 0.3 cm with purulent (opaque, milky; sometimes green) tissue type Necrotic Tissue . Review of Resident #123's INTEGRATED WOUND CARE Follow-up Progress Note dated 8/16/2024, revealed .vascular and diabetic right ankle was observed and documented with moderate serosanguinous exudate with tissue type 60% slough and 40% granulation .the wound measured 2.3 cm x 1.9 cm x 0.3 cm . Cleanse with dakins, pat dry apply honey followed by xeroform then gauze wrap QD /prn . Review of Resident #123's physician orders dated 8/17/2024, revealed .Cleanse vascular and diabetic right ankle with dakins pat dry apply hydrogel silver followed by xeroform then gauze wrap daily and prn . Review of Resident #123's INTEGRATED WOUND CARE Follow-up Progress Note dated 8/23/2024, revealed .vascular and diabetic right ankle was observed and documented with light serosanguinous exudate with tissue type 40% slough and 60% dermis .the wound measured 2.0 cm x 1.5 cm x 0.3 cm .recommend empiric abx [antibiotic] (bactrim ds bid [two times a day] x [for] 10 days) for infection . Review of Resident #123's progress note dated 8/26/2024, revealed .RIGHT HEEL .PURULENT DRAINAGE .the wound had drainage Friday .ABT [antibiotic] was recommended . During an interview on 8/26/2024 at 2:40 PM, LPN C confirmed the progress note from 8/23/2024 and 8/26/2024 were observations made by the Wound NP and herself (LPN C), on those days. Observation and interview in the resident's room with LPN C on 8/26/2024 at 2:45 PM, revealed Resident #123's arterial right ankle wound as a round area with 50% slough with purulent white drainage with a foul odor, measuring 2.0 cm x 1.5 cm x 0.3 cm. LPN C stated, .we recognized on Friday [8/23/2024] of purulent drainage .NP seen the wound on 8/23/2024 and made a recommendation for an antibiotic .the wound is worse today I reached out [called] to NP yesterday LPN C was asked when the Wound NP last saw the wound. LPN C stated, .the wound NP seen the wound Friday (8/23/2024) and today (8/26/2024). LPN C was asked when the antibiotic should have been started. LPN C stated, We [Wound NP and LPN C] saw the wound appearance was worse on 8/23/2024 and we should have wrote [written] an order that day. LPN C was asked if it takes 4-5 days to start a recommended antibiotic for an infected wound. LPN C stated, . sometimes .we just reach out [call/communicate] to NP for an order of the recommended antibiotic . LPN C was asked did you contact the MD. LPN C stated, We usually call NP or 3rd Eye [after hour on-call agency] . LPN C was asked if the wound appeared worse today (8/26/2024) than on Friday 8/23/2024. LPN C stated, .the odor is there and there is purulent drainage .yes it may be worse today [than it was on 8/23/2024] . Review of Resident #123's physician order dated 8/27/2024, revealed .Bactrim DS [Trimethoprim/[and] Sulfamethoxazole] .800-160 mg .1 oral twice a day for 10 days for wound healing . The facility failed to start Resident #123's recommended antibiotic (Bactrim DS 800-160 mg for 10 days) for wound healing on 8/23/2024. The antibiotic was started 5 days later on 8/27/2024. Review of Resident #123's INTEGRATED WOUND CARE Follow-up Progress Note dated 8/30/2024, revealed .vascular and diabetic right ankle was observed and documented with moderate serosanguinous exudate with tissue type 30% slough and 30% dermis, 10% eschar and 30% granulation .the wound measured 2.0 cm x 1.5 cm x 0.3 cm .cleanse with dakins, pat dry, apply hydrogel silver followed by xeroform then gauze wrap QD [every day]/ [and] PRN [as needed] . bactrim ds bid x 10 days. Needs vascular consult d/t [due to] lack of improvement in wounds .culture obtained last week . During an interview on 9/4/2024 at 10:10 AM, the Wound NP was asked why Resident #123's wounds were re-classified 5 months after the Right Lower Extremity Arterial Duplex Ultrasound. The Wound NP did not give an answer for the question. During an interview on 9/4/2024 at 11:30 AM, the DON was asked if a resident had a recommendation for an antibiotic from the Wound NP for an infected wound, should that Resident with an infected wound wait 5 days for an antibiotic to be started. The DON stated, No. The DON was asked why Resident #123's wounds were re-classified 5 months after the Right Lower Extremity Arterial Duplex Ultrasound. The DON stated, .I'm not sure .he is being scheduled for a vascular consult . In summary, Resident #123 who was dependent on staff for repositioning and turning and risk for developing wounds, developed a right heel and right ankle wounds. The wounds were classified as pressure ulcer/injuries for over 5 months before they were classified as vascular/diabetic wounds. The right heel was assessed with s/sx of infection with antibiotics recommended on 8/23/2024. The antibiotic was not started until 8/27/2024. 2. Review of the closed medical record revealed Resident #479 was admitted on [DATE], with diagnoses including End Stage Renal Disease, Hemodialysis, Pulmonary Embolism, Heart Failure, Type 2 Diabetes Mellitus, Rheumatoid Arthritis, Morbid Obesity, Polyneuropathy, Unspecified Psychosis, Essential Hypertension, and Sarcoidosis. Review of the Wound Management Detail Report dated 8/31/2023 - 9/11/2023 for the left calf Diabetic Ulcer revealed the following: On 8/31/2023 the left calf Diabetic Ulcer was identified and measured 4.2 cm x 4.6 cm x 0.1 cm with 100% necrotic tissue/eschar. The facility did not identify the ulcer until it was necrotic. On 9/5/2023 the left calf Diabetic Ulcer measured 2.5 cm x 11.6 cm with 70% necrotic tissue and 30% granulation and was declining. On 9/11/2023 the left calf Diabetic Ulcer measured 13.8 cm x 8 cm, had heavy purulent drainage, and was declining. During an interview on 9/5/2024 at 1:50 PM, LPN H was asked if she would expect the diabetic ulcer wound located on Resident #479's left lower leg to be observed and assessed prior to the area having 100% necrotic tissue/eschar, LPN H stated, .I would expect it to be reported before then. When asked if Certified Nursing Assistants (CNAs) report when they see a change in a resident's skin. LPN H stated, I would beg [the CNAs to report]. We are short a lot and the CNAs may be in a rush. I really can't speak as to why it's not seen. It should have been. But that's how it is here .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure care and services were provided for 1 of 4 (Resident #91) residents reviewed for the use of a Percutaneous Endoscopic Gastrostomy (PEG) tube (a PEG tube is inserted into the stomach to give medications and food supplements). The findings include: 1. Review of the facility's policy titled Care and Treatment of Feeding Tube revised 5/31/2023, revealed .It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible .Feeding tubes will be utilized according to physician orders .The resident's plan of care will address the use of feeding tube, including strategies to prevent complications .Examination and cleaning of the insertion site in order to identify, lessen, or resolve possible skin irritation and local infection . 2. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Malignant Neoplasm of the Breast and Colon, History of Breast Cancer, Needs Assistance with Personal Care, Diabetes, Acute Kidney Failure, Severe Protein Malnutrition, Pressure Ulcer of Left and Right Buttocks Stage 3 and Obstructive Reflux Uropathy. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #91 scored a 4 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. Resident #91 has a PEG tube for medications and feeding. Review of the Medical Regiment Review Report revealed, .Start date .6/14/2024 .Enteral Feeding (Bolus) .Administer ONE carton Nepro Carb Steady [enteral feeding supplement] via [by way of] PEG at Rate q [every] 6 hrs [hours] to provide total of 948 ml [milliliters] . Review of the Care plan last reviewed and revised 7/3/2024, revealed, .Problem Start Date .7/3/2024 .Feeding Tube .requires feeding tube R/T [related to] dysphagia .Provide peg tube care as ordered . Review of the June 2024 and July1-16, 2024 Treatment Administration Record (TAR), revealed no documentation Resident #91 received PEG site care. Observation in the resident's room on 8/19/24 at 10:56 AM, 3:01 PM, and on 8/20/2024 at 8:25 AM, revealed PEG tube feeding Nephro infusing at 65ml/hr and auto flush at 40ml/hr. Observation in the resident's room on 8/26/24 at 2:16 PM, revealed enteral feeding supplement and syringe on the bedside table labeled and dated 8/26/2024. Observations in the resident's room on 8/28/24 at 8:00 AM, 11:29 AM, and 3:32 PM, revealed PEG feeding syringe and enteral feeding supplement on the bedside table labeled and dated 8/28/2024. Observation in the resident's room on 8/29/24 at 11:33 AM, revealed PEG feeding syringe and enteral feeding supplement on the over the bed table labeled and dated. The facility failed to ensure care and services for the use of a PEG tube for Resident #91 when peg site care was not performed.

Based on policy review, medical record review, observation, and interview, the facility failed to obtain services for the behavioral health care needs for 1 of 1 resident (Resident #1) reviewed. The findings include: Review of the facility's policy titled, Behavioral Management Plan, dated 1/02/2020, revealed . Residents who exhibit behavioral concerns .a behavioral management plan to ensure they are receiving appropriate services and interventions .any behavioral interventions should be included on the care plan behavior should be documented clearly concisely by facility staff documentation should include specific behaviors time and frequency of behaviors interventions and outcomes . Review of the facility's policy titled, Behavioral Health Services , dated 8/30/2022, revealed .It is the policy of this facility to ensure all residents receive necessary behavioral health services . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Cerebral Infraction and Psychosis. Review of Physician Order for Resident #1 dated and signed 1/9/2023, revealed an order for Psychiatric services. There was no documentation the Resident had received the Psychiatric services as ordered. Review of a progress note dated 3/17/2023, revealed .Patient repeatedly .continues to remove wound care dressings and incontinence brief .disassembles his brief, consuming the cotton .referred to psychiatric services . The Administrator (ADM)was asked should Resident have been seen by a psych provider after the documented behavior by nursing on 3/17/2023, the stated yes Review of a progress noted dated 3/29/2023, revealed .continues to pull pieces of brief apart and throw on floor. Pieces of brief in mouth and spit . Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #1 had Brief Interview for mental Status score of 2, which indicated severe cognition impairment. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #1 had Brief Interview for mental Status score of 2, which indicated severe cognition impairment. During an interview on 4/20/2023 at 9:58 AM CNA # 2 stated, . Resident #1 keeps picking pieces off his brief .Resident #1 will pick and pick at his brief and then throw it on the floor. CNA # 2 was asked how long had Resident #1 been picking and removing pieces off his in continent brief. CNA # 2 stated, ever since Resident #1 has been here. I thought it might be due to the wound on his hip and so I started to make sure his brief was loose .he still would pull pieces off the brief, I have tried tucking his shirt in his pants, I have tried .pants with a drawstring .he would still get to the brief and pull the pieces from it . During an interview on 4/20/2023 at 12:54, LPN #1 was asked how long has Resident #1 exhibited the behaviors. LPN #1 stated .I charted and it is in my notes LPN #1 was asked what was the cause of this behavior LPN # 1 stated .I don't know but not because he is soiled, not because brief fitting incorrectly . During an interview on 4/20/2023 at 2:32 PM , C NA #3 was asked are there any behaviors that you have Resident #1 exhibit. CNA #3 stated, he pulls, tears at his brief .it comes off in strips .does it almost all the time .I ask him to not to pull the brief apart and I clean the pieces off the floor . his response .is yeah but will do it again . CNA was asked does he dig in his brief because he is itchy. CNA #3 stated, he does not. CNA #3 was asked does he indicate irritation or pain at the brief area. CNA #3 stated, No. C NA #3 confirmed she has observed Resident #1 pull and tear his incontinent brief apart and throw it on the floor since 2/2023. During an interview on 4/21/2023 at 9:50 AM, CNA #4 stated, .Resident #1 tears and shreds his brief .he listens but still goes back to doing it .he eats the cotton .Resident #1 eat the plastic .ever since I been taking care of him Resident #1 does this .he can tear it so bad we have to change the brief, when we say don't do that .he stops and he goes right back to it he don't know no better . Observation on 4/24/2023 2:21 PM, at the North Second (2nd) Floor Nurse Station on 4/24/2023 at 2:21 PM, revealed Licensed Practical Nurse (LPN) # 1 confirmed Resident #1 had torn pieces from his incontinent brief in his mouth. LPN # 1 confirmed the torn pieces were pieces from Resident #1's brief. During an interview on 4/26/2023 at 2:44 PM the Administrator confirmed Resident #1 was admitted on ,d+[DATE], but was not seen by a Psychiatric provider until 4/18/2023. The Administrator stated, .January referrals .just now seeing .will start a process for following up on referrals .

Based on policy review, medical record review, and interview the facility failed to ensure 1 of 1 (Resident #1) were free from the use of restraints. The findings include: Review of the facility's policy titled, Resident Rights , dated 3/22/2022, revealed . The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents . The resident has the right to a dignified existence . the right to be free from physical or chemical restraints impose for purposes of discipline or convenience and not required to treat the residents medical symptoms Review of the facility's policy titled, Restraint Free Environment, dated 3/22/2022, revealed . A physical restraint is defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restrict freedom of movement or normal access to one's body. Physical restraints may include .Applying legs or arm restraints .that the resident cannot move . Review of the facilities investigated revealed a statement written and dated 3/28/2023, by Certified Nursing Assistant CNA #1. The statement revealed that CNA #1 took flat sheet, turned him [Resident #1] over and tied it in knot-wrapped like a new born baby. He [Resident #1] had on gown and a pillow between his legs .last did it at 10:30 PM yesterday . Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #1 had Brief Interview for mental Status score of 2, which indicated severe cognition impairment During an interview on 4/20/2023 at 12:54 PM, and 4/21/2023 at 9:33 AM, Licensed Practical Nurse (LPN) #1 stated on 3/28/2023, she worked and her shift and started at 7:00 AM. During the medication pass, LPN #1 was asked to come to Resident #1's room. LPN #1 confirmed she observed Resident #1's lower part of the gown was confined around his [Resident #1] legs . LPN #1 stated, . anything restricting movement I want to prevent that from happening we are a no restraint facility . the gown at the bottom was wrapped around the bottom part of his [Resident #1] legs at the shin I broke it free by taking it apart it was not knotted .together in a way that he could not easily get out . a full body assessment did not see injury or new issues as a result what was his demeanor calm, no pain, no distress then notified the Administrator .one end on the gown tuck under his left shin and the other end of the gown tucked under the right shin, the ends were tied .I had has to loose them .it was under her legs in a way that I had to loosen the ends. During a cell phone interview on 4/21/2023 at 12:15 PM, CNA #1 confirmed on 3/27/2023, she placed a flat sheet under Resident #1, turned the resident toward one side of the bed and tucked the flat sheet under the resident's brief, and then turned the resident to the other side of the bed and tucked the flat sheet under the resident's brief . CNA #1 stated .trying to be thoughtful for people coming up on the next shift so they won't have to sweep the pieces off the floor .stop him from picking it apart .it is like snowfall on the floor .consuming it . During an interview on 4/26/2023 at 3:54 PM, the Assistant Director of Nursing (ADON), at time of incident, confirmed that she observed Resident #1 with a sheet wrapped around the resident's brief area on 3/28/2023. The ADON stated it was wrapped and tied she had to untie the sheet from the waist down to ankle. The ADON stated she had reported to this to the Administrator, and had CNA #1 to write a statement. The ADON confirmed CNA #1 was assigned to Resident #1 on 3/28/2023 on the 3:00 PM to 11:00 PM shift and CNA #1 admitted that she had tied a sheet around the resident to prevent the resident from eating his brief. During an interview on 4/27/2023 at 8:18 AM, the Administrator was asked the definition of a restraint. The Administrator reviewed the facilities definition of restraints and stated, .physical, chemical, medical, discipline, convenience and a medical symptom are all types of restraints . The Administrator was asked was taking a sheet and wrapping it around a resident to prevent a behavior, would that be a restraint the Administrator stated, .looking at our definition of restraint I would say by definition yes . In summary, the facility completed an investigation on 3/28/2023, after being notified by staff that Resident #1 had a flat sheet wrapped around his brief. CNA # 1 was identified and stated she used a wrapped bed sheet and a gown to attempt to prevent Resident #1 from pulling and tearing his brief apart on 3/27/2023 and 3/28/2023. During at interview on 4/21/2023 at 12:15 pm CNA #1 confirmed the written statement on the facility's investigation is her statement. CNA #1 confirmed she tucked and wrapped a flat sheet around the resident's waist and placed a gown as a final layer to prevent Resident #1 from throwing pieces of his torn brief on the floor, prevent staff from having to sweep the pieces off the floor, and resident would not place the pieces in his mouth. CNA #1 confirmed her actions were for the convenience of staff when stated, .trying to be thoughtful for people coming up on the next shift so they won't have to sweep the pieces off the floor .

Based on policy review, job description review, record review, medical record review, and interview, facility Administration failed to administer the facility in a manner to provide oversight, to monitor and provide a safe environment, ensure systems and processes were in place and consistently followed by staff to address quality concerns related to safe individualized resident care when the facility failed to provide sufficient licensed nursing staff, failed to administer medications as ordered by the physician, failed to identify wounds and provide necessary treatment and services for residents determined to be at risk for pressure ulcer injury and other wounds. The facility Administration failed to have in place a system to provide sufficient licensed nursing staff with knowledge and skills necessary to ensure residents were free from significant medication errors when medications were not administered as ordered by the physician for 40 of 63 sampled residents (Resident #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #59, #60, #68, #69, #71, #72) reviewed that required medications and treatments. The medications not administered included anti-diabetics, anticoagulants, anticonvulsant's, antiarrhythmic's, Hypertensives, and cardiac medications were not administered as ordered by the physician, when insufficient staffing of licensed nurses to perform assessments, treatments, monitor and meet individualized resident needs were not provided. The facility Administration failed to ensure residents with wounds received appropriate assessments and received wound treatment for 6 of 9 sampled residents (Resident #1, #3, #4, #5, #6, and #8) reviewed for pressure ulcer wounds and other wounds. Resident #1 did not receive treatments for a pressure ulcer wound identified upon admission and the wound worsened, Resident #3 did not receive treatments for wounds identified upon admission, Resident #4 did not receive treatments when a Stage 2 pressure wound was identified and developed to a Stage 4, Resident #5 was admitted with pressure ulcer wounds, the resident did not receive treatments as ordered and developed additional pressure ulcer wounds, Resident #6 did not receive treatments as ordered and was not identified with gangrene to her finger, Resident #8 did not receive treatments for a pressure ulcer wound identified upon admission and developed infection to the wound. The facility's failure to administer medications as ordered and provide care and services for residents with wounds resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional Director of Operations, Area Director of Clinical Services, Regional Director of Clinical Services, and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F684 and F686 on 1/17/2023 at 6:12 PM, in the Chapel. The Administrator, Regional Director of Operations, Area Director of Clinical Services, and Special Projects Nurse were notified of the Immediate Jeopardy (IJ) for F600, F725, F760, F835, and F867 on 1/24/2023 at 12:38 PM, in the Chapel. The facility was cited Immediate Jeopardy at F600, F684, F686, F725, F760, F835, and F867. The facility was cited Immediate Jeopardy at F600, F684, F725, F835, and F725 at a scope and severity of K which is Substandard Quality of Care. The facility was cited F686 at a scope and severity of J which is Substandard Quality of Care. The facility was previously cited Immediate Jeopardy at F600, F835, and F867 during a complaint survey on 9/19/2022 through 9/20/2022. Non-compliance of F600, F725, F760, F835, and F867 continues at a scope and severity of K. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled Nursing Services and Sufficient Staff revised 8/30/2022 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. a. Except when waived, licensed nurses; and b. Other nursing personnel, including but not limited to nurse aides .The facility is required to provide licensed nursing staff 24 hours a day, 7 days a week .Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to residents' needs . Review of the Administrator job description, dated 12/2018 revealed, .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Essential Duties & [Symbol for and] Responsibilities: .Identify and participate in process improvement, initiatives that improve the customer experience, enhance work flow, and/or improve the work environment .management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .Lead the facility management staff and consultants in developing and working from the business plan that focuses on all aspects of facility operations, including setting priorities and job assignments .Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed .Oversee regular rounds to monitor delivery of nursing care .and ensure resident needs are being addressed .Responsible for the QA [Quality Assurance] program .Manage turnover and solidify current and future staffing through development of recruiting sources, and through appropriate selection, orientation, training, staff education and development .Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services . Review of the Director of Nursing job description, dated 12/2011 revealed, .to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .Identify and participate in process improvement initiatives that improve the customer experience, enhance work floor, and/or improve the work environment. Management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .In the absence of the Administrator and Assistant Administrator (if applicable), assume responsibility of the facility .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department. Participate in Department Supervisor Meetings, Resident Care Plan Meetings, Budget Committee Meetings, Safety Committee Meetings, Quality Assessment and Assurance Committee Meetings, In-service Education, Family Council and any other meeting as directed by the Administrator. Meet monthly with staff on each unit .Participate in coordination of resident services through departmental and appropriate staff committee meetings. Meet monthly with nursing staff regarding Chart Audit and Physician's Orders. Review audit with Medical Records prior to submitting to Administration .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guideline .Perform nursing services and deliver resident care services in compliance with corporate policies and State and Federal regulations .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Study Infection Control Reports, Medication Incident Reports and Resident Incident Reports for corrective action. Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures for a more efficient operation .Ensure that all nursing service personnel follow established departmental policies and procedures .Assure residents a comfortable, clean, orderly and safe environment .Confirm accurate completion of forms/reports .Review and verify that documentation procedures for nursing are met according to corporate, state and federal guidelines. Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Review Quality Indicator reports and submit to [NAME] President of Clinical Services on monthly basis .Participate in monthly QA. Ensure staffing levels are maintained .Along with the Administrator engage the medical director in all department activity . 2. Review of facility policies, medical record review, observation, and interview during the survey revealed Residents #1, #3, #4, #5, #6, and #8 did not receive the necessary services and treatments for pressure ulcer wounds and other wounds. Refer to F684, and F686. 3. Review of facility policies, medical record review, observation, and interview revealed Residents #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #58, #59, #60, #68, #69, #71, #72 did not receive their anticonvulsant medications, antiarrhythmic medications, antihypertensive medications, antibiotics, anti-platelet medications, Antidiuretic medications, and antipsychotic medications in accordance physican orders. Refer to F600, F684, F725, and F760. 4. During an interview on 1/11/2023 at 12:15 PM, when asked who was responsible to ensure there was adequate staff on each shift to provide care to all residents, the Administrator stated, I'm not involved with the daily staffing. That would be the DON [Director of Nursing] and SDC [Staff Development Coordinator] . During an interview on 1/11/2023 at 12:47 PM, when asked if the facility had a Nurse supervisor or charge nurse on all shifts, the DON stated, .They are all charge nurses. They should have known what to do .It was an unexpected staff shortage [1/9/2023] .We rely on agency staff to pick up shifts and no one responded . During an interview on 1/11/2023 at 3:47 PM, when asked if she was aware there was no nurse to provide medications and services to the residents on the 3rd floor on 1/9/2023, the Regional Director of Operations stated, I was told there was no nurse and no one responded .We have plenty of available bodies by using agency [contract staff] .Nobody has said anything to me about workload .They should have called the DON .I don't know the specifics of the on-call person, each building is different . During an interview on 1/23/2023 at 10:15 AM, the Area Director of Clinical Services reviewed the Quality Assurance Performance Improvement (QAPI) minutes and stated, We see the problems you are finding .We know staffing is one of the problems . During an interview on 1/23/2023 at 10:46 AM, when asked if staffing had been addressed in the QAPI Committee meetings, the Regional Special Projects Nurse reviewed the QAPI minutes and stated, I don't see anything on staffing discussed in the forms I have in front of me . Refer to F600, F684, F686, F725, and F760.

Based on policy review, job description review, record review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to safe individualized resident care when the facility failed to provide sufficient licensed nursing staff, failed to administer medications as ordered by the physician, failed to identify wounds and provide necessary treatment and services for residents determined to be at risk for pressure ulcer injury and other wounds. The facility failed to ensure the QAPI committee reviewed and validated systemic problems and determined a system was in place to ensure sufficient licensed nursing staff with knowledge and skills necessary to assure safety and provide individualized care for 40 of 63 sampled residents (Resident #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #59, #60, #68, #69, #71, #72) reviewed that required medications and treatments, and provide appropriate assessments and treatments for 6 of 9 (Resident #1, #3, #4, #5, #6, #8) sampled residents with wounds that worsened resulting in Immediate Jeopardy. Resident #1 did not receive treatments for a pressure ulcer wound identified upon admission and the wound worsened, Resident #3 did not receive treatments for wounds identified upon admission, Resident #4 did not receive treatments when a Stage 2 pressure wound was identified and developed to a Stage 4, Resident #5 was admitted with presuure ulcer wounds, the resident did not receive treatments as ordered and developed additional pressure ulcer wounds, Resident #6 did not receive treatments as ordered and was not identified with gangrene to her finger, Resident #8 did not receive treatments for a pressure ulcer wound identified upon admission and developed infection to the wound, when medications antidiabetics, anticoagulants, anticonvulsants, antiarrhythmics, hypertensives, and cardiac medications were not administered as ordered by the physician, when insufficient staffing of licensed nurses to perform assessments, treatments, monitor and meet individualized resident needs. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional Director of Operations, Area Director of Clinical Services, Regional Director of Clinical Services, and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F684 and F686 on 1/17/2023 at 6:12 PM, in the Chapel. The Administrator, Regional Director of Operations, Area Director of Clinical Services, and Special Projects Nurse were notified of the Immediate Jeopardy (IJ) for F600, F725, F760, F835, and F867 on 1/24/2023 at 12:38 PM, in the Chapel. The facility was cited Immediate Jeopardy at F600, F684, F686, F725, F760, F835, and F867. The facility was cited Immediate Jeopardy at F-600, F684, F725, F760, F835, and F867 at a scope and severity of K which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F686 at a scope and severity of J. The facility was previously cited Immediate Jeopardy at F600, F835, and F867 during a complaint survey on 9/19/2022 through 9/20/2022. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F684 and F686, was received on 1/19/2023, and the Removal Plan was validated onsite by the surveyors on 1/24/2023 through policy review, medical record review, observation, review of education records, and staff interviews. Non-compliance of F600, F725, F760, F835, and F867 continues at a scope and severity of K. The IJ began on 12/16/2022 and is ongoing for F867. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled Quality Assurance and Performance Improvement [QAPI] dated 8/20/2022 revealed, .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides .The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan .Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements .The QAPI plan will address the following elements .Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: Tracking and measuring performance. Establishing goals and thresholds for performance improvements. Identifying and prioritizing quality deficiencies. Systematically analyzing underlying causes of systemic quality deficiencies. Developing and implementing corrective action or performance improvement activities. Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed .The facility must also consider the incidence, prevalence, and severity of problems or potential problems identified .The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include but is not limited to: The written QAPI plan. Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events. Data collection and analysis at regular intervals. Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 2. Review of the Administrator job description dated 12/2018 revealed, .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Essential Duties & [Symbol for and] Responsibilities: .Identify and participate in process improvement, initiatives that improve the customer experience, enhance work flow, and/or improve the work environment .management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .Lead the facility management staff and consultants in developing and working from the business plan that focuses on all aspects of facility operations, including setting priorities and job assignments .Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed .Oversee regular rounds to monitor delivery of nursing care .and ensure resident needs are being addressed .Responsible for the QA [Quality Assurance] program .Manage turnover and solidify current and future staffing through development of recruiting sources, and through appropriate selection, orientation, training, staff education and development .Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services . Review of the Director of Nursing job description dated 12/2011 revealed, .to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .Identify and participate in process improvement initiatives that improve the customer experience, enhance work floor, and/or improve the work environment. Management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .In the absence of the Administrator and Assistant Administrator (if applicable), assume responsibility of the facility .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department. Participate in Department Supervisor Meetings, Resident Care Plan Meetings, Budget Committee Meetings, Safety Committee Meetings, Quality Assessment and Assurance Committee Meetings, In-service Education, Family Council and any other meeting as directed by the Administrator. Meet monthly with staff on each unit .Participate in coordination of resident services through departmental and appropriate staff committee meetings. Meet monthly with nursing staff regarding Chart Audit and Physician's Orders. Review audit with Medical Records prior to submitting to Administration .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guidelines .Perform nursing services and deliver resident care services in compliance with corporate policies and State and Federal regulations. Inform state of any reportable incidents within appropriate time frames. Complete investigative analysis as required .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Study Infection Control Reports, Medication Incident Reports and Resident Incident Reports for corrective action. Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures for a more efficient operation .Ensure that all nursing service personnel follow established departmental policies and procedures .Assure residents a comfortable, clean, orderly and safe environment .Confirm accurate completion of forms/reports .Review and verify that documentation procedures for nursing are met according to corporate, state and federal guidelines. Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Review Quality Indicator reports and submit to [NAME] President of Clinical Services on monthly basis .Participate in monthly QA. Ensure staffing levels are maintained .Along with the Administrator engage the medical director in all department activity . 3. Review of the QAPI documentation dated 9/7/2022 and 11/22/2022 revealed no documentation or evidence of data collection and analysis, documentation demonstrating the development, implementation and evaluation of corrective actions or performance improvement activities. During an interview on 1/19/2023 at 12:12 PM the Director of Nursing stated, .I don't see anything in September of data analysis .No we have no quantitative or qualitative anything. We have nothing like that .I don't see any documentation of a November meeting .I have no documentation of any PIPs [performance improvement plan] . During an interview on 1/23/2023 at 10:41 AM, the Area Director of Clinical Services confirmed September 2022 and November 2022 QAPI meeting contained no documentation of data collection and analysis at regular intervals and of reports demonstrating systematic identification, reporting, investigating, analysis, and prevention of adverse events. She stated, .I expect to see data collection and analysis .I can't locate analysis or any of that [development, implementation and evaluation] .If you don't have analysis you can't have the other things .We have policies but failed to follow the policies . 4. The QAPI committee failed to ensure all residents' right to be free of abuse neglect by failure to follow policies to provide needed care and services for all residents. Refer to F600 5. The QAPI committee failure to complete assessments, provide the necessary care, services and treatments for residents with pressure ulcer wounds and other wounds. Refer to F684 and F686 6. The QAPI committee failed to establish, monitor, and implement policies and procedures to ensure adequate staffing. Refer to F725 7. The QAPI committee failed to ensure residents were free from significant medication errors when significant medications including antidiabetic, antiarrhythmics, antihypertensive, anticonvulsant, antiplatelets and cardiac medications were not administered as ordered by the physician. Refer to F760 8. The QAPI committee failed to ensure the facility Administration was administered in a manner to provide oversight, to monitor and provide a safe environment, ensure systems and processes were in place and consistently followed by staff to address quality concerns related to safe individualized resident care when the facility failed to provide sufficient licensed nursing staff, failed to administer medications as ordered by the physician, failed to identify wounds and provide necessary treatment and services for residents determined to be at risk for pressure ulcer injury and other wounds. Refer to F835

Based on policy review, medical record review, observation, and interview the facility failed to ensure the implementation of Residents' Right to be free of abuse neglect as evidenced by the failure to complete assessments, provide the necessary care, services and treatments for residents determined to be at risk of skin breakdown for 4 of 7 sampled residents (Resident #1, #4, #5, and #8,) reviewed for pressure ulcer wounds; failed to complete assessments and provide treatments as ordered for 2 of 2 sampled residents (Resident #3 and #6) reviewed with other wounds; and the facility failed to provide sufficient licensed nursing staff to administer significant medications as ordered by the physician for 40 of 63 sampled residents (Resident #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #59, #60, #68, #69, #71, #72) reviewed with significant medications ordered. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 did not receive treatments for a pressure ulcer wound identified upon admission and the wound worsened and required debridement. Resident #4 did not receive treatments for a Stage 2 pressure ulcer wound and the wound developed to a Stage 3. Resident #5 had a Stage 3 pressure ulcer wound that the facility failed to identify. Resident #8 did not receive treatments for a pressure ulcer wound identified upon admission and developed an infection in the wound. The facility failed to identify and provide wound treatments for for Resident #3 and #6 and the wounds developed into gangrene; and the facility failed to provide a licensed nurse to assess, monitor, and administer medications as ordered by the physician. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Regional Director of Operations, the Area Director of Clinical Services, the Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-684 and F-686 on 1/17/2023 at 6:12 PM, in the Chapel. The Regional Director of Operations, the Area Director of Clinical Services, the Regional Special Projects Nurse, and the Administrator were notified of the Immediate Jeopardy (IJ) for F600, F725, F760, F835, and F867 on 1/24/2023 at 12:38 PM, in the Chapel. The facility was cited Immediate Jeopardy at F600, F684, F686, F725, F760, F835, and F867. The facility was cited Immediate Jeopardy at F686 at a scope and severity of J which is Substandard Quality of Care. The facility was previously cited Immediate Jeopardy at F600, F835, and F867 during a complaint survey on 9/19/2022 through 9/20/2022. Non-compliance of F600, F684, F725, F760, F835, and F867 continues at a scope and severity of K. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F684 and F686, was received on 1/19/2023, and the Removal Plan was validated onsite by the surveyors on 1/24/2023 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ began on 12/16/2022 through 1/24/2023 for F684 and F686. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, Abuse, Neglect and Exploitation revised 3/3/2022 revealed, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect .'Neglect' means failure of a facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Define how care provision will be changed and/or improved to protect residents .Training of staff on changes made and demonstration of staff competency .Identification of staff responsible for implementation or corrective actions .Identification of staff responsible for monitoring the implementation of the plan . Review of the facility's policy titled Wound Treatment Management dated 3/24/2022 revealed, .To promote healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .Wound treatments will be provided in accordance with physicians orders, including the cleansing method, type of dressing, and frequency of dressing changes .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .Treatments will be documented on the Treatment Administration Record .The effectiveness of treatments will be monitored through ongoing assessment of the wound . Review of the facility's undated policy titled Skin Assessment revealed, .It is our policy to perform a full body assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment .A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury . Review of the facility's policy titled Nursing Services and Sufficient Staff revised 8/30/2022 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans .a. Except when waived, licensed nurses; and b. Other nursing personnel, including but not limited to nurse aides .The facility is required to provide licensed nursing staff 24 hours a day, 7 days a week .Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to residents' needs . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Intestinal Obstruction, Muscle Weakness, Cognitive Communication Deficit, Dysphagia, and Hypertension. Review of the Braden Scale assessment completed on admission revealed Resident #1 was a high risk of developing a pressure ulcer. Review of a Treatment Nurse Communication Form dated 12/16/2022 revealed Resident #1 had a wound to the sacral region with measurements of length by (x) width x depth (LxWxD) of 0.4 centimeters (cm) x 3.5 cm x 0.4 cm, a wound to the left heel with measurements of 4.0 cm x 3.2 cm x 0.2 cm, and a wound to the right heel with measurements of 0.2 cm x 3.0 cm x 0.1 cm. Review of the admission nursing assessment dated [DATE] documented, .Right heel Bruising to heel .Left heel Bruising to heel .Sacrum Pressure sore on sacrum . Review of a Nurse's Progress Note dated 12/16/2022 documented, .Resident has pressure sore to sacrum and flaky skin, as well as bruising to heels . Review of the Care Plan initiated on 12/19/2022 documented, .The resident has pressure ulcer with potential for further pressure ulcer development .Assess/record/monitor wound healing as ordered and per protocol. Measure length, width, depth where possible. Assess and document status of wound perimeter, wound bed and healing progress . Review of a Physician's order dated 12/21/2022 with a start date of 12/22/2022 documented, .Cleanse Unstageable wound to Sacrum with sound cleanser. Pat dry. Apply Santyl and Calcium alginate to site. Cover with dry foam dressing. Change dressing daily on Monday, Wednesday, and Friday and Prn (as needed) until resolved . There was no documentation of treatment orders for the sacral pressure ulcer wound from the admitted [DATE] until 12/21/2022. Review of a Physician's order dated 12/21/2022 with a start date of 12/22/2022 documented, .Cleanse Unstageable wound to R [right] heel with wound cleanser. Pat dry. Apply medi-honey and cover with Calcium alginate with silver. Cover site with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . There was no documentation of treatment orders to the right heel pressure ulcer wound from the admitted [DATE] until 12/21/2022. Review of a Physician's order dated 12/21/2022 with a start date of 12/22/2022 documented, .Cleanse Unstageable wound to L [left] heel with wound cleanser. Pat dry. Apply medi-honey and cover with Calcium alginate with silver. Cover site with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . There was no documentation of treatment orders to the left heel pressure ulcer wound from the admitted [DATE] until 12/22/2022. Review of the wound care Physician's Initial Progress Note dated 12/21/2022 revealed an Unstageable Pressure Ulcer to the Sacrum which measured 5 cm x 7cm with 50 percent (%) dermis and 50% eschar. The right heel was documented as unstageable and measured 7 cm x 5 cm with 50% dermis and 50% eschar. The left heel was documented as unstageable and measured 9 cm x 7 cm with 50% eschar and 50% serum filled blister. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 scored an 11 on the Brief Interview of Mental Status (BIMS) which indicated moderately impaired cognition. The resident required extensive assistance for bed mobility and was dependent for transfers. Review of the wound care Physician's Initial Progress Note dated 1/4/2023 revealed an Unstageable Pressure Ulcer to the Sacrum and measured 8.3 cm x 7.2 cm x 0.2 cm with 75% slough and 25% granulation. Review of the wound care Physician's Initial Progress Note dated 1/11/2023 revealed an Unstageable Pressure Ulcer to the Sacrum and measured 6.0 cm x 6.5 cm x 0.2 cm with 75% slough and 25 % granulation. The pressure ulcer wound was debrided on 1/11/2023. Review of the Treatment Administration Record (TAR) for December 2022 revealed there was no treatment administered as ordered for the unstageable wound to the sacrum, unstageable wound to the right heel, and unstageable wound to the left heel on 12/28/2022 and 12/30/2022. Review of the TAR for January 2023 revealed there was no treatment administered as ordered for the unstageable wound to the sacrum, unstageable wound to the right heel, and unstageable wound to the left heel on 1/6/2023. Observations in the resident's room on 12/27/2022 at 3:40 PM revealed Resident #1 lying supine in bed. The resident was alert and oriented. When asked if she had any wounds to her skin she stated, I have a sore on my bottom .The nurse puts a cover [dressing] on it now. I guess it got worse. During an interview on 12/27/2022 at 1:02 PM, Resident #1's family member stated, .She has been here about a week or 10 days I guess and has a bad sore. That tells me they are not turning her as they should .That bed sore has gotten much worse in the 10 days she has been here . During an interview on 12/29/2022 at 9:59 AM, the Licensed Practical Nurse (LPN) #5 reviewed the Physician orders and the TAR and stated, This is not okay. She [Resident #1] came in on the 16th [12/16/2022] and the order is not until the 21st [12/22/2022]. That's not okay . During a telephone interview on 12/29/2022 at 10:21 AM, when asked what the meaning was of unstageable related to a pressure ulcer wounds, LPN #1 stated, You can't measure the depth. When asked if she could measure the depth of the sacral wound and the wound to the right heel and left heel of Resident #1 upon admission, LPN #1 stated, Yes ma'am. I guess I should have called it a Stage 2 . When asked if treatments and wound care was provided for Resident #1, LPN #1 stated, Documented on the place where we document treatments if I did them . During an interview on 12/29/2022 at 11:08 AM, the DON confirmed there was no documentation of wound assessments or care provided for the pressure ulcer wounds from 12/16/2022 until 12/23/2022. The DON stated, If not documented, it wasn't done. What I see is an order on 12/21 [2022]. I see nothing before that. During an interview on 1/4/2023 at 4:02 PM, when asked when the first treatment was administered to the pressure ulcer wounds the LPN #5 stated, .From the 16th till the 21st when [Named physician] saw her there is no documentation of a treatment. That's awful. When asked if there was documentation of wound assessments that described the wounds appearance, LPN #5 stated, I didn't document any assessments in the computer. I threw the papers away. I don't have any of my papers prior to the 7th [1/7/2023]. That's when I was inserviced what to document in the computer. When I came here, I wasn't told about pressure and non-pressure assessments. I did not receive the proper training for this system to document. I threw my papers away that had the assessments . During an interview on 1/4/2023 at 10:38 AM, the Regional Director of Clinical Services (RDCS) stated, We did a facility wide skin sweep over the weekend. We found some new wounds and we are taking care of that. When asked what she meant by a skin sweep the RDCS stated, A skin assessment of every resident to see if there were any wounds that had been missed . During an interview on 1/5/2023 at 9:58 AM, when asked if Resident #1 had Pressure Ulcer wounds, LPN #2/Unit Manager stated, I don't remember what her wounds are. I looked at her paperwork from the hospital .If there are wounds it's passed on to the treatment nurse. I wouldn't know about the wound location . 3. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Covid-19, and Epilepsy. (a) Review of the Braden Scale assessment completed on 9/21/2022 and 1/3/2023 revealed Resident #4 was at risk of developing a pressure ulcer. Review of the quarterly MDS dated [DATE] revealed Resident #4 scored a 13 on the BIMS which indicated no cognitive impairment. The resident required extensive assistance for bed mobility and activities of daily living. Review of the Weekly Skin Reviews dated 11/30/2022, 12/7/2022, 12/14/2022, 12/21/2022, 12/28/2022, and 1/4/2023 revealed Resident #4 had redness to the sacrum. Review of the Nursing Daily Skilled Services assessments dated 12/29/2022, 1/1/2023, 1/2/2023, 1/3/2023, 1/9/2023, 1/10/2023, and 1/11/2023 documented there was no change in the resident's skin integrity. Review of the current Shower Day Skin Inspection sheet dated 1/1/2022 (2023) revealed Resident #4 had a Stage 2 open area to the sacral region. There were no documented descriptions or measurements of the wound. Review of a Physician's order dated 1/1/2023 revealed, .Cleanse stage 2 pressure ulcer to R [right] buttock with wound cleanser. Pat dry. Apply hydrocolloid dressing to site and cover with bordered foam dressing MWF [Monday-Wednesday, Friday] and PRN [as needed] . Review of a Physician's order dated 1/4/2023 revealed, .Cleanse stage 2 pressure ulcer to sacrum with wound cleanser. Pat dry. Apply medi-honey followed by collagen. Cover with bordered foam dressing MWF and PRN . Review of the wound care Physician's Initial Progress Note dated 1/4/2023 revealed a Stage 3 Pressure Ulcer to the sacrum which measured 4.2 cm x 3.7 cm x 0.1 cm with 25% slough, 50% epithelial, and 25% serum blister. Review of the wound care Physician's Progress Note dated 1/11/2023 revealed a Stage 3 Pressure Ulcer to Resident #4's lower back which measured 2.3 cm x 0.5 cm x 0.1 cm with 50% slough and 50% dermis. During an interview on 1/5/2023 at 12:44 PM, when asked when the Stage 2 to the sacrum was first identified, the DON stated, We did a facility wide skin sweep on the 1st [1/1/2023] and that is when it was found . The DON confirmed there was no documentation describing the wound or measurements of the wound until 1/4/2023. During an interview on 1/9/2023 at 1:47 AM, The DON stated, She has no TARs for months other than January. During a telephone interview on 1/6/2023 at 2:45 PM, when asked if she was notified of the Stage 2 Pressure Ulcer on 1/1/2023, the wound care Physician stated, Not that I recall. I saw the wound during my visit on the 4th [1/4/2023]. It was a Stage 3. Nurse was probably not aware of the slough . During an interview on 1/19/2023 at 2:55 PM, when asked when the Stage 3 to the lower back was first identified the LPN/Wound Nurse stated, Identified by [Named Wound Care Physician] during her visit on the 11th [1/11/2023]. (b) Review of the Physician's medication order dated 9/1/2022 for Resident #4 revealed, .Alogliptin Benzoate 12.5 MG (milligrams) Tablet Give one tablet by mouth one time a day related to TYPE 2 DIABETES MELLITUS .AmLODIPine Besylate Tablet 10 MG Give one tablet one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Review of the Medication Administration Record (MAR) dated December 2022 revealed no documentation of Alogliptin administered at 9:00 AM on 12/4/2022 and 12/25/2022 as ordered by the physician. There was no documentation the Amlodipine was administered at 9:00 AM or 9:00 PM on 12/4/2022 and 12/25/2022. There was no documentation to reveal the resident's blood pressure was assessed. 4. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Paraplegia, Chronic Osteomyelitis, Open Wound of Buttock, History of Failed Surgical Flap, Peripheral Vascular Disease, Anemia, and Protein-Calorie Malnutrition. Review of the annual MDS dated [DATE] revealed Resident #5 scored a 15 on the BIMS which indicated no cognitive impairment. The resident required supervision for activities of daily living. The MDS Section M Skin Conditions documented no pressure ulcer wounds and one surgical wound. (a) Review of the Physician's orders dated 11/2/2022, documented .Cleanse Surgical Site to L [left] buttock with wound cleaner. Dry with 4x4, Pack wound with dry collagen. Cover with dry bordered foam dressing Mon [Monday] Wed [Wednesday] Fri [Friday], and PRN . Review of the TAR for November 2022 and December 2022 revealed treatments were not provided as ordered for the surgical site to the left buttock on 11/7/2022, 11/14/2022, 11/21/2022, 11/25/2022, and 12/28/2022. Review of the Braden Scale assessment completed on 1/3/2023 revealed Resident #5 was at risk of developing a pressure ulcer. Review of the Physician's orders dated 1/4/2023 documented, .Cleanse pressure ulcer to Right medial buttock with wound cleanser. Pat dry. Apply honey followed by collagen. Cover with bordered foam MWF and PRN . Review of the wound care Physician's progress note dated 1/4/2023 revealed Resident #5 had a new Stage 3 Pressure Ulcer wound to the right medial buttock which measured 2.8 cm x 2.3 cm x 0.2 cm with 50% slough and 50% dermis. Review of the Weekly Summary dated 1/6/2023 documented no Pressure Ulcer wounds. Observations in the resident's room on 1/5/2023 at 10:41 AM revealed the Resident was propelling himself in a wheelchair in his room and able to transfer himself to the bed. He was alert and oriented. Resident #5 stated, I had a bad place on my butt. I had surgery on that. Now they say I've got a new wound. I need a new cushion, but it hadn't come in yet. During an interview on 1/9/2023 at 12:57 PM, when asked when the Stage 3 to the right medial buttock was first identified, the DON stated, It was identified on the 4th [1/4/2023] on the other side of the buttock. The DON confirmed the new pressure ulcer was identified during the facility wide skin sweep on 1/1/2023. (b) Review of the Physician's medication orders for Resident #5 revealed, .Start Date 10/21/2022 Lantus SoloStar 100 UNIT/ML (milliliter) Solution pen-injector Inject 10 unit subcutaneously at bedtime for DM [Diabetes Mellitus] .Start Date 8/2/2019 Minocycline HCL capsule 100 MG Give 100 mg by mouth two times a day for infection .Start Date 2/1/2022 rifAMpin Capsule 300 MG Give 300 mg by mouth two times a day for chronic osteomyelitis . Review of the MAR dated December 2022 revealed no documentation Lantus Solostar, Minocycline HCL, and Rifampin was administered at 9:00 PM on 12/22/2022 and 12/31/2022 as ordered by the physician. During an interview on 1/11/2023 at 1:10 PM when asked if Resident #5 received the medications as ordered on 12/22/2022 and 12/31/2022 LPN #2 stated, No, I don't see that. Could have been when there was only one nurse on the hall and she may have missed it . 5. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region, Sepsis Unspecified Organism, Urinary Tract Infection, Cerebral Infarction, Type 2 Diabetes Mellitus, Acute Embolism and Thrombosis of Deep Vein or Right Upper Extremity, and Osteomyelitis. Review of the quarterly MDS dated [DATE] revealed Resident #8 scored a 7 on the BIMS which indicated severe cognitive impairment. The resident required extensive assist for activities of daily living. The MDS Section M Skin Conditions documented one unstageable pressure ulcer wound. (a) Review of the Shower Day Skin Inspection sheet dated 12/22/2022 revealed Resident #8 had a wound to the sacral region which measured 6.8 cm x 11.3 cm x 0.0 cm. Review of the Braden Scale assessment completed on 12/23/2022 revealed Resident #8 was a very high risk of developing a pressure ulcer wound. Review of the admission nursing assessment dated [DATE] revealed Resident #8 had a pressure related skin condition. There was no assessment with descriptions of the wound. Review of the Physician's orders dated 12/23/2022 documented, .Cleanse Unstageable pressure ulcer to Sacrum with wound cleaner. Pat dry. Apply Dakin's wet to dry dressing to site. Cover with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . Review of the TAR for December 2022 revealed there was no treatment administered as ordered for the unstageable Pressure Ulcer wound to the sacrum, identified upon admission from 12/22/2022 - 12/31/2022. Review of the Physician's orders dated 1/4/2023 documented, .Cleanse DTI [Deep Tissue Injury] to lateral L foot with wound cleanser. Pat dry. Apply skin prep MWF and PRN .Santyl Ointment 250 UNIT/GM [gram] (Collagenase) Apply to sacrum topically every day shift every Mon, Wed, Fri for stage 4 pressure ulcer to sacrum. Cleanse stage 4 ulcer to sacrum with Dakin's solution. Pat dry. Apply santyl and medihoney followed by calcium alginate. Cover with bordered foam MWF and PRN . Review of the wound care Physician's Progress Note dated 1/4/2023 documented, .Debrided sacrum of necrotic tendon, bone, and fascia. Recommend Ciprofloxacin 750 mg BID [twice daily] PO [by mouth] for osteomyelitis .Sacrum Pressure Ulcer Stage 4, 7.8 [cm] x 11.3 [cm] .Left lateral foot Deep Tissue Injury .8.5 [cm] x 3.7 [cm] x 0 [cm] . Review of the Physician's orders dated 1/5/2023 documented, .Ciprofloxacin HCL Tablet 750 MG [milligrams] by mouth two times a day related to OSTEOMYELITIS OF VERTEBRA, SACRAL AND SACROCOCCYGEAL REGION for 4 weeks . Review of the TAR for January 2023 revealed there was no treatment administered as ordered for the unstageable Pressure Ulcer wound to the sacrum on 1/2/2023. Observations in the resident's room on 1/4/2023 at 9:30 AM revealed Resident #8 lying supine in bed. She was alert with confusion. During an interview on 1/4/2023 at 2:36 PM when asked when the Pressure Ulcer was wound to Resident #8's left foot was first identified the LPN/Wound Care Nurse stated, .It was actually noted today during Physician rounds as a left lateral deep tissue injury. I would assume no one saw it or looked at the foot . During an interview on 1/6/2023 at 2:45 PM when asked when was the first notification Resident #8 had a Pressure Ulcer wound to the sacrum the wound care physician stated, I saw her on Wednesday [1/4/2023] for the first time. That was the first time my attention was brought to the wound . During an interview on 1/10/2023 at 9:50 AM when asked from the admission measurements on 12/22/2022 until the physician was notified on 1/2/2022 was the Pressure Ulcer to the sacrum assessed and monitored, and the LPN/Wound Care Nurse stated, Those assessments were not completed. When asked if the TAR had documentation of the treatments administered the LPN/Wound Treatment Nurse stated, They [TAR dates] are all blank. She [LPN #1] didn't sign off that she did the treatments .That's awful . During an interview on 1/10/2023 at 2:10 PM the DON confirmed no assessments were completed and no treatments were administered for the Pressure Ulcer wounds from admission on 12/22/2022- 1/2/2023. (b) Review of the Physician's orders revealed, .Start Date 12/25/2022 Doxycycline Monohydrate Capsule 100 MG Give 100 mg by mouth two times a day for sepsis .Start Date 12/23/2022 Eliquis Tablet 5 MG (Apixaban) Give 5 mg by mouth two times a day .Start Date 12/29/2022 Metronidazole Tablet 500 MG Give 500 mg by mouth three times a day for sepsis .Start Date 12/29/2022 NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 60-149 = 0 units: 150-199 = 4 units; 200-249 = 6 units; 250-299 = 8 units; 300-349 = 10 units; 350-400 = 12 units .subcutaneously two times a day related to DIABETES MELLITUS . Review of the MAR dated December 2022 revealed no documentation Doxycycline Monohydrate, Eliquis, Metronidazole was administered at 9:00 PM on 12/31/2022, the Novolog insulin per sliding scale was not administered on 12/29/2022-12/31/2022, and the blood glucose levels were tested as ordered by the physician. 6. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region Stage 4, History of Venous Thrombosis and Embolism, Human Immunodeficiency Disease, Protein-Calorie Malnutrition, and Hypertension. Review of the admission MDS dated [DATE] revealed Resident #3 scored a 12 on the BIMS which indicated moderately impaired cognition. The resident required extensive assistance for bed mobility and was dependent for transfers. Resident #3 had 1 Stage 2 pressure ulcer and 1 Stage 4 pressure ulcer documented in Section M Skin Conditions. (a) Review of the admission nursing assessment dated [DATE] documented, .Right toe(s) open area . There was no documentation of skin assessments describing the open area to the right toe(s) that was observed upon admission. Review of a Weekly Skin Review dated 12/28/2022 and 1/4/2023 revealed no new skin issues identified. Review of a Telemedicine note by the wound care Physician dated 12/30/2022 documented, .Pt [patient - Resident #3] is being seen today for evaluation and treatment of .gangrene to left toes 1-5 and right toes 1-5 . left Toes 1-5 Gangrene 4 cm x 8.2 cm x 0 cm .right Toes 1-5 Gangrene 3.8 cm x 8.5 cm x 0 cm . Review of a Physician's order with a start date of 12/31/2022 documented, .Cleanse thick, dry flaky skin to toes 1-5 to L [left] foot with wound cleanser. Pat dry. Apply skin repair cream to foot and leave open to air MWF [Monday, Wednesday, Friday] and PRN .Cleanse thick, dry flaky skin to toes 1-5 to R [right] foot with wound cleanser. Pat dry. Apply skin repair cream to foot and leave open to air MWF and PRN . Review of a Physician's order with a start date of 1/2/2023 documented, .Cleanse gangrene to toes 1-5 to L foot with wound cleanser. Pat dry. Apply calcium alginate with silver and wrap with kerlix MWF and PRN .Cleanse gangrene to toes 1-5 to R foot with wound cleanser. Pat dry. Apply calcium alginate with silver and wrap with kerlix MWF and PRN . Review of the Treatment Administration Record (TAR) for December 2022 revealed there was no treatment administered as ordered for the gangrene to the toes of the right and left foot on 12/31/2022. During an interview on 1/5/2023 at 9:53 AM when asked if she was aware Resident #3 had wounds to her toes Certified Nursing Assistant (CNA) #1 stated, .Yes Ma'am. I only saw the sores on her toes. I didn't see the heels. I told the nurse last weekend . During an interview on 1/9/2023 at 4:15 PM, the LPN/Wound Care Nurse confirmed the treatments for the gangrene to the toes of the right and left foot were not administered as ordered. (b) Review of the Physician's orders revealed, .Start Date 12/23/2022 Azithromycin Tablet 500 MG Give 1 tablet by mouth one time a day for HIV [Human Immunodeficiency Virus] .Start Date 12/22/2022 Bactrim DS Tablet 800-160 MG Give 1 tablet by mouth one time a day for bacterial infection .Biktarvy Tablet 50-200-25 MG Give 1 tablet by mouth one time a day for HIV .Start Date 12/23/2022 Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day .Eliquis Tablet 5 MG Give 5 mg by mouth two times a day . Review of the MAR dated December 2022 revealed no documentation Carvedilol was administered at 9:00 AM on 12/23/2022 and 9:00 AM and 9:00 PM on 12/25/2022 as ordered by the physician, Eliquis was not administered on 12/23/2022 and 12/24/2022 at 9:00 PM and 9:00 AM on 12/25/2022. There was no documentation Bactrim DS and Biktarvy were administered at 9:00 AM and 9:00 PM on 12/25/2022 and Azithromycin was not administered at 9:00 AM on 12/25/2022. 7. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of End Stage Renal Disease, Dependence Upon Dialysis, Pressure Ulcer of Sacral Region Stage 4, Heart Failure, Type 2 Diabetes Mellitus, Nontraumatic Subarachnoid Hemorrhage, Encephalopathy, and Severe Protein-Calorie Malnutrition. Review of the Physician's order with a start date of 12/7/2022 documented, .Cleanse diabetic ulcer to L lateral heel with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon [Monday], Wed [Wednesday], Fri [Friday] and PRN .Cleanse diabetic ulcer to R calf with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon, Wed, Fri and PRN .Cleanse diabetic ulcer to R lateral heel with wound cleanser. Pat dry. Apply collagen and cover with bordered gauze Mon, Wed, Fri, and PRN . Review of a Physician's order with a start date of 12/9/2022 documented, .Cleanse diabetic ulcer to R medial heel with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon, Wed, Fri, and PRN . Review of the quarterly MDS dated [DATE] revealed Resident #6 scored 13 on the BIMS which indicated no cognitive impairment. The resident required extensive assistance for activities of daily living, except for eating. Review of a Physician's order with a start date of 12/28/2022 documented, .Cleanse diabetic ulcer to R lateral heel with wound cleanser. Pat dry. Apply collagen and cover with bordered gauze Mon, Wed, Fri, and PRN . Review of the TAR for December 2022 revealed the following: There was no documentation treatment was administered as ordered for the wounds to the left lateral heel and the right calf on 12/19/2022, 12/26/2022, and 12/28/2022. There was no documentation the treatment was administered as ordered for the wound to the right lateral heel on 12/19/2022 and 12/26/2022. There was n [TRUNCATED]

Based on policy review, medical record review, observation, and interview the facility failed to identify wounds and provide treatments for 2 of 2 sampled residents (Resident #3 and #6) reviewed with wounds and failed to ensure medications were administered as ordered for 40 of 63 sampled residents (Resident #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #59, #60, #68, #69, #71, and #72) reviewed with significant medications. The facility's failure resulted in Immediate Jeopardy (IJ) when the facility failed to identify and provide treatments for wounds for Resident #3 and #6 and the wounds developed into gangrene and the facility's failure to administer significant medications as ordered had the likelihood to cause serious adverse outcomes and unstable declines in the residents' medical conditions. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Regional Director of Operations (RDO), the Area Director of Clinical Services (ADCS), the Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-684 on 1/17/2023 at 6:12 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-684. The facility was cited Immediate Jeopardy F-684 at a scope and severity of K which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 1/19/2023, and the Removal Plan was validated onsite by the surveyors on 1/24/2023 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ began on 12/16/2022 through 1/24/2023. Noncompliance continues at F684 at a scope and severity of E. The findings include: 1. Review of the facility's policy titled, Wound Treatment Management dated 3/24/2022, revealed .To promote healing of various types of wounds .Wound treatments will be provided in accordance with physicians orders .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .Treatments will be documented on the Treatment Administration Record .The effectiveness of treatments will be monitored through ongoing assessment of the wound . Review of the facility's undated policy titled, Skin Assessment, revealed .A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included a Stage 4 Pressure Ulcer to the Sacral area. The 12/28/2022 admission Minimum Data Set (MDS) revealed Resident #3 had moderately impaired cognition, required extensive assistance for bed mobility and was dependent for transfers. a. Review of the 12/21/2022 admission nursing assessment revealed .Right toe(s) open area . There was no skin assessment describing the area to the right toe(s) upon admission. Review of a Telemedicine note by the wound care Physician dated 12/30/2022 documented, .Pt [patient - Resident #3] is being seen today for evaluation and treatment of .gangrene to left toes 1-5 and right toes 1-5 . left toes 1-5 Gangrene 4 cm x 8.2 cm x 0 cm. right toes 1-5 Gangrene 3.8 cm x 8.5 cm x 0 m Review of the 12/31/2022 Physician's order revealed an order to cleanse thick, dry flaky skin to toes 1-5 to left and right feet with, wound cleanser. Pat dry. Apply skin repair cream to foot and leave open to air Monday, Wednesday, and Friday, and as needed. Review of the Treatment Administration Record (TAR) for December 2022 revealed there was no treatment administered as ordered for the gangrene to the toes of the right and left feet on 12/31/2022. Review of a Weekly Skin Review dated 12/28/2022 and 1/4/2023 revealed no new skin issues identified. Review of the 1/2/2023 Physician's order revealed an order change to cleanse gangrene to toes 1-5 to left and right feet with, wound cleanser, pat dry, apply calcium alginate with silver and wrap with kerlix MWF [Monday-Wednesday-Friday] and PRN [as needed]. During an interview on 1/5/2023 at 9:53 AM, when asked if she was aware Resident #3 had wounds, Certified Nursing Assistant (CNA) #1 stated, .Yes Ma'am. I only saw the sores on her toes. I didn't see the heels. I told the nurse last weekend . During an interview on 1/9/2023 at 4:15 PM, the LPN/Wound Care Nurse confirmed the treatments for the gangrene to the toes of the right and left foot were not administered as ordered. b. Review of Resident #3's medication orders revealed on 12/22/2022 the Physician ordered Bactrim DS 800-160 milligrams (mgs) 1 tablet by mouth one time a day for bacterial infection, and Biktarvy Tablet 50-200-25 mg 1 tablet by mouth one time a day for Human Immunodeficiency Virus (HIV). The 12/23/2022 Physician's orders revealed Azithromycin Tablet 500 mg 1 tablet by mouth one time a day for HIV, Carvedilol Tablet 6.25 mg 1 tablet by mouth two times a day, and Eliquis 5 mg by mouth two times a day. Review of the December 2022 MAR revealed the following: Carvedilol was not administered on 12/23/2022 at 9:00 AM; and on 12/25/2022 at 9:00 AM and 9:00 PM as ordered. The Eliquis was not administered on 12/23/2022 and 12/24/2022 at 9:00 AM 9:00 PM. There Bactrim DS and Biktarvy was not administered on 12/25/2022 at 9:00 AM and 9:00 PM. The Azithromycin was not administered on 12/25/2022 at 9:00 AM. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Pressure Ulcer of Sacral Region Stage 4, Type 2 Diabetes Mellitus, and Severe Protein-Calorie Malnutrition. The quarterly MDS dated [DATE] revealed Resident #6 had no cognitive impairment and required extensive assistance for activities of daily living except for eating. Review of the Physician's order dated 12/7/2022 documented the following: .Cleanse diabetic ulcer to L [left] lateral heel with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon,Wed, Fri [Monday, Wednesday, Friday] and PRN .Cleanse diabetic ulcer to R [right] calf with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon, Wed, Fri and PRN . Cleanse diabetic ulcer to R lateral heel with wound cleanser. Pat dry. Apply collagen and cover with bordered gauze Mon, Wed, Fri, and PRN . Review of the 12/9/2022 Physician's order revealed, Cleanse diabetic ulcer to R medial heel with wound cleanser. Pat dry. Apply skin prep and cover with dry bordered dressing Mon, Wed, Fri, and PRN . An additional 12/28/202 Physician's order revealed, .Cleanse diabetic ulcer to R lateral heel with wound cleanser. Pat dry. Apply collagen and cover with bordered gauze Mon, Wed, Fri, and PRN . Review of the December 2022 TAR revealed the following: There was no treatment administered as ordered for the right lateral heel wound on 12/19/2022, 12/26/2022, and 12/28/2022. There was no treatment administered as ordered for the right medial heel wound on 12/19/2022, 12/26/2022, and 12/28/2022. There was no treatment administered as ordered for the left lateral heel and the right calf wounds on 12/19/2022, 12/26/2022, and 12/28/2022. Review of a Shower Day Skin Inspection sheet dated 1/1/2022 (2023), used to record skin assessment observations for January 2023, revealed there was no documentation the skin condition of Resident #6's fingers was assessed. Review of a 1/4/2023 Physician's order revealed, .Cleanse gangrene to 4th digit of R hand with wound cleanser. Pat dry. Apply skin prep MWF and PRN . Observations in the resident's room on 1/4/2023 at 4:46 PM revealed Resident #6 was alert and oriented. The skin of the 4th finger on her left hand appeared dry and dark black from the first joint of the finger to the tip. She had very long, painted fingernails that needed cleaning. The resident stated, .The doctor saw my finger today and said she will get some medicine for it . During an interview on 1/5/2023 at 10:05 AM, when asked if Resident #6 had a wound to her finger, CNA #2 stated, I know her finger is black. I saw it last week when I cleaned her nails. I thought it was a blood blister. It was like a bruise, but with a red color. When asked if she reported the discoloration to anyone, CNA #2 stated, Yes, I told the nurse .I don't know her name. She was agency [contract staff]. During a telephone interview on 1/6/2023 at 2:45 PM, when asked what the signs and symptoms of gangrene are, the wound care Physician stated, .The beginning signs and symptoms would be a color change in the skin, pain, coldness, and after a day or so there may be a blood blister. She [Resident #6] has dry gangrene. I want to refer her to a vascular surgeon for evaluation for removal of the affected area of the finger . During an interview on 1/9/2023 at 3:20 PM, when asked if a skin assessment would include a resident's hands and fingers, the DON stated, Yes it would. When asked if the change in condition of Resident #6's finger was observed during the assessment on 1/1/2023 or during assisted bathing, the DON stated, She likes to do things for herself. She has long nails. I can't answer why it wasn't seen. I don't know if it was reported. During a telephone interview on 1/19/2023 at 1:34 PM with Resident #6's family member stated, When I came on the 1st [1/1/2023] I told them about her finger. I was upset. It looked like a blister .They were not aware until I told them. How could they not see that? . 4. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Covid-19, and Epilepsy. Review of the 9/1/2022 Physician's medication order revealed, Alogliptin Benzoate 12.5 milligrams (mg) 1 tablet by mouth one time a day related to Type 2 Diabetes Mellitus, and Amlodipine Besylate 10 mg 1 tablet daily related to Hypertension. Review of the December 2022 Medication Administration Record (MAR) revealed the Alogliptin was not administered at 9:00 AM on 12/4/2022 and 12/25/2022 as ordered. The Amlodipine was not administered at 9:00 AM or 9:00 PM on 12/4/2022 and 12/25/2022. There was no documentation the resident's blood pressure was assessed. 5. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Osteomyelitis and an open wound to the buttocks. The 10/26/2022 MDS revealed Resident #5 had no cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 8/2/2019 - Minocycline HCL 100 mg 2 times a day infection. 10/21/2022 Lantus SoloStar 100 units/milliliter - give 10 units subcutaneously at bedtime for Diabetes Mellitus. 2/1/2022 Rifampin Capsule 300 mg - 1 tablet two times a day for Osteomyelitis. Review of the the December 2022 MAR revealed on 12/22/2022 and 12/312022 the Lantus Solostar, Minocycline HCL, and Rifampin were not administered at 9:00 PM on 12/22/2022 and 12/31/2022 as ordered. During an interview on 1/11/2023 at 1:10 PM, LPN #5 was asked if the medications were administered on 12/22/2022 and 12/31/2022. LPN #2 stated, No, I don't see that. Could have been when there was only one nurse on the hall and she may have missed it . 6. Review of the medical record revealed Resident # 7 was admitted on [DATE] with diagnoses that included Diabetes and Hypertension (HTN). Review of the Physician Orders revealed the following dates and orders: 10/4/2022 - Amlodipine Besylate 5 mg 1 tablet two times a day for HTN. 11/22/2022 - Basaglar KwikPen 100 units/ml inject 32 unit subcutaneously at bedtime related to Type 2 Diabetes. Review of the January 2023 MAR revealed on 1/9/2023 the Amlodipine Besylate 5 mg and Basaglar KwikPen was not administered at 9:00 PM as ordered. 7. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region, Sepsis Unspecified Organism, Urinary Tract Infection, Cerebral Infarction, Type 2 Diabetes Mellitus, Acute Embolism and Thrombosis of Deep Vein or Right Upper Extremity, and Osteomyelitis. The 12/29/2022 MDS revealed the resident had severe cognitive impairment. Review of the Physician's orders revealed the following dates and orders: 12/23/2022 - Eliquis (Apixaban) 5 mg by mouth two times a day. 12/25/2022 - Doxycycline Monohydrate Capsule 100 mg by mouth two times a day for sepsis. 12/29/2022 - Metronidazole Tablet 500 mg by mouth three times a day for sepsis, and NovoLOG FlexPen 100 units/ml sliding scale related to Diabetes Mellitus. Review of the December 2022 MAR dated revealed the Doxycycline Monohydrate, Eliquis, Metronidazole were not administered at 9:00 PM on 12/31/2022 and the Novolog insulin per sliding scale was not administered on 12/29/2022-12/31/2022 as ordered. 8. Review of the medical record revealed Resident #14 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The 11/21/2022 MDS revealed the resident had no cognitive impairment. Review of the Physician's orders revealed the following dates and orders: 11/30/2022 - Clonidine HCL 0.3 mg 1 tablet by mouth three times a day for hypertension. HOLD for SBP [systolic blood pressure] < [less than]100, DBP [diastolic blood pressure] < 60, HR [heart rate] < than 60. Notify MD. 12/1/2022 - Minoxidil Tablet 2.5 mg 1 tablet by mouth two times a day related to Hypertension. 12/10/2022 - Methlmazole 5 mg 1 tablet by mouth one time a day related to Thyrotoicosis. Review of the January 2023 MAR revealed the Methlmazole was not administered at 9:00 AM on 1/1/2023. The Minoxidil was not administered on 1/4/2022 and 1/6/2022 at 9:00 AM; and on 1/4/2022 and 1/5/2022 at 9:00 PM as ordered. During an interview on 1/10/2023 at 3:37 PM Resident #14 stated, .Sometimes I don't get my early morning medicine for my thyroid problem. They tell me they don't want to wake me up. I just want my pill brought to me . 9. Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus and Hypertension. The 11/19/2022 MDS revealed the resident had no cognitive impairment. Review of the Physician's orders revealed the following dates and orders: 6/10/2021 - Midodrine HCL Tablet 10 mg 1 tablet by mouth every 8 hours for Postural Hypotension hold for SBP greater than (>) 110, and DBP > 70 and; Novolog FlexPen 100 units/ml Give as per sliding scale for elevated blood glucose levels before meals and at bedtime . 7/13/2022 - Metoprolol Tartrate 50 mg 1 tablet by mouth every 12 hours for hypertension Hold for SBP less than 110, DBP less than 60 or heart rate less than 60 beats per minute; and Sacubitril-Valsartan 24-26 mg 1 tablet by mouth every 12 hours. Review of the January 2023 MAR revealed no documentation Metoprolol Sacubitril-Valsartan was administered at 9:00 PM on 1/9/2023 as ordered. The Midodrine was not administered at 10:00 PM on 1/9/2023 and at 6:00 AM on 1/10/2023. The Novolog Insulin was not administered on 1/9/2023 at 8:00 PM as ordered and the resident's blood glucose level was not assessed at 8:00 PM. There was no documentation the resident's Blood pressure was checked. During an interview on 1/10/2023 at 7:10 PM Resident #23 was was asked about the medications that were not administered. Resident #23 stated, .I didn't get it. No nurse here. The CNA told me. I went to the desk downstairs and the receptionist said they trying to get someone to come. No one came . 10. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses that included History of Venous Thrombosis and Embolism. The 1/8/2023 MDS revealed the resident had no cognitive impairment. Review of the 9/25/2021 Physician's orders revealed Apixaban Tablet (Eliquis) 5 mg give by mouth two times a day. Review of the January 2023 MAR revealed the Apixaban was not administered on 1/9/2023 at 9:00 PM as ordered. During an interview on 1/10/2023 at 4:01 PM the resident was asked about the 1/9/2023 medication. Resident #24 stated, No, I didn't get all my medicine. There was no nurse. 11. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses including Supraventricular Tachycardia. The 1/4/2023 MDS revealed the resident had moderate cognitive impairment. Review of the 4/30/2020 Physician's orders revealed Metoprolol Tartrate Tablet 25 mg give by mouth two times a day for HTN Hold for heart rate less than 60 or SBP less than 110. Review of the January 2023 MAR revealed the Metoprolol Tartrate was not administered on 1/9/2023 at 9:00 PM as ordered or the resident's blood checked. 12. Review of the medical record revealed Resident #29 was admitted on [DATE] with the diagnosis of Heart Failure. The 12/8/2022 MDS revealed the resident had moderate cognitive impairment. Review of the 12/17/2020 Physician's orders revealed Carvedilol Tablet 25 mg give by mouth two times a day for Heart Failure. Hold if HR less than 60 bpm. Review of the January 2023 MAR revealed the Carvedilol was not administered on 1/9/2023 at 9:00 PM as ordered or the heart rate checked. 13. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis Left Nondominant Side, Osteoarthritis, and Benign Neoplasm of Skin. The 12/13/2022 MDS revealed the resident had no cognitive impairment. Review of the 11/06/2021 Physician's orders revealed Apixaban Tablet 5 mg 1 tablet two times a day for anticoagulant therapy, and Carvedilol Tablet 6.25 mg 1 tablet by mouth two times a day. Review of the January 2023 MAR revealed the Apixaban and Carvedilol were not administered on 1/9/2023 at 9:00 PM as ordered. 14. Review of the medical record revealed Resident #31 admitted on [DATE] with diagnoses that included Hypertension, History Transient Ischemic Attack, and Cerebral Infarction. The 12/24/2022 MDS revealed the resident had no cognitive impairment. Review of the 10/24/2022 Physician's orders revealed Diltiazem HCL 30 mg give 1 tablet by mouth three times a day for HTN, hold for SBP < 100, DBP < 60, or HR < 60. Review of the January 2023 MAR revealed the Diltiazem was not administered on 1/9/2023 at 9:00 PM as ordered. There was no documentation the resident's blood pressure and heart rate were assessed. 15. Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus. The 10/15/2022 MDS revealed the resident had no cognitive impairment. Review of the 9/20/2022 Physician's orders revealed Lantus SoloStar 100 units/ml inject 26 units Intradermally at bedtime. Review of the January 2023 MAR revealed the Lantus insulin was not administered on 1/9/2023. 16. Review of the medical record revealed Resident #34 admitted on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. The 12/14/2022 MDS revealed the resident had no cognitive impairment. Review of the 12/08/2022 Physician's orders revealed Insulin Lispro (1 Unit Dial) 100 unit/ml pen-injector, inject 3 units subcutaneously before meals, and Insulin Glargine-yfgn 100 units/ml pen-injector inject 40 units subcutaneously at bedtime. Review of the December 2022 MAR revealed the Insulin Lispro was not administered on 12/15/2022 at 5:00 PM as ordered, and the Insulin Glargine-yfgn was not administered on 1/9/2023 at 9:00 PM as ordered. 17. Review of the medical record revealed Resident #35 was admitted on [DATE] with a diagnosis of Essential Hypertension. The 12/14/2022 MDS revealed the resident had no cognitive impairment. Review of the physician's orders revealed the following orders and dates: 3/13/2021- Eliquis Tablet 2.5 mg give 1 tablet by mouth two times a day. 10/24/2022 - Coreg Tablet 6.25MG (Carvedilol) give 1 tablet by mouth two times a day for HTN. Hold for SBP less than 100, DBP less than 60 or HR less than 60, Review of the January 2023 MAR revealed the Coreg and Eliquis were not administered on 1/9/2023 at 9:00 PM as ordered. There was no documentation the resident's blood pressure and heart rate were assessed. 18. Review of the medical record revealed Resident #36 was readmitted on [DATE] with diagnoses that included Hypertension and Hypothyroidism Disease. The 11/10/2022 MDS revealed the resident had no cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 12/17/2022 - Levothyroxine Sodium Tablet 150 MCG Give 150 micrograms (mcg) by mouth on time a day every Mon, Tue, Wed, Thu, Fri, and Sat. Review of the January 2023 MAR revealed the Levothyroxine and Hydralazine were not administered on 1/9/2023 at 9:00 PM as ordered. 19. Review of the medical record revealed Resident #37 was readmitted on [DATE] with diagnoses that included Epilepsy, Cerebral Infarction, and Schizoaffective Disorder, and Hallucinations. The 12/14/2022 MDS revealed the resident had a severe cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 10/6/2022 - Lacosamide Tablet 200 mg give 200 mg by mouth two times a day for seizure disorder. 12/13/2022 - Risperidone Tablet 0.5 mg give 1 tablet by mouth at bedtime related to schizoaffective disorder. Review of the January 2023 MAR the Risperidone and Lacosamide were not administered on 1/9/2023 at 9:00 PM as ordered. 20. Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus and Unspecified Psychosis. The 1/2/2023 MDS revealed the resident had severe cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 6/10/2022 - Depakote Tablet Delayed Release 250 mg give 1 tablet by mouth three times a day. 8/4/2022 - Humalog KwikPen 100 units/ml pen-injector inject as per sliding scale subcutaneously before meals and at bedtime. Review of the January 2023 MAR revealed the Depakote was not administered on 1/9/2023 at 9:00 PM as ordered, and the Humalog insulin was not administered on 1/9/2023 at 8:00 PM as ordered by the physician. The MAR revealed the resident's blood glucose level was not checked for the sliding scale insulin on 1/9/2023 as ordered. 21. Review of the medical record, revealed Resident #39 readmitted on [DATE] with diagnoses that included Cerebral Infarction, Atrial Fibrillation, and Hypothyroidism. The 12/2/2022 MDS revealed the resident had severe cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 6/6/2022 - Eliquis Tablet 5 mg give 1 tablet by mouth two times a day, and Levetiracetam Tablet 500 mg give 1000 mg by mouth two times a day. 6/25/2022 - Levothyroxine Sodium Tablet 125 MCG give 1 tablet by mouth one time a day. Review of the January 2023 MAR the Levothyroxine was not administered on 1/10/2023 at 6:00 AM as ordered, and the Eliquis and Levetiracetam were not not administered on 1/9/2023 at 9:00 PM as ordered. 22. Review of the medical record revealed Resident #40 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Seizures, Asthma, and Hypothyroidism. The 11/2/2022 MDS revealed the resident had moderate cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 7/27/2022 - Levothyroxine Sodium Tablet 100 MCG give 1 tablet by mouth one time a day, Rosuvastatin Calcium Oral Tablet 5 MG give 5 mg by mouth at bedtime, and Levetira tablet 250 MG give 250 mg by mouth two times a day. 8/10/2022 - Basaglar KwikPen 100 units/ml pen-injector inject 10 units subcutaneously at bedtime. Review of the January 2023 MAR revealed the Basaglar insulin, Rosuvastatin Calcium, and Levetiracetam were not administered on 1/9/2023 at 9:00 PM as ordered. The Levothyroxine was not administered at 6:00 AM on 1/10/2023 as ordered. 23. Review of the medical record revealed Resident #41 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, End Stage Renal Disease on dialysis, Atrial Fibrillation, Congestive Heart Failure, Chronic Pulmonary Edema, and Atherosclerotic Heart Disease. The 12/24/2022 MDS revealed the resident had moderate cognitive impairment. Review of the Physician's orders revealed the following orders and dates: 11/30/2021 - Hydralazine HCL 25 mg give 50 mg by mouth two times a day. 5/22/2021 - Clopidogrel Bisulfate 75 mg give 1 tablet by mouth one time a day, and Isosorbide Mononitrate ER (extended release) 30 mg give 1 tablet by mouth one time a day. 1/5/2023 - Carvedilol Oral 12.5 mg give 1 tablet by mouth two times a day. Review of the January 2023 MAR revealed the Clopidogrel, Isosorbide Mononitrate, and Hydralazine were not administered on 1/10/2023 at 6:00 AM as ordered. The Carvedilol was not administered on 1/9/2023 at 9:00 PM as ordered. 24. Review of the medical record revealed Resident #42 was admitted on [DATE] and had a diagnosis of Diabetes. The 12/28/2022 MDS revealed the resident 42 had no cognitive impairment. Review of the Physician Orders revealed the following orders and dates: 3/11/2022 - Janumet XR ER ,d+[DATE] mg give 1 tablet by mouth one time a day for Diabetes Mellitus. 8/2/2022 - Lantus SoloStar 100 units/ml pen-injector inject 30 units subcutaneously at bedtime related to TYPE 2 DIABETES. 11/22/2022 - Glimepiride 1 mg by mouth one time a day for Diabetes Mellitus. Review of the January 2023 MAR revealed the Glimepiride 1 mg and the Janumet ER ,d+[DATE] mg were not administered at 6:00 AM on 1/10/2023. The Lantus SoloStar 100 units/ml was not administered at 9:00 PM on 1/9/2023 as ordered. 25. Review of the medical record revealed Resident #45 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Atherosclerotic Heart Disease, and Hypertension. The 1/7/2023 MDS the resident had no cognitive impairment. Review of the Physician Orders revealed the following orders and dates: 3/10/2022 - hydralazine HCl 25 MG give 1 tablet by mouth two times a day related to Hypertension. 5/20/2022 - Entresto 49-51 mg give 1 tablet by mouth two times a day related to Other Heart Failure. Review of the January 2023 MAR revealed the Entresto 49-51 mg was not administered at 9:00 PM on 1/9/2023. The Hydralazine 25 mg was not administered at 8:00 PM on 1/9/2023 as ordered. 26. Review of the medical record revealed Resident #46 admitted on [DATE] had a diagnosis of Hypertension. The 12/3/2022 MDS revealed the resident had moderate cognitive impairment. Review of the 11/21/2022 Physician Orders revealed Metoprolol Tartrate 12.5 mg by mouth two times a day for hypertension. Review of the January 2023 MAR revealed the Metoprolol 12.5 mg was not administered at 9:00 PM on 1/9/2023 as ordered. 27. Review of the medical record revealed Resident #47 was admitted on [DATE] and had diagnoses that included Anxiety Disorder and Schizoaffective Disorder. The 11/4/2022 MDS revealed the resident had no cognitive impairment. Review of the 10/20/2022 Physician Orders revealed Quetipine Fumerate 100 mg give 1.5 tablet by mouth at HS for a total dose of 150 mg related to Schizoaffective Disorder. Review of the January 2023 MAR revealed the Quetipine Fumerate was not administered at 9:00 PM on 1/9/2023 as ordered. 28. Review of the medical record revealed Resident #48 was admitted on [DATE] and had a diagnosis Diabetes The 12/18/2022 MDS revealed the resident had a severe cognitive impairment. Review of the 7/21/2022 Physician Orders revealed Glargine-yfgn insulin 100 units/ml pen-injector inject 28 unit subcutaneously two times a day related to Diabetes. Review of the January 2023 MAR revealed the Glargine-yfgn 100 units/ml was not administered at 9:00 PM on 1/9/2023 as ordered. 29. Review of the medical record, revealed Resident #49 admitted on [DATE] with diagnoses that include Diabetes, and Hypertension. The 12/16/2022 MDS revealed the resident was severely impaired cognitive impairment. Review of the Physician Orders revealed the following orders and dates: 8/12/2021 - Metoprolol Tartrate 100 mg give 1 tablet by mouth two times a day for Hypertension. 1/19/2022 - Novolog FlexPen 100 units/ml pen-injector inject subcutaneously before meals and at bedtime related to Diabetes. 10/4/2022 - Verapamil HCl 40 MG give 40 mg by mouth three times a day for Hypertension. Review of the January 2023 MAR revealed the Metoprolol Tartrate Tablet 100 MG was not administered at 9:00 PM on 1/9/2023 as ordered. The Verapamil HCl Tablet 40 MG was not administered at 10:00 PM on 1/9/2023 and 6:00 AM on 1/10/2023 as ordered. The Novolog FlexPen 100 UNIT/ML was not administered at 6:30 AM on 1/3/2023, at 6:30 AM and 8:00 PM on 1/9/2023, and at 6:30 AM on 1/10/2023 as ordered. 30. Review of the medical record, revealed Resident #50 admitted on [DATE] with a diagnosis of Hypertension. The 11/08/2022 MDS revealed the resident had moderate cognitive impairment. Review of the Physician Orders dated 11/17/2022 revealed Hydralazine HCl 50 mg give 1 tablet by mouth four times a day for Hypertension. Review of the January 2023 MAR revealed the Hydralazine HCl 50 mg was not administered at 9:00 PM on 1/9/2023 as ordered. 31. Review of the medical record revealed Resident #51 was admitted on [DATE] with a diagnosis of Hypertension. The 11/25/2022 MDS revealed the resident had a severe cognitive impairment. Review of the 3/1/2022 Physician Orders revealed Eliquis 5 mg give 5 mg by mouth two times a day for blood thinner related to Hypertension. Review of the January 2023 MAR revealed the Eliquis 5 mg was not administered at 8:00 PM on 1/9/2023 as ordered. 32. Review of the medical record revealed Resident #52 was admitted on [DATE] with diagnoses of Cerebral Infarction, Seizures, and Hypertension. The 12/17/2022 MDS revealed the resident had a moderate cognitive impairment. Review of the 3/12/2022 Physician Orders dated 3/12/2020 revealed Levetiracetam 1000 mg give 1000 mg by mouth two times a day for Seizures. Review of the January 2023 MAR revealed the Levetiracetam 1000 mg was not administered at 9:00 PM on 1/9/2023 as ordered. 33. Review of the medical record revealed Resident #53 was admitted on [DATE] with a diagnosis of Hypertension. The 12/3/2022 MDS revealed the resident had moderate cognitive impairment. Review of the 10/4/2022 Physician Orders revealed Hydralazine HCl 25 mg give 1 tablet by mouth two times a day for Hypertension. Review of the January 2023 MAR revealed the Hydralazine HCl 25 MG was not administered at 9:00 PM on 1/9/2023 as ordered. 34. Review of the medical record revealed Resident #55 was admitted on [DATE] with diagnoses that included of Atrial Fibrillation, Diabetes and Hypertension. The 11/2/2022 MDS revealed the resident had severe cognitive impairment. Review of the Physician Orders, revealed the following orders and dates: 2/12/2020 Apixaban 2.5 mg give 2.5 mg by mouth two times a day for Anticoagulation, and Metoprolol Tartrate 12.5 mg give by mouth two times a day for Hypertension. 9/21/2021 - Lantus SoloStar 100 units/ml pen-injector inject 5 unit subcutaneously at bedtime for Diabetes. 10/27/2022 - Humalog 100 units/ml pen-injector inject subcutaneously before meals and at bed

Based on policy review, daily staffing records, medical record review, observation, and interview, the facility failed to ensure a sufficient number of licensed staff was available to provide care and services to all residents based on physician orders when there was no nurse to provide assessments and services for 1 of 2 sampled residents (Resident #22) admitted to the 3rd floor on 1/9/2023 and administer significant and other medications for 29 of 40 sampled residents (Resident #7, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, 52, #53, #55, #56, and #57) reviewed on the 3rd floor with orders for medications. The facility's failure to ensure staffing was sufficient to provide oversight of the residents and ensure timely assessments and medications were administered resulted in Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Regional Director of Operations, Area Director of Clinical Services, Special Projects Nurse, and the Administrator, were notified of the Immediate Jeopardy (IJ) for F600, F725, F760, F835, and F867 on 1/24/2023 at 12:38 PM, in the Chapel. The facility was cited Immediate Jeopardy at F600, F684, F686, F725, F760, F835, and F867. The facility was cited Immediate Jeopardy at F725 at a scope and severity of K which is Substandard Quality of Care. The Immediate Jeopardy for F725 began on 1/9/2023 and is ongoing. The facility was previously cited Immediate Jeopardy at F600, F835, and F867 during a complaint survey on 9/19/2022 through 9/20/2022. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled Nursing Services and Sufficient Staff revised 8/30/2022 revealed, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. a. Except when waived, licensed nurses; and b. Other nursing personnel, including but not limited to nurse aides .The facility is required to provide licensed nursing staff 24 hours a day, 7 days a week .Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to residents' needs . Review of the Director of Nursing job description dated 12/2011 revealed, .to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department .Perform nursing services and deliver resident care services in compliance with corporate policies and State and Federal regulations .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Ensure that all nursing service personnel follow established departmental policies and procedures .Assure residents a comfortable, clean, orderly and safe environment . Review of the facility's policy titled Medication Administration dated 1/21/2022 revealed, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. If other than PO [by mouth] route, administer in accordance with facility policy for the relevant route of administration [i.e., injection, eye, ear, rectal, etc.] .Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR .Report and document any adverse side effects or refusals .Example guidelines for Medication Administration [unless otherwise ordered by physician], this list is not all-inclusive .Medication requiring vital signs prior to administration: Digitalis, Lanoxin, Digoxin, Anti-Hypertensives .Medication timing [excludes insulin]: .AC [before meals] 30 minutes before meal service. PC [administered after meals]. BID [twice daily] 9 am, 9 pm. HS [at bedtime] 9 pm. QD [daily] 9 am. QID [four times daily] 9 am, 1 pm, 5 pm, 9 pm . Review of the facility's CMS Daily Staffing Record dated 1/9/2023 revealed on the 7:00 PM - 7:00 AM shift the facility had a total of 3 Licensed Practical Nurses (LPNs) with a total of 21 actual hours worked with a census of 146 residents. Review of the Census By Floors form dated 1/9/2023 revealed a total census of 145 residents. A total of 54 residents resided on the 3rd floor. Review of the printed electronic Medication Administration Record (MAR) revealed the MAR had pre-printed medication due times for each medication per physician orders. 2. Review of the medical record revealed Resident #22 was admitted to the facility 1/9/2023 with diagnoses of Seizures, Syncope and Collapse, Rhabdomyolysis, Metabolic Encephalopathy, Essential Hypertension, Muscle Weakness, and Dysphagia. Review of Resident #22's medical record revealed no assessments were completed upon admission and no documentation was in the medical record related to the resident's condition and needs. Review of the hospital transfer orders dated 1/9/2023 revealed, .Admit To Midtown Health and Rehab .Stg [Stage] III [3] B [bilateral] buttocks and sacrum .multiple erupted blister B heel blisters . The resident had no medications ordered. Review of a Nurse's Progress Note dated 1/10/2023 timed 12:59 PM revealed staff were unable to feed Resident #22 due to the Resident clinching her teeth together and being combative. Resident #22 was transferred to the hospital for evaluation. During an interview on 1/10/2023 at 2:05 PM, when asked if she was notified there was no nurse on the 3rd floor on 1/9/2023 for the 7:00 PM-7:00 AM shift, LPN #6 stated, I left here about 7 [7:00 PM] last night. I was on call for staff. [Named LPN] called me and said he was waiting on a nurse. I called the SDC [Staff Development Coordinator] and she put out a call to [Named agency]. I went to bed. I got here the next morning at 8:06 [AM]. There were 2 admissions came in. Not sure if anyone did the admissions . During an interview on 1/10/2023 at 3:41 PM, when asked if she was notified there was no nurse on the 3rd floor on 1/9/2023 for the 7:00 PM-7:00 AM shift, the SDC stated, The nurses called out. [Named LPN] called me and asked me to put out a post. I put a post out to agency. Nobody responded. I watched for awhile then I went to bed. I wasn't on call, so I didn't follow up . During an interview on 1/10/2023 at 1:30 PM, when asked if the residents on the 3rd floor received medications on 1/9/2023 as ordered by the physician, the Director of Nursing (DON) stated, No, they did not. There was no nurse. When asked if the 2 newly admitted residents were assessed and provided care and services the DON stated, I'll find out. I know one [Resident #22] had to be sent out to the hospital already. During an interview on 1/11/2023 at 1:28 PM the DON stated, .[Named LPN] made it to the floor at 8:28 [AM on 1/10/2023]. He put her medication orders in and went in and checked on her . When asked if Resident #22 was assessed on 1/9/2023, the DON stated, If it wasn't documented, it wasn't done. 3. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses of Diabetes, Unspecified Sequelae of Cerebral Infarction, Anxiety Disorder, and Hypertension. The Quarterly MDS assessment dated [DATE], revealed Resident # 7 with a BIMS of 14 which indicated no cognitive impairment. Review of the Physician Orders revealed, .start date 10/4/2022 AmLODIPine Besylate Tablet 5 MG Give 5 mg by mouth two times a day for HTN .start date 11/22/2022 Basaglar KwikPen 100 UNIT/ML Solution pen-injector Inject 32 unit subcutaneously at bedtime related to TYPE 2 DIABETES . Review of the MAR dated January 2023 revealed the Amlodipine Besylate Tablet 5 MG was not administered at 9:00 PM on 1/9/2023, and the Basaglar KwikPen 100 UNIT/ML was not administered at 9:00 PM on 1/9/2023 as ordered. 4. Review of the medical record revealed Resident #23 admitted on [DATE] with diagnoses of Atrial Fibrillation, Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Angina Pectoris, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS dated [DATE] revealed the resident scored a 13 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following: Start Date 6/10/2021, Midodrine HCL Tablet 10 MG Give 1 tablet by mouth every 8 hours for Postural Hypotension. Hold for SBP [Systolic Blood pressure] > [greater than] 110, DBP [Diastolic Blood pressure] > 70. Novolog FlexPen 100 UNIT/ML pen-injector give as per sliding scale: If 150-200 give 2 units; 201-250 give 4 units; 251-300 give 6 units; 301-350 give 8 units; 351-400 give 10 units; 401 an greater give 12 units and notify MD before meals and at bedtime. Start Date 7/13/2022 Metoprolol Tartrate Tablet 50 MG give 1 tablet by mouth every 12 hours for Hypertension. Hold for SBP < 110, DBP < 60 or HR equal to or less than (=/<) 60 beats per minute (bpm). Sacubitril-Valsartan Tablet 24-26 mg give 1 tablet by mouth every 12 hours. Review of the MAR dated January 2023 revealed no documentation Metoprolol Sacubitril-Valsartan were administered at 9:00 PM on 1/9/2023 as ordered by the physician. The Midodrine was not administered at 10:00 PM on 1/9/2023 and 6:00 AM on 1/10/2023. The Novolog Insulin was not administered on 1/9/2023 at 8:00 PM as ordered by the physician. The resident's blood glucose level was not assessed at 8:00 PM. During an interview on 1/10/2023 at 7:10 PM when asked if he received medications timely on 1/9/2023, Resident #23 stated, .I didn't get it. No nurse here. The CNA told me. I went to the desk downstairs and the receptionist said they trying to get someone to come. No one came . 5. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses of Cerebral Palsy, Essential Hypertension, History of Venous Thrombosis and Embolism, and Rhabdomyolysis. Review of the quarterly MDS dated [DATE] revealed the resident scored a 15 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 9/25/2021 Apixaban Tablet 5 MG Give 5 mg by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation Apixaban was administered on 1/9/2023 at 9:00 PM as ordered by the physician. During an interview on 1/10/2023 at 4:01 PM, when asked if she received her medications on 1/9/2023, Resident #24 stated, No, I didn't get all my medicine. There was no nurse. 6. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses of Supraventricular Tachycardia, Schizophrenia, Osteoarthritis, and Anemia. The MDS dated [DATE] revealed the resident scored 9 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 4/30/2020 Metoprolol Tartrate Tablet 25 MG Give 25mg by mouth two times a day for HTN Hold for HR <60 or SBP <110 . Review of the MAR dated January 2023 revealed no documentation Metoprolol Tartrate was administered on 1/9/2023 at 9:00 PM as ordered by the physician. 7. Review of the medical record revealed Resident #29 was admitted on [DATE] with diagnoses of Heart Failure, Glaucoma, Essential Hypertension, Tremor, Chest Pain, and Hypomagnesia. The quarterly MDS dated [DATE], revealed the resident scored 11 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 12/17/2020 Carvedilol Tablet 25 MG Give 25 mg by mouth two times a day for Heart Failure Hold if HR less than 60 . Review of the MAR dated January 2023 revealed no documentation Carvedilol was administered on 1/9/2023 at 9:00 PM as ordered by the physician. 8. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis Left Nondominant Side, Osteoarthritis, and Benign Neoplasm of Skin. The annual MDS dated [DATE] revealed the resident scored 12 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 11/06/2021 Apixaban Tablet 5 MG Give 1 tablet two times a day for anticoagulant therapy .Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation the Apixaban and Carvedilol were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 9. Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Thyrotoxicosis, Essential Hypertension, History Transient Ischemic Attack, and Cerebral Infarction. The quarterly MDS dated [DATE], revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 10/24/2022 Diltiazem HCL Tablet 30 MG Give 1 tablet by mouth three times a day for HTN Hold for SBP < 100, DBP < 60, or HR < 60 . Review of the MAR dated January 2023 revealed no documentation the Diltiazem was administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the resident's blood pressure and heart rate were assessed. 10. Review of the medical record revealed Resident #33 was admitted on [DATE] with diagnoses of Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Anemia, and Chronic Obstructive Pulmonary Disease. The quarterly MDS dated [DATE] revealed the resident scored 15 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 9/20/2022 Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 26 units Intradermally at bedtime . Review of the MAR dated January 2023 revealed no documentation Lantus insulin was administered on 1/9/2023 as ordered by the physician. 11. Review of the medical record revealed Resident #34 was admitted on [DATE] with diagnoses of Congestive Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, and History of Malignant Neoplasm of Prostate. The admission MDS dated [DATE], revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 12/08/2022 Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen-injector Inject 3 units subcutaneously before meals .Insulin Glargine-yfgn 100 UNIT/ML Solution pen-injector Inject 40 units subcutaneously at bedtime . Review of the MAR dated December 2022 revealed no documentation the Insulin Lispro was administered on 12/15/2022 at 5:00 PM as ordered by the physician and there was no documentation Insulin Glargine-yfgn was administered on 1/9/2023 at 9:00 PM as ordered by the physician. 12. Review of the medical record revealed Resident #35 was admitted on [DATE] with diagnoses of End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes, Essential Hypertension, and Major Depressive Disorder. The admission MDS dated [DATE], revealed the resident scored 12 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 10/24/2022 Coreg Tablet 6.25 MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN. Hold for SBP < 100, DBP < 60 or HR <60 .Start Date 3/13/2021 Eliquis Tablet 2.5 MG Give 1 tablet by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation Coreg and Eliquis were administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the resident's blood pressure and heart rate were assessed. 13. Review of the medical record revealed Resident #36 was readmitted on [DATE] with diagnoses of End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus, Essential Hypertension, Hypothyroidism, and Human Immunodeficiency Virus Disease. The admission MDS dated [DATE] revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 12/17/2022 Levothyroxine Sodium Tablet 150 MCG [micrograms] Give 150 mcg by mouth on time a day every Mon, Tue, Wed, Thu, Fri, Sat .Start Date 12/16/2022 Hydralazine HCL Tablet 25 MG Give 1 tablet by mouth three times a day . Review of the MAR dated January 2023 revealed no documentation Levothyroxine and Hydralazine were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 14. Review of the medical record revealed Resident #37 was readmitted on [DATE] with diagnoses of Epilepsy, Cerebral Infarction, Type 2 Diabetes Mellitus, Schizoaffective Disorder, and Hallucinations. The quarterly MDS dated [DATE] revealed the resident scored 8 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed, .Start Date 12/13/2022 Risperidone Tablet 0.5 MG Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER .Start Date 10/6/2022 Lacosamide Tablet 200 MG Give 200 mg by mouth two times a day for SEIZURE DISORDER . Review of the MAR dated January 2023 revealed no documentation Risperidone and Lacosamide were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 15. Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Unspecified Psychosis, and Essential Hypertension. The quarterly MDS dated [DATE], revealed the resident scored 4 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed, .Start Date 6/10/2022 Depakote Tablet Delayed Release 250 MG Give 1 tablet by mouth three times a day .Start Date 8/4/2022 HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale . The sliding scale orders revealed If blood glucose levels were 0-149 give 0, if less than 70 call MD, if 150-180 give 1 unit, if 181-210 give 2 units, if 211-240 give 3 units, if 241-270 give 4 units, if 271-300 give 5 units, if greater than 300 notify MD, subcutaneously before meals and at bedtime. Review of the MAR dated January 2023 revealed no documentation the Depakote was administered on 1/9/2023 at 9:00 PM as ordered by the physician and Humalog insulin was not administered on 1/9/2023 at 8:00 PM as ordered, and the resident's blood glucose level was not checked for the sliding scale insulin on 1/9/2023 at 8:00 PM as ordered. 16. Review of the medical record revealed Resident #39 was readmitted on [DATE] with diagnoses of Epilepsy, Type 2 Diabetes Mellitus, Cerebral Infarction, Atrial Fibrillation, and Hypothyroidism. The quarterly MDS dated [DATE] revealed the resident scored 5 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed, .Start Date 6/25/2022 Levothyroxine Sodium Tablet 125 MCG Give 1 tablet by mouth one time a day .Start Date 6/6/2022 Eliquis Tablet 5 MG Give 1 tablet by mouth two times a day .levetiracetam Tablet 500 MG Give 1000 mg by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation the Levothyroxine was administered on 1/10/2023 at 6:00 AM as ordered by the physician and the Eliquis and Levetiracetam were not administered on 1/9/2023 at 9:00 PM as ordered by the physician. 17. Review of the medical record revealed Resident #40 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Seizures, Asthma, and Hypothyroidism. The quarterly MDS dated [DATE] revealed the resident scored 11 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 8/10/2022 Basaglar KwikPen 100 UNIT/ML Solution pen-injector Inject 10 units subcutaneously at bedtime .Start Date 7/27/2022 Levothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth one time a day .Rosuvastatin Calcium Oral Tablet 5 MG Give 5 mg by mouth at bedtime .Start Date 7/27/2022 levETIRAcetam Tablet 250 MG Give 250 mg by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation the Basaglar insulin, Rosuvastatin Calcium, and Levetiracetam were administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the Levothyroxine was administered at 6:00 AM on 1/10/2023 as ordered by the physician. 18. Review of the medical record revealed Resident #41 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, End Stage Renal Disease, Dependence on Renal Dialysis, Atrial Fibrillation, Congestive Heart Failure, Chronic Pulmonary Edema, and Atherosclerotic Heart Disease. The quarterly MDS dated [DATE] revealed the resident scored 10 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 5/22/2021 Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day .Isosorbide Mononitrate ER [extended release] Tablet 30 MG Give 1 tablet by mouth one time a day .Start Date 1/5/2023 Carvedilol Oral Tablet 12.5 MG Give 1 tablet by mouth tow times a day .Start Date 11/30/2021 HydrALAZINE HCL Tablet 25 MG Give 50 mg by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation the Clopidogrel, Isosorbide Mononitrate, and Hydralazine were administered on 1/10/2023 at 6:00 AM as ordered by the physician. There was no documentation Carvedilol was administered as ordered on 1/9/2023 at 9:00 PM as ordered by the physician. 19. Review of the medical record revealed Resident #42 was admitted on [DATE] with diagnoses of Atherosclerotic Heart Disease, Diabetes, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 42 had a BIMS score of 13 which indicated no cognitive impairment. Review of the Physician Orders revealed, .start date 11/22/2022 Glimepiride Tablet 1 MG Give 1 mg by mouth one time a day for Diabetes Mellitus .start date 3/11/2022 Janumet XR Tablet Extended Release 24 Hour [PHONE NUMBER] MG (SITagliptin-metFORMIN HCl ER) Give 1 tablet by mouth one time a day for Diabetes Mellitus .start date 8/2/2022 Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 30 unit subcutaneously at bedtime related to TYPE 2 DIABETES . Review of the MAR dated January 2023 revealed no documentation of the Glimepiride Tablet 1 MG administered at 6:00 AM on 1/10/2023, Janumet XR Tablet Extended Release 24 Hour [PHONE NUMBER] MG administered at 6:00 AM on 1/10/2023, Lantus SoloStar 100 UNIT/ML administered at 9:00 PM on 1/9/2023 as ordered by the physician. 20. Review of the medical record revealed Resident #45 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Atherosclerotic Heart Disease, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 45 had a BIMS score of 13 which indicated no cognitive impairment. Review of the Physician Orders revealed, .start date 5/20/2022 Entresto Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day related to OTHER HEART FAILURE .start date 3/10/2022 hydrALAZINE HCl Tablet 25 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Review of the MAR dated January 2023 revealed no documentation of the Entresto Tablet 49-51 MG administered at 9:00 PM on 1/9/2023, hydrALAZINE HCl Tablet 25 MG administered at 8:00 PM on 1/9/2023 as ordered by the physician. 21. Review of the medical record revealed Resident #46 was admitted on [DATE] with diagnoses of Gastro-Esophageal Reflux Disease, Blindness, One Eye, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 46 had a BIMS score of 12 which indicated moderate cognitive impairment. Review of the Physician Orders dated 11/21/2022 revealed, .Metoprolol Tartrate Tablet Give 12.5 milligram by mouth two times a day for hypertension . Review of the MAR dated January 2023 revealed no documentation of the Metoprolol Tartrate 12.5 mg administered at 9:00 PM on 1/9/2023 as ordered by the physician. 22. Review of the medical record revealed Resident #47 was admitted on [DATE] with diagnoses of Functional Quadriplegia, Anxiety Disorder, Schizoaffective Disorder, Insomnia, and Spinal Stenosis. The annual MDS assessment dated [DATE] revealed Resident # 47 had a BIMS score of 15 which indicated no cognitive impairment Review of the Physician Orders revealed, .start date 12/20/2022 QUEtipine Fumerate Tablet 100 MG Give 1.5 tablet by mouth at HS for a total dose of 150 mg related to SCHIZOAFFECTIVE DISORDER . Review of the MAR dated January 2023 revealed no documentation the Quetipine Fumerate was administered at 9:00 PM on 1/9/2023 as ordered by the physician. 23. Review of the medical record revealed Resident #48 was admitted on [DATE] with diagnoses of Diabetes, Dementia, and Hypertension. The quarterly MDS assessment dated [DATE] revealed Resident # 48 had a BIMS score of 5 which indicated severe cognitive impairment. Review of the Physician Orders dated 7/21/2022 revealed, .Insulin Glargine-yfgn 100 UNIT/ML Solution pen-injector Inject 28 unit subcutaneously two times a day related to TYPE 2 DIABETES . Review of the MAR dated January 2023 revealed no documentation the Insulin Glargine-yfgn 100 UNIT/ML was administered at 9:00 PM on 1/9/2023 as ordered by the physician. 24. Review of the medical record revealed Resident #49 was admitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Diabetes, and Hypertension. The Quarterly MDS assessment dated [DATE] revealed Resident #49 with Severely impaired cognitive skills and no behaviors. Review of the Physician Orders revealed, .start date 8/12/2021 Metoprolol Tartrate Tablet 100 MG Give 1 tablet by mouth two times a day for HTN [hypertension] .start date 10/4/2022 Verapamil HCl Tablet 40 MG Give 40 mg by mouth three times a day for HtN . Start date 1/19/2022 .NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject subcutaneously before meals and at bedtime related to TYPE 2 DIABETES .NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 60 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = Call MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS . Review of the MAR dated January 2023 revealed no documentation of Metoprolol Tartrate Tablet 100 MG administered at 9:00 PM on 1/9/2023, Verapamil HCl Tablet 40 MG administered at 10:00 PM on 1/9/2023 and 6:00 AM on 1/10/2023, the Sliding scale blood glucose/sugar checks and the NovoLOG FlexPen 100 UNIT/ML administered at 6:30 AM on 1/3/2023, and at 06:30 AM, and 8:00 PM on 1/9/2023, and at 6:30 AM on 1/10/2023 as ordered by the physician. 25. Review of the medical record revealed Resident # 50 was admitted on [DATE] with diagnoses of Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Cerebral Infarction, and Hypertension. The Annual MDS assessment dated [DATE], revealed Resident # 50 had a BIMS score of 10 which indicated moderate cognitive impairment. Review of the Physician Orders dated 11/17/2022 revealed, .hydrALAZINE HCl Tablet 50 MG Give 1 tablet by mouth four times a day for hypertension . Review of the MAR dated January 2023 revealed no documentation of hydrALAZINE HCl Tablet 50 MG administered at 9:00 PM on 1/9/2023 as ordered by the physician. 26. Review of the medical record revealed Resident # 51 was admitted on [DATE] with diagnoses of Dementia, Acute Kidney Failure, Alzheimer's Disease, and Hypertension. The Quarterly MDS assessment dated [DATE] revealed Resident # 51 had a BIMS score of 2 which indicated severe cognitive impairment. Review of the Physician Orders dated 3/1/2022 revealed, .Eliquis Tablet 5 MG .5 mg by mouth two times a day for blood thinner related to ESSENTIAL (PRIMARY) HYPERTENSION . Review of the MAR dated January 2023 revealed no documentation of the Eliquis Tablet 5 MG administered at 8:00 PM on 1/9/2023 as ordered by the physician. 27. Review of the medical record revealed Resident #52 was admitted on [DATE] with diagnoses of Cerebral Infarction, Seizures, and Hypertension. The Quarterly MDS assessment dated [DATE] revealed Resident # 52 had a BIMS score of 9 which indicated moderate cognitive impairment. Review of the Physician Orders dated 3/12/2020 revealed, .levETIRAcetam Tablet 1000 MG Give 1000 mg by mouth two times a day for Seizures . Review of the MAR dated January 2023 revealed no documentation of the levETIRAcetam Tablet 1000 MG administered at 9:00 PM on 1/9/2023 as ordered by the physician. 28. Review of the medical record revealed Resident #53 admitted on [DATE] with diagnoses of Diabetes, Chronic Obstructive Pulmonary Disease, Hypertension, and Cardiomegaly. The Quarterly MDS assessment dated [DATE], revealed Resident # 53 with a BIMS of 8 which indicated moderate cognitive impairment. Review of the Physician Orders dated 10/4/2022 revealed, .HydrALAZINE HCl Tablet 25 MG Give 1 tablet by mouth two times a day for HTN . Review of the MAR dated January 2023 revealed no documentation of HydrALAZINE HCl Tablet 25 MG administered at 9:00 PM on 1/9/2023 as ordered by the physician. 29. Review of the medical record revealed Resident #55 admitted on [DATE] with diagnoses of Heart Failure, Atrial Fibrillation, Diabetes, and Hypertension. The Annual MDS assessment dated [DATE] revealed Resident #55 had a BIMS score of 7 which indicated severe cognitive impairment. Review of the Physician Orders revealed, .start date 9/21/2021 Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 5 unit subcutaneously at bedtime for DIABETES .start date 2/12/2020 Apixaban Tablet 2.5 MG Give 2.5 mg by mouth two times a day for ANTICOAGULATION .Metoprolol Tartrate Tablet Give 12.5 mg by mouth two times a day for HTN .start date 10/27/2022 HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject subcutaneously before meals and at bedtime related to TYPE 2 DIABETES .Humalog KwikPen100 units/ml solution pen-injector Inject as per sliding scale . The sliding scale revealed if blood glucose sugar levels are 0 - 149 give 0 units, 150 - 200 give 2 units, 201 - 250 give 4 units, 251 - 300 give 6 units, 301 - 350 give 8 units, 351 - 400 give 10 units, if greater than 400 Call MD or NP for orders, subcutaneously before me[TRUNCATED]

Based on policy review, medical record review, and interview, the facility failed to ensure residents were free from significant medication errors when significant medications including anti-diabetics, antiarrhythmic's, antihypertensive, anticonvulsant, anti-platelets and cardiac medications were not administered as ordered by the physician. One or more unit doses scheduled to be administered were not administered for 40 of 63 sampled residents (Resident #3, #4, #5, #7, #8, #14, #23, #24, #28, #29, #30, #31, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #45, #46, #47, #48, #49, #50, #51, #52, #53, #55, #56, #57, #59, #60, #68, #69, #71, #72) reviewed with significant medications. The facility's failure resulted in Immediate Jeopardy when these residents failed to receive the necessary significant medications resulting in a likelihood of a serious adverse outcome such as cardiac complications, seizures, risk of bleeding, or death. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, Regional Director of Operations, Area Director of Clinical Services, Regional Director of Clinical Services, and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-684 and F-686 on 1/17/2023 at 6:12 PM, in the Chapel. The Administrator, Regional Director of Operations, Area Director of Clinical Services, and Special Projects Nurse were notified of the Immediate Jeopardy (IJ) for F-600, F725, F760, F835, and F867 on 1/24/2023 at 12:38 PM, in the Chapel. The facility was cited Immediate Jeopardy at F600, F684, F686, F725, F760, F835, and F867. The facility was cited Immediate Jeopardy at F760 at a scope and severity of K which is Substandard Quality of Care. The facility was previously cited Immediate Jeopardy at F600, F835, and F867 during a complaint survey on 9/19/2022 through 9/20/2022. The Immediate Jeopardy for F760 began on 1/9/2023 and is ongoing. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled Medication Administration dated 1/21/2022 revealed, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: .Identify resident by photo in the MAR [medication administration record] .Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .Review MAR to identify medication to be administered .Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. If other than PO [by mouth] route, administer in accordance with facility policy for the relevant route of administration [i.e., injection, eye, ear, rectal, etc.] .Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR .Report and document any adverse side effects or refusals. Correct any discrepancies and report to nurse manager .Example guidelines for Medication Administration [unless otherwise ordered by physician], this list is not all-inclusive .Medication requiring vital signs prior to administration: Digitalis, Lanoxin, Digoxin, Anti-Hypertensives .Medication timing [excludes insulin]: .AC 30 minutes before meal service. PC administered after meals. BID [twice daily] 9 am, 9 pm. HS [at bedtime] 9 pm. QD [daily] 9 am. QID [four times daily] 9 am, 1 pm, 5 pm, 9 pm . Review of the facility's policy titled Blood Glucose Monitoring dated 1/2/2020 revised 3/4/2022 revealed, .It is the policy of this facility to perform blood glucose monitoring to diabetic residents as per physician's orders. Policy Explanation and Compliance Guidelines: The facility will perform blood glucose monitoring as per physician's orders. The nurse will perform the blood glucose test utilizing the glucometer as per manufacturer's instructions .Report critical test results to physician timely . 2. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region Stage 4, History of Venous Thrombosis and Embolism, Human Immunodeficiency Disease, Protein-Calorie Malnutrition, and Hypertension. The admission MDS dated [DATE] revealed Resident #3 had. Review of the Physician's orders revealed the following medications: .Start Date 12/22/2022 Bactrim DS Tablet 800-160 MG [milligrams] [Human Immunodeficiency Virus] Give 1 tablet by mouth one time a day for bacterial infection .Biktarvy Tablet 50-200-25 MG Give 1 tablet by mouth one time a day for HIV . .Start Date 12/23/2022 Azithromycin Tablet 500 MG Give 1 tablet by mouth one time a day for HIV [Human Immunodeficiency Virus] .Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day .Eliquis Tablet 5 MG Give 5 mg by mouth two times a day . Review of the Medication Administration Record [MAR] dated December 2022 revealed no documentation the following medications were administered as ordered on the listed dates and times: Carvedilol at 9:00 AM on 12/23/2022; and 9:00 AM and 9:00 PM on 12/25/2022. Eliquis on 12/23/2022 and 12/24/2022 at 9:00 PM, and 9:00 AM on 12/25/2022. Bactrim DS and Biktarvy at 9:00 AM and 9:00 PM on 12/25/2022. Azithromycin at 9:00 AM on 12/25/2022. 3. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Covid-19, and Epilepsy. The quarterly MDS dated [DATE] revealed Resident #4 had no cognitive impairment. Review of the Physician's order dated 9/1/2022 revealed the following medications: Alogliptin Benzoate 12.5 MG Tablet Give one tablet by mouth one time a day related to DIABETES MELLITUS. AmLODIPine Besylate Tablet 10 MG Give one tablet one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION. Review of the MAR dated December 2022 revealed no documentation the following medications and/or checks were administered as ordered on the listed dates and times: Alogliptin at 9:00 AM on 12/4/2022 and 12/25/2022. Amlodipine at 9:00 AM or 9:00 PM on 12/4/2022 and 12/25/2022; there was no documentation to reveal the resident's blood pressure was assessed. 4. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Paraplegia, Chronic Osteomyelitis, Open Wound of Buttock, History of Failed Surgical Flap, Peripheral Vascular Disease, Anemia, and Protein-Calorie Malnutrition. The annual MDS dated [DATE] revealed Resident #5 scored a 15 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 8/2/2019, . Minocycline HCL capsule 100 MG Give 100 mg by mouth two times a day for infection . Start Date 2/1/2022, .rifAMpin Capsule 300 MG Give 300 mg by mouth two times a day for chronic osteomyelitis . Start Date 10/21/2022, .Lantus SoloStar 100 UNIT/ML (milliliter) Solution pen-injector Inject 10 unit subcutaneously at bedtime for DM [Diabetes Mellitus] . Review of the MAR dated December 2022 revealed no documentation the Lantus Solostar, Minocycline HCL, and Rifampin were administered at 9:00 PM on 12/22/2022 and 12/31/2022 as ordered by the physician. During an interview on 1/11/2023 at 1:10 PM, when asked if Resident #5 received the medications as ordered on 12/22/2022 and 12/31/2022, LPN #2 stated, No, I don't see that. Could have been when there was only one nurse on the hall and she may have missed it . 5. Review of the medical record revealed Resident #7 was admitted on [DATE] with diagnoses of Diabetes, Unspecified Sequelae of Cerebral Infarction, Anxiety Disorder, and Hypertension. The Quarterly MDS assessment dated [DATE] revealed Resident # 7 with a BIMS of 14 which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start date 10/4/2022, .AmLODIPine Besylate Tablet 5 MG Give 5 mg by mouth two times a day for HTN . Start date 11/22/2022, .Basaglar KwikPen 100 UNIT/ML Solution pen-injector Inject 32 unit subcutaneously at bedtime related to TYPE 2 DIABETES . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: AmLODIPine Besylate Tablet 5 MG at 9:00 PM on 1/9/2023. Basaglar KwikPen 100 UNIT/ML at 9:00 PM on 1/9/2023 as ordered by the physician. 6. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region, Sepsis Unspecified Organism, Urinary Tract Infection, Cerebral Infarction, Type 2 Diabetes Mellitus, Acute Embolism and Thrombosis of Deep Vein or Right Upper Extremity, and Osteomyelitis. The quarterly MDS dated [DATE] revealed Resident #8 scored a 7 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date, .12/25/2022 Doxycycline Monohydrate Capsule 100 MG Give 100 mg by mouth two times a day for sepsis Start Date, .12/23/2022 Eliquis Tablet 5 MG (Apixaban) Give 5 mg by mouth two times a day . Start Date 12/29/2022, .Metronidazole Tablet 500 MG Give 500 mg by mouth three times a day for sepsis . Start Date 12/29/2022, .NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 60-149 = 0 units: 150-199 = 4 units; 200-249 = 6 units; 250-299 = 8 units; 300-349 = 10 units; 350-400 = 12 units .subcutaneously two times a day related to DIABETES MELLITUS . Review of the MAR dated December 2022 revealed no documentation the following medications were administered as ordered on the listed dates and times: Doxycycline Monohydrate, Eliquis, and Metronidazole at 9:00 PM on 12/31/2022. Novolog insulin and sliding scale blood glucose level check on 12/29/2022-12/31/2022. 7. Review of the medical record revealed Resident #14 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Congestive Heart Failure, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3, Insomnia, and Obstructive Sleep Apnea. The quarterly MDS dated [DATE] revealed the resident scored a 14 on the BIMS which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 12/10/2022, .methlMAzole tablet 5 MG Give 1 tablet by mouth one time a day related to THYROTOXICOSIS . Start Date 12/1/2022, .Minoxidil Tablet 2.5 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Start Date 11/30/2022, .CloNiDine HCL Tablet 0.3 MG Give 1 tablet by mouth three times a day for hypertension. HOLD for SBP < 100 DBP < 60 HR < than 60. Notify MD . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Methlmazole at 9:00 AM on 1/1/2023. Minoxidil on 1/4/2022 and 1/6/2022 at 9:00 AM, and 1/4/2022 and 1/5/2022 at 9:00 PM. During an interview on 1/10/2023 at 3:37 PM Resident #14 stated, .Sometimes I don't get my early morning medicine for my thyroid problem. They tell me they don't want to wake me up. I just want my pill brought to me . 8. Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Chronic Congestive Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Angina Pectoris, and Chronic Obstructive Pulmonary Disease. The quarterly MDS dated [DATE] revealed the resident scored a 13 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 7/13/2022, .Metoprolol Tartrate Tablet 50 MG Give 1 tablet by mouth every 12 hours for hypertension Hold for SBP [Systolic Blood Pressure] < [less than] 110, DBP [diastolic blood pressure] < 60 OR HR = [equal to]/< 60 .Sacubitril-Valsartan Tablet 24-26 MG Give 1 tablet by mouth every 12 hours . Start Date 6/10/2021, .Midodrine HCL Tablet 10 MG Give 1 tablet by mouth every 8 hours for POSTURAL HYPOTENSION HOLD FOR SBP > 110, DBP > 70 .Novolog FlexPen 100 UNIT/ML Solution pen-injector Give as per sliding scale: If 150-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401 AND GREATER GIVE 12 UNITS AND NOTIFY MD by mouth before meals and at bedtime . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Metoprolol Sacubitril-Valsartan at 9:00 PM on 1/9/2023. Midodrine at 10:00 PM on 1/9/2023 and 6:00 AM on 1/10/2023. There was no documentation the Resident's blood pressure had been checked to determine if the medication should be held. Novolog Insulin on 1/9/2023 at 8:00 PM. The resident's blood glucose level was not assessed at 8:00 PM. During an interview on 1/10/2023 at 7:10 PM when asked if he received medications timely on 1/9/2023, Resident #23 stated, .I didn't get it. No nurse here. The CNA told me. I went to the desk downstairs and the receptionist said they trying to get someone to come. No one came . 9. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses of Cerebral Palsy, Essential Hypertension, History of Venous Thrombosis and Embolism, and Rhabdomyolysis. The quarterly MDS dated [DATE] revealed the resident scored a 15 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 9/25/2021 Apixaban Tablet 5 MG Give 5 mg by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation Apixaban was administered on 1/9/2023 at 9:00 PM as ordered by the physician. During an interview on 1/10/2023 at 4:01 PM, when asked if she received her medications on 1/9/2023, Resident #24 stated, No, I didn't get all my medicine. There was no nurse. 10. Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses of Supraventricular Tachycardia, Schizophrenia, Osteoarthritis, and Anemia. The quarterly MDS dated [DATE] revealed the resident scored 9 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 4/30/2020 Metoprolol Tartrate Tablet 25 MG Give 25mg by mouth two times a day for HTN [hypertension] Hold for HR < 60 or SBP < 110 . Review of the MAR dated January 2023 revealed no documentation Metoprolol Tartrate was administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the Resident's blood pressure had been checked to determine if the medication needed to be held. 11. Review of the medical record revealed Resident #29 admitted on [DATE] with diagnoses of Heart Failure, Glaucoma, Essential Hypertension, Tremor, Chest Pain, and Hypomagnesia. The quarterly MDS dated [DATE] revealed the resident scored 11 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed, .Start Date 12/17/2020 Carvedilol Tablet 25 MG Give 25 mg by mouth two times a day for Heart Failure Hold if HR less than 60 . Review of the MAR dated January 2023 revealed no documentation Carvedilol was administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the Resident's HR had been checked to determine if the medication needed to be held. 12. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis Left Nondominant Side, Osteoarthritis, and Benign Neoplasm of Skin. The annual MDS dated [DATE] revealed the resident scored 12 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 11/06/2021 Apixaban Tablet 5 MG Give 1 tablet two times a day for anticoagulant therapy .Carvedilol Tablet 6.25 MG Give 1 tablet by mouth two times a day . Review of the MAR dated January 2023 revealed no documentation Apixaban and Carvedilol were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 13. Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Thyrotoxicosis, Essential Hypertension, History Transient Ischemic Attack, and Cerebral Infarction. The quarterly MDS dated [DATE] revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 10/24/2022 Diltiazem HCL Tablet 30 MG Give 1 tablet by mouth three times a day for HTN Hold for SBP < 100, DBP < 60, or HR < 60 . Review of the MAR dated January 2023 revealed no documentation Diltiazem was administered on 1/9/2023 at 9:00 PM as ordered by the physician. There was no documentation the resident's blood pressure and heart rate were assessed. 14. Review of the medical record, revealed Resident #33 admitted on [DATE] with diagnoses of Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, Anemia, and Chronic Obstructive Pulmonary Disease. The quarterly MDS dated [DATE] revealed the resident scored 15 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed, .Start Date 9/20/2022 Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 26 units Intradermally at bedtime . Review of the MAR dated January 2023 revealed no documentation Lantus insulin was administered on 1/9/2023 as ordered by the physician. 15. Review of the medical record, revealed Resident #34 admitted on [DATE] with diagnoses of Congestive Heart Failure, Type 2 Diabetes Mellitus, Essential Hypertension, and History of Malignant Neoplasm of Prostate. The admission MDS dated [DATE] revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 12/08/2022, .Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen-injector Inject 3 units subcutaneously before meals . Start Date 12/8/2022, .Insulin Glargine-yfgn 100 UNIT/ML Solution pen-injector Inject 40 units subcutaneously at bedtime . Review of the MAR dated December 2022 and January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Insulin Lispro on 12/15/2022 at 5:00 PM. Insulin Glargine-yfgn on 1/9/2023 at 9:00 PM. 16. Review of the medical record revealed Resident #35 admitted on [DATE] with diagnoses of End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes, Essential Hypertension, and Major Depressive Disorder. The admission MDS dated [DATE] revealed the resident scored 12 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 3/13/2021, .Eliquis Tablet 2.5 MG Give 1 tablet by mouth two times a day . Start Date 10/24/2022, .Coreg Tablet 6.25MG (Carvedilol) Give 1 tablet by mouth two times a day for HTN. Hold for SBP < 100, DBP < 60 or HR <60 . Review of the MAR dated January 2023 revealed no documentation the Coreg and Eliquis on 1/9/2023 at 9:00 PM as ordered. There was no documentation the Resident's blood pressure had been checked to determine if the medication should be held. 17. Review of the medical record revealed Resident #36 was readmitted on [DATE] with diagnoses of End Stage Renal Disease, Dependence on Renal Dialysis, Type 2 Diabetes Mellitus, Essential Hypertension, Hypothyroidism, and Human Immunodeficiency Virus Disease. The admission MDS dated [DATE] revealed the resident scored 14 on the BIMS assessment which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 12/16/2022, .Hydralazine HCL Tablet 25 MG Give 1 tablet by mouth three times a day . Start Date 12/17/2022, .Levothyroxine Sodium Tablet 150 MCG Give 150 mcg by mouth on time a day every Mon, Tue, Wed, Thu, Fri, Sat . Review of the MAR dated January 2023 revealed no documentation the Levothyroxine and Hydralazine were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 18. Review of the medical record revealed Resident #37 was on 10/6/2022 with diagnoses of Epilepsy, Cerebral Infarction, Type 2 Diabetes Mellitus, Schizoaffective Disorder, and Hallucinations. The quarterly MDS dated [DATE] revealed the resident scored 8 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 10/6/2022, .Lacosamide Tablet 200 MG Give 200 mg by mouth two times a day for SEIZURE DISORDER . Start Date 12/13/2022, .Risperidone Tablet 0.5 MG Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER . Review of the MAR dated January 2023 revealed no documentation Risperidone and Lacosamide were administered on 1/9/2023 at 9:00 PM as ordered by the physician. 19. Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Unspecified Psychosis, and Essential Hypertension. The quarterly MDS dated [DATE] revealed the resident scored 4 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 6/10/2022, .Depakote Tablet Delayed Release 250 MG Give 1 tablet by mouth three times a day . Start Date 8/4/2022, .HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: If 0-149 = 0 less than 70 call MD; 150-180=1 unit; 181-210=2 units; 211-240=3 units; 241-270=4 units; 271-300=5 units greater than 300 notify MD, subcutaneously before meals and at bedtime . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Depakote on 1/9/2023 at 9:00 PM. Humalog insulin was not administered and there was no evidence a sliding scale blood glucose level check was performed on 1/9/2023 at 8:00 PM. 20. Review of the medical record revealed Resident #39 was readmitted on [DATE] with diagnoses of Epilepsy, Type 2 Diabetes Mellitus, Cerebral Infarction, Atrial Fibrillation, and Hypothyroidism. The quarterly MDS dated [DATE] revealed the resident scored 5 on the BIMS assessment which indicated severe cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 6/6/2022, .Eliquis Tablet 5 MG Give 1 tablet by mouth two times a day .levetiracetam Tablet 500 MG Give 1000 mg by mouth two times a day . Start Date 6/25/2022, .Levothyroxine Sodium Tablet 125 MCG Give 1 tablet by mouth one time a day . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Levothyroxine on 1/10/2023 at 6:00 AM. Eliquis and Levetiracetam on 1/9/2023 at 9:00 PM. 21. Review of the medical record revealed Resident #40 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Seizures, Asthma, and Hypothyroidism. The quarterly MDS dated [DATE], revealed the resident scored 11 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 7/27/2022, .Levothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth one time a day .Rosuvastatin Calcium Oral Tablet 5 MG Give 5 mg by mouth at bedtime . Start Date 7/27/2022 .levETIRAcetam Tablet 250 MG Give 250 mg by mouth two times a day . Start Date 8/10/2022, .Basaglar KwikPen 100 UNIT/ML Solution pen-injector Inject 10 units subcutaneously at bedtime . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Basaglar insulin, Rosuvastatin Calcium, and Levetiracetam on 1/9/2023 at 9:00 PM. Levothyroxine at 6:00 AM on 1/10/2023. 22. Review of the medical record revealed Resident #41 was readmitted on [DATE] with diagnoses of Type 2 Diabetes Mellitus, End Stage Renal Disease, Dependence on Renal Dialysis, Atrial Fibrillation, Congestive Heart Failure, Chronic Pulmonary Edema, and Atherosclerotic Heart Disease. The quarterly MDS dated [DATE], revealed the resident scored 10 on the BIMS assessment which indicated moderate cognitive impairment. Review of the Physician's orders revealed the following medications: Start Date 5/22/2021, .Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day .Isosorbide Mononitrate ER [extended release] Tablet 30 MG Give 1 tablet by mouth one time a day . Start Date 11/30/2021, .HydrALAZINE HCL Tablet 25 MG Give 50 mg by mouth two times a day . Start Date 1/5/2023, .Carvedilol Oral Tablet 12.5 MG Give 1 tablet by mouth tow times a day . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Clopidogrel, Isosorbide Mononitrate, and Hydralazine on 1/10/2023 at 6:00 AM. Carvedilol on 1/9/2023 at 9:00 PM. 23. Review of the medical record revealed Resident #42 was admitted on [DATE] with diagnoses of Atherosclerotic Heart Disease, Diabetes, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 42 had a BIMS score of 13 which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start date 3/11/2022, .Janumet XR Tablet Extended Release 24 Hour [PHONE NUMBER] MG (SITagliptin-metFORMIN HCl ER) Give 1 tablet by mouth one time a day for Diabetes Mellitus . Start date 8/2/2022, .Lantus SoloStar 100 UNIT/ML Solution pen-injector Inject 30 unit subcutaneously at bedtime related to TYPE 2 DIABETES . Start date 11/22/2022, .Glimepiride Tablet 1 MG Give 1 mg by mouth one time a day for Diabetes Mellitus . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Lantus SoloStar 100 UNIT/ML at 9:00 PM on 1/9/2023. Glimepiride Tablet 1 MG at 6:00 AM on 1/10/2023. Janumet XR Tablet Extended Release 24 Hour [PHONE NUMBER] MG at 6:00 AM on 1/10/2023. 24. Review of the medical record revealed Resident #45 was admitted on [DATE] with diagnoses of Atrial Fibrillation, Atherosclerotic Heart Disease, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 45 had a BIMS score of 13 which indicated no cognitive impairment. Review of the Physician's orders revealed the following medications: Start date 3/10/2022, .hydrALAZINE HCl Tablet 25 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Start date 5/20/2022, .Entresto Tablet 49-51 MG (Sacubitril-Valsartan) Give 1 tablet by mouth two times a day related to OTHER HEART FAILURE . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: On 1/9/2023 HydrALAZINE HCl Tablet 25 MG at 8:00 PM and at 9:00 PM Entresto Tablet 49-51 MG. 25. Review of the medical record revealed Resident #46 was admitted on [DATE] with diagnoses of Gastro-Esophageal Reflux Disease, Blindness, One Eye, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 46 had a BIMS score of 12 which indicated moderate cognitive impairment. Review of the Physician Orders dated 11/21/2022, revealed .Metoprolol Tartrate Tablet Give 12.5 milligram by mouth two times a day for hypertension . Review of the MAR dated January 2023 revealed no documentation of Metoprolol Tartrate Tablet Give 12.5 milligram administered at 9:00 PM on 1/9/2023 as ordered by the physician. 26. Review of the medical record revealed Resident #47 was admitted on [DATE] with diagnoses of Functional Quadriplegia, Anxiety Disorder, Schizoaffective Disorder, Insomnia, and Spinal Stenosis. The annual MDS assessment dated [DATE] revealed Resident #47 had a BIMS score of 15 which indicated no cognitive impairment. Review of the Physician Orders revealed, .start date 12/20/2022 QUEtipine Fumerate Tablet 100 MG Give 1.5 tablet by mouth at HS for a total dose of 150 mg related to SCHIZOAFFECTIVE DISORDER . Review of the MAR dated January 2023 revealed no documentation Quetipine Fumerate was administered at 9:00 PM on 1/9/2023 as ordered by the physician. 27. Review of the medical record revealed Resident #48 was admitted on [DATE] with diagnoses of Diabetes, Dementia, and Hypertension. The quarterly MDS assessment dated [DATE], revealed Resident # 48 had a BIMS score of 5 which indicated severe cognitive impairment. Review of the Physician Orders dated 7/21/2022 revealed, .Insulin Glargine-yfgn 100 UNIT/ML Solution pen-injector Inject 28 unit subcutaneously two times a day related to TYPE 2 DIABETES . Review of the MAR dated January 2023 revealed no documentation Insulin Glargine-yfgn 100 UNIT/ML administered at 9:00 PM on 1/9/2023 as ordered by the physician. 28. Review of the medical record revealed Resident #49 admitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Diabetes, and Hypertension. The Quarterly MDS assessment dated [DATE], revealed Resident # 49 with Severely impaired cognitive skills and no behaviors. Review of the Physician's orders revealed the following medications: Start date 8/12/2021, .Metoprolol Tartrate Tablet 100 MG Give 1 tablet by mouth two times a day for HTN [hypertension] . Start date 10/4/2022, .Verapamil HCl Tablet 40 MG Give 40 mg by mouth three times a day for Htn [hypertension] . Start date 1/19/2022, .NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject subcutaneously before meals and at bedtime related to TYPE 2 DIABETES .NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 60 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = Call MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS . Review of the MAR dated January 2023 revealed no documentation the following medications were administered as ordered on the listed dates and times: Metoprolol Tartrate Tablet 100 MG administered at 9:00 PM on 1/9/2023. Verapamil HCl Tablet 40 MG at 10:00 PM on 1/9/2023 and 6:00 AM on 1/10/2023. Novolog FlexPen 100 UNIT/ML and no documentation of blood glucose level checks at 6:30 AM on 1/3/2023, at 6:30 AM, and 8:00 PM on 1/9/2023, 6:30 AM on 1/10/2023. 29. Review of the medical record revealed Resident # 50 was admitted on [DATE] with diagnoses of Atherosclerotic Heart Disease [TRUNCATED]

Based on policy review, medical record review, observation, and interview the facility failed to complete skin assessments and administer wound treatments for residents determined to be at risk of skin breakdown for 4 of 7 sampled residents (Resident #1, #4, #5, and #8,) reviewed for pressure ulcer wounds. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 did not receive treatments for a pressure ulcer wound identified upon admission with measurable depth and the wound worsened to unstageable and required debridement, Resident #4 did not receive treatments for a Stage 2 pressure ulcer wound and the wound developed to a Stage 3, Resident #5 was admitted with pressure ulcer wounds, the resident did not receive treatments as ordered and developed additional pressure ulcer wounds, and Resident #8 did not receive treatments for a pressure ulcer wound identified upon admission and developed infection to the wound. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Regional Director of Operations, the Area Director of Clinical Services, the Regional Director of Clinical Services, the Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-686 on 1/17/2023 at 6:12 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-686. The facility was cited Immediate Jeopardy F-686 at a scope and severity of J which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 1/19/2023, and the Removal Plan was validated onsite by the surveyors on 1/24/2023 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ began on 12/16/2022 through 1/24/2023. The findings include: 1. Review of the facility's policy titled, Wound Treatment Management dated 3/24/2022, revealed .To promote healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .Wound treatments will be provided in accordance with physicians orders, including the cleansing method, type of dressing, and frequency of dressing changes .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse .The facility will follow specific physician orders for providing wound care .Treatments will be documented on the Treatment Administration Record .The effectiveness of treatments will be monitored through ongoing assessment of the wound . Review of the facility's policy titled, Wound Care-Pressure Injuries Overview dated 3/24/2022, revealed .The purpose of this procedure is to provide information regarding clinical identification of pressure injuries and associated risk factors, which is derived from the definitions in 483.25(b)(1) Pressure Injuries (F686) .Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device .Eschar/Slough .is dead or devitalized tissue that is hard or soft in texture, usually black, brown, or tan in color, and may appear scab-like .Slough is non-viable yellow, tan, gray, green or brown tissue .Slough may be adherent to the base of the wound or present throughout the wound bed .Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis .presenting as a shallow open ulcer .The wound bed is viable, pink or red, moist, and may also appear as an intact or open/ruptured blister .Granulation tissue, slough and eschar are not present .Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss .the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar . Review of the facility's undated policy titled, Skin Assessment, revealed .It is our policy to perform a full body assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment .A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury . Review of the facility's policy titled Nursing Services and Sufficient Staff dated, 8/30/2022, revealed .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Intestinal Obstruction, Muscle Weakness, Cognitive Communication Deficit, Dysphagia, and Hypertension. Review of the Braden Scale assessment completed on admission revealed Resident #1 was a high risk of developing a pressure ulcer. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 scored an 11 on the Brief Interview of Mental Status (BIMS) which indicated moderately impaired cognition. The resident required extensive assistance for bed mobility and was dependent for transfers. Review of a Treatment Nurse Communication Form dated 12/16/2022, revealed Resident #1 had pressure ulcer wounds as follows: Sacral region with measurements of length by (x) width x depth (LxWxD) of 0.4 centimeters (cm) x 3.5 cm x 0.4 cm. Left heel with measurements of 4.0 cm x 3.2 cm x 0.2 cm. Right heel with measurements of 0.2 cm x 3.0 cm x 0.1 cm. Review of the admission nursing assessment dated [DATE] documented .Right heel Bruising .Left heel Bruising .Sacrum Pressure sore . Review of a Nurse's Progress Note dated 12/16/2022 documented .Resident has pressure sore to sacrum and flaky skin, as well as bruising to heels . Review of the Care Plan initiated on 12/19/2022 documented, .The resident has pressure ulcer with potential for further pressure ulcer development .Assess/record/monitor wound healing as ordered and per protocol. Measure length, width, depth where possible. Assess and document status of wound perimeter, wound bed and healing progress . There was no documentation of treatment orders to the sacrum, right heel and left heel pressure ulcer wounds from the admitted [DATE] until 12/21/2022. Review of a 12/21/2022 Physician's orders with a start date of 12/22/2022 documented the following treatment for sacral, right heel and left heel: .Cleanse Unstageable wound to Sacrum with sound cleanser. Pat dry. Apply Santyl and Calcium alginate to site. Cover with dry foam dressing/ Change dressing daily on Monday, Wednesday, and Friday and Prn (as needed) until resolved . .Cleanse Unstageable wound to R [right] heel with wound cleanser. Pat dry. Apply medi-honey and cover with Calcium alginate with silver. Cover site with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . .Cleanse Unstageable wound to L [left] heel with wound cleanser. Pat dry. Apply medi-honey and cover with Calcium alginate with silver. Cover site with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . Review of the 12/21/2022 wound care Physician's Initial Progress Note revealed: Unstageable Pressure Ulcer to the Sacrum which measured 5cm x 7cm with 50% dermis and 50% eschar. Right heel was documented as unstageable and measured 7cm x 5 cm with 50% dermis and 50% eschar. Left heel was documented as unstageable and measured 9cm x 7cm with 50% eschar and 50% serum filled blister. Review of the Treatment Administration Record (TAR) for December 2022, revealed there was no treatment administered as ordered for the unstageable wound to the sacrum, unstageable wound to the right heel, and unstageable wound to the left heel on 12/28/2022 and 12/30/2022. Review of the 1/4/2023 wound care Physician's Initial Progress Note revealed an Unstageable Pressure Ulcer to the Sacrum and measured 8.3 cm x 7.2 cm x 0.2 cm with 75% slough and 25% granulation. Review of the wound care Physician's Initial Progress Note dated 1/11/2023, revealed an Unstageable Pressure Ulcer to the Sacrum and measured 6.0 cm x 6.5 cm x 0.2 cm with 75% slough and 25 % granulation. The pressure ulcer wound was debrided on 1/11/2023. Review of the TAR for January 2023, revealed there was no treatment administered as ordered for the unstageable wound to the sacrum, unstageable wound to the right heel, and unstageable wound to the left heel on 1/6/2023. Observations in the resident's room on 12/27/2022 at 3:40 PM, revealed Resident #1 lying supine in bed. The resident was alert and oriented. When asked if she had any wounds to her skin she stated, I have a sore on my bottom .The nurse puts a cover [dressing] on it now. I guess it got worse. During an interview on 12/27/2022 at 1:02 PM, Resident #1's family member stated, .She has been here about a week or 10 days I guess and has a bad sore. That tells me they are not turning her as they should .That bed sore has gotten much worse in the 10 days she has been here . During an interview on 12/29/2022 at 9:59 AM, the Licensed Practical Nurse (LPN)/Wound Nurse reviewed the Physician orders and the TAR and stated, This is not okay. She [Resident #1] came in on the 16th [12/16/2022] and the order is not until the 21 [12/21/2022]. That's not okay . During a telephone interview on 12/29/2022 at 10:21 AM, when asked what the meaning was of unstageable related to a pressure ulcer wounds, LPN #1 stated, You can't measure the depth. When asked if she could measure the depth of the sacral wound and the wound to the right heel and left heel of Resident #1 upon admission, LPN #1 stated, Yes ma'am. I guess I should have called it a Stage 2 . When asked if treatments and wound care was provided for Resident #1, LPN #1 stated, Documented on the place where we document treatments if I did them . During an interview on 12/29/2022 at 11:08 AM, the DON confirmed there was no documentation of wound assessments or care provided for the pressure ulcer wounds from 12/16/2022 until 12/23/2022. The DON stated, If not documented, it wasn't done. What I see is an order on 12/21 [2022]. I see nothing before that. There were no treatments provided to the resident's sacrum, right heel and left heel from 12/16/2022 until 12/22/2022. During an interview on 1/4/2023 at 4:02 PM, when asked when the first treatment was administered to the pressure ulcer wounds, the LPN/Wound Nurse stated, .From the 16th till the 21st when [Named physician] saw her there is no documentation of a treatment. That's awful. When asked if there was documentation of wound assessments that described the wounds appearance, LPN/Treatment Nurse stated, I didn't document any assessments in the computer. I threw the papers away. I don't have any of my papers prior to the 7th [1/7/2023]. That's when I was inserviced what to document in the computer. When I came here, I wasn't told about pressure and non-pressure assessments. I did not receive the proper training for this system to document. I threw my papers away . During an interview on 1/4/2023 at 10:38 AM, the Regional Director of Clinical Services (RDCS) stated, We did a facility wide skin sweep over the weekend. We found some new wounds and we are taking care of that. When asked what she meant by a skin sweep the RDCS stated, A skin assessment of every resident to see if there were any wounds that had been missed. During an interview on 1/5/2023 at 9:58 AM, when asked if Resident #1 had Pressure Ulcer wounds, LPN #2/Unit Manager stated, I don't remember what her wounds are. I looked at her paperwork from the hospital .If there are wounds it's passed on to the treatment nurse. I wouldn't know about the wound location. 3. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypothyroidism, Covid-19, and Epilepsy. Review of the quarterly MDS dated [DATE] revealed Resident #4 scored an 13 on the BIMS which indicated no cognitive impairment. The resident required extensive assistance for bed mobility and activities of daily living. Review of the Braden Scale assessment completed on 9/21/2022 and 1/3/2023 revealed Resident #1 was at risk of developing a pressure ulcer. Review of the Weekly Skin Reviews dated 11/30/2022, 12/7/2022, 12/14/2022, 12/21/2022, 12/28/2022, and 1/4/2023 revealed Resident #4 had redness to the sacrum. Review of the Nursing Daily Skilled Services assessments dated 12/29/2022, 1/1/2023, 1/2/2023, 1/3/2023, 1/9/2023, 1/10/2023, and 1/11/2023 documented there was no change in the resident's skin integrity. Review of the Shower Day Skin Inspection sheet dated 1/1/2022 [2023], revealed Resident #4 had a Stage 2 open area to the sacral region. There were no documented descriptions or measurements of the wound. Review of a Physician's order dated 1/1/2023, documented, .Cleanse stage 2 pressure ulcer to R buttock with wound cleanser. Pat dry. Apply hydrocolloid dressing to site and cover with bordered foam dressing MWF and PRN . Review of a Physician's order dated 1/4/2023, documented .Cleanse stage 2 pressure ulcer to sacrum with wound cleanser. Pat dry. Apply medi-honey followed by collagen. Cover with bordered foam dressing MWF and PRN . Review of the wound care Physician's Initial Progress Note dated 1/4/2023, revealed a Stage 3 Pressure Ulcer to the sacrum which measured 4.2cm x 3.7 cm x 0.1 cm with 25% slough, 50% epithelial, and 25% serum blister. Review of the wound care Physician's Progress Note dated 1/11/2023, revealed a Stage 3 Pressure Ulcer to Resident #4's lower back which measured 2.3 cm x 0.5 cm x 0.1 cm with 50% slough and 50% dermis. The facility failed to document accurate skin assessments and failed to identify that the resident's sacral pressure ulcer wound had progressed to a Stage 3. During an interview on 1/5/2023 at 12:44 PM, when asked when the Stage 2 to the sacrum was first identified, the DON stated, We did a facility wide skin sweep on the 1st [1/1/2023] and that is when it was found . The DON confirmed there was no documentation describing the wound or measurements of the wound until 1/4/2023. During a telephone interview on 1/6/2023 at 2:45 PM, when asked if she was notified of the Stage 2 Pressure Ulcer on 1/1/2023, the wound care Physician stated, Not that I recall. I saw the wound during my visit on the 4th [1/4/2023]. It was a Stage 3. Nurse was probably not aware of the slough . During an interview on 1/19/2023 at 2:55 PM, when asked when the Stage 3 to the lower back was first identified the LPN/Wound Nurse stated, Identified by [Named Wound Care Physician] during her visit on the 11th [1/11/2023]. 4. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Paraplegia, Chronic Osteomyelitis, Open Wound of Buttock, History of Failed Surgical Flap, Peripheral Vascular Disease, Anemia, and Protein-Calorie Malnutrition. Review of the annual MDS dated [DATE], revealed Resident #5 scored a 15 on the BIMS which indicated no cognitive impairment. The resident required supervision for activities of daily living. The MDS Section M Skin Conditions documented no pressure ulcer wounds and one surgical wound. Review of the Physician's orders dated 11/2/2022, documented .Cleanse Surgical Site to L buttock with wound cleaner. Dry with 4x4, Pack wound with dry collagen. Cover with dry bordered foam dressing Mon [Monday] Wed [Wednesday] Fri [Friday], and PRN . Review of the TAR for November 2022 and December 2022 revealed treatments were not provided as ordered for the surgical site to the left buttock on 11/7/2022, 11/14/2022, 11/21/2022, 11/25/2022, and 12/28/2022. Review of the Braden Scale assessment completed on 1/3/2023 revealed Resident #5 was at risk of developing a pressure ulcer. Review of the Physician's orders dated 1/4/2023, documented .Cleanse pressure ulcer to Right medial buttock with wound cleanser. Pat dry. Apply honey followed by collagen. Cover with bordered foam MWF and PRN . Review of the 1/6/2023 Weekly Summary revealed the did not have any Pressure Ulcer wounds. The weekly skin summary failed to identify the resident's right medial buttock pressure ulcer wound. Review of the wound care Physician's progress note dated 1/4/2023, revealed Resident #5 had a new Stage 3 Pressure Ulcer wound to the right medial buttock which measured 2.8 cm x 2.3 cm x 0.2 cm with 50% slough and 50% dermis. Observations in the resident's room on 1/5/2023 at 10:41 AM, revealed he was propelling himself in a wheelchair in his room and able to transfer himself to the bed. He was alert and oriented. Resident #5 stated, I had a bad place on my butt. I had surgery on that. Now they say I've got a new wound. I need a new cushion, but it hadn't come in yet. During an interview on 1/9/2023 at 12:57 PM, when asked when the Stage 3 to the right medial buttock was first identified, the DON stated, It was identified on the 4th [1/4/2023] on the other side of the buttock. The DON confirmed the new pressure ulcer was identified during the facility wide skin sweep on 1/1/2023. The facility failed to identify the right medial buttock pressure ulcer wound until progression to a Stage 3. 5. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer Sacral Region, Sepsis Unspecified Organism, Urinary Tract Infection, Cerebral Infarction, Type 2 Diabetes Mellitus, Acute Embolism and Thrombosis of Deep Vein or Right Upper Extremity, and Osteomyelitis. Review of the Shower Day Skin Inspection sheet dated 12/22/2022, revealed Resident #8 had a wound to the sacral region which measured 6.8 cm x 11.3 cm x 0.0 cm. Review of the Physician's orders dated 12/23/2022, documented .Cleanse Unstageable pressure ulcer to Sacrum with wound cleaner. Pat dry. Apply Dakin's wet to dry dressing to site. Cover with dry foam dressing. Change dressing daily, Monday, Wednesday, and Friday, and prn until resolved . Review of the admission nursing assessment dated [DATE], revealed Resident #8 had a pressure related skin condition. Review of the Braden Scale assessment completed on 12/23/2022 revealed Resident #8 was a very high risk of developing a pressure ulcer wound. Review of the quarterly MDS dated [DATE], revealed Resident #8 scored a 7 on the BIMS which indicated severe cognitive impairment. The resident required extensive assist for activities of daily living. The MDS Section M Skin Conditions documented one unstageable pressure ulcer wound. Review of the TAR for December 2022, revealed there was no treatment administered for the unstageable Pressure Ulcer wound to the sacrum from 12/22/2022 - 12/31/2022. Review of the Physician's orders dated 1/4/2023, documented .Cleanse DTI [Deep Tissue Injury] to lateral L foot with wound cleanser. Pat dry. Apply skin prep MWF and PRN . Santyl Ointment 250 UNIT/GM [gram] (Collagenase) Apply to sacrum topically every day shift every Mon, Wed, Fri for stage 4 pressure ulcer to sacrum. Cleanse stage 4 ulcer to sacrum with Dakin's solution. Pat dry. Apply santyl and medihoney followed by calcium alginate. Cover with bordered foam MWF and PRN . Review of the wound care Physician's Progress Note dated 1/4/2023, documented .Debrided sacrum of necrotic tendon, bone, and fascia. Recommend Ciprofloxacin 750 mg BID [twice daily] PO [by mouth] for osteomyelitis .Sacrum Pressure Ulcer Stage 4 7.8 [cm] x 11.3 [cm] .Left lateral foot Deep Tissue Injury .8.5 [cm] x 3.7 [cm] x 0[cm] . There was no documentation the facility identified the left lateral foot wound until 1/4/2023. Review of the Physician's orders dated 1/5/2023, documented .Ciprofloxacin HCL Tablet 750 MG [milligrams] by mouth two times a day related to OSTEOMYELITIS OF VERTEBRA, SACRAL AND SACROCOCCYGEAL REGION for 4 weeks . Review of the TAR for January 2023, revealed there was no treatment administered as ordered for the unstageable Pressure Ulcer wound to the sacrum on 1/2/2023. Observations in the resident's room on 1/4/2023 at 9:30 AM, revealed Resident #8 lying supine in bed. She was alert with confusion. During an interview on 1/4/2023 at 10:47 AM, when if the facility wide skin assessments completed on all residents had revealed new wounds, the Regional Director of Clinical Services RDCS stated, I have a list. There were several new wounds. We are on it now though. Started an inservice already. When asked what monitoring was being done to ensure skin assessments were completed, the RDCS stated, We are meeting about that today. During an interview on 1/4/2023 at 2:36 PM, when asked when the Pressure Ulcer wound to Resident #8's left foot was first identified, the LPN/Wound Care Nurse stated .It was actually noted today during Physician rounds as a left lateral deep tissue injury. I would assume no one saw it or looked at the foot . During an interview on 1/6/2023 at 2:45 PM, when asked when the was the 1st notification Resident #8 had a Pressure Ulcer wound to the sacrum, the wound care physician stated, I saw her on Wednesday [1/4/2023] for the first time. That was the first time my attention was brought to the wound . During an interview on 1/9/2023 at 11:18 AM, when asked where in the medical record would the nurse completing a weekly summary describe a new wound that had been identified, the DON stated, I would have to go look. I'm not sure. During an interview on 1/10/2023 at 9:50 AM, when asked from the admission measurements on 12/22/2022 until the physician was notified on 1/2/2022 was the Pressure Ulcer to the sacrum assessed and monitored, the LPN/Wound Care Nurse stated, Those assessments were not completed. When asked if the TAR had documentation of the treatments administered, the LPN/Wound Treatment Nurse stated, They [TAR dates] are all blank. She [LPN #1] didn't sign off that she did the treatments .That's awful . During an interview on 1/10/2023 at 2:10 PM, the DON confirmed no assessments were completed and no treatments were administered for the Pressure Ulcer wounds from admission on 12/22/2022 - 1/2/2023 for Residnet #8. The surveyors verified the Removal Plan by: 1. The DON/SDC (Staff Development Coordinator)/and three Nursing Supervisors will conduct skin assessments on all current residents on 1/18/2023. Any additional concerns will be addressed immediately. The surveyors confirmed this by record review and interview. 2. A medical record review was completed on all residents admitted to the facility after 12/27/2022 by DON/ADCS(Area Director Clinical Services)/RDCS (Regional Director Clinical Services) to ensure initial skin assessments were completed on 1/17/2023. The surveyors confirmed this by record review and interview. 3. A care plan audit was conducted by the Care Plan Coordinator(s) to ensure that treatment recommendations/orders were on the care plan that the care plan was being followed. Audit was complete on 1/18/2023. The surveyors confirmed this by record review and interview. 4. All facility policies and procedures related to skin care, wound care, and pressure injury prevention were reviewed by the Administrator, DON and QAPI (Quality Assurance Performance Improvement) team on 1/18/2023 without the need for amendment. The surveyors confirmed this by record review and interview. 5. DON/SDC provided education to all licensed nurses on facility policies and procedures related to skin/wound care, assessing residents upon admission, and assuring completion of treatments as ordered. Education began on 1/17/2023 and was completed on 1/18/2023. New nurses and agency nurses will not be able to work until they have been educated. The surveyors confirmed this by review of sign in sheets and interviews. 6. DON/SDC educated all nurse aides on preventative skin care beginning 1/17/2023 with 100% of CNAs (Certified Nursing Assistant) being educated by 1/18/2023. No additional concerns have been noted related to preventative care. The surveyors confirmed this by review of sign in sheets and interviews. 7. Beginning 1/18/2023 the DON/SDC/Unit Managers will conduct daily treatment record and nursing documentation audits to ensure accurate and complete documentation of skin related treatments and preventative measures. Audits will be conducted Monday thru Friday in the Clinical meeting. Weekend audits will be conducted by the DON or house supervisor assuring that audits are complete 7 days a week. Audits will include all current treatment orders as well as assuring that all new admission have a head-to-toe skin assessment documented within 24 hours of admission. Audits will be on-going. The surveyors confirmed this by record review and interviews. 8. A QAPI PIP (Performance Improvement Project) has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA (Quality Assessment and Assurance) meeting. Monitoring/auditing and reporting will continue for a minimum of three months. The surveyors confirmed this by record review and interviews.

Based on policy review, job description review, facility investigation review, medical record review, observation, and interview, the facility failed to ensure thorough investigations of elopement and resident-to-resident abuse were completed for 5 of 5 (Resident #1, #2, #3, #4 and #5) sampled residents reviewed for wandering/elopement behaviors and physically aggressive behaviors, which resulted in Immediate Jeopardy when Resident #1, a cognitively impaired resident who was at risk for wandering, eloped from the facility, walked approximately 1 mile from the facility, crossed a total of 6 lanes of high-volume traffic at a main intersection and got into a car with a passing motorist. The resident was found by a family member in a neighborhood known for drug deals. The facility failed to thoroughly investigate 3 incidents of resident-to-resident altercations when Resident #3 hit Resident #2 in the head with a book, Resident #4 willfully pushed Resident #2 to the floor, and Resident #5 willfully pushed Resident #1 causing the resident to fall to the floor and hit his head. This had the potential to cause serious injury to all 5 residents, which resulted in Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Director of Clinical Services, Administrator, and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 5/13/2022 at 6:30 PM, in the Chapel. The facility was cited at F-610 at a scope and severity of K, which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/14/2022 at 1:44 PM, and the corrective actions were validated onsite by the surveyors on 5/17/2022 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ existed from 2/20/2022 through 5/16/2022. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, revised 3/3/2022, revealed .Written procedures for investigation include .Identifying staff responsible for the investigation .Identifying and interviewing all involved persons .Focusing the investigation on determining if abuse, neglect, or exploitation, and/or mistreatment has occurred, the extent, and cause .Providing complete and thorough documentation of the investigation . The facility's undated policy titled Quality Assurance Performance Improvement [QAPI], revealed .'Adverse events' is an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof, including near misses .An investigation will be conducted on each identified medical error or adverse event to analyze causes. Preventive actions and mechanisms will be implemented to prevent medical errors and adverse events, including feedback and education . Review of the facility's Director of Nursing Job Description updated 12/2011, revealed .Complete investigative analysis as required .Ensure that all nursing service personnel follow established departmental policies and procedures .Assure residents a comfortable, clean, orderly and safe environment . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had impaired cognition, impaired vision, an unsteady gait, required physical assistance for balance with transfers, and had range of motion impairment in the upper and lower extremities on one side of the body. Review of the Elopement/Wandering Risk assessment dated [DATE], revealed Resident #1 scored a 9, which indicated a moderate risk. Review of the Incident Report dated 2/20/2022, revealed .the receptionist received a call from the nurse [Licensed Practical Nurse (LPN) #1] who worked 7a [7:00 AM] to 7p [7:00 PM] today stating it look like a third floor resident was on [Named Street]. I asked receptionist who and she stated resident's name [Resident #1] .I went to check to see if he was there, he was not. Staff of the building searched for resident with no success . Review of a Social Service Progress Note dated 2/21/2022 at 9:15 AM, revealed .Resident [Resident #1] returned to facility via family's car with sister and daughter at his side. Resident ambulated to door of the facility with an unsteady gait. Resident refused assistance from staff and family as he entered the building . Observation in the resident's room on 5/10/2022 at 11:40 AM, revealed Resident #1 standing and looking out the window. He ambulated across the room with a right dominant limp and an unsteady gait. He was alert but was unable to determine his orientation due to his loss of ability to express himself verbally. He did not respond to open-ended questions but could respond with yes/no gestures. Resident #1 did not answer questions related to the elopement incident. Review of the facility's investigation revealed no written statements or interviews with the staff from the shift prior to the elopement time. During an interview on 5/11/2022 at 11:15 AM, the DON was asked what interventions were implemented after the elopement incident. The DON stated, .Family did not want him going out without notification .family was to pick him up twice a week [the family member stated in an interview that they had told the facility they could not come every week], he was 1 on 1 [1:1] with a CNA [Certified Nursing Assistant] .involve in more activities . When asked if the intervention of the family taking Resident #1 out for a leave twice weekly was implemented, the DON stated, I don't know .I guess they do .I don't know . During an interview on 5/11/2022 at 12:05 PM the Administrator was asked if staff from all shifts were included in the investigation to determine possible care needs and behaviors of the resident prior to his elopement. The Administrator stated, I don't know. Not sure how many interviews were done. We interviewed the staff that was here. I didn't get a call until 8 [8:00 PM] . During a telephone interview on 5/13/2022 at 11:28 AM, LPN #1 was asked to give the details of Resident #1's elopement. LPN #1 stated, .I remember he [Resident #1] came to the desk on the 3rd floor. He was standing alone and not in his usual dress. He was wearing new white tennis shoes, a new gray heavy winter jacket, new clothes, and sweatpants. I asked where he was off to and he was going to smoke. He just giggled .I maybe left [left facility] about 7:30 [PM]. I was headed up [Named Street]. He was on my right side at the light [traffic light]. He was crossing to go toward median [on left, across 6 lanes]. He slapped the hood of my car .I opened my door and he sped up .I was afraid he would fall .I saw a navy bluish or black car. He got in .I lost sight of the car .I pulled over and called the building and spoke with the receptionist I called back to the building about 8 [8:00 PM] .She [receptionist] told me no resident was missing .[Named nurse] called me at home about an hour later and said he [Resident #1] was missing . LPN #1 was asked if the Administrator or the DON had questioned her about the elopement details. LPN #1 stated, .On Monday [2/21/2022] I brought a statement in early .No one has talked to me since I brought the statement. No one from the facility .I wasn't questioned what his behaviors were prior to the elopement . During a telephone interview on 5/16/2022 at 11:08 AM, a family member of Resident #1 was asked about the elopement incident. The family member stated, .They [staff] called me at 8:16 PM and was saying they didn't know where he was. They said they last saw him at 7:05 [PM]. I thought someone watched that front door. I asked how did you let a man that walks slow with a limp get out of your sight .Next morning my mom called me and said my cousin had found him in [Named] neighborhood where he [Resident #1] used to do drugs .I brought him back. He didn't seem to be on any drugs, seemed the same . When asked what interventions the facility put in place to prevent elopement from happening again the family member stated, .They put a thing [Wanderguard, a sensor alarm system worn by residents to alert staff if a resident attempts to exit through a monitored door] on his leg .I told them I can't come every week . During a telephone interview on 5/17/2022 at 11:36 AM, Registered Nurse (RN) #1 was asked about Resident #1's elopement. RN #1 stated, .The receptionist asked me if I would watch the desk while she took them [residents] out to smoke at 7:00 PM. I was at the desk telling visitors to sign in and log in and I was on the phone .About 7:15 he [Resident #1] came to me and put some change on the counter. I told him I didn't have any money .He walked away .that is the last I saw him. It was a busy time with the visitors coming in and the phone calls . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 scored 7 on the Brief Interview for mental Status (BIMS) scale, which indicated the resident had severe cognitive impairment for decision making. The functional status assessment revealed locomotion on the unit was per wheelchair with oversight. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #3 scored a 15 on the BIMS scale, which indicated cognitively intact for decision making. Review of a Nurses' Note dated 4/28/2022 at 7:37 PM, revealed .18:40 [6:40 PM] per nurse was inform from CNA [Certified Nursing Assistant] she was picking up trays coming out of room [number] [a resident's room] with resident tray to put on food cart and saw [Named Resident #3] hitting [Named Resident #2] with a bible in the head, resident remove [removed] from room [number] [Resident #3's room] to hallway, per nurse enter [entered] room [number] [Resident #3's room] an [and] ask [asked] resident [Resident #3] what happen [happened] resident stated 'he [Resident #2] enter [entered] my room and I try [tried] to get him out' per nurse ask [asked] [Named Resident #3] did she hit him with anything resident stated, 'No' head to toe assessment done [Named Resident #2] small rise [swollen] area with redness to left side of head denies pain at site, per nurse ask [asked] [Named Resident #2] what happen [happened] resident stated 'she hit me on the side of my head' .administrator notified . Review of a Social Service note dated 4/29/2022 at 4:46 PM, revealed, .Social worker spoke to resident [Resident #2] today .Redness noted to resident face . Review of a Social Service note dated 5/3/2022 at 4:53 PM, revealed, .Resident [Resident #2] was seen by psych [psychiatric] services on 4/29/22 [2022] regarding follow up to recent behaviors . Administration was unable to produce documentation of a psych service visit on 4/29/2022 even though the State Agency requested it multiple times during the investigation on 5/10/2022 - 5/17/2022. During an interview on 5/10/2022 at 4:00 PM, the Administrator was asked what immediate interventions were implemented to keep Resident #2 from entering other residents' rooms. The Administrator stated, .I don't know . During an interview on 5/11/2022 at 12:00 PM, the DON was asked what behaviors Resident #2 was exhibiting prior to the resident-to-resident altercation. She stated, .I don't know . When asked if staff were interviewed about the resident's behaviors prior to the altercation. She stated, .No . There was no documentation of a thorough investigation of the resident-to-resident altercation. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS dated [DATE], revealed Resident #4 scored a 15 on the BIMS scale, which indicated the resident was cognitively intact for decision making. Review of Resident #4's Nurses' Note dated 5/5/2022 at 1:11 PM, revealed, .Ms. [Named Resident #4] stated a male resident [Resident #2] came into her room while she was sleeping overnight. She was sleeping on her right side facing the window, she felt the mattress moving and a knee was on her leg. He [Resident #2] didn't touch her upper body. She [Resident #4] thought it was her roommate; however, she turn [turned] to the left and saw a white man. She said to him Wrong Bed/Wrong Room and the male resident repeated what was said to him. She push [pushed] him out her bed and he fell on to the floor. He was reaching for help, and she refuse [refused] to help him due to her being fearful of falling and hurting herself. She push [pushed] the call light for help but staff didn't respond. So, both her and the male resident [Resident #2] was screaming and hollowing [hollering] loud Help .before staff came to assist and remove male resident from her room. Resident [Resident #4] also stated she's not violent . Review of a Nurses' Note dated 5/8/2022 at 6:31 AM, revealed, .Patient [Resident #4] called on the unit phone stating another resident [Resident #2] had entered her room. The patient was upset and stated this is the second time this has happened, and they said he would be watched. I explained to the patient that I was unaware of the situation and would ensure that the male resident [Resident #2] did not return to her room . During an interview on 5/10/2022 at 3:57 PM, RN #2 was asked what interventions were implemented after the altercation of Resident #2 and Resident #3 on 4/28/2022. She stated, .we did hourly safety checks . When RN #2 was shown the date of onset for hourly safety checks was 3/3/2022, she stated, .Oh I see nothing new . When she was asked what interventions were implemented after the altercation of Resident #2 with Resident #4 on 5/5/2022 and she stated, .continue hourly safety checks .supposed to have close supervision .to be honest we failed to supervise him . During an interview on 5/10/2022 at 4:00 PM, the Administrator was asked what investigation was conducted to determine interventions for the wandering behaviors of Resident #2 entering other resident rooms that resulted in resident-to-resident altercations. The Administrator stated, .I don't know .I see what you mean . There was no evidence of a thorough investigation of the resident-to-resident altercations. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Emergency Department Physician Note dated 9/17/2021, revealed .History of IV [intravenous] drug use [drugs entered through the veins where blood flows in the body] .Alcohol use current type beer, liquor, wine .Substance use current type cocaine . Review of a Nurses' Note dated 11/29/2021 at 10:05 PM, revealed .The CNA reported to this nurse writer that the resident [Resident #5] was drinking liquor in his room. An empty bottle of [Named] Vodka was confiscated from his shoebox. Resident denied drinking However this nurse observed resident's behavior as being loud, using inappropriate language, cursing, unsteady gait . Review of an Incident Report dated 2/9/2022 at 6:31 PM, revealed .This resident [Resident #5] initiated physical and verbal aggression against another resident [Resident #1] in the lobby area of the nurse's station .This resident [Resident #5] got out of his wheelchair as he was talking loudly and accusing the resident [Resident #1] of stealing approached Mr. [Named Resident #1] then forcibly pushed the resident down to the floor near the window causing the resident to hit his head against wall. This incident was witnessed per nurses . Review of a Nurses' Note dated 2/9/2022 timed 6:38 PM, revealed .This nurse observed an altercation between resident [Resident #5] and resident [Resident #1]. The resident [Resident #5] was following [Named Resident #1]. [Named Resident #5] was in his wheelchair, he was coming down hallway stating that the resident [Resident #1] He stole something from me. He know [knows] he stole from me. Resident [#5] stood up from his wheelchair and pushed [Named Resident #1] into the window, were [where] [Named Resident #1] fell and struck his head. [Named Resident #1] was transferred from the floor unto [into] the chair .Police discovered from the resident [Resident #5] that they had been drinking in the room. [Named Resident #1] was re-assigned to another room temporarily until crisis over . Review of resident #5's Nurses' Note dated 2/9/2022 at 6:40 PM, revealed .Resident [#5] became verbally and physically abusive toward another resident [Resident #1] pushed another resident down to the floor .Resident [#5] reported to [Named Police Department] he had been drinking . Review of the x-ray of the skull report dated 2/10/2022, revealed Resident #1 had .no acute fracture .conclusion normal skull series . During a telephone interview on 5/13/2022 at 10:53 AM, LPN #3 confirmed she was not asked to provide a written statement or details of the incident of resident-to-resident altercation on 2/9/2022. During a telephone interview on 5/13/2022 at 2:57 PM, LPN #4 stated, .I reported him [Resident #5] drinking to the Administrator and the Director of Nursing back in November 2021. I told them about the empty Vodka bottle, and he may have been under the influence. Loud and talking a lot and a shift in his behavior . During an interview on 5/13/2022 at 3:35 PM, the Administrator was asked if the incident of staff finding an empty bottle of alcohol in Resident #5's room on 11/29/2021 and the resident was exhibiting behaviors was investigated. The Administrator stated, .No, it was never brought to my attention .No, we never investigated it . The facility failed to provide documentation of witness statements, an investigation of the events and behaviors before the incident, an investigation to determine triggers for the behaviors, and documentation of monitoring the resident or implementing appropriate interventions. Refer to F-600 and F-689. The surveyors verified the Removal Plan by: 1. Resident #1 was placed on 15 minutes checks until 10:00 PM on 5/13/2022, and then hourly checks ongoing. A staff member was assigned to monitor the resident's location and movements daily. Staff escorts Resident #1 out to smoke during smoke break. The resident's Brief Interview for Mental Status (BIMS) was reassessed on 5/13/2022. The Nurse Practitioner reevaluated the resident on 5/13/2022. The preadmission evaluation was updated to reflect Resident #1's current status on 5/13/2022. All exit doors were checked for function on 5/13/2022. There were no concerns noted. Resident #2 was discharged on [DATE]. This was confirmed by record review, report review, and interviews. 2. Residents with BIMS scores of 8 or above were interviewed for abuse or potential for abuse by 5/14/2022. A resident with a BIMS below 8 will have a skin assessment conducted by 5/14/2022. Elopement assessments were conducted on all residents on 5/14/2022 by Social Service and Nursing Supervisors. This was confirmed by record review, report review, and interviews. 3. On 5/14/2022, the Administrator and DON re-inserviced staff on how to conduct an investigation to include documentation, monitoring, details of the events, and providing appropriate interventions to prevent occurrence or reoccurrence of elopement or resident to resident abuse. This was confirmed by report review, form review, review of education sign-in sheets, and interviews on all shifts. 4. 100 percent (%) of staff were in-serviced by the DON, Nurse Supervisor, Staff Development Coordinator, or department head on the abuse, neglect, and exploitation policy, elopement and wandering resident policy, prevention, and reporting. Staff not at work will be called and re-educated via phone. Staff that were not able to be educated via phone will be educated prior to returning to work. Care plans were updated with new interventions. In the event of any future resident exiting, the resident will be placed on 1:1 supervision until primary care, nursing and psychiatric evaluations can be completed. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. This was confirmed by review of the education sign-in sheets, record review, and interviews on all shifts 5. An Interdisciplinary Team (IDT) meeting was held to review the results of the BIMS scores, the abuse interviews, the skin assessments, and elopement assessments on 5/14/2022. This was confirmed by review of the IDT sign in sheet, audit review, and interviews. 6. Facility system changes include reviewing progress notes daily during morning clinical meeting for trigger words. Any triggers will be reported to the Administrator immediately and the licensed nursing home Administrator makes the initial report to the State of Tennessee via URIS 3.0 system and completes investigation within 5 days. QAPI meetings will occur weekly for four weeks to monitor progress and then monthly thereafter. The Maintenance Supervisor will check all doors for functionality weekly and as needed. This was confirmed by review of records, reports, sign in sheets, audit sheets, and interviews. 7. The DON, Nurse Supervisor, or Staff Development Coordinator will conduct abuse, neglect, and elopement audits. The audits will include identifying residents with exit seeking behaviors daily for 4 weeks, then 3 times per week for 4 weeks, then 2 times a week for 4 weeks, then weekly ongoing. This was confirmed by review of audit sheets and interviews. 8. The DON or Staff Development Nurse will report findings of the abuse and neglect audit to the monthly Quality Assurance Performance Improvement (QAPI) Committee members which include the Committee Chairperson - Administrator, DON, Assistant Director of Nursing, Medical Director, Dietary Director, Pharmacy Representative, Social Services Director, Activities Director, Environmental Director/ Safety Representative, Infection Control Representative/Staff Development Coordinator, Rehabilitation Director, and Medical Records Director for 4 months for further suggestions and/or follow up as needed. The DON, Assistant Director of Nursing, Minimum Data Set (MDS) Nurse, Nurse Supervisor, or Staff Development Coordinator will review the outcome of the abuse and neglect audit monthly and ongoing. Any aberrancies will be addressed, interventions developed, and corrective actions taken. This was confirmed by review of the QAPI tool and interviews. The facility's noncompliance of F-610 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, facility investigation review, facility incident report review, medical record review, observation, and interview, the facility failed to ensure a safe environment, provide adequate supervision to prevent elopement, and failed to ensure wandering assessments were completed for 2 of 6 sampled residents (Resident #1 and #2) reviewed; when a cognitively impaired resident who was at risk for wandering, eloped from the facility, walked approximately 1 mile from the facility, crossed a total of 6 lanes of high-volume traffic at a main intersection and got in a car with a passing motorist. The resident was found by a family member in a neighborhood known for drug deals. Resident #1 was unsupervised outside the building for approximately 14 hours; and the facility failed to supervise safe smoking practices when Resident #1 was observed smoking unsupervised. The facility failed to provide an adequate smoking apron for 4 of 14 sampled residents (Resident #1, #6, #7, and #8) reviewed for safe smoking, and the facility failed to prevent accidents and provide interventions for 5 of 5 sampled residents (Resident #1, #2, #3, #4 and #5) reviewed with aggressive behaviors. The facility's failure to provide adequate supervision to prevent elopement and the failure to provide adequate supervision while smoking resulted in Immediate Jeopardy for Resident #1. The facility's failure to prevent accidents and provide interventions resulted in Immediate Jeopardy for 3 incidents of resident-to-resident altercations when Resident #3 hit Resident #2 in the head with a book, Resident #4 willfully pushed Resident #2 to the floor, and Resident #5 willfully pushed Resident #1 causing the resident to fall to the floor and hit his head had the likelihood to cause serious injury to all 5 residents. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Director of Clinical Services, the Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 5/13/2022 at 6:30 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of K, which is Substandard Quality of Care. The IJ existed from 2/20/2022 through 5/16/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/14/2022 at 1:44 PM, and the corrective actions were validated onsite by the surveyors on 5/17/2022 through policy review, medical record review, observation, review of education records, and staff interviews. The findings include: Review of the facility's undated policy titled, Accidents and Supervision, revealed .each resident receives supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazards(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary .The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents .Implementation of Interventions-using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes .Communicating the interventions to all relevant staff .Documenting interventions .Ensuring that the interventions are put into action .Facility-based interventions may include, but are not limited to .educating staff .developing or revising policies and procedures .The facility will provide adequate supervision to prevent accidents .Based on the individual resident's assessed needs and identified hazards in the resident environment . Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .The facility is equipped with door locks/alarms to help avoid elopements .Staff are to be vigilant in responding to alarms in a timely manner .Adequate supervision will be provided to help prevent accidents or elopements .Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol . Review of the facility's undated policy titled, Resident Alarms, revealed .It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being .Wander/elopement alarms - includes devices such as bracelets .worn/attached to the resident that alert staff when the resident nears or exits an area or building .The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms .Implementation of interventions .Supervision and other resident-specific interventions shall be implemented and documented prior to the use of alarms .Interventions shall be communicated to all relevant staff, including frequency/time frame and responsibility .Monitoring and modification a. Supervision shall be provided to the resident in accordance with the resident's plan of care .b. When alarms are utilized, additional monitoring shall be provided . Review of the facility's policy titled, Elopement/Wandering Residents, dated 12/2010, revealed .It is the intent of this facility to determine which residents have significant wandering behavior and enhance staff awareness as well as educate them on how to deal with such residents .An elopement/wandering assessment will be completed upon admission located in the nursing admission information packet and quarterly thereafter .A wandering/elopement notebook containing pictures and pertinent demographics information will be maintained by social services and kept at each nurse's station and front lobby. Update notebook quarterly . Review of the facility's undated policy titled, Resident Smoking, revealed .This facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking .Smoking is prohibited in all areas except the designated smoking area .Safety measures for the designated smoking areas will include .Provision of ashtrays made of noncombustible material and safe design .Accessible metal containers with self-closing covers into which ashtrays can be emptied .Residents who smoke will be further assessed, using the resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all .All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking . Review of the facility's Elopement/Wander Risk Assessment tool revealed a scale with scores as follows: 0-8 indicated a low risk, 9-10 indicated a moderate risk, 11 or above indicated a high risk to wander. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of [CONDITION(S)] and [CONDITION(S)] Following Cerebral Infarction Affecting Left Non-Dominant Side, Seizures, Mood Disorder, [CONDITION(S)], [CONDITION(S)] Infarction, Diabetes, and [CONDITION(S)]. Review of the admission Elopement/Wandering Risk assessment dated [DATE], revealed Resident #1 scored a 4, which indicated a low risk. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had impaired cognition, impaired vision, an unsteady gait, required physical assistance for balance with transfers, and had range of motion impairment in the upper and lower extremities on one side of the body. Review of the Elopement/Wandering Risk assessment dated [DATE], revealed Resident #1 scored a 9, which indicated a moderate risk. Review of the Incident Report dated 2/20/2022, revealed .the receptionist received a call from the nurse [Licensed Practical Nurse (LPN) #1] who worked 7a [7:00 AM] to 7p [7:00 PM] today stating it look like a third floor resident was on [Named Street]. I asked receptionist who and she stated resident's name [Resident #1] .I went to check to see if he was there, he was not. Staff of the building searched for resident with no success . Review of the facility's investigation file dated 2/21/2022, revealed a typed statement from a resident who witnessed Resident #1 exiting the building. The statement revealed .He [Resident #1] went out the front door around the brick and I couldn't see him anymore. Did you see the receptionist at that time he said 'yes', What was she doing at the time you saw him go out the door 'She was on the telephone.' . Review of a Social Service Progress Note dated 2/21/2022 at 9:15 AM, revealed .Resident [Resident #1] returned to facility via family's car with sister and daughter at his side. Resident ambulated to door of the facility with an unsteady gait. Resident refused assistance from staff and family as he entered the building . Review of a Social Service Progress Note dated 3/10/2022, revealed, .Resident [Resident #1] cognition is impaired .Resident is at risk for elopement. Wander guard [a sensor alarm system worn by residents to alert staff if a resident attempts to exit through monitored exit doors] is in place . During an interview on 5/10/2022 at 11:29 AM, LPN #2 was asked when a Wanderguard was checked for placement. LPN #2 stated, .We check location that it [Wanderguard] is on the resident. We don't check if it's working or not .Are we supposed to . Observation in the resident's room on 5/10/2022 at 11:40 AM, revealed Resident #1 standing and looking out the window. He ambulated across the room with a right dominant limp and an unsteady gait. He was alert but was unable to determine his orientation due to his loss of ability to express himself verbally. He did not respond to open-ended questions but could respond with yes/no gestures. Resident #1 did not answer questions related to the elopement incident. During an interview on 5/11/2022 at 11:15 AM, the DON was asked what interventions were implemented after the elopement incident. The DON stated, .Family did not want him going out without notification .family was to pick him up twice a week [the family member stated in an interview that they had told the facility they could not come every week], he was 1 on 1 [1:1] with a CNA [Certified Nursing Assistant] .involve in more activities . When asked if the intervention of the family taking Resident #1 out for a leave twice weekly was implemented, the DON stated, I don't know .I guess they do .I don't know . During an interview on 5/11/2022 at 3:15 PM, LPN #6 was asked if there was a list of residents at risk to wander or elope. LPN #6 stated, I don't know. If they [residents] were high risk I would need to watch them. But I don't know about a list . During an interview on 5/11/2022 at 3:17 PM, LPN #7 was asked if there was a list of residents at risk to wander or elope, LPN #7 stated, Word of mouth if resident is a wanderer. I check to see if the Wanderguard is on, but I don't test it . LPN #7 had no knowledge of a notebook that listed the residents at risk for elopement/wandering. Observation on the 200 Hall, 300 Hall, and 400 Hall on 5/12/2022 at 12:32 PM, revealed the Elopement/Wandering notebooks located on each hall had inaccurate lists of residents assessed at risk for elopement/wandering. During a telephone interview on 5/13/2022 at 11:28 AM, LPN #1 was asked to give the details of Resident #1's elopement. LPN #1 stated, .I remember he [Resident #1] came to the desk on the 3rd floor. He was standing alone and not in his usual dress. He was wearing new white tennis shoes, a new gray heavy winter jacket, new clothes, and sweatpants. I asked where he was off to and he was going to smoke. He just giggled .I maybe left [left facility] about 7:30 [PM]. I was headed up [Named Street]. He was on my right side at the light [traffic light]. He was crossing to go toward median [on left, across 6 lanes]. He slapped the hood of my car .I opened my door and he sped up .I was afraid he would fall .I saw a navy bluish or black car. He got in .I lost sight of the car .I pulled over and called the building and spoke with the receptionist I called back to the building about 8 [8:00 PM] .She [receptionist] told me no resident was missing .[Named nurse] called me at home about an hour later and said he [Resident #1] was missing . During an interview on 5/13/2022 at 5:55 PM, the Administrator was asked if the elopement notebooks were accurate. The Administrator stated, .No, I did not realize it until it was brought our attention . During a telephone interview on 5/16/2022 at 11:08 AM, a family member of Resident #1 was asked about the elopement incident. The family member stated, .They [staff] called me at 8:16 PM and was saying they didn't know where he was. They said they last saw him at 7:05 [PM]. I thought someone watched that front door. I asked how did you let a man that walks slow with a limp get out of your sight .Next morning my mom called me and said my cousin had found him in [Named] neighborhood where he [Resident #1] used to do drugs .I brought him back. He didn't seem to be on any drugs, seemed the same . When asked what interventions the facility implemented to prevent another elopement, the family member stated, .They put a thing [Wanderguard] on his leg .I told them I can't come every week . During an interview on 5/16/2022 at 12:38 PM, LPN #8 was asked if there was a list of residents at risk to wander or elope. LPN #8 stated, .If have a Wanderguard they [residents] are a risk. I don't know about those that wander. I don't know who they are. LPN #8 had no knowledge of a notebook that listed residents at risk for elopement/wandering. During a telephone interview on 5/17/2022 at 11:36 AM, Registered Nurse (RN) #1 was asked about Resident #1's elopement. RN #1 stated, .The receptionist asked me if I would watch the desk while she took them [residents] out to smoke at 7:00 PM. I was at the desk telling visitors to sign in and log in and I was on the phone .About 7:15 he [Resident #1] came to me and put some change on the counter. I told him I didn't have any money .He walked away .that is the last I saw him. It was a busy time with the visitors coming in and the phone calls . Review of the Safe Smoking Screen dated 2/21/2022, revealed Resident #1 needed to use a smoking apron and required direct supervision while smoking. Observation at the Front Patio on 5/10/2022 at 12:09 PM, revealed Resident #1 was seated and smoking a cigarette. Three other residents were also on the patio. There were no staff present. Observation at the Front Patio on 5/10/2022 at 12:16 PM, revealed RN #2 asked Resident #1 if he had a lighter. He shook his head to answer No. RN #2 stated, I'm going to let him smoke that cigarette because he will get agitated if I try to take it. I'll see about the lighter . During an interview on 5/10/2022 at 12:13 PM, Receptionist #1 was asked if Resident #1 was allowed to smoke on the Front Patio. Receptionist #1 stated, .They can't smoke on the patio. I didn't know he [Resident #1] was out there. When asked if the Wanderguard alarm on the door sounded she stated, .It is busy here .If it wasn't this much noise it would seem louder .I don't know how that happened . Review of a Nurses' Note dated 5/15/2022, revealed .This writer walked pass [past] [Resident #1's room] and smelled smoke .upon entering the room I could smell smoke and observed the resident standing by the window tossing something out of the open window .Resident became visible [visibly] upset and walked towards this writer with fist balled up in a threatening attempt to fight . During an interview on 5/16/2022 at 12:21 PM, LPN #2 was asked if Resident #1 had been found smoking in his room. LPN #2 stated, .I was walking down the hall and the sitter was outside his door. The door was closed .I smelled smoke and I knew that the smell was cigarette smoke. I opened the door. It was smokey, very smokey. He tossed something out the window. I searched the room. He wouldn't let me pat him down . During an interview on 5/17/2022 at 1:35 PM, the Central Supply Manager was asked if a lighter was found in Resident #1's room. The Central Supply manager stated, .I went in his room and told him to give me the lighter .He let me pat him down and I felt the lighter in the zippered pocket of his sweatpants . The lighter was found on Resident #1 on 5/16/2022 after he was found smoking unsupervised on 5/15/2022. Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia with Behavior, Repeated Falls, Cerebral Infarction, [CONDITION(S)], and Hypertension. Review of Resident #2's Elopement/Wandering Risk assessment dated [DATE], revealed a score of 13, on 3/28/2021 revealed a score of 18, and on 2/23/2022 revealed a score of 15. All scores indicated the resident was a high risk for wandering. There was no documentation of quarterly wandering assessments. During an interview on 5/11/2022 at 12:00 PM, the DON was asked how often the facility performed a wandering risk assessments for residents. She stated, .on admission and should be done with every MDS quarterly and annually . Review of Resident #2's Care Plan dated 3/3/2022, revealed .[Resident #2] is an elopement risk/wanderer and requires use of wanderguard to decrease risk of unauthorized exiting from the facility .Check placement and function of safety monitoring device every shift .Provide safety check every hour .Reorient/validate and redirect resident as needed . Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 scored a 7 on the Brief Interview for Mental Status (BIMS) scale, which indicated the resident had severe cognitive impairment for decision making. The functional status revealed locomotion on the unit was per wheelchair with oversight. Review of Resident #2's Medication Administration Record (MAR) dated 4/2022 and 5/2022, revealed .Wanderguard placement to decrease risk of unauthorized exiting from the facility. Check to insure intact every shift for Wandering . There was no documentation of the Wanderguard being checked for functioning. During an interview on 5/10/2022 at 3:57 PM, RN #2 stated, .We check that the Wanderguard is on the resident. We don't check if working or not . During an interview on 5/13/2022 at 12:30 PM, the Director of Social Services was asked if the facility had any documentation to show residents' Wander Guards were checked for function every shift. The Director of Social Services stated, .No, we don't have any documentation showing the Wanderguard is checked every shift for functioning .I am responsible for getting the Wanderguard and placing it on the resident. I make sure it is activated and working initially . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Pulmonary [CONDITION(S)], Diabetes, and Guillain-Barre Syndrome. Review of the annual MDS dated [DATE], revealed Resident #3 scored a 15 on the BIMS scale, which indicated cognitively intact for decision making. Review of Resident #3's Nurses' Note dated 4/28/2022 at 6:40 PM, revealed, .This nurse enter [entered] resident room an [and] ask [asked] what happen [happened], resident stated He [Resident #2] enter [entered] my room an [and] I try [tried] to get him out. This nurse ask [asked] resident if she allegedly hit resident, resident stated No . Review of a Nurses' Note dated 4/28/2022 at 7:37 PM, revealed .18:40 [6:40 PM] per nurse was inform from CNA she was picking up trays coming out of room [number] [a resident's room] with resident tray to put on food cart and saw [Named Resident #3] hitting [Named Resident #2] with a bible in the head, resident [Resident #2] remove [removed] from room [number] [Resident #3's room] to hallway, per nurse enter [entered] room [number] [Resident #3's room] an [and] ask [asked] resident [Resident #3] what happen [happened] resident stated 'he enter [entered] my room and I try [tried] to get him out' per nurse ask [asked] [Named Resident #3] did she hit him with anything resident stated, No head to toe assessment done [Named Resident #2] small rise area with redness to left side of head denies pain at site, per nurse ask [asked] [Named Resident #2] what happen [happened] resident stated 'she hit me on the side of my head' v/s [vital signs] [blood pressure] 142/70, p [pulse] 80, r [respiration] 18, [temperature] 98.4 .1845 [7:45 PM] NP [Nurse Practitioner] notified .1848 7:48 PM] call rp [responsible party] no answer, 1849 [7:49 PM] administrator notified . Review of a Social Service Progress Note dated 4/29/2022 at 4:46 PM, revealed .Social worker spoke to resident [Resident #2] today. Resident was unable to recall event of wandering last night. BIMs assessment was completed. Resident BIMs score is a 5 [Severely impaired cognitively for decision making] .Redness noted to resident face . Review of a Social Service Progress Note dated 5/3/2022 at 4:53 PM, revealed .Resident [Resident #2] was seen by psych [psychiatric] services on 4/29/2022 regarding follow up to recent behaviors . Administration was unable to produce documentation of a psychiatric service visit on 4/29/2022 visit they were asked multiple times for the information during the survey dated 5/10/2022 - 5/17/2022 . During an interview on 5/10/2022 at 3:29 PM, Resident #3 stated, .He [Resident #2] comes in my room rolling in his wheelchair day and night. I tell him not your room, not your room. On that day [4/28/2022] I was in bed and kept telling him not your room. He kept coming. I was yelling and he tried to go into my closet and bathroom. I kept hearing him bumping into things like the door and wall as he was moving his wheelchair around in that area. In the meantime, while I was yelling at him, I was trying to transfer myself to my wheelchair. I had to remove the arm of my wheelchair to get in it. The whole time yelling not your room. It took a while for me to get in my wheelchair and then the CNA got him out .No, I didn't hit him. He probably bumped his head/face on the door or wall .They need to keep him out of my room. I don't like it .the staff's answer is oh that is just [Resident #2] he wanders in others room. I told them that is not ok . During an interview on 5/11/2022 at 12:00 PM, the DON was asked what behaviors Resident #2 exhibited prior to the resident-to-resident altercation. She stated, .I don't know . When asked if staff were interviewed about the resident's behaviors prior to the altercation. She stated, .No . Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Radiculopathy Lumbar Region, Fracture of Vertebra, Sacral and Sacrococcygeal Region, and Diabetes. Review of the admission MDS dated [DATE], revealed Resident #4 scored a 15 on the BIMS scale, which indicated the resident was cognitively intact for decision making. Review of Resident #4's Nurses' Note dated 5/5/2022 at 1:11 PM, revealed, .Ms. [Named Resident #4] stated a male resident [Resident #2] came into her room while she was sleeping overnight. She was sleeping on her right side facing the window, she felt the mattress moving and a knee was on her leg. He [Resident #2] didn't touch her upper body. She thought it was her roommate; however, she turn [turned] to the left and saw a white man. She said to him Wrong Bed/Wrong Room and the male resident repeated what was said to him. She push [pushed] him out her bed and he fell on to the floor. He was reaching for help, and she refuse [refused] to help him due to her being fearful of falling and hurting herself. She push [pushed] the call light for help but staff didn't respond. So, both her and the male resident [Resident #2] was screaming and hollowing [hollering] loud .before staff came to assist and remove [removed] male resident from her room . Review of Resident #2's Nurses' Note dated 5/5/2022 at 8:06 PM, revealed, .Late entry: this AM @ [at] 02:15 [2:15 AM] Resident [#2] wanders into room [number] [Resident #4's room]. The staff CNA answered called light in [Resident #4's room] and noted Resident [#2] on floor in between Bed A and bed B at the foot. Resident [#2] in sitting position in front of w/c chair [wheelchair]. Resident [#2] was placed in wheelchair taken to his room [room number]. Resident [#2] assessed with no new bruises, redness or open areas . Review of Resident #4's Nurses' Note dated 5/8/2022 at 6:31 AM, revealed, .Patient called on the unit phone stating another resident [Resident #2] had entered her room. The patient was upset and stated this is the second time this has happened, and they said he would be watched. I explained to the patient that I was unaware of the situation and would ensure that the male [Resident #2] did not return to her room. Patient stated I'm reporting this because this is unacceptable .I again assured the patient that I would keep close watch on the male [Resident #2] and make sure he does not enter her room again . During an interview on 5/10/2022 at 3:45 PM, Resident #4 confirmed the Nurses' Notes dated 5/5/2022 at 1:11 PM and 5/8/2022 at 6:31 AM. She stated, .this man [Resident #2] came into my room [5/5/2022] and attempted to get in bed with me. I was turned on my right side facing the window when I felt a knee on my leg and the bed moving. I rolled over to see what was happening and this white man was trying to get into my bed. I yelled and instinctively pushed him back and he lost his balance and fell on to the floor. I started yelling Help and he would repeat everything I said help but in a weaker voice. I pushed the call light no answer by staff, and we continued to yell until staff came in .They told me oh, that is Mr. [Named Resident #2] and he wanders that is just what he does. I said no, that is not ok .Then a few days later [5/8/2022] he came into my room again. I picked up the phone and called the facility. They came in and got him. I told that nurse about what had happened before, and that agency nurse said she didn't know anything about him. I said ya'll told me you would watch him . During an interview on 5/10/2022 at 3:57 PM, RN #2 was asked what interventions were implemented after the 4/28/2022 altercation of Resident #2 and Resident #3. She stated, .we did hourly safety checks . When RN #2 was shown the date of onset for hourly safety checks was 3/3/2022 she stated, .Oh I see nothing new . When she was asked what interventions were implemented after the 5/5/2022 altercation of Resident #2 and Resident #4, she stated, .continue hourly safety checks .supposed to have close supervision .to be honest we failed to supervise him . During an interview on 5/11/2022 at 12:00 PM, the DON was asked what behaviors Resident #2 exhibited prior to the resident-to-resident altercation. She stated, .I don't know . When asked if staff were interviewed about the resident's behaviors prior to the altercation, she stated, .No . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Fracture First Lumbar Vertebra, Multiple Rib Fractures, and Fracture Shaft of Humerus. Review of Resident #5's ED [Emergency Department] Note Physician dated 9/17/2021, revealed .History of IV [Intravenous] drug use [drugs entered through the veins where blood flows in the body] .Alcohol use current type beer, liquor, wine .Substance use current type cocaine . Review of Resident #5's Nurses' Note dated 11/29/2021 at 10:05 PM, revealed .The CNA reported to this nurse writer that the resident was drinking liquor in his room. An empty bottle of [Named] Vodka was confiscated from his shoebox. Resident denied drinking However this nurse observed resident's behavior as being loud using inappropriate language, cursing, unsteady gait. Resident meds [medications] held. Resident state I don't have to have it .Resident instructed on hazard of taking sedative and narcotic with alcohol. Resident insistent he has not drunk any alcohol. Will monitor. Resident went straight to sleep without prompting . Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 15 on the BIMS scale, which indicated the resident was cognitively intact for decision making. Review of the Incident Report dated 2/9/2022 at 6:31 PM, revealed .This resident [Resident #5] initiated physical and verbal aggression against another resident [Resident #1] in the lobby area of the nurse's station to resident [Resident #1]. This resident [Resident #5] got out of his wheelchair as he was talking loudly and accusing the resident [Resident #1] of stealing approached Mr. [Named Resident #1] then forcibly pushed the resident down to the floor near the window causing the resident [Resident #1] to hit his head against wall. This incident was witnessed per nurses . Review of Resident #1's Nurses' Note dated 2/9/2022 at 6:38 PM, revealed, .This nurse observed an altercation between resident [Resident #5] and resident [Resident #1]. The resident [Resident #5] was following [Resident #1]. [Resident #5] was in his wheelchair, he was coming down hallway stating that the resident [Resident #1] He stole something from me. He know [knows] he stole from me. [Resident #5] stood up from his wheelchair and pushed [Resident #1] into the window .[Resident #1] fell and struck his head. [Resident #1] was transferred from the floor unto the chair .Police discovered from the resident [Resident #5] that they had been drinking in the room. [Resident #1] was re-assigned to another room temporarily until crisis over . Review of the Resident #5's Nurse's Note dated 2/9/2022 at 6:40 PM, revealed .Resident [#5] became verbally and physically abusive toward another resident [Resident #1] pushed another resident down to the floor .Resident [#5] reported to [Named Police Department] he had been drinking . Review of the skull series x-ray report dated 2/10/2022, revealed Resident #1 had .no acute fracture .conclusion normal skull series . Review of Resident #5's Care Plan revised 5/10/2022, revealed no documentation that empty Vodka bottles were found in the resident's room on 11/29/2021 and 2/9/2022, that the resident was drinking liquor in his room, or the behaviors of loud, inappropriate language, and cursing. During a telephone interview on 5/13/2022 at 2:57 PM, LPN #4 stated, .I reported him [Resident #5] drinking to the Administrator and the Director of Nursing back in November 2021. I told them about the empty Vodka bottle, and he may have been under the influence. Loud and talking a lot and a shift in his behavior . During an interview on 5/13/2022 at 3:35 PM, the Administrator was asked about the documentation of the incident on 11/29/2021 when an empty bottle of alcohol was found in Resident #5's room and the behaviors documented in a Nurses' Note dated 11/29/2021. When asked if the incident was investigated, the Administrator stated, .No, it was never brought to my attention .No, we never investigated it . Observation in the Smoking Area on 5/11/2022 at 1:27 PM, revealed Resident #1 was given a smoking apron that was torn, had multiple holes and frayed edges, [TRUNCATED]

Based on job description review, medical record review, observation, and interview, facility Administration failed to provide administration and oversight of its resources effectively to attain and maintain the highest practicable well-being of residents with wandering/elopement behaviors. Administration failed to provide oversight and training of staff to prevent neglect and provide appropriate care to meet resident's needs, failed to provide adequate supervision to prevent elopement, failed to provide safe smoking practices, failed to complete a thorough investigation of a resident elopement when a resident exited the facility without staff knowledge, and failed to thoroughly investigate resident-to-resident abuse. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1, a cognitively impaired resident who was at risk for wandering, eloped from the facility, and walked approximately 1 mile from the facility, crossed a total of 6 lanes of high-volume traffic at a main intersection and got in a car with a passing motorist. The resident was found by a family member in a neighborhood known for drug deals. Resident #1 was unsupervised outside the building for approximately 14 hours. The facility's failure to thoroughly investigate 3 incidents of resident-to-resident altercations when Resident #3 hit Resident #2 in the head with a book, Resident #4 willfully pushed Resident #2 to the floor, and Resident #5 willfully pushed Resident #1 causing the resident to fall to the floor and hit his head had the likelihood to cause serious injury or harm. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Director of Clinical Services, Administrator, and Director of Nursing (DON) were notified of the Immediate Jeopardy for on 5/13/2022 at 6:30 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-600, F-610, F-689, F-835, and F-867. The facility was cited Immediate Jeopardy at F-600 at a scope and severity of J, which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-610 and F-689 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy existed from 2/20/2022 through 5/16/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/14/2022 at 1:44 PM, and the corrective actions were validated onsite by surveyors on 5/17/2022 through review of education records, review of audits, meeting minutes, and staff interviews. The findings include: Review of the Administrator Job Description dated 12/2018, revealed .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Identify and participate in process improvement initiatives that improve the customer experience, enhance work flow, and/or improve the work environment. Management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .Monitor company identified Key Performance Indicators and address issues that affect performance of the facility .Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach and discipline as needed .Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; morale of the staff; and ensure resident needs are being addressed .Responsible for the QA [Quality Assurance] program. Maintain a working knowledge of and confirm compliance with all governmental regulations . Review of the Director of Nursing Job Description updated 12/2011, revealed .to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .Identify and participate in process improvement initiatives that improve the customer experience .Management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .In the absence of the Administrator .assume responsibility of the facility .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department .Meet monthly with staff on each unit .Participate in coordination of resident services through departmental and appropriate staff committee meetings .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guidelines .Perform nursing services and deliver resident care services in compliance with corporate policies and State and Federal regulations. Inform state of any reportable incidents within appropriate time frames. Complete investigative analysis as required .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Study Infection Control Reports, Medication Incident Reports and Resident Incident Reports for corrective action .Ensure that all nursing service personnel follow established departmental policies and procedures .Assure residents a comfortable, clean, orderly and safe environment .Review Quality Indicator reports and submit to [NAME] President of Clinical Services on monthly basis .Participate in monthly QA [Quality Assurance] . Review of the facility's investigation, Incident Report, and Progress Notes, revealed Resident #1 eloped from the facility on 2/20/2022. On her way home from work Licensed Practical Nurse (LPN) #1 saw the resident on a (Named Street) crossing 6 lanes of traffic. The nurse called the facility and informed them she thought she had seen a resident from the facility walking down the street. LPN #1 saw the resident get into a car with a passing motorist. The resident was found by his family approximately 14 hours later in a neighborhood known for drug deals. During an interview on 5/10/2022 at 11:29 AM, LPN #2 was asked when staff checked a Wanderguard (a sensor alarm system worn by residents to alert staff if a resident attempts to exit through monitored exit doors) for placement. LPN #2 stated, .We check location that it [Wanderguard] is on the resident. We don't check if it's working or not .Are we supposed to . Observation in the resident's room on 5/10/2022 at 11:40 AM, revealed Resident #1 looking out the window. He ambulated across the room with a right dominant limp and an unsteady gait. He was alert but was unable to express himself verbally. He did not respond to open-ended questions but could respond with yes/no gestures. Resident #1 did not answer questions related to the elopement incident. During an interview on 5/11/2022 at 11:15 AM, the DON was asked what interventions were implemented after the elopement incident. The DON stated, .family was agreeable to a Wanderguard, family was to pick him up twice a week. [the family member stated in an interview that they had told the facility they could not come every week] he was 1 on 1 [1:1] with a CNA [Certified Nursing Assistant] .involve in more activities . When asked if his family takes him out twice weekly, the DON stated, I don't know .I guess they do .I don't know . Observation at the side of the building near the designated Smoking Area on 5/11/2022 at 1:22 PM, revealed the side door was propped open with a 5-gallon water dispensing bottle and at the end of the sidewalk was an open gate to the parking lot. During an interview on 5/11/2022 at 1:52 PM, the DON was asked if a resident could exit the building and go through the open door and onto the parking lot through the open gate. The DON stated, That door should not be open. It goes to where they are working in therapy. Construction guys left the gate open .It goes to the parking lot. During an interview on 5/11/2022 at 2:13 PM, the Administrator was asked if a resident could leave the building through the therapy department which was under construction. The Administrator stated, They could walk right out and go through the gate and right to the parking lot. When asked if the building was secured, the Administrator stated, I see what you mean. No, it's not. I thought the construction crew knew to keep the door locked . During an interview on 5/11/2022 at 3:15 PM, Licensed Practical Nurse (LPN) #6 was asked if there was a list of residents that were assessed at risk to wander or elope. LPN #6 stated, I don't know. If they [residents] were high risk, I would need to watch them. But I don't know about a list . During an interview on 5/11/2022 at 3:17 PM, LPN #7 was asked if there was a list of residents that were assessed at risk to wander or elope. LPN #7 stated, Word of mouth if resident is a wanderer. I check to see if the Wanderguard is on, but I don't test it . LPN #7 had no knowledge of a notebook containing a list of residents assessed at risk of elopement/wandering. Observation in the Chapel on 5/12/2022 at 11:43 AM, revealed the exit door from the Chapel to the parking lot was not secured. The door opened after pushing on it for 15 seconds, but no alarm sounded. After the door was closed it did not lock. During an interview on 5/12/2022 at 11:46 AM, the Maintenance Director was asked if the exit door in the Chapel was secured and stated, I don't know what's wrong. Looks like no power to the door. The alarm should sound. It's not working . Observation on the 200 Hall, 300 Hall, and 400 Hall, on 5/12/2022 beginning at 12:32 PM, revealed the Elopement/Wandering notebooks on each hall had inaccurate lists of residents assessed at risk of elopement and wandering. Observation on 5/12/2022 at 1:45 PM, revealed Resident #1 walked out of the lobby onto the Front Patio. The Wanderguard alarm sounded when the resident walked through the exit door. The receptionist was on the telephone at the desk. The alarm was difficult to hear due to residents, staff, and visitors talking and laughing in the Lobby area. No staff responded to the sounding alarm. Observations on 5/12/2022 at 2:34 PM, 5/13.2022 at 2:00 PM, and 5/14/2022 at 1:55 PM revealed the following: a. 1st floor - Exit door at the northeast side of the building was not secure and the double doors at the north end of the building were not secure. The door to the therapy department that was under construction had an alarm that was disabled, the side door on the hallway that opened to the parking lot was under construction and was not secured, the doors to the 2 stairwells to the 2nd floor were not secured. b. 2nd floor - the doors to the 2 stairwells from the 1st floor to the 3rd floor were not secured, the door at the stairwell that led to the designated outside Smoking Area for residents opened without any difficulty. c. 3rd floor - the doors to the 2 stairwells from the 2nd and 4th floor were not secure. d. 4th floor - the 2 doors to the stairwells from the 3rd floor were not secured. e. The stairwells on the 2nd, 3rd, and 4th floors on the northeast side of the building that led to the 1st floor exit door that was unlatched and led to the employee parking lot. During an interview on 5/12/2022 at 6:02 PM, the DON stated, .We did find discrepancies in the resident wander/elopement risk assessments . When asked what the discrepancies were, who had them, and how many residents were involved, she stated, .don't know who had them and how many . When asked for the documentation of what was done to address the discrepancies, she stated, .We didn't document what we did about it . When asked if there were interventions implemented to address the discrepancies and if the effectiveness of the interventions were evaluated, she stated, .No .I see what you mean . During an interview on 5/12/2022 at 6:02 PM, the Administrator confirmed education was not provided to all staff including agency personnel. She stated, .No, we didn't do it . The Administrator confirmed she did not provide specific education to the receptionist staff about wandering and elopement residents and their responsibility about the front door and the Wander Guard system doors. She stated, .No, we didn't do it . The Administrator confirmed she did not evaluate if any interventions were implemented on 3/2022 or 4/2022 and to see if the interventions were evaluated to determine if they were effective. She stated, .No, we didn't . The Administrator confirmed the wandering/elopement books were not accurate. She stated, .No, did not realize it until was brought to our attention . During a telephone interview on 5/13/2022 at 11:28 AM, LPN #1 was asked about the elopement. LPN #1 stated the resident came to the 3rd floor desk wearing new clothes and just giggled when asked where he was going. LPN #1 stated she left the facility about 7:30 PM, was at a traffic light, and saw Resident #1 crossing 6 lanes of traffic. LPN #1 tried to locate him but was unsuccessful and called the facility but was told no resident was missing. A nurse called about an hour later and stated Resident #1 was missing. During an interview on 5/13/2022 at 5:55 PM, the Administrator was asked if the elopement notebooks were accurate. The Administrator stated, .No, I did not realize it until it was brought our attention . During a telephone interview on 5/16/2022 at 11:08 AM, a family member of Resident #1 was asked what interventions the facility implemented to prevent another elopement (after the elopement), the family member stated, .They put a thing [Wanderguard] on his leg .I told them I can't come every week . During an interview on 5/16/2022 at 12:38 PM, LPN #8 was asked if there was a list of residents at risk to wander or elope. LPN #8 stated, .If have a Wanderguard they are a risk. I don't know about those that wander. I don't know who they are. LPN #8 had no knowledge of a notebook with a listing of residents at risk of elopement and wandering. During a telephone interview on 5/17/2022 at 11:36 AM Registered Nurse (RN) #1 stated she was at the receptionist's desk while the receptionist took the residents out to smoke at 7:00 PM. It was extremely busy answering the telephone and visitors signing in. Resident #1 came to the desk, placed some money on the desk, but then left and RN #1 did not see him again. Review of the Safe Smoking Screen dated 2/21/2022, revealed Resident #1 needed to use a smoking apron and required direct supervision while smoking. Observation on 5/10/2022 at 12:09 PM, revealed Resident #1 seated outside the building on the Front Patio smoking a cigarette. Three other residents were also on the patio. There was no staff member present. During an interview on 5/10/2022 at 12:13 PM, Receptionist #1 was asked if Resident #1 was allowed on the Front Patio. Receptionist #1 stated, .I didn't know he was out there. When asked if the Wanderguard alarm on the door had sounded, she stated, .It is busy here .I don't know how that happened . Observation on 5/10/2022 at 12:16 PM, revealed RN #2 asked Resident #1 if he had a lighter. He shook his head to answer No. RN #2 stated, I'm going to let him smoke that cigarette because he will get agitated if I try to take it. I'll see about the lighter . Review of a Nurses' Note dated 5/15/2022, revealed the nurse had walked past Resident #1's room and smelled smoke, entered the room, and observed Resident #1 tossing something out of the open window. The Resident became upset and approached the nurse in a threatening manner. During an interview on 5/16/2022 at 12:21 PM, LPN #2 was asked if Resident #1 had been found smoking in his room, LPN #2 stated, .I was walking down the hall and the sitter was outside his door. The door was closed .I smelled smoke and I knew that the smell was cigarette smoke. I opened the door. It was smokey, very smokey. He tossed something out the window. I searched the room. He wouldn't let me pat him down . During an interview on 5/17/2022 at 1:35 PM, the Central Supply Manager was asked if a lighter was found in Resident #1's room. The Central Supply Manager stated the lighter was in the zippered pocket of his sweatpants. The lighter was found on the resident on 5/16/2022, after he was found smoking unsupervised on 5/15/2022. Review of Resident #3's Nurses' Notes dated 4/28/2022, revealed a CNA saw Resident #3 hitting Resident #2 in the head with a Bible. Review of Resident #3's Nurse's Notes dated 4/28/2022 at 6:40 PM, revealed, .This nurse enter [entered] resident room an ask [asked] what happen [happened], resident stated He [Resident #2] enter [entered] my room an [and] I try [tried] to get him out. This nurse ask [asked] resident if she allegedly hit resident, resident stated No . During an interview on 5/11/2022 at 12:00 PM, the DON was asked what behaviors Resident #2 was exhibiting prior to the resident-to-resident altercation. She stated, .I don't know . When asked if staff were interviewed about the resident's behaviors prior to the altercation. She stated, .No . Review of Resident #4's Nurses' Notes dated 5/5/2022 at 1:11 PM, revealed, Resident #4 stated Resident #2 came into her room while she was sleeping. She was sleeping on her right side facing the window, she felt the mattress moving and a knee was on her leg. She told him he was in the wrong room and pushed him out of her bed and he fell on to the floor. Review of Resident #4's Nurses' Notes dated 5/8/2022 at 6:31 AM, revealed that Resident #4 called stating Resident #2 had entered her room. She was upset and stated it was the second time this had happened, and they had told her he would be watched. The nurse assured Resident #2 he would be watched and would not return to her room. During an interview on 5/10/2022 at 3:57 PM, RN #2 was asked what interventions were implemented after the 4/28/2022 altercation between Resident #2 and Resident #3. RN #2 stated they did hourly safety checks. When RN #2 was shown the documentation of the date the hourly safety checks were done was 3/3/2022, she stated, .Oh I see nothing new . When she was asked what interventions were implemented after the 5/5/2022 altercation of Resident #2 with Resident #4, she stated, .continue hourly safety checks .supposed to have close supervision .to be honest we failed to supervise him . During an interview on 5/11/2022 at 12:00 PM, the DON was asked what behaviors Resident #2 exhibited prior to the resident-to-resident altercation. She stated, .I don't know . When asked if staff were interviewed about the resident's behaviors prior to the altercation. She stated, .No . Review of Resident #5's Nurses' Notes dated 11/29/2021 at 10:05 PM, revealed a CNA reported to the nurse that Resident #5 was drinking liquor in his room. An empty bottle of Vodka was confiscated from his shoebox. Resident #5 denied drinking, but the nurse observed the resident's behavior as being loud, using inappropriate language, and had an unsteady gait. Review of the Incident Report and Nurses' Notes dated 2/9/2022, revealed Resident #5 initiated physical and verbal aggression against Resident #1 in the Lobby of the Nurses' Station. Resident #5 got out of his wheelchair as he was talking loudly and accused Resident #1 of stealing from him and then forcibly pushed Resident #1 to the floor causing Resident #1 to hit his head against the wall. Review of the radiology x-ray skull series report dated 2/10/2022, revealed Resident #1 had .no acute fracture .conclusion normal skull series . During a telephone interview on 5/13/2022 at 2:57 PM, LPN #4 stated the incident of Resident #5 drinking was reported to the Administrator and the DON in November 2021. They were told about the empty Vodka bottle, and .he may have been under the influence. Loud and talking a lot and a shift in his behavior . During an interview on 5/13/2022 at 3:35 PM, the Administrator was asked if the 11/29/2021 incident of an empty bottle of alcohol found in Resident #5's room and the nurses' documentation of the resident behaviors exhibited was investigated. The Administrator stated, .No, it was never brought to my attention .No, we never investigated it . Refer to F-600, F-610, F-689 and F-867. The surveyor verified the Removal Plan by: 1. Resident #1 was placed on 15 minutes checks until 10:00 PM on 5/13/2022, then hourly checks ongoing. A staff member was placed outside Resident #1's room to monitor the resident's location. Staff will escort resident out to smoke. Resident#1's BIMS was reassessed on 5/13/2022. Family Nurse Practitioner reevaluated Resident #1 on 5/13/2022. Preadmission evaluation will be updated to reflect the resident status. The Care Plan was updated with new intervention. Resident #2 was discharged on [DATE]. This was confirmed by observations, record review, and interviews with all staff. 2. All residents have the potential to be affected. Residents with BIMS score of 8 or above will be interviewed for abuse or potential for abuse. Residents with a BIMS below 8 will have a skin assessment conducted. Smoking assessments will be conducted on 100 percent (%) of residents. This was confirmed by record review, audit tools review, and interviews. 3. 100% of staff will be in-serviced by the DON, Nurse Supervisor, Staff Development Coordinator or department head on the abuse and elopement policy, prevention and reporting, and smoking policy. Abuse and neglect, smoking policy and elopement policy were reviewed. Staff not at work will be called and re-educated via phone. Staff that were not able to be educated will be educated prior to returning to work. In the event of any future resident exiting, the resident will be placed on 1:1 supervision until primary care, nursing and psychiatric evaluations can be completed. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. During smoke break, 2 staff will supervise smoking break when there are more than 6 residents present. This was confirmed by review of the revised smoking policy, review of the education sign-in sheets, and interviews on all shifts. 4. On 5/14/2022 the Nursing Home Administrator was educated on the role of Administrator, the job description, tools, and resources available to effectively administer a nursing facility operation by the Regional Director of Clinical Services. This was confirmed by review of education sign-in sheet and interview. 5. The Nursing Home Administrator was educated on Abuse, Neglect, and Exploitation on 5/14/2022 by the Regional Director of Clinical Services. This was confirmed by review of the education sign-in-sheet and interview on. 6. Quality Assurance Performance Improvement (QAPI) meetings will occur weekly for four weeks to monitor progress and then monthly thereafter. This was confirmed by review of sign in sheet and interview. 7. The DON, Nurse Supervisor, or Staff Development Coordinator will conduct abuse and neglect audits and smoking audits. The audits will include identifying residents with exit seeking behavior, unsafe or unsupervised smoking daily for four (4) weeks, then three times per week for four (4) weeks, then two (2) times week for four (4) weeks, then weekly ongoing. This was confirmed by review of audit sheets and interviews. 8. Regional Director of Operations or Regional Director of Clinical will provide oversight of facility administration with a weekly 1:1 interaction reviewing the completed audits and QA findings. The Plan of Correction will be reviewed weekly to ensure all the audits are completed and concerns are identified for 4 weeks and/or until substantial compliance is achieved. Monthly QAPI meetings will be conducted and attended by Regional Director of Operations and Regional Director of Clinical for a period of three months to ensure compliance is sustained. This was confirmed by review of audit tools and interviews. 9. Results of all audits will be brought to the QAPI Committee. The members include Committee Chairperson - Administrator; Director of Nursing; Assistant Director of Nursing; Medical Director; Dietary Director; Pharmacy Representative; Social Services Director; Activities Director; Environmental Director/ Safety Representative; Infection Control Representative/Staff Development Coordinator; Rehabilitation Director; and Medical Records Director for 4 months for further suggestions and/or follow up as needed. The DON, Assistant Director of Nursing (ADON), Multi Data Set Nurse, Nurse Supervisor, or Staff Development Coordinator will review the outcome of the abuse and neglect audit monthly and ongoing. Any aberrancies will be addressed, interventions developed, and corrective actions taken. This was confirmed by review of the revised QAPI tool and interviews with QAPI members. The facility's noncompliance of F-835 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, Quality Assurance Performance Improvement (QAPI) report, medical record review, observation, and interview, the QAPI committee failed to ensure systems and processes were in place that involved tracking/trending, quantitative and qualitative data analysis, evaluation/reevaluation of interventions, data, and trends to address quality concerns related to wandering and elopement behaviors, resident to resident abuse, and safe smoking practices. The QAPI committee failed to ensure a thorough investigation of a resident elopement and a thorough investigation of resident-to-resident abuse, failed to provide safe smoking practices and supervision of residents that smoked, failed to identify quality deficiencies and effective interventions, failed to monitor the effectiveness of the interventions, and failed to assess staff knowledge of the care of residents with wandering/elopement behaviors in order to identify deviations and adverse events when a resident exited the facility without staff knowledge, and failed to ensure a safe environment for Resident #1, #2, #3, #4 and #5 that demonstrated resident to resident altercations. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1, a cognitively impaired resident assessed as a risk for wandering/elopement and a high fall risk left the facility unsupervised and was missing for approximately 14 hours, and there were three incidents of resident-to-resident abuse when Resident #3 hit Resident #2 in the head with a book, Resident #4 willfully pushed Resident #2 to the floor, and Resident #5 willfully pushed Resident #1 to the floor hitting his head which had the likelihood to cause serious injury. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Director of Clinical Services, Administrator, and Director of Nursing (DON) were notified of the Immediate Jeopardy on 5/13/2022 at 6:30 PM, in the Chapel. The facility was cited Immediate Jeopardy (IJ) at F-600, F-610, F-689, F-835, and F-867. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. The facility was cited F-610 and F-689 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy existed from 2/20/2022 through 5/16/2022. An acceptable Removal Plan, which removed the immediacy of jeopardy, was received on 5/14/2022 at 1:44 PM, and the corrective actions were validated onsite by surveyors on 5/17/2022 through review of in-service sign-in sheets, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's undated policy titled, Quality Assurance & Performance Improvement (QAPI) Plan for [Named] Healthcare Management, revealed .QAPI focuses on systems and processes .the emphasis is on identifying system gaps rather than on blaming individuals. Our organization makes decisions based on data .The QAPI program at [Named] Healthcare Management will aim for safety and high quality .while emphasizing autonomy and choice in daily life for residents, by ensuring our data collection tools and monitoring systems are in place and are consistent for a proactive analysis .The QAPI plan will guide your facility's performance improvement efforts. This is a living document that you will continue to refine and revisit .The governing body assures adequate resources exist to conduct QAPI efforts. This includes designating one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment and technical training as needed .governing body is ultimately responsible for overseeing the QAPI Committee .The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction .[Named] Healthcare Management facilities will put in place systems to monitor care and services .It will include using performance indicators to monitor a wide range of care processes and outcomes, and reviewing findings against benchmarks .It also includes tracking, investigating, and monitoring adverse events/medical errors every time they occur, and action plans implemented through the Plan Do Study Act (PDSA) and Root Cause Analysis to prevent recurrences .The QAPI team will review our sources of information to determine if gaps or patterns exist in our systems of care that could result in quality problems . Review of the facility's Administrator Job Description dated 12/2018, revealed .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies .Monitor company identified Key Performance Indicators and address issues that affect performance of the facility .Oversee regular rounds to monitor delivery of nursing care, operation of support departments .Responsible for the QA [Quality Assurance] program. Maintain a working knowledge of and confirm compliance with all governmental regulations . Review of the facility's Director of Nursing Job Description updated 12/2011, revealed .to manage the overall operations of the Nursing Department .Identify and participate in process improvement initiatives that improve the customer experience, enhance work floor, and/or improve the work environment .Participate in .Quality Assessment and Assurance Committee Meetings, In-service Education .Complete investigative analysis as required .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Study .Resident Incident Reports for corrective action. Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures for a more efficient operation .Confirm accurate completion of forms/reports .Review Quality Indicator reports and submit to [NAME] President of Clinical Services on monthly basis .Participate in monthly QA [Quality Assurance] .Along with the Administrator engage the medical director in all department activity . Review of Resident #1's medical record, revealed Resident #1 exited the facility unsupervised and without staff knowledge on 2/20/2022 at approximately 7:00 PM, was out of the facility approximately 14 hours, and returned on 2/21/2022 at approximately 9:30 AM, when he was found by a family member in a neighborhood that was known for drug deals. Review of the QAPI meeting sign-in sheet dated 2/23/2022, revealed the Medical Director did not attend. Review of the QAPI folder dated 2/23/2022 on 5/12/2022 at 5:30 PM, revealed there was no documentation of quantitative or qualitative data obtained from the audit of records for wandering/elopement risk assessments, if there were any interventions implemented as a result of the data obtained, and if there was an assessment of the effectiveness of any interventions implemented. Review of the education sign-in sheets dated 2/21/2022 and 2/22/2022 revealed all staff were not educated on the topic of elopement and wandering. Only the staff working on the day of the elopement had any education provided and there was no documented plan to educate all staff including the agency staff. There was no documentation of quantitative or qualitative data obtained as a result of monitoring the door closure or the Wander Guard (a sensor alarm system worn by residents to alert staff if a resident attempts to exit through monitored exit doors) system or if any interventions were implemented and assessed for effectiveness. There was no documentation of an elopement drill completed for 2021 and no plans documented to conduct an elopement drill in 2022. There was no documentation of completion of a root cause analysis to identify or better understand the problems as stated in the facility's QAPI policy. During an interview on 5/12/2022 at 6:02 PM, the DON stated, .We did find discrepancies in the resident wander/elopement risk assessments . When asked what the discrepancies were, who had them and how many, she stated, .don't know who had them and how many . When asked for the documentation of what was done, she stated, .We didn't document what we did about it . When asked what the quantitative and qualitative data revealed, what interventions were implemented, and if the interventions were evaluated for effectiveness. She stated, .No .I see what you mean . During an interview on 5/12/2022 at 6:02 PM, the Administrator confirmed education was not provided to all staff including agency personnel. She stated, .No, we didn't do it . The Administrator confirmed there was no specific education provided the receptionist staff regarding residents that had wandering and elopement behaviors and the receptionist responsibility regarding monitoring the front door and being aware of the Wanderguard system doors. She stated, .No, we didn't do it . The Administrator confirmed they did not evaluate if any interventions were implemented on 3/2022 or 4/2022 and there was no process to determine if the interventions implemented were effective. She stated, .No, we didn't . The Administrator confirmed the wandering/elopement books were not accurate. She stated, .No, did not realize it until was brought to our attention . The Administrator confirmed they did not do a root cause analysis as stated in the facility's QAPI policy. She stated, .No, we did not do a root cause analysis .I see what you mean . During a telephone interview on 5/16/2022 at 8:17 AM, the Medical Director stated, .A couple of days later after the elopement I was notified that it happened .that he [Resident #1] got out and that was it .I had no input about it and they didn't ask for my input . During an interview on 5/16/2022 at 11:16 AM, the Administrator stated, .I am just going to be honest with you the Medical Director did not attend and was not called for the ad hoc meeting . Review of the Safe Smoking Screen dated 2/21/2022, revealed Resident #1 needed to use a smoking apron and required direct supervision while smoking. Observation on 5/10/2022 at 12:09 PM, revealed Resident #1 was seated outside on the Front Patio smoking a cigarette. Three other residents were also on the patio. There was no staff present. During an interview on 5/10/2022 at 12:13 PM, Receptionist #1 was asked if Resident #1 was allowed on the Front Patio. Receptionist #1 stated, .I didn't know he was out there. When asked if the Wander Guard alarm on the door had sounded, she stated, .It is busy here .I don't know how that happened . Review of a Nurses' Note dated 5/15/2022, revealed .This writer walked pass [past] [room number] [Resident #1's room] and smelled smoke .upon entering the room I could smell smoke and observed the resident [Resident #1] standing by the window tossing something out of the open window .Resident became visible [visibly] upset and walked towards this writer with fist balled up in a threatening attempt to fight . Review of Resident #3's Nurses' Notes dated 4/28/2022, revealed a Certified Nursing Assistant (CNA) saw Resident #3 hitting Resident #2 in the head with Bible. Review of Resident #3's Nurses' Notes dated 4/28/2022 at 6:40 PM, revealed .This nurse enter [entered] resident room an ask [asked] what happen [happened], resident stated He [Resident #2] enter [entered] my room an [and] I try [tried] to get him out. This nurse ask [asked] resident if she allegedly hit resident, resident stated No . During an interview on 5/11/2022 at 12:00 PM, the DON was asked what behaviors Resident #2 exhibited prior to the resident-to-resident altercation. She stated, .I don't know . When asked if staff were interviewed about the resident's behaviors prior to the altercation. She stated, .No . Review of Resident #4's Nurses' Notes dated 5/5/2022 at 1:11 PM, revealed, Resident #4 stated Resident #2 came into her room while she was sleeping during the night. She was sleeping on her right side facing the window, felt the mattress moving, and a knee was on her leg. She told him he was in the wrong room and pushed him out her bed and he fell on to the floor. Review of Resident #4's Nurses' Note dated 5/8/2022 at 6:31 AM, revealed Resident #4 called on the unit phone stating Resident #2 had entered her room. She was upset and stated this is the second time this has happened, and they said he would be watched. The nurse ensured the resident that Resident #2 would be watched and would not return to her room. During an interview on 5/10/2022 at 3:57 PM, Registered Nurse (RN) #2 was asked what interventions were implemented after the 4/28/2022 altercation of Resident #2 with Resident #3. She stated, .we did hourly safety checks . When RN #2 was shown the date of onset for hourly safety checks was 3/3/2022, she stated, .Oh I see nothing new . When she was asked what interventions were implemented after the 5/5/2022 altercation of Resident #2 with Resident #4, she stated, .continue hourly safety checks .supposed to have close supervision .to be honest we failed to supervise him . During an interview on 5/11/2022 at 12:00 PM, the DON was asked what behaviors Resident #2 exhibited prior to the resident-to-resident altercation. She stated, .I don't know . When asked if staff were interviewed about the resident's behaviors prior to the altercation. She stated, .No . Review of Resident #5's Nurses' Notes dated 11/29/2021 at 10:05 PM, revealed a CNA reported to the nurse that Resident #5 was drinking liquor in his room. An empty bottle of Vodka was confiscated from his shoebox. Resident #5 denied drinking, but the nurse observed the resident exhibited behavior of being loud, using inappropriate language, and had an unsteady gait. Review of the Incident Report and Nurses' Notes dated 2/9/2022, revealed Resident #5 initiated physical and verbal aggression against Resident #1 in the Lobby of the Nurses' Station. Resident #5 got out of his wheelchair talking loudly and accusing Resident #1 of stealing from him and then forcibly pushed Resident #1 to the floor near the window causing Resident #1 to hit his head against the wall. During a telephone interview on 5/13/2022 at 2:57 PM, Licensed Practical Nurse (LPN) #4 stated, .I reported him [Resident #5] drinking to the Administrator and the Director of Nursing back in November 2021. I told them about the empty Vodka bottle, and he may have been under the influence. Loud and talking a lot and a shift in his behavior . During an interview on 5/13/2022 at 3:35 PM, the Administrator was asked about the 11/29/2021 incident of finding an empty bottle of alcohol in Resident #5's room and the behaviors he exhibited and were documented in a Nurses' Note dated 11/29/2021. When asked if the incident was investigated, the Administrator stated, .No, it was never brought to my attention .No, we never investigated it . Refer to F-600, F-610, F-689 and F-835. The surveyors verified the Removal Plan by: 1. Resident #1 was placed on 15-minute checks until 10:00 PM on 5/13/2022, then hourly checks ongoing. A staff member was placed outside Resident #1's room to monitor the resident's location. Staff will escort residents out to smoke. Resident #1's BIMS was reassessed on 5/13/2022. The Family Nurse Practitioner reevaluated Resident #1 on 5/13/2022. Preadmission evaluation will be updated to reflect Resident #1's status. The Care Plan was updated with new interventions. Resident #2 was discharged on [DATE]. This was confirmed by observations, record review, and interviews. 2. Residents with Brief Interview for Mental status (BIMS) scores of 8 or above will be interviewed for abuse or potential for abuse. Residents with a BIMS below 8 will have a skin assessment conducted. Smoking assessments were conducted on 100 percent (%) of residents 5/14/2022. This was confirmed by record review, audit tool review, and interviews. 3. On 5/14/2022 the Nursing Home Administrator and DON were educated by the Regional Director of Clinical Services on the QAPI process, to include systems review, and performance improvement process. This was confirmed by review of the education sign-in sheet and interviews. 4. 100% of staff will be in-serviced by the DON, Nurse Supervisor, Staff Development Coordinator or department head on the abuse and elopement policy, prevention and reporting, and smoking policy. Abuse and neglect, smoking policy and elopement policy were reviewed. Staff not at work will be called and re-educated via phone. Staff that were not able to be educated will be educated prior to returning to work. In the event of any future resident exiting, the resident will be placed on 1 on 1 (1:1) supervision until primary care, nursing and psychiatric evaluations can be completed. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. During smoke break, 2 staff will supervise smoking break when there are more than 6 residents present. This was confirmed by review of revised smoking policy, review of the education sign-in sheets, and interviews on all shifts. 5. On 5/14/2022 the Nursing Home Administrator was educated on the role, job description, tools, and resources available to effectively administer nursing facility operations by the Regional Director of Clinical Services. This was confirmed by review of education sign-in sheets and interviews. 6. Nursing Home Administrator was educated on Abuse, Neglect, and Exploitation on 5/14/2022 by the Regional Director of Clinical Services. This was confirmed by review of the education sign-in sheet and interview. 7. The DON, nurse supervisor, or staff development coordinator will conduct abuse and neglect audits and smoking audits. The audits will include identifying residents with exit seeking behaviors and unsafe or unsupervised smoking daily x four (4) weeks, then three times per week x four (4) weeks, then two (2) x week x four (4) weeks, then weekly ongoing. This was confirmed by review of audit sheets and interviews on 5/17/2022. 8. Quality Assurance Performance Improvement (QAPI) meetings will occur weekly for four weeks to monitor progress and then monthly thereafter. This was confirmed by interviews. 9. The Regional Director of Operations or Regional Director of Clinical will provide oversight of facility administration with a weekly 1:1 interaction reviewing the completed audits and QA findings. The Plan of Correction will be reviewed weekly to ensure all the audits are completed and issues are identified for 4 weeks and/or until substantial compliance is achieved. Monthly QAPI meetings will be conducted and attended by Regional Director of Operations and Regional Director of Clinical for a period of three months to ensure compliance is sustained. This was confirmed by review of audit tools and interviews. 10. Results of all audits will be brought to the QAPI Committee members which include Committee Chairperson - Administrator; Director of Nursing; Assistant Director of Nursing; Medical Director; Dietary Director; Pharmacy Representative; Social Services Director; Activities Director; Environmental Director/ Safety Representative; Infection Control Representative/Staff Development Coordinator; Rehabilitation Director; and Medical Records Director for 4 months for further suggestions and/or follow up as needed. The DON, Assistant Director of Nursing (ADON), Multi Data Set Nurse, Nurse Supervisor, or Staff Development Coordinator will review the outcome of the abuse and neglect audit monthly and ongoing. Any aberrancies will be addressed, interventions developed, and corrective actions taken. This was confirmed by review of the revised QAPI tool and interviews. The facility's noncompliance of F-867 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, review of facility investigation statement, medical record review, observation, and interview, the facility neglected to provide adequate supervision to prevent elopement for 1 of 6 sampled residents (Resident #1) reviewed for elopement/wandering behaviors and neglected to prevent resident-to-resident abuse for 2 of 5 sampled residents (Resident #2 and #4) reviewed for abuse. The facility's failure to provide adequate supervision and to prevent resident-to-abuse resulted in Immediate Jeopardy when Resident #1, a cognitively impaired resident who was at risk for wandering, eloped from the facility, and walked approximately 1 mile from the facility, crossed 6 lanes of high-volume traffic at a main intersection and got into a car with a passing motorist. The resident was found by a family member in a neighborhood known for drug deals. Resident #1 was unsupervised out of the facility for approximately 14 hours. Resident #2 entered Resident #4's room on 2 different occasions, resulting in resident-to-resident altercations between the residents. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Regional Director of Clinical Services, the Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 5/13/2022 at 6:30 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-600. The facility was cited Immediate Jeopardy at F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed from 2/20/2022 through 5/16/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 5/14/2022 at 1:44 PM, and the corrective actions were validated onsite by the surveyors on 5/17/2022 through policy review, medical record review, observation, review of education records, and staff interviews. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 3/3/2022, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect .'Neglect' means failure of a facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .Establish policies and procedures to investigate any such allegations . Review of the facility's undated policy titled, Elopements and Wandering Residents, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had impaired cognition, impaired vision, an unsteady gait, required physical assistance for balance with transfers, and had range of motion impairment in the upper and lower extremities on one side of the body. Review of the Elopement/Wandering Risk Assessments revealed the following: a. On 10/2/2021, the admission assessment, Resident #1 scored a 4, which indicated a low risk. b. On 2/20/2022, Resident #1 scored a 9, which indicated a moderate risk. Review of an Incident Report dated 2/20/2022, revealed that the receptionist received a call from Licensed Practical Nurse (LPN) #1 who had worked the 7:00 AM to 7:00 PM shift on 2/20/2022 and was on her way home, stating she thought she saw a third-floor resident on a Named Street. LPN #1 stated the resident's name (Resident #1), staff checked to see if he was in the facility, and he was not. Staff in the building searched for the resident without success. Review of a Social Service Progress Note dated 2/21/2022 at 9:15 AM, revealed that Resident #1 returned to the facility in a family's car with his sister and daughter at his side. Resident #1 ambulated to the door of the facility with an unsteady gait. Resident #1 refused assistance from staff and family as he entered the building. Review of a typed statement dated 2/21/2022 from a resident who witnessed Resident #1 exit the building revealed He went out the front door around the brick and I couldn't see him anymore . Review of the Fall Scale Risk assessment dated [DATE], revealed Resident #1 was a high risk for falling, had previous falls, and had a weak gait. During an interview on 5/11/2022 at 11:15 AM, when asked what interventions were implemented after the elopement incident, the DON stated, .family was agreeable to a Wanderguard [a sensor alarm system worn by residents to alert staff if a resident attempts to exit through monitored exit doors], family was to pick him up twice a week [the family member stated in an interview that they had told the facility they could not come every week]. He was 1 on 1 [1:1] with a CNA [Certified Nursing Assistant] .involve in more activities . When asked if his family takes him out twice weekly, the DON stated, I don't know .I guess they do .I don't know. Observation on 5/11/2022 at 1:22 PM at the side of the building near the designated Smoking Area, revealed the side door was propped open with a 5-gallon water dispensing bottle and at the end of the sidewalk there was an open gate to the parking lot. During an interview on 5/11/2022 at 1:52 PM, the DON was asked if a resident could exit the building, go through the open door, and go onto the parking lot through the open gate. The DON stated, That door should not be open. It goes to where they are working in therapy. Construction guys left the gate open .It goes to the parking lot. During an interview on 5/11/2022 at 2:13 PM, the Administrator was asked if a resident could leave the building through the therapy department which was under construction. The Administrator stated, They could walk right out and go through the gate and right to the parking lot. When asked if the building was secure, the Administrator sated, I see what you mean. No, it's not. I thought the construction crew knew to keep the door locked . Observation at the Chapel Exit Door on 5/12/2022 at 11:43 AM, revealed the door from the Chapel to the parking lot was not secured. The door opened after pushing on the door for 15 seconds. No alarm sounded. The door did not lock after it was closed. During an interview on 5/12/2022 at 11:46 AM, the Maintenance Director was asked if the exit door in the Chapel was secure. The Maintenance Director stated, I don't know what's wrong. Looks like no power to the door. The alarm should sound. It's not working . Observation on 5/12/2022 at 1:45 PM, revealed Resident #1 walked out of the Lobby onto the Front Patio. The Wanderguard alarm sounded when the resident walked through the door. The receptionist was on the telephone at the desk. No staff responded to the sounding alarm. Observation on 5/12/2022 at 2:34 PM, 5/13/2022 at 2:00 PM, and 5/14/2022 at 1:55 PM, revealed the following: a. 1st floor - Exit door at the northeast side of the building was not secure and the double doors at the north end of the building were not secured. The door to the therapy department had an alarm that was disabled, the side door on the hallway under construction opened to the parking lot and was not secured, doors to the stairs to go to the 2nd floor were not secured b. 2nd floor - the doors to the staircase from the 1st floor to the 3rd floor were not secured, the door at the staircase at the west end of the 200 Hall accessed easily to enter the designated outside Smoking Area. c. 3rd floor - the doors to 2 staircases from the 2nd and 4th floor were not secured. d. 4th floor - the 2 doors to the staircases from the 3rd floor were not secured. e. The stairwells on the 2nd, 3rd, and 4th floors on the northeast side of the building that led to the 1st floor exit door and into a foyer with an exit door that was unlatched and led to the employee parking lot. During a telephone interview on 5/13/2022 at 11:28 AM, LPN #1 was asked about Resident #1's elopement. LPN #1 stated, .I remember he [Resident #1] came to the desk on the 3rd floor. He was standing alone and not in his usual dress. He was wearing new white tennis shoes, a new gray heavy winter jacket, new clothes, and sweatpants. I asked where he was off to and he was going to smoke. He just giggled .I maybe left [left the facility] about 7:30 [PM]. I was headed up [Named Street]. He was on my right side at the light [traffic light]. He was crossing to go toward the median [on left, across 6 lanes]. He slapped the hood of my car .I opened my door and he sped up .I was afraid he would fall .I saw a navy bluish or black car. He got in .I lost sight of the car .I pulled over and called back to the building about 8 [8:00 PM] and spoke with the receptionist. She told me no resident was missing .[Named nurse] called me at home about an hour later and said he [Resident #1] was missing . During a telephone interview on 5/16/2022 at 11:08 AM, a family member of Resident #1 was asked about the resident's elopement. The family member stated, .They [staff] called me at 8:16 PM and was saying they didn't know where he was. They said they last saw him at 7:05 [PM]. I thought someone watched that front door. I asked how did you let a man that walks slow with a limp get out of your sight .Next morning my mom called me and said my cousin had found him in [Named] neighborhood where he [Resident #1] used to do drugs .I brought him back. He didn't seem to be on any drugs, seemed the same . When asked what interventions the facility put in place to prevent elopement from happening again the family member stated, .They put a thing [Wanderguard] on his leg .I told them I can't come every week . During a telephone interview on 5/17/2022 at 11:36 AM, Registered Nurse (RN) #1 was asked about Resident #1's elopement. RN #1 stated, .The receptionist asked me if I would watch the desk while she took them [residents] out to smoke at 7:00 PM. I was at the desk telling visitors to sign in and log in and I was on the phone .About 7:15 he [Resident #1] came to me and put some change on the counter. I told him I didn't have any money .He walked away .that is the last I saw him. It was a busy time with the visitors coming in and the phone calls . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #2 scored a 7 on the Brief Interview for Mental Status (BIMS) scale, which indicated the resident had severe cognitive impairment for decision making. The functional status revealed locomotion on the unit was per wheelchair with oversight. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #4 scored a 15 on the BIMS scale, which indicated the resident was cognitively intact for decision making. Review of Resident #4's Nurses' Note dated 5/5/2022 at 1:11 PM, revealed .Ms [Named Resident #4] stated a male resident [Resident #2] came into her room while she was sleeping overnight. She was sleeping on her right side facing the window, she felt the mattress moving and a knee was on her leg. He [Resident #2] didn't touch her upper body. She thought it was her roommate; however, she turn [turned] to the left and saw a white man. She said to him Wrong Bed/Wrong Room and the male resident repeated what was said to him. She push [pushed] him out her bed and he fell on to the floor. He was reaching for help, and she refuse [refused] to help him due to her being fearful of falling and hurting herself. She push [pushed] the call light for help but staff didn't respond. So, both her and the male resident [Resident #2] was screaming and hollowing [hollering] loud .before staff came to assist and remove [removed] male resident from her room . Review of Resident #2's Nurses' Note dated 5/5/2022 at 8:06 PM, revealed .Late entry: this AM @ [at] 02:15 [2:15 AM] Resident [#2] wanders into [room number] [Resident #4's room]. The staff CNA answered call light in [room number] [Resident #4's room] and noted resident [#2] on floor in between Bed A and bed B at the foot. Resident [#2] in sitting position in front of w/c chair [wheelchair]. Resident [#2] was placed in wheelchair taken to his room [room number]. Resident [#2] assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Nurses' Note dated 5/8/2022 at 6:31 AM, revealed, .Patient called on the unit phone stating another resident [Resident #2] had entered her room. The patient was upset and stated this is the second time this has happened, and they said he would be watched. I explained to the patient that I was unaware of the situation and would ensure that the male [Resident #2] did not return to her room. Patient stated I'm reporting this because this is unacceptable .I again assured the patient that I would keep close watch on the male [Resident #2] and make sure he does not enter her room again . During an interview on 5/10/2022 at 3:45 PM, Resident #4 confirmed the Nurses' Notes dated 5/5/2022 at 1:11 PM and 5/8/2022 at 6:31 AM. She stated, .this man [Resident #2] came into my room [5/5/2022] and attempted to get in bed with me. I was turned on my right side facing the window when I felt a knee on my leg and the bed moving. I rolled over to see what was happening and this white man was trying to get into my bed. I yelled and instinctively pushed him back and he lost his balance and fell on to the floor. I started yelling Help and he would repeat everything I said help but in a weaker voice. I pushed the call light no answer by staff, and we continued to yell until staff came in .They told me oh, that is Mr. [Named Resident #2] and he wanders that is just what he does. I said no, that is not ok .Then a few days later [5/8/2022] he came into my room again. I picked up the phone and called the facility. They came in and got him. I told that nurse about what had happened before, and that agency nurse said she didn't know anything about him. I said ya'll told me you would watch him . During an interview on 5/10/2022 at 3:57 PM, RN #2 was asked what interventions were implemented after the 5/5/2022 altercation of Resident #2 and Resident #4, she stated, .continue hourly safety checks .supposed to have close supervision .to be honest we failed to supervise him . During an interview on 5/11/2022 at 12:00 PM, the DON was asked what behaviors Resident #2 exhibited prior to the resident-to-resident altercation. She stated, .I don't know . When asked if staff were interviewed about the resident's behaviors prior to the altercation, she stated, .No . Refer to F-610 and F-689. The surveyors verified the Removal Plan by: 1. Resident #1 was placed on 15 minutes checks until 10:00 PM on 5/13/2022, then hourly checks that were ongoing. A staff member was assigned to monitor the resident's location and movements daily. A staff member escorts the resident out to smoke during smoke break. The resident's BIMS was reassessed on 5/13/2022. The Family Nurse Practitioner reevaluated the resident on 5/13/2022. The Preadmission evaluation was updated to reflect Resident #1's current status on 5/13/2022. All exit doors were checked for functioning on 5/13/2022. There were no concerns noted. Resident #2 was discharged on [DATE]. This was confirmed by record review, report review, and interviews on all shifts. 2. Resident with BIMS scores of 8 or above were interviewed for abuse or potential for abuse by 5/14/2022. Residents with a BIMS below 8 will have a skin assessment conducted by 5/14/2022. Elopement assessments were conducted on all residents on 5/14/2022 by Social Services and the Nursing Supervisors. This was confirmed by record review and interviews on all shifts. 3. 100 percent (%) of staff were in-serviced by the DON, Nurse Supervisor, Staff Development Coordinator or department head on the abuse, neglect and exploitation policy, the elopement and wandering resident policy, prevention, and reporting. Staff not at work will be called and re-educated via phone. Staff that were not able to be educated will be educated prior to returning to work. Care Plans were updated with new interventions. In the event of any future resident exiting, the resident will be placed on 1:1 supervision until primary care, nursing and psychiatric evaluations can be completed. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. This was confirmed by review of the education sign in sheets, record review, and interviews on all shifts. 4. The Interdisciplinary Team (IDT) meeting was held to review results of BIMS, abuse interviews, skin assessments, and elopement assessments on 5/14/2022. This was confirmed by review of the sign-in sheets, audit review, and interviews with the IDT. 5. The Facility System changes included: a. Review progress notes daily during morning clinical meeting for trigger words. Any triggers will be reported to the Administrator immediately and the licensed nursing home Administrator makes the initial report to the State of Tennessee via URIS 3.0 system and completes the investigation within 7 days. b. Quality Assurance Performance Improvement (QAPI) meetings will occur weekly for four weeks to monitor progress and then monthly thereafter. c. The Maintenance Supervisor will check all doors for functionality daily for 4 weeks, then weekly ongoing. These changes were confirmed by review of records, reports, sign-in sheets, audit sheets, and interviews on all shifts. 5. The DON, Nurse Supervisor, or Staff Development Coordinator will conduct abuse, neglect, and elopement audits. The audits will include identifying residents with exit seeking behavior daily for 4 weeks, then 3 times per week for 4 weeks, then 2 times week for 4 weeks, and then weekly ongoing. This was confirmed by review of audit sheets and interviews on all shifts. 6. The DON or Staff Development Nurse will report findings of the abuse, neglect, and elopement audits to the monthly QAPI Committee. The members include the Committee Chairperson - Administrator; DON; Assistant Director of Nursing (ADON); Medical Director; Dietary Director; Pharmacy Representative; Social Services Director; Activities Director; Environmental Director/Safety Representative; Infection Control Representative/Staff Development Coordinator; Rehabilitation Director; and Medical Records Director. This will continue for 4 months for further suggestions and/or as follow up is needed. The DON, ADON, Multi Data Set Nurse, Nurse Supervisor, or Staff Development Coordinator will review the outcome of the abuse and neglect audits monthly and ongoing. Any aberrancies will be addressed, interventions developed, and corrective actions taken. This was confirmed by review of the QAPI tool and interviews of QAPI members. The facility's noncompliance of F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on policy review, medical record review, and interview, the facility failed to report an allegation of resident-to-resident abuse and failed to timely report an allegation of resident-to-resident abuse to the State Survey Agency for 4 of 5 (Resident #1, #2, #4 and #5) sampled residents. The findings include: Review of the facility's policy Abuse, Neglect and Exploitation revised 3/22/2022, revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 5 on the Brief Interview of Mental Status (BIMS) scale, which indicated the resident had severe cognitive impairment for decision making. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 scored 15 on the BIMS scale, which indicated the resident was cognitively intact for decision making. Review of the Incident Report dated 2/9/2022 at 6:31 PM, revealed .This resident [Resident #5] initiated physical and verbal aggression against another resident [Resident #1] in the lobby area of the nurse's station to resident [Resident #1]. This resident [Resident #5] got out of his wheelchair as he was talking loudly and accusing the resident [Resident #1] of stealing approached Mr. [Named Resident #1] then forcibly pushed the resident [Resident #1] down to the floor near the window causing the resident [Resident #1] to hit his head against wall. This incident was witnessed per nurses . Review of Resident #5's Nurse's Note dated 2/9/2022 at 6:40 PM, revealed .Resident [#5] became verbally and physically abusive toward another resident [Resident #1] pushed another resident [Resident #1] down to the floor. The Administrator and DON was notified. The DON is present and spoke with the resident about incident .Resident [#5] reported to [Named Police Department] he had been drinking . Review of Resident #5's Nurse's Note dated 2/10/2022 at 3:24 AM, revealed .This resident [Resident #5] was physically aggressive toward another resident in the common, lobby area near nurses' station on 4th floor. This resident [Resident #5] rolled up toward the resident [Resident #1] cursing and accusing resident of stealing. Stood up and walk toward the other resident [Resident #1] then forcibly shove [shoved] him down to the floor causing the other resident [Resident #1] to hit the back of his head against the wall at the base of the window . Review of the radiology x-ray skull series report dated 2/10/2022, revealed Resident #1 had .no acute fracture .conclusion normal skull series . Review of Resident #1's Nurse's Note dated 2/9/2022 at 6:38 PM, revealed .This nurse observed an altercation between resident [Resident #5] and resident [Resident #1]. The resident [Resident #5] was following [Resident #1]. [Resident #5] was in his wheelchair, he was coming down hallway stating that the resident [Resident #1] He stole something from me. He know [knows] he stole from me. This nurse attempted to keep the two apart. [Resident #5] stood up from his wheelchair and pushed [Named Resident #1] into the window .[Resident #1] fell and struck his head. [Resident #1] was transferred from the floor unto the chair .Police discovered from the resident [Resident #5] that they had been drinking in the room. Resident [#1] was re-assigned to another room temporarily until crisis over . During an interview on 5/13/2022 at 3:35 PM, the Administrator was asked about the incident of resident to resident abuse on 2/9/2022 and if the incident was reported to the State as required for resident-to-resident abuse. She stated, .No we didn't report the altercation to the State. I thought someone else was going to do it and no one did . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #2 scored a 7 on the BIMS scale, which indicated the resident had severe cognitive impairment for decision making. The functional status revealed, locomotion on the unit was per wheelchair with oversight and set up help only. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS assessment dated [DATE], revealed Resident #4 scored 15 on the BIMS scale, which indicated the resident was cognitively intact for decision making. Review of Resident #4's Nurse's Note dated 5/5/2022 at 1:11 PM, revealed .Ms [Named Resident #4] stated a male resident [Resident #2] came into her room while she was sleeping overnight. She was sleeping on her right side facing the window, she felt the mattress moving and a knee was on her leg. He [Resident #2] didn't touch her upper body. She thought it was her roommate; however, she turn [turned] to the left and saw a white man. She said to him Wrong Bed/Wrong Room and the male resident repeated what was said to him. She push [pushed] him out her bed and he fell on to the floor. He was reaching for help, and she refuse [refused] to help him due to her being fearful of falling and hurting herself. She push [pushed] the call light for help but staff didn't respond. So, both her and the male resident [Resident #2] was screaming and hollowing [hollering] loud .before staff came to assist and remove male resident from her room. Resident also stated she's not violent . Review of a Nurse's Note dated 5/5/2022 at 8:06 PM for Resident #2 revealed .Late entry: this AM @ [at] 02:15 [2:15 AM] Resident [Resident #2] wanders into room [Resident #4's room]. The staff CNA [Certified Nursing Assistant] answer [answered] called [call] light in [room number] [Resident #4's room] and noted [Resident #2] on floor in between Bed A and bed B at the foot. [Resident #2] in sitting position in front of w/c chair [wheelchair]. [Resident #2] was placed in wheelchair taken to his room [room number]. [Resident #2] assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/10/2022 at 3:45 PM, Resident #4 confirmed the incident on 5/5/2022 at 1:11 PM documented in the Nurses' Note and the Nurses' Note dated 5/8/2022 at 6:31 AM. She stated, .this man came into my room [5/5/2022] and attempted to get in bed with me. I was turned on my right side facing the window when I felt a knee on my leg and the bed moving. I rolled over to see what was happening and this white man was trying to get into my bed. I yelled and instinctively pushed him back and he lost his balance and fell on to the floor. I started yelling Help and he would repeat everything I said help but in a weaker voice. I pushed the call light no answer by staff, and we continued to yell until staff came in .They [staff] told me oh, that is Mr. [Named Resident #2] and he wanders that is just what he does. I said no, that is not ok .Then a few days later [5/8/2022] he came into my room again. I picked up the phone and called the facility. They came in and got him. I told that nurse about what had happened before and that agency nurse said she didn't know anything about him. I said ya'll told me you would watch him . Review of the facility's report submitted to the State Agency related to the resident to resident abuse allegation between Resident #2 and Resident #4 revealed the received the report was dated 5/5/2022 at 3:38 PM. The date the occurrence happened at the facility was 5/5/2022 at 2:15 AM. During an interview on 5/13/2022 at 3:35 PM, the Administrator confirmed the resident to resident altercation between Resident #2 and Resident #r occurred on 5/5/2022 at 2:15 AM and the report was not sent until 5/5/2022 at 3:38 PM. She stated, .It was late .

Based on policy review, job description review, record review, medical record review, observation, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to safe individualized resident care when the staff failed to provide the ordered modified diet meal, failed to provide assistance with meals, and failed to ensure nursing staff followed the facility process for identifying residents during the delivery of the meal trays. The facility failed to ensure the QAPI committee reviewed and validated systemic problems and determined a system was in place to ensure nursing staff had the knowledge and skills necessary to assure safety and provide individualized care for 9 of 12 sampled residents (Resident #1, #2, #5, #7, #8, #9, #10, #11, and #12) reviewed that required modified and therapeutic diets and/or required assistance with meals. The facility's failures resulted in Immediate Jeopardy when Resident #1, a cognitively impaired resident who required assistance eating, was fed a regular diet instead of the ordered pureed (a texture modified diet in which all foods have a soft, pudding like consistency) diet and the resident was left unattended after feeding the resident bites of solid food. Resident #1 was found unresponsive, a portion of a hotdog was removed with forceps by Emergency Medical Services (EMS) attendants, and Resident #1 expired in the emergency room (ER). The facility's failures resulted in Immediate Jeopardy for Resident #2, #5, #7, #8, #9, #10, #11, and #12 when these residents required modified diets and/or assistance with meals and staff did not follow the process for identifying residents during delivery of the meal trays. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Interim Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on [DATE] at 6:50 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-600, F-689, F-726, F-835, and F-867. The facility was cited F-600 at a scope and severity of J, and F-689 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy was received on [DATE] at 2:26 PM. The corrective actions were validated onsite by the surveyors on [DATE] through observation, review of audits and meeting minutes, and staff interviews. The findings include: Review of the facility's policy titled, Quality Assurance Performance Improvement Plan, revised [DATE], revealed .The purpose of QAPI in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents .To do this, all employees will participate in ongoing QAPI efforts which support our mission by enhancing quality of life by nurturing individuality and independence .The QAPI program at [Named Management Company] will aim for safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident's agents), by ensuring our data collection tools and monitoring systems are in place and are consistent for a proactive analysis .The governing body assures adequate resources exist to conduct QAPI efforts .[Named Management Company] company's facilities governing body is ultimately responsible for overseeing the QAPI Committee. The president has direct oversight responsibility for all functions of the QAPI Committee and reports directly to the governing body. The QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction .Feedback systems will actively incorporate input from staff, residents, families, and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigating, and monitoring adverse events/medical errors every time they occur, and action plans implemented through the Plan Do Study Act (PDSA) and Root Cause Analysis to prevent recurrences .The QAPI team at [Named Management Company] facilities will review our sources of information to determine if gaps or patterns exist in our systems of care that could result in quality problems; or if there are opportunities to make improvements .[Named Management Company] facilities use a systematic approach to determine when in-depth analysis is needed to fully understand the problem, its causes, and implications of a change . Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised ,d+[DATE], revealed .It is the policy of this facility to provide protection for the health, welfare and rights of each resident .'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .The facility will develop and implement written policies and procedures that: .d. establish coordination with the QAPI program .The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written . Review of the Administrator job description dated ,d+[DATE], revealed .Lead and direct the overall operations of the facility in accordance with customer needs . with focus on maintaining excellent care for the residents .Oversee regular rounds to monitor delivery of nursing care .and ensure resident needs are being addressed .Responsible for the QA [Quality Assurance] program .Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services . Review of the EMS Prehospital Patient Record dated [DATE], Emergency Department (ED) Physician Documentation dated [DATE], and the facility's investigation revealed CNA #20, an Agency CNA, served Resident #1 another resident's supper tray, which was a regular diet instead of the ordered pureed diet. Resident #1 was found unresponsive, a portion of a hotdog was removed from the resident's airway with forceps by the Emergency Medical Services (EMS) attendants, and Resident #1 expired in the hospital ER. Observations were made on [DATE] and [DATE] during meal tray delivery that revealed staff did not verify residents were the right residents by comparing the meal card pictures of the residents, did not identify residents with their armbands nor did staff ensure all residents had arm bands for identification purposes and staff did not ensure residents received the correct physician ordered meals. These residents observed were residents which required assistance with eating and/or modified/therapeutic diets. During an interview on [DATE] at 1:01 PM, the Administrator stated, .There is no routine or QA [Quality Assurance] to audit armband compliance . During an interview on [DATE] at 1:24 PM the Administrator was asked what her role in the QAPI program was and she stated, Had always been overseen by the DON .QA [quality assurance] reports were kept in the DON's office in a binder. When the Administrator was asked if the facility's audit included the identifier of the arm band, she stated, .No, it does not . The Administrator was asked where the facility documented the collection of the data and observations of the staff verifying the meal card picture with the name of the resident and the armband when delivering the resident's meal tray to be certain the correct resident receives the correct tray. The Administrator stated .There is no documentation we are auditing that .I would have to have faith they [staff] did what [they] was supposed to do . During a telephone interview on [DATE] at 3:00 PM, when asked if the facility had identified the root cause of the incident of Resident #3 when she was served the incorrect ordered meal, the Chief Operating Officer stated, .isolated freaky accident . Refer to F-600, F-689, and F-726. The surveyors verified the Removal Plan by: 1. On [DATE] an Ad Hoc (as needed) QAPI meeting was conducted with the Administrator, DON, Unit Managers, Regional Director of Operations, and Area Director of Clinical Services to discuss this event. The surveyors reviewed the minutes and interviewed the QAPI members. 2. On [DATE], the Administrator was educated on QAPI as it relates to self-identifying, monitoring and correcting in-house process issues, to include bringing identified issues to the committee for review, revision, and monitoring. The surveyors confirmed this by reviewing the education review and an interview with the Administrator. 3. On [DATE], the Nursing Home Administrator and Interim DON were educated by the Area Director of Clinical Services regarding the QAPI process to include systems review and Performance Improvement Process. Results of audits will be brought to the QAPI committee meetings and will be reviewed and discussed with the members of QAPI, which include the Administrator, DON, Unit Managers, Medical Director, Social Services, Activities Director, Maintenance, and the Dietary Managers. The surveyors reviewed the education and interviewed the Administrator and Interim DON. The facility's noncompliance at F-867 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, record review, medical record review, observation, and interview, facility Administration failed to administer the facility in a manner to provide oversight, to monitor and provide a safe environment related to identification of residents when delivering the meal trays, and failed to ensure nursing staff had the knowledge and skill sets necessary to assure safety and provide individualized resident care for 9 of 12 sampled residents (Resident #1, #2, #5, #7, #8, #9, #10, #11, and #12) reviewed that required modified or therapeutic diets and/or required assistance with meals. These failures resulted in Immediate Jeopardy when Resident #1 was fed a regular diet instead of the pureed (a texture modified diet in which all foods have a soft, pudding like consistency) diet that was ordered and an Agency Certified Nursing Assistant (CNA) left the resident unattended after feeding the resident a piece of a hotdog. Resident #1 was found unresponsive, a portion of a hotdog was removed from the resident's airway with forceps by the Emergency Medical Services (EMS) attendants, and Resident #1 expired in the emergency room (ER) at a local hospital. The facility's failures resulted in Immediate Jeopardy for Resident #2, #5, #7, #8, #9, #10, #11, and #12 when these residents required modified diets and/or assistance with meals and staff did not follow the process for identifying residents during delivery of the meal trays. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on [DATE] at 6:50 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-600, F-689, F-726, F-835, and F-867. The facility was cited F-600 at a scope and severity of J, and F-689 at a scope and severity of K, which is Substandard Quality of Care. The Immediate Jeopardy was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 2:26 PM, and was validated onsite by the surveyors on [DATE] through medical record review, observation, review of education provided to staff members, audits, and staff interviews. The findings include: Review of the facility's policy titled, Administration of Facility, dated [DATE], revealed .This facility will provide policies and systems to ensure that it is administered in a manner that will focus on attaining and maintaining the highest practicable physical, mental, and psychosocial well-being of each resident .The facility will employ professionals necessary to carry out the provisions of requirements . Review of the Administrator Job Description dated ,d+[DATE] revealed .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Essential Duties & [Symbol for and] Responsibilities: .management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .Lead the facility management staff and consultants in developing and working from the business plan that focuses on all aspects of facility operations, including setting priorities and job assignments .Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed .Oversee regular rounds to monitor delivery of nursing care .and ensure resident needs are being addressed .Responsible for the QA [Quality Assurance] program .Manage turnover and solidify current and future staffing through development of recruiting sources, and through appropriate selection, orientation, training, staff education and development .Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services . The DON job description was requested on two separate occasions but was not submitted to the surveyors as requested. The facility's policy titled, Abuse, Neglect and Exploitation, revised ,d+[DATE] revealed .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .The facility will make individual determination in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment .The facility will provide ongoing oversight and supervision of staff in order to assure that it's policies are implemented as written .The facility will make individual determination in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment . Review of employee personnel files revealed that CNA #4, #6, and #13 and Agency CNA #19 and #20 had no documentation of a competency evaluation for the employees, no documentation of the employee's skills, or orientation of the employees to the facility processes and protocols related to the individual care of residents needing assistance with activities of daily living which included eating and modified diets. There was no documentation the CNAs or the Agency CNAs were determined to be competent to provide care for the residents in the facility. Review of the EMS Prehospital Patient Record dated [DATE], Emergency Department (ED) Physician Documentation dated [DATE], and the facility's investigation revealed CNA #20, an Agency CNA, served Resident #1 another resident's supper tray, which was a regular diet instead of the ordered pureed diet. Resident #1 was found unresponsive, a portion of a hotdog was removed from the resident's airway with forceps by the Emergency Medical Services (EMS) attendants, and Resident #1 expired in the ER of a local hospital. Observations were made on [DATE] and [DATE] during meal tray delivery that revealed staff did not verify residents were the right residents to the meal card pictures of the residents, did not identify residents with their armbands nor did staff ensure all residents had arm bands for identification purposes and staff did not ensure residents received the correct physician ordered meals. These residents observed were residents which required assistance with eating and/or modified/therapeutic diets. During an interview on [DATE] at 1:01 PM, the Interim DON stated, .We had no policy for identification and meal pass .After the incident [on [DATE]] we put into place the breakfast, lunch and dinner meal pass process and audit .The staff deliver the tray to the room and verify the meal card against the resident's arm band . When asked if every resident had an armband, the DON stated, .They should . During an interview on [DATE] at 1:20 PM, the Administrator was asked how staff identified residents. She stated, .I have to have confidence the audit tool that was done on the 8th [[DATE]] is correct .I would have to assume that she [Unit Manager] identified the resident. I would have faith that she did it correctly . During an interview on [DATE] at 1:24 PM, the Administrator was asked when she received notification of the event involving Resident #1. The Administrator stated, .I was at home. I received notification she [Resident #1] received an incorrect tray and was transported to the hospital .the CNA [Agency CNA #20] didn't properly identify the meal tray with the resident .She left the room, then went back into the room, then called for help . The Administrator was asked if the facility had an orientation program for contract staff. The Administrator stated, .The DON was the point of contact for the agency staffing . When asked if she was involved in the orientation of newly hired employees and contract staff, the Administrator stated, No, not right now. When the Administrator was asked what her role in the QAPI program was, she stated, Had always been overseen by the DON .QA [quality assurance] reports were kept in the DON's office in a binder. When the Administrator was asked if the facility's audit included the identifier of the arm band, she stated, .No, it does not . The Administrator was asked where the facility documented the collection of the data and observations of the staff verifying the meal card picture with the name of the resident and the armband when delivering the resident's meal tray to be certain the correct resident receives the correct tray. The Administrator stated .There is no documentation we are auditing that .I would have to have faith they [staff] did what [they] was supposed to do . During an interview on [DATE] at 2:37 PM, the Interim DON stated she had received the contract employee files from the staffing agency. When asked if the files contained the education and competency of each CNA, the Interim DON shook her head no. During an interview on [DATE] at 3:30 PM, the Interim DON stated, .The pictures [on the meal card] are grainy .I didn't realize how many of our residents wore hats in their pictures and so many of them [residents] look alike .We need to see if dietary system can print the pictures clearer like they are in [Named Electronic Healthcare Software] . During an interview on [DATE] at 1:35 PM, the Interim DON confirmed there were no contract employee files validating any orientation or competency checks in the facility or at the agency. The Administrator and the Interim DON were unable to present any employee personnel files or contract personnel files that contained the employee's competency determination. The facility did not have any Agency employee personnel files. Refer to F-689 and F-726 The surveyors verified the removal Plan by: 1. On [DATE], the Regional Director of Operations (RDO) educated the Administrator on the role of the Administrator, the job description, the tools and resources available to effectively administer nursing facility operations. The surveyors confirmed this through interviews with the RDO and the Administrator. 2. On [DATE], the Regional Director of Clinical Services educated the Administrator on the Accident Policy. The surveyors confirmed this by review of the education provided, interview with the Regional Director of Clinical Services and the Administrator. 3. On [DATE], the Administrator was educated by the RDO and the Regional Director of Clinical Services on the full orientation agenda/education required by all staff, both agency and full-time staff, prior to working at the facility. The surveyors confirmed this by reviewing the education provided, interview with the Regional Director of Clinical Services and the Administrator. 4. The Administrator was educated on Quality Assessment and Performance Improvement (QAPI) as it relates to self-identifying, monitoring and correcting in-house process issues. This included bringing identified issues to the committee for review, revision, and monitoring. The surveyors confirmed this through review of the education provided and interview with the Administrator. 5. Beginning [DATE], direct meal tray observations will be conducted by the Nurse Managers, Charge Nurses and other Nursing Managers. They will conduct direct observations of meal trays at each meal to ensure facility and agency staff are following the process for meal delivery to ensure the right tray with the right meal is being provided to the right resident and this is ongoing. The surveyors confirmed this through observation and interview. 6. The Administrator and/or designee will review results of the direct meal tray observations daily beginning [DATE] and this will be ongoing. The results will be presented to the QAPI committee for review, monitoring and discussion. The surveyors confirmed this through interview with the Administrator and review of the audit tool. 7. An agency orientation checklist was created on [DATE] by the DON and was provided to each unit for them to begin using immediately. This will be completed for all agency staff on their first shift and will include all the above policies and procedures. The Staff Development (SDC)/Unit Managers will ensure the orientation packet is completed prior to the start of the first shift in the facility. This process is overseen daily with each new agency staff person by the DON or designee beginning [DATE] and will be ongoing. Monitoring of agency staff performance will be conducted by Charge Nurses, Unit managers and other Nursing Management team members each shift. Any concerns with the agency staff member performance will be addressed and corrected immediately by the same facility staff person with input from the DON. The DON will have the overall responsibility of evaluating the performance of agency staff. The surveyors confirmed this through interview with the Staff Development (SDC)/Unit Managers and the Interim DON. 8. The RDO and Area Director of Clinical Services provide oversight of facility administration with a weekly 1:1 interaction reviewing the completed audits and QA findings. The plan of correction will be reviewed weekly to ensure all the audits are completed and concerns are identified for 4 weeks and/or until substantial compliance is achieved. The QAPI meetings will be conducted monthly and attended by the RDO and Area Director of Clinical Services for a period of three months to ensure compliance is sustained. The surveyors confirmed this through interview with the RDO, Area Director of Clinical Services, and the Administrator. The facility's noncompliance at F-835 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, medical record review, observation, and interview, the facility failed to ensure staff provided the ordered modified diet and provided the needed assistance with meals, failed to ensure necessary safe individualized resident care was provided, and failed to ensure nursing staff followed the facility process for identifying residents during delivery of meal trays for 9 of 12 sampled residents (Resident #1, #2, #5, #7, #8, #9, #10, #11, #12) reviewed that required modified diets and/or required assistance with meals. The facility's failure resulted in Immediate Jeopardy when Resident #1 was fed a regular diet instead of the prescribed pureed diet (a texture modified diet in which all foods have a soft, pudding like consistency) and the Agency Certified Nursing Assistant (CNA) left the resident unattended after feeding the resident. Resident #1 was found unresponsive and a portion of a hotdog was removed with forceps from the resident by Emergency Medical Services (EMS) attendants. Resident #1 expired in the emergency room (ER) of a local hospital. The facility's failures resulted in Immediate Jeopardy for Resident #2, #5, #7, #8, #9, #10, #11, and #12 when these residents required modified diets and/or assistance with meals and staff did not follow the process for identifying residents during the delivery of the meal trays. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Interim Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on [DATE] at 6:50 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of K which is Substandard Quality of Care. The Immediate Jeopardy was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 2:26 PM. The corrective actions were validated onsite by the surveyors on [DATE] through observation, review of audits and meeting minutes, and staff interviews. The findings include: Review of the facility's policy titled, Assistance with Meals, revised ,d+[DATE], revealed .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Facility staff will serve resident trays and will help residents who require assistance with eating. Residents who cannot assist themselves will be assisted with attention to safety, comfort and dignity . Review of the undated facility's policy titled, Consistency Modified Diets, revealed .Dysphagia [difficulty swallowing] is the impairment or loss of skills involved in swallowing foods and/or liquids .Pureed is the first consistency for solid foods that may be used after NPO [nothing by mouth] or liquid diets or for those with dysphagia. Puree consistency eliminates the need for chewing. All foods must be presented in a form that is homogenous [uniform consistency] and cohesive in nature, e.g. [for example] foods should have a pudding or mousse [light spongy texture] like consistency. Most foods will be pureed and/or strained to ensure a smooth cohesive quality without lumps . Review of the CNA job description dated ,d+[DATE], revealed .Perform direct resident care duties under the supervision of licensed nursing personnel .Essential Duties & Responsibilities .assistance is provided to those residents who cannot feed themselves . Review of the facility's Breakfast, Lunch, and Dinner Meal Pass Audit, dated [DATE], revealed .To ensure each Resident receive their proper meal tray, the following procedures need to take place .2. CNA deliver tray to room and verify ticket against Resident's armband . Review of the undated facility's meal pass protocol titled, The 5 Rights of Meal Service Administration, attached to an in-service dated [DATE], revealed, .1. Right diet. 2. Right liquid. 3. Right resident. 4. Check door tag. 5. Check arm band .6. Check resident's armband with the name on the tray . Review of employee personnel files revealed that CNA #4, #6, and #13 and Agency CNA #19 and #20 had no documentation of a competency evaluation for the employees, no documentation of the employee's skills, or orientation of the employees to the facility processes and protocols related to the individual care of residents needing assistance with activities of daily living which included eating and modified diets. There was no documentation the CNAs or the Agency CNAs were determined to be competent to provide care for the residents in the facility. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of Cerebral Infarction, [CONDITION(S)], Dysphagia (the impairment of loss of skills involved in swallowing foods and/or liquids), [CONDITION(S)], Asthma and Anxiety Disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had no natural teeth or tooth fragments (edentulous). Review of the Physician's Orders dated [DATE], revealed .Regular diet Pureed texture, Nectar Thickened Fluids consistency . Review of the quarterly MDS assessment dated [DATE], revealed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 6, which indicated Resident #1 was severely cognitively impaired for decision making, required extensive assistance for eating, had complaints of difficulty or pain with swallowing, and required a mechanically altered diet of pureed food. Review of the facility's investigation dated [DATE], revealed .On [DATE], during the dinner meal pass, [Named CNA #20, an Agency CNA] .grab [grabbed] a tray that had the letter F and the letter B on the tray card. The tray she picked [with a regular diet instead of ordered puree diet] had another resident [picture] with a hat on, causing it to look similar to Ms. [Named Resident #1] picture; both Resident [Resident #1 and Resident #2, which was the resident's tray she selected to deliver to Resident #1] had hats on in their pictures [pictures of the residents are located on the bottom of the tray card] .[Named CNA #20] failed to carefully validate the tray she selected belonged to the resident in question. Additionally, she failed to utilize the identifier process [the resident wristband] to correctly identify resident [Resident #1] before giving Ms. [Named Resident #1] another resident's tray .After giving the wrong tray, [Named CNA #20] exited the resident's room to take a tray to another resident. Leaving the resident alone to eat should not have occurred, as resident [Resident #1] required assistance eating .[CNA #20 called for assistance when she reentered the room about ,d+[DATE] minutes later] Upon entering the room, the RN [Registered Nurse] noted that Resident [Resident #1] was not responding to verbal commands and was not making any sounds .Floor staff were told to call 911 and bring the crash cart to the resident's room Paramedics arrived at the resident's room at 18:07 [6:07 PM] and exited the facility with the resident at 18:35 [6:35 PM] .At 20:00 [8:00 PM] the facility received notification the Resident [Resident #1] has [had] expired at the hospital . Review of the EMS Prehospital Patient Record dated [DATE] at 6:08 PM, revealed .U4 [unit 4] was dispatched to an emergency call. upon arrival .Pt [patient] [Resident #1] in [CONDITION(S)] and CPR [cardiopulmonary resuscitation] in progress. Pt is 80 yo [year old] female who went into .[CONDITION(S)] while eating and appeared to choke. First initial rhythm was asystole [no pulse, no rhythm] .A 1-inch section of hotdog was removed from obstructing the patient's airway using [NAME] forceps .Pt remained in asystole .Pt was moved to stretcher and secured. Moved to unit .Upon arrival at ER .Pt care was transferred to RN. Shortly after transfer of care, resuscitation efforts were terminated by ER doctor . Review of the ED [Emergency Department] Physician Documentation dated [DATE] at 7:05 PM, revealed .The patient [Resident #1] presents with .arrest while eating hot dog. CPR in progress upon arrival .EMS pulled hot dog out of airway .EMS has been performing out of hospital ACLS [Advanced Cardiac Life Support] for approximately 30 minutes by the time pt [patient] arrived in ed [emergency department]. The onset was unknown .Medical Decision Making: Primary concern for respiratory arrest given reported history of choking on hot dog and then becoming nonresponsive at nursing home. EMS removed some hot dog from airway during intubation .EMS reports rhythm was asystole initially and transiently PEA [pulseless electrical activity]. CPR continued on arrival, prolonged downtime > [greater than] 30 minutes, further resus [resuscitation] efforts deemed futile and pt pronounced [dead] in ed. time of death 18:55 [6:55 PM] . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure, Dysphagia, Esophagitis with Bleeding, Pneumonia due to Coronavirus 2019, and Wheezing. Review of the Physician's Orders dated [DATE], revealed the following orders .NAS [No Added Salt] diet Regular texture, Thin Liquids consistency .Skilled ST [Speech Therapy] services 5 to 7 times a week for 30 days to increase functional communication, memory, and problem solving skills, and for planning of LRD [least restrictive diet] with Dysphagia Management . Review of the admission MDS assessment dated [DATE], revealed Resident #2 was assessed to have a BIMS score of 6, which indicated the resident had severe cognitive impairment for decision making, needed extensive assistance for eating, and her nutritional approach was for a low salt therapeutic diet. Observation of Resident #1 and Resident #2's pictures on their individual meal card on [DATE] at 10:30 AM, revealed a picture quality that was not clear, both African American women had elongated faces and both were wearing hats. Resident #1's first name started with the letter F. Resident #2's last name started with the letter F and both residents resided in a B bed in different rooms. Observation in the resident's room on [DATE] at 12:03 PM, revealed CNA #4 delivered the lunch tray to Resident #2 and failed to check the resident's armband or verify the picture on the meal card. Resident #2 had no armband and stated, I never had one. CNA #4 did not look for the armband. Observations on the 2nd, 3rd, and 4th floors on [DATE] and [DATE] during delivery of the lunch trays revealed there was no monitoring of the tray delivery to the residents. There was no monitoring at the bedside to determine facility staff identified the residents and delivered the correct meal trays to the correct residents. During a telephone interview on [DATE] at 5:21 PM, CNA #20 confirmed her witness statement. She stated, .I pulled the last tray out I thought was hers [Resident #1]. I looked at the picture thought was [Named Resident #1] but it was [Named Resident #2] .I glanced down at the picture and saw name and took tray in room thought the tray already there was the noon tray [lunch] from earlier .I did not open the tray. I didn't even touch the tray .I fed her with the spoon two bites of coleslaw and pinched off with my fingers two bites of hotdog. I put that in her mouth, and she chewed on it. She made a face and said don't want no more. I left and went across the hall. I left her sitting up in bed. I was gone for about five to seven minutes. I came back and saw she was pale in color and just looking at me. I yelled for [Named CNA #19]. I performed the [MEDICATION(S)] maneuver [process for dislodging something lodged in a person's windpipe] and some coleslaw came out and goldish color fluids .The nurse came in and took over .I thought it [dinner tray] was [Named Resident #1], I saw clearly a F and thought it was [Named Resident #1] .[Resident #1's first name started with the letter F. Resident #2's last name started with the letter F and both residents resided in the B bed in different rooms] . During an interview on [DATE] at 1:24 PM, the Administrator was asked when she received notification of the event involving Resident #1. The Administrator stated, .I was at home. I received notification she [Resident #1] received an incorrect tray and was transported to the hospital .the CNA [CNA #20] didn't properly identify the meal tray with the resident .She left the room, then went back into the room, and then called for help . During an interview on [DATE] at 3:30 PM, the Interim DON stated, .The pictures [on the meal card] are grainy .I didn't realize how many of our residents wore hats in their pictures and so many of them [residents] look alike .We need to see if the dietary system can print the pictures clearer like they are in [Named Electronic Healthcare Software] . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Dysphagia, [CONDITION(S)] and [CONDITION(S)] Affecting Left Dominant Side, Neurologic Neglect Syndrome, and Dysarthria. Review of the Physician's Orders dated [DATE], revealed .diet Mechanical Soft texture, Nectar Thickened Fluids consistency . Review of the annual MDS assessment dated [DATE], revealed Resident #5 was assessed to have a BIMS score of 0, which indicated the resident had severe cognitive impairment for decision making, needed supervision when eating, and the resident's nutritional approach was for a mechanically altered diet with nectar thick liquids. Observation in the resident's room on [DATE] at 12:03 PM, revealed CNA #7 failed to identify the resident by checking Resident #5's armband and the picture on the meal card. Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Dysphagia, [CONDITION(S)], Type 2 Diabetes, [CONDITION(S)], Heart Failure, and a Foot Ulcer. Review of the quarterly MDS assessment dated [DATE], revealed Resident #7 was assessed to have a BIMS score of 15 which indicated the resident had no cognitive impairment for daily decision-making tasks and needed supervision when eating. Observation in the resident's room on [DATE] at 12:20 PM, revealed CNA #6 failed to identify the resident by checking Resident #7's armband and the picture on the meal card. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Convulsions, Cerebral Infarction, Dysphagia, [CONDITION(S)], [CONDITION(S)], and Dementia with Behaviors. Review of the quarterly MDS assessment dated [DATE], revealed Resident #8 was assessed to have a BIMS score of 14 which indicated the resident had no cognitive impairment for daily decision-making tasks, needed set up help only when eating, complained of difficulty or pain with swallowing, and received a mechanical altered diet. Observation and interview in the resident's room on [DATE] at 12:19 PM, revealed CNA #21 failed to identify Resident #8 by checking the resident's armband and the picture on the meal card during delivery of the lunch tray. When CNA #21 was asked if the armband had been checked, she stated, yes. The surveyor and CNA #21 walked back into the room and CNA #21 stated, .maybe I didn't .I lied .I did not look for an armband . Resident #8 did not have an armband. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Diabetes Mellitus Type 2, [CONDITION(S)], Heart Failure, [CONDITION(S)], [CONDITION(S)] Disease, Dementia without Behaviors and was [CONDITION(S)]. Review of the quarterly MDS assessment dated [DATE], revealed Resident #9 was assessed to have a BIMS score of 0 which indicated the resident had severe cognitive impairment for daily decision-making tasks, needed supervision and tray set up when eating, complained of difficulty or pain when swallowing, and received a mechanical altered diet of pureed food. Observation in the resident's room on [DATE] at 11:53 AM, revealed CNA #13 failed to verify Resident #9's picture on the meal card with his armband during delivery of the lunch tray. Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Dysphagia, and [CONDITION(S)]/[CONDITION(S)] on the right side. Review of the quarterly MDS assessment dated [DATE], revealed Resident #10 was assessed to have a BIMS score of 9 which indicated the resident had moderate cognitive impairment for daily decision-making tasks, needed extensive assistance when eating, complained of difficulty or pain with swallowing, and received a mechanically altered diet of pureed food. Observation in the resident's room on [DATE] at 12:09 PM, revealed RN #5 failed to verify Resident #10's identity by checking the picture on the meal card and checking Resident #10's armband. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Supraventricular Tachycardia, Dementia without Behaviors, Dysphagia, and [CONDITION(S)]. Review of Resident #11's Physician's Orders dated [DATE], revealed a diet that was mechanical soft with thin liquids, was vegetarian and abstained from the consumption of meat. Review of the quarterly MDS assessment dated [DATE], revealed Resident #11 was assessed to have a BIMS score of 9 which indicated the resident had moderate cognitive impairment for daily decision-making tasks, needed extensive assistance when eating, complained of difficulty or pain with swallowing, and required a mechanically altered diet of soft foods. Observation in the resident's room on [DATE] at 11:57 AM, revealed CNA #4 failed to verify the picture on the meal card with Resident #11's armband. CNA #4 placed the tray on the over bed table and prepared the resident's tray for dining. RN #1 entered the room and stated, .She [Resident #11] is vegetarian check that taco to see if meat . CNA #4 took the spoon and lifted the lettuce. She stated, .It is ground beef . Review of Resident #11's meal card revealed the resident was to receive large portions of mechanical soft fortified foods. There was no documentation the resident was to receive a vegetarian diet and was not to receive beef or pork. During an interview on [DATE] at 1:01 PM, the Dietary Manager (DM) confirmed Resident #11 received a regular diet with beef, the meal card and diet listing documented an incorrect diet and did not match the Physician's Order for a vegetarian diet. She stated, .Yes, this can happen again .the resident gets the wrong diet and cause problems for them . She stated, .We removed hotdogs and smoked sausage on [DATE] from the Always Available Menu . Observation on the 2nd, 3rd, and 4th floors on [DATE]-[DATE], revealed a posted sign that documented .Always Available Menu (Lunch & Dinner) that included chicken tenders, hot dogs, French fries, and hamburgers. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Malignant Neoplasm of the Breast, Hypertension, and a [CONDITION(S)]. Review of the quarterly MDS assessment dated [DATE], revealed Resident #12 was assessed to have a BIMS score of 15 which indicated the resident had no cognitive impairment for daily decision-making tasks, needed supervision when eating, and received a mechanical altered diet with no added salt (NAS). Observation in the resident's room on [DATE] at 12:01 PM, revealed Graduate Practical Nurse (GPN) #1 failed to check Resident #12's armband and verify the picture on the meal card during delivery of the lunch meal tray. During an interview on [DATE] at 12:23 PM, CNA #6 who had been employed for one month was asked how she identified a resident. CNA #6 stated, A log at the front desk with name and room number. I haven't seen it . When asked if she received training in orientation about the facility's process for identifying residents during delivery of the meal trays, CNA #6 stated, No ma'am. CNA #6 confirmed she was unaware of a resident Kardex which included individualized resident care directives. During an interview on [DATE] at 12:30 PM, CNA #7 who had been employed for 2 weeks was asked how she identified a resident. CNA #7 stated, The name on the door. When asked if during orientation she received training on the facility process for identifying residents during delivery of the meal trays. CNA #7 stated, I know there is a name on the door. CNA #7 confirmed she was not aware of a resident Kardex which included individualized resident care directives and that each resident had an armband. During an interview on [DATE] at 11:01 AM, Licensed Practical Nurse (LPN) #3 was asked if the facility had an orientation program for agency staff. LPN #3 stated, .We don't have anything in writing, It is all verbal .They [staff] are supposed to look at armbands every day when they pass meds [medications] and meal trays .With agency [agency staff] when they come we make walking rounds, give a census sheet and shown the Kardex. The computer gives more information . When asked if each resident had an armband, LPN #3 stated, Residents take them off all the time . During an interview on [DATE] at 11:56 AM, CNA #10 was asked if she received orientation from the facility before providing resident care. CNA #10 stated, .No, they [facility] didn't give me nothing about that here . During an interview on [DATE] at 1:01 PM, the Interim DON stated, .We had no policy for identification and meal pass .After the incident [on [DATE]] we put into place the breakfast, lunch and dinner meal pass process and audit .The staff deliver the tray to the room and verify the meal card against the resident's armband . When asked if every resident had an armband, she stated, .they should . During an interview on [DATE] at 1:01 PM, the Administrator stated, .There is no routine or QA [quality assurance] to audit armband compliance . During an interview on [DATE] at 1:20 PM, the Administrator was asked how the staff identified residents. She stated, .I have to have confidence the audit tool that was done on the 8th [[DATE]] is correct .I would have to assume that she identified the resident. I would have faith that she did it correctly . During a telephone interview on [DATE] at 5:21 PM, CNA #20 stated, .No one told me how to get information about the resident. They just put us on the floor. We had no training. They didn't teach us about any Kardex book. [Named Nursing Facility] didn't tell me anything . During a telephone interview on [DATE] at 11:30 AM, CNA #19 was asked if she received information about the facility or assignments prior to working with the residents. CNA #19 stated, .No information about this facility or assignment. You just show up. Nothing about a Kardex . During an interview on [DATE] at 12:06 PM, CNA #2 confirmed she was not told about the resident's information in the Kardex binder. CNA #2 stated, .I ain't seen that. I don't know about a book or binder . During an interview on [DATE] at 1:24 PM, the Administrator was asked if the facility had an orientation program for contract staff. The Administrator stated, .The DON was the point of contact for the agency staffing . When asked if she was involved in the orientation of newly hired employees and contract staff, the Administrator stated, No, not right now. During an interview on [DATE] at 1:24 PM, the Administrator was asked if the facility audits included comparing the armband with the meal ticket to identify the correct resident and she stated, .No, it does not . The Administrator was asked where on the audit tool did the nurse or person that was auditing the meal delivery document the CNA or staff member observed had identified the correct resident before serving the tray. She stated, .It's not . The Administrator was asked what audit tool or data gathering documentation of observations at the bedside was used to verify the meal card picture, name of the resident, and armband were checked to assure the meal tray was delivered to the correct resident. She stated .There is no documentation. We are auditing that .I would have to have faith they did what was [they were] supposed to do . During an interview on [DATE] at 2:37 PM, the Interim DON stated she had received the contract employee files from the staffing agency. When asked if the files contained the education and competency of each CNA, the DON shook her head no. The Interim DON confirmed the facility had no employee personnel files and no contract personnel files to reflect facility orientation and competency determination. During an interview on [DATE] at 1:17 PM, LPN #2 was asked if there was a book or binder with resident information and resident care directives for the staff to access. LPN #2 stated, .Don't ask me. I'm agency. I don't know . During an interview on [DATE] at 1:35 PM, the Interim DON confirmed there were no facility employee files or contract employee files that documented any orientation or competency checks. The Administrator and Interim DON were unable to present any employee personnel files or contract personnel files that contained competency assessments. During an interview on [DATE] at 2:25 PM CNA #10 stated, .There is no sheet in the Kardex book for [Named Resident #3]. During an interview on [DATE] at 2:27 PM, LPN #1 confirmed there was no Visual/Kardex Report for Resident #3 in the Kardex. She stated, I need to update this whole thing. The surveyors verified the Removal Plan by: 1. On [DATE], a tray audit was completed by the Dietary Manager to ensure that residents are receiving the correct consistencies on the resident's trays compared to the resident's diet slips with no discrepancies identified. The surveyors confirmed this through review of the tray audit and interview with the Dietary Manager. 2. Hotdogs were removed from the menu on [DATE] by the Dietary Manager. The surveyors confirmed this through review of the menus and interview with the Dietary Manager. 3. On [DATE], the Care Plans, Kardexes and the electronic healthcare systems (the system the CNAs use for electronic documentation) of 127 residents were reviewed for appropriate level of assistance for eating by the Unit Managers and no concerns were identified. The surveyors confirmed this through observation, record review, and interviews with the Unit Managers. 4. The agency orientation packet was reviewed, and a checklist of all items covered including the updated guidance of the five rights of meal administration added on [DATE] by the DON were reviewed. The surveyors confirmed this through review of the orientation packed and checklist, and interview with the Interim DON. 5. Resident pictures were reviewed on [DATE] by Unit Managers and all were present in the electronic healthcare systems. Unit Managers will check daily in the electronic healthcare system to ensure pictures are present on new admissions in the system. The surveyors confirmed this through interviews with the Unit Managers. 6. Residents with hats or other accessories, which included facial coverings, that are not worn daily in the center, new pictures will be taken to display the usual appearance so the resident will be more correctly identified. The surveyors confirmed this through review of the pictures and interviews with staff on all shifts. 7. Meal tray audits will be completed by the Floor/Charge LPN/RN or their designee for resident tray passes at each meal. Any discrepancies will be addressed and resolved immediately by nursing staff and the dietary manager/designee, reviewing physician orders in the electronic healthcare system, dietary communication slips, and dietary tray card system to identify where the breakdown occurred. The surveyors confirmed this through observations of the delivery of the meal trays, record reviews and interviews with staff on all shifts. 8. Beginning on [DATE], managers will oversee meal tray delivery process at each meal to ensure the right tray, the right person, the right assistance is provided and is ongoing. Diets or assistance provided that is found to be in error are corrected immediately. Incorrect meal trays are removed from the cart immediately and reviewed to determine how the discrepancy occurred. This is completed by the nursing staff and dietary manager at time of the occurrence. Assistance needed is audited by the floor nurse with oversight by the nursing managers to ensure the correct level of assistance needed is provided and any discrepancies identified are corrected immediately and reviewed by the nursing manager to determine the breakdown and it is resolved immediately. The surveyors confirmed this through observation of the delivery of the meal trays and interviews with managers. 9. Door name tags and armbands were audited on [DATE] by the Wound Care Nurse for all 127 residents with no discrepancies identified. The surveyors confirmed this through observation and interviews on all shifts. 10. Audits of wristbands and door name plates were completed on [DATE] by Medical Records with no additional issues identified. The surveyors confirmed this through observations and interviews on all shifts. 11. Audits of wristbands and door name plates will be completed daily Monday-Friday by Medical Records/designee and Saturday and Sunday by the Manager on Duty to ensure compliance. Issues identified will be corrected immediately. The surveyors confirmed this through review of the audits and interviews with Medical Records and managers. 12. All nursing staff were in-serviced by the Staff Development Coordinator (SDC) on the following policies and procedures between [DATE]-[DATE]. The policies and procedures were Assistance with Meals, Therapeutic Diets, Abuse, Neglect and Exploitation, The Five Rights of Meal Administration guidelines that was developed by the Unit Managers and reviewed by the Administrator on [DATE]. Any staff not in-serviced by [DATE] for any reason will not be allowed to work until education is received. The surveyors confirmed this through review of sign in sheets, employee rosters and interviews on all shifts. 13. An agency orientation checklist was created on [DATE] by the DON and provided to each unit to begin using immediately for all agency staff on their first shift which included all of the above policies and procedures. The SDC/Unit Managers will ensure the orientation packet is completed prior to the start of the first shift in the facility. This process is overseen daily with each new agency staff by the DON or designee beginning [DATE] and is ongoing. Monitoring of agency staff performance will be conducted by the Charge Nurses, Unit managers and other nursing management team members each shift and any issues with performance will be addressed and corrected immediately by the same with input from the DON. Overall responsibility of performance of agency staff will be the DON. The surveyors confirmed this through review of the checklist and interview with the Interim DON. 14. Direct meal tray observations will be conducted by the Nurse Managers, Charge Nurses and other Nursing Managers. They will provide direct observation of the meal trays at each meal to ensure facility and agency staff are following the process for meal delivery to ensure the right tray with the right meal is being provided to the right residents begin[TRUNCATED]

Based on policy review, employee job description, facility employee file review, agency employee file review, medical record review, and interview, the facility failed to ensure the Certified Nursing Assistants (CNAs) had the competencies and skill sets necessary to assure safety and provide individualized care for 9 of 12 sampled residents (Resident #1, #2, #5, #7, #8, #9, #10, #11, and #12) reviewed with modified and therapeutic diet orders and/or required assistance with meals. The facility's failure to ensure the CNAs had the specific knowledge, skill sets, and orientation necessary to provide the resident's individual needs resulted in Immediate Jeopardy when Resident #1 was fed a regular diet instead of the ordered pureed diet (a texture modified diet in which all foods have a soft, pudding like consistency) and CNA #20 (an Agency CNA) left the resident unattended after feeding the resident a regular diet. Resident #1 was found unresponsive and a portion of a hotdog was removed with forceps by Emergency Medical Services (EMS) attendants. Resident #1 expired in the emergency room (ER) of a local hospital. The facility's failures resulted in Immediate Jeopardy for Resident #2, #5, #7, 8, #9, #10, #11, and #12 when these residents required modified diets and/or assistance with meals and staff did not follow the process for identifying residents during delivery of the meal trays. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on [DATE] at 6:50 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-726. The Immediate Jeopardy was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 2:26 PM, and was validated onsite by the surveyors on [DATE] through medical record reviews, observations, review of education provided, audits, and staff interviews. The findings include: Review of the facility's policy titled, Assistance with Meals, revised ,d+[DATE], revealed .Resident shall receive assistance with meals in a manner that meets the individual needs of each resident .Residents who cannot assist themselves will be assisted with attention to safety, comfort and dignity .All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling . Review of the Administrator job description dated ,d+[DATE], revealed .Lead and direct the overall operations of the facility .management duties including, but not limited to, hiring, training and developing, coaching and counseling .Monitor each department's activities, communicate policies, evaluate performance .Oversee regular rounds to monitor delivery of nursing care .and ensure resident needs are being addressed .Manage turnover and solidify current and future staffing through development of recruiting sources, and through appropriate selection, orientation, training, and staff education and development . Review of the CNA job description dated ,d+[DATE], revealed .Perform direct resident care duties under the supervision of licensed nursing personnel .Essential Duties & Responsibilities .assistance is provided to those residents who cannot feed themselves . Review of employee personnel files revealed that CNA #4, #6, and #13 and Agency CNA #19 and #20 had no documentation of a competency evaluation for the employees, no documentation of the employee's skills, or orientation of the employees to the facility processes and protocols related to the individual care of residents needing assistance with activities of daily living which included eating and modified diets. There was no documentation the CNAs or the Agency CNAs were determined to be competent to provide care for the residents in the facility. Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Regular diet Pureed texture, Nectar Thickened Fluids consistency . Review of the quarterly MDS assessment dated [DATE], revealed Resident #1 needed extensive assistance for eating and had complaints of difficulty or pain with swallowing and required a mechanically altered diet of pureed food. Review of the EMS Prehospital Patient Record dated [DATE] at 6:08 PM, revealed .U4 [unit 4] was dispatched to an emergency call. upon arrival .Pt [patient] [Resident #1] in [CONDITION(S)] and CPR [cardiopulmonary resuscitation] in progress. Pt is 80 yo [year old] female who went into .[CONDITION(S)] while eating and appeared to choke. First initial rhythm was asystole [no pulse, no rhythm] .A 1-inch section of hotdog was removed from obstructing the patient's airway using [NAME] forceps .Pt remained in asystole .Pt was moved to stretcher and secured. Moved to unit .Upon arrival at ER [emergency room ] .Pt care was transferred to RN [Registered Nurse]. Shortly after transfer of care, resuscitation efforts were terminated by ER doctor . Review of the Emergency Department (ED) Physician Documentation dated [DATE] at 7:05 PM, revealed .The patient [Resident #1] presents with .arrest while eating hot dog. CPR in progress upon arrival .EMS pulled hot dog out of airway .EMS has been performing out of hospital ACLS [Advanced Cardiac Life Support] for approximately 30 minutes by the time pt arrived in ed [emergency department]. The onset was unknown .Medical Decision Making: Primary concern for respiratory arrest given reported history of choking on hot dog and then becoming nonresponsive at nursing home. EMS removed some hot dog from airway during intubation .EMS reports rhythm was asystole initially and transiently PEA [pulseless electrical activity]. CPR continued on arrival, prolonged downtime > [greater than] 30 minutes, further resus [resuscitation] efforts deemed futile and pt pronounced [dead] in ed. time of death 18:55 [6:55 PM] . Review of the facility's investigation dated [DATE], revealed .On [DATE], during the dinner meal pass, [Named CNA #20, an Agency CNA] .grab [grabbed] a tray that had the letter F and the letter B on the tray card. The tray she picked [with a regular diet instead of ordered puree diet] had another resident [picture] with a hat on, causing it to look similar to Ms. [Named Resident #1] picture; both Resident [Resident #1 and Resident #2, which was the resident's tray she selected to deliver to Resident #1] had hats on in their pictures [pictures of the residents are located on the bottom of the tray card] .[Named CNA #20] failed to carefully validate the tray she selected belonged to the resident in question. Additionally, she failed to utilize the identifier process [the resident wristband] to correctly identify resident [Resident #1] before giving Ms. [Named Resident #1] another resident's tray .After giving the wrong tray, [Named CNA #20] exited the resident's room to take a tray to another resident. Leaving the resident alone to eat should not have occurred, as resident [Resident #1] required assistance eating .[CNA #20 called for assistance when she reentered the room about ,d+[DATE] minutes later] Upon entering the room, the RN noted that Resident [Resident #1] was not responding to verbal commands and was not making any sounds .Floor staff were told to call 911 and bring the crash cart to the resident's room Paramedics arrived at the resident's room at 18:07 [6:07 PM] and exited the facility with the resident at 18:35 [6:35 PM] .At 20:00 [8:00 PM] the facility received notification the Resident [Resident #1] has [had] expired at the hospital . Observation of Resident #1 and Resident #2's picture on their individual meal cards on [DATE] at 10:30 AM, revealed a picture quality that was not clear, both African American women had elongated faces and both were wearing a hat. Resident #1's first name started with the letter F. Resident #2's last name started with the letter F and both residents resided in a B bed in different rooms. During a telephone interview on [DATE] at 5:21 PM, CNA #20 confirmed her witness statement. She stated, .I pulled the last tray out I thought was hers [Resident #1]. I looked at the picture thought was [Named Resident #1] but it was [Named Resident #2] .I glanced down at the picture and saw name and took tray in room thought the tray already there was the noon tray [lunch] from earlier .I did not open the tray. I didn't even touch the tray .I fed her with the spoon two bites of coleslaw and pinched off with my fingers two bites of hotdog. I put that in her mouth, and she chewed on it. She made a face and said don't want no more. I left and went across the hall. I left her sitting up in bed. I was gone for about five to seven minutes. I came back and saw she was pale in color and just looking at me. I yelled for [Named CNA #19]. I performed the [MEDICATION(S)] maneuver [process for dislodging something lodged in a person's windpipe] and some coleslaw came out and goldish color fluids .The nurse came in and took over .I thought it [dinner tray] was [Named Resident #1], I saw clearly a F and thought it was [Named Resident #1] .[Resident #1's first name started with the letter F. Resident #2's last name started with the letter F and both residents resided in the B bed in different rooms] . Review of the Minimum Data Set (MDS) assessments and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in the resident's room on [DATE] at 11:53 AM, revealed CNA #13 failed to verify Resident #9's picture on the meal card to his armband during delivery of the lunch meal tray. Observation in the resident's room on [DATE] at 12:01 PM, revealed Graduate Practical Nurse (GPN) #1 failed to check Resident #12's arm band and verify the picture on the meal card during delivery of the lunch meal tray. Observation in the resident's room on [DATE] at 12:03 PM, revealed CNA #4 failed to check Resident #2's armband and verify the picture on the meal card during delivery of the the lunch meal tray. Resident #2 had no armband and stated, I never had one. CNA #4 did not look for the armband. Observation in the resident's room on [DATE] at 12:03 PM, revealed CNA #7 failed to check Resident #5's armband and verify the picture on the meal card during delivery of the lunch meal tray. Observation in th resident's room on [DATE] at 12:09 PM, revealed RN #5 failed to verify the picture on the meal card with Resident #10's armband during delivery of the lunch meal tray. Observations in the resident's room on [DATE] at 12:20 PM, revealed CNA #6 failed to check Resident #7's armband and verify the picture on the meal card during delivery of the lunch meal tray. Observation in the resident's room on [DATE] at 11:57 AM, revealed CNA #4 failed to verify the picture on the meal card with Resident #11's armband during delivery of the lunch meal tray. CNA #4 placed the tray on the over bed table and prepared to set up the tray. RN #1 entered the room and stated, .She [Resident #11] is vegetarian. Check that taco to see if meat . CNA #4 took the spoon and lifted the lettuce. She stated, .It is ground beef . Review of Resident #11's meal card revealed a diet of fortified foods, mechanical soft large portions, and no documentation of a vegetarian diet or that the resident was not to have beef or pork. During an interview on [DATE] at 1:01 PM, the Dietary Manager confirmed Resident #11 received a regular diet with beef, the meal card and diet listing documented an incorrect diet and did not match the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Yes, this can happen again .the resident gets the wrong diet and cause problems for them . She stated, .We removed hotdogs and smoked sausage on [DATE] from the Always Available Menu . Observation and interview in the resident's room on [DATE] at 12:19 PM, revealed CNA #21 failed to check Resident #8's armband and verify the picture on the meal card during delivery of the lunch meal tray. When CNA #21 was asked if she checked the armband she stated, yes. The surveyor and CNA #21 walked back into room and CNA #21 stated, .maybe I didn't .I lied .I did not look for an armband . Resident #8 did not have an armband. Observations on the 2nd, 3rd, and 4th floors on [DATE]-[DATE], revealed a posted sign that documented Always Available Menu (Lunch & Dinner) that included chicken tenders, hot dogs, French fries, and hamburgers. During an interview on [DATE] at 12:23 PM, CNA #6 who had been employed for one month, was asked how she identified a resident. CNA #6 stated, A log at the front desk with name and room number. I haven't seen it . When asked if she received training in orientation about the facility's process for identifying residents during meal pass, CNA #6 stated, No ma'am. CNA #6 confirmed she was not aware of a resident Kardex which included individualized resident care directives. During an interview on [DATE] at 12:30 PM, CNA #7 who had been employed for 2 weeks, was asked how she identified a resident. CNA #7 stated, The name on the door. When asked if she received training in orientation about the facility process for identifying residents during delivery of the meal trays. CNA #7 stated, I know there is a name on the door. CNA #7 confirmed she was not aware of a resident Kardex which included individualized resident care directives and each resident having an armband. During an interview on [DATE] at 11:01 AM, Licensed Practical Nurse (LPN) #3 was asked if the facility had an orientation program for agency staff. LPN #3 stated, .We don't have anything in writing, It is all verbal .They [staff] are supposed to look at armbands every day when they pass meds [medications] and meal trays .With agency [agency staff] when they come we make walking rounds, given a census sheet and shown the Kardex. The computer gives more information . When asked if each resident had an armband, LPN #3 stated, Residents take them off all the time . During an interview on [DATE] at 11:56 AM, CNA #10 was asked if she received orientation from the facility before providing resident care. CNA #10 stated, .No, they [facility] didn't give me nothing about that here . During an interview on [DATE] at 1:01 PM the Interim DON was asked if the facilty had a policy for the identification of the resident to be certain the correct resident received the correct diet/medication and the DON stated, .We had no policy for identification and meal pass .After the incident [on [DATE]] we put into place the breakfast, lunch and dinner meal pass process and audit .The staff deliver the tray to the room and verify the meal card against the resident's armband . When asked if every resident had an armband, she stated, .they should . During an interview on [DATE] at 1:20 PM, when the Administrator was asked how the staff identified the residents, she stated, .I have to have confidence the audit tool that was done on the 8th [[DATE]] is correct .I would have to assume that she identified the resident. I would have faith that she did it correctly . During a telephone interview on [DATE] at 5:21 PM, CNA #20 stated, .No one told me how to get information about the resident. They just put us on the floor. We had no training. They didn't teach us about any Kardex book. [Named Nursing Facility] didn't tell me anything. During a telephone interview on [DATE] at 11:30 AM, CNA #19 was asked if she received information about the facility or assignments prior to working with the residents. CNA #19 stated, .No information about this facility or assignment. You just show up. Nothing about a Kardex . During an interview on [DATE] at 12:06 PM, CNA #2 confirmed she was not told about the resident's information in the Kardex binder. CNA #2 stated, .I ain't seen that. I don't know about a book or binder. During an interview on [DATE] at 1:24 PM, the Administrator was asked if the facility had an orientation program for contract staff. The Administrator stated, .The DON is the point of contact for the agency staffing . When asked if she was involved in the orientation of newly hired employees and agency staff, the Administrator stated, No, not right now. The Administrator was asked the number of nursing positions that the facility currently had and the Administrator stated .Off the top of my head the facility has 4 RNs, 12 LPNs, and 16 CNAs . The Administrator was asked how she was made aware of how things were progressing in the facility and she stated that information was directed to the DON. She was also asked if the audit instrument included staff identification of the armband and the Administrator stated No, it does not . During an interview on [DATE] at 2:37 PM, the Interim DON stated she had received the contract employee files from the staffing agency. When asked if the files contained the education and competency of each CNA, the Interim DON shook her head no. The Interim DON confirmed the facility had no employee personnel files and no contract personnel files for facility orientation and competency determination. During an interview on [DATE] at 1:17 PM, LPN #2 was asked if there was a book or binder with resident information for the staff to use with resident care directives. LPN #2 stated, .Don't ask me. I'm agency. I don't know. During an interview on [DATE] at 1:35 PM, the Interim DON confirmed there were no facility employee files or contract employee files for orientation or competency checks. During an interview on [DATE] at 2:25 PM, CNA #10 stated, .There is no sheet in the Kardex book for [Named Resident #3]. During an interview on [DATE] at 2:27 PM, LPN #1 confirmed there was no Visual/Kardex Report for Resident #3 in the book [Kardex]. She stated, I need to update this whole thing. The Administrator and Interim DON were unable to present any employee personnel files or contract personnel files that contained competency assessments. Refer to F-689 The surveyors verified the removal Plan by: 1. On [DATE], a tray audit was completed by the Dietary Manager to ensure that residents are receiving the correct consistencies on the resident's trays compared to the resident's diet slips with no discrepancies identified. The surveyors reviewed the audits. 2. On [DATE], hotdogs were removed from the menu by the Dietary Manager. The surveyors made observations, reviewed the menus, and interviewed staff on all shifts. 3. On [DATE], Care plans, Kardexes and (named electronic healthcare software system used by CNAs for electronic documentation) were reviewed for appropriate level of assistance for eating by Unit Managers and of the 127 residents reviewed no concerns were identified. The surveyors made observations, reviewed the Care Plans and Kardexes, and interviewed the Unit Managers. 4. On [DATE], an agency orientation packet was reviewed, and a checklist of all items covered including the updated guidance of the five rights of meal administration were added by the DON. The surveyors reviewed the orientation packets. 5. On [DATE], resident pictures were reviewed by Unit Managers and all were present in (named electronic healthcare systems). Unit Managers will check daily in (named electronic healthcare systems) to ensure pictures are present on new admissions in (named electronic healthcare systems). The surveyors reviewed the pictures and interviewed the Unit Managers. 6. Residents with hats or other accessories (to include facial coverings) that are not worn daily in the center, will have pictures retaken to display usual appearance so the resident will be more correctly identified. The surveyors reviewed the pictures. 7. Meal tray audits will be completed by the Floor/Charge LPN/RN or their designee for resident meal tray delivery at each meal. Any discrepancies will be addressed and resolved immediately by nursing staff and dietary manager/designee reviewing physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors made observations and interviewed the Charge Nurses. 8. Beginning on [DATE], managers oversee meal tray delivery process at each meal to ensure the right tray, right person, right assistance is provided, and this is ongoing. The surveyors observed meal tray deliveries and interviewed the managers. 9. Diets or assistance provided that is found to be in error are corrected immediately. Incorrect meal trays are removed from the cart immediately and reviewed to determine how the discrepancy occurred. This is completed by the nursing staff and dietary manager at the time of the occurrence. Assistance needed is audited by floor nurse with oversight by nursing managers to ensure correct level of assistance needed is provided and any discrepancies identified are corrected immediately and reviewed by nursing managers to determine breakdown and resolved immediately. The surveyors observed the delivery of the meal trays and interviewed nursing staff. 10. On [DATE], door name tags and armbands were audited by the Wound Care Nurse on all residents with no discrepancies identified in the 127 residents in the facility on that day. The surveyors reviewed the audits. 11. On [DATE], audits of wristbands and door name plates were completed by Medical Records with no additional issues identified. The surveyors reviewed the audits. 12. Audits of wristbands and door name plates will be completed daily Monday-Friday by Medical Records/designee and Saturday and Sunday by the Manager on Duty to ensure compliance. Issues identified will be corrected immediately. The surveyors reviewed the audit forms and interviewed Medical Records and managers. 13. Between [DATE]-[DATE], all nursing staff were in-serviced by the Staff Development Coordinator on the following policies and procedures: Assistance with Meals, Therapeutic Diets, Abuse, Neglect and Exploitation, The Five Rights of Meal Administration guidelines (developed by the Unit Managers and reviewed by Administrator on [DATE]). Any staff not in-serviced by [DATE] for any reason will not be allowed to work until education was received. The surveyors reviewed the sign in sheets, education, and interviewed staff on all shifts. 14. On [DATE], agency orientation checklist was created by the DON and provided to each unit to begin using immediately ([DATE]) for all agency staff on their first shift which includes all the above policies and procedures. Staff Development Coordinator/Unit Managers will ensure orientation packet is completed prior to start of the first shift in facility. This process is overseen daily with each new agency staff by the DON/designee beginning [DATE] and is ongoing. Monitoring of agency staff performance will be conducted by the Charge Nurses, Unit Managers, and other nursing management team members each shift and any issues with performance will be addressed and corrected immediately with input from the DON. Overall responsibility of performance of agency staff will be the DON. The surveyors reviewed the orientation packet and interviewed staff on all shifts. 15. Beginning [DATE], Nurse Managers, Charge Nurses and other Nursing Managers will direct meal tray observations and will provide direct observation of meal tray delivery at each meal to ensure facility and agency staff are following the process for meal delivery to ensure the right tray with the right meal is being provided to the residents and this is ongoing. The surveyors observed delivery of the meal trays and interviewed the Charge Nurses and Nurse Managers. 16. The dietary tray cards were altered by Information Technology to make the room number font the same size as the resident name font. The surveyors observed the dietary tray cards. 17. On [DATE], training was conducted for the Dietary Manager, Registered Dietitian and Dietary Supervisor by (named dietary software) on the tray card system that dietary uses, and included instructions for updating/editing profiles, preferences, and dietary orders to ensure consistency. The surveyors reviewed the education and interviewed dietary staff. Noncompliance at F-726 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure safety and provide individualized resident care for 1 of 12 sampled residents (Resident #1) reviewed with modified diets and/or required assistance with meals. The facility failure resulted in Immediate Jeopardy when Resident #1 was fed a regular diet instead of the ordered pureed diet (a texture modified diet in which all foods have a soft, pudding like consistency) and the Agency Certified Nursing Assistant (CNA) left the resident unattended after feeding the resident. Resident #1 was found unresponsive, a portion of a hotdog was removed with forceps by Emergency Medical Services (EMS), and Resident #1 expired in the emergency room (ER) of a local hospital. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 6:50 PM, in the Chapel. The facility was cited Immediate Jeopardy at F-600. The facility was cited F-600 at a scope and severity of J, which is Substandard Quality of Care. The IJ was effective from [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on [DATE] at 2:26 PM and was validated onsite by the surveyors on [DATE] through observation, review of audits and meeting minutes, and staff interviews. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised ,d+[DATE], revealed .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Neglect' means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .The facility will make individual determination in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment . Review of the facility's policy titled, Assistance with Meals, revised ,d+[DATE], revealed .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Facility staff will serve resident trays and will help residents who require assistance with eating. Residents who cannot assist themselves will be assisted with attention to safety, comfort and dignity . Review of the facility's undated policy titled, Consistency Modified Diets, revealed .Dysphagia [difficulty swallowing] is the impairment or loss of skills involved in swallowing foods and/or liquids .Pureed is the first consistency for solid foods that may be used after NPO [nothing by mouth] or liquid diets or for those with dysphagia. Puree consistency eliminates the need for chewing. All foods must be presented in a form that is homogenous [uniform consistency] and cohesive [sticks together] in nature, e.g. [for example] foods should have a pudding or mousse like [light spongy texture] consistency. Most foods will be pureed and/or strained to ensure a smooth cohesive quality without lumps . Review of the facility's undated meal pass protocol titled, The 5 Rights of Meal Service Administration, attached to an in-service dated [DATE], revealed .1. Right Diet 2. Right Liquids 3. Right Resident 4. Check Door Tag 5. Check Armband .Check the resident's armband with the name on the tray . Review of the facility's Breakfast, Lunch, and Dinner Meal Pass Audit dated [DATE], revealed .To ensure each Resident receive their proper meal tray, the following procedures need to take place .2. CNA deliver tray to room and verify ticket against Resident's armband . Review of the facility's CNA Job Description dated ,d+[DATE], revealed .assistance is provided to those residents who cannot feed themselves . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had no natural teeth or tooth fragments (edentulous). Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Regular diet Pureed texture, Nectar Thickened Fluids consistency . Review of the quarterly MDS assessment dated [DATE], revealed Resident #1 was assessed to have a Brief Interview of Mental Status (BIMS) score of 6, which indicated Resident #1 was severely cognitively impaired for decision making, required extensive assistance for eating, had complaints of difficulty or pain with swallowing and required a mechanically altered diet of pureed food. Review of the EMS Prehospital Patient Record dated [DATE] at 6:08 PM, revealed .U4 [unit 4] was dispatched to an emergency call. upon arrival .Pt [patient] [Resident #1] in [CONDITION(S)] and CPR [cardiopulmonary resuscitation] in progress. Pt is 80 yo [year old] female who went into .[CONDITION(S)] while eating and appeared to choke. First initial rhythm was asystole [no pulse, no rhythm] .A 1-inch section of hotdog was removed from obstructing the patient's airway using [NAME] forceps .Pt remained in asystole .Pt was moved to stretcher and secured. Moved to unit .Upon arrival at ER .Pt care was transferred to RN [Registered Nurse]. Shortly after transfer of care, resuscitation efforts were terminated by ER doctor . Review of the Emergency Department (ED) Physician Documentation dated [DATE] at 7:05 PM, revealed .The patient [Resident #1] presents with .arrest while eating hot dog. CPR in progress upon arrival .EMS pulled hot dog out of airway .EMS has been performing out of hospital ACLS [Advanced Cardiac Life Support] for approximately 30 minutes by the time pt arrived in ed [emergency department]. The onset was unknown .Medical Decision Making: Primary concern for respiratory arrest given reported history of choking on hot dog and then becoming nonresponsive at nursing home. EMS removed some hot dog from airway during intubation .EMS reports rhythm was asystole initially and transiently PEA [pulseless electrical activity]. CPR continued on arrival, prolonged downtime > [greater than] 30 minutes, further resus [resuscitation] efforts deemed futile and pt pronounced [dead] in ed. time of death 18:55 [6:55 PM] . Review of the facility's investigation dated [DATE], revealed .On [DATE], during the dinner meal pass, [Named CNA #20, an Agency CNA] .grab [grabbed] a tray that had the letter F and the letter B on the tray card. The tray she picked [with a regular diet instead of ordered puree diet] had another resident [picture] with a hat on, causing it to look similar to Ms. [Named Resident #1] picture; both Resident [Resident #1 and Resident #2, which was the resident's tray she selected to deliver to Resident #1] had hats on in their pictures [pictures of the residents are located on the bottom of the tray card] .[Named CNA #20] failed to carefully validate the tray she selected belonged to the resident in question. Additionally, she failed to utilize the identifier process [the resident wristband] to correctly identify resident [Resident #1] before giving Ms. [Named Resident #1] another resident's tray .After giving the wrong tray, [Named CNA #20] exited the resident's room to take a tray to another resident. Leaving the resident alone to eat should not have occurred, as resident [Resident #1] required assistance eating .[CNA #20 called for assistance when she reentered the room about ,d+[DATE] minutes later] Upon entering the room, the RN noted that Resident [Resident #1] was not responding to verbal commands and was not making any sounds .Floor staff were told to call 911 and bring the crash cart to the resident's room Paramedics arrived at the resident's room at 18:07 [6:07 PM] and exited the facility with the resident at 18:35 [6:35 PM] .At 20:00 [8:00 PM] the facility received notification the Resident [Resident #1] has [had] expired at the hospital . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .NAS [No Added Salt] diet Regular texture, Thin Liquids consistency .Skilled ST [Speech Therapy] services 5 to 7 times a week for 30 days to increase functional communication, memory, and problem solving skills, and for planning of LRD [least restrictive diet] with Dysphagia Management . Review of the admission MDS assessment dated [DATE], revealed Resident #2 was assessed to have a BIMS score of 6, which indicated the resident had severe cognitive impairment for decision making. Resident #2 needed extensive assistance for eating and her nutritional approach was for a therapeutic [low salt] diet. Observation of Resident #1 and Resident #2's pictures on their individual meal card on [DATE] at 10:30 AM, revealed a picture quality that was not clear, both were African American women with elongated faces and both were wearing a hat. Resident #1's first name started with the letter F. Resident #2's last name started with the letter F and both residents resided in a B bed in different rooms. Observation in the resident's room on [DATE] at 12:03 PM, revealed CNA #4 failed to check Resident #2's armband and verify the picture on the meal card during the lunch meal tray pass. Resident #2 had no armband and stated, I never had one. CNA #4 did not look for the armband. During a telephone interview on [DATE] at 5:21 PM, Agency CNA #20 confirmed her witness statement and stated, .I pulled the last tray out I thought was hers [Resident #1]. I looked at the picture thought was [Named Resident #1] but it was [Named Resident #2] .I glanced down at the picture and saw name and took tray in room thought the tray already there was the noon tray [lunch] from earlier .I did not open the tray. I didn't even touch the tray .I fed her with the spoon two bites of coleslaw and pinched off with my fingers two bites of hotdog. I put that in her mouth, and she chewed on it. She made a face and said don't want no more. I left and went across the hall. I left her sitting up in bed. I was gone for about five to seven minutes. I came back and saw she was pale in color and just looking at me. I yelled for [Named CNA #19]. I performed the [MEDICATION(S)] maneuver [process for dislodging something lodged in a person's windpipe] and some coleslaw came out and goldish color fluids .The nurse came in and took over .I thought it [dinner tray] was [Named Resident #1], I saw clearly a F and thought it was [Named Resident #1] .[Resident #1's first name started with the letter F, Resident #2's last name started with the letter F, and both residents resided in a B bed] . During an interview on [DATE] at 1:24 PM, the Administrator was asked when she received notification of the event involving Resident #1. The Administrator stated, .I was at home. I received notification she [Resident #1] received an incorrect tray and was transported to the hospital .The CNA [Agency CNA #20] didn't properly identify the meal tray with the resident .She left the room, then went back in the room, and then called for help . During an interview on [DATE] at 3:30 PM, the Interim DON stated, .The pictures [on the meal card] are grainy .I didn't realize how many of our residents wore hats in their pictures and so many of them [residents] look alike .We need to see if dietary system can print the pictures clearer like they are in [Named Electronic Healthcare Software] . The nursing home utilized temporary staffing agencies for the provision of CNAs, and did not have processes in place to provide orientation, medical or care plan information to the temporary staff regarding the individual resident's needs on the unit they were assigned. Refer to F 689. The surveyors verified the removal Plan by: 1. On [DATE], a tray audit was completed by the Dietary Manager to ensure that residents are receiving the correct consistencies on the resident's trays compared to the resident's diet slips with no discrepancies identified. The surveyors reviewed the audits and observed delivery of meal trays. 2. On [DATE], Care plans, Kardexes and the facility Electronic Healthcare System that the CNAs use for electronic documentation, were reviewed by the Unit Managers for the appropriate level of assistance required for eating and of the 127 residents reviewed there were no issues identified . The surveyors reviewed the Care Plans, Kardexes, interviewed the Unit Managers, and observed the delivery of the meal trays. 3. On [DATE], the agency orientation packet was reviewed, and a checklist of all items covered including the updated guidance of the five rights of meal administration was added by the DON. The surveyors reviewed the orientation packets. 4. On [DATE], resident pictures were reviewed by Unit Managers and all were present in the facility Electronic Healthcare System. The Unit Managers will check daily in the facility Electronic Healthcare System to ensure pictures are present for the new admissions. The surveyors reviewed the pictures and interviewed the Unit Managers. 5. Meal tray audits will be completed by the Floor/Charge Licensed Practical Nurse (LPN)/RN or their designee for resident tray passes at each meal. Any discrepancies will be addressed and resolved immediately by the nursing staff and dietary manager/designee reviewing the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyors reviewed the audits and interviewed nurses on all shifts. 6. Beginning on [DATE], managers will oversee the meal tray delivery process at each meal to ensure the right tray, right person, right assistance is provided and will be ongoing. The surveyors observed the delivery of the meal trays and interviewed the managers. 7. On [DATE], door name tags and armbands were audited for the 127 residents by the Wound Care Nurse with no discrepancies identified in the facility on that day. The surveyors reviewed the audits. 8. Audits of wristbands and door name plates will be completed daily Monday-Friday by Medical Records/designee and Saturday and Sunday by the Manager on Duty to ensure compliance. Concerns identified will be corrected immediately. The surveyors reviewed the audits and interviewed Medical Records and managers. 9. On [DATE], an agency orientation checklist was created by the DON and provided to each unit to begin using immediately ([DATE]) for all agency staff on their first shift which includes all above policies and procedures. The Staffing Development Coordinator (SDC)/Unit Managers will ensure orientation packet is completed prior to start of first shift in facility. This process is overseen daily with each new agency staff by DON/designee beginning [DATE] and is ongoing. Monitoring of agency staff performance will be conducted by Charge Nurses, Unit Managers, and other nursing management team members each shift and any issues with performance will be addressed and corrected immediately by the same with input from DON. Overall responsibility of performance of the agency staff will be the DON. The surveyors reviewed the orientation packet and interviewed staff on all shifts. 10. On [DATE], audits of wristbands and door name plates were completed by Medical Records with no additional concerns identified. The surveyors reviewed the audits. 11. Beginning [DATE], direct meal tray observations will be conducted by Nurse Managers, Charge Nurses and other Nursing Managers will provide direct observation of meal tray at each meal to ensure facility and agency staff are following the process for delivery of the meal trays to ensure the right tray with the right meal is being provided to the correct residents and this will be ongoing. The surveyors observed meal tray passes and interviewed nursing staff. 12. On [DATE], the DON began re-education of all nursing staff regarding the resident identifiers to be used prior to delivering a meal tray. These include a combination of any two of the following: resident photo; name on door; name on wristband; verbalization of resident (by asking resident to state their name); and/or asking facility staff to identify the resident. No staff will be allowed to work until educated on the above by Charge Nurses, Nurse Managers, DON. The surveyors reviewed the education, the in-service sign in sheets, and interviewed staff on all shifts. 13. On [DATE], the dietary tray cards were altered by Information Technology (IT) to make the room number font the same size as the resident name font. The surveyors reviewed the dietary tray cards. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, medical record review, observation and interview, the facility failed to follow resident care plan interventions related to pressure ulcers, nutrition and behavior monitoring for 6 of 31 (Resident #2, 53, 49, 64, 92, and 135) sampled residents reviewed for care planning of the 36 residents included in the Stage 2 review. The facility's failure to follow pressure ulcer-related care plan interventions to provide treatments and assessments when the pressure ulcers worsened resulted in actual harm for Resident #2 and #53. The findings included: 1. The facility's Interdisciplinary Assessments policy documented, .Each resident shall have a plan of care developed by the interdisciplinary team. Disciplines shall include, but not be limited to, medical, nursing, social service, nutrition, activities and any other discipline indicated in treatment of [REDACTED].Plans of care shall include the care to be given, objectives to be accomplished (which are measurable and time limited) and the staff and/or professional discipline responsible for each element of care .Modifications to the interdisciplinary plans of care are done by licensed personnel .Changes in a resident's condition may indicate changes to be made in the plan of care .When changes in condition, medications, treatments or approaches occur, the plan of care will be updated .Problems that are no longer applicable will be discontinued . 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders provided for 9/14/16, 9/28/16 and 10/3/16 revealed the following: a. 9/14/16- .Cleanse sacral wound c (with) wound cleanse (WC). Pat dry. Apply a [MEDICATION NAME] dressing QOD (every other day) for 14 days . b. 9/14/16- .Calcium Alginate c [MEDICATION NAME] QOD for 14 days . c. 9/28/19- .Continue with Calcium Alginate and [MEDICATION NAME] to sacral wound until resolved . d. 10/3/16- .Continue Calcium Alginate c [MEDICATION NAME] QOD until resolved . Review of a treatment record for September 2016 revealed there was no documentation of the treatments administered as ordered on 9/17, 9/18, 9/19, 9/20, 9/21, and 9/22/16. D/C (discontinue) was written on each date from 9/22/16 through 9/30/16. There was no physician's order to discontinue the wound treatment and the wound was still present on 10/4/16. Review of a treatment record for October 2016 revealed there was no documentation the treatments were administered as ordered on [DATE], 10/2/16 or 10/3/16. A care plan dated 9/6/16 documented, .Problem .Resident has Pressure Ulcer (s) .SACRUM ONSET 09/06/2016 .STAGEII .Approach .9/20/16 wound treatment as ordered . The failure of the facility to follow the care plan interventions to provide wound care as ordered resulted in actual harm to Resident #2 when the wound deteriorated from a stage 2 to a stage 3. 3. Medical record review revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. a. The care plan dated 7/17/15 and revised on 9/1/16 documented, .Problem .is at nutrition risk for unavoidable weight loss due to .poor PO intake, current unhealed pressure wound decreased protein status .Approach .Weigh and monitor results .report any significant changes to physician .Assist resident to eat if he/she becomes fatigued during meals . Review of the weight work sheet revealed the following weekly weights for the month of September, 2016: On 9/7/16 the resident weighed 163.2 pounds (lbs). On 9/16/16 the resident weighed 162.2 (lbs). On 9/29/16 the resident weighed 154.0 (lbs). This resulted in a significant weight loss of 5.6 %. There were no weekly weights documented for the third week in September. A telephone order dated 9/12/16 documented, .assist with all meals due to weight loss . Observations in Resident #53's room on 10/12/16 at 8:35 AM, revealed Resident #53 lying in bed, with a breakfast tray sitting on the bedside table with no staff in room assisting her as ordered. Observations in Resident #53's room on 10/12/16 at 6:04 PM, revealed Resident #53 lying in bed, with her uneaten supper tray sitting on the bedside table with no staff in room assisting her as ordered. Interview with Certified Nursing Assistant (CNA) #1 on 10/12/16 at 6:20 PM, by the 3rd floor nurses station, CNA #1 was asked if she assisted Resident #53 with her meals. CNA #1 stated, .no, she is just a set up . Interview with CNA #2 on 10/13/16 at 8:59 AM, by the 3rd floor nurses station, CNA #2 was asked if she assisted Resident #53 with her meals. CNA #2 stated, .we normally set it up for her and come back .sometimes she eats good and sometimes she don't . Interview with Nurse Practitioner (NP) on 10/12/16 at 1:15 PM, on the 3rd floor nurses station, the NP was shown Resident #53 weekly weight report regarding her weight loss. NP was working on Resident #53 history and physical with a weight of 163 lbs documented for 10/5/16, and was asked where she had gotten that weight. The NP stated, .I went by 9/7 . The NP was shown the weekly weight report that indicated a weight on 10/4/16 of 150.80 lbs, a 13 lb difference. The NP was asked should there have been interventions put in place for a 13 lb weight loss. The NP stated, .didn't know about all this .definitely going to do something about it . I'm just floored that this has gotten by us .we haven't done what we needed to do .I will be on top of this .I had no idea her weight had dropped .oh my gosh, that's huge . The facility failed to assist the resident with all meals in accordance with the plan of care, ordered by the physician. b. The care plan dated 7/17/15 and revised on 9/14/16 documented, .Problem .at risk for developing skin breakdown due to needs assist with bed mobility .history of pressure ulcers, left above knee amputation .poor appetite .Approach .Provide treatments as ordered . A physician order dated 9/8/16 documented, .APPLY HYDRAGUARD BARRIER CREAM WITH EACH INCONTINENT EPISODE .SACRAL WOUND . There was no documentaion that wound care was administered as ordered from 9/7/16 through 9/29/16. Interview with LPN #1 on 10/4/16 at 5:24 PM, in the Chapel, LPN #1 was asked about Resident #53's pressure wound. LPN #1 stated, I got here .around the 6th of September .it has progressed .not bad .it's a stage 4 now that's what I've known it as .it has undermining .the surface area is smaller .I think its deteriorated because of nutrition status and her comorbidities .she is heavy . LPN #1 was asked where do you document that you have performed wound treatments. LPN #1 stated, .should have a zero on it (MAR) .this is all new to me. LPN #1 confirmed treatments were not done. Interview with the Director of Nursing (DON) on 10/4/16 at 5:57 PM, in the Chapel, the DON was asked about Resident #53's pressure ulcer. The DON stated, .I don't think she had wounds when she came in. The DON was asked the stage of Resident #3's pressure ulcer. The DON stated, .I think it's a three . The DON was asked if empty spaces on the MAR mean that no wound care was provided. The DON stated, .means no documentation . The failure of the facility to follow care plan interventions for nutrition and wound care treatments as ordered resulted in actual harm to Resident #53 when the resident experienced a significant weight loss and the wound developed undermining. 4. Medical record review revealed Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order dated 9/6/16 documented .cleanse area to R (right) hip c (with) wound cleaner and pat wound dry. skin prep around area. apply xeroform to site and cover c [MEDICATION NAME] 4x4 . A physician's order dated 9/21/16 documented .xeroform daily to R hip wound x 14 days santyl to L hip wound daily x 14 days . A care plan dated 9/23/16 documented, .Problem .Pressure Ulcers xs 2 (times 2) Right Hip Left Hip .Approach .Wound Care as ordered by physician . A physician's order dated 9/29/16 documented .santyl daily to R right and L left hip wounds x 14 days . Review of the MAR indicated [REDACTED]. There was no documentation the facility provided treatments as ordered in accordance with the plan of care. 5. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 8/25/16 documented, Problem .8/25/2016 .at risk for developing skin breakdown .8/29/16 .N.O. (new order) L left (and) R right buttock shearing .9/7/16 .tx (treatment) to sacral wound .As ord (ordered) .9/9/16 requires skilled level II care services D/T (due to) daily wound care for Sacral UTS (unstageable) .Problem .8/25/2016 .has disruption of surface .Left buttock fluid filled blister .Approach .Provide supplemental protein, amino acids .as ordered by the physician to promote wound healing .Treatment as ordered .Problem .9/7/2016 .has Pressure Ulcer .SACRUM .Stage 3 .wound treatment as ordered to sacral . A physician's telephone order dated 9/7/16 documented, .Santyl Daily to sacral wound x 14 days . Review of the MAR for September 2016 revealed no documentation the Santyl treatment was completed on 9/11/16, 9/18/16, 9/19/16, or 9/20/16. A physician's telephone order dated 9/21/16 documented, .Santyl daily to Sacral/Intergluteal Wound x 14 days. Review of the MAR for September 2016 revealed no documentation the Santyl treatment was completed on 9/23/16, 9/25/16, 9/27/16, or 9/29/16. A physician's telephone order dated 9/28/16 documented, .Santyl daily to Sacral/Intergluteal Wound x 14 days . Review of the MAR for October 2016 revealed no documentation the Santyl treatment was completed on 10/2/16. The physician's orders signed 10/4/16 documented, .Order Date 9/7/2016 JUVEN PACKET .MIX 1 PACKET IN LIQUID GIVE ORALLY TWICE DAILY X 30 DAYS DX (diagnosis): Unstageable wound of the sacrum .Stop Date .10/8/2016 . Review of the MAR for September 2016 revealed there was no documentation that the morning dose of Juven was administered on 9/22/16. Interview with LPN #1 on 10/4/16 at 6:38 PM, LPN #1 was asked about the missing treatment documentation. LPN #1 stated, That was me doing that EMR (electronic medical record) stuff thinking I was doing it right, but I was doing it wrong .It was documentation error, a computer error. Telephone interview with the Medical Director (MD) #1 on 10/13/16 at 5:45 PM, MD #1 was asked whether he expected nurses to perform wound assessments and treatments as ordered. MD #1 stated, Absolutely. MD #1 was asked whether he expected the nurses to document when a treatment or assessment was completed. MD #1 stated, Absolutely. If you've done the treatment, it needs to be documented. 6. Medical record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 10/3/16 documented, .at risk for and/or experiencing depression .Taking medications as prescribed ([MEDICATION NAME] 25 mg (milligrams)daily) .Approach .10/3/2016 .Monitor behaviors per tracking tool . The facility was not able to provide documentation the behaviors were monitored in accordance with the plan of care. Interview with the Social Services Director (SSD) on 10/13/16 at 1:49 PM, in the Chapel, the SSD was asked how residents are monitored for behaviors related to depression. The SSD stated, We monitor them for behaviors and depression .The nurses let us know. They are supposed to check that on the nurses note . Interview with Registered Nurse (RN) #1 on 10/13/16 at 3:15 PM, in the Chapel, RN #1 was asked how the resident was monitored for behaviors. RN #1 stated, There is no documentation for behavior monitoring in this record. The nurse failed to check the box (in electronic medical records system) for side effect monitoring .There will be monitoring for the [MEDICATION NAME] side effects from now on. I know that won't help what occurred prior to today . 7. Medical record review revealed Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order dated 8/20/16 documented, .CLEANSE RIGHT INNER WIYH (with) NORMAL SALINE OR WOUND CLEANER, PAT DRY, COVER WITH FOAM DRSG (dressing) CHANGE EVERY OTHER DAY DX: WOUND . A physician's order dated 8/21/16 documented, .CLEANSE RIGHT MEDIAL ANKLE WITH WOUND CLEANER AND PAT DRY. APPLY WOUND GEL AND [MEDICATION NAME] NON-ADHESIVE AND SECURE WITH KERLIX EVERY 3 DAYS AND PRN (when necessary). DX: STAGE 2 . A physician's order dated 8/26/16 documented, .HYDROGEL CLEANSE RIGHT MEDIAL ANKLE WITH WOUND CLEANER AND PAT DRY. APPLY WOUND GEL AND [MEDICATION NAME] NON-ADHESIVE AND SECURE WITH KERLIX DAILY . The care plan dated 8/21/16 documented, Problem .Resident has pressure ulcer(s) .R. Medial Ankle .Stage 1 with a line drawn through it .Stage 2 with a line drawn through it .R. Medial Ankle .Stage 4 .Approach .Observe effectiveness of / response to treatment(s) as ordered - (see physician's orders and EZ-MAR .Wound care as ordered by physician - see current Wound Treatment and Progress Record . The August 2016 MAR indicated [REDACTED].CLEANSE RIGHT MEDIAL ANKLE WITH WOUND CLEANSER AND PAT DRY. APPLY WOUND GEL AND [MEDICATION NAME] NON-ADHESIVE AND SECURE WITH KERLIX DAILY . This wound care was not documented as being performed on 8/29/16. The September 2016 MAR indicated [REDACTED]. APPLY WOUND GEL AND [MEDICATION NAME] NON-ADHESIVE AND SECURE WITH KERLIX EVERY 3 DAYS . This wound care was not documented as being performed on 9/5/16 and 9/11/16. Interview with the DON on 10/12/16 at 4:55 PM, in the DON's office, the DON was asked if she expected her staff to follow the resident's care plan interventions. The DON stated, Yes.

Based on National Pressure Ulcer Advisory Panel (NPUAP) reference guide, policy review, medical record review, and interview, the facility failed to timely identify, accurately assess and/or treat pressure ulcers for 2 of 7 (Residents #2 and 53) sampled residents with pressure ulcers. The facility's failure to timely identify, accurately assess and/or treat pressure ulcers resulted in actual harm to Resident #2, and #53 when the pressure ulcers deteriorated. The findings included: 1. Review of the NPUAP quick reference guide defined a Stage II (2) pressure ulcer as, .Partial thickness loss of dermis, presenting as a shallow open ulcer with a red pink bed, without slough. May also present as an intact or open/ruptured serum filled blister . Review of the NPUAP quick reference guide defined a Stage III (3) pressure ulcer as, .Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling . Review of the NPUAP quick reference guide defined a Stage IV (4) pressure ulcer as, .Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleous do not have (adipose) subcutaneous tissue and these ulcers can be shallow . Stage IV ulcers can extend into muscle and/or supporting structures . making osteo[DIAGNOSES REDACTED] (bone infection) or osteitis (bone inflammation) likely to occur. Exposed bone/muscle is visible or directly palpable . Review of the NPUAP quick reference guide defines an Unstageable wound as, .full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Stage III (3) or IV (4) . 2. The facility's Pressure Ulcer Risk Assessment policy documented, .The purpose of this procedure is to provide guidelines for assessment and identification of residents at risk of developing pressure ulcers .Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues .Pressure ulcers are a serious skin condition for the resident .Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated .Staff will perform routine skin inspections (with daily care) .Nurses will conduct skin assessments at least weekly to identify changes .Document the procedure .The type of assessment conducted .the name and title (or initials) of the individual who conducted the assessment .If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal . 3. Medical record review revealed Resident #2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A skin assessment dated [DATE] documented, .RESIDENT SKIN ASSESSED PER TREATMENT NURSE .READMISSION .SCAR TISSUE NOTED TO SACRAL AREA . Review of a quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #2 was severely cognitively impaired, was totally dependent on staff for all activities of daily living (ADLs) and did not have any pressure ulcers. The Braden Risk Assessment Reports (indicating risk for developing pressure ulcers) dated 6/15/16 documented a Braden score of 12 indicating the resident was at high risk for developing pressure ulcers. Review of an annual MDS dated [DATE] documented Resident #2 was severely impaired cognitively, was totally dependent on staff for all ADLs and did not have any pressure ulcers. A care plan dated 9/6/16 documented, .Problem .Resident has Pressure Ulcer (s) .SACRUM ONSET 09/06/2016 .STAGEII .Approach .9/20/16 wound treatment as ordered . The weekly skin report dated 9/6/16 documented, Wound Location: .Sacrum .Wound Type .Open Area .Status: Ulcer .L (length) 0.8 x W (width) 0.9 x D (depth) 0.1 .Present On Admission: False . A Wound Physician (WP) note dated 9/7/16 documented, Was asked to see this resident yesterday by 3rd floor staff nurse with concerns of open area noted to sacrum with pink tissue with no drainage or odor . Review of the physician's wound care order dated 9/14/16 revealed .Cleanse sacral wound c (with) wound cleanse (WC). Pat dry. Apply a [MEDICATION NAME] dressing QOD (every other day) for 14 days . An Interdisciplinary Team (IDT) Note dated 9/16/16 documented, .At risk review per IDT r/t (related to) Stg (Stage) II IHPU (in house acquired pressure ulcer) on Sacrum . The Braden Risk Assessment Reports (indicating risk for developing pressure ulcers) dated 9/22/16 documented a Braden score of 12 indicating the resident was at high risk for developing pressure ulcers. The Weekly Wound report dated 9/22/16 documented, .Wound Location: .Sacrum .Wound Type: .Pressure Ulcer .Wound Measurements (LxW) 0.2000 x 0.2000cm (centimeters) .Depth: 0.1000cm . Stage 3 . The report revealed the pressure ulcer had deteriorated from a stage 2 to a Stage 3. A Weekly Wound assessment dated [DATE] and 9/28/16 documented, .Wound Location .Sacrum .Wound Measurements 0.2000 (L) centimeters (cm) x 0.2000 (W) cm .Depth (D) 0.1000cm Present On Admission: False Wound Stage .3 . The WP evaluation dated 9/27/16 documented, .She presents with a stage 2 wound sacrum of at least 21 days duration. There is light serous exudate . with measurements of 0.3 (L) x 0.3 (W) x 0.1 (D) cm. and no change in progress . The WP note revealed the wound had increased in size by 0.1 cm. Review of the physician's wound care order dated 9/28/19 revealed .Continue with Calcium Alginate and [MEDICATION NAME] to sacral wound until resolved . Review of the Weekly Condition Report (WCR) dated 9/28/16 revealed Resident #2 had a sacral wound with a date identified of 9/6/16 with an initial stage of UN (unstageable) of the sacrum. There was a line drawn through the UN and stage 3 was written in. The WCR revealed the pressure ulcer was initially identified on 9/6/16 as unstagable and then changed to a Stage 3. The care plan with the same date of 9/6/16 documented the initial pressure ulcer was a Stage 2. The Weekly Wound report dated 9/28/16 documented, .Wound Location: .Sacrum .Wound Type: .Pressure Ulcer .Wound Measurements 0.3000 (L) x 0.3000 (W) cm .0.1000 (D) cm .Wound Stage: stage 3 . An IDT Note dated 9/30/16 documented, .IDT/PAR (Patient At Risk) review r/t FAPU (facility acquired pressure ulcer), Stage III (3) to Sacrum . Review of the physician's wound care order dated 10/3/16 revealed, .Continue Calcium Alginate c [MEDICATION NAME] QOD until resolved . There was not an order to discontinue the wound treatment and the wound was still present on 10/4/16. Review of the Weekly Pressure Wound Tracking report dated 10/4/16 - 10/10/16 revealed Resident #2 had a stage 3 pressure ulcer to her sacrum. A WP progress note dated 10/4/16 documented, .PLEASE NOTE TYPOGRAPHICAL ERROR, THE WOUND STAGE CHANGED FROM STAGE 2 STAGE 3 . Review of a treatment administration record (TAR) dated 9/1/16 through 9/30/16 revealed there was no documentation the treatments were administered as prescribed on 9/17, 9/18, 9/19, 9/20, 9/21, and 9/22/16. D/C (discontinue) was written on each date from 9/22/16 through 9/30/16. There was no physician's order to discontinue the wound treatment and the wound was still present on 10/4/16. Review of a TAR dated 10/1/16 through 10/31/16 revealed that treatments were not documented as performed on 10/1/16, 10/2/16 or 10/3/16. Observations in Resident #2's room on 10/4/16 at 1:15 PM, revealed Licensed Practical Nurse (LPN) #1 preparing to perform wound care. The dressing dated 10/4/16 was removed by LPN #1. The sacral wound was dry with pink tissue approximately 0.1cm x 0.1 cm x 0.1 cm. There was no odor noted. Interview with LPN #1 on 10/4/16 at 12:50 PM, in the Chapel, LPN #1 was asked about the missed treatments and documentation. LPN #1 stated, .I did assess it on 9/7/16 I think that I am the one that found it and I did not know how to do Wound Sense at that time .it was pink tissue Stage 2, I guess. 9/7/ (16) is the first day I rounded with (Named wound Doctor) .when the wound went from stage 2 to 3, I gave her that, it developed a little bit of slough so we had to call it a 3 .I was new to EMAR (electronic documentation system), I wasn't clear about click on the box and not just mark it . LPN #1 was asked how she documented treatments on the 8th, 10th, 12th, 14th, and 16th and nothing else until 9/22 when the TAR documentation showed the treatments were discontinued. LPN #1 was asked if she was unsure of how to document, how she documented on those dates? LPN #1 stated, .I just got lucky .we rewrite the order every 14 days if it is not changed . LPN #1 was asked why the TAR had discontinue if the order was still current. LPN #1 stated, .I don't know, I don't dc (discontinue) them . Interview with LPN #1 on 10/4/16 at 1:00 PM, in the elevator, LPN #1 stated, .when I came here around 9/6 (16) I was used to the paper TAR. I was unsure about the computer system .I had to learn it on my own. The SDC (Staffing Development Coordinator) didn't even know how to use it . Interview with the Director of Nursing (DON) on 10/4/16 at 2:35 PM, in the Chapel, the DON was shown the IDT notes from 9/16/16 documenting a stage 2 IHPU on the sacrum, the IDT note dated 9/30 documented a stage 3 to the resident's sacrum and the WP's note on 9/6/16 that documented a stage 2 wound on the resident's sacrum. The DON was asked why the wound deteriorated between 9/16 and 9/30. The DON stated, Let me look at my notes before I answer that . At 2:55 PM, the DON stated, .It started out as 2 but we had to say a 3 because of slough. It was superficial. It was a small open area. It wasn't large enough to warrant a catheter, it is in the crack .it could be my mistake with the computer . Telephone interview with the WP on 10/4/16 at 3:40 PM, the WP was asked if the wound deteriorated from a stage 2 to a stage 3 due to the discrepancy in documentation. The WP stated, .Let me look at my notes .it was as stage 2 on both of my notes I have a stage 2 .I think it was my error . The WP was asked if treatments not being done as ordered could cause a wound to deteriorate. The WP stated, .If missed treatment, it could .they had a gap with the weekend, the nurses, some worked over .I don't know if they had a dedicated weekend nurse (for treatments) or not .that computer system I'm not sure about it, but it seems a bit much . Interview with the DON on 10/4/16 at 4:00 PM, in the Administration office, the DON was asked who does treatments on the weekend when LPN #2 is off, since she works Monday through Friday. The DON stated, .(LPN #1) has worked last 2 Saturdays and (LPN #4) will do treatments when (LPN #1) is off. (LPN #3) used to do treatments; I am looking for a weekend treatment nurse . Interview with the DON on 10/4/16 at 5:45 PM, in the Chapel, the DON was asked about the omitted treatments on the TAR. The DON stated, .We had some issues with EMAR and (Named Electronic Wound Program). We noticed in March documented treatments were missing and people that did not have wounds were where it was showing up. We could pull it up electronically and see the treatments were done, but would not show up on print out. We also had that issue in July . The DON was asked if she could pull it up electronically now and see that. The DON stated, .No . The DON was then asked if there was any back up documentation to show that treatments had been done. The DON stated, No . The DON was asked if there was a work order or something that would show the concern with the documentation in the electronic system. The DON stated, No .we QA'ed it in April . There was no documentation provided from April. The facility's failure to timely identify, accurately assess and/or treat the pressure ulcer resulted in actual harm when Resident #2 developed an unstageable pressure ulcer to her sacrum. 4. Medical record review revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the WOUND CARE SPECIALIST EVALUATION of the stage 3 coccyx wound revealed the wound on 5/3/16 to measure 0.4 L x 0.2 W x 0.3 D in cm. Review of the May 2016 Weekly Wound of the Stage 3 coccyx wound revealed the following wound measurements: a. 5/11/16 0.1 L x 0.3 W x 0.6 D b. 5/18/16 0.2 L x 0.1 W x 0.4 D There were no weekly wound assessments provided for the stage 3 coccyx wound for the week of 5/25/16. Review of the June 2016 Weekly Wound revealed on 6/1/16 the Stage 3 coccyx wound measured 0.5 L x 0.2 W x 0.4 D. The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #53 had a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #53 is cognitively intact per staff assessment and had one stage three pressure ulcer with length (L) 1.7 centimeters (cm) width (W) 0.7 cm depth (D) 0.3 cm. A physician order dated 9/8/16 documented, .APPLY HYDRAGUARD BARRIER CREAM WITH EACH INCONTINENT EPISODE .SACRAL WOUND . The care plan dated 7/17/15 and revised on 9/14/16 documented, .Problem .at risk for developing skin breakdown due to needs assist with bed mobility .history of pressure ulcers, left above knee amputation .poor appetite . Approach .Provide treatments as ordered . There was no documentaion that wound care was administered as ordered from 9/7/16 through 9/29/16. Review of the September 2016 Weekly Wound of the Stage 3 coccyx wound revealed the following measurements: a. 9/6/16 2.1 L x 1.0 W x 0.6 D b. 9/14/16 1.5 L x 0.5 W x 0.5 D c. 9/21/16 2.0 L x 2.0 W x 0.1 D A physician order dated 10/4/16 documented, .[MEDICATION NAME] packing to undermining area q (every) day x 14 days Start 10-5-16 . The pressure ulcer had become larger in size and developed undermining. Observations in Resident #53's room, on 10/12/16 at 10:03 AM, revealed LPN #1 preparing to perform wound care. Upon entering the room LPN #1 stated, .I've already measured the wound it's .2.2 (L) lx1.2 (D) x 0.5 (D) .only difference is undermining 3x5 .treatment everyday I think the problem is she doesn't eat . Interview with LPN #1 on 10/4/16 at 5:24PM, in the Chapel. LPN #1 was asked about Resident #53's pressure wound. LPN #1 stated, I got here .around the 6th of September .it has progressed .not bad .it's a stage 4 now .that's what I've known it as .it has undermining .the surface area is smaller .I think its deteriorated because of nutrition status and her comorbities .she is heavy . LPN #1 was asked where she documented the wound treatments. LPN #1 stated, .should have a zero on it .this is all new to me. LPN #1 confirmed that treatments were not performed. Interview with the DON on 10/4/16 at 5:57 PM, in the Chapel, the DON was asked about Resident #53's pressure ulcer. The DON stated, .I don't think she had wounds when she came in. The DON was asked if she knew the stage of Resident #53's pressure ulcer. The DON stated, .I think it's a three . The DON was asked if empty spaces on the TAR mean that no wound care was provided. The DON stated, .means no documentation . Interview with LPN #1 on 10/4/16 beginning at 6:20 PM, in the Chapel, LPN #1 was shown Resident #53's weekly assessment where she had staged Resident #53's pressure wound as a stage 3. LPN #1 was asked if Resident #53 had a stage 3 or a stage 4 pressure ulcer. LPN #1 stated, .it's a stage 3 or a stage 4 .it's a stage 4 because it's on her coccyx . At 6:38 PM, LPN #1 returned to the Chapel and stated, .it is a stage 4 .the doctor did an addendum that it wasn't a stage 4 because can't see bone . Interview with LPN #1 on 10/12/16 at 3:43 PM, in the Chapel, LPN #1 was asked if Resident #53 should be receiving weekly wound assessments. LPN #1 stated, .yes . LPN #1 was asked about the empty spaces on the TAR for the month of September for wound care. LPN #1 was unable to provide documentation that wound care had been provided from 9/7/16 through 9/29/16. Interview with LPN #3 on 10/13/16 at 9:38 AM in the Chapel, LPN #3 was asked if she used to be the facility's wound nurse. LPN #3 stated, Yes . LPN #3 unit was asked if she had provided wound care treatments for Resident #53 . LPN #3 stated, Yes . LPN #3 was shown the September 2016 TAR where no treatments had been documented from 9/7 to 9/29 and was asked if she could provide documentation for wound care for those dates. LPN #3 stated, No . The facility was unable to provide documentation the resident's wound care was performed as ordered, the wound became larger in size and developed undermining, resulting in in actual harm to Resident #53.

Based on policy review, medical record review, observation and interview, the facility failed to follow physician orders [REDACTED].#53, and 90) sampled residents reviewed for nutrition of the 36 included in the stage 2 review. The failure to provide nutritional interventions resulted in an avoidable significant weight loss and harm to Residents #53 and #90. The findings included: 1. Review of the facility's Weight Monitoring policy documented, .Interventions for Weight Management .if significant weight change is identified .the physician and responsible party will be notified .Residents will be weighed weekly X 4, and reviewed until the resident's weight has stabilized or the issue is resolved . 2. Medical record review revealed Resident #53 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the DATA COLLECTION/EVALUATION NUTRITIONAL report dated 2/19/16 revealed, .Problem .Increased protein and calorie needs, unintentional wt (weight) loss, altered nutrition .Etiology .related to skin breakdown, possible protein calorie malnutrition .evidenced by pressure area, 5.7% wt loss upon readmission .Nutrition Plan .promod 4oz (ounces) BID (twice a day), med pass 4oz BID, amino acids, Vit (vitamin) C, Zinc Sulfate, MVI (multivitamins) . Review of the monthly weight records revealed the following: 4/6/16 the resident weighed 191.2 pounds (lbs) 5/4/16 the resident weighed 181.8 pounds lbs 6/8/16 the resident weighed 177 pounds lbs (revealing a 14.2 pound, 7.42% significant weight loss in 2 months). Review of the DATA COLLECTION/EVALUATION NUTRITIONAL report revealed, .06/16/16 .1.1% wt loss x (times) 30 days .4.3% x 90 days. Currently on weekly weights .med pass TID (three times a day) .Resident reported good appetite .no problem noted with chewing/swallowing . There was no documentation of interventions to address the weight loss until 6/16/16 when the med pass was increased to TID. Further review of the monthly weight records revealed the following: 7/6/16 the resident weighed 179 pounds lbs 8/5/16 the resident weighed 164 pounds lbs The annual Minimum Data Set ((MDS) dated [DATE] documented Resident #53 had a Brief Interview for Mental Status (BIMS) score of 13 indicating Resident #53 was cognitively intact per staff assessment and had weight loss. The care plan dated 7/17/15 and revised on 9/1/16 documented, .Problem .is at nutrition risk for unavoidable weight loss due to .poor PO intake, current unhealed pressure wound decreased protein status, .Approach .Weigh and monitor results .report any significant changes to physician . Review of the monthly weight records revealed on 9/7/16 the resident weighed 163.2 pounds lbs (revealing an additional 15.8 pound (8.8 %) significant weight loss in 2 months.) Review of the DATA COLLECTION/EVALUATION NUTRITIONAL report revealed, 09/24/2016 .Recent weight 162.2 .On weekly weights .Diet intake 25-100% with brk(breakfast) and lunch 0-25% with dinner .new order .assist pt (patient) with meals .wt loss per NP (nurse practitioner) .Pt welcomes assistance with intake. She reported that sometimes she gets tired. No new interventions at this time . Review of telephone orders revealed on 9/12/16 the physician ordered to assist Resident #53 with all meals due to weight loss. Observations in Resident #53's room on 10/12/16 at 8:35 AM, revealed Resident #53 lying in bed, with breakfast tray sitting on the bed table with no staff in room assisting her as ordered. Observations in Resident #53's room on 10/12/16 at 6:04 PM, revealed Resident #53 lying in bed, with her uneaten supper tray sitting on the bed table with no staff in room assisting her as ordered. Interview with Certified Nursing Assistant (CNA) #1 on 10/12/16 at 6:20 PM, by the third floor nurse's station, CNA #1 was asked if she assisted Resident #53 with her meals. CNA #1 stated, .no, she is just a set up . Interview with CNA #2 on 10/13/16 at 8:59 AM, by the third floor nurse's station, CNA #2 was asked if she assisted Resident #53 with her meals. CNA #2 stated, .we normally set it up for her and come back .sometimes she eats good and sometimes she don't . Observations and interviews revealed Resident #53 had not received the assistance with meals as ordered. There were no other interventions implemented to address the weight loss. Further review of the monthly weight record revealed continued significant weight loss on 10/4/16 with the resident weighing 150.8 pounds lbs. This was an additional 12.4 pounds (7.5%) significant weight loss in 1 month. The DATA COLLECTION/EVALUATION NUTRITIONAL report revealed, .10/10/2016 .Recent weight 150.8 .PO (by mouth) continues to be inadequate which is contributing to continued wt. loss .Diet order and supplements provided to meet needs if at least 75% consumed. Will continue with current POC (plan of care) .No further recommendations at this time . There was no documentation additional interventions were implemented to address the continued significant weight loss. Interview with Registered Dietician (RD) #1 on 10/12/16 at 11:59 AM, in the chapel, RD #1 was asked about Resident #53's weight loss. RD #1 stated, .has a history of [MEDICAL CONDITION] and current breast mass .not for sure if that's the contributing factor .on multiple supplements .25-50% intake from lunch and dinner .I have recommend appetite stimulate . RD #1 was asked when she had recommended it . RD #1 stated, .I don't see it . RD #1 was asked what a signification weight loss is. RD #1 stated, 5% in a month . RD #1 was informed Resident #53 lost 13 lbs from September to October 2016 and was asked what interventions she had put in place. RD #1 stated, .saw her on 9/24 was my last note .last intervention .6/16 .was fortified foods . RD #1 was asked what the weight loss percentage for Resident #53 was for the last 30, 90 and 180 days. RD #1 stated, .7.6% in one month for October .for 3 month 15.8% .6 months .21.1% . RD #1 was asked if that was a significant weight loss. RD #1 stated, Yes, Ma'am . RD #1 stated, .she is on weekly weights . RD #1 was asked does she have a weight for the third week of September. RD #1 stated, No Ma'am . RD #1 was asked should there have been. RD #1 stated, Yes, Ma'am . RD #1 was asked what weight she used for her assessment on September 24th. RD #1 stated, . 9/16 .I saw her on the 24th .we get weekly report we go through and circle the significant changes .but it wouldn't show significant for one week would be for two weeks . RD #1 returned to the chapel at 12:57 PM and presented the Resident Weight Report Weekly and stated, she wasn't circle .I should have reviewed it . RD #1 was asked if Resident #53 had an assessment that week. RD #1 stated, .not by me . RD #1 was asked with Resident #53's 9.2 lb recent weight loss should she have looked at her. RD #1 stated, .she should had been looked at . RD #1 was asked when was Resident #53's last assessment. RD #1 stated, .10/11 . RD #1 was asked was anything put in place for the recent weight loss of 12 lbs . RD #1 stated, .no . RD #1 was asked should there have been interventions put in place. RD #1 stated, .there will be when we get through talking . There was no documentation an appetite stimulant or fortified foods was recommended by the RD. The RD failed to identify, accurately reassess, and implement nutritional interventions to address the continued significant weight loss Resident #53 sustained. Interview with the Nurse Practitioner (NP) on 10/12/16 at 1:15 PM, on the 3rd floor nurses station, the NP was shown Resident #53 weekly weight report regarding her weight loss. The NP was working on Resident #53's history and physical with a weight of 163 lbs documented for 10/5/16, and was asked where she had gotten that weight. The NP stated, .I went by 9/7 . The NP was shown the weekly weight report that documented her current weight on 10/4 was 150.80 lbs which was a 13 lb weight loss. The NP was asked should there have been an intervention put in place for the 13 lb weight loss. The NP stated, .didn't know about all this .definitely going to do something about it . I'm just floored that this has got by us .we haven't done what we needed to do .I will be on top of this .I had no idea her weight had dropped .oh my gosh that's huge . The facility's failure to identify, accurately assess and provide nutritional interventions resulted in harm to Resident #53 who had an avoidable significant weight loss. 3. Medical record review revealed Resident #90 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the weight records revealed that Resident #90 weighed 91.3 pounds on 10/4/16 and 85.8 pounds on 10/12/16. Resident #90 had a 6% weight loss in 8 days which represented a severe weight loss. A physician's orders [REDACTED].D/C (discontinue) CCHO (controlled carbohydrate) portion of diet .Nepro (with) meals and HS (bedtime) .early lunch on [MEDICAL TREATMENT] days . Review of the Medication Administration Record [REDACTED]. Observations in Resident #90's room on 10/12/16, beginning at 10:10 AM, revealed CNA #3 preparing Resident #90 for [MEDICAL TREATMENT] transport. Resident #90 was transported to [MEDICAL TREATMENT] at 10:40 AM. Resident #90 did not receive an early lunch tray before he went to [MEDICAL TREATMENT]. Interview with Dietary Staff #1 on 10/12/16 at 10:46 AM, in the hallway outside the kitchen, Dietary Staff #1 was asked what Resident #90 received before he went to [MEDICAL TREATMENT]. Dietary Staff #1 stated, .a sack lunch .pudding, Ensure Clear and an applesauce .we always give pudding, 2 puddings, applesauce and Ensure Clear in his sack lunch for [MEDICAL TREATMENT] . Interview with Registered Nurse (RN) #1 on 10/12/16 at 6:28 PM, at the second floor nurses station, RN #1 was asked if the 10/7/16 physician's orders [REDACTED]. RN #1 looked at the electronic record for Resident #90 and stated, It's not in here. RN #1 was asked if Resident #90 had received an early lunch tray on [MEDICAL TREATMENT] days and had Resident #90 been receiving the Nepro as ordered. RN #1 stated, No ma'am .the nurse signed it off but she didn't put it in the computer .it makes me want to check all the orders written that day . Interview with the Director of Nursing (DON) on 10/13/16 at 11:25 AM, in the chapel, the DON was asked if nursing staff should put the physicians orders in the computer to make sure they get on the electronic MAR. The DON stated, Yes, they should. Interview with the DON on 10/13/16 at 1:43 PM, in the chapel, the DON was asked if nurses should transcribe orders on the MAR indicated [REDACTED]. The DON stated, .Well I don't think orders should be written late on Friday . The DON was asked if she expected nurses on every shift to be able to transcribe orders to make sure they get put in the electronic system and on the MAR. The DON stated, Yes, but there should still be some communication . The DON was asked if she thought there was a communication breakdown between the nurses and the registered dietician. The DON stated, With her .I sure do . The facility failed to provide recommended and ordered nutritional interventions that resulted in an avoidable significant weight loss and harm to Resident #90.

Based on review of the Administrator's job description, policy review, medical record review, observation and interview, the Administrator failed to ensure pressure ulcers were timely identified, accurately assessed and/or treated which resulted in actual harm to Residents #2 and #53, the Administrator failed to ensure physician orders [REDACTED].#53 and #90. The Administrator failed to ensure the quality assurance (QA) program identified and addressed concerns within the facility. The findings included: 1. Review of the Administrator JOB DESCRIPTION revealed, .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company Policies, with focus on maintaining excellent care for the residents .Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services . 2. Interview with the Director of Nursing (DON) on 10/4/16 at 5:45 PM, in the Chapel, the DON was asked about the omitted treatments for pressure ulcers on the treatment records. The DON stated, .We had some issues with EMAR and (Named Electronic Wound Program). We noticed in March documented treatments were missing and people that did not have wounds were where it was showing up. We could pull it up electronically and see the treatments were done, but would not show up on print out. We also had that issue in July . The DON was asked if she could pull it up electronically now and see that. The DON stated, .No . The DON was then asked if there was any back up documentation to show that treatments had been done. The DON stated, No . The DON was asked if there was a work order or something that would show the concern with the documentation in the electronic system. The DON stated, No .we QA'ed it in April . There was no documentation provided from April. 3. Interview with the Administrator on 10/13/16 at 7:30 PM in the Administrator's office, the Administrator was asked if there had been any concerns with weight loss. The Administrator stated, .I knew there were concerns in August .didn't have calibration guy come .the maintenance man from another building came .it was my second day .had calibrated in August .We identified it (weight loss) in September . The Administrator was asked what interventions were put in place at that time. The Administrator stated, .Resident evaluations on admission .weight every week for 4 weeks after that, then every month .and RD interventions . The Administrator was asked if nurses should do weekly weights recommended by the RD for residents The Administrator stated, Yes. The Administrator was asked if she expected interventions to be put in place for significant weight loss. The Administrator stated, I would expect, yes . The Administrator was asked if there had been concerns with physician orders [REDACTED]. The Administrator stated, I don't know the answer . The Administrator was asked if the facility experienced computer problems would some sort of back up charting for nurses be in place. The Administrator stated, I know you have to have a back up system .you have to have paper .have to prove that you do it . The Administrator was asked if she had concerns with lost documentation. The Administrator stated, That was before my time. The Administrator was asked if the facility had identified any concerns with wound assessments and treatments not being performed or documented correctly. The Administrator stated, I don't think so. 4. Telephone interview with the Medical Director (MD) on 10/13/16 at 5:45 PM, the MD was asked if he was aware of any problems with electronic documentation. The MD stated, There was one problem we had with communication/documentation, unfortunately. There are a couple of different programs .there's one for the medications which is a propriety thing for (named pharmacy), another for notes, another for wounds .They're not integrated per se. We have had some issues come up. In QA (Quality Assurance) meeting we talked about that, maybe sometime between March and June. I'm not sure exactly, but would probably say maybe April or May. We were to develop an intervention or to address the documentation in (the electronic wound program). The Medical Director (MD) was asked if the nurse was told to write in the chart or some other way to back up the electronic records during the time there were problems. The MD stated, I don't know if they had a back up. I don't know. I apologize. The MD was informed during survey that wounds were identified with missing treatments or assessments. The MD was asked whether he expected nurses to perform wound assessments and treatments as ordered. The MD stated, Absolutely. The MD was asked whether he expected them to document when a treatment or assessment was completed. The MD stated, Absolutely, if you've done the treatments, it needs to be documented. Administration failed to identify, develop and implement appropriate plans of action to ensure care plans were revised to reflect the current status of pressure ulcers that resulted in actual Harm to Resident #2. Refer to F280 Administration failed to identify, develop, and implement appropriate plans of action to ensure care plan interventions were implemented for care of residents with pressure ulcers resulting in actual harm to Residents #2 and #53. Refer to F282 Administration failed to ensure nurses completed timely wound assessments, accurately assessed and/or treated pressure ulcers resulting in actual harm to Residents #2 and #53. Refer to F314 Administration failed to identify, develop, and implement appropriate plans of action and failed to follow up on the implementation of the plan to prevent further weight loss that resulted in actual Harm to Residents #53 and #90. Refer to F325 Administration failed to ensure an effective Quality Assurance program that recognized an ongoing concern with weight loss and wound care interventions that resulted in actual Harm to Residents #2, #53 and #90. Refer to F520

Based on review of the Administrator's job description, record review, medical record review, observation and interview, the facility failed to ensure an effective Quality Assurance (QA) program that recognized an ongoing concern with pressure ulcers and weight loss, identified the root cause of the problems, developed appropriate plans and ensured systems and processes were in place and consistently followed by staff to address quality concerns. The QA committee failed to address concerns to ensure residents at risk for pressure ulcers had accurate assessments and that ordered treatments were administered, that interventions to prevent weight loss were consistently implemented or followed, and that the facility was administered in a manner that enabled it to use its resources effectively and efficiently. Failure of the facility to accurately assess and provide treatments resulted in actual harm to Resident #2 and #53 when the pressure ulcers deteriorated. Failure of the facility to implement and/or provide interventions for residents with significant weight loss resulted in actual harm to Resident #53 and #90. The findings included: 1. A typed note dated May 5, 2016 documented, Ad Hoc QA (Quality Assurance) R/T (related to) E-MAR/TAR (Electronic Medication Record/Treatment Administration Record) (Named Electronic Wound Program) Loss of Documentation Random charts have been noted to have lost documentation of treatments in the TAR and (Named Electronic Charting Program for wounds) . 2. Review of a QAPI (Quality Assurance Program Improvement meeting) sign in sheet dated 5/5/16 documented the Director of Nursing (DON), Administrator, and the Medical Director's signatures as present at the meeting. 3. An Email (electronic mail) related to (Named Electronic Charting Program for wounds) documentation dated 7/25/16 documented, .I will discuss this personally with the physicians and follow up with the nurse (Named Electronic Wound Program) has been unreliable over the past 3 months. Documentation has been lost, transposed on the wrong patients and this concern has been reflected in our QA minutes . This Email was signed by the DON. 4. Interview with the DON on 10/4/16 at 5:45 PM, in the Chapel, the DON was asked about the omitted treatments on the treatment records. The DON stated, .We had some issues with EMAR and (Named Electronic Wound Program). We noticed in March documented treatments were missing and people that did not have wounds were where it was showing up. We could pull it up electronically and see the treatments were done, but would not show up on print out. We also had that issue in July . The DON was asked if she could pull it up electronically now and see that. The DON stated, .No . The DON was then asked if there was any back up documentation to show that treatments had been done. The DON stated, No . The DON was asked if there was a work order or something that would show the concern with the documentation in the electronic system. The DON stated, No .we QA'ed it in April . There was no documentation provided from April. Interview with the DON on 10/13/16 at 1:43 PM, in the Chapel, the DON was asked if nurses should transcribe orders in the MAR so they will be on the MAR to be performed for residents such as Resident #90 to receive supplements. The DON stated, .Well I don't think orders should be written late on Friday . The DON was asked if she expected nurses on every shift to be able to transcribe orders to make sure they get put in the electronic system and on the MAR. The DON stated, Yes, but there should still be some communication . The DON was asked if she thought there was a communication breakdown between the nurses and the registered dietician. The DON stated, With her .I sure do . Telephone interview with the Medical Director (MD) on 10/13/16 at 5:45 PM, the MD was asked if he was aware of any problems with electronic documentation. The MD stated, There was one problem we had with communication/documentation, unfortunately. There are a couple of different programs .there's one for the medications which is a propriety thing for (named pharmacy), another for notes, another for wounds .They're not integrated per se. We have had some issues come up. In QA (Quality Assurance) meeting we talked about that, maybe sometime between March and June. I'm not sure exactly, but would probably say maybe April or May. We were to develop an intervention or to address the documentation in (Named Electronic Wound Program). MD was asked if the nurses were told to write in the chart or some other way to back up the electronic records during the time there were problems. The MD stated, I don't know if they had a back up. I don't know. I apologize. The MD was informed during survey that wounds were identified with missing treatments or assessments. The MD was asked whether he expected nurses to perform wound assessments and treatments as ordered. The MD stated, Absolutely. The MD was asked whether he expected them to document when a treatment or assessment was completed. The MD stated, Absolutely, if you've done the treatments, it needs to be documented. 5. The facility's QA Committee failed to identify, develop and implement appropriate plans of action to ensure timely and accurate identification of pressure ulcers, and providing treatments as ordered, that resulted in actual Harm to Resident #2 . Refer to F280 6. The facility's QA committee failed to identify, develop, and implement appropriate plans of action to ensure care plan interventions were implemented for care of residents with pressure ulcers that resulted in actual harm to Residents #2 and #53. Refer to F282 7. The facility's QA committee failed to ensure nurses completed timely wound assessments, and accurately assessed and/or treated pressure ulcers that resulted in actual harm to Residents #2 and #53. Refer to F314 8. The facility's Quality Assurance committee failed to identify, develop, and implement appropriate plans of action and to follow up on the implementation of the plans to address/prevent weight loss that resulted in actual Harm to Residents #53 and #90. Refer to F325 9. The facility's QA committee failed to identify, develop and implement appropriate plans of action and to follow up on the implementation of the plan to ensure the facility was administered in a manner to use its resources effectively and efficiently to maintain the highest practicable well being of Residents #2, #53, and #90. Refer to F490

Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention, policy review, medical record review, observation and interview, the facility neglected to provide services to avoid physical harm related to the in house development of unstageable pressure ulcers for 5 of 9 (Resident #3, 22, 23, 24, and 25) sampled residents with pressure ulcers. The facility neglected to prevent the development of avoidable in-house pressure ulcers and failed to identify pressure ulcers before they were unstageable which placed Resident #3, 22, 23, 24, and 25 in immediate jeopardy (IJ). Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 8/26/15 at 5:00 PM in the conference room. The facility was cited an Immediate Jeopardy at F224-K which is Substandard Quality of Care. A partial-extended survey was completed on 8/28/15. The Immediate Jeopardy is effective 3/17/15, and is ongoing. The findings included: 1. The facility .Neglect. policy documented, .neglect. prohibited. Neglect - means failure to provide goods and services necessary to avoid physical harm. The facility will ensure that prevention techniques are implemented to identify, correct and intervene in situations where abuse and/or neglect are more likely. Proper assessment, care planning and monitoring of residents with needs. which might lead to. neglect. The Skin Management and Prevention policy documented, .3. If a skin alteration (wound) is identified the nurse will notify the physician to obtain a treatment order. 12. On shower/bath days, CNAs (Certified Nursing Assistant) will complete total body skin observations. If a new skin issue is identified, the CNA will report it to the charge nurse and a copy of the form will be given to the ADON (Assistant Director of Nursing)/designee. 2. The National Pressure Ulcer Advisory Panel Pressure Ulcer Prevention Quick Reference Guide, documented, .The purpose of the prevention recommendations is to guide evidence-based care to prevent the development of pressure ulcers. The guideline is intended for the use of health care professionals who are involved in the care of patients and vulnerable people who are at risk of developing pressure ulcers. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Unstageable / Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III (Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include underminng and tunneling) or IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling). Skin Assessment. Each health care setting should have a policy in place that includes recommendations for a structured approach to skin assessment. It should make clear recommendations for documenting skin assessment and communicating information to the wider health care team. Educate professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [MEDICAL CONDITION], and induration (hardness). Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. Ongoing assessment of the skin is necessary to detect early signs of pressure damage. Pressure Ulcer Prevention Points. Implement pressure ulcer prevention educational programs that are structured, organized, comprehensive, and directed at all levels of health care providers, patients, family, and caregivers. Include mechanisms to evaluate program effectiveness in preventing pressure ulcers. 3. Closed medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 3/10/15 documented, .Potential for skin breakdown and pressure ulcers D/T (due to) poor mobilities and B/B (bowel/bladder) Incontinence. OBSERVE SKIN FOR REDNESS/TEARS/SHEARING WITH CARE PROVIDED. A nursing assessment dated [DATE] at 11:00 AM documented, .Newly Developed Pressure Ulcer - Unstageable. LEFT BUTTOCK. CNA (Certified Nurse Assistant) Noted During AM Care. Wound Bed: Slough (moist yellow or gray necrotic tissue). A pressure ulcer record dated 3/17/15 documented, Facility Acquired STAGE Unstageable MEASUREMENTS Length (cm) (centimeters) 4.0 x (by) Width (cm) 1.0 Depth (cm) U (unable to determine). WOUND BED. Slough - moist yellow or gray necrotic tissue. A telephone order dated 3/17/15 documented, Cleanse Left buttock with wound cleanser or normal saline. Apply Santyl, cover with dry dressing. Interview with the certified treatment nurse Licensed Practical Nurse #6, on 8/26/15 at 8:30 AM, in the conference room, Licensed Practical Nurse (LPN) #6 was asked if the pressure ulcer record was the description of what the wound looked like. LPN #6 stated, Yes, If I wrote it (slough) that's what it looked like. Telephone interview with Resident #3's physician, who was also the facility's Medical Director, on 8/26/15 at 1:58 PM, in the conference room, the Medical Director was asked if he expected the facility to notify him of pressure ulcers. The Medical Director stated, Normally we would be notified when the skin changes start. The Medical Director was asked if the notification of the pressure ulcer should have been before it progressed to being unstageable. The Medical Director, stated, Yes, before it got to that stage. Interview with CNA #7 on 8/26/15 at 4:45 PM, on the 300 hall, CNA #7 was asked when should a CNA assess a resident's skin. CNA #7 stated, When we (do) baths, turn, dry (a resident) we check for blisters, scrapes, red areas and report them to the nurse. The facility neglected to prevent the development of an avoidable in-house pressure ulcer and failed to identify the pressure ulcer before it was unstageable with slough. This placed Resident #3 in IJ. 4. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The initial nursing assessment dated [DATE] documented, a Braden score of 13, which indicated a moderate risk for skin concerns, and to proceed to the Interim Plan of Care. The nursing assessment further documented a surgical wound with staples to the right hip, bruising on bilateral hands, and a red/purple area to the left shin. The assessment documented no concerns with the residents heels. The interim care plan dated 7/1/15 documented, .Alteration in skin integrity. Will not develop skin breakdown. Skin assessment weekly. Incontinence care as needed. T&P (turn and position) or reposition q (every) 2 (two) hrs (hours). Treatment as ordered. The CNA bathing report for July 2015, documented Resident #22 had a full bath on 7/6/15 at 1:22 PM and a half bath on 7/7/15 at 3:23 AM. The facility was unable to provide the CNA skin care alert for this resident's wound to be reported to the charge nurse and ADON/designee. A nursing assessment dated [DATE] at 10:00 AM documented, .Newly Developed Pressure Ulcer specific information Location and description of the ulcer: BLACK AREA NOTED TO RIGHT HEEL. Wound Bed: Eschar (Thick, Hard, Leathery, Black Necrotic Tissue). Nursing Interventions. Incontinence Management/ Protection of Body Prominences. A nurse's note, signed by the treatment nurse, dated 7/7/15 documented, .Area of suspected deep tissue injury noted to right lateral heel. New order received for skin protectant wipe to area daily for protection. A pressure ulcer record dated 7/7/15 documented, the right heel wound measured 0.8 centimeters (cm) by (x) 2.0 cm, the the depth was unable to be determined. An intervention for Prevalon boots was put into place. The pressure ulcer record dated 8/10/15, documented .right heel.Unstageable. and measured 2.5 cm by 2 cm, and no depth documented. Observations in Resident #22's room on 8/26/15 at 2:35 PM, revealed the resident in a low bed with mats on the floor at bedside. The head of the bed was approximately 30 degrees, and the resident was fidgeting with her hand, and mumbling. The resident had a Prevalon boot on her right foot. On 8/26/15 at 5:00 PM, the resident had Prevalon boots on both feet, and the resident's son was at the bedside feeding the resident, who had eaten everything on her tray. Observations in Resident #22's room on 8/28/15 at 1:48 PM, revealed Resident #22's right heel pressure ulcer had a black center and yellow slough 1/2 inch round, with a scant amount of drainage on the dressing, with no odor. The facility neglected to accurately assess skin conditions and failed to identify a pressure ulcer until it was unstageable with black eschar which placed Resident #22 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer that developed within one week of the resident's admission. 5. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 8/14/15, documented .Apply Providone Iodine to right heel daily for protection. A care plan dated 7/2/15 documented, .risk for developing skin breakdown. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. float heels in bed or use Prevalon boots. A nursing assessment dated [DATE] documented, .Wound care nurse was doing her rounds and noted deep tissue injury to left heel. Were any new nursing interventions implemented? Yes Document the implemented interventions: tx (treatment) in place. A nurses progress note dated 8/10/15 documented, Wound care nurse (#6) notified nurse (#7) that resident has bilateral heel and ankle deep tissue wound. Staff informed to use heel booths (boots) to keep pressure off. Daily skilled nurses notes dated 8/10/15, 8/11/15, 8/12/15, and 8/13 15 documented no skin concerns. There was no documentation the heel boots had been used to prevent pressure. A pressure ulcer record dated 8/14/15 documented, .right heel.Unstageable. Length (cm) 2 x Width (cm) 2. WOUND BED Eschar - thick, hard, leathery, black necrotic tissue. The CNA bathing report for August 2015, documented Resident #23 had a shower on 8/12/15 at 1:32 PM and a full bath on 8/13/15 at 2:48 PM. The facility was unable to provide the CNA skin care alert for this resident's wound to be reported to the charge nurse and ADON/designee. A CNA skin care alert dated 8/14/15 documented, .Skin Clear: Yes. Observations in Resident #23's room on 8/26/15 at 2:15 PM, revealed Resident #23 in bed facing the ceiling with the head of the bed elevated 30 degrees. Prevalon boots were present on bilateral feet. The resident did not respond verbally to questions. Observations in Resident #23's room on 8/26/15 at 4:00 PM, revealed Resident #23 in bed with Prevalon boots on bilateral feet. Interview with LPN #6 on 8/26/15 at 2:30 PM, on the 300 hall, LPN #6 was asked about the right heel ulcer. LPN #6 stated, Found on 8/14/15 unstageable on right heel 2 by 2 cm, all eschar. On 8/18 it remained 2 by 2 all eschar and on 8/26/15 it measured 2 by 2 and was all eschar. The facility neglected to provide services to accurately assess skin conditions, failed to implement interventions to prevent the development of a pressure ulcer and failed to identify a pressure ulcer before it was unstageable with eschar. This placed Resident #23 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer. 6. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 7/24/15, documented .providine iodine 10% (percent) sol (solution) (L) (left) heel.decubitus ulcer c (with) necrosis. Review of the Braden scale for predicting pressure sore risk dated 5/22/15 revealed the resident was chair-fast, mobility was very limited, and at moderate risk for developing pressure sores. Review of the Minimum Data Set and comprehensive care plan with dates of 6/1/15, revealed the resident was at risk for developing pressure sores. The CNA bathing report for July 2015, documented Resident #24 had a full bath on 7/19/15 at 2:57 PM and a half bath on 7/20/15 at 4:44 AM. The facility was unable to provide the CNA skin care alert for this resident's wound to be reported to the charge nurse and ADON/designee. The weekly skin integrity review dated 7/20/15 documented, .Skin Condition: Skin Intact. harden (hardened) area. New. (foot diagram of left heel circled). A nursing assessment dated [DATE] documented, .Newly Developed Pressure Ulcer - Unstageable. HAS A ECHAR (eschar) AREA TO LEFT FOOT OUTER HEEL AREA. WAS FOUND DURING SKIN ASSESSMENT (7/20/15). TREATMENT NURSE EVALUATED AND IMPLEMENTED A TREATMENT AT THIS TIME. This pressure ulcer was identified on 7/20/15, yet no treatment was implemented until 7/24/15. A pressure ulcer record dated 7/24/15 documented, .left heel.Facility acquired. Unstageable MEASUREMENTS Length (cm): 3.0 x Width (cm) 3.0 x Depth (cm) U. WOUND BED. Eschar - thick, hard, leathery, black necrotic tissue. Observations in the 4th floor resident common area on 8/26/15 at 3:15 PM, revealed Resident #24 sitting in a wheelchair with the left foot supported on the foot rest. The resident's left foot was wrapped in clean and dry Kerlix. Observations of Resident #24, on 8/28/15 at 1:50 PM, revealed Resident #24's left lateral heel had eschar loosening from the pressure ulcer edges with scant amount of drainage with no odor, area was 3.5 cm by 3 cm, unable to determine depth. Interview with Resident #24 on 8/26/15 at 3:15 PM, in the 4th floor resident common area, Resident #24 was asked if he had a sore on his left heel. Resident #24 nodded his head and stated, Yeah. Interview with Nurse #11 on 8/26/15 at 3:25 PM, at the 4th floor nurses' station, Nurse #11 was asked about the documentation on the weekly skin integrity review dated 7/20/15, describing a new hardened area on Resident #24's left heel. Nurse #11 stated, I seen something there (left heel area), forgot to let the treatment nurse know to come up with a plan. It was a hardened area, when I did inform her, she did start a treatment. The facility neglected to provide treatment for [REDACTED].#24 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer. 7. Medical record review revealed Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated 11/10/14 documented, .at risk for developing skin breakdown AND PRESSURE ULCERS D/T (due to) NEED FOR ASSIST WITH MOBILITIES AND B/B (bowel and bladder) INCONT. (incontinence). OBSERVE SKIN WITH ALL CARE PROVIDED FOR REDNESS, RASH, TEARS, MOTTLING (a condition of spotting with patches of red or purple coloring). The CNA bathing report for June 2015, documented Resident #25 had a full bath on 6/8/15 at 2/24 PM, a half bath on 6/8/15 at 2:46 PM and 8:26 PM, and on 6/10/15 at 2:20 PM. The facility was unable to provide the CNA skin care alert for this resident's wound to be reported to the charge nurse and ADON/designee. A nurse's note dated 6/10/15 documented, Resident noted with black eschar to right heel. A pressure ulcer record dated 6/10/15 documented, Facility acquired STAGE Unstageable MEASUREMENTS Length (cm) 4.0 x Width (cm) 5.0 Depth (cm) U. WOUND BED. Eschar- thick, hard, leathery, black necrotic tissue. A physician's orders [REDACTED]. Observations in Resident #25's room on 8/26/15 at 4:50 PM, revealed Resident #25 lying on her back in her bed, Prevalon boots noted on bilateral feet, a clean, dry dressing was on her right foot, the bed was locked in lowest position, and a fall mat was on the floor beside her bed. Observations in Resident #25's room on 8/28/15 at 2:00 PM, revealed Resident #25's right heel pressure ulcer was a 1 inch round wound with yellow/light brown slough, no odor and scant amount of drainage. Interview with the Director of Nursing (DON) on 8/26/15 at 5:18 PM, in the DON's office, the DON was asked if it was acceptable for pressure ulcers to be identified when they were unstageable and having developed eschar. The DON stated, I would hope that it would be found earlier. The facility neglected to provide services necessary to avoid physical harm by failing to identify a pressure ulcer until it was unstageable with eschar and necrosis which placed Resident #25 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer. 8. Interview with certified treatment nurse (LPN #6) on 8/26/15 at 1:25 PM, on the 200 hall, the certified treatment nurse, LPN #6, was asked, Do you feel that the nurses notify you when there are new skin concerns? LPN #6 stated, It's a lot better, now that we have a weekend treatment nurse. In the last few months, I have harped on them (nurses) to initiate a treatment, even if it's wrong. Call the doctor. Still will find notes on my cart to look at someone's wound. LPN #6 was asked if she felt the CNA's were notifying the nurses of new areas. LPN #6 stated, Honestly, they have too much to do. (CNAs) Can't give 15 baths before lunch. No concerns with turning and repositioning, more (concerned) with incontinent care. Interview with LPN #2 on 8/26/15 at 4:55 PM, outside room [ROOM NUMBER], LPN #2 was asked, What is your responsibility if a CNA tells you a resident has a new skin issue. LPN #2 stated, Go assess it, call the doctor, call the family, start a treatment, notify the treatment nurse. Interview with CNA #4 on 8/26/15 15 4:58 PM, on the 200 hall, CNA #4 was asked, What is your responsibility when you find new skin concerns on a resident? CNA #4 stated, Notify the nurse, as soon as you see redness. Interview with CNA #5 on 8/26/15 at 5:05 PM, outside the 200 hall dining room, CNA #5 was asked, What is your responsibility when you find new skin concerns on a resident? CNA #5 stated, Notify the nurse as soon as I find it. Interview with CNA #1 on 8/26/15 at 5:08 PM, outside the 300 hall dining room, CNA #1 was asked, What is your responsibility when you find new skin concerns on a resident? CNA #1 stated, Notify my nurse, make sure she (nurse) checks it (skin). See what she (nurse) wants me to do, cream, boots. The facility neglected to prevent the development of avoidable in-house pressure ulcers and failed to identify pressure ulcers before they were unstageable which placed Resident #3, 22, 23, 24, and 25 in immediate jeopardy.

Based on medical record review, observation and interview, the facility failed to follow the care plan to identify, assess, and provide preventive measures to prevent the development of avoidable in-house pressure ulcers for 4 of 9 (Residents #3, 23, 24, and 25) sampled residents with pressure ulcers. Failure of the facility to identify, assess, and/or provide care and treatments for pressure ulcers resulted in an Immediate Jeopardy (IJ) when Residents #3, 23, 24, and 25 developed avoidable in-house acquired pressure ulcers that were unstageable before they were identified by the staff. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 8/26/15 at 5:00 PM in the conference room. The Immediate Jeopardy is effective 3/17/15, and is ongoing. The findings included: 1. Closed medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 3/10/15 documented, .Potential for skin breakdown and pressure ulcers D/T (due to) poor mobilities and B/B (bowel/bladder) Incontinence. OBSERVE SKIN FOR REDNESS/TEARS/SHEARING WITH CARE PROVIDED. A nursing assessment dated [DATE] at 11:00 AM documented, .Newly Developed Pressure Ulcer - Unstageable. LEFT BUTTOCK. CNA (Certified Nurse Assistant) Noted During AM Care. Wound Bed: Slough (moist yellow or gray necrotic tissue). A pressure ulcer record dated 3/17/15 documented, Facility Acquired STAGE Unstageable MEASUREMENTS Length (cm) (centimeters) 4.0 x (by) Width (cm) 1.0 Depth (cm) U (unable to determine). WOUND BED. Slough - moist yellow or gray necrotic tissue. A telephone order dated 3/17/15 documented, Cleanse Left buttock with wound cleanser or normal saline. Apply Santyl, cover with dry dressing. Interview with certified treatment nurse Licensed Practical Nurse (LPN) #6 on 8/26/15 at 8:30 AM, in the conference room, LPN #6 was asked if the pressure ulcer record was the description of what the wound looked like. LPN #6 stated, Yes, if I wrote it (slough) that's what it looked like. Interview with CNA #7 on 3/26/15 at 4:45 PM, on the 300 hall, CNA #7 was asked when should a CNA assess a resident's skin. CNA #7 stated, When we (do) baths, turn, dry (a resident) we check for blisters, scrapes, red areas and report them to the nurse. The facility failed to implement care plan interventions to accurately assess skin conditions and failed to identify a pressure ulcer before it became unstageable with eschar. This placed Resident #3 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer. 2. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 7/2/15 documented, .risk for developing skin breakdown. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. float heels in bed or use prevalon boots. A nursing assessment dated [DATE] documented, .Wound care nurse was doing her rounds and noted deep tissue injury to left heel. Were any new nursing interventions implemented? Yes Document the implemented interventions: tx (treatment) in place. A nurses progress note dated 8/10/15 documented, Wound care nurse notified nurse that resident has bilateral heel and ankle deep tissue wound. Staff informed to use heel booths (boots) to keep pressure off. Daily skilled nurses notes dated 8/10/15, 8/11/15, 8/12/15, and 8/13 15 documented no skin concerns. There was no documentation that the heel boots had been used to prevent pressure as care planned. A pressure ulcer record dated 8/14/15 documented, Unstageable. Length (cm) 2 x Width (cm) 2. WOUND BED Eschar - thick, hard, leathery, black necrotic tissue. A CNA skin care alert dated 8/14/15 documented, .Skin Clear: Yes. Observations in Resident #23's room on 8/26/15 at 2:15 PM, revealed Resident #23 in bed facing the ceiling with the head of the bed elevated 30 degrees. Prevalon boots were present on bilateral feet. The resident did not respond verbally to questions. Observations in Resident #23's room on 8/26/15 at 4:00 PM, revealed Resident #23 in bed facing the door. Prevalon boots were present on bilateral feet. Interview with certified treatment nurse LPN #6 on 8/26/15 at 2:30 PM, on the 300 hall, LPN #6 was asked about the right heel ulcer. LPN #6 stated, Found on 8/14/15 unstageable on right heel 2 by 2 cm, all eschar. The facility failed to implement care plan interventions to accurately assess skin conditions and failed to identify a pressure ulcer before it became unstageable with eschar. This placed Resident #23 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer. 3. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The nursing admission skin evaluation dated 5/22/15 documented, .Both feet needed lotion due to extreme dryness. The comprehensive care plan dated 6/1/15 documented, .Resident is at risk for developing skin breakdown. Needs extensive/total assist with Bed Mobility. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. The facility was unable to provide documentation of the form the CNAs used to notify the nurse of skin assessments performed during bathing/shower in July 2015 when the pressure ulcer developed. The weekly skin integrity review dated 7/20/15 documented, .Skin Condition: Skin Intact. harden (hardened) area. New. (foot diagram of left heel circled). A nursing assessment dated [DATE] documented, Newly Developed Pressure Ulcer - Unstageable. HAS A ECHAR (eschar) AREA TO LEFT FOOT OUTER HEEL AREA. WAS FOUND DURING SKIN ASSESSMENT (7/20/15). TREATMENT NURSE EVALUATED AND IMPLEMENTED A TREATMENT AT THIS TIME (7/24/15). There was treatment provided from 7/20/15 until 7/24/15. A pressure ulcer record dated 7/24/15 documented, .Facility acquired. Unstageable MEASUREMENTS Length (cm): 3.0 x Width (cm) 3.0 x Depth (cm) U. WOUND BED. Eschar - thick, hard, leathery, black necrotic tissue. Observations on 8/26/15 at 3:15 PM, in the 4th floor resident common area, revealed Resident #24 sitting in a wheelchair with the left foot supported on the foot rest. The resident's left foot was wrapped in a clean and dry Kerlix dressing. Interview with Resident #24 on 8/26/15 at 3:15 PM, in the 4th floor resident common area, Resident #24 was asked if he had a sore on his left heel. Resident #24 nodded his head and stated, Yeah. Interview with Nurse #11 on 8/26/15 at 3:25 PM, at the 4th floor nurses' station, Nurse #11 was asked about the documentation on the weekly skin integrity review dated 7/20/15 describing a new hardened area on Resident #24's left heel. Nurse #11 stated, I seen something there (left heel area), forgot to let the treatment nurse know to come up with a plan. It was a hardened area. When I did inform her (4 days later), she (treatment nurse) did start a treatment. The facility failed to follow the plan of care for reporting skin issues and provide treatment for [REDACTED]. This placed Resident #24 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer. 4. Medical record review revealed Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 11/10/14 documented, .at risk for developing skin breakdown AND PRESSURE ULCERS D/T (due to) NEED FOR ASSIST WITH MOBILITIES AND B/B (bowel and bladder) INCONT. (incontinence). OBSERVE SKIN WITH ALL CARE PROVIDED FOR REDNESS, RASH, TEARS, MOTTLING (a condition of spotting with patches of red or purple coloring). A nurse's note dated 6/10/15 documented, Resident noted with black eschar to right heel. A pressure ulcer record dated 6/10/15 documented, Facility acquired STAGE Unstageable MEASUREMENTS length (cm) 4.0 x width (cm) 5.0 depth (cm) U. WOUND BED. Eschar - thick, hard, leathery, black necrotic tissue. A physician's orders [REDACTED]. Observations in Resident #25's room on 8/26/15 at 4:50 PM, revealed Resident #25 lying on her back in her bed, Provolon boots noted on bilateral feet, a clean, dry dressing was on her right foot. The facility failed to accurately assess skin conditions according to the plan of care and failed to identify a pressure ulcer before it became unstageable with eschar and necrosis. This placed Resident #25 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer. 5. Interview with the certified treatment nurse (LPN #6), on 8/26/15 at 1:25 PM on the 200 hall, the certified treatment nurse, LPN #6, was asked, Do you feel that the nurses notify you when there are new skin concerns? LPN #6 stated, It's a lot better, now that we have a weekend treatment nurse. In the last few months. I have harped on them (nurses) to initiate a treatment, even if it's wrong. Call the doctor. Still will find notes on my cart to look at someone's wound. Nurse #6 was asked if she felt the CNAs were notifying the nurses of new areas. LPN #6 stated, Honestly, they (CNAs) have too much to do. Can't give 15 baths before lunch. No concerns with turning and repositioning, more (concerned) with incontinent care. Telephone interview with the Medical Director on 8/26/15 at 1:58 PM, in the conference room, the Medical Director was asked when he expected the facility to notify him of pressure ulcers. The Medical Director stated, Normally we would be notified when the skin changes start. The Medical Director was asked if the notification should have been before the wound progressed to unstageable. The Medical Director stated, Yes, before it got to that stage. Telephone interview with the Nurse Practitioner on 8/26/15 at 3:30 PM, in the conference room, the Nurse Practitioner was asked if she would expect to be notified of wounds before they developed into unstageable wounds with slough or eschar. The Nurse Practitioner stated, Right (indicating should be notified before the pressure ulcer became unstageable). Interview with LPN #2 on 8/26/15 at 4:55 PM, on the 200 hall, LPN #2 was asked, What is your responsibility if a CNA tells you a resident has a new skin issue. LPN #2 stated, Go assess it, call the doctor, call the family, start a treatment, notify the treatment nurse. Interview with CNA #4 on 8/26/15 15 4:58 PM, on the 200 hall, CNA #4 was asked, What is your responsibility when you find new skin concerns on a resident? CNA #4 stated, Notify the nurse, as soon as you see redness. Interview with CNA #5 on 8/26/15 at 5:05 PM, outside the 200 hall dining room, CNA #5 was asked What is your responsibility when you find new skin concerns on a resident? CNA #5 stated, Notify the nurse as soon as I find it. Interview with CNA #9 and CNA #12 on 8/26/15 at 5:05 PM, on the 400 hall, they were asked when did they performed a head to toe skin assessments. CNA #9 and CNA #12 stated, When giving a full bath. CNA #9 and CNA #12 were asked what they do when a skin issue was found. CNA #9 and CNA #12 stated, We have a shower sheet, document on the shower sheet and let the nurse know. CNA #9 and CNA #12 were asked what they do if no issues are found. CNA #9 and CNA #12 stated, Check the place on the sheet for skin clear. Interview with CNA #1 on 8/26/15 at 5:08 PM, outside the 300 hall dining room, CNA #1 was asked, What is your responsibility when you find new skin concerns on a resident? CNA #1 stated, Notify my nurse, make sure she checks it (skin). See what she wants me to do, cream, boots. Interview with the Director of Nursing (DON) on 8/26/15 at 5:18 PM, in her office, the DON was asked if it was acceptable for pressure ulcers to be identified when they were unstageable due to the presence of eschar. The DON stated, I would hope that it would be found earlier. Interview with the DON on 8/28/15 at 1:45 PM, in the elevator the DON was asked what did she expect the staff to do in regard to care plans. The DON stated, Review to see if it is adequate to meet the residents needs. The DON was asked, if she expected the staff to follow the care plan. The DON stated, Yes. Interview with the minimum data set (MDS) coordinator on 8/28/15 at 2:00 PM, MDS coordinator was asked who develops the care plans. The MDS coordinator stated, I do. The MDS coordinator was asked do you expect the care plan to be followed. The MDS coordinator stated, Yes. The MDS coordinator was asked if she was aware the care plans were not being followed. The MDS coordinator stated, I did not know they were not being followed until the other day.

Based on National Pressure Ulcer Advisory Panel Pressure Ulcer Prevention Quick Reference Guide, policy review, medical record review, observation, and interview, the facility failed to identify, assess and provide preventive measures to prevent the development of avoidable pressure ulcers for 5 of 9 (Residents #3, 22, 23, 24, and 25) sampled residents with pressure ulcers. Failure of the facility to identify, assess, and/or provide care and treatments for pressure ulcers resulted in an immediate jeopardy (IJ) when Residents #3, 22, 23, 24, and 25 developed avoidable in-house acquired pressure ulcers that became unstageable before they were first identified by the staff. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 8/26/15 at 5:00 PM, in the conference room. The facility was cited an Immediate Jeopardy at F314-K which is Substandard Quality of Care. A partial-extended survey was completed on 8/28/15. The Immediate Jeopardy is effective 3/17/15, and is ongoing. The findings included: 1. The National Pressure Ulcer Advisory Panel Pressure Ulcer Prevention Quick Reference Guide, documented, .The purpose of the prevention recommendations is to guide evidence-based care to prevent the development of pressure ulcers. The guideline is intended for the use of health care professionals who are involved in the care of patients and vulnerable people who are at risk of developing pressure ulcers. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Unstageable / Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III (Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include underminng and tunneling) or IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling). Skin Assessment. Each health care setting should have a policy in place that includes recommendations for a structured approach to skin assessment. It should make clear recommendations for documenting skin assessment and communicating information to the wider health care team. Educate professionals on how to undertake a comprehensive skin assessment that includes the techniques for identifying blanching response, localized heat, [MEDICAL CONDITION], and induration (hardness). Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. Ongoing assessment of the skin is necessary to detect early signs of pressure damage. Pressure Ulcer Prevention Points. Implement pressure ulcer prevention educational programs that are structured, organized, comprehensive, and directed at all levels of health care providers, patients, family, and caregivers. Include mechanisms to evaluate program effectiveness in preventing pressure ulcers. The Skin Management and Prevention policy documented, .3. If a skin alteration (wound) is identified the nurse will notify the physician to obtain a treatment order. 12. On shower/bath days, CNAs (Certified Nursing Assistant) will complete total body skin observations. If a new skin issue is identified, the CNA will report it to the charge nurse and a copy of the form will be given to the ADON (Assistant Director of Nursing)/designee. 2. Closed medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 3/10/15 documented, .Potential for skin breakdown and pressure ulcers D/T (due to) poor nobilities and B/B (bowel/bladder) Incontinence. OBSERVE SKIN FOR REDNESS/TEARS/SHEARING WITH CARE PROVIDED. A nursing assessment dated [DATE] at 11:00 AM documented, .Newly Developed Pressure Ulcer - Unstageable. LEFT BUTTOCK. CNA (Certified Nurse Assistant) Noted During AM Care. Wound Bed: Slough (moist yellow or gray necrotic tissue). A pressure ulcer record dated 3/17/15 documented, Facility Acquired STAGE Unstageable MEASUREMENTS length (cm) (centimeters) 4.0 x (by) width (cm) 1.0 depth (cm) U (unable to determine). WOUND BED. Slough - moist yellow or gray necrotic tissue. A telephone order dated 3/17/15 documented, Cleanse Left buttock with wound cleanser or normal saline. Apply Santyl, cover with dry dressing. Interview with the certified treatment nurse Licensed Practical Nurse (LPN) #6 on 8/26/15 at 8:30 AM, in the conference room, LPN #6 was asked if the pressure ulcer record was the description of what the wound looked like. LPN #6 stated, Yes, If I wrote it (slough) that's what it looked like. Telephone interview with Resident #3's physician, who was also the facility's Medical Director, on 8/26/15 at 1:58 PM, in the conference room, the Medical Director was asked when did he expect the facility to notify him of pressure ulcers. The Medical Director stated, Normally we would be notified when the skin changes start. The Medical Director was asked if the notification should have been before the wound progressed to unstageable. The Medical Director stated, Yes, before it (pressure ulcer) got to that stage. Interview with CNA #7 on 8/26/15 at 4:45 PM, on the 300 hall, CNA #7 was asked when should a CNA assess a resident's skin. CNA #7 stated, When we (do) baths, turn, dry (a resident) we check for blisters, scrapes, red areas and report them to the nurse. The facility failed to accurately assess skin conditions and failed to identify a pressure ulcer before it became unstageable with slough. This placed Resident #3 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer. 3. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The initial nursing assessment dated [DATE], documented a Braden score of 13, which indicated a moderate risk for skin concerns, and to proceed to the Interim Plan of Care. The nursing assessment further documented a surgical wound with staples to the right hip, bruising on bilateral hands, and a red/purple area to the left shin. The assessment documented no concerns with the residents heels. The interim care plan dated 7/1/15, documented, .Alteration in skin integrity. Will not develop skin breakdown. Skin assessment weekly. Incontinence care as needed. T&P (turn and position) or reposition q (every) 2 (two) hrs (hours). Treatment as ordered. The CNA bathing report for July 2015, documented Resident #22 had a full bath on 7/6/15 at 1:22 PM and a half bath on 7/7/15 at 3:23 AM. The facility was unable to provide the CNA skin care alert for this resident's wound to be reported to the charge nurse and ADON/designee. A nursing assessment dated [DATE] at 10:00 AM documented, .Newly Developed Pressure Ulcer specific information Location and description of the ulcer: BLACK AREA NOTED TO RIGHT HEEL. Wound Bed: Eschar (Thick, Hard, Leathery, Black Necrotic Tissue). Nursing Interventions. Incontinence Management / Protection of Body Prominences. A nurse's note, signed by the treatment nurse (Nurse #6), dated 7/7/15, documented, .Area of suspected deep tissue injury noted to right lateral heel. New order received for skin protectant wipe to area daily for protection. Review of a pressure ulcer record dated 7/7/15, revealed the wound measured 0.8 centimeters (cm) by 2.0 cm, the the depth was unable to be determined. An intervention for Prevalon boots was put into place. This intervention was not put in place until after the development of the avoidable pressure ulcer. The pressure ulcer record dated 8/10/15, documented .Unstageable. and measured 2.5 cm by 2 cm, and no depth documented. Observations in Resident #22's room on 8/26/15 at 2:35 PM, revealed Resident #22 in a low bed with mats on the floor at bedside. The head of the bed was approximately 30 degrees, and the resident was fidgeting with her hand, and mumbling. Resident #22 had a Prevalon boot on her right foot. At 5:00 PM, Resident #22 had Prevalon boots on both feet, and the resident's son was at the bedside feeding the resident, who had eaten everything on her tray. Observations in Resident #22's room on 8/28/15 at 1:48 PM, revealed Resident #22's right heel pressure ulcer had a black center and yellow slough 1/2 inch round, with a scant amount of drainage on the dressing, with no odor. The facility failed to accurately assess skin conditions, failed to implement preventative measures, and failed to identify a pressure ulcer before it became unstageable with black eschar. This placed Resident #22 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer that developed within one week of the resident's admission. 4. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 8/14/15, documented .Apply Providone Iodine to right heel daily for protection. A care plan dated 7/2/15 documented, .risk for developing skin breakdown. Notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care. float heels in bed or use Prevalon boots. A nursing assessment dated [DATE] documented, .Wound care nurse was doing her rounds and noted deep tissue injury to left heel. Were any new nursing interventions implemented? Yes Document the implemented interventions: tx (treatment) in place. A nurses progress note dated 8/10/15 documented, Wound care nurse (#6) notified nurse (#7) that resident has bilateral heel and ankle deep tissue wound. Staff informed to use heel booths (boots) to keep pressure off. Daily skilled nurses notes dated 8/10/15, 8/11/15, 8/12/15, and 8/13/15 documented no skin concerns. There was no documentation the heel boots had been used to prevent pressure. The CNA bathing report for August 2015, documented Resident #23 had a shower on 8/12/15 at 1:32 PM and a full bath on 8/13/15 at 2:48 PM. The facility was unable to provide the CNA skin care alert for this resident's wound to be reported to the charge nurse and ADON/designee. A pressure ulcer record dated 8/14/15 documented, Unstageable. Length (cm) 2 x Width (cm) 2. WOUND BED Eschar - thick, hard, leathery, black necrotic tissue. A CNA skin care alert dated 8/14/15 documented, .Skin Clear: Yes. Observations in Resident #23's room on 8/26/15 at 2:15 PM, revealed Resident #23 in bed facing the ceiling with the head of the bed elevated 30 degrees. Prevalon boots were present on bilateral feet. The resident did not respond verbally to questions. Observations in Resident #23's room on 8/26/15 at 4:00 PM, revealed Resident #23 in bed facing the door. Prevalon boots were present on bilateral feet. Interview with LPN #6 on 8/26/15 at 2:30 PM, on the 300 hall, LPN #6 was asked about the right heel ulcer. LPN #6 stated, Found on 8/14/15 unstageable on right heel 2 by 2 cm, all eschar. On 8/18 it remained 2 by 2 all eschar and on 8/26/18 it measured 2 by 2 and was all eschar. The facility failed to accurately assess skin conditions, failed to implement preventative interventions, and failed to identify a pressure ulcer before it became unstageable with eschar. This placed Resident #23 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer. 5. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's telephone order dated 7/24/15, documented .providine iodine 10% (percent) sol (solution) (L) (left) heel.decubitus ulcer c (with) necrosis. Review of the Braden Scale for predicting pressure ulcer risk dated 5/22/15 revealed the resident was chair-fast, mobility was very limited, and at moderate risk for developing pressure sores. Review of the Minimum Data Set and the comprehensive care plan with dates of 6/1/15 revealed the resident was at risk for developing pressure ulcers. The CNA bathing report for July 2015, documented Resident #24 had a full bath on 7/19/15 at 2:57 PM and a half bath on 7/20/15 at 4:44 AM. The facility was unable to provide the CNA skin care alert for this resident's wound to be reported to the charge nurse and ADON/designee. The weekly skin integrity review dated 7/20/15 documented, .Skin Condition: Skin Intact. harden (hardened) area. New. (foot diagram of left heel circled). A nursing assessment dated [DATE] documented, Newly Developed Pressure Ulcer - Unstageable. HAS A ECHAR (eschar) AREA TO LEFT FOOT OUTER HEEL AREA. WAS FOUND DURING SKIN ASSESSMENT (7/20/15). TREATMENT NURSE EVALUATED AND IMPLEMENTED A TREATMENT AT THIS TIME. This pressure ulcer was identified on 7/20/15, yet no treatment was implemented until 7/24/15. A pressure ulcer record dated 7/24/15 documented, .Facility acquired. Unstageable MEASUREMENTS Length (cm): 3.0 x Width (cm) 3.0 x Depth (cm) U. WOUND BED. Eschar - thick, hard, leathery, black necrotic tissue. Observations of Resident #24, on 8/26/15 at 3:15 PM, in the 4th floor resident common area, revealed Resident #24 sitting in a wheelchair with the left foot supported on the foot rest. The resident's left foot was wrapped in Kerlix. Observations of Resident #24, on 8/28/15 at 1:50 PM, revealed Resident #24's left lateral heel had eschar loosening from the pressure ulcer edges with scant amount of drainage with no odor, area was 3.5 cm by 3 cm, unable to determine depth. Interview with Resident #24 on 8/26/15 at 3:15 PM, in the 4th floor resident common area, when asked if he had a sore on his left heel, the resident nodded his head and stated, Yeah. Interview with Nurse #11 on 8/26/15 at 3:25 PM, at the 4th floor nurses' station, Nurse #11 was asked about the documentation on the weekly skin integrity review dated 7/20/15 described a new hardened area on Resident #24's left heel. Nurse #11 stated, I seen something there (left heel area), forgot to let the treatment nurse know to come up with a plan. It (pressure ulcer) was a hardened area. When I did inform her (treatment nurse), she did start a treatment. The facility failed to identify a pressure ulcer before it became unstageable and Nurse #11 failed to implement treatment for [REDACTED].#11 did not notify the treatment nurse of the unstageable pressure ulcer for 4 days. This placed Resident #24 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer. 6. Medical record review revealed Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated 11/10/14 documented, .at risk for developing skin breakdown AND PRESSURE ULCERS D/T (due to) NEED FOR ASSIST WITH MOBILITIES AND B/B (bowel and bladder) INCONT. (incontinence). OBSERVE SKIN WITH ALL CARE PROVIDED FOR REDNESS, RASH, TEARS, MOTTLING (a condition of spotting with patches of red or purple coloring). The CNA bathing report for June 2015, documented Resident #25 had a full bath on 6/8/15 at 2/24 PM and a half bath on 6/8/15 at 2:46 PM and 8:26 PM, and on 6/10/15 at 2:20 PM. The facility was unable to provide the CNA skin care alert for this resident's wound to be reported to the charge nurse and ADON/designee. A nurse's note dated 6/10/15 documented, Resident noted with black eschar to right heel. A pressure ulcer record dated 6/10/15 documented, Facility acquired STAGE Unstageable MEASUREMENTS length (cm) 4.0 x width (cm) 5.0 depth (cm) U. WOUND BED. Eschar - thick, hard, leathery, black necrotic tissue. A physician's orders [REDACTED]. Observations in Resident #25's room on 8/26/15 at 4:50 PM, revealed Resident #25 lying on her back in her bed. Prevalon boots were noted on both feet and a clean, dry dressing was on her right foot. The bed was locked in lowest position, and a fall mat was on the floor beside her bed. Observations in Resident #25's room on 8/28/15 at 2:00 PM, revealed Resident #25's right heel pressure ulcer was a 1 inch round wound with yellow/light brown slough, no odor and scant amount of drainage. Interview with the Director of Nursing (DON) on 8/26/15 at 5:18 PM, in the DON's office, the DON was asked if it was acceptable for pressure ulcers to be identified when they were unstageable due to the presence of eschar. The DON stated, I would hope that it would be found earlier. The facility failed to assess skin conditions and failed to identify a pressure ulcer before it became unstageable with eschar and necrosis. This placed Resident #25 in IJ. This unstageable pressure ulcer was an avoidable in-house acquired pressure ulcer 7. Interview with the certified treatment nurse (LPN #6) on 8/26/15 at 1:25 PM on the 200 hall, the certified treatment nurse, LPN #6, was asked, Do you feel that the nurses notify you when there are new skin concerns? LPN #6 stated, It's a lot better, now that we have a weekend treatment nurse. In the last few months, I have harped on them to initiate a treatment, even if it's wrong. Call the doctor. Still will find notes on my cart to look at someone's wound. Nurse #6 was asked if she felt the CNAs were notifying the nurses of new areas. Nurse #6 stated, Honestly, they have too much to do. Can't give 15 baths before lunch. No concerns with turning and repositioning, more (concerned) with incontinent care. Telephone interview with the Medical Director, on 8/26/15 at 1:58 PM, in the conference room, the Medical Director was asked when he expected the facility to notify him of pressure ulcers. The Medical Director stated, Normally we would be notified when the skin changes start. The Medical Director was asked if the notification should have been before the wound progressed to unstageable. The Medical Director stated, Yes, before it (pressure ulcer) got to that stage. Telephone interview with the Nurse Practitioner on 8/26/15 at 3:30 PM, in the conference room, the Nurse Practitioner was asked if she would expect to be notified of wounds before they developed into unstageable wounds with slough or eschar. The Nurse Practitioner stated, Right (indicating the staff should notify her of a pressure ulcer before it became unstageable). Interview with the Administrator on 8/26/15 at 4:45 PM, in the conference room, the Administrator was asked, What is expected of the CNAs regarding resident skin issues? The Administrator stated, The CNAs complete and sign a daily skin assessment form they use when they give showers/baths. They turn these forms into the charge nurse who reviews and signs off on them. Interview with LPN #2 on 8/26/15 at 4:55 PM, outside room [ROOM NUMBER], LPN #2 was asked, What is your responsibility if a CNA tells you a resident has a new skin issue. LPN #2 stated, Go assess it. Call the doctor, call the family, start a treatment, notify the treatment nurse. Interview with CNA #4 on 8/26/15 15 4:58 PM, on the 200 hall floor, CNA #4 was asked, What is your responsibility when you find new skin concerns on a resident? CNA #4 stated, Notify the nurse as soon as you see redness. Interview with CNA #5 on 8/26/15 at 5:05 PM, outside the 200 hall dining room, CNA #5 was asked, What is your responsibility when you find new skin concerns on a resident? CNA #5 stated, Notify the nurse as soon as I find it. Interview with CNA #1 on 8/26/15 at 5:08 PM, outside the 300 hall dining room, CNA #1 was asked, What is your responsibility when you find new skin concerns on a resident? CNA #1 stated, Notify my nurse. Make sure she (nurse) checks it (skin). See what she wants me to do, cream, boots.

Based on review of the Administrator's job description, National Pressure Ulcer Advisory Panel Pressure Ulcer Prevention Quick Reference Guide review, policy review, medical record review, observation, and interview, the facility failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being by not identifying pressure sores before they became unstageable, not providing preventive measures to prevent the development of avoidable pressure ulcers and failed to follow care plan interventions for the care of pressure ulcers. The failure of the facility to be effectively and efficiently administered placed 5 of 9 (Residents #3, 22, 23, 24, and 25) sampled residents with pressure ulcers in immediate jeopardy (IJ). Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 8/26/15 at 5:00 PM in the conference room. The facility was cited an Immediate Jeopardy at F224-K and F314-K which is Substandard Quality of Care. A partial-extended survey was completed on 8/28/15. The Immediate Jeopardy is effective 3/17/15, and is ongoing. The findings included: 1. The Job Description for the Administrator signed 12/29/14 by the Administrator, documented, .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations. with focus on maintaining excellent care for the residents. Oversee regular rounds to monitor delivery of nursing care. ensure resident needs are being addressed. Utilize survey information, in addition to other source documents, to address areas of importance as defined by our customers. Responsible for the QA (Quality Assurance) program. Consult with department managers. to assist in eliminating/correcting problem areas, and/or improvement of services. 2. During an interview with the Administrator on 8/26/15 at 12:20 PM, in the Administrator's office, the Administrator was asked what the Wound Sense Program in-service was about. The Administrator stated, It is a new program to identify and track wounds, it is a result of our PIP (performance improvement plan), we did an evaluation in January (2015) and found wounds were a problem so we implemented a plan, we did a re-evaluation later and still had issues so we decided to do the new program. 3. Administration failed to ensure residents were not neglected when staff failed to consistently monitor residents' skin integrity during care and failed to identify a pressure ulcer before it became unstageable and/or developed a deep tissue injury. This placed Residents #3, 22, 23, 24, and 25 in IJ. Refer to F224. 4. Administration failed to ensure services were provided to attain or maintain the highest practical physical, mental and psychosocial well-being in accordance with the plan of care by not monitoring skin integrity, not appropriately identifying, and immediately reporting changes in skin integrity during bathing and/or daily care until residents had developed unstageable/Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling) pressure ulcers which resulted in IJ for Residents #3, 23, 24 and 25. See F282. 5. Administration failed to ensure staff provided continuous monitoring, and appropriate identification of skin concerns, failed to put preventative measures in place to prevent the development of pressure ulcer, and failed to identify pressure ulcers before residents developed suspected deep tissue injury or unstageable wounds, and failed to initiate treatments which resulted in IJ for Residents #3, 22, 23, 24, and 25. See F314. 6. Administration failed to ensure the Medical Director assisted with addressing clinical concerns and provided guidance regarding resident care by failing to ensure there was an effective process that monitored and addressed the potential for adverse consequences related to skin integrity. The failure of the Medical Director to ensure skin assessments were performed, preventative measures were put in place before the development of a pressure ulcer and ensure pressure ulcers were identified prior to becoming unstageable resulted in IJ for Residents #3, 22, 23, 24, and 25. 7. Administration failed to ensure an effective Quality Assurance Committee recognized an ongoing concern with skin integrity/pressure ulcers, and failed to implement effective interventions to resolve concerns identified in January 2015. Unstageable pressure ulcers were identified in March, June, July, and August 2015 which resulted in IJ for Residents #22, 23, 24, and 25. See F520.

Based on review of the Administrator's job description, National Pressure Ulcer Advisory Panel Pressure Ulcer Prevention Quick Reference Guide review, policy review, medical record review, observation, and interview, the governing body failed to ensure the facilities policies were implemented to maintain the highest practicable physical and psychosocial well being of 5 of 9 (Residents #3,22,23,24,and 25) sampled residents with pressure ulcers in immediate jeopardy (IJ). The governing body failed to ensure the facility was being administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being by not identifying pressure sores before they became unstageable, not providing preventive measures to prevent the development of avoidable pressure ulcers and failed to follow care plan interventions for the care of pressure ulcers. The failure of the governing body to ensure the facility was to be effectively and efficiently administered placed 5 of 9 (Residents #3, 22, 23, 24, and 25) sampled residents with pressure ulcers in immediate jeopardy (IJ). Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 8/26/15 at 5:00 PM in the conference room. The facility was cited an Immediate Jeopardy at F224-K and F314-K which is Substandard Quality of Care. A partial-extended survey was completed on 8/28/15. The Immediate Jeopardy is effective 3/17/15, and is ongoing. The findings included: 1. The job description for the administrator signed 12/29/14 by the Administrator, documented, .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations. with focus on maintaining excellent care for the residents. Oversee regular rounds to monitor delivery of nursing care. ensure resident needs are being addressed. Utilize survey information, in addition to other source documents, to address areas of importance as defined by our customers. Responsible for the QA (Quality Assurance) program. Consult with department managers. to assist in eliminating/correcting problem areas, and/or improvement of services. Interview with the Administrator on 8/26/15 at 12:20 PM, in the Administrator's office, the Administrator was asked what the Wound Sense Program in-service was about. The Administrator stated, It is a new program to identify and track wounds, it is a result of our PIP (performance improvement plan), we did an evaluation in January (2015) and found wounds were a problem so we implemented a plan, we did a re-evaluation later and still had issues so we decided to do the new program. Refer to F490. 3. The governing body failed to ensure Administration ensured residents were not neglected when staff failed to consistently monitor residents' skin integrity during care and failed to identify a pressure ulcer before it became unstageable and/or developed a deep tissue injury. This placed Residents #3, 22, 23, 24, and 25 in IJ. Refer to F224. 4. The governing body failed to ensure that Administration ensured services were provided to attain or maintain the highest practical physical, mental and psychosocial well-being in accordance with the plan of care by not monitoring skin integrity, not appropriately identifying, and immediately reporting changes in skin integrity during bathing and/or daily care until residents had developed suspected deep tissue injury of avoidable in-house unstageable pressure ulcers which resulted in IJ for Residents #3, 23, 24 and 25. See F282. 5. The governing body failed to ensure Administration ensured staff provided continuous monitoring, and appropriate identification of skin concerns, failed to put preventative measures in place to prevent the development of pressure ulcer, and failed to identify pressure ulcers before residents developed suspected deep tissue injury or unstageable wounds, and failed to initiate treatments which resulted in IJ for Residents #3, 22, 23, 24, and 25. See F314. 6. The governing body failed to ensure Administration ensured an effective Quality Assurance Committee recognized an ongoing concern with skin integrity/pressure ulcers, and failed to implement effective interventions to resolve concerns identified in January 2015. Unstageable pressure ulcers were identified in March, June, July, and August 2015 which resulted in IJ for Residents #3, #22, 23, 24, and 25. See F520.

Based on contract review, policy review, National Pressure Ulcer Advisory Panel Pressure Ulcer Prevention Quick Reference Guide review, policy review, medical record review, observation, and interview, the facility failed to ensure the Medical Director assisted with addressing clinical concerns and provided guidance regarding resident care by failing to ensure there was an effective process that monitored and addressed the potential for adverse consequences related to skin integrity. The failure of the Medical Director to ensure skin assessments were performed, preventative measures were put in place before the development of a pressure ulcer and ensure pressure ulcers were identified prior to becoming unstageable placed 5 of 9 (Residents #3, 22, 23, 24, and 25) sampled residents in immediate jeopardy (IJ). Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 8/26/15 at 5:00 PM in the conference room. The Immediate Jeopardy is effective 3/17/15, and is ongoing. The findings included: 1. The Medical Director (MD) contract signed 12/10/10 by the MD, documented .Physician shall at all times comply with all state and federal laws and regulations. Role and Responsibilities. provide clinical guidance and oversight regarding the implementation of resident care policies. help develop, implement and evaluate resident care policies and procedures. help the Facility identify, evaluate and address/resolve medical and clinical concerns and issues that; a. Affect resident care, medical care and quality of life or, b. Are related to the provision of services by physicians and other licensed health care practitioners. 3. The Medical Director's input promotes the attainment of optimal resident outcomes. The roles and functions of the Facility Medical Director will reflect the expectations of CMS (Centers of Medicare and Medicaid). and the position of the American Medical Directors Association. Quality of Care. The Medical Director is expected to bring a medical frame of reference to evaluating the quality of the Facility's clinical care systems. i. Help the Facility establish systems and methods for reviewing the quality and appropriateness of clinical care. ii. Participate in the Facility's quality improvement and utilization review process and attend the Quality Assurance Committee meeting monthly. Telephone interview with the facility's Medical Director, on 8/26/15 at 1:58 PM, in the conference room, the Medical Director was asked when he expected the facility to notify him of pressure ulcers. The Medical Director stated, Normally we would be notified when the skin changes start. The Medical Director was asked if the notification should have been before the wound progressed to unstageable. The Medical Director stated, Yes, before it (pressure ulcer) got to that stage. 2. Interview with the Administrator on 8/26/15 at 4:45 PM, in the conference room, the Administrator was asked, What is the Medical Directors role in Quality Assurance meetings? The Administrator stated, The Medical Director meets every month with the Quality Assurance (QA) committee, he is active in the meetings, he is aware of the performance improvement reports and was active in helping us get the new wound specialist physician. 3. The Medical Director failed to ensure residents were not neglected when staff failed to consistently monitor residents' skin integrity during care; failed to implement measure to prevent the development of pressure ulcers; and failed to identify pressure ulcers before they became unstageable or a suspected deep tissue injury. This placed Residents #3, 22, 23, 24, and 25 in IJ. Refer to F224. 4. The Medical Director failed to ensure services were provided to attain or maintain the highest practical physical, mental and psychosocial well-being in accordance with the plan of care by not monitoring, appropriately identifying, and immediately reporting changes in skin integrity during bathing and/or daily care until residents developed unstageable pressure ulcers which placed Residents #3, 23, 24 and 25 in IJ. See F282. 5. The Medical Director failed to ensure staff provided continuous monitoring, and appropriate identification of skin concerns, and failed to identify pressure ulcers before residents developed suspected deep tissue injury or unstageable pressure ulcers, and failed to initiate treatments which placed Residents #3, 22, 23, 24, and 25 in IJ. See F314. 6. The Medical Director failed to ensure an effective Quality Assurance Committee recognized an ongoing concern with skin integrity/pressure ulcers, and failed to implement effective interventions to resolve concerns identified in January 2015. Unstageable pressure ulcers were still being identified to present. See F520.

Based on review of the administrator's job description, review of the Medical Director's Contract, review of performance improvement plans, review of the National Pressure Ulcer Advisory Panel Pressure Ulcer Prevention Quick Reference Guide, medical record review, observation, and interview, the facility failed to ensure an effective Quality Assurance (QA) program recognized an ongoing concern with skin integrity/pressure ulcers, identified the root cause of the problems, developed appropriate plans and ensured systems and processes were in place and consistently followed by staff to address quality problems. The QA committee failed to identify and address concerns to ensure residents at risk for neglect and the development of avoidable pressure ulcers were assessed timely, that interventions to prevent pressure ulcer development were consistently implemented, that care plan interventions were implemented or followed, that the facility was administered in a manner that enabled it to use its resources effectively and efficiently, that the Medical Director assisted the facility with identifying evaluating, and addressing clinical concerns, coordinated the medical care and provide clinical guidance and oversight regarding the implementation of resident care policies and procedures for pressure ulcers. This placed Residents #3, #22, #23, #24, and #25 in immediate jeopardy when they developed avoidable in-house unstageable pressure ulcers. Immediate Jeopardy is a situation in which the provider's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 8/26/15 at 5:00 PM in the conference room. The facility was cited an Immediate Jeopardy at F224-K and F314-K which is Substandard Quality of Care. A partial-extended survey was completed on 8/28/15. The Immediate Jeopardy is effective 3/17/15, and is ongoing. The findings included: 1. Review of the quality performance / peer review facility plan of action / continuous quality improvement report dated 1/2/2015 documented Increased FAPU (facility acquired pressure ulcer) with actions of 1. Charge nurses, TX. (treatment) nurse and nurse management to place tags under random at risk residents. 2. Nurses to make walking rounds with shift report. 3. ADONS (assistant directors of nursing) to ensure body audits are assigned. 4. Braden scales (which indicates the resident's risk for developing pressure ulcers) to be reviewed on admission and PRN (as needed) for accuracy. Review of PIP (performance improvement plan) for pressure ulcer with a start date of 4/7/15 and targeted date of July 7, 2015 documented, .To reduce in house wounds and improve outcomes. CNA (certified nursing assistant) bathing skin review completed per CNA and reviewed with charge nurses. Conclusions Was this PIP successful? Pending. 2. Interview with the Administrator on 8/26/15 at 12:20 PM, in the Administrator's office the Administrator was asked what the Wound Sense Program in-service was about. The Administrator stated, It is a new program to identify and track wounds, it is a result of our PIP, we did an evaluation in January (2015) and found wounds were a problem so we implemented a plan, we did a re-evaluation later and still had issues so we decided to do the new program. 3. The facility's Quality Assurance (QA) committee failed to identify, develop and implement appropriate plans of action to ensure care plan interventions are implemented for care of pressure ulcers Resident's #3, #23, #24, and #25. Refer to F282. 4. The facility's Quality Assurance committee failed to identify, develop and implement appropriate plans of action to prevent neglect and the development of ongoing avoidable pressure ulcers for Resident's #3, 22, #23, #24, and #25. Refer to F224 and F314. 5. The facility's Quality Assurance committee failed to identify, develop and implement appropriate plans of actions to ensure the facility was administered in a manner to to use its resources effectively and efficiently to maintain the highest practicable physical and psychosocial well being of Residents #3, #22, #23, #24, and #25 and all residents residing in the facility at risk to develop avoidable pressure ulcers. Refer to F490. 6. The facility's Quality Assurance committee failed to ensure the Medical Director assisted with identifying, evaluating and addressing clinical concerns, coordinate the medical care and provide clinical guidance and oversight regarding the implementation of resident care policies and procedures that reflect the current standards of practice for Resident's #3, #22, #23, #24, #25 and all residents residing in the facility at risk to develop avoidable pressure ulcers. Refer to F501.

Intakes: TN 532, TN 605 Based on policy review, review of a time detail sheet, review of a suspension form, medical record review and interview, it was determined the facility failed to immediately report an alleged rape to the Director of Nursing (DON) or administrator, failed to thoroughly investigate this allegation and failed to prevent further potential abuse during the investigation for 1 of 15 (Resident #130) sampled residents reviewed for abuse of the 39 residents included in the stage 2 review, which placed Resident #130 in immediate jeopardy. Immediate jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The immediate jeopardy for F225 constitutes substandard quality of care. An extended survey was completed on 8/26/14 and 8/27/14. A meeting was conducted in the conference room on 8/18/14 at 4:52 PM, with the Administrator and the Director of Nursing (DON) at which time they were informed of the Immediate Jeopardy. The facility provided an acceptable Allegation of Compliance (AOC) on August 25th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 25, 2014, had removed the Immediate Jeopardy. The immediate jeopardy (IJ) existed from 2/14/14 through 8/24/14. The IJ was removed on 8/25/14. Noncompliance for F225 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: Review of the facility's abuse policy documented, "...Verbal, sexual, physical and mental abuse... are prohibited... If the person reporting the abuse believes there is a lack of response from the charge nurse the person will then notify the DON and/or Administrator. If DON/Administrator are not in the facility staff will notify them via phone... The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation... The charge nurse will immediately notify the Administrator, DON, and/or Abuse Coordinator... All allegations of abuse will be investigated..." Medical record review for Resident #130 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/21/14 documented Resident #130 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident is moderately cognitively impaired, and required extensive assistance from staff for all Activities of Daily Living (ADLs). The MDS documented Resident #130 had no mood or behavioral symptoms. Review of a quarterly MDS for Resident #130 with an ARD of 7/12/14 documented a BIMS of 7, indicating the resident is severely cognitively impaired, and the resident was totally dependent on staff for all ADLs. The MDS documented that Resident #130 had no mood or behavioral symptoms. Review of a nurse's note dated 2/15/14 at 2:30 PM, documented, "...CNA (certified nursing assistant #33) reported, (Resident #130) stated he was raped. Reported to Supervisor (Nurse #22) of what resident said..." This note was written by Nurse #21. Review of the social service progress notes documented the following: a. 2/17/14 - "...(CNA #33) informed Nurse (#22) that resident (#130) stated he had been raped 2-14-14. DSS (Director of Social Services)... spoke with resident... Resident (#130) stated the name of a male CNA (#34) who raped him..." b. 2/20/14 - "...DSS visited with resident. Resident (#130) said everything he reported (alleged rape on the night of 2/14/14 by CNA #34) to me the other day was true..." Review of CNA #34's "TIME DETAIL" sheet documented CNA #34 worked Friday, 2/14/14, from 3:00 PM to 9:45 PM and 10:15 PM until 10:58 PM, Saturday, 2/15/14, from 3:28 PM to 9:53 PM and 10:27 PM to 11:06 PM, Sunday, 2/16/14, from 2:59 PM to 9:56 PM and 10:26 PM to 11:00 PM, and Monday, 2/17/14 from 2:58 PM to 4:01 PM. Review of a suspension form dated 2/17/14 documented, "...(CNA #34) name... Date of Incident: 2/14/14..." The suspension form was signed and dated by the DON, the Administrator, a Human Resources witness and accused CNA #34 on 2/17/14. Accused CNA #34 was not suspended until 3 days after the alleged rape. Review of a physician's progress note on Resident #130 dated 3/20/14 documented, "...allegation of sexual contact/assault last month..." Review of Resident #130's mental health and behavioral health visit notes documented the following: a. 3/27/14 - "...RECENT PHYSICAL DECLINE AND CLAIMS OF SEXUAL ABUSE BY STAFF... APPETITE REMAINS POOR AND OVERALL MOOD APPEARS HOPELESS AND WITHDRAWN..." b. 4/3/14 - "...Chief Complaint... RECENT PHYSICAL DECLINE AND CLAIMS OF SEXUAL ABUSE BY STAFF... Delusions... None... Hallucinations... None..." c. 4/4/14 - Resident #130 was demonstrating sleep disturbances, loss of appetite, weight loss, increased dependency in self-care, increased withdrawal/isolation, depressed mood, decreased energy, decreased enjoyment/interest, and tearfulness. The psychiatric consult documented, "...Processed alleged assault experience w (with) / patient-reviewed / explored details of incident & (and) related thoughts, emotions... Patient was initially guarded re (related to): alleged assault & his depressive symptoms; however, he became more forthcoming as session progressed. He discussed as many details as he could recall, as well as his thoughts and emotions re: incident (alleged rape on night of 2/14/14)..." During an interview in Resident #130's room on 8/14/14 at 2:10 PM, Resident #130 was asked whether anyone had ever mistreated him here at the facility. Resident #130 stated that once a homosexual man had spoken inappropriately to him. The interview was postponed due to Resident #130's roommate being present in the room. Later on 8/14/14 at 3:25 PM, Resident #130 was asked for more information regarding the mistreatment he had spoken of earlier. Resident #130 stated, "He (CNA #34) tried to have sexual intercourse, tried to penetrate, the girl (CNA #33) that washed me and cleaned me up asked me why I had all this grease on me." Resident #130 stated he had told her (CNA #33) what happened and she told the nurse (#21). Resident #130 was asked whether he had been taken to the doctor when the incident occurred. Resident #130 stated he had not. During an interview in the conference room on 8/14/14 at 3:00 PM, the DON was asked what should happen if a resident reports rape or sexual abuse. The DON stated, "Staff should tell me immediately, interview the resident for details, body audit of the resident." The DON was asked what type of exam was performed and how soon was it done after the alleged rape was reported. The DON stated, "A body audit, remove the clothes, look at the area, look at the anal area if they say they were penetrated. Physician and families are notified, suspend the alleged perpetrator if identified, try to get them done immediately." The DON was asked whether the resident should be sent to the emergency room (ER) for a rape kit after an instance where there was possible physical evidence, such as jelly-like substance found on the resident's buttocks. The DON stated, "Yes, then we could send them to the ER." Resident #130 was not examined immediately nor was he sent to the ER for a rape kit. During an interview in the conference room on 8/14/14 at 6:05 PM, the DON was asked why the exam on Resident #130 was not performed until 3 days after the alleged incident. The DON stated the incident "Was not reported to us (administrative staff) until later (2/17/14)." The DON was asked whether the police had been notified. The DON stated, "No." The DON was asked whether a physician had examined Resident #130 after the incident occurred. The DON stated, "I don't know." During an interview in the conference room on 8/14/14 at 6:10 PM, the Administrator was asked what is the facility's protocol if an alleged rape is reported. The Administrator stated, "We would definitely investigate thoroughly." The Administrator was asked whether the resident would be sent to the hospital for a rape kit. The Administrator was nodding her head in agreement and stated, "We would do that or get a doctor or nurse practitioner to examine him." During a telephone interview on 8/15/14 at 3:37 PM, accused CNA #34 was asked what had happened during his shift on 2/14/14 regarding Resident #130 and the alleged abuse allegation. Accused CNA #34 stated, "The allegation was false. I resigned. They (facility) did no rape kit or anything. If they would have called the police, I would have been fine with it. They (facility) did not do a proper investigation." Accused CNA #34 was asked whether he had been suspended during the investigation. Accused CNA #34 stated, "No Ma'am. I was not suspended. I worked all the way through. I worked that weekend." During a telephone interview on 8/18/14 at 2:56 PM, CNA #33 was asked what she recalled of the alleged rape of Resident #130 on the night of 2/14/14. CNA #33 stated she had gone in to talk to Resident #130 at the beginning of her shift on 2/15/14, like she normally does. He told her that he thought he had been raped. CNA #33 stated she had told the nurse on duty (Nurse #21) and the nurse supervisor (Nurse #22). CNA #33 stated, "They (Nurse #21 and Nurse #22) did not tell me anything. I waited a couple of hours, and then I went and cleaned him (Resident #130) up. There was a jelly-like substance on him that was clear." CNA #33 was asked whether the police were called. CNA #33 stated she did not know. CNA #33 was asked whether Resident #130 had been taken to the hospital for an exam after the alleged incident. CNA #33 stated, "Not that I know of." During an interview in the conference room on 8/18/14 at 3:15 PM, the DSS was asked what is the facility's policy if a resident reports abuse. The DSS stated, "It's reported to the supervisor immediately. They call the Administrator and the DON. The accused is suspended immediately, authorities are notified, police, elder abuse, (Named Administrator). Have been talking about that. We should have reported this one to the police." During an interview at the nurses' station on 8/19/14 at 8:05 AM, Nurse Practitioner (NP) #1 was asked if she remembered the incident that occurred with Resident #130 on 2/14/14 regarding the alleged abuse. NP #1 stated, "It was such a significant event. (Named Nurse #12 nurse manager for the floor) told me there had been an occurrence. The resident had complained he was molested or raped, and she (Nurse #12) said could you examine him. She (Nurse #12) said it had happened 3 or 4 days ago (2/14/14). Cannot find my progress note. I vaguely remember asking someone to copy it, and handed it to someone, but cannot remember who it was. There is a billing sheet attached to my sheets, and every time I document, I tear it off and put it in my bag. I don't have that either. It's not at the office either, very unfortunate." This was not done. During an interview at the fourth floor nurse's station on 8/20/14 at 8:45 AM, Nurse #12 was asked about the alleged rape of Resident #130 that occurred on the night of 2/14/14. Nurse #12 stated, the allegation "happened over the weekend (2/14/14). Was a couple of days before I found out. I did a body audit." Nurse #12 was asked what is the facility's policy regarding sexual abuse allegations. Nurse #12 stated, "They are supposed to report to the nurse. Suppose to triage it. The person they are accusing is suspended, police should be called, the patient should actually be sent out at the time of the incident, immediately do a body audit, send patient to the hospital. Notify the DON." The facility was unable to provide any written evidence that a physical exam had been performed on Resident #130 concerning the alleged sexual assault on 2/14/14. The facility failed to promptly suspend the alleged perpetrator; failed to notify the police; failed to provide a complete and appropriate medical examination; failed to promptly notify the DON or Administrator and failed to thoroughly investigate an allegation of rape which placed Resident #130 in immediate jeopardy. Validation of the Credible Allegation of Compliance (AOC) was accomplished on-site August 26, 2014, through review of facility documents, audits, review of in-service records and interviews with nursing and administrative staff. The surveyors validated the corrective actions stated in the AOC were implemented which removed the immediate jeopardy. The facility provided evidence that all staff received an abuse in-service and an abuse questionnaire, on which they were required to answer 100 percent correctly. Review of 5 of 5 new hire personnel files were reviewed and contained evidence of background and abuse registry checks before hire. Interviews were completed with nursing and administrative staff to ensure staff were knowledgeable of proper procedures regarding the reporting of abuse and protection of the residents. An interview was conducted with the Abuse Prevention Coordinator, in which she stated that weekly Performance Improvement meetings have been scheduled. The facility will remain out of compliance at a scope and severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction.

Based on policy review, review of the Sorensen and Luckmann's Basic Nursing a Psychophysiologic Approach, review of the investigator's report, review of an autopsy, medical record review and interview, it was determined the facility neglected to follow physician orders [REDACTED].#261) sampled residents reviewed for neglect of the 39 residents included in the stage 2 review. The facility neglected to monitor Resident #261 during dining and staff neglected to perform the [MEDICATION NAME] Maneuver to prevent choking and suffocation which resulted in the choking death of Resident #261. This incident resulted in an immediate jeopardy (IJ) which is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The immediate jeopardy for F224 constitutes substandard quality of care. An extended survey was completed on 8/26/14 and 8/27/14. A meeting was conducted in the conference room on 8/18/14 at 4:52 PM, with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) when they were informed of the IJ. The facility provided an acceptable Allegation of Compliance on August 25th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 25, 2014, had removed the Immediate Jeopardy. The immediate jeopardy (IJ) existed from 3/27/14 through 8/24/14. The IJ was removed on 8/25/14. Noncompliance for F224 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: Review of the facility's neglect policy documented, "...neglect... of the resident... are prohibited..." Review of the Sorensen and Luckmann's Basic Nursing a Psychophysiologic Approach, third edition, page 576, management of obstructed airway, documented, "The two techniques for relieving foreign body airway obstruction are manual chest and abdominal thrusts ([MEDICATION NAME] maneuver) and finger sweeps." Medical record review for Resident #261 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of a care plan dated 5/16/13 and reviewed 2/14 documented a problem that Resident #261 is a nutrition risk due to a swallowing problem related to dysphagia and requires a mechanically altered diet. The interventions to provide the diet as ordered by the physician, monitor the intake and no bread. The care plan documented Resident #261 was to be upright for all meals, staff to feed all meals and aspiration precautions. Review of a nurses note dated 3/28/14 documented, "...cna (certified nursing assistant #30) served resident's (Resident #261) supper. The supper consisted of the following items 4 oz (ounces) of pulled pork... at approximately 5:31 PM the cna (#30) returned to check on him (Resident #261)... the cna (#30) immediately sought out the nurse (#20) at 5:32pm... LPN (licensed practical nurse) #20 immediately responded... noticed that the resident was in ditress (distress) and noted resident's (#261) lips were bluish in color... the resident was still breathing at this time. The LPN (#20) stimulated the resident with cardiac massage... a code blue was called... compressions were commenced until EMT's (Emergency Medical Technicians) arrived. Breaths were administered between compressions... EMT arrived at 5:45pm...The EMT's and the first responder hooked him (Resident #261) up to a monitor... stopped the code at approximately 5:55pm..." There was no documentation the facility staff performed the [MEDICATION NAME] maneuver on Resident #261. Review of the investigator's report signed and dated on 3/27/14 documented, "... (Named Rescue Team) arrived on the scene and cleared his (Resident #261) airway but asystole (no heart beat) was confirmed at 1755 (5:55 PM) by paramedics... (Named Officer) advised the following: this black male was eating dinner and began choking on his food... Fire department paramedics removed the food from his airway and staff threw it away. Due to this accident jurisdiction was accepted and this black male was transported to the (Named) forensic center for further examination (autopsy)..." Review of the autopsy report signed and dated on 5/16/14 documented, "...Date of Autopsy Examination: March 28, 2014... CAUSE OF DEATH: Asphyxia due to choking... INTERNAL EXAMINATION... RESPIRATORY SYSTEM... Non-digested food and mucus partially occlude the upper airway, and pieces of non-digested food occlude the lobar bronchi and some more distal branches... SUMMARY AND INTERPRETATION... Based on the autopsy findings... the cause of death is attributed to asphyxia due to choking..." During an interview in the conference room on 8/14/14 at 4:30 PM, the DON was asked what Resident #261 choked on. The DON stated, "I believe it was pulled pork or roast beef." During an interview in the conference room on 8/14/14 at 5:00 PM, CNA #30 was asked if she was present during Resident #261's choking incident. CNA #30 stated, "I brought his tray in his room... He usually would eat out in the dining room... I went back in to check on him and he seemed like he was in stress, like something was wrong. I asked him if he was okay, and he raised up his hand... When black people hold their hand up we know something's wrong. I went immediately and got the nurse. After that, the nurses took over..." CNA #30 was asked about how long it took the nurse to respond. CNA #30 stated, "It didn't really take long... I yelled in the hallway. 'Mr. (first name of Resident #261) is in distress'. She (Nurse #20) came right there." CNA #30 was then asked what type of diet was Resident #261 on. CNA #30 stated, "I don't really remember if he was on a regular diet or a pureed diet. It looked like roast beef, it was like stringy. I can't remember what else he had." CNA #30 was asked if the meat was pureed and if it had gravy on it. CNA #30 stated, "It (meat) didn't look like pureed. I don't remember any gravy on it." The facility neglected to ensure Resident #261 received the proper therapeutic diet, neglected to monitor Resident #261 during dining, and neglected to perform the [MEDICATION NAME] maneuver when Resident #261 was noted to be in distress, which resulted in an immediate jeopardy when Resident #261 subsequently choked to death. Validation of the Credible Allegation of Compliance (AOC) was accomplished on August 26, 2014, through review of facility documents, audits, review of in-service records, observations and interviews with nursing, dietary and administrative staff. The surveyors validated the corrective actions stated in the AOC were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign in sheets, for all staff on the [MEDICATION NAME] maneuver, tray service to include review of each meal ticket for verification of correct diet served and color coded meal tickets for therapeutic diets. The facility provided evidence of in-service training for all dietary personnel regarding identification and preparation of diets, competencies for food preparation and thickened liquids by the certified dietary manager. The facility provided evidence of audits for accuracy of meals served to residents to include trays from the kitchen to the floors and tray tickets verified with meals on the trays. Interviews with CNAs, nurse managers, charge nurses conducted in the facility, staff verbalized how to properly check for proper diets and matching the tray tickets, what a colored meal ticket means, and how to do the [MEDICATION NAME] maneuver. Nurse managers verbalized how they would continue to monitor and audit the accuracy of the meal delivery. Observations in the kitchen on 8/26/14 revealed the meal ticket being checked at each station, the condiments and fluid station, the entree station and at the bread and dessert station the entire meal tray was reviewed by that staff member to ensure the tray was correct. Observations in the facility on 8/26/14 revealed staff physically checking the meal tickets to the food tray when the cart was delivered to the halls, and then a second check by the staff member when the tray is delivered to the resident. The facility will remain out of compliance at a scope and severity level of "D", an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction.

Based on policy review, review of a time detail sheet, review of a suspension form, medical record review and interview, it was determined the facility failed to implement their abuse policy when staff failed to immediately report an alleged rape to the Director of Nursing (DON) or administrator, failed to thoroughly investigate this allegation and failed to protect residents from potential abuse during an alleged abuse investigation for 1 of 15 (Resident #130) sampled residents reviewed for abuse of the 39 residents included in the stage 2 review. The facility failed to notify the police after a staff to resident rape allegation; failed to provide an appropriate medical exam and failed to promptly suspend the alleged perpetrator which placed Resident #130 in immediate jeopardy. Immediate jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The immediate jeopardy for F226 constitutes substandard quality of care. An extended survey was completed on 8/26/14 and 8/27/14. A meeting was conducted in the conference room on 8/18/14 at 4:52 PM, with the Administrator and the Director of Nursing (DON) at which time they were informed of the immediate jeopardy. The facility provided an acceptable Allegation of Compliance on August 25th. It was determined on August 26, 2014 the corrective actions implemented on August 25, 2014, had removed the immediate jeopardy. The immediate jeopardy (IJ) existed from 2/14/14 through 8/24/14. The IJ was removed on 8/25/14. Noncompliance for F226 continues at a "D" level citation. The facility is required to submit a plan of correction. The findings included: Review of the facility's abuse policy documented, "...sexual, physical and mental abuse... are prohibited... All allegations of abuse... Protection of the Resident... If the person reporting the abuse believes there is a lack of response from the charge nurse the person will then notify the DON and/or Administrator. If DON / Administrator are not in the facility staff will notify them via phone... The charge nurse will immediately remove the suspected perpetrator from resident care areas, obtain the staff members witness statement and immediately suspend the employee pending the outcome of the investigation... The charge nurse will immediately notify the Administrator, DON, and/or Abuse Coordinator as appropriate... Investigation... All allegations of abuse will be investigated... The Administrator/designee will make all reasonable efforts to investigate and address alleged reports..." Medical record review for Resident #130 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a nurse's note dated 2/15/14 at 2:30 PM, documented, "...CNA (certified nursing asssitant #33) reported, (Resident #130) stated he was raped. Reported to Supervisor (Nurse #22) of what resident said..." This note was written by Nurse #21. Review of the social service progress notes documented the following: a. 2/17/14 - "...(CNA #33) informed Nurse (#22) that resident (#130) stated he had been raped 2-14-14. DSS (Director of Social Services)... spoke with resident... Resident (#130) stated the name of a male CNA (#34) who raped him..." b. 2/20/14 - "...DSS visited with resident. Resident (#130) said everything he reported (alleged rape on the night of 2/14/14 by CNA #34) to me the other day was true..." Review of the CNA #34's "TIME DETAIL" sheet documented CNA #34 worked Friday, 2/14/14, from 3:00 PM to 9:45 PM and 10:15 PM until 10:58 PM, Saturday, 2/15/14, from 3:28 PM to 9:53 PM and 10:27 PM to 11:06 PM, Sunday, 2/16/14, from 2:59 PM to 9:56 PM and 10:26 PM to 11:00 PM, and Monday, 2/17/14 from 2:58 PM to 4:01 PM. Review of a suspension form dated 2/17/14 documented, "...(CNA #34) name... Date of Incident: 2/14/14..." The suspension form was signed and dated by the DON, the Administrator, a Human Resources witness and CNA #34 on 2/17/14. The accused CNA was not suspended until 3 days after the alleged incident was reported. During an interview in Resident #130's room on 8/14/14 at 2:10 PM, Resident #130 was asked whether anyone had ever mistreated him here at the facility. Resident #130 stated that once a homosexual man had spoken inappropriately to him. The interview was postponed due to Resident #130's roommate being present in the room. Later on 8/14/14 at 3:25 PM, Resident #130 was asked for more information regarding the mistreatment he had spoken of earlier. Resident #130 stated, "He (CNA #34) tried to have sexual intercourse, tried to penetrate, the girl (CNA #33) that washed me and cleaned me up asked me why I had all this grease on me." Resident #130 stated he had told her (CNA #33) what happened and she told the nurse (#21). Resident #130 was asked whether he had been taken to the doctor when the incident occurred. Resident #130 stated he had not. During an interview in the conference room on 8/14/14 at 3:00 PM, the DON was asked what should happen if a resident reports rape or sexual abuse. The DON stated, "Staff should tell me immediately, interview the resident for details, body audit of the resident." The DON was asked what type of exam was performed and how soon was it done after the incident was reported. The DON stated, "A body audit, remove the clothes, look at the area, look at the anal area if they say they were penetrated. Physician and families are notified, suspend the alleged perpetrator if identified, try to get them done immediately." The DON was asked whether the resident should be sent to the emergency room (ER) for a rape kit after an instance where there was possible physical evidence, such as jelly-like substance found on the resident's buttocks. The DON stated, "Yes, then we could send them to the ER." Resident #130 was not examined immediately nor was he sent to the ER for a rape kit. During an interview in the conference room on 8/14/14 at 6:05 PM, the DON was asked why Resident #130 was not examined until 3 days after the alleged incident. The DON stated the incident "Was not reported to us until later (2/17/14)." The DON was asked whether the police had been notified. The DON stated, "No." The DON was asked whether a physician had examined Resident #130 after the incident occurred. The DON stated, "I don't know." During an interview in the conference room on 8/14/14 at 6:10 PM, the Administrator was asked what is the facility's protocol if a rape is reported. The Administrator stated, "We would definitely investigate thoroughly." The Administrator was asked whether the resident would be sent to the hospital for a rape kit. The Administrator was nodding her head in agreement and stated, "We would do that or get a doctor or nurse practitioner to examine him." During a telephone interview on 8/15/14 at 3:37 PM, accused CNA #34 was asked what had happened during his shift on 2/14/14 regarding Resident #130 and the alleged abuse allegation. Accused CNA #34 stated, "The allegation was false. I resigned. They (facility) did no rape kit or anything. If they would have called the police, I would have been fine with it. They (facility) did not do a proper investigation." Accused CNA #34 was asked whether he had been suspended during the investigation. Accused CNA #34 stated, "No Ma'am. I was not suspended. I worked all the way through. I worked that weekend." During a telephone interview on 8/18/14 at 2:56 PM, CNA #33 was asked what she recalled of the alleged rape of Resident #130 on the night of 2/14/14. CNA #33 stated she had gone in to talk to Resident #130 at the beginning of her shift on 2/15/14, like she normally does. He told her that he thought he had been raped. CNA #33 stated she had told the nurse on duty (Nurse #21) and the nurse supervisor (Nurse #22). CNA #33 stated, "They (Nurse #21 and Nurse #22) did not tell me anything. I waited a couple of hours, and then I went and cleaned him (Resident #130) up. There was a jelly-like substance on him that was clear." CNA #33 was asked whether the police were called. CNA #33 stated she did not know. CNA #33 was asked whether Resident #130 had been taken to the hospital for an exam after the alleged incident. CNA #33 stated, "Not that I know of." During an interview in the conference room on 8/18/14 at 3:15 PM, the DSS was asked what is the facility's policy if a resident reports abuse. The DSS stated, "It's reported to the supervisor immediately. They call the Administrator and the DON. The accused is suspended immediately, authorities are notified, police, elder abuse, (Named Administrator). Have been talking about that. We should have reported this one to the police." During an interview at the nurses' station on 8/19/14 at 8:05 AM, Nurse Practitioner (NP #1) was asked if she remembered the incident that occurred with Resident #130 on 2/14/14 regarding the alleged abuse. NP #1 stated, "It was such a significant event. (Named Nurse #12 the nurse manager) told me there had been an occurrence. The resident (#130) had complained he was molested or raped, and she (Nurse #12) said could you examine him. She (Nurse #12) said it had happened 3 or 4 days ago (2/14/14). Cannot find my progress note. I vaguely remember asking someone to copy it, and handed it to someone, but cannot remember who it was. There is a billing sheet attached to my sheets, and every time I document, I tear it off and put it in my bag. I don't have that either. It's not at the office either, very unfortunate." During an interview at the fourth floor nurse's station on 8/20/14 at 8:45 AM, Nurse #12 was asked about the alleged rape of Resident #130 that occurred on the night of 2/14/14. Nurse #12 stated, the allegation "happened over the weekend (2/14/14). Was a couple of days before I found out. I did a body audit." Nurse #12 was asked what is the facility's policy regarding sexual abuse allegations. Nurse #12 stated, "They are supposed to report to the nurse. Suppose to triage it. The person they are accusing is suspended, police should be called, the patient should actually be sent out at the time of the incident, immediately do a body audit, send patient to the hospital. Notify the DON." The facility was unable to provide any written evidence that a physical exam had been performed on Resident #130 concerning the alleged sexual assault on 2/14/14. The facility failed to implement and follow their abuse policy when they failed to thoroughly investigate an alleged rape by not promplty notifing the DON or Administrator; failed to promptly complete a medical examination; failed to notify the police and failed to protect residents from potential abuse by not promptly suspending the alleged perpetrator which placed Resident #130 in immediate jeopardy. Validation of the Credible Allegation of Compliance (AOC) was accomplished on-site August 26, 2014, through review of facility documents, audits, review of in-service records and interviews with nursing and administrative staff. The surveyors validated the corrective actions stated in the AOC were implemented which removed the immediate jeopardy. The facility provided evidence that all staff received an abuse in-service and an abuse questionnaire, on which they were required to answer 100 percent correctly. Random new hire personnel files were reviewed and contained evidence of background and abuse registry checks before hire. Interviews were completed with nursing and administrative staff to ensure staff were knowledgeable of proper procedures regarding the reporting of abuse and protection of the residents. An interview was conducted with the Abuse Prevention Coordinator, in which she stated that weekly Performance Improvement meetings have been scheduled. The facility will remain out of compliance at a scope and severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction.

Based on review of Sorensen and Luckmann's Basic Nursing reference, medical record review review of the investigator's report, review of an autopsy and interview, it was determined the facility failed to ensure services provided met professional standards of quality as evidenced by staff not performing the [MEDICATION NAME] maneuver (action to remove what is blocking the airway) when a resident was noted to be choking for 1 of 15 (Resident #261) sampled residents reviewed for neglect of the 39 residents included in the stage 2 review. The facility failed to perform the [MEDICATION NAME] maneuver to prevent choking and suffocation which resulted in the choking death of Resident #261, which resulted in immediate jeopardy, a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. A meeting was conducted in the conference room on 8/18/14 at 4:52 PM, with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) when they were informed of the immediate jeopardy (IJ). The facility provided an acceptable Allegation of Compliance on August 25th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 25, 2014, had removed the immediate jeopardy. The immediate jeopardy (IJ) existed from 3/27/14 through 8/24/14. The IJ was removed on 8/25/14. Noncompliance for F281 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: Review of the Sorensen and Luckmann's Basic Nursing a Psychophysiologic Approach, third edition, page 576, management of obstructed airway, documented, "The two techniques for relieving foreign body airway obstruction are manual chest and abdominal thrusts ([MEDICATION NAME] maneuver) and finger sweeps." Medical record review for Resident #261 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a care plan dated 5/16/13 and reviewed 2/14 documented a problem that Resident #261 is a nutrition risk due to a swallowing problem related to dysphagia and requires a mechanically altered diet. The care plan documented Resident #261 is to be upright for all meals, staff to feed all meals and aspiration precautions. Review of a nurses note dated 3/28/14 documented, "...cna (certified nursing assistant #30) served resident's (Resident #261) supper. The supper consisted of the following items 4 oz (ounces) of pulled pork... at approximately 5:31 PM the cna (#30) returned to check on him... the cna immediately sought out the nurse at 5:32pm... LPN (licensed practical nurse) #20 immediately responded... noticed that the resident was in ditress (distress) and noted resident's (Resident #261) lips were bluish in color... the resident was still breathing at this time. The LPN (#20) stimulated the resident with cardiac massage... a code blue was called... compressions were commenced until EMT's (Emergency Medical Technicians) arrived... EMT arrived at 5:45pm... The EMT's and the first responder hooked him up to a monitor... stopped the code at approximately 5:55pm... " There was no documentation the facility staff performed the [MEDICATION NAME] maneuver for Resident #261. Review of the investigator's report signed and dated on 3/27/14 documented, "...(Named Rescue Team) arrived on the scene and cleared his airway but asystole (no heart beat) was confirmed at 1755 (5:55 PM) by paramedics... (Named Officer) advised the following: this black male was eating dinner and began choking on his food... Fire department paramedics removed the food from his airway and staff threw it away. Due to this accident jurisdiction was accepted and this black male was transported to the (Named) forensic center for further examination (autopsy)..." Review of the autopsy report signed and dated on 5/16/14 documented, "...Date of Autopsy Examination: March 28, 2014... CAUSE OF DEATH: Asphyxia due to choking... INTERNAL EXAMINATION... RESPIRATORY SYSTEM... Non-digested food and mucus partially occlude the upper airway, and pieces of non-digested food occlude the lobar bronchi and some more distal branches... SUMMARY AND INTERPRETATION... Based on the autopsy findings... the cause of death is attributed to asphyxia due to choking..." During an interview in the conference room on 8/14/14 at 5:00 PM, CNA #30 was asked if she was present during Resident #261's choking incident. CNA #30 stated, "I brought his tray in his room... I went back in to check on him and he seemed like he was in stress, like something was wrong. I asked him if he was okay, and he raised up his hand... When black people hold their hand up we know something's wrong. I went immediately and got the nurse. After that, the nurses took over..." CNA #30 was asked about how long it took the nurse to respond. CNA #30 stated, "It didn't really take long... I yelled in the hallway. 'Mr. (first name of Resident #261) is in distress'. She (Nurse #20) came right there." The facility staff failed to perform the [MEDICATION NAME] maneuver when Resident #261 was noted to be in distress, which resulted in an immediate jeopardy when Resident #261 subsequently choked to death. Validation of the Credible Allegation of Compliance (AOC) was accomplished on-site August 26, 2014, through review of facility documents, audits, review of in-service records, observations and interviews with nursing, dietary and administrative staff. The surveyors validated the corrective actions stated in the AOC were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign in sheets, for all staff on the [MEDICATION NAME] maneuver. Interviews with CNAs, dietary staff, nurse managers, charge nurses conducted in the facility, staff verbalized how to do the [MEDICATION NAME] maneuver. The facility will remain out of compliance at a scope and severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction.

Based on medical record review, review of an autopsy, review of a meal ticket, observation and interview, it was determined the facility failed to follow the care plan interventions for a therapeutic diet and/or assistance with dining for 2 of 39 (Residents #261 and 6) sampled residents of the 39 residents included in the stage 2 review. The failure of the facility to follow the care plan interventions for a therapeutic diet or provide assistance with dining resulted in an immediate jeopardy when Resident #6, who was at risk for choking, received a whole hot dog on a bun and Resident #261 received pulled pork, was left alone to eat in his room and chocked to death. Immediate jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. A meeting was conducted in the conference room on 8/18/14 at 4:52 PM, with the Administrator and the Director of Nursing (DON), when they were informed of the immediate jeopardy (IJ) related to choking. The facility provided an acceptable Allegation of Compliance on August 25th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 25, 2014, had removed the immediate jeopardy. The immediate jeopardy (IJ) existed from 3/27/14 through 8/24/14. The IJ was removed on 8/25/14. Noncompliance for F282 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. Medical record review for Resident #261 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] documented resident was receiving a mechanically altered diet. Review of a care plan dated 5/16/13 and reviewed 2/14 documented a problem that Resident #261 is a nutrition risk due to a swallowing problem related to dysphagia and requires a mechanically altered diet. The interventions to provide the diet as ordered by the physician, monitor the intake and no bread, rice or salad. The care plan documented Resident #261 is to be upright for all meals, staff to feed all meals and aspiration precautions. Review of a nurses note dated 3/28/14 documented, "...cna (certified nursing assistant #30) served resident's (Resident #261) supper. The supper consisted of the following items 4 oz (ounces) of pulled pork... at approximately 5:31 PM the cna (#30) returned to check on him... the cna immediately sought out the nurse at 5:32pm... LPN (licensed practical nurse) #20 immediately responded... noticed that the resident was in ditress (distress) and noted resident's (Resident #261) lips were bluish in color..." Resident #261, who had a swallowing problem related to dysphagia, was served the wrong diet and was left alone in his room to feed himself on 3/27/14. The facility failed to follow the care plan interventions for a therapeutic diet of pureed meat and the resident is to be feed. Review of the autopsy report signed and dated on 5/16/14 documented, "...Date of Autopsy Examination: March 28, 2014... CAUSE OF DEATH: Asphyxia due to choking... INTERNAL EXAMINATION... RESPIRATORY SYSTEM... Non-digested food and mucus partially occlude the upper airway, and pieces of non-digested food occlude the lobar bronchi and some more distal branches... SUMMARY AND INTERPRETATION... Based on the autopsy findings... the cause of death is attributed to asphyxia due to choking..." During an interview in the conference room on 8/14/14 at 5:00 PM, CNA #30 was asked what type of diet was Resident #261 on. CNA #30 stated, "I don't really remember if he was on a regular diet or a pureed diet. It looked like roast beef, it was like stringy. I can't remember what else he had." CNA #30 was asked if the meat was pureed and if it had gravy on it. CNA #30 stated, "It (meat) didn't look like pureed. I don't remember any gravy on it." CNA #30 was asked about Resident #261's choking incident. CNA #30 stated, "I brought his tray in his room... He usually would eat out in the dining room. I left... I went back in to check on him and he seemed like he was in stress, like something was wrong. I asked him if he was okay, and he raised up his hand... When black people hold their hand up we know something's wrong. I went immediately and got the nurse..." During an interview in the conference room on 8/18/14 at 3:10 PM, the Dietary Manager (DM) was asked who updated Resident #261's current nutrition care plan. The DM stated, "I did. I wrote that on the care plan from the order dated 12/17/12 (out of bed for all meals spoon feed all meals and upright for all meals)." The facility failed to follow the care plan interventions for a therapeutic diet and assisting with dining resulted in the accidental choking death of Resident #261, which resulted in immediate jeopardy. 2. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE] documented Resident #6 received a mechanically altered diet and a therapeutic diet. Review of a telephone physician order [REDACTED]. Review of a physician's orders [REDACTED]. Review of a care plan dated 9/25/13 and reviewed 2/14 documented, "...Problem... Resident is a nutrition risk: As evidenced by... NEED FOR MECH ALTERED DIET... NEED FOR THERAPEUTIC DIET... Approach... Provide diet as ordered (see current physician orders)... ASSIST WITH ALL MEALS AS NEEDED... No bread... on trays..." Review of a tray meal ticket dated 8/22/14 documented, "...DIET: MS (Mechanical Soft), NAS, no bread..." Observations in Resident #6's room on 8/22/14 at 5:48 PM, revealed Resident #6 received a dinner tray with a regular hot dog on a bun. CNA #32 stated, "Resident is a choke risk and I will have to stay with him until he is finished eating." Further observations revealed CNA #32 cut the hot dog in half and handed one half to the resident. The surveyor stopped the resident from placing the hot dog in his mouth. CNA #32 was asked to look at the meal ticket. CNA #32 stated, "I almost made a big mistake. Thank you for catching it. I just looked at mechanical soft. We forget." The facility failed to follow the care plan interventions for a therapeutic diet when Resident #6 received a whole hot dog on a bun, which placed Resident #6 at risk for choking, and Immediate Jeopardy. Validation of the Credible Allegation of Compliance (AOC) was accomplished on-site August 26, 2014, through review of facility documents, audits, review of in-service records, observations and interviews with nursing, dietary and administrative staff. The surveyors validated the corrective actions stated in the AOC were implemented which removed the immediate jeopardy. The facility provided evidence of in-service training with sign in sheets, for all staff on the tray service to include review of each meal ticket for verification of correct diet served and color coded meal tickets. The facility provided evidence of in-service training for all dietary personnel regarding identification and preparation of diets, competencies for food preparation and thickened liquids by the certified dietary manager. The facility provided evidence of audits that included physician orders [REDACTED]. Accuracy of meals served to residents to include trays from the kitchen to the floors and tray tickets verified with meals on the trays. Interviews with CNAs, nurse managers, charge nurses conducted in the facility, staff verbalized how to properly check for proper diets and matching the tray tickets and what a colored meal ticket meant. Nurse managers verbalized how they would continue to monitor and audit the accuracy of the meal delivery. Observations in the facility on 8/26/14 and 8/27/14 revealed staff physically checking the meal tickets to the food tray when the cart was delivered to the halls, and then a second check by the staff member when the tray is delivered to the resident. The facility will remain out of compliance at a scope and severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction.

Based on review of the Sorensen and Luckmann's Basic Nursing a Psychophysiologic Approach, medical record review, review of the investigator's report, review of an autopsy, review of a tray card, observation and interview, it was determined the facility failed to provide care and services necessary to maintain the highest practicable physical, mental, and psychosocial well-being of residents when staff failed to follow physician orders [REDACTED].#261 and 6) sampled residents included in the stage 2 review. The facility failed to follow therapeutic diets when Resident #6, who was at risk for choking, received a plate that included a whole hot dog on a bun and Resident #261 received a plate that included pulled pork instead of pureed meat. The facility failed to monitor Resident #261 during dining and staff failed to perform the [MEDICATION NAME] maneuver (action to remove what is blocking the airway) to prevent choking and suffocation which resulted in the accidental choking death of Resident #261. These incidents resulted in an immediate jeopardy which is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The immediate jeopardy for F309 constitutes substandard quality of care. An extended survey was completed on 8/26/14 and 8/27/14. A meeting was conducted in the conference room on 8/18/14 at 4:52 PM, with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) when they were informed of the immediate jeopardy (IJ). The facility provided an acceptable Allegation of Compliance on August 25th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 25, 2014, had removed the immediate jeopardy. The immediate jeopardy (IJ) existed from 3/27/14 through 8/24/14. The IJ was removed on 8/25/14. Noncompliance for F309 continues at a "D" level citation. The facility is required to submit a plan of correction. The findings included: 1. Review of the Sorensen and Luckmann's Basic Nursing a Psychophysiologic Approach, third edition, page 576, management of obstructed airway, documented, "The two techniques for relieving foreign body airway obstruction are manual chest and abdominal thrusts ([MEDICATION NAME] maneuver) and finger sweeps." Medical record review for Resident #261 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of a quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #261 received a mechanically altered diet. Review of a care plan dated 5/16/13 and reviewed 2/14 documented a problem that Resident #261 is a nutrition risk due to a swallowing problem related to dysphagia and requires a mechanically altered diet. The interventions to provide the diet as ordered by the physician, monitor the intake and no bread. The care plan documented Resident #261 is to be upright for all meals, staff to feed all meals and aspiration precautions. Review of a nurses note dated 3/28/14 documented, "...cna (certified nursing assistant #30) served resident's (Resident #261) supper. The supper consisted of the following items 4 oz (ounces) of pulled pork... at approximately 5:31 PM the cna (#30) returned to check on him... the cna immediately sought out the nurse at 5:32pm... LPN (licensed practical nurse) #20 immediately responded... noticed that the resident was in ditress (distress) and noted resident's (Resident #261) lips were bluish in color... the resident was still breathing at this time. The LPN (#20) stimulated the resident with cardiac massage... a code blue was called... compressions were commenced until EMT's (Emergency Medical Technicians) arrived. Breaths were administered between compressions... EMT arrived at 5:45pm... The EMT's and the first responder hooked him up to a monitor... stopped the code at approximately 5:55pm..." There was no documentation the facility staff performed the [MEDICATION NAME] maneuver. Review of the investigator's report signed and dated on 3/27/14 documented, "...(Named Rescue Team) arrived on the scene and cleared his (Resident #261) airway but asystole (no heart beat) was confirmed at 1755 (5:55 PM) by paramedics... (Named Officer) advised the following: this black male was eating dinner and began choking on his food... Fire department paramedics removed the food from his airway and staff threw it away. Due to this accident jurisdiction was accepted and this black male was transported to the (Named) forensic center for further examination (autopsy)..." Review of the autopsy report signed and dated on 5/16/14 documented, "...Date of Autopsy Examination: March 28, 2014... CAUSE OF DEATH: Asphyxia due to choking... INTERNAL EXAMINATION... RESPIRATORY SYSTEM... Non-digested food and mucus partially occlude the upper airway, and pieces of non-digested food occlude the lobar bronchi and some more distal branches... SUMMARY AND INTERPRETATION... Based on the autopsy findings... the cause of death is attributed to asphyxia due to choking..." During an interview in the conference room on 8/14/14 at 4:30 PM, the DON was asked what Resident #261 choked on. The DON stated, "I believe it was pulled pork or roast beef." During an interview in the conference room on 8/14/14 at 5:00 PM, CNA #30 was asked if she was present during Resident #261's choking incident. CNA #30 stated, "I brought his tray in his room... He usually would eat out in the dining room... I went back in to check on him and he seemed like he was in stress, like something was wrong. I asked him if he was okay, and he raised up his hand... I went immediately and got the nurse..." CNA #30 was then asked what type of diet was Resident #261 on. CNA #30 stated, "I don't really remember if he was on a regular diet or a pureed diet. It looked like roast beef, it was like stringy. I can't remember what else he had." CNA #30 was asked if the meat was pureed and if it had gravy on it. CNA #30 stated, "It (meat) didn't look like pureed. I don't remember any gravy on it." During an interview in the conference room on 8/18/14 at 3:10 PM, the Dietary Manager (DM) was asked about Resident #261's order for the therapeutic diet and who updated Resident #261's current nutrition care plan. The DM stated, "I did. I wrote that on the care plan from the order dated 12/17/12 (out of bed for all meals spoon feed all meals and upright for all meals)." During a telephone interview on 8/18/14 at 3:50 PM, the Registered Dietician (RD) was asked about Resident #261's diet orders and need for assistance. The RD stated, "His diet order changed a lot. He was at high risk of choking. There was other food he couldn't have. As far as I know he was supposed to be fed." The RD was asked if he should have been left alone in his room to eat. The RD stated, "I don't think so (this was stated with emphasis)." The facility failed to ensure Resident #261 received the proper therapeutic diet, failed to monitor Resident #261 during dining and failed to perform the [MEDICATION NAME] maneuver when Resident #261 was noted to be in distress, and subsequently choked to death, which resulted in an immediate jeopardy. 2. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS dated [DATE] documented Resident #6 received a therapeutic, mechanically altered diet. Review of a care plan dated 9/25/13 and reviewed 2/14 documented, "...Problem... Resident is at nutrition risk: As evidenced by... NEED FOR MECH (mechanical) ALTERED... THERAPEUTIC DIET... Approach... Provide diet as ordered (see current physician orders)... ASSIST WITH ALL MEALS AS NEEDED..." Review of a physician's orders [REDACTED]. Review of a supper tray card dated 8/22/14 documented, "...DIET: MS (Mechanical Soft), NAS (No Added Salt), no bread..." Observations on the 4th floor north hall on 8/22/14 at 5:48 PM, CNA #32 delivered a tray to Resident #6's room. The meal was a regular hot dog on a bun with french fries. CNA #32 stated, "He is a choke risk and I will have to stay with him until he is finished eating" CNA #32 cut the hot dog in half and handed it to Resident #6. The surveyor stopped the resident from placing the hot dog in his mouth. CNA #32 was asked to look at the meal ticket. CNA #32 stated, "I almost made a big mistake. I just looked at mechanical soft. We forget." During an interview at the 4th floor nurses' desk on 8/23/14 at 7:40 AM, the DM was asked about Resident #6 receiving the wrong diet on the 8/22/14 dinner tray which was a regular hot dog on a bun. The DM stated, "The person at the end of the line didn't catch it. Two people looked at it and didn't catch it, didn't pay enough attention, will be clarified today... anybody on mechanical soft diet is at risk for choking. My department missed it. I own it." The facility failed to follow the physician order [REDACTED]. Validation of the Credible Allegation of Compliance was accomplished on-site August 26, 2014, through review of facility documents, audits, review of in-service records, observations and interviews with nursing, dietary and administrative staff. The facility provided evidence of in-service training with sign in sheets, for all staff on the [MEDICATION NAME] maneuver, tray service to include review of each meal ticket for verification of correct diet served and color coded meal tickets. The facility provided evidence of in-service training for all dietary personnel regarding identification and preparation of diets, competencies for food preparation and thickened liquids by the certified dietary manager. The facility provided evidence of audits that included physician orders [REDACTED]. Accuracy of meals served to residents to include trays from the kitchen to the floors and tray tickets verified with meals on the trays. Interviews with CNAs, dietary staff, nurse managers, charge nurses conducted in the facility, staff verbalized how to properly check for proper diets and matching the tray tickets. Nurse managers verbalized how they would continue to monitor and audit the accuracy of the meal delivery. Observations in the facility on 8/26/14 and 8/27/14 revealed staff physically checking the meal tickets to the food tray when the cart was delivered to the halls, and then a second check by the staff member when the tray is delivered to the resident. The facility will remain out of compliance at a scope and severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction.

A. Based on policy review, medical record review, observation and interview, it was determined the facility failed to ensure the immediate availability of properly functioning tracheal suctioning equipment to provide proper [MEDICAL CONDITION] (trach) care for 1 of 2 (Resident #193) sampled residents with a [MEDICAL CONDITION] of 39 residents included in the stage 2 review. The failure of the facility to ensure properly functioning suction equipment placed Resident #193 in immediate jeopardy, a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The immediate jeopardy for F328 constitutes substandard quality of care. An extended survey was completed on 8/26/14 and 8/27/14. A meeting was conducted in the conference room on 8/18/14 at 4:52 PM, with the Administrator and the Director of Nursing (DON) when they were informed of the Immediate Jeopardy. The facility provided an acceptable Allegation of Compliance on August 26th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 26, 2014, had removed the immediate jeopardy. The immediate jeopardy (IJ) existed from 8/21/14 through 8/25/14. The IJ was removed on 8/26/14. Noncompliance for F328 continues at a "D" level citation. The facility is required to submit a plan of correction. The findings included: Review of the facility's [MEDICAL CONDITION] suctioning policy documented, "...Maintain an adequate airway..." Medical record review for Resident #193 documented an admission date of [DATE] and re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/3/14 and quarterly MDS with ARD 6/28/14 documented a brief interview of mental status (BIMS) of 15, indicating Resident #193 was not cognitively impaired and had a [MEDICAL CONDITION]. Review of a physician order [REDACTED]. Observations and interview in Resident #193's room on 8/21/14 at 9:55 AM, revealed Nurse #7 was giving morning medications to Resident #193 per the feeding tube. Resident #193 started coughing and [MEDICAL CONDITION] noted with sputum bubbling inside the cannula. Nurse #7 stopped giving medications to [MEDICAL CONDITION]. Nurse #7 attempted to suction Resident #193. Nurse #7 stated, "It (the suction machine) does suction, but it's lousy." Resident #193 was asked if he felt stuff in his throat. Resident #193 nodded his head "Yes." Nurse #7 stated, "I'm going to go get another suction machine." Nurse #7 was asked how often is Resident #193 suctioned. Nurse #7 stated, "I don't know, but he can let you know when he needs suctioning." Nurse #7 left the room at 10:10 AM, went to the oxygen room by the nurses' station and got another suction machine. Nurse #7 brought the second suction machine to the room. Nurse #7 hooked the suction machine up, but the suction machine would not work. Nurse #7 moved tubing around on the suction machine. Nurse #7 stated, "This (suction machine) isn't working either." Nurse #7 connected Resident #193 back up to the oxygen at 10:15 AM. Nurse #7 was asked do you have a problem with the suction machines not working. Nurse #7 stated, "Yes. I called the company 2 weeks ago. They were supposed to send replacements. I want to scream." Nurse #7 was asked what would you do if you needed a suction machine immediately. Nurse #7 stated, "I would pray the one on the crash cart is working." Nurse #7 left the room and got the suction machine off the crash cart. Nurse #7 returned to Resident #193's room and suctioned Resident #193.[MEDICAL CONDITION] was finished at 10:48 AM. During an interview on the 2nd floor on 8/21/14 at 11:55 AM, Nurse #14 was asked how often the suction machines are checked to see if they are working. Nurse #14 stated, "Every day. If one is not functioning, we put a X on it (suction machine)... goes back to central supply." During an interview in the conference room on 8/21/14 at 12:46 PM, the central supply manager (CSM) was asked about problems with the suction machines. The CSM stated, "The filters on the suction machine are bad, aren't working properly. After one use the bacterial filter seems like they are clogging. The ones that get clogged up, I just take a paper clip and unclog it." During an interview in the Rehab Director's office on 8/21/14 at 1:07 PM, the Rehab Director (who is a Speech Therapist) was asked if there have been any problems with the suction machine in the rehab department. The Rehab Director stated, "Sometimes we do." During a telephone interview on 8/22/14 at 11:10 AM, the operation manager with the company that supplies the suction equipment stated, "The two machines that weren't working - one machine the gauge was broken. Wasn't fur sure about the other one. We are just going to replace both of them." During an interview in the education room on 8/25/14 at 3:40 PM, the operation manager and the accounts director with the company that supplies the suction equipment were asked if the filters get clogged, what should staff do. The accounts director stated, "They have to be replaced." The accounts director was asked when the filters don't work, should the maintenance man be putting a hole in them. The accounts director stated, "No." The facility failed to ensure there was immediate availability of properly functioning tracheal suctioning equipment, which placed Resident #193 in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on August 26, 2014, through review of facility of in-service records, and interviews with suction machine company supervisors, nursing and administrative staff and observations of new functioning suction machines. The facility provided evidence of in-service training with sign in sheets for licensed nurses on proper suctioning, [MEDICAL CONDITION] care, availability of suction machines, suction supplies and facility process for non-functioning equipment. During an interview on 8/26/14 with the suction company's operations manager and director of accounts, it was verified the preventive maintenance schedule is ongoing for all new machines delivered. Observations on 8/26/14 of the new suction machines delivered revealed all machines serviced by the suction machine company and were in working order. The facility will remain out of compliance at a scope and severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction. B. Based on medical record review, observation and interview, it was determined the facility failed to ensure staff provided proper [MEDICAL CONDITION] care to prevent potential infections when a disconnected [MEDICAL CONDITION] drainage tubing that had been laying on the floor and/or laying on the bed was reconnected to the drainage bag for 1 of 5 (Resident #102) sampled residents with an indwelling catheter of the 39 residents included in the stage 2 review. The findings included: Medical record review for Resident #102 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/14 was marked for an indwelling catheter. Review of the care plan dated 6/25/14 documented, "...Resident has urinary catheter... At risk for developing UTI (Urinary Tract Infection) due to catheter use..." Review of a physician's orders [REDACTED]. Observations and interview in Resident #102's room on 8/20/14 at 11:50 AM, revealed the catheter tubing was disconnected from the bedside drainage bag (BSB) and laying on the floor. Certified Nursing Assistant (CNA) #12 stated, "It (tubing from the bag) comes apart all the time." CNA #12 picked the catheter tubing up from the floor and reconnected it to the BSB. As CNA #12 was sitting Resident #102 up for breakfast, the tubing came disconnected from the drainage bag again. CNA #12 reconnected the tubing back to the BSB. During an interview in Resident #102's room on 8/20/14 at 12:36 PM, CNA #12 was asked what she should have done when she saw the catheter tubing become disconnected and laying on the floor. CNA #12 stated, "Should have got the nurse." Observations in Resident #102's room on 8/26/14 at 10:23 AM, revealed Nurse #6 performing [MEDICAL CONDITION] care. Nurse #6 proceeded to remove the [MEDICAL CONDITION] bag, disconnected it from the bedside drainage bag (BSB), and placed the drainage bag tubing on the bed, then applied the ostomy bag and reconnected the tubing back to the BSB. During an interview on the 400 north hall on 8/26/14 at 10:35 AM, Nurse #6 was asked if the drainage bag tubing should be placed on the bed. Nurse #6 stated, "I shouldn't have placed it on the bed. I should have held on to it until ready to reconnect or placed it on my clean working space." During an interview in the conference room on 8/22/14 at 3:30 PM, Nurse Practitioner (NP) #1 was asked, Would you expect staff to reconnect a foley or [MEDICAL CONDITION] tubing that had been laying on the floor." NP #1 stated, "No, because bacteria can travel back up and cause infections."

Based on review of the geriatric medication handbook, medical record review and interview, it was determined the facility failed to ensure there was monitoring of [MEDICATION NAME] therapy (a blood thinning medication) when the physician was not promptly notified of elevated anticoagulant laboratory (lab) test results for 2 of 6 (Residents #25 and 205) sampled residents receiving [MEDICATION NAME] and failed to ensure there was monitoring of [MEDICAL CONDITION] medications for 3 of 39 (Residents #35, 47 and 219) sampled residents included in the stage 2 review. The failure of the facility to ensure the physician was promptly notified of anticoagulant laboratory (lab) test results of residents who were at an increased risk for bleeding placed Resident #25 and 205 in Immediate Jeopardy, a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Immediate Jeopardy for F329 constitutes substandard quality of care. An extended survey was conducted on 8/26/14 and 8/27/14. A meeting was conducted in the conference room on 8/20/14 at 12:15 PM, with the Administrator and the Director of Nursing, at which time they were notified of the immediate jeopardy. The facility provided an acceptable Allegation of Compliance on August 25th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 25, 2014, had removed the Immediate Jeopardy. The immediate jeopardy (IJ) existed from 7/10/14 through 8/24/14. The IJ was removed on 8/25/14. Noncompliance for F329 continues at a "D" level citation. The facility is required to submit a plan of correction. The findings included: 1. Medical record review for Resident #25 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/11/14 and a significant change in status assessment with an ARD of 7/6/14 documented Resident #25 had received anticoagulant medications 7 of 7 days of the review period. Review of Resident #25's care plan documented, "...7/6/14... at risk for abnormal bleeding or hemorrhage related to use of anticoagulant... Resident's PT ([MEDICATION NAME] Time) and INR (International Normalized Ratio) values should be maintained with therapeutic range..." Review of physician orders [REDACTED]. Review of a lab report for Resident #25 dated 7/10/14 documented the lab had called critical high INR results to Nurse #17 (who in turn notified Nurse #18 who cared for Resident #25) at the facility on 7/10/14, and that Nurse #17 verbally verified the results to the caller. The lab report documented, "...PT Checked x (times) 2... (normal) Ref. (reference) Range/Males...11.5- (to) 12.7 secs (seconds)... H (high) 38.7... INR... Ref. Range/Males... 0.0-3.0... H! (high critical) 8.6..." Review of the nurse notes dated 7/10/14 documented, "...Alert lab on INR 8.6 called...on call FNP (family nurse practitioner) still waiting on return call." Review of the physician progress notes [REDACTED]. Not called to provider..." A telephone physician order [REDACTED]. Resident #25 received [MEDICATION NAME] from 7/10/14 to 7/17/14. The [MEDICATION NAME] would have been stopped on 7/10/14 if the physician had been notified of the 8.6 INR when it was received. During a telephone interview on 8/20/14 at 11:38 AM, Nurse Practitioner (NP #2) was asked if she recalled the incident where Resident #25's critical INR result had not been reported to her from 7/10/14 until 7/17/14. NP #2's consult notes from 7/17/14 were read to her. NP #2 stated, "Don't remember." NP #2 was asked what she expected staff to do if they receive a critical lab result on a resident. NP #2 stated, "Call the provider." During an interview in the conference room on 8/20/14 at 5:39 PM, the Medical Director was asked what he expected staff to do if they receive critical lab results on a resident. The Medical Director stated, "We would expect to be called." The Medical Director was asked what he considered to be a timely report. The Medical Director stated, "Ideally when it comes back." The Medical Director was asked what he would have done if he had been notified of the critical high INR of 8.6. The Medical Director stated he would have held the [MEDICATION NAME]. The failure of the facility to ensure proper monitoring for Resident #25 related to [MEDICATION NAME] therapy placed Resident #25 at increased risk for bleeding, resulting in immediate jeopardy. 2. Medical record review for Resident #205 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. (7/16/14)..." Review of the 7/16/14 INR results was documented as 3.3 (normal reference range is 0.0 to 3.0). There was no documentation the physician or the nurse practitioner was notified of the 3.3 result drawn on 7/16/14, and no orders were written regarding the 7/16/14 result. Review of the Medication Administration Sheet (MAR) dated 7/1/14 through (-) 7/31/14 documented Resident #205 received 3 mg of [MEDICATION NAME] daily from 7/10/14-7/30/14. Review of a telephone physician order [REDACTED]. T, (Tuesday) T, (Thursday) S, (Saturday) S (Sunday) and 2 mg on M (Monday) W (Wednesday) F (Friday)..." During an interview at the 4th floor nurses desk on 8/22/14 at 9:25 AM, Nurse #12 stated she called medical records and was informed there were no signed lab results for Resident #205 in medical records. Nurse #12 was asked if she saw where the nurse practitioner or physician had been notified of the 7/16/14 INR result. Nurse #12 stated, "I don't know where it is. No, I don't see where the NP #1 was notified of this result." During an interview at the 3rd floor nursing desk on 8/26/14 AT 9:20 AM, NP #1 was asked if she was notified of the abnormal lab result drawn on 7/16/14 of 3.3 for Resident #205. NP #1 stated, "It ([MEDICATION NAME]) should have been held at 3.3 (on 7/16/14). We wouldn't give it due to high risk for bleeds. It looks like the 3 mg dose was given even though the INR was documented at 3.3 on the MAR. No, I would have held it." The failure of the facility to ensure proper monitoring for Resident #205 related to [MEDICATION NAME] therapy placed Resident #205 at increased risk for bleeding, resulting in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on August 26, 2014, through review of facility documents, review of in-service records and interviews with nursing and administrative staff. The facility provided evidence of Lab/Lab Values in-service training with sign in sheets for all nursing staff on notifying the physician of lab value results. Interviews with nursing staff revealed nursing staff were aware of lab policy and when to notify physician of lab value results. The facility will remain out of compliance at a scope and severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction. 3. Medical record review for Resident #35 documented an admission date of [DATE] and a readmission date of [DATE], with [DIAGNOSES REDACTED]. Review of an annual MDS assessment with ARD of 1/31/14 and a quarterly MDS with an ARD of 7/22/14 documented Resident #35 was severely cognitively impaired, and had received antipsychotic and hypnotic medications for 7 of the 7 days of the review period. Review of Resident #35's care plan documented, "...01/31/14... Problem... Use of [MEDICAL CONDITION] drug places resident at risk for drug-related... AIMS (Abnormal involuntary movements)... Goal... Resident will be free from signs and symptoms of drug-related... Abnormal involuntary movements..." There was no AIMS assessment documented in the medical record until 8/22/14 after the surveyor had brought this to the attention of the facility staff. Review of the physician orders [REDACTED]...3/6/2014... [MEDICATION NAME] 0.5 MG 1 TABLET PER TUBE TWICE DAILY..." During an interview in the second floor MDS coordinator's office on 8/22/14 at 11:20 AM, Nurse #2 was asked when should an AIMS assessment be done. Nurse #2 stated, "Every three months if they are on an antipsychotic." During an interview on the third floor on 8/25/14 at 4:15 PM, Nurse #1 was asked whether behavioral monitoring documentation was performed. Nurse #1 stated, "No..." 4. Review of the geriatric medication handbook, eleventh edition, page 10, identified [MEDICATION NAME] as an antipsychotic medication. Medical record review for Resident #47 documented an admission date of [DATE] with a readmission date of [DATE], and [DIAGNOSES REDACTED]. Review of an annual MDS with an ARD of 4/25/14 and a quarterly MDS with ARD of 7/20/14 documented Resident #47 had received antidepressant medications for 7 of 7 days of the review period. There was no use of antipsychotic medications coded on the MDS's. Review of Resident #47's care plan dated 8/25/14 did not address antipsychotic medications. Review of Resident #47's [MEDICAL TREATMENT] consult notes dated 4/23/14 and 5/8/14 documented the resident was receiving [MEDICATION NAME] 10 mg 1 tablet by mouth (po) daily. Review of Resident #47's physician orders [REDACTED]. a. 6/12/14 - "(decrease) [MEDICATION NAME] to 5 mg PO hs (bedtime)... GDR (gradual dose reduction)..." b. 8/5/14 - "[MEDICATION NAME] 5 MG TABLET... GIVE ONE BY MOUTH DAILY @ (at) BEDTIME..." The facility was unable to provide documentation of an AIMS assessment for Resident #47. During an interview at second floor nurses' station on 8/21/14 at 7:52 AM, Nurse #14 was asked if there should be an AIMS assessment for Resident #47 related to her [MEDICATION NAME] therapy. Nurse #14 stated, "We wouldn't do an AIMS for [MEDICATION NAME] because it is an antidepressant. We only do those for antipsychotics." During an interview in the second floor MDS coordinator's office on 8/22/14 at 11:20 AM, Nurse #2 was asked when should an AIMS assessment be done. Nurse #2 stated, "Every three months if they are on an antipsychotic." 5. Medical record review for Resident #219 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an admission MDS assessment with an ARD of 4/8/14 documented Resident #219 had received antipsychotic and antidepressant medications for 7 of 7 days of the review period, and hypnotic medications 1 of the 7 days. The quarterly MDS with an ARD of 7/3/14 documented Resident #219 had received antipsychotic and antidepressant medications 7 of 7 days of the review period. Review of Resident #219's care plan dated 4/8/14 documented, "...Administer and monitor the effectiveness and side effects of medications as ordered..." Review of the physician orders [REDACTED]...4/18/14... [MEDICATION NAME] 0.5 MG TABLE (tablet) INCREASE [MEDICATION NAME] TO 0.5 MG PO Q (every) HS..." During an interview in second floor MDS office on 8/22/14 at 11:20 AM, Nurse #2 was asked when should an AIMS assessment be done. Nurse #2 stated, "Every three months if they are on an antipsychotic." During an interview at the second floor nurse's station on 8/25/14 at 4:20 PM, Nurse #14 was asked whether behavioral monitoring was done for Resident #219. Nurse #14 stated, "We haven't had any issues. He just came down here from the third floor. They said he wasn't having any issues." During an interview on the second floor, on 8/25/14 at 4:33 PM, Nurse #18 was asked whether behavioral monitoring is conducted or documented for Resident #219. Nurse #18 stated, "He should have a behavioral monitoring sheet since he is on Risperidal." The facility was unable to provide documentation that an AIMS assessment had been performed for Resident #219.

Based on review of an autopsy report, review of meal tray card, medical record review, observation and interview, it was determined the facility failed to provide the correct therapeutic diet for 2 of 39 (Residents #261 and 6) sampled residents of the 39 residents included in the stage 2 review. The facility failed to follow therapeutic diets when Resident #6, who was at risk for choking, received a plate that included a whole hot dog on a bun and Resident #261 received a plate of pulled pork instead of pureed meat and subsequently choked to death. These incidents resulted in immediate jeopardy, a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. A meeting was conducted in the conference room on 8/18/14 at 4:52 PM, with the Administrator and the Director of Nursing (DON), when they were informed of the Immediate Jeopardy (IJ) related to choking. The facility provided an acceptable Allegation of Compliance on August 25th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 25, 2014, had removed the immediate jeopardy. The immediate jeopardy (IJ) existed from 3/27/14 through 8/24/14. The IJ was removed on 8/25/14. Noncompliance for F365 continues at a "D" level citation. The facility is required to submit a plan of correction. The findings included: 1. Medical record review for Resident #261 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of a nurses note dated 3/28/14 documented, "...CNAs (certified nursing assistant #30) served resident's (Resident #261) supper. The supper consisted of the following items 4 oz (ounces) of pulled pork..." Review of the autopsy report signed and dated on 5/16/14 documented, "...Date of Autopsy Examination: March 28, 2014... CAUSE OF DEATH: Asphyxia due to choking... Based on the autopsy findings... the cause of death is attributed to asphyxia due to choking..." During an interview in the conference room on 8/14/14 at 4:30 PM, the Director of Nursing (DON) was asked what Resident #261 choked on. The DON stated, "I believe it was pulled pork or roast beef." During an interview in the conference room on 8/14/14 at 5:00 PM, CNAs #30 was asked what type of diet was Resident #261 on. CNAs #30 stated, "I don't really remember if he was on a regular diet or a pureed diet. It looked like roast beef, it was like stringy. I can't remember what else he had." CNAs #30 was asked if the meat was pureed and if it had gravy on it. CNAs #30 stated, "It (meat) didn't look like pureed. I don't remember any gravy on it." During a telephone interview on 8/18/14 at 3:50 PM, the Registered Dietician (RD) was asked about Resident #261's diet orders. The RD stated, "His diet order changed a lot. He was at high risk of choking. There was other food he couldn't have..." The facility failed to ensure Resident #261 received the proper therapeutic diet which resulted in an immediate jeopardy when the resident subsequently choked to death. 2. Medical record review for Resident #6 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set ((MDS) dated [DATE] documented Resident #6 received a mechanically altered diet and a therapeutic diet. Review of a physician's orders [REDACTED]. Review of a supper tray card dated 8/22/14 documented, "...DIET: MS (Mechanical Soft), NAS (No Added Salt), no bread..." Observations on the 4th floor north hall on 8/22/14 at 5:48 PM, CNAs #32 delivered a tray to Resident #6's room. The meal was a regular hot dog on a bun with french fries. CNAs #32 stated, "He is a choke risk and I will have to stay with him until he is finished eating" CNAs #32 cut the hot dog in half and handed it to Resident #6. The surveyor stopped the resident from placing the hot dog in his mouth. CNAs #32 was asked to look at the tray card. CNAs #32 stated, "I almost made a big mistake. I just looked at mechanical soft. We forget." During an interview at the 4th floor nurses' desk on 8/23/14 at 7:40 AM, the Dietary Manager (DM) was asked about Resident #6 receiving the wrong diet on the 8/22/14 dinner tray which was the regular hot dog on a bun. The DM stated, "The person at the end of the line didn't catch it. Two people looked at it and didn't catch it, didn't pay enough attention, will be clarified today... anybody on mechanical soft diet is at risk for choking. My department missed it. I own it." The facility failed to follow the physician order [REDACTED].#6 received a whole hot dog on a bun, which placed Resident #6 at risk for choking, resulting in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site August 26, 2014, through review of facility documents, audits, review of in-service records, observations and interviews with nursing, dietary and administrative staff. The facility provided evidence of in-service training with sign in sheets, for all staff on tray service to include review of each meal ticket for verification of correct diet served and color coded meal tickets. The facility provided evidence of in-service training for all dietary personnel regarding identification and preparation of diets, competencies for food preparation and thickened liquids by the certified dietary manager. The facility provided evidence of audits that included physician orders [REDACTED]. Interviews with CNAs, dietary staff, nurse managers, charge nurses conducted in the facility, staff verbalized how to properly check for proper diets and matching the tray tickets. Nurse managers verbalized how they would continue to monitor and audit the accuracy of the meal delivery. Observations in the kitchen on 8/2614 and 8/27/14 revealed staff physically checking the meal tickets to the food tray before being placed on the cart. Observations in the facility on 8/2614 and 8/27/14 revealed staff physically checking the meal tickets to the food tray when the cart was delivered to the halls, and then again by the staff member when the tray was delivered to the resident. The facility will remain out of compliance at a scope and severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction.

Based on observation and interview, it was determined the facility failed to ensure the immediate availability of properly functioning tracheal suctioning equipment for 1 of 2 (Resident #193) sampled residents with a [MEDICAL CONDITION] of 39 residents included in the stage 2 review. The failure of the facility to ensure properly functioning suction equipment placed Resident #193 in immediate jeopardy, a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. A meeting was conducted in the conference room on 8/18/14 at 4:52 PM, with the Administrator and the Director of Nursing (DON) when they were informed of the Immediate Jeopardy. The facility provided an acceptable Allegation of Compliance on August 26th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 26, 2014, had removed the immediate jeopardy. The immediate jeopardy (IJ) existed from 8/21/14 through 8/25/14. The IJ was removed on 8/26/14. Noncompliance for F456 continues at a "D" level citation. The facility is required to submit a plan of correction. The findings included: Observations and interview in Resident #193's room on 8/21/14 at 9:55 AM, revealed Nurse #7 was giving morning medications to Resident #193 per the feeding tube. Resident #193 started coughing and [MEDICAL CONDITION] noted with sputum bubbling inside the cannula. Nurse #7 stopped giving medications to [MEDICAL CONDITION]. Nurse #7 attempted to suction Resident #193. Nurse #7 stated, "It (the suction machine) does suction, but it's lousy." Resident #193 was asked if he felt stuff in his throat. Resident #193 nodded his head "Yes." Nurse #7 stated, "I'm going to go get another suction machine." Nurse #7 was asked how often is Resident #193 suctioned. Nurse #7 stated, "I don't know, but he can let you know when he needs suctioning." Nurse #7 left the room at 10:10 AM, went to the oxygen room by the nurses' station and got another suction machine. Nurse #7 brought the second suction machine to the room. Nurse #7 hooked the suction machine up, but the suction machine would not work. Nurse #7 moved tubing around on the suction machine. Nurse #7 stated, "This (suction machine) isn't working either." Nurse #7 connected Resident #193 back up to the oxygen at 10:15 AM. Nurse #7 was asked do you have a problem with the suction machines not working. Nurse #7 stated, "Yes. I called the company 2 weeks ago. They were supposed to send replacements. I want to scream." Nurse #7 was asked what would you do if you needed a suction machine immediately. Nurse #7 stated, "I would pray the one on the crash cart is working." Nurse #7 left the room and got the suction machine off the crash cart. Nurse #7 returned to Resident #193's room and suctioned Resident #193.[MEDICAL CONDITION] was finished at 10:48 AM. During an interview on the 2nd floor on 8/21/14 at 11:55 AM, Nurse #14 was asked how often the suction machines are checked to see if they are working. Nurse #14 stated, "Every day. If one is not functioning, we put a X on it (suction machine)... goes back to central supply." During an interview in the conference room on 8/21/14 at 12:46 PM, the central supply manager (CSM) was asked about problems with the suction machines. The CSM stated, "The filters on the suction machine are bad, aren't working properly. After one use the bacterial filter seems like they are clogging. The ones that get clogged up, I just take a paper clip and unclog it." During an interview in the Rehab Director's office on 8/21/14 at 1:07 PM, the Rehab Director (who is a speech Therapist) was asked if there had been any problems with the suction machine in the department. The Rehab Director stated, "Sometimes we do." During a telephone interview on 8/22/14 at 11:10 AM, the operation manager with the company that supplies the suction equipment stated, "The two machines that weren't working - one machine the gauge was broken. Wasn't for sure about the other one. We are just going to replace both of them." During an interview in the education room on 8/25/14 at 3:40 PM, the operation manager and the accounts director with the company that supplies the suction equipment were asked if the filters get clogged, what should staff do. The accounts director stated, "They have to be replaced." The accounts director was asked when the filters don't work, should the maintenance man be putting a hole in them. The accounts director stated, "No." The facility failed to ensure there was immediate availability of properly functioning tracheal suctioning equipment, which placed Resident #193 in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on August 26, 2014, through review of facility of in-service records, and interviews with suction machine company supervisors, nursing and administrative staff and observations of new functioning suction machines. The facility provided evidence of in-service training with sign in sheets for licensed nurses on proper suctioning, [MEDICAL CONDITION] care, availability of suction machines, suction supplies and facility process for non-functioning equipment. During an interview on 8/26/14 with the suction company's operations manager and director of accounts, verified the preventive maintenance schedule is ongoing for all new machines delivered. Observations on 8/26/14 of the new suction machines delivered revealed all machines serviced by the suction machine company and were in working order. The facility will remain out of compliance at a Scope and Severity level "D" an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction.

Based on policy review, review of the Sorensen and Luckmann's Basic Nursing a Psychophysiologic Approach, review of a time detail sheet, review of a suspension form, review of an investigator's report, review of an autopsy report, review of a meal tray card, medical record review, observation and interview, it was determined the facility failed to be administered in a manner that enabled it to use it's resources effectively and efficiently to maintain the highest practicable physical and psychosocial well-being of the residents as evidenced by: failing to ensure residents were protected from potential staff to resident abuse, to ensure the abuse policy was implemented to ensure allegations of abuse and neglect were thoroughly investigated and reported to administration for 2 of 15 (Residents #130 and 261) residents; failing to ensure adherence to current medical standards of practice related to emergency services for choking for 1 of 39 (Resident #261) residents; failing to ensure staff followed current plans of care and physician orders [REDACTED].#6 and 261) residents; failing to provide properly functioning medical equipment for a resident with a [MEDICAL CONDITION] for 1 of 2 (Resident #193) residents with a [MEDICAL CONDITION]; failing to ensure residents were free from unnecessary medications related to the use of anticoagulant medications and failing to ensure timely physician notification of abnormal lab results for 2 of 15 (Residents 25 and 205) residents receiving [MEDICATION NAME]; and failure to ensure the quality assurance program was effective in identifying issues and concerns related to the noncompliance identified above. The incidents noted above resulted in immediate jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. A meeting was conducted in the conference room on 8/18/14 at 4:52 PM, with the Administrator and the Director of Nursing (DON) at which time they were informed of the IJ related to abuse and choking. A meeting was conducted in the conference room on 8/20/14 at 12:15 PM, with the Administrator and the DON, at which time they were informed of the IJ related to timely lab result notification. A meeting was conducted in the conference room on 8/21/14 at 12:46 PM, with the Administrator and the DON, at which time they were informed of the IJ related to malfunctioning suction equipment which resulted in improper [MEDICAL CONDITION] care. The facility provided two acceptable Allegation of Compliance on August 25th, 2014 and one on August 26th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 25 and 26, 2014, removed the IJ. The immediate jeopardy (IJ) existed from 2/14/14 through 8/25/14. The IJ was removed on 8/26/14. Noncompliance for F490 continues at a "D" level citation. The facility is required to submit a plan of correction. The findings included: 1. The administration failed to ensure residents were protected from potential staff to resident abuse during investigation of an abuse allegation, and failed to ensure the abuse and neglect policies were implemented to ensure allegations of abuse were thoroughly investigated and reported to administration, placing Resident #130 in immediate jeopardy; and neglected to ensure physician orders [REDACTED].#261 in IJ and resulted in the choking death of Resident #261. Refer to F224, F225 and F226. 2. The administration failed to ensure staff adhered to current medical standards of practice related to emergency services for choking, when staff failed to perform the [MEDICATION NAME] maneuver when Resident #261 choked to death which placed Resident #261 in IJ. Refer to F281. 3. The administration failed to ensure the staff followed the care plan interventions and physician orders [REDACTED].#6 and 261. Resident #6 received a whole hot dog on a bun instead of a mechanical soft diet as ordered and Resident #261 received pulled pork instead of pureed meat and was left alone to eat in his room and choked to death. Theses incidents resulted in an IJ. Refer to F282, F309 and F365. 4. The administration failed to ensure that suction equipment was readily available and functional for Resident #193 to ensure proper [MEDICAL CONDITION] care was provided, which placed Resident #193 in IJ. Refer to F328 and F456. 5. The administration failed to ensure proper drug monitoring and ensure timely reporting of anticoagulant lab values to the physician placed Residents #25 and 205 in IJ. Refer to F329 and F505. 6. The administration failed to ensure the Quality Assessment and Assurance (QAA) committee established and implemented an effective quality assurance program that thoroughly and systematically identified and addressed concerns and noncompliance within the facility. Refer to F520. Validation of the Credible Allegation of Compliance (AOC) was accomplished on August 26, 2014, through review of facility documents, audits, review of in-service records, observations and interviews with dietary, suction machine company supervisors, nursing, dietary staff and administrative staff administrative staff. The surveyors validated the corrective actions stated in the AOC were implemented which removed the immediate jeopardy. The facility provided evidence that all staff received an abuse in-service and an abuse questionnaire, on which they were required to answer 100 percent correctly. Review of 5 of 5 new hire personnel files were reviewed and contained evidence of background and abuse registry checks before hire. The facility provided evidence of in-service training with sign in sheets, for all staff on the [MEDICATION NAME] Maneuver, tray service to include review of each meal ticket for verification of correct diet served and color coded meal tickets for therapeutic diets. The facility provided evidence of in-service training for all dietary personnel regarding identification and preparation of diets, competencies for food preparation and thickened liquids by the certified dietary manager. The facility provided evidence of in-service training with sign in sheets for licensed nurses on proper suctioning, [MEDICAL CONDITION] care, availability of suction machines, suction supplies and facility process for non-functioning equipment. The facility provided evidence of Lab/Lab Values in-service training with sign in sheets for all nursing staff. The facility provided evidence of audits that included physician orders [REDACTED]. Accuracy of meals served to residents to include trays from the kitchen to the floors and tray tickets verified with meals on the trays. Observations in the kitchen on 8/26/14 revealed the meal ticket being checked at each station, the condiments and fluid station, the entree station and at the bread and dessert station the entire meal tray was reviewed by that staff member to ensure the tray was correct. Observations in the facility on 8/26/14 revealed staff physically checking the meal tickets to the food tray when the cart was delivered to the halls, and then a second check by the staff member when the tray is delivered to the resident. Observations on 8/26/14 of the new suction machines delivered revealed all machines serviced by the suction machine company and were in working order. Interviews on 8/26/14 were completed with nursing and administrative staff to ensure staff were knowledgeable of proper procedures regarding the reporting of abuse and protection of the residents. An interview was conducted with the Abuse Prevention Coordinator, in which she stated that weekly Performance Improvement meetings have been scheduled. Interviews on 8/26/14 with CNAs, dietary staff, nurse managers, charge nurses conducted in the facility, staff verbalized how to properly check for proper diets and matching the tray tickets, what a colored meal ticket means, and how to do the [MEDICATION NAME] maneuver. Nurse managers verbalized how they would continue to monitor and audit the accuracy of the meal delivery. Interviews on 8/26/14 with the suction company's operations manager and director of accounts, it was verified the preventive maintenance schedule is ongoing for all new machines delivered. Interviews on 8/26/14 with staff verified the use of [MEDICATION NAME] flow sheets at each nursing desk that will be taken daily to the clinical meetings for review and follow up. Interviews with nursing staff revealed nursing staff were aware of lab policy and when to notify physician of lab value results. Interview on 8/27/14 the Quality Assurance (QA) Coordinator stated that weekly performance Improvement meetings began on 8/23/14 and will be held weekly for four weeks and then monthly. The administrator will have oversight to ensure an effective plan is in place. The facility will remain out of compliance at a scope and severity level of "D", an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction.

Based on policy review, medical record review and interview, it was determined the facility failed to promptly notify the physician of [MEDICATION NAME] Time / International Normalized Ratio (PT/INR) laboratory (lab) results for 2 of 6 (Residents #25 and 205) sampled residents receiving [MEDICATION NAME] (an anticoagulant blood thinning) medication of the 39 residents included in the stage 2 review. The failure of the facility to ensure the physician was made aware of elevated lab results placed Residents #25 and 205 in Immediate Jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. A meeting was conducted in the conference room on 8/20/14 at 12:15 PM, with the Administrator and the Director of Nursing (DON) at which time they were informed of the IJ. The facility provided an acceptable Allegation of Compliance on August 25th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 25, 2014, had removed the IJ. The immediate jeopardy (IJ) existed from 7/10/14 through 8/24/14. The IJ was removed on 8/25/14. Noncompliance for F505 continues at a "D" level citation. The facility is required to submit a plan of correction. The findings included: 1. Review of the facility's laboratory testing reporting policy documented, "...Responsibility... The Director of Nursing/designee will be responsible to ensure that lab... studies are obtained from approved labs/diagnostic providers and that the physician or non-physician practitioner receive the results timely... Abnormal labs will be called to the MD (medical doctor) for follow-up at the time of receipt with information noted on the lab to include date, time, initials, and orders... MD-review of copies are to be filed in medical record after review completed." 2. Medical record review for Resident #25 documented an admission date of [DATE], with [DIAGNOSES REDACTED]. Physician's progress note for Resident #25 documented the following: a. 2/6/14 - "...a past medical history that is complex and includes... history of [MEDICAL CONDITION] ([MEDICAL CONDITION] with IVC (inferior vena cava) filter and... remains on [MEDICATION NAME] has a cerebral aneurysm, which was repaired... We will continue with his PT/INR's..." b. 5/6/14 - "...HIGH COMPLEXITY VISIT... PROBLEMS... status [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/11/14 and a significant change in status assessment with an ARD of 7/6/14, documented Resident #25 had received anticoagulant medications 7 of 7 days of the review periods. Review of Resident #25's care plan documented, "... 7/6/14... at risk for abnormal bleeding or hemorrhage related to use of anticoagulant... Resident's PT and INR values should be maintained with therapeutic range..." Physician orders [REDACTED]. a. 6/5/14 - "... [MEDICATION NAME] SODIUM 1 MG (milligrams) TABLET... 1 TABLET ORALLY TUE (Tuesday) & (and) THURS (Thursday) (TOTAL DOSE 3.5MG)... [MEDICATION NAME] SODIUM 2.5 MG TABLET... 1 TABLET ORALLY TUE & THURS (TOTAL DOSE 3.5MG)... [MEDICATION NAME] SODIUM 4 MG TABLET... 1 TABLET ORALLY ON SUN (Sunday), MON (Monday), WED (Wednesday), FRI (Friday) & SAT (Saturday)..." b. 7/8/14 - "[MEDICATION NAME] SODIUM 4 MG TABLET...1 TABLET ORALLY ON SUN, MON, WED, FRI, & [MEDICATION NAME] 3.5 MG GIVE 3.5 MG ON TUES AND THURS..." Review of a lab result report for Resident #25 dated 7/10/14 documented the lab called the facility and notified Nurse #17 (who in turn notified Nurse #18 who cared for Resident #25) of the critical INR value of 8.6 on 7/10/14, and Nurse #17 verbally verified the results to the caller. The lab report documented, "... PT Checked x (times) 2... (normal) Ref. (reference) Range/Males... 11.5- (to) 12.7 secs (seconds)... H (high) 38.7... INR... Ref. Range/Males... 0.0-3.0... H! (high critical) 8.6..." Review of a nurse note dated 7/10/14 documented, "... Alert lab on INR 8.6 called (Named Physician #1) on call FNP (family nurse practitioner) still waiting on return call..." Review of a physician's progress note dated 7/17/14 documented, "...lab found in book dated 7/10/14 (critically high) INR 8.6. Not called to provider (physician/FNP)..." A physician telephone order dated 7/17/14 documented, "...STAT (immediately) INR (INR 8.6 on 7/10/14) D/C (discontinue) [MEDICATION NAME] today..." During an interview at the 4th floor nurses' station on 8/20/14 at 8:35 AM, the DON was asked what she expects nurses to do when they receive a critical lab value on a resident. The DON stated the nurse should call the physician until they get an answer. The DON stated if there is no answer, they should call the physicians on the on-call list until they receive an answer. During an interview at the 4th floor nurses' station on 8/20/14 at 8:45 AM, Nurse #12 (nurse manager for the 4th floor) was asked if she was notified of Resident #25's critical INR lab value on 7/10/14. Nurse #12 stated, "It was not given to me." Nurse #12 was asked what she expected nurses to do when they receive a critical lab value result. Nurse #12 stated they should call the physician, and if no answer, they should call the medical director. During a telephone interview on 8/20/14 at 11:38 AM, Nurse Practitioner (NP #2) was asked if she recalled the incident where Resident #25's critical INR result had not been reported to her from 7/10/14 until 7/17/14. NP #2's consult notes from 7/17/14 were read to her. NP #2 stated, "Don't remember." NP #2 was asked what she expected staff to do if they receive a critical lab result on a resident. NP #2 stated, "Call the provider (physician or NP)." During an interview in the conference room on 8/20/14 at 5:39 PM, the Medical Director was asked what he expected staff to do if they receive critical lab results on a resident. The Medical Director stated, "We would expect to be called." The Medical Director was asked what he considered to be a timely report. The Medical Director stated, "Ideally when it comes back." The Medical Director was asked what he would have done if he had been notified of the critical high INR of 8.6. The Medical Director stated he would have held the [MEDICATION NAME]. During an interview in the conference room on 8/20/14 at 6:05 PM, Nurse #18 (who cared for Resident #25) confirmed that she had received the critical INR lab results for Resident #25 on 7/10/14. Nurse #18 stated she had "...called the on-call nurse practitioner and left a message stating the INR was 8.6. She didn't call me back." The facility failed to follow up and promptly notify the physician of a critical high PT/INR level for a resident receiving [MEDICATION NAME], which placed Resident #25 in immediate jeopardy. 2. Medical record review for Resident #205 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. (7/16/14)..." Review of the 7/16/14 INR results was documented as 3.3 (normal reference range of 0.0 to 3.0). There was no documentation the physician or the nurse practitioner was notified of the 3.3 result drawn on 7/16/14, and no orders were written regarding the 7/16/14 result. Review of the Medication Administration Sheet (MAR) dated 7/1/14 through (-) 7/31/14 documented Resident #205 received 3 mg of [MEDICATION NAME] daily from 7/10/14 through 7/30/14. Review of a telephone physician order [REDACTED]. T, (Tuesday) T, (Thursday) S, (Saturday) S (Sunday) and 2 mg on M (Monday) W (Wednesday) F (Friday)..." During an interview at the 4th floor nurses desk on 8/22/14 at 9:25 AM, Nurse #12 stated she called medical records and was informed there were no signed lab results for Resident #205 in medical records. Nurse #12 was asked if she saw where the nurse practitioner or physician had been notified of the 7/16/14 INR result. Nurse #12 stated, "I don't know where it is. No, I don't see where the NP #1 was notified of this result." During an interview at the 3rd floor nursing desk on 8/26/14 at 9:20 AM, the NP #1 was asked if she was notified of the abnormal lab result drawn on 7/16/14 of 3.3 for Resident #205. NP #1 stated, "It ([MEDICATION NAME]) should have been held at 3.3 (on 7/16/14). We wouldn't give it due to high risk for bleeds. It looks like the 3 mg dose was given even though the INR was documented at 3.3 on the MAR. No, I would have held it." The failure of the facility to promptly notify the physician of the PT/INR results, placed Resident #205 in immediate jeopardy. Validation of the Credible Allegation of Compliance was accomplished on-site August 26, 2014, through review of facility documents, review of in-service records, and interviews with nursing and administrative staff. The facility provided evidence of Lab/Lab Values in-service training with sign in sheets for all nursing staff. Interviews with nursing staff revealed nursing staff is aware of lab policy and when to notify physician of lab value results. Interviews with staff verified the use of [MEDICATION NAME] flow sheets at each nursing desk that will be taken daily to the clinical meetings for review and follow up. The facility will remain out of compliance at a scope and severity level "D" isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction.

Based on review of the Sorensen and Luckmann's Basic Nursing a Psychophysiologic Approach, policy review, review of the investigator's report, review of an autopsy report, review of a meal tray card, medical record review, observation and interview, it was determined the facility's Quality Assessment and Assurance (QAA) committee failed to ensure corrective actions were consistently monitored to ensure the staff followed physician orders [REDACTED].#261 and 6) residents and failed to ensure functioning medical equipment to immediately perform tracheal suctioning for 1 of 2 (Resident #193) residents with a [MEDICAL CONDITION]. The incidents noted above resulted in immediate jeopardy (IJ), a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. A meeting was conducted in the conference room on 8/18/14 at 4:52 PM, with the Administrator and the Director of Nursing (DON) at which time they were informed of the IJ related to choking. A meeting was conducted in the conference room on 8/21/14 at 12:46 PM, with the Administrator and the DON, at which time they were informed of the IJ related to malfunctioning suction equipment for [MEDICAL CONDITION] care. The facility provided acceptable Allegations of Compliance (AOC) on August 25th, 2014 and an AOC on August 26th, 2014. It was determined on August 26, 2014 the corrective actions implemented on August 25th and 26th, 2014, removed the IJ. The immediate jeopardy (IJ) existed from 2/14/14 through 8/25/14. The IJ was removed on 8/26/14. Noncompliance for F520 continues at a "D" level citation. The facility is required to submit a Plan of Correction. The findings included: 1. The quality assurance (QA) committee identified the problem in which residents may receive an incorrect diet after the accidental choking death of Resident #261 in March, 2014. Inservices began for the dietary staff and the nursing staff related to proper diet delivery, identification of therapeutic diets and proper set up. Documentation for cook skills checklists dated during April 2014 and facilitated by the Dietary manager, documented training objectives to include pureed foods and mechanical soft foods. All staff disciplines received inservicing beginning on 3/28/14 that included: The difference between pureed foods, mechanical soft, honey thick liquids and nectar thick liquids. Comparing the actual meal to the tray ticket. How to read a tray ticket. Tray tickets are highlighted for residents that at risk for choking, which includes all residents on mechanical soft or pureed diets and those with thickened liquids. The proper position for residents at risk for choking. All of these inservice sheets were reviewed and verified. The Quality Assessment and Assurance (QAA) Committee had implemented corrective actions related to the dietary issues following the choking death of Resident #261. The QA committee failed to continuously identify and failed to sustain performance improvement initiatives related to meal delivery and training on correct diet identification and meal tray delivery as evidenced by an observation on 8/22/14 when Resident #6 received a regular hot dog on a bun when a mechanical soft diet with no bread was ordered by the physician. There was no system in place to monitor staff performance related to checking the meal trays to ensure the correct diet was delivered to the residents. Refer to F282, F309 and F365. 2. The facility failed to ensure suction equipment was readily available and functional for proper [MEDICAL CONDITION] care for Resident #193. Nurse #7, the Rehab Director and the Central Supply Manager verified the facility had issues with the suctions machines not always functioning properly. Refer to F328 and F456. 3. During an interview in the Director of Social Services (DSS) office on 8/27/14 at 11:45 AM, the DSS stated, the Quality Assessment and Assurance (QAA) Committee had not implemented plans of corrective action related to the dietary issues resulting in Resident #261's choking death. The DSS's statement is not accurate, in that the surveyors verified that initial corrective actions had actually been implemented following the choking of Resident #261. 4. Validation of the Credible Allegation of Compliance (AOC) was accomplished on August 26, 2014, through review of facility documents, audits, review of in-service records, observations and interviews with dietary, suction machine company supervisors, nursing, dietary staff and administrative staff administrative staff. The surveyors validated the corrective actions stated in the AOC were implemented which removed the IJ. The facility provided evidence of in-service training with sign in sheets, for all staff tray service to include review of each meal ticket for verification of correct diet served and color coded meal tickets for therapeutic diets. The facility provided evidence of in-service training for all dietary personnel regarding identification and preparation of diets, competencies for food preparation and thickened liquids by the certified dietary manager and registered dietician. The facility provided evidence of in-service training with sign in sheets for licensed nurses on proper suctioning, [MEDICAL CONDITION] care, availability of suction machines, suction supplies and facility process for non-functioning equipment. The facility provided evidence of audits that included physician orders [REDACTED]. Accuracy of meals served to residents to include trays from the kitchen to the floors and tray tickets verified with meals on the trays. Observations in the kitchen on 8/26/14 revealed the meal ticket being checked at each station, the condiments and fluid station, the entree station and at the bread and dessert station the entire meal tray was reviewed by that staff member to ensure the tray was correct. Observations in the facility on 8/26/14 revealed staff physically checking the meal tickets to the food tray when the cart was delivered to the halls, and then a second check by the staff member when the tray is delivered to the resident. Observations on 8/26/14 of the new suction machines delivered revealed all machines serviced by the suction machine company and were in working order. Interviews on 8/26/14 with CNAs, dietary staff, nurse managers, charge nurses conducted in the facility, staff verbalized how to properly check for proper diets and matching the tray tickets, what a colored meal ticket means, and how to do the [MEDICATION NAME] maneuver. Nurse managers verbalized how they would continue to monitor and audit the accuracy of the meal delivery. Interviews on 8/26/14 with the suction company's operations manager and director of accounts, it was verified the preventive maintenance schedule is ongoing for all new machines delivered. Interview on 8/27/14 the Quality Assurance (QA) Coordinator stated that weekly performance Improvement meetings began on 8/23/14 and will be held weekly for four weeks and then monthly. The administrator will have oversight to ensure an effective plan is in place. The facility will remain out of compliance at a scope and severity level of "D", an isolated deficient practice that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility is required to submit a plan of correction.

Based on review of the "National Pressure Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE", policy review, medical record review, observation and interview, it was determined the facility failed to properly assess residents for pressure ulcers or vision for 2 of 16 (Residents #5 and 189) sampled residents reviewed of the 40 residents included in the Stage 2 review. The facility's failure to properly assess and identify skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #5. The findings included: 1. Review of the "National Pressure Advisory Panel Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "...9 ... Unstageable/Unclassified: Full thickness skin or tissue loss-depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV... 12... 3. Inspect skin regularly for signs of redness... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin..." Review of the facility's "Skin Care Protocol" policy documented, "...New skin breakdown A. Treatment nurse, nurse manager, M.D. (Medical Doctor), and D.O.N. (Director of Nursing), notified of new breakdown B. Treatment nurse [MEDICATION NAME], writes, and initiates orders..." Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a "C.N.A. (Certified Nursing Assistant) SKIN CARE ALERT" form dated 2/18/12 documented a lesion to Resident #5's right foot. Review of a "DAILY SKILLED NURSE'S NOTE" dated 2/19/12 documented, "...Skin WNL (within normal limits) (check mark)..." Review of a "DAILY SKILLED NURSE'S NOTE" dated 2/20/12 documented, "...Skin WNL (within normal limits) (check mark)..." and a written narrative of "...Resident noted with area of eschar plantar aspect. New order received for [MEDICATION NAME] daily..." Review of an "INDIVIDUAL SKIN REPORT" dated 2/20/12 documented, "...DATE OF ONSET: 2-20-12 R (Right) plantar... Facility Acquired: (check mark)... (check mark) Pressure... (check mark) Unstageable Pressure Ulcers due to slough and/or eschar... Measurements (cm) (centimeters)... L (length) 2.0 W (width) 2.0 D (diameter) U (unable)... Type Wound PU (pressure ulcer) Stage U (unstageable)..." Review of a "Weekly Skin Rounds" documented the following: a. 2/15/12 "...Skin Condition: clear..." b. 2/20/12 "...Skin Condition: Rt (right) foot Ball of foot below great toe..." c. 2/22/12 "Skin Condition: Good... Necrosis R (right) gt (great) toe unchanged..." Review of the "TREATMENT RECORD" for the month of February, 2012 documented, "...Paint area to right plantar aspect with [MEDICATION NAME] daily..." This treatment was started 2/20/12. Review of the care plan dated 7/4/11, updated 9/1/11 and 2/20/12 documented, "...Problem, Need, Strength, Potential Concern... Resident has POTENTIAL FOR pressure ulcer (s)... Approach... Notify nurse immediately of any new areas of skin breakdown, redness, blisters, discoloration noted during bathing or daily care..." There was no documentation of any treatment or of a wound by a nurse until 2/20/12 after the lesion was noted 2/18/12 by the CNA. Observations in Resident #5's room on 3/25/12 at 3:23 PM, revealed Resident #5 lying on her right side in the bed, dressing intact to her right foot, an air mattress on the bed, and a heel boot on her right foot. Observations in Resident #5's room on 3/26/12 at 8:31 AM, revealed Resident #5 lying in the bed, an air mattress on the bed, a heel boot on her right foot. Observations in Resident #5's room on 3/27/12 at 8:10 AM, revealed Resident #5 lying on her right side, bilateral feet on the mattress, and no pillows between her legs. Observations in Resident #5's room on 3/27/12 at 10:25 AM, during a dressing change with Nurse #4, revealed Resident #5 lying on her left side, a wound to the ball of the right foot circular, some slough to the edges, and granulation tissue to the center of the wound, her great toe turned upright at the joint, and contracted at the ankles and knees. Observations in Resident #5's room on 3/27/12 at 3:46 PM, revealed Resident #5 lying supine with a heel boot to her right foot. During an interview at the 2nd floor nurses' station on 3/26/12 at 4:25 PM, Nurse #4 (Treatment Nurse) stated, "She (Resident #5) has an open area to the plantar region of her right foot. It was a necrotic area when it started. Nurse #4 was asked if the wound was in-house acquired. Nurse #4 stated, "Yes, it started here." Nurse #4 was asked what preventive measures were in place before the wound was identified. Nurse #4 stated, "We didn't have anything for her feet at the time. She is so contracted it is hard to position her." During a telephone interview in the conference room on 3/27/12 at 11:45 AM, the resident's physician (also the facility's Medical Director) was asked if an area of eschar/necrotic skin could occur from 2/19/12 until 2/20/12 and reviewed the scenario of Resident #5's occurrence of this unstageable pressure ulcer. The resident's physician stated, "Theoretically it could. I'm hard pressed to think it could happen. I'm hard pressed to believe it did. I think it could be Stage II, but to get eschar is highly unlikely. I've not seen that occur. It usually begins as red then on to Stage II. Highly unlikely..." During an interview in Resident #5's room on 3/27/12 at 12:02 PM, CNA #1 stated, "...we sometimes use pillows to position but she throws them on floor so we don't use them..." CNA #1 was asked if Resident #5 uses heel boots. CNA #1 stated, "uhhuh, just one." During an interview in the conference room on 3/27/12 at 4:50 PM, Resident #5's physician stated, "They have produced these papers ("C.N.A SKIN CARE ALERT" form) of documentation that something was found on the 18th (2012). That changes the view of this wound occurring. From the beginning on the 18th (2012) until the 20th (2012) it could have progressed..." The facility had no documentation of any treatment or documentation of a wound by a nurse until 2/20/12, when the area is "...Resident noted with area of eschar plantar aspect..." Eschar is unstageable. During an interview in the conference room on 3/27/12 at 5:00 PM, Nurse #8 was asked what preventive measures were put into place on the 18th when the change was noted on the foot. Nurse #8 stated, "She (Resident #5) already had boots when she would wear them. They tried to use them on her when she would wear them... The CNA put the sheet in a folder for me. She (CNA) would have put it in my folder on Friday. It was the 18th (2012). I would not have known about it until Monday and that is when the treatment was started." Nurse #8 was asked what was done differently starting on the 18th when the area was found. Nurse #8 stated, "Just the boots." The facility's failure to properly assess and identify skin breakdown prior to the development of a an unstageable pressure ulcer resulted in actual harm to Resident #5. The facility's failure to properly assess and identify skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #5. 2. Medical review for Resident #189 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) with an assessment reference date of 10/18/11 documented Resident #189 with impaired vision and corrective lenses used. Review of the quarterly MDS with an assessment reference date of 1/12/12 documented Resident #189 with impaired vision and no corrective lenses used. Observations in Resident #189's room on 3/25/12 at 3:20 PM and on 3/26/12 at 4:35 PM, revealed Resident #189 seated in a wheelchair in his room, with glasses on the night stand. Observations in Resident #189's room on 3/27/12 at 6:15 PM, revealed Resident #189 seated in a wheelchair in his room eating supper meal and watching television, with glasses on the night stand. During an interview in Resident #189's room on 3/28/12 at 8:40 AM, Resident #189 stated he does wear glasses, mostly for reading. Resident #189 stated, "I need them (glasses) all the time but I wear the glasses to read something." Resident #189 was asked if the staff remind him to wear the glasses and he stated, "No, I wear them when I want to." During an interview at the 2nd floor nurses' station on 3/28/12 at 9:00 AM, Nurse #6 was asked if Resident #189 has any vision problems. Nurse #6 stated, "Not that I'm aware of." Nurse #6 was asked if Resident #189 wears glasses. Nurse #6 stated, "I don't know. I'm not sure." During an interview at the 2nd floor nurses' station on 3/28/12 at 9:15 AM, Nurse #8 was asked if Resident #189 wears glasses. Nurse #8 stated, "He has glasses and usually wears when he wants to wear them." Nurse #8 was asked if the quarterly MDS was correct for no corrective lenses. Nurse #8 stated, "that must be a typo. It's not right. He has glasses."

Based on review of the "National Pressure Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE", policy review, medical record review, observation and interview, it was determined the facility failed to properly assess residents for pressure ulcers, and/or follow interventions and treatment orders for 2 of 4 (Residents #5 and 35) sampled residents reviewed of the 7 residents with in house acquired decubiti wounds. The facility's failure to properly assess and identify skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #5. The findings included: 1. Review of the "National Pressure Advisory Panel Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "...Unstageable/Unclassified: Full thickness skin or tissue loss-depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV... 12... 3. Inspect skin regularly for signs of redness... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness), especially in individuals with darkly pigmented skin..." Review of the facility's "Skin Care Protocol" policy documented, "...New skin breakdown A. Treatment nurse, nurse manager, M.D. (Medical Doctor), and D.O.N. (Director of Nursing), notified of new breakdown B. Treatment nurse [MEDICATION NAME], writes, and initiates orders..." Medical record review for Resident #5 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a "C.N.A. (Certified Nursing Assistant) SKIN CARE ALERT" form dated 2/18/12 documented a lesion to Resident #5's right foot. Review of a "DAILY SKILLED NURSE'S NOTE" dated 2/19/12 documented, "...Skin WNL (within normal limits) (check mark)..." Review of a "DAILY SKILLED NURSE'S NOTE" date 2/20/12 documented, "...Skin WNL (within normal limits) (check mark)..." and a narrative documented "...Resident noted with area of eschar plantar aspect. New order received for [MEDICATION NAME] daily..." Review of an "INDIVIDUAL SKIN REPORT" dated 2/20/12 documented, "...DATE OF ONSET: 2-20-12 R (right) plantar... Facility Acquired: (check mark)... (check mark) Pressure... (check mark) Unstageable Pressure Ulcers due to slough and/or eschar... Measurements (cm) (centimeters)... L (length) 2.0 W (width) 2.0 D (diameter) U (unstageable)... Type Wound PU (pressure ulcer) Stage U (unstageable)..." Review of a "Weekly Skin Rounds" documented the following: a. 2/15/12, "...Skin Condition: clear..." b. 2/20/12, "...Skin Condition: Rt (right) foot Ball of foot below great toe..." c. 2/22/12, "Skin Condition: Good... Necrosis R (right) gt (great) toe unchanged..." Review of Resident #5's "TREATMENT RECORD" for the month of February, 2012 documented, "...Paint area to right plantar aspect with [MEDICATION NAME] daily..." This treatment was started 2/20/12. Review of the care plan dated 7/4/11, updated 9/1/11 and 2/20/12 documented, "...Problem, Need, Strength, Potential Concern... Resident has POTENTIAL FOR pressure ulcer (s)... Approach... Notify nurse immediately of any new areas of skin breakdown, redness, blisters, discoloration noted during bathing or daily care... Avoid skin to skin contact... Minimize pressure over bony prominence's... USE PILLOWS TO PAD HIGH RISK AREAS... 2/20/12 Tx (treatment) as ordered heel boots to protect..." There was no documentation of any treatment or of a wound by a nurse until 2/20/12 after the lesion was noted on 2/18/12 by the Certified Nursing Assistant (CNA). Observations in Resident #5's room on 3/25/12 at 3:23 PM, revealed Resident #5 lying on her right side in the bed, a dressing intact to her right foot, an air mattress on the bed and a heel boot on her right foot. Observations in Resident #5's room on 3/26/12 at 8:31 AM, revealed Resident #5 lying in the bed, an air mattress on the bed, a heel boot on her right foot. Observations in Resident #5's room on 3/27/12 at 8:10 AM, revealed Resident #5 lying on her right side, bilateral feet on the mattress, with no pillows between her legs. Observations in Resident #5's room on 3/27/12 at 10:25 AM, during a dressing change with Nurse #4, revealed Resident #5 lying on her left side, a wound to the ball of the right foot circular, some slough to the edges, and granulation tissue to the center of the wound, her great toe turned upright at the joint, and contracted at the ankles and knees. Observations in Resident #5's room on 3/27/12 at 3:46 PM, revealed Resident #5 lying supine with a heel boot to her right foot. During an interview at the 2nd floor nurses station on 3/26/12 at 4:25 PM, Nurse #4 (Treatment Nurse) stated, "She (Resident #5) has an open area to the plantar region of her right foot. It was a necrotic area when it started. Nurse #4 was asked if the wound was in-house acquired. Nurse #4 stated, "Yes, it started here." Nurse #4 was asked what preventive measures were in place before the wound was identified. Nurse #4 stated, "We didn't have anything for her feet at the time. She is so contracted it is hard to position her." During a telephone interview in the conference room on 3/27/12 at 11:45 AM, Resident #5's physician (also the facility's Medical Director) was asked if an area of eschar/necrotic skin could occur from 2/19/12 until 2/20/12 and reviewed the scenario of Resident #5's occurrence of this unstageable pressure ulcer. Resident #5's physician (also facility's medical director) stated, "Theoretically it could. I'm hard pressed to think it could happen. I'm hard pressed to believe it did. I think it could be Stage II, but to get eschar is highly unlikely. I've not seen that occur. It usually begins as red then on to Stage II. Highly unlikely..." During an interview in Resident #5's room on 3/27/12 at 12:02 PM, CNA #1 stated, "...we sometimes use pillows to position but she throws them on floor so we don't use them..." CNA #1 was asked if Resident #5 uses heel boots. CNA #1 stated, "uhhuh, just one." During an interview in the conference room on 3/27/12 at 4:50 PM, Resident #5's physician stated, "They have produced these papers ("C.N.A SKIN CARE ALERT" form) of documentation that something was found on the 18th (2012). That changes the view of this wound occurring. From the beginning on the 18th (2012) until the 20th (2012) it could have progressed..." There was no documentation of treatment or documentation of a wound by a nurse until 2/20/12. During an interview in the conference room on 3/27/12 at 5:00 PM, Nurse #8 was asked what preventive measures were put into place on the 18th (2012) when the change was noted on the foot. Nurse #8 stated, "She already had boots when she would wear them. They tried to use them on her when she would wear them... The CNA put the sheet in a folder for me. She (CNA) would have put it in my folder on Friday. It was the 18th (2012). I would not have known about it until Monday and that is when the treatment was started." Nurse #8 was asked what was done differently starting on the 18th when the area was found. Nurse #8 stated, "Just the boots." The facility's failure to properly assess and identify skin breakdown prior to the development of an unstageable pressure ulcer resulted in actual harm to Resident #5. 2. Medical record review for Resident #35 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the "INDIVIDUAL SKIN REPORT" documented, "...DATE OF ONSET: 8-1-11 RIGHT GLUTEUS... Type Wound SHEAR Stage PARTIAL... DATE OF ONSET: 8-1-11 LEFT GLUTEUS... Type Wound SHEAR Stage PARTIAL..." Review of the "DECUBITUS / PRESSURE ULCER REPORT" documented Stage 2 decubitus wounds to right and left gluteal first observed as 9/9/11. Review of the physician's recertification orders dated 9/7/11 documented, "...8-1-11 Clean gluteal wounds c (with) NS (normal saline) (and) apply [MEDICATION NAME] blue q (every) 2- (to) 3 days (and) prn (as needed)..." Review of the care plan dated 12/27/11 documented to provide treatments as ordered as an intervention. Review of the August, 2011 Treatment Record documented, "...Clean R (and) L gluteal wounds c NS (and) apply [MEDICATION NAME] blue q 2-3 days (and) prn..." There were no documented treatments from 8/13/11 through (-) 8/17/11 or from 8/20/11-8/31/11. Review of the September, 2011 Treatment Record (TR) documented, "...Clean R (and) L gluteal wounds c NS (and) apply [MEDICATION NAME] blue q 2-3 days (and) prn..." with a DC (discontinue) date of 9/22/11. There was no documentation that treatments were done from 9/8/11-9/13/11 and from 9/16/11-9/18/11. Observations in Resident #35's room on 3/27/12 at 3:15 PM, revealed Resident #5 in bed, on her back, eyes closed, the head of bead elevated, upper 1/4 side rails up, Nepro infusing per PEG, with an air mattress on the bed. Observations in Resident #35's room on 3/28/12 at 8:45 AM, revealed Resident #35 lying on her right side, with wedge and pillow for positioning, Nepro infusing per PEG, 1/4 upper side rails up, the head of bed elevated 30 degrees, and an air mattress present on the bed. During an interview in the conference room on 3/27/12 at 6:30 PM, Nurse #4 was asked about documentation on the September 2011 TR. Nurse #4 (Treatment Nurse) stated, "...someone wrote over dates as August but I believe this is the September TR, I started on 9/22/11 and got new orders for the wounds, the previous treatment nurse had a [MEDICAL CONDITION]"