Every finding on record at Monroe Health Services

Based on observation and interview, the facility did not store and prepare food in accordance with professional standards for food service safety. This has the potential to affect all 43 residents. Surveyor observed items opened and undated in the refrigerators and coolers. Surveyor observed food items unsealed and/or unmarked in the freezers. Surveyor observed food items in the freezer with visible freezer burn. Surveyor observed the facility's industrial stand mixer to be unclean. Surveyor observed an unclean ice bin. Surveyor observed staff sanitizing food thermometer with alcohol wipe without allowing it to dry before placing it in another food item during lunch service. Evidenced by: Facility policy, entitled General Food Preparation and Handling dated 8/16/22 states in part, . Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. Policy Explanation and Compliance Guidelines. 2. Food Storage b. i. Food will be covered for storage. c. Food in broken packages. or food with an abnormal appearance or odor will be discarded. 5. Equipment a. All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. On 12/1/25 at 8:38 AM, during initial tour of the kitchen, Surveyor observed items opened and not dated in the facility's refrigerators and coolers, including lettuce, egg patties, and pizza crusts. Surveyor observed chicken pieces with no date, no label, and visible freezer burn. Surveyor observed puff pastry and cookies in the freezer with no date or label. Surveyor observed a package of polish sausages stored in the freezer with a hole in the bag. Surveyor observed the facility's industrial stand mixer covered but noted dried white splatters near the mixing blade. Surveyor interviewed [NAME] H who indicated that the food observed undated, unlabeled, and not appropriately sealed were not currently being properly stored according to food safety standards. [NAME] H also noted the freezer burned chicken, which she immediately discarded. [NAME] H indicated that the stand mixer is not normally used and should have been cleaned appropriately before being covered and stored. On 12/1/25 at 11:55 AM, Surveyor observed [NAME] H taking the food temperatures before lunch service. Surveyor observed [NAME] H placing the food thermometer in the cooked cauliflower, noodles, pureed and ground chicken, hamburger patty, chicken breasts, hot dog, pureed cauliflower, mashed potatoes, and tomato soup. Surveyor observed that each time [NAME] H inserted the food thermometer in one food item, cleaned the thermometer with an alcohol wipe, and then immediately insert the food thermometer into the next item. Surveyor observed that [NAME] H did not allow the food thermometer to dry at least 10 seconds before re-inserting the thermometer in the next food item, thereby increasing the risk of cross-contamination. On 12/3/25 at 7:47 AM, Surveyor inspected the ice machine with NHA A (Nursing Home Administrator). Surveyor observed a thin layer of black substance on the inside of the freezer hood. Surveyor interviewed NHA A who indicated that she would expect the ice machine to be clean and free of mold. Surveyor shared with NHA A , Surveyors observations of food that was open, not labeled, and improperly stored during the kitchen tour. NHA A stated that she would expect the food to be properly stored in the freezers and refrigerators. On 12/3/25 at 10:00 AM, Surveyor interviewed KM I (Kitchen Manager). Surveyor shared with KM I her observations of food that was open, not labeled, and improperly stored during the kitchen tour. KM I indicated that she would expect that the food would be prepared and stored in a safe and sanitary manner.

Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status and consult with the residents Physician on this for 1 of 2 residents (R3) reviewed for nutrition of a total sample of 13 residents.R3 has diagnoses including congestive heart failure and Stage 5 renal disease. R3 is dependent on renal (kidney) dialysis. Staff are not obtaining R3's daily weight per Physician orders. R3 had weight gain that was not reported to R3's provider. This is evidenced by:The facility does not have a policy and procedure for weights. The Facility policy, Change in Condition of the Resident, revised 9/20/22, documents the following, in part: A facility should immediately inform the resident; consult with the resident's physician; and notify.a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). When to report to MD (Medical Doctor)/NP (Nurse Practitioner)/PA (Physician Assistant) Immediate Notification - Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and; A Marked Change in relation to usual symptoms and signs, or Unrelieved by measures already prescribed. The facility follows INTERACT, a quality improvement program for managing acute changes in condition, using tools and strategies to prevent hospital transfers, for Change in Condition. INTERACT for Vital signs documents as follows:Vital Signs: Weight GainReport Immediately: 3 lbs (pounds) in 3 days or 5 lbs in 7 days in resident with: Heart Failure, Chronic Renal Failure, other volume overload state. R3 is a long-term resident of the facility. R3 has the following diagnoses: chronic combined systolic (congestive) and diastolic (congestive) heart failure (the heart cannot pump blood efficiently), end stage renal disease-stage 5 (the most severe stage of chronic kidney disease where kidney function is extremely low).R3 is dependent on renal (kidney) dialysis. On 7/7/25 R3's physician ordered the following: WEIGHT - daily - right away in the morning, update provider if weight gain of 3# (pounds) in one day or 5# in one week one time a day for dialysis.On 11/7/25 R3's physician ordered the following: WEIGHT on admit, daily x2 (two times), weekly x3 (three times per week), monthly. Obtain reweight if change of 5 lbs (pounds) since last weight. One time a day every 1 month(s) starting on the 1st for 1 day.The facility did not obtain a daily weight for R3 on the following dates since 10/1/25: 12/2, 11/29, 11/27, 11/26, 11/23, 11/22, 11/18, 11/16, 11/15, 11/11, 11/6, 11/5, 11/4, 10/29, 10/26, 10/25, 10/24, 10/22, 10/18, 10/14, 10/13, 10/12, 10/10, 10/9, 10/8, 10/5, 10/4, 10/2, and 10/1.It is important to note; there is no indication that a re-weight was obtained 9/13/25 - 12/2/25 to confirm or refute whether that weight was accurate or not.R3's Progress Notes, Vital Signs, and MAR (Medication Administration Record) reviewed from 10/1/25 through 12/2/25, there is no documentation that R3's Physician was made aware of R3's weight gain.R3's care plan, Edema/excess fluid volume as evidenced by: cardiac disease, renal disease, dated 9/16/25, documents the following Goal: Will be free from complications r/t (related to) edema/excess fluid volume. Interventions: Report S&S (signs/symptoms) of edema/fluid overload, such as change in mental status, weight gain, neck vein distention, abnormal lung sounds, extremity swelling, etc.R3's care plan for Renal (kidney) insufficiencies, dated 9/16/25, documents the following Goal: No complications r/t (related to) dialysis devices or treatment; Interventions: .Dialysis 3 times /week.On 12/3/25 at 2:30 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, where do staff document weights. DON B stated, under weights (in Vital Signs). DON B stated CNA's (Certified Nursing Assistants) report weights to RN's (Registered Nurses) and LPN's (Licensed Practical Nurses) and the RN's and LPN's document the weight. Surveyor asked DON B, if a resident has an order for a daily weight, do you expect staff to weigh the resident daily. DON B stated, yes. Surveyor shared R3's orders with DON B. Surveyor asked DON B, do you expect staff to obtain a daily weight for R3. DON B stated, absolutely. DON B stated, she last addressed obtaining daily weights in an all staff meeting on 11/19/25. Surveyor requested documentation from the staff meetings. (No further information was provided.) Surveyor asked DON B, what time does R3 leave for dialysis. DON B stated, on 12/1/25 he left at 8:15 AM. Surveyor asked DON B, would you expect staff to obtain R3's daily weight before he goes to dialysis. DON B stated, yes, she would expect him to be weighed on his way to the dining room before breakfast. Surveyor reviewed the following weight increases with DON B. 11/8/25: 221 +11.5 pounds (1 day)11/7/25: 209.5DON B stated, R3 was readmitted to facility on 11/7/25. DON B stated, R3 would have been on 72-hour monitoring. DON B stated, she's not seeing that R3's weight gain was addressed and Physician notified. Surveyor asked DON B, should R3's weight gain of 11.5 pounds in 1 day have been addressed and assessed. DON B stated, absolutely. Surveyor asked DON B, should staff have re-weighed R3. DON B stated, yes, absolutely. DON B stated, it's concerning to her because it is the same nurse. DON B stated, she wonders if it is an error. Surveyor asked DON B, should staff have notified the Physician. DON B stated, yes, because R3's order clearly stated to notify the provider of 3-pound weight gain in 1 day. 11/2/25: 215 +4.8 pounds (1 day)11/1/25: 210.2 Surveyor asked DON B, should staff have re-weighed R3. DON B stated, yes. Surveyor asked DON B, should staff have notified the Physician. DON B stated, yes, absolutely because it is more than a 3 pound weight gain in 1 day. 10/27/25: 217.5 +14.0 pounds (4 days) - went to dialysis - Weighty after dialysis at 1:46 PM is 217.5 10/23/25: 203.5Surveyor asked DON B, would you expect staff to recheck R3's weight. DON B stated, yes, staff should have re-weighed R3 right away. Surveyor asked DON B, should staff have notified the Physician. DON B stated, yes.9/17/25: 236 + 14 pounds (1 day) - readmission 9/16/25: 222Surveyor asked DON B, would you expect staff to re-weigh R3. DON B stated, yes. Surveyor asked DON B, would you expect staff to notify the Physician. DON B stated, absolutely.9/13/25: 238.7 +18.7 pounds ( 5 days)9/8/25: 220Surveyor asked DON B, would you expect staff to re-weigh R3. DON B stated, yes, no questions asked every time they should re-weigh. Surveyor asked DON B, would you expect staff to notify the Physician. DON B stated, yes. Surveyor asked DON B, why is it important to re-weigh R3 in the examples (above). DON B stated, to ensure the weights are accurate. DON B stated, it is important to notify the Physician per Physician Orders due to R3 being in hear failure and retaining fluids. DON B stated, if a resident is retaining fluids they are having a change in condition. DON B stated, staff need to continue monitoring R3. DON B added, if staff had contacted the Physician he or she would more than likely increased the order of furosemide for 3 days, so we are not sending the resident into fluid overload. DON B stated that's why it is important. DON B added, it is capturing the change in condition before it gets worse.

Based on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a change in condition. This occurred for 1 of 5 Residents (R46) reviewed for notification of change in condition.R46 had a heart rate above the facilities change of condition policy, and facility did not notify the physician timely.Evidenced by:The facility's Change in Condition of the Resident policy, dated 9/20/2022, states in part: Immediate Notification: Immediate notification for any symptom, sing or apparent discomfort that is: ii. A marked change in relation to usual symptoms and signs. Vital Signs, Pulse: Resting pulse > 100, Report Immediately .R46 was admitted to the facility on [DATE] with diagnoses that include displaced fracture of the greater trochanter of R (right) femur (leg bone), Atherosclerotic Heart Disease (plaque buildup inside your hearts arteries, which narrows them and restricts blood flow), and longstanding persistent Atrial Fibrillation (irregular and fast heartbeat).R46's MDS (minimum data set) dated 6/18/25 show a Brief Interview for Mental Status (BIMS) evaluation, with a score of 13, indicating R46 has normal cognitive function.R46's progress notes indicate the following:6/23/2025 09:33 (9:33 AM) Vitals Note Note Text: This writer noted vitals on resident. Resident has increased heart rate at 135. This writer did a head-to-toe assessment. No s/s of infection noted to the resident hip. Resident lungs clear throughout. Resident HR was noted apical to be 130. 6/23/2025 12:38 (12:38 PM) General Note Note Text: This writer did a reassessment on the resident r/t (related to) increase in heart rate. Residents heart rate was still increased at 130.Will continue to monitor resident. 6/23/2025 13:55 (1:55 PM) General Note Note Text: 1305 (1:05 PM) this writer updated the on-call provider with the increased heart rate. Per on call provider she would like to have resident be sent to the ER for a further workout. This writer then went to the resident and talked to him about what the on-call provider stated and suggested him [sic] to be seen in the ER. (Of note: R46's provider was updated approximately 3.5 hours after the elevated pulse was noted.) 6/23/2025 16:35 (4:45 PM) Health Status Note: Note Text: Per ED resident is being admitted to the hospital for PE and UTI. On 12/03/2025 at 1:04 PM, Surveyor asked RN E (Registered Nurse) when she would call the doctor for an abnormal vital signs. RN E stated she would contact the doctor right away after retaking the vitals for a second time. On 12/03/2025 at 1:11 PM, Surveyor asked LPN D (Licensed Practical Nurse) when he would call the doctor for abnormal vital signs. LPN D stated there should be parameters to follow. LPN D stated that his (R46) NP is in the building three times a week, and he will run it by her if he sees something out of the normal for the patient. LPN D stated he can always call the on-call NP or doctor right away too. On 12/03/2025 at 2:43 PM, Surveyor interviewed RN C (Registered Nurse) and asked about what you would consider a change of condition. RN C stated anything outside their baseline. Surveyor asked when you would call the doctor when vital signs are out of range. RN C stated that residents, depending on their baseline, might be running on the lower side. Some residents have parameters on their orders. If it was out of parameters, I would talk to the nurse practitioner or call the on-call nurse. Surveyor asked RN C to explain what happened with R46 on 6/23/25. RN C stated his heart rate was increased so she did a head-to-toe assessment, and he didn't have any other symptoms. RN C reported checking his vitals again and R46's heart rate was still elevated. Surveyor asked why RN C waited so long (approximately 3.5 hours) before calling the doctor. RN C stated that she felt like R46 had metoprolol ordered and she thought she wanted to see if the metoprolol helped first. Surveyor asked what the facility policy was for reporting an abnormal vital sign. RN C stated immediately. RN C stated that she did call the NP on call that day. On 12/03/2025 at 3:18 PM, Surveyor interviewed NP F (Nurse Practitioner). Surveyor asked NP F if she had a record of a call from facility on 6/23/25 regarding R46. NP F stated she has a telephone contact message from RN C to NP on call at 1:30 PM on 6/23/25. Surveyor asked NP F if she would expect the RN to call the doctor with an abnormal HR immediately. NP F stated yes. On 12/03/2025 at 3:21 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked what expectations for nurses are when they have abnormal vital signs. DON B stated that nurses needed to recheck to make sure the reading was accurate. Surveyor asked DON B when she would expect the nurses to call the doctor. DON B stated immediately.

Based on observation, interview, and record review, the facility did not provide the right to refuse a transfer to another room in the facility when the purpose of the move is solely for the convenience of staff for 1 of 5 residents (R41) reviewed for room changes.R41 was moved from one unit to another for the convenience of therapy staff without allowing the opportunity to refuse the transfer. This is evidenced by: Facility policy titled Private Rooms, implemented in 2/2018 and reviewed/revised in 07/2022, states, Procedure: Neither Medicare or Medicaid reimburse for a private room. If the facility has all private rooms, this is not an issue. However, when the facility has semi-private rooms, the resident will be admitted to a semi-private room unless the resident wishes to pay out of pocket privately or is deemed to require an isolation room related to an infection control issue. When isolation is no longer needed, the resident will be moved to a different room providing a different level of care. Note: The 400 hall in the facility has private rooms near the therapy wing and the 100 and 200 halls have shared rooms. Surveyor reviewed letters sent to residents residing in the 400 hall of the facility in August 2025, which state, in part: We are writing to inform you of an upcoming room change that will affect your current placement. As part of our ongoing efforts to better serve our residents and improve care delivery, we are designating the 400 Hall for therapy patients. This change will allow us to provide easier and quicker access to therapy services, as the 400 Hall is closest to the therapy department. At this time, you are not being billed for a private room. In order to accommodate this new arrangement, we will be moving residents who are not paying for private accommodations to either the 100 or 200 Halls. These halls continue to offer the same quality of care and comfort.If you would prefer to remain in your current private room on the 400 Hall, you may choose to do so at a rate of $390 per day, which reflects the cost of a private room.Please let us know your preference by Tuesday, August 12th, so we can make the appropriate arrangements. Example 1: R41 was initially admitted to the facility on [DATE]. R41 is insured through Medicaid. R41's quarterly MDS (Minimum Data Set) assessment, dated 8/31/25, indicated that R41 has a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating she has intact cognition. On 12/1/25 at 9:55 AM, Surveyor interviewed R41. R41 indicated she recently moved from the 400 hall of the facility to the 100 hall because the facility was making the 400 hall for rehab residents. R41 told the administrators she did not want to move, but if she did not move, she was told she would have to pay $390 per day. R41 indicated she was the only one on the hallway who had to move. R41 also indicated she was actively participating in physical therapy. On 12/2/25 at 12:21 PM, Surveyor interviewed R41 again. R41 reiterated that she had not wanted to change rooms. Surveyor reviewed R41's admission agreement, signed on 10/22/20. Section G states the following, Short-stay/Rehabilitation stay: If this admission is anticipated to be a short stay for rehabilitation, Resident understands that their room may be within a section of the Center that is programmatically designed to serve the needs unique to residents who are expected to stay at for only a short period of time for purposes of rehabilitation. If your needs require longer than an anticipated short stay, you will be asked to move to a different room within the Center so that we may provide medically and socially appropriate services for a longer stay. You acknowledge in advance, that should your needs require a longer stay, that you will be asked to transfer to a room that is more suited to a longer-term stay. R41's census notes indicate she had been in a room on the 400 hall since 11/21/22. R41 was relocated to the 100 hall on 9/11/25. On 12/2/25 at 12:27 PM, Surveyor interviewed SW G (Social Worker) about the room changes at the facility. SW G indicated the facility wants to turn the 400 wing of the building back into a rehabilitation wing so therapy can save time and steps going back and forth getting people for therapy. The wing is centrally located to be close to the therapy gym. SW G indicated she and another staff member had gone to hand out letters to residents on the 400 wing who would have to move. So far, only two residents had moved from the 400 wing: R41 and another resident who moved due to a decline so more eyes could be on him. SW G was unsure why the other three residents on the wing had not moved yet. SW G indicated R41 had expressed not wanting to move rooms but could not afford to pay the extra private room fee of $390 per day. On 12/2/25 at 2:35 PM, Surveyor interviewed NHA A (Nursing Home Administrator) about room changes at the facility. NHA A indicated the 400 hallway was originally built for therapy. Since therapy is closer to that hallway, the goal is to bring it back to why it was added on in the first place. NHA A indicated she wrote a letter to residents on the 400 hall in August explaining they had to choose whether to pay the private room fee or not. If they chose not to, they would have to move. Room changes occur as rooms open or residents have an increase in care needs and must be more in the front of the building. NHA A indicated reactions have been mixed about moving rooms. NHA A indicated R41 was the first person to move and was not happy about it. NHA A indicated the facility told R41 she had an increase in care and had to be observed more closely. Surveyor asked NHA A what had changed with R41's care. NHA A indicated she was moved to a Hoyer lift, but no longer uses it.(Of note: R41's room on the 100 hall is at the end of the hallway and not close to the nurses' station.) Surveyor asked why other residents on the 400 hall had not moved yet. NHA A indicated two are actively seeking to move out of the facility. The facility is planning on moving the other resident this week. Surveyor asked if this resident had an increase in care needs as a reason for the move. NHA A said no. They had been waiting to move the resident until a room opened and there was a compatible roommate. On 12/2/25 at 3:09 PM, Surveyor spoke with NHA A. NHA A indicated the facility does not have specific beds licensed for Medicare and Medicaid-insured residents. On 12/3/25 at 3:33 PM, Surveyor spoke with NHA A. NHA A acknowledged Surveyor's concern with room transfers.

Based on interviews, record review, facility document review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation of property for one of three sample residents (Resident (R) 1) reviewed for misappropriation. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 07/15/22, 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 . Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .The facility will have written procedures that include .analyzing the occurrence to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes may be needed to prevent further occurrences .training of staff on changes made and demonstration of staff competency after training is implemented. Review of R1's undated Resident Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] with diagnosis that included chronic respiratory failure, muscle weakness, and diabetes mellitus. Review of R1's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/24 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating the resident was cognitively intact. Review of the Misconduct Incident Report provided by the facility, documented that the incident was discovered 12/24/24, that R1's phone was missing and said that a housekeeper took it. Patient was worried about her phone. Police were called and [R1] did not want to pursue it with the police. The Administrator was called immediately, and the housekeeper was suspended immediately. Police called. Certified Nursing Assistant (CNA) 1 wrote a witness statement on 12/24/24 that stated, R1 turned her call light on and I answered it .she then asked about her phone saying the house keeper put her phone in her pocket. The actions taken by the Administrator stated, On 12/24/2024 at 1300 [1:00 PM], the administrator was notified that [R1's] phone was missing. [R1] made a comment that she thought it might be the [Housekeeper (HSK) 2] as she thinks she saw her put it in her pocket. [HSK2] was immediately suspended. Staff immediately started searching for it and the police were called. The police started interviewing [R1]. [R1] told the police officer that she did not want anything done. Police Officer . called the administrator and stated that, 'he would not proceed because [R1] did not want anything done' .The Assistant Director of Nursing (ADON) was interviewing staff and searching for the phone. Staff searched the grounds and around cars and saw the phone in [HSK3's] passenger seat. [HSK2] was outside waiting for a ride from [HSK3] and walked with staff to her co-worker's [HSK3] vehicle because she received rides to work and saw the phone was under a package of Kleenex in the front seat, she asked that we not tell [HSK3]. The phone was returned to [R1] immediately. The conclusion documented that, Between staff and resident interviews .[HSK2] was scheduled in [R1's] hallway .[R1] saw housekeeper put it in her pocket. The phone was found with staff and [HSK2] present, in the car that she rode in. [Facility] and the .police department are unable to substantiate the theft of the phone, but due to the evidence provided in the investigation, we are terminating [HSK2]. During an interview on 01/17/25 at 9:45 AM, CNA1 said that she remembered R1 was upset about someone who had cleaned her room and had taken and put something into her pocket, and now she could not find her phone. She said she helped the resident search her room, but it could not be found. She said a lot of staff were looking in her room to find it, but they could not. CNA1 said she reported it and wrote her statement and gave it to management. She said it was the end of her shift and went home. She said she heard the phone was found in the housekeeper's car. She stated she was not aware of any other residents expressing similar concerns. During an interview on 01/17/25 at 10:10 AM, HSK1 said that she completed a regular background check when she applied to the housekeeping company and had received abuse training. She could not recall if she had received any after the incident with R1, but believed it was after the last facility survey. During an interview on 01/17/25 at 10:26 AM, the Housekeeping Manager (HSKM) said she did the hiring for the housekeeping staff. She said the process to check for references, and background checks were done by her company, which was separate from the facility itself. She said she was not at the facility that day, but the Administrator told her what happened. She said she called HSK2 who said she did not do it. HSKM said R1 had stated she saw HSK2 take her phone. She said the District Manager of her company had called her to discuss the situation, and that they were doing their own investigation. She stated that since the incident she did not believe there had been any reeducation or training on abuse that she could recall. She stated the facility used Relias and her company used a separate system, but she could not recall any since the misappropriation of property. During an interview on 01/17/25 at 11:36 AM, the Director of Nursing (DON) said that although he was not at the facility during the incident, he was informed. He said the facility did the self-report and education. He confirmed they interviewed other residents, and none had concerns. He said they sent the report to the contracted housekeeping company that HSK2 worked for, since she was not a direct employee. During an interview on 01/17/25 at 11:39 AM, the Regional Administrator said he was involved in the termination of the employee. He stated they could not 100% confirm she took the phone, but the evidence suggested that she took it. He confirmed that the contract company she worked for was now handling it. During an interview on 01/17/25 at 12:05 PM, R1 said that she saw HSK2 in her room and put her cell phone into HSK2's pocket. She said she told the staff, and they found the phone in HSK2's friend's car. She said she knew HSK2 took it, but she did not know why. She said the police came in and asked her if she wanted to press charges. She stated she did not. She said she wanted the housekeeper to come and apologize, but she did not. R1 said it was an unfortunate situation, and she just wished she knew why HSK2 did it. During an additional interview on 01/17/25 at 12:20 PM, the Regional Administrator said there were no additional findings of missing property, and if there was it would be on the grievance log. There were none reported. During an interview on 01/17/25 at 12:27 PM, the ADON said it was Christmas Eve in the afternoon and the girls reported to her that R1 could not find her cell phone. She stated they looked everywhere in her room. She stated staff came back and said they could not find it. She stated R1 was very adamant that she saw HSK2 take it. She said she talked to HSK2 who swore she did not take it. She stated HSK2 was carpooling with HSK3. She said she called the Director of Nursing then to see what to do, because she knew there had to be an investigation, and get statements. She stated HSK2 finished her work before HSK3 and went to the car she was carpooling with HSK3, because she had access to it when she was on breaks. She stated that HSK2 came and told her that she saw a phone on the car seat and had taken a picture of it. ADON said she did not know what R1's phone looked like, so another staff member validated that it was hers. She said she had brought HSK3 into the office and asked her about the phone and said she had not taken it; it was not hers. She stated she was not aware of what had happened. ADON said she told the Administrator and Director of Nursing, and they told her to call the police, and get statements. ADON stated when the police came, they interviewed R1, and she said the same thing. She stated R1 got her phone back and identified HSK2 because she could recall what she looked like. She said that the Housekeeping Manager was their supervisor, and she was told to handle it on her end. She said that since then there had been additional education on abuse, and they had the nursing staff sign and review. During an interview on 01/17/25 at 12:40 PM, the Administrator said the Director of Nursing had nursing meetings, talked with every new hire, and that there was also online training that the staff received to go over all the abuse training. He said they also did in-services for abuse and talked about it, that it was ongoing. He confirmed that housekeeping services was a contracted company and that the Housekeeping Manager was to provide abuse education to her staff as well. A review of the abuse training on 12/26/24 revealed the HSKM had attended, but not the housekeeping staff. During an interview on 01/17/25 at 12:49 PM, HSKM said she had brought in the available training that was completed for her housekeeping staff. She confirmed that none of the housekeeping staff had received abuse reeducation since the incident. A review of the housekeeping staff training revealed none of the staff had received abuse training since the incident with HSK2 and R1. During a concurrent interview on 01/17/25 at 12:52 PM with the Administrator, Regional Administrator, and DON, they confirmed the misappropriation of R1's property had occurred, and that they had provided retraining on abuse to the facility staff. They confirmed HSKM had attended this reeducation, and that she would have been responsible for educating the housekeepers since they were a contracted company.

Based on interview and record review, the facility did not immediately consult with the resident's physician when there was a need to alter treatment for 1 of 3 residents (R1) reviewed for physician notification. R1's provider was not notified of abnormal lab results. This is evidenced by: The facility policy titled, Change in Condition of the Resident, reviewed/revised 9/20/22, indicates, in part: Policy: A facility should immediately inform the resident; consult with the resident's physician .when there is .a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .3. Notify resident's physician - Use Interact Change in condition: When to report to the MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician Assistant) as a guideline . The facility Interact Version 4.5 Tool - Change in Condition: When to report to the MD/NP/PA, indicates, in part, the following lab results should be reported immediately: .Chemistry: Blood/Urea/Nitrogen (BUN) >60mg/dl . R1 was admitted to the facility on [DATE] with diagnoses that include, in part: Chronic Kidney Disease, Stage 4 (Severe), Anemia in Chronic Kidney Disease, Malignant Neoplasm of Overlapping Sites of Left Female Breast, Type 2 Diabetes, Chronic Heart Failure and Metabolic Encephalopathy (when the brain is not functioning properly because of an imbalance in the body's chemicals). R1's most recent MDS (Minimum Data Set), dated 10/29/24, indicates a BIMS (Brief Interview for Mental Status) score of 9, indicating R1's cognitive status is moderately impaired. R1's physician orders indicate the following: BMP (Basic Metabolic Panel) and CBC (Complete Blood Count) without diff one time only for Lab Monitoring until 10/28/24. Order date: 10/26/24. Start Date: 10/28/24. Surveyors reviewed the lab results from 10/28/24, which included, in part: --BUN: 83 (Blood Urea Nitrogen) Normal Range: 7-19mg/dl --Creatinine: 4.17 Normal Range: 0.57 - 1.11 mg/dl --GFR: 10 (Glomerular Filtration Rate -- a measure of how well your kidneys are working) Normal Range: >=60 ml/min/1.73m2) Of note, surveyors could not find evidence in R1's medical record that the lab results were called to nor reviewed by a provider. On 11/25/24 at 3:00 PM, Surveyor interviewed NP (Nurse Practitioner) C who indicated she saw R1 once, on the day of admission 10/23/24. NP C indicated she ordered labs for 10/28/24 and that they were completed. NP C indicated her notes show that there was not a provider who reviewed the results. NP C indicated she was on vacation and there was another NP taking her calls. NP C indicated if the facility would have notified her or the on-call provider of the lab results they would have discussed options of sending to the hospital versus remaining at the facility. NP C reviewed with Surveyor R1's previous labs and noted that they were trending down prior to admission. On 11/25/24 at 3:12 PM, Surveyor interviewed DON B who indicated that when an order is received for labs it is put into the system and put into a file box at the nurse's station. DON B indicated usually he, ADON E (Assistant Director of Nursing), or the lab will come and complete the draw and take the sample(s) to the hospital. DON B indicated, usually UM D (Unit Manager) pulls up the lab results and either her or the nurse call the provider or NP C. If NP C is not at the facility then we contact (Physician Name) or whoever is on call. DON B indicated they do not have an exact timeframe for how long they wait to check for lab results and that there are always outliers but would expect within that day. On 11/25/24 at 3:30 PM, Surveyor interviewed UM (Unit Manager) D who indicated she is responsible for ensuring orders are completed for labs and that the results are taken off the fax and follow up occurs. UM D indicated she will make sure NP C reviews the results because NP C is often in the building. UM D indicated she does not recall R1's labs for 10/28/24. UM D indicated she would look into the follow up for R1's labs on 10/28/24. It is important to note no further documentation was provided by UM D. On 11/25/24 at 3:40 PM, DON (Director of Nursing) B indicated if UM D is not in facility any of the nurses can take lab results off of the fax machine. DON B indicated staff know if they take something off the printer they should give it to the nurse or the DON. DON B indicated he does not see anything in the documentation regarding results for R1's labs on 10/28/24. DON B indicated he would expect someone at the facility to follow up with the provider once the lab results are received. DON B indicated if the lab results were not received he would expect someone at the facility to follow up. R1's provider was not contacted regarding R1's Lab results from 10/28/24.

Based on interview and record review, the facility did not develop a comprehensive person-centered care plan for 1 sampled resident (R35) of 5 reviewed for unnecessary medications. Surveyor reviewed R35's comprehensive care plan. There is no care plan indicating the use of Melatonin for insomnia. The facility does not have a sleep assessment or sleep tracking for R35's Melatonin use. Evidenced by: The facility policy, entitled Comprehensive Care Plan, dated 9/23/22, states, in part: . POLICY: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Definitions: .Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives . Policy Explanation and Compliance Guidelines: . 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . f. Resident specific interventions that reflect the resident's needs and preferences . R35 admitted to the facility on [DATE], and has diagnoses that include weakness, obstructive sleep apnea (intermittent airflow blockage during sleep), and depression. R35's Minimum Data Set (MDS) Quarterly Assessment, dated 5/10/24, shows R35 has a Brief Interview of Mental Status (BIMS) score of 14, indicating R35 is cognitively intact. R35's Physician's Orders, dated 6/4/24 and 5/14/24, states, in part: . Melatonin Oral Tablet 3 MG (milligrams) (Melatonin) Give 2 tablets by mouth one time a day for Sleep . Order Status: Active Order Date: 3/28/24 Start Date: 3/28/24 . R35's Care Plan, dated 2/11/24, states, in part: . Focus: Sleep cycle issues as evidenced by poor sleep r/t (related to) depression. Date Initiated: 2/11/24. Revision on: 2/11/24. Goal: Resident will exhibit fewer signs of adequate sleep by review date. Date Initiated: 2/11/24. Target Date: 11/3/24. Interventions: Administer medications as ordered. Date Initiated: 2/11/24 . Surveyor reviewed R35's electronic health record and there is no documented sleep assessment from February 2024. Surveyor reviewed R35's Medication Administration Record (MAR) from May 2024 through July 2024 and there is no sleep tracking or effectiveness of Melatonin documented. On 8/8/24 at 1:15 PM, Surveyor interviewed VPS F (Vice President of Success). VPS F informed Surveyor the facility does not have a sleep assessment for R35. On 8/8/24 at 3:05 PM, Surveyor interviewed DON B (Director of Nursing) and asked if DON B would expect a sleep assessment for a resident on Melatonin for sleep. DON B indicated probably so. Surveyor asked DON B if a resident receiving Melatonin for sleep, would you expect sleep monitoring. DON B indicated yes; you would want to see if the Melatonin was effective.

Based on interview and record review, the facility failed to meet professional standards of quality for 1 of 1 Residents (R40) reviewed for weights out of a total sample of 16. R40 had an order for daily weights for seven (7) days. Weights were not completed 3 out of 7 days. Evidenced by: The facility policy, entitled Weight Monitoring, dated 12/21/22, states, in part: .The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents.routine weights will be measured montly thereafter, unless ordered more frequently by the physician. Weights will be recorded in the individual's electronic health record. The nursing staff will notify the individual or responsible party, physician, and RDN (Registered Dietician Nutritionist) or designee of any individual with an unintended significant weight change. R40 was admitted to the facility on [DATE] with diagnoses that includes in part, essential hypertension (high blood pressure). R40's Minimum Data Set (MDS) dated [DATE], shows that R40 has a Brief Interview of Mental Status (BIMS) score of 12, indicating that R40's cognition is moderately impaired. R40's physician orders, dated 7/24/24, state; *Daily weights for next 7 days R40's Medication Administration Record (MAR) states, in part: daily weights for next 7 days, notify MD if > (greater than) 3# (pounds) in 1 day or 5# in 1 week . start 7/25/24. R40's Weights and Vitals Summary shows: *7/26/24 268 Lbs (pounds) *7/27/24 267 Lbs *7/30/24 266.8 Lbs *7/31/24 265.6 Lbs Important to note: There is no documentation of weight for 7/25/24, 7/28/24, or 7/29/24 though the MAR has signatures for the 7 dates of 7/25/24 through 7/31/24. On 8/7/24 at 4:33 PM, Surveyor interviewed RN C (Registered Nurse) and asked where weights are documented. RN C stated on the MAR or under vitals in PCC (Point Click Care--facility's electronic health record system). On 8/8/24 at 8:06 AM, Surveyor interviewed DON B and asked where weights are documented. DON B stated in PCC, as a rule; the CNAs (certified nursing assistants) write the weight on a weight sheet and the nurses document in PCC. Surveyor asked when the nurse is to document the weight in PCC. DON B stated same day. Surveyor asked if daily weights should be documented in PCC every day. DON B stated yes. Surveyor asked if staff would be aware of need to update the physician regarding change in weight if the weight was not documented in PCC. DON B stated no. Surveyor showed DON B that weights had not been documented in PCC for 3 of the 7 ordered dates. Surveyor asked DON B if facility would expect that all weights be documented in PCC to ensure that nurses would know when to update the physician. DON B stated yes. DON B asked if the facility expected that weights be documented in PCC if staff have signed for them on the MAR. DON B stated yes. The facility did not ensure that physician orders were followed for R40's daily weights.

Based on observation, interview, and record review, the facility did not ensure that residents (R) receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, or per resident's choice for 2 of 5 residents (R35 & R11) reviewed for non-pressure wounds and 1 of 5 residents (R15) reviewed for change in condition out of a total sample of 16 Residents. R35 has blanks on his Treatment Administration Record (TAR) indicating R35's wound care had not been completed. R35 sees the wound doctor weekly. On 5/2/24 the wound doctor had ordered a treatment to R35's left shin and the order did not get transcribed onto the TAR or completed. R11 had blanks on his TAR indicating R11's wound care was not completed on those days. R15 sustained a fall. R15 was moved off the floor, after a fall, without a thorough assessment by an RN (Registered Nurse) and was later found to have a fracture. Evidenced by: The facility's policy, entitled Pressure Injuries and Non pressure Injuries, dated 7/20/22, states, in part: .Policy: . For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity . Policy Explanation and Compliance Guidelines: .2. Weekly: .iii. Initiate treatment per order . The facility policy, entitled Non-Controlled Medication Orders, dated 1/23, states, in part: .Policy: Medications are administered only upon the receipt of a clear, complete and signed order by a person lawfully authorized to prescribe . Documentation of the Medication Order: . 2. Each medication order is documented in the resident's medical record . a. New orders . -Order is recorded on the MAR (Medication Administration Record)/TAR (Treatment Administration Record) . d. Orders faxed from the prescriber's office. -The nurse on duty at the time the faxed order is received notes the order and enters it into the medical record . -Order is recorded on the MAR/TAR . Example 1: R35 admitted to the facility on [DATE], and has diagnoses that include Encounter for orthopedic aftercare following surgical amputation, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (a long-term condition in which the body has trouble controlling blood sugar and using it for energy. Polyneuropathy is a complication of type 2 diabetes mellitus that occurs when the body's peripheral nerves malfunction). R35's Minimum Data Set (MDS) Quarterly Assessment, dated 5/10/24, shows R35 has a Brief Interview of Mental Status (BIMS) score of 14, indicating R35 is cognitively intact. R35's Specialty Physician (wound physician) Initial Wound Evaluation and Management Summary, dated 5/2/24, includes: Non-Pressure Wound of the Left Shin . Dressing Treatment Plan: Primary Dressing: Leptospermum (flower from the manuka plant) Honey apply once daily for 30 days. Secondary Dressing: Gauze island with border once daily for 30 days. R35's May 2024 TAR includes the following: -Wound Care to blister on LLE (left lower extremity): Paint intact blister on LLE with betadine daily. One time a day for wound care- blister Start Date: 5/7/24 . D/C (discontinue) Date: 5/17/24 . Dates 5/8/24, 5/12/24, 5/13/24, 5/14/24 and 5/16/24 are left blank/not signed out on the TAR for this order. -Wound Care to LLE: Cleanse open wounds to LLE with soap and water, pat dry, then apply Foam dressing with border. Change every 3 days, and PRN (as needed) until healed one time a day every 3 days for wound care. Start Date: 5/7/24 . D/C Date: 5/17/24 . Dates: 5/13/24 and 5/16/24 are left blank/not signed out on the TAR for this order. Note: There is no order on TAR for the ordered Primary Dressing: Leptospermum honey apply once daily for 30 days. Secondary Dressing: Gauze island with border once daily for 30 days to Left Shin as ordered on 5/2/24. R35's July TAR includes the following: Apply skin prep to areas on left toe once daily one time a day for skin. (Start Date: 6/14/24.) Dates 7/12/24 and 7/17/24 are left blank/not signed out on the TAR for this order. R35's Care Plan, dated 2/2/24, states, in part: .Focus: At risk for alteration in skin integrity related to: recent surgery, decreased mobility, diabetes .Interventions: . Treatment as ordered per MD (medical doctor). See wound MD as needed. Date Initiated: 5/2/24. No documentation was provided to show that R35's wound care treatments were done on the dates that were left blank/not signed out on the TAR. On 8/8/24 at 1:22 PM, Surveyor interviewed IP D (Infection Preventionist/Wound Nurse). Surveyor asked IP D what the process is when the wound doctor comes to the facility and writes new orders for wound care. IP D indicated she does rounds with him. The wound doctor's notes go under the miscellaneous tab in PCC (Point Click Care). The next day IP D looks at the orders and if there are changes IP D updates the TAR. IP D indicated she took over as wound care nurse in June and she is responsible for entering orders into the TAR. On 8/8/24 at 3:10 PM, Surveyor interviewed DON B (Director of Nursing) and asked what the process is when the wound doctor comes to the facility and writes new orders for wound care and who is responsible. DON B indicated IP D is responsible for entering the orders into the TAR. DON B indicated at the end of the day when the wound doctor is at facility, IP D is responsible for entering the new orders into the TARS. DON B indicated the new orders are expected to be started the next day. Surveyor asked DON B, looking at the wound doctor's orders dated 5/2/24, were these orders entered into the TAR and completed. DON B looked through the TAR in the computer and indicated no, the orders are not in the TAR and were not completed. Surveyor asked if the orders should have been entered into the TAR on 5/2/24 and DON B indicated yes. DON B indicated he would have expected the orders to be started the next day on 5/3/24. Surveyor asked DON B if there are blanks on the TAR what does that indicate. DON B indicated if not documented it is not done. Surveyor showed DON B the blanks on R35's TAR (5/8, 5/12, 5/13, 5/14, 5/16) and asked if these treatments were completed and DON B indicated if not documented it is not done. R35's wound treatments were not completed per MD orders. 36192 Example 2: R11 was admitted on [DATE] with diagnoses of orthopedic aftercare following surgical amputation, acute osteomyelitis (right hand,) and peripheral vascular disease. July 2024 Treatment of Administration (TAR) record indicates the following: Arterial wound left 2nd finger, full thickness, apply iodosorb gel and cover with bordered gauze once daily for 30 days (start 7/13/24, D/C (discontinue) date 7/19/24) is blank/not signed out on the TAR for night shift on 7/19/24. Arterial wound left 2nd finger, full thickness, apply iodosorb gel and cover with bordered gauze once daily for 30 days (start 7/20/24, D/C (discontinue) date 7/30/24) Wound care: Monitor left hand tip of thumb and thumb nail is necrotic. Apply betadine once daily, leave open to air one time a day for wound care (start date 7/14/24) is blank/not signed out on the TAR for PM shift on 7/17/24. Wound care: Right hand, daily dressing changes. Cleanse with normal saline, pat dry, apply xeroform over the sutures, and wrap with a rolled gauze followed by ace wrap one time a day for wound care (start date: 7/3/24) is blank/not signed out on AM shift on 7/17/24 and 7/24/24. No documentation was provided to show that R11's wound care treatments were done on the dates that were blank/not signed out on the TAR. On 8/8/24 at 3:18 PM, Surveyor interviewed DON B (Director of Nursing) regarding R11's treatments. When informed that R11 has blanks/dates not signed out for treatments on his TAR, DON B stated, If it's not documented it's not done. 39849 Example 3 The facility policy, titled Fall Prevention and Management Guidelines, with a reviewed/revised date of 7/18/24, indicates, in part: .Policy Explanation and Compliance Guidelines: .7. When any resident experiences a fall, the facility will: a. Complete a post-fall assessment and review: 1) Physical assessment with vital signs . 4) Resident and/or witness statements regarding fall .e. Document all assessments and actions . R15 was admitted to the facility on [DATE], diagnoses include, in part: Hemiplegia (one sided paralysis) and Hemiparesis (one sided partial weakness) following cerebral infarction (stroke) affecting right dominant side, difficulty in walking, age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases and can increase the risk of fractures), and Parkinsonism. R15's Minimum Data Set (MDS) with a target date of 5/21/24 indicates a Brief Interview for Mental Status (BIMS) summary score of 12, indicating R15's cognition is moderately impaired. R15's Nursing Progress Notes indicate the following, in part: --5/9/24 12:47 PM - Clinical Follow-up: Note Text: The current status is sitting in w/c (wheelchair) eating lunch. monitor per policy. --5/9/24 1:44 PM - Communication with Physician: Situation: recent fall at 11AM - c/o (complains of) right hip pain. Background: reaching for snack and fell out of w/c. Assessment (RN)/Appearance(LPN): right hip swollen. Assessment: requesting to go to ER (emergency room ). Recommendations: Response: Order received to send to ER. --5/9/24 2:00 PM - General Note: Note Text: requesting to be sent to ER d/t (due to) c/o right hip/leg pain .EMS (Emergency Medical Services) arrived at 1:50 PM . On 8/8/24 Surveyor was unable to locate a Fall Report/Investigation for R15 in the medical record and requested this from the facility. On 8/8/24 the facility provided the following, in part, and indicated it was from their risk management documentation: The document indicates Risk Management at the top of the document with an effective date of 5/9/24. There is no complete patient name on the document, only a first name in the note text and there is no documentation of who the author is. Note Text indicates: R15's family brought in cupcakes for his birthday. R15 was eating one and dropped it on the floor. Patient reached for cupcake on the floor and fell . Resident States, I was reaching for a cupcake that my brother brought me for my birthday. Patient showed no signs or symptoms of pain or discomfort and was transferred back to wheel chair. Education on call light was given immediately. Patient stated I know I should of used by call light to ask for help Patient transferred back to bed with 2 person full body lift where he started to complain of pain in hip. Orders to send to ER for eval (evaluation). R15's Post Fall Assessment, with an effective date and time of 5/9/24 at 12:38 PM, includes, in part: Date and Time of Fall 5/9/24 00:00 (Of note, this time differs from the 5/9/24 1:44 PM nursing progress note that indicated the fall occurred at 11:00 AM) .Current vitals: Blood Pressure 175/79, Pulse 61, Respiration 20 . The document is electronically signed by RN E (Registered Nurse) It is important to note, this document does not include a full physical assessment such as range of motion, shortening of extremity concerns, internal or external rotation concerns, level of pain in general or pain with palpation, obvious signs of injury, etc. R15's Post Event Observation, with an effective date and time of 5/9/24 at 12:47 PM, includes, in part: A. Focus 1. Reason. 2. Fall . A. Focus 6. Most Recent Pain Level: Pain Level: 0 Date: 5/9/24 6:39 AM (Of note, this time is prior to the time the fall was documented as occurring.) 6a. Pain location: right leg. 7. Current status: sitting in w/c eating lunch. 8. Action taken: monitor per policy. This document is electronically signed by RN E. R15's Hospital Discharge Summary for admitted s 5/9/24 to 5/15/24 indicate, in part: Clinical Resume: R15 .was admitted with Right Intertrochanteric Fracture due to a combination of osteoporosis and trauma, as trauma alone would not have caused the fracture . On 8/8/24 at 9:57 AM, Surveyor interviewed RN E via telephone regarding R15's fall on 5/9/24. During the interview RN E indicated that if the facility had not provided the risk management documentation to us that some of her documentation would be in there. RN E indicated R15's brother had brought him cupcakes and R15 reached over to get one, the container was closed, and he ended up tipping out of his chair when he went to get one. RN E indicated she was up by the nurse's station assisting another resident when someone alerted there was a resident on the floor. RN E indicated that she saw NHA A (Nursing Home Administrator), who she states is also an LPN (Licensed Practical Nurse), go down and that as soon as she was done assisting the resident she was with she went down to the room. RN E indicated that NHA A cannot do an assessment because he is an LPN. RN E indicated by the time she got to the room R15 had already been picked up off the floor so she did not know what position he was in and couldn't assess him on the floor as he had already been moved. RN E indicated R15 had been moved into a wheelchair and that a CNA (Certified Nursing Assistant) and NHA A were in the room when she arrived. RN E could not recall who the CNA was. RN E indicated she brought the vitals machine and completed neuro checks per protocol but did not complete a full assessment. RN E indicated that she asked R15 if he was having pain and he said a little bit in his right leg. RN E indicated R15 said he just wanted to go to lunch and to get him to lunch and refused further assessment. RN E indicated she told R15 she needed to assess him but he didn't want to and kept saying just get me to lunch. RN E indicated after lunch he started to complain of more pain in the right leg and so she messaged the provider and got an order to send him out for evaluation to the ER. Surveyor asked RN E if she was able to assess R15's leg after lunch. RN E indicated she was not able to assess his leg after lunch either because he was sitting in the w/c and she asked him and he refused for her to assess the hip and so she asked him if he wanted an x-ray and he said yes. Surveyor asked RN E if R15 stayed in his w/c until EMS (Emergency Medical Services) arrived. RN E indicated they put him in bed as EMS was getting there. Surveyor asked RN E if she recalled how they got R15 into bed. RN E indicated she did not remember and that she may not have been there because she may have been getting paperwork ready. Surveyor asked RN E if she would have given approval for staff to move R15 from the w/c to the bed. RN E indicated she did not recall if she did or not. Surveyor asked RN E with the amount of pain R15 was in if he should have been moved or left in the w/c for EMS to assist. RN E indicated, they should have left him in the w/c where he was. It is important to note that R15 was moved, after a fall, on two separate occasions without evidence of a complete RN assessment. On 8/8/24 at 10:36 AM, Surveyor interviewed R15 regarding the fall on 5/9/24. R15 was not able to provide details from the fall or post fall other than that he recalled he was reaching for a cupcake and fell out of his w/c and broke his hip. R15 indicated he could not recall staff assisting him after the fall or recall being moved or refusing to allow staff to physically assess him. On 8/8/24 at 3:51 PM, Surveyor interviewed DON B (Director of Nursing) and asked what the expectation of nursing staff is immediately after a resident has a fall. DON B indicated: Risk management documentation and follow-up; An assessment, to included: vital signs, a head to toe assessment, and depending on the incident, range of motion; Contact physician, DON, family, MCO (Managed Care Organization). Surveyor asked DON B if any staff member should move a resident prior to a RN assessment. DON B indicated, no. Surveyor asked DON B what he knew of R15's fall on 5/9/24. DON B indicated it was reported to him that it was R15's birthday and he dropped a cupcake on his floor and was reaching for it, slid out of his w/c, and landed on his bottom. They put R15 into his bed, he had no complaints of pain or injury. DON B indicated he could not give an exact time but he thought about 2 hours later he began complaining of right leg pain. DON B indicated he went in and assessed R15's leg and he had pain in the pelvis area and 911 was called and he was transported. Surveyor asked DON B if as far as he was aware R15 went directly to his bed after the fall. DON B indicated he was aware of RN E doing an assessment and then her and the CNA laying R15 back in bed. Surveyor asked DON B if he documented his assessment or if he had documentation of RN E's assessment. DON B indicated he was not sure and began looking in the facility EHR (Electronic Medical Record). DON B indicated he was unable to locate documentation of the assessments and that they should be documented in the medical record. On 8/8/24 at 4:18 PM Surveyor interviewed NHA A and asked what he knew of R15's fall on 5/9/24. NHA A indicated that R15 was reaching for a cupcake because it was his birthday and he fell reaching for it. NHA A indicated he assisted with the post fall risk management information. Surveyor asked NHA A if he went to R15's room when he fell . NHA A indicated he thought he went after the fact, just to see where it happened. Surveyor asked NHA A if he cared for R15 at anytime between the fall and when he was moved. NHA A indicated, not that he recalled. Surveyor asked NHA A if he recalled what nurse went to take care of R15 after the fall. NHA A indicated, I believe it was RN E, the documentation I saw was her. Surveyor asked NHA A if he knew who moved R15 after the fall. NHA A indicated he believed it was a CNA and RN E. Surveyor asked NHA A if he was able to find documentation of an RN assessment prior to R15 being moved. NHA A indicated he could not see one and there should have been one completed. Surveyor asked NHA A if he, at any time, moved R15. NHA A indicated, no. There is no evidence documented of a complete physical assessment by a Registered Nurse prior to R15 being moved from the floor to the w/c after a fall.

Based on observation, interview, and record review, the facility did not implement professional standards of practice to promote healing or prevent pressure injury (PI) development for 1 of 2 residents reviewed for PIs out of a sample of 16 residents (R147). On 5/23/24 the wound doctor ordered Leptospermum honey (honey from the flowers of the Manuka bush) apply once daily for 23 days. Secondary Dressing: Gauze island with border apply once daily for 23 days for R147. This order did not get entered/transcribed onto R147's Treatment Administration Record (TAR) and was not completed as ordered on multiple days. Evidenced by: The facility's policy, entitled Pressure Injuries and Non pressure Injuries, dated 7/20/22, states, in part: .Policy: . For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity . Policy Explanation and Compliance Guidelines: . 2. Weekly: . iii. Initiate treatment per order . The facility policy, entitled Non-Controlled Medication Orders, dated 1/23, states, in part: .Policy: Medications are administered only upon the receipt of a clear, complete and signed order by a person lawfully authorized to prescribe .Documentation of the Medication Order: .2. Each medication order is documented in the resident's medical record . a. New orders . -Order is recorded on the MAR (Medication Administration Record)/TAR (Treatment Administration Record) . d. Orders faxed from the prescriber's office. -The nurse on duty at the time the faxed order is received notes the order and enters it into the medical record . -Order is recorded on the MAR/TAR . R147 admitted to the facility on [DATE], and has diagnoses of osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), paraplegia (a chronic condition that causes a loss of muscle function in the lower half of the body, including the legs, feet, toes, and sometimes abdomen), and weakness. R147's Specialty Physician Wound Evaluation and Management Summary, dated 5/23/24, states, in part: .Stage 3 Pressure Wound of the Left Calf . Dressing Treatment Plan: Primary Dressing: Leptospermum honey apply once daily for 23 days. Secondary Dressing: Gauze island with border apply once daily for 23 days. (until 6/14/24) . R147's Care Plan, dated 4/16/24, states, in part: . Focus: The resident has healing pressure ulcer Right and Left Calf r/t (related to) paraplegia .Interventions: .Administer treatments as ordered and monitor for effectiveness. Date Initiated: 4/16/24 .Weekly treatment documentation to include measurement .Date Initiated: 4/16/24 . R147's May TAR includes: Wound Care to left calf. Cleanse area and pat dry. Apply medihoney and cover with bordered gauze daily. One time a day. Start Date: 4/19/24 . D/C (discontinue) Date: 5/21/24 . Note: TAR shows no treatment to left calf from 5/21/24 through 5/31/24. R147's June TAR includes: Left Calf- Cleanse wound and apply medihoney and cover with bordered gauze once daily one time a day. Start Date: 6/7/24. D/C Date: 6/28/24. Note: TAR shows no treatment to the left calf from 6/1/24 - 6/6/24. (Of note: R147's wound was present upon admit and did not worsen during the time frames that the wound care was not completed.) On 8/8/24 at 3:35 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor reviewed the wound doctor orders dated 5/23/24 with DON B and asked if these orders were entered onto R147's TAR and completed as ordered. DON B indicated the orders were not on R147's TAR from 5/21/24- 6/6/24. Surveyor asked DON B if these orders should be on R147's May TAR and DON B indicated yes, he would expect them to be on the TAR and completed. Surveyor asked DON B if these orders had been completed and DON B indicated if it was not documented it was not done. Treatment to R147's pressure injury was not completed per physician orders on multiple days.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 34 opportunities that affected 2 out of 2 residents (R12 and R35) included in the medication pass task, which resulted in an error rate of 5.88%. RN C (Registered Nurse) did not assess the resident's heart rate or blood pressure prior to administration according to physician orders. LPN G (Licensed Practical Nurse) administered a medication with breakfast instead of one hour before breakfast according to physician orders. This is evidenced by: Facility policy entitled, Medication Administration, dated 01/2023, states in part: Policy: Medications are administered as prescribed in accordance with manufacturers' specifications . Procedures: Medication Preparation: . 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record .Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber . 2. Obtain and record any vital signs as necessary prior to medication administration. 3. Medication administration timing parameters include the following: a. Medications to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to 2 hours prior to meals . 14. Medication are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes . Example 1: R12's Physician Orders state, in part: Lisinopril Oral Tablet 10 MG (milligram) (Lisinopril) Give 1 tablet by mouth one time a day related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE (I11.9) hold if SBP (systolic blood pressure) <100 (less than 100) or DBP (diastolic blood pressure) <60 or HR (heart rate) <60 and notify MD (medical doctor). (Start date: 7/20/2024) On 8/7/24 at 8:00 AM, Surveyor observed RN C prepare 22 medications for R12, including one Lisinopril 10 MG tablet. Surveyor observed this medication be added to the small, plastic medication cup and administered to the resident. After reviewing R12's physician orders, it was found that R12's Lisinopril order included parameters to hold the medication for a blood pressure under 100 systolic and 60 diastolic, as well as orders to hold for a heart rate less than 60. Of note: Surveyor did not observe R12 assess the resident's vital signs prior to medication administration. The last vital signs recorded for R12 were taken on 8/5/24. On 8/7/24 at 11:38 AM, Surveyor interviewed RN C. Surveyor asked RN C how often R12's vital signs should be taken. RN C states that it used to be daily, but about a month ago that was discontinued, and RN C believes that now it is once a week. Surveyor asked RN C if she took R12's vital signs this morning. RN C states no, she did not. Surveyor asked RN C to review R12's Lisinopril order and asked what the order indicates. RN C states that there are hold orders for vital sign parameters. Surveyor asked RN C, knowing this, should R12's vital signs been taken this morning prior to the Lisinopril being administered. RN C stated, yes, absolutely. Example 2: R35's Physician Orders state, in part: Omeprazole Oral Tablet Delayed Release 20 MG (Omeprazole) Give 1 tablet by mouth one time a day for GERD (Gastroesophageal Reflux Disease) Give one hour before breakfast. On 8/7/24 at 8:14 AM, Surveyor observed LPN G prepare 12 medications for R35, including one Omeprazole 20 MG tablet. Surveyor observed this medication be added to the small, plastic medication cup and administered to the resident. While in R35's room, Surveyor observed the resident sitting upright in a wheelchair in front of a bedside table with his breakfast tray on top and uncovered. After reviewing R35's physician orders, it was found that R35's Omeprazole order included instructions that the medication be administered 1 hour before breakfast. On 8/7/24 at 11:47 AM, Surveyor interviewed LPN G. Surveyor asked LPN G if I what R35's Omeprazole order states. LPN G states that the Omeprazole should be administered one hour before breakfast. Surveyor asked LPN G if R35 had his breakfast tray when the medications were administered. LPN G states, yes. Surveyor asked LPN I if R35 was administered his omeprazole one hour before he ate breakfast. LPN G states, no. Surveyor asked LPN G if R35's Omeprazole should have been administered one hour before he ate breakfast. LPN G states, yes. On 8/7/24 at 12:55 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if it is his expectation that medications be administered as ordered. DON B states, yes. Surveyor asked DON B if he would expect vital signs to be taken if medication have a hold order with vital sign parameters. DON B states, yes. Surveyor asked DON B if he would expect a medication with orders to be given one hour before breakfast to be administered as ordered. DON B states, yes. Surveyor asked DON B if he would consider administering the lisinopril without taking vital signs and administering omeprazole with breakfast instead of one hour before medication errors. DON B states, yes and that he has already started the facility medication error process including notifying the physician. Surveyor asked DON B if vital signs should have been taking prior to administering lisinopril. DON B states, yes. Surveyor asked DON B if omeprazole should have been given an hour before breakfast. DON B states, yes. R12 and R35's medications were not administered per physician orders.

Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, no later than 24 hours if the events that cause the suspicion do not result in serious bodily harm for 1 of 3 sampled residents reviewed (R10). R10 was found to have a injury of unknown origin (bruise) on her upper right arm on 7/7/24. This was not reported to the State Agency until 7/11/24. This is evidenced by: According to S483.12(c)(1) of the State Operations Manual; all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility policy entitled, Abuse, Neglect, and Exploitation, dated 7/15/22, includes in part: IV. Identification of Abuse, Neglect, and Exploitation . B. Possible indicators of abuse include, but are not limited to: . 2. Physical marks such as bruises or patterned appearances . 3. Physical injury of a resident, of unknown source . VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 3 hours after the allegation is made, if the vents that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the event that causes the allegation do not involve abuse and do not result in serious bodily injury . R10 was admitted to the facility on [DATE], with diagnosis that include, in part: Alzheimer's disease, osteoporosis, dementia, generalized anxiety disorder, and major depressive disorder. Review of R10's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/24 indicates R10 has no Brief Interview for Mental Status (BIMS) score due to the resident is rarely or never understood. Progress note dated 7/7/24 at 10:07 PM states: [CNA] reported to this writer that resident was in pain every time[sic] she/they repositioned her. Noted bruise on her right upper arm 3.5cm x 8.5cm. This writer lift [sic] resident's arm slowly and she flinched[sic], with facial grimacing noted. This writer notified hospice and talked to [Nurse], and that she will send someone tomorrow morning to assess her, to notify her family since its not urgent, and to update her medications; to give her some tylenol for now for pain prn (as needed). Progress note dated 7/11/24 at 8:19 AM, states: This writer heard resident's daughter [Name], in resident's room talking loudly towards staff doing cares. This writer asked her to come to SS (Social Services) office to discuss further. Daughter continued to express her frustrations to SS; Admin. also introduced himself to daughter; offered care conference with family. SS will contact APOA (Activated Power of Attorney) [Name] to schedule. The Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report was initially submitted by NHA A (Nursing Home Administrator) on 7/11/24 at 9:56 AM. The Allegation type is listed as injury of unknown source: injury was not observed and is suspicious because of the extent or location. (of note, this is over the required reporting time) The final investigation was submitted on 7/17/24 at 3:00 PM. R10's Physician Progress note, dated 7/16/24, indicates an x-ray was conducted on 7/12/24 that indicates a fracture with displacement of the humeral head with osteoporosis. The note also states, She has contractures. I suspect that during routine care (dressing/bathing), the upper arm may have been manipulated to change her clothing or provide hygiene and she developed a pathological fracture due to osteoporosis. On 8/8/24 at 1:43 PM, Surveyor interviewed NHA A. Surveyor asked NHA A what his process is for reporting and investigating injuries of unknown origin. NHA A states that if we suspect anything we suspend employees as necessary and notify family. NHA A also states he could guess what I was referring to and states that R10's family did not want anything done at first, and when they did the facility started with x-ray and labs. The Physician then ordered R10 adaptive clothing due to the discovery of a pathologic fracture. Surveyor asked NHA A how soon injuries of unknown origin should be reported to the State Agency. NHA A states as soon as we know there was an injury, NHA A also states that he did report it and DON B (Director of Nursing) also knew about it right away and when he assessed it, DON B determined that the bruise was from changing R10's clothing so it was not an injury of unknown origin. Surveyor asked NHA A when the injury was discovered. NHA A stated 7/7/24, but DON B determined that the injury was not of unknown origin as it came from changing R10's clothes. Surveyor asked NHA A when his initial report was submitted. NHA A states, 7/11/24. NHA A also states the only reason he reported this incident at all was because R10's family came in and was yelling at facility staff, alleging abuse. On 8/8/24 at 4:02 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how he was notified about R10's bruise. DON B states he was called immediately after the injury was discovered. DON B states that a CNA found the bruise and that it was small, about the size of a 50-cent coin. DON B gestured a small circle with his hand, roughly the same size as a 50-cent coin. Surveyor asked DON B if he would consider this bruise an injury of unknown origin. DON B states, I guess I would call it that. The next day when I came back in to reassess the resident the bruise was halfway down her arm. DON B gestures from the middle of his upper arm down to just below the elbow area. DON B also states that R10 has a long history of osteoporosis. Surveyor asked DON B what made the facility decide to further pursue an x-ray after the family initially denied it. DON B states because the bruise got bigger. DON B also states that he has seen multiple injuries in the past where a shoulder can be injured that can also cause these types of bruises to grow. Surveyor asked DON B when the decision was made to report this injury to the State Agency. DON B states when a family member came in screaming and alleging abuse. Surveyor asked DON B how soon abuse or injuries of unknown origins need to be reported. DON B states, immediately, especially when alleging physical harm. Of note, according to DON B, the bruise became significantly bigger on 7/8/24 and the injury was still not reported until 7/11/24, after R10's family member alleged abuse. R10's injury of unknown origin was not reported within the required timeframe.

Based on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 (R2) supplemental residents reviewed for antibiotic stewardship. R2 was given an antibiotic before all test results were returned and continued to take it after results despite lack of appropriate indications for its use. This is evidenced by: The facility policy titled, Antibiotic Stewardship Program, with a reviewed date of 1/24/24, indicates, in part: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Policy Explanation and Compliance Guidelines: .4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility uses the updated McGeer criteria to define infections .b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made . On 8/7/24 and 8/8/24 Surveyor reviewed the facility's Infection Control Line List documentation as part of the facility's Infection Control Program review. R2 was admitted to the facility on [DATE] and the July 2024 Infection Control Line List indicated the following for R2: Type of Infection: UTI (Urinary Tract Infection) .Signs and Symptoms: dysuria, urgency and abdominal pain. Criteria Met: Yes. Date of Onset: 7/12/24. Results/Organism: >=100,000 mixed flora .Treatment: Cefuroxime .Notes: UTI treated with cefuroxime x 7 days. An electronic encounter (a communication with the provider via electronic messaging), electronically signed by the physician on 7/12/24 at 2:31 PM, indicates the following: Looks like a UTI. Until culture is back, let's treat with cefuroxime 250 mg bid (twice a day) x 7 days with 0 refills. A Urine Culture Order with a collected date of 7/12/24 and a last resulted date of 7/13/24 indicates the following: Result Note: Urine Culture >= 100,000 CFU/ml (colony forming units/ml). No further workup performed. Mixed multiple morphologies present including potential uropathogens; suggest recollection if clinically indicated. R2's Medication Administration Record (MAR) indicates the following: Cefuroxime Axetil .Give 250mg (milligrams) by mouth two times a day for UTI until 7/19/24 .Start Date: 7/13/24. This medication is marked as administered twice daily from 7/13/24 through 7/18/24 and once in the AM of 7/19/24. On 8/8/24 at 8:59 AM, Surveyor interviewed ADON/IP D (Assistant Director of Nursing/Infection Preventionist) and DON B (Director of Nursing). Surveyor reviewed the above information regarding R2 and asked if it met criteria for treating with an antibiotic. ADON/IP indicated that she just went by the >100,000 for treatment. Surveyor reviewed the note on the urine culture indicating: No further workup performed. Mixed multiple morphologies present including potential uropathogens; suggest recollection if clinically indicated, with ADON/IP D and DON B. DON B indicated in the interview that his expectation with this culture result would have been for the physician to be contacted to discuss the results and to collect a new urine sample if needed. R2 was started on an antibiotic for suspected UTI prior to urine culture results being finalized. R2 was kept on an antibiotic after urine culture results indicated mixed flora (no specific bacteria was isolated) and that no further work-up would be performed. Therefore, a sensitivity, which would determine the effectiveness of the antibiotic against the microorganisms (germs) such as bacteria, was not performed. A recollection was not obtained or discussed with the Physician.

Based on interview and record review the facility did not maintain medical records on each resident that are complete; accurately documented; readily accessible, and systematically organized for 1 of 16 sampled residents (R39) reviewed for fall risk. R39's medical record contains inaccurate fall risk assessments following five (5) falls within the facility over the span of three (3) months. This is evidenced by: R39 was admitted to the facility on [DATE] with diagnosis that include in part: encephalopathy (brain disease or dysfunction that causes and altered mental state), vascular dementia, and polyneuropathy (peripheral nerve damage causing weakness, numbness, and pain). R39's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 7/25/24, indicates a Brief Interview of Mental Status (BIMS) of 3 out of 15, indicating R39 is severely cognitively impaired. Section GG indicates the resident utilizes a wheelchair for mobility. GG0170: Mobility indicates R39 requires partial/moderate assistance to move from sitting to standing. It also indicates R39 requires substantial/maximal assistance for chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. GG0170 also indicates that the facility could not attempt to have R39 walk 10 feet due to a medical condition or safety concerns. R39's Comprehensive Care Plan indicates, in part: Focus: R39 is a high risk for falls due to a history of falls, medications, weakness, decreased mobility, and a recent hospitalization . Date initiated: 4/19/24. Interventions include: room move if family is ok, lay down after meals, toilet after meals, bed in low position, dycem in w/c (wheelchair). Focus: R39 will use w/c while eating and in activities. Date initiated: 4/19/24. Interventions include: encourage to transfer and change positions slowly, FALL RISK (FYI), Have commonly used articles within easy reach, reinforce need to call for assistance, reinforce w/c safety as needed such as locking brakes, report development of pain, bruises, change in mental status, ADL (activities of daily living) function, appetite or neurological status post fall, sign to ask for help when getting up by recliner. R39's falls include: Post Fall assessment dated [DATE] at 12:00 PM. Assessment indicates that a fall occurred on 5/9/24 at 11:40 AM. Progress notes indicate that the fall was unwitnessed, and resident was found on the floor. The Fall Risk Assessment, which is included with the Post Fall Assessment, indicates a score of 22 indicating high fall risk. Post Fall assessment dated [DATE] at 11:42 PM. Assessment indicates a fall occurred on 5/9/24 at 7:00 PM. Progress notes indicate a second unwitnessed fall that was believed to have occurred when R39 attempt to use the bathroom by himself. The Fall Risk Assessment, which is included with the Post Fall Assessment, indicates a score of 10 indicating low fall risk. Post Fall assessment dated [DATE] at 2:40 AM. Assessment indicates a fall occurred on 5/10/24 at 7:10 PM. Progress note indicates that this is the third unwitnessed fall. The Fall Risk Assessment, which is included with the Post Fall Assessment, indicates a score of 15 indicating moderate fall risk. Post Fall assessment dated [DATE] at 2:11 PM. Assessment indicates a fall occurred on 6/5/24 at 1:00 PM. Assessment indicates that this is the fourth unwitnessed fall. The Fall Risk Assessment, which is included with the Post Fall Assessment, indicates a score of 9 indicating low fall risk. Of note: This Fall Risk Assessment indicates that R39 had no falls in the past 30 days and 1-2 falls in the past 90 days, when they actually had 3 falls. Additionally, it does not indicate the medications that R39 is has physician orders for that increase fall risk including a diuretic, a laxative, a psychotropic medication, and an antidepressant that are indicated on some prior assessments. Post Fall assessment dated [DATE] at 6:01 PM. Assessment indicates a fall occurred on 8/1/24 at 6:00 PM. Assessment indicates that this is the fifth unwitnessed fall. The Fall Risk Assessment, which is included with the Post Fall Assessment, indicates a score of 10 indicating low fall risk. Of note: This Fall Risk Assessment indicates that R39 had 1-2 falls in the past 90 days and 1-2 falls in the past 180 days, when the resident actually had 4 falls in the past 90 days. Additionally, it does not indicate the medications that R39 is has physician orders for that increase fall risk including a diuretic, a laxative, a psychotropic medication, and an antidepressant that are indicated on some prior assessments. On 8/8/24 at 8:44 AM, Surveyor interviewed LPN H (Licensed Practical Nurse). Surveyor asked LPN H what the process is after a resident falls. LPN H states, we get vitals, do an assessment, make sure nothing is hurting, utilize a hoyer lift to get them back up. Once the resident is off the floor, we ask them what happened, ask witnesses what happened, do notifications for the physician and HCPOA (Healthcare Power of Attorney), and then we do the fall risk assessment and continue neurological checks. Surveyor asked LPN H if recent falls increase someone's fall risk. LPN H states of course they do, along with a resident BIMS and medications. Surveyor asked LPN H if R39 is a high fall risk. LPN H states yes, due to his BIMS score, he has a sore ankle, and his recent intervention of the sign next to his chair is hit or miss for effectiveness. On 8/8/24 at 8:55 AM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C what the process is after a resident falls. RN C states, after I am notified, I go right to the room, assess for injury, ask what happened and if the resident hit their head. After that, RN C would start neurologic checks, assess vital signs, assist the resident off the floor, notify the physician and HCPOA, assess for skin issues, notify DON (Director of Nursing) and NHA (Nursing Home Administrator), and do a post fall and risk assessment. Surveyor asked RN C if previous falls increase resident fall risk. RN C states, absolutely. Surveyor asked RN C if R39 was a high fall risk. RN C states, yes. On 8/8/24 at 3:52 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what his expectations were for staff after a resident falls. DON B states staff are to do an incident report, risk management, document the fall, notify family, the physician, and himself. Surveyor asked DON B what the assessment includes. DON B states vital signs, head-to-toe assessment, and range of motion. Surveyor asked if this would also include a fall risk assessment. DON B states, yes, I would expect them to be filled out. Surveyor discussed with DON B that 3 out of 5 of R39's post fall assessments, R39 was determined to be a low fall risk. Surveyor then asked DON B if he would consider these to be accurate fall risk assessments. DON B states, no. Surveyor asked DON B if these assessments should be accurate. DON B states, yes.

Based on staff/resident interview and record review, the facility did not make prompt efforts to resolve grievances for 1 of 3 sampled residents (R1). R1 reported to DON B (Director of Nursing) multiple times regarding call light wait times and being left wet for long periods of time, as well as concerns regarding demeanor of two (2) staff members. DON B did not report these grievances to NHA A (Nursing Home Administrator), the Grievance Officer. Therefore, the grievances were not documented on the grievance log, and there is no documented follow-up with R1. The facility did not ensure prompt resolution of voiced grievances. As evidenced by: The facility's policy Grievance Policy, revised 7/2022, states as follows: The facility will seek to resolve concerns, complaints or grievances and provide residents, responsible parties, staff and other feedback and resolution in a timely manner per 483.10 (J)(1). The resident has a right to voice grievances without fear or retaliation. Residents, residents' families and responsible parties, facility staff and facility contractors will be in-serviced on the Grievance procedure, how to initiate a grievance, who the Grievance Officer is and how resolutions will be communicated. When a Complaint/Grievance Report is initiated: A copy of the initiated concern form will be placed in the Grievance Notebook as a reminder that the Grievance is still being investigated and resolved. The original form will then be forwarded to the department head for which the Grievance pertains to (i.e. Dietary Manager for food and dining related issues, DON for any nursing or clinical related issues The Department Head that is assigned the concern form is responsible for investigating the issue and following up to provide a resolution to the issue within 72 hours of being assigned the grievance. The Grievance Officer will ensure: During the investigation, the Grievance Officer will prevent any potential or further violation of resident rights. The receipt of the concern will immediately report allegation or neglect and/or abuse . Once resolution of the grievance is achieved, the Grievance Officer will ensure that follow up with the concerned party, explanation of the investigation and the resolution and document of the concerned party's response to the resolution take place. The Grievance Officer will ensure .written grievance resolution decisions include the date when the original concern was received, a summary statement of concern, steps taken to investigate, a summary of findings or conclusions regarding the concern, whether the concern was confirmed or not, any corrective action taken and the date the written decision was issued. By using the Grievance Report form - these action items should be achieved. On 2/7/24 at 9:10 AM and 11:35 AM, Surveyor spoke with R1. Surveyor asked R1, are staff taking good care of you. R1 stated, she thinks there are a lot of good CNA's (Certified Nursing Assistants) here. R1 stated she has concerns regarding her call light response time and being left soiled. R1 stated sometimes she waits around 40 minutes. R1 was unable to recall further details. Surveyor asked R1, did you you tell anybody regarding your concerns. R1 stated, she spoke with DON B. R1 stated she also had a concern regarding a staff member and shared that concern with DON B. Surveyor asked R1, do you feel safe at the facility. R1 stated, Yes. On 2/7/24 at 10:34 AM, Surveyor spoke to NHA A (Nursing Home Administrator). Surveyor asked NHA A, are there any grievances, investigations or a soft file for R1. NHA A stated, No. (Note there is only 1 grievance for R1 regarding food). Surveyor asked NHA A, does the facility have call light wait time logs. NHA A stated, no. On 2/7/24 at 4:23 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated, R1 and I (DON B) are friends, she tells me everything that's going on with her. DON B stated, he talks with R1, 2-3 times per week or more. Surveyor asked DON B, has R1 shared concerns with you regarding the facility. DON B stated, Yes, everything about A to Z. Surveyor asked DON B, has she voiced concerns to you. DON B stated, Yes. Surveyor asked DON B, who is the Grievance Officer. DON B stated, NHA A is the Grievance Officer. Surveyor asked DON B, did R1 share concerns with you regarding a staff member. DON B stated, R1 shared concerns regarding the demeanor of two (2) staff members. DON B added, R1's concerns were regarding the way the staff members talked and interacted. DON B stated, it was residents rights and customer service concerns. Surveyor asked DON B, what date(s) did R1 voice the concerns regarding staff. DON B stated, he is unsure as he did not document the information, and did not document when he followed up with R1. Surveyor asked DON B, did R1 voice concerns regarding call light response time and being left soiled. DON B stated, yes, R1 voiced concerns regarding call light response time and being left wet, not soiled. Surveyor asked DON B, what date did R1 voice the concerns call lights and being left wet. DON B stated, he is unsure as he did not document the information, and did not document when he followed up with R1. DON B stated, R1 has reported multiple concerns to him regarding call light response time. DON B stated, R1 did not want to file a grievance and stated, she doesn't want to get anybody in trouble. On 2/7/24 at 4:40 PM, Surveyor spoke with R1. Surveyor asked R1, when you shared your concerns regarding call light wait times and a staff member, did DON B ask if you wanted to file a grievance. R1 stated, No. R1 asked Surveyor, what is a grievance? R1 asked, is it like suing? Surveyor explained what a grievance is and the process to file a grievance. R1 was not offered to file a grievance for her concerns, the grievance officer was not made aware of R1's concerns and there is no evidence of facility staff following up with R1 with a resolution to her concerns that were voiced to DON B.

Based on observation, interview, and record review, the facility did not ensure 1 of 1 sampled residents (R1) reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R1 was admitted with an unstageable pressure injury (PI) to her right heel. Treatment orders were not completed as ordered. Findings include: R1 was admitted to the facility 1/2/24 with diagnoses including, but not limited to: acute on chronic congestive heart failure, chronic respiratory failure, acute kidney failure, and chronic kidney disease (CKD) stage 3. R1's Minimum Data Set (MDS) with an Assessment Reference Date of 1/9/24 indicates a Brief Interview of Mental Status score of 14 indicating she is cognitively intact. Section GG of the MDS indicates R1 requires supervision or touching assistance to roll left and right. Section M of the MDS indicates R1 has a unstageable PI due to coverage of wound bed by slough and/or eschar upon admission to the facility. R1 is at risk for pressure injuries. R1's comprehensive care plan, dated 1/11/24, indicates, in part, as follows: The resident has pressure ulcer to right heel r/t (related to) decreased mobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions: .Administer treatments as ordered and monitor of effectiveness. The wound physician assessed R1 for the first time on 1/4/23. On 1/11/24 the wound physician assessed R1 and documented the following: Unstageable (Due to Necrosis) of the Right Heel, Full Thickness Wound Size: 2.5 x 3.0 x Not Measurable cm (centimeters) (Length x width x depth) - Depth is unmeasurable due to presence of nonviable tissue and necrosis. Stage: Unstageable Necrosis Stage: Unstageable Necrosis Duration: Greater than 17 days Exudate (drainage): Moderate Sero-Sanguineous (composed of red blood cells and serous fluid, known as blood serum) Thick adherent devitalized necrotic (dead) tissue: 10% Granulation tissue: 90% Wound Progress: Not at Goal Dressing Treatment Plan: Primary Dressing: Alginate calcium with silver apply once daily for 30 days. Secondary Dressing: Gauze island with bdr (border) apply once daily for 23 days. R1's Treatment Administration Record (TAR) indicates the following: (Start Date 1/11/24) Wound care to right heel. Cleanse wound with gentle soap and water, rinse thoroughly and gently dry area. Apply calcium alginate with silver to wound bed and cover with bordered gauze daily and as needed. R1's TAR indicates R1's treatment was not completed on 1/15/24. On 2/7/24 at 3:19 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, do you expect staff to follow physician orders. DON B stated, Yes. Surveyor shared with DON B that R1's dressing change to her right heel was not completed on 1/15/23 per physician orders. Surveyor asked DON B, should staff have documented and completed R1's treatment per R1's physician orders. DON B stated, Yes. DON B added, As we know, if it's not documented it's not done.

Based on interview and record review, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 residents (R1). R1's Physician Orders dated 1/17/24 indicate the following order: Decrease lasix to 20 mg (milligrams) twice daily. The facility did not enter the updated order nor administer the updated lasix dose until 1/19/24. This is a medication error. Evidenced by: The facility policy, Medication Administration, dated 1/2023, indicates, in part, as follows: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices Medications are administered in accordance with written orders of the prescriber. R1 was admitted to the facility 1/2/24 with diagnoses including, but not limited to: acute on chronic congestive heart failure, chronic respiratory failure, acute kidney failure, and CKD (chronic kidney disease) stage 3b (moderate to severe loss of kidney function). On 1/17/24, R1 had an appointment with a Nephrologist (a Physician that specializes in kidney disease). The Physician documented the following order: Decrease lasix to 20 mg (milligrams) twice daily. Note, this order was in bold with a large font on R1's physician orders to emphasize the medication order change. R1's visit diagnosis: Stage 4 chronic kidney disease - Acute renal failure superimposed on stage 3b chronic kidney disease. R1's Medication Administration Record (MAR) documents the following medication administration: Furosemide Oral Tablet 20 mg (milligrams) (Start Date: 1/19/24) - Give 1 tablet by mouth two times a day for edema (AM and PM). R1's MAR indicates Furosemide 20 mg was not administered until 1/19/24 (2 days after it was prescribed). Furosemide Oral Tablet 40 mg (Start Date: 1/2/24 Discontinue Date: 1/18/24) - Give 1 tablet by mouth two times a day for edema (AM and PM). It is important to note, R1 did not receive any furosemide on 1/18/24. On 2/7/24 at 4:23 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, is it your expectation that staff follow Physician orders. DON B stated, Yes. Surveyor asked DON B, does the facility have any medication errors. DON B stated, no. Surveyor shared R1's physician orders on 1/17/24 with DON B. Surveyor stated that R1's lasix order was changed on 1/17/24 and the new order was not entered or administered until 1/19/24. Surveyor asked DON B, would you have expected R1's order for lasix to be entered and administered prior to 1/19/24. DON B stated, Yes. Surveyor asked DON B, how soon would you have expected staff to enter and start administering the new order. DON B stated, Within a 24 hour period or before. DON B was unaware of this medication error.

Based on record review and interviews, the facility did not ensure therapy services were provided for 1 of 6 residents (R1) reviewed for therapy services. R1 had an order for physical therapy (PT) and occupational therapy (OT) evaluation and treatment on discharge orders from hospital on 9/7/23. R1 was not evaluated and did not receive PT/OT services. This is evidenced by: R1 was admitted to the facility on [DATE] with diagnoses that include Calcinosis Cutis (a condition in which calcium salts are deposited in the skin and subcutaneous tissue), Type 2 Diabetes Mellitus (a condition that affects the way the body processes blood sugar. The body either doesn't produce enough insulin, or it resists it.), and Varicose Veins (gnarled, enlarged veins, most commonly appearing in the legs and feet) of Right Lower Extremity. R1's Hospital Discharge Summary, dated 9/7/23, states, in part: . Ambulatory Referral to occupational eval (evaluation) and treat . Ambulatory Referral to physical therapy eval and treat . R1's September 2023 Physician's Orders includes: *OT (Occupational Therapy) eval and treat as indicated *PT (Physical Therapy) eval and treat as indicated. R1's Client Coordination Note Report from Hospice, dated 9/8/23, states, in part: . Note: 1. Reason admission did not occur: Patient/Family wanting to pursue therapy and further extensive evaluation of current conditions . Of note: There are no PT/OT notes around 9/7/23 or after. There was no evidence of an evaluation assessment being completed for R1. On 12/5/23, at 3:45 PM, Surveyor interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator) and asked if they would expect physician orders to be followed. DON B indicated yes. Surveyor asked, when R1 returned to facility from hospital with discharge orders for physical and occupational therapy eval and treat on 9/7/23 would you expect those orders to be carried out. DON B and NHA A indicated yes. NHA A indicated he would look for documentation and consult with corporate and get back to Surveyor. No documentation was provided regarding therapy evaluation and treatment being completed for R1.

Based on observation, interview, and record review, the facility did not ensure the preparation of food in a clean and sanitary environment with the potential to affect all 33 residents residing in the facility. Surveyor observed dust collecting on piping above food preparation area in the facility's stove hood unit. Surveyor observed a dust covered fan within 6 inches of food preparation area while food was being prepared. Surveyor observed a dust covered radio and desk top file folder holder above open prepared food. This is evidenced by: The facility policy, entitled Nutrition Services Practice Manual dated July 2015, states: .Promote a clean and sanitary environment for its employees, residents, and visitors. The entire nutrition services team maintains clean and sanitary kitchen centers and equipment. Walls, floors, ceilings, equipment, and utensils are clean, sanitized, and in good working order .Procedure 1. Complete the nutrition services cleaning schedule (copy form) to ensure equipment and kitchen cleanliness . (It is important to note the Facility Dining services daily opening checklist, Dining services daily closing checklist, and Daily cleaning log failed to include the cleaning of fan and items stored on the kitchen shelfing, above the food preparation area, including the radio and desktop file folder to the facility's nutrition services cleaning schedules.) Example 1 Stove Hood On 4/23/23 at 10:16 AM Surveyor observed dust collecting on loose plumber's tape at the joints of the pipes located in the facility's stove hood unit directly above where food was being prepared and behind the stove unit. Surveyor also observed dust on shelving connected to the stove, electrical cords hanging above the food prep table. On 4/23/23 at 10:16 AM during an interview, DM D (Dietary Manager) indicated there is dust that has attached itself to the plumber's tape that was used to seal the joints and there is potential for the dust to fall into food being prepared on the stove. DM D also indicated the dust behind the stove unit and on the hanging electrical cords could dislodge and contaminate the food being prepared under them. Example 2 Fan On 4/23/23 at 10:16 AM Surveyor observed an oscillating pedestal fan placed within 6 inches of the stove. Dust was visible on the plastic covering of the engine, the cage, and fan blades. Surveyor also observed food particles speckled throughout the unit. On 4/25/23 at 4:13 PM DM D (Dietary Manager) indicated the fan has dust and food particles on it. DM D also indicated the facility does not have a schedule for cleaning the fan and they should. Example 3 Radio/File Folder Holder On 4/25/23 at 10:15 AM Surveyor observed an uncovered cake cooling on a food prep work surface below a grated wire shelfing with openings. On the shelf was a radio with visible dust on the topside and a desktop file folder holder with visible dust on the base. On 4/25/23 at 10:29 AM Surveyor interviewed Cook E who indicated there is a potential for the dust to fall off the radio and onto the food below. On 4/25/23 at 04:13 PM Surveyor interviewed DM D who indicated that there is potential for the dust to fall on food being prepared on the surface below the radio and file folder holder.

Based on observation, interview, and record review, the facility failed to treat a resident with dignity and respect for 1 of 2 Residents (R5) reviewed for dignity out of a total of 16 residents sampled. R5 required staff assistance to meet her needs in toileting and her commode was left in her room with feces on and in the commode. R5 stated she was embarrassed when Surveyors conducted an interview. The findings included: Facility's policy, entitled Resident Rights, includes, in part: Residents do not leave their individual personalities or basic human rights behind when they move to a long term care facility. Residents will be treated with respect and dignity. Care for each resident will be given in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality . R5 was admitted to the facility on [DATE] with diagnoses including: chronic respiratory failure with hypoxia, morbid obesity, unsteady on feet, abnormal gait and mobility, muscle weakness, neuromuscular dysfunction of bladder, acute kidney failure, anxiety, and demyelinating disease (condition that results in damage to the protective covering (myelin sheath) that surrounds nerve fibers) of the central nervous system. R5's Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 4/2/23, indicates R5 is cognitively intact with a Brief Interview For Mental Status (BIMS) score of 15 out of 15. R5's MDS also indicates she requires extensive physical assistance of 2 or more staff to meet her needs in the following areas: bed mobility, transfer, toileting, dressing, and personal hygiene. R5's Care Plan, initiated on 1/12/23, includes: bed mobility: 2 assist with four wheeled walker toileting: 2 assist transfer: 2 assist stand pivot with gait belt, walker, and dycem under feet On 4/23/23 at 11:21 AM Surveyor knocked on R5's door. R5 invited Surveyor into her room. Surveyor observed R5's commode to be in the middle of her room with a large amount of feces on the seat and hanging on the edge of the commode bucket. R5 indicated she was a Certified Nursing Assistant (CNA) for years and she had high expectations of the care she is in need of. R5 indicated she was sorry for the dirty commode left in her room and she was embarrassed by the mess. On 4/23/23 at 11:30 AM RN C (Registered Nurse) entered R5's room. R5 indicated again she was embarrassed by the unclean commode in the center of her room while all of this company is here. Surveyor asked RN C if the commode could be cleaned up. During an interview RN C indicated R5 needs assistance by 1 to 2 staff members to meet her toileting needs and those staff are to clean up after the task is completed and didn't. RN C indicated she would flag down another staff member to clean the commode. On 4/25/23 at 2:30 PM during an interview R5 apologized for the messy commode in her room again indicating she should have tried to hide it before letting Surveyor and other guests in her room. R5 stated, I am embarrassed. R5 and Surveyor reviewed R5's care plan together, focusing on the care level required to meet R5's needs at this moment. R5 voiced understanding that 2 staff are to assist to meet her needs in toileting and the task includes clean up. On 4/25/23 at 2:38 PM during an interview, DON B indicated staff are to clean R5's commode after each use and it will be stored in the corner of her room covered when not in use.

Based on observation, interview and record review, the facility did not ensure all residents who smoke did so safely and did not take immediate action when a resident was identified as smoking while wearing oxygen for 2 of 2 residents reviewed for smoking (R2 and R7). The facility's failure to implement safety and accident prevention measures for residents that smoke created a finding of immediate jeopardy that began on 12/11/21. The nursing Home Administrator (NHA A) was notified of the immediate jeopardy on 3/16/22 at approximately 2:15 PM. The immediate jeopardy was removed by the facility on 3/16/22. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include The facility's smoking policy, effective 5/9/19, includes the following: *Smoking use includes the use of smokeless tobacco, cigarettes, e-cigarettes, and vaping *Residents who smoke shall have a nicotine assessment completed upon admission, quarterly annual and PRN. *Residents or visitors who do not comply with procedure may be asked to restrict or relinquish smoking privileges *A resident is determined to be a hazardous smoker if he/she demonstrates one or more of the following risk factors and will have a care plan developed that may also include room and pocket searches: smoke in unauthorized areas, give cigarettes or lighting materials to others *Residents who smoke will keep nicotine materials in a locked box in a secure designated area when not in use *There will be no sharing of nicotine products and/or lighters *Residents are not to maintain items in their rooms *Oxygen tanks are not allowed in nicotine use areas and must be removed and maintained in the center prior to exiting the building for smoking. According to information from OSHA, a normal environment is one that is comprised of 16.5 - 23% oxygen. This level changes to one of oxygen-enrichment both around the oxygen tank, because of the venting that occurs, and around the nasal cannula. An oxygen-[MEDICATION(S)] environment makes the air highly combustible and makes burning more efficient. A spark from a match, a lighter, or a cigarette, could cause lit materials to combust and burn more vigorously and hotter (between 1500 - 3000 degrees F.) As a result, various sources advise keeping flames five to six feet away from anyone receiving oxygen. About 45 people die each year in the United States, and more than 1,000 are burned from fires fueled by home oxygen equipment, mostly caused by smoking, according to the National Fire Protection Association. [NAME] Home Health Care writes, Smoking around oxygen is extremely dangerous and may cause clothing and hair to catch fire and burn much more vigorously than in air. Never smoke or allow someone else to smoke nearby whilst using your oxygen equipment .Your clothing could become [MEDICATION(S)] with oxygen as you use your medical oxygen. Clothing and materials which become [MEDICATION(S)] with oxygen will burn vigorously if ignited. Your clothing will continue to be [MEDICATION(S)], even after you have turned off your oxygen supply. This company recommends that oxygen users ventilate their clothing for 20 minutes in open air before smoking. (www.bochomeoxygen.co.uk) The New York State Office of Fire Prevention and Control gives these warnings: Stay at least five feet from gas stoves, candles, lighted fireplaces and other heat sources. Keep oxygen cylinders and vessels in a well-ventilated area (not in closets, behind curtains, or other confined space). The small amount of oxygen gas that is continually vented from these units can accumulate in a confined space and become a fire hazard. (https://www.health.ny.gov/prevention/injury_prevention/children/toolkits/fire/docs/home_oxygen_fire_safety.pdf) An online demonstration by Vitas Healthcare shows how much more quickly a fire ignites and [CONDITION(S)], and [CONDITION(S)] hotter, in an oxygen-[MEDICATION(S)] environment. (https://www.vitas.com/family-and-caregiver-support/caregiving/providing-care-at-home/demonstrations-the-dangers-of-oxygen-and-smoking) Example 1 R2 was admitted to the facility on [DATE] and has diagnoses that include [CONDITION(S)] ([CONDITION(S)]), chronic respiratory failure and chronic heart failure. Her most recent MDS (Minimum Data Set), dated 12/9/21, shows a BIMS (Brief Interview for Mental Status) score of 8, indicating R2 is moderately cognitively impaired. R2 has orders to use oxygen every shift for [CONDITION(S)]. The facility conducted a nicotine assessment for R2 on 12/3/21 that states R2 does not currently smoke. A facility progress note dated 12/11/21 at 12:03 PM states, Found patient lying in bed smoking. This writer turned oxygen off and took cigarette away from patient and placed in sink. R2 told Surveyor on 3/16/22 at 3:33 PM that she bought the cigarettes before she was admitted to the facility and brought them with her. R2 stated she had been smoking her whole life. The facility did not complete a nicotine assessment for R2 until 1/16/22. This assessment noted that R2 currently smokes, has been smoking for [AGE] years and smokes 1-2 times per day. The assessment also stated R2 was assessed to be able to smoke independently. Additionally, the facility added smoking to R2's care plan on 1/16/22. The care plan states, Focus: At risk for smoking related injury related to smoking independently .Goal: Maintain independence safely while smoking .Interventions: Remove supplemental oxygen device prior to entering designated smoking area. A facility progress note on 3/13/22 at 12:43 PM states, Resident was observed outside with stepdaughter and was smoking a cigarette while she had her oxygen tank on back of wheelchair. When they came in, I reminded her and her stepdaughter that if resident wants to go outside to smoke, she must leave her oxygen tank at the nurse's station, and we will put it back on her when she comes back in. Resident stated, I'm not doing that. The facility presented R2 with a risks vs benefits on 3/14/22, which stated R2 was to leave her oxygen in the building and if not could result in Catching on fire, blowing self-up, blowing others up, leading to death. On 03/16/22 at 12:03 PM, Surveyor interviewed LPN C (Licensed Practical Nurse), who wrote the note detailing R2 smoking outside with oxygen tank. LPN C stated she was passing medications in the hallway when CNA D (Certified Nursing Assistant) came up to her and said R2 was outside smoking with her oxygen on. LPN C stated she was unsure of how long it was between when she was told of the event and when R2 came back in the building, but thought it was 5-10 minutes. LPN C stated she did not go outside when she was notified but waited until R2 came back into the building. When R2 entered the building, LPN C was then at the nurse's station and notified R2 and her family that R2 needed to leave her oxygen tank at the nurse's station before leaving the building to smoke. LPN C stated she had seen R2 outside earlier sitting around with her family but didn't think anything of it because she (R2) had agreed in the past to turn her oxygen off. When asked if she should have intervened immediately upon being notified of R2 smoking outside, LPN C stated, It was the weekend, and I was so busy in here. Additionally, LPN C stated she had not received any education after the event on the smoking policy or the need to intervene when a resident is smoking while wearing or near oxygen. On 3/16/22 at 11:34 AM, Surveyor interviewed CNA D who stated staff usually help R2 outside to smoke and that she is supposed to leave her oxygen tank inside but sometimes she doesn't. When asked how she goes outside and smokes if she has her oxygen, CNA D stated, Well she (R2) said she turned it off. On 3/17/22 at 2:31 PM, CNA D told Surveyor that she had told LPN C on 3/13/22 about R2 being outside while wearing her oxygen and LPN C told her (CNA D) that it was OK as R2 was instructed to turn her oxygen off. CNA D also stated that she had not received any education on the smoking policy following the observation of R2. No evidence was found or provided that the facility provided any education to staff regarding the facility's smoking policy or the need to act when a resident is observed smoking with oxygen on or nearby. On 3/17/22 at 9:00 AM, Surveyor interviewed FM E (Family Member) who stated that some of the nurses and aides at the desk had told her that R2 needs to take her oxygen tank off before she could go outside and smoke. FM E went on to say, So one day I went up to the desk and asked if as long as I'm with her (R2), can I just keep her tank on her wheelchair but turn the oxygen off and the staff told me that was OK. FM E was unable to remember who the staff was but stated this happened some time in February. Additionally, FM E stated it became a hassle to continually look for staff to get R2's smoking materials at the desk, so she would simply bring materials for R2. FM E stated that perhaps that was not the best idea. FM E stated the facility should have talked to her sooner about the oxygen, the policy, and their expectations to leave the oxygen tank inside the building. FM E stated, Certain staff will allow me to take her out smoking with the oxygen tank and others will not. On 3/16/22 at 1:18 PM, Surveyor interviewed DON B, who stated LPN C should have been more proactive about R2 smoking outside with her oxygen and should have intervened as soon as it was known R2 was smoking while wearing or near oxygen. Example 2 R7 was admitted to the facility on [DATE] and has diagnoses that include heart failure. Her most recent MDS, dated [DATE], shows a BIMS score of 15, indicating R7 is cognitively intact. R7 has orders for oxygen as needed. R7 stated to Surveyors on 3/14/22 at 7:25 PM that she only wears her oxygen when in bed, but does so every night. The facility documented the following progress notes for R7: 4/15/21 at 1:09 AM: This writer went and check, and we could smell the smoke going in her room. Resident denies that she smoked, and said she was just watching television. This writer asked resident where her cigarettes were and she said, I don't have any! This writer asked resident if I can look inside her bag and she said yes. This writer found 1 pack of cigarette and a lighter, oxygen is on; after a long talk and education with her she states I am sorry I lied to you! You don't know what I am feeling right now, I just want to go home! per statement. Will contact DON (Director of Nursing) in the morning. 4/22/21 at 3:30 PM: Executive Director was notified by CNA that she saw an e-cigarette on resident's bed while turning her and the e-cigarette was warm. It was immediately removed from resident's room and stored away appropriately. 5/18/21 at 8:35 PM: Resident has been in and out facility to smoke, she wakes up around midnight wanting to go outside to smoke. This writer told resident No! the cut off time was 10:00 PM and it's facility policy for safety purposes. Resident begging this writer to go out, told resident that she just has to wait until the morning. 5/23/21 at 10:45 PM: Resident went out to smoke and told CNAs that this writer said okay for her to go out at this time. This writer approached resident by the entry door as to why she's going out to smoke at this time when she has been told about the facility policy about smoking schedule, and she said, You told me I can go out, and nobody talked to me about the policy you're talking about!. DON was notified and aware. Resident refusing to come back inside and still pursuing to go out and smoke. 7/28/21 at 5:43 AM: Resident was informed and educated about smoking times. 3:30 AM resident came out and asked to go smoke. She was told no; it is not a smoking time. She said well I want to go out please. She then headed for the door. This nurse told her she cannot be physically stopped. She continued outside to smoke. 7/28/21 at 10:36 PM: Resident is insisting to go out to smoke, she said she was asleep since 8pm. This writer re-oriented and re-educated resident about smoking schedule and that she was awake at 2100 because she asked for [MEDICATION(S)] and went outside to smoke. Resident did not remember that she went outside and said she's been in bed. 7/31/21 at 4:41 AM: Resident was educated on smoking times. She went outside twice this NOC shift following a warning that she needs to not go out since it is not an authorized smoking time. 8/12/21 at 12:21 AM: Resident went out to smoke after smoking hours. She stays by the building for safety. 8/9/21 at 11:21 PM: Resident went out to smoke and states the facility has been letting her out to smoke now. 8/30/21 1:36 AM: Resident went out to smoke again. This writer told her it's not scheduled to go out, and she states I can go out whenever I want now 1/18/22 10:55 AM: Resident made aware of our smoking policy. Resident has been non-compliant with smoking in designated smoking area. Placing rock in door. Not having nicotine locked up. Sharing cigarettes and not putting cigarette butts in the proper place. All these concerns discussed with resident. Gave copy of smoking policy. Discussed smoking cessation. Resident denies wanting to quit smoking. All smoking materials locked in nurse's station room. R7's care plan for smoking, dated 4/22/21 states, Focus: Resident is a smoker. History of smoking in community/inappropriate smoking related to non-compliance with policy. On 3/14/22 at 7:25 PM, Surveyor interviewed R7 who stated she had been rolling her own cigarettes since October of 2021. She lent a cigarette to R2 on 1/14/22 and as a result, the facility confiscated all her cigarette supplies. R7 stated that she could get her supplies from the nurse and roll cigarettes in the activity room. R7 stated she did this a few times, but then due to the hassle of getting into the activity room, she decided to keep her supplies. R7 was not sure the exact date she did not give her supplies back but it was within a few days of being confiscated. R7 stated that nobody had taken the supplies back since that time in January. R7 also stated that she regularly rolls cigarettes in her room and has not tried to hide it. R7 was sure staff had seen her rolling cigarettes in her room since January. On 3/15/22 at 3:54 PM, Surveyor observed R7's smoking supplies in her room. R7 pulled her lighter out of her pocket when asked if she had one. R7 then stated she doesn't have anything at the desk where the supplies are supposed to be kept. On 3/15/22 at 3:50 PM, Surveyor asked LPN C where resident smoking supplies were, to which she replied she did not know. At 4:10 PM, Surveyor observed CNA F and CNA G at the nurse's station. When asked where the smoking supplies were at, CNA F stated R7 does not keep her stuff at the desk, she keeps them in her room. CNA F stated she did not know R7 smoked. On 3/16/22 at 11:30 AM, Surveyor interviewed CNA H, who primarily works the night shift. CNA H stated R7 does go out to smoke at night, but that she (CNA H) doesn't ever pay any attention to where she (R7) gets her smoking supplies. CNA H stated she knows what R7 is supposed to do, but wants to treat R7 with respect. CNA H stated the smoking supplies are supposed to be locked up at the desk, but staff doesn't keep track because R7 is so independent. On 3/16/22 at 11:34 AM Surveyor interviewed CNA D and CNA I, both of whom stated R7 did not keep her smoking supplies at the nurse's station, and they had seen R7 rolling cigarettes in her room within the last few weeks (unable to recall specific dates). On 3/16/22 at 12:39 PM, Surveyor interviewed DON B who stated R7's smoking materials should be locked up in the medication room behind the nurse's station. Surveyor and DON B went to med room and unlocked the metal case where resident smoking supplies are to be locked up. Only R2's smoking materials were in the case. Nothing for R7 was in the case. When asked if there was anywhere else R7's smoking supplies would be stored, DON B stated no. On 3/16/22 at 4:21 PM, Surveyor interviewed RN J (Registered Nurse), who stated DON B took R7's smoking materials earlier in the year. RN J stated R7 goes out whenever she wants to smoke, and she (RN J) doesn't get any supplies for R7 when she goes out and has stuff in her room. Additionally, RN J stated R7 doesn't follow the facility's smoking policy. On 3/16/22 at 1:18 PM, Surveyor interviewed DON B who confirmed that R7 had lent a cigarette to R2, had had her cigarette supplies confiscated as a result and could only access them from the nurse's station. DON B also stated the facility should have had a more proactive approach to keeping the smoking supplies out of her room. The facility was aware R2 and R7 had a history of non-compliance with the facility's smoking policy and did not ensure the residents and staff understood and implemented the facility's smoking policy to ensure R2's and R7's safety. R2 was observed smoking with oxygen on 12/11/21 and the facility did not complete a smoking assessment or care plan for R2's smoking use until 1/16/22. When R2 was observed smoking while wearing her oxygen again on 3/16/22, the facility did not intervene as they believed the oxygen was simply off. R7 was observed, and admitted to, smoking with oxygen on inside the building and was also observed with a hot e-cigarette on a later date. Although the facility tried to confiscate R7's smoking materials in January 2022, R7 was able to get them back within a few days and, although the facility care planned R7's non-compliance with the smoking policy, continued to allow R7 to smoke independently and did not take steps to ensure she did not have smoking materials in her possession. The facility's failure to implement safety and accident prevention measures for residents that smoke created a reasonable likelihood that serious harm could occur. This led to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 3/16/22 when it implemented the following: ~All staff educated prior to their next working shift on the following ~Facility smoking policy ~Secure smoking materials from residents that smoke ~Timely completion of nicotine assessment ~Removing oxygen tanks prior to allowing residents to smoke ~Family Member educated that oxygen tanks must be removed by staff prior to resident smoking. ~Smoking materials were secured by NHA and DON ~Interdisciplinary team completed full house sweep for any unsecured smoking materials. ~DON completed a new nicotine assessment on residents. ~DON/designee will audit residents for securement of smoking materials every shift for 4 weeks. ~DON/designee will audit staff removal of oxygen tanks every shift for 4 weeks. ~Results of audits will be brought to monthly Quality Assurance and Performance Improvement meeting for review and recommendations until compliance is achieved.

Based on interview and record review, the facility did not ensure residents are free from verbal and mental abuse for 1 of 3 total residents (R1) from Certified Nursing Assistant (CNA) C, who would yell, slam doors, and complain. This resulted in psychosocial harm when R1 would not use his call light despite needing assistance with care because he wanted to avoid the feelings of intimidation, being afraid, being yelled at and talked down to, and being made to feel as if he was a burden. The facility did not have a system in place to ensure CNA C did not continue to abuse residents after the facility substantiated an allegation of abuse. CNA C was allowed to return to work and work alone with vulnerable elders despite the facility's substantiated findings of abuse. This is evidenced by the following: Facility policy, entitled Abuse Prevention Program, dated 3/2018, includes in part: The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences . It is the policy of the facility to prevent and prohibit all types of abuse and neglect by the following measures including, but not limited to: providing a safe environment that delivers needed care and services by sufficient numbers of qualified staff . The facility's immediate response is to protect the alleged victim. To protect the alleged victim, the facility has clear delineated roles of those responsible for investigating and will respond to ensure protection of the alleged victim, identify any other alleged victims, and ensure the safety of all other residents and the integrity of the investigation . The alleged perpetrator will immediately be removed from the facility and denied access to the alleged victim and all other residents. If the alleged perpetrator is found to be at fault or if there is sufficient doubt about their innocence, the employee will be terminated and the NHA will follow the state's regulations regarding abuse findings . The employee will be ineligible for rehire and a notation to that effect will be placed in their record. R1 is a [AGE] year-old male, admitted to the facility on [DATE] for purpose of rehabilitation for weakness and history of falls at home. R1's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 10/25/21 indicates R1 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 out of 15. R1's MDS also indicates he requires physical assistance by 2 or more staff to meet his needs in the following areas: bed mobility, transferring, dressing, toileting, hygiene. R1's MDS indicates he requires limited physical assistance by two or more staff members to meet his needs in walking. Facility Self Report, dated 11/29/21, includes, in part: Affected person: R1 . Accused person: CNA C . On 11/28/21 CNA D reported to NHA A R1 told her he was scared of CNA C and didn't want her taking care of him anymore. Business Office Manager (BOM E) interviewed him shortly thereafter and he told her he thought CNA C was unprofessional but it was okay, he could deal with her. Then on 11/29/21, R1 reported to SW F he was frightened of CNA C and afraid to put his call light on, with this change of mind, we made self-report, suspended CNA C pending investigation and the investigation was begun. R1 is an alert and oriented person with no record of behaviors. CNA C denied the allegation and nurses were not made aware of the incident at the time. Conclusion: We determined the allegation to be substantiated. CNA C was issued a disciplinary action for the event and re-educated on Abuse prevention . Investigation Summary: On 11/28/21 CNA D reported to NHA A that R1 told her he was scared of CNA C and didn't want her taking care of him anymore. CNA C was yelling and being rude. BOM E interviewed him. R1 told BOM E, CNA C is very unprofessional, slams doors, and complains about her working conditions . Then on 11/29/21 R1 met with SW F at 8:30 AM and told her he is frightened of this CNA. That he feels like he should not even push the call button, but needs assistance, that she is going to bite your head off. NHA A and BOM E interviewed R1 and he affirmed that he feels intimidated by CNA C and that she yells at me when you put your call light on, you don't know what to expect . LPN G stated that CNA C was very upset and angry and continued to flail her arms, and talk loudly at nurse station during her shift. -CNA D's written statement, dated 12/2/21, includes: I was in with (R1) and he stated to me that one of our CNAs were being mean to him by yelling and being rude. He stated he was scared for his life. He stated she came at me with force and was very intimidating. He then said he didn't want to get anyone in trouble but he didn't want her to take care of him anymore. -LPN G's written statement, undated, includes: On Saturday PM shift . 11/27/21 . (CNA C) was very upset and angry. I'm tired of working by myself. I'm calling (union representative named). (CNA C) copied the schedule/assignment sheets. I don't get my breaks or supper. I'm not doing this anymore. (Union representative named) better do something. (CNA C) continued to [NAME] arms and talk loudly at the nurse station. -BOM E (Business Office Manager) written statement, dated 11/28/21, includes: Interviewed (R1) on 11/28/21 at 10:10 AM He feels (CNA C) is very unprofessional. When she has to work by herself he has to hear all her complaining and he shouldn't have to. She slams the doors all the time. I asked if he felt safe if she works today and he said he was not afraid of her but sick of her unprofessional work style and her complaining all of the time. - SW F's written statement, dated 11/29/21 and signed by R1, includes: Self report- patient this morning wheeled to this writer's office. Patient is reviewing this morning his upset view of CNA C over the weekend {sic}- a situation that happened on Friday night 11/27/21. Report of patient pressing the button, and feels he is going to get yelled at by CNA C. She comes off like she is going to bite your head off, and if you get feces on the seat, report from patient that CNA C will say, Well if you sit a bit up front, not so far back, there would not be such a mess. CNA C also mentioned that she is the only staff member on duty, and no house cleaning available, and additional work such as cleaning up after patient is not needed. Patient reports he tries to be mindful. He does not expect the exact minute when the button is pushed for help but per patient he tries to be understanding, respectful to all staff, but does not need to be treated in this manner. Patient reports he is frightened of this CNA C. Writer completed safety survey with patient a few days ago and patient reports to writer if completed this survey a couple day later with the patient his answers on the survey would be different. Patient reports he would have said yes to being afraid of staff member. Patient reports he understands that at times help is limited, but patient feels like a burden, and at times feels like he should not even push the call button, due to not having to feel like a burden. Patient reports he does have to go to the bathroom and needs assistance. Writer provided active listening along with emotional support. Writer to update NHA A regarding the above information. Patient reports he feels guilty for the report . but believes CNA C's actions are not in line with patient rights. -R1 written statement, written by NHA A, dated 11/29/21, includes: Met with (R1) as a clarification on reports of 11/28 with BOM E and 11/29 with SW F. Today, he states that he is intimidated by (CNA C) that she yells at me and is afraid to use the call light. Something about her intimidates me, when you press the call light and don't know what to expect. He states that he is afraid of her. She slams cabinet doors and complains about her working conditions. (It is important to note the allegations of abuse told to multiple staff members and how R1 reports this makes him feel intimidated, frightened, afraid, guilty, and like a burden.) CNA C's personnel file included the following disciplinary actions: -10/4/21 predisciplinary counseling . verbally inappropriate to resident on 10/3/21 . -11/17/21 Supervisor Report: Resident is fearful of this employee on 11/17/21 . -12/1/21 An alert resident made complaint about CNA C's behavior, approach, and demeanor on 11/27/21. He stated that he is afraid of her, afraid to use his call light for help, and feels like he is going to get yelled at by CNA C. On 12/15/21 at 12:54 PM during an interview, LPN G indicated CNA C is often inappropriate in her position, stating, She is always yelling at residents with dementia. She is offensive and comes across hostile. LPN G indicated CNA C has been re-educated and continues to verbally abuse residents. LPN G indicated CNA C should not be working with residents who depend on her and has reported these allegations to NHA A. On 12/15/21 at 1:30 PM during an interview CNA D indicated on 11/28/21 in the morning, R1 voiced an allegation of abuse to her and she reported it to NHA A immediately. The allegation was that CNA C was mean to R1 by yelling and being rude and intimidating R1. CNA D indicated R1 did not want her taking care of him anymore. CNA D stated, (CNA C) worked that following shift, on 11/28/21. CNA D indicated CNA C yells at residents with dementia and tells them to stop or no don't do that when they are wandering or having behaviors. CNA D indicated many staff have voiced complaints about CNA C being verbally abusive to residents. On 12/15/21 at 1:45 PM during an interview BOM E indicated she was the manager on duty when CNA D reported an allegation of abuse to NHA A, 11/28/21. NHA A then called BOM E and asked her to ask R1 if he was afraid or would feel unsafe if CNA C came to work that afternoon. BOM E and Surveyor reviewed BOM E's statement, included in the facility self-report. BOM E indicated slamming cabinets or doors could be intimidating to a resident. BOM E also indicating complaining about her job in front of a resident who depends on her could also cause fear, intimidation, or worry to a resident. BOM E indicated at the time, she did what was asked of her and took directions from NHA A. BOM E indicated CNA C worked with R1 that evening on the PM shift. On 12/15/21 at 2:00 PM during an interview, NHA A indicated she viewed R1's first voiced concern on 11/28/21 as a customer service issue and when R1 voiced concern to SW F on 11/29/21, she thought it sounded more like an abuse allegation. NHA A stated CNA C was educated on the abuse policy and issued a written warning discipline. NHA A indicated CNA C has been working independently since the conclusion of the investigation. Surveyor asked what NHA A's investigation concluded. NHA A indicated the abuse was substantiated. CNA C's time card, for time period 12/2021 indicates CNA C worked the following days: 12/1, 12/3, 12/6, 12/8, 12/10, 12/11, 12/12, 12/13, and 12/15. During these shifts CNA C worked on all three units of the facility. On 12/15/21 at 3:35 PM - 4:00 PM Surveyor observed CNA C working on 2 different hallways. She was observed working independently without supervision. She entered several resident rooms and shut the door behind her so only she and the resident were inside of room. On 12/15/21 at 4:10 PM during an interview, Surveyor asked how NHA A is making sure CNA C is not continuing to abuse residents. NHA A indicated again that she educated CNA C on abuse and on staff burnout. Surveyor asked if all residents in the home were interviewable and able to report abuse. NHA A indicated they are not. Surveyor and NHA A reviewed facility abuse policy together. NHA A indicated she was unaware that the abuse policy stated, If the alleged perpetrator is found to be at fault or if there is sufficient doubt about their innocence, the employee will be terminated and the NHA will follow the state's regulations regarding abuse findings . The employee will be ineligible for rehire and a notation to that effect will be placed in their record. NHA A stated, I don't want further abuse to occur. I need to get with my IDT (Interdisciplinary Team) and figure out an extra layer of protection. Surveyor shared with NHA A two more allegations voiced during interviews of abuse by CNA C. NHA A indicated she was not made aware of these allegations by staff who witnessed them and told Surveyor she should have been. On 12/21/21 at 8:20 AM during a phone interview, RR H (Resident Representative) indicated R1 was afraid of CNA C because she always yelled at him. RR H indicated R1 would not call for help at times, because he knew CNA C was working and he was afraid of her. RR H indicated CNA C intimidated R1 by yelling at him, talking down to him, and slamming doors. RR H said, I don't want her to hurt anyone else. That is why (R1) reported it. R1 experienced psychosocial harm by being made to feel intimidated and afraid, resulting in a hesitancy to use his call light even though he needs assistance with cares, because he never knew what kind of reaction he would get from CNA C.

Based on observation, interview, and record review, the facility did not ensure that residents received sufficient amounts of fluids based on individual needs and maintain acceptable parameters of nutritional status such as body weight. The facility did not provide hydration and nutritional care and services to each resident, consistent with each resident's Comprehensive Care Plan, including monitoring daily intakes and notifying the physician and responsible party of significant weight loss for 3 of 12 residents reviewed (R23, R9 and R19). R23's Nutritional Assessment Summary, dated 11/22/17, indicated R23 was not meeting her estimated fluid needs. On 12/11/17, R23 was not responding as she normally would and family requested she go to the ER (emergency room ) for evaluation. R23 was found to be dehydrated and was given IV (intravenous) fluids. R23 returned to the facility on [DATE]. R23's hydration was not assessed and the care plan was not updated to address R23's need for fluids or to monitor R23's fluids. The facility did not monitor R23's fluid intake to ensure she met her fluid needs. On 12/26/17, R23 was found not responding; pupils were dilated fixated. R23 was sent to the ER where she was found to be dehydrated. On 12/28/17, R23 returned to the facility. R23's hydration was not assessed and the care plan was not updated to reflect R23's needs for fluids or to monitor R23's fluids. R9 had two weights that reflected significant weight loss. Re-weights were not checked until 15 days later for one and, for the other, weight wasn't rechecked until after Surveyor brought it to the facility's attention, 26 days after the questionable weight. When R9's weight was rechecked, it reflected R9 had gained 9.8 pounds. R19 was assessed as at risk for altered nutrition and was to be weighed monthly per facility policy. R19's last weight was done 11/3/17. Evidenced by: The facility's Hydration Policy, dated July, 2015, includes, in part, the following: Procedure: 1. Calculate fluid requirements for all residents using the Nutrition Risk Data Collection and Assessment form upon: Admission. Significant change of condition - nutrition related. As deemed necessary by the resident clinical condition as it relates to Nutrition Services. 2. Identify causes and/or risk factors for dehydration, which may include, but are not limited to, the following: Fluid loss and increased fluid needs. Diuretic medications. Functional impairments that make it difficult to drink, reach fluids, or communicate fluid needs (e.g. dysphasia, [MEDICAL CONDITION], dysphagia). Dementia in which a resident forgets to drink or forgets how to drink. Use of thickened liquids. 3. Monitor for physical signs of dehydration. 4. Monitor and evaluate biochemical data to assess hydration status. 6. Identify and honor resident beverage preferences using the Food Preference Record. 7. Add additional fluids to meals or in between meals for those residents with increased fluid needs per resident preference. 8. Closely monitor weights of those individuals on diuretic. 9. Provide a minimum of 1500 cc (cubic centimeters)/day with meals unless contraindicated. 10. Provide thicken liquids as needed. 12. Present resident at the next schedule Comprehensive Care Plan Review meetings following admission or change in condition. 13. Develop individualized interventions to reduce/prevent risk of dehydration. 14. Review interventions as needed for effectiveness and revise as applicable. Example 1 R23's [DIAGNOSES REDACTED]. R23 has an HCPOA (health care power of attorney) and is not her own decision maker. R23's most recent Quarterly MDS with an ARD (assessment reference date) of 11/27/17 indicates R23 has severe cognitive impairment, needs supervision with eating and drinking, and is on a mechanically altered diet. R23's Nutrition Assessment, dated 11/22/17, includes, in part, the following: 1. Estimated Nutrient Needs. 4. Fluid: 1750 - 2100 cc/day. 5. Nutrition Goals. Maintain UBW (usual body weight). Consume fluids to meet fluid needs - 1750 - 2100 cc/day. 6. Summary. Quarterly assessment: Res (Resident) continues on NDD3 (National Dysphagia Diet) diet with nectar thick liquids as appropriate for medical hx (history). PO (oral) intakes average 69% meals past 7 days which is below needs of 79% meals served to meet 100% nutrition needs. Fluid intake average 1482 cc/day is below need of 1750 - 2100 cc/day. Skin: peg tube (Feeding tube) recently removed . Good po intakes should provide adequate nutrition for healing. Will continue to monitor wts (weights), po intakes and skin integrity. R23's Care Plan Focus: Risk for alteration in hydration r/t (related to) presence of [DEVICE] (gastrostomy tube), history [MEDICAL CONDITION](stroke), dependent on staff, dysphagia. Date initiated 11/8/17. Interventions: Administer medication per MD (Medical Doctor) orders, initiated 11/8/17. Administer water flushes via [DEVICE] as ordered by physician, initiated 11/8/17. Monitor hydration status every shift for antibiotic use, initiated 11/8/17. Obtain lab results as ordered and notify MD of results, initiated 11/8/17. Report changes r/t signs of fluid deficit (tongue furrows, dry mouth, etc.), initiated 11/8/17. Report changes r/t signs of fluid overload such as SOB (shortness of breath), [MEDICAL CONDITION], mental status changes, etc.), initiated 11/8/17. Report [MEDICAL CONDITION] or changes in [MEDICAL CONDITION] level, initiated 11/8/17. Therapy eval (evaluation) and treat as ordered, initiated 11/8/17. Thickened liquids per MD orders, nectar thick liquids, initiated 11/29/17. R23's Care Plan Focus: Diuretic Therapy to treat ([MEDICAL CONDITION]): At risk for adverse effects, initiated 11/8/17. Interventions: Administer medication per MD orders. Date initiated - 11/8/17. Report S & S (signs and symptoms) of dehydration, [MEDICAL CONDITION], dizziness, etc. Date initiated 11/8/17. Review electrolytes/renal function lab results. Notify MD of results. Date initiated 11/8/17. R23's Fluid Intake includes, in part, the following: 12/1/17 - 840 cc 12/2/17 - 50 cc 12/3/17 - 2400 cc 12/4/17 - 0 12/5/17 - 1570 cc 12/6/17 - 0 12/7//17 - 720 cc 12/8/17 - 820 cc 12/9/17 - 960 cc 12/10/17 - 290 cc 12/11/17 - 125 cc R23's documented fluid intake during these 11 days was 34-40% of her estimated fluid need. R23's Progress Notes includes, in part, the following: 12/11/17, 13:01 (1:01 PM), Resident not as bright as usual today. Had 2 small episodes of emesis today, mostly liquid. LS (lung sounds) diminished but clear. VS (vital signs) WNL (within normal limits) for her. (R23's Physician's) notified. Asked if she would like testing done, labs, UA (urinalysis), etc. 12/11/17, 16:04 (4:04 PM), Resident awakened after napping all afternoon. VS still stable, but resident is not responding as she normally would. Family would like her to go to ER for further evaluation. Order to send to ER obtained. Son (R23's Son) notified. 12/11/17, 21:35 (9:35 PM), ED (Emergency Department) states (R23) has been diagnosed with [REDACTED]. Resident will be returning back to (Facility) shortly. R23's ED Provider Notes, dated 12/11/17, includes, in part, the following: Pt (patient) presents from (Facility Name) with c/o (complaints of) weakness and not acting like herself. Pt has h/o (history of)[MEDICAL CONDITION](stroke) that left her mostly aphasic, although she apparently can say family member's names sometimes. Normally she walks with assistance and is able to feed herself. Son states he had to help feed her last night and she seemed sleepy. He had to call her name to awaken her; she seemed less responsive than normal. Over the last day or two, she has not been walking. She vomited a bit this morning. No fever. No diarrhea. Current Outpatient Prescriptions: . [MEDICATION NAME] ([MEDICATION NAME]) (a diuretic) 1 mg (milligram) tablet. Take 3 tabs by mouth daily. Physical Exam: HENT (Head/Eyes/Nose/Throat): Slightly dry mucus membranes. Number of [DIAGNOSES REDACTED]. Risk of Complications, Morbidity and/or Mortality: Pt is unremarkable vs is responsive, per family, less so than usual. Will check head CT: nothing acute? EKG (Electrocardiogram): afib ([MEDICAL CONDITION]) that is not new. Mild dehydration on labs. Will give 1 L (liter) ns (normal saline). Per family, pt perks up with this and she does seem more engaged. Pt able to eat Jell-O in ER and tolerates po challenge. No indication to admit pt at this time. Pt more at risk as admission to hospital for hospital acquired pneumonia or [DIAGNOSES REDACTED] ([MEDICAL CONDITION]) and will be better served with po antibiotics and continued po intake at (Facility). Will transfer back to (Facility). R23's Fluid Intake includes, in part, the following: 12/12/17 - 1160 cc 12/13/17 - 1320 cc 12/14/17 - 1125 cc 12/15/17 - 960 cc 12/16/17 - 960 cc 12/17/18 - 100 cc 12/18/17 - 170 cc 12/19/17 - 960 cc 12/20/17 - 250 cc 12/21/17 - 1570 cc 12/22/17 - 1890 cc 12/23/17 - 1780 cc 12/24/17 - 0 12/25/17 - 0 12/26/17 - 480 cc R23's documented fluid intake over these 15 days was 40 - 48% of her estimated fluid need. R23's Progress Notes includes, in part, the following: 12/12/17, 12:59 (PM), Writer sent Epic (Health Services) message regarding resident having a hard time swallowing food at lunch today. Will await reply from (R23's physician). 12/13/17, 9:19 (AM), if resident continues to have problems with swallowing in the next couple of meals, please ask speech therapy to see for evaluation and management. 12/15/17, 17:51 (5:51 PM), Resident had appt (appointment) at clinic today with (R23's Nurse Practitioner). Was sent from clinic to ER for further evaluation of altered mental status and gargling speech. No new orders, resume previous orders. Follow up with (R23's Physician) in 1 week or sooner if symptoms worsen or prn (as needed). 12/26/17, 10:40 (AM), Resident found per OT (Occupational Therapy) sitting in her w/c not responding to therapy. Non-verbal, pupils dilated fixated, vitals documented, RR (Respiratory Rate) 16. Notified MD and family per LPN (Licensed Practical Nurse). 911 called ambulance here at 10:55 AM. R23's Hospital Discharge Summary, dated 12/28/17, includes, in part, the following: HPI (History of Present Illness): . According to the family, (R23) is unable to feed herself, and she is barely taking anything for last 3 days. Patient is on diuretics for [MEDICAL CONDITION]. Hospital Course: (R23) was admitted and noted to have an elevated Creatinine of 2.14 and acute kidney injury from an unknown baseline, but it was 1.39 on 11/22/17. She has had decreased oral intake per her son and her nurse at (Facility). I fear she is failing to thrive and simply won't drink enough to promote kidney health in the outpatient setting. At the time of discharge she was stable, noted she felt well enough to go back to (Facility) and her unresponsiveness may have been related to her dehydration status. Her Creatinine had improved to 1.6 at the time of discharge. Her [MEDICATION NAME] was decreased from 3 mg to 1 mg daily. She had known [MEDICAL CONDITION], but she is failing to intake orally at (Facility) and the 3 mg dose is aggressive and will likely result in further dehydration. I called and discussed with her nurse about the medication change and will obtain a BMP (Basic Metabolic Panel) in 3 days to check Creatinine. If Creatinine not improved or worse then I recommended stopping the [MEDICATION NAME] all together. I also instructed them to weigh her daily and if she gains 5 lbs (pounds) to add a second [MEDICATION NAME] for 3 - 5 days. The BMP results in 3 days should go to her primary physician to make recommendations on the diuretic. I think that if she continues to intake poorly she will ultimately come off the [MEDICATION NAME] all together at some point. She was stable at the time of discharge. Medications at Discharge: [MEDICATION NAME] changed to 1 mg from 3 mg daily, secondary to dehydrated status and elevated Creatinine. Discharge to Skilled Nursing Facility . Labs to be Drawn: BMP in 3 days. (It is important to know there was no evidence that R23 had a BMP drawn after discharge from the hospital as ordered.) R23's Dehydration Risk Screener, signed 12/29/17, includes, in part, the following: Score: 10. I. Scoring: Scores of 10 or higher indicate resident is AT RISK for dehydration and further assessment should be conducted to review resident's fluid status. R23's Fluid Intake includes, in part, the following: 12/28/17 - nothing documented 12/29/17 - 2880 cc 12/30/17 - 1920 cc 12/31/17 - 1740 cc 1/1/18 - 1670 cc 1/2/18 - 1765 cc 1/3/18 - 2140 cc 1/4/18 - 745 cc 1/5/18 - 1520 cc 1/6/18 - 2030 cc 1/7/18 - 3240 cc 1/8/18 - 1680 cc 1/9/18 - 1080 cc R23's document fluid intake over these 13 days was 82 - 99% of her estimated fluid need. R23's Progress Notes includes, in part, the following: 12/28/17, 12:20 (PM), N/O (new order): d/c (discontinue) [MEDICATION NAME] daily, start 1 mg [MEDICATION NAME] daily & continue daily weights. 12/28/18, 12:24 (PM), Resident arrived via w/c van accompanied by daughter at 0930 (AM). To repeat BMP in 3 days per MD to monitor hydration and Creatinine levels. On 1/10/18 at 2:22 PM, Surveyor interviewed RD J (Registered Dietician). RD J stated R23's [DEVICE] was removed within the past 30 to 60 days and R23's care plan should have been updated to reflect the [DEVICE] removal. RD J stated she was not aware R23's fluids were not being monitored. RD J stated R23's care plan should also have addressed R23's fluid intake, focusing on monitoring R23's fluid intake, which should have been updated when R23's Nutrition Assessment indicated she did not meet her estimated fluid needs. RD J stated R23's fluids intake should be monitored. On 1/10/18 at 2:34 PM, Surveyor interviewed RN O. RN O stated she works with R23. RN O stated she monitors the fluids she gives R23, dietary monitors what R23 receives in the dining room. RN O stated she does not monitor all the fluids R23 receives to see what her total fluid intake is each day. RN O stated if R23 didn't meet her fluid needs we would call doctor and POA to find out what he wants us to do about it and update the doctor with his wishes, On 1/10/18 at 2:40 PM, Surveyor interviewed LPN H. LPN H stated CNA monitors what residents drink in the dining room. LPN H stated she monitors what she gives residents with medication pass. LPN H stated she does not monitor what residents take in as a total each day. On 1/10/18 at 3:17 PM, Surveyor interviewed DON B. DON B stated RD J should have notified nursing when she completed R23's Nutrition Assessment, on 11/22/17, when she noted R23 was not meeting her estimated fluid needs. R23's care plan should have addressed fluid intake and been updated when R23's [DEVICE] was removed, on 11/17/17, as she was receiving additional fluids thru her [DEVICE] prior to removal. DON B stated staff should have assessed R23's hydration risk and pushed fluids when R23 returned from the HospitalER on [DATE], which means to offer fluid with med pass, each contact, meals, and document the fluid intake. DON B stated R23's fluid intake should be monitored daily, looking at the total overall fluid intake and document if R23 refuses, calling R23's Physician and her HCPOA if she does not meet her estimated fluid needs. DON B stated we will have to assign someone to monitor daily fluid intakes on residents who are at risk. On 1/11/18 at 8:48 AM, Surveyor interviewed DON B. DON B stated when R23 returned from the hospital on [DATE] a Dehydration Risk Screener was completed. If R23 did not meet her fluid needs the computer will notify nursing on the computer dashboard, but thru this investigation we realized this is not coming up on the dashboard, we were not capturing the overall fluid intake on the computer and not one was tallying the overall intake. DON B stated we were relying on the dashboard; we are now going to manually be adding the fluid intake and monitoring it that way. Example 2 Facility procedure entitled Weight Monitoring, dated 7/2015, reads, in part: CNA Responsibilities 3. Weigh the resident monthly to monitor stability. 4. Report the weight to the Licensed Nurse. a. Weight will be verified for accuracy by the Licensed Nurse. Licensed Nurse Responsibilities 1. Verify accuracy of the weight by comparing the weight with the most recently recorded weight. 2. Compare weights using the Weight Change Grid to determine 3% weight change. 3. Supervise the CNA while re-weighing the resident to assure that correct process is followed, if the weight has changed with a gain or loss of 3% or greater. On 1/8/18 and 1/9/18, Surveyor observed resident seated in her w/c and noted her lower legs were quite [MEDICAL CONDITION]. R9 was wearing [MEDICATION NAME] stockings. R9 has [DIAGNOSES REDACTED]. R9's Care Plan Focus Area: Resident is at risk for altered nutritional status r/t or evidenced by Obesity - above weight range BMI (body mass index), [MEDICAL CONDITION] . Contained the following intervention, dated 11/03/17: Weigh resident per facility protocol. Inform Supervisor about any variation in weight of + or - 2 lbs. R9's same Care Plan with the Focus Area of [MEDICAL CONDITION] r/t CAD [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), hx (history) of [MEDICAL CONDITION] embolism, [MEDICAL CONDITIONS](hypertension), dated 11/3/17, included an intervention, dated 11/3/17, of Obtain weights as needed/ordered. Report significant change. R9's MDS assessment, dated 10/22/17, listed R9's weight as 170 lbs and identified R9 had a weight loss. Surveyor then reviewed R9's weight tracking record. A weight for R9, on 09/07/17, was 188.0 lbs. The next weight charted for R9 was on 10/19/17, and was listed as 170.4 lbs. The next weights for R9 were: 11/3/17 - 190.4 lbs, 11/04/17 - 189.8 lbs, 11/18/17 - 188.2 lbs, 12/16/17 - 152.4 lbs. On the weight tracking summary for R9, a line was drawn through the 10/19/17 weight of 170.4 lbs. An entry made by RD J on 11/08/17, read Disputed value. R9's next weight was not rechecked until 11/03/17. R9's 12/16/17 weight of 152.4 lbs, also had a line drawn through it and contained an entry by RD J, dated 12/18/17, that read Disputed value. No further weights were listed for R9. A Progress Note, dated 10/25/17, by RD J read: WEIGHT WARNING: Value 170.4 Vital Date: 2017-10-19. -3% change from last weight (9.4%, 17.6). Resident triggered for weight loss. PO intakes remain good averaging 79% meals past 14 days. Requested re-weigh from Nursing/CNA staff. Will continue to monitor wts and po intakes. The 10/19/17 weight that was 170.4 lbs, was entered into R9's 10/22/17's MDS, is what triggered the warning. R9's re-weigh was not done until 11/03/17, and was 190.4. On 01/11/18 at 1:43 PM, Surveyor interviewed R9's weight discrepancies with RD J. RD J said R9 refuses to be weighed from time to time. Surveyor told RD J she could not locate any documentation of R9 refusing to be weighed. At 2:00 PM on 1/11/18, Surveyor asked RD J what it meant when there is a line drawn through a weight. RD J said she went back into R9's record and struck out (put a line through it) the 170.4 lb weight and wrote in it as a disputed value. Surveyor asked RD J what the -3% change from last weight (9.4%, 17.6) meant. RD J explained the system will flag a change of 3%, 5% or 10%. The 9.4% is the percentage of loss and the 17.6 was the number of lbs lost. Surveyor asked RD J about R9's weight of 152.4 lbs, obtained on 12/16/17. That weight compared to R9's prior weight, 188.2 lbs, on 11/18/17, would represent a 35.8 lb loss. RD J said she struck that out too and documented it as a disputed value and requested a re-weigh be done. RD J looked in R9's Medical Record and could not find documentation of a further weight being checked after the 12/16/17 weight. Surveyor reviewed R9's Progress Notes for 12/2017, and noted there were no nursing or dietary notes that addressed the 152.4 lb weight obtained on 12/16/17. Nor was there documentation of a re-weigh being done or an assessment of R9 food intake. On 1/11/18 at approximately 2:10 PM, Surveyor showed DON B R9's Weight Record and explained the above concerns. DON B also looked and was unable to find a further weight for R9. Surveyor asked DON B how often are they to weigh residents. DON B said she thought weekly, but a resident can refuse. Surveyor said yes they can, but Surveyor was unable to find any documentation of R9 refusing to be weighed. 01/11/18 at 2:23 PM, RD J showed Surveyor copies of R9's Weekly Skin Assessment sheets, also called Shower Sheets. RD J said R9 refuses her showers often. Surveyor said even though she refuses her showers couldn't they still weigh her as they are two separate things. Surveyor reviewed R9's Shower Sheets. For 12/16/17, the sheet contained an entry that read Weekly Weight with an entry of 152.4 lbs. The next Weekly Skin Assessment/Shower Sheet was dated 12/26/17. No weight was listed. A note read: Resident refused-in too much pain. The next sheet, dated 12/30/17, had no weight listed on it. An entry read: Resident Refused-washed up in bed. The last sheet, dated 1/2/18, contained no weight. An entry read: Refused shower-accepted bed bath. On 01/11/18 at 2:27 PM, Surveyor asked LPN H if they have a scale they can put a w/c on to weigh residents. LPN H said yes, they do. Surveyor asked LPN H how often they weigh residents. LPN H said usually on bath days or if they have a specific order. Surveyor reviewed R9's Physician order [REDACTED]. On 01/11/18 at 2:29 PM, CNA M told Surveyor they had just done a weight on R9 and it was 198 lbs. This shows a 9.8 lb increase since the last undisputed weight done on 11/18/17. Surveyor asked CNA M how she weighed R9. CNA M said with the w/c scale, without her foot pedals on. CNA M said we need to do it the same way each time. Example 3 Surveyor reviewed R19's Weight Tracking Log and noted R19 had been weighed last on 11/03/17. R19's weight, on that date, was 113.5 lbs. No further weights were recorded. R19's Care Plan includes a Focus Area of: Resident is at risk for altered nutritional status r/t or evidenced by dementia . An intervention under this focus area for R19 read: Weigh resident per facility protocol.

Based on observation, interview and record review the facility failed to ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 resident out of 11 sampled residents reviewed (Resident 2). Resident 2 was observed during transfers with a grimace on her face, looking panicked, yelling ow, please, God Dammit, the son of a [***] hurts, feels like it's broke. Certified Nursing Assistants (CNAs) I, J, K and L stated they did not inform the nurse of Resident 2's complaints of pain. Resident 2 did not have a complete assessment addressing her pain. Resident 2 did not have a care plan addressing her pain. Resident 2 did receive [MEDICATION NAME] (a pain medication) 20 times in September, 2016 and 25 times in October, 2016 for her pain. Evidenced by: The facility's Pain Management policy dated 7/2015, includes, in part, the following: Pain Management. The center recognizes that a resident's response to pain is subjective and individual. Additional expressions of pain that need to be included in an evaluation include: a. Vocalization of pain, crying/ whining, yelling, gasping/sighing, moaning/groaning/grunting, verbal outbursts. b. Vocal complaints of pain, That hurts, Stop, Ouch. c. Facial Expressions, grimaces, winces, wrinkled forehead, furrowed brow/frowning, clenched teeth or jaw. e. Non-verbal cues/behaviors, restlessness, agitation, rapid eye blinking, rocking, fidgeting, repositioning, tense body language, distorted posture, noisy breathing. f. Change in unusual activity or behavior, aggression, withdrawn, impaired mobility. All residents are initially screened for pain upon admission, quarterly, with a significant change in condition that may cause an onset or increase in pain and any time it is suspected a resident is in pain. The facility's Pain Assessment and Management policy dated 7/2015, includes, in part, the following: Pain Assessment and Management. 1. Review interdisciplinary assessments for pain indicators. Indicators may include, but not limited to: Decrease in functional ability. Increase in behaviors (e.g. striking out, yelling, and moaning). Change in mood. Withdrawal. Family or significant other expressing concern about change in condition. Pain in Cognitively Impaired Resident. Pain is frequently under treated in cognitively impaired residents. Contrary to a commonly held belief, these residents are often able to report feeling pain. In cognitively impaired individuals, therefore, self reports of pain should be taken seriously, although the resident may be unable to describe pain characteristics in detail. 2. Complete and review the Pain Data Collection and Assessment form. Review for the following: Self report of pain. Verbal or nonverbal responses that may indicate pain. Conditions/[DIAGNOSES REDACTED].g. falls, fracture, recent surgery, procedures). 3. Review medical record for possible factors associated with pain in the elderly. 6. Initiate the Pain Management Care Plan. 7. Discuss [MEDICATION NAME] medication options with the resident, family, consulting pharmacist and provider as appropriate. One non-pharmacological intervention should be tried along with pharmacological interventions. 12. Evaluate and document effectiveness of interventions on the Medication Administration Record [REDACTED]. Reassess resident status as indicated or with significant change at Comprehensive Care Plan Review Meetings. Resident 2's [DIAGNOSES REDACTED]. Resident 2 has an activated Health Care Power of Attorney. Resident 2's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/27/16 indicated Resident 2 is cognitively impaired. Section J0100, Pain Management, indicated Resident 2 had received scheduled pain medications, received PRN (as needed) pain medications, and did not receive any non-medication interventions for pain. Resident 2's Pain Data Collection and Assessment, dated 9/27/16, includes, in part, the following: A. Medical Record Review: 2. History of pain medication use (include current pain medications and effectiveness): Resident denies pain and does not use any pain medication at this time. 3. Current PRN use (include current pain medications and effectiveness): None used since admission. 4. Non-pharmacologic approaches tried (and effectiveness): None. 5. Current mood issues/behaviors: Pleasant. B. Observations of Interviewer & other Staff (e.g. labored breathing, vocalizations, facial expressions, body language): 1. Interviewer's observations of indicators of pain: Denies pain. 2. Direct care givers & other staff observations of pain: (this was left blank). C. Resident Interview (Attempt interview. If resident unable to communicate answers, proceed to PAINAD): 1. Have you had any pain or hurting at any time over the last five days? No. 2. Are you having any pain or hurting right now? No. D. Location of Pain: (this entire section is not completed) E. Effect on function (interviewable resident): 1. Over the past five days, has pain limited your ability to move, to participate in activities or do the things you like to do? No. F. Interventions: What things have you found that help relieve or reduce your pain? These things could be medications or non-medications. If the resident dos not mention current medications, ask specifically about them and if they are providing satisfactory relief. (This entire section is not completed) G. Goals. Ask Resident: 1. Sometimes people have goals for pain management such as being able to sleep through the night or being able to participate in therapy. Do you have any goals for your pain management? Denies pain. 2. Using the same pain rating scale you used earlier in this assessment can you tell me what your acceptable level of pain would be: GOAL (this section is not complete) H. Summary: Evaluation of pain management plan: 4. Current plan is effective. No change necessary to Care Plan. I. Signature: 1. Signature of nurse completing assessment: (Signature of Registered Nurse (RN) S) J. PAINAD to be completed for residents with dementia or non-interviewable resident: 1. Breathing: Normal breathing. 2. Negative Vocalizations: None. 3. Facial Expressions: Smiling or inexpressive. 4. Body Language: Relaxed. 5. Consolability: No need to console. K. Complete for non-interviewable residents - Staff/family observations: (this section is not complete) L. Family Input: Family available: No. M. Summary: Based on Medical record review and input from (check all that apply): 1a. Resident. 1c. Staff. Evaluation of pain management plan: 2d. Current plan is effective. No changes necessary to Care Plan. N. Signature: Signature of nurse completing assessment: (Signature of RN S) Signed Date: 9/29/16. It is important to know Resident 2's comprehensive care plan did not include a care plan addressing Resident 2's pain. Resident 2's Progress Notes included, in part, the following: 9/5/16, 16:27 (4:27 PM) . Resident found sitting on the floor next to her bed . 9/7/16, 16:53 (4:53 PM) . Resident found lying on the floor on her right side. No severe injury apparent, resident displaying full range of motion to all extremities, but complaining of right hip pain . 9/7/16, 18:14 (6:14 PM) . Notified (Physician's Name) and notified that the resident is complaining of a lot of right hip/groin pain and requested a mobile hip x-ray. 9/8/16, 01:28 (AM) .c/o (complaints of) RT (right) hip pain. Prn (as needed) Tylenol 325 given. eff (effective) . 9/8/16, 09:38 (AM), Resident had an unwitnessed fall this am at 0900. Resident found on floor next to bed by PT (Physical Therapy). Notified (Physician's Name) and requested order for low bed with mat to floor, a stronger [MEDICATION NAME] for pain and allevyn to open lesion on left buttock . 9/8/16, 09:46 (AM), Received order for low bed, mat to floor, allevyn to left buttock change every 3 days until healed and [MEDICATION NAME] 50 mg (milligrams) 1 tab po (by mouth) every 6 hours as needed. 9/11/16, 22:18 (10:18 PM) . resident cooperative, pain with movements and on touch, pain in left buttock, r (right) hip and r leg. 9/15/16, 11:48 (AM) . Resident continues to yell out in pain with transfers, she is now using a sit to stand for transfers and is using w/c (wheelchair) for transfers around the facility. Resident is currently using 2 - 3 [MEDICATION NAME] 50 mg PRN throughout day. 9/15/16, 15:58 (3:58 PM), Received new order from (Physician's Name) for a [MEDICATION NAME] and lumbar spine x-rays and to look for compression fracture. 9/16/16, 23:50 (11:50 PM) . No c/o pain. Resident calling out frequently all this shift. Seems to rest, then awaken anxious in a cyclic pattern. Close monitoring and support. 9/17/16, 01:58 (AM) . res (resident) attempted to get out of bed at beginning of shift, res gotten up & brought up to nurses station in w/c (wheelchair). Res very confused c/o back pain prn pain med (medication) given, eff, resident sleeping comfortably, no further c/o pain or discomfort . 9/17/16, 10:06 (AM) . Resident currently in wheelchair, voices needs, c/o pain and yells out when being assisted confused, no other complaints voiced, will continue to monitor. 9/18/16, 09:37 (AM), . Resident currently in wheelchair, voices needs, c/o pain and yells out when being assisted, confused, no other complaints voiced, vss (vital signs stable), will continue to monitor. 9/19/16, 14:56 (2:56 PM) . Resident is transferred by hoyer lift. No compression fx (fracture) to spine. 9/19/16, 19:30 (7:30 PM) . Resident was yelling from room and was found on floor, hoyered to chair, no c/o at this time . 9/25/16, 23:13 (11:13 PM) . [MEDICATION NAME] given with good relief of hip discomfort. 9/26/16, 10:56 (AM), (Physician's Name) appt (appointment) finding dementia worsening as expected, recommendation no change in regimen. 9/27/16, 20:42 (8:42 PM) . Denies pain at this time, but stiff in movement. 10/8/16, 21:45 (9:45 PM), Resident restless this evening, when asked if she had pain she replied yes, all over. PRN [MEDICATION NAME] given at 1900 (7:00 PM), [MEDICATION NAME] effective as resident is resting quietly. 10/11/16, 16:38 (4:38 PM), Therapy recommendation. Two assist with stand-pivot transfers. 10/12/16, 09:05 (AM), Resident has had a decline in function within the last month. Ambulation program has been discontinued as it is no longer appropriate for resident. AROM (Active Range of Motion) program put in place remains on dressing and grooming programs. Will continue to monitor for any further decline. 10/28/16, 14:52 (2:52 PM), Fax received from (Physician's Name) to change [MEDICATION NAME] 50 mg tablet, 1 tab (tablet) PO every 4 hours as needed for pain. Resident 2's August, 2016, Medication Administration Record [REDACTED]. Resident 2's September, 2016, Medication Administration Record [REDACTED]. Resident 2's September, 2016, Medication Administration Record [REDACTED]. The following documentation, in part, is on Resident 2's PRN [MEDICATION NAME] Record/Pain Flow Sheet for September, 2016: Resident's goal for pain management: (this is blank). 9/7/16, 1700 (5:00 PM) R hip/groin pain, in bed, Tyl (Tylenol) 325 2 (tablets) 9/8/16, 0430 (AM), R hip (pain location), trying to stand pivot to wheelchair. Tyl 325 2 (tablets) . 0530 (AM) (pain relief) don't know . 9/8/16, 1430 (2:30 PM), R hip groin (pain location), yelling in w/c, Tram ([MEDICATION NAME]) x (times) 1 . (pain relief) sleeping. 9/8/16, 1800 (6:00 PM), R hip (pain location), in bed, Tram x 1 9/12/16, hip (pain location), unable to des (describe) (pain location), up to bath (activity), [MEDICATION NAME] x 1 . 0200 (AM) (result time), sleeping, effective 9/12/16, 1530 (3:30 PM), R hip (pain location), yelling, (up) in w/c, tram 50 1 9/20/16, 0720 (AM), R hip (pain location), yelling (up) in w/c, tram 50 x 1 . 9/23/16, 1900 (7:00 PM), R hip (pain location), yelling (up) I w/c, tram 50 x 1, 2000 (8:00 PM) (result time), resting in bed. Resident 2's October, 2016, Medication Administration Record [REDACTED]. Resident 2's October, 2016, Medication Administration Record [REDACTED]. The following documentation, in part, is on Resident 2's PRN [MEDICATION NAME] Record/Pain Flow Sheet for October, 2016: Resident's goal for pain management: (this is blank). 10/7/16, 7p (7:00 PM), yelling, in w/c going to bed, Tram 1, 8p (8:00 PM) (result time), resting. 10/7/16, 7p, restless in w/c, [MEDICATION NAME] 1, 8p (result time), resting. 10/10/16, 7p, restless in w/c, Tram ([MEDICATION NAME]) 1, 8p (result time), resting. 10/14/16, 1920 (7:20 PM), yelling out in w/c, Tram 1, 8p, resting. 10/26/16, 0730 (AM), yelling out in w/c, tram 50 mg 1, 810 (AM) (result time), resting. 10/28/16, 830 (AM), calling out, transfer, [MEDICATION NAME] 50 mg, 1. 10/28/16, 2030 (8:30 PM), yelling transfer to bed, Tram 50 x 1, 930p (PM) (result time), resting. 10/31/16, 0750 (AM), yelling, transferring, [MEDICATION NAME] 1, 9a (AM) (result time), resting. Resident 2's November, 2016, Medication Administration Record [REDACTED]. Resident 2's medical record included, in part, the following telephone order: 9/7/16, R hip pain, post fall, R hip mobile x-ray. Resident 2's Radiology Report, dated 9/7/16, included, in part, the following: Results: The right hip joint is in alignment, but there is narrowing of the joint space due to mild [MEDICAL CONDITION] changes There is mild [MEDICAL CONDITION] spurring involving acetabular border and femoral head and neck junction. No fracture or dislocation is seen. Pubic rami are intact. Decreased [DIAGNOSES REDACTED] pattern suggested. Conclusion: Single view exam. Mild arthritis of the right hip. Correlate with CT (Computerized Tomography) for greater detail, as deemed indicated, particularly if there is ongoing concern for fracture. It is important to note there was no documentation to show there was follow up regarding the CT. Resident 2's Physician's Fax Sheets included, in part, the following: To: (Resident 2's Physician's Name) Date: 9/5/16, Situation: Resident fall unwitnessed to her buttocks while in her room. (No) pain. (No) obvious injury. Gait remains steady. Denies hitting head. (No) neuro symptoms. Physician Response/Orders: no new treatment needed. (Signed by Resident 2's physician). To: (Resident 2's Physician's Name) Date 9/8/16, Situation: Resident had a fall on pm, hip x-ray done & (negative). Resident is yelling out when moved and not walking. She currently only has an order for [REDACTED]. MD Response: 1. Low bed, mat to floor. 2. Allevyn to L (left) buttock laceration (change) every 3 days until healed. 3. [MEDICATION NAME] 50 mg 1 PO (every) 6 (hours) prn, pain. (Signed by Resident 2's physician). To: (Resident 2's physician's name). Date 9/15/16. Comments: Resident continues to yell out in pain (with) transfers after her fall last week. She use to transfer independently transfer and now uses a sit to stand. She is using 2 - 3 [MEDICATION NAME] 50 mg PRN per day. She is in a w/c (wheelchair) for transfers throughout facility. Please review and advise if any changes. (Response) obtain [MEDICATION NAME] and lumbar spine x-rays to look for compression fracture. Resident 2's Physician Visit Summary, dated 9/26/16, includes, in part, the following: History of present illness . Rapidly declining in ability to ambulate prefers to be lying in bed, moans when moved (we x-rayed hips, back, and no fracture) . Resident 2's Physical Therapy note, dated 10/11/16, included, in part, the following: Pt (patient) approached in AM, however declined therapy services. PM session: pt agreeable to amb (ambulate) with PT (Physical Therapy). When transported to therapy gym, pt declined amb or transferring. Redirecting to task with pt agreeable to amb with FWW (front wheeled walker). Pt amb 20 (feet) and 8 (feet) with FWW and CGA (care giver assist) with w/c follow and min (minimal) A (assist) for FWW management. Pt requested to sit in w/c and became agitated and began swearing/cursing when PT attempted to use hand-over-hand to locate w/c behind pt to sit. Once in sitting, pt pleasant and desired to have water. Pt amb with short, shuffling gait pattern with increased L hip external rotation. On 11/2/16 at 10:25 AM Surveyor observed Resident 2's transfer from her wheelchair to the toilet. Surveyor stood behind the curtain. Certified Nursing Assistant (CNA) J explained to Resident 2 the procedure. CNA J applied the gait belt around Resident 2's waist. CNA J and CNA I proceeded to stand Resident 2 up. Resident 2 started yelling, ow, please, God Dammit, the son-of-a [***] hurts throughout the transfer. CNA J and CNA I proceeded to transfer Resident 2 without stopping when Resident 2 was yelling and complaining of pain. CNA J asked Resident 2 if she was done, CNA J explained to Resident 2 that CNA J and CNA I would stand Resident 2 up and assist with pulling up her pants. Surveyor observed Resident 2 after she was fully clothed during the transfer. Resident 2 stated ow, it hurts. Resident 2's facial features were grimacing and pinching her eyes closed as if in pain. CNA J and CNA I completed the transfer without stopping when Resident 2 was expressing complaints of pain and discomfort. On 11/2/13 at 10:25 AM Surveyor observed Resident 2's transfer from her wheelchair to the toilet. Surveyor observed Resident 2's facial expression as panicked in a severe grimace, loudly, verbally expressing complaints of pain and discomfort, cursing, saying put me down and take that off. On 11/2/16 at 10:45 AM Surveyor interviewed CNA J. CNA J stated she did not inform the nurse of Resident 2 verbally expressing complaints of pain and discomfort. CNA J stated she did not inform the nurse because she always yells that it hurts. On 11/2/16 at 10:50 AM Surveyor interviewed CNA I. CNA I stated Resident 2 has been yelling during transfers since she fell in September, 2016. CNA I stated prior to Resident 2's falls in September, 2016, she would transfer and ambulate independently. CNA I stated Resident 2 usually yells it hurts and ow only when she is transferred or being moved. CNA I stated she did not did not inform the nurse about Resident 2 expressing complaints of pain and discomfort during the transfer. CNA I stated she does not inform the nurse as she charts it as a behavior. At 11/4/16 at 4:30 PM Surveyor observed CNA K and CNA L transfer Resident 2 from her bed to the wheelchair. CNA L asked Resident 2 if her back hurt. Resident 2 stated yes. CNA L stated OK we will sit you up slowly. CNA L and CNA K sat Resident 2 up onto the side of the bed, applied a gait belt and attempted to have Resident 2 stand. Resident 2 stated ow, oh my, had a panicked look on her face and sat back down onto the bed. Again CNA L and CNA K attempted to transfer Resident 2 into her wheelchair. Resident 2 loudly yelled ow, had a panicked look on her face and squeezed her eyes shut and sat back down onto the bed. Resident 2 stated feels like it is broke. Again CNA L and CNA K attempted to transfer Resident 2 into her wheelchair. Resident 2 stated ow, had an expression of pain, stated ow again. CNA L and CNA K transferred Resident 2 into her wheelchair. CNA K asked Resident 2 if she needed to use the bathroom. Resident 2 asked where she could pee. CNA K and CNA L wheeled Resident 2 into the bathroom. CNA K and CNA L stood Resident 2 up, Resident 2 stated ouch, just wait a minute, keep your f ------ mouth shut, Resident 2's face was grimacing and showed expressions of pain. Surveyor stepped behind the curtain. CNA K stated you are on the toilet to Resident 2. CNA L asked Resident 2 if she was done. Resident 2 stated yeah. CNA K stated she would wipe and your pants are up now. Surveyor observed the transfer after Resident 2 was fully covered. Resident 2 had a panicked look on her face stating it hurts, ouch. Resident 2 sat down into the wheelchair. CNA L removed the gait belt and assisted Resident 2 to the dining room. On 11/2/16 at 5:10 PM Surveyor interviewed CNA K. CNA K stated Resident 2's behaviors have increased since her falls in September, 2016. CNA K stated she did not know if Resident 2 was in pain or not, she can scream I hurt, ow and when she would ask Resident 2 where it hurt Resident 2 answers something else. CNA K stated she does not always tell the nurse that Resident 2 voices complaints of pain during transfers. On 11/2/16 at 5:15 PM Surveyor interviewed CNA L. CNA L stated she did not inform the nurse of Resident 2's expressing complaints of pain and discomfort during the transfer. On 11/2/16 at 5:20 PM Surveyor interviewed Licensed Practical Nurse (LPN) M. LPN M stated she was working with Resident 2. LPN M stated no staff had informed her of Resident 2 having any complaints of pain or discomfort during the current shift. LPN M stated she asked staff how the transfer went with a surveyor watching and staff told her it went fine. LPN M stated Resident 2 will yell and get combative. LPN M stated it is hard to tell what Resident 2 is doing or why as she is not interviewable due to her cognition, she yells, makes sound like ahhhh, owwww, sounds painful. LPN M stated once Resident 2 is given a [MEDICATION NAME] she seems to calm down. LPN M stated Resident 2 does not answer appropriately and it is difficult to decide if Resident 2 is in pain or if it is a behavior. LPN M stated she would expect the CNA staff to let her know when Resident 2 expresses complaints of pain and discomfort or any unusual behaviors. LPN M stated she thinks Resident 2 has pain from her falls in September, 2016; this is when the behaviors of pain started. LPN M stated she was informed by CNA N during a PM shift a week ago that Resident 2 struck her and drew blood. LPN M stated CNA N told her this happens all the time. LPN M stated the PM CNA staff does not inform her of Resident 2's behaviors on a regular basis. On 11/3/16 at 1:40 PM Surveyor interviewed LPN O. LPN O stated Resident 2 will say ow, ow, ow, during her transfers, once she is in her chair or bed then she is fine. LPN O stated she will give Resident 2 [MEDICATION NAME] and she appears to be more comfortable. On 11/3/16 at 2:45 PM Surveyor interviewed Director of Nursing (DON) B. DON B stated she would expect all staff working with Resident 2 to inform Resident 2's nurse when she is expressing complaints of pain and discomfort so Resident 2 can be properly assessed and treated if needed. DON B stated she did not know whether or not Resident 2's physician had been asked if she would like to have a CT completed as was recommended on her x-ray results since Resident 2 was still expressing complaints of pain and discomfort. DON B also stated she would expect Resident 2 to be thoroughly assessed for her pain and for Resident 2 to her pain care planned. Resident 2 has a [DIAGNOSES REDACTED]. Resident 2 is cognitively impaired and not interviewable. Since Resident 2's falls she no longer transfers and ambulates independently. Resident 2's pain was not properly assessed or care planned. Resident 2 was complaining of pain, her pain medications were being administered and the amount of the medication was being increased by Resident 2's physician upon request of the facility nursing staff. There was no documentation of follow up with Resident 2's physician as to whether or not a CT should be completed as was recommended on her x-ray results. CNA staff did not inform Resident 2's nurse that she was expressing complaints of pain and discomfort during transfers.

Based on record review and interview in 1 of 7 total residents reviewed, (Resident 23), the services provided or arranged by the facility did not meet professional standards of quality. Resident 23 wished to receive full CPR (Cardiopulmonary Resuscitation) efforts in the event of a medical emergency which would necessitate such action. The facility did not immediately initiate CPR when Resident 23 was found to have no pulse and no respirations. When the facility began CPR, they did not place the resident on a hard surface. In addition, facility staff RN did not immediately assess Resident 23 when she was informed of a significant change in condition (staff unable to obtain BP (blood pressure) or when told that the resident was convulsing. The failure to provide care in accordance with current professional standards of care, and as requested by Resident 23, negated Resident 23's only chance for survival. This created a finding of Immediate Jeopardy that began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The facility administrator was notified of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE]; severity / scope continued at an E level (potential for harm that is not immediate jeopardy/pattern) until the facility had completed all staff re - education and training to include code blue (Medical Emergency / pulseless, non breathing / immediate action required) drills daily for 2 weeks on every shift, and CPR policies and procedures. The deficient practice was corrected on [DATE]. This is evidenced by the following: Chapter N 6 Standards of Practice for Registered Nurses and Licensed Practical Nurses states: "N6.03 Standards of practice for registered nurses. (1) General Nursing Procedures. An RN shall utilize the nursing process in the execution of the general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation.... (a) Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formation of a nursing diagnosis." Circulation by the American Heart Association Part 5: Basic Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care states: "Pulse check ... The healthcare provider should take no more than 10 seconds to check for a pulse and, if the rescuer does not definitely feel a pulse within that time period, the rescuer should start chest compressions. "...To maximize the effectiveness of chest compressions, place the victim on a firm surface when possible, in a supine position with rescuer kneeling beside the victim's chest... or standing beside the bed... Hospital beds are typically not firm and some of the force intended to compress the chest results in mattress displacement rather than chest compression, we have traditionally recommended the use of a backboard despite insufficient evidence for or against use of backboards during CPR." The facility's policy and procedure for "Cardiopulmonary Resuscitation (CPR) - Basic Life Support (BLS)" dated ,[DATE], revised ,[DATE] and [DATE] states: "Unless a decision not to initiate CPR has previously been made by the resident and State guidelines are in place, CPR will be initiated on any resident that experiences a witnessed or unwitnessed cardiopulmonary arrest while in the center... Resident 23's [DIAGNOSES REDACTED]. Resident 23 was reviewed as a closed record. Resident 23's record contains 2 "(CPR) Cardiopulmonary Resuscitation Consent" forms. One of the forms, signed by Resident 23 and dated [DATE], indicates Resident 23 wishes "No Resuscitation (No cardiopulmonary Resuscitation or External Defibrillation)." The second form, signed by Resident 23 but not dated, indicates Resident 23 wishes "Resuscitation. I am expressing a desire to have CPR and / or external defibrillation performed in the event of a [MEDICAL CONDITION]. I understand that in the event of an observed or unobserved arrest, nursing staff will initiate CPR and the use of the AED (Automated External Defibrillator) device and emergency medical personnel will be called." Resident 23's record contains the following documentation: [DATE] Nurses Notes - Late entry for [DATE] by RN C "At 0030 (12:30 am) this writer notified that resident had a (sic) XL (extra large) BM (bowel movement). Was foul smelling. This writer questioned CNA (Certified Nursing Assistant) staff if it was a[DIAGNOSES REDACTED] (,[MEDICAL CONDITION]. Difficle) smell? They stated no, that it was almost a liver smell and that it was dark in color. Told CNA staff to obtain a sample of stool and that this writer would guiac it (test for blood). Samples obtained. Performed 2 guiacs. Both were neg (negative) for blood. Assessed resident. LS (lung sounds) clear Bil (bilaterally). BS (Bowel sounds) were hypoactive after BM. Resident stated at that time 0030 (12:30 am) that she was having back pain. Resident repositioned; pain med (medication) given at this time. Resident able to swallow pill whole with H2O (water). Drsg (Dressing) to R (right) hip D&I (dry & intact). (No) drainage noted at this time. "0115 (1:15 am) - 0130 (1:30 am) - While charting this writer noted BP low ,[DATE]. Asked staff to retake BP. Unable to obtain. Call placed to (on call) (Physician's name). Reported BP low earlier and now unobtainable. Informed on call resident was [MEDICAL TREATMENT] patient and was lethargic at [MEDICAL TREATMENT] per family. Orders received to send resident to ER (emergency room )." (Note: According to the physician's telephone order, this occurred at 1:15 AM.) "Staff then reported to this writer resident unresponsive and twitching, possible [MEDICAL CONDITION]. On way to room CNA staff then reported she felt she (Resident 23) had passed. This writer asses (sic) pt (patient) again. (No) carotid pulse; (no) apical pulse. Not breathing. (No) LS; (No) BS present. All extremities cold to touch. Call placed to DON (Director of Nursing). Instructed to start CPR and call 911." (Note: According to CNA E's interview and timecard, this would have been at approximately 1:45 AM.) "Call placed to 911." (Note: According to the police record, below, this call was made at 1:56 AM.) " Resident a full code. CPR initiated (with) the aid of another floor nurse. AED applied at this time. AED stated not to shock at this time. Continued CPR until EMT (Emergency Medical Technician) (EMS) (Emergency Medical Service) arrived. EMT's (sic) lowered resident to the floor; took over CPR; applied pads for monitor. Started IV (intravenous) line for liquids and access for medication. O2 (oxygen) also applied. EMT worked for over 30 min (minutes) initiating CPR and meds. (No) palpable pulse or sinus rhythm obtained on monitor. Resident shocked also x 2. Called placed to (Physician) by EMT to call code. Code called. Coroner notified of death because of fall within last 6 wks...." Resident 23's record contains a Physician Telephone Order dated [DATE] at 1:15 am which states: "Declining status: Send to ER" Interview RN C On [DATE] at 10:15 am Surveyor spoke with RN (Registered Nurse) C via telephone. RN C was the nurse caring for Resident 23 in the early morning hours of [DATE] and the author of the above late entry for [DATE]. Surveyor asked RN C to describe the events of those morning hours of [DATE], and the incident with Resident 23. RN C stated she had been in to see Resident 23 in the very early morning hours (around 12:30 am on [DATE]) and gave her a pain medication. RN C stating "she (Resident 23) was fine." RN C stated that while she was charting she noted that Resident 23's BP had been recorded as low. RN C stated she asked facility staff to recheck Resident 23's BP, but they were unable to obtain a BP. Surveyor asked RN C if she went to assess Resident 23 after she had been informed that a BP was unobtainable. RN C stated she did not go down to check Resident 23, but immediately called the on call physician to report the situation, stating she wanted to "get things started" (initiate the transfer process). RN C stated she obtained an order to send Resident 23 to the ER. RN C stated she then went down to Resident 23's room, but on the way down the CNAs told her "she (Resident 23) had gone." RN C told Surveyor she went into the room and found Resident 23 to be "ice cold" with no pulses. RN C stated she then went to the chart and noted Resident 23 to be a full code. RN C stated she then called the DON (Director of Nursing) to see what to do. Surveyor asked RN C why she did not immediately begin CPR. RN C stated "I didn't know ... She was ice cold ... she had been away (in the hospital) ... I didn't know." RN C stated when DON B instructed her to begin CPR she went down to Resident 23's room and started CPR. RN C stated she (with the assistant from other staff) performed CPR on Resident 23 until EMS arrived. Surveyor asked RN C if Resident 23 was on a hard surface while CPR was being performed. RN C stated it was "a regular mattress." Surveyor asked RN C if she had concerns that Resident 23 was not on a hard surface while CPR was being performed. RN C stated "I didn't know. There was so much confusion." Interview CNA D On [DATE] at 10:47 am Surveyor spoke with CNA D. CNA D was working the early morning hours of [DATE] and assisted in the care of Resident 23 that shift. Surveyor asked CNA D to describe the events of [DATE] and the incident with Resident 23. CNA D stated she was the float CNA during the early morning hours of [DATE]. CNA D stated CNA E had gone on break and she was covering for her. CNA D told Surveyor RN C asked her to recheck a blood pressure on Resident 23. CNA D stated she took the mechanical blood pressure machine to Resident 23's room. CNA D stated Resident 23 was "confused but talking". CNA D told Surveyor she was unable to get a BP with the mechanical machine so she went to get equipment for a manual check. CNA D told Surveyor when she did return to Resident 23's room she found Resident 23 to be convulsing. CNA D stated she went back to the desk and told RN C who stated that Resident 23 would be sent out (to the ER). Surveyor asked CNA D if RN C went to Resident 23 to assess her. CNA D stated RN C did not go to Resident 23 at this time. CNA D stated she (CNA D) went to get a sliding board and returned to Resident 23's room to prepare Resident 23 for the eminent transfer to ER. CNA D stated while she (CNA D) was arranging the furniture (making room for the ambulance stretcher that was coming) Resident 23 stopped convulsing, took a deep breath, and then stopped breathing. CNA D told Surveyor she went to tell RN C Resident 23 was no longer breathing. CNA D stated she found RN C at the copy machine making copies (for the transfer). CNA D stated she told RN C that Resident C was no longer breathing and together they went to Resident 23's room. CNA D told Surveyor that this was the first time RN C came down to Resident 23's room since CNA D had reported to RN C the difficulty in getting Resident 23's BP. CNA D stated RN C listened for a heartbeat but found none. CNA D stated RN C instructed her to go to the chart and check if Resident 23 was a code. CNA D stated she could not find this information in the chart and went to report this to RN C. CNA D told Surveyor that she and RN C both went back to the nurses' station (leaving Resident 23 alone in her room) and found Resident 23's CPR information in the copy machine. CNA D stated Resident 23 was a full code, but the form was not dated. CNA D stated RN C "didn't know what to do". CNA D stated: "I asked if I should get the crash cart. She (RN C) said 'no'. I asked if I should get the AED. She said 'no'. I asked if I should get the other nurse. She said 'no'." CNA D stated at this time RN C "called (DON B). She had to leave a message... He called back in about 5 minutes.... She told him (DON B) she (Resident 23) was a full code but the form was not dated. He (DON B) told her (RN C) to start CPR, so we all went down." CNA D stated when the AED was placed on Resident 23 it said not to shock so CPR was begun by the nurses. CNA D stated she asked if they should put Resident 23 on the floor (for a hard surface) but RN C stated 'no'. CNA D stated the nurses did CPR until the EMS came and the first thing they did was put her on the floor. Interview DON B On [DATE] at 10:54 am Surveyor spoke with DON B regarding the events of [DATE] and Resident 23. Surveyor asked DON B to describe his involvement in the events of the early morning hours of [DATE], and the incident with Resident 23. DON B stated he received a phone call from RN C "letting me know that a resident had passed." DON B stated that when RN C told him she (Resident 23) was a full code "I asked her (RN C) if she had done CPR. When she told me 'No' I told her to start (CPR)." DON B could not recall at what time this occurred. Surveyor asked DON B when the CPR / DNR form is signed by residents. DON B stated the form is signed when a resident first comes into the facility. DON B could not explain the undated form and did not know who presented the form to Resident 23. On [DATE] at 10:35 am Surveyor asked DON B what he would have expected facility staff to do when they discovered Resident 23 to be pulseless and non - breathing. DON B told Surveyor that he would have expected staff to "begin CPR and then call me afterwards with an update. Call the doctor to update afterwards as well." Interview RN F On [DATE] at 12:45 pm Surveyor spoke with RN F via telephone. RN F was working the early morning hours of [DATE] on the opposite wing as RN C. RN F did assist in performing CPR on Resident 23. Surveyor asked RN F to describe her involvement in the events of ,[DATE] and the incident with Resident 23. RN F stated when she entered Resident 23's room they had not yet started CPR. RN F stated Resident 23 had no pulse and was not breathing, CPR was initiated. RN F could not recall at what time this took place. Surveyor asked where Resident 23 was when CPR was being performed. RN F stated Resident 23 was on the bed until the paramedics came, at which time they (EMTs) placed Resident 23 on the floor. Surveyor asked RN F if she had concerns that CPR was not being performed on a hard surface. RN F stated: "We did have a slid board. At one time we had 2 (slide boards). I'm not sure where they came from but at first, no we did not have one." Interview CNA E On [DATE] at 12:57 pm Surveyor spoke with CNA E. CNA E was working the early morning hours of [DATE]. Surveyor asked CNA E to describe her involvement the events of [DATE] and the incident with Resident 23. CNA E stated: "About 1:55 am I was coming back from break. RN C was on the phone talking to (DON B). She (RN C) filled me in and I went to get (RN F). (CNA D) went to get the AED and crash cart. (RN C) called 911... EMS took over at about 2:00 am." Surveyor asked CNA E if Resident 23 was on a hard surface when CPR was being performed. CNA E stated that the EMS put Resident 23 on the floor. CNA E stated: "The police were the first to be here and he asked if there was anything hard." CNA E stated the EMS then came and placed Resident 23 on the floor. (Please note, time sheets documenting the time CNA E returned from her break on [DATE] indicate CNA E clocked back in from break at 1:45 am on [DATE].) City Police Records The City's Police Department Report documents that the incident was reported to them on [DATE] at 1:56 am. This report goes on to document: 1:57 am: "pnb (pulseless non - breathing) - cpr in progress by staff..." 2:30 am: "advising cpr stop" 2:36 am: "called the on call..." 3:50 am: "(Resident 23) passed after suffering a believed [MEDICAL CONDITION]. Coroner (Name) was paged..." Interview RN Manager G On [DATE] at 3:15 pm Surveyor spoke with RN Manager G regarding Resident 23's undated CPR consent form. RN Nurse Manager G stated Resident 23 was re-admitted on [DATE] and he (RN Manager G) had reviewed / completed Resident 23's CPR consent with her upon readmission on [DATE]. RN Manager G stated: "I should have dated it." RN Manager G went on to state that if a resident is gone from the facility for greater than 24 hours all assessments are re - done including the CPR consent. The facility was aware Resident 23 had been readmitted to the facility on [DATE] and another CPR consent was completed by Resident 23 albeit undated, at that time. This created confusion due to the presence of 2 CPR consent forms in the chart: one requesting DNR (dated [DATE]), and one requesting CPR (undated). Contrary to professional standards of practice, the nurse did not assess Resident 23 when told that the resident was convulsing. RN C did not immediately initiate CPR when Resident 23 was found to be pulseless and no - breathing, but left Resident 23 alone in her room, taking the time to place a call to the DON for guidance and then wait five minutes for a response. When CPR was first initiated a hard surface was not utilized. According to the American Heart Association ' s Chain of Survival, the chances for survival decrease ,[DATE]% for each minute that CPR is delayed following a sudden [MEDICAL CONDITION]. Brain damage can occur within ,[DATE] minutes. After 10 minutes of delay, " few attempts at resuscitation succeed. " <http://www.chainofsurvival.com/cos/Timing_detail.asp> The failure to follow professional standards of practice within the timeframe and manner described created a finding of Immediate Jeopardy. The facility removed the Immediate Jeopardy on [DATE] when: *A full house audit was completed to ensure all residents had a completed and accurate CPR Consent form in their medical record. *Re education and training was initiated to all nursing staff. The deficiency was corrected on [DATE] by which time: *The facility completed code blue drills on every shift for 2 weeks with different scenarios to assure staff react properly. Just in time education done if any breaks in following policy and procedure. *All center nursing staff were re - educated on CPR policy and procedures. after the facility reviewed all residents' charts to ensure accurate and completed CPR / DNR (Do Not Resuscitate) advanced directives, and began inservicing staff on policies and procedures of CPR.

Based on record review and interview in 1 of 7 total residents reviewed (Resident 23), the facility did not ensure that each resident received, and the facility provided, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident 23 wished to receive full CPR (Cardiopulmonary resuscitation) efforts in the event of a medical emergency which would necessitate such action. The facility did not immediately initiate CPR when Resident 23 was found to have no pulse and no respirations. There was approximately a 15-minute delay between the time staff found the resident pulseless and non-breathing and when staff began CPR. When CPR was started, staff did not ensure that the resident was on a hard surface. The failure to provide the care needed by Resident 23 as requested negated Resident 23's only chance for survival. This created a finding of Immediate Jeopardy that began on [DATE]. The Immediate Jeopardy was identified on [DATE]. The facility administrator was notified of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE] Severity / scope continued at an E level (potential for harm that is not immediate jeopardy/pattern) until the facility had completed all staff re - education and training to include code blue (Medical Emergency / pulseless, non-breathing - immediate action required) drills daily for 2 weeks on every shift, and CPR policies and procedures. The facility was corrected on [DATE]. This is evidenced by the following: The facility's policy and procedure for "Cardiopulmonary Resuscitation (CPR) - Basic Life Support (BLS)" dated ,[DATE], revised ,[DATE] and ,[DATE] states: "... at least one CPR - certified staff member(s) will be on duty 24 hours a day, 7 days per week.... "Unless a decision not to initiate CPR has previously been made by the resident and State guidelines are in place, CPR will be initiated on any resident that experiences a witnessed or unwitnessed cardiopulmonary arrest while in the center..." "The (CPR) Cardiopulmonary Resuscitation Consent will: Be presented to each resident / or legal representative upon admission... Be presented to the resident / or legal representative if they change their original CPR choice." Resident 23's [DIAGNOSES REDACTED]. Resident 23 was reviewed as a closed record. Resident 23's record contains 2 "(CPR) Cardiopulmonary Resuscitation Consent" forms. One of the forms, signed by Resident 23 and dated [DATE], indicates Resident 23 wishes "No Resuscitation (No cardiopulmonary Resuscitation or External Defibrillation)." The second form, signed by Resident 23 but not dated, indicates Resident 23 wishes "Resuscitation. I am expressing a desire to have CPR and / or external defibrillation performed in the event of a [MEDICAL CONDITION]. I understand that in the event of an observed or unobserved arrest, nursing staff will initiate CPR and the use of the AED (Automated External Defibrillator) device and emergency medical personnel will be called." Resident 23's record contains the following documentation: [DATE] Nurses Notes - Late entry for [DATE] "At 0030 (12:30 am) this writer notified that resident had a (sic) XL (extra large) BM (bowel movement). Was foul smelling. This writer questioned CNA (Certified Nursing Assistant) staff if it was a[DIAGNOSES REDACTED] ([MEDICAL CONDITION]) smell? They stated no, that it was almost a liver smell and that it was dark in color. Told CNA staff to obtain a sample of stool and that this writer would guiac it (test for blood). Samples obtained. Performed 2 guiacs. Both were neg (negative) for blood. Assessed resident. LS (lung sounds) clear Bil (bilaterally). BS (Bowel sounds) were hypoactive after BM. Resident stated at that time 0030 (12:30 am) that she was having back pain. Resident repositioned; pain med (medication) given at this time. Resident able to swallow pill whole with H2O (water). Drsg (Dressing) to R (right) hip D&I (dry & intact). (No) drainage noted at this time." "0115 (1:15 am) - 0130 (1:30 am) - While charting this writer noted BP (blood pressure) low ,[DATE]. Asked staff to retake BP. Unable to obtain. Call placed to (on call) (Physician's name). Reported BP low earlier and now unobtainable. Informed on call resident was [MEDICAL TREATMENT] patient and was lethargic at [MEDICAL TREATMENT] per family. Orders received to send resident to ER (emergency room ). Staff then reported to this writer resident unresponsive and twitching, possible [MEDICAL CONDITION]. On way to room CNA staff then reported she felt she (Resident 23) had passed. This writer asses (sic) pt (patient) again. (No) carotid pulse; (no) apical pulse. Not breathing. (No) LS; (No) BS present. All extremities cold to touch. Call placed to DON (Director of Nursing). Instructed to start CPR and call 911." "Call placed to 911. Resident a full code. CPR initiated (with) the aid of another floor nurse. AED applied at this time. AED stated not to shock at this time. Continued CPR until EMT (Emergency Medical Technician) (EMS) (Emergency Medical Service) arrived. EMT's (sic) lowered resident to the floor; took over CPR; applied pads for monitor. Started IV (intravenous) line for liquids and access for medication. O2 (oxygen) also applied. EMT worked for over 30 min (minutes) initiating CPR and meds. (No) palpable pulse or sinus rhythm obtained on monitor. Resident shocked also x 2. Called placed to (Physician) by EMT to call code. Code called. Coroner notified of death because of fall within last 6 wks...." Resident 23's record contains a Physician Telephone Order dated [DATE] at 1:15 am which states: "Declining status: Send to ER" Interview RN C On [DATE] at 10:15 am Surveyor spoke with RN (Registered Nurse) C via telephone. RN C was the nurse caring for Resident 23 in the early morning hours of [DATE] and the author of the above referenced late entry note for [DATE]. Surveyor asked RN C to describe the events of those morning hours of [DATE], and the incident with Resident 23. RN C stated she had been in to see Resident 23 in the very early morning hours (around 12:30 am on [DATE]) and gave her a pain medication. RN C stating "she (Resident 23) was fine." RN C stated that while she was charting she noted that Resident 23's BP had been recorded as low. RN C stated she asked facility staff to recheck Resident 23's BP, but they were unable to obtain a BP. Surveyor asked RN C if she went to assess Resident 23 after she had been informed that a BP was unobtainable. RN C stated she did not go down to check Resident 23, but immediately called the on call physician to report the situation, stating she wanted to "get things started" (initiate the transfer process). RN C stated she obtained an order to send Resident 23 to the ER. RN C stated she then went down to Resident 23's room, but on the way down the CNAs told her "she (Resident 23) had gone." RN C told Surveyor she went into the room and found Resident 23 to be "ice cold" with no pulses. RN C stated she then went to the chart and noted Resident 23 to be a full code. RN C stated she then called the DON (Director of Nursing) to see what to do. Surveyor asked RN C why she did not immediately begin CPR. RN C stated "I didn't know ... She was ice cold ... she had been away (in the hospital) ... I didn't know." RN C stated when DON B instructed her to begin CPR she went down to Resident 23's room and started CPR. RN C stated she (with the assistant from other staff) performed CPR on Resident 23 while she was in bed until EMS arrived. Surveyor asked RN C if Resident 23 was on a hard surface while CPR was being performed. RN C stated it was "a regular mattress." Surveyor asked RN C if she had concerns that Resident 23 was not on a hard surface while CPR was being performed. RN C stated "I didn't know. There was so much confusion." Interview CNA D On [DATE] at 10:47 am Surveyor spoke with CNA D. CNA D was working the early morning hours of [DATE] and assisted in the care of Resident 23 that shift. Surveyor asked CNA D to describe the events of [DATE] and the incident with Resident 23. CNA D stated she was the float CNA during the early morning hours of [DATE]. CNA D stated CNA E had gone on break and she was covering for her. CNA D told Surveyor RN C asked her to recheck a blood pressure on Resident 23. CNA D stated she took the mechanical blood pressure machine to Resident 23's room. CNA D stated Resident 23 was "confused but talking." CNA D told Surveyor she was unable to get a BP with the mechanical machine so she went to get equipment for a manual check. CNA D stated on the way to get the equipment she asked RN C if Resident 23 has been confused. CNA D stated RN C told her that Resident 23 had been confused since she returned from the hospital. CNA D stated as she returned to Resident 23's room with the BP equipment she (CNA D) responded to a call light and toileted one of the other residents. CNA D told Surveyor when she did return to Resident 23's room she found Resident 23 to be convulsing. CNA D stated she went back to the desk and told RN C who stated that Resident 23 would be sent out (to the ER). Surveyor asked CNA D if RN C went to Resident 23 to assess her. CNA D stated RN C did not go to Resident 23 at this time. CNA D stated she (CNA D) went to get a sliding board and returned to Resident 23's room to prepare Resident 23 for the eminent transfer to ER. CNA D stated while she (CNA D) was arranging the furniture (making room for the ambulance stretcher that was coming) Resident 23 stopped convulsing, took a deep breath, and then stopped breathing. (This was at approximately 1:30 AM.) CNA D told Surveyor she went to tell RN C Resident 23 was no longer breathing. CNA D stated she found RN C at the copy machine making copies (for the transfer). CNA D stated she told RN C that Resident C was no longer breathing and together they went to Resident 23's room. CNA D told Surveyor that this was the first time RN C came down to Resident 23's room since CNA D had reported to RN C the difficulty in getting Resident 23's BP. CNA D stated RN C listened for a heartbeat but found none. CNA D stated RN C instructed her to go to the chart and check if Resident 23 was a code. CNA D stated she could not find this information in the chart and went to report this to RN C. CNA D told Surveyor that she and RN C both went back to the nurses' station (leaving Resident 23 alone in her room) and found Resident 23's CPR information in the copy machine. CNA D stated Resident 23 was a full code, but the form was not dated. CNA D stated RN C "didn't know what to do." CNA D stated: "I asked if I should get the crash cart. She (RN C) said 'no'. I asked if I should get the AED. She said 'no'. I asked if I should get the other nurse. She said 'no'." CNA D stated at this time RN C "called (DON B). She had to leave a message... He (DON B) called back in about 5 minutes.... She (RN C) told him (DON B) she (Resident 23) was a full code but the form was not dated. He (DON B) told her (RN C) to start CPR, so we all went down." (According to CNA E ' s interview, below, DON B was on the phone when CNA E returned from break. According to CNA E ' s timecard, this was at 1:45 AM, around 15 minutes since CNA D had stated the Resident 23 had taken her last breath.) CNA D stated when the AED was placed on Resident 23 it said not to shock so CPR was begun by the nurses. CNA D stated she asked if they should put Resident 23 on the floor (for a hard surface) but RN C stated 'no'. CNA D stated the nurses did CPR until the EMS came and the first thing they did was put Resident 23 on the floor. Interview DON B On [DATE] at 10:54 am Surveyor spoke with DON B regarding the events of [DATE] and Resident 23. Surveyor asked DON B to describe his involvement in the events of the early morning hours of [DATE], and the incident with Resident 23. DON B stated he received a phone call from RN C "letting me know that a resident had passed." DON B stated that when RN C told him she (Resident 23) was a full code "I asked her (RN C) if she had done CPR. When she told me 'No' I told her to start (CPR)." DON B could not recall at what time this occurred. Surveyor asked DON B when the CPR / DNR form is signed by residents. DON B stated the form is signed when a resident first comes into the facility. DON B could not explain the undated form and did not know who presented the form to Resident 23. On [DATE] at 10:35 am Surveyor asked DON B what he would have expected facility staff to do when they discovered Resident 23 to be pulseless and non - breathing. DON B told Surveyor that he would have expected staff to "begin CPR and then call me afterwards with an update. Call the doctor to update afterwards as well." Interview RN F On [DATE] at 12:45 pm Surveyor spoke with RN F via telephone. RN F was working the early morning hours of [DATE] on the opposite wing as RN C. RN F did assist in performing CPR on Resident 23. Surveyor asked RN F to describe her involvement in the events of ,[DATE] and the incident with Resident 23. RN F stated CNA E "got me from the opposite end of the building. I was in another room. She said she would take over for me because (RN C) needs me to do CPR. I quickly went (to Resident 23's room)." RN F stated when she entered Resident 23's room they had not yet started CPR. RN F stated Resident 23 had no pulse and was not breathing, CPR was initiated. RN F could not recall at what time this took place. Surveyor asked where Resident 23 was when CPR was being performed. RN F stated Resident 23 was on the bed until the paramedics came, at which time they (EMTs) placed Resident 23 on the floor. Surveyor asked RN F if she had concerns that CPR was not being performed on a hard surface. RN F stated: "We did have a slid board. At one time we had 2 (slide boards). I'm not sure where they came from but at first, no we did not have one." Interview CNA E On [DATE] at 12:57 pm Surveyor spoke with CNA E. CNA E was working the early morning hours of [DATE]. Surveyor asked CNA E to describe her involvement the events of [DATE] and the incident with Resident 23. CNA E stated: "About 1:55 am I was coming back from break. RN C was on the phone talking to (DON B). She (RN C) filled me in and I went to get (RN F). (CNA D) went to get the AED and crash cart. (RN C) called 911. I went down to (Resident 23's) room when I was done with (taking care of) the other residents.... EMS took over at about 2:00 am." Surveyor asked CNA E if Resident 23 was on a hard surface when CPR was being performed. CNA E stated that the EMS put Resident 23 on the floor. CNA E stated: "The police were the first to be here and he asked if there was anything hard." CNA E stated the EMS then came and placed Resident 23 on the floor. (Please note, time sheets documenting the time CNA E returned from her break on [DATE] indicate CNA E clocked back in from break at 1:45 am on [DATE].) The City's Police Department Report documents that the incident was reported to them on [DATE] at 1:56 am. This report goes on to document: 1:57 am: "pnb (pulseless non - breathing) - cpr in progress by staff..." 2:30 am: "advising cpr stop" 2:36 am: "called the on call..." 3:50 am: "(Resident 23) passed after suffering a believed [MEDICAL CONDITION]. Coroner (Name) was paged..." Interview RN Manager G On [DATE] at 3:15 pm Surveyor spoke with RN Manager G regarding Resident 23's undated CPR consent form. RN Nurse Manager G stated Resident 23 was re-admitted on [DATE] and he (RN Manager G) had reviewed / completed Resident 23's CPR consent with her upon readmission on [DATE]. RN Manager G stated: "I should have dated it." RN Manager G went on to state that if a resident is gone from the facility for greater than 24 hours all assessments are re - done including the CPR consent. The facility was aware Resident 23 had been readmitted to the facility on [DATE] and another CPR consent was completed by Resident 23, albeit undated. This created confusion due to the presence of 2 CPR consent forms in the chart (on requesting DNR (dated [DATE]) and one requesting CPR (undated). The facility did not immediately initiate CPR when Resident 23 was found to be pulseless and non - breathing, but left Resident 23 alone in her room, taking the time to place a call to the DON for guidance. According to the American Heart Association ' s Chain of Survival, the chances for survival decrease ,[DATE]% for each minute that CPR is delayed following a sudden [MEDICAL CONDITION]. Brain damage can occur within ,[DATE] minutes. After 10 minutes of delay, " few attempts at resuscitation succeed. " <http://www.chainofsurvival.com/cos/Timing_detail.asp> The failure to immediately begin CPR created a finding of immediate jeopardy. The facility removed the Immediate Jeopardy on [DATE] when: *A full house audit was completed to ensure all residents had a completed and accurate CPR Consent form in their medical record. *Re education and training was initiated to all nursing staff. The deficiency was corrected on [DATE] when: *The facility completed code blue drills on every shift for 2 weeks with different scenarios to assure staff react properly. Just in time education done if any breaks in following policy and procedure. *All center nursing staff were re - educated on CPR policy and procedures.

Based on record review and interview the facility did not immediately consult with the resident's physician and notify the resident's legal representative when there was a significant change in the resident's physical status or a need to alter treatment significantly for 2 of 12 residents (Residents 1 and 3). Resident 1, who is a diabetic and who, subsequently, is at risk for significant complications from injuries to her feet, had a significant change in her toe/foot when redness and swelling were noted. Resident 1's physician was not immediately consulted regarding this significant condition change and the need to change treatment. The physician was not consulted until three days later, by which time the resident had developed [MEDICAL CONDITION] and had [MEDICAL CONDITION] infection. In lieu of surgery or ampution, the resident's family elected conservative treatment and, subsequently, hospice care. Following the resident's return to the facility, Resident 1's power of attorney and physician were not notified when another necrotic area was later noted on Resident 1's foot. The failure to notify Resident 1's physician about the change in condition of her toe created a finding of Immediately Jeopardy. The Immediate Jeopardy began on 4/11/13. The NHA was notified of the Immediate Jeopardy on 5/2/13 at 1:30 PM. The Immediate Jeopardy was removed on 5/2/13 but the deficiency continues at a scope/severity of G (actual harm that is not immediate jeopardy/isolated) based on the additional example below. Resident 3 receives blood thinning medications. Resident 3 was observed to have blood in the catheter bag of urine. The facility did not consult with Resident 3's physician regarding this change. Additionally, Resident 3's physician was not consulted for 10 days after the discovery of a change in the range of motion to her foot, which was subsequently diagnosed as a [MEDICATION NAME] fracture. This is evidenced by the following: The facility's policy for "Notification of Resident Change in Condition," revised July 2011 indicates to follow AMDA (American Medical Directors Association) for determining if a change in the resident's condition is critical. Procedures include: 2. Notify the physician and family or legal representative immediately if there is a significant change in condition... b. Contact the Medical Director if unable to contact attending physician or on-call physician. Example 1 Resident 1's [DIAGNOSES REDACTED]. According to the article "Complications of [MEDICAL CONDITION] in Diabetic Foot Infections," "Patients with diabetes have a 30-fold higher risk of lower-extremity amputation due to infection compared with patients without diabetes." This article also notes that "Diabetic foot infections that are not appropriately treated because of delayed [DIAGNOSES REDACTED]." http://www.medscape.com/viewarticle/ 0>. Resident 1's nursing notes include the following documentation (note all documentation by Licensed Practical Nurses): -4/6/13 Resident 1 was noted with a new open area on her left foot second digit. The physician was notified and a treatment was obtained. -4/11/13 at 10:00 PM Resident 1's open area on the left foot is not improving. Area is red and swollen but no warmth noted. Serosanguinous drainage noted. Physician faxed (even though office was closed) will call on 4/12/13. -4/12/13 at 10:00 PM attempted to call resident 1's physician and left voicemail. Relayed information to nurse that Nurse Practitioner Z had requested. Still no phone call back was told would receive call by the end of the day with new orders still never received new orders for the treatment. Will continue to monitor resident. Surveyor interviewed NP Z regarding Resident 1 on 5/1/13, at 2:26 PM. NP Z stated she would expect the facility to contact her or the physician anytime an open area is getting worse. NP Z reviewed the communication log form 4/12/13 and stated there was a communication break when the facility had called and she requested additional information. NP Z stated if the facility would have called on 4/12/13 with the red foot and swelling she would have instructed them to have Resident 1 seen in the clinic if possible or have sent her to the emergency room . -4/13/12 Treatment to Resident 1's left foot second digit completed. "Toe red, swollen, slightly warm, scant serosang (Serosanguinous) drainage, agitated when touched." On 4/14/13 a physician communication and progress note was completed for Resident 1 indicating the following: Calling about Resident 1 left foot second digit infection. Problem is worse. Red, warm, swollen, moderate amount of purulent drainage, +3 [MEDICAL CONDITION] to foot. Open area to Resident 1's second digit on left foot swollen, warm, red. Area larger than noted with last dressing change. Serosanguinous purulent drainage present with foul odor. Most of foot also red, swollen warm, +3 [MEDICAL CONDITION]. Noncommunicable but appears to have pain when area touched. Order to send to emergency room . The emergency room note, dated 4/14/13 at 1:10 PM, indicates Resident 1 was evaluated for left foot [MEDICAL CONDITION] and given [MEDICATION NAME] 900 mg IV (intravenous). Blood cultures were done. Plan to continue [MEDICATION NAME] 300 mg by mouth three times a day for 10 days. Resident 1 cultures came back positive [MEDICAL CONDITIONS]. Resident 1's family elected conservative treatment instead of surgery/amputation and, on 4/19/13, elected hospice care. On 5/1/13, at approximately 9:45 AM, Surveyor interviewed Director of Nursing (DON) B and Unit Manager I regarding contacting a physician. DON B stated a physician is notified the same day with any new open areas and with any changes or if getting worse. DON B confirmed that if redness or swelling is noted the physician should be contacted due to the possibility of an infection. DON B reviewed Resident 1's nursing notes and stated he would have expected the physician to have been called on 4/11/13 with the redness, swelling and drainage. Unit Manager I stated if they cannot get a hold of the physician she would expect them to be persistent and call the Unit Manager and if needed the Medical Director would be contacted. Resident 1's nursing notes on 4/28/13 by LPN O include: Left foot open area second digit painted with [MEDICATION NAME] per order. Toe is black and necrotic. Necrotic area is also noted to left great toe on the medial aspect measures 1.8 cm by 1 cm. There is no indication the physician was updated on this new area. On 5/1/13, at 5:42 PM, Surveyor interviewed LPN O. LPN O confirmed she performed the treatment to Resident 1 on 4/28/13. LPN O stated the black area on Resident 1's bunion had been there a while about a week. LPN O stated when she noticed it she reported it to the Hospice staff that was in the building and that staff member stated she would report it to the Hospice nurse. LPN O stated the bunion area is the area she was referring to in her notes when she indicated the medial side of the foot and misdocumented it. There is no indication Resident 1's physician or power of attorney for health car was updated on the new necrotic area or when the areas on the toes appeared. On 5/1/13, at 10:30 AM, Surveyor observed Registered Nurse (RN) Y perform the treatment to Resident 1's toe. When RN Y removed Resident 1's heel lift boot Surveyor noted a necrotic area about the size of a nickel on the outside/bunion area of Resident 1's left great toe. Surveyor also noted pinpoint areas on each toe and 3 on the outside along the pinky toe. There was no documentation of these areas. The failure to immediately consult with a physician regarding a condition change that can be signficant for a diabetic created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 5/2/13 when they developed and began instituting the following plan: All residents (including Resident 1) with a skin alterations/wounds will have an appropriate assessment and care plan to prevent infection, prevent wound deterioration, prevent new wounds from developing and promote wound healing. -Resident 1's skin will be assessed by an RN, physician notified of assessment appropriate treatment and care plan will be updated. -RN staff will complete a skin assessment for all residents to ensure all skin alterations have been identified and appropriate care plan/treatment is in place (Skin Sweep). Any concerns will be assessed, MD called, Care plan updated and appropriate treatment order in place. -Licensed nursing staff will be re-educated on the center's policy and procedures for wound prevention and treatment (to include:wound assessment, notification of physician of new wounds or change, appropriate treatments, care plan creation/implementation, wound prevention and management) -Licensed will complete a weekly skin check to monitor for new wounds and/or changes in existing wounds that would warrant MD notification or treatment change. (any concerns identified will be addressed by the he DON in daily clinical meetings) Wound certified nurse will do weekly wound rounds to measure and assess wounds. All wounds will be monitored by facility policy and procedures. -DON or designee along with IDT team will monitor for weekly skin assessment completion, weekly wound rounds completed by an RN, physician notification, RN assessment and appropriate treatment. Any concerns identified will be addressed. -DON or designee will audit 5 charts with wounds weekly for the next 12 weeks to ensure that the policy and procedures for wounds is being followed. The DON or designee will review the results of these audits at the QPI meeting and the QPI committee will make recommendations. Cross reference F 309 Example 2 According to State of Wisconsin, Department of Health Services DQA Memo 08-002, (March 4, 2008), "...Monitoring Beyond INR: Besides monitoring for INR, facility staff can monitor for signs and symptoms of bleeding. Those symptoms include bruising, bleeding from the gums during teeth brushing, blood in the stool, sudden onset confusion that may indicate bleeding in the brain, or recent changes in breathing patterns or sounds that may indicate bleeding in the lungs. These symptoms need to be reported to the physician and addressed quickly as they may be an indication that [MEDICATION NAME] has become toxic. [MEDICATION NAME] can be a lifesaving medication; it can also be life threatening. Residents and patients rely upon the caregivers and other members of the interdisciplinary team to make sure [MEDICATION NAME] monitoring is conducted to minimize or prevent negative outcomes related to [MEDICATION NAME] use..." The facility uses the Interact (Interventions to Reduce Acute Care Transfers) (2010) as a tool to manage changes in condition. This document states the following regarding reporting a hematuria: "...Non Immediate (Notify the attending or on-call on the next work day): New onset blood-tinged urine without fever or other signs of bleeding..." Resident 3's April, 2013 "physician's orders [REDACTED]." During an observation of cares on 4/29/13 at 3:07 PM, Surveyor noted that Resident 3's urinary catheter bag was filled with urine that was red (blood) color. Certified Nursing Assistant (CNA) C and CNA R assisted Resident 3 with cares. Surveyor spoke with CNA C on 4/29/13 at 4:10 PM. CNA C stated that (Resident 3's) urine "does that." CNA C also stated that she does not know if this was a new symptom or not. Surveyor asked if she had told any nurse about this. CNA C stated that she had not done so. Surveyor next spoke with CNA R. CNA R stated that she thinks it is from when they put a new catheter in. CNA R stated that she had not spoken to anyone yet about this. "Progress Notes" dated 4/29/13 state, "0530 (5:30 AM)...F/C (Foley catheter) patent et (and) draining dk (dark) amber color urine...1400 (2:00 PM)...Tx (treatment) to perirectal ulcer done per MD order...Foley patent draining dark, amber urine; encouraged resident to drink more fluids..." "Progress Notes" dated 4/30/13 state, "F. Catheter patent resident encouraged to drink more. Urine dark amber in color..." The facility did not have evidence that a physician was consulted with regarding Resident 3's noted red-colored urine. Surveyor spoke with Director of Nursing (DON) B on 5/1/13 at 8:20 AM. DON B stated that staff should check the resident and let their supervisors know about it. DON B stated that next the medical record would be checked and medications would be reviewed. DON B stated that there would be questions about labs and consultation with the physician. Surveyor informed DON B of the observations and noted lack of reaction by the facility. Example 3 The facility completed a "Misconduct Incident Report" in relation to Resident 3's unknown source of fracture to the distal tibia/fibula. This report states the following: "...On Sunday, October 21, 2012 (Certified Nursing Assistant (CNA) JJ) went into resident room to get (Resident 3) up. (CNA JJ) started to dress (Resident 3) and lifted her leg up to put pants on when (CNA JJ) noticed her foot moved. It never moved before. (CNA JJ) looked at the other foot and it didn't move. (CNA JJ) did not notice any bruises or swelling. (CNA JJ) notified (Registered Nurse (RN) KK), the AM nurse and showed her. (RN KK) went in and assessed ankle. It was moveable, but was not red, swollen or bruised. Resident did not voice complaint of injury or pain. So (RN KK) did not think there was a problem..." It is important to note that Resident 3 has [DIAGNOSES REDACTED]. The facility did not have evidence that a physician was consulted with regarding this noted change to the range of motion to the ankle. The facility continued their investigation as follows: "...On Tuesday, October 23, 2012 (CNA JJ) was working the north hall and told (Licensed Practical Nurse (LPN) O) the AM nurse on the south hall about (Resident 3's) left ankle and that it moves. (LPN O) looked (SIC) (Resident 3's) left ankle and there was no bruises or swelling, resident did not voice complaints. On Wednesday, October 24, 2012 (CNA JJ) was bringing (Resident 3) back from a meal and stopped by to see (RN I, Interim DON) and showed her (Resident 3's) ankle. (RN I) stated she would look into it. On Friday, October 26, 2012 (Resident 3) went to the ER for another issue. On Tuesday, October 30, 2012 (RN I) examined the ankle noted that it was more relaxed than usual. No bruising, swelling or pain was noted on examination. On Wednesday, October 31, 2012 (RN I) called the on call physician (name). The physician note stated if pain or crepitus beyond baseline, non-urgent x-ray and since there was no bruising or swelling or pain to the area notify the primary physician in the AM. On Thursday, November 1, 2012 an x-ray was taken by Accurate Imaging, Inc. of the left ankle. The findings were [MEDICATION NAME] fracture distal tibia with offset of the distal fracture fragment..." The facility became aware of the change in Resident 3's range of motion to the left ankle on 10/21/12. The facility did not consult with a physician for 10 days after becoming aware of the change, despite CNA JJ's continued notification to a licensed nurse. Surveyor spoke with RN I on 5/1/13 at 4:20 PM. RN I stated that (Resident 3's) doctor should have been called right away.

Based on interview and record review the facility did not ensure the services provided or arranged by the facility met professional standards of quality for 3 of 12 residents (Residents 1, 7, and 3). Resident 1, who is a diabetic and who, subsequently, is at risk for significant complications from injuries to her feet, had a significant change in her toe/foot when redness and swelling were noted. Resident 1's wound was not assessed by a Registered Nurse nor was a Registered Nurse called to assess Resident 1. No nursing assessment occurred until three days later, by which time the resident had developed [MEDICAL CONDITION] and had [MEDICAL CONDITION] infection. In lieu of surgery or amputation, the resident's family elected conservative treatment and, eventually, hospice care. The failure of the facility to provide care in accordance with professional standards of practice by failing to ensure that RNs were assessing a change in resident condition created a situation of Immediate Jeopardy beginning on 4/9/13. The NHA was notified of the immediate jeopardy on 5/2/13 at 1:30 PM. The immediate jeopardy was removed on 5/2/13 however the citation continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) for the following examples. Resident 7's weekly wound assessment was completed by a LPN with no RN oversight. Resident 3's pressure ulcer was not consistently assessed by a Registered Nurse. This is evidenced by the following: The Wisconsin Board of Nursing has interpreted the Rules and Regulations that address the delegation of nursing acts. A position paper titled "Delegation" was prepared to clarify the regulations. The position paper indicates the following: The Registered Nurse is directly responsible for ensuring that Assessment, Planning, Intervention and Evaluation are performed in order to maintain health, prevent illness, or care for the ill. The only portion of the Nursing Process that contains nursing acts that can be delegated to LPN's is in the Intervention phase, which includes the collection of data (vital signs etc.) necessary to continuously Assess, Plan, and Evaluate care. A RN who delegates nursing actions to an LPN is required to provide direction and assistance to those supervised, observe and monitor the activities of those supervised and evaluate the effectiveness of acts performed under supervision. Example 1 Resident 1 is a long term resident of the facility and has [DIAGNOSES REDACTED]. Resident 1's [DIAGNOSES REDACTED]. According to the article "Complications of [MEDICAL CONDITION] in Diabetic Foot Infections," "Patients with diabetes have a 30-fold higher risk of lower-extremity amputation due to infection compared with patients without diabetes." This article also notes that "Diabetic foot infections that are not appropriately treated because of delayed [DIAGNOSES REDACTED]." http://www.medscape.com/viewarticle/ 0>. Resident 1's Skin Grids document the following for Resident 1's left second toe: -4/6/13 --new open area/scratch 0.4 cm by 0.2 cm. No drainage. Physician notified. Order was obtained on 4/6/13 for an Allevyn dressing to the second toe. -4/8/13 the order was changed to paint the area with iodine and cover with dry dressing daily. - 4/9/13 -0.6 cm by 0.4 cm Serosanguinous drainage. Color pink and small red area. Area has a small amount of redness, no warmth to the area. No signs or symptoms of infection noted. Completed by a LPN (Licensed Practical Nurse). There is no evidence that an RN assessed the resident's foot. Resident 1's nursing notes include the following documentation. (Note that all documentation was completed by Licensed Practical Nurses; there is no evidence that RNs - who are trained professionally to assess - assessed the resident's foot.) -4/11/13 at 10:00 PM Resident 1's open area on the left foot is not improving. Area is red and swollen but no warmth noted. Serosanguinous drainage noted. Physician faxed will call on 4/12/13. -4/12/13 at 10:00 PM attempted to call resident 1's physician and left voicemail. Relayed information to nurse that Nurse Practitioner Z had requested. Still no phone call back was told would receive call by the end of the day with new orders still never received new orders for the treatment. Will continue to monitor resident. -4/13/12 Treatment to Resident 1's left foot second digit completed. "Toe red, swollen, slightly warm, scant serosang (Serosanguinous) drainage, agitated when touched." On 4/14/13 a physician communication and progress note was completed for Resident 1 indicating the following: Calling about Resident 1 left foot second digit infection. Problem is worse. Red, warm, swollen, moderate amount of purulent drainage, +3 [MEDICAL CONDITION] to foot. Open are to Resident 1's second digit on left foot swollen, warm, red. Area larger than noted with last dressing change. Serosanguinous purulent drainage present with foul odor. Most of foot also red, swollen warm, +3 [MEDICAL CONDITION]. Noncommunicable but appears to have pain when area touched. Order to send to emergency room . The emergency room note, dated 4/14/13 at 1:10 PM, indicates Resident 1 was evaluated for left foot [MEDICAL CONDITION] and given [MEDICATION NAME] 900 mg IV (intravenous). Blood cultures were done. Plan to continue [MEDICATION NAME] 300 mg by mouth three times a day for 10 days. Resident 1 cultures came back positive [MEDICAL CONDITIONS] on 4/16/13. Notes by NP Z indicate the family elected conservative treatment over surgery. Resident 1's family elected to have hospice services on 4/19/13. On 5/1/13, at approximately 9:45 AM, Surveyor interviewed Director of Nursing (DON) B and Unit Manager I regarding contacting a physician. DON B confirmed that if redness or swelling is noted the physician should be contacted due to the possibility of an infection. DON B reviewed Resident 1's nursing notes and stated he would have expected the physician to have been called on 4/11/13 with the redness, swelling and drainage. Unit Manager I stated if they cannot get a hold of the physician she would expect them to be persistent and call the Unit Manager and if needed the Medical Director would be contacted. Following Resident 1's return, nursing notes on 4/28/13 by LPN O include: Left foot open area second digit painted with [MEDICATION NAME] per order. Toe is black and necrotic. Necrotic area is also noted to left great toe on the medial aspect measures 1.8 cm by 1 cm. There is no indication the physician was updated on this new area or that a Registered Nurse assessed the area. On 5/1/13, at 5:42 PM, Surveyor interviewed LPN O. LPN O confirmed she performed the treatment to Resident 1 on 4/30/13. LPN O stated the black area on Resident 1's bunion had been there a while about a week. LPN O stated when she noticed it she reported it to the Hospice staff that was in the building and that staff member stated she would report it to the Hospice nurse. LPN O stated the bunion area is the area she was referring to in her notes when she indicated the medial side of the foot and misdocumented it. There was no indication a RN assessed Resident 1's foot when the new area was noted. On 5/1/13, at 1:22 PM, Surveyor interviewed DON B regarding wounds. DON B confirmed he is also the facility wound nurse. DON B stated if a resident is noted to have a new open area staff is to complete an incident report, let DON B and call the resident's physician to get a treatment order. DON B stated the skin sheets are completed by whoever sees the new area first. DON B stated he knew Resident 1's toe started as a small scratch and was not aware of any other wounds on Resident 1's foot. DON B again stated if there were any new areas there would be a nursing note and they would let me know. DON B also stated he reviews the incident reports daily. Surveyor then asked DON B to observe Resident 1's foot. At 1:30 PM Surveyor and DON B observed Resident 1's left foot and noted a nickel sized black area on the bunion, the second toe was black and pinpoint areas on each toe and three on the side. DON B then separated Resident 1's toes and another area was noted between the great toe and the second toe on the great toe. DON B stated he was not aware of the areas. Failure to ensure that nursing followed professional standards of practice and ensured RN assessment of Resident 1's changing condition created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 5/2/13 when they developed and instituted the following plan: -All residents (including Resident 1) with a skin alterations/wounds will have an appropriate assessment and care plan to prevent infection, prevent wound deterioration, prevent new wounds from developing and promote wound healing. -Resident 1's skin will be assessed by an RN, physician notified of assessment appropriate treatment and care plan will be updated. -RN staff will complete a skin assessment for all residents to ensure all skin alterations have been identified and appropriate care plan/treatment is in place (Skin Sweep). Any concerns will be assessed, MD called, Care plan updated and appropriate treatment order in place. -Licensed nursing staff will be re-educated on the center's policy and procedures for wound prevention and treatment (to include:wound assessment, notification of physician of new wounds or change, appropriate treatments, care plan creation/implementation, wound prevention and management) -Licensed will complete a weekly skin check to monitor for new wounds and/or changes in existing wounds that would warrant MD notification or treatment change. (any concerns identified will be addressed by the he DON in daily clinical meetings) Wound certified nurse will do weekly wound rounds to measure and assess wounds. All wounds will be monitored by facility policy and procedures. -DON or designee along with IDT team will monitor for weekly skin assessment completion, weekly wound rounds completed by an RN, physician notification, RN assessment and appropriate treatment. -DON or designee will audit 5 charts with wounds weekly for the next 12 weeks to ensure that the policy and procedures for wounds is being followed. The DON or designee will review the results of these audits at the QPI meeting and the QPI committee will make recommendations. -An in house RN will be available to assess wounds and follow up with MD that was identified by an LPN. -All nursing staff will have education on identification of signs and symptoms of infection, and educated on the Interact II for changes of condition and physician notification. -Will review the nurse practice act with all licensed nursing staff. Cross reference F309 Example 2 Resident 7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident 7's document titled, Skin Grid- Pressure/Venous Insufficency Ulcer/Other" dated 11/14/12 was completed by a LPN with no RN oversight. The document included wound measurements, drainage, wound bed appearance, and pain. Review of Resident 7's document titled, Skin Grid- Pressure/Venous Insufficency Ulcer/Other" dated 12/12/12 was completed by a LPN with no RN oversight. The document included wound measurements, drainage, wound bed appearance, and pain. On 5/1/13 at 10:15 AM, Surveyor asked DON B about LPN performing assessments. DON B stated, "No, LPN's cannot assess. I oversee the wound documentation, just must not have signed the sheet." Example 3 The facility documented on Resident 3's wound on 2/12/13. This assessment "Skin Integrity Assessment: Pressure/[MEDICAL CONDITION] Ulcer/Other" is signed as completed by Licensed Practical Nurse (LPN) CC. The facility documented on Resident 3's wound on 3/5/13. This assessment "Skin Integrity Assessment: Pressure/[MEDICAL CONDITION] Ulcer/Other" is signed as completed by Licensed Practical Nurse (LPN) F. The facility documented on Resident 3's wound on 4/2/13. This assessment, "Skin Integrity Assessment: Pressure/[MEDICAL CONDITION] Ulcer/Other" is signed as completed by Licensed Practical Nurse (LPN) F. The facility did not consistently ensure that Resident 3's pressure ulcer was assessed by a registered nurse. Surveyor spoke with Registered Nurse (RN)/Unit Manager I and RN/Unit Manager J on 5/1/13 at 4:30 PM. RN/UM I stated that RNs, not LPNs need to assess pressure ulcers.

Based on observation, interview and record review the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 2 of 12 residents (Residents 1, and 7). Resident 1, is a diabetic, who developed an open area on her toe. Prevention measures were not put into place to prevent additional open areas. Staff did not routinely complete a thorough assessment of Resident 1's foot. When changes were noted there was not an RN assessment nor was the physician notified. After nursing had noted that the toe was worse, Resident 1 was seen in the emergency room , where he was subsequently diagnosed with [REDACTED]. The family elected conservative treatment vs. surgery or an amputation and Resident 1 returned to the facility and placed on hospice care. A new open area developed on the foot and staff did not ensure RN assessment or immediate physician consultation. Additionally, Resident 1 did not receive pain medications prior to treatment as ordered and staff did not use proper precautions to prevent the spread of infection during the treatment. The facility did not coordinate care with Hospice related to the wounds on Resident 1's foot. The failure to provide the necessary care that Resident 1 needed created a finding of Immediately Jeopardy. The Immediate Jeopardy began on 4/9/13. The NHA was notified of the Immediate Jeopardy on 5/2/13 at 1:30 PM and the Immediate Jeopardy was removed on 5/2/13. The deficiency continues at a scope/severity of G (actual harm/isolated) based on the additional example below. Resident 7 did not have a bowel movement for 9 days and was hospitalized with a fecal impaction. The facility administered MOM and did not monitor or document the results of the medication Example 1 The facility's Wound Prevention and Management policy, revised April 2010, includes a "wound algorithm." Per the algorithm on admission an assessment is completed and preventative measures are put into place. If there is a skin impairment (non pressure ulcer) continue preventative/treatment interventions. Monitor area of skin impairment weekly using the skin grid and daily using the treatment administration record until healed. The facility's policy for an infected wound treatment, revised January 2013, includes: "Infection is an important cause of delayed healing..." Signs and symptoms of infection may include, but are not limited to: Swelling, induration or [DIAGNOSES REDACTED], increasing pain/tenderness at the site... Procedure: 1. Assess and evaluate the wound for signs and symptoms of infection. 8. Contact the physician for potential orders. 14. Evaluate the wound daily and document using the Treatment Administration Record. The facility's policy for Contact Precautions, revised July 2012, includes: Utilize Contact Precautions in addition to Standard Precautions, or the equivalent, for specified residents known or suspected to be infected with, epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin to skin contact that occurs when performing resident-care activities that require touching the resident's dry skin) or indirect contact (touching) with environmental surfaces or resident-care items in the resident environment. *Gloves and Handwashing: 1. Wear gloves when entering the room. 3. Remove gloves before leaving the room and use appropriate hand hygiene immediately. a. Ensure that hands do not touch potentially contaminated environmental surfaces or items in the room after glove removal. *Gown: 1. Wear a gown when entering the room. 2. Remove the gown before leaving the resident environment and discard in appropriate container. a. Ensure clothing does not contact potentially contaminated environmental surfaces after gown removal. Resident 1 is a long term resident of the facility and has [DIAGNOSES REDACTED]. Resident 1's "Skin Integrity Assessment: Prevention and Treatment Plan of Care," dated 5/9/12, indicates the following: Protect elbows and heels as needed, monitor wound weekly and as needed. This plan was updated 4/6/13 (gripper socks), 4/14/13 ([MEDICATION NAME]), and 4/14/13 (foot buddy (for use on a wheelchair)). The box indicating Impaired blood flow due to [MEDICAL CONDITION] was not checked. Resident 1 is identified as at risk for skin impairment and did have a slit on her coccyx on 3/4/13 per the care plan. Surveyor did observe Resident 1 with a heel lift boot on her left foot throughout the 3 day survey however the facility was unable to identify when that intervention was put into place. Resident 1 did not have other preventive measures to prevent breakdown i.e. heels were not floated and blankets were not kept off her toes. Development of [MEDICAL CONDITION] According to the article "Complications of [MEDICAL CONDITION] in Diabetic Foot Infections," "Patients with diabetes have a 30-fold higher risk of lower-extremity amputation due to infection compared with patients without diabetes." This article also notes that "Diabetic foot infections that are not appropriately treated because of delayed [DIAGNOSES REDACTED]." <http://www.medscape.com/viewarticle/ 0>. Resident 1's nursing notes and skin grid notes include the following documentation (note all documentation by Licensed Practical Nurses): -4/6/13 Nursing notes: Resident 1 was noted with a new open area on her left foot second digit. The physician was notified and a treatment was obtained. Resident 1's Skin Grids document the following for Resident 1's left second toe: 4/6/13 new open area/scratch 0.4 cm by 0.2 cm. No drainage. Physician notified. Order was obtained on 4/6/13 for an Allevyn dressing to the second toe. -4/8/13. The Skin Grid documents that the order was changed to paint the area with iodine and cover with dry dressing daily. -4/9/13 (Skin grid): 0.6 by 0.4 Serosanguineous drainage. Color pink and small red area. Area has a small amount of redness, no warmth to the area. No signs or symptoms of infection noted. Completed by an LPN. There is no evidence that an RN, who is trained professionally to assess, was notified of this change. -4/11/13 at 10:00 PM (nursing notes): Resident 1's open area on the left foot is not improving. Area is red and swollen but no warmth noted. Serosanguineous drainage noted. Physician faxed (even though office was closed) will call on 4/12/13. No RN assessment and no consultation with a physician. -4/12/13 at 10:00 PM (nursing notes): Attempted to call resident 1's physician and left voicemail. Relayed information to nurse that Nurse Practitioner Z had requested. Still no phone call back was told would receive call by the end of the day with new orders still never received new orders for the treatment. Will continue to monitor resident. No RN assessment and no consultation with a physician. Surveyor interviewed NP Z regarding Resident 1 on 5/1/13, at 2:26 PM. NP Z stated she would expect the facility to contact her or the physician anytime an open area is getting worse. NP Z reviewed the communication log form 4/12/13 and stated there was a communication break when the facility had called and she requested additional information. NP Z stated if the facility would have called on 4/12/13 with the red foot and swelling she would have instructed them to have Resident 1 seen in the clinic if possible or have sent her to the emergency room . NP Z stated the first time she saw the open area on Resident 1's foot was two days after Resident 1 had gone to the emergency room . -4/13/12 (nursing notes): Treatment to Resident 1's left foot second digit completed. "Toe red, swollen, slightly warm, scant serosang (Serosanguineous) drainage, agitated when touched." No RN assessment and no consultation with a physician. On 4/14/13 a physician communication and progress note was completed for Resident 1 indicating the following: Calling about Resident 1 left foot second digit infection. Problem is worse. Red, warm, swollen, moderate amount of purulent drainage, +3 [MEDICAL CONDITION] to foot. Open area to Resident 1's second digit on left foot swollen, warm, red. Area larger than noted with last dressing change. Serosanguineous purulent drainage present with foul odor. Most of foot also red, swollen warm, +3 [MEDICAL CONDITION]. Noncommunicable but appears to have pain when area touched. Order to send to emergency room . The emergency room note, dated 4/14/13 at 1:10 PM, indicates Resident 1 was evaluated for left foot [MEDICAL CONDITION] and given [MEDICATION NAME] 900 mg IV (intravenous). Blood cultures were done. Plan to continue [MEDICATION NAME] 300 mg by mouth three times a day for 10 days. Resident 1 cultures came back positive [MEDICAL CONDITIONS] on 4/16/13. On 4/16/13, Resident 1 was seen by NP Z. NP Z's notes indicate an open ulcer of the second toe of the left foot on the proximal interphalangeal joint, almost the entire toe is black with a well-demarcated area of ischemia extending 1.5 cm from the ulcer. The tissue surrounding the ulcer is draining and macerated. The entire dorsal surface of the left foot with [DIAGNOSES REDACTED] and warmth with a well-demarcated line. Discussed options with power of attorney and he chose comfort with conservative treatment over surgery. NP Z also changed the antibiotic to [MEDICATION NAME] 100 mg twice a day for 10 days. Resident 1's family elected to have Hospice services on 4/19/13. On 5/1/13, at approximately 9:45 AM, Surveyor interviewed Director of Nursing (DON) B and Unit Manager I regarding contacting a physician. DON B stated a physician is notified the same day with any new open areas and with any changes or if getting worse. DON B confirmed that if redness or swelling is noted the physician should be contacted due to the possibility of an infection. DON B reviewed Resident 1's nursing notes and stated he would have expected the physician to have been called on 4/11/13 with the redness, swelling and drainage. Unit Manager I stated if they cannot get a hold of the physician she would expect them to be persistent and call the Unit Manager and if needed the Medical Director would be contacted. On 4/25/13 hospice ordered [MEDICATION NAME] 20 mg/ml sublingual (pain medication), give 5 mg 30 minutes prior to each wound treatment. Development of a second wound Resident 1's nursing notes on 4/28/13 by LPN O include: Left foot open area second digit painted with [MEDICATION NAME] per order. Toe is black and necrotic. Necrotic area is also noted to left great toe on the medial aspect measures 1.8 cm by 1 cm. There is no indication the physician was updated on this new area or a Registered Nurse assessed the area. On 5/1/13, at 5:42 PM, Surveyor interviewed LPN O. LPN O confirmed she performed the treatment to Resident 1 on 4/28/13. LPN O stated the black area on Resident 1's bunion had been there a while about a week. LPN O stated when she noticed it she reported it to the Hospice staff that was in the building and that staff member stated she would report it to the Hospice nurse. LPN O stated the bunion area is the area she was referring to in her notes when she indicated the medial side of the foot and misdocumented it. There is no indication Resident 1's physician or power of attorney for health care was updated on the new necrotic area or when the areas on the toes appeared. On 5/1/13, at 1:22 PM, Surveyor interviewed DON B regarding wounds. DON B confirmed he is also the facility wound nurse. DON B stated if a resident is noted to have a new open area staff is to complete an incident report, let DON B and call the resident's physician to get a treatment order. DON B stated the skin sheets are completed by whoever sees the new area first. DON B stated he knew Resident 1's toe started as a small scratch and was not aware of any other wounds on Resident 1's foot. DON B again stated if there were any new areas there would be a nursing note and they would let me know. DON B also stated he reviews the incident reports daily. Surveyor then asked DON B to observe Resident 1's foot. At 1:30 PM Surveyor and DON B observed Resident 1's left foot and noted a nickel sized black area on the bunion, the second toe was black and pinpoint areas on each toe and three on the side. DON B then separated Resident 1's toes and another area was noted between the great toe and the second toe on the great toe. DON B stated he was not aware of the areas. On 5/1/13, at 5:07 PM the facility received a fax from the Hospice nurse: Follow up phone call received from wound nurse regarding the wound on Resident 1's left lower extremity second digit, also the new area to the inside of the left great toe. The area on the second digit has increased in size to 2 cm width and 3 cm length this area is necrotic. There is a new area that has formed on the inside of her left great toe. This necrotic area is approximately the size of a pencil eraser. It appears that the cause is pressure from the second digit. At this time these are the only necrotic areas present and noted on the assessment completed on 4/30/13. The wound nurse was going to review this information with the physician. On 5/1/13, at 9:00 PM, Surveyor received the skin grids for the new open areas on Resident 1's left foot. Surveyor 7 asked DON B why the sheets were not signed. DON B stated he is waiting until he talks with the physician to see if there is a new treatment order. DON B stated he put a call in but is still waiting to hear back. Infection control On 4/30/13, at 8:04 AM, Surveyor noted Hospice CNA AA providing cares to Resident 1. Hospice CNA AA stated she was giving Resident 1 a bed bath. Hospice CNA AA did not have a gown on. At 8:22 AM, Surveyor observed Hospice CNA AA and CNA L transfer Resident 1. CNA L did not have gloves or a gown on and Hospice CNA AA wore gloves. After the transfer CNA L donned gloves and used Santi Wipes to clean the lift. Hospice CNA AA did not have gloves on and proceed to remake Resident 1's bed. Surveyor noted Resident 1's boot was dirty with what appeared to be iodine on the outside of the boot and Resident 1's toe was left open to air. Surveyor also noted there were no gowns in the isolation cart. At 8:33 AM Surveyor interviewed CNA L. CNA L stated Resident 1 [MEDICAL CONDITION] in her second toe on the left foot. CNA L stated when we work with her left foot we use contact precautions-gown, gloves. CNA L stated she did not put them on because she was working with Resident 1's upper half. On 4/30/13, at 9:00 AM, Surveyor interviewed Hospice CNA AA. Hospice CNA AA stated she has been working with Resident 1 for only 3 days. Hospice CNA AA stated she gave Resident 1 a complete bed bath, dressed her and assisted with oral cares before transferring her into the recliner and assisting her with her food. Hospice CNA AA stated she has a care sheet that indicates she [MEDICAL CONDITION] so Hospice CNA AA wears gloves and does not reach over her. Hospice CNA AA stated she was not instructed to wear a gown. On 5/1/13, at 10:30 AM, Surveyor observed Registered Nurse (RN) Y perform the treatment to Resident 1's toe. Upon entering the room RN Y did not don a gown. When RN Y removed Resident 1's heel lift boot Surveyor noted a necrotic area about the size of a nickel on the outside/bunion area of Resident 1's left great toe. Surveyor also noted pinpoint areas on each toe and 3 on the outside along the pinky toe. There was no documentation of these areas. RN Y did not place a barrier on the over bed table nor under Resident 1's foot. RN Y then poured normal saline over Resident 1's toe that ran down her foot onto the heel lift boot and dripped onto the mat on the floor. RN Y patted Resident 1's toe with gauze then removed her gloves and washed her hands. After completing the rest of the dressing change RN Y washed her hands then without gloves on was touching Resident 1's foot and put the boot back on. RN Y left the room and was about to place the supplies from Resident 1's room back in the treatment cart. Surveyor stopped RN Y and interviewed her regarding Resident 1's infection. RN Y looked at Resident 1's door and noted the "See Nurse Before Entering" sign and stated she believed Resident 1 was on precautions due [MEDICAL CONDITION] in her toe. RN Y stated she should have worn a gown and used a barrier on her chair under her foot and that now the supplies were contaminated too. Surveyor also asked about Resident 1's pain medication. RN Y stated she gave Resident 1 her morning medications around 8:00 AM. RN Y stated she only gave her the scheduled medications and did not give her any additional medications before the treatment. Note: Resident 1 does not receive any scheduled pain medications. Surveyor reviewed Resident 1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 5/1/13, at 10:54 AM, Surveyor interviewed DON B. DON B stated Resident 1 is on contact isolation for [MEDICAL CONDITION] in her toe. DON B stated staff is to wear a gown and gloves when they enter her room and might touch something. DON B stated even if just assisting Resident 1 with her meal staff should wear a gown and gloves because the area is open to the air and you don't know what may have been touched. DON B stated when performing the treatment he would expect staff to wear a gown and gloves and to use barriers for the clean supplies and under Resident 1's foot. DON B stated when a resident is ordered to pre-medicate before a treatment he would expect them to receive the medication as ordered and not more than 2 hours before. The facility removed the immediate jeopardy on 5/2/13 when they developed and began instituting the following plan: -All residents (including Resident 1) with skin alterations/wounds will have an appropriate assessment and care plan to prevent infection, prevent wound deterioration, prevent new wounds from developing and promote wound healing. -Resident 1's skin will be assessed by an RN, physician notified of assessment appropriate treatment and care plan will be updated. -RN staff will complete a skin assessment for all residents to ensure all skin alterations have been identified and appropriate care plan/treatment is in place (Skin Sweep). Any concerns will be assessed, MD called, Care plan updated and appropriate treatment order in place. -Licensed nursing staff will be re-educated on the center's policy and procedures for wound prevention and treatment (to include: wound assessment, notification of physician of new wounds or change, appropriate treatments, care plan creation/implementation, wound prevention and management) -Licensed will complete a weekly skin check to monitor for new wounds and/or changes in existing wounds that would warrant MD notification or treatment change. (any concerns identified will be addressed by the he DON in daily clinical meetings) -Wound certified nurse will do weekly wound rounds to measure and assess wounds. All wounds will be monitored by facility policy and procedures. Certified Nursing Assistants will observe skin during cares and will complete an "Early Warning tool" for any new skin alterations. -DON or designee along with IDT team will monitor for weekly skin assessment completion, weekly wound rounds completed by an RN, physician notification, RN assessment and appropriate treatment. -Center's staff will coordinate care with Hospice staff to ensure all care provided is clearly communicated to the center. Hospice staff will meet with center staff prior to leaving center to discuss resident's status. -DON or designee will audit 5 charts with wounds weekly for the next 12 weeks to ensure that the policy and procedures for wounds is being followed. The DON or designee will review the results of these audits at the QPI meeting and the QPI committee will make recommendations. -An in house RN will be available to assess wounds and follow up with MD that was identified by an LPN. -All nursing staff will have education on identification of signs and symptoms of infection, and educated on the Interact II for changes of condition and physician notification. -Will review the nurse practice act with all licensed nursing staff. Cross reference F309 Example 2 The facility Policy Titled, "Bowel and Bladder Program" with a revision date of January 2009 states the following: Subject: Constipation Policy: Extendicare Health Services recognizes constipation is the most frequent complaint in older people regarding bowel function. Actual constipation is defined as three or more days without defecation. Standard bowel care to relieve constipation (in the absence of bowel obstruction) with a provider order may include the following: *Milk of Magnesia 30 cc PO every third day without BM *[MEDICATION NAME] Suppository rectally is no results from the Milk of Mahgnesia *Fleets Enema rectally if no results from the [MEDICATION NAME] Suppository Resident 7 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's Comprehensive MDS (Minimum Data Set) with a completion date of 12/03/12 indicates that Resident 7 is able to understand others and make self understood and able to make daily decisions. Resident 7 requires extensive assist of 2 for transfers, bed mobility, and is nonambulatory. The MDS also indicates that Resident 7 is frequently incontinent of bowel and bladder. Resident 7's incontinence CAA's (Care Area Assessment) with a completion date of 12/3/12 indicates that Resident 7 is incontinent due to altered mobility, cognition and environmental changes, and that staff are to assist with bathroom privileges. Resident 7's care plan titled, "Alteration in Bowel Elimination" dated 6/4/12 under problem the box incontinence is checked, and "Bladder and Bowel Assessment indicates resident's bowel dysfunction appears related to the following: weakness, 2A (2 assist) with transfers STS(lift) Goal,- will have BM (bowel Movement) q(every) 3days. Interventions: toilet q 3hrs, provide medication as ordered to aid in elimination as ordered. Resident 7's signed physician ordered for 4/2013 indicates an order with a initial date of 3/29/11 for Milk of Magnesia SUSP'N Give 30 ml by mouth every 12 hours as needed for constipation. Resident 7's medical record indicated that on 8/4/12 Resident 7 was sent to the emergency room for a chief complaint of abdominal pain. During the hospitalization Resident 7 received the [DIAGNOSES REDACTED]. Review of Resident 7's nurses' notes indicates the following: 7/18/12 2:00 PM: "Resident has not had a bowel movement in a couple days. Resident refused to take anything to help move bowels. Educated resident about no bowel movement and resident still refused." 7/18/12 at2:30 PM, "Called primary to address lab orders, stated that had the information and they would call us back. No call back yet, 2nd shift nurse notified." * Please note there is no entry notifying the physician of Resident 7 not having a bowel movement for a "couple days" or for Resident 7's refusal of medications to move the bowels*. 7/18/12, "Called to get clarification of INR orders. VS WNL, A&Ox3, BS active all 4 quadrants, no complaints of pain". 7/20/12 "A&Ox3 No complaints, BS active in all four quadrants." 7/23/12 "A&Ox3, No complaints of pain, BS active in all four quadrants." 7/24/12 1900, "A&Ox3, BS active all four quadrants." 7/28/12 1900, "A&Ox3, BS active all four quadrants." 8/4/12 @ 0630, " received in report that residents abdomen distended and [MEDICATION NAME] suppository given for BM. Upon assessment by the nurse abdomen round, soft, bowel sounds present in all four quadrants. BM in rectum, non nauseated. Resident unable to sit on commode due to Hoyer and weak legs. Enema given per prn orders, results of medium BM, soft brown. complaints of gas pain, did pass some gas". 8/4/12 @ 0930,"Resident ate no breakfast, no appetite, no further BM, did take prn milk of mag, called on call MD, gave order for one enema now and one in one hour, if no results call MD back. Resident agrees to orders and enema." 8/4/12 @ 1230, "Resident has had 1 medium BM and just now had a large BM, soft, brown. passing much [MEDICATION NAME]." 8/4/12 at 2200,"Attempted straight cath on resident, and she complains its too painful will send to ER per MD." 8/5/12 0050,"called hospital and resident is being admitted for Ureosepsis." Review of Resident 7 hospital discharge summary dated 8/19/12 indicates the following diagnosis, Diarrhea, related to overflow diarrhea. Maintain adequate bowel regime, fecal impaction, X-ray with possibly some mild improvement in dilitation still appears constipated. The Narrative Summary states the following, but not all inclusive; "[AGE] year old female presented from the nursing home with abdominal pain and confusion. She was found to have ureosepsis with ESBL E. Coli and fecal impaction. Attempts to treat the fecal impaction resulted in a lower GI bleed." Review of Resident 7's bowel movement record from 7/19/12- 8/3/12 indicates the following: 7/19/12: 1 Large Bowel Movement 7/20, 7/21, 7/22, 7/23, 7/24, 7/25/12: No Bowel Movements,* Please note that Resident 7 did not have a bowel movement for 6 days* 7/26/12: 1 Small Bowel Movement 7/27, 7/28, 7/29, 7/30/12: No Bowel Movements,*Please note that Resident 7 did not have a bowel movement for 4 days.* 8/1, 8/2, 8/3/12: No Bowel Movements, *Please note that Resident 7 did not have a bowel movement for 3 days. 8/4/12: 1 medium bowel movement, 1 large bowel movement, and 1 episode of diarrhea. Review of the bowel movement record for Resident 7 indicates that from 7/19/12 through 8/3/12 Resident 7 had 2 small bowel movements, 1 medium bowel movement and 1 large bowel movement over a total of 16 days. Resident 7 ' s MAR (Medication Administration Record) for 7/2012 indicates that on 7/19/12 at 12:30 PM, and 7/30/12 at 0900 AM, Resident 7 received Milk of Magnesia 30 ml by mouth. Surveyor was unable to locate the effectiveness of the Milk of Magnesia. On 5/1/13 at 0800 AM, Surveyor interviewed RN (Registered Nurse)E regarding the facility's bowel management program. RN E stated, "I think that if a resident does not have a bowel movement in 8 hours we give milk of magnesia, then a suppository and then an enema. If nothing happens then we assess the patient. I am not really sure on the time frame. The CNA's (Certified Nursing Assistants) tell us on a daily basis, and document in caretracker, I do not look in caretracker. The unit manager generates a sheet every day with an update." On 5/1/13 at 9:15 AM Surveyor interviewed DON B regarding Resident 7's hospitalization with the [DIAGNOSES REDACTED]. DON B stated, "If the resident has not had a bowel movement in 3 days then milk of magnesia is to be given." Surveyor then reviewed Resident 7's bowel movement record from July 19 2012 up to August 4, 2012 when Resident 7 was hospitalized . DON B stated, "I was not here when this happened to Resident 7, and yes it could have been avoided if the bowel protocol had been followed. I did not know about this until you (Surveyor ) were here for the survey. What we have been doing since I started here in November is print out all the residents ' bowel movements records every day and give the documentation to the floor nurses to follow up. We put an action plan in place on 4/30/13." Surveyor then reviewed Resident 7's MAR for the month of July 2012 for as needed usage medications. Surveyor asked DON B if there should be follow up documented in Resident 7's medical record for the PRN Milk of Magnesia that was administered to Resident 7 on 7/19/12 and 7/30/12. DON B stated, "Yes the nurse is to document the results." Surveyor then asked DON B if result were documented for the PRN Milk of Magnesia Resident 7 received on 7/19/12 and 7/30/12, DON B stated, "No."

Based on observation, interview and record review, the facility did not ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 3 of 11 residents reviewed (Residents 2, 5, and 12). Resident 2 has a stage three pressure ulcer to his buttock. The facility did not provide the appropriate ordered treatment to his buttock. The facility did not remove a soiled brief from under Resident 2's bottom, upon completion of the treatment. Resident 2 has a stage three pressure ulcer to the ankle. The facility did not provide the wedge under the ankle, per Resident 2's plan of care. Resident 2 was not assessed for an appropriate mattress. Resident 2 claimed that his mattress was painful to his bottom. The mattress in use for Resident 2 was recommended for use through stage two pressure ulcers. Resident 5 has an order for [REDACTED]. Resident 12 has a stage III pressure ulcer to her coccyx and a physician's orders [REDACTED]. Resident 12 was observed up in her wheelchair for 1 and ? hours. This is evidenced by the following: The facility's titled "Pressure Ulcer Prevention/Treatment" revised April, 2009 states the following: "Extendicare Health Services, Inc. (EHSI) requires the use of the Braden Risk Assessment and Skin Integrity Assessment: Prevention and Treatment Plan of Care. All residents will be assessed on admission and weekly for four weeks, quarterly, and with a significant change of condition using the Braden Risk Assessment and Skin Integrity Assessment: Prevention and Treatment Plan of Care. EHSI recognizes it is difficult to describe a set of protocols that would fit every circumstance. However, Braden recommends the following: Manage moisture, manage nutrition, manage friction and shear, manage other general care issues ...Procedure: ...2. Review assessments and identify individualized interventions using the Skin Integrity Assessment: Prevention and Treatment Plan of Care. Interventions may include, but are not limited to: a. Manage Pressure: use support surfaces on bed or wheelchair; use turning and repositioning; off load heel pressure; B. Manage Moisture: Use appropriate moisture barrier; use absorbent incontinent products; address underlying cause if possible; offer toileting and fluids with turning schedules ..." According to the National Pressure Ulcer Advisory Panel's "treatment of [REDACTED]. If pressure over the area cannot be relieved by repositioning or if there are pressure ulcers on multiple turning surfaces, evaluate the individual and provide a support surface properly matched to his/her needs, considering pressure redistribution, shear reduction, and microclimate control. Keep the individual off of the area as much as possible ..." The American Medical Directors Association's (AMDA) "Pressure Ulcers in Long Term Care Settings-Clinical Practice Guideline" (2008) recommends the following: " ...Cover and protect the ulcer and surrounding skin. The goals of dressing an ulcer are to: Keep the ulcer bed moist and the surrounding skin dry; Protect the ulcer from contamination; Promote healing ...Use cover dressings that provide sufficient protection against contamination. For example, in incontinent patients, cover sacral and ischial ulcers with waterproof tape, a transparent adhesive dressing, or another impermeable dressing." In addition, AMDA recommends the following:"...Enzymatic debridement: Enzymatic debridement is often used in long-term care facilities and in home care. This method should be considered when the patient cannot tolerate surgery and when the ulcer does not appear to be infected. Enzymatic debridement is accomplished by applying topical [MEDICATION NAME] agents to devitalized tissue on the ulcer's surface. Several studies support the effectiveness of [MEDICATION NAME], a biologic licensed by the Food and Drug Administration (FDA), in ulcer debridement. According to www.drugs.com <http://www.drugs.com>, Santyl ointment is an enzymatic [MEDICATION NAME] ointment, with the generic name of [MEDICATION NAME]. Example 1 Resident 2 has the following diagnoses, according to "[DIAGNOSES REDACTED]. The facility completed a Significant Change Minimum Data Set (MDS) assessment, with an assessment reference date of 12/14/11. This assessment indicates that Resident 2 is understood and understands and scored 15 points on his Brief Interview for Mental Status (BIMS) assessment, indicating that Resident 2 is cognitively intact. Section E0800 of this assessment indicates that Resident 2 did not exhibit behaviors of rejecting care. Section G-Functional Status indicates that Resident 2 needed extensive assistance (resident involved in activity, staff provide weight bearing support) and two person physical assist for transferring, bed mobility, toilet use, and personal hygiene. Section M, Skin Conditions, conveys that Resident 2 is at risk for pressure ulcers, has one stage two pressure ulcer and one stage three pressure ulcer. This section states that Resident 2 has a pressure reducing device for chair and bed, is on a turning/repositioning program, nutrition or hydration intervention and ulcer care. Resident 2's Care Area Assessments (CAA) for Pressure Ulcers, dated 12/22/11 states the following: "Care Plan? Yes; Document Reasons care plan will/will not be developed: impaired skin integrity; Referral(s) to other discipline(s) is warranted (to whom and why): dietary and nursing." The facility completed a "Braden Risk Assessment Scale" on 10/25/11 in which Resident 2 scored 15 points, indicating that Resident 2 is at minimal risk for pressure ulcer development. "Admission Skin Assessment" dated 12/8/11 does not indicate impaired skin to the right buttock or ischial area. (Resident 2 was readmitted to the facility from an acute care hospital at this time.) A document titled Accident/Incident Report, dated 12/29/11 states "CNA (Certified Nursing Assistant) reported to nurse (name) open area on R (right) buttock, 4.5 X 3.75, peri care being administer and noted ...Immediate action taken to prevent further incidents: Notified wound care nurse, Dimethicone applied, see TAR (treatment administration record) for further reference. Physician Notified: (name) 12/30/11 1345 (1:45 PM)." Resident 2's TAR for December, 2011 indicates a treatment order for "Remedy Skin Repair Cream-apply topically to buttocks, legs, feet all bony prominences for moisturizer." This TAR indicates that Resident 2 received this treatment for 27 of 31 days in December, 2011. It is important to note that Resident 2 received the treatment, acquired a pressure ulcer, and the treatment continued after discovery of the pressure ulcer to the right buttock. Remedy Skin Repair cream is a lotion containing the ingredient Dimethicone. Progress Notes, dated 12/29/11 state the following: "Pt (patient) alert and oriented (X3) afebrile, opening noted by aide on R iliam and nurse was informed. Site appears reddened on surrounding tissue and black in the center. Resident denies pain/discomfort. Wound nurse informed. Dimethicone applied and will continue to use for treatment." Progress Notes dated 12/30/11 state, "IDT (interdisciplinary team) met to review incident last PM. Open area to R buttock found. Resident has been refusing to use hoyer noncompliant with care plan-transferring to w/c (wheelchair) c (with) 2A (2 assist) using slideboard ...(Dr.'s name) out of office and msg (message) left for (Nurse Practitioner) for order of PT (physical therapy) eval and Tx (treat) ..." Progress Notes dated 1/2/12 state "Resident buttock R (right) reddened, opened mod (moderate) bleeding to site. Wound care nurse informed. PRN (as needed) cream applied per orders." Progress Notes dated 1/5/12 state, "Late entry for 1/2/12 wound rounds ...Stage II PU (pressure ulcer) to R ischium measures 10.0 X 5.0 X <0.1, wound bed pink, peri wound pink, PUSH (pressure ulcer scale for healing) score 13, may be combination stool inc (incontinence) and pressure from use of slideboard edge, verbally denies pain, cleansed wound c NS (normal saline) pat dry, barrier cream applied, non bordered gauze over area ...Stage III PU to L (left) malleolous measures 4.0 X 4.0 X 0.1 ...on PO (by mouth) supplement, prostat, wears blue heel booty at L LE (lower extremity) at all times, air mattress to bed, is no slideboard transfer, Hoyer c 2A for all transfers from/to bed and electric w/c. Has appt (appointment) scheduled for ABI (ankle-brachial index) indexing upcoming to determine blood flow ..." 1/9/12 Progress notes indicate that Resident 2's ABI was normal. Progress Notes dated 1/10/12 state, "Call placed to (Dr.'s name) office r/t (related to) Rt (right) ischium Stage III PU. Await return call from (Dr.) for tx A (change) to right ischium PU ...received call from (Dr.s' nurse) ...tx order received, TAR updated ..." Resident 2's January, 2012 TAR indicates the following order initiated on 1/11/12: To stage III PU to right ischium, cleanse c (with) wound cleanser rinse c NS, pat dry, light application zinc oxide to periwound, Santyl to wound bed, cover c foam drsg (dressing), change daily and prn if loose, absent, soiled." A telephone order dated 1/10/12 dictates the same treatment. Notes from an office visit on 1/16/12 state "Recommendations: will continue iodosorb to ankle and santyl to ischium, moisture associated [MEDICAL CONDITION]: [MEDICATION NAME] and zinc oxide to perineum, groin and scrotum ...pressure offloading: needs to limit time in chair, repositioning frequently-he move independently in bed with trapeze, PT/OT to evaluate chair/cushion/transfers ..." The facility completed "Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other" for tracking of Resident 2's pressure ulcer to the right ischium. This document indicates the following wound characteristics: 12/29/11: Stage II, 4.5 cm long by 3.75 cm wide 1/3/12: Stage II, 10.0 X 5.0 X less than 0.1 (depth), wound bed and periwound pink *It is important to note that Resident 2's pressure ulcer increases in length by 5.5 centimeters and there is no indication that the facility consulted with a physician regarding the change in size of the pressure ulcer. 1/9/12: Stage II, 10.0 X 5.0 X <0.1, slight improvement, remains inc bowel, currently transfers with Hoyer, no slideboard. 1/16/12: Stage III, 10.0 X 8.0 X 0.1, 100% yellow slough periwound pink, no exudate. 1/23/12: Stage III, 5.0 X 12.0 X 0.1, 100% yellow slough adherent to wound bed, no pain, incontinent of stool, pressure from slideboard use, slowly resolving. 1/30/12: Stage III, 6.0 X 9.0 by 0.1, wound bed pink scattered granulation buds. 2/6/12: Stage III, 3.0 X 6.5 X 0.1, very slowly resolving, resident chooses to stay in w/c > (greater than) 2? (hours), re-educated-dressing often loose, soiled, inc of bowel, stool on dressing. 2/13/12: Stage III, 4.0 X 8.0 X 0.2, wound bed pink, bleeds with cleansing, no pain, treatment changed, incontinent of bowel. *It is important to note that the facility did not obtain a different treatment on 2/13/12, as noted in the wound tracking. There is no evidence that a physician was consulted with regarding commencement of a new treatment to the area. 2/20/12: Stage III, 5.0 X 7.0 X 0.2, wound bed red, periwound pink, refuses air mattress. The facility did not have evidence that the option of an air mattress was discussed with Resident 2 or that the mattress in place for Resident 2 was assessed to be adequate for his multiple pressure areas, including two pressure ulcers a Stage II and a Stage III. The mattress in place during the survey (2/20/12 to 2/23/12) was a Panacea Clinical Mattress. Manufacturer's information indicates the following: "May be appropriate through Stage II wounds. Mattress wound stage ratings are general usage guidelines. Resident specific assessment could alter your particular usage of these mattresses." Resident 2's Plan of Care titled "Skin Integrity Assessment: Prevention and Treatment Plan of Care" with an initial date of 2/21/11 indicates the following interventions for Resident 2: "Completed PUSH Tool Weekly, if PU; Completed Braden Scale upon admission and weekly times 4 weeks, quarterly, and with a change of condition; Manage Moisture: Use absorbent Pads of Diapers that Wick & Hold Moisture; Offer bedpan/urinal and glass of water in conjunction with Turning Schedules; Manage Nutrition: Act quickly to alleviate deficits; Consult dietician; Manage Friction and Shear: Use trapeze when Indicated; Use lift sheet to move Resident; Protect elbows and heels if being exposed to friction; Other General Care Issues: No massage of bony prominences; No donut-type devices; Maintain good hydration; Avoid dry skin; ...Specialty Mattress: perimeter ...provide treatment per MD order; Update MD within 2 weeks if no evidence of healing; L (left) elevating leg rest c foam support to protect ankle; Tx as ordered ..." It is important to note that Resident 2's plan of care for skin does not dictate a turning or repositioning schedule for Resident 2. The facility uses CNA care sheets (untitled) to instruct care interventions. Surveyor reviewed the CNA care sheet, dated 2/20/12. This document does not indicate a turning or repositioning schedule for Resident 2. This column is noted to be blank on the care sheet. The following Treatment Administration Record (2/2012) was reviewed by Surveyor on 2/21/12, prior to observing wound care provided by RN D on 2/22/12: Resident 2's TAR for February, 2012 indicates the following order for Resident 2's treatment to the left ankle pressure ulcer: Profo boot to L ? (lower) extremity when in bed-keep heel elevated with wedge; Contact isolation ESBL (Extended Spectrum Beta Lactamase); L ankle ulcer: apply skin prep to periwound, Scant amt (amount) iodosorb to wound bed, cover c nonadherent drsg secure c Kerlix. No Tape, A QOD (every other day) and prn. Resident 2's TAR for February, 2012 indicates the following treatment "1/11/12: Cleanse wound once daily and as needed F/B (followed by) NS (normal saline) rinse, pat dry and light application of zinc oxide to periwound, Santyl to wound bed, cover c foam dressing, A QD (everyday) and prn." It is important to note that this treatment does not indicate the location of the body for which the treatment is to be applied. This is however, the same treatment initiated on 1/11/12 for Resident 2's stage III pressure ulcer to the right ischium. Resident 2's TAR for February, 2012 also indicates the following order: "Zinc Oxide 20% Ointment: Apply topically as directed to groin, scrotum and perineum. This document also directs staff to complete the following: "Mix [MEDICATION NAME] and [MEDICATION NAME] power (powder) (50/50), apply to denuded areas on buttocks QD and PRN, 2/10/12." Observations per Surveyor : On 2/22/12, at 9:50 AM, Surveyor observed Assistant Director of Nursing (ADON) D perform a treatment on Resident 2. ADON D assisted Resident 2 to roll to his right side. Resident 2 did not have a dressing on his stage 3 pressure ulcer to the right ischium. Surveyor observed an adult brief lying under Resident 2 buttocks area. The adult brief was observed to be soiled with multiple areas of red and brown drainage to the entire mid section of the adult brief. ADON D applied gloves and began to cleanse Resident 2's right and left buttocks, coccyx, scrotum and right ischium areas with the wound cleanser. During this observation, Surveyor and ADON D observed the stage 3 pressure ulcer to Resident 2's right ischium. Surveyor asked ADON D if the area present with depth to the right ischium presented with yellow slough indicating the right ischium was a stage 3 pressure ulcer. ADON D stated yes that is yellow and pointed with her gloved finger to the observed area. ADON D removed the tube of [MEDICATION NAME] ointment and the container of Stoma Adhesive powder from the plastic bags. ADON D then squeezed the [MEDICATION NAME] ointment into a 30 ml (milliliter) plastic cup approximately to the 20 ml mark. ADON D then sprinkled 4 shakes of the the Stoma adhesive powder on top of the [MEDICATION NAME] Ointment. ADON D applied new gloves and mixed the [MEDICATION NAME] ointment and the Stoma adhesive powder mixture together. ADON D applied the mixture with the use of the tongue blade to Resident 2's stage 3 pressure on his right ischium. ADON D did not apply Santyl or Zinc to the stage 3 area on Resident 2's right ischium. ADON D did not cover Resident 2's stage 3 pressure ulcer with a foam dressing. ADON D with the same gloves placed her hand into the 30 ml container and removed the rest of the [MEDICATION NAME] ointment and the Stoma adhesive powder mixture with her gloved fingers. ADON D began to spread the [MEDICATION NAME] Ointment and Stoma adhesive mixture on to Resident 2's left thigh and buttock. Resident 2's left thigh and buttocks was observed to have multiple open denuded areas. Using the same mixture and gloves, ADON D then began to spread the mixture to Resident 2's scrotum. Resident 2's scrotum was observed to have multiple open areas due to moisture associated [MEDICAL CONDITION]. ADON D continued to spread the mixture to Resident 2' right buttock onto the multiple open denuded areas on Resident 2's right buttock using the same mixture and the same gloves. ADON D did not apply Zinc Oxide to the scrotum during the treatment observation. ADON D then assisted Resident 2 to move from his right side onto his back placing the open stage 3 pressure ulcer and the denuded areas onto the soiled adult brief. ADON D removed her gloves and washed her hands. ADON D did not have a gown on during the cleansing or the application of the treatment to Resident 2. ADON D did not remove the soiled brief from under Resident 2's buttock prior to leaving Resident 2's room. ON 2/23/12, AT 12:40 PM, Surveyor spoke with Director of Nursing (DON) regarding Resident 2's treatment performed by ADON D with the use of the [MEDICATION NAME] and Stoma adhesive powder. DON B stated the nurses are currently estimating how much [MEDICATION NAME] ointment and Stoma adhesive powder the nurses are to mix for Resident 2. DON B stated the order is for a 50/50 of each mixture and there is no order or direction by the pharmacy indicating how much of the [MEDICATION NAME] ointment or the Stoma Adhesive powder to use. DON B continued to state the nurses were given no direction on the TAR of how to mix the 50/50 and each nurses does the mixing differently. In addition, DON B stated there should be clear orders for the mixing of the [MEDICATION NAME] ointment and the Stoma adhesive powder for Resident 2. ON 2/23/12, AT 12:40 PM, Surveyor spoke with DON B regarding the treatment performed to Resident 2's Stage 3 pressure ulcer to the right ischium and the open [MEDICAL CONDITION] to Resident 2's scrotum. DON B stated the Santyl, Zinc and the foam dressing should have been applied to Resident 2's stage 3 area on his right ischium. DON B also stated Resident 2's current order to the moisture associated [MEDICAL CONDITION] to Resident 2's scrotum is Zinc Oxide. In addition, DON B stated ADON D applied the wrong treatment to Resident 2's stage 3 pressure ulcer on his right ischium and to Resident 2's scrotum. DON B continued to state she would have expected ADON D to remove the soiled adult brief from Resident 2's bed prior to the start of Resident 2's treatment. On 2/22/12 at 9:50 AM, Surveyor observed Assistant Director of Nursing (ADON) D complete Resident 2's treatment to the ankle. Surveyor noted that ADON D did not wear the appropriate personal protective equipment, per Resident 2's TAR. ADON D covered the wound to the left ankle with Kerlix and used tape to secure it in place. ADON D removed the wedge from under Resident 2's left foot, and did not replace in upon completion of the observed treatment. After observation of wound cares provided by ADON D on 2/22/12 at 9:50 AM, Surveyor again reviewed the Treatment records for Resident 2. Surveyor noted that the treatment orders, contained in the TAR had been changed, at some point on 2/22/12. Alterations were made as follows: An Addition of "R ? Buttock" was made to the "1/11/12: Cleanse wound once daily and as needed F/B (followed by) NS (normal saline) rinse, pat dry and light application of zinc oxide to periwound, Santyl to wound bed, cover c foam dressing, A QD (everyday) and prn" treatment. This treatment was then highlighted (to indicate discontinuation) and a statement "See new order 2/10/12" was added to the above order. Surveyor spoke with ADON D about the changes on the TARs on 2/22/12 at 3:20 PM. ADON D stated that the [MEDICATION NAME] and [MEDICATION NAME] powder treatment supersedes the Santyl treatment. ADON D stated that the she should get an order to discontinue the Santyl. ADON D stated that she did put the [MEDICATION NAME] and [MEDICATION NAME] mixture on the stage III pressure ulcer this morning. Surveyor asked ADON D if the Santyl treatment should had been done this morning. ADON D stated that it should have been done this morning and that she did not do it. ADON D stated that she should date changes made to medical records. Surveyor spoke with Director of Nursing (DON) B on 2/22/12 at 3:35 PM. DON B stated that the facility should have d/c orders to stop orders. DON B stated that the medical record should be dated, to show when things are stopped or changes. Surveyor told DON B about her observations of cares and changes made to Resident 2's TAR without orders to change. DON B stated that this was falsifying records. DON B stated that ADON D should have done the Santyl treatment for [REDACTED]. On 2/22/12 at 3:50 PM, Surveyor spoke with RN J about Resident 2's TAR. RN J stated that when items on the TAR are highlighted, it means that that they are discontinued. RN J stated that she discontinued (via the highlighter) the Santyl treatment just this afternoon. Surveyor asked RN J if there was an order to discontinue the Santyl for Resident 2. RN J said that she should check for an order before discontinuing a treatment. RN J stated that today she added the "R ? buttock" portion to the order that she highlighted today. Surveyor asked RN J for the discontinuation order for Resident 2's Santyl treatment. No further information was provided. Surveyor spoke with ADON D, RN C and DON B, and Nursing Home Administrator (NHA) A on 2/23/12 at 10:31 AM. DON B stated that each resident undergoes a systemic review and skin check with two nurses upon admission to reveal pressure ulcer development risk. DON B stated that the facility uses the Braden assessment for pressure ulcer prediction. DON B stated that interventions are placed accordingly. DON B stated that the facility then continues to follow up on pressure ulcers, once identified. ADON D stated that it is her expectation that the doctor is notified right away after the discovery of a new wound. DON B stated that the facility uses the National Pressure Ulcer Advisory Panel (NPUAP) as their standard of practice for prevention and treatment of [REDACTED]. DON B stated that education was completed related to documentation of where the treatment should completed (on the body). ADON D, the facility's wound care certified (WCC) nurse, stated that when treatment orders are obtained, the facility should get specifications as to where the on the body the treatment should be done. On 2/23/12 at 12:00 PM, Surveyor spoke with ADON D about Resident 2's pressure ulcers. ADON D stated that on 12/29/11, the area to the ischium was discovered and the Nurse practitioner responded on 12/30/11 for a PT/OT eval. ADON D stated that the treatment for [REDACTED]. Surveyor asked ADON D if Remedy lotion was already being used for prevention for Resident 2. ADON D reviewed the TAR for December, 2011 and stated that it looked like this was already being used. ADON D stated that it does not appear that there was a new treatment initiated. ADON D stated that there should be consultation with a doctor related to the wound and new orders. Surveyor asked ADON D about the observations of the inappropriate treatment on 2/22/12. ADON D stated that there was confusion with the treatment because the TAR was not clear. Surveyor asked if there was a physician's orders [REDACTED]. ADON D stated that there is no order to discontinue the Santyl treatment. Surveyor asked ADON D if the facility attempted to get an appropriate mattress for Resident 2 with the evolution of a stage III pressure ulcer. ADON D stated that Resident 2 declined the air mattress. Surveyor asked ADON D for information regarding the air mattress. ADON D stated that there should be a resident choice care plan. Surveyor and ADON D reviewed Resident 2's plan of care. ADON D agreed that there was not a care plan that indicated Resident 2 declined the use of a different mattress. Surveyor asked ADON D for additional information regarding the facility's assessment for a different or alternative mattress. Surveyor asked if Resident 2 should have the wedge in place for the ankle ulcer and shared her observation of ADON D removing the wedge from Resident 2's lower extremity. ADON D indicated that she should have placed the wedged under Resident 2's leg. On 2/23/12, Surveyor spoke with DON B about Resident 2. DON B stated that residents should be assessed for the mattress that they are using and should be changed to be appropriate, as in Resident 2's case. On 2/23/12 at 10:00 AM, Surveyor spoke with Resident 2 about his mattress. Resident 2 stated that he had a mattress with sides on it before, but then it was changed. Resident 2 stated that the mattress on his bed was not very comfortable for his bottom. Resident 2 stated that he did talk to his wife about changing mattresses and that some residents have more comfortable ones. Resident 2 stated that this mattress was too hard for his bottom. Surveyor asked Resident 2 if the facility has ever tried a different mattress. Resident 2 stated that the facility had never tried a different one. Resident 2 stated that he did have quite a bit of pain with his bottom. No additional information was provided. Example 2 Resident 5 was re-admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Resident 5's 12/16/11 Quarterly MDS, Section G ADL's, indicates that Resident 5 is an extensive assist of 2 for bed mobility, transfers and toilet use. Section H Bowel and Bladder indicates that Resident 5 is always incontinent of urine and frequently incontinent of bowel. Section M Skin Condition indicates that Resident 5 is at risk for pressure ulcer development. Resident 5's physician's orders [REDACTED]. Continue with Repositioning Q 2 hrs and PRN". The fax was signed and returned to the facility on [DATE] at 7:28 AM, and another faxed order dated 1/10/12 for " 1. Has a Stage 1 nonblanchable Pressure Ulcer to the left heel. Request order for skin prep to heel, Allevyn Dressing, change every 3 days and PRN, 2. Prevelon boots while in bed to reduce pressure to heels". On 2/21/12 at 1:15 PM Surveyor observed cares being provided to Resident 5 by CNA P and CNA V. Surveyor did not observe a dressing on Resident 5's coccyx. On 2/22/11 review of Resident 5's TAR indicated that orders were written in for the following: * Coccyx Stage II PU(Pressure Ulcer): Skin Prep cover with bordered Allevyn drsg(dressing) change every 5 days and prn- preventive measure- re-written 2/20/12. Please note that the treatment is not signed out as being completed until 2/22/12. * Apply skin prep to the left heel f/b(followed by) Allevyn q 3 days and prn, please note that this treatment is not initialed as being done, and there is no date on the hand written order indicating when the treatment was started and the treatment was blocked off to have been done on 2/21/12. On 2/22.12 at 2:15 PM, Surveyor interviewed CNA P and CNA V regarding dressings on Resident 5's coccyx and left heel. CNA P and CNA V stated that Resident 5 did not have any dressings on his left heel or coccyx on 2/21/12. Surveyor then asked CNA P and CNA V if Resident 5 had a dressing on his coccyx, and his left heel on 2/22/11. Both CNA's stated, "NO we thought the areas were healed." On 2/22/12 at 2:30 PM, Surveyor interviewed ADON D regarding the dressings to Resident 5's coccyx and left heel. Surveyor asked ADON D if the dressings should be signed out on the TAR and on Resident 5's coccyx and left heel. ADON D stated, "Yes." On 2/23/12 at 7:50 AM, Surveyor interviewed RN F regarding the treatment orders for Resident 5. RN F stated, "The dressings are on Resident 5's coccyx and left heel are on there now. I did not know about the dressings for Resident 5." On 2/23/12 at 10:50 AM, Surveyor interviewed ADON D regarding the process for changes in treatment orders and how staff knows about the changes. ADON D stated, "First the order is faxed to pharmacy, then it is written on the MAR indicated [REDACTED]. I did not know that Resident 5 did not have any dressings on, and do not know why they were not put on, but when you brought it to my attention I addressed the issue." Example 3 Resident 12 was admitted to the facility on [DATE] with [MEDICAL CONDITION] of the liver, heart failure, Diabetes, and reoccurring pressure ulcer to the coccyx (stage III). Resident 12's 1/16/12 Quarterly Minimum Data Set (MDS) assessment indicates that Resident 6 scored 15 points on the Brief Interview for Mental Status. This indicates that Resident 12 is cognitively intact. Resident 12's physician's orders [REDACTED]. Resident 12's Skin Grid dated 2/20/12 indicates she has a stage III pressure ulcer to her coccyx measuring 5 centimeters (cm) by 4 cm and .1 cm depth. Resident 12's physicians order dated 2/13/12 states "Limit time in chair to 1 hour every shift. Resident 12's Skin Integrity Assessment: Prevention and Treatment Plan of Care dated 7/29/11 states Resident 12 can be up in her wheelchair 1 hour per shift with an addition (no date) "can be up longer". On 2/23/12 at 7:15 AM Surveyor observed Resident 12 up in her wheelchair and was still up at 8:00 AM eating in the dining room. At 8:15 AM and 8:45 AM Resident 12 was observed in her wheelchair in her room. On 2/23/12 at 8:50 AM Surveyor interviewed CNA Q who stated she assisted Resident 12 to get up into her wheelchair this morning. CNA Q stated Resident 12 got into her wheelchair at approximately 7:00 AM this morning. On 2/23/12 at 1:00 PM Surveyor interviewed Resident 12 who stated that she lets staff know when she wants to lay down. On 2/23/12 at 12:15 PM Surveyor interviewed Director of Nursing (DON) B who agreed

Based on observation, record review, and interview the facility did not ensure that a resident having pressure sores received the necessary treatment and services to promote healing and prevent new sores from developing for 1 (Resident 1) of 6 residents reviewed for skin integrity issues, from a total sample of 15 residents. For Resident 1, the facility did not follow MD (Medical Doctor) orders and care plan for blue boots on BLE (Bilateral Lower Extremity) and keep pressure off toes. This is evidenced by the following: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility completed a Braden Skin Risk assessment dated ,[DATE] (no year indicated) indicated with a skin risk assessment score of 11. A score of 10-12 indicated high risk for skin breakdown. Facility policy titled Pressure Ulcer Prevention/Treatment dated November 1998 revised January 2009; April 2009 indicates but not all inclusive Braden high risk (10-12) ~ Reduce pressure to heels. The RAP (Resident Assessment Protocol) dated 6/2/10 indicated that Resident 1 had increased risk of pressure ulcers related to decreased ability to reposition and incontinence of bowel at times. Stated proceed to care plan. The care plan dated 10/18/10 interventions include keep pressure off feet, Blue boots on feet to keep pressure off and provide treatment per MD order. MD order dated 10/26/10 states No shoes, Blue boots and keep pressure off toes. MD skin and wound care consultation documentation dated 10/28/10 indicates under assessment and plan: Her heels are in pressure relieving boots. Per Skin Grid dated 1/26/11 Resident 1 currently has a stage 1 open area to her right foot 3rd toe measures 0.3x0.2 cm no depth and right foot 4th toe 0.8x0.5 cm no depth. Surveyor observed Resident 1 on 1/31/11 at 11:40 AM. Resident 1 without blue boots on BLE, Resident 1 had socks and slippers to BLE. On 1/31/11 at 2:02 PM Surveyor observed Resident 1 in bed with socks and slippers on BLE, heels resting on bed, and blankets resting on toes. Again no blue boots to BLE. Surveyor observed Resident 1 on 2/1/11 at 7:12 AM, Resident 1 in wheelchair with slippers on BLE. On 2/1/11 at 9:02 AM Surveyor interviewed CNA T (certified nursing assistant) CNA T stated she takes care of Resident 1 about 2 times a week. Stated Resident 1 always wears slippers as she has sores between toes. Surveyor asked CNA T about blue boots, CNA T looked at her care card and stated care card states blue boots to be worn. On 2/1/11 at 9:20 AM, Surveyor interviewed CNA L. CNA L stated she takes care of Resident 1 almost everyday and she got Resident 1 up this AM and placed slippers on Resident 1. CNA L stated care card states Resident 1 should have blue boots on at all times and she was not sure last time resident had them on. On 2/1/11 at 2:58 PM, Surveyor interviewed ADON C (assistant director of nursing). ADON C stated Resident 1 is to wear blue boots at all times per her MD order, care plan and care card. ADON C stated her expectation is that Resident 1 should wear blue boots at all times, and if blue boots are not on resident should have a heels up device or pillows floating heels when in bed.