Every finding on record at Mountain Meadows Health and Rehabilitation

Number of residents sampled: Number of residents cited: [NAME] Based on observation, interview, and facility policy review, the facility failed to ensure food items stored in the freezer were covered or sealed, and staff washed their hands between dirty and clean tasks and before handling clean equipment for 3 of 3 meals observed. The findings include: During an observation and interview on 08/10/2025 at 10:34 AM, Dietary Aide (DA) #1 turned on the hand washing sink faucet and washed her hands. After washing her hands, DA # 1 turned off the faucet with her bare hands, which contaminated her hands. Without rewashing her hands, DA #1 placed gloves on her hands, contaminating the gloves. DA #1 used her gloved hands to place slices of strawberries on top of the cake to be served to the residents for lunch. This surveyor asked DA #1 what she should have done after touching dirty objects and before handling food items. DA #1 stated she should have washed her hands. During an observation and interview on 08/10/25 at 10:52 AM, this surveyor observed an opened box of fish on a shelf in the walk-in freezer. The box was not covered or sealed, which exposed it to freezer burn. The Dietary Manager confirmed that the box of fish was not covered and would result in freezer burn. During an observation and interview on 08/10/25 at 11:04 AM, DA #1 used a marker to write the date on lids that covered bowls and contained cake to be served to the residents for lunch. Without washing her hands, she placed gloves on her hands, contaminating the gloves. DA #1 used her gloved hands, with her fingers inside the clean bowls, to be used in portioning dessert to be served to the residents for lunch, contaminating the bowls. DA #1 stated that before picking up the bowls she should have washed her hands. During an observation and interview on 08/10/25 at 11:59 AM, this surveyor observed DA #2 turn on the food preparation sink faucet to fill a pitcher with water. DA #2 turned the water off with her bare hands, contaminating her hands. Without washing her hands, DA #2 used her contaminated hands to pick up cups by the rims, placed them on the counter and poured water into the cups to be served to the residents for lunch. This surveyor asked DA #2 what she should have done after touching dirty objects and before handling clean equipment. DA #2 stated she should have washed her hands. During an observation and interview on 08/10/2025 at 3:50 PM, this surveyor observed DA #3 remove a pitcher that contained beverage from the refrigerator and placed it on the counter. Without washing his hands, DA #3 picked up cups by the rims and placed them on the counter. DA #3 poured beverages into the cups to be served to the residents for supper. This surveyor asked DA #3 what he should have done after touching dirty objects and before handling clean equipment. DA #3 stated, he should have washed his hands. During an observation and interview on 08/11/2025 at 7:35 AM, this surveyor observed DA #4 who was assisting with the breakfast meal, picked up cartons of yogurt, milk, milk shakes, and condiments and placed them on trays. Without washing her hands, DA #4 picked up cups with beverages in them by the rims and placed them on the trays to be served to the residents during the breakfast meal. This surveyor asked DA #4 what she should have done after touching dirty objects and before handling clean equipment. DA #4 stated, she should have washed her hands. A review of a facility policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary indicated, employees should wash their hands whenever entering or reentering the kitchen, before encountering any food surfaces, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and after engaging in other activities that contaminate the hands.

Number of residents sampled: Number of residents cited: Based on observations, interviews, and facility policy review, the facility failed to ensure that staff handled, stored, processed, and transported laundry in a manner that prevented the spread of infection based on two of two observations made. The findings include: During an observation on 08/10/2025 at 11:44 AM, Certified Nursing Assistant (CNA) #5 walked out of room [ROOM NUMBER] with linens that were touching her clothes. She took the linen to a linen room that was next door to room [ROOM NUMBER]. When asked, CNA #5 indicated the linens were removed from one of the beds in room [ROOM NUMBER]. During an observation on 08/10/2025 at 11:45 AM, CNA #6 walked out of room [ROOM NUMBER] with linens that were touching her clothes. She took the linen to a linen room next door to room [ROOM NUMBER]. She indicated these linens were removed from one of the beds in room [ROOM NUMBER]. During an interview on 08/10/2025 at 11:50 AM, CNA #5 stated that the dirty linen should have been in a plastic bag to prevent the spread of germs. She stated the facility was out of the plastic bags that were used to transport linen and there have not been dirty linen bags available for two days. During an interview on 08/10/2025 at 10:56 AM, CNA #6 stated that there were no bags on the unit large enough for the dirty linen. She acknowledged that the dirty linen should not have been touching her clothes. During an interview on 08/12/2025 at 5:20 PM, the Director of Nursing (DON) stated dirty linen should be in a bag when transported. He stated the dirty linen should be in a barrel in the shower room that's located outside of the secure unit and that housekeeping keeps 10-gallon trash bags for blankets. The DON pointed to the trash bags that were located on top of a barrel outside of the laundry room. During an interview on 08/12/2025 at 5:55 PM, the Administrator stated that linen should be placed in a trash bag before being taken out of a resident's room. During an interview on 08/13/2025 at 12:54 PM, Housekeeper #7 stated that the Housekeeping Department provided the staff with bags to put the linen in and that the bags were big enough for one blanket. Review of a policy titled, Laundry and Bedding Soiled, indicated that soiled laundry should be handled and transported according to best based practice for infection control. Contaminated linen should not be held close to the body during transport.

Based on observation, interview, and record review, the facility failed to ensure that residents receive a diet that meets their nutritional needs, is visually pleasing, prepared in a manner to maintain nutritional content and taste to encourage consumption and maintenance of good nutrition and hydration status. The findings are: 1. Resident #25 had a diagnosis of unspecified dementia. a. Review of the Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 02/28/2024 revealed Resident #25 received a score of 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status. Resident #25 required set up only for eating as they were capable of eating independently. a. On 05/05/2024 at 12:33 PM, Resident # 25 is observed with their lunch meal. The resident took a fork and inserted it multiple times into a large square of meatloaf. The resident is heard to say that the meatloaf looks like something that has been pulled from the toilet. The resident is observed to take a bit of the meatloaf and immediately lay the fork down on the plate. Resident #25 described the meatloaf as having no taste. b. On 05/05/2024 at 12:50 PM, a test tray was requested from the dietary department. Dietary Aide (DA) #1 reported they had run out of scalloped potatoes and meatloaf. DA #1 was asked how many residents didn't receive the meatloaf and scalloped potatoes. DA #1 relayed her belief that there were 2 or 3 residents who were given the substitute which was a beef patty and mashed potatoes. DA #1 was asked to retrieve the Dietary Manager (DM) who was outside. Upon entry, the DM was asked how many residents did not receive the meatloaf and scalloped potatoes. The DM reported everyone received the menu items. The DA provided a test tray consisting of a beef patty with tomato sauce, Brussels sprouts, and mashed potatoes. Upon initial entry into the kitchen the Brussels sprouts were observed on top of the range in large pots of water being cooked for lunch. The DM accompanied this surveyor to the conference room. This surveyor sampled a Brussels sprout. The texture of the Brussels sprout suggested it was overcooked, and it was void of any seasoning with a bitter flavor. A second surveyor agreed the vegetable was overcooked and tasted as if no seasoning of any kind had been added. The DM stated, Well, it's warm. The mashed potatoes were also bland and void of seasoning. The DM described the potatoes as needing more salt. c. On 05/06/2024 at 2:30 PM, a resident council meeting was held with 6 residents who unanimously agreed that the food in the facility was not good. The food was described as poorly cooked and lacking seasoning. Resident #28 described an incident in which he/she returned breakfast because it was inedible. Resident #28 described receiving a fried egg that was cooked hard, which was not his/her preference and toast that was burned on one side. Resident #27 described asking if he/she could have another tray. When the second plate arrived, it contained a second hard fried egg and burned toast. The resident reports that he/she was told by the staff, just don't turn it over. Resident #401 concurred with Resident #28, confirming the poor breakfast meal. d. On 05/07/2024 at 8:04 AM, three trays, 2 pureed and 1 regular, were observed sitting in the kitchen window waiting to be delivered. DA #1 was asked to obtain a thermometer so that the temperature of the pureed food could be measured. DA obtained a thermometer and cleaned the end with an alcohol pad. The thermometer was submerged into the pureed bread. When digital numbers stabilized the reading was 127 degrees Fahrenheit. The thermometer was removed, cleaned with an alcohol pad, and placed into what was identified as scrambled eggs. The eggs registered at 125.2 degrees Fahrenheit. At this time the Dietary Manager returned from the hall and began placing covers on top of the unserved trays. e. On 05/07/2024 at 8:10 AM, a test tray was requested and was brought to the conference room. The Dietary Manager was asked to identify the type of egg product that was used. The Dietary Manager described a liquid product that is packaged in a carton. The serving of eggs on the plate was observed to have a perfectly smooth surface on top, unlike scrambled eggs. Two surveyors, the Dietary Consultant, and the Nursing Consultant each took a sample of the egg product. The eggs were congealed into a solid mass that could be cut with a spoon. The eggs were void of any seasoning. f. On 05/08/2024 at 9:02 AM Review of the facility grievance records reveal Resident #55 filed a grievance on 03/18/2024 concerning the menus, food temperatures, and cooking procedures. During a follow-up on 04/02/2024 Resident #55 expressed that the food had been fine lately, however on 05/05/2024 at 10:20 AM the resident continued to verbalize dissatisfaction with the food. g. On 05/08/2024 at 10:00 AM, the DM was asked if she tasted the food served in the kitchen and the reply was yes. The DM was asked if the kitchen seasons the food prior to serving. The DM discussed that she is continually reminding the cooks that the recipe can be added too, but they can't delete ingredients, that she tells the cooks to season as if they were at home. The DM was asked how long Brussels sprouts should be cooked prior to serving. The DM described the presence of a new cook in the kitchen. The DM reports coming in on Sunday and seeing the Brussels sprouts being cooked on top of the stove, ready to serve at 10:20 AM. When asked when preparation of the vegetable should have taken place the DM verbalized that the cooking shouldn't have started until 10:30 AM. She continued that normally they would have been cooked in the oven. 2. A review of the Quarterly Minimum Data Set with an Assessment Reference Date (ARD) of 04/10/2024 indicated Resident #21 scored a 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. On 05/05/2024 at 12:15 PM, Resident #21 stated that Food here is not even fit to feed to the dogs. b. On 05/06/2024 at 1:38 PM, Resident #21 pulled a 1/2 a baked potato out of the refrigerator and stated, This is what I was served one day, only 1/2 a baked potato not a full one. The surveyor observed that the skin was wrinkled, the potato itself was dark brown with white throughout with a small portion missing. Resident #21 then stated, You can see where I tried to eat it but its inedible, this is what we are served for meals the food is disgusting here. Resident #21 reported they had not lost weight because of the snacks kept in their room.

Based on observation and interview the facility failed to ensure food was used prior to the use by date. The findings are: On 05/05/2024 at 10:30 AM, the following items were observed in what is referred to as the cook's refrigerator, all of which had a use by date of or before 05/04/2024: 1. 1/4 steam table pan of sliced ham 2. 1/4 steam table pan of macaroni and tomatoes. 3. 1/2 gallon container 1/2 full of stewed tomatoes. 4. 1/4 steam table pan of mechanical soft ham. 5. 1/4 quarter steam table pan of mechanical soft meatballs. 6. A plastic container of pizza sauce, 1/3 full. Also located in the cook's refrigerator was a plastic bag containing 4 hard-boiled eggs with a use by date of 04/28/2024 and a plastic 1 pound bag of sliced turkey with no use by date. On 05/05/2024 at 10:40 AM, a plastic container 1/2 full of chopped tomatoes was located in the walk in refrigerator. The tomatoes had a use by date of 05/04/2024. On 05/05/2024 at 10:47 AM, a 1 pound bag of spaghetti was observed on a shelf in the dry storage area. The bag was not sealed, leaving the food item exposed to air and contamination. On 05/05/2024 at 11:00 AM, a clear plastic container was observed on the bottom shelf of the work table. Inside the container were 14 individually bagged sugar cookies that had no date. On 05/08/2024 at 10:00 AM, the Dietary Manager (DM) said leftovers are utilized by the facility for no longer than two days. Review of a Policy titled Food Receiving and Storage revealed, all foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by

Based on observation, record review, interviews, and facility policy review, the facility failed to provide a meaningful program of activities for twelve residents reviewed for activities. Specifically, the facility failed to ensure the activity program was designed to meet the individual activity needs, interests, and abilities for Residents who reside on the secure unit, and the facility failed to ensure that activities were provided on the weekend for all 97 residents in the facility. The findings are: On 05/05/2024 at 11:20 AM, the surveyor identified that there were no activities being provided on the secure unit. A jigsaw puzzle was observed on the table. No residents were observed to attempt the puzzle. On 05/06/2024 at 2:30 PM, during the resident council meeting 6 members of the council reported that no activities are being held on the weekends. They reported that occasionally a CNA (Certified Nursing Assistant) will put-in a movie or games will be left in the dining room, but no structured activities are held. On 05/07/2024 at 2:07 PM, the surveyor observed no activities taking place on the secure unit. On 05/08/2024 at 11:00 AM, the Activity Director (AD) was asked to address the provision of activities on the secure unit. The AD described how the Unit Coordinator is typically responsible, however she is not working this week and it is virtually impossible to do both. The AD reported that in March of this year the previous AD and her assistant both quit on the same day. The AD reports that the Administrator is aware of the situation however there is nothing in place right now, but they are attempting to hire someone. When asked about weekend activities the AD described how she frequently comes in on Saturday to play bingo but that isn't something she can do all the time. When asked if anyone from the nursing staff was assigned to assist with activities on the weekend AD replied, Not at this time. On 05/08/2024 at 11:00 AM, the surveyor observed no activities being provided on the secure unit. CNA #4 was asked if an activity had been completed this morning. CNA #4 reported that the activity director came and turned on some gospel music. CNA #4 was asked how often someone from the activity department comes to the secure unit to complete an activity. CNA #4 reported, Usually never. CNA #4 continued to describe how the Unit Coordinator tries to have activities when working, however she is on vacation. CNA #4 reported no activities are usually held on the weekend. Review of a Policy titled, Preparation for Activities indicated the Activity Director/Coordinator is responsible for the scheduling of activity functions and programs, and that activity programs are coordinated with Nursing, Therapy, Dietary and Housekeeping Services, as well as any special services such as dialysis and outside appointment by individuals.

49689 50682 Based on observation, record review, and interview, the facility failed to ensure that resident had incontinent care performed before wound treatment care to prevent potential cross contamination of infection for 1 (Resident #19) sampled resident, to ensure a Percutaneous Endoscopic Gastrostomy (PEG) tube syringe was properly changed or cleaned after use for 1 (Resident #57) sampled resident, and to ensure a catheter bag was properly maintained for 1 (Resident #67) sampled resident. 1. Review of Medical Diagnoses revealed Resident #19 had diagnoses of multiple sclerosis and pressure ulcer of sacral region, stage 4. a. A quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 03/11/24 documented the resident scored 15 (13-15 indicates intact cognition) on a Brief Interview for Mental Status [BIMS]. b. On 05/05/2024 at 10:00 AM, Resident #19 said, I am worried about my pressure ulcer [PU]. I got my PU at another facility, and I had to get part of my sacrum removed. I am supposed to get a wound vac [Vacuum Assisted Closure of Wound - negative pressure wound therapy that helps wounds heal more quickly] but I currently have an infection and am worried about it healing. c. On 05/06/2024 at 10:09 AM, wound treatment for Resident #19 was observed. Licensed Practical Nurse [LPN] #2 was observed donning a gown and gloves required for Enhanced Barrier Precautions [EBP] before performing wound care. With staff assistance, resident was rolled to right side and resident's brief was opened. Solid waste measuring 2 inches by 4 inches was observed between the resident's buttocks and soiled the bottom edge of the bandage covering the wound. LPN #2 removed the soiled bandage and packing from wound, discarded in biohazard bag along with gloves. Performed hand hygiene with Alcohol Based Hand Rub [ABHR] then donned new gloves. d. On 05/06/2024 at 10:15 AM, LPN #2 cleansed inner to outer circumference around wound with moistened 4 inch x 4 inch gauze. With each swiping motion, a scant amount of solid waste was observed on the gauze as it was being placed in biohazard bag. e. On 05/06/2024 at 10:20 AM, LPN #2 packed 1 foot of saturated gauze in the base of wound with sterile cotton tipped applicator, then covered with an abdominal pad. The edge of the abdominal pad was 1/4 inch away from the solid waste and secured with tape. A scant amount of solid waste was observed on the tapes edge closest to the bm. f. A review of a Physician Order dated 04/18/2024: Wound Vac, Stage 4 Pressure Ulcer to Sacrum to be changed every Tuesday and Saturday in facility and on Thurs [Thursday] in clinic and as needed. Cleanse wound with Dial soap and water, Pat dry with gauze, use skin prep pad to peri wound, then use clear drape to peri wound to create a window pane around the wound. Cut black foam to fit wound bed. Do not allow black foam to touch intact skin, bridge away from bony areas, cover with the drape and confirm seal. Every day shift every Tue, Thurs, Sat AND as needed. g. A review of the Physician's order [PO] dated 4/25/24: Cleanse stage 4 pressure ulcer to sacrum with wound cleanser, pat dry with gauze, moisten [named brand of gauze], pack into wound loosely, cover with abdominal pad, secure with paper tape daily and as needed, until resident returns to wound clinic, every day shift and as needed. h. On 05/06/2024 at 10:30 AM, the surveyor asked LPN #2 if there was anything they would have done differently. LPN #2 said I would have went ahead and let the aides [CNAs -Certified Nursing Assistants] clean and change the resident's incontinent brief before I did treatment. I didn't want to change the brief because I haven't done that for a long time and could only remember, clean front to back, but that is about it honestly. The surveyor asked what could be a negative outcome of leaving solid waste in a resident's brief while performing treatment? LPN #2 said there was a potential for cross contamination. i. A facility policy provided on 05/07/2024 at 01:30 PM by the Nurse Consultant titled Wound Care did not address performing wound treatment before performing incontinent care. 2. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/24/2024 indicated Resident #57 scored a 5 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). A. A review of the Order Summary indicated Resident #57 had medical diagnoses of gastrostomy status and dysphagia following cerebral infraction. B. A review of the Order Summary revealed Resident #57 had an order that indicated Change feeding tube syringe every 24 hours. C. On 05/05/2024 at 12:15 PM, the surveyor observed a feeding tube syringe in a clear plastic bag hanging from an IV (intravenous) pole, water was collected in the bottom of the plastic. The surveyor observed a printed date that read, 02/05/24. D. On 05/06/2024 at 8:30 AM, the Surveyor observed that the feeding tube syringe had not been changed. E. On 05/07/2024 at 9:16 AM, during observation of medication administration for 400 Hall with Licensed Practical Nurse (LPN) #01, Resident #57 had a purple-colored syringe with no written date on the outside of the bag but with a stamped expiration date of 02/05/2024. LPN #1 used the syringe to verify placement of the resident's PEG tube with ten milliliters (mL) of air. Sixty mL of water flush, medication mixed with water, 60 mL of flush followed after medication through tube. LPN #01 placed syringe tube back inside the syringe but did not clean the syringe prior to putting it back in the storage bag and hung it back on the IV pole. F. On 05/07/2024 at 10:10 AM, the surveyor interviewed LPN #01 and asked, Should the PEG tube syringe have been cleaned and dried prior to you putting the plunger in the syringe and placing both in the storage bag? He stated, Probably. When asked, What is the date on the bag the PEG tube syringe is stored in? He stated, 02/05/2024 is the expiration date. When asked, How often should the syringe be changed? He stated, Supposed to be changed every night. G. On 05/08/2024 at 09:25 AM, the Surveyor interviewed the Director of Nursing (DON) and asked, How often should PEG tube syringed be changed? He stated, Every twenty four (24) hours. When asked, Why should they be changed every 24 hours? He stated, To prevent bacteria and stuff from harboring in the syringe. When asked, Should the PEG tube syringe be cleaned and dried after medication administration before replacing the syringe plunger back in the tube and placed both back in the storage bag? He stated, Yes. When asked, Why should it be cleaned and dried prior to putting the tube in the syringe and placing it back in the storage bag? He stated, That way it is clean and ready for the next scheduled use of it. H. The Facility provided a policy title, Enteral Tube Feeding via Syringe (Bolus) with a revision date of November 2018 that documented, General Guidelines 1. Use aseptic technique when preparing or administrating enteral feedings. 3. Review of an Admission Record revealed Resident #67 had a diagnosis of retention of urine. a. On 05/05/2024 at 11:00 AM, Resident # 67 was observed in bed with catheter bag uncovered and in the floor underneath the bed with an ant crawling on it. b. On 5/05/2024 at 11:00 AM, Resident # 67's nebulizer mask was observed lying on the nightstand uncovered, not in a bag. The bag laying on Resident # 67's nightstand was dated 4/27. c. On 05/07/2024 at 8:30 AM, Resident # 67's nebulizer mask in the drawer of his night stand and the nebulizer mask was not in a bag. d. On 5/07/24 at 8:30 AM, RN #1 stated that Resident #67's Foley catheter should have been in a privacy bag hanging from the bedside and not in the floor. e. On 05/07/24 at 8:30 AM RN #1 stated that Resident #67's nebulizer bag should have been stored in a plastic bag and not laying on the bedside night stand or in the drawer. Review of an Infection Control Policy indicated that 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. Review of a Foley Catheter insertion, Male resident with a revision date of October 2010 documented: Steps in procedure 25. Attach catheter to drainage tubing. Tape catheter to top of thigh or lower abdomen. Secure drainage tubing to bottom bed sheet with clip from drainage bag.

Based on observation, record review, and interview, the facility failed to ensure residents' fingernails were kept clean for 01 (Residents #08) of 01 sample mix residents; that residents were showered on scheduled shower days for 01 (Resident #81) of 01 sample mix resident; and that male residents were shaved to promote good personal hygiene for 02 (Resident R #81, #08) of 02 sample mix resident. The findings are: 1. Review of a Care Plan for Resident #81 dated 12/28/2023 revealed, .The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) dementia, debility, weakness, UTI (urinary tract infection) . Personal Hygiene/ Oral Care: The resident is able to: set up assist .Bathing/ Showering: The resident is able to: set-up assist . a. Review of a Facility In-service dated 01/29/2024 revealed, Medicare residents' showers MUST be done on their scheduled day. If a Medicare resident refuses, notify your nurse as you would with the LTC (Lont Term Care) resident. If a Medicare resident is in with therapy, work around therapy's schedule. Any issues or questions, come see me . b. Review of a Facility In-service dated 02/2024 revealed, Do not select not applicable when documenting showers. If you are unable to complete showers, leave them blank . c. Review of Resident #81's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/01/2024 revealed, .GG0130. Self-Care . E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. Supervision or touching assistance . I. Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands (excludes baths, showers, and oral hygiene). Supervision or touching assistance . d. Review of document titled ADL Bathing Task revealed that for 30 days, 04/09/2024 through 05/02/2024, Resident #81 received a shower/bath on 04/09/2024; 04/16/2024; 04/25/2024; and 05/02/2024 with a documented refusal on 04/23/2024. Resident #82 did not receive a shower on schedule days 04/11/2024; 04/13/2024; 04/18/2024; 04/20/2024; 04/27/2024; 04/30/2024; 05/04/2024. As of the time of receipt of this document, 10:07 AM, Resident #81 was not yet bathed today, 05/07/2024. e. On 05/05/2024 at 10:50 AM, the Surveyor observed Resident #81 lying in bed. The resident appeared unshaven. f. On 05/06/2024 at 08:44 AM, the Surveyor observed Resident #81 sitting up on side of bed. The resident appeared unshaved. g. On 05/06/2024 at 08:56 AM, the Surveyor interviewed Resident #81 and asked, Do you prefer to be unshaven with hair on your face? The resident stated, I would like the hair off of my face. h. On 05/07/2024 at 10:04 AM, the Surveyor interviewed Registered Nurse (RN) #01 at Resident #81's bedside and asked, Does Resident #81 appear well groomed? She stated, No. When asked, Does Resident #81 appear to need to be shaved? She stated, Yes. When asked, Can you tell me why Resident #81 should be clean shaved? She stated, Preferences and good grooming. When asked, When was the residents last bath/ shower? She stated, Last bath was on [05/02/2024]. When asked, Should the resident be shaved on shower days and as needed? She stated, Yes. i. On 05/08/2024 at 09:25 AM, the Surveyor interviewed the Director of Nursing (DON) and asked, Should the Resident #81 be bathed/ showered on the scheduled shower day? He stated, Yes, all residents be showered on their scheduled day. When asked, How often should Resident #81 be shaved? He stated, On shower days and as needed. 2. Review of the Order Summary indicated that Resident #8 had diagnoses of cerebral infarction and hemiplegia on left non dominant side. a. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/05/2024 indicated that Resident #8 scored a 14 (13-15 indicates cognitively intact) on the Brief Interview Mental Status (BIMS). b. Review of the Care Plan for Resident #8 revealed, Focus: the resident has an ADL self-care deficit, Goal: the resident will improve current level of function in ADLs through the review date, Interventions: Bathing/Showering: extensive assist X1, resident prefers shower. c. On 05/05/24 at 12:30 PM Surveyor observed that Resident #8's fingernails were an inch past the nail bed. The surveyor observed the nails were jagged, yellowing, and had a brown substance underneath them. The surveyor also observed that Resident #8 had not been shaved. Resident #8 stated they wanted their nails cleaned and trimmed and had asked staff for something to clean them with. Resident #8 then stated I would like to be shaved as well. d. On 05/06/2024 at 9:00 AM, the surveyor observed that Resident #8 had not been shaved or had nail care performed. e. On 05/07/2024 at 1:48 PM, the surveyor asked Certified Nursing Assistant (CNA) #4 to described Resident #8's nails. CNA #4 stated they are dirty and long. Surveyor asked if they needed to be trimmed and when should the task be done. CNA #4 said confirmed they did, and it should be done every time they get a shower. The surveyor asked what could happen with the resident having long nails. CNA #4 said could cause infection. The surveyor asked CNA #4 to look at Resident #8's face. CNA #4 said the Resident needs shaved. The surveyor asked what could be the issue for a Resident to not have their face shaved regularly. CNA #4 said dignity. f. On 05/07/2024 at 1:51 PM, the surveyor asked Licensed Practical Nurse (LPN) #1 to described Resident #8's nails. LPN #1 said they are long and need trimmed. The surveyor asked what could happen with the resident having long nails. LPN #1 said scratches. The surveyor asked for LPN #1 to look at Resident #8's face. LPN#1 said that they need shaved. g. A review of the facility policy Activities of Daily Living (ADLs), Supporting states Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure physician orders were followed to maintain a medication rate of less than 5% to prevent complications for 02 (Resident # 79, #57) of 03 residents observed during medication pass resulting in medication errors. Six errors were identified in 27 opportunities resulting in a medication error rate of 22.22%. The findings are: 1. Review of a Physician's Order for Resident #67 dated 08/28/2023 revealed, .[named brand] Inhalation Aerosol Powder Breath Activated 100-25 mcg/ACT (microgram/activation) (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day related to chronic obstructive pulmonary disease with (acute) exacerbation. Rinse/ spit after administration. (This is a combination medication for the treatment of chronic obstructive pulmonary disease and asthma. It contains fluticasone furoate, an inhaled corticosteroid.) a. On 05/07/2024 at 08:14 AM, during observation of medication administration for the 100 Hall with Registered Nurse (RN) #01, RN #01 did not have Resident #67 rinse their mouth after receiving this medication via inhaler, instead giving Resident #67 additional medications and had them swallow pills with water. b. On 05/07/2024 at 08:26 AM, the Surveyor interviewed RN #01 and asked, Should Resident #67 have rinsed and spit after the use of the inhaler? She stated, Yes, I forgot. When asked, Why should Resident #67 rinse and spit after inhaler use? She stated, Because of the risk of thrush. (Thrush is a fungal (yeast) infection that can grow in your mouth, throat, and other parts of your body.) 2. Review of a Physician's Order for Resident #79 dated 03/15/2024 documented, .Hydrocodone-Acetaminophen Tablet 5-325 mg (milligram) Give 1 tablet by mouth two time a day related to Primary Osteoarthritis, Left Shoulder Hold Date from 05/06/2024 at 12:37 PM to 05/07/2024 at 8:00 AM .Order dated 04/27/2024 Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 0.5 mg by mouth two times a day related to Dementia Hold Date from 05/06/2024 1239 to 05/07/2024 0800 . Refresh Tears Ophthalmic Solution . Instill 2 drops in both eyes four times a day for dry eyes . a. On 05/07/2024 at 08:31 AM, during observation of medication administration for the 100 Hall with Registered Nurse (RN) #01, Resident #79 did not receive Hydrocodone-Acetaminophen, and Lorazepam. Resident #79 was given one (01) drop per eye of the physician order eye drops. b. Review of Resident #79's Medication Administration Record (MAR) revealed the resident did not receive Hydrocodone-Acetaminophen Tablet 5-325 mg or Lorazepam Oral Tablet 0.5 mg (Lorazepam). The MAR also documented Refresh Tears Ophthalmic Solution .Instill 2 drops in both eyes four times a day for dry eyes administration times: 0600; 1200; 1600; 2000. c. On 05/07/2024 at 10:04 AM, the Surveyor interviewed RN #01 and asked, If a medication is on hold, but to be administered at 08:00 AM today, 05/07/2024, should the resident have receive it? She stated, Yes, it should be given. When asked, Why should it be given? She stated, Because it's following the order. When asked, If eye drops are not ordered at 0800 should they be administered? She stated, No. When asked, If the physician order documents 02 drops per eye should 02 drops be instilled? She stated, Yes. When asked, Why? She stated, So they are getting the required amount. 3. Review of a Physician's Order for Resident #57 dated 01/08/2024 revealed, .Guaifenesin Oral Tablet 400 .Give 400 mg via PEG (percutaneous endoscopic gastrostomy) tube two times a day for cough .New order placed at 10:40 AM, after medication pass, documented, Guaifenesin ER Tablet Extended Release 12 Hour 600 mg Give 1 tablet by mouth every 12 hours as needed for cough/ congestion .Change feeding tube syringe every 24hours . a. On 05/07/2024 at 09:16 AM, during observation of medication administration for 400 Hall with Licensed Practical Nurse (LPN) #01, Resident #57 did not receive Guaifenesin oral tablet that was ordered to be administered at 8:00 AM through PEG tube. Purple colored syringe with no written date on the outside of the bag but had a stamped expiration date of 02/05/2024 was used to verify placement with ten milliliters (mL) of air. Sixty mL of water flush, medication mixed with water, 60 mL of flush followed after medication through tube. LPN #01 placed syringe tube back inside syringe, and without cleaning the syringe placed it back in the storage bag and hung it back on the intravenous (IV) pole. b. On 05/07/2024 at 10:10 AM, the surveyor interviewed LPN #01 and asked, What is the date on the bag the PEG tube syringe is stored in? He stated, 02/05/2024 is the expiration date. When asked, How often should the syringe be changed? He stated, Supposed to be changed every night. c. On 05/07/2024 at 10:31 AM, LPN #01 came to the conference room and stated to the surveyor, The APN (Advanced Practice Nurse) said to discontinue the 400 mg and do Mucinex 600 mg. When asked, Should the order have been clarified prior to the end of the medication pass? He stated, I guess so, probably. d. On 05/08/2024 at 09:25 AM, the surveyor interviewed the Director of Nursing (DON) and asked, If a resident has a medication placed on hold until 05/07/2024 at 08:00 AM should it be administered on 05/07/2024 at 08:00 AM? He stated, Yes. When asked, Why should it be administered at that time? He stated, Because that's what the order says. When asked, If a resident has a physician order for [named brand] Ophthalmic Solution instill 02 drops in both eyes and is ordered for 0600; 1200; 1600; and 2000 be administered at 08:31 AM? He stated, No. When asked, Why should the eye drops not have been administered at that time? He stated, It wasn't the scheduled time. When asked, Where would the nurse sign off at that time? He stated, There is not a place. When asked, If the orders stated two drops per eye how many drops should be instilled in the residents eyes? He stated, Two. When asked, Why should two drops be instilled in the residents eyes? He stated, That's what the order says to do. When asked, If a resident uses an inhaler should the nurse have the rinse their mouth after administration and spit out the water? He stated, Yes. When asked, Why should they resident rinse and spit? He stated, To get the nasty taste out. When asked, If a resident has an order for Mucinex 400 mg due at 08:00 AM should the facility have the Mucinex 400 mg to administer to the resident? He stated, Yes. When asked, Why should the facility ensure it had the Mucinex 400 mg dosage? He stated, Because its ordered for the resident. When asked, Should the LPN ask the APRN to change the order to match the Mucinex 600 mg that the facility has in stock? He stated, No, that shouldn't happen. When asked, How often should PEG tube syringed be changed? He stated, Every twenty four (24) hours. When asked, Why should they be changed every 24 hours? He stated, To prevent bacteria and stuff from harboring in the syringe. When asked, Should the PEG tube syringe be cleaned and dried after medication administration before replacing the syringe plunger back in the tube and placed both back in the storage bag? He stated, Yes. When asked, Why should it be cleaned and dried prior to putting the tube in the syringe and placing it back in the storage bag? He stated, That way it is clean and ready for the next scheduled use of it. e. Review of Manufacturer Guidelines for [named brand] (fluticasone furoate 100 mcg and vilanterol 25 mg inhalation power) on 05/08/2024 at 11:49 AM that documented, .[named brand] can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using [named brand] to help reduce your change of getting thrush . 4. The facility provided a policy title, Enteral Tube Feeding via Syringe (Bolus) with a revision date of November 2018 that included, General Guidelines 1. Use aseptic technique when preparing or administrating enteral feedings. 5. The facility provided a policy titled, Administering Medications with a revision date of April 2019 that included, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed . 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions . Medications are administered in accordance with prescriber orders, including any required time frame . 6. Medication errors are documented, reported, and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee to inform process changes and or the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) . 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next. 23. As required or indicted for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered . 25. Staff follows established infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable . 6. The facility provided a policy titled, Documentation of Medication Administration with a revision date of November 2022 that documented, Policy heading: A medication administration record is used to document all medications administered. Policy Interpretation and Implementation 1. A nurse or certified medication aide (where applicable) documents all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication is documented immediately after it is given. 3. Documentation of medication administration includes, as a minimum: . e. date and time of administration . 7. The facility provided a policy titled, Adverse Consequences and Medication Error with a revision date of February 2023 that documented, .Medication Errors 1. A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications error include: a. Omission- a drug is ordered but not administered .Wrong time; and/ or h. Failure to follow manufacturer's instructions and/ or accepted professional stands (e.g., failure to shake medication that is labeled shake well; crushing a medication on the do not crush list without an order.

Based on observation, record review, and interview, the facility failed to ensure all pharmaceuticals were available for, and provided to, residents during medication administration for 2 (Residents #79 and #57) sampled residents. The finding are: 1. Review of Physician Orders for Resident #79 revealed an order dated 03/15/2024 that indicated, .Hydrocodone-Acetaminophen Tablet 5-325 mg (milligram) Give 1 tablet by mouth two time a day related to Primary Osteoarthritis, Left Shoulder Hold Date from 05/06/2024 1237 to 05/07/2024 at 8:00 AM Another order dated 04/27/2024 indicated, Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 0.5 mg by mouth two times a day related to Dementia Hold Date from 05/06/2024 at 12:39 PM to 05/07/2024 at 8:00 AM . a. On 05/07/2024 at 08:31 AM, during observation of medication administration for the 100 Hall with Registered Nurse (RN) #01, Resident #79 did not receive Hydrocodone- Acetaminophen and Lorazepam. b. On 05/07/2024 at 09:47 AM, the Surveyor interviewed RN #01 and asked, Should Resident #79 have received Hydrocodone-Acetaminophen and Lorazepam during the 08:00 AM medication pass? She stated, No, it's been on hold. c. On 05/07/2024 at 6:44 PM, a review of Resident #79's Medication Administration Record (MAR) revealed the resident did not receive Hydrocodone-Acetaminophen Tablet 5-325 mg or Lorazepam Oral Tablet 0.5 mg (Lorazepam). 2. Review of Physician Orders for Resident #57 revealed an order dated 01/08/2024 that indicated, .Guaifenesin Oral Tablet 400 (Guaifenesin) Give 400 mg (milligram) via PEG (percutaneous endoscopic gastrostomy) tube two times a day for cough . New order placed at 10:40 AM, after medication pass, documented, Guaifenesin ER Tablet Extended Release 12 Hour 600 mg Give 1 tablet by mouth every 12 hours as needed for cough/ congestion . a. On 05/07/2024 at 09:16 AM, during observation of medication administration for 400 Hall with Licensed Practical Nurse (LPN) #01, Resident #57 did not receive Guaifenesin oral tablet. b. On 05/07/2024 at 09:16 AM, LPN #02 stated, We only have the 600 mg Mucinex, but the APRN is here today, so I'll get her to change it. c. Review of a Progress Note dated 05/07/2024 at 09:49 AM revealed, Guaifenesin oral tablet 400 mg .Give mg via PEG-Tube two times a day for cough order to be clarified. d. Review of Physician Orders for Resident #57 revealed an order dated 05/07/2024 at 10:40 AM that specified, guaifenesin oral tablet 400 mg (Guaifenesin) Give mg via PEG-Tube two times a day for cough discontinue. e. Resident #57's MAR was reviewed on 05/07/2024 at 5:54 PM and indicated the resident did not receive the first ordered dose of Guaifenesin Oral Tablet 400 mg on 05/07/2024. f. On 05/08/2024 at 09:25 AM, the surveyor interviewed the Director of Nursing (DON) and asked, If a resident has a medication placed on hold until 05/07/2024 at 08:00 AM should it be administered on 05/07/2024 at 08:00 AM? He stated, Yes. When asked, Why should it be administered at that time? He stated, Because that is what the order says. When asked, If a resident has a physician order for Mucinex 400 mg due at 08:00 AM, should the facility have Mucinex 400 mg to administer? He stated, Yes. When asked, Should the LPN go to the Advanced Practice Registered Nurse (APRN) after the medication was due and not found to have the correct dosage and have the APRN change the order? He stated, No, that should not happen. g. Review of a Policy titled Administering Medications with a revision date on 2019 that indicated, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frames .

43262 49689 Based on observation, interview, and record review, the facility failed to (1) ensure that residents receiving inhaled corticosteroids (an anti-inflammatory medication) were instructed to rinse their mouths to prevent irritation and infection for 1 (Resident #67) sampled resident, (2) ensure residents receive medications as ordered for 2 (Residents #57 and #79) sampled residents, (3) ensure that wound care was performed in a manner to prevent contamination and infection for 1 (Resident #19) sampled resident, and (4) ensure that residents were monitored and treated for urinary tract infections for 1 (Resident #22) sampled resident. The findings are: 1. Review of an Admission Record revealed Resident #67 was readmitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure. a. Review of a 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/2024 revealed Resident #67 scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). b. Review of a Physician's Order dated 08/28/2023 revealed, .[named brand] Inhalation Aerosol Powder Breath Activated 100-25 mcg/ACT (microgram/activation) (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day related to chronic obstructive pulmonary disease with (acute) exacerbation. Rinse/ spit after administration. a. On 05/07/2024 at 08:14 AM, during observation of medication administration for the 100 Hall with Registered Nurse (RN) #01, RN #1 did not have Resident #67 rinse mouth after receiving corticosteroid medication via inhaler, instead giving Resident #67 additional medications and had the resident swallow pills with water. b. On 05/07/2024 at 08:26 AM, the surveyor interviewed RN #01 and asked, Should Resident #67 have rinsed and spit after the use of the inhaler? She stated, Yes, I forgot. When asked, Why should Resident #67 rinse and spit after inhaler use? She stated, Because of the risk of thrush. c. Review of Manufacturer Guidelines for [named brand] (fluticasone furoate 100 mcg and vilanterol 25 mg inhalation power) that were received on 05/08/2024 at 11:49 AM revealed, .[named brand] can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using [named brand] to help reduce your change of getting thrust . 2. Review of Physician's Orders for Resident #79 revealed diagnoses of osteoarthritis, dementia, and blepharitis (inflammation of the eyelids). a. Review of a quarterly MDS with an ARD of 05/01/2024 revealed that Resident #79 scored 0 (0-7 indicates severe cognitive impairment) on the BIMS. b. Review of Physician's Orders revealed an order dated 03/15/2024 that specified, .Hydrocodone-Acetaminophen Tablet 5-325 mg (milligram) Give 1 tablet by mouth two time a day related to Primary Osteoarthritis, Left Shoulder Hold Date from 05/06/2024 1237 to 05/07/2024 0800 .Order dated 04/27/2024 Lorazepam Oral Tablet 0.5 mg (Lorazepam) Give 0.5 mg by mouth two times a day related to Dementia Hold Date from 05/06/2024 1239 to 05/07/2024 0800 . [named brand] Ophthalmic Solution Instill 2 drops in both eyes four times a day for dry eyes . c. On 05/07/2024 at 08:31 AM, during observation of medication administration for the 100 Hall with RN #01, Resident #79 did not receive Hydrocodone-Acetaminophen and Lorazepam. Resident #79 was given one drop per eye of the ordered eye drops. d. Review of Resident #79's Medication Administration Record (MAR) revealed the resident did not receive Hydrocodone-Acetaminophen Tablet 5-325 mg or Lorazepam Oral Tablet 0.5 mg (Lorazepam). e. On 05/07/2024 at 10:04 AM, the surveyor interviewed RN #01 and asked, If a medication is on hold, but to be administered at 08:00 AM today, 05/07/2024 should the resident have receive it? She stated, Yes, it should be given. When asked, Why should it be given? She stated, Because it's following the order. When asked, If eye drops are not ordered at 0800 should they be administered? She stated, No. When asked, If the physician order documents two drops per eye should two drops be instilled? She stated, Yes. When asked, Why? She stated, So they are getting the required amount. 3. On 05/07/2024 at 09:16 AM, during observation of medication administration for 400 Hall with Licensed Practical Nurse (LPN) #01, Resident #57 did not receive Guaifenesin oral tablet that was ordered to be administered at 08:00 AM via Percutaneous Endoscopic Gastrostomy (PEG) (a tube is passed into the stomach through the abdominal wall to provide nutrition or medication) Purple colored syringe with no written date on the outside of the bag but had a stamped expiration date of 02/05/2024 was used to verify placement with ten milliliters (mL) of air. Sixty mL of water flush, medication mixed with water, 60 mL of flush followed after medication through tube. LPN #01 placed syringe tube back inside syringe without cleaning the syringe before putting it back in the storage bag and hung it back on the intravenous (IV) pole. a. On 05/07/2024 at 10:10 AM, the surveyor interviewed LPN #01 and asked, Should the PEG tube syringe have been cleaned and dried prior to you putting the plunger in the syringe and placing both in the storage bag? He stated, Probably. When asked, What is the date on the bag the PEG tube syringe is stored in? He stated, 02/05/2024 is the expiration date. When asked, How often should the syringe be changed? He stated, Supposed to be changed every night. a. On 05/08/2024 at 09:25 AM, the Surveyor interviewed the Director of Nursing (DON) and asked, If a resident has a physician order for Refresh Tears Ophthalmic Solution instill 02 drops in both eyes and is ordered for 0600; 1200; 1600; and 2000 be administered at 08:31 AM? He stated, No. When asked, Why should the eye drops not have been administered at that time? He stated, It wasn't the scheduled time. When asked, Where would the nurse sign off at that time? He stated, There is not a place. When asked, If the orders stated two drops per eye how many drops should be instilled in the residents eyes? He stated, Two. When asked, Why should two drops be instilled in the residents eyes? He stated, That's what the order says to do. When asked, If a resident uses a [named brand] inhaler should the nurse have the rinse their mouth after and administration and spit out the water? He stated, Yes. When asked, Why should they resident rinse and spit? He stated, To get the nasty taste out. When asked, How often should PEG tube syringed be changed? He stated, Every twenty four (24) hours. When asked, Why should they be changed every 24 hours? He stated, To prevent bacteria and stuff from harboring in the syringe. When asked, Should the PEG tube syringe be cleaned and dried after medication administration before replacing the syringe plunger back in the tube and placed both back in the storage bag? He stated, Yes. When asked, Why should it be cleaned and dried prior to putting the tube in the syringe and placing it back in the storage bag? He stated, That way it is clean and ready for the next scheduled use of it. b. Review of a 'Med Pass Observation Report' for RN #01 dated 04/12/2024 that revealed, .Observation: Ophthalmic administered properly (i.e. 3-5 minutes between drops): met . Inhalers properly administered (i.e. 1 min between puffs); mouthpiece cleaned . Medication administered per manufacturers specifications . Calculated Error Rate: Total # of errors: 0 x 100/ Total # of Doses Given: 3= 0% c. Review of a 'Med Pass Observation Report' for LPN #02 with no date revealed, .Observation: Medication via feeding tube properly administered (i.e. flushed with water before & after med) . Calculated Error Rate is not filled in. d. Review of a Policy titled, Enteral Tube Feeding via Syringe (Bolus) with a revision date of November 2018 that documented, General Guidelines 1. Use aseptic technique when preparing or administrating enteral feedings. 4. Review of Medical Diagnoses revealed Resident #19 had diagnoses of multiple sclerosis and pressure ulcer of sacral region, stage 4 (indicates full-thickness skin loss extends through the fascia with considerable tissue loss). a. Review of a quarterly MDS with an ARD of 03/11/24 revealed Resident #19 scored 15 (13-15 indicates intact cognition) on the BIMS. b. On 05/06/2024 at 10:09 AM, Licensed Practical Nurse [LPN] #2 was observed performing wound care. With assistance from another staff, the resident was rolled to right side and resident's brief was opened. Solid waste 2 inches by 4 inches was observed between resident's buttocks and soiled the bottom edge of bandage covering the wound. No barrier was placed under the soiled brief nor was incontinent care performed before performing wound care. c. On 05/06/2024 at 10:20 AM, when LPN #2 was finishing wound care, the edge of an abdominal pad was 1/4 inch away from the solid waste and secured with tape. A scant amount of solid waste was observed on the tapes edge closest to the solid waste. d. Review of the Physician's Order dated 04/25/2024 indicated, Cleanse stage 4 pressure ulcer to sacrum with wound cleanser, pat dry with gauze, moisten [named gauze and antimicrobial solution], pack into wound loosely, cover with abdominal pad, secure with paper tape daily and as needed. e. On 05/06/2024 at 10:30 AM, the surveyor asked LPN #2, Is there anything you would have done differently? LPN #2 said I would have gone ahead and let the aides [CNAs - Certified Nursing Assistants] clean and change Resident #19's incontinent brief before I did treatment. I didn't want to change the brief because I haven't done that for a long time and could only remember, clean front to back, but that is about it honestly. The surveyor asked what could be a negative outcome of leaving solid waste in brief while performing treatment. LPN #2 said, The potential for cross contamination. 5. Review of the Order Summary indicated that Resident #22 had diagnoses of Alzheimer's disease and urinary tract infection. a. Review of the Order Summary indicated that Resident #22 had a telephone order for UA (urinary analysis) w/reflex to Culture (STAT (immediately) Eligible) on 04/26/2024. b. Review of the Lab Results that was received on 04/26/2024 and reviewed on 04/30/2024 indicated that Resident #22 had brown, cloudy urine that contained excess bacteria and mucus. c. Review of the MAR for May indicated that Resident #22 received Ceftriaxone Sodium Solution Reconstituted 1 GM Use 1 gram intravenously one time only for UTI for 1 Day was administered on 05/01/24 at 2:40 PM. (This medication is an antibiotic.) d. Review of the Care plan for Resident #22 specified, Focus: resident has an ADL (activities of daily living) self-care deficit, Goal: the resident will improve current level of function in ADLs through the review date, Interventions: Personal Hygiene: the resident requires 1 assist by 1 staff with personal hygiene, Toileting: the resident requires extensive assist of 2 staff for toileting. e. Review of the Quarterly Minimum Data Set (MDS with an Assessment Reference Date of 03/29/24 indicated that Resident #22 received a score of 0 (severe cognitive impairment) on the BIMS. Section H indicated that Resident #22 is always incontinent of bowel and bladder. f. On 05/07/2024 at 8:45 AM, the surveyor asked CNA #1 if Resident #22 is exhibiting symptoms of a urinary tract infection (UTI). CNA #1 responded, I first reported it two weeks ago, when giving a shower the resident had a puddle of pee in the floor. It was bloody, brown in color and the odor was fishy. The surveyor asked if they had any symptoms more recent than two weeks ago. CNA #1 said, Yes, we have reported it to the nurse. The surveyor asked what could happen to the resident with continued symptoms. CNA #1 said, Well she can go septic. g. On 05/07/2024 at 8:50 AM, the surveyor asked Licensed Practical Nurse (LPN) #1 to look at Resident #22's UA (Urinalysis) lab results. LPN #1 read off the results and stated that the resident received a one-time Rocephin shot. The surveyor asked if Resident #22 had any orders or reported symptoms since then. LPN #1 said, No. The Surveyor asked what could happen if resident does have continued symptoms. LPN #1 said the resident could go septic, and that they should have followed up on Resident #22. h. On 05/07/2024 at 9:20 AM, the surveyor asked the Director of Nursing (DON) the protocol for lab work. DON stated, We use [named laboratory], the results are reviewed by the APN (advanced practice nurse) who reviews and adjust orders as needed. i. On 05/07/2024 at 10:48 AM, the surveyor asked the APN, What is the protocol for ordering a resident a Rocephin injection for a UTI. The APN stated, Monitor the site they give it in When asked, Is the residents urine retested to verify the injection was effective. The APN stated, No, we do not retest urine. j. On 05/07/2024 at 1:30 PM, the surveyor asked CNA #2 if they had reported symptoms of a continued UTI for Resident #22. CNA #2 stated that they overheard a CNA report it to LPN #1 on Sunday when surveyors entered the building around lunch. k. On 05/07/2024 at 1:53 PM, CNA #2 approached the surveyor stating that CNA #3 wanted to have a phone interview. The surveyor went into the shower room on 100 Hall with CNA #2 who called CNA #3. The surveyor asked when CNA #3 last worked. CNA #3 stated, I work Thursday, Friday, Saturday, and Sunday. The surveyor asked what happened with Resident #22. CNA #3 stated that about two weeks ago she reported that Resident #22 was still bleeding to LPN #1, who told them that the UA had not been reported. CNA #3 continued stating they reported the symptoms again and was told the resident was on an antibiotic a few days later. CNA #3 stated they reported the same symptoms again last weekend, and that LPN #1 made the CNA feel brushed off about it. After the phone interview CNA #2 said that the last time they had Resident #22 in the shower, they had urine in the floor. The surveyor asked CNA #2 to describe what the urine looked like. CNA #2 said the urine was blood tinged, with a foul odor, and it had lumps that looked like clots. CNA #2 stated they only wanted what was best for Resident #22. l. Review of Progress Notes, revealed an entry dated 05/07/2024 at 2:54 PM and authored that LPN #4 that documented, CNA at 1430 (2:30 PM) reported resident has blood in urine in AM shower, was with CNA when they changed .brief at 1430 scant amount of blood noted in brief, no foul odor noted, u/a with c/s performed resident tolerated well. Another progress note indicated, : IN/OUT catheter performed using sterile technique. Urine noted to be blood tinged. No foul odor noted. UA obtained and sent to WRMC. Resident tolerated procedure well. Signed by the ADON (Assistant Director of Nursing) on 05/07/2024 at 1:30 PM. Another progress note indicated, Received preliminary result from u/a, contacted DON and APRN (advanced practice registered nurse) and received orders from APRN to start [cranberry] tabs 2 tabs TID (three times a day) x 2 days until culture grows out on specimen. signed by LPN #4 on 05/07/2024 at 2:54 PM. Another progress note states Ertapenem Sodium Solution Reconstituted 1 GM Inject 1 gram intramuscularly every 24 hours for infection for 10 Days signed by LPN #3 on 05/08/2024 at 11:39 AM. m. Review of the Order Summary indicated new orders for Resident #22 on 05/07/2024 that indicated Cath UA with c/s r/t blood in urine and Azo Tabs Oral Tablet (Phenazopyridine HCl) Give 2 tablet by mouth three times a day related to UTI. An order on 05/08/24 states Ertapenem Sodium Solution Reconstituted 1 GM Inject 1 gram intramuscularly every 24 hours for infection for 10 Days.

Based on observation, interview, and record review, the facility failed to ensure that smokeless tobacco was kept at the nurses station to prevent accidents for 2 (Resident #45 and Resident #66) out of 2 sampled residents and failed to ensure that a fall mat was well maintained for 1 (Resident #20) of 1 sampled residents. The findings are: 1. A review of the annual Minimum Data Set (MDS) with an Assessment reference Date (ARD) of 04/17/2024 revealed Resident #45 scored a 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. A review of the Care Plan for Resident #45 revealed, Focus: The Resident uses smokeless tobacco, Goal: The Resident will not use smokeless tobacco without supervision through the review date, Interventions: Instruct the resident about the facility policy on smoking: locations, times, safety concerns. b. On 05/05/2024 at 11:40 AM, the surveyor observed Resident #45 sitting up in recliner, on the bedside table over Resident #45's lap sat two plastic containers of wintergreen snuff. One of the plastic containers was missing a lid, with smokeless tobacco lining the inside of the container. The surveyor observed a brown liquid dripping down Resident #45's chin, a lump is observed on the right side bottom lip area. c. On 05/06/2024 at 9:30 AM, the surveyor observed that the smokeless tobacco is still sitting on the bedside table. The surveyor observed brown stains in the floor next to the bedside table. d. On 05/07/2024 at 8:45 AM, Certified Nursing Assistant (CNA) #1 said that they did not know if Resident #45 could have tobacco, and it had always there as long as they worked in the facility. The surveyor asked what could happen with the smokeless tobacco on the bedside table. CNA #1 stated that another resident could get into it. e. On 05/07/2024 at 8:50 AM, Licensed Practical Nurse (LPN) #1 stated that the smokeless tobacco has always been on [Resident #45's] table for the four years they had worked there. The surveyor asked what could happen with the smokeless tobacco on the bedside table. LPN #1 stated the resident could choke on it. f. A review of the Smoking Safety Screen and Care plan revealed that 1. Notes on Safety from IDTC (i.e. resources required to support resident, other resident safety, potential injury, capabilities): Resident is able to use smokeless tobacco under supervision of staff. Smokeless tobacco is stored in nurse's station. 2. Review of an Admission Record revealed Resident #67 had diagnoses of urine retention and nicotine dependence. a. Review of a Care Plan initiated 01/23/2023 revealed, Resident will not use smokeless tobacco without supervision throughout review date . b. On 05/05/2024 at 11:00 AM, the surveyor observed Resident #67 sitting up at bedside with chewing tobacco in their mouth and dribbling from their mouth. A package of chewing tobacco was observed in the resident's left front shirt pocket, another on the bedside table, and multiple packs of chewing tobacco noted in drawer at bedside. c. On 05/06/2024 at 9:00 AM, the surveyor observed Resident #67 lying in bed with a package of chewing tobacco in front pocket. d. On 05/07/2024 at 8:10 AM, the surveyor observed Resident # 67 sitting up in bed with chewing tobacco dribbling from mouth and a package of chewing tobacco in their front shirt pocket. e. On 05/07/2024 at 8:30 AM, Registered Nurse (RN) #1 verified Resident #67 had smokeless tobacco in their mouth and in their pocket. RN #1 said that the family brings in chewing tobacco and that staff will take it to the nurse's station and store it. f. A facility policy provided by the Administrator in the Survey Readiness Book titled Smoking Policy-Residents with revision date of December 2007 stated .15. Smoking articles for residents without independent smoking privileges: Residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc . Anyone who provides smoking supervision to residents shall be advised of any restrictions/concerns and the plan of care related to smoking. 3. Review of the Care Plan for Resident #20 dated 12/20/2023 revealed, .The resident is at risk for falls r/t (related to) impaired mobility, severely impaired cognition, ALZ (Alzheimer's)/dementia, incontinence, behaviors, AEB (as evidenced by) fall risk score, h/o (history of) falls, uses w/c (wheelchair) for mobility & lift for transfers. 2-1-21 unwitnessed fall; 6/7/22 Resident had unwitnessed fall with no injury; 8/25/23- unwitnessed fall with no injury Date Initiated: 12/20/2023 .fall mat at bedside . a. Review of the quarterly MDS with an ARD of 03/13/2024 revealed Resident #20 scored 03 (indicates severely impaired) on the Staff Assessment for Mental Status (SAMS). b. On 05/05/2024 at 10:34 AM, the surveyor observed Resident #20 lying in bed. A fall mat on the floor by the bed had a tear near the center, and a piece of the fall mat is missing from the side. c. On 05/06/2024 at 2:36 PM, the surveyor observed the fall mat by the bed of Resident #20 to have a tear near the center and a piece of the fall mat missing from the side. d. On 05/06/2024 at 2:37 PM, the surveyor interviewed Certified Nurse Aide (CNA) #5 at Resident #20's bedside and asked, Should the residents fall mat be torn and have a piece missing from the side? She stated, No, ma'am it shouldn't. When asked, Why should the fall mat be in proper working condition without tears and pieces missing from the side? She stated, Because it'll get where us or the resident can get caught on it and fall. e. On 05/06/2024 at 02:28 PM, the surveyor interviewed the Director of Nursing at Resident #20's bedside and asked, Should the residents fall mat be torn and have a piece missing from the side? He stated, No, ma'am it needs to not have any missing pieces or tears in case they fall that way it protects them from any injuries. f. The facility policy titled, Hazardous Areas, Devices and Equipment with a revision date of 2017 included, Policy Statement: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Policy Interpretation and Implementation 1. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the Safety Committee .Identification of Hazards: 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to .Devices and equipment that are improperly used or poorly maintained .Assessment and Analysis of Hazards: 1. Assessment and analysis of hazardous areas and equipment will include resident-specific information including identification of vulnerable residents. 2. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous . 50682

Based on record review and interview, the facility failed to ensure the comprehensive care plan was individualized to addressed appropriate care and services for use of oxygen for 01 (Resident #54) of 01 sampled residents. The findings are: Review of a Face Sheet revealed Resident #54 was admitted to the facility on [DATE] with a diagnosis of dyspnea. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/2024 reveled a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). On 05/05/2024 at 10:50 AM, the Surveyor observed a lab technician currently in Resident #54's room conducting a chest x-ray. On 05/05/24 at 11:07 AM, the Surveyor interviewed Resident #54 and asked, Do you know why you just had a chest x-ray? Resident #57 stated, They did the x-ray because I can't breathe. Resident #57 is observed to be receiving 2.5-3.0 liters of oxygen via nasal cannula. On 05/07/24 at 01:36 PM, the Surveyor observed Resident #54 on 2 liters of oxygen via nasal cannula. Review of Physician Orders revealed an order dated 05/05/2024, .Oxygen as needed for Shortness of Breath 2 liters/min per nasal cannula (As needed) PRN . Review of a Care plan for Resident #57 which was revised on 05/06/2024 did not reveal an indication the resident was receiving oxygen. On 05/07/2024 at 10:32 AM, the Surveyor interviewed the Minimum Data Set (MDS) Coordinator and asked, Should Resident #54's care plan document oxygen use? She stated, Yes. When asked, Why should it document oxygen use?, she stated, So it is accurate, is placed on the care plan, and staff know [the resident] uses oxygen. On 05/07/2024 at 03:05 PM, the Surveyor interviewed the Director of Nursing (DON) and asked, Should Resident #54's care plan document oxygen use? He stated, Yes. When asked, Why should it document oxygen use?, he stated, That way all the staff know. Review of a facility policy titled, Care Planning- Interdisciplinary Team, revision date of September 2013, revealed, Policy Statement: Our facility's Care Planning/ Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on observation, record review, and interview, the facility failed to ensure that before a resident was allowed to self-administer updraft treatments, the Interdisciplinary Team (IDT) conducted an assessment to determine if this practice was safe, obtain a physician order for self-administration, and develop a care plan to address educating the resident on self-administration, to prevent potential errors in administration for 1 (Resident #64) sampled resident. The findings are: Review of a quarterly Minimum Data Set with an Assessment Reference Date of 05/01/2024 revealed Resident #64 scored 00 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status. Review of Resident #64's Physician Orders did not reveal a self-administration order. Review of Resident #64's Care Plan did not reference the resident self-administrating medication. On 05/07/2024 at 8:01 AM, Resident #64's was observed lying in bed. A nebulizer treatment was running with the mask not secured to the resident's face, and no nurse present in the room. The surveyor went to the hallway and asked Registered Nurse (RN) #1 to come to Resident #64's bedside. Upon entry to Resident #64's room and seeing the nebulizer, she stated, I didn't put that on [Resident #64], but it's not good. When asked, Do you know how long Resident #64 has had the nebulizer running with the face mask off? She stated, No, it must've been this morning's dose, they increased it, but I'd say it's been since [6:00 AM] in the morning or so. I'd have to look at the documentation. When asked, Does Resident #64 have a self-administration order? She stated, No, [the resident] does not, [he/she] has to be watched. On 05/07/2027 at 8:06 AM, the Surveyor interviewed the Director of Nursing (DON) and asked, Can you tell me what you observe? He stated, Resident #64 with [his/her] nebulizer mask not on [Resident #64's] face, it's hanging off. When asked, Do you know how long Resident #64 has had the nebulizer running with the mask off? He stated, No. When asked, Does Resident #64 have a self-administration order? He stated, No. When asked, Should the resident be left unattended to self-administer medications?, he stated, No. On 05/07/2027 at 8:08 AM, the Surveyor interviewed the Assistant Director of Nursing (ADON) and asked, Can you tell me what you observe? She stated, Resident #64's been left with nebulizer on face, and I don't know how long it's been unattended. When asked, Does resident #64 have a self-administration order?, she stated, I don't think so. When asked, Should the resident be left unattended to self-administer medications?, she stated, No. The facility provided a policy titled, Self-Administration of Medications with a revision date of December 2016 that documented, Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. 3. If the team determine that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications . The facility provided a policy titled, Administering Medications with a revision date of April 2019 that documented, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .27. Residents may self-administer their own medications only if the Attending Physician, in conjunction with their Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) was accurately coded to indicate the presence of a Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 (Resident #57) out of 1 sampled resident. The findings are: 1. Review of an Order Summary revealed Resident #57 had diagnoses of gastrostomy status and dysphagia following cerebral infraction. 2. Review of a quarterly MDS with an Assessment Reference Date of 04/24/2024 revealed Resident #57 scored a 5 (0-7 indicates severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Section K indicated, Feeding Tube (e.g., nasogastric, or abdominal PEG) .No had been on 04/24/2024 at 5:58 AM. 3. On 05/08/2024 at 11:25 AM, the Surveyor interviewed the MDS Coordinator, and asked them to check section K in the most recent MDS, dated [DATE], and identify if Resident #57 was coded for a PEG tube. The MDS Coordinator stated, Resident #57 has a peg tube, and it's marked no. Should have been marked yes. The MDS Coordinator said it was important to have an accurate MDS to provide the correct plan of care. Review of the facility policy Certifying Accuracy of the Resident Assessment revealed, All personnel who completes any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment.

Based on interview and record review, the facility failed to ensure that changes in the status or care were reflected in the care plan in a timely manner and that care plans were reviewed in a timely manner for 1 (Resident # 67) sample mix resident. The findings are: 1. Review of an Admission Record indicated Resident #67 had a diagnosis of urine retention. 2. Review of the 5-day Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 04/10/2024, revealed that in Section H Bladder and Bowel, H0100 Appliances- a. indwelling catheter was checked. Resident #67 received a score of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). 3. Review of the Care Plan for Resident #67 revealed it had not been revised to reflect the placement of an indwelling catheter. 4. On 05/07/2024 at 10:30 AM, the MDS coordinator was asked if the care plan should have been revised when Resident #67 was readmitted and the MDS 5-day admission reflected the resident was admitted with a indwelling catheter. The MDS Coordinator confirmed it should have been. The MDS Coordinator reviewed the care plan and said the care plan was not revised to include the indwelling catheter after the MDS reflected it. The MDS Coordinator was asked if a care plan should be updated when a resident has a change such as the placement of a indwelling catheter and she confirmed it should have been. 5. On 05/07/2024 the Administrator reported that the facility did not have a policy or procedure concerning care plans or the timely revision of care plans.

Based on observation, and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect all 91 residents who received meals from the kitchen (Total Census: 91) as documented on the Midnight Census report provided by the Administrator on 04/03/23 at 3:07 PM. The findings are: 1. On 04/04/23 at 9:38 AM, Dietary Employee (DE) #1 opened the refrigerator door and removed pitchers of orange juice and tea and a bottle of cranberry juice and placed them on the counter. Without washing her hands, she picked up glasses by the rims and placed them on the counter. She then poured the beverages into the glasses to be served to the residents with their lunch meal. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 2. On 04/04/23 at 9:42 AM, DE #1 opened the refrigerator door and removed a half gallon of milk and placed it on the counter. At 9:45 AM, she washed her hands, pulled tissue papers from the dispenser, and turned off the faucet. She used the same tissue to dry her hands, contaminating her hands. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents who received a pureed diet. She picked up the bowls with her fingers touching the interior surfaces of the bowls and put them up. 3. On 04/04/23 at 10:11 AM, DE #2 removed a ziplock bag of cheese slices from the refrigerator and placed it on the counter. She picked up a bag of bread from the counter and untied the bag. Without washing her hands, she removed slices of bread from the bag and placed them on a plate. She removed slices of cheese from the bag and placed them on the slices of bread and topped them with slices of bread. She then put cheese sandwiches in individual bags and placed them on a shelf in the refrigerator to be served to the residents who asked for a cheese sandwich with their lunch meal. 4. On 04/04/23 at 10:41 AM, DE #1 turned on the faucet and washed her hands. She turned off the faucet with tissue paper, contaminating the tissues. She then, used the same tissue to dry her hands, contaminating her hands. She picked up plates, with her fingers inside of the plates, and placed them on the plate warmer. 5. On 04/04/23 at 11:00 AM, DE #2 opened the refrigerator door and removed a pitcher of apple juice and placed it on the counter. Without washing her hands, she picked up a glass by the rim and placed it on the counter. She poured apple juice into the glass and placed the glass on the cold side of the steam table to be served to the resident with their lunch meal. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 6. The facility policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, provided by the Dietary Supervisor on 04/04/23 at 12:11 PM documented, .6. Employees must wash their hands: .h. After engaging in other activities that contaminates the hands .

Based on observation, and interview, the facility failed to ensure expired medications and medical supplies were removed and placed into an area for destruction to prevent potential administration to residents. The failed practice had the potential to affect all 91 residents who resided in the facility and received medication and or medical supplies from 2 of 2 medication rooms and 1 medication cart according to a list provided by the Administrator on 04/03/23 at 3:07 p.m. The findings are: 1. On 04/06/23 at 9:45 a.m., the following items were in the Medication Supply Room: a. 2 - Incentive Spirometer with an expiration date of 1/28/2021. b. 1 - Urinary Catheter Kit dated 1/28/23. c. 1 - Hypodermoclysis Prep Kit with an expiration date of 9/25/22. d. 1 - Intravenous Start Kit with an expiration date of 1/13/23. e. 2 - Statlocks with expiration dates of 12/28/2021 and 5/28/2022. f. 1 - medium (red top) vial with an expiration date of 1/17/2022. 2. On 04/06/23 at 9:50 a.m., the following items were in the 200 Hall Medication Room: a. 1 - 8oz bottle of hand sanitizer with an expiration date of 7/22. b. 3 - Angio catheters with expiration dates of 6/2016, 12/31/2020 and 1/28/2022. c. 4 - red top tubes with expiration dates of 6/17/2021 and 7/10/2021. d. 1 - Pink top tube with an expiration date of 9/10/2021. e. 1 - Grey told tube with an expiration date of 6/30/2020. f. 1 - Sani cloth with an expiration date of 7/2020. g. 1 - Sterile single use needle with an expiration date of 11/2022. 3. On 04/06/23 at 10:00 a.m., the 300 Hall Medication Cart, contained the following expired medication: a. 1 container of hemorrhoid ointment with an expiration date of 1/2023. 4.The facility policy titled, Storage of Medications, provided by the Administrator on 04/06/23 at 11:51 a.m. documented, .Policy Interpretation and Implementation . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be destroyed .

Based on observation, and interview, the facility failed to ensure a comprehensive, person-centered care plan was developed to address the necessary care and monitoring related to the administration of antidepressants and psychotropic medications to enable staff to determine the effectiveness of the medication and promptly identify any potential adverse effects for 1 (Resident #89) of 18 (Residents #2, #11, #22, #24, #29, #32, #39, #42, #53, #66, #69, #71, #75, #80, #81, #82, #86 and #89) sampled residents who had Physician Orders for an antidepressant and 3 (Residents #75, #82 and #89) sampled residents who had Physician Orders for an antipsychotic. The findings are: Resident #89 had diagnoses of Alzheimer's Disease with Late Onset, Unspecified, Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/22/23 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received an antipsychotic medication and an antidepressant medication 4 of the 7 day look back period. a. The Physician Orders dated 02/22/23 documented, .Escitalopram Oxalate Oral Tablet 10 MG [milligram] (Escitalopram Oxalate) Give 1 tablet by mouth one time a day related to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety . Risperidone Oral Tablet 0.25 MG (Risperidone) Give 0.25 mg by mouth two times a day related to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety . b. The Care Plan with an initiated date of 02/22/22 did not address the use of antidepressant and/or antipsychotic medications. c. On 04/06/23 at 10:14 AM, the Surveyor asked the Administrator who was responsible for writing Care Plans. She directed this Surveyor to Registered Nurse (RN) #1 and stated, He is responsible for our long-term care, Care Plans. d. On 04/06/23 at 10:16 AM, the Surveyor asked RN #1 if the use of antidepressant and antipsychotic medications should be included on the plan of care. RN #1 stated, Yes. The Surveyor asked RN #1 to review Resident #89's Care Plan to determine if the use of antidepressant and antipsychotic medications were listed. After reviewing the plan of care RN#1 stated, No, it's not there. e. The facility policy titled, Goals and Objectives, Care Plans, provided by the Administrator on 04/06/23 at 11:51 AM documented, Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved .

Based on observation, record review and interview, the facility failed to ensure privacy was provided during the provision of perineal hygiene care to prevent potential exposure of the resident's body to visitors or other residents for 1 (Resident #49) of 33 (Residents #49, #58, #21, #57, #26, #15, #18, #3, #69, #63, #40, #67, #8, #1, #45, #2, #24, #59, #11, #27, #17, #75, #327, #6, #51, #38, #71, #54, #61, #65, #22, #46 and #20) sampled residents who required assistance with bathing. This failed practice had the potential to affect all 77 residents who required assistance with bathing, according to list provided by the Director of Nursing (DON) on 2/09/22. The findings are: Resident #49 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 11/23/21 documented the resident was severely impaired in cognitive skills for daily decision-making per a Staff Assessment for Mental Status, required extensive physical assistance of two-plus persons for toilet use, and was always incontinent of bowel and bladder. a. The Care Plan with a revision date of 11/23/21 documented, .The resident has bladder incontinence r/t [related to] Confusion, Dementia, Impaired Mobility, Inability to communicate needs, Loss of peritoneal tone . Clean peri-area with each incontinence episode . b. On 02/07/22 at 8:48 AM, Resident #49 was lying in bed. The window blinds beside her bed were open, leaving the window that overlooked the front driveway exposed. Certified Nursing Assistant (CNA) #1 and CNA #2 performed perineal (peri) care. They removed Resident #49's incontinent brief, cleaned Resident #49's perineal area with wet wipes and applied a new brief. Both CNAs then washed their hands and exited the room. CNA #1 was asked, How should you have provided privacy while you were providing peri care? She stated, I should have closed the curtain. I am sorry. The resident's spouse, who was standing in the room, stated, .I am glad you said something about that. c. On 2/8/22 at 9:50 AM, the Director of Nursing (DON) was asked, When do you expect your staff to provide privacy when performing peri care on a resident? She stated, Any time they are doing peri care. She was informed of the blinds on the window by Residents #49's bed not being closed during peri care. She stated, People driving by could have seen in . d. The facility policy titled, Perineal Care, provided by the DON on 02/10/22 at 8:31 AM, documented, .The purposes of this procedure are to provide cleanliness and comfort to the resident to prevent infections and skin irritation and to observe the resident's skin condition . The policy did not address providing privacy.

Based on observation, interview and record review, the facility failed to ensure staff routinely changed the linens on a resident's bed to maintain a comfortable and homelike environment for 2 (Residents #67 and #75) of 46 (Residents #67, #75, #58, #21, #57, #26, #15, #18, #3, #69, #63, #40, #77, #41, #1, #45, #2, #24, #59, #49, #11, #27, #17, #76, #127, #6, #51, #38, #71, #54, #61, #55, #22, #46, #20, #327, #43, #12, #9, #25, #44, #8, #78, #47, #377 and #65) sampled residents were dependent on staff to change their bed linens. The findings are: 1. Resident #75 had diagnoses of Dementia, Kidney Failure, and Type II Diabetes. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/22 documented the resident scored 15 (13-15 13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), required limited assistance of two-plus persons with personal hygiene, required one-person physical assistance with bathing, and was always continent of bowel and bladder. a. The Care Plan with a revision date of 10/27/21 documented, .The resident has an ADL [activities of daily living] self-care performance deficit . history of falls, Gait balance problems . The resident has MIXED bladder incontinence r/t [related to] requiring toileting transfer assist . Clean peri-area with each incontinence episode . b. On 2/6/22 at 12:47 PM, Resident #75 stated, We don't get a bath as often as we should, and we don't get our sheets changed once a week. c. On 2/6/22 at 2:13 PM, Resident #75 stated her sheets were not being changed and that she scratches at night due to having bugs in her bed. d. On 2/6/22 at 2:29 PM, the Director of Nursing (DON) accompanied the surveyor to Resident #75's room because the resident stated she thought she had bugs in her bed. The DON inspected the resident's bed, and there were brown specks scattered on the linens, but no bugs were identified. e. On 02/08/22 at 1:48 PM, Certified Nursing Assistant (CNA) #1 was asked, How often are the residents' linens changed? She stated, Every other day or if soiled; we change them when they get their bath. 2. Resident #67 had diagnoses of Type 2 Diabetes, Urinary Incontinence and Altered Mental Status. The Quarterly MDS with an ARD of 1/13/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and was independent with setup for personal hygiene and bathing. a. The Care Plan with a revision date of 11/25/21 documented, .The resident has an ADL [activities of daily living] self-care performance deficit r/t unsteady gait .falls .has limited physical mobility . b. On 2/6/22 at 12:48 PM, Resident #67 stated she was admitted in late November (2021) and her sheets were not changed until she was moved to the COVID Unit in late January (2022). 3. On 02/08/22 at 1:52 PM, CNA #5 was asked, How often are the residents' sheets changed? She stated, They are changed when they get their showers. She was asked, What if the resident refuses their shower or does not get their shower? She stated, If they don't get their shower, then if they ask us or if we see it's dirty, we will change them. She was asked, Are you aware of [Resident #75] or [Resident #67] not getting their bed linens changed for over a week at a time? She stated, I don't work this hall a lot . I'm just helping out . 4. The facility policy titled, Bed, Making an Occupied, provided by the DON on 02/10/22 at 8:31 AM documented, .The purpose of this is to provide the resident with a clean and comfortable environment and to prevent skin irritation and breakdown . The policy did not address how frequently the bed should be made.

Complaint # (AR 589) was substantiated, all or in part, with these findings: A. Based on record review and interview, the facility failed to ensure adequate supervision was provided to prevent an elopement for 1 (Resident (R) #34) of 2 (Residents #34 and #14) case mix residents who were a high risk for elopement. The failed practice resulted in Immediate Jeopardy which caused or was likely to cause caused serious harm, injury or death for Resident #34, who was a high risk for elopement and left the building through a propped open door and had the potential to cause more than minimal harm to 16 residents who were at risk for elopement, as documented on a list provided by the Nurse Consultant on 11/2/20 at 8:17 p.m. The Nurse Consultant was informed of the Immediate Jeopardy situation on 11/2/20 at 7:09 p.m. 1. R #34 had a [DIAGNOSES REDACTED]. The Medicare 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/20 documented the resident scored a 2 (0 - 7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS); required supervision with bed mobility, transfers, eating and toileting, was ambulatory, had verbal behavioral symptoms occurring 1 to 3 days; and wandering behavior occurring 1 to 3 days. a. The Comprehensive Care Plan with an initiated date 3/10/20 documented, .Resident needs secured/special care neighborhood due to [MEDICAL CONDITION] and ambulatory. Goals Resident will benefit from placement on the secured neighborhood as evidenced by having a secure environment in which to wander with no episodes of elopement the next review period .Interventions/Tasks Address wandering behavior by walking with resident, redirect from inappropriate area, engage in diversionary activity of choice Date initiated 6/24/20, Administer and monitor the effectiveness and side effects of medications as ordered. Date initiated 6/24/20 .Investigate possible uncommunicative physical needs, pain, over stimulation etc as possible behavioral triggers and address PRN (as needed) Date initiated 6/24/20 . The resident is an elopement risk/wanderer r/t (related to) Alzheimer's/dementia, unaware of safety issues and ambulatory Date initiated 3/10/20 .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .Identify patterns of wandering: is wandering purposeful, aimless or escapist? Is resident looking for something? Does it indicate the need for more exercise. Intervene as appropriate .Resident has a current [DIAGNOSES REDACTED].Interventions/Tasks .Redirect resident as needed. Date initiated 10/30/20 . b. The Nsg (Nursing) Elopement Risk with Care Plan with date of 4/8/20 documented, (Resident #34), Category: High Risk to Wander, Score: 13, Description: 1 month, Date 4/8/20 .Instructions: complete on admission/readmission, at 72 hours, and one month later, with change of condition and annually on all residents. For residents at risk or high risk to wander, update quarterly. C. 1 month .C Mobility 3. Is ambulatory .E. History of Wandering. 2. Has history of wandering .F. Diagnosis. 5. Medical [DIAGNOSES REDACTED].H. Complete at 1 month, quarterly, annually with significant change and ADHOC screening. 2. Has wandered in the past month. K. Care Plan At risk for elopement 1 Care Plan Focus: The resident is an elopement risk/wander rt Alzheimer's/dementia, unaware of safety issues and ambulatory. Intervention: Distract resident rom wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Intervention: Identify patterns of wandering: Is wondering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate .Provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes . c. On 11/2/20 at 11:03 Am, The Nsg (Nursing) Elopement Risk with Care Plan with date of 10/26/20 documented, Resident #34, Category: High Risk to Wander, Score: 13, Description: 1 month, Date 10/26/20 .Instructions: complete on admission/readmission, at 72 hours, and one month later, with change of condition and annually on all residents. For residents at risk or high risk to wander, update quarterly. g. other .C Mobility 3. Is ambulatory .E. History of Wandering. 2. Has history of wandering .F. Diagnosis. 5. Medical [DIAGNOSES REDACTED].H. Complete at 1 month, quarterly, annually with significant change and ADHOC screening. 2. Has wandered in the past month. K. Care Plan At risk for elopement 1 Care Plan Focus: The resident is an elopement risk/wander rt Alzheimer's/dementia, unaware of safety issues and ambulatory. Intervention: Distract resident rom wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Intervention: Identify patterns of wandering: Is wondering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate .Provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes . d. Progress notes with date of 9/29/20 documented, Alert Note Text: Threatening Behavior Monitored Tried Well Being model and tried redirecting resident away, resident has refused all interventions, Advanced [MEDICATION NAME] Registered Nurse (APRN) notified as with hall manger, DON (Director of Nursing) were notified. e. Progress notes dated of 9/29/20 documented, Note Text: when this nurse came back to unit to do HS (hours of sleep) med (medication). Pass at 2030 (8:30 p.m.) resident was standing next to med (medication) cart c/o (complaining) about other resident on how she was being a cry baby and how she should take care of her. HS medications taken with ease, resident continued to harass new roommate, Well Being model and attempts to give cool down were unsuccessful r/t (related to) no matter where we moved resident and tried to stay away from resident to let cool down resident would follow, resident finally found a resident to talk with. Resident went and laid down in bed for a while. CNA (Certified Nursing Assistant) reports that at last rounds resident had gotten OOB (out of bed) and was yelling at roommate stating that she had to go to bed now. CNA redirected her, resident then started wondering though rooms, CNA went into a room to redirect her from sleeping resident that she went out then help door closed on CNA, to where CNA had to use personal cell phone to call for help. This nurse and LPN went to help, tried redirecting to get her to let go of the door, redirection only agitated her more to where resident was hitting staff with coat hangers, throwing pitcher of water at staff and residents, then throwing shoes, was on phone with APRN (Advanced Practical Nurse Practitioner), explaining this behavior, (APRN) heard resident threating staff with violence and screaming has ordered a 1 time only 0.5ml (milliliters) of [MEDICATION NAME] IM (intramuscular), resident received that in left gluteal area as resident is attempting to bite staff and kick at staff. This nurse and 2 other nurses left secure area of our memory unit to give cool down as shift change started, I was on my other hall receiving report and med count when the 3rd shift CNA came and stated she needed help on the unit that this resident was attacking another resident with a fly swatter, resident has now got a large skin tear and unsure of any bruising from being hit with Fly swatter. Called APRN #1 stating resident attacked another resident explaining what has happened. While on the phone with Physician resident threw pitcher of water on this nurse and was screaming. [MEDICATION NAME] is at this time seems to be working, other resident is with general population. Resident has 1 nurse to be 1 on 1 with at this time to keep other residents and this resident from harm. f. The Nsg -I and A (Incident and Accident) Follow up dated 9/29/30 documented, 2300 (11:00 p.m.) resident became aggressive and twisted another resident's arm causing a skin tear Long Term Intervention: placed on one on supervision until discharge to geri psych evaluation, resident transferred to (geri-psyche facility) for geri-psych eval Added to the Care Plan: yes Ensure MD (medical doctor) & (and) Family Notification: APRN #1 2315 (11:15 p.m.) 2400 (12:00 a.m.). g. Progress Notes dated 9/30/20 documented, Physician Communication Conversation: (Registered Nurse (RN) #2) Sent 9/28/2020 2:56 PM, .I have done a COC (Change of Condition) and family notified on (R 34) d/t (due to) resident being observed using inappropriate and abusive language towards her roommate on 2 separate occasions, also stating she feels like everyone is talking about her and she should just leave Staff found her belongings packed in her room. h. The Progress Note dated 9/30/20 documented, Pushing monitored, unable to redirect and cool down periods ineffective .Note text: kicking, hitting Monitored unable to redirect and cool down periods ineffective. APN #1 notified and orders given to send resident to (geri-psych) for eval (evaluation). i. The OLTC Witness Statement Form with date of 10/26/20 documented, Witness Full Name: (Nursing Aide (NA) #1,) Job Title: NA, Shift 1st .State in your own words what you witnessed (be very descriptive) and sign below: I stepped to take trash out on 300 Hall. As I walking out I notice (Resident #34) walking in the parking lot out back. I call her over to me and got the nurse to walk her back to the 400 Hall . The Office of Long Term Care (OLTC) Witness Statement Form with date of signed date of 11/3/20 documents, Date 10/26/20, Witness Full Name: CNA #13, Job Title: CNA . State in your own words what you witnessed (be very descriptive) and sign below. I do not know what happened. Signature of Witness with date of 11/3/20. The Office of Long Term Care (OLTC) Witness Statement Form with date of 11/10/10, received from the Administrator was reviewed and documeneds, Time 2:30 Witness Full Name: Housekeeping #5, Job Title Housekeeping .State in you own words what you witnessed (be very descriptive and sign below. I was on 400 hall helping Housekeeping #4 clean, we talked to R 34 went inside another room to clean. When we came outside the room they were searching for R 34. She had had escaped from the side door due to the door being propped open for meal trays. They found her outside by 300 Hall patio. The OLTC Witness Statement Form with date of 10/26/20 documented, ;Witness Full Name: (CNA #12) Job Title: C NA, Shift 7-3 (7:00 a.m. - 3:00 p.m.) .State in your own words what you witnessed (be very descriptive) and sign below: There was one other CNA, 2 Housekeepers, and a charge nurse on 10/26/20. At the time of the incident, I was feeding a resident, and everyone was aware of that. My partner came into the room and asked if I had seen that resident that escaped. I stated, no we notified the nurse and we all began to search. I have no knowledge who opened the door because I was feeding another resident. j. Progress Notes documented, Effective Date 10/26/20 14:29 Physician Contact: APRN 1430 (2:30 p.m.) Family Contact: (family member), Incident Description: Resident was located trying to elope from the exterior door on 400 Hall, Immediate Intervention: Resident was brought back inside from the outside . k. The Incident Witness Statement with date of 10/26/20 documented, Relation: Staff, Name: (CNA #1), Position: Certified Nursing Aide, Date: 10/26/20, Who took statement: (RN #2), Statement: Stated (Resident #34) was just in her room when she passed by to go into another room to help feed and deliver lunch trays. She looked in (Resident #34) room when passing back by and she did not see her so she alerted all staff on the hall and immediately began looking for her. She was noted to be walking out the door at the end of hallway behind staff member taking out the trash. l. The Nsg-I and A (Incident and Accident) follow up with date of 10/30/20 documented, Date and I and A Description: 10/26/20 1347. Long Term intervention: Resident attempted to elope out the 400 hall door. Will in-service staff to redirect resident away from the door when resident is at the door. Added to the Care Plan: Yes . The Multi-Purpose In-Service Training/Communication Form documented, Date initiated 10/30/20, Name of instructor/person initiating form: DON, Topic of training or communication: R #34 is to be redirected away from entry ways when she is by the doors. Signatures documented on the sheet only contained 9 Certified Nursing Assistants (CNA's), 3 Licensed Practical Nurses (LPN's) and 1 Registered Nurse (RN). The facility used the same intervention of redirecting resident that was originally put on the Care plan on 6/24/20 after the elopement and the intervention was not put on the Care Plan until 10/30/20. m. On 11/01/2020 at 11:13 AM, the there was a plastic blocking on the 400-hall inside the building. The Surveyor walked around building to the 400-hall exit door. The door was propped open with a rock and no alarm was sounding. Photos taken of door and rock holding door open. This Surveyor was met at the door by CNA #1 and was asked why the door was propped open. She stated, We were getting fresh air. n. On 11/1/20 at 11:22 AM, R #34 was seen wandering the 300 hall. o. The Nsg Elopement Risk with Care Plan with date of 11/2/20 documented, (Resident #34), Category: High Risk to Wander, Score: 13, Description: other, Date 11/2/20 .Instructions: complete on admission/readmission, at 72 hours, and one month later, with change of condition and annually on all residents. For residents at risk or high risk to wander, update quarterly. G.other .C Mobility 3. Is ambulatory .E. History of Wandering. 2. Has history of wandering .F. Diagnosis. 5. Medical [DIAGNOSES REDACTED].H. Complete at 1 month, quarterly, annually with significant change and ADHOC screening. 2. Has wandered in the past month. K. Care Plan At risk for elopement 1 Care Plan Focus: The resident is an elopement risk/wander rt Alzheimer's/dementia, unaware of safety issues and ambulatory. Intervention: Distract resident rom wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Intervention: Identify patterns of wandering: Is wondering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate .Provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes . p. On 11/2/20 at 1:39 PM, the Nurse Consultant was asked, Did you do a reportable on (R 34's) elopement? She stated, I didn't recall an elopement, but she went outside, didn't do a reportable because she was in line of sight. q. On 11/2/20 at 1:40 PM, the Administrator was asked via telephone Tell me about (R 34's) elopement on 10/26/20? She stated, To my knowledge, we never lost sight. The Administrator was asked, How long was she out of the building? She stated, Just a couple of minutes. The Administrator was asked, Where was she located when she was found? She stated, On sidewalk at end of 400 Hall. The Administrator was asked, Who located (R 34?) She stated, One of the CNA's. The Administrator was asked, How did (R 34) get out of the building? She stated, I wasn't here at that time but was told she held door for 15 seconds, they heard alarm and watched her walk out and brought her back. r. On 11/2/20 at 2:58 PM, the exit door on the 400 hall was tested by this surveyor. The door will open by just pushing a green emergency egress button. The door can also open by putting in a code on a keypad. s. On 11/4/20 at 2: 51 PM, Certified Nursing Assistant (CNA) #1 stated, all I know, we were in the middle of passing trays and I noticed (R 34) talking to housekeeper, when I came out of giving a tray, I asked where (R 34) was, so I started looking for her, she likes to go to others bathrooms and she roams, I told the other girl, (staff), she said (R 34) isn't in her room and we started looking for her. CNA #1 was asked, When did you start looking for her? She stated, About 1:10 p.m., while we were looking for her someone brought her back, don't know who brought her back and don't know where found her. CNA #1 was asked, Does she wander? She stated, Yes. That is why she was on the lock down unit on the 300 hall. CNA #1 was asked, What interventions were put in place after she eloped? She stated, Every 15-minute checks, we finished doing that day and told second shift. CNA #1 was asked, Did you notify nurse when you thought she was missing? She stated, Yes. CNA #1 was asked, How long have you worked on the 400 Hall? She stated, CNA #1 was asked, Have you observed the 400 hall door propped open? She stated, Yes. I have seen it propped open, but it is guarded like getting laundry or personal clothes. CNA #1 was asked, Do you believe that a resident (R 34) who wanders, is a high risk for elopement, should be on a non-secured unit without proper interventions? She stated, No. But she tested positive. CNA #1 was asked, What protections did the facility put in place when they knew she had wandering behavior and high risk for elopement? She stated, I don't know what they did. t. On 11/4/20 at 3:08 PM, Registered Nurse (RN) #2 was asked, When was (R #34) admitted to the secure unit? She stated, 3/10/20. RN #2 was asked, Is (R #34) a high risk for elopement? She stated, She was. RN #2 was asked, Does (R #34) wander and how often? She stated, she does and generally a couple of days a week. RN #2 was asked, Can you tell me what happened the day (R 34) eloped? She stated, She was in her room, then had came out, she had wandered a little before that, seemed agitated, so I talked to the APRN and she put in an order for [REDACTED].#1 say she wasn't in her room, she checked the bathroom, I went to the exit door on 400 Hall and there was a gentleman coming from the 300 hall and he had her, we brought her back in and I put her on q (every) 15 minute checks, notified APRN, Administrator, ADON, DON. RN #2 was asked, How did she get out of the building? She stated, I don't know. RN #2 was asked, Who was the guy who brought her had her after she got out of building? She stated, I don't know, he had PPE (Personal Protective Equipment) on. RN #2 was asked, Did you hear the door alarm go off? She stated, No ma'am. RN #2 was asked, What was the immediate intervention put in place for (R 34) after she eloped? She stated, 15 minute checks and redirection. RN #2 was asked, Was the alarms working the day she eloped? She stated, I don't believe I heard an alarm go off . On 11/2/20 at 2:30 PM, the fifteen-minute checks for R 34 were reviewed. The document does not have a date on it and started at 18:20 and the last check was on 2300. u. On 11/5/20 at 8:15 AM, the Maintenance Director was asked, When was the alarm on top installed? He stated, Before I got here, it was supper glued on, I came in on Monday (11/2/20) or Friday (10/30/20) and changed the battery, the bottom had screw missing. The Maintenance Director was asked, So, Monday was the top alarm working? He stated, The battery was taken out when I think was turned into isolation ward. The Maintenance Director was asked, When was that (turned into an isolation ward)? He stated, 2 or 3 weeks ago. The Maintenance Director was asked, So, 2 or 3 weeks ago the battery for the top alarm was taken out? He stated, Yes. v. A policy titled Wandering and Elopements documented, Policy Statement The facility will identify who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .1. If identified as at risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . A policy titled Elopements documented, Policy Statement Staff shall investigate and report all cases of missing residents . A document titled Multi-Purpose In-service Training/Communication Form documented, Date initiated 11/2/20, Name of instructor/person initiating form the DON, Topic of training or communication: Door Propping and closing doors, Description of training provided or information communicated: Door propping is not allowed and will result in termination if caught. Also, please ensure that doors close completely and lock behind you when accessing entrances. A form titled Multi-Purpose In-service Training/Communication Form documented, Date initiated 11/2/20, Name of instructor/person initiating form DON, Topic of training or communication: Elopement Book, Description of training provided or information communicated: The elopement books can be found in each nursing station. These books have the information needed if a resident elopes as well as the residents at risk for elopement. Please review these books and be familiar with the contents of the book. A form titled Multi-Purpose In-service Training/Communication Form documented, Date initiated 11/2/20, Name of instructor/person initiating form DON, Topic of training or communication: Elopement Risk assessments, Description of training provided or information communicated: Elopement Risk assessments are to be done on admission, readmission, quarterly, annually, change of condition, and any elopement events. w. On 11/10/20 at 10:36 AM, Nurse Aide (NA) #1 was asked, Can you tell me what happened when (R 34) eloped? She stated, I was on the 300 hall, I go to take the biohazard trash out that day and came out door and was going to biohazard shed. When I got to the parking lot, I seen (R 34) behind smokers shack. I asked her what she was doing and asked her to come with me. I got her to follow me to 300 Hall door and knocked on 300 hall back door, and asked (LPN #1) what hall she belonged to, he got her. NA #1 was asked, Was there any staff outside when you found her in the parking lot out by the smoker's shack? She stated, No, ma'am. No one was out smoking, and no nurses or nobody was in the smoking shack or outside. It was just me catching her by taking out biohazard trash. I didn't touch her because my hands were dirty from taking out the biohazard trash. (LPN #1) walked her around the where she belonged. NA #1 was asked, Does (R #34) wander and how often? She stated, Yes. She wanders often in and out of residents' rooms. NA #1 was asked, So, you did you see any other staff outside when you found her in parking lot? NA #1 was asked, She stated, No. she was by smoking shack, she said I was looking for my room. On 11/10/20 at 10:53 AM, CNA #12 was asked, Where you working the 400 Hall when (R 34) eloped? She stated, Yes. CNA #12 was asked, Tell me what happened? She stated, I was feeding a resident when she got out, I didn't know she got out. My hall partner-CNA #1, she asked if I had seen (R #34,) I told her no. So, I immediately got up from feeding, told (RN #2. ()CNA 1) and I proceeded to go in and out of rooms and bathrooms and didn't see her, so I looked around side of building on the 400 hall and didn't see her and the nurse was still on hall. I came back in and said I didn't see her, then me and (CNA #1) kept looking for her in the room and a few minutes later the nurse came back from outside with (R #34)( and told us that (R 34) had been around back. CNA #12 was asked, Who did you tell you didn't see her? She stated, (RN # 2). CNA #12 was asked, Where was (RN #2) at when you told her you didn't see her after looking for her? She stated, in the clean room (on the 400 hall)? CNA #12 was asked, Has the 400 hall door been propped open before? She stated, Yes, when my hall partner would go to smoke. CNA #12 was asked, Who is your hall partner? She stated, (CNA #1). CNA #12 was asked, Was the door alarm working when she eloped? She stated, No. I don't remember that. CNA #12 was asked, Where you in-serviced about (R #34's) elopement? She stated, A few days later. CNA #12 was asked, Were 15 minutes checks done on (R 34)? She stated, Yes. On 11/10/20 at 11:07 AM, the Minimum Data Set Coordinator (MDS) #1 was asked, What happened on the day R #34 eloped? She stated, I don't know what, I was told. MDS Coordinator #1 was asked, Does ()R 34 have a [DIAGNOSES REDACTED]. MDS Coordinator #1 was asked, Does she wander and how often? She stated, She does wander, and I don't know how much. MDS Coordinator #1 was asked, What interventions were put in place to protect (R 34), who is a high risk for elopement, dx of wandering and wanders, when she was moved off a secure hall (300 Hall) to 400 Hall? She stated, the door is secured with a code. MDS Coordinator #1 was asked, What immediate intervention was put in place after (R 34) eloped? She stated, I do not know. MDS Coordinator #1 was asked, What long term intervention was put in place after (R #34) eloped on 10/26/20? She stated, I don't know. MDS Coordinator #1 was asked, When was the intervention of redirecting (R #34) put on the Care Plan and how many days later after she eloped? She stated, On 10/30/20, 4 days after. MDS Coordinator #1 was asked, Was the intervention of redirecting R #34 used again after elopement? She stated, Yes. MDS Coordinator #1 was asked, When was the intervention of redirecting first put on the Care Plan? She stated, On 6/24/20. MDS Coordinator #1 was asked, When was the second intervention of redirecting (and same) put on the Care Plan? She stated, On 10/30/20. On 11/10/20 at 11:25 AM, the Minimum Data Set Coordinator (MDS) for Long Term Care #2 was asked, Do you know what happened when (R 34) eloped? She stated, I don't know? MDS Coordinator #2 was asked, Does (R #34) have a [DIAGNOSES REDACTED]. MDS Coordinator #2 was asked, Does she wander and how often? She stated, Yes. When she was on the 300 hall she wandered up and down the hall and daily. MDS Coordinator #2 was asked, What interventions were put in place to protect (R #34) when she was moved to the 400 hall and was a high risk for elopement, had a [DIAGNOSES REDACTED].? She stated, Not sure. MDS Coordinator #2 was asked, Who would know? She stated, The DON. MDS Coordinator #2 was asked, Tell me how you can get out of the 400 Hall exit door? She stated, It has a code for key pad and if you push the green button it will open. MDS Coordinator #2 was asked, Can you just push the green button and get out the 400 hall exit door? She stated, Yes. MDS Coordinator #2 was asked, What immediate interventions were put in place after (R 34) eloped? She stated, I believe 15-minute checks. MDS Coordinator #2 was asked, What long term interventions were put in place after (R 34) eloped? She stated, To redirect as needed. MDS Coordinator #2 was asked, When was the intervention of redirecting put on the Care plan? She stated, On 10/30/20. MDS Coordinator #2 was asked, How many days after she eloped? She stated, 4. MDS Coordinator #2 was asked, Should an intervention be on the Care plan before that? She stated, Yes. It should have been the next day, we should have followed up on the elopement. MDS Coordinator #2 was asked, Was the intervention of redirecting R #34 used two times? She stated, It was already on the Care Plan. MDS Coordinator #2 was asked, Was the same intervention used again? She stated, Yes. MDS Coordinator #2 was asked, What is the difference between a secure unit and the other halls? She stated, The secure unit has more people in place to keep residents supervised and both doors locked. MDS Coordinator #2 was asked, On 9/28/20, did (R 34) state she wanted to leave and packed her stuff? She stated, According to her notes, yes. MDS Coordinator #2 was asked, Who documented that she wanted to leave and was found with her belonging packed? She stated, (RN #2). On 11/10/20 at 11:35 AM, Assistant Director of Nursing (ADON) was asked, Does (R #34) have a [DIAGNOSES REDACTED]. Does she wander and how often? She stated, Yes, daily. The Assistant Director was asked, What interventions were put in place to protect (R #34)( when she was moved to the 400 hall and was a high risk for elopement, had a [DIAGNOSES REDACTED].? She stated, Essentially, it should be locked, can't tell you the specifics. The Assistant Director was asked, What immediate interventions were put in place after R #34) eloped? She stated, Put on Q 15 checks. The Assistant Director was asked, What long term interventions were put in place after (R #34)( eloped? She stated, Redirect from door when resident is at door. The Assistant Director was asked, When was the intervention of redirecting put on the Care Plan? She stated, on the 30th. What does the Care Plan do? She stated, it tells you how and what the Plan of Care is for the resident. The Assistant Director was asked, Should an intervention been put on the Care plan before 4 days later after an elopement? She stated, Should have. The Assistant Director was asked, Do you think a resident (R 34) who is a high risk for elopement, wanders and stated she wanted to go home and packed her stuff should be put on a non-secured hall without appropriate interventions in place to protect her? She stated, It appears we have made a mistake with that. On 11/10/20 at 1:00 PM, the Director of Nursing (DON) was asked, What happened when (R #34) eloped? She stated, What I read, they had taken out the trash and she walked out behind them. The DON was asked, Who is they? She stated, That I don't know who it is. The DON was asked, Does (R #34) have a [DIAGNOSES REDACTED]. The DON was asked, Does she wander and how often? She stated, 1 to 2 times a week. The DON was asked, What immediate interventions were put in place after (R 34) eloped? She stated, I believe they put her on 15 minutes checks and in-serviced staff to redirect if wandering by door. The DON was asked, What was the long-term intervention put in place after (R #34) eloped? She stated, Was redirecting away from door and when out of isolation, put back on secure unit. On 11/10/20 at 1:37 PM the Administrator was was asked, Can you tell me what happened with R #34 when she eloped? She stated, Based on the I and A (Incident and Accident) I saw, she went out of the 400 hall door when staff was taking out trash and followed her out the building? The Administrator was asked, Who was the staff that was taking out the trash? She stated, I was told it was the housekeeper. The Administrator was asked, Did you get a witness statement from the housekeeper? She stated, No. I did not, based on the staff I talked to since I have been back, the CNA saw her and took her back to hall. The Administrator was asked, If you didn't get a witness statement from the housekeeper that she supposedly followed out, how do you know they had line of sight on her? She stated, I can't answer that, I wasn't here, didn't do the investigation or interviews. The Administrator was asked, Who did the investigation and interviews? She stated, The Director of Operations and the AIT (Administrator in Training). On 11/10/20 at 2:59 PM, the Ho (TRUNCATED)

Complaints # (AR 069) and # (AR 108) were substantiated, all or in part, in these findings: Based on observation, record review, and interview, the facility failed to ensure a manual bed crank used to raise and lower the bed was retracted when not in use, in order to provide a walking path free from trip hazards and prevent a fall with injury for 1 (Resident #1) of 2 (Residents #1 and #4) case mix residents who had manual-crank beds. The failed practice resulted in past noncompliance at the level of actual harm to Resident #1, who tripped and fell over the extended bed crank and sustained a subdural hematoma, and had the potential to cause more than minimal harm for 65 residents who had manual-crank beds, as per a list provided by the Administrator on 6/8/17 at 8:50 a.m. The findings are: 1. Resident #1 (closed record) had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/17 documented the resident scored 9 (8 - 12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 1 person for transfers, limited assistance of 1 person for ambulation in room, and had no falls. a. The Care Plan dated as initiated on 4/12/16 documented, .The resident has had an actual fall . 4/12/2016 . Continue interventions on the at-risk plan . date initiated: 4/12/16 . The resident is high risk for falls r/t (related to) unaware of safety needs and history of falls, history of dizzy spells . 1/29/17 resident slid out of bed, no injury . 2/7/17 resident fell in room, hit head . Interventions/Tasks . Anticipate and meet the resident's needs . educate staff to ensure foot rests are folded to the side of the wheelchair . Educate the resident / family / caregivers about safety reminders and what to do if a fall occurs . Follow facility fall protocol . The facility's Falls Clinical Protocol, provided by the Director of Nursing (DON) on 6/13/17, documented, .Risk factors for subsequent falling include lightheadedness or dizziness . gait and balance disorders . cognitive impairment . environmental hazards, confusion . The protocol did not address the need to keep walkways free of obstructions / trip hazards. b. The Nursing Morse Fall Scale and Care Plan dated 1/29/17 documented the resident was at high risk for falls. c. The Incident and Accident Note dated 2/7/17 at 4:00 p.m. documented, .resident found face down on floor in room. When this nurse entered the room she was motionless lying on her belly with the right side of her face on the floor in her room. Resident footwear intact. CNA (Certified Nursing Assistant) and this nurse turned resident around so she was lying on her back. Resident eyes were fixed and not looking around. Pupils equal. Lacerated (laceration) located to right eye brow. ST (Skin Tear) to right wrist and elbow. Called out to this resident for about 5 mins (minutes) before she came to. She lifted her arms to reach out to staff to lift her off the floor. Gait belt applied and she was lifted off the ground by 2 nurses and a CNA. Resident placed in her recliner and I (Licensed Practical Nurse (LPN) #1) asked her if she (Resident #1) was hurting and no reply. Skin treatment applied to stop bleeding from the rt (right) eyebrow and arm. CNA stated that she heard the resident ask 'what happened?' . Immediate Intervention . Cranks to bed sticking out. Cranks placed in the up position and out of the way . Author . (LPN #1) . d. The Incident and Accident Follow-up dated 2/8/17 at 11:08 a.m. documented, .ambulated in room with RW (Rolling Walker) to visit her roommate, tripped over bed cranks that were in the outward position causing fall. Hit head. Laceration to right eyebrow and skin tear to right wrist. Unable to answer questions and follow commands at time of incident. After resident was assessed for further injuries and assisted to recliner she appeared overstimulated when asked if she was hurting anywhere she stated 'okay'. V/S (vital signs) obtained. Neuros (neurological checks) started . Incident Location . Resident's room . Incident Description: Nurse called to resident's room . resident slid out of wheelchair . hit (right) elbow on floor . Resident's Description . I slid too close to edge. Immediate Action Taken . bed (and) chair alarm applied . e. The hospital emergency room Note dated 2/7/17 at 4:23 p.m. documented, .(Resident #1) Sent from NH (Nursing Home) for evaluation after presumed unwitnessed fall. Was found prone and altered per report. Cut to rt (right) orbit. Pain to right arm. Has hx (history) of Dementia and difficulty hearing. Patient denies pain except for right arm . PMH (Past Medical History) . Syncope in the past . weakness . ED (Emergency Department) Course . 2/7/17 17:35 (5:35 p.m.) . Patient CT (computerized tomography) scan returned concerning for epidural hematoma on the right. Neurologically intact and alert, however. Discussed with radiologist. Despite appearance, he feels it is more likely a subdural hematoma but feels she should be observed by NSG (nursing) . Patient shown a written explanation of her condition and need for possible emergency surgery . Clinical Impression . Intracranial hemorrhage, fall, facial laceration . f. The Radiology Report dated 2/7/17 at 4:24 p.m. documented, .Exam . CT head Trauma / Anticoagulants . Reason . Fall with possible injury . CT of the Head . Demonstrates a 1/7 cm (centimeter) subdural hematoma, which extends over a 7 cm region. There is no significant midline shift. There is no evidence of skull fracture. A hematocrit level is visualized within the blood . g. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/17 documented the resident scored 3 (0 - 7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 2-plus persons for transfers, limited assistance of 1 person for ambulation in room and corridor, fell in the last month prior to admission/entry or reentry, and fell in the last 2 to 6 months prior to admission/entry or reentry. h. The Radiology Report dated 2/21/17 at 3:50 p.m. documented, .CT Head without (Contrast) . CT of the head is performed without contrast. Comparison made with 2/7/2017 . Findings: Extra-axial hemorrhage along the right frontotemporal region is again noted. Majority of the collection has decreased in density, however, there remains an ill-defined hyperdense focus centrally . Impression . Right-sided extra-axial hemorrhage as above. Extent of the collection may be slightly increased from prior . i. On 6/7/17 at 8:30 a.m., Licensed Practical Nurse (LPN) #1 was asked, Can you tell me what happened when (Resident #1) fell and hit her head? LPN #1 stated, She (Resident #1) was walking from her side of the room to her roommate's side of the room, because her roommate was crying. (Resident #1) got her walker caught in the crank (of the bed) that was sticking out and she fell and hit her head. I really did not even think she was going to make it, because she was not moving or anything when I came in the room. The LPN was asked, How certain are you that she tripped over the crank? LPN #1 stated, One hundred percent sure. The walker was hung in one of the cranks. LPN #1 was asked, Do you remember which CNA was taking care of her? LPN #1 stated, No, I can't remember. j. On 6/7/17 at 3:48 p.m., the Assistant Director of Nursing (ADON) was asked to accompany members of the survey team to a resident's room with a crank-bed identical to Resident #1's bed. The bed had 3 cranks at the foot of the bed, all of which were positioned downward, and thus did not protrude into the walkway of the room. The ADON was asked to demonstrate the functionality of the cranks, and then to position the cranks as she had witnessed them to be positioned after Resident #1 fell on [DATE]. The ADON reached down and pulled one of the crank levers and extended the lever outward so the lever could be used to raise the height of the bed. Once she demonstrated the process of raising the bed, she was asked to demonstrate how the crank was positioned when the resident fell . The ADON released the lever from her grip and the lever fell , facing upward and protruding approximately 8 inches outward from the footboard, into the walkway of the room. The ADON was asked, How do you know that she tripped over the crank? The ADON stated, .The walker was hung on the crank, which had been left facing upward and sticking out. You have to manually turn it downward, so that it doesn't stick out, and that is what they did. They left it out . (Resident #1) was walking from her recliner and was walking to 'B' bed to see her roommate, and she fell , hitting her head on the frame of her roommate's bed . 2. The facility corrected the failed practices on 2/9/17, prior to the survey, as evidenced by the following: a. The Incident and Accident Follow-up form dated 2/8/17 documented, .Long Term Intervention: Bed cranks were placed in downward position facing underneath bed. Performed a complete building audit ensuring all cranks were turned in the downward position underneath bed. In-servicing staff on proper positing of cranks . Added to the Care Plan . yes . b. A Care Plan revision dated 2/8/17 documented, .In-service staff to ensure cranks to bed are turned inward . c. In-service documentation dated 2/9/17 documented 30 employees were trained on proper positioning of bed cranks. The in-service was conducted by the Director of Nursing and documented the following information: staff training on proper position of bed cranks to be placed underneath the bed when not in use; full building audit (2/7/17) to ensure crank handles are positioned underneath the bed by the Director of Nursing and the Assistant Director of Nursing; and Nurse Managers to monitor bed crank handles position to ensure they are underneath the bed when not in use (ongoing). d. Observation Rounds forms, provided by the Administrator on 6/7/17 at 3:20 p.m., documented the facility initiated daily audits of all bed cranks on 2/7/17 and had continued the daily monitoring on an ongoing basis. e. On 6/7/17 at 4:49 p.m., the surveyor observed multiple manual-crank beds throughout the facility. The cranks for all beds were properly positioned out of the walkways in the resident rooms.

Complaint # was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure the physician was promptly consulted regarding the deterioration in the condition of a pressure ulcer for 2 (Residents #1 and #5) of 3 (Residents #1, #3, and #5) case mix residents who had pressure ulcers. The facility also failed to notify the family of significant declines in condition for 2 (Residents #1 and #5) of 3 (Residents #1, #3, and #5) case mix residents who had pressure ulcers. The facility's failure to immediately consult the physician regarding deterioration in the condition of a pressure ulcer resulted in a pattern of actual harm for Resident #1 who had a decline in the healing of pressure sores resulting in hospitalization . The failed practices also had the potential cause more than minimal harm to 5 residents who had pressure ulcers as documented on a list provided by the Director of Nursing (DON) on 11/16/12 at 11:50 a.m. The findings are: 1. The Notification Policy provided by the Assistant Director of Nursing (ADON) on 11/16/12 at 11:10 a.m. documented, "... Notification of Changes: ... (i) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is: ... (B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); ...". 2. Resident #1 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/12/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) and had an unstageable pressure ulcer. a. The Care Plan dated 7/30/12 documented, "...Resident is at risk for skin breakdown due to needing extensive assist with ADLs (activities of daily living) - incontinence. 10/9/12 has unstag (unstageable) wound to coccyx, onset 9/25/12. ... Report changes in skin status (i.e.: s/s (signs and symptoms) infection, non healing, new areas) to physician..." b. Nurses Notes dated 9/25/12 and signed by a treatment nurse documented, "Area noted to coccyx measuring 2.5 X 0.6 X UTD (unable to determine). Wound open (with) small amt (amount) of serosanguineous exudate (and) (no) odor present. Wound bed covered (with) slough. Wound is area of scar tissue from previous wound. MD (medical doctor) faxed requesting TX (treatment) orders for Santyl (and) dry drsg (dressing) QD/PRN. Awaiting response...." c. A Nurse's Communication Fax to Physician #1 dated 9/25/12 at 1:10 p.m., (transmission ok), documented, "... Re (regarding): (Resident #1), ... Resident noted to have open area to coccyx measuring 2.5 X 0.6 X UTD R/T (related to) slough. Small amt of clear exudate present..." d. A physician order [REDACTED]." e. Nurses Notes dated 9/28/12 and signed by the treatment nurse documented, "Area to coccyx remains. Measures 3.5 X 1.5 X UTD. Scant amt of serosanguineous exudate (and) (no) odor present. ... Spoke (with) family (and made aware of (changes)..." There was no documentation the physician was notified of the increased size and drainage. f. Nurses Notes dated 10/4/12 and signed by the treatment nurse documented, "Wound to coccyx remains (and) now measures 3.5 X 1.0 X UTD. Wound presents as open area (with) slough present. Scant amt of serosanguineous exudate (and) ( no) odor noted. ... QD (and) PRN (with Santyl (and) dry drsg..." There was no documentation the physician was notified of the increased size and drainage since 9/25/12. g. Nurses Notes dated 10/11/12 and signed by the treatment nurse documented, "Wound to coccyx measures 3.5 X 1.0 X UTD. Wound bed covered (with) slough. Scant amt of serosanguineous exudate (and) slight odor present. TX conts (continues) QD (and) PRN (with) Santyl (and) dry drsg..." There was no documentation that the physician was notified of the increased size, drainage and odor since 9/25/12. h. A Nurse's Communication Fax to Physician #1 dated 10/17/12 at 12:10 p.m., (Function was not completed, ... Busy/no signal), documented, "... FYI (for your information): Wound to coccyx now presents as open area covered (with) black eschar (and) has foul odor. TA conts (with) Santyl QD (and) PRN. Wound Consultant assessed last wk (week) (and) suggests that we cont current TX, but wanted you to be aware of (change)..." i. Nurses Notes dated 10/18/12 and signed by the treatment nurse documented, "Wound to coccyx deteriorated. Area presents as open area covered (with) black eschar. Small amt of serosanguineous exudate (and) foul odor present. Wound measures 4.5 X 3.5 X UTD. TX (with) Santyl (and) dry drsg conts QD (and) PRN. ... MD faxed 10/17/12 R/T (changes). (No) N.Os. (new orders) rec'd (received) thus far. Will cont to TX (treat) (and) monitor." j. A copy of the same Nurse's Communication Fax to Physician #1 dated 10/17/12 was sent 10/26/12 at 11:09 a.m., (transmission ok), documented, "... FYI (for your information): Wound to coccyx now presents as open area covered (with) black eschar (and) has foul odor. TA conts (with) Santyl QD (and) PRN. Wound Consultant assessed last wk (week) (and) suggests that we cont current TX, but wanted you to be aware of (change)..." k. Nurses Note dated 10/22/12 at 10:56 a.m. documented "... T (temperature) 101... MD (medical doctor) notified of elevated temp... will continue to monitor..." Nurses Note at 1:15 p.m. documented, "Send to (hospital) for eval (evaluation) & (and) tx (treatment) d/t (due to) (elevated) temp & abnormal chest x-ray." The entry was signed by Licensed Practical Nurse (LPN) #3 and there was no documentation the family was notified of the resident's transfer to the hospital. l. On 11/16/12 at 10:53 a.m. LPN #3 stated that on 10/22/12 she had called the family and left a message that the resident was sent to the hospital. She stated that she had never received a call back. m. The hospital records dated 10/25/12 documented, "... Operation ... Excision of sacral pressure ulcer in preparation for closure. ... Final Surgical Pathology Report: The specimen labeled "sacral decubitus" is received in fixative. It consists of an irregular piece of tissue measuring 7.5 X 6.5 X 3 cm. (centimeters). ... Final Diagnosis: [REDACTED]. n. On 11/16/12 at 12:20 p.m. the resident's physician, Physician #1 was interviewed by telephone and was asked if he had been aware of the deterioration of the pressure ulcer on 10/17/12 and 10/18/12. He stated that he had not received the fax dated 10/17/12 until 10/26/12 and at that time the fax had the information that the resident was in the hospital and had debridement of the wound. The physician also stated that if he had received the fax, he may not have changed the treatment to the pressure ulcer due to the decline in the resident's condition. o. On 11/16/12 at 1:35 p.m. the DON and the ADON were informed of fax not going through on 10/17/12 to Physician #1. Neither were aware that the fax had not been sent to the physician until 10/26/12 and neither were aware of who sent it. 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 10/30/12 documented the resident was severely impaired in cognitive skills for daily decision making per a SAMS, was totally dependent on staff for activities of daily living, at risk for pressure ulcers and had a Stage 4 Pressure Ulcer. a. The Care Plan documented a problem dated 2/27/12 and last reviewed on 11/9/12 of "...Risk for Pressure ULC (ulcer)... at risk for developing skin breakdown related to impaired mobility and incontinence... has unstag (unstageable) to sacrum. Approaches Notify nurse/physician immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care..." a. A physician's orders [REDACTED]." As of 11/15/12 there were no other physician's orders [REDACTED]. b. A Nurse's Note dated 10/30/12 at 9:00 a.m. documented, "... Pressure sore to coccyx with redness, no drainage, non-blanchable..." c. The November 2012 Treatment Record (TR) documented, "11/2/12 Cleanse pressure ulcer to coccyx (with) wound cleanser. Apply Santyl and dry dressing. (Change) QD/PRN." d. On 11/15/12 at 9:55 a.m., LPN #1 was asked, "Were you notified at the end of October that (Resident #5) had a non-blanchable area on her coccyx?" LPN #1 stated, "I need to look at the skin record and my nurse's note to tell you the exact day. It was red and non-blanchable at first. Then I came back over the weekend and it was open. It was a Stage II, then it went to Stage III. I have only worked here for 3 weeks, only about 2 weeks on my own." e. On 11/15/12 at 10:10 a.m., during the body audit, a wound on the coccyx was observed with eschar around margins and yellow slough in the center of the wound bed. LPN #1 stated, "I would stage at Stage III but the wound consultant said unstageable because of necrotic tissue and slough." f. On 11/15/12 at 2:20 p.m., LPN #1 was asked, "Did the nurse notify you of the non-blanchable area on (Resident #5) coccyx that she identified on 10/30/12?" LPN #1 answered, "Yes, she told me about it 10/31/12. We didn't notify the doctor that it was not blanchable. There was already a treatment going and we weren't going to change it. We did notify the doctor when it opened up. We got an order for [REDACTED]. g. On 11/15/12 at 3:50 p.m., the ADON was asked, "Are you kept informed of new pressure ulcers?" The ADON answered, "The treatment nurse should notify me of any new wounds. We have a stand-up meeting every morning Monday through Friday and one of the questions is 'Are there any new pressure ulcers?' That is just part of stand-up every morning and the treatment nurse is there. She would notify us if there was a drastic worsening." The ADON was asked, "When it changed from blanchable to non-blanchable should you have notified the doctor?" The ADON answered, "She should have and I would have. I was not aware it's drastically worse." When asked, "Do you know what Stage it is now?" The ADON answered, "No, I don't." h. The "Wound/Skin Healing Record" provided on 11/16/12 at 1:05 p.m. by LPN #1 documented, "11/2/12 Presents As Unstageable, Size in CM (centimeters) Length and Width: 1.7 X 0.6... Wound Bed Pink/Beefy Red... 11/9/12 Presents as Unstageable, Size in CM 2.1 X 1.4...Wound Bed Slough..." i. On 11/16/12 at 1:12 p.m., LPN #1 was asked, "Have you notified the family of the wound on her coccyx?" The LPN answered, "I have not notified the family of the new wound on her coccyx."