Every finding on record at Northgate Unit Of Lakeview Christian Home

Based on observation, record review, and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure:Expired food was disposed of and food items were labeled and dated.Refrigerator temperature logs were not complete.Perform hand hygiene during servingThese deficient practices have the potential to affect all 77 residents as identified by the census provided by the Administrator (ADM) on 05/17/26. If food is not being stored properly and safe food handling practices are not followed then the residents could be at risk of getting foodborne illnesses and becoming ill. The findings are: Expired and unlabeled food stored in the kitchen: A. On 05/17/26 at 10:13 am, an interview and observation of the kitchen revealed the following: Items stored in the refrigerator: 1. One box containing cups of yogurt with an expiration date of 04/17/26. 2. One box containing cups of yogurt with an expiration date of 05/16/26. 3. Two bags of what appeared to be shredded lettuce or shredded cabbage with no label or date. 4. One bag with what appeared to be a sliced red onion with dates of 03/06/26 and 03/25/26 written on it. 5. A gallon of lactose free milk with an expiration date of 05/07/26. 6. A bottle of Italian salad dressing with an expiration date of 01/31/26. B. On 05/17/26 at 10:27 am, during an interview with Dietary Aide (DA) #2, she confirmed the yogurt, bag of lettuce or cabbage, bag of sliced red onion, lactose free milk and the Italian salad dressing were expired and should have been disposed of. Items stored in the freezer: 1. Two bags of what appeared to be frozen chicken with no label or date. 2. Two bags of unidentified frozen meat with no label or date. C. On 05/17/26 at 10:35 am, during an interview with DA #3, she confirmed that the bags of frozen meat were not labeled and dated. DA #3 then placed labels on the bags of frozen meat and put the date of 05/17/26 on the label. D. On 05/20/26 at 10:19 am, an interview and observation of the kitchen revealed one box containing yogurt cups with an expiration date of 05/16/26 in the refrigerator. DA #2 confirmed the yogurt was expired and disposed of it. Cleaning of and Sanitizing of equipment and surfaces: E. On 05/17/26 at 10:13 am, an interview and observation of the kitchen revealed the following: 1. The stove and oven were covered with dried, burnt on food particles and splashes. The stove and oven appeared to be covered in a layer of grease. 2. DA #2 tested the sanitizer bucket, the test proved to be inconclusive. DA #3 confirmed the water in the bucket did not contain the required chemicals needed to sanitize. Refrigerator Logs F. On 05/17/26 at 9:41 am, during a random observation of dining area in the 200 hall, the log on the refrigerator was missing temperature values for 05/02/26, 05/03/26. 05/09/26. 05/10/26, 05/14/26. 05/15/26, 05/16/26, and 05/17/26. G. On 05/17/26 at 9:43 am during an interview with Social Worker (SS) she confirmed that the refrigerator logs were not complete and confirmed the missing dates. H. On 05/17/26 at 10:03 am, during a random observation of the dining are in the 400 hall, the log on the refrigerator was missing temperature values for 05/02/26, 05/03/26, 05/09/26, 05/10/26, 05/16/26, and 05/17/26. I. On 05/17/26 at 10:15 am, during an interview with Certified Nurses Aide (CNA) #2, she confirmed the refrigerator logs were not complete and confirmed the missing dates. Refrigerator Items J. On 05/17/26 at 9:45 am during a random observation of dining area in the 200 hall, the refrigerator in the dining area, there were three pitchers of different colored liquids that were not labeled to identify their contents or adate to indicate when it was made. K. On 05/17/26 at 9:47 am Licensed Practical Nurse (LPN) #1 confirmed the pitchers in the refrigerator were not labeled and dated properly, L. On 05/17/26 at 10:04 am during a random observation of the dining area in the 200 hall, the pitcher labeled apple juice was dated for 05/15/26. M. On 05/17/26 at 10:16 am during an interview with CNA #2, she confirmed the date on the pitcher labeled apple juice was 05/15/26. N. Record review of food storage policy dated 02/24/22 indicated that all products should be dated upon receipt and when they are prepared. O. On 05/17/26 at 11:27 pm, during a random observation and interview, DA #1 confirmed brown liquid that appeared to be tea in a pitcher being served to residents was not labeled or dated. P. On 05/18/26 at 11:20am, during a random observation of dinning, Nurse Aide in Training (NAIT) #2 touched her chair, put a protective covering on R #67 and R #73, then grabbed her chair to sit back down, and began to assist R #67 and R #73 with feeding without preforming hand hygiene. Q. On 05/18/26 at 11:40 am, during an interview with NAIT #2, she confirmed she should have sanitized what? before assisting R #67 and R #73 with their meal.

Based on observation and interview, the facility failed to maintain corridor handrails for one identified location, this deficiency could compromise safe navigation and support for all 77 residents as identified by the census provided by the Administrator (ADM) on 05/17/26 who use handrails.A. On 05/17/26 at 9:48 am during an observation, a rail along the corridor in west hall just past the main entrance could be easily pulled away from the wall.B. On 05/17/26 at 10:05 am, during an interview with Physical Therapy Assistant (PTA), she confirmed the rail was loose and was easily pulled away from the wall.C. On 05/21/26 at 10:12 am, during an interview with Director of maintenance, he confirmed the rail was loose and needed to be repaired.

Based on record review and interview the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. This deficient practice has the potential to affect all 77 residents as identified by the census provided by the Administrator on 05/17/26 and could likely result could likely result in serious injury or death if residents become trapped between the mattress, side rail, footboard and headboard. The findings are: A. Record review of occupational therapy bed inspection form provided by the administrator on 5/20/26 revealed: 1. Inspection of the bed height 2. Inspection of securement of wheelchair cushion. 3. Includes issues identified with bed height and seat cushion. 4. No inspection of frames, mattresses or rails to identify areas of possible entrapment. B. On 05/20/26 at 4:00 pm, during an interview with the Administrator (ADMIN) she confirmed that they do not have a check list or routine maintenance to inspect all bed frames, bed mattresses and bed rails. If they have an issue with bedrails they put in a work order and it is repaired at that time. C. On 05/21/26 at 10:12 am, during an interview with the Maintenance Director (MAINT), he confirmed they do not have a routine maintenance program in place to inspect all bed frames, bed mattresses and bed rails unless a work order is placed.

Based on observations and interviews, the facility failed to properly store medications and medical supplies located in the facility medication storage room when the staff failed to ensure: -Insulin multidose vials are dated when they are first used and dated 28 days after first use.-Blood collection tubes were not expired.-Lancets (small, sharp, sterile needle used to prick the skin) were not expired.-Hypodermic (under the skin) Injection needles were disposed of after expiration date.-Bluetooth glucose monitoring strips were not expired.-Intravenous (IV; into the vein) catheters were not expired.-Intravenous start kits were not expired.These deficient practices have the potential to affect all 77 residents (as identified by the census provided by the Administrator (ADM) on 05/17/26, resulting in expired medications and medical supplies being used in resident care and could put residents at risk of possible infections and not receiving the full benefits of medications. The findings are:A. On 05/19/26 at 8:10 am, during a random observation of the 200 hall medical storage room, the following items were found to have expired:- 50 lancets expired 02/26,-54 green top blood collection tubes expired on 05/02/25,-74 blue top blood collection tubes expired on 09/01/25,-27 yellow top blood collection tubes expired on 07/01/25,-20 hypodermic needles, 27-gauge (indicates how thickness or thinness of a needle) with safety protection expired on 03/01/26,-22 safety needles, 22-gauge expired 02/20/26,-Two boxes of Bluetooth glucose monitoring strips expired 04/02/26.B. On 05/19/26 at 8:26 am, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed these items were expired and should have been removed from stock.C. On 05/19/24 at 8:33 am, during a random observation of the east medical storage room, the following items were found to have expired:- 23 green top blood collection tubes expired on 01/01/26,- One blue top blood collection tube expired on 03/03/26.- 25 blue top collection tubes expired on 01/01/26,- One multi-use vial of regular insulin found in refrigerator opened without an open date located on box or vial. D. On 05/19/26 at 8:43 am, during an interview with Certified Medication Aide (CMA) #1, she confirmed that an open date and an expiration date was not put on the vial and should have been; she also confirmed the medical supplies had expired and should have been removed from stock.E. On 05/19/26 at 8:40 am, during a random observation of the 400 hall medical storage room, the following items were found to have expired:- One 22 gauge [NAME] Introcan Safety Intravenous (IV; into a vein) catheter expired on 05/01/26,- One 18 gauge IV catheter expired on 12/01/24,- Three 22 gauge IV catheters expired on 01/01/25,- One box of 20 gauge IV catheters expired on 02/01/25,- 11 Excel safety needles, 27 gauge-1.5 inches expired on 03/01/26,- One IV start kit expired on 10/31/25.F. On 05/21/26 at 12:27 pm, during an interview with the Director of Nursing (DON) she stated allowing medical supplies to remain in the working stock does not meet her expectation, she also stated her expectation is to date medications of any type to be labeled and dated according to policy.

Based on observation, record review and interview, the facility failed to post nurse staffing data daily at the beginning of the shift that included the following:- Facility name.-The current date.-The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift.1. Registered nurse,2. Licensed practical nurse,3. Certified nurse aides,4. Resident census.The deficient practice has the potential to affect all 77 residents as identified by the census provided by the Administrator (ADM) on 05/17/26 and could likely result in residents and visitors not having the staffing information readily available. The findings are:A. On 05/17/26 at 9:30 am, a random observation of the facility revealed the facility's staff data posting sheet and noted that no staffing data posting sheet was visible in a conspicuous, accessible area. B. Record review of 18 months of staff postings:January 2026: 31 days of postings were reviewed: 31 out of 31 days lacked census documentation.February 2026: 28 days of postings were reviewed; 24 out of 28 days lacked census documentation.C. On 05/21/26 at 8:27 am, during a random observation of the facility revealed the staff data posting sheet was dated for 05/20/26 and the document was not complete. D. On 05/21/26 at 8: 35 am, during an interview, Certified Nurses Aide (CNA) #1 confirmed that the current posted sheet dated 05/20/26 only included the morning shift staffing, and that the resident census was not documented.

Based on observation, record review, and interview, the facility failed to maintain an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) for 3 (R #2, R #17, and R #58) of 6 (R #1, R #2, R #7, R #8, R #17, and R #58) residents reviewed by not:1. Ensuring staff followed proper infection prevention protocols for R #2 who had contact precautions (used for individuals with infections that can spread through direct or indirect contact with the patient or their environment) in place and for R #17 who had enhanced barrier precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) in place.2. Ensuring EBP was in place and signs were posted outside of R #58's room with personal protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) readily available.If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illnesses. The findings are:R #2A. Record review of R #2's Face Sheet revealed he was admitted to the facility on [DATE] and has the following diagnoses:1. Quadriplegia (paralysis of all four limbs),2. Neuromuscular dysfunction of bladder (bladder does not work properly),3. Multiple pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin),4. Methicillin resistant Staphylococcus aureus infection (MRSA; a type of bacteria that is resistant to certain antibiotics),5. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar).B. On 05/17/26 at 10:30 am, a random observation of R #2's room revealed a sign hanging near his door indicating contact precautions were in place; a cart with drawers of PPE sat next to the door.C. On 05/17/26 at 11:41 am, an observation of R #2's room revealed the following:1. Certified Nurse Aide (CNA) #4 knocked on R #2's door and entered his room. CNA #2 was not wearing any PPE.2. CNA #2 came out of R #2's room a few moments later carrying a metal drink cup with a lid, she walked over to the serving/dining area where other residents were being served or already eating lunch and put ice in the cup, filled the cup up with tea, and microwaved a plate of food. CNA #2 did not wash or sanitize her hands.D. On 05/17/26 at 12:51 pm, during an interview and observation with R #2 in his room, he stated that he understands the reason for needing to be on contact precautions but doesn't mind if staff come in without wearing the gowns. The only trash can in the room was placed next to R #2's tray near his bed. E. On 05/17/26 at 12:55 pm during an interview with CNA #2, she confirmed that all PPE should be discarded in the trash can that is near his bed and then walk across the room to the door to leave.F. On 05/21/26 at 9:23 am, during an interview with the Director of Nursing (DON), she confirmed that contact precautions are in place for R #2. The DON stated that staff are expected to don (put on) PPE prior to entering R #2's room and doff (take off) the used PPE when exiting the room. The DON confirmed that the trash can used to dispose of used PPE should be near the entrance/exit of the room. R #17G. On 05/17/26 at 10:30 am, a random observation of R #17's room revealed a sign hanging near her door indicating EBP was in place and a cart with drawers of PPE sat next to the door.H. Record review of R #17's Face Sheet revealed she was admitted to the facility on [DATE] and has the following diagnoses:1. Non-pressure chronic ulcer (a long-lasting open sore) of skin with necrosis of bone (death of bone tissue),2. Open wound, unspecified lower leg.I. On 05/18/26 at 3:24 pm, an interview and random observation of the facility revealed the following:1. Registered Nurse (RN) #1 knocked on R #17's door and entered the room pulling a vital sign machine (machine used to take vital signs such as blood pressure, pulse, and temperature) without wearing any PPE.2. RN #2 exited R #17's room a few moments later and stated that he was only taking R #17's vital signs, did not touch her wound, so PPE is not required.J. On 05/21/26 at 9:30 am, during an interview with the DON, she confirmed that PPE is required for all care, including taking vital signs, for residents where EBP is in place. R #58K. Record review of R #58's Face Sheet revealed she was admitted to the facility on [DATE] and has the following diagnoses:1. Pressure ulcer, stage 3 (a pressure ulcer with full thickness skin loss that extends into deeper tissue and fat but not into muscle, tendon, or bone) on the foot,2. Unspecified open wound, right foot,L. Record review of R #58's care plan dated 08/28/25 revealed R #58 is at risk for pain and infection due to an open wound. R #58 has a stage 3 pressure ulcer to the right foot.M. On 05/17/26 at 1:36 pm, an observation of R #58's room revealed no signage regarding EBP or PPE was seen outside of R #58's room.N. On 05/15/26 at 10:46 am, during an interview with the DON, she confirmed that R #58 should be on EBP due to her open wound. The DON stated that she expects all residents that have open wounds to be on EBP and confirmed that R #58 was not.

Based on record review and interview, the facility failed to ensure all residents that have a personal funds account with the facility can access their funds on weekends/evenings. This deficient practice is likely to affect all residents having an account with the facility. If residents are unable to access their funds when desired, then residents are likely to not be able to participate in activities and purchase food or personal items when they choose.A. On 05/19/26 at 9:32 am, during an interview with the Resident Council members [R #8, R #16, R #17, R #25, R #31, R #38, R #39, R #46, R #59, R #65, R #72, R #77, and R #78], they stated that they are not allowed to get money when the front office is closed (evenings and weekends). The residents stated the only way to request money is in advance.B. Record review of the facility's Resident Accounts policy, not dated, revealed the following:1. The person responsible for resident's accounting system is the receptionist.2. The facility will keep an amount of approximately $100 as cash on hand for residents and the remainder of the residents' funds is placed in a checking account at a local bank.C. On 05/20/26 at 3:02 pm, during an interview with the Administrator (ADM) she stated that residents are to request money in advance. The ADM stated that if an emergency happens anytime the office is closed, facility staff will call her or the Business Office Manager and one of them will go to the facility to check money out.

Based on record review and interview, the facility failed to ensure a resident or their representative were aware of a medication taken by the resident, which included the risks and benefits associated with that medication for 3 (R #18, R #37, and R #56) of 4 (R #8, R #18, R #37, and R #56) residents reviewed for unnecessary medications. If residents and/or their representative are not informed of the risks and benefits of each medication, then they are likely not able to make informed decisions. The findings are: R 18: A. Record review of R #18's Resident Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Wedge compression fracture of first lumbar vertebra (spinal injury where the front part of the L1 vertebra (the top bone in your lower back) collapses inward, creating a wedge-shaped deformity), 2. Acute pain (starts suddenly and ends when its cause is treated or healed), 3. Chronic diastolic (congestive) heart failure (CHF; impaired heart function), 4. Chronic atrial fibrillation (A-Fib; irregular heart rhythm), 5. Major depressive disorder (MDD; a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 6. Insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep). B. Record review of R #18's physician's orders revealed an order dated 04/17/26 for Sertraline (anti-depressant medication), 50 milligrams (mg) to be given by mouth once a day for depression. C. Record review of R #18's electronic health record (EHR) revealed no consent was present for the Sertraline medication. D. On 05/21/26 at 1:25 pm, during an interview with the Director of Nursing (DON), she confirmed staff did not obtain the consent for the increased dose of the Sertraline. The DON stated this does not meet her expectations because the consent forms are to be obtained prior to the start of the medications and these were not. R 37: E. Record review of R #37's Resident Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Encephalopathy (a degenerative brain disease that alters brain function or structure), 2. Pneumonia (PNA; infection and inflammation of the lung), 3. Dementia (group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), 4. Chronic atrial fibrillation, 5. Major depressive disorder, 6. Generalized anxiety disorder (GAD; feelings of fear or apprehension). F. Record review of R #37's physician's orders revealed the following: 1. An order dated 11/21/24 for Lexapro (anti-depressant medication), 10 mg to be given by mouth once a day for depression. 2. An order dated 01/11/26 for an increase in Lexapro dose from 10 mg to 20 mg to be given by mouth once a day for depression. G. Record review of R #37's EHR revealed no consent was present for the increased dose of Lexapro medication. H. On 05/21/26 at 1:25 pm, during an interview with the DON, she confirmed staff did not obtain the consent for the increased dose of Lexapro. The DON stated this does not meet her expectations because the consent forms are to be obtained prior to the start of the medications and these were not. R #65 I. Record review of R #65's Face Sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Major depressive disorder, 2. Insomnia, 3. Dementia with mood disturbance, 4. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 5. Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination). J. Record review of R #65's physician order dated 06/27/26 revealed an order for Bupropion (anti-depressant) 150 mg to be given once a day. K. Record review of R #65's EHR revealed no consent was present for the Bupropion. L. On 05/21/26, at 12:54pm, during an interview with the DON she confirmed R #65 did not have a consent prior to the use of Bupropion and should have.

Based on record review and interview, the facility failed to develop and implement an adequate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 3 (R #12, R #20, and #58) of 6 (R #2, R #7, #12, R #20, R #58, and #80) residents reviewed for baseline care plans. If the facility fails to develop and implement an adequate baseline care plan within 48 hours of admission for residents, then staff may lack necessary guidance to provide appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident due to medical care or lack of medical care). The findings are:R #12A. Record review of R #12's Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Rheumatoid arthritis (RA; chronic joint disease that causes pain and swelling) with rheumatoid factor (proteins made by the immune system that can attack healthy tissue in the body),2. History of falling,3. Longstanding persistent atrial fibrillation (A-Fib; irregular heart rhythm),4. Chronic pain syndrome,5. Calculus of lower urinary tract (a condition where hard, mineralized deposits (stones) form in the urinary system), 6. Disorder of urinary system.B. Record review of R #12's Baseline Care Plan dated 03/25/26 revealed the form to be blank (containing no information).C. On 05/21/26 at 9:23 am, during an interview with the Director of Nursing (DON), she confirmed that R #12's Baseline Care Plan does not meet her expectations because the form contains no information. R #20D. Record review of R #20's Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Congestive heart failure (CHF; impaired heart function),2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),3. Osteoarthritis (chronic degeneration of the joint cartilage),4. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),5. Chronic kidney disease (CKD; impaired kidney function),6. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),7. Generalized anxiety (feelings of fear or apprehension) disorder,8. History of falling.E. Record review of R #20's electronic health record (EHR) revealed no baseline care plan.F. On 05/21/26 at 9:13 am, during an interview with the DON, she confirmed that the facility failed to develop a baseline care plan for R #20 when she was admitted to the facility. R #58G. Record review of R #58's Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Hemiplegia and hemiparesis (paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) affecting right dominant side,2. Dementia, unspecified severity, with other behavioral disturbance,3. Depression,4. Unspecified open wound on the right foot,5. Chronic pain syndrome,6. Neuromuscular dysfunction of bladder (bladder does not function properly),7. Atrial fibrillation.H. Record review of R #58's EHR revealed no baseline care plan.I. On 05/21/26 at 8:58 am, during an interview with the DON, she confirmed that the facility failed to develop a baseline care plan for R #58 when she was admitted to the facility.

Based on observation and interview, the facility failed to ensure call lights in residents' rooms were within resident's reach for 1 (R #2) of 4 (R #2, R #7, R #12, R #20) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they need assistance. The findings are: A. On 05/17/26 at 12:51 pm, during an interview and observation with R #2 in his room, R #2 was attempting to activate his call light and could not get it activated. R #2 stated that he likes the tap activated call light because it is easier for him to use.B. On 05/17/26 at 12:55 pm, during an interview with Certified Nurse Aide (CNA) #4, she could not activate the call light until she raised the position of R #2's bed. CNA #4 confirmed that the cord to R #2's call light was pinched between the bed and was stopping the call light from working.

Based on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #10) of 2 (R #10 and R #11) residents reviewed when staff failed to update R #10's care plan to include a security alarm bracelet. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #10's face sheet revealed she was originally admitted to the facility on [DATE] with the following diagnoses:1. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),2. Schizoaffective bipolar type (a mental condition that causes both psychosis and mood problems),3. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),4. Bipolar II Disorder (is similar to bipolar I disorder, with moods cycling between high and low over time). B. On 05/18/26 at 10:30 am, an observation of R #10 revealed she had a security alarm bracelet (discreet wearable device tracks movement and triggers automated security responses when a resident nears a restricted area) on her left ankle. C. Record review of physician orders R #10's revealed an order dated on 11/05/24 for a secure alarm bracelet to minimize the risk of elopement. The order was discontinued and renewed on 05/16/26. D. Record review of R #10's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 04/10/26, revealed the following:1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of six indicating severe impairment.2. R #10 required a wander/elopement alarm. E. Record review of R 10's care plan revised on 04/16/26 revealed R #10 had behavioral problems which included wandering behavior but did not indicate the use of a security alarm bracelet. F. On 05/20/26 at 9:47 am, during an interview Nurse aide in training (NAT) #1 confirmed that R #10 has worn the security guard bracelet for a while and staff will check placement every shift. G. On 05/24/26 at 1:29 pm, during an interview with the Director of Nursing (DON), she confirmed that R #10's security bracelet had not been included in R #10's care plan and should have been.

Based on observation and interview, the facility failed to safeguard resident's personal health information by leaving a list of residents with their associated vital sign readings in plain view. This deficient practice had the potential to affect all 38 people residing in the rooms on the East 1 and East 2 halls by allowing unauthorized people access to their personal health information. The findings are: A. On 08/27/25 at 1:00 pm, a random observation of the facility revealed a paper document with names of the residents and their vital sign readings sitting face up on the nurses station countertop. B. On 08/27/25 at 1:11 pm, during an interview with ST #1 confirmed that the clipboard was left face up with resident information visible. C. On 08/27/25 at 3:15 pm, during an interview with the Director of Nursing (DON), she confirmed that all personal health information should be safeguarded and should never be left in view of people that are not authorized to see it.

Based on record review and interview, the facility failed to ensure the Minimum Data Set Assessment (MDS; a federally mandated assessment instrument completed by facility staff)) was accurate for 1 (R #1) of 1 (R #1) resident reviewed for MDS assessment accuracy. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #1's admission Record revealed the following diagnoses: 1. Dizziness (sensation of feeling faint).2. Senile Dementia (a mental deterioration associated with age by loss of intellectual ability). 3. Osteoporosis (bones become extremely porous and are subject to fracture and slow healing). B. Record review of progress notes dated 03/18/25 revealed the resident had an unwitnessed fall at 7:00 pm. C. Record review of R #1's physician orders revealed the following: 1. An order dated 03/18/25, Initiate Fall Prevention Program; Lower bed at appropriate height to prevent fall/injury.2. An order dated 03/18/25, Monitor status for 72 hours for bruising, change in mental status/condition, pain, or other injuries related to fall.3. An order dated 03/18/25, With Suspected head trauma - Neuro checks Q (every) 15 minutes x (times) 4, then Q1 hour x 2, then Q2 hours x 2, then Q4 hours x 2, then Q shift x 3. D. Record review of R #1's annual MDS assessment dated [DATE] revealed R #1 has not had any falls since admission/entry or reentry or the prior MDS assessment. E. On 08/27/25 at 3:15 pm, during an interview with the MDS Coordinator (MDS), she confirmed R #1's MDS is not accurate because R #1 had a fall on 03/18/25.

Based on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to wear hairnets while in the kitchen. This deficient practice is likely to affect all 79 residents listed on the resident census list provided by the Administrator on 04/02/25. The findings are: A. On 04/04/25 at 12:23 pm, a random observation of the kitchen revealed Dietary Aide #1 and Dietary Aide #2 were not wearing a hairnet while in the kitchen. B. On 04/04/25 at 12:46 pm during an interview with Assistant Dietary Manager, she confirmed that all staff should be wearing hairnets while in the kitchen.

Based on record review and interview, the facility failed to develop and implement an accurate, person-centered comprehensive care plan for 2 (R #33 and R #51) of 4 (R #1, R #3, R #33 and R #51) residents reviewed for care plans. This deficient practice is likely to result in staff being unaware of the current and actual needs of the residents. The findings are: R #33 A. Record review of R #33's Face Sheet revealed she was admitted to the facility on [DATE]. B. Record review of R #33's care plan dated 04/19/24 revealed that R #33 requires oxygen therapy. C. Record review of R #33's current medical orders revealed no order for the use of supplemental oxygen. D. On 04/04/25 at 2:45 pm during an interview with the Director of Nursing (DON) she stated that R #33 does not use supplemental oxygen. The DON confirmed that R #33's care plan is not accurate. R #51 E. Record review of R #51's Face Sheet revealed she was originally admitted to the facility on [DATE] with the following diagnoses: 1. Atherosclerotic (plaque containing cholesterol and lipids that build up on artery walls) heart disease, 2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), 3. Dependence on supplemental oxygen, (oxygen therapy; a therapy treatment which provides extra oxygen). F. Record review of R #51's care plan last revised on 11/07/24 and on 03/06/25 revealed the care plan did not contain any information regarding R #51's use of oxygen. G. On 04/04/25 at 2:45 pm during an interview with the DON, she confirmed that R #51 does use supplemental oxygen, should have a care plan for the use of oxygen. R #51 does not have a care plan in place for oxygen use. The DON confirmed that any resident that uses supplemental oxygen should have a care plan in place. 51616

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 2 (R #34, and R #51) of 4 (R #3, R #33, R #34, and R #51) residents reviewed when staff failed to: 1. Revise #34's care plan for the use of assist bars. 2. Revise #51's care plan for hospice care. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #34 A. Record review of R #34's face sheet revealed R #34 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: 1. Abnormalities of gait and mobility (a deviation from the normal pattern of walking), 2. Lack of coordination, 3. Polyosteoarthritis (a condition where pain and inflammation occur in multiple joints at once), 4. Parkinsons disease (a progressive neurological disorder that primarily affects movement) with Dyskinesia (a movement disorder characterized by involuntary, repetitive, and often purposeless movements) B. Record review of R #34's assist bars evaluation dated 08/11/20 revealed the following: 1. R #34 requested to have assist bar while in bed for safety and security, 2. Bilateral (horizontal bars that attach to the side of a bed, extending a quarter of the length of the bed) bars indicated bed mobility and transfers. 3. R #34 consented to assist bars for bed mobility and transfers. C. Record review of R #34's care plan dated 07/23/24 revealed there was not a care plan for assist bar use. D. On 04/02/25 at 9:55 am during an observation of R #34's bed revealed quarter size assist bars on each side of the bed. E. On 04/02/25 at 9:55 am during an interview, R #34 stated he was aware he had assist bars on each side of the bed and used the bars to help with repositioning himself and bed mobility. F. On 04/04/25 at 2:46 pm during an interview with the Director of Nursing (DON), she stated R #34 did not have a care plan for assist bars and should have. R #51 G. Record review of R #51's Face Sheet revealed R #51 was originally admitted to the facility on [DATE] with the following diagnoses: 1. Atherosclerotic (plaque containing cholesterol and lipids that build up on artery walls) heart disease, 2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), 3. Hypertensive heart disease (a condition where long-term high blood pressure puts extra strain on the heart) with heart failure. H. Record review of R #51's medical orders revealed an order to admit R #51 to hospice dated 08/13/24. I. Record review of R #51's care plan dated with last care conference date of 12/05/24 revealed there was no care plan present for hospice care or services. J. On 04/04/25 at 2:46 pm, during an interview with the DON, she confirmed that R #51 is on hospice and does not have a care plan in place that addresses hospice. The DON stated that her expectation is to have a hospice care plan in place for all residents that are on hospice. 51616

Based on record review and interview, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #58) of 2 (R #51 and R #58) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the residents not receiving the services they need. The findings are: A. Record review of R #58's Face Sheet revealed R #58 was admitted to the facility on [DATE] with multiple diagnoses including a diagnosis of major depressive disorder (depression; a mood disorder that causes a persistent feeling of sadness and loss of interest), recurrent. B. Record review of R #58's PASRR dated 05/31/24, revealed staff documented that R #58 does not have a diagnosis or suspected mental illness. C. On 04/03/25 at 2:31 pm, during an interview with the Director of Nursing (DON), she stated R #58 does have a diagnosis of major depressive disorder which is listed as a mental illness on the first question of section C on the New Mexico PASRR Level 1 Identification Screen form and confirmed that R #58's PASRR is incorrect.

Based on observation and interviews, the facility failed to ensure all treatment carts were locked while unattended. This deficient practice had the potential to affect all 18 people residing in the 200 through 216 rooms by allowing unauthorized people access to their medical supplies and personal health information. The findings are: A. On 04/02/25 at 9:38 am, during a random observation of the facility, the treatment cart located in the the hall of the 200 rooms was unlocked, and the facility employees were not in the area. B. On 04/02/25 at 9:42 am, during an interview with Case Manager (CM) #1, he confirmed the treatment cart was unlocked and then walked away from the area. C. On 04/02/25 at 9:43 am, during an interview with Registered Nurse (RN) #1, he confirmed the treatment cart was unlocked and locked the cart. RN #1 stated the treatment cart should be locked and secured while not in use.

Based on observation and interview, the facility failed to serve food under sanitary conditions by professional standards of food service safety. This failure could potentially affect all 76 residents in the facility who eat food prepared in the kitchen. Residents were identified by the Resident Matrix provided by the Administrator on 03/25/24. When they failed to: 1. Have staff perform hand hygiene when distributing food trays to residents in the H Unit. 2. Have staff perform hand hygiene when assisting residents in the main dining room. If the facility fails to adhere to safe food handling practices and hygiene practices, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins). The findings are: A. On 03/26/24 at 11:27 AM, during an observation of the dining room of the H Unit revealed the following: 1. CNA #33 did not wash or sanitize her hands with hand sanitizer in between meal pass. B. On 03/26/24 at 11:31 AM, during an observation of the dining room the following was revealed: 1. CNA #24 and Nurse Aide (NA) #21 sat at one table with four residents (R #7, R #19, R #20, and R #57). 2. CNA #24 assisted R #19 and R #20 with eating and drinking. 3. CNA #24 did not perform hand hygiene when she moved between R #19 and R #20. CNA #24 took turns feeding the resident in succession (one after the other). 4. NA #21 assisted R #7 and R #57 with eating and drinking. 5. NA #21 did not perform hand hygiene when she moved between R #7 and R #5. NA #21 took turns feeding the residents in succession. C. On 03/28/24 at 9:18 AM, during an interview with NA #21, she confirmed the following: 1. NA #21 did not perform hand hygiene when she moved between R #7 and R #57, while she took turns feeding the residents in succession during the lunch meal on 03/26/24. 2. CNA #24 did not perform hand hygiene when she moved between R #19 and R #20, while she took turns feeding residents in succession during the lunch meal on 03/26/24. 3. Staff do not typically perform hand hygiene between feeding residents. 4. Staff should perform hand hygiene when feeding separate residents. D. On 04/02/04 at 11:25 AM, during an interview with the DON, she said that staff do not need to perform hand hygiene when alternating between feeding two different residents unless a resident touches the item the staff member is using to feed the residents. 50497

Based on record review and interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This deficient practice has the potential to affect all 76 residents in the facility. Residents identified on the matrix provided by the Administrator on 03/25/24. This deficient practice could likely result in the inappropriate use of antibiotics that can lead to resistance of multi-drug resistant organisms. The findings are: A. Record review of the Antibiotic Sterwardship Program Policy dated 02/29/24, revealed that nursing staff will conduct an antibiotic timeout within 48-72 hours of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings. B. On 03/26/24 at 10:49 AM, during an interview with family member (FM) #1, he said R #31 was recovering from a UTI. C. Record review of R #31 physician's orders revealed the following: 1. On 03/19/24 ceftriaxone (antibiotic) for UTI (an infection in any part of the urinary system) discontinued on 03/21/24. 2. On 03/26/24 ceftriaxone for UTI discontinued on 03/28/24. D. Record review of R #31's MAR for March 2024 revealed the following: 1. Staff document ceftriaxone was administered to R #31 as ordered through 03/21/24 for UTI. 2. Staff document ceftriaxone was administered to R #31 as ordered starting on 03/26/24 for UTI. E. On 03/29/24 at 12:02 PM, during an interview, the IP stated that the normal protocol is to have staff talk about residents and the antibiotics they are on every day. The IP said that they discuss how the residents are doing on the antibiotics and if the residents are having any adverse reactions to them. The IP confirmed that the physician is not involved in the daily meetings. F. On 03/29/24 at 12:17 PM, during an interview with DON she said that they do not do 48 hour time outs for antibiotics. 50497

§483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: This REQUIREMENT is Not Met as evidenced by: Based on record review and interview, the facility failed to: 1) seek immediate medical attention for a resident experiencing an injury, 2) failed to request the results of an x-ray in a timely manner, 3) failed to obtain the necessary medical device to immobilize the leg as ordered by the physician 4) failed to request a pain medication that would address a resident's increasing pain, and 4) failed to administer medication as ordered by the physician to treat muscle spasms for one (R#6) of one (R#6) residents reviewed for injuries. This failure likely resulted in R #6 experiencing increased pain after sustaining a tibia (the shin bone, the long bone of the lower leg found between the knee and the ankle)/fibula (leg bone on the side of the tibia) [MEDICAL CONDITION] leg. The findings are: A. Record review of a facility incident report dated 04/18/17 at 2:00 pm indicated that on 04/12/17 at 5:30 am, Certified Nursing Assistants (CNA) #9 and #10 were transferring R #6 to the wheelchair when the resident began sliding forward out of the wheelchair. The report indicates the resident slipped even further with her knees impacting the foot pedals of the wheelchair. B. Record review of facility progress notes for R #6 indicated the following after the 04/12/17 incident: 1. 04/12/17 8:41 am, resident asking for [MEDICATION NAME] (over the counter pain reliever) because of left knee pain. 2. 04/12/17 4:42 pm, resident complaining of pain on the left lower leg. (name of Register Nurse (RN) #5) checked resident and saw left lower leg swollen with bruise on the posterior-medial (side and back). Give prn (as needed) [MEDICATION NAME] (over the counter pain reliever) 650 milligram (mg) will continue to monitor. 3. 04/13/17 (no time), Resident requested x-ray of the affected area from fall due to pain and swelling . 4. 04/13/17 11:00 am, Resident transported to (name of local emergency department) for x-rays of the left foot, ankle, knee, and hip. Official reading to follow. 5. 04/17/17 10:30 am, daughter requesting information about x-ray results from last week after resident's fall from the wheelchair. Social Services Director (SSD) stated the facility did not have the results. 6. 04/17/17 4:25 pm, x-ray results sent to Certified Nurse Practitioner (CNP). Results indicated displaced tibia and fibular fractures. CNP ordered orthopedic referral. 7. 4/18/17 12:26 am, resident had pain and limitation of movement of left leg. [MEDICATION NAME] 650 mg given and cold compress kept in place. 8. 04/18/17 3:46 pm, CNP orders leg immobilizer for left leg. 9. 04/18/17 5:03 pm, leg immobilizer not available in facility central supply. Resident advised to go to emergency department of hospital (ED) to get one. 10. 04/18/17 5:29 pm, resident says she has kept ice on leg all afternoon and also keeps on at night because of the pain. 11. 04/19/17 (not timed) contacted (name of local ED) and (name of ambulance service) for transfer of resident for immobilizer application on left lower extremity due to fracture. 12. 04/19/17 1:45 pm, resident came back to facility with immobilizer and a prescription for [MEDICATION NAME] (narcotic pain reliever) 7.5/325 mg. 13. 04/19/17 11:45 pm, resident's lower left extremity still swollen 14. 04/20/17 3:25 pm, got an order for [REDACTED]. 15. 04/21/17, resident has an appointment with (name of orthopedic physician) on Thursday (04/27/17). 16. 4/27/17, came back from(name of orthopedic physician) Doctor didn't check resident due to not receiving documents needed. Rescheduled for 5/1/17. 17. 5/1/17, 3:40 pm, got new order for balcofen (muscle relaxant) since [MEDICATION NAME] (muscle relaxant) not covered by insurance prescription plan. C. On 06/06/17 at 3:30 pm, during an interview, R #6 stated, when my leg was broken, I cried it was so painful. When they would transfer me, it would hurt. I just wanted to stay in bed for 4 days. I couldn't use the manual wheelchair, so staff had to push me everywhere. It really hurt when my leg would jerk, I guess because of spasms. D. Record review of facility stand up-stand down meetings revealed the following: 1. 04/12/17 - resident has left knee pain. 2. 04/14/17 - awaiting x-ray results. 3. 04/17/17- awaiting x-ray results. 4. 04/20/17 -anti spasm medication ordered. 5. 04/25/17- resident's anti spasmodic needs prior authorization. 6. 04/26/17 - resident needs prior authorization for [MEDICATION NAME]. 7. 04/28/17-resident upset after appointment with (name of orthopedic physician) due to not being seen by physician. Refusing manual wheelchair. E. Record review of the facility Medication Administration Record [REDACTED] 1. [MEDICATION NAME] 10 mg as needed for muscle spasms ordered on [DATE]. Further review of this MAR indicated [REDACTED]. 2. R #6 began receiving [MEDICATION NAME] ( a narcotic pain medication ) on 04/19/17, seven days after the fracture, in which R #6 experienced pain and limitation of movement of the lower left leg. F. Record review of the MAR for R#6 dated 05/01/17-05/06/17 indicated R #6 was not given medication as ordered ([MEDICATION NAME]) for muscle spasms during this six day time frame. The resident began receiving an alternate muscle relaxant ([MEDICATION NAME]) 05/07/17, seventeen days after the medication was initially ordered for muscle spasms. G. On 06/06/17 at 11:55 am, during an interview, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated the previous DON was tracking x-rays. They stated the charge nurse should have followed up when the x-ray results were not sent to the facility. They also stated the facility should not have waited for R #6's family member to call before the x-ray results were obtained. They stated that part of the seven day delay in transporting the resident for a leg immobilizer and pain medication was because R #6 requires transportation in an vehicle that can accommodate a gurney. They stated there is only one Medicaid approved non-emergency transportation service in the local area, and sometimes the service can not transport right away. When asked if a leg fracture with pain, swelling, bruising, and limitation of movement could be considered an emergency, the DON stated, yes. H. On 06/06/17 at 2:15 pm, during an interview, the ADON stated the charge nurse should have followed up with the Certified Nurse Practitioner ( CNP) to get authorization for the [MEDICATION NAME]. The ADON stated she had spoken with R #6's CNP on 06/06/17 and the CNP stated she remembers working on filling out an authorization for the [MEDICATION NAME], but the CNP was dealing with two different residents at two different facilities regarding [MEDICATION NAME] during that time. The CNP stated she did not have evidence of the authorization, also stating, that was seven weeks ago.

During random observation on 01/25/17, Certified Nurse Aide (CNA) #6 was observed leaving R #8's room pulling a hoyer lift machine. Interview with R #8 and CNA #6 confirmed that he (CNA #6) provided transfer assistance using the hoyer lift without additional staff assisting. Interviews with several other staff confirmed that due to a shortage of staff, it has been regular practice to transfer residents only using one person assist. The Director of Nursing (DON) provided an inservice staff sign in sheet dated 01/17/17 verifying that she provided training on hoyer lift transfers highlighting that it is best practices for 2 staff to provide hoyer lift transfers, however not all staff attended the training and the DON was uncertain if staff were using 2 persons to transfer residents. Additional interview with staff and R #8 on 02/22/17 confirmed that staff were still transferring residents with the hoyer lift by themselves (without staff assistance), putting residents at serious risk of injury. This deficient practice resulted in Immediate Jeopardy being identified at Level 4, Scope K. The Administrator, DON #1 and DON #2 were notified on 02/22/17 at 12:50 pm. A. Plan of removal was approved on 02/22/17 at 3:50 pm which included: 1. An update to the patient lift policy which identifies that 2 trained staff will provide hoyer lift assistance. 2. All nursing staff inserviced on 02/22/17 regarding the patient lift policy and requirement of 2 trained staff members to transfer any resident requiring 2 people for proper lift. 3. Any off-duty nursing staff will be required to sign understanding of the policy prior to returning to duty. 4. Only trained staff will be allowed to use the mechanical lifts. 5. Monitoring for compliance includes licensed nurse, DON or designee and Therapy observations of hoyer lift transfers daily for 2 weeks. This resulted in the scope and severity to be lowered to Level 3, Scope H due to R #22. Based on observation, interview and record review, the facility failed to provide appropriate supervision and assistance to prevent accidents for 4 (R #'s 8, 9, 22 and 24) of 8 (R #'s 4, 8, 9, 22, 24, 38, 39 and 40) residents reviewed hoyer lifts, pain and behaviors and for accidents by: 1) Not ensuring that two staff provide hoyer (mechanical device used to lift residents) lift transfers for R #8 and 9 which could likely result in residents falling during transfer. 2) Not providing a safe 2 person transfer for R #24 which likely resulted in her experiencing a shoulder injury 2) Not providing appropriate supervision and ensuring that potential weapons were removed from R #22's room after he verbalized wanting to harm himself which likely resulted in self injury. The findings are: Findings for R #8 A. On 01/25/17 at 7:50 am during an observation, Certified Nursing Assistant (CNA) #6 came out of R #8's room pulling a Hoyer machine. Observation of the room revealed no other staff was in the room. CNA #6 was asked who helped s/he lift R #8. CNA #6 stated, I lifted (Name of R #8) by myself and always do. I always lift patients by myself. We are short-handed. CNA #6 was asked if s/he had attended the in-service on Hoyer lifts and stated, No, I was working on the floor. CNA #6 was asked to go to the foot of R # 8's bed and read the sign posted on it. CNA #6 read, (Name of R #8) - 2 person assist. B. On 01/25/17 at 8:00 am, during an interview, Registered Nurse (RN) #3 was asked if s/he knew CNA #6 was in R #8's room alone lifting R #8 with the Hoyer. RN #3 stated, I knew (Name of CNA #6) was down there. If (Name of CNA #6) needed help (Name of CNA #6) should have called me or the other CNAs. C. On 01/25/17 at 2:25 pm, during an interview, Co-Director of Nursing (CDN) #1 was asked why CNA #6 lifted R #8 by him/herself. CDN #1 stated that CNA #6 had been trained on the proper use of the Hoyer and should have asked for help from the charge nurse or another aide. D. On 02/22/17 at 8:50 am during an interview, R #8 was asked if she was still being lifted with the Hoyer by one person. R #8 said it was CNA #6 that lifted her, a few days ago, by himself. He was working the morning shift when he did it. Findings for R #9 E. On 01/11/17 at 1:18 pm during an interview, R #9 stated one person has been putting him/her in the Hoyer Lift and that (Name of CNA #3) lifted him/her this morning by themselves. F. On 01/13/17 at 9:35 am, during an interview, Registered- Nurse (RN) #3 was asked if R #9 was a one or two person assist. RN #3 stated, (Name of R #9) is a transfer by Hoyer and (name of R #9) is a minimum of two assist. It's the facility policy. G. On 01/13/17 at 9:55 am, during an interview, RN #2 was asked if R #9 was a one or two person assist. RN #2 stated, (Name of R #9) is a two person assist. I often have to help with the Hoyer lifts because we are short staffed. At times when there are only three CNAs, one person only does the Hoyer. We have too many residents to watch CNAs on the Hoyer. We don't have enough CNAs. H. On 01/13/17 at 1:45 pm, during an interview, Co-director of nursing (CDN) #1 was asked if R #9 is a one or two person assist on the Hoyer. CDN #1 stated, If (name of R #9) is in bed, she is a one person assist. If (name of R #9) is being moved by the Hoyer (name of R #9) is a two person assist. I. On 01/24/17 at 9:00 am, during an observation of R #9's room, a sign located on the foot of the bed read (name of R #9) 2 person - Hoyer. J. On 01/18/17 at 3:38 pm, during a phone interview, CNA #4 confirmed that she has transferred residents using the hoyer lift. I always use the Hoyer by myself when I am on the east wing. I have no other staff member helping me. I lifted (Names of R #'s 9, 8, 6). The only one we have to get help on is R #4. I have to wait to get help on (Name of R#4) because there is a video camera in there (her room). CNA #4 was asked how long she has lifted residents by herself, she stated, This has been going on since I started about a year ago. K. On 01/19/17 at 10:30 am, during an interview, the Physical Therapy Director (PTD) was asked if resident's should be lifted by the Hoyer Lift with one person. The PTD stated, Always by two people. The PTD provided a list of resident's evaluated for Hoyer, two person assist, dated 01/19/17. The list included R #'s 4, 6, 8, and 9. L. On 04/22/17 at 4:22 pm, during interview with CNA #6, he confirmed that when he was hired he received hoyer lift training which included demonstrating use of the hoyer lift with another staff member pretending to be the resident. CNA #6 confirmed that the demonstration was demonstrated with him using the hoyer lift alone. M. On 02/21/17 at 4:31 pm, during interview with RN #2, she confirmed that the only hoyer lift training she had received was at another facility. N. On 02/21/17 at 5:36 pm, during interview with CNA #4, she confirmed that the only hoyer lift training she had received was when she was oriented. O. On 02/22/17 at 8:55 am, during interview with R #8, she confirmed that a couple nights ago a CNA did transfer her using the hoyer lift without any other staff assisting. R #8 stated that she didn't want to state who the CNA was as to not get that person in trouble. P. On 02/22/17 at 9:08 am, during interview with the PTD, she stated, I have seen one person (staff) go in the room with a hoyer. They (staff) say they are short staffed but that is no excuse. The PTD confirmed that a couple days ago, she observed an unidentified CNA go into a resident's room with a hoyer lift and come out of the room with the resident in a wheelchair. The PTD confirmed that there was no other staff in the room. Q. Record review of the facility In-service sign in sheet dated 01/17/17 with topic: Hoyer, pericare, cleaning shower chair in between, res (resident) 02 (oxygen) schedule, keeping cabinets locked, shower rooms revealed, CDN #1, RN #2, RN #3, and CNA #6 did not sign the in-service training sign-in sheet. R. On 02/22/17 at 10:29 am, during interview with Director of Nursing (DON) #1, she stated that she conducted an inservice on 01/17/17 related to hoyer lifts about the proper use of the hoyer lift, how to clean the hoyer lift, charging the batteries and storage of the hoyer lift. DON #1 confirmed that the training was lecture only and did not include a demonstration. DON #2 stated I did explain to them (staff) that the best practice is 2 (staff to use the hoyer). DON #2 confirmed that if staff did not sign the inservice sheet, they did not receive the most recent training (01/17/17). There was a problem when you guys were visiting us (January 2017), that (2 person transfer for hoyer lifts) wasn't happening at that particular time. When asked how she is ensuring that staff are using 2 persons to transfer using the hoyer lift, she stated I have been popping into rooms (resident rooms). When asked which residents' rooms she has been checking on, she stated I don't write it down or anything. S. Record review of the facility's Patient Lift Policy (no date) revealed, The purpose of using a mechanical lifter is to make the lifting and transferring of residents safer and easier. All nursing staff must be trained on the operation and use of the Hoyer lift and the Stand-lift before using this equipment. Proper use of the lifters will result in fewer injuries to staff and residents. Findings for R #24 T. Record review of Incident report dated 01/23/17 indicated resident (R #24) was being turned in bed and experienced pain to her left shoulder. On 01/24/17 at 10:50 am R #24 spoke with Director Of Nursing (DON) about her pain. POA (Power of Attorney) and Doctor were notified. U. On 02/21/17 at 5:06 pm, during an interview with R #24, she stated, On the day of the incident (01/23/17) a young guy and a young girl came to put me to bed they got me up off the wheelchair ok and then they got in a hurry and they got rough. One of them pulled on my shoulder and I felt pain right away. I then asked them to call the nurse, but she never came. I could not call my daughter because I could not reach my phone and I did not have a call light next to me so I could not call for help. The next day I asked the young girl to give me my phone. My shoulder hurt so bad, I called my daughter and she called the facility. V. On 02/22/17 at 9:08 am, during interview with Physical therapy Director regarding R #24, she stated, She is a two person transfer. She is too heavy and unsteady on her feet. I have seen them only transfer with one person. Before the incident, I told them I would write them up if I saw them only use one person. She probably is afraid of falling (following the incident). Her fear (is that), they jacked her up under her arms. I get on them all the time and they don't listen to me. They (staff) jacked her up under her arm. There is no other reason they could have hurt her that way. W. On 02/22/17 at 5:10 pm, during an interview with Family Member (FM) #2 she stated, I was not informed about the incident prior to my mother calling me the next day and telling me she was in a lot of pain. I had to call the facility and ask them what was going on. X. Record review of the Progress Notes dated 01/25/17 revealed Resident was complaining of pain in L (left) shoulder area, when assessed by (Name of Physical Therapy Director), and this nurse indention of L upper chest was noted; swelling was observed as well. Decided to send to (name of hospital) for further evaluation to rule out shoulder fx (fracture) or dislocation Resident came back with arm sling L (left) and [DIAGNOSES REDACTED]. Y. Record review of facility face sheet revealed R #22 was admitted to facility on 05/20/15 and was discharged on [DATE] after an incident of self-harming behaviors. Z. Record review of progress notes dated 02/07/16 revealed the following: 1) At 3:42 pm, CDN (Co-Director of Nursing) #1 revealed she was approached by Admin stating R #22 needed to be assessed because his behaviors were out of the normal .while walking with R #22, CDN #1 smelled mouthwash on his breath . he was very angry .CDN #1 explained to R #22 that she needed to draw his blood due to new dr's orders and if positive, she (NP) would discontinue pain medications .resident became angry and started kicking some boxes but agreed to have his blood drawn. 2) At 5:52 pm, Minimum Data Set Coordinator (MDSC) revealed R #22 smelled of mouth wash .she requested a blood draw .rsd (resident) angry and agitated, questioned MDSC, Am I going to lose my narcotics .admitted he drank a little and stated, 'I can't live without my narcs (sic)' .Began punching glass on framed picture .Resident continues to blame others for intake of alcohol. Odor of mouthwash present. 3) At 8:26 pm, MDSC revealed new orders were received to taper Oxycodone to .5 mg (milligrams) and to discontinue Tramadol, offer resident counseling and drug rehab facilities, and make appointment with psychologist. MDSC told R # 22 .Resident states 'I can't do that .I can't live without my narcs .I would rather take a bullet in the mouth that be without my narcs .I will just die without my narcotics' Arrangements were being made for resident to be observed closely for 15 minute visual checks. 4) At 10:05 pm, MDSC wrote: at 2105 (9:05 pm) she saw (Name of R #22)'s call light on, observed certified nursing assistant (CNA) assisting another resident in the room, pulled privacy curtain to check on R #22 . wrote, Resident seated in recliner. Blood spatter noted on floor and armrest and resident lap, multiple superficial cuts and fresh bleeding noted to right upper posterior extremity from wrist. Scratches noted on left hand also covered by thin layer of blood .(Name of R #22) remained combative .attempting to reach scissors which were removed from room EMTs and Police arrived at 2135 (9:35 pm), report given EMTs located a large swiss army type knife in drawer after resident admitted using it and scissors to cut himself .Resident also admitted to police officer that he had attempted to harm himself. Resident left via stretcher at 2145 (9:45 pm). AA. On 02/22/07 at 9:08 am, during interview, Social Service Director (SSD) stated that after R #22 was discharged , we found razors, empty bottles of mouth wash and a hacksaw. BB. On 02/22/17 at 10:48 am, during interview, CDN #1 revealed the last couple of months at the facility, R #22 started to have different behaviors out of character . There was (sic) times when his gait was unsteady .he was sleeping in the activity center, his speech was a little slurred. CDN #1 stated, We (staff) started to note the scent of mouthwash. CDN confirmed she was working on 02/7/17 and had interactions with R #22. CDN #1 stated she spoke with R #22 in the afternoon and he smelled of mouthwash and notified the NP who ordered a blood alcohol level and that after getting the orders, CDN #1 spoke to R #22 who was upset and began kicking boxes. CDN #1 stated, Finally we get the results. It was definitely high for alcohol. We notified the NP. She gives the orders (to reduce R #22 medications). CC. On 02/22/17 at 11:27 am, during interview, Nurse Practitioner (NP) revealed that drinking Listerine (mouth wash) would be endangering and the effects of the opioids would be intensified and not for therapeutic (purposes). DD. On 02/22/17 at 12:21 pm, during interview, MDSC confirmed being present on 02/07/17 and stated the following: I got the blood (from R #22) . I had a couple conversations (with R #22) and I assured him I don't know the results .He kept saying, 'I am going to lose my narcs. I really messed up' .He understood if continued to drink alcohol, his narcs (sic) would be cut off .At one point he was banging his fist in the picture frame; I tried to calm him the best I could .At some point around 6 or 7 pm, I was still in the building and we got the result back and it was 103 .I called the nurse practitioner and she gave me orders to taper his narcotics, I think it was oxycodone . I called Admin and CDN #1 .My thought was that if he is going to be angry I'd rather him be angry with less people and patients in the hallway .CDN #1 was in the hallway when I went in .I told him we got the blood alcohol level back and 80 was intoxicated and he was at 100 . I told him we were going to taper narcotics . He was sitting in his recliner . still and calm, flat affect but upset he started to say things about self-harm .I asked if he was going to kill himself and his response was something like, I'm not stupid I'm not going to tell you. MDSC confirmed being afraid R #22 might hurt himself and called the Nurse practitioner to put him on Q (every) 15 minute checks. MDSC stated the R #22 returned to his room and that about 30 minutes later, before leaving the building for the night she went to check on him, noticing that R #22's call light was on. She stated I saw blood through the curtain crack where he had the curtain pulled. I stood in front of (Name of R #22). At that point (Name of R #22) became combative and he jumped up to reach for the scissors in the drawer. I didn't let him have them, and he sat back down. MDSC confirmed that the wounds were superficial and she felt that the priority at the time was to keep him calm. When asked if after R #22 was placed on q 15 minute checks his room was inspected to ensure that there were no items he could hurt himself with, she stated No. EE. On 02/22/17 at 3:13 pm, during interview, Chief Executive Officer (CEO), she stated We weren't aware of him having anything in his room to harm himself . He knew he couldn't have a weapon I don't know where he got scissors Could be from the dollar store or a desk, I don't know. FF. Record review of 15 minute checks revealed a start date of 02/07/17 with one signature (eligible) at 8:45 pm only.

br> The following deficiency was a result of a complaint survey that was initiated 09/04/15. A continuing immediate jeopardy was identified at a scope and severity of K on 09/15/15 at 5:30 pm. The facility administrator was notified. Based on record review and interview, the facility failed to inform the physician of a change in condition for 2 (R #1 and R #2) of 3 (R #1, 2, and 3) residents reviewed for pressure ulcers by: 1) Not notifying the physician of the worsening of a pressure ulcer that had heavy, large amount of thick, purulent (full of pus) exudate (any fluid released from the body with a high concentration of protein, cells, or solid debris) and a foul smell for R #1. 2) Not notifying the physician of four newly developed stage 2 (partial thickness skin loss) pressure ulcers for R #2. The deficient practice likely resulted in the physician being unaware of the worsening pressure ulcers and the new pressure ulcers resulting in a delay of treatment. The findings are: Findings for Resident #1 (R #1): A. Record review of R #1's Skin Checks (SC) for the pressure ulcers located on the coccyx (the tailbone) revealed: 1. 05/28/15 at 3:30 pm, .Both (buttocks) have red wound bed with yellowish slough (a mass of dead tissue) and foul smelling. There is no notation of exudate in the SC. 2. 06/09/15 at 3:20 pm, Left buttock .draining clear liquid. Right buttock has no notation of any drainage. 3. 06/19/15 at 5:36 pm, There is no notation of any drainage from either buttock pressure ulcer. 4. 07/13/15 at 8:02 pm, Left buttock .no bleeding, draining clear liquid, no foul odor . Right buttock .draining minimal liquid, no foul odor . 5. 07/27/15 at 7:28 pm, .heavy, large amount thick, purulent exudate, foul smelling on dressing removal. 6. 08/03/15 at 8:27 pm, .wound dressing soaked and soiled with heavy exudate. Exudate is creamy, tan colored, purulent and large in amount. 7. 08/14/15 at 8:28 pm, .Wound dressing soaked and soiled with heavy exudate. Exudate is creamy, tan colored, purulent and large in amount. Has some foul slight foul odor noted, not as much as before. 8. 08/17/15 at 8:52 pm, .Wound dressing soaked and soiled with heavy exudate. Exudate is creamy, tan colored, purulent and large in amount. Has foul odor noted. 9. 08/25/15 at 6:00 pm, .Wound dressing soaked and soiled with heavy exudate. Exudate is creamy, tan colored, purulent and in large amount. Has foul odor noted. 10. 08/31/25 at 12:23 pm, .Wound dressing soaked and soiled with heavy exudate. Exudate is creamy, tan colored, purulent and in large amount with a tinge of blood. Has foul odor noted. Resident was admitted to (name of hospital) on 09/02/15 and has not been readmitted to the facility. B. Record review of nurses notes (NN) revealed: No evidence in the 07/27/15 and 08/03/15 notes of documentation of the exudate. C. Record review of R #1's medical record, including nursing notes and skin check sheets indicated R #1's pressure ulcers were worsening and there is no evidence of the physician being notified about the worsening conditions noted on 07/25/15 or 08/03/15. D. On 09/10/15 at 12:30 pm, during an interview with the facility Physical Therapist/Wound Care Certified (PT/WCC), stated that she had not notified the physician of the exudate noted on 07/27/15 or 08/03/15. E. On 09/10/15 at 3:35 pm, during an interview with RN/CM #1, the RN/CM #1 stated that she could find no indication the exudate or deteriorating condition of the pressure ulcer had been reported to the physician on either date. Findings for R #2 F. Record review of a skin check form dated 09/08/15 for R #2 revealed the following: 1. A section of the skin check form with the notation, New skin and wound findings (of the right fingers) seen during this visit. 2. Stage 2 pressure ulcer on the inner little finger measuring 1.0 x 0.8 cm; 3. Stage 2 pressure ulcer on the middle of the ring finger, measuring 1.5 cm x 0.9 cm; 4. Stage 2 pressure ulcer on the right side of the middle finger, measuring 0.5 x 0.5 cm; 5. Stage 2 pressure ulcer on the left side of the middle finger measuring 0.5 x 0.5 cm. 6. Documentation in the skin check sheets for 09/08/15 by Registered Nurse (RN) #2 revealed During this visit, I called (name of family friend) to report the new skin findings and told her that red spots and new sores are developing on the patient's right hand due to use of . finger separator in constant contact/pressure on the right hand. G Review of R #2's medical record indicated no documentation to indicate R #2's physician was notified of the discovery and development of four new stage 2 pressures ulcers to the fingers of the resident's right hand. H On 09/10/15 at 2:15 pm, during an interview with the facility Physical Therapist/Wound Care Certified (PT/WCC), the PT/WCC was asked if the new wounds to the fingers of R #2's right hand had been reported to the resident's physician, the PT/WCC stated that the family knew about the pressure ulcers, but that she had not contacted the physician.

The following deficiency was a result of a complaint survey that was initiated 09/04/15. A continuing immediate jeopardy was identified at a scope and severity of K on 09/15/15 at 5:30 pm. The facility administrator was notified. Based on record review, observation, and interview the facility failed to prevent pressure ulcers from developing and worsening for two (R #1 and #2) of three residents (R #'s 1, 2, and 3) reviewed for pressure ulcer risk by: 1) Not preventing a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer from developing undermining (an area around the edges of the pressure ulcer that tunnels into the surrounding tissue), for tissue), for R #1; 2) Not preventing a Stage 2 (partial thickness skin loss) pressure ulcer from becoming a Stage 3 (full thickness skin loss potentially extending into deeper tissue layer), for R #1, 3) Not preventing a pressure ulcer from becoming infected for R #1; 4) Not notifying the physician when a pressure ulcer developed a foul odor, heavy and large amounts of thick, purulent (discharging pus), exudate (fluid emitted by a wound), for R #1; and 5) Not evaluating and monitoring the use of a finger separator for R #2, and 6) Failure to clarify physician orders for R #2. The facility took corrective action by providing an acceptable Plan of Removal on 09/22/15 at 2:30 pm. Based on the plan of removal, interventions included: 1. in-services for pressure ulcer prevention and management, policies and procedures relating to physician notification and deterioration of wounds, resident changes of condition, 24 report system, Interact system that includes interventions to reduce acute care transfers, SBAR ( situation, background, appearance and review) assessment tool, skin checks, significant change, training and development of care plans, completion of the Braden Scale and training and education on the Briggs weekly wound log; 2. audit of 100 percent of nursing notes starting 09/17/15 to ensure physician has been notified of significant changes, 3. conduct skin assessments on all residents on 09/23/15, 4. new skin issues will be documented and a care plan initiated, 5. 24 hour report will be reviewed in the daily QAPI morning meeting, 6. implementation of a weekly wound team, 7. implementation of overall infection control practices and surveillance, and 8. review of physician telephone orders Monday through Friday during the morning QAPI meeting FINDINGS FOR RESIDENT #1 A. Record review of Nursing Notes (NN) and General Notes (GN) dated 05/28/15 thru 09/02/15 revealed: 1. NN dated: 05/28/15 at 3:30 pm, admitted a 59 y/o (year old) female, alert and oriented, bed bound to room (number of residents room) .Dx (diagnosis) of DM (diabetes mellitus) Type 2,[MEDICAL CONDITION](hypertension), with PEG (a tube into the stomach for feeding) tube, indwelling foley catheter. .Stage 4 pressure ulcer on coccyx (tail bone): right buttock measuring 7.5 cm (centimeter ) x (by) 4 cm x 4 cm, left buttock measuring 4.5 cm x 5.5 cm x 3.5 cm (depth). Both have red wound bed with yellowish slough (a layer or mass of dead tissue separated from surrounding living tissue) and foul smelling. [DIAGNOSES REDACTED] (redness) on buttocks area . 2. NN dated 06/19/15 at 5:30 pm, resident said that she is not feeling well. Upon assessment she was confused, febrile (an elevated body temperature), and nauseated. 3. NN dated 07/09/15 at 2:45 pm, readmitted (Name of Hospital) .DX of Pressure Ulcer Stage 4, DM II,[MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staph aureous) (a bacterium responsible for several difficult-to-treat infections in humans), VRE ([MEDICATION NAME] resistant [MEDICATION NAME]) (a type of bacteria resistant to the antibiotic [MEDICATION NAME]), central line (a catheter placed in a large vein in the neck, chest or groin), PEG tube . and FC (foley catheter). 4. GN dated 07/16/15 at 6:35 pm, .The following skin and wound assessment findings were noted: 1. Stage 1 pressure ulcer on right heel measuring 0.5 cm x 0.5 cm . 5. GN dated 07/21/15 at 5:06 pm, .The following are today's skin and wound assessment findings and their management: 1. New Stage 3 pressure ulcer around the right thigh, elongated ulcer, resembling an outlined tube on the patient's skin. Possibly coming from prolonged pressure against her indwelling catheter or fecal tube. Measurement taken 0.5 cm x 18.0 cm. Cleansed with saline and Lantispetic Skin Protectant cream applied. 2. New Stage 2 pressure ulcer noted on posterior (toward the back) upper thigh of the right lower extremity measuring 1.0 cm x 3.0 cm. Cleansed with saline and [MEDICATION NAME] Skin Protectant cream applied. 3. New Stage 2 pressure ulcer noted on the sacral area measuring 1.5 cm x 2.0 cm. Cleansed with saline and [MEDICATION NAME] Skin Protectant cream applied. 4. New deep tissue injury noted to right lateral (away from the midline) malleolar (ankle) prominence, measuring 0.5 cm x 0.5 cm. [MEDICATION NAME] Skin Protectant cream and Heel protector (a device that cushions and protects the heels) in place. Patient had a leakage in fecal tube and will benefit from follow up with physician for possible check up and re-insertion, if necessary. 6. NN dated 08/13/15 at 8:30 pm, readmitted resident from (name of hospital) .Indwelling foley catheter intact, draining to gravity clear, yellow urine. 2 Stage IV decubitus ulcers present on sacral area measuring 5 cm x 6 cm and 6 cm x 7 cm. Also 3 [DIAGNOSES REDACTED]tous areas on right ankle (locations on the right ankle are not indicated) measuring 1 cm x 1.5 cm, 1 cm x 1 cm and 2 cm x 1.5 cm. 7. NN 09/02/15 at 7:30 am, resident sent to ER . for lethargy and coughing. B. Record review of hospital records for R #1 dated 06/19/15 thru 09/02/15 revealed: 1. ED (emergency department) Physician Documentation dated 06/19/15 revealed, HPI (history of present illness) Patient sent from nursing home with altered mental status. Has PEG tube and indwelling foley, febrile. Disposition: Preliminary [DIAGNOSES REDACTED]. Bed requested for Intensive Care, Condition is critical. 2. Discharge summary and admission H&P (history and physical) for TCU (Transitional Care Unit) dated 06/23/15, .Final [DIAGNOSES REDACTED].Sacral decubitus ulcer Stage 3-4 present on admission. Patient's symptoms improved and patient was discharged to TCU for IV (intravenous) antibiotic therapy as her nursing home declined to cover for IV meropenem (synthetic broad-spectrum antibacterial) .We continued her routine wound care for her sacral decubitus ulcer. 3. ED Nurse Documentation dated 08/10/15 under section Triage Assessment sub-section titled, .Derm (dermatology (skin)): Skin is fragile, is thin, skin is dry,skin is pale, skin temperature is hot. Decubitus located on sacrum approximately left 3 cm x 4 cm, tunneling approximately 4 cm at 12 o'clock; right 3 cm x 6 cm tunneling 3 cm to 2 o'clock is deep. Tissue has macerated (soften or become softened by soaking in a liquid) edges is draining large amount malodorous purulent. 4. Hospital Discharge Summary dated 08/13/15, under section titled, Final Diagnoses: [REDACTED]. Urinary tract infection, 3. Acute kidney injury secondary to dehydration, 4. Stage IV decubitus ulcer present on admission, 5. Recurrent urinary tract infections. Under section titled, Discharge Disposition, Transfer to long-term acute care (LTAC). Under section titled, Plan, .Physician at (name of skilled nursing facility) to resume care upon patient's arrival at the nursing home. 5. ED Nurse Documentation dated 09/02/15 at 7:44 am, under section titled, Triage Assessment: .Dermatological (Derm): Decubitus is located on sacrum approximately 2.6 cm to 7.5 cm has denuded edges has [DIAGNOSES REDACTED]tous edges has macerated edges bed has eschar (area of dead tissue on the skin) present .is draining moderate amount of malodorous, purulent. 6. Physician (Hospitalist) Progress Note dated 09/05/15 at 8:04 pm, under section titled, Impression: Made today as follows: .2.[MEDICAL CONDITION], ongoing with main source of infection from the decubitus ulcer .4. Decubitus ulcer ongoing with treatment by the wound care team. C. Record Review of Skin Check documentation for R #1 dated 05/28/15 thru 08/31/15 revealed: 1. Initial admission skin check: 05/28/15 - Stage 4 - Right buttock (coccyx) - 7.5 cm x 5.5 cm x 3.5 cm depth (d), Stage 4 - left buttock (coccyx) - 4.5 cm x 5.5 cm x 3.5 cm (d). 2. 06/09/15 - Stage 4 - Right buttock (coccyx) - 8 cm x 4 cm x 4 cm (d), black spot 2 cm x 2 cm 11 o'clock. Stage 4 - left buttock (coccyx) - 5.5 cm x 5.5 cm x 4 cm (d). 3. 06/15/15 - Stage 4 - Right buttock (coccyx) - 6 cm x 5 cm x 6 cm (d), 11 o'clock 3 cm x 3 cm x 2 cm gray area. Stage 4 - left buttock (coccyx) -5.5 cm x 4 cm x 5 cm (d). 4. 07/09/15 - Stage 4 - Right buttock (coccyx) - 4.2 cm x 6.8 cm x 2.0 cm (d), Undermining: 12 o'clock - 3.4 cm, 3 o'clock - 1.5 cm, 7 o'clock - 4.3 cm. Stage 4 - left buttock (coccyx) - 4.8 cm x 3 cm x 1.5 cm (d), Undermining: 12 o'clock - 3.4 cm, 9 o'clock - 1.5 cm, 7 o'clock - 0.5 cm. 5. 07/13/15 - Stage 4 - Right buttock (coccyx) - 5.5 cm x 7 cm x 4.5 cm (d), Undermining: 7 o'clock - 3.0 cm, no further undermining noted. Stage 4 - left buttock (coccyx) - 6 cm x 4 cm x 4 cm (d), no undermining noted. 6. 07/27/15 - Stage 4 - Right buttock (coccyx) - 5 cm x 5 cm no depth noted, Undermining: 12 o'clock - 12 cm, 3 o'clock - 2 cm, 7 o'clock - 2.8 cm. Stage 4 - left buttock (coccyx) - 4.2 cm x 3.5 cm no depth noted, Undermining: 11 o'clock - 4 cm, 9 o'clock - 2.5 cm. Stage 2 - right thigh - 5 cm x 0.5 cm. Heavy, large amount of thick, purulent (consisting of, containing or discharging pus), exudate (a fluid emitted by an organism through pores or a wound), foul smelling on dressing removal. 7. 08/03/15 - Stage 4 - Right buttock (coccyx) - 5 cm x 4 cm no depth noted, Undermining: 11 o'clock - 3.5 cm, 9 o'clock - 2.0 cm. Stage 4 - left buttock (coccyx) - 6 cm x 5 cm no depth noted, Undermining: 12 o'clock - 4.5 cm, Tunneling: 7 o'clock - 2.3 cm. Stage 3 - right thigh - 6 cm x 0.5 cm x 0.3 cm (d). 8. 08/14/15 - Stage 4 - Right buttock (coccyx) - 6 cm x 7 cm no depth noted, Undermining: 12 o'clock - 4 cm, Tunneling: 7 o'clock - 2.5 cm. Stage 4 - Left buttock (coccyx) - 5 cm x 6 cm no depth noted, Undermining: 11 o'clock - 4 cm, 9 o'clock - 2 cm, 12 o'clock - 2 cm. Stage 1 - (a) right ankle (outer) - 1 cm x 1.5 cm. .(buttocks) Wound dressing soaked and soiled with heavy exudate. Exudate is creamy, tan colored, purulent and large in amount. Has some slight odor noted. 9. 08/17/15 - Stage 4 - Right buttock (coccyx) - 6 cm x 4.5 cm no depth noted, Undermining: 11 o'clock - 3.2 cm. Stage 4 - left buttock (coccyx) - 5.5 cm x 6 cm no depth noted, Undermining: 1 o'clock - 4.5 cm, 3 o'clock - 2 cm, 7 o'clock -2.5 cm. Stage 1 - (a) right ankle (outer) - 1 cm x 2 cm. Stage 1 - (b) right ankle (outer) - 2 cm x 1 cm. .(buttocks) Wound dressing soaked and soiled with heavy exudate. Exudate is creamy, tan colored, purulent and large in amount. Has some slight odor noted, not as much as before. 10. 08/25/15 - Stage 4 - Right buttock (coccyx) - 4 cm x 6 cm no depth noted, Undermining: 1-2 o'clock - 4 cm, 3 o'clock - 1 cm, 7 o'clock - 2.5 cm, 12 o'clock - 2 cm. Stage 4 - left buttock (coccyx) - 7 cm x 6.5 cm no depth noted, Undermining: 10-11 o'clock - 3.5 cm. Stage 2 - right buttock (main muscle area) - 1.4 cm x 3 cm. Stage 1 - (a) right ankle - 1 cm x 2 cm. Stage 1 - (b) right ankle - 1 cm x 1 cm. .(buttocks) Wound dressing soaked and soiled with heavy exudate. Exudate is creamy, tan colored, purulent and in large amount. Has foul odor noted. 11. 08/31/15 - Stage 4 - Right buttock (coccyx) - 4 cm x 5.6 cm no depth noted, Undermining: 1-2 o'clock - 4 cm, 3 o'clock - 2.5 cm, 7 o'clock - 2.5 cm, 12 o'clock - 1.5 cm. Stage 4 - left buttock (coccyx) - 7 cm x 5 cm no depth noted, Undermining: 11 o'clock - 3.5 cm, 12 o'clock - 1.5 cm, 9 o'clock - 1.5 cm. Stage 2 - right buttock (main muscle area) - 1.4 cm x 3 cm. Stage 1 - (a) right ankle - 1 cm x 2 cm. Stage 1 - (b) right ankle - 1 cm x 1 cm. D. Record review of the skin check sheets from 05/28/15 to 08/31/15 revealed no evidence of the physician being notified of 1) increasing sizes of the existing pressure ulcers including undermining and increased depth. 2) notification of new pressure ulcers. and 3) failure to notify the physician of large discharges of purulent exudate in the wound. E. On 09/09/15 at 10:30 am, during an interview with emergency room RN #2, she stated, (name of R #1) came to the ED (emergency department) via ambulance on 09/02/15. Foley was disgusting, removed the foley and she had a large amount of pus and yellow discharge. She had a decubitus ulcer, Stage 4, on both sides of her buttocks not dressed, stool in her diaper, wet to dry dressing in the wound but no dressing covering the wound. F. On 09/09/15 at 10:46 am, during an interview with emergency room RN #3, stated, (name of R #1) came into triage and assessment via stretcher from the ambulance on 09/02/15. I could smell yeast, urine and feces .Foley looked very nasty, very dirty tubing that looked like it hadn't been changed in awhile .wound had feces in it, tunneling, it was large. Doctor said it didn't look clean and it was worse. G. On 09/09/15 at 11:20 am, during an interview with emergency room Tech (ED Tech), stated, When (name of resident) came in she looked very unkept. She had a . huge decubitus ulcer that was not covered and smelled of feces. The ulcer was dried out, with no dressing and open to the world. H. On 09/10/15 at 12:30 pm, an interview was conducted with the facility Physical Therapist/Wound Care Certified (PT/WCC), When asked if she had reported to the physician the Heavy, large amount of thick, purulent, exudate, foul - smelling on dressing removal. noted on 07/27/15 and 08/03/15 the PT/WCC stated, No, I did not. When asked if the Stage 2 pressure ulcer on the right thigh, had increased to a Stage 3, the PT/WCC stated, Yes, it had increased. I. On 09/10/15 at 3:35 pm, during an interview with Registered Nurse/Case Manager RN/CM #1, she stated, I can find no indication that the physician was notified of the drainage on either date. Findings for Resident #2 J. Record review of R #2's medical record indicated a date of birth of 12/31/81 and that the resident was admitted to the facility on [DATE]. R #2's admission [DIAGNOSES REDACTED]. Review of the current [DIAGNOSES REDACTED]. K. Record review of a clinical narrative note by the nurse from the wound care specialist treating R #2 revealed, 08/04/15 at 11:15 am, - Pt (patient) presents with complaints of open wounds to RT (right) thumb and #2 digit caused by pressure due to contracted hands x (times) four months. Pt was seen in ER (emergency room ) in (Name of town resident lives), where patient lives in a SNF (skilled nursing facility). Pt's thumb was infected and pt was put on IV (intravenous) antibiotics. Pt. was seen and treated in (Name of town and physician). R #2 was prescribed topical antibiotic ointment. Will continue with topical ointments QOD (every other day), SNF to change dressings. RTC (return to clinic) x 1 week. L. Record review of a skin check form dated 09/08/15 for R #2 revealed the following: 1. A section of the skin check form with the notation, New skin and wound findings (of the right fingers) seen during this visit. 2. Stage 2 pressure ulcer on the inner little finger measuring 1.0 x 0.8 cm; 3. Stage 2 pressure ulcer on the middle of the ring finger, measuring 1.5 cm x 0.9 cm; 4. Stage 2 pressure ulcer on the right side of the middle finger, measuring 0.5 x 0.5 cm; 5. Stage 2 pressure ulcer on the left side of the middle finger measuring 0.5 x 0.5 cm. 6. Documentation in the skin check sheets for 09/08/15 by Registered Nurse (RN) #2 revealed During this visit, I called (name of family friend) to report the new skin findings and told her that red spots and new sores are developing on the patient's right hand due to use of . finger separator in constant contact/pressure on the right hand. M. On 09/09/15 at 3:40 pm, observation of the removal of the finger separator on R #2's right hand was conducted with the PT/WCC and Registered Nurse (RN) #1. The observation revealed and the PT/WCC and RN #1 confirmed the four stage 2 pressure ulcers identified by the facility on 09/08/15 were still present. N. Record review of the physician progress notes [REDACTED]. 08/04/15 at 12:40 pm - In section Pressure Reduction the word foam was written in. Restrictions: Keep dressing dry. 2. 08/11/15 at 12:10 pm - In section Pressure Reduction, washcloths to bilateral hands, was written in. Restrictions: Keep dressing dry. 3. 08/18/15 at 15:15 pm - In section Pressure Reduction, apply rolled washcloths to bilateral hands for off loading, was written in. Restrictions: Keep dressing dry. 4. 09/01/15 at 10:30 am - In section Pressure Reduction, foam, hand off loading device, was written in. Restrictions: Keep dressing dry. O. There was no documentation to indicate the facility clarified with the physician regarding the use of a hand off loading device. P. Record review of Resident #2's care plan dated 10/03/14 and updated 06/16/15 revealed, Plan reviewed to address change in skin problems. Approach to include: 1. Use of finger and cone separator as tolerated. 4. Keep pressure off affected area as much as possible. Q On 09/10/15 at 12:15 pm, during an interview with the facility's PT/WCC when asked about the use of the finger separator, the PT/WCC stated the OT (Occupational Therapist) was involved for a while and we discontinued the finger separator, because of redness a while back. The PT/WCC stated she was unsure of the date the finger separator was discontinued. (There was no physician order for [REDACTED]. R. Record review of R #2' s primary physician orders dated 09/02/15 and signed 09/10/15 revealed, place finger/cone separator in right hand, off load pressure to thumb. S. On 09/10/15 at 2:15 pm, during a second interview with PT/WCC, the PT/WCC stated that there was no documentation that the wound care specialist physician was contacted to verify the use of the finger separator. The PT/WCC further stated that the family knew and were making arrangements to take her back to the wound specialist, but she had not contacted the wound care specialist physician. T. On 09/18/15 at 9:40 pm, during an interview with the physician from the wound care clinic, the physician stated the pressure ulcers between the right thumb, index finger, and other fingers on R #2's hand could have been prevented. The physician stated R #2 had been seen by him on four occasions and the week of 09/17/15 was the first time the facility had contacted him about the pressure ulcers on R #2's right hand.

Based on record review and interview, the facility failed to follow the care plan for one (#1) of one (R #1) resident reviewed for UTI's (Urinary Tract Infections) by not monitoring the resident for complications of foley catheter use, including S/S (signs and symptoms) of Urinary Tract infections (UTI's). This deficient practice likely resulted in Resident #1, being admitted to the hospital 3 times with UTI's. The findings are: A. Record review of R #1's care plan dated 06/18/15 for UTI's revealed, Problem: (name of resident) is at risk of developing UTI R/T (related to) indwelling catheter use. Goal: Will be free from complications of foley catheter use through next review. Approach: Monitor resident for complications of foley catheter use. (S/S of UTI). Change catheter per protocol. Anchor catheter to prevent excessive tension in the catheter. Position the draining system (tube, draining bag) to facilitate the flow of urine. Exercise caution with mobility and positioning to prevent accidental removal of catheter. Perform careful pericare; keep catheter free of crusting. Use collection bag cover while in wheelchair. B. Record review of Nursing Notes (NN) revealed: 1. 06/19/15 at 5:30 pm, Resident said that she was not feeling well. Upon assessment she was confused, febrile (a elevated body temperature), and nauseated .resident was sent to (name of hospital) ER (emergency room ) thru 911. 2. 08/10/15 at 4:48 pm, (this is the time the NN was charted. The NN does not indicate a time the incident occurred), Resident noted to be weak, responses limited to one word and nodding head. Refusing to eat/drink anything. Face flushed, skin warm to touch, .Temp (temperature) 102.6 .(name of ambulance service) called, (name of hospital) called for report. Left facility at 9:50 am. 3. 09/02/15 at 7:30 am, resident sent to ER ordered by (name of nurse practitioner) for lethargy and coughing C. Record review of laboratory results for R #1 revealed: 1. 06/19/15 at 7:08 pm, UA (urinalysis). Urinalysis was positive for 3+ leukocytes (white blood cells) (normal lab is negative), 3+ blood (normal lab is none seen) and 2+ bacteria (normal lab is none seen). 2. 08/10/15 at 10:21 am, UA. 08/10/15 at 12:13 pm, Interpretation: Abnormal: Blood urine dipstick 3+ (normal lab is negative), Urine leukocyte esterase (white blood cell enzymes) 3+ (normal lab is none seen) , Bacteria - urine 2+ (normal lab is none seen). 3. 09/02/15 at 8:11 am, UA. 09/02/15 at 11:32 am, Interpretation: Abnormal: Urine leukocyte esterase 3+ (normal lab is negative), White blood cells - urine >50 (normal lab is none seen), Bacteria - urine 3+ (normal lab is none seen), Triple [MEDICATION NAME] (calcium, ammonium and magnesium [MEDICATION NAME]) crystals - moderate (normal lab is none seen). D. Record review of hospital laboratory results revealed: A urine culture collected on 06/19/15 at 7:32 pm, during an emergency room visit, which resulted in hospitalization , revealed growth of Escherichia coli (a bacteria in the human intestine) and Pseudomonas aeruginosa (a bacteria that may cause life threatening infections in humans including urinary tract infections [MEDICAL CONDITION]). E. Record review of hospital laboratory results revealed: A urine culture collected on 08/10/15 at 11:28 am, during a emergency room visit, which resulted in hospitalization , revealed growth of Escherichia coli and Citrobacter amalonaticus (a human bacteria that can cause infections of the urinary tract). F. Record review of hospital laboratory results revealed: A urine culture collected on 09/02/15 at 11:29 am, during a emergency room visit, which resulted in hospitalization , revealed growth of Proteus mirabilis (abundant in nature and an occasional human bacteria (e.g., of the urinary tract)) G. On 09/09/15 at 8:11 am, during an interview with emergency room Registered Nurse (RN) #2, stated, (name of Resident #1) came to the ED (emergency department) via ambulance. Foley was disgusting, removed the foley and (name of resident) had large, pus, yellow discharge. H. On 09/09/15 at 10:46 am, during an interview with emergency room RN #3, stated, (name of R #1) came into triage and assessment via stretcher from the ambulance. I could smell yeast, urine and feces.Foley looked very nasty, very dirty tubing that looked like it hadn't been changed in awhile. I. On 09/11/15 at 9:55 am, during an interview with the facility Director of Nursing (DON) the DON was asked for the P&P on foley catheter care. The DON stated that she cannot find any P&P for foley catheter care. J. On 09/11/15 at 10:15 am, during an interview with the Administrator (ADM), the ADM was asked for in-service sheets for foley catheter care. The ADM returned with in-service sheets that showed toileting was addressed in several in-services, but could not produce any specific in-service for foley catheter care.

Based on record review, observation and interview the facility failed to ensure that 3 (R#1, 4, and 5) of 3 (#1, 4 and 5) residents reviewed for urinary catheter use received adequate services to prevent potential urinary tract infections by: 1) Monitoring of the resident for complications of foley catheter use - signs and symptoms of Urinary Tract Infections (UTI's) for R #1. 2) Catheter change per protocol for R #1 3) careful pericare; keep catheter free of crusting, for R # 1. 4) Positioning of the draining system (tube and drainage bag) to facilitate the flow of urine for R #4 and R #5. This deficient practice likely resulted in Resident #1, being admitted to the hospital 3 times with UTI's and could cause incorrect urine flow from placement above the bladder and create an increase of risk for urinary tract infections. The findings are: A. Record review of Nursing Notes (NN) revealed: 1. 05/28/15 at 3:30 pm, admitted a 59 y/o (year old) female, alert and oriented, bed bound to room (number of residents room) .Dx (diagnosis) of DM (diabetes mellitus) Type 2, with PEG (a tube into the stomach for feeding) with indwelling foley catheter. There is no evidence of further NN regarding the foley catheter monitoring for UTI's prior to discharge to (name of hospital) on 06/19/15. 2. 06/19/15 at 5:30 pm, Resident said that she was not feeling well. Upon assessment she was confused, febrile (a elevated body temperature), and nauseated .resident was sent to (name of hospital) ER (emergency room ) thru 911. 3. 08/10/15 at 4:48 pm (this is the time the NN was charted, the NN does not indicate a time the incident occurred), Resident noted to be weak, responses limited to one word and nodding head. Refusing to eat/drink anything. Face flushed, skin warm to touch, Temp (temperature) 102.6 .(name of ambulance service) called, (name of hospital) called for report. Left facility at 9:50 am. 4. 09/02/15 at 7:30 am, resident sent to ER ordered by (name of nurse practitioner) for lethargy and coughing . B. Record review of Treatment Administration Records (TAR) for R #1 revealed no treatment orders for foley catheter care prior to 08/08/15. C. Record review of R #1's care plan dated 06/18/15 for UTI's revealed: Problem: (name of resident) is at risk of developing UTI R/T (related to) indwelling catheter use. Goal: Will be free from complications of foley catheter use through next review. Approach: Monitor resident for complications of foley catheter use. (S/S (signs and symptoms) of UTI). Change catheter per protocol. Anchor catheter to prevent excessive tension in the catheter. Position the draining system (tube, draining bag) to facilitate the flow of urine. Exercise caution with mobility and positioning to prevent accidental removal of catheter. Perform careful pericare; keep catheter free of crusting. Use collection bag cover while in wheelchair. D. Record review of laboratory results for R #1 revealed: 1. 06/19/15 at 7:08 pm, UA (urinalysis). Urinalysis was positive for 3+ leukocytes (white blood cells) (normal lab is negative), 3+ blood (normal lab is none seen) and 2+ bacteria (normal lab is none seen). 2. 08/10/15 at 10:21 am, UA, 08/10 at 12:13 pm, Interpretation: Abnormal: Blood urine dipstick 3+ (normal lab is negative), Urine leukocyte esterase (white blood cell enzymes) 3+ (normal lab is none seen) , Bacteria - urine 2+ (normal lab is none seen). 3. 09/02/15 at 8:11 am, UA. 09/02/15 at 11:32 am, Interpretation: Abnormal: Urine leukocyte esterase 3+ (normal lab is negative), White blood cells - urine >50 (normal lab is none seen), Bacteria - urine 3+ (normal lab is none seen), Triple [MEDICATION NAME] (calcium, ammonium and magnesium [MEDICATION NAME]) crystals - moderate (normal lab none seen). E. Record review of laboratory results revealed: A urine culture collected on 06/19/15 at 7:32 pm, during an emergency room visit, which resulted in hospitalization , revealed growth of Escherichia coli (a bacteria in the human intestine) and Pseudomonas aeruginosa (a bacteria that may cause life threatening infections in humans including urinary tract infections [MEDICAL CONDITION]). F. Record review of laboratory results revealed: A urine culture collected on 08/10/15 at 11:28 am, during a emergency room visit, which resulted in hospitalization , revealed growth of Escherichia coli and Citrobacter amalonaticus (a human bacteria that has been known to infect the urinary tract). G. Record review of laboratory results revealed: A urine culture collected on 09/02/15 at 11:29 am, during a emergency room visit, which resulted in hospitalization , revealed growth of Proteus mirabilis (abundant in nature and an occasional human bacteria (e.g., of the urinary tract)) H. On 09/09/15 at 10:30 am, during an interview with emergency room RN #2, stated, (name of Resident #1) came to the ED (emergency department) via ambulance. Foley was disgusting, removed the foley and (name of R #1) had large, pus, yellow discharge. I. On 09/09/15 at 10:46 am, during an interview with emergency room RN #3, stated, (name of R #1) came into triage and assessment via stretcher from the ambulance. I could smell yeast, urine and feces.Foley looked very nasty, very dirty tubing that looked like it hadn't been changed in awhile. J. On 09/09/15 at 2:15 pm, observations were made of Resident #4 and Resident #5. During the observation the foley drainage bags (bags used to collect the urine draining from the bladder), for both residents, were observed to be positioned above the level of the bladder (correct positioning is below bladder level so urine does not drain back into the bladder). K. On 09/09/15 at 2:30 pm, during an interview with Nursing Assistant #1 (NA #1), the NA stated that foley care was to not pull on it, hang it down on walker, and on the wheelchair place it on the arm (arm would be above the level of the bladder). L. On 09/10/15 at 10:10 am, during an observation with RN #4, R #5 was seen moving down the hallway in R #5's wheelchair with the foley bag hanging high on the wheelchair. At this time RN #4 was asked if the positioning of the foley bag was correct. RN #4 stated that the foley bag was too high. M. On 09/11/15 at 7:45 am, the facility Director of Nursing (DON) was asked for the facility Policy and Procedure (P&P) protocol for foley catheter care. At. 9:55 am, the DON stated, I cannot find any P&P for foley catheter care. N. On 09/11/15 at 10:15 am, during an interview with the Administrator (ADM), the ADM was asked for in-service sheets for foley catheter care. The ADM produced in-service sheets that showed toileting was addressed in several in-services, but could not produce any specific in-service for foley catheter care. The facility provided no other evidence of training on foley catheter care.

br> The following deficiency was a result of a complaint survey that was initiated 06/18/16. An immediate jeopardy was identified on 06/19/15 and a plan of removal accepted 06/19/15. A partial extended survey as a result of the findings on 06/19/15 was initiated on 07/06/15. A second immediate jeopardy was identified on 07/07/15 and a plan of removal accepted 07/10/15. Based on record review and interview the facility failed to inform the physician timely for 1) the worsening of a pressure ulcer that was increasing in size and had an odor for 1 (R#4) of 3 (R #1,2, and 4) residents reviewed for pressure ulcers; and 2) low blood pressure, signs and symptoms of infection, and deteriorating medical condition for 1 (R #7) of 3 ( R ##5, 6, and 7) residents reviewed for accuracy of admission assessments. Failure to notify a resident's physician of a significant change in condition likely resulted in a delay in treatment. The findings are: FINDINGS FOR RESIDENT #4 A. Record review of nurses note (NN) for R #4 revealed: 1. NN dated 04/28/15 at 12:46 pm, .Peri-care (washing the genitals and anal area) provided with redness to buttocks only. 2. NN dated 05/21/15 at 1:27 pm, Upon peri care CNA (Certified Nurse Aide) noted a wound to coccyx (tailbone) area. Upon assessment noted a stage 2 - 1.5 centimeter (cm) x 3 cm wide wound to coccyx area. New order per Protocol for wound care - tx (treatment) administered. 3. NN dated 05/29/15 at 1:54 pm, Stage 2 wound to coccyx area deteriorating. 4. NN dated 06/09/15 at 12:29 pm, Wound site not improving-noted foul odor upon tx - also increasing in size. 5. NN dated 07/03/15 at 9:43 am, Wound measures 7 cm x 4 cm wide x 2 cm (depth) with necrotic tissue and foul smelling odor. B. Record review of R #4's medical record, including nursing notes, indicated R #4's physician was not notified that the pressure ulcer on the resident's coccyx was worsening after 06/14/15. C. On 07/08/15 at 10:50 am, observation of R #4's wound was conducted with License Practical Nurse (LPN) #1, Registered Nurse/Case Manager (RN/CM) #1 and the Director of Nursing (DON). The observation revealed, a stage 4 coccyx wound measuring 8 cms x 5 cms wide, with tunneling (channels extending from the central injury into the surrounding tissue, such as muscle and skin) of 2.5 cms, and 1 cm deep (measurements were stated by LPN #1 and confirmed by the DON). The wound bed was also observed to have grey, yellow slough (dead tissue) and eschar (thick, dry, black necrotic tissue) and a foul odor. D. Record Review of a hospital discharge summary for R #4 dated 07/10/15, from the hospital admission on 07/08/15 revealed, Patient does have a stage IV pressure ulcer on coccyx about the size of the fist, about 5-8 cm deep extending to the bone, very foul odor. E. On 07/09/15 at 9:30 am, during an interview, the facility Medical Director stated she was not aware of R #4's pressure ulcers or the worsening of the condition. She stated she should have been notified so that appropriate treatment could have occurred. F. On 07/10/15 at 10:30 am, during an interview, the facility Certified Nurse Practitioner (CNP) #1 stated she is the first contact the facility should make notification to in regards to change in condition. She stated she was very surprised that she was not notified of the worsening of R #4's pressure ulcer after 06/14/15. She stated she had been physically in the building on 06/28/15 and facility nursing did not alert her to any change in condition for Resident #4. FINDINGS FOR RESIDENT #7 A. Record review of nursing notes dated 04/03/15 to 04/11/15 indicated R #7 had signs and symptoms of resident not communicating well, remaining in bed entire shift, poor appetite, pale coloring, increased lower abdominal pain, short of breath, nauseated, and drainage to abdominal area that had a foul odor. B. Record review of nursing notes for R #7, indicated no documentation that R #7's physician was notified of these significant changes in condition until 04/12/15. C. Record review of nursing notes dated 04/28/15 to 07/04/15 for R #7 indicated 26 times R #7 was experiencing low blood pressure and/or her blood pressure medication was not given due to low blood pressure. There is no documentation to indicate R #7's physician was notified of these low blood pressures. D. Record review of nursing notes dated 06/14/15 to 06/20/15 for R #7 indicated five documented instances of the resident's foley catheter draining dark brown, cloudy, or greenish colored urine. There is no documentation to indicate the resident's physician was notified. E. Record review of nursing notes dated 06/14/15 to 06/30/15 indicated six documented occasions in which R #7's foley catheter had no output. The is no documentation to indicate the resident's physician was notified of no output of urine for Resident #7. F. On 07/10/15 at 10:00 am during an interview with the facility Nurse Practitioner (NP), she stated she was the physician contact for the facility. She stated she is available 24 hours a day, 7 days a week and can respond almost immediately to any change in resident condition. She stated the facility should have contacted her about Resident #7's low blood pressure, no urine ouput from the R #7's foley catheter, and if the urine was dark, brown, or cloudy.

The following deficiency was a result of a complaint survey that was initiated 06/18/16. An immediate jeopardy was identified on 06/19/15 and a plan of removal accepted 06/19/15. A partial extended survey as a result of the findings on 06/19/15 was initiated on 07/06/15. A second immediate jeopardy was identified on 07/07/15 and a plan of removal accepted 07/10/15. Based on record review and interview the facility failed to develop a care plan for two (R #4 and R #8) of four (R #'s 1, 2, 4, and 8) reviewed for pressure ulcers and Urinary Tract Infections (UTI's). This failure had the potential to effect the four residents identified by the administrator as having pressure ulcers and four residents identified at risk for UTI's on the 802 presented by the administrator on 07/06/15. This failed practice likely resulted in Resident #4, admitted with no pressure ulcer, developing a stage 4 pressure ulcer to Resident #4's coccyx (tailbone), and resulted in Resident #8 having 4 UTI's from January 2015 to July 2015, with the UTI in July 2015 having 2 infectious organisms. The findings are: FINDINGS FOR RESIDENT #4 A. Record review of the care plan for Resident #4 dated 05/04/15 and 05/11/15 revealed, only two problems, activities and nutrition. B. Record review of the Care Area Assessment (CAA - the medicare assessment tool) for R #4 dated 05/11/15 revealed, that a care plan should be developed for the risk of pressure ulcers due to the Resident being incontinent of bowel and bladder, with a [DIAGNOSES REDACTED]. C. On 07/08/15 at 10:50 am, observation of the dressing change and wound treatment for [REDACTED].#1, RN/CM #1, and the Director of Nursing (DON). The observation revealed, a stage 4 coccyx wound measuring 8 cms (centimeters) x (by) 5 cms wide with tunneling (channels extending from the central injury into the surrounding tissue, such as muscle and skin) of 2.5 cms, and 1 cm deep (measurements were stated by LPN #1 and confirmed by the DON). The wound bed was also observed to have grey, yellow slough (dead tissue) and eschar (thick, dry, black necrotic tissue), with a foul odor. D. On 07/07/15 at 11:13 am, during an interview, Registered Nurse/Case Manager (RN/CM) #1 was asked if a care plan was developed for R #4 that included pressure ulcer care. RN/CM #1 stated that the CAA dated 05/11/15 for R #4 triggered for pressure ulcer risk and should have been care planned. RN/CM #1 also stated that activities and nutrition were the only two care plan problems developed. FINDINGS FOR RESIDENT #8 A. Record review of the medical record revealed, R #8 had 4 Urinary Tract Infections (UTI's) from 01/28/15 to 07/02/15 and a care plan to address the UTI's was not developed prior to or after these UTIs B. Record review of urinalysis laboratory (lab) results revealed: 1. A urine culture lab test was collected on 01/28/15 with results of Escherichia Coli (infection from a bacteria) growth on 01/30/15. 2. A urine culture lab test was collected on 03/17/15 with results of Aerococcus Urinae (bacteria) growth on 3/21/15. C. A physician progress notes [REDACTED].#1, dated 04/24/15 for R #8 revealed, Bactrim (antibiotic) 1 tab PO (by mouth) daily DX (diagnosis): UTI. D. A urine culture collected on 07/02/15 during an emergency room visit, which resulted in a hospitalization , revealed growth of klebesiella Pneumoniae (a nosocomial (facility acquired infection) bacteria.), and [MEDICAL CONDITION][MEDICATION NAME] (A fungus that is normally present on the skin and in mucous membranes. The fungus also can travel through the blood stream and affect the throat, intestines, and heart valves). E. On 07/09/15 at 9:20 am, during an interview with Resident #8's Family Member (FM) #1 stated that (name of Resident #8) went to the ER for an x-ray, and had a sprained wrist, and was admitted to the hospital [MEDICAL CONDITION], and an UTI. FM #1 stated that she had been telling them (the facility) that she (R #8) had a history of [REDACTED]. F. On 07/22/15 at 1:10 pm, during an interview, the Director of Nursing stated that there had not been a care plan for R #8, for UTI's since 07/2014, when it was discontinued.

The following deficiency was a result of a complaint survey that was initiated 06/18/16. An immediate jeopardy was identified on 06/19/15 and a plan of removal accepted 06/19/15. A partial extended survey as a result of the findings on 06/19/15 was initiated on 07/06/15. A second immediate jeopardy was identified on 07/07/15 and a plan of removal accepted 07/10/15. Based on record review and interview the facility failed to 1) implement the care plan for 1 (R #1 ) of 2 (R #1 and #4)) residents reviewed for pressure ulcers, and 2) ensure that the care plan was updated and revised with specific goals and objectives for 1 (R #8) of 1 (#8) residents reviewed for falls. This deficient practice is likely to cause residents who were identified and assessed at risk for pressure ulcers and falls to develop pressure ulcers and continue to fall. The findings are: FINDINGS FOR RESIDENT #1 A. Record Review of R #1's care plan dated 05/06/15, indicated R #1 was at risk of developing skin breakdown. The care plan indicated R #1 required total assist with her activities of daily living (adl), has contracted arms and legs, and history of resolved ulcers. The care plan indicated approaches for the risk of skin breakdown were to use foam finger separators, keep digits (fingers) dry, monitor for skin breakdown especially around contracted extremities, and conduct regular skin checks. B. On 06/18/15 at 12:10 pm during an interview with FM #2, she stated that on 06/12/15 at approximately 11:00 am she took Resident #1 to her house for a short visit. FM #2 stated Resident #1 had a bandage on her right thumb. FM #2 stated she noticed a bad smell coming from Resident #1's body and began looking for the source of the smell. FM #2 stated the right thumb was very swollen and red and that (name of R #1)was yelling and crying. FM #2 stated she called the facility, told them what she had found and that she was bringing Resident #1 back to facility. She stated she arrived back at the facility at approximately 3:30 pm with Resident #1 and Registered Nurse (RN) Case Manager (CM) #2 put another bandage on the thumb. FM #2 stated approximately 45 minutes later the bandage fell off and she told Licensed Practical Nurse (LPN) #2. FM #2 stated when LPN #2 came to the room and looked at the thumb, she stated, it wasn't like this on Wednesday. I will call (name of the Director of Nursing (DON)) to get a second opinion. FM #2 stated when the DON got to the facility, the DON stated the sore on the Resident's right thumb did look infected and smelled. C. Record review of a lab report dated 06/15/15, regarding the results of the wound culture on Resident #1's right thumb indicated heavy growth of streptococcus pyogenes (bacteria that causes life-threatening infection of the blood). Record review of Nurse Practitioner #1's hand writing on the lab results faxed to the facility at 9:50 am indicated what abx (antibiotic) was started? If none-[MEDICATION NAME] 200 mg (milligram)-give 10 ml (millimeter) q (every) day x 5 days. D. On 06/18/15 at 12:10 pm, during an interview with FM #2 she stated that when the family asked to see the R #1's thumb on 06/13/15 and 06/14/15 nursing staff would state, everything is fine, we just changed the dressing. FM #2 stated that on 06/15/15 during a visit to the facility, the family observed the resident's right thumb. FM #2 stated it looked worse to her. She stated R #1 was also in pain, yelling and crying. FM #2 stated she kept waiting for the facility to do something about the resident's thumb. She stated she felt her daughter was in pain all the time. FM #2 stated that on 06/17/15 when she was getting no response from the nursing staff or the Director of Nursing (DON), she took the resident to the local Emergency Department (ED) in her (FM #2) personal vehicle. E. Record review of an ED Physician Documentation dated 06/17/15 at 4:29 pm, indicated the following: the patient (Resident #1) presents with [MEDICAL CONDITION] (bacterial skin infection) of the palmar (palm of hand) aspect of distal phalanx (bone) of right thumb. It is [DIAGNOSES REDACTED]tous (reddening of skin), swollen and warm. Possible cause is contractures causing pressure. F. On 06/18/15 at 9:30 am during an interview, with the DON, RN #1, and RN #2, they stated the pressure ulcer and infection of Resident #1's right thumb was preventable. They stated the Resident's right thumb was healed on 06/02/15. They stated the care plan for the risk of skin breakdown and pressure ulcers appeared to not be followed after the original pressure ulcer healed. They stated there was no consistent documentation of the pressure ulcer from 06/13/15 until 06/17/15. They stated skin checks of Resident #1 were required weekly. They stated there should have been nursing skin checks completed for Resident #1 on 05/31/15, 06/07/15, and 06/14/15 and they were not. FINDINGS FOR RESIDENT #8 A. Record review of the facility's Resident Incidents report dated 04/01/15 through 07/20/15 revealed, R #8 fell on [DATE], and twice on 04/15/15. B. Record review of NN for Resident #8 revealed the following falls that were not documented on the facility resident incident log: 1. 04/13/15 at 5:05 am, . (name of Resident #8) has had legs off the bed and one time sat on floor, scooting herself in room. 2. 05/31/15 at 7:48 am, 03:00 am, (name of Resident #8) crawled off the bed and was found siting on the floor. C. Record review of nurses notes (NN) for Resident #8 revealed the following: 1. NN dated 04/01/15 at 9:25 am, 08:45 am, (name of Resident #8) found on the floor lying on the floor besides her bed, crying and hysterical, hits staff while assisting her to get up. Assessment done, no injury noted. 2. NN dated 04/15/15 at 8:41 am, Reported per (name of Certified Nursing Aide (CNA) #8) that resident is on floor-found her by her door in supine position.Then within 10 minutes found on floor again between her bed and w/c (wheelchair) - laying on her left side. 3. NN dated 04/15/15, At 12:30 pm, resident refused to go to dining area for lunch. Floor tray brought to room and refused to get up for meal-laying in her bed. (name of CNA #8) left tray in room and left to deliver floor trays to others and within seconds found resident on floor. (Name of R #8) told (name of CNA #8) - she had wiggled out of bed unto floor. 4. 05/15/15 at 7:25 pm, (name of Resident #8) found on the floor in front of her w/c. Resident stated she was trying to stand when she just sat down. 5. 05/23/15 at 4:17 pm, (name of Resident #8) keeps sliding down on the floor from her w/c 3 x (times). D. Record review revealed there was no NN for the fall on 04/05/15 that was identified on the Resident Incident report dated 04/01/15 through 07/20/15. E. Record review of the Care Plan dated 01/14/15, with a revised date of 04/02/15 for Resident #8 revealed, Problem; (Name of Resident) is at risk of a fall and possibly getting injured. Goal; (Name of Resident) will be free from injury daily by next review. Approach; Provide a clutter free environment, explain use of call light PRN (as needed), Encourage her to ask for help when help is needed, pharmacist in Q (every) month to review her meds (medications), alert her Dr (doctor) PRN with any medication issues, supervise/cue transfers. F. Record review of the facility's undated policies and procedures for Falls, Accidents, and Incidents revealed: 1. each resident will be assessed for risk of falls on admission and following falls; 2. a fall assessment will be completed after each fall, and; 3. the care plan and aide assignment sheet will be updated as needed. G. On 07/22/15 at 12:55 pm, during an interview, the Director of Nursing (DON) stated there were no new interventions added to R #8's care plan after the seven falls that occurred from 04/05/15 through 05/31/15.

The following deficiency was a result of a complaint survey that was initiated 06/18/16. An immediate jeopardy was identified on 06/19/15 and a plan of removal accepted 06/19/15. A partial extended survey as a result of the findings on 06/19/15 was initiated on 07/06/15. A second immediate jeopardy was identified on 07/07/15 and a plan of removal accepted 07/10/15. Based on record review and interview, the facility failed to prevent an un stageable pressure ulcer for one (Resident #1) of one (Resident #1) residents reviewed for pressures ulcers. This failed practice likely resulted in Resident #1 developing a pressure ulcer on the right thumb that became infected and required debridement (the medical removal of dead, damaged, or infected tissue). This deficient practice resulted in an Immediate Jeopardy at a scope and severity of K, being identified at the facility on 06/19/15 at 11:40 am. The facility administrator was notified at this time. The facility took corrective action by providing an acceptable Plan of Removal on 06/19/15 at 5:20 pm. Based on the Plan of Removal, interventions included: 1. The pressure ulcer care plan for Resident #1 was updated. 2. The physician was notified of Resident #1's condition (s). 3. The certified wound care specialist was to make recommendations regarding the right thumb pressure ulcer. 4. All residents with pressure ulcers and residents with a Braden scale of less then 12 would have full skin assessments completed by the end of shift and the physician notified. 5. Care plans will be updated within 24 hours for any resident identified with skin issues. 6. The three RN case mangers will check three residents per week for three months to ensure that all skin checks are completed. 7. Policies and Procedures for pressure ulcers were reviewed and updated and provided to each nurse. No nurse will be allowed to assume responsibility of resident care without this revised training. SECOND IMMEDIATE JEOPARDY Based on record review, observation and interview the facility failed to prevent a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer, for 1 Resident (R #4) of 3 (R #1, 2 and 4) residents reviewed for pressures ulcers. This failed practice likely resulted in Resident #4 who was admitted with no pressure ulcer, to develop a stage IV pressure ulcer to R #4's coccyx (tailbone, final segment of the vertebra). This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J being identified at the facility on 07/07/15 at 3:00 pm. The facility administrator was notified at this time. The facility took corrective action by providing an acceptable Plan of Removal on 07/10/15 at 7:54 pm. Based on the Plan of Removal, interventions included: 1. The care plan and Braden scale were updated for R #4, the physician was notified of the condition of the wound and new orders were obtained for a wound culture and a pain assessment was completed, R #4 was seen by the facility's Physical Therapist/Certified Wound Care Specialist (PT/CWCS) #1 on 07/08/15 and the specialist recommended surgical debridment (the medical removal of dead, damaged, or infected tissue). R #4 was sent to the hospital for surgical debridement and admitted to the hospital. 2. Full skin assessments were conducted for all residents. Residents with skin issues will have an updated care plan, documentation will be noted in the record, and the physician will be notified. 3. Training was provided to all nurses by the AMT consultant on 07/09/15 regarding wound care, documentation and infection control. 4. The NP (Nurse Practitioner) #1 visualized wounds on 07/10/15 and a new protocol was established by the medical director and NP #1. 5. The QA (quality assurance) team will meet weekly to track pressure ulcer documentation and ensure care planning is completed. 6. Case managers will perform two dressing changes per week on Residents with pressure ulcers to ensure visualization, measuring, and complete/correct documentation. The PT/CWCS will provide weekly recommendations. 7. Policies and procedures for documentation, pain, and pressure ulcers reviewed and updated on 07/10/15. Based on the Plan of Removal and observation, the IJ was lifted on 07/10/15 at 7:54 pm. This resulted in the scope and severity being reduced from a scope and severity of K to a scope and severity of H. Based on record review, observation, and interview the facility failed to prevent pressure ulcers from developing and worsening for two (R #1 and #4) of three residents ( R #'s 1, 2, and 4) reviewed for pressure ulcer risk by: 1) prevent a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer for R #4; 2) prevent an unstageable ( full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer for R #1; 3) develop a plan of care to address pressure ulcer risk for R #4; 4) implement plans of care to address pressure ulcer risk for R #1; 5) prevent pressure ulcers from becoming infected for R #1 and #4; and 6) failed to document skin assessments, treatment, and physician orders [REDACTED].#4. These failures likely resulted in Resident #1 and #4 being harmed and place at risk for immediate threat of life threatening infections and bone loss. The findings are: FINDINGS FOR RESIDENT #1 A. On 06/18/15 at 12:10 pm during an interview with R #1's Family Member (FM) #2, she stated that on 06/12/15 at approximately 11:00 am she took Resident #1 to her house for a short visit. FM # 2 stated R #1 had a bandage on her right thumb. FM #2 stated she noticed a bad smell coming from Resident #1's body and began looking for the source of the smell. FM #2 stated the right thumb was very swollen and red and that the resident was yelling and crying. FM #2 stated she called the facility, told them what she had found, and that she was bringing Resident #1 back to facility. She stated she arrived back at the facility at approximately 3:30 pm with Resident #1. FM #2 stated that (name of Registered Nurse (RN) Case Manager (CM) #2) put another bandage on the thumb. FM #2 stated approximately 45 minutes later the bandage fell off and she told Licensed Practical Nurse (LPN) #2. FM #2 stated when LPN #2 came to the room and looked at the thumb, LPN #2 stated, it wasn't like this on Wednesday. I will call (name of the Director of Nursing (DON)) to get a second opinion. FM #2 stated when the DON got to the facility, the DON stated the sore on the R #1's right thumb did look infected and smelled. B. Record review of R #1's medical record indicated a date of birth of 12/31/81 and that the resident was admitted to the facility on [DATE]. R #1's admission [DIAGNOSES REDACTED]. C. Record review of a careplan for R #1 dated 05/06/15 for the risk of skin breakdown indicated staff will continue to do dressing changes, use of foam finger separator, and keep digits dry. D. Record review of the 06/15 treatment administration record (TAR) for R #1 indicated a physician's orders [REDACTED]. E. Record review of the nursing notes for Resident #1 dated 06/02/15 through 06/12/15 indicated the following: 1. 06/02/15- Previously present pressure right thumb healing pressure ulcer-0.5 x 0.8 cm depth 0.2 cm-wound bed healthy, no slough (dead tissue) redressed after the assessment with foam and tape. 2. 06/12/15 at 4:54 pm- Wound assessment done-unstageable pressure ulcer on palmar (palm) surface of right thumb measuring 1.6 x 1.1 x 0.2 cm with undermining (deep tissue damage around the wound); 40% slough 60% granulation with a small amount of serosanguinous (discharge composed of serum and blood) drainage; surrounding skin is macerated (moist and deteriorating), warm to touch (+) redness. 3. 06/12/15 at 5:40 pm-obtain a wound culture. F. Record review of the lab report dated 06/15/15 regarding the results of the wound culture on Resident #1's right thumb indicated heavy growth of streptococcus pyogenes (bacteria that causes life-threatening infection of the blood). Record review of Nurse Practitioner #1's hand writing on the lab results faxed to the facility at 9:50 am indicated what abx (antibiotic) was started? If none-[MEDICATION NAME] 200 mg (milligram)-give 10 ml (millimeter) q (every) day x 5 days. 1. Record review of the 06/15 Medication Administration Record [REDACTED]. G. On 06/18/15 at 12:10 pm, during an interview with R #1's FM #2 she stated that when the family asked to see the resident's thumb on 06/13/15 and 06/14/15, nursing staff would state, everything is fine, we just changed the dressing. FM #2 stated that on 06/15/15 during a visit to the facility, the family observed the resident's right thumb. FM #2 stated it looked worse to her. FM #2 stated R #1 was also in pain, yelling and crying. FM #2 stated she kept waiting for the facility to do something about the resident's thumb. She stated she felt R #1 was in pain all the time. FM #2 stated that on 06/17/15 when she was getting no response from the nursing staff or the Director of Nursing (DON) she took the resident to the local Emergency Department (ED) in her personal vehicle. H. Record Review of the facility's nursing notes and skin checks indicated there were not documented assessments of Resident #1's pressure ulcer on 06/13/15, 06/14/15, 06/15/15, or 06/16/15. I. Record review of the ED triage sheet dated 06/17/15 at 4:18 pm indicated Resident #1 presented to the ED with a complaint of a sore on her right thumb since Friday and now is getting bigger. J. Record review of the ED Physician Documentation dated 06/17/15 at 4:29 pm indicated the following: the patient (Resident #1) presents with [MEDICAL CONDITION] (bacterial skin infection) of the palmar (palm of hand) aspect of distal phalanx (bone) of right thumb. It is [DIAGNOSES REDACTED]tous (reddening of skin), swollen and warm. Possible cause is contractures causing pressure. K. Record review of the ED Nurse Documentation dated 06/17/15 at 5:15 pm indicated: complains of pain in right hand, pain is 9 out 10 on a pain scale, appears distressed, and uncomfortable. Nursing documentation dated 06/17/15 at 5:49 pm indicated Resident #1 was given 2 mg of [MEDICATION NAME] to address the Resident's pain. I. During an interview on 06/18/15 at 9:30 am with the DON, RN #1, and RN #2, they stated the pressure ulcer and infection of Resident #1's right thumb was preventable. They stated the Resident's right thumb was healed on 06/02/15. They stated the care plan for the risk of skin breakdown and pressure ulcers appeared to not be followed after the original pressure ulcer healed. They stated there was no consistent documentation of the pressure ulcer from 06/13/15 until 06/17/15. They stated skin checks of Resident #1 were required weekly. They stated there should have been nursing skin checks completed for Resident #1 on 05/31/15, 06/07/15, and 06/14/15 and they were not. They stated sending a resident to higher level of care was a nursing judgement and they really could not answer why Resident #1's family had to be the ones to take the resident to the ED. FINDINGS FOR RESIDENT #4 A. Record review of the Admission Comprehensive Nurse Note dated 04/27/15 for R #4 revealed no skin problems except for a skin tear on the resident's left foot. B. Record Review of the Care Area Assessment (CAA-the Medicare resident tool assessment) dated 05/11/15 revealed, that Resident #4 was to have a care plan developed for the risk of pressure ulcers. R #4's [DIAGNOSES REDACTED]. C. Record review of the care plan for Resident #4 dated 05/04/15 and 05/11/15 revealed, only two problems, Activities and Nutrition. D. On 07/07/15 at 11:13 am, during an interview, RN/CM#1 was asked if a care plan was developed for R #4 that included pressure ulcer care. RN/CM #1 stated that the CAA dated 05/11/15 for R #4 triggered for pressure ulcer risk and should have been care planned. RN/CM #1 also stated that activities and nutrition were the only two care plan problems developed. E. Record review of nurses notes (NN) for Resident #4 revealed: 1. NN dated 04/28/15 at 12:46 pm, .Peri-care (washing the genitals and anal area) provided with redness to buttocks. 2. NN dated 05/21/15 at 1:27 pm, Upon peri care Certified Nurse Aide (CNA) noted a wound to coccyx (tailbone) area. Upon assessment noted a stage 2 ( Partial thickness loss presenting as a shallow, open ulcer) - 1.5 centimeters cm) x 3 cm wide wound to coccyx area. New order per Protocol for wound care - tx (treatment) administered. 3. NN dated 05/29/15 at 1:54 pm, Stage 2 wound to coccyx area deteriorating. 4. NN dated 06/05/15 at 12:38 pm, Noted no improvements to stage 2 wound to coccyx area. 5. NN dated 06/09/15 at 12:29 pm, Wound site not improving-noted foul odor upon tx -also increasing in size. 6. NN dated 06/14/15 at 12:55 pm, pressure ulcer is a Stage 4 (full thickness tissue loss with exposed tendon, bone, or muscle) a new order was received. 7. NN dated 07/03/15 at 9:43 am, revealed Wound measures 7 cm x 4 cm wide x 2 cm (depth) with necrotic (dead) tissue and foul smelling odor. F. Record Review of Resident #4's medical record indicated the resident's physician was not notified that the pressure ulcer on the resident's coccyx was worsening from 06/14/15 to 07/07/15. 1. Review of NN for Resident #4 dated 07/07/15 at 7:30 pm, revealed a telephone order from the Resident's physician for a culture to be obtained for the Stage IV pressure ulcer on the resident's coccyx. G. On 07/08/15 at 10:50 am, observation of the dressing change and wound treatment for [REDACTED].#1 and Registered Nurse/Case Manager (RN/CM) #1, and the Director of Nursing (DON). The observation revealed, a stage 4 coccyx wound measuring 8 centimeters (cm) x 5 cms wide, with tunneling (channels extending from the central injury into the surrounding tissue, such as muscle and skin) of 2.5 cms, and 1 cm deep (measurements were stated by LPN #1 and confirmed by the DON). The wound bed was also observed to have grey, yellow slough (dead tissue) and eschar,(thick, dry, black necrotic tissue), with a foul odor. 1. On 07/08/15 at 11:30 am during an interview with LPN #1, she stated she did not know anything about obtaining a wound culture and began looking through the basket of lab requests. LPN #1 found the lab requisition and stated the culture had not been done. H. Record review of the Hospital discharge summary dated 07/10/15 indicated Resident #4 was admitted to the medical floor of the hospital on [DATE] with a Stage 4 pressure ulcer on her coccyx about the size of a fist, about 5-6 cm deep, extending to the bone, with a very foul odor. The discharge summary also documents the size of the pressure ulcer as very extensive. The discharge summary also indicates that one of the final [DIAGNOSES REDACTED]. 1. Record review of the wound culture lab result from Resident #4's pressure ulcer dated 07/12/15 indicated a heavy growth of streptococcus anginosus (bacteria that causes abscesses). I. Record review of the Certified Wound Care Practitioner (CWCP) narrative note dated 07/08/15 at 5:10 pm, indicated a recommendation for Resident #4 to undergo surgical debridement to clean out necrotic tissue on the wound bed. 1. On 07/09/15 at 10:00 am, during an interview with the PT/CWCP), she stated she was not asked to conduct a evaluation of Resident #4's pressure ulcer until 07/08/15. J. On 07/09/15 at 9:30 am, during an interview, the facility Medical Director stated she was not aware of Resident #1 or Resident #4 pressure ulcers or the worsening of their conditions. She stated she should have been notified so that appropriate treatment could have occurred. L. On 07/10/15 at 10:30 am during an interview, the facility Certified Nurse Practitioner stated she is the first contact the facility should make notification to in regards to change in condition. She stated she was very surprised that she was not notified of the development and worsening of pressure ulcers for Resident #1 and Resident #4. She stated she had been physically in the building on 06/28/15 and facility nursing did not alert her to any change in condition for Resident #1 or Resident #4.

Based on record review and interview the facility failed to decrease repeated Urinary Tract Infections (UTI's) for 1 (R #8) of 1 (R #8) resident reviewed for UTI's. Resident #8 had 4 UTI's from January 2015 to July 2015, with the UTI in July 2015 having 2 infectious organisms. The findings are: A. On 07/09/15 at 9:20 am, during an interview, R #8's Family Member (FM) #1 stated that she is very upset because (name of R #8) just got back from the hospital. (name of Resident #8) was sent to the hospital on [DATE] when I came to visit and found her in a ball with her knees pulled up, crying different from her normal cry. I knew something wasn't right. FM #1 stated that (name of Resident #8), was admitted to the hospital [MEDICAL CONDITION], and an UTI. FM #1 also stated that she had told the facility that the resident has a history of UTI's. B. Record review of the Record Summary for R #8 with a date of birth of 08/05/1931 revealed, an original admission date of [DATE]. C. Record review of Minimum Date Set ((MDS) - Medicare form for comprehensive assessment) revealed the following: 1. [DIAGNOSES REDACTED]. 2. [DIAGNOSES REDACTED]. D. Record review of the annual MDS dated [DATE] for R #8 revealed the following coding: 1. Section G0110. Activities of daily living (ADL) Assistance section, revealed 1.C. Walk in room - how resident walks between locations in his/her room was coded an 8 for self performance (means activity did not occur), was coded an 8 for support (means did not occur.) 2. Section G0300, Balance During Transitions and walking, revealed, B. Walking - 8, C. Turning around - 8, D. Moving on and off toilet - 1 (1 - indicates, not steady, but able to stabilize without staff assistance), and E. Surface-to-surface transfer - 1. 3. Section C - Cognitive Patterns, subsection C0500, summary score (the total score of all questions asked) was annotated as 01. Scores are noted as 00-15 with 00 being the lowest level of cognitive ability and 15 being the highest level of cognitive ability as determined by the MDS. E. Record review of nurses notes (NN) revealed the following: 1. 01/28/15 - UA (urinalysis) obtained per night nurse. Rec'd (received) results: UR (urine results) Clarity - Turbid (can not see through the specimen), positive for blood, leukocyte esterase (white blood cells that indicates infection) and bacteria. 2. 03/12/15 - R #8 crying out this morning. Unable to determine cause due to speech impairment. In main dining room crying, refusing to eat breakfast. Brought back to room and noted room had strong odor of urine smell. I asked if having any problems upon urination and pointed to lower abd. (abdomen)- stating hurting. Order noted for UA (urinalysis) with C & S (culture and sensitivity). 3. 04/24/15 at 4:00 pm - received resident back form (name of hospital)-ER (emergency room ), per report from ER nurse, resident (R #8) had a UTI Further review indicated this latest UTI was positive for the presence of [MEDICATION NAME], blood, increased white blood cell count too, and bacteria, all of which are associated with the presence of an infection. F. Record review of laboratory (lab) results for Resident #8's UTI's revealed the following: 1. A urine culture lab test was collected on 01/28/15 with results of Escherichia Coli (bacteria) growth on 01/30/15. 2. A urine culture lab test was collected on 03/17/15 with results of Aerococcus Urinae (bacteria) growth on 3/21/15. 3. A urine culture collected on 07/02/15 for Resident #8, during an emergency room visit, which resulted in a hospitalization on [DATE] revealed, growth of klebesiella Pneumoniae (bacteria) and [MEDICAL CONDITION][MEDICATION NAME] (a fungus that can travel through the blood stream and affect the throat, intestines, and heart valves). G. A physician progress notes [REDACTED].#1 dated 04/24/15 for R #8 revealed, Bactrim 1 tab PO (by mouth) daily DX (diagnosis): UTI. H. Record review of the Nurse Aides Activities of Daily Living (ADL) charting in section Toileting revealed from 07/01/15 to 07/22/15 R #8 was wet, incontinent and peri-care given. I. Record review of the care plan for R #8 dated 05/04/15 revealed there was no current care plan to decrease and attempt to prevent recurring UTI's. J. On 07/22/15 at 01:10 pm, during an interview, the Director of Nursing (DON) stated that Resident #8 did not have a care plan for the risk of UTIs since the July 2014 care plan was discontinued.

Based on record review and interview, the facility failed to implement their written policies and procedures for reporting and investigating injuries of unknown source for 1 (R #8) of 1 (R #8) resident reviewed for injuries of unknown source. R #8 sustained a sprained wrist and significant bruising to the right side of her upper body and the facility was unaware of the cause of these injuries. Without reporting and investigating injuries of unknown source, the facility is unable to determine if the injuries are a result of abuse. The facility is also unable to determine strategies to try and prevent further injuries. The findings are: A. On 07/09/15 at 9:20 am, during an interview with R #8's Family Member (FM) #1, she stated she was very upset because (name of R #8) just got back from the hospital. (name of Resident #8) had to be sent to the hospital after I came to visit and found her in a ball with her knees pulled up, crying different from her normal cry. I knew something wasn't right. FM #1 stated that (name of R #8) went to the ER for an x-ray, and had a sprained wrist, and was admitted to the hospital [MEDICAL CONDITION], and an UTI. FM #1 also stated a while back she found a huge bruise on her (R #8) shoulder and took a picture of it. FM #1 further stated that when she asked the staff about what happened, they did not know. B. Record review of a skin check report dated 04/14/15 for R #8 revealed, Reported to this nurse at 12:45 by Certified Nurse Aide (CNA) #1 (Name of CNA) that resident has new bruises. Assessed resident, has numerous bruises to right side. The upper right scapula area measures 4 cms (centimeters) x (by) 7 cms wide. Right shoulder area measures 8 cm x 5.5 cm wide. Upper right torso measures 16 cm x 7 cm wide. Right elbow measures 3 cm x 3 cm wide. Review of R#8's medical record revealed there was no evidence of an incident report. C. Record review of the nurses' notes dated 07/02/15 for R #8 revealed, Resident refused to get up for breakfast. 08:50 am, complaining of left hand pain, Tylenol 650 mgs (milligrams) and due medications given. 09:20 am, resident is crying, looking about her clothes line (this is what R #8 calls most things/items), [MEDICATION NAME] (anticonvulsant ([MEDICAL CONDITION] medication) maybe used for panic disorder) 0.5 mg given. 09:30 am, Called (Name of Nurse Practitioner (NP #1)) to obtain order for X-ray of left hand (swollen), informed thru voice mail message. Case Manager notified. Daughter in law and husband around. 11:05 am, sent resident to (Name of Hospital) for X-ray. D. Record review of the facility's Resident Incident list, dated from 04/01/15 to 07/08/15 revealed R #8 was not listed for either incident. E. Record review of the facility's policy titled, Falls, Accidents, and Incidents, undated revealed, 1. Reporting Procedures: a. Regardless of how minor an accident or incident may be, including injuries of an unknown source and unwitnessed, it must be reported to the department supervisor, and an incident report form must be completed before the end of the shift that the accident or incident occurred. g. Report all significant injuries and unexplained injuries to Licensing and Certification through the complaint hotline: [PHONE NUMBER]. 4. Investigative action: a. The charge nurse and/or the department director of supervisor must conduct an immediate investigation of the accident or incident. F. On 07/08/15 at 12:15 pm, during an interview, the Incident Coordinator/Social Worker IC/SW was asked about R #8's sprained wrist, the IC/SW stated that they talked about it in QA (quality assurance) but did not report it or do a investigation. G. On 07/22/15 at 1:10 pm, during an interview, with the Director of Nursing and RN/CM #3, when asked about reporting the bruises, stated that the bruising was not reported because they assumed the bruises were from rolling out of bed.

Based on record review and interview, the facility failed to ensure residents were free from potential abuse for 1 (R# 8) of 2 (R #8, and #9) residents reviewed for injuries of unknown source, by not having evidence that bruising and a sprained wrist for R #8 was investigated and reported to the State Survey Agency. The deficient practice presents a risk of potential harm to resident safety. When incidents of possible abuse are not investigated, the facility is unable to determine what happened in order to prevent it from reoccurring. The findings are: A. On 07/09/15 at 9:20 am, during an interview with R #8's Family Member (FM)#1,she stated that she is very upset because R #8 just got back from the hospital. (name of Resident #8) had to be sent to the hospital after I came to visit and found her in a ball with her knees pulled up, crying different from her normal cry. I knew something wasn't right. FM #1 stated that (name of R #8) went to the ER for an x-ray, and had a sprained wrist, and was admitted to the hospital [MEDICAL CONDITION], and an UTI. FM #1 also stated a while back she found a huge bruise on her (R #8) shoulder and took a picture of it. FM #1 stated when she asked the staff about what happened, they did not know. B. Record review of a skin check dated 04/14/15 for R #8 revealed, Reported to this nurse at 12:45 by Certified Nurse Aide (CNA) #1 (Name of CNA) that resident has new bruises. Assessed resident, has numerous bruises to right side. The upper right scapula area measures 4 cms (centimeters) x (by) 7 cms (wide). Right shoulder area measures 8 cm x 5.5 cm. Upper right torso measures 16 cm x 7 cm. Right elbow measures 3 cm x 3 cm. Further review of the medical revealed an incident report was not completed for these unexplained and injuries of unknown source. C. Record review of the nurse's notes dated 07/02/15 for R #8 revealed, Resident refused to get up for breakfast. 08:50 am, complaining of left hand pain, Tylenol 650 mgs (milligrams) and due medications given. 09:20 am, resident is crying, looking about her clothes line (this is what R #8 calls most things/items), [MEDICATION NAME] ([MEDICAL CONDITION] medication) 0.5 mg given. 09:30 am, Called (Name of Nurse Practitioner (NP #1)) to obtain order for X-ray of left hand (swollen), informed thru voice mail message. Case Manager/notified. Daughter in law and husband around. 11:05 am, sent resident to (Name of Hospital) for X-ray. D. Record review of the facility's Resident Incident list, from 04/01/15 to 07/08/15 revealed, R #8 was not listed for either incident. E. Record review of the facility's policy titled, Falls, Accidents, and Incidents, undated revealed, 1. Reporting Procedures: a. Regardless of how minor an accident or incident may be, including injuries of an unknown source and unwitnessed, it must be reported to the department supervisor, and an incident report form must be completed before the end of the shift that the accident or incident occurred. g. Report all significant injuries and unexplained injuries to Licensing and Certification through the complaint hotline: [PHONE NUMBER]. F. On 07/08/15 at 12:15 pm, during an interview, the Incident Coordinator/Social Worker IC/SW was asked about R #8's sprained wrist, the IC/SW stated that they talked about it in QA (quality assurance) but did not report it or do a investigation. G. On 07/22/15 at 1:10 pm, during an interview, with the Director of Nursing and RN/CM #3, when asked about reporting the bruises, stated that the bruising was not reported because they assumed the bruises were from rolling out of bed.

Based on observation and interview, the facility failed to establish an Infection Control Program to control, to the extent possible, the spread of infection within the facility by not cleaning the glucometer (a device used to obtain a blood sample from the resident after using a fingerstick device) between resident use for 4 (#19, 27, 30, 93) of 4 (#19, 27, 30, 93) residents observed during blood glucose monitoring. This failure had the potential to carry blood born pathogens from resident to resident from particles of blood on the meter. This resulted in an Immediate Jeopardy (IJ). The IJ was called on 08/22/13 at 4:00 pm. At that time, the Administrator (ADM) and the Director of Nurses (DON) were informed. The facility provided an acceptable Plan of Removal on 08/22/13 at 5:56 pm. Acceptance of the Plan of Removal lowered the scope and severity level to a level E, and included the following interventions: Immediate Plan: 1. Immediate Corrective Action: Nurses on duty were immediately inserviced regarding the need to clean and sanitize the glucometers in between each resident. All glucometers were immediately cleaned and sanitized. Supplies for cleaning/sanitizing glucometers provided which included alcohol (70% solution) wipes and Sani-Cloth Germicidal disposable wipes. 2. Policy and procedure for cleaning and sanitizing glucometers being established. 3. Policy will be placed on each wing and each shift will be instructed on the policy. Mandatory Nurse Inservice called for Friday (08/23/13) at 10:00 am. All staff will be educated prior to performing any blood glucose testing. This failure had the potential to carry blood born pathogens from resident to resident from particles of blood on the meter. The findings are: A. On 08/20/13 at 3:30 pm, Registered Nurse (RN) #1 was observed with Resident #27, doing a finger stick to obtain a blood sample and then using the glucometer to obtain the blood sample and determine the blood glucose level. The glucometer was not cleaned or disinfected before or after use. B. On 08/21/13 RN #2 was observed performing finger sticks to residents to obtain blood samples, and then using the glucometer to obtain the blood sample to determine the blood glucose level. The glucometer was not cleaned or disinfected before or after each of the following residents use: 1. Resident #27 at 11:00 am. 2. Resident #30 at 11:10 am. 3. Resident #93 at 11:15 am. 4 Resident #19 at 11:20 am. C. On 08/21/13 at 11:10 am, Licensed Practical Nurse (LPN) #1 was asked if she cleaned the glucometer between residents. LPN #1 stated that the facility policy does not say they should clean it, just if it is dirty. LPN #1 thought the night shift cleaned them but was not really sure. D. On 08/21/13 at 11:30 am, RN #2 was asked if the glucometer was cleaned between each resident use. RN #2 stated that there had not been training to clean them. She did not know she should do that. E. On 08/21/13 at 12:45 pm, the Director of Nurses (DON) was asked if the facility had a policy and procedure for cleaning the glucometer before each resident use. The DON stated, "No, not that I am aware of, but I will investigate and see what the instructions for our meter say. F. On 08/22/13 at 10:20 am, the DON provided the facility instruction book for cleaning the glucometer. The book recommended cleaning between each use. The DON was asked if the facility was aware of the requirement to clean the glucometer between each use or use individual glucometers. The DON stated that she was not aware of the requirement to clean between uses and the facility did not have but one glucometer for uach unit. Based on observation, record review and interview, the facility failed to use safe and sanitary techniques when providing wound care for two Stage IV pressure ulcers to 1 (#86) of 2 (#52,86) residents observed during wound care. This failure to protect from cross-contamination by failing to use good hand hygiene, consistent with standards of practice, had the potential for infection to be spread from wound to wound, and to other residents in the facility. The findings are: A. On 08/22/13 at 1:45 pm, observations of wound care to Resident #86 revealed that RN #3 was assisted by Licensed Practical Nurse (LPN) #2 providing wound treatment to Resident #86's heel and coccyx. The bedside table that was used for the clean wound care supplies was cluttered with the resident's personal items and the nurse's clipboard. RN #3 applied gloves then picked up a wedge cushion off the floor. A clean pad was placed on the cushion and the left leg of the resident was put on the cushion for wound care. RN #3 used scissors to remove the dressing, which was soaked with a large amount of drainage that was purulent (contained pus) and serosanguineous (bloody), from the left heel. The scissors were then placed on the bedside table with the clean supplies. The dressings were placed in a red biohazard bag and, without changing her contaminated gloves, RN #3 reached into a package of clean three by three gauze sponges, contaminating the other sponges, and then changed her gloves. RN #3 reached into a box containing multiple clean normal saline (NS) three cc (cubic centimeter) tubes and used the tubes of NS to wash the surface of the heel wound. With those dirty gloves, RN #3 replaced the unused NS tubes back into the box containing the clean tubes. Using the same dirty gloves, RN #3 picked up the tube of [MEDICATION NAME] (medication used for wound healing) and applied [MEDICATION NAME] to the wound surface using a contaminated three by three gauze sponge. RN #3 then handed the contaminated tube of [MEDICATION NAME] to LPN #2. This contaminated the gloves that LPN #2 was wearing. When the dressing change was complete, RN#3, wearing gloves with visible blood on them, opened the door of the room, leaving a small spot of blood on the knob and answered her cell phone. RN #3 then removed the dirty gloves, picked up items off the floor that had spilled out of the biohazard bag and then tied the biohazard bag with her bare hands. Without washing her hands, RN #3 then gave Resident # 86 a drink of water, holding the straw for him. RN #3 took the soiled pad out from under the left heel and placed it by the resident's head. At 2:20 pm, the coccyx wound treatment was then initiated for Resident #86 by RN #3 with clean gloves worn. The serosanguineous soaked dressing was removed and placed in a red bag. Using the dirty gloves, RN #3 searched on the bedside table and in the resident's drawer for supplies. During both dressing changes, there was no hand washing before procedures, after changing gloves, or prior to leaving the room. B. Review of the Infection Control Policy undated revealed: 1. "Infection Control Policy: The primary purpose of the facility's infection control policies are to provide a safe and sanitary and comfortable environment and help prevent the development and transmission of disease and infection." 2. "Procedure: Washing Your Hands: Handwashing is the single most important intervention in preventing the transmission and spread of disease and infection." C. On 08/23/13 at 10:10 am, an interview was conducted with the Director of Nurses (DON), RN#4, and RN#5 regarding the wound care observation that occurred on 08/22/13 involving Resident #86. The DON stated that the dressing change was not done correctly and did not follow infection control measures.