Every finding on record at Oak Woods Home for the Elderly

Based on observations, interviews, and record reviews, the facility failed to provide assistance for residents who were unable to carry out activities of daily living (ADL) by failing to maintain good grooming and personal hygiene for 3 (#2, #42, #57) of 3 residents reviewed for activities of daily living.Findings:Resident #2Review of the medical record for resident #2 revealed the resident had diagnoses in part of left above the knee amputation, nail dystrophy, atrial fibrillation, atherosclerosis of native arteries of extremities with gangrene, Type 2 Diabetes Mellitus, cardiomegaly, acute kidney failure, and cerebral infarct.Review of the significant change MDS dated [DATE] revealed the resident had a BIMS that was unable to be assessed. The resident was dependent on staff for personal hygiene. Review of the care plan revealed self-care deficit related to resident needs assistance with activities of daily living. Further review revealed the following approaches: resident will be clean, dry, dressed neatly, odor free, and well-groomed daily this quarter. Morning Care- face washed, hair brushed, oral care--includes brushing dentures/teeth, hands washed, and nail care. Evening care- face washed, hair brushed, oral care- includes brushing teeth/soaking dentures, hands washed.Review of the current Physician orders revealed nail care weekly, trimming as needed every day shift every Wednesday and as needed for long or jagged nails. On 03/23/2026 at 9:09 a.m. observation of resident #2's fingernails revealed they were long and had dark substance under the nails. On 03/23/2026 at 3:50 p.m. observation again of resident #2's fingernails revealed they remained long and continued to have the dark substance under the fingernails. On 03/24/2026 at 8:20 a.m. observation of resident #2's fingernails revealed they continued to have the dark substance under the fingernail. On 03/24/2026 1:30 p.m., an interview and observation of resident #2's fingernails with S5CNA Supervisor agreed the fingernails were not clean. Resident #42Review of the record for resident $42 revealed diagnoses in part of cerebral infarct, hypertension, chronic kidney disease, and depression.Review of the quarterly MDS dated [DATE] revealed resident #42 had a BIMS of 14 indicating the resident was cognitively intact. The resident required supervision or touching assistance with personal hygiene. Review of the care plan revealed self-care deficit related to resident needs assistance with activities of daily living. Further review revealed the following approaches: resident will be clean, dry, dressed neatly, odor free, and well-groomed daily this quarter. Morning Care- face washed, hair brushed, oral care--includes brushing dentures/teeth, hands washed, and nail care. Evening care- face washed, hair brushed, oral care- includes brushing teeth/soaking dentures, hands washed.Review of the current Physician orders revealed nail care weekly, trimming as needed every day shift every Wednesday and as needed for long or jagged nails. On 03/23/2026 at 10:34 a.m. observation of resident #42's fingernails revealed they were long and dirty having a dark substance under the nails. Resident #42 said his fingernails were a little dirty. On 03/24/2026 at 8:30 a.m. observation of resident #42's fingernails revealed they remained long and had a dark substance under them. Resident #42 stated his nails had not been cleaned yet and that he had tried to clean them but didn't get very far with them. On 03/24/2026 at 1:30 p.m. observation of the resident's fingernails and interview with S5CNA Supervisor agreed the resident's fingernails were not clean. Resident #57Review of the record for resident #57 revealed the resident was admitted [DATE] with diagnoses in part of hemiplegia and hemiparesis following cerebral infarct affecting the left non-dominant side, dysphagia, and epilepsy. Review of the 5-day admission MDS revealed resident #57 had a BIMS of 15 indicating the resident was cognitively intact. Further review of the MDS revealed the resident required substantial to maximal assistance with personal hygiene. Review of the care plan revealed the resident had a self-care deficit related to needs assistance with ADL's due to decreased mobility. Further review revealed the following approaches: resident will be clean, dry, dressed neatly, odor free, and well-groomed daily this quarter. Morning Care- face washed, hair brushed, oral care--includes brushing dentures/teeth, hands washed, and nail care. Evening care- face washed, hair brushed, oral care- includes brushing teeth/soaking dentures, hands washed.Review of the current Physician orders revealed nail care weekly, trimming as needed every day shift every Wednesday and as needed for long or jagged nails. On 03/23/2026 at10:16 a.m. observation of resident #57 fingernails revealed they were long and had a buildup of a dark substance under the nail. Resident #57 stated that his fingernails were long and needed to be cleaned. On 03/23/2026 at 3:45 p.m. observation of resident #57 fingernails revealed they remained long with the buildup of the dark substance under the fingernail. Resident #57 stated his fingernails had not been cleaned yet.On 03/24/2026 at 8:20 a.m. observation of resident #57's fingernails again revealed they remained with the same dark substance under the fingernails.On 03/24/2026 at 1:30 p.m. observation of resident #57's fingernails with S5CNA Supervisor revealed the fingernails remained with the same dark substance under the nails and S5CNA agreed the resident's fingernails were not clean. On 03/24/2026 at 2:00 p.m. S2DON was notified of the unclean fingernails for residents #2, #42, and #57.

Based on record reviews and interviews, the facility failed to ensure residents have the right to be free from any chemical restraints by having PRN orders for psychotropic drugs exceeding the 14 day limit for 2 (#1 and #7) of 5 residents reviewed for unnecessary medications. Findings: Resident #1 Record review revealed Resident #1 was initially admitted to the facility on [DATE] with a readmit date of 12/17/2025. Resident #1 had diagnoses that included essential (primary) hypertension, unspecified sequelae of cerebral infarction, chronic respiratory failure, depression, anxiety, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, acute on chronic systolic (congestive) heart failure, and myocardial infarction. Review of quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated intact cognition for daily decision making. Review of the March 2026 physician orders revealed an order dated 11/25/2025 for Hydroxyzine HCL 25 mg, give 1 tablet every 6 hours as needed for anxiety. On 03/25/2026 at 8:55 a.m., an interview with S2DON confirmed Resident #1 had an order for Hydroxyzine 25 mg po q 6 hours prn for anxiety dated 11/25/2025. S2DON further confirmed the PRN psychotropic medication was ordered beyond 14 days with no stop date. Resident 7 Review of the record for Resident #7 revealed an initial admission date of 05/13/2024 with a readmit date of 08/05/2025. Resident #7 had diagnoses that included Parkinson's disease, anxiety, insomnia, low back pain, and depression. Review of the 5-day Medicare MDS assessment dated [DATE] revealed Resident #7 had a BIMS score of 15 which indicated intact cognition for daily decision making. Further review of the MDS revealed Resident #7 received an antianxiety medication. Review of the March 2026 physician orders revealed an order dated 08/05/2025 for Lorazepam .5 mg, give two tablets by mouth every 24 hours PRN for anxiety. Review of the March 2026 MAR for Resident #7 revealed documented evidence that the resident received Lorazepam .5 mg, two tablets by mouth on 03/05/2026. On 03/25/2026 at 8:55 a.m. interview with S2DON confirmed the resident had an order for Lorazepam .5 mg, give two tablets by mouth every 24 hours PRN for anxiety dated 08/05/2025. S2DON further confirmed the PRN psychotropic medication was ordered beyond the 14 days with no stop date.

Based on observations and interviews, the facility failed to ensure that its medication error rates are not 5 percent or greater by having a medication error rate of 17% for 2 (#57, #58) of 2 residents observed for a medication pass.Findings:Resident #57On 03/24/2026 at 8:50 a.m., a medication pass was observed with Resident #57.Staff S3LPN reported the medication Losartan 50 mg was due at the morning medication pass but it was not available for administration. This resulted in an error by omission.After the medication pass was completed, review of the March 2026 physician orders revealed there was an additional omission of the medication Xarelto 10 mg which was due on the morning medication pass. Resident #58On 03/24/2026 at 9:20 a.m., a medication pass was observed with S3LPN for Resident #58.After the medication pass was completed, review of the March 2026 physician orders revealed there was an omission of the medications Lisinopril 20 mg and Tamsulosin 0.4 mg.S3LPN administered Vitamin B-12 during the medication pass. Review of the March 2026 physician orders revealed Resident #58 should have received Thiamin (Vitamin B-1). On 03/24/2026 at 10:45 a.m., S2DON was informed of the 5 medications errors and that it resulted in a 17% medication error rate. S2DON also confirmed the 5 medications should have been administered as ordered.

Based on record review and interview, the facility failed to ensure it provided routine drugs and biologicals to its residents by failing to have a medication available for administration for 1 (#57) of 2 residents observed during a medication pass.Findings:On 03/24/2026 at 8:50 a.m., a medication pass was observed with Resident #57.Staff S3LPN reported the medication Losartan 50 mg was due at the morning medication pass but it was not available for administration. Review of the March 2026 physician orders confirmed Losartan 50 mg was due to be administered during the morning medication pass.On 03/24/2026 at 10:45 a.m., S2DON was informed that Resident #57's Losartan 50 mg was not available for administration during the morning medication pass.

Based on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by 1) failing to monitor the heart rate with the administration of metoprolol succinate for Resident #1 and 2) failing to obtain a lipid panel as ordered for Resident #1 of 5 residents reviewed for unnecessary medications.Findings:Record review revealed Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included essential (primary) hypertension, presence of aortocoronary bypass graft, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified sequelae of cerebral infarction, chronic respiratory failure, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, acute on chronic systolic (congestive) heart failure, and myocardial infarction. Review of the current March 2026 Physician Orders revealed the following: Order dated 12/20/2025 - metoprolol succinate ER 25 mg tablet give 1 tablet by mouth qd (hold for SBP less than 100 or HR less than 60); an order dated 10/16/2025 - atorvastatin calcium 80 mg tablet give 1 tablet by mouth at bedtime; and an order dated 10/17/2025 - lipid panel every 6 months. Review of the February and March 2026 EMAR revealed Resident #1 received metoprolol succinate and atorvastatin as ordered. Further review revealed there was no documentation of Resident #1's heart rate being obtained with the administration of metoprolol succinate. Review of Resident #1's medical record revealed no documented evidence of a lipid panel. On 03/25/2026 at 8:55 a.m. an interview with S2DON confirmed there was no documentation of Resident #1's heart rate being obtained with the administration of metoprolol succinate. On 03/25/2026 at 10:35 a.m. an interview with S2DON confirmed there was no documentation of Resident #1 having a lipid panel drawn.

Based on observations, interviews and record reviews, the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.The facility failed to 1) implement enhanced barrier precautions for 1 (#6) of 1 residents reviewed for enhanced barrier precautions and 2) follow facility policy for the cleaning, storage and replacement of piston syringes for 1 (#26) of 1 residents reviewed for tube feedings.Findings: Resident #6 Review of the facility's Enhanced Barrier Precautions policy and procedure (undated) revealed the following in part: It is the policy of this facility to implement Enhanced Barrier Precautions (EBP) to reduce the transmission of multidrug-resistant organisms (MDROs) and other infectious agents among residents. EBP will be applied according with current CDC guidelines and applicable federal and state regulations within the Oak Woods. Definition: Enhanced Barrier Precautions: Infection control interventions that include the use of gown and gloves during high-contact resident care activities for residents known or suspected to be colonized or infected with MDROs. Indications for EBP: EBP should be used for residents who: Are colonized or infected with an MDRO, have wounds, indwelling medical devices (e.g., urinary catheters, central lines, feeding tubes). Staff must wear gloves and gown during high-contact care activities, including: dressing, bathing/showering, transferring, providing hygiene, changing linens, wound care, and device care. Record review revealed Resident #6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified dementia, gastrostomy status, anorexia, displaced fracture of base of neck of right femur, subsequent encounter for closed fracture with routine healing, generalized muscle weakness, and need for assistance with personal care. Review of Resident #6's current care plans revealed EBP in place related to increase risk for infection related to peg tube. Goal: Resident will not have an infection this quarter. Intervention: apply appropriate PPE before providing care to resident. On 03/23/2026 at 10:35 a.m., an observation outside Resident #6's room revealed signage posted indicating EBP. Surveyor knocked on door and entered Resident #6's room and observed S7CNA was securing a plastic bag that had a soiled brief and wipes. S7CNA was not wearing a gown. S7CNA reported she had just finished providing incontinent care and changed Resident #6's brief. S7CNA reported she wore gloves, but did not wear a gown when she provided incontinent care for Resident #6. Surveyor asked S7CNA about the EBP signage posted outside Resident #6's room. S7CNA reported Resident #6 was not on EBP, they must have forgot to take the sign down. On 03/24/2026 at 9:30 a.m. surveyor informed S2DON of the observation and interview with S7CNA that occurred on 03/23/2026 at 10:35 a.m. S2DON revealed Resident #6 was on EBP related to her peg tube. S2DON confirmed S7CNA should have worn a gown when she provided incontinent care for Resident #6. Review of the facility's Enteral Feeding Policy and Procedure: Cleaning and maintenance of syringes (undated) revealed the following in part: After each use, rinse syringe with warm water immediately. Draw water in and out several times to clean barrel and tip. Allow syringe to air dry completely. Store in a clean container labeled with resident's name. Replace syringe every 24 hours. Resident #26 Review of the medical record for resident #26 revealed an admission date of 12/31/2024. Further review of the record revealed Resident #26 had a gastrostomy tube for feedings. On 03/23/2026 at 8:48 a.m., observation of the piston syringe located at the bedside for Resident #26 revealed the tip was filled will a dark fluid and the bag that contained the syringe also had a dark fluid on the inside of the bag. The date of the bag that contained the syringe was dated 03/06/2026. Interview with Resident #26 confirmed the syringe was used for his gastrostomy tube. On 03/24/2026 at 10:45 a.m., interview with S2DON confirmed the syringe should have been cleaned and stored appropriately and the syringe should be changed daily.

Based on observations, record reviews, and interviews, the facility failed to ensure that licensed nurses have the specific competencies, and skill sets necessary to care for resident needs by having a nurse leave prescription medications at Resident #30's bedside unattended for 1 (#30) of 1 residents reviewed for nurse competency. Findings: Review of the facility's Medication Management Policy and Procedure (undated) revealed the following in part:2. PurposeThe purpose of this policy is to establish standardized procedures for prescribing, ordering, receiving, storing, administering, documenting, monitoring, and disposing of medications in a safe and consistent manner. 6.3 StorageMedications shall be stored securely and in accordance with manufacturer guidelines. Review of the medical record for Resident #30 revealed an initial admission date of 11/05/2025 with a readmit date of 11/17/2025. Resident #30 had diagnoses that included COPD, DM, hypertension, and tremors. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 had a BIMS score of 15 which indicated intact cognition for daily decision making. Review of the care plan for Resident #30 revealed self-care deficit related to the resident needs assistance with ADLs, and has decreased mobility. On 03/23/2026 at 9:15 a.m. observation of Resident #30 revealed he was in the bed. Further observation revealed 3 pills were observed in a medication cup on his overbed table. On 03/23/2026 at 9:20 a.m. S4LPN observed the medications on Resident #30's overbed table. S4LPN revealed the medications were from the night shift because she had not given Resident #30 any medications. S4LPN confirmed the pills should not have been left at the bedside unattended. On 03/24/2026 at 10:10 a.m. interview with S2DON confirmed the medications should not have been left at the bedside unattended.

Based on record review and interview, the facility failed to ensure each resident was assessed using the quarterly review instrument approved by CMS not less frequently than once every 3 months by failing to ensure a quarterly MDS was completed timely for 1 (#18) of 1 residents reviewed for resident assessments.Findings:Review of the medical record for resident #18 revealed she had an admission date of 11/14/2025. The admission MDS was completed on 11/21/2025. The next quarterly MDS was due on 03/07/2026. There was no documentation that a quarterly MDS was completed by 03/07/2026.On 03/25/2026 at 9:20 a.m., interview with S1Administrator confirmed the MDS for Resident #18 was not completed and submitted by the due date.

Based on record review and interview the facility failed to accurately submit mandatory direct care staffing information, based on payroll, to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 4 2024 (July 1 - September 30). Findings: Review of the PBJ (Payroll Based Journal) Staffing Report for FY Quarter 4 2024 (July 1- September 30) revealed the facility triggered for Failed to Submit Data for the Quarter, One Star Staffing Rating, Excessively Low Weekend Staffing, No Registered Nurse (RN) hours, and failed to have Licensed Nursing Coverage 24 hours/day. On 02/02/2025 at 11:20 a.m. interview with S1Administrator confirmed the former Human Resources Director was not submitting the staffing information based on payroll to CMS. 40238

Based on observations, record reviews and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to the installation for 3 (#18, #24 and #27) of 3 residents reviewed for accident hazards. Findings: Resident 24 Review of the medical record revealed for resident #24 revealed an admitted [DATE] with diagnoses of heart disease, hypertension, anxiety, coronary artery dissection, osteoarthritis, and depression. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #24's Brief Interview for Mental Status (BIMS) score was 13 which indicated no cognitive impairment for daily decision making. Further review of the MDS revealed was independent with bed mobility, and required setup help with transfers. On 02/02/2025 at 10:12 a.m., and 02/03/2025 at 9:00 a.m. observations of resident #24 revealed she was sitting in her room in a wheelchair. Further observations revealed the bed had one quarter rail up on the right side of the bed and the bed rail on the left side was in the down position. Review of the February 2025 physician orders revealed an order dated 01/31/2025 that resident #24 may use bilateral quarter rails to aide in bed mobility. Review of the current care plan revealed resident #24 was at high risk for falls. Interventions included that resident #24 may use bilateral quarter rails to aide in mobility. Review of the medical record revealed no documented evidence that resident #24 was assessed for the entrapment of bed rails prior to installation. On 02/04/2025 at 2:10 p.m. interview with S2Director of Nursing (DON) revealed the facility did not assess for the entrapment risk for the bed rails prior to installation. Resident 27 Review of the medical record for sampled resident #27 revealed admitted [DATE] with diagnoses of muscle weakness, abnormality of gait and mobility, lack of coordination, major depression, pain, psychosis, and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE] revealed the facility was unable to determine the resident's BIMS score, and required extensive assistance with bed mobility and was totally dependent on staff for transfers. On 02/02/2025 at 9:10 a.m., 02/02/2025 at 2:35 p.m., and on 02/04/2025 at 9:45 a.m. observations of resident #27 revealed she was in the bed with one quarter bed rail up on the left side of the bed. Review of the February 2025 physician orders revealed an order dated 01/31/2025- may use bilateral quarter rails to aide in bed mobility every shift related to muscle weakness. Review of the current care plan revealed resident #27 needed quarter bed rails to assist with bed mobility. The interventions included to monitor for effectiveness of use of bed rails, monitor quarter rails to ensure no abnormalities are present that could impair skin integrity. Review of the medical record revealed no documented evidence that resident #27 was assessed for the entrapment of bed rails prior to installation. On 02/04/2025 at 2:10 p.m., an interview with S2DON revealed the facility did not assess for the entrapment risk for the bed rails prior to installation. 22575 Resident #18 Review of the medical record for resident #18 revealed an admitted [DATE]with diagnoses of essential hypertension, paroxysmal atrial fibrillation, generalized osteoarthritis, and unspecified dementia with behavioral disturbance. Review of the annual MDS assessment dated [DATE] revealed resident #18's BIMS score was 99, which indicated they were unable to complete the test. Further review of the MDS revealed she was dependent on staff for all activities of daily living. Review of the February 2025 physician orders revealed an order dated 01/31/2025 that resident #18 may use bilateral quarter rails to aide in bed mobility. Review of the current care plan revealed resident #18 required quarter bed rails. Interventions included that resident #18 may use bilateral quarter rails to assist with turning and repositioning. Review of the medical record revealed no documented evidence that resident #18 was assessed for the entrapment of bed rails prior to installation of the bed rails. On 02/04/2025 at 2:10 p.m., an interview with S2DON revealed the facility did not assess for the entrapment risk for the bed rails prior to installation.

Based on observations the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The failed practice was made evident by uncleanliness of the kitchen which included the food storage areas, meal serving area, cooking areas and the three compartment sink. Findings: On 02/02/2025 at 8:15 a.m., an initial tour of kitchen revealed grease buildup behind and underneath the deep fryer. Splattered food was observed on the wall and glass in front of the serving counter where the resident meal trays were prepared. Rust and food particles were observed on the storage shelf beneath the serving counter. Dust/dirt build up was observed on the circulating fan inside the walk in refrigerator which had blown the dust/dirt onto the ceiling and wall opposite of the fan inside the walk in refrigerator. Observation of the three compartment sink revealed what appeared to be a lime scale buildup on the top of the three compartment sink. On 02/02/2025 at 12:17 p.m., a confirmation interview/observation was conducted with S6Dietary Manager (DM). S6DM was shown the grease buildup behind and underneath the deep fryer, the food splattered on the wall and glass in front of the serving line, and the rust on the storage shelf beneath the serving counter. S6DM was also shown the dust/dirt build up on the circulating fan inside the walk in refrigerator. S6DM was shown the uncleanliness of the three compartment sink. S6DM confirmed the areas were in need of cleaning.

Based on observations, interviews and record reviews the facility failed to provide respiratory care consistent with professional standards for 4 (#2, #18, #35, #22) of 4 (#2, #18, #35, #22) sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was: 1) stored properly for resident #2, #18, #35, and #22, 2) changed in a timely manner for resident #2 and #35 and, 3) dated for resident #2 and #18. Findings: Resident #2: Review of the medical record for sampled resident #2 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease, chronic bronchitis, and history of cerebral infarction. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #2 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact for daily decision making. Review of the physician's orders dated 03/26/2024 revealed administer oxygen (O2) at 2 liters for comfort/shortness of breath every shift as needed (prn). Review of the current care plan for resident #2 revealed may use oxygen at 2 liters per nasal cannula prn. On 02/02/2025 at 1:50 p.m., an observation revealed resident #2's nasal cannula tubing was dated 01/12/2025 and the oxygen tubing was draped over the top of the oxygen concentrator and part of the tubing was touching the floor. Further observation revealed the oxygen tubing was not stored in a bag while not in use. Also, resident #2's nebulizer and nebulizer tubing was on the bedside table and was not dated or stored in a bag. An interview with resident #2 revealed the nebulizer tubing was changed the same time as the other oxygen tubing, which was 01/12/2025. On 02/04/2025 at 2:30 p.m. S2Director of Nursing (DON) confirmed resident # 2's above oxygen equipment was not changed timely and was not stored properly. She further confirmed the nebulizer equipment was not dated or stored properly. Resident #18: Review of the medical record for sampled resident #18 revealed an admitted [DATE] with diagnoses including essential hypertension, paroxysmal atrial fibrillation, unspecified dementia, and anxiety disorder. Review of the annual MDS assessment dated [DATE] revealed resident #18 had a BIMS score of 99 which indicated they were unable to complete the test. Further review revealed she was dependent on staff for all activities of daily living (ADLs). Review of the physician's orders dated 12/01/2024 revealed administer oxygen at 2 liters per nasal cannula, titration increased 1 liter until oxygen saturations are 95% or above every 4 hours as needed for hypoxemia. On 02/02/2025 at 9:00 a.m., 02/03/2025 at 8:49 a.m., and on 02/03/2025 1:00 p.m. observations revealed resident #18's nasal cannula tubing was draped over the top of the oxygen concentrator and part of the tubing was touching the floor. Further observation revealed there was no date noted on the tubing and it was not stored in a bag. On 02/04/2025 at 2:10 p.m., and interview with S2DON confirmed the facility failed to ensure resident #18's oxygen tubing was dated, and stored properly in a bag when not in use. Resident #35: Review of the medical record for sampled resident #35 revealed an admitted [DATE] with diagnoses including hypertension, and history of myocardial infarction. Review of the quarterly MDS assessment dated [DATE] revealed resident #35 had a BIMS score of 11 which indicated he was moderately cognitively impaired. Further review revealed he required moderate to maximum assistance for most ADLs. On 02/02/2025 at 10:18 a.m. and 02/02/2025 at 2:00 p.m., observations revealed resident #35's nasal cannula tubing was dated 01/12/2025. The oxygen tubing was draped over the oxygen concentrator and was not stored in a bag. On 02/04/2025 at 2:30 p.m. S2DON was informed that resident #35's oxygen nasal cannula tubing was dated 01/12/2025, was not changed timely, and was not stored in a bag. She confirmed the tubing should be changed weekly and stored in a bag when not in use. 40238 Resident #22 Record review revealed resident #22 was admitted to the facility on [DATE] with diagnoses that included pneumonia. Further review of the medical record revealed an active order written for resident #22 for Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) milligrams (mg)/3 milliliter (ml) (Ipratropium-Albuterol) -1 vial inhale orally four times a day via nebulizer related to pneumonia. On 02/02/2025 at 8:50 a.m., observation revealed resident #22 had a nebulizer mask uncovered resting on top of the nebulizer machine. The mask and tubing was open to air and not stored in any type of storage container. On 02/02/2025 at 3:00 p.m., observation revealed resident #22 had a nebulizer mask uncovered resting on top of the nebulizer machine. On 02/03/2025 at 1:10 p.m., observation revealed resident # 22 had a nebulizer mask uncovered resting on top of the bedside table. The mask and tubing was not stored in the storage bag which was on top of the table next to the nebulizing machine. On 02/04/2025 at 8:20 a.m., an interview with S2DON, confirmed the nebulizer mask should be kept in a storage bag when not in use.

Based on observation and interview, the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance from toileting facilities. The failed practice was evidenced by a public bathroom having a call light pull cord wrapped around a grab bar which prevented it from being available to activate if a resident needed to activate the call light from the floor. Findings: On 02/02/2025 at 8:30 a.m., observation during a tour of the facility revealed there was an unlocked bathroom located near the chapel. The bathroom was accessible to residents. Observation of the bathroom revealed the call light pull cord was wrapped several times around the grab bar. The call light could not be activated by pulling on the end of the cord. On 02/03/2025 at 8:10 a.m., observation/interview with S3Houskeeping Supervisor revealed the bathroom remained unlocked and the pull cord remained wrapped around the grab bar. S3Houskeeping Supervisor also confirmed the call light cord was wrapped around the garb bar and could not be activated by a resident on the floor if they needed to call for assistance.

Based on observations, record reviews and interviews the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and help to prevent the development and transmission of communicable diseases and infections by failing 1) to have signage on residents' doors that were COVID positive and/or Enhanced Barrier Precautions (EBP) that included specific personal protective equipment (PPE) required for staff use for 4 (#35, #43, #47, and #154), and 2) to ensure indwelling catheter tubing was not touching the floor for 2 (#35 and #154) of 5 (#14, #35, #43, #47, and #154) residents reviewed for infection control. Findings: Resident 43 Review of the medical record for resident #43 revealed the resident tested positive for COVID infection and was placed on isolation on 01/28/2025 through 02/07/2025. Review of the current care plan for resident #43 revealed the resident was COVID positive and isolation precautions were in place. Observation on 02/02/2025 at 8:05 a.m. of resident #43's door revealed there was no signage on the outside of the door to alert staff and/or visitors of the specific PPE required prior to entering the resident's room. On 02/02/2025 at 9: 15 a.m. interview with S2Director of Nursing (DON) confirmed resident #43's door should have signage regarding PPE requirements for the resident on isolation. Resident 154 Review of the medical record for resident #154 revealed the resident had an indwelling catheter. Observation on 02/02/2025 at 2:39 p.m. of resident #154's door revealed there was no signage on the outside of the door to alert staff and/or visitors of the specific PPE required for a resident on EBP regarding his indwelling catheter. On 02/03/2025 at 8:45 a.m. interview with S5Registered Nurse (RN)/Infection Preventionist confirmed resident #154's door should have signage to indicate the specific PPE required for a resident on EBP. On 02/03/2025 at 9:08 a.m., and on 02/03/2025 at 9:00 a.m. observations of resident #154 revealed he was in his room and an indwelling catheter was observed hanging on his walker and the catheter tubing was directly touching the floor. On 02/03/2025 at 4:00 p.m., interview with S2DON confirmed resident #154's catheter tubing should not have been allowed to touch the floor. 22575 Resident 35 Review of resident #35's current physician's orders revealed an order dated 12/19/2024 for an indwelling Foley catheter. Observation on 02/02/2025 at 10:18 a.m. of resident #35's door revealed the sign on his door read Please see nurse before entering which failed to include which PPE was required for EBP regarding his indwelling catheter. On 02/04/2025 at 2:30 p.m. an interview with S2DON confirmed resident #35's door should have signage regarding specific PPE requirements for a resident on EBP. On 02/02/2025 at 10:18 a.m., 02/02/2025 at 2:00 p.m., and 02/03/2025 at 1:15 p.m. observations of resident #35 revealed he was in his room in bed and an indwelling catheter was observed hanging on the left side of his bed. Further observations revealed the catheter tubing and bag were touching the floor. On 02/04/2025 at 2:30 p.m., an interview with S2DON confirmed resident #35's catheter tubing and bag should not have been allowed to touch the floor. Resident 47 Review of the medical record for resident #47 revealed the resident tested positive for COVID infection and was placed on isolation on 01/28/2025 through 02/07/2025. Review of the current care plan for resident #47 revealed the resident was COVID positive and isolation precautions were in place. Observation on 02/02/2025 at 8:38 a.m. of resident #47's door revealed the sign on her door read Please see nurse before entering which failed to include the specific PPE required before staff entered the resident's room. On 02/04/2025 at 2:30 p.m., an interview with S2DON confirmed the above sign on the resident's door should have included specific PPE requirements for staff.

Based on record review and interview the facility failed to ensure appropriate treatment and services were provided to prevent potential complications from enteral feeding by failing to record feedings and water flush amounts for 1 (#7) of 2 (#7 and #22) residents reviewed for tube feedings. Findings: Resident #7 Review of the medical record revealed resident #7 received enteral feedings by way of a percutaneous endoscopic gastrostomy (PEG) tube for the diagnosis of adult failure to thrive. Further review of the February 2025 physician orders revealed an order for Two-Cal high nutrition (HN) tube feeding at 45 milliliters per hour from 6:00 p.m. to 6:00 a.m. There was also an order for the PEG tube to be flushed with 150 milliliters of water every four hours while the feeding was not infusing from 6:00 a.m., to 6:00 p.m. Review of the February medication administration record revealed there was no documentation of the PEG tube flushes or tube feedings. On 02/03/2025 at 4:00 p.m., an interview with S2Director of Nursing (DON) confirmed there should have been documentation of the nighttime feeding and daytime water flushes in the medical record.

Based on record reviews and interviews, the pharmacist failed to identify and report irregularities to the attending physician, the facility's medical director and director of nursing (DON) for 2 (#8 and #19) of 6 (#2, #8, #19, #24, #46 and #154) residents reviewed for unnecessary medications. Findings: Resident 19 Review of the medical record for resident #19 revealed an admitted [DATE] with diagnoses including atrial fibrillation, fatty liver, cardiac pacemaker, prosthetic heart valve, heart failure, anxiety, glaucoma, hyperlipidemia and major depression. Review of the current care plan revealed resident #19 was at risk for fluid volume deficit related to the use of diuretics. Interventions included to assess daily for signs and symptoms of dehydration and over hydration, and to assess for edema every day. Further review of the care plan revealed resident #19 had the potential for abnormal bleeding due to anticoagulant therapy use. Interventions included to monitor for signs and symptoms of abnormal bleeding. Review of the February 2025 physician's orders revealed an order dated 09/13/2024 for Apixaban (anticoagulant) 5 milligrams (mg), give 1 pill two times a day, and an order dated 09/14/2024 for Lasix (diuretic) 20 mg to be given every day. Review of the medical record for resident #19 revealed no documented evidence that the nurses monitored for edema and bleeding as stated in the care plan. Review of the record for resident #19 revealed the pharmacist performed a monthly Drug Regimen Review (DRR) dated 01/08/2025, 12/02/2024 and 11/05/2024. Further review of the DRR revealed no documented evidence that the pharmacist addressed the bleeding and edema monitoring was not documented for the resident. On 02/04/2025 at 9:00 a.m. an interview with S2Director of Nursing (DON) confirmed there was documentation that edema and bleeding was monitored for resident #19. S2DON further confirmed the pharmacist failed to address that edema and bleeding was not monitored for resident #19 during the monthly DRR. 13974 Resident #8 Review of the medical record for resident #8 revealed she received the blood thinner Clopidogrel 75 mg daily with a supporting diagnosis of cerebral infarction. Review of resident #8's medication administration record revealed there was no documentation that the facility was monitoring the resident for bleeding. Review of the monthly drug regimen review revealed consultant pharmacist failed to identify that resident #8 was not being monitored for bleeding. On 02/03/2025 at 4:00 p.m., interview with S2DON confirmed there was no bleeding monitoring for resident #8 and the consultant pharmacist failed to report the irregularity to the facility.

Based on observations and interview the facility failed to ensure the nurse staffing data was posted daily. The facility failed to ensure the nurse staffing data was readily accessible to residents and visitors. Findings: On 02/02/2025 at 7:45 a.m., observation revealed a daily nurse staffing sheet dated 01/8/2025 in a glass case at the front entrance of the facility. The nurse staffing sheet was filled out correctly but was not for the correct day. On 02/03/2025 at 7:50 a.m., observation revealed a daily staff posting dated 02/01/2025 in a glass case at the front entrance of the facility. On 02/04/2025 at 7:50 a.m., observation revealed a daily staff posting dated 02/01/2025 in a glass case at the front entrance of the facility. On 02/04/2025 at 10:01 a.m., an interview with S1Administrator confirmed the daily staffing sheets were not posted daily.

Based on record reviews and interview, the facility failed to ensure there was sufficient staff available at all times to provide nursing and related services to meet the resident's needs and safety in a manner that promotes each resident rights, physical, mental and psychosocial well-being. The facility failed to ensure there was sufficient staff on 07/21/2024, 07/28/2024 and on 08/31/2024 to provide care and services to the residents residing in the facility. Findings: Review of the Payroll Based Journal (PBJ) staffing data submission for fiscal year 2024, Quarter 4 (July 1 - September 30) revealed one star staffing rating, excessively low weekend staffing and failed to have nursing coverage 24 hours/day triggered. Review of the facility's staffing patterns provided to the survey team revealed Sunday, 07/21/2024, hours provided to the residents were 135 hours and the required hours were 129.25 with 55 residents. Review of the actual time sheets for the staff providing care and services to the residents on 07/21/2024 revealed the total hours were 106.91 hours. Review of the facility's staffing patterns provided to the survey team revealed Sunday, 07/28/2024, hours provided to the residents were 136 hours and the required hours were 131.6 with 56 residents. Review of the actual time sheets for the staff providing care and services to the residents on 07/28/2024 revealed the total hours were 76.07 hours. Review of the facility's staffing patterns provided to the survey team revealed Sunday, 08/31/2024, hours provided to the residents were 140 hours and the required hours were 136.3 with 58 residents. Review of the actual time sheets for the staff providing care and services to the residents on 08/31/2024 revealed the total hours were 124.02 hours. On 02/04/2025 at 2:30 p.m. interview with S1Administrator confirmed that the hours on the time sheets were less than the required hours on the staffing patterns. On 02/04/2025 at 3:10 p.m. interview with S1Administrator confirmed she did not have any more time sheets or hours to provide to the surveyor for the dates listed above.

Based on record reviews and interviews, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to 1) monitor edema for a resident who received a diuretic for 2 (#2, and #19), and 2) monitor for bleeding for a resident who received an anticoagulant for 3 (#8, #19 and #46) of 6 (#2, #8, #19, #24, #46 and #154) residents reviewed for unnecessary medications. Findings: Resident 19 Review of the medical record for resident #19 revealed an admitted [DATE] with diagnoses including atrial fibrillation, fatty liver, cardiac pacemaker, prosthetic heart valve, heart failure, anxiety, glaucoma, hyperlipidemia and major depression. Review of the current care plan revealed resident #19 was at risk for fluid volume deficit related to the use of diuretics. Interventions included to assess daily for signs and symptoms of dehydration and over hydration, and to assess for edema every day. Further review of the care plan revealed resident #19 had the potential for abnormal bleeding due to anticoagulant therapy use. Interventions included to monitor for signs and symptoms of abnormal bleeding. Review of the February 2025 physician's orders revealed an order dated 09/13/2024 for Apixaban (anticoagulant) 5 milligrams (mg), give 1 pill two times a day, and an order dated 09/14/2024 for Lasix (diuretic) 20 mg to be given every day. Review of the record for resident #19 revealed no documented evidence of monitoring for bleeding or edema checks as stated in the care plan. On 02/03/2025 at 4:00 p.m. interview with S2Director of Nursing (DON) confirmed resident #19 received Apixaban and Lasix and there was no documentation of monitoring for bleeding or edema documented for resident #19. 13974 Resident #8 Review of the medical record revealed resident #8 received the blood thinner Clopidogrel 75mg daily with a supporting diagnosis of cerebral infarction. Review of resident #8's medication administration record revealed there was no documentation that the facility was monitoring the resident for bleeding. On 02/03/2025 at 4:00 p.m., interview with S2DON confirmed there was no recorded monitoring for bleeding related to resident #8. 22575 Resident 2 Review of the medical record for resident #2 revealed an admitted [DATE] with diagnoses including edema, and hypertension. Review of the February 2025 physician's orders revealed an order dated 01/22/2025 for Bumetanide (diuretic) 1 mg, give by mouth 1 time a day for fluid retention related to edema. Review of the current care plan revealed resident #2 was on diuretic therapy. Further review revealed an intervention to administer diuretic medications as ordered by physician and monitor for side effects and effectiveness every shift. Review of the record for resident #2 revealed no documented evidence of monitoring for edema checks. On 02/04/2025 at 2:30 p.m., an interview with S2DON confirmed there was documentation of monitoring resident #2 for edema. 40238 Resident #46 On 02/02/2025 at 10:36 a.m., an interview with resident #46 revealed he took the blood thinner, Coumadin every night since being admitted to the facility in March of 2024. Record review revealed resident #46 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, cerebral infarction, and myocardial infarction. Further record review revealed an active order for warfarin sodium (anticoagulant) oral tablet 2 mg to be given by mouth at bedtime related to cerebral infarction. Review of the January and February 2025 medication administration record revealed resident #46 had been taking warfarin sodium oral tablet 2 mg nightly as ordered. Further review of the medical record revealed no documented evidence of monitoring for bleeding while receiving an anticoagulant. On 02/03/2025 at 4:10 p.m., an interview with S2DON confirmed resident #46 had not been monitored for bleeding for the months of January and February 2025 while receiving anticoagulant treatment.

Based on record reviews and interview, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid Services) not less frequently than once every 3 months for 2 (#36, #46) of 2 (#36, #46) residents reviewed for resident assessment out of a total of 18 sampled residents. Findings: Resident #46 Record review revealed resident #46 was admitted to the facility on [DATE] and remained as an active resident at the facility. The most recent quarterly Minimum Data Set (MDS) assessment was completed on 08/26/2024. Resident #36 Record review revealed resident #36 was admitted to the facility on [DATE] and remained as an active resident at the facility. The most recent quarterly MDS assessment was completed on 08/14/2024. 02/03/2025 at 3:44 p.m., an interview with S2Director of Nursing (DON) confirmed the MDS quarterly assessments had not been completed every 120 days for residents #36 and #46.

Based on observations, record reviews and interviews, the facility failed to ensure an effective Infection Prevention and Control Program; including the establishment and implementation of measures to prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect any of the 47 COVID-19 negative residents currently in the facility out of a total census of 63 residents. An Immediate Jeopardy situation was identified by the survey team on 09/14/2020 at 9:00AM when they observed staff members entering the facility for work without having their temperatures checked and / or filling out the questionnaire for symptoms of COVID 19. Interview with the Administrator at this time revealed all staff were responsible for taking their own temperatures and completing their own questionnaire. The facility did not have anyone assigned to the designated area to ensure all staff were completing these requirements upon entrance into the facility. The facility had an increase of 6 staff positive for COVID-19 and an increase of 16 residents positive for COVID-19 beginning on 09/04/2020. There were no COVID-19 positive cases in the facility from 06/08/2020 through 09/03/2020. The Administrator was notified of the immediate jeopardy on 09/14/2020 at 3:50PM. The Immediate Jeopardy was removed on 09/14/2020 at 5:45PM when the facility submitted the following Immediagte Jeopardy Plan of Removal which included: 1. Immediate removal a. All exit door codes were changed and only the Administrator will know the codes to ensure every staff comes through the front door. i. This will be completed at 10:00 AM 09/15/2020 b. An employee was immediately placed at the front door to ensure adequate screening, and an employee will be placed there on all shifts. This will be a CNA, nurse, housekeeper or any other employee as designated by Administrator. i. Specific staff will be set in place by the Administrator to take this position. Staff that will be sitting at the front desk will be in-serviced by DON, Administrator and/or Charge Nurse. Administrator will give verbal demonstration on what is to be done and monitored and also a written instruction list to be left at the desk at all times. The competency of these employees will be monitored by DON, Administrator, and or Charge Nurse weekly by a questionnaire. ii. This policy and procedure was set in place at 10:00 AM on 09/14/2020. 2. The root cause of the immediate jeopardy was that proper screening was not completed thoroughly by individuals and employees entering the building. The faults fell on the Administrator and DON not ensuring proper monitoring and supervision of this was taking place. 3. Necessary Changes a. Our policy and procedure will now read that all employees entering the building will have to be screened and monitored adequately by a designated employee assigned to the front desk. Each employee will receive a sticker once they have adequately checked in and met all safe criteria. The sticker will have the date of work written on it. Staff will be randomly checked by Administrator, DON and or designee to ensure each person has a sticker each day with the proper date. b. Any employee that does not check in the proper way will be immediately terminated to ensure safety. c. All staff will be in-serviced on immediate changes on 09/14 and then again on 09/15 until all staff is in-serviced. Administrator will in-service oncoming shift. All staff (including PRN staff) will be in-serviced on 09/15 when their COVID testing takes place. 4. All staff clocked in at work will be monitored every day for 4 weeks and randomly thereafter to ensure that a sticker was given and everyone has checked in adequately and safely. This will be completed by Administrator, DON, ADON, Charge Nurse, and/or designee. A list of the coming on scheduled at the front desk for each department so that all staff may be checked when coming into work. May there be any issues and symptoms, the certain employee will be sent home immediately and the Administrator will be immediately notified. The deficient practice continued at a potential for more than minimal harm for 47 COVID-19 negative residents who resided in the facility. Findings: On 09/14/2020 at 8:45AM upon entrance into the facility, an observation revealed a table set up with a clip board with a document labeled employee shift symptom questionnaire to be completed upon entrance into the facility. Interview with the Administrator at this time revealed all staff are supposed to come through the front door when entering the facility, go to the time clock, check their own temperature and document, answer the COVID-19 screening questions and document under the appropriate column as to yes for symptoms or no if not having any symptoms and clock in for work. The Administrator revealed staff are responsible for documenting their own screening upon arrival to work. Review of the COVID-19 Policy and Procedures in part revealed: A front desk will be set up to monitor all staff and visitors upon coming into the building. All staff must be monitored before coming on shift for temperature, and asked a series of questions that include: 1. Are you showing any flu-like symptoms that include, fever, sore throat, SOB (shortness of breath), and cough? 2. Have you been out of the country or to any hotspots, such as Shreveport or New Orleans in the last 14 days? 3. Have you been in contact with anyone that has been presumed to be positive with the COVID-19 virus? All staff that may answer yes to any of the following questions or may have a temperature will immediately be suspended from work for 14 days. On 09/14/2020 at 9:00AM, observation of the front entrance revealed S4 country store manager came through the front doors, went to the time clock, clocked in without taking her temperature or answering the employee shift symptom questionnaire. She then opened up the country store and immediately assisted resident #1 inside the country store. On 09/14/2020 at 9:10AM, an interview with S4 country store manager confirmed she did not take her temperature or answer the employee symptom questionnaire upon entering the facility. On 09/14/2020 at 10:00AM, copies were obtained of the employee shift symptom questionnaire and the time card report for 09/14/2020. Review of the time card reports revealed there were 33 staff on duty on 09/14/2020 for the day shift. Review of the employee shift symptoms questionnaire for 09/14/2020 revealed there were 7 staff members that clocked in that did not document answering the COVID-19 questionnaire after taking their temperature and there were 13 employees that were clocked in per the employee time card report for 09/14/2020 but did not document completing the screening process at all to include taking their temperature and answering the COVID-19 questionnaire. Review of the tracking and trending forms of the COVID-19 positive cases from 06/08/2020 until 08/26/2020 revealed the facility had no known cases of COVID-19 and starting on 09/04/2020 there has been an increase of 6 staff positive for COVID-19 and an increase of 16 residents positive for COVID-19. On 09/14/2020 at 10:15AM, further interview with the Administrator revealed they do not have a specific person that sits at the front door to screen all employees and the nurse that works the hall closet to the front door generally watches the door but there is no specific real time monitor in place. She further revealed that the log in sheets are checked at the beginning of the day for the prior day but they were only checking to see if a temperature was recorded and not checking to ensure staff were completing the COVID-19 questionnaire. On 09/14/2020 at 10:50AM, interview with S5 housekeeper revealed when she arrives to work she enters though the front door, sanitizes her hands, clocks in, takes her temperature and writes that down and then goes to work. Review of the employee shift symptom questionnaire revealed no documentation by S5 housekeeper that she completed the screening process for COVID-19 upon entrance into the facility on [DATE]. Further interview with S5 housekeeper at that time confirmed she did not document completing the screening process upon entrance into the facility on [DATE]. On 09/14/2020 at 11:15AM, interview with S7 SSD (Social Services Director) revealed she enters the building through the back door by the 600 hall which is only used by Administrative staff, she goes to the time clock and clocks in and takes her temperature. She further revealed she does not document anything else while clocking in for work. Review of the employee shift symptom questionnaire revealed no documentation by S7 SSD that she completed the screening process for COVID-19 upon entrance into the facility on [DATE]. Further interview with S7 SSD at that time confirmed she did not document completing the screening process upon entrance into the facility on [DATE]. On 09/14/2020 at 11:30AM observation of the door on the 600 hall that S7 SSD enters revealed there was no thermometer or screening station located by the door and the staff members have to walk down the 600 hall, across the foyer of the building to the time clock. On 09/14/2020 at 3:45PM, interview the Administrator and DON (Director of Nurses) both confirmed they did not perform the screening process for COVID-19 when entering the facility 09/14/2020. Further interview with the Administrator and DON both confirmed they have recently had an increase in 6 staff and 16 residents test positive for COVID-19 starting on 09/04/2020. The facility had been COVID-19 free from 06/08/2020 until the 09/01/2020 weekly testing for COVID-19 showed this increase in positive COVID-19 cases on 09/04/2020 (date received test results).

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and/or to prevent the development of new ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 7 (Residents #54, #71, #46, #69, #50, #53, and #19) of 7 residents reviewed for pressure ulcers. Systemic failures were identified due to the facility's failure to: 1. Ensure residents (#54, #71, #46, 69, #50, #53, and #19) with pressure ulcers were assessed weekly by an RN (registered nurse) as stated in the facility's wound care protocols, 2. Ensure a resident (#54) with a worsening pressure ulcer was sent for a higher level of care when deemed necessary, and, 3. Ensure weekly skin assessments were completed per resident's plan of care (#54, #71, #46, #69, #53, and #19). This deficient practice resulted in an Immediate Jeopardy for resident #54 who was found to have a blister on her right heel on 02/22/19 that deteriorated by 03/21/19. The facility did not refer the resident for a higher level of care due to the fact that staff thought she was a hospice resident. Resident #54 had been discharged from hospice services six months earlier on 09/17/18. Resident #54's pressure ulcer continued to worsen to eschar. On 4/04/19, the S3DON identified two new pressure ulcers with deep tissue injuries on resident #54's skin. This deficient practice resulted in an Immediate Jeopardy for resident #71 on 03/19/19 after the resident was found to have 4 pressure ulcers on his feet within 21 days of admission to the facility. The resident was admitted on [DATE] and the first skin assessment was documented on 03/15/19 which noted skin was not intact - existing, but the documentation failed to describe how the skin was not intact. On 03/19/19, another skin assessment was done and 3 pressure ulcers were identified on the resident's feet. The fourth pressure ulcer was found on the resident's foot on 03/21/19. On 3/22/2019, another pressure ulcer was identified on the resident's left, fifth toe. This pressure ulcer was unstageable due to suspected deep tissue injury. This deficient practice resulted in an Immediate Jeopardy for resident #46 who developed a stage 2 pressure ulcer to the coccyx on 11/19/18 that increased in size and depth to a stage 4 pressure ulcer. Resident #46 was to receive bi-weekly wound assessments and bi-weekly skin assessments. Although wound assessments were ordered bi-weekly, Resident #46 received 1 wound assessment in (MONTH) 2019, 1 wound assessment in (MONTH) 2019, and 2 wound assessments in (MONTH) 2019. S2Administrator and S3DON (Director of Nurses) were notified of the Immediate Jeopardy on 04/04/19 at 4:30PM. The Immediate Jeopardy was removed on 04/05/19 at 1:00PM when the facility submitted the following Plan of Removal which included: - All resident's skin was assessed on 04/04/19 immediately. This was completed by the DON, ADONs, Treatment Nurse, and floor nurses. - Resident in Room ___ was referred to wound clinic on 04/04/19. (Exhibit B) - New policies and procedures are to be made on these deficiencies. This will include practices on assessments, proper referrals to wound clinics, and the skin assessments. This will also include all of the lines of communication throughout the nursing team in these processes. This is to be completed by 04/05/19. (Exhibit C) - All nurses are in-serviced on the importance of documentation and assessing residents' skin at least weekly, accurately. This was completed by the Administrator and Director of Nursing. The nurses that were not currently on working rotation were called and given verbal instruction on the importance of skin assessment and documentation and accuracy. This was completed on 04/03/19 at 3:30 in the afternoon and calls were made on 04/04/19 to nurses not in the building. When returning nurses come into work, they will be in-serviced in person and given hand out documentation on proper procedures on these practices. Nurses will be tested on the in-serviced information in the two days following. This will be done with a series of questions completed by the Director of Nursing. (Exhibit D) - Treatment Nurse was counseled on doing BRADEN Assessment upon new admissions and readmissions weekly thereafter for 4 weeks. This was done by the Director of Nursing. These preventative practices will be monitored by the DON weekly for 6 weeks thereafter. The treatment nurse was also counseled on infection control issues during wound care practices. This was completed by the Director of Nursing. She was given a hand out on proper practices. The treatment nurse will be tested on the in-serviced information in two days following. This will be done with a series of questions completed by the Director of Nursing. The treatment nurse let her wound care certification go in (YEAR). Facility will be getting her re-certified in wound care practices. The wound care nurse will be observed periodically daily by the DON/RN on duty to ensure proper techniques of practices until she gets her re-certification. - The list of individual hospice patients will be listed thoroughly during daily QA meetings. This will ensure that there is no confusion on which patients are receiving hospice care. This information will also be relayed to the nurses on the floor and updated lists will be posted at each nurses' station and updated as needed thereafter. Nurses will be tested on the in-serviced on who on their hall is receiving hospice care in the next week following. This will be done with questioning completed by the Director of Nursing and / or the Administrator. - American Health Tech contacted on 04/04/19 in to enable RN software wound signage abilities. DON counseled on the importance of documentation her measurements and assessments, even if it is in nurses' notes, by the administrator. This was completed on 04/04/19 at 5:00PM. Administrator will monitor proper wound documentation signage by RN/DON for 4 weeks. - All CNAs were in-serviced regarding the importance of reporting skin issues, new or changing, to the nurse on duty immediately. This was completed by the Director of Nursing. This was completed on 04/04/19 at 4:00PM. CNAs will be tested on the in-serviced information in the next week following. This will be done with a series of questions completed by the Director of Nursing. The DON was assigned _____ _____, LPN and _____ _____, LPN to ensure that proper training and oversight is being taken place on the night shifts. The monitoring of CNA training will be immediately following hire and monitored for all CNAs in the building biweekly for 4 weeks on all shifts. ____ ____. LPN, CNA Supervisor will make periodic check throughout the evening and night shifts to ensure that proper training is taking place. - Nurses were instructed to document in the nurses notes and fill out a wound care referral form and give a copy to DON, weekend RN/RN on duty and/or treatment nurse if anything new was found during assessment. These were given to all nurses during in-service and copies were placed in the ward clerk office and at all nurses' stations. - An order was placed on the physician orders [REDACTED]. This will be placed on the MAR and signed off by all the completing nurses. American Health Tech will be notified on 04/05/19 to make immediate drop over tab into the nurses' notes, if possible, for easy access charting of findings. If not, all findings will be continued to be placed in the nurses' notes. This will take place on 04/04/19. The MARS and system will be monitored by DON and ADON daily for 4 weeks, then biweekly for another 4 weeks and then weekly for 4 weeks. Any discrepancies will be addressed immediately. (Exhibit F) - Medical director was notified and a QA/QI will take place at the facility monthly for the following 6 months. This will take place instead of the normal quarterly meetings held. All monitored wound data will be discussed address immediately. - Placement of hospice patients individual names will be added to our daily QA meeting form. (Exhibit G) - Placement for skin assessment issues and new or worsened wound issues was added to the daily QA forms. (Exhibit G) This deficient practice continued at a potential harm for the 7 residents in the facility who currently had pressure ulcers. Findings: Review of the Skin Integrity Policy provided by S2Administrator on 04/04/19 revealed, in part, the following: 1. All pressure wounds will be inspected by the RN (registered nurse) with findings documented on Wound Assessment, and 2. A weekly status report will be completed. Review of the Wound Care Protocol provided by S2Administrator on 04/04/19 revealed, in part, the wound care RN makes weekly assessments of skin conditions. The RN determines which wound care protocol to initiate according to the type & site of wound and the amount of drainage a wound presents. Resident #54 Resident #54 was admitted on [DATE] and had [DIAGNOSES REDACTED]. Review of the 02/25/19 Minimum Data Set for Resident #54 revealed, in part, the following: at risk of developing pressure ulcer; cognitive status was severely impaired and the resident never/rarely made decisions; bed mobility - 2 person physical assist; and transfer - extensive assistance, 2 person physical assist. Review of nurses' note dated 02/22/19 at 12:19PM revealed, S4WCN (wound care nurse) was summoned to assess Resident #54's right heel by the floor nurse. An intact blister was noted with no open area. The area was noted as tender to touch and was cleaned and MD notified. There was no documentation to indicate a registered nurse had assessed and measured the resident's newly identified pressure ulcer to the right heel. Review of the (MONTH) 2019 physician's orders [REDACTED]. with [MEDICATION NAME] and wrap with kling and tape daily til resolved. Review of the current care plan for Resident #54 revealed, in part, the following: a 08/21/13 problem regarding potential for impaired skin integrity with an approach for weekly skin assessments per nurse. The current care plan also had the following problems listed: 02/22/19 - stage 2 pressure ulcer to right bottom of heel, and 03/25/19 - deep tissue injury to right lateral foot (newly identified pressure ulcer). Review of Weekly Wound Assessments for Resident #54 revealed, in part, the following: 02/21/19- newly identified pressure ulcer on 02/21/19, Stage 2 to right bottom of heel, 2 cm (centimeters) x 3.5 cm x 0 cm-100% granulation, electronically signed by S4WCN, 02/28/19- Stage 2 to right bottom of heel, measured 2.5 cm x 3.5 cm x 0- 100% granulation, wound status unchanged, electronically signed by S4WCN, 03/07/19- Stage 2 to right bottom of heel, 4 cm x 4 cm x 0- 100% granulation, wound status deteriorated, electronically signed by S4WCN, 03/14/19- Stage 2 to right bottom of heel, 3 cm x 3 cm x 0 cm- 100% granulation, wound status improved, electronically signed by S4WCN, 03/21/19- Stage 2 to right bottom of heel, 4 cm x 4 cm x 0 cm-100% granulation, wound status improved- (although wound bed increased in size), electronically signed by S4WCN. 03/25/19- new pressure ulcer identified to right lateral foot- identified 03/25/19, 4 cm x 1.5 cm un-stageable due to suspected deep tissue injury, no electronic signature of which staff assessed the pressure ulcer. Further review revealed no documented Weekly Wound Assessment of the pressure ulcer to the right bottom of the heel since 03/21/19- 13 days. Further review of the Weekly Wound Assessments revealed no documentation that the pressure ulcers were measured or assessed by a registered nurse. Observation of pressure ulcer wound care by S4WCN on 04/02/19 at 1:21PM for Resident #54 revealed the resident was seated in her recliner with the foot of the recliner raised. There was a heel protector on the right foot, no heel protector on the left foot. Observation of Resident #54's right heel revealed the pressure ulcer had black eschar covering the wound bed. S4WCN reported the resident's pressure ulcer was getting worse and stated they had wanted to get the wound debrided a while back but since the resident was receiving hospice services, they had not contacted the wound clinic. Wound care nurse went on to say that the current wound treatment was not getting down to the bed of the wound by wiping [MEDICATION NAME] across the top of the eschar. S4WCN confirmed that she was not wound care certified. Review of the (MONTH) 2019 physician's orders [REDACTED]. Further review of Resident #54's medical record revealed hospice services were discontinued on 09/17/18. On 04/04/19 at 10:15AM, an interview with S3DON was conducted and she was asked if she had assessed the pressure ulcer on the resident' right heel since 03/21/19, she stated that she couldn't remember. She reported that she had been printing out the wound assessments and signing them. Surveyor requested signed documentation by S3DON to indicate that she performed the wound assessments. The documentation was never provided. Additionally, S3DON was asked about missing weekly skin assessments for Resident #54. S3DON reported that they are aware they have a problem with weekly skin assessments. S3DON confirmed that weekly skin assessments had been missed and no one had been monitoring to make sure weekly skin assessments were completed. On 04/04/19 at 10:40AM, S4WCN presented her 'jot pad' and said she had measurements from Resident #54's pressure ulcer on her right heel from 03/28/19- 'DTI' and '4 cm x 4.5 cm' were handwritten on the paper. S4WCN reported that the wound had deteriorated at that time. S4WCN also reported that Resident #54's pressure ulcers would be measured again today. Surveyor requested to observe when the pressure ulcers were measured. S4WCN went on to say that on the 25th (03/25/19) Resident #54's wound was still kind of red but that she had talked to the nurse practitioner about sending the resident to the wound care clinic so it could be cleaned out. S4WCN reported that the nurse practitioner had told her Resident #54 was on hospice services so she couldn't go to wound care clinic. When asked if pressure ulcer had deteriorated since that time, wound care nurse confirmed that the pressure ulcer was bigger and had deteriorated to eschar. She reported that the resident's daughter called yesterday and was concerned about the resident complaining of pain now in her heel. On 04/04/19 at 1:45PM, Resident #54 was seated in her recliner with the foot of the recliner raised. The resident was wearing a heel protector on the right foot only. S4WCN and S3DON were in the resident's room to assess the resident's pressure ulcers. An observation of S3DON measuring the resident's pressure ulcers revealed the following: 1. Right heel- 4 cm x 4 cm, DTI (previously Stage 2) and S3DON stated that it had deteriorated to eschar, and 2. Right lateral foot- 5 cm x 2 cm (previously identified on 03/25/19). S3DON stated there were two new pressure ulcers on Resident #54's right foot with measurements as follows: 1. Upper ankle 1 cm x 5 cm- deep tissue injury, and 2. Left lateral foot 4 cm x 1 cm- deep tissue injury. Review of Weekly Skin Assessments for Resident #54 since 01/01/19 revealed the following: 01/10/19- skin intact, 01/17/19- skin intact, 01/25/19- skin intact, and 03/25/19- skin not intact- new. Review of the nurses' notes dated 03/25/19 revealed no description of the negative finding of skin not intact noted on the weekly skin assessment. On 04/04/19 at 5:30PM, an interview with S12LPN confirmed that she did not always document weekly skin assessments. On 04/04/19 at 4PM, an interview with S3DON confirmed that Resident #54's weekly skin assessments were not completed and no one had been monitoring to assure they were completed. S3DON did not provide documentation, as previously requested, to indicate that Resident #54's pressure ulcers had been assessed by a registered nurse. S3DON confirmed that there was no weekly wound assessments of resident #54's right bottom of the heel documented since 03/21/19. S3DON was informed that S4WCN stated that when Resident #54's pressure ulcer to the right bottom of heel had deteriorated on 03/25/19, the wound care clinic was not contacted because staff thought the resident was on hospice services and not eligible to go to clinic. Record review revealed the resident had been discharged from hospice services on 09/17/18. Resident #71 A review of Resident #71's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident #71's current physician's orders [REDACTED]. A review of Resident #71's Minimum (MDS) data set [DATE] revealed the resident requires extensive assistance by two people with bed mobility, toileting, and transferring. The resident was coded as at risk for developing a pressure ulcer. A review of Resident #71's Braden risk assessment report dated 03/01/19 by S4WCN revealed a score of 12, indicating resident is a high risk for pressure ulcers. Resident #71 was coded as very limited sensory perceptions, responds only to painful stimuli, and can't communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over half of the body. It further stated resident is bedfast with very limited mobility and makes occasional slight changes in body extremity position but unable to make frequent or significant changes independently A review of Resident #71's care plan revealed a problem onset on 03/07/19 of I am at risk for pressure ulcers. Interventions included: I need full skin evaluation weekly with bath/shower. A new problem onset dated 03/19/19 for pressure ulcer/open skin areas requiring treatment was care planned. Interventions included: have the Registered Nurse assess my wound weekly. A review of skin assessments revealed Resident #71 has had only one weekly skin assessment completed, and that was on 03/15/19. It stated Skin not intact - existing by S9LPN. It did not have any other documentation regarding the details of the assessment. A review of wound care notes revealed on 03/19/19 that three new wounds were identified on Resident #71. All three wounds were documented as new wounds, and the wounds were not present on admission. The 03/19/19 notes revealed the following documentation on the three new wounds: 1.) Right top of foot, right inner foot was documented as an intact blister that measured 4.0cm (centimeters) x 3.5cm x 0cm; 2.) Left heel-documented as un-stageable due to suspected deep tissue injury and measured 2.5cm x 3.0cm x 0; and 3.) Right heel-documented as pressure ulcer, un-stageable due to suspected deep tissue injury and measured 6.0cm x 4.0cm x 0. Review of a wound care note dated 03/21/19 revealed another wound was found on Resident #71's right foot. This fourth wound was identified as a stage 2 pressure ulcer to the right top of foot, right plantar of foot, measuring 3.5cm x 4.0cm x 0.10cm. Review of a wound care note dated 03/22/19 revealed another wound was found on Resident #71's left, fifth toe. This fifth wound was identified as an un-stagable pressure ulcer, due to suspected deep tissue injury to left fifth toe/left distal lateral pinky toe. It measured 1.5cm x 1.0cm and stated it was not present on admission. On 04/03/19 at 10:09AM, wound care by S4WCN was observed. S4WCN reported Resident #71 has three DTIs (deep tissue injury) and one stage 2 pressure ulcer to his right inner foot. Resident was wearing heel protectors. Observations revealed the following: 1.) Pressure ulcer to right inner foot was open with white in the middle of the wound bed and pink surrounding the area; 2.) Pressure ulcer to left heel noted to be slightly smaller than a quarter with a pink wound bed; 3.) A large DTI was noted to the right heel; and 4.) Lateral aspect pressure ulcer to the right foot was small, round and had eschar in the middle. In an interview with S12LPN (licensed practical nurse) on 04/04/19 at 5:30PM, she confirmed skin assessments were not documented as per facility protocol. In an interview with S9LPN on 04/04/19 at 5:40PM, she confirmed skin assessments were not being documented as ordered. In an interview on 04/04/19 at 2:30PM, S3DON confirmed the weekly skin assessments were not being performed as scheduled. S3DON further confirmed no one was monitoring to assure skin assessments were completed. A review of resident #71's medical record revealed no documentation of a registered nurse measuring the pressure ulcers weekly. This information was requested from S3DON on 04/04/19 at 10:15AM and it was never provided. Resident #46: A review of Resident #46's medical record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. A review of Resident #46's current physician's orders [REDACTED]. A review of Resident #46's 02/08/19 Minimum Data Set revealed the resident requires extensive assistance by two people with bed mobility, transferring, and toileting. The resident was coded as having one stage 2 pressure ulcer and one stage 4 pressure ulcer. A review of Resident #46's current care plan revealed the resident had a problem onset on 10/19/18 of I am high risk for pressure ulcers. Interventions included: I need a bi-weekly skin assessment by nurse. Further review of the care plan revealed a problem onset dated 12/24/18 of Stage 2 to mid-spine and Stage 4 pressure ulcer. Interventions included: I need a bi-weekly evaluation of wound healing and I need a full skin evaluation with bath/shower. Skin assessments (due bi-weekly) were completed on the following dates: 11/15/18 11/19/18 12/13/18 12/21/18 12/28/18 01/25/19 02/22/19 03/07/19 03/22/19 03/29/19 The entries noted above only had: skin not intact - existing). There was no documentation in the record of the reason why the skin was not intact on these dates. Review of Resident #46's wound care notes revealed an entry of a stage 2 pressure ulcer identified on 11/19/18 to the coccyx, which was not present on admission. It was documented as a new wound and it measured 3.0cm x 0.5cm x 0.10cm (length x width x depth). Review of the wound care assessments (due bi-weekly) revealed the wound progressed to a stage 4. See the dates and measurements as follows: 11/29/18 3.5 x 1.5 x 0.1 12/06/18-5 x 4.3 x 0.2 12/13/18-7 x 10.10. x 0.2 12/20/18-12 x 10.5 x 0.2 12/24/18-9 x 9 x 3.5 01/10/19-10.5 x 9.5 x 2.5 02/14/19-10.5 x 11 x 2.5 03/07/19-11 x 9 x 2.5 03/28/19-9.0 x 11.5 x 2.5 On 04/03/19 at 10:52AM, an observation of wound care by S4WCN revealed a large coccyx pressure ulcer that was deep and almost completely pink. After cleaning the pressure ulcer, S4WCN filled the area with calcium alginate X2 dressings, covered with pad and large adhesive dressing. S4WCN then cleaned small pressure ulcer to mid-back with wound cleanser and covered with skin protectant. Resident #46 tolerated procedure well with no signs of pain. In an interview with S12LPN (licensed practical nurse) on 04/04/19 at 5:30PM, she confirmed skin assessments were not documented as per facility protocol. In an interview with S9LPN on 04/04/19 at 5:40PM, she confirmed skin assessments were not being documented as ordered. In an interview on 04/04/19 at 2:30PM, S3DON confirmed Resident #46's weekly skin assessments were not being performed bi-weekly. S3DON further confirmed that no one was monitoring to assure skin assessments were completed. A review of resident #46's medical record revealed no documentation of a registered nurse measuring the pressure ulcers bi-weekly. This information was requested from S3DON on 04/04/19 at 10:15AM and it was never provided. Resident #69 Record review revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The 03/25/19 Minimum Data Set had under Section C (cognitive patterns) a BIMS (brief interview of mental status) score of 15 indicating no cognitive impairment. Review of the record revealed resident #69 was admitted to a local hospital on [DATE] for treatment of [REDACTED]. Resident #69 was admitted back to the facility on [DATE]. Review of (MONTH) 2019 physician's orders [REDACTED]. 1) Clean stage 3 to left ischium with wound cleanser, pat dry with 4 x 4`s, apply Santyl , [MEDICATION NAME] to wound bed and pack loosely with Calcium Alginate and cover with 4 x 4`s then secure with tape every day until resolved, 2) Biweekly skin assessment performed by nurse due to at risk for skin breakdown started on 08/23/18, and, 3) (MONTH) be up no more than 2 hours in the AM and 2 hours in the PM. Review of the medical record revealed the skin assessment reports from 01/01/19 through 4/3/19 contained only 3 documented skin assessments which were dated 02/09/19, 02/24/19 and 03/10/19. The 3 dates noted above only had: skin not intact - existing). There was no documentation in the record of the reason why the skin was not intact on these dates. Review of Wound Assessments documented in the electronic health record by S4WCN were as follows: 03/13/19 (day sent to hospital for debridement) Stage 3 left buttock: left ischium L (length) 6.40 cm (centimeters) W (width) 4.90 cm D (depth) 4.30 cm 03/19/19 (day after return to facility from hospital) Stage 3 left buttock: left ischium L 5.50 cm W 9.00 cm D 3.00 cm Wound status- improved- although pressure ulcer wound bed increased in size, 3/25/19 Stage 3 left buttock: left Ischium L 5.50 cm W 9.00 cm D 3.0 cm Wound status-improved- although pressure ulcer wound bed remained the same size, 04/04/19 at 11:30AM - surveyor observed Stage 3 left buttock: left ischium L 6.5 cm W 6.5 cm D 7.5 cm (increased by 4.5 cm) Tunneling (new) 2 cm and 2.5 cm in 2 different areas of wound, Wound status- deteriorated On 04/01/19 at 1:40PM, an interview with resident # 69 revealed he was recently hospitalized due [MEDICAL CONDITION] originating from the pressure ulcer on his buttock. Resident # 69 said he only gets out of bed for 2 hours in the morning and 2 hours in the evening in hopes of his wound healing. On 04/02/19 at 1:19PM, resident # 69 was interviewed while sitting in electric scooter on the hallway. He revealed his 2 hours was almost up and he was headed back to bed. On 04/03/19 at 10:50AM, an observation of wound care performed by S4WCN revealed the pressure ulcer appears to be much larger than documented on the last wound assessment dated [DATE], 9 days ago. On 04/04/19 at 10:20AM, an interview with S3DON confirmed S4WCN was not wound care certified. S3DON stated that she measures the wounds on Thursdays. S3DON confirmed skin assessments have not been done as ordered. S3DON further confirmed the wound assessments have not been signed by a registered nurse. On 04/04/19 at 11:40AM, S3DON was observed measuring resident #69`s wounds. The left buttocks wound measurements were: L 6.5 cm; W 6.5 cm; D 7.5 cm (increased by 4.5 cm) with Tunneling (new) 2 cm and 2.5 cm in 2 different areas of wound. S3DON confirmed the pressure ulcer had deteriorated since the last measurement which was on 03/25/19 (9 days ago). S3DON confirmed S4WCN was documenting the measurements in the medical record and a registered nurse should have documented weekly on the wound assessment. On 04/04/19 at 5:40PM, S4WCN confirmed bi-weekly skin assessments were signed off on the treatment administration record but the negative results were not documented as they should have been in the skin assessment. Resident #50 Record review revealed an admission date of [DATE]. Active [DIAGNOSES REDACTED]. The 02/23/19 Minimum Data Set had documentation under Section C (Cognitive patterns) that the resident had a BIMS score of 3, indicating severe cognitive impairment. Record review revealed weekly skin assessments documented on 03/14/19, 03/21/19 and 03/28/19 noted skin was not intact-existing. There was no corresponding documentation describing the skin issues on each of the three skin assessment dates. Review of a physician's orders [REDACTED].`s apply honey gauze to wound bed and cover with border gauze dressing every day until resolved. On 04/02/19 at 9:45AM, an interview with resident #50 while she was seated in her wheelchair stated her buttock hurts and it feels like there is a sore on it. There was a wheelchair pad in the seat. The resident stated the nurse looks at it all the time and says nothing is wrong with it. Resident #50 was oriented to self and facility, but was confused about details of why she is here. On 04/02/19 at 1:34PM, surveyor observed S4WCN perform wound care to resident #50`s coccyx. The Stage 2 wound to coccyx was resolving. On 04/04/19 at 10:30AM, an interview with S3DON revealed there should have been corresponding documentation when the skin assessments were performed describing the condition of the skin that was not intact. Resident #53 Review of the medical record for sampled resident #53 revealed [DIAGNOSES REDACTED]., [MEDICAL CONDITION], [DIAGNOSES REDACTED], [MEDICAL CONDITION], anxiety, [MEDICAL CONDITION], hypertension, muscle weakness, lack of coordination and received hospice services. Review of the 02/23/19 significant change Minimum Data Set revealed resident #53 had severe cognition for daily decision making and required extensive assistance with two or more persons for bed mobility, and transfers. Further review of the MDS revealed the resident required extensive assistance with one person physical assistance for dressing, toileting and hygiene. The resident was totally dependent and required one person physical assistance with eating. Review of the 02/15/19 care plan revealed the resident had a stage 3 pressure ulcer to the coccyx with approaches to reposition every two hours and as needed, pressure reducing mattress bed, and daily observation of skin with routine care. Further review of the care plan revealed the resident was at risk for skin impairment and weekly skin assessments per nurse were to be performed. <b (TRUNCATED)

Based on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 7 (#54, 71, 19, 46, 50, 53, 69) of 7 (#54, 71, 19, 46, 50, 53, 69) residents reviewed for pressure ulcers. Systemic failures were identified due to the facility's failure to: 1. Ensure residents ( #54, #71, #46, 69, #50, #53, and #19) with pressure ulcers were assessed weekly by an RN (registered nurse) as stated in the facility's wound care protocols, 2. Ensure a resident (#54) with a worsening pressure ulcer was sent for a higher level of care when deemed necessary, 3. Ensure weekly skin assessments were completed per resident's plan of care (#54, #71, #46, #69, #53, and #19). This deficient practice resulted in an Immediate Jeopardy for resident #54 who was found to have a blister on her right heel on 02/22/19 that deteriorated by 03/21/19. The facility did not refer the resident for a higher level of care due to the fact that staff thought she was a hospice resident. Resident #54 had been discharged from hospice services six months earlier on 09/17/18. Resident #54's pressure ulcer continued to worsen to eschar. On 4/04/19, the S3DON identified two new pressure ulcers with deep tissue injuries on resident #54's skin. This deficient practice resulted in an Immediate Jeopardy for resident #71 on 03/19/19 after the resident was found to have 4 pressure ulcers on his feet within 21 days of admission to the facility. The resident was admitted on [DATE] and the first skin assessment was documented on 03/15/19 which noted skin was not intact - existing, but the documentation failed to describe how the skin was not intact. On 03/19/19, another skin assessment was done and 3 pressure ulcers were identified on the resident's feet. The fourth pressure ulcer was found on the resident's foot on 03/21/19. On 3/22/2019, another pressure ulcer was identified on the resident's left, fifth toe. This pressure ulcer was unstageable due to suspected deep tissue injury. This deficient practice resulted in an Immediate Jeopardy for resident #46 who developed a stage 2 pressure ulcer to the coccyx on 11/19/18 that increased in size and depth to a stage 4 pressure ulcer. Resident #46 was to receive bi-weekly wound assessments and bi-weekly skin assessments. Although wound assessments were ordered bi-weekly, Resident #46 received 1 wound assessment in (MONTH) 2019, 1 wound assessment in (MONTH) 2019, and 2 wound assessments in (MONTH) 2019. S2Administrator and S3DON (Director of Nurses) were notified of the Immediate Jeopardy on 04/04/19 at 4:30PM. The Immediate Jeopardy was removed on 04/05/19 at 1:00PM when the facility submitted the following Plan of Removal which included: - All resident's skin was assessed on 04/04/19 immediately. This was completed by the DON, ADONs, Treatment Nurse, and floor nurses. - Resident in Room ___ was referred to wound clinic on 04/04/19. (Exhibit B) - New policies and procedures are to be made on these deficiencies. This will include practices on assessments, proper referrals to wound clinics, and the skin assessments. This will also include all of the lines of communication throughout the nursing team in these processes. This is to be completed by 04/05/19. (Exhibit C) - All nurses are in-serviced on the importance of documentation and assessing residents' skin at least weekly, accurately. This was completed by the Administrator and Director of Nursing. The nurses that were not currently on working rotation were called and given verbal instruction on the importance of skin assessment and documentation and accuracy. This was completed on 04/03/19 at 3:30 in the afternoon and calls were made on 04/04/19 to nurses not in the building. When returning nurses come into work, they will be in-serviced in person and given hand out documentation on proper procedures on these practices. Nurses will be tested on the in-serviced information in the two days following. This will be done with a series of questions completed by the Director of Nursing. (Exhibit D) - Treatment Nurse was counseled on doing BRADEN Assessment upon new admissions and readmissions weekly thereafter for 4 weeks. This was done by the Director of Nursing. These preventative practices will be monitored by the DON weekly for 6 weeks thereafter. The treatment nurse was also counseled on infection control issues during wound care practices. This was completed by the Director of Nursing. She was given a hand out on proper practices. The treatment nurse will be tested on the in-serviced information in two days following. This will be done with a series of questions completed by the Director of Nursing. The treatment nurse let her wound care certification go in (YEAR). Facility will be getting her re-certified in wound care practices. The wound care nurse will be observed periodically daily by the DON/RN on duty to ensure proper techniques of practices until she gets her re-certification. - The list of individual hospice patients will be listed thoroughly during daily QA meetings. This will ensure that there is no confusion on which patients are receiving hospice care. This information will also be relayed to the nurses on the floor and updated lists will be posted at each nurses' station and updated as needed thereafter. Nurses will be tested on the in-serviced on who on their hall is receiving hospice care in the next week following. This will be done with questioning completed by the Director of Nursing and / or the Administrator. - American Health Tech contacted on 04/04/19 in to enable RN software wound signage abilities. DON counseled on the importance of documentation her measurements and assessments, even if it is in nurses' notes, by the administrator. This was completed on 04/04/19 at 5:00PM. Administrator will monitor proper wound documentation signage by RN/DON for 4 weeks. - All CNAs were in-serviced regarding the importance of reporting skin issues, new or changing, to the nurse on duty immediately. This was completed by the Director of Nursing. This was completed on 04/04/19 at 4:00PM. CNAs will be tested on the in-serviced information in the next week following. This will be done with a series of questions completed by the Director of Nursing. The DON was assigned _____ _____, LPN and _____ _____, LPN to ensure that proper training and oversight is being taken place on the night shifts. The monitoring of CNA training will be immediately following hire and monitored for all CNAs in the building biweekly for 4 weeks on all shifts. ____ ____. LPN, CNA Supervisor will make periodic check throughout the evening and night shifts to ensure that proper training is taking place. - Nurses were instructed to document in the nurses notes and fill out a wound care referral form and give a copy to DON, weekend RN/RN on duty and/or treatment nurse if anything new was found during assessment. These were given to all nurses during in-service and copies were placed in the ward clerk office and at all nurses' stations. - An order was placed on the physician orders [REDACTED]. This will be placed on the MAR and signed off by all the completing nurses. American Health Tech will be notified on 04/05/19 to make immediate drop over tab into the nurses' notes, if possible, for easy access charting of findings. If not, all findings will be continued to be placed in the nurses' notes. This will take place on 04/04/19. The MARS and system will be monitored by DON and ADON daily for 4 weeks, then biweekly for another 4 weeks and then weekly for 4 weeks. Any discrepancies will be addressed immediately. (Exhibit F) - Medical director was notified and a QA/QI will take place at the facility monthly for the following 6 months. This will take place instead of the normal quarterly meetings held. All monitored wound data will be discussed address immediately. - Placement of hospice patients individual names will be added to our daily QA meeting form. (Exhibit G) - Placement for skin assessment issues and new or worsened wound issues was added to the daily QA forms. (Exhibit G) This deficient practice continued at a potential harm for the 7 residents in the facility who currently had pressure ulcers. Findings: Cross refer to findings at F686. Review of the Skin Integrity Policy provided by S2Administrator on 04/04/19 revealed, in part, the following: 1. All pressure wounds will be inspected by the RN (registered nurse) with findings documented on Wound Assessment, and 2. A weekly status report will be completed. Review of the Wound Care Protocol provided by S2Administrator on 04/04/19 revealed, in part, the wound care RN makes weekly assessments of skin conditions. The RN determines which wound care protocol to initiate according to the type & site of wound and the amount of drainage a wound presents. On 04/04/19 at 4:30, an interview with S2Administrator and S3DON confirmed the facility had a system failure regarding residents with pressure ulcers and that the facility failed to follow their wound care protocols and skin integrity policies.

Based on observation, record review and interview, the facility failed to ensure that residents remained free of accident hazards for 1 of 1 sampled resident with 3 occurrences of choking in the last 6 months, requiring the Heimlich maneuver and CPR to be initiated. The facility failed to: 1. identify the resident's risk of another choking accident and 2. implement interventions consistent with the resident's needs to prevent further choking accidents. As a result, resident #37 choked on sliced bread for a second time in three months, became unconscious, required the Heimlich maneuver and was sent to the hospital. Resident #37 was placed in Immediate Jeopardy on [DATE] when the facility was aware the resident choked on a slice of bread and the resident continued to be served sliced bread. The Director of Nurses and the Administrator were informed of the Immediate Jeopardy for resident #37 on [DATE] at 3:40PM. The facility submitted a plan of removal to the surveyors including: 1. Immediate care and dietary staff were inserviced on [DATE] at 1:30PM that bread would not be served to residents receiving pureed diets unless it is in pureed form. 2. Bread was not served beginning with the evening meal on the same date of the incident and this continues. This will be monitored by Administrative staff to ensure compliance. 3. Resident #37's diet was changed on [DATE] to a pureed diet, may have bread only in pureed form. The surveyors determined that the Immediate Jeopardy ended for resident #37 on [DATE] at 1:30PM. Findings: Review of the record for sampled resident #37 revealed an admitted [DATE] with [DIAGNOSES REDACTED]. The record revealed that the resident was admitted to the locked dementia unit on [DATE]. Further review of the record revealed the resident was independent for ambulation, transfers and toileting. The resident was dependent on staff for set-up assistance with eating. Review of the physician orders [REDACTED]. Review of the nurses notes dated [DATE] at 12:00PM, revealed the resident was at the dining table eating lunch and choked on piece of chicken and collapsed. The Heimlich was performed and was unsuccessful. CPR was initiated and a piece of chicken was removed. The resident was transferred to the emergency room per ambulance. The resident returned to the facility the same day at 2:40PM. Review of the emergency room discharge orders revealed an order to serve a very soft pureed diet to prevent choking. Review of a telephone order from the resident's primary physician dated [DATE] revealed an order for [REDACTED]. Review of the notes from the Registered Dietician dated [DATE] revealed the facility was to monitor the resident for adequate intake and tolerance consistency. There were no further visits from the RD since [DATE]. Review of nurses notes dated [DATE] at 12:00PM revealed that while the resident was eating lunch, she began choking. The Heimlich maneuver was initiated with success. A piece of bread was dislodged. The ambulance was notified but then canceled after the resident's physician was notified. A pureed diet was ordered on [DATE]. There were no documented nurses notes in the record from [DATE] until [DATE]. There was no documentation that the resident was being monitored for tolerance to the pureed diet or any further choking episodes after being changed to the pureed diet. Review of a letter dated [DATE] that was faxed to the resident's physician (and letter mailed to family member) regarding the issue of weight loss revealed that the resident was currently on a mechanical soft with chopped meat diet. The resident had an order for [REDACTED]. Review of the nurses notes dated [DATE] revealed the resident was receiving a mechanical soft diet with chopped meats. The resident had an order for [REDACTED]. Review of S8 Dietary Manager's notes dated [DATE] revealed that the resident continues on a mechanical soft diet with chopped meats, although the resident had an order to be on a pureed diet. Review of the nurses notes dated [DATE] at 8:00PM revealed the resident received a mechanical soft diet with chopped meats and had a good appetite. The notes further revealed that the resident fed herself. Review of the MAR dated [DATE] revealed documented evidence that the resident received a mechanical soft diet with chopped meats for the whole month. The resident had an order to receive a pureed diet. review of the resident's medical record revealed [REDACTED]. Review of the progress notes from the physician revealed that he recommended an EGD with dilation of the esophagus. On [DATE] at 2:15PM, interview with S3DON revealed that the resident has not had the EGD because her family refused. On [DATE] at 12:00PM, observation of the serving line in the kitchen revealed that all residents on pureed diets also received a whole slice of white bread with their tray. Review of the menu, approved by the RD, revealed that residents on pureed diets were to receive one slice of bread, served whole, pureed or soaked in a slurry. On [DATE] at 12:15PM, upon entering the dining room, observation revealed the staff was performing the Heimlich maneuver on resident #37. Further observations at that time revealed that the resident lost consciousness after several attempts of the Heimlich maneuver. Observation of the resident's tray, at that time, revealed that the resident had a half piece of bread on her plate. Interviews at that time with the staff revealed that the resident choked on a piece of white bread. Further observations revealed the staff transported the resident to her room where several abdominal thrusts were performed and a piece of bread was finally dislodged from the resident's mouth. The resident then regained consciousness and was transferred to the hospital. At 12:40PM, interview with the resident's nurse for that day, S4LPN, confirmed that the resident should not have been served whole bread. On [DATE] at 2:15PM, interview with S3DON revealed that she was aware that the resident choked in [DATE], but was not aware that the resident had choked on a piece of white bread. S3DON further revealed that the facility continued to serve the resident slices of white bread after she choked on white bread on [DATE].