Every finding on record at Oakwood Village East Health and Rehab Center

Based on observation, interview, and record review, the facility did not ensure each resident receives care consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 1 of 1 sampled residents (R2), out of a total sample of 3 residents reviewed.The facility inaccurately assessed R2's risk of skin breakdown.The facility failed to create a robust plan of care to prevent PI development.The facility failed to update R2's care plan timely with interventions to prevent worsening pressure injuries or prevent more injuries from developing.Staff inconsistently staged R2's wound and failed to describe characteristics of the wound bed in weekly assessments.R2's pressure injury presented with signs of deterioration and symptoms of infection. The facility failed to update R2's Medical Doctor (MD) timely with these changes.Staff did not give R2 risks and benefits when he refused to wear offloading boots for treatment of his pressure injuries.Staff did not follow standards of practice when performing wound care and treatment orders were not followed as prescribed by the physician.The facility's failure to provide care for R2, consistent with current SOP to prevent and treat PIs led to the development of multiple stage 3 or unstageable PIs and led to an infected stage 3 or unstageable PI. This created a finding of Immediate Jeopardy (IJ) that began on 8/31/25. NHA A (Nursing Home Administrator) was notified of the IJ on 10/8/25 at 2:15 PM. The immediate jeopardy was removed on 10/9/25. However, the deficient practice continues at a scope/severity of D (Potential for Harm/Isolated) as the facility continues to implement its action plan.Evidenced by:The American Medical Directors Association (AMDA) clinical practice guideline entitled, 'Pressure Ulcers and Other Wounds, dated 2017 states in part: .A pressure ulcer [Injury] is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear.Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications.The National Pressure Ulcer Advisory Panel (NPUAP) at www.NPUAP.com defines PI's in the following categories:Category/Stage I: Non-blanchable erythemaIntact skin with non-blanchable redness of a localized area usually over a bony prominence.Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister.Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location.Category/Stage IV: Full thickness tissue loss - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling.Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV.Suspected Deep Tissue Injury (DTI) - depth unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.The facility's policy Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 4/18, includes: The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing (occlusive, absorptive, etc.), and application of topical agents.The facility's policy Change in a Resident's Condition or Status, dated 2/21, includes: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a(an): e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times) [sic]; Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.The facility's policy Support Surface Guidelines, dated 9/13, includes: The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Redistributing support services are to promote comfort for all bed-or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Support surfaces alone are not effective in preventing pressure ulcers, but studies indicate that the use of appropriate support surfaces with interventions such as turning, repositioning and moisture management can assist in reducing pressure ulcer development. Use a pressure ulcer risk scale such as the Braden Scale to help determine need for and appropriate type of pressure relieving devices. For residents that recline and depend on staff for repositioning, change positions at least q (every) 2 hours.The facility's policy Prevention of Pressure Injuries, dated 4/20, includes: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs (Activities of Daily Living). Reposition resident as indicated on the care plan. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. Teach residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change position. Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis.The facility's policy Pressure Injuries Overview, dated 3/20, includes: The purpose of this procedure is to provide information regarding definitions and clinical features of pressure injuries. Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions that are consistent with the resident needs, resident goals, and professional standards of practice; Monitoring or evaluation of the impact of the interventions; or Revision of the interventions as appropriate. Infected Refers to the presence of micro-organisms in sufficient quantity to overwhelm the defenses of viable tissues and produce the signs and symptoms of infection. Debridement Is the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. Eschar Is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color; and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. Slough Is non-viable yellow, tan, gray, green or brown tissue; usually moist; can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. Purulent exudate/drainage/discharge is any product of inflammation that contains pus (e.g., leukocytes, bacteria, and liquefied necrotic debris). Granulation tissue is the pink-red moist tissue that fills an open wound when it starts to heal. It contains new blood vessels, collagen, fibroblast, and inflammatory cells.The facility's policy Pressure Injury Risk Assessment, dated 3/20, includes: The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs). The purpose of a pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify. Risk factors that increase a resident's susceptibility to develop or to not heal PIs include but are not limited to: Impaired/decreased mobility and decreased functional ability; The presence of previously healed PI; Impaired sensory perception; Resident refusal of some aspects of care and treatment. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. Supplement the risk assessment tool with assessment of additional risk factors. Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risk for pressure injuries. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. The interventions must be based on current, recognized standards of care. The effects of the interventions must be evaluated. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Notify the supervisor if the resident refuses the procedure.The facility's policy Assisting the Nurse in Examining and Assessing the Resident, dated 9/10, includes: The purpose of this procedure is to assist the nurse in gathering information about the overall condition of the resident and his or her performance of activities of daily living. The primary purpose of assessing the resident is to gather detailed information that will help to develop a plan of care that is appropriate for the resident.The facility's policy Wound Care, dated 10/10, includes: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hand thoroughly. 6. Put on gloves. 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 12. Apply treatments as indicated. 13. Dress wound. 16. Remove disposable gloves and discard into designated container. Wash and dry your hand thoroughly.Facility Standing Orders, undated, includes Wound/Skin Orders- . Pressure Injury - wash wound with soap and water. Apply Silicone cream and cover with Kerrafoam dressing. Contact MD/NP (Medical Doctor/Nurse Practitioner as soon as possible for further wound orders.R2 admitted to the facility on [DATE] with the following diagnoses including urinary retention and severe kidney injury and necrobiosis lipoidica (a rare, chronic skin condition). R2's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/4/25 indicates R2's cognition is 15 out of 15 indicating R2 is cognitively intact. R2's MDS also indicates he is dependent on staff assistance to meet his needs in toileting hygiene, substantial/maximal assist in rolling left to right, substantial/maximal assist in sitting to lying, partial/moderate assist in lying to sitting, partial/moderate assist in sitting to lying, partial/moderate assist in chair/bed to chair transfer and requires contact guard assist walking 10 feet.R2's hospital referral dated 7/28/25, includes: . was admitted on [DATE] with urinary retention and severe acute kidney injury with creatinine of 15. He has changes in his legs and dermatology was consulted and we are continuing topical triamcinolone for bilateral necrobiosis lipoidica . Transfers: sit to stand- contact guard assist with gait belt and walker. stand to sit- contact guard assist with gait belt and walker. requires minimal assist to stand from lower height toilet. Declines gait outside of room. Heavy reliance on bilateral upper extremities to offload lower left extremity due to pain. Reports arm pain. Gait slow, drags feet especially when fatigued. Requires standing and seated rest breaks to recover from fatigue and pain. 7/17/25 wounds present on admission: pressure injury left inner gluteal cleft, traumatic abrasion midline back scrape from fall in shower, pressure injury posterior, right knee linear, and closed blisters on left posterior leg.It is important to note R2's history of having pressure injuries.R2's Braden Scale for Predicting Pressure Sore Risk, dated 7/30/25, includes a score of 22 which means not at risk. Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. Ability to change and control body position: No Limitation: Makes major and frequent changes in position. Degree of physical activity: Walks Frequently: Walks outside room at least twice a day and inside room at least once every two hours during waking hours . Sensory Perception: No Impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort .It is important to note R2's referral included a history of having pressure injuries and the facility scored R2 as not at risk for pressure injury development.R2's Comprehensive Care Plan, initiated 7/29/25, includes potential for PI development related to disease process (specify). Interventions: Administer treatments as ordered . Frequent repositioning . Good nutrition . Taking care during ambulating and mobility. Follow facility policy and protocol for prevention of skin breakdown. Moisturize. Do not massage over bony prominences. Use mild cleansers . If R2 refuses treatment confer with family, resident, and IDT (Interdisciplinary Team) to find out why. Monitor, document, and report any changes in skin status such as appearance, color, wound size, stage, signs and symptoms of infection. Treat pain as ordered prior to treatment/turning, . to ensure resident's comfort. 8/1/25 potential for PI development related to decreased mobility, weakness. requires bed as flat as possible to reduce sheer. Moisturize twice daily . If R2 refuses treatment confer with family, resident, and IDT to find out why. Requires 2 assist for turning and repositioning in bed. 1 staff to move between surfaces with walker.R2's physician orders state in part; start date: 7/30/25 Air mattress for bed related to potential skin breakdown.R2's Nurse Shower Review Skin Assessment, dated 7/31/25, indicates R2 has redness in his gluteal fold and in his abdominal folds.R2's Dermatology MD Note, dated 8/1/25, includes recommendations: triamcinolone for necrobiosis lipoidica as well as edema bullae on posterior legs. no other chronic wounds.R2's Nurse Notes, dated 8/3/25, include: 4:03 AM.11:43 AM Skin check completed on resident after bed bath this shift. Multiple small open areas noted to resident's bottom and coccyx. Mepilex applied and education provided to resident on importance of repositioning. NP (Nurse Practitioner) updated. R2's Nurse Shower Review Skin Assessment, dated 8/3/25, indicates R2 has reddened areas in his gluteal fold, an open area to his coccyx, and an open area on his buttock. The medical record does not include measurements or other description/characteristics of the open area.R2's Physician Orders state in part; Start date: 8/3/25 Offer frequent repositioning as resident allows.R2's Braden Scale, dated 8/4/25, indicates R2 is at risk for pressure injury development with a score of 16, at risk.R2's Comprehensive Care Plan, updated 8/4/25, includes pressure ulcer to coccyx. Pressure relieving device in bed and chair.R2's Weekly Wound Observation Tool, dated 8/6/25, which is 3 days after the areas were first identified, includes date acquired- 8/6/25. Location - left gluteal fold. In house acquired. Type - Pressure. Pressure Ulcer stage - stage 2. Visible tissue - epithelial pink tissue. Drainage Type - bloody. Amount of drainage - scant. Odor - no. Wound measurements (in centimeters) - 1.0 x 1.0 x 0.0. Describe the extent of tunneling or undermining- blank. peri-wound tissue description- blank. Wound edges description - blank. Current treatment plan - Mepilex foam border every 3 days. Special equipment/preventative measures - air mattress, repositioning schedule, cushion in wheelchair.Facility's Wound Excel Form, dated 8/6/25, includes coccyx.stage 2. 2.0 x 0.5 x 0.0. 100% epithelial.left gluteal fold. stage 2. 100% epithelial. 1.0 x 1.0 x 0.0.It is important to note this form is not part of R2's medical record but was found in a wound care binder where the facility documents wound assessments.R2's Nurse Shower Review Skin Assessment, dated 8/10/25, includes reddened areas in abdominal folds and gluteal fold. Intervention: Zinc applied to glute area.R2's Weekly Wound Observation Tool, dated 8/13/25, includes Location- left gluteal fold. Type- pressure. Pressure Ulcer Stage- Stage 2. Overall impression- worsening. Visible tissue- Epithelial pink tissue present. Granulation tissue present. Drainage- Type- none. Odor- none. Wound measurements (in centimeters)- 3.0 x 2.0 x 0.0. Peri- wound tissue- bright red, bleeding. Describe any changes to treatment plan in the last week- discontinued Mepilex, barrier cream only. Current treatment plan- barrier cream, offer frequent repositioning. Wound progress- worsening, length and width.Special equipment/preventative measures- air mattress, repositioning schedule, cushion in wheelchair. Medical Doctor updated.Facility's Wound Excel Form, dated 8/13/25, includes coccyx. stage 2. 2.0 x 0.5 x 0.0. epithelial, granulation.left gluteal fold. stage 2. 3.0 x 2.0 x 0.0. epithelial, granulation. worsening. The documentation does not include how much of the wound is granulation and how much of the wound is epithelial tissue.R2's Nurse Shower Review Skin Assessment, dated 8/17/25, includes reddened areas noted in abdominal folds and groin, rash noted in abdominal folds and groin, and an open area on buttock.R2's Weekly Wound Observation Tool, dated 8/20/25, was not included in R2's medical record.Facility's Wound Excel Form, dated 8/20/25, includes coccyx. stage 2. 2.0 x 0.5 x 0.0. epithelial, granulation. left gluteal fold. stage 2. 3.0 x 2.0 x 0.0. This documentation was not included in the R2's medical record. It is important to note this form is not part of R2's medical record but was found in a wound care binder where the facility documents wound assessments.R2's Telephone Order, dated 8/22/25, includes open area on gluteal fold. Cleanse with soap and water and cover with Mepilex. Change every other day and as needed.R2's Nurse Shower Review Skin Assessment, dated 8/24/25, includes: no new skin injury noted. No new issues. No interventions.R2's Weekly Wound Observation Tool, dated 8/27/25, includes: Location- left gluteal fold. Type- pressure. Pressure ulcer stage- 2. Visible tissue- epithelial pink tissue present. Comments- possible sheering injury. Drainage- none. Odor- no. Wound measurements (in centimeters)- 1.5 x 1.0 x 0.0 . Peri- wound tissue- intact, pink, blanchable. Wound edge description- rolled, skin flap unable to approximate, no signs and symptoms of infection noted, resident denies pain. Current treatment plan- barrier cream, offer repositioning. Evaluation- improving, possible sheering injury as opposed to pressure.According to https://blog.wcei.net/friction-vs-shearing-in-wound-care-whats-the-difference#:~:text=Studies%20from%20the%20National%20Institutes,factors%20in%20pressure%20injury%20formation.Studies from the National Institutes of Health (NIH) list friction and shear as two main factors in pressure injury formation. A shearing wound damages the skin on a deeper level. Shearing occurs when tissue layers laterally shift in relation to each other; as when bone and deep tissue layers move in opposite directions. While shearing wounds typically occur when patients' skin rubs against bed sheets, it may also happen when patients shift or scoot themselves across a surface instead of fully lifting their pelvis from the bed or chair. Wounds affected by shear will often have tunneling or undermining due to the deep layers of tissue destruction.However, shearing can only contribute to and compound the damage created by pressure. (It can't cause a pressure injury by itself.) A purely shear-based injury is a traumatic wound caused by enough inertia to keep the body moving in one direction.Facility's Wound Excel Form, dated 8/27/25, includes coccyx.stage 2. healed. left gluteal fold. stage 2. 1.5 x 1.0 x 0.0. epithelial. possible sheering injury.R2's Nurse Shower Review Skin Assessment, dated 8/31/25, includes abrasion to midback, left foot 2 open areas, bilateral malleolus (ankle). see progress note. Mepilex applied to abrasion mid back.R2's Nurse Note, dated 8/31/25, includes Open areas noted- Left ankle 1.5cm (centimeters) x 1.5cm. Open area on left lateral malleolus (ankle) with eschar present. Open area on left lateral foot measuring 1.75cm x 4.0cm, no eschar present, area is reddened, no drainage present, no complaints of pain in either area. Patient feels like he may have bumped it during therapy or on the wheelchair. Right ankle-open area on right lateral malleolus measuring 1.75cm x 1.5cm. Both heels are dry, no open areas at this time. Both feet washed and wound cleanser used on the 3 areas, foam dressing to affected areas for protection. Patient is up walking with therapy this shift. No complaints of pain at this time. Will continue to monitor and await any additional orders. May consider heel boots to be used while in bed. R2's Telephone Order, dated 9/2/25, includes heel boots- bilateral at night. Pressure injury right and left lateral malleolus and left lateral foot. Wash with soap and water and cover. 3 sites with Mepilex dressings. change every other day or as needed.R2's Weekly Wound Observation Tool, dated 9/3/25, includes: Location- left gluteal fold. Type- pressure. Pressure ulcer stage- stage 2. visible tissue- epithelial tissue present. Drainage- none. Odor- no. Wound measurements (in centimeters)- 1.3 x 1.0 x 0.0. Peri-wound- intact, pink, blanchable. Wound edge description- rolled, skin flap unable to approximate, no signs and symptoms of infection noted. Current treatment- barrier cream, offer frequent repositioning.R2's MD Note, dated 9/3/25, includes seeing today for newly reported bilateral ankle wounds. Skilled nursing facility reporting new wounds in bilateral feet found over the weekend. Unsure when these started. Patient reports reusing same socks that he came in with from home at the end of July. Wounds are on bilateral malleolus which are covered with eschar. He also has a wound on mid-lateral plantar aspect of left foot as well as another on right heel which is an open flap. Right heel has been draining serosanguinous malodorous output. Others are not draining. Wounds have surrounding erythema and tenderness with palpation. R2 rates pain 3 out of 10 with wound care today. Denies fever or chills. It is suspected that these wounds started with feet rubbing against footrests on his wheelchair. Has mild neuropathy and decreased sensation. Assessment/Plan- R2. with history of hypertension, .presented at hospital with urinary retention of unclear duration and acute non-traumatic kidney injury. Hospitalization complicated with urinary retention, acute kidney injury, bladder stones, Atrial fibrillation, weakness, and gastric ulcers. He was discharged to skilled nursing facility. On 7/29/25 for rehab. Multiple wounds present. Bilateral malleolus wounds- unstageable pressure injuries due to covering eschar/necrotic tissue. Stage 3 right heel wound- draining malodorous serosanguinous output with surrounding erythema, tenderness, and warmth- infection. Left lateral plantar wound- unstageable pressure injury due to covering callus. All wounds with surrounding erythema and tenderness on palpation. No fever or chills, no signs of systemic infection, will check complete blood count and x ray to rule out osteomyelitis. Debridement agent needed for necrotic tissue resolution, will e-consult with dermatology for others. New orders: Bilateral ankle 3 view x rays. Indication- wounds, rule out osteomyelitis. Start levofloxacin 750mg once daily for 7 days for wound infection. Start doxycycline 100mg two times a day for 7 days for wound infection. Start bilateral heel protectors for protection and wound healing. Update NP (Nurse Practitioner) on 9/9/25 with update on wounds. May have to extend antibiotics. Start Prostat renal care once daily for wound healing. Start Santyl 250 unit/gm (grams) ointment once daily on bilateral malleolus wounds- ones with eschar. Vitals two times a day until infections are healed. Start wound care to bilateral malleolus- where eschar is present. Remove old dressing carefully. Clean with normal saline or wound cleanser. Apply- use spatula or gauze pad to apply Santyl ointment directly to the wound once daily. The layer should be 2mm thick, or the thickness of a nickel. Do not apply beyond the wound edges. Cover the treated area with a clean non-adherent dressing. Start wound care to left lateral plantar wound. Clean with normal saline or wound cleanser. Cover with Mepilex dressing for now. Start wound care to right heel. Clean with normal saline or wound cleanser. Cover with Mepilex for now.Due to the wound infection, R2's treatment included two antibiotics.R2's MD Note, dated 9/3/25, includes: . Ensure that wounds stay moist. Apply Vaseline over top of the Santyl and then apply wound dressing.Facility's Wound Excel Form, dated 9/3/25, includes left gluteal. stage 2. 1.3 x 1.0 x 0.0. epithelial possible sheering injury. Right malleolus . unstageable. 1.75 x 1.50 x 0.5. Left malleolus. unstageable.1.5 x 1.5 x 0.5. Right heel. stage 3. 1.5 x 1.5 x 0.5. Left lateral planter foot. unstageable. 1.75 x 1.5 x 0.5.It is important to note this form is not part of R2's medical record but was found in a wound care binder where the facility documents wound assessments.R2's Radiology Report, dated 9/4/25, includes Ankle: Anterior-posterior medial oblique, lateral views of the right ankle. No prior studies. No ankle fracture or dislocation. Talar dome preserved. Hindfoot degenerative changes. Mineralization decreased. Calcaneal enthesophyte at the insertion of the plantar fascia and Achilles tendon. No convincing plain film evidence of osteomyelitis.R2's Physician orders state in part; start date: 9/4/25 Malleolus where eschar is present, clean with normal saline or wound cleanser. Apply: Use a spatula or gauze pad to apply Santyl ointment directly to the wound once daily. The layer should be about 2 millimeters thick or the thickness of a nickel. Do not apply beyond the wound edges. Cover the treated area with a clean nonadherent dressing.R2's Physician Orders state in part; start date 9/4/25 Bilateral heel boots place on both feet at bedtime.Start date: 9/5/25 Left lateral plantar wound- cleanse with normal saline or wound cleanser, cover with Mepilex every day shift.R2's MD Note, dated 9/5/25, includes Please ensure that wounds in bilateral malleolus stay moist. Add Vaseline over top of the Santyl and then apply wound dressing per Dermatology recommendations. I ordered bilateral ankle brachial index test for both legs to rule out vascular insufficiency given fast developing wounds. Patient has an appointment for this test on Friday 9/19/25 at 10:30 AM.R2's Physician Orders state in part; start date: 9/5/25 Right heel wound, clean with normal saline or wound cleanser, cover with Mepilex every day shift.R2's Physician orders state in part; start date: 9/6/25 Please ensure that wounds in bilateral malleolus (ankle) stay moist. Add Vaseline over the top of the Santyl and then apply dressing every day shift.R2's Nurse Shower Review Skin Assessment, dated 9/7/25, includes redness noted in buttock area, 4 open sores noted on right and left outer foot, one open sore noted on right heel and labeled new .R2's Weekly Wound Observation Tool, dated 9/10/25, includes Location- left gluteal fold. Type- pressure. Pressure ulcer stage- SDTI (Suspected Deep Tissue Injury). Visible tissue- epithelial pink tissue present. Drainage- none. Odor- no. Wound measurements (in centimeters)- 0.0 x 0.0 x 0.0. Description of peri-wound- intact, pink, blanchable. Current Treatment Plan- barrier cream, offer frequent repositioning. Wound progress- improving, possible sheering injury as opposed to pressure. Special Equipment/ Preventative measures- pressure relieving boots, repositioning schedule.In the assessment of R2's left gluteal fold, dated 9/10/25, staff down staged R2's wound and called the wound a SDTI with epithelial pink tissue. According to standards of practice, pressure injuries should not be down staged. In addition, did not include shearing as a cause of pressure.R2's Weekly Wound Observation Tool, dated 9/10/25, includes Location- right malleolus. In house acquired. Date acquired- 8/31/25. Type- pressure. Pressure Ulcer Stage- stage 3. Visible tissue- granul

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (R1) reviewed for foley catheter (a thin, flexible tube inserted into the urethra to drain urine from the bladder) management.The facility manipulated and removed R1's foley catheter against physician orders.This is evidenced by:The facility's policy Change in a Resident's Condition or Status, dated 2/21, includes: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a(an): need to alter the resident's medical treatment significantly.The facility's policy Acute Condition Changes - Clinical Protocol, dated 3/18, includes: The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition or status. The nurse and physician will discuss and evaluate the situation. The physician will help identify and authorize appropriate treatments.The facility's policy Emergency and/or Alternative Physician Care, dated 4/13, includes: All residents shall be provided with emergency and/or alternative physician care. Should an emergency arise, and the resident's attending physician is not available, the emergency physician on-call must be contacted. The staff will follow designated protocols for evaluating and triaging medical symptoms and changes in condition and for gathering and reporting information to attending physicians and covering practitioners. The staff will use appropriate procedures to contact physicians, depending on arrangements and the urgency of a situation. If a physician and his/her backup coverage do not respond in a timely or appropriate manner to facility notification of medical issues, the nursing staff will contact the medical director for assistance. The facility's policy Indwelling (Foley) Catheter Removal, dated 8/22, includes: The purpose of this procedure is to provide guidelines for the approved method of removing an indwelling catheter. Verify that there is a physician's order for this procedure.R1 admitted to the facility on [DATE] with a foley catheter.R1's physician orders include DO NOT manipulate, flush, or exchange foley catheter, established with [Hospital] Urology, contact if any issues or questions. [Phone number provided], dated 9/3/25.R1's comprehensive care plan, printed 9/8/25, includes Do NOT PULL FOLEY OUT ONLY UROLOGY CAN DO THAT.R1's nurse progress notes include:9/3/25 3:34 PM . Do not manipulate, flush, or exchange foley catheter, contact [Hospital] Urology with any issues or questions.9/4/25 6:56 AM Progress Note Text: Monitor urine output every shift & document mL (milliliter) every shift Catheter not in place this AM, balloon felt close to the meatus and patient c/o (Complained of) pain. RN (Registered Nurse) found only 3mL in balloon [sic] on aspiration. Patient bed was soaking wet and appeared to have leaked around it all night. RN removed the catheter, notified NP (Nurse Practitioner) of the removal. Waiting for Urology clinic orders on re-insertion.9/4/25 10:48 AM Note Text: resident was sent out to [Hospital] ER (Emergency Room) to replace foley by urologist. Resident was accompanied by daughter. On 10/6/25 at 11:41 AM, Surveyor interviewed RN D (Registered Nurse) about R1's foley catheter. RN D indicated on 9/4/25 around 6:00 AM, she was made aware R1's foley catheter was not draining properly. RN D indicated R1's bed was wet with urine. RN D indicated she reviewed R1's medical record and was aware of the physician order to note manipulate, flush, or exchange foley catheter and to not pull foley out. RN D indicated she was aware urology needed to be notified of any issues with the foley catheter. RN D indicated she aspirated the foley catheter balloon and noted there was only 3mL of fluid in the balloon. RN D indicated she believed the catheter was not in the proper place in R1's bladder so she pulled the foley catheter out. RN D indicated she left a voicemail for R1's primary provider and attempted to call urology after she removed the catheter. RN D indicated she did not speak to a provider before or after the removal of the foley catheter.On 10/6/25 at 12:11 PM, Surveyor interviewed UCN E (Urology Clinical Nurse) regarding R1's foley catheter. UCN E indicated the clinic does have an afterhours number to contact a physician for urology concerns. UCN E indicated the facility should have left the catheter in place since the nurse would have been unable to determine placement. UCN E indicated the facility should have contacted a provider and should not have removed the catheter.On 10/6/25 at 1:41 PM, Surveyor interviewed DON B (Director of Nursing) regarding R1's foley catheter. Surveyor asked if removing fluid from the balloon would be considered manipulation of the foley catheter. DON B indicated she did not believe removing the 3mL of fluid from the foley catheter balloon was considered manipulation of the foley catheter. Surveyor asked DON B if RN D should have consulted with a provider prior to removing the foley catheter. DON B indicated RN D removed the foley catheter since RN D did not think the catheter was in the correct place. DON B indicated RN D attempted to contact the provider and urology clinic after the removal as this event took place prior to the clinic opening at 8:00 AM.

Based on observation, interview and record review, the facility did not 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. This had the potential to affect all 33 residents. One staff member returned to work too soon after experiencing GI (gastrointestinal) symptoms. Five staff members on the facility’s line list did not have the date of last symptoms listed. R63 and R13, did not have accurate symptoms reflected on the line listing. Staff did not perform appropriate hand hygiene per Standards of Practice while providing catheter care to R6. This is evidenced by: The facility policy entitled Communicable/Contagious Diseases, Employee, with a revision date of December 2024, states in part:“Policy Statement: Personnel with active communicable infections may not be in contact with residents, resident-care items and equipment, or resident environments (e.g., common areas or resident rooms) until they are no longer clinically infectious or contagious. Work restrictions and return to work criteria for specific illnesses are determined by the infection preventionist based on the risk of transmission.Policy Interpretation and Implementation:1. Personnel are required to report suspected or confirmed infection with communicable or infectious diseases to their supervisor.…1. Personnel must report the following symptoms to their supervisor upon onset or prior to reporting to their scheduled shift: a. Temperature greater than 100° F; b. Nausea/vomiting; c. Head or body lice (pediculosis); d. Skin rashes, poison ivy/oak; e. Acute diarrheal illness with other symptoms (i.e. fever, abdominal cramps, bleeding, etc.) or diarrhea lasting longer than twenty-four (24) hours; f. Skin lesions or infections; and/or g. Acute upper or lower respiratory infection…. 6. Recommendations for transmission-based precautions are available at: https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/selected-infections/index.html.”According to the CDC (U.S. Centers for Disease Control and Prevention), for GI symptoms, “Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms” (https://www.cdc.gov/infection-control/hcp/norovirus-guidelines/summary-recommendations.html#:~:text=14.,FDA%20Food%20CodeExternal%20website). Example 1: Surveyor reviewed the staff line list provided by the facility and used for infection surveillance when staff members report an illness. The list reports the following information for CNA J (Certified Nursing Assistant): Last Worked: 7/18/2025 / Type of Known Infection: GI / Tested for COVID 19: 0 / Signs/Symptoms: Diarrhea / Date of Onset: 7/19/2025 / Date Form Received: 7/21/2025 / Date of F/U (Follow-Up): 7/21/2025 / Date of Last Symptoms: 7/19/2025 / Return to Work: 7/20/2025. On 7/29/25 at 10:45 AM, Surveyors interviewed DON B (Director of Nursing) and IP I (Infection Preventionist) about the staff line list. Surveyors pointed out that CNA J returned to work the following day after the date of her last GI symptoms. DON B reviewed the list and said, “I see what you mean.” DON B agreed that CNA J’s return to work date should have been 48 hours after symptoms resolved. Example 2: Surveyor reviewed the staff line list provided by the facility and used for infection surveillance when staff members report an illness. The list has 23 staff members on it from January-July 2025. The “Date of Last Symptoms” column is missing dates for five staff members:-CNA T: Last Worked: 1/8/2025 / Signs/Symptoms: Fever / Date of Onset: 1/8/2025 / Date of Last Symptoms: Blank / Return to work: 1/15/2025.-UC U (Unit Clerk): Last Worked: 2/12/2025 / Signs/Symptoms: COVID / Date of Onset: 2/12/2025 / Date of Last Symptoms: Blank / Return to work: 2/19/2025.-EFC V (Exercise and Fitness Coordinator): Last Worked: 1/21/2025 / Signs/Symptoms: COVID-19 / Date of Onset: 1/21/2025 / Date of Last Symptoms: Blank / Return to work: 1/31/2025-CNA W: Last Worked: 1/26/2025 / Signs/Symptoms: GI / Date of Onset: 2/8/2025 / Date of Last Symptoms: Blank / Return to work: Blank-CNA X: Last Worked: 7/15/2025 / Signs/Symptoms: GI / Date of Onset: 7/16/2025 / Date of Last Symptoms: Blank / Return to work: 7/27/2025 On 7/29/25 at 10:45 AM, Surveyors interviewed DON B (Director of Nursing) and IP I (Infection Preventionist) about the staff line list. Surveyors asked how proper illness tracking can be done for staff members when the line list is not filled out completely and how the administration can determine when staff members can return to work if the date of their last symptoms is missing on the tracking tool. IP I indicated this information should be on the line list. DON B agreed that all information should be filled out on the line list because this is the tracking tool they are using for surveillance purposes. Example 3: R63 was admitted to the facility on [DATE] and discharged on 6/10/25 with diagnoses that include encounter for surgical aftercare following surgery on the circulatory system, cardiogenic shock (the heart cannot pump enough blood to meet the body’s needs), and urinary tract infection. Surveyor reviewed R63’s progress notes. On 5/25/25, a UA (urinalysis) was ordered because “the resident’s urine was cloudy and smelled malodorous” and the resident “described a ‘burning sensation when urinating.’” A UA was collected on 5/26/25. Surveyor reviewed the UA and C&S (culture and sensitivity) results. Cefpodoxime Proxetil was ordered to be administered from 5/28/25-6/2/25. Surveyor reviewed the May 2025 and June 2025 line lists. The following is listed for R63 on the June 2025 line list: admit date : [DATE] / Type of Infection: UTI / Onset Date: blank / Signs/Symptoms: blank / Antibiotic Prescribed? Yes / Antibiotic Name or Medication: Ciprofloxacin / Route: Oral / Start date: 6/9/2025 / End date: blank / Precautions: blank / Organism: blank / Criteria met? blank / Facility or hospital acquired? facility / Labs: blankThe UTI detected by the UA on 5/25/25 was not on the May 2025 line list. On 7/29/25 at 10:30 AM, Surveyors interviewed DON B (Director of Nursing). DON B agreed that the line list was missing information. She indicated many different people have been working on this list together since the facility’s previous infection preventionist left. DON B said the information on the line list should be complete. DON B agreed that accurate surveillance cannot be done without accurate information on the line list. Example 4 Surveyor reviewed the July 2025 line list. The following is listed for R13 on the July 2025 line list (Note: the resident’s name was misspelled): admit date : [DATE] / Type of Infection: UTI / Onset Date: 7/2/25 / Signs/Symptoms: frequency, urgency / Antibiotic Prescribed? Yes / Antibiotic Name or Medication: Cipro oral 250 / Route: oral / Start date: 7/2/25 / End date: 7/9/25 / Precautions: standard / Organism: ref / Criteria met? Yes / Facility or hospital acquired? blank / Labs: blank Surveyor reviewed the Revised McGeer Criteria for Infection Surveillance Checklist completed by the facility. The following boxes are checked under Table 2. Urinary Tract Infection (UTI) Surveillance Definitions Criteria: 1. Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate / 2. Greater than 10^5 cfu/ml of no more than 2 species of organisms in a voided urine sample. The information on the line list does not match the information on the McGeer Criteria for R13. On 7/29/25 at 10:30 AM, Surveyors interviewed DON B (Director of Nursing). DON B agreed that the line list was missing information. DON B said the information on the line list should be complete. DON B agreed that accurate surveillance cannot be done without accurate information on the line list. Example 5 The facility’s policy entitled “Handwashing/Hand Hygiene,” dated 10/2023, states, in part: … “Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene: … 2. All personnel are expected to adhere to hand hygiene policies and practices… Indications for Hand Hygiene: 1. Hand Hygiene is indicated: … g. immediately after glove removal… Applying and Removing Gloves: 5. Perform hand hygiene before applying non-sterile gloves…” R6 admitted to facility on 3/27/2025 and has diagnoses that include retention of urine and encounter for fitting and adjustment of urinary device. R6’s Physicians Orders, dated 7/25/25, states, in part: … -empty foley and record in MLs(milliliters)/provide foley cares every shift… Order Date: 3/28/2025 Start Date: 3/28/2025 -urinary catheter care every shift… Order Date: 4/16/2025 Start Date: 4/16/2025…” R6’s Care Plan, dated 6/12/2025, states, in part: … “Focus: Risk for Infection r/t (related to) chronic indwelling foley catheter… Date Initiated: 6/12/2025… Interventions: … -Manage indwelling catheter to minimize risk of infection every shift and PRN (as needed). Date Initiated: 6/22/2025 -Staff to follow standard precautions, including proper hand washing techniques, to minimize microorganism transmission. Date Initiated: 6/12/2025…” On 7/24/25, at 10:53 AM, Surveyor observed CNA C (certified nursing assistant) perform catheter care for R6. CNA C changed gloves four times while providing catheter cares without performing hand hygiene. On 7/24/25, at 11:15 AM, Surveyor interviewed CNA C and asked when hand hygiene should be performed during catheter cares. CNA C indicated before and after. Surveyor asked if hand hygiene should be performed with glove changes and CNA C indicated yes, with hand sanitizer or wash with soap and water. Surveyor asked CNA C if she had performed hand hygiene with glove changes while providing catheter care and CNA C indicated yes. Surveyor informed CNA C that it was observed four times glove changes without hand hygiene while CNA C performed catheter care. CNA C indicated she is about to perform hand hygiene now her hands are just full. On 7/24/25, at 2:40PM, Surveyor interviewed DON B (Director of Nursing) and informed DON B of observation of catheter care with CNA C with 4 glove changes with no hand hygiene. DON B indicated she would expect hand hygiene to be performed with glove changes per standard of care practice.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 5 of 5 abuse investigations reviewed involving 1 of 1 sampled Residents (R1) and 4 of 4 supplemental Residents (R35, R61, R62 and R60). Facility became aware of an abuse allegation involving R1 on 12/4/24 and 7/14/25 and failed to report the allegations to the State Agency. R35 and R35’s representative (RR P) used the concerns/grievance process to voice a concern regarding unwanted touching of her vaginal area by LPN K (Licensed Practical Nurse) even after she asked him to stop. The facility failed to report R35’s allegation of sexual abuse to the state agency. CNA O (Certified Nursing Assistant) heard RN S (Registered Nurse) yelling at R60 and intervened. CNA O observed RN S pull R60’s blanket off without warning and throw it on the floor. CNA O observed RN S slam R60’s room door and bathroom door. CNA O reported the allegation of verbal abuse/mental abuse to DON B (Director of Nursing). The facility did not report the allegation of abuse to the state agency. R62’s representative used the facility’s grievance process to voice a concern of a staff member refusing to provide care for R62. The facility did not report R62’s allegation of neglect to the state agency. R61 used the facility’s grievance process to voice a concern of a staff member being very rough with her during cares. This allegation of abuse was not reported to the state agency. Evidenced by:The facility policy entitled “Abuse, Neglect, Misappropriation, Mistreatment, and Exploitation, Preventing, Investigating, and Mandatory Reporting Policy,” updated 8/25/2023, states, in part: …“Policy: It is the policy of Oakwood Village to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion, or misappropriation of resident property from abuse, corporal punishment, neglect, misappropriation of resident property, and exploitation… The Nursing Home Administrator or designee will report “abuse” to the state agency per State and Federal requirements… It is the policy of Oakwood Village that each resident will be free from “Abuse.”… (5) Investigations Components: The first responsibility of the facility is to assure resident safety. In the event of an allegation of abuse, neglect, mistreatment, misappropriation of resident property, and exploitation made against a staff member, visitor, contractor, and/or family member, the facility shall take immediate steps to ensure the safety of the resident(s) and prevent the risk of future or further harm. Such steps shall minimally include:*Suspension of the staff member until investigation of the allegation is complete…*Examine the resident for any signs of injury, including a physical and/or psychosocial assessment as needed.a. All reports of suspected crime and/or alleged sexual abuse will be immediately reported to local law enforcement for additional investigation…(7) Reporting and Response Components:All personnel, residents, family members, visitors, etc., are expected to report incidents of, or suspected incidents of abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. Such reports must be made immediately to the Administrator and may be made without fear of retaliation from the facility or its staff…a. The facility will ensure that all allegations of abuse, including injuries of unknown source, neglect, mistreatment, misappropriation of resident property, and exploitation are reported to DQA.*For allegations of abuse or serious bodily injury, immediately, but not later than 2 hours after the allegation is made*For allegations that do not involve abuse or do not result in serious bodily injury, no later than 24 hours.Submit the Misconduct Incident Report to: Department of Health Services…” Example 1:R1 was admitted to facility on 1/02/24 and has diagnoses that include mild cognitive impairment, anxiety and depression. R1’s Concern Form, dated 12/4/24, states, in part: …“What is your concern(s) about? Care Provided.When did your concern happen? 12/2 PM shift…Investigation details: R1 states that RN D (Registered Nurse) “Threw a pill in her mouth after dinner time and told me I need to learn how to control myself.”Summary of the pertinent findings or conclusions: Staff member reports the accusation were false and investigation were done with some inconsistence.Corrective action or resolution: Education and training on customer service and medication administration relating to customer service. Dated 12/12/24.” On 7/28/25, at 10:05 AM, DON B indicated to Surveyor regarding the abuse allegations that it is what the resident says it is, and DON B believes the residents. Surveyor asked DON B, looking at the concern form dated 12/4/24 when R1 indicates nurse threw a pill in her mouth and told her she needed to learn how to control herself, could that be considered an allegation of abuse. DON B indicated yes an allegation, not abuse. DON B indicated it should have been reported along with all allegations of abuse should be reported and investigated. Example 2: R1 was admitted to facility on 1/02/24 and has diagnoses that include mild cognitive impairment, anxiety and depression. R1’s Concern Form, dated 7/14/25, states, in part: …“What is your concern(s) about? Care Provided.When did your concern happen? On 7/14/25…How can we make this situation better for you? “I don’t want the cna (certified nursing assistant) in my room again.” … Investigation details: AM floor nurse stated R1 mentioned that the med tech gave her the bruise. After speaking with R1, she mentioned that it was a cna that did it that morning. NOC (night) shift cna and nurse stated they had seen the bruise during shower prior to the morning R1 was explaining it happened. Stated R1 was wobbly in the shower. Stated she almost fell…” R1’s interview, undated, states: “R1 stated the cna had kept encouraging her to change her clothing on her own. R1 stated that the cna was helping her lean up from sitting to change and grabbed her hand. She said that the cna grabbing her hand to pull her up-right is what caused the bruise…” R1’s progress note, dated 7/14/25 at 10:06AM, states, in part: … “CNA stated that the resident has a bruise to her left hand. CNA also stated that “The resident says that I caused the bruise by being rough with her… Writer went and assessed a medium sized bruise to the resident’s left hand with a pain rated at a 9/10… Client stated that the med tech was the one who caused the bruise… On 7/24/25, at 1:23 PM, Surveyor interviewed DON B (Director of Nursing) and ADON E (Assistant Director of Nursing). ADON E indicated it was reported to her by a cna that there was a bruise on R1’s hand from a staff member that hurt her. ADON E indicated R1 indicated to her that R1 had a falling out with a staff member and had received this bruise. R1 informed ADON E that a cna was helping her that morning and grabbed her hand and now she has a bruise. Surveyor asked ADON E when this was reported to her and ADON E indicated 7/14/25 between 8:00AM – 9:00AM. ADON E indicated she had reported it to DON B right away. DON B then indicated to Surveyor that ADON E, ANHA (Assistant Nursing Home Administrator) and herself went to R1 right away. R1 had indicated a staff member was trying to help her and was holding her hand and gave her a bruise and then R1 also indicated someone was trying to catch her from falling in the shower. Surveyor asked DON B and ADON E if that could be an allegation of abuse and if “being rough” as was documented in R1’s progress notes could be an allegation of abuse. DON B indicated yes. Surveyor asked DON B if an allegation of abuse should be reported to state and investigated and DON B indicated yes and it had not been reported. On 7/28/25, at 10:46AM, Surveyor interviewed SW G (Social Worker) who indicated the grievance process as once a concern form is received and reviewed, the ANHA and DON B come together and make a decision whether or not to submit to the state the concern. Surveyor asked if “being rough” could be an allegation of abuse and SW G indicated yes. Surveyor asked if grabbing a resident’s hand and pulling could be an allegation of abuse and SW G indicated it could. Surveyor asked SW G if allegations of abuse should be reported to the state and investigated and SW G indicated yes. On 7/28/25, at 11:23 AM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A indicated the facility would investigate whoever is involved with the concern and then it is decided if it is reportable, or it the concern goes as a grievance. Surveyor asked if staff should follow the facility’s abuse policy and NHA A indicated yes. Example 3 R35 admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease with exacerbation, chronic respiratory failure, and need for assistance with personal care. R35’s most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 7/1/25 indicates R35’s cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. R35’s concern/grievance form, dated 6/26/25, includes: this writer spoke with R35 and R35’s representative on 6/26/25 regarding a concern that she had expressed about her cares the previous evening… R35 had stated that LPN K (Licensed Practical Nurse) had come into her room to complete her skin assessment check as part of her admission to the health and rehab center on the PM shift of 6/25/25. She stated that she was lying in bed. She stated that LPN K had put lotion on her arms and then proceeded to apply lotion to her legs and groin area. R35 stated she told LPN K that she was able to apply lotion to this area on her own. She stated that she felt uncomfortable with the cares being provided so she asked LPN K to get a female nurse or caregiver to assist her instead. She stated that LPN K told her “I’m the nurse and I have to do this.” R35 stated that the interaction made her feel uncomfortable and she described that while LPN K was putting lotion on her upper thighs and groin area that his fingers touched her vagina. She explained that there was nothing inserted into her vagina during the interaction. R35 reported that she feels safe at the health and rehab center. She has requested to not have LPN K or other male nurses, caregivers, or therapists assist her with peri cares. She stated she would not like to work with LPN K in the future during her rehab stay. This writer updated DON B (Director of Nursing) and ANHA F (Assistant Nursing Home Administrator) of this care concern after interviewing R35 on 6/26/25… On 7/24/25 at 9:00 AM LPN N indicated she had concerns that the facility’s management is not following the abuse policy and procedures. LPN N indicated an incident occurred with R35 and LPN K. LPN N indicated R35 claimed LPN K was applying lotion to her vagina and she asked him to go get a female caregiver. LPN N indicated R35 and RR P reported this to her. LPN N indicated RR P stated to her that R35 was afraid she would get raped. LPN N indicated she was not asked to write a statement when she reported it to the management team, LPN K was never taken off of the floor and left working independently with other vulnerable residents. LPN N also indicated she did not think the facility reported the incident to the state agency or the local law enforcement. On 7/28/25 at 9:28 AM RR P (Resident representative) indicated the LPN K was putting lotion on R35 and put it between her legs and came in contact with her labia. RR P indicated R35 asked LPN K to stop and get a female caregiver to assist her, but LPN K stated that he was the nurse and he continued to assist her. RR P indicated she and R35 reported this to the facility together and they did not understand why he was going down there when the dry skin was on her arms and legs and they did not understand why he did not stop when R35 asked him to find a female caregiver. On 7/28/25 at 10:43 AM SW G (Social Worker) indicated a concern of unwanted touching by a staff member in a private area could be an allegation of abuse. SW G indicated the facility policy is that all allegations of abuse or neglect will be reported to the state agency and if there is suspicion of a crime being committed then the facility would notify the police. SW G indicated that unwanted touching in a private area could be a crime. On 7/28/25 at 11:22 AM NHA A (Nursing Home Administrator) indicated when staff receive an allegation of abuse the management team will conduct some initial interviews to see if abuse really occurred. NHA A indicated then the facility will report if necessary. NHA A indicated the facility policy is that all allegations of abuse or neglect are to be reported to the state agency within 2 hours but not to exceed 24 hours. NHA A indicated all allegations means all allegations, not just the substantiated allegations. NHA A indicated unwanted touching of a person in their private area could be sexual abuse. NHA A indicated when a resident asks staff to stop they should stop. NHA A reviewed R35’s grievance and stated, “Given the initial information this could be an allegation of abuse and would require report to the state agency.” On 7/28/25 at 1:12 PM RN Q indicated a concern related to a staff member touching a resident in a private area when they did not want to be is an allegation of abuse. RN Q indicated when a resident asks for another caregiver, staff should stop and get another caregiver. On 7/28/25 at 3:25 PM LPN K indicated while he was completing an initial skin assessment and applying lotion to R35’s body she asked him to get a female caregiver. LPN K indicated this was R35’s first day/night in the facility. LPN K indicated at one point during his assessment, R35 said she doesn’t feel comfortable with LPN K and asked him to get a female nurse. LPN K indicated he told R35 that he is the only nurse on this floor and continued to finish his assessment and apply lotion to resident. LPN K indicated R35 stated she had to use the bathroom. LPN K assisted R35 to a seated position on her bed when another male CNA walked into the room. LPN K indicated he did not tell the second male caregiver that R35 requested a female to assist her. LPN K indicated the second male CNA and LPN K assisted R35 into the bathroom. Then LPN K indicated he left the room and the male CNA finished assisting R35. LPN K indicated he should have stopped when R35 asked for a female caregiver and he should have gotten a female CNA to assist R35 to the bathroom. LPN K indicated CNAs can apply lotion and there were female CNAs working at the time of the incident. LPN K indicated he did not report to management that R35 told him she was uncomfortable and requested a female nurse. LPN K indicated it could be intimidating to R35 that 2 male caregivers were in the room after she verbalized she was uncomfortable and requested a female caregiver during her assessment. On 7/28/25 at 4:21 PM DON B and ADON E indicated they were unaware when LPN K did not stop providing cares when R35 stated she was uncomfortable, a second male caregiver entered R35’s room so two male caregivers were present. DON B and ADON E indicated this could have been intimidating to R35. (It is important to note facility staff indicated a complaint voiced regarding a staff member touching a resident in a private area when she has asked them to stop is an allegation of sexual abuse and the facility provided no evidence of this allegation of sexual abuse being reported to the state agency.) Example 4 R60 admitted to the facility on [DATE] with the following diagnoses: need for assistance with personal care, cerebral infarction, unsteady on feet, and mild cognitive impairment. R60’s concern/grievance form, dated 6/21/25, includes: person submitting concern: CNA O (Certified Nursing Assistant)… ADON E (Assistant Director of Nursing) obtained verbal statement at time of incident from CNA O and RN S. CNA O concerned RN S raised her voice at R60. R60 was yelling out, staff unable to calm R60. RN S admits to yelling… No harm to R60 reported. RN S admits to raising voice at R60… On 7/24/25 at 9:00 AM LPN N indicated she had concerns that the facility’s management is not following the abuse policy and procedures. LPN N indicated CNA O called DON B (Director of Nursing) in the middle of the night to report RN S verbally abused R60 and DON B did not report this to the state agency and did not remove RN S from the floor to protect R60 and other residents. On 7/24/25 at 1:18 PM CNA O stated, “I observed verbal abuse. It was a little busy at night. I had a call light or two on. I saw R60’s call light on and I was trying to get down to her. I heard the wall shake as RN S slammed the door shut. She then slammed the bathroom door too. I knocked and opened the door. RN S was shouting and screaming at R60.” CNA O indicated RN S was saying to R60, “Get up out of this bed,” and she was using a loud voice of authority. CNA O stated, “She took the blanket from the patient, threw it on the floor, and spilled her water. The patient was calling out for help. We were only 45 minutes into our shift. We just started. I don’t know why she was so worked up. I asked her if she needed help. The patient looked panicked. I told RN S I need you to leave the room three times. The third time, I told her to leave, I said you are abusing the patient and I need you to leave right now. I will assist the patient.” CNA O indicated RN S continued to work through the shift and was not removed from patient care pending an investigation. CNA O indicated this incident was not reported, was not investigated, and she does not understand why the facility does not follow the abuse policy. On 7/24/25 at 1:43 PM ADON E and DON B indicated they take turns being on call for the health and rehab center. ADON E indicated around midnight she received a call from CNA O who reported RN S raised her voice at a resident and looked frazzled so CNA O had to take over cares. ADON E indicated CNA O reported that RN S lost her patience, yelled at R60, and she asked RN S to leave. ADON E indicated then she called and spoke with RN S who stated that she used a loud, stern voice but R60 was safe. ADON E indicated R60 has some cognitive impairment and was not able to recall the incident. DON B indicated RN S was not removed from the floor pending an investigation and that statements were not collected by other staff or residents regarding this incident. DON B indicated RN S continued to work with residents and the allegation of verbal abuse was not reported to the state agency. DON B and ADON E indicated a staff member raising her voice at a resident, yelling at a resident, intimidating a resident, or using a loud stern voice with a resident could be an allegation of abuse and should be reported to the state agency within 2 hours. On 7/28/25 at 10:43 AM SW G (Social Worker) indicated a concern of a staff yelling at a resident could be an allegation of abuse. SW G indicated the facility policy is that all allegations of abuse or neglect will be reported to the state agency. On 7/28/25 at 11:22 AM NHA A (Nursing Home Administrator) indicated when staff receive an allegation of abuse the management team will conduct some initial interviews to see if abuse really occurred. NHA A indicated then the facility will report if necessary. NHA A indicated the facility policy is that all allegations of abuse or neglect are to be reported to the state agency within 2 hours but not to exceed 24 hours. NHA A indicated all allegations means all allegations, not just the substantiated allegations. NHA A indicated a concern of a staff member yelling at a resident, pulling a blanket off and throwing it on the floor, and slamming doors could an allegation of abuse. On 7/28/25 at 1:12 PM RN Q indicated a concern related to a staff member yelling at a resident, using a loud and stern voice, slamming doors, and taking a blanket off a resident and throwing it on the floor is an allegation of abuse. (It is important to note facility staff indicate a complaint voiced regarding a staff member yelling at, pulling a blanket off without notice and tossing it to the floor, slamming resident doors, and/or intimidating a resident could be an allegation of abuse and the facility provided no evidence of this allegation of verbal/mental abuse being reported to the state agency.) Example 5 R62 admitted to the facility on [DATE] with the following diagnoses: need for assistance with personal care, generalized anxiety disorder, type 2 diabetes mellitus, polyneuropathy, and acute kidney failure. R62’s grievance/concern form, dated 4/14/25, includes: (R62’s representative named) reported that the day he admitted he asked (LPN K) after 3:00 PM to please help move him from the wheelchair to the edge of the bed so he could stretch his legs. He had been in the wheelchair since he left the hospital at noon. (LPN K) responded that he was the nurse and this was not his role. On 7/24/25 at 1:43 PM DON B and ADON E indicated a concern of a staff member refusing to assist a resident is an allegation of neglect and should be reported to the state agency within 2 hours of becoming aware. On 7/28/25 at 10:43 AM SW G (Social Worker) indicated a concern of a staff member refusing services could be an allegation of neglect. SW G indicated the facility policy is that all allegations of abuse or neglect will be reported to the state agency. On 7/28/25 at 11:22 AM NHA A (Nursing Home Administrator) indicated when staff receive an allegation of abuse the management team will conduct some initial interviews to see if abuse really occurred. NHA A indicated then the facility will report if necessary. NHA A indicated the facility policy is that all allegations of abuse or neglect are to be reported to the state agency within 2 hours but not to exceed 24 hours. NHA A indicated all allegations means all allegations, not just the substantiated allegations. NHA A indicated a concern of a staff member refusing goods or services could be an allegation of neglect. On 7/28/25 at 1:12 PM RN Q indicated a concern related to a staff member refusing to assist a resident could be neglect. (It is important to note facility staff indicate a complaint voiced regarding a staff member refusing to provide care could be an allegation of neglect and the facility provided no evidence of R62’s allegation of neglect being reported to the state agency.) Example 6 R61 admitted to the facility on [DATE] with the following diagnoses: congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, emphysema, and need for assistance with personal care. R61’s grievance/concern form, dated 1/14/25, includes: R61 states (Certified Nursing Assistant named) was very rough with her during evening cares. On 7/24/25 at 1:43 PM DON B and ADON E indicated a concerns of a staff member being very rough during cares could be an allegation of neglect and should be reported to the state agency. DON B indicated the facility policy is that all allegations of abuse and/or neglect are reported to the state agency within 2 hours of becoming aware. On 7/28/25 at 10:43 AM SW G (Social Worker) indicated a concern of a staff member being very rough during cares could be an allegation of abuse. SW G indicated the facility policy is that all allegations of abuse or neglect will be reported to the state agency. On 7/28/25 at 11:22 AM NHA A (Nursing Home Administrator) indicated when staff receive an allegation of abuse the management team will conduct some initial interviews to see if abuse really occurred. NHA A indicated then the facility will report if necessary. NHA A indicated the facility policy is that all allegations of abuse or neglect are to be reported to the state agency within 2 hours but not to exceed 24 hours. NHA A indicated all allegations means all allegations, not just the substantiated allegations. NHA A indicated a concern of a staff member being very rough during cares could be an allegation of abuse and he would want to know more information about the word rough. On 7/28/25 at 1:12 PM RN Q indicated a concern related to a staff member being very rough during cares is an allegation of abuse. (It is important to note facility staff indicate a complaint voiced regarding a staff member being very rough while providing cares could be an allegation of abuse and the facility provided no evidence of R61’s allegation of abuse being reported to the state agency.)

Based on interview and record review, the facility did not ensure a thorough investigation of abuse/exploitation was completed for 1 of 1 sampled Residents (R1) and 4 of 4 supplemental Residents (R35, R61, R62 and R60) reviewed for abuse. Facility became aware of an abuse allegation involving R1 on 12/4/24 and 7/14/25 and failed to complete a thorough investigation. R35 and R35’s Resident representative (RR P) used the concerns/grievance process to voice a concern regarding unwanted touching of her vaginal area by LPN K (Licensed Practical Nurse) even after she asked him to stop. The facility failed to conduct a thorough investigation of the incident. CNA O (Certified Nursing Assistant) heard RN S (Registered Nurse) yelling at R60 and intervened. CNA O observed RN S pull R60’s blanket off without warning and throw it on the floor. CNA O observed RN S slam R60’s room door and bathroom door. CNA O reported the allegation of verbal abuse/mental abuse to DON B (Director of Nursing). The facility did not conduct a thorough investigation of the incident. R62’s representative used the facility’s grievance process to voice a concern of a staff member refusing to provide care for R62. The facility did not conduct a thorough investigation of the incident. R61 used the facility’s grievance process to voice a concern of a staff member being very rough with her during cares. The facility failed to conduct a thorough investigation, including gathering statements from other staff or other residents who may have had information regarding the incident. Evidenced by: The facility policy entitled “Abuse, Neglect, Misappropriation, Mistreatment, and Exploitation, Preventing, Investigating, and Mandatory Reporting Policy,” updated 8/25/2023, states, in part: …“Policy: It is the policy of Oakwood Village to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion, or misappropriation of resident property from abuse, corporal punishment, neglect, misappropriation of resident property, and exploitation… The Nursing Home Administrator or designee will report “abuse” to the state agency per State and Federal requirements… It is the policy of Oakwood Village that each resident will be free from “Abuse.”… The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention…1)Screening2)Training3)Prevention4)Identification5)Investigation6)Protection7)Reporting and Response… (5) Investigations Components:The first responsibility of the facility is to assure resident safety. In the event of an allegation of abuse, neglect, mistreatment, misappropriation of resident property, and exploitation made against a staff member, visitor, contractor, and/or family member, the facility shall take immediate steps to ensure the safety of the resident(s) and prevent the risk of future or further harm. Such steps shall minimally include:*Suspension of the staff member until investigation of the allegation is complete…*Examine the resident for any signs of injury, including a physical and/or psychosocial assessment as needed.a. All reports of suspected crime and/or alleged sexual abuse will be immediately reported to local law enforcement for additional investigation… (7) Reporting and Response Components:All personnel, residents, family members, visitors, etc., are expected to report incidents of, or suspected incidents of abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. Such reports must be made immediately to the Administrator and may be made without fear of retaliation from the facility or its staff…a. The facility will ensure that all allegations of abuse, including injuries of unknown source, neglect, mistreatment, misappropriation of resident property, and exploitation are reported to DQA.*For allegations of abuse or serious bodily injury, immediately, but not later than 2 hours after the allegation is made*For allegations that do not involve abuse or do not result in serious bodily injury, no later than 24 hours. Submit the Misconduct Incident Report to: Department of Health Services…” Example 1:R1 was admitted to facility on 1/2/24 and has diagnoses that include mild cognitive impairment, anxiety and depression. R1’s Concern Form, dated 12/4/24, states, in part: …“What is your concern(s) about? Care Provided.When did your concern happen? 12/2 PM shift…Investigation details: R1 states that RN D (Registered Nurse) “Threw a pill in her mouth after dinner time and told me I need to learn how to control myself.”Summary of the pertinent findings or conclusions: Staff member reports the accusation were false and investigation were done with some inconsistence.Corrective action or resolution: Education and training on customer service and medication administration relating to customer service. Dated 12/12/24.”On 7/28/25, at 10:05 AM, DON B indicated to Surveyor regarding the abuse allegations that it is what the resident says it is, and DON B believes the residents. Surveyor asked DON B, looking at the concern form dated 12/4/24 when R1 indicates nurse threw a pill in her mouth and told her she needed to learn how to control herself, could that be considered an allegation of abuse. DON B indicated yes an allegation, not abuse. DON B indicated it should have been reported along with all allegations of abuse should be reported and investigated.On 7/28/25, at 11:23 AM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A indicated the facility would investigate whoever is involved with the concern and then it is decided if it is reportable, or it the concern goes as a grievance. Surveyor asked if staff should follow the facility’s abuse policy and NHA A indicated yes. R1’s incident was not thoroughly investigated. Example 2R1’s Concern Form, dated 7/14/25, states, in part: …“What is your concern(s) about? Care Provided.When did your concern happen? On 7/14/25…How can we make this situation better for you? “I don’t want the cna (certified nursing assistant) in my room again.” …Investigation details: AM floor nurse stated R1 mentioned that the med tech gave her the bruise. After speaking with R1, she mentioned that it was a cna that did it that morning. NOC (night) shift cna and nurse stated they had seen the bruise during shower prior to the morning R1 was explaining it happened. Stated R1 was wobbly in the shower. Stated she almost fell…” R1’s interview, undated, states: “R1 stated the cna had kept encouraging her to change her clothing on her own. R1 stated that the cna was helping her lean up from sitting to change and grabbed her hand. She said that the cna grabbing her hand to pull her up-right is what caused the bruise…” R1’s progress note, dated 7/14/25 at 10:06AM, states, in part: … “CNA stated that the resident has a bruise to her left hand. CNA also stated that “The resident says that I caused the bruise by being rough with her… Writer went and assessed a medium sized bruise to the resident’s left hand with a pain rated at a 9/10… Client stated that the med tech was the one who caused the bruise… On 7/24/25, at 1:23PM, Surveyor interviewed DON B (Director of Nursing) and ADON E (Assistant Director of Nursing). ADON E indicated it was reported to her by a cna that there was a bruise on R1’s hand from a staff member that hurt her. ADON E indicated R1 indicated to her that R1 had a falling out with a staff member and had received this bruise. R1 informed ADON E that a cna was helping her that morning and grabbed her hand and now she has a bruise. Surveyor asked ADON E when this was reported to her and ADON E indicated 7/14/25 between 8:00AM – 9:00AM. ADON E indicated she had reported it to DON B right away. DON B then indicated to Surveyor that ADON E, ANHA (Assistant Nursing Home Administrator) and herself went to R1 right away. R1 had indicated a staff member was trying to help her and was holding her hand and gave her a bruise and then R1 also indicated someone was trying to catch her from falling in the shower. Surveyor asked DON B and ADON E if that could be an allegation of abuse and if “being rough” as was documented in R1’s progress notes could be an allegation of abuse. DON B indicated yes. Surveyor asked DON B if an allegation of abuse should be reported to state and investigated and DON B indicated yes and it had not been reported. On 7/28/25, at 10:46AM, Surveyor interviewed SW G (Social Worker) who indicated the grievance process as once a concern form is received and reviewed, the ANHA and DON B come together and make a decision whether or not to submit to the state the concern. Surveyor asked if “being rough” could be an allegation of abuse and SW G indicated yes. Surveyor asked if grabbing a resident’s hand and pulling could be an allegation of abuse and SW G indicated it could. Surveyor asked SW G if allegations of abuse should be reported to the state and investigated and SW G indicated yes. On 7/28/25, at 11:23 AM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A indicated the facility would investigate whoever is involved with the concern and then it is decided if it is reportable, or it the concern goes as a grievance. Surveyor asked if staff should follow the facility’s abuse policy and NHA A indicated yes. R1’s incident was not thoroughly investigated. Example 3 R35 admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease with exacerbation, chronic respiratory failure, peripheral vertigo, and need for assistance with personal care. R35’s most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 7/1/25 indicates R35’s cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. R35’s concern/grievance form, dated 6/26/25, includes: this writer spoke with R35 and R35’s representative on 6/26/25 regarding a concern that she had expressed about her cares the previous evening… R35 had stated that LPN K (Licensed Practical Nurse) had come into her room to complete her skin assessment check as part of her admission to the health and rehab center on the PM shift of 6/25/25. She stated that she was lying in bed. She stated that LPN K had put lotion on her arms and then proceeded to apply lotion to her legs and groin area. R35 stated she told LPN K that she was able to apply lotion to this area on her own. She stated that she felt uncomfortable with the cares being provided so she asked LPN K to get a female nurse or caregiver to assist her instead. She stated that LPN K told her “I’m the nurse and I have to do this.” R35 stated that the interaction made her feel uncomfortable and she described that while LPN K was putting lotion on her upper thighs and groin area that his fingers touched her vagina. She explained that there was nothing inserted into her vagina during the interaction. R35 reported that she feels safe at the health and rehab center. She has requested to not have LPN K or other male nurses, caregivers, or therapists assist her with peri cares. She stated she would not like to work with LPN K in the future during her rehab stay. This writer updated DON B (Director of Nursing) and ANHA F (Assistant Nursing Home Administrator) of this care concern after interviewing R35 on 6/26/25… On 7/24/25 at 9:00 AM LPN N indicated she had concerns that the facility’s management is not following the abuse policy and procedures. LPN N indicated an incident occurred with R35 and LPN K. LPN N indicated R35 claimed LPN K was applying lotion to her vagina and she asked him to go get a female caregiver. LPN N indicated R35 and RR P reported this to her. LPN N indicated RR P stated to her that R35 was afraid she would get raped. LPN N indicated she was not asked to write a statement when she reported it to the management team, LPN K was never taken off of the floor and left working independently with other vulnerable residents. LPN N also indicated she did not think the facility conducted an investigation into the incident. On 7/28/25 at 9:28 AM RR P (Resident representative) indicated the LPN K was putting lotion on R35 and put it between her legs and came in contact with her labia. RR P indicated R35 asked LPN K to stop and get a female caregiver to assist her, but LPN K stated that he was the nurse and he continued to assist her. RR P indicated she and R35 reported this to the facility together and they did not understand why he was going down there when the dry skin was on her arms and legs and they did not understand why he did not stop when R35 asked him to find a female caregiver. On 7/28/25 at 10:43 AM SW G (Social Worker) indicated a concern of unwanted touching by a staff member in a private area could be an allegation of abuse. SW G indicated staff should stop when a resident asks them to stop. SW G indicated the facility policy is that all allegations of abuse or neglect will be thoroughly investigated. SW G indicated no other residents were interviewed regarding the incident and no other staff members who were working this day were interviewed regarding the incident. SW G indicated LPN K was not pulled from working with residents pending an investigation. On 7/28/25 at 11:22 AM NHA A (Nursing Home Administrator) indicated the facility is to conduct a thorough investigation for all allegations of abuse and neglect. NHA A indicated a thorough investigation will contain interviews by staff and residents who may have knowledge related to allegation. On 7/28/25 at 3:25 PM LPN K indicated while he was completing an initial skin assessment and applying lotion to R35’s body she asked him to get a female caregiver. LPN K indicated this was R35’s first day/night in the facility. LPN K indicated at one point during his assessment, R35 said she doesn’t feel comfortable with LPN K and asked him to get a female nurse. LPN K indicated he told R35 that he is the only nurse on this floor and continued to finish his assessment and apply lotion to resident. LPN K indicated R35 stated she had to use the bathroom. LPN K assisted R35 to a seated position on her bed when another male CNA walked into the room. LPN K indicated he did not tell the second male caregiver that R35 requested a female to assist her. LPN K indicated the second male CNA and LPN K assisted R35 into the bathroom. Then LPN K indicated he left the room and the male CNA finished assisting R35. LPN K indicated he should have stopped when R35 asked for a female caregiver and he should have gotten a female CNA to assist R35 to the bathroom. LPN K indicated CNAs can apply lotion and there were female CNAs working at the time of the incident. LPN K indicated he did not report to management that R35 told him she was uncomfortable and requested a female nurse. LPN K indicated it could be intimidating to R35 that 2 male caregivers were in the room after she verbalized she was uncomfortable and requested a female caregiver during her assessment. On 7/28/25 at 4:21 PM DON B and ADON E indicated they were unaware when LPN K did not stop providing cares when R35 stated she was uncomfortable, a second male caregiver entered R35’s room so two male caregivers were present. DON B and ADON E indicated this could have been intimidating to R35. (It is important to note facility staff indicated a complaint voiced regarding a staff member touching a resident in a private area when she has asked them to stop is an allegation of sexual abuse and the facility provided no evidence of a thorough investigation being completed including interviews by other residents and other staff. It is important to note the facility did not remove LPN K from working with residents pending an investigation.) Example 4 R60 admitted to the facility on [DATE] with the following diagnoses: need for assistance with personal care, cerebral infarction, unsteady on feet, and mild cognitive impairment. R60’s concern/grievance form, dated 6/21/25, includes: person submitting concern: CNA O… ADON E (Assistant Director of Nursing) obtained verbal statement at time of incident from CNA O and RN S. CNA O concerned RN S raised her voice at R60. R60 was yelling out, staff unable to calm R60. RN S admits to yelling… No harm to R60 reported. RN S admits to raising voice at R60… On 7/24/25 at 9:00 AM LPN N (Licensed Practical Nurse) indicated she had concerns that the facility’s management is not following the abuse policy and procedures. LPN N indicated CNA O called DON B (Director of Nursing) in the middle of the night to report RN S verbally abused R60 and DON B did not remove RN S from the floor to protect R60 and other residents. On 7/24/25 at 1:18 PM CNA O (Certified Nursing Assistant) stated, “I observed verbal abuse. It was a little busy at night. I had a call light or two on. I saw R60’s call light on and I was trying to get down to her. I heard the wall shake as RN S slammed the door shut. She then slammed the bathroom door too. I knocked and opened the door. RN S was shouting and screaming at R60.” CNA O indicated RN S was saying to R60. “Get up out of this bed,” and she was using a loud voice of authority. CNA O stated, “She took the blanket from the patient, threw it on the floor, and spilled her water. The patient was calling out for help. We were only 45 minutes into our shift. We just started. I asked her if she needed help. The patient looked panicked. I told RN S ‘I need you to leave the room’ three times. The third time, I told her to leave, I said you are abusing the patient and I need you to leave right now. I will assist the patient.” CNA O indicated RN S continued to work through the shift and was not removed from patient care pending an investigation. CNA O indicated she was not asked to write a statement regarding the incident. CNA O indicated this incident was not investigated and she does not understand why the facility does not follow the abuse policy. On 7/24/25 at 1:43 PM ADON E (Assistant Director of Nursing) and DON B indicated they take turns being on call for the health and rehab center. ADON E indicated around midnight she received a call from CNA O who reported RN S raised her voice at a resident and looked frazzled so CNA O had to take over cares. ADON E indicated CNA O reported that RN S lost her patience, yelled at R60, and she asked RN S to leave. ADON E indicated then she called and spoke with RN S who stated that she used a loud, stern voice but R60 was safe. ADON E indicated R60 has some cognitive impairment and was not able to recall the incident. DON B indicated RN S was not removed from the floor pending an investigation and that statements were not collected by other staff or residents regarding this incident. DON B indicated RN S continued to work with residents. ADON E and DON B indicated the facility’s policy is that all allegations of abuse and/or neglect are thoroughly investigated. ADON E indicated she was unsure what makes a thorough investigation. On 7/28/25 at 10:43 AM SW G (Social Worker) indicated a concern of a staff yelling at a resident could be an allegation of abuse. SW G indicated the facility policy is that all allegations of abuse or neglect will be thoroughly investigated. SW G indicated no other residents or staff were interviewed regarding the incident. On 7/28/25 at 11:22 AM NHA A (Nursing Home Administrator) indicated the facility policy is that all allegations of abuse or neglect are to be thoroughly investigated. NHA A indicated a concern of a staff member yelling at a resident, pulling a blanket off and throwing it on the floor, and slamming doors could an allegation of abuse. (It is important to note facility staff indicate a complaint voiced regarding a staff member yelling at, pulling a blanket off without notice and tossing it to the floor, slamming resident doors, and/or intimidating a resident could be an allegation of abuse and the facility provided no evidence of this allegation being thoroughly investigated. It is also important to note RN S was not removed from working with residents pending an investigation.) Example 5 R62 admitted to the facility on [DATE] with the following diagnoses: need for assistance with personal care, generalized anxiety disorder, type 2 diabetes mellitus, polyneuropathy, and acute kidney failure. R62’s grievance/concern form, dated 4/14/25, includes: (R62’s representative named) reported that the day he admitted he asked (LPN K (Licensed Practical Nurse)) after 3:00 PM to please help move him from the wheelchair to the edge of the bed so he could stretch his legs. He had been in the wheelchair since he left the hospital at noon. (LPN K) responded that he was the nurse, and this was not his role. On 7/24/25 at 1:43 PM ADON E (Assistant Director of Nursing) and DON B (Director of Nursing) indicated the facility’s policy is that all allegations of abuse and/or neglect are thoroughly investigated. ADON E indicated she was unsure what makes a thorough investigation. DON B indicated a concern of an RN refusing to assist a resident is an allegation of neglect. On 7/28/25 at 10:43 AM SW G (Social Worker) indicated a concern of a staff member refusing services could be an allegation of neglect. SW G indicated the facility policy is that all allegations of abuse or neglect will be reported to the state agency. (It is important to note facility staff indicate a complaint voiced regarding a staff member refusing to provide care could be an allegation of neglect and the facility provided no evidence of R62’s allegation of neglect being thoroughly investigated. It is also important to note LPN K was not removed from working with residents pending an investigation.) Example 6 R61 admitted to the facility on [DATE] with the following diagnoses: congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, emphysema, and need for assistance with personal care. R61’s grievance/concern form, dated 1/14/25, includes: R61 states (Certified Nursing Assistant named) was very rough with her during evening cares. On 7/24/25 at 1:43 PM ADON E (Assistant Director of Nursing) and DON B (Director of Nursing) indicated a concern of a staff member being very rough during cares could be an allegation of abuse. DON B and ADON E indicated the facility’s policy is that all allegations of abuse and/or neglect are thoroughly investigated. ADON E indicated she was unsure what makes a thorough investigation. On 7/28/25 at 10:43 AM SW G (Social Worker) indicated a concern of a staff member being very rough during cares could be an allegation of abuse. SW G indicated the facility policy is that all allegations of abuse or neglect will be reported to the state agency. On 7/28/25 at 11:22 AM NHA A (Nursing Home Administrator) indicated NHA A indicated a concern of a staff member being very rough during cares could be an allegation of abuse and he would want to know more information about the word rough. NHA A indicated the facility policy is that all allegations of abuse or neglect would be thoroughly investigated. On 7/28/25 at 1:12 PM RN Q (Registered Nurse) indicated a concern related to a staff member being very rough during cares is an allegation of abuse. (It is important to note facility staff indicate a complaint voiced regarding a staff member being very rough while providing cares could be an allegation of abuse and the facility provided no evidence of R61’s allegation of abuse being thoroughly investigated, including other resident interviews or other staff interviews.) Cross reference F609

Based on record review and interview the facility did not complete the PASARR Level II (Preadmission Screening and Resident Review) when it was realized that 4 of 4 Residents (R3, R40, R6, & R14) would reside in the facility for more than 30 days. R3, R40, R6, and R14 were admitted to the facility with diagnoses that included a major mental disorder and were prescribed medication to treat symptoms of a major mental disorder. R3, R40, R6, and R14 resided in the facility for more than 30 days and no evidence was provided that a PASRR Level II Screen was completed for R3, R40, R6, and R14. Evidenced by: The Preadmission Screen and Resident Review Level 1 Screen directions include, in part, the following: 42 CFR 4830128(a) requires that the resident or his/her legal representative receive a written notice (copy of this front page) if the resident is suspected of having a serious mental illness or a developmental delay, and therefore, will require a Level II Screen. You may tell the resident or his/her legal representative that the Level II Screen will determine if the resident does have a serious mental illness or developmental disability, as defined in the federal regulations, and if so, if the resident is appropriate for nursing facility placement and if the resident needs specialized services or specialized psychiatric rehabilitative services to address his/her disability needs…The following situations, which are all for short-term admissions, are the only exemptions from Level II Screening… Hospital Discharge Exemption- 30 Day Maximum If, during the short term stay, it is established that the person will be staying for a longer period of time than permitted above, the person must be referred for a Level II Screen on or before the last day of the permitted time period…” Facility policy, titled Admission, Transfer, Discharge, includes, in part: All new admissions and readmissions are screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid Pre-admission Screening and Resident Review process. The facility conducts a Level 1 PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets criteria… Example 1 R3 admitted to the facility on [DATE]. Her diagnoses include Major Depressive Disorder and Anxiety Disorder. R3’s PASRR, dated 2/27/25, includes: Does the person have a major mental disorder: No… Has the person received psychotropic medications to treat symptoms or behaviors of a major mental disorder: Yes… Medication List: Mirtazapine, Buspirone… Hospital Discharge 30 day exemption: Yes… R3’s Physician Orders, dated 7/11/25, include: Buspirone HCl 5mg give one tablet by mouth every morning for mood/anxiety… Mirtazapine 15 mg give one tablet by mouth at bedtime for mood/depression. R3 still resides in the facility on 7/24/25. It is important to note this is more than 30 days since admission. On 7/29/25 at 9:47 AM SW G and SW H indicated R3 should have had a level 2 screen completed when the facility realized she was going to be staying for longer than 30 days. On 7/29/25 at 1:03 PM ANHA F (Assistant Nursing Home Administrator) indicated there was a change of staff in the social workers department and the responsibility of the PASRR program was not picked back up by another staff member, but the facility will sweep the house and make sure all are up to date. ANHA F indicated R3’s PASRR level 2 should have been completed when she stayed in the facility for longer than 30 days. Example 2 R40 admitted to the facility on [DATE]. Her diagnoses includes: Major Depressive Disorder and Anxiety Disorder. R40’s PASRR, dated 6/18/25, includes: Does the person have a major mental disorder: Yes… Has the person received psychotropic medications to treat symptoms or behaviors of a major mental disorder: Yes… Medication List: Wellbutrin, Clonazepam… Hospital Discharge 30 day exemption: Yes… R40’s current Physician Orders, dated 7/7/25, includes: bupropion HCl give one tablet by mouth one time a day for Major Depressive Disorder… Clonazepam 0.5mg give one tablet by mouth one time a day for anxiety… R40 still resides in the facility on 7/24/25. It is important to note this is more than 30 days since admission. On 7/29/25 at 9:47 AM SW G and SW H indicated R40 should have had a level 2 screen completed when the facility realized she was going to be staying for longer than 30 days. On 7/29/25 at 1:03 PM ANHA F indicated there was a change of staff in the social workers department and the responsibility of the PASRR program was not picked back up by another staff member, but the facility will sweep the house and make sure all are up to date. ANHA F indicated R40’s PASRR level 2 should have been completed when she stayed in the facility for longer than 30 days. Example:3 R6 was admitted to the facility on [DATE] with diagnoses that include major depressive disorder. R6’s Physician Orders, dated 7/25/25, states, in part: … “-Duloxetine HCI (hydrochloride) Capsule Delayed Release Particles 20 mg (milligrams)- Give 1 capsule by mouth in the morning for depression… -Haloperidol Tablet 1 mg- Give 1 tablet by mouth every 4 hours as needed for delirium, agitation, hospice care, restlessness…” R6’s PASRR Level I Screen was completed on 3/27/25 and indicated that R6 has a major mental disorder and is on medication to treat symptoms or behaviors of a major mental disorder. This screen also indicates that R6 is a person entering the nursing facility from the hospital for the purpose of convalescing from a medical problem for 30 days or less. R6 still resides at the facility on 7/29/25, more than the maximum 30 days exemption. Example 4: R14 was admitted to the facility on [DATE] and has diagnoses that include delirium due to known physiological condition. R14’s Physicians Orders, dated 7/11/25, state, in part: … “-Trazodone HCI Oral Tablet 100 mg- Give 1 tablet by mouth at bedtime for insomnia…” R14’s PASRR Level I Screen was completed on 12/23/24 and indicated that R14 has a major mental disorder and is on medication to treat symptoms or behaviors of a major mental disorder. Medications: Seroquel- Delirium and Trazodone- Insomnia. This screen also indicates that R14 is a person entering the nursing facility from the hospital for the purpose of convalescing from a medical problem for 30 days or less. R14 still resides at the facility on 7/29/25, more than the maximum 30 days exemption. On 7/29/25, at 9:51AM, Surveyor interviewed SW H (Social Worker) and SW G. SW H indicated R6 had Level I PASRR completed on 3/27/25 and R6 needs a Level II completed. SW G indicated the Level II should have been completed by 4/27/25. SW G indicated they had a shift in staff as the old social worker moved to assisted living and SW H was on a FMLA (Family Medical Leave Absence) and the PASRR Level II for R6 got missed along with others. On 7/29/25, at 1:00PM, Surveyor interviewed ANHA (Assistant Nursing Home Administrator) who indicated he would expect staff to follow the facility’s PASRR policy. At 1:30PM, ANHA indicated R14 should have had another PASRR completed at the end of the exemption due to the facility is to look at past and current history.

Number of residents sampled: 12Number of residents cited:1Based on record review and interview, the facility failed to ensure resident's advanced directives were accurate and up to date in the resident's electronic medical records for 1 of 12 residents (R20) reviewed for advanced directives.R20's CPR (Cardiopulmonary Resuscitation) preference form indicated he wanted CPR attempts and R20's electronic medical record reflected he was a DNR (Do Not Resuscitate).This is evidenced by:The facility's policy titled Advance Directives, dated 9/22, includes the following: The resident has the right to formulate an advance directive. 2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff. The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the resident's medical record and plan of care. The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan.R20 admitted to the facility on [DATE].R20's Resident CPR Preference Form states in part: Yes I want cardiopulmonary resuscitation (CPR) attempts. In the even that my heart and breathing should suddenly stop, I elect to have the facility staff to apply force to my chest with their hands, thus compressing the heart (chest compressions) and breathe into my mouth, filling my lungs with air (artificial respiration). The form was signed on [DATE] by R20 and a facility RN (Registered Nurse).On [DATE] at 3:29 PM, Surveyor spoke with RN L regarding R20's advance directives. RN L indicated R20's resident CPR preference form states R20 is a full code (wants CPR) and R20's electronic medical record indicated R20 is a DNR. RN L stated this was a discrepancy and indicated the resident's CPR preference should be reflected in the resident's electronic medical record.R20's physician orders printed on [DATE] include: DNR (Do Not Resuscitate). Order date [DATE]. Discontinue on [DATE].Of note, the DNR physician order was discontinued after Surveyor made staff aware of the discrepancy between the physician order and the resident CPR preference form.On [DATE] at 3:30 PM, Surveyor interviewed LPN K (Licensed Practical Nurse) regarding residents' advance directives. LPN K indicated a resident's code status is in the electronic health record and in the resident's hard chart. LPN K indicated the hard chart and electronic health record should match.On [DATE] at 12:45 PM, Surveyor interviewed RN M regarding residents' advance directives. RN M indicated residents' code stats is in the computer and the resident's hard chart. RN M indicated both locations should match.On [DATE] at 1:17 PM, Surveyor interviewed ADON E (Assistant Director of Nursing) regarding R20's advance directive. ADON E stated she discontinued R20's DNR physician order on [DATE] because she was given updated information. ADON E indicated on [DATE], she was made aware of the discrepancy between R20's physician orders and R20's CPR preference form. On [DATE] at 1:17 PM, Surveyor interviewed DON B (Director of Nursing) regarding R20's advance directives. DON B stated that once the facility became aware on [DATE] that R20 wanted to be a full code, the staff obtaining the new advance directive should have changed the order in the computer but did not. DON B indicated the resident's CPR preference and physician orders should match and R20's did not.

Based on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 6 supplemental residents (R41 and R63) reviewed for antibiotic stewardship. A UTI (urinary tract infection) was not documented on the line list for R63. The UTI that was documented had incomplete information. The facility did not obtain a C&S (culture and sensitivity) for R63's UA (urinalysis) results or complete a McGeer Criteria checklist to indicate if UTI criteria was met.There was incorrect documentation on the line list for R41 and the facility did not show that the antibiotic was necessary. This is evidenced by:The facility policy entitled Antibiotic Stewardship - Orders for Antibiotics, with a revision date of December 2016, states in part: Policy Statement: Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing.Policy Interpretation and Implementation:3. Appropriate indications for use of antibiotics include:a. criteria met for clinical definition of active infection or suspected sepsis; andb. pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending).5. If a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders.The facility policy entitled, Surveillance for Infections, with a revision date of April 2025, states in part: Policy Statement: The infection preventionist conducts ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative symptoms.Policy Interpretation and Implementation. 3. Infections that are included in routine surveillance include those with:a. Evidence of transmissibility in a healthcare environment; b. available processes and procedures that prevent or reduce the spread of infections; c. clinically significant morbidity or mortality associated with infection (e.g., pneumonia, UTIs, C. difficile); d. pathogens associated with serious outbreaks (e.g., invasive Streptococcus Group A, acute viral hepatitis, norovirus, scabies, influenza); and e. infections that are included in reporting requirements (i.e., acute respiratory illnesses and vaccination data).McGeer revised criteria indicates the following, in part: .Table 2. Urinary Tract Infection (UTI) Surveillance Definitions .UTI without indwelling catheter. Must fulfill both 1 AND 2.1. At least one of the following signs or symptoms.- Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate.- Fever or leukocytosis, and greater than or equal to 1 of the following:- Acute costovertebral angle pain or tenderness; suprapubic pain; gross hematuria; new or marked increase in incontinence; new of marked increase in urgency; new or marked increase in frequency.- If no fever or leukocytosis, then greater than or equal to 2 of the following:- Suprapubic pain; gross hematuria; new or marked increase in incontinence; new of marked increase in urgency; new or marked increase in frequency.2. At least one of the following microbiological criteria.- Greater than 10^5 cfu/ml (colony forming unit per milliliter) of no more than 2 species of organisms in a voided urine sample.- Greater than or equal to 10^2 cfu/ml of any organism(s) in a specimen collected by an in-and-out catheter. Example 1:R63 was admitted to the facility on [DATE] and discharged on 6/10/25 with diagnoses that include encounter for surgical aftercare following surgery on the circulatory system, cardiogenic shock (the heart cannot pump enough blood to meet the body's needs), and urinary tract infection. Surveyor reviewed R63's progress notes. On 5/25/25, a UA (urinalysis) was ordered because the resident's urine was cloudy and smelled malodorous and the resident described a ‘burning sensation when urinating.' A UA was collected on 5/26/25. Surveyor reviewed the UA and C&S (culture and sensitivity) results. Cefpodoxime Proxetil was ordered to be administered from 5/28/25-6/2/25.The facility completed a Revised McGeer Criteria for Infection Surveillance Checklist dated May 28. At the bottom of the form, UTI criteria met is checked.Of note: R63's symptoms do not meet McGeers criteria.On 6/6/25, a second UA was done by the lab and results showed a continued infection. Progress notes on 6/7/25 indicate no new orders were given yet, as the doctor was waiting on sensitivity results. Ciprofloxacin HCl was ordered on 6/9/25 for five days to treat R63's UTI.Surveyor requested documentation from the facility for this UTI. The facility did not provide a Revised McGeer Criteria for Infection Surveillance Checklist for this UTI. There are no progress notes discussing any symptoms to have a second UA done. The facility provided documentation for the UA collected on 6/6/25 but did not provide documentation for the C&S results to show that R63 received the correct antibiotic for treatment.On 7/29/25 at 10:30 AM, Surveyors interviewed DON B (Director of Nursing). DON B agreed that the line list was missing information. DON B said the information should be complete. DON B agreed that accurate surveillance cannot be done without accurate information.Example 2:R41 was admitted to the facility on [DATE] and discharged on 7/12/25 with diagnoses that include aftercare following joint replacement surgery, presence of right artificial hip joint, and anxiety disorder.Surveyor reviewed R41's progress notes.On 6/30/25 at 1:42 AM, a note reads as follows: .Pt [patient] stated that she had an episode of bowel incontinence that went into her virginal [sic] during the pm shift. She mentioned that, she had a shower, but still felt that, she has to go to the hospital to have flushes done to said area and also be placed on oral abx [antibiotic], as a prophylaxis for infection.[Doctor] stated that, he is not comfortable sending pt to the ER [emergency room] tonight.R41 went to the ED (emergency department) on 6/30/25. Surveyor reviewed the notes from R41's ED visit: Vitals reassuring. Skin exam shows surgical incision at right hip well healing, no erythema [skin redness] or fluctuance [swelling or fluid], no crepitus [crackling or grating sound when moving a joint] or eschar [dead tissue]. Labs reassuring.No clinical signs or symptoms of infection.UA [urinalysis] negative for infection. Patient unlikely to have skin infection.No signs of feces in vaginal vault. Patient likely had stool accident with concern for causing surgical incision infection. Will treat with prophylactic abx d/t [due to] patient concerns for infection.R41 had the following labs done during her ED visit: CBC (complete blood count) with Differential, Basic Metabolic Panel, and Urinalysis with Microscopy.Order: Cephalexin (Keflex) 500 mg / Details: Take one cap by mouth 4 times daily for 7 days.On 7/10/25 at 3:02 AM, a progress note reads as follow: Resident s/p [status post] abx therapy as a preventative measures [sic] for UTI [urinary tract infection].Surveyor reviewed the Revised McGeer Criteria for Infection Surveillance Checklist completed by the facility. Date of infection: 6/30/25. The following notes are handwritten: Hospital seen resident put her on cephalexin.Diagnosis for skin infection and concern for infection with hip replacement. At the bottom of the form, UTI criteria NOT met is checked with the following written note: Hospital provider education on meeting McGeer.The facility did not provide documentation on Table 4. Skin and Soft Tissue Infection (SSTI) Surveillance Definitions.Of note: there is no documentation pertaining to the facility discussing McGeer Criteria with the provider.Surveyor reviewed the July 2025 line list. The following is listed for R41 on the July 2025 line list (Note: the resident's name was grossly misspelled): admit date : [DATE] / Type of Infection: skin / Onset Date: 6/30/25 / Signs/Symptoms: n/a / Antibiotic Prescribed? Yes / Antibiotic Name or Medication: cephalexin 500 mg / Route: oral / Start date: 7/1/25 / End date: 7/7/25 / Precautions: standard / Organism: n/a / Criteria met? Yes / Facility or hospital acquired? Hospital / Labs: yes On 7/29/25 at 10:30 AM, Surveyors interviewed DON B and ADON E (Assistant Director of Nursing). Surveyors asked why there were no signs and symptoms documented on the line list. Surveyors also asked how the facility could say that criteria was met with no signs or symptoms documented. ADON E indicated R41 went to the hospital and was prescribed an antibiotic. DON B indicated the hospital paperwork said R41 had cellulitis. ADON E indicated that she updated the form with R41's signs and symptoms and asked if the surveyors wanted an updated copy of the line list. DON B said the information on the line list should be complete. DON B agreed that accurate surveillance cannot be done without accurate information.

Based on interviews and record review, the facility failed to protect the residents' right to be free from verbal abuse, mental abuse, and sexual abuse by staff for 2 of 8 Residents Reviewed for abuse (R35 and R60).R35 and R35's representative (RR P) used the concerns/grievance process to voice a concern regarding unwanted touching of her vaginal area by LPN K (Licensed Practical Nurse) even after she asked him to stop.CNA O (Certified Nursing Assistant) heard RN S (Registered Nurse) yelling at R60 and intervened. CNA O observed RN S pull R60's blanket off without warning and throw it on the floor. CNA O observed RN S slam R60's room door and bathroom door. CNA O reported the allegation of verbal abuse/mental abuse to DON B (Director of Nursing).Evidenced by:Facility's policy, titled Abuse, Neglect, Misappropriation, Mistreatment, Exploitation, Preventing, Investigating, and Mandatory Reporting, updated 8/25/23, includes: . this includes but is not limited to freedom from. abuse, neglect, exploitation, involuntary seclusion, or misappropriation of resident property, corporal punishment, neglect. Residents will not be abused by anyone, including but not limited to facility staff, other residents, consultants, volunteers, agency staff, family members, legal guardians, friends, or other individuals. Definitions: Verbal abuse is using oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to: threats of harm, saying things to frighten a resident. Sexual abuse is nonconsensual sexual contact with a resident, including harassment, inappropriate touching, and assault. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment, deprivation. It is the policy of the facility that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse.Example 1R35 admitted to the facility on [DATE] with a need for assistance with personal care.R35's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 7/1/25 indicates R35's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15.R35's concern/grievance form, dated 6/26/25, includes: this writer spoke with R35 and R35's representative on 6/26/25 regarding a concern that she had expressed about her cares the previous evening. R35 had stated that LPN K had come into her room to complete her skin assessment check as part of her admission to the health and rehab center on the PM shift of 6/25/25. She stated that she was lying in bed. She stated that LPN K had put lotion on her arms and then proceeded to apply lotion to her legs and groin area. R35 stated she told LPN K that she was able to apply lotion to this area on her own. She stated that she felt uncomfortable with the cares being provided so she asked LPN K to get a female nurse or caregiver to assist her instead. She stated that LPN K told her I'm the nurse and I have to do this. R35 stated that the interaction made her feel uncomfortable and she described that while LPN K was putting lotion on her upper thighs and groin area that his fingers touched her vagina. She explained that there was nothing inserted into her vagina during the interaction. R35 reported that she feels safe at the health and rehab center. She has requested to not have LPN K or other male nurses, caregivers, or therapists assist her with peri cares. She stated she would not like to work with LPN K in the future during her rehab stay. This writer updated DON B (Director of Nursing) and ANHA F (Assistant Nursing Home Administrator) of this care concern after interviewing R35 on 6/26/25. On 7/24/25 at 9:00 AM LPN N indicated she had concerns that the facility's management is not following the abuse policy and procedures. LPN N indicated an incident occurred with R35 and LPN K. LPN N indicated R35 claimed LPN K was applying lotion to her vagina and she asked him to go get a female caregiver. LPN N indicated R35 and RR P reported this to her. LPN N indicated RR P stated to her that R35 was afraid she would get raped. LPN N indicated she was not asked to write a statement when she reported it to the management team, LPN K was never taken off of the floor and left working independently with other vulnerable residents. LPN N also indicated she did not think the facility conducted an investigation into the incident. On 7/28/25 at 9:28 AM RR P (Resident representative) indicated the LPN K was putting lotion on R35 and put it between her legs and came in contact with her labia. RR P indicated R35 asked LPN K to stop and get a female caregiver to assist her, but LPN K stated that he was the nurse and he continued to assist her. RR P indicated she and R35 reported this to the facility together and they did not understand why he was going down there when the dry skin was on her arms and legs and they did not understand why he did not stop when R35 asked him to find a female caregiver. On 7/28/25 at 10:43 AM SW G (Social Worker) indicated a concern of unwanted touching by a staff member in a private area could be an allegation of abuse. SW G indicated staff should stop when a resident asks them to stop. On 7/28/25 at 11:22 AM NHA A (Nursing Home Administrator) indicated unwanted touching of a person in their private area could be sexual abuse. NHA A indicated when a resident asks staff to stop they should stop. NHA A reviewed R35's grievance and stated, Given the initial information this could be an allegation of abuse. On 7/28/25 at 1:12 PM RN Q indicated a concern related to a staff member touching a resident in a private area when they did not want to be is an allegation of abuse. RN Q indicated when a resident asks for another caregiver, staff should stop and get another caregiver. On 7/28/25 at 3:25 PM LPN K indicated while he was completing an initial skin assessment and applying lotion to R35's body she asked him to get a female caregiver. LPN K indicated this was R35's first day/night in the facility. LPN K indicated at one point during his assessment, R35 said she doesn't feel comfortable with LPN K and asked him to get a female nurse. LPN K indicated he told R35 that he is the only nurse on this floor and continued to finish his assessment and apply lotion to resident. LPN K indicated R35 stated she had to use the bathroom. LPN K assisted R35 to a seated position on her bed when another male CNA walked into the room. LPN K indicated he did not tell the second male caregiver that R35 requested a female to assist her. LPN K indicated the second male CNA and LPN K assisted R35 into the bathroom. Then LPN K indicated he left the room and the male CNA finished assisting R35. LPN K indicated he should have stopped when R35 asked for a female caregiver and he should have gotten a female CNA to assist R35 to the bathroom. LPN K indicated CNAs can apply lotion and there were female CNAs working at the time of the incident. LPN K indicated he did not report to management that R35 told him she was uncomfortable and requested a female nurse. LPN K indicated it could be intimidating to R35 that 2 male caregivers were in the room after she verbalized she was uncomfortable and requested a female caregiver during her assessment. On 7/28/25 at 4:21 PM DON B and ADON E (Assistant Director of Nursing) indicated they were unaware when LPN K did not stop providing cares when R35 stated she was uncomfortable, a second male caregiver entered R35's room so two male caregivers were present. DON B and ADON E indicated this could have been intimidating to R35.(It is important to note R35 asked LPN K to get a female caregiver because she was uncomfortable with the cares he was providing (rubbing lotion on her private area) and LPN K did not stop and did not get a female caregiver. It is important to note LPN K told R35 he was the only nurse on the floor and no one else was available while there were other female staff working.)Example 2R60 admitted to the facility on [DATE] with the following diagnoses: need for assistance with personal care, cerebral infarction, unsteady on feet, and mild cognitive impairment.R60's concern/grievance form, dated 6/21/25, includes: person submitting concern: CNA O. ADON E (Assistant Director of Nursing) obtained verbal statement at time of incident from CNA O and RN S. CNA O concerned RN S raised her voice at R60. R60 was yelling out, staff unable to calm R60. RN S admits to yelling. No harm to R60 reported. RN S admits to raising voice at R60. On 7/24/25 at 9:00 AM LPN N indicated she had concerns that the facility's management is not following the abuse policy and procedures. LPN N indicated CNA O called DON B (Director of Nursing) in the middle of the night to report RN S verbally abused R60. On 7/24/25 at 1:18 PM CNA O (Certified Nursing Assistant) stated, I observed verbal abuse. It was a little busy at night. I had a call light or two on. I saw R60's call light on and I was trying to get down to her. I heard the wall shake as RN S slammed the door shut. She then slammed the bathroom door too. I knocked and opened the door. RN S was shouting and screaming at R60. CNA O indicated RN S was saying to R60. Get up out of this bed, and she was using a loud voice of authority. CNA O stated, She took the blanket from the patient, threw it on the floor, and spilled her water. The patient was calling out for help. We were only 45 minutes into our shift. We just started. I asked her if she needed help. The patient looked panicked. I told RN S ‘I need you to leave the room' three times. The third time, I told her to leave, I said you are abusing the patient and I need you to leave right now. I will assist the patient. CNA O indicated RN S continued to work through the shift and was not removed from patient care pending an investigation. CNA O indicated she does not understand why the facility does not follow the abuse policy.On 7/24/25 at 1:43 PM ADON E (Assistant Director of Nursing) and DON B indicated they take turns being on call for the health and rehab center. ADON E indicated around midnight she received a call from CNA O who reported RN S raised her voice at a resident and looked frazzled so CNA O had to take over cares. ADON E indicated CNA O reported that RN S lost her patience, yelled at R60, and she asked RN S to leave. ADON E indicated then she called and spoke with RN S who stated that she used a loud, stern voice but R60 was safe. ADON E indicated R60 has some cognitive impairment and was not able to recall the incident. ADON E and DON B indicated yelling at a resident, using a loud stern voice towards a resident could be intimidating and is verbal abuse.On 7/28/25 at 10:43 AM SW G (Social Worker) indicated a concern of a staff yelling at a resident could be an allegation of abuse. SW G indicated CNA O witnessed the verbal abuse and intervened.On 7/28/25 at 11:22 AM NHA A (Nursing Home Administrator) indicated a staff member yelling at a resident, pulling a blanket off and throwing it on the floor, and slamming doors is verbal abuse and mental abuse.(It is important to note RN S admitted to using a loud stern voice at R60 and admitted to yelling at R60.It is important to note CNA O reported that she witnessed RN S slam R60's bedroom door and her bathroom door, yell at R60, pull a blanket off of R60 without warning and throw it on the floor spilling R60's water.)

Based on interview and record review, the facility did not ensure the resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunization; and (B) That the resident either received the influenza and/or pneumococcal immunization or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal. This affected 1 of 5 residents (R3) reviewed for immunizations.R3 did not sign, date, or check consent or declination for the influenza vaccination for 2024/2025 until 7/29/25.This is evidenced by:The facility policy entitled Influenza Vaccine, with a revision date of March 2022, states in part: Policy Statement: All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccines against influenza.Policy Interpretations and Implementation: 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized.2. Employees hired or residents admitted between October 1st and March 31st should be offered the vaccine within five (5) working days of the employee's job assignment or the resident's admission to the facility. 6. A resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record.Example 1:R3 was admitted to the facility on [DATE].R3 had documentation for the Influenza vaccine administered on 12/9/23.R3 did not have an influenza vaccine listed in her Electronic Health Record (EHR) for the last influenza season 2024/2025.On 7/28/25 at 4:15 PM, Surveyor requested influenza administration or declination documentation for the influenza vaccine for R3.On 7/29/25 at 10:50 AM, Surveyor asked DON B (Director of Nursing) about the influenza vaccine documentation for R3. DON B indicated there should be a declination form, but they were still looking for it.The facility provided an admission Immunization Assessment form with a checkmark indicating that R3 does not want the flu vaccine. R3 signed the form on 7/29/25. On 7/29/25 at approximately 12:30 PM, DON B told Surveyor that she had found the influenza vaccine declination form for R3. Surveyor reviewed the document. R3 and the staff assessing the vaccine status had both signed the form and dated it on 7/29/25.

Based on interview and record review, the facility has not established 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. This has the potential to affect all 36 residents (R) in the facility. The facility failed to identify a COVID-19 outbreak when OT H (Occupational Therapy) tested positive for COVID-19. The facility did not recognize Centers for Disease Control and Prevention (CDC) guidance as one positive COVID-19 positive resident or staff qualified as an outbreak. The facility failed to notify public health of a COVID-19 outbreak per CDC guidelines. The facility failed to notify the Medical Director (MD) of a COVID-19 outbreak. The facility failed to implement COVID-19 outbreak protocols, including the notification of residents, families,with initial outbreak. The facility failed to document testing of residents and staff who displayed COVID-19 symptoms. The facility's COVID-19 summary was inaccurate and incomplete. The facility's line list was inaccurate and incomplete. Three different line lists were provided for January 2024 with differing symptomology. This is evidenced by: The facility policy titled Infection Control Policies, last updated 11/2/2023, indicates in part: .IP (Infection Preventionist)/designee reviews available information and laboratory results and ensure correct isolation procedure is implemented, as necessary. They will also ensure that isolation carts are stocked and placed by the door of the isolated room . A. The Employee Surveillance Line List: .The IP will follow up with the employee and update the line list/notify the supervisor .the Infection Preventionist will review the line list routinely to address any trends or potential outbreaks. In the event of an outbreak .DHS (Department of Health Services) and Public Health of [NAME] and [NAME] County are to be notified . Resident Surveillance: .The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility, and reports surveillance findings to .public health authorities when required . B. Elements needed and documented on the Resident Infection Control Surveillance Report .listing of symptoms . Infection Control for Commonly Encountered Diseases: COVID-19: Prevention Policies .In order to protect vulnerable residents, source control will still be implemented. Staff with symptoms of COVID-19 should immediately test themselves either at home or in the Infection Prevention office prior to the start of their shift. They should be wearing masks and if positive should return home and follow the instructions of the IP . The facility January 2024 COVID outbreak states A COVID outbreak was observed in the [HRC] beginning January of 24 on 1/6 with the infection of an occupational therapist. On 1/9 two more cases were identified, with the executive director and social work departments impacted. Cases reported to public health. First resident spread noticed on 1/11 with resident being sent out to (local hospital name) due to hypoxia. Negative tests in house but tested positive in the hospital. Mask mandates and unit testing were put in place, 3 more resident cases revealed with minor symptoms. 3 more staff would test positive with last case on 1/24 and unit masking and isolation ending on 2/6/24. COVID-19 General Testing and Reporting Guidelines: -As of 11/1/23 it is no longer necessary to report COVID-19 infections to public health or DHS (Department of Health Services) unless it is associated with a hospitalization . -Following a confirmed outbreak (defined as 2 or more cases of staff or residents in the same unit within a 14-day period) if COVID-19 in the Assisted Living or Skilled Nursing units of (facility name) masking will go into effect in units experiencing an outbreak, and general testing will occur in order to prevent widespread transmission . -Anyone with mild symptoms regardless of vaccination status should receive a viral test as soon as possible . Outbreak and Isolation Guidelines .The approach to an outbreak is to isolate the infected individual if they are a resident and to place them on airborne precautions .Testing in an outbreak will occur immediately, and then once again on day three and 5. In the event of more cases, testing will occur again on day 7. Masking signs will be placed on the doors of affected units. All visitors and staff must wear a mask . CMS (Centers for Medicare & Medicaid Services) .outbreak definition for nursing homes is as follows: A single new case of COVID-19 occurs among residents or staff to determine if others have been exposed. Example 1 On 6/5/24 and 6/6/24, Surveyor reviewed Infection Control Line lists for the facility. The January line lists indicated, in part, the following for OT H: -Last date worked of 1/6/24. -Symptom on set date of 1/8/24. -Symptoms including sore throat, sinus congestion and cough (contagious). -Date of last symptoms of 1/14/24. -Other: COVID positive -Return to work date of 1/17/24. The second January line list that was supplied, indicated in part the following for OT H: -Last date worked of 1/6/24. -Symptom on set date of 1/8/24. -Symptoms including sore throat. -Date of last symptoms of 1/14/24. -Other: COVID positive -Return to work date of 1/17/24. The second January line list that was supplied, indicated in part the following for OT H: -Last date worked of 1/6/24. -Symptom on set date of 1/8/24. -Symptoms including sore throat. -Date of last symptoms of 1/14/24 -Other: COVID positive -Return to work date of 1/17/24. Example 2 The January line lists indicated, in part, the following for AD I (Administration): -Last date worked of 1/9/24. -Symptom onset date of 1/9/24. -Symptoms including sore throat, cough (productive or dry), sinus congestion, headache, cough (contagious), and fatigue/muscle aches. -Date of last symptoms of 1/14/24. -Other: COVID positive. -Return to work date of 1/18/24. The second January line lists indicated, in part, the following for AD I: -Last date worked of 1/9/24. -Symptom on set date of 1/9/24. -Symptoms including cough (productive or dry), headache, cough (contagious), and fatigue/muscle aches. -Date of last symptoms of 1/14/24. -Other: COVID positive. -Return to work date of 1/18/24. The third January line lists indicated, in part, the following for AD I: -Last date worked of 1/9/24. -Symptom on set date of 1/9/24. -Symptoms none indicated. -Date of last symptoms of 1/14/24. -Other: Covid positive. -Return to work date of 1/18/24. Example 3 The January line lists indicated, in part, the following for ST J (Staff Member): -Last date worked of 1/5/24. -Symptom on set date of 1/10/24. -Symptoms fatigue, sinus congestion, cough (contagious). -Date of last symptoms of 1/15/24. -Other: COVID positive. -Return to work date of 1/18/24. The second January line lists indicated, in part, the following for ST J: -Last date worked of 1/5/24. -Symptom on set date of 1/10/24. -Symptoms sore throat, cough (productive or dry), fatigue, cough (contagious). -Date of last symptoms of 1/15/24. -Other: COVID positive -Return to work date of 1/18/24. The third January line lists indicated, in part, the following for ST J: -Last date worked of 1/5/24. -Symptom on set date of 1/10/24. -Symptoms none indicated. -Date of last symptoms of 1/15/24. -Other: COVID positive -Return to work date of 1/18/24. Example 4 The January line lists indicated, in part, the following for SS K (Social Services): -Last date worked of 1/9/24. -Symptom on set date of 1/9/24. -Symptoms sore throat, cough (contagious). -Date of last symptoms of 1/17/24. -Return to work date of 1/20/24. Example 5 The January line lists indicated, in part, the following for CNA L (Certified Nursing Assistant): -Last date worked of 1/28/24. -Symptom on set date of 1/24/24. -Symptoms sore throat, cough (productive or dry), fatigue, sinus congestion, cough (contagious), and fatigue/muscle aches. -Date of last symptoms of 1/29/24. -Return to work date of 2/6/24. Example 6 The January line lists indicated, in part, the following for RN M (Registered Nurse): -Last date worked of 1/24/24. -Symptom on set date of 1/24/24. -Symptoms sore throat, cough (productive or dry), sinus congestion, cough (contagious), and fatigue/muscle aches. -Date of last symptoms of 1/28/24. -Return to work date of 1/31/24. Example 7 The January line lists indicated, in part, the following for R292. -Type of Infection: COVID -Symptom on set date of 1/11/24. -Symptoms including hypoxia. -Date of infection resolved of 1/21/24. -Comment: Transported to hospital on 1/11/24. Negative for COVID in-house, positive at hospital. Note: The facility provided Surveyor with three COVID line lists which contained different symptoms for staff listed. This makes it difficult to determine which line list is correct. This holds true for all additional examples. On 6/6/24 at 2:01 PM, Surveyor interviewed IP C (Infection Preventionist) and asked when a COVID outbreak would be declared, and IP C indicated when two positive cases of staff or residents in the same unit within a 14-day period. IP C indicated the outbreak began on 1/9/24. Surveyor asked IP C where he received that information and IP C indicated CDC. Surveyor showed IP C the CDC guidance of one positive case declares an outbreak. Surveyor asked IP C with knowing that when should testing have started and IP C indicated with the first positive case of COVID on 1/6/24. IP C indicated the outbreak should have been declared on 1/6/24. IP C indicated masking and testing for all residents and staff did not start until 1/9/24. Surveyor asked IP C if masking and testing should have started earlier, and IP C indicated with first positive case. IP C indicated that staff were requested to test before they returned to work on 1/9/24 and that the PM shift coordinator or lead should have tested them each shift. Surveyor asked what the testing dates for staff and residents were and IP C was indicated 1/9/24, 1/12/24, 1/15/24, and 1/18/24. Surveyor asked IP C if he had any documentation of staff or resident testing. IP C stated he did not. Surveyor asked IP C if resident testing should be documented in the resident medical record. IP C confirmed that per facility policy, when residents are tested it should be documented in their chart. Surveyor asked if there was any documentation of testing in the medical chart. IP C replied that he was not sure. Surveyor asked IP C how staff were notified of an outbreak. IP C stated that staff would be notified by their supervisors. Surveyor asked IP C how he ensured that outbreak notification had been completed. IP C stated that he was on vacation and did not return until 1/10/24 so the MA (medical assistant) was in charge of this, and the supervisors would have assisted. Surveyor asked if the Medical Director had been notified of the outbreak and IP C indicated he was not sure. IP C indicated he did not notify the Medical Director. Surveyor asked IP C if public health had been notified when a resident was hospitalized , and IP C indicated not knowing when public health was notified but should be notified within 24 hours of an outbreak. Surveyor asked IP C when an COVID outbreak would be cleared. IP C indicated 14 days after last positive. IP C indicated the outbreak ended too soon. The facility was not following CDC recommendations to recognize one positive COVID-19 indicates an outbreak and therefore, did not notify public health, the medical director, or the community of the outbreak in a timely manner. The facility failed to document COVID-19 in the resident medical record or staff files. The facility failed to maintain an accurate line list. With having 3 separate line lists with 3 different sets of symptoms, it would be difficult to determine which symptomology was used to determine outbreak surveillance and tracking. The facility failed to establish and maintain an effective infection prevention and control program that prevented the transmission of COVID-19 to staff and residents.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 36 residents residing at the facility. Surveyor observed no lids on the garbage cans in the kitchenettes. Garbage cans were placed near food prep/serve area. Surveyor observed no lids on the garbage cans near the food prep area in the main kitchen. Surveyor observed crumbs and dried on substance in the containers where the spatulas and spoons are kept in the main kitchen. Surveyor observed staff not following standard practice for temping food. Surveyor observed kitchenettes on 1st and 2nd floor to have crumbs and dust inside cupboards. Surveyor observed the microwave on the 1st floor to have dried on food inside microwave. Surveyor observed Dietary Aide not following proper glove and hand hygiene. Evidenced by: Management provided Surveyor cleaning checklist schedules. Management also provided Surveyor staff meeting notes that included expectations of cleaning kitchen and kitchenettes. The facility policy titled, Resource: Taking Accurate Temperatures, dated, 2017, states, in part; .Thermometers should be sanitized according to manufacturer's instructions. Bimetallic thermometers may be sanitized using a dish machine or three sink method. In between uses at one meal, an alcohol swab may be used to sanitize. (Use a new swab for each sanitizing.) . Example 1 On 6/4/24 at 9:29 AM, Surveyor observed garbage cans near the food prep area with no lids. Surveyor observed crumbs, dried-on substance in the containers where the spatulas and spoons are kept. Director of Culinary Services E indicated everyone is responsible for cleaning up after themselves and there are cleaning checklists that are followed as well. Example 2 On 6/4/24 at 10:47 AM, Surveyor observed Executive Chef G temping food for lunch. Surveyor observed Executive Chef G putting thermometer in food, temping, taking thermometer out, and putting it in liquid sanitizer. Surveyor observed thermometer dripping with the solution and Executive Chef G placing the thermometer in the next food that needed to be temped. Surveyor asked Executive Chef G about the process for temping. Executive Chef G indicated he wipes the thermometer with his glove and Surveyor observed him doing this twice. Surveyor observed Executive Chef G touching other items such as the end of the thermometer, binder, pen, and counter, and then dry the thermometer with glove. Executive Chef G indicated understanding and stated he thinks they have alcohol wipes that could be used instead. Example 3 On 6/4/24 at 11:10 AM, Surveyor observed kitchenettes on 1st and 2nd floor. On 1st floor Surveyor observed food splatter dried on the inside of the microwave. DSM F (Dietary Services Manager) indicated the microwave is cleaned once or twice a day. DSM F indicated that the splattered food could be from last night. Surveyor observed kitchen drawers to have dried-on substance, crumbs, and dust. Surveyor observed cups and lids to cups in the drawers. DSM F indicated the cups are for residents. DSM F indicated he would add cleaning the drawers to the cleaning lists. Surveyor observed garbage cans near the food service area with no lids. On the 2nd floor kitchenette Surveyor observed dried gray substance and dust in the cupboard that had pots and pans. DSM F indicated the kitchenettes could use a deep clean. On 6/6/24 at 10:20 AM, Surveyor met with DSM F and DCS E (Director of Culinary Services). Both indicated understanding of the above and indicated they would expect staff to follow cleaning expectations, follow proper hand hygiene when working with food, and follow correct temping procedures. DCS E indicated education will be provided to staff. DCS E indicated the facility has alcohol wipes that could be used for temping and DSM F indicated understanding on having lids on the garbage cans near the food prep areas. 50285 Example 4 Facility staff were observed touching multiple items in the kitchenette while serving and handling food without changing gloves or performing proper hand hygiene. DA N (Dietary Aide) was observed dishing up lunch from the steam table with gloves on. DA N stepped away from the steam table and touched several other items in the kitchenette. DA N returned to the steam table with the same gloves on and continued dishing up the lunch meal. Evidenced by: Facility policy, entitled Infection Control Policies, Hand Hygiene, last updated 11/2/2023, includes in part, How germs spread: Germs can spread from person to person or from surfaces to people when you .prepare or eat food and drinks with unwashed hands .touch surfaces or objects that have germs on them. When to wash hands/perform hand hygiene: Before, during, and after preparing food .immediately before and after glove removal .Gloves .Oakwood Staff are expected to adhere to all standard precaution guideline. On 6/4/24 at 11:50 AM, Surveyor observed DA N dishing up food from the steam table wearing gloves. Surveyor observed DA N touching meal tickets, microwave, plates, plate covers, cupboard handle, fridge handle, touching cake as it was dished up, and returning to dish up food from the steam table, all while wearing the same gloves. On 6/4/24 at 12:23 PM, DA N took food from a Styrofoam container wearing the same pair of gloves and put it on a resident plate after touching multiple kitchen doors, handles, milk jug, refrigerator, all with no glove change or hand hygiene. On 6/4/24 12:32 PM, Surveyor interviewed DA N who said that he wore gloves so that he doesn't touch the food and that it was an extra safety precaution. DA N stated that he had been educated on the proper use of rubber gloves the week prior during his orientation. Surveyor asked DA N if his gloves should be changed when he touches food, DA N stated yes. Surveyor asked DA N if he had changed his gloves before touching the resident's food in the Styrofoam container, DA N replied that he had not changed his gloves. Surveyor asked DA N if he should change his gloves after touching multiple surfaces in the kitchenette. DA N stated yes, he should have changed gloves, and no, he had not done so.

Based on interview and record review, the facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 4 of 5 residents (R11, R10, R13, and R32) reviewed for unnecessary medications. R11 was prescribed psychotropic medications without adequate monitoring of side effects, individualized behavior monitoring, or non-pharmacological approaches/interventions utilized. R10 was prescribed a hypnotic without a sleep assessment, an antipsychotic medication and an antidepressant medication without individualized behavior monitoring, and non- pharmacological approaches/ interventions utilized. R13 was prescribed an antidepressant without adequate monitoring of side effects, individualized behavior monitoring, or non-pharmacological approaches/interventions utilized. R32 prescribed an antidepressant without adequate monitoring of side effects, individualized behavior monitoring, or non-pharmacological approaches/interventions utilized. Findings include: The facility's policy titled Psychotropic Drug Use, dated 11/1/21, states in part: .Admission Orders or Initiation of Psychotropic Medication Use .5. Nurse will initiate behavior monitoring for behaviors specific to resident. Targeted behavior monitoring will be recorded in the Medication Administration Record (MAR). 6. Nurse/ Social Worker will update Care Plan including goals and interventions, including non- pharmaceutical approaches. 7. Nurse to initiate medication and administer medication per MD (Medical Doctor) order. Ongoing monitoring for adverse side effects and therapeutic effects of medication use . Example 1 R11 was admitted to the facility on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD; a group of lung diseases that blocks the airflow and makes it difficult to breathe), Type 2 Diabetes Mellitus, depression, and anxiety. R11 is taking the antidepressants buspirone daily for anxiety and sertraline daily for depression. R11 is also taking the antianxiety medication lorazepam on an as needed basis. R11's MAR (Medication Administration Record) does not list resident specific behaviors to monitor for. R11's MAR states, Record negative statements each shift and Record number of anxious episodes each shift. There are no non-pharmacological approaches/ interventions listed. There is no documentation that the facility is monitoring R11 for side effects or efficacy of psychotropic medications. Example 2 R10 was admitted to the facility on [DATE] with diagnoses that include bipolar disorder, major depressive disorder, and insomnia. R10 is taking the antidepressant Venlafaxine daily for Major Depressive Disorder, the anti- convulsant medication Divalproex Sodium daily for manic depression (this medication can be used and an anticonvulsant or as a mood stabilizer), and the antidepressant trazodone daily for insomnia (this medication can be used as an antidepressant or for insomnia). R10 also takes the antipsychotic medication olanzapine daily for bipolar disorder. R10's MAR does not list resident specific behaviors to monitor for. R10's MAR states, Record negative statements each shift and Record number of agitated episodes each shift, Number of hours slept each shift. There are no non-pharmacological approaches/ interventions listed. It is important to note that Surveyor requested a copy of R10's sleep assessment and none was provided. Example 3 R13 was admitted to the facility on [DATE] with diagnoses that include right ankle fracture, Type 2 Diabetes Mellitus, and depression. R13 takes the antidepressant duloxetine daily for depression. R13's MAR does not list resident specific behaviors to monitor for. R13's MAR states, Record negative statements each shift There are no non-pharmacological approaches/ interventions listed. Example 4 R32 was admitted to the facility on [DATE] with diagnoses that include generalized anxiety disorder, Multiple Sclerosis (a disease where the immune system eats away at the protective covering of the nerves), and status- post abdominal surgery. R32 is taking the antidepressant sertraline daily for generalized anxiety disorder. R32's MAR does not list resident specific behaviors to monitor for. R13's MAR states, Record anxious episodes each shift There are no non-pharmacological approaches/ interventions listed. There is no documentation that the facility is monitoring R32 for side effects or efficacy of psychotropic medications. On 6/6/24 at 2:00 PM, Surveyor interviewed RN O (Registered Nurse). Surveyor asked RN O what targeted behaviors are being monitored for R10 and R13, RN O states that for R10 they are monitoring for anxiety and negative statements. RN O reported that R10 is very happy right now and negative statements would be unusual for R10. Surveyor asked RN O what the process is for a resident that has an order for a hypnotic medication, RN O stated that they would have to get consent, and the resident will have a targeted behavior to monitor for hours slept. Surveyor asked RN O if they conduct a sleep assessment, RN O stated that she was not sure. On 6/6/24 at 3:19 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what individualized target behaviors these residents are being monitored for, DON B stated that if a resident is on an antidepressant, they monitor for negative statements, if they are on an antianxiety medication, they monitor for anxiety and agitation; DON B then stated that it was blanket monitoring. Surveyor asked DON B if staff should be monitoring for side effects of psychotropic medications, DON B stated that she hoped it was being captured in the behavior documentation. Surveyor asked DON B what they process was for a resident that is admitted on a hypnotic/ medication for sleep, and if R10 had a sleep assessment completed, DON B stated that R10 did not have a sleep assessment and she would have expected that on would have been completed. Surveyor asked DON B what non- pharmacological interventions have been put in place for these residents with depression and anxiety, DON B stated that she was not sure. It is important to note that Surveyor requested a policy for sleep assessments and DON B reported that they did not have one.

Based on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 12 (R5) sampled residents and 4 of 4 (R9, R23, R4, R291) supplemental residents reviewed for antibiotic stewardship. R9 was on antibiotic for urinary tract infection without an appropriate indication. Facility did not have documentation of Urinalysis (UA) and Culture and Susceptibility (C&S). R23 was on antibiotic for urinary tract infection without an appropriate indication. R4 was on antibiotic for urinary tract infection without an appropriate indication. R5 was on antibiotic for urinary tract infection without an appropriate indication. Facility did not have documentation of an UA and C&S. R291 was on antibiotic for urinary tract infection without an appropriate indication. Facility did not have documentation of an UA and C&S. Evidenced by: The facility policy entitled Antibiotic Stewardship, dated 11/2/23, states, in part: . As part of the continuing commitment to provide high-quality care to all our residents, the leadership team of Oakwood has created an Antibiotic Stewardship Program (ASP). This program will promote the appropriateness of antibiotics in our facility. The overall goal of ASP is to prevent undesirable outcomes related to antibiotic misuse . Antibiotic Prescribing Guidelines: . 2. The decision to prescribe an antibiotic will be guided by medical knowledge, best practices, and professional guidelines . Antibiotic Stewardship Policies: 5. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: . ii. The McGeers, and/or Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics . b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made . ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility, shall be reviewed for appropriateness. iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness . viii. All antibiotic use shall be added to the Antibiotic Stewardship Spreadsheet and maintained regularly to ensure all information is correct and up to date . The facility policy entitled Infection Control Policies, dated 11/2/23, states, in part: . Resident Surveillance . Surveillance criteria are designed to increase the likelihood that all residents courted truly have the infection of interest. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility . Data is collected from multiple sources to trend resident infections and prevent outbreaks. Oakwood utilizes McGeers as a standardized tool to define clinical criteria . B. Elements needed and documented on the Resident Infection Control Surveillance Report . : 2. Listing of Symptoms 3. Origin of Infection 4. Type of Infection . 8. Testing/Culture Information . Example 1 R9 was admitted to the facility on [DATE]. Surveyor reviewed the facility Monthly Infection Control Log (Line List) for May 2024. R9 was listed on the line list for Urinary Tract Infection (UTI). The line list indicated the following: . -Pathogen: Behavioral Change -Symptoms: Mood swings, irritable -Criteria Met- yes -Date Started: 5/2/24 -Date Infection Resolved or Antibiotic Stopped: 5/5/24 -Antibiotic Type: Cefpodoxime -Facility Acquired or Hospital Acquired: Facility Acquired -Comments: Acquired in Assisted Living (AL). New behavioral changes second Urinalysis (UA) pending. Facility did not provide UA and C&S for this UTI. On 6/6/24 at 9:31 AM, Surveyor interviewed IP C (Infection Preventionist) and asked if criteria were met, and IP C indicated yes. Surveyor asked what standard of practice the facility follows, and IP C indicated McGeers and sometimes Loebs. Surveyor asked IP C if mood swings and irritable are indicative of appropriate symptoms per McGeers/Loeb. IP C indicated it is possible he did not mark all symptoms that would meet criteria. Surveyor asked IP C if symptoms should be identified to know whether criteria was met for antibiotics and IP C indicated yes. Example 2 R23 admitted to the facility on [DATE]. Surveyor reviewed the facility Monthly Infection Control Log (Line List) for May 2024. R23 was listed on the line list for UTI. The line list indicated the following: -Pathogen: MDR (Multi Drug Resistant) e. coli (Escherichia coli, an organism) -Symptoms: not documented -Criteria Met- no -Date Started: 5/12/24 -Date Infection Resolved or Antibiotic Stopped: 5/17/24 -Antibiotic Type: Macrobid -Oakwood or Hospital Acquired: Oakwood -Comments: cause not documented, UA ordered, foley removed 5/6 R23's culture results dated 5/10/24 show >100,000 CFU/mL (colony forming unit per milliliter) Escherichia coli ***Multi- Drug Resistant*** and nitrofurantoin (Macrobid)- < 16 susceptible On 6/6/24, at 09:31 AM, Surveyor interviewed IP C and asked if criteria were met. IP C indicated he couldn't find the symptoms in the notes and yes symptoms should be on the line list. Surveyor asked IP C about the comments on the line list indicating cause not documented and IP C indicated R23 should not have been on an antibiotic. Example 3 R4 admitted to the facility on [DATE]. Surveyor reviewed the facility Monthly Infection Control Log (Line List) for May 2024. R4 was listed on the line list for UTI. The line list indicated the following: -Pathogen: Enterococcus faecalis -Symptoms: (blank) -Criteria Met: yes -Date Started: 5/11/24 -Date Infection Resolved or Antibiotic Stopped: (blank) -Antibiotic Type: Levoflaxin -Oakwood or Hospital Acquired: Hospital -Comments: no symptoms listed or justification . R4's culture results dated 5/7/24 shows: >100,000 CFU/Ml Enterococcus faecalis. Levoflaxin not on susceptibility list. Note of order to stop Levoflaxin and start amoxicillin. Ampicillin susceptible. On 6/6/24 at 9:31 AM, Surveyor interviewed IP C and asked if symptoms should be on the line list to know if criteria were met and IP C indicated yes, and they were not listed. IP C indicated R4 should not have been on an antibiotic. Surveyor asked if there should be a resolve date on the line list. IP C indicated he is working on better documentation. Example 4 R5 admitted to the facility on [DATE]. Surveyor reviewed the facility Monthly Infection Control Log (Line List) for May 2024. R23 was listed on the line list for UTI. The line list indicated the following: -Pathogen: MSSA (methicillin-susceptible Staphylococcus aureus) -Symptoms: Bacteremia -Criteria Met: yes -Date Started: 5/10/24 -Date Infection Resolved or Antibiotic Stopped: 5/20/24 -Antibiotic Type: Augmentin -Oakwood or Hospital Acquired: Hospital -Comments: Transferred off IV antibiotics to Augmentin Facility unable to supply UA and C&S. On 6/6/24 at 9:31 AM, Surveyor interviewed IP C and asked if criteria were met, and IP C indicated yes. Surveyor asked IP C how one would know without having the UA and C&S. Surveyor asked IP C if he has the UA and C&S for R5 and IP C indicated no. Surveyor asked if IP C should have UA and C & S and IP C indicated yes, he usually gets it off EPIC but this one he could not locate. Example 5 R291 admitted to the facility on [DATE]. Surveyor reviewed the facility Monthly Infection Control Log (Line List) for March 2024. R291 was listed on the line list for UTI. The line list indicated the following: -Pathogen: not listed -Criteria Met: yes -Symptoms: (blank) -Date Started: 3/9/24 -Date Infection Resolved or Antibiotic Stopped: 3/13/24 -Antibiotic Type: Amoxicillin -Oakwood or Hospital Acquired: Hospital -Comments: 2xs for 5 days- cystitis- no documented signs . Facility did not supply the UA and C&S. On 6/6/24 at 9:31 AM, Surveyor interviewed IP C and asked if R291 had symptoms and IP C indicated no symptoms were listed. Surveyor asked IP C how one would know if criteria was met. IP C indicated R291 should not have been on an antibiotic. IP C indicated he could not find the UA and C&S in Epic (Electronic Health Record).

Based on observation, interview, and record review, the facility did not ensure that self-administration of medications was determined to be clinically appropriate for 1 (R10) of 1 residents reviewed out of a sample of 12 residents. Surveyor observed R10 to have medication sitting on the nightstand. R10 indicated it is an as needed medication (PRN) and was unable to remember if a self-administration assessment was completed. Evidenced by: The facility did not provide a Self-Administration policy. R10 was admitted to the facility on [DATE] with diagnoses including fracture of left foot, need for assistance with personal care, history of falling, cognitive communication deficit, abnormalities of gait and mobility, muscle weakness, kidney disease, depression, bipolar, edema, and reflux disease. On [DATE] at 9:23AM, Surveyor met R10. Surveyor observed R10 to have a liquid medication bottle sitting on the nightstand near R10's clock. R10 indicated it is an as needed medication. The medication label stated, Hydrocortisone/Nystatin/Tetracycline .Allergy relief .2gm/6mil .Discard after [DATE] . Surveyor reviewed R10's current orders and care plan. The medication was not listed in either. Surveyor reviewed R10's electronic file for a self-administration assessment. R10 did not have a self-administration assessment on file. On [DATE] at 4:31 PM, LPN D (Licensed Practical Nurse) indicated R10 does not self-administer medications. LPN D indicated he has not seen this medication before, there is not a current order for it, and it is expired. LPN D indicated he would destroy the medication and talk with R10. LPN D indicated the medication should not be in R10's bedroom. On [DATE] at 3:58 PM, DON B (Director of Nursing) indicated R10 does not have a self-administration assessment and the medication should not have been in R10's bedroom. At 4:22 PM, DON B indicated she has educated R10's family regarding bringing in medications.

Based on interview and record review the facility did not develop a comprehensive person-centered care plan for 2 of 5 residents (R11 and R32) reviewed for unnecessary medications. R11 does not have a care plan for the use of an antidepressant medications and an antianxiety medication. R32 does not have a care plan for the use of antidepressant medication. This is evidenced by: The facility's policy titled Psychotropic Drug Use, dated 11/1/21, states in part: .Admission Orders or Initiation of Psychotropic Medication Use .5. Nurse will initiate behavior monitoring for behaviors specific to resident. Targeted behavior monitoring will be recorded in the Medication Administration Record (MAR). 6. Nurse/ Social Worker will update Care Plan including goals and interventions, including non- pharmaceutical approaches. 7. Nurse to initiate medication and administer medication per MD (Medical Doctor) order. Ongoing monitoring for adverse side effects and therapeutic effects of medication use Example 1 R11 was admitted to the facility on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease (COPD; a group of lung diseases that blocks the airflow and makes it difficult to breathe), Type 2 Diabetes Mellitus, depression, and anxiety. R11 is taking the antidepressants buspirone and sertraline daily. R11 is also taking the antianxiety medication lorazepam on an as needed basis. R11's care plan does not address the use of the antidepressant or antianxiety medication, side effects to monitor for, or non- pharmacological interventions used to assist with alleviating feelings of depression or anxiety. Example 2 R32 was admitted to the facility on [DATE] with diagnoses that include generalized anxiety disorder, Multiple Sclerosis (a disease where the immune system eats away at the protective covering of the nerves), and status- post abdominal surgery. R32 is taking the antidepressant sertraline daily for generalized anxiety disorder. R32's care plan does not address the use of the antidepressant medication, side effects to monitor for, or non- pharmacological interventions used to assist with alleviating feelings of anxiety. On 6/6/24 at 3:19 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if staff should be monitoring residents for side effects of psychotropic medications, DON B stated that her hope was that it would be captured in the behavior documentation. Surveyor asked DON B if psychotropic medications should be addressed in the care plan, DON B stated absolutely. Surveyor asked DON B what non-pharmacological interventions are in place for residents with depression and/ or anxiety, DON B stated that she was not sure. Surveyor requested a copy of the facility's care plan policy, and it was not provided.

Based on interviews and record review, the facility did not ensure the facility provided pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 4 residents (R1, R4) out of a total sample of 4. RN D (Registered Nurse) administered hydralazine instead of carvedilol to R1 resulting in a medication error. R4 missed a dose of Lyrica. This is evidenced by: Evidenced by: The facility policy titled Errors: Medication Treatment / Policy / Procedures: 01/19/21 states in part General Information: 1. A medication/treatment error is any occurrence that includes any of the following: Administration of medication to the wrong or different resident other than the resident intended. Example 1: R1 was admitted to the facility on [DATE] from a hospital for short-term rehabilitation following a surgical procedure with Primary Discharge Diagnoses of: Right shoulder dislocation s/p (status post) reduction and Paroxysmal supraventricular tachycardia. R1's Secondary Discharge Diagnoses include Myocardial ischemia without infarction (heart attack) due to tachycardia and chronic hyponatremia (low sodium). R1's Physician Orders, signed 7/12/23, indicate the following order: Carvedilol 3.125 mg (milligrams) oral 2 x daily. On 7/19/23 at 8:00 PM, the facility documented the following Medication Error Report regarding R1. The facility documented the following information: Actual Error Type of Medication: Oral Type of Problem: Unauthorized medication (i.e., extra dose, wrong med) Source of Order: Wrong resident Medication Name & Exact Order: Resident given hydralazine 50 mg (milligrams) instead of carvedilol 3.125 (mg). How many doses given in error: 1. What intervention was performed following discovery of error: close monitoring of vitals VS (Vital Signs): BP: 135/54, T (Temperature) 97.7, P (Pulse) 76, R (Respirations) 15, Ox (Oxygen saturation): 97% . Notification as appropriate: Family/POA: Own person Family's Response: Upset/tearful. Physician/GNP (Geriatric Nurse Practitioner) notified. Physician/GNP statement/orders: called 7/20/23 to send to ED (emergency department)/patient refused to go. (Note, R1 did eventually agree to go to the hospital.) Possible Causes: Lack of staff education (Competency validation, new or unfamiliar drugs/devices, orientation process, feedback about errors/prevention, etc.) Yes. Rights of medications med given from different resident. Significant error. Summary of Action: Attempted to call RN (Registered Nurse) in question; no answer. RN contacted; concerns about meds (medications) educated and resolved. On 7/27/23 at 1:09 PM, Surveyor spoke with RN C (Registered Nurse) who is 1 of 3 Clinical Care Coordinators at the facility. RN C stated, he was notified of the medication error on 7/20/23 around 2:00 AM by an LPN (Licensed Practical Nurse). RN C stated, he was told R1 was given hydralazine versus carvedilol. RN C stated there's a significant difference between the two medications. RN C stated he provided directions to the LPN on duty. RN C stated, he and a second RN tried to convince R1 to go to the hospital, but he was refusing. That afternoon R1 agreed to go to the emergency department. RN C stated, he provided education to RN D, and when DON B (Director of Nursing) returns from vacation she will be providing additional education to all staff. Of note, the facility has had 14 medication errors over the past 4 1/2 months. DON B began educating staff prior to leaving for vacation. As of 7/27/23, only 7 out of 20 nurses (Registered Nurses and Licensed Practical Nurses) have been educated regarding medication errors. On 7/27/23 at 2:00 PM, Surveyor spoke with RN D (Registered Nurse). RN D stated, she became distracted during medication pass and stated, I didn't read the name before I passed it. RN D stated she noted the error right after she administered the medication to R1. RN D stated, RN C discussed the medication error with her. looked at the root cause and how to prevent future medication errors. Example 2 R4 was admitted to the facility on [DATE] with diagnosis include in part chronic pain, chronic obstructive pulmonary disease, chronic respiratory failure, and dementia with anxiety. R4's Physician orders include in part: Lyrica oral capsule 100 mg (milligrams) (Pregabalin) Give 100 mg by mouth three times a day for pain. On 7/25/23 the facility's Medication Error Report notes that R4's Lyrica was not given at 10:00 PM - was signed out as given. Actual Error Type of Medication: Oral Type of Problem: Med not administered RN (Registered Nurse) error. Source of order: Other: Dose missed. Medication name and exact order: Lyrica 100 mg give 3 times daily. How many doses given in error: 1. Notification: 7/26/23 NP (Nurse Practitioner) notified Summary of Action: Blank Supervisor Signature: Blank DON/Nurse Supervisor Signature: Blank Note, as of 7/27/23 there has been no follow up regarding this medication error. On 7/27/23 1:09 PM, Surveyor spoke with RN C (Registered Nurse) regarding R4's medication error. Surveyor asked RN C, when were you made aware of this medication error. RN C stated, he was made aware yesterday at 12:13 PM. Surveyor asked RN C, how did this error occur. RN C stated, the pill was still in the medication card, however, it was charted as given but not signed out in the narcotic book. Surveyor asked RN C, did R4 have any negative effects because of the medication error. RN C stated, no. RN C added, the facility notified the Nurse Practitioner with no new orders. RN C stated training is currently in process. RN C added, we do monthly nurses' meetings where we review the errors as well. DON B has been on vacation since 7/17 and will return on 8/1/23. RN C stated there's absolutely no reason why R4's Lyrica was not administered as ordered. RN C stated, all medications should be administered per Physician orders. The facility recognized errors in medication administration for residents however did not complete thorough education to all the nurses and did not audit to assure all nurses were following correct procedures for medication administration and medication errors continue to occur.

Based on interview and record review, the facility did not ensure that residents are free from significant medication errors for 1 resident (R3) of 3 sampled residents. R3 received twice the dose of prescribed metoprolol on 5 days from 5/5/23 to 5/9/23. Evidenced by: The facility policy titled Errors: Medication Treatment / Policy / Procedures: 01/19/21 states in part General Information: 1. A medication/treatment error is any occurrence that includes any of the following: .administration of the wrong dose. R3 was admitted to the facility on [DATE] from a hospital for short-term rehabilitation following a surgical procedure with diagnoses of: encounter for surgical aftercare following surgery on the circulatory system, presence of cardiac pacemaker (an implanted device that keeps the heart beating at a set rate), paroxysmal atrial fibrillation (a condition of the heart when it suddenly and unexpectedly starts quivering and unexpectedly returns to normal beating shortly after), hypotension (low blood pressure), essential hypertension (high blood pressure with no identifiable cause), and peripheral vascular disease (decreased blood flow to the limbs). R3's most recent Brief Interviews for Mental Status (BIMS) score on 5/19/23 was 13/15, which indicates intact cognition. R3's was discharged from a hospital with an order for metoprolol succinate 25mg 24 hr. tablet, take 12.5 mg by mouth daily. R3's electronic Medication Administration Record (eMAR) lists Metoprolol Succinate ER [extended-release formulation] Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 0.5 tablet by mouth one time a day for HTN [hypertension] -Start Date- 05/05/2023 0800 -D/C [discontinue] Date- 05/19/23 1338. The eMAR shows that nurses documented this medication order as administered on May 5 through 19, 2023. A Medication Error Report was found that reveals resident was given the wrong dose of metoprolol. The Narrative Description of Error states Order was for metoprolol 12.5mg - medication was packaged as metoprolol 25mg & medication was given for 5 days before noting wrong dose in package. This is identified on the report as a significant error. The report was signed by the DON B (Director of Nursing). On 7/27/23 at 3:46 PM Surveyor interviewed RN C (Registered Nurse) who had DON B on the phone. DON B stated that the pharmacy had sent whole tablets of metoprolol instead of half tablets in R3's medication card and those were given by nurses instead of half-tablets as ordered. RN C then provided surveyor with a paper copy of R3's metoprolol card from 5/9/23 that shows 5 used bubbles from numbers 5 through 9, and whole tablets in the bubbles numbered 10 and 11. The card states the correct dose. RN C stated that medications should be given as ordered and that is the expectation at this facility the error was made when a full tab was given instead of a half tab.

Based on interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice related to assessment and monitoring for change in condition for 1 resident (R1) of 3 residents reviewed for change of condition out of a total of 8 sampled residents. The facility did not recognize and notify the Physician of R1's repeated refusals of insulins. On 5/6/22 at approximately 1:35 AM, R1 complained of an upset stomach and vomited during a tube feeding. The facility did not recognize R1's stomach pain, nausea, and vomiting as a potential symptom of ketoacidosis. R1 presented with a significant change in physical status. The facility failed to immediately obtain vitals and complete a full nursing assessment of R1's condition, or consult with a physician, which delayed R1 in receiving needed emergency medical services. R1 was transferred to the emergency roiagnom on [DATE] at 8:00 AM (6 1/2 hours later). R1 was hospitalized from 5/6 - 5/11/22 with primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/13/22 at 6:00 AM, R1's blood sugar was 40. R1 has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] <70 or >500 contact provider. The facility did not follow R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility administered [MEDICATION(S)] and orange juice, R1 later became unresponsive, diaphoretic, and was drooling prior to the facility consulting with R1's provider at 8:25 AM. R1's was sent to the emergency department (ED) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/19/22 at 5:43 PM, a staff member accidentally marked R1's bedtime (HS) dose of insulin [MEDICATION(S)] sliding scale as Refused (Code 2) on the Medication Administration Record (MAR). At approximately 9:00 PM R1's blood sugar was 497. LPN D (Licensed Practical Nurse) reported R1's blood sugar to the RN E (Registered Nurse-agency). RN E stated to LPN D that she was going to take a break. RN E did not continue monitoring R1 or share this information with the oncoming night (NOC) shift staff. R1 was transferred to the hospital on 5/20/22 at 12:30 AM when his blood sugar read HIGH indicating it was over 600 and he was complaining of abdominal pain. R1 was hospitalized from 5/20 - 5/27/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Likely due to medication errors at nursing home. This is evidenced by: The facility's policy, Change in Resident's Condition/Status Policy, dated 2/4/22, states in part, the following: The facility will notify the resident, his or her Attending Physician/provider, and responsible party of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) All non-acute changes in resident status reported to the Attending Physician will be assessed ongoing as needed a documented in the medical record by the nursing staff. Procedure 1. Nursing will notify the resident's Attending Physician or On-Call Physician, utilizing the Physician Notification Guidelines, when there has been: .d. A significant change in the resident's physical/emotional/mental condition, e. A need to alter the resident's medical treatment significantly, f. Refusal of treatment or medications, g. A need to transfer the resident to a hospital/treatment center ., i. Specific instructions to notify the physician of changes in the resident's condition Addressing Changes in Resident Condition: 1. LPN gathers, or RN assesses information about the resident based on the change of condition. 2. The nurse discusses the findings with the resident and reports findings to primary physician or designee (Physician Assistant or Nurse Practitioner). 5. Completes documentation in the medical record that MD/family notified, and care plan as appropriate. According to N6, Wisconsin Nurse Practice Act: An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set (MDS) assessment dated [DATE] notes a Brief Interview for Mental Status (BIMS) score of 15/15 indicating R1 is cognitively intact. R1 requires extensive assistance of 2+ staff for bed mobility, dressing, transfers, toileting, hygiene, and bathing. R1 is his own decision maker. R1's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] (Order Date 3/24/22) Check blood glucose four times daily. Notify MD/NP [Medical Doctor/Nurse Practitioner] if BG [blood glucose] is greater than 500 four times a day for Diabetes Management. (Order Date 2/8/222) Check blood glucose at 12:30 AM one time a day for DMII. (Order Date 5/11/22) Insulin [MEDICATION(S)] [MEDICATION(S)] Solution Pen-Injector 100 unit/ml [Insulin [MEDICATION(S)]] Inject as per sliding scale: if 181-225=6 units; 226-270-7 units; 271-310=9 units; 311-350=12 units; 351-400=15 units; 401-450=17 [NAME] If, <70 or >500 contact provider, subcutaneously with meals for diabetes control. R1 prefers to eat his food prior to dosing insulin with meals. (Telephone Order Date 5/12/22) (Start Date 5/13/22) *Resident may adjust Insulin [MEDICATION(S)] if he is not eating well, every day and evening shift. (Note: this order was not in place prior to R1's hospitalization and there is no documentation that R1's Physician was notified of his insulin refusals). (4/22/22) R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Give 12 units sub q daily 9:00 AM - 10:00 AM as per resident request.) (Order Date 2/22/22) Tube Feeding Orders: Enteral Feed Order in the evening for supplemental feeding - Five 15 ml/hr. [milliliters/hour] via J-tube at 6:30 PM stopping at 6:30 AM. Enteral Feed Order in the morning for supplemental feeding stop feeding Nepro 15ml/hr. feeding at 6:30 AM. R1's Comprehensive Care plan documents a Focus area: The resident has Diabetes Mellitus. Goal: R1 will have no complications related to diabetes through the review date (5/10/22). Interventions: Diabetes medication as ordered by doctor and allowed by R1. Monitor/document for side effects and effectiveness .Monitor/document PRN [as needed] any s/sx [signs/symptoms] of [CONDITION(S)]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, *abdominal pain, Kussmaul breathing, acetone breath [smells fruity], stupor, coma. Monitor/document/report PRN any s/sx of [CONDITION(S)]: Sweating, Tremor, Increased heart rate [[CONDITION(S)]], Pallor, Nervousness, Confusion, Slurred speech, Lack of coordination, Staggering gait Example 1 - Change in Condition - hospitalized ,d+[DATE] - 5/11/22 On 5/2/22, R1's MAR documents R1's refusals of Insulin [MEDICATION(S)]: *5/2/22 8:30 AM - Blood glucose = 221 *5/2/22 at 5:30 PM Blood glucose = 227 *5/5/22 at 6:30 AM Blood glucose = 208 *5/5/22 at 12:30 PM Blood glucose =250 *5/5/22 at 5:30 PM Blood glucose = 299 It is important to note that R1's blood glucose level is trending upward. The facility did not consult with R1's Physician regarding his multiple refusals of insulin. On 5/6/22 at 1:35 AM, LPN J (Licensed Practical Nurse) documented the following progress note: R1 requested having the feeding and sited not eating for two days which he did have small meals, but not enough to met [sic] facility requirements. Blood glucose was checked and was 485. R1 was frequently calling and requesting massages, repositioning etc. [sic] resident was getting agitated when being told it would be a minute d/t [due to] a floor emergency. R1 started raising and lowering the bed while feeding was going. R1 then began c/o [complaining of] upset stomach and then had a liquid emesis and it appeared it came out of R1's nose and resident stated it did. LS [lung sounds] are adventitious in right lobes and dim in left lobes. Note, LPN J did not obtain R1's full set of vitals, document that she consulted with the facility's RN (Registered Nurse) on call or DON B (Director of Nursing), or consult with a Physician, which delayed R1 in receiving needed emergency medical services. The facility did not recognize: 1. R1's repeated refusals of insulin and now vomiting as a need to consult with the Physician. It is important to note that R1 has a history of aspiration pneumonia. 2. R1's stomach pain, nausea and vomiting as potential symptoms of DKA. On 5/6/22 at 8:00 AM, the following SNF/NF (Skilled Nursing Facility/Nursing Facility) Transfer Form was completed for R1's change in condition: Relevant Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Most recent glucose: 5/5/22 at 10:34 PM: 357.0 Blood Pressure: 5/5/22 10:34 PM: 160/60 Heart Rate: 5/6/22 4:00 AM: : 82 Respirations: 5/6/22 4:00 AM: 16 Temperature:5/5/22 6:06 PM: 98.3 Oxygen Saturation: 5/6/22 4:00 PM: 98% Most recent pain level: 5/6/2 6:16 AM: 7 Usual mental status/cognitive function before the acute change in condition: Alert, oriented, follows instructions Diet: Enteral feeding 15ml/hr. [milliliters/hour] Special Consistency: Thick liquids but resident does get to pick what liquids Behavioral Issues and Interventions: Resident was putting head of bed up and down after tube feeding and later throwing up and had emesis coming out his nose. Sent to: Hospital Date of Transfer: 5/6/22 at 8:00 AM On 5/6/22 at 8:07 AM, R1's progress notes indicate the following: Writer [LPN I, a Licensed Practical Nurse] called residents provider on call to get an order to send resident to the hospital due to resident aspiration risk after vomiting after tube feeding. Writer spoke with wife and update that he was on his way to the hospital. On 5/6/22 at 8:46 AM, R1's hospital report states, in part, the following: Chief Complaint: Vomiting R1 is a 64 y.o. male who presents with possible aspiration. The patient has ALS and receives tube feedings daily. This morning he had a tube feeding at 7:00 AM and then at 8:00 AM vomited. Staff at nursing facility are concerned about aspiration. he has had this happen in the past. The patient has body aches all over. Communication is difficult due to his ALS. I was able to reach the wife at 8:50 AM. She reports that the patient has not been feeling well intermittently for about 5 days. He has had frequent stools which she relates to recent bout of constipation treated with an enema or suppository. He has had ongoing pain in the left side from previous rib fractures and was vomiting yesterday. She reports a history of episodes like this where the patient starts vomiting and then developed aspiration pneumonia. HENT (head, eyes, ears, nose, throat) Assessment: Mucous membranes are dry Thorax and Lungs: Mild crackles in the left lung base Neurologic: Alert. Moaning. Speech incomprehensible. Follows commands. Generalized weakness and [CONDITION(S)] Labs: BUN 56 (High) (Reference Range: 8-28) Creatinine: 1.83 (High) (Reference Range: 0.50-1.20) BUN/Creatinine Ratio 30.6 (High) (Reference Range: 8.0-26) Osmolality Calculated 322 (High) (Reference Range: 275-295) Creatinine Based eGFR 38 (Low) (Reference Range: >60) Anion Gap 30 (High) (Reference Range: 7-14) Pro BNP 7,292 (High) (Reference Range: 0-124) Chest pain - Patient states he has had some central chest discomfort with [CONDITION(S)] to the left side, but he attributes that to straining his voice to be heard by nursing staff when asking or yelling for help over the last 48 hours. EKG [electrocardiogram] in the emergency department did show some lateral and inferior T wave changes, Troponin 0.03. AKI [Acute Kidney Injury] - Appears pre-renal in setting of dehydration and DKA [Diabetic Ketoacidosis], IVF [intravenous fluids] per DKA [Diabetic Ketoacidosis protocol]. FU [follow up] BMP [Basic metabolic panel] as noted above. Impression: This is a 64 y.o. male with complex past medical history including ALS and diabetes presenting with vomiting and DKA. Patient will be admitted and started on an insulin drip. Per my review, CXR [chest x-ray] shows no pneumonia. Care Everywhere checked. Past medical history confirmed as noted. Labs consistent with DKA [Diabetic Ketoacidosis]. Insulin protocol ordered with IV [intravenous] fluids. I spoke with Physician from the hospitalist service. He will admit. Addendum: Pt [Patient] continued with severe metabolic acidosis in the ED [Emergency Department], but now has improved slightly with initiation of insulin infusion and fluids. Procal [a blood test that can indicate [CONDITION(S)]] came back weakly positive, will cover with ctx [antibiotic] considering ongoing emesis and very high risk for aspiration pneumonia. Finally, [NAME] [troponin] increased with positive delta. Most likely demand type NSTEMI [[CONDITION(S)]] but noted pt. already on asa [aspirin], atorva [[MEDICATION(S)]], beta blocker. Will continue to trend. If keeps going up, would obtain serial ecg and possibly start DAPT [Dual Antiplatelet Therapy] and consult cards [Cardiology]. R1 was hospitalized from 5/6-5/11/22. R1's Primary Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. DKA with T1DM [Diabetic Ketoacidosis with Type 1 Diabetes Mellitus] 2. Aspiration pneumonia 3. NSTEMI [[CONDITION(S)]] 4. Poorly controlled [CONDITION(S)] [hypertension, also known as high blood pressure] R1's Secondary Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. ALS 2. Chronic dysphagia 3. Chronic sacral and left forearm wounds On 5/26/22 at 12:00 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B should staff consult with R1's Physician when he refuses insulin. DON B stated, R1 refuses insulin all the time. DON B stated, the Nurse Practitioner (NP) is aware that R1 refuses insulin and there is an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Order Date: 5/12/22) (Start Date: 5/13/22)). Note, this order was not in place at the time of R1's hospitalization on [DATE]. Surveyor asked DON B if a facility RN was consulted regarding R1's change in condition. DON B stated an LPN (Licensed Practical Nurse) called (unknown time, not documented) to update her and gave report at 7:15 AM when DON B arrived to work. DON B stated NP F was updated the morning of 5/6/22 to send R1 to the ED (approximately 8:00 AM). Note: this is approximately 6 1/2 hours after R1 was documented as c/o [complaining of] upset stomach and then had a liquid emesis and it appeared to come out of resident nose and resident said it did. DON B indicated NP F is on vacation and is aware of R1's refusals of insulin. Note, if the facility consulted with R1's Physician or NP F timely regarding R1's refusals of insulin, this may have prevented R1's DKA from occurring. Example 2 - Emergency Department 5/13/22 R1's Physician Orders, signed 5/18/22, indicate the following order: (Order date 5/11/22) Insulin [MEDICATION(S)] [MEDICATION(S)] Solution Pen-Injector 100 unit/ml (Insulin [MEDICATION(S)]) Inject as per sliding scale: if 181-225=6 units; 226-270-7 units; 271-310=9 units; 311-350=12 units; 351-400=15 units; 401-450=17 [NAME] If , <70 or >500 contact provider, subcutaneously with meals for diabetes control R1 prefers to eat his food prior to dosing insulin with meals. On 5/13/22 at 7:15 AM, R1's progress note indicates the following: Writer [an agency LPN] checked Res (R1's) BGL [blood glucose level] at approx. [approximately] 6:00 AM which read 40. Res was not responding when his name was called. Resident given [MEDICATION(S)] as well as orange juice via Jtube. BGL [blood glucose level] increased to 41 and upon further BGL checks reading was 46. Writer continued to stay with Resident and check Resident's BGL and got reading shortly after of 51 and then shortly after 136. Resident able to be aroused [sic] slightly and responded opening eyes briefly and looking at writer and nodding when asked if he recognized writer. Med Tech [Medication Technician] also came in room at this time and observed. Writer gave report to oncoming RN [Registered Nurse] and after shift report, went back in to check on Resident and check BGL again. BGL 179. Res opened eyes briefly in response to his name and nodded appropriately in response to questions. Res able to be aroused with verbal stimuli, opening eyes briefly and nodding. Writer passed this information on to oncoming staff before ending shift. Note: NOC shift is from 10:45 PM - 7:15 AM and AM shift is from 6:45 AM - 3:15 PM. On 5/13/22 at 8:17 AM, R1's progress note indicates the following: Writer [RN K, a Registered Nurse] was given report this morning and was told that the 6:00 am BG [blood glucose] was 40, resident was given [MEDICATION(S)] x2 as well as orange juice via Jtube, BG increased to 41 then 46, after OJ [orange juice], staff went to see resident and stated he was not answering but would open his eyes briefly. When writer assess resident, he was not answering or opening his eyes, is diaphoretic, and drooling. Writer rechecked BG and it was 198. Wife present and notified of situation, NP notified of situation and gave order to send to ER for eval and tx [treat]. VSS [vital signs stable] when evaluated by previous nurse, 911 called and to be transferred to hospital. The facility did follow R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/13/22 at 8:25 AM, R1's Physician Telephone Order, signed 5/14/22, indicates: Send to ER via 911 due to [CONDITION(S)] and altered mentation. On 5/13/22 at 9:01 AM, R1's arrived at the hospital, per the hospital timeline. On 5/13/22 at 9:25 AM, R1's hospital report states, in part, the following: Chief Complaint: Low Blood Sugar - Events leading to and Treatment PTA: Pt. presents via EMS with [CONDITION(S)] and altered mental status. Pt. has hx of ALS and Type I diabetes. Pt lives at SNF [Skilled Nursing Facility] and this AM was found unresponsive with a blood sugar of 42. SNF administered 2 doses of [MEDICATION(S)] and some OJ through his G tube. Pt. had blood sugar of 200 upon EMS [Emergency Medical Services] arrival but pt. was still not responsive. EMS states pt. became responsive in route after a sternal rub. Upon arrival, pt. is alert and oriented, wife is at bedside and sates he is back to his baseline. Pt does not remember this event this morning. Clinical Impression: [CONDITION(S)] Patient was given his morning insulin but no tube feeding. [There is no documentation in R1's Medication Administration Record or medical record that this occurred]. He was found with altered mental status. Blood sugar low. He was given glucose for the feeding tube and then [MEDICATION(S)]. IM [intramuscular] and transported here. He woke up on way here. Course and Medical Decision Making: Patient's fluids given a meal. Blood sugars rechecked and are stable. Impression: This is a 64 y.o. male with recent hospitalization for aspiration pneumonia presenting here after an episode of [CONDITION(S)]. Renal function is slightly worse than previous values which may make him more susceptible to [CONDITION(S)]. I recommend closely monitoring blood sugars. He has chronic [CONDITION(S)]. White count elevation of the clear etiology. Doubt acute infection. R1 returned to the facility at 2:33 PM. On 5/26/22 at 12:00 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B if she expects staff to follow Physician Orders. DON B stated, yes. Surveyor asked DON B did R1 receive insulin the morning of 5/13 prior to being sent out and before eating. DON B checked on this and returned stating, no, R1 did not receive insulin prior to breakfast on 5/13/22. Surveyor stated to DON B that R1 has an order to contact the Physician when his blood glucose is less than 70. Surveyor asked DON B should staff have contacted the Physician. DON B stated she remembers staff calling her regarding this and she was awake at the time. Note, there is no documentation that staff (an LPN) consulted with DON B. DON B stated if interventions are ineffective staff should contact the Physician. Example 3 - Change in Condition - Significant Medication Error - hospitalized ,d+[DATE] -5/27/22 R1's Physician Orders, signed 5/18/22, indicate the following: (Order Date 5/11/22) Insulin [MEDICATION(S)] Flex Pen Solution Pen-Injector 100 unit/ml (Insulin [MEDICATION(S)]) Inject as per sliding scale: if 181-225=6 units; 226-270-7 units; 271-310=9 units; 311-350=12 units; 351-400=15 units; 401-450=17 [NAME] If, <70 or >500 contact provider, subcutaneously with meals for diabetes control. R1 prefers to eat his food prior to dosing insulin with meals. On 5/19/22 R1's MAR documents the following for Insulin [MEDICATION(S)]: 5/19/22 HS [bedtime] dose is documented by Med Tech C (Medication Technician) as 2 which indicates Drug Refused in the legend. The blood sugar documented at 5:34 PM is 229. 5/19/22 Blood glucose 229 at 5:34 PM declined administration of insulin when offered. Signed out in PCC [PointClickCare] documentation as refused at 5:43 PM by Med Tech C. Also at 5:43 PM, by mistake, HS [bedtime] sliding scale insulin signed out as refused by Med Tech C who was training with LPN D. LPN D was unaware of mistake made by Med Tech C causing insulin order not to trigger as due on PCC. On 5/19/22 at 9:05 PM, LPN D reports she notified RN E of blood glucose level of 497 and informed her no insulin was administered. LPN D encourages RN E to contact on call to address [CONDITION(S)] before she ended her shift. RN E denies knowing R1's blood glucose was elevated. No insulin was administered to treat blood sugar reading of 497. There was no RN assessment of R1's condition and no ongoing assessment/monitoring. There was no report to the next shift of R1's condition. On 5/20/22 at 1:32 AM, LPN G (Licensed Practical Nurse) documented the progress note for R1: Writer entered resident's (R1's) room at 11:30 PM with CAN [sic] (Certified Nursing Assistant) to answer call-light. Resident was lethargic but still alert and answering questions. Writer asked resident multiple time if he was feeling okay, to which he replied oxy ([MEDICATION(S)]). Writer then saw that resident's HS BG (Bedtime blood glucose) was 497. When asked if he receive any insulin at HS, writer [sic] denied receiving any insulin. Writer then decided to get BG reading-Lactometer only reading HIGH with no value. [Note: this indicates R1's blood sugar is over 600.] .Resident .was sent emergently (911) via ambulance to the hospital for further evaluation. On 5/20/22 at 1:08 AM, R1's hospital report states, in part, as follows: Patient has history of insulin-dependent diabetes. Also, history of advancing ALS, essentially bedridden. G-tube in place. Also, history of hypertension, recent admission of the hospital earlier this month for DKA [diabetic ketoacidosis] and type II MI [[CONDITION(S)]], aspiration pneumonia. Since discharge, patient has had 1 ED [emergency department] visit for [CONDITION(S)]. Tonight, per EMS [Emergency Medical Services], staff thinks that they missed his insulin dose. On arrival here, difficult for patient to talk due to his ALS. States he feels generally weak. [sic] Pain. Physical Exam .On arrival, patient lying in bed, sitting up, alert, looks around, able to answer only simple questions, difficulty talking due to ALS. Appears deconditioned, weak. Accu-check on arrival 460. ED work-up remarkable for the following: Blood sugar 527. Serum [MEDICATION(S)] positive. A little acidotic with VBG showing pH of 7.31. [MEDICATION(S)] positive. EKG shows slight ST depression lateral leads but troponin negative. DKA [Diabetic Ketoacidosis]. Likely due to medication errors at nursing home. ED therapies involved 2L [liters] normal saline IV [intravenous], initiation of insulin drip. ED documents, EMS state their glucometer read HI as well (indicating R1's blood sugar is over 600). R1 was hospitalized for 7 days due to the facility's significant medication error. Staff Statements On 5/20/22 at 1:35 AM, LPN D (Licensed Practical Nurse) emailed the following statement to CC H (Care Coordinator): .Right before I left last night I went in and took his BG again and it was 490 something. I passed this along to RN E since I was leaving. I also told her that I did not see any insulin for him outstanding in the MAR and that she might need call [sic] and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . (I hope I didn't accidentally do that!!). So, it was passed off to RN E when I left. On 5/20/22 at 1:01 PM, RN E (Registered Nurse-agency) emailed the following statement to CC H (Care Coordinator): I was not made aware of R1's blood sugar level. The Med Tech on duty was also a nurse. She came back up from downstairs at around 8:45 PM as I was starting to prepare his medications as he was the past patient that was due, but I was waiting on her as it states in his MAR (Medication Administration Record) that two nurse/med tech's have to witness administering his medications. She came up with I think another med tech who she was training, and they took over again as she stated she has a good repore [sic] with R1. I took one blood sugar in the beginning of the shift as I wasn't sure who does what. But then her and the med tech came back from downstairs at 4:30 PM and stated they take all the blood sugars and because she's a nurse she said she'll just do all the insulins. She never updated me with any abnormal glucose results or omitted any insulin that I'm aware of. Root Cause Analysis: .LPN D recognized the [CONDITION(S)] was an issue and reported blood glucose level of 497 and no insulin administered at that time. LPN D suggested a call to on-call physician was needed. RN E, an agency nurse, denies knowledge of elevated blood sugar reading. No on call provider consulted as a result. This was RN E's second shift at the facility. It was also RN E's first time working on the second floor with R1. On 5/25/22 at 1:31 PM, Surveyor spoke with LPN G (Licensed Practical Nurse). LPN G worked the NOC (night) shift on 5/19 into 5/20/22. LPN G stated no information regarding R1's high blood sugar reading earlier in the evening was shared in report. LPN G stated R1 put his call light on, the CNA answered the light and LPN G entered R1's room with the CNA. LPN G stated, I immediately noticed something wrong. LPN G stated she asked R1 if he is feeling okay. R1 replied, Oxy ([MEDICATION(S)] - a narcotic pain medication). LPN G stated R1 is diabetic, and he stated his stomach hurt which is not good (Note, this is a sign of Diabetic Ketoacidosis). LPN G stated R1's abdomen was not distended, and he had normal bowel sounds. LPN G stated she went to the MAR (Medication Administration Record) and noticed his blood sugar was 497 tonight. LPN G stated she noted R1 did not receive insulin at bedtime tonight. LPN G stated if R1's blood sugar is over 300 he will always take insulin. LPN G stated, if R1's blood sugar was 497, He absolutely would have taken insulin. LPN G stated she checked his blood sugar and the glucometer read, HIGH with no numeric value. LPN G stated, I didn't cause this but, this is how I found you (R1). LPN G stated she called CC H (Care Coordinator) and she recommended a call to R1's family member. CC H stated with a reading of HIGH that indicates his blood sugar is over 600 - just send him out. R1 agreed to be sent out. LPN G stated she called 911 and when the Paramedics arrived and assessed R1, he refused to go to the hospital. LPN G stated R1 just want to hear directly from his family member that he should go to the hospital. LPN G contacted R1's family member who told R1 he needs to be seen in the emergency room . LPN G stated, R1 was agreeable to go at this point. LPN G stated while she had R1's family member on the phone she stated to R1 that his blood sugar was 497 at bedtime and he didn't have any insulin, we don't know where your blood sugar is at now. After R1 left for the ED (emergency department) LPN G stated she started digging into the situation .LPN G stated on 5/19 at 5:43 PM, R1 refused his 5:00 PM insulin and the bedtime insulin was signed out in error as refused. LPN G stated, she is concerned that no contact was made with the Physician with R1's elevated blood sugar level and there was no information shared in report. LPN G stated there was obviously no follow up . There was no RN assessment of R1 when his blood sugar level was 497. There was no report to the next shift that R1's blood sugar level had been 497, thus no immediate monitoring or assessment of R1.

Based on interview and record review, the facility did not ensure residents are free of significant medication errors for 1 of 8 total sampled residents (R1). On 5/19/22 at 5:43 PM, a staff member accidentally marked R1's bedtime (HS) dose of insulin [MEDICATION(S)] sliding scale as Refused (Code 2) on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN D (Licensed Practical Nurse) reported R1's blood sugar to the RN E (Registered Nurse-agency). RN E stated to LPN D that she was going to take a break. RN E did not continue monitoring R1 or share this information with the oncoming night (NOC) shift staff. R1 was transferred to the hospital on 5/20/22 at 12:30 AM when his blood sugar read HIGH indicating it was over 600 and he was complaining of abdominal pain. R1 was hospitalized from 5/20 - 5/27/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Likely due to medication errors at nursing home. As evidenced by The facility policy, Medication Errors, undated, states in part: A medication error is defined by the Food and Drug Administration (FDA) as a preventable event that may cause or lead to inappropriate medication use or resident harm. Medication errors can involve prescription meds, over the counter meds, vitamins, and supplements. Errors can happen when: .b. A medication is dispensed improperly. Error Statistics: .the FDA receives more than 100,000 reports every year that are associated with medication errors (FDA, 2019). Antidiabetic agents, oral anticoagulants, antiplatelet agents, and opioids account for more than 50% of ER (emergency room ) visits for adverse drug events (ADEs) in Medicare patients ([NAME], 2021). Every year 7,000 - 9,000 Americans die because of a medication errors (NCBI, 2021). Medication errors cause at least one death every day in the U.S. (United States) (WHO, 2017). Safety Considerations: Stay Focused: Avoid distractions. Push your med cart from room to room. Don't pass meds from busy areas like the nurses's station. Communicate with the staff to keep interruptions to a minimum when you are standing at the med cart preparing meds Report: Report all near misses, errors, and adverse reactions. This not only can protect the resident, but it also allows the facility to analyze the date which can lead to improvements in process. High-Alert medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . These are medications that are likely to cause harm, even when used as intended. Some of the most common high alert medications are anticoagulants, narcotics, insulins, and sedatives. Seven Rights of Medication Administration: Here at the facility, we will adopt the 7 rights of medication administration. ([NAME], 2015): 1. The right resident 2. The right medication 3. The right dose 4. The right route 5. The right time 6. The right reason 7. The right documentation When an Error Occurs: When a medication error occurs, the nurse's first response should be to at once check the resident's condition and watch for any side effects from the medication. Secondly, the nurse must notify the nurse manager and prescribing provider of the error. The provider may provide added orders to [MEDICATION(S)] the medication's side effects or to monitor for potential adverse reactions. In some situations, family members of the resident who are legal guardians or powers of attorney should also be notified. Lastly, an error report should be submitted documenting the incident. Error reports are reviewed at QAPI (Quality Assurance and Performance Improvement) and are intended to identify if patterns of errors are occurring due to system-wide processes that can be modified to prevent future errors. The facility policy, Medications - Medication Administration/Liberalized Medication Schedule Policy, dated 5/3/22, states in part, as follows: Med times will be interpreted as: C. HS (bedtime) medications will be given upon hour of sleep, generally between 7:00 PM - 10:00 PM. R1's Physician Orders, signed 5/18/22, indicate the following: (Order Date 5/11/22) Insulin [MEDICATION(S)] [MEDICATION(S)] Solution Pen-Injector 100 unit/ml (Insulin [MEDICATION(S)]) Inject as per sliding scale: if 181-225=6 units; 226-270-7 units; 271-310=9 units; 311-350=12 units; 351-400=15 units; 401-450=17 units If , <70 or >500 contact provider, subcutaneously with meals for diabetes control. R1 prefers to eat his food prior to dosing insulin with meals. On 5/19/22 R1's MAR (Medication Administration Record) documents the following for Insulin [MEDICATION(S)]: 5/19/22 HS (bedtime) dose is is documented by Med Tech C (Medication Technician) as 2 which indicates Drug Refused in the legend. The blood sugar documented at 5:34 PM is 229. On 5/20/22 at 1:32 AM, LPN G (Licensed Practical Nurse) documented the progress note for R1: Writer entered resident's (R1's) room at 11:30 PM with CNA (Certified Nursing Assistant) to answer call-light. Resident was lethargic but still alert and answering questions. Writer asked resident multiple time if he was feeling okay, to which he replied oxy ([MEDICATION(S)]). Writer then saw that resident's HS BG (Bedtime blood glucose) was 497. When asked if he received any insulin at HS, writer [sic] denied receiving any insulin. Writer then decided to get BG (blood glucose) reading-Glucometer only reading HIGH with no value. (Note, this indicates R1's blood sugar is over 600.) Writer asked resident if he would go to the hospital, which he refused. Resident requested writer call the on-call doctor to ask for 20 units of insulin-writer explained that without a BG (blood glucose) value to report, an on-call could not provide any orders safely. Resident then agreed with writer that calling R1's family member for her opinion on transfer was appropriate. R1's family member agreed that sending resident out was best. Once paramedics arrived, resident again refused to be transferred to hospital. Writer was able to contact R1's wife again to speak to resident about going to the hospital. Resident agreed after several minutes and was sent emergently (911) via ambulance to the hospital for further evaluation. On 5/20/22 at 12:45 AM, R1's progress notes indicate the following: NP F (Nurse Practitioner) alerted of omission of HS sliding scale [MEDICATION(S)]. No new orders at this time due to being inpatient at the hospital. On 5/20/22 at 1:08 AM, R1's hospital report states, in part, as follows: Patient has history of insulin-dependent diabetes. Also, history of advancing ALS, essentially Bedbound. G-tube in place. Also, history of hypertension, recent admission of the hospital earlier this month for DKA [diabetic ketoacidosis] and type II MI [[CONDITION(S)]], aspiration pneumonia. Since discharge, patient has had 1 ED (emergency department) visit for [CONDITION(S)]. Tonight, per EMS [Emergency Medical Services], staff thinks that they missed his insulin dose. On arrival here, difficult for patient to talk due to his ALS. States he feels generally weak,? [sic] Pain. Physical Exam .On arrival, patient laying in bed, sitting up, alert, looks around, able to answer only simple questions, difficulty talking due to ALS. Appears deconditioned, weak. Accu-check on arrival 460. ED (emergency department) work-up remarkable for he following: Blood sugar 527. Serum [MEDICATION(S)] positive. A little acidotic with VBG (venous blood gas) showing pH of 7.31. [MEDICATION(S)] positive. EKG (electrocardiogram) shows slight ST depression lateral leads but troponin negative. DKA (Diabetic Ketoacidosis). Likely due to medication errors at nursing home. ED therapies involved 2L (liters) normal saline IV (intravenous), initiation of insulin drip. R1 was hospitalized for 7 days due to the facility's significant medication error. The facility's Medication Error Report, undated, documents the following: Resident: R1 Type of Problem: Omission Medication Name and Exact Order: Insulin [MEDICATION(S)] sliding scale at bedtime Narrative Description of Error: See timeline of events and root cause analysis What intervention was performed following discovery of error? patient sent to hospital - see root cause, analysis. VS (Vital Signs) BP (Blood Pressure): 143/66, T (Temperature): 98.2, P (Pulse) 70, R (Respirations): 16, O2 (Oxygen saturation) 97% Physician/GNP (General Nurse Practitioner) statement/orders: NP F (Nurse Practitioner) Date/Time: 5/20/22 at 12:05 AM Physician/GNP statement/orders: no changes at this time due to inpatient hospital status Staff Completing Report: CC H (Care Coordinator) Staff Involved in Error: Med Tech C (Medication Technician/Nurse Extern), LPN D (Licensed Practical Nurse), RN E (Registered Nurse-agency), LPN G (Licensed Practical Nurse) Supervisor Notified: Yes Significant Error: Yes 5/19/22 Blood glucose 229 at 5:34 PM declined administration of insulin when offered. Signed out in PCC [PointClickCare] documentation as refused at 5:43 PM by Med Tech C. Also at 5:43 PM, by mistake, HS [bedtime] sliding scale insulin signed out as refused by Med Tech C who was training with LPN D. LPN D was unaware of mistake made by Med Tech C causing insulin order not to trigger as due on PCC. On 5/19/22 at 9:05 PM, LPN D reports she notified RN E of blood glucose level of 497 and informed her no insulin was administered. LPN D encouraged RN E to contact on call to address [CONDITION(S)] before she ended her shift. RN E denied knowing R1's blood glucose was elevated. No insulin was administered to treat blood sugar reading of 497. R1's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/20/22 at 12:51 AM, LPN G checked R1's blood glucose and the glucometer read HIGH which indicates a blood sugar over 600. LPN G called 911 and R1 was sent to the hospital via ambulance. Note: the result range of most available glucometers are 20-600 mg/dL. (milligrams per deciliter). If blood glucose values are within this range, the glucometer displays the values. If the blood glucose is out of this range, then the glucometer doesn't show the value. Instead, it displays HI or HIGH. On 5/19/22 at approximately 11:50 AM, LPN G checked R1's blood sugar due to lethargy and HIGH reading obtained. LPN G recognized that R1 required medical attention due a change in condition and attempted to encourage evaluation in ED, but met with refusal by patient until reaching out to family member to aid in transfer for evaluation. After family member became involved, R1 was agreeable to transfer to the ED. R1 was sent emergently to the hospital at 12:30 AM once agreeable, after consultation with family member. Staff Statements Med Tech C (Medication Technician) provided the following, undated, statement: On 5/19 at the facility, I, Med Tech C (Medication Technician) was training with Med Tech [Note: this is LPN D, Licensed Practical Nurse]. I went in the patients [sic] (R1) to take the blood sugar according to the blood sugar that was due. I came out to tell LPN D, I wrote it down on sheet an entered it into the computer. LPN D told me to ask the patient if he would like his insulin, after telling the patient what his blood sugar was. The patient said no. I came out after giving the rest of the medications that were due and recorded this in the computer. When I got to the insulins, I asked LPN D should I put patient refused for the insulins listed and she said yes. Then under both insulins listed for the medications due I recorded patient refused. On 5/20/22 at 1:35 AM, LPN D (Licensed Practical Nurse) emailed the following statement to CC H (Care Coordinator): Ok, so we did his meds and blood sugar, I think it was shortly before 6 last night. It was right after [family member's name] left. His BG [blood glucose] was 200 something. I cannot remember exactly what it was. I confirmed that he had already eaten dinner since I did not see a tray. I am not sure if he ate our food or if [family member's name] brought him something. Med Tech C (Medication Technician) told him what his blood sugar reading was and asked him if he wanted any insulin and he shook his head no and very clearly said no. Right before I left last night I went in and took his BG again and it was 490 something. I passed this along to RN E since I was leaving. I also told her that I did not see any insulin for him outstanding in the MAR [Medication Administration Record] and that she might need call [sic] and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] ? (I hope I didn't accidentally do that!!). So, it was passed off to RN E when I left. On 5/20/22 at 1:01 PM, RN E (Registered Nurse-agency) emailed the following statement to CC H (Care Coordinator): I was not made aware of R1's blood sugar level. The Med Tech on duty was also a nurse. She came back up from downstairs at around 8:45 PM as I was starting to prepare his medications as he was the last patient that was due but I was waiting on her as it states in his MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She came up with I think another med tech who she was training and they took over again as she stated she has a good repore [sic] with R1. I took one blood sugar in the beginning of the shift as I wasn't sure who does what. But then her and the med tech came back from downstairs at 4:30 PM and stated they take all of the blood sugars and because she's a nurse she said she'll just do all the insulins. She never updated me with any abnormal glucose results or omitted any insulin that I'm aware of. Root Cause Analysis: A combination of errors occurred contributing to omission of insulin for R1 on 5/19/22. Sliding scale insulin at bedtime scheduled to administer in time frame from 6:00 PM - 11:00 PM entered in PCC by CC F on 5/11/22 in order to accommodate R1's time preference of administration. In PCC unable to edit start time of range to better accommodate start of HS insulin administration. Med Tech C, training with LPN D was unaware that bedtime insulin was also signed out as refused by mistake simultaneously. LPN D recognized the the [CONDITION(S)] was an issue and reported blood glucose level of 497 and no insulin administered at that time. LPN D suggested a call to on-call physician was needed. RN E, an agency nurse, denies knowledge of elevated blood sugar reading. No on call provider consulted as a result. This was RN E's second shift at the facility. It was also RN E's first time working on the second floor with R1. Corrective Action: Internal investigation of omission of insulin initiated on 5/20/22. NP F notified of omission of insulin at bedtime on 5/19/22. No new orders at this time. Patient remains under care of hospital for evaluation and treatment. Sliding scale insulin at HS changed in PCC from time range of 6:00 PM - 11:00 PM to 8:00 PM to avoid any overlap that may have occurred. Sliding scale insulin at mealtime and bedtime separated for easier read and avoid missing two different sliding scales in PCC. Med Tech C and LPN D updated on medication error and causative factors contributing to omission. Plan is to provide further education to both Med Tech C and LPN D when in person. IDT [Interdisciplinary Team] to discuss assignment of agency staff versus the facility's staff for optimal care for R1. IDT will also look at staffing for appropriate levels. IDT will evaluate if further oversight, education or reprimand needed for those involved. On 5/25/22 at 1:31 PM, Surveyor spoke with LPN G (Licensed Practical Nurse). LPN G worked the NOC shift on 5/19 into 5/20/22. LPN G stated no information regarding R1's high blood sugar reading earlier in the evening was shared in report. LPN G stated R1 put his call light on, the CNA (Certified Nursing Assistant) answered the light and LPN G entered R1's room with the CNA. LPN G stated, I immediately noticed something wrong. LPN G stated she asked R1 if he is feeling okay. R1 replied, Oxy ([MEDICATION(S)] - a narcotic pain medication). LPN G stated R1 is diabetic and he stated his stomach hurt which is not good (Note: this is a sign of Diabetic Ketoacidosis). LPN G stated R1's abdomen was not distended and he had normal bowel sounds. LPN G stated she went to the MAR (Medication Administration Record) and noticed his blood sugar was 497 tonight. LPN G stated she noted R1 did not receive insulin at bedtime tonight. LPN G stated if R1's blood sugar is over 300 he will always take insulin. LPN G stated, if R1's blood sugar was 497, He absolutely would have taken insulin. LPN G stated she checked his blood sugar and the glucometer read, HIGH with no numeric value. LPN G stated, I didn't cause this but, this is how I found you (R1). LPN G stated she called CC H (Care Coordinator) and she recommended a call to R1's family member. CC H stated with a reading of HIGH that indicates his blood sugar is over 600 - just send him out. R1 agreed to be sent out. LPN G stated she called 911 and when the Paramedics arrived and assessed R1, he refused to go to the hospital. LPN G stated R1 just want to hear directly from his family member that he should go to the hospital. LPN G contacted R1's family member who told R1 he needs to be seen in the emergency room . LPN G stated, R1 was agreeable to go at this point. LPN G stated while she had R1's family member on the phone she stated to R1 that his blood sugar was 497 at bedtime and he didn't have any insulin, we don't know where your blood sugar is at now. After R1 left for the ED (emergency department) LPN G stated she started digging into the situation. LPN G stated she saw that R1 refused his dinner insulin and his blood sugar was in the 200's; LPN G stated it's normal that R1 will refuse insulin if his blood sugar is in the 200's. LPN G stated R1 has 5:00 PM sliding insulin and HS sliding insulin and the HS pass pops up at the same time as 5:00 PM. LPN G stated, the problem was Med Tech C (Medication Technician). LPN G stated on 5/19 at 5:43 PM, R1 refused his 5:00 PM insulin and the bedtime insulin was signed out in error as refused. LPN G stated, she is concerned that no contact was made with the Physician with R1's elevated blood sugar level and there was no information shared in report. LPN G stated there was obviously no follow up, I was a little beside myself. LPN G stated she called DON B (Director of Nursing) at approximately 2:00 AM. LPN G stated DON B instructed her to chart everything. LPN G stated she printed off the administration history, highlighted the error and provided it to CC H (Care Coordinator) and sent an email to NHA A (Nursing Home Administrator), CC H, and DON B. On 5/25/22 at 2:25 PM, Surveyor spoke with Med Tech C (Nurse Extern). Med Tech C stated she just started a Nurse Externship at the facility and working with LPN D the night of the medication error. Med Tech C stated, she took R1's blood sugar and it was somewhere in the 200's. LPN D asked me to ask R1 if he wants insulin. LPN D was with me in R1's room when he refused his insulin (dinner insulin only) . Med Tech C stated while in the MAR (Medication Administration Record) she saw two (2) insulins. Med Tech C stated she was not administering insulin. Med Tech C asked LPN D if she she should refuse it (the HS insulin), LPN D said, yes. Med Tech C stated, there were two (2) insulins and I was not aware of the error. Surveyor asked Med Tech C if the facility has put any safeguards in place to prevent this from happening in the future. Med Tech C stated, CC F said she does not want insulins to pop up at the same time to prevent this error from occurring again. Med Tech C stated, LPN D was right next to me looking and didn't notice there were two (2) orders. Med Tech C stated, I didn't realize she wasn't paying attention. Surveyor asked Med Tech C if she has received any additional training since this medication error occurred. Med Tech C stated DON B spoke with her and we will be looking at orders and different kinds of insulin later this week. Currently, the facility has not provided additional training to Med Tech C or other staff. Med Tech C stated she worked yesterday, 5/24/22. On 5/26/22 at 12:00 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated LPN G (Licensed Practical Nurse) identified the insulin omission and CC H (Care Coordinator) investigated the incident as DON B was on off from 5/20-5/23/22. DON B stated the facility rescheduled the time R1's HS (bedtime) insulin medication administration will appear for medication pass to avoid future errors. DON B stated she will be providing training to staff and has not yet done so. Surveyor asked DON B should medication be administered per Physician orders. DON B stated, yes. DON B stated the error occurred and the facility is taking the necessary steps to address the significant medication error. On 5/26/22 at 1:15 PM, Surveyor spoke with LPN D (Licensed Practical Nurse). LPN D has worked at the facility since February 2022 and usually works the 7:00 AM - 7:00 PM shift. Surveyor asked LPN D if she could describe the situation that occurred on 5/19/22 regarding R1's medication error. LPN D stated on 5/19/22 she was working from 3:00 PM - 9:00 PM and training Med Tech C. LPN D stated she and Med Tech C took R1's supper blood sugars around 6:45 PM and R1's family member was here eating dinner with him. R1's family member asked staff to come back after they were done with dinner. R1's family member left after dinner. Med Tech C (Medication Technician) asked R1 if he wanted insulin scheduled at dinner time. LPN D stated R1 refused this insulin (dinner). LPN D stated R1's blood sugar was 200 something. LPN D stated, she told Med Tech C to put Refused (Code 2 = Drug Refused) in the MAR. LPN D stated Med Tech C was working until 8:00 PM. LPN D stated she was finishing med pass on 2nd floor but needed to help 1st floor with med pass. After 9:00 PM, she saw that R1 was still not done so she told RN E (Registered Nurse) she would take R1's blood sugar and RN E got R1's pills. LPN D stated R1's blood sugar was 497. LPN D stated she came out of R1's room and told RN E while she was sitting at the desk that R1's blood sugar is 497 and she didn't see an insulin. LPN D stated all the medications were green (indicating completed) for the 3:00 - 11:00 PM shift. LPN D stated she told RN E she should call to get an order. LPN D stated RN E mentioned going on break and LPN D left at 9:20 PM. LPN D stated at that time she did not realize that Med Tech C accidentally signed out R1's HS dose of insulin. Surveyor asked LPN D has the facility provided any training to you regarding this medication error. LPN D stated, we're having a meeting but I'm not sure when. LPN D is working at the facility today and has not yet had additional training. Cross Reference F684

The facility did not ensure each resident received adequate supervision when 1 of 6 sampled residents (R1), who is dependent on staff, was left outside for over four hours on a hot day (real feel temperature of 95 degrees) without routine monitoring or staff awareness that the resident was outside. The failure to ensure that a system for checking on a dependent resident when they are outside or to alert oncoming staff a resident was outside resulted in a finding of Immediate Jeopardy. The Immediate Jeopardy began on 6/9/21. NHA (Nursing Home Administrator) A was notified of the Immediate Jeopardy on 6/16/21 at 3:26 PM. The Immediate Jeopardy was removed on 6/16/21. However the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The Facility does not have a Policy and Procedure in place for monitoring residents when outdoors or reporting to oncoming staff that a resident is outside. R1 admitted to this facility with the intention of being a short term rehab resident; however due to medical complications, R1 has been in this facility almost a year. R1's most recent MDS (Minimum Data Set), dated 5/24/21, documents the following, in part: .R1 knows the season, location of room, staff names/faces and he is in a nursing home, moderately impaired cognition, .his locomotion off unit is totally dependent with 1 staff assist . R1 has the following diagnoses: Type 1 diabetes mellitus, PLS (primary [CONDITION(S)], neuromuscular disorder that affects the central motor neurons and is characterized by painless but progressive weakness and stiffness of the muscles of the legs), Other speech disturbances, voice and resonance disorder, [CONDITION(S)] disorder, Weakness, Other abnormalities of gait and mobility, Other lack of coordination, and muscle weakness (generalized). R1 has also recently been diagnosed with ALS (amyotrophic [CONDITION(S)], Lou Gehrig's disease, a nervous system disease that weakens muscles and impacts physical function). R1's CNA (Certified Nursing Assistant) care card documents that R1 transfers with 1 assist and use of EZ stand lift. R1's Nursing care plan does not discuss his joy in going outside or his medical requirement for assistance with this task. R1 takes the following eight medications that have potential side effects of making one more photosensitive, thus, increasing the risk for sunburn, heatstroke or dehydration: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Niefedipine, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and Sodium bi carb. Of note, persons with ALS have a diminished ability to regulate their body temperature. R1 likes being outside as much as possible and asks to be taken out to the patio whenever the weather is nice. On 6/16/21 at 10:26 AM, Surveyors made observation of the balcony. The patio area is visible through windows from inside and is in line of sight from the nurse's station. The patio is covered by a [NAME]. From outside, on the balcony, you cannot see back into the facility, you get a reflection of another part of the building. When walking out onto the balcony, to the left is a table and chairs and to the right are some potted plants and a bench. When facing inside the facility, the single width door is in the middle with windows on both sides and to the left of the door there is a green knob/button that says Push for Help. It is important to note if R1 was sitting by the table and chairs, this knob/button would be approximately 10-12 feet away and if sitting near potted plants, this knob/button would be approximately 4 feet behind him. Either way, it would be difficult for him to press the knob/button. On 6/1 or 6/2/21, staff took R1 out to the patio at his request. About 1½ hours later he wanted to come in, and he tried calling the facility on his cell phone. No one answered. R1 repeatedly tried calling, and no one ever answered. The resident then called his wife, who repeatedly called the facility until a nurse on first floor answered. Both R1 and his wife voiced their anger over this incident, but the facility did not put systems in place to prevent it from occurring again. On 6/9/21 staff took R1 out to the patio area around 12:30 PM. Between 1:30 PM and 2:00 PM, RN C came out and checked on him. R1 was OK and stated he had his phone and water and didn't need anything. He wanted to stay outside longer. Per timeanddate.com, the temperature over the next few hours ranged from 88 to 91 degrees. Humidity was 43%, making the heat index 95 degrees. Winds were eight miles per hour, and it was partly sunny. At 3:15 PM change of shift occurred. No one on the day shift informed anyone on the evening shift that this resident was outside. No one checked on him. At approximately 5:00 PM LPN I could not find R1 when she went to check his blood sugar level. She looked for the resident and found him on the patio. R1 stated he fell asleep outside and, despite this, was extremely exhausted. He was very upset that he had been outside so long. He was not sunburned. R1 stated that no one answered the phone when he called to ask to be taken inside. Per R1's VS (vital sign) records from 6/9/21 after he was brought in from outside, his VS's were: temperature= 98.3, respirations= 16, oxygen saturation= 94% on RA (room air), blood pressure= 154/68, and blood sugar= 262. No pulse was recorded. R1's medical record does not have any type of assessment documented after R1 was brought into the facility. On 6/16/21 at 4:31 PM, Surveyor asked Agency RN M if she remembered what R1 was wearing on 6/9/21. Agency RN M said probably shorts, a tee shirt and [MEDICATION(S)] to left arm. On 6/15/21 at 9:24 AM, Surveyor interviewed R1. When Surveyor asked R1 what he likes to do in the facility, R1 said he enjoys sitting out on the balcony. When Surveyor asked R1 how he alerts staff if he needs assistance when he is outside on balcony, R1 stated, Since the 9th, I can text the staff. Surveyor asked R1 how he alerted staff prior to 6/9/21. R1 said, I think they presumed I could get to call bell, would take a lot of effort and a lot of time. On 6/15/21 at 3:42 PM, Surveyor interviewed LPN I (Licensed Practical Nurse). Surveyor asked LPN I if she knew anything about R1 being left outside on the balcony, LPN I stated . I went to check his blood sugar and he wasn't in his room, nobody told the oncoming shift. Surveyor asked LPN I what time this was, LPN I said around 5:00 PM; the CNA brought him back in. Surveyor asked LPN I if the CNAs were aware R1 was outside. LPN I stated, The CNAs were not told by day shift he was out there. Surveyor asked LPN I how R1 was when he was brought inside, LPN I said he was upset but he looked fine. Surveyor asked LPN I if R1 said anything to her. LPN I stated, I don't remember. LPN I said R1 has his phone at all times but he didn't call. Surveyor asked LPN I if she reported to anyone R1 was upset. LPN I stated, I don't know actually he was mad at day shift. Surveyor asked LPN I what she did once he was back inside. LPN I said she did his VS which were fine and checked his blood sugar. Surveyor asked LPN I how R1 would let staff know he was ready to come in; LPN I stated, I don't know. I know he usually calls staff so I'm going to go with that. Surveyor asked LPN I if she knew how long R1 had been outside. LPN I said, I want to say he said three hours, he usually goes out for a long time, he loves to sit out there. Surveyor asked LPN I if R1 had something to drink out there. LPN I said I don't know, I would hope so! On 6/16/21 at 4:27 PM, Surveyor asked LPN I if she remembered what R1 was wearing on 6/9/21. LPN I said no. Surveyor asked LPN I if she remembered where R1 was sitting outside on 6/9/21, LPN I said no. On 6/16/21 at 8:27 AM, Surveyor interviewed RN C. Surveyor asked RN C what she could remember about the incident on 6/9/21 with R1 being outside for an extended period of time; RN C explained R1 got up after lunch and was taken outside. She went out between 1:30-2 PM to do his vital signs and I did ask him if he needed anything at that time. He said no. Surveyor asked RN C if she knew what time R1 was taken outside. RN C said maybe 12:30 PM. Surveyor asked RN C what transpired on 6/10/21. RN C explained R1 was mad because the cell phone wasn't working. FM D called and I apologized to her, and R1 yelled at me and belittled me for leaving him outside for four hours. RN C went on to explain previous to this incident, the staff had programmed into R1's cell phone the desk number for the facility and had offered to put the cell phone number in there too, but R1 declined. Surveyor asked RN C what if anything changed after the incident on 6/9/21. RN C stated The cell phone number is programmed into R1's cell phone so he can text now, which is easier for him; he is checked on often, and I even offered to program into his cell phone my personal cell phone number because my texts come across on my watch, but he declined. On 6/16/21 at 8:39 AM, Surveyor interviewed FM D. Surveyor asked FM D what she is most concerned with. FM D stated, Them not watching him when he's outside, about a week before 6/9/21 the same thing happened. I called them, and so they can't say they didn't know. Surveyor asked FM D if she knew the date of this previous incident. FM D said it was either 6/1/21 or 6/2/21. Surveyor asked FM D what happened on that date. FM D explained, R1 was outside and wanted to come in but he said no one was answering the phone, so I called for 30 minutes before I got anyone to answer. I have to call often and many, many times before someone picks up the phone. Surveyor asked FM D what happened on 6/9/21, FM D stated, R1 was taken outside around lunch, I'm not sure if he ate outside or in his room, he does both, after about 3 hours outside, he wanted to come in but he couldn't get an answer when he called, then he fell asleep and when he woke up and realized he was still outside he was mad and upset; R1 said he tried waving his arms hoping someone inside would see him but no one came; I had to call the facility just to get them to do an assessment on him! On 6/16/21 at 9:26 AM, Surveyor asked R1 what time he went outside on 6/9/21. R1 said probably around 12:00 PM. Surveyor asked R1 how long he was outside. R1 said over four hours. Surveyor asked R1 to explain what he did to attempt to get staff's attention to come assist him; R1 stated I tried calling the facility but no one answered. I tried waving my arms but I can't see into the building from out there, so I didn't even know if there was anyone out there to see me trying; then I fell asleep and when I woke up and realized I was still outside, I was mad! Surveyor asked R1 how he felt when he got back into the facility. R1 stated I was exhausted, even though I had been asleep, I was exhausted. Surveyor asked R1 if there was anything further about the incident prior to this one, on 6/1/21 or 6/2/21, he thought he should share; R1 stated I think the staff think, 'Out of sight, out of mind' with me. Surveyor asked R1 if there was anything else he felt was important to share, R1 explained last summer he was outside as much as possible but his mobility was better then and he could get himself back inside independently; now his mobility is worse and he just can't. R1 went on to say from inside, you can see out onto the balcony and if you are at the desk, you can see out there too, so he doesn't understand how no one knows he's out there. On 6/16/21 at 10:05 AM, Surveyor asked CNA K, who had worked the day shift on 6/9/21, if she knew who put R1 outside on 6/9/21 on AM shift. CNA K stated I have no idea. Surveyor asked CNA K if it was reported to PM shift that R1 was still outside at change of shift. CNA K stated, I believe we told 2nd shift when we went through report. Surveyor asked CNA K do you recall who you gave report to, CNA K said I think it was CNA G and someone from Agency that day but the Agency CNA wasn't there when we gave report. CNA K looked at schedule to see what time Agency CNA was scheduled (4:30 PM) and stated The only one we would have given report to was CNA G. On 6/16/21 at 8:05 AM, Surveyor asked CNA K how you know if a resident is outside. CNA K said whoever puts them out there will tell us, usually we know they're out there because we let one another know. Surveyor asked CNA K when this information is relayed. CNA K said right after they are put out there. Surveyor asked CNA K did you report to PM shift R1 was outside on 6/9/21. CNA K replied during report we go room by room and say they're still sitting outside or where they are etc., so we should have. Surveyor asked CNA K if there is a process to check on residents when they are outside, CNA K said if they eat out there, we go out to pick up tray. The nurse sometimes goes out with medications, somebody goes in and out pretty often. Surveyor asked CNA K if there is a set time to be outside or to be checked on, CNA K stated she was unsure but usually people are out pretty often and there is a call light outside. Surveyor asked CNA K if R1 goes outside. CNA K stated, R1 goes out for lunch every day after he gets up, a lot of times he goes to bed at 3:00 AM and goes outside at 12-12:30 PM. Surveyor asked CNA K how R1 notifies you if he needs something when he's outside. CNA K stated he always has his cell and can call us or turns around and waves and we can see him. On 6/16/21 at 10:57 AM, Surveyor interviewed CNA G, who worked the second shift on 6/9/21. Surveyor asked CNA G if she recalled who she worked with the PM shift of 6/9/21. CNA G said I believe an Agency CNA and she wasn't here at shift change. Surveyor asked CNA G if AM shift had reported to her that R1 was outside on the balcony. CNA G stated, No, I was not told he was outside, most times it is reported to us. Surveyor asked CNA G how R1 alerts staff if he needs something while outside. CNA G said he texts the facility cell phone now. Surveyor asked CNA G how R1 alerted staff prior to the use of the cell phone. CNA G replied R1 doesn't like to be checked on, he gets mad but it is for his safety that we do it, usually someone knows when he wants to come in and we bring him in. Surveyor asked CNA G if R1 is able to move around once out on balcony. CNA G said R1 can move a little bit but not much. Surveyor asked CNA G if R1 always had his cell phone and fluids when he would be outside, CNA G said yes. On 6/16/21 at 4:30 PM, Surveyor asked CNA G if she remembered what R1 was wearing on 6/9/21. CNA G said no. Surveyor asked CNA G if she remembered where R1 was sitting outside on 6/9/21. CNA G said no. As evidenced below, staff interviews revealed there is no established process or procedure for checking on residents who go outside. On 6/15/21 at 4:50 PM, Surveyor asked CNA G how you know if a resident is outside. CNA G said you can see them out there, staff members tell you, or some residents tell you they are going out there. Surveyor asked CNA G if there is a process to check on residents when they are outside. CNA G stated, It is all different for each resident; some we ask do you want me to come out in 10-15 minutes or maybe stay out for another 15 minutes?, Some call or text our staff phone. R1 does that because he gets irritated with too many check ins. Surveyor asked CNA G what if R1 drops his phone. CNA G stated, Then we will go check on him, I check on him because I know he can't move his wheelchair and it's a safety issue. When Surveyor asked CNA G if she's had any training on this, CNA G said no. Surveyor asked CNA G what would be different if there is inclement weather (i.e. too hot). CNA G replied, He likes to take his shoes off, make sure he has a drink with him. I'd ask him where he wants to sit sun or shade, and I saw he pushed back into shade once. On 6/15/21 at 5:00 PM, Surveyor asked CNA J how you know if a resident is outside, CNA J said whoever takes them out lets others know they are out there. Surveyor asked CNA J if there is a process to check on residents when they are outside, CNA J replied to check on them every 10-15 minutes and make sure they are ok; if they are outside with family we give them privacy. Surveyor asked CNA J if she's had any training on this. CNA J said no, not this specific topic, general safety training on computer. Surveyor asked CNA J what would be different if there is inclement weather (i.e. too hot), CNA J stated, I would suggest not to go out or take out for 5 minutes to get fresh air and then back in. On 6/15/21 at 5:05 PM, Surveyor interviewed LPN H. Surveyor asked LPN H how you know if residents are outside. LPN H said we assist them outside unless they are outside with their families. Surveyor asked LPN H how often residents are checked on and who checks on them when they are outside. LPN H replied that depends, an hour or so is typical; typically the CNAs will check on them but the Nurses check too. Surveyor asked LPN H what if there is inclement weather. LPN H said it depends on the resident's situation, would advise against it or make sure they are appropriately dressed. On 6/16/21 at 8:35 AM, Surveyor asked CNA L how you know if a resident is outside. CNA L said staff relay to one another. Surveyor asked CNA L if this was documented anywhere. CNA L said no, just word of mouth, no documentation. Surveyor asked CNA L if there is a process to check on residents when they are outside. CNA L stated we check every 15-20 minutes. Surveyor asked CNA L is anything done differently for R1. CNA L stated, I personally have never taken him outside but I think they give him a call light. Surveyor asked CNA L if she had any training on this. CNA L stated not that I'm aware of. Surveyor asked CNA L what would be different if there was inclement weather (i.e. too hot). CNA L said to ensure they are appropriately dressed and to check on more frequently, may not be a good choice to go out. On 6/16/21 at 9:57 AM, Surveyor asked CNA E if she recalls R1 going outside on 6/9/21, CNA E said yes. Surveyor asked CNA E if she took R1 outside, CNA E said no she didn't. Surveyor asked CNA E how the next shift would know if R1 was outside. CNA E said AM shift would report to them in shift report. Surveyor asked CNA E how R1 alerts staff if he needs something while outside, CNA E said he calls the nurses. When Surveyor asked CNA E if there is a schedule of when to monitor or check on R1 when outside, CNA E said no. Surveyor asked CNA E if she recalled who she worked with R1 that AM, CNA E said it was CNA K. On 6/16/21 at 8:27 AM, Surveyor asked RN C if there was a protocol for how often to check on or monitor R1 or anyone that is outside. RN C said no, there's no protocol. Surveyor asked RN C where R1 sits when he is out on balcony. RN C said where R1 sits changes because sometimes he wants to sit in the sun and sometimes he doesn't. Surveyor asked RN C how the staff is aware if R1 is outside. RN C stated we communicate with each other. RN C went on to say R1 enjoys being warm and he always has a mug with something to drink in it and his cell phone. On 6/16/21 at 10:01 AM, Surveyor interviewed RNCC F (Registered Nurse Care Coordinator). Surveyor asked RNCC F what the protocol was for checking on or monitoring R1 when he is outside. RNCC F said generally check on him every hour to see if he needs anything. I prefer he be out on balcony so he is able to be seen, that way he is within eyesight. Surveyor asked RNCC F if someone is talking to him every hour or looking out at him every hour, RNCC F said not talking to him, looking out at him. Surveyor asked RNCC F if she had any information in regard to R1 being outside and unable to get back in or reach staff; RNCC F stated, I heard about a time at the end of May but can't tell you anything more about it and then last week RN C didn't have the cell phone on her when R1 was trying to call to come in and he was upset. On 6/15/21 at 4:54 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she was aware R1 had been outside on 6/9/21 for approximately four hours. DON B said she received an email from RN C (Registered Nurse) stating R1 was upset because he couldn't reach RN C when he was trying to call her and the reason was because the cell phone hadn't been charged overnight. As a result, RN C wasn't carrying the cell phone. DON B stated RN C apologized to R1 and his wife for this. DON B printed the email from RN C and kept in a soft file for this incident for R1. On the email there was a handwritten note that said resolved. Surveyor asked DON B if there was any education done after the 6/9/21 incident. DON B said yes, RN C was educated to ensure the cell phone was charged. When Surveyor asked DON B if any other education was completed, DON B said no. DON B explained R1 is the only resident that goes outdoors alone and he always has his cell phone with him. When Surveyor asked DON B what if R1 were to drop his cell phone, would he be able to pick it up, DON B replied no. Surveyor asked DON B from a medical aspect, what you would expect your staff to do; DON B stated A full set of VS, push fluids, and a head to toe assessment. Surveyor asked DON B where this would be documented. DON B said in the progress notes. It is important to note there is no assessment of any kind documented in the progress notes in R1's medical record. In summary, the facility does not have a procedure in place to report when a resident is outside and a process to check on residents, especially dependent residents, when they are outside. On 6/9/21, R1 was taken outside on AM shift at approximately 12:30 PM. This information was not passed onto PM shift. PM shift on 6/9/21 discovered R1 was outside when LPN I went to check his blood sugar. R1 was outside for approximately 4 hours, during which time he did want to come back in and had attempted to call the facility with no answer. R1 subsequently fell asleep outside and when brought back inside stated he was exhausted. With extreme temperatures on 6/9/21 and R1's diagnoses and medications, R1 was placed at significant risk. The failure to ensure a system for checking on residents when they are outside or to alert oncoming staff a resident was outside resulted in an Immediate Jeopardy to the health and safety of R1. The Immediate Jeopardy was removed on 6/16/21 after the facility completed the following: On 6/16/21 a facility house sweep was completed and it was determined all current residents require physical assistance from staff to go outdoors. Education for staff began on 6/16/21 and will continue prior to each staff next shift until all staff have received education non-areas below. On 6/16/21 a facility outdoor policy has been implemented for all residents: Resident going outside and remaining outdoors alone - follow these directions: 1. Date/time sign out - staff to document on log 2. Offer/provide sunscreen (in med room) 3. Offer/provide hydration to take outside 4. Encourage to take personal cell phone with outside a. Nursing unit phone numbers have been posted on patio areas b. Staff taking resident outside will manually check resident phone to ensure it is charged 4. Offer/provide shade (example umbrella on HRC floor two balcony) 5. Large loud sign to be hung on doorway indicating to all staff resident is out doors currently. This will serve as visual cue resident is outside. 6. It is the expectation of all staff to check on residents when out outside. a. Residents are outside as of 6/16/21 bright signs to be posted - once available: flag up/down process will replace signage to indicate to all staff when residents are outdoors. b. The staff member first physically taking resident outdoors is ultimately responsible for this resident while outside. Staff are to report off to a co-worker residents are outdoors during any breaks and at change of shift. Example therapy staff must verbally report off to nursing staff and sign on log. c. Flag system is also visual reminder to all staff resident is outdoors. 7. (Upon arrival of remote door chimes) Resident outside will be provided with pendant with a door bell chime - that can be used for needs while outside. Until doors chimes arrive (ETA Friday 6/18/21) 30 min checks will be in place for when residents outside. Checks are documented on log. a. Facility is pursuing the option of pendant system to be added to our call light system for term plan if system able to accommodate. 8. Document Time back inside building and staff initial (Example) This will be posted also on the door in a clip board. Upon arrival of door chimes will update taking resident name off/30 min check off this log. Will be noted patio check or balcony check. The following information will be documented on a grid- Resident Name and Room #, Date and time first outside, Name of staff taking resident outside, 30 min checks Time and initial, Outside Location of resident, Time return inside/initial of staff, and other notes. Extreme weather policy will be reviewed, updated and posted in each department. Residents choosing to go outside on extreme weather alert days will be monitored every 30 minutes and no resident will be outside for more than two hours per sitting on extreme weather days. Extreme weather days are detailed in policy. All staff education will be completed on these procedures. Staff will be educated on all areas prior to their next working shift. Residents will be educated on the new outdoor procedure. Any resident going outside will be able to use call system, cell phone or pendant to alert staff to needs. QAPI: NHA, DON or designee will observe residents who are outdoors to ensure monitor/call system is readily available and residents are able to alert staff to needs using cell phone properly or call device. This will be monitored daily X 14, weekly x 4 then randomly thereafter. Follow up will be reviewed at QAPI meeting.

Based on observation, interviews and record review, the facility did not ensure 2 out of 7 residents (Residents 4 and 2) reviewed for pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Resident 4 entered the facility without any pressure ulcers. Resident 4 ' s Norton skin assessment indicated Resident 4 was at high risk for the development of pressure ulcers. The facility did not initiate preventative measures his plan of care for off-loading of his feet to prevent pressure ulcers from developing. The facility did not provide evidence in his record that he refused to offload his heels. Resident 4 has a current healing unstagable pressure ulcer on his right medial heel. Resident 2 is at risk for skin problems. Resident 2's heels were not floated as indicated in his care plan. This is evidenced by: A Quick Reference Guide entitled "Pressure Ulcer Prevention" published by the National Pressure Ulcer Advisory Panel in 2009 indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Using a pillow under the calves so the heels are elevated (i.e., "floating") will accomplish reduction of pressure on heels. The facility's policy for Skin Risk Assessment, dated 4/2010 indicates: Objective : To identify residents at risk for skin problems, including pressure ulcers and to define early interventions form prevention. Policy: All residents will be assessed on admission, quarterly and upon any change of condition for risk factors related to skin breakdown. Upon identification of those at risk, specific approaches will be included in residents ' plan of care to minimize risk and assure adequate assessment and early identification of potential skin problems. The facility did not identify approaches in Resident 4's plan of care to prevent pressure ulcers from developing. Protocol for Problem Identification and Follow-up. 1. Weekly CNA (Certified Nursing Assistant) bath day and skin condition worksheet is completed during each resident's weekly shower. The CNA and Nurse will observe the resident's skin. (Resident 4 is diabetic and there is no evidence the facility did daily foot checks to identify pressure areas to prevent his unstagable pressure ulcer). The facility's policy for Standards of Care, dated 5/10 indicates: I. Objectives To establish staff accountabilities while providing care. II. General Information: *Extension of the care plan. Both must have same information. *CNA is accountable for the information before caring for the resident. *CNA is accountable for updating the information with the Team Leader. B. Personal Hygiene and Cleanliness Personal cares are provided by the CNA, but can be performed by Licensed staff, therapy staff and activities if CNA. *Floating heels: Offer to float heels for all residents when in bed. Place one pillow per leg under the heel. The heel is not to touch the pillow or the bed. If residents decline-notify the nurse. C. Turning and repositioning: *Turn approximately every 2 hours. *High risk of Pressure Ulcer reposition in wheelchair-every hour. (The policy did not indicate an approach for a resident in a recliner or bed). Example 1 Resident 4's [DIAGNOSES REDACTED]. He was admitted on [DATE]. Resident 4's Norton scale assessment upon admission, dated 7/26/11, indicated he was at high risk for developing a pressure ulcer, he scored 8 (a score of 10 or less indicates high risk). On 7/26/11, an admission nurses note indicated Resident 4 was intermittently confused, pleasant and cooperative. The nurse ' s note did not mention his skin. His BIMS (Brief Interview Mental Status) was 15 (no cognitive impairment). A physical therapy note, dated 8/24/11 indicated he walked 50 feet with a 2 wheel walker followed by staff and wheel chair. On 8/25/1 he was discharged from physical therapy to nursing care. He was to walk with a 2 wheel walker with a CNA following him with wheel chair. Resident 4's care plan for Skin breakdown, dated 8/5/11 did not indicate his heels should be raised off the bed. (The facility indicated it was their standard of practice to offload all residents ' heels and the nurses were to document when Resident 4 refused to offload his heels). There was little evidence nurses documented that Resident 4 refused to raise his heels off the bed). Resident 4's care sheet that directs his cares did not indicate his heels were to be elevated off his bed to protect his heels though he was a high risk for pressure ulcers. Resident 4's MDS 30 day (Minimum Data Set), dated 8/21/11 indicated his BIMS were 15 (No Cognitive Impairment), he needed extensive assistance with bed mobility and transfers. On 8/26/11 a nurse ' s note indicates Resident 4 had 2 stage 2 pressure ulcers. The pressure ulcers were blisters on his right and left heels. The right medial heel ulcer measured 3cm (centimeters) x 1cm and the left heel ulcer measured 2.5cm x 1cm. The note indicated his shoes were tight and were removed. The staff was instructed not to put his shoes on. After the development of the ulcers staff elevated his feet on pillows when in bed. The facility elevated his feet after the pressure ulcers developed. His record did not indicate his heels were a stage 1 at any time. (Staff indicated the pressure ulcers developed from rubbing his feet together but did not protect his feet before developing the ulcers. There was no evidence the facility elevated his heels off the bed before the development of the pressure ulcers). On 8/27/11 float heels while in bed was added to Resident 4's TAR (treatment administration record). This was not added to his care plan. Floating his heels was added after the pressure ulcers appeared as stage 2. There was no evidence the facility floated his heels prior to the development of the ulcers. (The facility said all refusals are noted in the nurses ' notes and refusals were noted only a few times). Additionally, EZ boots to be worn while in bed was added to the TAR. This treatment was added to his skin breakdown care plan. The nurse ' s note dated 9/1/11 indicates Resident 4's pressure ulcer measured 3.5cm x 5.0cm, is a stage 2 and his pain is a 3 out 10. The treatment is [MEDICATION NAME] twice a day with skin prep around the wound. No shoes are to be worn and EZ boots are to be worn. A consult for diabetic shoes is in place. On 9/8/11 Resident 4's nurse ' s note indicates the right heel ulcer is a stage 2, measures 4.0cm x 7.4cm and continues as a blister. Resident 4 describes his pain as very painful when you applied the treatment. He rates it at 3 out of a scale of 1 to 10 with 10 being very painful. The treatment remains the same. On 9/14/11 Resident 4's nurses notes indicate his right medial heel ulcer is a stage 2, measures 3.9cm x 4.9cm and has 15% white macerated tissue and 85% red granulation tissue. The treatment is skin prep to periwound and heel and [MEDICATION NAME] to macerated edges. The blister has popped since last wound charting. The date the blister popped is not indicted in the nurses ' notes. An MD order was noted on 9/15/11 for Resident 4 to wear protective boots to heels on feet at bedtime. On 9/23/11 Resident 4 ' s nurses ' notes indicate his right medial heel ulcer was a stage 2, measured 4.5c. x 6.3cm, was 50% white tissue and 50% granulation tissue. He calls out in pain but won't rate it. The treatment was changed to [MEDICATION NAME] covered with a [MEDICATION NAME] plus to be changed every 3 days. He continues to use the EZ boots. Resident 4's Pain care plan, dated 9/30 indicated he required 2 assistants using the EZ stand lift with a sling for safety. On 10/1/11 Resident 4's nurse's note indicated his left heel ulcer was healed. His right medial heel ulcer is now referred to as a deep tissue injury, measures 3.5cm x 7.4cm, has white area of 0.6cm radius, and 20% white macerated tissue and 80% purple tissue. The treatment remains the same. On 10/2/11 a telephone order indicated Resident 4 was transferred to the hospital for evaluation of his right heel pressure ulcer. He was admitted to the hospital. His wound was cultured for infection. The results of the wound culture indicated he was infected with Morganell morganii [MEDICAL CONDITION]. He was treated with an antibiotic A WOC Nurse wound/skin consult note on 10/3/11 indicated Resident 4's right heel pressure ulcer is unstageable due to presence of dry black eschar over the wound bed. The eschar measures 4.5cm x 4cm. There is a 2-3cm rim of [DIAGNOSES REDACTED] around the eschar. A small amount of serosanguinous drainage was present on the gauze dressing. The ulcer is boggy under the eschar and there is a foul odor to the wound. He complains of constant right heel pain. The eschar is considered as unstable at this point due to the [DIAGNOSES REDACTED], odor and drainage and will require debridement to remove the infection. His bilateral pedal pulses are audible with a Doppler. The wound nurse recommended sharp debridement per surgical service of the right heel pressure ulcer followed with topical wound care twice a day pack with 0.25% Dakin's moistened gauze packing. Keep pressure off of both heels at all times-PRAFOs to bilateral lower extremities on 6 hours/off 2 hours., elevate heels off of bed surface at all times. Surveyor received the manufacturer ' s information on the Prafo boots on 7/11/12. The information indicated the applications and indications are for: early intervention for the evolving rehab patient: offloads vulnerable soft tissue. It is primary worn during ambulation and while recumbent (without a shoe) and when patient is at risk for skin breakdown. Recommend to wearing schedule: With patients having compromised sensation, at risk for skin breakdown or disruption of soft tissue surface - not to exceed 6 hours of wear without removal from 30 minutes to 1 hour then reapply. His TAR indicated the prafo was to be checked every four hours. There was no evidence this was done. Additionally, the intervention was not on the care plan. On 10/4/11 the vascular surgeon noted the ABI (Ankle Brachial Index) indicated Resident 4's pulse volume recordings appear to demonstrate good or normal arterial circulation, Doppler wave form indicated he has small vessel disease bilateral. PVR's (Peripheral Vascular Resistance) demonstrate adequate flow. He ordered to continue to keep pressure off both heels and elevate. On 10/7/11 the prafo boots were added to Resident 4's TAR. It was not added to his plan of care until 2/29/12. On 10/10/11 Resident 4's nurses note indicates his right medial heel ulcer is unstageable, measures 5.2cm x 8.2cm, 100% eschar with drying skin around the eschar. The edges are regular. He has pain when touched. The treatment is [MEDICATION NAME] daily. Resident 4's therapy notes on 10/10/11 indicate he can WBAT (weight bear as tolerated) when his heel ulcer improved. He has an active infection in his right heel ulcer that extends into weight bearing surface. He is to avoid weight bearing until healed. Resident 4 ' s Pain care plan, dated 10/10/11 indicated his transfer was changed to the Hoyer lift, no pressure on his right heel. On 12/28/11 Resident 4 ' s Pain care plan indicated he was not to bear weight and is to use an EZ stand lift for transferring. (The EZ stand lift requires a resident to assist and stand on his feet). On 10/20/11 Resident 4's nurses note indicates his right medial heel ulcer remains unstageable, measures 5.5cm x 8.0cm with total eschar measuring 5.3cm (90%) with 10% dried white tissue. Pain is rated at 2 out of 10. A consultant/clinic visit form indicated Resident 4 needed his wound on right heel addressed by wound nurse and his right heel sore is very tender: recommend continue non weight bearing on right foot until healed to prevent further tissue loss. The MD ordered [MEDICATION NAME] 100mg (milligram) twice a day for 7 more days and to continue wound treatment. On 10/20/11 a MD note indicated vascular surgery did not feel debridement was necessary and to paint (The eschar) daily until it falls off. The facility assessed and documented wound measurements weekly from 10/29/11 with measurements of 5.2 x 8.2cm, is 100% eschar through 1/19/12 measures 3.7cm x 5.8cm with 100% eschar. With little change in the wound and no changes to treatment. On 1/19/12 there is some tan drainage noted under the eschar, not actually draining. The treatment remains the same. The wound is unchanged. On 1/26/12 Resident 4's nurse ' s note indicates his right heel ulcer is unstageable, measures 3.2cm x 6.3cm with 90% eschar and 10% tan slough, no drainage. He complains of pain with palpitation. The treatment remains to same. The wound is unchanged. On 1/31/12 Resident 4's nurse ' s note indicates his right heel ulcer is unstageable, measures 3.4cm x 6.7cm with 95% eschar and 5% slough. The periwound has slight [DIAGNOSES REDACTED] around the base. He has pain with palpitation. The treatment is to clean with normal saline, paint with [MEDICATION NAME], cover with [MEDICATION NAME] and wrap with kling wrap. The wound is unchanged. On 2/11/12 Resident 4's nurse ' s note indicates his right heel ulcer is unstageable, measures 3.2cm x 5.9cm with 100% eschar. Slough is noted under eschar and slight erythma around the base. The wound was cultured and treated with antibiotic [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) in the wound. He has slight pain with palpitation. On 2/17/12 Resident 4's nurses note indicates his right heel ulcer is unstageable, measures 3.2cm x 5.7cm with 95% eschar and 5% tan slough. The periwound is slightly pink. The wound has scant tan/brown drainage. The treatment remains the same. On 2/21/12 Resident 4's nurses note indicates his right heel ulcer is unstageable, measures 3.1cm x 5.5cm with 95% eschar and 5% tan slough. The periwound is slightly pink. There is 25% tan slough drainage. He complains of pain with palpitation. Ez boots are on at all times. He will be sent to a wound consultant. The wound is unchanged. An MD note on 3/12/12 indicated Resident 4's wound was debrided by plastic surgery on 2/29/12. On 3/1/12 Resident 4's nurse ' s note indicates his right heel ulcer is unstageable, measures 3.3cm x 5.6cm with 90% slough and 10% granulation tissue. Drainage is 100% slough. He has pain with palpitation. The treatment changed to clean with normal saline, apply Vaseline to periwound, moisten 4x4 gauze with dakis and apply to slough, cover with 4x4 gauze and wrap with kling wrap. He wears Ez boots. The wound is healing. On 3/15/12 Resident 4's nurses note indicates his right heel ulcer is a healing unstageable, now stage 3. It measures 2.0cm x 4.4cm with 90% slough. He has drainage of 30% slough. He has slight pain with palpation. The treatment remains the same as above. He will occasionally take off boots due to not liking then on in bed. (It should be noted that the boots were not ordered until the pressure ulcer developed).The wound is healing. On 3/24/12 Resident 4's nurses note indicates his right heel ulcer is a healing unstageable, now stage 3. It measures 2.2cm x 4.6cm x 0.3cm in depth. The periwound is yellow/brown and hard. The drainage is yellow/tan. He complains of pain with palpation. The treatment is Vaseline to the periwound, santyl and [MEDICATION NAME] powder sprinkled on the santyl on the wound bed and cover with dry gauze. His boot is on his right foot when in bed and his shoe is on when he is up. His wound is healing. On 4/1.12 Resident 4's nurse ' s note indicates his right heel ulcer is a healing unstageable, measures 2.4cm x 4.4cm x 0.3cm. The periwound is yellow/brown and hard. There is yellow/tan drainage. He has pain with palpation. The treatment remains the same as above. He wears the boot in bed and his shoe when up. The wound is healing. On 4/7/12 Resident 4's nurse ' s note indicates his right heel ulcer is a healing unstageable, now stage 3. The wound measures 2.2cm x 4.2cm x 0.4cm with 25% slough. The wound below the malleolus is red and painful with palpitation. The wound has 50% serous drainage. The treatment remains the same. The boot is on when in bed and shoe on when up. The wound is healing. 4/10/12 Resident 4's nurses note indicates his right heel ulcer is a healing unstageable, now stage 3. The wound measures 1.9cm x 3.9cm x 0.4cm with 25% slough. He has 50% tan drainage on the gauze with some serous drainage on the Kling wrap. He complained of some pain with palpitation. The treatment changed to A&D to periwound in place of Vaseline. His boot is on when in bed and his shoe is on when up. On 4/22/12 Resident 4's nurses note indicates his right heel ulcer is a healing unstageable, now stage 3. The wound measures 1.5cm x 3.9cm x 0.4cm with 10% slough. There is 50% tan drainage. He has pain on the bottom of the wound with palpitation. The treatment remains the same as above. The nurse ' s note indicates he has been refusing to wear or keep the prafo boot on. (The facility did not provide evidence that the resident refused the treatment). On 4/24/12 Resident 4's nurse ' s note indicates his right heel ulcer is a healing unstageable, now stage 3. The wound measures 1.3cm x 3.3cm with depth flush and 5%slough. 50% of the 2 x 2 gauze has serous drainage. He has pain with palpitation. The treatment remains the same as above. On 5/5/12 Resident 4's nurses note indicates his right heel ulcer is a healing unstageable, now stage 3. The wound measures 1.3 x 3.7cm and has 5% slough. The skin around the wound is dry. The wound has 25% drainage of slough/tan. He continues to have pain with palpitation. The treatment remains the same. The wound is healing. On 5/12/12 Resident 4's nurses note indicates his right heel ulcer is a healing unstageable, now stage 3. The wound measures 1.5cm x 3.7cm with 10% slough. There is 75% slough/tan drainage. He has pain with palpitation. The treatment remains the same. He continues to wear the boot while in bed but often refuses and his shoe when up. The facility does not track or document his refusals. On 5/19/12 Resident 4's nurses note indicates his right heel ulcer is a healing unstageable, now stage 3. The wound measured 1.1cm x 3.6cm with 5% slough. The periwound is dry and flaky. The wound drainage was 100% of the 2x2 gauze and was tan. The treatment remains the same as above. He continues to wear the boot at night and shoe when he is up. The Nurse Practitioners note on 5/22/12 indicates Resident 4 ' s spouse states he has not been able to bear weight on his legs for months due to the pressure ulcer on his heel. She would like physical therapy re-initiated immediately. His wife felt discharging him from therapy is a "death sentence. " She believes he was indeed making progress, had more energy, was eating better and overall improving while he was attending physical therapy. On 5/23/12 Resident 4's nurse ' s note indicates his right heel ulcer is a healing unstageable. The wound measured 1.0cm x 3.3cm with 5% slough. He had pain with palpitation. The periwound was dry and flaky. On 6/2/12 Resident 4's nurses note indicates his right heel ulcer is a healing unstageable, now stage 2. The wound measured 1cm x 3cm. The treatment changed to meplix change every other day. He continues to had the order to wear the boot when in bed and his shoe when up. However, he is non-adherent to wear the boot in bed. The wound is healing. (Although the nursing notes indicate the resident is " non-adherent " with the boot there is no indication of how the facility will address these refusals or alter the intervention to gain compliance.) On 6/16/12 Resident 4's nurse ' s note indicates his right heel ulcer is a healing unstageable. The wound measured 0.8cm x 2.2cm x <0.1cm with 25% tan drainage. He complained of slight pain around the wound. He is non-adherent to wearing boots in bed at times. (Again, it should be noted that there is no evidence staff educated him on the importance of wearing the boot or how often the refusals were happening.) On 6/20/12 Resident 4's nurses note indicates his right heel ulcer is a healing unstageable, now stage 2. The wound measured 1.1cm x 3.7cm x 0.1cm with 100% white tissue. On 6/30/12 Resident 4's nurse ' s note indicates his right heel ulcer measured 0.4cm x 0.7cm x 0.1cm with a small amount of tan drainage. He complained of mild pain when palpated. His boot is on when in bed. On 7/7/12 Resident 4's nurse ' s note indicates his right heel ulcer is a healing unstageable. He has 2 small open areas: one measures 0.5cm x 0.5cm with 100% white tissue, this one is closest to his toes. The second wound is closest to his heel and measures 0.4cm x 0.7cm x 0.1cm with 100% white tissue. He continues to wear the prafo boot when in bed. On 7/10/12, at 10:45 am Surveyor observed the treatment done by RN (Registered Nurse)/Wound Nurse to Resident 4's right medial heel pressure ulcer. No measurements were completed during the observation. He had two areas that were open and white on the medial right heel. No drainage or odor was noted. RN D said the ulcers started as a blister. When RN/Wound Nurse finished the treatment she laid the resident ' s heel directly on the bed. Surveyor asked RN/Wound Nurse D how the pressure ulcer developed. She said he rubbed his feet together and blisters developed. On 7/10/12, at 4:00 pm Surveyor was asked by staff to speak with Resident 4's family per their request. Surveyor proceeded to talk with Resident 4 ' s wife. She said she wanted the resident ' s physical therapy to be paid for. She said he has not been able to walk since he got the pressure ulcer. She said they never placed pillows under his legs to offload his heels and prevent the pressure ulcer. Resident 4 agreed with his wife. On 7/11/12, at 7:05 am Surveyor observed Resident 4 in bed lying on his left side. On 7/11/12, at 7:20 am Surveyor observed Resident 4 in bed lying on his left side with his prafo boot on, however his right medial heel was resting on the mattress. His pressure ulcer was not protected from pressure. On 7/11/12, at 9:20 am Surveyor observed Resident 4 in bed lying on his left side. His right medial heel, with the prafo boot on, was resting directly on his mattress. On 7/11/12, at 9:45 am, Surveyor observed Resident 4 lying in bed on his left side. He had his prafo boot on his right foot and a blue boot on his left foot. (It should be noted that the boots did not provide protection). Both were lying directly on the bed. His heels were not elevated off the bed for protection. On 7/11/12, at 10:10 am Surveyor asked RN (Registered Nurse) L when a resident is at risk for pressure ulcers and needs to protect their skin and elevate their heels off the bed how does your staff know to do this. She said it is a standard of practice and we do it on every resident. On 7/11/12, at 10:40 am Surveyor observed Resident 4's prafo boot. The inside was lined with sheepskin type material; the strength of the boot was plastic and metal. When Surveyor observed the prafo boot, the sheepskin like material was flattened in the area of the pressure ulcer from wearing it. Additionally, the sheepskin type material was observed stained with a dark colored substance. (The surveyor was told later that the substance was [MEDICATION NAME] from the treatment). The prafo boot did not relieve the pressure on his medial heel ulcer. On 7/12/12 at 2:15 pm Surveyor asked DON (Director of Nursing) B how the staff keeps track of the resident's refusal to offload his heels. She said the CNA should tell the nurse and the nurse would document the refusals. She said she would expect his heels to be offloaded and if he refuses it should be documented. She said there is new charting for the CNAs in starting in September. She said the facility tried soft protective boots to prevent the pressure ulcer and stop the rubbing. (It should be noted there was no evidence the facility tried the soft boot.) She said the nurses do a head to toe assessment every week; she did not indicate a foot assessment was done daily on the Resident 4's though he is diabetic. On 7/12/12, at 1:30 pm Surveyor asked CNA (Certified Nursing Assistant) C if Resident 4's heels are offloaded. She said he refused the offloading most of the time. He doesn't reposition off his left side. His back hurts to lie on. His urinal is on the left side of him so he can reach it easily. Again, no evidence of his refusal to offload his heels was provided. On 7/12/12, at 3:15 pm Surveyor asked CNA E how she knew if she had to offload a resident's heels off the bed. She said she would look at the CNA care sheet; certain people are on the care sheet to float heels. Resident 4's care sheet did not indicate to off load his heels off the bed. Example 2 Resident 2 was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. On 7/10/12 at 1:00 PM Surveyor observed Resident 2 lying in bed. Resident 2's heels were on the mattress. Resident 2's heels were not being floated. On 7/10/12 at 3:20 PM Surveyor observed Resident 2 lying in bed. Resident 2's heels were on the mattress. Resident 2's heels were not being floated. On 7/11/12 at 8:05 AM Surveyor observed Resident 2 lying in bed. Resident 2's heels were on the mattress. Resident 2's heels were not being floated. On 7/10/12 at 1:15 PM Surveyor reviewed the following information in Resident 2's medical record. Resident 2's care plan problem, at risk for skin problems related to decreased mobility included the following approach: Float heels when in bed. On 7/12/12 at 10:30 AM Surveyor interviewed RN (Registered Nurse) M. RN M stated he would expect Resident 2's heels to be floated when he is lying in bed. RN M stated if Resident 2 refused to have his heels floated he would expect staff to inform the nurse caring for Resident 2 and the refusal charted. On 7/12/12 at 10:35 AM Surveyor interviewed CNA (Certified Nursing Assistant) N. CNA N stated he would float Resident 2's heels if he laid him down. CNA N stated if Resident 2 refused to have his heels floated he would report the refusal to the nurse. On 7/12/12 at 2:50 PM Surveyor interviewed DON (Director of Nursing) B. DON B stated she would expect staff to follow Resident 2's care plan and float Resident 2's heels. DON B stated if Resident 2 refused to have his heels floated she would expect staff to inform the nurse caring for Resident 2 and the refusal charted. DON B stated she could not find any charting to reflect Resident 2 refusing to have his heels floated.