Every finding on record at Paloma Springs Healthcare LLC

Based on record review, interview, and observation, the facility failed to ensure medical records were complete and accurate for 1 (R #18) of 3 (R #16, R #17, and R #18) residents reviewed for behavioral health treatment when staff failed to:Document R #18's behaviors.Document side effects (any unintended effect of a medication) from R #18's anti- anxiety medication (used to treat anxiety symptoms). These deficient practices could likely cause staff to not have the most accurate resident information and adversely impact the care staff provides. The findings are:A. Record review of the facility's Behavior Management Policy, revised January 2026, revealed the following: 1. When a resident exhibits adverse behavioral symptom (e.g., crying, yelling, hitting, biting, etc.), licensed nursing staff will document the behaviors in the medical record, noting the time the behavior(s) occur, antecedent events, possible causal factors and interventions attempted. 2. Nursing staff will document the resident's response to medication, including behaviors and side effects on the Medication Administration Record (MAR). B. Record review of R #18's admission Record, no date, revealed the following:1. R #18 was admitted to the facility on [DATE].2. R #18 had the following diagnoses: a. Senile degeneration of brain (an older, non-specific term for age-related cognitive decline that leads to dementia). b. Dementia, unspecified severity, with agitation. c. Anxiety disorder (persistent, excessive fear or worry that interferes with daily life). d. Delirium (a serious, sudden-onset state of severe confusion characterized by disorganized thinking, inattention, and fluctuating awareness of one's surroundings). e. Disorientation (a temporary altered mental state where a person struggles to recognize time, place, or personal identity). f. Altered mental status (a broad, nonspecific term describing a change in a person's baseline awareness, cognition, or arousal). C. On 06/24/26 at 12:38 PM, an observation and interview with R #18 revealed the following:1. R #18 did not appear to be in any distress.2. R #18 was confused about where she was or why she was there. D. Record review of R #18's physician's orders revealed the following: 1. An order dated 01/26/26 and discontinued on 06/09/26, for lorazepam 2 milligrams per milliliter (mg/ml) by mouth one time a day for anxiety or agitation.2. An order dated 06/09/26, for haloperidol lactate (Haldol, used to rapidly control acute psychotic episodes, severe agitation, and aggression) 0.5 ml my mouth one time a day for agitation. E. Record review of R #18's nursing progress notes revealed the following:1. On 06/08/26, staff documented the Social Services Director was asked to follow up with R #18 due to behaviors. Staff did not document what behaviors R #18 was exhibiting.2. On 06/09/26, staff documented an order was received for Haldol due to R #18's increased behaviors. Staff did not document what behaviors R #18 was exhibiting, which required an order for Haldol to be given daily.3. Staff did not document why the order for daily lorazepam was discontinued on 06/09/26. F. On 06/25/26 at 11:21 AM, during an interview, RN #18 stated the following: 1. R #18 was frequently confused. 2. R #18 was frequently agitated (he did not specify what agitated R #18). G. On 06/25/26 at 11:26 AM, during an interview, CNA #16 stated the following: 1. R #18 would go into other people's rooms because she thought her family member (FM) or her things were in there. 2. R #18 was difficult to redirect when she was agitated. 3. He told the nurse whenever R #18 was agitated. H. Record review of R #18's MAR, dated June 2026, revealed the following:1. Staff documented R #18 had no behaviors between 06/01/26 and 06/24/26.2. Staff did not document any side effects from anti-anxiety medication. I. On 06/25/26 at 11:37 AM, during a joint interview, ADON #1 and ADON #2 stated the following: 1. When one of R #18's FM's would visit her, R #18 would cry, yell, and scream if anyone got near her FM. 2. R #18's FM would visit her almost every day. 3. Lorazepam was making R #18 drowsy so the provider changed the order to Haldol. 4. Haldol did not make R #18 drowsy and she seemed to have a better quality of life. 5. They confirmed staff did not document R #18's behaviors in progress notes or TAR. 6. They confirmed staff did not document that lorazepam was making R #18 drowsy. 7. They confirmed staff were expected to document all resident behaviors and interventions in the medical record. 8. They confirmed staff were expected to document side effects of medication in the medical record.

Based on record review and interview, the facility failed to report an injury of unknown origin to the State Agency (SA) for 1 (R #1) of 3 (R #1, R #2 and R #3) residents sampled for neglect. If the facility fails to report allegations of possible neglect to the SA, then the SA is unable to ensure residents are free from neglect and have a safe home environment. The findings are:A. Record review of the facility's incident report for R #1 dated 09/28/25 at 6:30 AM revealed the following: 1. Incident documented as other. 2. Nursing description of incident: R #1 was found in bed with blood on her face, her bed, the floor and in the trashcan. 3. Resident description of incident: R #1 stated she was not sure what happened. When asked if she fell resident stated I'm not sure, I don't remember what happened. I don't know if I fell. 4. Immediate action taken by staff: R #1 was assessed by nursing staff, provider was notified of the incident and R #1 was sent to the emergency room for further evaluation. B. On 12/04/25 at 2:53 PM, during an interview with LPN #1 revealed the following: 1. LPN #1 stated she assessed R #1 at approximately 6:20 AM on 09/28/25. 2. R #1 had a knot (bump) on her forehead, blood on her face, and abrasions (scrapes) to both her elbows and her knees. LPN #1 stated she could not tell where the blood had come from. 3. LPN #1 stated R #1 said she could not remember what happened. 4. LPN #1 contacted the on-call provider, and R #1 was sent out to the emergency room for further evaluation 09/28/25 at 6:45 AM. 5. R #1 returned to the facility on [DATE] at approximately 12:00 PM. 6. R #1 was diagnosed with a contusion (bruising that does not break the skin and is characterized by tenderness and swelling in the affected area). C. On 12/05/25 at 12:20 PM, during an interview with the administrator, the following was revealed: 1. R #1's incident was listed as other because initially the facility staff did not know how R #1 was injured. 2. R #1's incident was not reported to the SA. 3. R #1's incident was discussed by the interdisciplinary team (IDT; group of health care professionals from various disciplines who collaborate to address the comprehensive needs of the resident), and the conclusion was made that R #1 had likely fallen. 4. The administrator revealed that looking at all the evidence the facility should have probably reported the incident to the SA as an injury of unknown origin.

Based on record review and interview, the facility failed to complete a significant change (major decline or improvement in the patient's health status) MDS Set assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for MDS. This deficient practice could likely result in the residents not receiving the appropriate care and services they need. The findings are:A. Record review of R #1's physician orders revealed an order dated 11/06/25 admit to hospice care (special kind of care that focuses on a person's quality of life and dignity near the end of life) effective 11/06/25. B. Record review of R #1's significant change of condition MDS assessment dated [DATE], revealed the MDS assessment was not signed off by the RN until 12/01/25. C. On 12/05/25 at 12:40 PM, during an interview with the MDS coordinator, she confirmed that the significant change MDS assessment for R #1 was not signed off within 14 days. The MDS Coordinator confirmed that the significant change MDS assessments should be signed by the RN within 14 days of the change of condition.

Based on record review and interview, the facility failed to ensure that an MDS assessment was completed every three months for 1 (R #8) of 4 (R #8, R #9, R #10, and R #11) residents reviewed for MDS assessments, when they failed to complete quarterly MDS assessments timely (completed 14 days after the assessment reference date (ARD)). This deficient practice could result in resident's assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are: A. Record review of R #8's quarterly MDS assessment dated [DATE] revealed the following: 1. ARD date of 11/14/25. 2. Not signed by the RN for completion. B. On 12/05/25 at 9:49 AM, during an interview, the MDS Coordinator (MSC) confirmed that R #8's MDS assessment was not completed on time.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #1) of 3 (R #1, R #2 and R #3) residents reviewed for documentation accuracy. This deficient practice has the potential to have a negative impact on the care staff provide to residents due to missing or inaccurate records and resident information. The findings are: A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had the following diagnoses: a. Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that cause airflow obstruction and breathing problems) with acute exacerbation (a sudden worsening of symptoms in a chronic condition). b. Respiratory failure unspecified whether with hypoxia or hypercapnia (condition where you do not have enough oxygen in the tissues in your body [hypoxia] or when you have too much carbon dioxide in your blood [hypercapnia]. B. Record review of R #1's care plan dated 01/08/25 revealed the following: 1. Focus: R #1 has pain. Goal: R #1's pain will be kept to minimal (mild and barely noticeable). Approaches (actions taken by facility staff): Monitor/Record pain characteristics: Quality (nature of pain, describing how it feels, such as sharp, dull, throbbing, or burning), severity (intensity of pain, determine by 0-10 scale; 0 is no pain and 10 is the worst pain imaginable), anatomical location (where on the body the pain is occurring), onset (when the pain began), duration (how long the pain lasts), aggravating factors (what makes pain worse), relieving factors (what helps decrease pain). 2. Focus: R #1 has COPD. Goal: R #1's medical conditions will be managed on a daily basis. Approaches (actions taken by facility staff): administer PRN meds, listen to lungs sounds PRN, check oxygen saturation PRN, notify family and doctor of respiratory distress. C. Record review of R #1's nursing progress notes revealed the following: 1. 04/12/25 at 3:40 AM, R #1 complained of shortness of breath (SOB; not being able to get enough air, chest tightness or working harder to breathe). The nurse administered PRN albuterol inhaler (inhaled medication that relaxes muscles in the airways which helps to open them up an make it easier to breathe). 2. 04/12/25 at 3:41 AM, R #1 was given hydroxyzine (medication that helps relieve allergies and has a sedative effect that helps decrease anxiety) for complaints of shortness of breath. 3. 04/12/25 at 4:17 AM, albuterol inhaler and hydroxyzine effective (helped alleviate the symptoms).4. 04/12/25 at 4:21 AM, the resident reported shortness of breath and anxiety. The nurse administered PRN albuterol inhaler and hydroxyzine and notified the on-call provider. R #1 refused to go to the emergency room. 5. 04/12/25 at 7:08 AM, R #1 requested and was given acetaminophen (pain reliever and fever reducer used to treat mild to moderate pain and reduce fever) for complaint of headache. 6. 04/12/25 at 8:01 AM, acetaminophen effective resident reports no pain or discomfort at this time. 7. 04/12/25 at 4:19 PM, R #1 requested and was given acetaminophen. 8. 04/12/25 at 4:20 PM, R #1 requested and was given albuterol inhaler. 9. 04/12/25 at 5:21 PM, acetaminophen and albuterol inhaler effective resident reports no pain or discomfort at this time. Resident reports no SOB or discomfort at this time. 10. 04/12/25 at 11:54 PM, R #1 was given hydroxyzine. 11. 04/13/25 at 2:40 AM, hydroxyzine effective. 12. 04/13/25 at 4:53 AM resident was given acetaminophen. 13. 04/13/25 at 6:20 AM, acetaminophen effective. 14. 04/13/25 at 4:53 PM, R #1 has been short of breath throughout my shift, progressively worsening. Unable to get oxygen above 83-84% (95%-100% oxygen level is considered normal for most adults) this evening, with crackles (abnormal breath sounds that may be heard in the lungs of people with raspatory diseases) in both lower lung bases (bottom of each lung). R #1 also has increased weakness noted this evening. Primary care provider responded with the following feedback: Send to local emergency room via emergency medical services (ambulance). 15. Further record review of R #1's progress notes revealed staff did not document the quality, severity, onset, duration, aggravating factors or relieving factors of pain when they administered acetaminophen for complaints of pain on 04/12/25 at 7:08 AM, 04/12/25 at 4:19 PM, and on 04/13/25 at 4:53 PM. D. On 08/19/25 at 11:42 AM, during an interview, RN #1 stated the following: 1. She was the day shift nurse that worked with R #1 on 04/13/25. 2. On 04/13/25 after lunch (unable to remember the exact time) approximately 12:30 R #1 complained of shortness of breath and anxiety. 3. RN #1 stated this was not an uncommon complaint for R #1, RN #1 further stated R #1 would have increased anxiety related to diagnosis of COPD which causes her to have difficulty breathing. 4. RN #1 stated she administered hydroxyzine to R #1 at approximately 12:30 to help decrease her anxiety and help her to breathe easier. 5. RN #1 stated R #1 received her scheduled nebulizer treatment at approximately the same time (12:30 PM). 6. RN #1 stated she returned to check on R #1 after she had given her the hydroxyzine and scheduled ipratropium-albuterol (combination medication with two bronchodilators [inhaled medication that relaxes muscles in the airways which helps to open them up an make it easier to breathe]) nebulizer (approximately 1:00 PM) and resident reported the medication had helped. 7. RN #1 stated she checked on R #1 again at approximately 4:00 PM, R #1 complained of shortness of breath. RN #1 administered the PRN albuterol nebulizer treatment. 8. RN #1 stated she checked on R #1 at approximately 4:45 PM. R #1 still complained of shortness of breath and at that time also had increased weakness. RN #1 stated she contacted the on-call provider and received orders to send the resident to the emergency room via ambulance. E. Record review of R #1's administration record (spreadsheet where nurses initial to indicate the completion of a treatment or administration of medication), dated April 2025, revealed the following: 1. RN #1 did not document that she administered PRN hydroxyzine on 04/13/25 at 12:30 PM. 2. RN #1 did not document that she administered PRN albuterol nebulizer treatment on 04/13/25 at 4:00 PM. F. On 08/19/25 at 1:24 PM, during an interview with the DON, the following was confirmed: 1. RN #1 did not document her assessments of R #1 throughout the day that prompted her to administer PRN medications. 2. Staff are expected to document all resident assessments. 3. RN #1 did not document the administration of the PRN medications she administered on 04/13/25 4. Staff are expected to document all medications administered on the administration record when they are given. 5. Staff did not document the pain characteristics as indicated on R #1's care plan. 6. Staff are expected to document at minimum the pain levels for which they are administering PRN pain medications.

Based on observation and interview, the facility failed to store food under sanitary conditions for all 81 residents who eat food from the kitchen (residents were identified by the resident census provided by the Administrator on 04/21/25), when they failed to label and date dessert items in the kitchen refrigerator. If the facility fails to store food under safe and sanitary conditions then this could likely lead to foodborne illnesses (Foodborne illness can occur if you eat foods that are contaminated with harmful pathogens such as bacteria, viruses, and fungi) in residents. The findings are: A. On 04/21/25 at 10:24 AM, during an observation of the kitchen, revealed the walk-in refrigerator had 1 tray with 12 desserts on tray with eight (8) out of 12 desserts did not have a date to indicate when they were prepared. B. On 04/21/25 at 10:24 AM, during an interview with the Dietary Director, she confirmed eight (8) out of 12 desserts on the 1 tray in the refrigerator did not have dates on lids. The Dietary Director stated, having a few with a date on the lids on the same tray should suffice. C. Record review of the facilities Food Labeling and Dating policy revised date 01/25/25 revealed that any food items prepared for a meal will be labeled and dated.

Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #62) of 5 (R #9, R #45, R #46, R #62 and R #90) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are: A. Record review of R #62's physician's orders revealed the following: 1. An order for fluvoxamine oral tablet (psychotropic medication; any drug that affects brain activities associated with mental processes and behavior), 50 milligrams (mg) Give one tablet by mouth two times daily for post-traumatic stress disorder (PTSD; mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). Start date: 08/23/24. B. Record review of R #62's medical record revealed staff did not document consent for fluvoxamine. C. On 04/25/25 at 10:47 AM, during an interview, the Director of Nursing (DON) confirmed that staff did not obtain the consent form for the fluvoxamine for R #62. The DON confirmed that staff are expected to complete the psychotropic medication consent form prior to the resident starting psychotropic medications.

Based on record review and interview, the facility failed to notify the provider of missed medication doses for 1 (R #90) of 1 (R #90) resident reviewed for diarrhea, when they failed to notify the provider that R #90 missed 8 doses of Questran (medication that can provide relief of diarrhea caused by surgery or disease of the small bowel) and 12 doses of fiber (can be used to relieve mild-to-moderate diarrhea. Soluble fiber soaks up water in the digestive tract, which makes stool firmer and slower to pass) medication. This deficient practice could likely result in residents not receiving necessary care or worsening medical condition due to lack of treatment. The findings are: A. Record review of R #90's admission record (no date) revealed the following: 1. R #90 was admitted to the facility on [DATE]. 2. R #90 had the following diagnoses: a. Diarrhea (loose, watery stools that occur more frequently than usual). b. Noninfective gastroenteritis and colitis (involve inflammation of your stomach and intestines). c. Cellulitis of abdominal wall (a rare sign of acute appendicitis that presents as aggressive intra-abdominal inflammation). d. Acquired absence of other parts of digestive tract (missing parts of your digestive organs due to an injury or operation). B. Record review of R #90's physician orders revealed the following: 1. An order dated 03/24/25, for fiber oral tablets; give two tablets by mouth at bedtime for colon health. 2. An order dated 03/25/25, discontinued on 03/27/25, for Questran 4 grams; give one packet by mouth for diarrhea, two times a day for 10 days. 3. An order dated 03/27/25, for Questran 4 grams; give one packet by mouth for diarrhea three times a day for 10 days. 4. An order dated 04/04/25, for Imodium A-D (medication used to treat diarrhea) 2 mg; give two tablets by mouth every 6 hours as needed for diarrhea. C. Record review of R #90's medication administration record (MAR; a form used to document medication administration), dated March 2025, revealed staff documented the following: 1. On 03/25/25 at 9:00 PM, Questran, staff documented not administered, see progress note (Code 7). 2. On 03/26/25 at 8:00 PM, fiber, staff documented other, see nurses note (Code 9). 3. On 03/27/25 at 12:00 PM, Questran, staff documented code 7. 4. On 03/27/25 at 8:00 PM, fiber, staff documented Code 9. 5. On 03/28/25 at 8:00 PM, fiber, staff documented Code 9. 6. On 03/29/25 at 8:00 PM, fiber, staff documented Code 9. D. Record review of R #90's medication administration record, dated April 2025, revealed staff documented the following: 1. On 04/01/25 at 8:00 PM, fiber, staff documented Code 9. 2. On 04/02/25 at 8:00 PM, fiber, staff documented Code 9. 3. On 04/03/25 at 4:00 PM, Questran, staff documented Code 7. 4. On 04/03/25 at 8:00 PM, fiber, staff documented Code 9. 5. On 04/04/25 at 12:00 PM, Questran, staff documented Code 7. 6. On 04/04/25 at 4:00 PM, Questran, staff documented Code 7. 7. On 04/04/25 at 8:00 PM, fiber, staff documented Code 9. 8. On 04/05/25 at 8:00 AM, Questran, staff documented Code 7. 9. On 04/05/25 at 12:00 PM, Questran, staff documented Code 7. 10. On 04/05/25 at 4:00 PM, Questran, staff documented Code 7. 11. On 04/05/25 at 8:00 PM, fiber, staff documented Code 9. 12. On 04/10/25 at 8:00 PM, fiber, staff documented Code 9. 13. On 04/11/25 at 8:00 PM, fiber, staff documented Code 9. 14. On 04/12/25 at 8:00 PM, fiber, staff documented Code 9. E. Record review of R #90's progress notes for March and April 2025, revealed staff documented the following for R #90's fiber and Questran medications: 1. On 03/25/25 at 10:38 PM, Questran, staff documented, on order, notify nurse. 2. On 03/26/25 at 9:19 PM, fiber, staff documented, waiting for delivery. Nurse aware. 3. On 03/27/25 at 9:15 PM, fiber, staff documented, waiting for delivery. Nurse aware. 4. On 03/28/25 at 9:08 PM, fiber, staff documented, waiting for delivery. Nurse aware. 5. On 03/29/25 at 8:39 PM, fiber, staff documented, waiting for delivery. Nurse aware. 6. On 04/01/25 at 10:43 PM, fiber, staff documented, on order. 7. On 04/02/25 at 9:13 PM, fiber, staff documented, waiting for delivery. Nurse aware. 8. On 04/03/25 at 4:03 PM, Questran, staff documented, waiting on pharmacy delivery. 9. On 04/03/25 at 9:36 PM, fiber, staff documented, waiting for delivery. Nurse aware. 10. On 04/04/25 at 8:50 AM, Questran, staff documented, waiting on pharmacy delivery. 11. On 04/04/25 at 11:21 AM, Questran, staff documented, waiting on pharmacy delivery. 12. On 04/04/25 at 3:19 PM, Questran, staff documented, waiting on pharmacy delivery. 13. On 04/04/25 at 8:51 PM, fiber, staff documented, waiting for delivery. Nurse aware. 14. On 04/05/25 at 9:28 AM, Questran, staff documented, waiting on pharmacy delivery. 15. On 04/05/25 at 1:20 PM, Questran, staff documented, waiting on pharmacy delivery. 16. On 04/05/25 at 3:02 PM, Questran, staff documented, waiting on pharmacy delivery. 17. On 04/05/25 at 9:10 PM, fiber, staff documented, waiting for delivery. Nurse aware. 18. On 04/10/25 at 11:25 PM, fiber, staff documented, waiting for delivery. Nurse aware. 19. On 04/11/25 at 8:52 PM, fiber, staff documented, waiting for delivery. Nurse aware. 20. On 04/12/25 at 8:13 PM, fiber, staff documented, waiting for delivery. Nurse aware. 21. Staff did not document that the provider was notified about R #90 missing doses of fiber and Questran medications. F. Record review of R #90's entire medical record, no date, revealed the medical record did not contain documentation that the provider was notified about R #90 not receiving doses of Questran or Fiber medications. G. On 04/24/25 at 2:23 PM, during an interview, LPN #16 stated the following about regular processes regarding missing medication: 1. When the CMA's notify her that a medication is not available, she checks the facility medication management system to see if the medication is available there. 2. If the resident will miss any doses, she notifies the provider and documents the communication with the provider and enters any order changes in the resident's medical record. H. On 04/25/25 at 9:21 AM, during an interview, the DON confirmed the following: 1. R #90 missed several doses of Questran and fiber medications in March and April 2025. 2. She stated staff contacted the on-call provider through the facility communication application on 04/05/25 at 6:45 AM, to notify them that R #90 did not have any Questran medication, and the provider ordered Immodium A-D to be added to R #90's treatment. 3. Prior to 04/05/25, staff had not contacted the on-call provider regarding R #90's missed doses of fiber or Questran medication. 4. Staff should have notified the provider at the time of each missed dose to see if the provider wanted to change R #90's treatment.

Recite from 02/12/2024 Based on record review and interview, the facility failed to ensure care plan revisions and care plan meeting requirements occurred for 7 (R #1, R #9, R #15, R #37, R #45, R #89 and R #90) of 8 (R #1, R #9, R #15, R #37, R #45, R #62, R #89 and R #90) residents when the staff failed to: 1. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participate in the care plan meeting for R #9, R #15, R #45, R #89, and R #90. 2. Ensure the care plan meeting was held within 7 days from the completion of the MDS assessment when creating the care plan for R #1, R #9, and R #45. 3. Revise the care plan with the most current resident information for R #1, R #45, and R #90. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: IDT Team R #9 A. Record review of R #9's Care Plan Conference form, dated 02/11/25, revealed the following: 1. Staff documented the individuals that were present at the meeting were: R #9's representative and the Social Services Director (SSD). 2. Staff documented not applicable for the RN, MDS case manager, Nurse Aide, food service staff, Physician, Activity Director as contributors. B. On 04/25/25 at 11:30 AM, during an interview, the SSD stated that the required IDT did not attend the meeting because the meeting that was held on 02/11/25 was not a scheduled care plan meeting. The SSD stated the meeting was held because R #9's representative was at the facility on 02/11/25. R #15 C. Record review of R #15's Care Plan Conference form, dated 01/14/25, revealed the following: 1. The individuals that were contributors to the meeting were: R #15, R #15's representative, an RN, the activity director, the social services director, the director of rehabilitation, and two ombudsmen. 2. Staff documented not applicable for Nurse Aide and Physician as contributors. R #37 D. Record review of R #37's Care Plan Conference form, dated 03/16/25, revealed the following: 1. The individuals that were present to the meeting were: R #37's representative, the RN, the Food Service Staff, the Activities Director, and the Social Services Director. 2. Staff documented not applicable for MDS Coordinator, Nurse Aide and Physician as contributors. R #45 E. Record review of R #45's care plan assessment, dated 02/11/25, revealed the individuals that were present at the meeting were: the RN, the MDS Coordinator, Food Service Staff, and the Social Services Director (SSD). R #89 F. Record review of R #89's care plan assessment, dated 03/27/25, revealed the individuals that were present at the meeting were: R #89, R #89's POA (Power of Attorney), the RN, the Activity Director (AD), and the Social Services Director (SSD). R #90 G. Record review of R #90's Care Plan Conference form, dated 03/26/25, revealed the following: 1. The individuals that were contributors to the meeting were: R #90, an RN, food services staff, the activity director, and the social services director. 2. Staff documented not applicable for Nurse Aide and Physician as contributors. H. On 04/25/25 at 9:55 AM, during an interview, the DON confirmed the following: 1. The provider does not usually attend care plan meetings. 2. Staff do not usually contact the provider to ask for input prior to each resident's care plan meeting. 3. CNA's do not usually attend care plan meetings. 4. CNA's do not usually provide input for the care plan meetings. Timing R #1 I. Record review of R #1's Annual MDS, dated [DATE], revealed the assessment was signed by the Registered Nurse (RN) on 02/15/25. J. Record review of R #1's entire medical record, no date, revealed staff did not document that a care plan meeting took place within seven days after the completion of R #1's Annual MDS on 02/15/25. K. On 04/24/25 at 9:23 AM, during an interview with the Social Services Director, she confirmed that there was no care plan meeting after R #1's Annual MDS was completed. R #9 L. Record review of R #9's Admission MDS, dated [DATE], revealed the assessment was signed by the Registered Nurse (RN) on 01/26/25. M. Record review of R #9's Care Plan Conference form, dated 02/11/25, revealed that the care plan meeting was not held within 7 days of the completion of R #9's Admission MDS. N. On 04/25/25 at 11:30 AM, during an interview with the SSD, she confirmed that R #9's care plan meeting was not held within 7 days of the completed of R #9's Admission MDS. R #45 O. Record review of R #45's Quarterly MDS, dated [DATE], revealed the assessment was signed by the Registered Nurse (RN) on 02/21/25. P. Record review of R #45's Care Plan Conference, dated 02/11/25, revealed that the care plan meeting was held before the completion of R #45's Quarterly MDS on 02/21/25. Q. On 04/24/25 at 9:23 AM, during an interview, the Social Services Director confirmed that R #45's care plan meeting was held before his Quarterly MDS was completed. Revisions R #1 R. Record review of R #1's admission documents, no date, revealed R #1 was admitted to the facility on [DATE]. S. Record review of R #1's physician order, dated 04/14/25 revealed an order to apply lotion to R #1's upper and lower extremities daily (arms, including everything from the shoulders to the hands, and legs, including everything from the hips to the feet). T. Record review of R #1's care plan, dated 02/17/25 revealed staff did not revise R #1's care plan to include applying lotion to R #1. R #90 U. Record review of R #90's admission record (no date) revealed the following: 1. R #90 was admitted to the facility on [DATE]. 2. R #90 had the following diagnoses: a. Diarrhea (loose, watery stools that occur more frequently than usual). b. Noninfective gastroenteritis and colitis (involves inflammation of your stomach and intestines). c. Cellulitis of abdominal wall (a rare sign of acute appendicitis that presents as aggressive intra-abdominal inflammation). d. Acquired absence of other parts of digestive tract (missing parts of your digestive organs due to an injury or operation). V. Record review of R #90's physician's orders, revealed the following: 1. An order dated 03/24/25, for fiber (can be used to relieve mild-to-moderate diarrhea. Soluble fiber soaks up water in the digestive tract, which makes stool firmer and slower to pass) oral tablets; give two tablets by mouth at bedtime for colon health. 2. An order dated 03/24/25 (discontinued on 03/26/25) for Imodium A-D (medication that can treat diarrhea) 2 mg; give two tablets by mouth every 12 hours as needed for loose stools. 3. An order dated 03/25/25 for Acidophilus Probiotic (a probiotic that is used to help maintain the number of healthy bacteria in your stomach and intestines) oral tablet; give one tablet by mouth two times a day for gastrointestinal health for 14 days. 4. An order dated 03/27/25 for Questran (can provide relief of diarrhea caused by surgery or disease of the small bowel) 4 grams; give one packet by mouth for diarrhea, three times a day for 10 days. 5. An order dated 04/04/25 for Imodium A-D 2 mg; give two tablets by mouth every 6 hours as needed for diarrhea. 6. An order dated 04/12/25 for Imodium A-D 2 mg; give two tablets by mouth for diarrhea four times a day until 04/15/25. 7. An order dated 04/14/25, for a consultation with a gastroenterologist (a specialist with expertise in the disorders and diseases that affect the digestive system). 8. An order dated 04/17/25 for Imodium A-D 2 mg; give two tablets by mouth four times a day for diarrhea for three days. W. Record review of R #90's care plan, dated 03/12/25, revealed staff did not revise R #90's care plan to include his diagnosis of diarrhea or the interventions in place to treat his diarrhea. X. On 04/25/25 at 9:43 AM, during an interview, the DON confirmed the following: 1. R #90 had diarrhea over a prolonged period of time. 2. R #90 had several orders in place to treat his diarrhea. 3. R #90 had an order to see the gastroenterologist due to frequent diarrhea. 4. Staff should have included R #90's diagnosis of diarrhea and the interventions in place to treat his diarrhea. 47510 49313 52223

Based on record reviews and interviews, the facility failed to meet professional standards of quality for 1 (R #90) of 1 (R #90) resident when staff failed to administer medications according to physician's orders. If the facility is not providing care that meets professional standards of quality, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: A. Record review of R #90's admission record (no date) revealed the following: 1. R #90 was admitted to the facility on [DATE]. 2. R # 90 had the following diagnoses: a. Diarrhea (loose, watery stools that occur more frequently than usual). b. Noninfective gastroenteritis and colitis (involve inflammation of your stomach and intestines). c. Cellulitis of abdominal wall (a rare sign of acute appendicitis that presents as aggressive intra-abdominal inflammation). d. Acquired absence of other parts of digestive tract (missing parts of your digestive organs due to an injury or operation). B. Record review of R #90's physician orders, multiple dates, revealed the following: 1. An order dated 03/24/25 for fiber (can be used to relieve mild-to-moderate diarrhea. Soluble fiber soaks up water in the digestive tract, which makes stool firmer and slower to pass) oral tablets; give two tablets by mouth at bedtime for colon health. 2. An order dated 03/25/25, discontinued on 03/27/25, for Questran (can provide relief of diarrhea caused by surgery or disease of the small bowel) 4 grams; give one packet by mouth for diarrhea two times a day for 10 days. 3. An order dated 03/27/25 for Questran 4 grams; give one packet by mouth for diarrhea, three times a day for 10 days. C. Record review of R #90's medication administration record (MAR; a form used to document medication administration), dated March 2025, revealed staff documented the following: 1. On 03/25/25 at 9:00 PM, Questran, staff documented not administered, see progress note (Code 7). 2. On 03/26/25 at 8:00 PM, Fiber, staff documented other, see nurses note (Code 9). 3. On 03/27/25 at 12:00 PM, Questran, staff documented code 7. 4. On 03/27/25 at 8:00 PM, Fiber, staff documented Code 9. 5. On 03/28/25 at 8:00 PM, Fiber, staff documented Code 9. 6. On 03/29/25 at 8:00 PM, Fiber, staff documented Code 9. D. Record review of R #90's medication administration record, dated April 2025, revealed staff documented the following: 1. On 04/01/25 at 8:00 PM, Fiber, staff documented Code 9. 2. On 04/02/25 at 8:00 PM, Fiber, staff documented Code 9. 3. On 04/03/25 at 4:00 PM, Questran, staff documented Code 7. 4. On 04/03/25 at 8:00 PM, Fiber, staff documented Code 9. 5. On 04/04/25 at 12:00 PM, Questran, staff documented Code 7. 6. On 04/04/25 at 4:00 PM, Questran, staff documented Code 7. 7. On 04/04/25 at 8:00 PM, Fiber, staff documented Code 9. 8. On 04/05/25 at 8:00 AM, Questran, staff documented Code 7. 9. On 04/05/25 at 12:00 PM, Questran, staff documented Code 7. 10. On 04/05/25 at 4:00 PM, Questran, staff documented Code 7. 11. On 04/05/25 at 8:00 PM, Fiber, staff documented Code 9. 12. On 04/10/25 at 8:00 PM, Fiber, staff documented Code 9. 13. On 04/11/25 at 8:00 PM, Fiber, staff documented Code 9. 14. On 04/12/25 at 8:00 PM, Fiber, staff documented Code 9. E. Record review of R #90's progress notes for March and April 2025, revealed staff documented the following for R #90's fiber and Questran medications: 1. On 03/25/25 at 10:38 PM, Questran, staff documented, on order, notify nurse. 2. On 03/26/25 at 9:19 PM, Fiber, staff documented, waiting for delivery. Nurse aware. 3. On 03/27/25 at 9:15 PM, Fiber, staff documented, waiting for delivery. Nurse aware. 4. On 03/28/25 at 9:08 PM, Fiber, staff documented, waiting for delivery. Nurse aware. 5. On 03/29/25 at 8:39 PM, Fiber, staff documented, waiting for delivery. Nurse aware. 6. On 04/01/25 at 10:43 PM, Fiber, staff documented, on order. 7. On 04/02/25 at 9:13 PM, Fiber, staff documented, waiting for delivery. Nurse aware. 8. On 04/03/25 at 4:03 PM, Questran, staff documented, waiting on pharmacy delivery. 9. On 04/03/25 at 9:36 PM, Fiber, staff documented, waiting for delivery. Nurse aware. 10. On 04/04/25 at 8:50 AM, Questran, staff documented, waiting on pharmacy delivery. 11. On 04/04/25 at 11:21 AM, Questran, staff documented, waiting on pharmacy delivery. 12. On 04/04/25 at 3:19 PM, Questran, staff documented, waiting on pharmacy delivery. 13. On 04/04/25 at 8:51 PM, Fiber, staff documented, waiting for delivery. Nurse aware. 14. On 04/05/25 at 9:28 AM, Questran, staff documented, waiting on pharmacy delivery. 15. On 04/05/25 at 1:20 PM, Questran, staff documented, waiting on pharmacy delivery. 16. On 04/05/25 at 3:02 PM, Questran, staff documented, waiting on pharmacy delivery. 17. On 04/05/25 at 9:10 PM, Fiber, staff documented, waiting for delivery. Nurse aware. 18. On 04/10/25 at 11:25 PM, Fiber, staff documented, waiting for delivery. Nurse aware. 19. On 04/11/25 at 8:52 PM, Fiber, staff documented, waiting for delivery. Nurse aware. 20. On 04/12/25 at 8:13 PM, Fiber, staff documented, waiting for delivery. Nurse aware. 21. Staff did not document what was done to try to get the fiber or Questran medications for R #90. 22. Staff did not document that the provider was notified about R #90 missing doses of fiber and Questran medications. F. On 04/24/25 at 2:23 PM, during an interview with LPN #16, she stated the following: 1. When the CMA's notify her that a medication is not available, she checks the facility medication management system to see if the medication is available there. 2. If the medication management system does not have the medication, she contacts the pharmacy to see when the medication will arrive. 3. If the medication is an over-the-counter medication, she notifies the staff member that orders supplies so she can go to the local grocery store to pick it up. 4. If the resident will miss any dose, she notifies the provider and documents the communication with the provider and enters any order changes in the resident's medical record. G. On 04/25/25 at 9:21 AM, during an interview with the DON, she confirmed the following: 1. R #90 missed several doses of Questran and fiber medications in March and April 2025. 2. Staff are expected to contact the pharmacy to see when the medication will arrive. 3. If the medication is an over-the-counter medication, staff are expected to notify the staff member that orders supplies so she can go to the local grocery store to pick up the medication. 4. Staff are expected to notify the provider at the time of each missed dose to see if the provider wants to change the resident's treatment. 5. She stated that staff contacted the on-call provider through the facility communication application on 04/05/25 at 6:45 AM to notify them that R #90 did not have any Questran medication. 6. Prior to 04/05/25, staff had not contacted the on-call provider regarding R #90's missed doses of fiber or Questran medication. 7. She was unable to determine if staff notified the staff member who ordered supplies to pick up fiber medication from the local grocery store. 8. She was unable to determine if staff contacted the pharmacy regarding R #90's Questran medication. H. Record review of the facilities Medication Ordering and Receiving From Pharmacy Provider: Medication Shortages policy, dated January 2023 revealed the following instructions: 1. Nursing staff shall, if the shortage will impact the patient's immediate need of the ordered product: a. Notify the attending physician of the situation, explain the circumstances, expected availability and optional therapy(ies) that are available. b. Obtain a new order and cancel/discontinue the order for the non-available medication. c. Notify the pharmacy of the replacement order.

Recite from 02/12/24 Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the residents' medical record for 2 (R #45 and R #46) of 5 (R #9, R #45, R #46, R #62, and R #90) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #45 A. Record review of R #45's face sheet no date revealed the following: 1. R #45 was admitted to the facility on [DATE], 2. R # 45 was diagnosed with the following diagnosis a. Major Depressive Disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), recurrent, mild. b. Sleep disorder (a condition that disrupts normal sleep patterns, affecting the quality, timing, and duration of sleep). c. Post Traumatic Stress Disorder (PTSD) (mental health condition that can develop after a person has experienced or witnessed a traumatic event). d. Nightmare Disorder (sleep disorder characterized by recurrent, vivid, and frightening dreams that cause distress and impairment). B. Record review of R #45's physician's orders revealed the following orders: 1. An order dated 10/07/24 for Doxepin (used to treat anxiety, depression and insomnia) give 1 tablet 100 mg, by mouth at bedtime for insomnia. 2. An order dated 10/23/24 for Prazosin (used to treat symptoms of post-traumatic stress disorder) give 2 tablets by mouth at bedtime for nightmares. 3. An order dated 02/18/25 for Bupropion XL (Wellbutrin) (used Major Depressive Disorder) give 2 tablets by mouth every morning for major depressive disorder. C. Record review of R #45's pharmacy recommendation summary report dated 01/14/25, revealed the following: 1. R #45 is currently receiving Doxepin 100 mg at bedtime, consider gradual dose reduction (GRD). 2. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication. D. Record review of R #45's pharmacy recommendation summary report dated 02/29/25, revealed the following: 1. R #45 is currently receiving Prazosin 2 mg at bedtime, consider gradual dose reduction (GRD). 2. Physician documented that an outside provider prescribed the medication. 3. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication. 4. Staff did not document that the recommendation was sent to the outside provider for review and consideration. E. Record review of R #45's pharmacy recommendation summary report dated 03/19/25, revealed the following: 1. R #45 is currently receiving Bupropion 400 mg at bedtime, consider gradual dose reduction (GRD). 2. Physician documented that an outside provider prescribed the medication. 3. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication. 4. Staff did not document that the recommendation was sent to the outside provider for review and consideration. F. On 04/25/25 at 12:36 PM, during an interview, the DON confirmed that the provider did not provide a rationale for recommendation, follow up, or supporting information as to why the resident is still on medication Doxepin, Prazosin, and Bupropion. The DON said that the recommendations for February and March were not sent to R #45's outside provider. R #46 G. Record review of R #46's Admission Record (no date) revealed the following: 1. R #46 was admitted to the facility on [DATE]. 2. R #46 was diagnosed with the following: a. Unspecified dementia, severe (condition where confusion or cognitive impairment cannot be clearly diagnosed by a specific type of dementia characterized by significant cognitive decline and the need for constant assistance with daily activities), with anxiety (feeling of uneasiness, nervousness or fear). b. Anxiety disorder, unspecified (diagnostic category uses when anxiety symptoms cause significant distress or impairment in daily functioning but do not meet criteria of other specific anxiety disorders). c. Auditory hallucinations (when an individual perceives sounds without any actual auditory stimulus, can include hearing voices or noises that are not present in the environment). H. Record review of R #46's physician's orders revealed the following: 1. An order dated 09/27/24 for hydroxyzine oral tablet (antihistamine medication which can help alleviate feelings of anxiety and promote calmness), 10 mg give 1 tablet by mouth two times a day for agitation (state of restlessness or inner tension). 2. An order dated 12/06/24 for haloperidol oral concentrate (antipsychotic medication that is commonly used to treat schizophrenia [serious mental health condition that affects how people think, feel and behave]) 2 MG/ML give 0.5 ml by mouth every four hours as needed for agitation. I. Record review of R #46's Medication Regimen Review forms dated 02/20/25, revealed the following: 1. Gradual Dose Reduction (GDR; decreasing a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) for medication hydroxyzine 10 mg twice daily. a. residents who use psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) must have gradual dose reduction attempts, unless clinically contraindicated, in an attempt to discontinue these drugs. b. Do you feel a reduction could be attempted on the above medication at this time? c. The form was marked other, and the written response was Hospice pt (patient). 2. As needed (PRN) psychotropic for medication haloperidol. a. all PRN psychotropics, if continued past 14 days of use, must have clinical rationale and anticipated duration of use documented. There is no hospice exception to this CMS (Centers for Medicare and Medicaid Services) regulation. b. consider discontinuing the above medication. If resident still benefits from PRN use, please document below. c. resident requires PRN psychotropic due to area was left blank. d. anticipated duration of use area was left blank. e. the form was marked disagree and the written response was continues to benefit from medication due to unnecessary behaviors with dementia. J. On 04/25/25 at 12:48 PM, during an interview, the DON confirmed that the provider did not provide rationale in R #46's medical record regarding the GDR for hydroxyzine or the continued use of PRN haloperidol and the haloperidol order did not have an end date. 47510

Based on record review and interview, the facility failed to keep residents free from psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for 2 (R #45 and R #46) of 5 (R #9, R #45, R #46, R #62 and R #90) residents reviewed for unnecessary medications when they failed to: 1. Carry out a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued) and failed to document clinical rationale to continue psychotropic medications for R #45 and R #46. 2. Ensure that as needed (PRN) psychotropic orders were limited to 14 days and ensure that if the prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for R #46. If consultant pharmacist recommendations and physician's orders are not implemented in a timely manner, residents are likely to be administered medications they do not need and could likely suffer from adverse side effects. The findings are: R #45 A. Record review of R #45's face sheet revealed R #45 was admitted to the facility on [DATE] with the following diagnosis: 1. Major Depressive Disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), recurrent, mild. 2. Schizophrenia (chronic mental disorder that affects a person's ability to think, feel, and behave clearly). 3. Bipolar Disorder (mental illness characterized by dramatic shifts in mood, energy, and activity levels, including both manic and depressive episodes) 4. Schizoaffective disorder, bipolar type (a mental health condition characterized by the combined presence of symptoms of schizophrenia and bipolar disorder). 5. Sleep disorder (a condition that disrupts normal sleep patterns, affecting the quality, timing, and duration of sleep). 6. Post Traumatic Stress Disorder (PTSD) (mental health condition that can develop after a person has experienced or witnessed a traumatic event). 7. Nightmare Disorder (sleep disorder characterized by recurrent, vivid, and frightening dreams that cause distress and impairment). B. Record review of R #45's physician's orders revealed an order dated 10/07/24 for Doxepin (used to treat anxiety, depression and insomnia) give 1 tablet 100 mg, by mouth at bedtime for insomnia. C. Record review of R #45's MAR dated February 2025 revealed staff documented that R #45 was given Doxepin as ordered daily. D. Record review of R #45's pharmacy recommendation summary report dated 01/14/25 revealed the following: 1. R #45 is currently receiving Doxepin 100 mg at bedtime, consider gradual dose reduction (GRD). 2. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication. 3. R #45's physician failed to document clinical rationale to continue R #45's use of Doxepin. E. Record review of R #45's physician's orders revealed an order dated 10/23/24 for Prazosin (used to treat symptoms of post-traumatic stress disorder) give 2 tablets by mouth at bedtime for nightmares. F. Record review of R #45's MAR dated February 2025 revealed staff documented that R #45 was given Prazosin as ordered nightly. G. Record review of R #45's pharmacy recommendation summary report dated 02/29/25 revealed the following: 1. R #45 is currently receiving Prazosin 2 mg at bedtime, consider gradual dose reduction (GRD). 2. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication. 3. R #45's physician failed to document clinical rationale to continue R #45's use of Prazosin. H. Record review of R #45's physician's orders revealed an order dated 02/18/25 for Bupropion (Wellbutrin) (used Major Depressive Disorder) give 2 tablets by mouth at bedtime for nightmares. I. Record review of R #45's pharmacy recommendation summary report dated 03/19/25 revealed the following: 1. R #45 is currently receiving Bupropion 400 mg at bedtime, consider gradual dose reduction (GRD). 2. R #45's physician did not provide rationale with patient specific information as to why R #45 needed to remain on medication. 3. R #45's physician failed to document clinical rationale to continue R #45's use of Bupropion. J. On 04/25/25 at 12:36 PM, during an interview, the DON confirmed that there was no rationale from the physician in R #45's medical record regarding the gradual drug reduction recommendations for R #45. R #46 K. Record review of R #46's admission Record (no date) revealed the following: 1. R #46 was admitted to the facility on [DATE]. 2. R #46 was diagnosed with the following: a. Unspecified dementia, severe (condition where confusion or cognitive impairment cannot be clearly diagnosed by a specific type of dementia characterized by significant cognitive decline and the need for constant assistance with daily activities), with anxiety (feeling of uneasiness, nervousness or fear). b. Anxiety disorder, unspecified (diagnostic category uses when anxiety symptoms cause significant distress or impairment in daily functioning but do not meet criteria of other specific anxiety disorders). c. Auditory hallucinations (when an individual perceives sounds without any actual auditory stimulus, can include hearing voices or noises that are not present in the environment). L. Record review of R #46's physician's orders revealed the following: 1. An order dated 09/27/24 for hydroxyzine oral tablet (antihistamine medication which can help alleviate feelings of anxiety and promote calmness), 10 mg give 1 tablet by mouth two times a day for agitation (state of restlessness or inner tension). 2. An order dated 12/06/24 for haloperidol oral concentrate (antipsychotic medication that is commonly used to treat schizophrenia [serious mental health condition that affects how people think, feel and behave]) 2 MG/ML give 0.5 ml by mouth every 4 hours as needed for agitation. M. Record review of R #46's Medication Regimen Review forms dated 02/20/25 revealed the following: 1. Gradual Dose Reduction (GDR; decreasing a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) for medication hydroxyzine 10 mg twice daily. a. residents who use psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) must have gradual dose reduction attempts, unless clinically contraindicated, in an attempt to discontinue these drugs. 2. As needed (PRN) psychotropic for medication haloperidol. a. all PRN psychotropics, if continued past 14 days of use, must have clinical rationale and anticipated duration of use documented. N. Record review of R #46's medication administration records (MAR; a form used to document medication administration) revealed the following: 1. R #46 received hydroxyzine 10mg twice daily from 01/01/25 through 01/31/25. 2. R #46 received hydroxyzine 10mg every morning from 02/01/25 through 02/28/25. 3. R #46 received hydroxyzine 10mg at night from 02/01/25 through 02/10/25. 4. R #46 received hydroxyzine 10mg at night from 02/12/25 through 02/28/25. 5. R #46 received hydroxyzine 10mg every morning from 03/01/25 through 03/22/25. 6. R #46 received hydroxyzine 10mg every morning from 03/23/25 through 03/31/25. 7. R #46 received hydroxyzine 10mg twice daily from 04/01/25 through 04/23/25. 8. R #46 received PRN haloperidol 0.5 ML 01/29/25. 9. R #46 received PRN haloperidol 0.5 ML 04/02/25 and 04/06/25. O. On 04/25/25 at 12:48 PM, during an interview, the DON confirmed that R #46 did not have a GDR done for her hydroxyzine and continues to receive it and PRN haloperidol order has been in place greater than 14 days with no end date (anticipated duration).

Based on observation and interview, the facility failed to provide a comfortable and homelike environment for 1 (R #1) of 3 (R #1, R #45, and R #78) residents sampled for environment, when staff failed to do the following: 1. Keep the residents' floor free of trash and orange peels. 2. Remove the residents' lunch tray after they had finished. 3. Empty and remove full urinal from the tray table. These deficient practices could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued. The findings are: A. On 04/21/25 at 2:15 PM, during an observation of R #1's room, revealed there were orange peels on the R #1's floor. There were food crumbs on the floor around R #1's bed. R #1's floor also had paper trash on the floor. On R #1's tray table, there was a lunch tray from lunch service (lunch was served at 12:00 pm). There was a full urinal on R #1's lunch tray. B. On 04/21/25 at 2:21 PM, during an interview, CNA #8 confirmed that there were orange peels, trash, and spills on the floor. CNA #8 confirmed that R #1's lunch tray was still in R #1's room. CNA #8 also confirmed that there was a full urinal on the resident's lunch tray. CNA #8 said R #1's tray should have been picked up. CNA #8 said that the urinal should be emptied and that it should not be on R #1's tray or tray table. C. On 05/02/25 at 9:11 AM, during an interview, the Administrator said that orange peels should have been cleaned up and the lunch tray should be picked up when R #1 is done eating. The Administrator said that the urinal should have been emptied and taken off of R #1's tray table.

Recite from 02/12/24 Based on record review and interview, the facility failed to ensure residents, or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 2 (R #32 and R #90) of 2 (R #32 and R #90) residents reviewed for hospitalization. This deficient practice could likely result in the residents and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #32 A. Record review of R #32's transfer notification, dated 04/16/25, revealed R #32 was sent to the hospital for cough and congestion. B. Record review of R #32's medical record, no date, revealed staff did not complete a written bed hold notification for R #90's transfer to the hospital on [DATE]. R #90 C. On 04/21/25 at 3:33 PM, during an interview, R #90 stated the following: 1. R #90 was sent to the hospital on [DATE], because the staff thought he was having heart issues. 2. Staff did not provide him with a written bed hold notification. D. Record review of R #90's progress note, dated 04/16/25, revealed the following: 1. R #90 was sweating, had nausea, and chest pain. 2. R #90 was transferred to the hospital by ambulance. E. Record review of R #90's medical record, no date, revealed staff did not complete a written bed hold notification for R #90's transfer to the hospital on [DATE]. F. On 04/25/25 at 9:45 AM, during an interview, the DON confirmed the following: 1. Staff did not complete a bed hold notification for R #32's transfer to the hospital on [DATE]. 2. Staff did not complete a bed hold notification for R #90's transfer to the hospital on [DATE]. 3. Staff are expected to complete a written bed hold notification and give it to the resident or their representative at the time of the transfer to the hospital.

Based on interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) were accurate for 2 (R #9 and R #46) of 5 (R #9, R #29, R #46, R #62 and R #78) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: R #9 A. On 04/22/25 at 09:20 AM, during an interview, R #9 stated she did not have any teeth and needed dentures. B. Record review of R #9's admission record revealed R #9 was admitted on [DATE]. C. Record review of R #9's Admission MDS dated [DATE] revealed: 1. Section L0200, Dental, check all that apply a. Staff did not check that R #9 had no natural teeth or tooth fragments (edentulous; the state of being without teeth). D On 04/25/25 at 11:03 AM, during an interview, the MDS Coordinator stated that she was unaware that R #9 was edentulous. E. On 04/25/25 at 12:15 PM, during an interview, the MDS Coordinator confirmed that R #9 was edentulous and that she did not enter R #9's accurate dental status on the Admission MDS. R #46 F. Record review of R #46's physician's orders revealed the following: 1. An order dated 12/06/24: haloperidol oral concentrate (antipsychotic medicine that is commonly used to treat schizophrenia [serious mental health condition that affects how people think, feel and behave]) 2 MG/ML, give 0.5 ml by mouth one time a day for agitation. G. Record review of R #46's medication administration records (MAR; a form used to document medication administration) revealed the following: 1. R #46 received 0.5 ml of haloperidol at 3:00 PM daily from 01/01/25 through 01/31/25. 2. R #46 received 0.5 ml of haloperidol at 3:00 PM daily from 02/01/25 through 02/28/25. 3. R #46 received 0.5 ml of haloperidol at 3:00 PM daily from 03/01/25 through 03/31/25. 4. R #46 received 0.5 ml of haloperidol at 3:00 PM daily from 04/01/25 through 04/24/25. H. Record review of R #46's Quarterly MDS, dated [DATE], revealed the following: 1. Section N0450 Antipsychotic Medication (drugs that treat symptoms of psychosis such as delusions, hallucinations, paranoia, and confusion) Review a. Did the resident receive antipsychotic medications since admission/entry or reentry? facility staff documented No, Antipsychotics were not received I. On 04/25/25 at 11:09 AM, during an interview, the MDS Coordinator confirmed that R #46 was receiving haloperidol daily and that she did not accurately enter this information for R #46's Quarterly MDS.

Recite from 02/12/24. Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 1 (R #90) of 2 (R #32 and R #90) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #90's admission record (no date) revealed the following: 1. R #90 was admitted to the facility on [DATE]. 2. Diagnosis of Edema (swelling caused by too much fluid trapped in the body's tissues). B. Record review of R #90's physician order dated 03/11/25, revealed an order for Furosemide (diuretic medication used to treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions) 40 mg, once a day for edema. C. Record review of R #90's Admission Minimum Data Set Assessment, dated 03/17/25, revealed Section N- Medications: N0415 High-Risk Drug Classes; Staff selected diuretic (medication that increases the removal of water from the body, through the kidneys). D. Record review of R #90's care plan, revised on 03/24/25, revealed staff did not document the following: 1. R #90 had a diagnosis of edema. 2. R #90 had an order for the high-risk medication furosemide for edema. E. On 04/25/25 at 9:48 AM, during an interview, the DON confirmed the following: 1. R #90 had an order for furosemide, which is a high-risk medication. 2. R #90's care plan did not include that he was taking furosemide. 3. High-risk medications should be included on resident care plans.

Recite from 02/12/24. Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #90) of 1 (R #90) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: A. Record review of R #90's admission record (no date) revealed the following: 1. R #90 was admitted to the facility on [DATE]. 2. R # 90 had the following diagnoses: a. Diarrhea (loose, watery stools that occur more frequently than usual). b. Noninfective gastroenteritis and colitis (involves inflammation of your stomach and intestines). c. Cellulitis of abdominal wall (a rare sign of acute appendicitis that presents as aggressive intra-abdominal inflammation). d. Acquired absence of other parts of digestive tract (missing parts of your digestive organs due to an injury or operation). B. Record review of R #90's physician orders, multiple dates, revealed the following: 1. An order dated 03/24/25 for fiber oral tablets; give two tablets by mouth at bedtime for colon health. 2. An order dated 03/25/25, discontinued on 04/27/25, for Questran 4 grams; give one packet by mouth for diarrhea, two times a day for 10 days. 3. An order dated 03/27/25 for Questran (can provide relief of diarrhea caused by surgery or disease of the small bowel) 4 grams; give one packet by mouth for diarrhea, three times a day for 10 days. C. Record review of R #90's medication administration record (MAR; a form used to document medication administration), dated March 2025, revealed staff documented the following: 1. On 03/25/25 at 9:00 PM, Questran, staff documented not administered, see progress note (Code 7). 2. On 03/26/25 at 8:00 PM, fiber, staff documented other, see nurses note (Code 9). 3. On 03/27/25 at 12:00 PM, Questran, staff documented code 7. 4. On 03/27/25 at 8:00 PM, fiber, staff documented Code 9. 5. On 03/28/25 at 8:00 PM, fiber, staff documented Code 9. 6. On 03/29/25 at 8:00 PM, fiber, staff documented Code 9. D. Record review of R #90's medication administration record, dated April 2025, revealed staff documented the following: 1. On 04/01/25 at 8:00 PM, fiber, staff documented Code 9. 2. On 04/02/25 at 8:00 PM, fiber, staff documented Code 9. 3. On 04/03/25 at 4:00 PM, Questran, staff documented Code 7. 4. On 04/03/25 at 8:00 PM, fiber, staff documented Code 9. 5. On 04/04/25 at 12:00 PM, Questran, staff documented Code 7. 6. On 04/04/25 at 4:00 PM, Questran, staff documented Code 7. 7. On 04/04/25 at 8:00 PM, fiber, staff documented Code 9. 8. On 04/05/25 at 8:00 AM, Questran, staff documented Code 7. 9. On 04/05/25 at 12:00 PM, Questran, staff documented Code 7. 10. On 04/05/25 at 4:00 PM,Questran, staff documented Code 7. 11. On 04/05/25 at 8:00 PM, fiber, staff documented Code 9. 12. On 04/10/25 at 8:00 PM, fiber, staff documented Code 9. 13. On 04/11/25 at 8:00 PM, fiber, staff documented Code 9. 14. On 04/12/25 at 8:00 PM, fiber, staff documented Code 9. E. Record review of R #90's entire medical record, no date, revealed staff did not document that the provider was notified about R #90 missing Questran or fiber medication doses. F. On 04/25/25 at 9:21 AM, during an interview with the DON, she confirmed the following: 1. R #90 missed several doses of Questran and fiber medications in March and April 2025. 2. She stated that staff contacted the on-call provider through the facility communication application on 04/05/25 at 6:45 AM to notify them that R #90 did not have any Questran medication, and the provider ordered another medication to be added to R #90's treatment. 3. Staff did not document communication with the on-call provider on 04/05/25 in R #90's medical record. 4. Staff were expected to document all communication with providers in the resident's medical record.

Past noncompliance Based on record review and interview, the facility failed to prevent staff to resident exploitation when Activity Aide (AA) #1 used R #16's bank debit card to make an unauthorized (without the account holders permission) money withdrawals or purchases for 1 (R #16) of 3 (R #16, R #17, and R #18) residents reviewed for abuse, neglect, and exploitation. This deficient practice could likely result in residents not having money available when they need it, psychosocial distress, and a loss of trust in staff. The findings are: A. Record review of the facility's self report, dated 09/13/24, revealed the following: 1. The self-report was submitted to the State Agency due to allegations of misappropriation (wrongful use of another's belongings, money, etc.) of funds for R #16. 2. R #16's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) reported that R #16's bank account was missing nearly $3,000 and there were multiple suspicious (showing a cautious distrust) charges. 3. The police were called and started an investigation. B. Record review of the 5 day follow-up report, dated 09/19/24, revealed the following: 1. The facility assisted R #16 with obtaining six months of bank statements. 2. R #16's POA identified charges from a phone company that did not match R #16's phone provider and other charges for vendors R #16 does not shop with. 3. The administrator went over the suspicious charges on the bank statements with the R #16. 4. R #16's POA had R #16's debit card shut off and replaced with a new card. 5. Staff were instructed that only the Activities Director would be allowed to use residents debit cards for shopping. 6. Residents who use their debit cards for shopping were encouraged to only give their debit card to the Activities Director for shopping. 7. The Activity Department used a dual signature system to verify shopping lists match receipts. 8. The police began an investigation. 9. The police were waiting for video footage from local businesses and an ATM machine to identify the individual who used R #16 debit card without authorization. C. Record review of the follow-up to 5 day report, dated 12/10/24, revealed the following: 1. The police detective used security footage from local vendors to identify AA #1 as the individual who used R #16's debit card. 2. The investigation revealed that AA #1 had used R #16's debit card to purchase the following: i. Gas ii. Groceries iii. Baby clothes iv. Alcohol v. Various other personal items. 3. The facility attempted to reach AA #1 to notify her that she was terminated, but her phone number was not valid. 4. A criminal complaint was filed against AA #1 for fraud. 5. An arrest warrant was served to AA #1 on 11/20/24 and she was arrested. 6. During the facility investigation, the facility identified that AA #1 had been destroying documents and receipts. D. Record review of the Activity Director (AD) written statement, no date, revealed the following: 1. On 09/07/24, the AD was notified by an AA #2 that R #16's debit card was found on the printer in the activity office. 2. R #16 told the AD that AA #1 was supposed to go to the store and purchase some items for R #16. 3. R #16 told the AD that she had not received her debit card or her items. 4. AA #1 told the AD that R #16's debit card did not work so AA #1 was unable to purchase the items R #16 requested. 5. The AD notified R #16 that AA #1 was unable to purchase the items she requested due to her card did not work. R #16 told the AD that she should have money in her account. 6. The AD offered to go to an ATM to check R #16's account balance and R #16 agreed. 7. R #16's account balance was -$85. 8. On 09/24/24, AA #1 was placed on suspension. E. Record review of a police report, dated 09/14/24, revealed the following: 1. R #16's debit card had various unauthorized charges between June 2024 and September 2024. 2. In June 2024, there was a $223 charge for a local cable company. 3. In July 2024, there were fraudulent charges totaling $1,878.28 for local gas stations, cell phone providers, local grocery store, Online purchases, local furniture store, ATM withdrawals, and a local automotive part store. 4. In August 2024, the fraudulent charges were in the amount of $1,014.04 for online purchases, local gas stations, and a local furniture store. 5. In September 2024, the fraudulent charges totaled $730.93 for local gas stations, online purchases, and an ATM withdrawal. 6. AA #1 was identified through surveillance footage at a local grocery store as having used R #16's debit card to purchase large bags of chicken nuggets and toddlers clothing. 7. On 11/18/24, AA #1 was arrested and admitted to using R #16's debit card to purchase items for personal use. She denied using the card for online purchases. F. On 01/22/25 at 12:35 PM, during a joint interview with the administrator and AD, the following was revealed: 1. The facility became aware that R #16 was missing money after R #16's sister notified the facility that R #16 had suspicious charges on her account. 2. The Administrator reviewed R #16's bank statements to identify any suspicious charges. 3. The administrator began to suspect that AA #1 was responsible because she had called into work due to car troubles and there was a charge for a local automotive part store at the time of AA #1's call in. 4. AA #1 destroyed receipts and resident's shopping lists. 5. The police investigated and identified AA #1 as the person who had used R #16's debit card. 6. AA #1 was arrested. 7. AA #1 was terminated. 8. At the time of the incident, the activities department had the AD and two Activities Aides. 9. At the time, anyone in activities could go shopping for residents. 10. They found that several of the shopping lists were not filled out completely and not signed by the staff or residents. 11. The facility instituted a new process that only the AD is allowed to shop for residents. 12. The AD kept a binder with all the resident shopping lists and the shopping lists must be signed by the resident and the AD at the time the resident provides their form of payment. 13. After the purchases are complete, the AD returns the resident's card or change and reviews the receipt with the resident. 14. The resident and the AD sign the form indicating that the resident received their card or change and the receipt. 15. The AD completes an audit at the end of the month to ensure all the forms are filled out completely. G. On 01/23/25 at 11:51 AM, during an interview with the administrator, the following was revealed: 1. All staff were retrained on abuse, neglect, and exploitation on 10/09/24. 2. All staff were educated on 10/09/24 about the facility shopping process and that the AD is the only staff member who is allowed to shop for residents. 3. All staff were educated on 10/09/24 that they are not to accept residents money or payment cards. H. On 01/23/25 at 1:54 PM, during an interview with the AD, the following was revealed: 1. All residents who have the facility shop for them have been educated on the shopping process. 2. All residents who have the facility shop for them have been advised to only give their method of payment to the AD. 3. During Resident Council meetings, on 10/08/24, 11/12/24, 12/12/24, and 01/07/25, the facility reviewed the shopping process. 4. When resident's turn in their shopping lists, the activities staff will review the shopping process including that the resident's are to only give their method of payment to the AD. This deficient practice was cited as past noncompliance: Based on the facility's investigation of R #16's exploitation, the following interventions were implemented prior to survey investigation which included: The facility shopping process was revised to include that only the Activity Director (AD) is allowed to shop for residents and use the residents financial cards for authorized purchases. Shopping list forms must be filled out completely and signed by the resident and AD at the time the residents card or change is returned. The AD conducts monthly audits to ensure that all residents cards, change, and receipts were returned to the residents. -Record review of the facility's shopping list forms, multiple dates, revealed all of the shopping list forms were filled out completely and signed by the AD and the resident to confirm residents received their card and receipt. -Record review of the facility's audit report forms for October 2024, November 2024, and December 2024 revealed the shopping list forms were filled out completely and included the appropriate signatures. Staff educated residents on the revised facility shopping process. Completed 10/08/24. -Record review of the Resident Council Meeting Minutes, dated 10/08/24, revealed the residents were educated about the revised facility shopping process and how to file a grievance. Staff education on abuse, neglect, and exploitation and revised facility shopping process. Completed on 10/09/24. - Record review of the Staff Meeting Minutes, dated 10/09/24, revealed staff were educated on Abuse, Neglect, and Exploitation and the revised facility shopping process. Activity Director completed audits monthly during the months of October 2024, November 2024, and December 2024 to ensure the return of debit cards, change, and receipts to the residents. Completed on 10/28/24. -Record review of the Resident Shopping lists, multiple dates, revealed all shopping list forms, were filled out completely and signed by the resident and AD. -Surveyor verified the implementation of the revised facility shopping process and did not identify any further non-compliance with samples residents (R #17 and R #18).

Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #1) of 2 (R #1 and #2) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #1's face sheet no date, revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's Electronic Medical Record (EMR) revealed a fall risk evaluation (an evaluation to determine a residents risk of falls), dated 04/26/24, indicated R #1 was a high fall risk. C. Record review of R #1's baseline care plan, dated 04/29/24, revealed staff did not develop a Baseline Care Plan that included R #1 was a high fall risk within 48 hours. D. On 07/23/24 at 2:36 PM, during an interview with the Assistant Direct of Nursing (ADON), she confirmed R #1's baseline care plan did not include resident was a high risk for falls.

Based on record review and interview, the facility failed to ensure residents received care and treatment for pressure ulcers in accordance with professional standards of care (reasonable degree of care a person should provide to another person, typically in a professional or medical setting) for 1 (R #242) of 2 (R #192 and R #242) residents reviewed for pressure ulcers, when staff failed to: 1. Monitor wound progression. 2. Notify the provider about changes in wound condition. 3. Administer prescribed antibiotics in a timely manner. This deficient practice likely resulted in unnecessary worsening of R #242's wound, pain, and suffering. The findings are: A. Record review of R #242's medical record revealed the following: 1. R #242 was admitted to the facility on [DATE]. 2. R #242 discharged to another facility on 10/25/23. 3. R #242 had a diagnosis of the following: a. Hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side. b. Dementia (impaired ability to remember, think, or make decisions) c. Unspecified protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function). d. Muscle wasting and atrophy (waste away) multiple sites. e. Type 2 diabetes mellitus (a disease of inadequate control of blood levels of glucose) without complications. B. Record review of R #242's nurse progress notes revealed the following: 1. On 06/28/23, staff identified a stage 1 pressure wound (wound caused by pressure but has no breaks or tears) and described it as a friction/shear wound (wound that occurs when an object is dragged or rubbed across the skin) to right buttock. 2. Wound care orders were obtained from the provider. C. Record review of R #242's wound orders revealed the following: 1. Wound care orders for a right hip shear wound, order date 06/28/23, clean with wound cleanser, pat dry, apply medihoney, and cover with optifoam dressing every three days. 2. No change in wound care orders between 06/29/23 and 07/20/23. 3. Wound care orders for right hip, order date 07/20/23, clean with wound cleanser, pat dry, apply medihoney, and cover with optifoam dressing every other day. 4. Wound care every day for open wound [unstageable pressure wound] on right buttock, order date 07/28/23, for 5 days. 5. Wound care orders for Stage 4 right ischium pressure injury, order date 09/09/23, clean with normal saline, pat dry, apply skin prep to peri wound, followed by clear drape, inert black foam to wound bed, attach wound vac (a vacuum-assisted closure of a wound. A type of therapy to help wounds heal) to 125 mmHg continuous flow, every Tuesday, Thursday, Friday, and as needed (prn). D. Record review of R #242's Treatment Administration Record (TAR) revealed the following: 1. June 2023 TAR revealed that staff documented that wound care was completed as ordered. 2. July 2023 TAR revealed that staff documented that wound care was completed as ordered. 3. August 2023 TAR revealed that staff documented that wound care was completed as ordered. 4. September 2023 TAR revealed that staff documented that wound care was completed as ordered. 5. October 2023 TAR revealed that staff documented that wound care was completed as ordered. E. Record review of R #242's nursing progress notes revealed the record did not contain documentation of communication with the provider between 06/29/23 and 07/21/23 regarding changes to the pressure wound. F. Record review of R #242's weekly skin checks revealed the following: 1. The record did not contain documentation of pressure wound between 06/25/23 and 07/23/23. 2. First documentation of pressure wound on 07/24/23, mild odor. 3. On 08/01/23 documentation revealed, moderate odor. 4. On 08/09/23 documentation revealed, purulent drainage (liquid or discharge that oozes from a wound, usually observe has a milky look and texture), odor at 4 feet distance, maceration (a softening and breaking down of skin resulting from prolonged exposure to moisture) present. G. Record review of the facility's repositioning report revealed the CNAs documented they repositioned R #242 every two hours on every shift, between June 2023 and August 2023. The CNAs did not document specific times of repositioning. H. Record review of R #242's provider progress notes revealed the following: 1. On 07/21/23, the nurse reported to the provider the wound changed and had purulent drainage, eschar (dead tissue that sheds or falls off from the skin), and slough (the yellow/white material in the wound bed). 2. On 07/21/23, the nurse practitioner assessed the wound and described the wound as an unstageable pressure ulcer. 3. On 07/28/23, the provider ordered Clindamycin 300 mg, four times daily, for 10 days. I. Record review of R #242's Physicians orders revealed the following: 1. Order date 07/28/23, R #242 was referred to an out of facility wound care specialist. 2. Order date 08/01/23, [4 days after provider note ordering antibiotic] Clindamycin 300 mg four times daily for 10 days. J. Record review of R #242's wound care consultation documents revealed the following: 1. On 08/02/23, R #242 had first appointment with the wound care specialist. 2. On 08/07/23, the wound care specialist ordered the following: a. Discontinue doxycycline (antibiotic used to treat and prevent infections) [R #242 had order for Clindamycin]. b. Stop hydroxyzine (antihistamine used to treat anxiety, nausea, vomiting, allergies, skin rash, hives, and itching) for duration of antibiotic treatment. c. Start Levaquin (antibiotic medication that treats bacterial infections). d. Start linezolid (antibiotic used to treat bacterial infections, including skin infections and pneumonia). e. Hold Remeron (antidepressant used to treat depression) for duration of antibiotic treatment. 3. On 08/16/23, the wound care specialist documented the following: a. The ADON from the facility notified the wound care specialist that the facility did not start R #242's antibiotic until 08/15/23 and the wound had a strong odor. b. The wound care specialist completed a wound culture on 08/02/23 which revealed R #242's wound was positive for multiple types of bacteria. c. The wound had a moderate amount of purulent drainage [signs of an active infection]. d. The wound had a strong odor. e. The wound was deteriorating. f. The wound care specialist completed a debridement (the removal of damaged tissue or foreign objects from a wound) of the wound. 4. On 09/07/23, the wound care specialist ordered a wound vac for R #242's wound. K. Record review of R #242's medical record revealed the record did not contain documentation of communication between the facility and the wound care specialist about the order to discontinue Doxycycline and that R #242 took Clindamycin, not Doxycycline. L. Record review of R #242's Medication Administration Record (MAR), dated August 2023, revealed the following: 1. Clindamycin administered between 08/01/23 and 08/11/23. 2. On 08/16/23, staff administered the first dose of Levaquin in the evening. 3. On 08/16/23, staff administered the first dose of Linezolid in the evening. M. On 02/09/24, at 11:08 AM, during an interview with the DON, she stated the following: 1. She started working at the facility in August 2023. 2. There was a change in medical providers at the facility in December 2023. 3. She could not identify any current staff who would have provided wound care for R #242. 4. There was a nine day delay in starting Levaquin and Linezolid antibiotics. 5. A delay in starting antibiotics would cause worsening of R #242's wound because the infection was not controlled. 6. The DON was unsure why there was a delay in starting the antibiotics. 7. It was expected the nurses would notify the provider immediately when they received an order from the wound care specialist and obtain orders from the facility providers.

During a complaint survey, the following deficient practice was found to be Immediate Jeopardy: 1) R #3 had been admitted with a stage II pressure wound that healed and later developed a facility acquired Pressure wound (developed in the facility) that progressed to an infected (osteo[DIAGNOSES REDACTED] - infection of bone) stage 4 pressure ulcer (very deep, reaching into muscle and bone and causing extensive damage) on his left buttock (In the same area that had previously healed). 2) Record review of R #3's care plan dated 07/02/18 revealed vague interventions for his pressure ulcers to include a lack of timing for repositioning to prevent and/or heal pressure ulcers. 3) Record review of R #3's medical record revealed no documentation of when staff repositioned him. 4) The DON stated that the system does not allow for CNAs to document repositioning unless there is a specific order from the physician placed in the CNA electronic documentation platform. 5) There was no monitoring of staff repositioning residents at risk or currently with pressure ulcers. 6) Observations of wound care revealed improper infection control practices: a) hand hygiene, b) aseptic (clean) technique, c) and the return of contaminated wound care supplies to the common stock to be used for others. 7) the facility failed to reassess and observe the 48-hour antibiotic time out (to allow the pysician to determine if the antibiotic was effective) for R #3's Bactrim ds (antibiotic) for his infected pressure wound on his left buttock. Documentation shows odor still present (this indicated taht the wound was still infected) from R #3's left buttock pressure wound on 07/02/18 and 07/05/18. Bactrim ds started on 06/29/18. This resulted in an Immediate Jeopardy that was called on 12/19/18 at 2:35 pm. A Plan of Removal was submitted on 12/20/18 at 10:44 am, 1:15 pm, 2:47 pm and were rejected. On 12/20/18 at 4:08 pm, the final Plan of Removal was approved. Plan of Removal: To Whom It (MONTH) Concern: As an organization, we are fully committed to maintaining compliance with the rules and regulations set forth by regulatory entities. In that vein, we wish to address the following alleged instances of non-compliance and provide a comprehensive plan to address each. Facility action re: 1. Immediate evaluation of all residents for identification of wounds. Verification of orders with physician for accuracy, all physician orders [REDACTED]. 2. Immediate comprehensive clinical nursing assessment of all residents with pressure wounds and follow up on any pertinent findings with physician. Immediate compliance with 48-hour time out for antibiotic usage. Nursing staff will continue to monitor residents with infections, antibiotic usage and signs and symptoms of infections and the continued effectiveness of the antibiotic and notifying the physician and DON if symptoms continue or worsen. 3. Immediate re-education started 12/19/2018 for all licensed staff regarding facility policy related to wound care treatment techniques, rational for the treatment, and related wound care procedures. Staff that are unable to attend will not begin working until educated. 4. Immediate education to begin for staff regarding facility policy related to infection control techniques to include hand hygiene. Immediate education for licensed staff for policies related to wound care treatment and infection control techniques, e.g. cross contamination specific to treatment cart and wound care supplies. Staff that are unable to attend will not begin working until educated. 5. Immediate education to begin 12/19/2018 for direct care staff with regards to documentation of turning and repositioning of those residents identified at risk and with pressure injuries. Staff will document the turning and repositions of residents every 2-hours, licensed nurses will validate on the same form procedure compliance. During Clinical IDT and committee will review the turning and repositioning documentation for compliance. The plan to be updated to include turning and reposition required at least every 2-hours or as indicate by resident expressed preferences and/or comfort requests. The facility will ensure this deficiency does not recur by: 1. Completing a facility-wide skin sweep and documenting findings to be completed by (MONTH) 20, (YEAR). 2. Reviewing all physician orders [REDACTED]. 3. Monitoring the wound care treatment through treatment observation on a weekly basis for 12 weeks. 4. The Director of Nursing and Nursing Home Administrator are responsible for the correction of this deficiency. Attachments: Policy Wound Care Updated 121/20/2018 FORM-Turning and repositioning Completion date: ALL FTE(full time employees)/PTE (part time employees) by (MONTH) 20, (YEAR) Upon implementation of the Plan of Removal and surveyor verification, the Immediate Jeopardy was lifted on 12/20/18 at 7:10 pm. This resulted in the scope and severity reduced from a K to an H. Based observation, interview, and record review, the facility failed to provide services to residents to prevent the development and promote healing of pressure ulcers (damaged skin caused by staying in one position for too long) for 1 (R #3) of 4 (R #1, R #2, R #3, R #4) sampled for pressure ulcers, when they failed to 1) have specific timeframe's in R #3's care plan when referring to repositioning to prevent the progression and healing of his pressure ulcers while he was up in his wheelchair, 2) have a system in place to have CNAs document repositioning and other nursing staff were not monitoring for repositioning of residents. This deficient practice resulted in R #3 having an infected Stage 4 pressure ulcer on his left buttock area that became infected. The findings are: A. On 12/18/18 at 9:10 am, during an interview, R #3's Power of Attorney (POA) stated that R #3 was always up in his wheelchair from 6 am -7 pm. The POA stated that the facility had sent R #3 to the wound clinic for treatment, but when they arrived the wound doctor sent them to the E.R. (emergency room at a hospital) because She said this is beyond my ability, he needs a surgeon. The POA continued to state that at the hospital, R #3 had to have surgery for [REDACTED]. B. Record review of the Emergency Department Record Physician Documentation for R #3 dated 07/16/18 revealed The patient presents with his power of attorney sent over from (Name of local wound clinic), they sent him here for further evaluation and treatment for [REDACTED].today after a visit to the (Name of local wound clinic) for a pressure decubitus ulcer (pressure ulcer) that the wound care physician felt was too deep and against the bone requiring hospitalization . The patient presents with [MEDICAL CONDITION] (potentially serious bacterial skin infection) of the buttocks. Description: a stage IV decubitus ulcer on the left gluteus (muscle uder the buttock) with surrounding [MEDICAL CONDITION] . Possible cause(s): A pressure decubitus situation. Associated signs and symptoms: Pertinent positives: Weakness, foul discharge, open wound, purulent (discharging pus), green foul discharge .Skin: There is a 6 cm defect about the left pressure decubitus area of the butt down to the bone of the sacrum and ischium. There is a foul smell. Culture is collected from deep within the wound. The patient had no sensation of that area. There is some surrounding [MEDICAL CONDITION] . Preliminary [DIAGNOSES REDACTED]. C. Record review of the Laboratory Summary report dated 07/19/18 revealed Left buttocks . Strep, E. Faecalis (bacterial infection) D. Record review of the skin assessments revealed: 1. 04/23/18 .Redness noted on sacrum . 2. 05/29/18 a. left buttock 1 cm x1 cm pressure sore, reddened no discharge b. coccyx healed 4. 06/05/18 23:17 a. left buttock 1 cm x 1 cm pressure sore, reddened no discharge coccyx healed . and left buttocks 5. 06/18/18 18:57 a. left buttock 1 cm x 1 cm pressure sore, wound bed red, no exudate (sic), periwound intact 6. 06/25/18 07:25 Left buttocks measures 4 cm x 4 cm, irregular circle, wound bed covered with slough, minimal drainage noted, positive odor. 7. 07/07/18 22:18 #1 Right ischium unstageable (not stagable) 7 cm x 6 cm, undermining 4.5 cm, 90% slough (dead tissue ), moderate drainage 8. 07/13/18 17:48 R ischium unstageable 7 cm by 6 cm undermining 5 cm E. Record review of R #3 Progress Notes revealed: 1. 04/24/18 .Resident with stage 2 pressure ulcer when admitted . 2. 05/04/18 09:36 Resident is alert and oriented, Needs 2 person extensive assist during transfer and ADLs (activities of daily living), able to turn with assist when in bed. Use wheelchair for ambulation. 3. 05/10/18 12:09 .Change dressing on sacrum start to heal and close some part of the open skin. measure 2.8 cm x 0.2 cm . 4. 05/14/18 14:42 .Dressing changed on sacrum with no odor, no drainage, measures approx 0.5 cm x 1 cm. 5. 05/21/18 01:12 .Wound dressing done on sacrum. Sacral wound almost healed. Surrounding tissue intact. 6. 05/22/18 13:17 .He has been up in wheelchair most of day. two-person transfer . 7. 05/27/18 18:51 . Coccyx wound almost clear. On ABT (antibiotic) due to pneumonia . 8. 05/28/18 00:09 Open skin noted on left buttock about 1 cm x 1 cm, circular in shape with 25% slough. Non-blanchable redness noted on the surrounding area. Wound care done on the affected area. DON and ADON notified. Will notify POA in AM. 9. 05/28/18 14:14 Resident is on antibiotics for pneumonia no side effects of same . Resident has two small pressure sores on either buttock dressings were changed this morning and are clean dry and intact. 10. 05/28/18 16:43 POA notified by this writer on the skin alteration noted on left buttocks. Will continue with the initated (sic) treatment. 11. 05/29/18 11:30 Left buttock measure 1.0 cm x 0.7 cm, open skin, wound bed is red, no noted slough, cleanse with NS (normal saline) and cover with [MEDICATION NAME]. 12. 05/31/18 12:05 Coccyx area is a Stage 2. Continue with current treatment. 13. 06/01/18 10:53 New blister noted on left buttock skin intact measure 0.6 cm x 1.0 cm. 14. 06/04/18 14:21 IDT (interdisciplinary team) weekly meeting held today related to fluid-filled blister skin alteration on lateral left buttock. Measures approx 0.5 cm x 0.25 cm. No drainage, intact skin surrounding. Will continue with the treatment of [REDACTED]. 15. 06/07/18 12:28 Left buttock pressure measure 4.5 cm x 2.5 cm with slough, noted black on the wound bed of 2.5 cm x 1.5 cm . 16. 06/12/18 01:05 Left buttock pressure measure 4 cm x 3.8 cm with 90% slough, no odor, redness noted on the surrounding area. 17. 06/12/18 09:14 left buttock measure 3.5 cm x 4.7 cm, grayish slough part measure 2.5 cm x 2.8 cm. will notify DON for wound dressing changes. 18. 06/15/18 11:00 Left buttock stage 2 left buttocks measure 6.0 cm x 2.8 cm, wound bed 90% slough edges is red. 19. 06/19/18 02:37 Resident's wound on left buttock noted with drainage. Wound care done and noted total wound bed 6 cm x 3 cm. Wound edges noted partially granulating (grainy surface). 20% eschar noted, and slough in the middle about 3 cm x 2 cm. 20. 06/21/18 15:40 Left buttock pressure measure 4 cm x 2 cm with 90% slough, no odor, redness noted on the surrounding area. 21. 06/25/18 22:57 Wound care treatment done Left buttocks measures 4 cm x 4 cm, irregular circle, wound bed covered with slough, minimal drainage noted, positive odor. 22. 06/26/18 07:40 Wound care treatment done Left buttocks measures 4 cm x 4 cm, irregular circle, wound bed covered with, slough, minimal drainage noted, positive odor. 23. 07/02/18 .Wound care done on left buttock and noted 5 cm x 4 cm x 3 cm measurement. Wound irregular in shape, covered with slough, positive drainage and odor . 24. 07/05/18 7:05 On oral ABT due to Citrobacter freundii (bacteria) on his left buttock. Odor still noted on left buttock wound. No adverse reaction noted at this time. Afebrile. 25. 07/06/2018 22:24 IDT meeting held related to wounds on: #1 Right ischium unstageable with undermining 4.5 cm tunneling (sic), 7-9 o'clock undermining,90% slough, moderate drainage, care plan revised to include appropriate treatment at this time with the presence of wound care specialist to start on santyl, calcium alginate rope and [MEDICATION NAME] blue every 3 days. 26. 07/08/18 .Mostly in his wheelchair . 27. 07/09/18 .For breakfast and lunch up in the wheelchair most of the day . 28. 07/11/18 23:15 Wound care treatment done. Right ischium unstageable 7 cm x 6 cm, undermining 5 cm, 100% slough, moderate drainage, odor noted . 29. 07/15/18 21:24 wound care treatment done on : #1 Right ischium unstageable with undermining 3 cm x 3 cm with tunneling of 2 cm, 7-9 o'clock undermining, 90% slough, moderate drainage, applied santyl, calcium alginate rope and [MEDICATION NAME] blue every 3 days and PRN (as needed). 30. 07/17/18 08:43 Resident admitted to Memorial Hospital for his appointment but was advised to stay for admission . DON informed. 7/16/2016 @ 3 pm F. Record review of R #3's care plan dated 07/02/18 revealed the following: 1. (Name of R #3) is at risk for complications R/T (related to) L (left) buttock wound infection requiring antibiotic therapy. 07/05/18: has open area on is gluteal fold. (Name of R #3) infection will resolve without complications by next review. Antibiotic therapy as ordered. Monitor for adverse reaction. Encourage increased fluid intake unless contraindicated. Monitor for s/s (signs and symptoms) of worsening condition. Notify MD as needed. (Name of R #3) has a pressure ulcer on left buttock, stage 2. Wound on left heel and left back of lower leg; skin alteration in between toes. Update 6/13/2018 left heel: unstageable PU. Update 7/8/18: left buttocks now unstageable. 2. (Name of R #3) skin issues will heal without complications by next review. In the event of power outage, plug air mattress to generator powered outlet as indicated. Or transfer resident to wheelchair/chair if requested. Refer to wound clinic Air mattress. Assess pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin as indicated. Diet as ordered. Encourage fluids unless contraindicated. Heel floaters as ordered. Roho cushion on wheelchair Sheepskin on wheelchair footrest and leg support. Skin assessment as indicated Supplements as ordered. Treatment as ordered. Turn and reposition routinely and as indicated. Encourage frequent weight shifts when in chair. 3. (Name of R #3) is at risk for pressure ulcers R/T decline in his ability to be mobile, left [MEDICAL CONDITION] (Name of R #3) skin will remain intact by the next review Air mattress Avoid shearing (Name of R #3) skin during positioning, transferring, and turning Conduct a systematic skin inspection as indicated. Pay particular attention to the bony prominence's Keep clean and dry as possible. Minimize skin exposure to moisture Keep linens clean, dry, and as wrinkle free as possible Maintain the head of the bed at the lowest degree of elevation possible Provide incontinence care after each incontinent episode Report any signs of skin breakdown (sore, tender, red, or broken areas). Treatments as ordered to areas of breakdown Turn and reposition on routine rounds and prn G. Record Review of R #3's physician's orders [REDACTED]. H. On 12/19/18 at 10:14 am, during an interview the DON confirmed that when R #3 was discharged , he had an unstageable on his left buttock. The DON also confirmed that R #3 was admitted with a stage 2 Pressure wound his sacrum that healed at roughly the same time he developed another pressure would on his left buttock. The DON stated that the documentation of the right ischium is the unstageable pressure would on his left buttock, He only had the one on the left buttock. The Don continued They did wound culture and positive for infection and (name of R #3's doctor) ordered Bactrim. The DON was asked if R #3 had any factors that could have contributed to R #3 developing the pressure would and worsening, The DON stated, He had pneumonia and put on antibiotic and he had an infection in his blood he was septic. After reviewing R #3's chart, the DON confirmed that R #3 had been treated for [REDACTED]. He did have [MEDICAL CONDITION] (swelling) during the same time he healed his other pressure wound. I. On 12/19/18 at 11:13 am, during an interview CNA #2 stated that she documents transfer and mobility for Activities of Daily Living but does not document repositioning. I have not found a place to document that. It should be every 2 hours. J. On 12/19/18 at 12:03 am, the DON confirmed that the CNA's electronic documentation platform does not allow the CNA's to document repositioning unless the physician has ordered a specific time. The DON was asked how the facility monitors if residents are repositioned. The DON stated that it is done during the wet/dry checks. Documentation of this is supposed to be done every 2 hours (repositioning every 2 hours is the standard practice for prevention or healing of pressure ulcers). The DON confirmed that this was a review of the documentation and not of the repositioning itself. The DON also confirmed that facility did not have a policy specifically outlining 2-hour repositioning that is why it not outlined in the care plan. K. On 12/19/18 at 2:53 pm, during an interview RN #1 was asked how she monitors residents being repositioned every 2 hours. She stated For residents in bed, I can see them when I do rounds or walk by if they are in the same position. When asked about residents in wheelchairs, RN #1 stated That's tough for people who are in wheelchair. They are always on the go.

During a complaint survey the following deficient practice was found to be Immediate Jeopardy: 1) R #3 had been admitted with a stage II pressure wound that healed and developed a facility acquired Pressure wound (developed in the facility) that progressed to an infected (osteo[DIAGNOSES REDACTED] - infection of bone) stage 4 pressure ulcer (very deep, reaching into muscle and bone and causing extensive damage) on his left buttock. 2) Record review of R #3's care plan dated 07/02/18 revealed vague interventions for his pressure ulcers to include a lack of timing for repositioning to prevent and/or heal pressure ulcers. 3) Record review of R #3's medical record revealed no documentation of when staff repositioned him. 4) The DON stated that the system does not allow for CNAs to document repositioning unless there is a specific order from the physician placed in the CNA electronic documentation platform. 5) There was no monitoring of staff repositioning residents at risk or currently with pressure ulcers. 6) Observations of wound care revealed improper infection control practices: a) hand hygiene, b) aseptic (clean) technique, c) and the return of contaminated wound care supplies to the common stock to be used for others. 7) the facility failed to reassess and observe the 48-hour antibiotic time out for R #3's Bactrim ds (antibiotic) for his infected pressure wound on his left buttock. Documentation shows odor still present from R #3's left buttock pressure wound on 07/02/18 and 07/05/18. Bactrim ds started on 06/29/18. This resulted in an Immediate Jeopardy that was called on 12/19/18 2:35 pm. A Plan of Removal was submitted on 12/20/18 at 10:44 am, 1:15 pm, 2:47 pm and were rejected. On 12/20/18 at 4:08 pm the final Plan of Removal was approved. Plan of Removal To Whom It (MONTH) Concern: As an organization, we are fully committed to maintaining compliance with the rules and regulations set forth by regulatory entities. In that vein, we wish to address the following alleged instances of non-compliance and provide a comprehensive plan to address each. Facility action re: 1. Immediate evaluation of all residents for identification of wounds. Verification of orders with physician for accuracy, all physician orders [REDACTED]. 2. Immediate comprehensive clinical nursing assessment of all residents with pressure wounds and follow up on any pertinent findings with physician. Immediate compliance with 48-hour time out for antibiotic usage. Nursing staff will continue to monitor residents with infections, antibiotic usage and signs and symptoms of infections and the continued effectiveness of the antibiotic and notifying the physician and DON if symptoms continue or worsen. 3. Immediate re-education started 12/19/2018 for all licensed staff regarding facility policy related to wound care treatment techniques, rational for the treatment, and related wound care procedures. Staff that are unable to attend will not begin working until educated. 4. Immediate education to begin for staff regarding facility policy related to infection control techniques to include hand hygiene. Immediate education for licensed staff for policies related to wound care treatment and infection control techniques, e.g. cross contamination specific to treatment cart and wound care supplies. Staff that are unable to attend will not begin working until educated. 5. Immediate education to begin 12/19/2018 for direct care staff with regards to documentation of turning and repositioning of those residents identified at risk and with pressure injuries. Staff will document the turning and repositions of residents every 2-hours, licensed nurses will validate on the same form procedure compliance. During Clinical IDT and committee will review the turning and repositioning documentation for compliance. The plan to be updated to include turning and reposition required at least every 2-hours or as indicate by resident expressed preferences and/or comfort requests. The facility will ensure this deficiency does not recur by: 1. Completing a facility-wide skin sweep and documenting findings to be completed by (MONTH) 20, (YEAR). 2. Reviewing all physician orders [REDACTED]. 3. Monitoring the wound care treatment through treatment observation on a weekly basis for 12 weeks. 4. The Director of Nursing and Nursing Home Administrator are responsible for the correction of this deficiency. Attachments: Policy Wound Care Updated 121/20/2018 FORM-Turning and repositioning Completion date: ALL FTE(full time employees)/PTE (part time employees) by (MONTH) 20, (YEAR) Upon implementation of the Plan of Removal and surveyor verification, the Immediate Jeopardy was lifted on 12/20/18 at 7:10 pm. This resulted in the scope and severity reduced from a K to an H. Based observation, interview, and record review the facility failed to provide services to residents to prevent the development and promote healing of pressure ulcers (damaged skin caused by staying in one position for too long) for 1 (R #3) of 4 (R #1, R #2, R #3, R #4) sampled for pressure ulcers, when they failed to 1) prevent R #3 from developing an infected stage 4 pressure ulcer (very deep, reaching into muscle and bone and causing extensive damage) on his left buttock area when R #3 had a stage 2 pressure (partial-thickness skin loss into but no deeper than the dermis) wound he was admitted with that healed, 2) have specific timeframe's in R #3's care plan when referring to repositioning to prevent the progression and healing of his pressure ulcers while he was up in his wheelchair, 3) have a system in place to have CNAs document repositioning and staff were not monitoring for repositioning of residents, 5) provide wound care appropriately and incongruently with infection control practices for 2 (R #4, R #5) of 2 (R #4, R #5) sampled for wound care, and 6) to reassess and observe the 48-hour antibiotic time out for R #3's Bactrim ds for his infected pressure wound on his left buttock. Documentation from the progress notes shows odor still present from R #3's left buttock pressure wound on 07/02/18 and 07/05/18. Bactrim ds started on 06/29/18. This deficient practice resulted in R #3 having an infected Stage 4 pressure ulcer on his left buttock area. The findings are: R #3 A. On 12/18/18 at 9:10 am during an interview, R #3's Power of Attorney (POA) stated that R #3 was always up in his wheelchair from 6 am -7 pm. The POA stated that the facility had sent R #3 to the wound clinic for treatment, but when they arrived the wound doctor sent them to the E.R. because She said this is beyond my ability, he needs a surgeon. The POA continued to state that at the hospital R #3 had to have surgery for [REDACTED]. B. Record review of the Emergency Department Record Physician Documentation for R #3 dated 07/16/18 revealed The patient presents with his power of attorney sent over from (Name of local wound clinic), they sent him here for further evaluation and treatment for [REDACTED].today after a visit to the (Name of local wound clinic) for a pressure decubitus ulcer (pressure ulcer) that the wound care physician felt was too deep and against the bone requiring hospitalization . The patient presents with [MEDICAL CONDITION] (potentially serious bacterial skin infection) of the buttocks. Description: a stage IV decubitus ulcer on the left gluteus with surrounding [MEDICAL CONDITION] . Possible cause(s): A pressure decubitus situation. Associated signs and symptoms: Pertinent positives: Weakness foul discharge, open wound, purulent (discharging pus) green foul discharge .Skin: There is a 6 cm defect about the left pressure decubitus area of the butt down to the bone of the sacrum and ischium. There is a foul smell. Culture is collected from deep within the wound. The patient had no sensation of that area. There is some surrounding [MEDICAL CONDITION] . Preliminary [DIAGNOSES REDACTED]. C. Record review of the Laboratory Summary report dated 07/19/18 revealed Left buttocks . Strep, E. Faecalis (bacterial infection) D. Record review of the skin assessments revealed: 1. 04/23/18 .Redness noted on sacrum . 2. 05/29/18 a. left buttock 1 cm x1 cm pressure sore, reddened no discharge b. coccyx healed 4. 06/05/18 23:17 a. left buttock 1 cm x 1 cm pressure sore, reddened no discharge coccyx healed . and left buttocks 5. 06/18/18 18:57 a. left buttock 1 cm x 1 cm pressure sore, wound bed red, no exudate (sic), periwound intact 6. 06/25/18 07:25 Left buttocks measures 4 cm x 4 cm, irregular circle, wound bed covered with slough, minimal drainage noted, positive odor. 7. 07/07/18 22:18 #1 Right ischium unstageable (not stagable) 7 cm x 6 cm, undermining 4.5 cm, 90% slough (dead tissue ), moderate drainage 8. 07/13/18 17:48 R ischium unstageable 7 cm by 6 cm undermining 5 cm E. Record review of R #3 Progress Notes revealed: 1. 04/24/18 .Resident with stage 2 pressure ulcer when admitted . 2. 05/04/18 09:36 Resident is alert and oriented, Needs 2 person extensive assist during transfer and ADLs (activities of daily living), able to turn with assist when in bed. Use wheelchair for ambulation. 3. 05/10/18 12:09 .Change dressing on sacrum start to heal and close some part of the open skin. measure 2.8 cm x 0.2 cm . 4. 05/14/18 14:42 .Dressing changed on sacrum with no odor, no drainage, measures approx 0.5 cm x 1 cm. 5. 05/21/18 01:12 .Wound dressing done on sacrum. Sacral wound almost healed. Surrounding tissue intact. 6. 05/22/18 13:17 .He has been up in wheelchair most of day. two-person transfer . 7. 05/27/18 18:51 . Coccyx wound almost clear. On ABT (antibiotic) due to pneumonia . 8. 05/28/18 00:09 Open skin noted on left buttock about 1 cm x 1 cm, circular in shape with 25% slough. Non-blanchable redness noted on the surrounding area. Wound care done on the affected area. DON and ADON notified. Will notify POA in AM. 9. 05/28/18 14:14 Resident is on antibiotics for pneumonia no side effects of same . Resident has two small pressure sores on either buttock dressings were changed this morning and are clean dry and intact. 10. 05/28/18 16:43 POA notified by this writer on the skin alteration noted on left buttocks. Will continue with the initated (sic) treatment. 11. 05/29/18 11:30 Left buttock measure 1.0 cm x 0.7 cm, open skin, wound bed is red, no noted slough, cleanse with NS (normal saline) and cover with [MEDICATION NAME]. 12. 05/31/18 12:05 Coccyx area is a Stage 2. Continue with current treatment. 13. 06/01/18 10:53 New blister noted on left buttock skin intact measure 0.6 cm x 1.0 cm. 14. 06/04/18 14:21 IDT (interdisciplinary team) weekly meeting held today related to fluid-filled blister skin alteration on lateral left buttock. Measures approx 0.5 cm x 0.25 cm. No drainage, intact skin surrounding. Will continue with the treatment of [REDACTED]. 15. 06/07/18 12:28 Left buttock pressure measure 4.5 cm x 2.5 cm with slough, noted black on the wound bed of 2.5 cm x 1.5 cm . 16. 06/12/18 01:05 Left buttock pressure measure 4 cm x 3.8 cm with 90% slough, no odor, redness noted on the surrounding area. 17. 06/12/18 09:14 left buttock measure 3.5 cm x 4.7 cm, grayish slough part measure 2.5 cm x 2.8 cm. will notify DON for wound dressing changes. 18. 06/15/18 11:00 Left buttock stage 2 left buttocks measure 6.0 cm x 2.8 cm, wound bed 90% slough edges is red. 19. 06/19/18 02:37 Resident's wound on left buttock noted with drainage. Wound care done and noted total wound bed 6 cm x 3 cm. Wound edges noted partially granulating (grainy surface). 20% eschar noted, and slough in the middle about 3 cm x 2 cm. 20. 06/21/18 15:40 Left buttock pressure measure 4 cm x 2 cm with 90% slough, no odor, redness noted on the surrounding area. 21. 06/25/18 22:57 Wound care treatment done Left buttocks measures 4 cm x 4 cm, irregular circle, wound bed covered with slough, minimal drainage noted, positive odor. 22. 06/26/18 07:40 Wound care treatment done Left buttocks measures 4 cm x 4 cm, irregular circle, wound bed covered with, slough, minimal drainage noted, positive odor. 23. 07/02/18 .Wound care done on left buttock and noted 5 cm x 4 cm x 3 cm measurement. Wound irregular in shape, covered with slough, positive drainage and odor . 24. 07/05/18 7:05 On oral ABT due to Citrobacter freundii (bacteria) on his left buttock. Odor still noted on left buttock wound. No adverse reaction noted at this time. Afebrile. 25. 07/06/2018 22:24 IDT meeting held related to wounds on: #1 Right ischium unstageable with undermining 4.5 cm tunneling (sic), 7-9 o'clock undermining,90% slough, moderate drainage, care plan revised to include appropriate treatment at this time with the presence of wound care specialist to start on santyl, calcium alginate rope and [MEDICATION NAME] blue every 3 days. 26. 07/08/18 .Mostly in his wheelchair . 27. 07/09/18 .For breakfast and lunch up in the wheelchair most of the day . 28. 07/11/18 23:15 Wound care treatment done. Right ischium unstageable 7 cm x 6 cm, undermining 5 cm, 100% slough, moderate drainage, odor noted . 29. 07/15/18 21:24 wound care treatment done on : #1 Right ischium unstageable with undermining 3 cm x 3 cm with tunneling of 2 cm, 7-9 o'clock undermining, 90% slough, moderate drainage, applied santyl, calcium alginate rope and [MEDICATION NAME] blue every 3 days and PRN (as needed). 30. 07/17/18 08:43 Resident admitted to Memorial Hospital for his appointment but was advised to stay for admission . DON informed. 7/16/2016 @ 3 pm F. Record review of R #3's care plan dated 07/02/18 revealed the following: 1. (Name of R #3) is at risk for complications R/T (related to) L (left) buttock wound infection requiring antibiotic therapy. 07/05/18: has open area on is gluteal fold. (Name of R #3) infection will resolve without complications by next review. Antibiotic therapy as ordered. Monitor for adverse reaction. Encourage increased fluid intake unless contraindicated. Monitor for s/s (signs and symptoms) of worsening condition. Notify MD as needed. (Name of R #3) has a pressure ulcer on left buttock, stage 2. Wound on left heel and left back of lower leg; skin alteration in between toes. Update 6/13/2018 left heel: unstageable PU. Update 7/8/18: left buttocks now unstageable. 2. (Name of R #3) skin issues will heal without complications by next review. In the event of power outage, plug air mattress to generator powered outlet as indicated. Or transfer resident to wheelchair/chair if requested. Refer to wound clinic Air mattress. Assess pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin as indicated. Diet as ordered. Encourage fluids unless contraindicated. Heel floaters as ordered. Roho cushion on wheelchair Sheepskin on wheelchair footrest and leg support. Skin assessment as indicated Supplements as ordered. Treatment as ordered. Turn and reposition routinely and as indicated. Encourage frequent weight shifts when in chair. 3. (Name of R #3) is at risk for pressure ulcers R/T decline in his ability to be mobile, left [MEDICAL CONDITION] (Name of R #3) skin will remain intact by the next review Air mattress Avoid shearing (Name of R #3) skin during positioning, transferring, and turning Conduct a systematic skin inspection as indicated. Pay particular attention to the bony prominence's Keep clean and dry as possible. Minimize skin exposure to moisture Keep linens clean, dry, and as wrinkle free as possible Maintain the head of the bed at the lowest degree of elevation possible Provide incontinence care after each incontinent episode Report any signs of skin breakdown (sore, tender, red, or broken areas). Treatments as ordered to areas of breakdown Turn and reposition on routine rounds and prn G. Record Review of R #3's physician's orders [REDACTED]. H. On 12/19/18 at 10:14 am, during an interview the DON confirmed that when R #3 was discharged he had an unstageable on his left buttock. The DON also confirmed that R #3 was admitted with a stage 2 Pressure wound his sacrum that healed at rough the same time he developed another pressure would on his left buttock. The DON stated that the documentation of the right ischium is the unstageable pressure would on his left buttock, He only had the one on the left buttock. The Don continued They did wound culture and positive for infection and (name of R #3's doctor) ordered Bactrim. The DON was asked if R #3 had any factors that could have contributed to R #3 developing the pressure would and worsening, The DON stated, He had pneumonia and put on antibiotic and he had an infection in his blood he was septic. After reviewing R #3's chart the DON confirmed that R #3 had been treated for [REDACTED]. I. On 12/19/18 at 11:13 am, during an interview CNA #2 stated that she documents transfer and mobility for Activities of Daily Living but does not document repositioning. I have not found a place to document that. It should be every 2 hours. J. On 12/19/18 at 12:03 am, the DON confirmed that the CNA's electronic documentation platform does not allow the CNA's to document repositioning unless the physician has ordered a specific time. The DON was asked how the facility monitors if residents are repositioned, The DON stated that wet/dry checks documentation, it is supposed to be done every 2 hours (repositioning every 2 hours is the standard practice for prevention or healing of pressure ulcers). The DON confirmed that this was a review of the documentation and not of the repositioning itself. The DON also confirmed that facility did not have a policy specifically outlining 2-hour repositioning that is why it not outlined in the care plan. K. On 12/19/18 at 12:03 am, the DON confirmed that the CNA's electronic documentation platform does not allow the CNA's to document repositioning unless the physician has ordered a specific time. The DON was asked how the facility monitors if residents are repositioned, The DON stated that wet/dry checks documentation, it is supposed to be done every 2 hours. The DON confirmed that this was a review of the documentation and not of the repositioning itself. The DON also confirmed that facility did not have a policy specifically outlining 2-hour repositioning that is why it not outlined in the care plan. L. On 12/19/18 at 1:11 pm, during an interview the DON confirmed that the facility had not done the 48-hour antibiotic timeout for R #3 (Documentation from the progress notes shows odor still present from R #3's left buttock pressure wound on 07/02/18 and 07/05/18. Bactrim ds started on 06/29/18). The DON stated that the staff had not had the education at that time. M. On 12/19/18 at 2:53 pm, during an interview RN #1 was asked how she monitors residents being repositioned every 2 hours, she stated For residents in bed I can see them when I do rounds or walk by if they are in the same position. When asked about residents in wheelchairs, RN #1 stated That's tough for people who are in wheelchair. They are always on the go. Wound Care Observations R #4 N. On 12/19/18 at 8:50 am, during observation of wound care performed by RN (Registered Nurse) #2 for R #4 the following was observed: RN #2 placed a disposable pad onto the R #4's bedside table table, then placed packages of foam dressings, calcium alginate (a product used to absorb excess fluid in wound), long cotton tip swabs, and non packaged items--disposable measuring tape measures, 4 x 4 gauze sponges and other items. Later, RN #2 dropped the scissors onto the floor. RN #2 picked up the scissors and wiped them with MicoKill (a disposable wipe) wipes. RN #2 removed her gloves and regloved without performing hand hygiene between the gloving. RN #2 finished arranging supplies and assisted the resident to his side. She placed her gloved hands on the resident as she helped him turn, repositioned his leg for comfort, and adjusted the bed height with the electronic controls in the bed rail. RN #2 removed her gloves and regloved without performing hand hygiene between gloving. After removing soiled dressings, RN #2 removed her gloves then reached into her pocket and took out a bottle of waterless hand cleanser and performed hand hygiene and regloved. RN #2 used 10 cc (cubic centimeters) syringe to drip sterile saline into the wounds starting with the small wound at the rt buttock, then used a second syringe of saline to place saline into the larger, deeper wound at sacrum before measuring the wounds. No further cleansing of the wound was observed. RN #2 picked up one of the measuring tapes that were placed together on the field and opened 2 packages of the swabs that were in a small bundle of swabs on the field and measured the wounds. She removed gloves and regloved then opened the package of calcium alginate, took the strip in her hand and placed it into a disposable cup that had [MEDICATION NAME] gel (a product to aid in wound healing), then sprinkled collagen powder (a powder used to aid in wound healing) in the cup. She used a tongue blade to stir the contents of the cup. RN #2 took the strip in her hands and formed it into a small ball before pushing it into the open wound at the sacrum. RN #2 repeated the process for the other wound. When the dressing were in place. RN #2 removed her gloves, performed hand hygiene. RN #2 gathered the unused packages and unwrapped supplies into a basin, took the basin to the treatment care and restocked the supplies that had been on the field into the supply stock in the cabinet. R #5 O. Record review of physician orders [REDACTED]. Wrapped with compression/bulkee and coband (self adhering roll over dressing). P. On 12/19/18 at 9:50 am, during observation of wound care for R #5's left heel by RN #2, it was observed RN #2 used a small bottle of sterile water to cleanse the wound. The stream of water was poured slowly, running over intact skin before going into the wound. There was no other cleansing of the wound. RN #2 applied Arasept gel and covered the wound with a foam dressing before wrapping the foot and leg with a cotton roll followed by Coban (a self sticking roll to hold dressings in place). Q. On 12/19/18 at 10:55 am, during an interview with RN #2, when asked if the doctor's ordered instructed the wound to be packed. RN #2 stated, I forgot to pack the wound with the calcium alginate. R. On 12/29/18 at 11:00 am, during an interview with the DON (Director of Nurses), when asked about RN #2 not doing hand hygiene between gloves changes after having performed unclean tasks, she stated, (Name of RN #2) did hand hygiene many times during the dressing changes for R #4. The DON affirmed that returned packages or unwrapped items that had been on a field used for wound care would be a problem for cross contamination. The DON confirmed that RN #2 should have followed the physician orders [REDACTED]. S. Record review of the facility Wound Care procedure, revised 10/2010, revealed: 7. Use no touch technique . 8. Be certain all clean items are on clean field 22. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. T. Review of Center for Disease Control, Hand Hygiene, updated (MONTH) 25, (YEAR) (https://www.cdc.gov/handhygiene/providers/index.html) revealed: When to clean your hands: Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed) After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient If hands will be moving from a contaminated-body site to a clean-body site during patient care After glove removal When and How to Wear Gloves Wearing gloves is not a substitute for hand hygiene. Always clean your hands after removing gloves. Steps for Glove Use: Put on gloves before touching a patient's non-intact skin, open wounds or mucous membranes, such as the mouth, nose, and eyes Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face) Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination.

During a complaint survey the following deficient practice was found to be Immediate Jeopardy: 1) R #3 had been admitted with a stage II pressure wound that healed and developed a facility acquired (developed in the facility) that progressed to an infected (osteo[DIAGNOSES REDACTED] - infection of bone) stage 4 pressure ulcer on his left buttock 2) Record review of R #3's care plan dated 07/02/18 revealed vague interventions for his pressure ulcers to include a lack of timing for repositioning to prevent and/or heal pressure ulcers. 3) Record review of R #3's medical record revealed no documentation of when staff repositioned him. 4) The DON stated that the system does not allow for CNAs to document repositioning unless there is a specific order from the physician placed in the CNA electronic documentation platform. 5) There was no monitoring of staff repositioning residents at risk or currently with pressure ulcers. 6) Observations of wound care revealed improper infection control practices: a) hand hygiene, b) aseptic (clean) technique, c) and the return of contaminated wound care supplies to the common stock to be used for others 7) the facility failed to reassess and observe the 48-hour antibiotic time out for R #3's Bactrim ds for his infected pressure wound on his left buttock. Documentation shows odor still present from R #3's left buttock pressure wound on 07/02/18 and 07/05/18. Bactrim ds started on 06/29/18. This resulted in an Immediate Jeopardy that was called on 12/19/18 2:35 pm. A Plan of Removal was submitted on 12/20/18 at 10:44 am, 1:15 pm, 2:47 pm and were rejected. On 12/20/18 at 4:08 pm the final Plan of Removal was approved. Plan of Removal To Whom It (MONTH) Concern: As an organization, we are fully committed to maintaining compliance with the rules and regulations set forth by regulatory entities. In that vein, we wish to address the following alleged instances of non-compliance and provide a comprehensive plan to address each. Facility action re: 1. Immediate evaluation of all residents for identification of wounds. Verification of orders with physician for accuracy, all physician orders [REDACTED]. 2. Immediate comprehensive clinical nursing assessment of all residents with pressure wounds and follow up on any pertinent findings with physician. Immediate compliance with 48-hour time out for antibiotic usage. Nursing staff will continue to monitor residents with infections, antibiotic usage and signs and symptoms of infections and the continued effectiveness of the antibiotic and notifying the physician and DON if symptoms continue or worsen. 3. Immediate re-education started 12/19/2018 for all licensed staff regarding facility policy related to wound care treatment techniques, rational for the treatment, and related wound care procedures. Staff that are unable to attend will not begin working until educated. 4. Immediate education to begin for staff regarding facility policy related to infection control techniques to include hand hygiene. Immediate education for licensed staff for policies related to wound care treatment and infection control techniques, e.g. cross contamination specific to treatment cart and wound care supplies. Staff that are unable to attend will not begin working until educated. 5. Immediate education to begin 12/19/2018 for direct care staff with regards to documentation of turning and repositioning of those residents identified at risk and with pressure injuries. Staff will document the turning and repositions of residents every 2-hours, licensed nurses will validate on the same form procedure compliance. During Clinical IDT and committee will review the turning and repositioning documentation for compliance. The plan to be updated to include turning and reposition required at least every 2-hours or as indicate by resident expressed preferences and/or comfort requests. The facility will ensure this deficiency does not recur by: 1. Completing a facility-wide skin sweep and documenting findings to be completed by (MONTH) 20, (YEAR). 2. Reviewing all physician orders [REDACTED]. 3. Monitoring the wound care treatment through treatment observation on a weekly basis for 12 weeks. 4. The Director of Nursing and Nursing Home Administrator are responsible for the correction of this deficiency. Attachments: Policy Wound Care Updated 121/20/2018 FORM-Turning and repositioning Completion date: ALL FTE(full time employees)/PTE (part time employees) by (MONTH) 20, (YEAR) Upon implementation of the Plan of Removal and surveyor verification, the Immediate Jeopardy was lifted on 12/20/18 at 7:10 pm. This resulted in the scope and severity reduced from a K to an H. Based observation, interview, and record review the facility failed to implement an antibiotic stewardship program for 1 (R #3) of 4 (R #1, R #2, R #3, R #4) sampled for pressure ulcers (skin caused by staying in one position for too long), when they failed to reassess and observe the 48-hour antibiotic time out for R #3's Bactrim ds for his infected pressure wound on his left buttock. Documentation shows odor still present from R #3's left buttock pressure wound on 07/02/18 and 07/05/18. Bactrim ds started on 06/29/18. This deficient practice resulted in R #3 having an infected Stage 4 pressure ulcer on his left buttock area. The findings are: A. On 12/18/18 at 9:10 am, during an interview R #3's Power of Attorney (POA) stated that R #3 was always up in his wheelchair from 6 am -7 pm. The POA stated that the facility had sent R #3 to the wound clinic for treatment, but when they arrived the wound doctor sent them to the E.R. because She said this is beyond my ability, he needs a surgeon. The POA continued to state that at the hospital R #3 had to have surgery for [REDACTED]. B. Record review of the Emergency Department Record Physician Documentation for R #3 dated 07/16/18 revealed The patient presents with his power of attorney sent over from (Name of local wound clinic), they sent him here for further evaluation and treatment for [REDACTED].today after a visit to the (Name of local wound clinic) for a pressure decubitus ulcer that the wound care physician felt was too deep and against the bone requiring hospitalization . The patient presents with [MEDICAL CONDITION] of the buttocks. Description: a stage IV decubitus ulcer on the left gluteus with surrounding [MEDICAL CONDITION] . Possible cause(s): A pressure decubitus situation. Associated signs and symptoms: Pertinent positives: Weakness foul discharge, open wound, purulent green foul discharge .Skin: There is a 6 cm defect about the left pressure decubitus area of the butt down to the bone of the sacrum and ischium. There is a foul smell. Culture is collected from deep within the wound. The patient had no sensation of that area. There is some surrounding [MEDICAL CONDITION] . Preliminary [DIAGNOSES REDACTED]. C. Record review of the Laboratory Summary report dated 07/19/18 revealed Left buttocks . Strep, E. Faecalis (bacterial infection) D. Record review of the skin assessments revealed 1. 04/23/18 .Redness noted on sacrum . 2. 05/29/18 a. left buttock 1cm x1cm pressure sore, reddened no discharge b. coccyx healed 4. 06/05/18 23:17 a. left buttock 1 cm x 1 cm pressure sore, reddened no discharge coccyx healed . and left buttocks 5. 06/18/18 18:57 a. left buttock 1cmx1cm pressure sore, wound bed red, no exudate (sic), periwound intact 6. 06/25/18 07:25 Left buttocks measures 4cmx4cm, irregular circle, wound bed covered with slough, minimal drainage noted, positive odor. 7. 07/07/18 22:18 #1 Right ischium unstageable 7cmx6cm, undermining 4.5cm, 90% slough, moderate drainage 8. 07/13/18 17:48 R ischium unstageable 7 cm by 6 cm undermining 5 cm E. Record review of R #3 Progress Notes revealed 1. 04/24/18 .Resident with stage 2 pressure ulcer when admitted . 2. 05/04/218 09:36 Resident is alert and oriented, Needs 2 person extensive assit during transfer and ADLs, able to turn with assist when in bed. Use wheelchair for ambulation. 3. 05/10/18 12:09 .Change dressing on sacrum start to heal and close some part of the open skin. measure 2.8 cm x 0.2 cm . 4. 05/14/18 14:42 .Dressing changed on sacrum with no odor, no drainage, measures approx 0.5 cm x 1 cm. 5. 05/21/18 01:12 .Wound dressing done on sacrum. Sacral wound almost healed. Surrounding tissue intact. 6. 05/22/18 13:17 .He has been up in wheelchair most of day. two-person transfer . 7. 05/27/18 18:51 . Coccyx wound almost clear. On ABT due to pneumonia . 8. 05/28/18 00:09 Open skin noted on left buttock about 1cmx1cm, circular in shape with 25% slough. Non-blanchable redness noted on the surrounding area. Wound care done on the affected area. DON and ADON notified. WIll notify POA in AM. 9. 05/28/18 14:14 Resident is on antibiotics for pneumonia no side effects of same . Resident has two small pressure sores on either buttock dressings were changed this morning and are clean dry and intact. 10. 05/28/18 16:43 POA notified by this writer on the skin alteration noted on left buttocks. Will continue with the initated (sic) treatment. 11. 05/29/18 11:30 Left buttock measure 1.0 cm x 0.7 cm, open skin, wound bed is red, no noted slough, cleanse with NS and cover with [MEDICATION NAME]. 12. 05/31/18 12:05 Coccyx area is a Stage 2. Continue with current treatment. 13. 06/01/18 10:53 New blister noted on left buttock skin intact measure 0.6 cm x 1.0 cm. 14. 06/04/18 14:21 IDT weekly meeting held today related to fluid-filled blister skin alteration on lateral left buttock. Measures approx 0.5cmx0.25cm. No drainage, intact skin surrounding. Will continue with the treatment of [REDACTED]. 15. 06/07/18 12:28 Left buttock pressure measure 4.5 cm x 2.5 cm with slough, noted black on the wound bed of 2.5 cm x 1.5 cm . 16. 06/12/18 01:05 Left buttock pressure measure 4 cm x 3.8 cm with 90% slough, no odor, redness noted on the surrounding area. 17. 06/12/18 09:14 left buttock measure 3.5 cm x 4.7 cm, grayish slough part measure 2.5 cm x 2.8 cm. will notify DON for wound dressing changes. 18. 06/15/18 11:00 Left buttock stage 2 left buttocks measure 6.0 cm x 2.8 cm, wound bed 90% slough edges is red. 19. 06/19/18 02:37 Resident's wound on left buttock noted with drainage. Wound care done and noted total wound bed 6cmx3cm. Wound edges noted partially granulating. 20% eschar noted, and slough in the middle about 3 cm x 2 cm. 20. 06/21/18 15:40 Left buttock pressure measure 4 cm x 2 cm with 90% slough, no odor, redness noted on the surrounding area. 21. 06/25/18 22:57 Wound care treatment done Left buttocks measures 4 cm x 4 cm, irregular circle, wound bed covered with slough, minimal drainage noted, positive odor. 22. 06/26/18 07:40 Wound care treatment done Left buttocks measures 4 cm x 4 cm, irregular circle, wound bed covered with, slough, minimal drainage noted, positive odor. 23. 07/02/18 .Wound care done on left buttock and noted 5cmx4cmx3cm measurement. Wound irregular in shape, covered with slough, positive drainage and odor . 24. 07/05/18 7:05 On oral ABT due to Citrobacter freundii on his left buttock. Odor still noted on left buttock wound. No adverse reaction noted at this time. Afebrile. 25. 07/06/2018 22:24 IDT meeting held related to wounds on: #1 Right ischium unstageable with undermining 4.5cm tunneling (sic), 7-9 o'clock undermining,90% slough, moderate drainage, care plan revised to include appropriate treatment at this time with the presence of wound care specialist to start on santyl, calcium alginate rope and [MEDICATION NAME] blue every 3 days. 26. 07/08/18 .Mostly in his wheelchair . 27. 07/09/18 .For breakfast and lunch up in the wheelchair most of the day . 28. 07/11/18 23:15 Wound care treatment done. Right ischium unstageable 7cmx6cm, undermining 5cm, 100% slough, moderate drainage, odor noted . 29. 07/15/18 21:24 wound care treatment done on : #1 Right ischium unstageable with undermining 3cmx3cm with tunnelling of 2cm, 7-9 o'clock undermining,90% slough, moderate drainage, applied santyl, calcium alginate rope and [MEDICATION NAME] blue every 3 days and PRN 30. 07/17/18 08:43 Resident admitted to Memorial Hospital for his appointment but was advised to stay for admission . DON informed.7/16/2016 @ 3pm F. Record review of R #3's care plan dated 07/02/18 revealed the following: 1. (Name of R #3) is at risk for complications R/T (related to) L (left) buttock wound infection requiring antibiotic therapy. 07/05/18: has open area on is gluteal fold. (Name of R #3) infection will resolve without complications by next review. Antibiotic therapy as ordered. Monitor for adverse reaction. Encourage increased fluid intake unless contraindicated. Monitor for s/s of worsening condition. Notify MD as needed. (Name of R #3) has a pressure ulcer on left buttock, stage 2. Wound on left heel and left back of lower leg; skin alteration in between toes. Update 6/13/2018 left heel: unstageable PU. Update 7/8/18: left buttocks now unstageable. 2. (Name of R #3) skin issues will heal without complications by next review. In the event of power outage, plug air mattress to generator powered outlet as indicated. Or transfer resident to wheelchair/chair if requested. Refer to wound clinic Air mattress. Assess pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin as indicated. Diet as ordered. Encourage fluids unless contraindicated. Heel floaters as ordered. Roho cushion on wheelchair Sheepskin on wheelchair footrest and leg support. Skin assessment as indicated Supplements as ordered. Treatment as ordered. Turn and reposition routinely and as indicated. Encourage frequent weight shifts when in chair. 3. (Name of R #3) is at risk for pressure ulcers R/T decline in his ability to be mobile, left [MEDICAL CONDITION] (Name of R #3) skin will remain intact by the next review Air mattress Avoid shearing (Name of R #3) skin during positioning, transferring, and turning Conduct a systematic skin inspection as indicated. Pay particular attention to the bony prominences Keep clean and dry as possible. Minimize skin exposure to moisture Keep linens clean, dry, and as wrinkle free as possible Maintain the head of the bed at the lowest degree of elevation possible Provide incontinence care after each incontinent episode Report any signs of skin breakdown (sore, tender, red, or broken areas). Treatments as ordered to areas of breakdown Turn and reposition on routine rounds and prn G. Record review of the Lab report for R #3 wound culture revealed positive for infection. H. Record Review of R #3's physician's orders [REDACTED]. I. On 12/19/18 at 10:14 am, during an interview the DON confirmed that when R #3 was discharged he had an unstageable on his left buttock. The DON also confirmed that R #3 was admitted with a stage 2 Pressure wound that healed at rough the same time he developed another pressure would on his left buttock. The DON stated That the documentation of the right ischium is the unstageable pressure would on his left buttock, He only had the one on the left buttock. The Don continued They did wound culture and positive for infection and (name of R #3's doctor) ordered Bactrim. The DON was asked if R #e had any factors that could have contributed to R #3 developing the pressure would and worsening, The DON stated, He had pneumonia and put on antibiotic and he had an infection in his blood he was septic. After reviewing R #3's chart the DON confirmed that R #3 had been treated for [REDACTED]. J. On 12/19/18 at 11:13 am, during an interview CNA #2 stated that she documents transfer and mobility for Activities of Daily Living but does not document repositioning. I have not found a place to document that. It should be every 2 hours. K. On 12/19/18 at 12:03 am, The DON confirmed that the CNA's electronic documentation platform does not allow the CNA's to document repositioning unless the physician has ordered a specific time. The DON was asked how the facility monitors if residents are repositioned, The DON stated that wet/dry checks documentation, it is supposed to be done every 2 hours. The DON confirmed that this was a review of the documentation and not of the repositioning itself. The DON also confirmed that facility did not have a policy specifically outlining 2-hour repositioning that is why it not outlined in the care plan. L. On 12/19/18 at 1:11 pm, during an interview the DON confirmed that the facility had not done the 48-hour antibiotic timeout for R #3 (Documentation from the progress notes shows odor still present from R #3's left buttock pressure wound on 07/02/18 and 07/05/18. Bactrim ds started on 06/29/18). The DON stated that the staff had not had the education at that time. M. On 12/19/18 at 2:53 pm, during an interview RN #1 was asked how she monitors residents being repositioned every 2 hours, she stated For residents in bed I can see them when I do rounds or walk by if they are in the same position. When asked about residents in wheelchairs, RN #1 stated That's tough for people who are in wheelchair. They are always on the go.

Based on record review, interview, and observation, the facility failed to ensure that a resident's physician was notified when the resident has a decline (resident quit taking food and fluids, becoming weaker) for 1 (R #2) of 1 (R #2) resident surveyed for complaint of neglect. This deficient practice resulted in the resident being hospitalized for [REDACTED]. The findings are: A. Record review of the local hospital's emergency room records for R #2, dated 07/15/18, revealed: R #2 was brought to ER (emergency room ) for a fall and had a skin tear to the right forearm and a 3 cm bump (small contusion and with skin tear) on the right side of his head. A CT ( A computerized tomography scan (CT or CAT scan) uses computers and rotating X-ray machines to create cross-sectional images of the body) of the brain contrast revealed: Right frontal scalp soft tissue swelling, No post traumatic changes. Chronic ischemic (lack of blood flow) changes. The resident was discharged with instructions for daily dressing changes and observe for signs and symptoms of infection. B. Record review of the facility care plan dated 07/21/18 revealed: R #2 was admitted on [DATE] with these Diagnoses: [REDACTED]. C. Record review of the MDS (Minimum Data Set) for R #2, dated 07/19/18 revealed: 1. Section G: Functional Status: Bed mobility: How resident moves to and from lying position, turns side to side, and positions body while in bed: Required extensive assistance, a one person physical assist Eating: How resident eats and drinks: Limited assistance, one person assist 2. Record review of Section GG (Functional Abilities and Goals on Admission): Eating: The ability to use suitable utensils to bring food to the mouth and swallow food on admission:Supervision and or touching assistance. D. Record Review of the Progress Notes for R #2: 1. 07/15/18, revealed: Around 10 am, this resident was reported to this nurse that he is on the floor at the dining room. This nurse immediately responded and witnessed the resident on his right side with full (ROM) (range of motion), with 3 cm (centimeter-a metric unit of measure) x 3 cm bump on right forehead with minimal bleeding and a 0.25 cm tear in the middle of the bump, noted 1.5 cm x 2 cm skin tear on adjacent (sic) of right antecubital (interior bend of the elbow) area .Resident returned (from Emergency Department) around 2 pm with negative result of CT (CAT Scan) of head. 2. 07/16/18 Continue with wound care treatment for [REDACTED]. Refer to MD (Medical Doctor) as needed. 3. 07/17/18 .limited assist with eating There is no notation in the note of the skin tear. 4. 07/18/18 21:52 (9:52 pm) needs assistance and supervision when eating. Pain medication given as resident complained of pain but unable to identify where. 5. 07/19/18 5:04 (5:04 am) Resident's RT (right) arm is noted to have dry scab, but puss (sic) pocket at 6 o'clock and surrounding area red, warm to touch. Will refer in the morning. 6. 07/19/18 18:54 (6:54 pm) Resident still has redness surrounding dry scab on rt arm .VS (vital sign) checked, WNL (within normal limits). Noted with amber colored urine on his brief. Encouraged to increase oral fluid intake. (There is no note that fluids were offered or refused) 7. 07/19/18 22:03 (11:03 pm) Resident is warm to touch, T(temperature)=100.5 F (Fahrenheit) (average normal temperature 98.6 F). PRN (as needed) Tylenol (a medication used for symptoms of fever or pain) as ordered. 8. 07/20/18 12:43 (12:43 pm) Resident alert for meals but wanting to go back to bed afterwards. Temp 98.8 fluids encouraged. Right arm skin tear section measures 4 cm x 5 cm and has pus in the center. Area around this swollen, reddened and has an area where there appears to be pus under the skin. Phone call to Dr and resident started on 10 day course of [MEDICATION NAME] (an antibiotic) BID (twice a day). 9. 07/21/18 22:57 (10:57 pm) Resident is alert and weak looking .still has redness and swelling on rt forearm, dressing intact .on ABX (antibiotic) for [MEDICAL CONDITION] .Encouraged to increase oral fluid intake as tolerated. (There is no notation that fluids were offered) 10. 07/22/18 16:24 (4:24 pm) Resident alert but drowsy .able to express pain on movement of right arm dressing changed. Area of skin tear is now 10 cm x 3 cm but whole area that had yellow purulent (pus) tissue underneath the level of skin has come (sic) and was cleansed off .island dressing applied. 11. 07/23/18 0:17 (12:17 am) Resident is alert, weak looking, complained of pain, PRN pain medication given. Rt FA (forearm) with approximated 10 cm x 3 cm 60% flap (skin that had lifted up with injury and laid back into place), just above it is a skin tear about 2 x 2 cm. Areas are reddened with purulent discharge. Wound care done, applied xeroform (a Vaseline impregnated dressing) and covered with a Kerlix (bulky dressing in a roll) wrap .resident still on ABT (antibiotic therapy) .encouraged to increase fluid intake as provided. Snack provided. (there is no notation that fluids were offered or refused. 12. 07/23/18 at 8:15 (8:15 am) resident total assist with transfers and mobility, dressing toileting and hygiene. Total assist with feeding. Very lethargic and difficult to arouse .O2 (oxygen) sat (saturation) dropped to 86 started on 2 at liters .Remains on ATB (antibiotic therapy) for [MEDICAL CONDITION] to right forearm. E. Record review of the Intake of Food and Fluids from Vital Sign Intake for R #2 for (MONTH) (YEAR) revealed the following: 1. 07/23/2018 08:50 Breakfast: Not Taken, Reason not taken: Refused 2. 07/22/2018 13:11 Breakfast: None 3. 07/21/2018 08:25 Breakfast: Not Taken, Reason Not Taken Deferred due to condition 4. 07/19/2018 09:34 Breakfast: Not Taken, Reason not taken: Refused 5. 07/18/2018 12:44 Breakfast: 1-25% 6. 07/17/2018 08:30 Breakfast: 26-50% 7. 07/16/2018 07:47 Breakfast: 51-75 LUNCH 1. 07/23/2018 12:24 Lunch: Not Taken, Reason not taken: Refused 2. 07/22/2018 13:11 Lunch: None 3. 07/21/2018 12:20 Lunch: None 4. 07/19/2018 12:56 Lunch: 76-100% 5. 07/18/2018 12:44 Lunch: 26-50% 6. 07/17/2018 12:18 Lunch: Not Taken, Reason not taken: Refused 7. 07/16/2018 11:52 Lunch: Not Taken, Reason not taken: Refused 8. 07/15/2018 14:41 Lunch: Not Taken, Reason not taken: Deferred due to condition 9. 07/14/2018 12:12 Lunch: 26-50% 10. 07/13/2018 13:55 Lunch: 1-25% PM Snacks 1. 07/22/2018 23:35 PM Snack: 76-100% Dinners Taken From 07/13/18 To 07/24/18 1. 07/20/2018 21:53 Dinner: None 2. 07/16/2018 18:18 Dinner: 76-100% 3. 07/15/2018 18:48 Dinner: 76-100% 4. 07/14/2018 19:13 Dinner: 76-100% Intake : Fluids Taken From 07/13/18 To 07/24/18 1. 07/24/2018 07:46 Fluids: Not Taken 2. 07/23/2018 12:25 Fluids: Not Taken 3. 07/23/2018 08:50 Fluids: Not Taken 4. 07/22/2018 23:35 Fluids: 170 ml (a metric unit of volume, 30 ml=1 oz) 5. 07/20/2018 21:53 Fluids: 0 ml 6. 07/19/2018 12:56 Fluids: 500 ml 7. 07/19/2018 09:34 Fluids: Not Taken 8. 07/18/2018 12:45 Fluids: 240 ml 9. 07/18/2018 12:45 Fluids: 420 ml 10. 07/17/2018 12:18 Fluids: Not Taken 11. 07/17/2018 08:30 Fluids: 300 ml 12. 07/16/2018 18:18 Fluids: 360 ml 13. 07/16/2018 11:52 Fluids: Not Taken 14. 07/16/2018 07:47 Fluids: 300 ml 15. 07/15/2018 18:48 Fluids: 360 ml 16. 07/15/2018 14:40 Fluids: 360 ml 17. 07/14/2018 19:13 Fluids: 360 ml 18. 07/14/2018 12:13 Fluids: 360 ml 19. 07/14/2018 12:12 Fluids: 360 ml 20. 07/13/2018 13:55 Fluids: 240 ml 21. 07/13/2018 10:09 Fluids: 400 ml F. Record review of the care plan for R #2, dated 07/21/18 revealed: 1) Problem: 07/20/18 Dehydration/Fluid Maintenance - at risk for complications R/T (related to) [MEDICAL CONDITION] infection on right arm requiring antibiotic therapy. Short Term Goal Target Date: 07/30/18 .infection will resolve without complications by next review. Approach: Antibiotic therapy as ordered. Monitor for adverse reaction. Encourage increased fluid intake unless contraindications. Monitor for s/s (signs and symptoms) of worsening condition. Notify MD (Medical Doctor) as needed. 2) Problem 07/13/18 .has the following skin issues: dry scabs on his BLE (bilateral lower extremities), BUE (bilateral upper extremity bruising, RUE (right upper extremity) bruising, left elbow open area (this reflects skin condition on admission). Goal: Short Term Target Date: 08/13/18 .skin issue will be resolved by next review. Approach: Monitor for s/s of infection. Skin assessment as indicated. Treatment as indicated/ordered. 3) Problem: 07/13/18 Nutritional Status .current dietary order is CCHO (controlled carbohydrate) diabetic diet, mechanical soft (easy to chew). Long Term Goal Target Date: 10/13/18 Adhere to dietician's recommendation and physician order for [REDACTED]. Approach: Monitor/record oral intake of food and fluids . G. On 10/16/18 at 2:50 pm, during an interview with CNA #1 about R #2, she stated, I was out from work and when I came back they (other staff) said he was sick with infection. He had a fall and then got a [MEDICAL CONDITION]--he just went steadily downhill. He didn't eat or drink much after he got sick and I would try to get him up and he just didn't want it. The nurses knew all that; I didn't have to tell them. H. On 10/17/18 at 3:00 pm, during an interview, RN #2 stated, I did not look his intake. The CNAs tell us if the resident is not eating or drinking. I don't remember much. I. Record review of a local hospital records, dated 07/23/18, for R #2, revealed: admitted [DATE] with altered mental status, febrile, acute (sudden occurance) [MEDICAL CONDITION] probably secondary to dehydration, [MEDICAL CONDITION] right arm, and protein calorie malnutrition. The hospital progress note, dated 07/27/18 revealed: Large ulceration of the right forearm over the extensor surface with purulent (having pus) base. The records revealed: hospital admission 07/23/18 and discharge on 07/31/18. J. On 10/17/18 at 3:36 pm, during an interview, the DON said R#2 had been started on antibiotics for [MEDICAL CONDITION] on 07/20/18. She stated the nurses would have given him fluids with his medications, but she was unable to provide documentation of that. The DON said the physician should have been notified on 07/21/18 that he (R #2) had no intake, but as she reviewed the progress notes she said there was no documentation that he had been called that day. The DON affirmed the care plan should have been upated to reflect the skin tear. K. On 10/17/18 at 12:00 noon, during an interview with the POA (Power of Attorney-the person with legal authority to speak for resident since he could not speak for himself) she stated, I went to see him twice in the time he was there and he was in bed both times. I talked to (Name of nurse) about the [MEDICAL CONDITION]. I said I was worried. I don't know exact date, a Wednesday. She (the nurse) said it was fine, not an issue. It (the wound) was not covered and it was red and hot. I called the DON on that Friday and said I told the nurse it was hot and red. No one (at the facility) answered the phone all weekend. Monday I said we would just take him out (to the hospital). He should have gone to the hospital that Friday. I believe there was negligence. L. On 12/20/18 at 4:00 pm, during an interview, RN #1 stated, I remember his wound, I remember the yellow underneath the skin. He would sit at the table (in the dining room) and he would drift off and sleep. He was a person I had to keep and eye on. Over there (the Memory Unit), they don't have water in the resident rooms. They (residents) just get fluids at meals. I did not call the doctor about the wound. I think he (R #2) was ok. M. On 12/19/18 at 11:45 am, during an interview with the DON, when asked about the 07/20/18 to 07/23/18 when R #2 only had 170 cc (about 5 1/2 ounces) and a snack; she stated, Poor intake was his normal. The nurses should have probably noticed that and his intakes should have recorded. We did not call the physician for that. When asked about if the care plans to monitor food and fluid intake were followed she stated, No. When asked if the physician had been notified of the increasing wound size, the DON stated, I do not believe the nurses were measuring the wound correctly. When asked if the nurses could have noted the clinical signs of R #2's deterioration sooner and intervened, the DON said the nurses were treating his (R #2's) fever symptoms with Tylenol (a medication used to reduce fever) and giving the antibiotics the doctor prescribed. N. Record review of the facility policy Change in a Resident's Condition or Status, revised 12/2016 revealed: Our facility shall promptly notify the resident, his or Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been an d. significant change in the resident's physical/mental condition; e. need to alter the resident's medical treatment significantly, g. need to transfer the resident to a hospital/treatment center. 2. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant pertinent information for the provider, including (for example) information prompted by the Interact SBAR (form used to guide gathering and disseminating information--situation, background, assessment and recommendation) Communication form. O. Record review of the facility policy Resident Hydration and Prevention of Dehydration, revised 10/2011 revealed: 6. Nurses will assess for signs and symptoms of dehydration during daily care. 7. Nurses Aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml/day to nursing staff. 13. Nursing will monitor and document fluid intake and the Dietician will be kept informed of status. Interdisciplinary Team will update care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved. P. Record review of the facility policy Skin Tears-Abrasions and Minor Breaks, Care of, revised 09/2013 revealed: Reporting: Notify the physician of any abnormalities (i.e. excessive bleeding, localized swelling, redness, drainage, tenderness, pain etc.)

Based on record review, interview, and observation, the facility failed to ensure that a resident received timely assessments and interventions for a wound infection and decline (resident quit taking food and fluids, becoming weaker) for 1 (R #2) of 1 (R #2) resident surveyed for complaint of neglect. This deficient practice resulted in the resident being hospitalized for [REDACTED]. The findings are: A. Record review of the local hospital's emergency room records for R #2, dated 07/15/18, revealed: R #2 was brought to ER (emergency room ) for a fall and had a skin tear to the right forearm and a 3 cm bump (small contusion and with skin tear) on the right side of his head. A CT ( A computerized tomography scan (CT or CAT scan) uses computers and rotating X-ray machines to create cross-sectional images of the body) of the brain contrast revealed: Right frontal scalp soft tissue swelling, No post traumatic changes. Chronic ischemic (lack of blood flow) changes. The resident was discharged with instructions for daily dressing changes and observe for signs and symptoms of infection. B. Record review of the facility care plan dated 07/21/18 revealed: R #2 was admitted on [DATE] with these Diagnoses: [REDACTED]. C. Record review of the MDS (Minimum Data Set) for R #2, dated 07/19/18 revealed: 1. Section G: Functional Status: Bed mobility: How resident moves to and from lying position, turns side to side, and positions body while in bed: Required extensive assistance, a one person physical assist Eating: How resident eats and drinks: Limited assistance, one person assist 2. Record review of Section GG (Functional Abilities and Goals on Admission): Eating: The ability to use suitable utensils to bring food to the mouth and swallow food on admission:Supervision and or touching assistance. D. Record Review of the Progress Notes for R #2: 1. 07/15/18, revealed: Around 10 am, this resident was reported to this nurse that he is on the floor at the dining room. This nurse immediately responded and witnessed the resident on his right side with full (ROM) (range of motion), with 3 cm (centimeter-a metric unit of measure) x 3 cm bump on right forehead with minimal bleeding and a 0.25 cm tear in the middle of the bump, noted 1.5 cm x 2 cm skin tear on adjacent (sic) of right antecubital (interior bend of the elbow) area .Resident returned (from Emergency Department) around 2 pm with negative result of CT (CAT Scan) of head. 2. 07/16/18 Continue with wound care treatment for [REDACTED]. Refer to MD (Medical Doctor) as needed. 3. 07/17/18 .limited assist with eating There is no notation in the note of the skin tear. 4. 07/18/18 21:52 (9:52 pm) needs assistance and supervision when eating. Pain medication given as resident complained of pain but unable to identify where. 5. 07/19/18 5:04 (5:04 am) Resident's RT (right) arm is noted to have dry scab, but puss (sic) pocket at 6 o'clock and surrounding area red, warm to touch. Will refer in the morning. 6. 07/19/18 18:54 (6:54 pm) Resident still has redness surrounding dry scab on rt arm .VS (vital sign) checked, WNL (within normal limits). Noted with amber colored urine on his brief. Encouraged to increase oral fluid intake. (There is no note that fluids were offered or refused) 7. 07/19/18 22:03 (11:03 pm) Resident is warm to touch, T(temperature)=100.5 F (Fahrenheit) (average normal temperature 98.6 F). PRN (as needed) Tylenol (a medication used for symptoms of fever or pain) as ordered. 8. 07/20/18 12:43 (12:43 pm) Resident alert for meals but wanting to go back to bed afterwards. Temp 98.8 fluids encouraged. Right arm skin tear section measures 4 cm x 5 cm and has pus in the center. Area around this swollen, reddened and has an area where there appears to be pus under the skin. Phone call to Dr and resident started on 10 day course of [MEDICATION NAME] (an antibiotic) BID (twice a day). 9. 07/21/18 22:57 (10:57 pm) Resident is alert and weak looking .still has redness and swelling on rt forearm, dressing intact .on ABX (antibiotic) for [MEDICAL CONDITION] .Encouraged to increase oral fluid intake as tolerated. (There is no notation that fluids were offered) 10. 07/22/18 16:24 (4:24 pm) Resident alert but drowsy .able to express pain on movement of right arm dressing changed. Area of skin tear is now 10 cm x 3 cm but whole area that had yellow purulent (pus) tissue underneath the level of skin has come (sic) and was cleansed off .island dressing applied. 11. 07/23/18 0:17 (12:17 am) Resident is alert, weak looking, complained of pain, PRN pain medication given. Rt FA (forearm) with approximated 10 cm x 3 cm 60% flap (skin that had lifted up with injury and laid back into place), just above it is a skin tear about 2 x 2 cm. Areas are reddened with purulent discharge. Wound care done, applied xeroform (a Vaseline impregnated dressing) and covered with a Kerlix (bulky dressing in a roll) wrap .resident still on ABT (antibiotic therapy) .encouraged to increase fluid intake as provided. Snack provided. (there is no notation that fluids were offered or refused. 12. 07/23/18 at 8:15 (8:15 am) resident total assist with transfers and mobility, dressing toileting and hygiene. Total assist with feeding. Very lethargic and difficult to arouse .O2 (oxygen) sat (saturation) dropped to 86 started on 2 at liters .Remains on ATB (antibiotic therapy) for [MEDICAL CONDITION] to right forearm. E. Record review of the Intake of Food and Fluids from Vital Sign Intake for R #2 for (MONTH) (YEAR) revealed the following: 1. 07/23/2018 08:50 Breakfast: Not Taken, Reason not taken: Refused 2. 07/22/2018 13:11 Breakfast: None 3. 07/21/2018 08:25 Breakfast: Not Taken, Reason Not Taken Deferred due to condition 4. 07/19/2018 09:34 Breakfast: Not Taken, Reason not taken: Refused 5. 07/18/2018 12:44 Breakfast: 1-25% 6. 07/17/2018 08:30 Breakfast: 26-50% 7. 07/16/2018 07:47 Breakfast: 51-75 LUNCH 1. 07/23/2018 12:24 Lunch: Not Taken, Reason not taken: Refused 2. 07/22/2018 13:11 Lunch: None 3. 07/21/2018 12:20 Lunch: None 4. 07/19/2018 12:56 Lunch: 76-100% 5. 07/18/2018 12:44 Lunch: 26-50% 6. 07/17/2018 12:18 Lunch: Not Taken, Reason not taken: Refused 7. 07/16/2018 11:52 Lunch: Not Taken, Reason not taken: Refused 8. 07/15/2018 14:41 Lunch: Not Taken, Reason not taken: Deferred due to condition 9. 07/14/2018 12:12 Lunch: 26-50% 10. 07/13/2018 13:55 Lunch: 1-25% PM Snacks 1. 07/22/2018 23:35 PM Snack: 76-100% Dinners Taken From 07/13/18 To 07/24/18 1. 07/20/2018 21:53 Dinner: None 2. 07/16/2018 18:18 Dinner: 76-100% 3. 07/15/2018 18:48 Dinner: 76-100% 4. 07/14/2018 19:13 Dinner: 76-100% Intake : Fluids Taken From 07/13/18 To 07/24/18 1. 07/24/2018 07:46 Fluids: Not Taken 2. 07/23/2018 12:25 Fluids: Not Taken 3. 07/23/2018 08:50 Fluids: Not Taken 4. 07/22/2018 23:35 Fluids: 170 ml (a metric unit of volume, 30 ml=1 oz) 5. 07/20/2018 21:53 Fluids: 0 ml 6. 07/19/2018 12:56 Fluids: 500 ml 7. 07/19/2018 09:34 Fluids: Not Taken 8. 07/18/2018 12:45 Fluids: 240 ml 9. 07/18/2018 12:45 Fluids: 420 ml 10. 07/17/2018 12:18 Fluids: Not Taken 11. 07/17/2018 08:30 Fluids: 300 ml 12. 07/16/2018 18:18 Fluids: 360 ml 13. 07/16/2018 11:52 Fluids: Not Taken 14. 07/16/2018 07:47 Fluids: 300 ml 15. 07/15/2018 18:48 Fluids: 360 ml 16. 07/15/2018 14:40 Fluids: 360 ml 17. 07/14/2018 19:13 Fluids: 360 ml 18. 07/14/2018 12:13 Fluids: 360 ml 19. 07/14/2018 12:12 Fluids: 360 ml 20. 07/13/2018 13:55 Fluids: 240 ml 21. 07/13/2018 10:09 Fluids: 400 ml F. Record review of the care plan for R #2, dated 07/21/18 revealed: 1) Problem: 07/20/18 Dehydration/Fluid Maintenance - at risk for complications R/T (related to) [MEDICAL CONDITION] infection on right arm requiring antibiotic therapy. Short Term Goal Target Date: 07/30/18 .infection will resolve without complications by next review. Approach: Antibiotic therapy as ordered. Monitor for adverse reaction. Encourage increased fluid intake unless contraindications. Monitor for s/s (signs and symptoms) of worsening condition. Notify MD (Medical Doctor) as needed. 2) Problem 07/13/18 .has the following skin issues: dry scabs on his BLE (bilateral lower extremities), BUE (bilateral upper extremity bruising, RUE (right upper extremity) bruising, left elbow open area (this reflects skin condition on admission). Goal: Short Term Target Date: 08/13/18 .skin issue will be resolved by next review. Approach: Monitor for s/s of infection. Skin assessment as indicated. Treatment as indicated/ordered. 3) Problem: 07/13/18 Nutritional Status .current dietary order is CCHO (controlled carbohydrate) diabetic diet, mechanical soft (easy to chew). Long Term Goal Target Date: 10/13/18 Adhere to dietician's recommendation and physician order for [REDACTED]. Approach: Monitor/record oral intake of food and fluids . G. On 10/16/18 at 2:50 pm, during an interview with CNA #1 about R #2, she stated, I was out from work and when I came back they (other staff) said he was sick with infection. He had a fall and then got a [MEDICAL CONDITION]--he just went steadily downhill. He didn't eat or drink much after he got sick and I would try to get him up and he just didn't want it. The nurses knew all that; I didn't have to tell them. H. On 10/17/18 at 3:00 pm, during an interview, RN #2 stated, I did not look his intake. The CNAs tell us if the resident is not eating or drinking. I don't remember much. I. Record review of a local hospital records, dated 07/23/18, for R #2, revealed: admitted [DATE] with altered mental status, febrile, acute (sudden occurance) [MEDICAL CONDITION] probably secondary to dehydration, [MEDICAL CONDITION] right arm, and protein calorie malnutrition. The hospital progress note, dated 07/27/18 revealed: Large ulceration of the right forearm over the extensor surface with purulent (having pus) base. The records revealed: hospital admission 07/23/18 and discharge on 07/31/18. J. On 10/17/18 at 3:36 pm, during an interview, the DON said R#2 had been started on antibiotics for [MEDICAL CONDITION] on 07/20/18. She stated the nurses would have given him fluids with his medications, but she was unable to provide documentation of that. The DON said the physician should have been notified on 07/21/18 that he (R #2) had no intake, but as she reviewed the progress notes she said there was no documentation that he had been called that day. The DON affirmed the care plan should have been upated to reflect the skin tear. K. On 10/17/18 at 12:00 noon, during an interview with the POA (Power of Attorney-the person with legal authority to speak for resident since he could not speak for himself) she stated, I went to see him twice in the time he was there and he was in bed both times. I talked to (Name of nurse) about the [MEDICAL CONDITION]. I said I was worried. I don't know exact date, a Wednesday. She (the nurse) said it was fine, not an issue. It (the wound) was not covered and it was red and hot. I called the DON on that Friday and said I told the nurse it was hot and red. No one (at the facility) answered the phone all weekend. Monday I said we would just take him out (to the hospital). He should have gone to the hospital that Friday. I believe there was negligence. L. On 12/20/18 at 4:00 pm, during an interview, RN #1 stated, I remember his wound, I remember the yellow underneath the skin. He would sit at the table (in the dining room) and he would drift off and sleep. He was a person I had to keep and eye on. Over there (the Memory Unit), they don't have water in the resident rooms. They (residents) just get fluids at meals. I did not call the doctor about the wound. I think he (R #2) was ok. M. On 12/19/18 at 11:45 am, during an interview with the DON, when asked about the 07/20/18 to 07/23/18 when R #2 only had 170 cc (about 5 1/2 ounces) and a snack; she stated, Poor intake was his normal. The nurses should have probably noticed that and his intakes should have recorded. We did not call the physician for that. When asked about if the care plans to monitor food and fluid intake were followed she stated, No. When asked if the physician had been notified of the increasing wound size, the DON stated, I do not believe the nurses were measuring the wound correctly. When asked if the nurses could have noted the clinical signs of R #2's deterioration sooner and intervened, the DON said the nurses were treating his (R #2's) fever symptoms with Tylenol (a medication used to reduce fever) and giving the antibiotics the doctor prescribed. N. Record review of the facility policy Change in a Resident's Condition or Status, revised 12/2016 revealed: Our facility shall promptly notify the resident, his or Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been an d. significant change in the resident's physical/mental condition; e. need to alter the resident's medical treatment significantly, g. need to transfer the resident to a hospital/treatment center. 2. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant pertinent information for the provider, including (for example) information prompted by the Interact SBAR (form used to guide gathering and disseminating information--situation, background, assessment and recommendation) Communication form. O. Record review of the facility policy Resident Hydration and Prevention of Dehydration, revised 10/2011 revealed: 6. Nurses will assess for signs and symptoms of dehydration during daily care. 7. Nurses Aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml/day to nursing staff. 13. Nursing will monitor and document fluid intake and the Dietician will be kept informed of status. Interdisciplinary Team will update care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved. P. Record review of the facility policy Skin Tears-Abrasions and Minor Breaks, Care of, revised 09/2013 revealed: Reporting: Notify the physician of any abnormalities (i.e. excessive bleeding, localized swelling, redness, drainage, tenderness, pain etc.)

Based on record review, and interview, the facility failed to ensure a resident received sufficient fluid intake to maintain proper hydration for 1 (R #2) of 2 (R #2 and R #3) residents reviewed for hydration. This deficient practice contributed to R #2's hospitalization for acute renal (kidney) failure, dehydration, [MEDICAL CONDITION] (a bacterial infection of the skin and tissues beneath the skin) right arm, malnutrition. The findings are: A. Record review of the facility care plan dated 07/21/18 revealed: R #2 was admitted on [DATE] with these: vascular (blood vessel related) dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), other frontotemporal (an area of the brain) dementia with Bx (biopsy-[DIAGNOSES REDACTED]. B. Record review of a local hospital records, dated 07/23/18, for R #2, revealed: admitted [DATE] with altered mental status, febrile, acute (sudden occurance) [MEDICAL CONDITION] probably secondary to dehydration, [MEDICAL CONDITION] right arm, and protein calorie malnutrition. The hospital progress note, dated 07/27/18 revealed: Large ulceration of the right forearm over the extensor surface with purulent (having pus) base. The records revealed: hospital admission 07/23/18 and discharge on 07/31/18. C. Record review of the MDS (Minimum Data Set) for R #2, dated 07/19/18 revealed: 1. Section G: Functional Status: Bed mobility: How resident moves to and from lying position, turns side to side, and positions body while in bed: Required extensive assistance, a one person physical assist Eating: How resident eats and drinks: Limited assistance, one person assist 2. Record review of Section GG (Functional Abilities and Goals on Admission): Eating: The ability to use suitable utensils to bring food to the mouth and swallow food on admission:Supervision and or touching assistance. D. Record Review of the Progress Notes for R #2: 1. 07/15/18, revealed: Around 10 am, this resident was reported to this nurse that he is on the floor at the dining room. This nurse immediately responded and witnessed the resident on his right side with full (ROM) (range of motion), with 3 cm (centimeter-a metric unit of measure) x 3 cm bump on right forehead with minimal bleeding and a 0.25 cm tear in the middle of the bump, noted 1.5 cm x 2 cm skin tear on adjacent (sic) of right antecubital area .Resident returned (from Emergency Department) around 2 pm with negative result of CT (CAT Scan) of head. 2. 07/16/18 Continue with wound care treatment for [REDACTED]. Refer to MD as needed. 3. 07/17/18 .limited assist with eating There is no notation in the note of the skin tear. 4. 07/18/18 21:52 (9:52 pm) needs assistance and supervision when eating. Pain medication given as resident complained of pain but unable to identify where. 5. 07/19/18 5:04 (5:04 am) Resident's RT (right) arm is noted to have dry scab, but puss (sic) pocket at 6 o'clock and surrounding area red, warm to touch. Will refer in the morning. 6. 07/19/18 18:54 (6:54 pm) Resident still has redness surrounding dry scab on rt arm .VS (vital sign) checked, WNL (within normal limits). Noted with amber colored urine on his brief. Encouraged to increase oral fluid intake. (There is no note that fluids were offered or refused) 7. 07/19/18 22:03 (11:03 pm) Resident is warm to touch, T(temperature)=100.5 F (Fahrenheit) (average normal temperature 98.6 F). PRN (as needed) Tylenol (a medication used for symptoms of fever or pain) as ordered. 8. 07/20/18 12:43 (12:43 pm) Resident alert for meals but wanting to go back to bed afterwards. Temp 98.8 fluids encouraged. Right arm skin tear section measures 4 cm x 5 cm and has pus in the center. Area around this swollen, reddened and has an area where there appears to be pus under the skin. Phone call to Dr and resident started on 10 day course of [MEDICATION NAME] (an antibiotic) BID (twice a day). 9. 07/21/18 22:57 (10:57 pm) Resident is alert and weak looking .still has redness and swelling on rt forearm, dressing intact .on ABX (antibiotic) for [MEDICAL CONDITION] .Encouraged to increase oral fluid intake as tolerated. (There is no notation that fluids were offered) 10. 07/22/18 16:24 (4:24 pm) Resident alert but drowsy .able to express pain on movement of right arm dressing changed. Area of skin tear is now 10 cm x 3 cm but whole area that had yellow purulent (pus) tissue underneath the level of skin has come (sic) and was cleansed off .island dressing applied. 11. 07/23/18 0:17 (12:17 am) Resident is alert, weak looking, complained of pain, PRN pain medication given. Rt FA (forearm) with approximated 10 cm x 3 cm 60% flap (skin that had lifted up with injury and laid back into place), just above it is a skin tear about 2 x 2 cm. Areas are reddened with purulent discharge. Wound care done, applied xeroform (a Vaseline impregnated dressing) and covered with a Kerlix (bulky dressing in a roll) wrap .resident still on ABT (antibiotic therapy) .encouraged to increase fluid intake as provided. Snack provided. (there is no notation that fluids were offered or refused. 12. 07/23/18 at 8:15 (8:15 am) resident total assist with transfers and mobility, dressing toileting and hygiene. Total assist with feeding. Very lethargic and difficult to arouse .O2 (oxygen) sat (saturation) dropped to 86 started on 2 at liters .Remains on ATB (antibiotic therapy) for [MEDICAL CONDITION] to right forearm. E. Intake of Food and Fluids from Vital Sign Intake for R #2 1. 07/23/2018 08:50 Breakfast: Not Taken, Reason not taken: Refused 2. 07/22/2018 13:11 Breakfast: None 3. 07/21/2018 08:25 Breakfast: Not Taken, Reason Not Taken Deferred due to condition 4. 07/19/2018 09:34 Breakfast: Not Taken, Reason not taken: Refused 5. 07/18/2018 12:44 Breakfast: 1-25% 6. 07/17/2018 08:30 Breakfast: 26-50% 7. 07/16/2018 07:47 Breakfast: 51-75 LUNCH 1. 07/23/2018 12:24 Lunch: Not Taken, Reason not taken: Refused 2. 07/22/2018 13:11 Lunch: None 3. 07/21/2018 12:20 Lunch: None 4. 07/19/2018 12:56 Lunch: 76-100% 5. 07/18/2018 12:44 Lunch: 26-50% 6. 07/17/2018 12:18 Lunch: Not Taken, Reason not taken: Refused 7. 07/16/2018 11:52 Lunch: Not Taken, Reason not taken: Refused 8. 07/15/2018 14:41 Lunch: Not Taken, Reason not taken: Deferred due to condition 9. 07/14/2018 12:12 Lunch: 26-50% 10. 07/13/2018 13:55 Lunch: 1-25% PM Snacks 1. 07/22/2018 23:35 PM Snack: 76-100% Dinners Taken From 07/13/18 To 07/24/18 1. 07/20/2018 21:53 Dinner: None 2. 07/16/2018 18:18 Dinner: 76-100% 3. 07/15/2018 18:48 Dinner: 76-100% 4. 07/14/2018 19:13 Dinner: 76-100% Intake : Fluids Taken From 07/13/18 To 07/24/18 1. 07/24/2018 07:46 Fluids: Not Taken 2. 07/23/2018 12:25 Fluids: Not Taken 3. 07/23/2018 08:50 Fluids: Not Taken 4. 07/22/2018 23:35 Fluids: 170 ml (a metric unit of volume, 30 ml=1 oz) 5. 07/20/2018 21:53 Fluids: 0 ml 6. 07/19/2018 12:56 Fluids: 500 ml 7. 07/19/2018 09:34 Fluids: Not Taken 8. 07/18/2018 12:45 Fluids: 240 ml 9. 07/18/2018 12:45 Fluids: 420 ml 10. 07/17/2018 12:18 Fluids: Not Taken 11. 07/17/2018 08:30 Fluids: 300 ml 12. 07/16/2018 18:18 Fluids: 360 ml 13. 07/16/2018 11:52 Fluids: Not Taken 14. 07/16/2018 07:47 Fluids: 300 ml 15. 07/15/2018 18:48 Fluids: 360 ml 16. 07/15/2018 14:40 Fluids: 360 ml 17. 07/14/2018 19:13 Fluids: 360 ml 18. 07/14/2018 12:13 Fluids: 360 ml 19. 07/14/2018 12:12 Fluids: 360 ml 20. 07/13/2018 13:55 Fluids: 240 ml 21. 07/13/2018 10:09 Fluids: 400 ml F. Record review of the care plan for R #2, dated 07/21/18 revealed: 1. Problem: 07/20/18 Dehydration/Fluid Maintenance - at risk for complications R/T (related to) [MEDICAL CONDITION] infection on right arm requiring antibiotic therapy. Short Term Goal Target Date: 07/30/18 .infection will resolve without complications by next review. Approach: Antibiotic therapy as ordered. Monitor for adverse reaction. Encourage increased fluid intake unless contraindications. Monitor for s/s (signs and symptoms) of worsening condition. Notify MD (Medical Doctor) as needed. 2. Problem 07/13/18 .has the following skin issues: dry scabs on his BLE (bilateral lower extremities), BUE (bilateral upper extremity bruising, RUE (right upper extremity) bruising, left elbow open area (this reflects skin condition on admission). (There is no updated note of the skin tear sustained 07/15/18 and the subsequent [MEDICAL CONDITION] of the right forearm) Goal: Short Term Target Date: 08/13/18 .skin issue will be resolved by next review. Approach: Monitor for s/s of infection. Skin assessment as indicated. Treatment as indicated/ordered. 3. Problem: 07/13/18 Nutritional Status .current dietary order is CCHO (controlled carbohydrate) diabetic diet, mechanical soft (easy to chew). Long Term Goal Target Date: 10/13/18 Adhere to dietician's recommendation and physician order for [REDACTED]. Approach: Monitor/record oral intake of food and fluids . G. On 10/16/18 at 2:50 pm, during an interview with CNA #1 about R #2, she stated, I was out from work and when I came back they (other staff) said he was sick with infection. He had a fall and then got a [MEDICAL CONDITION]--he just went steadily downhill. He didn't eat or drink much after he got sick and I would try to get him up and he just didn't want it. The nurses knew all that, I didn't have to tell them. H. On 10/16/18 at 3:20 pm, during an interview with the Dietary Manager, she stated, I assessed him on 07/17/18. He was on a CCHO (Controlled Carbohydrate Diet), Mechanical Soft (easy to chew). His weight was 120 pounds and height was 5' 6 so his BMI (body was index) was 19.4 which is normal. He had a low [MEDICATION NAME] (protein indicator) so I referred him to the dietician. The resident was discharged before the dietician saw him. I had not concerns about his eating or drinking, and he had the referral. I look at intakes for food and fluid every day. I see looking at the record there were just a few recorded as not taken. I do that recall what I thought about it. I. On 10/17/18 at 3:00 pm, during an interview with RN #2, she stated, I did not look his intake, the CNAs tell us if the resident is not eating or drinking. I don't remember much. J. On 10/17/18 at 3:36 pm, during an interview, the DON said R#2 had been started in antibiotics for [MEDICAL CONDITION] on 07/20/18. She stated the nurses would have given him fluids with his medications, but she was unable to provide documentation of that. The DON said the physician should have been notified on 07/21/18 that he (R #2) had no intake, but as she reviewed the progress notes she said there was no documentation that he had been called that day. K. On 12/20/18 at 4:00 pm, during an interview, RN #1 stated, I remember his wound, I remember the yellow underneath the skin. He would sit at the table (in the dining room) and he would drift off and sleep. He was a person I had to keep and eye on. Over there (the Memory Unit) they don't have water in the resident rooms. They (residents) just get fluids at meals. I did not call the doctor about the wound. I think he (R #2) was ok. L. On 12/19/18 at 11:45 am during an interview with the DON, when asked about the 07/20/18 to 07/23/18 when R #2 only had 170 cc (about 5 1/2 ounces) and a snack, she stated, Poor intake was his normal. The nurses should have probably noticed that and his intakes should have recorded. We did not call the physician for that. When asked about if the care plans to monitor food and fluid intake were followed she stated, No. When asked if the physician had been notified of the increasing wound size, the DON stated, I do not believe the nurses were measuring the wound correctly. When asked if the nurses could have noted the clinical signs of R #2's deterioration sooner and intervened, the DON said the nurses were treating his (R #2's) fever symptoms with tylenol (a medication used to reduce fever) and giving the antibiotics the doctor prescribed. M. Record review of the facility policy Change in a Resident's Condition or Status, revised 12/2016 revealed: Our facility shall promptly notify the resident, his or Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been an d. significant change in the resident's physical/mental condition; e. need to alter the resident's medical treatment significantly, g. need to transfer the resident to a hospital/treatment center. 2. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant pertinent information for the provider, including (for example) information prompted by the Interact SBAR (form used to guide gathering and disseminating information--situation, background, assessment and recommendation) Communication form. N. Record review of the facility policy Resident Hydration and Prevention of Dehydration, revised 10/2011 revealed: 6. Nurses will assess for signs and symptoms of dehydration during daily care. 7. Nurses Aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml/day to nursing staff. 13. Nursing will monitor and document fluid intake and the Dietician will be kept informed of status. Interdisciplinary Team will update care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved. N. Review of the journal article Nutrition and Healthy Aging, (YEAR); 4(3): 227-237, revealed: Published online (YEAR) [DATE]. Prepublished online (YEAR) [DATE]. doi: 10.3233/NHA- 6) Inadequate hydration in the elderly is associated with increased morbidity (disease) and mortality (death). In some individuals, the loss of as little as 2-3% of body fluid can cause physical and cognitive impairment (4). The elderly population is at an increased risk for dehydration for a number of reasons, including a decrease in the thirst sensation, a decrease in renal perfusion (blood flow delivered to kidneys) , an altered sensitivity to antidiuretic hormone ( a hormone that acts to maintain blood pressure, blood volume and tissue water content by controlling the amount of water) and neurocognitive (thinking) deficits (1, 4-7). In addition to [MEDICAL CONDITION] (blood clot formation and the clot travelling through the body) there are numerous other consequences of dehydration among the elderly population, including [MEDICAL CONDITION], confusion, infections, falls, and fractures (10-12). However, a significant gap in hydration health literacy was observed . when they failed to associate fevers or kidney failure with fluid loss.

Based on interview and record review, it was determined that: 1) R #2 was on a bladder retraining program after the facility removed his Foley catheter. Due to the removal of the foley R #2 required monitoring of urine output. 2) R #2 did not have an order to d/c (discontinue) his Foley catheter. 3) R #2 was also at risk for complications (dehydration, low urine output) from being on fluid restrictions. 4) The facility did not revise R #2's care plan to d/c his Foley catheter/start bladder retraining program, and did not follow R #2's care plan for monitoring low urine output from being on fluid restrictions. 5) Urine output logs show no record of R #2 having any urine output from 5:00 am on 09/30/17 to when R #2 was sent to theER on [DATE] at around 10:00 am (discharging nurse was unable to recall exact time of discharge but recalled approximately 10:00 am). 6) R #2 was sent to the hospital where they discovered R #2 had [MEDICAL CONDITION] and an UTI that progressed into septic shock and [MEDICAL CONDITION]. 7) R #2 was hospitalized for [REDACTED]. This resulted in an Immediate Jeopardy with a starting date of 09/30/17. The facility was notified on 10/23/17 at 3:50 PM. A plan of removal was received on 10/24/17 at 4:05 PM and approved. Upon implementation of the plan of removal, the IJ was lifted on 10/25/17 at 3:45 PM. This dropped the scope and severity down to H. Based on record review and interview, the facility failed to ensure the residents were free from neglect for 2 (R #1, and R #2) of 4 (R #1, R# 2, R #3, and R #4) residents reviewed for neglect related to urinary catheters and incontinence care when they failed to 1) monitor urine output for R #2 after his Foley catheter was removed, and 2) failed to respond to R #1's request to go to bed and was left in a wheelchair for several hours. These deficient practices likely resulted in 1) R #2's development of septic shock and hospitalization secondary to a urinary tract infection, and 2) R #1, a resident with a Stage IV pressure wound (a full thickness wound with exposed tendon, ligament or bone) on his sacrum (lower backside), sitting with unrelieved pressure for seven hours in his wheelchair and was left at risk for worsening the wound or development of a new pressure ulcers, with the resident feeling neglected and frustrated. The findings are: R #2 A. Record review of R #2's medical record revealed the following: 1. R #2 was admitted on [DATE] 2. [DIAGNOSES REDACTED]. B. On 10/23/17 at 1:00 PM, during an interview, R #2's Family Member (FM) stated that R #2 had Foley catheter and that someone took it out. The facility did not discuss wanting to put R #2 on bladder retraining program. R #2 was sent out to the hospital because he was septic from not having urinated for 2 days. FM also stated that R #2 had to be intubated (the process of inserting a tube, called an endotracheal tube (ET), through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing.) due to septic shock. When I called the nurse, she was unable to find the order to d/c (discontinue the) Foley. They should have monitored the urine output on someone who has a history or [MEDICAL CONDITION]. C. Record review of R #2's History and Physical from local hospital dated 10/01/17 revealed, The patient has had an indwelling catheter since hip surgery performed in august 2017. Patient in rehabilitation and in skilled nursing following hospitalization with indwelling Foley and was removed for 2 days. The patient had a large amount of [MEDICAL CONDITION] and when catheterized, urine was purulent (consisting of, containing, or discharging pus). D. Record review of R #2's Discharge Summary from local hospital dated 10/14/17 revealed, Acute hypoxic [MEDICAL CONDITION] secondary to septic shock . septic shock secondary to urinary tract infection, 2 sets of blood cultures positive for E coli (is a type of bacteria that normally lives in your intestines) . patient was transferred to (name of local hospital) ER after noted to be septic secondary to severe urinary tract infection . patient was in [MEDICAL CONDITION] on mechanical ventilator . R #2 was admitted to the hospital on [DATE] and discharged on [DATE]. E. Record review of R #2's physician's orders [REDACTED].#2's Foley catheter. F. Record review of R #2's Care Plan dated 09/26/17 revealed the following: 1. (Name of R #2) is at risk for complication R/T (related to) 1000 cc fluid restriction . Monitor for s/s (signs and symptoms) of dehydration. Extreme thirst, less frequent urination, dark-color urine, fatigue, dizziness, confusion, offer liquids within the daily limit as ordered. 2. (Name of R #2) requires an indwelling urinary catheter R/T [MEDICAL CONDITION] . Assess the drainage every shift for amount, color odor. Observe for leakage . position bag below level of bladder . G. On 10/24/17 at 1:44 PM, during an interview, LPN #2 stated that R #2 was sent to the ER around 10:00 am or 11:00 am on 10/01/17. LPN #2 stated that he could not recall any of the CNAs reporting that R #2 had not had any urine output. H. On 10/24/17 at 11:58 am, during an interview, RN #1 stated that the residents should be checked for incontinence care and to empty the Foley urine bag. The urine output for every resident should be documented in the record. I cannot remember whether anyone told me but they should have. I. Record review of R #2's Urine Output Log dated from 09/01/17 to 10/01/17 revealed on 09/30/17 at 5:12 am, (U)rine: Small. No documentation was found that recorded R #2's urine output from 5:00 am on 09/30/17 to when R #2 was sent to theER on [DATE] at around 10:00 am (discharging nurse was unable to recall exact time of discharge but recalled approximately 10:00 am). J. On 10/23/17 at 2:01 PM, during an interview the DON confirmed that there was no order for R #2 to d/c his Foley catheter. It (d/c orders) should be stated on the bladder retraining but the does not say d/c. The DON also confirmed that there was no documented urine output since 5 am on 09/30/17, R #2 was sent to the hospital on [DATE] about 11:00 am. To my knowledge, the CNAs did not report to the nurse there was no urine output (for R #2). The nurse should have documented this. He (R #2) had asked the nurse practitioner if he could have it (Foley catheter) removed. He was on the bladder retraining program. K. On 10/24/17 at 11:50 am, during an interview, DON confirmed that the nurses and CNAs had not been following R #2's care plan for monitoring urine output, and did not care plan R #2's bladder retraining program. R #1 L. Record review of the facility incident report for an incident on 09/10/17 revealed: On 09/10/17, around 4:00 am the resident reported to the nurse on duty that he was not transferred to his bed and that he was in in his wheelchair since 7 pm. The resident was checked by the nurse and vital signs were withing normal limits except for a temperature of 100.2F. He had presented symptoms of chills and ever, and was given his PRN (as needed) antipyretic (fever reducing medication) and [MEDICATION NAME] (pain medication) for complain (sic) of pain. (Name of CNA (Certified Nursing Assistant) #9 stated he was unaware the catheter bag needed to be emptied every 2 hours, thus failed to check on the resident. Resident was treated at the hospital for a urinary tract infection. Resident told nurse that he requested from (Name CNA #10) and (Name CNA #9) to put him to bed around 10 pm and they failed to return to his room until the nurse had seen him up at 4:00 am in his wheelchair. M. On 10/24/17 at 11:20 am, during an interview with R #1 regarding a complaint of his being left in wheelchair for an extended period of time in September. He stated, The call-lights didn't work from the afternoon. I wanted to go to bed at 9 (PM) (on 09/09/17). I told them (CNAs) (Certified Nursing Assistants) when they came in. It takes 2 people to move me. No one came back. Someone came to do the ice (pass the ice) and I told them I wanted to go to bed. The guy (a CNA) said, 'Wait until I am through with ice.' They never checked on me until 4 am (09/10/17) when the nurse came to give a pill. My butt was hurting. I have a wound back there. I felt neglected and a little frustrated. N. On 10/24/17 at 2:50 PM, during an interview, RN #1 stated, I took care of him ( R #1) for 3 days of consecutive night duty (09/09/17, 09/10/17, and 09/11/17 ). The second day he reported fever and chills and I sent a urine sample because I suspected a UTI (Urinary Tract Infection). That was the day he was up several hours. At 9 PM, I gave meds and he said he had no concerns. At 9:30 (PM), I removed ace wrap on his lower extremity. I had the CNAs help me. I delegated to a CNA to unwrap legs. I passed medications and attended to my nursing duties and obligation to him, and the other 49 residents under my care. A CNA reported (to me) the resident (R #1) had complained of leg pain at 10:30 or 11:00 (PM) so I gave pain meds. The CNAs had been working 4 months with me and knew their jobs. At 4 am, when I gave meds, I was surprised to find him (R #1) still up. I said, 'You woke up early.' He (R #1) said, 'I was not put in bed.' I did vital signs and he was normal. I was shocked and I told the CNAs to put him in bed. I'm not sure if he had asked to go to bed. I checked on him with medications and treatment .with 49 other residents I have to maximize my time. I had another resident that fell in the night. It is a hard time time (sic) caring for that many residents. I had already suspected (R #1 of having) a UTI . O. Record review of the facility 5 day follow up report revealed: On 09/10/17, (Name of R #1) had been up in his wheelchair from 7:00 PM on 09/10/17 to 4:00 am on 09/11/17. The report read, The 2 CNAs on duty had been requested by R #1 to be put to bed around 10 PM and the CNAs failed to return to room. The RN discovered the resident still up in his wheelchair at 4 am. P. On 10/24/17 at 11:20 am, during an interview, R #1 stated, Just this past weekend, one day, Saturday (10/21/17) I think, I wanted to get up. I asked the aide who was collecting breakfast trays and he said he would go up (sic) to the aide on the floor and tell them. No one came. My light was on from 9:30 (am) to lunch. Only dietary came in for orders. The nurse and CNAs didn't came (sic). My [MEDICAL CONDITION] (a surgical opening allowing fecal material to exit the body by an alternate route) bag started leaking; I had to hold poop in my hand. I finally starting yelling, (Name of CNA #7) came to help and got the nurse. It's frustrating. I would like to get the care I feel I deserve. Q. On 10/24/17 at 12:00 PM, during an interview, CNA #7 stated, I worked Saturday morning. I was working other end (hall). I had given report and handed off my beeper (pager) and was leaving, but he (R #1) needed help. His bag ([MEDICAL CONDITION]) had pulled away and he was holding it. I let the nurse know, and I cleaned him up and let the nurse know to change it. I had asked one of CNAs that was responsible in that hall and said (Name of R #1) wanted to get up; that was around 9 am. At 1:30 PM, he ( R #1) was still in bed. He was upset they hadn't got him up. R. On 10/25/17 at 11:52 am, during an interview, LPN #2, when asked about the weekend care for R #1, he stated I did change his [MEDICAL CONDITION] bag. It was leaking. One of CNAs came and said the [MEDICAL CONDITION] is leaking and needs to be changed. The CNA went and cleaned the resident's hands because it was leaking out on his hands. I was not aware of any problem of with him wanting to getting him out of bed. S. On 10/25/17 at 12:35 PM, during an interview with the DON about R #1 and R #3 waiting for help to get into and out of bed, she stated, They (the residents) should not have to wait too long. They (CNAs) should have responded sooner to the requests or get another CNA to help.

Based on interview and record review, it was determined that: 1) R #2 was on a bladder retraining program after the facility removed his Foley catheter. Due to the removal of the foley R #2 required monitoring of urine output. 2) R #2 did not have an order to d/c (discontinue) his Foley catheter. 3) R #2 was also at risk for complications (dehydration, low urine output) from being on fluid restrictions. 4) The facility did not revise R #2's care plan to d/c his Foley catheter/start bladder retraining program, and did not follow R #2's care plan for monitoring low urine output from being on fluid restrictions. 5) Urine output logs show no record of R #2 having any urine output from 5:00 am on 09/30/17 to when R #2 was sent to theER on [DATE] at around 10:00 am (discharging nurse was unable to recall exact time of discharge but recalled approximately 10:00 am). 6) R #2 was sent to the hospital where they discovered R #2 had [MEDICAL CONDITION] and an UTI that progressed into septic shock and [MEDICAL CONDITION]. 7) R #2 was hospitalized for [REDACTED]. This resulted in an Immediate Jeopardy with a starting date of 09/30/17. The facility was notified on 10/23/17 at 3:50 PM. A plan of removal was received on 10/24/17 at 4:05 PM and approved. Upon implementation of the plan of removal, the IJ was lifted on 10/25/17 at 3:45 PM. This dropped the scope and severity down to H. Based on record review and interview, the facility failed to revise Care Plans for 1 (R #2) of 4 (R #1, R #2, R #3, R #4) resident sampled for catheter and incontinence care, when they failed to revise R #2's care plan for the removal of his Foley catheter and placement in a bladder retraining program. This deficient practice caused R #2 to have an UTI that resulted in [MEDICAL CONDITION] from septic shock. The findings are: A. Record review of R #2's medical record revealed the following: 1. R #2 was admitted on [DATE] 2. [DIAGNOSES REDACTED]. B. On 10/23/17 at 1:00 PM, during an interview, R #2's Family Member (FM) stated that R #2 had Foley catheter and that someone took it out. The facility did not discuss wanting to put R #2 on bladder retraining program. R #2 was sent out to the hospital because he was septic from not having urinated for 2 days. FM also stated that R #2 had to be intubated (the process of inserting a tube, called an endotracheal tube (ET), through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing.) due to septic shock. When I called the nurse, she was unable to find the order to d/c (discontinue the) Foley. They should have monitored the urine output on someone who has a history or [MEDICAL CONDITION]. C. Record review of R #2's History and Physical from local hospital dated 10/01/17 revealed, The patient has had an indwelling catheter since hip surgery performed in august 2017. Patient in rehabilitation and in skilled nursing following hospitalization with indwelling Foley and was removed for 2 days. The patient had a large amount of [MEDICAL CONDITION] and when catheterized, urine was purulent (consisting of, containing, or discharging pus). D. Record review of R #2's Discharge Summary from local hospital dated 10/14/17 revealed, Acute hypoxic [MEDICAL CONDITION] secondary to septic shock . septic shock secondary to urinary tract infection, 2 sets of blood cultures positive for E coli (is a type of bacteria that normally lives in your intestines) . patient was transferred to (name of local hospital) ER after noted to be septic secondary to severe urinary tract infection . patient was in [MEDICAL CONDITION] on mechanical ventilator . R #2 was admitted to the hospital on [DATE] and discharged on [DATE]. E. Record review of R #2's physician's orders [REDACTED].#2's Foley catheter. F. Record review of R #2's Care Plan dated 09/26/17 revealed the following: 1. (Name of R #2) is at risk for complication R/T (related to) 1000 cc fluid restriction . Monitor for s/s (signs and symptoms) of dehydration. Extreme thirst, less frequent urination, dark-color urine, fatigue, dizziness, confusion, offer liquids within the daily limit as ordered. 2. (Name of R #2) requires an indwelling urinary catheter R/T [MEDICAL CONDITION] . Assess the drainage every shift for amount, color odor. Observe for leakage . position bag below level of bladder . G. On 10/24/17 at 1:44 PM, during an interview, LPN #2 stated that R #2 was sent to the ER around 10:00 am or 11:00 am on 10/01/17. LPN #2 stated that he could not recall any of the CNAs reporting that R #2 had not had any urine output. H. On 10/24/17 at 11:58 am, during an interview, RN #1 stated that the residents should be checked for incontinence care and to empty the Foley urine bag. The urine output for every resident should be documented in the record. I cannot remember whether anyone told me but they should have. I. Record review of R #2's Urine Output Log dated from 09/01/17 to 10/01/17 revealed on 09/30/17 at 5:12 am, (U)rine: Small. No documentation was found that recorded R #2's urine output from 5:00 am on 09/30/17 to when R #2 was sent to theER on [DATE] at around 10:00 am (discharging nurse was unable to recall exact time of discharge but recalled approximately 10:00 am). J. On 10/23/17 at 2:01 PM, during an interview the DON confirmed that there was no order for R #2 to d/c his Foley catheter. It (d/c orders) should be stated on the bladder retraining but the does not say d/c. The DON also confirmed that there was no documented urine output since 5 am on 09/30/17, R #2 was sent to the hospital on [DATE] about 11:00 am. To my knowledge, the CNAs did not report to the nurse there was no urine output (for R #2). The nurse should have documented this. He (R #2) had asked the nurse practitioner if he could have it (Foley catheter) removed. He was on the bladder retraining program. K. On 10/24/17 at 11:50 am, during an interview, DON confirmed that the nurses and CNAs had not been following R #2's care plan for monitoring urine output, and did not care plan R #2's bladder retraining program.

Based on interview and record review, it was determined that: 1) R #2 was on a bladder retraining program after the facility removed his Foley catheter. Due to the removal of the foley R #2 required monitoring of urine output. 2) R #2 did not have an order to d/c (discontinue) his Foley catheter. 3) R #2 was also at risk for complications (dehydration, low urine output) from being on fluid restrictions. 4) The facility did not revise R #2's care plan to d/c his Foley catheter/start bladder retraining program, and did not follow R #2's care plan for monitoring low urine output from being on fluid restrictions. 5) Urine output logs show no record of R #2 having any urine output from 5:00 am on 09/30/17 to when R #2 was sent to theER on [DATE] at around 10:00 am (discharging nurse was unable to recall exact time of discharge but recalled approximately 10:00 am). 6) R #2 was sent to the hospital where they discovered R #2 had [MEDICAL CONDITION] and an UTI that progressed into septic shock and [MEDICAL CONDITION]. 7) R #2 was hospitalized for [REDACTED]. 8) R # 3 was observed in bed sleeping with leg bag full of urine and bulging with no space from more drainage. 9) R #3 was per with staff it was determined this resident was routinely put to bed with a leg bag. 10) The facility policy on urinary catheters directs that the drainage bag should be lower than the bladder. This resulted in an Immediate Jeopardy with a starting date of 09/30/17. The facility was notified on 10/23/17 at 3:50 PM. A plan of removal was received on 10/24/17 at 4:05 PM and approved. Upon implementation of the plan of removal, the IJ was lifted on 10/25/17 at 3:45 PM. This dropped the scope and severity down to H. Based on record review, interview, and observation the facility failed to meet professional standards for 3 ( R #1, R #2, and R #3) of 4 ( R #1, R #2, R #3, and R #4) residents sampled for neglect related to catheters, urinary incontinence, and pressure wounds when they failed to: 1) provide for pressure relief to facilitate healing of pressure wounds and help prevent the development of new pressure wounds and maintain the skin integrity for R #1, 2) failed to monitor urine output after a Foley catheter was removed for R #2, 3) failed to assure unobstructed urine flow from a Foley catheter for R #3, and 4) failed to ensure appropriate hand hygiene was performed, and gloves were worn when touching urinary drainage bags and tubing by staff for 4 (R #1, R #3, R #5, and R #6) of 5 ( R #1, R#3, R #4, R #5, and R #6) residents. These deficient practice can likely result in the delay or prevention of wound healing, and prevention of development of pressure wounds, and the risk of urinary tract infection, both of which can lead to illness, infection, debility and death. The findings are: R #2 A. Record review of R #2's medical record revealed the following: 1. R #2 was admitted on [DATE] 2. [DIAGNOSES REDACTED]. B. On 10/23/17 at 1:00 PM, during an interview, R #2's Family Member (FM) stated that R #2 had Foley catheter and that someone took it out. The facility did not discuss wanting to put R #2 on bladder retraining program. R #2 was sent out to the hospital because he was septic from not having urinated for 2 days. FM also stated that R #2 had to be intubated (the process of inserting a tube, called an endotracheal tube (ET), through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing.) due to septic shock. When I called the nurse, she was unable to find the order to d/c (discontinue the) Foley. They should have monitored the urine output on someone who has a history or [MEDICAL CONDITION]. C. Record review of R #2's History and Physical from local hospital dated 10/01/17 revealed, The patient has had an indwelling catheter since hip surgery performed in august 2017. Patient in rehabilitation and in skilled nursing following hospitalization with indwelling Foley and was removed for 2 days. The patient had a large amount of [MEDICAL CONDITION] and when catheterized, urine was purulent (consisting of, containing, or discharging pus). D. Record review of R #2's Discharge Summary from local hospital dated 10/14/17 revealed, Acute hypoxic [MEDICAL CONDITION] secondary to septic shock . septic shock secondary to urinary tract infection, 2 sets of blood cultures positive for E coli (is a type of bacteria that normally lives in your intestines) . patient was transferred to (name of local hospital) ER after noted to be septic secondary to severe urinary tract infection . patient was in [MEDICAL CONDITION] on mechanical ventilator . R #2 was admitted to the hospital on [DATE] and discharged on [DATE]. E. Record review of R #2's Physician's Orders dated September 2017 revealed no order to discontinue R #2's Foley catheter. F. Record review of R #2's Care Plan dated 09/26/17 revealed the following: 1. (Name of R #2) is at risk for complication R/T (related to) 1000 cc fluid restriction . Monitor for s/s (signs and symptoms) of dehydration. Extreme thirst, less frequent urination, dark-color urine, fatigue, dizziness, confusion, offer liquids within the daily limit as ordered. 2. (Name of R #2) requires an indwelling urinary catheter R/T [MEDICAL CONDITION] . Assess the drainage every shift for amount, color odor. Observe for leakage . position bag below level of bladder . G. On 10/24/17 at 1:44 PM, during an interview, LPN #2 stated that R #2 was sent to the ER around 10:00 am or 11:00 am on 10/01/17. LPN #2 stated that he could not recall any of the CNAs reporting that R #2 had not had any urine output. H. On 10/24/17 at 11:58 am, during an interview, RN #1 stated that the residents should be checked for incontinence care and to empty the Foley urine bag. The urine output for every resident should be documented in the record. I cannot remember whether anyone told me but they should have. I. Record review of R #2's Urine Output Log dated from 09/01/17 to 10/01/17 revealed on 09/30/17 at 5:12 am, (U)rine: Small. No documentation was found that recorded R #2's urine output from 5:00 am on 09/30/17 to when R #2 was sent to theER on [DATE] at around 10:00 am (discharging nurse was unable to recall exact time of discharge but recalled approximately 10:00 am). J. On 10/23/17 at 2:01 PM, during an interview the DON confirmed that there was no order for R #2 to d/c his Foley catheter. It (d/c orders) should be stated on the bladder retraining but the does not say d/c. The DON also confirmed that there was no documented urine output since 5 am on 09/30/17, R #2 was sent to the hospital on [DATE] about 11:00 am. To my knowledge, the CNAs did not report to the nurse there was no urine output (for R #2). The nurse should have documented this. He (R #2) had asked the nurse practitioner if he could have it (Foley catheter) removed. He was on the bladder retraining program. K. On 10/24/17 at 11:50 am, during an interview, DON confirmed that the nurses and CNAs had not been following R #2's care plan for monitoring urine output, and did not care plan R #2's bladder retraining program. R #3 L. Record review of the physician orders for R #3 dated 10/01/17 to 10/31/17 revealed: Order from 2/24/17 for suprapubic catheter (a foley catheter that has been inserted in a surgically made opening above the pubic bone) care every shift. M. Record review of the care plan for R #3 dated 02/02/17 revealed: Problem: Indwelling Catheter. Goal: dated 08/04/17 Will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection . Approach: Dated 02/02/17 Assess the drainage type, color, odor as needed. Observe for leakage . Care plan documentation does not include provision for, or parameters for using a leg bag such was under what circumstances a leg bag can be used. N. On 10/20/17 at 4:10 am, during observation, CNA (certified nursing assistant) #1 went to R #3's room, pulled back the covers and pressed the leg bag. The bag was full and bulging. The resident was lightly snoring and asleep. O. On 10/20/17 at 4:10 am, during an interview with CNA #1, she stated, The CNAs empty the drainage bags every 2 hours, it is about due to be emptied. We keep him in a leg bag in case he gets up night. She stated she had never been told to change to the large, bedside drainage bag at night. P. On 10/20/17 at 4:15 am, during an interview with RN (Registered Nurse) #1, she stated, They (residents) can have either a leg bag or regular bag when they are in bed. The CNAs empty the bags every 2 hours, that is what they are trained to do. She said she did not know the leg bag was full. When asked what the repercussion to the resident could be from having a full bag, and also having the drainage bag at the level of the bladder she said, There could be a backflow of urine and infection. Q. On 10/23/17 at 2:00 pm, during an interview with the DON, she stated, The CNA staff are responsible for switching over the bags (from leg bag to large drainage bag) and charting the I (intake of fluids) and O (output of urine). The leg bags should be emptied every 2 hours. The risk of a full leg bag is infection. It could mean infection (for the resident) if the bag is full or it is above the bladder. R. On 10/23/17 at 2:50 pm, during an interview with LPN #1 she stated, The CNAs make sure the bags (urinary drainage bags) are emptied and chart the output under vital signs. I don't know how they record it, just small, medium, and large or by cc (cubic centimeter, a measure of volume). I don't look at that page (where the urine output is recorded). If they (the CNAs) had a concern they would let me know. They use leg bags during the day -- they use bigger (larger volume) bags at night. (Name of R #3) has a lot of output (urine), we might should put him in a big bag during the day. He gets full really quickly. He lays down and naps-they change him to bigger bag when he lays down. S. On 10/23/17 at 3:00 pm, during observation and interview, R #3 was in bed, dozing. There was no visible drainage bag on the bed frame. The surveyor asked LPN #1 what type of urine drainage was being used for the resident. LPN #1 went to the room and revealed a leg bag, about half full (approximately 250 cc (cubic centimeters, a metric unit of measure) was in place. LPN #1 said R #1 had been in bed since shift change at 2 pm, and should have been switched from a leg bag (to a large drainage bag). T. Review of the facility policy and procedure for Emptying a Urinary Drainage Bag, dated as revised October 2010) revealed: General Guidelines, 1. Empty the urinary drainage bag at least every eight (8) hours or more often if needed to keep the bag from becoming full. Keep the drainage bag below the level of the resident's bladder. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The amount of urine emptied form the drainage bag. 6. Character of urine such as color, clarity, and odor. 10. The name and title of the individual (s) who performed the procedure. U. Review of the facility urinary procedure, dated revised September 2014, for Urinary Catheter Care revealed: Input/Output: 1. Observe the resident's urine for noticeable increases or decreases. Maintaining Unobstructed Urine Flow. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Infection Control: Use standard precautions (infection prevention practices including handwashing and use of PPE (personal protective equipment--like gloves) when handling of manipulating the drainage system. R #1 V. Record review of the facility records date 07/02/17 for R #1 revealed: Pressure ulcer of the sacral region (lower back), Stage IV (wound that is open to bone, tendon, ligament or muscle) upon admission on 07/02/17. W. Record review of the MDS (Minimum Data Set) for R #1, dated 10/22/17 revealed: Activities of Daily Living: Bed Mobility (How the resident moves to and from lying position, turns, and positions body): requires extensive assistance and a 2 person physical assist, Transfers (how resident moves from bed to wheelchair) R #1 requires total assistance, and 2 persons to assist. X. Record review of the Care Plan dated 07/03/17 revealed: Problem: Stage 4 coccyx (tailbone) ulcer (a wound) Goal: Ulcer with heal without complications by next review Approach: Utilize air mattress, continue wound treatments as ordered, Conduct a systematic skin inspection as needed, Continue wound care. There are no provisions for repositioning in the bed or in the wheelchair, patient education on need for position changes, use of a support surface (special cushion) in his wheelchair. Y. On 10/24/17 at 4:20 pm, during an interview with CNA (Certified Nursing Assistant) #4, she stated, We do not need to reposition him ( R #1). He is on an air bag (air mattress), and he is up in his chair a lot. Z. On 10/25/17 at 1:20 pm, during an interview with CNA #3, when asked the care R#1 needs, she stated, I do pericare (cleansing of the genital and anal area) on him, get him up, cleaned up good (sic), and alert the nurse (of problems). He stays up in chair--he sits in the wheelchair mostly. I don't know about position changes, I don't need to do that. AA. On 10/25/17 at 4:20 pm, with the MDSC (Minimum Data Set Coordinator), when asked if R #1 should be care planned for repositioning in bed, repositioning in his wheelchair, and use of pressure relief cushion in his wheelchair, the MDSC stated, I assumed repositioning would be care of the CNA (Certified Nursing Assistant) duties. I don't know if the devices (pressure relief devices) should be care planned, I would need to check. BB. On 10/24/17 at 4:20 pm, during an interview with CNA (Certified Nursing Assistant) #4, she stated, We do not need to reposition him ( R #1). He is on an air bag (air mattress), and he is up in his chair a lot. CC. On 10/25/17 at 1:20 pm, during an interview with CNA #3, when asked about the care R#1 needs, she stated, I do pericare (cleansing of the genital and anal area) on him, get him up, cleaned up good (sic), and alert the nurse (of problems). He stays up in chair--he sits in the wheelchair mostly. I don't know about position changes, I don't need to do that. DD. Review of the Prevention and treatment of [REDACTED]. Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014, revealed: Repositioning frequency: Determine frequency with consideration to tissue tolerance, mobility, general medical condition, overall treatment objects, and skin condition and comfort. Recommendations for Individual with Existing Pressure Ulcers for Repositioning in a Chair: If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia (lower part of the hip), limit sitting to three times a day in periods of 60 minutes or less. Consult a seating specialist to prescribe an appropriate seating surface and/or positioning techniques to avoid or minimize pressure on the ulcer. Recommendations for Individuals with Existing Pressure Ulcers: Continue to turn and reposition the individual regardless of the support surface in use. Establish turning frequency based on the characteristics of the support surface and the individual's response. No support surface provides complete pressure relief. Hand Washing EE. On 10/20/17 at 4:10 am, during observation, CNA (certified nursing assistant) #1 went to R #3's room, pulled back the covers, pressed the leg bag and rearranged the tubing without performing hand washing either before or after touching R #3. FF. On 10/20/17 at 4:12 am, during an interview with CNA #1, when asked if she should have performed hand hygiene and worn gloves when touching R #3's urinary drainage system she stated, I usually do wash my hands. GG. On 10/23/17 at 2:24 pm, during an observation of the residents with catheters, CNA #3 touched R #1's and R #5's catheter urine collection bag and tubing without gloves. Upon leaving the room CNA #3 did not perform hand hygiene. HH. On 10/23/17 at 2:28 pm, during an observation of the residents with catheters, CNA #8 touched R #6's catheter urine collection bag and tubing without gloves. Upon leaving the room CNA #8 did not perform hand hygiene. II. On 10/23/17 at 3:00 pm, during observation in, LPN #1 walked into R #3's room and revealed he was wearing a leg bag. LPN #1 touched R #3, his clothing and the leg bag. LPN #1 then returned to the computer and began to use the computer, she had not performed hand hygiene before or after touching the resident. JJ. On 10/23/17 at 2:00 pm, during an interview with the DON (Director of Nurses), she stated, The staff know they are supposed to wash their hands between residents, it could cause an infection. KK. Record review of the Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16):(p29, p32) revealed the following: CDC (Centers for Disease Control and Prevention ) has recommended that HCWs (health care workers) wear gloves to 1) reduce the risk of personnel acquiring infections from patients, 2) prevent health-care worker flora from being transmitted to patients, and 3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another . The Occupational Safety and Health Administration (OSHA) mandates that gloves be worn during all patient-care activities that may involve exposure to blood or body fluids that may be contaminated with blood . Recommendations: 1. Indications for handwashing and hand antisepsis (the practice of using antiseptics to eliminate the microorganisms that cause disease) A. When hands are visibly dirty or contaminated with proteinaceous (relating to, containing, resembling, or being protein) material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water (IA) (66). B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J (IA) (74,93,166,169,283,294,312,398). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J (IB) (69-71,74). C. Decontaminate hands before having direct contact with patients (IB) (68,400). D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter (catheter into the blood vessel) (IB) (401,402). E. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters (catheter placed in a peripheral vein), or other invasive devices that do not require a surgical procedure (IB) (25,403). F. Decontaminate hands after contact with a patient ' s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) (IB) (25,45,48,68). G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA) (400). H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care (II) (25,53). I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (II) (46,53,54). J. Decontaminate hands after removing gloves (IB) (50,58,321). K. Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water (IB) (404-409). L. Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of HCWs, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap (IB) (160,161). M. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis (the organism that causes anthrax) is suspected or proven. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, [MEDICATION NAME] (disinfectant and antiseptic), odophors (chemical), and other antiseptic agents have poor activity against spores (II) (120,172, 224,225) . 2. Hand-hygiene technique: A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry (IB) (288,410). Follow the manufacturer's recommendations regarding the volume of product to use. B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB) (90-92,94,411). Avoid using hot water, because repeated exposure to hot water may increase the risk of [MEDICAL CONDITION] (inflammation of the skin) (IB) (254,255) . 1. The following performance indicators are recommended for measuring improvements in HCWs' hand-hygiene adherence: A. Periodically monitor and record adherence as the number of hand-hygiene episodes performed by personnel/number of hand-hygiene opportunities, by ward or by service. Provide feedback to personnel regarding their performance. B. Monitor the volume of alcohol-based hand rub (or detergent used for handwashing or hand antisepsis) used per 1,000 patient-days. C. Monitor adherence to policies dealing with wearing of artificial nails. D. When outbreaks of infection occur, assess the adequacy of health-care worker hand hygiene.

Based on interview and record review, it was determined that: 1) R #2 was on a bladder retraining program after the facility removed his Foley catheter. Due to the removal of the foley R #2 required monitoring of urine output. 2) R #2 did not have an order to d/c (discontinue) his Foley catheter. 3) R #2 was also at risk for complications (dehydration, low urine output) from being on fluid restrictions. 4) The facility did not revise R #2's care plan to d/c his Foley catheter/start bladder retraining program, and did not follow R #2's care plan for monitoring low urine output from being on fluid restrictions. 5) Urine output logs show no record of R #2 having any urine output from 5:00 am on 09/30/17 to when R #2 was sent to theER on [DATE] at around 10:00 am (discharging nurse was unable to recall exact time of discharge but recalled approximately 10:00 am). 6) R #2 was sent to the hospital where they discovered R #2 had [MEDICAL CONDITION] and an UTI that progressed into septic shock and [MEDICAL CONDITION]. 7) R #2 was hospitalized for [REDACTED]. This resulted in an Immediate Jeopardy with a starting date of 09/30/17. The facility was notified on 10/23/17 at 3:50 PM. A plan of removal was received on 10/24/17 at 4:05 PM and approved. Upon implementation of the plan of removal, the IJ was lifted on 10/25/17 at 3:45 PM. This dropped the scope and severity down to H. Based on record review and interview the facility failed to follow Care Plans for 1 (R #2) of 4 (R #1, R #2, R #3, R #4) resident sampled for catheter and incontinence care, when they failed to monitor R #2's urine output after removing he foley catheter. This deficient practice caused R #2 to have an UTI that resulted in [MEDICAL CONDITION] from septic shock. The findings are: A. Record review of R #2's medical record revealed the following: 1. R #2 was admitted on [DATE] 2. [DIAGNOSES REDACTED]. B. On 10/23/17 at 1:00 PM, during an interview, R #2's Family Member (FM) stated that R #2 had Foley catheter and that someone took it out. The facility did not discuss wanting to put R #2 on bladder retraining program. R #2 was sent out to the hospital because he was septic from not having urinated for 2 days. FM also stated that R #2 had to be intubated (the process of inserting a tube, called an endotracheal tube (ET), through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing.) due to septic shock. When I called the nurse, she was unable to find the order to d/c (discontinue the) Foley. They should have monitored the urine output on someone who has a history or [MEDICAL CONDITION]. C. Record review of R #2's History and Physical from local hospital dated 10/01/17 revealed, The patient has had an indwelling catheter since hip surgery performed in august 2017. Patient in rehabilitation and in skilled nursing following hospitalization with indwelling Foley and was removed for 2 days. The patient had a large amount of [MEDICAL CONDITION] and when catheterized, urine was purulent (consisting of, containing, or discharging pus). D. Record review of R #2's Discharge Summary from local hospital dated 10/14/17 revealed, Acute hypoxic [MEDICAL CONDITION] secondary to septic shock . septic shock secondary to urinary tract infection, 2 sets of blood cultures positive for E coli (is a type of bacteria that normally lives in your intestines) . patient was transferred to (name of local hospital) ER after noted to be septic secondary to severe urinary tract infection . patient was in [MEDICAL CONDITION] on mechanical ventilator . R #2 was admitted to the hospital on [DATE] and discharged on [DATE]. E. Record review of R #2's physician's orders [REDACTED].#2's Foley catheter. F. Record review of R #2's Care Plan dated 09/26/17 revealed the following: 1. (Name of R #2) is at risk for complication R/T (related to) 1000 cc fluid restriction . Monitor for s/s (signs and symptoms) of dehydration. Extreme thirst, less frequent urination, dark-color urine, fatigue, dizziness, confusion, offer liquids within the daily limit as ordered. 2. (Name of R #2) requires an indwelling urinary catheter R/T [MEDICAL CONDITION] . Assess the drainage every shift for amount, color odor. Observe for leakage . position bag below level of bladder . G. On 10/24/17 at 1:44 PM, during an interview, LPN #2 stated that R #2 was sent to the ER around 10:00 am or 11:00 am on 10/01/17. LPN #2 stated that he could not recall any of the CNAs reporting that R #2 had not had any urine output. H. On 10/24/17 at 11:58 am, during an interview, RN #1 stated that the residents should be checked for incontinence care and to empty the Foley urine bag. The urine output for every resident should be documented in the record. I cannot remember whether anyone told me but they should have. I. Record review of R #2's Urine Output Log dated from 09/01/17 to 10/01/17 revealed on 09/30/17 at 5:12 am, (U)rine: Small. No documentation was found that recorded R #2's urine output from 5:00 am on 09/30/17 to when R #2 was sent to theER on [DATE] at around 10:00 am (discharging nurse was unable to recall exact time of discharge but recalled approximately 10:00 am). J. On 10/23/17 at 2:01 PM, during an interview the DON confirmed that there was no order for R #2 to d/c his Foley catheter. It (d/c orders) should be stated on the bladder retraining but the does not say d/c. The DON also confirmed that there was no documented urine output since 5 am on 09/30/17, R #2 was sent to the hospital on [DATE] about 11:00 am. To my knowledge, the CNAs did not report to the nurse there was no urine output (for R #2). The nurse should have documented this. He (R #2) had asked the nurse practitioner if he could have it (Foley catheter) removed. He was on the bladder retraining program. K. On 10/24/17 at 11:50 am, during an interview, DON confirmed that the nurses and CNAs had not been following R #2's care plan for monitoring urine output, and did not care plan R #2's bladder retraining program.

Based on interview and record review, it was determined that: R #1 1) R #1 was identified as possibly having a urinary tract infection 2) subsequently had 2 days, 09/10/17 and 09/11/17 where the urine output was not recorded. R #2 3) R #2 was on a bladder retraining program after the facility removed his Foley catheter. Due to the removal of the foley R #2 required monitoring of urine output. 4) R #2 did not have an order to d/c (discontinue) his Foley catheter. 5) R #2 was also at risk for complications (dehydration, low urine output) from being on fluid restrictions. 6) The facility did not revise R #2's care plan to d/c his Foley catheter/start bladder retraining program, and did not follow R #2's care plan for monitoring low urine output from being on fluid restrictions. 7) Urine output logs show no record of R #2 having any urine output from 5:00 am on 09/30/17 to when R #2 was sent to theER on [DATE] at around 10:00 am (discharging nurse was unable to recall exact time of discharge but recalled approximately 10:00 am). 8) R #2 was sent to the hospital where they discovered R #2 had [MEDICAL CONDITION] and an UTI that progressed into septic shock and [MEDICAL CONDITION]. 9) R #2 was hospitalized for [REDACTED]. R #3 10) R # 3 was observed in bed sleeping with leg bag full of urine and bulging with no space from more drainage. 11) R #3 was per with staff it was determined this resident was routinely put to bed with a leg bag. 12) The facility policy on urinary catheters directs that the drainage bag should be lower than the bladder. This resulted in an Immediate Jeopardy with a starting date of 09/30/17. The facility was notified on 10/23/17 at 3:50 PM. A plan of removal was received on 10/24/17 at 4:05 PM and approved. The facilities Plan of removal revealed the following: Plan of removal -Resident(s) found to be affected by identified: (Name of R #2) was discharged on [DATE]. Potential residents to be affected by identified practice: Seven residents have been identified as utilizing an indwelling catheter. Care plans were reviewed, revised and updated as appropriate 10/24/17. One resident was identified as using antibiotics for a [DIAGNOSES REDACTED]. Fifty-seven residents were identified as being incontinent requiring routine incontinence care. Care plans were reviewed, revised and updated as appropriate 10/24/17. These residents have been identified on Certified Nursing Assistant care sheets. Corrective action implemented so identified practice will not recur: Staff educated on proper hand hygiene to include competency checkoffs initiated on 10/23/2017 and to be completed 10/24/17. Staff will not return to work until educated. Staff educated on catheter/peri/incontinence-care, emptying of Foley catheter bag, and utilization of a gravity drainage bag maintained below the bladder always. Education to include competency check off's, initiated on 10/23/2017 and to be completed by 10/24/17. Staff will not return to work until educated. Charge Nurses will be educated on documentation of care services provided, signs and symptoms of a urinary tract infection (using McGeer's criteria). In addition, the nurses will in-serviced on the INTERAC Change in Condition related to urinary tract infection: When to report to the MD/NP/PA. Nurses will assess all residents every shift and document on the TAR. Nurses' aides will be educated on reporting of low or no urine output during an 8- hour period to the charge nurse who will then report to the physician when urine output is (<30 ml/hours) was initiated on 10/23/17 and to be completed by 10/24/17. Staff will not return to work until educated. The Infection Control and Surveillance program will be managed by one designated nurse with oversight by the DON. The DON in-serviced the infection control nurse on 10/23/17 regarding; utilization of catheter orders to identify residents with catheters, verification that culture and sensitivity reports are returned and followed through the appropriate antibiotic utilization. The infection control nurse will attend training on Fundaments of Infection Prevention presented through (name of agency) on 11/2 and 11/3/17. Licensed Nurses for residents who may exhibit S/S of UTI to validate that the patient meets identified criteria of a UTI diagnoses. The facility will review the catheter orders and with physician approval revise the orders to meet CDC guidelines for changing catheters on a prn basis for blockage. In addition, the facility will follow up with the CNP/MD regarding guidelines for reinsertion of a catheter or straight catheter if needed following removal. CNP/MD, and MDS Coordinators will be educated on the McGeer's criteria by 10/25/17. The facility will conduct random audits on a weekly basis for on-going compliance with appropriate handwashing, utilization of gravity drainage bags appropriately, catheter/incontinence care provided appropriately and documentation of services provided. The DON/designee will audit the infection control program for accuracy of tracking and trending for appropriate antibiotic therapy. Results of audit will be reviewed at the monthly QAPI meeting until substantial compliance is maintained. Upon implementation of the plan of removal, the IJ was lifted on 10/25/17 at 3:45 PM. This dropped the scope and severity down to H. Based on record review, interview, and observation the facility failed ensure the residents received appropriate treatment and services to prevent a urinary tract infection for 3 ( R #1, R #2, and R #3) of 4 ( R #1, R #2, R #3, and R #4) residents sampled for neglect related to catheters and urinary incontinence when they failed to1) monitor urine output on R#1 who had been identified as possibly having a urinary tract infection, 2) failed to monitor urine output after a Foley catheter was removed for R #2, 3) failed to assure unobstructed urine flow from a Foley catheter for R #3 and failed to prevent the backflow of urine when the drainage bag was left at the level of the bladder, and 4) failed to ensure appropriate hand hygiene was performed, and gloves were worn when touching urinary drainage bags and tubing by staff for 4 (R #1, R #3, R #5, and R #6) of 5 ( R #1, R#3, R #4, R #5, and R #6) residents. This deficient practice resulted in R #2 going into septic shock and [MEDICAL CONDITION]. The findings are: R #2 A. Record review of R #2's medical record revealed the following: 1. R #2 was admitted on [DATE] 2. [DIAGNOSES REDACTED]. B. On 10/23/17 at 1:00 PM, during an interview, R #2's Family Member (FM) stated that R #2 had Foley catheter and that someone took it out. The facility did not discuss wanting to put R #2 on bladder retraining program. R #2 was sent out to the hospital because he was septic from not having urinated for 2 days. FM also stated that R #2 had to be intubated (the process of inserting a tube, called an endotracheal tube (ET), through the mouth and then into the airway. This is done so that a patient can be placed on a ventilator to assist with breathing.) due to septic shock. When I called the nurse, she was unable to find the order to d/c (discontinue the) Foley. They should have monitored the urine output on someone who has a history or [MEDICAL CONDITION]. C. Record review of R #2's History and Physical from local hospital dated 10/01/17 revealed, The patient has had an indwelling catheter since hip surgery performed in august 2017. Patient in rehabilitation and in skilled nursing following hospitalization with indwelling Foley and was removed for 2 days. The patient had a large amount of [MEDICAL CONDITION] and when catheterized, urine was purulent (consisting of, containing, or discharging pus). D. Record review of R #2's Discharge Summary from local hospital dated 10/14/17 revealed, Acute hypoxic [MEDICAL CONDITION] secondary to septic shock . septic shock secondary to urinary tract infection, 2 sets of blood cultures positive for E coli (is a type of bacteria that normally lives in your intestines) . patient was transferred to (name of local hospital) ER after noted to be septic secondary to severe urinary tract infection . patient was in [MEDICAL CONDITION] on mechanical ventilator . R #2 was admitted to the hospital on [DATE] and discharged on [DATE]. E. Record review of R #2's Physician's Orders dated September 2017 revealed no order to discontinue R #2's Foley catheter. F. Record review of R #2's Care Plan dated 09/26/17 revealed the following: 1. (Name of R #2) is at risk for complication R/T (related to) 1000 cc fluid restriction . Monitor for s/s (signs and symptoms) of dehydration. Extreme thirst, less frequent urination, dark-color urine, fatigue, dizziness, confusion, offer liquids within the daily limit as ordered. 2. (Name of R #2) requires an indwelling urinary catheter R/T [MEDICAL CONDITION] . Assess the drainage every shift for amount, color odor. Observe for leakage . position bag below level of bladder . G. On 10/24/17 at 1:44 PM, during an interview, LPN #2 stated that R #2 was sent to the ER around 10:00 am or 11:00 am on 10/01/17. LPN #2 stated that he could not recall any of the CNAs reporting that R #2 had not had any urine output. H. On 10/24/17 at 11:58 am, during an interview, RN #1 stated that the residents should be checked for incontinence care and to empty the Foley urine bag. The urine output for every resident should be documented in the record. I cannot remember whether anyone told me but they should have. I. Record review of R #2's Urine Output Log dated from 09/01/17 to 10/01/17 revealed on 09/30/17 at 5:12 am, (U)rine: Small. No documentation was found that recorded R #2's urine output from 5:00 am on 09/30/17 to when R #2 was sent to theER on [DATE] at around 10:00 am (discharging nurse was unable to recall exact time of discharge but recalled approximately 10:00 am). J. On 10/23/17 at 2:01 PM, during an interview the DON confirmed that there was no order for R #2 to d/c his Foley catheter. It (d/c orders) should be stated on the bladder retraining but the does not say d/c. The DON also confirmed that there was no documented urine output since 5 am on 09/30/17, R #2 was sent to the hospital on [DATE] about 11:00 am. To my knowledge, the CNAs did not report to the nurse there was no urine output (for R #2). The nurse should have documented this. He (R #2) had asked the nurse practitioner if he could have it (Foley catheter) removed. He was on the bladder retraining program. K. On 10/24/17 at 11:50 am, during an interview, DON confirmed that the nurses and CNAs had not been following R #2's care plan for monitoring urine output, and did not care plan R #2's bladder retraining program. R #3 L. Record review of the physician orders for R #3 dated 10/01/17 to 10/31/17 revealed: Order from 2/24/17 for suprapubic catheter (a foley catheter that has been inserted in a surgically made opening above the pubic bone) care every shift. M. Record review of the care plan for R #3 dated 02/02/17 revealed: Problem: Indwelling Catheter. Goal: dated 08/04/17 Will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection . Approach: Dated 02/02/17 Assess the drainage type, color, odor as needed. Observe for leakage . Care plan documentation does not include provision for, or parameters for using a leg bag such was under what circumstances a leg bag can be used. N. On 10/20/17 at 4:10 am, during observation, CNA (certified nursing assistant) #1 went to R #3's room, pulled back the covers and pressed the leg bag. The bag was full and bulging. The resident was lightly snoring and asleep. O. On 10/20/17 at 4:10 am, during an interview with CNA #1, she stated, The CNAs empty the drainage bags every 2 hours, it is about due to be emptied. We keep him in a leg bag in case he gets up night. She stated she had never been told to change to the large, bedside drainage bag at night. P. On 10/20/17 at 4:15 am, during an interview with RN (Registered Nurse) #1, she stated, They (residents) can have either a leg bag or regular bag when they are in bed. The CNAs empty the bags every 2 hours, that is what they are trained to do. She said she did not know the leg bag was full. When asked what the repercussion to the resident could be from having a full bag, and also having the drainage bag at the level of the bladder she said, There could be a backflow of urine and infection. Q. On 10/23/17 at 2:00 pm, during an interview with the DON, she stated, The CNA staff are responsible for switching over the bags (from leg bag to large drainage bag and charting the I (intake of fluids) and O (output of urine). The leg bags should be emptied every 2 hours. The risk of a full leg bag is infection. It could mean infection. (for the resident) if the bag full or is above the bladder. R. On 10/23/17 at 2:50 pm, during an interview with LPN #1 stated, The CNAs make sure the bags (urinary drainage bags) are emptied and chart the output under vital signs. I don't know how they record it, just small, medium, and large or by cc (cubic centimeter, a measure of volume). I don't look at that page (where the urine output is recorded). If they (the CNAs) had a concern they would let me know. They use leg bags during the day -- they use bigger (larger volume) bags at night. (Name of R #3) has a lot of output (urine), we might should put him in a big bag during the day. He gets full really quickly. He lays down and naps-they change him to bigger bag when he lays down. S. On 10/23/17 at 3:00 pm, during observation, R #3 was in bed, dozing. There was no visible drainage bag on the bed frame. The surveyor asked LPN #1 what type of urine drainage was being used for the resident. LPN #1 went to the room and revealed a leg bag, about half full (approximately 250 cc (cubic centimeters, a metric unit of measure) was in place. LPN #1 said R#1 had been in bed since shift change at 2 pm, and should have been switched from a leg bag (to a large drainage bag). T. Review of the facility policy and procedure for Emptying a Urinary Drainage Bag, dated as revised October 2010) revealed: General Guidelines, 1. Empty the urinary drainage bag at least every eight (8) hours or more often if needed to keep the bag from becoming full. Keep the drainage bag below the level of the resident's bladder. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The amount of urine emptied form the drainage bag. 6. Character of urine such as color, clarity, and odor. 10. The name and title of the individual (s) who performed the procedure. U. Review of the facility urinary procedure, dated revised September 2014, for Urinary Catheter Care revealed: Input/Output: 1. Observe the resident's urine for noticeable increases or decreases. Maintaining Unobstructed Urine Flow. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Infection Control: Use standard precautions (infection prevention practices including handwashing and use of PPE (personal protective equipment--like gloves) when handling of manipulating the drainage system. V. Review of the Center for Disease Control Guideline for Prevention of Catheter Associated Urinary Tract Infections 2009 revealed: III. Proper Techniques for Urinary Catheter Maintenance . B. Maintain unobstructed urine flow. (Category IB) (Key Questions 1B and 2D) 1.Keep the catheter and collecting tube free from kinking. (Category IB) 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. (Category IB) R #1 W. On 10/24/17 at 2:50 pm, during an interview with RN (Registered Nurse) #1, she stated, I took care of him ( R #1) for 3 days of consecutive night duty ( in September 09/09/17, 09/10/17, and 09/11/17). The second day he reported fever and chills and I sent a urine sample because I suspected a UTI (urinary Tract Infection). I checked on him with medications and treatment .with 49 other residents I have to maximize my time. I had another resident that fell in the night. It is a hard time time (sic) caring for that many residents. The Foley bag had dark urine, It was 1/3 full, it was not minimum. I had already suspected ( R #1 of having) a UTI . I know the CNAs empty the Foley q (every) 2 hrs, I don't know the amount. I check it when I have enough time and assess their needs. X. Record review of the facility progress notes dated 09/09/17 at 2:30 revealed: Resident complained of chills Urine dipstick done: 1+ leukocytes (white blood cells that counter infection), 2+ protein, 3+ blood, 1+ bilirubin (the pigment in bile) Notified doctor, Urine CS (sic) (Culture and Sensitivity done to determine what organism is the source of infection and what antibiotics the organism is sensitive to). Y. Record review of the facility progress note dated 09/10/17 at 1:02 revealed: Foley catheter draining dark colored urine. There is no notation of the amount of urine being produced. Z. Record review of the facility progress noted dated 09/11/17 at 1:52 revealed: Still awaiting urine C/S (Culture and Sensitivity). Foley catheter draining dark colored urine. There is not notation of the amount of urine being produced. AA. On 10/25/17 at 12:35 pm, during an interview with the DON (Director or Nurses) regarding the documentation of R #1's urine output on 09/10/17 and 09/11/17. I don't see any urine output for September 10th and 11th. The output should have been evaluated on September 10th and 11th. We do not know what his urine output was on those days. BB. Record review of the hospital records for R #1 dated 09/11/17 revealed: Admission for Urinary Tract Infection. The History and Physical revealed: Came to the ER (emergency room ) having urinary symptoms started (sic) a few days ago. Hand Washing CC. On 10/20/17 at 4:10 am, during observation, CNA (certified nursing assistant) #1 went to R #3's room, pulled back the covers and pressed the leg bag and rearranged the tubing without performing hand washing either before or after touching R #3. DD. On 10/20/17 at 4:12 am, during an interview with CNA #1, when asked if she should have performed hand hygiene and worn gloves when touching R #3's urinary drainage system she stated, I usually do wash my hands. EE. On 10/23/17 at 2:24 pm, during an observation the residents with catheters, CNA #3 touched R #1's and R #5's catheter urine collection bag and tubing without gloves. Upon leaving the room CNA #3 did not perform hand hygiene. FF. On 10/23/17 at 2:28 pm, during an during an observation the residents with catheters, CNA #8 touched R #6's catheter urine collection bag and tubing without gloves. Upon leaving the room CNA #8 did not perform hand hygiene. GG. On 10/23/17 at 3:00 pm, during observation, LPN #1 walked into R #3's room and revealed he was wearing a leg bag. LPN #1 touched R #3 his clothing and the leg bag. LPN #1 then returned to the computer and began to use the computer, she had not performed hand hygiene before or after touching the resident. HH. Record review of the Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16):(p29, p32) revealed the following: CDC (Centers for Disease Control and Prevention ) has recommended that HCWs (health care workers) wear gloves to 1) reduce the risk of personnel acquiring infections from patients, 2) prevent health-care worker flora from being transmitted to patients, and 3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another . The Occupational Safety and Health Administration (OSHA) mandates that gloves be worn during all patient-care activities that may involve exposure to blood or body fluids that may be contaminated with blood . Recommendations: 1. Indications for handwashing and hand antisepsis (the practice of using antiseptics to eliminate the microorganisms that cause disease) A. When hands are visibly dirty or contaminated with proteinaceous (relating to, containing, resembling, or being protein) material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water (IA) (66). B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J (IA) (74,93,166,169,283,294,312,398). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J (IB) (69-71,74). C. Decontaminate hands before having direct contact with patients (IB) (68,400). D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter (catheter into the blood vessel) (IB) (401,402). E. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters (catheter placed in a peripheral vein), or other invasive devices that do not require a surgical procedure (IB) (25,403). F. Decontaminate hands after contact with a patient ' s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) (IB) (25,45,48,68). G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA) (400). H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care (II) (25,53). I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (II) (46,53,54). J. Decontaminate hands after removing gloves (IB) (50,58,321). K. Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water (IB) (404-409). L. Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of HCWs, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap (IB) (160,161). M. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis (the organism that causes anthrax) is suspected or proven. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, [MEDICATION NAME] (disinfectant and antiseptic), odophors (chemical), and other antiseptic agents have poor activity against spores (II) (120,172, 224,225) . 2. Hand-hygiene technique: A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry (IB) (288,410). Follow the manufacturer's recommendations regarding the volume of product to use. B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB) (90-92,94,411). Avoid using hot water, because repeated exposure to hot water may increase the risk of [MEDICAL CONDITION] (inflammation of the skin) (IB) (254,255) . 1. The following performance indicators are recommended for measuring improvements in HCWs' hand-hygiene adherence: A. Periodically monitor and record adherence as the number of hand-hygiene episodes performed by personnel/number of hand-hygiene opportunities, by ward or by service. Provide feedback to personnel regarding their performance. B. Monitor the volume of alcohol-based hand rub (or detergent used for handwashing or hand antisepsis) used per 1,000 patient-days. C. Monitor adherence to policies dealing with wearing of artificial nails. D. When outbreaks of infection occur, assess the adequacy of health-care worker hand hygiene.

Based on interview and record review, it was determined that: Infection Control Program 1) Infection control program did not provide timely surveillance for 16 residents the facility identified as having UTIs 2) Facility staff did not perform adequate hand hygiene before and after touching urinary catheter equipment/residents using them R #3 3) R # 3 was observed in bed sleeping with leg bag full of urine and bulging with no space from more drainage 4) R #3 was per with staff it was determined this resident was routinely put to bed with a leg bag 5) The facility policy on urinary catheters directs that the drainage bag should be lower than the bladder This resulted in an Immediate Jeopardy with a starting date of 09/30/17. The facility was notified on 10/23/17 at 3:50 PM. A plan of removal was received on 10/24/17 at 4:05 PM and approved. Upon implementation of the plan of removal, the IJ was lifted on 10/25/17 at 3:45 PM. This dropped the scope and severity down to H. Based on record review and interview the facility failed to ensure proper infection control practices for 16 (R #1, R #2, R #7, R #8, R #9, R #10, R #11, R #12, R #13, R #14, R #15, R #16, R #17, R #18, R #19, and R #20) of 88 residents residing in the facility (residents were identified as having urinary tract infections on the September 2017 infection report that was provided by the Infection Control Nurse on 10/23/17), when they failed to 1) implement a proper infection control program when they did not provide timely surveillance (the ongoing systematic collection, analysis, interpretation and dissemination of data to identify infections) of facility identified urinary tract infections for 16 residents, 2) ensure appropriate hand hygiene was performed, and gloves were worn when touching urinary drainage bags and tubing by staff for 4 (R #1, R #3, R #5, and R #6) of 5 ( R #1, R#3, R #4, R #5, and R #6) residents and 3) failed to ensure urine collection bags were kept lower than the bladder, and were emptied to allow for unobstructed urine flow for 1 (R #3) of 4 (R #1, R #2, R #3, and R #4) reviewed for Foley catheters (a flexible tube, indwelling in the bladder, used to drain urine). This deficient practice likely lead to 1) delay in investigation of the cause of the infections and initiating measures for prevention, 2) cross contamination between residents of potentially infectious agents, 3) increased risk of urinary tract infection that can lead to infection, debility and death. The findings are: Infection Control Program A. On 10/23/17 at 12:49 pm, during an interview with the ICN (Infection Control Nurse), she stated, I haven't done the monthly infection prevention and control report for September. I have not discussed September results yet with the DON (Director of Nurses), it is a bit higher than usual. We discuss infection control in our daily IDT (interdisciplinary team meetings) if there is a change in condition to see if the care plan needs to be updated for being on an antibiotic. The NP (nurse practitioner) sees the culture reports. They would come to me if there is something like an MDROs (multidrug resistant organism). When asked how would you know what infections are going on in your building right now, the ICN replied, I can look it up quick. There is an infection summary report I can can run at the end of the month. I rely on the NP to look at the culture and sensitivity reports to see if the antibiotic is appropriate. She would tell me if I needed to know something. When asked about the 16 infections that had been identified on the September Infection Report, she stated, I didn't realize it was quite that many. B. Record review of the facility Infection Report dated September 2017 revealed 16 residents (R #1, R #2, R #7, R #8, R #9, R #10, R #11, R #12, R #13, R #14, R #15, R #16, R #17, R #18, R #19, and R #20) identified as having urinary tract infections with the onset date in September 2017. C. On 10/24/17 at 11:00 am, during an interview withe the DON, she stated, I was not aware of the 16 UTI (urinary tract infections) in September, but should have been made aware sooner, we could have worked on what was going on. Hand Hygiene D. On 10/20/17 at 4:10 am, during observation, CNA (certified nursing assistant) #1 went to R #3's room, pulled back the covers and pressed the leg bag and rearranged the tubing without performing hand washing either before or after touching R #3. E. On 10/20/17 at 4:12 am, during an interview with CNA #1, when asked if she should have performed hand hygiene and worn gloves when touching R #3's urinary drainage system she stated, I usually do wash my hands. F. On 10/23/17 at 2:24 pm, during an observation the residents with catheters, CNA #3 touched R #1's and R #5's catheter urine collection bag and tubing without gloves. Upon leaving the room CNA #3 did not perform hand hygiene. G. On 10/23/17 at 2:28 pm, during an during an observation the residents with catheters, CNA #8 touched R #6's catheter urine collection bag and tubing without gloves. Upon leaving the room CNA #8 did not perform hand hygiene. H. On 10/23/17 at 3:00 pm, during observation, LPN #1 walked into R #3's room and revealed he was wearing a leg bag. LPN #1 touched R #3, his clothing and the leg bag. LPN #1 then returned to the computer and began to use the computer, she had not performed hand hygiene before or after touching the resident. I. On 10/23/17 at 2 pm, during an interview with the Director of Nursing, she stated, The staff know they are supposed to wash their hands between residents, it could cause an infection. J. Record review of the Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16):(p29, p32) revealed the following: CDC (Centers for Disease Control and Prevention ) has recommended that HCWs (health care workers) wear gloves to 1) reduce the risk of personnel acquiring infections from patients, 2) prevent health-care worker flora from being transmitted to patients, and 3) reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another . The Occupational Safety and Health Administration (OSHA) mandates that gloves be worn during all patient-care activities that may involve exposure to blood or body fluids that may be contaminated with blood . Recommendations: 1. Indications for handwashing and hand antisepsis (the practice of using antiseptics to eliminate the microorganisms that cause disease) A. When hands are visibly dirty or contaminated with proteinaceous (relating to, containing, resembling, or being protein) material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water (IA) (66). B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J (IA) (74,93,166,169,283,294,312,398). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J (IB) (69-71,74). C. Decontaminate hands before having direct contact with patients (IB) (68,400). D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter (catheter into the blood vessel) (IB) (401,402). E. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters (catheter placed in a peripheral vein), or other invasive devices that do not require a surgical procedure (IB) (25,403). F. Decontaminate hands after contact with a patient ' s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) (IB) (25,45,48,68). G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA) (400). H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care (II) (25,53). I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (II) (46,53,54). J. Decontaminate hands after removing gloves (IB) (50,58,321). K. Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water (IB) (404-409). L. Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of HCWs, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap (IB) (160,161). M. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis (the organism that causes anthrax) is suspected or proven. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, [MEDICATION NAME] (disinfectant and antiseptic), odophors (chemical), and other antiseptic agents have poor activity against spores (II) (120,172, 224,225) . 2. Hand-hygiene technique: A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry (IB) (288,410). Follow the manufacturer's recommendations regarding the volume of product to use. B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB) (90-92,94,411). Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis (inflammation of the skin) (IB) (254,255) . 1. The following performance indicators are recommended for measuring improvements in HCWs' hand-hygiene adherence: A. Periodically monitor and record adherence as the number of hand-hygiene episodes performed by personnel/number of hand-hygiene opportunities, by ward or by service. Provide feedback to personnel regarding their performance. B. Monitor the volume of alcohol-based hand rub (or detergent used for handwashing or hand antisepsis) used per 1,000 patient-days. C. Monitor adherence to policies dealing with wearing of artificial nails. D. When outbreaks of infection occur, assess the adequacy of health-care worker hand hygiene. R #3 S. Record review of the physician orders for R #3 dated 10/01/17 to 10/31/17 revealed: Order from 2/24/17 for suprapubic catheter (a foley catheter that has been inserted in a surgically made opening above the pubic bone) care every shift. T. Record review of the care plan for R #3 dated 02/02/17 revealed: Problem: Indwelling Catheter. Goal: dated 08/04/17 Will have catheter care managed appropriately as evidenced by not exhibiting signs of urinary tract infection . Approach: Dated 02/02/17 Assess the drainage type, color, odor as needed. Observe for leakage . Care plan documentation does not include provision for, or parameters for using a leg bag such was under what circumstances a leg bag can be used. K. On 10/20/17 at 4:10 am, during observation, CNA (certified nursing assistant) #1 went to R #3's room, pulled back the covers and pressed the leg bag. The bag was full and bulging. The resident was lightly snoring and asleep. L. On 10/20/17 at 4:10 am, during an interview with CNA #1, she stated, The CNAs empty the drainage bags every 2 hours, it is about due to be emptied. We keep him in a leg bag in case he gets up night. She stated she had never been told to change to the large, bedside drainage bag at night. M. On 10/20/17 at 4:15 am, during an interview with RN (Registered Nurse) #1, she stated, They (residents) can have either a leg bag or regular bag when they are in bed. The CNAs empty the bags every 2 hours, that is what they are trained to do. She said she did not know the leg bag was full. When asked what the repercussion to the resident could be from having a full bag, and also having the drainage bag at the level of the bladder she said, There could be a backflow of urine and infection. M. On 10/23/17 at 2 pm, during an interview with the DON, she stated, The CNA staff are responsible for switching over the bags (from leg bag to large drainage bag and charting the I (intake of fluids) and O (output of urine). The leg bags should be emptied every 2 hours. The risk of a full leg bag is infection. It could mean infection (for the resident) if the bag full or is above the bladder. N. On 10/23/17 at 2:50 pm, during an interview with LPN #1 stated, The CNAs make sure the bags (urinary drainage bags) are emptied and chart the output under vital signs. I don't know how they record it, just small, medium, and large or by cc (cubic centimeter, a measure of volume). I don't look at that page (where the urine output is recorded). If they (the CNAs) had a concern they would let me know. They use leg bags during the day -- they use bigger (larger volume) bags at night. (Name of R #3) has a lot of output (urine), we might should put him in a big bag during the day. He gets full really quickly. He lays down and naps-they change him to bigger bag when he lays down. O. On 10/23/17 at 3:00 pm, during observation, R #3 was in bed, dozing. There was no visible drainage bag on the bed frame. The surveyor asked LPN #1 what type of urine drainage was being used for the resident. LPN #1 went to the room and revealed a leg bag, about half full (approximately 250 cc (cubic centimeters, a metric unit of measure) was in place. LPN #1 said R#1 had been in bed since shift change at 2 pm, and should have been switched from a leg bag (to a large urine collection bag). P. Review of the facility policy and procedure for Emptying a Urinary Drainage Bag, dated as revised October 2010) revealed: General Guidelines, 1. Empty the urinary drainage bag at least every eight (8) hours or more often if needed to keep the bag from becoming full. Keep the drainage bag below the level of the resident's bladder. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The amount of urine emptied form the drainage bag. 6. Character of urine such as color, clarity, and odor. 10. The name and title of the individual (s) who performed the procedure. Q. Review of the facility urinary procedure, dated revised September 2014, for Urinary Catheter Care revealed: Infection Control: Use standard precautions (infection prevention practices including handwashing and use of PPE (personal protective equipment--like gloves) when handling of manipulating the drainage system.

On 06/18/15 at 11:48 am, Resident (R) #2 was observed in the dining room with no pants or undergarments on. R #2 had only a blanket over her legs, leaving her left buttock, left and right hip, and stomach exposed through her wheelchair armrests. On 06/18/15 at 11:52 am, the Director of Nursing (DON) confirmed resident was exposed and took resident back to her room. While the DON wheeled R #2 out of the dining room to get some clothing, R #2 urinated on the floor in the dining room. None of the staff present noticed or tried to clean up urine on the floor. Multiple residents were observed walking by the urine on the floor. On 06/18/15 at 11:56 am, surveyor brought the urine to the DON's attention, where she confirmed the urine. On 06/18/15 at 12:04 pm, Housekeeping Supervisor #1 (HS #1) placed a caution wet floor sign over urine spot and left dinning all with the urine still on the floor. On 06/18/15 at 12:11 pm, HS #1 mopped up the urine on the floor. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 06/18/15 at 1:55 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included: 1. Resident was removed from the area and taken to her room. Resident was provided ADL care per care plan. Wheelchair was cleaned and disinfected. 2. Housekeeping immediately cleaned up the urine on floor and disinfected identified area. 3. Staff will continue to offer resident brief/undergarments to prevent urination on floor and document on treatment flow sheet of refusals. 4. Resident will be offered incontinence pads in wheelchair to absorb urine at all times including in the dining room and other common areas. Staff will do every 2 hour checks and will document on a paper flow sheet. 5. Staff will be educated on location of wet floor signs, location of mop buckets and the proper policy on cleaning spills or splashes of blood or bodily fluids by June 19, 2015. 6. Staff will be educated on care plan updates by June 19, 2015 Based on the Plan of Removal and observation, the IJ was lifted on 06/19/15 at 1:03 pm. This resulted in the scope and severity being reduced from a scope and severity of L to Level 2, Scope F. Based on observations, record review, and interview, the facility failed to ensure that residents were free from accident hazards when they 1) failed to monitor R #2 incontinence, 2) failed to identify and remove urine from the floor, and 3) failing to implement interventions allowing R #2 to continuously urinate on the floor. This deficient practice had the potential to affect all 82 resident in the facility, identified on the Facility Census List provided by the Administrator on 06/15/15, by residents slipping and falling on urine on the floor which is likely to result in injury. The findings are: Immediate Jeopardy A. On 06/18/15 at 11:48 am, an observation of the dining room revealed R #2 was seated at a table closest to the main entry/exit of the dining room, on one of the main pathways for residents and staff walking in and out of the dining room. R #2 was not wearing pants or undergarments. R #2 had only a blanket over her legs, leaving her left buttock, left and right hip and stomach exposed through her wheelchair armrests. B. On 06/18/15 at 11:52 am, during an interview with DON and observation of R #2 in the dining room, the (DON) confirmed resident was exposed and took resident back to her room. While the DON wheeled R #2 out of the dining room to get some clothing, a puddle of urine was observed underneath R #2's wheelchair in the dining room. Dining staff were at the opposite end of the dining room handing out food trays. R #19 was walking past the puddle leaving the dining room. Two other Random Residents (RR #1, RR #2) were observed walking past the puddle of urine out of the dining room. C. On 06/18/15 at 11:56 am, during observation, the urine was still on the floor and it was brought to the DON's attention. DON confirmed the presence of urine on the floor. DON left the dining room leaving the puddle of urine unattended. D. On 06/18/15 at 12:00 pm, during observation, R #19 entered the dining room walking past the unattended puddle. E. On 06/18/15 at 12:04 pm, HS #1 placed a caution wet floor sign over urine spot and left dinning all with the urine still on the floor. F. On 06/18/15 at 12:11 pm, HS #1 mopped up the urine on the floor. History G. On 06/15/15 at 1:30 pm, an observation and interview, R #2 stated Go get someone I just peed myself. A puddle of urine was observed under her wheelchair. H. On 06/16/15 at 2:09 pm, an observation of the resident hallway. R #2 came to her doorway and stated Can someone come help me? I peed the floor. I. On 06/18/15 at 11:33 am, an interview with Certified Nursing Aid #1 (CNA #1) stated Most of the time she (R #2) does not let us know when she needs to go to the bathroom. She only tells us after she has an accident. This happens on a daily basis. This has been going on for a couple months. She goes (urinates) on the bed or the wheelchair, anywhere. It could be anywhere in the facility. J. On 06/18/15 at 11:38 am, an interview with Licensed Practical Nurse #1 (LPN #1) stated She has issues going to the bathroom. She can get to the bathroom with help, but she will often have accidents once or twice a day. This has been going on for a few months. It usually happens in the TV room and hallway. K. On 06/18/15 at 11:51 am, an interview with the DON in her office stated the resident (R #2) refuses to wear attends and does urinate on the floor. It has been continuous since she came in. L. On 06/18/15 at 1:24 pm, an interview with CNA #1 stated When there is water on the floor, I feel if we don't have a sign, there is a concern (of someone falling). M. On 06/18/15 at 1:30 pm, an interview with the DON confirmed There is a concern for residents of visitors (slipping, falling and being exposed to urine and fecal matter). The real concern is when she started to urinate and stopped calling for staff help. She would be wet and she would not even know it. She has gotten to that level in the last 30 days. N. Record review of R #2's Care Plan dated 04/23/15 revealed incontinence and resistant to incontinence care. Approach. Allow resident to choose options. Reiterate the purpose and advantages of care. Resident has agreed to wear boxer briefs. Eliminate intake of fluids with dehydrating or irritating effects on bladder-resident. No other intervention were noted on R #2's care plan. O. Record review of the Resident Progress Notes revealed: 1. 04/04/15 at 7:14 pm, by LPN #2 revealed, Resident has reported 3 episodes of incontinent bowel movement. She was asked to wear pull up incontinent pads but has refused. Will continue to encourage resident to wear incontinence briefs. 2. 04/13/15 at 09:50 by Physician (P) #1 revealed (Name of R #2) who is c/o (complaining of) inability to control her urine. When she gets the urge she has to go immediately or she will soil herself. Urge/Stress incontinence. 3. 05/07/15 at 11:29 pm, by Registered Nurse (RN) #1 revealed Resident has had 3 showers today due to having 'accidents', a while ago, she's demanding another shower because she had another accident. She'll be given one but I asked her to wear pull ups to which she agreed. I informed DON about these and that social service needs to talk to her about it. 4. 05/21/15 at 11:24 pm, by RN #1 revealed Peed on the floor 3x (times) this evening shift and refused to wear pull ups. 5. 05/28/15 at 12:45 am, by RN #1 revealed Continues to pee on her pants, thrice since my shift started. Shower given, Refused to wear pull ups. 6. 06/04/15 at 2:48 am, by RN #1 revealed Incontinent of bowel and bladder. Constantly pees on herself, does not elect to wear pull ups. Occasionally poops on herself. 7. 06/05/15 at 10:43 pm, by RN #1 revealed Resident being rude to staff. Shower was given per request after peeing on her wheelchair. 8. 06/12/15 at 4:33 pm, by Executive Director (ED) revealed This worker spoke to the resident this week about unrealistic expectations. According to the report that this worker received from staff, Resident requested 3 baths each day on the week-end and told staff is (sic) they didn't give her one she would have a bowel movement so they would have to. This worker explained to patient that these needs cannot be met and if this is the level of care that she required I would have to discharge her to a more appropriate setting. Patient denied stating this but stated she understood the abilities of the facility. As a way of working with resident on putting on depends or undergarments to her urinating throughout the building. 9. 06/17/15 at 4:59 pm, by Social Services #1 revealed This worker spoke with rsd (resident) regarding the importance of her wearing her depends as she has being (sic) urinating on the floor and is causing a health concern for other rsds as well as staff, rsd was upset and asked why she had to wear them. This worker explained that because she is putting others at risk because she is urinating throughout the building. The DON and Administrator are asking if she would please comply as don't want to have to give her a 30 day notice as she is putting others at risk and that she will do it but she is not happy. P. Record review of Psychology Consult dated 02/25/15 revealed Reason for referral: Patient refuses to wear underwear or brief. Incontinent, and seems not to care. Manipulative behavior. She has [DIAGNOSES REDACTED]. Ability to engage in treatment based on: relational, oriented. Staff and/or family report the following about the pattern of symptomatology: Direct care staff know patient well, and are skeptical about behavior plan working. Goals, Objectives and Interventions: Psychotherapy .

On 06/18/15 at 11:48 am, R #2 was in the dining room with no pants or undergarments on. R #2 had only a blanket over her legs, leaving her left buttock, left and right hip, and stomach exposed through her wheelchair armrests. On 06/18/15 at 11:52 am, the Director of Nursing (DON) confirmed resident was exposed and took resident back to her room. While the DON wheeled R #2 out of the dining room to get some clothing, a puddle of urine was observed underneath R #2's wheelchair in the dining room. On 06/18/15 at 11:56 am, surveyor brought the urine to the DON's attention, where she confirmed the urine. On 06/18/15 at 12:04 pm, Housekeeping Supervisor #1 (HS #1) placed a caution wet floor sign over urine spot and left dinning all with the urine still on the floor. On 06/18/15 at 12:11 pm, HS #1 mopped up the urine on the floor. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 06/18/15 at 1:55 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included: 1. Resident was removed from the area and taken to her room. Resident was provided ADL care per care plan. Wheelchair was cleaned and disinfected. 2. Housekeeping immediately cleaned up the urine on floor and disinfected identified area. 3. Staff will continue to offer resident brief/undergarments to prevent urination on floor and document on treatment flow sheet of refusals. 4. Resident will be offered incontinence pads in wheelchair to absorb urine at all times including in the dining room and other common areas. Staff will do every 2 hour checks and will document on a paper flow sheet. 5. Staff will be educated on location of wet floor signs, location of mop buckets and the proper policy on cleaning spills or splashes of blood or bodily fluids by June 19, 2015. 6. Staff will be educated on care plan updates by June 19, 2015 Based on the Plan of Removal and observation, the IJ was lifted on 06/19/15 at 1:03 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope E. Based on record review and interview, the facility failed to revise care plans for 2 residents (R #2, and R #10) of 8 residents (R #2, R #10, R #35, R #79, R #107, R #120, R #126 and R #130) reviewed for incontinence and nutrition, when they 1) did not revise R #2's care plan to include interventions for urinary incontinence resulting in R #2 urinating on herself and on the floor daily and 2) did not revise R #10's care plan when there was a change in treatment orders. This deficient practice has the potential to cause physical and emotional harm to residents that did not have current interventions for revised care plans affecting safety of the resident and other residents. The findings are: Findings for Resident #2: A. On 06/15/15 at 1:30 pm, an observation and interview, R #2 stated Go get someone I just peed myself. A puddle of urine was observed under her wheelchair. B. On 06/16/15 at 2:09 pm, an observation of the resident hallway during medication administration revealed Take out. R #2 came to her doorway and stated Can someone come help me? I peed the floor. C. On 06/18/15 at 11:33 am, an interview with Certified Nursing Aid #1 (CNA #1) revealed Most of the time she (R #2) does not let us know when she needs to go to the bathroom. She only tells us after she has an accident. This happens on a daily basis. This has been going on for a couple months. She goes on the bed or the wheelchair, anywhere. It could be anywhere in the facility. D. On 06/18/15 at 11:38 am, an interview with Licensed Practical Nurse #1 (LPN #1) revealed She has issues going to the bathroom. She can get to the bathroom with help, but she will often have accidents once or twice a day. This has been going on for a few months. It usually happens in the TV room and hallway. E. On 06/18/15 at 11:48 am, an observation of the dining room revealed R #2 was seated at a table closest to the main entry/exit of the dining room, on one of the main pathways for residents and staff walking in and out of the dining room. R #2 was not wearing pants or undergarments. R #2 had only a blanket over her legs, leaving her left buttock, left and right hip and stomach exposed through her wheelchair armrests. F. On 06/18/15 at 11:51 am, an interview with the DON in her office revealed the resident (R #2) refuses to wear attends and does urinate on the floor. It has been continuous since she came in. G. On 06/18/15 at 11:52 am, during an interview with DON and observation of R #2 in the dining room, the (DON) confirmed resident was exposed and took resident back to her room. While the DON wheeled R #2 out of the dining room to get some clothing, a puddle of urine was observed underneath R #2's wheelchair in the dining room. Dining staff were at the opposite end of the dining room handing out food trays. R #19 was walking past the puddle leaving the dining room. Two other Random Residents (RR #1, RR #2) were observed walking past the puddle of urine out of the dining room. H. On 06/18/15 at 11:56 am, during observation, the urine was still on the floor and it was brought to the DON's attention. DON confirmed the presence of urine on the floor. I. Record review of R #2's Care Plan dated 04/23/15 revealed incontinence and resistant to incontinence care. Approach. Allow resident to choose options. Reiterate the purpose and advantages of care. Resident has agreed to wear boxer briefs. Eliminate intake of fluids with dehydrating or irritating effects on bladder-resident. No other intervention were noted on R #2's care plan. J. On 06/18/15 at 1:30 pm, an interview with the Director of Nursing (DON) confirmed that the care plan needed to be revised. K. On 06/19/15 at 10:44 am, an interview with Minimum Data Set Coordinator MDSC #1 stated These approaches (in R #2 Care Plan) do not say what we are going to do, they speak to what she (R #2) has done. Findings for Resident #10: L. Record review of R #10 care plan dated 05/21/15 revealed Problem Category: Nutritional Status (Name of R #10) is at risk for alteration in nutrition related to inconsistent PO intake, dementia, Alzheimer's and being hard of hearing (name of R #10) does have a fluctuating weight. GOAL (Name of R #10) will be without weight loss by next review in 90 days. Approach Provide additional nutrition via: med pass 4oz (ounces) TID (three times a day). M. Record review of physician's orders [REDACTED]. N. On 06/19/15 at 10:14 am, an interview with Certified Medical Aid #1 revealed, Resident is not receiving med pass. O. On 06/19/15 at 10:34 am, an interview with #1 (MDSC #1) revealed that (med pass) should have been taken off her care plan.

The facility failed to provide a pureed diet to 1 (R #44) of 1 (R #44) sampled residents on the locked Memory Care unit with swallowing difficulties. Resident #44 had [DIAGNOSES REDACTED]. On 08/20/14 at 4:32 pm, during/before the evening meal, Resident #44 was observed taking a hamburger off the plate of another resident with dementia and putting it into her mouth. One NA (nurse assistant) identified as NA #1 had observed this and did nothing. The other staff were observed continuing to pass out lunch trays. Resident #44 was observed to be pocketing the hamburger on the side of her cheek inside her mouth at this time. No staff at this time including the nurse on duty prevented the resident from putting the hamburger in her mouth. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 08/20/14 at 6:00 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included 1) holding a mandatory in-service, 2) assigning a charge nurse to all meals to monitor safety 3) validate diets are being followed, 4) a black napkin program to inform staff residents who are on a pureed diet, and 5) signs posted in dining rooms to alert families when bringing in food. Based on the Plan of Removal and observation, the IJ was lifted on 08/22/14 at 8:30 am. This resulted in the scope and severity being reduced from a scope and severity of J to Level 2, Scope D. Based on observation, record review, and interview, the facility failed to follow doctors order for a puree diet for 1 (R #44) of 1 (R #44) sample residents to prevent accidents such as choking. This deficient practice had the potential to affect residents at risk for choking. The findings are: A. On 08/20/14 at 4:32 pm, during observation of Resident #44 revealed the resident eating a hamburger in the dining room on the locked Memory Care unit, the following was noted: 1. NA #1 telling Resident #52's family member, (who brought in some hamburgers for R #52), that Resident #44 could not eat that food, (referring to a hamburger) because she, (Resident #44), is on a pureed diet. 2. In front of Resident #52's family member, there was an empty McDonald's bag. 3. Resident #44 was still observed eating the hamburger when NA #1 told the visitor that she (Resident #44) wasn't allowed to eat those foods. Resident #44 was observed holding and chewing the hamburger. 4. Staff were observed passing out meal trays to the rest of the resident's during this time, (and not addressing Resident #44). 5. At this time, the nurse (who was identified as Registered Nurse (RN) # 1 was observed to be sitting at a computer within the enclosed nurses station down the hall. B. Review of the medical record for Resident #44 indicated the following: 1. Face Sheet (no date) indicated Resident #44 had [DIAGNOSES REDACTED]. 2. Physician order [REDACTED]. Special Instructions: Monitor resident with snacks give puree snacks only with thin liquids." 3. Care Plan dated 06/13/14 indicated, "Problem: Nutritional Status...(Name of Resident #44)...needs assistance with meals. Staff are to follow diet as ordered and monitor and record intake of food all meals." 4. Care Plan dated 07/19/14 indicated, "(Name of Resident #44) is at risk for alteration in nutrition related to dx (diagnosis) of dementia, [DIAGNOSES REDACTED].#44) as needed with eating, serve diet as ordered. 5. Annual Minimum Data Set ((MDS) dated [DATE] indicated, Resident #44 is on a mechanically altered diet (referring to pureed food). C. On 08/20/14 at 4:32 pm during interview, RN #1 was asked what type of diet Resident #44 is on and RN #1 stated that, "She is pureed." D. On 08/20/14 at 4:33 pm, during interview and observation, RN #1 was asked if Resident #44 eating a hamburger would be bad. At this time RN #1 immediately got up from the computer, left the nurses station and went very quickly into the dining room. RN #1 went straight to Resident #44 and removed the small remaining piece of a hamburger from her hand. Resident #44's mouth was observed to be full of hamburger. RN #1 did not tell Resident #44 why he was taking the hamburger away or try taking what was in her (Resident #44's)mouth out to prevent her from choking. RN #1 was observed to just ask Resident #44 to give him the food. RN #1 was then observed asking a Nursing Assistant (NA) to bring in her (Resident #44's) pureed tray. During this time, RN #1 stated that, "(Resident #44) will wander and pick up food from other residents plates... Thank you for noticing." F. On 08/20/14 at 4:40 pm, during interview with RN #1, when asked if Resident #44 needs supervision while eating, RN #1 stated, "Not really. As long as they (visitor's) don't bring in food from the outside. She (Resident #44) mainly concentrates on liquids. She'll pick up someone's drink and drink it. Now that she's on a pureed diet, as long as she doesn't have solid foods within reach, she's ok." When asked why Resident #44 is on a pureed diet, RN #1 stated, "She has difficulty swallowing. She tends to choke on solid foods, well not choke, but cough. She can't swallow them appropriately." G. On 08/20/14 at 5:15 pm during interview, NA #1 indicated that they (referring to staff) told her that Resident #44 wasn't allowed to eat food like that (referring to a hamburger) because she (the resident) was on a pureed diet. NA #1 indicated that she was aware of what type of diet Resident #44 was on by stating, "I knew she was supposed to be on a pureed diet." H. On 08/20/14 at 5:20 pm, during interview RN #1 stated, "When the Surveyor came and got me and asked what diet is she (Referring to R #44) on, I said a pureed diet." When RN #1 was asked, How do they (the staff) know if a resident is on a pureed diet? he stated, "They know." When asked specifically how RN #1 stated, "Wow, that's a good question. I guess during their training. It's pretty much word of mouth. I don't know if we even have a list of pureed people... I'm not going to make one up, its too late, you already caught me." RN #1 then stated, "The care plan says that she (Resident #44) is at risk for alteration/nutrition and a hamburger would not fit into a pureed diet." I. On 08/20/14 at 5:25 pm, observation of the Memory Care food prep kitchen area where residents meals are posted on a dry erase board indicated Resident #44 was on a pureed diet. J. On 08/20/14 at 5:26 pm, during interview when food prep staff #1 was asked how do you know which residents are supposed to be on a certain diet, he stated, "We have meal tickets that says what diet they are on. She (Resident #44) is on a puree diet. That is also written on our board here (referring to the dry erase board)." K. On 08/20/14 at 6:12 pm, during interview regarding the incident that occurred with Resident #44, CNA #2 was asked what is Resident #44s diet, the CNA stated, "It's a puree." CNA #2 then stated, "Every now and again when she's (Resident #44) is eating her puree, she'll kinda cough. That's why we stay with her. We try to keep the purees at the same table, if they grab something off of someone else's plate." L. Review of the Facility Assistance with Meals Policy and Procedure revised October 2009 indicated, "Residents shall receive assistance with meals in a manner that meets the individual needs of each resident." M. Review of the Facility Foods brought by Family/Visitors Policy and Procedure revised December 2008 indicated, "Staff must be aware of, and approve, food(s) brought to a resident by family/visitors...The dietician or a nurse supervisor should assure that the food is not in conflict with the resident's prescribed diet plan...foods that present a potential choking hazard for residents with impaired cognitive function or swallowing difficulty will be taken from the resident..." Based on record review and interview, the facility failed to follow the plan of care to provide incontinence care after each episode for 1 (R #58) of 1(R #58) sampled residents reviewed. Resident #58 used the call light during the night shift and was left wet on multiple nights. This deficient practice may lead to skin breakdown, pain and distress for R #58. The findings are: A. Review of Resident #58's Face Sheet (no date) revealed the following Diagnosis: [REDACTED]. B. Review of the resident Care Plan dated 03/25/14 revealed the following: 1. "(Resident #58) is at risk for pressure ulcers R/T (related to) decreased mobility and incontinence of urine. Goal Target Date: 09/22/14 (Resident 58's) skin will remain intact by next review in 90 days. Provide incontinence care after each incontinent episode. Report any signs of skin breakdown (sore, tender, red, or broken areas). Keep clean and dry as possible. Minimize skin exposure to moisture. Conduct a systematic skin inspection weekly." 2. "(Resident #58) experiences bladder incontinence R/T involuntary loss of urine [MEDICAL CONDITION], diuretic use. Goal target date: 09/22/14 Provide incontinence care after each incontinent episode. Keep call light in reach. Report any signs of skin breakdown (sore, tender, red, or broken areas)." C. On 08/19/14 at 1:30 pm during interview with R #58 in her room the resident stated, "I was given Milk of Magnesia and had a loose stool around 3:00 am to 4:00 am on 08/18/14. I pushed my call light. Certified Nursing Assistant (CNA) #8 came in and I said that I need to be changed cause I'm dirty. She turned the light off and never did come back. I was in loose stool until right before morning shift change. I have a rash and now have developed sores where I am wet and in the creases of my upper thighs. They are putting the diaper on too tight or they are too small and tight on my rash area. On graveyard they only have two people on the whole floor including rooms 119-230, 130-219, 200-208. CNA #9 on graveyard didn't clean me well and just being wet has aggravated the rash and I now have sores in the crease of my thighs. Graveyard is very slow and sometimes does not respond to the call light. They bring in new girls that don't know what to do, how to clean me or help me. I often have to ask them to go get someone that actually knows what to do and show them what to do. I think that makes them mad. My roommate is a better helper than the CNAs. She does some of the stuff the CNAs should be doing. I push the button and she will go out and look for a CNA. Later on 08/19/14 at 2:00 pm, during interview when asked if the doctor has looked at the rash and sores from being wet R #58 stated, "The charge nurse looked at it and they are applying some cream." D. Review of Nurses Notes dated 08/14/14 at 3:30 pm revealed the following: "Resident (#58) is awake, alert, coherent and oriented to self and environment. Needs 2x (times) maximum assistance in all her ADLs (activities of daily living) and transfers... Is B&B (bowel and bladder) continent. Able to verbalize needs and thru call lights... Has some rashes in between her legs as seen by CNA when brief/pads were being changed in the morning verbalizing that they had been putting a smaller brief. Clazime (sic) lotion ([MEDICATION NAME], zinc oxide based paste) was applied in the affected area after every brief change..." E. Review of the Psychologist Progress Notes for R #58 dated 12/20/13 revealed the following: "She complains of trouble with the staff, she says she feels ignored when she uses the call light saying, 'They don't pay attention to me.'"

The facility failed to provide a pureed diet to 1 (R #44) of 1 (R #44) sampled residents on the locked Memory Care unit with swallowing difficulties. Resident #44 had [DIAGNOSES REDACTED]. On 08/20/14 at 4:32 pm, during/before the evening meal, Resident #44 was observed taking a hamburger off the plate of another resident with dementia and putting it into her mouth. One NA (nurse assistant) identified as NA #1 had observed this and did nothing. The other staff were observed continuing to pass out lunch trays. Resident #44 was observed to be pocketing the hamburger on the side of her cheek inside her mouth at this time. No staff at this time including the nurse on duty prevented the resident from putting the hamburger in her mouth. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 08/20/14 at 6:00 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included 1) holding a mandatory in-service, 2) assigning a charge nurse to all meals to monitor safety 3) validate diets are being followed, 4) a black napkin program to inform staff residents who are on a pureed diet, and 5) signs posted in dining rooms to alert families when bringing in food. Based on the Plan of Removal and observation, the IJ was lifted on 08/22/14 at 8:30 am. This resulted in the scope and severity being reduced from a scope and severity of J to Level 2, Scope D. Based on observation, record review, and interview the facility failed to ensure 1 (R #44) of 1 (R #44) sample residents received the necessary supervision to prevent accidents such as choking. The facility also failed to monitor residents in the dining room who had pureed diets and swallowing difficulties, and act immediately when the resident was at risk for choking. This deficient practice had the potential to affect residents at risk for choking. The findings are: A. On 08/20/14 at 4:32 pm, during observation of Resident #44 revealed the resident eating a hamburger in the dining room on the locked Memory Care unit, the following was noted: 1. NA #1 telling Resident #52's family member, (who brought in some hamburgers for R #52), that Resident #44 could not eat that food, (referring to a hamburger) because she, (Resident #44), is on a pureed diet. 2. In front of Resident #52's family member, there was an empty McDonald's bag. 3. Resident #44 was still observed eating the hamburger when NA #1 told the visitor that she (Resident #44) wasn't allowed to eat those foods. Resident #44 was observed holding and chewing the hamburger. 4. Staff were observed passing out meal trays to the rest of the resident's during this time, (and not addressing Resident #44). 5. At this time, the nurse (who was identified as Registered Nurse (RN) # 1 was observed to be sitting at a computer within the enclosed nurses station down the hall. B. Review of the medical record for Resident #44 indicated the following: 1. Face Sheet (no date) indicated Resident #44 had [DIAGNOSES REDACTED]. 2. Physician order [REDACTED]. Special Instructions: Monitor resident with snacks give puree snacks only with thin liquids." 3. Care Plan dated 06/13/14 indicated, "Problem: Nutritional Status...(Name of Resident #44)...needs assistance with meals. Staff are to follow diet as ordered and monitor and record intake of food all meals." 4. Care Plan dated 07/19/14 indicated, "(Name of Resident #44) is at risk for alteration in nutrition related to dx (diagnosis) of dementia, [DIAGNOSES REDACTED].#44) as needed with eating, serve diet as ordered. 5. Annual Minimum Data Set ((MDS) dated [DATE] indicated, Resident #44 is on a mechanically altered diet (referring to pureed food). C. On 08/20/14 at 4:32 pm during interview, RN #1 was asked what type of diet Resident #44 is on and RN #1 stated that, "She is pureed." D. On 08/20/14 at 4:33 pm, observation was made of Resident #44 still eating the hamburger and staff still not addressing the resident. At this time, observation revealed RN #1 was still sitting down the hall at the enclosed nurses station on the computer. RN#1 could not see R #44 from the nurses station. E. On 08/20/14 at 4:33 pm, during interview and observation, RN #1 was asked if Resident #44 eating a hamburger would be bad. At this time RN #1 immediately got up from the computer, left the nurses station and went very quickly into the dining room. RN #1 went straight to Resident #44 and removed the small remaining piece of a hamburger from her hand. Resident #44's mouth was observed to be full of hamburger. RN #1 did not tell Resident #44 why he was taking the hamburger away or try taking what was in her (Resident #44's)mouth out to prevent her from choking. RN #1 was observed to just ask Resident #44 to give him the food. RN #1 was then observed asking a Certified Nursing Assistant (CNA) to bring in her (Resident #44's) pureed tray. During this time, RN #1 stated that Resident #44, "Will wander and pick up food from other residents plates... Thank you for noticing." F. On 08/20/14 at 4:34 pm, a NA #1 was observed bringing out a tray of pureed food to Resident #44. G. On 08/20/14 at 4:34 pm during interview, RN #1 stated that she (Resident #44) probably got it (the hamburger) from her (Resident #52's) plate." H. On 08/20/14 at 4:40 pm, during interview with RN #1, when asked if Resident #44 needs supervision while eating, RN #1 stated, "Not really. As long as they (visitor's) don't bring in food from the outside. She (Resident #44) mainly concentrates on liquids. She'll pick up someone's drink and drink it. Now that she's on a pureed diet, as long as she doesn't have solid foods within reach, she's ok." When asked why Resident #44 is on a pureed diet, RN #1 stated, "She has difficulty swallowing. She tends to choke on solid foods, well not choke, but cough. She can't swallow them appropriately." When RN #1 was asked again if Resident #44 needed to be supervised during meals, he stated, "Not really. She does that often (referring to R #44 taking other resident's food or drinks). She mainly does it with liquids, not really foods. We normally sit them (residents)together, (referring to the pureed diets and the feeders). We try to put feeders (people who need assistance with meals) on either side of her (Resident #44)." RN #1 then stated, Resident #52 "Is not pureed. She is mech (mechanical) soft (a diet that is softer in texture than regular food). She (R #52) is not one we should have put next to her (R #44). What might have happened was her (R #52's family member) visited, and they just sat down beside her (R #44) and we didn't pick up on it. It's our fault." When asked if staff is aware of the seating arrangements, RN #1 stated, "They should be, but I will inservice them again today." I. On 08/20/14 at 5:15 pm during interview, NA #1 indicated that they (referring to staff) told her that Resident #44 wasn't allowed to eat food like that (referring to a hamburger) because she (the resident) was on a pureed diet. NA #1 indicated that she was aware of what type of diet Resident #44 was on by stating, "I knew she was supposed to be on a pureed diet." When NA #1 was asked if she noticed Resident #44 eating anything while talking to the family member of Resident #52, NA #1 stated,"The burger. It's not normal for her (to be eating it). Everybody said she (the resident) will be upset if we take it away from her, so I just left it to the other CNA's to take it away." NA #1 stated, what happened was, I noticed her (Resident #44) eating a hamburger, and I was told that she choked in the past. I didn't want her to choke, but everybody says that she will get upset if you take her food away. There was a lady sitting next to her and her (family member) brought in some food, and he offered her (Resident #44) one (hamburger) and she grabbed it. When I turned around, she was already eating it. I was the only one in the dining area at this time. The nurse was at the nurses station and the other staff were in the kitchen area. I was looking for everybody. This had been the first time I had seen her do this. When I told the staff, one CNA said 'just let her eat it. She will get upset if we take it away from her.' I couldn't find the nurse at the time." When NA #1 was asked if she was aware of staff having to sit next to Resident #44 because she like to grab things, NA #1 stated, "Nobody told me that." J. On 08/20/14 at 5:20 pm, during interview RN #1 stated, "I was doing paper work at the nurses station. When the Surveyor came and got me and asked what diet is she (Referring to R #44) on, I said a pureed diet. I went and got the hamburger from her (the resident). I noticed a McDonalds bag was on the table. One resident's husband had brought a meal in, and she (Resident #44) got a hold of it." When RN #1 was asked, how do you monitor for residents on special diets or family members who bring in food, RN #1 stated, "That is a good question." RN #1 then stated, "Normally she (Resident #44) sits with two pureed diets on either side of her (referring to sitting at the table with two other residents on pureed diets) so if she does reach for food, it's pureed. We try to keep pureed people at the first table. We don't have assigned seats we just monitor it." When RN #1 was asked, how do you monitor? RN #1 stated, "We just monitor to make sure she doesn't grab anything. Obviously, we didn't do a good job monitoring her today." When RN #1 was asked, How do they (the staff) know if a resident is on a pureed diet? he stated, "They know." When asked specifically how RN #1 stated, "Wow, that's a good question. I guess during their training. It's pretty much word of mouth. I don't know if we even have a list of pureed people..."I'm not going to make one up, its too late, you already caught me." RN #1 then stated, "The care plan says that she (Resident #44) is at risk for alteration/nutrition and a hamburger would not fit into a pureed diet." K. On 08/20/14 at 5:25 pm, observation of the Memory Care food prep kitchen area where residents meals are posted on a dry erase board indicated Resident #44 was on a pureed diet. L. On 08/20/14 at 5:26 pm, during interview when food prep staff #1 was asked how do you know which residents are supposed to be on a certain diet, he stated, "We have meal tickets that says what diet they are on. She (Resident #44) is on a puree diet. That is also written on our board here (referring to the dry erase board)." M. On 08/20/14 at 5:59 pm, during interview regarding the incident that occurred with Resident #44, CNA #1 stated, "I was running up and down the hall making sure everyone was out for dinner." CNA #1 indicated that she was not in the dining room at this time and, "Was in the hall as far as I know." When CNA #1 was asked, How do you monitor Resident #44 who is on a puree diet, she stated, "Just keeping an eye on her (Resident #44) from grabbing other peoples food. She is known for doing that." When CNA #1 was asked if she was aware of Resident #44's swallowing or choking issues, the CNA stated, "Yes." When CNA #1 was asked, How do you know if a resident is on a puree diet, she stated, "We have the tickets. It says their name, room number, if there is any diet restrictions, and what type of diet they're on." When CNA #1 was asked, What do you do if Resident #44 is eating solid foods, she stated "Be nice and try to get it away from her. Sometimes she'll get upset if you try to take it away." N. On 08/20/14 at 6:12 pm, during interview regarding the incident that occurred with Resident #44, CNA #2 stated, "I was walking out of the kitchen and I saw (name of NA #1) telling Resident #52's (family member) that (name of Resident #44) is on a pureed diet so she can't have things like that (referring to the hamburger). I was in and out of the kitchen at that time." When CNA #2 was asked what is Resident #44s diet, the CNA stated, "It's a puree." CNA #2 then stated, "Every now and again when she's (Resident #44) is eating her puree, she'll kinda cough. That's why we stay with her. We try to keep the purees at the same table, if they grab something off of someone else's plate." O. Review of the Facility Safety and Supervision of Residents Policy and Procedure revised December 2007 indicated, "Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. P. Review of the Facility Assistance with Meals Policy and Procedure revised October 2009 indicated, "Residents shall receive assistance with meals in a manner that meets the individual needs of each resident." Q. Review of the Facility Foods brought by Family/Visitors Policy and Procedure revised December 2008 indicated, "Staff must be aware of, and approve, food(s) brought to a resident by family/visitors...The dietician or a nurse supervisor should assure that the food is not in conflict with the resident's prescribed diet plan...foods that present a potential choking hazard for residents with impaired cognitive function or swallowing difficulty will be taken from the resident..."