Every finding on record at Parkdale Health and Rehab

Based on interviews, document review, and facility policy review, the facility failed to implement a quality assurance and performance improvement program to evaluate and monitor resident falls in the facility. This deficient practice had the potential to affect all residents who currently resided in the facility. Findings included: A facility policy titled, Quality Assessment and Assurance Plan, revised in December 2009, revealed, This facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assessment and Assurance Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. Policy Interpretation and Implementation The primary purposes of the Quality Assessment and Assurance Plan are: 1. To provide a means to identify and resolve present and potential negative outcomes related to resident care and safety. Per the policy, 2. The Administrator is responsible for assuring that this facility's Quality Assessment and Assurance Program complies with federal, state, and local regulatory agency requirements. An undated, untitled typed document presented to the survey team, revealed the facility held a quality assurance (QA) committee meeting on the second Tuesday of each month at 12:00 PM and the QA team lead was the Administrator. During an interview on 05/16/2024 at 12:33 PM, the Director of Nursing (DON) stated she had been working on getting together a QAPI for falls, but it was not currently in place. During a follow-up interview on 05/18/2024 at 6:41 PM, the DON stated the facility did not track and trend residents falls and they only reviewed the fall to make sure interventions were completed (implemented). During an interview on 05/18/2024 at 7:00 PM, the Administrator presented the survey team with a document that detailed a list of residents and when they had fallen. Per the document, during the timeframe of 11/20/2023 to 05/11/2024, Resident #16 had a total of 10 falls, with four of the falls being unwitnessed and Resident #28 had a total of nine falls, with one being an unwitnessed fall. The Administrator stated there was no evidence to indicate any tracking or trending of residents falls in the facility.

Based on interviews and facility policy review, the facility failed to conduct mandatory training for all staff on the facility's quality assurance and performance improvement (QAPI) program. This deficient practice affected all residents who currently resided in the facility, Findings included: A facility policy titled, Quality Assessment and Assurance Plan, revised in December 2009, revealed, This facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assessment and Assurance Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. The policy did not address staff training on the facility's QAPI program. During an interview on 05/17/2024 at 5:00 PM, the Director of Nursing (DON) stated there was not specific staff training on QAPI. During an interview on 05/18/2024 at 9:15 AM, the Administrator stated there had not been any staff training on QAPI. During an interview on 05/18/2024 at 9:35 AM, [NAME] Aide #17 stated he was not sure what QAPI was and had not received any training on it. During an interview on 05/18/2024 at 9:41 AM, Certified Nursing Assistant #18 stated she did not know what QAPI was. During an interview on 05/18/2024 at 9:44 AM, Housekeeper #19 stated she had no idea what QAPI was and had never been talked to about it. During a follow-up interview on 05/18/2024 at 11:19 AM, the DON stated she was not aware QAPI training was required for all staff and it was missed because it was not on their policy. During a follow-up interview on 05/18/2024 at 12:07 PM, the Administrator stated she was not aware QAPI training was required for all staff.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to develop a care plan to address the supplemental oxygen usage for 4 (Residents #1, #8, #11, #23) of 6 sampled residents reviewed for respiratory care and a care plan to address the fall status of 1 (Resident #16) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Care Plans, Comprehensive Person - Centered, revised in January 2024, revealed, A comprehensive, person-centered care plan that includes measurable objective and timetables to meet resident's physical, psychological and functional needs is developed and implemented for each resident. The policy specified, 1. An Admission Record revealed the facility readmitted Resident #23 on 04/05/2024, with diagnoses to include acute respiratory failure with hypoxia and congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. had intact cognition. The MDS revealed the resident used oxygen therapy. Resident #23's care plan, with an admitted [DATE], revealed no evidence of a care plan that addressed the resident's use of supplemental oxygen. On 05/13/2024 at 9:18 AM and 11:52 AM, the surveyor observed an oxygen tank/cylinder in Resident #23's room. During an interview on 05/16/2024 at 1:32 PM, the Director of Nursing (DON) stated Resident #23 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/16/2024 at 1:43 PM, the Administrator stated Resident #23 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/17/2024 at 1:29 PM, the MDS Coordinator stated Resident #23 did not have a care plan for their use of supplemental oxygen. During a follow-up interview on 05/17/2024 at 1:07 PM, the DON stated Resident #23 did not have a care plan to address their use of supplemental oxygen. 2. An Admission Record revealed the facility admitted Resident #8 on 01/19/2024, with diagnoses to include acute respiratory failure with hypoxia, emphysema, pneumonia, and shortness of breath. An admission Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 02/24/2024, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident moderate cognitive impairment. The MDS revealed the resident used oxygen therapy. Resident #8's care plan, with an admitted [DATE], revealed no evidence of a care plan that addressed the resident's use of supplemental oxygen. On 05/13/2024 at 9:29 AM and 05/14/2024 at 10:16 AM, the surveyor observed Resident #8 had supplemental oxygen on by way of a nasal canula and the oxygen concentrator was in the on position, set a three and a half liters per minute. During an interview on 05/16/2024 at 1:32 PM, the Director of Nursing stated Resident #8 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/16/2024 at 1:43 PM, the Administrator stated Resident #8 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/17/2024 at 1:43 PM, the MDS Coordinator stated Resident #8 did not have a care plan that addressed their supplemental oxygen usage. 46863 3. An Admission Record revealed the facility readmitted Resident #16 on 03/22/2024, with diagnoses to include disruption of wound, abnormal posture, and repeated falls. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS revealed the resident had one fall in the last month, one fall in the last two to six months, and one fracture related to a fall in the six months. Resident #16's care plan, initiated on 08/13/2022 and cancelled on 03/22/2024, revealed the resident was at high risk for falls per the standardized fall scale, gait/balance problems, paralysis, and being unaware of their safety needs. Resident #16's CAA [care area assessment] Worksheet, signed by the MDS Coordinator and dated 04/15/2024, revealed falls/functional status of the resident would be addressed in the resident's care plan. Resident #16's comprehensive care plan, with an admitted [DATE], revealed no current care plan with goals or interventions that addressed the resident's falls/functional status. During an interview on 05/17/2024 at 9:01 AM, the Director of Nursing (DON) stated the MDS Coordinator was responsible for residents' care plan. Per the DON, care plans should be developed and/or updated on admission, quarterly, and when there was a significant change in a resident's status. During an interview on 05/18/2024 at 12:09 PM, the Administrator stated she deferred care plan questions to the DON and MDS Coordinator as she did not know what all was obligated to be placed in a resident's care plan. During an interview on 05/18/2024 at 1:04 PM, the MDS Coordinator stated she was responsible for the completion of a resident's comprehensive care plan. The MDS Coordinator acknowledged Resident #16 should have had a care plan that addressed falls upon readmission to the facility. 4. An Admission Record revealed the facility admitted Resident #11 on 04/16/2024, with diagnoses to include chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, pneumonia, and bronchitis. An admission Minimum Data Set (MDS), with an Assessment References Date (ARD) of 04/22/2024, revealed Resident #11 used oxygen therapy. Resident #11's care plan, with an admitted [DATE], revealed no evidence of a care plan that addressed the resident's use of supplemental oxygen. On 05/13/2024 at 11:50 AM, Resident #11 was observed lying in bed with oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. On 05/18/2024 at 9:53 AM, Resident #11 was observed in the hall by the nurses' station. The resident had oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. During an interview on 05/14/2024 at 3:12 PM, the Director of Nursing (DON) stated Resident #11 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/14/2024 at 3:13 PM, the Administrator stated Resident #11 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/14/2024 at 4:03 PM, Licensed Practical Nurse #9 stated Resident #11 wore supplemental oxygen all the time. During a follow-up interview on 05/18/2024 at 12:09 PM, the Administrator stated she would expect a resident's use of supplemental oxygen to be addressed on the resident's care plan. During an interview on 05/18/2024 at 1:04 PM, the MDS Coordinator stated she was responsible for the completion of a resident's comprehensive care plan. Per the MDS Coordinator, Resident #11's use of supplemental oxygen should be care planned. 46565 5. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2024, revealed the facility admitted Resident #1 on 03/13/2024. Per the MDS, the resident had active diagnoses to include chronic obstructive pulmonary disease and asthma. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Per the MDS, the resident used oxygen therapy. Resident #1's Order Recap Report, for the timeframe 03/01/2024 to 05/31/2024, revealed an order dated 03/27/2024, for continuous supplemental oxygen by way a nasal cannula at two to five liters per minute. Resident #1's comprehensive care plan did not reveal evidence to indicate the resident had a care plan that addressed their supplemental oxygen usage. On 05/13/2024 at 9:41 AM and 05/16/2024 at 1:21 PM, the surveyor observed Resident #1 with supplemental oxygen on. During an interview on 05/18/2024 at 1:04 PM, the MDS Coordinator stated she was responsible for the completion of a resident's comprehensive care plan. Per the MDS Coordinator, a resident's use of supplemental oxygen should be care planned. During an interview on 05/18/2024 at 12:09 PM, the Administrator stated she would expect a resident's use of supplemental oxygen to be addressed on the resident's care plan.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure adequate supervision was provided to maintain safety and prevent potential injury during smoke breaks for 1 (Resident #1) of 4 sampled residents reviewed for accidents. On 05/14/2024 at 11:57 AM, Resident #1 was smoking outside in the designated smoking area with a portable oxygen tank on the back of their wheelchair and, a nearby propane tank. The facility further failed to ensure 2 (Resident #16 and Resident #28) of 4 sampled residents reviewed for accidents received adequate supervision and/or assistive devices to prevent falls. Findings included: 1. A facility policy titled, Smoking Policy - Residents, revised in August 2022 revealed, 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Electronic cigarettes are permitted in designated areas only. Smoking is not allowed inside the facility under any circumstances. 3. Oxygen use is prohibited in smoking areas. Per the policy, 11. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. An Admission Record revealed the facility initially admitted Resident #1 on 05/12/2023, with a medical history that included diagnoses of chronic obstructive pulmonary disease, moderate asthma, obstructive sleep apnea, and nicotine dependence, cigarettes. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed Resident was a current tobacco user and used oxygen therapy. Resident #1's care plan, initiated on 03/13/2024 and revised on 05/03/2024, revealed the resident was a smoker. The goals of the care plan were the resident would not suffer an injury from unsafe smoking practices and would not smoke without supervision. Resident #1's Order Recap Report for the timeframe 03/01/2024 through 05/31/2024, revealed an order dated 03/27/2024, for continuous supplemental oxygen at two to five liters per nasal cannula. Resident #1's NSG [nursing]: Additional Admission Assessments, dated 03/13/2024, revealed the resident smoked and there was a goal that specified the resident would not smoke without supervision. On 05/14/2024 at 11:57 AM, the surveyor observed a sign on a door in the dining room that led to the smoking area that specified, No Oxygen Beyond This Point. The surveyor noted Resident #1 was outside smoking and their oxygen tank was on the back of their wheelchair in the off position and the resident's nasal cannula rested on their left chest area. Resident #1 informed the surveyor that no staff went outside in the designated smoke area, so they could smoke. The surveyor noted another ashtray was about five to 10 feet from Resident #1 and that ashtray touched an outdoor grill that had an attached propane tank. During an interview on 05/14/2024 at 12:47 PM, the Administrator and Director of Nursing (DON) stated they were aware of the issue in the smoking area and they were changing their smoking policy immediately. Per the Administrator and the DON, the maintenance staff would lock the back door so that all residents who smoke would have to be let out by staff. They both stated oxygen tanks were normally taken off the back of the wheelchair and left in the resident's room. Per the Administrator and DON, they were not sure what happened and acknowledged staff did not have their eyes on Resident #1 and that was where the breakdown occurred. During an interview on 05/15/2024 at 1:07 PM, Certified Nursing Assistant (CNA) #11 stated when Resident #1 came for their cigarettes, she usually took the resident's oxygen tank off in the resident's room, but it was lunch time and busy and she overlooked it on 05/14/2024. During an interview on 05/14/2024 at 1:12 PM, Resident #1 stated once or twice they forgot to turn off their oxygen tank before they started to smoke a cigarette. Resident #1 stated no one had ever asked them to put their oxygen tank in a holder inside the facility prior to going outside to smoke. During an interview on 05/14/2024 at 2:39 PM, Registered Nurse (RN) #1 stated she completed Resident #1's smoking assessment when the resident admitted to the facility. RN #1 stated that, according to the assessment, a staff member should be outside supervising Resident #1 while the resident smoked. RN #1 stated that Resident #1's oxygen should be turned off and removed from the wheelchair prior to Resident #1 going outside to smoke, but since Resident #1 returned on 04/27/2024, staff did not ensure the resident's oxygen tank was removed during smoke breaks. During an interview on 05/14/2024 at 3:10 PM, Licensed Practical Nurse (LPN) #9 stated Resident #1's oxygen tank should not have been on the resident's wheelchair when the resident went outside to smoke as that is a huge safety risk. According to LPN #9, it had been Resident #1's practice to leave their oxygen tank on the back of the wheelchair and turn it off when they went outside to smoke; however, he was unsure if it was safe for the resident to do that on their own. 28193 2. A facility policy titled Fall and Fall Risk, Managing, revised in March 2018, revealed Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. An Admission Record revealed the facility originally admitted Resident #28 on 08/20/2023, with diagnoses to include abnormalities of gait and mobility, abnormal posture, fall on the same level, and polyneuropathy. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required substantial/maximal assistance with sit to stand and chair/bed-to-chair transfers. Per the MDS, the resident had one fall in the last month, one fall in the last two to six months, and a fracture related to a fall in the last six months. Resident #28's care plan initiated on 02/01/2024, revealed the resident was at risk for falls per the standardized fall scale. An incident report dated 04/04/2024, revealed Resident #28 was found on the floor next to their bed. Per the incident report, the resident stated did not remember if they hit their head. The incident report revealed the resident would be sent to the hospital for further evaluation to rule out internal injuries and/or fractures. Resident #28's History and Physical, from the local hospital with an admitted [DATE], revealed the resident presented to the hospital after they had a fall. Per the History and Physical, the resident was found to have a thoracic (T) 9 through T11 rib fracture with a subpleural hematoma. Resident #28's care plan initiated on 02/01/2024, revealed the resident was at risk for falls per the standardized fall scale. Interventions initiated on 04/05/2024, revealed the Medical Doctor would review the resident's medication regimen. During an interview on 05/15/2024 at 10:42 AM, the Director of Nursing stated there was not a medication review done after the resident fell on [DATE] to determine if some of the resident's ordered medication attributed to their fall. During an interview on 05/16/2024 at 12:44 PM, the Administrator stated not following up on falls and implementing interventions could result in serious injuries and/or death of a resident. 46863 3. A facility policy titled, Fall and Fall Risk, Managing, revised in March 2018, revealed, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. An Admission Record revealed the facility readmitted Resident #16 on 03/22/2024, with diagnoses to include disruption of wound, abnormal posture, and repeated falls. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS revealed the resident had one fall in the last month, one fall in the last two to six months, and one fracture related to a fall in the six months. On 05/14/2024 on 11:54 AM, the surveyor observed a transfer pole (a floor to ceiling grab bar that provided support for sitting, standing, or transferring from one place to another) on the right side of the resident's bed. An incident report dated 03/24/2024 at 5:05 PM, revealed Resident #16 had an unwitnessed fall in their room that resulted in a bruise to the top of the head, bruising above and around the right eye, and a small hematoma around the right eyebrow. Per the incident report, the resident stated they lost their balance. Resident #16's Incident Audit Report, for the unwitnessed fall the resident sustained on 03/24/2024 at 5;05 PM, revealed the resident stated as they attempted to transfer themself to their bed, with the use of the transfer pole in their room, they lost their balance and fell . Per the Incident Audit Report, an intervention after the fall was to have the maintenance and therapy staff evaluate the transfer pole for appropriate placement and resident safety during transfers as the staff and the resident reported the transfer pole needed to be two to three inches closer to the resident's bed. During an interview on 05/15/2024 at 7:52 AM, the Administrator stated prior to Resident #16's readmission to the facility on [DATE], the transfer pole was reinstalled in the resident's rom. Per the Administrator, the best placement of the transfer pole was not evaluated. During an interview on 05/16/2024 at 1:58 PM, the Director of Rehabilitation (DOR) stated the maintenance staff ordered the transfer pole and he in Resident #16's room when the transfer pole was installed prior to the resident being readmitted to the facility. The DOR stated he was unable to provide documentation to indicate the facility determined Resident #16 was safe to use transfer pole. During a follow up interview on 05/18/2024 at 12:09 PM, the Administrator stated she expected for there to be an assessment of the resident before a transfer pole was installed in their room. The Administrator stated the transfer pole was a good intervention as it had worked in the past; however, it was a bad call to have the transfer pole installed before the resident was assessed to be able to use it when they readmitted to the facility in March 2024.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure respiratory equipment was stored in a manner to prevent the spread of infection for 4 (Residents #8, #11, #21, and #23) of 6 sampled residents reviewed for respiratory care. Findings included: The facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised in January 2024, revealed The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The policy specified, 8. Keep the oxygen canulae and tubing used PRN [pro re nata, a Latin phrase that meant as the circumstances arises] off floor or in a plastic bag when not in use. 1. An Admission Record revealed the facility readmitted Resident #23 on 04/05/2024, with diagnoses to include acute respiratory failure with hypoxia and congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. had intact cognition. The MDS revealed the resident used oxygen therapy. During an observation on 05/13/2024 at 11:52 AM, Resident #23's oxygen tubing and nasal cannula were observed wrapped around the resident's bed rails and uncovered. attached the oxygen concentrator and uncovered, while the resident was noted in the dining room. During an observation on 05/14/2024 at 11:53 AM, Resident #23's nasal cannula and tubing was uncovered on the back of the resident's chair. During an interview on 05/14/2024 at 4:47 PM, Resident #23 stated there use to be a bag to store their nasal cannula and oxygen tubing in, but the bag disappeared some time ago. During an interview on 05/17/2024 at 1:07 PM, the Director of Nursing (DON) stated oxygen tubing should be off the floor and in a bag. The DON stated her expectation was for the nurses and aides to place the oxygen tubing and nasal cannula in the bags provided to keep them covered and clean to help prevent respiratory infections. 2. An Admission Record revealed the facility admitted Resident #8 on 01/19/2024, with diagnoses to include acute respiratory failure with hypoxia, emphysema, pneumonia, and shortness of breath. An admission Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 02/24/2024, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident moderate cognitive impairment. The MDS revealed the resident used oxygen therapy. During an observation on 05/13/2024 at 9:29 AM, Resident #8 had on a nasal cannula that was attached to an oxygen concentrator in their room; however, there was another nasal cannula and oxygen tubing wrapped around the top of the oxygen cylinder that was uncovered. During an observation on 05/13/2024 at 11:59 AM, Resident #8's nasal cannula and tubing remained wrapped around the top of the oxygen cylinder, on the back of the wheelchair, uncovered. During an observation on 05/14/2024 at 10:16 AM, Resident #8's oxygen tubing and nasal cannula remained wrapped around the oxygen cylinder, uncovered. During an observation on 05/14/2024 at 4:12 PM, Resident #8's nasal cannula and tubing wrapped around the oxygen cylinder, uncovered. During an interview on 05/17/2024 at 1:07 PM, the Director of Nursing (DON) stated oxygen tubing should be off the floor and in a bag. The DON stated her expectation was for the nurses and aides to place the oxygen tubing and nasal cannula in the bags provided to keep them covered and clean to help prevent respiratory infections. 46863 3. An Admission Record revealed the facility admitted Resident #11 on 04/16/2024, with diagnoses to include chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, pneumonia, and bronchitis. An admission Minimum Data Set (MDS), with an Assessment References Date (ARD) of 04/22/2024, revealed Resident #11 used oxygen therapy. On 05/13/2024 at 9:56 AM, the surveyor observed Resident #11's oxygen tubing was not stored in a bag and attached to an oxygen concentrator. On 05/13/2024 at 11:52 AM, the surveyor observed Resident #11's nasal cannula directly touched the metal part of the oxygen concentrator and the oxygen tubing was not stored in a bag. During an interview on 05/17/2024 at 4:05 PM, Licensed Practical Nurse (LPN) #2 stated oxygen tubing should be kept off the floor. Per LPN #2, ideally oxygen tubing should be coiled and kept somewhere it would not get dirty. During an interview on 05/17/2024 at 4:28 PM, Registered Nurse (RN) #3 stated oxygen tubing should not touch the floor. Per RN #3, the facility had no bags to store oxygen tubing. During an interview on 05/18/2024 at 10:48 AM, the Interim Medical Director stated ideally oxygen tubing should not touch the floor and it should not encounter high contact surfaces such as a resident's wheelchair handles. During an interview on 05/18/2024 at 12:09 PM, the Administrator stated she would expect oxygen tubing to not touch the floor and for the nasal cannula to not touch high-touched surface areas. 47914 4. An Admission Record revealed the facility admitted Resident #21 on 03/21/2023, with a diagnosis to include shortness of breath. Per the Admission Record, on 05/10/2024, Resident #21 received a diagnosis of chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2024, revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident used oxygen therapy. Resident #21's care plan, initiated on 03/29/2023, revealed the resident had shortness of breath. Resident #21's Order Summary Report, that contained active orders as of 05/17/2024, revealed an order dated 08/29/2023, for ipratropium-albuterol inhalation solution, inhale three milliliters orally by way of nebulizer every six hours as needed for chronic obstructive pulmonary exacerbation. On 05/13/2024 at 10:05 AM and 05/16/2024 at 9:00 AM, Resident #21's nebulizer was observed uncovered on the resident's nightstand. During an interview on 05/17/2024 at 1:07 PM, the Director of Nursing stated bags were purchased for all residents to store their oxygen equipment when not in use, so she did not know why there was not a bag in Resident #21's room to store their oxygen equipment.

Based on observations, interviews, and record reviews, the facility failed to ensure there was a physician's order for the use of supplemental oxygen for 3 (Residents #8. #11, and #23) of 6 sampled residents reviewed for respiratory care. Findings included: 1. An Admission Record revealed the facility admitted Resident #8 on 01/19/2024, with diagnoses to include acute respiratory failure with hypoxia, emphysema, pneumonia, and shortness of breath. An admission Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 02/24/2024, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident moderate cognitive impairment. The MDS revealed the resident used oxygen therapy. Resident #8's Order Summary Report, with active orders as of 05/13/2024, did not reveal a physician's order for the resident's use of supplemental oxygen. On 05/13/2024 at 9:29 AM and 05/14/2024 at 10:16 AM, the surveyor observed Resident #8 had supplemental oxygen on by way of a nasal canula and the oxygen concentrator was in the on position, set a three and a half liters per minute. During an interview on 05/16/2024 at 1:32 PM, the Director of Nursing (DON) stated Resident #8 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/16/2024 at 1:43 PM, the Administrator stated Resident #8 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/17/2024 at 1:48 PM, the MDS Coordinator stated there were only two people at the facility who looked at the physician's orders, so apparently either she or the DON missed the physician's order for Resident #8's supplemental oxygen use. During a follow-up interview on 05/17/2024 at 1:07 PM, the DON acknowledged Resident #8 did not have a physician's order for their supplemental oxygen use. Per the DON, it was an oversight on the part of the admission nurse. 2. An Admission Record revealed the facility readmitted Resident #23 on 04/05/2024, with diagnoses to include acute respiratory failure with hypoxia and congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. had intact cognition. The MDS revealed the resident used oxygen therapy. Resident #23's Order Summary Report, with active orders as of 05/13/2024, did not reveal a physician's order for the resident's use of supplemental oxygen. On 05/13/2024 at 9:18 AM and 11:52 AM, the surveyor observed an oxygen tank/cylinder in Resident #23's room. During an interview on 05/16/2024 at 1:32 PM, the Director of Nursing (DON) stated Resident #23 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/16/2024 at 1:43 PM, the Administrator stated Resident #23 had received supplemental oxygen ever since they admitted to the facility. During an interview on 05/17/2024 at 1:29 PM, the MDS Coordinator acknowledged there was no physician's order for Resident #23's use of supplemental oxygen. During a follow-up interview on 05/17/2024 at 1:07 PM, the DON acknowledged Resident #23 did not have a physician's order for their supplemental oxygen use. Per the DON, it was an oversight on the part of the admission nurse. 46863 3. An Admission Record revealed the facility admitted Resident #11 on 04/16/2024, with diagnoses to include chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, pneumonia, and bronchitis. An admission Minimum Data Set (MDS), with an Assessment References Date (ARD) of 04/22/2024, revealed Resident #11 used oxygen therapy. Resident #11's Order Summary Report, for the timeframe 04/16/2024 to 05/31/2024, did not reveal a physician's order for the resident's use of supplemental oxygen. On 05/13/2024 at 11:50 AM, Resident #11 was observed lying in bed with oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. On 05/18/2024 at 9:53 AM, Resident #11 was observed in the hall by the nurses' station. The resident had oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. During an interview on 05/14/2024 at 3:12 PM, the Director of Nursing (DON) stated Resident #11 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/14/2024 at 3:13 PM, the Administrator stated Resident #11 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/14/2024 at 4:03 PM, Licensed Practical Nurse #9 stated Resident #11 wore supplemental oxygen all the time. During an interview on 05/18/2024 at 10:48 AM, the interim Medical Director stated the staff should not administer supplemental oxygen to a resident without a physician's order. During a follow-up interview on 05/18/2024 at 12:09 PM, the Administrator stated there should be a physician's order for Resident #11's use of supplemental oxygen. During a follow-up interview on 05/18/2024 at 11:18 PM, the DON stated there should be a physician's order for Resident #11's use of supplemental oxygen. Per the DON, the staff failed to ensure the physician's order.

Based on interviews, record reviews, and facility policy review, the facility failed to conduct neurological assessments following unwitnessed falls for 2 (Resident #16 and Resident #28) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Neurological Assessment, revised in October 2010, revealed, The purpose of this procedure is to provide guidelines for a neurological assement:1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition. 1. An Admission Record revealed the facility originally admitted Resident #16 on 08/11/2022, with diagnoses to include abnormal posture, hypertension, and personal history of traumatic brain injury. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS revealed the resident required substantial/maximal assistance with sit to stand, sit to lying, and chair/bed-to-chair transfers. The MDS revealed the resident had one fall in the last month, one fall in the last two to six months, and one fracture related to a fall in the six months. Resident #16's care plan, initiated on 08/13/2022 and cancelled on 03/22/2024, revealed the resident was at high risk for falls per the standardized fall scale, gait/balance problems, paralysis, and being unaware of their safety needs. An incident report dated 11/23/2023 at 9:25 PM, revealed Resident #16 had an unwitnessed fall in their room. Per the incident report, the resident reported they attempted to transfer themselves to bed and fell to floor. The incident report, the resident denied they hit their head. An incident report dated 01/03/2024 at 3:15 PM, revealed Resident #16 had an unwitnessed fall in their room. Per the incident report, the resident stated they tried to transfer themself to their chair, when their leg became weak, so they sat on the floor. An incident report dated 01/07/2024 at 2:10 PM, revealed Resident #16 was found lying on the floor in front on their bed. Per the incident report, the resident reported as they reached for their wheelchair, they lost their balance and fell . An incident report dated 01/14/2024 at 7:32 PM, revealed a registered nurse (RN) entered Resident #16's room and found the resident on the floor. Per the incident report, the resident stated when they tried to transfer themselves, they stood up, lost their balance, and fell to the floor. Resident #16's medical record revealed no evidence to indicate the facility conducted neurological assessments after the resident had unwitnessed falls on 11/23/2023, 01/03/2024, 01/07/2024, and 01/14/2024. During an interview on 05/15/2024 at 9:27 AM, the Administrator stated neurological checks should be done immediately for all unwitnessed falls. During an interview on 05/15/2024 at 11:26 AM, the MDS Coordinator stated facility staff had been unable to locate the neurological assessment documentation for when Resident #16 had an unwitnessed fall on 01/032024. The MDS Coordinator stated a neurological assessment was not conducted when Resident #16 had witnessed falls on 01/07/2024 and 01/14/2024. Per the MDS Coordinator a neurological assessment should be conducted for 72 hours after a resident experienced an unwitnessed fall. During a telephone interview on 05/16/2024 at 5:08 PM, RN #5 stated a neurological assessment should be conducted for 72 hours after a resident had an unwitnessed fall. During an interview on 05/17/2024 at 11:05 AM, the Director of Nursing stated neurological checks should be completed for 72 hours after the resident sustained an unwitnessed fall. The DON acknowledged neurological checks were not done and they should have been. During an interview on 05/17/2024 at 4:28 AM, RN #3 stated neurological assessments should be conducted whenever a resident had an unwitnessed fall. 28193 2. An Admission Record revealed the facility originally admitted Resident #28 on 08/20/2023, with diagnoses to include abnormalities of gait and mobility, abnormal posture, fall on the same level, and polyneuropathy. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2024, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident required substantial/maximal assistance with sit to stand and chair/bed-to-chair transfers. Per the MDS, the resident had one fall in the last month, one fall in the last two to six months, and a fracture related to a fall in the last six months. Resident #28's care plan initiated on 02/01/2024, revealed the resident was at risk for falls per the standardized fall scale. An incident report dated 04/04/2024, revealed Resident #28 was found on the floor next to their bed. Per the incident report, the resident stated did not remember if they hit their head. Resident #28's medical record revealed no evidence to indicate the facility conducted neurological assessments after the resident had an unwitnessed fall on 04/04/2024. During an interview on 05/16/2024 at 12:33 PM, the Director of Nursing (DON) stated neurological checks were to be completed after an unwitnessed fall per the facility policy and were to be continued for three days post fall. The DON stated she was aware that currently, very few neurological checks were being completed after a resident had an unwitnessed fall. The DON stated she expected the staff to follow the policy and non-compliance could result in serious injury and/or death.

Based on interviews, record review, and facility policy review, the facility failed to notify the physician after a resident sustained a fall for 1 (Resident #16) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Change in a Residents Condition or Status, revised in May 2024, revealed, Policy Statement Our facility promptly notifies the resident, his or her attending physician, and resident representative 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 a(n): a. accident or incident involving the resident. An Admission Record revealed the facility originally admitted Resident #16 on 08/11/2022, with diagnoses to include abnormal posture, hypertension, and personal history of traumatic brain injury. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS revealed the resident had one fall in the last month, one fall in the last two to six months, and one fracture related to a fall in the six months. Resident #16's care plan, initiated on 08/13/2022 and cancelled on 03/22/2024, revealed the resident was at high risk for falls per the standardized fall scale, gait/balance problems, paralysis, and being unaware of their safety needs. Resident #16's incident report dated 11/23/2023, revealed the resident was found lying on the floor near their bed. According to the incident report, the resident stated they attempted to transfer themselves from the bed and fell to the floor. Per the incident report, there were no agencies or people notified of the resident's fall. Resident #16's incident report dated 01/07/2024, revealed the resident was found lying on the floor in front of their bed. According to the incident report, the resident stated as they reached for their wheelchair, they lost their balance and fell on to the buttocks. Per the incident report, the Administrator and Director of Nursing (DON) were notified of the resident's fall. During an interview on 05/13/2024 at 11:29 PM, Resident #16 stated they had fallen twice recently. During an interview on 05/16/2024 at 5:34 PM, the interim Medical Director stated she expected to be notified of every fall a resident had. During an interview on 05/17/2024 at 11:05 AM, the DON stated the physician should be notified of the resident's falls. During a follow-up interview on 05/17/2024 at 11:34 AM, the DON stated she did not find evidence to indicate the physician was notified of Resident #16's fall that occurred on 11/23/2023 and 01/07/2024. During an interview on 05/17/2024 at 4:28 AM, Registered Nurse #3 stated when a resident had a fall, the staff were expected to notify the DON, Administrator, the resident's emergency contact, and the physician. During an interview on 05/18/2024 at 12:09 PM, the Administrator stated she expected staff to notify her, the DON, and the physician when a resident fell .

Based on interviews, record reviews, and facility policy review, the facility failed to ensure an appropriate diagnosis was obtained for all psychotropic medications ordered for 2 (Resident #7 and Resident #11) of 5 sampled residents reviewed for unnecessary medication, psychotropic medications, and medication regimen review. Findings included: A facility policy titled, Psychotropic Medication Use, dated July 2022, revealed, Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 1. An Admission Record revealed the facility admitted Resident #7 on 04/01/2024, with diagnoses of chronic respiratory failure with hypoxia, type 2 diabetes mellitus, protein-calorie malnutrition, unsteadiness on feet, encephalopathy, pneumonia, end stage renal disease, arteriovenous fistula, bipolar disorder, and dependence on renal dialysis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed in the last seven days of the assessment period, the resident did not have an active diagnosis of seizures of insomnia. Resident #7's Order Summary Report, with active orders as of 05/13/2024, revealed an order dated 04/01/2024, for divalproex sodium (a medication used to treat seizure disorders, certain psychiatric conditions, and to prevent migraine headaches) oral tablet delayed release, give 500 milligrams (mg) by mouth two times a day for seizures and an order dated 04/11/2024, for trazodone hydrogen chloride (an antidepressant medication) oral tablet, give 50 mg by mouth at bedtime for insomnia. Resident #7's medical record did not reveal evidence to indicate the resident had a diagnosis of seizures or insomnia. During an interview on 05/17/2024 at 1:22 PM, the MDS Coordinator stated Resident #7 did not have a diagnosis in their medical record for all the medications the resident was prescribed. The MDS Coordinator stated obviously something got missed. According to the MDS Coordinator, she would contact the physician to get a diagnosis or have the physician's orders changed. During an interview on 05/18/2024 at 9:50 AM, the Director of Nursing (DON) stated the facility tried to eliminate errors in physician's orders and made it where only she and the MDS Coordinator implemented a resident's physician orders into the resident's medical record. The DON stated she could not explain how medications were ordered for Resident #7 when the resident did not have an appropriate diagnosis for the medication. During an interview on 05/18/2024 at 12:22 PM, the Administrator stated she expected the staff to follow the policy. 46863 2. An Admission Record revealed the facility admitted Resident #11 on 04/16/2024, with diagnoses to include chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, pneumonia, and bronchitis. An admission Minimum Data Set (MDS), with an Assessment References Date (ARD) of 04/22/2024, revealed Resident #11 was unable to complete the Brief Interview for Mental Status. The MDS revealed in the last seven days of the assessment period, the resident did not have an active diagnosis of seizures of insomnia. Resident #11's Order Summary Report, revealed an order dated 05/13/2024, for trazodone hydrogen chloride (an antidepressant medication) oral tablet, give 50 milligrams by mouth every 24 hours as needed for insomnia for 14 days. Resident #11's medical record did not reveal evidence to indicate the resident had a diagnosis of insomnia. During an interview on 05/17/2024 at 1:22 PM, the MDS Coordinator stated Resident #11 did not have a diagnosis in their medical record for all the medications the resident was prescribed. The MDS Coordinator stated obviously something got missed. According to the MDS Coordinator, she would contact the physician to get a diagnosis or have the physician's orders changed. During an interview on 05/18/2024 at 9:50 AM, the Director of Nursing (DON) stated the facility tried to eliminate errors in physician's orders and made it where only she and the MDS Coordinator implemented a resident's physician orders into the resident's medical record. The DON stated she could not explain how medications were ordered for Resident #11 when the resident did not have an appropriate diagnosis for the medication. During an interview on 05/18/2024 at 12:22 PM, the Administrator stated she expected the staff to follow the policy.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property for 4 of 7 sample residents were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In addition, the facility did not report the results of all investigations to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident. Resident identifiers: 1, 2, 3, and 7. Findings include: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses that included history of falls, aftercare following joint replacement surgery, scalp contusion, polyneuropathy, and protein calorie malnutrition. Resident 7's medical record was reviewed on 12/12/23 On 9/13/23 at 8:07 PM, a nurses note indicated that, RN (Registered Nurse) was walking down the hallway and [resident 7] was sitting on her couch asking for help RN entered her room and asked what she needed help with she states she needs help to her bed she then told the RN that she was brushing her hair and fell to the floor but was able to get herself to her couch. RN assessed her and found no wounds or signs of falling, [Resident 7] was able to stand up with stand by assist and ambulate to her bed with no problems. [Resident 7] was assisted to bed and given a pain pill. Per nurses notes, on 9/14/23 resident 7 was sent to the hospital for pain, and was diagnosed with a urinary tract infection and an acute T11 burst fracture. Review of the facility's form 358 for this incident indicated that although the incident occurred on 9/13/23 at 8:07 PM, the facility Administrator (ADM) was not made aware of the potential abuse and neglect allegation until 9/14/23 at 8:30 AM. Review of the facility's form 359 for this incident indicated that the report was submitted to the State Survey Agency (SSA) on 9/22/23, which was not within 5 working days of the incident. 43212 3. Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertensive encephalopathy, mild cognitive impairment, unsteadiness on feet, abnormal posture, delerium and major depressive disorder. Resident 1's medical record was reviewed. A nurses note dated 8/3/23 at 1:45 AM revealed,Note Text: Diagnosis of hypertensive encephalopathy. She is alert and oriented to person, place, and time. She has slight confusion with some things. She has been education on call light usage. She participates in PT. She is independent to the bathroom and continentof bowel and bladder. She walks around the facility without a cane or walker. She wandered from the facility, found by the police and brought back to the facility. Her husband is currently staying with her. A nurses note dated 8/3/23 at 1:49 AM revealed, Note Text: She had requested a cigarette. A man later came to the facility saying she has wandered from the facility. The man and his wife asked her to come back to the facility and [resident 1] refused. [Resident 1] kept walking farther and police were notified to start a search. She was found by carbon avenue. The family was notified and came to the scene. She was with the family for some time and later came back to the facility. Her husband is currently with her. She is being checked on frequently and door alarms are on. On 8/7/23 at 9:45 AM, an Interdisciplinary Team (IDT) review was conducted. The progress note revealed, IDT review of patient elopement. Patient is a new admitted from hospital. Patient was alert and oriented x3. Patient is a smoker on day of admit the husband had spent the day with her and assisted her with smoking. When husband left staff had assisted patient out to the smoking area for a cigarette and decided to walk home, left through the back gate of back yard. She was found near the pool by a community member that called and alerted staff which they immediately went to her location. The aide continuedto follow her until were able to get her back in the building with the help of officers. patient was more confused than normal. Family was also called and was present when bringing her back to facility. Family reports this is an abnormal behavior for her. Staff immediately implemented Q 5-10 min checks for patient location. Wander guard placed to patient ankle. Patient had found a way to remove the wandergaurd from her ankle. Staff were able to place the device in the cuff of her shoe and new bracelet placed to her wrist. IDT team had conference with family discussion about frequent checks and family involvement including providing activities of choice to help with transition. Family will provide assistance with day time monitoring. Staff will continuewith frequent safety checks. Activities of choice such as puzzles, coloring books and drawings. Attendees: IDT review of patient elopement. Patient is a new admitted from hospital. Patient was alert and oriented x3. Patient is a smoker on day of admit the husband had spent the day with her and assisted her with smoking. When husband left staff had assisted patient out to the smoking area for a cigarette and decided to walk home, left through the back gate of back yard. She was found near the pool by a community member that called and alerted staff which they immediately went to her location. The aide continuedto follow her until were able to get her back in the building with the help of officers. patient was more confused than normal. Family was also called and was present when bringing her back to facility. Family reports this is an abnormal behavior for her. Staff immediately implemented Q 5-10 min checks for patient location. Wander guard placed to patient ankle. Patient had found a way to remove the wandergaurd from her ankle. Staff were able to place the device in the cuff of her shoe and new bracelet placed to her wrist. IDT team had conference with family discussion about frequent checks and family involvement including providing activities of choice to help with transition. Family will provide assistance with day time monitoring. Staff will continuewith frequent safety checks. Activities of choice such as puzzles, coloring books and drawings. On 8/3/23 at 3:00 PM, an exhibit 358 was submitted to the State Survey Agency. The report stated that the incident occurred on 8/2/23 at 8:20 PM. The administrator was made aware of the incident on 8/2/23 at 8:20 PM. Exhibit 359 was reviewed. The report was submitted on 8/10/23 at 2:30 PM, which was outside of the 5 day time limit for investigation reporting. 4. Resident 3 was admitted to the facility initially on 5/18/23 and again on 11/12/23 with diagnoses that included chronic obstructive pulmonary disease, acute and chronic respiratory failure, alcoholic liver disease, deep vein embolism and thrombosis of lower right extremity, pancytopenia and orthopedic aftercare. Resident 3's medical record was reviewed. On 5/21/23, a fall risk assessment was completed. The fall risk assessment revealed that resident 3 was a high fall risk. Resident 3's care plan was reviewed. A care area regarding falls, dated 5/19/23, included the following interventions to prevent falls: a. Answer call lights promptly b. Be sure bed is in lowest position and locked in place. c. Assess assistive devices for proper fit and use. d. Continually educate resident regarding safety issues. e. Encourage self-mobile residents to rise slowly and be sure of their steadiness prior to walking. A nurses progress note dated 11/6/23 at 8:42 AM revealed, Resident was found by staff on the floor to the side of her bed, She had pushed her button. Assessment showed pain in the left hip. Unable to move her to her bed. Made her comfortable with pillow under leg. She was comfortable unless moved. Ambulance wascalled and she was transported. Vitals within normal limits. Regular and unlabored respirations. 02 (oxygen concentration) was 93% on RA (room air). A nurses progress note dated 11/6/23 at 10:59 AM revealed, [Hospital emergency room ] called to report that patient does have a fracture to her L (left) hip. Will tentatively be having surgery today. On 12/12/23 at 12:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated when a resident sustained a fall and the fall was unwitnessed, the resident was assessed by the nurse on duty and an incident report was initiated. LPN 1 stated the Director of Nursing (DON), Physician, and resident's representative would be notified. LPN 1 stated the DON usually makes the determination if a resident would be sent to the hospital, however, if it was evident that the resident needed immediate care, the nurse on duty could call EMS. LPN 1 stated resident 3's bed was in the low position as per her care plan when she fell . LPN 1 stated resident 3 did not call for assistance to transfer. An exhibit 358 was submitted to the State Survey Agency at 11:20 AM on 11/6/23. The report stated the incident occurred at 7:30 AM on 11/6/23 and the Administrator was made aware at 7:35 AM. The submission was beyond the 2 hour requirement for submission. An exhibit 359 was submitted to the State Survey Agency at 3:18 PM on 11/14/23, which was outside of the 5 day time limit for investigation reporting. 45470 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, protein-calorie malnutrition, essential hypertension, hyperlipidemia, anemia, hypothyroidism, major depressive disorder, hallucinations, and pain in left and right feet. Residents medical record was reviewed on 12/12/23. A nursing progress note dated 6/21/23 at 3:55 AM documented, Resident was attempting to get up to go to the restroom, her silent bed alarm went off, the CNA [certified nursing assistant] approached room and heard a clatter she opened the door to find resident on the floor. CNA called for RN [registered nurse] to assist. RN assessed resident c/o [complaints of] pain to right shoulder and right toe. RN and CNA assisted resident into bed and assisted her to change her brief . resident had verbal complaints of pain frequently calling out. RN notified emergency contact #1 and Dr. resident was sent . to ER [emergency room ] for assessment and x-ray on right shoulder. Resident left facility at 0352 report was called into the ER. The facility initial entity report form exhibit 358 documented, [resident 2] had fallen getting up during the night and was sent to the ER. She did return to the facility a few hours later. Resident returned from the ER with dx [diagnosis] of right humerus fx [fracture] treated with immobilizer orders. Review of the exhibit 358 entity report documented the staff became aware of the incident on 6/21/23 at 5:00 AM and the administration was notified on 6/21/23 at 7:30 AM. The incident was reported to the SSA on 6/21/23 at 1:16 PM. On 12/12/23 at 3:52 PM an interview with administrator (ADM) was conducted. The ADM stated that she was under the impression that once we had confirmation of a significant injury, like a broke bone, then we begin the investigation process and complete the 358 report 2 hours after that. The ADM stated that once she learned about the resident having a broken bone or serious injury, she would start on the 358 and submitted it within 2 hours.

Based on interview and record review, the facility did not ensure that all allegations of abuse were thoroughly investigated. Specifically, the facility completed a form 359 as a summary for allegations of abuse, but did not have additional evidence of the complete investigation for 4 of 7 sample residents. Resident identifiers: 1, 2, 3 and 7. Findings include: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses that included history of falls, aftercare following joint replacement surgery, scalp contusion, polyneuropathy, and protein calorie malnutrition. Resident 7's medical record was reviewed on 12/12/23 On 9/13/23 at 8:07 PM, a nurses note indicated that, RN (Registered Nurse) was walking down the hallway and [resident 7] was sitting on her couch asking for help RN entered her room and asked what she needed help with she states she needs help to her bed she then told the RN that she was brushing her hair and fell to the floor but was able to get herself to her couch. RN assessed her and found no wounds or signs of falling, [Resident 7] was able to stand up with stand by assist and ambulate to her bed with no problems. [Resident 7] was assisted to bed and given a pain pill. Per nurses notes, on 9/14/23 resident 7 was sent to the hospital for pain, and was diagnosed with a urinary tract infection and an acute T11 burst fracture. The facility's form 359 for this incident was reviewed. Under the section Summary of interview(s) with witness(es), what the individual observed or knowledge of the alleged incident or injury, the facility staff wrote what the nurses note stated of the incident on 9/13/23. The facility did not provide additional documentation of specific interviews that were completed as part of the investigation, if any, in addition to what was documented in the resident record. 43212 3. Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertensive encephalopathy, mild cognitive impairment, unsteadiness on feet, abnormal posture, delerium and major depressive disorder. Resident 1's medical record was reviewed. A nurses note dated 8/3/23 at 1:49 AM revealed, Note Text: She had requested a cigarette. A man later came to the facility saying she has wandered from the facility. The man and his wife asked her to come back to the facility and [resident 1] refused. [Resident 1] kept walking farther and police were notified to start a search. She was found by carbon avenue. The family was notified and came to the scene. She was with the family for some time and later came back to the facility. Her husband is currently with her. She is being checked on frequently and door alarms are on. An exhibit 359 was submitted to the State Survey Agency on 8/10/23 at 2:30 PM. A summary of the progress note documenting the event was included in the area for Steps taken to investigate. The summary of interviews for staff who had oversight of the resident included that the resident was more conused than usual. It states that the family was notified and present when the resident was returned to the facility and that family stated it was unusual behavior. Corrective action included having an interdisciplinary team meeting and discussion with family about frequent checks on the resident and family involvement. Additional documentation of interviews and education were requested, but were not provided. 4. Resident 3 was admitted to the facility on [DATE] and again on 11/12/23 with diagnoses that included chronic obstructive pulmonary disease, acute and chronic respiratory failure, alcoholic liver disease, deep vein embolism and thrombosis of lower right extremity, pancytopenia and orthopedic aftercare. Resident 3's medical record was reviewed. A nurses progress note dated 11/6/23 at 8:42 AM revealed, Resident was found by staff on the floor to the side of her bed, She had pushed her button. Assessment showed pain in the left hip. Unable to move her to her bed. Made her comfortable with pillow under leg. She was comfortable unless moved. Ambulance wascalled and she was transported. Vitals within normal limits. Regular and unlabored respirations. 02 (oxygen concentration) was 93% on RA (room air). An exhibit 359 submitted on 11/14/23 at 3:18 PM included that the resident was a representative for herself. A summary of the interview with the resident stated she was trying to get up for breakfast and tripped on the leg of her wheelchair. It also states that she had not called for help prior to falling. A summary of interviews conducted with staff and others who had knowledge of the incident included that the resident was independent with mobility and transfers and was preparing to discharge home. There were no additional interviews with staff or residents provided. A checklist about the incident was reviewed and included that witness statements were taken and staff education was provided, however, the information was not included with exhibit 359 and was not provided with additional requested documents. 45470 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, protein-calorie malnutrition, essential hypertension, hyperlipidemia, anemia, hypothyroidism, major depressive disorder, hallucinations, and pain in left and right feet. Residents medical record was reviewed on 12/12/23. A nursing progress note dated 6/21/23 at 3:55 AM documented, Resident was attempting to get up to go to the restroom, her silent bed alarm went off, the CNA [certified nursing assistant] approached room and heard a clatter she opened the door to find resident on the floor. CNA called for RN [registered nurse] to assist. RN assessed resident c/o [complaints of] pain to right shoulder and right toe. RN and CNA assisted resident into bed and assisted her to change her brief . resident had verbal complaints of pain frequently calling out. RN notified emergency contact #1 and Dr. resident was sent . to ER [emergency room ] for assessment and x-ray on right shoulder. Resident left facility at 0352 report was called into the ER. The facility initial entity report form exhibit 358 documented, [resident 2] had fallen getting up during the night and was sent to the ER. She did return to the facility a few hours later. Resident returned from the ER with dx [diagnosis] of right humerus fx [fracture] treated with immobilizer orders. The facility follow-up investigation report form exhibit 359 documented, Resident [2] returned from ER with dx of right humerus fx . The summary of interview with witnesses stated, Resident was attempting to get up to go to the restroom, her silent bed alarm went off, the CNA approached room and heard a clatter she opened the door to find resident on the floor. CNA called for RN to assist. RN assessed resident c/o pain to right shoulder and right toe. RN and CNA assisted resident into bed and assisted her to change her brief. Neuro checks started. Resident had verbal complaints of pain frequently calling out. RN notified emergency and was sent vis EMS non emergent to ER for assessment and x-ray on right shoulder. Resident left facility at 0352 [3:52 AM] report was called into the ER. The findings of the investigation was documented as inconclusive. No additional interviews from staff and/or resident were documented in the follow-up investigation. On 12/12/23 at 2:24 PM an interview with CNA 1. CNA 1 stated that she came to work the day after resident 2 had fallen and broken her arm. CNA 1 stated that resident 2 had fallen in the past. CNA 1 stated that the interventions to keep resident 2 safe from falls were; resident 2's room was close to the nurses station, the bed had a silent alarm which alerted staff if resident 2 was getting up from her bed, and staff checked on all residents at least every 2 hours, but staff typically checked on resident 2 about every hour. CNA 1 stated that resident 2 had some confusion and would attempt to get up by herself. CNA 1 stated that staff assist resident 2 to the bathroom and resident 2 was typically a 1-person assist. CNA 1 stated that resident 2 was typically able to tell staff if she needed to use the bathroom. On 12/12/23 at 3:53 PM an interview with the administrator (ADM) was conducted. The ADM stated that she did not interview other staff or residents because the fall was unwitnessed. The ADM stated that she did not begin the investigation process for resident 7 until it was confirmed from the hospital that she had a fracture. The ADM stated that she did not have any interviews with staff or residents regarding neglect.

Based on interview and record review, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, facility staff administered intravenous (IV) medications without being certified to administer intravenous medications to 2 of 7 sampled residents. Resident identifiers: 1 and 2. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included sepsis, methicillin resistant staphylococcus aureus (MRSA), psoas muscle abscess, osteomyelitis of the vertebrae, muscle weakness, malnutrition, human immunodeficiency virus, malignant neoplasm of anus, syphilis, and anxiety. On 3/30/23 the medical record of resident 1 was reviewed. A physician's order dated 1/14/23 revealed Vancomycin HCl (hydrochloride) Intravenous Solution. Use 1 gram intravenously one time a day for MRSA. A physician's order dated 1/13/23 revealed Sodium Chloride 0.9% (percent) 10 ml flush every shift for maintenance. A physician's order dated 1/24/23 revealed, Heparin Lock Flush Solution 100 UNIT/ML (milliliter). Use 5 ml intravenously one time a day for PICC (peripherally inserted central catheter). The January, February and March Medication Administration Records (MARs) for resident 1 documented that the Vancomycin had been administered intravenously by a staff member who was not IV certified on the following dates: a. 1/15, 1/16, 1/17, 1/18, 1/21, 1/22, 1/25, 1/27, 1/28, and 1/31 b. 2/1, 2/2, 2/5, 2/7, 2/8, 2/11, 2/12, 2/14, 2/16, 2/17, 2/21, 2/22, 2/27, and 2/28 c. 3/1 and 3/2 The MAR for resident 1 documented that the Sodium Chloride flush solution had been administered intravenously by a staff member who was not IV certified on the following dates: a. 1/15, 1/16, 1/17, 1/21, 1/22, 1/25, 1/27 and 1/31 b. 2/1, 2/2, 2/5, 2/7, 2/8, 2/9, 2/11, 2/12, 2/14, 2/16, 2/17, 2/21, 2/22, 2/27 and 2/28 c. 3/1, 3/2, 3/4, 3/5, 3/7, 3/9, 3/10, 3/11 and 3/15 The MAR for resident 1 documented that the Heparin flush solution had been administered intravenously by a staff member who was not IV certified on the following dates: a. 1/26, 1/28 and 1/31 b. 2/1, 2/2, 2/3, 2/5, 2/7, 2/8, 2/11, 2/12, 2/14, 2/16, 2/17, 2/21, 2/22, 2/25, 2/27, and 2/28 c. 3/1, 3/2, 3/5, 3/7, 3/9, 3/11 and 3/15 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, emphysema, asthma, chronic obstructive pulmonary disease, malnutrition, type II diabetes, Parkinson's disease, and major depressive disorder. On 3/30/23 the medical record of resident 2 was reviewed. A physician's order dated 3/4/23 revealed Ertapenem Sodium solution 1 GM (gram). Use 1 GM intravenously every 24 hours. The March 2023 MAR for resident 2 documented that the Ertapenem Sodium solution had been administered intravenously by a staff member who was not IV certified on the following dates: a. 3/4, 3/5, 3/7, 3/8, 3/9, and 3/10. On 3/30/23 at 9:45 AM, an interview was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated the facility did not have any Licensed Practical Nurses (LPNs) who were IV certified and that she had been trying to get the facility to get them certified for a long time. On 3/30/23 at 11:27 am, an interview was conducted with LPN 1. LPN 1 stated he did not do anything with the IVs. LPN 1 stated it would be the Director of Nursing (DON) or one of the other Registered Nurses (RNs). LPN 1 stated the nurse who administered the IV medication or flush should have charted it in the MAR. LPN 1 stated the nurse who administered the medication should have charted the flushes and everything. LPN 1 stated that he was not IV certified and only IV certified staff could take care of a residents IV. On 3/30/23 at 11:28 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated they put an RN on duty during each shift and if there is not an RN on duty then the DON would be there to administer any IV medication. The CRN stated it was the expectation of the facility that the nurse who administered the medication would also chart that the medication had been given. On 3/30/23 at 11:50 AM, an interview was conducted with the Director of Nursing In Training (DONIT). The DONIT stated the RNs are the only staff who do anything with the IVs. The DONIT stated the LPNs would obtain the IV medication or flush from the medication supply room and give it to the RN to administer. The DONIT stated the LPN who obtained the medications was also the staff member who would document the administration of the IV medication in the medical record. The DONIT stated sometimes the administering RN would write a progress note in the medical record, but not always. The DONIT stated the RNs were expected to chart any medications that they administered, including IV medications. And that the charting of the administration of IV medications should not be done by any staff who did not administer the medication.

Based on interview and record review, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, for 1 out of 20 sampled residents, a resident that developed pressure ulcers on both heels did not have the treatment implemented according to the physician's orders. In addition, the resident's left anterior pressure ulcer developed an infection. Resident identifier: 80. Findings included: Resident 80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included, but were not limited to, aftercare following joint replacement surgery, encounter for removal of internal fixation device, presence of left artificial hip joint, acute respiratory failure, moderate protein-calorie malnutrition, difficulty in walking, benign prostatic hyperplasia, obstructive and reflux uropathy, hypertension, dementia, and acute kidney failure. Resident 80's medical record was reviewed on 12/13/22. A Braden Scale for Predicting Pressure Sore Risk dated 10/21/22, documented that resident 80 was at risk for pressure sores with a score of 17. [Note: A score of 15 to 18 indicated At Risk.] On 11/9/22 at 5:36 PM, a Nurses Note documented cna [Certified Nursing Assistant], [name removed], reported a sore to resident's right heal [sic]. looks like it was a blister that broke open. placed a bandage on it. On 11/10/22 at 2:39 PM, a Nurses Note documented Notified [name of primary care physician removed] of sores on bilat [bilateral] heels. Orders given to place foam heel protectors when resident in bed and in wheelchair. Apply optifoam dressing and change MWF [Monday, Wednesday, Friday]. Both appear to be blister from resting heels of feet on wheelchair. No bleeding or drainage noted. The Order Summary Report was reviewed. A physician's order dated 11/10/22, documented Foam heel protectors while resident in bed or in wheelchair. Optifoam dressing to bilat heels. [Note: The order did not include a start date.] On 11/11/22 at 2:34 PM, a Skin/Wound Note documented resident's right heal [sic] dressing was changed. dead skin was removed from wound, macerated skin around the perimeter. new skin looks intact. On 11/13/22 at 9:49 PM, a Skin/Wound Note documented was addressing resident's heal [sic] wounds and he showed me his right elbow. it is swollen, pink, and spongy. not hot to touch no drainage noted, no pain indicated. looks like it needs to be drained. The November 2022 Treatment Administration Record (TAR) was reviewed. The physician's order for the heel treatment was unable to be located on the TAR. A care plan Focus initiated on 11/14/22, documented The resident has potential/actual impairment to skin integrity of the (bilat hip surgical incision, blister bilat heels ) r/t [related to]. The interventions initiated on 11/14/22, included: a. Foam heel protecting boots while in bed and while in wheelchair. b. Keep skin clean and dry. Use lotion on dry skin. Do not apply on (Specify: site of injury). c. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to Medical Director. The notes from the Long Term Care Facility that resident 80 transferred to were reviewed. The notes included, but were not limited to, the following: a. On 11/16/22 at 4:30 PM, a Category: Skilled Charting documented . Right hip has 5 staples, Left hip has 8 staples, no redness to sites. Buttock above gluteal crease has a dressing, removed dressing, skin is red and discolored, covered with a Allevyn dressing to provide protection. Right hand middle finger knuckle has a S/T [skin tear] with dry skin rolled up. cleaned and applied ABX [antibiotic]. ointment with a telfa dressing, Right anterior foot has dry blood, cleaned with NS [normal saline] 0.9 deep dark bruising with outer redness, Right outer foot a dark pressure sore 2.5cm [centimeters] x [by] 0.5cm. Right heel pressure sore discolored redness 3.5cmx3.5cm . Left heel dressing removed, odor is very strong gauze removed, pressure sore is white 7.8cm x 7.8cm unable to stage. Ankle with no edema feet puffy +1 . b. On 11/17/22 at 12:31 PM, a Category: Medication, Treatment, Telephone Order documented Met with [name of physician removed] to review plan of care, discussed redness to left anterior foot, pressure injuries to bilateral feet, staples still in place upon arrival to bilateral hips from surgery in October, has not had ortho [orthopedic] follow up since surgery. Informed him of follow up appointment made with [name of physician removed]. New orders received: Mupirocin ointment apply to wounds on feet BID [two times a day], D/C [discontinue] Staples, Bactrim DS [double strength] PO [by mouth] BID x [for] 10 days - for left anterior foot infection, Keflex 500 mg [milligrams] TID [three times a day] x 10 days for left anterior foot infection. Informed daughter and resident of new orders, they agree with plan of care. c. On 11/17/22 at 2:38 PM, a Category: Medication documented Keflex 500 mg tab PO TIDx10 days for infection of L [left]/foot; Bactrim DS 800mg/160 mg tab PO BID x 10 days for infection of L/foot. Pt tolerating it well. No adverse reaction noted at this time. The Orthopedic Surgery note dated 11/29/22, documented . he got some heel ulcers at the care center out there and these [sic] been treating with offloading and bandages and stuff of that nature. Not getting around much due to the heel sores. On 12/13/22 at 2:11 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated when entering a new physician's order into the resident's medical record she would go to the clinical assessment for the resident and click the orders tab. RN 1 stated for a wound order she would click new other for wounds and order type wounds tar. RN 1 stated she would complete the ordered by and communication method phone, verbal, or written order. RN 1 stated she would complete the description area by entering the description of the order. RN 1 stated the scheduling details would be completed by clicking if the order was routine, one time only, or as needed. RN 1 stated that she would also add additional directions to the order. RN 1 stated that she would enter the start date of the order and an end date. RN 1 stated the end date for the order could be specific or indefinite. RN 1 stated she would then enter the time the order would start. RN 1 stated she would also add any supplementary documentation that could include a pain level. RN 1 stated if supplementary documentation was included the system would trigger the supplementary documentation be entered prior to administering the order. RN 1 verified the wound order for resident 80's heel dressings were not scheduled. RN 1 stated if the order was not scheduled the order would not be activated on the TAR. On 12/14/22 at 8:46 AM, an interview was conducted with the Director of Nursing (DON) at another Long Term Care Facility. The DON stated that their facility Physician saw resident 80 after admission and thought that one of resident 80's heel wounds was infected. The DON stated that resident 80 was started on two antibiotics. On 12/14/22 at 10:13 AM, an interview was conducted with the Wound Nurse. The Wound Nurse stated that resident 80 had multiple falls while he was a resident at the facility and resident 80 had a few skin tears from the falls. The Wound Nurse stated that resident 80 had a skin tear on his elbow that was pretty bad and one on his hand. The Wound Nurse stated that resident 80 had mostly skin tears. The Wound Nurse stated that resident 80 had a stroke and was sent to the local hospital and then shipped to another hospital in the valley. The Wound Nurse stated that the heel wounds were not there before resident 80 was discharged to the hospital. [Note: The discharge to the hospital was on 9/30/22 and resident 80 was readmitted to the facility on [DATE].] The Wound Nurse stated that she was on leave a week in November and not in the facility. The Wound Nurse stated resident 80's heel blister was present when she returned. The Wound Nurse stated when she returned the nursing staff had precautions in place with heel protectors and pillows under resident 80's knees to elevate. The Wound Nurse was unable to state when resident 80's heel wounds were identified. The Wound Nurse stated that resident 80 had gotten better at using the call light to get up. The Wound Nurse stated there were wound orders for the skin tear but there were no wound orders for resident 80's heel wounds. The Wound Nurse stated when she returned from leave she officially took over as the wound nurse. On 12/14/22 at 2:46 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that once the wounds were identified the staff notified the nurse. The RNC stated that the nurse would put a physician's order in place and some sort of treatment. The RNC stated the nurse would put in the order and notify the Wound Nurse and physician. The RNC stated the Wound Nurse and the physician assessed the wound and if the order was accurate they would not change the treatment. The RNC stated that the order for resident 80's heel treatment and heel protectors should have been separated and not entered together. The RNC stated it was an oversight that the wound order was not scheduled.

Based on interview and record review, the facility failed to inform residents, resident representatives, and resident families of the occurrence of a single confirmed infection of coronavirus disease of 2019 (COVID-19), or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other by 5:00 PM the next calendar day. Specifically, three facility staff members tested positive for COVID-19 and residents, resident representatives, and resident families were not notified of the outbreaks. Findings included: Review of the Facility COVID Testing - Employee Outbreak tracking log revealed the following: a. On 11/17/22, the Administrator (ADM) tested positive. b. On 11/21/22 Therapy 1 tested positive [Note: The Resident Advocate (RA) tested positive on 10/26/22, the results were not documented on tracking log.] Resident progress notes were reviewed for residents 1, 10, 12, 13, 19, 23, and 24. No documentation was found that indicated residents, resident representatives, or resident families were notified of the COVID-19 outbreaks on 10/26/22 and 11/21/22. The facility's Policies and Procedures for Infection Prevention and Control were reviewed. Under section Interventions for Resident Care when COVID-19 is Confirmed it stated Family Notification: The facility will follow guidance from CDC [Centers for Disease Control and Prevention] and CMS [Centers for Medicare & Medicaid Services] about notifying families and responsible parties about the spread of COVID-19 in the facility: Following the occurrence of a single confirmed infection of COVID-19 OR Three or more residents or staff with new onset of respiratory symptoms occurring within seventy-two hours of each other. This notification should include all efforts made by the facility to manage the confirmed infection or cluster of symptomatic residents/staff. Notification may be made through email, website posting, and/or telephone message by 5pm the next calendar day after a COVID-19 infection is confirmed or a cluster of symptomatic residents/staff is identified. After the initial notification, updates must be provided when there are new confirmed infections or clusters. If no new cases are identified, weekly updates must be provided until the infections are resolved. The facility's website was reviewed. In the COVID-19 Facility Status section, the Coronavirus COVID-19 Update revealed the website was last updated on 8/2/22. The last paragraph stated, No news is good news - so if we haven't updated this statement, it means we haven't had any positive tests or other significant issues regarding COVID-19. On 12/12/22 at 2:22 PM, an interview was conducted with the Administrator in Training (AIT). The AIT stated families were notified when there was a COVID-19 outbreak via a phone call. The AIT stated they also posted the information on the front door. The AIT stated the Director of Nursing (DON) oversaw the phone calling but delegated the task to other staff members. The AIT stated she did not know how notifications were documented but stated the RA or DON would know. On 12/12/22 at 2:37 PM, an interview was conducted with the ADM. The ADM stated he tested positive for COVID-19 on Thursday, November 17, 2022. The ADM stated he went into the building, was tested , then left. The ADM stated he had been in the facility Monday through Wednesday prior to testing positive. The ADM stated he did not consider it an outbreak. The ADM stated he was unsure if the residents and their families were notified that he had COVID-19. The ADM stated when someone tested positive for COVID-19, they tried to determine who that person had been in contact with at the facility and tested those specific individuals. The ADM stated he felt the DON would be better able to answer the questions and proceeded to call her. On 12/12/22 at 2:49 PM, an interview was conducted with the DON via phone. The DON stated that the RA notified resident families via phone when there was a COVID-19 outbreak. The DON stated she was unsure how the RA documented the notification phone calls, as this was a new responsibility for the RA. The DON stated that the ADM left the building the day he tested positive and had not been in the building prior. The DON stated the ADM had been at a conference Monday through Wednesday prior to being tested on Thursday. The DON stated there was a folder with this information in her desk. The DON stated the last resident outbreak was a while ago, probably August. The DON stated the facility sent a resident to the hospital where they got COVID-19 and when they returned to facility, they were still positive for COVID-19. The DON stated the last staff outbreak was before Thanksgiving. The DON stated the staff member tested positive and was sent home. On 12/13/22 at 11:17 AM, an interview was conducted with the RA. The RA stated when there was a COVID-19 outbreak, she was responsible to call all resident families and write a progress note that stated the call was made. The RA stated that no one had tested positive for COVID-19 since she received this assignment so she had not made any notification phone calls yet. The RA stated she was assigned the task in August 2022. The RA stated she came to work on 10/26/22, and was tested for COVID-19. The RA stated the test came back positive for COVID-19. The RA stated she had only been at work for three hours before testing positive. The RA stated she had no idea if anyone notified residents or called resident families. The RA stated the last resident who tested positive for COVID-19 that she recalled was in July.

Based on interview and record review, the facility did not ensure that each resident was offered an influenza and/or pneumococcal immunization and that the medical record included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, for 3 out of 20 sampled residents, residents that had consented to the pneumococcal immunization did not have documentation that the pneumococcal immunization was provided. In addition, a resident that had consented to the influenza immunization did not have documentation that the influenza immunization was provided. Resident identifiers: 19, 23, and 24. Findings included: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses which included hypothyroidism, altered mental status, and essential hypertension. On 12/12/22, resident 19's medical record was reviewed. A signed pneumococcal immunization consent form dated 7/20/22, was located in resident 19's medical record but both the consent and decline options were marked on the form. No documentation could be found that indicated whether resident 19 had or had not received the pneumococcal immunization. 2. Resident 23 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, type 2 diabetes mellitus, unsteadiness on feet, schizophrenia, and acute kidney failure. On 12/12/22, resident 23's medical record was reviewed. A signed pneumococcal immunization consent form dated 10/19/22, was located in resident 23's medical record but no documentation could be found that indicated resident 23 had received the pneumococcal immunization. 3. Resident 24 was admitted to the facility on [DATE] with diagnoses which included pneumonia, chronic obstructive pulmonary disease, hypoxemia, chronic viral hepatitis C, personal history of traumatic brain injury, paranoid schizophrenia, and chronic respiratory failure. On 12/12/22, resident 24's medical record was reviewed. A signed pneumococcal immunization consent form dated 11/4/22, was located in resident 24's medical record but no documentation could be found that indicated resident 24 had received the pneumococcal immunization. A signed influenza immunization consent form dated 11/4/22, was located in resident 24's medical record but no documentation could be found that indicated resident 24 had received the influenza immunization. On 12/13/22 at 8:32 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the facility held vaccination clinics for the staff and residents who wanted to get vaccinated. CNA 1 stated the facility had just held a flu clinic for anyone who wanted the influenza vaccination. On 12/13/22 at 10:18 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated the facility had a weekly in-service which included education on COVID-19 and the vaccine. The IP stated they had occasional vaccine clinics for residents and staff. The IP stated they just had a influenza vaccination clinic and that a COVID-19 vaccination clinic would be coming up.

Based on interview and record review, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with the Coronavirus disease of 2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 5 out of 20 sampled residents, the facility did not provide the resident or resident representative with education of the benefits and potential risks associated with the COVID-19 vaccination. In addition, the resident's medical record did not include documentation regarding the residents' COVID-19 vaccination refusal or acceptance. Resident identifiers: 14, 15, 19, 23, and 24. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses that included non-ST-elevation myocardial infarction, type 2 diabetes mellitus with hypoglycemia, major depressive disorder, chronic pain syndrome, heart failure, and peripheral autonomic neuropathy. On 12/12/22, resident 14's medical record was reviewed. No documentation was found regarding resident 14's COVID-19 immunization status. No documentation was located that indicated resident 14 or resident 14's representative were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. 2. Resident 15 was admitted to the facility on [DATE] with diagnoses which included encounter for orthopedic aftercare, displace trimalleolar fracture of left lower leg, epilepsy and epileptic syndromes with complex partial seizures, essential hypertension, and personal history of traumatic brain injury. On 12/12/22, resident 15's medical record was reviewed. No documentation was found regarding resident 15's COVID-19 immunization status. No documentation was located that indicated resident 15 or resident 15's representative were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. 3. Resident 19 was admitted to the facility on [DATE] with diagnoses which included hypothyroidism, altered mental status, post COVID-19 condition, and essential hypertension. On 12/12/22, resident 19's medical record was reviewed. No documentation was found regarding resident 19's COVID-19 immunization status. No documentation was located that indicated resident 19 or resident 19's representative were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. 4. Resident 23 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, type 2 diabetes mellitus, unsteadiness on feet, schizophrenia, and acute kidney failure. On 12/12/22, resident 23's medical record was reviewed. No documentation was found regarding resident 23's COVID-19 immunization status. No documentation was located that indicated resident 23 or resident 23's representative were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. 5. Resident 24 was admitted to the facility on [DATE] with diagnoses which included pneumonia, chronic obstructive pulmonary disease, hypoxemia, chronic viral hepatitis C, personal history of traumatic brain injury, paranoid schizophrenia, and chronic respiratory failure. On 12/12/22, resident 24's medical record was reviewed. No documentation was found regarding resident 24's COVID-19 immunization status. No documentation was located that indicated resident 24 or resident 24's representative were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. On 12/13/22 at 8:32 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the facility held vaccination clinics for the staff and residents who wanted to get vaccinated. CNA 1 stated the facility had just held a flu clinic for anyone who wanted the influenza vaccination. On 12/13/22 at 10:18 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated the facility had a weekly in-service which included education on COVID-19 and the vaccine. The IP stated they had occasional vaccine clinics for residents and staff. The IP stated they just had a influenza vaccination clinic and that a COVID-19 vaccination clinic would be coming up.

Based on observation, interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 3 out of 20 sampled residents, a resident with orders to follow up with the Orthopedic Surgeon two weeks after discharge from the hospital did not have a follow up and the surgical staples were not removed until four weeks after discharge from the hospital. A resident with a nephrostomy tube did not receive wound care as ordered by the Physician Assistant (PA) professional wound specialist and a resident with a rash and itchy skin was not treated. Resident identifiers: 12, 15, and 80. Findings included: 1. Resident 80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included, but were not limited to, aftercare following joint replacement surgery, encounter for removal of internal fixation device, presence of left artificial hip joint, acute respiratory failure, moderate protein-calorie malnutrition, difficulty in walking, benign prostatic hyperplasia, obstructive and reflux uropathy, hypertension, dementia, and acute kidney failure. Resident 80's medical record was reviewed on 12/13/22. On 10/16/22 at 1:34 PM, a Fall Note documented Resident found on floor of his room at 1045 [10:45 PM]. He came to rest on his left side. Staff assessed him and found a skin tear on his left elbow. Stopped the bleeding with direct pressure. He was then assisted to his wheelchair. We then cleaned and dressed the skin tear. He then was assisted to the nurses station so he could be monitored and neuro [neurological] checks made. Step daughter contacted and [name of primary care physician removed] was notified of citation. He was able to transfer to the toilet at 1200 [12:00 PM] when he would not weight bear on the rightleg [sic]. Palpated right femur and found a bump proximal to hip socket. [Name of primary care physician removed] was then called and he wanted him checked out at the ER [emergency room ]. Non emergency transport was called. Transported at 1326 [1:36 PM] to the ER. On 10/16/22 at 10:08 PM, a Nurses Note documented Called the hospital for update. Resident has a broken L [left] femur. Staying over night at the hospital. On 10/19/22, the Hospital History/Physical And Discharge Summary documented under the Physician Orders section FOLLOW-UP APPT [appointment] w/pcp [with primary care physician] 3-5 days. [Name of Orthopedic Surgeon removed] in 2 weeks. On 10/20/22, a physician's order documented Daily dressing change of surgical incision until dry. Clean using wound cleanser, apply sterile border gauze. one time a day. On 10/21/22 at 5:46 PM, a Nurses Note documented changed dressings to hips bilaterally. incisions show no s/s [signs or symptoms] of infection. staples still in place. states pain 4/10. no other needs at this time. call light in reach. On 11/1/22 at 2:19 PM, a Nurses Note documented Resident admitted for left hip repair and orthopedic aftercare. Surgical incisions healing. No s/s of infection. Wound cleaned,dried and dressed. Pain medications and repositioning help to relieve pain. On 11/2/22 at 10:12 AM, a Nurses Note documented Resident comes to us with left hip repair and orthopedic aftercare. Compliant with medications and cares. Wounds cleaned, dried and dressed. NO signs of infection. On 11/6/22 at 2:18 AM, a Fall Note documented Resident stated that his left leg was hurting. Surgical wound inspected, intact without redness. Resident was transferred to his wheelchair and back to his bed. On 11/16/22 at 12:37 PM, a Nurses Note documented Resident was picked up by a facility transport driver at 1145 [11:45 AM]. Wheeled to the car in wheelchair. He was helped into the vehicle. Paperwork signed. [Note: Resident 80 transferred to another Long Term Care Facility.] The notes from the Long Term Care Facility that resident 80 transferred to were reviewed. The notes included, but were not limited to, the following: a. On 11/17/22 at 10:02 AM, a Category: Telephone Order documented Called [name of Orthopedic Surgeon removed] office in price, he is the surgeon who performed residents surgery on 10/17/22. Spoke with [name removed] (his nurse) resident has not had a follow up since surgery. Let her know that staples are still in place to all 3 incisions. She said the staples should have already been removed by now. Received new order: remove staples today. b. On 11/17/22 at 12:31 PM, a Category: Medication, Treatment, Telephone Order documented Met with [name of physician removed] to review plan of care, discussed redness to left anterior foot, pressure injuries to bilateral feet, staples still in place upon arrival to bilateral hips from surgery in October, has not had ortho [orthopedic] follow up since surgery. Informed him of follow up appointment made with [name of physician removed]. New orders received: Mupirocin ointment apply to wounds on feet BID [twice daily], D/C [discontinue] Staples, . Informed daughter and resident of new orders, they agree with plan of care. c. On 11/17/22 at 3:38 PM, a progress note documented Assisted resident to bed, provided privacy to remove stapled [sic] to R [right] hip and L hip incisions as ordered by physician. 5 staples removed from R hip. 7 staples removed from each surgical site on L hip. Resident tolerated well. No complaints of pain. No complications noted. Applied bacitracin to all sites and applied dressings preventatively. Resident positioned for comfort, call light within reach and bed alarm in place. Resident denies any needs at this time. Implemented treatment to watch sites. On 12/13/22 at 3:42 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated the facility did not have any notes because resident 80 did not see the Orthopedic Surgeon prior to discharging to another Long Term Care Facility. The RNC stated resident 80 was scheduled to see the Orthopedic Surgeon on 11/21/22. The RNC stated that she had called the Orthopedic Surgeons office to find out when resident 80's appointment was scheduled. The RNC stated resident 80 discharged from the facility on the 11/16/22. The RNC stated that the Business Office Manager scheduled the resident appointments and was usually unable to get the residents in within the two week time frame that the hospital wanted. The RNC stated that the Administrator in Training would scan the hospital discharge orders into the resident's medical record and would give the packet to the Director of Nursing (DON). On 12/13/22 at 3:54 PM, an interview was conducted with the Business Office Manager (BOM). The BOM stated that the DON would receive the resident admission packet from the hospital and within the packet was the residents appointments. The BOM stated the DON would make a copy of those appointments and bring them to her to schedule the appointments. The BOM stated a new resident would require a follow up with their Primary Care Physician (PCP) within 7 to 10 days after admission to the facility. The BOM stated that some surgeons and PCP were harder to get into than others. The BOM stated that surgeons were usually booked out three weeks. The BOM stated she had called the Orthopedic Surgeon for resident 80 and the earliest they could get him in was four weeks after resident 80 readmitted to the facility from the hospital. The BOM stated resident 80 had discharged from the facility prior to the appointment. The BOM stated that she would let the surgeon know what the hospital orders were. The BOM stated that resident 80's appointment was on 11/21/22, and that was the earliest the Orthopedic Surgeon could get resident 80 in. The BOM stated she did not make a progress note regarding the appointment but had wrote it on a post-it note. The BOM stated that the offices would also call if an opening happened but that was rare. The BOM stated the DON would make the referrals to the house doctor. On 12/14/22 at 8:46 AM, an interview was conducted with the DON at another Long Term Care Facility. The DON stated that resident 80's surgical staples were removed at their facility. The DON stated that resident 80 was seen by the local Orthopedic Surgeon for a follow up on the Monday after admission. The DON stated resident 80 had not had a follow up since his surgery in October 2022. On 12/14/22 at 2:14 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the Orthopedic Surgeon could not get resident 80 in for an appointment within the two week period. The ADON stated that the facility staff could remove resident 80's staples if they got a physician's order to remove the staples. The ADON stated when a resident was readmitted to the facility from the hospital the orders were input into the medical record and the admission paperwork would be resigned. The ADON stated that the DON would go through the orders again and would input the orders and the physician visits. The DON would them give the physician visits to the BOM to schedule. The ADON stated if the resident was suppose to be seen within two weeks after discharge from the hospital she probably would have called and asked the Orthopedic Surgeon what they would have liked them to do. The ADON stated that she would have been able to remove the staples if there was a physician's order. On 12/14/22 at 2:52 PM, an interview was conducted with the RNC. The RNC stated she would have had a discussion with the Orthopedic Surgeon if he was unable to get the resident in for the two week follow up. The RNC stated she would have put in the physician's order and had the facility staff remove the staples if the Orthopedic Surgeon agreed and then the Orthopedic Surgeon would followup at the scheduled appointment. The RNC stated that resident 80's PCP did not see resident 80 within the three to five days after discharge from the hospital as ordered. The RNC stated that the PCP signed the admission orders but did not have a visit note. 2. Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, encounter for surgical aftercare following surgery on the genitourinary system, hydronephrosis with ureteral stricture, calculus of kidney, type 2 diabetes mellitus, sepsis due to Escherichia Coli, atrial fibrillation, hypertension, acute kidney failure, pain, and anxiety disorder. On 12/12/22 at 2:41 PM, an interview was conducted with resident 12. Resident 12 stated that her nephrostomy tube was not connected to a bag and her down drain Foley catheter came out. Resident 12 stated that the nephrostomy tube was not connected to anything and she did not know if it was draining. Resident 12 stated that her nephrostomy was infected. Resident 12's medical record was reviewed on 12/14/22. On 11/1/22 at 8:01 PM, a Nurses Note documented resident admitted to facility for PT [physical therapy]/OT [occupational therapy] strength training and medication management with dx [diagnosis] of surgical aftercare following surgery on the genitourinary system. she has a Foley catheter that is draining clear yellow urine, she also has a nephrostomy tube on the left flank that is draining clear yellow urine. On 11/8/22 at 3:26 PM, a Nurses Note documented Dr. [doctor] appointment attended today. orders to exchange left nephrostomy tube. Consult to address infections. May also place new tube on right side. On 11/8/22 at 9:29 PM, a Nurses Note documented . resident had a doctor appointment today and the Foley catheter was removed. resident has a nephrostomy tube on the left side that is putting out very little urine. On 11/12/22 at 9:43 PM, a Nurses Note documented nephrostomy tube has had no output. On 11/20/22 at 10:00 PM, a Nurses Note documented no output from nephrostomy bag for afternoon shift. On 11/21/22 at 6:00 AM, a Nurses Note documented no output for night shift from nephrostomy. On 11/30/22 at 3:03 PM, a Nurses Note documented Placed a call to [name of urology clinic removed] concerning [name of resident 12 removed] nephrostomy. Reported to the FNP [Family Nurse Practitioner] that [name or resident 12 removed] is no longer producing urine from the urostomy. She stated that it will need to be replaced as soon as possible. They will return a call today when they are able to schedule the procedure. On 11/30/22 at 8:15 PM, a Nurses Note documented attempted to flush nephrostomy tube per doctor orders the valve leaked around the base where it connects to the part inserted into her back. DON notified it was not able to be flushed. On 12/6/22 at 8:14 PM, a Nurses Note documented . resident has a nephrostomy tube on the left side that has no output. On 12/8/22 at 3:09 PM, a Nurses Note documented During nephrostomy site dressing change, connection to the bag was found broken. This may be why the bag is no longer collecting. Urology was called to see what they would like to do with the site or if they would like to replace the bag. Waiting a call back. On 12/8/22, a progress note by the PA professional wound specialist documented on the assessment that resident 12 had dermatitis associated with moisture. The wound orders included Remove dressing, cleanse wound with standard wound care protocol, apply the following treatment order: Left Flank: apply nystatin/triamcinolone cream and cover with bordered foam, Change dressing once daily and PRN [as needed] if dislodged. Clinical Notes: 12/8/22: Wound nurse reports patient is non-compliant with treatment and refused showers. Nephrostomy drain will not be removed by surgeon until surrounding skin is clear. Follow up: 1 week. On 12/9/22 at 2:18 AM, a Nurses Note documented padding applied to the sharp hard plastic piece of the nephrostomy tube where the bag had been connected. area cleaned and dressing applied to insertion site. On 12/13/22 at 9:09 PM, a Nurses Note documented . resident has a surgical site on her left flank with a nephrostomy tube coming out but there is no bag attached to the tube. On 12/15/22 at 10:39 AM, an interview was conducted with the PA professional wound specialist and the Wound Nurse. The PA stated that he had seen resident 12 for the first time last week. The PA stated that he was trying to get the infection cleared up so the surgeon would take out resident 12's nephrostomy tube. The Wound Nurse stated that resident 12 had seen the Urologist but was told that they wound not take the nephrostomy tube out until it was healed. The Wound Nurse stated if the wound orders were not on the Treatment Administration Record (TAR) it was because she had not put the orders there yet. The Wound Nurse stated the facility staff were trying to get resident 12 to be more compliant with cares. On 12/15/22 at 10:49 AM, an observation was conducted with the PA professional wound specialist and the Wound Nurse. The Wound Nurse was observed to clean the left flank area on resident 12 with wound cleaner. There were no bandages observed over the nephrostomy tube in the left flank area. The Wound Nurse was observed to apply the nystatin/triamcinolone cream to the left flank area and covered the nephrostomy tube with bordered foam. The PA stated to resident 12 that he wanted to continue with the daily dressing changes. The PA stated to resident 12 that the area looked good and by next week it should be cleared up and the PA would be able to call the Urologist and schedule to get the nephrostomy tube removed. On 12/15/22 at 10:55 AM, a follow up interview was conducted with the Wound Nurse. The Wound Nurse stated that resident 12 had a hard time keeping the bandage on because of where it was placed. The Wound Nurse stated that she could not tell me exactly when the bandage fell off. The Wound Nurse stated that she changed resident 12's dressing on Wednesday. [Note: Resident 12's wound treatment was unable to be verified because the wound orders were not entered onto the TAR in resident 12's medical record.] 45470 3. Resident 15 was admitted to the facility on [DATE] with diagnoses which include displaced trimalleolar fracture of left lower leg, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, essential hypertension, personal history of traumatic brain injury, difficulty in walking, other psychoactive substance abuse, major depressive disorder, mood disorder, and personal history of other venous thrombosis and embolism. One 12/13/22 at 8:18 AM, an interview with resident 15 was conducted. Resident 15 stated that he had an itchy rash that was bothering him. Resident 15 stated that the rash was on his legs and started to spread to his back and torso. Resident 15 stated that he had told staff about the rash and requested to see a doctor, but staff told him that he did not have a rash. Resident 15 stated that the rash was really itchy and he stated that he sometimes bled due to scratching. On 12/14/22, resident 15's medical record reviewed. A Nurses Note dated 11/9/22 at 2:21 AM, stated, [Resident 15] called staff in his room states he needs to see a medical professional because the rash that is on his leg has spread to his back. RN [Registered Nurse] assessed his back and hold him he does not have a rash on his back. He [resident 15] states it itches and there are bumps on his back. [Resident 15] was told he has random red bumps on his back that look like acne and not a rash. [Resident 15] then states he has it on his abdomen and his belly button, RN told him there is nothing on his abdomen, chest, legs, or belly button, [Resident 15] became upset with the RN and started scratching his abdomen and back yelling it itches. He then insists that the rash has spread. [Resident 15] was told there is not a doctor available at 2:20 [AM] in the morning. Staff left his room and left his door open [resident 15] then yelled 'shut my damn door.' RN went back in his room and told him he is not to yell that other people are trying to sleep. [Resident 15] was reminded he is supposed to leave his door open and insisted it be shut. A review of resident 15's physician's orders was conducted. Resident 15 did not have any medications or physician's orders to treat symptoms of a rash. On 12/15/22 at 8:21 AM, an interview with Certified Nursing Assistant (CNA) 2 was conducted. CNA 2 stated that she recalled resident 15 complaining about a rash. CNA 2 stated she was not sure if the nurses contacted the doctor about the itchy rash. On 12/15/22 at 9:59 AM, a follow up interview was conducted with resident 15. Resident 15 stated that he had told staff multiple times about his legs being itchy and he wished to speak with a doctor about the issue. An observation of resident 15's right leg was made. Resident 15's right leg had a small amount of blood on it. Resident 15 stated that his leg was bleeding due to scratching it. On 12/15/22 at 10:04 AM, an interview with the ADON was conducted. The ADON stated that she worked with resident 15 twice a week and she did not recall resident 15 mentioning a rash. The ADON stated she was unaware of the nurses note dated 11/9/22 at 2:21 AM, which stated that resident 15 was complaining of a rash. The ADON stated that nurses typically pass that information onto the next shift or inform the doctor. On 12/15/22 at 10:55 AM, an interview with the Medical Director (MD) was conducted. The MD stated that he did not recall any staff member informing him about resident 15 having a rash. On 12/15/22 at 12:37 PM, an physician's order was placed for resident 15 that stated, Dry skin (bilateral legs and thighs): Clean with wet wipes, pat dry. Apply A&D Ointment to affected areas BID. Every shift for dry skin AND as needed for relief of dry itchy skin. Apply PRN every 6 hrs [hours].

Based on interview and record review, the Minimum Data Set (MDS) assessment did not accurately reflect the resident's status. Specifically, for 2 out of 20 sampled residents, a resident was incorrectly coded as not having a Traumatic Brain Injury (TBI) and a resident was incorrectly coded as being discharged to the hospital. Resident identifiers: 15 and 26 Findings included: 1. Resident 15 was admitted to the facility on [DATE] with diagnoses which include displaced trimalleolar fracture of left lower leg, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, essential hypertension, personal history of traumatic brain injury, difficulty in walking, other psychoactive substance abuse, major depressive disorder, mood disorder, and personal history of other venous thrombosis and embolism. Resident 15's admission MDS assessment dated [DATE], was marked No for resident 15 having a TBI. On 12/13/22 at 2:43 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that she was responsible for filling out the resident MDS assessments. The ADON stated that the MDS for resident 15 should have been marked Yes for having a TBI. 2. Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include chronic osteomyelitis, non-pressure chronic ulcer, chronic respiratory failure with hypoxia, cellulitis, sepsis, prediabetes, hyperlipidemia, bipolar disorder, anxiety disorder, and plantar fascial fibromatosis. Resident 26's discharge MDS assessment dated [DATE], was coded as being discharged to an acute hospital. A progress note dated 10/21/22 at 12:06, titled Discharge Summary revealed that resident 26 was discharged home. On 12/13/22 at 2:43 PM, an interview with the ADON was conducted. The ADON stated that resident 26 had discharged home but was accidentally coded as being discharged to a hospital on the discharge MDS assessment.

Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, for 2 out of 20 sampled residents, a resident's care plan was left blank in multiple sections and a resident's wound care plan was not updated. Resident identifiers: 16 and 80. Findings include: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses which include acute osteomyelitis (left ankle and foot), chronic obstructive pulmonary disease, dementia, major depressive disorder, schizoaffective disorder, post-traumatic stress disorder, generalized anxiety disorder, cellulitis of left lower limb, peripheral vascular disease, chronic systolic heart failure, adult failure to thrive, muscle weakness, essential hypertension, and malignant neoplasm of unspecified part of unspecified bronchus or lung. On 12/12/22 at 4:17 PM, an interview with resident 16 was conducted. Resident 16 stated that he was upset because he had been a resident at the facility for over a month and he was unsure of what his plan of care consisted of. Resident 16 stated that he did not know why he was at this facility, and that he did not have any meetings with staff concerning his plan of care. On 12/13/22, resident 16's medical record was reviewed. It was revealed that multiple sections in resident 16's care plan were incomplete. a. The first incomplete focus area stated, The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t [related to]. The specific location was not filled out and there was no information given about what the impairment was related to. The goal for this care area stated, The resident's skin injury (SPECIFY) of the (location) will be healed by review date. There was no information given about the specific skin injury or location. The interventions section was left blank. b. The second incomplete focus area stated, Resident requires long term care services related to: There was no further information given. The goal section was left blank. The intervention stated, Provide Care Conference for residents and families. c. The third incomplete focus area stated, The resident has Peripheral Vascular Disease (PVD) r/t. There was no further information given. The goal and the intervention were left blank. d. The fourth incomplete focus area stated, The resident has shortness of breath (SOB) r/t. There was no further information given. The goal stated, The resident will have no complications related to SOB through the review date. The intervention section was left blank. e. There was no behavioral care plan for resident 16's diagnosis of post-traumatic stress disorder. f. There was no behavioral care plan for the resident 16's diagnosis of Major Depressive Disorder. On 12/14/22 at 10:01 AM, an interview with the Resident Advocate (RA) was conducted. The RA stated that she would expect a care plan for post-traumatic stress disorder and depression for residents with those diagnoses. On 12/14/22 at 1:46 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated that she completed the resident care plans. The ADON stated that if a resident had a diagnoses of post-traumatic stress disorder or depression, the resident would have a care plan for those diagnoses. The ADON stated that she looked at resident 16's care plan and stated that it was incomplete. The ADON stated that the facility was trying to catch up on completing care plans. On 12/15/22 at 9:22 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that a resident with depression and or post-traumatic stress disorder should have a care plan. The DON stated that she was aware that some care plans were not completed. The DON stated that completing care plans was something that the staff needed more education on. 33215 2. Resident 80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included, but were not limited to, aftercare following joint replacement surgery, encounter for removal of internal fixation device, presence of left artificial hip joint, acute respiratory failure, moderate protein-calorie malnutrition, difficulty in walking, benign prostatic hyperplasia, obstructive and reflux uropathy, hypertension, dementia, and acute kidney failure. Resident 80's medical record was reviewed on 12/13/22. On 11/9/22 at 5:36 PM, a Nurses Note documented cna [Certified Nursing Assistant], [name removed], reported a sore to resident's right heal [sic]. looks like it was a blister that broke open. placed a bandage on it. On 11/10/22 at 2:39 PM, a Nurses Note documented Notified [name of primary care physician removed] of sores on bilat [bilateral] heels. Orders given to place foam heel protectors when resident in bed and in wheelchair. Apply optifoam dressing and change MWF [Monday, Wednesday, Friday]. Both appear to be blister from resting heels of feet on wheelchair. No bleeding or drainage noted. The Order Summary Report was reviewed. A physician's order dated 11/10/22, documented Foam heel protectors while resident in bed or in wheelchair. Optifoam dressing to bilat heels. [Note: The order did not include a start date.] The November 2022 Treatment Administration Record (TAR) was reviewed. The physician's order for the heel treatment was unable to be located on the TAR. A care plan Focus initiated on 11/14/22, documented The resident has potential/actual impairment to skin integrity of the (bilat hip surgical incision, blister bilat heels ) r/t [related to]. The interventions initiated on 11/14/22, included: a. Foam heel protecting boots while in bed and while in wheelchair. b. Keep skin clean and dry. Use lotion on dry skin. Do not apply on (Specify: site of injury). c. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to Medical Director. [Note: The care plan was not updated with the treatment orders.] On 12/14/22 at 2:14 PM, an interview was conducted with the ADON. The ADON stated the staff had a morning stand up meeting and they would go over anything new with a resident. The ADON stated if a resident had a fall, a risk meeting would be held and interventions would be added to the care plan. The ADON stated she would update the resident care plans within 24 hours. On 12/14/22 at 2:16 PM, an interview was conducted with the Wound Nurse. The Wound Nurse stated that the wound specialist came to the facility on ce a week and the Wound Nurse did rounds with the wound specialist. The Wound Nurse stated that the wound specialist addressed everything skin related even surgical wounds. The Wound Nurse stated every time a resident dressing was changed, which was three times a week, the resident care plan would be updated or at least reviewed. On 12/15/22 at 1:01 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated a resident baseline care plan would be completed on admission. The RNC stated the Minimum Data Set nurse would complete the comprehensive care plan within two weeks after admission. The RNC stated the Wound Nurse would update the resident care plan at the time the wound was discovered. The RNC stated the resident care plan should be updated with any changes. The RNC further stated the staff went through the resident care plans quarterly.

Based on interview and record review, the facility did not ensure the residents right to participate in the development and implementation of his or her person-centered plan of care. Specifically, for 1 out of 20 sampled residents, a resident that was admitted to the facility on [DATE], had not had a care conference and the resident was unsure what the plan of care consisted of. Resident identifier: 16 Findings included: Resident 16 was admitted to the facility on [DATE] with diagnoses which include acute osteomyelitis (left ankle and foot), chronic obstructive pulmonary disease, dementia, major depressive disorder, schizoaffective disorder, post-traumatic stress disorder, generalized anxiety disorder, cellulitis of left lower limb, peripheral vascular disease, chronic systolic heart failure, adult failure to thrive, muscle weakness, essential hypertension, and malignant neoplasm of unspecified part of unspecified bronchus or lung. On 12/12/22 at 4:17 PM, an interview with resident 16 was conducted. Resident 16 stated that he was upset because he had been a resident at the facility for over a month and he was unsure of what his plan of care consisted of. Resident 16 stated that he did not know why he was at this facility, and that he did not have any meetings with staff concerning his plan of care. On 12/13/22, resident 16's medical record was reviewed. It was revealed that multiple sections in resident 16's care plan were incomplete. a. The first incomplete focus area stated, The resident has potential/actual impairment to skin integrity of the (SPECIFY location) r/t [related to]. The specific location was not filled out and there was no information given about what the impairment was related to. The goal for this care area stated, The resident's skin injury (SPECIFY) of the (location) will be healed by review date. There was no information given about the specific skin injury or location. The interventions section was left blank. b. The second incomplete focus area stated, Resident requires long term care services related to: There was no further information given. The goal section was left blank. The intervention stated, Provide Care Conference for residents and families. c. The third incomplete focus area stated, The resident has Peripheral Vascular Disease (PVD) r/t. There was no further information given. The goal and the intervention were left blank. d. The fourth incomplete focus area stated, The resident has shortness of breath (SOB) r/t. There was no further information given. The goal stated, The resident will have no complications related to SOB through the review date. The intervention section was left blank. e. There was no behavioral care plan for resident 16's diagnosis of post-traumatic stress disorder. f. There was no behavioral care plan for the resident 16's diagnosis of Major Depressive Disorder. A progress note dated 11/9/22 at 8:57 AM, stated, Care Conference: Attempted to hold care conference for [Resident 16]. He was lying in bed asleep. Asked [resident 16] if he wanted to have conference and he said no. Will attempt at a later day. A review of resident 16's progress notes revealed there were no further attempts to have a care conference with resident 16. On 12/14/22 at 2:16 PM, an interview with the Resident Advocate (RA) was conducted. The RA stated that the goal for new residents was to hold a care conference within the first seven days of the resident being at the facility. The RA stated that after the first care conference, the residents would then have a care conference every three months. The RA stated that care conferences were held to go over the residents' goals and their plan of care. The RA stated that she was unaware if resident 16 ever had a care conference. The RA stated that resident 16 did not want to participate in the first scheduled care conference and she did not know if the meeting was rescheduled. On 12/15/22 at 9:22 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that she had a one-on-one care conference with resident 16 on 12/5/22. It should be noted that 12/5/22, would have been 24 days after resident 16 was admitted to the facility. The DON stated that she spoke with resident 16 about what cares he wanted and his current goals. The DON stated that she did not know if there was any documentation of the care conference. A review of resident 16's medical record revealed that there was no documentation of a care conference.

Based on observation, interview, and record review it was determined, for 2 of 19 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff did not obtain additional medical care for four days after a resident fell causing a broken leg above a recent artificial knee. This delay was determined to have occurred at a harm level. Additionally, a resident was transferred by a Certified Nursing Assistant (CNA) who did not lock the wheelchair wheels during the transfer causing the resident to fall. Resident identifiers: 11 and 22. Findings include: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/17/21 at 3:20 PM, resident 22 was observed rubbing her left knee. Resident 22 was interviewed and stated that she had a fall, had multiple surgeries on her left leg, and had knee pain. On 5/20/21, resident 22's electronic medical record review was completed. On 4/9/21 at 3:24 AM, a nursing note revealed that resident 22 appears very anxious all thur (sic) out evening crying out and on the light most of the night. restless in bed not .restless in bed not keeping [CONDITION(S)] on .on the light often with different needs one being that of pain asked for a pain med which was given around 0100 (1:00 AM) up to bathroom approx. q (every) 3 times using walker. At 0200 (2:00 AM) am pts (patient) yelling out and when entering the room .pt (sic) was found sitting on the floor .sts (states) she fell straight on her butt while leaving the bathroom. pt frightened that her knee replacement could of messed up or reinjured and would this keep her from going home Monday? 0300 (3:00 AM) still upset.light on very often. Because unwitnessed fall pt was placed on freq v/s (vital signs) sheet. Do (sic) to her fear and feeling hopeless will continue with freq v/s and checking on her often as well.icemachine applied to knee replacement. Was a 2 person assist to wheelchair and then assisted to bed On 4/9/21 at 9:10 AM, a nursing note revealed, .resident had a fall during the night. Repositioned he in bed when morning meds were passed and she did it all herself. She then needed the left leg repositioned and again she was asked to straighten and move it over. She did it on her own. Pain medication was given for 5/10 level. She stated it was uncomfortable. Therapy went to get her for therapy and she was screaming in pain at 0900. Ice was applied for the swelling. Called [the surgeon's] office and he is not in today. The nurse instructed us to monitor and take her to the ER if needed. Her next appointment is on April 14th. On 4/9/21 at 4:57 PM, an IDT (interdisciplinary team) event review revealed, .She had ice man on her knee and no changes noted to healed surgical wound. Swelling noted to Left knee . On 4/9/21 at 5:34 PM, a nursing note revealed that resident 22 had been to therapy and tolerated it well. On 4/9/21 the occupational therapy note revealed, On 4/9/21, resident 22 worked with occupational therapy (OT). Patient remarks/goals: Patient had fall at around 2AM while coming out of the bathroom as reported per patient causing increased pain in L knee at 1100 patient reports .zero pain with leg still and 5/10 with movement . Nursing to address [pain.] [Resident 22 was] educated on safety and engaged in bed mobility tasks with mod (moderate) assist due to increased pain in LLE (left lower leg). [Resident 22] engaged in functional reaching tasks in sitting while weight bearing in LLE with increased pain .increased challenge with tasks and compliant with skilled intervention . On 4/9/21, the physical therapy note revealed, Patient presents with increased Left knee pain and swelling due to fall as noted. Patient Left knee will be reassessed after the weekend and has apt. to see the surgeon. The PTA (physical therapy aide) assessed patient's left knee, she reported falling earlier in the am. Knee increased [CONDITION(S)] and pain. Nursing notified surgeon, iced knee and performed gental (sic) PROM (passive range of motion) with knee flex/ext (flexed/extended), static standing and transfers. Resident 22 did not work with therapy on 4/10/21. On 4/11/21, a nursing daily assessment revealed that resident 22 required moderate assistance, an increase from the previous level that required supervision only. Resident 22 worked with occupational therapy on 4/11/21. On 4/11/21, an occupational therapy note revealed, .Patient engaged in bed mobility with mod assist. Patient unable to lift leg in to bed. Patient engaged in repositioning self and reports pain in LLE with movement. Patient engaged in sit to stand and standing activity with walker, but patient unable to bear weight on LLE due to pain Patient engaged in self care tasks in sitting in WC (wheelchair) at sink and repositioning self in prep for self feeding while laying in bed Patient presents with increased difficulty in functional movement due to pain and decreased ability to bear weight on LLE. Barrier to treatment, due to pain consistently > (greater than) 6, current medical schedule causing drowsiness and mental slowing . discussion with interdisciplinary team. On 4/11/21, resident 22 had pain with a high of 8/10 and a low of 4/10. Resident 22's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/12/21, OT summary: .patient engaged in functional transfers with mod/max assist due to increased pain and inability to bear weight on LLE. Patient seen by MD (medical doctor) today and X-rays taken due to decreased stability of knee .barriers impacting treatment: pain consistently > 6, current medical schedule causing drowsiness and mental slowing . The referral form for resident 22's X-ray of her left knee was dated 4/12/21 and stated, Had a fall on 4-9-21. [Surgeon] was made aware. Has a f/u (follow up) [with] him on Wednesday. He encouraged an x-ray if swelling [increased or changed]. Can you perform X-ray @ your clinic today? - or give order to have done at [a local hospital] today? The findings were, X-ray [left] knee. Consulted [surgeon]. Sent to ER. 4 mg (milligrams) of [MEDICATION(S)] given .Progress notes, '[Resident 22] fell on Friday. She went to the restroom [with] assistance or walker. Since that time has had increase pain + swelling in [left] TKA (total knee arthroscopy). Surgery performed on March 2.' New Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Transferred via ambulance to [local hospital]. [Surgeon] contacted. He wants her transported to [another hospital].' On 4/14/21 at 8:12 AM, a hospital note stated that resident 22 was still working with rehabilitation when she had a ground-level fall exiting her bathroom on April 9. She was eventually sent to [a local hospital] due to persistent pain from that fall and they found a left distal femoral periprostehtic fracture, so patient was transferred to [another hospital] for orthopedic management. She underwent a submuscular plating on 4/13/2021 and tolerated this well. On 5/19/21 at 3:25 PM, a physical therapy assistant (PTA) was interviewed. The PTA stated that resident 22 fell overnight on 4/9/21 at about 2:00 AM. The PTA stated that resident 22 was evaluated at about 8:30 AM or 9:00 AM. The PTA stated that resident 22 had a lot more swelling than she had previously. The PTA stated that prior to the fall, resident 22 had minor swelling on the medial (inside) area of the knee, but on 4/9/21 it was significantly more swollen and included the entire knee cap. The PTA stated that she remembered that resident 22 had yelled out in pain when the PTA attempted to manipulate the knee, so the evaluation was discontinued. The PTA stated that when the Physical Therapy Manager (PTM) arrived and evaluated resident 22, she was in less pain, but was not walking. The PTA stated that resident 22 would not let anyone touch her knee and did not fully participate in her therapy. The PTA stated that the therapy staff communicated this change in resident 22's knee to the nursing staff. The PTA stated that resident 22 did not participate in therapy on 4/11/21 and resident 22 needed to use the sit-to-stand lift to transfer. The PTA stated that resident 22 expressed that she was not confident to bear weight on her left leg. The PTA stated that the nursing staff contacted the surgeon and the surgeon's office told the nursing staff to keep an eye on resident 22 and to get her to the emergency room if needed. The PTA stated that on Monday, 4/12/21, resident 22 allowed a physical therapy staff (PTS) to manipulate her leg. The PTA stated that resident 22 was not having much pain, but when therapy moved her leg, they detected some serious issues with the knee. The PTA stated that staff could tell the leg was not right. On 5/20/21 at 6:55 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that resident 22 did not refuse to go out to the hospital after her fall. LPN 3 stated that because resident 22 fell in the middle of the night, resident 22 was not sent to the ER immediately because she was not in a lot more pain. LPN 3 stated that resident 22 was concerned that she messed up her knee replacement. LPN 3 stated that she made a mistake by not sending resident 22 for X-rays. LPN 3 stated that the nursing administration had talked to her about recognizing a change of condition. LPN 3 stated that she did not know why the next nurse did not send resident 22 to the hospital. On 5/20/21 at 7:35 AM, LPN 1 was interviewed. LPN 1 stated that the physical therapy staff worked closely with the nursing staff. LPN 1 stated that often, the nurse would go into therapy when a resident was working out to get a progress report. LPN 1 stated that physical therapy conveyed any new information about a resident to the nurses, as they were right by the nurses' station. LPN 1 stated that therapy also participated in huddles, care conferences, and stand-ups. LPN 1 stated that the facility staff had completed an inservice about recognizing changes of residents' conditions and proper management after this incident. 5/20/21 at 1:41 PM resident 22 was reinterviewed. Resident 22 stated that she did not refuse to go to the hospital or clinic after her fall on 4/9/21. Resident 22 stated that she would have liked an X-ray to make sure her knee was not messed up from the fall. On 5/20/21 at 1:43 PM, the Director of Nursing (DON) was interviewed. The DON stated that she knew about resident 22's fall on 4/9, but was not informed about resident 22's additional knee swelling from 4/9/21 through 4/11/21. The DON stated that she was aware of the examination by therapy on 4/12/21. The DON stated that when resident 22 was not able to bear weight on her leg, she was sent out for X-rays. 2. Resident 11, an [AGE] year old female, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . coli, urinary tract infections, extended spectrum beta lactamase (ESBL) resistance, muscle weakness, [CONDITION(S)], polymyalgia rheumatica, [CONDITION(S)], protein malnutrition, [CONDITION(S)] (TIA), altered mental status, [CONDITION(S)], hypertension, opioid dependence, and dementia. On 5/18/21 at approximately 10:20 AM, resident 11 was observed to have a bandage on her left hand. Resident 11 stated that she hurt her hand, but was unsure what had happened. On 5/18/21, at approximately 9:00 AM, a record review was completed for resident 11. Resident 11's nursing notes revealed that on 5/17/21 at 8:37 PM, Resident was being assisted from her wheelchair to her recliner by [CNA 3] when the resident started to loose her footing she grabbed for her wheelchair and the wheels were not locked causing [Resident 11] to fall to the floor landing on her buttock and hitting her head on the arm of the couch. Resident also [sustained] a skin tear on the back of her left hand during the incident. [Resident 11] was c/o (complaining of) back, pelvis and head pain so ambulance was contacted to transfer her to the hospital. [Resident 11's family] was notified of the situation and her being transferred to the hospital. On 5/18/21 at approximately 10:00 AM, an interview was conducted with registered nurse (RN) 1. RN 1 stated that resident 11 is frequently confused and disoriented. RN 1 stated that resident 11 was not impulsive and always waited for assistance with transfers. RN 1 stated that resident 11 had a fall on 5/17/21 at 8:37 PM, while being assisted with a transfer from her chair to her recliner. RN 1 stated that the resident lost her footing and reached out to the wheelchair for balance. RN 1 stated the wheelchair's wheels were not locked, and the resident fell to the floor on her buttocks, hitting her head on the armrest of the recliner. Resident 11 complained of back, pelvis and head pain, and resident 11 had a skin tear on the back of her left hand. An ambulance was contacted, the MD was notified, and resident 11's family was called. On 5/20/21, at approximately 10:00 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated the proper procedures for transferring a resident from a wheel chair. The DON stated that the staff member should lock the wheels of the wheel chair for the residents' safety.

Based on observation, interview and medical record review, it was determined for 1 of 32 sample residents that the facility did not ensure that a resident with a pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing and to prevent the pressure ulcer from increasing in size. Specifically, one resident did not receive nutritional support, had significant weight loss and a large increase in size of her pressure ulcer. The deficient practice for the resident was found to have occurred at a harm level. Resident identifier: 26. Findings include: HARM 1. Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/4/19 at 12:02 PM, an observation was made of resident 26 in the main dining room as she received her lunch meal. Resident 26 was observed to have chopped roast beef. The majority of the pieces of roast beef measured approximately 2 to 3 inches by 3 to 4 inches. An observation of resident 26's diet card from the facility kitchen, revealed that resident 26 had an order for [REDACTED]. On 3/5/19 resident 26's medical record was reviewed. The facility Admit/Readmit Screener dated 1/28/19 revealed that resident 26 was admitted with a sacrum pressure ulcer. The facility Weekly Wound Observation Tool revealed the following: a. 1/28/19 - Pressure Ulcer Stage: Original 2, Current 2. First observation, [MEDICATION NAME] tissue present, moist. Length 17 mm (millimeters) (1.7 centimeters), Width 20 mm (2 centimeters), Depth 1 mm (0.1 centimeters). First observation. b. 2/4/19 - Pressure Ulcer Stage: Original 2, Current 2. Improving, [MEDICATION NAME] tissue present. Length 25 mm (2.5 centimeters), Width 20 mm (2 centimeters). (NOTE: No depth was recorded on 2/4/19.) c. 2/11/19 - Pressure Ulcer Stage: Original 2, Current 2. Unchanged, Granulation tissue present, moist. Length 10 mm (1 centimeter), Width 18 mm (1.8 centimeters), Depth 2 mm (2 centimeters). No change. d. 2/18/19 - Pressure Ulcer Stage: Original 2, Current 3. Worsening, Granulation tissue present, moist. Odor: yes, slight, musty. Length 6 mm (0.6 centimeters), Width 8 (0.8 centimeters), Depth 2 mm (0.2 centimeters). Decline noted, increased depth, decreased size, purple discoloration to the 5 o'clock position, blanchable redness noted to surrounding tissue. e. 2/25/19 - Pressure Ulcer Stage: Original 2, Current Unstageable. Worsening, Slough tissue. 100% slough. Odor: no. Length 3 cm (centimeters), Width 3 cm, No depth was recorded. Decline. f. 3/4/19 - Pressure Ulcer Stage: Original 2, Current unstageable. Improving, [MEDICATION NAME] tissue present, moist. Smaller size, 95% slough, 5% [MEDICATION NAME]. Odor: No. Length 14 mm (1.4 centimeters), Width 20 mm (2 centimeters), No depth recorded. Smaller size, [MEDICATION NAME] tissue noted to the middle portion of the ulcer. Wound Progress Notes revealed the following entries: a. 1/28/19 at 17:12 (5:12 PM), Stage 2 PU (pressure ulcer), R (right) upper buttock-measures (about) 1.7 x 2 x 0.1 cm. The wound bed has a red area that measures (about) 0.4 cm and the surrounding tissue is denuded. This is superficial. Small amount of yellow, clear, serous exudate is noted. The surrounding tissue is red and blanchable. The resident had no c/o (complaints of) pain r/t (related to) assessment. b. 2/4/19 at 17:34 (5:34 PM), Stage 2 PU, R Buttock-closed. Smooth, pink blanchable [MEDICATION NAME] tissue is noted. State 2 PU, L (left) UPPER BUTT[NAME]K-No change. Measures (about) 2.1 x 1 x 0.1 cm. Wound bed is 100% red. Moderate serous exudate is noted and no odor is noted. No undermining, tunneling or induration is noted. Blanchable redness is noted to the surrounding tissue. The resident has no c/o pain noted with assessmesment (sic) Stage 2 PU, C[NAME]CYX-New. This measures (about) 1 x 1.5 x 0.1 cm. Wound is red and moist. Moderate serous exudate and no odor is noted. no undermining, tunneling or induration is noted. The surrounding tissue is red and blanchable. The resident denies pain with assessment. c. 2/11/19 at 17:41 (5:41 PM), Stage 2 PU, L BUTT[NAME]K-No change noted, measures (about) 1 x 1.8 x 0.2 cm. Wound bed is beefy red. Wound margins are macerated. light serous exudate is noted and no odor noted. no warmth is noted, blanchable redness is noted to the surrounding tissue. The resident has no c/o pain r/t the dressing change. Stage 2 PU, C[NAME]CYX-improved. Wound measures (about) 0.5 x 0.3 x 0.1 cm. Wound bed is 100% red smooth tissue. Scant amount of serous exudateis (sic) noted. No odor is noted. No warmth is noted. The surrounding tissue is red and blanchable. The resident denies pain r/t the dressing change. d. 2/18/19 at 13:55 (1:55 PM), Stage 3 PU, L BUTT[NAME]K-Declined, previously stage 2. Measures (about) 0.6 x 0.8 x 0.2 cm. Wound bed is 100% beefy red tissue. Thin, tan, seroprurulent (sic) exudate is noted. Slight musty odor noted. I noted purple, non blanchable discoloration to the 5 oclock positionto (sic) the surrounding tissue immediate to the margin. Blanchable redness is noted to the remaining surrounding tissue. The resident denied pain with assessment. MD (medical doctor) updated, LAL (low air loss) mattress and pressure gel cushion to WC (wheelchair). Resident oral intake is 52%/7 days e. 2/25/19 at 16:41 (4:41 PM), UNST (unstageable) PU, L BUTT[NAME]K-Decline, measures (about) 3 x 3 x UTD (undetermined) cm. Wound bed is 100% slough. Moderate serous exudate noted. No odor noted. No tunneling, undermining or induration noted. The surrounding tissue is red and blanchable. The resident voiced no c/o pain withassessment (sic). f. 3/4/19 at 18:01 (6:01 PM), UNST PU, L BUTT[NAME]K-Measures 1.4 x 2 x UTD depth cm. Wound bed is 95% slough with 5% [MEDICATION NAME] tissue at the middle of the wound. [MEDICATION NAME] tissue is noted at the edges of the ulcer. Light serous exudate is noted. no odor is noted. No tunneling, undermining, or induration is noted. Blanchable redness is noted to the surrounding tissue. Resident denies pain r/t assessment and dressing change. Stage 2 PU, R buttock-This is a previously closed ulcer. Measures (about) 0.9 x 0.6 x 0.1 cm. 100% red, moist tissue. Light serous exudate is noted. No odor noted. No tunneling is noted. Blanchable redness is noted to the surrounding tissue. The resident denies pain r/t assessment and dressing change. MD updated. The resident receives a Mighty shake once a day as a nutritional supplement. LAL mattress is utilized and pressure reduction cushion is utilized when in the WC. She is repositioned frequently. The Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 26 required extensive one person physical assistance with eating. The facility Tasks revealed that percentages of meal consumption for resident 26 were documented in the following categories: a. 0-25% - 13 meals b. 26-50% - 26 meals c. 51-75% - 15 meals d. 76-100% - 25 meals e. Resident not available - 1 meal f. Resident refused - 2 meals g. Not applicable - 1 meal (NOTE: The diet cards for the residents were shredded after each meal. The percentage of the meal consumed by the resident was documented in a category section under the facility tasks. The actual percentage consumed by resident 26 was not available.) physician's orders [REDACTED]. a. 1/27/19, Regular diet, Mechanical Soft texture, Regular consistency. b. 2/9/19, Mighty Shake one time a day for weight loss. c. 3/5/19, MedPass 2.0 three times a day for weight loss. Resident 26's weight trends included the following: a. 1/27/19 at 5:30 PM - 138.6 pounds b. 2/6/19 at 12:08 PM - 125.4 pounds (NOTE: This was a 9.6% weight loss in 10 days.) c. 2/13/19 at 12:55 PM - 121.8 pounds (NOTE: This was a 2.9% weight loss in 1 week or 12.12% in 17 days. The weight loss noted on 2/13/19 was not addressed by the facility Registered Dietitian.) d. 3/1/19 at 11:04 PM - 111.2 pounds (NOTE: This was a 19.77% weight loss in 33 days. Resident 26 did not have a weight obtained for 17 days between 2/13/19 and 3/1/19 even though she was trending downward.) The Facility Registered Dietitian (RD) notes revealed the following entries: a. 2/5/2019 at 13:58 (1:58 PM), Registered Dietitian Note Text: Pressure Sore, Initial Note 95 yo (year old) female admitted for ortho (orthopedic) aftercare for fx (fractured) r (right) femur, 2 stage 2 pressure sores r/l (right/left) upper buttocks, [MEDICAL CONDITIONS], dementia,[MEDICAL CONDITION](hypertension), alzheimers, UTI (urinary tract infection), depression, anxiety, heart failure, high cholesterol, [MEDICAL CONDITION]. HT (height): 57 WT (weight): 138.6# (1/27/19) 100% of IBW (ideal body weight) IWR (ideal weight range): 121-149# BMI (body mass index): 21.7 DIET: REG (regular)/MS (mechanical soft)/THIN LIQUIDS HEARING: MINIMAL DIFFICULTY VISION: not assessed per screener. AMBULATION: wheelchair- assistance INTAKES: 50% average, about 1500 ml (milliliters) fluid intake/day Resident has refused some care when awake per screener. Confused, able to make needs known. Upper/lower dentures, needs assistance at meals, no long-term artificial nutrition per advanced directives. MEDS (medications):mvi (multivitamin), [MEDICATION NAME] sulfate, [MEDICATION NAME]. allergies [REDACTED].>Calculated needs based on increased needs: Calories: 2195 kcals (kilolcalories)/day (35 kcals/kg (kilogram) ABW (actual body weight) for increased needs) Fluid: 2195 ml (milliliters) fluid (35 ml/kg ABW for increased needs) Protein: 82 gm (grams) protein (1.3 g/kg ABW for increased needs) At risk for poor wound healing, weight loss, skin breakdown and altered nutrition status d/t (due to)increased needs and intake< (less than) needs, low somatic protein status AEB (as evidenced by)intake, pressure sores, calculations and dx (diagnoses). Recommend: 4 oz orange juice BID (twice daily) Mini SNP (supplemental nutrition program) Mighty Shake QD (every day) 2 cal (calorie) medpass 2 oz (ounces) TID (three times daily) Current weight. Will CTM (continue to monitor). (NOTE: The initial note by the facility RD was not completed for 9 days after resident 26 was admitted to the facility. The 9.6% weight loss was not addressed by the facility RD nor did she ask for a current weight on resident 26 for the 2/5/19 visit. Additionally, there was no RD visit or note which addressed the the weight loss on 2/13/19 of 2.9% in one week or 12.12% in 17 days. No orders could be located in the medical record to show that the orange juice BID, the Mini SNP and the 2 cal medpass TID had been implemented into resident 26's diet. The only thing that was added to the diet was the Mighty Shake QD which was added on 2/9/19, 4 days after the recommendation was made.) b. 3/1/2019 at 11:15 AM, Nutrition/Dietary Note Late Entry: Note Text: Nutrition At Risk Review. Resident had significant weight loss. -10.6#, 8.7% in two weeks to 111.2#. Has increased needs with pressure sore. Recommend return to assisted dining room and add Med Pass 2 oz TID. Will CTM . (NOTE: No orders could be located in the medical record to show that the 2 cal medpass TID was added to resident 26's diet until 3/5/19 after it was recommended by the facility RD on two separate occasions, 28 days after the first recommendation and 4 days after the second recommendation. Additionally, resident 26 was not returned to the assisted dining room per the RD recommendations. The facility Director of Nursing (DON) stated that she had placed resident 26 back in the assisted dining room, but because of staffing issues, had not passed the information along to the Certified Nursing Staff (CNA) and resident 26 inadvertently was placed back in the main dining room where there was no staff and no assistance with meals.) c. 3/5/2019 at 10:44 AM, Registered Dietitian Note Text: Pressure Sores Review. 2 pressure sores r/l upper buttocks HT: 57 Admit WT: 138.6#, 11.2# 3/1/19. PO (by mouth) intake 42% (percent). PO intake 68% in assisted dining. DIET: REG/MS/THIN LIQUIDS Supplements: 4 oz orange juice BID Mini SNP 2 cal medpass 2 oz TID MEDS:mvi, [MEDICATION NAME] sulfate, [MEDICATION NAME]. Calculated needs based admit weight and increased needs: Calories: 2195 kcals/day (35 kcals/kg ABW for increased needs) Fluid: 2195 ml fluid (35 ml/kg ABW for increased needs) Protein: 82 gm protein (1.3 g/kg ABW for increased needs) At risk for poor wound healing, weight loss, skin breakdown and altered nutrition status d/t increased needs and intake< needs, low somatic protein status AEB intake, pressure sores, calculations and dx. Recommend: Continue with assisted dining to increase po intake. Encourage increased fluid and food intake. Will CTM (NOTE: The overall weight loss for resident 26 was 27.4 pounds or 19.77% of her total body weight in 33 days. Additionally, there were no labs to indicate what resident 26's nutritional status was and there was no nutrition focused physical exam by the facility RD noting resident 26's appearance.) On 3/06/19 at 4:21 PM, an interview was conducted with the facility Wound Nurse. The facility Wound Nurse stated that she was not aware of the nutritional deficiencies for resident 26 documented by the facility RD. The facility Wound Nurse stated that she was not aware of the significant weight loss for resident 26. The facility Wound Nurse stated that she was not aware that resident 26's nutritional intake was lacking nor that resident 26 did not receive the assistance that she required for nutritional support. The facility Wound Nurse stated that she was not aware of resident 26 not receiving the prescribed diet for nutritional support. The facility Wound Nurse stated that she was not aware that the recommendations made by the facility RD were not implemented. The facility Wound Nurse stated that a lack of protein and nutrition always makes a pressure ulcer worse. The facility Wound Nurse stated that resident 26's pressure ulcer on her buttock was currently unstageable and covered with slough. On 3/5/19 at 2:30 PM, an interview was conducted with the facility Dietary Manager (DM). The facility DM stated that he had been the DM at the facility since (MONTH) (YEAR). The facility DM stated that he was not certified and that he had not enrolled in classes to become certified because he was too busy. The facility DM stated that he had not been trained how to be the dietary manager by the facility. The facility DM stated that he knew the different diets from working at the hospital. The facility DM stated that he had been shown the spreadsheet for modifications for each diet and for textures but did not use the spreadsheet since he had not been trained how to implement the modifications on the spreadsheet. The facility DM provided a handwritten paper that was taped above the food service area that showed instructions for chopped or cut up meat, mechanical soft diets, puree diets and for a controlled carbohydrate diet. The handwritten paper was behind another paper while taped to the food service area. The handwritten paper did not appear to be approved or signed by the facility RD. The facility DM was not able to explain why resident 26 did not receive ground up meat for her mechanical soft diet. On 3/5/19 at 2:36 PM, a telephone interview was conducted with the facility Registered Dietitian (RD). The facility RD stated that she was in the facility one time per week, usually on Fridays for the facility NAR (nutrition at risk) meetings but that she would remotely get onto the computer at home to document meeting notes. The facility RD stated that she had tried to train the facility DM but was told that the prior DM would train him. The facility RD stated that the facility DM did not have time to become certified since he only had time to cook at the facility. The facility DM stated that a mechanical diet would consist of ground meats, and all residents should have their therapeutic diets implemented. The facility RD did not know why resident 26 did not receive a mechanical soft diet. The facility RD stated that getting the correct diets for residents was imperative so that residents were getting the nutrition according to their nutritional needs. The facility RD stated that she had made the recommendation for resident 26 to be moved back to the assisted dining room as she was eating better when she received the assistance that she required. The facility RD stated that nutrition was extremely important for resident's with pressure ulcers. On 3/6/19 at 3:39 PM, an interview was conducted with the facility DON. The facility DON stated that she had placed resident 26 back into the assisted dining room this last weekend per the RD recommendations, but, that due to the lack of staffing in the facility, the Certified Nursing Assistants (CNAs) had not been informed that resident 26 was to be in the assisted dining room. The facility DON stated that because of the miscommunication, the CNAs had placed resident 26 back in the main dining room. The facility DON stated that all residents should have received the diets that had been ordered for them. The facility DON stated that without the proper nutrition, residents would have a difficult time with pressure ulcer healing. Cross refer F-692

Based on observation, interview, and record review it was determined, for 3 of 32 sample residents, that the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, one resident had recommendations by the facility Registered Dietitian that were not implemented and the resident had a weight loss of 19.77% and several residents were observed in the assisted dining room to ask to be fed and not receive the assistance they required. The deficient practice for resident 26 was found to have occurred at a harm level. Resident identifiers: 2, 14 and 26. Findings include: HARM 1. Resident 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/4/19 at 12:02 PM, an observation was made of resident 26 in the main dining room as she received her lunch meal. Resident 26 was observed to have chopped roast beef. The majority of the pieces of roast beef measured approximately 2 to 3 inches by 3 to 4 inches. An observation of resident 26's diet card from the facility kitchen, revealed that resident 26 had an order for [REDACTED]. On 3/5/19 resident 26's medical record was reviewed. The facility Tasks revealed that percentages of meal consumption for resident 26 were documented in the following categories: a. 0-25% - 13 meals b. 26-50% - 26 meals c. 51-75% - 15 meals d. 76-100% - 25 meals e. Resident not available - 1 meal f. Resident refused - 2 meals g. Not applicable - 1 meal (NOTE: The diet cards for the residents were shredded after each meal. The percentage of the meal consumed by the resident was documented in a category section under the facility tasks. The actual percentage consumed by resident 26 was not available.) The Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 26 required extensive one person physical assistance with eating. physician's orders [REDACTED]. a. 1/27/19, Regular diet, Mechanical Soft texture, Regular consistency. b. 2/9/19, Mighty Shake one time a day for weight loss. c. 3/5/19, MedPass 2.0 three times a day for weight loss. Resident 26's weight trends included the following: a. 1/27/19 at 5:30 PM - 138.6 pounds b. 2/6/19 at 12:08 PM - 125.4 pounds (NOTE: This was a 9.6% weight loss in 10 days.) c. 2/13/19 at 12:55 PM - 121.8 pounds (NOTE: This was a 2.9% weight loss in 1 week or 12.12% in 17 days. The weight loss noted on 2/13/19 was not addressed by the facility Registered Dietitian.) d. 3/1/19 at 11:04 PM - 111.2 pounds (NOTE: This was a 19.77% weight loss in 33 days. Resident 26 did not have a weight obtained for 17 days between 2/13/19 and 3/1/19 even though she was trending downward.) The Facility Registered Dietitian (RD) notes revealed the following entries: a. 2/5/2019 at 13:58 (1:58 PM), Registered Dietitian Note Text: Pressure Sore, Initial Note 95 yo (year old) female admitted for ortho (orthopedic) aftercare for fx (fractured) r (right) femur, 2 stage 2 pressure sores r/l (right/left) upper buttocks, [MEDICAL CONDITIONS], dementia,[MEDICAL CONDITION](hypertension), alzheimers, UTI (urinary tract infection), depression, anxiety, heart failure, high cholesterol, [MEDICAL CONDITION]. HT (height): 57 WT (weight): 138.6# (1/27/19) 100% of IBW (ideal body weight) IWR (ideal weight range): 121-149# BMI (body mass index): 21.7 DIET: REG (regular)/MS (mechanical soft)/THIN LIQUIDS HEARING: MINIMAL DIFFICULTY VISION: not assessed per screener. AMBULATION: wheelchair- assistance INTAKES: 50% average, about 1500 ml (milliliters) fluid intake/day Resident has refused some care when awake per screener. Confused, able to make needs known. Upper/lower dentures, needs assistance at meals, no long-term artificial nutrition per advanced directives. MEDS (medications):mvi (multivitamin), [MEDICATION NAME] sulfate, [MEDICATION NAME]. allergies [REDACTED].>Calculated needs based on increased needs: Calories: 2195 kcals (kilolcalories)/day (35 kcals/kg (kilogram) ABW (actual body weight) for increased needs) Fluid: 2195 ml (milliliters) fluid (35 ml/kg ABW for increased needs) Protein: 82 gm (grams) protein (1.3 g/kg ABW for increased needs) At risk for poor wound healing, weight loss, skin breakdown and altered nutrition status d/t (due to)increased needs and intake< (less than) needs, low somatic protein status AEB (as evidenced by)intake, pressure sores, calculations and dx (diagnoses). Recommend: 4 oz orange juice BID (twice daily) Mini SNP (supplemental nutrition program) Mighty Shake QD (every day) 2 cal (calorie) medpass 2 oz (ounces) TID (three times daily) Current weight. Will CTM (continue to monitor). (NOTE: The initial note by the facility RD was not completed for 9 days after resident 26 was admitted to the facility. The 9.6% weight loss was not addressed by the facility RD nor did she ask for a current weight on resident 26 for the 2/5/19 visit. Additionally, there was no RD visit or note which addressed the the weight loss on 2/13/19 of 2.9% in one week or 12.12% in 17 days. No orders could be located in the medical record to show that the orange juice BID, the Mini SNP and the 2 cal medpass TID had been implemented into resident 26's diet. The only thing that was added to the diet was the Mighty Shake QD which was added on 2/9/19, 4 days after the recommendation was made.) b. 3/1/2019 at 11:15 AM, Nutrition/Dietary Note Late Entry: Note Text: Nutrition At Risk Review. Resident had significant weight loss. -10.6#, 8.7% in two weeks to 111.2#. Has increased needs with pressure sore. Recommend return to assisted dining room and add Med Pass 2 oz TID. Will CTM . (NOTE: No orders could be located in the medical record to show that the 2 cal medpass TID was added to resident 26's diet until 3/5/19 after it was recommended by the facility RD on two separate occasions, 28 days after the first recommendation and 4 days after the second recommendation.) c. 3/5/2019 at 10:44 AM, Registered Dietitian Note Text: Pressure Sores Review. 2 pressure sores r/l upper buttocks HT: 57 Admit WT: 138.6#, 11.2# 3/1/19. PO (by mouth) intake 42% (percent). PO intake 68% in assisted dining. DIET: REG/MS/THIN LIQUIDS Supplements: 4 oz orange juice BID Mini SNP 2 cal medpass 2 oz TID MEDS:mvi, [MEDICATION NAME] sulfate, [MEDICATION NAME]. Calculated needs based admit weight and increased needs: Calories: 2195 kcals/day (35 kcals/kg ABW for increased needs) Fluid: 2195 ml fluid (35 ml/kg ABW for increased needs) Protein: 82 gm protein (1.3 g/kg ABW for increased needs) At risk for poor wound healing, weight loss, skin breakdown and altered nutrition status d/t increased needs and intake< needs, low somatic protein status AEB intake, pressure sores, calculations and dx. Recommend: Continue with assisted dining to increase po intake. Encourage increased fluid and food intake. Will CTM (NOTE: The overall weight loss for resident 26 was 27.4 pounds or 19.77% of her total body weight in 33 days. This would be classified as severe weight loss Additionally, there were no labs to indicate what resident 26's nutritional status was and there was no nutrition focused physical exam by the facility RD noting resident 26's appearance. The height recorded in the hospital History and Physical show that resident 26's height was 5 feet 4 inches, not the 4 feet 9 inches recorded by the facility RD, indicating that the calculations could be off for resident 26's BMI.) On 3/5/19 at 2:30 PM, an interview was conducted with the facility Dietary Manager (DM). The facility DM stated that he had been the DM at the facility since (MONTH) (YEAR). The facility DM stated that he was not certified and that he had not enrolled in classes to become certified because he was too busy. The facility DM stated that he had not been trained how to be the dietary manager by the facility. The facility DM stated that he knew the different diets from working at the hospital. The facility DM stated that he had been shown the spreadsheet for modifications for each diet and for textures but did not use the spreadsheet since he had not been trained how to implement the modifications on the spreadsheet. The facility DM provided a handwritten paper that was taped above the food service area that showed instructions for chopped or cut up meat, mechanical soft diets, puree diets and for a controlled carbohydrate diet. The handwritten paper was behind another paper while taped to the food service area. The handwritten paper did not appear to be approved or signed by the facility RD. The facility DM was not able to explain why resident 26 did not receive ground up meat for her mechanical soft diet. On 3/5/19 at 2:36 PM, a telephone interview was conducted with the facility Registered Dietitian (RD). The facility RD stated that she was in the facility one time per week, usually on Fridays for the facility NAR (nutrition at risk) meetings but that she would remotely get onto the computer at home to document meeting notes. The facility RD stated that she had tried to train the facility DM but was told that the prior DM would train him. The facility RD stated that the facility DM did not have time to become certified since he only had time to cook at the facility. The facility DM stated that a mechanical diet would consist of ground meats, and all residents should have their therapeutic diets implemented. The facility RD did not know why resident 26 did not receive a mechanical soft diet. The facility RD stated that getting the correct diets for residents was imperative so that residents were getting the nutrition according to their nutritional needs. The facility RD stated that she had made the recommendation for resident 26 to be moved back to the assisted dining room as she was eating better when she received the assistance that she required. On 3/6/19 at 3:39 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that she had placed resident 26 back into the assisted dining room this last weekend per the RD recommendations, but, that due to the lack of staffing in the facility, the Certified Nursing Assistants (CNAs) had not been informed that resident 26 was to be in the assisted dining room. Because of the miscommunication, the CNAs had placed resident 26 back in the main dining room. The facility DON stated that they had one person who was assigned to get weights on the residents, but, that due to the lack of facility staffing, other CNAs were trying to do weights if the assigned person was working the floor and the weights got missed at times. The facility DON stated that all resident's should have received the diets that had been ordered for them. Cross refer F-686 Not Harm: 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/4/19 at 11:00 AM, resident 2 was observed eating lunch alone in her room. Resident 2 was non-conversant but it was observed 50% of her meal had been eaten when dietary staff retrieved lunch trays. On 3/5/19 at 07:27 AM, a breakfast tray was observed being left on resident 2's bedside table by dietary staff while resident 2 was asleep in bed. Resident 2 awoke at 7:50 AM, sat up in bed and began feeding herself. At 8:15 AM the resident was observed back in her bed asleep. An observation of resident 2's breakfast meal revealed that two small bites taken out of her meal. The meal consisted of 2 eggs over easy, a round sausage cut into 1.5 inch pieces, and wheat toast. On 3/5/19 resident 2's medical record was reviewed. Resident 2's weights were recorded as follows: a. 1/01/2019 07:47 90.8 lbs (Pounds) b. 2/28/2019 15:42 85.2 lbs (NOTE: Resident 2 experienced a 6.17% weight loss.) The Dietary Care Plan dated 1/14/19 for resident 2 revealed the following: a. Focus area: The resident has unplanned/unexpected weight loss r/t (related to) poor food intake. b. Goals: The resident will consume 50% of three meals/day. The resident will regain 1-2 lbs (pounds) per month. c. Interventions: Give the resident multivitamin as ordered. Update snack preferences to snacks TID (three times a day), magic cup (high protein supplemental snack) and Mini SNP (supplemental protein addition to meals). Offer assistance at meals. If weight decline persists, contact physician and dietician immediately. Nursing progress notes revealed the following entries: a. 2/4/2019 at 10:14 AM, Registered Dietitian Note. Note Text: Significant Weight Change. -5% in 1 month, -7.5% 3 months, -10% 4 months .May need additional assistance at meals or/and appetite stimulant. Recommend: update preferences, update snack preferences -Snacks TID, Mini SNP, Magic Cup, TID . b. 2/18/2019 at 14:43 (2:43 PM), Registered Dietitian Note. Note Text: Annual nutrition note. Resident's weight has decreased past year approx. 10 lbs .It may be helpful for her to have assistance at meals .Resident is at risk for weight loss d/t (due to) po (by mouth) intake less than needs .Recommend: MVI (multivitamin) 8 oz (ounces) extra fluid at meals and between meals. Encourage food and fluid intake. Offer assistance at meals as needed. c. 3/1/2019 at 11:24 AM, Nutrition/Dietary Note. Note Text: Nutrition At Risk Review. Resident had significant weight loss -3.4 lbs .PO intake decreased 46% to 25%. Resident does not want to attend assisted dining and wants to eat in the room. Recommend encourage increased PO intake and offer assistance with meals in room . 3. Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/5/19 at 07:00 AM, breakfast was observed in the assisted dining room. CNA 3 was observed in the assisted dining room with 7 residents. Resident 14 was brought into the room at 7:10 AM. A food tray was placed in front of resident 14. Resident 14 received no help or supervision with her meal. The meal consisted of whole mini-pancakes, whole slices of bacon, and coffee. On 3/5/19 resident 14's medical record was reviewed. Resident 14's weights were recorded as follows: a. 1/03/2019 08:02 153.2 Lbs b. 2/06/2019 12:08 142.8 Lbs (6.79% loss since last weight) c. 2/28/2019 14:33 140.9 Lbs (6.9% loss since last weight) (NOTE: Resident 14 experienced an 8.03% weight loss since (MONTH) 3, (YEAR).) The Minimum Data Set (MDS) documenting resident 14's functional status indicated she required supervision and required a one person physical assist when eating meals. The Dietary Care Plan dated 1/10/19 for resident 14 revealed the following: a. Focus area: The resident has unplanned/unexpected weight loss r/t poor food intake. b. Goals: The resident will consume 50% of three meals/day. The resident will regain 1-2 lbs per month. c. Interventions: Give the resident multivitamin as ordered. Update snack preferences to snacks TID, magic cup and Mini SNP. Offer assistance at meals. If weight decline persists, contact physician and dietician immediately. The following progress note related to resident 14's weight loss revealed: a. 2/19/2019 15:24 (3:24 PM), Registered Dietitian. Note Text: Annual nutrition note. PO intake has decreased per nutrition report from 61% to 13% past month .At risk for continued weight loss d/t po intake < (less than) needs AEB (as evidenced by) recent significant weight loss and low appetite. Recommend: Mini SNP and Magic Cup QD (four times a day), MVI, DM to update resident's preferences . On 3/06/19 at 2:51 PM, the DON was interviewed. The DON stated, I have a weekly meeting with the RD and we discuss resident weights and who's care plan needs to be updated. When asked about resident 14's weight loss the DON stated she was not aware of the extent of resident 14's weight loss until just now. On 3/6/19 at 9:00 AM, the Registered Dietician (RD) was interviewed via phone. The RD stated, The diet recommendations I make are done in conjunction with the director of nursing (DON) on Fridays when we have our weekly weights meeting. I email meeting notes to the DON and the dietary manager (DM) and it's then up to the DM to implement these recommendations. I work remotely but when I'm back in the office on Fridays I follow up with the DM. On 3/6/19 at 3:00 PM, the DM was interviewed. When asked for a list of resident dietary orders and preferences he stated, Well, there's a book somewhere that lists all that stuff but I don't know where. But, the dietician emails us updates. When asked for the most current email he went to his computer and pulled up a record of received emails. He then stated, The latest email I have from dietary is dated (MONTH) 28th 2019. When asked if the kitchen staff are aware of resident's most current resident diet recommendations the DM stated, I don't know. When asked if residents 2 and 14 were receiving a Mini SNP diet, Med Pass, or a Magic Cup, the DM stated, I don't know. (NOTE: No observation was made of resident 14 receiving med pass, a magic cup nor of a mini SNP diet.)

Based on observations, interviews, and record review, the facility did not ensure that a resident received the necessary treatment and services to prevent aspiration pneumonia, vomiting, dehydration, and metabolic abnormalities. This failure created a situation of Immediate Jeopardy which had a potential for causing death or injury to a resident in the facility. The deficient practice identified for resident 75's positioning while tube feeding was infusing was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for resident 75 in regards to hyrdation and resident 57 in regards to not receiving tube feeding upon admission were found to have occurred at a no actual harm with potential for more than minimal harm and will not be included in the Immediate Jeopardy. Resident identifiers: 57 and 75. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator on 6/9/15 at approximately 4:15 PM. The Administrator was asked to develop an immediate plan of correction to ensure resident safety related to enteral feedings with appropriate assessments and positioning during feedings. PLAN: On 6/9/15 at approximately 7:15 PM, the Administrator provided the surveyors with a written plan of action to remove the Immediate Jeopardy to resident 75. The written plan, dated 6/9/15, stated the following: June 9, 2015 State of Utah Department of Health 3760 S Highland Drive, Suite 200 P.O. Box 3 Salt Lake City, UT -4103 RE: Plan of Correction for I.J. (Immediate Jeopardy) . F322 To Whom It May Concern: I am respectfully submitting the following Plan of Correction for resident (75). (Resident 75), who was admitted on [DATE], with [DIAGNOSES REDACTED]. (sic) It was noted by the survey team that this resident's bed was not elevated during tube feedings administration. Facility policy and resident's careplan (sic) indicate that during enteral feedings the head of the bed shall be at least 30 degrees or more during feedings. Facility immediately intervened with the following plan of correction: · Resident's bed was measured with a goniometer to at 30 degree angle. · Resident's bed was disabled and locked in a 30 degree position. · Orders were entered for nursing staff to check resident every two hours to ensure head of bed remains elevated. · Resident was immediately assessed for s/s (signs or symptoms) of aspiration and found to be without any signs or symptoms of aspiration. · An order was implemented to ensure both residents are checked every shift for signs and symptoms of aspiration pneumonia. (SOB (Shortness of Breath), wheezing, cyanosis, cough). · Resident (57) who also is on enteral feedings was checked for appropriate bed position and any potential aspiration signs and symptoms. None were found. · Current P&P (Policy and Procedure) was reviewed and clinical staff trained regarding the P&P on Enteral Feeding Administration and complications of enteral feedings. · A training program was developed that included: Enteral feeding process and assessment for potential enteral feeding complications. Post-test developed to ensure knowledge-based competency. All clinical staff to be trained and tested for competency by 6/10/15. We respectfully submit this plan of correction for your consideration. The Immediate Plan of Correction was signed and dated by the facility Administration. Prior to leaving the facility on 6/9/15, the surveyors confirmed the components outlined above in the written plan of action had been implemented. On 6/10/15 at approximately 4:15 PM, the facility Administrator provided a credible allegation that the Immediate Jeopardy had been removed as of 6/10/15 at 4:00 PM. On 6/10/15 at 4:15 PM, while completing the recertification and extended survey, surveyors confirmed the facility had implemented corrective action and that the Immediate Jeopardy had been abated as alleged. Upon removal of the Immediate Jeopardy, the remaining non-compliance of F-322 was determined to represent a potential for more than minimal harm with no actual harm. A. Immediate Jeopardy: Resident 75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The following observations were made of resident 75: a) On 6/8/15 at 10:40 AM, an initial tour was conducted of the facility. Resident 75 was observed laying in his bed with the head of the bed at approximately less than a 15 degree angle. Resident 75's tube feeding formula bag was labeled [MEDICATION NAME] 2.0 and was observed infusing at 24 ml (millimeters) per hour. b) On 6/8/15 at 2:00 PM, an observation was made of resident 75. Resident 75 was observed laying in bed with the head of the bed not elevated. Resident 75's tube feeding formula bag was labeled [MEDICATION NAME] 2.0 and was observed infusing at 24 ml per hour. c) On 6/8/15 at 4:05 PM, an observation was made of resident 75. Resident 75 was laying with his head of bed at approximately less than a 15 degree angle. Resident 75's tube feeding formula bag was labeled [MEDICATION NAME] 2.0. The tube feeding was observed infusing at 24 ml per hour. d) On 6/9/15 at 7:10 AM, an observation was made of resident 75. Resident 75 was observed laying in bed with his head of bed flat and the foot of resident 75's bed at approximately a 15 degree angle. The tube feeding formula bag was labeled [MEDICATION NAME] 2.0 and was infusing at 24 ml per hour. e) On 6/9/15 at 1:35 PM, an observation was made of resident 75. Resident 75 was laying in bed with his head of the bed at approximately less than a 15 degree angle. Resident 75 had a tube feeding bag labeled [MEDICATION NAME] 2.0 and was infusing at 24 ml per hour. f) On 6/9/15 at 2:05 PM, an observation was made of resident 75. Resident 75's head of bed was not elevated. Licensed Practical Nurse (LPN) 1 was observed to disconnect resident 75's feeding tube. CNA (Certified Nurses Assistant) 1 was observed to transfer resident 75 to a shower gurney, on which he was laying flat. g) On 6/9/15 at 3:00 PM, an observation was made of resident 75. Resident 75's was laying in bed with his head of the bed not elevated. Resident 75's tube feeding was connected to the pump with formula infusing at 24 ml/hr. Resident 75's medical record was reviewed on 6/8/15 and 6/9/15. Resident 75's nurses notes revealed the following entries: a) 5/15/15, .Can express agitation and pain but can not verbalize needs. [MEDICAL CONDITION] with humidification system and suction at bedside. Has clear frothy secretions. Has a G (gastrostomy) tube. b) 5/16/15, .I (nurse) suctioned [MEDICAL CONDITION] white, frothery (sic) secretions came out. All staff have been advised to check on him as they walk past his room to make sure he hasn't pulled any of his tubing. c) 5/25/15, .Suctions [MEDICAL CONDITION] with minimal output noted. d) 5/26/15, Resident not appearing to feel well; check temperature, fever present of 100.5 (degrees fahrenheit); gave Tylenol to reduce fever; no apparent problems at this time; will continue to monitor. e) 5/29/15, Resident has thick, frothy sputum draining [MEDICAL CONDITION] neck. Suctioned resident 3x (times) and cleaned him up. Notified Doctor (house physician) who advised to keep suctioning and notify Doctor (primary care physician). f) 5/30/15, .Trach needs to be suction frequently. Producing clear to yellowish color sputum.[MEDICAL CONDITION] in place and functioning. g) 5/31/15 at 4:02 AM, Resident has been experiencing an increase in heart rate tonight staying between 120-130 bpm (beats per minute), coughed up sputum and suctioned to remove excess secretions, . h) 5/31/15 at 6:00 AM, Resident began vomiting, suctioned resident to clear airways, sats (saturations) began dropping into the low 80s, began coughing and gagging on fluid and continued to suction. Oxygen was increase to 10L (liters) to try to oxygenate, ambulance was called and resident will be sent to (name of local hospital) for evaluation. i) 6/2/15, Resident vomited at approximately 0645 (6:45 AM); stopped feeing (sic) till 0830 (8:30 AM). j) 6/4/15, .suctioned several times; [MEDICAL CONDITION] and changed ties; [MEDICAL CONDITION] cleaned with hydrogen peroxide and sterile water; large amount of mucous removed from trach; early suctioning resulted in removed hard mucous plus; yellowish green in color; mucous cleaned [MEDICAL CONDITION] removal was white in color and thick. k) 6/6/15, Resident coughing up secretions and brownish colored sputum. Cleansed mask and suctioned trach.While resident sitting up he spit up copious amounts of brown [MEDICATION NAME] sputum. Resident 75's physician order [REDACTED]. (Note: On 6/9/15 at 2:05 PM, an observation was made of resident 75 being disconnected from his tubefeeding and resident 75 was continued to be positioned without the head of the bed elevated.) Resident 75's care plan dated 5/27/15 revealed a problem of (Resident 75) has a G tube for nutrition r/t (related to) larynx disease, treachostomy. Resident 75's goal was, . will maintain a stable weight x 90 days. The approaches developed for resident 75 to achieve the goal were, Tube feeding as ordered, Flush G tube with H2O (water) as ordered, elevate HOB to 30 degrees for feeding, monitor for aspiration, notify RP/MD (Medical Doctor) for any changes of condition. On 6/9/15 at 2:05 PM, an interview was conducted with CNA 1. CNA 1 stated that staff did not elevate resident 75's head while in bed. CNA 1 stated that if resident 75 had a hard time breathing then the nurses would perform CPT (chest percussion therapy) or suction his [MEDICAL CONDITION]. On 6/9/15 at 3:15 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that residents requiring tube feedings needed to have the head of the bed elevated to at least a 30 degree angle. RN 3 was shown the position that resident 75 was in. RN 3 stated that resident 75's head of bed was not elevated to at least a 30 degree angle. On 6/9/15 at 3:17 PM, an interview was conducted with CNA 2. CNA 2 stated that there were two residents who had to have their beds flat, but was unaware of any residents with medical conditions that required the heads of their beds to be elevated. On 6/9/15 at 3:20 PM, an interview was conducted with CNA 3. CNA 3 was unsure of any residents with medical conditions that required the heads of their beds to be elevated, and clarified with another staff member if there were any. CNA 3 stated, after consultation, that there were two residents in the building (resident 57 and 75) who needed to have the head of their bed elevated at 30 degrees while their tube feedings were connected and running. On 6/9/15 at 3:22 PM, LPN 1 was interviewed. LPN 1 stated that residents that required tube feedings were to have the head of the bed elevated to a 30 degree angle. LPN 1 further stated that resident 75's legs were elevated to prevent resident 75 from sliding down in the bed. On 6/9/15 at 3:13 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that residents that required a tube feeding needed to have the head of their beds elevated to a 30-50 degree angle during feedings. The DON stated that resident 75 needed to be elevated 30 to 50 degrees for a half hour after the tube feeding was infused. The DON stated that resident 75 started to have projectile fluid out of [MEDICAL CONDITION] 5/31/15. The DON stated that resident 75 was sent to the emergency room of the hospital. The DON stated that a chest x-ray was obtained and there was no evidence of aspiration pneumonia. B. POTENTIAL FOR HARM: 1. Resident 75 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 75's medical record was reviewed on 6/8/15 and 6/9/15. Resident 75's physicians orders revealed the following: a) On 5/15/15, [MEDICATION NAME] 2.0 (nutritional supplements) liquid; -; amt (amount): 250ml; oral Special Instructions: Dilute with 300 ml of sterile water. b) On 5/21/15 revealed, [MEDICATION NAME] 2.0 (nutritional supplements) liquid; -; amt: 250ml; oral Special Instructions: Run 45ml/hr for 22 hours a day. c) On 6/4/15 revealed, [MEDICATION NAME] 2.0.24mL (times) 22 hours. Resident 75's May 2015 Medication Administration Record [REDACTED] a) From 5/16/15 through 5/20/15 resident 75 was administered [MEDICATION NAME] 2.0 250 ml. Special instructions for resident 75 revealed, Dilute with 300 ml of sterile water. Run at 45 ml/hr for 24 hours a day. b) From 5/21/15 through 5/30/15 resident 75 was administered [MEDICATION NAME] 2.0 with Special Instructions to Run at 45ml/hr for 22 hours a day. (Note: Resident 75 was not administered free water flushes from 5/21/15 until 5/28/15.) Resident 75's RD (Registered Dietician) notes revealed the following: a) On 5/21/15, Resident admitted . Diet: NPO (nothing orally) TF (tube feeding): [MEDICATION NAME] 45 ml/hr x 24 hrs. Dilute with 300 ml sterile water. Provides 2160 kcals (calories), 86 g (grams) pro (protein), 1236 ml H20 (water).Recommend changing to [MEDICATION NAME] 45 ml/hr x 22 hrs. Flush with 100 ml H20 Q (every) 4 hrs (6(times per) day). Flush 30-50 ml H20 before and after meds. This provides 1980 kcals (kilocalories), 79 g pro, 1533 ml H20 .which better meets nutrition needs. Check BMP (Basic Metabolic Panel) for hydration status. CTM (continue to monitor) wts (weights) and adjust PRN (as needed). b) On 5/28/15, Noted 5/26 BMP (elevated) Na (Sodium) 158.[MEDICATION NAME] running 45 ml/hr (times) 22 hrs. No flush noted. Please Flush with 150 ml H20 Q (every) 4 hrs (6 (times per) day). Flush 30-50 ml H20 before and after meds (medications). Please check BMP. Resident 75's laboratory values were reviewed and revealed the following: a) On 5/26/15 a BMP was collected: i. Sodium level: 158 which was noted to be high. Normal levels according to the laboratory results form were 134-146 mmol/L (millimol per liter). ii. Chloride level: 120 was noted to be high. Normal levels according to the laboratory results from were 98 - 107 mmol/L. b) On 5/31/15 a CMP was collected at 7:12 AM: i. Sodium level: 166 which was noted to be critically high. ii. Chloride level: 126 which was noted to be high. iii. BUN (blood urea nitrogen) level: 37 mg/dL (milligrams per deciliter) which was noted to be high. Normal levels according to the laboratory results form were 7-22. iv. Magnesium level: 3.0 mg/dL which was noted to be high. Normal levels according to the laboratory results form were 1.8 - 2.4. c) On 5/31/15 a BMP was collected at 8:05 PM at the local hospital: i. Sodium level: 165 which was noted to be critically high. ii. Potassium: 3.4 mmol/L was noted to be low. Normal potassium levels according to the laboratory results form were 3.5-5.1. iii. Chloride level: 125 which was noted to be high. iv. BUN level: 32 mg/dL (milligrams per deciliter) which was noted to be high. Resident 75's History and Physical from the emergency room visit dated 5/31/15 revealed, .Impression:.2. [MEDICAL CONDITION]. Plan: 1. We will go ahead and place him on a D ([MEDICATION NAME])-5 half normal. 3. Follow-up labs later tonight and in the morning. On 6/9/15 at 3:13 PM, an interview was conducted with the facility DON. The DON stated that resident 75 was admitted from home with orders to dilute sterile water into tube feeding formula. The DON stated the the RD changed resident 75's tube feeding to have the formula with separate water flushes. The DON stated that resident 75 had a high sodium level on 5/26/15 and fluids were increased after the high sodium level. The DON stated that resident 75 was discharged to the local emergency room (ER). The DON stated that she was resident 75's ER nurse. The DON stated that resident 75 had elevated sodium level in the ER. The DON stated that upon admission to the hospital she discussed resident 75's elevated sodium level with the facility physician. The DON stated that she told the facility physician that resident 75's fluids were increased and continued to have evaluated sodium levels. The DON stated she did not know that resident 75 did not have documented flushes from 5/18/15 through 5/21/15. On 6/9/15 at 5:45 PM, an interview was conducted with the facility RD. The RD stated that resident 75 was not receiving enough fluid upon admission. The RD stated that resident 75 did not have orders for flushes upon admission. The RD stated that after resident 75's Initial Nutritional Assessment, she recommended to start flushes because mixing the formula and free water made calculating actual fluid intake difficult. The RD confirmed that she documented resident 75 was not receiving flushes of free water. The RD stated after resident 75 had an increased sodium level she recommended to increase the amount of fluids administered to resident 75. On 6/10/15 at 1:58 PM, an interview was conducted with the Facility Physician. The Physician stated that resident 75 needed free water flushes. The Physician stated that a sodium level could be decreased within 2 days after receiving hydration. The Physician further stated that he consulted with resident 75's Primary Care Physician (PCP) the day after admitting to the local hospital. The Physician stated that resident 75's PCP had a SWAG (scientific wild a** guess) that resident 75 had diabetes insipidus. The Physician stated that resident 75 was recently started on a new medication for the diabetes insipidus and resident 75's sodium level was decreasing. On 6/10/15 at 5:40 PM, an interview was conducted with resident 75's PCP. The PCP stated that resident 75's mother was under the care of his home health care company. The PCP stated that he was not resident 75's PCP prior to admission. The PCP stated that he wrote orders to admit resident 75 to the nursing home but had not assessed resident 75. The PCP stated that resident 75 did not have any basic laboratory values or clinical information prior to admission. The PCP stated that he assessed resident 75 in the Intensive Care Unit (ICU) on 6/1/15. The PCP stated that resident 75 had a high sodium level. The PCP stated that the facility physician was consulted and increasing fluids was discussed. The PCP stated he was not aware that resident 75 did not receive free water for 7 days prior to hospital admission. The PCP stated that was very concerning for resident 75's health. The PCP stated that resident 75 was started on new medications for diabetes insipidus. The PCP stated that resident 75's sodium level was decreasing after starting medications. 2. Resident 57 was admitted to the facility on [DATE] and last readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 57's medical record was reviewed on 6/10/15. Resident 57's April 2015 MAR (medication administration record) was reviewed and revealed that on 4/9/15 the [MEDICATION NAME] 1 Calorie was not administered. The reason resident 57 was not administered [MEDICATION NAME] 1 Calorie was because not able to locate pole and pump. On 6/11/15 at 9:46 AM, an interview was conducted with the DON. The DON stated that resident was admitted on [DATE] and the [MEDICATION NAME] was administered starting on 4/10/15. The DON stated that she did not know why there was not a pump and pole available on 4/9/15.

Based on interview and record review it was determined that the facility did not ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. In addition, the facility did not ensure that a resident having a pressure ulcer received the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Specifically, 2 of 25 sample residents developed pressure ulcers after admission; the facility nursing staff did not obtain orders for treatment to one pressure ulcer for 10 days after it was identified; the facility Registered Dietitian recommended nutritional interventions for wound healing which were not implemented by the facility staff for 17 days after the recommendation was made. The deficient practice identified in pressure ulcers for resident's 54 and 56 was found to have occurred at a Harm level. Resident identifiers: 54 and 56. Findings include: 1. Resident 56 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 56's medical record was reviewed on 4/15/14. Resident 56's Braden Scale for predicting pressure ulcer risk dated 10/9/13, revealed that resident 56 was not at risk for developing pressure ulcers. On 10/16/13, the facility licensed nursing staff completed an admission Minimum Data Set (MDS) assessment for resident 56. The MDS revealed that resident 56 did not have any unhealed pressure ulcers upon admission to the facility, but was at risk for developing pressure ulcers. The skin and ulcer treatments on the MDS included a pressure reducing device to the chair and a pressure reducing device to the bed. The MDS showed that resident 56 required extensive assistance with bed mobility and transfers. The nursing staff documented on the MDS that resident 56 had not exhibited any rejection of cares. On 11/6/13, the facility nursing staff completed a 30 day MDS assessment for resident 56. The MDS revealed that resident 56 did not have any unhealed pressure ulcers, but was at risk for developing pressure ulcers. The skin and ulcer treatments on the MDS included a pressure reducing device to the chair and a pressure reducing device to the bed. The MDS showed that resident 56 required extensive assistance with bed mobility and transfers. The nursing staff documented on the MDS that resident 56 had not exhibited any rejection of cares. On 12/4/13, the facility nursing staff completed a 60 day MDS assessment for resident 56. The MDS revealed that resident 56 did not have any unhealed pressure ulcers, but was at risk for developing pressure ulcers. The skin and ulcer treatments on the MDS included a pressure reducing device to the chair and a pressure reducing device to the bed. The MDS showed that resident 56 required extensive assistance with bed mobility and transfers. The nursing staff documented on the MDS that resident 56 had not exhibited any rejection of cares. On 1/8/14, the facility nursing staff completed a quarterly review MDS assessment for resident 56. The MDS revealed that resident 56 did not have any unhealed pressure ulcers, but was at risk for developing pressure ulcers. The skin and ulcer treatments on the MDS included a pressure reducing device to the chair and a pressure reducing device to the bed. The MDS showed that resident 56 required extensive assistance with bed mobility and transfers. The nursing staff documented on the MDS that resident 56 had not exhibited any rejection of cares. On 1/15/14, the facility nursing staff completed a significant change MDS assessment for resident 56. The MDS revealed that resident 56 had developed 2 pressure ulcers which were unstageable due to coverage of the wound bed by slough and/or eschar, was at risk for developing pressure ulcers, and was to receive a pressure reducing device to the chair and bed for skin and ulcer treatments. The nursing staff documented on the MDS that resident 56 had not exhibited any rejection of cares. (Note: No documentation could be located to indicate that a pressure reducing device was placed to resident 56's bed until 2/24/14. On 2/24/14 a physician's orders [REDACTED]. The Treatment Administration Record (TAR) also revealed that an air overlay mattress was implemented on 2/24/14.) On 2/28/14, the facility nursing staff completed a discharge MDS assessment for resident 56. The MDS revealed that resident 56 had two stage 2 pressure ulcers, one stage 3 pressure ulcer, and one unstageable pressure ulcer. (Note: Based on the admission MDS assessment, resident 56 did not have any pressure ulcers upon admission to the facility.) On 10/14/13, the facility nursing staff created a care plan for resident 56. The care plan revealed that resident 56 was "At risk for altered skin integrity, pressure ulcers, skin tears, abrasions, bruising, etc(etcetera) due to Diabetes, recent fx (fracture), cardiovascular disease, hx( history)of falls, sleep apnea, reflux, depression, [MEDICAL CONDITION], restless leg syndrome, impaired mobility, needs assistance with ADLs, incontinence, anti-anxiety use, anti-depressant use, narcotic [MEDICATION NAME] use, diuretic use, hypoglycemic use, hypnotic use, oxygen use." The goals on the care plan were "Risk will be reduced and skin issues will be promptly identified and treatment initiated timely daily thru next 90 days. " The approaches on the care plan included "(1) Skin check by CNA (Certified Nursing Assistant); (2) Change disposable undergarment after each incontinent episode as needed; (3) Podiatry care PRN (as needed) [DIAGNOSES REDACTED] toenails; (4) Diet as ordered; (5) Skin check Q (every) week by LN (Licensed Nurse); (6) Observe for S/S (signs and symptoms) of breakdown such as redness, excoriation, open area, etc, and notify MD (Medical Doctor); (7) Proper incontinent care after each incontinent episode with soap and water if applicable; (8) Bed linens, clothing and underpads smooth and free of wrinkles; (9) Keep skin clean and dry; (10) Pressure reducing mattress for pressure relief; (11) Position with pillows as needed to prevent added pressure to body prominences; (12) Reposition frequently as tolerated; (13) Protective ointment to buttocks and coccyx BID (twice a day) and PRN." (Note: The care plan for resident 56's risk for altered skin integrity did not address a wheel chair cushion or wheel chair pressure reducing device as recommended by the MDS assessments.) Resident 56's Braden Scale dated 1/6/14, revealed that resident 56 was at risk for developing pressure ulcers. The skin treatments on the Braden Scale included a pressure reducing device for the chair and bed. A review of resident 56's weekly head-to-toe skin assessments revealed that resident 56's skin was intact from 10/9/13 (date of admission to the facility) through 1/11/14. On 1/12/13, the facility nursing staff identified 2 new unstageable pressure ulcers on the backs of resident 56's legs. The nursing progress note revealed the following: "Resident asked me to look at the back of her legs. I noted an unstageable pressure ulcer that measures approximately 0.7 cm (centimeters) x 1.7 cm on the L (left) posterior thigh. No odor or exudate noted. There is brown eschar noted. The area surrounding the wound is red. No firmness or bogginess noted surrounding the wound. I cleansed the area with NS (normal saline) and applied a [MEDICATION NAME]. I noted a wound to the R (right) posterior thigh that measures approximately 0.7 x 0.6 cm. Brown eschar is noted. No odor or exudate noted. The area surrounding the wound is red. No firmness or bogginess noted surrounding the wound. I cleansed the area with NS and applied a mini island dressing for protection as the proper size [MEDICATION NAME] was unavailable. The proper size [MEDICATION NAME] will be applied when it becomes available." A review of resident 56's nurse progress notes and Pressure Ulcer Reports revealed the following stages and measurements for the pressure ulcer to the left posterior thigh (Note: All measurements were done in centimeters.) a. 1/12/14 - unstageable; 0.7 x 1.7 b. 1/17/14 - unstageable c. 1/21/14 - unstageable; 1 x 1 d. 2/4/14 - unstageable; 0.8 x 0.8 e. 2/12/14 - unstageable; 3.2 x 2 f. 2/18/14 - unstageable; 1.1 x 1.8 g. 2/25/14 - stage 3; 1.6 x 1 x 0.2 A review of resident 56's nurse progress notes and Pressure Ulcer Reports revealed the following stages and measurements for the pressure ulcer to the right posterior thigh (Note: All measurements were done in centimeters.) a. 1/12/14 - unstageable; 0.7 x 0.6 b. 1/17/14 - unstageable c. 1/21/14 - unstageable; 0.1 x 0.1 d. 2/4/14 - unstageable; 0.1 x 0.1 e. 2/12/14 - unstageable; 0.9 x 0.2 f. 2/19/14 - unstageable; 0.7 x 0.4 g. 2/25/14 - stage 3; 0.7 x 0.4 On 1/25/14, the facility nursing staff identified a new pressure ulcer to resident 56's gluteal cleft. The Nurse Progress Note revealed the following: ". . . noted a new wound to the R posterior thigh at the gluteal fold. This measures approximately 0.4 cm x 1.2 cm, no depth." A review of resident 56's nurse progress notes and Pressure Ulcer Reports revealed the following stages and measurements for the pressure ulcer to the right gluteal cleft. (Note: All measurements were done in centimeters.) a. 1/25/14 - no stage noted; 0.4 x 1.2 b. 2/4/14 - stage 2; 0.4 x 1.2 c. 2/18/14 - stage 2; 0.6 x 0.4 On 2/7/14, the Registered Dietician (RD) recommended the following: "Increased protein needs R/T (related to) wound healing AEB (as evidenced by) DTI (deep tissue injury) to right and left posterior thighs and stage II pressure ulcer to right gluteal per skin reports. . . Recommendations: 500 mg Vitamin C q (every) day and 220 mg (milligrams) Zinc Sulfate q day and 1 scoop protein powder TID (three times daily) with meals. Dietary staff met with resident today and discussed need for increased protein to support healing. Resident stated she would like to try the protein powder." (Note: No documentation could be located to indicate that resident 56 ever received protein powder TID with meals. In addition, based on the physician's orders [REDACTED].) Resident 56's weekly summaries were reviewed for the time period of 1/25/14 through 2/10/14. A weekly head-to-toe skin assessment was not located in resident 56's medical record from 1/25/14 through 2/10/14. On 2/11/14, the facility nursing staff completed an Event Report for resident 56. The Event Report revealed a stage 2 pressure ulcer on the bottom of resident 56's right foot. The Event Report revealed that the pressure ulcer was a blister to the bottom of the right foot. The pressure ulcer was noted to be closed and the surrounding tissue was intact. There was no exudate, necrotic tissue, eschar or slough noted to the wound on the Event Report. A review of resident 56's nurse progress notes and Pressure Ulcer Reports revealed the following stages and measurements for the pressure ulcer to the right heel. (Note: All measurements were done in centimeters.) a. 2/11/14 - stage 2; no measurement noted b. 2/20/14 - unstageable; 3 cm eschar, 4 x 4.3 cm redness c. 2/25/14 - unstageable; 6 x 7.5 cm (Note: The stage 2 pressure ulcer to resident 56's right foot was first identified on 2/11/14 as documented on the Event Report. No documentation could be located to indicate that resident 56 received treatment and services for a pressure ulcer to the right foot from 2/11/14 through 2/20/14.) On 2/20/14, the facility nursing staff completed a Pressure Ulcer Report for resident 56. The Pressure Ulcer Report revealed that resident 56 had an unstageable pressure ulcer to the right heel. The Pressure Ulcer Report revealed that the wound had necrotic tissue. (Note: Resident 56's pressure ulcer to the right heel/foot was assessed as a stage 2 on 2/11/14 and then assessed as unstageable on 2/20/14.) On 2/20/14, the facility nursing staff documented a nursing progress note. The progress note revealed the following: "Dressed wound to R heel and plantar area using aseptic technique. Cleansed with wound cleanser and NS. Aquagel applied and covered when wound is cleansed. Wound has an area of brown, soft eschar on the bony prominence that measures approximately 3 cm diameter. There is skin extending around the eschar that is yellow that measures approximately 0.8 cm. There is an area of redness that extends to the plantar area that measures 4 x 4.3 cm. The area of eschar and redness is boggy. Provider faxed." (Note: On 2/11/14, resident 56's pressure ulcer was assessed as a stage 2 with no necrotic tissue, eschar or surrounding tissue [DIAGNOSES REDACTED] (redness), as documented on the Event Report.) On 2/26/14, the facility nursing staff completed a Pressure Ulcer Report for the pressure ulcer on resident 56's right foot/heel. The Pressure Ulcer Report revealed that the pressure ulcer measured 6 x 7.5 cm. The Pressure Ulcer Report revealed that the pressure ulcer was unstageable, had slough, and contained a foul odor. (Note: On the Event Report dated 2/11/14, the pressure ulcer to the right heel/foot was assessed as a stage 2 pressure ulcer and was not noted to have an odor, slough, eschar or necrotic tissue.) On 2/20/14, a physician ordered the following for resident 56: "Heel protector to R heel at all times." (Note: This order was initiated 9 days after the ulcer was identified to resident 56's R heel/foot.) On 2/21/14, a physician ordered the following for resident 56: "Cleanse wound to R heel with wound cleanser, apply alginate and cover with [MEDICATION NAME]. Apply opsite to cover dressing for protection. Special Instructions: pressure ulcer. Once a day every 3 days." (Note: This order was initiated 10 days after the ulcer was identified.) On 2/24/14, a physician ordered the following for resident 56: a. "Vitamin C ([MEDICATION NAME] acid) tablet; 500 mg; amt (amount): 500 mg; oral once a day." The [DIAGNOSES REDACTED]. (Note: The RD recommended vitamin C for wound healing on 2/7/14 and it was not implemented until 2/24/14.) b. "zinc sulfate tablet; 220 mg; amt: 220 mg; oral once a day." (Note: The RD recommended zinc for wound healing on 2/7/14 and it was not implemented until 2/24/14.) c. "Air overlay mattress on bed. Keep in bed and turn Q 2 hours. Special Instructions: Ulcer care." (Note: The facility nursing staff documented on the admission MDS dated [DATE], risk for skin integrity care plan created 10/14/13 and Braden Scale dated 1/6/14 that resident 56 was to have a pressure reducing device on the bed and chair. No documentation could be located to indicate that resident 56 had a pressure reducing device to the chair prior to 1/7/14 or to the bed prior to 2/24/14.) On 4/16/14 at 1:55 PM, the Medical Records Employee (MRE) was interviewed. The MRE stated that resident 56 did not have a weekly head-to-toe skin assessment from 1/25/14 through 2/10/14. On 4/16/14 at 3:15 PM, Corporate Resource Nurse (CRN) 1 was interviewed. CRN 1 confirmed that resident 56 did not have a weekly head-to-toe skin assessment from 1/25/14 through 2/10/14. CRN 1 confirmed that there was a delay in the treatment of [REDACTED]. On 4/17/14 at 7:30 AM, the facility Director of Nursing (DON) was interviewed. The DON reported that resident 56 did not have a pressure relieving device on the bed prior to 2/24/14. The DON stated that the air mattress was not placed to resident 56's bed prior to the development of the sores because resident 56 did not have any problems or concerns before the development of the wounds. On 4/17/14 at 8:10 AM, the facility Director of Rehabilitation (DOR) was interviewed. The DOR confirmed that the air overlay mattress was placed on resident 56's bed the day that the physician's orders [REDACTED]. The DOR stated that a wheelchair cushion was placed in resident 56's wheelchair on 1/7/14 and provided a copy of the invoice for the wheelchair cushion to the survey team. The date on the invoice was 1/7/14. The DOR reported that, prior to 1/7/14, resident 56 had an in-house cushion, which was not really made for padding prior to 1/7/14. On 4/17/14 at 8:45 AM, the a second interview was conducted with the DON. The DON confirmed that there was a delay in implementing the dietary interventions for wound healing which were recommended by the RD on 2/7/14. The DON stated that they had attempted to contact resident 56's primary care physician regarding the orders for vitamin C and zinc, but the physician was not responding to the requests for the orders. The DON reported that there was not an attempt to contact the facility medical director in order to obtain the dietary orders for vitamin C and zinc. On 4/17/14 at 9:15 AM, the facility RD was interviewed. The RD confirmed that she had made dietary recommendations for zinc, vitamin C and protein powder for resident 56's wound healing on 2/7/14. The RD stated that she was not aware that there was a delay of 17 days in implementation of the dietary recommendations. The RD stated that the expectation was for the recommendations to be implemented within 3 days. The RD stated that the implementation of protein powder would only be documented on the care plan or the resident's dietary card. The RD stated that the residents' dietary cards were not kept after the residents are discharged from the facility, so the only place the protein powder would be documented would be on the resident's care plan. (Note: Resident 56's care plan was reviewed on 4/17/14 and an intervention for protein powder was not located on the resident's care plan. No documentation could be located to indicated that resident 56 received protein powder TID with meals for wound healing as recommended by the RD on 2/7/14.) A review of resident 56's comprehensive care plan on 4/17/14 revealed two care plans related to non-compliance. a. The first care plan addressed a problem that "(Resident 56) is non compliant with care r/t (related to) cleanliness. Resident urinating on the floor, despite educating resident risks of urinating on the floor." The goal on the care plan was "Room will be clean and free from odor." The approaches on the care plan included "Housekeeping to ensure daily cleaning and adequate cleanliness d/t (due to) resident urinating on the floor. Toileting offered every hour. Good peri care every shift and PRN. Frequent reminders/education to patient regarding safety and infection risks." The care plan had a problem start date and approach start date of 2/21/14. (Note: Resident 56 developed two unstageable pressure ulcers on 1/12/14. The care plan for non-compliance related to cleanliness was developed on 2/21/14.) b. The second care plan addressed a problem that "(Resident 56) is non-compliance (sic) with using hoyer lift." The goal on the care plan was "Will have no further skin breakdown x (times) 3 months." The approaches on the care plan included "Explained the risks/consequences vs. (versus) benefits of not following MD (medical doctor) orders such as non wt/ (weight) bearing on right foot and the importance of using the hoyer lift during transfers for safety and to avoid skin breakdown. Will continue to offer use of hoyer lift for safety and to prevent skin breakdown. Monitor for signs and symptoms of complications and notify MD promptly PRN." The care plan had a problem start date and approach date of 2/27/14. (Note: Resident 56 developed two unstageable pressure ulcers on 1/12/14. The care plan for non-compliance related to using the hoyer lift was developed on 2/27/14.) On 2/28/14, the facility nursing staff completed a Hospital Transfer Sheet. The Hospital Transfer Sheet revealed that resident 56 was to be transferred to the hospital due to "multiple wounds to BLE (bilateral lower extremities)." Resident 56's skin condition at the time of transfer included "Stage III (three) left posterior thigh, stage II (two) right posterior thigh, stage II (two) right gluteal fold. Unstageable to Right heel." On 2/28/14, the facility nursing staff completed a Physician Discharge Summary. The summary revealed that resident 56 was to be transferred to the hospital. The summary revealed that resident 56 had "Significant Changes in Condition" including "multiple pressure ulcers to BLE." On 2/28/14, a physician ordered for resident 56 to "Transfer to (name of hospital) per (name of ambulance) with current med (medication) and tx (treatment) orders. Special instructions: wound care." 2. Resident 54 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 54's medical record was reviewed on 4/15/14. Resident 54's admission skin assessment dated [DATE] revealed that resident 54 was at risk for developing pressure ulcers. On 2/6/14, the facility licensed nursing staff completed an admission MDS assessment for resident 54. The MDS revealed that resident 54 was at risk for pressure ulcers and had one unhealed stage II pressure ulcers upon admission to the facility. The facility staff documented the most sever tissue type for any pressure ulcer was "[MEDICATION NAME] tissue- new skin growing in superficial ulcer. It can be light pink and shiny, even in persons with darkly pigmented skin". The skin and ulcer treatments on the MDS included a pressure reducing device to the chair, a pressure reducing device to the bed and ulcer care. The MDS showed that resident 54 required extensive assistance with a one to two person assist for bed mobility, transfers, locomotion, toileting, dressing and personal hygiene. It was documented on the MDS by facility staff, that resident 54 was not steady and required human assistance to stabilize. The MDS also revealed that resident 54 was not on a bowel and bladder program and it was documented that the resident had occasional incontinence. On 2/27/14, the facility licensed nursing staff completed a 30 day MDS assessment for resident 54. The MDS revealed that resident 54 was at risk for pressure ulcers and had two unhealed stage II pressure ulcers upon admission to the facility. The facility staff documented the most sever tissue type for any pressure ulcer was "[MEDICATION NAME] tissue- new skin growing in superficial ulcer. It can be light pink and shiny, even in persons with darkly pigmented skin", and that one was worsening. The skin and ulcer treatments on the MDS included a pressure reducing device to the chair, a pressure reducing device to the bed and ulcer care. The MDS showed that resident 54 required extensive assistance with a one to two person assist for bed mobility, transfers, locomotion, toileting, dressing and personal hygiene. It was documented on the MDS by facility staff, that resident 54 was not steady and required human assistance to stabilize. The MDS also revealed that resident 54 was not on a bowel and bladder program and it was documented that the resident had occasional incontinence. On 4/3/14, the facility licensed nursing staff completed a 60 day MDS assessment for resident 54. The MDS revealed that resident 54 was at risk for pressure ulcers and had two unhealed stage II pressure ulcers upon admission to the facility. The facility staff documented the most sever tissue type for any pressure ulcer was "[MEDICATION NAME] tissue- new skin growing in superficial ulcer. It can be light pink and shiny, even in persons with darkly pigmented skin". The skin and ulcer treatments on the MDS included a pressure reducing device to the chair, a pressure reducing device to the bed and ulcer care. The MDS showed that resident 54 required extensive assistance with a one to two person assist for bed mobility, transfers, locomotion, toileting, dressing and personal hygiene. It was documented on the MDS by facility staff, that resident 54 was not steady and required human assistance to stabilize. The MDS also revealed that resident 54 had been on an attempted toileting program. (Note: A specialty mattress was delivered to resident 54 on 3/18/14. This was 2 1/2 months after identifying a stage I and the development of multiple stage II pressure ulcers. The ROHO pressure relieving cushion for the wheel chair was added to resident 54's wheelchair on 3/4/14. This was 5 weeks after identifying a stage I and the development of multiple stage II pressure ulcers.) On 10/14/13, the facility nursing staff created a care plan for resident 56. The care plan revealed that resident 56 was " At risk for altered skin integrity, pressure ulcers, skin tears, abrasions, bruising, etc. The goals on the care plan were " Risk will be reduced and skin issues will be promptly identified and treatment initiated timely daily thru next 90 days and wound will heal without complications. " The approaches on the care plan included "(1) Skin check by CNA; (2) Change disposable undergarment after each incontinent episode as needed; (3) Podiatry care PRN (as needed) [DIAGNOSES REDACTED] toenails; (4) Diet as ordered; (5) Skin check Q (every) week by LN (Licensed Nurse); (6) Observe for S/S (signs and symptoms) of breakdown such as redness, excoriation, open area, etc, and notify MD (Medical Doctor); (7) Proper incontinent care after each incontinent episode with soap and water if applicable; (8) Bed linens, clothing and underpads smooth and free of wrinkles; (9) Keep skin clean and dry; (10) Pressure reducing mattress for pressure relief; (11) Position with pillows as needed to prevent added pressure to body prominences; (12) Reposition frequently as tolerated; (13) Protective ointment to buttocks and coccyx BID (twice a day) and PRN; (14) tx (treatment) as ordered; (15) medications as ordered; (16) supplements as ordered; (17) turn and reposition at least every two hours and PRN." Review of the "physician's orders [REDACTED]. a. 2/6/14 "Cleanse wound to R buttock with NS (normal saline) and apply [MEDICATION NAME] to cover." b. 2/18/14 " Turn patient q 2 hours. Special Instructions: pressure ulcers/ excoriation." c. 2/19/14 "Cleanse wound to R buttock with NS and apply [MEDICATION NAME] to cover." d. 2/19/14 "To left buttock: cleanse with NS apply [MEDICATION NAME] dressing. Special Instructions: excoriation." e. 2/26/14 "To left buttock: cleanse with NS apply [MEDICATION NAME] dressing. Special Instructions: pressure ulcer" f. 3/4/14 "ROHO cushion to chair." g. 4/8/14 "To left buttock excoriated area: cleanse with NS apply [MEDICATION NAME] dressing." h. 4/14/14 "air mattress to bed at all times." (Note: review of the delivery ticket for the air mattress revealed that it was delivered on 3/18/14.) (Note: The care plan for resident 54's risk for altered skin integrity did not address a wheel chair cushion or wheel chair pressure reducing device as recommended by the MDS assessments.) Review of the "Event Reports" revealed the following: a. "Skin Integrity Events--Pressure Sore" dated 2/5/14. It was documented by facility staff in the report that resident 54 now had a stage II on the R ) buttock with a measurement of "2 x 2.7 ." The "interventions - immediate measure taken" were for a "pressure relieving device for the bed" and "turn and repositioning program". b. "Skin Integrity Events--Pressure Sore" dated 2/25/14. It was documented by facility staff in the report that resident 54 now had a stage II on the left buttock with a measurement of "0.7 x 0.7". The "interventions - immediate measure taken" were for a "turn and repositioning program", "Nutrition or hydration intervention to manage skin problems" and "Ulcer care". A review of resident 54's nurse progress notes and Pressure Ulcer Reports revealed the following measurements for the pressure ulcers to the right buttock (Note: all measurements are done in centimeters.) a. 2/5/14- 2.0 x 2.7 b. 2/12/14- 1.0 x 1.2 c. 2/18/14- 0.6 x 1.0 (Note: Interventions checked off and listed that had been applied were pressure relieving device for chair, pressure relieving device for bed (i.e. specialty mattress)). d. 2/25/14- 1.7 x 1.5 e. 3/4/14- 0.5 x 0.3 (Note: Interventions checked off and listed that had been applied were pressure relieving device for chair. This is the day that the ROHO was ordered). f. 3/12/14- PU (pressure ulcer) #1- 1.2 x 1.2 PU #2- 0.3 x 0.4 PU #3- 0.4 x 0.7 g. 3/19/14- 9.9 x 5.5 (red excoriated area) PU #1- 1.9 x 0.9 PU #2- 0.7 x 0.7 (Note: Interventions checked off and listed that had been applied were pressure relieving device for chair. Resident now has both devices at this point.) h. 3/25/14- 7.9 x 4.9 (red excoriated area) PU #1- 0.6 x 0.9 PU #2- 0.4 x 0.4 i. 4/1/14- 7.9 x 4.2 (red excoriated area) PU #1- 0.6 x 0.8 j. 4/8/14- 0.5 x 0.7 (Note: Interventions checked off and listed that had been applied were pressure relieving device for chair, pressure relieving device for bed (i.e. specialty mattress)). k. 4/15/14- No measurements A review of resident 54's nurse progress notes and Pressure Ulcer Reports revealed the following measurements for the pressure ulcer to the left buttock (Note: all measurements are done in centimeters.) a. 2/18/14- excoriation (Note: Interventions checked off and listed that had been applied were pressure relieving device for chair, pressure relieving device for bed (i.e. specialty mattress)). b. 2/26/14- 0.7 x 0.7 c. 3/4/14- 0.4 x 0.6 (Note: Interventions checked off and listed that had been applied were pressure relieving device for chair. This is the day that the ROHO was ordered). d. Left buttock is closed and non blanchable. e. 3/19/14- 8.0 x 5.8 (red excoriated area) PU #1- 1.2 x 0.7 (Note: Interventions checked off and listed that had been applied were pressure relieving device for chair, pressure relieving device for bed (i.e. specialty mattress). On 3/18/14 the air mattress was delivered). f. 3/25/14- 7.9 x 5.0 (red excoriated area) PU #1- 1.0 x 1.2 g. 4/1/14- 6.9 x 5.0 (red excoriated area) PU #1- 1.0 x 1.1 h. 4/8/14- excoriation Review of the RD notes revealed: a. 2/20/14- "...Appetite is good with average 75% meals plus Med Plus Supplement...Continue with orders and weigh weekly until stable." b. 2/27/14- "...past week AEB weight 169 # (pounds). Discussed in NAR meeting today...Reviewed skin reports and noted new PU (pressure ulcer) to left buttock stage II. Nutrition orders appropriate to support healing with Multivitamin w/ (with) Minerals and NSA ( no sugar added) Med Plus 2 oz (ounce) QID (four times daily) in place...Continue with POC (plan of care). c. 3/13/14- "...Increased protein & (and) calorie needs R/T (related to) wound healing AEB stage II pressure ulcer to left buttock (closed and non-blanchable) and stage II pressure ulcer to right buttock with 3 abraded areas per nursing notes..." d. 4/15/14- "...Increased protein & calorie needs R/T (related to) wound healing AEB stage II pressure ulcer to left buttocks...Nutrition orders remain appropriate to support wound healing with multivitamin w/ minerals and NSA Med Plus 2 0z QID. Continue with orders and F/U (follow up) PRN (as needed). Review of the NAR notes revealed: a. 02/21/2014 IDT: NAR "...Wt. loss of 2.9% in 1 week, Bedfast Resident: Resident is up in w/c daily with extensive assist, Pressure Ulcers: ulcer to buttock, Decline in late loss ADL: no significant change in ADL since admission to facility..." b. 2/27/14 IDT: NAR ": Wt. gain of 2.4% in the past week and Stage 2 on right buttock and left buttock, Bedfast Resident: Resident is up in w/c daily with extensive assist, Pressure Ulcers: St. 2 on right buttock 1.7x1.5cm, has worsened in size, wound bed i

Based on interview and record review, it was determined the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being as required. Specifically, 1 sampled resident sustained [REDACTED]. Resident identifier: 10. Findings include: Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 11/14/11 at 3:38 PM, a facility licensed nurse was interviewed. The licensed nurse was asked if resident 10 had a fall and/or sustained a fracture within the last 30 days. The licensed nurse reported that resident 10 had sustained a fall on 10/27/11 which resulted in a fractured clavicle requiring surgical repair. Resident 10's medical record was reviewed on 11/16/11. Review of the quarterly Minimum Data Set (MDS) assessment completed on 9/21/11 revealed that facility staff assessed resident 10 as requiring total dependence (full staff performance every time...) of a one person physical assist for transfers and locomotion on and off the unit. Facility staff further assessed resident 10's balance during transitions and walking as not being steady and only able to stabilize with human assistance when moving from a seated to a standing position, moving on and off the toilet, and when transferring from one surface to another. Resident 10 was assessed as having one prior fall with no injuries. Review of the "Nurse's Notes" revealed the following: a) 10/27/11 at 11:30 PM, "Pt. (patient) fell out of wheelchair @ (at) (8:00 PM) in hallway next to nurse's station. Pt. complained of left arm hurting, but no s/s (signs or symptoms) of injury noted. V/S (vital signs) taken immediately were B/P (blood pressure) 120/72, T (temperature) 98.2, P (pulse) 64, R (respirations) 14. Pt. was lethargic, but WNL (within normal limits). Pt. currently sleeping in bed monitoring q1h (every 1 hour) & (and) PRN (as needed) in place". b) 10/29/11 at 3:40 PM, "deformity to (left) shoulder noted. Contacted (physician) ordered resident to (local hospital) for radiographic eval (evaluation). Transport aide contacted to drive, resident to emergency department". c) A late entry (no date or time documented) for "..October 27th, 2011 @ (8:00 PM). Resident (resident name) was quietly sitting in his wheelchair up by the nurses desk. Showed (no) s/s of anxiety. Resident had fall out of his wheelchair landing on the floor. LPN (licensed practical nurse) & myself immediately responded. Pt. showed (no) s/s of injury. Pt. denied pain. Pt. stated 'I think I broke my arm'. Upon visually observing there was no noticeable injury. Upon examing (sic) there was no notice (sic) of injury. Started neuro (neurological) checks on resident while resident was still on floor. Again asking pt. if he had pain & denied any pain only stating his 'arm' was broke. Again examing (sic) pt. to find nothing. After doing neuro checks (another licensed nurse) & myself carefully sat him up, again examining to find nothing. Denied pain. We lifted resident up to his chair then put him in bed. Neuro checks q & 72 (hour) chart was started". (NOTE: the nurse's note documented on 10/27/11 at 11:30 PM, indicated that resident 10 complained of "left arm hurting".) On 10/27/11, a facility licensed nurse submitted the following facsimile to resident 10's primary care physician: "Pt. fell from wheelchair @ (8:00 PM). Pt. stated he thought he broke his arm, but did not respond to any pain stimuli. Neuro checks being conducted per facility protocol. No injuries found. ..." (NOTE: there was no documented follow up to resident 10's complaint that he "broke his arm".) Review of the IDT (Interdisciplinary Team) review dated 10/28/11 revealed that resident 10 fell from the wheelchair on 10/27/11 at 8:00 PM. Under the pain section of the IDT form, facility staff documented "yes, treated with oral medications and [MEDICATION NAME]". Review of the facility "Neurological Assessment Flow Sheet" revealed the following entries: a) 10/27/11 at 8:00 PM - Range of Motion (ROM) not assessed due to resident not being able to follow commands. b) 10/27/11 at 8:15 PM - ROM not assessed due to resident was not able to follow commands. c) 10/27/11 at 8:30 PM - ROM not assessed due to resident was not able to follow commands. d) 10/27/11 at 8:45 PM - ROM not assessed due to resident was not able to follow commands. e) 10/27/11 at 9:00 PM - ROM not assessed due to resident was not able to follow commands. f) 10/27/11 at 9:30 PM - ROM not assessed due to resident was not able to follow commands. g) 10/27/11 at 10:00 PM - ROM not assessed due to resident was not able to follow commands. h) 10/27/11 at 10:30 PM - ROM not assessed due to resident was not able to follow commands. i) 10/27/11 at 11:00 PM - ROM not assessed due to resident was not able to follow commands. j) 10/28/11 at 12:00 AM - Facility staff did not document completing ROM in the extremities. k) 10/28/11 at 1:00 AM - Facility staff did not document completing ROM in the extremities. l) 10/28/11 at 3:00 AM - Facility staff did not document completing ROM in the extremities. m) 10/28/11 at 5:00 AM - Facility staff did not document completing ROM in the extremities. n) 10/28/11 at 8:00 AM - Facility staff documented that resident 10 was able to move all extremities. o) 10/28/11 at 12:00 PM - Facility staff documented that resident 10 was able to move all extremities. p) 10/28/11 at 4:00 PM - Facility staff documented that resident 10 was able to move all extremities. q) 10/28/11 at 8:00 PM - Facility staff documented that resident 10 was able to move all extremities. r) 10/29/11 at 12:00 AM - Facility staff did not document completing ROM in the extremities. s) 10/29/11 at 6:00 AM - Facility staff documented that resident 10 refused ROM. t) 10/29/11 at 2:00 PM - Facility staff did not document completing ROM in the extremities. On 10/28/11, the facility occupational therapist documented the following on a "Rehab status [REDACTED]. Pt. was screened by occupational therapist. Pt. unable to verbalize pain but displays grimace during (right) UE (upper extremity) PROM (passive range of motion) with some limitation. Nurse was told of the pain..." Review of the hospital diagnostic imaging revealed that an x-ray of the left clavicle was obtained on 10/29/11. The radiologist impression of the x-ray revealed that resident 10 sustained a "grossly displaced distal clavicle fracture". (NOTE: the x-ray was not obtained until 2 days after resident 10 fell and complained that his "arm was broken".) On 11/16/11 at 10:30 AM, the facility Director of Nursing (DON) was interviewed related to the 2 day delay in resident 10 being sent to the emergency room for x-rays after complaining that he thought his "arm was broken". The DON was unable to provide additional clarifying information as to why the resident was not treated sooner. She was further unable to provide documentation that a follow up consultation with resident 10's physician was obtained after multiple statements of "I think I broke my arm"by the resident.