Every finding on record at Polo Rehabilitation & HCC

Based on observation, interview, and record review the facility failed to ensure a resident received the physician ordered dosage of medication after an order change which applies to 1 of 4 residents (R2) reviewed for pharmacy services in a sample of 4. The finding include: R2's Facility assessment dated [DATE] showed R2 is a [AGE] year old male resident admitted to the facility on [DATE] with diagnoses which includes depression. R2's discontinued Physician Order sheet printed on 9/16/24 showed R2's Doxepin 10 milligrams (mg) order was changed to Doxepin 5 mg on 3/14/24. No other modifications to R2's Doxepin orders were made until 9/12/24. This form showed R2's Doxepin order was changed from 5 mg to 10 mg on 9/12/24. R2's Progress notes dated 3/14/24 showed R2's physician gave a new order to reduce Doxepin to 5 mg. The facility could use the last of the 10 mg doses until the Veterans Affairs (VA) pharmacy could change the medication which could take up to 10 business days. Progress notes dated 3/15/24 showed the pharmacy requested a new order for Doxepin. Doxepin does not come in 5 mg capsules. Doxepin only comes in 3 mg, 6 mg, or 10 mg capsules. Progress Notes dated 4/29/24 showed the VA pharmacy needed a revised script for Doxepin 5 mg to be given in an elixir form. On 9/17/24 at 11:45 AM, V9 Pharmacy Clinical Manager stated Doxepin does not come in a 5 mg dose. It comes in 3 mg and 6 mg tablets and 10 mg, 25 mg and 50 mg capsules. If it needed to be a 5 mg dose it can be made into a 10 mg per milliliter (ml) elixir (suspension). Which could be given at 0.5 ml for the 5 mg dose. On 9/16/24 at 11:30 AM, V4 Registered Nurse (RN) removed R2's Doxepin bottle from the medication cart and one from storage. Both bottles showed Doxepin 10 mg capsules. V4 stated the medication comes in capsules which could not be cut in half like a tablet. V4 stated if a medication and order do not match we need to contact the physician to verify the order, and possibly hold the dose until we get the correct medication. V4 stated R2's Doxepin has always come in 10 mg capsules. V4 stated R4 has never had a liquid version of Doxepin. On 9/16/24 at 12:35 PM, V5 Licensed Practical Nurse stated R2 has always had 10 mg capsule for his Doxepin dose. V5 stated if a medication does not match the order the physician an pharmacy need to be notified so the order can be verified, and the medication can be changed to the correct dose if needed. R2's undated VA medication list showed R2 received Doxepin 10 milligram (mg) capsules with a last refill date of 7/10/24. On 9/16/24 at 11:45 AM, V2 Director of Nursing stated if a medication order and the medication do not match the physician needs to be contacted to verify the order. The pharmacy also needs to be contacted. In this case the VA provides R2's medications which should have been followed through with for the medication change. V2 stated she was not sure why the when the order changed the medication was not followed up on. The facility's Medication Pass Policy dated 5/2019 showed the five rights for medications administration which includes: verifying the drug against the eMAR (electronic medication administration record) ensuring the label matches the eMAR exactly, and verify the dose in each blister (container) against the eMAR.

Based on observation, interview, and record review, the facility failed to ensure a pureed diet was served with a smooth consistency for five of five residents (R7, R8, R11, R17, R18) reviewed for pureed diets in the sample of 13. The findings include: The facility's Diet Type Report dated July 29, 2024 shows R7, R8, R11, R17, and R18 are on pureed diets. On July 29, 2024 at 10:15 AM, V5 [NAME] pureed five salisbury steak patties with beef broth. V5 then added thickener powder. V5 then put the pureed salisbury steak into the oven to keep it warm. V5 said the pureed california vegetables were already pureed. On July 29, 2024 at 11:28 AM, lunch was served off of a steam table to all residents. On July 29, 2024 at 11:43 AM, a pureed test tray was sampled. The pureed vegetables had small chunks and casings in it. The pureed vegetables were not smooth in consistency. The pureed salisbury steak had chunks in it and required chewing. The pureed salisbury steak was not smooth in consistency. At 11:50 AM, V4 Dietary Manager sampled the pureed vegetables. V4 said the vegetables were stringy and not appropriate. V4 did not sample the pureed salisbury steak but said it looks gritty. V4 said that the salisbury steak is a processed meat and it is difficult to puree. V4 said pureed food should be a baby food consistency. V4 said pureed food should be smooth and not gritty. The facility's Puree Basics Fact Sheet dated October 31, 2003 shows, The puree diets are residents who cannot chew food or swallow without difficulty. Food is blended to a mash potato or applesauce consistence and requires no-chewing before they are swallowed.

Based on interview and record review the facility failed to follow their abuse policy by not identifying, investigating or reporting abuse for 1 of 13 residents (R16) reviewed for abuse in the sample of 13. The findings include: On 07/30/24 at 12:42 PM, R16 was in her room up in her wheelchair. R16 said she had room mate and they had recently moved her. R16 said that night that R18 was moved, R18 woke up and started messing with her brief. V6 Certified Nursing Assistant (CNA) came in and told R18 to lay down. R18 told V6 no and called her a B***. R18 said that she (R16) had her phone and went on and on. R16 said she told her that she didn't have her phone. R16 stated R18 she was mad, she is usually quiet and [NAME], but that night she was yelling at me and cussing at me. She called me a B**. If she could walk she would have been right here in my face. The nurse came in, it was at bedtime, and I had just started getting ready for bed. R18 kept on and on still yelling at me. It didn't make sense about the phone. She accused me getting information for the staff to use her account. They called V1 Administrator and she told them to move R18. V6 heard her cussing at me. The way her face looked, like she could kill me. It never looked like that before, it was kind of scary. I know they wouldn't let her hurt me but I was upset, it was intimidating. R16 said V1 had not come and talked to her about it yet. On 07/30/24 at 01:13 PM, V6 Certified Nursing Assistant (CNA) said she walked into help R16 to bed and R18 said R16 took her cell phone. V6 said she told R18 that is wasn't her phone and R18 said it was and it was her account. V6 said R18 then called her a F**** B*** and a liar and R18 was going to turn her in. V6 said then R18 started calling R16 a F****** B****. V6 stated R18's face was very scary. She kept yelling. I've never seen her act that way before. V6 said she let the nurse know and called V1 Administrator like she is supposed to do for abuse. V6 said she told V1 that R18 was calling R16 a F**** B****. V6 said V1 told her to move R18 to another room and herself and another CNA moved R18. R18's Nursing Progress Note dated 7/26/2024 06:18 shows Resident accused roommate of stealing her phone and her account to her phone putting it in hers. Resident used profanity toward roommate calling her a B***H multiple times. Administration made aware of situation. resident was removed from room and place into another one for the reminder of the night per administration orders. Writer explained to resident she did not have a phone. On 07/30/24 at 12:38 PM, V1 Administrator said the CNA called her and said R18 was yelling at R16 about a phone. V1 said R16 didn't take R18's phone. R18 accused R16 of having her phone, R18 never even had a phone. V1 said she had staff move R18 to another room. V1 said she didn't take the situation as abuse, she looked at it more like dementia like behavior. V1 said she didn't do an investigation or report. The facility's Abuse, Prevention and Prohibition Policy dated 1/24 shows Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.Verbal Abuse is defined as the oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within the hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. The facility's abuse prohibition program includes the following seven components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response.

Based on observation, interview, and record review the facility failed to ensure controlled medications were secured by a two locked system which applies to 1 of 13 (R3) reviewed for medication storage in a sample of 13. The findings include: On 7/29/24 at 11:35 AM the medication room door was open. This door opens into the dining room area. The nurse was not in the medication room or the dining room at this time. The medication room refrigerator was unlocked. The medication refrigerator contained R3's Morphine Sulfate Oral Solution. R3's physician order sheet printed on 7/30/24 showed R3's order as Morphine Sulfate (Concentrate) oral solution 20 milligrams (mg) per milliliter (ml) 0.25 mil by mouth every 1 hour as needed for pain/shortness of breath. On 7/29/24 at 11:40 AM, V2 Director of Nursing moved the medication cart into the medication room and closed the door. On 7/29/24 at 11:55 AM, V8 Registered Nurse stated the medication room door and refrigerator should be locked. The refrigerator has narcotics in it. On 7/29/24 at 12:00 PM, V2 stated the medication door and refrigerator is supposed to be locked so no one can get into the medications. Narcotics need to have 2 locks.

Based on interview and record review the facility failed to ensure a residents as needed psychotropic medication had a stop date for 1 of 5 residents (R17) reviewed for psychotropic medications in the sample of 13. The findings include: R17's Physician Orders show and order dated 7/2/24 for clonazepam 0.25 mg Give 1 tablet by mouth every 8 hours as needed for restlessness/agitation. There is no stop date for the order. R17's Pharmacy Consultation Report dated for 7/18/24 shows R17 has a PRN order for an anxiolytic, which has been in place for greater than 14 days without a stop date. Rationale for Recommendation: CMS requires that PRN orders for non-antipsychotropic psychotropic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. On 07/31/24 at 9:40 AM, V2 Director of Nursing said she faxed the pharmacy recommendations to the doctor and then waits for the response. V2 was not sure if she had got a response back on the latest pharmacy recommendations. The facility's Psychotropic Medication Use Policy dated 9/2022 shows The timeframe for PRN psychotropic medications, which are not antipsychotic medications, will be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner.

Based on observation, interview, and record review the facility failed to ensure a residents medications were not expired prior to administering it to the resident which applies to 1 of 13 residents (R3) reviewed for medication administration in a sample of 13. The findings include: R3's physician order sheet printed on 7/30/24 showed R3's Morphine Sulfate (Concentrate) oral solution 20 milligrams (mg) per milliliter (ml) 0.25 mil by mouth every 1 hour as needed for pain/shortness of breath was ordered on 8/27/23. On 7/29/24 at 11:35 AM, R3's Morphine Sulfate bottle had a pharmacy tag expiration date of 5/25/24 with 5 ml left in the bottle. V8 Registered Nurse confirmed the amount of medication in the bottle. V8 stated medications should not be used after expiration date. On 7/29/24 at 12:00 PM, V2 Director of Nursing stated the nurse/pharmacy should be checking for expired medications. Medications should not be administered after the expiration date. R3's Controlled Substance Record sheets (revised January 2023) showed R3 received 39 doses of Morphine sulfate after the expiration date (5/25/24). These doses were given from 5/30/24 through 7/28/24. The facility's Mediation Storage Policy dated 2022 showed Morphine Sulfate Oral Solutions should be discarded after manufacturer's expiration date unless otherwise indicated.

Based on observation, interview, and record review the facility failed to obtain treatment orders for non-pressure wounds for 1 of 13 residents (R15) reviewed for quality of care in the sample of 13. The findings include: On 07/29/24 at 09:19 AM, R15 was sitting up in his wheelchair in his room. R15's right arm was covered with a protective sleeve that had a small amount of dark red dried blood. R15 said he was not sure what happened to his arm, it happened a few days ago. R15 said he probably bumped it on something. On 07/29/24 at 11:26 PM, R15 was in his room sitting in his wheelchair. R15 still had the protective sleeve on his right arm. R15's legs were edematous and red in color. R15's right lower leg had an undated bandaid in place. R15 lowered the protective sleeve on his right arm and R15 had a pool of blood trapped under a clear occlusive dressing with a stream of blood leaking out the edge of the dressing. R15 said the bandaid had been on his leg for a few days and had not been checked or changed since the nurse put it on. R15 said the bandage on his arm had not been looked at since they put the dressing on it. On 07/30/24 at 9:57 AM, the same dressing was on R15's right arm and the bandaid on R15's leg remained. R15 said no one had looked at either. V2 Director of Nursing removed tegaderm and soaked up the dark red serous blood pool. R15 had a small skin flap intact with serous fluid draining. V2 said R15 is on antibiotics for his leg wound. R15 slowly peeled off the stuck on, undated bandaid on R15's right leg. There was yellow drainage on the bandaid. V2 stated this looks worse. V2 cleaned both wounds and measured the wounds. The arm wound was 1.8 cm long (no measurements were done on the width) and the leg wound was 2.5 cm x 1.5 cm. V2 applied triple antibiotic ointment and an occlusive dressing to both wounds. On 7/30/24 at 12:18 PM, V2 said there is no current treatment orders for R15's wounds. V2 said whoever identifies a wound, should call the doctor and get treatment orders, and should notify me and the family. R15's Physician Orders did not contain orders for R15's right arm skin tear or R15's right leg wound prior to 7/30/24. R15's Progress Note dated 7/25/24 shows small spot on shin; spot of blood, applied bordered gauze and antibiotic ointment, will monitor. R15's Progress Note dated 7/28/24 shows right arm, just below elbow outward facing-skin tear, approximately 1 inch long. resident is unaware of origin; skin flap intact. Tegaderm applied. will continue to monitor. The facility's Wound Assessment Policy dated 3/2021 shows It is the policy of the facility to asses each wound initially either at the time of admission or at the time the wound is identified. This policy does not address treatment of wounds. On 7/31/23 at 12:03 PM, V2 said the facility does not have any wound treatment policies.

Based on interview and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 13 residents (R16) reviewed for abuse in the sample of 13. The findings include: On 07/30/24 at 12:42 PM, R16 was in her room up in her wheelchair. R16 said she had room mate and they had recently moved her. R16 said that night that R18 was moved, R18 woke up and started messing with her brief. V6 Certified Nursing Assistant (CNA) came in and told R18 to lay down. R18 told V6 no and called her a B***. R18 said that she (R16) had her phone and went on and on. R16 said she told her that she didn't have her phone. R16 stated R18 she was mad, she is usually quiet and [NAME], but that night she was yelling at me and cussing at me. She called me a B**. If she could walk she would have been right here in my face. The nurse came in, it was at bedtime, and I had just started getting ready for bed. R18 kept on and on still yelling at me. It didn't make sense about the phone. She accused me getting information for the staff to use her account. They called V1 Administrator and she told them to move R18. V6 heard her cussing at me. The way her face looked, like she could kill me. It never looked like that before, it was kind of scary. I know they wouldn't let her hurt me but I was upset, it was intimidating. On 07/30/24 at 01:13 PM, V6 Certified Nursing Assistant (CNA) said she walked into help R16 to bed and R18 said R16 took her cell phone. V6 said she told R18 that is wasn't her phone and R18 said it was and it was her account. V6 said R18 then called her a F**** B*** and a liar and R18 was going to turn her in. V6 said then R18 started calling R16 a F****** B****. V6 stated R18's face was very scary. She kept yelling. I've never seen her act that way before. V6 said she let the nurse know and called V1 Administrator like she is supposed to do for abuse. V6 said she told V1 that R18 was calling R16 a F**** B****. V6 said V1 told her to move R18 to another room and herself and another CNA moved R18. R18's Nursing Progress Note dated 7/26/2024 06:18 shows Resident accused roommate of stealing her phone and her account to her phone putting it in hers. Resident used profanity toward roommate calling her a B***H multiple times. Administration made aware of situation. resident was removed from room and place into another one for the reminder of the night per administration orders. Writer explained to resident she did not have a phone. On 07/30/24 at 12:38 PM, V1 Administrator said the CNA called her and said R18 was yelling at R16 about a phone. V1 said R16 didn't take R18's phone. R18 accused R16 of having her phone, R18 never even had a phone. V1 said she had staff move R18 to another room. The facility's Abuse, Prevention and Prohibition Policy dated 1/24 shows Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Verbal Abuse is defined as the oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within the hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again.

Based on observation, interview, and record review the facility failed to ensure pressure prevention treatments were completed as ordered for 1 of 2 residents (R12) reviewed for pressure in the sample of 13. The findings include: On 07/30/24 at 08:55 AM, R12 was sitting up in wheelchair in his room. R12 said the nurse last night said she was going to change the dressings on his bottom but never came back and did them. On 07/30/24 at 09:02 AM, V7 Certified Nursing Assistant assisted R12 to stand and pulled down R12's pants and brief. R12 had a dressing to his right buttock that had yellow drainage, a dressing to his left buttock, and a dressing to his coccyx that all were dated 7/28/24. V7 said the dressings are dated 7/28/24. R12's Physician Orders dated 6/28/24 shows an order treatment to (3) pressure injuries to bilateral buttocks/coccyx areas: Wash gently with mild soap et water. Pat dry. Apply a thin layer of zinc oxide to wound beds. Cover with non-adherent pad . Change daily and PRN every day shift for wound care. On 07/30/24 at 12:18 PM, V2 Director of Nursing said R12's dressings should have been changed per the orders. The facility's Weekly Pressure Ulcer Report dated 7/24/24 shows R12 has a stage 2 pressure to the coccyx, a stage 3 pressure to the right buttocks, and a stage 2 pressure to the left buttocks. The facility's Pressure Ulcer/Pressure Injury Prevention Policy dated 3/22 shows If a pressure ulcer/pressure injury is present, provide treatment to heal it and prevent the development of additional pressure ulcer/injuries.

Based on interview and record review, the facility failed to have an Infection Preventionist. This failure had the potential to affect all 29 facility residents. The findings include: The facility's 5/3/23 Resident Census and Condition of Residents form showed 29 residents in the facility. On 05/03/23 at 09:53 AM, V6 MDS nurse said she was unable to locate her Infection Preventionist (IP) Certificate. At 09:55 AM, V1 Administrator said she could not produce her IP certificate. On 05/04/23 at 08:50 AM, V1 said she it's important to have an IP on staff to monitor and track illnesses trends for infectious diseases, minimize the risk of the spread of infection, and to monitor immunizations to prevent complications. The facility's 4/11/22 Infection Control Surveillance and Monitoring Policy showed the facility shall employ at a minimum, a part-time Infection Control Preventionist. The facility's 3/3/23 Infection Preventionist Job Description showed the Infection Preventionist (IP) is accountable for decreasing the incidence and transmission of infectious diseases between residents, staff, visitors and community. The IP maintains current knowledge of federal, state and local regulations and ensures that the facility leaders are informed of appropriate issues. Understands and complies with infection control, safety and OSHA (Occupational Safety and Health Administration) procedures and regulations. Participates in external reporting to CDC (Centers for Disease Control and Prevention) NHSN (National Healthcare Safety Network) system, and other post acute care specific quality organization. Authority and responsibility for ensuring appropriate intervention and education occurs with staff, volunteers and medical staff when healthcare infection trends, outbreaks or non-compliance to infection control/OSHA are identified.

Based on interview, and record review, the facility failed to ensure a Registered Nurse was on duty at least 8 hours a day. This had the potential to affect all 29 facility residents. The findings include: The facility's 5/3/23 Resident Census and Conditions of the Resident's form showed there were 29 facility residents. On 05/03/23 at 02:27 PM, V10 Licensed Practical Nurse (LPN) said she had been working at the facility since February. V10 said she works part time as needed on Sundays and during the month of April 2023 there were no Registered Nurses (RNs) or Administration staff present. On 05/03/23 at 03:55 PM, V9 LPN said she works as needed and during the month of April 2023 there were no RNs working while she was there. On 05/04/23 at 09:44 AM, V1 Administrator was shown the April 2023 nursing schedule. V1 said you're right and acknowledged there were no RNs scheduled to work any Sunday in April. V1 said she worked 4 hours on a Sunday in April but that doesn't cover all those days. The facility's schedule showed no RNs scheduled to work on 4/2, 4/9, 4/16, 4/23, and 4/30/23.

Based on observation, interview, and record review, the facility failed to ensure controlled medications were reconciled in a manner to prevent diversion for 3 of 3 residents (R79, R4, R13) reviewed for medication storage in the sample of 13 and failed to ensure a resident's pain medication was available for use for 1 of 1 resident (R83) reviewed for pain medications in the sample of 13. The findings include: On 05/02/23 at 08:53 AM, during the medication storage task with V3 Registered Nurse (RN) there were three boxes in the medication refrigerator. One box had R79's information on the label and included a sealed 15 milliliter (ml) bottle of morphine sulfate 100 milligrams (mg) per 5 ml oral solution and a sealed 30 ml bottle of lorazepam 2 mg per ml oral solution. Neither bottle had a reconciliation form to show it was controlled and accounted. A second box had R4's information on the label and contained a sealed 5 ml bottle of morphine sulfate 20 mg per ml oral solution and a sealed 5 ml bottle of lorazepam 2 mg per ml oral solution. Neither bottle had a reconciliation form to show it was controlled and accounted. A third box labeled with R13's information contained a sealed bottle of morphine sulfate 100 mg per 5 ml oral solution. This bottle did not have a reconciliation form to show it was controlled and accounted. On 5/2/23 at 9:00 AM, V3 said there aren't any count (reconciliation) sheets for the above medications, and they're not counted each shift. Morphine and lorazepam are both controlled drugs and should be counted. It's important to count controlled medications every shift because otherwise they can disappear and we wouldn't know. V3 said the boxes are comfort kits brought by hospice. On 05/03/23 at 12:56 PM, V1 Administrator said controlled medications should be reconciled to avoid diversion. When a controlled drug comes in, the nurse confirms the quantity, starts a reconciliation sheet and it is confirmed and counted at each shift change and each dose is signed out. The facility's 3/16/23 Controlled Substances Policy showed at the time a controlled substance is delivered, the charge nurse and the delivery person will count the controlled substance together to verify the count. If the controlled substance count is correct, a control sheet for each prescription will be initiated. The control sheet will contain: the residents name, ordering physician's name, issuing pharmacy, name and strength of the drug, quantity received, and date and time received. All schedule II drugs must be administered and recorded on a disposition sheet. The drugs in other schedules deemed necessary for control are placed under the same restrictions as schedule II drugs by the pharmacist. The drugs in schedule II (and those in other schedules which have been restricted and stored in the controlled substances cabinet) will be counted and reconciled by the nurse coming on duty and the nurse that is going off duty. 1. R79's face sheet showed admission to the facility on [DATE]. R79's diagnosis included Alzheimer's disease, major depressive disorder, anxiety disorder, hypertension, and atrial fibrillation. R79's physician order sheet showed a 4/19/23 order for hospice to evaluate and treat. This physician order sheet does not have a current order for morphine sulfate oral solution or lorazepam oral solution. 2. R4's face sheet showed admission to the facility on [DATE]. R4's diagnosis included heart failure, Type 2 diabetes, morbid obesity, depression, anxiety disorder, sleep apnea, and chronic obstructive pulmonary disease. R4's physician order sheet showed a 4/3/23 order for hospice to evaluate and treat. This physician order sheet does not have a current order for morphine sulfate oral solution or lorazepam oral solution. 3. R13's face sheet showed admission to the facility on [DATE]. R13's diagnosis included dementia, polyneuropathy, heart failure, major depressive disorder, and hypertension. R13's physician order sheet does not show an order for hospice or morphine sulfate oral solution. 34491 4. R83's Admission Record, printed by the facility on 5/3/23, showed she was admitted to the facility on [DATE]. R83's facility assessment dated [DATE] showed she is cognitively intact. On 5/02/23 at 9:40 AM, R83 was sitting in her room. V20 (R83's husband) was also in her room. V20 said the facility still has not received R83's Norco from the pharmacy and they are only able to give her the pain medication because he brought in a bottle that she had prior to coming to the facility. V20 was concerned that the supply he brought into the facility was getting low and the facility still has not received the pain medication from the pharmacy. R83 said she always has pain but the Norco helps with the pain. On 5/02/23 at 10:30 AM, V3 (Registered Nurse-RN) said in order to fill R83's Norco prescription, the pharmacy has to have an e-script. V3 said the facility only has a paper script from the hospital. V3 said she would call the pharmacy and see if they ever received the e-script from the hospital. V3 said she could not get the pain medication out of the C-box (a box containing controlled medications that is provided by the pharmacy) for R83 because there is no e-script. V3 said R83 has been receiving Norco for pain because V20 brought in a bottle of Norco to the facility for her. On 5/02/23 at 1:22 PM, V20 came to the conference room and asked this surveyor what she found out about R83's Norco. This surveyor informed V20 that V1 (Administrator) and V2 (Director of Nursing) were asked to look into it and update him and R83. This surveyor also informed V20 that she had spoken with V3 and she said the pharmacy has to have an e-script in order to fill the Norco and that V3 said she was going to call the pharmacy and see where they were at. ON 5/03/23 at 3:06 PM, V3 said when she (V3) came in on Saturday (4/29/23), R83 had about 5 pills that her husband had brought in for her. V3 showed this surveyor the reconciliation sheet that showed on 4/29/23 there were 6 Norco 5/325 mg pills for R83. V3 said she called the pharmacy and they said they would only accept an e-script from a doctor's office and not a paper script that was sent from the facility. V3 said she called the doctor's office that prescribed the Norco at the hospital and left a message. V3 said it was the weekend so there was no one at the doctor's office. V3 said on Monday the hospital doctor's office called back and said they did not feel comfortable sending an e-script for the Norco because they were the hospitalist that just happened to be working that day at the hospital. V3 said the hospitalist said that it would have to be the facility's doctor that sends an e-script over to the pharmacy. V3 said she called R83's doctor on Tuesday to get an e-script sent to the pharmacy. V3 said she is not sure why the nurse that was on duty Monday did not call the facility's doctor to get the e-script sent on Monday. V3 said she (V3) could have called the facility's doctor on Saturday to get the order for the Norco but she was waiting until she got the declination from the prescribing physician at the hospital. V3 said the facility received R83's Norco from the pharmacy last night (Tuesday 5/2/23). On 5/04/23 at 9:44 AM, V2 (DON) said R83 was admitted to the facility on [DATE] and her Norco 5-325 was delivered to the facility on [DATE] in the evening. V2 said that is not acceptable. V2 said with the e-script, the doctor needs to send it to the pharmacy. V2 said knowing it was the weekend, and they were not going to probably be able to contact the physician from the hospital that ordered the pain medication. The nurse on duty should have either called the resident's Primary Care Physician or the facility's Medical Director to have an e-script sent to the pharmacy so R83's medication would have arrived in a timely manner. V2 stated, It is not up to the family to make sure the residents' medications are available. That is all on us. R83's Order Summary Report for active orders as of 5/3/23, showed an active order for Norco 5-325 mg one tablet every 4 hours as needed for pain. That order showed a start date of 5/1/23. R83's April 2023 Medication Administration Record PRN (as needed) Medication Information sheet, dated 4/27/23, showed an order on 4/27/23 for Norco 5-325 mg every 4 hours as needed for pain. R83's Care Plan dated 5/3/23 showed she is taking pain medication related to back pain. R83's Controlled Substance Proof of Use form started with 6 Norco 5-325 milligram (mg) pills documented on the form on 4/30/23. The form showed 10 more Norco 5-325 mg pills were brought in on 5/2/23 when R83 only had 1 Norco left. V3 identified the source of the Norco 5-325 as V20 bringing in for R83. The Pharmacy Delivery Receipt dated 5/2/23 showed 30 Norco 5-325 mg tablets were delivered to the facility at 6:15 PM for R83 on 5/2/23. The facility's undated policy and procedure titled Pharmacy Medication Procurement was reviewed. the facility's Controlled Substances policy and procedure, with a review date of 3/16/23 was reviewed. The facility's policy and procedure titled Conformance with Physician Medication Orders, with a reviewed date of 9/27/17 was reviewed. None of the three previously listed policies addressed what to do if there is a problem or issue getting prescribed medications from the pharmacy (i.e., notify the Director of Nursing, the resident's Physician, or the facility's Medical Director).

Based on observation, interview, and record review the facility failed to ensure ADL (Activities of Daily Living) care was provided for 1 of 1 resident (R19) reviewed for activities of daily living in the sample of 13. The findings include: R19's face sheet printed on 5/3/23 showed diagnoses including but not limited to Huntington's Disease, muscle weakness, insomnia, gastrostomy status, and dysphagia. R19's facility assessment dated [DATE] showed no cognitive impairment and staff assistance needed for bed mobility, transfers, locomotion, dressing, eating, toilet use and personal hygiene. R19's ADL report for April 2023 showed total staff dependence for oral hygiene. On 5/2/23 at 9:52 AM, R19 was seated in a wheelchair in her room. R19 was alert and able to nod yes or no in answer but was non-verbal. R19's teeth, tongue, and lips were covered with a yellowish, crusty substance. R19's call light was lying on the floor, underneath her bed. At 9:55 AM, V5 (Certified Nurse Aide) said R19 can express her needs and uses the call light to ask for help. She needs help with transfers, incontinence care, and basically everything. She is aware of her surroundings and can express her needs with yes or no nods. At 12:28 PM, R19 was in her wheelchair and the call light was still in same position. At 3:20 PM, R19 was in bed and the call light was over her head. On 5/3/23 at 8:56 AM, R19 was asleep in bed. The call light was above her head, next to the pillow. At 11:54 AM, V3 (Registered Nurse) supplied liquid nutrition to R19 via her G-tube. R19's lips, teeth, and tongue were still caked with a yellowish, dried substance. V3 stated she should be getting oral care every shift. It is not getting done. R19 had a terrible lip sore from chapped lips last week and it was likely caused by lack of oral hygiene. V3 said R19 is very alert and just has a speech issue. V3 said R19 uses the call light when she needs assistance with any of her ADLs. The facility was unable to supply any documentation related to oral care being provided to R19. The facility Oral Care/Toothbrushing policy review dated 3/20/23 states: Policy-To provide adequate oral hygiene for all residents. 17. Repeat procedure as frequently as necessary.

Based on observation, interview, and record review, the facility failed to ensure personal cares were performed in a manner to maintain residents' dignity for 2 of 2 residents (R79, R2) reviewed for dignity in the sample of 13. The findings include: 1. R79's Admission Record, printed by the facility on 5/3/23, showed she had diagnoses including Alzheimer's disease with early onset, major depressive disorder, and anxiety disorder. R79's baseline Care Plan dated 4/18/23, showed she was dependent on 2 staff members for toileting and bathing. The assessment showed R79 was dependent on one staff for dressing. On 5/2/23 at 10:32 AM, V15 (Hospice CNA-Certified Nursing Assistant) exited R79's room with R79 sitting in a shower chair. R79 was naked from the waist down. A blanket was on R79's lap, covering her front area and legs. R79's buttocks was not covered and could be clearly seen from the nurse's desk. On 5/4/23 at 9:19 AM, V5 (CNA) said it is important to make sure a resident's body is covered when you are transporting them across the hall for their shower. You should not expose the resident's naked body to maintain their dignity and privacy. On 5/03/23 at 10:04 AM, V5 and V7 (CNA) transferred R79 from her hospice geriatric chair to her bed. V5 and V7 pulled down R79's pants and provided peri care for R79. V5 washed the middle then sides of R79's peri area, then rinsed and dried the same way. V5 and V7 rolled R79 onto her left side and washed, rinsed and dried her buttocks. The curtain in R79's room was wide open the entire time V5 and V7 performed personal care for R79 and the entrance area to the front of the building and parking area was clearly visible. R79 kept trying to pull her pants back up during care. V7 had to ask R79 to hold her hands, so R79 would not try pulling up her pants. On 5/03/23 at 1:42 PM, V5 CNA said she should have closed the curtains in R79's room prior to providing incontinent care for the resident's privacy and dignity. On 5/04/23 at 9:37 AM, V2 DON residents should be covered when they are being transferred down the hall to the shower for their dignity. The resident's curtains should be closed during personal cares for their dignity. 34891 2. R2's face sheet printed on 5/3/23 showed diagnosis including but not limited to rhabdomyolysis (severe muscle breakdown), dementia, multiple sclerosis, epilepsy, gastrostomy status, and history of cerebral infarction. R2's facility assessment dated [DATE] showed severe cognitive impairment and requires total staff assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. The same assessment showed R2 is always incontinent of urine and bowel. On 5/2/23 at 9:19 AM, V5 and V11 (Certified Nurse Aides) provided incontinence care to R2 while she was lying in bed. V5 and V11 removed the wet incontinence brief and rolled R2 from side to side while cleansing her. V5 and V11 removed R2's nightgown and put a fresh gown on her. R2 was naked and fully exposed to the window that was next to the bed. The window looked out to the front entry and a set of windows where a group activity was occurring. On 5/4/23 at 8:50 AM, V2 (Director of Nurses) stated window curtains should be closed while personal care is happening. It is especially important because all the resident rooms are on the main floor, and someone can easily see into the rooms. It does not feel good to be naked and exposed. Cognition levels make no difference. The curtains provide dignity and should be pulled closed during all cares. The undated Residents' Rights for People in Long-Term Care Facilities pamphlet (Produced by the Illinois Department of Aging) states: Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care.

Based on observation, interview, and record review, the facility failed to have an order for dialysis on a resident's Physician's Order Sheet (POS) and failed to develop a dialysis care plan for 1 of 1 resident (R 81) reviewed for dialysis in the sample of 13. The findings include: R81's Admission Record, printed by the facility on 5/4/23 showed R81 was admitted to the facility on [DATE] and had diagnoses of end stage renal disease, chronic kidney disease, depression, muscle weakness, major depressive disorder, type II diabetes mellitus, and other disorders of electrolyte and fluid balance. R81's facility assessment dated [DATE] showed he was cognitively intact and required extensive assist of two staff members for bed mobility and toileting. The assessment showed R81 was dependent on staff members for transfers, dressing and bathing. The assessment also showed that R81 was receiving dialysis. On 5/2/23 at 1:18 PM, R81 was in his room, sitting in his wheelchair. R81 said he had just got back from having dialysis at an outside facility. R81's Physician's Orders do not show an order for dialysis. R81's Baseline Care plan dated 4/14/23 does not show that R81 receives dialysis and does not list the location of the dialysis center, the days R81 receives dialysis, or the site on R81's body that he receives dialysis through. The Baseline Care Plan does not identify what to monitor for after R81 returns from dialysis, who and when to call if there are any concerns or provide information on any instructions prior to R81 receiving dialysis (i.e., what medications to give prior, what medications to hold prior to dialysis, etc.). On 5/04/23 at 9:40 AM, V2 (Director of Nursing-DON) said if a resident is receiving dialysis, there should be an order located in the Physician's Orders. The order should identify the days for dialysis, the location of dialysis, and what to monitor for post dialysis. V2 said there are things that need to be monitored when they receive dialysis, for their safety. V2 said there should also be a care plan in place for dialysis to guide staff in the care of a dialysis patient. The facility's policy and procedure titled Dialysis, with a review date of 3/17/23, showed the different types of dialysis. The policy that was provided listed things that are important to monitor for in a resident with an access site for dialysis. The policy provided by the facility did not address making sure there is an order for dialysis, including the days dialysis is scheduled. The policy that was provided also did not address developing a care plan for the care of the dialysis patient.

Based on observation, interview, and record review the facility failed to transfer a high fall risk resident safely and failed to ensure a resident did not hold smoking materials for 2 of 2 residents (R10, R82) reviewed for safety in the sample of 13. The findings include: 1. R10's face sheet printed on 5/3/23 showed diagnoses including but not limited to metabolic encephalopathy, muscle weakness, difficulty walking, unsteadiness on feet, and altered mental status. R10's facility assessment dated [DATE] showed total dependence on staff for transfers and toilet use. The same assessment showed R10 is always incontinent of urine and bowel. R10's Fall Risk assessment dated [DATE] showed a high risk for falls. The facility supplied fall log showed R10 has fallen five times within the last three months. On 5/2/23 at 9:02 AM, V5 and V7 (CNAs-Certified Nurse Aides) entered R10's room and wheeled her to the bathroom. V5 assisted R10 to stand and pivot to the toilet while holding her arm. V5 assisted R10 back into her wheelchair in the same manner after using the toilet. At no time was the gait belt, which was hanging on R10's door, put on her waist. V5 was questioned about the lack of gait belt and said she did not use the belt because there were grab bars in the bathroom. V5 said R10 can stand well without the gait belt so she does not use it for toileting. V5 said if R10 was transferring outside of the room then she would use it. V5 said R10 has had falls in the past but is doing pretty good now so the belt isn't needed. On 5/3/23 at 11:47 AM, V12 (Physical Therapist) said R10 needs help with transfers. Her cognition is not good, and she has poor safety awareness. V12 said gait belts are necessary to prevent falls. V12 said R10 is declining physically and mentally due to her disease processes. On 5/4/23 at 9:00 AM, V2 (Director of Nurses) stated gait belts are used for all resident transfers and ambulation. They are necessary for safety and to reduce falls. Gait belts reduce the chance of a resident being hurt from a fall. V2 said anyone who needs assistance with transfers or ambulation requires a gait belt. The facility Fall Prevention policy revision dated 12/09 states under the fall prevention interventions: 11. Transfer with proper number of assist and gait belt. The facility Transfer Belts/Gait Belts policy revision dated 12/17/12 states under the policy section: GAIT BELTS ARE MANDATORY. 2. R82's face sheet printed on 5/3/23 showed an admitted [DATE] and diagnoses including but not limited to complex febrile convulsions. On 5/2/23 at 3:27 PM, R82 was lying on her stomach in bed and dressed. R82 had three packs of cigarettes on the bed next to her and one pack on her nightstand. R82 was asked where she keeps her lighter and matches and replied, With me. R82 was asked to show this surveyor where she keeps them but closed her eyes and refused to speak. On 5/2/23 at 3:45 PM, R82 was outside smoking while being supervised by V3 (Licensed Practical Nurse). On 5/3/23 at 2:17 PM, V3 (LPN) said we do go out with her (R82) each time she smokes. She needs supervision. We do not hold her lighter or matches at the nurse station. I am not sure where she keeps them, but yesterday she pulled a lighter out of her own pocket. So yes, she is keeping them in her room someplace. At 2:28 PM, V14 (CNA) said R82 does need staff supervision to go outside and smoke. V14 stated R82 has her cigarettes and lighter with her each time he is with her. V14 said she keeps them in her coat pocket. On 5/3/23 at 2:37 PM, R82's chart was reviewed by this surveyor and V2 (DON) for a smoking assessment and care plan for safe smoking. None were located. At 3:02 PM, V1 (Administrator) reviewed R82's chart and was also unable to locate the documents. V1 said the smoking assessment is necessary to ensure a resident is safe to smoke. On 5/4/23 at 9:15 AM, V1 (Administrator) said residents are not allowed to hold their own smoking materials. It is a fire and safety hazard to themselves and others. V1 said R82 does need supervision to smoke and there is no reason she should have smoking items in her room. That is not safe, and the items should be locked in a med room until R82 wants to smoke. The facility supplied a Resident Smoking Assessment for R82 dated 5/3/23 (same day as survey). The assessment showed R82 was permitted to smoke per facility policies and procedures. The undated facility Smoking Policy states under the guidelines section: 2. Residents .may not keep his/her smoking materials.

Based on observation, interview, and record review the facility failed to identify the use of physical restraints and failed to follow their policy for restraints for 2 of 2 residents (R2, R79) reviewed for physical restraints in the sample of 13. The findings include: 1. R2's face sheet printed on 5/3/23 showed diagnosis including but not limited to rhabdomyolysis (severe muscle breakdown), dementia, multiple sclerosis, epilepsy, gastrostomy status, and history of cerebral infarction. R2's facility assessment dated [DATE] showed severe cognitive impairment and requires total staff assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene. The same assessment showed R2 is always incontinent. The assessment showed R2 was not using any type of physical restraint. On 5/2/23 at 9:36 AM, R2 was transferred from the bed to her wheelchair using a mechanical lift. V5 and V11 (CNAs-Certified Nurse Aides) reclined the high back wheelchair slightly and clipped a seat belt around R2's waist. At 11:38 AM, R2 was still in the wheelchair with the seat belt clipped across her waist. V5 approached and wheeled R2 down the hall and set her in the front foyer. The seat belt remained clipped around her waist. On 5/2/23 at 12:24 PM, V1 (Administrator) stated there are no restraints used in the building. The facility Matrix for Providers form supplied at entrance did not indicate any physical restraint use for R2 or R79. R2's active physician orders dated 5/3/23 showed an order for: Seat belt in cushion wheelchair. The order had no rationale for the use. R2's working paper chart care plan showed a focus area related to falls. A handwritten intervention dated 10/16/19 (3+ years ago) stated: ok to have seat belt in wheelchair as enable for positioning due to dx of MS (diagnoses of multiple sclerosis). There were no interventions related to release time or monitoring. On 5/3/23 at 11:24 AM, V13 (Nurse Practitioner) stated she was unaware R2 had a seat belt and there was no reason for it. V13 said R2 has severe dementia, requires total care, and absolutely could not remove it herself. V13 said any resident with a restraint requires a physician order, consent, and documentation of why it is needed. V13 said the facility protocol needs to be followed. V13 said she had no knowledge of who ordered the belt use from 2019 and possibly the therapy department would know. At 11:32 AM, V13 observed R2's wheelchair with seat belt and said, Yes, this is definitely not needed. Maybe it just came with the custom wheelchair and staff are using it because it is there. (R2) is always reclined back in her chair so the belt would serve no re-positioning purpose. She does not fall forward or move in the wheelchair. On 5/3/23 at 11:38 AM, V12 (Physical Therapist/Rehab Director) stated R2 tends to lean to the side while in her wheelchair but does have enough lateral support to keep herself upright. R2 does not have a problem rolling forward and the seat belt is not a therapy intervention. R2 does not need a seat belt for positioning in the wheelchair. On 5/4/23 at 8:52 AM, V2 (Director of Nurses) stated a physical restraint is anything that stops movement or freedom for a resident. V2 said she would consider a seat belt a restraint. It stops the resident from moving while in the chair. V2 said a consent and physician order are needed. Routine reassessments are required to ensure the need for use is still there. V2 said the misuse of physical restraints have a high risk of injury and can be undignified for a resident. On 5/4/23 at 9:10 AM, V1 (Administrator) said a restraint is any device that prevents a resident from moving the body. V1 said R2's seat belt is not a restraint because she needs it for re-positioning. V1 was asked who determined it was for repositioning and replied, I don't know. V1 said she has seen R2 and there is no possibility she could remove the belt herself. V1 said there is probably no reason for it. V1 said there should be a consent, assessment for the need, doctors order, quarterly reviews and how it should be used. All those items are important to ensure safety and that it is being used appropriately for the resident. V1 said restraints have the potential to cause entrapment, injury, and emotional stress. On 5/4/23 at 11:33 AM, V1 and V2 stated there was no documentation of R2's seat belt consent, physician order with reason for use, assessments, or attempt to reduce the use. 34491 2. R79's Admission Record, printed by the facility on 5/3/23, showed she had diagnoses including Alzheimer's disease with early onset, major depressive disorder, and anxiety disorder. R79's baseline Care Plan dated 4/18/23, showed she was dependent on 2 staff members for toileting and bathing. The care plan showed R79 was dependent on one staff for dressing. The care plan also showed R79 was a high fall risk and had poor safety awareness. The Care plan did not identify a restraint, a lap buddy or a table/tray. On 5/2/23 at 10:23 AM R79 was observed sitting in a low hospice geriatric chair in the common area, by the nurse's station. A tray was attached to the front of R79's geriatric chair. V15 (Hospice CNA-Certified Nursing Assistant) took R79 to give her a shower. After the shower, R79 was placed back into the low hospice geriatric chair and the tray was placed back on the chair. On 5/3/23 R79 was observed sitting in the dining room during the breakfast and lunch meals with the tray attached to her geriatric chair. The only time R79 was observed without the tray attached to her geriatric chair on 5/2/23 and 5/3/23 was when staff were providing incontinent care for her, or she was being provided a shower. On 5/2/23 and 5/3/23 a magazine was seen sitting on R79's tray table for a brief period. The magazine was open on both observations, however R79 was not looking at the magazine, or turning pages in the magazine. On 5/2/23 at 12:18 PM V1 (Administrator) said R79 has the table for activity purposes, she is a very busy person and likes to do things constantly. V1 said R79 is new to the facility and on hospice. V1 said hospice suggested they use the table to allow R79 to keep activities on the table top within reach. On 5/3/23 at 9:43 AM, V18 and V19 (R79's family) said the table attached to her low hospice geriatric chair was new. V19 added that last Wednesday when they came in, there was a cushion that went in front of R79 and under the arms of the chair (lap buddy). Both V18 and V19 said they think the tray table may be due to R79's frequent falls in the previous facility. V19 said R79 fell in the previous facility and had to have hip surgery. V18 said R79 would keep scooting forward and try to get up out of the chair. On 5/03/23 at 1:15 PM, V13 Nurse Practitioner-NP) said the table attached to R79's chair was definitely a restraint. V13 said the table is not the same as a lap buddy pad. V13 said the tray table is a hard table not a padded cushion. V13 said the tray would be a restraint and would need to have an order and a rationale for it. V13 said R79 did not have that when she came in to facility. V13 said a lap buddy pad and a hard tray are not the same thing. On 5/03/23 at 1:33 PM, V12 (Therapy Rehab Director) said R79 was not evaluated by the therapy department. V12 said R79 was on hospice when she was admitted . We did not have anything to do with the table on her chair. On 5/04/23 at 9:30 AM, (Director of Nursing-DON) said R79 would not be able to get out of the chair on her own with the tray. V2 said R79 would not be able to take the tray off. The tray is not a lap buddy pad. V2 said there should be an assessment, an order and a rationale for the restraint use. V2 said there should also be a signed consent for the restraint. R79's Physician's Order Sheet (POS), signed by R79's physician on 4/19/23, showed the following order: 4/25/23 Lap buddy pad may be used for patient comfort. No order for a tray/table restraint was listed on the POS. The Physical Restraint/Enabler Consent document in R79's paper medical record was not filled out and there was a line drawn through the document going from the right side in a downward motion to the left side of the document. The Physical Enabler/Restraint Use/Reduction Evaluation located in R79's paper medical record was not filled out and there were lines on page 2 and page 4 of the forms going from one side of the page down to the other side of the page. The facility was in the process of initiating electronic medical records for the facility. R79's electronic medical record was reviewed. There was no order for a table/tray restraint and no signed consent for the restraint in R79's orders tab, miscellaneous tab, or assessment tab. R79's Medication Record, provided by the facility on 5/4/23, showed Fax out re (regarding) lap buddy order. No information regarding a tray table was listed on R79's Medication Record. R79's Order Summary Report for active orders as of 5/3/23, showed no order for a Geri-chair tray table. R79's Medication Administration Record from 5/1/23-5/31/23 showed no order for a Geri-chair tray table. R79's Hospice Binder contained six pages in the binder: an In-Home Medical Group Order Form for Hospice Evaluation dated 4/14/23, a hospice form showing R79's name, date admitted to hospice and information on when the facility staff should call hospice with their number listed on the form. Another one of the forms provided a list of the Hospice Interdisciplinary Team and their contact numbers. Another form in the binder showed the Procedure for Death of a Hospice Patient in a Nursing Home. Another form was the Hospice' Admission Order Set. The Admission Order Set did not contain an order for a geri-chair tray table. The last document was the hospice Nursing Progress Notes. The notes did not mention anything about a geri-chair tray table. The facility's policy and procedure titled Physical Restraint/Enabler Policy, with a revision date of 7/24/18, showed Definition of a Physical Restraint: Physical restraints (are) any manual method or physical, or mechanical device, equipment, or material attached or adjacent to the resident's body, which the individual cannot remove easily and which restricts freedom of movement or normal access to his or her body. A device that may constitute a physical restraint may include, but is not limited to: bed rails, self-release waist restraints, soft waist restraints, lap top cushions, vest restraints, Geri-chair with tray table, arm restraints, leg restraints, personal alarms and hand mitts . The policy showed Procedure: 1. Complete Physical Enabler/Restraint Use/Reduction Evaluation. 2. Obtain verbal and/or written consent from resident/legally responsible party (May obtain verbal consent until able to receive written consent). 3. Document in nurse's notes the date, time, and which type of consent obtained prior to physical restraint being applied. 4. Obtain M.D. (Doctor) order for restraint or adaptive device/enabler. The order must include: Specific medical/physical reason, type of restraint/enabler, release and reposition at least every two hours, and when to be used .15. Document in nurse's notes type of restraint being used and resident's response to the physical restraint. 16. Place physical restraint problem on the resident's care plan. The care plan must address the duration, type, and circumstances under which the restraint can be used. 17. After initial documentation, all physical restraints require quarterly documentation regarding the type of physical restraint used, resident's response to the physical restraint, and if any reduction plan has been attempted. 18. Initiate Restraint Elimination/Reductions Program ninety days from application.

Based on observation, interview and record review, the facility failed to document an assessment of a pressure area and develop a care plan for 1 of 1 resident (R21) reviewed for pressure ulcers in the sample of 13. The findings include: R21's Admission Record, printed by the facility on 5/4/23, showed she was admitted to the facility on [DATE] with diagnoses including anemia, muscle spasm, malignant neoplasm of exocervix (the outer part of the cervix that opens into the vagina), obstructive (a condition in which urine cannot flow, either partially or completely, through the ureter, bladder or urethra due to some type of obstruction) and reflux uropathy (a condition in which the kidneys are damaged by the backward flow of urine into the kidney). R21's facility assessment dated [DATE] showed she was cognitively intact. The assessment showed R21 required extensive assist of two staff members for bed mobility and dressing, extensive assist of one staff member for personal hygiene, and was dependent on two staff members for toileting and transfers. The assessment also showed R21 had a limitation to her range of motion on one side of her upper and lower extremities. On 5/3/23 at 10:53 AM, V3 (Registered Nurse-RN) said R21 had a pressure ulcer on her buttocks. V3 said it started out as a shear and developed into a pressure injury. R21's Skilled Progress Notes from 4/1/23-5/3/23 did not show an assessment of the wound on R21's buttocks. R21's paper chart medical record did not have any assessment of R21's wound on her buttocks. R21's electronic medical record did not have any assessment of a pressure wound to R21's buttocks in the miscellaneous tab, assessment tab, or progress notes tab. The facility's Treatment Administration Record (TAR) binder was reviewed with no assessment for the pressure area on R21's buttocks in the tab marked with R21's name. R21's TAR (located in the binder) showed an order dated 4/20/23, Apply duoderm to left buttock every 72 hours and as needed for dressing failure. No assessment of the left buttocks was listed on the TAR. This surveyor asked V1 (Administrator) for the first assessment and the most recent assessment of the wound to R21's buttocks. On 5/4/23 at 7:50 AM, V6 (Licensed Practical Nurse-LPN/MDS Nurse) was asked to let this surveyor know when she was going to do the dressing change for R21 so an observation of the wound could be done. V6 agreed to the request. At 8:55 AM, V1 (Administrator) was asked to provide the first assessment for R21's pressure injury to her left buttocks, and the most recent assessment. At 10:40 AM, V1 said they were not able to locate any assessments for R21's pressure injury. At 10:48 AM, V6 said she had already changed the dressing for R21 because the dressing had come off. V6 said she assessed the area and updated the doctor. V6 said the order was changed to (barrier cream) and leave open to air, due to the area healing well. At 10:52 AM, V6, V16 and V17 (Certified Nursing Assistants-CNAs) rolled R21 onto her left side. R21 had two small open red areas to her left inner buttocks. When V6 pressed the area lightly, R21 said Ouch. V6 said the area was not healed, but it is healing well. V6's assessment and any written correspondence with R21's doctor on 5/4/21 regarding R21's pressure injury was requested. R21's Order Summary Report, showing active orders as of 5/4/23, showed an order for duoderm CGF (control gel formula) dressing (a flexible, waterproof dressing that forms a gel-like covering used to protect the open area and prevent infection). the order showed Apply to left inner buttock every 3 days and as needed for wound care. All R21's care plans were reviewed with no care plan for risk of skin alteration or pressure injury listed for R21. R21's Progress Note dated 5/4/23 at 10:42 AM, entered by V6, showed: Communication with Physician. pressure area to inner left buttock healing. Wound measures 0.5 centimeters (cm) length x 0.2 cm width. 100% epithelial tissue. Area 100% blanchable. The note showed R21's Physician gave a new order to discontinue duoderm at this time and resume the previous treatment of calmoseptine ointment (barrier cream) to the area every shift. Keep area free of pressure when able. R21's Progress Note dated 5/4/23 at 10:43 AM, entered by V6, showed: Communication with Physician. Pressure area to left inner buttock healing. Previous area of shear. Wound measures 0.2 centimeters (cm) length x 0.3 cm width. 100% epithelial tissue. 100% blanchable. The note showed R21's Physician gave a new order to discontinue the duoderm at this time and resume the previous treatment of calmoseptine ointment (barrier cream) every shift. Keep free of pressure when able. The facility's undated policy and procedure titled Decubitus Care/Pressure Areas showed: the purpose of the policy was to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. The Procedure showed: 1. Upon notification of skin breakdown, a Newly Acquired Skin Condition report will be completed and forwarded to the Director of Nurses. 2. The pressure area will be assessed and documented on the Treatment Administration Record (TAR). 3. Complete all areas of the TAR. i) Document size, stage site, depth, drainage, color, odor, and treatment (upon obtaining from the physician). ii) Document the stages of the pressure ulcer as follows: a) Suspected Deep tissue injury .b) Stage I .c) Stage II .d) Stage III .e) Stage IV .iii) Document the color .5. Documentation of the pressure area must occur upon identification and at least once each week on the TAR. The assessment must include: i) Characteristic (i.e., size, shape, depth, color, presence of granulation tissue, necrotic tissue, etc.) ii) Treatment and response to treatment .8. Initiate problem on care plan.

Based on interview and record review, the facility failed to ensure residents were offered immunization for influenza and pneumonia and failed to obtain historical immunization data for 3 of 5 residents (R21, R79, R81) reviewed for immunizations in the sample of 13. The findings include: On 05/03/23 at 03:08 PM, V8 Regional Director of Operations said there were no consents, historical data, or evidence of immunization for pneumonia or influenza being offered for R21, R79, and R81. On 05/04/23 at 08:50 AM, V1 said she it's important to ensure residents have their immunizations or at least offered and up to date. If residents are not immunized there is an increased risk of them becoming ill, an increased for spreading disease, and making them more susceptible to complications of infectious diseases. The residents live in a high risk environment and being immunized decreases their likelihood of getting flu & pneumonia. The resident immunization review in the infection control task revealed the facility had no influenza or pneumonia history, data, or evidence of offering the vaccines to R21, R79, or R81. The facility's 1/23/20 Immunization of Residents Policy showed the facility will offer immunizations and vaccinations that aid in the prevention of infectious diseases. The facility will explain to the resident, resident's guardian or the resident's Durable Power of Attorney for Health Care at the time of admission, the importance of vaccination against common illnesses such as pneumonia and influenza. Verify the date of the last vaccination. Obtain proof of Pneumococcal and Influenza vaccination for residents when able. Assess all newly admitted residents' pneumococcal and influenza vaccination status upon admission and record last known immunization on the resident's immunization record. Offer the PCV13 or PPSV23 (pneumonia vaccines) as indicated utilizing the Pneumococcal vaccination algorithm unless contraindicated. Offer the pneumococcal vaccination within 30 days of admission. The Centers for Disease Control (CDC) and Prevention algorithm showed to administer pneumococcal vaccination to adults age 65 and older if no immunocompromising condition present. Adults age 19-64 with specified immunocompromising conditions (including renal failure) were include in another algorithm recommending vaccination. 1. R21's face sheet showed a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included sepsis, hypertension, malignant neoplasm of exocervix, and obstructive uropathy. R21's physician orders showed a order for influenza and pneumococcal immunization. R21's medical record had no influenza or pneumococcal immunization data. The facility's immunization report had no information on R21's immunization status for flu or pneumonia. 2. R79's face sheet showed a [AGE] year old female admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease, major depressive disorder, anxiety disorder, and hypertension. R79's physician order sheet showed an order for influenza and pneumococcal immunization. R79's medical record had no influenza or pneumococcal immunization data. The facility's immunization report had no information on R79's immunization status for flu or pneumonia. 3. R81's face sheet showed a [AGE] year old male admitted to the facility on [DATE]. Diagnosis included end stage renal disease, depression, hypertension, Type 2 diabetes, repeated falls and benign prostatic hyperplasia. R81's physician order sheet showed an order for influenza and pneumococcal immunization. R81's medical record had an immunization record. The influenza and pneumococcal information was blank. The facility's immunization report had no information on R81's immunization status for flu or pneumonia.

Based on interview, and record review, the facility failed to ensure a residents medication was not misappropriated for one of three residents (R2) reviewed for misappropriation in the sample of 13. The findings include: R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Controlled Substance Proof of Use form dated 7/5/22 shows the facility staff used two different sheets with five [MEDICATION(S)] 25 mcg patches on each sheet. The Controlled Substance Proof of Use form with a start date of 7/31/22 shows there was only four [MEDICATION(S)] patches used, not five. (One [MEDICATION(S)] 25 mcg patch unaccounted for.) V6 RN (Registered Nurse) signed out a patch between 7/31/22-8/9/22 but did not place a date. There was no second signature next to V6's signature to verify a waste of the previous patch. R2's Controlled Substance Proof of Use form dated 8/3/22 showed a quantity of 10 [MEDICATION(S)] 12 mcg/hour patches were delivered and signed off by V6 RN. V6 RN crossed off the quantity of 10 and wrote five. V6 RN signed off that she received five 12 mcg patches. The facility is unable to account for the other Controlled Substance Proof of Use form to reflect the other five 12 mcg [MEDICATION(S)] patches. On 10/12/22 at 12:39 PM, V2 DON (Director of Nursing) stated she has provided a copy of all the Controlled Substances Proof of Use forms that she can locate. On 10/6/22 at 1:00 PM, V10 LPN (Licensed Practical Nurse) said she worked the weekend of 8/5/22-8/7/22. V10 said she placed new [MEDICATION(S)] patches on R2 on 8/6/22. V10 said that when she came back to work on the night shift of 8/7/22, she was performing a narcotic count sheet with V6 RN and the count was off by two patches for the [MEDICATION(S)] 25 mcg/hour and the Controlled Substances Proof of Use form was gone. V10 said that V6 asked V10 to look again and while V10 was doing that, V6 turned her back to V10, but V10 could see V6 going through V6's purse and V6 produced the two [MEDICATION(S)] patches and the folded up Controlled Substances Proof of Use form. V10 said that she notified V7 (Previous Administrator) and notified V2 DON. V10 said that V2 said she was shocked and that V6 would be fired. On 10/12/22 at 12:54 PM, V10 said when [MEDICATION(S)] patches are removed from the residents, two nurses sign off on the waste of the old patch. V10 said the [MEDICATION(S)] Patch 25 mcg/hour count has always been off by two patches, so when the narcotic count was done on 8/7/22, it was short an additional two patches to equal four [MEDICATION(S)] patches short. V10 said that when she notified V7, V7 directed V10 to write up a statement and put it under his door. V10 said that V6 forged V10's name on a narcotic count sheet for [MEDICATION(S)]. V10 said that V6 was acting nervous when V10 told V6 that V10's signature was not right on the count sheet. V10 said she did not know if the facility did an investigation or not. V10 said that she hasn't heard anything about the incident since then. V10 said she was very upset when V6 signed V10's name to account for the missing patch. V7 was not able to be interviewed as V7 no longer works for this facility. V1 (Current Administrator) said he was not involved in any abuse investigations for the last six months. The letter dated 8/7/22 at 6:15 PM written by V10 shows, I counted narcotics with [V6]. When we got to the [MEDICATION(S)] patches, she [V6] said no change since this morning. I always count the narcotics. The [MEDICATION(S)] 12 mcg count was correct but the 25 mcg were only nine. It should have been 11. I worked the night before and replaced residents [R2] patches so I knew what the count should be. The original narcotic count sheet was missing. I said I would count them again and while I was re-counting, she [V6] was digging around in her bag and blocking my view with her body. She [V6] was mumbling and making excuses. Then she [V6] went to the other med cart then to me, handed me the two missing patches and the missing narcotic sheet, saying something like, 'I must have moved them to the other cart.' The missing narcotic count sheet was folded in quarters. On one of the other narcotic sheets she [V6] had adjusted the amount to allow for the two missing patches. She [V6] forged by signature. 'I said [to V6] that is not my signature'. She [V6] put the missing sheet back into the book and scratched out the forged signature. [V6] was visibly anxious. On 10/6/22 at 11:32 AM, V2 DON said V6 had a lot of health issues. V2 said there was a time when a nurse said that she suspected that V6 was contemplating stealing a narcotic [MEDICATION(S)] patch because the count was off and V10 called V6 out on it. V2 said that she notified V7 and V7 told V2 to keep an eye on her. V2 said that V6 was terminated on 8/7/22. V2 said that V6 was terminated due to health issues. At 1:55 PM, V2 said she did not notify the state police. V2 said she notified her administrator which was V7 at the time. V2 said V6 did not work anymore at the facility after the incident involving the [MEDICATION(S)] patches. On 10/6/22 at 1:55 PM, V1 Administrator said if he received a report in regard to the above incident, then he would report it to the local state agency and begin an investigation. V1 said if forgery is involved, he would definitely do an investigation. V1 said the hiring manager performs reference checks. V1 said if a staff members reference checks shows that they are not available for re-hire, then the facility does not hire them. V6's Previous Employer Reference Release form dated 4/22/22 shows that V6 was not eligible for rehire. On 10/6/22 at 10:11 AM, V11 Pharmacist said ten patches of [MEDICATION(S)] was delivered on 8/3/22 and was signed by V6. (Controlled Substance sheet shows V6 crossed off the number 10 and wrote five. Five [MEDICATION(S)] patches unaccounted for). On 10/12/22 at 11:10 AM, V1 said he cannot find any evidence that anything was done in regard to the allegation of missing [MEDICATION(S)] patches. V1 said if V7 reported it, he cannot find any record of that. The facility's Abuse Prevention Program Policy revised 11/28/2016 shows, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This will be done by Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Identifying occurrences and patterns of potential mistreatment, exploitation, neglect, and abuse of residents and misappropriation of resident property. Misappropriation of resident property mean the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on observation, interview, and record review the facility failed to modify care interventions when they became aware a resident was self adjusting the tension on a fracture brace to his right hand. The facility failed to identify risk factors related to the use of a fracture brace. The facility failed to complete a wound assessment, failed to initiate a treatment plan and failed to notify the physician and family when a resident's skin breakdown was identified The facility failed to implement pressure relieving interventions (monitoinrg and repositioning) to prevent the development of a pressure ulcers This failure resulted in diminished circulation to R4's right fifth digit and the tip becoming necrotic. This applies to 4 of 9 residents (R3, R4, R9, R11) reviewed for pressure ulcers in the sample of 12. The findings include: 1. R4's hospital emergency room documentation dated July 22, 2015 at 8:21 PM shows closed fracture of metacarpal bone. R4's nurse note dated July 22, 2015 shows arrived back at facility per our van, right forearm and hand has soft cast immobilizer in place . Z2's (Orthopedic Surgeon) office note dated July 27, 2015 shows R4's soft brace was replaced with a Exo fracture brace (hard brace immobilizing smallest finger and extending over R4's forearm). R4's skin integrity care plan date July 27, 2015 shows R4 is at risk for skin breakdown related to decline in mobility, and has splint to right hand/wrist. The skin integrity care plan shows check for skin irritation from brace and CMS (circulation, motor function, sensation) to fingers on right hand. R4's nurse note dated August 11, 2015 at 3:30 PM, shows CNA (Certified Nurse Assistant) reported that when helping him (R4) to bed for a nap that he had (his) brace tight and that pinky finger on right hand, tip of it was black, upon my assessment he had brace tight and twisted with little finger bent inside of hand with straps of brace twisted. The incorrect placement of the brace lead to the development of a neurotic pressure area on R4's pinky finger. Z2's office noted dated August 12, 2015 shows R4 is definitely going to need some sort of revision amputation to his left small fingertip, but I would watch this for another couple of weeks just to let it fully demarcate .would like to see him in about 2 weeks so we can reevaluate the small finger and decide the level of amputation. Z2's noted dated September 24, 2015 shows treatment option for R4's finger includes an amputation most likely at the middle phalanx level versus continued observation expectant treatment . and with expectant treatment there is a possibility that the finger may just wither away and fall off, and if it leaves an exposed bony area, might need amputation at that time . R4's Physician order [REDACTED]. R4's MDS of October 9, 2015 shows R4 is cognitively impaired and requires extensive staff assistance with transfers, dressing, hygiene, bathing, and toileting. R4's skin risk assessment dated [DATE], and October 9, 2015 shows R4 is high risk for skin breakdown, and has a potential problem with fiction and shear R4's Weekly Wound Tracking dated October 18, 2015 shows a necrotic right pinky measuring 2.5 cm x 1.5 cm. No weekly assessments of R4's pinky have been completed since October 18, 2015 (over 2 weeks ago). On November 3, 2015 at 10:00 AM, R4 had his fingers curled towards his palm and resting on the lap tray. On November 3, 2015 at At 1:00 PM, R1 was in his wheelchair, and E2 (DON) helped R4 open his right hand. The tip of R4's right small finger was completely black all the way around the finger, with a small flap of dried black tissue present. R4 pulled his hand away from E2 and said no when she attempted to touch it. On November 3, 2015 at 11:15 AM, E16 (LPN) when they found the brace too tight on R4, his hand was inside his brace with his pinky laying flat, squeezed against the inside of his hand (palm). E16 said the tip of R4's finger was black and necrotic. R4's brace was as tight as it could go. E16 continued to say R4 would play with the brace and say I just want it off. R4 was caught turning the dial before they found the injury, and she was unsure how long it had been since the brace had been checked, before finding the injury. On November 3, 2015 at 3:00 PM, E7, Certified Nurse Assistant (CNA) said R4 would fidget with the dial on his brace, and would twist and turn it. E7 said R4 fidgeted with the brace quite often, and he was always playing with some part. and E5 (CNA) said she loosened R4's brace to wash his hands and then tighten it back up after she was done. On November 3, 2015 at 12:35 PM, E16 said when the necrotic area was found, the brace was all twisted and didn' t look like it was on correctly. E16 said at that time the tip of R4's fingers was necrotic. E16 said they would redirect R4 if they saw him playing with the brace but no interventions were in place to ensure the brace fit properly. On November 3, 2015 at 12:45 PM, E14, Licensed Practical Nurse (LPN) said the nurses should adjusted the brace. E14 said if R4's brace was tight enough he would not have been able to get his fingers inside the brace. On November 4, 2015 at 8:20 AM, Z2 (orthopedic surgeon) said, normally a resident would not get their hand inside the brace. Z2 said he was not aware R4 would mess or fidget with his brace and the first he was notified about that was after the injury occurred. Z2 said the brace could have been discontinued, and R4 could have been put in a cast. The October, 2006 facility policy Preventative Skin Care states Ensure proper fit of wheelchairs, splints, braces, prosthesis, etc 2. On November 2, 2015 at 8:06 PM, E4 and E8 (Certified Nurse Assistants-CNAs) transferred R4 from his wheelchair to the bed. E4 and E8 removed R4's pants, and incontinence brief. R4's incontinence brief was saturated with urine, and his bottom was red and discolored. E4 and E8 said R4 was toileted before supper (over 3 hours prior). E4 and E8 cleaned R4's bottom with a wet cloth and R4 said oh my god that hurts, damn near killed me. E4 said yes, his bottom is usually red from sitting, and he doesn't have much of a bottom. E4 said they usually get R4 up around 2:30-3:00 PM and toilet him before supper. E4 said R4 stays in his wheelchair for meals, and is only out of his chair when he is toileted before going to bed at night. On November 3, 2015 at 8:30 AM, R4 was in a wheelchair outside the nurse station asking for help with his crotch and saying it hurts. E6 (CNA) and E14 (Licensed Practical Nurse-LPN) transferred R4 from his wheelchair to the toilet and R4 said my crotch is killing me. E6 removed R4's incontinence brief and R4 was incontinent of stool and urine. E6 and E14 stood R4 in the bathroom and cleaned R4's bottom with a wet cloth. R4 yelled ow, ouch when cleaned between his bottom and scrotum. There was red blood on the cloth after wiping from the scrotum to the rectum. R4 had an open area between his scrotum and rectum and E14 said the blood was coming from an open spot below his scrotum, it looked like a tear, and that could explain why his crotch hurts. E6 said R4 does not usually lay down after breakfast because he is too agitated, and R4 was transferred back to his wheelchair after toileting. E6 and E14 did not offer to lay R4 down prior to taking him out in the hall. On November 3, 2015 at 9:50 AM, E14 said R4 has redness around his rectum and an open area between his scrotum and rectum. E14 said this was caused because R4 is incontinent of stool and urine, and R4 should be toileted frequently, at least every 2 hours. R4's nurse notes dated November 3, 2015 at 10:30 AM shows resident having complaints of pain to 'crotch' this am. Assessed area, observed small 0.25 cm open area between scrotum and rectum. On November 4, 2015 at 1:10 PM, E15 (Restorative Nurse) said bowel and bladder incontinence causes skin to become fragile and makes it easier for skin to breakdown and shear. R4's skin integrity care plan dated July 27, 2015 shows R4 is at risk for skin breakdown related to decline in mobility, and episodes of incontinence. The care plan shows interventions to assist to reposition at least every 2 hours and as needed, and offer naps in bed after meals. The October, 2006 facility policy Preventative Skin Care states to provide preventive skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, and well groomed, and free from pressure ulcers. Any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two (2) hours. Keep incontinent residents clean and dry. 3. On November 2, 2015 at 7:30 PM, R11 was transferred to bed by E7 and E11 (Certified Nursing Assistant - CNA). The seat and crotch of R11's pants were wet when R11 was moved from the wheelchair to bed. The incontinence brief was saturated and had strong urine odor. R11's buttocks were creased from the incontinence brief. An approximate 1 inch opening with oozing red blood was noted on the left buttocks along a crease line from the brief. E7 cleansed the area, and stated R11 has very delicate skin. No barrier cream was applied to the buttocks. E7 stated R11 had been in his chair since the start of her shift at 2 PM. R11's wheelchair did not have a pressure relieving cushion. On November 3, 2015 at 9:25 AM, E10 (CNA) and E2 (Director of Nurses - DON) observed an open area on R11's left buttock. The area was dry with crusty edges. E2 measured the open area at 2.5 cm in length. E10 (CNA) stated there was no report this morning of a new opening on R11's buttocks. E2 (DON) stated the facility procedure includes the CNA staff to report new openings to the nurse on duty. Barrier cream can be applied until the nurse obtains a treatment order from the physician. The nurse does the assessment initially and the wound is monitored weekly until healed. On November 3, 2015 at 9:40 AM, E16 (Licensed Practical Nurse - LPN) stated she was not aware of a new opening on R11's buttock, nothing was said in report this morning. E16 reviewed R11's medical record and stated she found no documentation about a new wound. The Minimum Data Set of August 26, 2015 shows R11 is at risk to develop pressure and has no unhealed pressure ulcers. The risk assessment for development of pressure ulcers shows R11's score of 16 (16 and less = high risk). The care plan for R11 shows to reposition R11 every 2 hours and to use a pressure reducing cushion in the wheelchair; and to apply house stock incontinent barrier cream to perineal area with every incontinent episode. 4. The facility's undated Profile Face Sheet show R3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R3's MDS (Minimum Data Set) dated August 19, 2015 show R3 is dependent on 2 staff members for transfers, positioning side to side, and body positioning. The MDS also shows R3 is dependent on 2 staff for toileting and has impairments on both sides of his upper and lower extremities. On November 2, 2015 at 7:40 PM, E8 and E4 (Certified Nursing Assistants-CNAs)transferred R3 using a mechanical lift. R3 was visibly saturated with stool and urine through his incontinence brief, pants, and the lift sling. E8 and E4 verified that R3 had soaked through his brief and pants, and that the sling under R3 was wet due to urine. E8 and E4 removed R3's pants and incontinence brief . R3 had a small irregular shaped opening to his left buttocks. E8 said it was open but it is better than it was. E4 said R3 got it from sitting. There was a pink healed irregular shaped area to R3's right buttocks. On November 3, 2015 at 8:20 AM, R3 was sitting in the dining room. R3's cardiac chair was slightly reclined back. At 8:50 AM R3 was taken back to his room. At 9:00 AM, and again at 9:30 AM, R3 was sitting in his cardiac chair in his room with the chair slightly reclined. At 9:30 AM E6 and E14 were in the hallway on the C wing. E6 apologized that it was longer than she said it would be, stating, I have just been busy. E6 said she would let this surveyor know when they were going to do care for R3. At 9:50 AM, 11:00 AM, and 11:50 AM, R3 was sitting in his cardiac chair in his room. R3's chair was slightly reclined and R3 was in the same position during all observations from 9:00 AM through 11:50 AM. At 11:50 AM, R3 was taken down to the dining room for lunch. At 1:00 PM, E6 and E9 (CNAs) transferred R3 from his cardiac chair to his bed using a mechanical lift. E6 was removing R3's incontinence brief and said R3 had a bowel movement. R3 had been incontinent of urine and there was a large amount of loose stool in R3's incontinence brief. E14 (LPN) entered R3's room and stated We can look, but I checked the TAR (Treatment Administration Record) and the open area on his buttocks was healed. E6 wiped stool from R3's buttocks at that time and E14 said Oh, he does have an open area, I will go get the barrier cream. R3's left and right mid-buttocks had a dark reddened area. There was an open area located in the dark red area on R3's left buttocks. R3's right buttocks had an area in the middle of the dark red area that appeared to have been open in the past, but was healed at this time. E14 said she was not sure if R3 had a previous open area on his right buttocks because she just started working on this wing. E14 said she was usually on the other wing. On November 3, 2015 at 12:12 PM, E6 (CNA) said R3 is so stiff and cannot sit on the toilet. E6 said the CNAs usually provide incontinent care in the morning at wake up and then again after lunch. E6 said R3 is a mechanical lift and they put him in bed to provide incontinence care. E6 said she checked R3's incontinence brief between breakfast and lunch and she could tell by the color of the triangles on R3's briefs that he was not wet. On November 4, 2015 at 9:50 AM, E2 (Director of Nursing- DON) said it is not acceptable for R3 to go from breakfast until after lunch without having incontinence care provided. E2 said that R3 should have been put in bed after breakfast and incontinence care provided. E2 also said it is not acceptable for any resident especially one with skin issues to be left in the cardiac chair in the same position from 8:30 AM until after lunch. E2 said it is not acceptable for the CNAs to rely on the color of the incontinent briefs to determine if the resident is incontinent. On November 3, 2015 at 12:12 PM, E15 (MDS Coordinator/Restorative Nurse) said incontinence care for R3 is in the morning when they get him up, after meals, and at night. E15 stated, the Day staff check to see if he is wet, if not, they reposition him. On November 4, 2015 at 9:25 AM, E14 (LPN) said the TAR (Treatment Administration Record) showed that R3 had a 0.5 cm circle area on October 24, 2015 that was resolved on October 28, 2015. E14 stated the only treatment on the TAR in October was barrier cream as needed. E14 also stated, I don't see any documentation on the TAR for skin checks. E14 said she did not see any documentation in the nursing notes regarding R3's open area until November 3, 2015 (after observing that the area on R3's left buttocks was open with this surveyor). On November 4, 2015 at 9:50 AM, E2 ( DON) said either herself, E15 (MDS Coordinator/Restorative Nurse), or E12 (2nd shift Registered Nurse) determine if an open area is due to pressure or other causes. E2 said they let the doctor know what the area looks like and sometimes the doctor will tell them (facility staff) if they (the doctor) think it is due to pressure or not. On November 4, 2015 at 3:03 PM, E12 (2nd shift Registered Nurse) said she had not looked at R3's open area and documented on it. E12went to assess the open area on R3's left buttocks. E12 stated, I think the cause of the open area on the left buttock is due to shear because he is always sliding down in the (cardiac) chair. E12 stated, I would not expect him to be left in his chair from breakfast until 1:00 PM. He should be laid down after all meals, he has had chronic problems with that area. E2 pressed on the reddened area on R3's left buttocks to check for blanching. E2 had to press on the reddened area 2 times in order to return a very faint blanching. E2 said it is very faint but it blanched. On November 6, 2015 at 8:25 AM, E2 said the desired outcome is that you would want to see an immediate blanching response. E2 said having to press 2 times and only getting a faint response would indicate an inadequate blood supply to the area. E2 said she believed R3's incontinence/moisture caused the open area on R3's left buttocks. E2 said a decreased blood supply to an incontinent, moisture related area can decrease the skin's strength and contribute to the open area. E2 said if R3 is sitting in the same position for an extended period of time it could contribute to the decreased blood supply. E2 said she did not think the cause of R3's open area is solely due to pressure, but said pressure may have possibly played a part in the open area. E2 said there was no documentation regarding any previous open area to R3's right buttocks. On November 6, 2015 at 8:20 AM, E15 said R3 was not able to communicate his needs. E15 said His speech is mostly incoherent; occasionally you might be able to understand a word or two. E15 said staff have to anticipate R3's needs and monitor for non-verbal cues. The facility's Weekly Wound Tracking sheet dated October 24, 2015 shows R3 had a 0.5 cm circle on his left buttocks. The document shows the area was resolved on October 28, 2015. The facility's Weekly Wound Tracking sheet dated November 3, 2015 shows R3 had an area measuring 0.5 x 0.5 cm on his left buttocks. The area is listed as reopen. There is no determination on the sheet that identifies the type of wound or characteristics of the wound site. The facility's Braden Scale for Predicting Pressure Ulcer Risk dated August 12, 2015 shows R3 was at high risk for the development of a pressure ulcer. The facility's Preventative Skin Care Policy revised October 2006 shows To provide preventative skin care through repositioning and careful washing, rinsing, drying, and observation of the resident's skin condition to keep them clean, comfortable, well groomed, and free from pressure ulcers. The policy shows any resident identified as being at high risk for potential skin breakdown shall be turned and repositioned at a minimum of every 2 hours. R3's ADL (Activities of Daily Living) Care Plan dated August 18, 2015 shows R3 needs extensive assistance for repositioning/bed mobility and needs help to reposition in wheelchair every 2 hours. The care plan also shows that R3 has no control of bowel or bladder and wears incontinence briefs during the day and has an incontinence pad on his bed at night. The care plan also shows that R3 is unable to sit on the toilet or commode due to poor trunk control/rigidity and is dependent on staff for incontinence care and application of barrier cream. R3's Skin Breakdown Care Plan dated November 4, 2015 shows R3 should be repositioned at least every 2 hours and R3's incontinent brief should be changed when wet and upon rising, at night before going to sleep and after meals. The plan shows R3 should be transferred out of his cardiac chair into bed after breakfast and lunch to change position and off-load pressure. R3's TAR (Treatment Administration Record) from October 1, 2015 through October 31, 2015 shows R3 should have a daily skin check and the nurses should chart on the back of the TAR. The TAR was signed off by the nursing staff, however, the only documentation on the skin check was either a C for clear, or an O for other. R3's TAR dated October 1, 2015 through October 31, 2015 does not show a treatment for [REDACTED]. R3's TAR dated November 1, 2015 through November 30, 2015 show orders for barrier cream to R3's left buttocks and to monitor the open area to left buttocks until healed was started on November 3, 2015. On November 4, 2015 at 9:50 AM, E2 said charting O (other) after doing the skin checks on the TAR could mean anything. E2 said the nurses should document what it is they see during the skin check. The facility's Skin Condition Monitoring sheet revised January 2002 shows Upon notification of a [MEDICAL CONDITION], wound, stasis ulcer or other skin abnormality, the Charge Nurse will assess and document the findings. The document shows Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: size, shape depth, color, presence of granulation tissue or necrotic tissue, treatment, and response to treatment. The facility's Decubitus Care/Pressure Areas sheet revised May 2007 shows all areas of the TAR should be completed and the size, stage, site, depth, drainage, color, odor, and treatment should be documented. 5. On November 2, 2015, at 7:25 PM and from 7:55 PM-9 PM, R9 was sitting in his chair in his room . On November 3, 2015 at 7:25 AM, 7:30 AM, 8:15 AM, 8:45 AM, 8:55 AM, 9:00 AM, 9:05 AM, 9:55 AM, 10:05 AM, 10:20 AM, 10:30 AM, 10:45 AM, 11:30 AM-11:45 AM, 12:00 PM, 12:15 PM, 12:30 PM, 12:45 PM, 1:15 PM and from 2:40 PM-3:45 PM , R9 was sitting in his chair . On November 4, 2015, at 7:30 AM, 7:50 AM, 8:00 AM, 8:10 AM and 8:20 AM, R9 was in his chair. No repositioning pressure relieving or toileting was observed during these times. On November 3, 2015 at 3:30 PM, E10 (Certified Nurse ' s Aide-CNA) stated that she was assigned to R9 ' s hall on this date and he was out of bed when she began her shift at 6:00 AM and she did not remove him from his chair for repositioning or toileting until 1:40 PM. E10 stated R9 ' s incontinent brief was wet when he was toileted at 1:40 PM and it takes two people to transfer/toilet this resident. On November 4, 2015 at 7:40 AM, E2 (Director of Nursing-DON) stated residents who are unable to communicate toileting needs should be toileted or incontinence care provided with am and has care, after every meal, as needed and should be checked on hourly rounds to see if incontinence care is needed. E2 stated if this toileting/incontinence care is not done skin breakdown, resident dignity and overall care becomes a concern. E2 stated repositioning of residents should occur during rounds if resident appears uncomfortable or agitated. E2 stated repositioning can occur by standing residents of offloading pressure with pillows to relieve areas that residents have been resting on. E2 stated if this repositioning does not occur skin breakdown, increased behaviors and overall care suffers. On November 4, 2015 at 10:30 AM, Z1 (Family Nurse Practitioner-FNP) stated R9 ' s right buttock wound would be a Stage II since the area is open and incontinence and failure to reposition contributed to wound formation. The undated facility-provided list of residents with decubitus ulcers shows R9 acquired a Stage II pressure wound to his right lower buttock while residing in this home. The October 1, 2015 nursing admission assessment shows R9 had no open areas to his buttocks. The October 1 and 12, 2015 Braden score for R9 was 14 which indicates R9 is a high risk for pressure ulcer development. R9 ' s October 2, 2015 ADL (activity of daily living) care plan shows he should be assisted to turn and/or reposition in chair at least every two hours. R9 ' s October 7, 2015 care plan shows R9 should be out of his chair at least two times per shift, assisted to reposition at least every two hours and toileting/change brief when wet and after meals. This care plan shows a shearing open area to R9 ' s right buttock on October 26, 2015. The facility October 2006 preventative skin care policy shows that any resident identified as being high risk for potential skin breakdown shall be turned and repositioned at a minimum of every two hours. The October 12, 2015 Minimum Data Set for R9 shows he is always incontinent of bowel and bladder and requires extensive assistance of two people to transfer ,toileting, hygiene, bathing and mobility. This MDS shows R9 is rarely/never understood and rarely/never understands others, is aphasic (cannot speak) and has non-Alzheimer ' s dementia The October 25, 2015 wound tracking flow sheet shows R9 acquired a new open area to his right lower buttock on October 25, 2015 that measured 2.3 cm X 1.1 cm (24 days after admission).

Based on interview and record review the facility failed to ensure the resident (R1) maintained a patent airway during a respiratory crisis and failed to provide oxygenation, rescue breaths and/or artificial ventilations using an Ambu bag when the resident was unable to breathe on their own. The facility failed to ensure staff were knowledgeable in performing cardiopulmonary resuscitation following the national guidelines and facility policy. On [DATE], R1 developed respiratory distress and the staff removed R1's [MEDICAL CONDITION]. An obturator was placed in the [MEDICAL CONDITION] opening blocking R1's airway. Interventions to maintain an oral airway were not utilized, nor were rescue breaths or artificial ventilations using an Ambu bag provided when R1 stopped breathing. These failures contributed to R1 being without oxygen for 10 minutes. R1 developed an [MEDICAL CONDITIONS] and required mechanical ventilation and treatment for [REDACTED]. An Immediate Jeopardy was identified on [DATE] at 10:15 AM. The Immediate Jeopardy began on [DATE]. While the immediacy was removed on [DATE] the facility remains out of compliance at a Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 1 resident (R1) of 4 residents reviewed with respiratory concerns in the sample of 4. The findings include: The hospital discharge summary dated [DATE] documents R1's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of [DATE] documents R1 has clear speech and is usually understood. R1's cognitive score is 15 (13 - 15 reflects the resident is cognitively intact) and does not have any short or long term memory problems. R1's care plan dated [DATE] states, "Frequently suctions herself as per her home routine". The nurses' notes for R1 dated [DATE] at 9:45 AM states R1 asked "Can I please have another (antianxiety medication) I feel really anxious today". At 10:00 AM, "R1's father came out to the hallway and stated I need a nurse in here. When coming into R1's room, the resident was sitting up in bed suctioning herself. R1 at this time was very cyanotic, O2 saturation was 65%....Director of Nurses (E2) entered the room...and removed the trach....tried to replace it with another...trach was tried several times to be replaced but no success...Orbiter (Obturator) was placed into R1'[MEDICAL CONDITION] to keep it patent...Pulse reading 55 beats per minute...911 called...O2 on by mask until ambulance came...Pulse ,[DATE] beats per minutes, oxygen saturation 48%...Ambulance arrived." Lewis, S. & Collier, I. & Heitkemper, M. (1996) Medical Surgical Nursing: Assessment and Management of Clinical Problems. (4th edition) Upper Respiratory Problems. (pp. ,[DATE]). "All ([MEDICAL CONDITION]) tubes have an obturator that is positioned in the inner cannula when the tube is inserted into the airway. After insertion the obturator is immediately removed so that air can flow through the tube. The obturator should be kept at the patient's bedside. In the case of accidental decannulation the obturator is required for placement of the [MEDICAL CONDITION]." On [DATE] at 2:40 PM, Z3 (Physician/Pulmonologist) explained the function of the obturator. "The device is used to guide the [MEDICAL CONDITION] into the stoma and then is immediately removed so the patient can be ventilated. The obturator is made of a stiff plastic, and fits inside the softer [MEDICAL CONDITION] cannula. You need the firmness to guide [MEDICAL CONDITION] the stoma. If the obturator was left in place, it would occlude the patient's airway." On [DATE] at 9:25 AM, Z2 stated, "I was visiting with my daughter and she was fine. All of a sudden she got awful white and I went out in the hall and asked for help." Z2 stated R1 appeared normal prior to the event, "She was sitting up in bed trying to suction herself." On [DATE] at 9:00 AM, Z1 stated, "R1 was capable of taking care of herself. She did her own suctioning". Z1 stated R1 expired at the hospital on [DATE]. On [DATE] at 11:40 AM, E2 (Director of Nurses-DON) stated, "I was called to R1's room by E3 (LPN). R1 was cyanotic, and was not responding verbally. I suspected [MEDICAL CONDITION] plugged so I told her I was going to change it. I pulled out her trach, then I tried 5 or 6 times (to replace it) and it would not go in. I have changed it before and did not have any difficulty. I was able to insert the obturator (into the stoma). I kept the oxygen over [MEDICAL CONDITION]. I don't believe she was breathing. I did start chest compressions when we could not get a pulse. We did not do any ventilations or bagging (Ambu). We placed oxygen over [MEDICAL CONDITION] and put an oxygen mask over her mouth too." E2 was asked about using an Ambu bag to deliver artificial ventilations, E2 stated, "We didn't use one. I guess we didn't think about using it." E2 continued, "When the obturator was in place R1 did not have any respirations. We checked the pulse and did compressions. When the oxygen saturation monitor showed her heart rate was 55 we stopped compressions, and we kept the oxygen mask on until the ambulance arrived." On [DATE] at 12:20 PM, E3 (Licensed Practical Nurse - LPN) stated, "I checked R1's oxygen saturation at 9:45 AM when she asked for another (anti-anxiety) medication. It was 98 % and her color was good. She just stated she felt a little anxious; but that was not unusual for her. When Z1 came out into the hall and asked for help, I entered the room, and she was awake but her skin color was cyanotic. Her oxygen saturation was 65%." E3 continued, "E2 (DON) entered the room and tried to replace [MEDICAL CONDITION] improve her airway. E2 was unable to insert the trach. She started (chest) compressions until we found R1 had a heartbeat. R1 was not breathing. We did not use an Ambu bag. The obturator was inserted; R1 was not breathing and her chest was not moving. The oxygen saturation monitor showed her heart rate dropped to 40's. There was no respiratory support provided when the resident quit breathing except the oxygen by mask." The incident time line was provided by E1 (Administrator). E1 stated this documentation was an approximate recall of the events and staff involved during the care of R1 on [DATE] prior to transfer to the hospital. The facility time line states the following: 10:00 AM, E3 at R1's bedside, R1 was cyanotic. 10:05 AM, E2 (DON) removed [MEDICAL CONDITION] R1 and attempted to replace it. 10:10 AM, E2 (DON) attempted reinsertion of [MEDICAL CONDITION] times with no success. The orbiter (obturator) from [MEDICAL CONDITION] placed into [MEDICAL CONDITION]. 10:20 AM, the oxygen saturation level for R1 was 48% per monitor. 10:20 AM, the ambulance arrived. The ambulance run sheet for R1 dated [DATE] documents the dispatch call was received at 10:14 AM. The service arrived at the facility at 10:16 AM and departed at 10:29 AM. The ambulance arrived at the local hospital (facility A) at 10:46 AM. The narrative note for R1 states, "Noted swelling and inflammation at the [MEDICAL CONDITION] site with small amount of blood present. Cardiac monitor is applied showing a sinus Brady rhythm...and oxygen saturation level is noted at 0 - 35%. Cap is removed from [MEDICAL CONDITION] and patient is intubated through the [MEDICAL CONDITION] oxygen saturation shows rapid improvement to 100% within 2 minutes...Patient skin color at this time is improved to normal...Patient shows physical signs of improvement, skin color, temperature all improved with patient showing increased spontaneous attempts at respiration." The [MEDICAL CONDITION] Critical Care Consultation (facility B) dated [DATE] for R1 documents the following: "R1 became cyanotic, hypoxemic, and was emergently transferred to the emergency room (facility A); and a [MEDICAL CONDITION] size 6 was emergently placed . She was placed on mechanical ventilation, subsequent to that she developed [MEDICAL CONDITION] which seemed to be [DIAGNOSES REDACTED]." The Discharge Summary (from facility B) by Z3 dated [DATE] documents R1 was transferred from the local hospital (facility A) Intensive Care Unit to the Trauma Hospital (facility B) after R1 developed uncontrolled [MEDICAL CONDITION]. The report confirms R1 died at the hospital on [DATE]. Final [DIAGNOSES REDACTED]. On [DATE] at 2:40 PM, Z3 stated, "[MEDICAL CONDITION] from anoxia will occur when the patient is without oxygen for 5 -10 minutes." Z3 confirmed that a lack of oxygen was "absolutely" the cause of R1's [MEDICAL CONDITIONS]. The facility policy for [MEDICAL CONDITION] Care (undated) does not include procedures for emergency decannulation. Wolters Kluwer. (2008). Nursing, Perfecting Clinical Procedures. (pp. 531) PA: Lippincott Williams & Wilkins, "Follow the facility policy regarding the procedure if a [MEDICAL CONDITION] is expelled or if the outer cannula becomes blocked. If the patient's breathing is obstructed - for example when the tube is blocked with mucus that can't be removed by suctioning or by withdrawing the inner cannula - call the appropriate code, and provide manual resuscitation with a handheld resuscitation bag or reconnect the patient to the ventilator. Don't remove the [MEDICAL CONDITION] entirely because this may allow the airway to close completely." On [DATE] at 12:20 PM, E3 (Licensed Practical Nurse - LPN) stated she was re-certified in Cardiopulmonary Resuscitation in [DATE]. E3 was asked what should be the response when a resident has a heart beat but no respirations. E3 responded, "Provide ventilations." On [DATE] at 11:30 AM, E3 stated, "I inserted the obturator to keep the hole patent. I did not insert it all the way, I'm not 100% sure, but I thought the air could get around it." E3 stated, "R1 did not have any oral obstructions that I am aware of". E3 stated she did not try to insert an oral airway, provide rescue breaths or use an Ambu bag for R1. On [DATE] at 12:35 PM, E5 stated, "My CPR card expired in April of this year (2011). We are required to maintain our CPR certification but we haven't connected to get it done." E5 was asked what her response would be when finding a person without a heart beat or breathing. E5 clarified, "Do you mean here or outside of here, because it would be different." E5 continued, "First, I would check the chart to see if they are a DNR (do not resuscitate). I would open the airway, listen and feel if the person is breathing. I would do breaths first, then compressions." The list of facility staff provided on [DATE] showed 3 of 7 Registered Nurses, 1 of 7 Licensed Practical Nurses, 18 of 27 Certified Nursing assistants had either lapsed their re-certification or not certified at all. The staff list showed the facility had 22 of 41 employees certified in CPR. The facility policy for performing Cardiopulmonary resuscitation states, "It is the policy...that CPR shall be initiated and maintained by qualified staff in cases of recognized cardiac and/or [MEDICAL CONDITION] arrest to sustain or support a resident's cardiac and/or [MEDICAL CONDITION] function until advanced life support systems are available." The procedure states, "If respirations are nonexistent or cease, place the resident on hard surface and initiate artificial respirations...Give rescue breaths or provide respirations through an Ambu bag." American Heart Association, 2010 Guidelines. Basic Life Support for Healthcare Providers, Professional Student Manual. (Book number ,[DATE]). Chapter 9, pp. 49. "When an adult has a pulse but is not breathing effectively, rescuers should give breaths without chest compressions. This is rescue breathing. Give 1 breath every 5 - 6 seconds (about 10 - 12 breaths per minute). Foundational Facts - Respiratory Arrest. Healthcare providers should be able to identify respiratory arrest. When respirations are absent or inadequate, the healthcare provider must immediately open the airway and give breaths to prevent [MEDICAL CONDITION] and hypoxic injury to the brain and other organs." E1 (Administrator) was informed of the Immediate Jeopardy situation on [DATE] at 10:15 AM. Through record review, interview and observation the surveyor confirmed the facility took the following actions to remove the immediacy of the situation: The facility immediately implemented a systematic review of Petersen Health Care's tracheotomy care and life sustaining efforts including: *The facility completed a full hour resident audit to ensure proper advance directive have been established and documented. *The facility completed a full house employee audit to ensure facility meets state and federal guidelines regarding employees with active CPR certifications. The facility immediately has conducted the following measures to ensure the alleged deficiency will no recur: *On [DATE] the facility provided an in service on emergency care including but not limited to CPR measures for licensed and certified staff. *On [DATE] the facility in serviced licensed staff on notification of change of resident status. *On [DATE] the facility in serviced licensed staff on tracheotomy polices and procedures. *On [DATE] the facility in serviced licensed staff on charting policies and procedures. *On [DATE] the facility inserviced licensed/certified staff on advanced directive including but not limited to DNR and CPR. *On [DATE] RCS [MEDICAL CONDITION] care provider, inserviced licensed staff on respiratory care including but not limited to basic tracheotomy care, tracheotomy cleansing, how to complete 100% oxygenation, bagging of tracheotomies during emergency situations, tracheotomy suctioning, completing proper facial ambuing of a tracheotomy resident and proper use of E tanks and concentrators. This inservice included all licensed staff employed by the facility. *On [DATE] the facility provided four CPR classes to certify additional staff on CPR. *The Medical Director has reviewed the respective removal of immediacy and has approved the steps the facility has taken to ensure continued compliance. All residents with tracheotomy have the potential to be affected, however, the above steps will help assure they will not be affected by the alleged deficiency. There are currently no residents residing in the facility that have a tracheotomy. At this time the facility has also implemented a systematic review of Petersen Health Care's tracheotomy care, code and life sustaining policies and procedures and found them to be in compliance of state and federal regulation. The following Quality Assurance measures have been implemented to ensure the alleged deficiency does not recur. *Tracheotomy care policy and procedure and life sustaining measures policy and procedures will be inserviced quarterly four times a year. *Upon admission all resident's will be assessed to ensure proper medical equipment is obtained for resident use. *DON and or designee will conduct quarterly employee CPR audits, which will be submitted to the Quality Assurance Committee upon completion. *The facility will assure that at a minimum two employees per shift will have active CPR certifications. *The Business Office Manager will maintain CPR certifications; these will be logged on a spreadsheet to list CPR certification and expiration date. *The administrator will complete random QA checks of the CPR certifications to ensure continued compliance. *The Medical Director will review any sentinel event to assist with remediations.

Based on interview and record review the facility neglected to have [MEDICAL CONDITION] and emergency care policies that include what to do in the event of de-cannulation and how respirations are to be maintained when this occurs. This failure contributed to staff removing R1 ' s [MEDICAL CONDITION] and R1 being without oxygen for 10 minutes. R1 developed an [MEDICAL CONDITIONS] and required mechanical ventilation and treatment for [REDACTED]. An Immediate Jeopardy was identified on 7/18/11 at 9:40 AM. The Immediate Jeopardy began on 1/27/11 when R1 was admitted to the facility. The immediacy was removed on 6/22/11 when R1 was transferred to the hospital. The facility has no other residents with a [MEDICAL CONDITION]. This applies to 1 resident (R1) of 4 residents reviewed with respiratory concerns in the sample of 4. The findings include: R1's [DIAGNOSES REDACTED]. R1 was admitted to the facility on [DATE], according to the Physician order [REDACTED]. The nurses' notes for R1 dated 6/22/11 at 9:45 AM show R1 was feeling anxious. At 10AM the nurse ' s notes show that R1 ' s father alerted E3 that she was needed in R1 ' s room. The notes show that at this time R1was very cyanotic and her oxygen saturation was 65%. At that point E2 Director of Nurses (DON) entered the room and removed the [MEDICAL CONDITION]. E2 tried to replace the [MEDICAL CONDITION] with no success. E2 placed an obturator into R1'[MEDICAL CONDITION] to keep it open. At that time R1 ' s Pulse reading was 55 beats per minute. 911 was called and an O2 mask was put on until the ambulance came. R1 ' s Pulse was now 40-55 beats per minutes and her oxygen saturation was 48%. On 7/7/11 at 2:40 PM, Z3 (Physician/Pulmonologist) explained the function of the obturator. The device is used to guide the [MEDICAL CONDITION] into the stoma and then is immediately removed so the patient can be ventilated. If the obturator was left in place, it would occlude the patient's airway. On 7/5/11 at 12:20 PM, E3 (Licensed Practical Nurse - LPN) stated, "I checked R1's oxygen saturation at 9:45 AM when she asked for another (anti-anxiety) medication. It was 98 % and her color was good " . E3 went on to say, " E2 (DON) entered the room (10:05AM) removed the [MEDICAL CONDITION] and tried to replace the tube to improve her airway. E2 was unable to insert the trach. She started (chest) compressions until we found R1 had a heartbeat. R1 was not breathing. We did not use an Ambu bag. The obturator was inserted; R1 was not breathing and her chest was not moving. The oxygen saturation monitor showed her heart rate dropped to 40's. There was no respiratory support provided when the resident quit breathing except the oxygen by mask." The facility policies provided during the survey (prior to 7/12/11) on Tracheotomy Suctioning (un-dated), [MEDICAL CONDITION] Care (un-dated), and policies provided on 7/12/11 on Notification for Change in Condition or Status, Cardio [MEDICAL CONDITION] Resuscitation and Emergency Care. None of these policies addressed what to do if the [MEDICAL CONDITION] becomes decannulated (the process whereby a [MEDICAL CONDITION] is removed) or how the airway is to be maintained if this occurs. On 7/18/2011 at 9:40 AM E1 (Administrator) was informed of an Immediate Jeopardy related to the failure of the facility ' s policies & procedures to address what to do when a [MEDICAL CONDITION] comes out or how the airway is to be maintained without the [MEDICAL CONDITION]. The surveyor confirmed through interview and record review that the facility took the following actions to remove the immediacy: 1. 6/22/2011, the facility called 911 and R1 was transferred to a local hospital. Since 6/22/11 no other residents in the facility have a [MEDICAL CONDITION]. 2. As of 7/18/11, the facility has a policy for Emergency procedures that includes emergency reinsertion of the tracheotomy tube, the reinsertion procedure, and how to assess the resident after reinsertion. 3. As of 7/18/11 the facility has in serviced all but 2 licensed staff on Emergency procedures. No licensed staff will be allowed to work until they have been in serviced. 4. As of 7/18/11 the medical director has reviewed the removal of immediacy plan and has approved the steps the facility has taken to assure compliance. 5. Beginning 7/18/11 the following Quality Assurance measures have been implemented to ensure this situation does not recur: a. Emergency procedures policy and procedures will be in-serviced quarterly four times a year b. All new employees will be in-serviced on emergency procedure at the time of orientation. c. The Medical Director will review any sentinel event to assist with remediation.

Based on observation, interview, and record review the facility failed to have interventions in place to minimize pressure for R'1s heels. The facility also failed to ensure that a resident at risk of developing pressure sores (R6) and a resident with a stage 4 pressure ulcer (R5) were repositioned every 2 hours. These failures resulted in R1 developing unstageable, bilateral heel ulcers This is for 3 (R1,5, & R6) of 6 residents reviewed for Pressure Sores. The findings include: 1. R1's first admission to the facility was on 1/28/2011, according to the nurse's notes. The Long Term Care admission orders [REDACTED]. The resident's admission Minimum Data Set of 2/4/2011 shows that the resident was admitted to the facility without any pressure ulcers. R1's Braden Scale of 1/28/2011 shows a score of 16. The scale shows that a score of 16 or less places a resident at high risk for skin breakdown. The resident's 1/28/2011 careplan shows that the facility identified the resident to be at risk for skin breakdown due to weakness, very poor motivation, poor appetite, frequent incontinence, low body weight, and surgical incision of the left hip. The careplan's original interventions were the following: ? Give multivitamin daily ? Keep bed linens clean, dry and wrinkle free ? Serve high protein diet and ensure 3 times daily ? Notify nurse of any areas of redness or changes in skin during personal care ? Assist to toilet before and after meals and at bedtime; assist with peri care and use barrier cream per protocol ? Pressure reducing mattress on bed ? Pressure reducing cushion in wheelchair ? Use pillows to help keep positioning in bed ? Assist to reposition every 2 hours during rounds ? Physical Therapy/Occupational Therapy to enhance mobility ? Daily skin Assessment ? Educate and firmly encourage resident that she needs to move and get out of bed to prevent breakdown and get stronger ? Monitor CMS of left leg and surgical incision to left his for signs/symptoms of infection. The initial careplan does not provide interventions to protect R1's heels from pressure against the mattress when in bed. On 2/7/2011 an intervention was added to the careplan to "float heels on pillow" and "skin prep to heels 3 times daily". A Shower/Abnormal Skin Report sheet of 2/3/2011 shows that E9 (Certified Nursing Assistant - CNA) circled both heels on the body diagram, and wrote "heels are going to break down". Nurse's Notes show that on 2/8/2011 at 9:50 PM, E2 (Registered Nurse - Director of Nursing) writes, "Left heel opened, MD notified. Dressing Applied...". On 3/8/2011 at 2:30 PM, E2 was asked how the staff monitor the skin of a resident who is at risk for skin break down. E2 said that the staff do daily skin checks with care. E2 was asked why it took 5 days, after E9 reported that R1's heels were going to breakdown, for R1 to receive treatment for [REDACTED]. She said any skin concerns are to be reported to her immediately. The Monthly Wound Tracking Reports were reviewed. On 2/8/2011 the facility identified R1 as having bilateral unstageable heel ulcers. The hospital Discharge Summary dated 3/3/2011 states, "...recent left [MEDICAL CONDITION], status [REDACTED]. The patient developed pressure ulcers on both heels with necrotic tissue and discharges with foul-smelling. The patient was seen in the office and she was admitted subsequently...The patient was taken to the OR and debridement was done to the necrotic tissue on both heels..." On 3/8/2011 at 1:26 Z1 was interviewed. He said he had not been aware that R1 had any pressure ulcers until she came to his office on 2/17/2011. He said the wound would be difficult to treat as an outpatient, so the resident was admitted to the hospital. Z1 said that R1 had unstageable bilateral heel ulcers that had necrotic tissue and foul smelling drainage. Z1 said the left heel was worse than the right. Z1 said, "You would think someone would have noticed the heels breaking down." 2. On 3/8/2011 at 11:20 AM, R5 was observed lying on her right side, facing the door. Hourly observations were made. At 2:55 PM, E5 and E6 (CNA's) were observed repositioning R5. E5 said she had worked all day. She said the last time the resident was turned was at 11:00 AM. E6 said, "Sometimes we just move her slightly. We don't always completely reposition her. It depends on her comfort." R5 was observed to have a [DEVICE] in place for a coccyx wound. The 3/8/2011 Monthly Wound Tracking Report shows that R5 has a stage 4 decubitus ulcer on her coccyx ( 2 X 2 centimeters - cm ) and a stage II ulcer on her left buttock ( 5 X 4 cm ) and her right buttock ( 2 X 3 cm ). R5's MDS of 2/7/2011 shows the resident is dependent upon staff for transfers, dressing, eating, hygiene, and bathing. The resident does not ambulate. R5's Skin Breakdown careplan of 2/1/2011 lists as an intervention to reposition every 1 to 2 hours from side to side in bed. 3. On 3/8/2011 at 11:20 AM, R6 was observed sitting up in a geriatric chair. R6's family was visiting. Z3 said when R6 was at home he developed pressure ulcers on his buttocks. Z3 said she always asks the facility about the condition of his skin because she is worried he will break down again. R6's Minimum Data Set of 2/25/2011 shows that the resident has cognitive deficits. He is dependent upon staff for transfers, dressing eating, bathing, and hygiene. Hourly observations were made from 11:30 AM through 3:30 PM. R6 was never moved from the geriatric chair, and always remained in the same position. It is not known what time the resident was placed in the chair. The facility's Monthly Wound Tracking Report of 2/8/2011 shows that R6 had a stage II Pressure Ulcer on his left buttock. The Interdisciplinary Care Plan Review (no date) documents the resident is at risk for skin breakdown due to weakness, poor cognition, incontinence of bowel and bladder, diabetes, [MEDICAL CONDITION], and potential shearing during reposition. The review shows that the resident is dependent upon staff for his activities of daily living. R6's Skin care plan of 2/1/2011 has an intervention to reposition the resident every 2 hours. On 3/8/2011 at 3:30 PM, E10 (Registered Nurse) confirmed the resident should have been repositioned every 2 hours. She said the resident is usually in bed when she comes on her shift at 2:00 PM.