Every finding on record at Portsmouth Health and Rehab

Based on interview, record review, and review of the facility's policy, the facility failed to ensure the nursing staff followed the resident's do not resuscitate (DNR) order for one of three residents (Resident (R) 109) reviewed for advance directives out of 47 sampled residents. On [DATE], R109 was found unresponsive in her room, the nursing staff did not verify her code status prior to providing chest compressions in the absence of a pulse; when the code status was verified the nurse stopped chest compressions and R109 was sent to the hospital. Additionally, the nursing staff were not aware where to locate the code status of the residents during a power outage. An Immediate Jeopardy was identified on [DATE] and was determined to exist [DATE] in S483.24, F678 Cardio-Pulmonary Resuscitation (CPR). The Administrator and Regional Clinical Director were notified on [DATE] at 3:08 PM that Immediate Jeopardy existed.The failure of the nursing staff to verify the resident's code status when found unresponsive resulted in the resident receiving CPR which did not honor her wishes created an immediate jeopardy situation. An acceptable Immediate Jeopardy Plan of Removal was provided on [DATE] at 6:24 PM and was validated on [DATE] at 10:00 AM. The Administrator was notified on [DATE] at 10:30 AM that the Immediate Jeopardy was removed. After the removal of the Immediate Jeopardy, the deficiency remained at a scope and severity of a D, (no actual harm with the potential for more than minimal harm).Findings include:Review of the facility's policy and procedure titled Cardiopulmonary Resuscitation (CPR), revised 4/2024, revealed Policy Residents advance directive will be honored . 1. Cardiopulmonary resuscitation is initiated on all residents except those with a no code order and appropriate documentation . Procedure 1. In the case of cardiac and/or pulmonary arrest, after the code status is checked, CPR is initiated if it is the residents' choice to have CPR, using the Red Cross or American Heart Association Guidelines for performing CPR .Review of R109's admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of pulmonary fibrosis and was discharged from the facility on [DATE]. Review of R109's Physician's Orders, dated [DATE], located in the EMR under the Orders tab revealed an order for DNR - do not resuscitate. Review of R109's Virginia Department of Health Durable Do Not Resuscitate Order, dated [DATE], located in the EMR under the Misc tab revealed 1. The patient is CAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment was marked and was signed by the resident and physician. The order stated that on the effective date noted above, to withhold cardiopulmonary resuscitation (cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, and related procedures) from the patient in the event of the patient's cardiac or respiratory arrest .Review of R109's General Note, dated [DATE], located in the EMR under the Prog Notes tab revealed at approximately 1:00 PM, patient observed ambulating back to her room pulling oxygen tank and verbalized to nurse, I'm ready for my Gabapentin now. A Certified Nursing Assistant (CNA) told the nurse that the patient did not look right, she was blue, and not responding. The nurse immediately ran to patient room. Nurse observed patient standing up against bed in a stance, staring with eyes wide open, blue in the face, dark purple around her mouth, mouth wide open. Nurse immediately yelled for assistance and crash cart. and placed the patient on her bed, lowered the head, immediately placed backboard under her. Nurse immediately administered oxygen. Patient remained in stiff, blue around the mouth, and now blue/gray around her eyes. Nurse was alerted by assisting staff that the patient code status was DNR. Nurse continued with oxygen. Nurse had assisting staff obtain VS [vital signs] of 96.3 [temperature]-116 [heart rate]-28 [respirations]-0-44/31-71 [blood pressure]-blood glucose 135. Nurse and assisting staff called PA [physician assistant] who came back to facility, assessed situation, and gave order to send patient to the hospital via 911. Nurse printed paperwork including the DNR code status. 911 was called by assisting staff member. 911 came and transported patient to ED.Review of the Facility Reported Incident (FRI) revealed, Certified Nursing Assistant (CNA)1 observed R109 in her room exhibiting cyanosis and minimal responsiveness and Licensed Practical Nurse (LPN)1 responded and assessed the resident and noted signs of distress. Despite a documented DNR order in place, LPN2 initiated chest compressions and upon verification of the DNR, chest compressions were immediately discontinued. R109 was noted to have shallow respirations and a pulse and was placed in a recovery position. Emergency Medical Services (EMS) was contacted and subsequently transported to the hospital emergency room (ER). Corrective actions included initiating a thorough investigation into the event by the Administrator; verifying the accuracy for all of the current resident's code status to ensure they align with their wishes by the Social Services Director (SSD); providing re-education to all current licensed nurses regarding advanced directives and the importance of following physician's orders by the former Director of Nursing (DON); providing re-education to all current licensed nurses on the proper response to an unresponsive resident, as well as code blue and CPR procedures, emphasizing the importance of reviewing advanced directives by the former DON; implementing mandatory code blue drills with all current licensed nurses and CNAs to reinforce proper response and awareness of advanced directives by the former DON; and re-educating all current staff members on the definition of neglect, specifically addressing the failure to provide services and care in accordance with a resident's advanced directive wishes by the Administrator. A telephone interview was attempted with R109 on [DATE] at 8:05 AM, however, it was the wrong number. During an interview on [DATE] at 7:56 PM, LPN1 stated CNA1 notified her that R109 was unresponsive in her room. LPN1 stated she asked for a crash cart, did not call a code blue because she felt a pulse, but she was struggling for air. LPN1 placed a nonrebreather on her, and then LPN2 began chest compressions until LPN4 notified LPN2 that she was a DNR. During an interview on [DATE] at 8:49 PM, LPN4 stated she was notified that the crash cart was needed for R109 by CNA1. LPN4 also stated when she arrived at the room, R109 was stiff and blue around the mouth, and she asked the nurses what her code status was. LPN4 indicated one of the nurses began chest compressions until LPN4 returned to the room and notified staff that R109 was a DNR. During an interview on [DATE] at 9:02 PM, LPN2 stated she entered R109's room, felt that she did not have a pulse and then she started chest compressions until the code status of DNR was reported by LPN4. LPN2 stated she was suspended for one day due to not following the DNR orders. During an interview on [DATE] at 9:17 PM, LPN3 stated she received a call for assistance with R109 from LPN1 and when she arrived at the room, she witnessed LPN2 giving chest compressions to the resident. LPN3 also stated that LPN2 halted chest compressions when LPN4 notified the nursing staff that R109 was a DNR. During an interview on [DATE] at 8:19 AM, LPN10 stated she had worked at the facility for three months was an agency employee, she would call a code blue and start CPR if she found a resident unresponsive. LPN10 also stated that you provide CPR then have someone verify the code status of the resident. During an interview on [DATE] at 8:37 AM, RN1 stated she had worked at the facility for one month and would call a code blue and start CPR if she found a resident unresponsive. RN1 also stated that you provide CPR then have someone verify the code status of the resident. During an interview on [DATE] at 8:58 AM, MDSC2 stated she would verify the code status of the resident prior to calling a code blue if the resident was found unresponsive. MDSC2 also stated she was not aware of a backup system in place when the power went out and the EMR could not be accessed. During an interview on [DATE] at 9:51 AM, LPN7 stated she did not know where to find the code status of the residents when the power went out and could not access the EMR. During an interview on [DATE] at 10:26 AM, Physician Assistant (PA) stated she was at the facility on [DATE] when R109 was found unresponsive in her room by CNA1 and LPN1. The PA stated she expected staff to initiate CPR until they determine their code status if found unresponsive. PA confirmed the staff did not honor R109's wishes of DNR when they began chest compressions on the resident. PA indicated she was concerned that the facility did not have the code status of the residents when the power went out in the building and the EMR could not be accessed.During an interview on [DATE] at 4:57 PM, the SSD confirmed when she began employment in [DATE], she performed an audit of the resident's code status, created a code status binder which included a copy of the resident's DNR order, CPR and Advance Directive policy and procedure, daily census for each unit, and then placed the binder at the two nurses' stations in the building for staff to use during a power outage. During an interview on [DATE] at 1:01 PM, the Medical Director stated he expected the nursing staff to follow the resident's code status orders and a DNR means no CPR was provided and the code status should be verified in the computer first. The Medical Director also stated R109 was sent to the hospital and returned unharmed.

Based on interview, record review, and policy review, the facility failed to ensure potential allegations of abuse was reported timely to the Administrator and to the State Survey Agency (SSA) two of six residents (Resident (R) 53 and R79) reviewed for abuse out of 47 sampled residents. This failure increased the risk of other vulnerable residents being abused.Findings include: Review of the facility's policy and procedure titled Resident Abuse, revised 01/2023, provided by the facility, revealed . G. procedure for reporting abuse i. all incidents of abuse are reported immediately to the licensed nurse in charge, director of nursing, or the administrator . iii. IF the events that caused the suspicion did not result in serious bodily injury the facility shall report within 24 hours . V. Employee obligation: a. all employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating their rights. Any employee who witnesses or has knowledge of an act of abuse to a resident is obligated to report such information to the licensed nurse in charge, don, or the administrator . 1.Review of R53's admission Record, located in the electronic medical record (EMR) under the profile tab, revealed the resident was admitted to the facility on [DATE] with a diagnosis of adjustment disorder with anxiety. Review of R53's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/27/25, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognately intact. Review of R53's General Note, dated 03/25/25, located in the EMR under the Prog Notes tab, revealed During nursing rounds, nurse was alerted that patient had a verbal altercation that was out of control, and no one could calm patient down. Nurse went to assess patient, and the patient was sitting on side of his bed, stating that he was upset. Nurse asked patient what happened. Patient explained to nurse the details of events. Nurse asked what could nurse do to calm him down. Patient stated he wanted to vent and be heard. He voiced that he felt better but refused to have nurse come back into his room. Nurse informed manager on call. Patient resting in bed, supine, lying on left side, call bell and PO [by mouth] fluids in reach. Review of the Facility Reported Incident (FRI), dated 03/25/25, revealed the facility performed an internal investigation and confirmed verbal abuse occurred on 03/23/25. The allegation of verbal abuse was submitted to the state agency on 03/25/25 (two days after the incident occurred). The investigation revealed that R53 reported that he was subjected to verbal abuse by Licensed Practical Nurse (LPN) 14 after she woke him up to administer his medications, she shoved the medications in his face so he became upset, he followed her out of his room, he picked up a wet floor sign in the hallway and threatened to hit her with it while she was standing at the medication cart. LPN14 picked up the water pitcher off the medication cart and threatened to crack him over the head with it if he came any closer to her. LPN1 heard R53 screaming at LPN14 in the hallway so she escorted him to his room and provided emotional support. LPN14 left the building after the incident and was terminated from employment. Abuse in-services were completed with all staff during the investigation from 03/25/25 and 03/26/25. Additional interventions included R53 receiving a visit from the psychologist for emotional well-being, receiving psychosocial follow-up from the Social Services Director (SSD), and the Director of Nursing (DON) and nurse management ensuring his safety and that his needs were met. During an interview on 09/17/25 at 5:22 PM, the Administrator confirmed she was not notified of the verbal abuse to R53 when it was observed by LPN1 and reported to the on-call manager on 03/23/25 around 11:00 PM. The Administrator confirmed she did not report it within two hours to the state survey agency (SSA), and did not submit the initial and 5-day follow-up report to the SSA within the required timeframes. The Administrator stated LPN1 left a concern note on 03/25/25 regarding the incident so she submitted the initial report to the SSA on 03/25/25, initiated the investigation, asked LPN14 to write a statement, substantiated abuse in the 5-day report on 04/03/25, and then training was conducted with all the staff on abuse, neglect, and reporting abuse. The Administrator also indicated LPN14 was suspended during the investigation and terminated on 03/25/25. During an interview on 09/18/25 at 5:33 PM, LPN14 stated R53 tried to attack her in the hallway with a wet floor sign and cursed at her at the medication cart after she administered his medications to him on 03/23/25. LPN14 confirmed she picked up the water pitcher off the medication cart and said she would crack him in the head if he didn't get away from her. LPN14 also stated she wrote a statement at the request of LPN1 and left for the evening, verbally quit, and only returned to the facility to provide another statement to the Administrator on 03/25/25. During an interview on 09/19/25 at 9:03 AM, LPN1 stated she saw LPN14 with a water pitcher in her hand at the medication cart in the hallway and R53 was screaming in front of her in his wheelchair with a wet floor sign in his hand. LPN1 indicated she reported abuse to the on-call manager but could not remember the name of the manager after R53 explained what occurred around 11:00 PM on 03/23/25. LPN1 also indicated the on-call manager instructed her to write a statement and to get one from LPN14. LPN1 also stated she thought she reported timely.

Based on interview, record review, and policy review, the facility failed to protect the residents' right to be free from a verbal threat of potential physical abuse by staff for one of five residents, (Resident (R) 53), reviewed for abuse out of a total sample of 47. This failure had the potential to cause physical or psychosocial harm to the resident.Findings include:Review of the facility's policy titled Resident Abuse, revised 1/2023, revealed Policy It is inherent in the nature and dignity of each resident at the facility that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse. 1. All employees of the facility are charged with a continuing obligation to treat all residents in the most humane manner possible. 2. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident . 2. Types of Abuse: . H. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.Review of R53's admission Record, located in the electronic medical record (EMR) under the profile tab, revealed the resident was admitted to the facility on [DATE] with a diagnosis of adjustment disorder with anxiety.Review of R53's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/27/25, located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognately intact.Review of R53's General Note, dated 03/25/25, located in the EMR under the Prog Notes tab, revealed During nursing rounds, nurse was alerted that patient had a verbal altercation that was out of control, and no one could calm patient down. Nurse went to assess patient, and the patient was sitting on side of his bed, stating that he was upset. Nurse asked patient what happened. Patient explained to nurse the details of events. Nurse asked what could nurse do to calm him down. Patient stated he wanted to vent and be heard. He voiced that he felt better but refused to have nurse come back into his room. Nurse informed manager on call. Patient resting in bed, supine, lying on left side, call bell and PO [by mouth] fluids in reach.Review of R53's Care Plan, dated 11/30/23, located in the EMR under the Care Plan tab, indicated the resident had behaviors which included cursing, screaming, shouting, tearing things up, and not easily redirected with interventions to tell him what you are doing before you begin. Two staff members in room during care with the resident was added on 04/23/25. R53's Care Plan, dated 06/04/25, revealed a focused area of can be verbally abusive to staff and follow behind staff in aggressive manners with interventions that included to observe the resident for triggers for verbally abusive episodes and intervene at first sign of trigger(s).Review of the Facility Reported Incident (FRI), dated 03/25/25, revealed the facility performed an internal investigation and confirmed verbal abuse occurred on 03/23/25. The allegation of verbal abuse was submitted to the state agency on 03/25/25. The investigation revealed that R53 reported that he was subjected to verbal abuse by Licensed Practical Nurse (LPN) 14 after she woke him up to administer his medications. LPN14 shoved the medications in his face so he became upset, he followed her out of his room, he picked up a wet floor sign in the hallway and threatened to hit her with it while she was standing at the medication cart. LPN14 picked up the water pitcher off the medication cart and threatened to crack him over the head with it if he came any closer to her. LPN1 heard R53 screaming at LPN14 in the hallway so she escorted him to his room and provided emotional support. LPN14 left the building after the incident and was terminated from employment. Abuse in-services were completed with all staff during the investigation from 03/25/25 and 03/26/25. Additional interventions included R53 receiving a visit from the psychologist for emotional well-being, receiving psychosocial follow-up from the Social Services Director (SSD), and the Director of Nursing (DON) and nurse management ensuring his safety and that his needs were met.During an interview on 09/15/25 at 4:05 PM, R53 stated that on 03/23/25 LPN14 entered his room to give him medications, woke him up by knocking on the door, he told her to come closer to him so he could get the medication cup from her, she shoved the medications in his face and he thought he heard her say something about him under her breath as she was exiting his room. R53 confirmed he got mad, so he got in his wheelchair, went to the hallway, yelled at her at the medication cart, picked up a wet floor sign off the floor, and then LPN14 picked up the water pitcher off the medication cart and threatened to crack him over the head with it. R53 also stated that LPN1 took him to his room, he reported it to her, and he did not see LPN14 for the remainder of the evening and hasn't since then. R53 indicated he felt safe in the facility, and the staff checked on him for weeks after the incident.During an interview on 09/17/25 at 5:22 PM, the Administrator confirmed LPN14 admitted that she threatened to hit R53 with the water pitcher when he threatened to hit her with the wet floor sign. The Administrator stated she suspended the nurse during the investigation and terminated her on 03/25/25.During an interview on 09/18/25 at 5:33 PM, LPN14 stated R53 tried to attack her in the hallway with a wet floor sign and cursed her at the medication cart after she administered his medications to him on 03/23/25. LPN14 confirmed she picked up the water pitcher off the medication cart and said she would crack him in the head if he didn't get away from her. LPN14 also stated she wrote her statement at the request of LPN1 and left for the evening, verbally quit, and has not returned to the facility. During an interview on 09/19/25 at 9:03 AM, LPN1 stated she saw LPN14 with a water pitcher in her hand at the medication cart in the hallway and R53 was screaming in front of her in his wheelchair screaming at her with a wet floor sign in his hand. LPN1 also stated she went to R53's room with him, he told her about the incident, and she stayed with him until he didn't want to be disturbed. LPN1 indicated LPN14 wrote a statement and then left the facility and has not returned to the facility.

Based on interview, record review, and review of the facility's policy, the facility failed to remove and destroy a controlled medication, lorazepam (narcotic medication), that was discontinued and subsequently administered to a resident during a seizure without an order for one of four residents (Resident (R) 13) reviewed for pharmacy services. out of a sample of 47 residents. This failure placed the resident at risk for complications related to administration of the medication without an order. (Cross Reference F658)Findings include:Review of the facility's policy titled Controlled Drug Medication Disposal, revised 1/2020, revealed Policy to ensure controlled substances are disposed of, according to Federal/State laws and regulations, by the Director of Nursing and consultant Pharmacist. Appropriate record keeping will be completed and maintained by the Director of Nursing and consultant Pharmacists . 2. Discontinued medication or resident has been discharged . A. The Director of Nursing will remove the medication from the medication cart and the Controlled Drug Declining Inventory Sheet from the MAR or Narcotic Book in the presence of another nurse. B. The Director of Nursing and the other nurse will sign the Controlled Drug medication sheet to verify removal. C. The Controlled Medication and Controlled Drug Declining Inventory Sheet will be held together with a rubber band and placed in a designated double locked area. Medication is to disposed of by the Director of Nursing and another professional person as designated by state policy .Review of R13's undated admission Record located in the electronic medical record (EMR) under the Profile tab, revealed he was admitted on [DATE] with epilepsy, unspecified, not intractable, with status epilepticus. Review of R13's Physician's Orders, dated [DATE], located in the EMR under the Orders tab, revealed an order for lorazepam injection solution 2 milligrams (MG)/Milliliters (ML) inject 0.5 ML intramuscularly one time only for agitation/combative for one day. Review of R13's Alert Note, dated [DATE], located in the EMR under the Prog Notes tab, revealed This nurse called to pt's [patient's] bedside for c/o [complaints of] distress by CNA. Pt. was found in bed, actively seizing . Pt. seized for 4 minutes then stopped for 10 sec [seconds] and seized again for 5 minutes. 0.5 cc [cubic centimeters] IM [intramuscular] Ativan given in right deltoid. Review of the facility's internal investigation, dated [DATE], revealed R13 exhibited seizure like activity on [DATE]. LPN5 provided supportive care and called for assistance from Registered Nurse (RN) 2. LPN5 contacted 911, and RN2 noted R13 had Ativan IM in the narcotic drawer, however, the medication had been discontinued and there was not an active order. LPN5 brought the medication to R13's room and RN2 administered the IM Ativan to stop the seizure. Actions taken included suspending LPN5 during the investigation on [DATE] then terminating him on [DATE]. RN2 was removed from the schedule and agency was informed that she was a do not return to the facility on [DATE]. All nursing staff were re-educated on following physician's orders, medication administration, and the narcotic destruction process for discontinued medications on [DATE] by Director of Nursing (DON) 2. DON2 audited the medication cart narcotic boxes and facilitated the destruction of the discontinued narcotics. During an interview on [DATE] at 11:22 AM, the Director of Nursing (DON) 1 stated discontinued narcotic medications should be pulled from the medication carts along with a completed narcotic sheet and then given to her to destroy with another nurse. During an interview on [DATE] at 1:59 PM, the Administrator stated DON2 initiated the investigation of the incident and facilitated the destruction of the discontinued narcotic medications on [DATE]. The Administrator stated DON2 facilitated destroying the controlled medications with the unit managers during the investigation. During an interview on [DATE] at 11:50 AM, DON2 stated she had worked for the facility a couple of weeks when she completed the investigation and determined RN2 administered R13's discontinued lorazepam which should have been pulled from the medication cart and given to her for destruction. DON2 also stated she asked the unit managers to remove discontinued and expired controlled medications from the medication carts and began destroying the medications with them after the incident on [DATE].

Based on interview and record review, the facility failed to provide one of four residents (Resident (R) 106) reviewed for activities out of a total sample of 47 with the opportunity to be offered diversional activities or to be moved to another room when his roommate (R119) passed away. This had the potential for a resident to be traumatized due to being a vulnerable resident.Findings include:Review of R106's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated the resident was admitted to the facility on [DATE].Review of R106's admission Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 09/10/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The assessment indicated the resident was able to ambulate on his own.Review of R106's Progress Note, located under the Prog (Progress) Note tab of the EMR and dated 12/17/24, failed to indicate the resident was offered a room change on 12/17/24 when R106's roommate passed away.2. Review of R119s admission Record located under the Profile tab of the EMR, indicated the resident was admitted to the facility on [DATE].Review of R119's death in the facility MDS, located under the MDS tab of the EMR and with an ARD of 12/17/24, revealed the resident passed away on this date.Review of a document for R119 titled Record of Death, located under the Misc (Miscellaneous) tab of the EMR and dated 12/17/24, indicated the resident passed away at 5:20 PM and his body was released to the funeral home at 10:11 PM.During an interview on 09/17/2025 at 2:48 PM, the Central Supply Manager (CSM) stated she was assigned to R106's room to ensure everything was in place. CSM stated she did not remember if the body of R119 was left in his room but stated it was the facility policy to offer the living resident another room.During an interview on 09/17/25 at 5:53 PM, the Administrator stated the process for a resident who has passed away was to offer the roommate outside diversional activities or to offer another room.During an interview on 09/18/25 at 8:37 AM, Licensed Practical Nurse (LPN) 9 who was an agency staff member stated when a resident has passed away, staff were to pull the curtain and offer any roommate another room.During an interview on 09/18/2025 at 3:58 PM, the MDS Coordinator (MDSC) stated she was the staff member who pronounced the death of R119 only and was not the staff member who spoke with R106 about moving to another room. The MDSC stated it was the facility's policy to offer the resident another room after a death of their roommate.During an interview on 09/18/2025 at 4:02 PM R106 stated he was not offered another room after R119 passed away.During an interview on 09/18/25 at 5:15 PM, the Administrator stated, We do not have a specific policy for dignity.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure the nursing staff provided care that met professional standards of practice when an order was not obtained from the physician for a controlled substance, lorazepam (narcotic medication), prior to administration to a resident during a seizure for one of four residents (Resident (R) 13) reviewed for nursing standards out of a sample of 47 residents. This failure placed the resident at risk for complications related to administration of the medication without an order.Findings include:Review of the facility's policy titled Physician Orders, dated 8/2021, provided by the facility, revealed . Procedure . Routine Orders: 1. A clinical nurse may accept a telephone order from the Physician, Physician's Assistant, or Nurse Practitioner as sate statue permits . 2. The order shall be recorded exactly as the physician dictates it on a telephone order form .Review of the facility's policy titled Medication Administration General Guidelines, dated 01/23, provided by the facility, revealed Policy Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only persons legally authorized to do so . Procedures Medication Preparation: . 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record . Review of R13's undated admission Record located in the electronic medical record (EMR) under the Profile tab, revealed he was admitted on [DATE] with epilepsy, unspecified, not intractable, with status epilepticus. Review of R13's Physician's Orders, dated 04/15/25, located in the EMR under the Orders tab, revealed an order for lorazepam injection solution 2 milligrams (MG)/Milliliters (ML) inject 0.5 ML intramuscularly one time only for agitation/combative for one day. Review of R13's General Note, dated 04/25/25, located in the EMR under the Prog Notes tab, revealed At approximately 6:00 PM, resident was reported to me by the CNA [certified nursing assistant] that he was having seizure at the hallway while I was passing medication, I rushed, and we guarded him, positioned him with the head turned to the left side. He was guarded to avoid sustaining any physical injury. The seizure lasted to about 6 minutes and when it stopped, he was assisted back to his room, laid him down with his bed lowered. The physician was called and did not answer, but voice note was left with detailed information and call back number to possibly obtain an order for lorazepam injection. Thereafter, the on-call nurse was notified as well to reach out to the physician on call, but she advised that for the seizure has lasted for about 6-7 minutes , there is no need for lorazepam injection pending when she will talk with the physician, thereafter a while she called me back that I should not administer it because the period of the seizure was very short. Then I was still waiting for the physician on call to call me back and at about 8:00 pm plus, the CNA came back again and reported 2nd episode of active seizure while in his bed and was well positioned to prevent aspiration. Then, other nurses in the facility were alerted for assistant [sic]. When they arrived, the seizure continued for 15 minutes. The RN [registered nurse], asked me to get the lorazepam so we can administer to him as he was in active and continuous seizure for breakthrough, but I told her that I was waiting for the approval of the order from the NP [nurse practitioner] as the nurse on call advised that I should not give without their approval, but she insisted that this is an emergency and has to be done. Then, I rushed and brought it to her then the RN give 0.5ml of it, injected to his right deltoid muscle, while the seizure was still active. Nurse, called 911 at about 8:18 PM, they arrived, took over the care and resident was transport [sic] via stretcher out of the facility. Thereafter, the NP was called again to notify her of the situation and the Lorazepam that was given by the RN for a verbal order as it was an emergency, but NP, refused giving the verbal order that the nurse must obtain an order from her before giving it regardless of emergency situation or not, then on call nurse was notified as well. The family member was notified @ [at] 9:39 PM. The night nurse was as well notified of the situation.Review of R13's Alert Note, dated 04/25/25, located in the EMR under the Prog Notes tab, revealed This nurse called to pt's [patient's] bedside for c/o [complaints of] distress by CNA. Pt. was found in bed, actively seizing. Pt's head was turned to left side. Pt. was spitting, and having pink tinged secretions from mouth. Pt. did not respond, to name calling. Pt continued to have rapid eye movement. Warm to touch. Nurse remained with patient, until 911 called by this nurse. Nurse was advised to maintained a safe environment for patient. Pt. seized for 4 minutes then stopped for 10 sec [seconds] and seized again for 5 minutes. 0.5 cc [cubic centimeters] IM [intramuscular] Ativan given in right deltoid. Pt. continued to seize after medication given. EMS [emergency medical services] arrived and toke [sic] over pt.'s care .Review of the facility's internal investigation, dated 04/29/25, revealed R13 exhibited seizure like activity on 04/25/25 and Licensed Practical Nurse (LPN) 5 provided supportive care for safety and contacted the on-call practitioner and left a message to return the call regarding the resident's change of condition. Before the on-call practitioner returned the call, R13 experienced another episode of seizure like activity. LPN5 provided supportive care and called for assistance from Registered Nurse (RN) 2. LPN5 contacted 911, and RN2 noted R13 had Ativan IM in the narcotic drawer, however, the medication had been discontinued and there was not an active order. LPN5 brought the medication to R13's room and RN2 administered the IM Ativan to stop the seizure. EMS arrived and transported R13 to the hospital in which R13 was admitted for seizures. Actions taken included suspending LPN5 during the investigation on 04/25/25 then firing him on 05/02/25. RN2 was removed from the schedule and agency was informed that she was a do not return to the facility on [DATE]. All nursing staff were re-educated on following physician's orders, medication administration, and the narcotic destruction process for discontinued medications on 04/26/25 by Director of Nursing (DON) 2. DON2 audited the medication cart narcotic boxes and facilitated the destruction of the discontinued narcotics. During an interview on 09/18/25 at 11:22 AM, the Director of Nursing (DON) 1 stated discontinued narcotic medications should be pulled from the medication carts along with a completed narcotic sheet and then given to her to destroy with another nurse. DON1 also stated it was not in nursing scope of practice to administer medications without an order, and nurses should verify or obtain an order prior to administering any medications to residents. During an interview on 09/18/25 at 1:59 PM, the Administrator stated DON2 initiated the investigation of the incident and facilitated the destruction of the discontinued narcotic medications. During an interview on 09/18/25 at 11:31 AM, the Physician Assistant (PA) stated she was not on call on 04/25/25 but expected the nurses to obtain an order from the on-call providers prior to administering any medications. The PA stated R13 had received lorazepam in the past for agitation and there were no negative outcomes because of receiving the medication. During an interview on 09/18/25 at 11:50 AM, DON2 confirmed her investigation was substantiated when RN2 was practicing out of scope when she administered the discontinued lorazepam to R13 without a new order while he experienced a seizure on 04/25/25. DON2 stated she terminated LPN5 on 05/01/25 and RN2 admitted she administered the medication without an order because it was an emergency. During an interview on 09/18/25 at 1:11 PM, the Medical Director stated he expected the nurses to obtain an order for medications and not administer discontinued medications for it was in their scope of their practice.

Based on interview, record review, and facility policy review, the facility failed to ensure narcotic pain medications were administered to one of three residents (Resident (R) 106) reviewed for pain management out of a total sample of 47. This resulted in the resident missing multiple doses of pain medication and potentially reducing his quality of life.Findings include:Review of a facility policy titled, Pain Management, dated 01/2020, indicated . Residents will be assessed for pain upon admission, readmission, quarterly, annually, upon significant change, when a resident experiences a new onset of pain or experiencing uncontrolled pain .Review of R106's admission Record, located under the Profile tab of the electronic medical record (EMR), indicated the resident was admitted to the facility on [DATE].Review of R106's admission Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 09/10/24, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The assessment indicated the resident was able to ambulate on his own. The assessment indicated at the time of the assessment, the resident had no pain.Review of R106's Care Plan, located under the Care Plan tab of the EMR and dated 11/04/24, indicated the resident had intermittent pain post motor vehicle accident. The intervention was to medicate for pain as ordered by physician and follow up for effectiveness.Review of R106's Order, located under the Orders tab of the EMR and dated 12/09/24, indicated the resident was ordered by Oxycodone HCI (a narcotic analgesic) tablet 5 milligrams (mg) to be administered every six hours for chronic pain.Review of R106's Medication Administration Record (MAR) for the month of 12/2024, located under the Orders tab of the EMR, indicated the facility failed to assess the resident's pain and administer Oxycodone 5 mg on the following dates: 12/10/24 at 6:00 AM; 12/15/24 at 6:00 AM; 12/23/24 at 12:00 AM; 12/26/24 at 12:00 AM and 6:00 AM; and on 12/28/24 at 6:00 AM.Review of R106's Progress Notes, located under the Prog (Progress) Note tab of the EMR and dated for the month of 12/2024, failed to contain evidence of why the resident was not assessed or administered his physician ordered pain medication.Review of R106's MAR, for the month of 01/2025 and located under the Orders tab of the EMR, indicated the facility failed to assess and administer Oxycodone 5mg on the following dates: 01/04/35 at 6:00 PM; on 01/05/25 at 6:00 AM and 6:00 PM; and on 01/06/25 at 12:00 AM.Review of R106's Progress Notes, located under the Prog Note tab of the EMR and dated for the month of 01/2025, failed to contain evidence of why the resident was not assessed or administered his physician ordered pain medication. During an interview on 09/18/25 at 10:36 AM, the Director of Nursing (DON) stated her expectation was if a resident was on routine pain medication and it was not administered, the nurse should have then documented the reason in the EMR.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure a resident was free of a significant medication error which resulted in an opioid overdose, which caused harm for 1 of 5 residents (Resident #4), in the survey sample. The findings included: Resident #4 was originally admitted to the facility 9/6/24 after an acute care hospital stay. The resident's admission diagnoses included acute osteomyelitis of the right foot and ankle and chronic pain. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from a nurse's note dated 9/6/24 at 11:59 PM. The resident Brief Interview for Mental Status (BIMS) score was 15 out of a possible 15. This indicated Resident #4's cognitive abilities for daily decision making was intact. A review of the resident's admission documentation did not reveal any type of transdermal patches were on the resident's body. The resident's care plan had a problem dated 9/7/24 which read, I have pain which I will rate. The interventions included medicate for pain as ordered by the physician and follow up for effectiveness. The resident's POS also revealed an order dated 9/6/24 to apply a Fentanyl Transdermal Patch 72 Hour, 25 MCG/HR on 9/7/24. Apply 1 patch transdermally one time a day, every 3 days for Pain Control and remove per schedule. The MAR was coded for application of a Fentanyl Transdermal Patch 25 MCG/HR at 3:52 PM on 9/7/24 but the removal of a previously applied Fentanyl Transdermal Patch was x out. A nurse's note dated 9/8/24 at 10:00 AM stated the nurse was notified that the resident was unresponsive. Upon the nurse's arrival the resident's blood oxygen level was at 73 percent on room air, blood sugar 202 mg/dl and his pupils were pinpoint and the resident responded only to a sternal rub. Emergency services was called, and the resident was transported to a local hospital. The emergency room (ER) notes dated 9/8/24 confirmed upon the resident's arrival he presented with a blood oxygen level of 64 percent, blood pressure 81/47, respirations at 22 breaths per minute and his heart rate was 107 and rising. The ER notes also stated the resident's eyes fluttered, but he remained non-verbal to stimuli. The ER notes further revealed that a Registered Nurse observed a Fentanyl Transdermal Patch to the resident's left shoulder. The Fentanyl Transdermal Patch was removed, and the area was wiped. The Physician was notified of the Fentanyl Transdermal Patch and an order for Narcan 0.4 mg intravenously (IV) push was administered, and the resident immediately woke up and began speaking clearly. The ER notes further revealed the resident had acute toxic encephalopathy related to an opioid overdose likely because of two/two (2/2) Fentanyl Transdermal Patches. Since 9/8/24 thirteen other residents were identified to receive as needed or scheduled opioid medications. Twelve of the thirteen received oral opioid medications and there were no symptoms of overdose documented in their clinical record. The thirteenth resident (Resident #3) was identified with an order for an opioid transdermal patch (Butrans Transdermal patch 7.5 mcg/HR to be applied weekly and remove per schedule). Random observations, and a review of Resident #3's POS, MAR and the person-centered care plan was completed. Resident #3 was admitted to the facility on [DATE] and his BIMS score on 8/8/24 was coded as 15 out of 15. This indicated Resident #3's cognitive abilities for daily decision making was intact. An interview was conducted with the resident on 10/2/24 at approximately 11:00 AM. The resident stated he was fully aware of why the Physician/Practitioner ordered the Butrans Transdermal patch, when and where the nurses applied the Butrans Transdermal patch, and he how he ensured it remained intact. The observation confirmed the Butrans Transdermal patch was in the correct place and there was only one Butrans Transdermal patch on the resident's body. On 10/2/24 at 12:34 PM an interview was conducted with LPN #1. LPN #1 stated they had an in-service recently regarding Fentanyl patches. She learned from the in-service to make sure that you look for Fentanyl patches on admission, document findings and find out the schedule for application and removal. Another nurse is required to validate removal of a Fentanyl patch. On 10/2/24 at 12:53 PM an interview was conducted with RN #1. RN #1 stated she was educated on how to identify Fentanyl patches on a resident, and she learned techniques to make the patches more visible, using a penlight. She stated she has never seen a Fentanyl patch outside the packaging before, but it was explained they are difficult to see. On 10/2/24 at 12:56 PM an interview was conducted with LPN #2. LPN #2 stated they were in-service that upon admission if a Resident has a Fentanyl patch ordered they are to a complete a body check with a CNA assistance identify the location of the patch, count the number of Fentanyl patches a resident has on their body and if they identify a patch, it is to be removed and a new one applied. LPN #2 stated Fentanyl patches are transparent and hard to see and if necessary, verified with the Unit Manager. LPN #2 stated nurses were not allowed to work until they attended the in-service on opioid transdermal patches. A 9/13/24 at 4:34 PM nurse's note in the resident's clinical record stated it had been brought to the facility's attention that Resident #4 was identified with two Fentanyl Transdermal Patches on his body while he was on leave to the hospital therefore the facility developed a five-point corrective action plan: 1. Resident #4 was no longer a resident of the facility. He was identified by the hospital's staff with two Fentanyl transdermal patch affixed to his body. 2. The facility determined current residents and new admissions with an order for a transdermal opioid medication has the potential to be affected. The center identified one current resident with an opioid transdermal medication order. The Director of Nursing (DON)/Designee validated the order. Placement was confirmed and only one patch was present on the resident's body as ordered. The resident was assessed for adverse effects related to opioid use and no negative findings were found. 3. Current licensed nurses will receive education on the admission order process related to opioid transdermal patch orders, placement verification, shift to shift validation of current residents with an opioid transdermal patch and the admission skin assessment process and the high risk for not seeing Fentanyl transdermal patch due to the size, clear appearance, and dependent on the resident's skin tone. Two licensed nurses will conduct the admission skin assessment for new admissions and readmissions. New hire licensed nurses will receive education by the DON/Designee during orientation. The DON/Designee will complete a second skin assessment of admissions/readmissions the first working day after the admitted . 4. The DON/Designee will conduct an order review and second skin assessment on the resident with a new order for a narcotic transdermal patch and new admission/readmissions with an order for a narcotic transdermal patch weekly times four weeks then monthly times two. Findings will be reviewed through a weekly Quality Assurance (QA) meeting and additional intervention will be initiated as needed. An Ad Hoc QAA meeting with attendance by Medical Director via teleconference was held on 9/20/24 at 3:00 PM and the plan was reviewed and accepted. 5. Compliance date was 9/19/24. A final interview was conducted with the Administrator, the Director of Nursing, two Nurse Consultants and the [NAME] President of Operation on 10/2/24 at approximately 4:15 PM regarding the above information. It was determined that the facility implemented its corrective action plan, and there was sufficient evidence obtained by review of the Ad Hoc QAA meeting, weekly audits, observations and an interview with Resident #3, as well as interviews with three licensed nurses, that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirement at F-760. Fentanyl is a strong opioid analgesic (pain medicine). It acts on the central nervous system (CNS) to relieve pain. Fentanyl skin patch is used to treat severe and persistent pain that requires an extended treatment period and when other pain medicines did not work well enough or cannot be tolerated. Symptoms of an overdose include drowsiness, extreme dizziness or weakness, irregular, fast or slow, or shallow breathing, pale or blue lips, fingernails, or skin, pinpoint pupils, relaxed and calm, slow heartbeat or breathing, seizures, sleepiness, trouble breathing, or cold, clammy skin. (https://www.mayoclinic.org/drugs-supplements/fentanyl-transdermal-route/description/drg-20068152)

Based on observations, resident interviews, staff interviews, clinical record review, and review of facility documents, the facility's staff failed to answer call bells promptly for 3 of 21 residents in the survey sample, Resident #106, Resident #108, and Resident #110 . The findings included: 1. Resident #106 was admitted to the facility on [DATE]. The resident's diagnoses included: Paraplegia, Weakness, and Metabolic Encephalopathy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 which indicated the resident was severely cognitively impaired. An observation was made on 5/21/2024 at approximately 1:55 PM, and the resident's call bell was activated . While waiting with the resident, at 2:11 PM, Others #7 Came in to answer the call bell. Resident #106 asked to be repositioned. Others #7 went to get nursing staff and returned at 2:17 PM with additional staff to reposition the resident. Resident #106 said he was frustrated with having to wait long periods of time to be helped. 2. Resident #108 was admitted to the facility on [DATE]. The resident's diagnosis included: hemiplegia, hemiparesis, and anxiety. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/3/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 which indicated the resident was cognitively intact. An observation was made on 5/22/2024 at approximately 10:30 AM, the resident's call bell was activated . While waiting with the resident, at 10:47 AM, Certified Nursing Assistant (CNA) #3 answered the call bell. CNA #3 stated that she was in another resident's room giving care. Resident #108 asked to be cleaned for incontinence. 3. Resident #110 was admitted to the facility on [DATE]. The resident diagnosis included: chronic obstructive pulmonary disorder (COPD), panic disorder, and anxiety. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/18/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 which indicated the resident was severely cognitively impaired. An observation was made on 5/22/2024 at approximately 11:00 AM, the resident was in the hallway screaming for help. The resident was on oxygen and expressed being short of breath and that her heart was racing. The resident's call bell was observed to be already on. After observing the resident ambulate back to her bed, the resident was observed putting on a personal pulse oximeter probe which read that her oxygen level was 92% and her heart rate was 85. An observation was made that the resident's oxygen concentrator was on 2.5 liters. Resident #110 was observed being anxious as she expressed having a history of tachycardia and how staff does not come when she needs them. At approximately 11:26 CNA #3 was observed walking past the resident's room and CAN #3 was informed the resident was in her room with her call light going off for 26 minutes while she was possibly experiencing shortness of breath and some anxiety . The resident stated she felt better by this time. An interview was conducted with Licensed Practical Nurse (LPN) #1, LPN #1 shared that she did follow up and assess Resident #110 and was stable. An interview was conducted with CNA#2, who shared she was busy taking care of another resident during the time Resident #10's call bell was going off during the 11: 00 AM hour. On 5/21/24 at 2:58 PM The Administrator emailed, noting that the facility does not have policies or protocols on nurse staffing or rounding expectations for residents . On 5/23/24 at approximately 10:50 AM, the above findings were shared with the [NAME] President of Operations, Mobile Administrator, and Administrator. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a wander guard was placed on an at risk, wandering, exit seeking resident for monitoring for 1 of 21 residents (Resident #112), in the survey sample. The findings included: Resident #112 was originally admitted to the facility 6/18/21 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Dementia. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/20/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #112 cognitive abilities for daily decision making were severely impaired. In sectionG(Physical functioning) the resident was coded as requiring total care of one person with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing, extensive assistance of one person/ two people, limited assistance of one person, supervision after set-up. The person-centered care plan read that Resident #112 is at risk for elopement related to attempts to leave the building. A goal for Resident #112 is that she will have no incident of elopement. An intervention for Resident #112 is to check for wander guard placement and functioning every shift and as needed. The Physician's Order Summary (POS) for May 2024 read: Check wander guard function 11/7 every night shift for Monitoring: Check wander guard placement every shift. Active 04/25/2022. On 5/22/24 at approximately 3:30 PM., an interview was conducted with the Interim Director of Nursing (IDON) said that a wander guard should be placed on resident's that meet the elopement criteria. The IDON also mentioned that an exit seeking resident ended up walking outside a few years ago. No injuries were received, and the staff was right behind him. The elopement book was reviewed on both units. Wandered guard placement on residents were checked by the nursing staff. On 5/22/24 at approximately 4:45 PM., Resident #112 was observed walking in the hallway with another resident. RN/UM #2 asked Resident #112 for permission to check her wander guard. No wander guard was observed on the resident's ankles or wrist upon inspection. RN #2 said that often times the resident or her friend (another resident) will remove her wander guard. RN #2 also mentioned that she will place another wander guard on resident's ankle. Elopement/Wandering - Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Facilities should have policies in place for assessing/identifying residents at risk for elopement, and how to manage/monitor those at risk. If alarm systems are used, then routine maintenance and testing should be done according to manufacturer's recommendations. Education should be provided to staff for proper steps to be taken when responding to a door alarm or the event of a potential elopement, in accordance with facility policy. https://proactiveltcexperts.com/f689-accident-hazards-supervision-devices/ The Policy reads: Nursing personnel must report and investigate all reports of missing residents. Upon admission, a resident's potential for elopement will be determined by risk factors which may include but not limited to: History of wandering or elopement. On 5/23/24 at approximately 5:15 PM, a final interview was conducted with the Administrator, Mobile Administrator, Interim Director of Nursing (DON), Regional [NAME] President of Operations (RVPO), and the Director of Clinical Services. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation, staff interviews and clinical record review the facility staff failed to ensure 1 resident (Resident #104), in the survey sample of 21 Residents who was unable to carry out activities of daily living receives the necessary services to maintain toenail care. The findings included: Resident #104 was originally admitted to the facility on [DATE]. Diagnosis for Resident #104 included but not limited to; Diabetes Mellitus. The most recent Minimum Data Set (MDS) an annual with an Assessment Reference Date (ARD) of 2/23/24 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 which indicated Resident #104 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities) the resident was coded as requiring partial/moderate assistance with showering/bathing, dependent with putting on and taking off footwear, requiring substantial maximal assistance with personal hygiene. A review of a psychotherapy note dated on 2/13/24 read that Resident #104 would like to participate more in rehab., but her toenails are causing her pain with certain movements. Resident #104 also said that she has not seen the podiatrist which visits the facility once every few months. During the initial tour on 5/21/24 at approximately 1:38 PM. An interview was conducted with Resident# 104. Resident #104 said that she has not seen a podiatrist in thirteen (13) months, my toenails are curving into my skin which affected physical therapy due to hurting. Resident #104 also said that the podiatrist recently visited but never saw her. Resident #104 said that she had informed the Unit Manager (UM) and the Social Worker (SW) of her need for podiatry care. Resident #104 was observed pushing the call bell to ask for CNA assistance. CNA #1 pulled back the covers to reveal the resident's toenails. The resident's toenails on her right foot were observed to be thick, yellow, curvy, and long. The toenails on the resident's left foot were observed to be short, thick, and curvy. CNA #1 said that once they notice resident need toenail care, they will inform the nurse and the nurse will put the resident's name in a book. On 5/21/24 at approximately, 2:10 PM., an interview was conducted with the SW concerning Resident #104. The SW presented a podiatry list but said that Resident #104 may not be on the list to receive podiatry services. The SW also stated that if the nurse or CNA informs her of the need, she will add the residents to the podiatry services list. The SW also mentioned that the podiatrist visited the facility on 5/14/24 but was not able to see the resident because she had just been informed of the residents need for podiatry services. On 5/23/24 at approximately 10:40 AM, an interview was conducted with Resident #104. Resident #104 said that she informed the administrator on yesterday that she needed podiatry care. Resident #104 also said that her therapist was in to visit her when the podiatrist came to the facility (5/14/24-podiatrist in the facility). I asked, am I on the Podiatry list today (5/14/24). Resident #104 also mentioned that the UM (RN #1) had promised her that she was on the list to receive podiatry care (5/14/24) On 5/22/24 at approximately 3:30 PM., an interview was conducted with the acting DON. The acting DON said that she didn't know that Resident #104 needed podiatry care but in cases that residents would need podiatry services sooner than the in-house podiatry visits, an appointment would be made to an outside podiatry office. A review of a general note dated on 5/21/24 read: Resident reports to nurse her toenails are long, thick, and painful and well as interfering with therapy. Upon examination, this nurse (RN #1/UM) notes that resident's toenails are indeed long and with the second right toe starting to overlap onto the right great toe. New orders received for podiatry consult outside of the facility as the podiatrist is not due to return until late June. Resident is aware. A review of a general note dated 5/21/24 at 3:02 PM., read that a podiatry appointment was scheduled for May 28, 2024, at 2:00 PM. According to the psychiatrist progress note dated on 2/13/24, Resident #104 had been waiting for podiatry care services before her visit to the psychiatrist. On 5/23/24 at approximately 5:15 PM, a final interview was conducted with the Administrator, Mobile Administrator, Interim Director of Nursing (DON), Regional [NAME] President of Operations (RVPO), and the Director of Clinical Services. The RVPO said that the podiatrist came on 5/14/24 but didn't have time to see the resident.

Based on observation, resident interview and staff interview, the facility's staff failed to ensure 1 of 21 residents (Resident #111) who was unable to carry out activities of daily living (ADL) received the necessary services to include nail care. The findings included: Resident #111 was originally admitted to the facility 07/22/20 and readmitted on [DATE] after an acute care hospital stay. The current diagnoses included; Hypertension. The admission, significant change, annual quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 05/06/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #111 cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities) the resident was coded as being dependent in oral hygiene, personal hygiene, toileting hygiene, showering and bathing. A review of a progress note dated 5/14/24 read that resident is dependent in Activities of Daily Living (ADL). An interview was conducted on 5/23/24 at approximately 11:00 AM. Resident #111 fingernails were observed to have a significant amount of black substance beneath them. On 5/23/24 at approximately 12:04 PM., an observation was made of Resident #111 fingernails. Resident #111 fingernails were observed to have a significant amount of dark substance underneath each fingernail. Resident #111 was asked if she wanted her fingernails cleaned and trimmed. She said that she only wanted them cleaned. On 5/23/24 at approximately 12:08 PM., Registered Nurse/Unit Manager (RN/UM) #1 entered the resident's room and was asked to look at the resident's fingernails. RN #1 said that resident's nails needed to be cleaned. On 5/23/24 at approximately 12:10 PM., Certified Nurse's Assistant (CNA) #4 entered the room shortly after RN #1 exited the room. CNA #4 said that she got distracted and didn't come back to clean the resident's fingernails. On 5/23/24 at approximately 12:15 PM., CNA #4 returned to clean the residents' fingernails. CNA #4 explained to Resident #111 that she was going to clean her nails. CNA #4 placed a dry wash cloth under the resident's hands, removed the dirt from under resident's fingernails with a manicure stick and filed each fingernail. On 5/23/24 at approximately 1:45 PM., an interview was conducted with RN #1 concerning Resident #111. RN #1 said that nail care should be done as needed and with a shower or bed bath. RN #1 also said that the CNA should have soak and washed the resident's nails. Process for Fingernail Care: Gather equipment: emery board, nail stick or soft nail brush, lotion, basin, soap, washcloths, towels, gloves. Fill basin with warm water. Process for Fingernail Care Continued. Shape nails - Move in one direction - File in a curve. Apply lotion from fingertips to wrists Remove excess with towel or washcloth. Empty, rinse, dry basin. Placed soiled linens in proper area. Remove and discard gloves. Perform hand hygiene. https://www.cdph.ca.gov/Programs/CHCQ/HAI/CDPH%20Document%20Library/ProjectFirstline8_CNA_NailCareShaving_English.pdf. On 5/23/24 at approximately 5:15 PM, a final interview was conducted with the Administrator, Mobile Administrator, Interim Director of Nursing (DON), Regional [NAME] President of Operations, and the Director of Clinical Services.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility failed to provide care that met the needs of residents with mental health disorders and/or behaviors requiring frequent monitoring. The facility staff failed to ensure sufficient staff was provided frequent safety checks with one-to-one supervision by staff to address the resident's behavioral health care needs and safety for 4 of 15 residents (Resident #1, Resident #3, Resident #5, and Resident #11) in the survey sample which resulted in immediate jeopardy. The findings include: 1. For Resident #1 the facility failed to provide care, that met the needs of the resident's mental health disorder schizophrenia, history of past mental health disorders, suicide attempt at the facility, voiced suicidal ideations, and other behavioral health needs. The facility staff failed to ensure that Resident #1 had sufficient staff to provide one-to-one (1-1) supervision to address the resident's behavioral health care needs, suicidal ideations, isolation behavior, and safety. While unsupervised, Resident #1 managed to partially swallow and lodge a wooden dresser knob in her throat, experiencing cardiac seizures due to insufficient oxygen to her brain and expired in the facility. Resident #1 was originally admitted to the facility on [DATE] after an acute care hospital stay for mental health problems which resulted in deconditioning. The resident's diagnoses included nervous debility, serotonin syndrome, and schizophrenia with episodes of catatonic-like symptoms (lack of movement, activity, or expression) and selective dysphagia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/10/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision-making were severely impaired. In section GG (Functional Abilities and Goals), the resident was coded as requiring supervision with eating, dependent with oral care, toileting, showers and bathing, upper and lower body dressing, putting on and taking off footwear, personal hygiene, partial/moderate assistance with moving from lying to sitting, moving from sitting to standing, and moving from the chair to the bed. The resident required substantial/maximal assistance with toilet transfers and was dependent for tub transfers. Attempts at walking were not assessed. In section D (Mood), the resident was coded for having little interest or pleasure in doing things 7-11 days, feeling down, depressed, or hopeless 7-11 days, trouble falling or staying asleep, or sleeping too much 7-11 days, feeling tired or having little energy 7-11 days, feeling bad about yourself or that you are a failure or have let yourself or your family down 2-6 days, over the last two weeks. The resident's total mood score was 9. A score of 9 indicated the resident was experiencing mild depressive symptoms. Resident #1 was originally admitted to the facility on [DATE]. The resident's diagnoses included schizophrenia, dementia, anxiety, depression, and hypertension. Resident #1's initial person-centered care plan dated 1/17/2024 mental health focus was, no complications with psychotropic drugs, and sometimes the resident had behaviors such as self-isolation. The care plan interventions were to engage the resident in activities, administer medications, and refer to a psychologist/psychiatrist as needed. The resident's revised active care plan had a problem dated 2/15/24 which read, I sometimes have behaviors which include self-isolation. The goal read, My behavior will stop with staff intervention through the next review, 4/23/24. The interventions included an attempt to engage me in activities that would draw me out of the room. let my physician know if my behaviors are interfering with my daily living. Offer me something I like as a diversion. Please refer me to my Psychologist/Psychiatrist as needed. Give me my medications as my doctor has ordered. A review of the local hospital's Discharge summary dated [DATE] accompanied the resident to the rehabilitation facility. The discharge summary stated that the local hospital recommended that Haldol 5 mg at night be continued, and the resident receive a psychiatric evaluation when she arrived at the rehabilitation facility for continued management of underlying chronic psychiatric illness and medication management. The facility staff did not refer the resident for psychiatric services until a few days before she was assessed by the Psychiatric Nurse Practitioner (PNP) on 2/29/24. The history and physical written by the resident's primary physician dated 1/17/24 stated that the resident was to be administered Haldol (an antipsychotic) for schizophrenia in the evening hours and to continue a follow-up with psychiatry. A follow-up was not scheduled for psychiatric services. The resident refused the Haldol on 2/29/24. The discharge summary listed Resident #1's other psychotropic medications that were stopped, and they were never restarted while she was at the facility. Those medications were: Paxil (paroxetine), Cogentin (benztropine), Remeron (mirtazapine), Prozac (fluoxetine), Depakote (valproic acid), Vraylar (cariprazine), and Paliperidone (invega sustenna). Progress notes indicated the following resident behavior and observations: On 1/11/24 the resident refused care; on 2/15/24 the resident was self-isolating, withdrawn, and barricading herself in her room with furniture; on 2/18/24 the resident was found on the floor with her hands around her neck attempting to choke herself and was sent out to the hospital for suicide attempt and a psychiatric evaluation; on 2/19/24 the resident returned to the facility. On 2/22/24 the facility's primary Nurse Practitioner (NP) saw the resident for post-self-harm hospitalization and wrote that the resident was being followed by the psychiatric NP (this was found to be false); on 2/27/24 the resident was found on the floor; on 2/27/24 the resident was placed on 1-1 observation, on 2/29/24 the resident taken off of one-to-one and was placed on every 2-hour observation per the progress note, on 3/2/24 at 3:15 AM, the resident came out the nursing station and expressed not feeling well, started having seizure-like activity, went unconscious, required resuscitation, EMS arrived and retrieved a foreign object in the resident's airway (later discovered to be a wooden dresser knob), she was pronounced deceased at the facility. On 3/14/24 at approximately 3:00 PM, an interview was conducted with the EMS Manager. He stated that they made an EMS run on 2/18/24 to the nursing facility due to the resident trying to strangle herself at which time the resident was transferred to the local hospital Emergency Department (ED) for evaluation. He said a second run to the nursing home resulted in finding the resident on the floor in front of the nurse's station, unresponsive with CPR in progress. He said when the EMS medics took over CPR and attempted to intubate the resident, a foreign object was identified in the resident's airway, and once extracted by [NAME] forceps the object appeared to be a wooden knob to a dresser. He said intubation was successful and CPR continued, but the resident was not revived and expired in the facility on 3/2/24 at 3:54 AM. The EMS Manager stated that it was obvious that the resident managed to carry out her attempts of suicide by swallowing the dresser knob to the extent that it blocked her airway which cut off oxygen to her brain causing cardiac seizures and death. There was no additional scheduled staffing evidence or recorded data provided by the Administrator, Director of Nursing, or Unit Manager that one-to-one supervision was ever provided by a dedicated staff member. An interview was conducted on 3/15/24 at 1:49 PM with LPN #4 who shared that when Resident #1 coded and died on 3/2/24, she was not on 1-1 observations. LPN #4 shared that EMS retrieved a foreign object from the resident's throat during the code. An interview was conducted with the primary NP on 3/18/24 at 12:19 PM. The primary NP said on 2/27/24 she ordered Resident #1 to be placed on 1-1 because she was told the resident was throwing herself on the floor repeatedly. She said on 2/29/24 she observed Resident #1 sitting at the nursing station with a staff person with no obvious observed behaviors. She received a call from the Assistant Director of Nursing (ADON) at the time, asking if the facility could take Resident #1 off 1-1 because they had staffing issues, and the resident did not seem to be having any behavioral concerns at that time. The primary NP said since she saw the resident and she appeared to be okay and it was her expectation that the psychiatric NP (PNP) was soon to see her, she discontinued Resident #1's 1-1 safety order. An interview was conducted on 3/18/24 at approximately 1:36 PM over the phone with the PNP. She answered no to getting a consult on Resident #1 when she was admitted to the facility on [DATE], and she answered no to getting a consult when Resident #1 attempted suicide on 2/18/24. On 3/21/24 at 3:22 PM, during another interview with the PNP, she shared that she recently on 2/25/24 got a consult from the DON via email which included a request for 3 residents to be evaluated by psychiatry with Resident #1 being one of the three. She indicated that there was no expressed urgency to see Resident #1, the resident's history was not shared, and nor was the suicide attempt or the resident's expressed suicidal ideations. The PNP said she did not discontinue or give any direction on Resident #1's one-to-one status. She said Resident #1 was not suicidal when she saw her on 2/29/24, but a full assessment to include a review and/or reinstatement of the resident's psychiatric medications was deferred pending the resident's urine lab results, which would medically clear her before she started any psychiatric medication management. The PNP further stated she would have evaluated the resident sooner if she had been contacted sooner with the resident mental health history and ongoing behaviors because she is in the facility one to two days per week. The facility staff failed to convey the resident's current and past mental health status including exhibited behaviors to the PNP to aid in identifying appropriate goals and interventions for the resident's acute and chronic mental health problems. The written psychiatric referrals from January, 2024 (1/2024) to March 3, 2024 (3/3/2024) did not include Resident #1's name. An interview was conducted on 3/18/24 at approximately 4:05 PM with the Registered Nurse (RN) Unit Manager of the unit where Resident #1 resided. She shared that Resident #1 was put on 1-1 safety checks after attempting to choke herself with her hands and stating she wanted to die. She said Resident #1 was seen by the psychiatric NP and the psychotherapist after the suicide attempt. It was discovered Resident #1 was not seen by the psych NP until 2/29/24 and was never seen by a psychotherapist at this facility. The Unit Manager said her knowledge of what a one-to-one meant was, that the resident must be always within eyesight or arm's length and that a sign-off checklist was completed every 15 minutes. On 3/18/24 at approximately 4:30 PM the DON stated, She (Unit Manager's name) told you wrong and I need to go tell her, that information is incorrect. One-to-one means you are always with the resident and there is no flowsheet or checklist we fill out every 15 minutes, but we will be starting a flow sheet. On 3/21/24 at approximately 5:30 PM, Corporate Consultant #2 shared the three levels of observation with one-to-one being the highest level of observation, always with the resident, with documentation every 15 minutes on the resident safety check flowsheet. She stated every 15-minute observation meant, checking on the resident at 15-minute intervals and every 2 hours meant, checking on the resident at two-hour intervals. On 3/19/24 at approximately 11:14 AM, a phone interview with the previous ADON of the facility who shared that the facility had issues with consistent psychiatric coverage. She indicated that she could not remember for sure what the staffing was during the time Resident #1's 1:1 supervision was discontinued, and said, If the NP said it was mentioned that staffing was an issue, it probably was. On 3/19/24 at 12:45 AM, a phone interview was conducted with Licensed Practical Nurse (LPN) #3. LPN #3 shared that when Resident #1 returned from the hospital after her suicide attempt, she did not have any orders for frequent monitoring or suicide precautions. She said she did not feel comfortable with that, so she put her on every 2-hour monitoring and wrote a note in the doctor's book notifying them of the intervention she initiated. She said she wrote in the nursing progress note when she has a resident placed on safety checks. She said she had some mental health behavior education in Relias but nothing in depth. LPN #3 indicated that the facility had a lot of residents with behaviors, and it was hard to care for them. She said Resident #1 was isolating herself and showing behaviors the entire time she was at the facility and the staff was instructed by leadership not to chart a lot of things to prevent them from getting tags. She stated, We did not do right by her. An interview was conducted with the DON on 3/21/24 at approximately 2:58 PM. The DON shared that the facility had no additional safety checklist forms, and that the staff were not doing them as they should have been. She shared she will be doing all that she can to educate and hold staff accountable for following the facility's policy and procedures for Resident Safety Checks. 2. For Resident #3 the facility failed to provide care, that met the needs of the resident's diagnosis of behavioral disturbance. The facility staff failed to ensure that Resident #3 had sufficient staff to provide one-to-one supervision to address the resident's verbal and physical aggressive behavior with residents and staff. Resident #3 was originally admitted to the facility on [DATE]. The resident's diagnoses also included dementia, anxiety, and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/7/2024 coded Resident #3 as completing the Brief Interview for Mental Status (BIMS) and scoring 99 which indicated severely impaired cognition. In section D Mood, the resident was coded negative for all areas. In section E, the resident was noted to have verbally threatened others 1-3 times. In section G Activities of Daily Living Assistance (ADLs), the resident was coded as requiring extensive assistance to being dependent on ADLs. Resident #3's person-centered care plan was last revised on 1/11/2024 with a mental health focus to include her diagnosis of dementia and Alzheimer's, behavior monitoring, and anxiety. Also noted was an intervention for one-to-one monitoring since 12/8/2023. Observation was made of Resident #3 on 3/19/24 at approximately 1:30 PM and on 3/21/24 at approximately 4:18 PM, both times sitting at the nursing station in her wheelchair periodically screaming out. No staff addressed her needs. Nursing progress notes indicated the following: On 11/12/23 the resident had an altercation with another resident and obtained a skin tear; on 12/6/23 the resident had a stat facial bone x-ray series ordered due to complaints of pain after being struck (does not specify details); on 12/8/23 the resident had another physical altercation with another resident and placed on 1-1 observation checks; on 12/9/23, 12/10/23, 12/14/23, and 12/18/23 the resident continued with 1-1 observation with staff, on 1/6/24 the resident was observed instigating an argument, and on 3/22/24 note read to continue with 1-1 observation. There was no scheduled additional staffing evidence or recorded data provided by the Administrator, Director of Nursing, or Unit Manager that one-to-one supervision was ever provided by a dedicated staff member before 3/22/24 after the issue was brought to their attention on 3/20/24. 3. For Resident #5 the facility failed to provide care, that met the needs of the resident's diagnosis of metabolic encephalopathy, altered mental status (AMS), anxiety, and other behavioral health needs. The facility staff failed to ensure that Resident #5 had sufficient staff to provide one-to-one supervision to address the resident's wandering, hoarding, and verbal and physical aggressive behaviors. Resident #5 was originally admitted to the facility on [DATE]. The resident was also Vietnamese and did not speak English. During an interview with LPN #3 on 3/19/24 at approximately 12:45 AM, she shared that the staff could not understand what the resident's needs were. The facility did not have a working language phone or interpreter service. The resident was discharged on 12/27/23. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/27/2023 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 which indicated severely impaired cognition. In section D Mood, the resident was noted to have some social isolation. In section E Behavior, the resident was noted to 1-3 days have physical behaviors toward others and behaviors not directed toward others. In section GG Activities of Daily Living Assistance (ADLs), the resident was coded as being independent with eating and independent with set-up for all other ADLS. Resident #5's person-centered care plan dated 9/21/2023 had a mental health focus problem including a language barrier, wandering behaviors, and physical abuse towards others. Resident #5 was being followed by psychiatric services. It was noted that the resident hoarded knives and forks. Progress notes indicated the following: On 11/2/23 the resident had a fall; on 11/6/23 the resident was observed hoarding food; on 11/9/23 the resident was observed pacing in the hallway; on 11/12/23 the resident had a fall in the hallway unwitnessed, on 11/14/23 the resident continues to hoard food, pace, and now threatening staff; on 11/15/23 the resident charged at nurse with a butter knife; on 11/27/23 the resident hit his roommate in the face with his fist; on 12/9/23 the resident was spoken to by a police officer about his behavior; on 12/10/23 the resident was placed on one-to-one observation safety checks; on 12/11/23 the resident was on 1-1 and managed to still hit a staff member, on 12/17/23 and 12/18/23 notes read that the resident remains on 1-1, and on 12/25/23 the resident was on 1-1 and struck another resident. There was no scheduled staffing evidence or recorded data in the clinical record provided by the Administrator, Director of Nursing, or Unit Manager that one-to-one supervision was ever provided by a dedicated staff member. 4. For Resident #11 the facility failed to provide care, that met his behavioral health needs. The facility staff failed to ensure that Resident #3 had sufficient staff to provide one-to-one (1:1) supervision to address the resident's agitation, inappropriate defecating in public behavior, and inappropriate sexual behavior. Resident #11 was originally admitted to the facility on [DATE]. The resident's diagnoses included dementia and alcohol abuse. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/1/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 which indicated severely impaired cognition. In section G Activities of Daily Living Assistance (ADLs), the resident was coded as requiring the supervision of one staff for ADLs. Resident #11's person-centered care plan was last revised on 1/11/2024 for a mental health focus problem that included rejecting care, wandering, social and sexual inappropriateness, and physical aggression. An intervention was put in place on the resident's care plan for a 1-1 safety check dated 3/20/24. A review of a psychiatric evaluation dated 2/1/24 for Resident #11, read he was seen for inappropriate behavior in public areas, agitation, and sexually inappropriate behavior. A review of Resident #11 progress notes read on 3/15/24 the resident was roaming around in other residents' rooms, and the resident was not redirectable, urinating and defecating on the floor. Also, the progress notes dated 3/16 /24 read Resident #11 urinated on the floor again. On 3/18/24 at approximately 1:00 PM, a staff person was seen in the resident's room. On 3/21/24 at approximately 3:55 PM an observation was made of Resident #11 in his room sitting on the bed with a 1-1 staff member sitter in the doorway. An interview was attempted with the resident, but he was confused. The Certified Nursing Assistant (CNA) #3 was the sitter and was observed using a safety check form. When asked how she got the form, she stated, They just gave me this form today and it is the first time I have ever used a safety check flow sheet and I have worked here for seven months. My assignment is usually 14-25 residents with sometimes not able to finish my work. I am currently assigned to (Resident #11). I am not sure why he is one-to-one, but I know he wanders and urinates on the floor. Before 3/21/24, there was no scheduled staffing evidence or recorded data in the clinical record provided by the Administrator, Director of Nursing, or Unit Manager that one-to-one supervision was provided for this resident by a dedicated staff member. Review of facility Policy and Procedure Title: Resident Safety Checks, effective 4/2021. Policy: Resident safety checks can be initiated by a physician or clinical nurse who deems a resident to be at risk to self or others Procedure: 1) Initiate resident safety check form with intervals designated by physician or clinical nurse noting reason for form. 2) Check resident at required intervals. 3) Initial form indicating check was complete. 4) Form is to be filed in the medical record . On 3/19/24 at approximately 2:30 PM the survey Team contacted the Long-term Care Supervisor and two additional OLC Long-term Care Supervisors of the above findings, observations, and interviews. On 3/20/24 at 2:52 PM the facility's Administrator Director of Nursing, Regional Director of Clinical Services, and [NAME] President of Operations were informed of the non-compliance which constituted Immediate Jeopardy identified in F-741 Sufficient and Competent Staff - Behavioral Health Needs at a Scope and Severity Level 4, pattern (K). The facility's staff presented several unaccepted Removal Plans on 3/21/24 through 3/22/24 which required revisions for the removal plans failed to detail how other resident identified would receive the necessary behavioral health services to avoid risk for serious injury, serious harm, serious impairment, or death because of their noncompliance. The Facility's Final/Accepted Removal Plan dated 3/22/24 at 12:15 PM: *(Name of the Provider Portsmouth Health and Rehab is taking immediate action to prevent serious harm, from occurring or recurring for other residents who are identified and/or demonstrated dangerous and imminent harm to self and/or others through some recent act, attempt, or threat by completing the following. Current residents will be reviewed that have like behaviors, demonstrated dangerous behaviors, imminent harm to self and/or others and residents with suicidal ideation. Those residents will be placed 1:1 until further evaluation by medical and/or psychiatric provider. The attached Resident Safety Check is required for all 1:1, 15-minute check, 30-minute checks etc. otherwise you will not be able to prove you had them on these very important checks. o Should be care planned and kardexed as a task for each C NA to sign every shift o the form should be collected and brought to the stand-up meeting DAILY reviewed by the IDT - looking for continued behavior or improvement in behavior to possibly take down to the next level o this decision requires an IDT note by either SSD or clinical to memorialize the decision o psych input is great however you are responsible for the fact and psych does not understand SNF regulations so please do not allow them to dictate your 1;1 or safety checks - but use them as a great resource o the form will need to be filed in the medical record after reviewed On-going re-education by the DON/Designee with staff regarding safety check process as identified. Social Services Coordinator/designee will complete a psychosocial assessment on current identified residents. Current residents interviewed by a member of the IDT regarding thoughts of self-harm or harming others. One previously identified resident who is currently on 1:1 verbalized thoughts of harm. Resident assessed by the Medical Director and Psychiatric Services NP on 03/21/2024. Remains on 1:1. Shift to shift education will be completed by the DON or designee on behavior monitoring, the safety check form, and the importance of not leaving the resident for any reason. The DON/Designee will oversee shift to shift confirmation of safety checks for Residents and the one-to-one observer is in place. Staffing will be reviewed no less than 3 days prior to confirm staffing is sufficient to provide the one-to-one observation. During the center staffing calls with central scheduling, the center will notify scheduling of number of residents on 1:1 and the 1:1 will be indicated on the daily schedule. The Administrator or DON will designate on the schedule the designated 1:1 if assigned after the staffing call. Psychiatric Service Referrals for residents with behavior and affect appears disturbed or indicates distress, exhibiting signs or verbalizing behaviors of harming self or others. Residents receiving a psychoactive medication. New admissions seen upon admission and anyone on above agents. Referrals face sheet placed in the psychiatric services referral log for patient in referral book. Psychiatric services Practitioner makes center visits 1 to 2 times per week and as need is indicated. Social Services, Administrator or Director of Nursing to ensure process is followed. NHA reviewed Removal plan with the Medical Director. NHA is responsible for the implementation of this plan of correction. An onsite review of the Facility's Removal Plan was conducted by the Survey Team. The review validated the removal plan was implemented by on site observations, interviews, and record review to verify that the proposed measures were being implemented. The Survey Team observed two (2) residents with active one-to-one order who had a designated staff member with them during observations. The safety check flowsheets were reviewed in use for those residents. The residents care plans were reviewed to assure they were updated to reflect the need for one-to-one observation. The Survey Team reviewed the education in-service records for residents with behaviors, safety checks, and one-to-one observations. The Survey Team interviewed the facility staff on 3/21/2024 and 3/22/2024 to assure the education received was understood. The Survey Team discussed the removal plan with Regional [NAME] President of Operations, Administrator, Director of Nursing, and Regional Director of Clinical Services. The fourth revision was accepted. After the facility's final Removal Plan was validated through observations, interviews and review of facility documents the Immediate Jeopardy was removed on 3/22/24 at 1:30 PM. The deficient practice was reassigned a Scope and Severity level of level two, isolated (E). On 2/22/24 at approximately 2:50 PM the above findings were shared with the [NAME] President of Operations, Administrator, Director of Nursing, Business Office Manager, Minimum Data Set Coordinator, MDS Assistant, and Registered Dietician. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on clinical record review, family interview, staff interviews, and review of facility documentation, the facility's staff failed to identify, address, and obtain necessary psychiatric services for the behavioral health care needs of 1 of 15 residents (Resident #1), in the survey sample who had self-harming behaviors that ultimately caused the resident's death and identification of Immediate Jeopardy. The findings included: The facility's staff failure resulted in Resident #1 self-harming behavior on [DATE] by putting her hands around her neck until bruising and bleeding occurred, throwing herself on the floor multiple times and sustaining a left periorbital subcutaneous hematoma on [DATE] and finally on [DATE] the resident swallowed a wooden object which lodged in her throat, blocked her airway, caused seizure activity, respiratory distress and cardiac arrest causing the resident's death. Resident #1 was originally admitted to the facility on [DATE] after an acute care hospital stay for mental health problems which resulted in deconditioning. The resident's diagnoses included nervous debility, serotonin syndrome, and schizophrenia with episodes of catatonic-like symptoms (lack of movement, activity, or expression) and selective dysphagia. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision-making were severely impaired. In section GG (Functional Abilities and Goals), the resident was coded as requiring supervision with eating, dependent with oral care, toileting, showers and bathing, upper and lower body dressing, putting on and taking off footwear, personal hygiene, partial/moderate assistance with moving from lying to sitting, moving from sitting to standing, and moving from the chair to the bed. The resident required substantial/maximal assistance with toilet transfers and was dependent for tub transfers. Attempts at walking were not assessed. In section D (Mood), the resident was coded for having little interest or pleasure in doing things 7-11 days, feeling down, depressed, or hopeless 7-11 days, trouble falling or staying asleep, or sleeping too much 7-11 days, feeling tired or having little energy 7-11 days, feeling bad about yourself or that you are a failure or have let yourself or your family down 2-6 days, over the last two weeks. The resident's total mood score was 9. A score of 9 indicated the resident was experiencing mild depressive symptoms. An interview was conducted with the Social Worker (SW) on [DATE] at 11:32 AM regarding the results from the Mood assessment of the [DATE] MDS assessment. The SW stated after the Mood information was obtained, she did not share it with the Interdisciplinary team to assist in determining if psychiatric services were warranted for the resident. The SW also stated the severity score was not used to ensure the residents received a referral for psychiatric services or to develop a care plan related to the identified mood symptoms. The facility's staff did not refer Resident #1 for psychiatric services based on her mood score indicating depressive symptoms. An interview was conducted with the Social Services Assistant (SSA) on [DATE] at 11:58 AM regarding the new admission Preadmission Screening and Resident Review (PASRR). The SSA stated that PASRR for all new admissions should be validated by the Social Services Department (SSD) and if the level I was not sent by the referring hospital the assessment would be conducted by the SSD with a referral for a level II as deemed necessary. The SSA stated after reviewing the PASARR audit book and the resident's records a PASRR could not be located. The facility staff did not ensure Resident #1 had a Level I PASRR completed, knowing that she had a diagnosis of a serious mental illness, schizophrenia. PASRR is an important tool for states to use to evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID). The PASRR is also used in rebalancing services away from institutions and towards supporting people in their homes, and to comply with the Supreme Court decision, [NAME] vs L.C. (1999), under the Americans with Disabilities Act, individuals with disabilities cannot be required to be institutionalized to receive public benefits that could be furnished in community-based settings. PASRR can also advance person-centered care planning by assuring that psychological, psychiatric, and functional needs are considered along with personal goals and preferences in planning long-term care (https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review/index.html). An interview was conducted with Family member (FM) #1 on [DATE] at 11:00 AM. FM #1 stated that Resident #1 had a lifelong history of mental illness and during psychosis, she had attempted to hurt herself and would pick up a knife, while stating I don't want to be here. FM #1 also stated the resident had been residing in a group home until she had an altercation with a peer and the staff contacted the police. FM #1 stated the resident was detained by the police and the police had the resident evaluated for mental competency at a mental hospital. FM #1 stated after the mental hospital adjusted the resident's medication regimen she returned to her baseline and was eating and walking. During the interview, FM #1 stated the resident was discharged from the mental hospital back to jail on a Friday in late [DATE] so she could appear in court the following Monday. FM #1 stated when the resident arrived at court, she was wheelchair bound and she had declined significantly in comparison to her state on Friday. FM #1 stated the court released the resident to him and no one offered information as to what had taken place over the weekend that caused the decline in her condition. FM #1 stated by [DATE] the resident was not eating, was unable to walk, and just stared therefore he took her to a local hospital for treatment because he knew they had her health records and would likely be able to get her back to her baseline. FM #1 further stated the resident was discharged from the local hospital to the rehabilitation facility on [DATE] to regain her strength after the lengthy hospital stay. He stated she required care from staff for all her activities of daily living including walking. FM #1 stated that at the time the resident was admitted to the rehabilitation facility he made it clear to the facility's staff the type of care she required and the importance of her receiving her medications, especially her mental health drugs. FM #1 also stated he asked if the facility could coordinate the medication regimen between the local hospital and what the mental hospital had prescribed for the resident was better with the mental hospital's medication regimen. The facility's staff did not notify psychiatric services to address FM #1's concerns regarding the resident's medication regimen. The facility's staff did not contact FM #1 to obtain any additional mental health history regarding Resident #1. A review of the local hospital's Discharge summary dated [DATE] accompanied the resident to the rehabilitation facility. The discharge summary stated that the local hospital recommended that Haldol 5 mg (an antipsychotic) at night be continued, and the resident to receive a psychiatric evaluation when she arrived at the rehabilitation facility for continued management of underlying chronic psychiatric illness. The facility staff did not refer the resident for psychiatric services until a few days before she was assessed by the Psychiatric Nurse Practitioner (PNP) on [DATE]. The history and physical written by the resident's primary physician dated [DATE] stated that the resident was to be administered Haldol for schizophrenia in the evening hours and to continue a follow-up with psychiatry. A follow-up was not scheduled for psychiatric services. The following information was obtained from the internet on [DATE]: Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality, which can be distressing for them and their family and friends. The symptoms of schizophrenia can make it difficult to participate in usual, everyday activities, but effective treatments are available. Many people who receive treatment can engage in school or work, achieve independence, and enjoy personal relationships. Schizophrenia symptoms can differ from person to person, but they generally fall into three main categories: psychotic, negative, and cognitive. Negative symptoms include loss of motivation, loss of interest or enjoyment in daily activities, withdrawal from social life, difficulty showing emotions, and difficulty functioning normally. For people with schizophrenia, the risk of self-harm and violence to others is greatest when the illness is untreated. It is important to help people who are showing symptoms to get treatment as quickly as possible (https://www.nimh.nih.gov/health/topics/schizophrenia). The resident's active care plan had a problem dated [DATE] which read, I sometimes have behaviors which include self-isolation. The goal read, My behavior will stop with staff intervention through the next review, [DATE]. The interventions included an attempt to engage me in activities that would draw me out of the room. Let my physician know if my behaviors are interfering with my daily living. Offer me something I like as a diversion. Please refer me to my Psychologist/Psychiatrist as needed. Give me my medications as my doctor has ordered. A review of a nurse's note dated [DATE] at 6:36 AM revealed Resident #1 was noted to be self-isolating in her room and pushing the bedside table and chair behind the closed door to keep others out. On [DATE] at 12:56 PM, a nurse's note stated the resident was identified as withdrawing from participation in out-of-room activities and would not engage with staff or other residents. An intervention was to contact the Psychiatric Nurse Practitioner (PNP) and the Psychologist. The facility's staff did not notify the PNP and/or the Psychologist to visit the resident. An interview was conducted with the PNP on [DATE] at 1:36 PM. The PNP stated she was not contacted about visiting Resident #1 until a few days before the [DATE] initial visit, around [DATE]. A review of a nurse's note dated [DATE] at 8:53 PM revealed a nurse walked into the resident's room to find her with her hands around her neck with bruising to the neck and forehead. The resident stated she was trying to harm herself and said she was tired and wanted to go. The resident was transferred to the hospital for an evaluation and returned to the nursing facility on [DATE] with no medication adjustments or a change in the treatment plan. The local hospital's After Visit Summary dated [DATE] read under the title Suicide Prevention Information, Your response to questions about suicide indicates an elevated risk. It is recommended that you follow up with a behavioral health provider after discharge. If you experience suicidal thoughts, call 911. An additional 24/7 resource is the National Suicidal Prevention Lifeline at 988. The facility staff failed to contact psychiatric services for a behavioral health visit as recommended by the local emergency room physician. A nurse's note dated [DATE] at 4:50 AM stated the resident was found sitting on the floor beside her bed. A nurse's note dated [DATE] at 2:15 PM stated that the resident would not take the medication ordered by the NP, and she was repeatedly forcing herself on the floor at the nurse's station therefore an order was obtained for one-to-one observation care. A nurse's note dated [DATE] at 10:09 AM stated the resident refused all medications. A nurse's note dated [DATE] at 5:49 PM stated the resident refused all medications and a nurse's note dated [DATE] at 5:52 PM stated that the resident was on the floor where she put herself and refused to get up. The note further stated the resident pulled away from the staff as they tried to get her up. Another nurse's note dated [DATE] at 10:00 AM stated the resident refused her medications. The resident was assessed by the primary NP and treated for a urinary tract infection (UTI). An interview was conducted with the primary Nurse Practitioner (NP) on [DATE] at 3:15 PM. The primary NP stated that she gave the order for one-to-one care for Resident #1 on [DATE] because of the resident's behaviors and she discontinued the order for one-to-one care by request of the ADON on [DATE] shortly after 4:00 PM. The primary NP stated that she treated Resident #1 for her physical health problems, diabetes, high blood pressure, and blood clots. The primary NP stated she does not treat mental illness or behavior problems related to mental illness. The primary NP also stated on [DATE] when she was informed that the resident was refusing her medications, continuing to throw herself on the floor and with cloudy urine, that most likely she had a UTI therefore she initiated treatment. The primary NP stated because of the interview with the resident and the report from the primary NP that the resident potentially had a UTI the primary NP recommendations were to follow up with Resident #1 mental status once the laboratory results are obtained. The primary NP also stated to continue the current medication regimen because the patient was receiving neuroprotective benefits with improvement in function. Staff to continue to monitor for changes in mood and/or behaviors and notify the practice as needed. A Psychiatric Nurse Practicioner (PNP) progress note dated [DATE] stated that an initial visit was conducted with Resident #1 for refusing medications, and mental status changes. The PNP progress note further stated that the resident was sitting behind the nurse's station quiet and cooperative, therefore the PNP escorted the resident to her room so she could conduct an interview. The PNP findings interview revealed that the resident was alert, oriented to self, denied feelings of harm toward self or others, reported she was sleeping, her appetite was okay, and denied auditory or visual hallucinations. On [DATE] at 3:22 PM, another interview was conducted with the PNP. The PNP stated the request to see Resident #1 came by email along with a request to see two additional residents whom the ADON asked her to see a few days before the [DATE] visit, around [DATE]. The PNP stated that the request to see Resident #1 stated she was experiencing mental status changes. The PNP stated she had not been informed that Resident #1 was exhibiting isolative and self-injurious behaviors, making negative statements, or that she had been evaluated in the emergency room for the behaviors, refusing medications and throwing herself on the floor. The PNP also denied she was not informed that the resident had been evaluated in a local emergency room for suicidal ideations and was discharged back to the facility with recommendations for psychiatric services. The PNP further stated she would have evaluated the resident sooner if she had been contacted sooner with the resident mental health history and ongoing behaviors because she is in the facility one to two days per week. The facility staff failed to convey the resident's current and past mental health status including exhibited behaviors to the PNP to aid in identifying appropriate goals and interventions for the resident's acute and chronic mental health problems. The written psychiatric referrals from January, 2024 (1/2024) to [DATE] ([DATE]) did not include Resident #1's name. A nurse's note dated [DATE] at 6:58 AM stated that Resident #1 approached the nurse's station at approximately 3:15 AM on [DATE] stating I don't feel well. Soon after, the resident began having seizure-like activity and she quickly became unresponsive. Vital signs revealed the resident was absent of a pulse, cardiopulmonary resuscitation (CPR) was initiated and 911 was called. CPR was started and performed until the emergency medical technicians (EMT) arrived and assumed care of the resident. The EMTs performed CPR for approximately 20 minutes before they decided to intubate the resident for the airway was initially managed with a bag valve mask. An attempt was made to intubate and upon insertion of the glide scope, a foreign object was identified in the resident's airway. It appeared to be a wooden knob to a dresser. A [NAME] forceps was used to successfully remove the foreign object, intubation was performed, and confirmed with a capnography, visualization, and breath sounds. Efforts were continued for approximately 20 minutes before a decision was made to contact medical control for orders to terminate. The ending rhythm was [NAME] pulseless electrical activity. An order to terminate resuscitative measures was received from a physician at a local hospital. The time of death was called at 3:54 AM on [DATE]. On [DATE] at approximately 2:30 PM the survey Team contacted the Long-term Care Supervisor and two additional OLC Long-term Care Supervisors of the above findings, observations, and interviews. On [DATE] at 2:52 PM the facility's Administrator Director of Nursing, Regional Director of Clinical Services, and [NAME] President of Operations were informed of the non-compliance which constituted Immediate Jeopardy identified in F-740 Behavioral Health Services at a Scope and Severity Level 4, pattern (K). The facility's staff presented several unaccepted Removal Plans on [DATE] which required revisions for the removal plans failed to detail how other residents identified would receive the necessary behavioral health services to avoid risk for serious injury, serious harm, serious impairment, or death because of their noncompliance. The Facility's Final/Accepted Removal Plan dated [DATE] at 5:00 PM: *(Name of the Provider) is taking immediate action to prevent serious harm, from occurring or recurring for other residents who are identified and/ or demonstrated dangerous and imminent harm to self and/or others through some recent act, attempt, or threat by: *Reviewing the residents with one-to-one observations in the last 30 days to confirm they are safe, and the observed behavior has improved. If behavior has not improved, they will be placed on one-to-one observation until medically and psychologically evaluated and the behavior improves or no longer occurs. *Current residents will be interviewed by a member of the IDT regarding thoughts of self-harm or harming others. One previously identified resident who is currently on one-to-one verbalized thoughts of harm. Resident assessed by the Medical Director and Psychiatric Services NP on [DATE]. Remains on one-to-one. *Residents being admitted hospital documentation with past medical and psychiatric history will be reviewed by the Nursing Home Administrator (NHA) and DON / designee prior to allowing admission of the referred patient. *Psychiatric Service Referrals for residents with behavior and affect appears disturbed or indicates distress, exhibiting signs or verbalizing behaviors of harming self or others. Residents receiving a psychoactive medication. New admissions seen upon admission and anyone on above agents. Referrals face sheet placed in the psychiatric services referral log for patient in referral book. Psychiatric services Practitioner makes center visits 1 to 2 times per week and as need is indicated. Social Services, Administrator or Director of Nursing to ensure process is followed. *During the center staffing calls with central scheduling, the center will notify scheduling of number of residents on one-to-one and the one-to-one will be indicated on the daily schedule. The Administrator or DON will designate on the schedule the designated one-to-one if assigned after the staffing call. *The residents PASRR level I will be reviewed by Social Services and referred for a level II if indicated based on history. Social Services will complete a PASRR as indicated. *Staff will be educated on the safety check process and reasons to place a resident on one-to-one or enhanced monitoring as indicated. *The Nursing Home Administrator (NHA) reviewed the Removal plan with the Medical Director. *The NHA is responsible for the implementation of this plan of correction. An onsite review of the Facility's Removal Plan validated the education provided to staff on [DATE] regarding Behavioral Health Care and was deemed mandatory for all staff before working a shift going forward. A staff member was interviewed from each department to ensure they were educated. An interview was conducted with the Social Services Assistant (SSA) on [DATE] at 11:58 PM regarding the new admission Preadmission Screening and Resident Review (PASRR). The SSA stated PASRR for all new admissions would be validated by the Social Services Department (SSD) and if the level I was not sent by the referring hospital the assessment would be conducted by the SSD with a referral for a level II as deemed necessary. A review of the PASRR audit book was conducted and it was found to be a reliable tool. An interview was conducted with the Administrator on [DATE] at 2:05 PM. The Administrator stated along with the DON/ADON the process for new admissions to the facility would include a review of a psychiatric history and a review of medications for the use of psychiatric medications. The Administrator stated if the use of behavioral health medications or a behavioral health diagnosis was identified the identified resident would be scheduled to be seen by the psychiatric practitioner during the next visit to the facility. The process was validated. An interview with the Regional Director of Clinical Services (RDCS) was conducted on [DATE] at 2:25 PM. The RDCS explained the Psychiatric referral book to the facility. The RDCS stated the staff would be utilizing a referral book for any resident with behaviors, those exhibiting signs of or verbalizing behaviors of harming themselves or others. It was validated through observations that the Psychiatric referral book included instructions for whom a referral would be made, what information to include in the book for each resident and to write their name on the log as well as to notify the Psychiatric Service Practitioners as indicated. After the facility's final Removal Plan was validated through observations, interviews, and review of facility documents the Immediate Jeopardy was removed on [DATE] at 6:00 PM. The deficient practice was reassigned a Scope and Severity level of level two, isolated (E). On [DATE] at approximately 2:50 PM the above findings were shared with the Administrator, Director of Nursing, Regional Director of Clinical Services, RN MDS Coordinator, LPN MDS Coordinator, Business Office Manager, and [NAME] President of Operations during the final interview. An opportunity was offered to the facility's staff to present additional information or voice concerns. No additional information was provided, and no concerns were voiced.

Based on observation, resident interview and staff interview, the facility's staff failed to ensure 1 of 21 residents (Resident #111) who was unable to carry out activities of daily living (ADL) received the necessary services to include nail care. The findings included: Resident #111 was originally admitted to the facility 07/22/20 and readmitted on [DATE] after an acute care hospital stay. The current diagnoses included Hypertension. The admission, significant change, annual quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 05/06/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #111 cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities) the resident was coded as being dependent in oral hygiene, personal hygiene, toileting hygiene, showering and bathing. A review of a progress note dated 5/14/24 read that resident is dependent in Activities of Daily Living (ADL). An interview was conducted on 5/23/24 at approximately 11:00 AM. Resident #111 fingernails were observed to have a significant amount of black substance beneath them. On 5/23/24 at approximately 12:04 PM., an observation was made of Resident #111 fingernails. Resident #111 fingernails were observed to have a significant amount of dark substance underneath each fingernail. Resident #111 was asked if she wanted her fingernails cleaned and trimmed. She said that she only wanted them cleaned. On 5/23/24 at approximately 12:08 PM., Registered Nurse/Unit Manager (RN/UM) #1 entered the resident's room and was asked to look at the resident's fingernails. RN #1 said that the resident's nails needed to be cleaned. On 5/23/24 at approximately 12:10 PM., Certified Nurse's Assistant (CNA) #4 entered the room shortly after RN #1 exited the room. CNA #4 said that she got distracted and didn't come back to clean the resident's fingernails. On 5/23/24 at approximately 12:15 PM., CNA #4 returned to clean the residents' fingernails. CNA #4 explained to Resident #111 that she was going to clean her nails. CNA #4 placed a dry wash cloth under the resident's hands, removed the dirt from under resident's fingernails with a manicure stick and filed each fingernail. On 5/23/24 at approximately 1:45 PM., an interview was conducted with RN #1 concerning Resident #111. RN #1 said that nail care should be done as needed and with a shower or bed bath. RN #1 also said that the CNA should have soak and washed the resident's nails. Process for Fingernail Care: Gather equipment: emery board, nail stick or soft nail brush, lotion, basin, soap, washcloths, towels, gloves. Fill basin with warm water. Process for Fingernail Care Continued. Shape nails - Move in one direction - File in a curve. Apply lotion from fingertips to wrists Remove excess with towel or washcloth. Empty, rinse, dry basin. Placed soiled linens in proper area. Remove and discard gloves. Perform hand hygiene. https://www.cdph.ca.gov/Programs/CHCQ/HAI/CDPH%20Document%20Library/ProjectFirstline8_CNA_NailCareShaving_English.pdf. On 5/23/24 at approximately 5:15 PM, a final interview was conducted with the Administrator, Mobile Administrator, Interim Director of Nursing (DON), Regional [NAME] President of Operations, and the Director of Clinical Services. No further information was provided prior to survey exit.

Based on observation, staff interviews and clinical record review the facility staff failed to ensure 1 resident (Resident #104), in the survey sample of 21 Residents who was unable to carry out activities of daily living receives the necessary services to maintain toenail care. The findings included: Resident #104 was originally admitted to the facility on [DATE]. Diagnosis for Resident #104 included but not limited to Diabetes Mellitus. The most recent Minimum Data Set (MDS) an annual with an Assessment Reference Date (ARD) of 2/23/24 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 which indicated Resident #104 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities) the resident was coded as requiring partial/moderate assistance with showering/bathing, dependent with putting on and taking off footwear, requiring substantial maximal assistance with personal hygiene. A review of a psychotherapy note dated on 2/13/24 read that Resident #104 would like to participate more in rehab., but her toenails are causing her pain with certain movements. Resident #104 also said that she has not seen the podiatrist which visits the facility once every few months. During the initial tour on 5/21/24 at approximately 1:38 PM. An interview was conducted with Resident# 104. Resident #104 said that she has not seen a podiatrist in thirteen (13) months, my toenails are curving into my skin which affected physical therapy due to hurting. Resident #104 also said that the podiatrist recently visited but never saw her. Resident #104 said that she had informed the Unit Manager (UM) and the Social Worker (SW) of her need for podiatry care. Resident #104 was observed pushing the call bell to ask for CNA assistance. CNA #1 pulled back the covers to reveal the resident's toenails. The resident's toenails on her right foot were observed to be thick, yellow, curvy, and long. The toenails on the resident's left foot were observed to be short, thick, and curvy. CNA #1 said that once they notice resident need toenail care, they will inform the nurse and the nurse will put the resident's name in a book. On 5/21/24 at approximately, 2:10 PM., an interview was conducted with the SW concerning Resident #104. The SW presented a podiatry list but said that Resident #104 may not be on the list to receive podiatry services. The SW also stated that if the nurse or CNA informs her of the need, she will add the residents to the podiatry services list. The SW also mentioned that the podiatrist visited the facility on 5/14/24 but was not able to see the resident because she had just been informed of the residents need for podiatry services. On 5/23/24 at approximately 10:40 AM, an interview was conducted with Resident #104. Resident #104 said that she informed the administrator on yesterday that she needed podiatry care. Resident #104 also said that her therapist was in to visit her when the podiatrist came to the facility (5/14/24-podiatrist in the facility). I asked, am I on the Podiatry list today (5/14/24). Resident #104 also mentioned that the UM (RN #1) had promised her that she was on the list to receive podiatry care (5/14/24) On 5/22/24 at approximately 3:30 PM., an interview was conducted with the acting DON. The acting DON said that she didn't know that Resident #104 needed podiatry care but in cases that residents would need podiatry services sooner than the in-house podiatry visits an appointment would be made to an outside podiatry office. A review of a general note dated on 5/21/24 read: Resident reports to nurse her toenails are long, thick, and painful and well as interfering with therapy. Upon examination, this nurse (RN #1/UM) notes that resident's toenails are indeed long and with the second right toe starting to overlap onto the right great toe. New orders received for podiatry consult outside of the facility as the podiatrist is not due to return until late June. Resident is aware. A review of a general note dated 5/21/24 at 3:02 PM., read that a podiatry appointment was scheduled for May 28, 2024, at 2:00 PM. According to the psychiatrist progress note dated on 2/13/24, Resident #104 had been waiting for podiatry care services before her visit to the psychiatrist. On 5/23/24 at approximately 5:15 PM, a final interview was conducted with the Administrator, Mobile Administrator, Interim Director of Nursing (DON), Regional [NAME] President of Operations (RVPO), and the Director of Clinical Services. The RVPO said that the podiatrist came on 5/14/24 but didn't have time to see the resident.

Based on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a wander guard was placed on an at risk, wandering, exit seeking resident for monitoring for 1 of 21 residents (Resident #112), in the survey sample. The findings included: Resident #112 was originally admitted to the facility 6/18/21 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Dementia. The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/20/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #112 cognitive abilities for daily decision making were severely impaired. In sectionG(Physical functioning) the resident was coded as requiring total care of one person with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing, extensive assistance of one person/ two people, limited assistance of one person, supervision after set-up. The person-centered care plan read that Resident #112 is at risk for elopement related to attempts to leave the building. A goal for Resident #112 is that she will have no incident of elopement. An intervention for Resident #112 is to check for wander guard placement and functioning every shift and as needed. The Physician's Order Summary (POS) for May 2024 read: Check wander guard function 11/7 every night shift for Monitoring: Check wander guard placement every shift. Active 04/25/2022. On 5/22/24 at approximately 3:30 PM., an interview was conducted with the Interim Director of Nursing (IDON) said that a wander guard should be placed on resident's that meet the elopement criteria. The IDON also mentioned that an exit seeking resident ended up walking outside a few years ago. No injuries were received, and the staff was right behind him. An anonymous complainant said that two residents eloped from the facility a few years ago. The elopement book was reviewed on both units. Wandered guard placement on residents were checked by the nursing staff. On 5/22/24 at approximately 4:45 PM., Resident #112 was observed walking in the hallway with another resident. RN/UM #2 asked Resident #112 for permission to check her wander guard. No wander guard was observed on the resident's ankles or wrist upon inspection. RN #2 said that often times the resident or her friend (another resident) will remove her wander guard. RN #2 also mentioned that she will place another wander guard on resident's ankle. Elopement/Wandering - Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Facilities should have policies in place for assessing/identifying residents at risk for elopement, and how to manage/monitor those at risk. If alarm systems are used, then routine maintenance and testing should be done according to manufacturer's recommendations. Education should be provided to staff for proper steps to be taken when responding to a door alarm or the event of a potential elopement, in accordance with facility policy. https://proactiveltcexperts.com/f689-accident-hazards-supervision-devices/ The Policy reads: Nursing personnel must report and investigate all reports of missing residents. Upon admission, a resident's potential for elopement will be determined by risk factors which may include but not limited to: History of wandering or elopement. On 5/23/24 at approximately 5:15 PM, a final interview was conducted with the Administrator, Mobile Administrator, Interim Director of Nursing (DON), Regional [NAME] President of Operations (RVPO), and the Director of Clinical Services. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to answer call bells in a timely manner for 3 of 21 residents in the survey sample. Resident #106, Resident #108, and Resident #110. The findings included: 1. Resident #106 was admitted to the facility on [DATE]. The resident's diagnoses included: Paraplegia, Weakness, and Metabolic Encephalopathy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 which indicated the resident was severely cognitively impaired. An observation was made on 5/21/2024 at approximately 1:55 PM, the resident's call bell activated. While waiting with the resident, at 2:11 PM, Others #7 Came in to answer the call bell. Resident #106 asked to be repositioned. Others #7 went to get nursing staff and returned at 2:17 PM with additional staff to reposition the resident. Resident #106 said he was frustrated with having to wait long periods of time to be helped. 2. Resident #108 was admitted to the facility on [DATE]. The resident's diagnosis included: hemiplegia, hemiparesis, and anxiety. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/3/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 which indicated the resident was cognitively intact. An observation was made on 5/22/2024 at approximately 10:30 AM, the resident's call bell activated. While waiting with the resident, at 10:47 AM, Certified Nursing Assistant (CNA) #3 came in to answer the call bell. CNA #3 stated that she was in another resident's room giving care. Resident #108 asked to be cleaned for incontinence. 3. Resident #110 was admitted to the facility on [DATE]. The resident diagnosis included: chronic obstructive pulmonary disorder (COPD), panic disorder, and anxiety. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/18/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 which indicated the resident was severely cognitively impaired. An observation was made on 5/22/2024 at approximately 11:00 AM, the resident was in the hallway screaming for help. The resident had on oxygen and expressed being short of breath and that her heart was racing. The resident's call bell was observed being already on. After observing the resident ambulate back to her bed, the resident was observed putting on a personal pulse oximeter probe which read that her oxygen level was 92% and her heart rate was 85. Observation was made that the resident's oxygen concentrator was on 2.5 liters. Resident #110 was observed being anxious as she expressed having a history of tachycardia and how staff does not come when she needs them. At approximately 11:26 CNA #3 was observed walking past the resident's room and I asked the CNA #3 to let the resident's nurse know that the resident has been in her room with her call light going off for 26 minutes while she was experiencing shortness of breath and possibly some anxiety. The resident stated she felt better by this time. An interview was conducted with Licensed Practical Nurse (LPN) #1, LPN #1 shared that she did follow up and assess Resident #110 and she was stable. An interview was conducted with CNA#2, who shared she was busy taking care of another resident during the time Resident #10's call bell was going off during the 11: 00 AM hour. On 5/21/24 at 2:58 PM The Administrator emailed, noting that the facility does not have policies or protocols on nurse staffing or rounding expectations for residents. On 5/23/24 at approximately 10:50 AM, the above findings were shared with the [NAME] President of Operations, Mobile Administrator, and Administrator. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observations, interviews, and record reviews, the facility failed to have a functioning call system that relayed a call to a staff member or to a centralized staff work area. The failure to have a functional call system resulted in immediate jeopardy for 70 of the 74 residents in the facility. Failure to have a functioning call system had the likelihood to result in harm or death as residents had no means to contact staff. On 05/24/21 at 6:46 PM, the Administrator and Director of Nursing (DON) were notified of an immediate jeopardy at F919-L Resident Call System. The immediate jeopardy began on 05/17/21 when the facility became aware that the call system was not functioning. The facility provided an acceptable plan for removal of the immediate jeopardy on 05/26/21 at 10:51 AM. The removal plan included providing a metal handheld bell to all residents cognitively and physically capable of using it, assigned staff members to continually monitor the halls for residents ringing the bells and to check on each resident at least every hour, and in-serviced all staff on the plan in place until the call system can be repaired. The survey team validated the immediate jeopardy was removed through observations, interviews, and review of inservice records. The deficiency remained at a lower scope and severity of an F following the removal of the immediate jeopardy. Findings include: On 05/24/21 at 11:14 AM, when asked about staff response to the call lights, resident (R) 42 stated the staff do not answer the call light because the call light was not working. R42 stated that when the button is pushed the light comes on but the light goes out when the button is no longer being pushed. The call light was checked by the surveyor and when pushed the light did not activate. R42's roommate's light was also checked and did not function. R42 stated the call light had not functioned in a long time. Review of R42's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/01/21 revealed R42 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating he was cognitively intact. Further review of this MDS revealed R42 required supervision with bed mobility, transfers, walking, dressing, eating, toilet use, and personal hygiene. On 05/24/21 at 11:36 AM, call lights in resident rooms 1 through 43 and rooms 53 through 72 were tested with the assistance of the Director of Nursing (DON). On 05/24/21 at 12:15 PM, the call lights in rooms 44, 45, 46, 47, 48, 49, 50, and 51 were tested with the assistance of the Maintenance Supervisor (MS). The call lights did not function in 53 of 55 occupied resident rooms and had the potential to affect 70 of the facilities 74 residents. At the time the lights were tested on [DATE], both the DON and MS verified the lights were not functioning. On 05/24/21 at 11:39 AM, R8 stated sometimes the call light works and sometimes it does not. R8 stated most of the time it did not work and when it did work it was so dimly lit over the door the staff could not tell it was on. On 05/24/21 at 11:39 AM, when tested by the surveyor, R8's call light would go on while the button was actively being pushed and then would immediately go off when it was not being pushed. The light over the door in the hall was very dim and it was hard to tell it was on. Review of R8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/18/21 revealed R8 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. Further review of this MDS revealed R8 required extensive assistance for bed mobility, dressing, toilet use, and hygiene. R8 was dependent on a wheelchair for locomotion. On 05/24/21 at 11:53 AM, when the door to R54's room was opened to check his call light, R54 stated he had been ringing a handheld bell for an hour, and no one had come because someone closed the door, and no one could hear the bell. R54 was in bed and wanted to get up in his chair. R54 stated the staff had given him the bell that day although the call light had not worked for six weeks. Review of R54's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/14/21 revealed a Brief Interview for Mental Status (BIMS) of 13 indicating he was cognitively intact. R54 required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. R54 was dependent on a wheelchair for locomotion. R54's diagnoses on this MDS included [CONDITION(S)] and pressure ulcers. While going from room to room checking the call lights on 05/24/21, the DON stated the facility had given some residents bells a couple of weeks ago because they found some rooms where the lights did not function. The DON stated she knew some of the lights did not function but did not know it was so widespread. On 05/24/21 at 10:42 AM, R48 stated his call light did not work. R48 stated that he must wait until someone comes in before he gets help. R48 did not have a handheld bell in his room. The call light for both beds in the room were tested at that time and neither one functioned. Review of R48's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/21 revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating he was cognitively intact. Further review of this MDS revealed R48 required supervision with dressing, eating, toilet use, and personal hygiene. R48 was not steady with transfers and walking and required the use of a walker for ambulation. On 05/24/21 at 11:14 AM, R4 stated his call light did not work and he was given a handheld bell to ring. R4 stated when he rings the bell no one ever answers it. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/12/21 revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating he was cognitively intact. Further review of this MDS revealed R4 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene; limited assistance with transfers; he was not steady with transfers and required a wheelchair for mobility. On 05/24/21 at 11:30 AM, R60's call light was checked and did not function. R60 had a bell in her room and when she was asked about the bell, she stated she did not know why she had it. Review of R60's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/16/21 revealed a Brief Interview for Mental Status (BIMS) of 9, indicating moderately impaired cognition. Further review of this MDS revealed R60 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. R60 was not steady with standing and transfers and utilized a wheelchair for mobility. During an interview on 05/24/21 at 11:26 AM, when R34 was asked where her call light /bell was, she stated it does not matter they do not come. When asked who is they? Resident indicated the people to help me [staff] they do not come. There was no bell observed in the R34's room and the call light did not work. Review of R34's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/21 revealed a Brief Interview for Mental Status (BIMS) of 99 indicating she was not cognitively intact. Further review of this MDS revealed R34 required supervision for bed mobility, transfers, dressing, toilet use and personal hygiene; she was not steady during transfers and walking; and she used a walker as a mobility device. Staff interviews regarding staff awareness of how long the call lights were not functioning revealed the following: On 05/24/21 at 2:09 PM, Licensed Practical Nurse (LPN) 1 stated she was aware the light had not been functioning and when ask what she does about it she stated she gives them another call cord or a handheld bell. On 05/24/21 at 2:12 PM, Certified Nursing Assistant (CNA) 2 stated she knows the call lights were not working and she stated she checks on the residents continuously. On 05/24/21 at 2:13 PM, LPN 2 stated she knew certain call lights do not work and she makes rounds to check on her residents and they now have bells. On 05/24/21 at 2:17 PM, CNA 1 stated that the call light system has not worked for at least eight weeks. On 05/24/21 at 3:38 PM, the Administrator stated that on 05/17/21 staff completed a 100% check of the call system and identified seven (7) rooms with non-functioning call lights. The Administrator stated two of the residents were relocated and the other residents in the affected rooms were provided with a handheld bell. The Administrator stated that since identifying the nonfunctioning call lights on 05/17/21, no monitoring of the call system had been in place and administration was relying on staff to tell them if the call lights were not functioning properly.

Based on observations, interviews, and record review, the facility failed to provide care and services to prevent the development of a pressure ulcer in one of four residents (Resident (R) 69) reviewed for pressure ulcers in a total sample of 20 residents. The failure to provide care and services resulted in the development of a deep tissue injury (DTI) and a Stage III pressure ulcer to R69's left foot which constitutes harm. Findings include: Review of R69's undated Face Sheet located in the electronic medical record (EMR) under demographic tab, revealed R69 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R69 was discharged to an acute care facility (hospital) on 02/02/21 and readmitted to the facility on [DATE]. Review of R69's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/07/21 revealed a Brief Interview of Mental Status (BIMS) score of 10 indicating R69 is moderately cognitively impaired. Further review of the MDS revealed R69 is dependent on staff for all ADLs requiring extensive assistance. Review of the undated Care Plan, located in the EMR under the care plan tab, revealed R69 has a physical functioning deficit related to generalized weakness, impaired mobility and cognition and left [CONDITION(S)], requires extensive to total assistance for all activities of daily living (ADLs) . interventions: . assistive devices as needed, bed mobility assistance assist times two, dressing assistance as needed . personal hygiene assistance as needed, turning and positioning, assist resident two person. Review of the undated Care Plan, located in the EMR under the care plan tab, revealed no care plan addressing R69's contractures. Review of R69's EMR revealed no documentation of staff consistently turning and repositioning R69 during March 2021, April 2021, and/or May 2021. Request for documentation of R69 being repositioned was made on 05/27/21 at 2:30 PM, from the Director of Nursing (DON). The DON reported on 05/27/21 at 3:27 PM she was unable to locate any documentation. Review of R69's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R69's orders revealed these orders for the hand splint were not reinitiated upon R69's readmission on 02/05/21. Further review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R69's Physician Orders, dated 05/09/21, located in the EMR under the orders tab, revealed wound care orders: Triad [MEDICATION(S)] wound dress paste (wound dressing) .apply to sacrum topically every shift for stage II [pressure ulcer] . During R69's wound care observation on 05/28/21 at 12:37 PM, accompanied by the wound care nurse (WCN) and wound care physician (WCP), it was discovered R69 did not currently have a sacral pressure ulcer but had a pressure ulcer on the left foot which was not documented on the undated pressure ulcer actual care plan. During an interview on 05/28/21 at 12:37 PM at R69's bedside, the WCP stated, I was notified by the facility by telemed last Saturday (05/22/21) about a new wound on the resident's foot. The WCP stated that on 05/28/21 the facility had shown a picture of the pressure ulcer on R69's foot. The WCP stated that the facility was advised the pressure ulcer would be assessed further on 05/28/21. The WCP stated after seeing the picture of the pressure ulcer, I didn't realize it [pressure ulcer] was that bad. During the wound observation on 05/28/21 at 12:37 PM, the WCP noted on the left distal medial [inner] foot a pressure ulcer that measured 5.5 centimeters(cm) by 2.9 cm and staged the wound as deep tissue injury (DTI- pressure injury deep into tissues under intact skin).The WCP noted on the left lateral [outer] distal foot pressure ulcer that measured 3.8 cm by 2.2 cm and 0.3 cm depth and staged as a stage III (full thickness loss down to subcutaneous tissue) pressure ulcer. The WCP was questioned if these wounds could have been avoided since the resident's lower extremities are severely contracted? The WCP stated, yes, the staff would need to reposition frequently and apply padding to the bony areas, we'll work on a plan. Observation conducted during the survey on 05/24/21, 05/25/21, and 05/26/21, revealed R69's left lower extremity curled in a fetal position with the right lower leg and foot laying on top of the left foot pressing it into the mattress. There was no padding on the left foot, between the foot and mattress or the right lower extremity. Review of the medical record revealed no treatment orders for the pressure ulcer were obtained prior to the assessment by the WCP on 05/28/21. During an interview conducted with CNA 4 on 05/27/21 at 1:30 PM, CNA 4 was asked how often does she turn the residents? CNA 4 stated, we try to turn them every two to three hours. During an interview on 05/27/21 at 2:15 PM, the DON was questioned what her expectations were of staff when it comes to repositioning residents? The DON stated her expectations are for the staff to turn the residents every three hours and as needed. Review of the facility's policy titled Wound Prevention Program, dated 08/2019, Pressure sore Prevention-Quick Look .protect skin against friction and shearing forces, avoid massage over bony prominences .turn and reposition at least every 2 hours in bed .active or passive range of motion for bed ridden residents to optimize the perfusion of peripheral capillary vessels, use pressure redistribution device and/or positioning device, relieve heel pressure, use heel/elbow protectors as appropriate, and use protective clothing for fragile skin.

Based on a complaint investigation, clinical record review, staff and family interview, the facility staff failed to assess, monitor and treat an identified problem on [DATE] based on Resident #3's symptomology of continued vaginal pain, as well as evidence from the results of a urine analysis on [DATE] which pointed to signs of a Urinary Tract Infection [MEDICAL CONDITION]. The resident was transported the local emergency department (ED) on [DATE] with [DIAGNOSES REDACTED]. The findings included: Resident #3 was admitted to the nursing facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the local hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident #3's most recent operational Minimum Data Set (MDS) assessment prior to discharge was dated [DATE]. The resident was coded with a score of nine out of a possible 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was moderately impaired with the cognitive skills necessary for daily decision-making. The resident was assessed to require extensive assistance of two staff for bed mobility and bathing. She was coded to require extensive assistance of two staff for dressing, toileting and personal hygiene. The resident was bedbound and did not ambulate or use a wheelchair. Resident #3 was assessed to require supervision (cueing and oversight) with set up for eating. Resident #3 was coded as always incontinent of bowel and bladder. The resident was not assessed to have a UTI within the last 30 days. The care plan revised on [DATE] identified pain as one of the resident's focus areas. The goal set for the resident by the staff was that the resident would maintain adequate level of comfort as evidenced by no signs/symptoms of unrelieved pain or distress, or verbalizing satisfaction with level of comfort. Some of the approaches the staff would implement to accomplish this goal included evaluate characteristics and frequency/pattern of pain and evaluate what makes the patient's pain worse and ensure care needs are met. The following nurse's notes is a chronology from [DATE] to discharge [DATE] with applicable interviews: -[DATE] at 12:38 a.m., Licensed Practical Nurse (LPN) #1 (,[DATE]) entered a Situation Background Assessment Recommendation (SBAR) indicated the resident complained of pain in her knees. Upon assessment, no signs of dislocation or fracture noted. The Nurse Practitioner (NP#1) was called and gave orders for [MEDICATION NAME] 600 milligrams (mg) by mouth (po) every eight hours as needed. An interview was conducted with LPN #1 on [DATE] at 11:25 a.m. She stated she called the NP to inform her of the resident's complaints of bilateral knee pain and thought it was different from the resident's normal complaints of general pain. -[DATE] at 11:42 p.m., LPN #2 (,[DATE] shift) entered Resident continues to complain of pain in her vaginal area. Order received from (NP#1's name) this evening for UA/C&S (urine analysis culture and sensitivity) related to pain. Staff will continue to monitor resident. No further assessment was conducted based on the resident's symptoms to include vital signs. *Resident #3 had a routine scheduled physician's orders [REDACTED]. A phone interview was conducted with NP #1 on [DATE] at 11:15 a.m. Although NP #1 gave an order for [REDACTED]. She also stated, I was called by a nurse stating the resident was having groin pain and not vaginal pain nor was I told that the pain had been continuing and from what timeframe. I ordered a UA/C&S suspicious of bladder problems, but nothing about the call led me to believe the situation was emergent. I may have had her evaluated if I knew it was vaginal pain. (Urinary tract infections don't always cause signs and symptoms, but when they do they may include: -A strong, persistent urge to urinate ·A burning sensation when urinating ·Passing frequent, small amounts of urine ·Urine that appears cloudy ·Urine that appears red, bright pink or cola-colored - a sign of blood in the urine ·Strong-smelling urine ·Pelvic pain, in women - especially in the center of the pelvis and around the area of the pubic bone. https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc- 447). -[DATE] at 2:02 p.m., LPN #3 indicated that Certified Nursing Assistant (CNA) #1 informed her that the resident had not voided during the ,[DATE] shift. LPN #3 called the physician and obtained an order to straight catheterize the resident and leave in place if [MEDICAL CONDITION] is greater than 100 cubic centimeters (cc). The nurse's note indicated the urinary output was less than 20 cc's with a white milky discharge and foul odor LPN #3 was interviewed on [DATE] at 11:37 a.m. According the LPN she was the assigned nurse on [DATE] for the ,[DATE] shift. She stated the resident was fine and did not look any different from the previous day nor had the night shift nurse reported any physical/medical issues, complaints or problems. She stated she was not in any acute signs of distress on the ,[DATE]/ shift and was administered her scheduled Tylenol. She stated at around 1:30 p.m., the Resident Representative informed her Resident #3 was complaining of vaginal pain, but she had just administered Tylenol at 1:00 p.m. She stated at 2:00 p.m., the CNA came to inform her the resident had not voided during the shift. She stated she called to inform the on call physician/nurse practitioner and received orders to strait catheterize the resident and leave catheter in place for urine output greater than 100 cc, but the output was only 20 cc. She said, upon catheterization the resident possessed a strong foul order with a white milky discharge. She stated she knew a U/A and C&S had been drawn and the results were pending. -[DATE] at 3:51 p.m., LPN #2 indicated the resident had low oxygen saturation of 82% (normal is ,[DATE]-https://www.mayoclinic.org/symptoms/hypoxemia/basics/causes/sym- 930), low blood pressure=,[DATE], respiratory rate=22, pulse=64 and temperature=98.2. Resident alert, lethargic, not talking, but able to talk. EMS (911) was called and the resident was placed on oxygen 2 liters/minute via nasal cannula continuously, every shift face mask applied (sic) until paramedics arrived. A phone interview was conducted on [DATE] at 5:40 p.m. with LPN #2 who entered the nurse's note on [DATE] at 11:42 p.m. and the nurse's note on [DATE] at 3:51 p.m. The LPN stated she called the physician on [DATE] due to the resident's continued vaginal pain. When asked how long had the resident had the vaginal pain, she responded, On and off. She stated she knew she performed an assessment of the resident's abdomen, bowel sounds and vital signs, but failed to document the assessment. She stated, I would have done all that before I called the physician so they would have this information, knowing they would need it. Maybe it is on the vital sign sheet for that day. The Director of Nursing (DON) searched and was not able to provide any additional assessment or vital signs documentation. LPN #2 stated, When I got the urine sample it was Saturday ([DATE]) and I was told no urine samples could go out STAT, so it was placed in the refrigerator until normal lab pick up on Monday ([DATE]). During continuation of the aforementioned interview, LPN#2 said on [DATE], a little after her shift started on ,[DATE], CNA #1 asked her to assess Resident #3 because she did not look well. The LPN stated, the resident's blood pressure was very low, she was lethargic and her O2 saturation levels were very low. LPN #2 stated she placed an oxygen mask on the resident and called 911. She stated the ,[DATE] nurse (LPN #3) did not report anything unusual about the resident at shift change. A phone interview was conducted with the facility's laboratory company on [DATE] at 4:05 p.m. They stated they a UA could have been ordered stat with a phone call to them and a pick up would be made within ,[DATE] hours and taken to the contracted hospital/facility for processing with results the next day, [DATE]. They stated that would offer an opportunity for the medical team whether or not to treat. An interview was conducted with Certified Nursing Assistant's (CNA) #1 and #2 on [DATE] at 3:00 p.m. CNA #1 stated she was frequently assigned to Resident #3, but on the evening of [DATE], the day the resident was sent to the hospital, she had the resident across the hall. The CNA stated, It was not unusual for me to check on the resident and when I went to see her she was really not herself. I could see her from across the hall though. She had taken off all her clothes, was lethargic, sweating and disoriented and did not respond to me as she normally did. She had been going down for about a week, not wanting to feed herself and was hardly drinking anything. I went to the nurse that I knew would go immediately and check on her, (LPN #2's name) and she went in right away to assess (the resident's name). CNA #1 stated she had been telling the nurses about a week that the resident was not eating well nor drinking, but felt they were not doing anything about it. When asked if she utilized the facility's Stop and Watch Early Warning Tool which would validate all the times she told the nurse, she stated, No, I just told them, but I guess I should have. During the interview, CNA #2 said she worked every other weekend and was assigned the resident on the [DATE] for the ,[DATE] shift and validated the condition the resident was in as described by CNA #1. During clinical record review, NP #2 progress notes dated [DATE] indicated Resident #3 was being seen for lab follow up and issues with abdominal pain. The U/A revealed positive [MEDICATION NAME] and positive leukocytosis with urine culture and sensitivity pending. The notes indicated Started [MEDICATION NAME] (antibiotic) mg q (every) 12 H (hours) until urine C&S results .Urine analysis for infection. The U/A laboratory report dated [DATE] revealed cloudy urine, positive [MEDICATION NAME] (negative=normal), 2+ leukocytes (negative=normal), 3+ blood (negative=normal), Red blood and white blood cells were TNTC (too numerous to count, ,[DATE]=normal). Review of the physician orders [REDACTED]. On [DATE] at 3:45 p.m., a phone interview was conducted with NP#2. The NP stated on [DATE] she wrote an order for [REDACTED]. I can't say what happened to the order and can't be responsible for what the nurses failed to do. The pharmacy shipping manifest forms reviewed from ,[DATE]-,[DATE], did not evidence [MEDICATION NAME] delivered the nursing facility for Resident #3. The Urine C&S report sent to the facility was dated [DATE] (resident had been transported to the local ED and admitted to the hospital) resulted in two organisms: 1. Greater than 100,000 CFU/ML proteus mirabilis 2. Greater than 100,000 CFU/ML providencia stuartII. NP #2 noted on the Urine C&S report that she saw the report on [DATE] and to start Bactrim DS one by mouth every 12 hours times 14 days. On [DATE] at 4:10 p.m., interviews were conducted with the Interim Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and current Unit Manager I and II. They searched through the paper chart, telephone orders and the Electronic Medical Director (EMS) and could not locate the orders [MEDICATION NAME] the NP#2 stated she wrote to be started on [DATE]. The DON stated all she knew was that she received a call from the nurse to inform her the resident was sent out to the hospital the evening of [DATE]. The Interim Administrator who was also a Registered Nurse stated it was her experience based on the results of the U/A on [DATE] and the resident's symptoms of vaginal pain that an antibiotic be administered [MEDICATION NAME], and it was also in keeping with their protocol. On [DATE] at 12:17 p.m., a phone interview was conducted with the Resident Representative (RR). She stated she was informed by the hospital that the resident was in severe septic shock based on the resident's symptoms and the lab results. She stated she was told to consider hospice. On [DATE] at 4:47 p.m., according to the emergency department (ED) documentation, Resident #3 presented with altered mental status and [MEDICAL CONDITION] (lack of sufficient oxygen, that can cause cellular injury to major organs-Elsevier: Pathophysiology, McCance &Huether, 2014), vital signs were BP=,[DATE]; P=92; T=97.7 degrees; RR=24. The RR relayed to the ED physician that the resident had been declining over the past few days. The ED physician documented that the services he provided to the patient were to treat and/or prevent clinically significant deterioration that could result in the failure of one or more body systems and/or organ systems due to septic shock. The lab findings revealed the following abnormalities that supported [MEDICAL CONDITION] and septic shock: -BUN (Blood urea nitrogen)=103 (7XXX,[DATE]mg/DL=normal) -Crt (creatinine)=2.76 (0XXX,[DATE].3 mg/DL) -BUN/Crt ratio=37 (,[DATE]=normal) -Alkaline [MEDICATION NAME]=179 (,[DATE] U/L=normal) -Blood Serum WBC (White Blood Cell)=27.1 (4XXX,[DATE].2=normal) -Blood serum RBC (Red Blood Cell)=3.36 (4XXX,[DATE].30 M/UL) -Blood serum Hgb/Hct=9XXX,[DATE].0 (Hgb-12XXX,[DATE].0g/dl=normal/Hct-35XXX,[DATE].0 %=normal) -Blood serum ABS. [DIAGNOSES REDACTED]s=24.7 (1XXX,[DATE].0 K/UL=normal) -Blood serum lactic Acid=2.46 (0XXX,[DATE].00 mmol/L=normal) The RR requested that Resident #3 be placed on comfort care with no aggressive treatments and discharged to hospice services within the hospital. The resident expired on [DATE] at 7:12 p.m. under hospice care. The nursing facility's policy and procedures titled Loeb Minimum Criteria for Initiation of Antibiotics dated 2001 indicated treatment would be warranted in resident's without indwelling urinary catheter if they exhibited acute dysuria (exhibited by Resident #3) or fever greater than 100 degrees Fahrenheit and at least one of the following: -New or worsening urgency -Frequency -Suprapubic pain (Resident #3's complaint) -Gross hematuria -Costovertebral angle tenderness -Urinary incontinence The facility's Interact Tool dated 2014 indicated the algorithm for resident change in condition included the CNA, other direct care staff or family alerts the LPN or Registered Nurse (RN) and a Stop and Watch early warning tool would be completed as supporting evidence that the LPN/RN were notified of the change in condition. The LPN/RN would complete an evaluation, process the SBAR form and nurse's note and notify the physician for further guidance. Septic shock is a serious condition that occurs when a body-wide infection leads to dangerously low blood pressure. Any type of bacteria can cause septic shock. Toxins released by the bacteria or fungi may cause tissue damage. This may lead to low blood pressure and poor organ function. Some researchers think that blood clots in small arteries cause the lack of blood flow and poor organ function. The body has a strong [MEDICAL CONDITION] response to the toxins that may contribute to organ damage. Septic shock can affect any part of the body, including the heart, brain, kidneys, liver, and intestines. Symptoms may include a high or very low temperature, little or no urine, low blood pressure, rapid heart rate, restlessness, agitation, lethargy or confusion and or decreased mental status. Septic shock has a high death rate. The death rate depends on the cause of the infection, how many organs have failed, and how quickly and aggressively medical therapy is started (https://medlineplus.gov/ency/article/ 8.htm).

Based on an Adult Protective Services Report, medical record review, staff interviews and facility document review the facility staff failed to ensure that assessed level of activities of daily living assistance was provide for 1 of 41 Residents in the survey sample to prevent an accident which resulted in harm for Resident #262. For Resident #262, the facility staff failed to use the assessed two person extensive assist for bed mobility during incontinent care on 3/11/18 that resulted in a fall with injury which constituted harm. The findings included: Resident #262 was a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #262's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/16/18 was reviewed. The Brief Interview for Mental Status for Resident #262 was coded as a 3 out of a possible 15 indicating the resident was cognitively impaired and incapable of daily decision making. Under Section G Functional Status the resident was coded as requiring extensive two person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture.) Under Section H Bladder and Bowel Resident #262 was coded as always incontinent for bowel and bladder. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/18 for Resident #262 was also reviewed. The Brief Interview for Mental Status for Resident #262 indicated short and long term memory issues and that the resident was severely cognitively impaired for daily decision making. Under Section G Functional Status the resident was coded as requiring extensive two person physical assist for bed mobility. Under Section H Bladder and Bowel Resident #262 was coded as always incontinent for bowel and bladder. Under Section J Health Conditions Resident #262 was coded as having 1 fall with an injury since admission/entry or reentry or the prior assessment. The Comprehensive Care Plan for Resident #262 last revised on 1/16/2019 was reviewed and is documented in part, as follows: Focus: I have a physical functioning deficit related to : Self care impairment, right arm [MEDICAL CONDITION], generalized weakness, impaired cognition. Date Initiated: 2/7/2015 Interventions: Bed mobility assistance as needed, use of siderails to assist. Date Initiated: 2/7/2015 Focus: At risk for further falls related to : History of falls, incontinence of bowel and bladder, use of daily antihypertensive. Date Initiated: 12/9/2016 Interventions: Staff Education, Sent to (Name) hospital for eval and treat. Date Initiated: 3/12/2018. Resident #262's Progress Notes were reviewed and are documented in part, as follows: 3/11/18 17:55 (5:55 P.M.) SBAR (Situation Background Assessment Recommendation) Change of Condition Situation: Fall Background: Traumatic amputation of right arm, old. Alert with confusion noted. Assessment: CNA (certified nursing assistant) approached this writer and stated that she was caring for resident, giving incontinent care and resident rolled off the bed. This nurse and other charge nurses in room. Resident noted with laceration and hematoma to right side of forehead just above eye. Also noted with blood coming out of mouth. Suctioning of mouth performed, unable to determine where is the injury. Neurocheck WNL (within normal limits). Response: (Name) Medical Doctor was notified and new order to send resident to (Name) Hospital ER (emergency room ) via 911 for eval. 911 was called. 911 personnel did arrive and resident was transported to the ER. 3/12/18 6:40 A.M. General Note Resident returned from (Name) Hospital ER related to follow up fall from bed. Resident presents with mouth swelling and sutures above his right eye brow. His mouth presents with dried blood around lips and remaining teeth. Bed is lowered to the floor and appears to be resting at this time. 3/13/18 2:38 A.M. General Note Resident received in bed sleeping. Resident status [REDACTED]. 3/13/18 9:23 A.M. General Note Late Entry for 3/12/18-Resident had a fall with injury on 3.11.18. Due to his right arm amputation, resident's ability to assist with repositioning when he is turned for care. Do to this event, he was reassessed and did meet the requirement of side rails. Resident #262's CNA MDS Kardex was reviewed and is documented in part, as follows: ADL: Bed Mobility, Self Performance: Extensive Assistance, Support: Two person physical assist. Vision: Impaired Functional Limitation in Room: Upper Extremity Bowel: Always Incontinent Bladder: Always Incontinent Resident #262's Quarterly Data Collection Tools were reviewed and are documented in part, as follows: 1/16/18: 5. Has the Resident Demonstrated Poor Bed Mobility or Difficulty Moving to a Sitting Position on the Side of the Bed? Yes 6. Does the Resident have Difficulty with Balance or Poor Trunk Control? Yes 9. Is the Resident Currently Using the Side Rails for Positioning and Support? Yes Mobility: Completely Immobile 15. Check all that apply: 1. At this Time, Side Rails are indicated to Provide Safety. 5. Does not have Ambulatory Ability. 6/10/18: 5. Has the Resident Demonstrated Poor Bed Mobility or Difficulty Moving to a Sitting Position on the Side of the Bed? Yes 6. Does the Resident have Difficulty with Balance or Poor Trunk Control? Yes 9. Is the Resident Currently Using the Side Rails for Positioning and Support? Yes Mobility: Completely Immobile 15. Check all that apply: 1. At this Time, Side Rails are indicated to Provide Safety. Resident #262's Facility Fall Investigation dated 3/12/18 was reviewed and is documented in part, as follows: What was the resident doing prior to fall? Getting incontinent care by CNA. Were 2-3 assists used? No What intervention was implemented after the fall? Sent to ER via 911- Needs half SR (side rails) Supervisor Report: 1. Did resident sustain injury? Yes 2. If so, what was the injury and how was it treated? Laceration over right eye. 3. Further investigations of fall required? Yes Fall Committee Review/Recommendations: 3/13/18 Staff education related to side rail removal. Siderail restraint eval. CNA'S Statement Attached to Fall Investigation: (Name) CNA #1 went into (Name) Resident #262's room to check to see if he need to be changed. I was changing him and turn him on his side to clean him up and this is when he fell in the floor, while I was cleaning him. CNA #1's Employee Progressive Action Memorandum dated 3/11/18 was reviewed and is documented in part, as follows: Employee, (Name) CNA #1 approached charge nurses at 17:40 (5:40 P.M.) notifying of resident in room [ROOM NUMBER] (Resident #262) had fallen to the floor while performing ADL care. Resident noted on the floor with blood clots from mouth and abrasion to right eyebrow, Resident was suctioned and pressure applied to areas of active bleeding. Resident sent to (Name) hospital emergency department for patient eval. and treat. Patient Diagnosis: [REDACTED]. A Restraint assessment dated [DATE] for Resident #262 was reviewed and is documented in part, as follows: Diagnosis/Conditions pertaining to Mobility: Partial Traumatic Amputation of Shoulder, Muscle Weakness. Mental/Cognitive Status/Vision/Safety Awareness: Diagnosis: [REDACTED]. History of Falls/Injuries: Fall-3/11/18 with facial injuries, the fall was from the bed. Body Alignment Status: Body is stiff, especially his legs. Team Recommendations: Siderails X 2- due to resident inability to bend lower extremities, recent fall from bed with injury. Resident #262's Hospital Emergency Department Summary dated 3/12/18 was reviewed and is documented in part, as follows: Date: 3/11/18 Chief Complaint: Fall ED (emergency department) Triage Notes: Patient arrived from Portsmouth Health and Rehab complaint of nursing aid rolled patient off bed. Patient only oriented to self, able to follow commands. On 2/5/19 at 1:53 P.M. an interview was conducted with LPN (Licensed Practical Nurse) #2 who was in charge of Resident #262 on 3/11/18 when his fall and injury occurred. LPN #2 was asked to describe what happened the night Resident #262 fell on the floor. LPN #2 stated, The CNA was giving care when he fell . She was turning him and he fell off the bed onto the floor. I went in to assess him and he was on the floor. He was bleeding from his head and his mouth. I sent him to the emergency room . He was total care, dependent. LPN #2 was asked how do the CNA's know how much assistance a resident needs with care/ bed mobility? LPN #2 stated, The aides have a Kardex that tell them what each resident requires for assistance. On 2/6/19 at 1:37 P.M. a phone interview was conducted with CNA #1, who was the CNA providing incontinent care to Resident #262 when he fell from the bed and was injured on 3/11/18. CNA #1 was asked to describe what happened when Resident #262 fell from his bed. CNA#1 stated, I go into change him and turned him to the left, there was no siderail so I pulled him towards me then turned him on his side and he just kept moving there was nothing there to stop him. He hit the floor. I was mad and upset because the man got hurt. He was bleeding from the mouth and head, I saw a blood clot. It was just me in there no other help, we do it by ourselves. I was upset all night because they took the rails off. They wrote me up, it was an accident. He only had one arm. CNA #1 was asked if another person had been on the other side of the bed would the resident have still fallen and been injured. CNA #1 stated, No, because that person would have kept him from falling on the floor. I guess I should have gotten some help. On 2/16/19 at 5:00 P.M. an interview was conducted with the Regional Director of Clinical Services regarding Resident #262's fall with an injury on 3/11/18. Based on the investigation and document review this surveyor asked to the Regional Director of Clinical Services if she felt this fall with an injury to Resident #262 could have been avoided. The Regional Director of Clinical Services stated, 'I agree with you, he should have had 2 person extensive assist as the resident's plan of care called for. The CNA's kardex lets them know the bed mobility status for the resident. The facility's Fall Prevention Program effective date 1/2017 was reviewed and is documented in part, as follows: 3. The assigned CNA on all shifts need to be held accountable to ensure that the Care Plan to eliminate falls is being implemented. On 2/7/19 at 5:40 P.M. a pre-exit conference was held with the Administrator, the Director of Nursing, the Regional Director of Clinical Services and the Chief Clinical Officer were the above information was shared. The Chief Clinical Officer stated, We should have followed his plan of care and had 2 person extensive assist for his bed mobility to prevent a fall with an injury to the resident. I hate that this happened but it did and we own it. No further information was provided by the facility staff prior to exit.

Based on observations, clinical record review, resident and staff interviews and facility documentation, the facility staff failed to ensure the necessary treatment, care and services were provided to promote healing and prevent new pressure sores from developing for 3 of 24 residents (Residents #1, #10 and #9 ) in the survey sample. 1. Resident #1 had a facility acquired pressure sore to the right inner heel that was first identified at an advanced stage (unstageable). Observations were made of the resident with the right heel in direct contact with the mattress, unprotected from pressure. The facility staff failed to demonstrate the development of the right inner heel pressure ulcer was un-avoidable. They failed to provide prompt treatment to the right inner heel pressure ulcer. They failed to make ongoing pressure ulcer risk assessments per their protocol. 2. The facility staff failed to identify, evaluate and implement treatment for [REDACTED].#10. 3. For Resident #9, the facility staff failed to apply physician ordered bilateral heel booties while the resident was in bed. The findings include: 1. Resident #1 acquired a pressure sore to the right inner heal that was first identified at an advanced stage (unstageable). Observations were made of the resident with the right heel in direct contact with the mattress, unprotected from pressure. The facility staff failed to demonstrate the development of right inner heel pressure ulcer was un-avoidable. They failed to make ongoing pressure ulcer risk assessments per their protocol. Resident #1 was admitted to the nursing facility on 4/1/14 with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident with a score of 13 (cognitively intact) on the Brief Interview for mental Status (BIMS). The resident had no problems understanding and was understood. She was not coded for any behavioral of mood problems. Resident #1 was totally dependent on two staff members for transfers and one staff for bed mobility and bathing. She was assessed to require extensive assistance of one staff member for locomotion on and off the unit, toilet use, personal hygiene and dressing. She was coded unsteady without staff assistance and was coded as impaired in her upper and lower extremities on both sides in range of motion (ROM). She was coded as using a wheelchair for mobility. She was coded always incontinent of bowel and bladder. The resident was assessed at risk for developing pressure ulcers and had one Stage II pressure ulcer. Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org). The admission nursing assessment/Clinical Health Status dated 4/1/14 indicated the resident had one skin concern, a small open area on the right dorsal foot. The Braden Scale (Pressure ulcer risk assessment tool) was inherent in the nursing assessment and assessed the resident as at risk for developing pressure ulcers. The Braden Scale indicated the resident was very limited in mobility and made only occasional slight changes in body or extremity position, but was unable to make frequent or significant changes independently. Per the Treatment Administration Record (TAR) the right outer foot pressure ulcer healed on 8/5/14. According to the facility's policy and procedures entitled Skin Integrity Guideline revised 2013: All residents would be assess/observed for risk of skin breakdown within 24 hours of admission, quarterly and as necessitated by change in condition. Resident #1 had no further Braden Scale risk assessment after the admission one dated 4/1/14. The initial care plan after admission was dated 4/1/14 and identified the resident was at risk for pressure ulcers. The current MDS (minimum data set) assessment was a significant change in status dated 7/16/14 and coded Resident #1 on the BIMS with a score of 14. She was assessed unchanged in functional status except improvement in personal hygiene requiring extensive assistance of one staff for personal hygiene. She was coded with two Stage II pressure ulcers, one of which was present on admission to the facility. She remained assessed at risk for developing pressure ulcers. The current care plan revised on 8/13/14 indicated Resident #1 was at risk for pressure ulcers and had actual pressure sores due to skin desensitization, obesity and bowel incontinence. Treatment regimen in place for current pressure ulcers and new one. The care plan indicated the resident remained at risk for back and buttock pressure ulcers due to her not wanting to get back in bed from the wheelchair. The goal the staff set for the resident included current pressure ulcer will heal without complication and would remain free from further breakdown. Some of the interventions that staff would implement to accomplish this goal included complete Braden Scale per facility protocol, float heels, heel boots, skin assessment to be completed per facility policy, turning and repositioning schedule per assessment, weekly wound assessment, conduct weekly skin inspection, provide pressure reduction/relieving mattress, referral to therapy, MA65 (pressure reduction) mattress to bed and continue to encourage resident to get back in bed for rest break to back and buttocks and for incontinent care. The current care plan also identified the resident had mobility impairment, ROM (range of motion) limitations to her upper and lower extremities. Some of the interventions in order to maintain her current level of physical functioning included inspect skin with care, report reddened areas, rashes, bruising or open areas to charge nurse, assist with turning and repositioning in wheelchair and in bed. The Wound Evaluation Flow Sheets indicated on 6/24/14 Resident #1 acquired a right buttock Stage II pressure sore, on 8/5/14 acquired a left posterior thigh Stage II pressure sore and on 8/11/14 acquired a left buttock Stage II pressure sore. On 8/19/14 at 11:45 AM, Resident #1 was observed in the dining room sitting at a table with other residents. When asked how everyone was doing, Resident #1 stated, "I have the worst sore heel (pointed to the right leg), I feel like pulling my hair out." She said she told her aide on 8/18/14 about the sore right heel. The resident was wearing gray non-skid socks and oversized tan slippers on both feet. It was obvious her right leg was turned inward and permanently bent/contracted at the knee in a 90 degree angle and she could not extend it. On 8/19/14 at 4:20 PM, Resident #1 was in her wheelchair and taken to her room by Registered Nurse (RN) #5 along with the Wing I Unit Manager (UM) RN #1 to have her heel examined. This writer requested a mirror to visualize the right heel because Resident #1 was in the wheelchair and could not extend her right leg. The inner aspect of the right heel was observed to have an open area of slough surrounded by a purple/red area. The area was described by RN #5 as unstageable with slough and was measured (the entire area) as 4 centimeters (cm) by (x) 6 cm. RN #5 stated on 8/19/14 around 1:00 PM, someone from the therapy department came to her and stated the resident was in therapy and complained of a sore heel. The RN stated she took Resident #1 to the bathroom and assessed the heel. She cleaned it with normal saline and covered it with a 6 inch x 6 inch [MEDICATION NAME] (foam) dressing. The resident grimaced and verbalized pain throughout the entire procedure. The Wing I UM RN #1 stated the heel ulcer originated from direct pressure and she expected staff to prevent heel ulcers by floating both heels at all times. During the above observation, the Wing I UM RN #1 stated skin assessments were done weekly by the licensed nurses and aides should fill out the Stop and Watch form at anytime if they observe redness and/or breakdown during care or from resident voiced complaints and forward the form to the nurse. The Wing I UM RN #1 stated the nurse would follow-up with a skin assessment and call the physician for orders if necessary. The Unit Manager stated, "I think this has been brewing about a month based on the Deep Tissue Injury (DTI) look of the heel with the center now opened up with necrotic tissue. We were not aware of this until today." The assigned Certified Nurse Assistant (CNA) #3 stated, "I had her 2 days ago on the 3/11 shift and took her socks off to go to bed and I didn't see anything or I would have told the nurse. She was up when I came on this evening, the nurse's said they saw a heel ulcer on the 7/3 shift." Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. Suspected Deep Tissue Injury - depth unknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org). On 8/19/14 at 4:30 PM, an interview was conducted with the Director of Rehabilitation. She stated the resident was brought down to the department to evaluate her wheelchair equipment for positioning. She said when they touched the heel the resident screamed and said, "Don't touch it and don't mess with it." The Director said she took the resident's socks off and went to the nurse's station and notified the Wing I UM RN #1 and the charge nurse (RN #5). She stated they took the resident in the bathroom to assess the heel. She said she was supposed to fill out the "Stop and Watch" early warning tool, but did not because she went immediately to get help for the resident. She returned at 5:15 PM and presented the form dated 8/19/14 5:00 PM. On 8/19/14 at 4:55 PM, RN #5 was asked if there was a physician's orders [REDACTED]." The physician gave an order for [REDACTED]. On 8/20/14 at 9:30 AM, Resident #1 was in bed and positioned on her right side. She did not have on socks. The small synthetic sheep skin heel protector was not secure on the resident's heel, but off to the side and nearly on the top of the foot and there was no pillow in position for heel floatation. The heel was observed embedded into the mattress. The resident said, "I hope you are not here to mess with my foot because it is killing me." The resident stated she was not able to lift the right foot or leg to put her heel in the heel protector. She said it may have twisted to the side when the aides pulled her up in bed. On 8/20/14 at 10:15 AM, one of the wound care nurses, LPN (licensed practical nurse) #1 stated there was no treatment order for the right heel. On 8/20/14 at 11:15 AM, another nurse at the desk checked and stated she could not find any orders to treat the right heel. On 8/20/14 at 11:28 AM, a second wound care nurse LPN #4 came to provide wound care to all of the resident's wounds. She observed the sheepskin heel protector off to the side of the resident's heel with the heel not floated and in direct contact with the mattress. The Wing I UM RN #1 was asked to come to the resident's bedside. The Wing I UM RN #1 said they would need Prevalon boots (a soft boot designed to lift the heel off of the mattress, minimizing pressure on the heel www.sageproducts.com) to both heels to ensure heel protection, as well as the change in her mattress to an alternating low air loss since positioning was an issue. On 8/20/14 at 11:30 AM, all of the resident's wounds were observed during wound care. The Wing I UM RN #1 was present during the observation. The right and left buttock and left posterior thigh all were observed as a Stage II with [MEDICATION NAME] tissue. They were cleaned with normal saline; Saf-gel (hydrating dermal wound gel-www.[MEDICATION NAME].com) was applied and secured with a [MEDICATION NAME] border dressing. When (licensed practical nurse) LPN #4 got to the heel, the Wing I UM RN #1 pulled the pillow that was under the right knee past the resident's heel and the resident hollered out in pain. It was at this time, they stated they would administer pain medication and return to try again. It was determined the resident had already had pain medication ([MEDICATION NAME] tablet 250 milligrams, 1 every 6 hours) and could not have anything else due to allergies [REDACTED]. LPN #4 and the Wing I UM RN #1 came back to the resident and asked if they could proceed and she said yes because she wanted to get out of bed as soon as possible. During the above dressing change observation, LPN #4 stated she did not have a treatment order, but would clean the area (R heel pressure sore) with normal saline, apply Saf-gel and cover with [MEDICATION NAME] until one was obtained. The Wing I UM RN #1 stated they needed to get the physician to order Santyl (topical debrider*) to treat the necrotic slough (dead tissue) areas of the heel ulcer. The assigned CNA (certified nursing assistant) #8 was asked if she had the resident on 8/19/14 and she stated, "I had her and I did not see anything. She may have told me about a sore heel, but I didn't tell anyone. I put her in the wheelchair and took her on to therapy. I bathed her today down to her socks and like I said I didn't see anything." It was at this time the Wing I UM RN #1 asked her (CNA #8) if she removed the socks to wash her (Resi8dent #1's) feet, to which the CNA responded, "She didn't have any on when I came on." The Wing I UM RN #1 told her (CNA #8) it could not be both, either the socks were on or off when Resident #1's feet were washed. CNA #8 stated, "I washed her feet yesterday and today and I did not see that place there. She is hard to position to see anything on that right foot because it's contracted." When the Wing I UM RN #1 and LPN #4 turned the resident on her right side to provide treatment to the heel, the inner heel was clearly visible. The heel ulcer center measured 1.5 cm long x 1.9 cm wide, with an undetermined depth due to slough and was unstageable. She documented swelling of the surrounding tissue, as well as pain. The Weekly Skin Integrity Review sheets from 8/2/14 through 8/16/14 signed by the licensed nurse and completed on the resident's bath days did not exhibit redness or skin breakdown on the right inner heel. On 8/20/14 at 1:00 PM the Interim Director of Nursing Services (IDNS) said when she started in June 2014 she pulled the Casper reports and identified a problem with pressure ulcers in the facility. She stated she in-serviced all CNAs' and licensed nurses in the facility on several care area concerns that included pressure sore prevention, the significance of early detection of pressure area, using the "Stop and Watch". She stated, "I thought with all the education that was provided on 6/25/14 and 6/26/14, the staff would be doing a better job taking care of the residents. I am very disappointed and I will need to go behind with some checks." On 8/21/14 at approximately 3:00 PM, the Assistant Director of Nursing Services (ADNS) presented the physician's orders [REDACTED]. The treatment order to the heel was: cleanse right heel with normal saline, pat dry, apply a nickel thick layer of Santyl and cover with [MEDICATION NAME] daily. Another order was obtained on 8/20/14 for a newly acquired friction burn to the left ischium (inferior dorsal portion of the hip bone: http://medical-dictionary.thefreedictionary.com/Ischium+(bone)). On 8/21/14 at 1:10 PM, the Administrator, the Administrator's mentor and the IDNS were made aware of the aforementioned findings involving Resident #1. The facility's policy titled Skin Care Protocol revised 6/2014 stated evaluation/observation of the skin is to be completed within 24 hours of admission, quarterly/significant change of condition using the Clinical Health Status Tool. The Certified Nurse Aides (CNA) is to observe the resident daily for reddened/open areas, [MEDICAL CONDITION] of the feet or sacrum. The CNA is to report changes to the licensed nurse and document. Licensed nurses are responsible for performing the skin evaluation/observation. The National Pressure Ulcer Advisory Panel (NPUAP) quick guidelines dated 2009 indicated the following: Ongoing assessment of the skin is necessary to detect early signs of pressure damage. Pressure ulcers are under-detected in individuals with darkly pigmented skin because of areas of redness are not easily seen, frequency of inspection may need to be increased in response to any deterioration in overall condition. High pressures over bony prominences, for a short period of time, and low pressures over bony prominence for a long period of time are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure she/he is exposed to. Repositioning frequency is determined by the individual's tissue tolerance, his/or her level of mobility, general medication condition, overall treatment objectives and assessments of the individual's skin. If not responding as expected to the repositioning regime, reconsider the frequency and method of repositioning. Repositioning should be influenced by the support surface. Avoid positioning on bony prominences and reposition in such a way that pressure is relieved or re-distributed. Limit time seated in a chair. Do not base the selection of a support surface solely on the perceived level of risk for pressure ulcer development or the category/stage of any existing pressure ulcers. Continue to turn and reposition regardless of support surface. Ensure heels are free from the surface of the bed and inspect heels regularly. Avoid subjecting the skin to pressure and shear. Lift and don't drag while positioning and use transfer aids. Avoid the use of synthetic sheepskin. * This information was obtained from the website: <http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=a7bf0341-49ff-4338-a339-679a3f3f953d> 2. The facility staff failed to identify, evaluate and implement treatment for [REDACTED].#10. Resident #10 was originally admitted to the facility on [DATE] and readmitted [DATE] after an acute hospital stay beginning 8/5/14. The current [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/3/14 coded the resident not able to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired decision making abilities. In section "G" (Physical functioning) Resident #10 was coded as requiring total assistance of 1-2 person(s) with all ADL's (activities of daily living) except walking which did not occur. On 8/20/14 at approximately 10:00 AM a current treatment administration record (TAR) for Resident #10 was obtained from wound care nurse #4. On 8/20/14 at approximately 10:10 AM, during the observation of wound care for Resident #10 all sites identified on the record were treated using good technique, but an additional site to the right inner heel was identified by the surveyor when the resident was positioned. The area had a dark red intact wound base with purplish margins and was approximately 3.5 X 5.0 cm (centimeter) in size. Wound care nurse #4 and unit manager #2 viewed the site and both stated they were unaware of the wound. Wound care nurse #4 again reviewed the TAR but no orders were present for the right inner heel wound. On 8/20/14 at approximately 10:30 AM an interview was conducted with unit manager #2. Unit manager #2 stated wound rounds are completed weekly at a time specified by the unit manager. Members of the rounding wound team met on Friday, and included the wound care nurse, unit manager, director of nursing service (DNS), assistant director of nursing service (ADNS) and the Dietitian. Unit manager #2 also stated the podiatrist was currently overseeing the care of Resident #10's foot wounds and the attending physician was aware of the pressure ulcers. Unit manager #2 stated the attending physician had visited Resident #10 since the 8/15/14 readmission but she did not know if the wounds were assessed by the physician. The clinical health status assessment completed upon readmission of Resident #10 on 8/15/14 was reviewed. The skin condition assessment identified 4 pressure sites. They were the sacrum, right buttock, left great toe and right great toe. The Braden scale for predicting pressure sore risk was also completed. Resident #10 scored 14 indicating a moderate risk. On 8/20/14 at approximately 11:20 AM the medical record was reviewed further. It revealed Resident #10 was initially identified with a right inner heel pressure ulcer on 7/14/14. It was described as a stage 2 fluid filled blister. The wound was to be treated with skin prep. On 8/4/14 the day prior to Resident #10's discharge to the hospital the right inner heel was described as a stage 2 undetermined pressure ulcer with intact skin and black margins. The treatment remained skin prep and beneath additional comments was the words "prevalon boots". On 8/21/14 at approximately 9:30 AM the surveyor requested a copy of all new orders for Resident #10 obtained on 8/20/14. Upon receipt of the orders there was no order for a treatment of [REDACTED]. A request was also made for the assessment of the right inner heel. The assessment was not readily accessible because wound care nurse #4 stated the information was written on a piece of paper and not logged on the TAR and the paper was misplaced. A telephone order dated 8/21/14 at 10:24 AM was brought in by the medical records clerk on 8/21/14 at approximately 11:00 AM. It was a treatment order to Resident #10's right inner heel. The order dated 8/21/14 documented skin prep to the right inner heel topically every shift related to Pressure Ulcer. On 8/21/14 at 11:15 AM, the Prevalon boots were not on the resident's feet with his heels making direct contact on the mattress surface. Certified Nursing Assistants (CNA) #1 and #2 stated they were on the bath team and did not put them on because they knew the wound care nurse would come in to do all of the wound care. On 8/21/14 at 11:40 AM, the wound care nurse stated she doesn't have a set time and would have preferred the CNA's put the boots on until she arrives at the bedside. The facility's policy titled Skin Care Protocol revised 6/2014 documented evaluation/observation of the skin is to be completed within 24 hours of admission, quarterly/significant change of condition using the Clinical Health Status Tool. The Certified Nurse Aides (CNA) is to observe the resident daily for reddened/open areas, [MEDICAL CONDITION] of the feet or sacrum. The CNA is to report changes to the licensed nurse and document. Licensed nurses are responsible for performing the skin evaluation/observation. The above findings were shared with the Administrator, the Administrator's mentor, the Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS) on 8/21/14 at approximately 1:10 PM. The DNS presented the assessment of the right inner heel dated 8/21/14 to the surveyor at approximately 3:00 PM on 8/21/14. The assessment dated [DATE] revealed a stage II pressure ulcer to the right inner heel measuring 3.0 X 4.5 X 0. The wound was red with dark margins and intact. This assessment was completed by wound care nurse #4. 3. For Resident #9, the facility staff failed to apply physician ordered bilateral heel booties while resident was in bed every shift. Resident #9 was admitted to the facility 4/4/2/14 with [DIAGNOSES REDACTED]. Resident #9's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 7/10/14 assessed Resident #9 with a cognitive summary score of 15 out of 15, indicating the resident was cognitively intact. The clinical record revealed a physician order [REDACTED]." The surveyor observed Resident #9 on 8/19/14 at 4:15 p.m. She was in bed. The surveyor did not observe any heel booties on either foot. The surveyor observed Resident #9 on the morning of 8/20/14 at 8:50 a.m. She was in bed, feet covered by a blanket but no heel booties observed. The surveyor observed Resident #9 on 8/20/14 at 3:50 p.m. Resident #9 was in bed, sipping juice. No bilateral heel booties were observed on either foot. The surveyor observed Resident #9 on 8/21/14 at 7:42 a.m. She was in bed. No bilateral heel booties were observed on either foot. The current comprehensive care plan initiated 8/18/14 revealed Resident #9 was at risk for pressure ulcers due to: hx (history) of pressure ulcer, require assist with bed mobility and incont (incontinent) of bowel. Interventions included heel boots. The surveyor and the executive director registered nurse #2 observed Resident #9 on 8/21/14 at 8:55 a.m. The executive director RN #2 checked Resident #9 for the presence of heel booties on both feet. She stated there were none. There was a pillow on the bed but neither foot was located on the pillow. Both heels checked by executive director R.N. #2. No evidence of skin breakdown. Both heels were intact. LPN #5 was informed that Resident #9 did not have the physician ordered bilateral heel booties on either foot. She stated she would get the boots and apply them to her feet. The surveyor informed the administrative staff of the above finding on 8/21/14 at 1:00 p.m. No further information was provided prior to the exit conference on 8/21/14.

Based on observations, record review, a complaint investigation, resident, staff and family interviews, and facility document review, the facility staff failed to provide one resident (Resident #15) with supervision to prevent a fall with injury and failed to provide one resident (Resident #17) with assistive devices in the survey sample of 24 residents. 1. The facility staff failed to provide Resident #15 with adequate supervision to prevent a fall with injury fractured left thumb. 2. The facility staff failed to address appropriate hand placement and to provide a protective device for Resident #17's hands, who propelled herself in her wheelchair, thus causing excoriations of her knuckles and skin tears. The findings included: 1. Resident #15 was admitted to facility on 7/1/14 with [DIAGNOSES REDACTED].*), Parkinson, multiple TIA's (transient ischemic attacks or mini-stroke*), history of glaucoma and heart disease. The facility staff failed to provide Resident #15 with adequate supervision to prevent a fall which resulted in a fractured thumb. An emergency room X-ray report dated 8/4/14 indicated: " CT head (negative), X-ray right hand (negative), X-ray left and right hips (negative), X-ray left and right knees (negative) X-ray left hand (fractured thumb)." Resident #15 was admitted to the facility with a decline in cognition and ability to follow simple commands. This resident had two CVA's and multiple TIA'S. In 2011 she had a fall that resulted in a sub-aracnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain. This area is called the subarachnoid space (1)). An admissions minimum data set (MDS) assessment dated [DATE] documented: "Resident #15 was assessed in the area of Cognitive Patterns with a Brief Interview for Mental Status (BIMS) as score of 6 out of 15 indicating the resident had severe cognitive impairment. In the area of Functional Status this resident was assessed as 3/3 (Extensive Assistance) (Requiring two person physical assist). Resident # 15 was assessed and coded as not able to walk between location in her room and as being totally total dependent for locomotion on and off the unit. Resident # 15 was coded as requiring extensive assistance with one person for toileting. The resident was assessed and coded as having impaired communication due to impaired cognition and impaired hearing. A Care Plan dated 7/2/14 documented: "Mobility, Functional transfers - moderate assistance X (times)-2 (26-75% with 2 people) maximum assistance x 2 (76-99% assist with 2 people). A nursing note dated 8/3/14 at 2154 (9:54 P.M.) documented: "Resident had on bootees and she was being taken to the bathroom and she slipped and fell on the floor in the bathroom her CNA (certified nursing assistant) was taking her in to use the toilet." A Nursing note dated 8/4/14 at (1:31 a.m.) documented: "Resident was being taken into bathroom. she lean (sic) and fell out the wheelchair." An Occupational Therapy (OT) Plan of Care dated 7/2/14 documented: "Reason for Referral- daughter reports her having had two CVA's and multiple TIA's. Had a fall that resulted in a subarachnoid hemorrhage. Co-morbidities include Parkinson's and history of multiple falls. Precautions: Falls, decreased safety awareness mechanical soft and nectar thick liquids. Underlying Impairments: Balance, Balance-Static Sitting F- (Able to maintain balance only with UE (upper extremity) support) Balance, Balance-Dynamic Sitting P- (Unable to maintain balance without mod/max support) Balance, Balance-Static Standing P+ (patient): requires handhold support and moderate assistance to maintain position Balance, Balance-Dynamic Standing P: Unable to accept challenge or move without loss of balance Balance, Standing Functional Reach Unwilling to reach- 8 x (times) more likely to fall Balance, sitting Forward Reach-Balance 3 inches-Impaired sitting balance Prior Resident and living arrangement: Daughter reports resident can't do much of anything, used to be able to stand but began to lose balance and fall over even with assistance. She used to feed self, assist with sitting on toilet but now presents with difficulty bending legs." During an interview on 8/20/14 at 4:11 P.M. with CNA #4 he stated, "He forgot the time but thought it was around 9:00 P.M., I was about to put her to bed. The lady in Bed-A was sitting in the aisle as we went around to the bathroom. I pushed Resident #15 into the bathroom; I did not lock her wheel chair. I was standing behind her and went back to her roommate in bed- A. She (Resident #15) fell forward hit her head on the floor. She had a bruise around her eye brow and scratches around her knees." When asked if Resident #15 required a safety belt or gait belt to transfer, CNA #4 stated, "No". CNA #4 stated I was behind her and had gone to Resident #15's roommate. She was not supervised nor was she provided assistance to transfer to the bathroom for toileting. During an interview on 8/21/14 at 10:00 A.M. with Resident #15's daughter, she stated, "Staff first called her and stated she had on slippers and slipped CNA #4 was "able to catch her." A few minutes later she got a call stating she had landed on her buttocks but staff was denying she hit her head. Resident #15's daughter stated, "I arrived the next day to find her head swollen and discolored. Her left arm was swollen and discolored. They lied to me about her being lowered to the ground when in fact she had "fell face forward." She cannot stand alone nor can she lean forward without falling that is why I could not take care of her at home. She was falling all the time and the doctor said her next fall with a head wound could be serious." During an interview on 8/21/14 at 10:30 A.M. with the Physical Therapy (PT) Director she stated, "Resident #15 was assessed as not being able to stand alone. Staff should never have left her alone, should have locked the wheelchair, and assisted her with a gait belt to transfer." A Facility Transfer Policy indicated: Purpose- to transfer the resident from bed to chair, toilet or tub safely. Equipment- appropriate type and size of wheelchair ... Transfer belt. General Instructions: 2. lock wheel chair brakes and lift foot rests. The facility staff failed to provide Resident #15 with adequate supervision to prevent a fall with injury fractured left thumb. (1) This information was obtained from the website: <http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm> * This information was obtained from the website: <http://www.nlm.nih.gov/medlineplus/ency/article/ 6.htm> <http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm> 2. The facility staff failed to address appropriate hand placement and to provide a protective device for Resident #17's hands, who propelled herself in her wheelchair, thus causing excoriations of her knuckles and skin tears. Resident #17 was admitted to the nursing facility on 5/21/14 with [DIAGNOSES REDACTED]. The resident's most recent minimum data set (MDS) was an admission assessment dated [DATE] and coded the resident with an 8 (moderately impaired in the skills needed for daily decision making) on the Brief Interview for Mental Status (BIMS). She was not coded as having any behavioral or mood symptoms during this assessment period. She used her wheelchair as the primary mode of mobility on and off the unit. Resident #17's care plan dated 5/21/14 identified the resident used a wheelchair for mobility and that wheelchair safety checks were to be performed, ensure balance in wheelchair and notify rehab (rehabilitation) for possible assessment. The care plan also indicated the resident had physical functioning deficit related to range of motion limitations from a left lower extremity fracture. The goal set by the staff for the resident was she would improve current level of physical functioning. One of the interventions to accomplish this goal included, inspect skin with care and report reddened areas, rashes, bruising or open areas to the charge nurse. On 8/19/14 at approximately 11:15 AM, Resident #17 was observed propelling herself in the wheelchair. She stopped periodically on her way to her room to shake her hands back and forth, and would then proceed again down the hallway. Once Resident # 17 had made it to her room, she was asked about why she was shaking her hands, to which she responded, "I keep rubbing my knuckles on the wheels, so I stop and get a break and keep going." The knuckles on her right hand were observed reddened and the skin was peeled on the middle and ring fingers. Resident #17 stated the aides knew about it, but no one had done anything about it. She stated she probably needed gloves because she wanted to continue to be independent in her wheelchair. On 8/19/14 at 2:00 PM, the resident was again observed propelling her wheelchair throughout the facility, stopping to shake out her hands and then continuing down the hallway. On 8/20/14 at 9:10 AM, an open area was observed on the knuckle of Resident # 17's right ring finger. On 8/21/14 at 11:30 AM, the resident was observed being wheeled down the hallway by a Certified Nursing Assistant (CNA) when this writer asked the Wing II Unit Manager #2 to look at Resident # 17's knuckles. The knuckles were reddened on the right hand and the skin tear clearly visible. The resident stated to the Wing II Unit Manager #2 that she needed gloves so she would stop scraping her fingers. The Wing II Unit Manager #2 stated she was told by the night nurse there was a broken area on the resident's (Resident # 17's) knuckle, but did not know it was from the wheelchair. She stated the areas were cleaned with normal saline and bacitracin (antibiotic ointment) applied. When asked if the resident refused to wear gloves, she stated she never had them, but she was going to get the Rehabilitation Department to assess her for something right away. The resident was observed on 8/21/14 at 2:55 PM in the Rehab (rehabilitation) department with white geri sleeve glove. The Rehab staff, Rehab aide #3 stated the resident would wear them until her Geri-glove arrives and that was the plan to prevent further skin breakdown and potential injury. Complaint Deficiency