Every finding on record at Prescott Nursing and Rehab Community

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene prior to administering medication to R7, R2, R8, and R9. This affected 4 out of 4 residents (R) reviewed for medication errors out of a sample of 9. This was evidenced by: The facility policy titled Hand Washing/Hand Hygiene, dated 1/2025, states in part: Practicing Hand Hygiene is a simple effective way to prevent infections by preventing the spread of germs.Wash hands and other skin surfaces when:2. After removing gloves or other personal protective equipment3. After care of each resident.4. Before and after nursing treatments or procedures (dressing changes, catheter insertion, eye drop instillation, etc.) The Center for Disease Control (CDC) guidelines titled, Clinical Safety: Hand Hygiene for Health Care Workers, dated 2/27/24, states in part: Healthcare personnel must perform hand hygiene to prevent infection transmission:* Before and after leaving a resident's room. On 7/13/26 at 12:00 PM, Surveyor observed Licensed Practice Nurse (LPN) K administer medications to R7. LPN K did not perform hand hygiene prior to preparing the medication. When the medication was prepared, LPN K locked the medication cart and entered R7's room to administer medication. LPN K did not perform hand hygiene prior to entering R7's room or administering the medication. After the medication was administered, LPN K exited R7's room and continued with preparing the next resident's medication. LPN K did not perform hand hygiene after administering R7's medication and exiting R7's room. On 7/13/26 at 12:06 PM, Surveyor observed LPN K administer medications to R2. LPN K did not perform hand hygiene prior to preparing the medication. When the medication was prepared, LPN K locked the medication cart and entered R2's room to administer the medication. LPN K did not perform hand hygiene prior to entering R2's room or administering the medication. After the medication was administered, LPN K exited R2's room to the medication cart and started preparing for the next resident's medication. LPN K did not perform hand hygiene after administering R2's medication and exiting R2's room. On 7/13/26 at 12:14 PM, Surveyor observed LPN K administer medications to R8. LPN K did not perform hand hygiene prior to preparing the medication. When the medication was prepared, LPN K locked the medication cart and entered R8's room to administer the medication. LPN K did not perform hand hygiene prior to entering R8's room or administering the medication. After the medication was administered, LPN K exited R8's room to the medication cart and started preparing for the next resident's medication. LPN K did not perform hand hygiene after administering R8's medication and exiting R8's room. On 7/13/26 at 12:20 PM, Surveyor observed LPN K administer medications to R9. LPN K did not perform hand hygiene prior to preparing the medication. When the medication was prepared, LPN K locked the medication cart and took R9's medication into the dining room where R9 was sitting. LPN K did not perform hand hygiene prior to entering the dining room and administering the medication. After the medication was administered, LPN K exited the dining room to the medication cart and started preparing for the next resident's medication. LPN K did not perform hand hygiene after administering R9's medication and exiting the room. On 3/23/26 at 10:33 AM, Surveyor interviewed LPN K who stated hand hygiene is before and after cares. Surveyor asked LPN K does medication pass count as care. LPN K stated yes, it does. Surveyor asked if LPN K had a small container of hand sanitizer in his pocket. LPN K stated no. Surveyor observed no hand sanitizer container on top of the medication cart. Surveyor asked if there was hand sanitizer kept in the medication cart. LPN K stated I don't think so. Surveyor asked LPN K if they should have been performing hand hygiene between the medication pass to R7, R2, R8 and R9. LPN K stated yes, LPN K should have. Surveyor asked if LPN K completed hand hygiene between R7, R2, R8, and R9. LPN K stated, no, I did not. On 3/23/26 at 12:32 PM, Surveyor interviewed Director of Nursing (DON) B who stated DON B's expectation for nursing staff is that hand hygiene or hand washing be completed between each individual, when leaving a room, before prepping meds, and administering meds.

Based on interview and record review, the facility did not ensure 1 of 5 residents (R) reviewed were free from chemical restraints. (R21)R21 was prescribed a hypnotic medication. There is no indication nonpharmacological interventions were tried prior to initiating the medication. The facility did not complete a sleep assessment, care plan, or monitor R21's sleep. R21 denied insomnia or history of sleep concerns. R21 is not informed that R21 is taking a psychotropic for sleep.Findings:R21 was admitted to the facility on [DATE] and has diagnoses including bipolar disorder, obstructive sleep apnea (adult) (pediatric), acute and chronic respiratory failure with hypoxia, asthma, manic episode, unspecified mood (affective) disorder, and anxiety disorder.R21's Minimum Data Set (MDS) assessment, dated 5/1/26, indicated R21 is dependent for assistance for all transfers and assistance with position changing. R21 can perform most activities of daily living with assistance of setting up the task. R21's Brief Interview of Mental Status scored 15/15, meaning R21 is cognitively intact. R21 is their own person and able to make their own decisions.R21's orders include:Trazodone tablet; 50mg; amt: 25mg; oral Special instructions: Administer 25mg at HS (bedtime) for sleep. Once A Day 07:00PM - 10:00PM Started 02/01/2026- open ended Trazodone tablet; 50mg; amt: 25mg; oral Special instructions: Administer 25mg at HS (bedtime) for sleep. Once A Day 07:00PM - 10:00PM Started 11/07/2025- 02/01/2026 ~ R21 does not have a completed sleep assessment.~ R21's care plan does not address insomnia, sleep disturbance or sleep issues with interventions for monitoring behaviors.~ The facility is not monitoring R21's sleep patterns.~ R21 does not have signed consent for trazadone. On 5/12/26 at 11:36 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F who stated R21 is on her call light a lot but CNA F tries to take care of everything she needs when CNA F is in the room. Surveyor asked CNA F if R21 has difficulty sleeping. CNA F stated CNA F does not work the night shift so is unable to speak to sleep problems. On 5/13/26 at 8:34 AM, Surveyor interviewed Registered Nurse (RN) H who stated if we need an order for a medication, we fill out the form for the doctor and put it in the doctor's book to sign off. RN H reviewed R21's record and could not find a sleep assessment or monitoring of hours slept, nor medication effectiveness. Surveyor interviewed RN H who stated usually we track how many hours a resident sleeps. RN H stated RN H was not sure of the indication for the trazodone, but R21 is up all night and probably needs it. On 5/13/26 at 8:50 AM, Surveyor interviewed Director of Nursing (DON) B who stated DON B has no idea what form RN H is referring to. DON B stated we do consent forms for psychotropics and high-risk meds and pharmacy reviews monthly. DON B stated the facility had to give R21 something to help R21 sleep. DON B stated R21 would not sleep when R21 was first admitted to the facility, and R21 would constantly use the call light. DON B stated nights were rough. On 5/13/26 at 9:06 AM, Surveyor interviewed DON B and asked about documentation for why a resident would require medication or sleep. DON B stated there would be progress notes on why the resident needed it. Surveyor could not find progress notes regarding R21's need for sleep medication and requested DON B provide the documentation. On 5/13/26 at 11:50 AM, Surveyor interviewed R21 who stated that I am a night person. I've always stayed up until 2 or 3 in the morning. Surveyor asked if R21 had difficulty sleeping here at the facility. R21 stated not really; I like being a night owl. Surveyor asked R21 if she received medication to help her sleep. R21 stated no, I don't think I get any medication for sleeping. I am falling asleep earlier and getting up earlier. They are changing me. Surveyor asked R21 how that makes R21 feel. R21 stated, I don't know I guess that is how it is here. Facility was unable to provide information regarding the need for Trazodone or any non-pharmacological interventions tried prior to initiating Trazodone.

Based on observation, interview, and record review, the facility did not ensure residents received the appropriate treatment and services to prevent complications for 1 of 1 resident (R) receiving nutrition through tube feedings (enteral nutrition) (R26).The facility did not ensure standards of practice were conducted by ensuring proper gastrostomy tube (G-tube) placement before administering medications via G-tube.The facility policy titled, Care and Treatment of Feeding Tubes, last reviewed 04/03/25 states under the section of Policy Explanation and Compliance Guidelines, .6.licensed nurses, will monitor and check that the feeding tube is in the right location (a). Tube placement will be verified before beginning a feeding and before administering medications.On 05/12/26, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] with a diagnosis of placement of a gastrostomy tube following surgery for right hemicolectomy.R26's admission Minimum Data Set (MDS) assessment, dated 02/06/2026, indicates having a Brief Interview for Mental Status score of 15/15 (cognitively intact). R26 required 51% of total calories through tube feeding.R26's care plan was updated on 04/10/26 with ability to eat orally.R26's physician orders were updated on 03/10/26 for all medications to be given via G tube or by mouth (patient prefers G-Tube). Flush with 30 cc before and after medication administration.On 05/12/2026 at 9:54 AM, Surveyor observed Licensed Practical Nurse (LPN) C administer R26's medications via G-tube without checking placement prior to administering medication.On 05/12/2026 at 12:43 AM, Surveyor interviewed LPN C regarding expectation of checking gastric content residual prior to medication administration via G-tube. LPN C stated, Are we supposed to do that? Director of Nursing (DON) B was walking down hallway while Surveyor was interviewing LPN C and Surveyor interviewed DON B of expectation of checking residual prior to medication administration. DON B stated the expectation would be to check residual prior to medication administration.

Based on observations, interviews, and record review, the facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 14 residents. (R4 and R7)-Certified Nursing Assistant (CNA) E did not place barrier between floor and graduate when emptying R4's Foley catheter bag.-CNA D did not sanitize the mechanical lift after transferring R6, nor prior to using mechanical lift to transfer R7. CNA D and CNA E used the EZ stand lift for R4's transfer from bed to wheelchair and did not sanitize after use. The facility policy titled, Cleaning/Disinfecting Resident-Care items and Equipment, reviewed on 01/20225 states, . Reusable items are cleaned and disinfected between residents . The facility procedure titled, Emptying a Urinary Drainage Bag Competency, states, . 4. Place a paper towel on floor next to the drainage bag. 5. Place graduate collection container on top of paper towel. Wisconsin Nursing Assistant Curriculum, Copyright © 2023 by WisTech, section 5.25 Skills Checklist: Emptying Catheter Drainage Bag, states: Procedure Steps: ~Put on gloves. ~Place a barrier (e.g., paper towel or disposable pad) on the floor under the drainage bag. ~Place the graduated cylinder on the barrier. Example 1 On 05/12/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including abnormal gait and mobility, weakness, spinal disc disorder, and urinary retention and obstruction. R4's care plan states: ~ Dated 07/07/25: Resident has a history of UTI (Urinary tract infection). Resident has a catheter increasing infection risk. ~ Dated 03/15/25: Resident requires enhanced barrier precautions related to: Fornier's Gangrene wounds, urinary catheter, and new colostomy. One assist with foley catheter care and emptying. ~ Dated 03/10/25: Self Care Deficit requiring 2 staff assist with EZ stand for transfers. On 05/12/2026 at 9:02 AM, Surveyor observed Certified Nursing Assistant (CNA) D and CNA E provide care for R4. CNA E emptied R4's foley catheter bag. During the process, CNA E placed the urinal directly on the floor then proceeded to empty the foley catheter bag without the barrier in place. CNA D and CNA E then transferred R4 from the bed to the wheelchair using an EZ stand mechanical lift. Following the transfer, R4 was disconnected from the lift, and the lift was placed out in the hallway without being sanitized. On 05/12/2026 at 9:23 AM, Surveyor asked CNA F when lifts are supposed to be sanitized. CNA F said, After every use, but sometimes we have a lack of purple wipes, so we do it when we can. On 05/12/2026 at 9:29 AM, Surveyor asked CNA D where antimicrobial wipes are located. CNA D led Surveyor to multiple storage rooms in three different areas of the building (two different hallways and central supply closet in the dining room). There were no antimicrobial wipes in any of the areas. CNA D then asked Licensed Practical Nurse (LPN) G where the purple wipes were located. LPN G stated the wipes are on the other hall on the vitals cart. CNA D told and showed Surveyor s/he uses premium adult washcloths (which do not meet the requirements for sanitizing medical equipment) if purple (antimicrobial) wipes are not available. CNA D stated, I am so sorry we forgot to wipe the lift after the transfer for [R4]. CNA D then retrieved antimicrobial wipes and wiped the lift. On 05/12/2026 at 11:14 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked what the expectation is for staff to wipe lifts after use. DON B stated that staff should wipe lifts with antimicrobial wipes after every use in the residents' rooms. DON B also confirmed the facility has 2 Hoyer lifts and 2 sit-to-stand with a total of 14 residents that require the use of mechanical lifts for transfers. Surveyor asked what the expectation is regarding emptying a foley catheter bag. DON B stated, We do not place a barrier on the floor. I was not aware of this. I will educate the staff. Example 2 On 5/12/26 at 8:18 AM, Surveyor observed CNA D use the Hoyer (mechanical full body lift) to transfer R6 to the wheelchair. At 8:37 AM, Surveyor observed CNA D transfer R6 to R6's wheelchair and then take the garbage and Hoyer lift out of R6's room. CNA D parked the Hoyer lift off to the side in the hallway outside R6's room. CNA D then went and discarded the garbage in the dirty utility. CNA D came out of the dirty utility room without performing hand hygiene and went to nurse's station. CNA D did not wipe down the soiled Hoyer lift. Surveyor continued to stand by the Hoyer lift and at 8:52 AM, Surveyor observed CNA D push the soiled Hoyer to R7's room, push the lift inside R7's room, and transfer R7 with the soiled Hoyer lift with assistance of a second CNA. On 5/13/26 at 11:32 AM, Surveyor asked CNA D if CNA D wiped the Hoyer down after using it with R6. CNA D stated CNA D thought it was sanitized but CNA D may have forgotten. CNA D stated the Hoyer lift should have been sanitized after use. On 5/13/26 at 1:38 PM, Surveyor interviewed DON B who stated DON B's expectation is that staff sanitize the Hoyer lift after each use.

Based on observation, interview and record review, the facility did not ensure the residents remain free of possible accidental hazards. Facility did not determine the correct mechanical full body lift (Hoyer) sling size and ensure staff were applying the correct size Hoyer sling to prevent accidents for 3 of 7 residents (R) reviewed. (R7, R37, R44). Facility developed a plan of care for R37 that listed the use of an xl (x-[NAME] large) Hoyer sling when a large sling should be used per manufacturer's guidelines. Certified Nursing Assistants (CNAs) used a medium Hoyer sling to transfer R37. Facility developed a plan of care for R44 that listed use of an xl sling when a large Hoyer sling should be used per manufacturer's guidelines. CNAs used a medium Hoyer sling to transfer R44. Facility developed a plan of care for R7 that listed use of an xl sling when a large Hoyer sling should be used per manufacturer's guidelines.Findings include:The Direct Supply Slings manufacturer's guidelines, no date, states, With Direct Supply slings, sizing is made simple! Check the trim color on each sling to quickly identify what size it is. In chart from the following is stated: Size x-small 50-100 pounds (lbs.) Black Trim Size small 75-150 lbs. Black Trim Size medium 125-200lbs. Purple Trim Size Large 175- 300lbs. [NAME] Size x-large- 275-500 lbs. Blue trim The Direct Supply Website titled, How Do I Determine What Sling My Resident Needs? dated 2009-2026, states: The determination of the correct sling model and size must be done by a licensed clinician. That designated licensed clinician should: . 2. Determine the correct lift/assist device and sling based on the resident assessment and the manufacturer's instructions. 3. Document the specific recommended lift/assist device (make, model and weight capacity) and sling (make, model and size.) https://www.directsupply.com/resources/blogs/how-to-select-and-use-lift-slings The U.S. Food and Drug Administration patient guide titled Patient Lifts, undated, states: A sling too large: a patient may slip out. A sling too small: patient may fall out, it may worsen patient's condition, it may cause skin tears or pressure injuries due to excessive pressure. Example 1 R37's plan of care dated 5/13/26 states: Resident to be A2 (assist of 2) for transfers using Hoyer lift. Started 5/15/23. Full Body Lift: Tollos XL (extra-large). Started 9/18/23. R37's weight on 5/10/26 was 236.8 lbs. Per manufacturer's guidelines a green trim (large) sling should be used with R37. On 5/13/26 at 1:15 PM, Surveyor walked around with Certified Nursing Assistant (CNA) D and observed Hoyer slings used with residents. Surveyor observed that R37 was sitting in his wheelchair with a blue with purple trim Hoyer sling under him. CNA D stated R37 is an assist of 2 transfer using the Hoyer lift. CNA D stated, Yes we would use the sling under him to transfer him into his chair. Example 2 R44's plan of care, dated 5/13/26, states, Transfers: 2 persons assist with [Hoyer] lift, sling size XL. Started 5/7/26. R44's weight on 5/13/26 was 244.2 lbs. Per manufacturer's guidelines a green trim (large) sling should be used with R44. On 5/13/26 at 1:15 PM, Surveyor walked around with CNA D and observed Hoyer slings used with residents. Surveyor observed that R37 was sitting on a blue with purple trim sling under him in his wheelchair. CNA D stated R37 hates to get in the sling, it hurts. We use a sling to transfer R37. Example 3 R7's plan of care dated 5/13/26, states: 2 assist EZ stand (XL) sling for all transfers. Can use Hoyer lift (XL sling) if lethargic and resident cannot participate in EZ stand transfer. Started 1/22/25. R7's weight on 5/12/26 was 230 lbs. Per manufacturer's guidelines a green trim (large) sling should be used with R7. On 5/13/26 at 1:15 PM, Surveyor walked around with CNA D and observed Hoyer slings used with residents. Surveyor observed that a blue sling with green trim was in R7's chair. CNA D stated this is the sling we use with R7. R7 stated slings stay with the residents in their rooms unless they are soiled, then we get one that looks the same. Surveyor asked CNA D what size sling R7 uses. CNA D stated he does not know what size sling to use. Surveyor asked, does that mean that if the wrong size is being used with a resident and a new sling is needed and grabbed based on the same color as the soiled, the use of the wrong size sling is perpetuated. CNA D stated yeah, I guess so. I see what you are asking. On 5/12/26 at 8:35 AM, Surveyor interviewed CNA D who stated CNA D thinks Hoyer slings are universal in size. CNA D said, well there are different sizes, and this one is definitely one of the smaller ones. (The sling being used was blue with purple trim). CNA D and CNA F tried to find a size on the sling and could not find a size on any of the labels. CNA D stated we aren't told which one to use, we just make sure the resident fits safely and isn't falling out. Each resident has their own sling, and it is kept in their room. Slings are not shared between residents. On 5/12/26 at 11:35 AM, Surveyor interviewed CNA F regarding sling use. CNA F showed Surveyor R6's sling. CNA F stated R6 is smaller, so you use a smaller sling. CNA F showed Surveyor R21's sling. CNA F stated that R21 is larger so we would use a larger sling. CNA F stated there are different sizes, but I don't think they are labeled. CNA F stated the different sizes have different color trim. CNA F states she has no idea what color is what size. CNA F stated there is no chart posted anywhere indicating sling size. CNA F stated the plan of care is how we (CNAs) know how to transfer residents. CNA F stated I don't think the plan of care tells you what size sling to use. CNA F stated I know that the sling should not be lower than this (touched back of head) and it should be down to here (touched the back of her knees). CNA F stated we are kind of just guessing, but we do have different sizes to choose from, and we make sure it is big enough, so they fit right. On 5/12/26 at 12:19 PM, Surveyor interviewed Physical Therapist (PT) J and Physical Therapy Director (PTD) I regarding Hoyer transfer and slings. PT J stated that residents are admitted with transfer orders from the hospital or provider. PT J stated that PT J assesses a new resident within a day or so of admission. PT J determines a resident's ability and how to transfer safely. PT J stated PT J fills out the form with recommendations to communicate with nursing. PT J stated PT J does not determine the sling size nursing does that. PT J stated CNAs would not be doing that. Should not be doing that. Nurses determine the sling size, and it is care planned. On 5/13/26 at 8:43 AM, Surveyor interviewed Registered Nurse (RN) H who stated that residents are admitted with transfers orders when admitted . Physical Therapy sees them a day or two later to assess strength. PT then communicate their recommendations to nursing on the communication form. The doctor or Physical Therapy determines if a resident needs to be transferred by Hoyer and which sling to use. Nursing does not do that. It is placed on the plan of care for the CNA to follow. On 5/13/26 at 11:41 AM, Surveyor interviewed CNA E who stated some residents have the sling size on their plan of care. CNA E stated no, you can't easily tell what size the sling is, but it is on the plan of care. CNA E stated it should say a size on the slings, but they don't. CNA E stated they (slings) do have different color trim. CNA E stated no, there is not a chart posted that tells us what color each size sling is. CNA E stated CNA E knows the slings have to have room on the side to hold them and residents need to be safely lying in the sling. The sling goes from back of head down to the knee. On 5/13/26 at 1:32 PM, Surveyor interviewed Director of Nursing (DON) B who stated that admissions have transfer orders when they are admitted that usually have an order for transfer method. PT assesses residents within a day or two after admission and completes the communication form with their recommendations. DON B stated that everything eventually gets in chart. DON B stated nurses usually determine the sling size, usually it is the MDS Coordinator or DON B. DON B stated we look at the body habitus to determine. CNA might make a recommendation on sling but wouldn't use it until we verify it is the appropriate sling.

Based on interview and record review, the facility did not ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident (R) reviewed. (R33) R33 was not given enteral feeding nutrition as ordered; instead R33 received twice as much as ordered resulting in vomiting and aspiration, requiring suctioning and transfer to hospital on [DATE] where R33 expired on [DATE]. The facility's failure to properly monitor, assess, and correctly follow physician (MD) orders and treatments for enteral feeding resulted in resident receiving twice as much enteral feeding as ordered and created a finding of Immediate Jeopardy (IJ) that began on [DATE]. The state agency notified Nursing Home Administrator (NHA) A of the immediate jeopardy on [DATE] at 3:00 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a level D (potential for harm/isolated) as the facility continues to implement its action plan. This is evidenced by: Facility policy titled, Tube Feeding, with a reviewed date of ,d+[DATE], states in part: Purpose: To provide nutritionally complete tube or parenteral feedings as ordered by the physician or the nourishment of residents who are unable to eat normally. When a resident requires special feeding techniques as ordered by the physician, the nursing and dietary departments are responsible for the adequate intake of nutritional support. Proficient management of tube feeders assures fewer complications and improved general health status .Problems with the administration of the tube feeding are monitored and corrected by nursing. Facility policy titled, Enteral Nutrition: Checking Residual Volume, with a reviewed date of ,d+[DATE], states in part: Policy: When enteral nutrition is initially instituted, gastric residual volume is assessed every 4 hours until the resident demonstrates an ability to empty his/her stomach. After this time period, volume is tested in accordance with a physician's order. R33 was admitted to the facility on [DATE] with pertinent diagnoses of malignant neoplasm of sigmoid colon, diabetes mellitus type 2, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, and paroxysmal atrial fibrillation. R33's most recent Minimum Data Set (MDS) assessment completed on [DATE] noted a Brief Interview for Mental Status (BIMS) score of 14 indicating cognition is intact, R33 is able to make self understood, and is able to understand others. Special treatments given include tube feedings. R33's care plan, dated [DATE], with a target date of [DATE], states, Problem: R33 is at risk of complications due to use of feeding tube Sigmoid cancer . Goals: R33 will have all nutritional and hydration needs met. Resident will be free of complications related to feeding tube use. Interventions: Administer feeding and flushes as ordered .assess for complications: .lung aspirations, pneumonia, shortness of breath, displacement into lung, .respiratory problems .check for residual as ordered . On [DATE], Surveyor reviewed R33's physician orders and noted: Enteral Feeding: Formula Osmolite Strength: 1.5 Flow Rate: 300ml @ 295ml/hr over 60 minutes. Water flushes of 60ml before and after administration of feeding four times a day. Start date: [DATE] Ipratropium-albuterol solution for nebulization; 0.5mg-3mg (2.5mg base)/3ml; Administer 3ml via inhalation four times a day as needed for shortness of breath/wheezing. Start date: [DATE] On [DATE], Surveyor reviewed R33's nursing progress notes and noted: [DATE] at 10:14 PM, Res received PRN Duoneb at HS. Res has been mouth breathing. Mouth is wide open, and almost making a snoring sound. Effective. R 16. O2 sats 96 room air. HOB elevated. Lung sounds clear. No abdominal distention, or residuals. TF ran without difficulty along with water flushes and medications. [DATE] at 2:08 PM Resident was accidentally overfed this am as a limit had not been set on her feeding pump. She received over twice her normal feeding. Her noon feeding was held. She developed a gurgle and cough and was given an aerobika treatment along with a duo neb. [The Aerobika is a handheld breathing device used to help clear mucous from the airways. It works by using a combination of oscillating and positive expiratory pressure to help loosen and dislodge mucus, making it easier to cough.] Oral suctioning was not clearing her throat but after several attempts to clear it she did have an emesis. Suctioning was provided again immediately to help clear her mouth and throat and she did sound better. O2 97%, R 18; T 97.9; BP ,d+[DATE]; P 64. Nurse Practitioner has been updated and a chest x-ray is going to be ordered. *Of note: review of MAR shows no administration of duo neb treatment. On [DATE], Surveyor reviewed R33's Medication Administration Record (MAR) and noted: [DATE], between the hours of 6:00 AM - 8:00 AM, R33's scheduled enteral tube feeding was not administered with a note stating, Not Administered: Due to Condition Comment: Overfed at AM time. [DATE], between the hours of 12:00 PM - 1:00 PM, R33 received 740ml of enteral feeding. On [DATE] at 10:36 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D who administered the wrong dosage of enteral tube feeding on [DATE]. LPN D stated that he documented the timing incorrectly on the MAR and the excess tube feeding occurred during the scheduled 6:,d+[DATE]:00 AM feeding and the 12:,d+[DATE] PM feeding was not administered. LPN D stated that at the time of this incident, no procedure/policy was in place for setting up the tube feeding machine, and the nursing staff all did so in different ways. LPN D stated that he set up and initiated R33's tube feeding sometime between ,d+[DATE] AM by clearing the volume previously infused on the machine and entering the ordered rate of 295ml/hr. LPN D stated he assumed the tube feeding limit was already set for the correct amount of 300ml to be administered and then the pump would stop infusing. LPN D did not verify this setting was in place. LPN D stated that he returned to R33's room at approximately 9 AM and observed the tube feeding was still infusing into the resident and he observed R33 coughing and making gurgling sounds. LPN D immediately stopped the tube feeding, completed suctioning multiple times, and administered an aerobika and duo neb treatment. LPN D stated this was not documented in the MAR due to the emergent situation. LPN D stated that R33 vomited and additional suctioning was required and when R33 appeared stable, LPN D then notified the provider, who was onsite at facility, of situation. LPN D stated the provider then assessed the resident. LPN D stated that he did not complete a lung sound assessment at any time after this incident occurred until the end of his shift at approximately 2:45 PM. [DATE], between the hours of 4:30 PM - 5:30 PM, R33's scheduled enteral tube feeding was not administered with a note stating resident refused. *Of note: Review of MAR for enteral feedings that began on [DATE] noted only one prior refusal of enteral feeding on [DATE] prior to this incident. [DATE] at 5:30 PM, order for chest x-ray stat 2 views for increased SOB cough after vomiting Not Administered: Other Comment: [Name of x-ray company] will be here ,d+[DATE] [DATE], between the hours of 8:30 PM - 9:30 PM, R33 received 300ml of enteral feeding. On [DATE], Surveyor reviewed R33's nursing progress notes and noted: [DATE] at 2:38 PM, Chest x-ray stat 2 views for increased SOB cough after vomiting. [DATE] at 5:52 PM, pulse 72, temp 97.5, resp 18, BP ,d+[DATE], O2 sats 97% [DATE] at 7:23 PM, NP updated x-ray scheduled for ,d+[DATE] and she stated fine. [DATE] at 9:56 PM, (IDT note), Medication error no harm [DATE] root cause: right medication wrong dosage of tube feed; 300ml (right) given 700ml (wrong) Interventions: vital signs, adverse reactions monitored, 6 rights of medications be reviewed by all nurses, safety medications check in serviced. X-ray, family, MD, DON notified. [DATE] at 10:05 PM, Resident refused afternoon feeding after feeling full. Night feeding of 300ml received well. No noted emesis. [DATE] at 12:52 AM, Noted change of condition with rale sound to lungs when resident breathing in. BP ,d+[DATE]; P 72; R 20; T 98.7. Xray to chest stat was ordered today by [name] NP .not able to do them until ,d+[DATE] in the afternoon. Called [provider name] with an update and order to send to ER was given. [DATE] at 1:15 AM, Order to send resident to ER for eval and treatment. [DATE] at 1:32 AM, Resident transported to . hospital in St. [NAME]. *Of note: Surveyor was unable to locate any additional assessments of R33's lung sounds after overfeeding occurred on [DATE]. Surveyor was unable to locate any documentation of assessing R33's residual volume amounts since admission on [DATE]. On [DATE] at 7:52 AM, Surveyor interviewed hospital Nurse Manager (NM) K at [hospital name] in St. [NAME]. NM K stated that R33's hospital discharge summary noted admission to hospital on [DATE] and expired at the hospital on [DATE]. NM K stated R33's discharge summary noted no cause of death but reported contributing factors of aspiration pneumonia, dysphagia, and stroke. On [DATE] at 10:01 AM, Surveyor interviewed Director of Nursing (DON) B who stated the facility did not have a procedure/policy in place at the time of this incident for setting up tube feeding machine parameters to administer enteral feeding. DON B stated the facility did not have a procedure/policy in place at the time of this incident that clearly outlines nursing assessment expectations to include frequency and timing for residents with tube feedings who develop complications related to enteral feedings. On [DATE] at 12:59 PM, Surveyor interviewed DON B regarding assessment and documentation of residual volume checks with tube feedings. DON B stated it is an expectation for nursing staff to assess residual volume but was unable to find any documentation of this for R33. DON B stated that re-education for tube feedings, including the use of tube feeding machines, was completed after this incident but was unable to provide documentation. Surveyor asked if education and competency for tube feedings were completed prior to this incident. DON B stated yes but was unable to provide documentation of completed training/competency. The facility's failure to provide the necessary treatment and services for enteral feeding to prevent complications for a resident with an enteral feeding created a reasonable likelihood for serious harm, which created a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a level D (potential for harm/isolated) as the facility continues to implement the action plan below: All licensed staff were educated on following of MD orders. All current and new staff educated on the specific tube feeding machine with competency for setting rate/length of run time. All staff educated on checking residual for placement prior to administration of tube feeding, checking placement of G-tube. All staff educated on change of G tube, need of RN assessment for possible dislodged G tubes. All staff educated on following MD orders, and for replacement or send to hospital for replacement, care provided to G tubes, care plan development for G tube. G tube/feeding policy is reviewed with medical director. Audit for G-tube care and administration completed by DON or designee, daily x 2 weeks, weekly x 8 weeks, monthly x 3 months. This will be reviewed with QAPI and will continue to follow recommendations.

Based on observation, record review and interview, the facility did not prepare, store or distribute foods in a sanitary manner. The facility practices had the potential to affect all 29 residents. Kitchen staff did not complete monitoring of sanitation chemicals used to clean kitchen surfaces. Food items stored in the resident refrigerator on the unit were beyond use by dates. This is evidenced by: Facility policy titled, Sanitation Terminology, with a revised date of ,d+[DATE], states in part: Quaternary Solutions: a)Use of quat for food contact surfaces bucket: Add quat to water and test concentration in the water by using test strip. It should read ,d+[DATE] PPM on the chart. Facility dietary guideline posted on resident refrigerator titled, Unit Fridge, with no date, states in part: Sandwiches made from dietary expires 3 days after preparation. Example 1 On [DATE] at 7:44 AM, Surveyor observed red sanitation bucket with a rag inside. No log sheets were observed in kitchen area to document the level of chemicals used in the sanitation bucket. On [DATE], Surveyor reviewed the facility's logs titled, Three Compartment Sink Sanitation Log, for the period of ,d+[DATE] - ,d+[DATE] and noted the following: Each log sheet is sectioned by breakfast, lunch, and dinner and include areas to document the sanitizer solution level obtained from a chemical parts per million (PPM) strip, the water temperature, and initials of the person documenting. Each month reviewed had multiple dates missing all documentation for approximately half of the days in the month. On [DATE] at 12:14 PM, Surveyor interviewed Dietary [NAME] (DC) J regarding sanitation log. DC J stated the three compartment sink is not used for dishes or sanitizing, but a bucket is. DC J stated that each morning, the cook on-duty is expected to fill the sanitization bucket with water and sanitizer, use a test strip to check the PPM, and document the result on the Three Compartment Sink Sanitation Log. DC J was unable to provide reason as to why the log was not being filled out daily as expected. On [DATE] at 12:23 PM, Surveyor interviewed Dietary Manager (DM) I regarding sanitation log. DM I stated the kitchen staff is expected to test the PPM in the sanitation bucket, at minimum, three times daily and document the result on the log sheet. DM I stated not being aware that these logs were not being filled out completely. DM I stated recognition of the potential risk for food-borne illness that may result from not ensuring sanitation chemicals are at the proper levels. DM I stated that staff would be re-educated on this. Example 2 On [DATE] at 11:08 AM, Surveyor observed the resident refrigerator located in the copy room on the resident unit. Inside the refrigerator, Surveyor observed a clear tray with 6 half sandwiches in clear plastic baggies. The clear tray containing the sandwiches had a sticker on the front stating, Ham and cheese ,d+[DATE]-,d+[DATE]; PB&J ,d+[DATE]-,d+[DATE]. Surveyor observed 2 of the sandwiches had handwritten date of ,d+[DATE] in black marker and 4 sandwiches only had ham & cheese written on the outside of the baggie. Surveyor observed a white sheet of paper that noted, ,d+[DATE] PB & J and Ham and Cheese ,d+[DATE]. On [DATE] at 11:27 AM, Surveyor asked Licensed Practical Nurse (LPN) H who was responsible for monitoring the expiration dates on the food in the resident refrigerator. LPN stated that kitchen staff dates and checks everything. On [DATE] at 11:58 AM, Surveyor interviewed Dietary [NAME] (DC) J about the unit refrigerator. DC J stated that kitchen staff and nursing share the responsibility for monitoring the food items and expiration dates. On [DATE] at 12:23 AM, Surveyor interviewed Dietary Manager (DM) I about the observations of expired food items. DM I stated that kitchen staff are responsible for dating the items for expiration when prepared and then ensuring the items for residents in the refrigerator on the unit are not expired. DM I stated frustration over expired items being in the refrigerator and stated kitchen staff would receive re-education on responsibilities of monitoring expiration dates.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 29 residents (R). -The facility did not have an infection surveillance process in place for a GI outbreak in March 2025. -Staff did not follow Enhanced Barrier Precautions (EBP) of wearing personal protective equipment (PPE) when providing IV medication administration for R236, when providing catheter care and positioning for R22, and when providing resident cares for R11. Findings include: Example 1 Surveyor reviewed Infection Control (IC) surveillance logs and found the facility identified the facility had an outbreak of Gastrointestinal virus labeled the Norovirus in March 2025, which affected 14 residents and 11 staff members. Surveyor reviewed surveillance logs for March and found data to be missing. Infection Preventionist who is also Director of Nursing (DON) B gave Surveyor all information pertaining to the identified GI outbreak in March. Surveyor reviewed GI outbreak logs which read, 15 residents were affected with symptoms of diarrhea and 10 staff members were affected with diarrhea. Surveillance logs were missing the type of test ordered, specimen collected, and date of collection if specimen was received. Surveillance logs were missing what type of isolation all residents and staff needed to be on and when the precautions were implemented. Surveillance logs were also missing when staff members were sent home and when they were told they could return to work. Resolution/well dates for residents and staff were not included in the surveillance log list. Surveyor could not find an outbreak map identifying on what wings the GI outbreak happened to decrease the spread. Surveyor could not find audits being performed by staff to decrease the spread of the GI outbreak. Surveyor could not find a thorough summary of the GI outbreak that identified the start of the outbreak or the end to the GI outbreak. Summary was very vague and did not specify the spread of infection or the resolution times of each infected resident/staff. The summary mostly talked about current uptick in Urinary Tract Infections and not information pertaining to GI outbreak. Interviews: On 4/2/2025 at 9:28 AM, Surveyor interviewed Director of Nursing (DON) B and asked about the GI outbreak that occurred in March 2025. DON B indicated that there was a GI outbreak in March that started with one resident at end of February and spread from there. Surveyor indicated to DON B that Surveyor did not find that information. DON B indicated that DON B did his best at tracking what he could. Surveyor asked DON B if the surveillance line list that was provided earlier all the information of the outbreak that DON B has. Surveyor asked why does the GI outbreak not have summary from start date, with who and when it ended, complete line list with type of test ordered, specimen collected, date of collection, what type of isolation all residents and staff needed to be on and when the precautions were implemented. The GI outbreak documentation did not confirm when staff members were sent home and when they were told they could return to work. The GI outbreak documentation did not confirm resolution/well dates for residents and staff. Surveyor indicated there was no map location to decrease the spread of infection and if there were audits being done for proper hand hygiene and PPE usage during the outbreak. DON B indicated that DON B should have tracked the GI outbreak better and does not have a formal process for tracking staff infections/sickness. DON B indicated that a facility map should have been utilized to decrease the spread, and infection surveillance should have all elements on the line list. 31086 Example 2 Facility's policy titled Enhanced Barrier Precautions with the reviewed date of 01/25, read in part, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities .2. Initiation of Enhanced Barrier Precautions .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. R236 was admitted to the facility on [DATE] with pertinent diagnosis of gas gangrene. Review of physician orders documented: 03/27/25 Enhanced barrier precautions (targeted gown and gloves use) during high contact resident care activities. Every shift. 03/27/25 cefazolin recon soln; 1 gram; amt: 2 grams; intravenous Special Instructions: Administer 2 grams every 12 hours for gangrene of foot. On 04/01/25 at 9:01 AM, Surveyor observed a sign outside of R236's door stating EBP. In R236's room was a bin containing PPE. Surveyor observed Licensed Practical Nurse (LPN) D enter R236's room, apply gloves and sanitize the over the bed tray table. LPN D removed gloves and sanitized hands. LPN D wiped the top of the bottle of cefazolin with an alcohol wipe, mixed the medication, primed the IV tubing, and set the IV pump. LPN D washed hands and applied gloves. LPN D did not apply a gown. LPN D went to R236's right arm and removed the cap to the PICC line and sanitized the port with an alcohol wipe. LPN D continued to set up the IV medication. On 04/01/25 at 10:19 AM, Surveyor interviewed LPN D about R236 having EBP and asked what is to be done when administering medication with an IV. LPN D indicated he did not think it was needed to wear PPE to administer an IV. LPN D indicated he reviewed with Director of Nursing (DON) B what PPE is required. DON B informed LPN D that PPE was needed when administering IV therapy. On 04/02/25 at 10:12 AM, Surveyor interviewed DON B about EBP and what PPE is to be worn with IV therapy. DON B indicated LPN D did tell DON B of not wearing a gown when completing IV therapy. Example 3 R22 was admitted to the facility on [DATE] with diagnoses of surgical aftercare, pressure ulcer of right buttock stage 4, retention of urine, colostomy, quadriplegia, and multiple sclerosis. On 04/01/25 at 10:40 AM, Surveyor observed a sign outside of R22's door stating EBP. In R22's room was a bin containing PPE. Surveyor observed Certified Nursing Assistant (CNA) F not wearing PPE of gown or gloves while assisting to place R22's protective heel boots on and hand braces. CNA E entered room and assisted CNA F to position R22 by removing pillows and adjust bedding. CNA E was not wearing PPE. Surveyor observed CNA E empty R22's catheter bag. CNA E applied gloves and did not wear a gown and placed the graduate directly on floor. CNA E took the catheter bag out of dignity holder, alcohol wiped the port and emptied the urine into the graduate. CNA E used an alcohol wipe to clean the port and placed the port into the catheter bag holder. CNA E measured the urine of 525 ml and emptied into the toilet. CNA E wiped the graduate with a paper towel and placed back next to bed. CNA E gathered the garbage and brought to soiled utility room and washed hands. On 04/01/25 at 10:47 AM, Surveyor interviewed CNA E asking about the enhanced barrier precautions sign on R22's door. CNA E indicated she should have worn a gown when emptying the catheter. Surveyor asked when CNA E and CNA F were positioning R22 should PPE been worn. CNA E indicated PPE is to be worn whenever touching the resident. On 04/02/25 at 10:14 AM, Surveyor interviewed DON B about EBP and what PPE is to be worn when emptying catheter and positioning a resident. DON B indicated CNA E did tell DON B of not wearing a gown when completing catheter care. DON B indicated PPE should have been worn for those tasks. 51804 Example 4 R11 was admitted on [DATE]. R11's Minimal Data Set (MDS) assessment indicates R11 is severely cognitively impaired with hallucinations and requires total assistance with eating, showering, personal cares, mobility, and position changes. R11 has a catheter and pressure ulcer stage 3 requiring Enhanced Barrier Precautions for infection control. On 04/01/25 at 2:14 PM, Surveyor observed LPN D after wound care, remove his gloves and gown, and perform hand hygiene. LPN D did not put on new gloves or a gown. LPN D proceeded to place R11's brief on, moving catheter tubing for fit, and finish cares without gloves or gown. On 4/2/2025 at 4:28 PM, Surveyor interviewed DON B. DON B stated his expectation is for staff to follow EBP and infection control practices. Residents with a wound or catheter require the extra precautions of a gown when providing cares. On 4/2/25 at 6:15 PM, Surveyor interviewed LPN D regarding use of EBP. LPN D stated that EBP means wearing a gown and gloves when you work with a resident who is on them. LPN D stated he should have used alcohol gel and put on new gloves and gown before touching R11's catheter, adjusting his brief, and assisting with cares.

Example 4 R22 was admitted to the facility on [DATE] with diagnoses of surgical aftercare, non-st elevation myocardial infarction, pressure ulcer of right buttock stage 4, encephalopathy, narcolepsy, retention of urine, colostomy, diabetes mellitus type 2, major depression, epilepsy, quadriplegia, and multiple sclerosis. On 01/02/25, results from R22's urine culture returned, and antibiotics were ordered. The physician gave an order to send R22 to the hospital to be evaluated. R22 remained in the hospital until 02/04/25. Review of R22's medical record did not document a notice of transfer was given to R22 or R22's representative. On 04/02/25, Surveyor requested transfer notice given to R22 and notification sent to the ombudsman of R22's hospital transfer. On 04/02/25 at 11:07 AM, Surveyor interviewed Director of Nursing (DON) B about the notice of transfer given to R22 and notification sent to ombudsman. DON B indicated the transfer notice was not given to R22, and ombudsman notification of transfer was not sent. Example 5 R2 was admitted to the facility on [DATE] and current diagnoses include Lennox-Gastaut syndrome, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant, cognitive communication deficit, muscle weakness, dysphagia, aphasia, lack of expected physiological development, convulsions, and anxiety, On 03/27/25, R2 had convulsions with seizure like episode and was transferred to the hospital. R2 was admitted to the hospital and returned to the facility on [DATE]. On 04/02/25, Surveyor requested documentation of notification to ombudsman of R2's transfer to the hospital. On 04/02/25 at 11:07 AM, Surveyor interviewed DON B about notification sent to ombudsman of R2's transfer to the hospital. DON B indicated the ombudsman notification of transfer was not sent. On 04/02/25 at 12:01 PM, Surveyor interviewed Social Services (SS) C and Nursing Home Administrator (NHA) A about notification of resident transfers and discharges being sent to the ombudsman. SS C indicated she had minimal training and was not aware this had to be completed. NHA A indicated the notification to the ombudsman was not being completed and now this will be completed. Example 2 R1 was admitted to the facility on [DATE] with pertinent diagnoses of congestive heart failure, atrial fibrillation, and hypertension. Review of R1's Minimum Data Set (MDS) record noted discharge return anticipated on 01/22/25 and 02/17/25. Surveyor reviewed R1's record and noted the following: On 01/22/25, R1 was transferred to the hospital with urinary changes and was admitted to the hospital. R1 returned to the facility on [DATE]. On 02/17/25, R1 was transferred to the hospital with increased shortness of breath and admitted to the hospital. R1 returned to the facility on [DATE]. Surveyor reviewed R1's medical record and was unable to locate documentation to support R1 received a written notice of transfer or Ombudsman notification for 01/22/25 or 02/17/25. On 04/02/25 at 12:00 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding written notice of transfers and Ombudsman notification. NHA A stated not being aware that Ombudsman notification was not being completed. NHA A provided Surveyor email communication with the Ombudsman noting no notices have been provided since 03/2023. Surveyor asked NHA A if there was a procedure/policy in place for staff to follow when transferring a resident to provide a written notice explaining the reason for transfer. NHA A provided Surveyor with the facility's transfer policy and stated not being aware that policy existed and did not know of the requirement to provide a written notice of transfer. NHA A stated he was under the assumption the bed hold had the reason for transfer stated. NHA A stated this was an oversight and will be corrected as soon as possible. Example 3 R33 was admitted to the facility on [DATE] with pertinent diagnoses of diabetes mellitus type 2, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, and paroxysmal atrial fibrillation. Review of R33's MDS record noted a discharge return not anticipated on 01/03/25. Surveyor reviewed R33's record and noted the following: On 01/03/25, R33 was transferred to the hospital with shortness of breath and vomiting and was admitted to the hospital. R33 did not return to the facility. Surveyor reviewed R33's medical record and was unable to locate documentation to support R33 received a written notice of transfer or Ombudsman notification for transfer/discharge. On 04/02/25 at 12:00 PM, Surveyor interviewed Director of Nursing (DON) B about the notice of transfer given to R33 and notification sent to ombudsman. DON B indicated the transfer notice was not given to R33, and ombudsman notification of transfer was not sent. Based on interview and record review, the facility did ensure notification in writing to the resident or resident representative, and the Office of the State Long-Term Care Ombudsman of residents' transfer or discharge from facility per regulation requirements. The facility practice affected 5 out of 5 residents (R) reviewed for the Office of the State Long-Term Ombudsman notice (R11, R1, R33, R22, R2), and 4 of 5 residents reviewed for transfer notice (R11, R1, R33, R22). Findings include: Facility policy titled, Resident Transfers and Discharge Notification, with a revised date of 04/20/20, states in part: Notice of Transfer or Discharge and Ombudsman Notification: For facility-initiated transfer or discharge of a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand .The facility must send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. The medical record must contain evidence that the notice was sent to the Ombudsman. Example 1 R11 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with diabetic neuropathy, resistance to multiple antimicrobial drugs, a right side nephrectomy (removal of kidney), chronic kidney disease, frequent urinary tract infections and difficulty swallowing. Surveyor reviewed R11's record and noted the following: R11's record shows R11 discharged from facility to hospital with return anticipated on 2/21/2025. R11's nurses note indicated: 02/21/25 3:51 PM Resident has displayed an acute change of status today. He was unable to be awakened this AM to take his medications. Resident did not eat his breakfast this morning or his lunch this afternoon. He was not waking up to engage in conversation Bed hold signed with reason for transfer . 03/31/25 7:59 PM Resident return from hospital via ambulance around 1500 . Surveyor reviewed R11's medical record and notice of transfer section was not completed with combined bed hold document and notification was not sent to State Ombudsman of transfer. On 03/31/25 at 2:46 PM, Surveyor interviewed R11's Family Member (FM) G. FM G stated that she does not receive anything in writing when R11 is transferred to hospital. FM G stated I signed something but I did not know I should get a copy of the document (bed hold and transfer). On 4/2/25 at 10:13 AM, Surveyor interviewed Licensed Practical Nurse (LPN) H. LPN H stated if they have to transfer a resident, LPN H starts with getting vitals, asking about pain, and assesses the situation. LPN H stated LPN H would then communicate with physicians and report findings. LPN H gets the bed hold form completed with the resident or their family, they can sign or tell us verbally. LPN H stated that form goes with the resident, and it comes back with the resident. On 4/2/25, at 12:00 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Social Services (SS) C regarding Ombudsman notifications and transfer notices. NHA A stated that Ombudsman notification has not happened since March 2023. SS C stated SS C was not aware this was required. NHA A stated the nurse would complete transfer/bed hold form and should complete the reason for transfer section, and the business manager would follow-up to ensure the form was completed. On 04/02/25 at 1:07 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the process for transfers is for the nurse to assess, communicate with provider, complete the bed hold and transfer notice, make a copy for the business office and send out with paperwork. On 4/2/25 at 1:09 PM, DON B stated the ombudsmen notification of transfer was not sent for R11. DON B reviewed bedhold form with Surveyor and agreed the transfer notice was missing also.

Based on interviews and record reviews, the facility did not notify provider as indicated for blood sugars outside of desired parameters for 1 of 12 residents, (R) R7, reviewed. This is evidenced by: Facility policy titled, Notification of Change, with a reviewed date of 01/2025 states in part: The resident's physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death .Some physicians may require different notification parameters for conditions such as blood glucose or other conditions. Please follow the physician's order in these cases. R7 was admitted to the facility on [DATE] with a pertinent diagnosis of diabetes mellitus type 2. R7's admission Minimum Data Set (MDS) assessment dated [DATE] noted medication administration of insulin injections and receives hemodialysis. R7's orders: 02/25/25: Insulin lispro 100 unit/ml give per sliding scale three times daily. Per sliding scale, subcutaneous, Three Times A Day, If blood sugar is less than 70, call MD. If Blood Sugar is 70 to 149, give 0 Units. If blood sugar is 150 to 199, give 2 Units. If blood sugar is 200 to 249, give 4 Units. If blood sugar is 250 to 299, give 6 Units. If blood sugar is 300 to 349, give 8 Units. If blood sugar is 350 to 399, give 10 Units. If blood sugar is greater than 399, give 12 Units. If blood sugar is greater than 399, call MD. 02/25/25: Notify physician for blood glucose readings less than 70mg/dL or greater than 300 mg/dL. On 04/01/25, Surveyor reviewed R7's blood sugars and noted the following: 03/26/2025 7:49 PM Blood Sugar: 366 mg/dL -provider not notified 03/26/2025 11:43 AM Blood Sugar: 312 mg/dL -provider not notified 03/25/2025 8:24 PM Blood Sugar: 417 mg/dL -provider not notified 03/24/2025 7:00 AM Blood Sugar: 327 mg/dL -provider not notified 03/22/2025 4:34 PM Blood Sugar: 378 mg/dL -provider not notified 03/22/2025 11:53 AM Blood Sugar: 302 mg/dL -provider not notified 03/21/2025 8:04 PM Blood Sugar: 435 mg/dL -provider not notified 03/16/2025 9:57 PM Blood Sugar: 327 mg/dL -provider not notified 03/16/2025 8:11 PM Blood Sugar: 434 mg/dL -provider not notified 03/16/2025 4:20 PM Blood Sugar: 399 mg/dL -provider not notified 03/16/2025 11:27 AM Blood Sugar: 344 mg/dL -provider not notified 03/15/2025 10:38 PM Blood Sugar: 310 mg/dL -provider not notified 03/15/2025 10:10 AM Blood Sugar: 377 mg/dL -provider not notified 03/14/2025 9:43 AM Blood Sugar: 368 mg/dL -provider not notified 03/12/2025 8:38 PM Blood Sugar: 378 mg/dL -provider not notified 03/11/2025 9:20 AM Blood Sugar: 533 mg/dL -provider not notified 03/08/2025 8:09 PM Blood Sugar: 380 mg/dL -provider not notified 03/08/2025 5:07 PM Blood Sugar: 311 mg/dL -provider not notified 03/08/2025 12:11 PM Blood Sugar: 370 mg/dL -provider not notified 03/08/2025 8:00 AM Blood Sugar: 381 mg/dL -provider not notified 02/27/2025 1:24 PM Blood Sugar: 325 mg/dL -provider not notified 02/27/2025 1:24 PM Blood Sugar: 325 mg/dL -provider not notified 02/27/2025 8:27 AM Blood Sugar: 328 mg/dL -provider not notified 02/27/2025 8:24 AM Blood Sugar: 328 mg/dL -provider not notified On 04/02/25 at 10:06 AM, Surveyor interviewed Director of Nursing (DON) B regarding notification of provider. DON B stated that nursing staff are expected to notify provider per order parameters. Surveyor asked DON B if nursing staff was aware of a separate order from the sliding scale insulin parameters for notification of blood sugars above 300 mg/dL. DON B stated yes, that nursing had to acknowledge this order on the Medication Administration Record (MAR). DON B was unable to provide rationale for not notifying provider of these blood sugars and stated re-education would be provided to nursing staff regarding provider notification.

Based on observation, interview and record review, the facility failed to ensure that services for a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, for 1 of 1 resident (R) R14 reviewed for respiratory assessment related to medication administration. R14 was administered a nebulizer treatment without a lung assessment completed prior to and after treatment. Evidenced by: Facility's policy titled Med Pass read in part, M. Nebulizer treatment administration.6. Assess pulse, respiratory rate, breath sounds, pulse oximetry before beginning treatment .12. Monitor patient's pulse, respiratory rate, breath sounds and pulse oximetry post treatment and as ordered by physician . According to the National Library of Medicine (2021), the standard of nursing care expected with small volume nebulizer treatment includes: .respiratory assessment pre/post treatment, respiratory rate, heart rate, and oxygen saturation. After treatment, the patient should be encouraged to cough and perform oral care. The patient's respiratory system should be reevaluated after the administration of inhaled medications to document therapeutic effects, as well as to monitor for adverse effects. R14 was admitted to the facility on [DATE] with a pertinent diagnosis of chronic respiratory failure. R14's orders included: 01/30/25: Budesonide suspension for nebulization; 0.5 mg/2 ml; amt: 0.5 mg; inhalation Special Instructions: Administer 1 neb twice per day for shortness of breath twice per day. Please rinse mouth with water after use. Do not swallow. 03/29/25: Perforomist (formoterol fumarate) solution for nebulization; 20 mcg/ 2 ml; amt: 20 mcg/ 2 ml (1 inhalation); inhalation Special Instructions: Monitor for worsening cough, wheezing, shortness of breath, or other COPD symptoms - DX: COPD, Twice a day. On 04/01/25 at 7:18 AM, Surveyor observed Licensed Practical Nurse (LPN) D poured Budesonide nebulizer suspension into R14's nebulizer canister on bedside table and gave mouthpiece to R14. LPN D turned on machine to start treatment and left room. RN C did not complete a lung assessment prior to starting nebulizer treatment. Review of R14's medical record did not document assessments or lung assessments prior or post nebulizer treatments. On 04/02/25 at 10:12 AM, Surveyor interviewed Director of Nursing (DON) B regarding assessments prior and post nebulizer treatments. DON B stated they would follow the physician's orders. Surveyor asked if they follow current standards of practice for nebulizer treatments. DON B stated was not aware of the standards. Surveyor asked if the resident is not assessed how would you know if the medication is working. On 04/02/25 at 6:00 PM, Surveyor interviewed LPN D regarding nebulizer treatments. Surveyor asked LPN D what the standard of practice is associated with administering nebulizers. LPN D stated that an assessment and lung sounds should be completed prior to and after treatment. Surveyor asked why assessments and lung sounds were not completed prior to treatment. LPN D stated was nervous at the time and did not complete the assessments.

Example 2 R21 was admitted to the facility on [DATE] with current diagnoses of chronic osteomyelitis, peripheral vascular disease, Parkinson's disease, restless legs syndrome and congestive heart failure. Review of R21's physician orders document on 02/13/25 trazodone tablet; 50 mg; amt: 50 mg; oral. Special instructions: Administer 50 mg once daily at bedtime for insomnia. Review of care plans identified no sleep hygiene care plan was developed with non-pharmacological interventions to promote sleep. Review of R21's medical record did not identify a sleep assessment with sleep patterns was completed prior to the start of medication and during use of the medication to determine the need for the medication or effectiveness of the medication. Review of R21's nursing progress notes documented on 02/11/25 at 3:12 PM, Res. requesting Trazodone 50 mg be reinstated. Portal message left for TCP requesting order due to res. c/o difficulty sleeping. Surveyor's review of R21's medical record identified no documentation of R21 having sleep disturbance prior to the start of trazodone on 02/13/25. On 04/02/25 at 10:21 AM, Surveyor interviewed DON B about the monitoring behavior for psychotropic medication. DON B indicated R21 is on trazadone and is monitored for side effects of the medication. Surveyor asked if resident is monitored for hours of sleep. DON indicated R21 is monitored if resident has sedation. Surveyor shared concern with DON B of no care plan developed with non-pharmacological interventions to promote sleep or sleep assessments to determine R21's sleep patterns. Based on observations, interviews and record reviews, the facility did not ensure they were monitoring the effectiveness of psychotropic drugs for 2 of 4 residents (R) (R14, R21). The facility did not complete behavior monitoring as outlined in the comprehensive care plan to determine adequate indication for use of antidepressant medications (duloxetine and buproprion) for R14. R21 receives trazodone, an antidepressant medication, for sleep with no adequate indication for use and no sleep hygiene care plan with non-pharmacological interventions to promote sleep. This is evidenced by: The facility policy, titled Behavioral Health Services, dated 1/2025, states: 7. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. Examples of individualized, non pharmacological interventions d. Indivdualizing sleep and dining routines The facility policy, titled Pyschotropic Medication Use, dated 1/2025, states: Residents are not given psychotropic medication unless the medication is necessary to treat a specific condition, as diagnoses and document in the clinical record. 1. Psychotropics medication include, but are not limited to: antipsychotics, antidepressants, anti-anxiety and hypnotics. 10. The resident response to the medication will be documented in the resident's medical record. 11. Use of psychotropic medication in specific circumstances: a. Acute or emergency situations b. Enduring conditions (i.e. non-acute, chronic or prolonged): i. The resident's symptoms and goals will be documented. Example 1 R14 was admitted to facility on 1/20/25 and has diagnoses that include peripheral vascular disease, unspecified, chronic respiratory failure with hypoxia, pressure ulcer of sacral region, stage 1, other amnesia, restless legs syndrome; no sleep, mental health or psychosis diagnosis listed. R14's Minimal Data Set (MDS) assessment, dated 1/27/2025, indicates that R14 has moderate cognitive impairment, with clear speech. R14 is able to make self-understood and understands others. R14's admission history and physical note on 1-23-25 states: Primary insomnia is reported stable. Currently on: trazadone 150mg. Major depressive disorder is reported stable. Currently on: duloxetine (Cymbalta/anti depressant) and bupropion. R14's physician orders include: Duloxetine capsule, delayed release 60mg once a day for pain started 1-20-25. Trazadone 150mg every day at bedtime for insomnia started 1-20-25 Bupropion 300mg once a day for depression started 1-20-25 Review of R14's care plan dated 2/4/2025 includes: Resident has DX of depression and anxiety and receives bupropion, duloxetine and trazodone. Resident is at risk for adverse side effects of psychotropic. start date 2/4/25 - last reviewed 2/24/25. Approach: Behavior monitoring log in place. Staff to document on any observed behaviors. Start 1-23-2025 No sleep hygiene care plan was developed with non-pharmacological interventions to promote sleep. Review of R14's medical record did not identify a behavior monitoring log implemented as outlined in care plan. On 4/1/2025 at 9:17 AM, Director of Nursing (DON) B stated that he could not find behavior monitoring sheets or an AIMS assessment (tardive dyskinesia assessment). On 4/1/2/2025 at 2:25 PM, DON B stated his expectations for residents taking psychotropic medications for any reason to have behavior monitoring and documentation. There should be a log. DON B stated anti-psychotic and anti-seizure medications should have monitoring and assessment for side effects also. There should be an AIMS or Tardive Dyskinesia assessment quarterly. DON B stated that R14's last assessment was 12/19/24. DON B stated it is overdue. Surveyor asked if it was missed. DON B said yes, it wasn't done on time so it would have fallen off the schedule.

Based on interview and record review, the facility did not provide written notice of bed-hold policy to the resident or their representative for 1 of 5 residents (R) reviewed for hospitalization. (R22) This is evidenced by: Facility's policy titled Bed Hold with the reviewed date of 01/25, documented in part, 1. The facility Social Worker or designee will provide a copy of the bed hold policy to the resident and/or the resident representative at the time of admission and again prior to a transfer due to hospitalization or therapeutic leave. The signed copies will be maintained in the resident's financial or personal file .3. In the event of an emergency transfer to a hospital, the facility social worker or designee will attempt to contact the resident or resident representative within 24 hours of the transfer and determine whether to hold the resident's bed. Documentation of the bed hold decision will be completed in the resident's medical record. The facility will document multiple attempts if necessary to reach the resident and/or resident representative in cases where the facility was unable to notify . R22 was admitted to the facility on [DATE] with diagnoses of surgical aftercare, non-st elevation myocardial infarction, pressure ulcer of right buttock stage 4, encephalopathy, narcolepsy, retention of urine, colostomy, diabetes mellitus type 2, major depression, epilepsy, quadriplegia, and multiple sclerosis. On 01/02/25, results from R22's urine culture returned, and antibiotics were ordered. The physician gave an order to send R22 to the hospital to be evaluated. R22 remained in the hospital until 02/04/25. Review of R22's medical record did not document a bed hold notice was given to R22 or R22's representative. On 04/02/25, Surveyor requested the bed hold notice given to R22. On 04/02/25 at 11:07 AM, Surveyor interviewed Director of Nursing (DON) B about the bed hold notice given to R22. DON B indicated the bed hold notice was not given to R22. On 04/02/25 at 12:01 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about bed hold notice given to residents when transferred out of the facility. NHA A indicated the nurse is to provide the bed hold notice and business office would follow up if there was no notice provided. NHA A indicated the process will be reviewed.

Based on interview and record review, the facility did not implement an effective discharge plan with a focus on identifying resident's need and an effective transition to post discharge care for 1 of 1 resident (R) who were ordered for discharge from the facility, R26. Findings include: Facility policy titled, Discharge/Transition Discharge Planning Process, dated reviewed on 01/2025 states in part, .Standard: All residents will have a discharge plan that supports a smooth transition to home or to the next care setting. The foundation of the plan will be developed for most residents at the time of admission. Procedure: 1. Social Services will facilitate the formulation of the discharge/transitional plan with resident, family, and interdisciplinary team. 2. Social Services will interview the resident and family after admission to determine their discharge and wellness goals. Form 3.6.A 3. The Social worker will develop the resident's initial discharge planning care plan to include the goals and plans. The care plan will be updated during care plan meetings and after the resident choice conversations that relate to discharge planning. 4. The Social worker coordinator will present the resident and or family with the Planning for Transition Pamphlet during the residents first care plan meeting, or within 30 days of discharge. 5. The Resident and or family will be asked to complete the Planning for Transition checklist within a few days after given to them. This should be returned to the social worker who uses information in planning transition. 7. Resident assessments are begun on the first day of admission and completed no later than the 14th day after admission. A baseline Care Plan will be initiated and completed within 48 hours from time of admission. A comprehensive Care plan is developed within 7 days of completing the resident assessment. 10. Within 30 days of discharge but not less than two weeks prior to discharge, the social worker will begin the discharge/transition process. The process includes the transitional location, ensuring that the residents needs will be met, scheduling needed appointments post discharge, home care, hospice care, transportation needs, and equipment needs . R26 was a rehabilitation admission to the facility on [DATE]. R26 had the following diagnoses: End stage renal disease, presence of aortocoronary bypass graft status post CABG x3, dependence on renal dialysis, type 2 diabetes mellitus with hyperglycemia, osteomyelitis of vertebra, lumbar region, and spinal stenosis. Surveyor reviewed R26's comprehensive care plan and Surveyor did not find a discharge care plan in place. Surveyor reviewed R26's progress notes: .-On 02/04/2025 at 1:29 PM, Care conference held today, son and spouse present with resident. Resident is here for short term PT (Physical Therapy) and OT (Occupational Therapy). Progressing well with therapy, will return home with in home therapy and services needed. Will determine what DME is needed. Plan is to return home in 2-3 weeks. -On 03/13/2025 at 10:41 AM, Writer tried to contact son again this morning to arrange a care conference for [R26]. Left another voicemail. Will continue to try to reach out. -On 03/20/2025 at 1:23 PM, Writer and Director of Nursing (DON) met with resident and his family today to discuss discharge planning during the care conference. Family had many questions regarding transportation to dialysis once discharged , DME, home health and his fistula surgery. Resident will return to facility after the fistula surgery for a day or two, and planned discharge date is 3/29/25. All agreed with the plan. I will reach out to [company name] for home health services for this patient and call ADRC to ask about transport options to dialysis. -On 03/26/2025 at 3:48 PM, Transportation options for R26 once discharged . ADRC - check in with her monthly. [PHONE NUMBER]. You are on a list in case a volunteer driver comes up in [NAME]. Their typical hours are 8-4:30 Monday through Friday. -On 03/27/2025 at 11:38 AM, Writer spoke with [company name] today. They have accepted him as a patient and will do an in-home visit on Tuesday, April 1. [company name] will call patient to set that up. -On 03/28/2025 at 3:46 PM, Writer received a call from the ADRC today. She is requesting that [R26] stay in facility due to transportation barriers to dialysis at 6 a.m. three days a week. She also mentioned that she was going to see [R26] at facility @1:30 on Monday, March 31, to help him fill out a Medicaid application. DON was going to have discussion with resident to update his care plan. -On 04/01/2025 at 11:06 AM, Writer spoke with ADRC in follow-up of [R26's] appointment. ADRC stated that [R26] decided to fill out a Medicaid Application and had a functional screening done. Goal is to enroll in Family Care program. [R26] does not have transportation to dialysis three times a week, so the ADRC asked if he could stay here until the Medicaid was approved. ADRC will keep us updated . Surveyor reviewed R26's PT notes: .-On 03/21/25, [R26] plan to discharge home next Friday. -On 03/25/25, [R26] does plan to return home end of this week. Notes: [R26] continues to have impaired judgement, he is determined to return to driving and community access. [R26] returned from home one day and did he fall at home. Prognosis: Discharge Home. Good with strong family support. Plan to discharge home this weekend . Surveyor reviewed R26's physician visit note: .-On 03/14/25, Physician visit was conducted for plans to be discharged from skilled facility on 03/29/25 . Surveyor reviewed R26's physician orders note: .-On 03/24/25, Orders sent to provider to sign for discharge orders. Anticipated discharge is on 03/29/25 . Observations and Interviews: On 03/31/25 at 12:43 PM, Surveyor interviewed R26 who had only one concern. R26 indicated that R26 was supposed to be discharged Saturday 03/29/25 but is still at the facility because R26 could not find services to help R26 get to and from dialysis for appointments once R26 was home. R26 stated, I am very upset as these services should have been figured out for me before it was time to discharge, and I want to go home. R26 indicated that Social Services just handed R26 a piece of paper with transportation phone numbers 3 days ago and was told to start calling the transportation services. On 04/02/25 at 12:49 PM, Surveyor interviewed Social Services (SS) C and asked SS C when does discharge planning begin for a resident who resides in the facility. SS C indicated care planning starts on admission for every resident. Surveyor asked SS C if SS C was familiar with the Discharge/Transition Discharge Planning Process policy the facility had in place. SS C indicated that SS C did not know the facility had a policy in place and has not seen the policy. Surveyor asked SS C if R26's discharge care planning started on admission for R26. SS C indicated that usually SS C will begin discharge planning at least two weeks before discharge date . SS C indicated that usually SS C will get home health in place or any other needed services. Surveyor indicated to SS C that R26 was to be discharged on 03/29/25 but is still residing in the facility. SS C indicated the plan was in place for R26 to discharge on [DATE] but R26 could not go home due to R26 not being able to drive self or find transportation to dialysis 3 times a week. SS C indicated that SS C did not know that residents are supposed to have a discharge care plan in place. SS C indicated that SS C called around to see if there was a volunteer that could transport R26 around and SS C indicated there was not a volunteer. SS C indicated that SS C gathered a list of options and wrote it down on paper for R26 to call around. SS C indicated that SS C gave this list to R26 a couple days before anticipated discharge of 03/29/25. SS C also called Aging, Disability, and Resource Center (ADRC) to have ARDC help with Medicaid application. Surveyor asked SS C if SS C ever initiated the discharge Form 3.6.A as per policy and gave the Planning for Transition pamphlet to R26 and R26's family. SS C indicated that SS C was unfamiliar with the Planning for Transition pamphlet and Form 3.6.A, and SS C did not initiate or deliver to R26 or R26's family.

Based on observation, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for 2 of 12 residents (R) (R1, R24) reviewed. Staff did not remove sutures per provider orders for R24 or implement hospital discharge orders upon readmission for R24. Facility did not enter and administer physician orders for R1. Example 1 Findings include: Facility policy titled, Skin Care, dated reviewed on 06/2019 states in part, .1. Nurses will complete a skin body assessment upon admission/readmission, then weekly, and as needed. 2. Certified Nursing Assistant will inspect resident skin during bathing activities and report any irregularities or concerns to the licensed nurse evaluation. 3. Interventions will be implemented, and care planned to reduce risk of skin impairment. 4. Non-pressure related skin impairment will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include size, location, type of wound, odor, drainage, peri-wound condition, wound edges, exudate, pain, symptoms of infection, and current treatment order . R24 was admitted on [DATE] with the following diagnoses: Unspecified severe protein-calorie malnutrition, unspecified dementia, displaced intertrochanteric fracture of right femur and fracture of right humerus, deep tissue injury to the right heel, and myasthenia gravis without exacerbation. R24's Minimum Data Set (MDS) assessment, dated 12/12/24, identified R24 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS also indicated that R24 was determined to be at risk for PIs. Surveyor reviewed R24's Pressure Injury (PI) Care Plan initiated on 12/13/24: - Conduct a systematic skin inspection biweekly and as needed. -Report any signs of further skin integrity issues. -Certified Nurse Assistant (CNA) to observe skin integrity during cares. Surveyor did not find a specific care plan or interventions addressing R24's surgical incision on the right hip. Surveyor reviewed Hospital discharge physician orders: .-Surgical site on right hip, remove sutures 2-3 weeks after surgery. Remove by 12/05/24, skilled facility may remove . Surveyor reviewed R24's Electronic Health Record (EHR) of the facility's physician orders and did not find any information regarding removal of R24's sutures placed in the Electronic Health Record (EHR). Surveyor reviewed R24's progress notes: -On 12/27/2024 at 9:30 PM, [Recorded as Late Entry on 12/28/2024 at 12:19 AM], Alert charting: Resident admitted for right femur and right humerus fracture. -On 12/31/2024 at 1:05 PM, Chart Review: R24 has been a resident of the facility since 12/9/24. She is a DNR code status and a member of hospice. She did admit with trochanter fracture, humerus fracture, fall history, Myasthenia gravis, PI to right heel, and malnutrition. On 04/01/25 at 10:15 AM, Surveyor observed Certified Nurse Assistant (CNA) L go into R24's room. Surveyor observed CNA L reposition R24 from left side to back. Surveyor observed 5 sutures located on R24's right hip area. Surveyor asked CNA L what the stitches were for. CNA L indicated that R24 has had stitches in since admission from surgery to the right hip after suffering a fall at home. On 04/01/25 at 10:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D and asked LPN D what is LPN D's process for performing a head-to-toe assessment on residents. LPN D indicated that LPN D's head to toe assessment consists of checking residents' skin after bath day that's usually once a week and assessing for any abnormal skin issues, breaks in skin, or pressure injuries. Surveyor asked LPN D if there are positive results on skin assessment then what does LPN D do with that information. LPN D indicated that LPN D would report the skin assessment to Director of Nursing (DON) B and all skin assessments are documented in the EHR. Surveyor asked LPN D if LPN D assessed R24 to have sutures in from R24's femur fracture surgery back in November. LPN D indicated to Surveyor that LPN D has not seen that R24 has sutures in place still. Surveyor requested LPN D check R24's skin with Surveyor present. LPN D rolled R24 over and removed brief. LPN D stated, Oh my, [R24] does have sutures still in place. Looks like there are about 5 sutures there. LPN D indicated to Surveyor the sutures should not still be there and they need to be removed. On 04/01/25 at 11:01 AM, Surveyor interviewed DON B and asked if DON B could explain why R24 still has sutures in R24's right hip from right femur hip surgery on November 26, 2024. DON B stated, I took sutures out myself when [R24] was admitted on [DATE], so [R24] should not have sutures in still. Surveyor asked DON B to follow Surveyor into R24's room so that DON B could assess the surgical site and see what DON B thinks. DON B viewed R24's right hip area and noted there to be several sutures left in R24's right hip. DON B indicated to Surveyor that R24's sutures should not still be in, and that DON B would get them removed as soon as possible. Surveyor asked DON B what is DON B's expectation for nursing staff to follow discharge orders from hospital and asked how that was missed. DON B indicated that DON B was unsure how the hospital discharge orders were missed. Surveyor asked DON B who oversees entering discharge orders into the EHR. DON B indicated that it is the charge nurse's job who is working that shift, or it is DON B's job to enter all orders into the EHR. Surveyor asked DON B how often skin assessments were completed for R24. DON B indicated that staff performs skin assessments weekly with R24. Surveyor asked if anyone has reported that R24 still had sutures in place from surgery in November. DON B indicated that sutures were not reported by any staff members. Surveyor asked what weekly skin assessments consist of for R24. DON B indicated that all staff are to be assessing R24's skin weekly and it starts with head-to-toe thorough skin assessments. It is documented in EHR with any abnormalities and then reported to DON B right away. DON B indicated that DON B did not know that R24 still had sutures in place. On 04/01/25 at 11:50 AM, DON B approached Surveyor and stated, I apologize. I did not realize there were two surgical incision sites, and back when I took the ones out on R24's right hip it was the lower set of sutures, and I guess I missed the upper set of sutures. DON B indicated that medical director was contacted and there are orders to remove the sutures right away today. On 04/01/25 at 1:23 PM, Surveyor observed DON B and Medical Doctor (MD) N assess R24's coccyx area. While MD N was trying to remove sutures from R24's right hip incision, Surveyor observed R24 reaching back trying to stop MD N and DON B from removing sutures. R24 stated, Ouch that hurts, Please stop, Please that alone, and Oww, that hurts bad, during the whole process of removal of 5 sutures. Surveyor observed R24 crying and begging for MD N and DON B to stop removing sutures. Surveyor observed MD N try to remove the very last suture out but could not as it was embedded deep. Surveyor observed DON B then try to remove the last suture. Surveyor observed DON B digging at the suture with the tweezers to try to grab it. Surveyor observed DON B finally get a hold of the suture and cut it. Surveyor observed R24 moaning in pain and trying to push DON B behind her to stop removing sutures. MD N confirmed that 5 sutures were removed, and MD N measured the suture openings. MD N indicated measurements were 0.6x0.6x0.3cm. Surveyor asked MD N if the sutures being embedded was normal. MD N indicated that sutures should not have stayed in for 5 months and should have been removed within the 2-3 weeks after surgery. Surveyor asked MD N what kind of post treatment will be applied to the surgical incision site after sutures were removed. MD N indicated that MD N will have DON B apply hydrogel. 49353 Example 2 According to the National Institutes of Health (NIH) Congestive Heart Failure (CHF): Nursing Diagnosis, 2023, indicates nurse assessment of CHF is to assess current symptoms such as dyspnea, fatigue, orthopnea, peripheral edema, vital signs, cardiovascular examination such as (abnormal heart sounds, jugular venous distention), respiratory examination such as (auscultate lung sounds for crackles or wheezing and assess respiratory effort), daily weights, edema assessments, dietary habits, weight changes, medication adherence and any side effects related to diuretics or blood pressure medications, and assess emotional well-being related to potential anxiety or depression related to the chronic nature of CHF. R1 was admitted to the facility on [DATE] with pertinent diagnoses of congestive heart failure, atrial fibrillation, and hypertension. R1's care plan dated 03/22/25, with a target date of 06/30/25, states: Problem: R1 is at nutritional/hydration risk related to .CHF, pulmonary hypertension, atrial fibrillation, recent CVA. Goals: R1 will have adequate nutrition/hydration with no signs/symptoms of fluid imbalance and no signs/symptoms of weight loss by next review. Interventions: weekly weight . R1's orders: 2/29/24 Monitor BID for fluid concerns. Chart level of edema and site of edema related to diuretic use. Special Instructions: Monitor BID for fluid concerns. Chart level of edema and site of edema related to diuretic use. Twice A Day 02/20/2025 Vital Signs every shift for 3 days (72 hours) following admission. Every Shift (d/c date) 02/23/2025 03/22/25 Weight weekly. Review of R1's hospital discharge orders on 02/20/24 noted: Additional After Hospital Orders .Vital Signs - Heart Failure Daily and more frequently as condition warrants -assess lung sounds daily . Weight Daily in AM Call physician if weight increases by 2 pounds in 24 hours or 5 pounds in 7 days from admission weight. Recommended discharge weight 151 lb. Review of R1's weights noted the following: 02/27/2025 148.2 lb 03/06/2025 147 lb 03/13/2025 142.2 lb 03/17/2025 148.8 lb 03/20/2025 151 lb 03/27/2025 149.2 lb Of note: no additional weights were noted during R1's record review. On 04/01/25, Surveyor reviewed R1's progress notes and no daily lung assessments were noted. On 04/02/25 at 9:04 AM, Surveyor interviewed Director of Nursing (DON) B regarding physician orders. Surveyor asked DON B if there was a procedure/policy for entering hospital discharge orders when a resident is admitted . DON B stated not having a written policy/procedure in place. Surveyor asked DON B who is responsible for reviewing and entering any admission orders for a resident. DON B stated he was. Surveyor asked DON B if he was aware that R1 had hospital discharge orders for 02/20/25 to have daily lung assessments and daily weights. DON B stated he was not and that he must have missed it.

Based on observations, interviews and record reviews, the facility did not ensure 2 of 3 residents (R24 and R11) reviewed for high risk of Pressure Injury (PI) development received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. - R24 is high risk for the development of PIs and has a stage 3 PI to the right heel. R24 was observed for 2 hours and 58 minutes in which she was lying in bed without staff offering or attempting to reposition and heels were not elevated as ordered. -Staff did not perform proper hand hygiene when applying topical prescriptions to R24's wound bed during wound dressing change. -Staff did not sanitize bedside tables for R24 and R11 during wound dressing change. This is evidenced by: Example 1 According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (2018), for immobile or bed bound individuals, a full change in position should be conducted a minimum of every two hours. Some individuals require more frequent repositioning due to their high-risk status. Facility policy titled, Pressure Injury Prevention and Care, dated reviewed on 06/2019 states in part, .5. C. Promote nutrition and hydration. F. Repositioning of residents; provision of required assistance as allowed and tolerated. I. Encourage and promote the elevation of resident heels when in bed and precent residents' feet from encountering foot board . R24 was admitted on [DATE] with the following diagnoses: Unspecified severe protein-calorie malnutrition, unspecified dementia, displaced intertrochanteric fracture of right femur and fracture of right humerus, deep tissue injury to the right heel, and myasthenia gravis without exacerbation. R24's Minimum Data Set (MDS) assessment, dated 12/12/24, identified R24 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, and for transfers. MDS also indicated that R24 was determined to be at risk for PIs. R24 has a Brief Interview of Mental Status (BIMS) score of 04/15 indicating severe impaired cognition. Surveyor reviewed R24's Pressure Injury (PI) Care Plan initiated on 12/13/24, last revised on 03/15/25: Resident admitted with a DTI to right heel with potential for infection and discomfort. - Turn and reposition every 2 hours and as needed including elevation of heels on pillows when in bed. -Encourage oral intake to promote good nutrition for skin integrity. - Keep resident off affected areas as much as possible. -Pressure reduction mattress. Specialty air mattress. -Supplement(s) as ordered. -Use pressure reduction devices for elevation of lower extremities/heels as needed. Surveyor reviewed R24's nutrition care plan initiated on 12/10/24, last revised on 04/02/25: Resident will receive food/fluids as tolerated for comfort. -Assist with meals as needed, needs cuing and assistance with meals in the dining room. -Supplements: Twice a day magic cups at afternoon and night snack, along with three times a day house nutrition shakes for increased intakes as tolerated for comfort. Surveyor reviewed the Braden Scale for Predicting Pressure Sore Risk Assessments completed for R24 and noted the most recent was dated 03/13/25, which scored 14. According to this assessment 13-14 indicate a moderate risk for the development of a PI. Surveyor reviewed R24's [NAME] notes from the wound clinic: -On 01/14/25, Plan of care recommendations to off-load wound, reposition per facility protocol, turn side to side in bed every 1-2 hours if able, pillow and pressure off-loading boot to right heel. -On 03/04/25, Plan of care recommendations pillow and pressure off-loading relieving boot. Surveyor reviewed R24's physician orders: -Three times a day house nutrition shakes at all meals. 7:00 AM-10:00 AM, 11:00 AM-1:30 PM, 4:00 PM-7:00 PM. - Twice a day magic cups at afternoon and night snack. Surveyor reviewed R24's weight measurements: -On 12/09/24, admission weight 111.4 pounds. -On 03/14/25, weight 88 pounds. Surveyor reviewed Dietician notes: -On 12/09/24, admission assessment: Provide staff assistance and encouragement with all meals. R24 was receiving twice a day Ensure, along with a fortified diet order d/t poor appetite per medical records (energy intake <75% of needs for >7 days). MLV on board for supplementation. Dentition noted to be poor. Monitor chewing/swallowing ability at this facility. Recommend a fortified diet, along with BID house nutrition shakes for increased nutrients. Provide staff assistance/encouragement with all meals and cutting up meats for increased intake. -On 02/06/25, Nutrition Update: R24 continues hospice care. Weight has declined 15 lbs over the past 2 months (96 lbs 1/26 vs 111.4 lbs 12/9). Weight loss is normal and anticipated with hospice care. Continue current diet textures in place. Provide nutrition supplements prn as desired by resident for comfort, and as tolerated for skin integrity. -On 03/21/25, Nutrition Update: R24 continues hospice care. Weight has declined 8 lbs over the past months (88.0 lbs 3/14 vs 96.0 lbs 2/9). Weight loss is normal and anticipated with hospice care. Continue current diet textures in place. Provide nutrition supplements prn as desired by resident for comfort, and as tolerated for skin integrity. Surveyor reviewed intake measurements from 12/09/24-04/01/25 and found inconsistency in documenting if R24 had meals or offered meals to promote healing of R24's PI of the right heel or to decrease further skin breakdown. Supplements were not documented as given or offered consistently three times a day and meals were not documented consistently of the percentage of food eaten or offered to R24. Observations consecutive time from 7:17 AM-10:15 AM. On 04/01/25 at 7:17 AM, Surveyor observed R24 lying in bed slightly on left side, pillow behind back, podus boots on but R24's feet lying directly on R24's air mattress. On 04/01/25 at 8:08 AM, Surveyor observed Certified Nurse Assistant (CNA) L walk down hallway with breakfast cart delivering breakfast room trays. Surveyor observed CNA L walk by R24's room and did not go into R24's room. Surveyor did not observe CNA L offer R24 breakfast/supplement shake. On 04/01/25 at 8:37 AM, Surveyor observed R24 lying in bed slightly on left side, pillow behind back, podus boots on but R24's feet lying directly on R24's air mattress. Surveyor did not observe any staff go into R24's room to reposition or offer breakfast/supplement shake. On 04/01/25 at 9:17 AM, Surveyor observed R24 lying in bed slightly on left side, pillow behind back, podus boots on but R24's feet lying directly on R24's air mattress. Surveyor did not observe any staff go into R24's room to reposition or offer breakfast/supplement shake. On 04/01/25 at 9:38 AM, Surveyor observed R24 lying in bed slightly on left side, pillow behind back, podus boots on but R24's feet lying directly on R24's air mattress. Surveyor did not observe any staff go into R24's room to reposition or offer breakfast/supplement shake. On 04/01/25 at 10:15 AM, Surveyor observed CNA L go into R24's room. Surveyor observed CNA L reposition R24 from left side to back. CNA L floated heels with a pillow and R24 has podus boots on. Surveyor observed CNA L exit R24's room. On 04/01/25 at 10:19 AM, Surveyor interviewed CNA L and asked how often is R24 supposed to be repositioned. CNA L indicated that since R24 is immobile staff should reposition R24 every 1-2 hours. Surveyor asked CNA L if R24's heels are supposed to be floated with pillow underneath podus boots. CNA L indicated that R24 should always have pillow under heels. Surveyor asked CNA L if R24 had eaten breakfast. CNA L indicated that R24 had not eaten breakfast. Surveyor asked CNA L if R24 was offered breakfast or R24's supplemental shake. CNA L indicated that CNA L delivered room trays for breakfast and did not go into R24's room to offer breakfast and probably should have. On 04/01/25 at 10:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D and asked LPN D what is LPN D's expectation for repositioning residents who are dependent on cares and are at risk for skin breakdown. LPN D indicated that all residents should be repositioned every two hours. Surveyor asked LPN D if LPN D has been in R24's room between 7:00AM-10:45 AM. LPN D indicated that LPN D always completes cares and medication administration for R24 when LPN D comes on shift at 6:00 AM. Surveyor asked if R24 received supplemental shake at breakfast or was offered. LPN D indicated that LPN D went in around 6:15 AM or so but has not been in R24's room since. LPN D indicated that R24 only had a sip of water with pills. LPN D indicated CNAs should have offered breakfast to R24. On 04/01/25 at 11:19 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for repositioning R24. DON B indicated that R24 should be repositioned and off loaded on pressure areas about every 2 hours. Surveyor asked what is DON B's expectation for offering or assisting dependent residents' meals such as R24 for breakfast. DON B indicated that sometimes R24 does not want to get up, but that CNA L should have at least offered breakfast to R24 and assist in room if need be. On 04/01/25 at 1:23 PM, Surveyor observed MD N and Director of Nursing (DON) B perform wound dressing change on R24. Surveyor observed DON B prepping R24's wound dressing supplies on top of treatment cart outside of R24's room. Surveyor observed DON B don gloves and then took gauze from package and set the supplies directly on the treatment cart. DON B then took the spray bottle, Santyl cream, and wound dressing to enter R24's room. DON B walked over to R24's bedside table and laid wound care supplies onto bedside table surface without wiping or disinfecting bedside table. DON B then laid a chuck pad down on bedside table and moved wound care supplies on top of the chuck pad. DON B applied Personal Protective Equipment (PPE), laid a clean chuck pad under R24's right heel and began removing R24's old dressing to the right heel. When MD N completed cleaning R24's right heel wound, DON B placed R24's uncovered wound on the contaminated chuck lying on the bed under R24's right heel. MD N instructed DON B to apply Santayl cream and calcium alginate dressing to R24's wound bed. DON B then changed contaminated gloves, sanitized in between, and applied new gloves. DON B then grabbed contaminated Santayl cream with left gloved hand, took top off with right gloved hand contaminating gloves. DON B then took index right finger and squeezed Santayl cream unto finger. DON B then took DON B's contaminated finger and wiped DON B's contaminated finger into R24's wound bed applying the Santayl cream. DON B then applied calcium alginate dressing and placed R24's podus boots back on. On 04/01/25 at 1:33 PM, Surveyor observed MD N assessing R24's left heel. MD N indicated to DON B to make sure staff continue to utilize podus boots and to continue to always elevate heels on pillows when R24 is lying in bed. On 4/2/2025 at 9:15 AM, Surveyor interviewed DON B and asked about wiping the treatment cart surface down on top before placing R24's wound supplies on the bare surface of the treatment cart. DON B indicated that the treatment cart should be wiped down in between each resident for wound cares. Surveyor asked what is DON B's expectation for sanitizing the bedside table in R24's room before placing wound care supplies onto surface. DON B indicated that DON B should have wiped down surface of bedside table before placing R24's wound care supplies on top of the table. Surveyor asked DON B to walk Surveyor through the correct process for applying Santyl cream to the wound bed. DON B indicated that if Surveyor is referencing DON B applying Santyl cream with DON B's finger, then DON B should not have done that and should have applied the Santyl cream to a clean Q-tip and then applied to the wound bed. 51804 Example 2 R11 was admitted on [DATE]. R11's Minimal Data Set (MDS) assessment indicates R11 is severely cognitively impaired with hallucinations and requires total assistance with eating, showering, personal cares, mobility, and position changes. R11 has a stage 3 pressure ulcer on his sacral region. Surveyor requested policy regarding wound dressing procedure and protocol, procedure and protocol not received. On 04/01/25 at 2:06 PM, Surveyor observed Licensed Practical Nurse (LPN) D enter R11's room to perform wound dressing change. LPN D had gloves on and was carrying dressing and medication tube. Surveyor observed LPN D take scissors out of his pocket, and with the wound supplies, laid it all down on R11's bedside table. LPN D never wiped off the scissors. Surveyor did not observe LPN D sanitize or wipe down bedside table or place a barrier, such as a chux, before laying wound supplies down. Surveyor observed LPN D grab contaminated scissors and cut xeroform dressing for R11's wound bed. LPN D prepared dressing for application by placing the open border gauze on dirty table, wound side was facing up. On top of that he placed the piece of xeroform LPN D had just cut, and on top of that LPN D applied Santyl. LPN D left the prepared dressing on the contaminated bedside table. LPN D then took off gloves, completed hand hygiene, and put on a gown and new gloves. LPN D then proceed to assist physician with resident positioning during his wound assessment. At end of physician assessment, LPN D proceeded to apply the prepared dressing waiting on the contaminated surface in one fluid move onto the wound bed of R11's sacral region. On 4/2/2025 at 4:28 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated his expectation is for staff to follow infection control practices. DON B stated that wound care is not a sterile procedure, but wound supplies should be kept clean and not placed on a dirty surface. DON B agreed equipment, such as scissors used in wound care, should be cleansed before using and between patients. 0n 4/2/25 at 6:15 PM, Surveyor interviewed LPN D regarding process for PI wound care and infection control. LPD D stated LPN D usually wipes down the bedside or places a barrier down before placing wound care supplies on table. LPN D was surprised to hear he had placed supplies on a dirty surface. LPN D stated I should have wiped down the surface or put a chux down or something.

Based on observations, interviews and record reviews, the facility failed to provide pharmaceutical services related to the accurate administration of steroid inhaler to meet the needs for 1 of 1 resident (R) reviewed, R14. This is evidenced by: Facility's policy titled Med Pass read in part, M. Nebulizer treatment administration.14. If inhaled medication included steroids, have patient rinse mouth and gargle with warm water after treatment . R14 was admitted to the facility on [DATE] with a pertinent diagnosis of chronic respiratory failure. R14's orders included: 01/30/25: Budesonide suspension for nebulization; 0.5 mg/2 ml; amt: 0.5 mg; inhalation Special Instructions: Administer 1 neb twice per day for shortness of breath twice per day. Please rinse mouth with water after use. Do not swallow. On 04/01/25 at 7:25 AM, Surveyor observed Licensed Practical Nurse (LPN) D poured Budesonide nebulizer suspension into R14's nebulizer canister on bedside table and gave mouthpiece to R14. LPN D turned on machine to start treatment and left room. On 04/01/25 at 7:35 AM, Surveyor observed LPN D enter R14's room when nebulizer treatment was completed. LPN D gave R14 oral medication omeprazole with a cola drink. LPN D set-up the next nebulizer treatment and gave to R14. LPN D did not have R14 rinse mouth and spit out the mouth rinse after the nebulizer treatment of budesonide. On 04/02/25 at 10:12 AM, Surveyor interviewed Director of Nursing (DON) B regarding post steroid nebulizer treatment of rinsing mouth. DON B stated they would follow the physician's orders. Surveyor reviewed with DON B R14's physician order to rinse mouth with water and do not swallow. Surveyor reviewed the observation of LPN D administering oral medication right after the steroid nebulizer treatment. On 04/02/25 at 6:00 PM, Surveyor interviewed LPN D regarding rinsing mouth after nebulizer treatment. LPN D stated would follow physician's order. Surveyor reviewed the physician's order stating to please rinse mouth with water after use and do not swallow. LPN D stated R14 drank cola with medication after treatment. Surveyor reviewed the order again to rinse with water and do not swallow. LPN D stated this was not done.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 39 residents (R). The facility had a sick employee with respiratory symptoms on duty delivering direct resident care. Improper hand hygiene was observed during wound care and personal care for R1 and R5. Facility laundry services had dirty linens on the floor and personal items were stored in a clean linen area. Staff carried soiled linens in the hallway without containing them in a plastic bag. Findings include: Surveyor requested and reviewed the facility policy titled Employee Illness Surveillance Practices dated last review January 2024. The policy reads in part: .#3. In the event an employee calls in due to illness it will be recorded on the employee call-in form. Illness symptoms will be recorded on the form and reported to the infection control preventionist, Director of Nursing, or designee. #4. In addition to the employee call-in, the employee's illness will also be tracked on the employee illness tracking log. The purpose of this is to provide real-time tracking of illness to better control the spread. #5. Employee illness will be reported to the ICP and/or DON/designee to determine necessary actions to contain and control the spread of illnesses. #7. An employee will be deemed appropriate to return to work following illness by the ICP of the facility before returning to work. The timeframe will depend on the specific illness experienced. Some illnesses will require a physician's approval to return to work . Example 1: On 02/14/24 at 8:21 AM, Surveyor observed Certified Nursing Assistant (CNA) I walk down hall D delivering room trays. Surveyor observed a resident in the hallway ask CNA I if CNA I was sick because CNA I was wearing a mask. Surveyor observed CNA I wearing a mask and CNA I told the resident that CNA I was not feeling the best and had a cough. On 02/14/24 at 11:27 AM, Surveyor overheard CNA I talking with a resident in the room and stated that CNA I was sick and trying to fight whatever CNA I had off. Surveyor observed CNA I wearing a mask when she exited the resident's room. On 02/14/24, Surveyor observed CNA I working 2 halls of the facility as well as assisting many residents in the dining room On 02/14/24 at 11:38 AM, Surveyor interviewed CNA I and asked CNA I why CNA I was wearing a mask. CNA I indicated that she became super sick on Sunday with a cold. CNA I indicated that luckily CNA I had Monday off, so CNA I called the facility to let Human Resources (HR) L know, and HR L told CNA I to feel better. CNA I indicated CNA I was not instructed to test or stay out of work for any period. CNA I came to work and worked with a mask on. CNA I indicated CNA I wanted to wear a mask so CNA I wouldn't get other residents sick. CNA I stated that usually if sick CNA I just calls in and lets facility know. CNA I acknowledged being sick. CNA I stated if staff had a fever staff are to stay home. CNA I denied having a fever. On 02/14/24 at 11:45 AM, Surveyor interviewed Regional Nurse Support O and asked about the expectations and process for sick staff members. Regional Nurse Support O indicated the facility expects that all staff who become sick to call in and report symptoms to Director of Nursing (DON) B. The facility would test staff members for COVID-19 and staff will stay home until fever-free and with no respiratory symptoms. On 02/14/24 at 11:56 AM, Surveyor interviewed DON B and asked about the expectations and process for sick staff members. DON B indicated that the staff needs to call HR L with symptoms. DON B is notified by HR L and then DON B finds coverage. Staff member who is sick is instructed to stay home until fever-free and with no respiratory symptoms. DON B would test for COVID-19 if symptomatic for COVID-19 symptoms and instructed to stay home. Surveyor asked DON B if DON B was aware of CNA I being sick and wearing a mask around the facility providing direct resident care. DON I indicated that he noticed CNA I was wearing a mask and was going to ask CNA I why CNA I called on Monday. DON B indicated that DON B was not notified by HR L that CNA I was sick. DON B clarified that usually HR L stays in good communication but did not let DON B know about CNA I's call in from Monday. Example 2: On 02/13/24 at 9:49 AM, Surveyor observed Registered Nurse (RN) D enter R5's room. RN D washed hands and applied gloves. RN D took the old dressing off that was labeled 02/11/24. RN D sprayed the wound with prophase wound cleaner and patted it dry with gauze. RN opened the new 2x3.5-inch dressing and wrote initials and date on it. RN D applied medi honey to the dressing in the middle. RN D laid the dressing down on the bed and then used a skin prep wipe to rub around the edges of the wound that extended past the original dressing area of the wound. RN D proceeded after the skin prep in placing the Medi honey dressing to R5's shoulder blade. RN D took gloves off and exited R5's room. Surveyor did not observe glove changes between taking old dressing off R5 and placing the new dressing on. Example 3: On 02/13/24 at 10:46 AM, Surveyor observed CNA C and CNA E go into R1's room to help assist resident to the bathroom. CNA C and CNA E applied gloves and began getting R1 out of bed. After getting R1 to the edge of the bed, CNA E realized there was not enough room to get R1 transferred to sit to stand so CNA E asked R1's roommate if she could move her out of the room. CNA E did not remove her gloves, grabbed her roommate's wheelchair, moved her out into the hallway, and stated CNA E would come back to get her. Surveyor observed CNA E wearing the same gloves to push R1's roommate out the door into the hallway and then come back into the room and start cares on R1. CNA C and CNA E hooked sit to stand to R1 and lifted R1 out of bed. CNA C and CNA E transferred R1 to the bathroom to use the toilet. Example 4: On 02/13/24 at 12:55 PM, Surveyor toured laundry services with Laundry Aide (LA) N. Surveyor observed dirty linens soiled with urine on the laundry room floor next to the dirty linen bin. Surveyor interviewed LA N and asked if that is normal to have dirty linens on the floor. LA N stated to Surveyor that LA N is getting ready to soak those linens in the dirty soaker sink but usually, we don't place dirty items on the floor. Surveyor observed a green jacket and hat lying on a table touching Hoyer slings. Surveyor asked LA N whose jacket was sitting in the clean linen area touching the Hoyer slings. Surveyor also asked if the Hoyer slings were clean. LA N indicated that the jacket was LA N's jacket and that it should be kept in the break room outside the door down the hall. LA N also indicated that personal items should not be stored in a clean linen area and the Hoyer slings were clean and ready to be used for resident use. On 02/14/24 at 2:25 PM, Surveyor interviewed DON B and asked about expectations for hand hygiene during cares and wound dressing changes. DON B indicated the facility expects all employees to wash their hands before and after resident care. DON B indicated that staff are to wash hands between glove usage and change gloves often if in contact with contaminated surfaces to clean dressing changes. Surveyor asked DON B expectations for sick employees. DON B indicated that CNA I was sent home sick now and DON B ordered a test to be taken to rule out COVID-19. Surveyor asked DON B what expectations are for dirty linens on the floor in the laundry area. DON B indicated that dirty linens should not be lying on the floor in laundry services. Surveyor asked DON B what expectations are for stored personal items in the clean linen area. DON B indicated that LA N should have placed personal items in the break room where staff store their items. DON B indicated the clean linen area needs to remain clean. 40181 Example 5: On 02/13/24 at 6:58 AM, Surveyor observed CNA H carry soiled incontinent pads from a resident room, down the hall to the soiled utility room. The incontinent pads were not in a bag. CNA H opened soiled utility room and threw the pads in the laundry hamper and removed gloves. CNA H washed hands with soap and water before leaving utility room. On 02/14/24 at 11:38 AM, Surveyor interviewed CNA I and asked the facility process for carrying soiled linens out of a resident room to place in soiled utility room. CNA I stated dirty linens were placed in a tied plastic bag before taking them out of the resident's room and carrying to the utility room. On 02/14/24 at 11:40 AM, Surveyor interviewed DON B and explained the observation of CNA H carrying soiled linens from a resident room to the utility room. The dirty linens were not contained in a plastic bag. DON stated staff should always place dirty linens in a bag before carrying them to the utility room.

Based on record review, observation and interview, the facility did not ensure to develop and implement a comprehensive individualized care plan to meet the needs of the residents (R). R18's care plan was not developed for intermittent urinary catheterization and for incontinence of bladder and bowel. This occurred for 1 of 13 sampled residents (R18). This is evidenced by: R18 was admitted to the facility on [DATE] and has a diagnosis of retention of urine. R18's Minimum Data Set assessment, dated 11/12/23, Section H: Bowel and bladder indicates R18 is intermittingly catheterized, is frequently incontinent of bladder and continent of bowel. Currently R18 is not continent of bowel. On 02/13/24 at 2:42 PM, Surveyor reviewed R18's current comprehensive care plan. R18 did not have a care plan for intermittent urinary catheterization or urinary and bowel incontinence. R18 did have a care plan with the start date of 10/07/23 for an indwelling Foley catheter. R18 does not have an indwelling Foley catheter. On 02/13/24 at 7:22 AM, Surveyor observed Certified Nursing Assistant (CNA) E performing cares for R18. During observation of cares, Surveyor observed that R18 was incontinent of urine and bowel. Review of R18's intake & output report from 01/01/24 through 02/13/24 shows that R18 is marked by nursing staff as incontinent of bowel and bladder. On 02/14/24 at 7:10 AM, Surveyor reviewed R18's current care plan with historical data. Review of care plan received shows a care plan for indwelling Foley catheter with a start date of 10/7/23 and resolved date of 2/13/24 and a urinary/bowel incontinence care plan which includes intermittent catheterization with created date of 02/13/24. This is after Surveyor requested information. On 02/14/24 at 10:55 AM, Surveyor interviewed CNA I. CNA I stated that R18 is incontinent of both urine and stool and needs 2 assist every 2 hours because R18 does wet a lot and has sores. CNA I stated, We put barrier cream on him. [R18] does have a bandage the nurse puts on, but we don't put cream under that. Just put cream on the reddened areas.

Based on observation, the facility did not close the privacy curtain to provide privacy during personal care to the resident's abdominal/groin area for 1 of 1 sampled resident (R18). This is evidenced by: R18 was admitted to the facility on [DATE] and has diagnoses that include type 2 diabetes mellitus with diabetic neuropathy, unspecified, dysphagia, oral phase, pressure ulcer of sacral region, stage 2, pressure ulcer of left buttock, stage 2, retention of urine, and unspecified, muscle weakness (generalized). R18's Minimum Data Set assessment, dated 11/12/23, indicates R18 has a Brief Interview for Mental Status (BIMS) score of 99 (severe cognitive impairment)-resident unable to complete interview. On 02/12/24 at 9:15 AM, Surveyor observed R18. Surveyor observed R18 in bed lying on his back with the head of the bed rolled up. Surveyor attempted to interview R18, with no response. On 02/13/24 at 7:22 AM, Surveyor observed Certified Nursing Assistant (CNA) E and Director of Nursing (DON) B providing activities of daily living (ADL) care. During this observation, CNA E was washing R18's groin and abdominal fold area. The door to the room was closed, but the privacy curtain was not pulled. While CNA E was drying R18's abdominal/groin area CNA E asked DON B about R18's collagen powder for his abdominal folds. R18 has an order to apply collagen sprinkles to abdominal folds due to redness. DON B left the bedside and went to the door, opened the door and was talking with the nurse in the hallway about the powder. This exposed R18's groin/abdominal area to the hallway. DON B received the collagen powder from the nurse, closed the door and then went to R18's bedside and applied the powder. A few minutes later the door opened and Licensed Practical Nurse (LPN) Q came into the room, stood there for a few minutes and then left. At this point CNA E pulled the privacy curtain. A reasonable person would not want to have their private area exposed to the hallway and other residents and staff.

Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation) for 1 of 1 residents (R) reviewed, in accordance with the resident's treatment options (R6). R6's treatment options at time of admission on [DATE] stated Full Resuscitation. On [DATE], nursing staff called 911 due to R6's low oxygen saturation and unresponsiveness. Paramedic's note stated R6 was pulseless upon their arrival, and CPR was started by paramedics. The paramedic note stated staff stated R6 may have been pulseless for 5 to 10 minutes. Nursing staff did not initiate CPR prior to the arrival of the paramedics. The facility's failure to provide basic life support, including CPR, in accordance with R6's wishes created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on [DATE] at 3:30 PM. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement it's removal plan Findings include: Per CMS S & C ,d+[DATE], nursing homes must have staff certified in CPR on duty every shift. These individuals must provide CPR for any resident who becomes pulseless and non-breathing unless: (1) the resident has a do not resuscitate (DNR) order; (2) the resident has obvious signs of clinical death (e.g., rigor mortis, dependent lividity [pooling of the blood that occurs after death and may look blue, purple or black and is similar to bruising], decapitation, transection, or decomposition) or (3) the initiation of CPR could cause injury or peril to the rescuer. Record review identified R6 was admitted to the facility on [DATE] following an acute care hospitalization for pneumonia. R6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 had additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's treatment options on the After Discharge Orders from the hospital stated, in part: Full Resuscitation. A nursing progress note dated [DATE] at 10:10 PM stated, Writer observed resident's respirations even but labored. O2 Sats [oxygen saturation] 58% via oxygen (mask). R: [respirations] 30. Resident difficult to arouse even with sternal rub. Oxygen increased to 5L [liters] and saturation went up to 77%. Writer sent NAR [nursing assistant] to stay with patient and called 911. Paramedics arrived at 2200 [10:00 PM] and started resuscitation efforts immediately. Spouse and DON notified via phone call. Emergency Medical Services (EMS) note dated [DATE] stated, in part, Dispatched for respiratory distress. Arrived to find [R6] lying in bed. Staff stated that [R6] had been declining since 14:30 [2:30 PM], with O2 sats in 80's. On arrival, Pt [patient] was grey in color, warm to touch, and apneic [a cessation of breathing.] Nurses standing around the bed stating that [R6] was not responding for some time. Pulse check revealed Pt was pulseless. Pt move to the floor, and De-fib [defibrillator] patches place, and manual compressions administered .Staff stated that Pt may have been pulseless for ,d+[DATE] minutes, but were unsure . Review of nursing progress notes did not identify any vital signs checks, including pulse, after the note at 10:10 PM which documented an oxygen saturation of 58% and respiratory rate of 30. No documentation was identified that indicated nursing staff initiated CPR prior to the arrival of EMS. A nursing progress note dated [DATE] at 11:56 PM stated, in part, Paramedics notified writer that resident had expired at 2245 [10:45 PM] . On [DATE] at approximately 1:00 PM, Surveyor asked to interview the nurse who was working with R6 on the evening of [DATE]. DON B stated that nurse was an agency nurse, who no longer worked at the facility, and was unsure if the agency had the nurse's contact information. On [DATE] at approximately 1:30 PM, Surveyor interviewed Registered Nurse (RN) C, who was working as the DON on the evening of [DATE]. RN C stated the staff did not start CPR on R6 prior to the arrival of EMS, because as far as RN C was aware, R6 had a pulse and was breathing. Surveyor asked RN C if the facility documentation showed that R6 had a pulse. RN C stated the nursing notes did not record a pulse, but did record a respiratory rate of 30. Surveyor reviewed the EMS documentation with RN C, which stated R6 was pulseless upon their arrival, and staff reported to EMS that R6 may have been pulseless for 5 to 10 minutes. RN C stated the first page of the EMS documentation noted under initial assessment P-71. RN C took that to mean R6 had a pulse of 71 when the EMS arrived. On [DATE] at approximately 2:00 PM, Surveyor interviewed EMS G over the phone. Surveyor asked EMS G to clarify the discrepancy on the EMS documentation. The document stated on page 1, under initial assessment, P-71. On page 2, the narrative stated R6 was pulseless upon arrival of EMS. EMS G reviewed the electronic documentation and stated the P-71 on the first page was an auto-generated number from the equipment. EMS G stated that was most likely artifact picked up from the paramedics performing chest compressions. EMS G then reviewed the electronic EKG readings from the time the paramedics arrived. EMS G stated all of the EKG readings stated asystole (no heart beat) from the time of arrival. EMS G stated the paramedics would not have started manual compressions immediately upon arrival if the resident had a pulse. The website http://www.AED.com notes that there is a 5 minute survival window for a victim of sudden [CONDITION(S)] with the survival depending upon early CPR and having access to an AED within that 5 minute timeframe .The Chain of Survival steps must all occur within 5 minutes: 1. Early Access to get help: Call 911 2. Early CPR to buy time: Begin CPR Compressions Immediately 3. Early Defibrillation to restart heart: Use AED as soon as possible on victim 4. Early ACLS to stabilize: Ambulance arrival time Failure to immediately begin CPR reduced the chances that this resident could recover and survive. Brain death can occur within ,d+[DATE] minutes of the brain being deprived of oxygen. Further, the chance for a successful outcome decreases 7% with each minute that CPR is delayed. The failure to provide basic life support, including CPR, in accordance with R6's wishes created a finding of immediate jeopardy that began on [DATE]. The facility removed the jeopardy on [DATE], when it had completed the following: All licensed nursing staff educated on ensuring CPR is initiated timely for those residents that have a full-code status. Once CPR is initiated, it must continue until resident recovers, or physician/NP provides pronouncement of death, or emergency response team arrives. * Licensed nursing staff trained to initiate CPR in the absence of a DNR/Advance Directive. * Licensed staff reeducated on Cardiopulmonary Resuscitation Policy & Procedure.

Based on interview and record review the facility did not consult with the resident's physician when the resident had a significant change in condition for 2 of 3 residents (R) reviewed (R6, R5). *R6 had a decrease in oxygen saturation and change in mental status and the physician was not consulted and medical intervention was not obtained. This resulted in the resident developing [CONDITION(S)], and the resident expired. Failure to consult with a physician when a resident had a significant change in condition created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on [DATE] at 3:30 PM. The immediate jeopardy was removed on [DATE], however the deficient practice continues at a level G (actual harm/isolated) as evidenced by: *R5 had a fall resulting in bleeding from a surgical incision. The physician was not consulted when the incision continued to bleed following an evaluation in the emergency room . As a result, the resident was hospitalized four days later with a wound dehiscence (splitting open of a wound.) Findings include: Example 1: Facility Policy on Notification of Change, last reviewed ,d+[DATE], states in part, The Resident's physician .must be notified .when the resident experiences a change in condition . AMDA (American Medical Directors Association) acute change of condition states, Acute change in mental status is to be reported immediately. Vital signs : Respirations >28 to be reported immediately. R6 was admitted to the facility on [DATE] following an acute care hospitalization for pneumonia. R6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 had additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's treatment options on the After Discharge Orders from the hospital stated, in part: Full Resuscitation. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review identified a nursing progress note dated [DATE] at 4:12 PM. The note stated in part: Resident admitted via allina transport .was discharged from [name] Hospital following treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional nursing progress note dated [DATE] at 1:57 PM, but recorded as Late Entry on [DATE] at 1:57 PM, stated: The resident was requesting [their] medication prior to eating breakfast. Nurse gathered [their] am scheduled medications and brought them to the resident. The nurse asked the resident how [they] take [their] pills and [they] responded that [they] usually take them with applesauce. [R6] was slightly drowsy at this time but did take [their] pills (2 at a time) with reminders to swallow them. It took a while for [R6] to make sure they were all taken completely. The head of [their] bed was up. Set [R6's] breakfast in front of [them], but [R6] did not eating [sic] much of anything. Therapies tried to work with [R6] too throughout the morning with no success due to [R6's] extreme drowsiness. Checked [R6's] O2 [oxygen saturation] readings in the low 80's on 3L [liters]. [R6] did have a nasal cannula but noted [R6] appeared to be a mouth breather so switched [R6] to a face mask. [R6] was still in the low 80's at 3L so increased the O2 flow up to 5L, which brought [R6] up to the low 90's, later checking [R6] an hour later O2 sats [oxygen saturations] were 95%. [R6] was still very drowsiness [sic] but would respond to my questions, such as open [R6's] eyes. It took 3 requests and 3 tries by [R6] to get [R6] to open [their] eyes slightly. Glucose levels were 180 at breakfast and 156 at lunchtime. [R6] was not alert enough to eat lunch. Nurse asked [R6] if [they] sleep this much at home and resident just kind of shrugged shoulders. Record review did not identify any documentation of communication with R6's physician about the low oxygen saturations, switching to an oxygen face mask, a change in the amount of oxygen applied, or the ongoing drowsiness. On [DATE] at approximately 11:10 AM, Surveyor interviewed Registered Nurse (RN) C, who reported RN C was working as DON on [DATE]. RN C stated the nurse caring for R6 informed RN C that R6's oxygen saturations had dropped into the low 80's. RN C instructed the nurse to switch from a nasal cannula to an oxygen mask because R6 was noted to be a mouth breather. Surveyor asked what type of mask was used, and RN C stated it would have been a standard oxygen face mask. Surveyor asked if a physician was consulted for orders to switch to the face mask for oxygen delivery, and RN C stated they were following the facility standing orders. RN C stated the nurse caring for R6 was instructed to update the physician. RN C stated later in the day, RN C followed up with the nurse and learned the nurse got busy and did not update the physician. RN C stated the nurse reported R6's oxygen level had returned to normal and R6 was doing much better. Surveyor asked if RN C was aware that R6 remained very drowsy, requiring 3 requests, and 3 attempts to open R6's eyes slightly. RN C stated the nurse did not report the drowsiness. Surveyor asked if a physician was notified of this change in condition. RN C stated RN C did contact a provider at TCP (Twin Cities Physicians.) RN C did not remember which provider RN C spoke to, or what time that call was made. Surveyor asked if there was documentation of that phone call, and RN C stated RN C did not document that phone call. RN C stated they would contact TCP to determine if they had a record of the phone call. Surveyor asked RN C if the physician was informed that R6 remained very drowsy and difficult to arouse. RN C stated the physician was not informed of that because the nurse caring for R6 did not report that to RN C. Record review identified a nursing progress note dated [DATE] at 6:48 PM. The note indicated R6 refused to eat supper, but took medications without any problems and fell right back to sleep. The note indicated R6's blood sugar level was 106 at 5:30 PM, and R6's oxygen saturation was 92% via oxygen at 4 liters. The note did not specify if the oxygen was being delivered via nasal cannula or face mask. There was no documentation of communication with a physician about R6's ongoing sleepiness. The next nursing progress note dated [DATE] at 10:10 PM stated: Writer observed resident's respirations even but labored. O2 Sats: 58% via oxygen (mask). R [respirations]: 30. Resident difficult to arouse even with sternal rub. Oxygen increased to 5L and saturation went up to 77%. Writer sent NAR [nursing assistant] to stay with patient and called 911. Paramedics arrived at 2200 [10:00 PM] and started resuscitation efforts immediately. Spouse and DON notified via phone call. A nursing progress note dated [DATE] at 11:56 PM stated the paramedics notified that R6 had expired at 10:45 PM. The family was present in the facility and were updated. The medical examiner was called. On [DATE] at 10:55 AM, Surveyor interviewed the facility Medical Director (MD) F. MD F was not familiar with R6. Surveyor reported R6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor then read the nursing progress notes as reported above to MD F. Surveyor asked if MD F would have expected nursing staff to report R6's condition to a physician based on the information provided. MD F stated the drop in oxygen saturation and the need to switch to an oxygen mask should have been reported to a physician. MD F expressed concern that even though R6's oxygen saturations returned to normal levels, the nursing notes indicated R6 remained very somnolent. MD F stated this condition should have been reported to a physician, because given R6's diagnoses, the altered mental status was a warning sign that R6 was likely retaining [MEDICATION(S)] and going into [CONDITION(S)]. According to Healthline's article, Acute [CONDITION(S)], Acute [CONDITION(S)] occurs when fluid builds up in the air sacs in your lungs. When that happens, your lungs can't release oxygen into your blood. In turn, your organs can't get enough oxygen-rich blood to function. You can also develop acute [CONDITION(S)] if your lungs can't remove [MEDICATION(S)] from your blood. [CONDITION(S)] happens when the capillaries, or tiny blood vessels, surrounding your air sacs can't properly exchange [MEDICATION(S)] for oxygen. The condition can be acute or chronic. With acute [CONDITION(S)], you experience immediate symptoms from not having enough oxygen in your body. In most cases, this failure may lead to death if it's not treated quickly. (Emphasis added.) https://www.healthline.com/health/acute-respiratory-failure The failure to notify a physician of a significant change in resident's condition, created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE] when it had completed the following: All licensed Nursing staff educated on the various steps to perform based on their professional judgement when a resident has a change of condition: A. Training to Assess (i.e. vital signs, mental status, major diagnosis, allergies, medication review, review recent pertinent lab work, pulse oximeter readings/O2 sats as pertinent, skin inspection, bowel sounds, lung sounds, pain level, voiced complaints by the residents, presence of advance directives, INTERACT Care Paths Implemented B. Planning (1. Training on INTERACT change in condition file cards and or care paths may be utilized to provide evidence based guidelines. 2. Training to ensure licensed nurse gathers and organizes the resident information prior to calling physician. 3. Training the nurses to anticipate questions the physician might ask and have the answers ready (utilizing SBAR communication & reference and follow INTERACT Care Paths) C. Training on Notification (physician, 911, Director of Nursing or designee, resident's legal representative) and document accordingly in medical record. D. Training on Evaluation - on how to reassess the resident's status and response to interventions and when to re-contact the physician if the resident's progress deviates from expected course. E. Licensed Nurses will be trained that in their professional judgement to IMMEDIATELY CALL 911 IN EMERGENCY SITUATIONS. On [DATE] the facility reviewed the policy and procedure on Change in Condition & Physician Notification to include Licensed Nursing Staff and the Facility Medical Director. All on duty Nursing Staff immediately educated. The remainder of the licensed staff will complete training prior to their next scheduled shift. The deficient practice continues at a scope/severity of G (actual harm/isolated) based on the following example: Example 2: Record review identified R5 was readmitted to the facility on [DATE] following hospitalization for a partial hip replacement after a fall with a hip fracture. There were orders dated [DATE] stating Do NOT remove dressing until follow up appointment with surgeon (week of [DATE]) - Keep dressing clean and dry. - If dressing is not sealed around the edges or is more than 60% saturated contact DON [Director of Nursing.] Review of nursing progress notes and weekly wound rounds notes from [DATE] through [DATE] indicate the dressing over the right hip incision remained dry and intact during that time period. A nursing progress note dated [DATE] at 9:21 PM indicated R5 was found on the floor in front of the wheelchair. The note indicated there was a bloody clear type liquid below right hip. The physician was notified and R5 was sent to the emergency room for evaluation. Nursing progress note dated [DATE] at 2:18 AM, stated, in part: Resident returned from ED [emergency department] around 23:05 [11:05 PM] via ambulance service .CNA [Certified Nursing Assistant] assisted [R5] into b/r [bathroom] and noted that right hip dressing was dripping blood. Noted ED had reinforced previous dressing covering it with ABD pad [absorbent wound dressing] and tape. Nurse then got an absorbent dressing and put over area where it was leaking and applied pressure. Noted it had stopped with visual check on rounds . The note further documents a call to the emergency department to clarify confusion about medication orders. It is noted there was no documentation of report to DON or physician about blood dripping from surgical dressing at that time. A nursing progress note dated [DATE] at 2:02 PM, stated, in part: .The right hip dressing that was saturated with sanguinous [bloody] drainage the dermna blend was left and pressure applied to the area (Abd). It is noted there was no documentation of report to DON or physician about the right hip dressing that was saturated with bloody drainage. A nursing progress note dated [DATE] at 9:47 AM, but recorded as Late Entry on [DATE] 09:52 AM, stated in part, WOUND ROUNDS: 1. R [right] thigh/surgical incision: Dr. order not to remove dressing/needs assessment at appt. Wound is draining/saturating pads. Covered with additional dressing. Appt. made to be seen . The next three nursing progress notes are as follows: ,d+[DATE]//21 at 12:52 PM Called to schedule appt at Clinic-Family Practice. [Physician] will be out, scheduled with [physician] on Friday [DATE] at 10:00 AM Clinic-2nd floor. F/U [follow up] from her fall on [DATE] . [DATE] at 3:01 PM Resident R [right] hip outer dressing changed due to leaking serous fluid. [R5] is scheduled to see physician on Wednesday this week . [DATE] at 4:21 PM Clarification needed, called TCP [Twin Cities Physicians.] Spoke with [Physicians Assistant]. Resident went to ED [emergency department] ,d+[DATE] and returned with orders hold [MEDICATION(S)] [blood thinner] for 1 day. Staff was unaware resident was taking [MEDICATION(S)]. Orders are in Matrix [electronic medical record], not printed out in MAR [Medication Administration Record]. [Physicians Assistant] advised to have her start taking [MEDICATION(S)] 5 mg [milligrams] today as prescribed . None of the above progress notes document notification to a physician that the right hip surgical dressing was leaking or saturating the outer dressing with bloody drainage. The next nursing progress note dated [DATE] at 2:29 PM stated: Resident had an appointment w/[physician]. They are admitting her to Hospital due to surgical wound dehiscence [splitting open of a wound] s/p [following] recent fall. She was a direct admit today for surgery washout procedure for R [right] hip hemi-arthroplasty [partial hip replacement]. Previous ED [emergency department] CT [form of x-ray image] of R hip (,d+[DATE]) was negative. After Visit Summary from Orthopedics dated [DATE] stated in part, You were seen in clinic today for the following issue: .2. Dehiscence of operative wound .Treatment plan .Other specific instructions: Surgery recommended for the right hip for irrigation and debridement. Patient will be direct admit . On [DATE] at approximately 2:30 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated she was not working at the facility at the time of this incident, but will speak with Registered Nurse C, who was working as DON at the time of this incident. Surveyor asked DON B if a physician was notified over the weekend, after the dressing was noted to be dripping blood after return from the emergency department. DON B stated the resident had just been seen in the emergency room , and the orthopedic surgeons would not be on call, or available to report this on the weekend. DON B would look for additional documentation. On [DATE] at approximately 8:30 AM, DON B informed Surveyor that RN C stated the nurse who documented the wound rounds on [DATE] communicated with the orthopedic physician on [DATE] about the bleeding from the surgical wound. Surveyor asked if there was documentation in the medical record to show this communication. DON B provided a copy of the paper wound rounds documentation dated [DATE]. Surveyor reviewed the document and found no documentation of communication with a physician to report the wound was draining bloody drainage and needed to be reinforced with an absorbent dressing. On [DATE] at approximately 1:30 PM, RN C came in to review nursing progress notes with Surveyor. RN C pointed out several nursing progress notes over the weekend of [DATE] through [DATE] that indicated R5's surgical dressing was dry and intact. Surveyor asked RN C if a physician was informed the surgical dressing was dripping blood during the night shift on [DATE], after returning from the ED. RN C pointed out the nursing progress note that stated the nurse called the ED to clarify the [MEDICATION(S)] hold orders. That note did not mention informing the physician, or ED staff of the blood dripping from the surgical wound, or the need to change the dressing that was applied in the ED. Surveyor showed RN C additional progress notes indicating the surgical wound continued to drain/leak and require dressing changes. RN C stated the nurse who did the wound rounds on [DATE] notified the orthopedic surgeon of this. Surveyor requested documentation to show this communication occurred. No additional documentation was provided showing facility staff had reported to a physician that R5's surgical incision was draining blood and saturating dressings following the fall on [DATE]. R5 was admitted to the hospital for surgery five days later, and remained in the hospital for 18 days.

Based on record review and interview, the facility did not ensure that 1 of 1 residents (R) reviewed received appropriate respiratory care, consistent with professional standards of practice (Wisconsin Nurse Practice Act), during a significant change in medical condition (R6). R6 had a significant change in medical condition with a drop in oxygen saturation to the low 80s. R6 had ongoing change in mental status despite improved oxygen saturations. The facility did not provide ongoing assessment, planning, intervention, or evaluation throughout the day. R6 developed respiratory failure and died . The facility's failure to recognize the significant change in condition, and provide appropriate respiratory care, created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on [DATE] at 3:30 PM. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings include: According to N6 Wisconsin Nurse Practice Act, the standard of practice for a registered nurse (RN) is: (1) GENERAL NURSING PROCEDURES. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. Review of R6's medical record identified R6 was admitted to the facility on [DATE] following an acute care hospitalization for pneumonia. R6 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 had additional diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's treatment options on the After Discharge Orders from the hospital stated, in part: Full Resuscitation. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated [DATE] at 1:57 PM, but recorded as Late Entry on [DATE] at 1:57 PM, stated: The resident was requesting [their] medication prior to eating breakfast. Nurse gathered [their] am scheduled medications and brought them to the resident. The nurse asked the resident how [they] take [their] pills and [they] responded that [they] usually take them with applesauce. [R6] was slightly drowsy at this time but did take [their] pills (2 at a time) with reminders to swallow them. It took a while for [R6] to make sure they were all taken completely. The head of [their] bed was up. Set [R6's] breakfast in front of [them], but [R6] did not eating [SIC] much of anything. Therapies tried to work with [R6] too throughout the morning with no success due to [R6's] extreme drowsiness. Checked [R6's] O2 [oxygen saturation] readings in the low 80's on 3L [liters]. [R6] did have a nasal cannula but noted [R6] appeared to be a mouth breather so switched [R6] to a face mask. [R6] was still in the low 80's at 3L so increased the O2 flow up to 5L, which brought [R6] up to the low 90's, later checking [R6] an hour later O2 sats [oxygen saturations] were 95%. [R6] was still very drowsiness [sic] but would respond to my questions, such as open [R6's] eyes. It took 3 requested and 3 tries by [R6] to get [R6] to open [their] eyes slightly. Glucose levels were 180 at breakfast and 156 at lunchtime. [R6] was not alert enough to eat lunch. Nurse asked [R6] if [they] sleep this much at home and resident just kind of shrugged shoulders. Surveyor noted the nursing documentation stated R6's oxygen saturation was in the low 80s on 3 liters of oxygen, however the order for oxygen at the time of admission was 4 liters per minute via nasal cannula continuously. Surveyor also noted no documentation of any other respiratory assessment, such as lung sounds, heart rate, respiratory rate, skin color, or any other assessment. On [DATE] at approximately 11:10 AM, Surveyor interviewed Registered Nurse (RN) C, who reported RN C was working as DON on [DATE]. RN C stated the nurse caring for R6 informed RN C that R6's oxygen saturations had dropped into the low 80s. RN C instructed the nurse to switch from a nasal cannula to an oxygen mask because R6 was noted to be a mouth breather. Surveyor asked what type of mask was used, and RN C stated it would have been a standard oxygen face mask. Surveyor asked if a physician was consulted for orders to switch to the face mask for oxygen delivery, and RN C stated they were following the facility standing orders. RN C later provided the facility standing orders, which stated in part, .7. Oxygen 0.,d+[DATE]L per nasal cannula OR 6 l/m [liters per minute] per mask for respiratory distress, chest pain, or cyanosis [bluish discoloration of the skin,] to keep SATS [oxygen saturations] > [greater than] 88%. If the resident has [CONDITION(S)], use minimal liter flow required. **The provider must be notified of the resident's condition** Surveyor noted the late entry nursing documentation from [DATE] at 1:57 PM stated R6's oxygen remained in the low 80s on 3 liters per minute of oxygen after switching to the oxygen mask. Surveyor asked RN C if oxygen at 3 liters per minute was an appropriate oxygen flow rate with a standard oxygen face mask. RN C stated the nurse was instructed to increase the oxygen flow rate, when it was noted R6's oxygen saturation was still in the low 80s. Surveyor noted the nursing documentation from [DATE] at 1:57 PM stated the oxygen flow rate was increased to 5 liters per minute when the oxygen saturations remained in the low 80s on 3 liters of oxygen via mask. The facility standing orders stated the oxygen flow rate for a mask should be 6 liters per minute. Further record review identified a nursing progress note dated [DATE] at 6:48 PM. The note stated in part, Resident refused to eat supper. He took his medications without any problems but fell right back to sleep .Blood sugar (1730) [5:30 pm] 106. O2 Sats: 92% via O2 (4L). Surveyor noted there was no documentation of any other respiratory assessment or vital signs documented on that note. It was also noted there was no documentation if the oxygen was being delivered via nasal cannula or face mask. No documentation was found to show a physician was updated about R6's ongoing sleepiness. The next nursing progress note dated [DATE] at 10:10 PM stated, Writer observed resident's respirations even but labored. O2 Sats: 58% via oxygen (mask). R:30. Resident difficult to arouse even with sternal rub. Oxygen increased to 5L and saturation went up to 77%. Writer sent NAR (nursing assistant) to stay with patient and called 911. Paramedics arrived at 2200 and started resuscitation efforts immediately. Spouse and DON notified via phone call. Surveyor noted there was no documentation in the nursing note stating R6's pulse, or any other assessment, such as skin color, or lung sounds. The note did not indicate what the oxygen flow rate was when the nurse observed resident's oxygen saturation at 58% via oxygen mask. The note did state the oxygen flow rate was turned up to 5 liters. The facility standing orders for oxygen flow rate with a mask was 6 liters. There was no documentation of R6's condition, respiratory rate, pulse, skin color, or responsiveness between the time the nurse increased the oxygen flow rate to 5 liters, and when the paramedics arrived and started resuscitation efforts. On [DATE] at 10:55 AM, Surveyor interviewed the facility Medical Director (MD) F. MD F was not familiar with R6. Surveyor reported R6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor then read the nursing progress notes as reported above to MD F. MD F expressed concern that even though R6's oxygen saturations returned to normal levels, the nursing notes indicated R6 remained very somnolent. MD F stated, given R6's diagnoses, the altered mental status was a warning sign that R6 was likely retaining [MEDICATION(S)] and going into respiratory failure. According to Healthline's article, Acute Respiratory Failure, Acute respiratory failure occurs when fluid builds up in the air sacs in your lungs. When that happens, your lungs can't release oxygen into your blood. In turn, your organs can't get enough oxygen-rich blood to function. You can also develop acute respiratory failure if your lungs can't remove [MEDICATION(S)] from your blood. Respiratory failure happens when the capillaries, or tiny blood vessels, surrounding your air sacs can't properly exchange [MEDICATION(S)] for oxygen. The condition can be acute or chronic. With acute respiratory failure, you experience immediate symptoms from not having enough oxygen in your body. In most cases, this failure may lead to death if it's not treated quickly. (Emphasis added.) https://www.healthline.com/health/acute-respiratory-failure According to the NIH article Respiratory Failure (https://www.nhlbi.nih.gov/health-topics/respiratory-failure) notes, Respiratory failure is a serious condition that develops when the lungs can't get enough oxygen into the blood. Buildup of [MEDICATION(S)] can also damage the tissues and organs and further impair oxygenation of blood and, as a result, slow oxygen delivery to the tissues. Respiratory failure can also develop slowly. When it does, it is called chronic respiratory failure. Symptoms include shortness of breath or feeling like you can't get enough air, fatigue (extreme tiredness), an inability to exercise as you did before, and sleepiness . Low oxygen levels in your blood can cause: Difficulty or extreme tiredness with routine activities such as dressing, taking a shower, and climbing stairs Shortness of breath or feeling like you cannot get enough air (called air hunger) Drowsiness A bluish color on your fingers, toes, and lips High [MEDICATION(S)] levels in your blood can cause: Blurred vision Confusion Headaches Rapid breathing You can have symptoms of low oxygen and high [MEDICATION(S)] at the same time. Some people who have respiratory failure become extremely sleepy or lose consciousness if their brain does not get enough oxygen or if [MEDICATION(S)] levels are very high . Respiratory failure can cause serious or life-threatening problems such as: Arrhythmias (irregular heartbeats) Brain injury Kidney failure Lung damage A nursing progress note dated [DATE] at 11:56 PM noted the paramedics notified the nurse that resident had died at 10:45 PM. Cross reference F580 (facility failure to promptly consult with an MD regarding R6's change in condition). The facility's failure to completely assess this resident at numerous times throughout the day on [DATE], when he remained extremely lethargic and had dropping oxygen saturation levels, or required increased oxygen, and provide appropriate respiratory care created a finding of immediate jeopardy that began on [DATE]. The facility removed the jeopardy on [DATE], when it had completed the following: Nursing staff received on-site training from Northwest Respiratory. * Nursing staff received education on change in condition related to Respiratory System. * Standing Orders for emergency concerns were laminated and placed and attached to all med carts for easy access. Licensed nurses were educated on this document. On [DATE] the facility reviewed the Oxygen Therapy policy and procedure with the Medical Director to ensure policy meets current standards of practice. Policy updated related to oxygen administration. All licensed staff educated on facility policy and procedures related to Oxygen Therapy and Respiratory Assessment. 1. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Oxygen will be administered according to training procedures set forth from Northwest Respiratory. 3. Licensed Nurse will report any intolerance to the physician. 4. In an emergency situation, the licensed nurse may administer no more than 4 liters of oxygen until the physician can be notified for further orders.

Based on record review and interview, the facility did not ensure that a resident (R) with bleeding and drainage from a surgical wound received the necessary care and treatment in accordance with professional standards of practice for 1 of 1 residents reviewed, (R5.) R5 had a fall on 06/18/21 and was evaluated in the emergency department (ED). R5 had bloody drainage noted from a right hip surgical dressing after the fall. The bleeding and drainage continued from the surgical dressing after R5 returned from the ED. The facility did not assess the surgical incision or dressing to determine if a change in treatment was needed. R5 was admitted to the hospital on 06/23/21 with wound dehiscence (splitting open of a wound.) Findings include: Record review identified R5 was readmitted to the facility on [DATE] following hospitalization for a right partial hip replacement after a fall with a hip fracture. The discharge information from the hospital indicated R5 also had a stroke while hospitalized . R6 had a Brief Interview for Mental Status (BIMS) score of 99, indicating R5 was unable to complete the screening due to severe cognitive impairment. R5 was also assessed as at risk for falls, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review identified R5 had a surgical dressing over the right hip incision with orders dated 06/07/21 stating, Do NOT remove dressing until follow up appointment with surgeon (week of 6/21/21) -Keep dressing clean and dry -If dressing is not sealed around the edges or is more than 60% saturated contact DON [Director of Nursing] The After Discharge Orders from the hospital dated 06/07/21 stated, in part, .Call your surgeon if you have: .any unusual bruising or bleeding some spotting is normal .if your dressing is not sealed well around the edges or more than 60% of your dressing is saturated please call your surgeon for further instruction . Review of R5's After Discharge Orders and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . (A blood thinner medication) A nursing progress note dated 06/18/21 at 9:21 PM indicated R5 was found on the floor in front of the wheelchair. R5 had bumped the right forehead on the floor. The note also indicated there was a bloody clear type liquid below right hip. A physician, the DON, and resident's family were notified, and R5 was sent to the ED via ambulance for evaluation. Nursing progress note dated 06/19/21 at 2:18 AM, stated, in part, Resident returned from ED around 23:05 [11:05 PM] via ambulance service .CNA [Certified Nursing Assistant] assisted [R5] into b/r [bathroom] and noted that right hip dressing was dripping blood. Noted ED had reinforced previous dressing covering it with ABD pad [absorbent wound dressing] and tape. Nurse then got an absorbent dressing and put over area where it was leaking and applied pressure. Noted it had stopped with visual check on rounds . The note further documents a call to the emergency department to clarify confusion about medication orders. It is noted there was no documentation of report to DON or surgeon about blood dripping from surgical dressing at that time. A nursing progress note dated 06/20/21 at 2:02 PM, stated, in part, .The right hip dressing that was saturated with sanguineous [bloody] drainage the dermna blend was left and pressure applied to the area (Abd). It is noted there was no documentation of report to DON or surgeon about the right hip dressing that was saturated with bloody drainage, or assessment of the surgical wound to determine if dressing seal was compromised or the amount of drainage was greater than 60% saturation per the physician orders. A nursing progress note dated 06/21/21 at 9:47 AM, but recorded as Late Entry on 06/25/21 09:52 AM, stated in part, WOUND ROUNDS: 1. R [right] thigh/surgical incision: Dr. order not to remove dressing/needs assessment at appt. Wound is draining/saturating pads. Covered with additional dressing. Appt. made to be seen . Further record review identified the following nursing progress notes: 06/21//21 at 12:52 PM Called to schedule appt at Clinic-Family Practice. [Physician] will be out, scheduled with [physician] on Friday 6/25/21 at 10:00 AM Clinic-2nd floor. F/U [follow up] from her fall on 06/18/21 . 06/21/21 at 3:01 PM Resident R [right] hip outer dressing changed due to leaking serous fluid. [R5] is scheduled to see physician on Wednesday this week . 06/21/21 at 4:21 PM Clarification needed, called TCP [Twin Cities Physicians.] Spoke with [Physicians Assistant]. Resident went to ED [emergency department] 6/18 and returned with orders hold [MEDICATION(S)] [blood thinner] for 1 day. Staff was unaware resident was taking [MEDICATION(S)]. Orders are in Matrix [electronic medical record], not printed out in MAR [Medication Administration Record]. [Physicians Assistant] advised to have her start taking [MEDICATION(S)] 5 mg [milligrams] today as prescribed . Also of note, the progress note dated 06/21/21 at 4:21 PM, indicated the Physicians Assistant (PA) gave orders for an additional blood thinner medication to be given to R5, but there was no documentation showing the PA was informed the surgical wound was continuing to drain. Review of all of the documentation related to the surgical wound showed that when nursing staff noted the increased drainage, they did not do a thorough assessment of the surgical wound to determine if the dressing was sealed well around the edges, or assess for greater than 60% saturation of the dressing. There were no further nursing progress notes found in the medical record after the note at 4:41 PM on 06/21/21, until a note dated 06/23/21 at 2:29 PM. That note stated, Resident had an appointment at Clinic w/[physician]. They are admitting her to Hospital due to surgical wound dehiscence [splitting open of a wound] s/p [following] recent fall. She was a direct admit today for surgery washout procedure for R [right] hip hemi-arthroplasty [partial hip replacement]. Previous ED [emergency department] CT [form of x-ray image] of R hip (6/19) was negative. After Visit Summary from Orthopedics dated 06/23/21 stated in part, You were seen in clinic today for the following issue: .2. Dehiscence of operative wound .Treatment plan .Other specific instructions: Surgery recommended for the right hip for irrigation and debridement. Patient will be direct admit . Record review identified an additional nursing progress note dated 06/24/21, at 5:55 PM, that stated, in part, Update from hospital, resident's surgical wound is infected. Was irrigated/debrided yesterday, again today. They will wait to suture the wound until they are sure the infection is under control. Possibly returning to this facility Sunday or Monday. Record review identified resident returned to the facility from the hospital on 07/11/21. On 08/17/21 at approximately 2:30 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated she was not working at the facility at the time of this incident, but will speak with Registered Nurse C, who was working as DON at the time of this incident. Surveyor asked DON B if a physician was notified over the weekend, after the dressing was noted to be dripping blood after return from the emergency department. DON B stated the resident had just been seen in the emergency room , and the orthopedic surgeons would not be on call, or available to report this on the weekend. DON B would look for additional documentation. On 08/18/21 at approximately 8:30 AM, DON B informed Surveyor that RN C stated the nurse who documented the wound rounds on 06/21/21 communicated with the orthopedic physician on 06/21/21 about the bleeding from the surgical wound. Surveyor asked if there was documentation in the medical record to show this communication or an assessment of the surgical wound and dressing. DON B provided a copy of the paper wound rounds documentation dated 06/21/21. Surveyor reviewed the document and found no documentation of communication with a physician or assessment of the surgical wound. On 08/18/21 at approximately 1:30 PM, RN C came in to review nursing progress notes with Surveyor. RN C pointed out several nursing progress notes over the weekend of 06/19/21 through 06/20/21 that indicated R5's surgical dressing was dry and intact. Surveyor asked RN C if a physician was informed the surgical dressing was dripping blood during the night shift on 06/19/21, after returning from the ED. RN C pointed out the nursing progress note that stated the nurse called the ED to clarify the [MEDICATION(S)] hold orders. That note did not mention informing the physician, or ED staff of the blood dripping from the surgical wound, or the need to change the dressing that was applied in the ED. The note does not contain an assessment of the surgical wound for dressing saturation greater than 60% or inspecting for a lack of a seal around the dressing edges. Surveyor showed RN C additional progress notes indicating the surgical wound continued to drain/leak and require dressing changes. RN C stated the nurse who did the wound rounds on 6/21/21 notified the orthopedic surgeon of this. Surveyor requested documentation to show this communication occurred. No additional documentation was provided showing facility staff had assessed R5's surgical incision when it was draining blood, and saturating dressings following the fall on 06/18/21. R5 was admitted to the hospital for surgery five days later, and remained in the hospital for 18 days.

Based on interview and record review, the facility did not immediately consult with the resident's physician when there is a need to alter treatment for 2 of 4 residents (R3, R4). R3 and R4's physician was not immediately notified when deterioration in wounds had occurred. This is evidenced by: The facility's policy on physician notification in part, The Resident's physician .must be notified when an event involving the resident occurs or when the resident experiences a change in condition .Planning 1. The licensed nurse is expected to utilize professional judgment to notify the physician sooner in any situation that the nurse deems necessary . 1. R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3 had behavioral manifestations with dementia that resulted in refusals of positioning with combative behaviors towards staff. R3 developed a stage 2 pressure injury on his right buttock on 11/07/18. R3 developed an area on his left buttock on 11/11/18. Nurses' notes in part, 11/11/2018 10:37 PM Resident upset with cleaning of buttocks and dressing change to L butt crease, requiring 3 persons as resident became combative and verbally outraged . physician progress notes [REDACTED].>01/22/19 [MEDICAL CONDITION]: largely stress driven, has been noted to scratch for attention . 02/13/19 Skin .Buttock wound is large, superficial skin breakdown, diffuse over sacral area . 02/26/19 .Also ulcer on buttock has been slow to heal but improving .Buttock ulcer is very shallow skin breakdown, healing well, no significant drainage . Wound assessments were done and the physician was kept updated through 02/26/19. The weekly pressure ulcer progress report dated 02/21/19 in part, lt (left buttocks 1.8 cm x 1.6 cm x .3 cm .left sacrum 3 x 4.3 cm.) 03/05/19 .left sacrum 4 cm x 4 cm .stage 2, wound odor: foul. Progress: improved. Date physician notified: 12/17/18. 03/06/19 .left sacrum 3 cm x 4 cm .No exudate, no odor, no change . 03/13/19 .left sacrum 3 cm x 4 cm, stage 2, Exudate moderate, purulent, wound odor: Foul. Progress: No change. 03/17/19 2:38 p.m.Resident has a worsening pressure ulcer left lower third of left buttocks, coccyx area 5 cm x 3 cm and 1.5 cm deep, full thickness loss .this started on: 3/17/19 .Name of physician and time called: Physician A, 02:30 p.m . Surveyor reviewed the physician orders [REDACTED]. The physician had seen R3 on 03/05/19 to examine a heel ulcer that had developed from R3 banging his foot on the floor with his behaviors. R3 was referred for a wound consult for the heel. There is no mention of an assessment of the sacral ulcer in the documentation. On 04/23/19 at 2:20 p.m., Surveyor interviewed Physician A about the above ulcer. Physician A indicated the last time she assessed the sacral area was on 02/26/19 and it was doing very well. Physician A indicated it was superficial open areas in multiple areas. Surveyor reviewed the 03/05/19 telephone order about a wound care consult. Physician A indicated she had assessed the heel ulcer on that date. The staff did not inform Physician A of any changes in the status of the sacral area. Surveyor asked when Physician A was made aware of the deterioration in the sacral ulcer. Physician A stated on 03/17/19. Physician A indicated the ulcer was deep with foul smelling drainage. Surveyor asked when Physician A would have expected to be notified. Physician A indicated as soon as the area showed changes in odor or drainage so that she could have implemented treatment changes for R3. physician progress notes [REDACTED]. the last time writer viewed the wound was told an update it was healing well., skin breakdown but no depth or focal ulcer. Today notified of large ulcer with 1 1/2 to 2 cm depth and large deep eschar + odor. Today the wound is as below: Deep yellowish green .this was partially debrided .continued eschar at edges therefore unstageable. Packed with wet to dry dressing, will continue and ask for wound nurse consult, this was ordered 3/5-but not clear if documented . On 04/23/19, Surveyor interviewed the interim Director of Nursing (DON) about the above. Surveyor asked what the expectation is for physician notification. The DON indicated the physician should have been notified when any changes such as increased drainage and odor had been documented on 03/05/19. 2. R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4 is on comfort cares. R4 was dependent on staff for all personal cares and transfers. Surveyor reviewed the medical record and noted a Weekly Pressure Ulcer Report completed on 02/20/19 that includes in part: .Date of initial discovery, 02/03/19 .Continue to cleanse right 2nd toe but increase to BID (twice a day) with saline cover with prevail bandage, unstageable, Exudate moderate, Wound Odor: Foul Progress: Deteriorated. Date physician notified: 02/03/19. This assessment was completed 17 days after the discovery of the toe ulcer. Surveyor reviewed the nurses' notes that include in part: 02/03/19 Resident has a petechiae type rash on LLE (left lower extremity) on top of foot, back of calf, on shin and behind ankle as well . 02/05/19 Dr .here to see resident new order Apply protective foam to patients left ankle/lower leg and pad the wheelchair wheel . 02/06/19 res noted to have an open sore on his right foot, second toe Area cleansed dried. and prevail dressing applied. Note left for RN and MD . 02/07/19 Dressing changed to res right second toe noting a large amount of bloody drainage. Toe is tender when touched for tx (treatment). 02/09/19 temp=102.2. Tylenol 650 mg given .Temp at 4 am was 99.5 .Drsg (dressing) intact on right second toe . 02/11/19 Resident noted to have temp of 100.7, prn Tylenol given down to 98.7. Resident stated, 'call my family' .family members here at this time . 02/13/19 MD here to see resident . The telephone orders on 02/07/19, .cleanse R (right) second toe daily with saline cover with Prevail bandage . The medical record contains no documentation of the status of the second right toe from 02/07/19 until 02/13/19 when next assessed by the physician. The progress note 02/13/19 in part, .Right 2nd toe with open sore over the proximal phalanx with thick purulent drainage, odor, tender to touch, swelling, erythyma .skin ulcer of toe of right foot with fat layer exposed . On 04/23/19 at 2:25 p.m., Surveyor interviewed Physician A asking about the above wound. Physician A indicated R4 had no skin issues when his assessment was done on 01/15/19. On 02/07/19, a colleague of hers ordered the first treatment for [REDACTED]. Physician A indicated on 02/13/19 the toe was yellow with 100% slimy slough with increased exudate and odor and the area was larger in size. Physician A indicated that if the dressings were being done daily she expected to be notified when the toe wound had changes. Physician A stated she would have changed the treatment had she been notified. On 04/23/19 at 2:50 p.m., Surveyor interviewed the DON to ask for clarification on the discovery date of 02/03/19. The DON reviewed the medical record and could find no documentation of this toe wound until the note on 02/06/19. The DON indicated the physician should have been notified when the toe showed signs of deterioration form 02/07 - 02/13/19.

Based on observation, record review and interview the facility did not ensure that indwelling bladder catheterization was necessary in 1 of 2 residents who have indwelling bladder catheters (Resident #5), with no attempts made to restore bladder functioning. Additionally, the facility did not ensure that 1 of 5 residents who are incontinent of bladder (Resident #5) received appropriate treatment and services to prevent urinary tract infections. This is evidenced by: Resident #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], confirmed that the resident has an indwelling urinary catheter. A hospital document, dated 2/20/12, entitled "Dismissal Summary" states that she "may possibly require a long term urinary catheter until she can ambulate to the restroom." This document is from an in-hospital Dermatological consult due to an open area that Resident #5 had on her coccyx area. Although the resident has a history of an open area on her coccyx, Surveyor did not observe any open areas. Surveyor reviewed Resident #5's Nursing Care Plan dated 3/19/12. Nursing Care Plan stated "Resident requires an indwelling urinary catheter related to difficulty with transferring. Resident has discomfort and shortness of breath when sitting up." Nurses notes revealed that Resident #5 is able to sit up in her wheel chair to transfer to the clinic for paracentesis and also to go on outings with her husband. Resident #5 was also receiving Physical Therapy 5 times a week. Resident #5 receives Lactolose therapeutically, with a goal of 4-5 bowel movements a day. This places Resident #5 at a high risk for infection related to the need for frequent perirectal cleansing. Resident #5 is offered a bedpan for bowel movements. On 6/30/12 at 1:31 p.m. Resident #5 complained of feeling like she needed to urinate. Foley catheter balloon was deflated and repositioned by the staff nurse, with little effect. Foley catheter was then changed by the staff nurse and reinserted with clear yellow urine upon return. A urinalysis was obtained. A urine culture would later reveal that Resident #5's urine was contaminated with E. Coli (Escherichia Coli) a bacteria present in stool. At 6:40 p.m. on 6/30/12 Resident #5 stated she felt better since the catheter was changed. On 7/1/12 at 10:36 a.m. Resident #5 again complained of feeling like she needed to urinate. Physician was notified and Resident #5 began [MEDICATION NAME] (an antibiotic) 500 mg. twice a day for 5 days. On 7/2/12 the Resident #5 continued to complain of bladder discomfort. Nurses notes on 07/3/12 and 07/04/12 state "no complaints of pain." On 07/05/12, Resident #5 again complained of feeling a fullness in her bladder and bladder pain. Her urinary catheter was changed again and reinserted by the staff nurse, with a documented return of amber colored urine. Resident #5's primary physician was notified of the resident's continued complaints of bladder pain. An order was received for [MEDICATION NAME] (a medication used to treat bladder spasms) 100 mg. twice a day for 3 days. Resident #5 continued to complain of bladder pain with spasm. On 7/6/12 the Nurse Practioner (NP) was notified of Resident #5's continued complaints, and an order was obtained for [MEDICATION NAME] 5/325 mg (a narcotic used to relieve pain) 1 tablet as needed every 4 hours. Resident #5 received one tablet on 7/6, 4 tablets on 7/7, 3 tablets on 7/8, 3 tablets on 7/9, 3 tablets on 7/10 and one tablet in the a.m. of 7/11. The resident rated her bladder pain (based on a scale ranging from 1-10, with 10 being excruciating and 1 being mild) as a "5" when asked. On 7/10/12, at 9:30 a.m., Surveyor interviewed the Director of Nursing (DON) regarding the facility's practices for bladder catheterization of residents, determination of the need for urinary catheterization and long term use of a urinary catheter post hospitalization . Surveyor asked the DON if she follows a professional standard of practice regarding Foley catheter usage and duration. The DON stated she does not follow a professional standard of practice related to urinary catheters. Surveyor asked the DON how she determines when urinary catheters should be used or left in post hospitalization . The DON told Surveyor that she "gets rid of them except in cases where the resident has a clinical [DIAGNOSES REDACTED]." The DON told Surveyor that she does not have a specific policy stating when urinary catheters should be discontinued. The DON acknowledged that Resident #5 does not have a clinical [DIAGNOSES REDACTED]. The DON stated that she had not talked to the resident regarding the risks of long term use of a urinary catheter (i.e. infection, bladder [MEDICAL CONDITION]). The DON then provided Surveyor the hospital Dermatological consult document mentioned above, which states "she possibly will require long term urinary catheterization until she can ambulate to the restroom." The DON stated that resident is receiving Physical Therapy although her progress is poor. The DON provided Surveyor a document entitled "Catheter care, urinary" which outlines the procedural steps to follow related to urinary catheter insertion and removal. The document does not address or provide recommendations for the duration of urinary catheters in the long term care setting. On 7/9/12 at 4:30 p.m., Surveyor observed Certified Nursing Assistants (CNA) I and CNA F assist resident #5 with pericare. Both CNA's entered resident #5's room, washed their hands and donned gloves. CNA I filled a basin with water and obtained wash cloths. CNA F offered Resident #5 use of the bedpan, which she declined. CNA F removed the brief soiled with feces and discarded it into the lined wastebasket. CNA F then changed gloves without washing his hands and cleansed the resident's perirectal area in a back to front motion, then cleansed the surrounding folds with the same soiled cloth. CNA F dried the perirectal area in the same back to front motion and draped the soiled wash cloth and towel on the footboard of the bed. CNA F then reached into resident's bedside table, where other personal items are stored, without taking off soiled gloves or washing hands, and obtained a tube of barrier cream. CNA F then applied the barrier cream in a back to front motion to the residents' peri rectal area. CNA F then placed the tube of barrier cream into the resident's bedside table. At this time, the resident received a telephone call. CNA F answered the residents' phone, handed the phone to the resident then replaced the phone after Resident #5 held a brief conversation. CNA F then changed gloves without performing hand hygiene. CNAs F and I assisted the resident with repositioning. CNA F placed the soiled linen from the foot of the bed into a plastic bag. CNA F carried the plastic bag out of the room and into the soiled utility room. CNA F then removed his gloves applied hand sanitizer. The DON informed Surveyor that the CNAs are trained on proper pericare and handwashing, and that she does periodic monitoring of staff to ensure proper handwashing and pericare.

Based on observation, staff interview, medical record review and facility policy review, the facility did not ensure that each resident receives assistance devices to prevent accidents for 5 of 9 residents reviewed for falls/accidents. Resident #1 had a fall on 08/26/11 and sustained a right hip fracture. Resident #1's care plan and facility policy directed a gait belt was to be used. Resident #1's care plan also directed non skid socks or shoes were to be on during transfers or ambulation. The nurse documented the Certified Nursing Assistant (CNA) was not using a gait belt and that Resident #1 was barefoot at the time of the fall. Resident #1 had a near fall on 04/21/12 and sustained bruises to her wrists. The CNA transferred Resident #1 by herself when Resident #1's care plan directed she was to be a two person assist with transfers. Resident #5 had a care plan in place which required 2 staff for transfers. On 04/22/12, Resident #5 was assisted off the toilet by 1 staff instead of 2, and without the use of a gait belt. Facility staff did not assure that the care plan was accurate and up to date so staff would consistently transfer the resident according to his needs and did not follow facility procedure related to the use of a gait belt for assisted transfers. The facility had not identified safety concerns, creating the possibility of residents being injured due to alarms not functioning properly (Residents #7 and #16) or sustaining skin tears from equipment with sharp edges (Resident #17). This is evidenced by: The facility policy titled "Resident Incident/Accident Reporting Protocol" dated 01/2011 read in part: 5.1 Overview It is the policy of this facility that all incidents or accidents occurring on our premises be investigated and reported to the Director of Nursing and/or Administrator. 8. If the incident/accident involves "suspected abuse or neglect or misappropriation of property" by a staff member toward a resident: That an investigation will be conducted by the Director of Nursing (DON), or designee. c. 3) Conduct a thorough investigation which includes but is not limited to obtaining statements from the resident, other residents, all staff working the unit upon which accident/incident occurred, visitors etc. 17) The DON will review all incidents/accident forms and the Incident Management Log for accuracy and completeness. The facility policy (date not provided) titled "Moving a Resident, Bed to Chair/Chair to Bed" 9. j. read "Support the resident by placing a belt around the resident's waist for you to hold and steady the resident." On 05/21/12 at the exit meeting, Surveyor asked the DON to verify if a resident's care plan reads transfer or ambulate with the assist of 1 or 2, (a mechanical lift or stand is not used), are staff to use a gait belt. The DON stated "Yes, they are." 1) During review of Resident #1's medical record beginning the morning of 05/21/12, Surveyor identified Resident #1 fell on [DATE] and had a fracture of her right hip. The initial nurses' note of this event written by Licensed Practical Nurse (LPN) A on 08/26/11 at 1:13 a.m. read in part "Res. (resident) was ambulating with CNA from bathroom back to her bed. CNA stated she 'tripped over her feet' and she 'lowered her to the floor.' When doing ROM (range of motion) to res. legs to yelled out in pain and held her right hip/groin area. Res. was not moved any further and MD (medical doctor) on call...was notified of fall and status change and gave order to send to ER (emergency room ) to eval and tx (treat). Message left to inform DON." Another nurses' note written by LPN A 08/26/11 at 6:19 a.m. read in part CNA (B's initials) wrote in her statement regarding the fall that res. Stumbled over her feet and fell hard onto her knees and said she tried to catch her before she hit the floor but was not able to." On 05/21/12 Surveyor requested to see the investigation, incident report and any information they had related to Resident #1's fall of 08/26/11. Surveyor was provided with a copy of the facility "Resident Safety Report" completed by LPN A for Resident #1 following the fall 08/26/11 read in part "Did shoes or clothing play a role in incident? She had bare feet. Was a gait belt used? No. Did the resident have interventions in place to prevent this incident? No." A document titled "Incident/Accident Report" completed by LPN A. The report contained the following information: "VII. Summary: 4. Was a different intervention implemented to prevent further falls: Explain: Yes, wear slippers or shoes when ambulating and use gait belt." Attached to the Incident/Accident Report was a document titled "Fall Prevention Program Care Plan" for Resident #1, dated 12/31/10 that read in part "At risk for falls and subsequent injury related due to: balance issues, assist /c (with) transfers. Interventions 5. Wear non skid shoes/non skid socks while transferring/ambulating." The 12/31/10 care plan indicates that non-skid footware was to worn during transfers and ambulation. At the time of the fall on 8/26/11, staff documented that a gait belt was not used and no foot ware was worn. The statement written by CNA B on 08/26/11 read "I took Resident bathroom on First rounds. I walked with walk (sic) ambulation from bathroom to bed and stumbled over her feet fell to knees real hard on the right side. Tried to catch before she hit the floor, I could not she was already down, so place a pillow under resident head and go (sic) the nurse." CNA B's written statement did not identify if she had a gait belt on Resident #1 or what Resident #1 had on her feet, if anything. CNA B's written statement differed from what CNA B had initially reported to LPN A in that she had told LPN A she lowered Resident #1 to the floor, yet she wrote she fell hard on the right side and she could not catch her. The "Post Incident Investigation Summary" dated 08/26/11 written by the DON read in part "Resident requires assist with all ambulation. Able to ambulate with A1 (assist of one) and walker. Resident was being toileted and returning to bed when resident tripped and fell - landing on knees then onto R with a circle around it (right) side. NAR (Nurse Aide Registered) unable to prevent fall. Resident had slippers on. Staff to place shoes on feet. Have 2 staff to assist with ambulation at night for safety. Continue to see PT (physical therapy) for ambulation. For future ambulation will initiate no slippers and only shoes." There was no conclusion in this report about the gait belt being used or not or addressing if Resident #1's care plan was being followed. On 05/21/12 Surveyor reviewed a copy of Resident #1's care plan for self care that was identified by the DON as what was in place at the time of the 08/26/11 fall. Surveyor identified Resident #1 was an assist of one for transfers and ambulation. A "Focus Summary #2" document completed 08/08/11 also identified Resident #1 was an assist of one for transfers using the gait belt and assist of one with ambulation. On 05/23/12 beginning at 7:20 a.m. a phone interview was conducted by Surveyor with LPN A regarding Resident #1's fall and fracture that occurred on 08/26/11. Surveyor asked LPN A if she remember how and where Resident #1 was positioned when she entered the room after the fall. LPN A stated she was lying on her back on the floor between her bed and the bathroom. LPN A was asked if Resident #1 had a gait belt on when LPN A entered the room. LPN A stated "I do not recall.' Surveyor read the resident safety report that stated she did not have a gait belt on. LPN A stated "I would assume my writing to be true." If I checked no gait belt that's how it was. I pride myself in trying to be accurate when someone falls and accurately document every thing." LPN A told Surveyor "I was suspicious of what CNA B said as her story changed." LPN A was asked if Resident #1 had any thing on her feet when LPN A entered the room. LPN A stated "If I charted she was barefoot, that's how it was." During the above phone interview Surveyor discussed with LPN A the discrepancy between her nurses' note that read Resident #1 was lowered to the floor and CNA B's written statement that said she fell real hard. LPN A stated "That is part of how her story changed. Her story made me wonder what really happened. All I had to work with was her (CNA B), there was no other witness." Surveyor asked if Resident #1 could tell her what happened. LPN A stated she could not related to her aphasia. LPN A was asked if the DON had spoken to her about the fall and the discrepancies. LPN A stated she had not. During an interview with the DON beginning at 11:05 a.m. on 05/21/12 Surveyor asked the DON if they had a copy of the CNA care card from 08/2011. The DON stated "No, we don't save a copy, it is in the computer. From now on, when we have an incident we will copy the care card. When the resident CNA care cards are updated in the computer the previous ones are not kept. They have no way to go back if changes have been made." During the above interview Surveyor brought to the attention of the DON that LPN A had documented that Resident #1 was barefoot at the time of the fall but the internal investigation that the DON had written read she had slippers on. Surveyor pointed out Resident #1 was to have non skid socks or shoes on. The DON said she had been told that she had slippers on from her interview with CNA B. The DON also stated CNA B had told her she had the gait belt on when she spoke to CNA B. The DON stated after the fall, Resident #1 was changed to a 2 person assist with transfers and ambulating at night. On 05/21/12 at 4:20 p.m. Surveyor interviewed the DON and asked if CNA B had been re-educated regarding transfer and ambulation according to the residents care cards and if there was any documentation of the re-education. The DON stated she spoke with CNA B and told her it was ok to get help and to follow the care cards. The DON stated there was no documentation of the re-education. Surveyor asked the DON if all nursing staff were re-educated regarding following resident's care cards after the incident of 08/26/11 where Resident #1 fell and fractured her hip. The DON stated "When an incident occurs we go over the issue, like not following the care cards. We tell the CNA's if they see something is different with the resident than what is on the care card or if they have questions or the care card needs to be changed they need to address it with Registered Nurse (RN) F, the DON or the wing nurses. "The DON was asked if there was any documentation of the re-education done for all the nursing staff. The DON stated "No." 2. On 05/21/12 during review of Resident #1's medical record Surveyor identified a nurses' note dated 04/22/12, 3:39 a.m. that read "CNA D from PM (Evening) shift notified this nurse and PM B/D wing nurse, RN E, that she was walking this resident to the bathroom and the resident started to fall. The CNA stabilized the resident by hers (sic) wrists and was able to stop her from actually falling. On midnight rounds, bruises were noticed on wrists bilaterally. DON notified." On 05/21/12 beginning at 12:47 p.m. Surveyor conducted an interview with the DON regarding Resident #1's nurses' note of 04/22/12. Surveyor pointed out to the DON what was written in the nurses' note differed from what CNA D had written in her statement. The nurses' note read CNA D was walking Resident #1 to the bathroom and CNA D's written statement read "When transferring Resident #1 4-22-12 (sic) to bed from her chair. Standing her with transfer belt, Resident #1 lost her balance and I corrected her by using belt and holding her wrist. After getting in bed realized that I had bruised her wrist in the transfer." Surveyor pointed out to the DON that CNA D's statement would not account for why Resident #1 had bruises on both wrists. Surveyor referred to the 04/22/12, 3:39 a.m. nurses' note and identified it was not documented what time the incident occurred and it was not included in CNA D's written statement. Surveyor asked the DON if she knew when CNA D had written her statement. The DON stated she assumed CNA D had wrote her statement that pm." The DON was asked if she knew what time the incident occurred as it was not documented. The DON stated she did not know. During the above interview Surveyor asked the DON if there had been an incident report filled out related to the bruises and the event that caused them. The DON stated "It was not considered an incident for a report to be filled out, it was not an unknown injury, they knew the cause of the bruises." The DON was asked if she would have expected CNA D to report it right after it happened. The DON said "Yes, and the nurse should have charted on it." Beginning at 2:30 p.m. an interview was conducted with CNA D by Surveyor . CNA D was provided with a copy of her written note from the incident. Surveyor asked CNA D what was the date she had wrote her statement. CNA D stated "I wrote it the same day it happened, 4/22." CNA D was asked if she had the gait belt on Resident #1. CNA D stated "Yes, I had the gait belt on her, I took hand off gait belt and took a hold of her wrist, she does bruise real easy." CNA D was asked what time the incident occurred. CNA D stated when she was putting her to bed, sometime between 7-8:30 (p.m.) CNA D was asked what time she told the nurse. CNA D stated "I told the nurse on last report around 9:30-10:00 (p.m.)" Surveyor showed CNA D the nurses' note and asked her if she knew why the nurse would have charted that she was walking Resident #1 to the bathroom and her statement said she was transferring her to her bed from her chair. CNA D stated "That's not what happened, I was not walking Resident #1, I was putting her from her wheelchair to bed. It got lost in translation." During the above interview with CNA D, Surveyor pointed out that the nurses' note identified Resident #1 had bruises on both of her wrists. CNA D stated "I saw it on one hand, didn't see the other wrist bruise. I noticed the right wrist, it looked like two finger marks, she is real susceptible to bruising." Surveyor asked CNA D to describe what happened. CNA D stated "She lost her balance, I let go of the belt and got her arm." Surveyor showed CNA D Resident #1's care plan that identified she was to be transferred with two staff. CNA D said "Yeah." CNA D was asked if there was someone else there that helped her with the transfer. CNA D said "No." CNA D was asked why she transferred Resident #1 by herself. CNA D stated "Because at the time there wasn't anybody to help me. That is a real busy hall." CNA D was then asked if the DON had spoke to her about following the resident's care plans. CNA D said "Yeah, I know I wasn't suppose to do it...I didn't think I would have any trouble..." On 05/21/132 beginning at 3:35 p.m. Surveyor conducted a phone interview with RN E, the nurse who was working the p.m. shift when the incident of 04/21/12 occurred. RN E stated "I do know that Resident #1 is to be a two person transfer and that CNA D knew that." On 05/21/12 beginning at 4:42 p.m. Surveyor interviewed the DON and asked if re-education had been done with CNA D and all other nursing staff regarding following the resident's care cards. The DON stated a verbal conversation had occurred with CNA D related to that matter. The DON was asked if they do training for CNA's regarding transferring and ambulating residents. The DON stated they do that on a yearly basis. The DON was asked if the training included what the CNA's are to do if a resident is falling. The DON said no, she wants to start a skills fair and address that. The DON was asked for information on when the last training on transfers was completed and CNA D's last competency training record. This information was not provided. 2) On various dates from 0515/12 - 06/04/12, Surveyor reviewed Resident #5's medical record as well as the facility's incident investigation related to a fall. Resident #5 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Resident #5's most recent Care Area Assessment Summary (CAAS) related to falls, corresponding with an annual Minimum Data Set (MDS) assessment with an assessment reference date of 09/17/12 identified the following: the resident was at risk for falls due to impaired balance and use of antidepressant medication; the resident had a history of [REDACTED]." Resident #5's most recent quarterly MDS with an assessment reference date of 03/14/12 identified that Resident #5 had moderate cognitive impairment. Self-performance was coded as extensive assist and support was coded as "Two+ persons physical assist" for transfers, ambulation and toileting. Resident #5's nurses' notes from 02/16/12 through 03/13/12 were contradictory with some identifying 1 assist for transfers (02/18, 03/01, 03/02, 03/03, 03/06, 03/10, 03/12, 03/13), some identifying 1-2 assist with transfers (02/27, 02/28), and some identifying 2 assist for transfers (02/16, 02/17, 02/20, 02/21, 02/23, 02/24, 02/25, 03/01, 03/05, 03/09, 03/12). It was noted that on both 03/01/12 and on 03/12/12, a nurse's note identified 1 assist to transfer while another nurse's note identified 2 to transfer on the same date. Nurses' notes after 03/12/12 did not identify how the resident was transferred. A Fall Risk Assessment completed by the facility, dated 03/29/12, stated that Resident #5 scored 12, which was moderate risk for falls. Resident #5's current comprehensive care plan stated the resident was at risk for falls and subsequent injury related to various factors including a history of falls, requiring extensive assistance with transfers and Activities of Daily Living (ADLs) and poor safety awareness. An intervention dated 09/23/10 stated the resident required the assist of 2 staff for a pivot transfer and toileting was "per incontinent regimen." An update was added on 04/22/12 to use 2 assist with toileting. The intervention related to the pivot transfer remained 2 assist and was not changed. Resident #5's medical record dated 04/22/12 at 1:04 p.m. identified that at 12:20 p.m. a Certified Nursing Assistant (CNA) was assisting the resident off the toilet when the resident's knees buckled and he fell to the floor onto his knees. It was stated there were no injuries noted, that the Director of Nursing (DON) was called and there was "staff education on proper transfers." During an interview with Surveyor on 05/21/12 at 4:30 and 4:45 p.m., the DON identified that gait belts were to be used for any "assisted" transfers. The DON stated that on 04/22/12, Resident #5 was to be transferred with only 1 staff assist which was changed to 2 staff assist after the incident. The DON stated there was a problem with the computerized care plans and the "dates" were not always getting changed. The DON was unable to explain why Resident #5's care plan, prior to 04/22/12, still included the intervention to use 2 staff assist for pivot transfers with no update to use only 1 assist. The DON stated that CNA H who was involved in the incident had worked at the facility for less than 90 days, had received training related to transfers/falls at orientation and again received training following the incident. The DON stated CNA H did not say why she did not use a gait belt. The DON confirmed staff routinely have competency checks and training annually at the time of their annual evaluation and there was no all staff training following the incident on 04/22/12. CNA H was unavailable for interview on 05/21/12. The facility's investigation of the incident which consisted of 6 different reports identified that Resident #5's "usual ambulatory status was "Assist of Two + With/Without Device" and that the resident was assisted off the toilet by 1 CNA who was not using a gait belt. 3) Surveyor noted on 05/15/12 and 05/21/12 that battery compartments on some alarm boxes were not secured with appropriate covers. Surveyor made the following observations. ~Resident #7 - 2:30 p.m. An alarm sounded in the resident's room and Housekeeper I responded. The resident was standing near the bed and Housekeeper I assisted the resident to her recliner approximately 3 feet from the bed. An alarm box (approximately 4 X 6 inches in size) and an alarm pad were setting on the resident's bedside stand next to the recliner. The alarm box had a large (approximately 1 X 6 inch) red and white striped "ALLERGY" sticker secured over the batteries on the back of the alarm box. Housekeeper I left the room with the alarm box which was sounding intermittently and stated she was going to get help for the resident. RN F entered the room, left, and returned along with the DON who both placed the alarm pad on the seat of the recliner and assisted the resident back into the recliner. It was noted the same alarm box (with the allergy sticker) was placed on the resident's bedside stand with the allergy sticker visible on both the front and back of the alarm box. The resident removed the alarm box from the top of the bedside stand and RN F then placed the alarm box on the floor between the bedside stand and the recliner. RN F and the DON left the room. ~Resident #7 - 2:50 p.m. CNA D came out of the resident's room. The resident remained in the recliner but the alarm box had been moved to set on the resident's bed, next to the recliner. ~Resident #7 - 2:40 p.m. The resident sat in the recliner, and visited with family (who confirmed the resident was sitting on the alarm pad). The alarm box sat on top of the resident's bed, next to the recliner. The alarm box did not have a covering to the batteries and no "allergy" sticker was in place. ~Resident #16 - 2:40 p.m. The resident (Resident #7's roommate) was not in the room. A sensor (floor-type) alarm box was noted on the resident's bedside stand. There was no covering on the back with the inside workings of the alarm exposed and the batteries secured with 2 red and white allergy stickers. Surveyor interviewed the DON on 05/21/12 at 2:45 p.m. who stated, "they just disappear," regarding the covers to the alarm boxes and added she would order more. ~Resident #17 - 2:45 p.m. The resident sat in his wheelchair with a lap buddy in place that was torn on all 4 corners, exposing cloth threads. Some of the torn edges were sharp to the touch which were pointed out to the DON at that time. Surveyor notified the DON this was the same lap buddy the resident had in place on 05/15/12 with no repairs having been done to prevent possible skin tears. The DON stated she would obtain a new lap buddy for the resident. On 05/21/12, Surveyor discussed the above situations with the Nursing Home Administrator (NHA) and the DON. Neither the NHA nor DON were able to confirm that not having appropriate coverings for the alarm boxes were looked at as being a potential safety hazard.

Based on observation, interview, and record review, the facility did not ensure that the resident environment remained as free of accident hazards as was possible for 7 sampled residents and 6 supplemental residents in a total census of 42. Resident #1 had moderate to severe cognitive impairment, an increase in the frequency of falls, increased anxiety, and an increase in attempts to get out of bed unassisted. The facility did not: ~Identify the electric baseboard heater (heat register) as a potential hazard for Resident #1 due to high temperatures inside the heater during operating times, and due to the possibility of access to the inside of the heater through an approximate one inch opening that ran along the entire length of the heater; ~Address Resident #1's risk factors in relation to the close proximity of the bed to the electric baseboard heater. Subsequently, on 12/12/10, Resident #1 was found with his feet in contact with the electric baseboard heater resulting in first and second degree burns to both feet including six toes, lacerations and skin tears, and the right great toenail was torn completely off and found inside the heater. Resident #1 required twice a day and then daily dressing changes to both feet, with an oral antibiotic initiated prophylactically to assist in preventing infection. Six other residents (Residents #2, #3, #4, #5, #6, and #7), were sampled (identified on the roster matrix to have cognitive impairment) when on the initial tour it was observed that their beds and/or recliners were within close proximity of the electric baseboard heaters with the surface of the heaters hot to the touch, surface temperatures at approximately 110 degrees Fahrenheit (F.), and the inside coils rapidly reaching 220 degrees F. (surveyor thermometer able to measure to only 220 degrees F.). Seven supplemental residents (Residents #8, 39, #10, #11, #12, and #13) are included due to cognitive impairment (per the facility roster) and observations of beds and/or recliners within close proximity of the heaters (not hot to touch). Following the incident on 12/12/10, the facility identified that the electric baseboard heaters posed a potential risk to residents and put a plan in place that included moving some of the beds, educating staff as well as alert and oriented residents about the risks of the heaters, and implementing a metal "guard" over Resident #1's heater with a plan to implement some type of protective covering for other residents. The facility did not: ~Adequately address the potential hazard of the electric baseboard heaters for the above residents creating the potential that these residents could also be burned. This is evidenced by: Surveyor toured the facility on 12/20/10, beginning at approximately 7:30 a.m. Most beds in double rooms consisted of the window bed with either the head of the bed or the foot of the bed at 90 degrees to the outside wall and the electric baseboard heater (some beds were parallel to the outside wall). The electric baseboard heaters were approximately 6 inches high and anywhere from 4 feet to 10 or 12 feet in length and ran along the bottom of the outside wall. The baseboard heaters were noted to have an opening near the top of the heater, approximately 1 inch high, which ran the entire length of the heater. Inside the 1 inch opening, it was noted there were metal "fins" toward the outside and metal fins toward the inside. When the heater was on, it was hot to the touch and the outside fins reached a temperature equal to or just slightly greater than the temperature of the top of the heater (approximately 110 degrees F.), while the inside fins rapidly reached a temperature reading of 220 degrees F. (surveyor thermometer able to measure to only 220 degrees F.). There were no coverings over the baseboard heaters, except in Room E5 where Resident #1 resided. Surveyor interviewed Director of Maintenance (DM) E on 12/20/10 at 2:50 p.m. who identified the heat source for all resident rooms in the facility as well as the dining room and the resident lounge was electric with each room having a thermostat and a baseboard heater that was either 4 feet to 6 feet in length, or 10 or 12 feet in length if the 4 or 6 foot units were placed together. The principle for the heat was explained that when the air temperature in the room went below what was set by the thermostat in the room, the electric baseboard heater "kicked on," and when the thermostat was "satisfied," it would shut the baseboard heater off, which was dependent on the temperature in the room and also the temperature outside. DM E stated there was a "thermo disk" inside the baseboard heater, as a safety precaution, that kept the heating element from overheating. DM E stated that most of the thermostats had lock boxes over them (to prevent visitors, staff, and residents from turning the thermostat up too high), but added that not all of them did. "WeatherUnderground.com" identified the outside temperature was 19.2 degrees F. at 7:32 a.m. on 12/20/10, at approximately the time the survey and the initial tour with observations of the environment began. Surveyor reviewed a State memo, 01-023, dated 05/21/01, regarding "Baseboard Heaters" in facilities that included nursing homes. The memo included the following information. "Baseboard heaters can present a danger to certain residents. Current regulations allow listed and properly installed heaters to be designed in accordance with the state building code. However, the Department's administrative codes state that certain residents, who are not able to ensure their own safety, must be reasonably protected from hazards by the facility...The facility must assess each individual resident for their susceptibility to environmental hazards. If a resident is highly susceptible to environmental hazards and a heater is experiencing excessive surface temperatures the facility shall take steps to provide for the safety of the resident. Facilities are required to properly maintain and monitor the operation of these heaters. Periodic measurements of surface temperatures and removal of malfunctioning equipment is highly recommended..." Resident #1 has resided at the facility for approximately 4 years. Current [DIAGNOSES REDACTED]. He has an activated Power of Attorney for Health Care (POA-HC). Resident #1's Minimum Data Set (MDS) assessment, dated 09/22/10, identified the resident had short and long term memory problems with moderate cognitive impairment, had several indicators of delirium including periods of altered perception and periods of restlessness, required extensive staff assistance for most Activities of Daily Living (ADL's), and had falls that occurred in the past 30 days. Resident #1's current nursing care plan, dated 10/05/10, identified the resident had complaints of chronic pain including both knees and ankles and decreased range of motion related to osteoarthritis. It was identified the resident was at risk for falls and subsequent injury related to a history of falls, and interventions related to falls included an alarm when in bed (dated 09/27/08) and when in the wheelchair (not dated), a laser alarm "near bed to alert staff to self-transfer attempts" (dated 03/12/10), a perimeter mattress (start date not identified), do not leave alone in room when in wheelchair (dated 10/23/10), dinner at 4:00 p.m. if awake and then assist to bed after dinner (dated 10/25/10), a low bed (dated 10/26/10), do not leave alone after meals (dated 10/29/10), and don't leave alone after meals and don't leave in bed alone if wide awake (dated 10/31/10). The care plan addressed the resident's diabetic neuropathy and interventions included to wear shoes at all times to avoid injury/trauma to the feet, but it did not address safety in bed when not wearing shoes and where the bed should be placed in relation to the electric baseboard heater. Surveyor reviewed the NIH Publication No. 08-3185, February, 2009, published by the National Diabetes Information Clearinghouse (NDIC), a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) included the following, "People with neuropathy need to take special care of their feet. The nerves to the feet are the longest in the body and are the ones most often affected by neuropathy. Loss of sensation in the feet means that sores or injuries may not be noticed and may become ulcerated or infected. Circulation problems also increase the risk of foot ulcers...Doctors estimate that nearly half of the amputations caused by neuropathy and poor circulation could have been prevented by careful foot care." Surveyor interviewed Laundry/Housekeeper (LH) A on 12/22/10 at 9:40 a.m. who identified she had worked at the facility for [AGE] years and that she had always been instructed that residents' beds should be at least 12 inches from the electric baseboard heaters when the heat was on. LH A stated that up until Resident #1 sustained injuries from the heater on 12/12/10, the resident's bed was situated parallel to and approximately 12 inches away from the outside wall and the heater, and added that there was no special rule at that time for vulnerable residents to have their beds any further away from the heaters. A review of Resident #1's nurses' notes from January, 2010 through September, 2010, identified 3 falls (2 of them out of bed). Nurses' notes in October, 2010 identified Resident #1 was restless and confused, and made persistent attempts to get out of bed unassisted, setting off alarms. Nurses' notes identified the resident fell while attempting to self transfer into bed on 10/23/10 and on 10/25/10. Nurses' notes identified the resident fell while attempting to self transfer into bed on 10/29/10 (the TAB alarm did not detach and trigger) and while attempting to self transfer out of bed on 10/31/10. Resident #1's care plan did not address that the when the low bed was initiated on 10/26/10, this would potentially place him closer to the electric baseboard heater. Nurses' notes for November, 2010, identified Resident #1 had increased anxiety and an increase in attempts to get out of bed unassisted: -11/01/10, on the evening shift was found crawling out of bed 5 times; -11/02/10, awake and sitting up in bed at 2:20 a.m., setting off the alarm; -11/06/10, started on an intravenous antibiotic for a urinary tract infection; -11/12/10, having increased anxiety and hallucinations; -11/15/10, wide awake around 1:30 a.m.; -11/16/10, up from approximately 1:00 a.m. to 3:00 a.m. -11/19/10, found crawling out of bed at 3:45 a.m. -11/29/10, slid out of his wheelchair; -11/30/10, set off the alarm and was found sitting up in bed at 4:00 a.m. "WeatherUnderground.com" identified the mean temperature was 40 degrees F. on 11/01/10 and 28 degrees F. on 11/30/10. The care plan was not updated related to the resident's persistent attempts to get out of bed unassisted during the early morning hours, and the hazard related to the baseboard heater was not identified even with outside temperatures becoming colder (which would cause the electric heaters to kick in more frequently). On 12/12/10, a nurse's note written by Registered Nurse (RN) B identified that Resident #1 had sustained injuries to his feet "in the heat register." It was identified the resident complained only that his knees ached. The wounds were identified as 3-4 skin tears and 7 areas of second degree burns, with the left great toenail removed, and a moderate amount of blood was stated to be on the floor and on the wall ("WeatherUnderground.com" identified the temperature was 0.5 degrees F. at 7:33 a.m. and 7:53 a.m.). Surveyor interviewed LH A on 12/22/10 at 9:40 a.m. who identified she was in Resident #1's room 2 times on the morning of 12/12/10 between 7:30 a.m. and 8:00 a.m., approximately 15 minutes apart, to pick up soiled laundry. LH A stated the first time she was in the room, she picked up the roommate's laundry and noted that Resident #1 was lying in his bed, but added that she did not look closely enough at him to see if his feet and legs were in or out of the bed at that time. LH A stated that when she returned to Resident #1's room for the second time that morning, she noted he was still lying in bed, covered and on his left side (facing the outside wall and the baseboard heater), with his feet hanging over the side of the bed, not moving and appearing as though he was asleep. LH A stated she then noticed "streaks of blood" smeared on the wall between the bottom of the window and the top of the heat register, and thought at first he might have had a bloody nose. LH A stated that as she looked closer, she observed at least 4 streaks of blood on the wall, each streak approximately 1 inch in width and approximately over 1 foot in length. LH A stated there was also blood on the top of the baseboard heater and a "puddle" of blood on the carpet next to the heater, approximately the size of a softball. LH A stated that Resident #1's toes of his left foot were inside the opening (that ran the length of the register) as far as they would go and that his right foot was resting on the edge of the opening. LH A stated the resident could move his right foot but not his left foot, and that it looked as if he had been attempting to remove his left foot from the register, causing the blood smears on the wall with his right foot. LH A identified the resident had his knees bent and his legs swung over the side of the bed, and stated it looked as though he couldn't lift his legs back up, possibly due to his chronic knee pain. LH A identified the resident had a TAB alarm attached and a motion sensor alarm on the side of the bed nearest the door, but added that (due to his positioning to the left side of the bed and still with his body in bed) neither alarm had sounded. LH A stated that when she removed the resident's left foot from inside the heat register, the toenail from his great toe was already off, and she added that she later removed the toenail from inside the register which looked like "a melted piece of tape." LH A identified she immediately summoned the nurse for assistance. Surveyor reviewed the facility's investigation of the incident which included an incident report, written statements by staff, a 15 minute monitoring sheet for 12/12/10, and a summary of the incident signed by the Director of Nursing (DON). The facility's summary concluded the following regarding Resident #1 and the incident that occurred on 12/12/10: A. He had significant cognitive impairment and was a "tremendous" fall risk, thus was on 15 minute checks; B. Sometime between 7:45 a.m. and 7:50 a.m. on 12/12/10 (within a 5 minute period of time), the resident placed his feet in the opening of the heat register vent and sustained trauma and significant burns to his feet; C. The resident's bed was measured by the DON on 12/12/10 to be 24 inches away from the heat register having been in the same position for 3 years without a similar incident; D. The heat register was cool to the touch when checked by the DON; E. The resident did not seem bothered by pain at the time of the incident; F. The incident was "unforeseeable and unpredictable." A. 15 MINUTE CHECKS Resident #1's care plan nor his nurses' notes identified he was on 15 minute checks, thus it was unclear when these were initiated. The facility's investigation included a 15 minute monitoring sheet for 12/12/10 that identified Resident #1 was asleep/in bed from midnight through 7:45 a.m.; a written statement by CNA C who stated she was in Resident #1's room at 6:15 a.m., at approximately 6:20 a.m., and at approximately 7:45 a.m. (after hearing the resident had his feet in the heat register); and, a written statement by LH A who stated she was in Resident #1's room at approximately 7:45 a.m. returning at approximately 8:00 a.m. to find the resident's feet in contact with the heat register. The times that LH A identified she was in Resident #1's room on the morning of 12/12/10 were not consistent with written documents in the facility investigation including CNA C's written statement and the incident report which identified the time of the incident at approximately 7:45 a.m., as well as written statements by the DON and the Nursing Home Administrator (NHA) that the DON was notified of the incident by the NHA via phone, at 7:49 a.m. Surveyor interviewed LH A on 12/22/10 at 9:40 a.m. who identified she was in Resident #1's room 2 times on the morning of 12/12/10 between 7:30 a.m. and 8:00 a.m., approximately 15 minutes apart, to pick up soiled laundry. LH A stated that after she left the room the first time, she went to 2 other wings to pick up laundry, then to the laundry room, and then returned to the floor to go to each wing again to pick up more laundry (direct care staff doing morning cares). According to the facility investigation, the time that LH A reported the incident was approximately 7:45 a.m. (if this time is correct, then the first time that LH A was in Resident #1's room was at approximately 7:30 a.m., placing the time that Resident #1 could have caught his left foot in the heater, rubbed blood on the wall with his right foot, and spilled a pool of blood on the floor, between 7:31 a.m. and 7:44 a.m., up to 13 minutes, confirming that 10 or 15 minute checks might not be sufficient to prevent residents from sustaining significant burns from the heaters). B. INJURIES OCCURRED WITHIN 5 MINUTES The facility's investigation identified that on 12/12/10, Resident #1 was observed to be asleep with all extremities in bed at 7:45 a.m. (15 minute check sheet initialed at 7:45 a.m. by CNA C) and was then found by LH A between 7:45 a.m. and 7:50 a.m. with blood on the wall and his feet in the slot (opening) of the heat register vent, sustaining significant burns to both feet. The facility's investigation included a written statement by the DON who confirmed, per her phone record, that she was notified of the incident at 7:49 a.m. The facility's investigation maintains the burns occurred in a short period of time (between 7:45 a.m. and 7:50 a.m.) which would confirm the hazard of the electric baseboard heaters and that significant burns could occur in a short period of time. Surveyor reviewed the American Society for Testing and Materials (ASTM) International Standard C1055-03, titled "Standard Guide for Heated System Surface Conditions that Produce Contact Burn Injuries, reapproved 2009, largely based on the work of Moritz and Henriques. The ASTM guide establishes a mean by which one can determine the acceptable surface temperature of an existing system where skin contact may be made with a heated surface. The scale for temperature-time relationship for burns identified that the contact skin temperature (the temperature of the skin, not the heated surface) was proportional to exposure time in seconds. A skin contact temperature of approximately 70 degrees Celsius (C)/158 degrees F. for 1 second would be enough to cause complete transepidermal (occurring through or across the epidermis) necrosis (cell death). A skin contact temperature of approximately 58 degrees C/136.4 degrees F for 10 seconds would be enough to cause complete transepidermal necrosis. A skin contact temperature of approximately 53 degrees C/127.4 degrees F for 100 seconds (or approximately 1.7 minutes) would be enough to cause complete transepidermal necrosis. A skin contact temperature of approximately 48 degrees C/118.4 degrees F for 1000 seconds (or approximately 16.7 minutes) would be enough to cause complete transepidermal necrosis. "For extremely high-temperature metallic surfaces (greater that 70 degrees Celsius), damage occurs almost instantaneously upon contact...If the surface temperature exceeds 70 (degrees Celsius) and the surface is metallic, it may present a hazard regardless of contact duration. Attempts should be made to lower the surface temperature below 70 (degrees Celsius)." The standard identifies that hot surfaces can cause serious burns with a high temperature and a short skin contact, or with a lower temperature and a longer skin contact. C. BED 24 INCHES FROM HEATER The facility's investigation included a written statement by LH A which identified she removed Resident #1's feet from the heat register, "moved the bed a little," and went out to get the nurse. Surveyor interviewed LH A on 12/22/10 at 9:40 a.m. who identified that when she found Resident #1 with his left foot inside the heater and his right foot resting on the heater, the bed was locked and in it's lowest position and approximately 10 inches from the heater. LH A stated that she removed the resident's feet from the heater and moved the bed away from the heater before leaving the room to summon help. The facility's investigation also included a written statement by the NHA who identified she notified the DON of the incident by phone at 7:49 a.m. and went immediately to Resident #1's room at which time she assisted with moving Resident #1's bed to allow for the nurse to provide first aid treatment until the ambulance arrived. The DON's summary of the incident included that on 12/12/10, she measured the distance from Resident #1's bed to the heat register (electric baseboard heater) which was 24 inches and the bed was in the locked position. Written statements by the NHA and LH A identified that Resident #1's bed was moved further away from the heater at least 2 times prior to the arrival of the DON. On 12/22/10, Surveyor requested and reviewed all facility policies/procedures provided related to the electric baseboard heaters. The DON stated the facility was still working on a policy/procedure specific for the baseboard heaters. The facility provided the following policies/procedures related to maintenance and housekeeping: "Air Temperature and Adequate Ventilation," dated 6/10; "Heating/Air Systems Inspection," dated 6/10; "Life Safety-Physical Environment," dated 6/10; and, "RESIDENT ROOM BASIC (underlined) CLEAN," not dated (procedure included to "wipe off" heat registers). None of the policies/procedures included anything related to how far the resident beds should be placed from the electric baseboard heaters. The facility also provided to Surveyor on 12/22/10 a "Preventive Maintenance Daily Rounds Log" for November and December, 2010. The log was completed on 3 to 5 days each week and included the outside temperature, and the inside air and water temperatures on each wing. There was no reference to checking the electrical heating system or any individual baseboard heaters. Surveyor interviewed LH A on 12/22/10 at 9:40 a.m. who identified residents' beds should be at least 12 inches from the electric baseboard heaters when the heat was on. LH A stated that when resident rooms were cleaned, which was daily except for every other weekend, the cleaning included dusting/wiping the registers (and beds could be observed at that time to assure that they were at least 12 inches from the heaters, although there was no facility policy/procedure that specified this was to be done). D. HEAT REGISTER COOL TO TOUCH The DON's summary of the investigation identified that Resident #1's heat register was cool to the touch on 12/12/10, following the incident and prior to his transport to the emergency room . Surveyor interviewed DM E on 12/20/10 at 2:50 p.m. who identified that when the air temperature in the room went below what was set by the thermostat in the room, the electric baseboard heater "kicked on," and when the thermostat was "satisfied," it would shut the baseboard heater off. Surveyor interviewed LH A on 12/22/10 at 9:40 a.m. LH A stated that when she pulled the resident's left foot out of the heater on 12/12/10, the heater felt warm to touch at that time but not hot. LH A stated that while staff were providing treatment to his wounds, the register "kicked" back on and became "very hot." LH A stated the resident liked his room warm and added that his thermostat was usually set between 76 and 78 degrees F. E. NO PAIN The DON's summary of the investigation identified that Resident #1 "did not seem bothered by pain" on 12/12/10, following the incident and prior to his transport to the emergency room . Surveyor 's review of Resident #1's record identified that [DIAGNOSES REDACTED]. 08-3185, February, 2009, published by the NDIC, a service of the NIDDK defines peripheral neuropathy as the most common type of diabetic neuropathy which causes "pain or loss of feeling" in the toes, feet, legs, hands, and arms. It was identified that symptoms may include a tingling sensation, sharp pains, extreme sensitivity to touch, and/or numbness or insensitivity to pain or temperature. Surveyor interviewed LH A on 12/22/10 at 9:40 a.m. LH A stated the resident did not complain of pain initially except that his knees hurt, but later when he was specifically asked if his feet hurt, he replied, "Yes." LH A stated the resident's great toes on both feet looked "like raw skin, hamburger, open." LH A stated she felt bad for Resident #1. F. "UNFORESEEABLE AND UNPREDICTABLE" DM E provided Surveyor a copy of "page 4" from his maintenance binder on 12/20/10, and then exchanged it for "page 3," identifying that this was the most representative information regarding the electric baseboard heaters currently in use by the facility. Information from page 3 identified the electric baseboard heater as an "MBB-M." DM E highlighted a section on page 3 related to the accessories and controls which identified the heating system to be from 45 to 135 degrees F. (not identified how hot the metal fins inside the heater were supposed to get). This information did not include the name of the heaters, the operation and maintenance instructions, clearance requirements, or safety information. Surveyor 's investigation of the incident identified the facility should have had adequate resources, personnel, and policies/procedures to assure that the electric baseboard heater was identified as a potential hazard for Resident #1, and to assure that Resident #1's risk factors were addressed in relation to the close proximity of his bed to the electric baseboard heater. Surveyor made the following observation on 12/20/10. Wing E, Room 5, Bed 2, Resident #1 -8:02 a.m. The foot of the bed was against the outside wall at 90 degrees to the electric baseboard heater and the (resident's) left side of the bed was against the inner wall. The baseboard heater started approximately 1 foot past the (resident's) right side of the foot of the bed and extended several feet out from the bed. The baseboard heater was several feet in length and was entirely covered with a lattice-type metal covering which would prevent anyone from putting fingers or toes inside the heater. The top of the baseboard heater was warm, but not hot to touch at that time. See Camera A, Pictures #8 through #13 which were taken on 12/20/10 at approximately 2:35 p.m. On 12/12/10, the nurse's note written by RN B identified that Resident #1's wounds were cleansed and the resident was transported via ambulance to the emergency room . The nurse's note identified that the (hospital) nurse reported the resident sustained [REDACTED]. It was stated the lower extremities were negative for fracture. Surveyor reviewed the emergency room report which identified first and second degree burns to both feet and avulsion (the tearing away) of the left great toenail. A review of Resident #1's record identified that, since the incident, he required twice a day and then daily dressing changes to both feet, with an oral antibiotic initiated prophylactically on 12/16/10 to assist in preventing infection. On 12/22/10, Surveyor observed Resident #1's injuries to his feet during a routine dressing change done at 11:05 a.m. by RN F and LPN G, and pictures were taken (see Camera B, Pictures #1 through #6). The pictures confirmed burns and/or traumatic injury to at least 3 of the five toes on the left foot (significant injury was noted to the great toe) as well as to a deeper area of injury on the bottom/lateral side of the left foot, and to at least 3 of the five toes on the right foot as well as a larger area on the lateral side of the right foot. The wounds consisted of varying degrees of color (pink to red to purple). Surveyor reviewed an article titled Thermal Burns by Jamie Goodis, MD, Emergency Medicine, Stanford University, updated June 28, 2010. It was identified that partial-thickness burns (second-degree) are often further delineated into superficial and deep types with the deeper the injury, the longer the healing time, which may vary from 7-21 days in the more superficial dermis burns to greater than 21 days in the deep dermis burns. It was stated that the American Burn Association has developed criteria for burn center admission that included any full-thickness or partial-thickness burn involving critical areas which included hands and feet, "as these have significant risk for functional and cosmetic problems..." It was also identified that elderly persons are at increased risk not only for having a burn-related injury, but for having increased morbidity due to their thinner skin and decreased healing abilities. 2. Surveyor made the following observation on 12/20/10. Wing D, Room 8, Bed 2, Resident #2 -7:42 a.m. and 9:28 a.m. The head of the bed was against the outside wall at 90 degrees to the electric baseboard heater and the (resident's) left side of the bed was against the inside wall. The baseboard heater started at the (resident's) right side of the bed and extended several feet from the side of the bed. The top of the baseboard heater was hot to the touch and registered 110 degrees F. on Surveyor 's thermometer at each observation. The opening near the top of the heater was large enough for toes or fingers to touch the metal fins inside the heater. The outside fins reached a temperature equal to or just slightly greater than the temperature of the top of the heater, while the inside fins (close enough to touch with toes or fingers) rapidly reached a temperature reading of 220 degrees F. (surveyor thermometer able to measure to only 220 degrees F.). There was no covering over the baseboard heater nor other protective measures that would prevent one from putting toes or fingers inside the heater. See Camera A, Pictures #15 and #16 which were taken on 12/20/10 at approximately 2:35 p.m. The facility's Roster Matrix received on 12/20/10 identified that Resident #2 had cognitive impairment. The resident record identified the resident was at risk for potential injury from the electric baseboard heater as evidenced below. Resident #2 is [AGE] years old, had been recently admitted to the facility on [DATE] after hospitalization following a fall at home where he was too weak to get up, and was found on the floor approximately 2 days later suffering lacerations and multiple bruises to the head and body. It was identified that current [DIAGNOSES REDACTED]. It was identified he was his own decision-maker but required family assistance in making decisions. Resident #2's current nursing care plan, dated 11/22/10 and 12/08-09/10, identified the resident had a memory problem related to mild confusion and forgetfulness, that he had impaired vision related to glaucoma, that his ADL abilities had deteriorated, that he experienced insomnia, and that he was at risk for falls and subsequent injury related