Every finding on record at Retirement Ranches Inc.

Based on record review and interview, the facility failed to ensure residents were provided with a choice about aspects of his/her life that are significant to the residents for 1 (R #1) of 5 (R #1, R #2, R #3, R #4, and R #5) residents reviewed by not having the choice to shower when they wanted. This deficient practice could likely result in residents feeling a loss of humanity (the quality of being human) by and a loss of dignity (the importance and value that a person has, that makes other people respect them or makes them respect themselves). The findings are: A. Record Review R #1's Face Sheet revealed R #1 was admitted to facility on 12/26/25 with the following diagnoses:1. Type 2 diabetes (DM2, a condition results from insufficient production of insulin, causing high blood sugar),2. Personal history of COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions),3. Hypertension (HTN; high blood pressure),4. Peripheral vascular disease (PVD; poor circulation),5. Chronic Pressure Ulcers (is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in conjunction with shear and/or friction) of left and right heel.B. Record review or R #1's Electronic Health Record (EHR) revealed R #1 tested positive for COVID-19 on 01/10/26 and was placed on transmission-based precautions (TBP; used to prevent the spread of infectious agents from individuals who are suspected to be infected. Includes contact precautions, droplet precautions, and airborne precautions. Examples are wearing gloves, face masks, and gowns or using disposable equipment).C. Record review of R #1's progress notes revealed:1. R #1 received a shower on 01/14/26.2. R #1 made a complaint to staff about not being able to shower on 01/16/26 due to being in isolation (the practice of separating residents who are infected or suspected of being infected with a contagious disease or infection) for COVID.3. R #1 made another request for a shower on 01/17/26 (Saturday) and was told by staff that her shower day is on Tuesdays.4. On 01/19/26, R #1 was upset about not being able to shower and stated that she stated she felt dirty and needed to take a shower.5. R #1 received a partial bed bath on the morning of 01/19/26 at 6:10 am and a complete bed bath that afternoon.6. R #1 received a shower on 01/20/26. D. Record review of R #1's Baseline Care Plan dated 07/01/25 indicates R #1's preference for hygiene is to have a shower, not bed baths.E. On 03/17/26 at 12:30 pm, during an interview with the Director of Nursing (DON), residents are informed at the time of isolation being put in place that during the time of isolation bed baths will be given instead of showers. The DON stated it is policy to allow residents to shower when they ask even if the residents are in isolation. The DON confirmed that it does not meet her expectation to allow a resident to go five days without showering especially when the resident is requesting a shower. F. On 03/17/26 at 12:50 pm, during an interview with the Certified Nurse's Aide Supervisor (CNAS), he stated that he does not recall being notified of the situation where R #1 was upset because she wasn't allowed to shower while she was in isolation. The CNAS stated that if R #1 requested a shower, then she should have been showered.

Based on record review and interview, the facility failed to: 1. Ensure that all residents can request or refuse emergency and lifesaving care by failing to obtain and review residents' wishes regarding code status (instructions regarding the type of medical interventions a person wants in the event of a medical emergency), medical interventions (comfort measures such as pain relief or use of oxygen, use of medical treatment such as intubation) and artificial hydration/nutrition (the provision of nutrition and fluids by methods other than normal eating and drinking), 2. Establish mechanisms for documenting and communicating the residents' choices of advanced directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law and relating to the provision of health care when the individual is incapacitated) to the staff responsible for residents' care. These deficient practices have the potential to affect all 83 residents residing at the facility as identified by the census provided by the Administrator on 09/23/25. If the facility does not know the residents' wishes and has no mechanisms for communicating the wishes to the staff responsible for providing care, then residents' wishes might not be followed. The findings are: R #3A. Record review of R #3's Face Sheet revealed the following: 1. R #3 was admitted to the facility on [DATE] with chronic kidney disease (CKD; impaired kidney function), acute kidney failure (sudden decline in kidney function), and hypertensive heart disease (heart disease caused by high blood pressure).2. The Advanced Directives section of the Face Sheet was blank. B. Record review of R #3's electronic health record (EHR) revealed the records did not contain any documentation stating what R #3's wishes are regarding medical interventions and artificial hydration/nutrition. R #4C. Record review of R #4's Face Sheet revealed the following: 1. R #4 was admitted to the facility on [DATE] with aphasia (disorder that results from damage to portions of the brain), hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), chronic kidney disease, and hypertensive heart disease.2. The Advanced Directives section of the Face Sheet was blank. D. Record review of R #4's EHR revealed the records did not contain any documentation stating what R #4's wishes are regarding code status, medical interventions, and artificial hydration/nutrition. R #25E. Record review of R #25's Face Sheet revealed the following: 1. R #25 was admitted to the facility on [DATE] with Alzheimer's disease (a progressive brain disorder that damages memory, thinking, and learning skills), unspecified convulsions (unclassified seizures), acute respiratory failure, and myocardial infarction (heart attack). 2. The Advanced Directives section of the Face Sheet was blank. F. Record review of R #25's electronic health record (EHR) revealed the records did not contain any documentation stating what R #25's wishes are regarding medical interventions and artificial hydration/nutrition.G. On 9/26/25 at 11:07 am during an interview with Admissions Director (AD), she confirmed the facility does not have record of residents' wishes regarding full code status, medical intervention or artificial hydration/nutrition. The AD stated there is no additional documentation of the residents' wishes for residents who do not already have an advance directive. She stated if the resident is a DNR (do not resuscitate) then an emergency medical services DNR form is completed, however it does not contain information regarding medical interventions and artificial hydration/nutrition. She stated that residents are only asked about advanced directives during admission and are not reviewed on a regular basis.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions by not ensuring food items stored in facility's freezer were opened, labeled, and dated. This deficient practice is likely to affect 83 residents listed on the resident census list provided by the Administrator on 09/22/25 and could likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are:A. On 09/22/25 at 10:43 am during observation of the facility's walk-in freezer the following items were found open, unlabeled and undated: 1. One open bag of what appeared to be frozen broccoli.2. One open bag of what appeared to be frozen pizza. 3. One open bag of what appeared to be frozen bacon. B. On 09/22/25 at 10:47 am during an interview with the Dietary Aide (DA) #1, she confirmed the items were not labeled and not dated. DA #1 stated it does not meet her expectations and everything in the fridge and freezer should be labeled and dated.

Based on observations and interviews, the facility failed to utilize enhanced barrier precautions (EBP; an infection control intervention) when providing direct care to 3 (R #4, R #12, and #15) of 3 (R #4, R #12, and #15) residents. Failure to utilize enhanced barrier precautions when performing direct care has the potential to spread organisms, diseases, and other health conditions among the residents. The findings are:A. On 08/22/25 at 10:15 am a random observation of the facility revealed the carts that held personal protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) were located at the entrance to each pod (group of resident rooms located near each other). The carts were located approximately fifteen to twenty feet from the nearest resident room that required PPE to be utilized. R #4 B. On 09/23/25 at 8:32 am during a random observation of the facility, a sign indicated EBP is required when providing direct care to R #4 was hanging on the wall near the entrance to his room. Certified Nurse Aide (CNA) #3 assisted R #4 into his room and closed the door behind them. CNA did not have any PPE with her. Approximately 20 minutes later CNA #3 and R #4 came out of the room. C. On 09/23/25 at 8:55 am, during an interview with CNA #3, she confirmed she just assisted R #4 with personal care (direct care provided by staff to assist a resident with activities of daily living such as changing adult briefs, changing clothes, catheter care, showering, etc.) and did not utilize the required PPE. R #12 D. On 09/23/25 at 9:17 am during a random observation of the facility, a sign indicated EBP is required when providing direct care to R #12 was hanging on the wall near the entrance to her room. CNA #4 assisted R #12 to her room and closed the door behind them. CNA #4 did not have any PPE with her. Approximately 25 minutes later, CNA #4 came out of the room. E. On 09/23/25 at 9:45 am during an interview with CNA #4, she confirmed she just assisted R #12 with personal care and did not utilize the required PPE. R #15 F. On 09/22/25 at 9:00 am, a random observation of R #15's room revealed a sign on the door that indicated R #15 was on enhanced barrier precautions (EBP), staff are required to wear personal protective equipment (PPE: gowns, masks, and gloves) when providing care for R #15. G. On 09/22/25 at 1:43 pm during an observation of R #15's room, CNA #2 provided care (vital signs) for R #15. CNA #2 did not wear gloves, gowns or masks while providing direct care to R #15. H. On 09/22/25 at 1:49 pm during an interview with CNA #2, she confirmed R #15 is on EPB, so staff should be wearing gloves, gowns, and masks to provide contact care and should have worn PPE for R #15. I. On 09/25/25 at 12:38 pm during an interview with the Director of Nursing (DON), she stated she expects all staff to utilize the required PPE using EBP precautions when providing direct care to residents that require EBP.

Based on observation and interview, the facility failed to provide personal privacy for 3 (R #29, R #61 and R #64) of 4 (R #4, R #29, R #61, and R #64) residents reviewed for privacy when staff administered medications in the commons area of the building after not giving the residents the chance to choose whether they received their medications privately. This deficient practice is likely to cause residents to feel embarrassed or ashamed. The findings are: A. On 09/22/25 at 12:13 pm during an observation of the lunch meal, R #29 sat in the commons area near his room, Certified Medical Assistant (CMA #2) walked up to him and administered his medications. There were seven other residents, several staff members and one family member present in the commons area. B. On 09/24/25 at 8:10 am a random observation of the facility revealed the following: 1. R #61 sat in the commons area near her room when CMA #1 walked up to her and said, here are your meds while she administered medications. 2. R #64 sat in the commons area near his room when CMA #1 walked up to him and said these are your meds while she administered his medications. 3. There were five other residents, one staff member, and one family member present in the commons area. C. On 09/25/25 at 1:10 pm during an interview with the Director of Nursing (DON), she stated that medications should be administered privately and confirmed that the commons areas where meals are also served is not private.

Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #2) of 2 (R #2 and R #5) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are:A. Record review of R #2's face sheet reveals R #2 was admitted to the facility on [DATE] with the following diagnosis:1. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).2. Adjustment disorder with mixed anxiety and depressed mood (a mental health condition characterized by significant emotional distress and behavioral changes that occur in response to a stressful life event).3. Generalized anxiety disorder (a common mental health condition characterized by excessive and persistent worry and anxiety that is difficult to control).4. Unspecified dementia, mild, with mood disturbance (a form of dementia that is mild, has not been specified to a particular type (like Alzheimer's or vascular dementia), and includes emotional changes such as depression, lack of interest/motivation, or loss of pleasure).B. Record review of R #2's physician's orders revealed the following: 1. An order for buspirone tablet (anxiolytic; medication used to treat anxiety disorders), 10 milligrams (mg). Give two tablets by mouth twice daily for major depressive disorder. Start date: 01/08/24.2. An order for hydroxyzine tablet (antihistamine; medications used to treat anxiety, allergic reactions and as a sedative before and after surgery), 25 milligrams (mg). Give one tablet by mouth at bedtime for major depressive disorder. Start date: 03/06/24.3. An order for Tylenol PM Extra Strength tablet (a combination mediation containing Acetaminophen [medication used to relieve mild to moderate pain and reduce fever] and Diphenhydramine hydrochloride [an antihistamine that promotes sleep]), 25-500 milligrams (mg). Give 1-2 tablets by mouth at bedtime for unspecified dementia with mood disturbance. Start date: 06/24/254. An order for Venlafaxine capsule (antidepressant: medication used to treat depression and various anxiety disorders) 150 milligrams (mg). Give 1 capsule by mouth one time daily for adjustment disorder with mixed anxiety and depressed mood. Start date 03/06/2023. C. Record review of R #2's medical record revealed the medical record did not contain any consent for the use of buspirone, hydroxyzine, Tylenol PM Extra Strength and Venlafaxine. D. On 09/25/25 at 12:37 pm, during an interview with the Director of Nursing (DON), she confirmed staff did not obtain the consent form for the use of psychotropic medications (psychotropic medication; any drug that affects brain activities associated with mental processes and behavior) for R #2. The DON confirmed staff are expected to complete the psychotropic medication consent form prior to the resident starting psychotropic medications and did not.

Based on observation, record review, and interview, the facility failed to provide two-person assistance for 1 (R #61) of 3 (R #4, R #29, and R #61) residents reviewed for transfer care (assisting a resident to move from one place to another). This deficient practice could likely result in R #61 being injured during a transfer. The findings are: A. On 09/24/25 at 8:30 am, during a random observation of the facility, Certified Nursing Assistant (CNA) #1 brought a mechanical lift into R #61's room, CNA #1 closed the door behind her, there were no other staff in the room. Approximately 15 minutes later, CNA #1 came out of R #61's room. B. On 09/24/25 at 8:51 am during an interview with CNA #1, she confirmed that she transferred R #61 using a mechanical lift by herself. CNA #1 stated that she used a maxi lift (a type of mechanical lift) and they can be operated using one person.C. Record review of R #61's care plan dated 08/26/25 revealed R #61 is to transfer using a maxi lift and two persons assist. D. On 09/24/25 at 11:53 am during an interview with Certified Nursing Assistant Coordinator (CNAC), he confirmed that according to the care plan, R #61 requires two staff to assist during transfers.

Based on record review and interview, the facility failed to update a resident's care plan to reflect new diagnosis and treatment plans for 1 (R #84) of 7 (R #1, R #8, R #10, R #14, R #30, R #80, and R #84) residents reviewed for comprehensive care plans. This deficient practice could likely result in resident care not being closely monitored and not managed to meet the needs of the residents. The findings are: A. Record review of R #84's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with the following diagnosis: 1. Type II Diabetes Mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar), 2. Chronic combined systolic (congestive) and diastolic (congestive) heart failure (CHF; impaired heart function), 3. Hypertensive heart disease with heart failure (heart disease caused by high blood pressure), 4. Complete traumatic amputation of left great toe, sequela (left big toe removed because of long-term effects of diabetes mellitus, 5. Benign prostatic hyperplasia without lower urinary tract symptoms (a condition where the prostate gland enlarges but does not cause any noticeable urinary problems). B. Record review of R #84's physician orders revealed the following: 1. An order for wound care dated 08/30/25, 2. An order for foley catheter (a thin, sterile tube inserted into the bladder to drain urine) care dated 09/10/25. C. Record review of R #84's care plan, last reviewed on 09/18/25, revealed the following: 1. The Care Plan did not contain any information about wound care and interventions, 2. The Care Plan did not contain any information about catheter care and interventions. D. On 09/26/25 at 1:00 pm, during an interview with the Director of Nursing (DON), she stated the care plan was not revised to include wound care and interventions or catheter care and interventions. The DON stated this does not meet her expectations and the care plan for R #84 should have been revised.

Based on interviews, the facility failed to ensure that residents are able to receive mail on Saturdays for all 83 residents residing at the facility as identified on the census provided by the Administrator (ADM) on 09/23/25. This deficient practice is likely to result in residents not receiving timely communication which could result in feelings of isolation. The findings are: A. On 09/24/25 at 3:00 pm, during the Resident's Council Meeting, the residents stated mail is not delivered on Saturdays and they would like to receive their mail when it is delivered to the facility. R #49 stated he has never received his mail on a Saturday, even when he is waiting for a package. B. On 09/25/24 at 1:33 pm, during an interview with the Social Services Director (SSD), she confirmed the mail is not delivered on the weekends. She stated she does not work on Saturdays so any mail that comes in over the weekend would not get delivered until Monday when she returns to work.

Based on observation and interview, the facility failed to ensure the treatment cart on the 200 hall was locked while unattended. This deficient practice had the potential to affect all 34 people residing in the [NAME] side (facility pods one, two, and three) of the facility by allowing unauthorized people access to their medical supplies and personal health information. The findings are: A. On 06/12/25 at 10:15 am, a random observation of the facility revealed the treatment cart located near the nurse's station in the 200 hall was unlocked, and facility employees were not in the area. B. On 06/12/25 at 10:17 am, during an interview with Registered Nurse (RN) #1, she confirmed the treatment cart was unlocked. RN #1 stated the treatment cart should be locked and secured while not in use.

Based on observations, menu review, interview, and facility policy review, the facility failed to ensure menus were in place for all physician prescribed diets and failed to follow the menu for 80 of 80 census residents. This failure has the potential for residents to get the incorrect food in accordance with their diets; not receive nutritionally adequate meals; and receive repetitive food items. Findings include: Review of the facility's policy titled, Menus with a revised date of October 2017, revealed menus for regular and therapeutic diets are written at least two (2) weeks in advance and are dated and posted in the kitchen at least one (1) week in advance .The dietitian reviews and approves all menus .Copies of menus (as served including substitutions) are kept on file for at least 5 weeks. The menu titled Main Meal Week 3 listed the breakfast, lunch, and dinner for Monday 07/28/24 through Saturday 08/03/24. The menu for the noon meal stated Picadillo, refried beans, flour tortilla, lettuce and tomato, sour cream, and creme [NAME] were supposed to be served. The menu did not include any portion sizes and did not specify a diet. On 07/31/24 at 11:01 AM, a menu for the resident diets and with portion sizes was requested. The Director of Dietary (DOD) stated that was the only menu he had, and he did not have menus listing the portion sizes or menus for the therapeutic or texture modified diets ordered by the physicians. He stated they just followed the menu provided, and the cook pureed or chopped the items on the menu. He stated if they could not be pureed, the cook decided what to serve them and decided on the portion sizes. During observations of the meal on 07/31/24 from 11:30 AM to 12:00 PM, the DOD and Cook1 served the noon meal from the steam table. They served the residents on regular diets a six-ounce scoop of Picadillo, one flour tortilla, six-ounce scoop of lettuce and tomato, sour cream, and a bowl of creme [NAME]. They served the residents on mechanical soft diets six ounces mechanical soft Picadillo, chopped up tortilla, six ounces chopped lettuce, and a cup of creme [NAME]; and the residents on puree diets received six-ounces of mashed potatoes, four-ounces of picadillo, gravy on the potatoes and picadillo and a bowl of tomato soup. The residents with orders for or a care plan intervention of finger foods received chicken fingers, fried zucchini strips, and tater tots. No refried beans were available on the steam table as listed on the menu for 07/31/24. During an interview on 07/31/24 at 12:00 PM, the Director of Dietary verified they did not serve the refried beans or equal alternate. He stated the refried beans were not available in the facility. He also verified the menu did not include any portion sizes and stated he did not have any planned menus for therapeutic or mechanically altered diets. He stated he had [AGE] years experience in the restaurant industry, and the cook had [AGE] years experience as a cook in a nursing home. He stated he felt they could make the decision on what to serve the residents on mechanically altered and therapeutic diets. During an interview on 07/31/24 at 12:48 PM, the Director of Nursing (DON) stated they should have followed the menu. The DON stated if they did not have refried beans then they could have run down to the store to buy some. During an interview on 07/31/24 at 1:10 PM, the Registered Dietitian (RD) stated she had only been the RD at the facility for a month. She stated the previous dietitian told her the DOD should have had a binder containing the spreadsheets/menus with portion sizes listed for the regular, therapeutic, and the texture modified diets. She stated she expected them to follow the individual diets/ menus listed on the menus/spread sheets. She stated the spread sheets would list the portion sizes and the food items planned on each of the diets. During an interview on 07/31/24 at 3:28 PM, the DOD stated he did not have any binders with menus and spread sheets. On 08/01/24 at 8:54 AM, the five-week cycle of menus were requested from the DOD and was not provided. During confidential resident interviews conducted on 07/29/24 and 07/30/24, three residents stated the menus were not consistently followed. Review of resident council meeting minutes, dated 04/29/24, revealed one resident stated the menus were not followed, and she had a hard time getting an alternate. During an interview on 07/29/24 at 11:56 AM, Certified Nurse Aid (CNA) 2 stated R34 and R42 were supposed to receive finger food. She stated most of the time they get fried chicken fingers and French fries. Observations revealed R34 and R42 received chicken fingers and fries on 07/29/24 and chicken fingers and tater tots on 07/31/24. On 07/31/24 at 1:20 PM the DON provided a document titled Order Report by Category: 07/01/24 - 07/31/24. She stated it contained the residents' diets as ordered by the physician. Review of the document revealed the facility had residents on the following diets: regular, regular with fortified foods, no added salt with fortified foods, low concentrated sweets, low concentrated sweets no added salt with fortified foods, puree texture diet, puree with fortified foods, mechanical soft with fortified foods, no added salt mechanically soft, cardiac regular diet with fortified foods, finger foods only with fortified foods, and regular gluten free foods with no [NAME] products. A review of the menu revealed there was no planned menu for these diets and the menu for the week only listed the food items and did not include portion sizes.

Based on observations, record reviews, interviews, and facility policy review revealed the facility failed to ensure one out of six medication carts and one out of two treatments carts were securely locked when unattended. This failure put the residents at risk of taking medications that were not theirs. Findings include: Review of the facility's policy titled, Security of Medication Cart with a revised date of April 2007, revealed the medication cart shall be secured during medication passes. Review of the Policy Interpretation and Implementation revealed the nurse must secure the medication cart during medication pass to prevent unauthorized entry .the medication cart should be parked in the doorway of the resident's room during the medication pass .the cart doors and drawers should be facing the resident's room .medications carts must be securely locked at all times when out of the nurses' view .when the medication cart is not being used, it must be locked and parked at the nurses' station. During an observation on 07/29/24 at 10:54 AM, one medication treatment cart on the 300 hall was left unlocked while Registered Nurse (RN) 1 went into a room on the 300-hall with the door was closed. Observation further revealed RN1 did not have the cart in her view. During an observation on 07/29/24 at 10:57 AM, RN1 went back to the medication cart on the 300-hall, and she did not lock it. During an observation on 07/29/24 at 11:33 AM, both the medication cart and the treatment cart were sitting side by side, unlocked and unattended by the nurses, adjacent to the electrical room on the 300-hall. Observation further revealed one staff walked by the carts. Observation revealed this surveyor was able to open the drawers and medications were inside. During an observation on 07/29/24 at 11:35 AM, RN1 walked to the medication cart and picked up something from it, left the cart unlocked, went into room [ROOM NUMBER] with the door closed, and the medication cart was not in her view. Observation further revealed a Certified Nursing Assistant (CNA) walked by the unlocked cart. During an observation on 07/29/24 at 11:35 AM, the treatment cart on the 300-hall was unlocked and the nurse was not in view of the cart. During an observation on 07/29/24 at 11:37 AM, RN1 went to the medication cart located on the 300-hall, prepared the medication, went into room [ROOM NUMBER], closed the door, and left the medication cart unlocked. Observation further revealed the medication cart was not in view of RN1. During an observation on 07/29/24 at 11:41 AM, RN1 went back to the medication cart on the 300-hall, retrieved something, and went back into room [ROOM NUMBER], closed the door and the medication cart was not in her view. Observation further revealed two CNAs walked by the medication cart. During an observation on 07/29/24 at 11:43 AM, RN1 walked back to the medication cart located on the 300-hall, prepared medications, left the medication cart unlocked and went into room [ROOM NUMBER]. Observation further revealed RN1 could not see her medication cart. Observation at 11:46 AM revealed RN1 went back to the medication cart, left it unlocked, and went back into room [ROOM NUMBER] which was out of her view. During an observation on 07/29/24 at 12:45 PM and 1:45 PM, the treatment cart located in the hallway by the nurse's station on the 200-hall by room [ROOM NUMBER] was unlocked and unattended. During an observation on 7/29/24 at 3:50 PM, RN1 went into room [ROOM NUMBER] to do an accucheck and left the medication cart on the 100-hall unlocked and not in her view. During an observation on 07/29/24 at 4:26 PM, the medication cart in the common area of the 100-hall was not locked and was not in view of the nurse. During an observation on 07/30/24 at 2:54 PM, the medication cart was unlocked on the 200-hall and RN1 was not in view of the medication cart. Observation further revealed one CNA walked by the cart. During the observation, RN1 came back to the medication cart, took something from it, and did not lock the medication cart. Observation further revealed RN1 walked down to the 300-pod completely out of view of the unlocked medication cart. Observation revealed there were medications in the drawer when opened. During an observation on 07/30/24 at 2:59 PM, RN1 revealed there were prescription medications and over the counter medications in the medication cart, and the cart was unlocked. During an interview on 07/30/24 at 2:59 PM, RN1 revealed she had not locked the medication cart because she was in and out of the resident's room. She further revealed the narcotic box located in the medication cart was secured with a lock even though the medication cart itself was unlocked. Interview with RN1 further revealed she had stayed within the vicinity of the medication cart and did not have to lock it if the medication cart was in view. Interview further revealed, when RN1 was asked if she considered in the vicinity when she walked from the 200- pod down the hall to the 300-pod and left the medication cart unlocked. RN1 revealed she was not in the vicinity and the medication cart should have been locked. Interview with RN1 revealed the medication cart was supposed to be locked when out of view so no one else could have access to the medications. During the interview RN1 stated a resident could get into the medication. During an interview on 07/30/24 at 4:16 PM, the Director of Nursing (DON) stated anytime the nurse was not in front of the medication and treatment carts the carts should be locked. The DON further stated you never knew who was around the corner that could get into the carts, which have medications and creams located in them. The DON stated a lot of the facility's residents had dementia and would not know to not take the medications or creams and could eat them. The DON stated the narcotics needed to be behind two locks and if the outside lock was not locked then the narcotics were only under one lock.

Based on observations, record review, and interview the facility failed to prevent an accident by not providing a safe transfer for 1 (R #4) of 4 (R #3, 4, 5 and 6) residents reviewed for falls when the facility failed to: 1. Ensure staff were adequately trained on how to use transfer lifts. 2. Identify number of staff needed for each resident to ensure a safe transfer. 3. Have a method for staff to determine for which residents the leg strap should be used. This deficient practice likely resulted in R #4 falling during transfer and sustaining a new fracture around the hardware in her femur (thigh bone) and a broken pelvis. The findings are: A. Record review of the face sheet for R #4 revealed that she was admitted to the facility on [DATE] and went out to the emergency room (ER) due to a fall on 10/11/23. B. Record review of the physical therapy assessment for R #4, dated 10/10/23, indicated she was at the facility for the following: orthopedic aftercare (recovery from surgery) fracture of unspecified part of neck of left femur (break in the thigh bone), fracture of superior rim of unspecified pubis (pelvis), wedge compression fracture of second lumbar vertebra [collapsed vertebra (the bone that makes the spine.)] C. Record review of the baseline care plan for R #4, completed on 10/11/23, did not indicate if resident required one or two staff for transfers. D. Record review of a progress note for R #4, dated 10/11/23, indicated the following: POC (plan of care) meeting sons here, resident refused to come to POC meeting. Therapy says she is challenging with therapy. She is very deconditioned (loss of physical fitness). She is very weak. Therapy is hoping with scheduled pain medications that will help. She has low activity tolerance, wants to stay in bed. OT (occupational therapy) is looking at reducing frequency to less than 5 days a week. E. Record review of the progress notes, dated 10/11/23, indicated the following: Writer called to patient room at 1655 (4:55 pm) code green (fall), upon initial assessment resident sitting on ground in front of bed, [NAME] [sic] lift (a type of mechanical lift used to transfer from one surface to another) cattycorner to resident. CNA (certified nursing assistant) reports while using lift, the resident's left leg slipped out from in front of her, causing her to slowly slip out of lift. CNA reports she slowly lowered resident to ground. CNA reports sling was in place and correctly buckled onto resident. Resident denies pain at this time. Left leg is showing visible shortening compared to right leg. Left leg is positioned slightly abducted towards the left side. Patient has copious bleeding noted around her leg and bottom. Sx (symptom) wound dressing is over saturated with blood and leaking out onto floor. No skin tears noted at this time. Assisted pt (patient) off the floor x4 (using four staff members) transfer into bed. Once laying supine, left leg was secured away from right leg. Dressing was removed from sx site. Sx site appears to have opened on top portion. Stitches were not present on open area. Site was actively bleeding .Spoke with hospital, resident (R #4) has a broken pelvis and femur and is being flown to Lubbock. F. Record review of the hospital records, dated 10/11/23, indicated R #4 had an acute fracture of the left pubic ramus (a fracture of the pelvis from a high impact trauma, falls, or repetitive strain) and an acute communicated periprosthetic fracture of the midshaft left femur (a broken bone that occurs around implants. It can happen during the surgery, within a few weeks after the procedure, or from a fall or other trauma). G. On 02/22/24 at 3:17 pm, during an interview with the Director of Rehabilitation (DOR), she stated she did not work with R #4 much. She stated R #4 was weight bearing (able to stand without support) as tolerated without restrictions. She required substantial assistance. R #4 did not help with transfers (R #4 would not help staff when they transferred her.) The DOR stated the only way to transfer the resident was with the Sara lift. She stated the resident was not strong enough for the [NAME] steady (non-powered device that assist with sit to stand transfers), a Hoyer lift (a mechanical lift designed to transfer a resident safely) was not appropriate due to her surgery, and she was too heavy for two staff to transfer without a machine. The DOR stated staff transferred the resident with the Sara lift three of four times before she fell . The DOR was not clear how many people were required when using the Sara lift. She stated two people are needed for the Hoyer lift and only one is needed for the [NAME] Stedy (manual sit to transfer aid that enables one caregiver to transfer a patient). H. On 02/22/24 at 4:03 pm, during an interview, the son of R #4 indicated his mother fell and broke her hip and femur at her assisted living home. R #4 had surgery and came to the facility for rehabilitation. The son stated his mother was at the facility for one day when she had a fall and rebroke her femur. He stated she called him and told him she could not do what the staff wanted her to do. He said she was [AGE] years old, just had surgery, and she was tired. He stated he wanted his mom to get better so she could go back to the assisted living home. The son stated his brother walked into their mother's room at the facility on 10/11/24 [right after the fall], and she was on the floor. His brother told him there was a lot of blood. He stated the staff got R #4 back into bed and called 911. When she got to the emergency room , the hospital staff took some x-rays that revealed R #4 re-broke the area that had just been fixed. I. On 02/23/24 at 9:11 am, during an interview with the Director of Nursing (DON), she stated R #4 came in with a partial or full hip replacement. The DON stated a CNA lowered R #4 to the floor during a transfer. The DON stated the resident's leg became twisted. R #4 stated the sling choked her, because it was around her neck. Then R #4 let go of the handles on the Sara lift. The DON stated the staff got the resident back into bed. She said there was an observable discrepancy in her leg length, and her leg was twisted out a little bit. The DON confirmed that during her investigation after the incident, it was determined that the leg strap on the lift was not used during R #4's transfer, and without the leg strap a resident was able to step off the machine. The DON stated the leg strap should have been used. J. On 02/23/24 at approximately 9:30 am, the DON performed a demonstration of the Sara lift (same type of lift involved with the fall) being used with the CNA Coordinator as the resident. The first sling the DON used did not stay tight. The DON tighten it, and it loosened up. She took the sling off and put another sling on. The second sling stayed in place. The CNA Coordinator sat in the sling, and it stayed tight. The Sara lift had the leg strap, and the DON used it during the presentation. The CNA Coordinator wore the sling around his waist and the leg strap around his legs, and the CNA Coordinator did not move during the transfer demonstration. K. On 02/23/24 at 10:15 am during an interview with the Licensed Practical Nurse (LPN) #1, she stated when she entered the room on 10/11/23, R #4 was on the ground with her legs spread apart. LPN #1 said there was a lot of blood, but she could not tell where it was coming from. She said, when the staff tried to lift the resident back into bed, R #4 was not able to assist (help lift herself up). The LPN stated the resident was dead weight and required four staff members to assist her back into bed. L. On 02/23/24 at 2:01 pm, during an interview, CNA #1 stated she was transferring R #4 from the bed to the wheelchair on 10/11/23, and the resident's leg started to contort. She stated she really did not know what happened with R #4's leg. She said the resident's leg just started to move, and the resident did not want to continue with the transfer. CNA #1 realized the resident slipped down, and she was not able to transfer R #4 back to the bed. CNA #1 stated she was not trained to use the Sara lift she used that day (10/11/23). She was trained on a different Sara lift. She stated the one she trained on had two leg straps, one for each leg, and they buckled in place sort of like a seat belt. The CNA stated, on the first day R #4 was at the facility, they transferred her with two staff using the Sara lift, and the resident was fine. The CNA said the next day when she went to transfer R #4, it was just her and there was not a second staff member. She stated she did not ask for a second staff to assist her, because they do not need two staff to use the Sara lift. CNA #1 stated the Sara lift she used to transfer R #4 on 10/11/23 did not have a leg strap so she did not use a leg strap. She stated, during the transfer, R#4 felt like she was choking due to the sling, but the sling was never around the resident's neck. CNA #1 stated she was not sure why R #4 felt like she was choking, because the sling was tight around the resident. The CNA stated the resident may have felt like she was choking when the sling came off over her head and arms. CNA #1 stated that during the transfer, the sling came completely off the resident. M. On 02/27/24 at 2:15 pm, during an interview with CNA #2, she stated she always used two people with any of the lifts, because it was safer. She stated the leg strap was always used as well. She stated the leg strap was attached to the machine so it was never lost. N. On 02/27/24 at 4:36 pm, during an interview with CNA #1, she stated she trained on the lift in Hall 6 that had the two leg straps. She was never told the leg strap had to be used for the specific Sara lift that she used with R #4 on 10/11/23. She also was not aware she needed two people to transfer the resident. She stated the lift she used with R #4 on 10/11/24 only required one person to transfer so she felt like that would be fine. She stated the day prior (10/10/24) there were three staff in the room when she transferred R #4. CNA #1 stated, No one said that she was two-person transfer. Regarding the incident, CNA #1 stated the resident slipped out of the sling. She said she really did not know how that happened, because the sling was tight. O. On 02/27/24 at 4:45 pm, during an interview with the DOR, she stated the lift did not have leg support when she [CNA #1] used it on 10/10/24 with R #4. She stated she thought the leg strap implementation came after the incident with R #4 occurred, but she was not sure. P. On 02/28/24 at 8:48 am during an interview with the CNA Coordinator, he stated everyone who provided direct care was taught on every lift they have in the building. New hires are trained on the lifts during their orientation. The Sara lifts the facility used through out the whole building, except the one on Hall 6 (which had a different type of leg strap), did not require the use of the leg strap to operate the machine. He said it had been optional to use the leg strap. He stated that sometime in April or May 2023, they did a training on the lifts that included putting the resident in the lift correctly and making sure you understand the lift before using it. He stated the DON implemented using the leg strap for all lifts at that time. Prior to this, staff did not use the leg straps on anyone. He stated the use of leg straps could vary. He said the leg straps could be used as needed and based on resident behavior. The CNA Coordinator did not have an answer on how staff would determine if a new resident needed to use the leg strap during a transfer. Q. On 02/28/24 at 2:20 pm, during an interview with CNA #3, she stated they always used the leg attachment. She said if they did not use the leg attachment then a resident would step off of the lift. CNA #3 stated it was a safety issue not to use it. She stated she always used two staff when using any of the lifts, for the protection of the CNA and the resident. R. On 02/28/2 at 2:30 pm, during an interview with CNA #4, she stated she always used the leg straps on the Sara lift. She said the resident had to be positioned correctly for the resident safety. CNA #4 said the resident cannot sit at an angle or lean to the side, and staff had to position the sling right or the resident could slip out of it. CNA #4 stated there was a lot that went into the use of lifts. CNA #4 also stated she used another staff to assist her when she used the lift, because it was safer. 40671 S. On 02/23/24 at 9:10 am, during an observation of a Sara lift located in Pod/Unit/Hall 4 revealed there was not a leg strap attached to the lift. Further observation revealed there was a loose leg strap near the lift. T. On 02/27/24 at 5:06 pm, during an interview with DON, she stated the leg straps were now tethered to the mechanical lift, because there were times when leg straps were misplaced or unavailable when needed. She stated this change, attaching the leg straps by a tether (tying) to the machines, was implemented prior to R #4's fall in October 2023. The DON stated it was implemented at the same time as a training on lifts in May 2023. U. On 02/27/24 at 5:15 pm during a random observation of Sara lift in Pod 4 revealed there was not a leg strap attached to the lift. Further observation revealed there was a loose leg strap near the lift. V. On 02/28/24 at 9:04 am during an interview with the Maintenance Director, he stated all the Sara lifts came with the leg straps. W. On 02/28/24 at 2:32 pm during an interview with CNA #6, she stated she was a CNA for nine years and trained on lifts while she was employed at another facility. CNA #6 stated she could not remember if she trained on lifts at this facility. Based upon observations and interviews, Immediate Jeopardy was identified on 02/28/24 at 10:52 am. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 02/28/24 at 4:00 pm. Implementation of the POR was onsite on 02/28/24 by conducting observations, record reviews, and staff interviews. Plan of removal: Effective February 28, 2024, Communication via [NAME] (a form of communication) testing to all staff that Sara lift leg straps must be used on all residents during every transfer with the Sara lift. Effective immediately February 28, 2024, all lift transfers, Maxi, [NAME], Sara Steady must be done with two person assist. This will continue until the reassessment of residents using lifts is completed on February 29, 2024. Training for all direct care staff to ensure they use the Sara lift, Maxi Lift, and Sara Steady. The training will include the mandatory use of leg straps when transferring residents. This training will be held February 28, 2024, at 8:15 AM and repeated at 2:00 PM. All residents that are transferred with a lift will be reassessed to determine the most appropriate and safe means of transfer including one or two person transfers. This will be completed by Therapy and/or the Director of Nursing. This will begin today (February 28, 2024) and will be completed on February 29, 2024.

Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 (R # 3) of 3 (R #3, 4, 5) resident reviewed for pain medications by not doing a thorough assessment, notification, and documentation on admission of the resident. This deficient practice could likely cause an overdose of narcotic medication and potentially death if the Nurse Practitioner (NP) is unaware of all medications the resident is currently taking. The findings are: A. Record review of a nursing progress notes for R #3 indicated R #3 fell on [DATE] at the facility. R #3 went to the emergency room where it was revealed she had a compression fracture at L2 vertebra (spine). R #3 returned to the facility on [DATE] with a prescription for fentanyl patches. B. Record review of the nursing progress notes for R #3, dated 01/02/2024 at 1:54 pm, the Nurse Practitioner (NP) received phone call from the pharmacist regarding concern for use of fentanyl patches on resident due to the resident received only intravenous (IV) fentanyl in the hospital. The pharmacist expressed concern for the resident getting too much fentanyl via the patch, if the conversion was not the same when converting from IV to topical (directly on skin). The NP gave an order to discontinue fentanyl patch, and order hydrocodone-APAP (pain killer), 5/325 milligram (mg), 1 to 2 tablets every 4 hours for 7 days, then 1 to 2 tablets every 6 hours as needed (prn) for pain C. Record review of the medical record progress notes for R #3 indicated on 01/05/24, R #3 went back to the hospital for altered mental status and low blood pressure. The resident returned to the facility on [DATE]. D. Record review of the nursing progress notes for R #3, dated 01/11/24, indicated R #3 was alert and oriented upon return to the facility from the hospital. R #3 had a fentanyl patch 25 micrograms (mcg) to right upper back with date of 01/09/24 and two lidocane patches on the lower back. Staff removed the lidocane patches prior to showering R #3, but they did not remove the fentanyl patch. E. Record review of R #3 medical record revealed the record did not contain any other documentation of the fentanyl patch staff found on 01/11/24. The record did not contain an order to continue, discontinue, or remove the patch. F. Record review of the current physician orders for R #3 indicated the following: - An order for hydrocodone-acetaminophen, 5-325 mg, 1 to 2 tablets every 6 hours, as needed. Dated 01/10/24 and discontinued on 01/12/24. - An order for hydrocodone-acetaminophen, 5-325 mg, 1 to 2 tablets every 6 hours, as needed. Dated 01/12/24 and discontinued on 01/13/24. G. Record review of the Medication Administration Record (MAR) for R #3, dated January 11th through 13th 2024, indicated the following: - Staff administered hydrocodone-acetaminophen, 5-325 mg, one dose on 01/11/24 and one dose on 01/12/24. - Staff administered hydrocodone-acetaminophen, 5-325 mg, two doses on 01/12/24 and three doses on 01/13/24. H. Record review of the nursing progress notes for R #3, dated 01/13/24, revealed a new order received from the NP for Tylenol 500 mg, every 6 hours as needed for three days, for pain control. The nursing progress notes also stated a Certified Medication Assistant (CMA) brought writer two 25 mg fentanyl patches that were located on the resident's upper right arm. Writer was unaware that fentanyl patches were present as there is no documentation stating the resident has fentanyl patches. According to (name of staff) the fentanyl patches were placed on the resident while she was admitted on the medical floor at (name of hospital). The patches are dated '1/9/24', the resident returned from (name of hospital) medical floor to (name of facility) on 1/11/24. POA and other family members expressed concern and frustration regarding the patches still being on. (Name of) CNA reports to the writer that the admitting nurse acknowledged the presence of both fentanyl patches and instructed the staff to keep them both on while she was being bathed. Two fentanyl patches have been wasted (destroyed) by writer with CMA . I. Record review of the nursing progress notes for R #3, dated 01/14/24, indicated R #3 experienced twitching in the bilateral upper extremities. NP notified, new orders received for STAT (now) lab draw. J. Record review of the nursing progress notes for R #3, dated 01/14/24, indicated R #3 was transported to the emergency room per family request due to signs and symptoms of dehydration and muscle twitching. K. Record review of the nursing progress notes for R #3, dated 01/17/24, indicated the following: Received report from Registered Nurse at hospital. Resident was admitted for altered mental status due to urinary tract infection (UTI) and overdose of 3 to 4 fentanyl patches (reported from previous hospital), narcotic and congestive heart failure (CHF) exacerbated (worsening). L. On 02/27/24 at 3:39 pm during an interview, Registered Nurse (RN) #4 stated she did the admission for R #3 on 01/11/24 and stated she remembered taking R #3 to the shower room so the resident could take a shower. RN #4 stated she remembered R #3 had a fentanyl patch on the back of her right shoulder. She said it was a 25 mcg, and it was dated 01/09/24. RN #4 stated the resident also had two lidocane patches that were removed prior to R #3's shower. The RN stated she left the fentanyl patch on the resident's right shoulder. M. On 02/27/23 at 4:00 pm, during an interview with Certified Medication Assistant (CMA), she stated on 01/13/24 she went into R #3's room, and R #3 was scratching her arm. She looked at R #3's arm and saw two 25 mcg fentanyl patches, each dated 01/09/24. The CMA took the patches off and took them to the nurse. She stated she had been giving R #3 her prescribed hydrocodone, which was two pills every 6 hours as needed. She was not aware that R #3 had the fentanyl patches. She stated she did not look at R #3's back or on any other part of her body to see if there were other patches. N. On 02/27/24 at 1:40 pm, during an interview with DON, she stated RN #4 did not take off the fentanyl patch she found on R #3's back shoulder on 01/11/24. O. On 02/27/24 at 4:18 pm, during an interview with DON, she confirmed staff removed two fentanyl patches from R #3's arm on 01/13/24. The DON stated she assumed R #3 did not have any other fentanyl patches on her body at that time. P. On 02/28/24 at 8:30 am, during an interview with NP, she stated she did not recall staff notified her of the fentanyl patch. She stated staff called her about the hydrocodone prescription, but she was not sure if staff notified her of the fentanyl patch noted on 01/09/24 upon admission. She remembered staff notified her after the two patches were found and removed on 01/13/24. The NP stated that she would not have prescribed hydrocodone if she knew R #3 had a fentanyl patch.

48690 Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 (R #45 ) of 1 (R #45) residents by not administering oxygen in accordance with the physician's orders. If the facility is not administering oxygen as prescribed, the resident is not likely to get the therapeutic results as needed. The findings for R #45 are: A. Record review of R #45's face sheet revealed the resident was admitted on [DATE] with following diagnoses. 1. Respiratory failure, unspecified with hypoxia (a condition that affects breathing function or the lungs, and causes low oxygen or high carbon dioxide levels in the blood) . 2. Hypertensive heart disease without heart failure (a long-term condition related to high blood 3pressure). 3. Shortness of breath (blanket term for a group of diseases that block airflow from the lungs). B. Record review of R #45's care plan, dated 02/02/23, revealed the following: Resident uses oxygen (O2) continuously at 2 liters per minute (L/M) via nasal cannula (NC) as per physician's order. Monitor that O2 is in use, on resident face. Assist as needed to keep on. Resident takes off frequently. Put it back on. Report to charge nurse when he refuses to wear. C. Record review of R #45's physicians orders, dated 02/02/23, revealed an order for continuous O2 at 2-3 L/M via NC. D. On 09/25/23 at 3:35 PM, it was observed that R #45 sat in a common area on unit without oxygen being administered. E. On 09/25/23 at 3:49 PM, during an interview and observation, Certified Nurse Aide (CNA) #1 stated R #45 will continuously take off his oxygen and is non-compliant with wearing the NC. This writer observed CNA #1 reapply oxygen to R #45. F. On 09/26/23 at 3:44 PM, during an interview, RN #1 stated CNAs should check if R #45 is wearing his oxygen every time they walk by him. G. On 09/26/23 at 3:49 PM during an observation and interview with CNA #2, it was observed that R #45's oxygen tank was on and set to 2 L/M without a NC attached to the tank. CNA #2 confirmed these findings and turned off the O2 tank. CNA #2 stated she was not sure if R #45's oxygen should be administered continuously or as needed (PRN), but she could check the resident's careplan. H. On 09/26/23 at 3:51 PM, during an interview, CNA #2 stated she was unable to confirm nor deny if R #45 had an order for O2 after reviewing R #45's care plan .

Based on interview, observation, and record review, the facility failed to assess 1(R #1) of 1(R #1) resident following an injury which likely resulted in a delay in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: A. Record review of Facility Narrative Investigation Report (5) dated 09/12/22 for incident that occurred on 09/03/22 revealed R #1 was being wheeled down hallway in her wheelchair when R #1 foot dropped off pedal causing wheelchair to twist foot. Resident has tibia and 5th metatarsal fractures. B. Record review of Nursing progress note dated 09/04/22 at 9:03 am revealed, Yesterday (09/03/22) resident was being wheeled to the dining room and she let her left foot drop to the floor. It twisted the ankle. She has been having pain ever since then. There is no more swelling or discoloring than her normal baseline. She has agreed to see how it goes until Tuesday (09/05/22). Will continue to monitor and keep her medicated for pain. Signed Name of RN (Registered Nurse) #3. C. On 10/05/22 at approximately 4:30 pm during an interview with CNA (Certified Nurse Assistant) #4, she stated, she was the CNA that was transporting R #1 when the incident occurred. She confirmed it was around dinner time and R #1 had asked to be taken to the dining room for dinner and they were going down the hallway when she heard R #1 yell out in pain and voicing that her foot was stuck under the wheel chair. CNA #4 stopped to assist resident and then proceeded to the nurses station to let the nurse know of the incident. RN #3 had observed the incident and had some pain medication ready to administer to R #1. RN #3 did not assess the resident but did administer pain medication. R #1 then asked to be taken to the dining room for dinner. CNA #4 further stated that she did observe her (R#1's) foot was pointed downward and did not look right and resident was complaining of pain after the incident and the days following the incident. D. On 10/05/22 at 12:30 pm during an interview with the DON (Director of Nursing), she stated, she believes R #1 should of been sent out to the emergency room after the incident (On 09/03/22 at 4:46 pm, R #1 was being transported by CNA and R #1's foot went under the wheelchair and her foot twisted under the wheelchair). R #1 was taken for an X-ray on 09/06/22 at an outpatient clinic and the results came back on 09/08/22 at 11:03 am. Results determined R #1 left 5th toe shaft was broken. R #1 had a scheduled ortho appointment on 09/09/22. After the ortho appointment NP (Nurse Practitioner) called from the ortho clinic confirming that R #1 in addition to the broken 5th toe shaft break, also had a broken Tibia that was observed from the 09/06/22 X-ray. R #1 at this time still had not been sent out to the emergency room for this left foot injury. R #1 was given PRN (as needed) [MEDICATION(S)] (medication used to treat pain) and Tylenol (pain medication) for any pain issues. DON further stated, the Nurse Practitioner was informed of incident [09/03/22] on 09/06/22 and then ordered the resident to be sent out for an xray at that time. The DON confirmed that after they received the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . E. Record review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 50 mg (miligrams) PRN (as needed) on: 1. 09/03/22 at 16:58 (4:58 pm), 2. 09/04/22 at 8:54 am, 3. 09/05/22 at 5:11 am, 4. 09/06/22 at 2:40 am and 8:47 am. Acetaminophen (medication to relieve pain) 500mg 2 tablets PRN was administered on: 5. 09/03/22 at 20:32 (8:32 pm), 6. 09/04/22 at 8:48 am and 20:53 (8:53 pm), 7. 09/05/22 at 7:33 am, 8. 09/06/22 at 9:23 am F. Record review of nursing progress noted dated 09/06/22 at 9:10 am revealed: Resident still having complaints of pain to left lower leg, ankle, and foot .Informed the NP (Nurse Practitioner) of situation and received order for X-ray to the left foot, ankle and leg due to wheelchair injury. Gave [MEDICATION(S)] at 8:45 am for pain G. On 10/05/22 during observation of a facility video dated 09/3/22 at 16:46 (4:46 pm) revealed a Certified Nurse Aide (CNA) #4 was observed transporting a resident down the hallway, CNA #4 stops, observed R #1's foot under the wheelchair and continues down the hallway. She is met by RN #3 in the hallway who did not assess R #1 but handed her a cup with medication (pain medication) CNA #4 continued down the hallway. H. On 10/05/22 at approximately DON confirmed RN #3 did not assess R #1. (This confirmation was after review of the facility video) I. Multiple attempts made to interview RN #3 were unsuccessful.

Based on record review, interview, and observation the facility failed to: 1. Ensure food items in the refrigerator and freezer were labeled and dated 2. Ensure that items were not stored on the bare floor 3. Ensure that temperature logs were kept for the chest freezer and that a thermometer was kept in the chest freezer at all times. 4. Ensure that sanitizer buckets used to wipe down cooking areas had sanitizer in the buckets. 5. Ensure food temperatures were documented in the food temperature logs on various dates These deficient practices are likely to affect all 85 residents residing in the facility. If the facility is not adhering to safe food handling practices the residents are likely to experience foodborne illnesses. A. On 10/03/22 at 12:33 pm during initial tour of the facility kitchen the following was observed: 1. 3 pans of what appeared to be bacon, were unlabeled and un-dated in the refrigerator 2. 1 bag of french fries was unlabeled and undated in the freezer 3. No temperatures logs for the chest freezer or thermometer in the chest freezer 4. Food temperatures were not logged on 09/01/22, 09/02/22, 09/05/22, 09/06/22, 09/07/22, 09/11/22, 09/12/22, 09/18/22, 09/19/22, 09/25/22, 09/26/22,09/28/22, and 09/29/22. B. On 10/03/22 at 12:40 pm during an interview with Certified Dietary Manager (CDM), she confirmed that all food items should be labeled and dated, and there should be a thermometer and temperature log for the chest freezer and there was not. CDM also confirmed that there were many food temperatures logs missing. C. On 10/06/22 at 11:52 am during follow-up tour of the facility kitchen, the following was observed: 1. No sanitizer in bucket in the dish area 2. Unlabeled and undated salad sitting on a cart. 3. 2 cases of Ensure (nutritional supplement), 1 case of hinged monogram containers (styro foam to go containers) were observed on the bare floor in the dry storage area in facility kitchen. D. On 10/06/22 at 11:58 am during an interview with Dietary Aide (DA) #1, she stated that the cooks are the ones responsible for changing the sanitizer in the buckets and DA's are not trained to fill up or change out sanitary buckets, When DA #1 used the test strip (strips used to test amount of sanitizer in the buckets) sanitizer buckets appeared not to have sanitizer in them. She further stated that there should not be anything stored on the bare floor in the dry storage area and nothing should be unlabeled and undated.

Based on observation, record review, and interview, the facility failed to meet professional standards of care for 1 (R #'s 46) of 2 (R #'s 38 and 46) residents reviewed for oxygen use. If the facility is not labeling, dating and changing O2 (Oxygen) tubing, then residents are likely to not get the therapeutic results of medication/treatment needed. The findings are: Findings for R #46: A. Record review of R #46's face sheet revealed R #46 was admitted into the facility on [DATE]. B. Record review of R #46's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LABEL BOTTLE AND TUBING WITH DATE MM/DD/YY [month/day/year] AND INITIALS. C. On 10/05/22 at 12:58 pm during an observation and interview with R #46, R #46 was observed wearing portable O2 with the O2 tubing not dated or initialed. R #46 confirmed he wears O2 daily. D. On 10/05/22 at 12:59 pm during an interview with Certified Nursing Assistant (CNA) #1, she stated, Yes, it [R #46's O2 tubing] should be [dated and initialed]. CNA #1 confirmed R #46's O2 tubing was not initialed or dated and should have been. E. On 10/05/22 at 2:11 pm during an interview with the Director of Nursing (DON), she stated, There's orders put in [for O2 tubing] and my expectation is it [resident O2 tubing] is changed weekly. DON confirmed residents O2 tubing should be initialed, dated, and changed per physician orders.

Based on record review and interview, the facility failed to complete a thorough investigation regarding allegations of abuse for 1 (R #6) of 1( R #6) residents reviewed for abuse allegation grievances. If the facility is not completing an accurate and thorough investigation for allegations of abuse and submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are: A. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE]. B. On 10/04/22 at 1:00 pm during an interview with R #6, he stated that staff are rude (in an aggressive manner) to him when they talk to him. C. On 10/05/22 at 12:53 pm during an interview with Certified Nursing Assistant (CNA) #1, she stated, He [R #6] has on an occasion [told her that staff was rude to him] (spoke to him in an aggressive manner) and I reported it to the charge nurse. CNA #1 confirmed R #6 has told her multiple times that staff is rude to him and she reported those allegations to the charge nurse. D. On 10/05/22 at 1:09 pm during an interview with CNA #3, she stated, Occasionally [R #6 will complain about rude staff], I'll tell the charge nurse. E. On 10/05/22 at 3:05 pm during an interview with Registered Nurse (RN) #2, he stated, Yes, that [R #6 complaining about staff being rude to him] is a common complaint. I look into it. Sometimes the complaints are so vague it's hard to understand. Sometimes he's probably confused and it doesn't make sense. I'll pass it [R #6's allegations of staff being rude to him] on the next shift and I'll tell [Name of the Staff Development Coordinator]. I never have reported his complaints to the Administrator [ADM] or Director of Nursing [DON]. F. On 10/05/22 at 3:21 pm during an interview with the Staff Development Coordinator (SDC), he stated, That there had been occasions when he [R #6] was complaining that the CNA's were rude. I always remind the staff that's its all perception. Sometimes he [R #6] will go into a very long explanation about something and I believe that could have caused the CNA to interrupt and he may have misinterpreted it to mean they were being rude to him. SDC confirmed the ADM and DON were notified of R #6's allegations that staff are rude to him and an investigation was never conducted. G. On 10/05/22 at 4:58 pm during an interview with the Administrator (ADM), he stated, If there's an allegation of abuse, it [abuse allegation] should go to [Name of Administrative Assistant] and I'm involved as well. I get involved and we do a full investigation to see if it needs to be reported to the State. ADM confirmed R #6's allegation of staff abuse should have been reported to him and an abuse investigation should have been conducted.

Based on record review and interview, the facility failed to ensure that a Minimum Data Set (MDS) assessment was completed every three months for 2 (R #'s 1 and 2) of 2 (R #'s 1 and 2) residents reviewed for MDS assessments. This failed practice is likely to result in resident assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are: Findings for R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's MDS Resident Assessment located in R #1's Electronic Health Record (EHR) revealed R #1's most recent MDS was an 08/05/22 in process-Quarterly Review. R #1's 08/05/22 quarterly review was never completed or submitted. First Quarterly was due 07/30/22 and was still in process 08/05/22 and had not been submitted. C. On 10/05/22 at 12:19 pm during an interview with the Minimum Data Set Coordinator (MDSC), she stated, It's [R #1's 08/05/22 Quarterly Review] in the process [and not completed or submitted]. I found this [R #1's 08/05/22 incomplete/not submitted Quarterly Review] the other day. MDSC confirmed R #1's 08/05/22 Quarterly Review MDS was not completed or submitted and should have been. Findings for R #2: D. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE]. E. Record review of R #2's MDS Resident Assessment located in R #2's EHR revealed R #2's most recent MDS was 05/12/22 Production Accepted- Quarterly Review. R #2 did not have an MDS completed and submitted after 05/12/22. F. On 10/05/22 at 12:20 pm during an interview with the MDSC, she stated, It [R #2's most recent MDS assessment] should have been 08/12/22 and we don't have her [R #2] on our list. I don't even have her [R #2] in my book [of MDS assessments schedule]. MDSC confirmed R #2 has not had an MDS quarterly review since 05/12/22 and R #2 should have.

The following deficiency was a result of a QIS (Quality Indicator Survey) Recertification/Complaint survey that was initiated on 02/13/17. An immediate jeopardy was identified on 02/20/17 and a plan of removal was accepted on 02/21/17. Based on record review and interview, the facility failed to develop a care plan for safety awareness for 1 (R #130) of 1 (R #130) residents reviewed for accidents. This failure likely resulted in R #130 sustaining 1st and 2nd [MEDICAL CONDITION] dropping a Styrofoam cup of hot coffee onto the inner thighs. These deficient practices resulted in an Immediate Jeopardy at a scope and severity of J, being identified at the facility on 02/20/17 at 5:30 pm. The facility Administrator was notified at this time. The facility provided an acceptable Plan of Removal on 02/21/17 at 4:35 pm. based on the Plan of Removal, interventions included: 1.) R #130 was educated on positioning by therapy to prevent further spills when drinking hot beverages. Additional interventions is giving resident hot beverages in a hard plastic cup with a lid at a temperature no hotter than 120 degrees Fahrenheit and using a clothing protector to absorb any spillage and prevent burning. 2.) All residents will be assessed, by 02/24/17, to determine if they can safely drink hot beverages and if they need interventions. 3.) On admission, all residents will be evaluated using the hot liquids safety evaluation form to determine if they can safely drink hot beverages/food or, if appropriate, an intervention needs to be put in place. Some interventions may be: repositioning education, lids on coffee cups, clothing protectors or cooling of hot beverages by adding ice etc. Based on the hot liquids safety evaluation form, residents who are alert and oriented and have no risk of burning themselves may have hot beverages at the recommended temperature of 180 degrees. Other residents may per assessment have hot beverages at this same temperature but with a hard plastic cup with a lid. Other residents with dementia may have coffee at no hotter than 120 degrees Fahrenheit with a lid. This will be based on assessment of each individual resident. The kitchen will maintain separate hot beverage containers at the appropriate temperatures (120 degrees up to 180 degrees Fahrenheit) based on the assessment of each resident. The kitchen will continue to monitor the temperature in the kitchen prior to serving or releasing the hot beverage to the residents. When the kitchen is closed charge nurses have thermometers to check hot beverages or food to determine correct temperatures for a resident. When food is delivered to dementia patients, a sample tray will be sent for temperature testing to determine that the food such as soups and hot cereals are not to hot for the resident to eat. Staff will be educated with the new policy on safety of hot beverages/food. An all staff mandatory meeting will be held on 02/22/17 at 8:00 am. Prior to the all staff meeting education will take place with staff in the building. Staff will be educated prior to working the floor. 4.) Our QA (Quality Assurance) nurse, Director of Nursing (DON) or Assistant DON or assigned staff member will perform audits to determine that all residents have been assessed using the hot liquids safety evaluation form and will assess that any interventions put in place to prevent a burn are being followed by staff. Audits will also be done in the kitchen of the containers holding the hot beverages to determine that the temperature does not exceed 120 degrees Fahrenheit for those residents determined to not have hot beverages at a temperature higher than 120 degrees Fahrenheit. Audits will also occur on the units/pods with focus on hot beverages at correct temperature based on evaluation as well as hot food served at a safe temperature for our residents. These audits will occur monthly for March, April and May. If there are no issues with these audits we will then do audits October of 2017 and March of 2018. Audits will be discussed during our QA meetings. Based on the Plan of Removal and observation, the IJ was lifted on 02/21/17 at 4:35 pm. This resulted in the scope and severity being reduced from a scope and severity of J to a scope and severity of G. Based on record review, observation and interview the facility failed to prevent serious injury for 1 (R #130) of 1 (R #130) reviewed for accidents by: 1.) failure to protect R #130 from hot [MEDICAL CONDITION] the inner thighs 2.) failure to protect R #130 from serious injuries that included lacerations to R #130's head requiring stitches. The findings are: A. Record review of facility census report revealed R #130 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of the facility Individual Event Reports for R #130 dated 11/21/16 thru 02/13/17 revealed, 15 falls and 7 other types of incidents during the three months since admission, including 1st and 2nd [MEDICAL CONDITION] the inner thigh from a hot beverage spill, [MEDICAL CONDITION] requiring stitches, bruises and skin tears. C. Record review of Nurses Progress Notes for R #130 revealed: 1. Dated 11/23/16 at 2:47 pm, . does not recognize his safety needs . 2. Dated, 11/28/16 at 7:27 am, . needs constant supervision. 3. Dated, 12/02/16 at 8:06 am, .constant one on one care . 4. Dated, 12/28/16 at 9:27 am, . poor safety awareness . 5. Dated 12/28/16 at 10:39 pm, .must be watched closely . 6. Dated, 12/29/16 at 9:01 am, .poor safety awareness . 7. Dated, 12/31/16 at 9:14 am, .poor safety awareness . 8. Dated 01/01/17 at 9:41 pm, .must be watched closely . 9. Dated, 01/19/17 at 2:07 pm, .poor safety awareness .must be closely monitored . D. Record review of an agenda for Mandatory Meeting for facility Nurses and CNA's dated 04/01/16 revealed, .When giving residents coffee please add water many residents are burning themselves because the coffee is way to hot! . E. On 02/21/17 at 10:40 am, during an interview R #130's wife stated, We were in one of the dining rooms, I don't remember which one, to drink some coffee and visit. I asked the Aide for some extra sugar and while she was away from the table my husband went to take a drink of his coffee, it was in a Styrofoam cup, and spilled it in his lap . F. Record review of Nurses Progress notes for R #130 dated, 02/07/17 revealed, Cool wet wash rag applied immediately after resident spilled coffee .no blisters till approximately 1 hour later . G. Record review of Nurses Progress notes for R #130 dated, 02/07/17 revealed, Recorded as Late Entry on 02/09/2017,12:50 Writer (Wound Care Nurse/Licensed Practical Nurse #3) was referred to see resident [MEDICAL CONDITION] his inner thighs. Noted redness and blistering to bilateral inner thighs. Left inner thigh with 29 cm X 11 cm with 60% 1st degree burn and 40% 2nd degree burn a/e (as evidenced by) by blistering. Blistering is serous filled. Right inner thigh with 10 cm x 3.5 cm burn with 80% 1st degree burn and 20% 2nd degree burn a/e by several small serous filled blisters to skin . H. On 02/20/17 at 3:30 pm, during an interview, the Dietary Manager (DM) was asked about the temperature of coffee being served in the Dining Room, the DM stated that, I have called the company for them to come turn the temperature on the coffee machine down. I have no documentation of the notification to the company and they have not come to turn down the temperature. I. On 02/20/17 at 4:20 pm, a temperature validation of fresh coffee was made with the DM. Temperature was measured, with calibrated thermometers by the DM and a member of the survey team. The temperature of the coffee was 170 degrees as measured by both individuals. J. On 02/20/17 at 1:00 pm, during an interview the Assistant Director of Nursing (ADON), when asked about R #130's care plans for safety awareness, stated, We did not have a care plan for safety awareness and after R #130 got burned with hot coffee we did not initiate a care plan to put any preventive measures in place. K. Record review of Nurses Progress Notes for R #130 dated, 12/18/16 revealed, Writer was documenting medications at desk when staff yelled to come quick from door of dining room. Writer responded to find resident lying next to his wheel chair with a 3.5 centimeter (cm) laceration to left side of forehead .Res (resident) stating his only pain was to his head . Placed dressing over wound . Emergency Medical Services (EMS) arrived approximately 0725 (7:25 am) and res transported via stretcher approximately 0730 (7:30 am). L. Record review of Nurses Progress Notes for R #130 dated, 12/18/16, At 12:05 pm, resident returned from the emergency room (ER) with stitches to his left side of forehead . M. Record review of Nurses Progress Notes for R #130 dated, 01/07/17 at 4:54 am, revealed, Resident present with 7 cm in length and 1.5 cm in width abrasion to left side of back . N. Record review of Nurses Progress notes for R #130 dated, 01/08/17 revealed, .Found res on the floor at the nurses station . Res (resident) was bleeding from the left temple. Was assisted up into his wheelchair to reveal a 2 cm laceration on the left temple near the eye .He denied pain except for the left eye .Called 911 .report to ER registered Nurse (RN) at 1635 (4:35 pm) . O. Record review of Nurses Progress Notes for R #130 dated, 01/08/17 revealed, Res returns to facility at 2105 (9:05 pm) .The laceration to the left forehead is approx. 2.5 cm, and has 5 sutures .Remove sutures in 7 days . P. Record review of Nurses Progress Notes for R #130 dated, 01/28/17 at 11:05 am, revealed, Resident found on floor at 7:08 am, in room sitting on bottom .resident had a red area to back and obtained 3 skin tears to right arm 9 cm half moon, 6 cm half moon, 2 cm half moon . Q. On 02/21/17 at 1:40 pm, during an interview, the Director of Nursing (DON) stated, We do not reassess a resident for fall risk after a fall. The fall risk assessment is only done on admission. When asked about the Nurses Progress Notes for R #130, where charting for poor safety awareness, constant one on one, constant monitoring and watch closely, was noted the DON stated, We may be doing one on one but not documenting it. If we did one on one and he still had a fall we would be liable.

The following deficiency was a result of a QIS (Quality Indicator Survey) Recertification/Complaint survey that was initiated on 02/13/17. An immediate jeopardy was identified on 02/20/17 and a plan of removal was accepted on 02/21/17. Based on record review and interview, the facility failed to protect residents from hot beverages that resulted in burns for 1 (R #130) of 1 (R #130) residents reviewed for accidents. The failure to monitor hot beverage temperatures likely resulted in Resident #130, after dropping a Styrofoam cup of hot coffee onto the inner thighs, receiving 1st and 2nd degree burns. These deficient practices resulted in an Immediate Jeopardy at a scope and severity of J, being identified at the facility on 02/20/17 at 5:30 pm. The facility Administrator was notified at this time. The facility provided an acceptable Plan of Removal on 02/21/17 at 4:35 pm. based on the Plan of Removal, interventions included: 1.) R #130 was educated on positioning by therapy to prevent further spills when drinking hot beverages. Additional interventions is giving resident hot beverages in a hard plastic cup with a lid at a temperature no hotter than 120 degrees Fahrenheit and using a clothing protector to absorb any spillage and prevent burning. 2.) All residents will be assessed, by 02/24/17, to determine if they can safely drink hot beverages and if they need interventions. 3.) On admission, all residents will be evaluated using the hot liquids safety evaluation form to determine if they can safely drink hot beverages/food or, if appropriate, an intervention needs to be put in place. Some interventions may be: repositioning education, lids on coffee cups, clothing protectors or cooling of hot beverages by adding ice etc. Based on the hot liquids safety evaluation form, residents who are alert and oriented and have no risk of burning themselves may have hot beverages at the recommended temperature of 180 degrees. Other residents may per assessment have hot beverages at this same temperature but with a hard plastic cup with a lid. Other residents with dementia may have coffee at no hotter than 120 degrees Fahrenheit with a lid. This will be based on assessment of each individual resident. The kitchen will maintain separate hot beverage containers at the appropriate temperatures (120 degrees up to 180 degrees Fahrenheit) based on the assessment of each resident. The kitchen will continue to monitor the temperature in the kitchen prior to serving or releasing the hot beverage to the residents. When the kitchen is closed charge nurses have thermometers to check hot beverages or food to determine correct temperatures for a resident. When food is delivered to dementia patients, a sample tray will be sent for temperature testing to determine that the food such as soups and hot cereals are not to hot for the resident to eat. Staff will be educated with the new policy on safety of hot beverages/food. An all staff mandatory meeting will be held on 02/22/17 at 8:00 am. Prior to the all staff meeting education will take place with staff in the building. Staff will be educated prior to working the floor. 4.) Our QA (Quality Assurance) nurse, Director of Nursing (DON) or Assistant DON or assigned staff member will perform audits to determine that all residents have been assessed using the hot liquids safety evaluation form and will assess that any interventions put in place to prevent a burn are being followed by staff. Audits will also be done in the kitchen of the containers holding the hot beverages to determine that the temperature does not exceed 120 degrees Fahrenheit for those residents determined to not have hot beverages at a temperature higher than 120 degrees Fahrenheit. Audits will also occur on the units/pods with focus on hot beverages at correct temperature based on evaluation as well as hot food served at a safe temperature for our residents. These audits will occur monthly for March, April and May. If there are no issues with these audits we will then do audits October of 2017 and March of 2018. Audits will be discussed during our QA meetings. Based on the Plan of Removal and observation, the IJ was lifted on 02/21/17 at 4:35 pm. This resulted in the scope and severity being reduced from a scope and severity of J to a scope and severity of G. Based on record review, observation and interview the facility failed to prevent accidents for 1 (R #130) of 1 (R #130) reviewed for accidents by: 1.) failure to protect R #130 from hot beverage burns to the inner thighs 2.) failure to protect R #130 from serious injuries that included lacerations to R #130's head requiring stitches 3.) failure to protect R #130 from repeated falls. The findings are: A. Record review of facility census report revealed R #130 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of the facility Individual Event Reports for R #130 dated 11/21/16 thru 02/13/17 revealed, 15 falls and 7 other types of incidents during the three months since admission, including 1st and 2nd degree burns to the inner thigh from a hot beverage spill, head lacerations requiring stitches, bruises and skin tears. C. Record review of Nurses Progress Notes for R #130 revealed: 1. Dated 11/23/16 at 2:47 pm, . does not recognize his safety needs . 2. Dated, 11/28/16 at 7:27 am, . needs constant supervision. 3. Dated, 12/02/16 at 8:06 am, .constant one on one care . 4. Dated, 12/28/16 at 9:27 am, . poor safety awareness . 5. Dated 12/28/16 at 10:39 pm, .must be watched closely . 6. Dated, 12/29/16 at 9:01 am, .poor safety awareness . 7. Dated, 12/31/16 at 9:14 am, .poor safety awareness . 8. Dated 01/01/17 at 9:41 pm, .must be watched closely . 9. Dated, 01/19/17 at 2:07 pm, .poor safety awareness .must be closely monitored . D. Record review of an agenda for Mandatory Meeting for facility Nurses and CNA's dated 04/01/16 revealed, .When giving residents coffee please add water many residents are burning themselves because the coffee is way to hot! . E. On 02/21/17 at 10:40 am, during an interview R #130's wife stated, We were in one of the dining rooms, I don't remember which one, to drink some coffee and visit. I asked the Aide for some extra sugar and while she was away from the table my husband went to take a drink of his coffee, it was in a Styrofoam cup, and spilled it in his lap . F. Record review of Nurses Progress notes for R #130 dated, 02/07/17 revealed, Cool wet wash rag applied immediately after resident spilled coffee .no blisters till approximately 1 hour later . G. Record review of Nurses Progress notes for R #130 dated, 02/07/17 revealed, Recorded as Late Entry on 02/09/2017,12:50 Writer (Wound Care Nurse/Licensed Practical Nurse #3) was referred to see resident for burns to his inner thighs. Noted redness and blistering to bilateral inner thighs. Left inner thigh with 29 cm X 11 cm with 60% 1st degree burn and 40% 2nd degree burn a/e (as evidenced by) by blistering. Blistering is serous filled. Right inner thigh with 10 cm x 3.5 cm burn with 80% 1st degree burn and 20% 2nd degree burn a/e by several small serous filled blisters to skin . H. On 02/20/17 at 3:30 pm, during an interview, the Dietary Manager (DM) was asked about the temperature of coffee being served in the Dining Room, the DM stated that, I have called the company for them to come turn the temperature on the coffee machine down. I have no documentation of the notification to the company and they have not come to turn down the temperature. I. On 02/20/17 at 4:20 pm, a temperature validation of fresh coffee was made with the DM. Temperature was measured, with calibrated thermometers by the DM and a member of the survey team. The temperature of the coffee was 170 degrees as measured by both individuals. J. On 02/20/17 at 1:00 pm, during an interview the Assistant Director of Nursing (ADON), when asked about R #130's care plans for safety awareness, stated, We did not have a care plan for safety awareness and after R #130 got burned with hot coffee we did not initiate a care plan to put any preventive measures in place. K. Record review of Nurses Progress Notes for R #130 dated, 12/18/16 revealed, Writer was documenting medications at desk when staff yelled to come quick from door of dining room. Writer responded to find resident lying next to his wheel chair with a 3.5 centimeter (cm) laceration to left side of forehead .Res (resident) stating his only pain was to his head . Placed dressing over wound . Emergency Medical Services (EMS) arrived approximately 0725 (7:25 am) and res transported via stretcher approximately 0730 (7:30 am). L. Record review of Nurses Progress Notes for R #130 dated, 12/18/16, At 12:05 pm, resident returned from the emergency room (ER) with stitches to his left side of forehead . M. Record review of Nurses Progress Notes for R #130 dated, 01/07/17 at 4:54 am, revealed, Resident present with 7 cm in length and 1.5 cm in width abrasion to left side of back . N. Record review of Nurses Progress notes for R #130 dated, 01/08/17 revealed, .Found res on the floor at the nurses station . Res (resident) was bleeding from the left temple. Was assisted up into his wheelchair to reveal a 2 cm laceration on the left temple near the eye .He denied pain except for the left eye .Called 911 .report to ER registered Nurse (RN) at 1635 (4:35 pm) . O. Record review of Nurses Progress Notes for R #130 dated, 01/08/17 revealed, Res returns to facility at 2105 (9:05 pm) .The laceration to the left forehead is approx. 2.5 cm, and has 5 sutures .Remove sutures in 7 days . P. Record review of Nurses Progress Notes for R #130 dated, 01/28/17 at 11:05 am, revealed, Resident found on floor at 7:08 am, in room sitting on bottom .resident had a red area to back and obtained 3 skin tears to right arm 9 cm half moon, 6 cm half moon, 2 cm half moon . Q. On 02/21/17 at 1:40 pm, during an interview, the Director of Nursing (DON) stated, We do not reassess a resident for fall risk after a fall. The fall risk assessment is only done on admission. When asked about the Nurses Progress Notes for R #130, where charting for poor safety awareness, constant one on one, constant monitoring and watch closely, was noted the DON stated, We may be doing one on one but not documenting it. If we did one on one and he still had a fall we would be liable.

Based on record review and interview, the facility failed to report head injuries requiring stitches [MEDICAL CONDITION] the state survey agency 1.) within 24 hours of the incident and 2.) failed to submit a 5 day follow-up investigation for 1 (R #130 ) of 1 (R #130) resident reviewed for serious injuries. The deficient practice could likely result in potential harm to resident safety. When incidents of possible abuse or neglect are not reported or investigated timely, the facility is likely to be unable to determine what happened in order to prevent it from reoccurring. The findings are: A. Record review of facility census report revealed R #130 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of the facility Individual Event Reports for R #130 dated 11/21/16 thru 02/13/17 revealed, 15 falls and 7 other types of incidents - bruises, skin tears [MEDICAL CONDITION] the inner thigh from a hot beverage during the three months since admission. C. Record review of Nurses Progress notes for R #130 dated, 02/07/17 revealed, Cool wet wash rag applied immediately after resident spilled coffee .no blisters till approximately 1 hour later . D. Record review of Nurses Progress notes for R #130 dated, 02/07/17 revealed, Recorded as Late Entry on 02/09/2017,12:50 pm, Writer (Wound Care Nurse/Licensed Practical Nurse #3 )was referred to see resident [MEDICAL CONDITION] his inner thighs. Noted redness and blistering to bilateral inner thighs. Left inner thigh with 29 centimeter (cm) X 11 cm with 60% 1st degree burn and 40% 2nd degree burn a/e (as evidenced by) by blistering. Blistering is serous filled. Right inner thigh with 10 cm x 3.5 cm burn with 80% 1st degree burn and 20% 2nd degree burn a/e by several small serous filled blisters to skin . E. Record review of Nurses Progress Notes for R #130 dated, 12/18/16 revealed, Writer was documenting medications at desk when staff yelled to come quick from door of dining room. Writer responded to find resident lying next to his wheel chair with a 3.5 cm laceration to left side of forehead .Res stating his only pain was to his head . Placed dressing over wound . Emergency Medical Services (EMS) arrived approximately 0725 (7:25 am) and res (resident) transported via stretcher approximately 0730 (7:30 am). F. Record review of Nurses Progress Notes for R #130 dated, 12/18/16, At 12:05 pm, resident returned from the emergency room (ER) with stitches to his left side of forehead . Paperwork with no new orders . G. Record review of Nurses Progress Notes for R #130 dated, 01/07/17 at 4:54 am, revealed, Resident present with 7 cm in length and 1.5 cm in width abrasion to left side of back . H. Record review of Nurses Progress notes for R #130 dated, 01/08/17 revealed, .Found res (resident) on the floor at the nurses station . Res was bleeding from the left temple. Was assisted up into his wheelchair to reveal a 2 cm laceration on the left temple near the eye .He denied pain except for the left eye .Called 911 .report to ER registered Nurse (RN) at 1635 (4:35 pm) . I. Record review of Nurses Progress Notes for R #130 dated, 01/08/17 revealed, Res returns to facility at 2105 (9:05 pm) .The laceration to the left forehead is approx. 2.5 cm, and has 5 sutures Remove sutures in 7 days . J. Record review of Nurses Progress Notes for R #130 dated, 01/28/17 at 11:05 am, revealed, Resident found on floor at 7:08 am, in room sitting on bottom .resident had a red area to back and obtained 3 skin tears to right arm 9 cm half moon, 6 cm half moon, 2 cm half moon . K. On 02/17/17 at 8:30 am, during an interview, the Director of Nursing (DON) stated, During a meeting at the State Health Care Association reporting of incidents was discussed. We were informed by State Survey Agency senior personnel that if we did a complete and thorough investigation of an incident, even if it was serious, like lacerations requiring stitches or burns, and had a firm conclusion as to what happened it did not need to be reported to the SA (State Agency).

Based on record review and interview, the facility failed to develop and implement their written policies and procedures for reporting and investigating serious injuries for 1 (R #130) of 1 (R #130) resident reviewed for head injuries requiring stitches and 1st and 2nd degree burns. If the facility is not reporting and investigating injuries, then the facility is likely to be unable to determine if the injuries are a result of abuse or neglect and identify strategies to try and prevent further injuries. The findings are: A. Record review of facility Policy titled: Abuse Investigations: Policy Statement: All reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by facility management. Policy Interpretation and Implementation: 1. Should an incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident .14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency .within five (5) working days of the reported incident. There is no evidence in this policy of the requirement to submit a incident report to the State Survey Agency within 24 hours. B. Record review of facility Policy titled: Accident and Incidents - Investigating and Reporting: Policy Statement: All accidents or incidents involving residents .occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .5. The Nurse Supervisor/Charge Nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident accident. There is no evidence in this policy to submit a follow-up investigation to the State Survey Agency within 5 business days. C. Record review of facility census report revealed R #130 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. D. Record review of the facility Individual Event Reports for R #130 dated 11/21/16 thru 02/13/17 revealed, 15 falls and 7 other types of incidents - bruises, skin tears [MEDICAL CONDITION] the inner thigh from a hot beverage during the three months since admission. E. Record review of Nurses Progress notes for R #130 dated, 02/07/17 revealed, Cool wet wash rag applied immediately after resident spilled coffee .no blisters till approximately 1 hour later . F. Record review of Nurses Progress notes for R #130 dated, 02/07/17 revealed, Recorded as Late Entry on 02/09/2017,12:50) Writer (Wound Care Nurse/Licensed Practical Nurse #3) was referred to see resident [MEDICAL CONDITION] his inner thighs. Noted redness and blistering to bilateral inner thighs. Left inner thigh with 29 centimeter (cm) X 11 cm with 60% 1st degree burn and 40% 2nd degree burn a/e (as evidenced by) by blistering. Blistering is serous filled. Right inner thigh with 10 cm x 3.5 cm burn with 80% 1st degree burn and 20% 2nd degree burn a/e by several small serous filled blisters to skin . G. Record review of Nurses Progress Notes for R #130 dated, 12/18/16 revealed, Writer was documenting medications at desk when staff yelled to come quick from door of dining room. Writer responded to find resident lying next to his wheel chair with a 3.5 cm laceration to left side of forehead .Res stating his only pain was to his head . Placed dressing over wound . Emergency Medical Services (EMS) arrived approximately 0725 (7:25 am) and res (resident) transported via stretcher approximately 0730 (7:30 am). H. Record review of Nurses Progress Notes for R #130 dated, 12/18/16, At 12:05 pm, resident returned from the emergency room (ER) with stitches to his left side of forehead . Paperwork with no new orders . I. Record review of Nurses Progress Notes for R #130 dated, 01/07/17 at 4:54 am, revealed, Resident present with 7 cm in length and 1.5 cm in width abrasion to left side of back . J. Record review of Nurses Progress notes for R #130 dated, 01/08/17 revealed, .Found res (resident) on the floor at the nurses station . Res was bleeding from the left temple. Was assisted up into his wheelchair to reveal a 2 cm laceration on the left temple near the eye .He denied pain except for the left eye .Called 911 .report to ER registered Nurse (RN) at 1635 (4:35 pm) . K. Record review of Nurses Progress Notes for R #130 dated, 01/08/17 revealed, Res returns to facility at 2105 (9:05 pm) .The laceration to the left forehead is approx. 2.5 cm, and has 5 sutures Remove sutures in 7 days . L. Record review of Nurses Progress Notes for R #130 dated, 01/28/17 at 11:05 am, revealed, Resident found on floor at 7:08 am, in room sitting on bottom .resident had a red area to back and obtained 3 skin tears to right arm 9 cm half moon, 6 cm half moon, 2 cm half moon . M. On 02/17/17 at 8:30 am, during an interview the Director of Nursing (DON) stated, During a meeting at the State Health Care Association reporting of incidents was discussed. We were informed by State Survey Agency senior personnel that if we did a complete and thorough investigation of an incident, even if it was serious, like lacerations requiring stitches or burns, and had a firm conclusion as to what happened it did not need to be reported to the SA (State Agency).

Based on observation, record review, and interview, the facility failed to notify the physician of changes in pressure ulcers (PU) so that the physician could make a change in treatment or order a treatment for 3 (#75, 78, 129) of 3 (#75, 78, 129) residents reviewed for pressure ulcers. For Resident #75, the facility failed to notify the physician of the pressure ulcer opening with drainage from 09/02/11 - 09/07/11. The facility then failed to get an antibiotic order from 09/09/11 - 09/12/11. The pressure ulcer developed purulent (pus) drainage indicating an infection. For Resident #78 the facility failed to notify the physician and get an order for [REDACTED]. For Resident #129 the facility failed to notify the physician and get an admission order for treatment from 07/06/11 - 07/11/11, 5 days for an existing PU. This had the potential for pressure ulcers to worsen for all 3 Residents. The findings are: A. Record review of Resident #75's Interdisciplinary Progress (IDP) Note dated 08/22/11 at 4:50 pm revealed, "...C/O (complains of) pain on left foot, R (right) heel. Observed Left foot (inner) underneath great toe with blister - intact 3.5 X 2.1 cm (centimeter). R heel intact blister 4.4 X 4.8 cm to paint with [MEDICATION NAME] Q (every) day." 1. Record review of the physician's orders [REDACTED]." a. An IDP Note dated 09/02/11 at 11:28 pm revealed, "R heel blister has open area 1 cm X 1 cm." b. An IDP Note dated 09/04/11 at 11:05 am revealed, "R heel blister with an open area to one edge, superficial, scabbed and dry, left foot first metatarsal joint scabbed and dry no s/s (signs and symptoms) of infection to both. [MEDICATION NAME] to both per orders..." c. Review of an IDP Note dated 09/05/11 at 11:53 am revealed, "Skin assessment...right heel with popped blister, cover overlay is white (macerated) R edge with brown border left edge 7-9 o'clock without segment of skin leaving approximately 1 cm of exposed skin, heel very tender to touch, brownish drainage on sock - heel protectors bilaterally on at all times." d. The IDP Note dated 09/07/11 at 1:36 pm revealed, "...right heel with loose skin overlay (old blister) portion torn away awhile back, today when sock adhered to drainage, skin was torn some over wound..." e. Review of a Hospice Nurse's Note dated 09/07/11, no time, revealed, "Pt (patient) up in W/C (wheelchair)...R foot without sock or protective covering, open wound was in contact with floor. R heel open to air. Loose flap of skin. Serous drainage, white with some blackish outer edges. Cleaned with [MEDICATION NAME] and applied protective foam dressing per (Name of physician). Notified RN (Registered Nurse) of new order also confirmed new order for referral to (Name of foot physician)..." f. An IDP Note dated 09/07/11 at 3:50 pm revealed, "...received new order for referral to Dr (Name of foot physician) and to apply protective dressing to R heel with [MEDICATION NAME]. R heel with loose skin, clear drainage..." g. An IDP Note dated 09/09/11 at 11:33 pm revealed, "R heel wound, pink in color with purulent drainage, redness observed on outer edges..." h. Resident #75's IDP Note dated 09/11/11 at 1:38 pm revealed, "R heel...while cleansing wound reddish green drainage came out from wound bed. Resident tolerated procedure well..." i. An IDP Note dated 09/12/11 at 2:51 pm revealed, "Skin assessment to feet...R heel blister with cloudy milky drainage, skin overlay removed in areas wound bed mixture of dark areas, pink, and ... moist skin 4.1 X 3.7 cm... hospice working on obtaining antibiotic for resident." j. On 09/12/11 a Physician's telephone order was received for [MEDICATION NAME], an antibiotic. 2. Observation of Resident #75's R heel on 09/14/11 at 4:00 pm revealed dried yellow skin from the blister that had popped, appearance of [MEDICATION NAME] staining (brown) around edges, beginning eschar (dried dead tissue) at edges, open area approximately 1 cm with pink tissue under open area. The left foot revealed no blisters or eschar and areas were resolving. No purulent drainage was noted on the old dressing. 3. On 09/16/11 at 10:10 am, an interview was conducted with the Director of Nursing (DON) about Resident #75's PU. When asked if it should have taken from 09/02/11 to 09/07/11 to notify the physician of the change in the PU with the open area, the DON stated that when the drainage started, the nurses should have notified the doctor and gotten an order to cover the PU. When asked if it should have taken from 09/09 to 09/12/11 to get an antibiotic order for the purulent drainage, the DON stated, "No. They should have called the doctor the same day they saw that." B. Closed record review for Resident #78's 08/20/11 at 3:52 pm IDP Note revealed, "...blister found on R lateral heel...Resident wore boot while in W/C to prevent popping of blister..." 1. On 08/22/11 a Physician Notification form revealed, "(name of Resident #75) has developed a blister to her right heel, presently intact, measures 3.5 cm X 2.0 cm. May we apply Vaseline gauze to blister and change it on bath days 3 times weekly until healed?" 2. Review of the August 2011 Treatment Record revealed PU treatment started 08/24/11 to "Monitor intact blister to Right lateral heel Q shift for worsening or opening." 3. The DON verified on 09/16/11 at 1:48 pm, that Resident # 78's treatment was not ordered until 08/24/11 and stated that one should have been started when the PU developed. C. Closed record review for Resident #129 revealed an 07/06/11 at 5:57 pm Admission Nursing Assessment. The assessment revealed a circle on an anatomical chart on the left buttock with "Pressure ulcer" hand written and a circle on the R buttock with "scab" hand written. 1. An IDP Note dated 07/06/11 at 10:39 pm revealed, "...Skin assessment completed. Superficial wound left buttock. Scab from previous wound on R buttock noted..." 2. Review of the July 2011 Treatment Record revealed that a treatment did not start until 07/11/11. The treatment was, "Apply barrier to bottom with toileting and daily care." 3. During an interview with the DON on 09/16/11 at 1:59 pm, the DON stated that the physician should have been notified prior to 07/11/11 for treatment. He stated that the physician should be notified for treatment orders as soon as a wound is noticed.

Based on interview, and record review the facility failed to revise the Comprehensive Care Plan for falls for 1 (#30) of 4 (#30, 54, 79, 156) residents sampled for falls. The failure to communicate current interventions through the plan of care had the potential for staff to not know the current interventions which could increase the risk of falls. The findings are: A. On 09/15/11 a review of Resident #30's open and closed records revealed: a facility "Event Report" dated 08/04/11 2105 (9:05) pm-"Resident lying on left side with incontinent bladder episode, shortening to left leg and decreased ROM (Range of Motion) to left leg, complaint of hitting left side of head. Resident in room next to her bed. Resident stated she was trying to get to the kitchen to fix food for her children. C/O (complaint of) 10/10 pain to left shoulder and left hip." Immediate action taken by Nurse included: "Sent to ER (emergency room ) for eval (evaluation)". In "Section II Investigation," revealed, "Actions Care Planned" was checked, "yes." "Will provide skilled nursing and PT/OT (Physical Therapy/Occupational Therapy). Will continue to evaluate Bowel and Bladder patterns; will consider alarms, put in low bed." B. On 09/15/11 a review of Resident #30's Comprehensive Care Plan dated 07/11/11 revealed, 1. "Potential for injury/falls AEB (as evidenced by) recurrent falls, HX (history) of falls with resultant Right [MEDICAL CONDITION] (Lost balance), requires assist with transfers, mobility needs, dressing, bathing tasks." 2. Interventions: "Resident occasionally requests use of 1 or 2 rails up when in bed as means of assistive device with re-positioning/bed mobility, but usually has side rails down, remind resident to allow for time to gain balance etc, when changing positions, especially laying to sitting, monitor for proper footwear in use for transfers/ambulation purposes. Resident transfers at night, early AM with one person minimal assist during day, usually only requires supervision. Ambulates with walker and wheelchair, walks behind WC (wheelchair) often. Remind resident to lock brakes on wheelchair before standing/transfers etc." 3. Revisions dated 08/04/11 included: "8/4/11 found on left side near her bed incontinent of urine. Stated ( name of Resident #30) had tried to get to the kitchen to feed her kids. Had been toileted x (times) two before incident, Sent to (Name of Hospital) ER, DX (Diagnosis) FX (Fracture) L (left) hip, FX left humerus transferred to (Name of Hospital) TX (Treatment) for FX." A revision dated 08/04/11-"Will bring back and provide skilled care with PT/OT. Resident return 08/10/11 SNF (Skilled Nursing Facility) 2 person assist with transfer." A revision dated 08/10/11 revealed, "Offer to assist to toilet q (every) 2 hours. 2 person transfer." There was no evidence of a revision to the Care Plan for a low bed. C. On 09/19/11 at 11:55 am, an interview was conducted with the Director of Nursing (DON) concerning Resident #30's fall. When asked about the Event Report investigation, the DON, stated, "We did implement lowest position for adjustable bed. Resident is doing well in PT/OT. (Resident #30) had cycles where she would not eat and would decline. Twice we have had her evaluated for Hospice, but she improves and Hospice is not necessary. Now (Resident #30) is on skilled, she is walking on the parallel bars and is making progress." D. On 09/20/11 at 8:40 am, an interview was conducted with the Assistant Director Of Nursing (ADON) concerning the facility's Event Report for Resident #30's fall. When shown the Event Report section of Investigation summary, "...will consider alarms, put in low bed. The ADON stated, "These investigations are done in IDT (Interdisciplinary Team) every Wednesday. This is shown by the IDT review which was checked and dated 08/10/11 and Actions Care Planned checked." When shown the Care Plan for Resident #30, the ADON stated, "The 08/04/11 notation is the DON's, but there is nothing listed for the intervention of the low bed." E. On 09/20/11 at 9:00 am, Registered Nurse (RN) #1 was interviewed about the implementation of the low bed for Resident #30. RN #1 stated, " I'm unaware about the low bed. By the time I get here (Resident #30) is up and the bed is in the regular position. To know if it is being implemented you would have to talk to the night shift." When asked if there was any information about the implementation, RN #1 reviewed the Nurses notes in Resident #30's clinical record and stated, "There's nothing in the notes, but there might be something in the CNA's (Certified Nurse Assistant) 'Bedside Flow Sheets', I'll go look." RN #1 returned from the residential pod and stated, "I can't find anything." F. On 09/20/11 at 9:15 am, the ADON was asked about the CNA Flowsheets and the interventions of the low bed. The ADON returned with a notebook and presented the Care Plan Flowsheets for CNA's with an effective date 08/31/11 for September that revealed, "...Low bed with mat, low position when in bed." When asked if the intervention was in place, should the Care Plan have been revised, the DON stated, "Yes, it should have." Based on interview, and record review the facility failed to revise the Comprehensive Care Plan for behavioral monitoring for 1 (#50) of 3 (#13, 5, 157) residents sampled for [MEDICAL CONDITION] drug use. The failure to communicate current interventions through the plan of care had the potential for staff to not know the interventions related to the use of [MEDICAL CONDITION] drugs. The findings are: A. On 09/15/11 a review of Resident #50's clinical record revealed, "Comprehensive Care Plan" dated 07/10/11-"Potential alteration Mood AEB (as evidenced by) wants to go back to bed soon after arising, lack of motivation, c/o (complains of) lack of sleep related to roommate,[MEDICATION NAME]/C'd (discontinued) on 7/05 family c/o confusion being caused by this med (medication). Family state she would frequently be in bed at home by 3 pm related to depression, resident has order for antianxiety medication but no DX anxiety." Revision dated 7/21 "DX for Klopopin (sic) Anxiety." Interventions-Revision dated 07/21/11 "Administer anti-anxiety as ordered by Physician." B. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. C. A review of the CNA Flow Sheets revealed a Psychoactive Medication Flow record dated September 2011 for Resident #50. The Flow record revealed, "Psychoactive/Dose-[MEDICATION NAME] 0.5 mg. BID-Diagnosis-Anxiety; Target Behavioral Symptoms-12. Increased Anxiety." D. On 09/15/11 at 2:00 pm, an interview was conducted with the Nurse Manager (NM)concerning Treatment sheets and Psychoactive Medication Flow Records for the use of [MEDICATION NAME] 0.5 mg BID. The NM stated that it was the facility's procedure to initiate a Psychoactive Medication Monthly Flow Record for the use of [MEDICATION NAME] (a benzodiazepine) but there was not a treatment sheet in the MAR indicated [REDACTED]. E. On 09/15/11 at 2:40 pm, an interview was conducted with the ADON. When asked how the behavior monitoring sheet is developed when there is a change in medication, the ADON stated, "The Nurses make sure there is a monitoring sheet." The ADON was asked to review the Care Plan revision for Resident #50. When asked if the Care Plan should have been revised to include monitoring of increased anxiety that was reflected on the monitoring sheets, the ADON stated, "There should have been a revision," Based on record review, and interview the facility failed to revise the care plan for 1 (#75) of 3 (#75, 78, 129) residents reviewed for pressure ulcers (PU) when there were changes to the PU. Resident #75's PU opened, did not receive a change in treatment and developed an infection. The findings are: A. Record review of an Interdisciplinary (IDP) Progress Note dated 08/22/11 at 4:50 pm for Resident #75 revealed, "...C/O (complains of) pain on left foot R (right) heel. Observed Left foot (inner) underneath great toe with blister - intact 3.5 X 2.1 cm (centimeter). R heel intact blister 4.4 X 4.8 cm to paint with [MEDICATION NAME] Q (every) day." 1. Review of an IDP Note dated 08/31/11 at 12:20 am revealed, "Writer noted boots to have been kicked off in bed around 2100 (9:00 pm) ...fluid noted around where heel was. Blister had popped. No s/s (signs and symptoms) of infection. No fluid left. Blister to left metatarsal intact..." 2. An IDP Note dated 09/02/11 at 11:28 pm revealed, "R heel blister has open area 1 cm X 1 cm." 3. Review of an IDP Note dated 09/05/11 at 11:53 am revealed, "Skin assessment...right heel with popped blister, cover overlay is white (macerated) right edge with brown border left edge 7-9 o'clock without segment of skin leaving approximately 1 cm of exposed skin, heel very tender to touch, brownish drainage on sock - heel protectors bilaterally on at all times." 4. The IDP Note dated 09/07/11 at 1:36 pm revealed, "...R heel with loose skin overlay (old blister) portion torn away awhile back, today when sock adhered to drainage, skin was torn some over wound..." 5. Review of a Hospice Nurse's Note dated 09/07/11, no time, revealed, "Pt (patient) up in W/C (wheelchair)...R foot without sock or protective covering, open wound was in contact with floor. R heel open to air. Loose flap of skin. Serous drainage, white with some blackish outer edges. Cleaned with [MEDICATION NAME] and applied protective foam dressing per (Name of physician). Notified RN (Registered Nurse) of new order also confirmed new order for referral to (Name of foot physician)..." 6. An IDP note dated 09/07/11 at 3:50 pm revealed, "...received new order for referral to Dr (Name of foot physician) and to apply protective dressing to R heel with [MEDICATION NAME]. R heel with loose skin, clear drainage..." 7. An IDP Note dated 09/09/11 at 11:33 pm revealed, "R heel wound, pink in color with purulent drainage, redness observed on outer edges..." 8. Resident #75's IDP Note dated 09/11/11 at 1:38 pm revealed, "R heel...while cleansing wound reddish green drainage came out from wound bed. Resident tolerated procedure well..." 9. An IDP note dated 09/12/11 at 2:51 pm revealed, "Skin assessment to feet...R heel blister with cloudy milky drainage, skin overlay removed in areas wound bed mixture of dark areas, pink, and ... moist skin 4.1 X 3.7 cm... hospice working on obtaining antibiotic for resident." 10. On 09/12/11 a Physician's telephone order was received for [MEDICATION NAME], an antibiotic. 11. Record review of Resident #75's 01/06/11 Care Plan revealed that on 08/29/11 the current PUs were listed. There were no goals on the care plan for the PUs to the feet. There were no revisions to the care plan other than 08/29/11, "Heel protectors at all times. Areas being assessed Q (every) shift." B. Observation of Resident #75's R heel on 09/14/11 at 4:00 pm revealed dried yellow skin from the blister that had popped, appearance of [MEDICATION NAME] staining (brown) around edges with developing eschar (thick dry black dead tissue), open area approximately 1 cm with pink tissue under open area. The left foot revealed no blisters or eschar and areas were resolving. No purulent (infection) drainage was noted on the old dressing. C. Resident #75 was interviewed on 09/15/11 at 10:30 am and asked if the PU was painful. Resident #75 was able to state, "Only when they touch it." Resident was not able to express pain on a pain scale. D. On 09/16/11 at 10:10 am, an interview was conducted with the Director of Nursing (DON) about Resident #75's PU. When asked if it should have taken from 09/02/11 to 09/07/11 to notify the physician of the change in the PU with the open area, the DON stated that when the drainage started the nurses should have notified the doctor and gotten an order to cover the PU. When asked if it should have taken from 09/09 to 09/12/11 to get an antibiotic order for the purulent drainage, the DON stated, "No. They should have called the doctor the same day they saw that." The DON checked on the appointment date with the foot physician. It was scheduled for 09/29/11. The DON stated that the date was not acceptable and would call to get the appointment sooner. The DON was asked if Resident #75's Care Plan had been revised. After reviewing the Care Plan, the DON stated that it had not been revised for the PU treatments and verified that there were no goals listed.

Based on observation, record review, and interview, the facility failed to prevent 2 avoidable pressure ulcers for 2 (#75, 78) of 3 (#75, 78, 129) residents reviewed for pressure ulcers (PU). The facility failed for 1 (#129)of 3 (#75, 78, 129) to assess the PU and develop a plan of care for the PU which potentially could lead to worsening of the pressure ulcer. Additional failures were evidenced by: The facility failed to prevent an avoidable PU for Resident #75 and failed to notify the physician of the pressure ulcer opening with drainage from 09/02/11 - 09/07/11. The pressure ulcer was exposed and then developed purulent drainage indicating an infection. The facility failed to get an antibiotic order from 09/09/11 - 09/12/11. The facility failed to follow up on an appointment with the foot doctor from 09/07/11 until the surveyor pointed this out. The facility failed to prevent an avoidable PU and implement interventions for Resident #78 who was assessed to be at risk for PU development. The resident developed an heel blister which then developed an eschar (thick dry black dead tissue) cap. The facility failed to get a treatment for 4 days when the PU was found. For Resident #129 the facility failed to assess the characteristics of, stage, and measure a PU that the resident was admitted with, failed to notify the physician and get a treatment for [REDACTED]. The facility failed to implement a Care Plan for the PU. There was no documentation as to when or if the PU healed. The findings are: A. Record review of Resident #75's Interdisciplinary (IDP) Progress Note dated 08/22/11 at 4:50 pm revealed, "...C/O (complains of) pain on left foot R (right) heel. Observed Left foot (inner) underneath great toe with blister - intact 3.5 X 2.1 cm (centimeter). R heel intact blister 4.4 X 4.8 cm to paint with [MEDICATION NAME] Q (every) day." 1. Record review of the physician's orders [REDACTED]." a. Review of an IDP Note dated 08/31/11 at 12:20 am revealed, "Writer noted boots to have been kicked off in bed around 2100 (9:00 pm) ...fluid noted around where heel was. Blister had popped. No s/s (signs and symptoms) of infection. No fluid left. Blister to left metatarsal intact..." b. An IDP Note dated 09/02/11 at 11:28 pm revealed, "R heel blister has open area 1 cm X 1 cm." c. An IDP Note dated 09/04/11 at 11:05 am revealed, "R heel blister with an open area to one edge, superficial, scabbed and dry, left foot first metatarsal joint scabbed and dry no s/s of infection to both. [MEDICATION NAME] to both per orders..." d. Review of an IDP Note dated 09/05/11 at 11:53 am revealed, "Skin assessment...right heel with popped blister, cover overlay is white (macerated) right edge with brown border left edge 7-9 o'clock without segment of skin leaving approximately 1 cm of exposed skin, heel very tender to touch, brownish drainage on sock - heel protectors bilaterally on at all times." e. Review of the Weekly Pressure Ulcer QI (Quality Indicator) Log dated 09/05/11 revealed for Resident #75, "R heel stage 2, no eschar, 4.0 cm X 4.3 cm, no odor, no drainage. f. The IDP Note dated 09/07/11 at 1:36 pm revealed, "...R heel with loose skin overlay (old blister) portion torn away awhile back, today when sock adhered to drainage, skin was torn some over wound..." g. Review of a Hospice Nurse's Note dated 09/07/11, no time, revealed, "Pt (patient) up in W/C (wheelchair)...R foot without sock or protective covering, open wound was in contact with floor. R heel open to air. Loose flap of skin. Serous drainage, white with some blackish outer edges. Cleaned with [MEDICATION NAME] and applied protective foam dressing per (Name of physician). Notified RN (Registered Nurse) of new order also confirmed new order for referral to (Name of foot physician)..." h. An IDP note dated 09/07/11 at 3:50 pm revealed, "...received new order for referral to Dr (Name of foot physician) and to apply protective dressing to R heel with [MEDICATION NAME]. R heel with loose skin, clear drainage..." i. An IDP Note dated 09/09/11 at 11:33 pm revealed, "R heel wound, pink in color with purulent drainage, redness observed on outer edges..." j. Resident #75's IDP Note dated 09/11/11 at 1:38 pm revealed, "R heel...while cleansing wound reddish green drainage came out from wound bed. Resident tolerated procedure well..." k. An IDP Note dated 09/12/11 at 2:51 pm revealed, "Skin assessment to feet...R heel blister with cloudy milky drainage, skin overlay removed in areas wound bed mixture of dark areas, pink, and ... moist skin 4.1 X 3.7 cm..hospice working on obtaining antibiotic for resident." l. On 09/12/11 a Physician's telephone order was received for [MEDICATION NAME], an antibiotic. m. Record review of the 01/06/11 Care Plan revealed that on 08/29/11 the current pressure ulcers were listed. There were no goals on the care plan for the PUs to the feet. There were no revisions to the care plan other than, "Heel protectors at all times. Areas being assessed Q (every) shift." 2. Observation of Resident #75 on 09/14/11 at 11:30 am revealed the resident had on foam protective boots with dressings intact. The resident was observed to pull her wheelchair forward using her right hand on the wheel and using the right foot and heel for leverage to move the wheelchair. 3. Observation of Resident #75's R heel on 09/14/11 at 4:00 pm revealed dried yellow skin from the blister that had popped, appearance of [MEDICATION NAME] staining (brown) around edges with beginning eschar, open area approximately 1 cm with pink tissue under open area. The left foot revealed no blisters or eschar and areas were resolving. No purulent drainage was noted on the old dressing. 4. Resident #75 was interviewed on 09/15/11 at 10:30 am and asked if the PU was painful. Resident #75 was able to state, "Only when they touch it." Resident was not able to express pain on a pain scale. a. An interview was conducted with RN #3 on 09/15/11 at 10:30 am. RN #3 stated that the resident moves constantly and they cannot position the resident as the resident changes positions frequently. RN #3 verified that friction could be a cause of the blister development due to the movement of the resident. b. On 09/16/11 at 10:10 am, an interview was conducted with the Director of Nursing (DON) about Resident #75's PU. When asked if it should have taken from 09/02/11 to 09/07/11 to notify the physician of the change in the PU with the open area, the DON stated that when the drainage started the nurses should have notified the doctor and gotten an order to cover the PU. When asked if it should have taken from 09/09 to 09/12/11 to get an antibiotic order for the purulent drainage, the DON stated, "No. They should have called the doctor the same day they saw that." The DON checked on the appointment date with the foot physician. It was scheduled for 09/29/11. The DON stated that the date was not acceptable and would call to get the appointment sooner. The DON was asked if Resident #75's Care Plan had been revised. After reviewing the Care Plan, the DON stated that it had not been revised for the PU treatments and verified that there were no goals listed. c. RN #2, who had received PU training and assessed the wounds in the facility, was interviewed on 09/20/11 at 9:20 am. RN # 2 was asked if this was an avoidable PU. RN #2 stated, "Yes." RN #2 also stated that she did not think the PU was from friction, but from being left in bed and from pressure. B. Closed record review for Resident #78 revealed an admission date of [DATE] and discharge to home date of 09/09/11 with home health. Further review revealed the following: 1. A Resident Data Collection form dated 07/22/11 revealed, "Heels boggy." a. An IDP Note on 07/22/11 at 7:10 pm revealed, "...left heel boggy and slightly tender medial side -R heel boggy and slightly tender to touch lateral to middle. Heels floated..." b. The 08/18/11 at 4:56 pm IDP Note revealed, "...res (resident) C/O heel pain-heels assessed finding pink blanchable heels with peeling skin...heels are being floated while in bed..." c. An 08/19/11 at 12:54 pm IDP Note revealed, "...heels intact, R heel with dry sloughing skin, voiced some relief of pain to feet with rubbing..." d. An 08/20/11 at 01:14 am IDP Note revealed, "...Res C/O soreness to heels, R heel has dry sloughing skin, massaged both heels with [MEDICATION NAME], put heel protector boots in place..." e. The 08/20/11 at 3:52 pm IDP Note revealed, "...blister found on R lateral heel...Resident wore boot while in W/C to prevent popping of blister..." f. On 08/22/11 a Physician Notification form revealed, "(name of Resident #75) has developed a blister to her right heel, presently intact, measures 3.5 cm X 2.0 cm. May we apply Vaseline gauze to blister and change it on bath days 3 times weekly until healed?" g. The 08/24/11 physician progress notes [REDACTED]. Todays visit is for evaluation of the right foot. The location of the discomfort is primarily the heel. The pain initially began 1-2 weeks ago. She characterizes the pain as of moderate severity, throbbing and aching...." h. Review of the August 2011 Treatment Record revealed PU treatment started 08/24/11 to "Monitor intact blister to Right lateral heel Q shift for worsening or opening." i. The 09/04/11 at 2:00 pm IDP Note revealed, "R lateral heel blister is hard, brown, and flat, no signs and symptoms of infection, denies pain..." j. An 09/05/11 at 3:38 am IDP Note revealed, "...R heel blister intact firm and dark maroon brown..." k. The 09/05/11 11:46 am IDP Note revealed, "Skin assessment to R heel, blister now firm without fluid, light brown eschar cap 3.0 cm (centimeters) X 2.0 cm continues to have +2 [MEDICAL CONDITION] to lower legs and feet...C/O tenderness with pressure, pedal pulses un-palpable, encouraged elevation few times daily and at night with heel protectors. l. The 09/05/11 Weekly Pressure Ulcer QI (Quality Indicator) Log described Resident #78's wound as, "Right heel, stage 2, no eschar, 3.0 cm X 2.0 cm, no depth, no odor, no drainage." m. Review of the Pressure Ulcer Care Area Assessment (CAA) from the Minimum (MDS) data set [DATE] revealed, "[DIAGNOSES REDACTED]. Other factors: newly admitted ...Analysis of findings: At risk for pressure ulcers will care plan for staff to provide assist with repositioning until resident able to do for self. Will care plan for resident to remain free from skin breakdown and injury." 7. Review of the Care Plan dated 08/11/11 revealed no care plan for at risk for PU. One entry made revealed, "Heel blister 3.5 X 2.0." There were no goals and no interventions to prevent PUs and no goals and interventions documented when the PU developed. 8. The DON verified on 09/16/11 at 1:48 pm, that Resident # 78's CAA triggered for at risk for PUs, and there was no Care Plan for "At risk for pressure ulcers", nor a Care Plan for when the pressure ulcer developed with interventions or goals. The DON also verified that a treatment was not ordered until 08/24/11 and stated that one should have been started when it developed. C. Closed record review for Resident #129 revealed an admission date of [DATE] and a discharge to home date of 08/04/11, a 30 day stay. 1. The 07/06/11 at 5:57 pm Admission Nursing Assessment revealed a circle on an anatomical chart on the left buttock with "Pressure ulcer" hand written and a circle on the right buttock with "scab" hand written. a. A skin chart dated 07/06/11 revealed a circle on the left buttock and "superficial opening" hand written. Additional skin charts were dated 07/13, 07/20, and 08/03/11 and were without measurements, characteristics, or staging of the left buttock PU. b. An IDP Note dated 07/06/11 at 10:39 pm revealed, "...Skin assessment completed. Superficial wound left buttock. Scab from previous wound on R buttock noted..." c. Review of the July 2011 Treatment Record revealed that a treatment did not start until 07/11/11. The treatment was, "Apply barrier to bottom with toileting and daily care." d. Record review revealed no initial "Bed side care plan" and no Comprehensive Care Plan for PUs. 2. On 09/16/11 at 11:30 am, RN #2 was asked if there were wound measurements for Resident #129. RN #2 reviewed the PU tracking forms. RN #2 stated that there were no measurements for Resident #129's PU, that this had occurred prior to her taking over as the RN who measured the wounds. 3. During an interview with the DON on 09/16/11 at 1:59 pm, he stated that there should have been a Care Plan for the PUs, and the physician should have been notified prior to 07/11/11 for treatment. He stated that the physician should be notified for treatment orders as soon as a wound is noticed.