Every finding on record at Roosevelt Park Nursing and Rehabilitation Communit

Based on interview and record review, the facility failed to ensure that they had Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 1 of 30 days (3/8/26) reviewed for RN coverage. Findings include: A review of the Daily Staffing sheets, dated 3/1/26 to 3/30/26, revealed the following that on Sunday 3/8/26 the facility had no RN coverage listed for that day. During an interview on 04/02/2026 at 10:30 AM, the Nursing Home Administrator (NHA) stated that she did not know why the Daily Staffing sheet for 3/8/26 did not include RN hours. She stated her Payroll Based Journal (PBJ) Staffing Data Report showed she had RN coverage for that day. The NHA stated that the staffing sheets that she provided to the survey team were the ones that they start the days with and if there was a change to the staffing sheets, it should be reflected on it. The NHA stated she did not know why the staffing sheet for 3/8/26 was not changed to reflect RN coverage. A copy of the facility's PBJ Staffing Data Report for 3/8/26, nursing working schedule with the actual hours worked by staff for 3/8/26, and the time sheets for the nurses for 3/8/26 was requested from the NHA. The NHA verbally confirmed the request. As of the completion of the survey and exit from the facility, the facility failed to provide any documentation that would reflect that they had RN coverage on 3/8/26.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 34 residents, resulting in the increased likelihood for cross-contamination, equipment failure and harborage conditions. Findings include:On 03/31/2026 at 9:05 AM, upon entering the kitchen for the initial tour [NAME] X revealed that the Dietary Manager had come in this morning, tossed his keys on his desk then stated he quit, he was done. We have someone coming to help us but right now, I'm in charge. [NAME] X was able to demonstrate knowledge. The Raetone and True Cooler Units were observed to have torn and improperly fitting door seals. Observation hood system revealed the light fixture located inside the hood system was not working resulting in insufficient amount of lighting to staff while they cooked. Further observation revealed the toggle switch that was used to turn on/off the lights was broken clean off the outside of the hood system. Review of the FDA 2017 Food Code Section, 4-501.11 Good Repair and Proper Adjustment. Reflects the following, (A) Equipment shall be maintained in a state of repair and condition that meets the requirements under 4-1 and 4-2. (B) EQUIPMENT components, such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.Observation of the can opener blade and the housing unit for the can opener reflected stuck on food residue and debris. Observation of the dish machine revealed it was dirty, soiled, with an accumulation of build-up on the top of the machine.Observation of the cooler and freezer units located throughout the kitchen were observed to have build-up of dust, mold, and food debris on the doors, door seals, fans and fan grates, shelving, bottoms, sides, handles and tops of the units.Review of the FDA 2017 Food Code Section, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces and Utensils. Reflects the following, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean sight to touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.The flooring throughout the kitchen, hallways in the kitchen and storage areas were observed to have a build-up of dust, dirt, food debris, and general garbage on the floor.Review of the FDA 2017 Food Code Section, 6-501.12 Cleaning, Frequency and Restrictions. Reflects the following, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. Observation of the hood system revealed the filters were dusty, dirty, and had an accumulation of build-up. Review of the FDA 2017 Food Code Section, 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition. Reflects the following, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials.Observation of the water lines on the Coffee and Juice Machines reflected that they did not have any backflow prevention. Further review of the coffee and juice machines reflected they were not connected to a water filter. Review of the FDA 2017 Food Code Section, 5-203.14 Backflow Prevention Device, When Required. Reflects the following, A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas containment into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose bib if a hose is not attached and backflow prevention is required by LAW, by: . (B) Installing an APPROVED backflow prevention device as specified under 5-202.14. Review of the FDA 2017 Food Code Section, 5-202.15 A water filter, screen, and other water conditioning device installed on water lines shall be designed to facilitate disassembly for periodic servicing and cleaning. A water filter element shall be of the replaceable type.During a follow-up visit of the kitchen on 3/31/26 at 11:55 AM, Regional Dietitian (RD) O confirmed that the Dietary Manager quit this morning. RD O revealed she would be working on getting things cleaned up, changing the menus out, and making the necessary repairs and finding a replacement for the Dietary Manager.

Based on observation, interview, and record review, the facility failed to follow policies and procedures for enhanced barrier precautions (EBP), hand hygiene, and monitoring for infection control practices for 2 (R14 and R24) of 2 residents reviewed for infection control. Findings include: Review of a Face Sheet revealed R14 originally admitted to the facility on [DATE] and had pertinent diagnoses of hemiplegia and hemiparesis (one-sided weakness), vascular dementia, and blindness in right eye. Review of the Care Plan revealed R14 is severely cognitively impaired. Review of the Care Plan revealed R14 received tube feedings and required enhanced barrier precautions (EBP) related to his feeding tube. R14 was also incontinent of bowel and bladder. During an observation and an interview on 3/31/26 at 1:35 PM, Certified Nursing Assistant (CNA) G started to provide incontinence care for R14 without the appropriate personal protective equipment. CNA G proceeded to provide care with her long hair hanging down touching the bed and the resident. When CNA G finished with peri-care, she used the same gloves to adjust the oxygen nasal cannula in R14's nose, repositioned his pillow and blankets, the bed remote and other close tangible items. CNA G then took off her gloves and transported the soiled linen down the hallway to the soiled utility. No hand hygiene was completed before leaving the room. In an interview on 3/31/26 at 2:03 PM, CNA G reported she was nervous when she was observed providing care for R14 and forgot to put on the appropriate PPE and perform hand hygiene after providing incontinence care. In an interview on 3/31/26 at 2:31 PM, the Director of Nursing (DON) and the Regional Nurse Consultant (RN) A reported hand hygiene should be done every time after providing incontinence care and moving from dirty to clean surfaces. Hand sanitizer is available outside the rooms and should be used after removing gloves and leaving the resident rooms. RN A reported the facility is to be doing audits for infection control practices on a weekly basis for all departments. In an interview with the Assistant Director of Nursing/Licensed Practical Nurse (LPN) I reported she was to do the infection control monitoring audits and provided the audits for December 2025 to February 2026. Review of these documents provided revealed only enhanced barrier precautions were audited. LPN I reported she did all the audits on one day each month. When questioned about other infection control monitoring and education such as hand hygiene, LPN I reported she had no other audits or documented staffing education. Review of a Hand Washing/Hand Hygiene policy last reviewed on 1/2025 revealed: Practicing Hand Hygiene is a simple effective way to prevent infections by preventing the spread of germs. Wash hands and other skin surfaces when: 1. After immediate contamination with blood, other body fluids or potentially contaminated articles; 2. After removing gloves or other personal protective equipment; 3. After care of each resident; . Education and Training All staff will be provided with education during new hire orientation. Annual education will be provided, Infection Control & Hand Hygiene Procedure Reminders in the Workplace such as: Postings of Procedural Practices, Visual Prompts, and campaigns. Review of the Enhanced Barrier Precautions policy last reviewed 1/2025 revealed: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. b. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. c. The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities. e. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. 4. High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, etc. h. Wound care: any skin opening requiring a dressing (may exclude shorter-lasting wounds, such as skin breaks or skin tears covered with a Band-aid or similar dressing). 5. Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility, or any high-contact activity. Review of the Infection Control Program policy last reviewed 1/2025 revealed: The major purposes of Infection Control Programs in the nursing facility are to minimize the effects of infections on residents and employees, and to educate the staff. A successful Infection Control Program requires an underlying commitment and facility-wide participation. It should not just be seen as a way to meet paperwork requirements but as a way to analyze and use information effectively to improve care and prevent problems. Elements of an Infection Control Program The elements of an infection control program consist of; coordination/oversight policies/procedures surveillance antibiotic stewardship program outbreak management prevention of infection employee health and safety The Centers for Medicare & Medicaid Services (CMS) require the long term care facilities to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. During an observation on 03/31/2026 at 7:45 AM, Licensed Practical Nurse (LPN) D poured R24's medications into her bare hand (no gloves) and handed them to R24 two, three, or four tablets at a time depending on the size of each tablet. LPN D stated R24 preferred to be handed the tablets individually versus all at the same time in a medication cup. LPN D was not observed washing/sanitizing her hands prior to, or following, administering R24 her medications. During an interview on 03/31/2026 at 3:30 PM, the Director of Nursing (DON) stated nurses are not supposed to handle medications with their bare hands. He also stated they are supposed to wash their hands between residents when they are administering medications. During an interview on 04/02/2026 at 8:15 AM, Registered Nurse (RN) E stated nurses should not handle medications with their bare hands. He stated if they did it would be an infection control issue. A review of the facility's Hand Washing/Hand Hygiene policy and procedure, reviewed 01/2025, revealed, Policy: Practicing Hand Hygiene is a simple effective way to prevent infections by preventing the spread of germs. Wash hands and other skin surfaces when. 3. After care of each resident; 4. Before and after nursing treatments or procedures (dressing changes, catheter insertion, eye drop instillation, etc.). A review of the facility's Medication Administration Procedures, dated 4/2020, revealed, C. Administration. 2. Do not touch any tablets or capsules with fingers. Maintain sanitary techniques during medication administration.

Based on interview and record review, the facility failed to honor a resident's desire for showers for 1 of 1 resident (R6) reviewed for choices. Findings include: A review of R6's Face Sheet, dated 4/1/26, revealed they were an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R6's Face Sheet revealed they had multiple diagnoses that included depression and generalized muscle weakness. A review of R6's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/4/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15 which revealed R6 was cognitively intact. In addition, R6's MDS revealed they needed supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for showers. During an interview on 03/31/2026 at 9:30 AM, R6 stated she does not get showers often. She stated she and her resident advocate have been fighting them over getting showers for a while. In addition, R6 stated she goes without showers for weeks. A review of the [NAME] End Shower Schedule, updated 3/1/2023, revealed showers were scheduled by room number and divided between morning and evening (AM and PM) shifts. The [NAME] End Shower Schedule revealed R6 was supposed to receive showers twice a week on Tuesdays and Thursdays during the AM shift (in the morning). A review of R6's electronic medical record (EMR), dated 10/30/25 to 3/31/26, revealed R6 had Skin Monitoring- CNA/STNA (Certified Nursing Assistant/State Tested Nurse Aide) Shower Review sheets for 12/24/25, 12/27/25, 1/3/26, and 1/8/26. During a second interview on 03/31/2026 at 11:55 AM, R6 stated she just received a shower. She stated she feels fresh. A review of the Resident Council Minutes, dated 11/18/25 to 3/26/26, revealed the following: - 11/18/25= Showers- not getting done- for example today [name of Resident #6] wasn't asked if she wanted a shower. Last shower was at 10 pm- she wants it earlier. - 12/16/25= Old Business: Showers being given. No. - 1/13/26= Old Business: Showers being given- No. Still No. - 2/17/26= Old Business: Showers- major improvements. - 3/24/26= Old Business: Showers- major improvements. New Business: Showers- not being offered. [Name of Resident #6]- over a week since she has been offered one. Feels she has to beg for a shower. A review of R6's progress notes, dated 10/30/25 to 03/31/2026 revealed the following: - Licensed Nurse (LPN/RN) note, dated 3/22/26, revealed, Pt's (patient's) daughter came to this nurse, telling this nurse that her mother has not had a shower since last week Saturday and that is not acceptable. She stated a CNA had told either her or resident that they have been short staffed and that is why she hasn't gotten her shower. Residents daughter stated she would be coming in to speak to management on this matter. During an interview on 03/31/2026 at 3:00 PM, RN A stated she looked at R6's Skin Monitoring- CNA/STNA Shower Review sheets, dated 03/01/2026 to 03/31/2026, and knows the facility has an issue with providing showers and/or documenting showers that were provided. During an interview on 04/01/2026 at 11:10 AM, R6's Skin Monitoring- CNA/STNA Shower Review sheets, dated 11/01/2025 to 02/28/2026, were requested from the Nursing Home Administrator (NHA). In addition, the NHA stated she had provided all R6's Skin Monitoring- CNA/STNA Shower Review sheets for March 2026 that they could locate to the survey team. During an interview on 04/02/2026 at 7:58 AM, Assistant Director of Nursing (ADON) I stated that R6's Skin Monitoring- CNA/STNA Shower Review sheet, dated 6/14/26, was actually the shower review sheet from 03/14/2026 since it was in the shower review sheet book kept at the nurse's station with R6's other shower review sheets for March 2026. She stated she does not know why it was 6/14/26 but would talk to the nurse about it. A review of R6's Skin Monitoring- CNA/STNA Shower Review sheets that the facility provided, dated 11/01/2025 to 03/31/2026, revealed R6 had a shower on 1/21/26, 3/14/26 (labeled 6/14/26), 3/19/26, and 3/24/26. Therefore, based on the Skin Monitoring- CNA/STNA Shower Review sheets that the facility provided, the Skin Monitoring- CNA/STNA Shower Review sheets that were scanned into R6's EMR, the Resident Council Minutes mentioned above, and the interview with R6 on 03/31/2026 at 11:55 AM, R6 only received eight showers between 11/01/2025 and 03/31/2026 even though R6 (and her family) had informed the facility as early as 11/18/25 that she was not receiving her scheduled showers.

Based on observations, interview, and record review, the facility failed to ensure licensed nurses followed professional standards of practice related to medication storage, medication administration, medication administration documentation, and treatment documentation for 4 residents (R2, R14, R110 & R111) out of 24 residents reviewed for professional standards. Findings Include: R14Review of a Face Sheet reflected R14 admitted to the facility with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, epilepsy, dysphagia following cerebral infarction (difficulty swallowing after a stroke), gastrostomy (feeding tube) and contractures. During an observation on 6/3/26 at 8:50 AM, Certified Nurse Aide (CNA) C and CNA D entered R14's room to assess his need for a brief change. R14 did not have bilateral palm protectors in place, and R14's left eye was matted with thick drainage. During the observation, CNA C attempted to place a palm protector (hand splint) in R14's left hand before cleaning R14's hand. R14's fingernails were long with sharp edges. CNA C was unable to place the palm protector in the left hand and instead put a rolled washcloth in its place. When CNA C gathered supplies to complete a brief change for R14, she was unable to locate baby wipes in R14's room and used washcloths to clean R14. CNA C was also unable to locate baby shampoo, also known as facility stock body wash. Review of a Care Plan initiated on 7/02/2024 reflected R14 was dependent on staff for ADLs. The care plan indicated R14 needed Bilateral palm protectors on in AM and off in PM. Hand hygiene completed prior to donning and after doffing. If palm protectors are soiled, handwash in sink and let dry. Report any skin irritation; Family preference to use baby wipes with all peri care. Family to provide wipes; status of transfers: Hoyer lift with 2 assist. The ADL care plan did not address bathing or showering. Further review of the entire care plan did not address bathing or showering needs and preferences. A footnote was noted in the care plan that reflected Evaluation Note: 8/12/2024, (name of former Director of Nursing) encourage (R14) to get up daily out of bed. Use hoyer and sits in geri-chair. R14 was not observed out of bed for the duration of the survey conducted 6/3/26 from 7:30 AM – 3:30 PM. Review of the Medication Administration Record (MAR) for June 2026 reflected the following orders:-Baby shampoo Eye Wash BID (twice a day).-Please use baby wipes provided by the family for peri-care.-(R14) is to be up in the Broda chair every M-W-F (Monday, Wednesday, Friday) Nurse to sign off that he is up, if not document the reason he is not. (6/3/26 is a Wednesday)-Apply bilateral palm protectors in AM after performing hand hygiene. Remove in PM All of the above orders had been documented as completed by Licensed Practical Nurse (LPN) A, as evidenced by LPN A's initials on the MAR for 6/3/26, despite observations to the contrary. During an observation on 6/3/2026, at 8:43 AM, Licensed Practical Nurse (LPN) A was observed walking away from the East Hall medication cart. The lock to the medication cart was not engaged and the drawers were unlocked. The lockable cover/lid of the narcotic compartment in the second drawer on the right side of the cart was not locked as evidenced by the cover lifted up when the drawer was opened. Upon opening the medication drawer for stock/over the counter medications, several stock medications were observed with the lids off, the medication containers were open to air and potential spillage. The top drawer of the medication cart held an oval tablet in a plastic medication cup without a label or name on the medication cup. There was a paper medication cup stacked on top of another cup with two dark round tablets. The top paper medication cup read iron without a resident name or room number. An orange retail pharmacy prescription container without any label was observed in the top drawer. Several tablets of varying size and color were observed in the unlabeled prescription bottle. LPN A reported that the unlabeled prescription bottle belonged to her. The medication cart was then locked, and LPN A was instructed to unlock the medication cart. LPN A retrieved the East Hall Medication Cart keys, that included the key to the narcotic box within the medication cart, from an open pink plastic container on top of the medication cart. During an interview on 6/3/2026 at 8:46 AM, LPN A reported the unlabeled prescription bottle in the medication cart belonged to her. LPN A did not have an explanation for why the East Hall medication cart keys were left unsecured on top of the medication cart rather than on her person. LPN A did not explain why the stock medications were uncovered without the lids on them in the drawer of the medication cart. During an interview on 6/3/2026 at 9:20 AM, Registered Nurse (RN)/Regional Nurse Consultant E reported that the standard practice at the facility is the licensed nurse would not store personal belongings in a medication cart, would not store unlabeled, preset medications and would be sure to secure the medication cart at all times, keeping controlled substances under double lock and key. Legal Guidelines for Documentation. Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence. Record must be accurate, factual, and objective. Be certain that each entry is thorough. A person reading your documentation needs to be able to determine that a patient received adequate care. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 366). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Negligence occurs when a nurse had a duty of care that is breached, a patient is physically harmed, and damages are provided to make the person whole; a reasonably prudent nurse under similar circumstances would have done care differently. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 319). Elsevier Health Sciences. Kindle Edition. Resident #2 (R2) Review of an admission Record revealed R2 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: kidney disease and lymphedema. Review of R2's Order Summary dated 5/27/26 revealed, hydrocodone-acetaminophen (Norco) 10-325 mg tablet Every 6 Hours-PRN (as needed). Review of R2's Medication Administration Record revealed a dose of Norco was administered on 5/28/26 at 4:09 PM. Review of R2's Controlled Substances Proof of Use form revealed no documentation that a dose of Norco was dispensed on 5/28/26 at 4:09 PM. Review of R2's Electronic Medical Record revealed no documentation pertaining to Norco administration on 5/28/26 at 4:09 PM. Resident #110 (R110) Review of an admission Record revealed R110 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with behavioral disturbances. Review of R110's Order Summary dated 5/30/26 lorazepam (Ativan) 0.5 mg tablet As Needed (no repeat interval was indicated on the order).Per on-call (name omitted) ok to add back onto medication list. Indicating the previous order dated 5/10/26-5/19/26 lorazepam (Ativan) 0.5 mg tablet Every 8 Hours-PRN was to be reinstated. Review of R110's Controlled Substances Proof of Use form revealed a dose of Ativan was dispensed on 5/30/26 at 4:43 PM and 5/30/26 at 7:26 PM. Review of R110's Medication Administration Record revealed a dose of Ativan was documented as administered on 5/30/26 at 4:45 PM and 5/30/26 at 7:26 PM (2 hours and 41 minutes between doses). Review of R110's Electronic Medical Record revealed no documentation for the rationale for the doses of Ativan being administered less than 3 hours apart. Resident #111 (R111) Review of an admission Record revealed R111 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: heart failure, lymphedema, and anxiety. Review of R111's Order Summary dated 1/29/26 revealed, alprazolam (Xanax) 0.5 mg tablet Twice A Day. To be administered in the morning and in the evening. Review of R111's Controlled Substances Proof of Use form revealed on 6/1/26 only 1 dose of Xanax was documented as dispensed (7:32 AM). Review of R111's Medication Administration Record revealed on 6/1/26 both the morning and evening dose of Xanax were documented as administered. Review of R111's Order Summary dated 1/29/26 revealed, hydrocodone-acetaminophen (Norco) 5-325 mg tablet Every 6 Hours-PRN. Review of R111's Controlled Substances Proof of Use form revealed a dose of Norco was dispensed on 6/2/26 at 9:45 PM. Review of R111's Medication Administration Record revealed no documentation that the dose of Norco was administered. Review of R111's Electronic Medical Record revealed no documentation for the rationale of the withholding of R111's Xanax in the evening of 6/1/26 or Norco in the evening of 6/2/26. During an interview on 6/3/26 at 2:56 PM, Regional Nurse (RN) I confirmed the medication errors and documentation discrepancies for R2, R110, and R111. During an interview on 6/3/26 at 3:15 PM, during the exit conference, RN I confirmed the expectation was that the licensed nurses were expected to follow professional standards of nursing practice and the rights of medication administration. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Professional standards such as Nursing: Scope and Standards of Practice (American Nurses Association [ANA], 2021) apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications .1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

Based on observation, interview, and record review, the facility failed to provide activities for 1 (R14) of 1 resident reviewed for activities.Findings include:Review of a Face Sheet revealed R14 originally admitted to the facility on [DATE] and had pertinent diagnoses of hemiplegia and hemiparesis (one-sided weakness), vascular dementia, and blindness in right eye. Review of the Care Plan revealed R14 is severely cognitively impaired. During an observation on 3/30/26 at 9:49 AM, R14 was lying in bed in his room. In an interview on 3/30/26 at 12:31 PM, the Guardian of R14 reported she had concerns of R14 being in bed all day and not attending activities. R14 liked religious activities like singing gospel songs and church activities. The Guardian reported R14 had not had a care conference in at least 6 months. During an observation on 3/31/26 at 9:16 AM, R14 was observed sleeping in bed. During an observation on 3/31/26 at 10:09 AM, R14 was lying in bed. During an observation on 3/31/26 at 11:40 AM, R14 was still in bed. During an observation on 3/31/26 at 1:07 PM, R14 was still in bed. In an interview on 3/31/26 at approximately 4:00 PM, Registered Nurse (RN) reported that R14 does not like to get out of bed and is scheduled to be out of bed on Mondays, Wednesdays, and Fridays. During an observation and an interview on 3/31/26 at 1:35 PM, R14 was lying in bed. Certified Nursing Assistant (CNA) G reported R14 only gets out of bed on Wednesdays and Saturdays. Review of the Care Plan for R14 revealed: - ADL Functional Status Care Plan dated 7/2/24- Goal- Approach: Staff assist and encourage to get up in the broda chair daily.- Enhanced Barrier Precautions Care Plan (EBP) (which did not reflect EBP and instead addressed activities of daily living) - tends to be passive or refuse group activities dated 6/10/24. If he is up in his broda chair he is more likely to come down to an activity, but he does not always like getting out of bed. Staff will encourage [R14] to get up in his chair daily but will respect his wishes if he chooses to stay in bed to watch TV channel 22 Westerns or sports. Approaches included: Res to watch sports or westerns channel 7 preferred by resident or guardian, initiated 7/3/25. Activity director will do quarterly re eval of [R14's] participation/satisfaction with their personal routine/activities, initiated 6/10/24. Encourage [R14]to attend musical programs, initiated 6/10/24. Encourage/invite [R14] to activities that suit their interest or is compatible to their prior life interests/hobbies. He enjoys going outside, listening to music, being around others, watching tv/movies, games, ect., initiated 6/10/24. Offer 1-1 visits PRN to provide companionship as [R14] is able to tolerate. Offer activities such as reading poetry or scripture, gentle hand massages, reminiscing/storytelling, singing, listening to music, looking at photographs, etc., initiated 6/10/24. Offer [NAME] a variety of materials such as books, magazines, puzzles, coloring books, cards, etc., initiated 6/10/24. Place monthly activity calendar in [NAME]'s room so family/friends/staff may also look for an activity they feel [NAME] might enjoy. When of interest [R14] enjoys, musical activities, watching bingo, going outside, sitting in the activity room, movies, tv, ect., initiated 6/10/24. Respect [R14's] right/wishes if they choose to decline attending a particular activity, initiated 6/10/24. Staff will assist transporting [R14] to/from activities as needed, initiated 6/10/24. -No care plan indicating R14 was to get out of bed on Mondays, Wednesdays and Saturdays. In an interview on 4/1/26 at 12:11 PM, Activities Director (AD) R reported R14 had not been involved in the facility activities in over a year. When questioned about attending religious activities like singing, AD R reported R14 does like to sing. AD R reported R14 refuses activities but did not have any documentation where activities of his interest were offered. AD R reported R14 used to come to activities more often when his room was closer to the activities room. Review of the facility's December 2025-February 2026 Activities Calendar revealed every Saturday a Pastor visited the facility at 10:30 AM. On Sundays a Bible Reading activity was on the schedule for 10:30 AM. No singing/musical activities offered and refusals to bingo and social hour were documented.

This citation refers to Intake 2806247 in addition to the recertification survey. Based on observation, interview, and record review, the facility failed to prevent accidents and/or maintain an environment that was free from accident hazards for 2 of 4 residents (R2 and R14) reviewed for accidents and/or accident hazards, for the bathrooms in 6 of 9 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER]/21, room [ROOM NUMBER]/24, room [ROOM NUMBER]/29, room [ROOM NUMBER], room [ROOM NUMBER]/33) reviewed for water temperatures, and 1 of 2 shower rooms (West Shower Room) reviewed for accident hazards. Findings include:An Environmental tour of the facility began on 4/01/26 at 12:05 PM with Director of Maintenance (DoM) K. During an observation of the [NAME] Shower Room on 04/01/2026 at 12:20 PM, the bathroom hand sink was noted to be missing the cold-water knob/handle and the water temperature coming out of the faucet was tempted at 130.3 degrees F. The hot water temperature coming out of the shower was 127.1 degrees F. Further observation of [NAME] Shower Room revealed call light switch located on the shower wall was not working. DoM K confirmed the shower call light switch was not activating the call lights located outside the shower room doors. DoM K stated, I will look into it. During the tour, the Resident in room [ROOM NUMBER] stated, Yes, I could come in check her room and water temperature, but the water gets really hot, be careful. The hot water temperature at the hand sink was 129.4 degrees F. Resident Rooms 19 & 21 share a bathroom, the hot water temperature coming out of their hand sink was 126.0 degrees F. Resident Rooms 22 & 24 share a bathroom, the hot water temperature coming out of their hand sink was 126.1 degrees F. Resident in room [ROOM NUMBER] stated, The water gets really hot, I always need to check the temperature before putting my hands in the water to wash them. Resident room [ROOM NUMBER] had a hand sink located in her room. The resident stated the water gets very hot. The hot water temperature coming out of the hand sink was 126.8 degrees F. Resident Rooms 27 & 29 share a bathroom, the hot water temperature coming out of their hand sink was 127.4 degrees F. Resident Rooms 31 & 33 share a bathroom, the hot water temperature coming out of their hand sink was 125.0 degrees F. Resident room [ROOM NUMBER] had hot water coming out of the hand sink at 120.7 degrees F. Observation of the boiler room reflected the temperature valve on the large holding tank was at 134 degrees. The temperature on the Mixing Valve was 130 degrees. DoM K stated he had last checked it on 3/26/26 and the recorded temperature on the log was 120 degrees. DoM K further stated that this was the temperature of the water that went out to the resident rooms. During an interview on 04/01/2026 at 1:26 PM, Regional Director of Operations (RDOO) U stated he understood that there are concerns with hot water temperatures. He revealed that staff are going through checking temperatures and educating staff. During an interview on 4/01/2026 at 2:28 PM, DoM K stated, I turned the water down to 110 degrees and ran a bunch of water out of the tank to help bring down the temperature in the lines. DoM K revealed the water temperature is usually consistent with the mixing valve temperature. During an interview on 4/01/2026 at 3:48 PM, RDOO U revealed that they were having a plumber come out to check things over. During an observation and an interview on 3/31/26 at 10:08 AM, R14 was in his room lying in bed and an unsecured oxygen tank was standing alone at the foot of the bed under the window. The Regional Nurse Consultant (RN) A reported the oxygen tank should be secured. R2 A review of R2's Face Sheet, dated 4/1/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R2's Face Sheet revealed they had multiple diagnoses that included reduced mobility, generalized muscle weakness, morbid obesity, depression, and anxiety. A review of R2's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 12/22/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 14 which revealed R2 was cognitively intact. In addition, R2's MDS revealed they had physical impairment in both of their upper extremities (arms), and they were dependent on staff for bath/showers and transfers. A review of R2's Interdisciplinary Team note, dated 3/3/26, revealed, Summary of event: Resident was up in Bariatric shower chair, while adjusting resident shower chair leg broke and resident fell to floor hitting his head on floor. Post fall findings: Nurse assessed resident. No injuries noted at time of fall. Resident sent to ED for eval related to hitting head. A review of R2's Event Report, dated 3/4/26, revealed on 3/3/26 R2 was being transferred to the shower room for a shower. Certified Nursing Assistant (CNA) J was present and R2 fell when the bariatric shower chair leg broke when he was adjusted in the shower chair. R2 hit his head on the floor, but there were not any visible injuries. R2 complained of pain at a 5 of 10. He was transferred to the hospital for an evaluation. A review of R2's weight records revealed on 2/12/26 R2 weighed 419.1 pounds and the day of the incident (3/3/26) R2 weighed 415.4 pounds. During an interview on 04/01/2026 at 2:32 PM, Director of Maintenance (DOM) K stated he does not do preventive maintenance checks on the shower chairs. He stated that the leg of the bariatric shower chair broke, so there would be no way to check it to see if that would happen. DOM K stated the only moveable parts would be the screws that support the armrests and he would not know what to check on equipment that did not really have any moveable parts. DOM K further stated, I'm not even sure if the chair was rated high enough for him. He's over 500 pounds. DOM K stated he did not know what brand the shower chair that broke was so he could not reference the manufacturer's instructions to see what the maximum weight was for the shower chair that broke or call anyone to find out. DOM K stated he believed the broken chair was already disposed of, but he would check and see if it was still at the facility. He stated if it had not been disposed of, he may be able to find a brand name for it and reference the manufacturer's website to see what the maximum allowable weight for that chair was. During a second interview on 04/01/2026 at 2:45 PM, DOM K stated he looked and the broken shower chair was already disposed of. He stated he does not know what brand the broken shower chair was and he does not have another one like it at the facility. DOM K stated that the maximum weight allowed for each shower chair was not printed on the chairs themselves. He stated he was going to order another bariatric shower chair and when he receives it he will write somewhere on the chair the maximum allowable weight. During an interview on 04/01/2026 at 3:41 PM, R2 he remembered falling in the shower room on 3/3/26. He stated the aides were going to roll him down the hallway in the shower chair, but the chair did not look like it would easily roll down the hallway with him in it. R2 stated he was told that they could not use the shower bed because he was too big (heavy) for it. He stated they had the shower chair in the shower room, and they brought him in using a mechanical lift. R2 stated when the aides took him into the shower room and he saw the shower chair he was not sure if it would hold his weight. I'm a big guy and that chair looked like it was made out of flimsy, thin PVC piping. He also stated that the chair looked a little small considering I'm a bigger guy. R2 stated when the aides lowered him into the shower chair using the mechanical lift and as one of them was unhooking the sling, the chair collapsed. He stated he did not remember falling. He just remembered one minute being lowered into the chair and the next minute he was on the floor with an aide standing over him. R2 stated they called the fire department and EMS (Emergency Medical Services) to get him off the floor. He stated when they got him onto the EMS stretcher, he could see that the shower chair had splintered into a million pieces. R2 stated it looked like shattered glass on the floor, but it was the PVC material instead of glass. He stated he had been told that the shower chair was over [AGE] years old. R2 stated he did not have any injuries from the fall. During an interview on 04/01/2026 at 4:30 PM, CNA F stated she knew what the weight limit of a shower chair was based on the color of the chair. She stated she did not know the colors and weight limits off hand of each shower chair but there were multiple colors for multiple weights. For example, there was a specific color for chairs that can hold up to 200 pounds, one for 300 pounds, one for 400 pounds, and one for 500 pounds and up. CNA F stated the color scheme for the shower chairs was not the same as the color scheme for mechanical lift slings, but it was based on a similar idea. During an interview on 04/02/2026 at 8:15, Registered Nurse (RN) E stated the shower chairs are color coded based on maximum weight limits. During an observation in the [NAME] Shower Room on 04/02/2026 at 9:00 AM, RN E was shown two shower chairs (one looked like a standard shower chair, and one looked more heavy duty like a bariatric shower chair). RN E stated he could not tell by looking at the shower chairs what their weight limits were. RN E also stated that he would have to look it up the shower chairs on the manufacturer's website(s) to see the amount of weight each shower chair could hold because he normally does not give residents showers. However, he also stated he could not find the manufacturer's name on the shower chairs he looked at so he would need to contact DOM K to ask what brand they were in order to check the manufacturer's website(s). RN E further stated he doubted that an aide would take the time to look up the weight information on a manufacturer's website if they did not know the weight limit of a particular chair. During another observation on 04/02/2026 at 9:15 AM, CNA G stated she does give residents showers. CNA G was shown the same two shower chairs in the [NAME] Shower Room that RN E was shown. CNA G looked at the two shower chairs and stated she did not know the weight limit for them. She stated the weight limit should be listed on the chair or written on the chair, but it was not.

Based on interview and record review, the facility failed to have regular hospice visits documented and/or communication for 1 (R36) of one resident reviewed for hospice services. Findings include:Review of a Face Sheet revealed R36 revealed she was receiving hospice services. Review of the Facility Matrix (Centers for Medicare/Medicaid Services (CMS) Form 802) that listed resident names with triggered care areas provided on 3/30/26 revealed R36 was not triggered for hospice services. Review of the Physician Order for R36 dated 1/9/26 revealed: This resident requires hospice services. Nurse: Monday; Aide: Tues/Fri. Review of the Electronic Medical Record (EMR) for R36 revealed no consistent documentation the resident was receiving regular Hospice visits. During an interview and record review on 3/31/26 at 12:27 PM, Licensed Practical Nurse (LPN) D reported hospice staff will give a verbal report when they visit but no formal sign in to show they were there. A hospice binder for R36 was provided with some handwritten visit documentation but did not reflect the weekly visits for R36. LPN D reported she will document in the progress notes in the EMR when Hospice comes to visit but could not speak for everyone else. The last note documented in the binder was on 3/25/26 from a hospice nurse. LPN D reported R36 received a hospice visit on 3/30/26. Review of the progress notes for R36 between 1/9/26 to 3/31/26 revealed some hospice visits were documented by the nurse, but no documentation reflected the hospice staff visiting R36 on 3/30/26. There was no orderly or consistent process for hospice visits documented.

Based on interview and record review, the facility failed to ensure vaccinations were offered and up to date according to the Centers for Disease Control (CDC) for 5 Residents (R6, R7, R31, R44, and R45) of 5 residents reviewed for vaccinations. Findings include:Review of the Electronic Medical Records (EMR) for R6, R7, R31, R44, and R45 on 3/31/26 revealed they did not have any vaccination information documented and/or any informed consent forms completed.In an interview on 3/31/26 at 8:25 AM, the Regional Nurse Consultant (RN) A verified all 5 residents (R6, R7, R31, R44, and R45) did not have any of their vaccinations entered the EMR and reported all 5 residents were not up to date on all their vaccinations. RN A reported she would look into the online [name of State vaccine registry] that may have some of their vaccinations in the past registered in the system.In a follow-up interview on 3/31/26 at 2:31 PM, RN A reported all vaccinations were to be offered upon admission and confirmed the 5 residents (R6, R7, R31, R44, and R45) were not newer admissions. RN A reported the influenza vaccination was seasonal, and the COVID vaccination is to be offered every 6 months. The facility had an influenza vaccination and COVID vaccination clinic last November or December 2025. RN A reported they just ordered the RSV (Respiratory Syncytial Virus) and her COVID vaccine for R6 this day of this interview and thought R6 received her influenza vaccine at dialysis but did not have a record of it. RN A reported R6 was caught up with her pneumonia vaccines per the [name of State vaccine registry] report. RN A reported R7 refused her COVID vaccine. RN A reported R31 will have vaccines ordered once her antibiotics were finished, and the other residents will get their vaccinations caught up this week. Review of the Infection Control Program policy last reviewed 1/2025 revealed: Prevention of Infection There are several important facets of prevention. These include identifying possible infections or potential complications of existing infections, instituting measures to avoid complications or dissemination, educating staff and ensuring that they adhere to proper techniques and procedures, screening for possible significant pathogens, and immunizing residents and staff to try to prevent illness. Immunization is a form of primary prevention. Influenza vaccine among resident and employees will be encouraged: . pneumococcal vaccine(s) will also be provided following a physician's order. A review of the rates, severity, or outcome of infections among vaccinated and unvaccinated residents will be available ton (sic) help establish the effectiveness of the facility's preventive efforts.

Based on observation, interview and record review, the facility failed to ensure that equipment was being maintained in proper working order, potentially affecting all residents that use the hot water, and eat food provided by the kitchen.Findings include:During an initial tour of the kitchen on 3/31/26 at 9:05 AM, the following concerns were observed: 1.) Raetone 2 Door Coolers door seals were no longer sealing properly and was maintaining a temperature of 44 F. (3 Degrees above the highest cold holding temperature.)2.) The True 2 Door Cooler Unit- had torn door seals.3.) Light fixture located inside the hood system did not work and provided no light to staff while they cooked the residents food. Further observation revealed the toggle switch that was used to turn on/off the lights was broken off of/removed from the hood fixture.4.) Observation of the water lines on the Coffee and Juice Machines reflected that they did not have backflow prevention. Further observation of the coffee and juice machines reflected they were not connected to a water filter.During an environmental tour of the facility on 4/1/26 started at 12:05 PM with the Director of Maintenance (DoM) K.During an observation on 04/01/2026 at 12:20 PM, of [NAME] Shower Room it was observed: 1.) The bathroom light was not working. 2.) The cold-water knob/handle on the bathroom sink was missing. 3.) The water temperature coming out faucet was 130.3 F. 4.) The hot water temperature coming out of the shower was 127.1 F. Further observation of W Shower Room revealed call light switch located on the shower wall was not working.DoM K confirmed the shower call light switch was not activating the call lights located outside the shower room doors. DoM K stated, I will look into it.Observation of the boiler room reflected the temperature valve on the large holding tank was at 134 degrees. The temperature on the Mixing Valve was 130 degrees. DoM K that he had last checked it on 3/26/26 and the recorded temperature on the log was 120 degrees. DoM K stated that this was the temperature of the water that went out to the resident rooms.During an interview on 4/01/2026 at 2:28 PM, DoM K stated, I turned the water down to 110 and ran a bunch of water out of the tank to help bring down the temperature in the lines. DoM K revealed the water temperature is usually consistent with the mixing valve temperature. Review of the [NAME] Boiler at Mixing Valve reflected weekly temperature monitoring log from January 5 -through March 26 where the water temperature was at or under 123 degrees prior to going out to resident rooms.During an interview on 4/01/2026 at 3:48 PM, RDOO U revealed that they were having a plumber come out to check things over.

Based on interview and record review, the facility failed to submit and ensure an accurate and timely Minimum Data Set (MDS) for 1 Resident (R11) of 4 residents reviewed for Resident Assessments.Findings: R11A review of R11's Face Sheet, dated [DATE], revealed the resident admitted to the facility on [DATE] and expired on [DATE]. R11's Face Sheet revealed they had multiple diagnoses that included Alzheimer's disease, anxiety disorder, spinal stenosis, Chronic Obstructive Pulmonary Disease and Squamous Cell Carcinoma on skin of scalp and neck. Review of R11's progress notes revealed he expired on [DATE]. During an interview on [DATE] at 12:25 PM, MDS Coordinator P revealed they had not completed a Discharge MDS for this resident and the last MDS completed was his admission MDS on [DATE]. During an interview on [DATE] at 12:33 PM, Regional Nurse A revealed that [Name of MDS Coordinator] was unsure of the MDS procedure for discharge/death of a resident. Regional Nurse A stated she was now aware that R11 had not been discharged and stated she would have someone help/assist MDS Coordinator P with the process.

Based on interview and record review, the facility failed to address Pre-admission Screening/Annual Resident Review (PASARR) in a timely manner for 1 Resident (R35) out of 17 reviewed.Findings include:Review of Social Service Policy & Procedure for Pre-admission admission PROCESS reviewed Date 01/25, revealed, Social Services we'll review each potential resident's Sycho social and behavioral needs and Pre-admission Assessment and Annual Resident Review (PASARR) as available from the referral Source prior to determining appropriateness of placement. Procedure: . 2. Social Services will ensure that the referring party obtains a Level 2 PASARR screening, when indicated. 3. Social services will determine the needed facility services and programs to meet the potential resident's psychosocial and behavioral needs based upon pre-admission assessment and PASARR information.Review of facilities form CMS-802 Matrix for Providers failed to reflect residents that required a PASARR Level II.R35Review of R35's Electronic Medical Record (EMR) on 3/31/26 at 9:34 AM revealed PASARR Level I was completed on 2/19/26 with diagnosis that included: Traumatic Brain Injury and bipolar disorder. Further review of the record failed to reflect Level II PASARR had been completed.Review of R35's EMR revealed the previous year's Level I Change of Condition PASARR was completed on 12/27/24. Further review of R35's EMR failed to reflect Level II had been completed in 2025.During an interview 03/31/2026 at 3:25 PM, Social Services (SS) T revealed she had just started in January and did not have OBRA access. SS T then stated, There is a Level I in (Name of R35's) record. SS T further stated, No, a Level II had not been requested/ completed but I will get back to you (this surveyor) if one was required for him (R35)On 4/1/26 at approximately 8:30 AM, the facility provided documentation that reflected, (Name of R35) had an OBRA Level II Evaluation dated February 07, 2025. Review of Level II Evaluation reflected if Individual remains in the nursing facility a Level II Evaluation is needed by February 06, 2026. The document was not observed in R35's EMR.

Based on observation, interview, and record review, the facility failed to provide daily care for one (R14) of one resident reviewed for cares of a dependent resident. Findings include:Review of a Face Sheet revealed R14 originally admitted to the facility on [DATE] and had pertinent diagnoses of hemiplegia and hemiparesis (one-sided weakness), vascular dementia, and blindness in right eye. Review of the Care Plan revealed R14 is severely cognitively impaired. During an observation on 3/30/26 at 9:49 AM, R14 was lying in bed, and his hands appeared to be contracted. Hand splints were observed sitting across the room on a table. In an interview on 3/30/26 at 12:31 PM, the Guardian of R14 reported concerns of not having a care conference in a long time to review R14's care. The Guardian reported concerns of R14 not being provided oral care. The Guardian reported she had concerns of R14 being in bed all day and not attending activities. R14 liked religious activities like singing gospel songs and church activities. During an observation on 3/31/26 at 9:16 AM, R14 was observed sleeping in bed and no oral swabs were observed in the room. R14's left eye had a white discharge that was noticeable. Hand splints were observed on the bedside table. During an observation on 3/31/26 at 10:09 AM, R14 was lying in bed, and his left eye had a whitish discharge observed. During an observation on 3/31/26 at 11:40 AM, R14 was still in bed, and no oral swabs were observed in the room. R14 was friendly and talked but did not understand questions regarding his care. R14 had a white discharge in his left eye that was more obvious when he opened his eye. Hand splints were not placed on his hands. During an observation on 3/31/26 at 1:07 PM, R14 was still in bed, and no oral swabs were observed in the room. During an observation and an interview on 3/31/26 at 1:35 PM Certified Nursing Assistant (CNA) G reported she changed R14's brief right before lunch. When questioned about staff not observed in his room during that time frame, CNA G reported she entered his room through the joined bathroom from the room next door. At this time CNA G was asked to check R14's brief and it was saturated. CNA G reported R14 was to be checked and changed every 2 hours. When questioned about R14's oral care, CNA G reported they are to use glycerin swabs to swab his mouth and confirmed there were no oral glycerin swabs readily accessible in his room. CNA G reported she did not provide oral care this day. R14's toenails were very long and wrapped around the tip of his toes. CNA G confirmed there was a discharge in R14's left eye and reported it had been that way for a couple of weeks. CNA G reported she did clean his eyes this day and reported she told the nurse about the discharge. CNA G reported R14 only gets out of bed on Wednesdays and Saturdays. In an interview on 3/31/26 at approximately 4:00 PM, Registered Nurse (RN) reported that R14 does not like to get out of bed and is scheduled to be out of bed on Mondays, Wednesdays, and Fridays. RN Q reported R14 has normal saline eye drops for his eyes to treat his eyes. When questioned about the white discharge from R14's left eye, RN Q reported that is why he gets the eye drops. Review of the Care Plan for R14 revealed: -Urinary Incontinence [related to] severe cognitive impairment, dependent for all ADLs (activities of daily living) and mobility. 1/15/24- Incontinent of bowel and bladder and is a check and change. -Enhanced Barrier Precautions 6/10/24- (R14) has a visual deficit d/t (due to) blindness in the left eye. Wash eyes and face daily. (R14) tends to be passive or refuse group activities. If he is up in his Broda chair he is more likely to come down to an activity, but he does not always like getting out of bed. Staff will encourage (R14) to get up in his chair daily but will respect his wishes if he chooses to stay in bed to watch TV channel . This is not in the Approach section of the care plan.- ADL Functional Status 7/2/24- Goal- . will be clean/well-groomed daily and will participate in cares to his fullest ability. On 7/17/25 an Approach regarding palm protectors: Bilateral palm protectors on in AM and off in PM. Approach: Staff assist and encourage to get up in the broda chair daily. Approach: Use toothettes BID (twice a day)-Evaluation notes at the end of the care plan- Encourage res to get up daily out of bed.-No care plan indicating R14 gets out of bed on any specific days of the week. In an interview on 4/1/26 at 2:39 PM, the Director of Nursing (DON) reported he talked to the nurse the day before about R14's discharge in his eye and put a communication note in the physician's book. The DON reported he did not see any discharge in R14's eye this morning and suggested that maybe the CNA did not clean his eyes per the care plan.

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated for 1 (R20) and the oxygen concentrator filter was clean for 1 (R14), of 2 residents reviewed for respiratory devices.Findings include: R20 A review of R20's Face Sheet, dated 3/31/26, revealed resident admitted to the facility on [DATE] with diagnosis that included Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, and Interstitial Pulmonary Disease. An observation on 03/30/2026 at 10:19 AM, revealed R20 was receiving 4.5 L of oxygen via nasal canula. The oxygen tubing was observed to be undated. An observation on 3/31/2026 at 08:26, revealed R20 was in her wheelchair receiving oxygen via nasal cannula. The oxygen tubing was observed to be undated. Review of physician orders reflected, Oxygen tubing to be changed weekly and dated. Clean oxygen filter weekly. Once A Day on Sun 01/02/2024 - Open Ended. During an interview on 03/31/2026 at 11:51 AM, Regional Nurse A stated, Oxygen tubing was supposed to be changed and dated weekly. Review of a Face Sheet revealed R14 originally admitted to the facility on [DATE] and had pertinent diagnoses of hemiplegia and hemiparesis (one-sided weakness), vascular dementia, and blindness in right eye. Review of the Physician Orders dated 1/16/24 for R14 revealed an order for 2 liters of oxygen via nasal cannula for comfort and oxygen saturations below 88%. During an observation on 3/30/26 at 9:49 AM, the oxygen concentrator in R14's room had a filter on the side that was densely dusty and R14 was receiving oxygen via nasal cannula. During an observation and an interview on 4/2/26 at 9:14 AM, Licensed Practical Nurse (LPN) P verified the filter looked dirty. LPN P then cleaned the filter and the plastic holder that was dusty and placed it back on the concentrator.

Based on observation, interview and record review, the facility failed to timely notify necessary parties, provide support and follow-up for 1 Resident (R27) out of 3 Residents having a psychosocial adjustment difficulty causing delay in care, services and the potential for further psychosocial, mental, and potential physical harm. Findings include:R27A review of R27's Face Sheet, dated 4/1/26, revealed they were a [AGE] year-old resident admitted to the facility on [DATE]. R27's Face Sheet further revealed they had multiple diagnoses that included chronic diastolic (congestive) heart failure, macular degeneration, paroxysmal atrial fibrillation, muscle weakness, need for assistance with personal care and chronic kidney disease.A review of R27's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/19/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 14 which revealed R27 was cognitively intact.Review of R27's progress note dated 2/19/26 at 12:00 PM (written by Social [NAME] (SS) T on 2/22/2026 at 11:07 AM) revealed, During resident care conference, resident and resident's son expressed that resident would be interested and talking with a counselor. Social worker completed a referral to BCS on resident to have an evaluation completed. Referral was faxed over and sent via email. Social work to follow up with resident and BCS once they reach out to schedule an evaluation date.Review of R27's Care Plan last reviewed/revised on 2/20/26 failed to reflect any psychosocial concerns/interventions.Review of progress note dated 03/13/2026 at 01:30 PM [Recorded as Late Entry on 03/13/2026 05:16 PM by (Name of Licensed Practical Nurse (LPN) V)] reflected, Entered resident's room to ask why she refused lunch and if she wanted something different to eat. Resident explained how upset she was over not being on the list to see the mobile service unit. Resident stated I have to get out of here one way or another. Not eating or drinking should only take a couple days. I asked if she wanted some music on, listen to a book, or watch TV. Resident replied, no I just want to be in here alone. I had offered prior to lunch to clip resident's toenails and she declined. I reported resident's suicidal ideations with a plan to social work.Further review of residents EMR as of 4/01/26 at 10:20 AM, failed to reflect any documentation/follow-up regarding R27's suicidal ideation.Review of R27's Electronic Medical Record (EMR) on 4/1/26 failed to reflect resident was evaluated/seen by BCS.During an interview on 04/01/2026 at 10:25 AM, concerns were brought to NHA's attention about (Name of R27's) progress notes about wanting to see a counselor, and concern with the suicidal ideation progress note and no follow-up documented in her EMR. During the interview with NHA, SS T walked up and stated she had BSC come out for an initial screen. SS T was asked for a copy of the document because there was no documentation found in the resident's record. SS T stated, Resident was seen and they just need to scan it in the record.During an interview on 4/01/26 at 10:40 AM, SS T stated the resident was seen by BCS on 3/13/26.Review of R27's EMR reflected, the last time she saw the physician was on 3/09/27.Further review of R27's EMR failed to reflect any correspondence/follow-up regarding R27's thoughts of suicidal ideation on 3/13/26 with R27's family, physician, Social Services, DON, and NHA.During an interview on 4/1/26 at approximately 2:30PM, R27 was asked what happened on 3/13/26. R27 stated, Everything happened that day. I truly felt like I could just die that day. I felt depressed, because of the lack of help, it just felt like nobody cared. I felt like giving up. I was upset because nobody had cut my toes nails, then the podiatrist came in and I wanted them to see me, but I was told they wouldn't because I was not on the list. However, I was so upset the old DON did them for me. R27 revealed she had not seen any doctor since then. When this surveyor asked, did any staff from here come in and talk to you about those feelings you were having, R27 stated, NO. I was just very depressed, but I don't feel that way now. R27 further revealed that, No, the social services lady did not come in and follow-up with me. Resident reflected that she doesn't feel like that anymore, but she is still trying to adjust to being here.On 4/1/26 PM at approximately 4:00 PM, SS T and NHA stated she had talked to (Name of R27) a little bit ago and reported the resident feels fine, safe with no concerns. This surveyor stated part of the concern was that this was not followed up on prior to bringing it to their attention. It was revealed to NHA AND SS T that R27 stated to this surveyor that she was depressed and had suicidal thoughts and feelings on 3/13.During an interview on 4/02/2026 at 8:03 AM, Physician W was asked if a resident was having suicidal ideation what would you expect? Physician W stated, I would expect staff to at least call me or call my service and report the concern. Physician W revealed he had not been notified of R27's concern but would follow-up on it.

Based on observation, interview, and record review, the facility failed to properly label medications in 1 of 1 medication carts inspected (West Medication Cart). Findings include: During an observation on 03/20/26 at 2:29 PM, the medication cart was inspected with Licensed Practical Nurse (LPN) S. The following observations and interviews were made: - An albuterol sulfate HFA box had 37D (a room number) written on it. However, the box and the inhaler did not have any pharmacy labels (they had been torn off) or identifying information that would indicate who the inhaler belonged to if it should become separated from the box and/or an open/discard date on the inhaler. LPN S stated she did not know who the inhaler belonged to (whether it was the resident in room [ROOM NUMBER]D or a resident that had previously been in that room). - A fluticasone propionate 50 mcg nasal spray had 16 (a room number) written on the box. However, the box and the nasal spray did not have any pharmacy labels or identifying information that would indicate who the nasal spray belonged to if it should become separated from the box and/or an open/discard date on the spray bottle. LPN S stated she did not know who the nasal spray belonged to (whether it was the resident in room [ROOM NUMBER] or a resident that had previously been in that room). - LPN S stated the individual vials/diskus/inhalers should be labeled with the resident's name and open/discard by date. She also stated that the boxes should have a pharmacy label on them to indicate who the medication was for. On 03/31/2026 at 11:00 AM, the facility's policy on labeling of medications in medication carts was requested from Regional Nurse (RN) A. On 03/31/2026 at 12:55 PM, the facility provided a copy of their Storage and Expiration Dating of Medications and Biologicals policy and procedure. However, the policy and procedure they provided did not address any labeling besides labeling the medications with open dates and discard dates. The policy and procedure did not address labeling medications, or ensuring medications are labeled, with individual resident names and/or any other identifying information. During an interview on 04/01/2026 at 3:00 PM, Nursing Home Administrator- Support Administrator (NHA-SA) B was informed that the facility sent me a copy of their labeling of medications which only addressed expiration and open/discard dates. She stated they had a general Pharmacy Policy and Procedure that including labeling of medications with resident names. A copy of that policy was requested from NHA-SA B. As of the completion of the survey and exit from the facility, the facility failed to provide a policy that addressed labeling of medications with anything besides open/ discard dates. A review of the facility's Storage and Expiration Dating of Medications and Biologicals policy and procedure, last revised 6/30/25, revealed, 11. Once any medication or biological is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (i.e., vial, bottle, inhaler) when the medication has a shortened expiration date once opened . Review of the FDA medication insert for Trelegy Ellipta reflected, TRELEGY ELLIPTA should be stored inside the unopened moisture-protective foil tray and only removed from the tray immediately before initial use. Discard TRELEGY ELLIPTA 6 weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. The inhaler is not reusable. Do not attempt to take the inhaler apart.(https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/209482s003lbl.pdf)

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 17 sampled residents (R9). Findings include: A review of R9's Face Sheet, dated [DATE], revealed R9 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R9's Face Sheet revealed they had multiple diagnoses that included bipolar disorder, mild cognitive impairment, cognitive communication deficit, obsessive-compulsive disorder (OCD), depression, and dementia with psychotic disturbance. A review of R9's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 4 which revealed R9 was severely cognitively impaired. A review of R9's electronic medical record (EMR), dated [DATE] to [DATE], revealed R9 had Letters of Guardianship (a court document appointing a guardian to a resident who is unable to make medical decisions) that expired on [DATE]. A further review of R9's EMR failed to reveal any currently active Letters of Guardianship and/or any other documentation that R9's guardianship was going to be addressed after [DATE] (e.g., a pending court date). During an interview on [DATE] at 9:50 AM, Social Services (SS) T stated she was new and she was not aware that Resident #9's guardianship papers had expired. She stated she had been a social worker at the facility since [DATE] (approximately 3 months prior to the interview). She stated she would contact R9's guardian and see if they have current Letters of Guardianship or a court date to re-address guardianship. During an interview on [DATE] at 10:00 AM, the Nursing Home Administrator (NHA) stated that her and SS T met with R9's guardian last week. She stated the guardian had stated she was going to continue to be the guardian. The surveyor requested any additional information that the NHA would like to provide showing that R9's guardian was going through the process of updating the guardianship papers (e.g., court date for a guardianship hearing, new Letters of Guardianship). During an interview on [DATE] at 10:10 AM, Regional Director of Operations (RDO) U stated the facility just contacted R9's guardian and she was sending them the paperwork for guardianship. On [DATE] at 5:08 PM, the facility submitted R9's Letters of Guardianship, dated [DATE], that expire on [DATE]. A second review of R9's EMR on [DATE] at 9:10 AM failed to reveal that the facility had scanned R9's current Letters of Guardianship, dated [DATE], into their EMR. Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org, retrieved on [DATE]).

Based on interview and record review, the facility failed to post complete and accurate Daily Staffing sheets for 3 of 30 sheets reviewed (3/3/26, 3/7/26, and 3/22/26). Findings include: A review of the Daily Staffing sheets dated 3/1/26 to 3/30/26, revealed the following: - No actual RN (Registered Nurse) hours for 3/3/26 (one RN listed but no hours worked). - No RN coverage for 3/7/26 and 3/22/26. During an interview on 04/02/2026 at 10:30 AM, the Nursing Home Administrator (NHA) stated that she did not know why the Daily Staffing sheets for 3/7/26 and 3/22/26 did not include RN hours. She stated her Payroll Based Journal (PBJ) Staffing Data Report showed she had RN coverage for those days. The NHA stated that the staffing sheets are the ones that they start the days with and if there was a change to the staffing sheets, it should be reflected on it. The NHA stated she did not know why the staffing sheets were not changed to reflect RN coverage. In addition, the NHA was notified that the Daily Staffing Sheet for 3/3/26 had one RN listed on it for 3rd shift, but no hours worked. A copy of the time sheets for the nurses that worked on 3/3/26, 3/7/26, and 3/22/26 were requested from the NHA. The NHA verbally confirmed the request. On 04/02/26 at 12:36 PM, the facility provided the survey team with the Punch Detail- Report for the RN that worked 3rd shift on 3/3/26, 2nd shift on 3/7/26, and 2nd shift on 3/22/26. These reports revealed that the facility had RN an RN that worked 9.18 hours on 3rd shift 3/3/26 and RN coverage on 3/7/26 and 3/22/26 that was not originally recorded on the Daily Staffing sheets for those dates and shifts (the facility modified them between 3/31/26 when copies were originally received and 4/2/26 when the Punch Detail-Reports were received with copies of the modified Daily Staffing sheets).

This citation pertains to intake # 2614154Based on interview and record review, the facility failed to prevent misappropriation of residents narcotic medication for 2 residents (Resident #1 and #2) and monitor and investigate the potential/ongoing misappropriation of resident narcotic medication for 4 residents (Resident #2, #3, #4, and #6) out of 7 residents reviewed for the misappropriation of narcotics, resulting in the diversion of narcotic medications and the potential for ongoing diversion of narcotic medications. Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old male, admitted to the facility on [DATE].Review of R1's Order Summary dated 3/3/22 revealed, Norco (hydrocodone-acetaminophen) tablet; 10-325 mg; amt: 1; oral Three Times A Day; 07:00 AM, 01:00 PM, 07:00 PM.Review of R1's Controlled Substances Proof of Use sheet in the column Quantity Remaining revealed:*On 8/22/25 at 7:20 AM there were 19 tabs of Norco remaining.*On 8/22/25 at 11:42 AM (the next entry) there were 17 tabs of Norco remaining. Indicating 2 tabs of Norco were dispensed instead of the ordered 1 tab. The handwritten entry of 17 was written bold and appeared to haven been written repeatedly as to obscure the previous documentation. Upon closer review, 18 was legible under the bold 17.*On 8/22/25 at 6:47 PM the handwritten 16 was repeatedly/boldly written. Beneath the 16, 17 was legible.*On 8/23/25 at 7:00 AM the handwritten 15 was repeatedly/boldly written. Beneath the 15, 16 was legible.*On 8/23/25 at 1:40 PM the handwritten 14 was repeatedly/boldly written.*On 8/23/25 at 6:00 PM the handwritten 12 was repeatedly/boldly written. Beneath the 12, 14 was legible. This entry indicated 2 tabs of Norco were dispensed instead of the ordered 1 tab.The falsification/modification of these entries left 2 tabs of Norco unaccounted for.Resident #2 (R2)Review of an admission Record revealed R2 was a [AGE] year-old female, admitted to the facility on [DATE].Review of R2's Order Summary dated 4/29/24 revealed, alprazolam (Xanax) - Schedule IV tablet; 0.5 mg; amt: 0.5 mg; oral Twice A Day; 06:00 AM - 10:00 AM, 06:00 PM - 10:00 PM.Review of R2's Controlled Substances Proof of Use sheet revealed an additional dose of Xanax was dispensed on 8/24/25, outside of the ordered times.Review of R2's August Medication Administration Record revealed no corresponding entry for the Xanax administration.Review of R2's Electronic Medical Record (EMR) revealed no entry related to the additional dose of Xanax.Review of the Facility Reported Incident (FRI) revealed: .Reported Incident On 8/23/2025, during a routine audit of controlled substances, an inaccuracy was discovered on the Controlled Substances Proof of Use sheet. Entries in the Quantity Remaining column had been altered, suggesting that the narcotic count was manipulated (for R1). Interviews with staff identified Agency Nurse (Licensed Practical Nurse [LPN] C) as the individual responsible for altering the documentation of counts entered by other nurses.During medication audits conducted by licensed nursing staff, it was discovered that a dose of Xanax for (R2) was signed out on the Controlled Substances Proof of Use sheet by (LPN C). No corresponding entry existed in the eMAR (electronic medication administration record) as medication was not scheduled at that time. It was determined that tablet was missing with no adverse physical impact on patient.Audits of both east and west medication carts were completed, revealing no additional discrepancies beyond the Xanax entry noted above.Medication Audits: Licensed nursing staff completed audits of both east and west medication carts. No additional discrepancies found except for the Xanax dose for resident (R2), which was signed out on the Controlled Substances Proof of Use sheet (by LPN C) without corresponding eMAR documentation. Review determined this medication is not scheduled to be administered during third shift, the shift (LPN C) worked. Consultant pharmacist completed audits of both east and west carts no further discrepancies identified. Staff & Policy Actions: Education to be provided to RN and LPN staff regarding controlled substances policy and proper medication count procedures.Summary Based on the facility's investigation, documentation review, staff interviews, and medication audits, it has been determined that misappropriation of controlled substances is substantiated. Evidence supports that Agency Nurse (LPN C) altered the narcotic count on the Controlled Substances Proof of Use sheet and that a Xanax dose for resident (R2) was documented as given without corresponding eMAR entry, during a shift when it was not prescribed to be administered.However, the alteration of records, missing documentation, and potential diversion meet criteria for misappropriation of medication. The facility has taken corrective actions, notified appropriate regulatory and law enforcement agencies, and implemented staff education to prevent recurrence.Review of LPN F's witness statement dated 8/28/25 revealed, On Friday August 22nd, 2025 this nurse (LPN F) passed the second med pass. The resident (R1) was given his Norco 10/325mg early as he had just gotten back from working out with Physical therapy and at that time he had 18 Norco 10/325 mg remaining. At shift change the count between the two nurses showed 18 tablets left and that was what the number was on our count sheets. Sometime over the weekend another nurse changed my number and others making MY number now to be 17 remaining at the time I gave out the med.Review of LPN E's witness statement dated 8/29/25 revealed, On August 24th when I arrived to work for my morning shift, I counted off with the night nurse (LPN C). As I went to signed (sic) my morning schedule medication out, I notice (sic) the numbers appeared to be changed in bold ink. I returned to the nurses station to look for previous nurse, she had already left the facility. I notified the administrator as I looked at the schedule and realized this was the same nurse at another facility with the same issues.Review of LPN G's witness statement dated 8/29/25 revealed, R/T (related to) (R1) norco-acet 10-325mg-On 8-22-25 to best of my memory, actual count was 17. It appears it was changed to a 16 count.Review of Registered Nurse (RN) D's witness statement (no date) revealed, I counted off with (LPN C) 8/23 from evening shift to nights. When I returned Sunday AM 8/24 and went to sign out a pt (patient) norco who has it scheduled and noticed a lot of the numbers changed in bold ink. The nurse was already gone so I contacted (Nursing Home Administrator [NHA]) to notify him what happen (sic).During an interview on 09/17/2025 at 7:39 AM, RN D reported that she works as an agency nurse for the facility as well as for other sister facilities. She reported she was the nurse that worked 8/23/25 on dayshift and reported off to LPN C. She then returned 8/24/25 to work dayshift following LPN C's nightshift. RN D reported that with each shift exchange narcotic counts are completed to ensure no discrepancies. RN D reported that the counts were correct (RN D verified the number of narcotics left in the medication sleeves while LPN C verbalized the number of narcotics that remained from the narcotic sheet), so she was not immediately aware of the diversion. When she reviewed the narcotic sheet, she identified that R1's narcotic sheet had been altered. RN D was unable to obtain an explanation from LPN C as she had already left the facility. RN D then reviewed the narcotic sheets with LPN E who was working on the other hall to confirm that the narcotic sheet had been altered. RN D reported that following the incident she and LPN E recalled that LPN C had been fired from a sister facility for committing narcotic diversion a few weeks prior. Resident #2 (R2)Review of R2's Order Summary dated 4/29/24 revealed, alprazolam (Xanax) - Schedule IV tablet; 0.5 mg; amt: 0.5 mg; oral Twice A Day; 06:00 AM - 10:00 AM, 06:00 PM - 10:00 PM.Review of R2's Controlled Substances Proof of Use sheet revealed:*On 9/2/25 at 7:00 PM there were 23 tabs of Xanax remaining.*On 9/3/25 at 10:20 AM (the next entry) there were 21 tabs of Xanax remaining. Indicating 2 tabs of Xanax were dispensed and not 1 as ordered. There was no 2nd nurse signature indicating the medication was wasted.Review of R2's Medication Administration Record revealed only 1 dose of Xanax was documented as administered in the morning of 9/3/25.Review of R2's Electronic Medical Record revealed no entry related to the dispensing and/or administration of 2 tabs of Xanax.During an interview on 09/17/2025 at 3:37 PM, DON reported she spoke with the nurse on duty at that time it was reported that the Xanax was dispensed early that morning, but the resident did not take the medication, so the nurse disposed of the medication. Shortly after, the resident accepted the medication which is why the Controlled Substances Proof of Use sheet reflects 2 tabs of Xanax dispensed. Unable to prove that the licensed nurse did not divert the Xanax or make a medication error (double the dose of Xanax) as she did not sign the Xanax out each time it was pulled from medication packet, she did not have a second nurse witness the disposal of the Xanax, and/or did not account for the second Xanax in the EMR. DON confirmed that the nurse did not follow the policy for controlled drug administration and confirmed that the lack of documentation reflected 2 tabs of Xanax were dispensed at 1 time.Resident #3 (R3)Review of an admission Record revealed R3 was a [AGE] year-old female, admitted to the facility on [DATE].Review of R3's Order Summary with a start date of 9/5/25 and the discontinuation dated of 9/12/25 revealed, tramadol - Schedule IV tablet; 50 mg; Amount to Administer: 1 tablet; Once A Day. to be D/C'd (discontinued) on 9/13/25Review of R3's Controlled Substances Proof of Use sheet revealed a dose of Tramadol was dispensed on 9/16/25 at 7:25 PM.Review of R3's Electronic Medical Record revealed no corresponding entry related to the administration of the Tramadol without a provider's order.During an interview on 09/17/2025 at 3:41 PM, Regional Nurse (RN) A confirmed the Tramadol was dispensed/administered without an active order and a medication error report would be completed.Resident #4 (R4)Review of an admission Record revealed R4 was an [AGE] year-old female, admitted to the facility on [DATE].Review of R4's Order Summary dated 8/26/24 revealed hydrocodone-acetaminophen - Schedule II tablet; 5-325 mg; amt: TID PRN (three times a day as needed).Review of R4's Controlled Substances Proof of Use sheet revealed on 9/12/25 at 5:38 PM a dose of Norco was dispensed.Review of R4's September Medication Administration Record revealed no corresponding entry related to the administration of the Norco on 9/12/25 at 5:38 PM.Review of R4's Electronic Health Record revealed no documentation regarding the administration of the Norco.During an interview on 09/17/2025 at 3:41 PM, RN A confirmed the Norco was not documented in the EMAR on 9/12/25 at 5:38 PM.Resident #6 (R6)Review of an admission Record revealed R6 was an [AGE] year-old male, admitted to the facility on [DATE].Review of R6's Order Summary dated 3/24/25 revealed, hydrocodone-acetaminophen (Norco) - Schedule II tablet; 5-325 mg; Amount to Administer: 0.5 tab; oral Every 6 Hours - PRN.Review of R6's Controlled Substances Proof of Use sheet revealed:*On 8/23/25 at 7:00 PM a dose of Norco was dispensed.*On 8/23/25 at 11:30 PM a dose of Norco was dispensed by LPN C only 4.5 hours after the last dose (not 6 hours as ordered).*On 9/6/25 at 4:02 PM a dose of Norco was dispensed.*On 9/7/25 at 11:30 PM a dose of Norco was dispensed.Review of R6's August and September Medication Administration Record revealed no corresponding entry related to the administration of the Norco on 8/23/25 at 7:00 PM, 9/6/25 at 4:02 PM, or 9/7/25 at 11:30 PM.Review of R6's Electronic Medical Record revealed no entry related to the administration of Norco on 8/23/25 at 11:30 PM outside of the ordered time.During an interview on 09/17/2025 at 3:41 PM, RN A confirmed the Norco was not documented in the EMAR on 8/23/25 at 7:00 PM, 9/6/25 at 4:02 PM, or 9/7/25 at 11:30 PM and confirmed the Norco was administered outside of the provider order by LPN C on 8/23/25.During an interview on 09/17/2025 at 3:54 PM, concerns regarding ongoing diversion of narcotics due to the incomplete and/or absent documentation for the administration of controlled drugs was discussed with DON and RN A. They confirmed that the licensed nurses were expected to follow professional standards of practice for medication administration and documentation and reported the licensed nurses would be reeducated and they would be completing additional audits to ensure compliance.Review of the facility policy Controlled Substances Standards of Practice last reviewed January 2025 revealed, .Nurses removing controlled substance from the narcotic storage require documentation on the Proof-of-Use Sheet the amount removed using a full last name signature. Nurse documentation of inventory balance on Proof-of-Use sheet MUST be made as soon as the controlled substance is removed from the package/cart. Avoid waiting until the end of med pass or end of shift.Review of the facility policies Abuse Prevention Program Policy and Procedure and Abuse Prevention Program 7 Components last reviewed 01/2025 revealed, Resident Drug Diversion (can also be indication of exploitation). Exploitation-Taking advantage of a resident for personal gain, using manipulation, intimidation, threats, or coercion. Possible Indicators of Exploitation Include, but is not limited to .The diversion of a residents' medication(s), including, but not limited to, controlled substances for staff use or personal gain.The facility Administrator and/or Director of Nursing will ensure corrective action will include the following .Taking all necessary actions as a result of the investigation, which may include,but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan.

Based on interview and record review, the facility failed to implement a system to prevent, recognize, and control the onset and spread of infection among staff and residents. Findings: Per the CDC, a norovirus outbreak is defined as an occurrence of two or more similar illnesses resulting from a common exposure that is either suspected or laboratory-confirmed to be caused by norovirus . Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. Resident #20 (R20) Review of an Admission Record revealed R20 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of the Resident Infection Control Log revealed that R20 began having gastrointestinal symptoms on 2/24/25 with a positive result of norovirus on 2/28/25. Review of the Employee Infection Control Log revealed: *On 2/23/25 a Certified Nursing Assistant exhibited gastrointestinal symptoms with aches/pain, nausea, and vomiting. There was no order for culture to confirm a norovirus diagnosis. Last symptom was 2/24/25 and returned to work 2/25/25. The location the employee last worked was not documented. *On 3/1/25 a Registered Nurse exhibited gastrointestinal symptoms with abdominal cramping, diarrhea, and nausea. There was no order for culture to confirm a norovirus diagnosis. The Registered Nurse returned to work on 3/2/25. The location the employee last worked was not documented. *On 3/2/25 a Certified Nursing Assistant exhibited gastrointestinal symptoms with aches/pain, body aches, fatigue. Condition does not warrant for culture. Last Symptom: 3/3/25 and returned to work 3/4/25. The location the employee last worked was not documented. *On 3/3/25 an unspecified staff member exhibited gastrointestinal symptoms with body aches, headache, and nausea. There was no order for culture to confirm a norovirus diagnosis. Last Symptom: 3/2/25 and returned to work 3/3/25. The location the employee last worked was not documented. Review of the Employee Infection Control Log for the reporting period of 1/1/25-6/3/25 revealed no floor/unit each employee worked last was documented. During an interview on 06/05/2025 10:15 AM, Director of Nursing (DON), who was the primary Infection Control Preventionist, reported that 1 positive norovirus is not considered an outbreak and therefore did not complete contact tracing. There was no documentation to identify which staff or residents that had been in contact with R20 were identified, assessed, and monitored to prevent additional transmission. There was no documentation to reflect that the DON identified that employees were exhibiting gastrointestinal illness at the time R20 was diagnosed with norovirus or that norovirus was ruled out. DON reported that she tracked employee call ins in real time in order to trend illnesses, although the last input on the Employee Infection Control Log was 5/16/25. DON reported she had employee call in slips on her desk and had not updated the log since 5/20/25. According to the Centers for Disease Control, The average incubation period for norovirus-associated gastroenteritis is 12 to 48 hours, with a median period of approximately 33 hours .Symptoms usually last 24 to 60 hours. Up to 30% of infections may be asymptomatic . Norovirus is a highly contagious virus that causes gastroenteritis, leading to symptoms such as vomiting, diarrhea, and stomach pain. According to the CDC, norovirus is responsible for about 70,000 hospitalization s and 800 deaths annually, primarily affecting young children and the elderly. It spreads easily, requiring only a small amount of virus particles to cause illness . No additional supporting documentation was received by 06/05/25 at 05:30 PM. Review of the Facility assessment dated [DATE] revealed, .3.11. Roosevelt Park Nursing & Rehabilitation Community evaluates the infection prevention and control program to include effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, that follow accepted national standards. Our infection Control Preventionist maintains a tracking and surveillance for all potential infectious and communicable diseases by infection and unit. Decisions are made regarding care and prevention based on the disease and overall needs. We discuss this daily (Monday-Friday) in our clinical AM review and again during monthly QAPI committee meeting. We maintain employee's health system by offering/providing influenza vaccines, education and training procedures to reduce risks of transmission of illness. Employees that are symptomatic during work time will be asked to leave work duties and remain off work until symptoms have subsided. Face masks may also be worn upon request from the Infection Control Preventionist. Review of the facility policy, Infection Control Program last reviewed 03/2023 revealed, .Elements of an Infection Control Program-The success of this Infection Control Program is base as (sic) facility-wide effort involving all disciplines and individuals, it should also be considered an integral part of the facility's overall quality assurance and performance improvement program, and have the active support of the administration, residents, families, clinical, support staff, and attending physicians. The elements of an infection control program consist of; *coordination/oversight *policies/procedures *surveillance *antibiotic stewardship program *outbreak management *prevention of infection * employee health and safety .This Infection Control Program contains components under which it-1. Investigates, controls, and prevents infections in the facility 2. Decides what procedures, such as isolation, should be applied to an individual resident 3. maintains a record of incidents and corrective actions related to infections .Coordination and Oversight-The Director of Nursing has the responsibility of coordination and oversight of the Infection Control Program. The Director of Nursing may appoint a clinical staff person with interest and additional training in infection prevention and control to assist in the coordination and oversight of the Infection Control Program. The duties of an Infection preventionist may include .*Surveillance activities *Monitoring tracking systems, collecting and analyzing data .*Helping manage outbreaks and acting as a liaison with public health agencies .*Ensuring that relevant information is transmitted to appropriate individuals .All infections are tracked and to be logged regularly .Surveillance-Surveillance refers to a system for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications. Prevention and treatment begin with recognizing the kinds of infections that occur and the signs and symptoms of their onset. Infections among the residents are not always obvious. Therefore, medical criteria and standardized definitions of infections are needed to help recognize and manage infections, Atrium with utilize McGeer's criteria to assist in the recognition of infections and ensure antibiotic usage is appropriate as part of their Stewardship program. Additional resources may be utilized to support quality Antibiotic Stewardship .Outbreak Management-Infectious outbreaks are infrequent but can be potentially devastating. The two most likely and potentially most dangerous categories of epidemics and outbreaks are respiratory infections such as influenza and COVID-19) and gastrointestinal infections .Atrium support staff will guide and assist as necessary the facility in compliance with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases .

Based on interview and record review, the facility failed to ensure residents received comprehensive pain assessments for 1 resident (Resident #33) reviewed for quality of care, resulting in unidentified/untreated pain, unidentified fractures, and a delay in treatment and the potential for the worsening of medical conditions. Findings: Resident #33 (R33) Review of an Admission Record revealed R33 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: closed burst fracture of lumbar vertebra. Review of a Minimum Data Set (MDS) assessment for R33, with a reference date of 7/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated R33 was moderately cognitively impaired. Review of the Functional Status revealed that R33 required limited assistance of one person for bed mobility, transferring, dressing, toileting, and personal hygiene. On 08/16/2023 at 4:41 PM, R33's pain assessments were requested from the time of admission until the time of transfer to the hospital on 7/24/23. During an interview on 08/18/23 at 12:13 PM, Director of Nursing (DON) reported that R33's pain had been assessed in the Nursing Progress Notes and provided the progress notes with highlights where pain was assessed. DON verified that the pain assessment did not include type, location, or numerical number and the efficacy of the pain medication was not addressed. Review of R33's Nursing Progress Note dated 07/21/2023 at 11:14 PM revealed, Observed resident lying on her right side, on the mat, facing her bed. Neurological assessment initiated, Neuros WNL to baseline. ROM good to all extremities, hand grasps equal and strong, resident alert with confusion noted. Resident stated, I was trying to get in my wheelchair. No apparent injuries apparent at this time. Residents call light was not on, but in reach, bed in low position. Scheduled pain medicine administered . The comprehensive assessment did not include palpation to identify injury or a pain assessment prior to the administration of the pain medication. Review of R33's Nursing Progress Note dated 07/22/2023 at 11:53 AM revealed, Pt. (patient) is alert with occasional confusion; slept most of the morning. Gums noticeably bleeding .Pain managed with medication. A description and the location of R33's pain or the efficacy of the pain medication was not completed. Review of R33's Nursing Progress Note dated 07/22/2023 at 11:38 PM revealed, Resident A/O (alert and oriented) to baseline, cooperative with care and needs 1 assist for ADLs. Transfers with 1 assist to W/C (wheelchair) .Resident continues on Neurological assessment r.t (related to) previous fall. VSS (vital signs stable) to baseline. Norco administered at 9:09 PM r/t 8/10 back pain . Indicating the worsening of R33's pain to a severe level without the location or type of R33's pain documented and without pain medication efficacy noted. Review of R33's Nursing Progress Note dated 07/23/2023 at 09:44 AM revealed, Resident resting in bed, chose not to get up into wc today thus far, fatigued with poor appetite, no c/o (complaints of) pain r/t fall, NEURO's WNL (within normal limits), VSWNL (vital signs within normal limits), ROM BUE (range of motion bilateral upper extremities) and BLE (bilateral lower extremities) WNL. Resident encouraged to rest in bed and to get up as tolerated with staff assistance. Indicating the worsening of R33's condition. Review of R33's Nursing Progress Note dated 07/23/2023 at 10:58 PM revealed, Resident continues on Neurological assessment r/t previous fall. VSS, ROM good. Appetite poor with assistance .Norco administered at 8:11 PM r/t 8/10 back pain . Indicating the worsening of R33's pain to a severe level without the location or type of R33's pain documented and without pain medication efficacy noted. Review of R33's Nursing Progress Note dated 07/24/2023 at 10:02 AM revealed, Resident LT (left) side of face swollen and painful, son called and ok to send to ER (emergency room ), (provider) called and ok to send to ER . Confirming R33 was sent to the emergency department related to facial swelling and not related to the fall sustained on 7/21/23. During an interview on 08/18/23 at 10:10 AM, Medical Doctor (MD) O reported that she had not been notified of increased pain regarding R33's fall on 7/21/23. MD O reported that during each resident assessment completed by the provider, vital signs, which includes pain, is reviewed. MD O reviewed R33's pain assessments and reported there would be no way to definitively identify that R33's pain worsened, what type of pain R33 was experiencing (sharp, dull, achy, etc), or where the pain was located because the facility did not complete appropriate pain assessments. MD O reported she would expect that a resident would have pain assessments documented after a fall and/or if on pain medications. ME O reported R33's pain documentation in the progress note was insufficient. ME O reported that the efficacy of pain medication is based on comprehensive pain assessments and trending up or down on the pain scale which R33 did not have. MD O reported that all other vital signs (blood pressure, pulse, heartrate, oxygenation, and respirations) were documented in the Electronic Health Record except pain. MD O reported that she and the physician assistant did not see R33 from 7/10/23 until her return from the hospital on 8/3/23 due to no concerns reported to them from the facility licensed nursing staff regarding R33's change in condition. During an interview on 8/18/23 at 11:25 AM, Physical Therapy (PT) W reported that R33 was on therapy case load in July. The fall on 7/21/23 was on the weekend, when therapy attempted to work with R33 on 7/24/23 the resident was clearly having increased pain and inability to participate with therapy. Therapy staff backdated a discharge to 7/21/23 due to it being the last day therapy worked with R33. Review of R33's Hospital Records dated 7/24/23 revealed, 93 (year old) female presents on 07/24/23 for fall and facial swelling. Patient presents via EMS (Emergency Medical Services) from (Facility) .Patient reportedly had fallen while she was trying to get out of bed 3 days ago. She has been complaining of right-sided face and flank pain since this time. Pain extends from right ear down to right hip .While in the ED (emergency department) .imaging revealed that patient has multiple thoracic compression deformities with a questionable new nondisplaced compression fracture at T8, as well as new fractures on right ribs 10 through 11, new burst compression fracture at superior L3 endplate, and acute fracture along the ischial tuberosity and posterior aspect of the right inferior pubic ramus .Patient was evaluated by the trauma service for any need for management of her multiple fractures. Due to ongoing infections they decided to undergo conservative management of her fractures with medications to obtain appropriate pain control .Lying in the hospital bed with eyes open, softly moaning .Patient moans in response to palpation over right ribs . Review of R33's Provider Progress Note dated 8/10/23 revealed, .She is still working with therapy but has immense pain whenever she moves. She is currently on morphine every 6 hours as needed. She is not her own person but is able to answer some questions appropriately. I did discuss her end of life wishes with her .Her son who is also her DPOA (Durable Power of Attorney) opted for comfort care treatment and not to send the patient back to the hospital . During an interview on 08/17/23 at 09:33 AM, Certified Nursing Assistant (CNA) U reported that since returning from the hospitalization from [DATE]-[DATE] R33 had not been her usual self and doesn't get out of bed anymore. Review of the CNA Care Guide dated 8/2/23 (prior to R33's return from her hospitalization on [DATE]) revealed R33 required 1 assist for transferring. Review of the CNA Care Guide dated 8/15/23 revealed R33 required 2 assist for transferring. Confirming a decline in R33's condition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Characteristics of Pain-Assessment of the characteristics of pain allows you to understand the type of pain, its pattern, and the types of interventions that bring relief. Use of assessment tools to quantify the extent and degree of pain depends on a patient being cognitively alert enough to be able to understand and follow instructions. Timing (Onset, Duration, and Pattern) Ask questions to determine the onset, duration, and time sequence of pain. When did it begin? How long has it lasted? Does it occur at the same time each day? Is it intermittent, constant, or a combination? How often does it recur? It is sometimes easier to diagnose the nature of pain by identifying time factors. Knowing the time cycle or pattern of pain helps you intervene before the pain occurs or worsens (see Box 44.5). Location Ask a patient to describe or point to all areas of discomfort to assess pain location. To localize the pain specifically, have him or her trace the area from the most severe point outward. This is difficult to do if pain is diffuse or involves several sites or parts of the body. Do not assume that your patient's pain always occurs in the same location. When describing pain location to other health care providers, use anatomical landmarks and descriptive terminology. The statement Pain is localized in the upper right abdominal quadrant is more specific than The patient states the pain is in the abdomen. Pain classified by location can be further classified as superficial or cutaneous, deep or visceral, referred, or radiating (Table 44.5). Severity One of the most subjective and therefore most useful characteristics for reporting pain is its severity. Nurses teach patients how to use pain scales to help them communicate pain severity or intensity. Many scales are available in several languages to aid nurses when a professional interpreter is not present. The purpose of using a pain scale is to identify a patient's perception of pain intensity over time so that the effectiveness of interventions can be evaluated (Pasero and [NAME], 2011). It is important to select the scale that is appropriate for a patient's age, language, condition, and ability and to ensure that the patient understands how to use it. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 1071-1072). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Application to Nursing Practice o Attempt a self-report of pain using simple yes/ no responses or vocalizations or a numerical rating scale (Chow et al., 2016). o Search for potential causes of pain (Horgas, 2018). Examples include pain associated with intravenous insertion site infiltrations, abdominal cramping and fullness, urinary retention, or prolonged pressure on body parts associated with immobility. o Assume that pain is present after ruling out other problems (infection, constipation) that cause pain. o Identify pathological conditions or procedures that cause pain. o Observe patient behaviors and list behaviors (e.g., facial expressions, vocalizations, body movements, changes in interactions or mental status) that indicate pain (Horgas, 2018). o Ask family members, parents, or caregivers for a surrogate report. o Use behavioral pain assessment tools. o Use evidence-based tools to ensure appropriate pain assessment (Horgas, 2018). o Use the PAINAD to assess pain in patients with advanced dementia (Horgas, 2018). o Use behavioral pain assessment tools. o Use evidence-based tools to ensure appropriate pain assessment (Horgas, 2018). o Use the PAINAD to assess pain in patients with advanced dementia (Horgas, 2018). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1071). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Because pain is dynamic, accurate assessment requires you to monitor it on a regular basis along with other vital signs. Some institutions treat it as the fifth vital sign. Pain assessment is not simply a number. Relying solely on a number fails to capture the multidimensionality of pain and may be unsafe, particularly when the number fails to reflect the entire pain experience or when a patient does not understand the use of the selected pain-rating scale. Pain assessment is a nursing responsibility. However, assistive personnel (AP), physical therapists, social workers, and others also screen for pain by asking patients whether they are uncomfortable or in pain. When pain is noted by any care provider, it is essential that a nurse be informed immediately so that he or she can make a thorough assessment to confirm the patient's discomfort and provide appropriate treatment. The ability to establish a nursing diagnosis, decide on appropriate interventions, and evaluate a patient's response (outcomes) to interventions depends on the fundamental activity of a factual, timely, accurate pain assessment. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1070). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The key to success is ongoing pain assessment and evaluation of the efficacy of interventions. Does the patient feel relief? Are there any unacceptable side effects from therapies? It is the responsibility of the health care team to collaborate to find the combination of therapy that works best for a patient. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1082). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to implement a post fall intervention for 1 resident (Resident #33), reviewed for falls, resulting in a subsequent fall with major injuries. Findings: Resident #33 (R33) Review of an Admission Record revealed R33 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: closed burst fracture of lumbar vertebra. Review of a Minimum Data Set (MDS) assessment for R33, with a reference date of 7/3/23 revealed a Brief Interview for Mental Status (BIMS) score of 11, out of a total possible score of 15, which indicated R33 was moderately cognitively impaired. Review of the Functional Status revealed that R33 required limited assistance of one person for bed mobility, transferring, dressing, toileting, and personal hygiene. Review of R33's Reportable Event/Root Cause Analysis revealed Date of Event: 7/11/23 at 6:45 AM .Resident was looking for a phone for (name omitted). She was observed on the floor in her room. Resident is confused with a BIMS of 11. MD (medical doctor) ordered again urine C+S (Culture and Sensitivity). Psych to evaluate + treat as needed. No injuries. No pain noted. [NAME] (sic) on floor next to bed. Care plan reviewed + updated as needed. Pending lab results .Explain what your intervention is going to be to prevent similar incidents from occurring to other residents in your facility .monitoring with rounding .continue to monitor with rounding . Review of R33's Event Report dated 7/11/23 revealed, .trying to find her phone she states .Evaluation Notes: Items within reach. Resident is confused. UA C&S requested. Psych to evaluate. No injury. No pain noted. MD and family aware. Neuro checks completed. Review of R33's Interdisciplinary Team (IDT) Note dated 07/12/2023 revealed, IDT met to review incident on 7/11/23. Resident was looking for a phone for (name omitted). She was observed on the floor in her room. Resident is confused with a BIMS of 11. Urine was sent lab but lab failed to run a culture. Nurse will obtain urine and resent to lab. Psych to evaluate and treat as needed R/T (related to) confusion. MD and family notified. No injuries noted. No pain noted. Care Plan reviewed and updated as needed. During an interview on 08/18/23 at 12:50 PM, MDS Registered Nurse (MDS RN) S reported that R33's Care Plan was updated after a fall on 7/6/23 but was not updated after the fall on 7/11/23. MDS RN S reported an intervention of a urinalysis with a culture and sensitivity was implemented after the fall on 7/11/23 due to concerns that R33 had a Urinary Tract Infection (UTI). MDS RN S reported that the root cause of R33's fall on 7/11/23 was determined to be the result of increased behaviors secondary to a UTI. Review of R33's Laboratory Results date specimen received 7/13/23 and date specimen results reported 7/16/23. The Laboratory Result scanned into the Electronic Health Record did not have an initial and date to indicate the provider had reviewed the testing results. Review of R33's Electronic Health Record revealed no provider notes regarding the review of R33's culture and sensitivity report or new orders for treatment. During an interview on 08/18/23 at 10:10 AM, Medical Doctor (MD) O reviewed and verified that she and the physician assistant had not been notified by the facility nurses or the Infection Control Preventionist of R33's positive urine culture on 7/16/23 and reported she would have expected facility nursing staff to notify the provider of the positive culture so appropriate treatment could be put in place. (MD O confirmed they had not been notified using the facility's Electronic Health Record as well as her clinic's Electronic Health Record.) MD O reported that based on the 7/16/23 culture result and symptoms R33 was experiencing (increased behaviors, agitation, hallucinations) she would have initiated antibiotic treatment. Review of R33's Reportable Event/Root Cause Analysis revealed date of event 7/21/23 at 11:14 PM-Resident was observed lying on her right side of the matt (sic). Neuros ongoing. Resident stated was trying to get in (wheelchair). Call light was not on, matt (sic) was in place + bed in low position. Prior to fall-resident was sleeping in bed. No injuries noted. Family, MD notified. BIMS-11 care plan reviewed + updated as needed. Place sign to remind resident to call for assistance . When were the last 2 times the resident was seen on 15mins, 30mins, 1 hr, 2 hours? Sleeping in bed (no times R33 was last seen documented) . Who was the person and what did they observe the resident doing at those times? Sleeping (no further documentation for this section) . After a thorough review of this incident, investigation and or incident explain the root cause that led to this incident? Resident attempted to transfer without assistance (review of the previous fall intervention to rule out UTI was not referenced or reviewed) . Fall Statement (no date or time) completed by Director of Nursing-Write the last time you saw resident (blank). Write what was the resident doing the last time you saw them-sleeping .Roommate was present when she fell . Fall Statement dated 7/21/23 completed by Licensed Practical Nurse (LPN) V-Write the last time you saw resident .3 P (3:00 PM) in bed .(approximately 8 hours prior to the incident). Fall Statement dated 7/21/23 completed by Certified Nursing Assistant (CAN) T-Write the last time you saw resident .Seen her in bed snatching the call light out of the wall .yelling and very agitated .very annoyed grabbing at things .She was yelling she's in pain and want 2 call the police .maybe she was yelling and lost her balance when she was pulling the call light out of the wall . During an interview on 08/17/23 at 09:33 AM, CNA U reported prior to R33's fall on 7/21/23 she had been increasingly anxious and agitated. (Signs of UTI in elderly patients include confusion, irritation, hallucinations, changes in behavior, and poor coordination.) During an interview on 08/17/23 03:50 PM, CNA T reported that she was working on the date R33 fell on [DATE]. CNA T reported that she had been in the room approximately 20 minutes prior to the fall and had observed R33 repeatedly yelling help and call the police and was attempting to rip the call lights out of the wall (both R33's call light and the roommates call light). CNA T reported that R33 was usually quiet but was agitated and anxious at that time. CNA T reported that R33 was continuously pulling at the call lights and both of her arms were tangled up in the call lights and R33 was wrapped all up in the call lights prior to her fall. CNA T reported she left R33 to assist another resident and by the time she returned R33 had fallen. CNA T stated, I don't know if they checked into a UTI, maybe that's what got her confused and agitated. During an interview on 08/16/23 at 04:31 PM, LPN V reported that she was the nurse for R33 on the date of the fall on 7/21/23 and observed R33 with increased agitation, attempting to get out of bed, and more anxious than her baseline. During an interview on 08/18/23 at 9:57 AM, Social Services Director (SSD) M reported there were no behavior logs for R33. SSD M reported that prior to her fall on 7/21/23 R33's confusion and behaviors were getting worse and R33 was more anxious than usual and was having increased hallucinations. Review of R33's Nursing Progress Note dated 07/21/2023 at 11:14 PM revealed, Observed resident lying on her right side, on the mat, facing her bed. Neurological assessment initiated, Neuros WNL (within normal limits) to baseline. ROM (range of motion) good to all extremities, hand grasps equal and strong, resident alert with confusion noted. Resident stated, I was trying to get in my wheelchair. No apparent injuries apparent at this time. Residents call light was not on, but in reach, bed in low position. Scheduled pain medicine administered. Resident was assisted with meal, drinking nectar thickened liquids. Residents bed is a low bed now. Resident has been sleeping. Review of R33's Hospital Records dated 7/24/23 revealed, 93 (year old) female presents on 07/24/23 for fall and facial swelling. Patient presents via EMS (Emergency Medical Services) from (Facility) .Patient reportedly had fallen while she was trying to get out of bed 3 days ago. She has been complaining of right-sided face and flank pain since this time. Pain extends from right ear down to right hip .While in the ED (emergency department) .imaging revealed that patient has multiple thoracic compression deformities with a questionable new nondisplaced compression fracture at T8, as well as new fractures on right ribs 10 through 11, new burst compression fracture at superior L3 endplate, and acute fracture along the ischial tuberosity and posterior aspect of the right inferior pubic ramus .Urinalysis showing large blood, large leukocytes, 3+ bacteria .patient was admitted to the general medical floor. Patient was evaluated by the trauma service for any need for management of her multiple fractures. Due to ongoing infections they decided to undergo conservative management of her fractures with medications to obtain appropriate pain control . (Confirming R33 was treated for a urinary tract infection which required intravenous antibiotics as well as multiple new fractures). Review of R33's Provider Progress Note dated 8/10/23 revealed, .She was recently hospitalized due to sepsis from a UTI .She has E. coli (bacterial infection) and MSSA (methicillin-susceptible Staphylococcus aureus/bacterial infection) which should respond to oral Augmentin (antibiotic) . Review of the facility policy Fall Prevention and Management Policy last reviewed 01/2022 revealed, .2. When a fall even occurs, a license nurse will: A. Complete an immediate physical assessment of the resident .E. Implement an appropriate intervention/preventative measure .H. Monitor the resident and follow-up if indicated .

Based on interview and record review, the facility licensed staff failed to follow professional standards of practice, monitor pertinent laboratory values, communicate effectively with a [CONDITION(S)] clinic and follow-up on pharmacy recommendations resulting in an Immediate Jeopardy (IJ) that was identified on 9/6/2022 and began on 2/8/2022 when the [CONDITION(S)] clinic discontinued testing PT/INR levels for Resident #26 who continued to receive [MEDICATION(S)] 6 mg (an anticoagulant) once a day at the facility for over 6 months without PT/INR monitoring. This deficient practice resulted in the high likelihood for Resident #26 to suffer an adverse drug reaction (hemorrhage or blood clot formation) that could result in serious harm, injury and/or death. Findings include: Review of a facility policy Anti-Coagulation Therapy reviewed 1/2022 reflected the purpose was To monitor anticoagulation regimes of residents at the facility and to provide accurate reporting of laboratory results and dosage adjustments to attending physicians. The goal of the policy was To assist the attending physicians in providing therapeutic anticoagulation to their resident while decreasing the potential morbidity and mortality associated with these treatments. The procedures were as follows: 1. The facility will establish and maintain an Anticoagulation Therapy Log that contains the name of each resident receiving anticoagulation medication. The information in the log will contain: date started, reason for anticoagulation, present dose, all lab work and date drawn, all dosage adjustments, when next lab work is ordered, and the date and staff member notifying the attending physician. 2. The DON/designee will identify any resident who is admitted on or started on anticoagulation therapy, and place an Anticoagulation log in the residents MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. When lab values are telephoned to an on-call physician, record any orders, the date the order was given, and the name of the on-call physician on the lab report, and fax to the attending physician for continuity of care. If the on-call physician does not respond to notification within a reasonable time, the Medical Director is to be called to provide coverage. 4. Attending physicians should review their residents' log during each visit to the facility to assure accuracy and continuity. 5. The DON/designee, Pharmacy Consultant, and Attending physician will review residents' medications for possible drug interactions. The pharmacy will employ a mechanism to identify possible drug interactions when new medications are added to any resident's drug profile who is receiving anticoagulation therapy. 6. When possible interactions are identified, the attending physician will be notified by telephone or fax. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the attending physician fails to respond to the notification, the Medical Director will be alerted. [MEDICATION(S)] ([MEDICATION(S)] Sodium) is a narrow therapeutic range drug and anticoagulation must be carefully monitored during [MEDICATION(S)] therapy. Adjust the [MEDICATION(S)] dose to maintain a typical target INR of 2.5 for [CONDITION(S)], pulmonary embolism and [CONDITION(S)] with an INR range of 2.0-3.0 for all treatment durations. Determine the INR daily after the administration of the initial dose until INR results stabilize in the therapeutic range. (Bristol-[NAME] Squibb Company, [NAME], New Jersey, October 2021) A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results. Prothrombin is a protein made by the liver. It is one of several substances known as clotting (coagulation) factors. When you get a cut or other injury that causes bleeding, your clotting factors work together to form a blood clot. Clotting factor levels that are too low can cause you to bleed too much after an injury. Levels that are too high can cause dangerous clots to form in your arteries or veins. A PT/INR test helps find out if your blood is clotting normally. It also checks to see if a medicine that prevents blood clots is working the way it should. (Accessed from: Prothrombin Time Test and INR (PT/INR): MedlinePlus Medical Test on 9/08/2022) Resident #26 (R26) Review of a facility Face Sheet reflected R26 originally admitted to the facility in 2013 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R26 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15 and was independent for bed mobility, transfers, locomotion, and eating and only needed supervision and setup help for toilet use. The assessment did not reflect that R26 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included a section to record the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Administration Records (MARS) from January 2022-September 2022 reflected that R26 was prescribed, and nurses administered [MEDICATION(S)] tablet; 6mg Amount to administer: 1; oral Start date 10/23/2021-9/6/2022. The MAR's indicated the doses were administered daily with some exceptions. Documentation on the MARs indicated R26 refused the medication once in March and April and two times in May 2022. R26 never refused the medication in June 2022 but refused the medication 8 times in July 2022. R26 refused the dose once in August and did not refuse the drug in September, 2022. No orders were found pertaining to testing PT/INR levels, instead the MARs indicated Other Test (no test) labs typically obtained at [CONDITION(S)]. 02/28/2017-Open Ended Review of a pharmacy Consultation Report dated 3/14/22 reflects (R26) receives [MEDICATION(S)] and the most recent INR documented in the medical record is from 1/18/22. The recommendation was Please consider monitoring an INR on the next convenient lab day and at least monthly thereafter increasing the frequency when clinically appropriate (e.g., acute illness, dose adjustments, change in interacting medication or diet, signs of bleeding). The rational for recommendation was [MEDICATION(S)] has a BOXED WARNING describing the potential for major, sometimes fatal, bleeding. To avoid adverse consequences (e.g., bleeding, [CONDITION(S)]), individuals should be closely monitored and continually assessed both clinically and through appropriate INR monitoring. The physician's response noted on the report was I accept the recommendation(s) WITH THE FOLLOWING MODIFICATION(S): [CONDITION(S)] doses INR and was signed by the physician but not dated. The report was also signed by the Director of Nursing (DON) without a date. No further pharmacy recommendations pertaining to R26's [MEDICATION(S)] therapy were found in the clinical record. Review of laboratory results in the Electronic Medical Record for R26 did not reflect that a PT/INR result had been obtained and added to the clinical record since January 2022. During a telephone interview on 9/06/22 at 2:30 PM, Registered Nurse (RN) J, Clinical Manager of the [CONDITION(S)] clinic where R26 received [CONDITION(S)] reported that PT/INR testing had been discontinued after February 8, 2022 due to R26 telling them he was no longer taking [MEDICATION(S)]. According to RN J, the expectation is that facility doctor would act on notification of the change. RN J said the [MEDICATION(S)] is prescribed by the physician and if the PT/INR results weren't sent with R26 after [CONDITION(S)] the nurses would normally call weekly asking for result. According to RN J, the [CONDITION(S)] clinic had not heard from the facility. RN J was asked to email evidence of communication from the [CONDITION(S)] clinic to the facility of the discontinuation order and of the February 8, 2022 PT/INR result. Review of an email communication from RN J dated 9/6/22 at 3:05 PM reflected that the only documentation from the [CONDITION(S)] clinic was a [MEDICATION(S)] log with a notation to discontinue PT/INR testing. No formal communication between the [CONDITION(S)] clinic to the facility pertaining to the changed order was noted. The last noted PT/INR level obtained was 2/8/2022. Review of physician and physician assistant progress notes from January-September 2022 do not reflect active monitoring of R26's [MEDICATION(S)] therapy. The notes indicate R26 is on chronic anticoagulation and taking [MEDICATION(S)] with labs done by the [CONDITION(S)] clinic and reviewed by the facility attending physician. During a telephone interview on 9/06/22 at 3:17 PM, Doctor of Osteopathy (DO) K reported he was not aware PT/INR labs were not being done for R26. DO K said he does not recall monitoring R26's dose of [MEDICATION(S)] and didn't notice staff were not calling the [CONDITION(S)] clinic for PT/INR results. According to DO K, a resident taking [MEDICATION(S)] typically has PT/INR measured once a week, or more often if indicated. DO K did not recall the pharmacy consultation report related to PT/INR results and could not explain why he did not follow up on the reported concern. On 9/6/22 at 3:30 PM the facility Nursing Home Administrator (NHA), Director of Nursing (DON) and Registered Nurse (RN) Consultant L were informed of the Immediate Jeopardy (IJ) that was identified on 9/6/2022 that began on 2/8/2022 when the [CONDITION(S)] clinic discontinued testing PT/INR levels for R26 who continued to receive [MEDICATION(S)] 6mg once a day at the facility for over 6 months without PT/INR monitoring. The State Agency validated the following actions were taken by the facility to remove the situation of Immediate Jeopardy (IJ): 1. On 9/6/22 at approximately 2:15 p.m. DO K, physician for Resident #26, was notified that Resident #26 was on [MEDICATION(S)] without orders for PT/INR monitoring. The physician discontinued [MEDICATION(S)] and ordered a stat INR. a. Lab results were: PT = 22.9, INR = 2.0 b. The Director of Nursing educated the physician on reviewing the anticoagulation status and/or lab results during visits to determine if dosage and/or medication changes are indicated. The education included the need to review/respond to pharmacy recommendations regarding anticoagulant medications. 2. On 9/6/22 at approximately 2:20 p.m. the resident's medical record was reviewed from February 2022 - September 2022 and revealed that licensed nurses have been completing ongoing side effect monitoring for bruising, bleeding, hematuria, tarry stools, epistaxis. No concerns were identified with [MEDICATION(S)] side effects; the resident has not experienced any evident bleeding as a result of [MEDICATION(S)] therapy. 3. On 9/6/22 at approximately 2:30 p.m. the Director of Nursing and Regional Nurse reviewed the orders of residents in the facility to review other residents who may by receiving [MEDICATION(S)] to ensure INR monitoring is being completed. No other residents are receiving [MEDICATION(S)] at this time. 4. 9/6/22 at 3:30 p.m. DO K ordered a STAT EKG to determine if Resident #26 has [CONDITION(S)]. The physician stated the [MEDICATION(S)] is to remain discontinued if the resident does not have [CONDITION(S)]. a. The EKG is scheduled to be obtained on 9/7/22, and the results will be shared with DO K when they are received. b. The Director of Nursing spoke with DO K regarding use of alternative anticoagulant medications if indicated. The physician stated that based on the results of the EKG an alternate anticoagulant will be considered. c. On 9/7/2022 an order for [MEDICAL RECORD OR PHYSICIAN ORDER] 5. On 9/6/22 at approximately 3:35 p.m. Resident #26 allowed the Director of Nursing to complete a partial skin assessment. No bruising, no open areas, or any signs or symptoms of bleeding were evident. 6. On 9/6/22 at approximately 3:45 p.m. skin assessments for Resident #26 were reviewed for the past 30 days. No concerns were identified with the resident's skin assessments. 7. On 9/6/22 at approximately 4:00 p.m. the consultant pharmacist was notified that an IJ was issued with preliminary fact analysis indicating a pharmacy recommendation was not completed for evaluation of PT/INR monitoring for Resident #26. The consultant pharmacist was requested to monitor for the presence of PT/INR monitoring for residents on [MEDICATION(S)] on future visits. a. The Director of Nursing reviewed with the consultant pharmacist with the revised anticoagulant therapy policy that has been proposed and includes the expectations of the consultant pharmacist: The consultant pharmacist will review residents on anticoagulation therapy during each medication regimen review. The review will include laboratory testing and monitoring. The consultant pharmacist will make recommendations to physicians as indicated and report any concerns to the facility administrator or Director of Nursing for follow-up. b. On 9/6/22 4:05 p.m. the Director of Nursing and Regional Nurse reviewed policy for anticoagulant therapy and deemed the policy inappropriate. Policy revisions and recommended updates were completed by the Regional Nurse and submitted to the parent company for review and approval. c. Changes to the proposed policy include: (1) added expectations of the consultant pharmacist (2) Removal of some references to paper, as facility is moving toward being fully-electronic to the extent possible (3) Expectations for the physician during visits were clarified d. Nurse education commenced at 4: 13 p.m. via mass educational text to all nurses from DON indicating INR monitoring must be completed if a resident is receiving [MEDICATION(S)]. Written education will follow on next working shift. 1. In-person education for nurses commenced on 9/6/22. 2. In-person education for nurses with a policy review will be provided on each nurse's next working shift. 3. On 9/6/22 at 4:25 p.m. a phone call was placed to Resident 26's Guardian to make him aware that resident #26 was receiving [MEDICATION(S)] without PT/INR monitoring. 4. On 9/7/2022 the Director of Nursing informed Resident #26's guardian that the resident is not receiving [MEDICATION(S)] therapy. Although the Immediate Jeopardy (IJ) was removed on 9/7/22, the facility remained out of compliance at a scope of Isolated and a severity of No actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the anti-coagulation therapy policies and procedures and sustained compliance has not been verified by the state agency.

Based on observation, interview and record review, the facility failed to prevent the development of a wound for 1 Resident (Resident #332) reviewed for alterations in skin integrity, resulting in the development of a wound for R332 and the potential for further skin breakdown, delayed wound healing, infection, and overall deterioration in health status. Findings: Resident #332 (R332) Review of a Face Sheet revealed R332 was a [AGE] year-old male originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for R332, with a reference date of 8/13/22 revealed the following Functional Status: R332 required limited assistance of 1 person for bed mobility and total dependence of 2 persons for transferring. Review of R332's Braden Skin assessment dated [DATE] revealed R332 was at risk for skin breakdown. Review of R332's Care Plan revealed, Problem Start Date: 08/09/2022 Alteration in ADLs - self care deficit r/t (related to) [CONDITION(S)], arthritis, dysphagia, hypertension, hx of falling Resident's ADL functioning and participation level does vary r/t (no further documentation) .Status of bed mobility: (blank) . Status of eating ability: (blank) . Status of mobility: (blank) . Status of toileting/elimination needs: (blank) . Status of transfers: (blank) . Review of R332's Care Plan revealed, Problem Start Date: 08/09/2022 Resident is at risk for skin breakdown R/T [CONDITION(S)], [CONDITION(S)], hypertension .Avoid shearing resident's skin during positioning, transferring, and turning .Turn and reposition every 2 hours as needed/tolerated by resident .Use cushion for pressure reduction when resident is in chair. (All interventions were dated 8/9/22). Review of R332's Care Plan revealed no new entry for R332's wound found on 8/31/22 with new care planned interventions initiated. Review of R332's Progress Note dated 8/28/22 at 3:04 PM revealed, Alert and oriented to baseline .transferring with mechanical lift into (wheelchair) prior to breakfast where he remained for the rest of the shift . (Day shift from 6AM to 2 PM). Indicating approximately 5 hours sitting up in wheelchair. Review of R332's Progress Note dated 8/30/22 at 12:46 PM revealed, Alert and oriented to baseline, 1 assist with ADL care, transferring the same way into (wheelchair) prior to breakfast where he remained for rest of shift . Review of R332's Progress Note dated 8/31/22 at 2:04 PM revealed, Alert and oriented to baseline, 1 assist with ADL care, transferring the same way into (wheelchair) prior to breakfast where he remained for rest of shift . Review of R332's Progress Note dated 9/1/22 at 2:56 PM revealed, .dressing clean, dry and intact, Roho pad provided along with stool to support legs . Indicating the care planned intervention from 8/9/22 for a wheelchair cushion was not in place at the time of the skin breakdown. R332's Care Plan was not updated to reflect stool to support legs. Review of R332's Skin Body assessment dated [DATE] revealed no areas of skin impairment. Review of R332's Skin Body assessment dated [DATE] revealed, New skin issue 8/31/22 .1/2 dollar sized abrasion to right lateral aspect of right leg. There was no description of measured size, stage, drainage, peri-wound condition, wound edges, pain, etc. During an observation and interview on 09/07/22 at 2:02 PM, CNA O reported that there were not enough staff to meet the needs of the residents. CNA O reported that residents were not repositioned as ordered, showers were not always completed, and their needs were unmet because it was impossible to get to all the residents with the number of staff available. CNA O reported that R332 had skin breakdown on the back of his right thigh from his wheelchair. CNA O reported that R332 required repositioning/offloading assistance in bed and in his wheelchair. R332 was transferred to bed from his wheelchair with 2 staff members (no hoyer was used to transfer). He had a bandage in place on the back of his right thigh that did not have a date it was placed written on it. During an interview on 09/07/22 at 1:53 PM, Director of Nursing (DON) reported that she and Wound Care Provider (WCP) P would be assessing R332's wound. DON reported that the wound had not been assessed by WCP P. DON reported that R332 required a hoyer transfer and she would be getting staff to assist him back to bed. During an interview and observation on 09/07/22 at 1:58 PM, R332 reported that he required assistance with wheelchair mobility, bed mobility, and transferring. R332 was sitting up in his wheelchair with a pressure prevention cushion in place. R332's foot stool was propped up against the bed and was not in place under his feet. R332's feet were not touching the floor (indicating additional pressure on the back of his thighs.) During an interview and observation on 09/07/22 at 2:30 PM, WCP P reported that R332's wound appeared to be a blister that opened. The wound was circular and pink and had the appearance of an opened blister. WCP P reported that based on the area of the wound, it was likely friction related skin breakdown from where his thigh was rubbing on his wheelchair. WCP P measured the area as 2.1 cm by 2.6 cm. Review of R332's provider Progress Note dated 9/7/22 revealed, (R332) is seen today to evaluate a wound on his right posterior thigh. Staff noted the wound a week ago. Staff were concerned that it could be due to his leg rubbing on the edge of his wheelchair seat, so they got resident a Roho cushion for his wheelchair. Staff have been covering the wound with a dry dressing. At this time resident is lying in his bed. He states the wound is not painful. He offers no other complaints today .On the right posterior thigh there is an area of pink, intact epithelial tissue consistent with a recently healed wound, there is a darkened area inferior to the pink area which appears to be a thin layer of epithelial tissue which likely came off the wound that was present superiorly and has dried out and adhered to the intact skin. Plan-The wound that was present on the right posterior thigh is now closed, it does appear to be a friction injury, likely either from the edge of his wheelchair seat or possibly from the Hoyer sling, again staff did get him a Roho cushion for his wheelchair which keeps his thigh up off the edge of the wheelchair seat . Again indicating the care planned intervention for wheelchair cushion from 8/9/22 was not in place prior to the wound formation. During an interview on 09/07/22 at 2:40 PM, DON reported that she was responsible for creating/updating Acute Care Plans (referring to R332's Care Plan.) Review of the facility policy Pressure Injury Prevention and Care last revised March 2021 revealed, Purpose: To promote and facilitate pressure injury prevention and implement appropriate interventions and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Procedure .4. Interventions will be implemented, and care planned to prevent pressure injury development or to promote pressure injury resolution .D. Promote nutrition and hydration-refer to Registered Dietician as needed .5. Pressure injuries will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include the size, location, category/stage, odor (if any), drainage (if any), per-wound condition, wound edges, undermining, tunneling, exudate, pain, and current treatment order .8. Potential/suggested procedure with pressure injury identification .C. Document the appearance of the pressure injury (eg: size, location, appearance, odor (if any), drainage (if any), condition of peri-wound, wound edges, stage, etc.) .F. Update the resident care plan to address the area of pressure injury, and approaches initiated .10. Resident at-risk for developing pressure injury will have a care plan implemented to minimize skin breakdown risk. Resident risk factors will be reviewed and considered when developing the plan of care . Review of an article from the National Library of Medicine titled Pressure Injury revealed, Pressure injuries are defined as localized damage to the skin as well as underlying soft tissue, usually occurring over a bony prominence or related to medical devices. They are the result of prolonged or severe pressure with contributions from shear and friction forces . Many factors are identified in contributing to pressure ulcer and injury formation, such as increased arteriole pressure, shearing forces, friction, moisture, and nutrition status. [NAME] N, [NAME] PM. Pressure Injury. [Updated 2021 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK 8/ Review of the Fundamentals of Nursing revealed, The increased risk for skin breakdown and the development of pressure injuries is related to changes in aging skin and to situations that occur in the acute care setting such as immobility, incontinence, and malnutrition. The key points in the prevention of skin breakdown are using a mattress appropriate for the risk of skin breakdown with proper positioning, reducing shear and friction, providing meticulous skin care and moisture management, and providing nutritional support (see Chapter 48). Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 192). Elsevier Health Sciences. Kindle Edition. Review of the Fundamentals of Nursing revealed, A pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device or other device. The injury can present as intact skin, a blister, or an open ulcer and may be painful. The injury occurs as a result of intense and/ or prolonged pressure or pressure in combination with shear (Edsberg et al., 2016). The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia A.; Hall, Amy. Fundamentals of Nursing - E-Book (p. 1236). Elsevier Health Sciences. Kindle Edition.

This citation pertains to intake MI 734 Based on interview and record review, the facility failed to implement the comprehensive Care Plan for Falls to prevent a fall of a resident (Resident #14) that is at high risk for falls, resulting in a fall with fracture and the potential for all facility residents at risk for falls to not have Care Plan interventions implemented to prevent falls and injury. Findings include: Resident #14 admitted to the facility 2/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] reflected the Resident was cognitively impaired, required two staff for toilet use, and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Facility Reported Incident (FRI) and the facility investigation revealed on 4/15/21 Resident #14 fell while self-transferring from her wheelchair. An assessment and X-Ray 4/18/21 revealed a fractured right femur. The facility investigation concluded a Root Cause of, (Resident #14) was attempting to self-transfer and ambulate to the bed from her wheelchair. She did not utilize her call light. She fell to the floor while transferring resulting in a fracture of her right femur that required surgical intervention to repair. The facility investigation included a Summary that reflected, It is reasonable to assume that (Resident #14's) femur fractured as a result of her twisting when she got out of her wheelchair (sic) on 4/15/21 or when she fell on [DATE]. Review of the facility Critical Admission Assessment for Resident #14 dated 2/12/21 reflected a Fall Risk Assessment that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The document reflected Resident #14 was high risk for falls. Review of the Care Plan for Resident #14 initiated 2/12/21 reflected the Resident was At risk for falls, can be impulsive, overestimates abilities, and attempts self -transfers. Interventions implemented on 2/12/21 included wearing non-skid socks or shoes, remind to use call light, and low bed. The Electronic Medical Record Progress Notes from 4/7/21 to 4/15/21 were reviewed: 4/7/21 at 2:56 PM, .multiple episodes of resident attempting to self-transfer .call light use reinforced. 4/8/21 at 11:27 PM, Resident needs reminders not to self-transfer. 4/10/21 at 3:16 PM, .multiple episodes of resident ambulating unassisted using walker .call light use reinforced. 4/10/21 at 9:37 PM Confused at times .up in hallway by herself several times .explained to her to use call light. 4/11/21 at 2:32 PM, multiple episode (sic) of resident ambulating unassisted using walker .call light use reinforced. 4/12/21 at 5:30 AM, Resident was up walking without walker and self-transferring. 4/13/21 at 2:34 PM, .multiple episode (sic) of resident ambulating unassisted while using walker .call light use reinforced. 4/13/21 at 9:36 PM, (Resident #14) has been caught multiple times self-transferring .reminded to use call light. 4/14/21 at 2:41 PM, .multiple episode (sic) of resident ambulating unassisted using walker .call light use reinforced. 4/15/21 at 2:28 PM, .multiple episode (sic) of resident ambulating unassisted using walker .call light use reinforced. This is the last Progress Note entry prior to fall. 4/15/21 at 9:20 PM, Resident was self-transferring from wheelchair to walker trying to get to bed and fell on her bottom . (Resident #14) (complaining of) right leg pain .no apparent injury .her legs are always painful . On 5/7/21 at 1:37 PM an interview was conducted with the Director of Nursing (DON). The DON reported that she was the nurse working at the time of the fall and that Resident #14 makes very frequent attempts to get out of bed. The DON reported that Resident #14 did not have grippy socks on when she fell on [DATE] (implemented on 2/12/21). The DON reported she and a Certified Nurse Aide (CNA) stood the resident up and assisted her back to the bed. The DON reported at that time Resident #14 was not in a low bed (implemented on 2/12/21) and the DON assisted the Resident back into bed by swinging her legs onto the bed. The DON reported grippy socks large enough to accommodate the Resident were found and that Resident #14 always has them on now. Review of the Care Plan reflected on 2/12/21 the intervention of keep bed in lowest position with brakes locked was implemented. Also documented as implemented on 2/12/21 was, Wear non-skid shoes/ non-skid socks (grippy socks) while transferring/ ambulating. Following the fall of 4/15/21 the intervention was added to the Care Plan for Resident #14: Grip socks to be on at all times. Given the documented history of self-transfers by Resident #14 this intervention was of no notable difference of the similar intervention of 2/12/21 that had not been implemented as indicated by the DON.

citation pertains to intake MI 734 Based on interview and record review, the facility failed to revise the comprehensive Care Plan for Falls of a resident (Resident #14) who was at high risk for falls, resulting in a fall with a fracture and the potential for all facility residents at risk for falls to not have their Care Plans revised to prevent falls and injuries. Findings include: Resident #14 was admitted to the facility 2/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] reflected the Resident was cognitively impaired, required two staff for toilet use and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Facility Reported Incident (FRI) and the facility investigation revealed on 4/15/21 Resident #14 fell while self-transferring from her wheelchair. An assessment and X-Ray on 4/18/21 revealed a fractured right femur. The facility investigation concluded a Root Cause of, (Resident #14) was attempting to self-transfer and ambulate to the bed from her wheelchair. She did not utilize her call light. She fell to the floor while transferring resulting in a fracture of her right femur that required surgical intervention to repair. The facility investigation included a Summary that reflected, It is reasonable to assume that (Resident #14's) femur fractured as a result of her twisting when she got out of her wheelchair (sic) on 4/15/21 or when she fell on [DATE]. Review of the facility Critical Admission Assessment for Resident #14 dated 2/12/21 reflected a Fall Risk Assessment that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The document reflected Resident #14 was high risk for falls. Review of the Care Plan for Resident #14 initiated 2/12/21 reflected the Resident was At risk for falls, can be impulsive, overestimates abilities, and attempts self -transfers. Interventions implemented on 2/12/21 included wearing non-skid socks or shoes, remind to use call light, and low bed. The Electronic Medical Record Progress Notes from 4/7/21 to 4/15/21 were reviewed: 4/7/21 at 2:56 PM, .multiple episodes of resident attempting to self-transfer .call light use reinforced. 4/8/21 at 11:27 PM, Resident needs reminders not to self-transfer. 4/10/21 at 3:16 PM, .multiple episodes of resident ambulating unassisted using walker .call light use reinforced. 4/10/21 at 9:37 PM Confused at times .up in hallway by herself several times .explained to her to use call light. 4/11/21 at 2:32 PM, multiple episode (sic) of resident ambulating unassisted using walker .call light use reinforced. 4/12/21 at 5:30 AM, Resident was up walking without walker and self-transferring. 4/13/21 at 2:34 PM, .multiple episode (sic) of resident ambulating unassisted while using walker .call light use reinforced. 4/13/21 at 9:36 PM, (Resident #14) has been caught multiple times self-transferring .reminded to use call light. 4/14/21 at 2:41 PM, .multiple episode (sic) of resident ambulating unassisted using walker .call light use reinforced. 4/15/21 at 2:28 PM, .multiple episode (sic) of resident ambulating unassisted using walker .call light use reinforced. This is the last Progress Note entry prior to fall. 4/15/21 at 9:20 PM, Resident was self-transferring from wheelchair to walker trying to get to bed and fell on her bottom . (Resident #14) (complaining of) right leg pain .no apparent injury .her legs are always painful . The medical record reflected ten Progress Note entries of multiple episodes, no identifiable number to these episodes, of self-transfers by Resident #14 in the eight days prior to the fall. The medical record did not reveal any documentation of increased supervision, Care Plan revisions, or concerns raised by this trend of behavior of a Resident at high risk for falls. Additionally, kept in place and implemented was the intervention to remind the resident to use the call light without revision despite ineffective results from this intervention. Further review of the Progress Notes revealed that, after the fall of 4/15/21, additional documentation of continued self-transfers (4/16/21 at 2:39 PM - multiple and 4/17/21 at 1:42 PM - four different times) without any documented increase of supervision. On 5/7/21 at 1:37 PM, an interview was conducted with the Director of Nursing (DON). The DON reported that she was the nurse working at the time of the fall and that Resident #14 makes very frequent attempts to get out of bed. The DON reported that Resident #14 did not have grippy socks on when she fell on [DATE]. The DON indicated Resident #14 was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON reported she was just outside the Residents room when she heard a crash and found the Resident on the floor. The DON reported Resident #14 did not hit her head despite that the DON did not witness the fall. The DON reported she and a Certified Nurse Aide (CNA) stood the resident up and assisted her back to the bed. The DON reported at that time Resident #14 was not in a low bed and the DON assisted the Resident back into bed by swinging her legs onto the bed. The DON reported grippy socks large enough to accommodate the Resident were found and that Resident #14 always has them on now. Review of the Care Plan reflected on 2/12/21 the intervention of keep bed in lowest position with brakes locked was implemented. Also documented as implemented on 2/12/21 was, Wear non-skid shoes/ non-skid socks (grippy socks) while transferring/ ambulating. Review of the medical record reflected a Doctor's Order dated 3/11/21 to, Wrap bilateral extremities from base of toes to just below the knees with Ace wraps every morning. Remove every evening. 7:00 AM, 8:00 PM. The medical record did not reflect any Care Plan revisions to the grippy socks (non-skid socks) intervention implemented on 2/12/21. No documentation was found that reflected difficulty with non-skid socks due to the Ace wrapping of the Resident's feet or why adequate non-skid sock were available after the fall and not prior to the fall. Following the fall of 4/15/21 the intervention was added to the Care Plan for Resident #14: Grip socks to be on at all times. Given the documented history of self-transfers by Resident #14 this intervention was of no notable difference of the similar intervention of 2/12/21 that had not been revised or implemented as indicated by the DON.

Based on interview and record review, the facility failed to assess pain complaints for a resident (Resident #14) who had fallen, resulting in pain and delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #14 was admitted to the facility 2/12/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] reflected the Resident was cognitively impaired, required two staff for toilet use and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Facility Reported Incident (FRI) and the facility investigation revealed on 4/15/21 Resident #14 fell while self-transferring from her wheelchair. On 4/18/21 an X-ray revealed a fractured right femur that required surgical intervention to repair. Review of the Electronic Medical Record (EMR) revealed a Progress Note entered on 4/15/21 at 9:20 PM. The entry reflected, Resident (#14) was self-transferring from wheelchair to walker trying to get to bed and fell on her bottom . (Resident #14) (complaining of) right leg pain .no apparent injury .her legs are always painful . On 5/7/21 at 1:37 PM, an interview was conducted with the Director of Nursing (DON). The DON reported that she was the nurse working at the time of the fall. The DON reported that Resident #14 did not have grippy socks on when she fell on [DATE]. The DON reported she was just outside the Residents room when she heard a crash and found the Resident on the floor. The DON reported Resident #14 did not hit her head despite that the DON did not witness the fall. The DON reported she and a Certified Nurse Aide (CNA) stood the resident up and assisted her back to the bed. The DON reported at that time Resident #14 was not in a low bed and the DON assisted the Resident back into bed by swinging her legs onto the bed. The DON reported that Resident #14 always has grippy socks on now. Review of the Care Plan reflected interventions documented as implemented on 2/12/21 included: keep bed in lowest position with brakes locked and Wear non-skid shoes/ non-skid socks (grippy socks) while transferring/ ambulating. Further review of the EMR post-fall documentation was conducted. EMR Progress Note entry of 4/17/21 reflected stated legs were hurting this morning and routine (Extra Strength) Tylenol was administered. No assessment of legs found in the EMR. EMR Progress Note entry of 4/17/21 at 10:38 PM revealed, Resident (complaining of) pain all over and pain in right leg, 8/10 pain at 9PM. Medication helpful. Lower (bilateral extremities) edematous. No further assessment noted. The EMR Progress Note of 4/18/21 at 12:16 PM reflected the Resident complained of pain in the right leg again. At this time, the Doctor was contacted, and an X-ray was ordered. An EMR Progress note of 4/18/21 at 1:53 PM reflected, (Resident #14) moaning in pain (complaining of) pain in right leg .Continues with therapy. The EMR entry of 4/18/21 at 3:15 PM reflected an X-ray result of a fractured right femur. The Doctor was notified, and the Resident was transported to the hospital for evaluation and treatment. The EMR Progress note of 4/18/21 at 11:12 PM reflected, .(X-Ray) results - right femur: oblique fracture distal shaft of right femur with some overriding of fracture fragments and slight lateral and posterior angulation at fracture site.

Based on observation, interview and record review, the facility failed to provide pressure ulcer care and communicate with other disciplines to prevent, heal, implement measures, and find root causes for 1 (Resident #11), resulting in a previously healed pressure wound to redevelop and the potential for future and/or worsening pressure ulcers. Findings include: Resident #11 Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #11 is an [AGE] year old female admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) revealed she is cognitively intact. Resident #11 requires extensive assistance of 2 staff for transfers and had 2 stage II pressure ulcers upon admission. Pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 5/4/21 at 10:50 a.m., Resident #11 observed on her back in her room and reported she is on a pureed diet and the food does not taste good. The resident reported that sometimes the family will bring her soup to eat that tastes good. She also reported she has had some weight loss. The resident confirmed she does have a pressure ulcer and reported that she thinks the nurse did her dressing change already this morning while she was sleeping. In an interview on 5/5/21 at 9:00 a.m., Resident #11 observed in bed on her back with her legs elevated. She reported she is in pain a lot from arthritis and just received some [MEDICATION(S)], but it had not kicked in yet. She reported that changing positions is not comfortable and causes pain/discomfort. She reported she goes to the pain clinic every 6-8 weeks but would like pain medication that would help her pain not spike when she is trying to sleep at night and wakes her up. She said the facility told her she just needs to ask for her pain medication, but that does not help her control the pain. She reported she is on pureed foods and does not eat much because it is hard to get the food down because it is hard to swallow. The resident had regular scrambled eggs on her plate, not pureed, and she did not touch them. During an observation on 5/5/21 at 11:31 a.m., Physician Assistant (PA) I performed a dressing change on Resident #11's pressure ulcers. The old dressing in place on Resident #11's coccyx was not adhered to the upper cleft of the buttock which could allow bodily fluids to contaminate dressing and wound. PA I removed the old dressing from Resident #11's coccyx and had a date of 5/2/21 written on it. PA I reported the wounds were improving. In an interview and record review on 5/6/21 at 10:30 a.m., Regional Nurse Consultant (RC) B reported Resident #11 admitted to the facility with one pressure ulcer and it had healed and then reopened again. RC B reported dressing changes for Resident #11 should be done every day as ordered. When queried about the potential root cause and if it is avoidable or unavoidable, RC B reported there was no root cause analysis done and later provided this surveyor with a document titled Determination of Unavoidable Pressure Wound that she completed this day for Resident #11. During an observation and an interview on 5/7/21 at 11:02 a.m., the Physical Therapist (PT) T was in Resident #11's room and verified there is no pressure reduction cushion in her room for her recliner or the wheelchair. The seat in the wheelchair is just a standard cushion but could order a pressure reduction cushion for her. In an interview on 5/6/21 at 10:22 a.m., the Regional Dietician (RD) C reported she reviewed the foods Resident #11 likes and dislikes. She is aware of the residents pressure ulcers and started a supplement in April that the resident refused. The facility is to offer alternate meals and do food acceptance logs. Resident #11 is now on a High calorie supplement provided by the nurses and is to get 60 milliliters (mLs) three times a day between meals and a magic cup (supplement) as a bedtime snack. When queried why these supplements were not on the orders or the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No physician notification done. In an interview on 5/6/21 at 12:13 p.m., Dietary Manager (DM) J reported Resident #11 is on a pureed diet and is aware the resident does not like the food and bored with the breakfast options. DM J reported their food supplier does have dieticians he could reach out to for residents on pureed foods but has not done so yet. He is unaware that Resident #11 is to get a Magic Cup at bedtime but would be easy to implement right away. When queried about the communication between disciplines for implementing supplements, DM J agreed there is a systematic breakdown in communication. DM J also reported since transferring to electronic medical records there is no recorded food acceptance intake for the residents. In an interview on 5/7/21 at 10:30 a.m., Regional Nurse Consultant (RC) B reported Resident #11 admitted with one pressure ulcer and then it closed and reopened again with two more pressure ulcers. Review of a Grievance/Complaint Form dated 2/10/21 for Resident #11 revealed: Not satisfied with food. It is pureed and does not look like what it is.Conclusion: I discussed meals with (Resident #11) and decided that she would like to receive mashed potatoes and chicken, gravy with pureed carrots each meal. She stated she is supposed to receive 6 small meals a day, but her diet order is just for pureed foods. Corrective Actions Taken: Waiting with Dietary Manager to ensure satisfied with food meeting 1 time per week. Resident states it is improved on 2/17/21. Review of a Grievance/Complaint Form dated 2/13/21 for Resident #11 revealed: Resident states she is worried that her pain medication is going to be changed. She states she wants it to remain the same and it is working the way it is. Wants to make sure she is involved with doctor in requests to any changes made to her mediation. Resident states she wants nurses to exhibit better customer service when explaining her pain meds. Spoke to resident via phone call to explain process. Summary of Findings/conclusion: Residents pain medication has not been changed. Will review with doctor and resident at any point where doctor would feel a med change is appropriate and would involve resident. Corrective Actions Taken: reviewed medication change process with resident. Explained that facility would involve her in any conversation related to pain medication. Will education nurses on customer service related to discuss meds. Spoke with resident on 2/16 and she is satisfied with the results. Review of the April 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover all the areas with a 6x6 comfort foam border dressing. Change daily and as needed if soiled or disrupted ordered 4/22/21. On 4/27/21 at 1:31 p.m. Not administered: Resident declined to get up out of recliner to have dressing changed. Will ask next shift to do at HS (bedtime). On 4/29/21 at 1:45 p.m., Not administered: Refused, requested to have it done later. On 4/30/21 at 1:19 p.m., Not administered: Resident unavailable. Was in the chair and with therapy. No follow up indicated dressings were completed. Review of the Pain Assessments on the April MAR for Resident #11 revealed she received pain medication everyday for pain on most days greater than a 7/10 and the follow to the pain medication not effective. Pain Assessment scale using 0-10 with a 0=No Pain, 1-3 Mild, 4-6 Moderate, 7-10 Severe. Review of the April MAR for Resident #11 revealed on 3/31/21 an order to Document Food Acceptance at Meals. No documentation for food acceptance noted. No supplements ordered, implemented, or given to the resident. Review of the May 2021 MAR for Resident #11 revealed orders to Cleanse ulcers on sacrum/buttocks with saline and gauze and pat dry. Cover all the areas with a 6x6 comfort foam border dressing. Change daily and as needed if soiled or disrupted ordered 4/22/21. Dressing charted done on 5/3/21 with an asterisk indicating a progress note entry and charted done on 5/4/21. Under the Reasons/Comments section dated 5/3/ at 3:04 p.m. revealed: Late Administration: Administered Late. Comment: In nurses meeting/res. was working with therapy. Review of the May MAR for Resident #11 revealed no order for documenting food acceptance noted. No supplements ordered, implemented, or given to the resident. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .She has a history of dysphagia and failure to thrive and subsequently is on 6 small meals per day. She presently has a stage II sacral pressure injury which was was admitted with. Regarding her chronic pain complaints she goes to the pain clinic about every 3 or 4 months for injections in the lumbar spine and knee. Today on examination she actually is not complaining of much in the way of pain . Summary of Plans . she had dysphagia and is to receive 6 small meals per day. She has a longstanding chronic history of lumbar and knee pain. she presently is on [MEDICATION(S)] and [MEDICATION(S)] ([MEDICATION(S)]). She did not complain of pain issues today. History of depression and anxiety, on [MEDICATION(S)] and [MEDICATION(S)] Review of a Dietary Progress note dated 2/18/21 at 12:47 p.m. for Resident #11 revealed: (Registered Dietician) review of high risk, new resident. she is pureed diet with thin liquids. She is eating poorly with supplement of proheal in place a t 30 ml daily. She has poor acceptance of proheal so would (discontinue) this. Recommendations: 1. d/c proheal (related to) refusals. 2. Start hi cal 2 oz (ounces) qid (four times a day) and a magic cup a HS (bed time) snack. 3. Start med hydration of 120 ml of water encouraged every shift from nursing. Nursing to monitor intake and acceptance or refusals of supplements so adjustments can be made as needed. Nutrition services to continue to monitor as well with recommendations made as needed. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .She has a history of chronic low back pain and leg weakness. She was admitted with coccyx pressure ulcers and is being seen routinely by wound care team. On examination she tells me she wakes up about 11:00 or midnight having pain in her back legs and needs a pain pill. She does have [MEDICATION(S)] available as needed. I explained to her that she just needs to ask for it. She thanked me for the information. Summary of plans: Resident continues to eat sparingly. Her weight has dropped a little bit but not overall too bad. Main concern at this point is for wound care. Wound care team is doing an excellent job. Resident does complain of chronic pain issues which she states wakes her up about midnight. She was informed she has [MEDICATION(S)] available at that time. Plan: Will continue with present medications and treatment plan. Review of the Progress Notes dated 5/3/21 at 9:57 p.m. for Resident #11 revealed: . Had [MEDICATION(S)] at 4:40 p.m. for generalized pain rated 10/10. Medication was stated to be somewhat effective at 5:40 p.m. Continues on routine [MEDICATION(S)] TID (three times a day) for chronic pain which she states is helpful. continues on puree diet with thin liquids, had a poor appetite at supper, and refused supplement. Ate some HS snack. Res. is incontinent of B&B (bowel and bladder) and [MEDICATION(S)] was applied. Wound dressing dry and intact on coccyx. Res refuses to be repositioned every 2 hours despite many attempts by staff. Refuses to have cushion in recliner when she is in it but does allow it when she is in her w/c (wheelchair). This progress note is duplicative in several progress notes by the same nurse on 4/22/21, 4/23/21, 4/26/21, 4/28/21, 4/29/21, 5/3/21, and 5/5/21. Review of a Care Plan for Resident #11 for Stage II Pressure Ulcer to coccyx and 2 unstageable areas to right sacral area: Problem start date 4/14/21: Approach: . Encourage oral intake to promote good nutrition for healing process and for skin integrity. Keep clean and dry as possible. Minimize exposure to moisture. Pressure reduction cushion. RD (Registered Dietician) to review as needed. Supplements as ordered. Review of a policy titled Pressure Ulcer Prevention/Risk Assessment last reviewed 9/2/20 revealed: Purpose: (Facility) has established a standardized policy with guidelines that assigns responsibility and provides procedures for identifying residents at risk for pressure ulcers; to provide guidelines for the prediction, prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Procedure: Residents level of risk for pressure ulcer development will initially be determined within 12 hours after admission or readmission taking into consideration the nature of risk to include underlying causes. Pressure Ulcer Preventative/Supportive approaches will be implemented appropriate to the residents level of risk and the residents care plan updated to reflect the approaches. Residents will automatically be HIGH risk when admitted with a. any pressure ulcers. Encourage proper dietary intake reflective of dietician's recommendations. Establish a 1 or 2 hour repositioning schedule as appropriate to meet the residents needs. Review of a Quality Assurance/Performance Improvement policy last reviewed 9/2/20 revealed: Each facility will form and maintain a Quality Performance Improvement Team that meets to ensure there is an ongoing process to prevent, identify and effectively treat existing pressure related wounds while avoiding complications.

Based on observation, interview and record review, the facility failed to implement measures to provide appropriate assessments, treatments and services to maintain or improve contractures for 1 (Resident #7), resulting in functional decline and increased pain. Findings include: Resident #7 Review of a Face sheet revealed Resident #7 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] for Resident #7 revealed she is cognitively intact and totally dependent on 2 staff for transfers and care. The resident had limited range of motion on bilateral upper and lower extremities. During an observation on 5/4/21 at 10:56 a.m., Certified Nursing Assistant (CNA) M and CNA N are in Resident #7's room for morning care. Her head was leaned to the right side and her left knee is contracted at a 90 degree angle. Both hands are contracted, and her left hand is in a clenched position where her fingernails press into the palm of her hand. Her sheets are soaking wet completely on the upper half of her bed, her brief is soiled, and her air pressure mattress control box is on the mattress at the foot of her bed with a broken hook so it cannot hang on the foot board. Tube feeding liquid is all over the floor under the resident's bed. Resident #7 complained of pain every time the CNAs had to move her to provide care. The CNA placed a pillow on the residents' right side and a knee pillow placed between her legs. No devices or interventions for her hands were done and no cleaning of hands or body noted except for peri care. No range of motion care provided. No devices in place for contractures noted. During an observation on 5/4/21 at 3:23 p.m., Resident #7 is in bed with pillows still on the right side and in the same position. No splints or devices noted in hands. During an observation on 5/5/21 at 9:50 a.m., Resident #7 noted in bed with knee pillow on the table. No splints or devices noted for hands. During an observation and an interview on 5/5/21 at 4:15 p.m., Registered Nurse (RN) O located the [MEDICATION(S)] patch on Resident #7's right upper chest and it had a clear plastic dressing cover over it. RN O reported they cover the [MEDICATION(S)] patches because they can fall off easy and the resident can scratch it off. In an interview on 5/6/21 at 11:47 a.m., the Interim Director of Nursing (DON) confirmed the [MEDICATION(S)] patch is on Resident #7's right upper chest and covered with a plastic covering because it falls off easily. Review of the April and May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On May 4th at 4:00 Resident #7 received a new [MEDICATION(S)] patch. In an interview on 5/7/21 at 11:54 a.m., the Regional Nurse Consultant (RC) B reported [MEDICATION(S)] patches should not be covered with a plastic dressing because it can increase the absorption. So consequently on the first day of wearing the patch it can be like getting a bolus of medication and decrease the effectiveness after that. During an observation and an interview on 5/6/21 at approximately 11:00 a.m., the Directory of Therapy (DT) P reported Resident #7 is to have a carrot device in her hands for the contractures. We both visited Resident #7's room and verified the resident did not have any devices in her hands and should at a minimum have a cloth in her hands to prevent her nails from digging into her palms. DT P was able to find a blue hand carrot and another carrot device in the residents' room and not sure why they were not being used. Review of a document titled PT/OT/ST (physical, occupational and speech therapy) Recommendations to Caregivers dated 1/13/20 for Resident #7 revealed: Problem: Bilateral upper extremities contractures. Tasks: 1. Range of motion to both shoulders, elbow, wrist. 2. Place both hands in warm water, soapy for hygiene and increase range of motion. 3. Place left hand orthotic in hand with wash cloth on for arm and posterior hand to protect for straps when all day/night. Off only for showers and a.m. ADL's. Approaches: 1. Check for blue left hand orthotic to be placed in hand correctly, or orthotic when off. 2. Gentle ROM to upper extremities. 3. Warm soap, water, immerse to both hands daily. Equipment: Left hand blue orthotic, current right hand blue cone on at all times unless therapy takes it off. Precautions/Assistive Device: Blue resting hand splint for left hand, blue cone for right hand. (sic) Review of a document titled PT/OT/ST (physical, occupational and speech therapy) Recommendations to Caregivers dated 1/31/20 for Resident #7 revealed: Flexion posturing right digits (right hand). Tasks: 1) Utilize blue cone to be placed in palm of patient right hand. Approaches: Blue cone: Apply 4 hours on and 4 hours off. Keep on at hour of sleep. Precautions/Assistive Device: 1) Move fingers and wrist slowly as patient very sensitive to pain. 2) may start with warm washcloth/warm water soak to soften joints prior to application of cone. 3) Can insert cone from pink finger end and slide up into palm of hand. Review of the MAR for April and May for Resident #7 revealed orders to soak (R) hand in warm soapy water daily, dry well, place dry washcloth in both hands once a day as needed. Do as resident allows, ordered 9/25/20. No documentation indicates this has been done. Review of an educational sign in sheet dated 2/3/20 for Resident #7's care Extension for skin check for posterior aspect of right knee joint revealed 4 nurses out of 13 were educated. No education noted for nursed hired since this date. Review of a Physical Therapy Treatment Note dated 9/28/20 for Resident #7 revealed: . Attempted to eval which pt (patient) agreed to participate in. Pt refused all functional mobility assessments and BLE (bilateral lower extremity) ROM and strength assessment. Pt states high pain level with ROM and displays RLE flexion spasm and LLE flaccid. Multiple contractures in BLE. Pt stated at end of assessment time that she will not work with therapy. Review of a Care Plan for Resident #7 revealed no care plan specific for contractures noted. The ADL (activities of daily living) care plan interventions revealed: Approach date: 1/20/2020, ROM (range of motion) to BUE (bilateral upper extremities) as (Resident #7) tolerates/allows. Approach date 4/3/2019, Status of personal items: . hand splints to be applied per OT (occupational therapy) recommendation. 3/6/19, Observe for presence of pain/intolerance during self-cares. No revisions to the pain care plan since 3/6/2019. Review of a policy titled Pain Management reviewed 2/2021 revealed: (Facility) believes pain is a personal experience that, if left undertreated or mismanaged, can radically change a residents' quality of life and impact their overall well-being. A residents' pain is best treated and managed by an interdisciplinary team that actively engages the resident in the development of an effective treatment plan. Our pain management program will utilize a combination of methods encompassing a holistic, person-centered approach. According to Potter, P.A., and Perry A.G. in Fundamentals of Nursing (6th Edition, 2005), ROM is defined as the maximum amount of movement available at a joint in one of the three planes of the body . (pg. 1434). Referring to the nursing assessment process, (pg. 938), assessing ROM is one of the first assessment techniques used to determine the degree of damage or injury to a joint. The nurse assesses ROM to collect data to answer questions about the joint stiffness, swelling, pain, limited movement, and unequal movement; the text continues (pg. 758) When putting each joint through its range of motion, the nurse makes a number of basic observations, noting pain, limited mobility, spastic movement, joint instability, stiffness and contracture.

This citation has two Deficient Practice Statements #1 of 2 This citation pertains to intake MI 734 Based on interview and record review, the facility failed to supervise a resident (Resident #14) that is at high risk for falls and implement measures to prevent a fall, resulting in a fall with fracture and the potential for all facility residents at risk for falls to not be properly supervised or have measures implemented to prevent falls and injury. Findings include: Resident #14 was admitted to the facility 2/12/21 with diagnoses that included: Heart Failure, Dementia, and Malnutrition. The Minimum Data Set (MDS) dated [DATE] reflected the Resident was cognitively impaired, required two staff for toilet use and had a history of falling prior to admission. Review of the Facility Reported Incident (FRI) and the facility investigation revealed on 4/15/21 Resident #14 fell while self-transferring from her wheelchair. An assessment on 4/18/21 for a complaint of pain revealed swelling of Resident #14's right leg. An X-ray revealed a fractured right femur that required surgical intervention to repair. The facility investigation concluded a Root Cause of, (Resident #14) was attempting to self-transfer and ambulate to the bed from her wheelchair. She did not utilize her call light. She fell to the floor while transferring resulting in a fracture of her right femur that required surgical intervention to repair. The facility investigation included a Summary that reflected, It is reasonable to assume that (Resident's #14) femur fractured as a result of her twisting when she got out of her wheelchair (sic) on 4/15/21 or when she fell on [DATE]. Review of the facility Critical Admission Assessment for Resident #14 dated 2/12/21 reflected a Fall Risk Assessment that the Resident had a history of falling prior to admission and displayed, Confusion, disorientation, overestimates/forgets limits. The document reflected Resident #14 was high risk for falls. Review of the Care Plan for Resident #14 initiated 2/12/21 reflected the Resident was At risk for falls, can be impulsive, overestimates abilities, and attempts self -transfers. Interventions implemented on 2/12/21 included wearing non-skid socks or shoes, remind to use call light, and low bed. The Electronic Medical Record Progress Notes from 4/7/21 to 4/15/21 were reviewed: 4/7/21 at 2:56 PM, .multiple episodes of resident attempting to self-transfer .call light use reinforced. 4/8/21 at 11:27 PM, Resident needs reminders not to self-transfer. 4/10/21 at 3:16 PM, .multiple episodes of resident ambulating unassisted using walker .call light use reinforced. 4/10/21 at 9:37 PM Confused at times .up in hallway by herself several times .explained to her to use call light. 4/11/21 at 2:32 PM, multiple episode (sic) of resident ambulating unassisted using walker .call light use reinforced. 4/12/21 at 5:30 AM, Resident was up walking without walker and self-transferring. 4/13/21 at 2:34 PM, .multiple episode (sic) of resident ambulating unassisted while using walker .call light use reinforced. 4/13/21 at 9:36 PM, (Resident #14) has been caught multiple times self-transferring .reminded to use call light. 4/14/21 at 2:41 PM, .multiple episode (sic) of resident ambulating unassisted using walker .call light use reinforced. 4/15/21 at 2:28 PM, .multiple episode (sic) of resident ambulating unassisted using walker .call light use reinforced. This is the last Progress Note entry prior to fall. 4/15/21 at 9:20 PM, Resident was self-transferring from wheelchair to walker trying to get to bed and fell on her bottom . (Resident #14) (complaining of) right leg pain .no apparent injury .her legs are always painful . Summary of the above; the medical record reflected ten Progress Note entries of multiple episodes, no numbers assigned to these episodes, of self-transfers by Resident #14 in the eight days prior to the fall. The medical record did not reveal any documentation of increased supervision, Care Plan revisions, or concerns raised by this trend of behavior of a Resident at high risk for falls. Additionally, kept in place and implemented was the intervention to remind the resident to use the call light without revision despite ineffective results from this intervention. Further review of the Progress Notes revealed that, after the fall of 4/15/21, additional documentation of continued self-transfers (4/16/21 at 2:39 PM - multiple and 4/17/21 at 1:42 PM - four different times) without any documented increase of supervision. On 5/7/21 at 1:37 PM, an interview was conducted with the Director of Nursing (DON). The DON reported that she was the nurse working at the time of the fall and that Resident #14 makes very frequent attempts to get out of bed. The DON reported that Resident #14 did not have grippy socks on when she fell on [DATE]. The DON indicated Resident #14 was being treated for swollen feet which included wrapping her feet with ace wraps and that grippy socks did not fit. The DON reported she was just outside the Residents room when she heard a crash and found the Resident on the floor. The DON reported Resident #14 did not hit her head despite that the DON did not witness the fall. The DON reported she and a Certified Nurse Aide (CNA) stood the resident up and assisted her back to the bed. The DON reported at that time Resident #14 was not in a low bed and the DON assisted the Resident back into bed by swinging her legs onto the bed. The DON reported grippy socks large enough to accommodate the Resident were found and that Resident #14 always has them on now. Review of the Care Plan for Falls reflected interventions documented as implemented on 2/12/21 included: keep bed in lowest position with brakes locked and Wear non-skid shoes/ non-skid socks (grippy socks) while transferring/ ambulating. Review of the medical record reflected a Doctor's Order dated 3/11/21 to, Wrap bilateral extremities from base of toes to just below the knees with Ace wraps every morning. Remove every evening. 7:00 AM, 8:00 PM. The medical record did not reflect any Care Plan revisions to the grippy socks (non-skid socks) intervention implemented on 2/12/21. No documentation was found that reflected difficulty with non-skid socks due to the Ace wrapping of the Resident's feet or why adequate non-skid sock were available after the fall and not prior to the fall. Following the fall of 4/15/21 two interventions were added to the Care Plan for Resident #14: Grip socks to be on at all times. Given the documented history of self-transfers by Resident #14 this intervention was of no notable difference of the similar intervention of 2/12/21. The second intervention added after the fall of 4/15/21 was, Staff to place walker out of reach of (Resident #14's) to decrease self-transferring. The Progress Notes reflected, following surgery, Resident #14 was readmitted to the facility on [DATE]. The Progress Notes reflected documentation that Resident #14 continued to be reminded to use call light and continued to self-transfer multiple and numerous times (4/24/21 - two entries, 4/25, 4/27, 4/28 - two entries, 4/29, 4/30, 5/1 - two entries, 5/2, and 5/3). The facility document titled SBAR Communication Form (situation, background, assessment, recommendation) dated 5/4/21 reflected Resident #14 fell and sustained a laceration to the right knee. The SBAR form reflected the Responsible Party was contacted. It is documented the Responsible Party indicated they may not want (Resident #14) to go through another surgery again . #2 Deficient Practice Statement of 2 Based on observation, interview, and record review, the facility failed to ensure safe transportation of a resident (Resident #238) in a wheelchair, resulting in the potential for injury to this resident and all facility residents in wheelchairs who are assisted by staff. On 5/6/21 at 8:11 AM, the Director of Nursing (DON) entered the conference room pushing Resident #238 in a wheelchair without foot pedals attached for the Resident to rest his feet on. Using a scale designed to weigh residents while seated in a wheelchair the DON obtained a weight on Resident #238 then pushed the Resident in the wheelchair out of the room. The DON was then observed pushing Resident #238 down the hall at a brisk pace with the Resident holding his feet off the floor and his legs straight out in front of him. On 5/6/21 at 10:56 AM, during an interview conducted in the conference room the DON was asked if it was common to transport wheelchair residents without foot pedals attached to their chairs. The DON stated, Well, yeah, and indicated that some residents don't use foot pedals on their wheelchairs. On 5/6/21 at 12:56 PM, an interview was conducted with Regional Nurse Consultant (RNC) B. RNC B reported that foot pedals should be in place on the wheelchair when transporting a resident. RNC B indicated there is a risk of the resident placing their feet onto the ground and potentially breaking an ankle or getting flung out of the chair face first onto the floor. An email was received by the survey team from the Nursing Home Administrator in response to a request for a wheelchair policy. The email reflected, I do not believe we have a wheelchair policy, but included an attachment titled, Wheelchair standard of care. This indicated that the information in the attachment is the guideline that staff are expected to adhere to regarding wheelchair use. The attachment was photocopied pages from an untitled resource book. The attachment reflected a section titled 'Wheelchair Safety with a bullet point of, Make sure the person's feet are on the footplates (foot pedals) before moving the chair. The person's feet must not touch or drag on the floor when the chair is moving.

Based on observation, interview and record review, the facility failed to implement measures to effectively follow up and manage pain for 2 (Resident #7 and Resident #11), resulting in prolonged pain and discomfort. Findings include. Resident #7 Review of a Face sheet revealed Resident #7 is a [AGE] year old female originally admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] for Resident #7 revealed she is cognitively intact and totally dependent on 2 staff for transfers and care. The resident had limited range of motion on bilateral upper and lower extremities. Resident #11 Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #11 is an [AGE] year old female admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) revealed she is cognitively intact. Resident #11 requires extensive assistance of 2 staff for transfers and had 2 stage II pressure ulcers upon admission. Pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 During an observation on 5/4/21 at 10:56 a.m., Certified Nursing Assistant (CNA) M and CNA N are in Resident #7's room for morning care. Her head was leaned to the right side and her left knee is contracted at a 90 degree angle. Both hands are contracted, and her left hand is in a clenched position where her fingernails press into the palm of her hand. Her sheets are soaking wet completely on the upper half of her bed, her brief is soiled, and her air pressure mattress control box is on the mattress at the foot of her bed with a broken hook so it cannot hang on the foot board. Tube feeding liquid is all over the floor under the resident's bed. Resident #7 complained of pain every time the CNAs had to move her to provide care. The staff changed the residents' sheets, and peri care provided. The CNA placed a pillow on the residents' right side and a knee pillow placed between her legs. No devices or interventions for her hands were done and no cleaning of hands or body noted except for peri care. No range of motion care provided. During an observation on 5/4/21 at 3:23 p.m., Resident #7 is in bed with pillows still on the right side and in the same position. During an observation on 5/5/21 at 9:50 a.m., Resident #7 noted in bed with knee pillow on the table. No splints or devices noted for hands. During an observation and an interview on 5/5/21 at 4:15 p.m., Registered Nurse (RN) O located the [MEDICATION(S)] patch on Resident #7's right upper chest and it had a clear plastic dressing cover over it. RN O reported they cover the [MEDICATION(S)] patches because they can fall off easy and the resident can scratch it off. In an interview on 5/6/21 at 11:47 a.m., the Interim Director of Nursing (DON) confirmed the [MEDICATION(S)] patch is on Resident #7's right upper chest and covered with a plastic covering because it falls off easily. Review of the April and May 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On May 4th at 4:00 Resident #7 received a new [MEDICATION(S)] patch. In an interview on 5/7/21 at 11:54 a.m., the Regional Nurse Consultant (RC) B reported [MEDICATION(S)] patches should not be covered with a plastic dressing because it can increase the absorption. So consequently on the first day of wearing the patch it can be like getting a bolus of medication and decrease the effectiveness after that. Review of a Physical Therapy Treatment Note dated 9/28/20 for Resident #7 revealed: . Attempted to eval which pt agreed to participate in. Pt refused all functional mobility assessments and BLE (bilateral lower extremity) ROM and strength assessment. Pt states high pain level with ROM and displays RLE flexion spasm and LLE flaccid. Multiple contractors in BLE. Pt stated at end of assessment time that she will not work with therapy. Review of a Care Plan for Resident #7 revealed no care plan specific for contractures noted. The ADL (activities of daily living) care plan interventions revealed: Approach date: 1/20/2020, ROM (range of motion) to BUE (bilateral upper extremities) as (Resident #7) tolerates/allows. Approach date 4/3/2019, Status of personal items: . hand splints to be applied per OT (occupational therapy) recommendation. 3/6/19, Observe for presence of pain/intolerance during self cares. No revisions to the pain care plan since 3/6/2019. Resident #11 In an interview on 5/5/21 at 9:00 a.m., Resident #11 observed in bed on her back with her legs elevated. She reported she is in pain a lot from arthritis and just received some [MEDICATION(S)], but it had not kicked in yet. She reported that changing positions is not comfortable and causes pain/discomfort. She reported she goes to the pain clinic every 6-8 weeks but would like pain medication that would keep her pain from spiking when she is trying to sleep at night and wake her up. She said the facility told her she just needs to ask for her pain medication, but that does not help her control the pain. She reported she is on pureed foods and does not eat much because it is hard to get the food down because it is hard to swallow. Review of the MAR for Resident #11 revealed she received 15 mg (milligram) tablet of [MEDICATION(S)] ([MEDICATION(S)]) extended release at 5:00 a.m. During an observation and an interview on 5/7/21 at 11:02 a.m. the Physical Therapist (PT) T was in Resident #11's room and verified there is no pressure reduction cushion in her room for her recliner or the wheelchair. The seat in the wheelchair is just a standard cushion but could order a pressure reduction cushion for her. In an interview on 5/7/21 at 10:30 a.m., Regional Nurse Consultant (RC) B reported Resident #11 admitted with one pressure ulcer and then it closed and reopened again with two more pressure ulcers. Review of a Nursing Progress note dated 1/30/21 at 6:30 p.m. for Resident #11 revealed: . Rates pain a 4 and stated she had [MEDICATION(S)] at 4 p.m. before she left the hospital. States she has chronic pain that is constant. Resident with [MEDICATION(S)] patch on L (left) chest. Medication list reviewed with on call clinician Review of a Nursing Progress noted dated 1/31/21 at 11:56 a.m. for Resident #11 revealed: accepted meds crushed in applesauce. Patient pain this am and requested pain medication, auth received from pharmacy and PRN (as needed) [MEDICATION(S)] for pain given it was effective. Message left for provider to review pain medications/orders for clarification. Patient discharged with [MEDICATION(S)] patch to [NAME] (left upper chest) not dated from hospital, no scripts received or order. Review of a Nursing Progress Note dated 1/31/21 at 12:25 p.m. for Resident #11 revealed: Return call received from (clinician), verbal order per (clinician) to remove [MEDICATION(S)] patch until provider addresses tomorrow. Patch removed and message for primary provider to review left. Review of a Nursing Progress note dated 2/1/21 at 4:50 a.m. for Resident #11 revealed: Resident slept all night and about 2 a.m. woke and asked for pain pill then she went back to sleep. Review of a Grievance/Complaint Form dated 2/13/21 for Resident #11 revealed: Resident states she is worried that her pain medication is going to be changed. She states she wants it to remain the same and it is working the way it is. Wants to make sure she is involved with doctor in requests to any changes made to her mediation. Resident states she wants nurses to exhibit better customer service when explaining her pain meds. Spoke to resident via phone call to explain process. Summary of Findings/conclusion: Residents pain medication has not been changed. Will review with doctor and resident at any point where doctor would feel a med change is appropriate and would involve resident. Corrective Actions Taken: reviewed medication change process with resident. Explained that facility would involve her in any conversation related to pain medication. Will education nurses on customer service related to discuss meds. Spoke with resident on 2/16 and she is satisfied with the results. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)]-acetaminophen ([MEDICATION(S)]) (pain medication) tablet, 7.5/325 mg, one tablet every 6 hours as needed, ordered 1/30/21. [MEDICATION(S)] (antianxiety medication) 10 mg tablet as needed, ordered 1/30/21. Review of the Pain Assessments on the April and May 2021 MAR for Resident #11 revealed she received pain medications every day for pain and on most of those days, she rated the pain greater than a 7/10 pain scale. Post pain medication administration is not documented on a pain scale to compare the before and after of the medication administration, and not rated as effective. Pain Assessment scale using 0-10 with a 0=No Pain, 1-3 Mild, 4-6 Moderate, 7-10 Severe. She has not received any of the [MEDICATION(S)] ordered. No indications that staff can crush medications due to [CONDITION(S)] obstruction/swallowing dysfunction noted. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .She has a history of dysphagia and failure to thrive and subsequently is on 6 small meals per day. She presently has a stage II sacral pressure injury which was was admitted with. Regarding her chronic pain complaints she goes to the pain clinic about every 3 or 4 months for injections in the lumbar spine and knee. Today on examination she actually is not complaining of much in the way of pain . Summary of Plans . she had dysphagia and is to receive 6 small meals per day. She has a longstanding chronic history of lumbar and knee pain. she presently is on [MEDICATION(S)] and [MEDICATION(S)] ([MEDICATION(S)]). She did not complain of pain issues today. History of depression and anxiety, on [MEDICATION(S)] and [MEDICATION(S)] Review of a Nursing Progress note dated 4/23/21 at 9:05 a.m. for Resident #11 revealed: During her morning medication administration resident spit her pills out in her napkin. When I attempted to look in the napkin and she grabbed it away from me. She stated, I just threw up a little. I then was able to look in napkin and her morning medications were in it. Resident denies this. I explained to resident that she needs to let staff know when she does not want her medications and she can discuss it with the Dr. Resident continues to deny that she spit medications out. (sic) Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .She has a history of chronic low back pain and leg weakness. She was admitted with coccyx pressure ulcers and is being seen routinely by wound care team. On examination she tells me she wakes up about 11:00 or midnight having pain in her back legs and needs a pain pill. She does have [MEDICATION(S)] available as needed. I explained to her that she just needs to ask for it. She thanked me for the information. Labs: TSH 32.10 (normal range is 0.35-5.5) (indicating hypothyroid). Summary of plans: Resident continues to eat sparingly. Her weight has dropped a little bit but not overall too bad. Main concern at this point is for wound care. Wound care team is doing an excellent job. Resident does complain of chronic pain issues which she states wakes her up about midnight. She was informed she has [MEDICATION(S)] available at that time. Plan: Will continue with present medications and treatment plan. Review of the Progress Notes dated 5/3/21 at 9:57 p.m. for Resident #11 revealed: . Had [MEDICATION(S)] at 4:40 p.m. for generalized pain rated 10/10. Medication was stated to be somewhat effective at 5:40 p.m. Continues routine [MEDICATION(S)] TID (three times a day) for chronic pain which she states is helpful. continues on puree diet with thin liquids, had a poor appetite at supper, and refused supplement. Ate some HS snack. Res. is incontinent of B&B (bowel and bladder) and [MEDICATION(S)] was applied. Wound dressing dry and intact on coccyx. Res refuses to be repositioned every 2 hours despite many attempts by staff. Refuses to have cushion in recliner when she is in it but does allow it when she is in her w/c (wheelchair). This progress note is duplicative in several progress notes by the same nurse on 4/22/21, 4/23/21, 4/26/21, 4/28/21, 4/29/21, 5/3/21, and 5/5/21. Review of a Care Plan for Resident #11 revealed on 1/30/21: Discuss with (Resident #11) the need to request pain medications before pain becomes severe . no new interventions since 1/30/21 for pain. Review of a [MEDICATION(S)] Patch 50 mcg/hr medication insert/instructions revealed: . Press the patch firmly for a few seconds to make sure it stays in place. If the patch does not stick, speak with your doctor or pharmacist. Do not cover the patch with bandage or tape unless instructed by your doctor or pharmacist. Review of a policy titled Pain Management reviewed 2/2021 revealed: (Facility) believes pain is a personal experience that, if left undertreated or mismanaged, can radically change a residents' quality of life and impact their overall well-being. A residents' pain is best treated and managed by an interdisciplinary team that actively engages the resident in the development of an effective treatment plan. Our pain management program will utilize a combination of methods encompassing a holistic, person-centered approach. According to Potter, P.A., and Perry A.G. in Fundamentals of Nursing (6th Edition, 2005), ROM is defined as the maximum amount of movement available at a joint in one of the three planes of the body . (pg. 1434). Referring to the nursing assessment process, (pg. 938), assessing ROM is one of the first assessment techniques used to determine the degree of damage or injury to a joint. The nurse assesses ROM to collect data to answer questions about the joint stiffness, swelling, pain, limited movement, and unequal movement; the text continues (pg. 758) When putting each joint through its range of motion, the nurse makes a number of basic observations, noting pain, limited mobility, spastic movement, joint instability, stiffness and contracture. According to Ostomy and Wound Management (2/2009) Pressure Ulcer Pain: A Systematic Literature Review and National Pressure Ulcer Advisory Panel White Paper: Pressure ulcer pain may be caused by tissue trauma from sustained loads, inflammation, damaged nerve endings, infection, dressing changes, debridement, operative procedures, and other treatments. The skin has more sensory nerves than any other body organ. As the pressure ulcer cellular damage expands, chemicals are released that irritate nociceptive nerve terminals. Nociceptive pain is an appropriate physiological response to a painful stimulus and involves acute or chronic inflammation. Pain, particularly acute pain, is also a stimulus to the stress response; thus, at the cellular level, [CONDITION(S)] may develop because of limited painful breathing and peripheral vasoconstriction and impede wound healing. 8 Pain also may diminish appetite and decrease nutritional status. The single most reliable indicator of the existence and intensity of pain and any resultant distress is the patient's self-report through the use of established reporting instruments. The [NAME] is an advocacy organization that believes that all pressure ulcers cause pain. Healthcare providers report that dressing change and wound treatment are among the most painful times for an individual with a pressure ulcer.

Based on observation, interview, and record review, the facility failed to follow CDC (Center for Disease Control) guidelines and recommendations to contain and prevent the spread of COVID-19, resulting in an Immediate jeopardy when (1) nursing staff treated a COVID-19 positive resident without the use of a face mask and then treated COVID-19 negative residents without the use of a face mask, (2) kitchen staff prepared food without the use of masks or gloves, and (3) residents positive for COVID-19 were not separated from the general population. This deficient practice placed all residents at risk for serious harm, injury, and /or death. Findings include: On [DATE] at 8:39 A.M. a COVID-19 Focused infection Control survey commenced. According to CMS (Centers for Medicare & Medicaid Services) notice COVID-19 Long Term Care Facility Guidance, dated [DATE], Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with patients and residents, * For the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility. * Long-term care facilities should separate patients and residents who have COVID-19 from patients and residents who do not, nor have an unknown status. According to the facility policy 2019 Novel Coronavirus (COVID-19) dated ,[DATE], Care should be taken with delivery and pick up of resident meal trays to resident's room requiring Transmission-Based Isolation. The tray should not enter the room, items should be removed from the tray and placed before the resident by an employee in appropriate PPE. This process is performed by two employees-one in the room and the other outside the room with the tray. Pickup of items is performed in much the same manner with items being placed back on the tray and the whole tray being bagged for delivery back to the kitchen. Once the cart reaches the kitchen, the bag(s) are put aside until ALL other dishes are washed. Once that has taken place, kitchen staff should use the thick rubber gloves, take the Isolation dishes and run them through the dish machine. The dish machine is then drained, and all surfaces are washed with soap and water and sanitized from top to bottom, inside and out. This also includes the rubber gloves. The policy goes on to specify Priorities for testing may include: High Priority-hospitalized patients with symptoms, Healthcare facility workers , workers in congregate living settings, and first responders with symptoms, Residents in long-term care facilities or other congregate living settings, including prisons and shelters with symptoms. According to Executive Order No. ,[DATE] signed by the Governor of the State of Michigan on [DATE], Enhanced protections for residents and staff of long-term care facilities during the COVID-19 pandemic section III, 4. A long-term care facility must adhere to the following protocol with respect to a COVID-19 affected resident who is medically stable: (a) If the long-term care facility has a dedicated unit and provides appropriate PPE to the direct-care employees who staff the dedicated unit, the facility must transfer the COVID-19-affected resident to its dedicated unit. (b) If the long-term care facility does not have a dedicated unit or does not provide appropriate PPE to the direct-care employees who staff the dedicated unit, it must transfer the COVID-19-affected resident to a regional hub, if one is available to accept the resident. If no regional hub is available to accept the transfer of the COVID-19-affected resident, the long-term care facility must attempt to send the resident to a hospital within the state that has available bed capacity. If no hospital will admit the COVID-19-affected resident, the long-term care facility must transfer the resident to an alternate care facility. R#1 Review of a Resident Face Sheet reflected Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#2 Review of an Resident Face Sheet reflected Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was also diagnosed with [REDACTED]. According to a physician progress notes [REDACTED].#2 .has not been eating or taking her medication for the past day or two. She is in bed, which is very unusual for her, staff was able to get a UA (urinalysis) this morning that her urine looks very cloudy. We are going to check a CBC (Complete Blood Count), CBC (Comprehensive Blood Count), UA, CXR (Chest x-ray) STAT (right away). She [MEDICATION NAME] [DATE]. We are going to empirically start her on [MEDICATION NAME] 1 gram daily for 3 days while awaiting urine results. Review of a Care Plan for Resident #2 started on [DATE] reflected Resident is positive or exhibiting signs and symptoms of COVID-19 infection. [DATE] - presents with Temp (temperature/fever) and SOB (Short of Breath) expired on [DATE]. Interventions included [DATE], administer COVID testing and record and report as ordered. Assess for any shortness of breath. Apply oxygen per physician orders, encourage resident to take deep breaths. Position resident to allow ease of breathing . Review of Resident Progress Notes dated [DATE] at 1:25 PM reflected Resident (Resident #2) A&O x 1 (alert and oriented to person only). No s/sx of pain noted or reported. Resident has been lethargic today. Will respond to her name. Refused medication and both meals today. Resident VSS (vital signs stable). Resident has been lying supine in bed since third shift. Lung sound CTA (clear to auscultation). Bowel sounds active x 4. Incontinent of B & B (bowel and bladder). No s/sx of hypo/[MEDICAL CONDITION] noted or reported. Blood sugars 97 and 105. (Medical Doctor) here this morning and did examine resident. New orders received, STAT (as soon as possible) CBC, CMP, UA and CXR and [MEDICATION NAME] 1 gram IM (intramuscular) x 3 days . Review of Resident Progress Notes dated [DATE] at 2:59 PM reflected Received chest x-ray results which show pneumonic infiltrates seen. (Physician) was notified and gave order for [MEDICATION NAME] 1 IM x 5 days total instead of 3 days . Review of Resident Progress Notes dated [DATE] at 6:45 AM reflected Res (Resident #2) alert to name but does not open eyes, continues to be non-verbal, remains on ABT (antibiotic) r/t pneumonia, res afebrile, res hypoxic with pulse ox stat rate at 89% the ,[DATE]% observed mouth breathing, O2 (oxygen) face mask at 2 L (liters) applied effective with pulse ox stat 98%. DON (Director of Nursing) notified, change reported to on-coming staff. Will continue to monitor. Review of Resident Progress Notes dated [DATE] at 1:54 PM reflected Resident #2 had a fever of 100.7 degrees Fahrenheit. Review of Resident Progress Notes dated [DATE] at 10:21 PM reflected (Resident #2) difficult to arouse. Will drink with cueing. Restless pulling O2 mask off. LS (lung sounds) CTA. O2 sats in the 80s with O2 at 3L via mask. Mouth breathing on an off. She is not talking, just moaning. T (temperature) at beginning of shift 102.5, Tylenol given per order. T came down to 101.8. Tylenol given again at 2100 (9:00 PM). At 2145 (9:45 PM), 97.2 . Review of Resident Progress Notes dated [DATE] at 1:50 PM reflected (Physician) in today, assessed resident, order received to extend [MEDICATION NAME] to total of 7 days. Resident afebrile, SpO2 ,[DATE]% ON O2 via face mask . Review of Resident Progress Notes dated [DATE] at 4:46 PM reflected Daughter called to follow-up with questions about nasal swab message left. Review of Resident Progress Notes dated [DATE] at 8:57 AM reflected Called to (Resident #2's) room by staff. Resident noted to have zero respirations, zero apical pulse. Verified by west end charge nurse. DON and (physician) notified. Order received to release to Funeral Home of family choice. DON will notify (Resident #2's daughter). During an interview on [DATE] at 10:39 AM, ADON A could not explain why Resident #2 was not tested for COVID-19 until [DATE]. Review of a laboratory report dated [DATE] reflected Resident #2 was tested for COVID-19 on [DATE]. The specimen was received by the laboratory on [DATE] and the result was positive for [DIAGNOSES REDACTED] CoV-2 on [DATE]. During an interview on [DATE] at 8:49 A.M., the Administrator (ADM) reported that the facility had 5 residents currently living in the facility, that had tested positive for COVID-19 and the facility did not have a separate dedicated unit for COVID positive residents. In addition, it was reported that a total of 15 residents had tested positive thus far, 5 of whom were now deceased . During an interview on [DATE] at 8:55 A.M., the ADM stated that all staff were to wear masks, face shields or goggles and a cover up (cover-all's, gown or lab coat) in resident common areas, i.e.: hallways, activity rooms, lounge areas). During an observation on [DATE] at 9:24 A.M., the following was noted: (1) rooms ,[DATE] were occupied by residents who had not been diagnosed with [REDACTED]. During an interview on [DATE] at 9:27 A.M., Certified Nurse Aid (CNA) C reported that the procedure for caring for a COVID positive resident was to doff the current PPE worn to care for COVID negative residents and worn in common areas, and don new PPE that included an N95 mask, gown, face shield, and gloves. CNA C further stated that once staff had donned new PPE, the staff would then enter the room and provide any necessary care for the residents. Once care was provided, staff would doff all the PPE while in the doorway of the resident room and replace the PPE with a new gown, face shield or goggles, and mask. During an observation on [DATE] at 9:31 A.M., Dietary Manager (DM) D was in the kitchen and did not have a mask on. Dietary staff (DS) E was preparing meatloaf without the use of a mask or gloves. During an interview on [DATE] at 9:39 A.M., DM D indicated that he did not have to have a mask on while in the kitchen, only when in resident common areas. DM D reported that food served to COVID positive residents was delivered on a reusable tray that went into COVID positive rooms and was then returned to the kitchen in a red biohazard bag. Kitchen staff would then discard the red biohazard bags and place the reusable trays in the washer with other items. DM D stated that the trays were washed in the order in which they returned to the kitchen and were not held until the end of the washing process. During an observation on [DATE] at 09:46 A.M., COVID positive R1 was out in the hallway without a mask on. During an observation on [DATE] at 10:01 A.M., COVID positive R1 was out in the hallway without a mask on. During an observation on [DATE] at 10:09 A.M., Licensed Practical Nurse (LPN) F entered the room of a COVID-19 positive resident (R3) without a mask on. LPN F brought medication, a stethoscope and blood pressure cuff into the room. After checking R3's blood pressure, the cuff and stethoscope were placed on R3's bedding. LPN F provided direct resident care and then exited the room. At no time during the delivery of care to R3 did LPN F have a mask on. LPN F placed the un-sanitized stethoscope and blood pressure cuff on the medication cart. LPN F completed the PPE donning and doffing process and did not perform any hand hygiene until he returned to the medication cart. LPN F proceeded to care for a resident who was not COVID positive and did not don a mask. During an interview on [DATE] at 10:25 AM, LPN F reported he had been educated about the use of PPE and the precautions to take in caring for residents who were COVID-19 positive. LPN F could not explain why he was not wearing a mask while caring for the COVID positive resident (R3). During an interview on [DATE] at 10:40 AM, Assistant Director of Nursing (ADON) A reported that LPN F continued to work the duration of his shift on [DATE] and again on [DATE] before being sent home for self-quarantine and COVID-19 testing. On [DATE] at 4:30 P.M., the Administrator was verbally notified of the immediate jeopardy, that began on [DATE] when A) Resident #2 was placed on transmission-based precautions with symptoms of suspected COVID infection and not placed on a dedicated COVID unit. R2 was not tested for COVID until [DATE] and was deceased on [DATE], and found to be COVID-19 positive when test results were reported on [DATE]. B) LPN F sustained an exposure to COVID-19 when caring for a COVID positive resident, then cared for COVID negative residents without a wearing a mask. C) Kitchen staff did not don appropriate PPE. The Administrator received written notification of the immediate jeopardy on [DATE] at 1:30 P.M. These deficient practices resulted in the high likelihood of serious harm, injury and death for all residents and staff at the facility On [DATE] the surveyor confirmed the facility implemented the following to remove the Immediate Jeopardy: 1. On [DATE] CDC Guidelines entitled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings updated [DATE] were reviewed by the facility ADM, DON and ADON. 2. On [DATE] staff was educated on Infection Control and Prevention with an emphasis on Transmission Based Precautions and Personal Protective Equipment (PPE) by the interim ADON A. Education included: PPE to utilize for residents on contact and droplet precautions, how to don and doff PPE and disinfecting multi-resident equipment after each resident use. 3. On [DATE] kitchen staff members were educated on utilizing gloves and mask by the Regional Registered Dietitian. 4. On [DATE] COVID positive residents were placed or moved to a dedicated unit separate from residents who are asymptomatic or tested negative for COVID-19. The dedicated COVID unit has dedicated equipment and dedicated staff. Signage was placed on the entrance to the COVID unit indicating Restricted: Authorized Personnel Only as well as Droplet and Contact Isolation signage. 5. On [DATE] COVID positive facilities were contacted for placement of one COVID-19 Positive resident (R1) and that resident was placed on the dedicated unit until placement can be found due to her cognitive status. 6. On [DATE] facility rounds were completed by DON or designee to ensure symptomatic resident, residents with positive COVID-19 results, and residents being tested for COVID-19 were on contact and droplet precautions and signage was placed on the doorways to the rooms indicating Transmission Based Precautions. 7. On [DATE] facility rounds were completed by DON or designee to ensure symptomatic resident, residents with positive COVID-19 results, and residents being tested for COVID-19 were on contact and droplet precautions and signage was placed on the doorways to the rooms indicating Transmission Based Precautions. 8. On [DATE] LPN F was sent home following his scheduled shift and tested for COVID-19 on [DATE]. Although the Immediate Jeopardy (IJ) was removed on [DATE], the facility remained out of compliance at a scope of widespread and a pattern of No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy due to not all staff had been in-serviced on revised procedures and sustained compliance has not been verified by the State Agency.

Based on observation, interview and record review, the facility failed to revise the care plan for 1 (Resident #31) of 12 residents reviewed, resulting in a lack of care plan evaluation, revision, and implementation of appropriated interventions, and the potential for unmet care needs. Findings include: Review of a Face Sheet for Resident #31 revealed an [AGE] year old female originally admitted on [DATE]. Pertinent [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #31 revealed a Brief Interview for Mental Status indicated she was cognitively intact, totally dependent on 2 staff for transfers, always incontinent of bowel and bladder, at risk for pressure ulcers, and no current pressure ulcers. Section K 0300 Weight Loss, Loss of 5% or more in the last month or 10% or more in the last 6 months was marked yes, and not on a physician prescribed weight loss regimen. Resident weighed 208 pounds. Review of the Annual Minimum Data Set ((MDS) dated [DATE] for Resident #31 revealed a Brief Interview for Mental Status indicated she was cognitively intact, totally dependent on 2 staff for transfers, always incontinent of bowel and bladder, and one Stage 4 Pressure Ulcer. Section K 0300 Weight Loss, Loss of 5% or more in the last month or 10% or more in the last 6 months was marked yes, and not on a physician prescribed weight loss regimen. Resident weighed 183 pounds. Review of the Annual Minimum Data Set ((MDS) dated [DATE] for Resident #31 revealed a Brief Interview for Mental Status indicated she was cognitively intact, totally dependent on 2 staff for transfers, always incontinent of bowel and bladder, and one Stage 4 Pressure Ulcer. Section K 0300 Weight Loss, Loss of 5% or more in the last month or 10% or more in the last 6 months was marked yes, and not on a physician prescribed weight loss regimen. Resident weighed 183 pounds. During an observation on 6/18/19 at 10:40 a.m., Registered Nurse (RN) H brought in supplies for Resident #31's dressing change on her coccyx. The supplies used included wound cleanser in a spray bottle, Dakin's solution, unwrapped roll gauze from a multi-use roll from the nurses' cart for wound packing carried in a plastic cup, unwrapped 4x4 gauze from a pink basin tub in Resident #31's room inside her closet, and a foam border dressing. All supplies placed on the residents' bedside table and did not clean it beforehand. RN H put on gloves and removed the old dressing from Resident #31's coccyx including the gauze packing. The large wound was deep with some undermining under the skin. RN H changed gloves after removing the old dressing and put on new gloves with no hand hygiene in between. RN H continued with dressing change. No hand hygiene done after care of the wound, dated the dressing and touched other things in the room then left with the soiled dressing in a bag down the hall to the door that led to the outdoor dumpster. When she came back in, RN H cleaned her hands in another residents' room next to the door that led to the dumpster. RN H reported that was how she always discarded the soiled dressings because they had a smell. During an observation on 6/18/19 at 11:00 a.m., Resident #31 moaned out load and heard in the hallway and in next room where this surveyor was with the door closed. During an observation and an interview on 6/19/19 at 12:40 p.m., Physician Assistant (PA) P observed in Resident #31's room for wound care. Supplies included Dakin's solution, wound cleanser, a few 4x4 gauze unwrapped and roll gauze unwrapped, sitting on top the packaged foam border dressing, with unwrapped cotton swabs. All supplies were placed on Resident #31's nightstand on top of papers and other personal items that belonged to the resident. Hand hygiene done and old wound dressing removed with bloody serous drainage noted. The wound was large and round with undermining noted. PA P reported the wound looked slightly better. The wound was beefy red. PA P performed hand hygiene and cleansed wound with wound cleanser, dabbed the wound with the 4x4 unwrapped gauze, then measured with wound with the unwrapped cotton swabs. The measurement was 5.6 cm (centimeters) x 5.1 cm x 1.2 cm, undermining from 8:00 to 1:00 was 5.2 cm, 10 % slough and 90% drainage. PA P did hand hygiene, put roll gauze in gloved hands, poured Dakin's solution into hands over the trash bin to wring out the excess and packed Resident #31's wound, and then placed the foam border dressing over the wound. PA P reported Resident #31 had the pressure ulcer for about 5 months and that she was the first one to start the dressing to the wound. PA P reported the first dressing had no depth and was just flush with the skin and was unstageable due to the slough that had about 80% slough when she first saw it. PA P reported Resident had recurrent moisture associated skin damage (MASD) before the pressure ulcer. PA P reported in (MONTH) the wound measured 3.5 cm x 1.8 cm and did expect it to get better at that point, but then Resident #31 started declining by not eating and had been in the hospital a couple times since then. PA P reported that if the resident would start eating more, she would have ordered a wound vac to help improve healing, but the main goal now was to keep the wound free from infection. PA P reported the facility supplied the large roll gauze for pressure ulcer dressings that came in a big roll and they cut off how much they need for dressing changes and that the 4x4's come in a large multipack. When asked if PA P had any concerns with infection control setting supplies on the nightstand and using the roll gauze from the big roll and the 4x4's from the multipack she reported that was what the facility provided and no comment on setting up supplies on the nightstand. In an interview on 6/20/19 at approximately 12:00 p.m., RN H reported Resident #31 always had a fragile area on her coccyx but could not describe what a fragile area meant other than it was pigmented d/t years of incontinence. On 1/31/19 when RN H noticed the pressure ulcer on Resident #31, RN H reported it just looked like it split open. RN H reported Resident #31 was not always compliant with medications and supplements and it was sometimes a power struggle but since she had a good rapport with Resident #31, RN H reported she was able to get Resident #31 to be compliant. In an interview on 6/20/19 at 12:50 p.m., Registered Dietician (RD) X reported she charted on Resident #31 once a month for weight issues but that did not mean she saw the resident once a month. RD X reported she visited Resident #31 on 2/27/19 and 5/30/19. RD X reported Resident #31 came up for pressure sores and weight loss. RD X She reported she was still working on this month's charting and last month on 5/31/19 she requested to change Resident #31 from ProStat to Proheal supplement and a multivitamin. In (MONTH) and (MONTH) of 2019 RD X reported there were no written changes. On 2/28/19, RD X reported Resident #31 was on a regular diet and her intake was variable and liked to bring in her own food so sometimes it looks like she is not eating. RD X reported she was a very picky eater and did not exactly like healthy foods. RD X reported she did not see the resident in (MONTH) but did see her on 12/24/18 which was Christmas Eve and Resident #31 had complaints of nausea and vomiting that day. RD X reported she just remembered she was sick that day and it had been an ongoing situation. RD X reported Resident #31 refused mighty shakes and magic cups back in (MONTH) and recommended HighCal supplement in early May, but she did not want that. RD X could not elaborate when ProStat started and was not aware Resident #31 had a pressure ulcer until the first of (MONTH) this year. RD X did not know if the facility provided fortified foods and has been the Registered Dietician since (MONTH) of (YEAR). RD X then reported all their buildings had the same supplements but will ask the facility what supplements they had. RD X was aware that Resident #31 did not like the food but does not make the menus, only helps to sign off on them. RD X reported that Resident #31 complains about the food at the facility every time she visits and only wants food that was specific to her likes. RD X reported she did not attend Resident Council meetings to discuss what residents liked and did felt more could should be for Resident #31. In an interview on 6/20/19 at approximately 12:15 PM, Resident #31 was sitting up in bed eating her lunch. She said she would eat more if she liked the food. She said she preferred to collard greens, cabbage, fried chicken, and black eyed peas. Resident #31 said the facility would give her the same thing every day and did not care for sweets. Resident #31 reported she did not really talk to a dietician about her food choices and remembered she only had fried chicken one time. Resident #31 said she wanted her pressure ulcer to get better and said she thought it was getting better. In an interview on 6/20/19 approximately 3:00 PM, CNA W reported Resident #31's daughter will bring in chicken for the resident and she will eat it depending on how she is feeling. CNA W reported Resident #31 mostly hated the shakes given to her but will drink them at times. Review of Nursing Progress Note dated 12/19/18 for Resident #31 revealed: New orders today . refer back to Gastro for Weight loss, nausea and dyspepsia For possible gastroparesis . Review of Dietary Progress Note dated 12/20/18 for Resident #31 revealed: Follow with (Resident #31) r/t (related to) food preferences she will let staff know her likes/dislikes on a daily basis as usual . we discussed her recent weight loss she said, I have been trying to lose weight for a while now. She has been having some stomach upset with recommendations for follow up with physician. Will continue to provide meals as she chooses to follow weight, intake, preferences. Referral to RD at next scheduled visit. (sic) Review of a Dietary Progress note dated 12/24/18 for Resident #31 revealed: RD Consult: Went in and talked to (Resident #31) today about the nausea and vomiting. According to her, it occurred today after lunch. Pinner her down and know that it does not occur because of taking meds on an empty stomach and there seems to be nothing that triggers it from occurring. No specific foods make her vomit either. She does say it's because she is fed canned food all the time. She stated that she brings her own food in for meals and sometimes only finds one food item on the menu that she likes. Encouraged her, next time that she gets sick, after she is finished ask to brush her teeth/mouthwash to help change the taste in her mouth, so she will not continue to get sick. She said she thought that was a good idea and would try it. At this point cannot find any trail that leads up to her vomiting. Will discuss it with her again next month. (RD X's next visit to Resident #31 was on 2/27/19.) Review of a Nursing Progress note dated 12/25/18 for Resident #31 revealed: . Eats meals in her room per her request and has a good appetite. Review of a Nursing Progress Note dated 1/31/19 for Resident #31 revealed: Fragile skin area to coccyx has opened. New order for treatment cleanse/calcium alginate/sm dressing daily. Order in updated to TAR (treatment assessment record). Dressing this today. Resident also repositioned every 2 hours off of coccyx. No description of wound documented Review of the (MONTH) 2019 Physician order [REDACTED].#31 revealed: Ordered Diet: 9/6/18-open ended Regular with SUGAR SUBSTITUTE, ordered 12/19/18-open ended Registered Dietician referral, residents likes/dislikes RE: nausea and possible diabetic GI issues, ordered 1/26/19 and discontinued 3/12/19- 2 OZ (ounce) HI-CAL supplement. Special Instructions: AS SHE ALLOWS/TOLERATES (HER CHOICE) Twice a Day, ordered 2/14/19 and discontinued 3/21/19- PROHEAL [MEDICATION NAME] 30 ml twice a day, Ordered 8/31/17-open ended Weekly Skin Assessment, once a day on Wed; Evenings, Ordered 4/1/13 - open ended, Bariatric Cushion when in chair continuous, Ordered 2/28/19 to 3/13/19- Dakin's Solution 0.125%, Special Instructions: Cleans coccyx wound with wound cleanser and Gauze Pack with Dakin's 0.125% moistened gauze, cover with non adhesive Derma Foam, Apply skin prep to periwound surrounding skin and secure dressing with profix tape. Change daily and PRN for disruption. Review of a Physician Assistant Progress Note dated 2/6/19 for Resident #31 revealed: . I have been consulted by (Physician) to evaluate (Resident #31) for a wound to her coccyx. Staff tell me resident has recurrent ulcerations to the coccyx area. They state with this most recent ulceration they were applying cream but it was getting worse, so a few days ago they started applying a dressing. It is noted resident is diabetic. At this time resident is lying in her bed. She states the wound in painful. She states normally she spends quite a bit of time up in her wheelchair, but that this past week she has spent most of her time in bed because the wound is painful when she is up in her wheelchair. She does have a cushion in her wheelchair but states she has had it for quite a while. She admits that her appetite hasn't been very good lately. Physical exam: Skin: Ulcer to the coccyx area measuring 3.5 x 1.8 cm, the wound base is 80% slough and 20% granulation tissue, there is moderate serous drainage with no odor, wound edges are intact ad attached, no [DIAGNOSES REDACTED] or induration to the periwound area. Plan: The wound appears to be a pressure ulcer, given the amount of slough it would be considered unstageable at this time, will have staff cleanse the wound with saline and gauze and cover with a comfort foam bordered dressing, change daily, given her poor appetite will check [MEDICATION NAME], will start resident on vitamin C 500 mg (milligrams) and Zinc 50 mg bid (twice daily) to help promote wound healing, she does have a Roho cushion in her wheelchair, it appears to be in working orders however will have therapy evaluate to be sure it is functioning properly. (sic) Review of a Physician Assistant Progress Note dated 2/13/19 for Resident #31 revealed: (Resident) is seen today to f/u on the pressure ulcer on her coccyx. I have had staff covering the wound with a bordered foam dressing daily. I also ordered a [MEDICATION NAME] last week which I note has come back low at 15.9. At this time resident is lying in her bed. She states the wound is painful at times. She admits she hasn't been eating very well. She states it is because she doesn't care for the food. Physical Exam: Skin: Ulcer to the coccyx area measures 2.6 x 2.2 cm, the wound base is 80% slough and 20% granulation tissue, there is moderate serous drainage with no odor, wound edges are intact and attached, no [DIAGNOSES REDACTED] or induration to the periwound area. Plan: Size of the wound is improved, will continue to have staff cleanse the wound with saline and gauze and cover with an adhesive foam dressing (comfort border foam), change daily, continue Vitamin C and Zinc, will add ProMod (or ProStat) 30 ml bid (twice daily) resident does have a Roho cushion in her wheelchair. (sic) Review of a Physician Assistant Progress Note dated 2/27/19 for Resident #31 revealed: (Resident) is seen today to f/u on the pressure ulcer on her coccyx. I have had staff covering the wound with a bordered foam dressing daily. I had also ordered a [MEDICATION NAME] which came back low at 15.9 so I recommended starting ProStat twice a day. Staff tell me that resident's wound has been looking worse. They state she has been refusing the ProStat as well as the HighCal supplement drink that is ordered for her. They state she complains that they are too sweet. Staff have tried mixing the drinks with other liquids but resident still refuses. At this time resident is lying in her bed. She states the wound is painful at times. She admits she has been refusing the supplements, stating they are too sweet. She admits her appetite still is not very good. Physical Exam: Skin: Ulcer to the coccyx area is noted to have thick slough today, after obtaining consent from the resident I cleansed the site with iodine and debrided nonviable tissue from the wound using a scalpel, I was able to debride down to healthy granulation tissue in some areas with no viable tissue debrided, total area debrided was 6.0 x 4.0 cm, there was approximately 30 cc of blood loss, resident tolerated procedure well. After debridement the wound measures 6.0 x 4.6 cm, there is approximately 1.5 cm of depth though this is not a true depth due to the presence of slough, the wound base is 90% slough and 10% granulation tissue, there is heavy tan drainage, there is a foul odor present, wound edges are intact and attached, no [DIAGNOSES REDACTED] or induration to the periwound area. Plan: Wound is significantly worse this week, wound was debrided today, resident has been refusing her ProStat and HighCal supplement, I spoke with resident about the importance of these supplements, and that without them her wound will continue to worsen as she is not takin in enough nutrients for her body to heal the wound, staff state resident has been spending most of her time in bed because it is painful for her to be up in her wheelchair, she did get a new wheelchair and cushion, will have staff cleanse the wound with saline and gauze, apply skin prep around the wound, pack the wound with Dakin's 0.125% moistened gauze, cover with a nonadhesive foam dressing (DermaFoam) and secure with Profix tape, change daily. (sic) Review of a Dietary Progress Note dated 2/28/19 for Resident #31 revealed: Monthly Weight/Wound Review: (Resident #31) is on a Regular diet with intake that is variable, and who also brings in her own food, at times. Her weight has dropped 20# in a month for this month. She also has a wound on her coccyx. She refuses supplements but will try HiCal 4 oz BID and see if she will accept that. She refuses Mighty Shakes and Magic Cups. This will add 476 kcals and 20 g of protein which will help with the healing. Her estimated needs are 1575-1925 kcal using 35 k cal/kg of adjusted IBW range, protein 36-72 g using 0.8-1.3 g/kg of the same and fluids 1350 1650 mL using 30 mL/kg of the same. She is also on diuretics which will affect her weight. Will monitor her weights/wound and intake. Review of the (MONTH) 2019 Physician order [REDACTED].#31 revealed: Ordered Diet: 9/6/18-open ended Regular with SUGAR SUBSTITUTE, ordered 12/19/18-open ended Registered Dietician referral, residents likes/dislikes RE: nausea and possible diabetic GI issues, Ordered 3/22/19 and discontinued 5/6/19- [MEDICATION NAME] 4 mg (milligrams) 1 tablet twice a day as needed, Ordered 3/27/19 and discontinued 4/17/19- [MEDICATION NAME] ([MEDICATION NAME]) (an antifungal) 500 mg tablet; special instructions: Crush 500 mg [MEDICATION NAME] tab, mix with Hydrogel, moisten gauze with mixture, pack wound/ulcer, cover with Dermafoam, secure with profix tape OR use 6x6 Comfort border dressing once a day. No orders noted on report for [MEDICATION NAME] as per the PA Progress note on 3/13/19. Review of a Dietary Noted dated 3/6/19 for Resident #31 revealed: Visit with Billie this day 3/6/19 Billie again declined increase in Hi-Cal and declined mighty shake supplement with or between meals, I encouraged her to try and eat a little extra protein to help heal her coccyx wound she said she would try. Will continue Hi-Cal 2oz. BID. Review of a Nursing Progress Noted dated 3/11/19 for Resident #31 revealed: Wet to dry dressing done to coccyx area, large wound bed about ¼ has black eschar tissue present 3/4 has pink fleshy tone. Review of a physician progress notes [REDACTED].#31 revealed: Resident had gastric emptying study done which does show gastroparesis (delayed gastric emptying). She has been complaining of nausea and vomiting after eating. She stated she has not had any vomiting for the past week. I discussed with her the options including 6 small meals per day and possibly [MEDICATION NAME] but she says she is feeling okay now and would like to wait. She also is being seen by wound care for the pressure ulcer on her coccyx area. She presently is lying on her side but is frequently and usually on her back. I did not examine the wound today as she will be seen by wound care in 2 days. I am recommending that they cleanse the wound and get a culture from deep tissue to avoid collecting normal flora. Residents weight has been dropping since receiving nutritional supplement (which she frequently refuses), her weight has picked up a few pounds. She is currently at about 170 pounds. I also reviewed her blood sugars and may have been very well controlled. I reviewed her medications she is taking [MEDICATION NAME] 5-3 25 twice daily which may be contributing to gastroparesis. She does need the [MEDICATION NAME] for pain related to her ulcer. (sic) Review of a Nursing Progress Noted dated 3/13/2019 for Resident #31 revealed: New orders from (PA) orders, Cleanse wound with saline and gauze, crush 500 mg [MEDICATION NAME] tab, mix with Hydrogel, moisten gauze with mixture, pack wound with moistened gauze, cover with comfort boarder dressing daily. Also Oral antibiotic [MEDICATION NAME] BID x 10 days. Orders in updated to MAR and TAR. Review of a Physician Assistant Progress note dated 3/13/19 for Resident #31 revealed: (Resident) is seen today to f/u on the pressure ulcer on her coccyx. I have had staff packing the wound with Dakin's moistened gauze and covering with a foam dressing daily. Staff state residents appetite continues to be poor and that she continues to frequently refuse the ProStat as well as the HighCal supplement drink. At this time resident is lying in her bed. She states the wound is painful at times. She admits she has been refusing the supplements. She states she has been having trouble keeping anything down, stating every time she tries to swallow anything, medicine or food, it comes right back up. Physical exam: Skin: Ulcer to the coccyx area measures 3.6 x 4.4, there is a depth of 2.0 cm, thought this is not a true depth due to the presence of slough there is undermining all the way around the wound measuring 3.6 cm at the deepest point, the wound base is 60% slough and 40 granulation tissue, there is a very small piece of bone palpable, there is moderate tan drainage, there is foul odor present, wound edges have some ulcerated areas, they are not attached. Plan: The wound measures smaller this week, but this is related to improvement in the superficial ulcerations around the wound, the wound opening itself appears bigger, there is undermining this week and there is now a small amount of bone palpable, resident continues to refuse her ProMod and nutritional supplements and her intake continues to be poor, will have (Physician) address her nausea, there is still an odor to the wound, will start resident on oral [MEDICATION NAME] 874/125 mg one tab twice a day for 10 days, will discontinue the Dakin's and will have staff cleanse the wound with saline and gauze with the mixture and pack the wound with the moistened gauze, crush a 500 mg [MEDICATION NAME] tablet and mix with hydrogel, moisten gauze, cover with a comfort foam border dressing, change daily, resident does have an APM mattress, encouraged resident to avoid laying on her back, resident's overall condition has been worsening, and if her appetite doesn't improve and she continues to refuse ordered supplements then the prognosis for her wound is very poor. (sic) Review of a Physician Assistant Progress Note dated 3/27/19 for Resident #31 revealed: . I have staff packing the wound with gauze moistened with a mixture of hydrogel and crushed [MEDICATION NAME] tablet and covering with a foam dressing daily. Staff state residents appetite continues to be poor and that she continues to frequently refuse the ProStat as well as the HighCal supplement drink . She admits that she continues to refuse the supplements, stating they are too sweet. Physical Exam: Skin: Ulcer to the coccyx area measures 3.7 x 5.5 cm, there is a depth of 1.5 cm, though this is not a true depth due to the presence of slough, there is undermining all the way around the wound measuring 4.2 cm at the deepest point at 11:00, the wound base is 20% slough, 10% bone, and 70 % granulation tissue, there is moderate serosanguinous drainage, there is no odor today, wound edges are intact but not attached. Plan: I explained to her that if she continues to have poor intake and refuses the supplements then I do not anticipate that the wound will heal. (sic) Review of the (MONTH) 2019 Physician order [REDACTED].#31 revealed: Ordered Diet: 9/6/18-open ended Regular with SUGAR SUBSTITUTE, ordered 12/19/18-open ended Registered Dietician referral, residents likes/dislikes RE: nausea and possible diabetic GI issues, Ordered 3/22/19 and discontinued 5/6/19- [MEDICATION NAME] 4 mg (milligrams) 1 tablet twice a day as needed, Ordered 3/27/19 and discontinued 4/17/19- [MEDICATION NAME] ([MEDICATION NAME]) (an antifungal) 500 mg tablet; special instructions: Crush 500 mg [MEDICATION NAME] tab, mix with Hydrogel, moisten gauze with mixture, pack wound/ulcer, cover with Dermafoam, secure with profix tape OR use 6x6 Comfort border dressing once a day. No supplements or change in diet noted in orders. Review of a Physician Assistant Progress Note dated 4/3//19 for Resident #31 revealed: . I have staff packing the wound with gauze moistened with a mixture of hydrogel and crushed [MEDICATION NAME] tablet . continues to refuse ProStat and HighCal supplement drink. Physical Exam: Skin: Ulcer to the coccyx area measures 3.4 x 4.5 cm x 2.0 cm, there is undermining from 3:00 to 9:00 measuring 6.0 cm at the deepest point at 11:00, the wound base is 20% slough and 80% granulation tissue, there was no bone palpable today, there is heavy serosanguinous drainage . Plan: The size of the wound opening is decreased today and there is no bone palpable, however the undermining has increased . resident asked again if I felt the wound was going to get better, I explained to her again that if she continues to have poor intake and refuses the supplements then I do not anticipate that the wound will heal. Review of a physician progress notes [REDACTED].#31 revealed: Chief Complaint/Nature of Presenting Problem: Depression, med review list. She has been refusing her nutrition supplements. She is not getting out of bed nearly as much and staff is reporting that she seems to be depressed. She told me she just did not feel like eating very much. She does have stage IV sacral pressure ulcer that is being treated by wound care team. Summary of Plans: Fall Risk Assessment: Resident has had significant weight loss. She has decreased appetite, withdrawing from activity. Blood sugars are well controlled. Due to decreased appetite and weight loss will reduce [MEDICATION NAME] to 500 mg twice daily. We will also increase her [MEDICATION NAME] to 100 mg daily. Wound care is ongoing. Physical Exam: Skin: Wound care team progress note noted. Review of the (MONTH) 2019 Physician order [REDACTED].#31 revealed: Ordered Diet: 9/6/18-open ended Regular with SUGAR SUBSTITUTE, ordered 12/19/18-open ended Registered Dietician referral, residents likes/dislikes RE: nausea and possible diabetic GI issues, .Ordered 5/6/19 to 6/10/19- [MEDICATION NAME] 4 mg tablet twice a day as needed, Ordered 5/9/19 to 6/3/19 Pro-Stat AWC (amino acids-protein hydrolys) liquid 17-100 gram-kcal/30 mL twice a day, Ordered 5/31/19 to 6/5/19-Cipro (antibiotic) 250 mg tablet once a day, Ordered 5/8/19 - open ended Dakin's Solution 0.125%, Special Instructions: Flush wound with saline and wipe gently with gauze pack wound with Dakin's 0.125% Moistened rolled gauze cover with silicone super absorbent dressing (6x7) change twice daily Review of a Physician Assistant Progress Note for Resident #31 dated 5/15/19 revealed: I have had staff packing he wound with Dakin's moistened gauze and covering with a silicone super absorbent dressing twice a day. I had also started resident on [MEDICATION NAME] 150 mg qd (every day) for 5 days due to candidiasis of the periwound. At this time resident is lying in her bed. She states her bottom is a little sore at times. She offers no other complaints today. I looked at her MAR (medication administration record) and note that in the past week since I restarted her ProStat she has taken it all but twice. Her nurse states it is quite a struggle to get her to take it, but she can usually coax her into taking it. Physical Exam: Skin: Ulcer to the coccyx are measures 6.4 x 5.5 x 3.0 cm, there is undermining from 9:00 to 3:00 m measuring 5.2 at the deepest point at 11:00, what can be seen of the wound base is 25% slough and 75% granulation tissue, there is no bone palpable today, there is heavy serosanguinous drainage with no odor, the vesiculopustular rash to the periwound skin is resolved. Plan: There has been notable improvement this week, will continue to have staff flush the wound with saline and wipe gently with gauze, pack wound with Dakin's 0.125% moistened rolled gauze and cover with a silicone super absorbent dressing, change twice a day. (sic) Review of the Daily Food Acceptance Record for Resident #31 revealed: (MONTH) (YEAR): 12/29/18 to 12/31/18 there was no documentation for food intake for breakfast and lunch. Most days, Resident ate more than 40% of all meals that were documented and as much as 80%, including a 100% of a bedtime snack. No supplements charted. January 2019: 1/1/19 to 1/30/19, Resident #31 ate all meals and documented intake was greater than 40% and as high as 80%, including a 100% of a bedtime snack. February 2019: 2/19/19 to 2/25/19 and for breakfast and lunch there is no documentation for intake. On 2/27/19 dinner there is no documentation and 2/28/19 for all meals there is no documentation of intake. Other days documented revealed Resident #31 had a food intake greater than 40% on most days and as high as 100%, including a 100% of a bedtime snack. March 2019: 3/27/19 had no dinner intake documented and 3/28/19 to 3/31/19 no food intake documented for all meals. 3/1/19 to 3/27/19 meals that were documented indicated Resident #31 had a food intake greater that 30% most days and as high as 75%. April 2019: 4/1/19 to 4/14/19 Resident #31 at 40% or more most days and as high as 80%. Bedtime snack intake was 50% or more. 4/21/19 to 5/6/19 Resident went to the hospital. May 2019: Resident #31 returned from the hospital on [DATE]. No documentation of food intake charted for 5/7/19 to 5/11/19 and 5/13/19 to 5/15/19. 5/16 Resident #31 refused breakfast and lunch but ate 60% of dinner. 5/17/19 to 5/21/19 breakfast and lunch intake not charted, and dinner acceptance was 40 to 60%. 5/22/19 to 5/31/19 had no food intake documented. No bedtime snacks documented. June 2019: 6/1/19 to 6/11/19 breakfast and lunch intake not documented, and dinner documented at 30% to 50% intake. 6/12/19 and 6/13/19 had intake documented. 6/14/19 to 6/17/19 (the beginning of this survey) there was no food intake documented. Review of the Care Plan for Resident #31 revealed: Problem start date: 5/6/19- (Resident #31) requires an indwelling catheter r/t stage 4 pressure wound on coccyx. Approach: Change catheter as ordered, irrigate catheter only as ordered if an obstruction is suspected . Problem start date: 2/6/19- (Resident #31) has a Stage 4 area to coccyx (unstageable crossed out with no revision date) with potential for infection and discomfort to area. Associated factors: noncompliance with position changes, incontinence, DM (diabetes mellitus), abnormal labs, paralyti[DIAGNOSES REDACTED], CKD [MEDICAL CONDITIONS]. Goal Target date: 9/27/19 Ulcer will heal without complications. Approach start date: 2/20/19- Specialty mattress, Administer [MEDICATION NAME] as ordered/if ordered prior to wound care, dressing changes or debridement, Assess the condition of skin surrounding ulcer during treatment and PRN (as needed), Assess ulcer for changes in size and characteristics weekly and PRN, Avoid friction and shearing during transfers (TRUNCATED)

Based on observation, interview and record review, the facility failed to prevent, monitor, document, immediately treat and improve a pressure ulcer for 1 (Resident #31), from a total sample of 12 residents reviewed, resulting in progressive decline and worsening of a pressure ulcer. Findings include: Review of a Face Sheet for Resident #31 revealed an [AGE] year old female originally admitted on [DATE]. Pertinent [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #31 revealed a Brief Interview for Mental Status indicated she was cognitively intact, totally dependent on 2 staff for transfers, always incontinent of bowel and bladder, at risk for pressure ulcers, and no current pressure ulcers. Section K 0300 Weight Loss, Loss of 5% or more in the last month or 10% or more in the last 6 months was marked yes, and not on a physician prescribed weight loss regimen. Resident weighed 208 pounds. Review of the Annual Minimum Data Set ((MDS) dated [DATE] for Resident #31 revealed a Brief Interview for Mental Status indicated she was cognitively intact, totally dependent on 2 staff for transfers, always incontinent of bowel and bladder, and one Stage 4 Pressure Ulcer. Section K 0300 Weight Loss, Loss of 5% or more in the last month or 10% or more in the last 6 months was marked yes, and not on a physician prescribed weight loss regimen. Resident weighed 183 pounds. Review of the Annual Minimum Data Set ((MDS) dated [DATE] for Resident #31 revealed a Brief Interview for Mental Status indicated she was cognitively intact, totally dependent on 2 staff for transfers, always incontinent of bowel and bladder, and one Stage 4 Pressure Ulcer. Section K 0300 Weight Loss, Loss of 5% or more in the last month or 10% or more in the last 6 months was marked yes, and not on a physician prescribed weight loss regimen. Resident weighed 183 pounds. During and observation on 6/18/19 at 10:12 a.m., Resident #31 observed laying on her back and reported she had some sores but did not want to talk at this time because she was uncomfortable in her current position. Resident tried to use the call light that clipped to the bed on the left side of her head at eye level and could not reach it. Resident placed her right hand over her forehead moaning in pain. Certified Nursing Assistant (CNA) V entered the room to check the residents brief and reposition her. CNA V left to get supplies and Resident #31 cried in pain. CNA V re-entered room and turned Resident #31 to her right side, dressing on coccyx observed dry and intact dated 6/17/19. Resident #31 reported she felt better on her right side. A pillow was noted on Resident #31's right side and was flat. CNA V place pillows under the resident's arms and heals. Resident pain subsided after care. During an observation and an interview on 6/18/19 at 10:22 a.m., Resident #31 moaned in pain while in bed and reported she was in pain while whimpering. Certified Nursing Assistant then entered the room. During an observation on 6/18/19 at 10:40 a.m., Registered Nurse (RN) H brought in supplies for Resident #31's dressing change on her coccyx. The supplies used included wound cleanser in a spray bottle, Dakin's solution, unwrapped roll gauze from a multi-use roll from the nurses' cart for wound packing carried in a plastic cup, unwrapped 4x4 gauze from a pink basin tub in Resident #31's room inside her closet, and a foam border dressing. All supplies placed on the resident's bedside table and did not clean it beforehand. RN H put on gloves and removed the old dressing from Resident #31's coccyx including the gauze packing. The large wound was deep with some undermining under the skin. RN H changed gloves after removing the old dressing and put on new gloves with no hand hygiene in between. RN H continued with dressing change. No hand hygiene done after care of the wound, dated the dressing and touched other things in the room then left with the soiled dressing in a bag down the hall to the door that led to the outdoor dumpster. When she came back in, RN H cleaned her hands in another residents' room next to the door that led to the dumpster. RN H reported that was how she always discarded the soiled dressings because they had a smell. During an observation on 6/18/19 at 11:00 a.m., Resident #31 moaned out load and heard in the hallway and in next room where this surveyor was with the door closed. During an observation and an interview on 6/19/19 at 12:40 p.m., Physician Assistant (PA) P observed in Resident #31's room for wound care. Supplies included Dakin's solution, wound cleanser, a few 4x4 gauze unwrapped and roll gauze unwrapped, sitting on top the packaged foam border dressing, with unwrapped cotton swabs. All supplies were placed on Resident #31's nightstand on top of papers and other personal items that belonged to the resident. Hand hygiene done and old wound dressing removed with bloody serous drainage noted. The wound was large and round with undermining noted. PA P reported the wound looked slightly better. The wound was beefy red. PA P performed hand hygiene and cleansed wound with wound cleanser, dabbed the wound with the 4x4 unwrapped gauze, then measured with wound with the unwrapped cotton swabs. The measurement was 5.6 cm (centimeters) x 5.1 cm x 1.2 cm, undermining from 8:00 to 1:00 was 5.2 cm, 10 % slough and 90% drainage. PA P did hand hygiene, put roll gauze in gloved hands, poured Dakin's solution into hands over the trash bin to wring out the excess and packed Resident #31's wound, and then placed the foam border dressing over the wound. PA P reported Resident #31 had the pressure ulcer for about 5 months and that she was the first one to start the dressing to the wound. PA P reported the first dressing had no depth and was just flush with the skin and was unstageable due to the slough that had about 80% slough when she first saw it. PA P reported Resident had recurrent moisture associated skin damage (MASD) before the pressure ulcer. PA P reported in (MONTH) the wound measured 3.5 cm x 1.8 cm and did expect it to get better at that point, but then Resident #31 started declining by not eating and had been in the hospital a couple times since then. PA P reported that if the resident would start eating more, she would have ordered a wound vac to help improve healing, but the main goal now was to keep the wound free from infection. PA P reported the facility supplied the large roll gauze for pressure ulcer dressings that came in a big roll and they cut off how much they need for dressing changes and that the 4x4's come in a large multipack. When asked if PA P had any concerns with infection control setting supplies on the nightstand and using the roll gauze from the big roll and the 4x4's from the multipack she reported that was what the facility provided and no comment on setting up supplies on the nightstand. In an interview on 6/19/19 at approximately 2:00 p.m., a timeline with supporting documentation for Resident #31's pressure ulcer was requested to the Director of Nursing (DON) and Regional Nurse Consultant (RN) T and they reported they will put one together right away. At 4:30 p.m., this surveyor was walking out the door when the DON and RN T reported they were ready to go over the timeline with me. This surveyor requested to have it available the next morning. Review of a timeline and an interview on 6/20/19 at 9:13 a.m., revealed the timeline for Resident #31's pressure ulcer was received with very vague information as follows, but not limited to: Wound-(Resident #31) unavoidable. Res was admitted [DATE] and assessed for her at risk skin status. Interventions placed and changed over the past [AGE] years of her stay. Nutritional interventions were implemented immediately and routinely evaluated. Multiple multiple progress notes present describing extensive refusal of vit, 2 different supplements, med, dressing changes at times, refusing BM (bowel movement) care. Res offered fluids however would decline at times. Preventative care including turning and repositioning, pressure relieving devices on bed and w/c (wheelchair) Res has more than 2 primary risk factors for the determination of this wound to be unavoidable. They are 1. Continuous urinary incontinence (prior to cath), 2. Severe [MEDICAL CONDITIONS], 3. Diabetic (non compliant), 4. Chronic bowel incontinence, 5. [MEDICAL CONDITION], and 6. CKD ([MEDICAL CONDITION]). Res did develop malnutrition despite interventions to eleviate. (See lab values) weight loss of 20 lbs (pounds) between feb and [DATE]. (sic) 1/31 coccyx opened from fragile skin-air flow mattress, scheduled (requested) wound PA r/t (related to) concerns of Kennedy ulcer. 2/6 seen by (PA P) 2/13 wound improved, [MEDICATION NAME] low, Res refusing food and supplements . (sic) There were no supporting documentation or measurements provided with the timeline including but not limited to the resident declining supplements or if alternative meals were provided with higher protein or fortified, refusal of medications, turn schedule implemented or decreased in timing, medications to improve appetite, skin assessments before the pressure ulcer or current skin assessments, ect . The DON reported the measurements were in the physician progress notes [REDACTED].#31 in the medical chart and did not do daily wound assessments from 1/31/19 to 2/6/19 when the Physician Assistant assessed the wound. Treatment Administration Records (TARS) or Medication Administration Records (MARS) were not provided. Informed the DON of a harm level concern and requested a clearer timeline of the pressure ulcer with measurements and supporting documentation to prove the pressure ulcer was unavoidable. No documentation provided that Resident #31 declined medications, supplements, food, or any other form of documented noncompliance from front line staff. In an interview on 6/20/19 at 10:23 a.m., RN T reported they were putting together a clearer timeline of Resident #31's pressure ulcer. RN T reported that PA P brought to their attention about using the 4x4 gauze from a large multi-use package and the big roll gauze used for the pressure ulcer dressing. RN T reported those items should not have been used for Resident #31's pressure ulcer dressing changes and that the individually wrapped 4x4 gauze and single use roll gauzes should be used for dressing changes. RN T reported they educated the staff and put individually wrapped 4x4 gauze and single use roll gauze in the nursing carts for wound care. In an interview on 6/20/19 at approximately 12:00 p.m., RN H reported Resident #31 always had a fragile area on her coccyx but could not describe what a fragile area meant other than it was pigmented d/t years of incontinence. On 1/31/19 when RN H noticed the pressure ulcer on Resident #31, RN H reported it just looked like it split open. RN H reported Resident #31 was not always compliant with medications and supplements and it was sometimes a power struggle but since she had a good rapport with Resident #31, RN H reported she was able to get Resident #31 to be compliant. In an interview on 6/20/19 at 12:50 p.m., Registered Dietician (RD) X reported she charted on Resident #31 once a month for weight issues but that did not mean she saw the resident once a month. RD X reported she visited Resident #31 on 2/27/19 and 5/30/19. RD X reported Resident #31 came up for pressure sores and weight loss. RD X She reported she was still working on this month's charting and last month on 5/31/19 she requested to change Resident #31 from ProStat to Proheal supplement and a multivitamin. In (MONTH) and (MONTH) of 2019 RD X reported there were no written changes. On 2/28/19, RD X reported Resident #31 was on a regular diet and her intake was variable and liked to bring in her own food so sometimes it looks like she is not eating. RD X reported she was a very picky eater and did not exactly like healthy foods. RD X reported she did not see the resident in (MONTH) but did see her on 12/24/18 which was Christmas Eve and Resident #31 had complaints of nausea and vomiting that day. RD X reported she just remembered she was sick that day and it had been an ongoing situation. RD X reported Resident #31 refused mighty shakes and magic cups back in (MONTH) and recommended HighCal supplement in early May, but she did not want that. RD X could not elaborate when ProStat started and was not aware Resident #31 had a pressure ulcer until the first of (MONTH) this year. RD X did not know if the facility provided fortified foods and has been the Registered Dietician since (MONTH) of (YEAR). RD X then reported all their buildings had the same supplements but will ask the facility what supplements they had. RD X was aware that Resident #31 did not like the food but does not make the menus, only helps to sign off on them. RD X reported that Resident #31 complains about the food at the facility every time she visits and only wants food that was specific to her likes. RD X reported she did not attend Resident Council meetings to discuss what residents liked and did felt more could should be for Resident #31. In an interview on 6/20/19 at approximately 12:15, Resident #31 was sitting up in bed eating her lunch. She said she would eat more if she liked the food. She said she preferred to collard greens, cabbage, fried chicken, and black eyed peas. Resident #31 said the facility would give her the same thing every day and did not care for sweets. Resident #31 reported she did not really talk to a dietician about her food choices and remembered she only had fried chicken one time. Resident #31 said she wanted her pressure ulcer to get better and said she thought it was getting better. In an interview on 6/20/19 at 1:31 p.m., DON and RN T were still working on the timeline for Resident #31's pressure ulcer. They reported they did not have wound measurements of Resident #31's wound and reported the only measurements they had were in the Physician Assistants Progress Notes and then hand wrote those measurements on the timeline. RN T reported there were no shower sheets for skin assessment and no Nursing Skin Assessment documentation for Resident #31. When queried about Resident #31's pressure ulcer assessed daily from 1/31/19 when discovered to 2/6/19 when the Physician Assistant assessed it, the DON reported she would try to see what she could find. In an interview on 6/20/19 at 2:41 p.m., CNA V reported they did some charting on the residents such as bowel, bladder, bathing and food intake but did not chart when residents including Resident #31 was repositioned. In an interview on 6/20/19 approximately 3:00 PM CNA W reported Resident #31's daughter will bring in chicken for the resident and she will eat it depending on how she is feeling. CNA W reported Resident #31 mostly hated the shakes given to her but will drink them at times. Review of Nursing Progress Note dated 12/19/18 for Resident #31 revealed: New orders today . refer back to Gastro for Weight loss, nausea and dyspepsia For possible gastroparesis . Review of Dietary Progress Note dated 12/20/18 for Resident #31 revealed: Follow with (Resident #31) r/t (related to) food preferences she will let staff know her likes/dislikes on a daily basis as usual . we discussed her recent weight loss she said, I have been trying to lose weight for a while now. She has been having some stomach upset with recommendations for follow up with physician. Will continue to provide meals as she chooses to follow weight, intake, preferences. Referral to RD at next scheduled visit. (sic) Review of a Dietary Progress note dated 12/24/18 for Resident #31 revealed: RD Consult: Went in and talked to (Resident #31) today about the nausea and vomiting. According to her, it occurred today after lunch. Pinner her down and know that it does not occur because of taking meds on an empty stomach and there seems to be nothing that triggers it from occurring. No specific foods make her vomit either. She does say it's because she is fed canned food all the time. She stated that she brings her own food in for meals and sometimes only finds one food item on the menu that she likes. Encouraged her, next time that she gets sick, after she is finished ask to brush her teeth/mouthwash to help change the taste in her mouth, so she will not continue to get sick. She said she thought that was a good idea and would try it. At this point cannot find any trail that leads up to her vomiting. Will discuss it with her again next month. (RD X's next visit to Resident #31 was on 2/27/19.) Review of a Nursing Progress note dated 12/25/18 for Resident #31 revealed: . Eats meals in her room per her request and has a good appetite. Review of a Nursing Progress Note dated 12/28/18 for Resident #31 revealed: Resident has an appointment with ([MEDICATION NAME]) on 1-23-2019, at 10:45 PM. Review of a Nursing Progress Note dated 1/31/19 for Resident #31 revealed: Fragile skin area to coccyx has opened. New order for treatment cleanse/calcium alginate/sm dressing daily. Order in updated to TAR (treatment assessment record). Dressing this today. Resident also repositioned every 2 hours off of coccyx. No description of wound documented. Review of the (MONTH) 2019 Physician order [REDACTED].#31 revealed: Ordered Diet: 9/6/18-open ended Regular with SUGAR SUBSTITUTE, ordered 12/19/18-open ended Registered Dietician referral, residents likes/dislikes RE: nausea and possible diabetic GI issues, ordered 1/26/19 and discontinued 3/12/19- 2 OZ (ounce) HI-CAL supplement. Special Instructions: AS SHE ALLOWS/TOLERATES (HER CHOICE) Twice a Day, ordered 2/14/19 and discontinued 3/21/19- PROHEAL [MEDICATION NAME] 30 ml twice a day, Ordered 8/31/17-open ended Weekly Skin Assessment, once a day on Wed; Evenings, Ordered 4/1/13 - open ended, Bariatric Cushion when in chair continuous, Ordered 2/28/19 to 3/13/19- Dakin's Solution 0.125%, Special Instructions: Cleans coccyx wound with wound cleanser and Gauze Pack with Dakin's 0.125% moistened gauze, cover with non adhesive Derma Foam, Apply skin prep to periwound surrounding skin and secure dressing with profix tape. Change daily and PRN for disruption. Review of a Physician Assistant Progress Note dated 2/6/19 for Resident #31 revealed: . I have been consulted by (Physician) to evaluate (Resident #31) for a wound to her coccyx. Staff tell me resident has recurrent ulcerations to the coccyx area. They state with this most recent ulceration they were applying cream but it was getting worse, so a few days ago they started applying a dressing. It is noted resident is diabetic. At this time resident is lying in her bed. She states the wound in painful. She states normally she spends quite a bit of time up in her wheelchair, but that this past week she has spent most of her time in bed because the wound is painful when she is up in her wheelchair. She does have a cushion in her wheelchair but states she has had it for quite a while. She admits that her appetite hasn't been very good lately. Physical exam: Skin: Ulcer to the coccyx area measuring 3.5 x 1.8 cm, the wound base is 80% slough and 20% granulation tissue, there is moderate serous drainage with no odor, wound edges are intact ad attached, no [DIAGNOSES REDACTED] or induration to the periwound area. Plan: The wound appears to be a pressure ulcer, given the amount of slough it would be considered unstageable at this time, will have staff cleanse the wound with saline and gauze and cover with a comfort foam bordered dressing, change daily, given her poor appetite will check [MEDICATION NAME], will start resident on vitamin C 500 mg (milligrams) and Zinc 50 mg bid (twice daily) to help promote wound healing, she does have a Roho cushion in her wheelchair, it appears to be in working orders however will have therapy evaluate to be sure it is functioning properly. (sic) Review of a Nursing Progress Note dated 2/13/19 for Resident #31 revealed: New order for PROHEAL 30 ml bid for wound healing. Updated to MAR. Review of a Physician Assistant Progress Note dated 2/13/19 for Resident #31 revealed: (Resident) is seen today to f/u on the pressure ulcer on her coccyx. I have had staff covering the wound with a bordered foam dressing daily. I also ordered a [MEDICATION NAME] last week which I note has come back low at 15.9. At this time resident is lying in her bed. She states the wound is painful at times. She admits she hasn't been eating very well. She states it is because she doesn't care for the food. Physical Exam: Skin: Ulcer to the coccyx area measures 2.6 x 2.2 cm, the wound base is 80% slough and 20% granulation tissue, there is moderate serous drainage with no odor, wound edges are intact and attached, no [DIAGNOSES REDACTED] or induration to the periwound area. Plan: Size of the wound is improved, will continue to have staff cleanse the wound with saline and gauze and cover with an adhesive foam dressing (comfort border foam), change daily, continue Vitamin C and Zinc, will add ProMod (or ProStat) 30 ml bid (twice daily) resident does have a Roho cushion in her wheelchair. (sic) Review of a Physician Assistant Progress Note dated 2/27/19 for Resident #31 revealed: (Resident) is seen today to f/u on the pressure ulcer on her coccyx. I have had staff covering the wound with a bordered foam dressing daily. I had also ordered a [MEDICATION NAME] which came back low at 15.9 so I recommended starting ProStat twice a day. Staff tell me that resident's wound has been looking worse. They state she has been refusing the ProStat as well as the HighCal supplement drink that is ordered for her. They state she complains that they are too sweet. Staff have tried mixing the drinks with other liquids but resident still refuses. At this time resident is lying in her bed. She states the wound is painful at times. She admits she has been refusing the supplements, stating they are too sweet. She admits her appetite still is not very good. Physical Exam: Skin: Ulcer to the coccyx area is noted to have thick slough today, after obtaining consent from the resident I cleansed the site with iodine and debrided nonviable tissue from the wound using a scalpel, I was able to debride down to healthy granulation tissue in some areas with no viable tissue debrided, total area debrided was 6.0 x 4.0 cm, there was approximately 30 cc of blood loss, resident tolerated procedure well. After debridement the wound measures 6.0 x 4.6 cm, there is approximately 1.5 cm of depth though this is not a true depth due to the presence of slough, the wound base is 90% slough and 10% granulation tissue, there is heavy tan drainage, there is a foul odor present, wound edges are intact and attached, no [DIAGNOSES REDACTED] or induration to the periwound area. Plan: Wound is significantly worse this week, wound was debrided today, resident has been refusing her ProStat and HighCal supplement, I spoke with resident about the importance of these supplements, and that without them her wound will continue to worsen as she is not takin in enough nutrients for her body to heal the wound, staff state resident has been spending most of her time in bed because it is painful for her to be up in her wheelchair, she did get a new wheelchair and cushion, will have staff cleanse the wound with saline and gauze, apply skin prep around the wound, pack the wound with Dakin's 0.125% moistened gauze, cover with a nonadhesive foam dressing (DermaFoam) and secure with Profix tape, change daily. (sic) Review of a Dietary Progress Note dated 2/28/19 for Resident #31 revealed: Monthly Weight/Wound Review: (Resident #31) is on a Regular diet with intake that is variable, and who also brings in her own food, at times. Her weight has dropped 20# in a month for this month. She also has a wound on her coccyx. She refuses supplements but will try HiCal 4 oz BID and see if she will accept that. She refuses Mighty Shakes and Magic Cups. This will add 476 kcals and 20 g of protein which will help with the healing. Her estimated needs are 1575-1925 kcal using 35 k cal/kg of adjusted IBW range, protein 36-72 g using 0.8-1.3 g/kg of the same and fluids 1350 1650 mL using 30 mL/kg of the same. She is also on diuretics which will affect her weight. Will monitor her weights/wound and intake. Review of a Dietary Noted dated 3/6/19 for Resident #31 revealed: Visit with Billie this day 3/6/19 Billie again declined increase in Hi-Cal and declined mighty shake supplement with or between meals, I encouraged her to try and eat a little extra protein to help heal her coccyx wound she said she would try. Will continue Hi-Cal 2oz. BID. Review of a Nursing Progress Noted dated 3/11/19 for Resident #31 revealed: Wet to dry dressing done to coccyx area, large wound bed about ¼ has black eschar tissue present 3/4 has pink fleshy tone. Review of a physician progress notes [REDACTED].#31 revealed: Resident had gastric emptying study done which does show gastroparesis (delayed gastric emptying). She has been complaining of nausea and vomiting after eating. She stated she has not had any vomiting for the past week. I discussed with her the options including 6 small meals per day and possibly [MEDICATION NAME] but she says she is feeling okay now and would like to wait. She also is being seen by wound care for the pressure ulcer on her coccyx area. She presently is lying on her side but is frequently and usually on her back. I did not examine the wound today as she will be seen by wound care in 2 days. I am recommending that they cleanse the wound and get a culture from deep tissue to avoid collecting normal flora. Residents weight has been dropping since receiving nutritional supplement (which she frequently refuses), her weight has picked up a few pounds. She is currently at about 170 pounds. I also reviewed her blood sugars and may have been very well controlled. I reviewed her medications she is taking [MEDICATION NAME] 5-3 25 twice daily which may be contributing to gastroparesis. She does need the [MEDICATION NAME] for pain related to her ulcer. (sic) Review of a Nursing Progress Noted dated 3/13/2019 for Resident #31 revealed: New orders from (PA) orders, Cleanse wound with saline and gauze, crush 500 mg [MEDICATION NAME] tab, mix with Hydrogel, moisten gauze with mixture, pack wound with moistened gauze, cover with comfort boarder dressing daily. Also Oral antibiotic [MEDICATION NAME] BID x 10 days. Orders in updated to MAR and TAR. Review of a Physician Assistant Progress note dated 3/13/19 for Resident #31 revealed: (Resident) is seen today to f/u on the pressure ulcer on her coccyx. I have had staff packing the wound with Dakin's moistened gauze and covering with a foam dressing daily. Staff state residents appetite continues to be poor and that she continues to frequently refuse the ProStat as well as the HighCal supplement drink. At this time resident is lying in her bed. She states the wound is painful at times. She admits she has been refusing the supplements. She states she has been having trouble keeping anything down, stating every time she tries to swallow anything, medicine or food, it comes right back up. Physical exam: Skin: Ulcer to the coccyx area measures 3.6 x 4.4, there is a depth of 2.0 cm, thought this is not a true depth due to the presence of slough there is undermining all the way around the wound measuring 3.6 cm at the deepest point, the wound base is 60% slough and 40 granulation tissue, there is a very small piece of bone palpable, there is moderate tan drainage, there is foul odor present, wound edges have some ulcerated areas, they are not attached. Plan: The wound measures smaller this week, but this is related to improvement in the superficial ulcerations around the wound, the wound opening itself appears bigger, there is undermining this week and there is now a small amount of bone palpable, resident continues to refuse her ProMod and nutritional supplements and her intake continues to be poor, will have (Physician) address her nausea, there is still an odor to the wound, will start resident on oral [MEDICATION NAME] 874/125 mg one tab twice a day for 10 days, will discontinue the Dakin's and will have staff cleanse the wound with saline and gauze with the mixture and pack the wound with the moistened gauze, crush a 500 mg [MEDICATION NAME] tablet and mix with hydrogel, moisten gauze, cover with a comfort foam border dressing, change daily, resident does have an APM mattress, encouraged resident to avoid laying on her back, resident's overall condition has been worsening, and if her appetite doesn't improve and she continues to refuse ordered supplements then the prognosis for her wound is very poor. (sic) Review of a Nursing Progress Note dated 3/14/2019 for Resident #31 revealed: Started oral antibiotic therapy today. Also new treatment to coccyx completed. Continues to be confused, took all meds, ate some breakfast and lunch. Position changes as she will tolerate. Review of a Nursing Progress Note dated 3/19/19 for Resident #31 revealed: Denied pain or discomfort with FLACC 0/10. Repositioned every 2 hours. Coccyx dressing dry and intact. Continues on antibiotics with no adverse effects and remains afebrile with temp. of 97.2 PO. Review of a Nursing Progress Note dated 3/22/19 for Resident #31 revealed: New PRN order from Dr Smalley today for [MEDICATION NAME] 4 mg to be taken up to BID for nausea. Order in and updated to MAR. Dressing done today, per order. Wound has minimal slough noted, mainly beefy red tissue. Review of a Nursing Progress Note dated 3/23/2019 for Resident #31 revealed: Denied pain or discomfort with FLACC 0/10. Repositioned every 2 hours. Coccyx dressing done today per order. Continues on antibiotics with no adverse effects and remains afebrile. Took pain medications today as ordered. Review of the (MONTH) 2019 Physician order [REDACTED].#31 revealed: Ordered Diet: 9/6/18-open ended Regular with SUGAR SUBSTITUTE, ordered 12/19/18-open ended Registered Dietician referral, residents likes/dislikes RE: nausea and possible diabetic GI issues, Ordered 3/22/19 and discontinued 5/6/19- [MEDICATION NAME] 4 mg (milligrams) 1 tablet twice a day as needed, Ordered 3/27/19 and discontinued 4/17/19- [MEDICATION NAME] ([MEDICATION NAME]) (an antifungal) 500 mg tablet; special instructions: Crush 500 mg [MEDICATION NAME] tab, mix with Hydrogel, moisten gauze with mixture, pack wound/ulcer, cover with Dermafoam, secure with profix tape OR use 6x6 Comfort border dressing once a day. No orders noted on report for [MEDICATION NAME] as per the PA Progress note on 3/13/19. Review of the Physician Assistant Progress Note dated 3/20/19 for Resident #31 revealed: . I have staff packing the wound with gauze moistened with a mixture of hydrogel and crushed [MEDICATION NAME] tablet and covering with a foam dressing daily. I also started resident on [MEDICATION NAME] last week for infection of the wound. Staff state resident's appetite continues to be poor and that the continues to frequently refuse the ProStat as well as the HighCal supplement drink. At this time resident tis lying in her bed. She states the wound is painful at times. She admits that she continues to refuse the supplements, complaining of nausea and vomiting. Physical exam: Skin: Ulcer to the coccyx area measures 4.1 x 5.3 cm, there is a depth of 1.6 cm, though this is not a true depth due to the presence of slough, there is undermining all the way around the wound measuring 5.4 cm at the deepest point at 11:00, the wound base is 20% slough and 80% granulation tissue, there are two very small pieces of pone palpable, there is moderate serous drainage, there is no odor today, wound edges are intact but not attached. Plan: Infection of the coccyx ulcer has improved, there is no odor today, the wound opening is bigger and there is increased undermining, although the wound base has improved with notably less slough today, resident continues to have a poor appetite and refuse her supple (TRUNCATED)

Based on observation, interview and record review, the facility failed to prevent and implement measures to accommodate nutrition needs for 1 resident (Resident #31), of 12 residents reviewed, resulting in significant weight loss and prolonged wound healing. Findings include: Review of a Face Sheet for Resident #31 revealed an [AGE] year old female originally admitted on [DATE]. Pertinent [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #31 revealed a Brief Interview for Mental Status indicated she was cognitively intact, totally dependent on 2 staff for transfers, always incontinent of bowel and bladder, at risk for pressure ulcers, and no current pressure ulcers. Section K 0300 Weight Loss, Loss of 5% or more in the last month or 10% or more in the last 6 months was marked yes, and not on a physician prescribed weight loss regimen. Resident weighed 208 pounds. Review of the Annual Minimum Data Set ((MDS) dated [DATE] for Resident #31 revealed a Brief Interview for Mental Status indicated she was cognitively intact, totally dependent on 2 staff for transfers, always incontinent of bowel and bladder, and one Stage 4 Pressure Ulcer. Section K 0300 Weight Loss, Loss of 5% or more in the last month or 10% or more in the last 6 months was marked yes, and not on a physician prescribed weight loss regimen. Resident weighed 183 pounds. Review of the Annual Minimum Data Set ((MDS) dated [DATE] for Resident #31 revealed a Brief Interview for Mental Status indicated she was cognitively intact, totally dependent on 2 staff for transfers, always incontinent of bowel and bladder, and one Stage 4 Pressure Ulcer. Section K 0300 Weight Loss, Loss of 5% or more in the last month or 10% or more in the last 6 months was marked yes, and not on a physician prescribed weight loss regimen. Resident weighed 183 pounds. Review of weights for Resident #31 are as follows: 10/2018 weight 208 pounds, 1/1/2019 183.2 pounds, 2/5/19 163.7 pounds, 2/20/19 171.4 pounds, 5/6/19 167.8 pounds, 6/12/19 149.6 pounds. From 10/2018 to 1/1/19, Resident #31 had an 11.92% weight loss. From 1/1/19 to 6/12/19, Resident #31 had a 18.34% weight loss. During and observation on 6/18/19 at 10:12 a.m., Resident #31 observed laying on her back and reported she had some sores but did not want to talk at this time because she was uncomfortable in her current position. Resident tried to use the call light that clipped to the bed on the left side of her head at eye level and could not reach it. Resident placed her right hand over her forehead moaning in pain. Certified Nursing Assistant (CNA) V entered the room to check the residents brief and reposition her. CNA V left to get supplies and Resident #31 cried in pain. CNA V re-entered room and turned Resident #31 to her right side, dressing on coccyx observed dry and intact dated 6/17/19. Resident #31 reported she felt better on her right side. A pillow was noted on Resident #31's right side and was flat. CNA V place pillows under the resident's arms and heals. Resident pain subsided after care. During an observation and an interview on 6/18/19 at 10:22 a.m., Resident #31 moaned in pain while in bed and reported she was in pain while whimpering. Certified Nursing Assistant then entered the room. During an observation on 6/18/19 at 11:00 a.m., Resident #31 moaned out load and heard in the hallway and in next room where this surveyor was with the door closed. During an observation and interview on 6/20/19 at approximately 12:15, Resident #31 was sitting up in bed eating her lunch. She said she would eat more if she liked the food. She said she preferred to collard greens, cabbage, fried chicken, and black eyed peas. Resident #31 said the facility would give her the same thing every day and did not care for sweets. Resident #31 reported she did not really talk to a dietician about her food choices and remembered she only had fried chicken one time. Resident #31 said she wanted her pressure ulcer to get better and said she thought it was getting better. In an interview on 6/20/19 at 12:50 p.m., Registered Dietician (RD) X reported she charted on Resident #31 once a month for weight issues but that did not mean she saw the resident once a month. RD X reported she visited Resident #31 on 2/27/19 and 5/30/19. RD X reported Resident #31 came up for pressure sores and weight loss. RD X She reported she was still working on this month's charting and last month on 5/31/19 she requested to change Resident #31 from ProStat to Proheal supplement and a multivitamin. In (MONTH) and (MONTH) of 2019 RD X reported there were no written changes. On 2/28/19, RD X reported Resident #31 was on a regular diet and her intake was variable and liked to bring in her own food so sometimes it looks like she is not eating. RD X reported she was a very picky eater and did not exactly like healthy foods. RD X reported she did not see the resident in (MONTH) but did see her on 12/24/18 which was Christmas Eve and Resident #31 had complaints of nausea and vomiting that day. RD X reported she just remembered she was sick that day and it had been an ongoing situation. RD X reported Resident #31 refused mighty shakes and magic cups back in (MONTH) and recommended HighCal supplement in early May, but she did not want that. RD X could not elaborate when ProStat started and was not aware Resident #31 had a pressure ulcer until the first of (MONTH) this year. RD X did not know if the facility provided fortified foods and has been the Registered Dietician since (MONTH) of (YEAR). RD X then reported all their buildings had the same supplements but will ask the facility what supplements they had. RD X was aware that Resident #31 did not like the food but does not make the menus, only helps to sign off on them. RD X reported that Resident #31 complains about the food at the facility every time she visits and only wants food that was specific to her likes. RD X reported she did not attend Resident Council meetings to discuss what residents liked and did felt more could should be for Resident #31. In an interview on 6/20/19 approximately 3:00 PM CNA W reported Resident #31's daughter will bring in chicken for the resident and she will eat it depending on how she is feeling. CNA W reported Resident #31 mostly hated the shakes given to her but will drink them at times. Review of a Physician Assistant Progress Note dated 12/12/18 for Resident #31 revealed: . She states her appetite and compliance is variable. She is currently eating peanut butter and crackers . Review of a Physician Assistant Progress Note dated 12/19/18 for Resident #31 revealed: Patient seen today in follow-up at her request. She reports ongoing intermittent nausea and vomiting. She recently had a colonoscopy which was reported as unremarkable. She has had continued weight loss. Plan: Follow up with GI ([MEDICATION NAME]). Review of Nursing Progress Note dated 12/19/18 for Resident #31 revealed: New orders today . refer back to Gastro for Weight loss, nausea and dyspepsia For possible gastroparesis. No new orders or interventions noted to assist Resident #31 with nausea and appetite. Review of Dietary Progress Note dated 12/20/18 for Resident #31 revealed: Follow with (Resident #31) r/t (related to) food preferences she will let staff know her likes/dislikes on a daily basis as usual . we discussed her recent weight loss she said, I have been trying to lose weight for a while now. She has been having some stomach upset with recommendations for follow up with physician. Will continue to provide meals as she chooses to follow weight, intake, preferences. Referral to RD at next scheduled visit. (sic) Review of a Dietary Progress note dated 12/24/18 for Resident #31 revealed: RD Consult: Went in and talked to (Resident #31) today about the nausea and vomiting. According to her, it occurred today after lunch. Pinner her down and know that it does not occur because of taking meds on an empty stomach and there seems to be nothing that triggers it from occurring. No specific foods make her vomit either. She does say it's because she is fed canned food all the time. She stated that she brings her own food in for meals and sometimes only finds one food item on the menu that she likes. Encouraged her, next time that she gets sick, after she is finished ask to brush her teeth/mouthwash to help change the taste in her mouth, so she will not continue to get sick. She said she thought that was a good idea and would try it. At this point cannot find any trail that leads up to her vomiting. Will discuss it with her again next month. (RD X's next visit to Resident #31 was on 2/27/19.) Review of a Nursing Progress note dated 12/25/18 for Resident #31 revealed: . Eats meals in her room per her request and has a good appetite. Review of a Nursing Progress Note dated 12/28/18 for Resident #31 revealed: Resident has an appointment with ([MEDICATION NAME]) on 1-23-2019, at 10:45 PM. Review of a physician progress notes [REDACTED].#31 revealed: . She has been seen by [MEDICATION NAME]. We have done x-rays in the past that do no show any acute process. She wanted to see me again today about the same complaints. Initially she seemed a little gruff but became very cheerful and happy after I showed her that I was paying attention to her concerns and complaints. Summary of Plans: I am concerned about her weight loss. She does have diabetes but her blood sugars have been well controlled . Review of a physician progress notes [REDACTED].#31 revealed: . She is eating and drinking well and has no nausea or vomiting although she does say that she has diarrhea every once in a while for the past 2 months. No changes recommended at this time . Review of a Nursing Progress Note dated 1/31/19 for Resident #31 revealed: Fragile skin area to coccyx has opened. New order for treatment cleanse/calcium alginate/sm dressing daily. Order in updated to TAR (treatment assessment record). Dressing this today. Resident also repositioned every 2 hours off of coccyx. Review of the (MONTH) 2019 Physician order [REDACTED].#31 revealed: Ordered Diet: 9/6/18-open ended Regular with SUGAR SUBSTITUTE, ordered 12/19/18-open ended Registered Dietician referral, residents likes/dislikes RE: nausea and possible diabetic GI issues, ordered 1/26/19 and discontinued 3/12/19- 2 OZ (ounce) HI-CAL supplement. Special Instructions: AS SHE ALLOWS/TOLERATES (HER CHOICE) Twice a Day, ordered 2/14/19 and discontinued 3/21/19- PROHEAL [MEDICATION NAME] 30 ml twice a day, Ordered 8/31/17-open ended Review of a Physician Assistant Progress Note dated 2/6/19 for Resident #31 revealed: . I have been consulted by (Physician) to evaluate (Resident #31) for a wound to her coccyx. Staff tell me resident has recurrent ulcerations to the coccyx area. They state with this most recent ulceration they were applying cream, but it was getting worse, so a few days ago they started applying a dressing. It is noted resident is diabetic. At this time resident is lying in her bed. She states the wound in painful. She states normally she spends quite a bit of time up in her wheelchair, but that this past week she has spent most of her time in bed because the wound is painful when she is up in her wheelchair. She does have a cushion in her wheelchair but states she has had it for quite a while. She admits that her appetite hasn't been very good lately. Physical exam: Skin: Ulcer to the coccyx area measuring 3.5 x 1.8 cm, the wound base is 80% slough and 20% granulation tissue, there is moderate serous drainage with no odor, wound edges are intact ad attached, no [DIAGNOSES REDACTED] or induration to the periwound area. Plan: The wound appears to be a pressure ulcer, given the amount of slough it would be considered unstageable at this time, will have staff cleanse the wound with saline and gauze and cover with a comfort foam bordered dressing, change daily, given her poor appetite will check [MEDICATION NAME], will start resident on vitamin C 500 mg (milligrams) and Zinc 50 mg bid (twice daily) to help promote wound healing, she does have a Roho cushion in her wheelchair, it appears to be in working orders however will have therapy evaluate to be sure it is functioning properly. (sic) Review of a Physician Assistant Progress Note dated 2/13/19 for Resident #31 revealed: (Resident) is seen today to f/u on the pressure ulcer on her coccyx. I have had staff covering the wound with a bordered foam dressing daily. I also ordered a [MEDICATION NAME] last week which I note has come back low at 15.9. At this time resident is lying in her bed. She states the wound is painful at times. She admits she hasn't been eating very well. She states it is because she doesn't care for the food. Physical Exam: Skin: Ulcer to the coccyx area measures 2.6 x 2.2 cm, the wound base is 80% slough and 20% granulation tissue, there is moderate serous drainage with no odor, wound edges are intact and attached, no [DIAGNOSES REDACTED] or induration to the periwound area. Plan: Size of the wound is improved, will continue to have staff cleanse the wound with saline and gauze and cover with an adhesive foam dressing (comfort border foam), change daily, continue Vitamin C and Zinc, will add ProMod (or ProStat) 30 ml bid (twice daily) resident does have a Roho cushion in her wheelchair. (sic) Review of a Dietary Progress Note dated 2/27/19 for Resident #31 revealed: Resident weight obtained 2/20/19 171.4# (pounds) compares to initial weight 2/5/19 163.7# (Resident #31) remains significant weight loss x 1,3,6 mos. -6.4% X1 mo., she is accepting Hi-Cal 2oz. BID sometimes she did decline increase in Hi-Cal or other supplement, recommend weekly weight monitoring, (Resident #31) did say she has not had vomiting recently and does not know why she is losing weight. Will continue to follow weight, intake, preferences. Review of the Daily Food Acceptance Record for Resident #31 revealed: (MONTH) (YEAR): 12/29/18 to 12/31/18 there was no documentation for food intake for breakfast and lunch. Most days, Resident ate more than 40% of all meals that were documented and as much as 80%, including a 100% of a bedtime snack. No supplements charted. January 2019: 1/1/19 to 1/30/19, Resident #31 ate all meals and documented intake was greater than 40% and as high as 80%, including a 100% of a bedtime snack. February 2019: 2/19/19 to 2/25/19 and for breakfast and lunch there is no documentation for intake. On 2/27/19 dinner there is no documentation and 2/28/19 for all meals there is no documentation of intake. Other days documented revealed Resident #31 had a food intake greater than 40% on most days and as high as 100%, including a 100% of a bedtime snack. March 2019: 3/27/19 had no dinner intake documented and 3/28/19 to 3/31/19 no food intake documented for all meals. 3/1/19 to 3/27/19 meals that were documented indicated Resident #31 had a food intake greater that 30% most days and as high as 75%. April 2019: 4/1/19 to 4/14/19 Resident #31 at 40% or more most days and as high as 80%. Bedtime snack intake was 50% or more. 4/21/19 to 5/6/19 Resident went to the hospital. May 2019: Resident #31 returned from the hospital on [DATE]. No documentation of food intake charted for 5/7/19 to 5/11/19 and 5/13/19 to 5/15/19. 5/16 Resident #31 refused breakfast and lunch but ate 60% of dinner. 5/17/19 to 5/21/19 breakfast and lunch intake was not charted, and dinner acceptance was 40 to 60%. 5/22/19 to 5/31/19 had no food intake documented. No bedtime snacks documented. June 2019: 6/1/19 to 6/11/19 breakfast and lunch intake not documented, and dinner documented at 30% to 50% intake. 6/12/19 and 6/13/19 had intake documented. 6/14/19 to 6/17/19 (the beginning of this survey) there was no food intake documented. Review of a policy titled Nutrition Plan for Weight Loss dated 1/2008 revealed: Nutritional Plan for Weight Loss: Always try food first. If a resident consumes a particular meal well (i.e. Breakfast), then provide double portions of the entrée. Increase milk to 8 ounces, increase gravies, margarines, ect. Provide a high calorie/high protein snack between meals. Food enhancement: Some resident's may benefit from protein powder being added to their beverage and/or food. (Puree diets already include some enhancement through puree product) Supplements should be the last step. If the above interventions have failed, the High Pro/High Cal shakes may be required. This included homemade milkshakes, ready to serve shakes, and Med Pass supplements recommended at QD (every day), BID (twice daily), TID (three times a day) or QID (four times a day) if needed. Oral medications such as [MEDICATION NAME] may benefit the resident. (NOTE: All interventions must be monitored through meal observation, specific snack times and intake of meal and supplement percentage. The DTR (doctor)/RD (registered dietician) should be notified if resident is refusing any or all interventions. The DTR/RD will then reassess the resident. If all interventions have been unsuccessfully tried, then discussion of alternative nutritional support will be discussed with the IDT, physician, resident, family and/or responsible party. Review of the (MONTH) 2019 Physician order [REDACTED].#31 revealed: Ordered Diet: 9/6/18-open ended Regular with SUGAR SUBSTITUTE, ordered 12/19/18-open ended Registered Dietician referral, residents likes/dislikes RE: nausea and possible diabetic GI issues, ordered 1/26/19 and discontinued 3/12/19- 2 OZ (ounce) HI-CAL supplement. Special Instructions: AS SHE ALLOWS/TOLERATES (HER CHOICE) Twice a Day, ordered 2/14/19 and discontinued 3/21/19- PROHEAL [MEDICATION NAME] 30 ml twice a day . Review of a Physician Assistant Progress Note dated 2/6/19 for Resident #31 revealed: . I have been consulted by (Physician) to evaluate (Resident #31) for a wound to her coccyx. Staff tell me resident has recurrent ulcerations to the coccyx area. They state with this most recent ulceration they were applying cream but it was getting worse, so a few days ago they started applying a dressing. It is noted resident is diabetic. She admits that her appetite hasn't been very good lately. Physical exam: Skin: Ulcer to the coccyx area measuring 3.5 x 1.8 cm, the wound base is 80% slough and 20% granulation tissue, there is moderate serous drainage with no odor, . given her poor appetite will check [MEDICATION NAME], will start resident on vitamin C 500 mg (milligrams) and Zinc 50 mg bid (twice daily) to help promote wound healing, . (sic) Review of a Physician Assistant Progress Note dated 2/13/19 for Resident #31 revealed: (Resident) is seen today to f/u on the pressure ulcer on her coccyx. I also ordered a [MEDICATION NAME] last week which I note has come back low at 15.9. She admits she hasn't been eating very well. She states it is because she doesn't care for the food. Physical Exam: Skin: Ulcer to the coccyx area measures 2.6 x 2.2 cm, the wound base is 80% slough and 20% granulation tissue, there is moderate serous drainage with no odor, wound edges are intact and attached, no [DIAGNOSES REDACTED] or induration to the periwound area. Plan: Size of the wound is improved, . continue Vitamin C and Zinc, will add ProMod (or ProStat) 30 ml bid (twice daily) resident does have a Roho cushion in her wheelchair. (sic) Review of a Nursing Progress Note dated 2/13/19 for Resident #31 revealed: New order for PROHEAL 30 ml bid for wound healing. Updated to MAR. Review of a Physician Assistant Progress Note dated 2/27/19 for Resident #31 revealed: (Resident) is seen today to f/u on the pressure ulcer on her coccyx. I had also ordered a [MEDICATION NAME] which came back low at 15.9 so I recommended starting ProStat twice a day. Staff tell me that resident's wound has been looking worse. They state she has been refusing the ProStat as well as the HighCal supplement drink that is ordered for her. They state she complains that they are too sweet. Staff have tried mixing the drinks with other liquids but resident still refuses. She admits she has been refusing the supplements, stating they are too sweet. She admits her appetite still is not very good. Physical Exam: Skin: Ulcer to the coccyx area is noted to have thick slough today, after obtaining consent from the resident I cleansed the site with iodine and debrided nonviable tissue from the wound using a scalpel, I was able to debride down to healthy granulation tissue in some areas with no viable tissue debrided, total area debrided was 6.0 x 4.0 cm, there was approximately 30 cc of blood loss, resident tolerated procedure well. After debridement the wound measures 6.0 x 4.6 cm, there is approximately 1.5 cm of depth though this is not a true depth due to the presence of slough, the wound base is 90% slough and 10% granulation tissue, there is heavy tan drainage, there is a foul odor present, wound edges are intact and attached, no [DIAGNOSES REDACTED] or induration to the periwound area. Plan: Wound is significantly worse this week, wound was debrided today, resident has been refusing her ProStat and HighCal supplement, I spoke with resident about the importance of these supplements, and that without them her wound will continue to worsen as she is not taking in enough nutrients for her body to heal the wound, staff state resident has been spending most of her time in bed because it is painful for her to be up in her wheelchair, she did get a new wheelchair and cushion, . (sic) Review of a Dietary Progress Note dated 2/28/19 for Resident #31 revealed: Monthly Weight/Wound Review: (Resident #31) is on a Regular diet with intake that is variable, and who also brings in her own food, at times. Her weight has dropped 20# in a month for this month. She also has a wound on her coccyx. She refuses supplements but will try HiCal 4 oz BID and see if she will accept that. She refuses Mighty Shakes and Magic Cups. This will add 476 kcals and 20 g of protein which will help with the healing. Her estimated needs are 1575-1925 kcal using 35 k cal/kg of adjusted IBW range, protein 36-72 g using 0.8-1.3 g/kg of the same and fluids 1350 1650 mL using 30 mL/kg of the same. She is also on diuretics which will affect her weight. Will monitor her weights/wound and intake. Review of the (MONTH) 2019 Physician order [REDACTED].#31 revealed: Ordered Diet: 9/6/18-open ended Regular with SUGAR SUBSTITUTE, ordered 12/19/18-open ended Registered Dietician referral, residents likes/dislikes RE: nausea and possible diabetic GI issues, Ordered 3/22/19 and discontinued 5/6/19- [MEDICATION NAME] 4 mg (milligrams) 1 tablet twice a day as needed . (The following orders were on the (MONTH) 2019 Physician order [REDACTED]. Special Instructions: AS SHE ALLOWS/TOLERATES (HER CHOICE) Twice a Day, ordered 2/14/19 and discontinued 3/21/19- PROHEAL [MEDICATION NAME] 30 ml twice a day .) Review of a physician progress notes [REDACTED].#31 revealed: Resident had gastric emptying study done which does show gastroparesis (delayed gastric emptying). She has been complaining of nausea and vomiting after eating. She stated she has not had any vomiting for the past week. I discussed with her the options including 6 small meals per day and possibly [MEDICATION NAME] but she says she is feeling okay now and would like to wait. She also is being seen by wound care for the pressure ulcer on her coccyx area. Residents weight has been dropping since receiving nutritional supplement (which she frequently refuses), her weight has picked up a few pounds. She is currently at about 170 pounds. I also reviewed her blood sugars and may have been very well controlled. I reviewed her medications she is taking [MEDICATION NAME] 5-3 25 twice daily which may be contributing to gastroparesis. She does need the [MEDICATION NAME] for pain related to her ulcer. (sic) Review of a Physician Assistant Progress note dated 3/13/19 for Resident #31 revealed: (Resident) is seen today to f/u on the pressure ulcer on her coccyx. Staff state residents appetite continues to be poor and that she continues to frequently refuse the ProStat as well as the HighCal supplement drink. She admits she has been refusing the supplements. She states she has been having trouble keeping anything down, stating every time she tries to swallow anything, medicine or food, it comes right back up. Physical exam: Skin: Ulcer to the coccyx area measures 3.6 x 4.4, there is a depth of 2.0 cm, thought this is not a true depth due to the presence of slough there is undermining all the way around the wound measuring 3.6 cm at the deepest point, the wound base is 60% slough and 40 granulation tissue, there is a very small piece of bone palpable, there is moderate tan drainage, there is foul odor present, wound edges have some ulcerated areas, they are not attached. Plan: The wound measures smaller this week, but this is related to improvement in the superficial ulcerations around the wound, the wound opening itself appears bigger, there is undermining this week and there is now a small amount of bone palpable, resident continues to refuse her ProMod and nutritional supplements and her intake continues to be poor, will have (Physician) address her nausea, . resident's overall condition has been worsening, and if her appetite doesn't improve and she continues to refuse ordered supplements then the prognosis for her wound is very poor. (sic) Review of a Nursing Progress Note dated 3/14/2019 for Resident #31 revealed: Started oral antibiotic therapy today. Also new treatment to coccyx completed. Continues to be confused, took all meds, ate some breakfast and lunch. Position changes as she will tolerate. Review of the Physician Assistant Progress Note dated 3/20/19 for Resident #31 revealed: .Staff state resident's appetite continues to be poor and that she continues to frequently refuse the ProStat as well as the HighCal supplement drink. She admits that she continues to refuse the supplements, complaining of nausea and vomiting. Physical exam: Skin: Ulcer to the coccyx area measures 4.1 x 5.3 cm, there is a depth of 1.6 cm, though this is not a true depth due to the presence of slough, there is undermining all the way around the wound measuring 5.4 cm at the deepest point at 11:00, the wound base is 20% slough and 80% granulation tissue, there are two very small pieces of pone palpable, there is moderate serous drainage, there is no odor today, wound edges are intact but not attached. Plan: Infection of the coccyx ulcer has improved, there is no odor today, the wound opening is bigger and there is increased undermining, although the wound base has improved with notably less slough today, resident continues to have a poor appetite and refuse her supplements therefore prognosis of the wound remains poor . has 3 more days left of her [MEDICATION NAME] . (sic) Review of a Nursing Progress Note dated 3/22/19 for Resident #31 revealed: New PRN order from Dr Smalley today for [MEDICATION NAME] 4 mg to be taken up to BID for nausea. Order in and updated to MAR. Dressing done today, per order. Wound has minimal slough noted, mainly beefy red tissue. Review of a Physician Assistant Progress Note dated 3/27/19 for Resident #31 revealed: . I have staff packing the wound with gauze moistened with a mixture of hydrogel and crushed [MEDICATION NAME] tablet and covering with a foam dressing daily. Staff state residents appetite continues to be poor and that she continues to frequently refuse the ProStat as well as the HighCal supplement drink . She admits that she continues to refuse the supplements, stating they are too sweet. Physical Exam: Skin: Ulcer to the coccyx area measures 3.7 x 5.5 cm, there is a depth of 1.5 cm, though this is not a true depth due to the presence of slough, there is undermining all the way around the wound measuring 4.2 cm at the deepest point at 11:00, the wound base is 20% slough, 10% bone, and 70 % granulation tissue, there is moderate serosanguinous drainage, there is no odor today, wound edges are intact but not attached. Plan: I explained to her that if she continues to have poor intake and refuses the supplements then I do not anticipate that the wound will heal. (sic) Review of the (MONTH) 2019 Physician order [REDACTED].#31 revealed: Ordered Diet: 9/6/18-open ended Regular with SUGAR SUBSTITUTE, ordered 12/19/18-open ended Registered Dietician referral, residents likes/dislikes RE: nausea and possible diabetic GI issues, Ordered 3/22/19 and discontinued 5/6/19- [MEDICATION NAME] 4 mg (milligrams) 1 tablet twice a day as needed, Ordered 3/27/19 and discontinued 4/17/19- [MEDICATION NAME] ([MEDICATION NAME]) (an antifungal) 500 mg tablet; special instructions: Crush 500 mg [MEDICATION NAME] tab, mix with Hydrogel, moisten gauze with mixture, pack wound/ulcer, cover with Dermafoam, secure with profix tape OR use 6x6 Comfort border dressing once a day. No supplements or change in diet. Review of a Physician Assistant Progress Note dated 4/3/19 for Resident #31 revealed: . I have staff packing the wound with gauze moistened with a mixture of hydrogel and crushed [MEDICATION NAME] tablet . continues to refuse ProStat and HighCal supplement drink. Physical Exam: Skin: Ulcer to the coccyx area measures 3.4 x 4.5 cm x 2.0 cm, there is undermining from 3:00 to 9:00 measuring 6.0 cm at the deepest point at 11:00, the wound base is 20% slough and 80% granulation tissue, there was no bone palpable today, there is heavy serosanguinous drainage . Plan: The size of the wound opening is decreased today and there is no bone palpable, however the undermining has increased . resident asked again if I felt the wound was going to get better, I explained to her again that if she continues to have poor intake and refuses the supplements then I do not anticipate that the wound will heal. Review of a physician progress notes [REDACTED].#31 revealed: Chief Complaint/Nature of Presenting Problem: Depression, med review list. She has been refusing her nutrition supplements. She is not getting out of bed nearly as much and staff is reporting that she seems to be depressed. She told me she just did not feel like eating very much. She does have stage IV sacral pressure ulcer that is being treated by wound care team. Summary of Plans: Fall Risk Assessment: Resident has had significant weight loss. She has decreased appetite, withdrawing from activity. Blood sugars are well controlled. She is on [MEDICATION NAME] 1000 mg twice daily. Due to decreased appetite and weight loss will reduce [MEDICATION NAME] to 500 mg twice daily. We will also increase her [MEDICATION NAME] to 100 mg daily. Wound care is ongoing. Physical Exam: Skin: Wound care team progress note noted. Summary of Plans: Resident has had significant weight loss. She has decreased appetite, withdrawing from activity. Blood sugars are well controlled. Due to decreased appetite and weight loss will reduce [MEDICATION NAME] . Wound care is ongoing. Review of a Physician Assistant Progress Note dated 4/10/19 for Resident #31 revealed: Staff state resident's appetite continues to be poor and that she continues to refuse the ProStat as well as the HighCal supplement drink . She states the wound hasn't been painful. Physical exam: Skin: Ulcer to coccyx are measures 3.7 x 4.3 cm x 2.2 cm, there is undermining from 8:00 to 3:00 measuring 5.4 cm at the deepest point at 11:00, the wound base is 10% slough and 90 % granulation tissue, there is heavy serosanguinous drainage with no odor, wound edges are intact with some [DIAGNOSES REDACTED]tous with no induration or increase in warmth. Plan: The undermining has decrease today, overall wound appears stable . Review of a Physician Assistant Progress Note dated 4/17/19 for Resident #31 revealed: . Staff state resident's appetite continues to be poor and that she continue (TRUNCATED)

Based on observation, interview and record review, the facility failed to prevent abuse and neglect of a resident for one resident (# 1) of four residents reviewed for abuse and neglect, resulting in a resident being abused and neglected. Findings include: Review of a facility Resident Face Sheet reflected, Resident #1 was a [AGE] year old woman admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #1 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14/15 and needed extensive assistance from one person for bed mobility and transfers, dressing, toilet use and limited assistance from one person for personal hygiene. During an interview on 7/26/18 at 9:51 AM, Resident #1 reported that two or three weeks ago she sat on the commode in her room after therapy in the morning until 11:00 p.m. that evening. Resident #3 said she called her husband because she was able to reach her cell phone but could not reach her call light. Resident #1 said her husband called the front desk and someone came to her room at that point and assisted her to bed. Resident #1 went on to explain that a Certified Nurse Aide (CNA) had accused her of lying, telling her that she had not been in bed and not on the commode all day, and stated I was brought up a Christian and if nothing else, I do not lie. It's the one thing that really hurts, I would have really loved an apology but I never got it. She (the CNA) came back and we blended back together again. Resident #1 said she may have told another staff person about it but that neither the Nursing Home Administrator NHA A nor the Director of Nursing (DON) B ever spoke to her about it. During a telephone interview on 7/26/18 at 10:31 AM, Resident #1's husband (Family Member-FM) EE reported that he had come to see his wife 7/21/18 at 1:50 in the afternoon. When he arrived to visit with Resident #1, she was on the bedside commode and ready to be assisted back to bed. FM EE reported he encouraged Resident #1 to use the call light which was answered in 10 minutes, however, that CNA (unnamed) said additional help was required, turned off the call light and promised to return. According to FM EE, help did not return, and after nearly an hour of sitting on the commode at approximately 3:00 PM, FM EE had to go to the nurses desk to get some attention for his wife. When asked, FM EE did recall an incident when his wife (Resident #1) called him late in the evening because she was unable to get staff to assist her back to bed. FM EE said he did call the nurse's station at his wife's request to get facility staff's attention. FM EE said he wondered if his wife was blending the two incidents together. On 7/26/18 at 11:32 AM, the incidents were reported to NHA A who denied any knowledge of the allegations made by Resident #1 or FM EE. NHA A said she would report the alleged neglect to the state agency and start an investigation. Review of an investigation statement dated 7/26/18, revealed FM EE told NHA A that on 7/11/18 (consistent with Resident #1's belief, an incident occurred two to three weeks prior to 7/26/18) he came to visit his wife at approximately 5:00 PM, leaving about an hour later. FM EE said when he left on the evening of 7/11/18, his wife was on the bedside commode. FM EE said he got a telephone call from Resident #1 at approximately 8:30 PM because she was still on the commode. FM EE said that he then called the facility directly to get staff to assist his wife back to bed, which they did. Review of an undated investigation statement provided to the facility by Registered Nurse (RN) FF reflected that, on 7/11/18 she responded to Resident #1's call light and found her to be in need of assistance back to bed. RN FF admitted in the statement she turned off the call light and promised to return with assistance for Resident #1 but forgot. RN FF believed she responded to Resident #1's call light prior to dinner on 7/11/18 (consistent with FM EE's account of the incident). Review of an investigation statement dated 7/27/18 revealed that CNA HH validated there had been an incident when FM EE called the facility after dinner one evening and CNA HH responded to his request for assistance for Resident #1. CNA HH recalled telling Resident #1 she had not been sitting on the commode, but in her wheelchair all day. Review of an investigation statement, dated 7/26/18, reflected that DON B and RN TT stood in Resident #1's doorway to validate RN TT as the person who did not return to assist Resident back to bed on 7/11/18 and told her she had been in bed the whole time. Resident #1 confirmed RN TT was the staff person in question. The investigation document reflected RN TT was then suspended pending the outcome of the investigation.

Based on observation, interview and record review, the facility failed to provide assistance/supervision to prevent falls, for two Residents (#5 and #28), of two Residents reviewed for falls, resulting in Resident #5 falling multiple times, sustaining lacerations and a fractures and Resident #28 not having interventions in place immediately after falls. Findings include: Resident #5 Review of Resident #5's face sheet (no date) revealed she was an [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #5 was not her own responsible party. Review of Resident #5's admission Minimum Data Set (MDS), nursing assessment tool, dated 4-8-18 documented her Brief Interview of Mental Status (BIMS) score was 5/15 (serve cognitive impairment). The assessment documented Resident #5 required extensive assistance of one person for transfers and walking in her room. The quarterly MDS dated [DATE] documented her BIMS declined to 4/15 and she remained extensive assistance of one person for transfers and walking in her room. On 7/23/18 at 10:17 AM, Resident #5 was observed in bed sleeping. Resident #5's bed was in a low position with a mat on the floor next to the left side, and the bed up against the wall. Prior to meeting with the Director of Nursing (DON) B on 7/30/18 at 10:29 AM, this surveyor requested all of Resident #5's incident/accident reports, fall investigations, fall care plans and progress notes since admission. DON B provided page 3, 4, 5, 10, 11, 14,15, 21, 22 and 23 of Resident #5's 24 page care plan, The care plan did not include a fall care plan but did document on the pain care plan that, on 5/21/18, Resident #5 had a fall with a fracture. On 7/30/18 at 10:29 AM, all documentation provided related to Resident #5's four documented falls was reviewed with DON B. Documentation revealed Resident #5 had two falls on 5/20/18, one at 12:00 PM and one at 11:00 PM. There were also reports for falls on 7/8/18 at 5:30 PM and 7/18/18 at 7:23 PM. Review of the Event Report for Resident #5 dated 5/20/18 at 12:00 PM and signed by DON B, revealed there was a fall in Resident #5's room. Resident #5's mat was at the bedside. Resident #5 had a laceration to her posterior scalp and no other unusual findings. At the bottom of page 5 of the Event Report documented Evaluation under immediate interventions were reviewed for effectiveness and need for additional interventions were reviewed was marked with a check and yes (no indication of what these interventions were). After Root Cause Analysis was completed and determined that the following cause (s) triggered the event: documented, Res (Resident thought she was going to the kitchen for a Pepsi. After action/measures measures to prevent re-occurrence were identified was written high traffic area when awake. No documentation was located that showed the interdisciplinary team did any analysis of this fall or began any new interventions to prevent accidents after this fall. DON B's fall statement indicated Resident #5 had been sleeping on her couch in her room [ROOM NUMBER] minutes prior to the fall and Resident #5 had used the toilet after breakfast. It was not known what time Resident went to her room or if she was assisted to bed after breakfast and using the toilet. Review of the Event Report for Resident #5 dated 5/21/18 at 4:21 PM (DON B said went with the 5/20/18 fall at 11:00 PM and the date and time did not match because the licensed practical nurse (LPN) S working that night did not complete it that night). This report documented Resident #5 fell in her room and the mat was next to her bed. Resident #5 had a 4 inch laceration to her forehead that required 7 stitches and had a fractured rib on her left side. Under evaluation documented, A root cause analysis was completed and determined that the following causes triggered the event. Res (Resident) woke up and TV was still on and she wanted it off. Actions/Measures to prevent re-occurrence were identified, they include: increased encounters to ensure needs are met, grippy socks at night, TV to be off when resident is sleeping at night. Review of an Incident/Accident Report for Resident #5 dated 5/20/18 at 11:00 PM, documented Resident #5 stated she was getting up to turn off television tripped and hit her head on the wall/door jam. Review of document Investigation for Resident #5, not dated and signed by the DON, documented Resident #5 had 3 falls since admission and fell several times at home prior to admission. Resident #5 was given a low bed and a mat at bedside. Resident #5 is very confused and has trouble following commands. Resident #5 gets herself up from the floor and is very agile. On this day (no date) Resident #5 was observed sleeping 10 minutes prior to the incident. Resident #5 used the toiled prior to falling asleep at 9:30 PM. Resident #5's bed and mat was in place per plan of care. When staff went past Resident room she had got herself off the floor and was bleeding. She told the Nurse and CNA's she was just trying to turn the TV off. Res (Resident) had on socks with no shoes. Intervention placed included: turn TV off when resident is sleeping, high traffic area when resident is awake, gripper socks on at night. Staff also instructed to increase encounters with resident to ensure needs are met. Review of a Reportable Event/Root Cause Analysis document (no signature) for Resident #5 dated 5/20/18 documented Resident #5 had a fall with a negative outcome, Rib fracture. Resident #5 was sleeping 10 & 20 minutes prior to fall. She was toileted at 9:30 PM. Resident had TV on when she went to sleep. When she woke up she decided she wanted it off and fell . There were 2 certified nurse aids (CNA's) and one licensed practical nurse (LPN) working at the time of the fall. Resident is impulsive. She has dementia and over estimates her capabilities. A review of Resident #5's progress note, dated 7/23/18 revealed, Resident was observed a few times attempting to get up and try to walk, though we were able to intervene and help her to walk a while and take her to dinner there to the bathroom and to get her hair done. Documentation for Resident #5's fall on 7/8/18 at 5:30 PM, documented she was in her room. Under root cause documented not able to comply with interventions. Actions improve safety of room. DON B said during the interview on 7/30/18 at 10:29 AM, that they moved Resident #5's dresser. The fall statement attached to this report documented Resident #5 was in bed 20 minutes prior to the fall. A hand written statement documented a house keeper observed Resident #5 standing on the mat in her room and called to her then she fell over and hit the back of her head on the her dresser. Review of the documentation for Resident #5's fall that occurred on 7/18/18 at 7:23 PM, documented Resident #5 fell in the hall. Root cause documented Resident #5 had decreased safety awareness. Action was to remove foot rests when Resident #5 was sitting in high traffic area as she tripped when attempting to get up. Resident #28 According to a facility face sheet dated 7/25/18 at 10:13 AM, Resident #28 was a [AGE] year old male admitted into the facility on [DATE] with the cumulative Diagnoses: [REDACTED]. Resident #28 was his own responsible party. Review of Resident #28's admission Minimum Data Set (MDS), nursing assessment tool, dated 6-15-18 documented his Brief Interview of Mental Status (BIMS) score was 13/15 (cognitively intact). The assessment documented Resident #28 required limited assistance of one person for transfers and walking in his room. On 7/25/18 at 5:05 AM, Resident #28 was observed in his room with Certified Nurses Aide I CNA I said she found Resident #28 sitting on the armrest of his lazy boy style chair and had to assist him to his wheelchair. Licensed Practical Nurse (LPN) F entered the room a few minutes later and said Resident #28 had fallen at 11:55 PM that night and said he had been on 30 minute checks prior to that fall and she started him on 15 minute checks at 11:55 PM. CNA I and LPN F were unable to locate 15 minute or 30 minute check sheets. LPN I said she forgot to start a 15 minute check sheet. CNA I she was not told about the 11:55 PM fall. Both CNA I and LPN F were asked if they could do 15 minute checks on 39 residents, with 3 staff working on 3rd shift, and both CNA I and LPN F admitted that 15 minute checks could not have been done that night due to the number of Residents needing care. Based on record review, it was revealed that Resident #28 had 6 falls between 6/21/18 and 7/24/18. All of Resident #28's falls occurred between 11:45 PM and 6:26 AM, with 4 of them concentrated between the hours of 11:45 PM to 1:40 AM. No documentation showing that increased supervision of 30 minute checks, and 15 minute checks, was ever provided by the facility.

Based on observation, interview and record review, the facility failed to manage pain for 1 Resident (#28), of 16 residents reviewed for pain, resulting in Resident #28 experiencing high levels of unrelieved pain, mental anguish and frustration. Findings include: Resident #28 On 7/23/18 at 10:08 AM, Resident #28 was observed bent over and having difficulty breathing. When queried at this time, Resident said he is not in pain at the moment, yet They will give me some pills, but it's not strong enough, and then when I do get the stronger ones, I'm hurting so bad I can hardly stand it. Resident #28's facility face sheet dated 7/25/18 revealed admission into the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 07/24/18 at 12:08 PM, Resident#28's Family Member (FM) R expressed concern with the resident's pain not being managed. FM R stated that the facility had changed Resident #28's medication since being here, but it didn't appear to be controlled. FM R and Resident #28 stated that was one of the reasons as to why he was here, so his pain could be managed. During an interview on 7/25/2018 at 10:00 AM, DON B stated a Hospice nurse was coming in to assess the resident and was due here at 10:30 AM. DON B stated she was going to have the Hospice nurse review Resident #28's medication, meet with his wife, then meet with this surveyor. On 07/25/18 at 11:11 AM, Hospice Registered Nurse (RN) CC was interviewed and stated, Resident #28 is tired of being ill, the resident is not consistently wearing his oxygen, has a weak heart, chronic back pain, [MEDICAL CONDITION], and restless legs. Resident #28 was started on [MEDICATION NAME] a week ago for restless legs and reassessed yesterday, and [MEDICATION NAME] was increased to 200 mg. RN CC stated that during the Revisit today the orders were changed to 5 mg on Roxinol every 4 hours and [MEDICATION NAME] PRN (as needed) was discontinued today. RN CC stated she told Nurse DD on 7/24/18 at 10:00 AM, after she had reviewed the MAR (medication administration record) that they, the facility, needed to provide the PRN medications first before she could increase the scheduled medications. RN CC stated when she reviewed the residents MAR's she noticed the resident rarely received any PRN medications and she saw multiple entries of pain being rated between 7 to 10. RN CC revealed that Resident #28 had stated he knew he will never be pain free, but that he can tolerate a pain level of 4 to 5. During an interview on 07/25/18 at 3:18 PM, DON B was asked where do recommendations go from hospice. DON B did not have an answer. DON Bstated we are not utilizing the PRN medications as we should DON B stated that the staff were worried they were going to over dose Resident #28. When asked if the Resident #28 had the PRN orders for Roxinal in order to help the resident achieve pain relief, DON B replied, yes. Review of Resident #28's Medication Administration Record [REDACTED] Per physician orders [REDACTED].#28 on every shift. Out of a possible 45 shifts, Resident #28's pain level was never documented below a 6. Resident's pain level was documented at a 6 for 4 shifts, level 7 for 5 shifts, a pain level 8 for 12 shifts, a pain level of 9 for 2 shifts, and a pain level of 10 for 19 shifts, 2 shifts the pain assessment were not legible, and one assessment was not taken for making a possible 45 shifts. Resident #28 had [MEDICATION NAME] concentrate- Schedule II solution; 100 mg/5 mL (20 mg/mL); .25 mL (5 mg); oral Every 2 hours PRN starting on 6/15/18- 6/27/18 Resident #28 received 49 doses out of a possible 156 doses that could have been given of [MEDICATION NAME] concentrate. During that time the Residents pain was never documented below a 6, and on 3rd shift the Residents pain was assessed at a 10 every night a pain assessment was taken. Review of Resident #28's [MEDICATION NAME] concentrate- Schedule II solution; 100 mg/5 mL (20 mg/mL); .25 mL Q2 hours routine; oral every 2 hours started on 6/28/18 at 4 PM and showed it was given every 2 hours through 6/30/18 at 10PM. During this time Resident #28 had 2 shifts where he rated his pain at a 6, 2 at 8, and 2 at a 10. Review of Resident #28's [MEDICATION NAME] tablet; 10-325 mg; 1 tablet oral every 4 hours PRN. Review of Resident's MAR from 6/15/18 -6/30/18 revealed that Resident#28 received 16 doses of PRN [MEDICATION NAME] out of a possible 96 doses. Review of Resident #28's Medication Administration Record [REDACTED]. From 7/01/18 -7/24/18 Resident #28 had 1 shift with a pain level documented at a 0, 5 shifts at 4, 4 shifts at 6, 8 shifts with pain level of 7, 8 shifts with at 9, and 27 shifts with a pain level at 10, 4 shifts that the pain level was not legible, and 4 shifts that didn't have a pain assessment marked for a total of 55 shifts. Review of Resident #28's scheduled for [MEDICATION NAME] concentrate- Schedule II solution; 100 mg/5 mL (20 mg/mL); 10mg (0.5 mL); Every 4 hours PRN starting on 7/06/18 -7/24/18 revealed from the MAR indicated [REDACTED]. Resident #28 had 49 shifts where he reported pain at a level 6 or higher, 27 of those shifts Resident #28 had a pain level of 10. Review of Resident #28's [MEDICATION NAME] 10-325 mg; 1 tablet oral every 4 hours PRN. Review of Resident 28's MAR from 7/01/18 -7/24/18 revealed that Resident#28 received 15 doses of PRN [MEDICATION NAME] out of a possible 144 doses that could have been given. On 7/25/18 at 5:05 AM, Resident #28 was observed in his room in his wheel chair. Certified Nurses Aide (CNA) I was in room and said she was walking by when she found Resident #28 on the edge of his lazy boy style chair and had to help him get to his wheel chair. CNA I said Resident #28 had been sleeping most of the night in his lazy boy. CNA I said he was on 30 minute checks because he had falls. At approximately 5:10 AM, License Practical Nurse (LPN) F came into the room and said Resident #28 had fallen at 11:55 PM and had been placed on 15 minute checks and was now in pain. Resident #28 told LPN F his pain was 8/10 at that time and he wanted his Roxinol (narcotic pain medication that is placed under the tongue). LPN F said he could not have Roxinol right now because she had given it at 4:00 AM and he could only have it every 4 hours. LPN I said the only pain medication she could provide at that time was [MEDICATION NAME]. Resident #28 became upset and pointed to the note on the wall and said, the note says I can have the Roxinol as needed, I was promised when I came here to die that my pain would be controlled and my pain is not controlled. LPN F left to check medication orders. LPN I reviewed the MEDICATION ORDERS FOR [REDACTED]. When asked if she thought [MEDICATION NAME] would be fast enough and strong enough medication for Resident #28 who had just reported his pain was 8/10, LPN I said no and called the physician T. Physician T ordered a one time dose of [MEDICATION NAME] ER 60 mg and administered it to Resident #28.

Based on observation, interviews, and record review, the facility failed to ensure fire doors were functioning properly and failed to prevent injuries/accidents (adequate assistance and supervision) for three Residents (#1, #5, #9), resulting in fire door not being able to be pushed open as required in an emergency and Resident #1 having multiple falls with no root cause investigation/new interventions to prevent falls, Resident #5 having multiple falls with fractures/injuries and Resident #9 having multiple falls/injuries and getting out side the facility unobserved and suffering injuries. Findings include: Resident #1 Review of Resident #1's face sheet (no date) revealed she was a [AGE] year old female admitted to the facility on [DATE] and was not her own responsible party. Resident #1 had the following Diagnoses: [REDACTED]. Resident #1 was not present in the facility at the time of the investigation. Review of Resident #1's incidents and accident reports for six months revealed Resident #1 had 8 falls from 2/24/16 to 7/15/16. Resident #1's incident reports and investigation of the falls was reviewed with the Director of Nursing (DON) A and Regional Nursing Director (RND) E on 8/16/16 at 3:30 PM. DON A and RND E could not locate any root cause analysis for any of Resident #1's falls (8) the investigations did not reveal the last time Resident #1 was provided care prior to most falls and the facility did not identify that Resident #1 required any increased supervision or assistance meeting her needs after each fall. Resident #1's fall on 5/2/16 resulted in a large hematoma to her right temple. The facility identified that resident #1 had unsafe transfers, and was non complaint with most falls but failed to identify a way to increase Resident #1's supervision/structure and assistance to prevent her falls. Resident #5 Review of Resident #5's face sheet, no date, revealed he was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #5 was not his own responsible party. Resident #5's last Brief Interview of Mental Status (BIMS) score dated, 4/28/16 was 3/15 severe mental impairment. Review of Resident #5's last completed Minimum Data Set (MDS) a assessment tool, dated 4/28/16 and his MDS dated [DATE] documented he required supervision when walking in his room and in the halls. Resident #5 was also assessed to need supervision with transfers on 1/27/16 and 4/28/16. Resident #5 was observed on tour 8/15/16 walking unassisted, unsteady on his feet and the majority of Resident #5's face was covered in yellow/green bruises. Resident #5's room was on Registered Nurse (RN) N unit. This Surveyor asked what happened to Resident #5's face and RN N said he had a fall. RN N said Resident #1 refuses to use his wheel chair, so when we catch him up we take is wheel chair to him and ask him to sit back down. RN N said Resident #5 had a resent Psychiatric hospitalization due to unsafe behaviors but had returned in worse condition. Resident #5 was observed walking, unsteady on his feet on multiple occasions on 8/15/16 and in the morning of 8/16/16. Staff generally came after Resident #5 within 5 minutes of being up walking with a wheel chair and asked Resident #1 to sit down and Resident #1 sat down in the wheel chair. Resident #5 was only observed interacting with staff when he was asked to sit down and there were no facility activities observed for Resident #5 to participate in at the times he was up walking. Review of Resident #5's incident/accident reports/investigations revealed Resident #5 had 9 falls from 4/11/16 to 8/9/16. Review of Resident #5's Incident/Accident Report dated 4/11/16 revealed he had an unwitnessed fall at 9:20 pm. There were no statements from staff working at the time of the incident but a typed document was proved the documented a Certified Nursing Assistant (CNA) unknown had just assisted Resident #5 to the toilet and back to bed. When this CNA (unknown) was assisting Resident #5's roommate this CNA heard resident #5 get up and watched him loose his footing as he was tangled in his sheets. The facility plan was to keep resident #5's bed sheets untucked. Review of Resident #5's Incident/Accident Report dated 4/21/16 revealed he had an unwitnessed fall at 7:35 PM and suffered abrasions and swelling to his left eye area, left cheek and chin. There were no statements from staff working at the time of the incident. There was a typed document that revealed Resident #5 walks in the halls all day and is redirected to use his wheel chair when tired but he is non-compliant. Resident #5 is known to take his shoes off and carry his shoes around. Resident #5 lacks safety awareness. Resident #5 was assisted to the toilet by an unknown CNA at 6:45 PM and found on the floor in his room at 7:35 PM. It was documented that Resident #5 was wearing socks and slipped on the floor and the plan was to ensure Resident #5 has his shoes on when up (this is a standard of care for all fall risk resident and does not make this a new intervention). Resident #5 was already assessed to need supervision when walking and this intervention did not address his need for supervision when walking. Review of Resident #5's Incident/Accident Report dated 4/27/16 revealed Resident #5 had an unwitnessed fall at 11:00 AM. and suffered an abrasion to his left elbow. There was diagram of the dinning room where Resident #5 was found on the floor that indicated Resident #5 was not near his wheel chair when he fell . The box for no shoe was marked on the investigation. No statements from staff working at the time were located and the typed document attached to the investigation documented Resident #5 was to have shoes on (same as the fall 4/21/16 and this time keep Resident #5 in areas of increased viability. Review of Resident #5's Incident/Accident Report dated 6/11/16 documented a fall at 2:30 PM. A diagram attached to the investigation showed a person on the floor by a medication cart and an unknown distance from a chair. Other attached documents indicated Resident #5 was standing in the day room eating a snack prior to the fall and staff was educated on having resident use his wheel chair at all times/ how to approach resident. Attached from's indicated Resident #5 was non-compliant with care. No staff statements were located for staff that observed the fall or were working at the time of the fall. Review of Resident #5's Incident/Accident Report dated 6/23/16 had an unwitnessed fall at 2:50 PM. Forms attached documented Resident #5 had been pacing halls and was non-compliant with interventions. The Post Fall Event documented Resident #5 was seen falling in the hall and multiple attempts to use wheel chair were offered, snack given with not effective and Resident #5 is non-compliant with interventions. No new intervention was identified to meet Resident #5's needs. Review of Resident #5's Incident/Accident Report dated 7/8/16 at 7:52 PM, revealed no name in the witness box. Documented a red area/abrasion on Resident #5's right shoulder. A sheet attached to the incident/ accident report documented Resident #5 was pacing from his wheel chair in the hall. The Post Fall Event for Resident #5 documented. Resident continues to pace without stop and walks 16 -18 hours a day and is not redirect. Resident #5 walked for an unknown reason all day. Resident #5 stood up from his wheel chair and walked to his room and fell after hitting the door frame. There was no new intervention only a plan for a medical review. (no increased supervision was offered). Review of Resident #5's Incident/Accident Report dated 7/9/16 documented a witnessed fall at 7:20 PM. Resident #5 was observed walking fast and unsteady. He was observed to loose his balance and fall on the floor. Abrasions were noted on the left side of Resident #5's face and left shoulder. Post Fall Event documented Resident #5 was pacing as normal 16-18 hours a day. Interventions were not effect. No new interventions were identified and this fall was just like the fall 7/8/16. Review of Resident #5's Incident/Accident Report dated 7/14/16 documented an unwitnessed fall at 9:15 PM. Resident #5 suffered pain on the left side of his head and a laceration to his left shoulder. The Post Fall Event documented staff were to keep Resident #5 where he can be observed when not sleeping. (same as previous falls). Other interventions were also identified in previous fall and were not affective. A typed note Post Note was attached and documented the physician evaluated Resident #5 the next day 7/15/16 and ordered a left shoulder x-ray. The x-ray revealed a nondisplaced fracture of the left distal clavicle. There was no new intervention to increase supervision or assistance identified. Medical Record review revealed Resident #5 was discharged to a Psychiatric hospital on [DATE] and return on 8/2/16. (above interview with RN N indicated Resident #5 returned from the Psychiatric hospitalization in worse condition) Review of Resident #5's fall care plan dated 8/2/16 and fall prevention program care plan did not indicate any close supervision of Resident #5. Review of Resident #5's Incident/Accident Report dated 8/9/16 at 4:30 AM documented a witnessed fall where Resident #5 fell into the wall in the hall and under steps to prevent documented, shoes/changed, shoes as they are poor fitting. Resident #5's face was still covered in bruise from the fall during the Survey. Resident #5 had multiple falls prior to this one related to poor foot ware. The facility did not identify any way to increase supervision and Resident #5 had been assessed since January 2016 to need supervision with ambulation. All of the above falls were Reviewed with the Director of Nursing (DON) B on 8/16/16 at 8:35 AM and DON B said she did not know how they could increase supervision to increase Resident #5's safety and explained that the problem was Resident #5 was non compliant with his care plan. (Resident #5 was not his own responsible party and it was well documented he lacked any safety awareness. On 8/16/16 at 12:35 AM, Resident #5 was observed resting in bed watch the television and CNA R was sitting in the chair next to Resident #5. CNA R said she was assigned to provide 1:1 care for Resident #5 at 10:39 AM today (8/16/16). CNA R said her only instruction was to keep Resident #5 safe. CNA R said she had known Resident #5 for a long time and generally will do what he is asked to do. CNA R said Resident #5 slept for about an hour today, ate a snack and likes to be pushed in his wheel chair. Resident #5 was observed on multiple occasions the afternoon of 8/16/16 and the morning of 8/17/16. On each occasion Resident #5 was being pushed in his wheel chair by staff and appeared happy/calm. Resident #5 was not observed attempting to stand or walk. Review of Resident #5's fall care plan dated 2/6/14 did not document any 1;1 intervention or pushing resident in wheel chair to keep him calm. The care plan only document the approach's listed with the incident/accident reports which the facility identified as not effective. Resident #9 Review of Resident #9's face sheet (no date), revealed she was a [AGE] year old female admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #9 was not her own responsible party. Resident #9's Brief Interview of Mental Status (BIMS) scores dated 4/254/16 was 6/15 and on 7/20/16 was 5/16 (both showed severe cognitive impairment) Review of Resident #9's Incident/Accident Report dated 3/8/16 at 8:40 PM documented Resident #9 went out the West end exit doors and alarm sounded and CNA's were observed with Resident #9 in the hall. Resident #9 had a left forehead abrasion and an abrasion on her right pinky finger. This incident report was signed by RN K. A typed report was attached to the Incident/Accident Report that documented. Resident #9 was witnessed exit seeking on 3/5/16 and was on 15 minutes check starting 3/5/16 to the time of the incident. The West end door alarmed at 8:40 pm and a CNA went out side and observed Resident #9 about 20 feet to the left of the door sitting on her bottom calling for help. Resident #9 was combative and agitated and trying to get up CNA assisted Resident #9 back in the facility. Resident #5 had suffered abrasions to the head. Resident #9 was placed on 1:1 care after this incident. The facility provided a list of all employees working on 3/8/16 at 8:40 PM. All employees were contacted by telephone. Licensed Practical Nurse (LPN) P return a telephone call on 8/17/16 and said she did not see Resident #9 leave the building. LPN P said she new Resident #9 was an elopement risk and was on 15 minute checks because she had made multiple attempts to leave the building. LPN P was at the other end of the building and did not hear the door alarm. When LPN P saw Resident back in the building, Resident #9 was in her pajama's coved in blood and bruises. RN K returned a telephone call on 8/17/16 at 1:10 PM. RN K said she completed the Incident/Accident Report for Resident #9 on 3/8/16. RN K said she remembered that night very well. RN K said Resident #9 was out of control prior to getting out side and she was at the East end of the building on the telephone with the Physician attempting to get an order for [REDACTED].#9 down. RN K said she was new to the facility and believed she needed management approval to put a resident on 1:1 care so she told the CNA's to just keep a close eye on her. RN K was educated after this event that she can place residents on 1:1 for concerns like Resident #9. RN K did not hear the door alarm and had to be paged over head to the West end to assess Resident #9. Resident #9 was back in the building by the time RN K got to the West end. Resident #9 was too agitated to assess at first and had blood on her face. Once Resident #9 received the injectable Ativan, Resident #9 calmed down and went to sleep. CNA M returned a call on 8/17/16 at 12:35 PM, CNA M said she was working the night Resident #9 got outside the building. CNA M said Resident #9 can read and when ever she got close to the door she would read the sign that said push and hold for 15 seconds and proceed to push on the door. Resident #9 had set off the alarms in the past but had never gotten outside the building. CNA M said she did not see Resident #9 leave the building that night. CNA M said there is no light and a big step out side that door. CNA M said when Resident #9 was brought back in the building she was covered in blood. Resident #9 was known to be agitated and exit seeking prior to exiting the building 3/8/16 and staff working were unaware they had the authority to increase supervision of Residents that were displaying unsafe behaviors. Resident #9 was observed on 8/7/17 at 10:20 AM walking in the hall with a wheeled walker and gait belt. Resident #9 was being assisted by physical therapy. Resident #9's Incident/Accident Reports document 10 additional falls since 3/8/16 (4/13/16 ,4/28/16, 5/13/16, 5/18/16, 5/23/16, 6/12/16, 7/1/16, 7/8/16 and 8/9/16) The facility does not have a currently care plan in place that assures Resident #9 will have supervision and assistance with transfers/ambulation and remains at high risk for fall and injuries. Resident #9 remains unpredictable for when she will attempt to walk and is known to require supervision when she is awake as she will not use a call light or ask for assistance. ( ) Fire Exits On 8/17/16 at 9:55 AM this Surveyor attempted to open the West fire exit door that Resident #9 had exited on 3/8/16. The Surveyor applied pressure to the door release for 45 seconds before it would open. The door immediately alarmed when pressure was applied to the release. The facility Maintenance Director (MD)I reset the door and the door did open within 15 seconds of an accelerated alarm. Other doors were tested after this door and the front doors and double doors on the West end could not be opened when pressure was applied for greater than one minute. MD I said he has to adjust these doors every 2-3 months but does not keep a record of each event. The State Fire Inspector (SFI) T was contacted by telephone on 8/17/16 and said he was in yesterday (8/16/16) and he did not physically test the doors of concern. SFI T tested on e door and it was not a problem. SFI T instructed this Surveyor to have MD I shut off the main over ride to the fire door at the nurses station and assure that all fire doors can open in the event of a real fire. On 8/17/16 at 11:00 AM, MD I demonstrated he fixed the front doors and west double doors. MD I was asked to turn off the fire door over ride at the nurses station and verify all fire doors could open in the event of a fire. The main dining room fire door would not open when the fire over ride switch was off. MD I had already called in a company to fix parts of the fire system and started to work with this company. On 8/17/16 SFI T was called and informed that the main dining room fire door did not open when the fire over ride switch was off. SFI I instructed this Surveyor to have MD I pull the fire alarm and assure all fire doors open. MD I notified the fire department of a drill and pull a fire alarm. All fire doors opened when the alarm was pulled. SFI I was notified and said he would stop back into the facility that night to verify the fire system remained operational. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MONITOR TO ENSURE A RELIABLE PROCESS FOR REDISTRIBUTING PRESSURE RELIEF IN THREE RESIDENTS (#1, #2, #3), FAILED TO ENSURE ADEQUATE IRRIGATION OF A PRESSURE ULCER WOUND IN ONE RESIDENT (#7), AND FAILED TO ADEQUATELY IDENTIFY, AND RE-EVALUATE RISK FACTORS FOR NEW PRESSURE ULCER DEVELOPMENT IN ONE RESIDENT (#2) OF FIVE RESIDENTS REVIEWED FOR PRESSURE ULCERS IN A TOTAL SAMPLE OF TEN RESIDENTS. THIS DEFICIENT PRACTICE HAS THE POTENTIAL TO RESULT IN A DELAYED HEALING OF PRESSURE ULCERS FOR RESIDENTS #1, #2, #3 & #7. FINDINGS INCLUDE: ACCORDING TO THE ADMISSION FACE SHEET, RESIDENT #1 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE MDS (MINIMUM DATA SET) ASSESSMENT, DATED 9/25/2012, RESIDENT #1 HAD MODERATELY IMPAIRED COGNITION (REASONING AND DECISION MAKING ABILITIES) AND REQUIRED EXTENSIVE ASSISTANCE WITH BED MOBILITY AND TRANSFERS. BASED ON REVIEW OF THE physician progress notes [REDACTED].#1 HAD A "COCCYX FISSURE" (SLIT IN THE TISSUE OVER HER TAILBONE) THAT HAD "GOTTEN SLIGHTLY LARGER AGAIN." BASED ON REVIEW OF RESIDENT #1'S 9/25/12 MDS, THE "COCCYX FISSURE" WAS NOT IDENTIFIED AS A PRESSURE ULCER ON THE MDS, BUT THE FISSURE WAS RECORDED ON THE FACILITY'S "WEEKLY PRESSURE ULCER PROGRESS REPORT" (FIRST ENTRY DATED 7/9/12) AND WAS DESCRIBED AS A "SPLIT". HOWEVER, ACCORDING TO THE RESIDENT ASSESSMENT INSTRUMENT (RAI) MDS 3.0, THE DEFINITION OF A PRESSURE ULCER IS A "LOCALIZED INJURY TO THE SKIN AND/OR UNDERLYING TISSUE, USUALLY OVER A BONY PROMINENCE, AS A RESULT OF PRESSURE OR PRESSURE IN COMBINATION WITH SHEAR AND/OR FRICTION." AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) TOOK PLACE ON 10/23/2012 AT 2:00 P.M. THE DON WAS ASKED WHY THE WOUND HAD DEVELOPED ON RESIDENT #1 AND THE DON RESPONDED "PROBABLY FROM SPREADING THE BUTTOCKS TOO FAR APART WHEN GIVING CARE." THE DON STATED SHE WAS NOT SURE WHY THE WOUND HAD NOT HEALED. BASED ON REVIEW OF THE physician progress notes [REDACTED]. ACCORDING TO THE "COCCYX FISSURE" CARE PLAN FOR RESIDENT #1, THE "APPROACHES" FOR HEALING THE WOUND INCLUDED DIRECTIVES TO AVOID SHEARING THE RESIDENT'S SKIN DURING POSITIONING, TRANSFERRING AND TURNING, HANDLING THE RESIDENT WITH CARE DURING DIRECT CARE, INCLUSION OF A PRESSURE REDUCTION CUSHION IN THE RESIDENT'S THE WHEELCHAIR, AND TURNING AND REPOSITIONING EVERY TWO HOURS. THE SPECIFIC INTERVENTIONS THAT WERE TO BE USED, IN ORDER TO AVOID TENSION ON RESIDENT #1'S BUTTOCKS AND STRETCHING OF THE SKIN COVERING THE COCCYX, WERE NOT DESCRIBED ON THE CARE PLAN. ACCORDING TO THE "WEEKLY PRESSURE ULCER PROGRESS REPORT" FOR RESIDENT #1, THE FOLLOWING WOUND MEASUREMENTS IN CM (CENTIMETERS) WERE RECORDED: 7/9/2012 0.4 X 0.2 X 0.1 NO DRAINAGE 7/23/2012 1.5 X 0.5 X 0.1 NO DRAINAGE 8/20/2012 1.4 X 0.4 X 0.2 NO DRAINAGE 9/10/2012 1.4 X 0.2 X 0.1 NO DRAINAGE 10/1/2012 0.3 X 0.2 X 0.1 NO DRAINAGE 10/8/2012 0.2 X 0.2 X 0.1 NO DRAINAGE THE BOX DESIGNATED ON THE FORM FOR DOCUMENTING THE "STAGE" OF RESIDENT #1'S WOUND (AS STAGE I, II, III OR IV) WAS LEFT BLANK. AN OBSERVATION WAS MADE OF RESIDENT #1'S DRESSING CHANGE ON 10/24/2012 AT 1:50 P.M. THE WOUND WAS OBSERVED TO BE APPROXIMATELY 1 ? INCHES LONG, AND IT APPEARED DEEP WHEN SPREAD APART SLIGHTLY. A REQUEST WAS MADE OF THE DON TO TAKE ACCURATE MEASUREMENTS AT THAT TIME. THE WOUND WAS MEASURED AS 1.8 CM X 0.4 CM X 0.2 CM, LARGER THAN WHAT WAS RECORDED ON 10/8/2012, WITH SLIGHT MACERATION AROUND THE WOUND AND A LARGE AREA OF REDNESS ON BOTH SIDES OF THE BUTTOCKS THAT WAS BLANCHABLE. THE WOUND WAS CONSISTENT IN APPEARANCE WITH A STAGE II PRESSURE ULCER (WITH LOSS OF BOTH THE DERMIS AND EPIDERMIS SKIN LAYERS.) AT THE TIME OF THE OBSERVATION, A QUILTED INCONTINENCE PAD WAS OBSERVED LYING OVER THE RESIDENT'S AIR MATTRESS. ACCORDING TO THE "CNA (CERTIFIED NURSE ASSISTANT) CARE GUIDES", FOR RESIDENT #1 DATED 10-24-12, NO PAD WAS TO BE PLACED IN HER BED DUE TO THE PAD COUNTERACTING THE EFFECT OF THE SPECIAL PRESSURE RELIEVING AIR MATTRESS. DURING AN INTERVIEW ON 10/24/2012 AT 4:50 P.M., CORPORATE NURSE CONSULTANT "A" VERIFIED THE PRESSURE RELIEVING MATTRESS SHOULD NOT HAVE HAD A PAD OVER IT. ON 10/23/2012 AT 1:15 P.M., RESIDENT #1 WAS OBSERVED SITTING IN HER WHEELCHAIR CLOSE BY THE NURSING DESK. LATER THAT SAME AFTERNOON, AT 3:50 P.M., RESIDENT #1 WAS AGAIN OBSERVED SITTING IN HER WHEELCHAIR AT THE NURSING DESK. RESIDENT #1 MOTIONED FOR THE SURVEYOR TO COME OVER TO HER. IN A VERY GARBLED VOICE, RESIDENT #1 ASKED TO LAY DOWN. ACCORDING TO THE "CNA (CERTIFIED NURSE ASSISTANT) CARE GUIDES", DATED 10-24-12, RESIDENT #1 WAS SUPPOSED TO LAY DOWN IMMEDIATELY AFTER MEALS IF SHE WAS RESTLESS, ANXIOUS OR YELLING, AND SHE WAS TO BE TURNED "Q" (EVERY) ONE TO TWO HOURS TO "TRY TO KEEP OFF BUTT." DURING AN INTERVIEW ON 10/25/2012 AT 11:00 AM, CNA "F" WAS ASKED WHAT THE TURNING SCHEDULE WAS FOR RESIDENT #1. STAFF "F" STATED SHE DID NOT KNOW WHAT HER TURNING SCHEDULE WAS. STAFF "F" SAID THAT THERE WAS NO PARTICULAR SCHEDULE IN USE THAT WOULD INDICATE WHEN TO TURN HER. DURING AN INTERVIEW ON 10/25/2012 AT 11:10 A.M., CHARGE NURSE, LICENSED PRACTICAL NURSE (LPN) "I" WAS ASKED HOW SHE WOULD BE ABLE TO VERIFY IF RESIDENT #1 WAS BEING TURNED EVERY ONE TO TWO HOURS, IN ACCORDANCE WITH THE PLAN OF CARE. LPN "I" RESPONDED SHE WOULD NOT HAVE A WAY OF KNOWING WITHOUT ASKING SOMEONE. AN INTERVIEW WITH THE DON TOOK PLACE ON 10/25/2012 AT APPROXIMATELY 11:25 A.M. THE DON WAS ASKED IF THE FACILITY UTILIZED A SPECIFIC POLICY, GUIDELINE OR TOOL TO ENSURE THAT A RESIDENT WAS BEING TURNED OFTEN ENOUGH. THE DON SAID THAT SHE EXPECTED STAFF TO REMEMBER WHEN THEY TURNED A RESIDENT. THE DON PROVIDED NO POLICY TO EXPLAIN HOW THE FACILITY WAS MONITORING TO ENSURE THAT RESIDENTS WERE BEING TURNED AND REPOSITIONED AS OFTEN AS REQUIRED BY THEIR PLANS OF CARE. DURING AN INTERVIEW ON 10/25/2012 AT 4:50 P.M., CNA "E" STATED SHE WAS RESIDENT #1'S REGULAR CAREGIVER. WHEN ASKED HOW SHE KNEW WHEN TO TURN RESIDENT #1, CNA "E" STATED SHE JUST TRIED TO REMEMBER. ( ) ACCORDING TO THE MDS dated [DATE], RESIDENT #7 WAS AN [AGE] year OLD MALE RE-admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. (A STAGE IV PRESSURE ULCER IS A WOUND CHARACTERIZED BY FULL THICKNESS SKIN LOSS WITH EXTENSIVE TISSUE DESTRUCTION AND/OR NECROSIS AND DAMAGE EXTENDING TO MUSCLE, BONE AND/OR SUPPORTING STRUCTURES.) ACCORDING TO THE RESIDENT'S HISTORY AND PHYSICAL, DATED 8/3/12, RESIDENT #7 had a history of [REDACTED]." REVIEW OF RESIDENT #7'S physician's orders [REDACTED]. CHANGE WOUND VAC EVERY MONDAY WEDNESDAY AND FRIDAY." THE WOUND CARE AND VAC DRESSING CHANGE PROVIDED RESIDENT #7 WERE OBSERVED ON 10/24/2012 AT 2:15 P.M. IN THE RESIDENTS ROOM. THE RESIDENT'S LEFT ISCHIAL WOUND WAS OBSERVED TO BE AN APPROXIMATELY 3 INCH BY 3 INCH CIRCULAR, VERY DEEP WOUND IN THE LEFT LOWER BUTTOCK AREA. REGISTERED NURSE (RN) "M" WAS OBSERVED TO USE A ONE-OUNCE, 30 CC (CUBIC CENTIMETERS) PLASTIC MEDICINE CUP FILLED WITH THE IRRIGATING SOLUTION TO TRY TO CLEANSE THE WOUND. RESIDENT #7'S WOUND WAS ANGLED UPWARD WHEN HE WAS LYING ON HIS SIDE. THE IRRIGATING SOLUTION WAS OBSERVED TO RUN DOWN THE EDGES OF THE WOUND, AND SETTLE IN THE BOTTOM OF THE WOUND, BUT NO SOLUTION WAS OBSERVED TO REACH THE BACK, TOP OR SIDES OF THE WOUND. THE AREAS INSIDE THE WOUND THAT WERE NOT REACHED BY THE IRRIGATING SOLUTION WERE NOT BEING PROPERLY CLEANSED, WHICH POTENTIALLY INCREASED THE RISKS OF INFECTION AND/OR DELAYED HEALING. RN "M" WAS ASKED IF SHE HAD CONSIDERED USING A SYRINGE, TO GET THE IRRIGATING SOLUTION TO ALL TISSUE IN THE WOUND. AFTER BEING PROVIDED A SYRINGE FROM ANOTHER STAFF PERSON, STAFF RN "M" WAS OBSERVED ABLE TO APPLY IRRIGATING SOLUTION TO ALL AREAS OF THE RESIDENT'S WOUND. BASED ON REVIEW OF THE RESIDENT'S RECORD, A NEW physician's orders [REDACTED]." ( ) BASED ON THE PHYSICIAN "PROGRESS NOTES", DATED 9/18/12, AND THE MINIMUM DATA SET (MDS) ASSESSMENTS, DATED 9/6/12 AND 10/10/12, RESIDENT #3 WAS A [AGE] year OLD COGNITIVELY IMPAIRED MALE WHOSE [DIAGNOSES REDACTED]. THE MDS ASSESSMENTS REFLECTED RESIDENT #3 WAS TOTALLY DEPENDENT ON TWO STAFF FOR BED MOBILITY AND TRANSFERS. RESIDENT #3 WAS INITIALLY admitted to the facility on [DATE], THEN readmitted AFTER A HOSPITAL STAY ON 9/27/12. THE "WEEKLY PRESSURE ULCER PROGRESS REPORT" REFLECTED THAT RESIDENT #3 HAD AN UNSTAGABLE WOUND (THE WOUND BED COULD NOT BE VISUALIZED TO EVALUATE THE DEPTH OF THE WOUND) OF THE RIGHT HEEL THAT WAS PRESENT AT THE TIME OF HIS FACILITY ADMISSION ON 9/27/12 AND MEASURED 1.6 CM BY 2.0 CM. THE MEASUREMENTS OF THE WOUND DOCUMENTED ON THE SAME RECORD, DATED 10/15/12, WERE 1.0 CM BY 0.8 CM. RESIDENT #3'S CARE PLAN RELATED TO THE RISK OF SKIN BREAKDOWN, DATED 8/24/12 AND LAST REVIEWED ON 10/18/12, REFLECTED RESIDENT #3'S HEELS WERE TO BE "ELEVATED/FREE FLOATING WHEN IN BED". THIS WAS CROSSED OUT, AND A NOTE WAS WRITTEN THAT INDICATED THE RESIDENT WAS REFUSING TO DO THIS. ON 10/1/12 THE INTERVENTION OF A PRESSURE RELIEVING BOOT TO THE RIGHT FOOT WAS ADDED. THE STATEMENT "WILL REMOVE AT TIMES. ENCOURAGE TO KEEP ON" WAS WRITTEN BESIDE THE ORDER FOR THE BOOT. THE PHYSICIan order for [REDACTED]. THE "CNA (CERTIFIED NURSE AIDE) CARE GUIDE", DATED 10/25/12, REFLECTED IN THE "SPECIAL INSTRUCTIONS COLUMN"...FLOAT HEELS, (BRAND NAME OF PRESSURE RELIEVING BOOTS) TO BIL (BILATERAL) FEET AAT'S (SIC) (AT ALL TIMES)..." ON 10/24/12 AT 11:30 A.M., RESIDENT #3'S RIGHT HEEL WOUND WAS OBSERVED WITH NURSING AIDE "F" IN RESIDENT #3'S ROOM WHILE RESIDENT #3 WAS IN BED. THE AREA WAS ON THE BACK OF THE HEEL HAD A CENTER AREA OF BLACK ESCHAR (DEAD TISSUE) RINGED WITH AN AREA OF RED TISSUE ABOUT 0.4 CM WIDE AND AN OUTER AREA OF INTACT SKIN WHERE THE TOP LAYER HAD PEELED AWAY. THE CURRENT treatment for [REDACTED]. JUST PRIOR TO THE OBSERVATION RESIDENT #3 WAS OBSERVED WEARING HIS PRESSURE RELIEVING BOOTS ON BOTH FEET. THE BOOTS WERE MADE OF A SOFT FABRIC, WITH VELCRO STRAPS IN FRONT THAT EXTENDED FROM TOES TO MID CALF, AND THE HEEL AREA WAS LEFT OPEN TO PREVENT PRESSURE ON THE HEEL. THE BOOTS WERE NOT OBSERVED BEING PUT BACK ON RESIDENT #3 AFTER THE OBSERVATION OF THE WOUND, AS RESIDENT #3 STATED THAT HIS FEET WERE TOO HOT. ON 10/24/12 AT 3:15 P.M., RESIDENT #3 WAS OBSERVED WITH HIS EYES CLOSED, LYING IN BED ON HIS BACK, WITH HIS RIGHT HEEL WOUND LAYING DIRECTLY ON THE MATTRESS. THE PILLOW THAT HAD BEEN PLACED UNDER HIS CALF AT 11:30 A.M. TO ELEVATE THE HEEL OFF THE BED WAS LYING ON TOP OF HIS LEG. THE PRESSURE RELIEVING BOOTS WERE NOT ON EITHER FOOT. ON 10/26/12 AT 9:55 A.M. AND 11:15 A.M. RESIDENT #3 WAS OBSERVED WITH HIS EYES CLOSED, LYING IN BED ON HIS BACK, WITH THE PRESSURE RELIEVING BOOTS ON BOTH FEET. HOWEVER, THE RIGHT BOOT WAS SO LOOSE THAT THE RIGHT FOOT WAS OUT OF THE BOOT, AND THE RIGHT HEEL WOUND WAS LYING ON THE EDGE OF THE BOOT. THE RESIDENT'S RIGHT FOOT WAS NOT BEING MAINTAINED IN AN ELEVATED POSITION, AS PRESCRIBED IN THE CARE PLAN AND THE CNA CARE GUIDE, WHICH CREATED PRESSURE ON THE EXISTING WOUND AND HAD THE POTENTIAL TO DELAY WOUND HEALING. ( ) BASED ON THE "RESIDENT ADMISSION RECORD", DATED 6/1/12 AND THE MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE], RESIDENT #2 WAS A [AGE] year OLD FEMALE WITH NO COGNITIVE IMPAIRMENTS WHOSE [DIAGNOSES REDACTED]. THE MDS REFECTED THAT RESIDENT #2 REQUIRED EXTENSIVE ASSISTANCE OF TWO STAFF FOR BED/CHAIR MOBILITY AND TRANSFERS. THE NURSING NOTES FOR RESIDENT #2, DATED 9/9/12 AT 10:51 P.M., REFLECTED THE FOLLOWING: "DURING BEDTIME IT WAS FOUND ON RIGHT HEEL A BRUISE LIKE AREA ABOUT 3 CM ROUND TO HER HEEL, THE AREA IS NOT OPEN, SHE (RESIDENT #2) WAS INSTRUCTED TO HAVE HER HEELS FLOATED, UNTIL WOUND NURSE COULD ASSESS HER HEEL. SHE REFUSED TO DO THAT." THE 9/2012 "TREATMENT RECORD" REFLECTED AN ORDER TO "MONITOR LT (LEFT) HEEL DAILY FOR CHANGE (SYMBOL FOR CHANGE) IN INTEGRITY" BEGINNING 9/14/12. HOWEVER, THERE WAS NO EVIDENCE THAT THE RIGHT HEEL BRUISE WAS BEING MONITORED. THE NEXT NURSING NOTE RELATED TO THE CONDITION OF RESIDENT #2'S FEET WAS DOCUMENTED ON 9/12/12 AT 9:33 P.M. AND REFLECTED THE FOLLOWING: "LEFT HEELS (SIC) ALSO NOTED TO BE SOFT, BOGGY, AND REDDENED. BLANCHES SLOWLY. ALLOWED CNA (CERTIFIED NURSE AIDE) TO ELEVATE FOOT OFF BED BUT REFUSED IT TO BE BRIDGED..." NO NEW INTERVENTIONS WERE FOUND ON THE 9/2012 "TREATMENT RECORD". THE "HEAD TO TOE WEEKLY SKIN BODY ASSESSMENT", SIGNED BY NURSE "G" ON 9/7/12, 9/14/12 AND 9/21/12, REFLECTED "NO AREAS OF SKIN IMPAIRMENT" AND CONTRADICTED THE FINDINGS OF IMPAIRED SKIN INTEGRITY THAT WERE DOCUMENTED IN THE NURSING NOTES. ON 9/21/12 AT 9:30 P.M., THE NURSING NOTES REFLECTED: "CNA REPORTS BLISTER TO BOTTOM OF RIGHT HEEL. UPON ASSESSING HEEL FIND AN INTACT AREA AT BOTTOM OF HEEL. OVAL SHAPED AREA IS YELLOW/GREEN IN COLOR, BOGGY TO TOUCH AND MEASURES 2.2 CM X (BY) 1.5. CM. AREA SURROUNDING THIS YELLOW/GREEN PORTION IS RED IN COLOR AND NONBLANCHING. RED AREA (WITH YELLOW/GREEN CENTER) MEASURES A TOTAL OF 3.4 CM X 3.2 CM. SKIN SURROUNDING THE REDDENED AREA IS BLANCHABLE. DENIES PAIN WITH PALPATION. NO FLUID FILLED AREA IS NOTED...KEEP SHOE OFF RIGHT FOOT AND KEEP FREE OF PRESSURE WHEN UP IN W/C (WHEELCHAIR)." THE "TREATMENT RECORD", DATED 9/2012, REFLECTED ORDERS TO MONITOR THE BOTTOM/SOLE OF THE RIGHT FOOT EVERY SHIFT AND NO SHOE OR PRESSURE TO THE RIGHT FOOT WHEN UP IN THE WHEELCHAIR BEGINNING ON 9/22/12. RESIDENT #2'S CARE PLAN RELATED TO THE RISK FOR SKIN BREAKDOWN, DATED 1/21/08 AND LAST REVIEWED ON 10/18/12, REFLECTED RESIDENT #2 WAS TO HAVE HER HEELS FLOATED WHILE IN BED, USE RIGHT FOOT PEDAL ON THE WHEELCHAIR AND AVOID SHEARING DURING POSITIONING (ALL DATED 3/15/11). THE INTERVENTION OF KEEPING THE SHOE OFF THE RIGHT FOOT AND PADDING THE RIGHT WHEELCHAIR FOOT REST WAS NOT ADDED UNTIL 9/24/12. ON 10/25/12 AT 10:45 A.M., THE DIRECTOR OF NURSING (DON) STATED THE RIGHT FOOT BRUISE IDENTIFIED FOR RESIDENT #2 IN THE 9/9/12 NURSING NOTES WAS THE SAME AREA AS THE CURRENT PRESSURE WOUND, WHICH WAS RECORDED ON THE "WEEKLY PRESSURE ULCER PROGRESS REPORT" ON 10/22/12 AS AN "UNSTAGEABLE" ULCER . THE DON CONFIRMED THERE WAS NO DOCUMENTATION ENTERED INTO THE CLINICAL RECORD, BETWEEN 9/9/12 AND 9/21/12, TO SHOW THAT THE FACILITY HAD BEEN MONITORING THE RIGHT HEEL OR INITIATING PREVENTATIVE INTERVENTIONS OR TREATMENT . THE RIGHT HEEL WOUND WAS OBSERVED AT 10:50 A.M. ON 10/23/12 IN RESIDENT #2'S ROOM AND WAS NOTED TO BE A FLAT, OVAL SHAPED, BROWN WOUND THAT HAD DRIED AND APPEARED TO BE RESOLVING. ON 10/24/12 AT 10:45 AM AT THE WEST NURSING STATION LICENSED PRACTICAL NURSE (LPN) "G" STATED THAT RESIDENT #2 HAD NEEDED HER SHOES REPLACED, AS THE PREVIOUS PAIR WERE TOO SMALL. LPN "G" FURTHER STATED THAT RESIDENT #2 WENT WITHOUT SHOES UNTIL A NEW PAIR WAS OBTAINED. LPN "G" STATED, DURING THE SEVERAL DAYS WHEN RESIDENT #2 WAS WITHOUT SHOES, HER RIGHT FOOT AT TIMES RESTED ON THE EDGE OF THE WHEEL CHAIR FOOTREST, CREATING PRESSURE OVER THE AREA WHERE THE BLISTER DEVELOPED. LPN "G" STATED THAT AFTER THE RESIDENT'S RIGHT LEG (ON HER PARTIALLY PARALYZED SIDE) WAS PLACED ON THE FOOT PEDAL BY STAFF, RESIDENT #2 COULD MOVE THE FOOT A SMALL AMOUNT WHILE CHANGING HER POSITION, BUT WAS NOT ABLE TO MOVE THE FOOT OFF THE EDGE OF FOOTREST ON HER OWN. BASED ON THE NURSING NOTES, DATED 9/11/12 AT 1:35 PM, RESIDENT #2 WENT SHOPPING AT THE MALL ON THAT DATE. DURING AN INTERVIEW ON 10/25/12 AT 10:45 AM THE DON CONFIRMED, ALONG WITH THE FACILITY SOCIAL WORKER "R", THAT THE NEW SHOES WERE PURCHASED ON 9/11/12. HOWEVER, RESIDENT #2 WAS NOT WEARING SHOES FOR SEVERAL DAYS PRIOR TO 9/11/12, AND THE INITIAL BRUISE TO HER RIGHT HEEL WAS IDENTIFIED ON 9/9/12. NEITHER THE DON NOR LPN "G" KNEW WHEN RESIDENT #2 STARTED WEARING THE NEW SHOES. THE DON HAD NO EVIDENCE TO SHOW THAT THE INCREASED RISK TO THE RESIDENT'S HEELS DURING THAT PERIOD HAD BEEN IDENTIFIED AS A CONCERN. DURING OBSERVATIONS INCLUDING BUT NOT LIMITED TO 10:30 A.M., 10:50 A.M. AND 12:20 P.M. ON 10/23/12, RESIDENT #2 WAS OBSERVED SEATED IN HER WHEELCHAIR. RESIDENT #2 WAS OBSERVED TO LEAN TO THE RIGHT, AND HER RIGHT FOOT RESTED ON THE FOOTPEDAL PADDED WITH A SHEEPSKIN TYPE MATERIAL. RESIDENT #2 ALSO WORE A PADDED HEEL PROTECTOR OVER THE RIGHT FOOT. RESIDENT #2 WAS INTERVIEWED ON 10/26/12 AT 11:00 AM IN HER ROOM, BUT DECLINED TO ANSWER QUESTIONS RELATED TO HER HEEL WOUND OR WHEN SHE BOUGHT THE NEW SHOES. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY IMPLEMENT PRESSURE RELIEVING INTERVENTIONS TO PROMOTE HEALING OF A PRESSURE ULCER FOR ONE RESIDENT (#15) OF FOUR RESIDENTS REVIEWED FOR PRESSURE ULCERS FROM A TOTAL SAMPLE OF SIX RESIDENTS. THIS DEFICIENT PRACTICE RESULTED IN THE DETERIORATION OF CONDITION AND INCREASE IN SIZE OF A FACILITY ACQUIRED PRESSURE ULCER WITH AN INCREASED RISK FOR INFECTION. FINDINGS INCLUDE: BASED ON REVIEW OF THE ADMISSION FACE SHEET (NO DATE), RESIDENT #15 WAS AN [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. ACCORDING TO THE DECEMBER 2012 FOOD ACCEPTANCE RECORD (UP TO DECEMBER 19, 2012) AND THE DIETICIAN NOTES FOR 11/2012, RESIDENT #15 WAS EATING 100% OF HER MEALS. HER LABORATORY TESTS FOR OCTOBER, NOVEMBER AND DECEMBER 2012 (THROUGH 12/19/2012) DID NOT REFLECT THAT RESIDENT #15 WAS AT SIGNIFICANTLY HIGH RISK FOR PRESSURE ULCER DEVELOPMENT. ACCORDING TO THE "WEEKLY PRESSURE ULCER PROGRESS REPORT", RESIDENT #15 WAS FIRST IDENTIFIED AS HAVING A STAGE 2 COCCYX (TAILBONE) PRESSURE ULCER ON 11/4/2012, APPROXIMATELY ONE WEEK AFTER THE FACILITY'S STANDARD SURVEY WAS CONDUCTED (WITH A COMPLETION DATE OF 10/26/2012 AND A PLAN OF CORRECTION DATE OF 12/3/2012). A STAGE 2 PRESSURE ULCER IS DEFINED AS A WOUND CHARACTERIZED BY PARTIAL THICKNESS SKIN LOSS INVOLVING THE EPIDERMIS, DERMIS, OR BOTH. THE FOLLOWING WOUND ASSESSMENTS WERE DOCUMENTED FOR RESIDENT #15 BETWEEN 11/4/12 AND 12/17/12: 11/4/2012 1.0 X 0.7 CM (CENTIMETERS) BY .1 IN DEPTH. 11/9/2012 1.1 X 0.5 CM BY 0.1 IN DEPTH. 11/16/2012 1.0 X 0.9 CM BY 0.1 IN DEPTH. 11/23/2012 1.1 X 0.1 CM BY 0.1 IN DEPTH. 11/30/2012 1.8 X 1.0 CM BY 0.1 IN DEPTH. 12/3/2012 3.2 X 0.8 CM BY 0.1 IN DEPTH. 12/10/2012 3.0 X 1.0 CM BY 0.3 IN DEPTH. ON ALL OF THE ABOVE DATES, RESIDENT #15'S WOUND WAS DESCRIBED AS PINK IN COLOR AND WAS NOT DESCRIBED AS HAVING ANY ODOR OR DRAINAGE. HOWEVER, ON 12/17/2012, RESIDENT #15'S WOUND WAS DESCRIBED IN THE "WEEKLY PRESSURE ULCER PROGRESS REPORT" AS MEASURING 1.2 X 2.0 CM BY 0.3 IN DEPTH, PINK IN COLOR, WITH A .5 X .5 CM AREA OF NECROTIC TISSUE NOTED. NO ODOR OR DRAINAGE WAS DOCUMENTED. RESIDENT #15'S WOUND WAS OBSERVED WITH CHARGE NURSE, LICENSED PRACTICAL NURSE (LPN) "D" AND CERTIFIED NURSING ASSISTANT (CNA) "B" IN THE RESIDENT'S BATHROOM FOLLOWING HER TOILETING AT 11:15 A.M. ON 12/20/2012. CNA "B" WAS OBSERVED TO REMOVE A SELF-ADHERING DRESSING FROM RESIDENT #15'S COCCYX WOUND. THE DRESSING WAS OBSERVED TO BE HEAVILY SOILED WITH A YELLOW-GREEN DRAINAGE AND HAD A FOUL ODOR. THE WOUND COULD ONLY BE VISUALIZED WITH ASSISTANCE FROM ANOTHER PERSON, WHO HELD THE RESIDENT'S BUTTOCKS APART. RESIDENT #15 WAS ASSISTED TO STAND WITH HER WALKER, WITH ASSISTANCE FROM THE CNA. CORPORATE NURSE CONSULTANT, REGISTERED NURSE "C" WAS PRESENT TO VISUALIZE THE WOUND. CORPORATE NURSE CONSULTANT "C" USED A COTTON-TIPPED APPLICATOR TO ASSESS THE DEPTH OF THE WOUND, AND IT WAS FOUND TO BE 1.2 CM DEEP. DURING THE OBSERVATION AT 11:15 A.M. ON 12/20/2012, RESIDENT #15'S WOUND WAS OBSERVED TO BE APPROXIMATELY 5.0 X 5.0 CM (2 INCHES X 2 INCHES) AND 1.2 CM DEEP. THE BACK OF THE WOUND COULD NOT BE VISUALIZED. THE WOUND HAD A FOUL ODOR WITH A LARGE AMOUNT OF YELLOW-GREEN DRAINAGE. WOUNDS THAT HAVE A FOUL ODOR AND GREEN DRAINAGE ARE CONSISTENT WITH THE PRESENCE OF AN INFECTION. YELLOW SLOUGH (NECROTIC TISSUE IN THE PROCESS OF SEPARATING FROM VIABLE TISSUE) WAS PRESENT IN THE WOUND BED, AND THE DEPTH OF THE WOUND HAD PENETRATED THROUGH THE SUB-CUTANEOUS LAYER OF SKIN, CONSISTENT IN APPEARANCE WITH A STAGE 3 (RATHER THAN A STAGE 2) PRESSURE ULCER WOUND. A STAGE 3 PRESSURE ULCER IS DEFINED AS A WOUND WITH FULL THICKNESS SKIN LOSS, INVOLVING DAMAGE OR NECROSIS OF SUBCUTANEOUS TISSUE THAT MAY EXTEND DOWN TO, BUT NOT THROUGH, UNDERLYING FASCIA (MUSCLE TISSUE). AN INTERVIEW WITH CORPORATE NURSE CONSULTANT "C" AND THE DIRECTOR OF NURSING (DON) TOOK PLACE IN THE CONFERENCE ROOM AT 12:05 P.M. ON 12/20/2012. THE DON WAS ASKED IF SHE WAS AWARE THAT RESIDENT #15'S COCCYX WOUND HAD DETERIORATED OVER THE PAST THREE DAYS, FROM THE SUPERFICIAL (STAGE 2) WOUND THAT WAS DOCUMENTED BY THE FACILITY ON 12/17/12 TO THE WOUND AS IT WAS OBSERVED ON 12/20/12. THE DON STATED THAT THE WOUND "WAS A STAGE 2 ON MONDAY" AND ALSO STATED THAT SHE HAD NOT BEEN MADE AWARE OF ANY ODOR OR DRAINAGE. CORPORATE NURSE CONSULTANT "C" WAS ASKED IF SHE CONSIDERED THE WOUND TO BE DETERIORATED IN APPEARANCE FROM WHAT WAS DOCUMENTED ON THE WOUND CARE SHEET THREE DAYS EARLIER. CORPORATE NURSE CONSULTANT "C" STATED, "ACCORDING TO OUR POLICY, IT IS NOW A STAGE 3." THE DON WAS ASKED WHY THE WOUND HAD DETERIORATED SO QUICKLY AND THE DON RESPONDED THAT RESIDENT #15 WOULD NOT GET OUT OF HER CHAIR UNLESS GOING TO THE BATHROOM AND WAS NON-COMPLIANT WITH STAFF LOOKING AT HER WOUND AND CHANGING HER DRESSING. THE DON ALSO STATED THAT RESIDENT #15 WOULD ONLY SLEEP IN HER RECLINER AND WOULD NOT SLEEP IN HER BED. THE DON ADDED THAT RESIDENT #15 WAS UP IN HER WHEELCHAIR AND/OR RECLINER 24 HOURS A DAY, EXCEPT WHEN SHE WAS OUT OF THE CHAIRS TO GO TO THE TOILET. WHEN ASKED WHAT INTERVENTIONS WERE IN PLACE TO ENSURE PRESSURE RELIEF TO THE RESIDENT'S COCCYX, THE DON STATED THAT RESIDENT #15 HAD A PRESSURE RELIEVING CUSHION IN HER WHEELCHAIR AND IN HER RECLINER CHAIR AT NIGHT. A REVIEW OF THE WOUND CARE SHEET FOR RESIDENT #15 FOR DECEMBER 2012 REFLECTED THAT THE PRESSURE WOUND DRESSING TO HER COCCYX HAD BEEN SCHEDULED TO BE CHANGED ELEVEN TIMES BETWEEN DECEMBER 11, 2012, AND DECEMBER 19, 2012. OF THOSE ELEVEN SCHEDULED DRESSING CHANGES, ONLY ONE ENTRY (DECEMBER 17TH) WAS CIRCLED TO INDICATE THAT THE DRESSING CHANGE WAS NOT DONE, AND IT WAS NOT INDICATED THAT THIS WAS DUE TO THE RESIDENT REFUSING THE DRESSING CHANGE. A REVIEW OF THE CARE PLAN FOR RESIDENT #15 FOR "STAGE 2 TO COCCYX WITH POTENTIAL FOR INFECTION AND DISCOMFORT", DATED 11/4/2012, REFLECTED THERE WAS AN APPROACH TO REDUCE PRESSURE BY USING A "PRESSURE REDUCTION CUSHION." HOWEVER, THE CARE PLAN DID NOT STATE THAT THE PRESSURE REDUCING CUSHION WAS TO BE IN THE RESIDENT'S RECLINER CHAIR AT NIGHT. A REVIEW OF THE "WORKING CARE GUIDE" (A DOCUMENT FOR THE CNA'S THAT IDENTIFIES THE CARE NEEDED FOR EACH RESIDENT) DATED 12/14/2012 REFLECTED AN ENTRY FOR RESIDENT #15 THAT READ: "CUSHION TO WHEEL CHAIR, CUSHION TO RIGHT LEG REST ON WHEELCHAIR..." THE DOCUMENT FAILED TO REFLECT ANY INSTRUCTIONS FOR USING A PRESSURE RELIEVING CUSHION IN THE RESIDENT'S RECLINER AT NIGHT. AN INTERVIEW WITH TWO CNA'S, STAFF "A" AND "B" (WHO VERIFIED THEY REGULARLY PROVIDED CARE TO RESIDENT #15), TOOK PLACE ON 12/20/2012 AT 2:00 P.M. CNA "A" STATED THAT RESIDENT #15'S PRESSURE RELIEVING CUSHION WAS ALWAYS KEPT IN RESIDENT #15'S WHEELCHAIR. CNA "A" AND CNA "B" VERIFIED THAT, SOMETIMES, THEY WERE THE STAFF TO GET RESIDENT #15 OUT OF HER RECLINER AND INTO HER WHEELCHAIR IN THE MORNINGS. CNA "A" STATED, "THE CUSHION IS ALWAYS IN THE WHEELCHAIR, NOT IN THE RECLINER." CNA "B" WAS OBSERVED TO PULL HER "WORKING CARE GUIDE" FROM HER POCKET, AND REVIEW IT, AND WAS THEN HEARD TO STATE, "IT JUST CALLS FOR THE CUSHION IN THE WHEELCHAIR, NOT IN THE RECLINER." AN INTERVIEW WITH THE DON TOOK PLACE IN THE CONFERENCE ROOM ON 12/20/2012 AT 2:10 P.M. THE DON WAS TOLD THAT CNA INTERVIEW INDICATED THAT RESIDENT #15'S PRESSURE RELIEVING CUSHION WAS NOT IN HER RECLINER WHEN THEY GOT HER UP FROM THE RECLINER IN THE MORNINGS. THE DON CONFIRMED THAT IT WAS HER EXPECTATION THAT THE CUSHION WAS TO BE IN THE RECLINER, WHEN THE RESIDENT WAS IN THE RECLINER, AND IN THE WHEELCHAIR, WHEN THE RESIDENT WAS IN THE WHEEL CHAIR. THE DON HAD NO EVIDENCE TO SHOW THAT THERE WAS ANOTHER OTHER PLAN IN PLACE FOR PROVIDING PRESSURE RELIEF FOR RESIDENT #15 WHILE SHE WAS SLEEPING IN HER RECLINER AT NIGHT. ( )

This citation pertains to intake MI 209, and MI 634. Based on interview and record review, the facility neglected to provide services necessary to avoid physical harm for 1 (#102) of 5 sampled residents, of a total sample of 5 residents, resulting in the delayed treatment of [REDACTED]. Findings include: In an interview on 8/29/12 at 8:50 am, Director of Nursing #2 stated Resident #102 had been discharged to the hospital on [DATE] with an increased sodium level. At the time of the investigation, Resident #102 was still in the hospital. Review of Resident #102's medical record revealed Resident #102 was an [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His minimum data set ((MDS) dated [DATE] indicated he was moderately impaired with cognitive skills, required extensive assistance of two persons for transfers and dressing, extensive assistance of one person for eating, and bathing, that he had experienced on fall with a minor injury, no complaints of pain, and had one stage II pressure wound. Facility incident/accident report dated 7/23/12 indicated at 8:10 pm, Resident #102's alarm was sounding and he was found on the floor in front of his wheelchair on his left side with his left arm pinned behind the night stand and against the radiator and an irregular angle. The incident report indicated Resident #102 complained of pain to the left arm, had an abrasion to the left top of his head, and was transferred to the hospital by ambulance at 8:30 pm. Hospital Emergency physician note for Resident #102, dated 7/23/12 indicated provisional [DIAGNOSES REDACTED]. The note indicated Resident #102 was placed in a shoulder immobilizer and the emergency room physician spoke with Orthopaedic Physician #5 (DR #5) regarding Resident #102 and that Resident #102 was to call for an appointment on 7/24/12 for evaluation regarding his arm fracture. Review of facility physician orders and facility nurse's notes for the month of July 2012 for Resident #102 did not reveal any orders or notes regarding an appointment or transfer to a physician appointment for Resident #102. Facility nurse's notes dated 7/24/12 at 1:16 am indicated Resident #102 returned from hospital with fractured humerus and appointment will be made with DR #5 for follow up, with left hand grip slightly weaker than right. A letter (undated), signed by the office practice manager (PM #19) for Orthopaedic Physician #5 (DR #5), which was located in Resident #102's medical record, was addressed to "Administrator" and indicated Resident #102 was seen in DR #5's office on 7/30/12. The letter indicated Resident #102 was "dropped off", nobody had accompanied him, and there had been no accompanying paperwork even though the office had sent paperwork to the facility prior to the appointment and that Resident #102 was unable to provide any information. The letter also indicated Resident #102 was to have a CAT scan and return for follow up and requested confirmation from the facility that Resident #102 had the CAT scan done and for the facility to call DR #5's office to schedule the follow up appointment. Doucmentation from the Orthopaedic physician office dated 7/30/12, provided to the surveyor by the facility, indicated that DR #5 reviewed the initial xrays of Resident #102'S left arm, found an obvious fracture of the "proximal left humerus" and it appeared to be a three part fracturebut he views were limited, therefore a decision could not be made regarding treatment options based on those xrays, so a CAT scan was ordered. Review of the entire medical record for Resident #102 did not reveal results of a CAT scan of Resident #102's left arm, or documentation of Resident #102 being seen by DR #5. There was no physician's order for a sling to Resident #102's left arm located. In an interview on 8/30/12 at 11:20 am, DON #2 stated the DR #5 spoke with Resident #102's son and told the son he was not going to do surgery on Resident #102's arm. DON #2 stated Resident #102 was originally supposed to see DR #5 on 7/27/12, but didn't go until 7/30/12. When the surveyor asked why Resident #102 didn't go on 7/27/12, DON #2 stated, I don't know. When the surveyor asked why Resident #102 was sent by himself, with no paperwork to a physician appointment, DON #2 stated, I don't know. When the surveyor asked DON #2 if Resident #102 was actually ever seen by DR #5, DON #2 stated she wasn't sure. DON #2 stated Resident #102 did go to the hospital on [DATE] and have an Xray of the left humerus. When the surveyor asked DON #2 why Resident #102 had another Xray on 8/10/12, DON #2 stated, "that I don't know". In an interview on 8/31/12 at 11:00 am, Resident #102's son stated he was never contacted by the orthopaedic physician (DR #5) and had not ever spoken with him regarding his father's arm. Resident #102's son stated the facility faxed him paper work to sign regarding surgery on his father's arm. Resident #102's son correctly identified the name of the practice for DR #5 and stated is was on the top of the paperwork he signed and faxed back to the facility. Resident #102's son stated he believed his father was going to have surgery on his arm to repair the fracture and the only hold up was getting the insurance straight. Resident #102's son stated he lived out of state and facility staff communicated with him via telephone. In an interview on 8/31/12 at 10:50 am, the surveyor asked Administrator #1 (AD #1) and Nurse Consultant #12 (NC #12) if Resident #102 ever had the CAT scan of his left arm done and if he had ever been seen for the follow up visit by the orthopaedic physician. AD #1 stated she did not know and NC #12 stated she did not know, but she would call the orthopaedic office to find out about the CAT scan. In an interview on 8/31/12 at 11:10 am, NC #12 stated she spoke with someone at DR #5's office and was told that the CAT scan for Resident #102 was on hold because they were waiting to talk to the Power of Attorney for Resident #102 and get permission. In an interview on 8/31/12 at 11:15 am, Practice Manager #19 for DR #5 (PM #19) stated she had not spoken with NC #12 on the phone that day. PM #19 then asked other staff in the office if they had spoken with a staff member at the facility, then PM #19 stated nobody in the office was reporting that they had spoken with NC #12 regarding Resident #102. PM #19 stated the CAT scan for Resident #102 was not on hold because it had already been done. PM #19 stated Resident #19 had been sent to the hospital by the facility on 8/10/12 to have a CAT scan of his left arm and DR #5's office had the results sent to the office by the hospital, so she had the results already. When the surveyor asked PM#19 if Resident #102 had been seen for the follow up visit since the CAT scan, PM #19 stated no he had not and the facility had not called to schedule the appointment. PM #19 stated she did speak with the administrator of the facility and told her how Resident #102 was "dumped" at the office on 7/30/12 and how important it was for Resident #102 to have the CAT scan of his left arm done and to be scheduled to return for follow up care. In an interview on 8/31/12 at 11:30 am, Administrator #1 (AD #1) stated she did not speak with anybody at the orthopaedic office regarding Resident #102. The surveyor had AD #1 review the letter addressed to Administrator regarding Resident #102 arriving to DR #5's office unaccompanied, with no paperwork, with a request for a CAT Scan and a follow up appointment. The surveyor asked AD #1 why Resident #102 was sent with a fractured arm, alone, to a physician's appointment, with no paperwork, and AD #1 stated she had no idea. The surveyor asked AD #1 if the CAT scan had been done, and AD #1 stated she did not know, she wasn't that involved. The surveyor asked AD #1 if she had been involved with investing and reporting the fall and fracture of Resident #102 to the regulatory agency, and AD #1 stated yes. AD #1 then stated she had no idea if she did or didn't speak to someone at the orthopaedic physician's office. In an interview on 9/4/12 at 2:45 pm, DON #2 stated it was her understanding that nothing was to be done for the fracture of Resident #102's left arm. The surveyor asked DON #2 how she came to that understanding and DON #2 stated when Resident #102 returned from the hospital with only an order for [REDACTED].#102 wear a sling on his left arm, lead her to the understanding that nothing was to be done for Resident #102's fractured arm, DON #2 stated yes. DON #2 stated she did not know why Resident #102 was not sent for a follow up visit after the CAT scan of his left arm was done. In an interview on 9/4/12 at 3:50 PM, NC #12 stated she heard Resident #102 did not return for a follow up visit with DR #5 because "they were unable to get him in for an appointment". In an interview on 9/5/12 at 4:20 pm, DR #5 stated Resident #5 was dropped off by the facility at his office with no records and nobody with him. DR #5 stated Resident #102 was demented and could not tell him (DR #5) anything and DR #5 could not tell Resident #102 anything. DR #5 stated Resident #102's fractured arm was something that needed to be discussed with Resident #102's Power of Attorney, but he (DR #5) had no records, so no way to find that information. DR #5 also stated he had no idea how or when the fracture happened. DR #5 stated the xrays taken at the hospital were not very clear, so he ordered a CAT scan to be done of Resident #102's left arm and for Resident #102 to return for a follow up visit as soon as the CAT scan was completed. DR #5 stated Resident #102 did not return for a follow up visit. The surveyor asked DR #5 if it could be possible that Resident #102 did not return for a follow up visit because the facility attempted to get him an appointment but could not get him in, and DR #5 stated, absolutely not. DR #5 stated at that point Resident #102 was an established patient, he needed to be seen as soon as possible, and his staff would have gotten him right in. DR #5 stated that is absolutely not true. DR #5 stated Resident #102's initial visit was incomplete due to unclear xrays and he (DR #5) was unable to give Resident #102 an exact [DIAGNOSES REDACTED].#5) was not able to give Resident #102 a treatment plan with left Resident #102 with a less than fully functional arm. Review of hospital physician history and physical form for Resident #102 dated 8/27/12 revealed the hospital physician spoke with Resident #102's son and it was his (Son's) desire that all treatment measures are provided and pursued. Review of July, 2012 and August, 2012 facility physician orders for Resident #102 revealed Resident #102 had written physician's orders to be a full code. #

This citation pertains to intake MI 209, and MI 634. Based on interview and record review, the facility failed to assess and monitor 1 (#102) resident of 5 sampled residents, of a total sample of 5 residents, for a decline in physical condition, resulting in Resident #102 developing [MEDICAL CONDITION] (high level of sodium in the blood) secondary to dehydration, large necrotic and infected pressure sores which required surgical intervention, and severe protein calorie [MEDICAL CONDITION]. Findings include: In an interview on 8/29/12 at 8:50 am, Director of Nursing #2 stated Resident #102 had been discharged to the hospital on [DATE] with an increased sodium level. At the time of the investigation, Resident #102 was still in the hospital. Review of Resident #102's medical record revealed Resident #102 was an [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His minimum data set ((MDS) dated [DATE] indicated he was moderately impaired with cognitive skills, required extensive assistance of two persons for transfers and dressing, extensive assistance of one person for eating, and bathing, that he had experienced on fall with a minor injury, no complaints of pain, and had one stage II pressure wound. His minimum (MDS) data set [DATE] indicated he was severely impaired with cognitive skills, required maximum assistance of two persons with transfers, required extensive assistance of two persons for dressing, extensive assistance of one person for eating and bathing, had one fall with a major injury, had nonverbal sounds of pain and facial grimacing 3 to 4 days a week, and now had 2 stage II pressure wounds. The 8/7/12 MDS also indicated that Resident #102 had a 5% or more weight loss in the last month or 10% or more weight loss in the last 6 months. Facility incident/accident report dated 7/23/12 indicated at 8:10 pm, Resident #102's alarm was sounding and he was found on the floor in front of his wheelchair on his left side with his left arm pinned behind the night stand and against the radiator and an irregular angle. The incident report indicated Resident #102 complained of pain to the left arm, had an abrasion to the left top of his head, and was transferred to the hospital by ambulance at 8:30 pm. Hospital Emergency physician note for Resident #102, dated 7/23/12 indicated provisional [DIAGNOSES REDACTED]. physician progress notes [REDACTED]. The physical exam under "extremities" revealed pain over left wrist and no [MEDICAL CONDITION]. physician progress notes [REDACTED]. food acceptance" and that he usually eats 100% of his meals. physician progress notes [REDACTED]. physician progress notes [REDACTED]. meal and recheck labs in 2 weeks. The progress note indicated Resident #102 had good food acceptance and also had involuntary facial movements. According to Resident #102's food acceptance record for the month of August 2012, Resident #102 consumed less than 50 percent or less of his breakfast meal 8/6, 8/13, 8/17, 8/18, 8/19, 8/20, 8/24, and 8/25. Resident #102 consumed less than 50 percent or less of his lunch meal 8/6, 8/10, 8/11, 8/13, 8/15-8/17, 8/18-8/22, 8/24-8/26. Resident #102 consumed less than 50 percent or less of his supper meal 8/11, 8/19, 8/21, 8/24, 8/25, and 8/26, and consumed none of his supplement on all days and all meals except breakfast 8/16, 8/17, 8/22, and 8/23. The food acceptance record also indicated Resident #102 was not offered an evening snack during the month of August 2012. Review of laboratory values for Resident #102 dated 7/10/12 indicated a sodium level of 143 (normal 134 to 146), calcium level 8.2 (normal 8.6 to 10.4), and [MEDICATION NAME] level of 13.9 (normal 20 to 40). Review of laboratory values for Resident #102 dated 8/2/12 indicated a urea nitrogen (BUN) level of 28 (normal 7 to 25) sodium level of 150, and chloride level of 112 (normal 98 to 110), [MEDICATION NAME] level of 2.8 (normal 3.6 to 5.1 measures protein levels), hemoglobin 10.8 (normal 13.2 to 17.1 measures iron containing oxygen transporting protein in the blood) Review of laboratory values for Resident #102 dated 8/9/12 indicated a urea nitrogen (BUN) level of 26 (normal 7 to 25) sodium level of 155, and chloride level of 116 (normal 98 to 110), a [MEDICATION NAME] level of 14 (normal 20-40). Review of laboratory values for Resident #102 dated 8/13/12 indicated a urea nitrogen (BUN) level of 26 (normal 7 to 25) sodium level of 155, and chloride level of 117 (normal 98 to 110), [MEDICATION NAME] level of 2.1 (normal 3.6 to 5.1 measures protein levels), hemoglobin 9.2 (normal 13.2 to 17.1 measures iron containing oxygen transporting protein in the blood) and a [MEDICATION NAME] of 8. Review of laboratory values for Resident #102 dated 8/23/12 indicated an [MEDICATION NAME] of 1.6, a [MEDICATION NAME] of 10, a BUN of 31, a sodium of 159, a chloride of 123. According to the online Medical Dictionary (http://medical-dictionary.thefreedictionary.com/p/osmolality), serum osmolality is "a measure of the number of dissolved particles per unit of water in serum... Measurement of the serum osmolality gives information about the hydration status within the cells because of the osmotic [MEDICATION NAME] that is constantly being maintained on either side of the cell membrane (homeostasis). Water moves freely back and forth across the membrane in response to the osmotic pressure being exerted by the molecules of solute in the intracellular and extracellular fluids. Serum osmolality reflects the status of hydration of the intracellular as well as the extracellular compartments and thus describes total body hydration". Normal adult blood osmolality is 285 to 296 mOsm/kg H2O with greater than 296 defined as dehydration. Serum Osmolality is calculated using the following formula: (2 x (NA) + (BUN/2.8) + (Glucose/18). The lab results for Resident #102 from 8/2/12 calculate his serum osmolality to be 316, or Dehydrated. The lab results for Resident #102 from 8/9/12 calculate his serum osmolality to be 325, or Dehydrated. The lab results for Resident #102 from 8/13/12 calculate his serum osmolality to be 325, or Dehydrated. The lab results for Resident #102 from 8/23/12 calculate his serum osmolality to be 335, or Dehydrated. Review of Weekly Pressure Ulcer Progress Report for Resident #102 prior to his fall and fractured arm on 7/23/12, revealed on 4/16/12 Resident #102 had a stage II shearing wound which measured 1 centimeter (cm) by 4 centimeters and 0.01 centimeters deep on 4/16/12 and on 7/23/12 he had the same wound which measured 2.7 cm by 4 cm and 0.1 cm deep, with no other wounds documented. Review of Weekly Pressure Ulcer Progress Report for Resident #102 after his fall and fractured arm on 7/23/12, revealed on 8/23/12 the wound on his left ischium had increased to 7 centimeters by 4.8 centimeters by .2 centimeters. Weekly Pressure Ulcer Progress Report dated 8/20/12 indicated Resident #102 had also developed a Stage II pressure wound to his right ischial which measured 1.8 cm by 1.6 cm by 0.1 cm, and an additional Pressure Ulcer Progress Report dated 8/23/12, indicated Resident #102 had developed a stage I wound on his right heel which measured 4 cm by 4 cm. Facility Nurse's note dated 8/16/12 indicated Resident #102 had a temperature and DON #2 was notified by nursing staff due to left ischium wound did not appear to be responding to treatment. Facility nurse's note dated 8/21/12 indicated Resident #102 moaned and groaned with movement. Facility nurse's note dated 8/24/12 indicated Resident #102's left ischium wound remained blackened with foul green purulent drainage and Resident #102 moaned during wound care. Facility nurse's note dated 8/26/12 indicated Resident #102 had a fever, low blood pressure, had a poor appettite, drank very little fluid, appeared dusky in color and remained in bed. The note indicated Resident #102 had a wound to his left buttock which was blackened , concave had tunneling, large amounts of grey, green, foul exudent is noted seeping from wound. Review of Resident #102's activity of daily living plan of care dated 6/24/2008 revealed he had a self care deficit with an intervention listed to include report any deterioration in status to doctor. However, the plan of care was not updated after he sustained a fracture to his left upper arm on 7/23/12. Review Resident #102's Pain plan of care dated 7/17/2007 indicated he had the potential for pain related to abnormal posture, multiple disease processes, history of hip and hand fractures, impaired mobility, and frequent skin tears, with updates 2/23/11 - no complaints of pain and 5/15/12 when he had complaints of back pain. The pain plan of care was not updated when Resident #102 fractured his left upper arm on 7/23/12. Review of Resident #102's nutrition/hydration risk plan of care dated 2/8/10 was updated 8/15/12 and indicated abnormal labs and Resident #102 refused meals at times with interventions listed (8/7/12) drinks in mugs with lid, and (8/15/12)extra 8 oz. fluids with meals. Review of Resident #102's potential for fluids imbalance plan of care and activity intolerance care plan dated 3/11/10 had not been updated sins 3/11/2010. Resident #102's plan of care for a pressure ulcer to his right heel with a start date of 4/9/12 had a goal target date listed of 6/9/12 and one intervention past 4/9/12 which was dated 8/6/12 of foam boot to right heal at all times. Resident #102's plan of care for [MEDICAL CONDITION] to left ischium dated 7/9/12 had all interventions listed with the date of 7/9/12 with one intervention of "give antibiotics as ordered, monitor for effectiveness, observe and report any adverse reactions such as discomfort, pain, or itching in the ear" crossed off and the dated of 8/20/12 written in. Resident #102's skin care plan dated 9/4/2008 indicated he developed shearing to left ischium in 4/12/12, a stage II wound to his right heel on 8/10/12, and a stage II wound to his right ischium on 8/6/12 with all interventions listed being prior to 4/20/12 except one intervention of an air mattress on 8/16/12. A cushion in Resident #102's wheelchair is listed as an intervention on 9/4/2008. In an interview on 8/31/12 at 1:25 pm, the Surveyor asked physician #16 if he had reviewed Resident #102's laboratory values in August and Physician #16 stated he had. Physician #16 stated Resident #102's sodium was going up, so he increased his fluids, but it went up again, so he sent him to the hospital. Physician #16 stated when he first noticed Resident #102 had an increased sodium and he ordered him to get additional fluids, he did not order for Resident #102 to be placed on Intake and Output (close monitoring and documentation of fluid intake and output). The surveyor asked physician #16 if he he thought Resident #102 received the additional fluids he (physician #16) had ordered, and Physician #16 stated, "I don't know". In an interview on 9/4/12 at 12:45 pm, the surveyor asked Dietary Manager #4 (DM #4) how she monitored whether Resident #102 received the additional fluids ordered by the physician on 8/14/12, and DM #4 stated she wrote it on his tray card so the kitchen staff would know to put it on his tray. The surveyor asked DM #4 how she monitored if Resident #102 was actually drinking it, and DM #4 stated it should be on his food acceptance sheet. The surveyor asked if there was any other location where flood or nutrition was documented and DM #4 stated no. DM #4 stated after Resident #102 fractured his arm, he was not able to pick up his mugs of fluid and drink by himself, and the mug of water in his room would have to be offered to him, because he would not pick it up and drink it himself. The surveyor asked DM #4 what interventions were in place to assist with wound healing for Resident #102 and DM #4 stated Resident #102 had high calorie, high protein foods on his trays and supplements at every meal. The surveyor had DM #4 review Resident #102's food acceptance sheet which revealed the section for supplements for the entire month of August except 4 breakfast meals were marked as zero, and decreased food intake for the month of August. Review of Nutritional Assessment for Resident #102 dated 6/5/12 revealed his daily fluid needs were between 2036 to 2430 cc's. Review of Resident #102's food acceptance sheets for the month of August 2012 revealed Resident #102 did not receive 1000 cc's of fluid in one day. In an interview on 9/4/12 at 2:45 pm, the surveyor asked DON #2, after physician #16 identified Resident #102 to have an increased sodium level, and ordered increased fluids, what was done by the facility staff to prevent dehydration and monitor Resident #102 for signs and symptoms of dehydration. DON #2 reviewed Resident #102's medical record, and then stated "nothing". The surveyor asked DON #2 if Resident #102 was placed on I & O to monitor his fluids and DON #2 stated no. The surveyor asked DON #2 what preventions were put into place for Resident #102 when he began to develop worsening pressure sores, and DON #2 stated they started turning Resident every 2 hours. The surveyor stated that intervention was already listed on the plan of care for Resident #102 for several years, and DON #2 stated, "we really started making sure we were doing it". DON #2 stated they put a cushion his Resident #102's wheelchair, and the surveyor also pointed out that intervention was listed previously on Resident #102's plan of care. DON #2 stated an air mattress was added to Resident #102's bed, treatments were done to his wounds and supplements were added to his meals. The surveyor had DON review Resident #102's food acceptance sheet which revealed the section for supplements for the entire month of August except 4 breakfast meals were marked as zero. Review of July, 2012 and August, 2012 facility physician orders [REDACTED]. Review of physician's orders [REDACTED].#102 to the hospital for evaluation and treatment. Facility Resident Transfer form dated 8/27/12 indicated resident #102 was transferred to the hospital with a primary [DIAGNOSES REDACTED]. Review of hospital physician history and physical form for Resident #102 dated 8/27/12 revealed Impression to include, [MEDICAL CONDITION] secondary to dehydration and general failure to thrive, suspect he has no free water access with his dementia and his broken arm, Large necrotic decubitus ulcer posterior to the scrotum, "This needs to be debrided today", and Protein calorie [MEDICAL CONDITION], severe by an [MEDICATION NAME] of 1.8. The history and physical indicated that the hospital physician spoke with Resident #102's son and it was his (Son's) desire that all treatment measures are provided and pursued. The History and Physical indicated there was tunneling in the wound on Resident #102's buttock and that he could stick his entire finger into the wound, which was large amounts of grey-brown purulence and pus (drainage). #

This citation pertains to intake #MI 102 Based on observation, interview and record review the facility failed to maintain functional safety devices in 1 of 4 sampled residents (#102), from a total sample of 4 residents, resulting in Resident #102 falling and sustaining a laceration to his head requiring emergency medical treatment and 11 staples. Findings include: Review of the Face Sheet revealed Resident #102 was not his own responsible party, was admitted on 9-1-11 with the following Diagnoses: [REDACTED]. Review the Minimum Data Set, ((MDS) dated [DATE] revealed Resident #102 had a Brief Interview for Mental Status (BIMS) score of 5/15 (severe cognitive impairment). The MDS indicated Resident #102 required extensive assistance with transfers and supervision with walking. Review of the Falls Prevention Risk assessment dated [DATE], revealed Resident #102 had a score of 14 (Moderate risk of falls). A Fall assessment dated [DATE] revealed Resident #102 scored 18 (High risk of falls). Review of the Hospice IDT Care Plan dated 12-9-11 to 12-26-11 revealed Resident #102 was, "High risk for falls due to elevated fall risk score and history. Interventions listed, bed alarm and personal alarm in use, bed to remain at lowest position , mats on floor at bedside (wall at bedside also padded to reduce risk of injury from striking head when sitting down on bed)." Review of the Fall Care Plan dated 9-2-11 revealed, "9-14-11 Resident (#102) was running in hall and ran into wall. Resident has history of turning off alarms at times, 9-20-11 Searching for water and ice chips. Non-compliant with waiting for staff to assist with ambulation." Under approach the care plan documented, keep bed in lowest position with brakes locked, mat on floor by bed. Review of incident/accident report dated 1-25-12, revealed Resident #102 was "found on floor, aide heard a noise and seen resident laying on back in room. Assessed for injury, none present. Continue to monitor for impulsive behavior, scoop mattress." Review of the incident/accident report dated 2-13-12, revealed Resident #102 was observed sitting on the floor at 12:30 PM with a laceration to the right side of his scalp. Review the Incident/Accident Summary dated 2-13-12, signed by the the Director of Nursing (DON) #1 revealed Resident #102 " was observed by nurse at approximately 12:30 PM on the floor, sitting in an upright position with blood noted to his head. Upon further observation, resident was noted to have a laceration to top of head measuring approximately 15 cm (centimeters) in length. Resident was apparently attempting to ambulate in room without assistance, falling to the floor and hitting his head on the anti-tippers located on the back of his wheelchair. We will initiate floor mat sensor alarm to alert staff when resident exits bed." Review of the Investigation Summary, dated 2-14-12, revealed, "On 2-13-12 at 12:30 PM Resident (#102) was observed sitting on the floor in his room, upon assessment the nurse noted a laceration to the top right side of his head. First aid was administered, EMS was notified along with the Physician and family. Resident #102 was taken by gurney to the Emergency Department for sutures. He returned approximately 1 hour later with 11 staples intact to the right side scalp region. On 2-13-12 Resident #102 turned of his bed fall sensor and had gotten out of bed where the nurse observed him on the floor. Resident #102 has been re-assessed for safety concerns, we have replaced his bed sensor that he turned off, to a floor sensor with the alarm controls across the room to prevent him from turning it off." During an interview on 3-9-12 at 2:45 PM, Licensed Practical Nurse (LPN) #1 said she was working on 2-13-12 when Resident #102 fell and sustained a laceration to his head. LPN #1 stated she had passed Resident #102's room 5-10 minutes prior to finding him on the floor and he was in bed with the bed low and a mat on the floor next to the bed. LPN #1 stated, "I believe he stood up and walked across the room because things on the furniture had been moved". LPN #1 took the Surveyor to Resident #102's old room and pointed out the location of the furniture and the location where she found Resident #102 on the floor. LPN #1 indicated Resident #102 was found in front of the bathroom approximately 10' from the bed. LPN #1 stated Resident #102's bed alarm did not sound. LPN #1 stated that Resident #102 had a history of [REDACTED]. LPN #1 could not recall any new fall precautions placed once staff were aware that Resident #102 was able to turn his alarm off. During an interview on 3-9-12 at 3:05 PM, Certified Nursing Assistant (CNA) #1 stated she was able to recall seeing Resident #102 playing with his alarm and turning it off prior to his fall on 2-13-12. CNA #1 recalled Resident #102 making it to the door way (standing) several times and the alarm would not be sounding. CNA #1 could not recall any new interventions being put in place to prevent falls once staff were aware that Resident #102 was able to turn his alarm off. During an interview on 3-9-12 at 3:16 PM, CNA #2 stated she was assigned to Resident #102 on 2-13-12 when he fell and sustained a laceration to his head. CNA #2 said she had provided care to Resident #102 with CNA #3, and put him back to bed about 3 minutes prior to his being found on the floor. CNA #2 said Resident #102's bed was in a low position, mat on the floor, and the sensor alarm was turned on. When the Surveyor asked why the alarm did not sound at the time of the incident, CNA #2 stated that Resident #102 was able to turn his alarm off. CNA #2 could not recall any new interventions being put in place to prevent falls once staff were aware that Resident #102 was able to turn his alarm off. Review of a handwritten note dated 2-13-12, signed by CNA #3, revealed "At 11:30 AM, I assisted CNA #2 with Resident (#102), with changing resident brief and positioning. Upon leaving CNA #2 turned the sensor alarm on." During an interview on 3-13-12 at 10:50 AM, LPN #2 stated that when she had worked second shift, she had observed Resident #102 standing and the alarm did not go off and she was aware that staff had turned it on prior to his standing. LPN #2 could not recall starting any new fall precautions after she was aware Resident #102 was able to turn off his alarm. Review of the Neurological assessment dated [DATE] through 2-16-12 revealed that Resident #102 Neurological Assessment began showing an alteration of his neurological status on the 2:00 PM to 10:00 PM shift, on 2-15-12 (Right Pupil sluggish and pupil size of 2). Review of the Progress Notes dated 2-15-12 at 9:59 PM, revealed "Resident (#102) continues on neuro checks and vitals related to fall and injury on 2-13-12. Left pupil reactive to light. Right pupil sluggish to light". Review of the Progress Note dated 2-16-12 at 5:25 AM, signed by LPN #2, revealed "At 2:45 AM, CNA reports to the nurse resident sounds 'gurgly'. This nurse assessed to note resident lungs wet bilateral, pupils non reactive, resident non responsive to verbal commands, Vital Signs: Blood Pressure 99/56 (low), Pulse 145 (high), Respirations 24 (high), and Temperature 102.5 (high), Oxygen Saturation on room air 58% (extremely low), Oxygen administered at 2 liters via nasal canula. Oxygen Saturation continued at 58%. Tylenol given per peg tube, Oxygen increased to 3 liters and Oxygen Saturation increased to 59%. 3 AM Hospice phoned. 3 AM doctor phoned to give ok to increase Oxygen to 4 liters, continue with comfort care, no further orders. 3:15 AM wife phoned informed of decline, states she will be in soon. 4 AM Temperature 102 axillary, Oxygen Saturation at 59%. 4:30 AM Wife at bedside." Review of Resident #102's Certificate of Death dated 2-17-12 revealed his documented cause of death was Adult Failure to Thrive, Dysphagia, and Dementia-Vascular. ( )

This citation pertains to intake number MI 285. Based on observation, interview and record review, the facility failed to supervise 1 of 4 sampled Residents (#101) in a total sample of 4 residents resulting in Immediate Jeopardy (IJ), when Resident #101 who had a history of [REDACTED].#1 as he was walking by his house. Neighbor #1 notified Facility staff of Resident #101's whereabouts and Resident #101 was brought back to the Facility without injuries. This deficient practice places all residents identified as elopement risks at a high risk for serious harm, injury, and/or death. Findings include: On 6/9/11 at 12:25 PM, upon entry to the Facility, a sign was observed which stated, "Attention. To ensure the safety of our residents. Please do not let residents follow you out through the door. Thank you." Another sign, located on the front lobby door stated, "Push until alarm sounds-Door can be opened in 15 seconds." The front door required a code to exit and not sound an alarm. On 6/14/11 at 3:15 P.M., this Surveyor and the Director of Nursing (DON) observed that the alarm on the front patio door of the facility had a 53 second delay after the code was entered and before an alarm sounded to alert staff of a possible elopement. The west gate, off the front patio and close to the street, was unlocked. An observation on 6/9/11 at 1:20 PM, revealed Resident #101, sitting in a wheelchair in the activity room. Resident #101's wife and Certified Nurse Aide (CNA) "G" was with him. The DON said in an interview at the time of the observation, that CNA "G" was assigned to be with Resident #101 for direct 1:1 supervision. Review of the Clinical Record for Resident #101 revealed that he was an [AGE] year old man admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the Elopement Risk assessment dated [DATE] revealed Resident #101 was assessed as a high elopement risk. Review of the Elopement Care plan dated 4/20/11 for Resident #101 under "elopement risk" revealed an intervention for nursing; "when he is adamant about leaving, staff member will complete 1:1 with him till he is calm." Review of the Facility incident report dated 5/3/11 at 6:55 PM revealed Resident #101 was observed exiting the front door in his wheelchair, with the alarm was sounding. Resident #101 was going around the corner, in the parking lot when the staff reached him and he was brought back inside by Facility staff without injuries. Review of the Facility incident report dated 6/5/11 at 7:45 PM revealed that the Facility was notified that a male resident (Resident #101), was sitting in a chair in a driveway. According to the report, Resident #101 was brought back to the Facility at 8:05 PM with no apparent injuries noted. In an interview on 6/9/11 at 4:10 PM, CNA "D" stated she was assigned to care for Resident #101 on Sunday, 6/5/11 from 2:00 PM - 10:00 PM. CNA "D" said after supper, Resident #101 was in the dining room going toward the exit door. CNA "D" said when she told him he had to come back, he told her he didn't have to and that he needed to leave. CNA "D" said Resident #101 "hung onto the table" in the dining room until she convinced him to leave the dining room. CNA "D" stated Resident #101 was talking about going to church and to Chicago. CNA "D" said he had street clothes and shoes on but she could not recall if his wheelchair alarm was on or not. In an interview on 6/9/11 at 3:10 PM, CNA "A" stated that on 6/5/11 at approximately 8:00 PM, Neighbor #1 was standing inside the front door of the Facility. CNA "A" stated Neighbor #1 asked if CNA "A" was missing anyone because there was a gentleman at his house across the street who said you were killing him and robbing him blind. CNA "A" informed Licensed Practical Nurse (LPN) "B" and they went across the street to Neighbor #1's house to attempt to bring Resident #101 back to the Facility but were unsuccessful. In an interview on 6/9/11 at 2:40 PM, LPN "B" reported that on 6/5/11 at approximately 8:00 PM, Neighbor #1 told LPN "B" that a visitor (Visitor #2) he encountered in the parking lot stated that the man sitting in his driveway was a resident who belonged at the Facility. LPN "B" reported that she went across the street and saw Resident #101 sitting in a lawn chair, his wheelchair was not with him. LPN "B" said she was not able to convince Resident #101 to go back to the Facility and she requested more assistance. LPN "B" reported CNA "A" and LPN "E" came to assist but were unable to convince Resident #101 to return to the Facility. LPN "B" reported Visitor #2 came with a wheelchair and persuaded Resident #101 to return to the Facility. LPN "B" said she assessed Resident #101 and found no injuries. LPN "B" said she did not hear any alarm and was unable to find his wheelchair. LPN "B" said she did not hear Resident #101's personal alarms (sensor pad or string alarm) sound and stated, "either he took them off or someone forgot to put them on". LPN "B" said Resident #101 "tried to leave everyday before this". LPN "B" said Resident #101 attempted to leave through every door on a daily basis. In an telephone interview on 6/14/11 at 10:10 AM, Visitor #2 said he arrived in the parking lot of the Facility on Sunday 6/5/11 at approximately 7:45 PM. Visitor #2 said it was before the basketball game started which started at 8:00 PM. Visitor #2 said he saw a man across the street from the facility who he recognized as a Resident #101 from the facility. Visitor #2 said he observed him for about 5 minutes and then 3 or 4 nurses came out to assist. In an interview on 6/14/11 at 9:20 AM, Neighbor #2 stated that on Sunday 6/5/11 after supper, she looked out her living room window and saw Resident #101 walking past her house, heading east. Neighbor #2 reported that Resident #101 looked like he was about to fall over, did not have a walker but looked as if he was walking with one, and had no wheelchair. Neighbor #2 said Resident #101 knocked on their door and said he needed a ride to his house on a street they had not heard of. Neighbor #2 said Resident #101 proceeded to get in and out of their parked car, which was in the garage. Neighbor #2 said her husband (Neighbor #1) called 911 but they didn't come right away so he walked across the street to the Facility to find out if they were missing anyone. Neighbor #2 said after about 20 minutes they (facility staff) were able to get Resident #101 to go back with them. On 6/14/11 at 11:00 AM, the Police Department dispatch secretary reported that a call was received on 6/5/11 at 7:43 PM from Neighbor #1 regarding a male Resident that was at their house. On 6/14/11 at 3:10 PM, the Police Officer said he received the call about a Resident that was at a neighbor's house wandering around trying to take things, but they had so many calls that Sunday he didn't get to the house until after Resident #101 was already gone. The Police Officer said he was told that Resident #101 was returned to the Facility and was safe so he did not talk to anyone at the Facility. In an interview on 6/9/11 at 2:00 PM CNA "F" said, Resident #101 "always wants to get out of here. He does this often (attempt to elope)." In an interview on 6/9/11 at 3:00 PM CNA "C" reported that Resident #101 always goes for the double doors. CNA "C" said, "I think he watches when people go in and out. He's smart and he's strong. He's taken his pull tab off and wrapped it around his chair." In an interview on 6/9/11 at 1:25 PM Resident #101's wife stated that Resident #101 banged on the door till it opened and it let him out about a month ago. Resident #101's wife said, "He can read and he read the sign." Resident #101's wife said, with tears running down her cheeks, "The other night he went across the street and now he has to leave. We have to find him another Nursing Home." Review of the Facility's Elopement Policy dated as revised in June 2010, under the section titled, "Hourly Watch" #4, instructs; "Watch to be adjusted for especially active residents (i.e. every 1/2 hour checks) per nursing judgment. (Form 2.1 (D)." Review of Form 2.1 (D) for June 2011 for Resident #101 revealed documentation that Resident #101 was on hourly checks and not 1/2 hour checks per policy. The Form revealed Resident #101 was not placed on 1:1 direct supervision until 6/5/11 at 8:05 PM after he was brought back to the Facility following his elopement. The Administrator was notified on 6-14-11 at 2:40 PM of the Immediate Jeopardy that began on 6/5/11 when Resident #101 who had a history of [REDACTED].#1 as he was walking by his house. On 6/15/11 this Surveyor confirmed that the Facility staff completed the following to remove the immediate jeopardy: 1. Beginning 6/5/11, Resident #101 was placed on 1:1 care/supervision. 2. On 6/5/11, all 33 of 33 residents accounted for who resided in the Facility. An hourly check of all residents continued for 24 hours to ensure all 33 Residents remained in the Facility. 3. On 6/5/11, 8 of 8 employees working at the facility at that time were in-serviced regarding the elopement procedures, 1:1 supervision, door alarms, and visitors entering and exiting the Facility. On 6/6/11, 29 employees were in-serviced on the same information. The DON ensured that no employee was allowed to work prior to receiving the in-service. As of 6/11/11 all 46 employees were been in-serviced. 4. On 6/5/11, the Maintenance Director checked the functionality of the 6 door alarms. He found 6 of 6 door alarms to be functioning properly. 5. On 6/6/11, 33 of 33 Residents were assessed for elopement; 11 Residents continued to be at risk for elopement. All 11 Residents' biographical data was contained in the elopement books at each of the two nurse's station; the 11 Residents were monitored at least hourly by facility staff, and documented. 6. On 6/6/11 a sign was posted on the front entrance door to alert visitors to be aware of Residents in the vicinity while they are punching in the door alarm code. This was done to ensure Residents were not able to exit from the Facility with visitors. 7. On 6/14/11, the sign to alert visitors to be aware of Residents in the vicinity while they are punching in the door alarm code was been added to the front and back patio doors where visitors may frequent, to ensure all possible exits are covered. The Maintenance Director has restrained the gates on the patios, preventing Resident from easily exiting from the patios. On June 14, 2011 the alarm sounding delay on the front patio door was adjusted with the delay shortened from 53 seconds to 15 seconds following code entry. 8. On 6/6/11 the door alarm access code was changed for additional security; it will be changed as needed but not less than monthly. On 6/14/11, the Maintenance Director changed the front patio door alarm reset delay to 15 seconds. 9. As of 6/14/11 the alarm sounding will be monitored, as well as the timed delay for the alarm reset. Any abnormalities are immediately reported to the Maintenance Director for correction. Door alarms continue to be checked by the Maintenance Director Monday-Friday and Housekeeping employees continue to check the door alarms on Saturday and Sunday for functionality as trained. 10. As of 6/14/11, Facility Department Managers meet every morning to review Residents that run a risk of potentially active exit seeking. If a Resident is identified as active exit seeking, 1:1 supervision will be immediately assigned and 1:1 supervision will not be discontinued until the Interdisciplinary Team determines that the Resident is no longer actively exit seeking. Although the Immediate jeopardy was removed on 6/14/11, the facility remained out of compliance at the scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to sustained compliance had not been verified by the state agency. #

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MANAGE PAIN FOR 1 OF 3 RESIDENTS REVIEWED FOR PAIN ISSUES (#5) AND FAILED TO MANAGE BOWEL IRREGULARITIES FOR 2 OF 9 RESIDENTS REVIEWED FOR BOWEL PROTOCOL (#5 AND #7), FROM A TOTAL OF 10 SAMPLED RESIDENTS, RESULTING IN UNRELIEVED PAIN AND DISCOMFORT AND FECAL IMPACTION FOR RESIDENT #5 AND THE POTENTIAL FOR CONSTIPATION FOR RESIDENT #7. FINDINGS INCLUDE: RESIDENT #5 WAS A [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT WAS ALSO RECENTLY diagnosed AS HAVING [MEDICAL CONDITION] AND HAD BEEN PLACED UNDER HOSPICE CARE IN DECEMBER 2010. THE MINIMUM DATA SET RESIDENT ASSESSMENT ((MDS) dated [DATE] REFLECTED THAT THE RESIDENT WAS EXPERIENCING ALMOST CONSTANT PAIN, HAD A HARD TIME SLEEPING AT NIGHT AND HAD LIMITED ACTIVITY INVOLVEMENT DUE TO PAIN. THE INTENSITY OF PAIN WAS RATED AT 10 ON A SCALE OF 1-10, 10 BEING THE MOST SEVERE PAIN. THE PAIN assessment dated [DATE] REFLECTED RESIDENT AS HAVING PAIN IN HIS RIGHT LEG. THE PAIN WAS DESCRIBED AS THROBBING AND ACHING ALL THE TIME. THE RESIDENT HAD STATED, " NO PAIN MEDICINE HELPED. LEG THROBBED, ACHED AND COULD NOT MOVE IT." DESPITE THESE VERBAL DESCRIPTIONS OF THE RESIDENT'S PAIN, THE NONVERBAL PAIN SCALE HAD BEEN CIRCLED AT SCORE OF 4 ON A SCALE OF 1-10, 10 BEING THE WORST POSSIBLE PAIN, AND "FLACC" SCALES INDICATED HIM AS HAVING MILD PAIN. ON 1/19/11 AT 2:00 P.M., THE RESIDENT WAS OBSERVED LYING IN BED ON HIS BACK, STILL WEARING A HOSPITAL GOWN. THE RESIDENT STATED HE COULD NOT GET OUT OF BED BECAUSE HE WAS HAVING A LOT OF PAIN IN BOTH OF HIS LEGS. HE SAID THE PAIN PILLS HELPED ONLY A SHORT TIME. HE RATED HIS PAIN AT 10 ON A SCALE OF 1-10, 10 BEING THE MOST SEVERE PAIN. REVIEW OF THE NURSING NOTES DATED 10/12/10 THROUGH 12/6/10 REFLECTED THAT THE RESIDENT WAS DESCRIBED AS HAVING PAIN ALMOST DAILY, MOSTLY IN HIS LEGS, MORE IN HIS RIGHT LEG THAN THE LEFT, RATED AS 8-10 FOR PAIN INTENSITY ON A SCALE OF 1-10, 10 BEING THE MOST SEVERE PAIN. THE NURSING NOTE DATED 11/24/10 REFLECTED THE RESIDENT HAD VERBALIZED SUICIDAL THOUGHTS DUE TO INEFFECTIVE PAIN CONTROL FROM THE PAIN MEDICATIONS PRESCRIBED. A NURSING NOTE DATED 12/7/10 REFLECTED THAT THE RESIDENT HAD BEEN admitted TO THE HOSPITAL DUE TO UNRESPONSIVENESS. ON 1/20/11 AT 10:00 A.M., THE HOSPICE NURSE (STAFF "O") STATED THE RESIDENT HAD BEEN GIVEN TOO MUCH [MEDICATION NAME] (ANTI-ANXIETY MEDICATION). WHILE THE RESIDENT WAS IN THE HOSPITAL HE HAD A LUNG SCAN THAT SHOWED RIGHT LUNG MASS MOST LIKELY FROM CARCINOGENIC ORIGIN. HE WAS THEN PLACED UNDER HOSPICE CARE. THE NURSING NOTES DATED 12/8/10 THROUGH 1/17/11 REFLECTED THE RESIDENT AS HAVING PAIN DAILY AGAIN IN HIS LEGS AND "ALL OVER" ( NEW DOCUMENTED PAIN LOCATION) AFTER HE WAS RETURNED FROM THE HOSPITAL. THE INTENSITY OF PAIN WAS AGAIN RATED AS 10 ON A SCALE OF 1-10. THE NURSING NOTE DATED 12/20/10 REFLECTED THE RESIDENT AS MAKING STATEMENTS ABOUT HURTING HIMSELF SO HE COULD GO TO THE HOSPITAL BECAUSE OF CONSTANT LEG PAIN. ON 1/20/11 AT 10:00 A.M., THE HOSPICE NURSE (STAFF "O") STATED THAT THE RESIDENT HAD BEEN RECEIVING [MEDICATION NAME] AND [MEDICATION NAME] WHICH WERE DISCONTINUED IN NOVEMBER 2010 WHEN HE WAS STARTED ON ROXINAL, [MEDICATION NAME] AND A [MEDICATION NAME] PATCH. IN JANUARY 2011 THE DOSAGE OF THE [MEDICATION NAME] PATCH WAS INCREASED TO 150 MCG AND THE MOST RECENT ORDER FOR ROXINAL INCLUDED 30-40 MG ORALLY EVERY 2 HOURS AS NEEDED. ON 1/21/11 AT 10:00 A.M., THE WEST WING CHARGE NURSE (STAFF "M") WAS ASKED WHAT MIGHT BE THE CAUSE OF THE RESIDENT'S PAIN. SHE STATED IT WAS RELATED TO THE RESIDENT'S STROKE WHICH AFFECTED HIS RIGHT SIDE INCLUDING HIS RIGHT LEG. NURSE "M" WAS ASKED HOW THE STAFF WERE MANAGING THE RESIDENT'S PAIN OTHER THAN WITH PAIN MEDICATIONS. SHE SAID THEY PROVIDED REPOSITIONING, KEEPING HIM WARM BY COVERING HIM UP WITH BLANKETS OR PUTTING SOCKS ON HIM. NURSE "M" STATED IF THOSE MEASURES DID NOT WORK SHE WOULD CALL THE HOSPICE NURSE. THE CARE PLAN RELATED PAIN DATED 9/12/2008 REFLECTED THE RESIDENT AS HAVING PAIN DUE TO A STROKE, LOW BACK PAIN, [MEDICAL CONDITION] AND [MEDICAL CONDITION]. THE INTERVENTIONS INCLUDED ASSESSING PAIN BY OBSERVING VERBAL AND NONVERBAL SIGNS OF PAIN, ADMINISTERING PAIN MEDICATIONS, OFFERING COMFORT MEASURES SUCH AS DISTRACTION, BACK RUBS, POSITIONING AND SLOW BREATHING. THE CARE PLAN HAD NO UPDATED INVESTIGATION OF THE UNDERLYING STATUS OR CAUSES OF THE PAIN, NO STRATEGIES AND FACTORS THAT MAY REDUCE THE PAIN, NO EVALUATION AND MONITORING OF THE PHARMACOLOGICAL TREATMENTS OR NON-PHARMACOLOGICAL INTERVENTIONS. IN ADDITION, THERE WAS NO ONGOING EVALUATION OF THE CONSEQUENCES, SUCH AS BOWEL REGIMEN OR PSYCHOLOGICAL IMPACT, RELATED TO PAIN MANAGEMENT. ON 1/21/11 AT 9:45 A.M., THE RESIDENT WAS SITTING IN A RECLINER IN HIS ROOM. HE HAD HIS EYES CLOSED AND HE LOOKED LIKE HE WAS SLEEPING. HOWEVER, HE WOKE UP WHEN HE WAS CALLED. HE STATED THAT HIS LEGS HURT, MORE IN HIS RIGHT LEG, AND THAT THE PAIN HAD NOT IMPROVED. ( ) RESIDENT #5 WAS RECEIVING DAILY SCHEDULED OPIOID NARCOTICS FOR HIS CHRONIC AND ONGOING PAIN. ADVERSE CONSEQUENCES OF OPIOIDS INCLUDE RESPIRATORY AND CENTRAL NERVOUS SYSTEM DEPRESSION AND CONSTIPATION. THE NURSING INTERVENTIONS DATED 9/12/08 INCLUDED ENCOURAGING FLUID INTAKE AND OFFERING PRUNE JUICE OR APPLE JUICE. THE NURSING ASSISTANT FLOW RECORDS DATED NOVEMBER 2010 THROUGH JANUARY 2011 REFLECTED THE RESIDENT HAD NO BOWEL MOVEMENT FROM 11/10/10 TO 11/30/10, REPRESENTING 20 DAYS IN A ROW, AND NO BOWEL MOVEMENT FROM 11/5/10 TO 11/7/10, REPRESENTING 3 DAYS IN A ROW. IN DECEMBER 2010, THE RESIDENT HAD NO BOWEL MOVEMENT FROM 12/6/10 TO 12/8/10, REPRESENTING 3 DAYS IN A ROW. IN JANUARY 2011, THE RESIDENT HAD NO BOWEL MOVEMENT FROM 1/8/11 TO 1/12/11, REPRESENTING 5 DAYS IN A ROW. THE PHYSICIAN ORDER [REDACTED]. THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE HOSPICE NOTE DATED 1/13/11 REFLECTED: "...HIS CHIEF PROBLEM TODAY IS SEVERE CONSTIPATION, WITH NO BM FOR 5 DAYS...HIS RECTUM IS DILATED WITH HARD STOOL, UNABLE TO MANUALLY REMOVE DUE TO DISCOMFORT FOR PATIENT...(NAME OF FACILITY STAFF) CALLING IN, REPORTING THAT (RESIDENT'S NAME) IS REALLY CONSTIPATED AND HAS HARD STOOL AT RECTAL VAULT...ASKED FOR SUPPOSITORY ORDER... " ON 1/21/11 AT 10:00 A.M., WEST WING CHARGE NURSE (STAFF "M") STATED THE RESIDENT HAD CONSTIPATION BECAUSE THE NURSES WERE NOT LOOKING AT THE NURSING ASSISTANT "FLOW RECORDS" AND THUS DID NOT ADMINISTER BOWEL REGIMEN MEDICATIONS. ( ) REVIEW OF THE CLINICAL RECORD FOR RESIDENT #7 WAS INITIATED ON 1/20/11 AND INCLUDED BOTH THE PAPER AND ELECTRONIC RECORDS. ACCORDING TO THE "RESIDENT ADMISSION RECORD", RESIDENT #7 WAS [AGE] year-old FEMALE admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. REVIEW OF THE "NURSING ASSISTANT FLOW RECORD" DATED 1/11 INCLUDED THE DATES FROM 1/1 THROUGH 1/20/11. THE FLOW RECORD DOCUMENTED BM'S (BOWEL MOVEMENTS) FOR RESIDENT #7. NO BM HAD BEEN DOCUMENTED FOR 14 SHIFTS, FROM 1/6 THROUGH 1/10 ON THE 2:00 P.M. TO 10:00 P.M. SHIFT. NO BM HAD BEEN DOCUMENTED FOR 11 SHIFTS FROM 1/12 THROUGH 1/15 ON THE 2:00 P.M. TO 10:00 P.M. SHIFT. THE MAR (MEDICATION ADMINISTRATION RECORD) DID NOT INDICATE THAT THE BOWEL PROTOCOL ("...NO BM AFTER THREE 3 DAYS...") HAD BEEN INITIATED PER STANDING ORDERS DURING THE TIME FRAME DESCRIBED ABOVE. THE CLINICAL RECORD CONTAINED NO ADDITIONAL "NURSING ASSISTANT FLOW RECORDS". ON 1/21/10 AT APPROXIMATELY 10:00 A.M., ADDITIONAL BM FLOW RECORDS (3 MONTHS) WERE REQUESTED, THE RECORDS WERE NOT AVAILABLE FOR REVIEW ON THE DAY REQUESTED. THE CARE PLAN FOR RESIDENT #7 DATED 9/28/10 AND LABELED "...RESIDENT EXPERIENCES BLADDER/BOWEL INCONTINENCE..." INDICATED UNDER THE "APPROACH" SECTION: "...GIVE BOWL (sic) MEDICATIONS AS NEEDED PER PROTOCOL..." ( )