Every finding on record at Santa Fe Care Center

Based on observation and interview, the facility failed to secure and lock medication and wound care cart leaving it open for easy access. This failure had the potential to affect all 103 residents that resided in the facility. This deficient practice is likely to cause harm if a resident were to access and consume unprescribed medications. The findings are: A. On 07/01/26 at 12:40 PM, during an observation of Wing One, a wound care cart sat unlocked, unattended and unsupervised. The cart contained wound care ointments. Further observation revealed the residents walked up and down the hallway in close proximity to the wound care cart. B. On 07/02/26 at 8:57 AM, during an observation of Wing One, a medication cart sat unlocked, unattended and unsupervised. Further observation revealed the resident's were observed wandering freely in the hallway. C. On 07/01/26 at 12:44 PM, during an interview, the Director of Nursing (DON) stated the wound cart should be locked when unattended. The DON stated all nursing staff were trained to keep the medication and wound care carts locked when not in use. D. On 07/02/26 at 9:00 AM, during an interview, the Licensed Practical Nurse (LPN) #1 stated the medications carts should be locked when unattended. LPN #1 stated she was attending to a medical emergency, so she left cart unlocked and unattended. LPN #1 stated she had been trained to lock the carts when not in use.

Based on and record review, observation, and interviews, the facility failed to maintain a safe and comfortable environment for all residents and occupants when staff failed to: - Maintain the oxygen tanks and cylinder storage in compliance with National Fire Protection Association (NFPA) 99 requirements. - Maintain the portable fire extinguishers (PFE) clearance to be readily accessible and immediately available, This failure had the potential to affect all facility occupants. If staff fail to maintain a safe environment, then the residents and occupants could find themselves in an emergency situation which could endanger their health and safety. The findings are:Oxygen Tank and Cylinder StorageA. Record review of NFPA 99, Health Care Facilities Code, 2012 edition, revealed the following:- 3.3.29.1: A liquid oxygen ambulatory container was a container used for liquid oxygen not exceeding 1.5 L (0.396 gal) specifically designed for use as a medical device as defined by 21 USC Chapter 9, the United States Food, Drug and Cosmetic Act, that is intended for portable therapeutic use and to be filled from its companion base unit, which is a liquid oxygen home care container. (MED).- 11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.- 11.6.2.3 (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. - 11.7.3.2: Cylinders shall be protected from damage by means of the following specific procedures:- Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.- Storage shall be planned so that cylinders could be used in the order in which they were received from the supplier.- If empty and full cylinders were stored within the same enclosure, empty cylinders shall be segregated from full cylinders.- Containers shall not be placed in the following areas: (1) Where they can be tipped over by the movement of a door (2) Where they interfere with foot traffic(3) Where they are subject to damage from falling objects(4) Where exposed to open flames and high-temperature devices. B. Record review of the facility's Life Safety Code policies and procedures revealed the records did not contain an oxygen maintenance, storage, and handling policy. C. On 07/01/26 at 11:50 am, observation revealed the door to the 300 Unit's oxygen storage room had a keypad handle, but the door was unlocked and accessible to anyone in the area. Further observation revealed two liquid oxygen ambulatory containers sat unsecured on the storage room floor. D. On 07/01/26 at 2:05 pm, observation revealed the 300 Unit's oxygen storage room contained one liquid oxygen unsecured on the floor. Further observation of the storage room revealed full oxygen cylinders mixed with empty cylinders. E. On 07/02/26 at 2:50 pm, during an interview, the Administrator stated the Maintenance Director provided facility staff with training on the storage, maintenance, administration, and handling of oxygen containers. He stated oxygen tanks and cylinders should be secured, and the full and empty oxygen containers should not be mixed together in the oxygen storage room. F. On 07/06/26 at 9:45 am, during an interview, the Maintenance Director stated he was responsible for maintaining the facility according to the LSC. He stated he trained facility staff on the storage, maintenance, administration, and handling of oxygen containers upon hire, annually, and during monthly safety meetings. The Maintenance Director stated he inspected the oxygen storage room monthly, but he was not aware of the unsecured containers and the mixed full and empty oxygen tanks in the 300 Unit oxygen storage room. He stated liquid oxygen ambulatory containers should not be unsecured, and the oxygen tanks in the storage room should be separated and stored under the designated signage. Portable Fire ExtinguishersG. Record review of NFPA 10, Standard for Portable Fire Extinguishers, 2010 edition, 6.1.3.1 - 6.1.3.7, revealed the following:- Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.- Fire extinguishers shall not be obstructed or obscured from view.- Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage. H. On 07/01/26 at 10:45 am, observation revealed the portable fire extinguisher, located in the facility's front entry next to the reception desk, was blocked by a 30-inch (in.) by (x) 16 in. paper-shredding cabinet and a red plastic trash can. I. On 07/02/26 at 12:45 pm and 07/02/26 at 2:45 pm, during an interview, the Administrator stated the Maintenance Director was responsible for maintaining the facility according to the LSC. The Administrator stated the facility's staff were trained to maintain the clearance for all portable fire extinguishers. He stated he was not aware the paper-shredding cabinet and trash can blocked the PFE at the reception desk. The Administrator stated the items should not block the portable fire extinguisher. J. On 07/06/26 at 9:28 am, during an interview, the Maintenance Director stated he was responsible for maintaining the facility according to the LSC, and he inspected the facility's portable fire extinguishers monthly and an outside company inspected the portable fire extinguishers annually. He stated he was not aware the shredding cabinet and the trash can blocked the PFE, but staff were trained to maintain the clearance around portable fire extinguishers. The Maintenance Director stated portable fire extinguisher should not be blocked.

Based on observation and interview, the facility failed to protect residents' personal health information (PHI; identifiable health information) when staff left a document containing PHI unattended on top of a nursing cart in hallway. This failure had the potential to affect 16 residents out of 104 residents residing in the facility. This deficient practice is likely to result in passerby having unauthorized access to sensitive information, placing residents' privacy at risk. The findings are:A. On 07/02/26 at 8:57 am, an observation on Wing One revealed a list of 16 residents lay on top of the treatment cart, unattended, and exposed to public view. Further observation revealed the list contained PHI residents' code status information. B. On 07/02/26 at 8:57 am, during an interview, the Licensed Practical Nurse (LPN) #1 stated any document containing resident information should not be left unattended or visible to passersby. LPN #1 stated PHI should not be left unattended or visible. LPN #1 stated it is expected staff would cover PHI or place the document in a place not visible to anyone. LPN #1 stated code statuses were handed out daily and nurses are to keep them on their person or some place with easy access in case of an emergency.

Based on interview and record review the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when staff failed to report and investigate a resident elopement for 1 (R #1) of 2 (R #1 and R #2) residents. If the facility does not report and conduct a thorough investigation when residents elope, then residents are likely to be at risk for harm and possible injuries. The findings are: A. Record review of a police report, dated 06/04/26, revealed the police responded to a welfare check at the facility on 06/01/26 at 7:17 pm through 8:25 pm. The police located R #1, who wandered away from the facility. The police returned R #1 to the facility staff and documented the incident. B. Record review of Facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated 04/2021, revealed the following:- Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. - Investigate and report any allegations within timeframes required by Federal requirements. C. Record review of R #1's five-day admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/01/26, revealed the resident was admitted on [DATE] with a diagnosis of dementia. D. Record review of R #1's Elopement Risk Tool, dated 05/29/26, revealed the resident was not at risk for elopement. E. Record review of the facility's incident reports, dated 02/02/26 through 07/01/26, revealed there was not an elopement report for R #1. F. Record review of R #1's nursing progress notes at 7:48 pm, dated 06/01/26, revealed at the resident was found wandering outside of the facility, was brought back to the facility, and an ambulance checked on resident. R #1 was stable at baseline (normal condition). G. On 07/02/26 at 11:30 AM, during an interview, the Director of Nursing (DON) stated R #1 was a new admit and was not considered at risk for elopement. The DON stated R #1 walked out of the unlocked front door on 06/01/26 at approximately 7:20 PM and wandered outside. The DON stated R #1 was brought back by the local police at 9:00 PM. The DON stated R #1 was gone for a while before staff discovered he was missing. H. On 07/02/26 at 12:28 PM, during an interview with CNA #1, she stated she had just left the facility for the day when the incident occurred. The CNA recalled staff were told at a meeting that R #1 left the building and was brought back by police. CNA #1 stated it was discovered by staff after dinner that R #1 was gone. The evening CNAs were doing their evening rounds when it was discovered. I. On 07/02/26 at 1:45 PM, during an interview, the Administrator stated he was aware of R #1's elopement incident, because staff mentioned it during the morning stand up meeting. He stated he did not conduct an investigation of the incident, and he did not report it to the State agency. The Administrator stated he felt the facility should have reported and investigated the elopement incident. J. On 07/02/26 at 2:00 PM, during a phone interview, R #1 was very confused and was unable to recall leaving the facility. K. On 07/02/26 at 2:05 PM, during a phone interview, R #1's sister stated she was responsible for R #1, and she was aware of the elopement. She stated she decided he was safer at home than in the facility, so she discharged him from the facility. She stated R #1 was found safe and nothing happened to him while he was missing from the facility.

Based on record review and interview, the facility failed to prevent significant medication errors for 3 (R #2, R #3, and R #9) of 5 (R #2, R #3, R #4, and R #5) residents reviewed for medication errors when the facility did not administer night medications on 03/30/26. This deficient practice is likely to result in residents having adverse effects (unwanted, harmful, or abnormal result). The findings are:R #2A. Record review of R #2's admission Record revealed he was originally admitted to the facility on [DATE] with the following diagnoses:1. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),2. Hyperlipidemia (a condition in which there are high levels of fat particles in the blood; high cholesterol),3. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),4. Anxiety (feelings of fear or apprehension),5. Gastroesophageal reflux disease (GERD; A digestive disease in which stomach acid or bile irritates the food pipe lining),6. Chronic obstructive pulmonary disease (COPD; lung disease),B. Record review of R #2's medication administration record (MAR) dated March 2026 revealed that on the night of 03/30/26 R #2 did not receive:1. Docusate sodium (a medication used to treat constipation),2. Fluticasone-salmeterol (an inhaled medication used to treat COPD), 3. Glipizide (a medication used to treat DM2),4. Insulin (a medication used to treat DM2),5. Nubeqa (a medication used to treat prostate cancer),6. Tolterodine tartrate ER (a medication used to treat overactive bladder). R #3C. Record review of R #3's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),2. Anxiety (feelings of fear or apprehension),3. Essential (primary) hypertension (HTN; high blood pressure).D. Record review of R #3's MAR dated March 2026 revealed that on 03/30/26 R #3 did not receive:1. Donepezil HCI (a medication used to treat dementia),2. Lorazepam (a medication used to treat anxiety),3. Trazodone HCI (a medication used to treat depression),4. Levetiracetam (a medication used to treat seizures),5. Metoprolol tartrate (a medication used to treat HTN). R #9E. Record review of R #9's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Essential hypertension,2. Insomnia (a common sleep disorder),3. Generalized edema (swelling caused by excess fluid).F. Record review of R #9's MAR dated March 2026 revealed that on the night of 03/30/26 R #3 did not receive:1. Melatonin (a medication used to treat insomnia),2. Senna (a tablet used to treat constipation),3. Eliquis (an anticoagulant medication),4. Gabapentin (a medication used to treat chronic pain),5. Lasix (a medication used to treat peripheral edema). G. Record review of the facility's Incident by Type log revealed no adverse reactions to residents that did not receive their medications on the night of 03/30/26.H. On 04/09/26 at 10:17 am, during an interview with the Administrator (ADM), he stated that there was a computer issue that stopped the facility staff that were working from accessing the MAR, so night medications were not given. The ADM stated that the facility staff that were working should have called administrative staff to report the issue and access the backup MARs but failed to do so. The ADM confirmed that no adverse reactions occurred due to this incident.

Based on record review and interview, the facility failed to report incidents involving allegations of abuse to the State Agency for 2 (R #2 and R #3) of 3 (R #2, R #3, and R #9) residents reviewed for abuse. If the facility fails to report allegations of abuse to the State Agency, then the State Agency is unable to ensure residents are free from abuse. The findings are:R #2A. Record review of the facility's Incident by Incident Type report provided by the Director of Nursing (DON) on 04/08/26 revealed an incident on 04/01/26 resulting in serious bodily injury (bruise) for R #2.B. Record Review of R #2's Change of Condition assessment dated [DATE] revealed R #2 was hit by another resident with a wallet chain. R #2 sustained red spotted bruises to left arm.C. Record review of the facility's reportable incident list provided by the Administrator (ADM) on 04/08/26 revealed no report for R #2 was submitted to the State Agency for the incident on 04/01/26.D. On 04/08/26 at 11:58 am, an interview and observation of R #2 revealed bruises on R #2's left arm. He confirmed he was in a physical altercation with another resident and was hit with a chain by the resident. R #3E. Record review of the facility's Incident by Incident Type report provided by the DON on 04/08/26 revealed an incident on 04/01/26 resulting in serious bodily injury (bruise) for R #3.F. Record review of progress note dated 04/01/26 revealed R #3 reported he was hit on the head by another resident. R #3 was noted to have a slightly reddened area on the right side of his head.G. Record review of the facility's reportable incident list provided by the ADM on 04/08/26 revealed no report for R #3 was submitted to the State Agency for the incident on 04/01/26.H. On 04/09/26 at 10:01 am during an interview with the ADM, he confirmed the reports for R #2 and R #3 were not filed.

Based on observations, interviews, and record reviews, the facility failed to protect the residents from the potential for accidents and hazards for 2 (R #s 24 and 71) of 2 (R #s 24 and 71) residents reviewed for falls when the facility did not provide fall mats as ordered by a physician and/or care planned. If the facility is not using fall mats for residents' safety as ordered by a physician, then this deficient practice could likely result in residents getting injured in avoidable accidents and putting residents at risk of serious injury, serious harm, and possibly death. The findings are: R #24: A. Record review of R #24's face sheet revealed R #24 was admitted into the facility on [DATE]. B. Record review of R #24's care plan dated 11/18/25 revealed R #24 was a high risk for falls related to confusion, gait/balance problems, and paralysis (the loss of the ability to move). Staff interventions included a fall mat to be present when R #24 was in bed for safety. C. On 11/18/25 at 5:23 pm, during an interview with R #24's daughter, she stated R #24 is a fall risk and should have a fall mat present near the bed when R #24 is lying in bed. R #24's daughter also stated when she visits R #24, a fall mat is often not present when R #24 is lying in bed. D. On 11/24/25 at 1:54 pm, observation of R #24's room revealed R #24 laid in bed asleep without a fall mat present next to R #24's bed. E. On 11/24/25 at 2:01 pm, during an interview with Certified Nursing Assistant (CNA) #1, she confirmed R #24 did not have a fall mat present while R #24 was lying in bed. CNA #1 stated a fall mat should be present. F. On 11/25/25 at 3:02 pm, during an interview with the Director of Rehab (DOR), she stated R #24 has a history of falls and a fall mat should be present for her when in bed. G. On 11/25/25 at 4:40 pm, during an interview with the Director of Nursing (DON), she stated a fall mat should be present every time when R #24 is in bed due to her being a fall risk. R #71: H. Record review of R #71's face sheet revealed R #71 was admitted into the facility on [DATE]. I. Record review of R #71's physician orders dated 11/24/25 revealed a fall mat should be present when R #71 is in bed. J. On 11/24/25 at 1:47 pm, observation of R #71's room, revealed R #71 laid in bed without a fall mat present. K. On 11/25/25 at 2:11 pm, during an interview with the Scheduler (SCH), she confirmed a fall mat was not present while R #71 was lying in bed. The SCH stated R #71 has a physician order for a fall mat, but there was not one in his room and should have been. L. On 11/25/25 at 4:41 pm, during an interview with the DON, she stated R #71 should have a fall mat present when he is in lying in bed as ordered by a physician.

Based on record reviews and interview, the facility failed to complete the required pharmacy review of resident medications for 5 (R #s 8, 9, 10, 11, and 71) of 7 (R #s 4, 8, 9, 10, 11, 20, and 71) residents reviewed for pharmacy reviews when the facility failed to: -Assure that residents' medications were reviewed by a licensed pharmacist monthly from August 2024, through October 2025 for R #s 10, 11, and 71 -To carry out pharmacy recommendations that were approved by the provider for R #s 8, and 9 These deficient practices are likely to result in residents receiving medications that are unnecessary for their health. The findings are: A. Record review of the facility's provided Pharmacy Recommendations for the month of October 2025 revealed a licensed pharmacist did not complete a pharmacy review for R #10. B. Record review of the facility's provided Pharmacy Recommendations for the month of October 2025 revealed a licensed pharmacist did not complete a pharmacy review for R #10. C. Record review of the facility's provided Pharmacy Recommendations for the month of June 2025 revealed a licensed pharmacist did not complete a pharmacy review for R #71. D. Record review of the facility's provided Pharmacy Recommendations revealed that Medication Regime Review (MRR) documentations for R #8 for the month of September 2025 was approved by the provider but the order was not carried out. -Discontinue Oxycodone (prescription medication used to treat pain) 5 milligrams (mg) every 8 hours as needed. -Discontinue Tramadol (prescription medication used to treat pain) 50 mg every 6 hours as needed. E. Record review of the facility's Pharmacy Recommendations for the month of August 2025 revealed that MRR documentations for R #9 for the month of August 2025 was approved by the provider but the order was not carried out to monitor for dermatological side effects (such as skin rash or allergic reaction like hives) and immediately contact the prescriber to discontinue allopurinol (prescription medication used to lower high uric acid levels in the blood) at the first sign of a skin rash or allergic reaction. F. Record review of the facility 's provided Pharmacy Recommendations for the month of March and June 2025 revealed MRR documentations for R #10 were approved by the provider but the orders were not carried out to monitor for involuntary movements now and at least every 6 months or per facility protocol. G. On 11/25/25 at 4:25 pm, during an interview with the Director of Nursing (DON), she confirmed that MMR for R #s 10, 11 and 71 were missed and should have been addressed monthly. DON also confirmed that the approved pharmacy recommendations for R #s 8, 9, and 10 should have been carried out with new orders added to the EMR (electronic medical records) and it did not occur.

Based on observation, record review and interview, the facility failed to develop and implement an accurate, person-centered comprehensive care plan for 1 (R #1) of 1 (R #1) resident reviewed for care plans. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. On 04/08/25 at 1:00 pm during observation of R #1 in his room and interview, R #1 had a cooler that was stored on the floor in the corner of his room. R #1 stated the cooler was where he kept his beer. He stated he was allowed to have on beer each day and that he would ask for or take a beer from the cooler daily. B. Record review of R #1's Admission Record revealed R #1 was admitted to the facility on [DATE]. C. Record review of R #1's medical orders dated on 03/13/2025, revealed R #1 may keep beer in an ice chest in his room. He is to have one beer with dinner every night per doctor's orders. D. Record review of R #1's care plan revised on 04/07/2025, revealed the following: I can drink one beer a day if I choose and my beer will be kept in the restorative fridge where it will be locked up. E. On 04/08/2025 at 2:06 pm, during an interview with Director of Nursing (DON), she confirmed that R #1 was allowed to have a beer daily per the provider's order. She further confirmed that the care plan stated the beer was to be kept in the facility fridge where it could be locked away. F. On 04/08/25 at 2:30 pm during interview with the Administrator (ADM), he confirmed that R #1 had a cooler in his room that contained beer that he was allowed to have. He stated the staff would keep ice in the cooler and R #1's family would bring beer to him as he needed. ADM further stated the care plan indicated he was to have beer kept in a locked refrigerator.

Based on record review and interview, the facility failed to notify the Providers (Physicians and Nurse Practitioners) and the Director of Nursing (DON) of a change in condition in which a resident experienced a large left forearm injury (skin tear- acute wound that is caused by mechanical force or a traumatic injury) for 1 (R #4) of 1 (R #4) residents reviewed for injury. This deficient practice likely resulted in R #4's injury becoming worse with increased bleeding due to the resident taking a blood thinner, and a delay going to the hospital. The findings are: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] and was discharged on [DATE]. B. Record review of R #4's care plan, dated 07/09/24, revealed R #4 experienced confusion, balance problems, vision and hearing problems; and R #4 was unaware of safety needs. C. Record review of R #4's physician orders, dated 07/09/24, revealed R #4 was prescribed apixaban (blood thinner), 5 milligrams (mg) twice a day, which was started on 07/09/24. D. Record review of R #4's Medication Administration Record (MAR), dated 09/01/24 through 09/09/24, revealed staff administered apixaban to R #4 twice a day, every day. E. Record review of R #4's nursing progress notes revealed the following: 1. Dated 09/09/24 at 6:10 am and written by Registered Nurse (RN) #1, a Certified Nursing Assistant (CNA) and an RN found R #4 at 6:00 am. The resident showed signs of confusion and required help changing into daily clothes. The RN discovered a large gash (skin tear/laceration) on R #4's left forearm that appeared to be self-inflicted, and the CNA and RN dressed the resident's wound. Assessment: R #4's wound measured 4 inches (in) length and 1.5 in. width. The RN reported R #4's injury to the oncoming RN, Director of Nursing (DON), and the Provider. 2. Dated 09/09/24 at 7:30 pm and written by RN #1, the deep tissue wound on R #4's left forearm (previously noted at 6:10 am as a large gash) bled profusely. R #4 was sent to the emergency room (ER). 3. Staff did not document any other progress notes between 6:00 am and 7:30 pm for R #4's left forearm injury, which indicated the facility's nursing staff did not assess R #4 again throughout the day and did not contact a provider or the DON to inform them of R #4's wound. D. Record review of R #4's ER documentation, dated 09/09/24 at 7:44 pm, revealed the following: 1. Left forearm laceration: Brought in by Emergency Medical Services (EMS) and laceration was found by nursing home nurse at 7:00 am. 2. Left forearm: Large skin tear (a type of injury where the skin is torn from the body) with painful range of motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point). Left forearm does have some full thickness flap loss [deep wounds that extend beyond the first two layers of the skin and may reveal subcutaneous (fatty) tissue, muscle, tendon, or even bone.] E. On 10/10/24 at 12:14 pm during an interview with RN #1, he stated a CNA asked him to assist with R #4 prior to shift change on the morning of 09/09/24. RN #1 stated he noticed R #4 was confused and had a large laceration on her left forearm that was actively bleeding, which required a bandage. RN #1 stated he informed the day shift nurse of R #4's injury that morning after he bandaged and wrapped R #4's left forearm. RN #1 stated that when he returned to shift later that evening on 09/09/24, he had to send R #4 to the ER due to R #4's left forearm injury (large gash noted at 6:10 am) became worse throughout the day. RN #1 stated R #4's left forearm still had the original bandage that he applied earlier that day and R #4's left forearm bandage was completely saturated with blood, indicating R #4's left forearm was still actively bleeding which required him to send R #4 to the hospital. RN #1 also confirmed the day shift did not document that they assessed R #4's laceration during their shift, and he notified the Director of Nursing (DON) and provider when he arrived for his night shift that R #4 required hospitalization . F. On 10/11/24 at 11:07 am during an interview with the Nurse Practitioner (NP), she stated the facility staff did not notify her about R #4's left forearm laceration on 09/09/24, but they should have. The NP confirmed that due to the size and severity of R #4's left forearm injury, the NP should have been notified immediately, so she could assess R #4's left forearm, provide additional treatment such as a topical ointment to clean the wound and stop bleeding, and advise nursing staff to send R #4 to the hospital right away. The NP confirmed her expectation was for nursing staff to notify her as soon as possible when residents experience a significant injury like R #4 did. G. On 10/11/24 at 12:30 pm during an interview with the DON, she stated she was not aware of R #4's left forearm injury on 09/09/24 until R #4 was sent her the hospital at 7:00 pm on 09/09/24. The DON confirmed it was her expectation for nursing staff to notify the facility providers and herself right away when a resident experienced a significant injury like R #4.

Based on observation, record review, and interview, the facility failed to monitor and provide appropriate interventions for 1 (R #4) of 3 (R #4, #5, and #6) residents reviewed for injury: 1. When the facility failed to provide proper wound care for R #4's left forearm laceration. 2. When the facility nurses failed to communicate the severity of R #4's left forearm laceration to other nursing staff. 3. When the facility failed to re-assess R #4's left forearm laceration for approximately 12 hours. These deficient practices likely resulted in R #4's left forearm laceration becoming worse with additional bleeding, that required hospitalization . The findings are: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] and was discharged on [DATE]. B. Record review of R #4's care plan, dated 07/09/24, revealed R #4 experienced confusion, balance problems, vision and hearing problems; and R #4 was unaware of safety needs. C. Record review of R #4's physician orders, dated 07/09/24, revealed R #4 was prescribed apixaban (blood thinner), 5 milligrams (mg) twice a day, which was started on 07/09/24. D. Record review of R #4's Medication Administration Record (MAR), dated 09/01/24 through 09/09/24, revealed staff administered apixaban to R #4 twice a day, every day. E. Record review of R #4's nursing progress notes revealed the following: 1. Dated 09/09/24 at 6:10 am and written by Registered Nurse (RN) #1, a Certified Nursing Assistant (CNA) and an RN found R #4 at 6:00 am. The resident showed signs of confusion and required help changing into daily clothes. The RN discovered a large gash (skin tear/laceration) on R #4's left forearm that appeared to be self-inflicted, and the CNA and RN dressed the resident's wound. Assessment: R #4's wound measured 4 inches (in) length and 1.5 in. width. The RN reported R #4's injury to the oncoming RN, Director of Nursing (DON), and the Provider. 2. Dated 09/09/24 at 7:30 pm and written by RN #1, the deep tissue wound on R #4's left forearm (previously noted at 6:10 am as a large gash) bled profusely. R #4 was sent to the emergency room (ER). 3. Staff did not document any other progress notes between 6:00 am and 7:30 pm for R #4's left forearm injury, or any evidence that the facility's nursing staff assessed R #4 throughout the day. F. Record review of R #4's Electronic Health Record (EHR) revealed staff completed one change in condition assessment for R #4 on 09/10/24, which revealed R #4 was sent to hospital on 09/09/24 at approximately 7:00 pm for a laceration to the left forearm. G. Record review of R #4's ER documentation, dated 09/09/24 at 7:44 pm, revealed the following: 1. Left forearm laceration: Brought in by Emergency Medical Services (EMS) and laceration was found by nursing home nurse at 7:00 am. 2. Left forearm: Large skin tear (a type of injury where the skin is torn from the body) with painful range of motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point). Left forearm had some full thickness flap loss [deep wounds that extend beyond the first two layers of the skin and may reveal subcutaneous (fatty) tissue, muscle, tendon, or even bone.] H. On 10/09/24 at 1:40 pm during an interview with R #4's Power of Attorney (POA), she stated she was notified on the evening of 09/09/24 that R #4 experienced a laceration (a wound produced by tearing) to her left forearm earlier in the day. She stated staff reported the laceration was bleeding profusely and required R #4 to go to the hospital. R #4's POA also stated the nurse told her that staff did not tend to R #4's left forearm laceration throughout the day, and the laceration became worse during that time, with increased bleeding and pain. I. On 10/10/24 at 12:14 pm during an interview with RN #1, he stated a CNA asked him to assist with R #4 prior to shift change on the morning of 09/09/24. RN #1 stated he noticed R #4 was confused and had a large laceration on her left forearm that was actively bleeding, which required a bandage. RN #1 stated he informed the day shift nurse of R #4's injury that morning after he bandaged and wrapped R #4's left forearm. RN #1 stated that when he returned to shift later that evening on 09/09/24, he had to send R #4 to the ER due to R #4's left forearm injury (large gash noted at 6:10 am) became worse throughout the day. RN #1 stated R #4's left forearm still had the original bandage that he applied earlier that day and R #4's left forearm bandage was completely saturated with blood, indicating R #4's left forearm was still actively bleeding which required him to send R #4 to the hospital. RN #1 also confirmed the day shift did not document that they assessed R #4's laceration during their shift, and he notified the Director of Nursing (DON) and provider when he arrived for his night shift that R #4 required hospitalization . J. On 10/11/24 at 11:04 am during an interview with the Nurse Practitioner (NP), she stated it was the nurses' jobs to assess all facility residents everyday. The NP stated R #4's left forearm injury was very large and noticeable, and the day shift nurses (on 09/09/24) should have re-assessed it instead of waiting for the night shift nurses to do it. The NP confirmed that due to the size and severity of R #4's left forearm injury, the NP should have been notified immediately so she could assess R #4's left forearm, provide additional treatment such as a topical ointment to clean the wound and stop bleeding, and advise nursing staff to send R #4 to the hospital right away. K. On 10/11/24 at 11:20 am during an interview with RN #2 [day shift nurse on 09/09/24], she stated RN #1 did not tell her about R #4's left forearm laceration on 09/09/24 when she began her day shift. RN #2 stated she did not see R #4's left forearm laceration on 09/09/24, so she did not re-assess R #4's arm throughout her shift. RN #2 confirmed she did not see R #4's injury until R #4 returned from the hospital. RN #2 stated, If he [RN #1] had noticed everything [with R #4's laceration], then he [RN #1] should have taken care of it [fully assessed R #4's left forearm injury, provided complete documentation for R #4's left forearm injury, notified the provider of R #4's left forearm injury, and sent R #4 to the hospital before he left the facility]. L. On 10/11/24 at 11:25 am during an interview with the Wound Care Nurse (WCN), she stated RN #2 did not tell her about R #4's left forearm laceration during the day shift on 09/09/24. The WCN stated RN #2 told her that RN #1 did not tell her about R #4's laceration either. The WCN confirmed she was not made aware of R #4's laceration until R #4 returned from the hospital on 09/10/24. M. On 10/11/24 at 11:32 am during an interview with RN #3, he stated the facility nurses should make a point to see every one of their assigned residents at least once throughout the shift. RN #3 also stated it was expected for nurses assess each of their residents every shift. N. On 10/11/24 and 11:55 am during an interview with CNA #2, he stated he saw R #4's left forearm laceration during the day shift on 09/09/24, because R #4's left forearm injury/skin tear was large with significant bruising, and blood was present on the bandages. CNA #2 stated he informed RN #2 of R #4's laceration, but RN #2 told him that RN #1 had already made her aware of the laceration during shift change. CNA #2 confirmed that he did not see RN #2 assess R #4's left forearm injury throughout the shift. O. On 10/11/24 at 12:28 pm during an interview with the Director of Nursing (DON), she stated RN #1 told her [DON] that he informed RN #2 of R #4's laceration during shift change, but RN #2 told her RN #1 did not report it to her [RN #2]. The DON stated RN #2 did not re-assess R #4 during the day shift, and RN #2 should have. The DON stated it was her expectation the facility nurses assess each one of their residents on every shift. P. On 10/25/24 at 12:38 pm during an interview with CNA #1, she stated R #4 did not have any injuries present when she assisted and changed R #4 on the night shift (09/08/24). CNA #1 stated R #4 needed the assistance of one staff for activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). She stated R #4 was more agitated than normal on 09/09/24 between 5:00 am and 5:30 am, and the resident grabbed at herself and CNA #1. CNA #1 then stated that after R #4 became agitated, she requested that RN #1 help her get R #4 dressed. CNA #1 stated that she briefly left R #4's room to answer a nearby call light and when she returned, approximately 5 to 10 minutes after RN #1 arrived to assist with R #4, she noticed that R #4 had a large skin tear on her left arm. RN #1 told her that R #4 did it to herself. CNA #1 stated RN #1 bandaged R #4's wound, but he did not clean it. CNA #1 stated she and RN #1 took R #4 out to the main lobby after the injury occurred where other staff and residents were present. CNA #1 also confirmed that she saw RN #1 go to the nurses station after that, but she did not know if RN #1 informed the day shift nurse of the incident. Q. On 10/25/24 at 1:35 pm during an interview with CNA #4, she stated she worked during the day shift on 09/09/24, and she was not aware of R #4's left arm injury. CNA #4 stated usually the nurse would let her know if a resident experienced an injury like that but RN #2 did not inform her. CNA #4 confirmed she saw R #4 during the shift, and R #4 was wearing a long shirt with bandaging on her arm, but she did not know why and she did not look at R #4's left forearm. R. On 10/25/24 at 2:25 pm during an interview with the DON, the DON stated that RN #1 should have properly dressed R #4's left arm injury on 09/09/24 and communicated the severity of R #4's left forearm injury with staff.

Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, nail care, and eating) assistance for toenail care by the facility staff for 1 (R #4) of 1 (R #4) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] and was discharged on [DATE]. B. Record review of R #4's care plan, dated 07/09/24, revealed R #4 required staff assistance with ADL care related to Alzheimer's disease (type of brain disorder that causes problems with memory, thinking and behavior), fatigue, impaired balance, and limited mobility. C. Record review of R #4's skin/bathing completion form, dated 08/12/24 through 09/11/24, revealed staff trimmed and cleaned R #4's toenails twice. D. Record review of R #4's emergency room (ER) clinical notes dated 09/16/24 revealed R #4's toenails were long and required trimming by hospital staff, so R #4 could have better mobility. E. On 10/09/24 at 1:42 pm during an interview with R #4's Power of Attorney (POA), she stated facility staff did not care for R #4's toenails, and she brought that up to the facility staff multiple times. F. On 10/11/24 at 11:41 am during an interview with Certified Nursing Assistant (CNA) #3, she stated staff document all toenail care on the skin/bathing completion forms. CNA #3 also stated she received a complaint from R #4's family about R #4's nail care, and the facility social worker also told her R #4's family complained about R #4's nail care. CNA #3 stated she completed R #4's nail care after receiving the complaint, but R #4's toenails looked like they were not tended to in quite some time. G. On 10/11/24 at 12:32 pm during an interview with the Director of Nursing (DON), she stated she expected CNAs to check residents' toenails during each shower, clean them, and trim them as needed. The DON confirmed R #4's toenails were not cared for as expected, but they should have been.

Based on record review and interview, the facility failed to ensure resident medical records were complete and accurate for 3 (R #1, #2 and #3) of 3 (R #1, #2 and #3) residents reviewed. This deficient practice will likely result in staff not knowing residents' daily care events, changes, and needs. The findings are: Resident #1 A. Record review of R #1 face sheet, dated 10/09/24, revealed he was admitted to facility on 06/17/24 with multiple diagnoses including: - Chronic pain due to trauma (injury), - Amputation of one right lesser toe (small toe of right foot), - Diabetes mellitus (a chronic condition in which the blood's sugar levels are not properly controlled by natural processes), - Malignant neoplasm (cancerous tumor) of prostate (male reproductive gland). B. On 10/09/24 at 2:20 pm during phone interview with Home Health Nurse (HHN) # 1, she stated the Home Health provider (a service that provides in home nursing and daily living care) required all patients to be weight bearing (able to bear weight on their feet.) She stated R #1's weight bearing status should have been included in his medical record. HHN stated that when she met with R #1 in his home, she found him lying on his couch, unable to stand or walk, because he was not weight bearing. HHN stated that if she had known R #1 was unable to bear weight, then he would not have been accepted into the home health program. C. On 10/09/24 at 3:25 pm during phone interview with R #1, he stated he was discharged from the facility on 10/01/24. He stated he was referred to and accepted into a Home Health provider when he was discharged from the facility. He stated he was mostly bed bound while a resident at the facility, and he needed staff assistance to sit up in bed, transfer to his wheelchair, and transfer back to bed. He stated he was never able to stand up and place weight on either of his feet while at the facility. D. Record review of R #1 daily nursing/medical care notes, dated 06/08/24 to 10/09/24, revealed the record did not contain any notations the resident was bed bound and unable to stand, walk, or move about while a resident. The record also did not include any notations to indicate the resident was non-weight bearing. E. Record review of R #1 care plan, dated 10/09/24, revealed multiple care plans, but none indicated R #1 was bed bound, unable to stand, unable to walk, or non-weight bearing. F. On 10/10/24 at 10:35 am during interview and record review with Social Services Coordinator (SSC), she stated she was the person who sent out documentation of R #1's referral to Home Health, and she sent it out via fax three days prior to his discharge. The SSC reviewed the documents she sent for R #1's referral and confirmed the record did not include or indicate R #1's weight bearing status. Resident #2 G. Record review of R #2 face sheet, dated 10/10/24, revealed she was admitted to facility on 08/16/24 with multiple diagnoses including: - Diabetes mellitus, - Emphysema (a respiratory disorder that results in the reduction of air intake), - Acute pulmonary edema (a sudden condition when the lungs become fluid filled), - COVID 19 (a viral respiratory disease). H. On 10/09/24 at 1:31 pm during phone interview with R #2's daughter, she stated her mother had been a resident of the facility. She stated one day her mother began to have difficulty breathing and was sent to hospital emergency room for evaluation. She stated her mother was admitted , tested positive for COVID 19, was treated, and returned to the facility. I. Record review of R #2's complete medical record revealed her daily care notes failed to report a time when she had difficulty breathing, any time she was transferred to hospital, and any time when she returned from hospital. Her medical record did not contain a report of a change of condition (a nursing note to indicate a significant medical change in a resident's medical status) to indicate the resident had difficulty breathing and was sent to hospital. J. On 10/10/24 at 1:49 pm during interview and record review with the Director of Nursing (DON), she stated R #2 was sent to hospital and returned. She reviewed R #2's medical record and confirmed the resident's transfer and return were not documented in the medical record. The DON stated staff should have documented several notes regarding the resident's breathing problems, transfer to hospital, change of condition, and return to the facility. Resident #3 K. Record review of R #3's face sheet, dated 10/10/24, revealed he was admitted to facility on 09/04/24 with multiple diagnoses including: - History of falling, - Myelodysplastic syndrome (a type of cancer of the blood) - Morbid obesity (severely overweight), - Monoplegia (paralysis of one limb) of right upper limb, - discharged from the facility on 09/19/24. L. Record review of daily care note, dated 09/19/24 revealed a entry which stated R #3 expressed ideas of suicide. Staff offered the resident care, and he refused. R #3 became verbally aggressive and stated he wanted to kill staff. The facility issued R #3 an immediate discharge notice, and the resident was sent to the hospital with his personal items. M. On 10/10/24 at 2:30 pm during interview with DON and Administrator (ADM), they stated R #3 had multiple incidents of refusing care, threatening staff, vomiting on staff, throwing vomit on another resident, and using racial slurs aimed at staff and other residents. N. Record review of R #3's daily care notes, dated 09/04 to 09/19/24 revealed the following: -09/05/24 Refused wound care and described the wound care nurse as a stupid, crazy Indonesian wound nurse who knows nothing, and she can't even speak english. -09/10/24 Described as mood is pleasant, no behaviors witnessed. -09/11/24 Described as mood is pleasant, no behaviors witnessed. -09/12/24 Described as mood is pleasant, no behaviors witnessed. -09/14/24 Described as mood is pleasant, no behaviors witnessed. -09/15/24 Described as mood is pleasant, no behaviors witnessed. -09/17/24 Described as mood is pleasant, no behaviors witnessed. -09/18/24 Described as mood is pleasant, no behaviors witnessed. -09/18/24 Refused to attend an appointment. -09/19/24 Refused to allow wound care There are no notes that document any instances of R #3 threatening staff, vomiting on staff, throwing vomit on another resident. O. On 10/10/24 at 2:45 pm during interview with ADM, he stated staff should have noted the resident's behavior in R #3's medical record. He stated he did not know why staff did not document the reported events in R #3's medical record.

Based on record review and interview, the facility failed to report an investigation regarding allegations of an injury of unknown origin for 1 (R #4) of 1(R #4) residents reviewed for injuries and wounds. If the facility is not submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The findings are: A. Refer to F684 for pertinent findings related to this citation. B. On 10/25/24 at 2:25 pm during an interview with the Director of Nursing (DON), she stated she spoke to Registered Nurse (RN) #2 about the incident. She stated she did not conduct a complete investigation, because she felt like she did not need to after speaking with RN #2. The DON also stated that she completed a unit investigation for multiple residents that involved RN #1 (RN involved in R #4 incident), but she did not specifically include R #4 and she should have. C. On 10/25/24 at 2:39 pm during an interview with the Administrator (ADM), he stated he did not complete an investigation for the resident's injury, because the Director of Nursing (DON) investigated the whole unit that R #4 was on for another incident, but that investigation did not specifically include R #4. The ADM confirmed that R #4 should have been included in a investigation and was not.

Based on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #4) of 1 (R #4) residents reviewed when staff failed to update the care plan to include anticoagulant (blood thinner) use. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] and was discharged on [DATE]. B. Record review of R #4's physician orders, dated 07/09/24, revealed an order for apixaban (blood thinner), 5 milligrams (mg) twice a day. C. Record review of R #4's care plan revealed the following: - Dated 07/09/24, R #4 was a risk for falls due to R #4 experienced confusion, balance problems, vision and hearing problems; and R #4 was unaware of safety needs. - The care plan did not include information regarding R #4's order for apixaban. D. On 10/25/24 at 2:27 pm during an interview with the Director of Nursing (DON), she stated staff should have care planned R #4's anticoagulant use, but they did not.

20402 25225 Based on observation, interview, record review, and review of facility policy, the facility failed to sanitize glucometers between use during fingerstick blood sugar tests (FSBS) in a manner that prevented cross-contamination for three (Resident (R) 58, R48, and R232) of three residents observed receiving FSBS tests; ensure enhanced barrier precautions (EBP) were in place as required for 10 of 10 sampled residents (Resident (R) 231, R56, R29, R42, R8, R10, R21, R131, R42, and R47) who had indwelling urinary catheters, suprapubic catheters, and/or feeding tubes and were reviewed for EBP out of a total sample of 20; update infection control policies and procedures on an annual basis; and have control measures in place to monitor their water safety management program. This had the potential to affect 87 of 87 residents who resided at the facility. This failure had the potential to lead to the spread of infection throughout the facility. Findings include: Review of the facility's policy titled, Blood Sampling - Capillary (Finger Sticks), revised September 2014, revealed .Equipment .Disinfect blood glucose meter .Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses .Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use .Replace blood glucose monitoring device in storage area after cleaning . Review of the undated blood glucose meter owner's manual revealed .Indirect transmission of Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) during the delivery of healthcare services has been increasingly reported. Persons using blood glucose monitoring systems have been identified as one risk group due to sharing .blood glucose meters .The meter MUST be cleaned and disinfected after use on each patient .The following disinfecting wipe can be used to clean and disinfect the meter. CAVIWIPES DISINFECTING TOWELETTES .Cleaning and Disinfecting frequency: after each use .Thoroughly wipe the entire surface of the meter with disinfecting wipes listed to clean any possible dirt, dust, blood and other body fluids. 2. Take another disinfecting wipe and wipe the meter thoroughly .Allow the surface to remain wet for 2 minutes .Allow to air dry . Review of the Quality, Safety and Oversite Memo dated 03/20/24, revealed In July 2022, the CDC [Centers for Disease Control and Prevention] released updated Enhanced Barrier Precautions [EBP] recommendations for Implementation of PPE [Personal Protective Equipment] Use in nursing homes to prevent spread of MDROs [multidrug-resistant organisms], and therefore, CMS [Centers for Medicare and Medicaid] is updating its infection prevention and control guidance accordingly. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply . Review of the facility's policy titled, Legionella Surveillance and Detection, revised September 2022, revealed Policy Statement: Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Legionella disease is included as part of our infection surveillance activities . Review of the facility's policy titled, Legionella Water Management Program, revised September 2022, revealed Policy Statement: Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation .f. The control limits or parameters that are acceptable and that are monitored . 1. Review of R58's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R58 was admitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus. Review of R58's Physician Orders, dated 07/01/24 and located under the Orders tab of the EMR, revealed R58 was to receive FSBS checks before each meal. Review of R48's Admission Record, located under the Profile tab of the EMR, revealed R48 was readmitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus with hyperglycemia (high blood sugars). Review of R48's Physician Orders, dated 06/28/24 and located under the Orders tab of the EMR, revealed R48 was to receive FSBS checks before each meal. Review of R232's Admission Record, located under the Profile tab of the EMR, revealed R232 was readmitted to the facility on [DATE] with diagnoses that included type two diabetes mellitus with hyperglycemia. Review of R232's Physician Orders, dated 07/09/24 and located under the Orders tab of the EMR, revealed R232 was to receive FSBS checks before each meal and at bedtime. During an observation on 07/09/24 at 10:42 AM, Registered Nurse (RN) 1 was observed completing a FSBS check for R58, using a [NAME] Quintet AC blood glucose meter. RN1 removed a basket containing lancets and a glucometer from the top drawer of the medication cart. RN1 gathered supplies including the glucometer, glucometer strips, a lancet, and alcohol wipes and proceeded to R58's room. Without sanitizing the glucometer, RN1 performed the FSBS check for R58 and then wiped the glucometer with an alcohol wipe. RN1 returned to the medication cart, placed the meter into the basket, removed her gloves, and performed hand hygiene. Continuing with the observation on 07/09/24 at 10:47 AM, RN1 removed the same glucometer used for R58 from the basket, gathered supplies of a lancet, glucometer strips, and alcohol wipes and proceeded to R48's room. Without sanitizing the glucometer, RN1 performed a FSBS check for R48 and then wiped the glucometer with an alcohol wipe. RN1 returned to the medication care, placed the glucometer into the basket, and placed the basket into the top drawer of the medication cart. During an observation and interview on 07/09/24 at 10:48 AM, RN1 was asked what she wiped the glucometer with after each use. She stated, Alcohol wipe. RN1 confirmed there was a container of Super Sani-Cloth disinfecting wipes in the fourth drawer on the left side of the medication cart. During an observation on 07/9/24 at 11:06 AM, Licensed Practical Nurse (LPN) 2 was observed completing a FSBS check for R232, using a blood glucose meter. LPN2 placed the glucometer into his right-side pants' pocket, obtained a container of glucometer strips, alcohol wipes, a lancet and proceeded to the dining room where R232 was seated. LPN2 placed the supplies on the dining room table and went to the therapy department to get gloves. LPN2 donned (put on) gloves and performed R232's FSBS check. At 11:10 AM, LPN2 returned to the medication cart, doffed (took off) his gloves, placed the glucometer on top of the medication cart, and began looking at the electronic charting system. He did not sanitize the glucometer. At 11:14 AM, LPN2 placed the glucometer back into his right-side pants' pocket, left the medication cart, and placed a phone call to the physician. From 11:15 AM through 11:26 AM, LPN2 moved throughout the facility attempting to locate the physician to inform him of R232's FSBS check result. The glucometer remained in his pocket. During an interview on 07/09/24 at 11:26 AM, LPN2 confirmed that he kept the glucometer in his pants' pocket. During an interview on 07/09/24 at 12:26 PM, RN1 confirmed the facility's policy was to use antiviral wipes to clean the glucometers before and after use. RN1 confirmed she did not use a sanitizing wipe to clean the glucometer. She stated, Honestly, I usually use an alcohol wipe. During an interview on 07/09/24 at 12:33 PM, LPN2 stated the facility's policy was to clean the glucometer after each use and to use alcohol wipes to clean it. LPN2 confirmed he carried the glucometer in his pants' pocket and that he did not sanitize the glucometer before placing it into his pocket or before or after performing R232's FSBS check. LPN2 stated he placed the glucometer in his pocket while he was working with an individual resident. He stated there were two glucometers on each cart, and that was the way he kept them separated while doing the FSBS checks. LPN2 confirmed there was a container of Clorox disinfecting wipes on his medication cart. During an interview on 07/09/24 at 12:36 PM, the Director of Nursing (DON) stated her expectation and the facility's policy was for glucometers to be sanitized between residents and allowed to dry. She stated that each medication cart had two glucometers so that one could dry while the other was used. The DON was asked what should be used to clean the glucometers. She stated she would have to look that up since she had only been at the facility for four weeks, and she was unsure what solution was used. The DON was asked if carrying the glucometer in a clothing pocket was appropriate. She stated, No, that is an infection control issue. Absolutely not. During an interview on 07/09/24 at 12:42 PM, RN1 confirmed she had used the same glucometer for R58 and R48. She stated there were two glucometers on her medication cart, but she had used the same one. During an interview on 07/09/24 at 2:00 PM, the Infection Preventionist (IP) stated it was the facility's policy to clean the glucometer before and after each use. The IP stated neither the facility's policy nor the glucose meter manual addressed what to use to clean the glucometer. 2. a. Review of R231's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R231 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder. Review of R231's Physician Orders, dated 06/27/24 and located under the Orders tab of the EMR, revealed R232 had an indwelling urinary catheter due to neuromuscular dysfunctions of the bladder. During an observation and interview on 07/08/24 at 11:13 AM, R231 was observed lying in her bed. The resident was noted to have an indwelling catheter. There was no signage noted detailing EBP were in place for the resident. There was no personal protective equipment (PPE) noted outside or inside R231's room. R231, who answered questions of orientation appropriately, stated staff wore gloves but did not wear a gown when assisting with transfers, cleaning her urinary catheter, providing care, or changing linens. Observations on 07/08/24 through 07/10/24 revealed no EBP were in place related to the urinary catheter. b. Review of R56's Admission Record, located under the Profile tab of the EMR, revealed R56 was admitted to the facility on [DATE] with diagnoses that included benign prostatic hyperplasia (BPH) with lower urinary tract symptoms and urinary retention. Review of R56's Physician Orders, dated 02/03/24 and located under the Orders tab of the EMR, revealed R56 had a suprapubic urinary catheter related to complications of BPH. During an observation on 07/08/24 at 11:05 AM, two staff members were observed transferring R56 from his bed to his wheelchair. The staff members did not have gowns on. There was no signage noted detailing EBP were in place for the resident. There was no PPE noted outside or inside R56's room. Observations on 07/08/24 through 07/10/24 revealed no EBP were in place related to the urinary catheter. c. Review of R29's Admission Record, located under the Profile tab of the EMR, revealed R29 was admitted to the facility on [DATE] with diagnoses that included BPH and urinary retention. Review of R29's Physician Orders, dated 06/06/24 and located under the Orders tab of the EMR, revealed R29 had a suprapubic urinary catheter. Review of R29's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/02/24 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R29 was cognitively intact. During an observation and interview on 07/08/24 at 11:02 AM, R29 was observed to have a suprapubic urinary catheter. There was no signage noted detailing EBP were in place for the resident. There was no PPE noted outside or inside R29's room. R29 stated staff wore gloves but did not wear a gown when transferring him, changing his linens, emptying his urinary drainage bag, or cleaning his suprapubic catheter. R29 stated he did not know what EBP were. Observations on 07/08/24 through 07/10/24 revealed no enhanced barrier precautions were in place related to the urinary catheter. d. Review of R42's Admission Record, located under the Profile tab of the EMR, revealed R42 was readmitted to the facility on [DATE] with diagnoses that included urinary retention. Review of R42's Progress Note, dated 06/11/24 at 4:46 PM and located under the Progress Notes tab of the EMR, revealed R42 had been sent to the emergency room due to urinary retention and returned to the facility with an indwelling urinary catheter. Review of R42's 5-day PPS (Pay Per Service) MDS, with an ARD of 07/01/24 and located under the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated R42 was cognitively intact. During an observation and interview on 07/08/24 at 11:59 AM, R42 was observed to have a urinary catheter in place. There was no signage noted detailing EBP were in place for the resident. There was no PPE noted outside or inside R42's room. R42 stated staff wore gloves but did not wear a gown when assisting him with transfers, changing his linens, emptying his urinary drainage bag, or cleaning his catheter. Observations on 07/08/24 through 07/10/24 revealed no EBP were in place related to the urinary catheter. During an interview on 07/09/24 at 1:30 PM, LPN2 was asked if he knew what EBP were. He stated no. During an interview on 07/10/24 at 8:55 AM, LPN5 was asked if she knew what EBP were. She asked, You mean like gloves and the whole works? EBP was explained to her. LPN5 stated, I don't remember that. During an interview on 07/10/24 at 1:52 PM, Certified Nurse Aide (CNA) 1 stated she did not know what EBP were and that she had not been educated on the subject. During an interview on 07/10/24 at 3:37 PM, the Administrator was asked if he had received the memo from the Centers of Medicare and Medicaid Services (CMS) that detailed the need and required implementation of EBP for residents with urinary catheters, feeding tubes, wounds, or indwelling medical devices. He stated he did not recall. The Administrator stated it was his responsibility to obtain CMS memos and disperse the information to his staff. The Administrator stated he did not recall if he had done so with the CMS memo related to EBP. e. Review of R8's undated Medical Diagnosis located in the EMR under the Med Diag tab, indicated diagnoses to include encounter for fitting and adjustment of gastrointestinal appliance and device, gastrostomy, diaphragmatic hernia, and Barrett's esophagus without dysplasia. Review of R8's Physician Orders, dated 09/28/23 and located in the EMR under the Orders tab, indicated Cleanse G-tube site daily and prn [as needed] every day shift. During an interview on 07/08/24 at 10:00 AM, when LPN3 was asked if there were any residents in isolation on the 100 unit, LPN3 stated, No. When asked if there were any residents on the 100 unit on any type of enhanced barrier precautions, LPN3 stated, No. During an observation on 07/08/24 at 11:00 AM, R8 was observed in his room. At this time, R8 was observed unable to communicate his needs. There was no evidence of any type of signage posted for enhanced barrier precautions. There was also no evidence of any type of isolation cart inside or outside of R8's room to include any type or PPE. During a second interview on 07/08/24 at 1:30 PM, LPN3 stated that R8 has a feeding tube. A g-tube. He eats in restorative dining and gets his medications and flushes through the G-tube. During an observation on 07/09/24 at 8:50 AM, R8 was observed to be laying in a low bed with a floor mat at the bedside. At this time, the door to R8's room was opened and there was no evidence of any signage for EBP in place, or any type of isolation cart inside or outside of the room containing PPE. f. Review of R10's undated Medical Diagnosis located in the EMR under the Med Diag tab, indicated diagnoses to include acute pyelonephritis, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, obstructive and reflux uropathy, and neuromuscular dysfunction of bladder. Review of R10's Physician Orders, dated 05/13/24 and located in the EMR under the Orders tab, indicated Suprapubic cath [catheter] 22 Fr [French] 10cc [cubic centimeters] change indwelling cath. Review of a Comprehensive Care Plan, dated 05/22/24 and located in the EMR under the Care Plan tab, indicated, Has an indwelling suprapubic catheter 22 Fr with 10cc balloon due to dx [diagnosis] of neurogenic bladder, urine retention and obstructive uropathy. During an interview on 07/08/24 at 1:30 PM, LPN3 stated that R10 had a suprapubic catheter in place. During an observation on 07/08/24 at 2:00 PM, R10 was observed sitting in his room in a wheelchair. At this time, R10 was not able to communicate his needs. Further observation revealed catheter tubing was in place and observed in a blue privacy bag. At this time, there was no signage posted on R10's door for EBP. There was also no isolation cart located inside or outside of R10's room to include any PPE. g. Review of R21's Admission Record located in the EMR under the Profile tab, indicated R21 was admitted on [DATE] with diagnoses of dependence on renal dialysis. Further review no indication of orders for EBP. During an interview on 07/08/24 at 10:00 AM, R21 stated he received dialysis and had a catheter on the right side of his chest. There was no indication the resident was on EBP such as signs or PPE. h. Review of R131's Admission Record located in the EMR under the Profile tab, indicated R131 was admitted on [DATE] with diagnoses pressure ulcer of buttock, contusion of left lower leg, and cellulitis of the right lower limb. Further review no indication of orders for EBP. During an interview on 07/08/24 at 11:02 AM, R131 was lying in bed and stated that she had a pressure ulcer on her buttocks and both feet had surgical dressings on them. There was no indication the resident was on EBP such as signs or PPE. i. Review of R43's Admission Record located in the EMR under the Profile tab, indicated R43 was admitted on [DATE] with of end stage renal disease, and complete traumatic amputation of right midfoot. Further review no indication of orders for EBP. During an interview on 07/08/24 at 1:21 PM, R43 stated he had a catheter for dialysis treatments on the right side of his chest and a wound at the site of his right foot amputation. There was no indication the resident was on EBP such as signs or PPE. j. Review of R47's Admission Record located in the EMR under the Profile tab, indicated R47 was admitted on [DATE] with diagnoses of pressure ulcer of sacral region and retention of urine. Further review no indication of orders for EBP. During an interview on 07/08/24 at 2:04 PM, R47 stated she had pressure ulcers on her coccyx and had a Foley catheter placed. There was no indication the resident was on EBP such as signs. or PPE. During an interview on 07/09/24 at 1:00 PM, MDS1 stated she had conducted some education for staff but was not aware of EBP. During an interview on 07/09/24 at 1:17 PM, the Administrator stated that his staff were professionals and he expected them to have knowledge. The Administrator stated he usually kept up with the update to rules and regulations but could not recall anything about EBP. During an interview on 07/09/24 at 1:33 PM, Assistant Director of Nursing (ADON) 1 stated that EBP would be used if a resident had an infection and there was going to be splashing of bodily fluids. The ADON stated staff needed to wear gown, gloves, and face shield. ADON1 was asked if there was anyone in the facility who should be on EBP and he stated, Not at this time. During an interview on 07/09/24 at 2:06 PM, ADON2 was asked about her knowledge of EBP. ADON2 stated EBP was when there was splashing of bodily fluids and staff should be wearing PPE. During an interview on 07/10/24 at 2:20 PM, RN3 was asked if she knew what EBP was and when to use it. RN3 stated we use standard precautions by wearing gloves and mask when need to. I don't know what EBP is. 3. Review of the facility's policies and procedures titled, Policy and Procedure [NAME] for Long-Term Care, Infection Control revealed various sections such as the following: Blood or body Fluids Exposure revised July 2016. Cleaning and Disinfection of Environmental Surfaces, revised August 2019. Cleaning and Disinfection of Resident-Care items and Equipment, revised September 2019. Cleaning Spills or Splashes of Blood or Body Fluids, revised February 2023. Exposure Classification of Tasks/Procedures, revised January 2012. Exposure Determinations, revised September 2020. Herpes Zoster Vaccine, revised August 2016. Infection Preventionist, revised September 2022. Influenza, Prevention and Control of Seasonal, revised March 2022. Influenza Vaccine, revised March 2022. Laundry Bedding Soiled, revised September 2022. Legionella Surveillance and Detection, revised September 2022. Legionella Water Management Program, revised September 2022. Mpox Virus, revised February 2023. Needlesticks and Cuts, revised August 2013. Outbreak Communicable Diseases, revised September 2022. Sharp Disposal, revised January 2012. Standard Precautions, revised September 2022. Surveillance of Infections, revised September 2017. Vaccination f Residents, revised October 2019. Visitation, Infection Control During, revised August 2019. Cleaning Broken Glass When Contaminated with Blood or Body Fluids, revised October 2011. Cleaning Spills or Splashes of Blood or Body Fluids, revised January 2012. Departmental (Environmental Services)- Laundry and Linen, revised January 2014. Departmental (Occupational Therapy)- Prevention of Infection, revised September 2010. Departmental (Physical Therapy)- Prevention of Infection, revised September 2010. Departmental (Recreational Therapy)- Prevention of Infection, revised September 2010. Departmental (Respiratory Therapy)- Prevention of Infection, revised November 2011. Diapers/ Underpads [sic], revised September 2010. Diarrhea and Fecal Incontinence, revised September 2010. Medical Waste, Handling of, revised September 2010. Needle Handling and/or Disposal, revised January 2012. Personal Protective Equipment- Using Face Mask, revised September 2010. Personal Protective Equipment- Using gloves, revised September 2010. Personal Protective Equipment- Using Gowns, revised September 2010. Personal Protective Equipment- Using Protective Eyewear, revised September 2010. During an interview on 07/11/24 at 2:20 PM, the Administrator stated, We use Med Pass and when there is an update we are sent that on a flash drive. We rely on med pass to send us the updated policies, but we have not gotten any new updated policies. Some policies don't change. We try and review annually. 4. During an interview on 07/10/24 at 12:39 PM, the Maintenance Director (MD) was asked what parameters or range you set for the determination of whether there was Legionella or not. The MD stated, We have to test it. The MD was asked for the test results. The MD stated, We just ordered a test kit. I don't have anything unless the city can provide it. We put a call out but have received nothing. They had a diagram of the building, and it indicated the areas of concern. The MD stated that he checked areas monthly and ran sinks that were not used weekly. No documentation was provided to confirm that was completed. During an interview on 7/11/24 at 2:20 PM, The Administrator was asked about the Legionella Program. He stated, We haven't had any outbreaks. We know where our at-risk areas are. The water heaters are checked out monthly. We have zero cases; we have never had a case. We know where our risk areas are. The ice machine, water heaters and any unused faucets, sinks, hoses are all flushed monthly. That is our preventative maintenance program. To my knowledge we are not doing testing. I was under the impression testing is conducted by the city. We don't have any hot tubs, fountains where it would breed.

Based on interview, record review, and facility policy review, the facility failed to have an Infection Preventionist (IP) that had completed specialized training in infection prevention and control. This deficient practice had the potential to allow staff to go without the proper knowledge and training of infection control practices for 87 census residents. Findings include: Review of the facility's policy titled, Infection Preventionist, revised September 2022, revealed Policy Statement: The infection preventionist is responsible for coordinating the implementation and updating of the infection prevention and control program .Specialized Training: 2. Evidence of training is provided through a certificate(s) of completion or equivalent documentation. During entrance conference interview on 07/08/24 at 9:00 AM, the Administrator indicated Minimum Data Set (MDS) 1 was the IP and had been the IP since February of 2024. Review of the certificates provided by the facility for the IP revealed there was no certificate presented for the IP named at entrance. During an interview on 07/09/24 at 1:00 PM, Minimum Data Set (MDS) 1 was asked if she was the IP. MDS1 stated, As of yesterday, (indicating 07/08/24). MDS1 was asked if she had any training for the IP position. MDS1 stated, I took a state training on COVID-19. I am starting the other training. During an interview on 07/09/24 at 1:17 PM, the Administrator was asked about the IP. The Administrator stated, Our former DON [Director of Nursing] was the IP, but she left in March of 2024. As of today, there is no IP. It would fall to the DON. The plan is to get the DON the training. She has only been here three weeks. MDS1 is working on the certification as we speak.

Based on observation, interview, record review and facility policy review, the facility failed to ensure the oxygen (O2) concentrators had a filter or dust free filters on the inlet where the air came into the machine for five of five residents (Resident (R) 7, R19, R16, R47, and R132) of 20 sample residents. This deficient practice had the potential to allow an increased chance of infection and unnecessary respiratory treatment. Findings include: Review of the facility's policy titled, Departmental (Respiratory Therapy)- Prevention of Infection, revised November 2011, revealed Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff .Steps in the procedure: Infection control Considerations Related to Oxygen Administration .9. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry . Review of the facility's policy titled, Oxygen Administration, dated October 2010 and provided by the facility, indicated Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. The policy further indicated, Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. 1. Review of R7's undated Face Sheet located in R7's electronic medical record (EMR) under the Med Diag (Medical Diagnosis) tab, indicated diagnoses to include hypoxemia (a low level of oxygen in the blood), and COPD (chronic obstructive pulmonary disease). Review of Physician Orders, dated 03/22/22 and located in R7's EMR under the Orders tab, indicated Change 02 [oxygen] tubing, water weekly and clean filter every day shift every Mon [Monday] to ensure infection control . Review of Physician Orders, dated 11/06/23 and located in R7's EMR under the Orders tab, indicated Oxygen @ 2L PM [at 2 liters per minute] via NC [nasal cannula] to keep saturations >90%. Review of the Care Plan, revised on 03/23/22 and located in R7's EMR under the Care Plan tab, indicated [R7] has COPD and hx [history] of smoking. She requires supplemental oxygen. Interventions on the care plan included, Change 02 tubing/water weekly and clean filter. During an observation on 07/08/24 at 1:03 PM, R7's oxygen concentrator was located in R7's room and was observed to have a black oxygen filter on the back of the concentrator. It was observed to be full of a buildup of white lint and heavy debris and was observed to be very dirty. A large amount of white lint was observed in the filter at this time. During an observation on 07/08/24 at 2:00 PM, R7's oxygen concentrator filter was again observed to have a very thick buildup of white lint and debris on the filter. When checked, a large amount of white lint was also observed to fall out off the back of the oxygen concentrator where the filter was located. During observations on 07/09/24 at 8:25 AM and at 8:44 AM, R7's oxygen concentrator filter was observed to have the same amount of dust buildup, full of debris and large amount of white lint buildup from the day before. When checked, the inside of the oxygen filter was observed to also have a large amount of white lint buildup coming out of the port holes on the back of the oxygen concentrator. During an interview on 07/09/24 at 3:33 PM, Licensed Practical Nurse (LPN) 3 was asked who was responsible for ensuring the oxygen filters were cleaned. LPN3 stated, Either Central Supply, the CNAs (Certified Nurse Aides) or me (with nursing). We should be changing them out at least once a week. I believe on Mondays on day shifts or if not, on evening shift. LPN3 stated, With the oxygen filters, we don't have extra of those, so the CNAs should be rinsing them off, or [name of Central Supply person] or the nurses get them and rinse them and put them back. During an observation and interview on 07/09/24 at 3:39 PM, R7's oxygen concentrator filter, in the presence of LPN3, was observed to have the same thick buildup of dust, lint, and heavy debris. When LPN3 observed this, she stated, It's a dusty filter for sure. When asked if she was aware of the heavy buildup of lint, dust, and debris on the oxygen filter, LPN3 stated, No, I don't think the staff even opened this to check it. LPN3 then stated, It's dirty. I will let someone know. We need to do an in-service on this. LPN3 then stated, I think [name of Central Supply person] is supposed to check these, but I'm not sure if anybody is specifically checking the filters. It is all of our responsibility. To me, it should be all of our responsibility to be checking the oxygen filters and making sure they are changed out and cleaned. During an interview on 07/09/24 at 3:43 PM, the Hospitality Aide (HA) stated, If the water in the oxygen humidifier is empty, I change it out and the oxygen tubing, I change that out and put a new cannula with the date, but the oxygen filters, No. I don't do anything with the filters. I don't know who is supposed to change those out. During an interview on 07/09/24 at 3:46 PM, the Central Supply (CS) staff was asked if he changed out the oxygen concentrator filters, he stated, Yes, if I see it's very dirty, I will change them myself. I do routine rounds every Monday and I keep a log. When specifically asked how often the oxygen concentrator filters were changed and cleaned, he stated, Every six months I would say. When the CS person was asked if he was checking the oxygen filters when his rounds were being done on Mondays, he stated, Yes, everything gets checked. When he was asked if he was aware of the heavy buildup of dust, lint, and heavy debris located on R7's oxygen concentrator, the CS person stated, I wasn't aware. I would expect the staff to let me know if there is a heavy buildup of dust on those, since I'm in charge of it all. I wasn't informed of anything. It would only take less than two minutes to fix. We would just rinse them with hot water. Review of an audit sheet located in the Central Supply mailbox, dated 07/08/24 and provided by the Director of Nursing (DON), indicated R7's name was on the list and date of her audit was 07/08/24, however there was no documentation to confirm R7's oxygen filter had been observed, cleaned, changed out, by any staff. During an observation and interview on 07/09/24 at 3:52 PM, the DON stated, Nursing on the night shift should be changing out the oxygen humidifiers. They can change out the equipment and with filters, our staff can clean those as well. During an observation of R7's oxygen concentrator filter in the presence of the DON, there was still a large amount of thick heavy white debris, dust, and white lint observed on R7's oxygen filter. At this time, the DON stated, I see it needs to be changed. I was not made aware of this, and I can see it needs to be cleaned out. We meet daily with nursing in our clinical meetings, and they should also be documenting this in the chart. I would say, by looking at this [referring to R7's oxygen concentrator filter] it is very dirty and needs to be cleaned right away. During an interview on 07/10/24 at 8:20 AM, the CS staff stated, With my audits, they are done every Monday. I change out the cannulas and I do the audits one resident at a time. I go to each room. When asked if he observed the heavy buildup of lint, dust, and debris on R7's oxygen filter, or changed it out during his audit on 07/08/24, he stated, As far as the filter, I may have missed it. I may have been called away to do something else. I'm not sure. I don't remember looking at her concentrator to be honest with you. That is something I normally do on my audits, and I may have missed it. During an interview on 07/11/24 at 9:28 AM with the DON and Administrator regarding the responsibility of ensuring resident oxygen filters were being cleaned, the Administrator stated, Central Supply is supposed to be completing audits and checking the filters to make sure they are being cleaned. The DON stated, They should also be cleaned every seven days on Mondays. When both the Administrator and DON were asked if they were aware, or made aware by any staff of R7's oxygen concentrator filter not being cleaned, or having a large amount of dust, and debris, both stated, No. The DON stated, I was not made aware until we both observed it and you showed it to me. 2. Review of R19's Admission Record, located under the Resident tab of the EMR, revealed R19 was admitted on [DATE] with diagnoses lobar pneumonia, unspecified organism, muscle weakness (generalized), and other malaise. Review of R19's quarterly Minimum Data Set (MDS) located in the EMR under the RAI [Resident Assessment Instrument] tab with an Assessment Reference Date (ARD) of 06/12/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R19 was cognitively intact. Review of R19 's Physician Order Sheet, located in the EMR under the Resident tab, revealed the following order, dated 07/10/24: Oxygen (O2) 1-5l/min to keep O2 sats 90% or better; every shift for sob (shortness of breath). During observations on 07/08/24 at 10:32 AM and, 07/09/24 at 10:26 AM, R19's oxygen concentrator had a dust filled filter. 3. Review of R16's Admission Record, located under the Resident tab of the EMR, revealed R16 was admitted on [DATE] with diagnoses of persistent vegetative state, and anoxic brain damage, not elsewhere classified. Review of R16's quarterly MDS located in the EMR under the RAI tab with an ARD of 06/10/24 revealed the resident had a BIMS score of zero out of 15, indicating R16 had severely impaired cognition. Review of R16 's Physician Order Sheet, located in the EMR under the Resident tab, revealed the following order, dated 06/14/24: Oxygen (O2) 1-5l/min to keep O2 sats 90% or better; two times a day. During observations on 07/08/24 10:30 AM and 07/10/24 9:42 AM, R16's oxygen concentrator had a dust filled filter. During an interview on 07/10/24 at 10:04 AM, Assistant Director of Nursing (ADON) 2 observed the oxygen concentrator in R16's room and stated the filter was dirty and she would get it cleaned. During an interview on 07/10/24 1:31 PM, ADON1 stated oxygen concentrator filters were cleaned weekly on Sunday evenings during the night shift. During an interview on 07/10/24 1:45 PM, the Director of Nursing (DON) stated oxygen concentrator filters should be cleaned every seven days. 4. Review of R47's Admission Record located in the EMR under the Profile tab, indicated R47 was admitted on [DATE] with diagnoses of acute respiratory failure with hypoxia (an absence of enough oxygen to sustain the function of the body tissue). Review of the Orders located in the EMR under the Orders tab, revealed on 04/08/24 R47 requires supplemental oxygen at 2 liters per minute via NC. Keep O2 sats (saturation) above 90%. Titrate off for RA [room air] sat greater than 90%. During an observation on 07/08/24 at 2:28 PM, R47 was in bed with oxygen on through nasal canula (NC) attached to an oxygen concentrator at two liters per minute. The concentrator did not have a filter on the inlet where the air entered the machine. During an observation on 07/09/24 at 9:30 AM, the concentrator did not have a filter on the inlet. R47 was sitting in bed with NC on. During an interview on 07/10/24 at 2:20 PM, Registered Nurse (RN) 3 was asked to look at the concentrator and look for the filter. RN3 looked at the machine and stated there was no filter. RN3 stated, There should be a filter. RN3 was asked who should see that there was a filter on the concentrator. RN3 stated the nurses should on Mondays when they change the tubing. 5. Review of R132's Admission Record located in the EMR under the Profile tab, indicated R132 was admitted on [DATE] with diagnoses of COPD and obstructive sleep apnea. Review of the Orders located in the EMR under the Orders tab, revealed on 06/19/24 R132, oxygen at 3-5 liters via nasal canula continuous to maintain saturation of 90% or greater. During an observation on 07/08/24 at 10:30 AM, R132 was observed in her room wearing a NC. There was a concentrator in her room with no filter on the inlet. During an interview on 07/10/24 at 2:25 PM, RN3 was asked to look at the concentrator and look for the filter. RN3 looked at the machine and stated there was no filter. RN3 stated, There should be a filter. During an interview on 0710/24 at 2:29 PM, the DON was asked her expectations for residents receiving oxygen therapy. The DON stated, I expect the equipment to be complete to include the inlet filters. The filters are there to keep dust and whatever is in the air out. 20402 27375

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5% with five errors out of 25 opportunities which resulted in a 20% error rate for three of three residents (Resident (R) 50, R48, and R56) observed for medication administration out of a total of 87 residents. The facility failed to ensure Lidoderm patches (used for neuralgic pain) were applied or removed as ordered by the physician for R50, levothyroxine (used to treat hypothyroidism) and lisinopril (used to treat hypertension) were administered as ordered by the physician for R48, and Vitamin B-12 was administered in the correct dosage for R56. This failure had the potential to affect resident medication safety. Findings include: Review of the facility's policy titled, Administering Medications, revised April 2019, revealed, .Medications are administered in a safe and timely manner, and as prescribed .Medications are administered in accordance with prescriber orders, including any required time frame . 1. Review of R50's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R50 was admitted to the facility on [DATE] with diagnoses that included pain in right shoulder. Review of R50's Physician Orders, dated 07/01/24 and located under the Orders tab of the EMR, revealed an order for R50 to receive, Lidoderm External Patch .Apply to affected area topically one time a day for pain. Applied to both shoulders in the morning and off at bedtime . During an observation on 07/09/24 at 8:29 AM, Licensed Practical Nurse (LPN) 3 was observed administering R50's medications. LPN3 entered R50's room and lifted his shirt. An undated Lidoderm patch was noted to R50's right shoulder. There was no patch on the left shoulder. LPN3 removed the patch on the right shoulder and asked R50 where he would like the new Lidoderm patch to be positioned on his right shoulder. LPN3 applied the Lidoderm patch and began to reposition R50's clothing. LPN3 noted there was a Lidoderm patch stuck inside R50's shirt. LPN3 removed the Lidoderm patch and exited R50's room. Review of R50's Medication Administration Record (MAR), dated 07/09/24 and located under the Orders tab of the EMR, and Progress Notes, dated 07/09/24 and located under the Progress Notes tab of the EMR, revealed no documented evidence that R50 had refused a Lidoderm patch to his left shoulder. There was no documented evidence of removal of the Lidoderm patches at bedtime on 07/08/24. During an interview on 07/10/24 at 9:12 AM, LPN3 was asked to read R50's physician's order for the Lidoderm patch. LPN3 stated, He doesn't want them for both shoulders. LPN3 stated R50 refused at times, and she had already asked him if he wanted a Lidoderm patch on both shoulders. LPN3 was asked if the order read for the Lidoderm patch to be removed at night. She stated, Yes. LPN3 was asked where removal of the patch would be documented. She stated, I don't work nights. LPN3 confirmed there had been a Lidoderm patch on R50's right shoulder on 07/09/24 at 8:29 AM and she had to remove it when she went to apply the new patch. During an interview on 07/10/24 at 9:46 AM, the Nurse Practitioner (NP) stated, If I wrote bilateral shoulders, that is what they [staff] are supposed to do. The NP stated the Lidoderm patch was supposed to be removed at night, but the electronic charting system did not allow for the removal to be listed on MAR. The NP stated she would have to re-educate the staff. 2. Review of R48's Admission Record, located under the Profile tab of the EMR, revealed R48 was admitted to the facility on [DATE] with diagnoses that included hypothyroidism and essential hypertension. Review of R48's Physician Orders, located under the Orders tab of the EMR, revealed an order, dated 06/01/24, for levothyroxine 175 micrograms (mcg) one tab daily and an order, dated 12/01/23, for lisinopril 40 milligrams (mg) one tab daily, hold if systolic blood pressure less than 100. During an observation on 07/10/24 at 8:26 AM, LPN5 was observed preparing medications for R48. LPN5 obtained R48's levothyroxine medication card, stated R48 refused the medication most of the time and then placed the medication card to the side. LPN5 did not place any levothyroxine in R48's medication cup. LPN5 stated R48's systolic blood pressure was above 100, so she would receive the ordered lisinopril. LPN5 placed the lisinopril medication card to the side without placing any into R48's medication cup. At 8:33 AM, LPN5 was asked to count the number of pills that were in R48's medication cup. She stated, Six. LPN5 entered R48's room and administered the medications from the medication cup. At 8:36 AM, LPN5 was asked what medications had been provided to R48. LPN5 reviewed the EMR and named seven medications. She was asked how many medications she had counted in the cup prior to administration. LPN5 stated, Six, what did I miss? LPN5 was informed she did not administer the lisinopril. During an interview on 07/10/24 at 8:51 AM, LPN5 was asked why she did not attempt to administer R48's levothyroxine. LPN5 stated, I usually ask, but I didn't this time. LPN5 stated R48 usually refused her levothyroxine because her dentist told her that it was causing her teeth to loosen. LPN5 stated, I should have asked her if she wanted to take it. 3. Review of R56's Admission Record, located under the Profile tab of the EMR, revealed R56 was admitted to the facility on [DATE] with diagnoses that included essential hypertension. Review of R56's Physician Orders, dated 07/04/24 and located under the Orders tab of the EMR, revealed R56 was to receive Vitamin B-12 500 mcg once a day. During an observation on 07/10/24 at 8:41 AM, LPN5 was observed preparing medications for R56. LPN5 placed a 1000 mcg Vitamin B-12 tablet in R56's medication cup and administered the medication. During an interview on 07/10/24 at 9:34 AM, LPN5 was asked to show the surveyor all the Vitamin B-12 containers in the medication cart. She stated, All we have is 1000 mcg. LPN5 confirmed R56 was supposed to receive 500 mg. She stated, We aren't supposed to cut anything in half. I've been giving 1000 mcg. LPN5 stated, Maybe we should just order 500 from the pharmacy. During an interview on 07/10/24 at 2:59 PM, the Administrator and Director of Nursing (DON) stated their expectation was for staff to attempt to give medications if they were ordered by the physician and to inform residents of medication risks and benefits. The Administrator stated the physician should be informed of any medication refusals. The Administrator and DON stated their expectation was for residents to receive medications in the dosages ordered by the physician and for medications to be administered per physician orders.

Based on record review, interviews, and facility policy review, the facility failed to have written documentation of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) CMS [Centers for Medicare and Medicaid Services]-10055 for one of three residents (Resident (R) 27) reviewed for beneficiary notices of 20 sample residents. The facility failed to have written documentation to indicate R27 or their legal representative were notified in writing of the SNFABN, the reason why Medicare might not pay for services, and the estimated daily cost the resident would be responsible for should they choose to receive skilled services. By not having written documentation, the resident was unable to make an informed decision and was unaware of additional costs and services when skilled services are ending. Findings include: Review of the facility's policy titled, Medicare and Medicaid Benefits, revised April 2017, indicated, Residents are provided with information verbally and in writing about how to apply for and use Medicare and Medicaid benefits .Upon admission, and when a resident become eligible for Medicare/Medicaid benefits, a representative of the business office will inform the resident verbally and in writing of: a. the services and items covered under the facility's Medicare/Medicaid payment rate; and b. the charges for non-covered items or services that are available to the resident .When changes are made to items and services covered by Medicare or Medicaid State plans, residents will be informed of these changes as soon as possible .Inquiries concerning Medicare and Medicaid eligibility requirements should be referred to the business office, and/or to the Social Services Department. Review of an undated list of Beneficiary Notice- Residents discharged Within the Last Six Months, document provided by the Administrator, listed residents who were discharged from Medicare covered Part A services with benefit days remaining who either were discharged home, transferred to another facility, or chose to remain in the facility. On the list R27 was the only resident marked as Remaining in the facility. Review of an undated document titled, SNF Beneficiary Notification Review for R27, indicated .Medicare Part A Skilled Services Episode State date was: 11/28/23. The last covered day of Part A Services was on 02/29/24 The form indicated, Benefit days weren't exhausted, resident wanted to stay . Further review of the document indicated, Was an SNF/ABN, Form (CMS-10055) provided to the resident? It was marked, No. The reason indicated was, MRA [Medical Reimbursement Arrangement] payor used NOMNC [Notice of Medicare Non-Coverage]. There was no written documentation or evidence that R27 was issued the SNF/ABN, no written documentation of the reason Medicare may not pay for services, and the estimated cost the resident would be responsible for while remaining in the facility was not included. Review of the complete medical record for R27 revealed no documentation that communication took place between R27 and/or representative to discuss potential additional costs that the resident might have to pay if they chose to continue to receive services. During an interview on 07/09/24 at 3:15 PM, the Social Services Director (SSD) stated, If there are a few extra days remaining I let them know that I talked with Physical Therapy and with the cost, if they are needing extra days to stay, I let them know the co-pays. I review the cost per day with them. When specifically asked if the SNFABN document was reviewed with R27 or the representative of R27 to include the estimated costs per day, or why Medicare may not pay for services, the SSD stated that she had not. During an interview on 07/09/24 at 4:44 PM, when asked about the process for issuing the SNFABNs, the Business Office Manager (BOM) stated, I have never issued or seen the SNFABN form. I'm not familiar with this form. When reviewing the SNF Beneficiary Notification Review document for R27 with the SSD and the BOM, the SSD stated a SNFABN was not issued to R27. The SSD stated that R27 chose to remain in the facility and receive services. During a second interview on 07/10/24 at 8:49 AM with the SSD and the BOM regarding R27, the BOM stated that the last covered day for skilled services was 02/29/24 and R27 Did have some remaining days to use for services. We did not use the SNFABN form for her and she is still here in the facility.

Based on record review and interview, the facility failed to ensure that 1 (R #4) of 2 (R #'s 4 and 6) residents received treatment and care in a timely manner and in accordance with professional standards of practice when R #4 experienced difficulty swallowing and did not eat or drink for multiple days, experienced increased lethargy (a state of sleepiness or deep unresponsiveness and inactivity), respiratory distress, and hypoxia (low oxygen in the blood). If the facility is not monitoring for residents' change in condition, residents are likely at risk of inadequate or delayed treatment. The findings are: A. Record review of R #4's face sheet revealed R #4 was admitted to the facility on [DATE] with the following diagnoses: 1. Type 2 diabetes mellitus with diabetic neuropathy (a group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet). 2. Hyperlipidemia (high levels of fats in the blood). 3. Other chronic pain. 4. High blood pressure. 5. Cardiomyopathy (an acquired or inherited disease of the heart muscle which makes it difficult for the heart to pump blood to other parts of the body). 6. Paroxysmal atrial fibrillation (a type of irregular heartbeat that comes and goes). 7. Chronic obstructive pulmonary disease (a disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough). 8. Complete traumatic amputation (removal of a limb) of left great toe. B. Record review of R #4's August, 2023 Documentation Survey Report [Activities of Daily Living (ADL) Tracking Form] revealed the following: 1. 08/04/23 - R #4 refused his dinner meal. 2. 08/05/23 - R #4 ate 0 percent (%) of his breakfast meal. 3. 08/05/23 - R #4 ate 0% of his lunch meal. 4. 08/05/23 - R #4 ate 0% of his dinner meal. 5. 08/06/23 - R #4 ate 0% of his breakfast meal prior to being sent to the ER. C. Record review of R #4's emergency room (ER) notes, dated 08/06/23, revealed R #4 was diagnosed with the following: 1. Sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever) due to methicillin resistant staphylococcus aureus (MRSA; a staph infection that is immuned to many types of antibiotic) with acute organ dysfunction (organ failure) and septic shock (widespread infection causing organ failure and dangerously low blood pressure). 2. Acute respiratory failure with hypoxia (below-normal level of oxygen in the blood). 3. Encephalopathy (a disease that affects brain structure or function). D. Record review of R #4's nursing progress notes, dated 08/05/23 and 08/06/23, revealed the record did not contain a progress note that documented R #4's lethargy and failure to eat or drink prior to being sent to theER on [DATE]. E. Record review of R #4's nursing progress notes, dated 08/07/23 at 8:08 am, revealed R #4 requested to go to theER on [DATE] at 9:00 am. The resident was wheezing and his condition did not improve. His wife was present, and staff told her the resident might have pneumonia [infection of the air sacs in one or both the lungs]. R #4 was sent to the hospital, per his request. F. Record review of R #4's nursing progress notes, dated 08/07/23 at 8:50 am, revealed R #4's wife told staff that R #4 did not eat or drink much fluids 08/04/23 through 08/05/23. G. On 11/17/23 at 12:15 pm during an interview with R #4's son #1, he stated he received a call from his sister-in-law and his mother on Friday, 08/04/23, and they said R #4 did not look good. Son #1 stated they told him the resident did not eat or take his medications. He said his brother (Son #2) took their mother to the facility the morning of 08/06/23, and the resident was pale. Son #1 stated his mother could not take it anymore, and she demanded the facility call an ambulance. Son #1 said the facility told them R #4 had not been eating. H. On 11/17/23 at 12:22 pm during an interview with R #4's son #2, he stated he arrived at the facility a little after 7:00 am on Saturday, 08/05/23, and R #4 was in the dining room. The resident had most of his breakfast on his plate, and his silverware was on the floor. He said there was not any staff around to help the resident. Son #2 stated the resident's condition concerned him. The son said on 08/06/23, the resident laid on his bed and had black stuff on his mouth. He said the resident was much quieter than what he usually was, and the resident seemed more tired. I. On 11/17/23 at 12:43 pm during an interview with R #4's daughter-in-law (DIL), she stated she went to the facility on Friday, 08/04/23, and R #4 sat in his wheelchair with his head completely back and his eyes closed. She said her mother-in-law told her the resident had been in that state all day. The DIL said the resident's mouth and skin were dry. The facility staff told her the resident had not eaten in a couple days. J. On 11/17/23 at 3:00 pm during an interview with R #4's wife, she stated she requested the ambulance for R #4 on 08/06/23. The wife said she arrived at the facility on the morning of 08/06/23 and told the facility nurses to call 911. She wanted the resident sent to the hospital. One nurse told her she thought the resident had pneumonia. The wife said the resident was bed ridden for three days before he went to the hospital. She said during those three days, when she arrived at the facility, the nursing staff told her the resident had a bad night. K. On 11/17/23 at 3:54 pm during an interview with Registered Nurse (RN) #1, he stated R #4 did not eat much and he was sleepier than usual a couple of days prior to 08/06/23. RN #1 stated he thought he spoke to the physician the day R #4 began to show signs of lethargy and failure to eat. The RN did not remember which day, because it was not documented. RN #1 stated he could not remember if he spoke to the physician about R #4's condition. L. On 11/20/23 at 12:44 pm during an interview, Licensed Practical Nurse (LPN) #3 confirmed R #4 did not eat the day before he went to the ER, and staff did not document in the medical chart when R #4 was sent to theER on [DATE]. LPN #3 said the staff should have documented in R #4's medical record when the resident was sent to the ER, when he was more lethargic, and when he did not eat or drink. M. On 11/20/23 at 4:09 pm during an interview with Physical Therapy Assistant (PTA), she stated R #4 was lethargic the days before he went to theER on [DATE], and the nursing staff were aware of it. The PTA said the resident did not verbally interact with the therapy staff days before being sent to theER on [DATE]. She said she did not notify nursing of this because she assumed nursing was aware of R #4 being lethargic. N. On 11/20/23 at 4:47 pm during an interview with Medical Doctor (MD) #1, he stated he received a call on 08/06/23 at 9:38 am from the facility. They said R #4 was sent to the ER for respiratory distress and hypoxia. The MD said it was expected staff would document and call him if the resident had a change of condition. He said he could not find a note or any documentation regarding R #4's change of condition. O. On 11/21/23 at 1:45 pm during an interview with Restorative Certified Nursing Assistant (RCNA) #1, she stated a couple days before R #4 went to the ER he was tired and slept in his chair a lot. P. On 11/21/23 at 2:08 pm during an interview with the Director of Nursing (DON), she stated it was expected staff would complete the change of condition when R #4 did not eat and became lethargic. The DON confirmed the staff did not complete the change of condition documentation or notification.

This is a repeat deficiency from a survey dated 10/20/22 Based on record review and interview, the facility failed to ensure residents received appropriate pain management for 4 (R #'s 23, 37, 86, and 183) of 4 (R #'s 23, 37, 86, and 183) residents by: 1. Failing to asses and administer pain medication as needed and as ordered for R #'s 23, 37, and 86. 2. Not completing pain assessments for R #183. This deficient practice likely resulted in R's #23 and 86 experiencing severe pain and causing unnecessary distress without timely relief. The findings are: 41988 A. Record review of the Pain Clinical Protocol Policy and Procedure revised March 2018 revealed 2. The nursing staff will assess each individual for pain upon admission to the facility .whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 3. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern and severity 4. The nursing staff will identify any situation or interventions where an increase in the resident's pain may be anticipated. Findings for Resident #23: B. Record review of R #23's face sheet revealed R #23 was originally admitted into the facility on [DATE] with the following diagnoses: 1. HYPERGLYCEMIA, UNSPECIFIED (High blood sugar) 2. OTHER ACUTE POSTPROCEDURAL PAIN (Pain response due to tissue damage caused by surgical procedures) 3. ACUTE POSTHEMORRHAGIC ANEMIA (condition that develops when you lose a large amount of blood quickly) 4. PHANTOM LIMB SYNDROME WITH PAIN (pain that feels like it's coming from a body part that's no longer there) 5. PERIPHERAL VASCULAR DISEASE, UNSPECIFIED (condition or disease affecting the blood vessels) 6. ACUTE EMBOLISM AND THROMBOSIS OF RIGHT POPLITEAL VEIN (Blood clot in lower limb vein) 7. DEHISCENCE (splitting open) OF AMPUTATION STUMP 8. TOBACCO USE 9. LONG TERM (CURRENT) USE OF ANTICOAGULANTS (Blood Thinners) 10. ACQUIRED ABSENCE OF RIGHT LEG BELOW KNEE 11. INFECTION OF AMPUTATION STUMP, RIGHT LOWER EXTREMITY (Lower Leg) C. On 05/17/23 at 11:31 am during an interview with R #23, she stated, On March 16th [2023], I asked to go to hospital because I fell , well it was not a fall because Therapy caught me but I went forward and bumped heads with her [Physical Therapist]. After that episode [fall], she [Physical Therapist] brought me back to my room. I was in a lot of pain. I asked the nurse to send me out to the ER [emergency room ], but they didn't [send R #23 to the ER]. Thank goodness that the next morning, [03/17/23] that the nice nurse came in I told him and he sent me to the ER. D. Record review of R #23's Physical Therapy Treatment Encounter Notes dated 03/16/23 revealed, In parallel bars [help clients re-build both lower and upper body strength, mobility, balance, endurance and increase their range of motion], sit to stand x 2 [times 2]; able to take 3 steps in the parallel bars, but had to sit down due to extreme pain and sharp stabbing at the LLE [left lower extremity-limb]; got ice for the pt [patient- R #23] to place on her knee and asked nursing for pain meds. Helped arrange pt in her [R #23] room so she can stay in her chair and prop her LLE up to reduce pains. E. On 05/18/23 at 2:30 pm during an interview with Director of Physical Therapy (DPT), she stated. [Name of R #23] took a step forward and one step back, it was a forward trunk lean [how far your torso (trunk) is pitching forward as you walk/run] was not a fall. I took [Name of R #23] to her room and sat her in room in her wheelchair. I let the nurse know that the resident was experiencing a lot of pain and was in her room. DPT did apply ice to her leg on the day it happened. The next day (03/17/23), DPT returned and was told she (R #23) had fractured her right leg. F. Record review of R #23's physician orders dated 09/29/22 revealed an order for traMADol HCl Tablet 50 MG [milligram] Give 50 mg by mouth every 6 hours as needed for PAIN. G. Record review of R #23's physician orders dated 09/29/22 revealed, Tylenol Extra Strength Tablet 500 MG (Acetaminophen) Give 500 mg by mouth every 6 hours as needed for Mild Pain Max 4000 mg/24 Hours from all sources. H. Record review of R #23's March 2023 Medication Administration Record (MAR) revealed the following: 1. Tramadol (pain medication was administered at 1905 (7:05 pm) on 03/16/23 which is documented as ineffective. 2. Tylenol Extra Strength (pain medication) at 1905 (7:05 pm) on 03/16/23- 500 mg which was ineffective. 3. Tramadol (pain medication) was administered at 1:30 am on 03/17/23 which is documented as ineffective. Follow-up pain scale was 7 (pain scale 0 being no pain 10 being worst pain). 4. Tylenol Extra Strength (pain medication) at 1:30 am on 03/17/23- 500 mg which was documented as ineffective. I. Record review of Change of Condition dated 03/16/23 at 2000 (8:00 pm) revealed Intractable (hard to control, unmanageable) pain knees, change in function and mobility, Pain level 9/10 (pain scale 0 being no pain 10 being worst pain). Assessment Intractable Pain uncontrolled by medication. Date and time reported 03/17/23 at 0700 (7:00 am). Send to ER (emergency room ). J. Record review of Nursing Progress Note date 03/16/23 at 22:37 (10:37 pm) revealed called on call Dr (doctor), patient complaining of increased pain bilateral (both) knees patient medicated with PRN (as needed) medications requesting to be sent to hospital. (note is crossed out). K. Record review of R #23's Nurse Progress note dated 03/17/23 at 4:14 am revealed, Called on call Dr [doctor] patient [R #23] complaining of increase pain bilateral [having two sides] knees patient medicated with PRN [as needed] medications requesting to be sent to hospital. L. Record review of R #23's eMAR-(electronic) Medication Administration Progress Note dated 03/17/23 at 4:44 am revealed, Tramadol Hcl Tablet 50 mg. Give 50 mg by mouth every 6 hours as needed for pain PRN administration was Ineffective Follow-up pain scale was 5. M. Record review of Transfer Form dated 03/17/23 at 7:00 am revealed sent to (Name of local hospital) for Intractable [hard to control] Nursing. N. Record review of Hospital Progress Notes dated 03/18/23 at 8:40 am revealed .Presents with mechanical fall R (right) leg pain R Distal Femur Fracture (fracture above the knee joint) on 03/17/23. O. Record review of Physician Assistant Orthopedics dated 03/18/23 at 10:44 am procedure: open reduction with internal fixation left distal femur intra-articular fracture (fracture that crosses a joint surface). P. On 05/18/23 at 2:55 pm during an interview with Registered Nurse (RN) #2, he stated, I was told the next morning [on 03/17/23] when I returned to work that she [R #23] was experiencing pain [since 03/16/23]. She [R #23] was working with Therapy and she was taking steps for the first time [with prosthetic], inadvertently she had the fracture. She [R #23] was in pain and she [R #23] said she had a miserable night [on 03/16/23 due to the pain]. I called 911 [emergency call line on 03/17/23 after arriving on shift in the morning] because she [R #23] wanted to be sent out because she did not feel good. I then called the Doctor and informed him. Q. On 05/19/23 at 1:24 PM during an interview with the Director of Nursing (DON), she stated, she remembered (name of R #23) was in therapy had received her new prosthetic (artificial limbs). She (R #23) was doing standing exercises and was walking and felt a pain and crack and later was complaining of pain. They sent her (R #23) out to get evaluated the next day. When she went to the hospital it (R #23's right leg) was severely demineralized (loss of minerals from bone) and she (R #23) had a fracture. When asked if R #23 had received any PRN pain medication per the MAR, DON stated, They don't always put the PRN [as needed] medications in there [in the MAR]. DON further stated, It doesn't look like she [R #23] was medicated before 1900 [7 pm]. My expectation would be that they [nurses] would go and assess the pain and do interventions to relieve the pain. If it was severe pain, I would advocate for the resident to be sent to the ER and not wait until the next day. Nurses do not have to wait for the Physician for them to send a resident out to the ER. Findings for R #86: R. Record review of R #86's face sheet revealed R #86 was admitted into the facility on [DATE] with the following diagnoses: 1. TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (high blood sugar) 2. MYASTHENIA GRAVIS (A neuromuscular disorder that leads to weakness of skeletal muscles) WITHOUT (ACUTE) EXACERBATION (to make worse) 3. ESSENTIAL (PRIMARY) HYPERTENSION (high blood pressure) 4. CHRONIC RESPIRATORY FAILURE WITH HYPOXIA (a below-normal level of oxygen in your blood) 5. CELLULITIS (A serious bacterial infection of the skin) OF RIGHT LOWER LIMB 6. ACUTE KIDNEY FAILURE, UNSPECIFIED 7. SEPSIS (An infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), UNSPECIFIED ORGANISM S. Record review of R #86's Progress Notes dated 05/11/23 revealed, Skin: Skin warm & dry, skin color WNL [within normal limits], mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Infection of the Foot (e.g.cellulitis, purulent drainage). Skin Issue Location: RIGHT LOWER LEG RIGHT LOWER LEG WITH ECCHYMOSIS [a discoloration of the skin resulting from bleeding underneath, typically caused by bruising] AND DISCOLORATION. T. On 05/15/23 at 3:14 pm during an interview with R #86, he stated, Yesterday [05/14/23], morning shift comes in at 6:00 am and I didn't get my medications. They took me to therapy and the therapist asked who was my nurse because I needed something for pain. They [facility staff] said the nurse isn't here yet, she is supposed to be here at 10, but she's not here yet. I waited until 11 [am], I asked the two nurses there if the nurse is here yet [for R #86's unit] and she said no, there's no nurse yet. My wing was without a nurse since the night nurse left and we were on our own. There's no nurse to help them. Finally at noon, I got my morning medications at noon. I was hurting so bad [R #86's right leg] that I called my sister and said I wanted to go AMA [Against Medical Advice] because it hurts. R #86 confirmed that his pain was 10/10 (pain scale). U. Record review of R #86's Pain Management Tool dated 05/11/23 revealed the following: 1. Pain Presence- Have you had pain or hurting at any time in the last 5 days? R #86 responded Yes. 2. Pain Frequency- How much of the time have you experienced pain or hurting over the last 5 days? R #86 responded Occasionally. 3. Pain Effect on Function- Over the past 5 days, has pain made it hard for you to sleep at night? R #86 responded Yes. Over the past 5 days, have you limited your day-to-day activities because of pain? R #86 responded Yes. 4. Pain Intensity- R #86 responded Moderate. The rest of R #86's pain assessment was not completed. V. Record review of R #86's Medication Administration Record (MAR) dated May 2023 revealed the following: 1. Lyrica Oral Capsule 75 MG [milligram] (Pregabalin) Give 1 capsule by mouth one time a day for Pain to be given at 8:00 am and was administered by the Assistant Director of Nursing (ADON) on 05/14/23 after 11:42 am (time when ADON arrived to the facility). 2. Gabapentin Oral Tablet 600 MG (Gabapentin) Give 2 tablet by mouth two times a day for Diabetic Neuropathy [a type of nerve damage that can occur if you have diabetes] and was administered by the Assistant Director of Nursing (ADON) on 05/14/23 after 11:42 am (time when ADON arrived to the facility). 3. Tylenol Oral Tablet 325 MG (Acetaminophen) Give 650 mg by mouth every 4 hours as needed for Pain and/or fever. W. On 05/19/23 at 1:43 pm during an interview with the DON, she stated, We had an agency staff that didn't show up [on 05/14/23]. [Name of ADON] was on call and he came in to help with med pass the night before so there would be 3 nurses. He [ADON] left on Saturday [05/13/23] at 11:20 pm. We weren't expecting that nurse [agency] to not show up [on 05/14/23]. I was out of town and when they [nursing staff] called him [ADON], it took him awhile to hear the call. By the time he [ADON] got up and drove here [to the facility], it was late [on 05/14/23]. He [ADON] arrived at 11:42 [am on 05/14/23]. DON confirmed R #86's Pain Assessment Tool dated 05/11/23 was not complete and should have been. DON also confirmed R #86's pain medication was not administered timely on 05/14/23 and should have been. Findings for R #183: X. Record review of R #183's face sheet revealed R #183 was admitted into the facility on [DATE] and was discharged on [DATE] with the following diagnoses: 1. COVID-19 (a contagious disease caused by a virus) 2. PARKINSON'S DISEASE (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) 3. UNSPECIFIED ASTHMA (a condition in which your airways narrow and swell and may produce extra mucus), UNCOMPLICATED 4. UNSPECIFIED DISLOCATION OF RIGHT HIP, SUBSEQUENT ENCOUNTER Y. Record review of R #183's hospital discharge documentation dated 02/24/23 revealed R #183 was discharged from the hospital to the facility with an Unspecified Trochanteric [Any of several bony processes on the upper part of the femur] Fracture of Femur. Z. Record review of R #183's Pain Management Tool dated 02/24/23 at 6:03 pm revealed the following: 1. Pain Presence- Have you had pain or hurting at any time in the last 5 days? R #183 responded No. The rest of R #183's pain assessment was not completed. AA. On 05/24/23 at 3:39 pm during an interview with the DON, she confirmed R #183's pain assessment was not completed and should have been after returning from the hospital with a recent fracture. These deficient practices resulted in Immediate Jeopardy being identified on 05/19/23. The facility Administrator was first notified of the Immediate Jeopardy on 05/19/23 at 2:11 PM. The Administrator and the Director of Nursing (DON) were notified at this time. Implementation of the Plan of Removal was validated on 05/21/23 onsite through observation and interview. The Plan of Removal Included: 1. All licensed nurses will be in serviced on our Pain Policy and Procedures. 2. Pain assessments will be completed on all residents by 05/21/23. 3. Pain interventions will be reviewed for residents with pain. 4. Effectiveness will also be monitored and adjusted accordingly. 5. Notification to provider and change of condition will be completed as necessary. 6. Educate staff on resident request to go to the hospital will be honored immediately. 7. Audit of last 60 days for pain effectiveness. 8. Pain level will be documented every shift on the Medication Administration Record. 9. The nurse in question was re-educated immediately per telephone call with emphasis on documentation and reassessment of effectiveness. 10. Nurses will be re-educated on pain assessment, interventions non-pharmacological and pharmacological, reassessment, documentation, and notifications. 11. DON and Administrator will both be notified of all incidents to ensure that pain policy is followed. Findings for R #37 BB. Record review of the Minimum Data Set (MDS) dated [DATE] identified that R #37 has vascular dementia and BIMs (Brief Interview for Mental Status) was identified as 99 (unable to assess). CC. On 05/24/23 at 8:06 am during random observation R #37 was observed to have a large bruise to her right temple, she was holding her right arm close to her body which was bent at the wrist. DD. On 05/24/23 at 8:10 am during interview with the Administrator (ADM), he stated, [Name of R #37] fell last night (early morning on 05/24/23) and sustained a bruise to her right temple. She [R #37] has been unsteady for last few days. EE. Record review of Progress note dated 05/24/23 at 00:48 (12:48 am) called to see resident [R #37] in her room as a result of fall, fall unwitnessed, resident sustained swelling a the left temple, close to the left eye socket as a result of collision with unidentifiable object assumed to be bedding due to her fall resident is alert and oriented to situation and place, with resident touching the swelling site signaling [sic] pain. Signed (Name of RN #3). Note did not identify if pain medication was administered or if a pain assessment was conducted during this interaction. FF. Record Review of eMAR note revealed the following medications were administered on 05/23/23 and 05/24/23: 1. Tylenol Tablet 325 mg give 2 tablets by mouth, every 4 hours as needed, for mild fever/pain was administered on 05/23/23 at 16:34 (4:34 pm) and 05/23/23 at 21:48 (9:48 pm) 2. Tramadol 50 mg by mouth every 12 hours as needed for pain was administered on 05/24/23 at 7:50 am and 05/24/23 at 11:51 am. 3. Lorazepam oral tablet 0.5 mg by mouth every 4 hours as needed for anxiety was administered at 05/23/23 at 2:54 am, 05/24/23 at 7:49 am and 05/24/23 at 11:52 am. 4. Morphine 0.25 ML (milliliters) by mouth as needed for pain and shortness of breath was administered 05/24/13 at 13:51 pm. GG. On 05/24/23 at 4:00 pm during interview, DON was asked if any pain medication had been administered to R #37 when she was expressing pain as identified in the progress note post fall on 05/24/23, DON confirmed that there was no pain medication documented as being given following the fall. HH. Record review of Fall Protocol revised March 2018 revealed After a fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine and extremities 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. II. On 05/24/23 at 5:35 PM during an interview with RN #3, he stated, he had gotten a report at the beginning of his shift [6:00 pm (05/23/23) to 6:00 am (05/24/23)] that R #37 had had a fall earlier in the day and when he went to check on R #37, she was in her room. At about 3:00 am [05/24/23] he was called to R #37's room because resident had another fall. He further stated that he noticed that R #37's face was swollen. She was signaling (showing signs of experiencing) pain, no skin injury recorded toward the fall. He reported that he had administered Lorazapam and that R #37 was sitting on her bed and the Certified Nurse Aide (CNA) had moved the resident prior to him (RN #3) being able to assess the resident for injury after her fall. JJ. Record review of RN #3 statement dated 05/24/23 regarding the fall post assessment [3:00 am] Resident is alert and oriented to situation and place, with resident touching the swelling site signaling pain, no skin injury recorded towards the fall. Resident reassured, tab (tablet) Tylenol 650 mg, Haldol 0.5 mg and Ativan 0.2 mg PO (by mouth) given to the effect. KK. Record review of Physicians orders dated May 2023 revealed: Haldol Decanoate Intramuscular Solution 50 mg/ml, Inject 1 mL intramuscularly (administered into a muscle) q-month (every month) every 30 days for Agitation. Order date 04/04/23. There was no order for po (by mouth) Haldol. 47091 Due additional findings identified on 05/24/23, Immediate Jeopardy was reinstated on 05/24/23. The facility Administrator and Director of Nursing were notified of the Immediate Jeopardy on 05/24/23 at 4:53 PM. Implementation of the Plan of Removal was validated onsite through observation and interview as being implemented on 05/24/23 The Plan of Removal Included: 1. All licensed nurses will be re-inserviced on our Pain Policy and Procedures. 2. Pain assessments were completed on all residents by 05/21/23. 3. Pain interventions will be reviewed for residents with pain. 4. Effectiveness will also be monitored and adjusted accordingly. 5. Notification to provider and change of condition will be completed as necessary. 6. Educate staff on resident request to go to the hospital will be honored immediately. 7. Audit of last 60 days for pain effectiveness. 8. Pain level will be documented every shift on the Medication Administration Record. 9. The nurse in question was re-educated immediately per telephone call with emphasis on documentation and reassessment of effectiveness. 10. Nurses will be re-educated on pain assessment, interventions non-pharmacological and pharmacological, reassessment, documentation, and notifications. 11. DON and Administrator will both be notified of all incidents to ensure that pain policy is followed.

Based on record review and interview, the facility failed to ensure that they had sufficient staff to meet the needs of all 27 residents residing in Wing 2 and Wing 3 when a Registered Nurse wasn't available to administer medications for residents for (6) hours. These deficient practices likely resulted in R #86 not receiving scheduled pain medication resulting in unnecessary pain. The findings are: A. Record review of the facility shift staffing dated 05/14/23 revealed a Registered Nurse (RN) for Wing 1, an RN for Wing 4, and Called off- [Name of Assistant Director of Nursing (ADON) filling in] for Wings 2 and 3. B. On 05/15/23 at 3:14 pm during an interview with R #86, he stated, Yesterday [05/14/23], morning shift comes in at 6:00 am and I didn't get my medications. They took me to therapy and the therapist asked who was my nurse because I needed something for pain. They [facility staff] said the nurse isn't here yet, she is supposed to be here at 10, but she's not here yet. I waited until 11 [am], I asked the two nurses there if the nurse is here yet [for R #86's unit] and she said no, there's no nurse yet. My wing since the night nurse left had no nurse and we were on our own. There's no nurse to help them. Finally at noon, I got my morning medications at noon. I was hurting so bad [R #86's right leg] that I called my sister and said I wanted to go AMA [Against Medical Advice] because it hurts. R #86 confirmed that his pain was 10/10 (pain scale). C. On 05/18/23 at 3:19 pm during an interview with Registered Nurse (RN) #4, she stated, It was about 7:30 [am], and I looked over and saw wing 2 and wing 3 didn't have a nurse. I saw [Name of Assistant Director of Nursing (ADON)] come in at 11:45 am. I could not possibly take 3 wings. I can't focus on 3 wings. Until 11:45 [am] there was no nurse there [wings 2 and 3] [Name of RN #5] was brand new and there's no way I could have done three wings [by myself]. They knew there was no nurse there [Wings 2 and 3 during day shift on 05/14/23]. D. On 05/18/23 at 4:37 pm during an interview with RN #5, she stated, I was in Wing 4 [on 05/14/23]. I don't know when [Name of ADON] showed up. I only took Wing 4 [to provide nursing duties]. [Name of RN #4] had wing 1 and [Name of ADON] took wings 2 and 3 [when he arrived]. E. On 05/19/23 at 1:43 pm during an interview with the Director of Nursing (DON), she stated, We had an agency staff that didn't show up [on 05/14/23]. [Name of ADON] was on call and he came in to help with med pass the night before so there would be 3 nurses. He [ADON] left on Saturday [05/13/23] at 11:20 pm. We weren't expecting that nurse [agency] to not show up [on 05/14/23]. I was out of town and when they [nursing staff] called him [ADON], it took him awhile to hear the call. By the time he [ADON] got up and drove here [to the facility], it was late [on 05/14/23]. He [ADON] arrived at 11:42 [am on 05/14/23]. 46064

This is a repeat deficiency from a complaint survey completed on 10/20/22. Based on observation, record review, and interview, the facility failed to ensure that 3 (R #13, #14, and #15) of 4 (R #13, #14, #15 and #16) residents reviewed for pressure ulcers, received care consistent with professional standards of practice to not develp pressure ulcers or prevent ulcers from worsening by: 1. Not providing pressure ulcer prevention measures as ordered for R #13 and R #14. 2. Not identifying pressure wound to R #15's heel until it was unstageable. 3. Not monitoring the effectiveness of treatments for wounds that were worsening for R #13 These deficient practices likely resulted in the development of facility acquired pressure injuries and led to the subsequent deterioration of several stageable pressure ulcers, resulting in these wounds becoming unstageable (full thickness tissue loss) pressure ulcers. Findings for R #13: A. Record review of R #13's face sheet revealed R #13 was admitted into facility on 10/03/22 with the following diagnosis which placed resident at risk for skin breakdown: 1. Acute Transverse Myelitis in Demyelinating Disease of Central Nervous System [interrupts the messages that the spinal cord nerves send throughout the body. This can cause pain, muscle weakness, paralysis, sensory problems, or bladder and bowel dysfunction, such as incontinence]. 2. Myasthenia Gravis [a chronic autoimmune, neuromuscular disease that causes weakness in the skeletal muscles. This can affect one's ability to walk or transfer on their own]. 3. Hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and Hemiparesis (mild or partial weakness or loss of strength on one side of the body) following Cerebral Infarction affecting left non dominant side weakness and paralysis following a stroke, affecting the left side of the body]. B. Record review of R #13's physician's orders revealed the following order: Active Order dated 11/29/22 Heel Protectors bilaterally [both right and left] while in her wheelchair and while in bed daily. This order is in place to prevent the development of facility acquired pressure ulcers to R #13's heels. C. On 02/16/23 at 8:30 am during random observation, R #13 was observed in her wheelchair not wearing her heel protectors as ordered. D. On 02/16/23 at 11:05 am R #13 was observed laying in bed without heel protectors. E. On 02/16/23 at 8:40 am during interview with Private Nurse Aide (PNA #1), PNA #1 stated heel protectors were located buried at foot of bed under several personal items. When asked why R #13 was not wearing them, PNA #1 stated they should be on, and she didn't know why they were not on R #13. F. On 02/16/23 at 11:05 am during an interview with RN (Registered Nurse) #1, RN #1 confirmed that R #13 did have an order for heel protectors and that they were not being utilized as ordered. G. Record review of Weekly Wound Report (WWR) dated 11/30/22 indicated that R #13 had acquired a Stage 2 pressure wound [Partial thickness loss of dermis/skin, presenting as a shallow open ulcer with a red/pink wound bed] to the left gluteal fold [LGF] [inside crease of left buttock] which measured 1 cm [centimeter] in length [L] x 1.2 cm [centimeter] in width [W] x 0.1 cm in depth [D]. Treatment: Bacitracin/Dressing [topical antibiotic cream used to prevent infection in small cuts]. 1. WWR dated 12/08/22 indicated R #13's Stage 2 pressure wound to LGF now measuring 0.5 cm =L x 0.7 cm= W x 0.1 cm =D. Treatment: Bacitracin/Dressing 2. WWR dated 12/15/22 indicated R #13's Stage 2 pressure wound to LGF measuring 1.5 cm= L x 1.2 cm=W x 01. cm=D. Treatment: Bacitracin/Dressing. Wound is worsening and treatment continues without change. 3. WWR dated 12/20/22 indicated R #13's Stage 2 pressure wound to LGF now measures 2 cm=L x 1 cm=W x 0.1 cm=D. Treatment: Bacitracin/Dressing. Wound continues to worsen; treatment remains the same. 4. WWR dated 12/28/22 indicated R #13's Stage 2 pressure wound to LGF measures 2.5 cm=L x 1.5 cm =W x 0.2 cm =D. Wound continues to worsen treatment continues without change. 5. WWR dated 01/06/23 indicated R #13's Stage 2 pressure wound to LGF now measures 2.1 cm=Lx 1.2 cm=W x 0.2 cm=D. Treatment: Bacitracin/Dressing. Wound shows slight improvement. 6. WWR dated 01/13/23 indicated R #13's Stage 2 pressure wound to LGF now measures 2.4 cm=L x 0.9 cm=W x 0.1 cm=D. Treatment: Bacitracin/Dressing. No change to treatment. 7. WWR dated 01/20/23 indicated R #13's Stage 2 pressure wound to LGF measures 2 cm=L, x 0.8 cm=W x 0.1 cm=D. Treatment: Bacitracin/Dressing. No change to treatment. No other wounds indicated at this time. 8. WWR dated 01/28/22 indicated R #13 had a new facility acquired wound Stage 1 [ Purple or maroon localized area of intact skin or blood-filled blister due to damage of underlying soft tissue from pressure], to Left Hip measuring 0.5 cm=L x 0.5 cm=W. Treatment: Open to Air [no bandage], Stage 2 pressure wound to LGF now measures 2.5 cm x=L x 1.5 cm=W x 0.1 cm =D. H. Record review of R #13's Physicians Orders dated 01/22/23 indicated that R#13 was referred to wound clinic on 01/22/23 for worsening LGF Stage 2 pressure sore and an order for a rojo cushion for wheelchair. This is the first indication of change to treatment or of physician being notified of wound worsening. I. Record review of R #13's Care Plan dated 11/02/22 revealed that a pressure redistributing mattress to bed and pad to chair was incorporated into care plan on 11/02/22. Care plan also indicated on 11/02/22: Review skin weekly with description of wound to include: measurements, description and progress; notify MD (Medical Doctor) of changes. Pressure redistributing mattress was put in place at this time. However, Rojo cushion was not ordered until 01/22/23 as reflected in physicians orders. J. Record review of Progress notes dated 01/22/23 revealed, Dressing changed today on coccyx (tailbone) and left hip. Off loaded left hip (reposition so that resident is not resting on the left hip) after dressing change. Husband present during dressing change and is aware of wound not improving. Rojo [Name of pressure relieving cushion] cushion will be placed when available. PT [Physical Therapy] notified of wound appearing worse. Physician notified. Will continue to monitor. This is the first time physician was notified that the wound was worsening. Findings for R #14: K. Record review of R #14's face sheet revealed R #14 was admitted into the facility on [DATE] with the following diagnosis which placed resident at risk for skin breakdown: 1. Persistent vegetative state. [the condition of individuals with severe anoxic brain injury who have progressed to a state of wakefulness without any meaningful response to their environment]. 2. Anoxic brain damage [anoxic brain injury occurs when the brain is deprived of oxygen]. L. Record review of R #14's physician's orders dated 04/20/20, Air mattress for pressure relief. M. On 02/16/23 at 9:15 am during an observation of wound care for R #14, it was observed that the alternating air mattress [special mattress used to prevent pressure injuries] was not functioning correctly due to the power button was missing. The air mattress was not in the on position or alternating air. N. On 02/16/23 at 9:20 am during an interview with Licensed Practical Nurse (LPN) #1, he confirmed there is an order for R #14's mattress, however R #14's mattress had not been working for several months and they somtimes needed to insert a pen into the controls to get it to work. It is unknown when or for how long the mattress has not been working. Findings for R #15: O. Record review of R #15's face sheet revealed R #15 was admitted into the facility on [DATE] with the following diagnosis which placed resident at risk for skin breakdown: Congestive heart failure [A progressive heart disease that affects pumping action of the heart muscles. This causes fatigue, shortness of breath] P. Record review of R#15's Weekly Skin Check dated 12/28/22 documented that resident had a unstageable ulceration to bottom left foot measuring 4 cm=L, x 1 cm=W, x 5 cm=D. This is the only wound that is documented at this time. Q. Record review of Weekly Wound Reports [WWR] from 12/20/22 to 01/20/23 revealed : 1. WWR dated 12/20/22 indicated R #15 arrived with an Unstageable Pressure wound to Left Foot Plantar [bottom surface of the left foot]. Wound measured 5 cm=L x 2.5 cm=W. Treatment: Paint with Betadine [Ointment used to help prevent infection and promote healing in skin wounds]. No other wounds were documented at this time. 2. WWR dated 01/13/23 now indicated that R #15 had a facility acquired Unstageable pressure wound to the Left Heel which measures 3.5 cm=L, x 3 cm=W. This is the first time the wound to the Left Heel is documented on the wound report. This is the same foot that the Plantar pressure injury is being treated. There is no prior documentation of this wound to date. 3. WWR dated 01/20/23 indicated R #15 had a wound to Left heel that was worsening with the following measurements: 4 cm=L, x 3.2 cm=W. There is no evidence that this change was reported to physician. R. Record Review of Care plan dated 01/04/23 does not reflect that pressure ulcer prevention measures such as heel protectors were being implemented at this time. S. Record Review of Physicians Orders dated 12/16/22 does not show order for heel protectors. T. Record Review of New Mexico Discharge to Home Instructions from previous facility dated 12/16/22 shows order that reads: Apply protective heel boots to both feet while in bed every day and night shift for pressure prevention. This order was not adopted to Physicians Orders when resident was admitted to current facility on 12/16/22. U. On 02/16/23 at 1:27 pm during phone interview with R #15 he stated they were taking care of a wound I had to the bottom of my left foot when I first got there. I don't believe I had any wounds on my heels until after I had been there for a while. When asked if they were doing anything to prevent wounds on his feet such as heel protectors R #15 replied not that I can recall. V. On 02/16/23 at 11:47 am during interview with Director Of Nursing (DON) R #15's record was reviewed and DON confirmed R #15 did develop unstageable pressure ulcer to left heel. DON further stated it was discovered as unstageable. When questioned regarding pressure ulcer prevention measures such as heel protectors DON stated I can't find the order for heel protectors.

Based on record review and interview, the facility failed to ensure that resident 1 (R #4) of 3 (R #4, #5 and #6) residents reviewed for wound care received care consistent with professional standards to treat and prevent pressure ulcers by: 1. Not measuring and documenting pressure ulcer on a weekly basis. Including how the wound was improving or worsening with current treatment measures. 2. Not accurately documenting the condition of the pressure ulcer including correct Stage [I, II, III, IV, unstageable]. 3. Not including all pressure ulcers requiring treatment or monitoring on the Treatment Administration Records (TAR) 4. Not notifying the provider in a timely fashion that resident needed to be seen. So that it could be determined that a higher level of care was needed. This deficient likely resulted in delayed healing, increased pain and discomfort, increased risk for further skin breakdown, risk of developing new pressure injuries, worsening of existing pressure injuries and leaving residents vulnerable to acquiring infections in the wounds. The findings are: A. Record review of R #4's Weekly Skin Check dated 07/07/22 revealed that R #4 has two affected areas (pressure injuries) to the coccyx area (also known as the tailbone), one on the right side and one on the left side. The left side pressure injury measures length as 1.5 cm (centimeter), width 2 cm, and depth 0.1 cm and stages the wound as a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister). R #4's Right-side pressure injury measures length 3 cm, width 2.5 cm and depth 0.1 cm, Stage II. B. Record review of R #4's Weekly Wound Report dated 07/07/22 revealed R #4 has excoriation (raw, irritated skin, may be caused by scratching) to bilateral Ischium (a paired, U-shaped bone of the pelvis which forms the top of the hip bone). R #4's Weekly Wound report does not document the two-pressure injury's to the right and left (R&L) of the coccyx area as identified on the Weekly Skin Check dated 07/07/22. Based on review, this confirmed that the Weekly Wound Report does not reflect the current status of the R #4's pressure wounds. C. Record review of R #4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Record review of R #4's hospital medical records revealed R #4 was admitted into the hospital on 07/17/22 with the following pertinent Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Large sacral decubitus ulcer Stage IV (Stage four: Full thickness tissue loss with exposed bone, tendon or muscle). Slough or eschar, (dead tissue) may be present on some parts of the wound bed. Often include undermining and tunneling (a cavity is present beneath the skin). These records confirm that the pressure injury is at a Stage IV, although facility records continue to document them as a Stage II. Since R #4 was seen at the hospital on 07/17/22, the wound has either progressed to a Stage IV in the last ten days, the pressure wounds were not being monitored, and were not being accurately assessed and treated accordingly. E. On 10/06/22 at 12:25 pm during an interview with R #4's Medical Power of Attorney (MPOA), they stated R #4 was admitted to the hospital on 07/17/22. R #4's hospital nurse brought to the MPOA's attention that R #4 had wounds on his coccyx, bottom of scrotum, hips. MPOA stated that at this time R #4 was In pain; he could feel this pressure back there. R #4's MPOA also stated that following R #4's hospital admission on 07/17/22, R #4 was sent from the local hospital to a Specialty Hospital for extensive wound care (a wound care specialist is assigned for management and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] F. Record review of R #4's Specialty Hospital Wound Assessment Details Report dated 08/19/22 revealed the following three pressure wounds present on admission on 07/29/22: 1. Pressure wound to coccyx classified as unstageable. Measurements are as follows: length 7 cm, width 3 cm, depth unknown. 2. Pressure wound to the left ischial tuberosity, present on admission, classified as unstageable. Measurements as follows: length 4 cm, width 3 cm, depth unknown. 3. Pressure wound to the right ischial tuberosity, classified as unstageable. Measurements as follows: length 4 cm, width 4 cm, depth unknown. G. Record review of R #4's Progress Note from Specialty Hospital dated 08/23/22 under subsection Assessment and Plan indicates: 1. Sacral (a large, triangular bone at the base of the spine) and buttock pressure injuries secondary to [CONDITION(S)]. 2. Patient treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Completed [MEDICATION(S)] (medication is used to treat a wide variety of bacterial infections) for [CONDITION(S)] in the wound on 08/03/22. However, patient had septic picture (appeared to have symptoms of [CONDITION(S)]), which is likely colonization (the presence of bacteria on a body surface), suspect this is still from his wound and started [MEDICATION(S)] (an antibiotic used to treat serious bacterial infections) x (times) 14 days, end of treatment date 08/17/22. 4. Wound care treating; will need further debridement's. H. Record review of R #4's Speciality Hospital Wound Care Discharge Orders dated 08/25/22 revealed the following: 1. Coccyx/ Bilateral IT (Left and Right ischial tuberosity): Cleanse wound with NS (Normal Saline a solution used to supply water and salt to the body), pat dry, skin prep outer wound edges, fill wound bed with Mesalt (a dressing containing salt used to absorb moisture and discharge from a wound) and cover with boarder gauze. Change daily and PRN (as needed) if soiled or missing. I. Record review of R #4's Weekly Skin Check dated 08/26/22 revealed R#4 has a pressure ulcer to his coccyx described as: Coccyx Stage Two-Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed. This Weekly Skin check does not reflect the accurate staging of the wound which should be unstageable. The pressure ulcer to R#4's coccyx is unstageable based on report from Specialty Hospital. J. On 10/06/22 at 1:21 pm during an interview with the Administrator (ADM) and Director of Nursing (DON), both confirmed that they are unsure how the Wound Care Nurse is documenting wounds. K. On 10/06/22 at 1:25 pm during an interview with the Wound Care Nurse (WCN) #1, WCN #1 was asked, How are wounds being monitored and documented? WCN #1 replied, I document them [resident wounds] in [Name of Electronic Health Record (EHR) under assessments and skin checks. We had a staffing issue and I had to be pulled to floor July through September for two to three times a week to alleviate burden from floor nurses. Some of these [resident wound care reports] have not been done because I was on the floor. The wound care reports are not updated during this time, the weekly care is documented in [Name of EHR]. In the morning meetings, we [staff] discuss all wounds and there is a checklist for wounds. L. On 10/06/22 at 3:18 pm during an interview with WCN #1, he stated that he compares resident wounds week to week, comparing previous note to current note. WCN #1 stated, The way I am comparing is by the log and measurements. If I notice this [resident wounds] is getting worse, outreach for more treatment options. When asked about how the physician is monitoring the wound care, WCN #1 replied, He [physician] is here twice a week. M. On 10/06/22 at 3:24 pm during an interview with the ADM, she stated, I audit every single week for skin sheets and Braden score. Also reviewing if [resident] wounds are progressing. When asked how often measurements are expected to be done? ADM replied, Weekly. N. On 10/06/22 at 3:27 pm during an interview with WCN #1, he confirmed that the wound care nurse does skin checks every week. WCN #1 stated, I look every week. Do measurements and update weekly skin check. WCN #1 is unable to find wound care orders for R #4 in the MAR/TAR. WCN #1 stated that for the couple of weeks after he returned to the facility he, Wasn't doing any assessments. O. Record review of R #4's Weekly Skin Check dated 08/27/22 revealed measurements to R #4's pressure ulcer present on coccyx as follows: Length 10.5 cm, Width 4.5 cm, Depth 2.5 cm. P. Record Review of R #4's Weekly Wound Report dated 8/27/22 revealed R #4 is not identified on wound report for the month of August 2022. There are no weekly assessments documented to describe R#4's pressure injuries. Q. On 10/06/22 at pm during an interview with WCN #1, he stated that when he returned to the facility, I wasn't working as the wound care nurse. I was in contact with [R #4's] niece, not [R #4's] physician. [R #4's] Niece would ask for progress of wounds. When he [R #4] came back, the only reason I went in there was she [R #4's niece] was taking pictures. She [R #4's niece] insisted I look at it [R #4's pressure injury to coccyx] together. It [R #4's coccyx pressure injury] wasn't a large fissure, necrotic tissue. There was a bunch of sloughs. I explained to her [R #4's niece] that I wasn't working as wound care nurse and had other obligations. I didn't do any documentation on it [R #4's pressure ulcer]. I wasn't aware that it [R #4's pressure ulcer] wasn't being documented on by the other nurses. The nurse when the patient comes in, they must do skin check and they are supposed to do whole total skin assessment. I have reiterated it to the nurses that they are responsible for the [resident] skin [assessments] on their own units. Once wound is there, we review the wounds. I then do my own skin assessment and measurements. [R #4's] Niece never provided any new orders from [Name of Speciality Hospital]. She [R #4's niece] would ask 'What are we doing here [with R #4 wounds]?' She [R #4's niece] called at least 2 times a week. I explained it [R #4's pressure ulcer] didn't look good. WCN #1 confirmed that he is unable to show what was happening with R#4's wounds from 08/26/22 to 09/17/22. WCN #1 also stated, I measured it [R #4's pressure ulcer] and looked at it with MPOA. I said I thought he needed a wound vac. We were going to order it but when I came back, he [R #4] was sent out. He [R #4] had excoriation. We were setting him [R #4] up with appointments to get to wound clinic. Communication between the facility and wound clinic is disjointed. It sometimes take 4 to 5 days to get information back. When staffing was better, it was no problem to manage residents before pulling to the floor. The continuity of care is not what it should be. R. Record review R #4's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . S. Record review of R #4's Weekly Wound report dated 09/05/22 revealed R #4 is not identified on wound report. There are no updated measurements for wound since last measurement on 08/27/22. T. Record review of R #4's Progress note dated 09/15/22 revealed the following: Dressing (bandage) changed d/t soiled dressing, wound has odor and yellow drainage. Wound bed packed with Mesalt dressing (a special dressing that uses sodium chloride [common salt] to absorb moisture and discharge from a wound) and covered with bordered gauze (an absorptive dressing). R#4 had a scheduled transportation for appointment at wound clinic on 09/16/22. This transportation was canceled due to insurance not covering it. Wound care visit was rescheduled for 09/20/22. Based on this note R#4 was not seen at wound clinic as ordered. R#4 was admitted to hospital 09/17/22. U. On 10/20/22 at 11:44 am during Interview with Registered Nurse (RN) #1, RN #1 was asked if R#4's wounds we assessed when R #4 returned from the Speciality Hospital on 08/26/22. RN #1 replied, Yes, when he [R #4] came in, he was coming back from [Name of Specialty Hospital] where he was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] #4] came in with wound care orders. I think they had ordered Mesalt. We updated the orders in the eTAR. When asked what R #4's wounds looked like, RN#1 answered, Deep, the wound on coccyx, it was unstageable. RN#1 was then asked if R #4's wound had worsened and RN#1 answered, The wound was a minor skin tear on the gluteal fold, the sacral sore was not present. Prior to hospital admission, when he [R #4] came back from [Name of Speciality Hospital], the wound stayed the same. When asked if the physician was involved in treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This interview reveals that resident was not accessed by the physician upon determination that a change of condition (Sacral pressure injury) had occurred. Further the physician was not contacted for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . V. On 10/28/22 at 12:46 pm during an interview with Nurse Practitioner (NP) #1, they confirmed R#4 was not seen by NP upon his return to the facility on [DATE]. R #4's pressure injuries were not assessed by the NP. NP stated, No, I did not see him [R #4] after he returned from [Name of Speciality Hospital]. Usually, the wound nurse, who I know very well, he [WCN #1] will come and tell me if I need to take a look at a resident for wounds, but he [WCN #1] did not tell me anything on this resident [R #4]. There was an issue with his [R #4's] sacral wound. He [R #4] was referred because I believe the wound care nurse told me we have tried everything, and we are at a stalemate. I did not get any prior report from the wound care nurse at the facility that the wound was getting worse, or that it may have been getting bigger and wider, or that he [R #4] came back with a worse wound then before he [R#4] had gone to the hospital. It would have been appropriate for them [facility staff], and the wound nurse to do a full assessment of the wound and inform me. That way we, could have then determine, if the wound had gotten worse.

Based on record review and interview, the facility failed to ensure that residents received effective pain management for 2 (R #2 and 3) of 2 (R #2 and 3) residents reviewed for pain by delay in delivery and administration of needed pain medication. This deficient practice likely resulted in residents experiencing unnecessary pain. The findings are: Findings related to R #2: A. Record review of the Hospital records dated 09/22/22 identified status post [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of the nursing home medical record for R #2 identified the following: 1. R #2 was admitted on [DATE] 2. Skin Only Evaluation dated 09/22/22 identified deep tissue injury on left forearm, left knee and right knee. General Notes included Left forearm with cast, Left fracture wrapped and Right knee Ace wrap. Evaluation did not identify any fracture or injury on the foot. C. Record review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Today he is complaining of severe pain of 10/10 and he needs his hard script faxed over to pharmacy. He describes his pain as generalized and worse with movement. I apologized to the patient D. Record review of R #2's medical record identified that a prescription for [MEDICATION(S)] 5 mg hard prescription dated 09/22/22 was provided with R #2's hospital discharge paperwork to the facility upon admission. E. Record review of the Omnicell (emergency medication dispensary) reservation sheet identified that [MEDICATION(S)] 5 mg was pulled by RN #1 on 09/23/22 at 5:46 pm. F. Record review of the Proof of Delivery identified that [MEDICATION(S)] 5 mg was received from the pharmacy on 09/23/22 at 10:34 pm. G. On 10/19/22 at 4:40 pm during interview with the Director of Nursing (DON) regarding R #2, she stated that R #2 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON explained that even if the medication hasn't been delivered yet, the nurse is able to contact the pharmacy and get an access code to the Omnicell to then be able to administer narcotic medications immediately. DON reported that she was unsure why there was a delay. The DON also stated that it would be up to the resident to ask for the [MEDICATION(S)] if the Tylenol was not providing effective pain relief. H. On 10/20/22 at 9:13 am during interview with the DON, she reviewed R #2's admitting hospital records and confirmed that with R #2's injuries, Tylenol would probably not have been an effective pain medication. DON reviewed R #2's records and confirmed that the prescription for [MEDICATION(S)] was dated 09/22/22 from the hospital but the medication prescription was not faxed to the pharmacy until 09/23/22 at 12:33 pm, but then not administered from the Omnicell until 5 pm on 09/23/22. The DON stated that this is not a typical timeline to expect to be able administer medication to the resident once the prescription is faxed. I. On 10/20/22 at 11:46 am during interview with Registered Nurse (RN) #1, he stated that on 09/23/22 when he worked with R #2, he had to fax over his prescription twice for the [MEDICATION(S)] because it wasn't received the first time. RN #1 stated that R #2 was provided Tylenol for pain but that it was not effective. I could see when he tried to move, he grimaced. RN #1 confirmed that he was not aware of R #2 broken toes or injury to his foot. J. Record review of R #2's Physical Therapy Discharge summary dated 09/25/22 identified Pt (patient) stated having severe pain in BLE (bilateral lower extremities) related to infection. He refused to do standing. He agreed to bed exercises. K. Record review of Occupational Therapy Treatment Encounters revealed the following: 1. 09/24/22 Patient had increased swelling and pain in R (right) foot which limited therapy evaluation. 2. 09/25/22 Patient reported that he's more in pain putting weight on his left elbow. Patient also reported that he was able to walk using a walker on Friday [09/23/22] but since yesterday he's been having right foot pain which affected his mobility. Patient reported that his sister came today and that his right foot is getting infected and cleaned his wound . L. Record review of the Treatment Administration Record (TAR) for R #2, identified wound care to the left knee. No other injuries or wounds were identified on the TAR for treatment or monitoring. M. Record review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no other record that [MEDICATION(S)] had been administered. N. On 10/06/22 at 11:28 am during interview with R #2 mother, she stated regarding R #2 stay at the nursing home, He wasn't getting care. I kept telling them there was something wrong with his foot. They were having him walk on a broken foot and didn't know it was broken. He also had a second degree burn on his foot. He was complaining that his foot was hurting really bad. He called me Monday [09/26/22] and said 'I can't bare the pain anymore and they want me to walk on it.' I made the decision to take him to [name of hospital]. The burn [on his foot] was already starting to get an infection and the dressing was stuck to his skin. When doctor [at hospital] tried to remove it [bandage], it was pulling his skin. O. Record review of the Hospital record dated 09/26/22 at 12:56 pm identified [AGE] year old male here for repeat visit for evaluation of right foot pain that is a constant soreness moderate severity since his injury secondary to an MVC last week patient's right lower extremity has loss of skin and some irritation and blistering. He has not been changing the bandage for the last week. Findings related to R #3: P. Record review of the hospital discharge summary dated 09/08/22 revealed female with chronic lower back pain s/p lumbar (spine) surgery in 1983 . presents with the c/o (complaint of) worsening lower back pain over the past 2 weeks. She states that she tripped and fell down multiple stairs 2 weeks ago which re-exacerbated her chronic lower back, buttock and thigh pain . Q. Record review of R #3's face sheet identified that she was admitted to the facility on [DATE]. R. Record review of R #3's pain assessment dated [DATE] identified that she had frequent pain in the last 5 days which had made it hard to sleep at night, limited her day to day activities, and was verbally described as severe. Pain management treatment identified [MEDICATION(S)] [MEDICATION(S)] (nerve pain medication). S. On 10/17/22 at 2:31 pm during interview with R #3, she stated that prior to leaving the hospital on the morning of 09/09/22, she was provided her medication. She arrived that the facility at about 9:00 am on 09/09/22. She reported that she was provided Tylenol (pain medication) and [MEDICATION(S)] around 2:30 pm for her pain. She reported that she also kept an ice pack on her back which she received from the hospital. She stated, By midnight I was hurting really bad. I was calling using the button, and it would take about 15 minutes [for someone to come]. I was asking about my pain meds [medications]. Then I waited another hour, and it took another 15 minutes [for someone to answer her call light]. R #3 described that a nurse [LPN #2] came to her room and said that he was not her nurse. It was midnight and I was about in tears. About 12:15 am, 12:30 am. He [LPN #2] walks in and had a whole cup of my medication and gave me my medicine. I took the cup of medicine, he gave me. It took until about 2:30 am to get relief. It was a 9 [pain scale out of 10]. I was crying. When asked if the Tylenol and [MEDICATION(S)] was effective [on 09/09/22], she stated that it was not very effective and her pain was a 7/10 but the ice really helped her during the day. R #3 described that the next morning, she called her cousin to pick her and left AMA (against medical advice). T. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 600 mg TID (Three times daily) was administered twice on 09/09/22 and in the morning on 09/10/22. 2. [MEDICATION(S)] (treat muscle spasms and pain) 750 mg every 6 hours was administered at 12:00 am and 6:00 am on 09/10/22. 3. [MEDICATION(S)] Patch 5% (pain medication) every day was provided on 9/10/22. Other pain medications available but not administered: 1. Naproxen (anti-[CONDITION(S)]) 220 mg every 6 hours as needed for pain 2. [MEDICATION(S)] (narcotic pain medication) 5 mg every 4 hours as needed for severe pain. Pain scale and pain effectiveness was not identified in the MAR. U. On 10/19/22 at 4:40 pm during interview with the DON regarding R #3, she reviewed the records and confirmed that the medications for R #3 were delivered at 10:39 pm. The DON stated that Tylenol should have been administered meanwhile and pain level and effectiveness should have been documented in the record. V. On 10/20/22 at 11:54 am during interview with RN #1 stated that he worked with R #3 on the morning of 09/10/22. Regarding R #3's pain medication, he stated that the hospital didn't resume (write a prescription) all her medication after her discharge and the hospital physician called after she arrived to provide the prescription. RN #1 stated that R #3 was in pain and was provided [MEDICATION(S)] and Naproxene because she was in pain. When asked if R #3's pain was managed, he stated For the most part. I was under the impression that she was ok. Her heart rate was ok. W. On 10/24/22 at 3:39 pm during interview with Licensed Practical Nurse (LPN) #2, he stated that he worked the evening shift of 09/09/22 on a different hall and R #3's nurse was taking a long time to pass medications and several times the CNA approached him asking if he could give her medication because she kept asking for her pain medication. LPN #2 stated finally he grabbed the keys from the nurse and gave her medications at about 10:30 pm. LPN #2 stated that R #3 reported that she had been asking for her pain medications for a couple hours and her pain was 8 out of 10. Per LPN #2 when he returned to check on the effectiveness of the medication, R #3 was asleep. LPN #2 confirmed that the hospital had called the facility that evening to ensure the medications were received but he didn't speak with the hospital staff on the phone. When asked if there has been a delay in medication delivery, he stated that the pharmacy has been unreliable and it has been frustrating because deliveries only come once a day usually in the late evening. LPN #2 also stated that even to get the code to access a narcotic from omnicell, it can take a couple hours and not all nurses have access to the omnicell.

Based on record review and interview, the facility failed to ensure that a resident received care needed to prevent the development and worsening of a pressure ulcer for 1(R#1) of 4 (R #1, 2, 3 and 6) residents reviewed for pressure ulcers when an unstageable wound to R #1's right heel was identified on 07/08/21. This deficient practice likely resulted in R #1 developing an unstageable pressure wound (full thickness skin and tissue loss in which extent of tissue damage within the ulcer cannot be confirmed) and worsening of wounds to R#1 right heel and ankle, left heel and excoriation to the coccyx. The findings are: A. Record review of Nursing Progress Notes for R #1 revealed the following: 1. 06/04/21: Identified an island dressing (an all-in-one dressing that conforms to wounds and seals on all four sides) to resident's right hip ([CONDITION(S)] surgical site). No other identifiable skin breakdown noted. 2. 07/15/21 Nurse note of wound care to right heel completed and both legs swollen 3. 07/15/21 Nurse note that they spoke with (residents' wife) about wound size and how it looked. (unidentified site) 4. 07/22/21 Nurse note of dressing change to residents' right heel unstageable wound. Described area as black and hard with surrounding dark purplish color measuring 7 cm (centimeters) x (by) 7 cm. Right ankle has 0.5 x 0.5 dark area with redness surrounding skin. 5. 07/26/21 02:22 am Nurse note did not identify any wounds or changes of condition; Alert and oriented x3 6. 07/26/21 14:25 pm Nurse note that resident brought back from therapy with O2 (oxygen) saturation of 72%; legs swollen 3+; order to send to hospital 7. 07/26/21 Nurses note that (residents' wife) was contacted that there was a sore on resident's foot and resident also had a [CONDITION(S)] (urinary tract infection) being sent to [local hospital]. B. Record review of R#1 Care Plans identified: 1. 06/04/21 No skin integrity issues noted 2. 06/09/21 Right hip surgical incision 3. 7/18/21 Care Plan updated to include Skin tear to left anterior leg. 4. No other mention of pressure wounds identified in the care plan. C. Record review of a Braden Assessments ( A tool that predicts the risk for developing a facility-acquired pressure ulcer or injury) for resident #1 revealed the following: 1. 06/04/21 indicated a score of 15 (At Risk for skin breakdown) 2. 06/11/15 indicated a score of 15 (at risk for skin breakdown) 3. 06/19/21 indicated a score of 15 (at risk for skin breakdown) 4. 06/26/21 indicated a score of 15 (at risk for skin breakdown) D. Record review of resident #1 evaluations by physician or nurse practitioner revealed the following: 1. 06/08/21 Admission screening did not identify any skin breakdown 1. 06/15/21 Evaluation by physician; residential staff does not report new issues; no skin breakdown noted; no [CONDITION(S)] (swelling caused due to excess fluid accumulation in the body tissue and can occur in any parts of the body) 2. 06/22/21 Evaluation by physician; residential staff does not report new issues; no skin breakdown noted; no [CONDITION(S)] 3. 07/06/22 Evaluation by physician; residential staff does not report new issues; 1-2+ lower extremity [CONDITION(S)] noted to left lower extremity and 1+ to the right lower extremity; no skin breakdown noted; will check bilateral lower extremity doppler due to BLE (bilateral extremity) [CONDITION(S)]. 4. 07/13/21 Evaluation by physician; residential staff does not report new issues; Having wound care to excoriations on the underside of the scrotum in the perineal region; Left [sic] heel ulcer that is 5 cm x 6 mm and oozing slightly; Trace bilateral lower extremity [CONDITION(S)]. 5. 07/20/21 Evaluation by physician; residential staff does not report new issues; heel wound impacting his ambulatory ability (no specified side); He continues with some wound care on the scrotum and perineum and continues to receive wound care to the heel. No [CONDITION(S)] noted to lower extremities. 6. 07/26/21 Evaluation by nurse practitioner for follow-up on pain monitoring and medication management; remains stable at this time. Physical exam: This patient is well developed and in no acute distress. E. Record review of Weekly skin checks for resident #1 revealed the following: 1. 06/11/21 Surgical wound to right hip clean, dry, and intact 2. 06/19/21 Surgical wound to right hip clean, dry, and intact 3. 6/26/21 Pressure ulcer mid- coccyx (most distal portion of the spine) with scabs, almost healing and covered with Allevyn; no stage identified 4. 07/04/21 Pressure ulcer on coccyx (healing); no stage identified 5. 07/08/21 Unstageable pressure ulcer identified on left [sic] heel measuring 4.2 x 6.1 cm; no description 6. 07/17/21 Skin tear to lower left leg (front) 7. 07/24/21 Skin tear to left lower leg (front) 1.5 x 1 cm; Unstageable pressure ulcer to right outer ankle 0.5 x 0.5 cm; unstageable pressure ulcer to right heel 7 x 7 cm; right and left buttocks excoriation; skin tear of left lower leg side 0.5 x 105 cm. Note: Dressing to right heel and ankle changed. Skin tear x 2 to left shin area drying and starting to scab, both areas have red surrounding skin. F. Record review of TAR (Treatment Administration Records) for R#1: 1. June 2021 revealed no wound care orders 2. 07/08/21 Sure Prep to left heel every day shift for unstageable; discontinued 07/14/21 3. 07/15/21 Left [sic] heel multipodus boot while weight bearing; heel protector in bed or while in wheelchair; elevate heel/float while in bed 4. 07/17/21 Monitor left lower anterior leg skin tear- no treatment noted after 07/22/21 5. 07/23/21 [MEDICATION(S)] (medication is used to treat and prevent minor skin irritations) to Coccyx every shift for redness 6. 07/26/21 Right heel while weight bearing place multipodus boot; heel protector in bed or in wheelchair; elevate heel/float while in bed. G. Record review of Shower Sheets for R#1 revealed the following: 1. 6/21/21 no wounds/skin issues identified 2. 6/28/21 no wounds/skin issues identified 3. 07/05/21 no wounds/skin issues identified by CNA #1 4. 07/08/21 no wounds/skin issues identified H. On 09/08/21 at 10:30am a telephone interview with CNA #1, she confirmed the services provided for all residents include Skin assessments are completed during showers and during changes. I check a residents back, elbows, arms, knees, heels and notify charge nurse of skin changes. CNA #1 stated that she remembers showering R #1 one time and that he needed help with the transfer from the wheelchair to shower chair; CNA # 1 said she noticed redness of skin on the tailbone. She confirmed that she notified the Charge Nurse. I. Record review of Order Summary report for resident #1 dated 09/01/21 indicated the following: 1. 07/14/21 order to clean left [sic] heel with normal saline and apply Sure-Prep ( fast drying skin protectant) and cover with Allevyn ( wound dressing designed to absorb a large amount of wound drainage) every day shift for unstageable 2. 07/14/21 order for Prostat (enzyme-hydrolyzed complete protein drink) for wound healing 3. 07/26/21 6:00 pm (ordered after resident sent to hospital) Referral to wound clinic for right heel wound that is not healing 4. 07/26/21 6:00 pm (ordered after resident sent hospital) Right heel multipodus boot while weight bearing; heel protectors while in bed or wheelchair; elevate heel/float while in bed. J. Record review of social services notes for R#1 identified the following: 1. 07/15/21 Spoke with (resident's wife) and apprised her of R #1 pressure sore on his heel (no site identified) and that ADON will give her a call. K. Record review of therapy note dated 07/15/21 noted a communication with the wound care in regard to application of multipodus boots to right lower extremity during therapy involving weight bearing tasks until Off-loading shoe is available. Also recommended application of soft boots/cushion in bed to bilateral lower extremities and elevate bilateral lower extremities with pillows to decrease swelling, promote pressure relief, and promote tissue healing. L. Record review of emergency department visit for R#1 dated 07/26/21 revealed he following: 1. 07/26/21 03:24pm Arrival to emergency room for evaluation 2. 07/26/21 05:30pm Clinical impression is urinary tract infection with hematuria (blood in urine), altered mental status, and [CONDITION(S)] (an infection of the blood stream), due to unspecified organism; Case discussed, we agreed that the patient appears to have more involvement than just a [CONDITION(S)] (urinary tract infection): Legs very hot to the touch and has heel ulcers and a prominent scab with surrounding [CONDITION(S)] left lateral calf. 3. 07/26/21 06:09 pm Hospital Admission History and Physical identified attempt to contact (nursing home) but no one answered. R#1 being admitted to (hospital) for cardiomegaly (enlarged heart), left lower lobe atelectasis or infiltrate, wound management, swallowing evaluation and treatment and physical therapy. 2+ Pitting [CONDITION(S)] (condition where excessive fluid builds up in the body, causing swelling that, when pressure is applied to the swollen area, makes a pit or indentation of th skin) of lower extremities; wound covered with scab on left shin, foul smelling purulent (consisting of,containing, or discharging pus) chronic wound of bilateral lower extremities. 4. 07/28/21 07:36 am Consult by DPM (doctor of podiatry medicine) stated Apparently admitted with [CONDITION(S)], possibly secondary to a [CONDITION(S)] (urinary tract infection). Having said this, it was noted that he has wounds on his heels, which could be contributing to the [CONDITION(S)] as well. Patient has a necrotic right heel wound which encompasses the entire heel; unknown depth. There is a strong malodor with some thickened drainage, surrounding [CONDITION(S)], [CONDITION(S)], warmth, but difficult to tell the depth of the wound. On the left side, he also has a necrotic heel ulceration, but is much smaller in size; no surrounding [CONDITION(S)], [CONDITION(S)], or warmth; no odor; mild drainage that does not look purulent. Assessment: Ulceration, unknown depth right heel; Ulceration unknown depth of left heel and [CONDITION(S)] of right foot. PLAN is for an MRI of right heel and speak with wife once the MRI is back to discuss options; I think the patient is at a very high risk to lose leg. M. On 09/02/21 at 1:32 pm during interview with the Assistant Director of Nursing (ADON) #1, she reported that she documents resident wounds on a wound report from the information provided the by floor nurses. ADON #1 confirmed that the nurses are responsible for completing weekly assessments. She reported that she was unsure if anyone was reviewing the assessments for accuracy. ADON #1 reported that she was aware that the wound for R #1 had gotten worse at the time he was transferred to the hospital [07/26/21] but that she didn't remember the wound ever being open or oozing. ADON #1 stated she was unsure why there was a delay in identifying the wound, stating that from one week to the next, it {wound} took a drastic turn. N. On 09/02/21 at 2:35 am interview with the Director of Nursing (DON) she reported that R #1 was admitted from the hospital with a right [CONDITION(S)] and he guarded his right side due to the pain. The DON stated I think most residents with decreased mobility and incontinence are at risk for skin integrity {breakdown]. I think the impaired circulation and pain and fracture on that same leg .all his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed that R #1 needed assistance getting dressed and staff would have had eyes on his heels every day. When asked how a wound becomes unstageable without being noticed, the DON stated Sometimes it can start off as boggy or a blister however staff should have noted the change. The DON confirmed that the reference to the left heel in the physician evaluations/orders and TARs was in error that R #1's wound was on his right heel only. O. On 09/17/21 at 11:20 am during interview with family member (FM) #1 she reported that her father was admitted to the facility following hip repair surgery and the family thought that the surgery would be a good thing for him. She reported that R #1's wife was notified once about a small pressure wound and that the facility assured her that they were taking care of it. The next call the family received was that they were sending him to the hospital because of his pressure wounds and that he had blood in his urine and they couldn't remove the catheter. Upon family seeing R #1 in the hospital, she reported He looked like death. He spent 3 weeks in the hospital. Per FM #1, the hospital wanted to give him a below the knee amputation due to the seriousness of the pressure wound, severe and to the bone on his heel. FM #1 stated He was unresponsive and thin. He was literally eyes closed and unresponsive in pain. FM #1 reported that R #1 after leaving the hospital, he was transferred to another facility out of state on hospice and passed away in August 2021. She stated It was an unnecessarily, painful death.

Based on record review and interview, the facility failed to develop an effective discharge plan for 3 (R # 81, R #137 and R # 280) of 3 (R #81, R #137 and R #280) residents reviewed for discharging planning. The facility failed to focus on: 1) Involving the resident and/or residents family in the discharge planning process and informing them of the final plan for discharge 2) Implementing and updating care plans as needed throughout the discharge planning process 3) Communicating with home health providers to ensure a smooth and safe transition from the facility 4) Ensuring that the residents post-discharge needs were identified and education and training was provided to the resident and/or the residents family members prior to or at the time of discharge These deficient practices likely resulted in #R 137's wounds becoming septic requiring hospitalization . These deficient practices could likely result in complicated and unsafe transitions from the facility to the residents post-discharge settings. Findings for R #81: A. Record review of R #81's admission record revealed she was most recently admitted to the facility on [DATE] and discharged on [DATE] on hospice (a form of health care that focuses on terminally ill residents symptoms and comfort and attending to their emotional and spiritual needs at the end of life) and tube feeding (a liquid form of nutrition delivered to the body through a tube into the stomach). B. On [DATE] at 1:12pm, during an interview, R #81's daughter reported I told them at the (name of facility) that I was worried and I requested directions from them on how to care for my moms' tube feeding. I feel that she (R #81) would have lived longer, if they trained me before she came home. When asked if there was a discharge planning meeting conducted prior to R #81's discharge home, R #81's daughter reported No, no one ever cared or paid attention to me. As a matter of fact, I drove all the way down there (to the facility) one day and the head nurse stood me up for our appointment to talk about bringing my mom home and I live over an hour away. I felt so lost and I can only imagine how my mom felt being over there (at the facility). She (R #81) had some dementia (a group of thinking and social symptoms that interferes with daily functioning) and she was probably really scared. Everything was last minute and it was stressful, because of the Thanksgiving holiday (resident discharged the day before Thanksgiving) and they didn't give me anything when we left (the facility), no nothing (paperwork, instructions, etc.). C. Record review of R #81's electronic medical record revealed a comprehensive care plan on file that listed an admission date of [DATE], but no discharge planning goals or interventions (actions taken to improve) listed. D. Record review of R #81's electronic medical revealed no documented outreach made to the residents daughter prior to R #81's discharge regarding the discharge planning process. E. On [DATE] at 2:32pm, during an interview, the Director of Nursing (DON) reported that they did not have any documentation of tube feeding education or training provided to R #81's daughter. She reported I remember we sent her (R #81) home with extra formula (liquid nutrition) and (name of the hospice provider) was going meet her there for the admission when she got home, but I don't see any documentation of that communication (between the facility and the hospice provider) in the system. F. Record review of R #81's electronic medical record revealed no documented outreach made to the hospice provider by the facility. G. On [DATE] at 9:28am, during an interview, the Social Services Director (SSD) reported that they do not routinely conduct discharge planning meetings close to the date of discharge date unless the resident and/or the residents family requests it. She reported that R #81's daughter did not request a discharge planning meeting prior to R #81's discharge. The SSD reported as we get close to the discharge date , we are in constant contact with the residents family, DME (durable medical equipment) providers, home health agencies and busy scheduling the post PCP (primary care physician) appointments, so we don't really need to do a meeting. The SSD reported that when a resident is discharging, a nurse reviews the Nurse Discharge Summary with the resident and/or their family, has them sign the summary and then provides them with a copy of the summary. She reported this paperwork (the Nurse Discharge Summary) provides them (the resident and/or their family) an overview of the residents stay (at the facility), services needed and how to care for the resident after they leave here (the facility). The SSD reported the expectation is that outreach is made to the residents family to confirm the pickup time, the nurse is informed to have everything (paperwork, medications, etc.) ready by that time, social services visits with the resident to say goodbye and does any needed follow up. When the family arrives at the facility, the nurse hands over the medication (to the resident and/or the residents family), goes through the medication reconciliation (the process of two or more people agreeing), everyone (the resident and/or the residents family and the nurse) signs and dates the Nurse Discharge Summary and a copy is provided to the resident and/or the residents family. H. On [DATE] at 2:28pm, during an interview, the DON reported that they do not have a signed Nurse Discharge Summary on file for R #81. Findings for R #137: I. Record review of R #137's admission record revealed that he was most recently admitted to the facility on [DATE] and discharged on [DATE]. J. On [DATE] at 11:50am, during an interview, R #137's brother reported My brother was sent home from (name of facility) with severe pressure sores (injuries to skin and underlying tissue caused by continual pressure and also known as pressure ulcers) on his feet, the back of one of his legs and on his lower back that [MEDICAL CONDITION] (infection of the blood stream) and it eventually led to his death on [DATE]th of last year (2020). R #137's brother reported that the resident was hospitalized about a week or two after his discharge from the facility and he passed away in the hospital. When asked if there was a discharge planning meeting conducted prior to R #137's discharge home, R #137's brother reported I think a meeting to talk about it (the discharge) was done over the phone, because of COVID (respiratory-breathing related illness caused by the coronavirus) about a month before my brother came home. I thought everything was in place and he was ready to go, but we were not made aware that (first name of R #137) had any pressure sores. I had to work the day my brother was discharged , so my son picked him up. I was his primary caregiver and we wanted to bring him home, but we had no idea he had pressure sores. K. Record review of the Physicians Discharge Summary dated [DATE] revealed under the Physical Exam section and category Skin: Wound care is in progress for Coccygeal/Sacral (tailbone; small triangular bone at the base of the spine) pressure ulcer. L. On [DATE] at 2:09pm, during an interview, the DON reported that R #137 had one pressure ulcer that was located on his coccyx (small triangular bone at the base of the spine) when he discharged on [DATE]. M. Record review of R #137's electronic medical record revealed a comprehensive care plan that listed an admission date of [DATE], but no discharge planning goals or interventions listed. N. Record review of R #137's Care Plan Conference Summary dated [DATE] revealed that R #137 was not listed as an attendee of the Care Plan Conference nor were any of his family members. O. Record review of the Physicians Discharge Summary dated [DATE] revealed that R #137 planned to return home to be cared for by his daughter. P. Record review of R #137's electronic medical revealed no documented outreach made to any of the residents family members prior to R #137's discharge regarding the discharge planning process or how to care for pressure sores. Q. On [DATE] at 9:30am, during an interview, the SSD reported that R #137 and his family did not request a discharge planning meeting prior to R #137's discharge. R. On [DATE] at 2:25pm, during an interview, the DON was asked how are you determining that the family can take care of the resident at home? The DON reported when we are conducting the care conference, we are communicating with the resident and the family and learn about them that way and usually social services is in contact frequently with the family while coordinating the discharge and that's how we determine it - the first care conference is important. S. Record review of R #137's electronic medical record revealed no documented wound care education or training with the resident or his family (brother, mother or daughter) prior to discharge and no documented outreach made to any of the residents family members prior to R #137's discharge regarding the discharge planning process or how to care for pressure sores. T. On [DATE] at 2:30pm, during an interview, the DON was asked did the facility provide wound care training and supplies for (first name of R #137) upon his discharge home? She reported no there is nothing documented about that. U. On [DATE] at 9:54am, during an interview, the SSD reported If a resident is not getting discharged with a provider (i.e. home health or hospice) any training (i.e. wound care, tube feeding) would be provided to the family by the facility, otherwise it's on the provider to provide the training and once we fax the discharge summary packet that gives them all of the information, then it's their (receiving providers) responsibility. V. On [DATE] at 10:16am, during an interview, the ADON was asked what is the expectation when you have a resident discharging home with pressure ulcers? She reported we make sure that they (the resident and/or residents family) understand that they need to make an appointment to follow up on the wound with their own doctor and teaching or at least discharge instructions are given to them on how to care for the wound. W. On [DATE] at 2:29pm, during an interview, the DON reported that they do not have a signed Nurse Discharge Summary on file for R #137. X. On [DATE] at 2:34pm, during an interview, the DON reported when a resident discharges the expectation would be to train anyone in the home on what's needed - dressing changes (for wounds), medication and administering the formula (tube feeding) and teach on prevention - how to keep from getting worse when it comes to hydration (taking in water), nutrition (food or other nourishment necessary for good health), repositioning and we would also send them home with supplies - enough to last until they can get some through the home health or hospice agency. Y. Record review of the residents electronic medical record revealed no documented outreach made to any home health care provider by the facility prior to R #137's discharge. Z. On [DATE] at 8:18am, during an interview, the Registered Nurse (RN) #2 at (name of home health care provider provided by SSD) reported that R #137 was admitted on [DATE] and discharged on [DATE]. She reported that they sent a nurse out to the home on [DATE] to conduct the intake and they ended up filing an incident report with the State of NM Adult Protective Services Department due to the condition of R #137's pressure sore on his buttock (lower rear area of the human body). The RN reported the wound was completely black, the brief he was wearing was soaked (in urine), he was covered in feces (human waste matter), the home environment was not sanitary (relating to cleanliness) and (name of R #137's) daughter/caregiver appeared to have a possible mental disability (name of daughter not on file). The RN reported that the nurse went back out to the home on [DATE] to conduct the discharge interview and while there, she called emergency medical services to transport the resident to emergency room . AA. On [DATE] at 9:39am, during an interview, the SSD was asked how do you ensure that the home health care providers receive referrals for care? She reported we call the home health care providers to make sure they can provide the care requested based on the orders and then we fax them a discharge summary packet. When asked if the outreaches are documented in the residents electronic medical record, the SSD reported we make outreach telephonically, but we do not routinely document those outreaches in the residents electronic medical record. BB. On [DATE] at 11:41am, during an interview, the Intake Coordinator (INTK COOR) #1 at (name of home health provider) reported that they received an incomplete referral/order from (name of the facility) on [DATE] by fax. She reported I only received a discharge summary report, an H&P (health and physical notes) and PT (physical therapy) notes and no orders for care, so I made outreach to (name of the facility) and did not receive what we needed from them after several attempts, so we contacted the VA (Veterans Administration) as we could not accept him (R #137) until we had what we needed (to provide care). The Intake Coordinator/LPN reported we finally received orders from the VA on [DATE] and we went out to the home that same day. She reported the orders from the VA included: home health nursing 3 times weekly and wound care nursing 3 times weekly. Findings for R #280: CC. Record review of R #280's admission record revealed he was admitted to the facility on [DATE] and discharged on [DATE]. DD. On [DATE] at 8:52am, during an interview, R #280 was asked did you attend any meetings regarding your discharge from (facility name) to discuss what you would need in place before you went home? He reported I don't remember having a meeting with them (facility staff), but there were a lot of services involved. R #280 reported I remember when I left they gave me some paperwork, but I just took it home and I'm not sure where it is right now. R #280 was asked did you discharge with home healthcare services? R #280 reported yes, (the name of a home health service provider not consistent with what was listed on the Discharge Order dated [DATE]) has done a great job for me. EE. Record review of R #280's MDS (Minimum Data Set) Resident Assessment and Care Screening dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14. BIMS scoring: ,[DATE] severe impairment, ,[DATE] moderately impaired and ,[DATE] cognitively intact. FF. On [DATE] at 2:25pm, during an interview, the DON reported we do not have a signed Nurse Discharge Summary on file for R #280. GG. Record review of R #280's electronic medical record revealed a comprehensive care plan that listed an admission date of [DATE], but no discharge planning goals or interventions listed. HH. Record review of R #280's Care Plan Conference Summary dated [DATE] revealed that R #280 was not listed as an attendee of the Care Plan Conference. II. Record review of R #280's electronic medical record revealed only one Care Plan Conference Summary on file between [DATE] and [DATE]. JJ. Record review of R #280's electronic record revealed that there was no outreach made to the home healthcare provider listed on the Discharge Order dated [DATE] regarding R #280's referral for home healthcare services. KK. On [DATE] at 10:35am, during an interview, INTK COOR #2 at (name of home healthcare provider) reported we received a referral from (facility name) on [DATE], but we did not accept the referral. LL. On [DATE] at 11:03am, during an interview, the SSD reported there is no documented outreach made to (name of the home healthcare provider listed on the Discharge Order dated [DATE]) for (name of resident). MM. On [DATE] at 11:05am, during an interview, the SSD was asked when you send an order to the home health services provider, do you verify that the order was received? She reported, yes, we do that by phone. The SSD was asked where is that documented? She reported we don't document it. NN. On [DATE] at 11:07am, during an interview, the SSD reported after the resident discharges, it's on the provider and the resident. If (name of home health provider) didn't start services, he (R #280) probably didn't answer his phone and I can't make him answer the phone. OO. On [DATE] at 11:10am, during an interview, the SSD was asked when you have folks that are going home with a caregiver or family, are you vetting them to ensure that they can take care of the residents. She reported Not really, just in conversation, we see if they've been in the residents life and in talking to the family, they give us feedback on, 'yes we can take care of them (resident).'

On [DATE] R #9 was found unresponsive (not responding to stimuli such as calling of her name and shaking her body) in the facility dining hall. She was taken from the dining area to her room prior to initiation of CPR (techniques to manually provide for blood circulation and oxygenation in an emergency) delaying this potentially life saving measure. During interviews with multiple staff in the facility, the staff could not immediately and accurately identify residents' code status. Some staff indicated they would start CPR on any resident found unresponsive until code status could be verified by looking in the Electronic Health Record (EHR) or a binder located at the Nurses Station, and then stop CPR if resident had elected to be Do Not Resuscitate (DNR) (Do not provide CPR services). Record review for CPR Certification status of staff revealed that the two certified Nursing Assistant's (CNA's) and the nurse involved in provision of CPR during the event on [DATE] with R #9 did not have up to date certification. This resulted in an immediate jeopardy (IJ) at a scope and severity of J (isolated jeopardy to resident health and safety) being identified on [DATE] at 2:15 pm. A Plan of Removal was approved and verified on [DATE] at 1:40 pm. Based on the Plan of Removal, the interventions included: 1. Completed audit of all residents' code status. 2. All clinical staff to have a list of residents' code status provided to them each shift that is updated daily. 3. All clinical nurses and Certified Nursing Assistants (CNA) were educated to begin CPR immediately for any resident who has elected it and found requiring it at the place at which they are found according to Basic Life Support (BLS) guidelines. 4. All nursing clinical staff to have current certification in BLS/CPR as of [DATE]. Based on the Plan of Removal, the Scope and Severity was reduced from the level J to a level [NAME] Based on record review and interview, the facility failed to: 1. Initiate CPR immediately for 1 (R #9) of 1 (R #9) residents reviewed for prompt provision of CPR when required. 2. Ensure there was a system in place for all clinical staff to immediately determine the code status (level of medical interventions a patient wishes to have if their heart or breathing stops). 3. Educate all clinical staff to provide care if a resident is discovered without breathing and/or heart beat that reflected residents wishes in accordance with their Advanced Directives. 4. Ensure clinical staff with current CPR certification are available to provide CPR if needed, at all times in the facility. These deficient practices have the potential to result in a resident not receiving immediate/effective basic Life Support/CPR if they have elected that or receiving CPR if not elected for any of the 94 residents identified as living in the facility on [DATE] by the administrator in the, Patients Census And Conditions Of Residents, (CMS-672). Findings related to R #9: [NAME] Record review of census and [DIAGNOSES REDACTED].#9 revealed, she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. B. Record review of nursing progress note on [DATE] at 5:54 am, (a late entry regarding the event [DATE]) revealed, At about 8 AM Pt. (patient/resident) non-responsive heart rate (beats per minute) and respirations diminished (less than her normal) Pt. is full code CPR started. 911 EMT's(Emergency Medical Technicians) notified. CPR was stopped when told by EMT's to stop when they took over. Pt. with V/S (vital signs, generally meant to be heart rate, respirations, blood pressure) and transported by EMT's to ER (emergency room ). C. On [DATE] at 8:35 am, during interview, the Director Of Nursing (DON) revealed regarding the event on [DATE] when R #9 became non-responsive in the dining room, That was a scary one .we came up (back to the facility) and watched the video, she (R #9) is sitting at the dining room table she reaches for her hot chocolate and takes a drink - puts it back and takes another drink and then all of a sudden she drops her cocoa and has shaking (demonstrates her arms mild shaking) then she dropped her head. Then (first name of CNA #5) came and sat in front of her and kind of looked closely and called for the nurse (LPN #1) they took her back to her room (There is a camera in the dining area and hall but not resident room) (Do you have the video still?) oh no, they only last about 7 days (Do you have a record of the code event?) No, (first name of LPN #1) did not complete one .(first name of LPN #1) said they did a finger sweep and could not find anything, so started CPR (how was she when she left the building?) They were bag / masking her (putting air into her lungs with a bag and mask). Then they (staff) called us and we came, the administrator and I . I went over to the hospital, she was in the ED (Emergency Department) still they were working on her .the nurse there told me it was a poker chip (a poker chip was found in her airway), she said they found it when they tried to intubate her (put a breathing tube into the airway ) .the tube wouldn't go in and that is when they got it out .She died about 11 (pm) that night .the daughter told me. D. Record review of event timeline provided on [DATE] by the DON, which she relayed was from watching the video of the event, revealed: 1. At 8:02:56 am, resident discovered in dining room by CN[NAME] 2. At 8:03:35 am, resident was back in her room. 2. At 8:05:03 the backboard was taken to the room. E. Record review of incident report dated [DATE] at 3:03 pm, written by CNA #1, We took (first name of R #9) to her room and notified the nurse on duty as we were taking (first name of R #9) down where (first name {misspelled} of CNA #2) and i checked her throat and didn't see anything. We proceeded after with the [MEDICATION NAME]. No results. We transferred her to the bed and performed CPR until Paramedics arrived and took over. F. On [DATE] at 8:55 am, during interview, LPN #1 revealed, Worked here [AGE] years. I went and got the backboard. We did a mouth sweep and one of the boys (CNA #1 or #2) gave her a [MEDICATION NAME] .My thought was she had a [MEDICAL CONDITION] .the EMT's showed up and took over, in maybe less than 15 minutes. I was on the phone with the 911 dispatcher for a few minutes. The CNA's (CNA #1 and CNA #2) were doing most of the CPR. Every time we did a compression, in between she was flat line (heart monitor showed no activity from heart). We were bagging her color was never cyanotic (bluish discoloration that can indicate lack of adequate oxygenation). [NAME] On [DATE] at 10:10 am the DON confirmed that LPN #1, CNA #1 and CNA #2 did not have current certification in BLS/CPR. Findings related to code status: H. On [DATE] at 8:55 am, during interview, LPN #1 revealed (How do you know which of your residents want CPR ?) We mostly know who is CPR or not. We do it (assess for their wishes/advanced directives (various documents that instruct/directive medical professionals and your family to the treatments you want to receive or refuse.)) mostly when a new resident comes in. (How many residents do you have today?) About 26 I think. (rooms?) Rooms 18 through 32 (Can you tell me which residents you have today who are full code (have directed that they want to receive CPR if indicated) verses DNR (have directed they do not want to receive CPR if they have lost the ability to breathe adequately or their heart rate is not adequate to sustain their life ?) Yes, I think so . He identified R # 10 and R # 11 as full code(have directed that they desire CPR if indicated) and the rest of his assigned residents no code(DNR). I. Record review of electronic health records (EHR's), for resident in rooms 18 through 32 on [DATE], revealed the following resident's had Advanced Directives indicating they desired CPR (full codes) if needed , R #'s, 10, 12, 13, 14 and 15. (This information was confirmed by the DON on [DATE] at 11:55 am). [NAME] On [DATE] at 10:45 am, during interview CNA #4 revealed, that regarding what he would do if he found a resident was non responsive, I would call for nurse .I would yell for help .I would start the CPR . I just recently got my CPR, it was last Thursday (how would you know if the resident wanted CPR or wanted to be a no code?) that information we don't have .I guess I wouldn't .if I . started it and the nurse said they were not CPR then I probably would stop. K. On [DATE] at 10:50 am, during interview, LPN #3 revealed, that regarding how she would respond on finding a non responsive resident, We would try to help her do what we know .(how would you know the residents Advanced Directive status?) I know most of them (you just remember?) yes. We used to have the charts up here (at nurses desk) and it was about a year ago (they went to the electronic health record (EHR)) I would start it (CPR) right here I wouldn't move her. Look at the EHR or the book they are making a book .it is up front there (indicates the front hall where DON and Administration offices are) Yes, that is new. If we happen to not know (if the resident wanted CPR or not) we start it (CPR) not knowing. L. On [DATE] at 11:03 am, during interview LPN #4 revealed, (if you find a resident laying in the courtyard no pulse no respirations and you do not know the code status what do you do?), you could start it and stop it (CPR). Regarding (name of R #14, what is his code status?) It is not on here (on the banner in the residents EHR) but I admitted him so I know he is a DNR. M. Record review of R #14's EHR revealed, he had an updated Advanced Directive that indicated he wanted CPR. (is a full code, not DNR). N. On [DATE] at 11:10 am, during interview, LPN #2 revealed that regarding initiation of CPR when a resident is found unresponsive, you immediately get down and assess them . you start CPR . you get somebody to check on the computer (at the nursing station) to find out (their advanced directive). (What if they didn't want CPR?) then you stop (CPR). It is true, if they are not on your floor you may not know (their advanced directive status).

Based on record review and interview, the facility failed to maintain ideal weights for 2 (R #s 33 and 99) of 4 (R #s 15, 33, 99 and 141) residents reviewed for weight loss by: 1. Not adequately implementing interventions to promote weight gain or prevent further weight loss; 2. Not notifying the Registered Dietician (RD) when weight loss occurred. This deficient practice is likely to result in malnutrition, decreased protein levels, and insufficient wound healing. The findings are: Findings for R #99: A. On 08/31/16 at 2:00 pm, during interview with R #99's spouse, she stated that there were issues with R #99's diet and that he lost a significant amount of weight during his 3 month stay at the facility. B. Record review of R #99's vital signs record from 01/01/16 to 05/09/16 indicated a 63 pound weight loss and the following weights: 1. 01/01/16: 245 lbs (pounds) 2. 02/01/16: 205 lbs 3. 03/01/16: 204 lbs 4. 04/01/16: 198 lbs 5. 05/09/16: 181.8 lbs C. Record review of the Care Plan dated 01/01/16 indicated the following: Problem: Risk for alteration in nutrition related to occasional refusal of meals and oral intake with increased risk r/t (related to) resistance to accepting assistance with meals and combativeness secondary to frontal lobe dementia. Interventions included: will consume greater than 75% of meals, maintain current weight of 205 lbs (pounds) for 90 days, record meal intake percentage. D. Record review of the Meal Intake documentation revealed 16 days in April 2016 in which meal intake percentages were not recorded. No other documentation was found. E. On 09/15/16 at 3:10 pm, during interview with the Director of Nursing (DON), she stated that she spoke with the Dietary Manager (DM) and retrieved some of the intake documentation of #99's meal and fluid intakes. She stated that at the time that R #99 was at the facility, the CNAs (Certified Nursing Assistants) should have been documenting meal intake percentages three times a day for each meal. She was only able to provide intake forms for 14 days in April. F. On 09/15/16 at 4:17 pm, during interview with the DM, she stated that she was unable to find any additional documentation of R #99's meal and fluid intakes. She stated that CNAs were responsible for documenting meal and fluid intake percentages and that these were reviewed by the RD on her visits once or twice a week. DM verified that without the intake documentation, staff would have a hard time determining if dietary interventions were appropriate and that tracking and trending weight loss would also be very difficult. G. On 09/16/16 at 9:56 am, during interview with the RD, she stated that the nursing staff typically initiates the dietician consult when there is weight loss concerns but that this didn't happen and she was not sure why this was the case. The RD stated that R #99 had an almost 40 pound weight loss in one month. The RD stated that she did not assess this R #99 as she had just started at the facility and the DM at the time did not give her copies of any referrals or information on weight loss. The RD stated that she did not know the reason that R #99 was not being closely followed for his weight loss and new interventions developed to address this issue. She stated that this seemed to have fallen through the cracks. Findings for R #33: H. Record review of R #33's medical record indicated that her height was 57 inches, and that: 1. On 08/31/16, she weighed 85.2 pounds on admission. 2. On 09/05/16, she weighed 83.6 pounds. 3. On 09/12/16, she weighed 79.4 pounds. I. Record review of R #33's Nutrition Assessment, completed on 09/08/16 by the RD, found: 1. that her goal weight was 100 pounds. 2. that she had a pressure ulcer (bed sore) on her coccyx (lower spine area), which would require adequate nutritional intake to promote healing. 3. a statement from the RD indicating that R #33's PO (oral) intake was poor. The RD noted that PO intake is inadequate to sustain resident's weight. Recommend fortifying diet, add Med Pass 4.0 (a nutritional supplement) 90 mLs (milliliters) TID (three times daily) between meals, Prostat (a nutritional supplement) 30 mLs BID (twice daily). J. Record review of R #33's current physician's orders [REDACTED]. K. On 09/16/16 at 10:13 am, during interview with the RD, she confirmed that she had assessed R #33 and determined that the resident was in need of specialized nutritional interventions, such as supplements. She stated that when she has a recommendation, she types it out in a template, and gives copies to the DON, the Administrator, and the Dietary Manager. She indicated that the facility's process was for the DON to advise the resident's assigned nurse of the recommendation, who would then contact the resident's physician to approve the order. She stated that some facilities get this done within 2 days, but at this facility it's more like 2 weeks. L. On 09/16/16 at 2:33 pm, during interview with the DON, she confirmed that the RD's recommendation had not been acted upon. She stated that the RD should have written the recommendation on a Telephone Order slip, which would trigger nursing staff to call the physician for approval. She stated that the RD had not followed the proper procedure in this case, and therefore she (the DON) had not seen the recommendation.

Based on interview and record review, the facility failed to immediately notify and consult with Resident #1 (R #1)'s physician about a significant change in condition. On 03/29/16, R #1 displayed a significant deterioration in mental and physical function. The facility staff failed to notify and consult R #1's physician until the fourth day on 04/01/16. R #1's Urinary Tract Infection [MEDICAL CONDITION] went undetected and progressed into [MEDICAL CONDITION] with Organ Dysfunction (Sepsis - a life-threatening bacterial infection of the blood. [MEDICAL CONDITION] -[MEDICAL CONDITION] causing insufficient blood flow to the organs.)/Urosepsis (sepsis localized to the urinary tract system)/Acute Kidney Injury (a sudden decrease in kidney function). Four residents (R #1-4) were reviewed for hospital transfers and recurring UTIs. The findings are: A. Record review of R #1's Admission Data Set (facility's baseline nursing assessment upon admission) dated 03/28/16 at 7:50 pm for skilled nursing services revealed: mental status of alert and oriented x4 (to person, place, time, and purpose). This document also revealed R #1's urine as yellow and clear with faint odor. Admit Vitals (03/28/16) - Blood Pressure (B/P): 122/68, Pulse (P): 74, Respirations (R): 20 and Temperature (T) 97.9. B. Record review of R #1's Face Sheet dated 03/28/16 revealed: Admitting diagnoses - Stress fracture of left femur (a crack in the left thigh bone resulting from stress or force), obesity, long term use of antibiotics, diabetes insipidus (a disorder of salt and water metabolism marked by intense thirst and heavy urination), history of blood clots, and major [MEDICAL CONDITION]. No diagnoses of dementia (loss of memory) or altered mental status upon admission. C. Record review of R #1's Medicare Note dated 03/28/16 at 11:30 pm revealed: Resident awake and alert. Vital sign(s) stable. D. Record review of R #1's Medicare Note dated 03/29/16 at 7:28 pm revealed: Resident was lethargic in the early morning hours and as the day progressed she was up to her wheelchair and assessed by therapy. E. Record review of R #1's Occupational Therapy Evaluation & Plan of Treatment dated 03/29/16 at 1:55 pm revealed: Clinical impressions: Pt (Patient) is very confused and has poor awareness of environment. F. On 06/22/16 at 9:17 am during interview with the Therapy Director (TD) about R #1's assessment on 03/29/16 he confirmed, She was definitely not together. She would say a few words and she was really incoherent and wasn't knowledgeable about where she was. G. Record review of the facility's Change of Condition Process revealed: To ensure the optimal outcome for the resident, nursing process of Assessment, Plan, Intervention, and Evaluation will be used. The licensed nurse is to complete the assessment for a change of condition using a tool called the Situation-Background-Assessment/Appearance-Request (SBAR) form. The form is used for the licensed nurse to report the assessment to the physician. Physician involvement is always required. H. On 06/21/16 at 3:50 pm during interview with Family Member (FM) #2 she stated, She was bedridden since she was admitted (to the facility) and incontinent (having no control over urination or defecation). She (R #1) had to wait 20 minutes to get help (after an incontinent episode) and then another 45 minutes to get another staff person to help. She sat in her own fecal matter which can cause a UTI. On Tuesday (03/29/16) she (R #1) was unable to recognize me. The nurses said it was the pain medication. I. On 06/22/16 at 10:58 am during interview with FM #1 he recalled, I noticed the next day I came in, on Wednesday (03/30/16), she wasn't doing as good, not as cognitive. Less talkative. J. Record review of History and Physical (H&P) created by Medical Doctor (MD) #1 and dated 03/30/16 and electronically signed at 1:29 pm revealed: Eye contact is very poor. She (R #1) is uncommunicative. She is awake, gazes out into space, she does not speak despite my being persistent in questioning her. K. On 07/28/16 at 9:40 am during interview, MD #1 confirmed assessing R #1 on 03/30/16. When asked if he was there on rounds or for a specific reason he stated: No it was my usual rounding day. MD #1 stated that R #1 was very confused and he read his notes aloud from his H&P dated 03/30/16. MD #1 stated: If she experienced that much of a change in mental status from admission, I would have sent her to the emergency room (ER) (on 03/30/16) since that would be a significant change in condition. When asked if any staff members alerted him after his visit about a change in condition for R #1, he only confirmed the call on 04/01/16 and stated, I do remember getting a call about a significant change in condition and that is when I told the staff to send her out to the hospital (on 04/01/16). MD #1 did not confirm receiving any reports of R #1 having foul smelling dark urine from any staff members. When asked what his expectations would be if nursing saw a significant change in condition MD #1 stated, I would expect them to call me. MD #1 was asked about R #1's pain and stated, I don't know about that, but usually I rely on the nurse to call me if the medication ordered is not sufficient for the pain. I don't remember, but if they would have (notified me) I would have prescribed something stronger if the Tylenol was not sufficient for the pain. I don't see that I ordered anything else (for R #1). L. Record review of the Laboratory Results Report dated 04/01/16 revealed that a urinalysis (UA) was collected by the facility on 03/31/16 at 8:14 pm. The results were received on 04/01/16 at 11:03 am and reported the urine to be dark yellow and cloudy, elevated protein, high white blood cell count, positive for bacteria/culture indicated. M. On 07/27/16 at 1:49 pm during interview, the Director of Nursing (DON) confirmed that if lab results for urine are abnormal the lab will immediately notify the facility by phone. The DON further confirmed that the nursing staff should then immediately notify the physician of the results. N. On 06/22/16 at 10:09 am, during interview with Registered Nurse (RN) #1, she recalled working with R #1 on 03/31/16 and stated, She was eating little bites only and drinking a little. She was in the bed sleeping most of the time. O. Record review of R #1's Soft Landing assessment (an assessment done by the facility's Activity Director (AD) through asking the resident questions for 3 days following admission) dated 03/29/16 through 03/31/16 revealed: On 03/31/16 there is a line through R #1's entire assessment with a written note that reads, Unable to answer, very (underlined) confused, nurse doing UA. P. On 06/23/16 at 4:21 pm during interview, the DON confirmed, (Name of AD) does those (soft landing assessments) first thing in the morning and confirmed that the AD will alert the nurse and bring the information to the morning stand-up meeting. Q. On 07/27/16 at 1:49 pm during interview, the DON confirmed, We meet with all the department heads at 8:30 each morning. (We) sit down and discuss new admits (and) anything else going on in the building. R. On 06/23/16 at 8:10 am during interview, the AD confirmed that R #1 had a significant change in condition on 03/31/16 in comparison to admission on 03/28/16. She said R #1 was out there. The AD further confirmed she reported these significant changes to the DON and at the morning stand-up meeting on 03/31/16. S. On 06/21/16 at 2:59 pm during interview with Certified Nursing Assistant (CNA) #1, when asked what she remembered about R #1 she answered, She was quiet and sleeping all the time. She would refuse for everything - food, liquids, everything. She didn't drink anything for days. CNA #1 was then asked if there was anything to note about R #1's urine she stated, It was dark yellow, cloudy and confirmed there was an odor. When asked if CNA #1 reported all concerns to a nurse she answered, Yes, to (name of Licensed Practical Nurse (LPN) #1). T. On 06/21/16 at 3:53 pm during interview with CNA #2, when asked what she remembered about R #1 she stated, I do remember her. She was quiet. She hardly said much but she didn't want to eat anything. She ate but not much, like a bird. She didn't like to drink a lot. When asked if CNA #2 reported this to a nurse, confirmed that she and CNA #1 both reported it to LPN #1. U. On 06/21/16 at 3:31 pm during interview with LPN #1, when explained R #1's condition from admission to discharge, in which the resident was admitted alert and oriented x4 and then staff began to see changes in condition such as altered mental status, decreased appetite, and dark cloudy urine. LPN #1 confirmed that this would be considered a significant change in condition. LPN #1 was also asked about the signs and symptoms of a UTI and stated, They would definitely have altered mental status or foul smelling urine or dark urine. V. On 06/22/16 at 9:37 am during interview with Social Services Director (SSD), when asked about her overall impression of R #1 she stated, She was out of it, asleep a lot. We needed to push her and try to wake her up. W. Record review of Nurses' Notes dated 04/01/16 documented at 1:58 pm revealed: R #1 was lethargic at 7:00 am. Her vital signs were - B/P: 115/51, P: 92, R: 20 and T: 99.4. The notes revealed that later Her (R #1) B/P dropped to 90/54 patient (pt) still lethargic, pt respond opens her eyes when calling her name. (Name of MD #1) notified and sent to (name of Hospital) ER (emergency room ) for EVAL & TX (evaluation and treatment). X. On 06/23/16 at 2:01 pm during interview with LPN #2 she recalled the events on 04/01/16 and confirmed, She (R #1) was lethargic. She continued to decline, mental status. I checked the B/P again and it was even lower and they (family) didn't want to send her to the hospital. I went and got (name of DON) so she could tell them. She (R #1) was continuing to decline and after (name of DON) told them that she really needed to go out they agreed. LPN #2 continued by stating, She (R #1) went from lethargic to not responding. She declined very fast so I was worried and she needed to go out. Y. Record review of Physician's Telephone Orders dated 04/01/16 revealed: R #1 was sent out to (Name of Hospital)'s ER for evaluation and treatment. This was noted by RN #1 at 2:00 pm. Z. On 06/22/16 at 8:41 am during interview with the DON recalled the events on 04/01/16 and stated, (Name of LPN #2) said there was a change, I went to look at her (R #1) and she was breathing and not responding to a sternal rub (painful stimulus technique to the breastbone for assessing the consciousness level of a person who is not responding to normal interaction, voice commands or shaking of the shoulders) and said we needed to send her out. AA. On 06/23/16 at 4:21 pm during interview with DON, explained R #1's condition from admission to discharge, in which the resident was admitted alert and oriented x4 and the staff began to see changes in condition such as altered mental status, decreased appetite, and dark cloudy urine. The DON confirmed, I would let the doctor know as soon as I notice a change. I would call the doctor and go from there - do whatever he ordered. When asked if she'd take vitals the DON stated, Yes, that's the only way I would know (there was a significant change). BB. On 06/23/16 at 11:14 am during interview with Assistant DON (ADON), explained R #1's condition from admission to discharge, in which the resident was admitted alert and oriented x4 and the staff began to see changes in condition such as altered mental status, decreased appetite, and dark cloudy urine. The ADON confirmed she would do a full assessment, take vitals, call the doctor, and if the doctor didn't take action then she would get the DON involved. She further stated, It wouldn't have gotten to day three. CC. Record review of the admitting hospital's Admission Notes dated 04/01/16 revealed: Originally (unresponsiveness) was thought to be narcotic induced as patient had just had a ORIF (open reduction internal fixation - an open surgery used to stabilize and heal a broken bone) of L (left) femur fracture here several days previous, however patient apparently was not being given any pain medications per the nursing home record, and did not respond to [MEDICATION NAME] (a medication used to arouse a person who is unconscious from narcotic medications) in the ED (emergency department). DD. Record review of the admitting hospital's H&P dated 04/01/16 revealed: Brief description of hospital course: (Name of R#1) who was recently discharged from our facility after an ORIF for a left [MEDICAL CONDITION], who was transferred from here to a skilled nursing facility and developed [MEDICAL CONDITION] and thus was transferred to the ICU (Intensive Care Unit - a special department of a hospital that provides intensive medical treatment). Diagnosis: [REDACTED]. Disposition at time of hospital discharge: Home with (Name of hospice company). Condition stable but overall poor prognosis.

Based on record review and interview, the facility failed to monitor, assess, and detect a decline in the condition for Resident #1 (R #1) requiring the physician to assess and plan her care. On 03/29/16 R #1 displayed a significant deterioration in mental and physical function. The facility staff failed to notify and consult R #1's physician until the fourth day on 04/01/16. R #1 had a Urinary Tract Infection [MEDICAL CONDITION] that went undetected and progressed into [MEDICAL CONDITION] with organ dysfunction (Sepsis - a life-threatening bacterial infection of the blood. [MEDICAL CONDITION] -[MEDICAL CONDITION] causing insufficient blood flow to the organs.)/Urosepsis (sepsis localized to the urinary tract system)/Acute Kidney Injury (a sudden decrease in kidney function), and also experienced unnecessary pain/discomfort while at the facility. Four residents (R #1-4) were reviewed for hospital transfers and recurring UTIs. The findings are: A. Record review of the hospital's Discharge/Transfer Final Report dated 03/28/16 revealed R #1 received an open reduction internal fixation (ORIF - an open surgery used to stabilize and heal a broken bone) on 03/20/16. Deterioration in mental/physical function: B. Record review of R #1's Admission Data Set (facility's baseline nursing assessment upon admission) dated 03/28/16 at 7:50 pm for skilled nursing services revealed: mental status of alert and oriented x4 (to person, place, time, and purpose). This document also revealed R #1's urine as yellow and clear with faint odor. Admit Vitals (03/28/16) - Blood Pressure (B/P): 122/68, Pulse (P): 74, Respirations (R): 20 and Temperature (T) 97.9. C. Record review of R #1's Face Sheet dated 03/28/16 revealed: Admitting diagnoses - Stress fracture of left femur (a crack in the left thigh bone resulting from stress or force), obesity, long term use of antibiotics, diabetes insipidus (a disorder of salt and water metabolism marked by intense thirst and heavy urination), history of blood clots, and major [MEDICAL CONDITION]. No diagnoses of dementia (loss of memory) or altered mental status upon admission. D. On 06/21/16 at 2:59 pm during interview with Certified Nursing Assistant (CNA) #1, when asked what she remembered about R #1 she answered, She was quiet and sleeping all the time. She would refuse for everything - food, liquids, everything. She didn't drink anything for days. CNA #1 was then asked if there was anything to note about R #1's urine she stated, It was dark yellow, cloudy and confirmed there was an odor. When asked if CNA #1 reported all concerns to a nurse she answered, Yes, to (name of Licensed Practical Nurse (LPN) #1). E On 06/21/16 at 3:53 pm during interview with CNA #2, when asked what she remembered about R #1 she stated, I do remember her. She was quiet. She hardly said much but she didn't want to eat anything. She ate but not much, like a bird. She didn't like to drink a lot. When asked if CNA #2 reported this to a nurse confirmed that she and CNA #1 both reported it to LPN #1. F. On 06/22/16 at 10:09 am, during interview with Registered Nurse (RN) #1 she recalled working with R #1 on 03/31/16 and stated, She was eating little bites only and drinking a little. She was in the bed sleeping most of the time. G. On 06/21/16 at 9:40 am during interview with Director of Nursing (DON), when asked about the process for skilled nursing services, she confirmed the staff are supposed to chart every shift and take vital signs. H. On 06/22/16 at 4:01 pm during phone interview with the Minimum Data Set (MDS) Coordinator, she was asked about the facility's policy on taking vitals and stated, We chart on all new admissions for 72 hours q (every) shift and must have admission vitals and then CMS (Center for Medicaid Services) requires weekly vitals. I. On 06/22/16 at 4:10 pm during interview with the DON, she was asked for R #1's vitals in the days between her admission and discharge and stated, I don't know, maybe if they aren't abnormal they get rid of them. The DON confirmed the vitals should be in the closed record and if not, they don't have them. J. On 06/23/16 at 9:09 am during interview with the MDS Coordinator, she was asked about a policy for taking vitals and charting every 72 hours for skilled residents (skilled services to include professional nursing care by a registered nurse, physical therapy, occupational therapy, social services, medications and other services necessary to the health of the resident) .and stated, I guess it is just verbal, I know we have always done it that way. I have been here since 2004. The MDS Coordinator confirmed there is no written policy. K. On 07/27/16 at 3:50 pm during interview, LPN #6 confirmed skilled residents should have their vitals taken and documented on every shift. LPN #6 explained that prior to Sunday (07/24/16) they would document all of the vitals in the computer system but now everything is on paper so they easily see any changes in condition. L. On 07/27/16 at 1:45 pm during interview, LPN #5 was asked about the protocol when a resident has a change in condition and confirmed he immediately alerts his CNA to go take the resident's vitals and LPN #5 will do a complete assessment. LPN #5 stated, If there is a change in behavior, I want to rule out a UTI so I will call the physician and report my findings and obtain orders if needed, such as a UA or if there's a problem with the lungs (we will do) an x-ray. I will try to handle it here to avoid sending them to the hospital. Altered mental status really gets my attention so pending circumstances and my assessment, I would send them out if it's something completely unusual for that resident. Each situation varies. When asked about documentation LPN #5 stated, I do an SBAR (Situation-Background-Assessment/Appearance-Request - a form used by nursing staff to document changes in condition) which is protocol for a change in condition. I put a copy in the chart under assessments and send a copy to the hospital if they go out so the treating physician has the information from my evaluation. The form is always used for a change in condition, not only when we send them to the hospital. It's used for the next nurse coming on shift so they are aware of the condition and the changes and what is being done for the resident. M. On 06/23/16 at 9:40 am during interview with Medical Director, she confirmed that nurses should be taking vital signs when a change in condition is noted. N. Record review of R #1's Medicare Note dated 03/29/16 revealed: Resident was lethargic in the early morning hours and as the day progressed she was up to her wheelchair and assessed by therapy. O. Record review of R #1's Occupational Therapy Evaluation & Plan of Treatment dated 03/29/16 revealed: Clinical impressions: Pt (Patient) is very confused and has poor awareness of environment. P. On 06/23/16 at 9:09 am during interview with MDS Coordinator, she confirmed meeting with R #1 on 03/29/16 and working R #1's hall on 03/30/16. MDS Coordinator stated, She (R #1) was very foggy and confused. Q. Record review of History and Physical (H&P) created by Medical Doctor (MD) #1 and dated 03/30/16 and electronically signed at 1:29 pm revealed: Eye contact is very poor. She (R #1) is uncommunicative. She is awake, gazes out into space, she does not speak despite my being persistent in questioning her. R. On 07/28/16 at 9:40 am during interview, MD #1 confirmed assessing R #1 on 03/30/16. When asked if he was there on rounds or for a specific reason he stated: No it was my usual rounding day. MD # 1 said she was very confused and he read his notes aloud from his H&P dated 03/30/16. MD #1 stated: If she experienced that much of a change in mental status from admission I would have sent her to the emergency room (ER) (on 03/30/16) since that would be a significant change in condition. When asked if any staff members alerted him after his visit about a change in condition for R #1, he only confirmed the call on 04/01/16 and stated, I do remember getting a call about a significant change in condition and that is when I told the staff to send her out to the hospital (on 04/01/16). MD #1 did not confirm receiving any reports of R #1 having foul smelling dark urine from any staff members. When asked what his expectations would be if nursing saw a significant change in condition MD #1 stated, I would expect them to call me. S. Record review of R #1's Soft Landing assessment (an assessment done by the facility's Activity Director for 3 days following admission) dated 03/29/16 through 03/31/16 revealed: A written note on 03/31/16 that reads, Unable to answer, very (underlined) confused, nurse doing UA. T. On 06/21/16 at 3:31 pm during interview with LPN #1, when explained R #1's condition from admission to discharge, in which the resident was admitted alert and oriented x4 and then staff began to see changes in condition such as altered mental status, decreased appetite, and dark cloudy urine. LPN #1 confirmed that this would be considered a significant change in condition. LPN #1 was also asked about the signs and symptoms of a UTI and stated, They would definitely have altered mental status or foul smelling urine or dark urine. U. Record review of Physician's Telephone Orders dated 03/30/16 hand written by MD#1 at time of examination 1:29 pm revealed: urinalysis (UA) with Culture and Sensitivity (C&S). V. Record review of the Laboratory Results Reported dated 04/01/16 revealed that the urinalysis (UA) was collected by the facility on 03/31/16 at 8:14 pm. The results were received on 04/01/16 at 11:03 am and reported the urine to be dark yellow and cloudy, elevated protein, high white blood cell count, positive for bacteria/culture indicated. W. On 07/27/16 at 1:49 pm during interview, the DON confirmed that if lab results for urine are abnormal the lab will immediately notify the facility by phone. The DON further confirmed that the nursing staff should then immediately notify the physician of the results. X. Record review of Nurses' Notes dated 04/01/16 documented at 1:58 pm revealed: R #1 was lethargic at 7:00 am. Her vital signs were - B/P: 115/51, P: 92, R: 20 and T: 99.4. The notes revealed that later Her (R #1) B/P dropped to 90/54 patient (pt) still lethargic, pt respond opens her eyes when calling her name. (Name of MD #1) notified and sent to (name of Hospital) ER (emergency room ) for EVAL & TX (evaluation and treatment). Y. Record review of Physician's Telephone Orders dated 04/01/16 revealed: R #1 was sent out to (Name of Hospital)'s ER for evaluation and treatment. This was noted by Registered Nurse (RN) #1 at 2:00 pm. Z. On 06/22/16 at 8:41 am during interview with the DON recalled the events on 04/01/16 and stated, (Name of LPN #2) said there was a change, I went to look at her (R #1) and she was breathing and not responding to a sternal rub and said we needed to send her out. AA. On 06/23/16 at 2:01 pm during interview with LPN #2 she recalled the events on 04/01/16 and confirmed, She (R #1) was lethargic. She continued to decline, mental status. I checked the B/P again and it was even lower and they (family) didn't want to send her to the hospital. I went and got (name of DON) so she could tell them. She (R #1) was continuing to decline and after (name of DON) told them that she really needed to go out they agreed. LPN #2 continued by stating, She (R #1) went from lethargic to not responding. She declined very fast so I was worried and she needed to go out. BB. On 06/22/16 at 11:23 am during interview with Family Member (FM) #2, he confirmed he was at the facility on the date R #1 was transferred to the ER and stated, I was concerned about her all the time but it wasn't until that morning (04/01/16) when I was really concerned. But it was up to the professionals - the charge nurse - to make the decision (to send her out to the hospital) and they did. CC. On 06/23/16 at 4:21 pm during interview with DON, she was briefed on R #1's condition from admission to discharge in which the resident was admitted alert and oriented x4 and the staff began to see changes in condition such as altered mental status, decreased appetite, and dark cloudy urine. The DON confirmed, I would let the doctor know as soon as I notice a change. I would call the doctor and go from there - do whatever he ordered. When asked if she'd take vitals the DON stated, Yes, that's the only way I would know (there was a significant change). DD. On 07/27/16 at 4:41 pm during interview, the DON confirmed the documentation on R #1 was unclear and stated, I see how we can make it (the documentation) more clear next time so that we can tell if a process is broken. The documentation isn't telling me clearly what happened (with R #1). EE. On 06/23/16 at 11:14 am during interview with Assistant DON (ADON), she was briefed on R #1's condition from admission to discharge, in which the resident was admitted alert and oriented x4 and the staff began to see changes in condition such as altered mental status, decreased appetite, and dark cloudy urine. The ADON confirmed she would do a full assessment, take vitals, call the doctor, and if the doctor didn't take action then she would get the DON involved. She further stated, (If I was the nurse) it wouldn't have gotten to day three. FF. Record review of the admitting hospital's H&P dated 04/01/16 revealed: Brief description of hospital course: (Name of R#1) who was recently discharged from our facility after an ORIF for a left [MEDICAL CONDITION], who was transferred from here to a skilled nursing facility and developed [MEDICAL CONDITION] and thus was transferred to the ICU (Intensive Care Unit - a special department of a hospital that provides intensive medical treatment). Diagnosis: [REDACTED]. Disposition at time of hospital discharge: Home with (Name of hospice company). Condition stable but overall poor prognosis. Pain: GG. Record review of Medicare Note written by LPN #4 dated 03/28/16 revealed Direct Skilled Nursing Services were to be provided for R #1 for pain management. HH. Record review of Medicare Note written by LPN #1 dated 03/29/16 revealed R #1 was experiencing a knowledge deficit (lack of understanding) R/T (related to) pain. II. Record review of R #1's Soft Landing assessment (an assessment done by the facility's Activity Director through asking the resident questions for 3 days following admission) dated 03/29/16 through 03/31/16 revealed a comment that R #1 stated she was in lots of pain and that her sleep was affected due to the pain. For 03/31/16 there is a line through R #1's entire assessment with a written note that reads: Unable to answer, very (underlined) confused, nurse doing UA. JJ. On 06/23/16 at 8:10 am during interview with the Activity Director (AD), she explained her Soft Landing program. When asked about R #1 the AD confirmed R #1 complained of pain and that R #1 self-identified pain relief as a level 2 - fair which means it really didn't cover the pain. The AD further confirmed she reported these significant changes to the DON and at the morning stand-up meeting on 03/31/16. KK. On 07/27/16 at 1:49 pm during interview, the DON confirmed, We meet with all the department heads at 8:30 each morning. (We) sit down and discuss new admits (and) anything else going on in the building. LL. Record review of R #1's physician's orders [REDACTED]. MM. On 06/22/16 at 10:09 am during interview and record review with Registered Nurse (RN) #1, RN #1 reviewed the MAR and confirmed that R #1 had an order for [REDACTED]. NN. Record review of R #1's telephone order from Occupational Therapy (OT) dated 03/29/16 revealed a plan for therapy to continue for 8 weeks to address pain. OO. Record review of R #1's Treatment Encounter Notes dated 03/30/16 and 04/01/16 revealed plans by Physical Therapy to reduce post-operative/post traumatic pain. PP. Record review of R #1's OT Evaluation & Plan of Treatment dated 03/29/16 revealed: Reason for Referral: Eval (evaluation) and tx (treatment) as indicated to address pain. Additional notes revealed R #1 was in pain when at rest at a level 3 on a 10-point scale (scale from 0 to 10 where 0 is the least pain and 10 is the most). R #1 was in constant pain at a level 7 on a 10-point scale (on the same 0-10 scale) with movement. QQ. Record review of PRN Flowsheet for [MEDICATION NAME] (pain reliever) and Other Medications created for R #1 revealed a blank sheet indicating R #1 did not receive any as needed (PRN) pain medications and her pain was not assessed during her stay by nursing staff. RR. On 06/22/16 at 8:12 am during interview with DON, she confirmed that R #1 was sent to the facility with an order for [REDACTED]. SS. Record review of all telephone orders and nursing notes dated 03/28/16 through 04/01/16 for R #1 revealed the physician was not notified of R #1's pain level and the staff did not request an order for [REDACTED]. TT. On 06/22/16 at 8:29 am during interview with DON, she provided the Admission Data Set, Medicare Notes, and Nurses' notes and confirmed that this is all of the documentation they have on R #1. UU. On 06/23/16 at 9:40 am during interview with the Medical Director, she was asked about the pain issue with R #1 and confirmed that if the hospital didn't prescribe pain medication, then it is up to the facility or nurse to contact the physician to request pain medication. The Medical Director confirmed that there is a physician on call 24 hours a day. VV. On 07/28/16 at 9:40 am during interview, MD #1 was asked about R #1's pain and stated, I don't know about that, but usually I rely on the nurse to call me if the medication ordered is not sufficient for the pain. I don't remember, but if they would have (notified me) I would have prescribed something stronger if the Tylenol was not sufficient for the pain. I don't see that I ordered anything else (for R #1). WW. Record review of the admitting hospital's Admission Notes dated 04/01/16 revealed: Originally (unresponsiveness) was thought to be narcotic induced as patient had just had a ORIF of L (left) femur fracture here several days previous, however patient apparently was not being given any pain medications per the nursing home record, and did not respond to [MEDICATION NAME] (a medication used to arouse a person who is unconscious from narcotic medications) in the ED (emergency department).

Based upon record review and interview during a complaint investigation related to falls, it was discovered that R #1 experienced a fall on [DATE] and sustained a fractured rib. Over the next 4 days, the facility failed to appropriately monitor the resident's status and provide needed interventions when the R #1's mental status and vital signs began to decline to the point of needing emergent medical interventions. The delay in treatment likely resulted in the resident's death. Following the incident, the facility did not identify root cause or contributions to the resident's decline and did not provide feedback and education to nursing staff to prevent any similar situations. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on [DATE] at 4:45pm.The facility Administrator was notified at this time. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 12:00 pm. Based on the plan, interventions included: 1. Staff working on this day were provided the information and topics included in the Plan of Removal 2. Changes in resident condition will be reported on the 24-hour report tool, discussed in IDT meetings, and interventions will occur as warranted. 3. The MD will be notified of any changes in condition for additional orders, diagnostic testing, follow-up and assessment/evaluation. Nurses will use their judgment involving emergency transport to acute care, even without an MD order, unless otherwise stated in the residents advance directive. The MD and responsible party will be notified following transport. 4. All oncoming staff will be inserviced on the center Stop and Watch (Early Intervention) principles related to informing the floor nurse of observed changes in the resident's condition. This will be included in New Hire orientation. 5. All oncoming nurses will be inserviced on change in condition agenda including: a. Documenting change in condition describing the change. b. Stop and Watch will be used to identify early warning signs of changes in condition. 6. Vital signs for all in-house residents have been taken and compared to baseline vitals and any negative findings will be reported to the MD immediately. Based on the Plan of Removal, the IJ was lifted. This resulted in the scope and severity being reduced from a J to Level 2, Scope D. Based on record review and interview, the facility failed to consult with the physician when 1 (R #1) of 4 (R #1, 2, 3 and 4) residents reviewed for falls, continued to have a decrease in blood pressure and oxygenation (amount of oxygen in a person's blood) and increase lethargy (drowsy) and change in mental status on [DATE] after interventions ([MEDICATION NAME] (medication used to treat the side effects of opioids, opioid overdose, and septic shock)) were implemented. By not notifying the physician of a lack of improvement after an intervention was provided, this deficient practice likely resulted in a delay in treatment and R #1's death. The findings are: A. Record review of Departmental Nursing Notes dated [DATE] revealed, At approximately 1250 pm, (name of staff member #1) in activities called my attention to a fall in room [ROOM NUMBER]A, on arriving I found (name of R #1) on the floor slanted towards the right side. I got him up to the wheelchair and asked him what happened. He said he was trying to put off the overhead light and fell because he couldn't support himself with his right hand in a splint. Resident refused hitting his head and reported pain in his lower back. Resident was otherwise stable and vital signs was ,[DATE] (blood pressure), T (temperature) 97.5 (Fahrenheit), P (pulse) 80, O2 (oxygen saturation in blood) 93%, R (respirations) 19. Pain was rated at ,[DATE], and 650 mg (milligrams) of Tylenol was given and one hour later was ,[DATE] (pain rating) .resident later opted for X-ray because of unrelieved pain . B. Record review of Radiology Interpretation dated [DATE] revealed that R #1 had a fractured rib. C. Record review of physician progress notes [REDACTED].#1 dated [DATE] revealed, Vital signs are stable. He is alert, cooperative, with clear speech .He is in no acute distress .Reparations (sic) (respirations) are normal, unlabored .no abnormal breath sounds are auscultated (heard). No pleural friction rubs (sounds when there is fluid in the lungs) or wheezing present . D. Record review of Departmental Nursing Notes reveled: 1. On [DATE] F/U fall [DATE] resident was complaining of pain to right rib area on [DATE] was examined by in house PA (PA #1) X-ray ordered to right chest 3 View the AP (front and back) view of chest with acute [MEDICAL CONDITION] 10th rib, Results called to MD (medical doctor #1) @ (at) 0625 (6:25 am) who gave no further orders but to keep residents pain in control with PRN (as needed) [MEDICATION NAME] (Opioid pain reliever) or [MEDICATION NAME] (Pain reliever) which was ordered on the previous day by PA (PA #1) . 2. On [DATE] Resident up with PT (physical therapy) today in chair and WC (wheel chair), refused breakfast but had lunch and dinner. Pain right rib cage area well controlled with [MEDICATION NAME] q (every) 6 hrs (hours) scheduled order. Right arm in sling, [MEDICATION NAME] (pain patch) to right shoulder, with positive relief of pain. 3. On [DATE] at 11:41 am Nurses Note: (name of R#1) was very somulent (sic) (drowsy) this morning. He was unable to articulate words. (Name of MD #1) ASSESSED him and decided to take him off routine [MEDICATION NAME] and to give him [MEDICATION NAME]. Vital signs as follows: BP (blood pressure) ,[DATE] P (pulse) 86 R (respirations) 16. O2 sat (oxygen saturation in the blood) to room air was 77% and on o2 at 3 liters it read at 88% at noon his was able to take his medications and swallowed without difficulty. More alert and able to answers yes and no questions. [MEDICATION NAME] ordered from pharmacy. I will give him the [MEDICATION NAME] as soon as it comes in. No congestion noted. His skin is pink warm, dry and intact. Has a sling on his left arm . E. Record review of physician progress notes [REDACTED]. He is sleeping but easily arousable but falls back to sleep when he stopped talking to him .Respiratory: .the breath sounds are diminished at both bases .Plan: .2. Give opiate [MEDICATION NAME] ([MEDICATION NAME]) when necessary moderate to severe pain. 3. [MEDICATION NAME] 0.4 mg (milligram) IM (intramuscular) x 1 dose . F. Record review of Physician Telephone Orders dated [DATE] revealed, 1- Give [MEDICATION NAME] on PRN (as needed) basis only for moderate to severe pain; otherwise, use Tylenol as ordered. 2- Vital signs TID (three times a day) x 1 wk then daily QAM (every morning) 4- Encourage po (by mouth) fluid intake when he's back to his pre-lethargic (pre-drowsy) state G. Record review of Departmental Notes dated [DATE] at 6:36 pm revealed, Nurses Note: I (RN #2) gave him [MEDICATION NAME] 0.4 mg IM (Intramuscular) on his left thigh at 11:30 and he was more alert a few min (minutes) after. He had two emesis (vomiting) of yellow colar (sic) emesis and I gave him [MEDICATION NAME] (medication to decrease nausea and vomiting) and the emesis subsided. His O2 sat is still low at 81% to o2 at 5 liters. BP ,[DATE]. P 106. T 97.3. more alert and able to answer questions. H. Record review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) dated [DATE] to [DATE] revealed vital signs in the following order: Temperature, Blood Pressure, Pulse, Respiration and Oxygen Saturation (in the blood): 1. [DATE]: 97.6 (Fahrenheit temperature), ,[DATE] (Blood Pressure), 60 (Pulse), 20 (Respiration), 95% (Oxygen Saturation) on room air (RA) 2. [DATE]: 97.7, ,[DATE], 72, 20, 92% RA 3. [DATE]: 96.7, ,[DATE], 76, 20, 98% RA 4. [DATE]: 98.6, ,[DATE], 80, 18, 92% RA 5. [DATE]: 98.1, ,[DATE], 83, 18, 92% RA 6. [DATE]: 97.4, ,[DATE], 74, 18, 96% RA 7. [DATE]: 97.3, ,[DATE], 86, 16, 93% RA 8. [DATE]: 97.6, ,[DATE], 86, 16, 87% (with supplemental oxygen) 9. [DATE]: 97.4, ,[DATE], 99, 16, 87% (with supplemental oxygen) I. Record review of Departmental Notes revealed: 1. On [DATE] at 1:04 pm, Change in Condition: Resident very lethargic since start of my shift at 6AM this morning. Had respiratory depression yesterday due to [MEDICATION NAME] ,[DATE], given [MEDICATION NAME]. Vitals signs improving from yesterdays, but o2 still <90 on %LNC (Liters Nasal Cannula). Hasn't been able to eat today and have difficulty verbalizing needs. Family is worried and wants him to be transferred to the hospital. MD notified and approved transfer. Vitals signs are as follows; 97.4, ,[DATE], 99, 18, o2 87% 5LNC. 2. On [DATE] 8:31 am Discharge summary: Resident was discharged to (name of Hospital (H) #1) on [DATE] per family's request. Resident is anticipated to return. J. Record review of Admission Notes from H #1 dated [DATE] revealed, HISTORY: This [AGE] year-old male .was admitted to this institution [DATE] for altered mental status, [MEDICAL CONDITION], and hypoxemia. The patient had a history of [REDACTED]. He had been at a skilled nursing facility/rehab facility since that time .On admission to the emergency room , the patient was delirious. Further medical evaluation revealed the patient had a type 2 non-STEMI ([MEDICAL CONDITION]), septic shock, hypercapnic [MEDICAL CONDITION] (arterial oxygen and/or carbon [MEDICATION NAME] levels are not maintained in normal ranges) with acute kidney failure. The patient was taken to critical care unit, where he has remained until today. He was intubated (breathing tube inserted) and given maximal medical support. The patient has now been exubated (breathing tube removed). He is off pressors (blood pressure medication). He is confused but following simple commands and answering simple questions mostly in Spanish. He has profound dysphagia (inability to swallow) and is unable to swallow more than a sip or two of liquid .PLAN: 1. Admit to Inpatient Hospice . K. Record review of Discharge-Transfer Documentation dated [DATE] at 4:09 pm revealed, Condition on Discharge: expired L. On [DATE] at 3:25 pm during and interview with MD #1, when asked what happened on [DATE] with R #1, he stated, The best of my recollection, they gave him the [MEDICATION NAME] and he was back to the way he was before he was lethargic, and then the family wanted him to go to the hospital. MD #1 confirmed that he only contacted by the facility when the order for [MEDICATION NAME] was given and when the family requested R#1 to be taken to the emergency room in the afternoon of [DATE]. He confirmed that at no other time was he contacted by the facility for R #1. M. On [DATE] at 9:45 am during an interview with Family Member (FM) #1, when asked if he could tell me what happened with R #1 on and before [DATE], he stated, I kept in touch calling there (facility). From my understanding he fell and broke some ribs. He requested to go to the hospital, and they said he couldn't go to the hospital because they couldn't do anything for him. His roommate told us that he wanted to go to the hospital. My sister and I were surprised. From day one that he broke his rib, it went downhill from there. His roommate requested that we don't tell anyone what happened because there would be retaliation. I thought they had changed his medication ([MEDICATION NAME]) after they thought it didn't work and he got so drowsy on it. That's what they said they did. When we went to (name of H #1) the cardiologist said that he had a [MEDICAL CONDITION]. When my sister came to see him (On [DATE] in the nursing facility), he was gray and not talking and she immediately ran to the nurses and told them he needs to go to the ER. They said that they were thinking of sending him, but they didn't send him. You think! He wasn't ok! They are nurses, and they should know to send him if he looks like that and he wasn't breathing well. His roommate even thought he should go and they didn't send him. I don't know if the outcome would have been any different, but if they had acted when they should have, it could have been. We can't know that. People go (die) when they have to, but we want to make sure this doesn't happen to someone else. That is all that we want. N. On [DATE] at 11:40 am during an interview with Registered Nurse (RN) #1 when asked what had happened with R #1 on [DATE], he stated, I took care of him the week before (the fall) and I saw him different (lethargic after the fall) from when I took care of him. I reported to the doctor that we needed to send him out. They said because he was on pain meds, he was drowsy. We gave him [MEDICATION NAME] and he responded to that and his sats (O2 saturation) improved after that. I guess he continued to get better. His sats were low, but he was doing better. I contacted the family that day ([DATE]) and I let them know what was going on. (Name of RN #2), the next day contacted the family because he was still not the same. With the help of the family, we decided to send him out. RN #1 confirmed that he gave the [MEDICATION NAME] one hour after it was ordered R #1's blood pressure and oxygen saturation improved, but were still lower than normal range (safe levels) for R #1. RN #1 confirmed that R #1 was vomiting in the morning of [DATE]. When asked if he suggested to send the resident to the emergency room , he stated, It wasn't a sense of urgency, but I knew something needed to be done. He confirmed that he considered sending him out that morning, but he needed a doctor's order to do so. He stated, The doctor was there (at the facility on [DATE]), so we couldn't send him out. We do what the doctor orders. When asked if there were any in services or education after the incident occurred, he confirmed that he received no in service or educations. O. On [DATE] at 11:55 am during interview with LPN #2, he confirmed that he had not received any inservices or education after [DATE]. When asked if he has the authority to call an ambulance if a resident needs, LPN #2 stated Yes, definitely. I can call the ambulance, if it is something I can't take care of here. P. On [DATE] at 12:04 pm during an interview with Nurse Practitioner #1, when asked if she can explain what the signs and symptoms one may see in someone having a [MEDICAL CONDITION], she stated, You may not see anything. You may see increased fatigue, changes in normal status, more lethargic, general chest discomfort. Anyone that is with it, they most likely have typical symptoms. Men present with more symptoms, normally. With vital signs, you may see no changes, big changes, tachy (increased heart rate), irregularities in heart rate, blood pressure can go down or up. The most important thing is to learn the residents so you can see those changes. When asked if someone may have nausea and vomiting related to a [MEDICAL CONDITION], she confirmed that they could. When asked if she had a resident presenting with the following vital signs: BP ,[DATE] P 86 R 16 and O2 sat to room air was 77% and on O2 at 3 liters it read at 88% (R #1's vital signs on [DATE]) She stated, I would send them out (to the emergency room ). When asked if the resident was given [MEDICATION NAME] and the vital signs improved, but were still out of range, what would she think, she stated, I would say that it improved because of the [MEDICATION NAME]. When asked if the resident presented the same way the next day, what would she do, she stated, I would have sent them out to begin with. I have an emergency medicine background, and I always assume the worst, especially if I know the patient. I question the care here and whether they know what they are doing. If I saw vital signs like this, I would assume the person has a PE (pulmonary embolism (blood clot in the lungs)), or is having an OD (over dose). With an OD, you would see the pulse drop. In this case, it was tachy (increased heart rate), I think that would point to something else. Q. On [DATE] at 3:45 pm during interview with R #5 (Roommate for R #1), he stated that after the fall, He looked terrible. He was unresponsive a lot. I knew something was wrong but I was told to not get involved. When the ambulance came to pick him up ([DATE]) and they took him away, he had his head down to the bed. I knew he was here to recover from a stroke and that he was doing real well up until the fall. I never really saw that the nurses were doing more for him after the fall. He would moan and groan everytime he moved and at night he would cry out in pain after the fall. R. On [DATE] at 4:20 pm during interview with the Administrator, he stated that he provided inservices to staff at stand up regarding stop and watch, what to do in an emergency situation, change of condition, and SBAR (Situaltion Background Assessment Reccomendation) {way to communicate from staff to staff). When asked, the Administrator confirmed that he provided these educations to RN #1 and RN #2 (Both nurses denied ever receiving training post [DATE]. See Finding N and T). S. At [DATE] on 8:35 am during an interview with Corporate Registered Nurse (CRN #1), she stated, I know as a nurse that you can make the call if the doctor isn't making the decisions needed. I definitely saw what you all were seeing. She confirmed that she saw the documentation on the incident, and it was not clear why they did not send him to the emergency room sooner. She stated, I see why you called it (the Immediate Jeopardy). As a nurse, you don't need an order to send someone out. T. On [DATE] at 9:32 am during an interview with RN #2, when asked what happened with R #1 from the time he came on shift on [DATE] until the R #1 was sent to the emergency room (ER), he stated, When I came on, I got report that he (R#1) is not feeling ok. So I didn't go physically assess him because he was still in bed. The nurse (Licensed Practical Nurse (LPN) #1) told me that the doctor didn't want to send him out. When I finally got to him, he wasn't looking good from the last time I saw him 3 days ago. I looked at him and contemplating sending him out. He wasn't eating, and couldn't take meds (medications). His family came in about 30 minutes after I saw him. The daughter asked me how he was and what I think. I told her he didn't look good and I think he should go out and she thought he needed to go out. I called the ambulance. I didn't do any nursing care with him that morning. When asked how soon after report he assessed R #1, he confirmed that he did not do an assessment or nursing care on him because he thought he was sleeping. When asked if the LPN #1 had given him a report of what had happened to the resident the day prior, he confirmed that he knew that the resident had fallen, and he was not doing well, but he did not get specifics about what had happened. He stated, What I do know is that the doctor saw him and didn't want to send him out, I didn't investigate further. The nurse (LPN #1) said she thought he should go out (in morning report). When asked if a nurse can call an ambulance without a doctors order, he confirmed that they can if they feel it is emergent. When asked if he received any report that R # 1 should be more closely monitored because of his condition the day prior, he confirmed that he got the residents vital signs once and no one had mentioned frequent monitoring. When asked if the resident's oxygen saturation (oxygen level in the blood) was low when he checked his vitals, he confirmed that his O2 sat was still lower than normal (below 90%) and that the resident was on oxygen. When asked if he received any in services, trainings or education after this incident happened, he confirmed that he did not get any in services or trainings. U. Record review of Nursing Services Policy and Procedure Manual: Making an Emergency Transfer or discharge date d 2001, revised [DATE] revealed Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident.

Based upon record review and interview during a complaint investigation related to falls, it was discovered that R #1 experienced a fall on [DATE] and sustained a fractured rib. Over the next 4 days, the facility failed to appropriately monitor the resident's status and provide needed interventions when the R #1's mental status and vital signs began to decline to the point of needing emergent medical interventions. The delay in treatment likely resulted in the resident's death. Following the incident, the facility did not identify root cause or contributions to the resident's decline and did not provide feedback and education to nursing staff to prevent any similar situations. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on [DATE] at 4:45pm.The facility Administrator was notified at this time. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 12:00 pm. Based on the plan, interventions included: 1. Staff working on this day were provided the information and topics included in the Plan of Removal 2. Changes in resident condition will be reported on the 24-hour report tool, discussed in IDT meetings, and interventions will occur as warranted. 3. The MD will be notified of any changes in condition for additional orders, diagnostic testing, follow-up and assessment/evaluation. Nurses will use their judgment involving emergency transport to acute care, even without an MD order, unless otherwise stated in the residents advance directive. The MD and responsible party will be notified following transport. 4. All oncoming staff will be inserviced on the center Stop and Watch (Early Intervention) principles related to informing the floor nurse of observed changes in the resident's condition. This will be included in New Hire orientation. 5. All oncoming nurses will be inserviced on change in condition agenda including: a. Documenting change in condition describing the change. b. Stop and Watch will be used to identify early warning signs of changes in condition. 6. Vital signs for all in-house residents have been taken and compared to baseline vitals and any negative findings will be reported to the MD immediately. Based on the Plan of Removal, the IJ was lifted. This resulted in the scope and severity being reduced from a J to Level 2, Scope D. Based on record review and interview, the facility failed to ensure that 1 (R #1) of 4 (R #1, 2, 3 and 4) residents reviewed for falls received the necessary services to maintain the highest practicable well-being by: 1. Not identifying that R #1's decrease in blood pressure and oxygenation (amount of oxygen in a person's blood) and increase lethargy (drowsy) and change in mental status on [DATE] required emergency medical treatment. 2. Not consulting with the physician on [DATE] after R #1 received [MEDICATION NAME] (medication used to treat the side effects of opioids, opioid overdose, and septic shock). and his blood pressure and oxygenation was below safe levels. By not identifying changes in a residents condition or notifying the physician of a lack of improvement after an intervention was provided it, this deficient practice likely resulted in a delay in treatment and R #1's death. The findings are: A. Record review of Departmental Nursing Notes dated [DATE] revealed, At approximately 1250 pm, (name of staff member #1) in activities called my attention to a fall in room [ROOM NUMBER]A, on arriving I found (name of R #1) on the floor slanted towards the right side. I got him up to the wheelchair and asked him what happened. He said he was trying to put off the overhead light and fell because he couldn't support himself with his right hand in a splint. Resident refused hitting his head and reported pain in his lower back. Resident was otherwise stable and vital signs was ,[DATE] (blood pressure), T (temperature) 97.5 (Fahrenheit), P (pulse) 80, O2 (oxygen saturation in blood) 93%, R (respirations) 19. Pain was rated at ,[DATE], and 650 mg (milligrams) of Tylenol was given and one hour later was ,[DATE] (pain rating) .resident later opted for X-ray because of unrelieved pain . B. Record review of Radiology Interpretation dated [DATE] revealed that R #1 had a fractured rib. C. Record review of physician progress notes [REDACTED].#1 dated [DATE] revealed, Vital signs are stable. He is alert, cooperative, with clear speech .He is in no acute distress .Reparations (sic) (respirations) are normal, unlabored .no abnormal breath sounds are auscultated (heard). No pleural friction rubs (sounds when there is fluid in the lungs) or wheezing present . D. Record review of Departmental Nursing Notes revealed: 1. On [DATE] F/U fall [DATE] resident was complaining of pain to right rib area on [DATE] was examined by in house PA (PA #1) X-ray ordered to right chest 3 View the AP (front and back) view of chest with acute [MEDICAL CONDITION] 10th rib, Results called to MD (medical doctor #1) @ (at) 0625 (6:25 am) who gave no further orders but to keep residents pain in control with PRN (as needed) [MEDICATION NAME] (Opioid pain reliever) or [MEDICATION NAME] (Pain reliever) which was ordered on the previous day by PA (PA #1) . 2. On [DATE] Resident up with PT (physical therapy) today in chair and WC (wheel chair), refused breakfast but had lunch and dinner. Pain right rib cage area well controlled with [MEDICATION NAME] q (every) 6 hrs (hours) scheduled order. Right arm in sling, [MEDICATION NAME] (pain patch) to right shoulder, with positive relief of pain. 3. On [DATE] at 11:41 am Nurses Note: (name of R#1) was very somulent (sic) (drowsy) this morning. He was unable to articulate words. (Name of MD #1) ASSESSED him and decided to take him off routine [MEDICATION NAME] and to give him [MEDICATION NAME]. Vital signs as follows: BP (blood pressure) ,[DATE] P (pulse) 86 R (respirations) 16. O2 sat (oxygen saturation in the blood) to room air was 77% and on o2 at 3 liters it read at 88% at noon his was able to take his medications and swallowed without difficulty. More alert and able to answers yes and no questions. [MEDICATION NAME] ordered from pharmacy. I will give him the [MEDICATION NAME] as soon as it comes in. No congestion noted. His skin is pink warm, dry and intact. Has a sling on his left arm . E. Record review of physician progress notes [REDACTED]. He is sleeping but easily arousable but falls back to sleep when he stopped talking to him .Respiratory: .the breath sounds are diminished at both bases .Plan: .2. Give opiate [MEDICATION NAME] ([MEDICATION NAME]) when necessary moderate to severe pain. 3. [MEDICATION NAME] 0.4 mg (milligram) IM (intramuscular) x 1 dose . F. Record review of Physician Telephone Orders dated [DATE] revealed, 1- Give [MEDICATION NAME] on PRN (as needed) basis only for moderate to severe pain; otherwise, use Tylenol as ordered. 2- Vital signs TID (three times a day) x 1 wk then daily QAM (every morning) 4- Encourage po (by mouth) fluid intake when he's back to his pre-lethargic (pre-drowsy) state G. Record review of Departmental Notes dated [DATE] at 6:36 pm revealed, Nurses Note: I (RN #2) gave him [MEDICATION NAME] 0.4 mg IM (Intramuscular) on his left thigh at 11:30 and he was more alert a few min (minutes) after. He had two emesis (vomiting) of yellow colar (sic) emesis and I gave him [MEDICATION NAME] (medication to decrease nausea and vomiting) and the emesis subsided. His O2 sat is still low at 81% to o2 at 5 liters. BP ,[DATE]. P 106. T 97.3. more alert and able to answer questions. H. Record review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) dated [DATE] to [DATE] revealed vital signs in the following order: Temperature, Blood Pressure, Pulse, Respiration and Oxygen Saturation (in the blood): 1. [DATE]: 97.6 (Fahrenheit temperature), ,[DATE] (Blood Pressure), 60 (Pulse), 20 (Respiration), 95% (Oxygen Saturation) on room air (RA) 2. [DATE]: 97.7, ,[DATE], 72, 20, 92% RA 3. [DATE]: 96.7, ,[DATE], 76, 20, 98% RA 4. [DATE]: 98.6, ,[DATE], 80, 18, 92% RA 5. [DATE]: 98.1, ,[DATE], 83, 18, 92% RA 6. [DATE]: 97.4, ,[DATE], 74, 18, 96% RA 7. [DATE]: 97.3, ,[DATE], 86, 16, 93% RA 8. [DATE]: 97.6, ,[DATE], 86, 16, 87% (with supplemental oxygen) 9. [DATE]: 97.4, ,[DATE], 99, 16, 87% (with supplemental oxygen) I. Record review of Departmental Notes revealed: 1. On [DATE] at 1:04 pm, Change in Condition: Resident very lethargic since start of my shift at 6AM this morning. Had respiratory depression yesterday due to [MEDICATION NAME] ,[DATE], given [MEDICATION NAME]. Vitals signs improving from yesterdays, but o2 still <90 on %LNC (Liters Nasal Cannula). Hasn't been able to eat today and have difficulty verbalizing needs. Family is worried and wants him to be transferred to the hospital. MD notified and approved transfer. Vitals signs are as follows; 97.4, ,[DATE], 99, 18, o2 87% 5LNC. 2. On [DATE] 8:31 am Discharge summary: Resident was discharged to (name of Hospital (H) #1) on [DATE] per family's request. Resident is anticipated to return. J. Record review of Admission Notes from H #1 dated [DATE] revealed, HISTORY: This [AGE] year-old male .was admitted to this institution [DATE] for altered mental status, [MEDICAL CONDITION], and hypoxemia. The patient had a history of [REDACTED]. He had been at a skilled nursing facility/rehab facility since that time .On admission to the emergency room , the patient was delirious. Further medical evaluation revealed the patient had a type 2 non-STEMI ([MEDICAL CONDITION]), septic shock, hypercapnic [MEDICAL CONDITION] (arterial oxygen and/or carbon [MEDICATION NAME] levels are not maintained in normal ranges) with acute kidney failure. The patient was taken to critical care unit, where he has remained until today. He was intubated (breathing tube inserted) and given maximal medical support. The patient has now been exubated (breathing tube removed). He is off pressors (blood pressure medication). He is confused but following simple commands and answering simple questions mostly in Spanish. He has profound dysphagia (inability to swallow) and is unable to swallow more than a sip or two of liquid .PLAN: 1. Admit to Inpatient Hospice . K. Record review of Discharge-Transfer Documentation dated [DATE] at 4:09 pm revealed, Condition on Discharge: expired L. On [DATE] at 3:25 pm during and interview with MD #1, when asked what happened on [DATE] with R #1, he stated, The best of my recollection, they gave him the [MEDICATION NAME] and he was back to the way he was before he was lethargic, and then the family wanted him to go to the hospital. MD #1 confirmed that he only contacted by the facility when the order for [MEDICATION NAME] was given and when the family requested R#1 to be taken to the emergency room in the afternoon of [DATE]. He confirmed that at no other time was he contacted by the facility for R #1. M. On [DATE] at 9:45 am during an interview with Family Member (FM) #1, when asked if he could tell me what happened with R #1 on and before [DATE], he stated, I kept in touch calling there (facility). From my understanding he fell and broke some ribs. He requested to go to the hospital, and they said he couldn't go to the hospital because they couldn't do anything for him. His roommate told us that he wanted to go to the hospital. My sister and I were surprised. From day one that he broke his rib, it went downhill from there. His roommate requested that we don't tell anyone what happened because there would be retaliation. I thought they had changed his medication ([MEDICATION NAME]) after they thought it didn't work and he got so drowsy on it. That's what they said they did. When we went to (name of H #1) the cardiologist said that he had a [MEDICAL CONDITION]. When my sister came to see him (On [DATE] in the nursing facility), he was gray and not talking and she immediately ran to the nurses and told them he needs to go to the ER. They said that they were thinking of sending him, but they didn't send him. You think! He wasn't ok! They are nurses, and they should know to send him if he looks like that and he wasn't breathing well. His roommate even thought he should go and they didn't send him. I don't know if the outcome would have been any different, but if they had acted when they should have, it could have been. We can't know that. People go (die) when they have to, but we want to make sure this doesn't happen to someone else. That is all that we want. N. On [DATE] at 11:40 am during an interview with Registered Nurse (RN) #1 when asked what had happened with R #1 on [DATE], he stated, I took care of him the week before (the fall) and I saw him different (lethargic after the fall) from when I took care of him. I reported to the doctor that we needed to send him out. They said because he was on pain meds, he was drowsy. We gave him [MEDICATION NAME] and he responded to that and his sats (O2 saturation) improved after that. I guess he continued to get better. His sats were low, but he was doing better. I contacted the family that day ([DATE]) and I let them know what was going on. (Name of RN #2), the next day contacted the family because he was still not the same. With the help of the family, we decided to send him out. RN #1 confirmed that he gave the [MEDICATION NAME] one hour after it was ordered R #1's blood pressure and oxygen saturation improved, but were still lower than normal range (safe levels) for R #1. RN #1 confirmed that R #1 was vomiting in the morning of [DATE]. When asked if he suggested to send the resident to the emergency room , he stated, It wasn't a sense of urgency, but I knew something needed to be done. He confirmed that he considered sending him out that morning, but he needed a doctor's order to do so. He stated, The doctor was there (at the facility on [DATE]), so we couldn't send him out. We do what the doctor orders. When asked if there were any in services or education after the incident occurred, he confirmed that he received no in service or educations. O. On [DATE] at 11:55 am during interview with LPN #2, he confirmed that he had not received any inservices or education after [DATE]. When asked if he has the authority to call an ambulance if a resident needs, LPN #2 stated Yes, definitely. I can call the ambulance, if it is something I can't take care of here. P. On [DATE] at 12:04 pm during an interview with Nurse Practitioner #1, when asked if she can explain what the signs and symptoms one may see in someone having a [MEDICAL CONDITION], she stated, You may not see anything. You may see increased fatigue, changes in normal status, more lethargic, general chest discomfort. Anyone that is with it, they most likely have typical symptoms. Men present with more symptoms, normally. With vital signs, you may see no changes, big changes, tachy (increased heart rate), irregularities in heart rate, blood pressure can go down or up. The most important thing is to learn the residents so you can see those changes. When asked if someone may have nausea and vomiting related to a [MEDICAL CONDITION], she confirmed that they could. When asked if she had a resident presenting with the following vital signs: BP ,[DATE] P 86 R 16 and O2 sat to room air was 77% and on O2 at 3 liters it read at 88% (R #1's vital signs on [DATE]) She stated, I would send them out (to the emergency room ). When asked if the resident was given [MEDICATION NAME] and the vital signs improved, but were still out of range, what would she think, she stated, I would say that it improved because of the [MEDICATION NAME]. When asked if the resident presented the same way the next day, what would she do, she stated, I would have sent them out to begin with. I have an emergency medicine background, and I always assume the worst, especially if I know the patient. I question the care here and whether they know what they are doing. If I saw vital signs like this, I would assume the person has a PE (pulmonary embolism (blood clot in the lungs)), or is having an OD (over dose). With an OD, you would see the pulse drop. In this case, it was tachy (increased heart rate), I think that would point to something else. Q. On [DATE] at 3:45 pm during interview with R #5 (Roommate for R #1), he stated that after the fall, He looked terrible. He was unresponsive a lot. I knew something was wrong but I was told to not get involved. When the ambulance came to pick him up ([DATE]) and they took him away, he had his head down to the bed. I knew he was here to recover from a stroke and that he was doing real well up until the fall. I never really saw that the nurses were doing more for him after the fall. He would moan and groan everytime he moved and at night he would cry out in pain after the fall. R. On [DATE] at 4:20 pm during interview with the Administrator, he stated that he provided inservices to staff at stand up regarding stop and watch, what to do in an emergency situation, change of condition, and SBAR (Situaltion Background Assessment Reccomendation) {way to communicate from staff to staff). When asked, the Administrator confirmed that he provided these educations to RN #1 and RN #2 (Both nurses denied ever receiving training post [DATE]. See Finding N and T). S. At [DATE] on 8:35 am during an interview with Corporate Registered Nurse (CRN #1), she stated, I know as a nurse that you can make the call if the doctor isn't making the decisions needed. I definitely saw what you all were seeing. She confirmed that she saw the documentation on the incident, and it was not clear why they did not send him to the emergency room sooner. She stated, I see why you called it (the Immediate Jeopardy). As a nurse, you don't need an order to send someone out. T. On [DATE] at 9:32 am during an interview with RN #2, when asked what happened with R #1 from the time he came on shift on [DATE] until the R #1 was sent to the emergency room (ER), he stated, When I came on, I got report that he (R#1) is not feeling ok. So I didn't go physically assess him because he was still in bed. The nurse (Licensed Practical Nurse (LPN) #1) told me that the doctor didn't want to send him out. When I finally got to him, he wasn't looking good from the last time I saw him 3 days ago. I looked at him and contemplating sending him out. He wasn't eating, and couldn't take meds (medications). His family came in about 30 minutes after I saw him. The daughter asked me how he was and what I think. I told her he didn't look good and I think he should go out and she thought he needed to go out. I called the ambulance. I didn't do any nursing care with him that morning. When asked how soon after report he assessed R #1, he confirmed that he did not do an assessment or nursing care on him because he thought he was sleeping. When asked if the LPN #1 had given him a report of what had happened to the resident the day prior, he confirmed that he knew that the resident had fallen, and he was not doing well, but he did not get specifics about what had happened. He stated, What I do know is that the doctor saw him and didn't want to send him out, I didn't investigate further. The nurse (LPN #1) said she thought he should go out (in morning report). When asked if a nurse can call an ambulance without a doctors order, he confirmed that they can if they feel it is emergent. When asked if he received any report that R # 1 should be more closely monitored because of his condition the day prior, he confirmed that he got the residents vital signs once and no one had mentioned frequent monitoring. When asked if the resident's oxygen saturation (oxygen level in the blood) was low when he checked his vitals, he confirmed that his O2 sat was still lower than normal (below 90%) and that the resident was on oxygen. When asked if he received any in services, trainings or education after this incident happened, he confirmed that he did not get any in services or trainings. U. Record review of Nursing Services Policy and Procedure Manual: Making an Emergency Transfer or discharge date d 2001, revised [DATE] revealed Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident.

Immediate Jeopardy related to Smoking: During observation of residents smoking on 07/21/15 and 07/23/15, R #10 and 101 were observed to display unsafe smoking practices when R #101 was extinguishing cigarettes on his pants, throwing a cigarette butt in a planter and dropping ashes on himself. R #10 was observed to drop ashes on himself while smoking. There was no staff supervision during these observations. This resulted in an Immediate Jeopardy (IJ) situation being called at a scope and severity (S&S) level K. The Director of Nursing (DON) was informed of the IJ on 07/23/15 at 4:08 pm. At 7:42 pm, the first plan of removal (POR) was received and was rejected at 8:10 pm. At 8:30 pm, a second POR was received and was accepted at 8:40 pm. The POR included performing new safe smoking assessment for residents (R #10, 73, 99 & 101), re-educating the four residents and the facility staff on the facility's smoking Policy and Procedure (P&P) and implementing a supervisory smoking schedule for residents who have been deemed incapable of independent smoking. At this time the S&S was lowered to a E. On 07/23/15 after the facility was informed of the IJ, R # 10, 73, 99 and 101, were re-assessed for safe smoking and were deemed capable of smoking independently. On 07/28/15 during an observation of resident smoking, R #10 was on the smoking patio. The resident was sleeping while holding a lighter and a lit pipe in his hand. There was no staff supervision or intervention at this time. This resulted in the IJ being re-instated at S&S level J, on 07/28/15 at 4:29 pm, when the Administrator (ADM) was notified. At 8:30 pm, the first POR was received and was rejected at 8:45 pm. On 07/29/15 at 8:25 am, a second POR was received and was accepted. This POR included enacting a supervised smoking schedule for all residents who smoke, re-assessing R #10's ability to smoke independently, updating his care plan, re-inservicing staff on the facility's smoking P&P and posting the supervised smoking schedule in a visible location for all residents and staff to see. At this time the S&S was lowered to a D. Immediate jeopardy related to thickened liquids: During observation of the restorative dining room on 07/27/15, R #46 and 138 were served and drinking regular (thin) consistency coffee on separate observations. Both residents had a physician's orders [REDACTED]. While drinking regular consistency coffee, R #46 was observed to cough on the liquid and spit some out. These deficient practices resulted in an IJ at a scope and severity K, being identified. The facility ADM was notified on 07/28/15 at 11:10 am. At 2:45 pm the first POR was received and was rejected at 3:15 pm. At 3:54 pm a second plan of removal was received and was accepted at 5:37 pm. The POR included: Auditing resident records to ensure correct orders that match in AHT (electronic documenting system (EDS)), AccuNurse (EDS) and Tray Trackers (a system used to track resident meals), as well as any telephone orders in the record. Confirming that tray cards were printed for all meals with the correct consistency of the liquids. 2. Reviewing diet orders for all residents to ensure the same processes and reconciliations were followed to ensure tray cards were printed with the correct consistency for liquids. 3. Assigning a licensed nurse for Meal Service Duty to thicken all needed liquids per M.D. (Medical Doctor) orders prior to the beverage cart service in the main dining room. 4. Re-educating staff about the center's policy and procedure for thickened liquids and in-servicing new hires as part of their new hire orientation. At this time the S&S was lowered to an E. Based on observation, record review and interview the facility failed to ensure that 5 (R #10, 46, 73, 101 & 138) of 6 (10, 46, 73, 99, 101 & 138) residents reviewed for thickened liquids and during smoking observation, remained free from potential accidents and hazards by: 1. Not providing adequate supervision for R #10 and 101 who had been assessed as being unsafe smokers. 2. Not providing R #46 and 138 with appropriate consistency liquids. These deficient practices are likely to result in residents who smoke experiencing burns, fire related explosions and ignition of their clothing. If residents are not provided the ordered liquid consistency, then they are likely to experience choking and aspiration which can result in pneumonia and death. The findings are. Findings related to unsafe smoking A. Record review of the facility's smoking Policy and Procedure (P&P) dated 06/01/15 revealed, Policy: The intent this policy is to provide opportunities for safe smoking for residents that desire to smoke. This Facility permits tobacco smoking residents to smoke in a designated area outside of the facility, subject to certain requirements and restrictions set forth below. 1. All residents who smoke will be assessed using the Safe Smoking Assessment form upon admission, quarterly and with a significant change in condition to determine any special smoking needs. Resident specific smoking needs will be addressed in the resident's plan of care. 2. A Resident deemed incapable of independent smoking may only smoke under staff supervision . B. On 07/21/15 at 1:37 pm, during an interview with R #30 he confirmed that resident are not supervised when smoking, stating We have to supervise ourselves. C. On 07/28/15 at 9:47 am, during an interview with the Staff Development Coordinator (SDC), when asked about the process for assessing smoking safety, SDC stated, We observe how they smoke, their dexterity, if they are on oxygen, and then we come back in and complete the assessment. It gets completed when they come in at admission. The assessments get completed quarterly and annually. If the resident is alert enough they will ask the resident (history). If not, we ask the family. We also look at their clothes when they come in. Assessments are also done if there is a change. The staff will let the charge nurse know about holes in clothing. Then the charge nurse would complete an assessment. SDC stated, Currently all smokers are safe to smoke independently. D. On 07/23/15 during interview with the DON, she was asked for the most recent smoking assessments for all resident that smoke. The DON provided the Safe Smoking Data Sets (SSDS) for R #101 dated 06/08/15 and the SSDS for R #10 dated 03/25/15. Findings of R #101: E. Record review of the Minimum Data Set (MDS) Section C: Cognitive Patterns, dated 05/01/15 revealed the resident was assessed using the BIMS (brief interview for mental status) tool and scored a 5 out of a possible 15, indicating the resident has severe impairment. F. Record review of R #101's SSDS dated 06/08/15 and performed by LPN #5 revealed the resident was identified as having dropped ashes on himself, having a history of sustaining burns to his self or his clothing and exhibit poor smoking awareness when smoking. A notation in the directions section of the assessment read, Answering yes to questions 2-6 (including dropping ashes on self & having a history of sustaining burns) require the resident to surrender smoking equipment (lighters, cigarettes, cigars, etc.) and to be supervised by a responsible adult when smoking. G. On 07/21/15 at 3:30 pm, during an observation of the smoking patio, R #101 was smoking a cigarette. When the resident was finished smoking, he extinguished the cigarette by wiping it on his pant leg, then dropped the butt into a planter. The resident was noted to have multiple burn holes on his jacket and wheelchair seat cushion. During the observation the resident was not wearing a smoking apron and no staff were on the patio supervising residents smoke. H. On 07/21/15 at 5:43 pm, during an observation of the smoking patio, R #101 was smoking a cigarette. When the resident was finished smoking, he extinguished the cigarette by wiping it on his pant leg. During the observation the resident was not wearing a smoking apron and no staff were on the patio supervising residents smoke. I. On 07/23/15 from 11:19 am to 11:30 am during an observation of the outside smoking area, R #44 handed R #101 a cigarette and lit it for him. While in his wheelchair, R #101 began smoking; the resident was not wearing a smoking apron and no staff on the patio supervising residents smoke. While R #101 was smoking, two short clumps of ashes fell from the resident's cigarette down to his groin area and onto the wheelchair seat cushion. The resident did not take notice of the ashes falling nor did he attempt to brush them off. When R #101 was finished smoking, he flicked the ashes off and extinguished the cigarette by wiping it on his pant leg and jacket, then placed the cigarette butt in his front jacket pocket. During the observation the resident was still noted to have multiple burn holes in his jacket and on the wheelchair seat cushion between his legs. J. On 07/23/15 at 2:25 pm during an interview with Minimum Data Set (MDS)/LPN #2, she confirmed that she has worked with R #101 and knows him well. She stated Him (R #101) and his roommate, (Name of R #73), they both need to be reminded not to lightup in their rooms when the weather is bad. (Name of R #101) he's a sleepy smoker, so he needs to be supervised. MDS/LPN #2 made the gesture that R 101's falls asleep while smoking. During the interview MDS/LPN #2 was asked what constitutes a resident to be a safe smoker, MDS/LPN #2 stated, Those assessments (SSDS). Things like if you can hold it (cigarette/pipe) by yourself, if they know they can't smoke with oxygen, they can light it themselves, and put it out properly, they don't have burn holes in their pants, they smoke away from the building. Things like that. K. On 07/23/15 at 3:34 pm, during an interview with the DON she was asked, how are residents deemed safe to smoke independently, the DON stated, With the smoking assessments (SSDS). When asked what constitutes a resident to be an un-safe smoker, the DON stated, On the assessments, if they answer 'Yes' on questions 2-6 (Does someone have to hold the resident's cigarette? Does the resident need assistance to extinguish a cigarette? Does the resident drop ashes on self? Does resident fall asleep while smoking? and Does the resident have a hisotry of sustaining burns to self or clothing?) L. Record review of the SSDS re-assessment dated [DATE] at 7:52 pm, performed by the DON after the IJ was called on 07/23/14, revealed the resident was identified as needing no assistance to extinguish a cigarette, not having dropped ashes on his self, not having fallen asleep while smoking, not having a history of sustaining burns to self or clothing, not exhibiting poor smoking awareness when smoking and needing no interventions when smoking. According to the SSDS, the resident was deemed safe to smoke independently. M. On 07/24/15 at 9:15 am, during an interview with R #101, when asked if he had ever burned himself while smoking, he stated, Maybe a little, but not too much. N. On 07/24/15 at 2:39 pm during an interview with the Guardian #1 of R #101, she stated, Someone should be outside with him (R #101) while he is smoking. I was not aware that he was putting the cigarettes out on his pant leg. He has a history of falling asleep while smoking. Findings for R #10 O. Record review of the physician's progress note dated 07/10/15 revealed the resident was noted to have to following past medical history including Brain surgery after GSW (gun shot wound) to head. The physical exam section of the progress note revealed, Patients dexterity and range of motion and overall strength appear to be blunted in the upper extremities. Patient's right lower extremities appears to be a bit worse. P. Record review of the resident's most recent SSDS dated 03/25/15 and performed by LPN #6 revealed the resident was identified as needing assistance to extinguish a cigarette, having dropped ashes on his self, having a history of falling asleep while smoking, having a history of sustaining burns to self or clothing, exhibiting poor smoking awareness when smoking and requiring interventions like supervision or a smoking apron when smoking. A notation in the directions section of the assessment read, Answering yes to questions 2-6 (including the aforementioned SSDS information) require the resident to surrender smoking equipment (lighters, cigarettes, cigars, etc.) and to be supervised by a responsible adult when smoking. Q. On 07/23/15 from 11:19 am during an observation of the smoking patio, R #10 was smoking a cigarette while sitting in his wheelchair. The resident was not wearing a smoking apron and no staff were on the patio supervising residents smoke. While smoking, multiple short clumps of ashes fell from the resident's cigarette on to his shirt and pants. At 11:21 am, the resident attempted to pick the ashes off of his shirt but did not take notice of the ashes that had fallen on his pants. The resident's sweat pants were noted to have burn holes on them. R. Record review of the SSDS re-assessment dated [DATE] at 7:42 pm, performed by the DON after the IJ was called on 07/23/14, revealed the resident was identified as needing no assistance to extinguish a cigarette, not having dropped ashes on his self, not having fallen asleep while smoking, not having a history of sustaining burns to self or clothing, not exhibiting poor smoking awareness when smoking and needing no interventions when smoking. According to the SSDS, the resident was deemed safe to smoke independently. S. On 07/24/15 at 10:42 am during an interview with the ADM and DON, both confirmed that all residents in the facility who smoke, were re-assessed and all were determined to be safe to smoke independently. T. On 07/28/15 at 1:48 pm during an observation of the smoking patio, R #10 was smoking in his wheelchair with his back facing the dining room. R #10 appeared to be sleeping, his eyes were closed and his head was hanging down in front of him. The resident had a smoking apron that was folded up and covered only his groin area. In the resident's left hand was a lighter and a still smoldering corncob style pipe; the lighter and pipe in the resident's hand were beginning to tilt away from him. The bowl of the tilted pipe was positioned over the resident's lower thigh area, where the folded up smoking apron did not shield. R #10 did not open his eyes or take notice of the lighter and pipe tilting away from his-self. No staff were on the patio supervising residents smoking. U. On 07/28/15 at 9:55 am, during interview with Laundry Aide #1, when asked if she noticed holes, like cigarette burns in residents' clothing, she stated, Yes, from room 46B (R #10) and 3B (R #73). Holes are in pants legs. Findings related to thickened liquids V. Record review of Thickened Liquids policy and procedure dated 06/03/14 revealed, The consistency of the liquid level for an individual is determined by the Speech Therapist and is ordered by the physician. It is important that liquid levels are followed as ordered. Nectar-thick liquids are liquids that will run off of a spoon, however the fluid has enough consistency that a light film will remain on the spoon's surface. If a resident wishes for a beverage that is not available pre-thickened, commercial thickeners are available to thicken the liquid, however, ONLY NURSES or the Speech Therapist are to thicken the liquids, Dietary staff and CNA's are not to thicken liquid beverages .Note also that ALL liquids provided to a resident need to be of the appropriate ordered consistency. W. Record review of physician's orders [REDACTED]. X. Record review of physician's orders [REDACTED].Nectar thick liquids. Y. Record review of meal ticket for R #138 dated 07/27/15 revealed the resident was to receive, Nectar thicken liquids. Z. Record review of the Speech Therapy discharge summary for R #138 dated 07/23/15 revealed, Will leave pt (patient) on nectar thick liquids due to the fact that he is inconsistent with thin liquids this consistency has proven to be safer for the pt. AA. On 07/27/15 at 11:53 am during an observation of the restorative dining room, R #46 and 138 were served 8 ounce cups of coffee with cream that was not thickened. R #46 was observed to be coughing and spitting out his coffee as he drank it. During an interview with Restorative Certified Nursing Assistant (RCNA #1) and Dietary Manager (DM) when asked what consistency liquids R #46 and R #138 should be receiving, RCNA #1 stated, Both (Name of R #46) and (Name of R #138) should be on thickened liquids. DM was asked what the consistency of coffee should be for R #46, she stated, Nectar. When asked what consistency of coffee R #46 was drinking, she stated, There is no thickener in that coffee, and the Ensure (nutritional drink/healthshake) for R #138 is pudding thick. I will take them back and go re-do them. BB. On 07/27/15 at 5:15 pm during an observation of the restorative dining room and interview with the Dietary Aide (DA #1): 1. R #46 and R #138 were each served an 8 oz. (ounce) cup of coffee with cream that were not thickened. When DA #1 was asked if the coffee for R #46 and R #138 were thickened before it was delivered to the residents she stated, No, I do not thicken coffee, I have never done it. 2. R #138 was not given a health shake as ordered on his meal ticket. When RCNA #1 was asked if R #138 should be given a health shake, he stated, Yes he should get one. At this point RCNA #1 asked DA #1 to bring R #138 a health shake, when she returned with the health shake, RCNA #1 informed DA #1 the shake needed to be thickened. DA #1 returned to the kitchen, and was observed to pour the health shake into a glass and add a scoop of thickener, mix it and delivered it to R #138 in the restorative dining room. The DM stated that the health shake was again pudding thick and took it back to the kitchen. CC. On 07/27/15 at 5:33 pm during an interview with DM when asked if the coffee for R #46 & 138 were thickened, she stated, Coffee is not thickened, nurses should be thickening all liquids. DM stated that her staff (Dietary Aides, cooks) should not be thickening liquids. DD. On 07/28/15 at 9:44 am during an interview with the Speech and Language Pathologist (SLP), she stated: 1. (Name of R #46) should be on nectar thick liquids. He coughs a lot when he combines liquid with food. He is at high risk. His dementia is severe. He does not follow cues, so that is why he is on puree and thickened liquids. He is a high risk for aspiration. He should not have thin liquids. 2. (Name of R #138) is inconsistent with thin liquids. we trialled him on thin liquids and he started coughing so I changed it back to nectar, I did ask him (R #138) if he would like to go back to thin liquids, he stated, 'No I feel safer with nectar.' It would be a risk for him (R #138) to go to thin liquids. Fifty per cent of the time he would aspirate. I don't want to put him at risk. He is safer on nectar. When asked if health shakes were nectar thick consistency, she stated, Health shakes are not nectar thick.

Based on observation, record review and interview the facility failed to ensure that assessments were accurate and used to implement safe smoking interventions for 2 (R # 10 and 101) for 4 (R #10, 73, 99 and 101) residents reviewed for smoking by: 1. Failing to use the results of safe smoking assessments to provide R #10 and 101 with adequate safe smoking supervision. 2. Failing to accurately perform safe smoking re-assessments for R #10 and R #101 on 07/23/15, after an Immediate Jeopardy situation was identified. This deficient practice likely resulted in R #10 and 101 being left without adequate supervision to prevent potential smoking related hazards from occurring. The findings are. Reference F323.

Based on observation, record review and interview, the facility failed to implement the care plan and follow physician's orders for 3 (R #46, 73 and 138) of 5 (R #11, 46, 73, 83, and 138) residents reviewed for pressure ulcers and thickened liquids by: 1. Not providing pressure relief to R #73's heels when in bed. 2. Not ensuring that R #73 did not wear hard shoes. 3. Not providing the correct thickened liquid consistency for R #46 and 138. This deficient practice likely resulted in R #73 developing a stage III (full thickness tissue damage) pressure ulcer and R #46 and 138 being placed at risk for aspiration from incorrectly thickened liquids. The findings are: Findings for R #73: A. On 07/22/15 at 10:14 am during an interview with LPN #1, he confirmed that R #73 had developed left and right heel pressure ulcers after admission to the facility. LPN #1 stated, He has had them for a few months. They were originally caused by ill-fitting shoes that his family brought in. We got him down to slippers. When asked what interventions are they taking to prevent further breakdown, he stated, We float heels at night, and put on heel protectors. We took his shoes away and he wears slipper without heels. LPN #1 confirmed that the left and right heel dressing changes for R #73 should be performed daily and documented in the TAR. When asked how often staff performed detailed assessments of the resident's pressure ulcers, he stated, I am not sure if there is a schedule, but I try to do it once a week. I will put measurements on there. B. Record review of Physicians Orders for R #73 dated 07/2015 revealed, QD (Every day) EMORN (Every morning) Ulcer: Left posterior heel 1. Cleanse with soap and water 2. Cleanse periulcer (tissue around wound) area with soap & water/skin prep (preparation) 3. Use medicine as the primary dressing 4. Use Allevyn foam (type of wound dressing), [MEDICATION NAME] (medical tape) and Stockinet (surgial bandage) as the secondary dressing. 5. Change daily for 2 weeks (There is no DC date noted in the orders). Start date 02/18/15 When in bed, off load weight from left heal Start date 02/18/15 No hard shoes to left foot until further notice Start date 05/20/15 Offloating boots for heels while in bed Dx: Bilat. (bilateral) Heel Ulcers C. Record review of Treatment Administration Record (TAR) for R #73 dated 03/01/15 to 03/31/15 revealed, QD woundcare to left heel with [MEDICATION NAME] (type of honey wound dressing), DSD (dry sterile dressing) heel protectors Bil (bilaterally) while sleeping. On 03/06/15 and 03/07/15 the treatment was signed and circled indicating that the treatment was not completed with the following note on both days: hour of sleep/bedtime (HS) woundcare not done-no supplies D. Record review of Care Plan for dated 05/12/15 identified the resident as being at risk for impaired skin integrity. Goals for this problem area included, Will be accepting of turning and positioning program Approaches this problem area included, Appropriate footwear, weekly skin checks, monitor feet and closely for s/sx (signs and symptoms) of wounds. E. On 07/22/15 at 1:17 pm during an interview with Certified Nurse's Aide (CNA) #1, when asked what the CNA's do for pressure ulcer prevention for R #73, she stated, We put on the blue heel protectors when he goes to bed. When asked if R #73 was on a turning schedule, she verified that he is not. F. On 07/22/15 at 1:18 pm, R #73 was observed to be laying on his back with his heels flat on the bed. The resident did not have a wound dressings on either heel or heel protectors. G. On 07/28/15 at 9:15 am, 9:59 am, and 11:15 am, it was observed that R #73 was lying in bed, on his back with no heel protectors/offloading of his heels. H. On 07/28/15 at 3:41 pm during an interview with (Name of local hospital) Wound Clinic Nurse Practitioner (WCNP) #1 when asked about R #73's wounds, she confirmed that the left heel pressure ulcer is not getting better and that the nursing home does not always follow wound dressing orders. She verified that he came with hydrogel (wound care gel) instead of metahoney on 7/21/15. She confirmed that it caused the wound maceration (softening if tissue) and wound looked worse on the left heel. I. On 07/28/15 at 10:25 am during an interview with Family Member #1, when asked if the facility had notified her that R #73's shoes did not fit him, she stated, They didn't notify me, he told me. I went in one day and he was only wearing one shoe and he said he had a blister. I went in one day and there was a wheelchair and I asked 'why is there a wheelchair?' He didn't use a wheelchair. They mentioned that his shoes didn't fit and he only wore them one day and they were brand new. He wore them to a funeral. It was in January. He said they fit well. He had stated he had already had those (the sores on his heels) going on. I bought them 3 pairs of morning shoes (slippers). They told me that he was getting them (pressure ulcers) from sliding on the bed and they got him lambs wool. He was wearing the shoes with no backs and I had to get extra large slippers because of the big dressings. She confirmed that she has never seen him wearing the heel protectors in bed and that she has only seen gauze on his heels. J. On 07/28/15 at 10:47 am during an interview with LPN #1, when asked where the ill fitting shoes are for R #73, she stated, I sent them home with his daughter about 2 months ago. I actually hid them in his closet so he wouldn't wear them and someone got them down and put them back on him. I let his daughter know and she bought him slippers and he has been wearing them every since. Findings related to thickened liquids: K. On 07/27/15 at 11:53 am during an observation of the lunch meal in restorative dining room R #8, # 34,#46, #48, #74, were unattended, three residents were served thickened juice and water (R#46, #83 and #138). R #46 had an 8 ounce cup of coffee that did not appear to be thickened. During an Interview with Restorative Certified Nursing Assistant (RCNA #1) when asked what consistency liquids R #46 should be receiving he stated, Both R #46 and R #138 should be on thickened liquids, Dietary Manager (DM) was passing by restorative dining room and was asked what the consistency of the coffee should be for R #46, she stated, Nectar. When asked what consistency of coffee R #46 was drinking, she stated, There is no thickener in that coffee,and the ensure for R #138 is pudding thick I will take them back and go re-do them. L. On 07/27/15 at 5:05 pm during an observation of restorative dining room R # 46 and R #138 were observed to be drinking an 8 ounce of cup coffee that did not appear to be thickened. M. On 07/27/15 at 5:15 pm during an interview with Dietary Aide (DA #1) when asked if the coffee for R #46 and R #138 was thickened in the kitchen before it was delivered to the dining room, she stated, I do not thicken coffee. I have never done it. N. On 07/27/15 at 5:15 during interview and observation of restorative dining room and kitchen DA#1 was observed delivering a shake to restorative dinning room and RCNA #1 whispered to her it needed to be thickened. DA #1 then took it back to the kitchen, opened it, poured it in a glass and added a scoop of thickener to the shake and returned it to restorative dining room. O. On 07/27/2015 5:33 pm during an interview with DM when asked if coffee R #46 and R #138 were drinking was thickened coffee, she stated, Coffee is not thickened, nurses should be thickening all liquids. My staff should not be thickening coffee. P. Record review of physicians telephone order dated 07/22/15 for R #46 revealed Speech Therapy clarification: Change liquids to nectar thick. Q. Record review of Physicians orders dated July 2015 for R #138 revealed: Head turn to right with every swallow. Nectar thick liquids with all meals. Resource 2.0 4 0z (ounces) nectar thick with meals. R. On 07/28/20 9:44 am during an interview with Speech and Language Pathologist (SLP), when asked if R #46 should have all his liquids thickened, she stated, R #46 should be on nectar thick liquids. He coughs a lot when he combines liquid with food. He is at high risk. His dementia is severe. He does not follow cues, so that is why he is on puree and thickened liquids. He is a high risk for aspiration. He should not have thin liquids. When asked about R #138 SLP stated, R #138 is inconsistent with thin liquids we trailed him on thin liquids and he started coughing so I changed it back to nectar, I did ask him (R #138) if he would like to go back to thin liquids, he stated, No I feel safer with nectar. It it would be a risk for him (R #138) to go to thin liquids fifty per cent of the time he would aspirate. I don't want to put him at risk. He is safer on nectar. When asked if healthshakes were nectar thick consistency, she stated, Healthshakes are not nectar thick. S. Record review of Meal Tracker Ticket for R #138 revealed Nectar Thickened Liquids. T. Record review of ST (Speech Therapy) discharge summary revealed, Will leave pt (patient) on nectar thick liquids due to the fact that he is inconsistent with thin liquids. This consistency has proven to be safer for the pt (patient). U. Record review of Care Conference Notes dated 2/16/15 for r #138 revealed a notation stating, nectar thickened not brought to him. (R #138 was not being given nectar thickened liquids as directed). V. Record review of physicians telephone order dated 07/22/15 for R #46 revealed Speech Therapy clarification: Change liquids to nectar thick. W. Record review of Physicians orders dated July 2015 for R #138 revealed: Head turn to right with every swallow. Nectar thick liquids with all meals. Resource 2.0 4 0z (ounces) nectar thick with meals.

Based on record review, interview and observation, the facility failed to ensure that 1 (R #73) of 2 (R #11 and 73) residents reviewed for pressure ulcers, did not develop pressure ulcers and provide treatments to promote healing by: 1. Not providing wound care dressing changes as ordered. 2. Not maintain sufficient wound care supplies to perform dressing changes. 3. Not ensuring that R #73's pressure ulcers were covered with clean dressings 4. Not providing positioning assistance with relieving pressure on the resident's heels. 5. Not using proper infection control techniques when performing dressing changes. This deficient practice likely resulted in the development and subsequent deterioration of an avoidable stage III (full thickness tissue damage) pressure ulcer. The findings are. A. Record review of Nurses Note dated 02/12/15 revealed, Ulcer to left heal (sic), measures about 2 x 2 cm (centimeters), stage 3, tunneled (a type of tissue damage that creates openings under the skin), needs wound care orders and treatment please. B. Record review of Minimum Data Set (MDS), section M: Skin Condition dated 03/02/15 revealed the resident was identified as having two-stage III (three) pressure ulcers that were not present upon admission/entry or re-entry to the facility. C. Record review of Telephone Physicians Orders dated 03/05/15 revealed, QD (every day) wound care to LT (left) heel with [MEDICATION NAME] (type of wound dressing), DSD (dry sterile dressing), heel protectors BIL (both sides) while sleeping. D. Record review of the Treatment Administration Record (TAR) dated 03/06/15 to 03/07/15 revealed a notation that indicated that wound care to the resident's pressure ulcer was not performed due to not having supplies. E. Record review of (Name of local hospital) wound clinic report of consultation (WCROC) sheet dated 03/12/15 revealed, Diagnosis: [REDACTED]. Dsg (dressing) appears old with Duoderm (a type of dressing), (positive) drainage . The new orders read, Renew order for [MEDICATION NAME] (a different type of ointment or dressing) F. Record review of the WCROC sheet dated 03/19/15 revealed, Findings: Note: BANDAGE NOT CHANGED SINCE 3/13! Ulceration remains full thickness post Lt heel, surrounded by callus (thickening of tissue) .increased drainage on bandage. Recommendation/New Orders: Aseptic debridement of ulcer (to remove dead or non-functional tissue) .Cont (continue) wound care (with) [MEDICATION NAME] QD (every day) G. Record review of nursing note dated 04/22/15 revealed, Resident has another stage II (partial thickness tissue damage) ulcer measuring 3/2.5 cm on right heel. Wound cleaned and dressing applied at the moment. Stage II ulcer on left heel appears to be necrotizing (dead tissue) around the edges. His wound care orders need to be reviewed . (This is the first documentation that identifies the right heel ulcer) H. Record review of the TAR dated 05/03/15 to 05/06/15 revealed no documentation that wound care had been performed to the resident's left heel pressure ulcer. I. Record review of the WCROC sheet dated 05/07/15 revealed that bilateral heel ulcers had not improved and the notation read, Full thickness ulcers heels BIL (on both sides of the body), macerated (softening and breaking down) tissue with fibrotic (thickening or scarring) base, each 3 cm. J. Record review of the TAR dated 06/14/15, 06/17/15, and 06/20/15 to 06/21/15 revealed no documentation that wound care had been performed to the resident's left heel pressure ulcer. K. Record review of high nursing facility daily notes dated 05/23/15 to 06/10/15, 06/12/15 to 06/20/15, and 06/22/15 to 07/24/15 revealed no documentation that wound care had been performed to any of the resident's pressure ulcers. L. Record review of the WCROC sheet dated 06/23/15 revealed, R (right) heel old ulcer healed. New ulcer lateral to old ulcer on heel . M. Record review of Report of Consultation dated 07/21/15 revealed, .L (left) heel ulcer worse, very macerated. Patient had hydrogel on wound not [MEDICATION NAME] gel .Recommendations/New Order: 1. Continue with [MEDICATION NAME] GEL on R heel, cover .Change q (every) 24 hours. 2. [MEDICATION NAME] Ag (a type of wound dressing) to L heel ulcer-cover with foam, q 24 hours. 3. Offload (to not let a resident's heels lay flat on a surface) while in bed. N. On 07/22/15 at 10:14 am during an interview with LPN #1, he confirmed that R #73 had developed left and right heel pressure ulcers after admission to the facility. LPN #1 stated, He has had them for a few months. They were originally caused by ill-fitting shoes that his family brought in. We got him down to slippers. When asked what interventions are they taking to prevent further breakdown, he stated, We float heels at night, and put on heel protectors. We took his shoes away and he wears slipper without heels. LPN #1 confirmed that the left and right heel dressing changes for R #73 should be performed daily and documented in the TAR. When asked how often staff performed detailed assessments of the resident's pressure ulcers, he stated, I am not sure if there is a schedule, but I try to do it once a week. I will put measurements on there. O. Record review of Care Plan for dated 05/12/15 identified the resident as being at risk for impaired skin integrity. Goals for this problem area included, Will be accepting of turning and positioning program Approaches this problem area included, Appropriate footwear, weekly skin checks, monitor feet and closely for s/sx (signs and symptoms) of wounds. P. On 07/22/15 at 1:17 pm during an interview with Certified Nursing Assistant (CNA) #1, when asked what CNAs do for pressure ulcer prevention for R #73, she stated, We put on the blue heel protectors when he goes to bed. When asked if R #73 was on a turning schedule, she confirmed he was not. Q. Record review of MDS, Section G: Functional Status dated 05/30/15 revealed the resident needed one person physical assistance with his bed mobility. R. On 07/22/15 at 1:18 pm, R #73 was observed to be laying on his back with his heels flat on the bed. The resident did not have a wound dressings on either heel. S. On 07/22/15 at 3:21 pm during an observation of wound care to the resident's bilateral heel pressure ulcers, R #73 still did not have wound dressings on either heel before the wound care began. While preparing to perform the wound care, LPN #1 had a Band-Aid on his (LPN#1) left hand covering a wound and began taking gauze out of the package with no gloves on. During the procedure LPN #1 did not take measurements of the wounds. The right heel appeared to be almost healed, and the left heel was approximately the size of a silver dollar with yellow slough (a type of non-functional tissue in a wound) around the edge with a pink wound base. T. On 07/28/15 at 9:15 am, 9:59 am, and 11:15 am, R #73 was observed to be resting in bed, lying on his back with his heels set directly on the bed with no heel protectors. At 9:59 am during an interview with R #73, when asked if his heels hurt him and what level of pain he was in, he confirmed that he was in pain and it was 8 out of 10 on a scale of 0-10, 10 being the worst pain he has ever felt. R #73 confirmed that he needs assistance putting the heel protectors on his feet. When asked if the heel protectors help with the pain, he confirmed that they do and that staff do not routinely assist him with putting them on when he is resting in bed during the day, as well as at night when he goes to sleep. R #73 stated that he was having trouble walking becuase of the sores on his heels. He confirmed that the pain has gotten worse over the past few months. He stated, I can hardly walk on them sometimes, they hurt so bad. U. On 07/28/15 at 10:25 am during an interview with Family Member #1, she confirmed that she has never seen the resident wearing heel protectors in bed and that she has only seen gauze on his heels. V. On 07/28/15 at 3:35 pm during an interview with Wound Clinic Medical Doctor (WCMD) #1, when asked about pressure ulcer development, he confirmed that a pressure ulcer can develop over a couple of hours if a person stays in the same position for that long without pressure relief. W. On 07/28/15 at 3:41 pm during an interview with Wound Clinic Nurse Practitioner (WCNP) #1, she confirmed that R #73'a left heel pressure ulcer had gotten worse and that the facility does not always follow wound dressing orders. She confirmed that the resident came into the clinic with hydrogel instead of Metihoney on 7/21/15. She confirmed that the application of the hydrogel caused the wound to worsen by way of macerating. She stated, It is hard with some facilities. I have offered to work with them on their formularies (wound care supplies). They said that they did not have what they needed a few times. When I offered to work with them on their formularies with the person that orders their wound supplies, they said that the janitor was not in, so I couldn't at that time. WCNP #1 stated that she has offered to provide inservices to the staff however the facility has not taken her up on the offer.

The facility failed to ensure that Resident (R) #44 received proper care and services by not performing Cardiopulmonary Resuscitation (CPR) on a resident who had a physician's orders [REDACTED]. This failure lead to an Immediate Jeopardy (IJ) being identified on [DATE] at 10:40 am. The facility was notified of the IJ at 10:50 am. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 3:45 pm and the IJ was lifted. The scope and severity was lowered to an E. The following is the Plan of Removal: 1. Current resident charts have been audited to verify code status as of [DATE] at 6:00 pm. Current resident charts now have a code status sticker on the chart to identify the resident preference. Resident charts have a red sticker stating DNR (Do Not Resuscitate) or green sticker stating Full Code. Upon admission residents code status paperwork will be filled out by Admission director/charge nurse with resident/responsible party, a call then will be placed to the attending physician for an order. 2. Licensed nursing staff will be in-serviced on falsification of documentation,code status and protocols for code status by 7:00 pm by [DATE] by the Director of Nursing (DON). Nursing staff who are on vacation or leave will be in-serviced prior to accepting an assignment. 3. Certified Nursing Assistants (CNA) and nursing assistants (NA) will be in-serviced on code status and where they are located by 7:00 pm on [DATE] by the DON. CNA's who are on vacation or leave will be in-serviced prior to accepting an assignment. 4. New employees will be in-serviced during orientation on code status, where to locate code status, and protocol of code status. 5. Nurse managers will review within 24 hours code status of any new admits Monday through Friday to verify completion and documentation daily and ongoing. The weekend manager will review code status on Saturday and Sunday for completion and documentation daily and ongoing. If for any reason the resident cannot sign and there is no responsible party, the resident will be identified as full code and the chart will identify that information. 6. Any concerns will be brought to QA (Quality Assurance) monthly for review for three months and then as needed. Based on record review and interview, the facility failed to protect 1 (R #44) of 1 (R #44) residents from neglect by not following Physician order [REDACTED]. R #44 did not have the opportunity to potentially be revived, and died . This failure could likely cause additional resident's who are a full code to not have CPR performed if their heart and respiration's stopped. The findings are: A. Review of the face sheet dated [DATE] revealed that R #44 was a Full Code. The resident was admitted on [DATE] and the face sheet revealed that the spouse was the emergency contact/Power of Attorney (POA). B. Review of the Transfer Orders dated [DATE] (from the local hospital) R #44 was discharged from on page 1, Code Status was marked "Full Code." a. On [DATE] at 8:10 am, during interview, Licensed Practical Nurse (LPN) #1 confirmed the orders but stated she had not seen it. C. Review of the Admission History and Physical dated [DATE] on page 3 of 4 revealed the following, "Code Status: apparently, the patient is Full Code." D. Review of the [MEDICAL CONDITION] consultation report dated [DATE] on page 2 of 3 revealed the following, "Social history: She is a full code for now." E. Review of the admission check list revealed the following, "code status must be completed and signed on admission by the resident/POA." The sheet was not dated or filled out. F. Review of the Acknowledgement of Receipt of Advance Directives/Medical Treatment Decisions (effective date ,[DATE]), was not filled out. G. Review of the Admission/Transfer orders, which were not dated, on page 4 of 4 revealed R #44's name on it with the date of birth and an "X" for "NO HEROIC RESUSCITATION EFFORTS." a. On [DATE] at 8:10 am, during interview, LPN #1 stated the page was initially blank and that she put an "X" on the "NO HEROIC RESUSCITATION EFFORTS," and attempted to get the daughter and/or husband to sign it the morning after the resident had passed away. She stated the family refused. The nurse verified she had altered the form. H. Review of the nurses notes dated [DATE] at 0415 (4:15 am) revealed a note by LPN #1 that read, "The resident was slumped over while sitting on toilet. At that time I also arrived to find resident unresponsive. Resident was put into bed and no v/s (Vital Signs) or O2 sat (oxygen saturation). I called family to notify them, husband and daughter. During conversation with daughter she mentioned to me that two days prior she had asked her mom regarding DNR (Do Not Resuscitate) status, she stated that mother had expressed not be to revived." I. Review of the nurses notes dated [DATE] at 0449 (4:49 am) revealed a note by Registered Nurse (RN) #2 that read, "Resident found unresponsive in bed. Pupils fixed and dilated. No respirations, no pulse, no blood pressure present. Daughter at bedside with resident." a. On [DATE] at 9:45 am, during interview with RN #2, she stated she was not aware of the code status and was asked by LPN #1 to pronounce the resident since there was no one in her facility that could pronounce. J. On [DATE] at 6:30 pm, the Executive Administrator, the Administrator, and the DON were interviewed. The DON confirmed that R #44 was a Full Code and that LPN #1 did not follow the doctors order or facility procedure. K. On [DATE] at 7:25 am, during interview, NA #1 stated she took R #44 to the bathroom and she (R #44) became weak. LPN #1 got CNA #2 to put R #44 to bed and at that time her Respirations were only 3 per minute. LPN #1 went to check the chart and call the family. RN #1 came in with LPN #1 to check her, but R #44's color had changed, and there were no respiration's. L. On [DATE] at 7:35 am, during interview, CNA #2 stated that R #44 was in the bathroom (BR). She looked like she had passed away. She was slumped down and unresponsive. CNA #2 stated he scooped her up and transferred her to bed. CNA #2 stated the resident was not responding and when he put her to bed, her mouth came open and her skin color had changed. The pulse oximetry registered zero. LPN #1 stated she was going to look at the chart and call the residents husband. The residents respiration's at that time were 3 a minute. They waited for LPN #1 to come back. When LPN #1 came back she stated the chart wasn't completely filled out so she couldn't tell if the resident was a DNR or Full Code and that she was waiting for the husband to call her back. LPN #1 then stated she was going to call the residents daughter. There was no respiration's after he took her V/S. LPN #1 checked her skin. LPN #1 told CNA #2 to call RN #1. RN #1 had his stethoscope and checked her heart rate and pupils. CNA #2 stated that LPN #1 was running back and forth. M. On [DATE] at 7:45 am, during interview, RN #1 stated that around 4:30 am CNA #2 called him to check R #44 and to pronounce her (but he was not certified). He stated he checked the pulse, heart rate, pupils and they were fixed. She was not moving. RN #1 confirmed if there is no code status, you treat them as a full code. N. On [DATE] at 8:05 am, during interview, CNA #3 stated when she walked in the BR, the resident was slumped over but was still breathing, was very pale, lips were blue so they put the emergency light on in the BR. CNA #2 came in and scooped her up and put her in bed. She stated the nurse came, but was running back and forth. LPN #1 got the blood pressure cuff, then oxygen saturation and her respiration's were 3 per minute. LPN #1 checked the chart, there was no code in the book, so she just tried to get ahold of the daughter or husband. There was no pulse or oxygen saturation. CNA #3 stated there's no communication who's a Full Code at the facility. O. On [DATE] at 8:10 am, during interview with LPN #1, she verified she was the nurse on duty the night R #44 died . She stated it was about 4:10 am when CNA #3 called her to the resident's room. When she arrived at the BR, NA #1 was holding her. R #44 slumped in LPN #1's arms and she tried to wake her but there was no response. They both tried to move her but couldn't, so they got CNA #2. CNA #2 scooped her up in his arms and put her in bed. LPN #1 stated she did an assessment on R #44, but could tell from her color and the way she was breathing that R #44 was almost dead. LPN #1 stated R #44 was a new admit and she was trying to see if she was a DNR. The page wasn't filled out, so she grabbed a stethoscope and told the CNA's to count her breaths before she left. She stated she looked at the face page and asked the husband if she could get the number to R #44's daughter. She stated she then ran back with the stethoscope and there was no heart rate, she was gone. She then got the RN on duty to check R #44 and he checked her vital signs and her pupils. LPN #1 then called the daughter again and she was on her way. The daughter ran in and LPN #1 stated she had told the daughter the sheet was not filled out. LPN #1 stated "I didn't know the code status." The daughter stated she had spoken to her mother just a couple of days ago and asked the exact same question. She didn't want CPR. "I've only had my license for only one year and I didn't know what to do." LPN #1 stated "that's the norm (normal process) here. People just go hold their (resident's in the dying process) hand and give them [MEDICATION NAME], this was just out of the norm." She stated when she talked to the husband, he said to send her to the hospital, but LPN #1 did not do that and she did not initiate CPR. She stated she thinks she asked him about CPR and he said send her to the hospital. LPN #1 stated, "But by the time I went back to the room, she was already gone. From the CNA to the BR to stop breathing, it was about a 10 minute time span. I looked through the chart and she went so quick. This was out of the normal for here. When you open the front flap, there's usually a grid page with allergies and code status. Under advance directives too, but the page was there but not signed or filled out. The norm is if someone is passing to give them comfort measures. I don't know why I didn't send her to the hospital when the husband said because I don't have much contact with him. I was more in contact with the daughter and I thought she was in charge. The admission transfer order was blank that morning. I asked the family to sign it and I checked the box that morning after she had already passed away. The daughter was crying and she said 'I don't want to sign anything. Do you dad' and he said 'No, I'm not signing anything because I told you to send her to the hospital.' They were distraught, but I thought it was from the death but it was because I didn't send her to the hospital. I didn't know he was the POA." P. On [DATE] at 9:45 am, during interview, RN #2 stated they called her to pronounce. She wasn't told anything about code status, just to pronounce. RN #2 stated, "I wouldn't check it (the code status) if they don't tell me. LPN #1 gave me a blank nursing note since they were still working on the admission. If there's not a code status, then I do a Full Code." Q. On [DATE] at 2:25 pm, during interview, the R #44's daughter stated "(Name of LPN #1) left a message saying mom was not doing well and that I better come and that she had called my dad. I headed right over." When she arrived there was no vital signs. She stated, "after Mom was gone, Dad and the family arrived in shock." LPN #1 wanted her or the resident's husband to sign a DNR form, she said right now. The daughter stated, "I was not in the mood to sign anything. Two days earlier I had talked about it to my mom because she was very sick and she said she was very sick but didn't know. She didn't want CPR, but was going to let the people decide that. When they called my dad, he told her (LPN #1) to send her (R #44) to the hospital, to call an ambulance." R. On [DATE] at 2:50 pm, during interview, R #44's husband/POA stated his wife was discharged from the hospital because she was stable. LPN #1 called him and stated R #44 had to go to the BR and then told the nurse she was not feeling well. She was put in bed and didn't wake up. I think she was overmedicated. They called around 4:45 am and stated R #44 was breathing slow. The husband stated, "I said take her to the emergency room (ER) right away, but they didn't. They asked if I wanted CPR and I said yes until the ambulance gets there and then she asked for my daughter's phone number and waited. The nurse then went back to the room and she had stopped breathing. She called my daughter around 4:23 am, so she must of called me at 4:15 am. The nurse went in the room when we were there and said my wife didn't have anything to be resuscitated and I had told her to do it. The nurse (LPN #1) told us they didn't have a chance to do it. We were all there and she said this was the only form you need to sign is what she said. She always said she wanted to be a full code, even before." S. On [DATE] at 2:25 pm, during interview, the DON confirmed that the husband was the POA and that LPN #1 should have listened to him and sent R #44 to the hospital as he requested. The DON stated, "she failed to do that. She was in a panic." When asked about the admission checklist, the DON confirmed that the code status should have been completed on admission, "that's the process." When asked about the "Acknowledgement of Receipt of Advance Directives/Medical Treatment Decision" form, the DON stated that it is another form that could be used. When asked about the admission/transfer orders, the DON stated "she was trying to get the daughter to sign it after the fact and that's the last thing you do. That's the form she checked off and wanted her to sign. If it's not signed, then they are a full code." When asked about the admission papers, the DON stated "The resident was a full code across the board."

The facility failed to ensure that Resident (R) #44 received proper care and services by not performing Cardiopulmonary Resuscitation (CPR) on a resident who had a physician's orders [REDACTED]. This failure lead to an Immediate Jeopardy (IJ) being identified on [DATE] at 10:40 am. The facility was notified of the IJ at 10:50 am. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 3:45 pm and the IJ was lifted. The scope and severity was lowered to an E. The following is the Plan of Removal: 1. Current resident charts have been audited to verify code status as of [DATE] at 6:00 pm. Current resident charts now have a code status sticker on the chart to identify the resident preference. Resident charts have a red sticker stating DNR (Do Not Resuscitate) or green sticker stating Full Code. Upon admission residents code status paperwork will be filled out by Admission director/charge nurse with resident/responsible party, a call then will be placed to the attending physician for an order. 2. Licensed nursing staff will be in-serviced on falsification of documentation,code status and protocols for code status by 7:00 pm by [DATE] by the Director of Nursing (DON). Nursing staff who are on vacation or leave will be in-serviced prior to accepting an assignment. 3. Certified Nursing Assistants (CNA) and nursing assistants (NA) will be in-serviced on code status and where they are located by 7:00 pm on [DATE] by the DON. CNA's who are on vacation or leave will be in-serviced prior to accepting an assignment. 4. New employees will be in-serviced during orientation on code status, where to locate code status, and protocol of code status. 5. Nurse managers will review within 24 hours code status of any new admits Monday through Friday to verify completion and documentation daily and ongoing. The weekend manager will review code status on Saturday and Sunday for completion and documentation daily and ongoing. If for any reason the resident cannot sign and there is no responsible party, the resident will be identified as full code and the chart will identify that information. 6. Any concerns will be brought to QA (Quality Assurance) monthly for review for three months and then as needed. Based on record review and interview, the facility failed to immediately report an incident of possible neglect to the State Agency (SA) when CPR was not provided to 1 (#44) of 1 (#44) resident. Resident #44 had Physician order [REDACTED]. Resident #44 was found without a pulse or respirations, and the facility failed to begin CPR. The resident did not have the opportunity to potentially be revived, and died . If incidents of possible neglect are not immediately reported, the SA is not aware of the incident, therefore, the SA is not able to follow up with the facility to ensure resident safety. The findings are: A. On [DATE] at 5:00 pm, during interview, the Executive Administrator and the Director of Nursing (DON) reported to this surveyor that R #44's family had called and were upset that CPR was not performed and that R #44 was not transported to the hospital as the husband (Power of Attorney (POA)) had requested. R #44 was a Full Code and was pronounced dead on [DATE] at 4:49 am, almost 36 hours from admission. B. On [DATE] at 6:30 pm, the Executive Administrator, the Administrator, and the DON were interviewed. The DON confirmed that R #44 was a Full Code and that LPN #1 did not follow the doctors order or facility procedure. C. Review of the face sheet dated [DATE] revealed that R #44 was a Full Code. The resident was admitted on [DATE] and the face sheet revealed that the spouse was the emergency contact. D. Review of page 1 of the Transfer Orders dated [DATE] (from the local hospital) revealed the Code Status for R #44 was marked "Full Code." E. Review of the Admission History and Physical dated [DATE] on page 3 of 4 revealed the following, "Code Status: apparently, the patient is Full Code." F. On [DATE] at 2:25 pm, during interview, the DON confirmed that the face sheet listed the responsible party (the POA) and in this case the nurse should have listened to the husband since he was the POA and sent the resident out to the hospital, "she failed to do that. She was in a panic." The DON stated that the resident was a full code across the board. G. Review of the intake report submitted to the SA revealed that the facility did not report this incident until [DATE] at 6:30 pm after the family called to complain to the DON.

The facility failed to ensure that Resident (R) #44 received proper care and services by not performing Cardiopulmonary Resuscitation (CPR) on a resident who had a physician's orders [REDACTED]. This failure lead to an Immediate Jeopardy (IJ) being identified on [DATE] at 10:40 am. The facility was notified of the IJ at 10:50 am. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 3:45 pm and the IJ was lifted. The scope and severity was lowered to an E. The following is the Plan of Removal: 1. Current resident charts have been audited to verify code status as of [DATE] at 6:00 pm. Current resident charts now have a code status sticker on the chart to identify the resident preference. Resident charts have a red sticker stating DNR (Do Not Resuscitate) or green sticker stating Full Code. Upon admission residents code status paperwork will be filled out by Admission director/charge nurse with resident/responsible party, a call then will be placed to the attending physician for an order. 2. Licensed nursing staff will be in-serviced on falsification of documentation,code status and protocols for code status by 7:00 pm by [DATE] by the Director of Nursing (DON). Nursing staff who are on vacation or leave will be in-serviced prior to accepting an assignment. 3. Certified Nursing Assistants (CNA) and nursing assistants (NA) will be in-serviced on code status and where they are located by 7:00 pm on [DATE] by the DON. CNA's who are on vacation or leave will be in-serviced prior to accepting an assignment. 4. New employees will be in-serviced during orientation on code status, where to locate code status, and protocol of code status. 5. Nurse managers will review within 24 hours code status of any new admits Monday through Friday to verify completion and documentation daily and ongoing. The weekend manager will review code status on Saturday and Sunday for completion and documentation daily and ongoing. If for any reason the resident cannot sign and there is no responsible party, the resident will be identified as full code and the chart will identify that information. 6. Any concerns will be brought to QA (Quality Assurance) monthly for review for three months and then as needed. Based on record review and interview, the facility failed to implement their policies for abuse and neglect by not immediately reporting to the State Agency (SA) an incident of possible neglect for 1 (R #44) of 1 (R #44) resident where CPR was not performed on a resident that was a full code. The resident did not have the opportunity to potentially be revived, and died . If the facility fails to implement their policies regarding reporting incidents of possible neglect to the SA, the SA is not aware of the incident, therefore, the SA is not able to follow up with the facility to ensure resident safety. The findings are: A. Review of the Policy and Procedures for Abuse Prevention Program read the following: "Policy: It is the policy of (name of facility) to affirm the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The facilities therefore prohibit mistreatment, neglect, or abuse of its residents, and have attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. Definitions: Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or in the deterioration of a resident's physical or mental condition. Procedure: 1. The Abuse Prevention Program has seven parts: screening, training, prevention, identification, investigation, protection and reporting/response." B. Review of the face sheet dated [DATE] revealed that R #44 was a Full Code. The resident was admitted on [DATE] and the face sheet revealed that the spouse was the emergency contact (Power of Attorney (POA)). C. Review of the Transfer Orders dated [DATE] (from the local hospital) R #44 was discharged from on page 1, Code Status was marked "Full Code." a. On [DATE] at 8:10 am, during interview, Licensed Practical Nurse (LPN) #1 confirmed the orders but stated she had not seen it. D. Review of the Admission History and Physical dated [DATE] on page 3 of 4 revealed the following, "Code Status: apparently, the patient is Full Code." E. Review of the [MEDICAL CONDITION] consultation report dated [DATE] on page 2 of 3 revealed the following, "Social history: She is a full code for now." F. Review of the admission check list revealed the following, "code status must be completed and signed on admission by the resident/POA." The sheet was not dated or filled out. G. Review of the Acknowledgement of Receipt of Advance Directives/Medical Treatment Decisions (effective date ,[DATE]), revealed that it was not filled out. H. On [DATE] at 6:30 pm, the Executive Administrator, the Administrator, and the DON were interviewed. The DON confirmed that R #44 was a Full Code and that LPN #1 did not follow the doctors order or facility procedure. I. On [DATE] at 7:45 am, during interview, RN #1 stated around 4:30 am CNA #2 called him to check R #44 and to pronounce her (but he was not certified). He stated he checked the pulse, heart rate, pupils and they were fixed. She was not moving. RN #1 confirmed if there is no code status, you treat them as a full code. J. Review of the intake report submitted to the SA revealed that the facility did not report this incident until [DATE] at 6:30 pm after the family called to complain to the DON.

The facility failed to ensure that Resident (R) #44 received proper care and services by not performing Cardiopulmonary Resuscitation (CPR) on a resident who had a physician's orders [REDACTED]. This failure lead to an Immediate Jeopardy (IJ) being identified on [DATE] at 10:40 am. The facility was notified of the IJ at 10:50 am. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 3:45 pm and the IJ was lifted. The scope and severity was lowered to an E. The following is the Plan of Removal: 1. Current resident charts have been audited to verify code status as of [DATE] at 6:00 pm. Current resident charts now have a code status sticker on the chart to identify the resident preference. Resident charts have a red sticker stating DNR (Do Not Resuscitate) or green sticker stating Full Code. Upon admission residents code status paperwork will be filled out by Admission director/charge nurse with resident/responsible party, a call then will be placed to the attending physician for an order. 2. Licensed nursing staff will be in-serviced on falsification of documentation,code status and protocols for code status by 7:00 pm by [DATE] by the Director of Nursing (DON). Nursing staff who are on vacation or leave will be in-serviced prior to accepting an assignment. 3. Certified Nursing Assistants (CNA) and nursing assistants (NA) will be in-serviced on code status and where they are located by 7:00 pm on [DATE] by the DON. CNA's who are on vacation or leave will be in-serviced prior to accepting an assignment. 4. New employees will be in-serviced during orientation on code status, where to locate code status, and protocol of code status. 5. Nurse managers will review within 24 hours code status of any new admits Monday through Friday to verify completion and documentation daily and ongoing. The weekend manager will review code status on Saturday and Sunday for completion and documentation daily and ongoing. If for any reason the resident cannot sign and there is no responsible party, the resident will be identified as full code and the chart will identify that information. 6. Any concerns will be brought to QA (Quality Assurance) monthly for review for three months and then as needed. Based on record review and interview the facility failed to follow physician's orders [REDACTED].#44) of 1 (R #44) Resident. R #44 did not have the opportunity to potentially be revived, and died . This failure could likely cause other resident's in the facility who have a Physicians Order for a Full Code status to not have CPR performed if their heart and respirations stopped. The findings are: A. Review of the physician admission orders [REDACTED]. B. Review of the nurses notes dated [DATE] at 0415 (4:15 am) revealed a note by Licensed Practical Nurse (LPN) #1 that read, "The resident was slumped over while sitting on toilet. At that time I also arrived to find resident unresponsive. Resident was put into bed and no v/s (Vital Signs) or O2 sat (oxygen saturation). I called family to notify them, husband and daughter. During conversation with daughter she mentioned to me that two days prior she had asked her mom regarding DNR (Do Not Resuscitate) status, she stated that mother had expressed not be to revived." C. Review of the nurses notes dated [DATE] at 0449 (4:49 am) revealed a note by Registered Nurse (RN) #2 that read, "Resident found unresponsive in bed. Pupils fixed and dilated. No respirations, no pulse, no blood pressure present. Daughter at bedside with resident." D. On [DATE] at 6:30 pm, the Executive Administrator, the Administrator, and the DON were interviewed. The DON confirmed that R #44 was a Full Code and that LPN #1 did not follow the doctors order or facility procedure.

The facility failed to ensure that Resident (R) #44 received proper care and services by not performing Cardiopulmonary Resuscitation (CPR) on a resident who had a physician's orders [REDACTED]. This failure lead to an Immediate Jeopardy (IJ) being identified on [DATE] at 10:40 am. The facility was notified of the IJ at 10:50 am. The facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 3:45 pm and the IJ was lifted. The scope and severity was lowered to an E. The following is the Plan of Removal: 1. Current resident charts have been audited to verify code status as of [DATE] at 6:00 pm. Current resident charts now have a code status sticker on the chart to identify the resident preference. Resident charts have a red sticker stating DNR (Do Not Resuscitate) or green sticker stating Full Code. Upon admission residents code status paperwork will be filled out by Admission director/charge nurse with resident/responsible party, a call then will be placed to the attending physician for an order. 2. Licensed nursing staff will be in-serviced on falsification of documentation,code status and protocols for code status by 7:00 pm by [DATE] by the Director of Nursing (DON). Nursing staff who are on vacation or leave will be in-serviced prior to accepting an assignment. 3. Certified Nursing Assistants (CNA) and nursing assistants (NA) will be in-serviced on code status and where they are located by 7:00 pm on [DATE] by the DON. CNA's who are on vacation or leave will be in-serviced prior to accepting an assignment. 4. New employees will be in-serviced during orientation on code status, where to locate code status, and protocol of code status. 5. Nurse managers will review within 24 hours code status of any new admits Monday through Friday to verify completion and documentation daily and ongoing. The weekend manager will review code status on Saturday and Sunday for completion and documentation daily and ongoing. If for any reason the resident cannot sign and there is no responsible party, the resident will be identified as full code and the chart will identify that information. 6. Any concerns will be brought to QA (Quality Assurance) monthly for review for three months and then as needed. Based on record review and interview, the facility failed to provide the necessary care and services, Cardiopulmonary Resuscitation (CPR), for 1 (#44) of 1 (#44) residents that was a full code. In the event of heart stoppage, CPR was to be started. When found without a heartbeat or respirations, CPR was not started. The resident did not have the opportunity to potentially be revived, and died . This failure could likely cause other resident's who are a full code to not have CPR performed if their heart and respirations stopped. The facility also administered a medication to R #44 without a Physicians's order. This deficient practice is likely to cause R #44 resident to experience side effects from the medication. The findings are: A. Review of the face sheet dated [DATE] revealed that R #44 was a Full Code. The resident was admitted on [DATE] and the face sheet revealed that the spouse was the emergency contact/Power of Attorney (POA). B. Review of the Transfer Orders dated [DATE] (from the local hospital) R #44 was discharged from on page 1, Code Status was marked "Full Code." a. On [DATE] at 8:10 am, during interview, Licensed Practical Nurse (LPN) #1 confirmed the orders but stated she had not seen it. C. Review of the Admission History and Physical dated [DATE] on page 3 of 4 revealed the following, "Code Status: apparently, the patient is Full Code." D. Review of the [MEDICAL CONDITION] consultation report dated [DATE] on page 2 of 3 revealed the following, "Social history: She is a full code for now." E. Review of the admission check list revealed the following, "code status must be completed and signed on admission by the resident/POA." The sheet was not dated or filled out. F. Review of the Acknowledgement of Receipt of Advance Directives/Medical Treatment Decisions (effective date ,[DATE]), was not filled out. G. Review of the Admission/Transfer orders, which were not dated, on page 4 of 4 revealed R #44's name on it with the date of birth and an "X" for "NO HEROIC RESUSCITATION EFFORTS." a. On [DATE] at 8:10 am, during interview, LPN #1 stated the page was initially blank and that she put an "X" on the "NO HEROIC RESUSCITATION EFFORTS," and attempted to get the daughter and/or husband to sign it the morning after the resident had passed away. She stated the family refused. The nurse verified she had altered the form. H. Review of the nurses notes dated [DATE] at 0415 (4:15 am) revealed a note by LPN #1 that read, "The resident was slumped over while sitting on toilet. At that time I also arrived to find resident unresponsive. Resident was put into bed and no v/s (Vital Signs) or O2 sat (oxygen saturation). I called family to notify them, husband and daughter. During conversation with daughter she mentioned to me that two days prior she had asked her mom regarding DNR (Do Not Resuscitate) status, she stated that mother had expressed not be to revived." I. Review of the nurses notes dated [DATE] at 0449 (4:49 am) revealed a note by Registered Nurse (RN) #2 that read, "Resident found unresponsive in bed. Pupils fixed and dilated. No respirations, no pulse, no blood pressure present. Daughter at bedside with resident." a. On [DATE] at 9:45 am, during interview with RN #2, she stated she was not aware of the code status and was asked by LPN #1 to pronounce the resident since there was no one in her facility that could pronounce. J. Review of the physician admission orders [REDACTED]. K. Review of the Medication Incident Report dated [DATE] at 2000 (8:00 pm) revealed the following, "nurse (name of LPN #1) administered Temazapam. This medication did not have a physician's orders [REDACTED]. L. Review of the administration of medication, not dated, provided by the DON read, "5 Rights to safe medication delivery to residents. These include the following: right drug; right patient; right dose; right route; and the right time. Nurses have 2 roles in medication error prevention: (1) they must check to see that other healthcare providers have not made any errors in any part of the medication order chain; and (2) they must ensure that they themselves do not make an error." M. Review of R #44's Controlled Drug Record revealed that on [DATE] at 2000 (8:00 pm) [MEDICATION NAME] 7.5 mg was administered by LPN #1, without an order. N. On [DATE] at 6:30 pm, the Executive Administrator, the Administrator, and the DON were interviewed. The DON confirmed that R #44 was a Full Code and that LPN #1 did not follow the doctors order or facility procedure. O. On [DATE] at 7:25 am, during interview, NA #1 stated she took R #44 to the bathroom and she (R #44) became weak. LPN #1 got CNA #2 to put R #44 to bed and at that time her Respirations were only 3 per minute. LPN #1 went to check the chart and call the family. RN #1 came in with LPN #1 to check her, but R #44's color had changed, and there were no respiration's. P. On [DATE] at 7:35 am, during interview, CNA #2 stated that R #44 was in the bathroom (BR). She looked like she had passed away. She was slumped down and unresponsive. CNA #2 stated he scooped her up and transferred her to bed. CNA #2 stated the resident was not responding and when he put her to bed, her mouth came open and her skin color had changed. The pulse oximetry registered zero. LPN #1 stated she was going to look at the chart and call the residents husband. The residents respiration's at that time were 3 a minute. They waited for LPN #1 to come back. When LPN #1 came back she stated the chart wasn't completely filled out so she couldn't tell if the resident was a DNR or Full Code and that she was waiting for the husband to call her back. LPN #1 then stated she was going to call the residents daughter. There was no respiration's after he took her V/S. LPN #1 checked her skin. LPN #1 told CNA #2 to call RN #1. RN #1 had his stethoscope and checked her heart rate and pupils. CNA #2 stated that LPN #1 was running back and forth. Q. On [DATE] at 7:45 am, during interview, RN #1 stated that around 4:30 am CNA #2 called him to check R #44 and to pronounce her (but he was not certified). He stated he checked the pulse, heart rate, pupils and they were fixed. She was not moving. RN #1 confirmed if there is no code status, you treat them as a full code. R. On [DATE] at 8:05 am, during interview, CNA #3 stated when she walked in the BR, the resident was slumped over but was still breathing, was very pale, lips were blue so they put the emergency light on in the BR. CNA #2 came in and scooped her up and put her in bed. She stated the nurse came, but was running back and forth. LPN #1 got the blood pressure cuff, then oxygen saturation and her respiration's were 3 per minute. LPN #1 checked the chart, there was no code in the book, so she just tried to get ahold of the daughter or husband. There was no pulse or oxygen saturation. CNA #3 stated there's no communication who's a Full Code at the facility. S. On [DATE] at 8:10 am, during interview with LPN #1, she verified she was the nurse on duty the night R #44 died . She stated it was about 4:10 am when CNA #3 called her to the resident's room. When she arrived at the BR, NA #1 was holding her. R #44 slumped in LPN #1's arms and she tried to wake her but there was no response. They both tried to move her but couldn't, so they got CNA #2. CNA #2 scooped her up in his arms and put her in bed. LPN #1 stated she did an assessment on R #44, but could tell from her color and the way she was breathing that R #44 was almost dead. LPN #1 stated R #44 was a new admit and she was trying to see if she was a DNR. The page wasn't filled out, so she grabbed a stethoscope and told the CNA's to count her breaths before she left. She stated she looked at the face page and asked the husband if she could get the number to R #44's daughter. She stated she then ran back with the stethoscope and there was no heart rate, she was gone. She then got the RN on duty to check R #44 and he checked her vital signs and her pupils. LPN #1 then called the daughter again and she was on her way. The daughter ran in and LPN #1 stated she had told the daughter the sheet was not filled out. LPN #1 stated "I didn't know the code status." The daughter stated she had spoken to her mother just a couple of days ago and asked the exact same question. She didn't want CPR. "I've only had my license for only one year and I didn't know what to do." LPN #1 stated "that's the norm (normal process) here. People just go hold their (resident's in the dying process) hand and give them [MEDICATION NAME], this was just out of the norm." She stated when she talked to the husband, he said to send her to the hospital, but LPN #1 did not do that and she did not initiate CPR. She stated she thinks she asked him about CPR and he said send her to the hospital. LPN #1 stated, "But by the time I went back to the room, she was already gone. From the CNA to the BR to stop breathing, it was about a 10 minute time span. I looked through the chart and she went so quick. This was out of the normal for here. When you open the front flap, there's usually a grid page with allergies and code status. Under advance directives too, but the page was there but not signed or filled out. The norm is if someone is passing to give them comfort measures. I don't know why I didn't send her to the hospital when the husband said because I don't have much contact with him. I was more in contact with the daughter and I thought she was in charge. The admission transfer order was blank that morning. I asked the family to sign it and I checked the box that morning after she had already passed away. The daughter was crying and she said 'I don't want to sign anything. Do you dad' and he said 'No, I'm not signing anything because I told you to send her to the hospital.' They were distraught, but I thought it was from the death but it was because I didn't send her to the hospital. I didn't know he was the POA." T. On [DATE] at 9:45 am, during interview, RN #2 stated they called her to pronounce. She wasn't told anything about code status, just to pronounce. RN #2 stated, "I wouldn't check it (the code status) if they don't tell me. LPN #1 gave me a blank nursing note since they were still working on the admission. If there's not a code status, then I do a Full Code." U. On [DATE] at 2:25 pm, during interview, the R #44's daughter stated "(Name of LPN #1) left a message saying mom was not doing well and that I better come and that she had called my dad. I headed right over." When she arrived there was no vital signs. She stated, "after Mom was gone, Dad and the family arrived in shock." LPN #1 wanted her or the resident's husband to sign a DNR form, she said right now. The daughter stated, "I was not in the mood to sign anything. Two days earlier I had talked about it to my mom because she was very sick and she said she was very sick but didn't know. She didn't want CPR, but was going to let the people decide that. When they called my dad, he told her (LPN #1) to send her (R #44) to the hospital, to call an ambulance." The daughter of R #44 stated she asked LPN #1 if she had given her mom her medications and LPN #1 told her she had given R #44 [MEDICATION NAME] (pain medication) and [MEDICATION NAME] (which was not ordered). V. On [DATE] at 2:50 pm, during interview, R #44's husband/POA stated his wife was discharged from the hospital because she was stable. LPN #1 called him and stated R #44 had to go to the BR and then told the nurse she was not feeling well. She was put in bed and didn't wake up. I think she was overmedicated. They called around 4:45 am and stated R #44 was breathing slow. The husband stated, "I said take her to the emergency room (ER) right away, but they didn't. They asked if I wanted CPR and I said yes until the ambulance gets there and then she asked for my daughter's phone number and waited. The nurse then went back to the room and she had stopped breathing. She called my daughter around 4:23 am, so she must of called me at 4:15 am. The nurse went in the room when we were there and said my wife didn't have anything to be resuscitated and I had told her to do it. The nurse (LPN #1) told us they didn't have a chance to do it. We were all there and she said this was the only form you need to sign is what she said. She always said she wanted to be a full code, even before." R #44's husband stated LPN #1 gave his wife medication for pain and for sleep. He stated he thinks she was overmedicated. W. On [DATE] at 2:25 pm, during interview, the DON confirmed that the husband was the POA and that LPN #1 should have listened to him and sent R #44 to the hospital as he requested. The DON stated, "she failed to do that. She was in a panic." When asked about the admission checklist, the DON confirmed that the code status should have been completed on admission, "that's the process." When asked about the "Acknowledgement of Receipt of Advance Directives/Medical Treatment Decision" form, the DON stated that it is another form that could be used. When asked about the admission/transfer orders, the DON stated "she was trying to get the daughter to sign it after the fact and that's the last thing you do. That's the form she checked off and wanted her to sign. If it's not signed, then they are a full code." When asked about the admission papers, the DON stated "The resident was a full code across the board." X. On [DATE] at 8:50 am, during interview with the DON, he stated a medication error report was completed because LPN #1 had given [MEDICATION NAME] to R #44 the night the resident passed away and there was not an order for [REDACTED].

Based on interview and record review, the facility failed to maintain the dignity of 3 (R #4, 47, 54) of 3 (R #4, 47, 54) residents by not providing incontinence products that promote the residents dignity and independence. This deficient practice likely caused the residents to feel embarrassed. The findings are: A. On 05/02/12 at 3:27 pm, during interview, when asked if she felt that staff treats R #54 with respect and dignity, R #54's daughter stated "They use pampers instead of pull-ups. They fall off much easier and it is a dignity issue because she (R #54) gets embarrassed." B. Review of R #54's record revealed the following: 1. Bladder and Bowel assessment dated [DATE] indicated that the resident was alert, oriented times one and has a diminished perception of need to void. 2. Minimum Data Set ((MDS) dated [DATE] indicated the following: a. [DIAGNOSES REDACTED]. b. Resident needs limited assistance, with a one person physical assist, for toilet use. 3. Care plan dated 08/12/10, with a revision date of 02/09/12, indicated under Problems "Potential for complications related to occasional incontinence of bladder. Requires limited assist with per-care. Wears pull-ups" 4. Care Plan Conference Attendance Record dated 03/02/12, under Resident/Family Concerns indicated "C/o (Complain of) 'diaper' wants pull ups." Under Follow Up, it indicates "use brief with liner." C. On 05/11/12 at 8:49 am, during interview, R #47 stated that she was upset when they stopped using the pull-ups. She stated that she preferred them because, when she uses the briefs, they are harder to use, so she has to ask for help and she feels embarrassed. D. Review of R #47's record revealed the following: 1. MDS dated [DATE] indicated the following: a. [DIAGNOSES REDACTED]. b. Resident needs limited assistance, with a one person physical assist, for toilet use. 2. Care plan dated 07/04/10, with a revision date of 03/15/12, indicated under Problems "Self-care deficit: Requires extensive assist with ADL's related to history of [MEDICAL CONDITION]. She is active in her own care. Able to dress upper and lower extremities with cueing with limited assist. Personal hygiene with set-up." E. On 05/11/12 at 9:02 am, during interview, R #4 stated that they took away the pull-ups several months ago and she does not like it. "We have to wear the briefs or those mesh panties with the pads. They are uncomfortable and they make me feel embarrassed. The pads that we use do not stay in place. I have seen residents walking down the hall with the pad coming down their leg and they are crying." F. Review of the Minimum Data Set (MDS) for R #4 dated 03/15/12 indicated the following: 1. [DIAGNOSES REDACTED]. 2. Resident was coded as needing extensive assistance with one person physical assist for toilet use. 3. Bladder and Bowel assessment dated [DATE] indicated that the resident was alert, oriented and had occasional bladder accidents. G. On 05/11/12 at 8:28 am, during interview, Certified Nursing Assistant #9 stated "Some of the residents prefer the pull-ups. They took away the pull-ups about 6 months ago. Some of the residents feel like it has affected their dignity." H. On 05/14/12 at 2:23 pm, during interview, the MDS Coordinator stated "We still have received complaints regarding the pads. The mesh panties with the pad do require more staff intervention to help ensure that the pad stays in place."