Every finding on record at Shalom Gardens Health & Rehabilitation

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide basic life support measures to include initiation of cardiopulmonary resuscitation (CPR) in accordance with the resident's wishes/advance directives for one of twenty-four residents in the survey sample (Resident #1). Resident #1, with physician orders for a full code status requiring CPR in case of cardiac/respiratory arrest, had no immediate assessment, basic life saving measures, or CPR efforts initiated, when the resident was found unresponsive and without pulse/respirations, resulting in the resident being pronounced deceased . This failure resulted in the identification of immediate jeopardy and substandard quality of care.The findings include:Resident #1, ordered with a full code resuscitation status, had no immediate assessment, CPR initiated, or other life sustaining measures initiated when the resident was found unresponsive and without pulse/respirations on [DATE], instead the resident was pronounced deceased .Resident #1 (R1) was admitted to the facility with diagnoses that included cerebral infarction (stroke) with hemiplegia, aphasia, dysphagia with gastrostomy, respiratory failure with hypoxia, diabetes, hypertension, insomnia and gastroesophageal reflux disease (GERD). The minimum data set (MDS) date [DATE] assessed R1 with severely impaired cognitive skills.R1's clinical record documented the resident was pronounced deceased on [DATE] at 12:30p.m.R1's clinical record documented a physician's order dated [DATE] for a full code resuscitation status in case of cardiac/respiratory arrest. R1's plan of care at the time of the resident's death listed the resident's resuscitation status as full code with interventions listed to follow code status as ordered by the physician and education of staff regarding the resident's resuscitation status.R1's clinical record included a nursing noted entered by licensed practical nurse (LPN) #1 on [DATE] stating a scheduled second nurse on the unit did not show for work. LPN #1 documented on [DATE], .I received the keys from the night nurse only because the scheduler said she just got off the phone with the second nurse and she would be here in 10 minutes. I started med [medication] pass with a lot of interruption it was extremely busy; I texted the scheduler around 10 am to say I don't see the 2nd nurse, she replied I'm working on getting someone in to work. After completing med pass around 12:30, DON [director of nursing] approached me to say I need to start med pass on the 2nd cart and to complete the blood sugars I went to check [Resident #1] and touched her arm to say I planned on doing and notice she was unresponsive I then called out to the CNA [certified nurse's aide] for help, then we contacted DON. (sic) LPN #1 documented no assessment of R1 for vital signs (blood pressure, pulse, respirations) and initiated no life support efforts including CPR and made no mention of the resident's code status.A nursing note was entered in R1's record by registered nurse (RN) #1 on [DATE] at 4:38 p.m. that documented, .Was alerted to come to the room. Resident was found unresponsive in the bed. Assessed resident and no spontaneous respirations observed. No palpable carotid pulse noted upon palpation. No heart sounds auscultated with stethoscope for one full minute. Extremities were cold to the touch. No signs of life observed. Pronounced deceased at 1230 [12:30 p.m.] . An addendum listed as a late entry was documented by RN #1 on [DATE] stating, .Was alerted to come to the room. Resident was found unresponsive in the bed. Assessed resident and no spontaneous respirations observed. No palpable carotid pulse noted upon palpation. No heart sounds auscultated with stethoscope for one full minute. Extremities were cold to the touch. Resident noted to be pale in color. Mouth open and eyes closed. Rigor mortis present. No other signs of life observed. Pronounced deceased at 1230 . RN #1 initiated no CPR, documented no mention of the resident's code status or any explanation of why CPR was not or had not been initiated.R1's clinical record documented a note by the then Administrator (other staff #5) stating that he notified R1's family on [DATE] at approximately 1 p.m. of the resident's death. This note documented, .Emergency Medical Technicians (EMTs) were notified and responded to the facility to assess [R1]. Upon their arrival and assessment, they confirmed that [R1] had expired . The Administrator documented no mention of R1's code status or any rationale for why staff had not initiated CPR.The nurses involved (LPN #1, RN #1), the DON and the Administrator documented no explanation of why CPR was not initiated when R1 was found responsive and subsequently with no pulse or respirations. The clinical record provided no explanation or rationale for why basic life saving measures were not initiated. It was unclear from the documentation of who called emergency medical services regarding the resident's condition.R1's clinical record documented the resident was assessed on [DATE] by the nurse practitioner for respiratory congestion and was prescribed an antibiotic and nebulizer treatments. The nebulizer treatment was administered on [DATE] at 9:00 p.m. with the antibiotic scheduled to start on [DATE] at 9:00 a.m. R1's clinical record documented care during the prior night shift (11:00 p.m. to 7:00 a.m.) with no changes in condition noted/documented. The night shift nurse caring for R1 on [DATE] until 7:00 a.m. documented changing of the gastric tube syringe, checking gastric tube residuals, care to the gastric tube site, gastric tube flushes as ordered in addition to a pain assessment with no care concerns noted. CNA #1 that cared for R1 on [DATE] starting at 7:00 a.m., documented care/assistance had been provided for R1 during the morning prior to 11:00 a.m. CNA #1 entered in the care tracking system on [DATE] at 10:53 a.m. that assistance had been provided for R1 that included bed mobility, dressing, personal hygiene and incontinence care for a bowel movement. R1's clinical record documented no nursing care, assessments or medication administration for R1 on day shift on [DATE] that started at 7:00 a.m. There was no nursing documentation for R1 until the resident was found unresponsive around 12:30 p.m. R1's physician ordered medications and treatments scheduled for [DATE] at 9:00 a.m., were not administered. This included the following: insulin per sliding scale (based on blood sugar reading), aspirin and Plavix for stroke prevention, esomeprazole magnesium for GERD, lisinopril and carvedilol for hypertension, polyethylene glycol for constipation, baclofen for dysarthria, and the antibiotic amoxicillin and albuterol nebulizer treatment for the newly diagnosed upper respiratory congestion.The nursing schedule was reviewed and documented two nurses were scheduled to work on R1's unit on the day shift (7:00 a.m. to 3:00 p.m.) on [DATE]. The as-worked schedule documented LPN #1 worked the shift starting at 7:00 a.m. but the other nurse slot was listed as open with no nurse listed as working prior to R1's death at 12:30 p.m.LPN #1 and CNA #1 that worked on R1's unit on the morning of [DATE] and the DON at the time of R1's death, were not available for interview as they no longer worked for the facility.On [DATE] at 2:25 p.m., RN #1 that pronounced R1's death on [DATE] was interviewed. RN #1 stated [DATE] was her first day working as a registered nurse after just completing education/testing. RN #1 stated she was not working on R1's unit on [DATE] but worked on the adjacent unit on the same floor. RN #1 stated the nurse from unit 2 (LPN #1) came over and said she thought that R1 had passed away. RN #1 stated she went, assessed the resident and pronounced her death. When asked what R1's code status was, RN #1 stated, I don't know. She [R1] was not my patient. When asked how nurses knew the code status for residents, RN #1 stated the code status displayed on the medication record, on physician orders and the 24-hour report sheet. RN #1 stated when she arrived and assessed R1, nobody had called a code or initiated CPR. RN #1 stated she pronounced the resident's death at 12:30 p.m. RN #1 stated that the DON was there. RN #1 stated she was not sure who called 911. RN #1 stated the DON was on the phone when she was assessing the resident and that she assumed the DON was calling 911. On [DATE] at 3:50 p.m. RN #1 was interviewed again about R1's death and no CPR. RN #1 stated the administrator nor the DON, discussed the resident's death with her. RN #1 stated she remembered getting education after the event about what to do if a resident was found unresponsive.On [DATE] at 2:53 p.m., the current DON was interviewed about any assessment or care that had been provided for R1 on the morning of [DATE] prior to being found unresponsive. The DON stated she reviewed the clinical record and CNA #1 documented on [DATE] at 10:53 a.m. that care had been provided that included incontinence care, dressing and personal hygiene. The DON presented no other documentation of care or assessment of R1 prior to being found unresponsive.On [DATE] at 4:52 p.m., the current Administrator, DON and ADON (RN #2) were interviewed about why no assessment and subsequent CPR was initiated for R1 when found unresponsive. The administrator stated none of the current administrative staff (administrator, DON, ADON) worked in the facility at the time of R1's death. The ADON stated she had reviewed the clinical record. When asked if CPR was initiated for R1 on [DATE] and if the resident had a do not resuscitate order, the ADON stated, No. The administrator, DON and ADON offered no explanation of why CPR was not initiated for R1 when the resident was a full code.On [DATE] at 8:26 a.m., the Administrator (other staff #5) at the time of R1's death was interviewed by phone. The former Administrator stated on the morning of [DATE], he was observing residents in the dining room on R1's unit. The former Administrator stated he saw the DON coming down the hall around 12:30 p.m. The former Administrator stated the DON said she was looking into rooms, performing rounds and that he accompanied the DON with the rounding. The former Administrator stated R1's room was the fourth room they observed during the walk-through. The former Administrator stated when they entered R1's room, R1 was in bed, the head of the bed up, eyes closed and that R1 looked like she had expired. The former Administrator stated the DON had a stethoscope and checked the resident and said R1 was no longer with us. The former Administrator stated the resident was cold, pale, bluish and had a stiff body. The Administrator stated he was not sure how long R1 had been in that condition. The Administrator stated he called the MDS nurse to come to assist with post-mortem care, that he left the room at that time and called to notify the family of the death. The Administrator stated emergency services were called and came but he did not recall who called them. When asked if CPR was initiated or attempted for R1, the former administrator stated, I cannot speak to that. The former Administrator stated he was not in the room when emergency services were called and no one else was in the room when he observed the resident other than the DON. The former Administrator stated R1 had been a long-term resident in the facility, and he was aware that she was a full code. The former Administrator stated that when he saw the resident and touched her, there were signs of rigor mortis and that was a reason listed in policy to not to do CPR. The former Administrator stated prior to entering the room with the DON, no staff members had informed him of the resident's death and that he had no conversation with LPN #1 or RN #1 about the death or circumstances surrounding the death. The former Administrator stated the DON did not appear shocked when they entered R1's room and found her with signs of death. The former Administrator was asked if there were concerns about why CPR had not been initiated or if the circumstances around R1's death were reviewed and/or discussed following the incident. The former Administrator stated he thought deaths were reviewed in the morning meeting. The former Administrator stated the next day was Friday ([DATE]) and he left the facility for an appointment at 11:30 a.m. and returned later in the afternoon. The former Administrator stated [DATE] was his last day working as Administrator of the facility and he was not sure what if any actions were taken in response to the death. The former Administrator offered no explanation of why R1 was not assessed when found unresponsive by LPN #1 or why staff had not started CPR when the resident had no pulse/respirations. The former Administrator stated that finding a resident with rigor mortis was in the policy as a reason not to perform CPR but did not indicate that was what occurred with R1's death. The former Administrator voiced that he was unaware of the resident's death until he entered the room with the DON, that the DON assessed the resident with a stethoscope in his presence and that he had no conversation with the RN that pronounced the resident's death (RN #1) or LPN #1 that first found the resident unresponsive. The facility presented certificates listing that LPN #1, RN #1 and the former DON (other staff #4) had been trained to perform CPR at the time of R1's death.The facility presented an in-service education sheet dated [DATE] addressed to all nurses and CNAs regarding the topic titled Code Blue. This education documented instructions that if a patient was found unresponsive, dial *88, call code blue and name room number, to start CPR if the patient was a full code until emergency services arrived. This sheet had signatures of forty-seven nursing staff members (RNs, LPNs, CNAs).The facility's policy titled Cardiopulmonary resuscitation (CPR) (undated) documented, The facility will provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care, prior to the arrival of emergency medical personnel, in accordance with physician orders, such as a DON, and the resident's advance directives . This policy defined basic life support as, .a level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital, and may include recognition of sudden cardiac arrest, activation of the emergency response system, early cardiopulmonary resuscitation . The policy listed under procedures/guidance, .Staff will initiate CPRT when cardiac or pulmonary arrest occurs, unless .A valid DO Not Resuscitate (DNR) order is in place .There is an obvious clinical sign of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition); or .Initiating CPR could cause injury or peril to the rescuer . The facility's policy titled Death of A Resident - Documenting (undated) documented, .Appropriate documentation shall be made in the clinical record concerning the death of a resident .All information pertaining to a resident's death (i.e., date, time of death, the name and title of the individual pronouncing the resident dead, etc.) will be recorded on the nurses' note .All records will be completed and maintained in the resident's medical record in accordance with federal/state law .Facility staff failed to immediately assess R1's vital signs when the resident was found unresponsive on [DATE] at around 12:30 p.m. LPN #1 documented she left the resident to notify staff of the resident's condition instead of assessing and initiating potentially life-saving CPR. RN #1 that came from another unit and assessed and pronounced the resident's death, stated she was not aware of the resident's code status because R1 was not her patient. The interview with the former administrator working in the facility when R1 died, provided conflicting information and timing to the events documented and/or stated by LPN #1 and RN #1. It was unclear to the survey team why the DON assessed R1 when seen with the administrator when the resident's death was pronounced by RN #1 at 12:30 p.m. It was unclear who called 911 emergency services for R1 or when and interviews with RN #1 and the former administrator offered no explanation of why R1 was not immediately assessed and CPR started as required. No staff members, including the DON or RN #1, documented that CPR was not initiated due to rigor mortis.On [DATE] at 10:45 a.m., after consulting with the state agency supervision, immediate jeopardy was identified regarding facility staff's failure to initiate CPR for R1 who had a physician order for CPR. The administrator, DON, ADON and regional nurse consultant were notified at this time of the immediate jeopardy, and a plan of removal was requested. The facility's plan of immediacy removal was presented and included the following.Resident #1 expired on [DATE]All residents currently residing at the facility have the potential to be affected by this practice. All residents' code status preferences verified and updated accordingly.Licensed nursing staff in-serviced on policy regarding Death of a resident and Cardiopulmonary Resuscitation. Any staff not present on [DATE] will be required to receive mandatory education prior to the start of their next shift. No staff will be allowed to return to work after [DATE] until this mandatory education has been completed. New hire orientation will include this education/training as part of the new hire process and all agency staff will be required to complete training/education prior to starting work in the facility.A 100% audit was completed on code status of admission and re-admission for resident preferences for advanced directives.The medical director was notified of the situation on [DATE].The facility conducted an Ad Hoc QAPI meeting to accept the immediate jeopardy removal plan on [DATE].Date of compliance [DATE] at 6:00 p.m.On [DATE], the survey team reviewed the facility policies for death of a resident and cardiopulmonary resuscitation. The audits of resident's code status conducted by the facility were reviewed and a sample of residents was reviewed to ensure accuracy and documentation within the clinical record of code status per residents' wishes. The survey team conducted staff interviews with licensed nurses and certified nursing aides on each of the units and confirmed education had been completed and staff were knowledgeable about the CPR and resident death policies. Staff records were reviewed and verified nursing staff had current CPR certification. After verification of the plan of immediate jeopardy removal and consultation with state agency supervisory staff, the immediate jeopardy was removed on [DATE] at 12:00 p.m. at which time the facility administration was notified. Following the removal of the immediate jeopardy status, this deficiency was cited at level 3, isolated (harm).

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide sufficient nursing staff for assessment/monitoring of one of twenty-four residents in the survey sample (Resident #1). With no nurse assigned, Resident #1 had no assessment or administration of medications/treatments on the morning [DATE]. Resident #1 was found unresponsive on [DATE] at 12:30 p.m. without pulse or respirations and was pronounced deceased without initiation of required CPR (cardio-pulmonary resuscitation). This resulted in the identification of immediate jeopardy.The findings include:Staffing schedules documented no nurse assigned to care for Resident #1 on [DATE] during the day shift (7:00 a.m. to 3:00 p.m.). Resident #1 had no documented nursing assessments or medications administered on the morning [DATE], was found at 12:30 p.m. unresponsive and subsequently without pulse or respirations and was pronounced deceased without initiation of required CPR. A nurse scheduled to report shortly after 7:00 a.m. did not report for duty and no other nurse was assigned to care for the resident.Resident #1 (R1) was admitted to the facility with diagnoses that included cerebral infarction (stroke) with hemiplegia, aphasia, dysphagia with gastrostomy, respiratory failure with hypoxia, diabetes, hypertension, insomnia and gastroesophageal reflux disease (GERD). The minimum data set (MDS) date [DATE] assessed R1 with severely impaired cognitive skills.R1's clinical record included a nursing noted entered by licensed practical nurse (LPN) #1 on [DATE] stating a scheduled second nurse on the unit did not show for work. LPN #1 documented on [DATE], .I received the keys from the night nurse only because the scheduler said she just got off the phone with the second nurse and she would be here in 10 minutes. I started my med [medication] pass with a lot of interruption it was extremely busy, I texted the scheduler around 10 am to say I don't see the 2nd nurse, she replied I'm working on getting someone in to work. After completing med pass around 12:30, DON [director of nursing] approached me to say I need to start med pass on the 2nd cart and to complete the blood sugars I went to check [Resident #1] and touched her arm to say I planned on doing and notice she was unresponsive I then called out to the CNA [certified nurse's aide] for help, then we contacted DON. (sic) LPN #1 documented no assessment of R1 for vital signs (blood pressure, pulse, respirations) and initiated no life support efforts including CPR and made no mention of the resident's code status.A nursing note entered in R1's record by registered nurse (RN) #1 on [DATE] at 4:38 p.m. documented, .Was alerted to come to the room. Resident was found unresponsive in the bed. Assessed resident and no spontaneous respirations observed. No palpable carotid pulse noted upon palpation. No heart sounds auscultated with stethoscope for one full minute. Extremities were cold to the touch. No signs of life observed. Pronounced deceased at 1230 [12:30 p.m.] . An addendum listed as a late entry was documented by RN #1 on [DATE] stating, .Was alerted to come to the room. Resident was found unresponsive in the bed. Assessed resident and no spontaneous respirations observed. No palpable carotid pulse noted upon palpation. No heart sounds auscultated with stethoscope for one full minute. Extremities were cold to the touch. Resident noted to be pale in color. Mouth open and eyes closed. Rigor mortis present. No other signs of life observed. Pronounced deceased at 1230 . R1's clinical record documented a note by the then Administrator (other staff #5) stating that he notified R1's family on [DATE] at approximately 1 p.m. of the resident's death. This note documented, .Emergency Medical Technicians (EMTs) were notified and responded to the facility to assess [R1]. Upon their arrival and assessment, they confirmed that [R1] had expired . R1's clinical record documented a physician's order dated [DATE] for a full code resuscitation status in case of cardiac/respiratory arrest. The nursing schedule was reviewed and showed two nurses were scheduled to work on R1's unit on the day shift (7:00 a.m. to 3:00 p.m.) on [DATE]. The as-worked schedule documented LPN #1 worked the shift starting at 7:00 a.m. but the second nurse for the unit was marked as open with no nurse listed as working this slot prior to R1's death at 12:30 p.m.R1's clinical record documented the resident was assessed on [DATE] by the nurse practitioner for respiratory congestion and was prescribed an antibiotic and nebulizer treatments. The nebulizer treatment was administered on [DATE] at 9:00 p.m. with the antibiotic scheduled to start on [DATE] at 9:00 a.m. R1's clinical record documented care during the prior night shift (11:00 p.m. to 7:00 a.m.) with no changes in condition noted/documented. The night shift nurse caring for R1 on [DATE] until 7:00 a.m. documented changing of the gastric tube syringe, checking gastric tube residuals, care to the gastric tube site, gastric tube flushes as ordered in addition to a pain assessment with no care concerns noted. R1's clinical record documented no nursing care, assessments or medication administration for R1 on day shift on [DATE] that started at 7:00 a.m. There was no nursing documentation for R1 until the resident was found unresponsive around 12:30 p.m. R1's physician ordered medications and treatments scheduled for [DATE] at 9:00 a.m. were not administered. This included the following: insulin per sliding scale (based on blood sugar reading), aspirin and Plavix for stroke prevention, esomeprazole magnesium for GERD, lisinopril and carvedilol for hypertension, polyethylene glycol for constipation, baclofen for dysarthria, and the antibiotic amoxicillin and albuterol nebulizer treatment for the newly diagnosed upper respiratory congestion.LPN #1 that worked on R1's unit on the morning of [DATE] and the DON at the time of R1's death, were not available for interview as they no longer worked for the facility.On [DATE] at 2:25 p.m., RN #1 that pronounced R1's death on [DATE] was interviewed. RN #1 stated [DATE] was her first day working as a registered nurse after just completing education/testing. RN #1 stated she was not working on R1's unit on [DATE] but worked on the adjacent unit on the same floor. RN #1 stated the nurse (LPN #1) from unit 2 came over and said she thought that R1 had passed away. RN #1 stated she went, assessed the resident and pronounced her death at 12:30 p.m. RN #1 stated that the DON was there and on the phone when she assessed/pronounced the resident. On [DATE] at 2:53 p.m., the current DON was interviewed about any assessment or care that had been provided for R1 on the morning of [DATE] prior to being found unresponsive. The DON stated she reviewed the clinical record and CNA #1 documented on [DATE] at 10:53 a.m. that care had been provided during the shift that included incontinence care, dressing and personal hygiene. The DON presented no documentation of nursing care, assessment or medicines administered for R1 prior to being found unresponsive.On [DATE] at 4:52 p.m., the current Administrator was interviewed about lack of staff on R1's unit on the morning of [DATE]. The Administrator stated none of the current administrative staff (administrator, DON, ADON - assistant director of nursing) worked in the facility at the time of R1's death. A review of the staffing schedule was requested. On [DATE] at 9:00 a.m., the current administrator, DON and ADON (RN #2) were interviewed about staffing on the day of R1's death. The ADON presented the as-worked schedule for [DATE] that documented LPN #1 worked on R1's unit starting at 7:00 a.m. and that another nurse slot was open for that unit with no nurse listed. The ADON stated the schedule indicated a nurse position that morning was open and not filled. The ADON stated she was not working in the facility at that time but currently two nurses were required on R1's unit to provide needed care/services. The ADON stated if a nurse was not available, nurse managers, infection preventionist, ADON or DON were expected to work so that required care was provided. The ADON stated she did not know if or why someone was not assigned to cover the medication cart and provide resident care/assessment for R1 on the morning of [DATE]. The scheduler at the time of R1's death was not available for interview as she no longer worked at the facility.The facility's policy titled Staffing (dated [DATE]) documented, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care pans and the facility assessment .Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care .Facility staff failed to provide sufficient nursing staff for care/services to R1 on the morning of [DATE]. LPN #1 documented reporting to the scheduler that no nurse had shown up to administer medications from the other cart on the unit. Schedules documented another nurse was scheduled for R1's unit on the [DATE] day shift, but the opening was not filled. R1 had no medications or treatment administered as ordered on the morning of [DATE] and no record of nurse monitoring the resident until the resident was found unresponsive. There was no evidence that nurse managers assigned anyone to provide care for R1 on the day shift on [DATE] until around 12:30 p.m. when the resident was found unresponsive and subsequently without pulse or respirations. R1 was pronounced dead on [DATE] at 12:30 p.m.On [DATE] at 10:45 a.m., after consulting with the state agency supervisory staff, immediate jeopardy was identified regarding facility staff's failure to provide sufficient nursing staff for provision of required care/services for R1. The administrator, DON, ADON and regional nurse consultant were notified at this time of the immediate jeopardy, a copy of the immediate jeopardy template was provided, and a plan of removal was requested. The facility's plan of immediacy removal was presented and included the following.Staffing vacancies were noted on [DATE]. Resident #1 no longer resides at the facility.All residents of the facility have the potential to be affected by this practice. The last 30 days of staffing schedules were audited for sufficient nursing staff for assessment/monitoring of the resident.Licensed nursing staff, administrative nursing and staffing coordinator will be re-educated on the Staffing policy regarding sufficient staffing to meet residents' needs. As part of the nursing on-call 24/7 process the designated nurse will fill in for staff vacancies as indicated.A 100% audit was completed of the last 30 days of staffing schedules for sufficient staff for assessment/monitoring of the residents.The medical director was notified of the situation on [DATE].The facility conducted an Ad Hoc QAPI meeting to accept the immediate jeopardy removal plan on [DATE].Date of compliance [DATE] at 6:00 p.m.On [DATE], the survey team reviewed the facility's nursing on-call schedule to ensure there was someone scheduled 24/7. The facility's staffing for the past 30 days was reviewed. The survey team conducted staff interviews with nurses and unit managers on each unit and verified staff were aware of what to do if a nurse did not arrive for their scheduled shift, were aware of the on-call schedule and how to reach the on-call person. Education was documented as provided as listed in the plan of removal. The facility policy regarding Staffing was reviewed.After verification of the facility's immediate jeopardy removal plan and following consultation with state agency supervisory staff, the immediate jeopardy was removed at [DATE] at 11:40am at which time the facility administration was notified. Following the removal of the immediate jeopardy stats, this deficiency was cited at a scope and severity level 3, isolated (harm).

Based on clinical record reviews, observations, staff interviews, and facility documentation the facility staff failed to review and revise the comprehensive person centered care plans for three residents, Resident #15 (R15), Resident # 23 (R23), and Resident #24 (R24) out of a survey sample of 24 residents. The findings included:1. Facility staff failed to implement fall interventions and precautions after R15 had a fall.On 5/5/26, a clinical record review was conducted. During the review, R15's care plan was reviewed. The care plan had a concave mattress as the intervention for R15's fall on 3/9/26 and was the only intervention for that fall.On 5/5/26 at 2:00 pm, an observation was made of R15's bed and he did not have a concave mattress on his bed. It was observed that R15 had an alternating pressure mattress on his bed.On 5/6/26 at 12:48 pm, the Assistant Director of Nursing, (ADON) stated that a concave mattress was initially considered as a fall intervention; however, it was not placed on the resident's bed. The resident currently has an alternating pressure mattress in place due to skin impairment. The ADON stated the concave mattress should have been implemented following the resident's fall on 3/9/26. ADON further acknowledged the care plan should have been updated to include the fall interventions and stated the care plan would be updated at this time. 2. Facility staff failed to implement interventions for R23's fallsOn 5/5/26, a clinical record was reviewed. During the review, there was a progress note written on 3/19/26 that read in part, .resident [R23] found sitting on floor in front of wheelchair. Resident [R23] states she was reaching for her snack and slipped out of chair. Resident [R23] denies pain, denies any injuries. Resident assisted back into chair. Vitals taken, WNL [within normal limits].During the clinical record review there was a progress note dated 4/16/26 that read in part, . This resident [R23] reported to OT that she had a fall yesterday. This writer asked the resident [R23] if she fell and she stated, She fell earlier in the day yesterday, when asked if anyone helped her up she said, some girl and when asked about injuries the resident stated she was not hurt. V/S 133/80, 77, 18, 97.8, 99% on room air. No skin concerns noted r/t to fall, or injuries noted during assessment by this writer. A review of R23's care plan revealed there were no falls or fall interventions implemented following the falls that occurred on 3/19/26 or 4/16/26.On 5/6/26 at 12:48 pm, an interview was conducted with the ADON, and she acknowledged that R23's care plan was not updated with the fall or fall interventions for the falls on 3/19/26 or 4/16/26. 3. Facility staff failed to include R24's behaviors and interventions in the resident's care plan.On 5/4/26 at 1:00 pm, during a tour of the nursing units R24 was observed sitting in her room on her phone yelling and cursing about facility staff members and things she felt they had done. She was saying the staff ignored her call bell, gave her the wrong medications, serves her food in cups and the food was cold. On 5/5/26, a clinical record review was conducted. Throughout the review, progress notes documented behaviors including agitation, yelling, screaming at staff, cursing, refusal of care and medications, wanting medications explained, and being tearful at times. A review of R24's care plan revealed there were no documented behaviors or interventions related to these behaviors.On 5/6/26 at 12:48 pm, An interview with the ADON was conducted regarding R24's care plan. The ADON stated they were waiting for the nurse practitioner to evaluate the resident so diagnoses could be obtained to address the behaviors and determine appropriate care plan interventions. The ADON stated she understood the resident's behaviors were documented throughout the progress notes and acknowledged the care plan had not been updated. The ADON stated, We need her to see the in-house psychiatric provider to see if we can meet her needs. ADON acknowledged the care plan needed to be completed and revised, stating, we are trying, but it's hard to do when her behavior is not the same daily.On 5/6/26, a facility documentation review was conducted. The facility policy titled, Care Planning - Comprehensive Person-Centered, read in part, . A person-centered comprehensive care plan that includes measurable objectives and resident. To the extent the resident's medical, nursing, mental and psychosocial needs shall be developed for each participate in the care planning practicable, the resident/resident representative will be provided with opportunities to participate in the care planning process. 16. The Care Planning/Interdisciplinary a. When Team is responsible for the review and updating of care plans: requested by the resident/ resident representative b. When there has been a significant change in the resident's condition; C. When the desired outcome is not met; d. When goals, needs, and preferences change e. When the resident has been readmitted to the facility from a hospital stay; and f. At least quarterly and after each OBRA MDS assessment. On 5/6/26, a meeting was held with the administrator, director of nursing, and the assistant director of nursing and they were made aware of the above concerns.No additional information was provided prior to exit conference.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow physician orders for medications/treatments for one of twenty-four residents in the sample (Resident #1) and failed to document ongoing assessments of a wound for one of twenty-four residents in the sample (Resident #3).The findings include:1. Resident #1 was not administered medications/treatments as ordered by the physician. Resident #1 (R1) was admitted to the facility with diagnoses that included cerebral infarction (stroke) with hemiplegia, aphasia, dysphagia with gastrostomy, respiratory failure with hypoxia, diabetes, hypertension, insomnia and gastroesophageal reflux disease (GERD). The minimum data set (MDS) date 6/3/25 assessed R1 with severely impaired cognitive skills.R1's clinical record documented on 8/14/25 the resident had current physician orders for the following medications/treatments that were scheduled for administration at 9:00 a.m.Lispro insulin per sliding scale (based upon blood sugar reading) for treatment of diabetes; aspirin 81 mg (milligrams) for stroke prevention, Plavix 75 mg for stroke prevention, esomeprazole magnesium 40 mg for GERD, lisinopril 10 mg for hypertension, carvedilol 12.5 mg for hypertension, polyethylene glycol 17 grams for constipation, baclofen 5 mg for dysarthria, albuterol sulfate 0.83% 3 milliliters nebulizer for respiratory congestion, amoxicillin 875-125 mg for respiratory congestion and zinc oxide to buttocks for skin protection.R1's medication administration record documented these medications/treatments were not administered on 8/14/25 at 9:00 a.m. as scheduled.R1's clinical record included a nursing note entered by licensed practical nurse (LPN) #1 on 8/14/25 stating a scheduled second nurse on the unit did not show for work. LPN #1 documented on 8/14/25, .I received the keys from the night nurse only because the scheduler said she just got off the phone with he second nurse and she would be here in 10 minutes. I started my med [medication] pass with a lot of interruption it was extremely busy, I texted the scheduler around 10 am to say I don't see the 2nd nurse, she replied I'm working on getting someone in to work. After completing med pass around 12:30, DON [director of nursing] approached me to say I need to start med pass on the 2nd cart and to complete the blood sugars . (sic)On 5/4/26 at 2:53 p.m., the current DON was interviewed about the medications/treatments not provided for R1 on 8/14/25 at 9:00 a.m. as ordered/scheduled. The DON stated the certified nurse's aide (CNA #1) provided care for R1 on the morning of 8/14/25 but presented no documentation the resident's medications or treatments were administered. On 5/5/26 at 9:00 a.m., the current administrator, DON and assistant director of nursing (ADON - RN #2) were interviewed about staffing on R1's unit on 8/14/25. The ADON stated the schedule indicated a nurse position on the morning on 8/14/25 was open and not filled. The ADON stated she was not working in the facility at that time but currently two nurses were required on R1's unit to provide needed care/services that included medication administration. The ADON stated if a nurse was not available, nurse managers, infection preventionist, ADON or the DON were expected to work so that required care was provided. The ADON stated she was not sure if or why someone was not assigned to administer medications for R1 on the morning of 8/14/25. This finding was reviewed with the administrator, DON, ADON and regional nurse consultant during a meeting on 5/5/26 at 4:30 p.m. with no further information provided prior to the end of the survey. 2. Facility staff failed to document thorough assessments of trauma wounds for Resident #3.Resident #3 (R3) was admitted to the facility with diagnoses that included gunshot wounds to both thighs, hyperlipidemia, cognitive communication deficit, dysphagia and respiratory failure with hypoxia. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact.R3's clinical record documented an admission nursing assessment dated [DATE] that listed the resident had gunshot wounds to the front of both thighs. A nursing note dated 8/21/25 at 7:51 p.m. documented diagnosis of gunshot wounds to bilateral extremities. The admission assessment and nursing note documented no assessment of the gunshot wounds describing the appearance, size, characteristics/presence of drainage, odor if any or condition of surrounding skin.R3's clinical record documented physician orders dated 8/22/25 for treatment for the gunshot wounds with daily dressing changes that included cleansing with normal saline, application of Iodoform packing and covering with gauze and ABD pad/tape. R3's medication administration record documented the wound care and dressing changes were provided daily as ordered from 8/22/25 until the resident's discharge on [DATE].Daily skilled nursing notes including weekly skin assessments documented the resident had thigh wounds but did not include descriptive assessment of the wounds. Dressing changes were performed daily as ordered but notes did not document a descriptive assessment of the wounds' status. A physician and/or nurse practitioner assessed R3 on 8/25/25, 8/28/25, 9/1/25, 9/3/25, 9/8/25, 9/9/25 and 9/10/25. The providers documented the wound dressings as intact but listed no descriptive assessment of the wounds. R3 went out of the facility for a surgical follow up visit regarding the gunshot wounds on 8/25/25. Nursing notes documented the surgical consultant requested no changes in treatment but documented no descriptive status of the wounds. A registered nurse assessed R3 on 9/9/25 and documented erythema and edema of the left thigh wound with serosanguineous drainage noted and no edema/drainage of the right thigh wound. This change in wound status was reported to the on-call provider with orders implemented in response to the change in condition. On 5/6/26 at 8:45 a.m., the director of nursing (DON) was interviewed about any wound assessments for R3's thigh wounds. The DON reviewed the clinical record and stated skin assessments were documented, that the resident was seen by the consultant surgeon on 8/25/25 with orders to continue treatments and that nurses monitored the wounds during daily dressing changes. The DON presented no documented descriptive assessments of R3's wounds.On 5/6/26 at 1:08 p.m., the nurse practitioner (other staff #6) that cared for R3 was interviewed. The NP stated dressing changes were performed as ordered. The NP stated R3 was assessed by a consultant surgeon as follow up care for the wounds. The NP stated she was not sure if nursing documented assessments when dressings were changed and that changes in condition or wound status were reported and addressed.The facility's policy titled Wound Care (effective 7/2024) documented the policy purpose was to monitor wounds for signs and symptoms of infection or other complications. This policy documented that wounds would be assessed on admission and at each dressing change with nursing noting the wound appearance (size, color, condition), odor if any, amount of drainage, type of dressing and any concerns if noted and that the nurse would chart their observations on admission and at each dressing change and notify the physician of any changes in condition.This finding was reviewed with the administrator, DON, assistant director of nursing and regional nurse consultant during a meeting on 5/5/26 at 4:30 p.m. with no further information presented prior to the end of the survey.

Based on staff interviews, clinical record reviews, and facility documentation the facility staff failed to assess the resident following a reported fall for one resident, Resident #23 out of a survey sample of 24 residents. The findings included:The facility staff failed to complete post fall assessments on R23 reported fall.5/4/26 at 2:10 pm an interview was conducted a registered nurse, RN1. RN1 stated that when a fall is reported the resident should be assessed and then the physician and responsible representative (RP) should be notified. She said, if a resident reports a fall, it should be treated as a fall and post assessments should be completed.On 5/6/26 at 12:48 pm, an interview was conducted with the assistant director of nursing, ADON. She stated that R23's fall occurred on 4/15/26. She further stated that post fall assessments were not completed. The ADON stated that agency staff were involved and that the staff member failed to complete the required fall assessments. On 5/6/26, a clinical record review was conducted. RN1 had a progress note she wrote that read in part, .4/16/2026 14:06 Writer asked resident when she had fallen. She stated this morning. Writer asked resident where did she fall at? Resident stated, out there. When writer asked resident how she got up, resident stated, I don't know I dragged myself up I guess. Writer asked nurse if she had any knowledge of this. The nurse stated that the resident said she had fallen the night before and that some woman got her up. Writer went back into residents room and spoke to resident and daughter. Daughter said well she must have fallen because she said so. Reviewed a progress note that was written by a licensed practical nurse, LPN6. The progress note read in part, .4/16/2026 08:48:27 This resident [R23] reported to OT that she had a fall yesterday. This writer [LPN6] asked the resident if she fell and she stated She fell earlier in the day yesterday, when asked if anyone helped her up she said some girl and when asked about injuries the resident stated she was not hurt. V/S 133/80, 77, 18, 97.8, 99% on room air. No skin concerns noted r/t to fall or injuries noted during assessment by this writer.During the review of the clinical record, there was no documentation of post- fall assessments for R23 following the fall on 4/16/26. There were no documented vital signs, neurological checks, or skin assessments completed after the initial progress note of the reported fall.On 5/6/26, a review of facility documentation was conducted. The facility document titled, Fall and Fall management, read in part, Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred (refer to Resident Assessment Instrument User's Manual. Version 3.0, Resident-Centered Approaches to Managing Falls and Fall Risk - 1. The staff, with the input of the attending physician/practitioner, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). This was the policy provided when policy for fall protocol and procedure was requested.On 5/6/26, a meeting was held with the administrator, the director of nursing, and the assistant director of nursing and the above concerns were discussed.No additional information was provided prior to exit conference.

Based on observations, staff interviews, and facility documentation the facility staff failed to ensure medications were securely stored, as evidenced by and unattended and unlocked medication cart on one unit, (Unit One) out of four units. The findings included:The facility staff failed to keep medications secured on one nursing unit.On 5/4/26 at 2:30 pm, an observation was made of a medication cart left unattended on the nursing unit one. The medication cart was positioned sideways in the middle of the hallway, unlocked, with no nurse present at or within sight of the cart. As a surveyor walked by a resident's room, a nurse was observed with her back toward the door and unable to see the medication cart. There were residents and staff in the hallway near the unattended medication cart.An interview was conducted with the licensed practical nurse, LPN5. LPN5 stated that she did not know who moved the cart into the middle of the hallway and stated she usually keeps it at the doorway of the resident's room.On 5/4/26 at 2:45 pm, a second observation was made of the same medication cart, on the same unit and the same nurse (LPN5) had left the cart unattended. The medication cart was sitting at the nurse's station unlocked, and the nurse was not present at the cart The cart was unattended while the nurse walked around from one of the hallways. There were residents and staff in the hallway near the unattended medication cart.An interview was conducted with LPN5 concerning the medication cart being unlocked. She stated it was her first day at the facility and acknowledged that the cart should have been locked.On 5/5/26 at 4:11 pm, an observation was made of an unlocked medication cart on unit one. There were no staff members present on the floor to secure the medication cart. There was residents and staff in the hallway near the unattended medication cart.An interview was conducted with a registered nurse, RN4. She stated that a resident had activated her call bell, so she went down the hall to speak with the resident. RN5 acknowledged that the medication cart should have been locked when she was away from the cart.On 5/5/26, a review of facility documentation was conducted. The policy titled, [ facility company name redacted] Medication Administration, read in part, .Policy Purpose: This policy establishes the guidelines for the safe and effective administration of medications at Hill Valley Healthcare. All medications administered within the facility are subject to these guidelines. Facility-specific nursing policies may override the procedures outlined here when applicable. Procedures I. Security 1. Medication storage areas, including carts, medication rooms, and central supply, must remain locked at all times unless they are in use and directly supervised by the medication nurse or aide.On 5/5/25, an end of day meeting was held with the administrator, director of nursing, assistant director of nursing, and regional of clinical services. The above concerns were discussed.No additional information was presented prior to exit conference.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure that residents were free from significant medication errors for one resident (Resident 104-R104) in a survey sample of seven residents. The findings included:For R104 the facility staff failed to ensure residents were free from significant medication errors by not giving available medication as ordered. R104 was admitted to the facility on [DATE] with diagnoses that included but were not limited to Parkinson's Disease, epilepsy, coronary artery disease, neuropathy, anxiety disorder, major depressive disorder, dementia and dysphagia. R104's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/22/26 coded R104 as having a BIMS (Brief Interview of Mental Status) score of 10 out of a possible 15, indicating moderate cognitive impairment. Section GG of the MDS coded the resident as Dependent on staff for all aspects of care, turning repositioning, mobility in wheelchair, sit to stand, turn and pivot, as well as all aspects of ADL (Activities of Daily Living) care. On 6/23/26 a review of the clinical record revealed that R104 had the following orders: Carbidopa-Levodopa Oral Tablet 25-100 Mg Give 2 tablet by mouth three times a day related to Parkinson's Disease -Start Date-10/26/2023 8 pm (Medication is for the treatment of Parkinsons Disease) Gabapentin Oral Capsule 100 MG Give 1 capsule by mouth one time a day related to mononeuropathy -Start Date-03/31/2026 9 am (This medication is used to control neuropathic pain) Gabapentin Oral Capsule 100 MG Give 2 capsules by mouth one time a day related to mononeuropathy capsules -Start Date-03/30/2026 7pm A review of the MAR (Medication Administration Record) revealed Gabapentin was not given on 6/19/26 at 9:00 am and 7:00 pm A review of the Progress Notes revealed the following entries: A review of the nurses notes revealed the following: 6/19/26 11:26 am Gabapentin Oral Capsule 100 MG Give 1 capsule by mouth one time a day related to mononeuropathy (9:00 AM ) Not available NP made aware with NNO [No New Orders]. NP [Nurse Practitioner] to reorder. 6/19/26 6:10 pm - Gabapentin Oral Capsule 100 MG Give 2 capsule by mouth one time a day related to mononeuropathy (7:00 PM) on order. A review of the MAR (Medication Administration Record) revealed that on 6/22/26 R104 was not given 2 doses of Carbidopa / Levodopa (the 8:00 am and 12:00 pm doses were coded as nine see nurses note). A review of the Progress Notes revealed the following: 6/22/26 Carbidopa-Levodopa Oral Tablet 25-100 MG Give 2 tablet by mouth three times a day related to PARKINSON'S DISEASE reordered A review of the Omni-cell (electronic medication dispenser aka stat box) contents revealed that gabapentin 100 mg and 300 mg, as well as Carbidopa-Levodopa 25-100 mg were available for use. On 6/24/26 at approximately 11 am an interview was conducted with the Director of Nursing (DON) who stated that it is the facility's expectation that nurses first check the omni-cell when they do not have medication on the cart. On 6/24/26 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on staff interviews, clinical record review, and facility documentations the facility staff failed to notify the responsible party about a fall for one resident, Resident #23 (R23) out of a survey sample of 24 residents. The findings included:Facility staff failed to notify the responsible party of R23's reported fall.On 5/4/26 at 2:10 pm an interview was conducted a registered nurse, RN1. RN1 stated that when a fall is reported the resident should be assessed and then the physician and responsible representative (RP) should be notified. She said, if a resident reports a fall, it should be treated as a fall and post assessments should be completed.On 5/6/26 at 12:48 pm, an interview was conducted with the assistant director of nursing, ADON. She stated that R23's fall occurred on 4/15/26. She further stated that post fall assessments were not completed. The ADON stated that agency staff were involved and that the staff member failed to complete the required fall assessments. She also acknowledged that the RP should have been notified but was not. Additionally, she acknowledged that the care plan was not updated following the fall. On 5/6/26, a clinical record review was conducted. RN1 had a progress note she wrote that read in part, .4/16/2026 14:06 Writer asked resident when she had fallen. She stated this morning. Writer asked resident where did she fall at? Resident stated, out there. When writer asked resident how she got up, resident stated, I don't know I dragged myself up I guess. Writer asked nurse if she had any knowledge of this. The nurse stated that the resident said she had fallen the night before and that some woman got her up. Writer went back into residents room and spoke to resident and daughter. Daughter said well she must have fallen because she said so. Reviewed a progress note that was written by a licensed practical nurse, LPN6. The progress note read in part, .4/16/2026 08:48:27 This resident [R23] reported to OT that she had a fall yesterday. This writer [LPN6] asked the resident if she fell and she stated She fell earlier in the day yesterday, when asked if anyone helped her up she said some girl and when asked about injuries the resident stated she was not hurt. V/S 133/80, 77, 18, 97.8, 99% on room air. No skin concerns noted r/t to fall or injuries noted during assessment by this writer.The clinical record had no documentation of any staff member notifying the responsible representative of the reported fall by R23 on 4/16/26 and the care plan had no recorded fall for that day or any interventions.On 5/6/26, facility documentation was reviewed. The document titled, Change in a Resident's .Condition, read in part, .The facility will promptly notify the resident, his or her physician/practitioner, resident's medical/mental condition and representative of changes in the etc.). and/or status (e.g., changes in level of care, billing/payments, resident rights. 1. The nurse a(an): will notify the resident's Attending Physician / practitioner or physician on call when there has a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in e. health, need to mental, or psychosocial status in either life-threatening conditions or clinical complications) alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times); g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the physician/practitioner of changes in the resident's condition.On 5/6/26 a meeting was held with the administrator, the director of nursing, and the assistant director of nursing and the above concerns were discussed.No additional information was presented prior to exit conference.

Based on observations, medical records review, and staff interviews, the facility failed to ensure one of five residents (Resident #3) received emergency treatment and care in accordance with professional standards of practice. The findings include: Resident #3 was admitted to the facility on [DATE] with a diagnosis of diabetes, cerebral infractions (stroke), dysphagia (difficulty swallowing), Muscle and Facial Weakness, Transient Cerebral Ischemic Attack, DNR, Contracture of Muscles (Right Upper Arm), and Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Right Dominant Side. Resident #3's Care Plan dated [DATE] documented the resident as having an Activity of Daily Living (ADL) self-care performance deficit determined by impaired mobility due to right hemiplegia related to Cerebral Vascular Accident (CVA). Resident requires assistance with personal care due to weakness. Resident #3's intervention established by the facility was to offer cues, supervision and a meal tray to be set up at mealtime. Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE], the resident was coded as needing supervision or touch assistance for eating (The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). An interview was conducted with Family Member #1 on [DATE] at 2:35 PM. He stated the DON contacted the family with details regarding Resident #3 choking incident. He expressed the DON told him the nurses were unable to perform Abdominal Thrusts because Resident #3 was in a wheelchair. He said the DON told him when Resident #3 became unconscious, there was nothing the nurses could do due to the resident's DNR order. Family Member #1 stated he requested several documents from the facility pertaining to Resident #3 cause of death. Resident #3's nursing notes dated [DATE] at 11:58 AM noted, Resident's tooth came out while eating an apple. No bleeding was noted at the time. Resident denies any pain or discomfort. Resident will continue to be monitored for changes. LPN #1 documented on [DATE] at 12:45 pm, she was notified by the CNAs that Resident #3 was coughing and choking. Resident was removed from the dining room, and large amount of food was retrieved from Resident's mouth. Resident #3 became unresponsive once the food was removed. Resident was assisted to bed by staff. The resident was noted to have no pulse, respiration, or blood pressure (BP). The supervisor and Hospice are aware. The resident expired at 1:08 PM on [DATE]. A Phone Interview was conducted with LPN #1 on [DATE] at 12:08 PM. LPN #1 stated that on [DATE], she was working on Unit 4 for the first time and was unfamiliar with the residents. LPN #1 said she was the only nurse working with three (3) Certified Nurse Assistants (CNAs) caring for 28 residents. LPN #1 stated that prior to lunch, Resident #3 lost a tooth while attempting to eat an apple. Resident #3 had no bleeding or complained of pain from the lost tooth. LPN #1 further stated that she was at the nurse's station with the CNAs when another resident's family member approached and made them aware that Resident #3 was in the dining room choking. No licensed or certified nursing staff monitored the dining room during the lunch meal. CNAs entered the dining room, removed the resident, using the resident's wheelchair, and pushed the resident directly to the nurse's station. LPN #1 stated she remained at the nurse's station, and Resident #3 was observed coughing and choking by the CNAs. LPN #1 said she could remove large amounts of food from the resident's mouth with her fingers. She said Resident #3, at this time, became unresponsive, and his head dropped forward. LPN #1 explained she was alone then, so she started pushing the resident down the hallway towards his room. She stated she attempted to perform abdominal thrusts while pushing the resident's wheelchair. LPN #1 stated she used one hand to push the resident's wheelchair while placing her other hand on the resident's chest, attempting to push down. LPN #1 stated, I really wasn't doing much. During the above interview, LPN #1 stated the CNAs arrived at Resident #3's room and assisted her with transferring the resident into bed. She said Resident #3 was lying in bed, non-responsive, with no pulse, and 911 was called at 12:49 PM. LPN #1 stated the nursing supervisor was notified and came to assist at 1:00 PM. RN #1 Nursing Supervisor, entered Resident #3's room and reassessed the resident to confirm no signs of life were present. Emergency Technicians arrived, and the facility confirmed the resident's hospice/DNR status. Resident #3 was pronounced deceased by the Hospice Nurse at 2:09 PM. LPN #1 stated that the Emergency Cart on the unit, which stored the emergency suction machine and oxygen equipment, was not retrieved during Resident #3's choking emergency. She said was current with her Cardiopulmonary Resuscitation (CPR) certification, which includes basic life support and abdominal thrusts for a conscious choking individual. LPN#1 said she could not confirm which tooth the resident lost just before lunch, and Resident #3 was not assessed for his ability to continue chewing. The surveyor reviewed Resident #4's lunch menu for [DATE], which consisted of Baked Glazed Ham, Baked Sweet Potato, [NAME] Beans, Chilled Pear, and Beverage. A phone interview was conducted on [DATE] at 11:08 AM with RN #1, who was the Nurse Supervisor on duty. RN #1 stated she was at lunch when the Code Blue was called on Unit 4. She was surprised the code was called for Unit 4 because all the residents in Unit 4 are Do Not Resuscitate (DNRs). RN #1 said that when she arrived in Unit 4, no additional staff were present for the emergency. Resident #3 was lying in bed unresponsive. She instructed the staff that Resident #3 was hospice and DNR. She said the emergency cart was not in Resident #3's room. RN #1 stated, If a 'Code Blue' is called, all available staff from other units must come to assist, and the emergency cart should be retrieved. The surveyor reviewed the Facility Emergency Procedure-Choking Policy dated [DATE]. Guidance for Conscious Resident Standing or Sitting: 1. Ask the resident if he or she is choking. Remember, a choking victim cannot speak or breathe and needs your help immediately. 2. Ask the resident to cough or speak, if at all possible, to determine if his or her airway is obstructed. 3. If able to cough, instruct and encourage the resident to continue coughing to dislodge or expel any foreign objects. 4. Call for help but stay with the resident. 5. Quickly assure the resident that you are going to stay and assist him or her. 6. If the resident cannot cough, only then should the abdominal thrusts be performed as follows: a. Stand behind the resident. b. Wrap your arms around the resident waist. c. Make a fist with one hand d. Place the thumb side of your fist against the resident's upper mid-abdomen, below the ribcage and above the navel. e. Grasp your clenched fist with your other hand. f. Press your fist into the resident's upper abdomen with a quick upward thrust. g. Do not squeeze the ribcage. Contain the force of the thrust to your hands. h. Repeat the thrusts until the foreign body is expelled or the resident loses consciousness. The surveyor was not provided any documentation to support why the facility did not immediately offer emergency treatment to Resident #3 while in the dining room per their policy. The facility did not provide any documentation to explain why Resident #3 was removed from the dining room, and his emergency care for a change in condition was delayed. The surveyor found no evidence in Resident #3's medical records supporting the fact that the facility's staff performed abdominal thrusts correctly in accordance with the facility's policy. The Surveyor conducted a tour of the facility Emergency Cart (EC) on Unit 4 with the Unit Manager (UM #1) on [DATE] at 12:15 PM. UM #1 stated not all the residents in Unit 4 were hospice or DNRs. UM #1 showed the Surveyor where Unit 4 EC was stored. UM #1 removed the protective covering from over the cart and started to identify what supplies were on the cart. The surveyor observed the suction machine canister was detached from the suction machine and positioned on the other side of the cart. UM #1 set up the suction machine for use which took approximately 5 minutes. A meeting was conducted with the Director of Nurses (DON) on [DATE] at 10:18 AM. The DON stated the facility utilizes agency nurses to assist with staffing needs. DON stated LPN #1 was an agency nurse who had worked at the facility numerous times. She wasn't aware if LPN #1 worked on Unit 4 previously. DON said that all agency nurses receive their training online and are ready to work when they arrive at the facility. She stated that Resident #3 had a DNR status, and the facility's nurses did everything possible. DON stated Resident #3 became unconscious after choking, and treatment was stopped because of the resident's DNR order. During the meeting, the DON presented the surveyor with undated, unsigned, typed statements regarding the incident from LPN #1 and RN #1. DON stated that the staff had provided the statements after the incident. The surveyor reviewed Resident #3 medical records and found the statements incongruent with the incident documentation in Resident #3's electronic medical records. The medical records did not reveal emergency treatment for the resident who was actively choking, including the implementation of abdominal thrusts that were evident in the typed statements. No CNA statements regarding the incident were presented to the surveyor. The surveyor requested a copy of all nursing staff's CPR cards for verification and the emergency cart facility assessment. All nursing staff had valid and up-to-date BLS cards. The exit meeting was conducted on [DATE] at 3:20 PM with the DON, Director of Clinical Operation (DCO), UM #2, and Facility Administrator. Surveyor informed the facility of concerns regarding Resident #3's treatment and documentation. DCO stated that the facility emergency cart (EC) should be used for any resident emergency because it stores oxygen and suction. She said that if a resident was crashing, it should be used anytime. DCO could not provide the surveyor with an explanation regarding why the CNAs pushed Resident #3 out of the dining room instead of immediately starting treatment. DCO requested a brief break to speak with her team and provided additional information. The exit meeting continued on [DATE] at 3:53PM with the DON, DCO, UM #2, and Facility Administrator. Although there was no documentation to support the actions of the CNAs during this choking incident, the DOC stated she felt that the facility policy for choking was followed. The CNAs were unavailable for interviews at this time. No additional information was provided to the surveyor regarding this matter. The surveyor requested the Facility Assessment regarding the Emergency Cart usage. The Facility Administrator was unable to provide the documentation.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to follow physician orders for 3 of 28 residents (#293, #2 and #30) in the survey sample The findings included: 1. Resident #293, the facility staff failed to ensure that a dressing for a wound on the resident's right lower extremity was changed according to physician's order. Resident #293 was originally admitted to the facility 6/26/24 after an acute care hospital stay. The current diagnoses included; Cellulitis of Right Lower Limb. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/26/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #293 cognitive abilities for daily decision making were moderately impaired. The Care Plan dated 6/27/24 read that Resident #293 has potential for impairment to the skin integrity related to Cellulitis of right lower leg. The goal for Resident #293 was that skin will be intact, free of redness and discoloration. An Intervention was to administer medications, supplements and treatments as ordered. Monitor/document. The June 2023 Order Summary dated 6/27/24 read: Right foot wound care-Remove old packing and apply the Lidocaine for 5 minutes prior to wound care. Cleanse the wound by irrigating it with the Vashe solution (use a syringe) and then wipe the wound bed. Pack the wound with Vashe moistened packing strip and then cover with an Calcium Ag w/silver and bordered dressing. Reapply the sock after dating/timing the dressing. change daily and as needed as needed for wound care. The order details dated 6/27/24 at 8:48 AM., read the above order. The Medication Administration Record (MAR) read to change the above dressing daily and as needed with a start date of 6/27/24 at 9:00 AM., On 6/28/24 at approximately 11:25 AM., Resident #293's family member was observed approaching Registered Nurse (RN) B, Unit Manager. The family member was heard asking RN, B if they going to change the resident's dressing. RN, B informed the family member that the dressing should be changed today. An interview was conducted on 06/28/24 at approximately 11:25 AM., concerning Resident #293. RN, B said that the dressing should be changed today. A review of the Medical Records/MR showed that RN, B revised the wound care orders on 6/28/24 at 11:27 AM., after speaking to the resident's family member concerning wound care. On 6/28/24 at approximately 11:27 AM., Resident #293's dressing was observed on her right foot with a date of 6/26/24. According to the Physician's Order Summary (POS), the dressing on the resident's right foot should have been changed on 6/27/24 during the day shift. On 6/28/24 at approximately 3:20 p.m., the above findings were shared with the Administrator, Director of Nursing (DON) and Corporate Consultant. The DON said that the dressing should have been change according to the orders. 34894 2. For Resident # 2, the facility staff failed to administer medications and treatments on several dates as ordered by the physician . Resident # 2 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Fracture of Left Fibula, Edema, Alzheimer's Disease, Gastroesophageal Reflux Disease, Anxiety and Hypertension. Resident #2's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 05/17/2024 was a quarterly assessment. The MDS coded Resident # 6 with a BIMS (Brief Interview for Mental Status) score of 2 out of 15, indicating severe cognitive impairment. The MDS coded Resident # 2 as requiring extensive to total staff assistance with Activities of Daily Living. Review of the clinical record was conducted 6/26/2024-6/28/2024. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for June 2024, and revealed medications were not administered as ordered by the physician. Those dates were as follows: There were valid Physician orders for the medications and treatments that were omitted. The nursing facility stated Mosby's as their nursing standard. Mosby's stated all medications must be administered by the physician's order. Guidance for nursing standards for the administration of medication provided by Fundamentals of Nursing, 7th Edition, Mosby's/ [NAME]-[NAME], p. 705 stated Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. Resident 2's care plan was reviewed and revealed a care plan that instructed to administer medications and treatments as ordered by the physician. On 6/27/2024 at 10:20 a.m., an interview was conducted with Licensed Practical Nurse D who stated the expectation was for nurses to administer medications and treatments as ordered by the physician. On 6/27/2024, during the end of day debriefing with all surveyors, the Administrator and Director of Nursing were made aware of the failure of staff to administer medications as ordered. The Director of Nursing stated the expectation was for the staff to administer medications and treatments as ordered by the physician. No further information was provided. 31199 3. For Resident #30, the facility staff failed to provide Lidocaine pain patches as ordered by a physician for a Resident with bilateral leg ulcers and leg pain, to manage that pain. The findings included; Resident #30 was admitted on [DATE], with diagnoses including; ESRD (end stage renal disease), dialysis, dysphagia, peripheral vascular disease (PVD) with vascular ulcers, heart failure, heart disease, and cardiac pacemaker. A review of the clinical record revealed that on admission, Resident #30 had no real cognitive impairment, and was able to make her needs known. A review of the clinical record revealed physician's orders given on 5-24-24 for the following; - Lidocaine external patch 4% apply 2 patches to skin topically two times per day for pain, to remove per schedule. The Lidocaine patches were intended for bilateral leg pain (one patch on each leg), and were only ever scheduled to be applied on the medication administration record (MAR) once per day at 9:00 AM, and scheduled to be removed at 9:00 PM. The patches were never scheduled to be applied twice per day as was ordered. On 6-25-24 at approximately 1:00 PM, the Resident was interviewed and stated my legs hurt all the time. The pain patches help but don't last long enough, I need them more often, and sometimes I don't get them at all and some of the girls say you were at dialysis and I can't get them. The MAR was reviewed and revealed that the patches were only scheduled to be given once per day at 9:00 AM, and they were not applied even once per day, and omitted entirely for both ordered doses on the following days; 6-3-24, 6-4-24, 6-5-24, 6-6-24, 6-7-24, 6-8-24, 6-11-24, 6-12-24, 6-18-24, 6-19-24, 6-24-24, and 6-27-24, omitting 12 of 27 daytime doses. All of the 27 evening doses that were ordered, were never scheduled for administration leaving the resident without the prescribed pain medication throughout the evening and night. The Resident only received the pain patches on 4 occasions on her dialysis days for the 27 day period. Those follow; 6-10-24, 6-14-24, 6-17-24, and 6-21-24. Resident #30 went to dialysis on Monday, Wednesday, and Friday, and was scheduled to leave for dialysis at 5:30 AM, (chair time 6:00 AM), and return to the facility at 9:30 AM. which would not have interfered with the 9:00 AM ordered administration time. An interview with LPNs on the afternoon of 6-25-24, revealed that if the medication was ordered to be given twice per day the person transcribing the order made a mistake. When asked to review the MAR, each stated yes, that's clear and it's a mistake. When asked if this meant the resident was without pain medication, the LPNs stated that Residents usually have an order for Tylenol that they can use. They were asked if they felt that Tylenol was adequate pain control for all types of pain, they stated that it was not. They also stated that Resident #30 often complained of leg pain, and back pain. The nursing facility stated Mosby's and [NAME] as their nursing standard. Both followed the NIH guidelines, as below; Nurses follow health care providers' orders unless they believe the orders are in error or harm patients. Therefore you need to assess all orders; if you find one to be erroneous or harmful, further clarification from the health care provider is necessary. To prevent medication or treatment errors, follow the six rights of medication administration consistently every time you administer medications or treatments. Many errors can be linked, in some way, to an inconsistency in adhering to these rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation Resident #30's care plan was reviewed and revealed a care plan for medications to be administered per physician's orders. On 6-26-24, during the end-of-day meeting, the Administrator and Director of Nursing (DON) were made aware of the findings, and they stated they had no further information to provide.

Based on observation, resident interview, facility staff interview, clinical record review, and facility documentation review, the facility staff failed to provide the necessary services to maintain personal hygiene for one resident (Residents # 43) in a survey sample of 28 residents. Findings included: 1. For Resident # 43, the facility staff failed to provide showers as scheduled and failed to document completion of bathing tasks every shift. Resident # 43 was admitted to the facility in June 2024 with diagnoses that included but were not limited to: Multiple Sclerosis, Pulmonary Embolism and Urinary Tract Infection. The most recent MDS (minimum data set) assessment was an Admission assessment with an ARD (Assessment Review Date) of 06/6/2024. The MDS coded Resident #43 with a BIMS (Brief Interview for Mental Status) Score of 15/15 indicating no cognitive impairment. Resident # 43 required extensive assistance of staff persons with ADLs (activities of daily living.) Resident # 43 was coded as continent of bowel and bladder. Review of the clinical record was conducted 6/26/2024-6/28/2024. On 6/27/2024 at 10:30 a.m., an interview was conducted with Resident # 43 who stated no showers had been provided by the facility staff during the 3 week stay at the facility (at the time of the survey.) Resident # 43 stated only on one evening, a Certified Nursing Assistant asked her about getting a shower that evening. Resident # 43 stated she declined the shower that evening because she did not feel well. Resident # 43 stated that she was not offered a shower on the next shift, next day nor any time after that evening. Resident #43 stated she would like to receive showers at least twice a week as scheduled. On 6/27/2024 at 11:20 a.m., an interview was conducted with the Unit Manager who stated she was not aware that Resident # 43 did not receive showers as scheduled. The Unit Manager stated Resident # 43 was alert and oriented with no cognitive impairment. The Unit Manager stated she wanted to talk with Resident # 43. The Unit Manager and surveyor went to Resident # 43's room. The Unit Manager asked Resident # 43 if she had received any showers. Resident # 43 stated she had not received any showers since admission to the facility. Certified Nursing Assistants (CNAs) were interviewed on all three units during survey, and indicated they documented all care in the Point of Care computerized system for each of their residents at the end of every shift. Review of the records for June 2024 revealed there was no documentation of showers being provided twice a week. Review of Resident # 43's physician orders, Treatment administration records (TAR's), Care plan, and progress notes indicated that Resident # 43 needed assistance with Activities of Daily Living. The records indicated that Resident # 43 was dependent on staff for bathing and showering. Review of the ADLs Bathing task revealed there were 9 shifts with missing documentation of the task being provided or completed since admission. Review of the Progress Notes revealed no documentation of reasons for the missing documentation of bathing or showering. On 6/27/2024, the Director of Nursing (DON), and Administrator were interviewed and asked about their expectation for bathing and showering. They stated all residents should receive showers twice a week and bed baths on the other days, and that the provision of care must be documented afterwards. Staff stated that the facility's policy was for residents to receive showers twice a week and bed baths on they days they did not get a shower. On 6/28/2024 at 3:05 p.m., an interview was conducted with the Director of Nursing who stated the expectation was for all residents to receive a bed bath on the days they did not receive a shower. The Director of Nursing stated the staff should document all baths and showers in the clinical record. A review was conducted of the facility policy titled, Activities of Daily Living (ADLs). The policy read, .4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); i. Each resident shall receive tub or shower baths as often as needed, but not less than twice weekly or as required by state law . During the end of day debriefing on 6/28/2024, the facility's Administrator, Director of Nursing and two Corporate Nurse Consultants (Employee-J and Employee N) were informed of the findings. No further information was provided.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure an area on the resident's groin was assessed and reported to the physician for 1 of 28 residents (Resident #74), in the survey sample. The findings included: Resident #74 was originally admitted to the facility 12/05/23 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Traumatic Brain Injury. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/07/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #74 cognitive abilities for daily decision making were intact. The Person-Centered Care Plan dated 12/13/23 read that resident has a potential for impairment to skin integrity related to muscle weakness and incontinence. The goal for the resident was to ensure skin remain intact. Interventions for the resident would be for staff to follow facility policies/protocol for routine skin monitoring and to report any changes and to administer medications, supplements and treatments as ordered. On 06/25/24 at approximately 2:01 PM., during the initial tour an interview was conducted with the resident and Responsible Party (RP). The RP said that Resident #74 has an Ingrown hair follicle to the left groin area for a week that causes irritation. Resident #74 says that the area only hurts when you press on it. The RP also said that she had informed Licensed Practical Nurse C saw the area a week ago. Certified Nursing Assistant (CNA) F entered the resident's room and assisted the RP to show resident's groin area. A visual observation was made of the resident's left groin area. A small brown bump with some redness was observed with no discharge noted. Shortly thereafter, Licensed Practical Nurse (LPN) D entered the room, assessed the area on the resident's left area saying that the Nurse Practitioner will be notified. On 6/26/24 at approximately 2:26 PM., NP, M entered the room, assessed the area on the resident's left groin, asked the resident how long has the area been on the groin. The RP stated that the area has been there for 1 week. The NP informed the resident that she will prescribe an antibiotic. On 06/28/24 at approximately 10:28 AM., an interview was conducted with LPN C. LPN C said that she was not assigned to the resident a week ago but stopped by to see how he was doing. LPN C also said she informed the resident and the resident's RP that the area on the left groin looked like a small hair bump. LPN C also said that she thought that the CNA assigned to the resident was going to inform the resident's nurse, but moving forward she should have informed the nurse as well. A progress note dated on 6/25/24 at approximately 3:14 PM., read: I was asked to exam bump to L groin. Wife reports she noticed it last week and does not think it has become larger in size. He reports mild tenderness to palpation. On exam folliculitis suspected to two (2) follicle areas to L groin merged into one larger nodule about 3/4 inch in length on exam with erythema, no current open pustule areas. Discussed antibiotic treatment with wife and patient and RN and watching catheter as tubing near area can be irritating as well. irritating as well. On 6/28/24 at approximately 3:20 p.m., the above findings were shared with the Administrator, Director of Nursing (DON) and Corporate Consultant. No further comments were made.

Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to provide pain management for one of 28 residents (R #30) in the survey sample. The findings included; For Resident #30, the facility staff failed to provide Lidocaine pain patches as ordered by a physician to manage pain for a Resident with bilateral leg ulcers and leg pain. Resident #30 was admitted on [DATE], with diagnoses including; ESRD (end stage renal disease), dialysis, dysphagia, peripheral vascular disease (PVD) with vascular ulcers, heart failure, heart disease, and cardiac pacemaker. A review of the clinical record revealed that on admission, Resident #30 had no real cognitive impairment, and was able to make her needs known. A review of the clinical record revealed physician's orders given on 5-24-24 for the following; - Lidocaine external patch 4% apply 2 patches to skin topically two times per day for pain, to remove per schedule. The Lidocaine patches were intended for bilateral leg pain (one patch on each leg), and were only ever scheduled to be applied on the medication administration record (MAR) once per day at 9:00 AM, and scheduled to be removed at 9:00 PM. The patches were never scheduled to be applied twice per day as was ordered. On 6-25-24 at approximately 1:00 PM, the Resident was interviewed and stated my legs hurt all the time. The pain patches help but don't last long enough, I need them more often, and sometimes I don't get them at all and some of the girls say you were at dialysis and I can't get them. The MAR was reviewed and revealed that the patches were only scheduled to be given once per day at 9:00 AM, and they were not applied even once per day, and omitted entirely for both ordered doses on the following days; 6-3-24, 6-4-24, 6-5-24, 6-6-24, 6-7-24, 6-8-24, 6-11-24, 6-12-24, 6-18-24, 6-19-24, 6-24-24, and 6-27-24, omitting 12 of 27 daytime doses. All of the 27 evening doses that were ordered, were never scheduled for administration leaving the resident without the prescribed pain medication throughout the evening and night. The Resident only received the pain patches on 4 occasions on her dialysis days for the 27 day period. Those follow; 6-10-24, 6-14-24, 6-17-24, and 6-21-24. Resident #30 went to dialysis on Monday, Wednesday, and Friday, and was scheduled to leave for dialysis at 5:30 AM, (chair time 6:00 AM), and return to the facility at 9:30 AM. which would not have interfered with the 9:00 AM ordered administration time. An interview with LPNs on the afternoon of 6-25-24, revealed that if the medication was ordered to be given twice per day the person transcribing the order made a mistake. When asked to review the MAR, each stated yes, that's clear and it's a mistake. When asked if this meant the resident was without pain medication, the LPNs stated that Residents usually have an order for Tylenol that they can use. They were asked if they felt that Tylenol was adequate pain control for all types of pain, they stated that it was not. They also stated that Resident #30 often complained of leg pain, and back pain. On 6-26-24, during the end-of-day meeting, the Administrator and Director of Nursing (DON) were made aware of the findings, and they stated they had no further information to provide.

Based on observations, clinical record review, staff interview and facility document review, the facility staff failed to acquire medications for 2 of 28 residents (R#2 and R#291) in the survey sample. The findngs include: 1. For Resident # 2, the facility staff failed to ensure medications were available for administration as ordered by the physician. Resident # 2 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Fracture of Left Fibula, Edema, Alzheimer's Disease, Gastroesophageal Reflux Disease, Anxiety and Hypertension. Resident #2's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 05/17/2024 was a quarterly assessment. The MDS coded Resident # 2 with a BIMS (Brief Interview for Mental Status) score of 2 out of 15, indicating severe cognitive impairment. The MDS coded Resident # 2 as requiring extensive to total staff assistance with Activities of Daily Living. Review of the clinical record was conducted on 6/26/2024 to 6/28/2024. Review of the Progress Notes revealed the following documentation regarding medications being unavailable: 6/25/2024-Protonix 40 milligrams one tablet by mouth on order. 6/15/2024-Boost supplement on order. 6/11/2024-Mucinex 400 milligrams three times per day x 3 days on order. Review of the Inventory of Medications on hand at the facility revealed Pantaprazole 40 milligrams was available as a bulk medication in the facility. Review of the June 2024 Medical Administration Record (MAR) revealed the medication, Protonix was documented as not available for administration on 6/25/2024. Review of Physicians Orders revealed valid orders for the medication not available for administration. On 6/27/2024 at 11:48 a.m., an interview was conducted with LPN (Licensed Practical Nurse) D who stated the staff should notify the Pharmacy when medications are not available for administration, check the Pixus STAT box, notify the MD (Medical Doctor) and make sure the Pharmacy sends the medication STAT. On 6/27/2024 at 12:10 p.m., an interview was conducted with the Unit Manager who stated if a medication was not available at the time of scheduled administration, the nurses should go to the Pixus (on-site Stat box) to see if the medication was available in that stock. On 6/27/2024 at 1:55 p.m., an interview was conducted with the Director of Nursing who stated the Pharmacy should have medications available for administration as per Physicians Orders. A copy of the Pixus Stat Box medications list to determine if the missing medications were available in that supply was requested and received. On 6/27/2024 at 3:05 p.m., an interview was conducted with the Director of Nursing who stated the Pharmacy was responsible for delivery of medications. The Director of Nursing stated the nurses had access to medications that were delivered to the facility, if a medication was not available at the time of scheduled administration, the nurses should go to the Pixus (on-site Stat box) to see if the medication was available in that stock. The Director of Nursing stated if the medication was not in the Pixus, the nurse was expected to inform the physician to see if there was another medication order or if the doctor would give the approval for the medication to be started later when available from the Pharmacy. The Director of Nursing stated the facility always had a supply of Boost supplement available for residents. She stated It should have administered as ordered by the physician. Review of the Pixus Medbank STAT box contents revealed Pantaprozole 40 milligrams was on hand and available as a bulk medication. During the end of day debriefing on 6/27/2024, the facility Administrator and Director of Nursing were informed of the findings. Review of Physicians Orders revealed valid orders for the medications not available for administration. Guidance from the National Institutes of Health in the article The nurses medication day stated that Nurses serve as a barrier, protecting residents from potential hazards. Calls were also common to request 'missing meds' followed by waits until they were delivered. Waiting reflected system failures ncbi.nlm.nih.gov accessed 6/28/2024. On 6/28/2024 at 9:15 a.m., the Director of Nursing was interviewed. The Director of Nursing stated she reviewed some of the documentation and noticed that several of the entries about medications being unavailable were written by one of the Agency nurses who worked in the facility as needed. The Director of Nursing stated some of those medications were available in the Pixus when the nurse documented they were not available. The Director of Nursing stated she and the Staff Development Coordinator would continue to conduct training with all of the nursing staff (including agency nurses) to make sure they understood the procedures regarding medications being unavailable. During the end of day debriefing on 6/28/2024, the Corporate Director of Clinical Services (Employee J), Director of Nursing and Administrator were informed of the findings. They stated medications should be available for administration. They also stated the facility's nursing staff and agency staff were being inserviced on the procedures to follow when medications were not available as ordered by the physician. No further information was provided. 40711 2. Resident #291, the facility staff failed to ensure her Over The Counter meds were available for administration for 9 days. Resident #291 was originally admitted to the facility 6/16/24 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; After Care Following Joint Replacement Surgery. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/16/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #291 cognitive abilities for daily decision making were intact. The Medication Administration Record (MAR) read: Apple Cider Vinegar Oral Tablet (Apple Cider Vinegar) Give 2 tablet by mouth one time a day for Supplement Start date 6/17/24. Beet Root Oral Capsule (Misc Natural Products) Give 6 tablet by mouth one time a day for Supplement. Start Date 6/17/24. Biotin Oral Tablet 5000 MCG (Biotin) Start Date 6/17/24. Give 6 tablet by mouth one time a day for Supplement Start Date 06/17/2024. The above medications were missed for 9 consecutive days June 17th -June 25th, 2024. Coded as 9 meaning see progress notes. A review of progress notes revealed no reason for the missed doses of the above medications. On 06/27/24 at approximately 5:01 PM., an interview was conducted with Resident #291 concerning medications. Resident #291 said that she has not received her vitamins since her admission. On 06/28/24 at approximately 11:34 AM., an interview was conducted with Resident #291 concerning her missed vitamins. Resident #291 said that she was informed by the staff this morning that she needs to bring her vitamins from home because they don't have them available at the facility. On 06/28/24 at approximately 11:20 AM., an interview was conducted with Registered Nurse B concerning the above missed medications. RN B said that the Over the Counter (OTC) meds that she was taking at home should have been brought to the facility. RN B also mentioned that the DON does the ordering of OTC meds. On 6/28/24 an interview was conducted with Licensed Practical Nurse (LPN) B. LPN B said that the Director of Nursing (DON) usually orders OTC medications in house. On 6/28/24 at approximately 3:20 p.m., the above findings were shared with the Administrator, Director of Nursing (DON) and Corporate Consultant. The DON said that she was not aware that the resident wasn't getting her OTC medication nor was she aware that she would have to get the medications from CVS pharmacy.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for one resident, Resident #1, in a survey sample of three (3) residents. The findings included: For Resident #1, facility staff failed to administer a nutritional supplement as ordered by the Nurse Practitioner on 02/22/2022. On 09/13/2023, Resident #1's clinical record was reviewed and revealed a prescribed order, Supplement: ProSource ZAC daily via PEG, Once a Day; 12:00 p.m., start date 02/22/2022. Resident #1 received the first dose on 02/23/2022. On 09/13/2023 at approximately 4:15 p.m., a group interview was conducted with the Director of Nursing (DON) and the ordering Nurse Practitioner (NP). The NP stated, During the IDT [Interdisciplinary Team] meeting on the morning of February 22nd, we discussed resuming [name redacted, Resident #1's] protein supplement following her readmission from the hospital the previous day [02/21/2022]. I gave the verbal order during the morning meeting to resume the ProSource as she had been getting it previously to help with wound healing, it was indeed my intent for her to start receiving it the same day [02/22/2022]. The DON stated, [Resident #1] should have been given the ProSource on the 22nd, it is readily available on the medication carts. According to [NAME] Manual of Nursing Practice, 11th edition, 2019, page 15, Standards of Practice-General Principles, item 1, read, The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable and Box 2-1, Common Legal Claims for Departure from the Standards of Care, item 8, read, Failure to implement a physician's, advanced practice nurse's, or physician assistant's order properly or in a timely fashion. On 09/13/2023 during the end of day conference, the DON was updated on the findings. No further information was provided.

Based on observations, staff interviews, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to prevent pressure wounds resulting in harm for one Resident (Resident #1) in a sample size of 3 Residents. For Resident #1, the facility staff failed to provide interventions to prevent the worsening of pressure wounds resulting in an avoidable stage 4 sacral wound and unstageable pressure wounds of bilateral heels. The Resident was hospitalized for infected pressure wounds. This is harm. The findings included: On 12/14/2021 at approximately 11:00 A.M., Registered Nurse B (RN B) and this surveyor observed Resident #1 in her room with the head of the bed elevated approximately 60 degrees. Resident #1 had a functional air mattress in place and soft boots on bilateral feet. Resident #1 had a wound vacuum Negative Pressure Wound Therapy (NPWT) for a sacral wound. At approximately 11:30 A.M., this surveyor observed the wound physician perform wound assessment and care. Also present in the room were Resident #1's nurse (RN B), the unit manager (Employee E), and Registered Nurse C (RN C), the nurse supervisor. The sacral wound bed was observed to have a small amount of exposed bone, muscle, devitalized (dead) tissue, and granulation (healing) tissue. The wound physician measured the wound to be 12.4 centimeters (length), 8.7 centimeters (width) and 2 centimeters (depth). The undermining was measured at 2.4 centimeters at 6 o'clock (meaning the undermining was located at the bottom portion of the sacral wound). The wound physician applied a topical anesthetic and removed wet, yellow (slough), dead tissue from the wound bed as well as dead connective tissue and bone. The unit manager then applied the new NPWT sponge/film dressing and achieved a vacuum seal with the wound vacuum device. At 11:50 A.M., the wound physician examined the right heel. The wound physician and this surveyor observed depigmented, epithelial tissue on the right heel. The wound physician stated the right heel wound was healed. The wound physician then examined the left heel wound. The wound was covered with black, dead tissue. The wound physician measured the wound to be 13.3 centimeters (length) and 11.6 centimeters (width). The wound physician applied a topical anesthetic and removed a small amount of the dead tissue on the lateral portion of the left heel wound. A new dressing was applied to the left heel and both feet were placed in soft boots to protect them from further damage from pressure. On 12/14/2021 at 12:20 P.M., an interview with the Director of Nursing (DON) was conducted. When asked about Resident #1's wounds, the DON indicated that [Resident #1] arrived from the hospital with a MASD [moisture-associated skin damage] rash and verified the wounds were acquired at the facility. A copy of the physician wound notes and nursing skin assessments were requested. On 12/14/2021 at approximately 5:15 P.M., the facility staff provided 8 pages of documents each entitled, Skin Monitoring CNA [certified nursing assistant] Shower Review. Each document had 2 anatomical figures (font and back) pictured and a list of options to select. The document dated 10/25/2021 [the day of readmission from the hospital] had handwritten by staff that the mid-posterior (back) section of the anatomical man labeled as rashes and handwritten in MASD. The posterior feet were labeled as soft heels and handwritten in redden [sic] non-blanchable [sic]. The document was signed by a CNA and Licensed Practical Nurse C (LPN C). There were no further descriptions or measurements included. The same type of document dated 10/28/2021 had the posterior feet labeled as swelling and soft heels. The posterior region of of the man diagram, had staff circling with a pen the right upper arm, right elbow, right forearm, right hand, and back region from the arm pits to the back of knees and labeled as rashes. The posterior feet (heels) were labeled as swelling and soft heels. The document was signed by a CNA and a nurse. There were no further descriptions or measurements included. The same type of document dated 11/04/2021 had the posterior mid-region labeled as pressure and the posterior feet labeled as abnormal color. The document was signed by a CNA and a nurse. There were no further descriptions or measurements. The same type of document dated 11/11/2021 labeled the posterior mid-region as decubitus and the posterior feet were labeled as blisters and abnormal color. The document was signed by a CNA and a nurse. There were no further descriptions or measurements included. On 12/14/2021 and 12/15/2021, Resident #1's electronic clinical record was reviewed. Upon review, it was revealed that Resident #1 had two recent hospitalization s on (10/21/2021-10/25/2021) and (11/18/2021-12/02/2021). During that review of the clinical record under the Observation tab, a document completed by (LPN C) dated 10/25/2021 at 3:54 P.M. entitled, Admission Skin Assessment included the following headers and documented the following answers from the nurse, for each header selection: Scars: no Bruises: no Skin Tears: no Reddened areas: no Pressure sores: no Rashes: no. The MASD and soft, reddened, non-blanchable heels that were documented on the CNA shower reviews were not documented, nor addressed in the admission skin assessment. A nursing readmission note written by (LPN C) dated 10/25/2021 at 2:00 P.M. was reviewed. The MASD and soft, reddened, non-blanchable heels were not documented nor addressed in the admission narrative note. There was no evidence the physician was notified of the findings. The care plan was reviewed. There was no evidence the care plan was revised to address the moisture-associated skin damage, nor the soft, reddened, non-blanchable bilateral heels on readmission (10/25/2021). The physician's orders for October 2021 were reviewed. There was a physician's order with a start date of 04/16/2021 that documented, Apply [MEDICATION(S)] after each incontinence episode and PRN [as needed] every shift. There were no admission physician orders regarding the bilateral heels. A review of the Treatment Administration Record (TAR) for October 2021 revealed that the [MEDICATION(S)] was not signed off as administered on 10/20/2021 day shift, nor on 10/21/2021 when Resident #1 was sent out to the hospital. The resident returned 10-25-21 from the hospital, and on 10/29/2021 the [MEDICATION(S)] was not signed off as administered on night shift. The nursing progress notes from 10/25/2021 through 11/04/2021 were reviewed. The MASD and soft, reddened, non-blanchable heels were not addressed within that date range. A nurse's note dated 11/04/2021 [10 days after admission] at 6:26 P.M. documented, CNA was changing resident and informed nurse of a sacral pressure ulcer. On assessment, a 2.5 cm x 5 cm open area with red, shiny tissue to wound bed noted. Scant amount of serosanguinous drainage with no odor present. Resident is non-verbal, but shows no signs of pain or discomfort. Surrounding tissue is non-blanchable. RP & MD [responsible party and medical doctor] notified. [MD name] was on call for [MD name]. He stated to have the NP [nurse practitioner] look at the area in the morning, otherwise, NNO [no new orders] given. Wound was cleaned with NS and dressing applied. Resident tolerated procedure well. The bilateral heels were not addressed in this narrative note. A weekly skin assessment dated [DATE] at 6:37 P.M. under the header Pressure Sores documented Sacral stage 2. The bilateral heels were not addressed in this assessment. There were no further weekly skin assessments documented until a readmission skin assessment dated [DATE]. A nursing progress note dated 11/04/2021 at 10:28 P.M. documented, Resident's Braden Score assessment of 9.0 indicates high risk for developing pressure ulcers. Will continue to monitor closely for signs of further skin breakdown. A nursing progress note written by (LPN C) dated 11/05/2021 at 2:27 P.M. documented, resident have [sic] new order for [MEDICATION(S)] sulfate 220 mg Po QD [220 milligrams by mouth daily], vit c 500 mg Po bid [vitamin C 500 milligrams by mouth twice a day], consult wound physician, clean open area on sacrum with normal saline, pat dry, apply xeroform, cover with 4x4 dressing. There were no further nursing notes until 11/09/2021. A review of the physician's orders for November 2021 revealed there were orders for wound physician consult dated 11/05/2021; [MEDICATION(S)] sulfate 220 mg QD with a start date of 11/06/2021 and vitamin C 500 mg twice a day with a start date of 11/06/2021. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M when it was not documented as administered. A physician's order with a start date of 11/06/2021 and end date of 11/10/2021 documented, cleans [sic] open area on sacrum with normal saline, pat dry, apply xeroform cover with dressing 4x4. A review of the Treatment Administration Record for November 2021 revealed that wound treatment entitled, cleans [sic] open area on sacrum with normal saline, pat dry, apply xeroform cover with dressing 4x4 was signed off as administered on 11/06/2021, 11/07/2021, and 11/09/2021. However, the wound treatment for 11/08/2021 was not documented as administered and left blank. An excerpt of a nurse practitioner's progress note dated 11/05/2021 documented, Notified by nursing of the sacral wound. Examined patient with nurse present. Wound measuring 2.5 cm x 5 cm, partial-thickness with red/pink wound base with mild serosanguineous drainage, no odor. Orders provided. Patient nonverbal at baseline. Discussed with nursing to ensure repositioning every 2 hours to offload sacral pressure. However, this order was never entered into the nursing care plan up until the time of survey. A nurse's note written by (RN C) dated 11/09/2021 at 6:01 P.M. documented, Resident seen by wound MD with no reported pain or discomfort during visit or treatment. Orders updated to continue treatments as ordered. V.O.R.B. [verbal order read back] per [wound physician name]: Cleanse Unstageable sacral wound with NS - Pat Dry - Apply a thin layer of Santyl Ointment - Cover with a Gauze Island Boarder Dressing Daily. MD/RP aware. Refer to wound notes. Will continue to monitor. The wound physician note dated 11/09/2021 under the header Review of Systems and sub-header Support Surface an excerpt documented, Bed: Group 2 [meaning a specialty air mattress was on the bed]. Under the header Focused Wound Exam (Site 1) Unstageable (due to necrosis) sacrum full thickness the following sub-headers and entries included but were not limited to: Wound size (L x W x D)[length x width x depth] .6.2 x 8.4 x 0.1 centimeters. Exudate [drainage]: light sero-sanguinous [serum and blood]. Thick adherent devitalized necrotic tissue: 75%. Granulation tissue: 25%. Under the sub-header Procedure note an excerpt documented, curette was used to surgically excise 39.06 square centimeters of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues were removed at a depth of 0.3 centimeters and healthy bleeding was observed. Under the header Exam an excerpt documented, Left lower extremity dry skin [CONDITION(S)] and Right lower extremity dry skin [CONDITION(S)]. However, the condition of the heels was not assessed. A nurse's note dated 11/13/2021 at 3:19 P.M. [19 days after the heels were noted to be reddened and non-blanchable on admission on 10/25/2021] documented, writer was helping cna to change resident when turning her we saw her left lateral heel 9 cm X 5 cm X 0 depth, left heel 8 cm X 5 cm X 0 depth and right heel 5 cm X 3 1/2 cm X 0 depth have dark color like bruise like looking. reported to the supervisor. There were no physician's orders dated 11/13/2021 addressing the bilateral heels. A nurse's note dated 11/14/2021 at 9:42 P.M. [10 days after sacral wound was discovered] documented, N.O. [nurse order] Turn and Reposition every 2 hours. Alternating from Left side to Right side then middle (supine). Repeat cycle to relieve pressure to area on sacrum. Writer spoke with [name] from dietary in reference to obtaining Prostat to be given via PEG for area to sacrum. [name] stated she will consult with nurse practitioner tomorrow to start Prostat via PEG. N.O. skin prep to skin prior to applying dressings to any area requiring dressing. RP aware. The Treatment Administration Record for November 2021 was reviewed. An order with a start date of 11/14/2021 and an end date of 11/18/2021 [the date Resident #1 went to the hospital] entitled, Turn and reposition every 2 hours. Alternating from left side to right side then middle (supine). Repeat cycle to relive pressure to area on sacrum was not signed off as administered on 11/14/2021 at 4:00 P.M. and 6:00 P.M. (blank) and on 11/15/2021 at 4:00 P.M. and 6:00 P.M. (indicating Resident #1 was left in the same position for 6 hours on 11/15/2021). This order was never documented in the nursing care plan up to the time of survey. A physician's order dated 11/15/2021 documented, Apply bilateral heel off loading boots to be worn anytime in bed. This physician's order for a pressure-reducing intervention was 21 days after the heels were noted to be reddened and non-blanchable on admission on 10/25/2021. This order was never documented in the nursing care plan up to the time of survey. A physician's order dated 11/15/2021 documented, Sureprep [skin protectant] bilateral heels twice a day. This physician's treatment order to protect the skin was 21 days after the heels were noted to be reddened and non-blanchable on admission on 10/25/2021. This order was never documented in the nursing care plan up to the time of survey. The care plan was reviewed. Under a problem which included Skin breakdown R/T [related to] immobility/incontinence with an approach start date of 12/15/2021 [51 days after the bilateral heels were noted to be soft, reddened, and non-blanchable] documented, Skin prep to bilateral heels. Applying off-loading boots to both feet was not on the care plan. A wound physician's note dated 11/16/2021 under the header Focused Wound Exam (Site 1) Unstageable (due to necrosis) sacrum full thickness and sub-header Wound Progress documented, Deteriorated. Under the header Additional Wound Detail it was documented, Now a stage 4, larger; d/c [discontinue] santyl, start Dakins [antiseptic solution] & crushed [MEDICATION(S)] [antibiotic]. Under the sub-header Procedure note an excerpt documented, curette was used to surgically excise 75.33 square centimeters of devitalized tissue and necrotic muscle and surrounding fascial fibers at a depth of 2.4 centimeters and healthy bleeding tissue was observed. Under the header Focused Wound Exam (Site 2) Unstageable DTI [deep tissue injury] of the left heel partial thickness, the following sub-headers and entries included but were not limited to: Etiology: Pressure; Stage: Unstageable DTI with intact skin; Wound size (L x W x D)[length x width x depth] .12.4 x 11.6 x (not measurable) centimeters. Under the header Focused Wound Exam (Site 3) Unstageable DTI [deep tissue injury] of the right heel partial thickness, the following sub-headers and entries included but were not limited to: Etiology: Pressure; Stage: Unstageable DTI with intact skin; Wound size (L x W x D)[length x width x depth] .4.5 x 5.2 x (not measurable) centimeters. A nurse's noted dated 11/18/2021 at 10:40 A.M. documented, resident have fever 100.3 given prn [as needed] Tylenol and altered mental status. np [nurse practitioner] assessed and want to be sent to hospital. Rp [responsible party] aware. The physician orders were reviewed. There was not a physician's order for an air mattress until 12/03/2021 upon Resident #1's readmission to the facility on [DATE]. A review of the hospital records revealed that the stage 4 sacral wound was infected. Resident #1 received intravenous antibiotics, a surgical debridement of the sacral wound, and a wound vac [NPWT] placement before returning to the facility on [DATE]. On 12/14/2021 at 2:00 P.M., an interview with (LPN C) was conducted. When asked about the process for Residents found to have reddened, non-blanchable area on the heels, (LPN C) stated that would be considered a stage 1 pressure wound. (LPN C) also stated that she would notify the NP or MD and enter in standing orders for skin prep (a skin protectant). When asked where the skin assessments are documented, (LPN C) stated that skin assessments are done weekly and entered into the electronic health record. (LPN C) stated there are also papers with an anatomical man (CNA shower sheet) that is filled out and given to the unit manager or the DON. When asked about the admission skin assessment for Resident #1, (LPN C) stated that she performed the skin assessment while giving Resident #1 a bed bath and recorded her findings on the CNA shower sheet. (LPN C) then stated she gave the Director of Nursing the paper once completed. When asked what her findings were, she stated she couldn't remember. On 12/15/2021, the facility staff provided a copy of their policy entitled, Pressure Ulcer Prevention and Treatment. In Section 3 under the header Assessment and sub-header entitled, When assessing the ulcer itself, the nurse will:, it was documented, Differentiate the type of ulcer (pressure-related versus non-pressure-related) or make a referral to the MD/NP for this differentiation. Interventions may vary depending on the specific type of ulcer; determine the ulcer's stage (for pressure ulcers) and describe and monitor the ulcer's characteristics; measure the size of the ulcer; monitor the progress toward healing and for potential complications; determine if the signs of infection are present; assess, treat, and monitor pain, if present; and monitor the application of dressings and treatments. Under the header Interventions in Section 1(a), it was documented, Based upon the assessment and the resident's clinical condition, choices and identified needs, basic or routine care for the resident at risk for pressure ulcer development should include interventions to .redistribute pressure (such as repositioning, protecting heels, etc.). On 12/15/2021 at approximately 4:15 P.M., the administrator and DON were notified of findings. The care plan was reviewed. Under a problem which included Skin breakdown R/T [related to] immobility/incontinence with an approach start date of 12/15/2021 [41 days after the discovery of the sacral wound and during survey] documented, Turn and reposition every 2 hours for pressure relief. On 12/16/2021, the facility staff submitted several written statements attesting to Resident #1 being on air mattress for many months. The facility staff also submit 2 Quality Assurance reports. On the Quality Assurrance report dated 11/04/2021 under the sub-header Date and results of most recent skin assessment, it was documented, 11/04/2021 open area to sacrum and red heels. However, there was no evidence in the clinical record that Resident #1's bilateral heel wounds were assessed/measured or a treatment plan put into place until 11/13/2021 and 11/14/2021, 9 days following their Quality Assurance report. Under the header Pressure Injury Investigation - Actions Taken, it was documented that Resident #1 had a urinary tract infection that was treated with antibiotics and [CONDITION(S)] resulting in a hospitalization (10/21/2021-10/25/2021). However, there were no pressure-reducing interventions or wound assessments or treatments included in the action plan. The Quality Assurance report dated 11/13/2021 contained the same action plan as the one dated 11/04/2021. Under the header Final Review/Summary of Actions documented the following: Physician notified; Resident/Resident Representative notified; referral to wound clinic/wound specialist; investigation did not find suggestions of abuse or neglect. On 12/16/2021 by the end of survey, the administrator and DON stated they had no further information or documentation to submit.

Based on observation, staff interview, Resident interview, clinical record review, facility document review, and in the course of a complaint investigation the facility staff failed to revise the care plan to reflect interventions for 3 pressure sores, for one Resident (Resident #1) in a sample of three residents. The findings included; Resident #1 was readmitted to the facility on [DATE] after a hospitalization . emergency room records from the hospitalization s on 10-21-21, and 11-18-21 were reviewed. The MDS document submission, dated 11-14-21, revealed the Resident had pressure sores. One which was unstageable due to slough or eschar (dead necrotic tissue) within the wound bed, which obscured from vision the depth of the wound, and two unstageable pressure injuries due to deep tissue injury (DTI). The care plan was reviewed and revealed the following interventions and the dates those interventions were added to the care plan. 12-2-21 wound care treatment per MD (doctor) order 12-15-21 Turn and reposition every two hours for pressure relief 12-15-21 Discontinue skin prep to bilateral heels It is notable to mention that the survey team entered the facility for survey on 12-14-21. The Administration was notified of findings during end of day conference on 12-15-21, and 12-16-21. Further documents were supplied by the facility on 12-16-21, however, the care plan was complete as stated by the DON, and Administrator when they were asked for a copy which was complete and included all discontinuances, changes, and additions from the Resident's initial/first admission to the time of survey. No further information was provided.

Based on observation, resident interview, clinical record review, facility document review, and in the course of a complaint investigation the facility staff did not maintain a complete and accurate clinical record for one Resident (Resident #1) in a survey sample of three residents. The findings included; Resident #1's clinical record had nursing skin assessments were incomplete, inaccurate, and in conflict with each other. On 12/14/2021 at 12:20 P.M., an interview with the Director of Nursing (DON) was conducted. When asked about Resident #1's wounds, the DON indicated that [Resident #1] arrived from the hospital with a MASD [moisture-associated skin damage] rash and verified the wounds were acquired at the facility. A copy of the physician wound notes and nursing skin assessments were requested. On 12/14/2021 at approximately 5:15 P.M., the facility staff provided 8 pages of documents each entitled, Skin Monitoring CNA [certified nursing assistant] Shower Review. Each document had 2 anatomical figures (font and back) pictured and a list of options to select. The shower review document dated 10/25/2021 [the day of readmission from the hospital] had handwritten by staff that the mid-posterior (back) section of the anatomical man labeled as rashes and handwritten in MASD. The posterior feet were labeled as soft heels and handwritten in redden [sic] non-blanchable [sic]. The document was signed by a CNA and Licensed Practical Nurse C (LPN C). There were no further descriptions or measurements included. During that review of the clinical record under the Observation tab, a document completed by (LPN C) dated 10/25/2021 at 3:54 P.M. entitled, Admission Skin Assessment included the following headers and documented the following answers from the nurse, for each header selection: Scars: no Bruises: no Skin Tears: no Reddened areas: no Pressure sores: no Rashes: no. The MASD and soft, reddened, non-blanchable heels that were documented on the CNA shower reviews were not documented, nor addressed in the admission skin assessment, thus contradicting each other. The same type of shower review document dated 10/28/2021 had the posterior feet labeled as swelling and soft heels. The posterior region of the man diagram, had staff circling with a pen the right upper arm, right elbow, right forearm, right hand, and back region from the arm pits to the back of knees and labeled as rashes. The posterior feet (heels) were labeled as swelling and soft heels. The document was signed by a CNA and a nurse. There were no further descriptions or measurements included. The same type of document dated 11/04/2021 had the posterior mid-region labeled as pressure and the posterior feet labeled as abnormal color. The document was signed by a CNA and a nurse. There were no further descriptions or measurements. The same type of document dated 11/11/2021 labeled the posterior mid-region as decubitus and the posterior feet were labeled as blisters and abnormal color. The document was signed by a CNA and a nurse. There were no further descriptions or measurements included. A nursing readmission note written by (LPN C) dated 10/25/2021 at 2:00 P.M. was reviewed. The MASD and soft, reddened, non-blanchable heels were not documented nor addressed in the admission narrative note. The Administrator and Director of Nursing were made aware of the incomplete and inaccurate clinical record on 12-15-21. No further information was provided for this particular deficiency.

Based on observations, resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to prevent abuse involving 4 Residents (Resident #30, #17, #2, #71) in a sample size of 33 Residents. The Findings included: 1. For Resident #30, the facility staff failed to protect her from 3 episodes of Resident-to-Resident altercations by another female Resident (Resident #2) on 07/20/2021. For Resident #17, the facility staff failed to prevent another female Resident (Resident #2) from rummaging through her closet and taking her purple top and floral sweater on 07/20/2021. Resident #30, a 95- year old female, was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #30's most recent Minimum Data Set with an Assessment Reference Date of 04/21/2021 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 9 out of possible 15 indicative of moderate cognitive impairment. Bed mobility and transfers were coded as requiring limited assistance from staff. Dressing was coded as requiring extensive assistance from staff. Mobility devices were coded as walker and wheelchair. Resident #17, an [AGE] year old female, was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #17's most recent Minimum Data Set with an Assessment Reference Date of 04/09/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Functional status for bed mobility, transfers, and dressing were coded as requiring extensive assistance from staff. Resident #2, a [AGE] year old female, was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2's most recent Minimum Data Set with an Assessment Reference Date of 03/08/2021 was coded as a quarterly assessment. Cognitive Skills for Daily Decision-Making were coded as severely impaired. Behavioral symptoms were coded as 0 meaning behaviors not exhibited during the 7-day lookback period. On 07/20/2021 at approximately 12:10 P.M., this surveyor entered Unit 4, the locked unit. At 12:13 P.M., this surveyor observed Certified Nursing Assistant A (CNA A) and another staff member attempt to redirect Resident #2 as she was yelling out to them. Resident #2 then hit CNA A on the left side of her head as she stood next to her. Resident #2 then sat down in a chair near the nurse's station. At approximately 12:15 P.M., this surveyor asked CNA A about the incident. CNA A stated that when [Resident #2] is [resistant], staff will redirect her and give her something to play with. CNA A also stated that [Resident #2] likes to clean so staff try to find things she can help us with. On 07/20/2021 at 12:20 P.M., Resident #2 was observed in Resident #17's room rummaging through the closet. Resident #17 was in her room seated in her wheelchair by her bed. Resident #2 then took a purple-colored top that was hanging on the door handle of Resident #17's room and proceeded to walk down the hall. Resident #2 then entered the room of Resident #30. Resident #30 was seated in her wheelchair and facing the hall just inside the threshold of her room entrance. Resident #2 walked past Resident #30, then turned and faced Resident #30 and shouted, Get out of here! Get out of here! Resident #30 stated, Why are you yelling at me? Licensed Practical Nurse A (LPN A) was there to redirect Resident #2 out of Resident #30's room. Resident #2 then walked back to Resident #17's room to the closet touching the clothes on hangers. A staff member stood in the doorway of Resident #17's room and tried to redirect Resident #2 to go to the dining room for lunch. Resident #2 stated, No! Get out of here! Resident #2 then took a floral sweater off of the hanger and walked back down the hall toward Resident #30's room with Resident #17's purple top and floral sweater. As Resident #2 entered Resident #30's room, LPN A and another staff member were heading toward Resident #30's room. Resident #2 started yelling unintelligibly. Resident #30 stated, I have no idea what she wants from me! Resident #2 then left Resident #30's room and stood outside her room door holding the purple top and floral sweater. LPN A positioned herself between Resident #2 and Resident #30 while trying to redirect Resident #2. Resident #2 then walked to the nurse's station area and sat in a chair nearby. On 07/20/2021 at 12:32 P.M., an interview with Registered Nurse A (RN A) was conducted. RN A was standing near the med card by the nurse's station. When asked about Resident #2's behaviors, RN A stated that Resident #2 had underlying mood behaviors. RN A also stated that [Resident #2] is usually easily redirected and we let her cool off. When asked if she has been involved in Resident-to-Resident Altercations, RN A stated, No. We don't see her yelling at other Residents. When asked about the process when a Resident-to-Resident Altercation occurs, RN A stated that they separate the Residents, try to figure out what happened, have activities come to offer snack, fluids, and games. RN A then stated they would document the altercation as well. On 07/20/2021 at 12:37 P.M., this surveyor noted Resident #2 was no longer sitting in the chair by the nurse's station. This surveyor went to Resident #30's room. The door was closed. This surveyor knocked on the door and heard Resident #30 state, Come in. From the hall, this surveyor observed Resident #30 in her wheelchair by a table just hanging up the phone and stated, I was just trying to call my son. Resident #30 then self-propelled her wheelchair near the entrance of her room. Her bathroom door was open slightly and situated to her left. When asked how she was feeling about what happened with [Resident #2], Resident #30 pointed to her bathroom and stated, She's washing something in my apartment! I don't know what the hell she wants! At that time, Resident #2 exited Resident #30's bathroom holding a roll of toilet paper and several paper towels in her left hand. Resident #2 spoke loudly in unintelligible speech. Resident #2 then grabbed Resident #30's right wheelchair handle and forcefully pushed Resident #30's wheelchair forward. The left side of Resident #30's wheelchair hit the door jamb of her room entrance. Resident #30 stated, Let go of my chair! Resident #2 then walked past Resident #30, exited her room, and walked down the hall with the roll of toilet paper and paper towels. When Resident #30 was asked if she was okay and how was she feeling about this, Resident #30 stated, I feel sorry for her. When asked if this happens frequently, Resident #30 stated, This has been happening a lot; especially today. There was no staff observed in the hall during this time. At 12:49 P.M., Resident #2 was observed seated by the nurse's station eating lunch. At 12:56 P.M., an interview with LPN A, the unit manager, was conducted. When asked about her perspective of the Resident-to-Resident altercation between [Resident #30 and Resident #2], LPN A stated that it sounded like [Resident #2] was telling [Resident #30] to get out of her own room. LPN A also stated that she was trying to redirect [Resident #2]. When asked if this occurs frequently, LPN A stated No. LPN A also stated that we try to redirect and normally that works. LPN A added that [Resident #2] was confused and upset about something. When asked about the process when a Resident-to-Resident Altercation occurs, LPN A stated that the staff is expected to make sure the one is safe and redirect the other. LPN A also stated that staff should reassure her [Resident #30] and make sure she [Resident #2] doesn't go back and do it again. LPN A also indicated the process included getting everyone to monitor her and keep an eye on her. LPN A was notified Resident #2 was observed by this surveyor in Resident #30's room for a third time and forcefully moving Resident #30's wheelchair into the door jamb. LPN A did not mention reporting Resident-to-Resident altercations to the administrator. At 1:36 P.M., this surveyor notified the administrator of the above observations of Resident to Resident altercations involving Resident #2, Resident #30, and Resident #17. The administrator stated he would send a Facility-Reported Incident (FRI) to the state agency and begin an investigation. On 07/20/2021 at 3:19 P.M., the facility staff provided a copy of the FRI that was submitted to the state agency related to the above observations. On 07/20/2021, Resident #2's clinical record was reviewed. A nurse's noted dated 07/20/2021 at 3:19 P.M. documented, Resident became agitated before lunch and went into another residents [sic] room then into her bathroom and washed her hands, came back out and resident in room [number] was sitting in her wheelchair and this resident shoved the wheelchair into the wall (resident in room [number] was unharmed) and left the room. A nurse's note dated 07/20/2021 at 3:19 P.M. documented, [Name] NP [nurse practitioner] notified and RP [responsible party] [name] via voicemail. Resident #2's care plan was reviewed. A focus dated 08/20/2020 documented, [Resident #2] exhibits the following behaviors: she has poor safety awareness and she will bump into walls, objects etc. when walking at a fast pace. Observed to wipe down tables and desk areas. Wandering in and out of other resident rooms and turning lights on and off, pushing on exit doors. Combative with ADL care. Refusing skin care treatments. Verbally, and physically aggressive with staff. Behavior increases with staff attempts at redirection or when providing care. hx [history of] of Hit [sic] staff with her shoe, smack staff in the chest area, picking up objects in attempt to use as a weapon toward staff . Use of profanity toward staff. Physically combative toward others, taking items of others, not belonging to her. Using others drinks to clean tables. Turning the lights on of others, removing the covers off of others, Not easily re-directed at times. Flailing her arms and yelling, cries. One intervention associated with this focus included but was not limited to the following: When resident becomes physically abusive, keep distance between resident and others to ensure safety of resident and others (e.g., staff, other residents, visitors). On 07/20/2021, Resident #30's most recent progress notes were reviewed. A nurse's note dated 07/20/2021 at 3:21 P.M., documented, Writer was notified that another resident entered this residents [sic] room and went into her bathroom and washed her hands then came out and told resident get out of the way and pushed resident's wheelchair into the wall with resident sitting in the chair - the chair hit the wall and the resident was unharmed. Writer went and spoke with resident about incident and she could not recall incident writer was describing. RP [responsible party] [name] notified - message left on voicemail. [name] NP [nurse practitioner] notified of above. At the end of day meeting on 07/20/2021 at 4:53 P.M., the administrator was asked about the process when a Resident-to-Resident altercation occurs, the administrator indicated that a FRI would be filled out; they would launch an investigation, obtain witness statements, compile all the information, have a plan, submit a 5-day follow-up [to the state agency] and re-evaluate the plan. On 07/20/2021, the facility staff provided a copy of their policy entitled, Abuse Prevention, Investigation and Reporting. An excerpt in Section IV (C) documented, Resident to Resident altercations are potentially situations of abuse.the facility will respond immediately to protect the safety of others, investigate the incident and respond with measure [sic] to prevent recurrence. On 07/21/2021 at 3:30 P.M., the administrator and Director of Nursing were notified of concerns with the repeated Resident-to-Resident altercations observed on 07/20/2021. By the end of survey on 07/22/2021, the administrator stated there was no further documentation or information to submit. 2. For Resident #71, the facility staff failed to ensure freedom from abuse by a contracted agency CNA. Resident #71, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #71's most recent MDS (Minimum Data Set) assessment coded Resident #71 as having a BIMS (Brief Interview of Mental Status) score of 4 indicating severe cognitive impairment. She was coded as requiring extensive assistance with all aspects of ADL (Activities of Daily Living). The Resident required the use of a sit to stand lift for transfers and a wheel chair for mobility. On 7/20/21 at approximately 12:30 PM during meal observations, Resident #71's family member requested to speak to surveyor A she stated she would like to come in the following day and bring her notes, a time was set for 7/21/21 at 9:30 AM. On 7/21/21 an interview was conducted at 9:36 AM with Resident #71's family member. During interview the family member stated that she comes to the facility every day. She showed folders where she takes notes on what is happening at the facility while she is present. She expressed concern that Resident #71 had recently been hit by an agency staff member while she was being given a shower. She further stated the incident was witnessed by 2 other staff. The family member got a call at 9:45 PM on 6/29/21 from the Administrator telling her of an incident involving her mother. She stated that he told her three CNA's were working in the memory care unit 2 were Agency and one was a staff CNA. One of the agency CNA's (CNA G) assigned to Resident #71 didn't want to give her shower. CNA G asked the other 2 CNA's for assistance with the shower as this Resident was confused and upset. While giving her a shower the Resident pushed CNA G's hand out of the way. CNA G then hit the Resident in the head with the hand held shower wand and sprayed her in the face with the water. [The facts of this story were corroborated by the FRI, Investigation and Witness Statements sent in to the OLC.] The family member stated I was upset because I was here at dinner time 5:30- ish and spoke to the 3 CNA's. They said they gave her a shower before dinner and everything was fine. Mom looked and smelled good. No one mentioned a word about the incident, and I didn't see any marks or bruises. So then at 9:45 PM [Administrator's name redacted] called and basically said it took the other 2 CNA's [that witnessed the incident] 3 hours to decide to report it She said The CNA that hit mom was a large intimidating woman the other two were younger they were intimidated by her. The facility told me they were firing the Agency CNA's and they asked me about the [NAME] employee, I told them I do want the [NAME] Sholom employee to work with mom because she knows her, yes she had a major lapse in judgement and should have reported it immediately, but in the end she did report it. A Review of the FRI submitted with the witness statements revealed that the supervisor sent the agency CNA's home that night, they did a head to toe assessment and no injuries were found at that time. 06/30/2021 12:26 AM - Writer assessed [Resident 71 name redacted] for injury and pain post reported incident, Resident denied pain and discomfort r/t incident and has no visible injurie's [sic] or skin impairments r/t incident. Will continue to monitor. On 7/21/20 at approximately 2:30 PM an interview was conducted with the DON who stated that she was made aware of the incident by [NAME]. She stated that it was her expectation that any time abuse is suspected the staff are to call her or the Administrator. She stated she came to the facility immediately after the phone call informing her of what happened. She stated that she suspended all three employees until the investigation was done. The agency CNA was terminated and banned from the building. They did a head to toe assessment to check for injuries and no bruises, red marks or open areas were found. Resident is unable to recall due to cognitive status. They submitted a FRI to the OLC on 6/29/21 at approximately 10:00 PM. The facility FRI was reviewed, and it included the initial FRI , the investigation witness statements and the subsequent statements that this employee was banned from working at the facility and the Ombudsman, APS, local police as well as the DPH were notified. All pieces of the FRI and Investigation were completed. The FRI investigation folder also contained in service education about timely reporting of abuse. During an interview with the Business office Manager on 7/22/21 at approximately 2:00 PM revealed the facility did not have the Agency Employee's VA State Police Criminal background check at the facility. They attempted to obtain it from the Agency however they only received a criminal check from a private company. She had a valid CNA license but they had no record of VA State Police Check to see if she had any barrier crimes prior to working in the facility. On 7/22/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, resident interview, group interview and staff interview, the facility staff failed to act promptly to resolve grievances discussed in the group interviews. For 6 of 6 residents in the Resident Council group, the facility staff failed to resolve the issues/concerns discussed in Resident Council. The Findings included: Review of the Resident Council meeting minutes from March 2021 through July 2021, revealed documentation of the same concerns during several of the months. There was no documentation of the facility administration's response to the concerns expressed during the meetings. 4/28/2021 Meeting agenda- New Business included statement Nursing: DON (Director of Nursing) and Administrator will remind nursing to introduce them self (sic) at the beginning of each shift. 5/19/2021- Meeting Minutes-Old Business Aides still not introducing themselves when they come on shift (residents would like to know who their aides are for the morning and night. Under New Business, the statement was included When residents need something, they are having to go and find the staff. Staff are not checking on them as they feel they should. 6/14/2021- Meeting Agenda- Old Business included Aids-Let you know who they are. Under Discussion of New Business was written Aids-poor attitudes, make beds/open blinds, responding to call bells, check on residents. Not enough aids on every shift Under Action items -an X was written beside the space for issues to raise within facility (Such as with Administrator or Quality Assurance Committee). 7/17/2021- Meeting Agenda-Council Old Business- Aids-not making beds or wrong way/still not introducing themselves, not enough. Under Discussion of New Business was written Aids-trying to get more/addressing continuing issues from old business Under Action items -an X was written beside the space for issues to raise within facility (Such as with Administrator or Quality Assurance Committee). On 7/21/2021 at 2:30 PM, a Group interview was conducted with six residents (Residents # 13, # 19, # 34, # 64, # 67 and # 78) who attended the meeting. One resident (Resident # 13) first spoke up and stated she wished the nursing assistants would introduce themselves to the residents at the beginning of their shifts. Resident # 13 stated it would help to know which Certified nursing assistant was working with them so they would know who would give them care that day and provide showers. All of the other residents agreed that there was an issue with the CNAs not introducing themselves. Resident # 13 stated it was :a problem almost every day that she did not know who was working with her that day. Residents # 67, # 34 and # 19 stated they continued to experience this problem even though they had talked about it several times to the Administration staff. The other residents nodded in agreement. 5 Residents in the group stated they do not get feedback after the Resident Council meetings. They stated they express their concerns and wait to hear back but do not hear any results. One stated she did not feedback but did not know how to answer that question since she was still waiting to hear an answer. On 7/22/2021 at 2:35 PM, an interview was conducted with the Director of Nursing about the concerns expressed during the Group Interview on 7/21/2021. The Director of Nursing reviewed the minutes of the Resident Council from March - July 2021 with Surveyor. The Director of Nursing stated the nursing staff including Certified Nursing Assistants should introduce themselves to the residents with whom they are scheduled. The Director of Nursing stated the nursing staff should make rounds at the beginning of their shift on the residents with whom they were scheduled and should introduce themselves The Director of Nursing stated the facility administration should follow up with the residents about their concerns expressed during the council meetings. The Director of Nursing stated the expectation was that all staff would know they should make rounds and she stated that the issue would be added to the staff education meetings ,new employee orientation and during regular staff meetings. The Director of Nursing stated the facility often used agency staff but the expectation was the same that staff would introduce themselves at the beginning of their shifts. The Director of Nursing stated she would follow up with the residents to let them know their concerns have been heard and of any steps taken to resolve them. During the end of day debriefing, the Administrator and Director of Nursing were informed of the findings. No further information was provided.

Based on observation, staff interview, clinical record and facility documentation review, the facility staff failed to ensure a safe dining environment to [MEDICAL CONDITION] spilling hot soup, resulting in harm from second [MEDICAL CONDITION] Resident #53 and Resident #23 in a survey sample of 22 residents. Both residents resided on the memory care unit. 1. On 10/5/17, Resident #53 sustained a second degree burn to her left upper thigh from spilling hot soup in her lap. 2. On 12/10/17, Resident #23 sustained six second [MEDICAL CONDITION] her inner thighs from spilling hot soup in her lap. The findings included: 1. Resident #53 sustained a second degree burn to her left inner thigh from spilling hot soup in her lap. Resident #53 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #53's most recent MDS was a quarterly assessment with an ARD of 12/7/17. Resident #53 had a BIMS score of 0 out of a possible 15, or severe cognitive impairment. The resident required extensive assistance with her ADL's (activities of daily living including bed mobility and dressing) of one staff member. The resident required stand by assistance for eating. On 01/16/18 12:39 PM, an observation of the dining experience was conducted. Resident #53 was served soup by a CNA (certified nursing assistant) who gave her a spoonful: Resident #53 drew back and stated that's hot. Temperature of the of soup was 180 degrees at serve (tray line in the kitchen) per dietary aide (Employee A), now was 138 degrees at the table before being served to residents. The temperature was taken by the dietary aide. The soup was served in a Styrofoam bowl as the dishwasher was not functional. The resident was able to eat the soup at this time and the aide was feeding the resident. Resident attempting to suck at end of spoon, She is so tired today, she usually feeds herself. Very hard of hearing. Feeding self sandwich and mashed potatoes. Review of the clinical record revealed the resident had sustained a first degree burn on 10/5/17 at lunch by spilling her soup on her lap. The area was assessed by the unit manager (RN-registered nurse) A who noted the measurements as 17 cm (centimeters) by 6 cm of a reddened area, no blistering. Cold compresses were applied. A nurse's note dated 10/6/17 read: Area has two blisters intact. Wound care notes dated 10/11/17 documented : Second degree burn to upper left thigh/groin. The FNP (family nurse practitioner) examined the resident and documented: The patient spilled soup on her upper thigh that caused a burn . The patient noted with a first degree burn area reddened . The patient complained of some pain. The physician ordered [MEDICATION NAME] ointment and as needed Tylenol every 8 hours. Review of the temperature logs for October, (YEAR), revealed the following temperatures: From (MONTH) 1 through (MONTH) 4, second soup temperatures ranged from 154 degrees 200 degrees. On 10/5/17 at lunch (when [MEDICAL CONDITION] sustained) the soup temperatures were 160 degrees to 159 degrees to 145 degrees. For the rest of the month, second soup temperatures ranged from 135 degrees to 190 degrees. Review of the facility's policy and procedure for hot liquid safety (revised 11/25/17) revealed the following: The facility promotes safety with hot liquids, while assuring all residents receive liquids at temperatures they enjoy and prefer. Dining services cooks and holds liquid foods at temperatures to provide food safety, and serves food cooperatively with nursing staff at temperatures that are also safe for consumption . Hot liquids are defined at temperatures above 140 degrees. The Burn Foundation gives the following information on burns: Coffee, tea, soup and hot tap water can be hot enough to cause serious burn injury: Hot Water Causes Third [MEDICAL CONDITION]. .in 1 second at 156º .in 2 seconds at 149º .in 5 seconds at 140º .in 15 seconds at 133º. On 1/18/18 at approximately 10:30 AM, an interview with the Food Service Manager (Employee D) was conducted. He stated hot liquid temperatures for soup, oatmeal and coffee should be 135 to 140 degrees. He explained the soup comes from the main kitchen to the unit. He stated the third temperature is taken before the soup is served. He went on to say that the sous chef (Employee C) was to monitor the food temperatures. A hot liquid assessment was completed for Resident #53 was completed on 10/10/17 and an Occupational Therapy consult was recommended and was done for positioning in her chair. All residents on the dementia unit were assessed for safety of hot liquids. 01/18/18 11:19 AM: The Administrator was notified that second [MEDICAL CONDITION] constitute a harm level deficiency. 01/18/18 02:37 PM: Met with kitchen supervisor (Employee C), worked in the facility for the last 6 yrs. Stated: Hot liquids over 140 degrees, we are not supposed to serve. Also stated: I started thoroughly reviewing the food temperatures in December. Stated he was not sure what happened with missing temperatures on and after 12/24/17. Review of the care plan for Resident #53 dated 12/12/17 contained the following: Is at risk for spilling food or liquids at meals, due to recent incident when she tipped bowl of soup and spilled some on self. Interventions were documented as started on 12/12/17 and contained: Conduct hot liquid assessment prn (as needed) change in condition, do not use Styrofoam or other lightweight materials in serving hot liquids. 2. Resident #23 sustained second [MEDICAL CONDITION] her inner thighs from spilling hot soup in her lap. Resident #23 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident resided in the Memory Care Unit. Resident #23's MDS (minimum data set) with an ARD (assessment reference date) of 11/9/17 was completed as a significant change in status assessment. The resident had a BIMS (brief interview of mental status) of 2 out of a possible 15, or severe cognitive impairment. Resident #23 required extensive assistance with ADL's (activities of daily living such as eating and bed mobility. 1/16/18 at 4:15 PM, an interview was conducted with CNA (C) regarding Resident #23's hot liquids. She stated, We supervise her hot liquids/soups. 01/17/18 11:53 AM, dietary aide (Employee A) washed her hands appropriately. Tray line temperatures were as followed: Tater tots 158, squash 170, soup 148, mechanical turkey 152, pureed soup 164 degrees, turkey salad: 46 degree, put on ice, lettuce and tomatoes 140 degrees. The soup's temperature was not rechecked. 01/17/18 12:07 PM: Soup was served to Resident #23 in a two handled cup in front of the resident; dietary staff was requested by surveyor to recheck the temperature of the soup before the resident could consume it. 01/17/18 12:13 PM: The temperature was rechecked by the dietician and was 144.8 degrees. The RD (registered dietician) stated, We let it sit. The temperature of the regular soup in bowls was 120 degrees. 01/17/18 12:17 PM: The RD rechecked soup temperature, the temperature was 135 degrees. I took the lid off. (RD). The soup cup was placed in front of the resident. Resident observed sipping soup on her own, CNA nearby. Resident able to reach for and sip from cup on her own. Review of the clinical record revealed on 12/10/17 at 5:45 PM, resident noted to have spilled soup from soup mug onto lap. Resident was taken to room immediately and clothing changed. Bright pink areas noted to bilateral thighs, no blistering noted. Further clinical record review revealed on 12/10/17 at 9:27 PM, Areas to bilateral thighs re-examined and a blister to the right inner thigh was discovered. It is noted to measure 3.5 by 1.5 cm. Smaller blisters were noted to left inner thigh. All were still intact. Further clinical record review on 12/11/17 at 8:39 AM, revealed a note by the wound care nurse (LPN- licensed practical nurse) which read: Assessed residents right and left upper thighs/groin area with NP. Resident has a fluid filled blister on right thigh and groin by groin area (lower) measuring 6 by 3 by 0 cm, right thigh/groin area (upper) measures 5 by 2 by 0 cm, . Left thigh/groin area (lower) 1 by 1 by 0 cm, 0.5 by 1.2 by 0 cm, 0.5 by 0.5 cm, 0.7 by 1.5 by 0 cm, . all stage two. On 12/28/17, the FNP followed up on Resident #23. The note read: For second degree burn after hot food spilling on right thigh and groin area, patient had multiple areas noted at time [MEDICAL CONDITION]. had [MEDICATION NAME] cream treatment done . today area scabbed, no signs of infection. On 1/17/18 at 3:00 PM, temperature logs for (MONTH) (YEAR) were reviewed. On 12/10/17 for the supper meal (when [MEDICAL CONDITION] sustained), the first soup temperature was recorded at 188 degrees. A second temperature was taken (no time documented) and was 160 degrees. A third temperature was taken (no time documented) which was 150 degrees. Review of (MONTH) days 1-11, (YEAR), supper time food temperatures revealed that second soup temperatures were between 160-190 degrees until 12/11/17 in which the temperatures decreased to 118-161 degrees; majority were not above 140 degrees. In December, there were several days of no recorded temperatures for the supper meal. On 1/17/18 for the lunch meal, the food temperatures were not recorded. Review of the care plan for Resident #23 dated 11/10/17 revealed the following: Resident is at risk for spilling food or liquids at meals, due to poor safety awareness related to [DIAGNOSES REDACTED]. On 12/191/7 the intervention was added: To use 8 ounce glass versus 4 ounce glass or cup or cup with handle for liquids. Hot liquids in a lidded cup, encourage use of built up utensils to improve hold on fork/spoon. Resident #23's second [MEDICAL CONDITION] tracked and care planned as pressure ulcers. On 1/18/18, the Quality Assurance (QA) nurse (RN-A) presented a QA Action Plan dated 10/5/17 and revision date of 12/10/17. The plan contained the following actions: * Identify residents at risk for hot [MEDICAL CONDITION] dietary database, for inclusion in reference list used by serving staff on units. Nursing to provide list to dietary. * Monitor serving temperatures to ensure that residents are not receiving liquids that remain over 145 degrees. * Change frequency of hot liquids risk assessment from admission/annual/significant change to admission/quarterly/significant change. On 12/10/17 Evaluation documented Resident (not identified on plan) spilled soup into her lap, causing reddened area to thighs. Temperatures taken post incident support that soup was served at 138 degrees. In actuality the last temperature taken was at 150 Degrees. The QA nurse stated, Oh, that was for the incident in October). The plan for the incident in (MONTH) was to Reduce serving temperature of hot liquids to 135 (degrees) and complaints of food being too cold. In addition, Purchase protective lap coverings for residents who will agree to wear the liquid resistant clothing protectors. No resident will be forced to wear these. The QA nurse stated: We started those last week. They are slow to be accepted. Not observed during the meal observations. On 1/18/18 at approximately 4:00 PM, the Administrator and Director of Nursing were notified of harm level deficiency for Resident # 53 and Resident #23.

Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to safely transfer a resident using a safety device (gait belt), which resulted in a fall and fracture of the left hip for one of 23 residents in the survey sample, Resident #4 and failed to safely transfer one of 23 residents using the required assistance of two people, Resident #10; the facility staff also failed to implement safety devices (alarms) for two of 23 residents in the survey sample, Residents #5 and 9. The facility staff failed to ensure a functioning call light was easily accessible in a common area bathroom. 1. Resident #4 was not safely transferred during a gait belt transfer, which resulted in a fall and fracture of the left hip. 2. The call light in the common area bathroom was observed tightly wrapped around the hand railing in the bathroom stall and not accessible in the event of an emergency. 3. Resident #9's safety alarms were not implemented for the prevention of accident with injury. 4. Resident #10 was not safely transferred as care planned with the assistance of two people. 5. Resident #5's safety alarms were not implemented for the prevention of accidents with injury. The findings include: 1. Resident #4 was not safely transferred during a gait belt transfer, which resulted in a fall and fracture of the left hip. Resident #4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) was a 30 day assessment. The resident was assessed as thirteen (13) for cognitive skills and 3/2 for transfers, extensive assistance with the aid of one person. On 12/3/14 at approximately 9:00 a.m., Resident #4's clinical record was reviewed to include the following notes: Nursing "8/11/14 3:45 a.m. This writer was helping resident to bedside commode gait belt was put on by this name. When trying to get her up resident started going down on floor. Upon looking at belt found up that out (sic) belt was not lock tight bruises Family was left message to call facility..." "8/11/14 2:40 p.m. MD (doctor/physician) came to see resident today r/t (related to) fall on 11/7 shift. resident c/o (complain of) left leg hurting and pelvic...N.OS (new orders) 1. Xray of L hip, L knee and pelvis to r/o (rule out) fracture S/P (status [REDACTED]. "8/11/14 5:30 p.m. Xray results back. Showed L hip fracture MD notified. N.O. Send out to (hospital named) hospital." Consult 8/12/14 Fracture Consult Note...Consult for left hip pain...seen for left hip pain. Injury was this am about 3am when she got up with assistance to use the bathroom, she slipped on the bathroom floor...Workup has revealed left hip fracture. Patient's ambulatory status includes non-ambulatory at the nursing home, her son says she uses a wheelchair to get around and she does not get up and walk with out help from the nursing staff...(sic)." On 12/3/14 at approximately 9:10 a.m., the certified nursing assistant, who will be identified as CNA #5 was interviewed in regards to the above incident and if the CNA had worked with the resident. CNA #5 stated, "No, but I do know her. I have seen her." CNA #5 was interviewed and asked how the resident was transferred, CNA #5 stated, "She is a gait belt for transfers, we have a list of resident over here, walking towards a board at the nursing station, and this is how we tell how the residents are transferred." This Surveyor reviewed the "Transfer List." Resident #4 was on the list for transfers with a gait belt x (times) one person. CNA #5 was interviewed regarding the procedure for the use of a gait belt and if she had received any in-service. CNA #5 stated, "Yes (by in-service coordinator named) but it's just for the CNA's not all the staff are in-serviced." CNA #5 proceeded to explain the procedure for gait belt transfers by stating, "First you introduce yourself and let the resident know what you are doing. Get another aide to help if the resident is a two person for transfers. Put the belt around the resident's waist making sure that it's snug but not too tight. I put my hand in there, check and make sure that the buckle is tightened, some have the teeth and some have the belt hook. I make sure it is fastened correctly. I have the resident lean forward then stand if they can and pivot for transfers." On 12/3/14 at approximately 9:20 a.m., the Facility Educator, who will be identified a Admin #3, was interviewed regarding in-services related to gait belt transfers and the facility staff that receives the training. Admin #3 stated, "Most of the time therapy does the in-services if the resident is on therapy; they will go over the plan of care and how to transfer. Restorative also show them, staff, and they, staff, will demonstrate how to apply the belt if needed with therapy." Admin #3 stated, "Would you like to see my in-service log?" This Surveyor agreed to review the in-service log. This Surveyor also requested a contact number for the nurse, who transferred the resident on 8/11/14 to conduct an interview. On 12/3/14 at approximately 9:28 a.m., Admin #3 returned to the nursing station with an "Mechanical Lifts Training Manual." Admin #3 stated, "The in-service is provided to the CNA's not the nurse's because the CNA's are the one's doing the transfers." Admin #3 was made aware that the transfer with the gait belt, that caused harm to the resident was documented in the clinical record as being performed by a nurse and not a CNA. Admin #3 was interviewed and asked how did the nurse's know how to transfer correctly if they were not in-serviced, Admin #3 stated, "Good question, no in-service is provided to nursing unless they state they do not know how to use the belt; most of the nurse's already know or they should know (sic)." Admin #3 was interviewed and asked without in-service for a return demonstration, how would you know if the nurse's were knowledgeable of how to use the gait belt. Admin #3 stated, "I see, you don't know." Admin #3 was asked to show this Surveyor the type of gait belt that was used during the transfer for the resident on 8/11/14. On 12/3/14 at approximately 9:40 a.m., Admin #3 returned to the nurse's station with a gait belt. Admin #3 stated, "This is the belt that was used. I talked with the director of rehab, we are mainly using the one's with the teeth. We are not using the plastic ones. We gradually done away with those last year and we are now using the one's with the teeth." On 12/3/14 at approximately 10:10 a.m., the nurse on the unit where Resident #4 resided, who was a licensed practical nurse and will be identified as LPN #8, was interviewed regarding in-services and if any were provided regarding gait belt transfers. LPN #8 stated, "I have not been in-serviced but I asked therapy to show me how to use the gait belt due to I wasn't familiar with using it. I knew how to use one but it's been a while since I used one. There is no standard in-service on gait belt usage not unless you ask." On 12/3/14 at approximately 10:25 a.m., the restorative nursing aide staff, who was a certified nursing assistant and will be identified as CNA #3 was interviewed regarding restorative nursing staff in-servicing staff on the proper use of a gait belt. CNA #3 stated, "No, I mean they should already know. They see us put them on the residents but we don't in-service staff (sic)." On 12/3/14 at approximately 12:30 p.m., the director of rehabilitation, who was an Occupational Therapist Registered/Licensed and will be identified as Other Staff (OS) #3 was interviewed regarding in-servicing staff on the use of a gait belt. OS #3 stated, "We do not do an in-service, we will teach staff how to use a device if it is an unusual situation. There is no standard policy that we do in-services." OS #3 was interviewed and asked if restorative nursing staff provided any in-services on the use of a gait belt. OS #3 stated, "No, they do special training for themselves on the usage of the belt but (in-service coordinator named) does the in-servicing and training on transfers." On 12/3/14 at approximately 2:11 p.m., the administrator, director of nursing (DON) and the assistant director of nursing (ADON) were made aware of the above findings. The DON stated, "I have to see if (nurse named, who transferred the resident incorrectly) was trained on transfers." On 12/4/14 at approximately 12:00 p.m., the DON stated that the nurse that transferred the resident on 8/11/14 received "Silver Chair training, a computerized training, four times" and that "gait is a part of Silver Chair Training." The DON further stated that the nurse's intent was to transfer the resident safely and that the resident does say that she does not want the belt on tight. The DON was interviewed and asked if the nurse documented that statement by the resident on 8/11/14; the DON stated, "No." The User Learning/Silver Chair Training Log for the nurse, who transferred the resident on 8/11/14 was reviewed. The Log evidenced that the nurse's training for "Resident Lifting and Transfers were conducted on 7/15/2005, 2/17/2006, 7/25/2007 and 11/27/2007. On 12/4/14 at approximately 12:20 p.m., the administrator was made aware of the time frame in which the training was conducted for the nurse who transferred the resident on 8/11/14. When interviewed and asked how often staff was supposed to receive training through Silver Chair, the administrator stated, "Training is done yearly." The administrator further stated, "She should have known how to apply the gait belt." A copy of the investigation was requested by this Surveyor. On 12/4/14 at approximately 12:30 p.m. a copy of the "Incident /Accident Report" was reviewed to include the following: "8/11/14 at 3:45 a.m. ...Statements: Resident's statement as to how this fall occurred: Gait belt was in place but nurse did not close it right...8/13/14 Employee Counseling...Problem: Failure to ensure a resident's gait belt was properly secure before transferring from commode. (Resident named) informed me that the gait belt was loose...Resolution of Problem or Action Taken: Inservice given on gait belt use..." After multiple attempts to contact the nurse, who transferred the resident on 8/11/14, this Surveyor was not able to obtain an interview regarding the above incident from the nurse. No other information was provided during the course of the survey regarding the resident being transferred incorrectly during a gait belt transfer. 2. The call light in the common area bathroom was observed tightly wrapped around the hand railing in the bathroom stall and not accessible in the event of an emergency. On 12/3/14 at approximately 4:48 p.m., this Surveyor entered an unlocked bathroom on the back hall in the lobby area. Upon entering the bathroom stall, this Surveyor observed a call light system attached to right side of the wall and slightly above a hand rail. The call light string was observed tightly wrapped around the railing. This Surveyor yanked the cord several times to attempt to activate the call system. The call system did not activate. On 12/4/14 at approximately 3:15 p.m., the cord to the call system was observed by another Surveyor on the team, wrapped tightly around the railing in the bathroom stall and not readily accessible in the event of an emergency. On 12/4/14 at approximately 3:30 p.m., the administrator was made aware of the above observation in the presence of the survey team; the administrator stated, "We need to fix that ASAP." 3. Resident #9 was observed in her wheelchair without a safety alarm in use as ordered by her physician. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #9 with short and long-term memory problems and severely impaired cognitive skills for decision-making. On 12/3/14 at 8:40 a.m. Resident #9 was observed in her wheelchair in the dining room. No safety alarm was in place on the resident's chair. On 12/3/14 at 9:50 a.m. Resident #9 was in her wheelchair in the hall near the nursing station without a chair alarm in use. Resident #9's clinical record was reviewed on 12/3/14. The record documented a physician's orders [REDACTED]." The resident's care plan (revised 11/18/14) listed the resident required staff assistance for transfers and was at risk of falls due to poor balance. Included among interventions for fall prevention was, "Apply personal alarm - bed/chair." On 12/3/14 at 10:00 a.m. accompanied by the certified nurses' aide (CNA #4) caring for Resident #9, the resident was observed in her chair in the beauty parlor. There was no alarm on the resident's wheelchair. CNA #4 located a wire for an alarm box in the seat of the wheelchair. The alarm cord had exposed wires visible and had no clip. There was no alarm box on the chair. CNA #4 was interviewed at this time about the alarm. CNA #4 stated she thought the resident was supposed to have an alarm but she would have to check with the nurse to be sure. CNA #4 stated she did not know the alarm cord was damaged. On 12/3/14 at 10:05 a.m. the licensed practical nurse (LPN #3) caring for Resident #9 was interviewed about the alarm. LPN #3 stated Resident #9 was supposed to have an alarm in place when up in the wheelchair for fall prevention. LPN #3 stated she did not know what happened to Resident #9's alarm. LPN #3 stated the resident usually had an alarm on her bed and an alarm on her chair. These findings were reviewed with the administrator and director of nursing on 12/3/14 at 2:15 p.m. 4. Resident #10 was transferred from bed to her wheelchair with the assistance of one person when she was assessed to require the assistance of two people for safe transfers. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #10 with short and long-term memory problems and severely impaired cognitive skills for decision-making. On 12/3/14 at 7:45 a.m. Resident #10 was observed sitting on her bedside. Certified nurses' aide (CNA) #2 was helping the resident get dressed. CNA #2 stated she was getting the resident dressed and assisting her into her wheelchair. No other staff members were in the room or assisting the resident. On 12/3/14 at 8:00 a.m. with the assistance of CNA #2, Resident #10 was transferred from her bed to her wheelchair. Resident #10's clinical record was reviewed on 12/3/14. The record documented a physician's orders [REDACTED]. The resident's care plan (revised 10/16/14) listed the resident required "extensive total assistance" with activities of daily living. Interventions for assistance with transfers included, "Gait belt x 2." On 12/3/14 at 9:35 a.m. CNA #2 was interviewed about the assistance required to transfer Resident #10. CNA #2 stated she routinely transferred the resident without any additional assistance. CNA #2 stated, "She (Resident #10) stands pretty good. I use one person." On 12/3/14 at 9:55 a.m. CNA #3 that routinely provided restorative nursing services for Resident #10 was interviewed about the assistance he used when transferring the resident. CNA #3 stated, "Yes. She's (Resident #10) a one person transfer." On 12/3/14 at 11:40 a.m. the licensed practical nurse (LPN #3) routinely caring for Resident #10 was interviewed about the assistance needed to transfer the resident. LPN #3 stated Resident #10 was supposed to be transferred with the assistance of two people. LPN #3 stated the resident was recently changed to a two person assist. LPN #3 referred to a posted transfer list posted on the board behind the nursing station. This form listed the assistance required for transferring each resident. Resident #10 was listed on the sheet as requiring two people for transfers. LPN #3 stated the transfer list was updated weekly and was posted as a reference for the CNA's. LPN #3 stated the intervention listed on the care plan as "Gait belt x 2" indicated the resident was supposed to be transferred by two people with use of a gait belt. These findings were reviewed with the administrator and director of nursing on 12/3/14 at 2:15 p.m. 5. Resident #5 was not wearing a personal alarm as ordered by the physician. Resident #5 was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 09/04/2013. Resident #5 was assessed as having difficulty with both long and short term memory and as being severely impaired with daily decision making skills. On 12/03/2014 at approximately 9:00 a.m., Resident #5 was observed sitting in a high back recliner in the dining room, being fed by a staff member. The clinical record was then reviewed. Observed on the POS (physician order [REDACTED]." At approximately 9:30 a.m., Resident #5 was through eating and was moved to the hallway outside of her bedroom door. Resident #5 was observed to have jerking movements of her arms and legs at non regular intervals. There was no alarm on the chair she was sitting in. LPN (licensed practical nurse) #1 was asked if there was an alarm on the chair that Resident #5 was sitting in. She went to the chair and stated, "I don't see one." LPN #1 then called for the CNA (certified nursing assistant) who had gotten Resident #5 up in the chair. CNA #1 came to Resident #5's room and stated, "I didn't put the alarm on her...I guess it is usually already in the chair." CNA #1 was asked if she had taken care of Resident #5 on other days. She stated, "Yes." CNA #1 was asked how she knew what to do for the residents she was assigned to. She stated, "We have a care plan." CNA #1 was asked if she had reviewed the care plan for Resident #5. She stated , "Yes." This surveyor then went to the care plan book used by the CNAs on the unit. The care plan did not contain interventions for the physician ordered care plan. LPN #1 came to the nurse's station and spoke with this surveyor. She stated, "We don't see the alarm...we are going to get her one." The above information was discussed with the administrator and the DON (director of nursing) during an end of the day meeting on 12/03/2014 at approximately 4:00 p.m. No further information was obtained prior to the exit conference on 12/04/2014.