Every finding on record at Spring River Rehabilitation and Care Center

Based on observations, record reviews, and interviews, the facility failed to ensure a resident was free from abuse and neglect for 1 (R #1) of 1 (R #1) resident, when facility staff left R #1 outside in direct sunlight for an unknown period of time. This deficient practice could have resulted in R #1 being found unresponsive with severe sunburns. The findings are: A. Record review of the facility's Resident Safety Rounding policy, not dated, revealed the following:1. The facility is to provide routine resident safety rounding and observation to promote resident safety, identify unmet needs, and reduce the risk of accidents, injuries, and adverse events. 2. The frequency and type of monitoring is to be individualized based on resident condition, assessed safety risks, physician orders, behavioral or cognitive status, fall risk, care plan interventions, and changes in condition. 3. During rounds, facility staff are to assess safety, comfort, environmental concerns, and unmet care needs. B. Record review of the facility's Abuse, Neglect, and Exploitation policy, not dated, revealed the following: 1. Neglect is the failure of the facility, its employees, or service providers to provide goods and services that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 2. The facility is to provide ongoing oversight and supervision of staff to ensure that its policies are implemented as written. 3. All facility staff are to be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation and then annually. C. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/08/26, revealed the following:1. R #1 was admitted to the facility on [DATE].2. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 07, moderately impaired.3. R #1 required substantial or maximal assistance (helper does more than half the effort) to complete transfers.4. R #1 utilized a wheelchair for mobility and required partial or moderate assistance (helper lifts, holds, or supports but provides less than half the effort) to propel 50 feet with two turns or to propel 150 feet. 5. R #1 had the following diagnoses:-Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), severe, with psychotic disturbance (a period of time during which an individual experiences a disconnection from reality, characterized by hallucinations and delusions),-Muscle weakness,-Lack of coordination,-Need for assistance with personal care,-Other abnormalities of gait and mobility,-Essential hypertension (HTN; high blood pressure),-Muscle spasm,-Coronary artery disease (heart disease). D. Record review of R #1's Care Plan Report revealed the following:1. Dated 03/05/26, Focus area for R #1 was at risk for impaired cognitive function or impaired thought processes due to dementia and a history of altered mental status. Interventions included facility staff to cue (a signal), reorient, and supervise R #1 as needed.3. Dated 03/06/26, Focus area for R #1 had a communication problem. Interventions included facility staff to anticipate and meet R #1's needs. E. Record review of R #1's Occupational Therapy Progress Report, dated 07/02/26, R #1 demonstrated a decline in functional performance, reduced activity tolerance, impaired functional reach, and diminished coordination. R #1's performance fluctuated from session to session and required ongoing skilled verbal and tactile cueing, physical assistance, and compensatory strategy training. F. Record review of R #1's Medication Admin Audit Report, dated July 2026, revealed Registered Nurse (RN) #1 administered quetiapine fumarate (antipsychotic medication) to R #1 at 11:16 am. G. Record review of the Emergency Services Prehospital Patient Care Report, dated 07/19/26, revealed the following:-At 3:29 pm, Emergency Medical Services (EMS) was called to the facility for a resident found outside in the courtyard and was unresponsive. R #1 was found by another resident of the facility.-When EMS arrived at the facility, they were greeted at the front door by a facility nurse who said, This is not my patient. The nurse is in the room with the patient, but here is the paperwork.- The EMS personnel went to R #1's room and saw three facility staff members around R #1's bed. The facility staff held manual and electric blood pressure machines and stated they could not obtain a blood pressure.-When EMS personnel arrived at R #1's room, the nurse reported another resident found R #1 outside.- The facility staff could not say when they last saw R #1. The nurse later stated she remembered seeing R #1 at lunch.-R #1 lay in his bed with a pillow under his head.-R #1 did not respond to painful stimuli and had two ice packs, one under his neck and one in his right armpit.-EMS personnel could not start an intravenous line on R #1. H. Record review of R #1's emergency documentation from a local hospital, dated 07/19/26, revealed R #1 arrived at the emergency room at 3:55 pm on 07/19/26 with altered mental status (AMS) and hyperthermia (a medical condition in which the body's core rises above normal, 98.6 degrees). R #1 could not communicate with staff during the encounter. The facility staff reported another resident found R #1 outside and unresponsive after an unknown amount of time. R #1 had sunburns on both legs, both arms, and the top of his head. He appeared well developed and well nourished, but dehydrated, frail, listless (lacking energy), and unkempt. His neurological exam was limited due to his mental status. R #1 showed weakened grip strength and delayed responses when asked to stick out his tongue, smile, and squeeze hands. R #1's temperature measured 103 degrees, indicating hyperthermia. R #1's blood pressure was 74/54 (normal range, 90/60 mm/Hg to 120/80 mm/Hg), his heart rate was 101 beats per minute (bpm; normal is 60 to 100 bpm), his oxygen saturation (SpO2) was 87 percent (%) on room air (normal range 95 to 100%), and he breathed rapidly at 40 breaths per minute (BPM; normal range is 12 to 20 bpm). The hospital staff started cooling measures, including ice pack application and cold IV fluids. I. Record review of the local weather forecast revealed the temperature measured 92 degrees, sunny without clouds, at 3:55 pm on 07/19/26. J. On 07/23/26 at 10:40 am, during an interview, RN #1 stated 07/19/26 was a busy day because she served as the floor nurse, medication technician, and wound care nurse. She stated she recalled seeing R #1 at lunchtime and later in the afternoon. She stated she could not remember the exact time she saw him in the afternoon. She stated a CNA told her R #1 was outside and was unresponsive. RN #1 stated she went to the courtyard, found R #1, and assisted two CNAs who brought him inside and to his room. She stated she and the two CNAs helped R #1 into his bed and began cooling him with cold wet washcloths and cold packs under his armpits and neck. She stated she observed R #1 was unresponsive and appeared sunburned. She stated another staff member called emergency services. RN #1 stated she was in R #1's room when paramedics arrived, and she told them another resident found R #1 unresponsive outside after an unknown amount of time. RN #1 stated two CNAs were assigned to R #1's hall and were responsible for his care. RN #1 stated she could not remember the names of the two CNAs. K. On 07/23/26 at 2:30 pm, during an observation, R #1 lay in bed and looked down at his blanket. The resident made eye contact but did not respond to questions. A skin assessment showed the resident's upper thighs had blisters and peeling skin. The right and left forearms had ruptured blisters, and the top of his head had ruptured and intact blisters. L. On 07/24/26 at 12:14 pm, during an interview, the Activity Assistant (AA) #1 stated she first saw R #1 outside in the courtyard at approximately 1:30 pm on 07/19/26. She stated she spoke to R #1, but he declined assistance back into the building. She stated she finished the smoke break with other residents and then went back inside the facility. She stated she thought whoever took R #1 outside would return to get him. AA #1 stated R #2 approached her at about 3:30 pm and stated R #1 was outside and leaning over in his wheelchair. She stated she looked outside, saw R #1 leaning over, and went down the hall to speak to one of the CNAs assigned to R #1's hall (unnamed CNA and CNA #1). She stated she told a CNA that R #1 was outside and needed help. AA #1 stated she could not remember the CNA's name. AA #1 stated the CNA told her she would go get R #1 after she finished making his bed. AA #1 then returned to her activities with other residents. She stated a few moments later, she looked out the window again and saw R #1 twitching. She stated she saw CNA #1, who was also assigned to R #1's hall, near the front entrance of the building. She stated she went to CNA #1 and told her that R #1 was outside and needed help. She stated CNA #1 went outside with her and directed her to get a nurse, and she did. M. On 07/27/26 at 10:45 am, during an interview R #1 stated he could not recall when or how the sunburn occurred. He stated he wished he could remember but could not. N. On 07/28/26 at 7:48 am, during an interview, CNA #1 stated R #1 spent most days in bed, but at times he pushed himself in his wheelchair around the facility. She stated R #1 needed redirection when he became lost and looked for his room. CNA #1 stated R #1 rarely, if ever, went to the courtyard. CNA #1 stated on 07/19/26 she just returned from her lunch break when AA #1 approached her and said a resident needed help in the courtyard. CNA #1 stated she went to the courtyard with AA #1 and saw R #1 slumped over in his wheelchair, with one leg hanging off the side. She stated R #1 was not responsive, so she sent AA #1 to get the nurse. She stated the three staff members (RN #1, CNA #1, and AA #1) helped R #1 back to his room and into his bed. She stated she received education on heat-related illness during her CNA certification, but she did not receive any additional training since she began working at the facility. O. On 07/28/26 at 9:25 am, during an interview, the Director of Nursing (DON) stated she did not expect non-medical staff to take action if they saw a resident twitching and slumped over in a wheelchair because non-medical staff were not trained to respond. She stated if non-medical staff had concerns about a resident, she assume they would stop and help. She stated facility staff did not receive formal education on heat related illnesses before this incident. She stated the facility did not have a policy for residents' use of the courtyard. Immediate Jeopardy was identified and the facility was notified on 07/28/26 at 3:15 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 07/29/26. The POR included the following: Corrective Action/Identification All residents residing in the facility have the potential to be affected by this alleged deficient practice. The following systematic measures were completed by 07/29/26.1. The facility took immediate measures to protect the residents from the identified risk related to resident supervision during periods of extreme heat and prevention of heat-related illness.2. Two additional hydration stations (a setup designed to provide convenient access to drinking water and other liquids to help residents stay hydrated) outside in the courtyard to improve resident access to fluids while outdoors.3. Two additional portable canopies were installed in the outdoor courtyard to provide increased shaded areas.4. The facility implemented courtyard monitoring to be completed hourly during the hours of 10:00 am and 7:00 pm. The courtyard monitoring includes hydration being offered to residents, observation of any signs or symptoms of heat-related illness, resident safety, and environmental conditions.5. The facility implemented a Resident Safety During Extreme Heat and Outdoor Activities policy which includes enhanced resident supervision, hydration practices, environmental monitoring, and interventions during periods of elevated temperatures. This policy established expectations for resident assessment, hydration, supervision, recognition of heat-related illness, and staff response.6. Facility-wide education completed on 07/28/26 or prior to the employee's next scheduled work shift on the following:-Resident safety during extreme heat and outdoor activities abuse and neglect prevention.-Recognition of heat-related illnesses,-Signs and symptoms of dehydration,-Resident supervision expectations,-Outdoor safety procedures,-Hydration requirements,-Immediate reporting of changes in resident conditions,-Abuse and neglect prevention and reporting responsibilities. 7. The facility ordered additional sun [NAME] (more permanent shade) for the courtyard. Implementation of the POR was verified onsite, and the IJ was removed on 07/29/26 at 9:45 am. The scope and severity were reduced from a K to a D. Implementation of the POR was verified by the following: 1. On 07/29/26 at 9:30 am, during an interview, Driver (DRV) #1 stated he received training on 07/28/26 on preventing, recognizing, and responding to heat related illnesses. DRV #1 stated the training informed him the residents were at a higher risk for heat related illnesses. He stated he knew to observe residents for signs of dehydration, changes in skin color, and alterations in their overall appearance because he was a CNA. 2. On 07/29/26 at 9:34 am, during an interview, Housekeeping (HK) #1 stated he received training on 07/28/26 on actions to take if he observed a resident of concern. HK #1 stated if he saw a resident in distress, then he would assist the resident with moving, if needed, and seek help from the nursing staff. 3. On 07/29/26 at 9:35 am, during an interview, Licensed Practical Nurse (LPN) #1 stated she knew how to prevent, recognize, and respond to heat related illnesses as part of her nursing role, but the facility provided additional training on the topic on 07/28/26. She stated her first action as a nurse would be to assess the resident, followed by notifying the medical provider, and implementing any orders received.4. On 07/29/26 at 9:38 am, during an interview, R #6 stated the facility added shade and new hydration stations in the courtyard. R #6 further stated the added shade made the courtyard significantly cooler.5. On 07/29/26 at 9:42 am, during an interview, CNA #2 stated she received training on 07/28/26 on preventing heat related illnesses and on immediately notifying a nurse if she became concerned about a resident.6. On 07/29/26 at 8:45 am, observation of the facility's outside courtyard revealed the following:1. Two hydration stations in the courtyard.2. Two portable canopies setup in the courtyard.7. Record review of the facility's training sign-in sheets for the heat-related illness education, dated 07/28/26 and 07/29/26, revealed all facility staff were trained in resident safety during outdoor activities, as well as on the prevention, recognition, and response to heat related illnesses.8. Record review of the facility's courtyard monitoring sheets, dated 07/28/26, revealed a facility staff observed the courtyard hourly until 10:00 pm.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) accurately reflected residents' clinical status for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for assessments. If staff do not accurately assess residents, then the resident may not receive the care needed to obtain optimal health. The findings are:A. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/08/26, revealed the following:1. R #1 was admitted to the facility on [DATE].2. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 07, moderately impaired.3. Staff did not document R #1's diagnosis of Type 2 diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin). B. Record review of R #1's Medical Diagnosis list, not dated, revealed R #1 had a diagnosis of DM2 present on admission. C. On 07/23/26 at 12:59 pm, during an interview, R #1's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) stated R #1 has been diagnosed with DM2 for as long as she can remember. D. On 07/28/26 at 3:15 pm, during an interview, the MDS Coordinator (MDS) stated R #1's MDS assessment, dated 06/08/26 was not accurate, because the MDS assessment did not reflect R #1's diagnosis of DM2. The MDS Coordinator stated he expected each resident to have an MDS assessment that accurately reflected the resident's diagnoses.

Based on observation, record review, and interview, the facility failed to provide necessary care and services to prevent the worsening of a pressure ulcer (injury to skin and underlying tissue from prolonged pressure) for 1 (R #1) of 5 (R #1, R #2, R #3, R #4, and R #5) residents reviewed for pressure ulcers/skin impairment. Specifically, the facility failed to accurately identify, assess, measure, stage, monitor, document, report, and adjust care for R #1's coccyx/sacral pressure ulcer. This deficient practice resulted in R #1's pressure ulcer progressing to an infected Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed bone, tendon, ligament, cartilage, or muscle), with exposed bone, purulent drainage (pus), cellulitis (skin infection), osteomyelitis (bone infection), hypotension (low blood pressure), tachycardia (fast heart rate), and systemic infection concerns (signs infection may have spread through the body). The findings are:Cross Reference: F-641, F-657, F-726, F-880 A. Record review of the facility's Wound Treatment Management policy, dated 12/01/25, revealed the following:1. Purpose: to promote wound healing and to provide treatments in accordance with current standards of practice and physician orders.2. Wound treatments will be provided in accordance with physician orders.3. Treatment decisions will be based on they type of wound and the characteristics of the wound.4. The effectiveness of the treatments will be monitored through ongoing assessment of the wound.5. Considerations for treatment modifications include lack of progress towards healing, changes in the characteristics of the wound, and changes in the resident's goals and preferences, such as end-of-life or resident rights. B. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses:1. Multiple sclerosis (MS; a chronic progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue), 2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),3. Protein-calorie malnutrition (PCM; a form of undernutrition caused by inadequate intake or absorption of protein, calories, or both),4. Stage 2 pressure ulcer (PU; partial thickness loss of skin presenting as a shallow, open ulcer with a red pink wound bed, may be an intact or a ruptured blister) to the sacrum (a large flat bone in the lower part of the spine, forming the rear section of the pelvis). C. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessments revealed the following:1. admission MDS dated [DATE] revealed:- A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 13, cognitively intact.- R #1 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene activities, showering or bathing, and personal hygiene activities.- R #1 is at risk of developing pressure ulcers.2. Quarterly MDS dated [DATE] revealed:- A BIMS score of 08, moderately impaired.-R #1 required substantial/maximal assistance for toileting hygiene activities and was dependent (helper does all the effort) in showering or bathing and personal hygiene activities.- R #1 did not have any pressure ulcers.- R #1 was at risk for developing pressure ulcers. D. Record review of R #1's care plan revealed the following:1. admission date 12/1/25.2. Dated 12/18/25 and last revised on 03/26/26, resident had a self-care deficit and needed assistance with self-care task, to include transfers, bed mobility, toilet use, and ambulation. Resident required the assistance of one staff for ADLs and two staff for transfers.3. Dated 12/18/25 with no revisions, resident had bowel incontinence related to multiple sclerosis. Staff to provide pericare after each incontinent episode. 4. Dated 03/27/26 and last revised on 04/02/26, resident elected to receive hospice services.5. Dated 12/22/25 and last revised on 04/01/26, resident was at risk for skin impairment related to advanced age, fragile skin, history of skin impairment, incontinence, and poor mobility. Interventions included cushion around and under boney prominences, pressure relieving device to bed, staff to keep skin clean and dry, low air loss mattress, staff to observe for abnormal skin issues and notify nurse of any impairments, pressure reducing cushion to wheelchair, staff to reposition the resident frequently, and licensed nurse to conduct weekly skin checks. E. Record review of R #1's progress notes revealed the following: 1. Skin check (weekly review of a resident's skin performed by staff), dated 12/18/25, R #1 had a Stage 2 pressure ulcer to his sacrum with partial thickness skin loss and exposed dermis (middle layer of skin). Wound was present on admission.2. Skin issue (weekly review of an identified skin impairment performed by the Wound Care Nurse), dated 12/26/25, R #1 had a pressure ulcer to his sacrum that was resolved. Wound was healed and closed.3. Skin check, dated 01/21/26, R #1 had an abrasion (a scrape; only affects the outer most layers of the skin) wound to his coccyx (tailbone) that was acquired in house (at the facility).4. Skin check, dated 01/23/26, R #1's skin issue to his coccyx was resolved.5. Skin check, dated 01/28/26, R #1 had a pressure ulcer located on his coccyx. Measurements are not documented as part of this assessment.wound nurse to measure.6. Skin check, dated 01/30/26, R #1 had an excoriation (superficial skin injury caused by scraping, scratching or picking, removes top layer of skin) wound to his coccyx, acquired in-house. It is unknown how long the wound has been present.7. Skin check, dated 02/04/26, R #1 had an excoriation wound to his coccyx, acquired in-house. It is unknown how long the wound has been present.8. Skin check, dated 02/06/26, R #1 had an excoriation wound to his coccyx, acquired in-house. It is unknown how long the wound has been present. R #1 has redness to penis and bilateral [both] buttocks.9. Skin check, dated 02/13/26, revealed R #1 had an excoriation wound to his coccyx, acquired in-house. It is unknown how long the wound has been present.10. Skin issue, dated 02/13/26, R #1 had an excoriation wound to his coccyx, acquired in-house. Overall wound characteristics improved and It is unknown how long the wound has been present.11. Skin check, dated 02/20/26, R #1 had an excoriation wound to his coccyx that was stable in progress and was previously deteriorating.12. Skin check, dated 02/27/26, R #1 had an excoriation wound to his coccyx, acquired in-house.13. Skin check, dated 02/27/26, R #1 had an excoriation wound to his coccyx that was stable in progress and was previously deteriorating.14. Skin check, dated 03/05/26, R #1 had an excoriation and small opening wound to his coccyx. It is unknown how long the wound has been present.15. Skin check, dated 03/06/26, R #1 had and an excoriation and small opening wound to his coccyx. It is unknown how long the wound has been present. Redness noted on coccyx area.16. Skin check, dated 03/13/26, R #1 had an excoriation and small opening wound to his coccyx. It is unknown how long the wound has been present.17. Skin check, dated 03/19/26, R #1 had an excoriation and small opening wound to his coccyx. It is unknown how long the wound has been present.18. Skin issue, dated 03/25/26, R #1 had an excoriation and small opening wound to his coccyx, It is unknown how long the wound has been present.19. Skin check, dated 03/26/26, R #1 had and excoriation and small opening wound to his coccyx. It is unknown how long the wound has been present.20. Skin check, dated 04/02/26, R #1 had an excoriation and small opening wound to his coccyx. It is unknown how long the wound has been present.21. Skin issue, dated 04/03/26, R #1 had an excoriation and small opening wound to his coccyx, that was stable in progress and was previously deteriorating. Staff documented, It is unknown how long the wound has been present. The wound measured 3.5 cm in length, 5.5 cm in width, 50% epithelial (indicates the outermost layer of tissue was half-closed), and had light exudate (weeping or oozing) of clear watery fluid. Odor was not present after cleansing.22. Skin check, dated 04/09/26, R #1 had a Stage 4 pressure ulcer with full thickness skin (a deep wound which extended entirely through the outermost, thinnest layer of skin, the thick middle layer of skin, and exposed fat, muscle, or bone) and tissue loss to the coccyx. F. Record review of R #1's physician orders revealed the following: 1. An order dated 12/18/25, wound care to the sacrum to cleanse with wound cleanser, pat dry, apply collagen (wound care solutions), cover with dry dressing every Monday, Wednesday and Friday and as needed for soiling or dislodgement. Stop date 12/26/25.2. An order dated 01/30/26, Calmoseptine (moisture barrier skin ointment) apply to sacrum every day and night for incontinence care. Stop date 03/25/26.3. An order dated 03/02/26, low air loss mattress (an air mattress to help prevent skin breakdown) due to reduced mobility and history of skin impairment.4. An order dated 03/15/26, wound care to the sacrum to cleanse with wound cleanser, pat dry, apply collagen particles (medical-grade, sterile powders designed for advanced wound care) mixed in Calmoseptine. Stop date 03/25/26.5. An order dated 03/25/26, wound care to the sacrum to cleanse with Vashe (wound cleanser), pat dry, apply alginate ag (a highly absorbent, seaweed-derived wound care product infused with silver), cover with dry dressing daily and as needed for soiling or dislodgement.6. An order dated 3/25/26, a referral to a local wound clinic for sacral wound.7. An order dated 03/26/26, R #1 to be evaluated and treated by a local hospice agency. G. Record review of R #1's Medication Administration Record (MAR; a staff tool used to document when medications are administered), dated January, February, and March 2026, revealed staff administered Calmoseptine ointment to R #1 as ordered from 01/31/26 through 03/25/26. H. Record review of R #1's Treatment Administration Record (TAR; a staff tool used to document when treatments are administered) revealed the following:1. Dated December 2025, staff administered wound care to the sacrum three times weekly, as ordered.2. Dated January, February, and March 2026, Calmoseptine was administered as ordered.3. Dated March 2026, a low air loss mattress was used on R #1's bed. Wound care to the sacrum was administered as ordered. I. Record review of R #1's hospice nurse progress note, dated 03/27/26, revealed the following:1. Dated 03/27/26, diagnosis multiple sclerosis and dementia, with related hypertension and chronic kidney disease. Resident was alert and oriented times 3 (person, place, and time) with intermittent confusion. Resident had a wound that progressively deteriorated to a Stage 3 pressure ulcer. Resident had increased pain due to pressure ulcer to sacrum. Resident refused facility staff attempts to turn him or to bathe him.2. Dated 03/27/26, admission note. Resident was completely bedbound and maximum assist with all ADLs. Resident incontinent of bowel and bladder. Resident had a large Stage 3 pressure ulcer to sacrum. Wound looked infected. Doctor notified and ordered Bactrim twice a day for 7 days. During wound care, the resident complained of pain. Resident stated laying on his bottom makes it hurt. He often refused for facility staff to turn and reposition him. Educated resident on allowing staff to turn and reposition him. Orders for oxycodone 5 milligram (mg) every four hours, as needed, and reposition resident every two hours.3. Dated 03/30/26, routine visit. Staff nurse reported the facility did not receive the resident's pain medications yet. Nurse stated she would call the pharmacy. Resident had urine soaked through his brief and onto his bedding. Wound care provided. Hospice nurse rolled resident to his right side and propped him with pillows.4. Dated 04/01/26, routine visit. Facility staff nurse stated they did not receive the resident's pain medication. The nurse was unsure if any called the facility over the last two days.5. Dated 04/03/26, routine visit. The resident lay in bed with a cup of water. The resident's blanket and sheet were wet. Wound care provided and bedding changed.5. Dated 04/06/26, routine visit. Nurse was informed to clean the resident's wound, because it had been a few days. Resident had a bowel movement. Brief changed and dirty dressing removed from wound. Wound care provided.6. Dated 04/08/26, routine visit. Removed resident's dirty brief and dirty wound dressings. Wound care provided. J. Record review of R #1's hospice Wound Assessment Tool Report revealed the following:1. Dated 03/27/26, wound to sacrum was a Stage 3 pressure ulcer and measured 6 cm long, 5 cm wide, and 1 cm deep. Surface area 30 square centimeters (sq. cm.) Depth full thickness; no granulation tissue (a type of connective tissue that forms on the surface of a wound during the healing process) present; edges none clearly visible; exudate (body fluid discharged by the body in response to tissue damage and wound healing) type purulent (a thick, opaque, yellow, green, or brown fluid composed of pus and indicating infection at the wound site); exudate amount small; epithelialization (a thin, continuous layer of cells) less than 25% of wound covered; necrotic (dead) tissue type yellow slough (yellow stringy tissue adhered to wound bed); necrotic tissue amount between 50% to 75% of wound covered; skin color surrounding wound white; no peripheral tissue edema (swelling); no undermining (significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface); faint odor. Follow up comments: None.2. Dated 03/30/26, wound to sacrum was a Stage 3 pressure ulcer and measured 10 cm long, 10 cm wide, and 1 cm deep. Surface area 100 sq. cm. Depth full thickness; no granulation tissue present; edges distinct; exudate type purulent; exudate amount small; epithelialization less than 25% of wound covered; no necrotic tissue present; skin color surrounding wound normal; no peripheral tissue edema; no undermining; faint odor. Follow up comments: New low air loss mattress ordered due to wound.3. Dated 04/06/26, wound to sacrum was a Stage 3 pressure ulcer and measured 6 cm long, 6 cm wide, and 2 cm deep. Surface area 36 sq. cm. No change in status. Depth description full thickness; no granulation tissue present; edges distinct; exudate type bloody; exudate amount small; epithelialization less than 25% of wound covered; no necrotic tissue present; skin color surrounding wound normal; no peripheral tissue edema; no undermining; no odor. Follow up comments: Wound decreasing in size and showing improvement.4. Dated 04/08/26, wound to sacrum was a Stage 3 pressure ulcer and measured 7 cm long, 8 cm wide, and 0 cm deep. Surface area 56 sq. cm. Depth full thickness, granulation tissue bright, beefy red with 25% to 75% of wound bed filled; edges distinct; exudate type purulent; exudate amount small; epithelialization less than 25% of wound covered; no necrotic tissue present; skin color surrounding wound bright red or blanches to touch; no peripheral tissue edema; faint odor. Undermining in all quadrants and measured between 1 to 3 cm. Follow up comments: None. K. Record review of R #1's physician notes from a local wound care clinic, dated 04/09/26, revealed the following:1. An initial visit for evaluation and management of a non-healing wound to the sacral (sacrum) area.2. A Stage 4 pressure ulcer measured 5.7 cm in length, 10 cm in width, and 2.7 cm in depth with active draining, foul smelling, and associated with exposed bone. The surrounding tissue was warm to touch and appeared cellulitic (bacterial skin infection).3. Wound Care Clinic sent R #1 to local emergency department for treatment. L. Record review of R #1's emergency room discharge paperwork, dated 04/09/26, revealed the following:1. R #1 presented with a Stage 4 decubitus ulcer (pressure ulcer) to the sacrum, purulent drainage present, foul-smelling, exposed bone, erythema present. Concerns for deep soft tissue infection and possible osteomyelitis. The resident was tachycardic (abnormally fast resting heart rate) and hypotensive (abnormally low blood pressure), which raised concerns for systemic infection.2. Resident had high white blood cell count, likely due to infected Stage 4 pressure ulcer which involved the sacrum. Osteomyelitis (inflammation of bone and bone marrow) present.3. The resident was administered the following medications in emergency department: Ketorolac (anti-inflammatory), ondansetron (nausea medication), fentanyl injection (pain medication), vancomycin (a powerful antibiotic), and Zosyn (antibiotic).4. The POA understood the resident was not a surgical candidate to remove the infected decubitus ulcer. The POA understood that outpatient treatment would be attempted but it was not a definitive treatment and the resident may succumb to this infection.5. The physician ordered Bactrim and frequent repositioning, and the resident would return to the nursing facility. M. On 05/12/26 at 2:00 pm, an observation of R #1's wound care and interview with Registered Nurse (RN) #1 revealed the following:1. RN #1 used a clean paper ruler to measure R #1's pressure ulcer to his sacrum which measured 3 inches in length and 2.5 inches in width.2. RN #1 was unable to give measurements of the wound in centimeters.3. RN #1 stated she could not obtain measurements for depth, because she does not know how. N. On 05/13/26 at 9:15 am during interview, R #1's Power of Attorney (POA) stated she e felt the facility was not caring for R #1's pressure ulcer and chose to put the resident on hospice. The POA was aware R #1 had a pressure ulcer but was not aware of the extent of the wound. The POA stated she was notified by the local emergency room physician that R #1 could pass away from this infection. O. On 05/13/26 at 12:06 pm during an interview, the Hospice Nurse (HRN) stated the Hospice Physician ordered antibiotics (medication) on 03/27/26 due to R #1's infected Stage 3 pressure ulcer to the sacrum. She stated the wound measured 6 cm length by 5 cm width by 1 cm depth, and it had a foul odor. P. On 05/13/26 at 4:10 pm during an interview, the Director of Nursing (DON) stated the following:1. The facility did not identify or document any characteristics of the wound prior to the hospital physician diagnosing R #1 with an infected, Stage 4 pressure ulcer, on 04/09/26.2. Skin checks were routine examinations of resident's skin, and the floor nurses completed the skin checks weekly. 3. Skin issues were routine examinations of an identified issue, and the Wound Care Nurse completed the skin issue examinations weekly. 4. The facility employed one full-time Wound Care Nurse, but the Wound Care Nurse left the faciity on [DATE].5. The facility hired the current Wound Care Nurse on 05/6/26.6. The current Wound Care Nurse was not available for interview.7. The DON would be responsible for completing skin issues if the Wound Care Nurse was not available.8. She did not observe R #1's wound, and she could not confirm if the skin check and skin issues records were accurate. 9. She did not know if staff notified the physician of the progression of R #1's wound, and the facility did not have any documented evidence to show staff notified the physician of the progression of the wound.10. It was her expectation for staff to follow facility policies and physician orders.11. The documented skin issues for R #1 did not meet her expectations for identifying wound characteristics, measurements, and staging of wound. 12. The facility's documentation of the wound did not show progressive deterioration. 13. The facility did not have any documentation to include characteristics of R #1 having a stageable pressure ulcer until the emergency room physician diagnosed it as a Stage 4, infected pressure ulcer. Q. The Medical Director was unavailable for interview during the survey. Attempt to contact the Medical Director was made on 05/13/26, but the Medical Director did not return the call. Immediate Jeopardy was identified and the facility was notified on 05/14/26 at 11:45 am. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 05/19/26 at 12:00 pm. The POR included the following:Corrective Action/IdentificationAll residents have the potential to be affected by this alleged deficient practice. The following measures and monitoring were completed by 05/19/2026.The resident's wound was immediately assessed, and documentation was clarified to reflect consistent anatomical location.The attending provider reviewed, clarified the anatomical location, and confirmed current wound staging and treatment plan. A skin assessment was completed on every resident in the facility where five new skin issues were identified. The facility ensured accurate classification, consistent anatomical documentation, and appropriate treatments and interventions were in place.Documentation was completed and added to the wound tracker.All responsible parties including the physician and POA were notified.Education was provided to all licensed nursing staff on:Documentation of findings from weekly skin checks.Wound identification and reporting.Consistent anatomical documentation.Documentation of care provided, refusals, and reapproaches.The facility has hired a new Infection Prevention/Wound Care Nurse that is trained and certified.Education was provided to the Administrator and Director of Nursing as well as all facility staff on identifying and reporting suspected abuse and neglect.Systemic MeasuresA standardized wound documentation process has been implemented to ensure consistency in anatomical identification and staging.Risk management reports will be completed for all new or worsening skin issues to ensure timely notification to the provider.Floor nurses will complete weekly skin checks, and the treatment nurse will complete weekly wound assessments on residents with identified skin issues.Wound audits will be conducted by the Director of Nursing three times per week for two weeks, then weekly for four weeks to ensure:Consistent documentationAccurate stagingAppropriate treatment implementationDocumentation of refusalsAn audit was conducted to ensure all residents requiring evidence based protocols (EBP) for skin integrity were identified and interventions were implemented. Implementation of the POR was verified onsite, and the IJ was removed on 05/19/26 at 12:00 pm. The scope and severity were reduced from a K to E. Implementation of the POR was verified by the following:1. Record review of R #1's progress notes revealed the following:A. Skin Issue, dated 05/14/26 revealed R #1: -Had a Stage 4 pressure ulcer with full thickness and tissue loss, -The pressure ulcer was acquired in-house, -The pressure ulcer measured 6 cm in length by 9 cm deep and tunnels from three to six o'clock.B. Record review of R #1's physician's progress note, dated 05/15/26, revealed the physician stated the following: -The pressure ulcer extends from the sacrum to the coccyx, -The plan of care is comfort based and unlikely to heal, -Since no bone was visible, the staging is Stage 3 but has been Stage 3-4 inthe past.2. Record review of R #1's physician orders revealed an order dated 05/14/26, for wound care to the sacrum. Staff are to cleanse the wound with wound cleanser, pat dry, apply alginate AG, cover with a dry dressing daily and as needed for soiling or dislodgement.3. Record review of the facility's skin assessments, last one dated 05/19/26, revealed the following: -Five new skin issues were assessed and treated. -Interventions were put in place for monitoring and treatment for the identified skin issues. - Physician orders were in place for the five identified skin issues.4. Record review of the facility's care plan audit revealed it was completed prior to 05/19/26.5. Record review of the wound tracker revealed all new skin issues were included in the tracking.6. Random observations of the facility revealed enhanced barrier precautions (EBP) were in place for all residents with open wounds.7. Record review of the facility's education logs dated 05/15/26 revealed education was provided to all licensed nursing staff on documentation of findings from weekly skin checks, wound identification and reporting, consistent anatomical documentation, and documentation of care provided, refusals, and reapproaches.8. Record review of the facility's education logs dated 05/15/26 revealed education was provided to all facility staff including the Administrator and Director of Nursing on identifying and reporting suspected abuse and neglect.9. On 05/19/26 at 1:36 pm, during an interview, Certified Nurse Aide (CNA) #3 stated she was recently trained on identifying skin issues and reporting them to the nurse on shift as soon as possible.10. On 05/19/26 at 2:05 pm, during an interview, CNA #4 stated the facility retrained them on identifying and reporting new skin issues.11. On 05/19/26 at 2:06 pm, during an interview, Registered Nurse (RN) #1 stated she was to report all new skin issues to the Wound Care Nurse who would measure and stage the wound.

Based on observation, interview, and record review, the facility failed to maintain an effective, comprehensive Infection Prevention and Control Program for 3 (R #1, R #5, and R #6) of 6 (R #1, R #2, R #3, R #4, R #5 and R #6) residents reviewed for infection control when the facility failed to:1. Post required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) signage for R #1, R #5 and R #6,2. Include R #1 in the facility's Antibiotic Stewardship monitoring program (tracking tool designed to ensure antibiotics are used only when necessary),3. Track R #1 within the facility's overall infection control program (ongoing process to collecting, analyzing and interpreting data to track, prevent and control the spread of infections).4. Ensure staff utilized appropriate Personal Protective Equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) when providing care for R #5 and R #6, These deficiencies are likely to place residents at risk for the development and transmission of communicable diseases.R #1A. Record review of R #1's admission Record revealed R #2 was admitted to the facility on [DATE]. B. Record review of R #1's progress notes revealed:1. Skin Check on 02/04/26, R #1 has an excoriation wound to his coccyx acquired in-house. It is unknown how long the wound has been present.2. Skin check on 02/27/26, R #1 has an excoriation wound to his coccyx that is stable in progress and was previously deteriorating.3. Skin check on 03/05/27, R #1 has an excoriation and small opening wound to his coccyx. It is unknown how long the wound has been present.4. Skin check on 03/26/26, R #1 has an excoriation and small opening wound to his coccyx. It is unknown how long the wound has been present.5. Skin check on 04/09/26, R #1 has a stage four pressure ulcer/injury with full thickness skin (extends entirely through the outermost, thinnest layer of skin and the thick middle layer of skin and through the subcutaneous (under the skin) fat exposing fat, muscle or bone) and tissue loss. C. Record review of R #1's physician orders revealed1. An order dated 3/27/26 for Bactrim (antibiotic medication) 800 milligrams (mg) to be given two times a day for wound to the sacrum area for seven days.2. An order dated 04/10/26, for Doxycycline (antibiotic medication) 100 mg to be given by mouth two times a day for sacral wound for 10 Days. D. Record review of Antibiotic stewardship program revealed R #1 was not on antibiotics in [NAME] 2026 or April 2026. E. Record review of the facilities infection program revealed R #1 did not have any wounds and did not have enhanced barrier precautions in place for the months of February 2026, March 2026, and April 2026. F. On 05/13/26 at 11:56 am, during an observation and interview with Certified Nurse Aide (CNA) #2, she confirmed R #1 did not have an EBP sign posted on his door. G. On 05/13/26 at 5:49 pm, during an interview with the Director of Nursing (DON) she confirmed:1. R #1 was not included in the antibiotic stewardship program for March 2026 and should have been because he was taking Bactrim.2. R #1 was not included in the antibiotic stewardship program for April 2026 and should have been because he was administered Bactrim and Doxycycline.3. R #1 is not included in the facility's Infection Control Program for the months of February 2026, Marh 2026, and April 2026 and should have been for tracking of wound and EBP. R #5H. Record review of R #5's admission Record revealed R #5 was admitted to the facility on [DATE] with the following diagnoses:1. Sepsis (a serious condition in which the body responds improperly to an infection),2. Pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region, Stage 4 (a deep wound that may impact muscle, tendons, ligaments, and bone),3. Need for assistance with personal care. I. Record review of R #5's physician orders revealed:1. An order dated 4/30/26 to clean the urinary catheter with soap and water ever shift and as needed.2. An order dated 4/30/26 to change wound vac (a medical device used to delever negative pressure wound therapy) canister when dressing change is done and as needed if three quarters full. J. On 05/14/26 at 3:02 pm during an observation and interview with Occupational Therapist (OT) #1 she confirmed:1. R #5 did not have an EBP sign posted.2. OT #1 was providing high contact care (transfers) to R #5 and was not wearing PPE. R #6 K. Record review of R #6's admission Record revealed R #6 was admitted to the facility on [DATE] with the following diagnoses:1. Extended spectrum beta lactamase (ESBL; enzymes produced by certain bacteria) resistance,2. Unspecified (the cause of an infection elsewhere in the body, without specifying the exact strain or subtype) Escherichia coli (E-coli; bacterium that normally lives in the gut), L. Record review of R #6's physician record dated 05/08/26 revealed an order for enhanced barrier precautions due to ESBL and E-coli. Ensure sign in placed on door/in room and gown and gloves to be worn for all high contact care. M. On 05/12/26 at 10:03 am during an observation and interview with Certified Nurse Aide (CNA) #2, she confirmed:1. R #6 did not have an EBP sign on the door.2. CNA #2 preformed high contact care (brief change) and did not wear PPE.

Based on record review and interview, the facility failed to complete a Significant Change (major decline or improvement in the patient's health status) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) within 14 days of a resident beginning hospice care for 1 (R #1) of 2 (R #1 and R #2) residents. Failure to complete a Significant Change MDS according within the required timelines may result in inaccurate or outdated care plans, missed identification of new or changing needs, or inadequate communication among interdisciplinary team members, which may lead to compromised resident safety and care. The findings are: A. Record review of R #1's admission Record revealed R #2 was admitted to the facility on [DATE] with the following diagnoses:1. Multiple Sclerosis (MS; a chronic progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue), 2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),3. Chronic Kidney Disease (CKD; impaired kidney function). B. Record review of R #1's Hospice Election Form, dated 03/26/26, revealed R #1's hospice care began 03/27/26. C. Record review of R #1's most recent MDS assessment dated [DATE] revealed R #1 is not on hospice. D. On 05/14/26 at 4:10 pm during an interview with the Director of Nursing, she stated the following:1. R #1 was admitted to hospice on 03/27/26.2. R #1 did not have a significant change MDS to reflect hospice care.

Based on record review and interview, the facility failed to administer medication according to physician orders for 1 (R #3) of 5 (R #1, R #2, R #3, R #4, and R #5) residents when staff administered a blood pressure medication outside of the parameters defined by the physician. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication. The findings are:A. Record review of R #3's admission Record revealed R #1 was admitted to the facility on [DATE] with hypertensive heart disease with heart failure (the result of unmanaged high blood pressure that weakens or stiffens the heart preventing it from pumping blood efficiently). B. Record review of R #3's physician order, dated 03/24/26, revealed an order for diltiazem (high blood pressure medication) 120 milligrams (mg) to be administered once daily. The medication should be held if systolic blood pressure (SBP; the top number in a blood pressure reading) was less than 110, diastolic blood pressure (DBP; the bottom number in a blood pressure reading) was less than 60, or the heart rate was less than 60. C. Record review of R #3's monthly Medication Administration Record (MAR; a tool used to document the administration of medications), dated May 2026, revealed staff administered diltiazem to R #3 on 05/10/26, and the resident's blood pressure measured 127/50 and her heart rate was 52. D. On 05/13/26 at 5:51 pm during an interview, the Director of Nursing stated staff did not follow the physician' s order when they administered diltiazem to R #3 on 05/10/26. She stated it was expected staff would not administer the medication when R #3's blood pressure and heart rate were outside the parameters.

Based on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 5 (R #3, R #9, R #10, R #12, and R #44) of 8 (R #2, R #3, R #5, R, #9, R #10, R #12, R #14, R and #44) residents reviewed for care plans when staff failed to:1. Develop and implement a care plan with interventions for R #3's oxygen therapy,2. Develop and implement a care plan with interventions for R #10's use of mobility bars and glasses,3. Develop and implement a care plan with interventions for placement in the secure/locked unit for R #9, R #12, and R #44.This deficient practice could likely result in proper care not being provided to residents.The findings are: R #3 A. Record review of R #3's admission record revealed R #3 was admitted into the facility on [DATE]. B. On 03/22/26 at 10:41 am, a random observation of R #3 in her room, revealed R #3 was lying in bed and had her oxygen on via nasal canula (a small, flexible tube that delivers oxygen to the nose through soft prongs). C. Record review of R #3's physician orders, revealed an order for oxygen three liters per minute (lpm), continuously via nasal canula. D. Record review of R #3's care plan, last revised on 02/25/26, revealed no care plan or interventions for R #3's use of oxygen therapy. E. On 03/22/26 at 2:37 pm, during an interview with Licensed Practical Nurse (LPN) #2, she confirmed R #3 does wear oxygen and should have a care plan with interventions for the use of oxygen. R #10 F. Record review of R #10's admission record revealed R #10 was admitted into the facility on [DATE]. G. On 03/22/26 at 2:13 pm, a random observation of R #10 in her room, revealed R #10 was lying in bed and had a quarter-sized bed rail (adjustable metal or rigid plastic bars that attach to the sides of a bed) located on the left upper bed. H. Record review of R #10's care plan, last revised on 03/18/26, revealed no care plan was developed or implemented for the use of quarter-sized bed rails. I. Record review of R #10's medical orders revealed an order for quarter-sized bed rails as an enabler for turning and repositioning in bed. J. On 03/22/26 at 2:37 pm, during an interview with LPN #1, she confirmed R #10 does utilize quarter-sized bed rails for positioning in bed and should have a care plan in place. R #9 K. Record review of R #9's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of oxygen and nutrients) with psychotic disturbance (a severe mental state characterized by a loss of contact with reality, often featuring delusions, hallucinations, and disorganized thinking or behavior). 2. Gastro-Esophageal Reflux Disease (GERD; A digestive disease in which stomach acid or bile irritates the food pipe lining), 3. Fibromyalgia (chronic muscle pain), 4. Hyperlipidemia (a condition in which there are high levels of fat particles in the blood; high cholesterol), 5. Psychosis (a symptom, involving a loss of contact with reality, where a person experiences the world differently from others) not due to substance or known condition. L. Record review of R #9's care plan dated 05/27/25 revealed no care plan to include interventions for secured/locked unit placement. M. On 04/06/26 at 11:27 am, during an interview with the Director of Nursing (DON) she confirmed R #9 was admitted directly to the secured/locked unit and does not have a care plan that was implemented and reviewed to include whether she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continued to meet her needs. R #12 N. Record review of R #12's admission Record revealed R #12 was admitted to the facility on [DATE] with the following diagnoses: 1. End stage renal disease (ESRD; chronic irreversible kidney failure), 2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar), 3. Insomnia (sleep disorder that can make it hard to fall asleep or stay asleep), 4. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with agitation, 5. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). O. Record review of R #12's care plan dated 09/11/24 revealed no care plan to include interventions for secured/locked unit placement. P. On 04/06/26 at 11:27 am, during an interview with the DON she confirmed R #12 was admitted directly to the secured/locked unit and does not have a care plan that was implemented and reviewed to include whether he continues to meet the criteria for remaining in the secured/locked area, and if the interventions continued to meet his needs. R #44 Q. Record review of R #44's admission Record revealed R #44 was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; lung disease), 2. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), 3. Muscle wasting atrophy (the loss of muscle tissue) in right and left legs, 4. Dementia with agitation, R. Record review of R #44's care plan dated 10/20/24 revealed no care plan to include interventions for secured/locked unit placement. S. On 04/06/26 at 11:27 am, during an interview with the DON she confirmed R #44 was admitted directly to the secured/locked unit and does not have a care plan that was implemented and reviewed to include whether he continues to meet the criteria for remaining in the secured/locked area, and if the interventions continued to meet his needs.

Based on record review and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 (R #1, R #27, and R #42) of 3 (R #1, R #27, and R #42) residents when staff failed to:1. Remove gloves and sanitize hands before touching surroundings.2. Sanitize blood pressure cuff in between residents after use.3. Sanitize hands before and after medication administration.4. Use proper handling techniques of drinks and bowls while distributing meals to residents in the dining room.If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are:R #1A. On 03/25/26 at 3:22 pm, during an observation of activities of daily living (ADL) care for R #1,1. Licensed Practical Nurse (LPN) #4 donned (put on) clean gloves and a gown.2. LPN #4 performed peri-care (cleaning from the front of the hips, between the legs and buttocks, and the back of the hips) for R #1.3. LPN #4 retrieved R #1's phone charger and handed it to her while wearing soiled gloves.4. LPN #4 moved a bedside table to within the resident's reach while continuing to wear soiled gloves.B. Record review of Centers for Disease Control (CDC) handwashing guidelines indicated that if gloves become soiled with blood or body fluids after task, the gloves should be removed, hands are to be sanitized and then put on clean gloves. Centers for Disease Control and Prevention. (2024, February 27). Clinical safety: Hand hygiene for healthcare workers. CDC. https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. R #42C. On 03/23/26 at 9:04 pm during an observation of medication administration Registered Nurse (RN) #1 did not sanitize the blood pressure cuff before using it for R #42 and did not cleanse after using it for R #42.D. Record review of the recommendations by the Centers for Disease Control (CDC) state that in long-term care facilities, blood pressure cuffs should be sanitized after use or between residents, using approved sanitizing cleanser. [Centers for Disease Control and Prevention. (n.d.). CDC - Centers for Disease Control and Prevention. https://www.cdc.gov].E. On 03/23/26 at 9:06 am, during an observation of medication administration, RN# 1 failed to sanitize hands prior to preparing medications for R #42 and RN # 1 failed to sanitize hands after administration of medications to R #42.F. Record review of the Medication Administration policy dated 12/01/25, revised 12/02/25, revealed staff will wash hands prior to and after medication administration. R #27G. On 03/21/26 at 12:23 pm, an observation of the lunch dining services revealed License Practical Nurse (LPN) #2, touched R #27's leg, placed his leg on the foot rest of his wheelchair, grabbed the back of R #27's wheelchair and moved him closer to the table, and then touched R #27's plate without washing or sanitizing her hands.H. On 03/21/26 at 12:37 pm during an interview with LPN #2, she confirmed that staff should be sanitizing or washing their hands after touching dirty surfaces and handling food items and trays.

Based on observation and interview, the facility failed to ensure call lights were within reach of the residents while in the room for 5 (R #6, R #30, R #39, R #54, and R #100) of 6 (R #2, R #6, R #30, R #39, R #54, and R #100) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they need assistance. The findings are:A. On 03/21/26 at 9:36 am, an observation and interview of the facility revealed the following: 1. R #39 was lying on her bed, and the call light was on the floor, underneath the bed. 2. Certified Medical Assistant (CMA) #1 confirmed the call light was not within reach and should have been. B. On 03/21/26 at 9:47 am, an observation and interview of the facility revealed the following: 1. R #6 was lying in her bed, and the call light was on the floor, at the head of the bed. 2. Certified Nurse Aide (CNA) #1 confirmed the call light was not within reach and should have been. C. On 03/21/26 at 9:53 am, an observation and interview of the facility revealed the following: 1. R #30 was lying in his bed, and the call light was on the floor, next to the bed. 2. R #100 was lying in his bed, and the call light was on the floor, next to the bed. D. Certified Nurse Aide (CNA) #1 confirmed the call lights for R #30 and R #100 were not within reach and should have been. R #54 E. On 03/21/26 at 10:54 am, a random observation of the facility revealed: 1. R #54 was lying in the recliner next to her bed and the call light was on the floor, underneath the bed. 2. Certified Nurse Aide (CNA) #2, confirmed the call light was not within reach and should have been.

Based on record review and interview, the facility failed to notify residents and their representatives in writing with explanation of why the move is required for 1 (R #7) of 1 (R #7) resident reviewed for room change notifications. If the facility fails to notify the resident and their representative(s) in writing, the resident and/or their representative(s) could experience confusion and frustration. The findings are: A. Record review of the facility's communication form for room change notification for R #7 dated 02/02/26 revealed R #7 and her representative were not informed prior to the room change.B. On 03/24/26 at 1:47 pm, during an interview with R #7's representative, he stated the facility did not notify him prior to moving R #7 to a new room. R #7's representative stated that when he came to visit R #7, he went to her old room and found she was no longer there and had to ask facility staff where she was.

Based on record review and interview, the facility failed to allow 1 (R #7) of 2 (R #7 and R #39) residents reviewed for hospice and pressure ulcers to choose the attending physician when they refused to accept medical orders for R #7's pressure ulcers from her hospice physician, instead sending R #7 to appointments at a wound clinic to obtain medical orders and care for pressure ulcers. If the facility does not allow residents to choose the physicians that are responsible for their care, then residents could experience feelings of frustration and depression. The findings are:A. Record review of R #7's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Osteomyelitis (inflammation of bone and bone marrow),2. Extended spectrum beta lactamase resistance (ESBL; a condition that makes infections harder to treat),3. Pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) of right heel, unstageable [a wound that has full thickness tissue loss but is covered with slough (dead tissue) or eschar (dark scab or falling away of dead skin) so that the true depth of the wound cannot be determined],4. Pressure ulcer of sacral region, stage 4 (a deep wound that may impact muscle, tendons, ligaments, and bone),5. Hypertensive heart disease without heart failure (a condition where chronic high blood pressure causes changes in the heart without the development of heart failure),6. Cutaneous abscess (a painful, swollen lump on skin caused by a bacterial infection) of buttock,7. Attention and concentration deficit (a condition characterized by persistent difficulties in focusing, sustaining attention, and maintaining concentration that affects a person's daily functioning).B. On 03/22/26 at 1:58 pm, during an interview with R #7's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care), he stated the facility is making his mom go to appointments at a wound clinic in a neighboring town because they won't accept the medical orders from her hospice physician. R #7's POA stated that they chose the hospice doctor to manage R #7's care but the facility is preventing that from happening. R #7's POA stated that hospice was chosen so the hospice physician should oversee her care instead the facility is not allowing them to choose the physician they want.C. On 03/23/26 at 11:00 am, during an interview with Hospice Executive Director ([NAME]) she stated the facility contacted her to obtain permission for R #7 to go to a wound clinic to get care for her pressure ulcers because they did not have anyone in house to provide the care. The [NAME] stated facility nurses are responsible for providing continuous wound care with a hospice nurse providing the wound care and taking measurements once weekly. The [NAME] stated the facility is still sending R #7 to appointments at the wound clinic even though she is on hospice.D. On 04/06/26 at 11:13 am, during an interview with the Assistant Director of Nursing (ADON) she stated that R #7 is going to the wound care clinic in a neighboring town because the facility does not have a wound care nurse.E. Record review of R #7's current physician order revealed an order dated 12/03/25 to admit R #7 to hospice care starting on 10/10/25.F. Record review of R #7's progress notes revealed progress notes dated 01/20/26, 01/21/26, 01/22/26, 01/26/26, 01/27/26, 01/28/26, 01/29/26, and 02/02/26 where R #7 had an appointment out of town at the wound clinic.

Based on record review, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen accurately reflected the resident's diagnosis or need for secondary screening for 1 (R #72) of 1 (R #72) resident reviewed for accuracy of PASARR screening. If the facility does not ensure PASARR screenings are completed accurately, then residents with serious mental illness may not receive required evaluations or specialized services, placing them at risk for unmet mental health needs and a decline in psychosocial well-being.The findings are:A. Record review of R #72's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra), 2. Surgical aftercare (the management of a patient's health immediately after a procedure and during their recovery), 3. Hypothyroidism (the thyroid is not making enough thyroid hormone), 4. Hypertension (HTN; high blood pressure), 5. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), 6. Hyperlipidemia (a condition in which there are high levels of fat particles in the blood; high cholesterol). B. Record review of R #72's PASARR dated 03/04/26 revealed R #72 did not have a diagnosis or suspected mental illness. C. On 04/01/26 at 12:21 pm, during an interview with the administrator, she confirmed R #72 does have a diagnosis of mental illness and the PASSAR is incorrect.

Based on observation, record review, and interviews, the facility failed to maintain acceptable parameters of nutritional status for 1 (R #7) of 2 (R #7 and R #106) residents reviewed for nutrition when staff failed to follow the diet order and nutritional recommendations allowing R #7 to have a 22 pound or 22.2% weight loss. This deficient practice is likely to lead to residents suffering from unplanned weight loss and malnutrition which could worsen medical conditions. The findings are: A. Record review of R #7's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Osteomyelitis (inflammation of bone and bone marrow), 2. Extended spectrum beta lactamase resistance (ESBL; a condition that makes infections harder to treat), 3. Pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) of right heel, unstageable [a wound that has full thickness tissue loss but is covered with slough (dead tissue) or eschar (dark scab or falling away of dead skin) so that the true depth of the wound cannot be determined], 4. Pressure ulcer of sacral region, stage 4 (a deep wound that may impact muscle, tendons, ligaments, and bone), 5. Hypertensive heart disease without heart failure (a condition where chronic high blood pressure causes changes in the heart without the development of heart failure), 6. Cutaneous abscess (a painful, swollen lump on skin caused by a bacterial infection) of buttock, 7. Attention and concentration deficit (a condition characterized by persistent difficulties in focusing, sustaining attention, and maintaining concentration that affects a person's daily functioning). B. On 03/22/26 at 1:58 pm, during an interview with R #7's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care), he stated that R #7 has lost about thirty pounds in the last few months. C. Record review of R #7's weight log revealed the following: 1. On 09/22/25, R #7 weighed 100.8 pounds. 2. On 12/23/25, R #7 weighed 94 pounds. 3. On 03/23/26, R #7 weighed 78.6 pounds. 4. R #7 had a weight loss of 22.02% (percent) in six months. D. Record review of R #7's care plan revised on 01/08/26 revealed staff are to: 1. Assist R #7 with meals using verbal and/or physical assistance. 2. Encourage R #7 to come out of her room for meals. 3. Monitor intake at all meals, offer alternative choices as needed. 4. Offer alternate food choices if 50% of meal is not consumed. D. Record review of R #7's Nutrition – Amount Eaten log dated 02/24/26 to 03/25/26 revealed fourteen days where R #7 did not eat more than 50% of any meal that day. E. Record review of R #7's electronic health record revealed no alternative meal choices offered to R #7 on the days when she ate less than 50% of her food. F. On 03/25/26 at 9:06 am, an observation and interview of R #7 in her room revealed the following: 1. R #7 received her food tray that consisted of a glass of milk, a glass of orange juice, hashbrowns, gravy with what appeared to be small bits of meat, and oatmeal that appeared watery. 2. R #7 is eating without assistance and only ate a small portion of her meal. 3. At 9:45 am, R #7's meal tray was picked up by facility staff. Staff did not ask R #7 if she was still hungry or if she wanted an alternative food option.

Based on record review and interview, the facility failed to effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 1 (R #8) of 4 (R #2, R #8, R #9, and R #72) residents reviewed for pain when the facility failed to administer medications as per physician's orders. This deficient practice could likely result in residents experiencing unnecessary pain and could compromise their quality of life. The findings are:A. Record review of R #8's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. End stage renal disease (ESRD; chronic irreversible kidney failure),2. Dependence on renal dialysis (treatment due to the inability of the kidneys to filter waste from the blood),3. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),4. Pressure ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left buttock, stage 3 (full thickness skin loss that extends into deeper tissue and fat but not into muscle, tendon, or bone),5. Chronic respiratory failure with hypoxia (a condition where the lungs fail to exchange gases leading to low oxygen levels in the blood),6. Epilepsy (a seizure disorder),7. Generalized anxiety (feelings of fear or apprehension) disorder,8. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),9. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).B. Record review of R #8's progress notes revealed a progress note dated 03/08/26 where R #8 fell while walking with her walker. R #8 was sent to a local emergency department for evaluation after complaining of excruciating (severe) pain in her hip.C. Record review of R #8's discharge paperwork from a local hospital dated 03/08/26 revealed R #8 sustained a closed fracture (broken bone where the skin remains intact) of right inferior pubic ramus (the flat bony structure located at the lower part of the hip bone) and a closed fracture of sacrum (a large flat bone in the lower part of the spine, forming the rear section of the pelvis).D. On 03/22/26 at 9:34 am, during an interview with R #8, she stated that she was in pain because she hasn't been given her pain pill for the past three days.E. Record review of R #8's medication administration record (MAR) for the month of March 2026 revealed the following:1. An order dated 03/09/26 for R #8 to have ten milligrams (mg) of oxycodone (a pain medication) every four hours as needed for moderate pain for ten days.2. R #8 received ten mg of oxycodone on 03/18/26 at 4:41 pm.3. R #8 did not receive this medication on 03/19/26.4. R #8 did not have an order for this pain medication on 03/20/26.5. An order dated 03/21/26 for R #8 to have five mg of oxycodone every six hours as needed for pain for fourteen days.6. R #8 did not receive this medication on 03/21/26.F. On 03/22/26 at 11:15 am, during an interview with Licensed Practical Nurse (LPN) #1 she stated that she hasn't been able to access the oxycodone for R #8 over the past few days so the other nurse on shift will be pulling it from the pyxis (a medication dispensing cabinet). LPN #1 stated that she did not report it to anyone because R #8 got the rest of her pain medication.

Based on observation, interview, and record review, the facility failed to ensure that resident preferences were honored for 1 (R #106) of 1 (R #106) residents reviewed when:- Alternative meals were not offered,- Meal did not contain adequate protein,-Facility meal ticket did not match the menu.This deficient practice is likely to result in residents being unable to make informed meal choices and not receiving meals consistent with their preferences.The findings are:R #106A. Record review of admission Record revealed R #106 was admitted to the facility on [DATE] with the following diagnoses:1. Chronic obstructive pulmonary disease (COPD; lung disease),2. Morbid obesity (severely overweight),3. Fluid overload (is a medical condition where the body retains an excessive amount of fluid, affecting tissues and organs),4. Shortness of breath,5. Type 2 diabetes (DM2, a condition results from insufficient production of insulin, causing high blood sugar).6. Heart Failure.B. On 03/25/26 at 9:02 am during an observation and interview, R #106 received her breakfast tray which consisted of oatmeal, hashbrowns, a small portion of egg, milk and juice. She stated that the menu she had been given listed biscuits with sausage and gravy and she didn't get any of that. R #106 stated that they are not asked about preferences, they just eat what is served and the menu rarely matches what is served.C. Record review of the menu dated March 2026 that was provided to R #106 revealed biscuit with sausage gravy as the main course.

Based on observation, record review and interview, the facility failed to provide assistive devices for 1 (R #106) of 5 (R #4, R #5, R #7, R #72, and R #106) residents reviewed during dining observation. If residents are not provided with special eating equipment as needed, then residents might be unable to consume their meals and beverages and is likely to result in weight loss, malnutrition, and dehydration. The findings are:A. On 03/25/26 at 9:25 am, an observation and interview with R #106 revealed:1. R #106 was observed trying to eat oatmeal with a weighted fork.2. No other utensils were available to R #106.3. R #106 stated she rarely gets a weighted spoon unless she asks for one.B. Record review of physician orders dated 01/26/26 revealed an order for R #106 to use a weighted utensil during meals.

Based on observation, record review, and interviews, the facility failed to ensure the nutritional needs and preferences were met for all 110 residents listed on the facility census provided by the Director of Nursing (DON) on 03/21/26, when staff failed to updated and post the correct menu. These deficient practices are likely to lead to residents experiencing frustration, depression, and weight loss due to not knowing what food is being served or being able to choose what they eat. The findings are:MenuA. On 03/21/26 at 12:11 pm, a random observation of the dining room revealed no lunch menu posted.B. On 03/21/26 at 12:18 pm during an interview with the Dietary Manager (DM), she confirmed the lunch menu was not posted.

Based on observation and interview, the facility failed to post nurse staffing data on a daily basis at the beginning of the shift that included the following:1. Facility name.2. The current date.3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:1. Registered nurses.2. Licensed practical nurses.3. Certified nurse aides.4. Resident census.This deficient practice has the potential to affect all 110 residents as identified by the census provided by the Director of Nursing on 03/21/26 and could likely result in residents and visitors not having the staffing information readily available. The findings are:A. On 03/21/26 at 10:57 am, an observation of the main entrance revealed the nurse staffing data sheet was dated 03/20/26.B. On 03/21/26 at 10:58 am during an interview with the Human Resources Director (HRD), he confirmed the nursing staffing data sheet should be posted daily and it was not.

Based on observation and interview, the facility failed to serve food under sanitary conditions when staff failed to use proper handling techniques of drinks and bowls while distributing meals to residents in the dining room. This deficient practice is likely to affect all 87 residents listed on the census provided by the Director of Operations (DOO) on 12/30/25 and could likely cause an increase in illnesses if safe food handling practices are not followed. The findings are: A. On 12/31/25 at 12:00 pm, an observation of the lunch dining services revealed the following:1. Certified Nurse Aide (CNA) #1 moved a chair from one table to another, moved the table over approximately two feet, touched a different chair at another table and then served drinks to all residents in the dining room without washing or sanitizing her hands.2. CNA #2 touched R #4's right arm and chair while assisting R #4 to sit down. CNA #2 served R #5 his lunch without sanitizing or washing her hands. CNA #2 touched R #5's cup and bowl by the top of the rim (cupping) when placing them on the table.3. CNA #3 pushed R #6's sleeve up her arm and then served R #1 her lunch without washing or sanitizing her hands. CNA #3 touched R #1's bowl by the top rim when placing it on the table.B. On 12/31/25 at 12:37 pm during an interview with the Dietary Supervisor (DS), she confirmed that staff should be sanitizing or washing their hands after touching dirty surfaces and handling food items and trays.

Based on interview and record review, the facility failed to provide a sufficient number of nursing personnel to meet the individualized care needs of its residents and failed to maintain accurate PPD (Person Per Day) to demonstrate compliance with federal staffing standards. This deficient practice has the potential to affect all 87 residents care residing in the facility. The findings are: A. Record review of the facility's PPD documentation dated 06/01/25 to 12/29/25 revealed the following:1. The facility failed to provide PPD documentation for 06/01/25 to 11/30/25 [change of ownership occurred on 12/01/25].2. Documentation for 12/03/25 revealed two Registered Nurses (RN) were scheduled to work two twelve-hour shifts for a total of 24 hours but 36 hours was reported.3. Documentation for 12/10/25 revealed two RN were scheduled to work two twelve-hour shifts for a total of 24 hours but 36 hours was reported.B. Record review of the facility's schedules and timecards revealed no documentation prior to 12/01/25 [change of ownership occurred on this day].C. On 12/30/25 at 11:15 am during an interview with the Director of Operations (DOO), she confirmed she cannot provide copies of the PPD, schedules, or timecards prior to 12/01/25 when the current company completed a Change in Ownership. The ADM confirmed she is not able to verify the facility had sufficient nurse staffing because the documentation prior to 12/01/25 is not available to her.D. On 12/31/25 at 10:36 am during an interview with the Director of Nursing (DON), she confirmed the PPD staffing totals that were reported for 12/03/25 and 12/10/25 were not accurate. The DON stated she had no PPD documentation prior to 12/01/25 [change in ownership occurred on this day].E. On 02/04/26 at 10:10 am, the DOO confirmed she is still not able to provide any copies of the PPD, schedules or timecards prior to 12/01/25 when Change in Ownership occurred.

Based on interview and record review, the facility failed to monitor residents' weights, assess the cause of unintentional weight loss and implement interventions to prevent further weight loss for 4 (R #1, R #2, R #3, and R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for nutrition. This deficient practice could likely result in the residents losing weight causing physical and mental health issues. The findings are: R #1 A. Record review of R #1's Face Sheet revealed that she was admitted to the facility on [DATE] with multiple diagnoses including: 1. Sepsis (a serious condition in which the body responds improperly to an infection), unspecified organism. 2. Muscle weakness, (generalized). 3. Colostomy Status [a surgical procedure in which the colon is connected to the abdominal wall and an opening (stoma) is created in the abdominal wall created to allow waste to leave the body]. 4. Encounter for surgical aftercare following surgery on the Genitourinary (the sex organs of the reproductive system and the organs of the urinary system) and Digestive (the organs responsible for breaking down food and liquids down into substances that the body uses) Systems. B. Record review of R #1's Care Plan revealed the following: 1. [Name of R #1] will consume [sign for greater than] 80% of meals through next review, dated 08/19/24. 2. [Name of R #1] will not have any significant weight changes through next review, dated 08/19/24. 3. Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated dated 08/19/24. 4. Offer snacks between meals dated 09/12/24. 5. Provide house supplement as ordered dated 09/12/24. C. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 09/12/24 revealed that she required substantial maximum assistance for dining. D. Record review of R #1's Documentation Survey Report for the months of August 2024 and September 2024 revealed that R #1 ate no more than fifty percent of any meal. E. Record review of Nutrition assessment dated [DATE], revealed a recommendation to get a current weight for R #1. F. Record review of Nutrition assessment dated [DATE], revealed a second recommendation to get a current weight for R #1. G. Record review of R #1's medical orders dated 08/08/24 revealed an order to weigh R #1 weekly, every Thursday for four weeks and monthly thereafter. H. Record review of R #1's Weight Summary revealed that R #1 weighed 126.3 pounds on 08/08/24. The Weight Summary does not contain any other weights for this resident. I. Record review of R #1's hospital discharge documents dated 09/25/24 revealed that R #1 was admitted to the hospital on the same date and weighed 89 pounds (loss of 37.3 pounds which equals 29.5% weight loss in 41 days). J. On 11/13/24 at 11:11 am during an interview with R #1's daughter, she stated that her mother passed away on 09/30/24 from complications related to COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) but feels like she would have been stronger and more able to fight off the disease if she was healthier and at a healthy weight. R #1's daughter stated that she didn't realize how much weight her mother lost because she was always laying in bed covered up when she visited. She stated that she sent her mother to the facility to be taken care of and feels like the facility failed her. K. On 11/14/24 at 11:43 am during an interview with the Administrator (ADM), he stated that the registered dietician was not available for interview but the Director of Clinical Operations was available and prepared to interview. L. On 11/14/24 at 11:45 am during an interview with the Director of Clinical Operations (DCO) she stated that she is a registered dietician. She confirmed that R #1's weight loss of 37.3 pounds in 41 days is significant and the nutritionist should have been notified. She stated the nutritionist made two separate recommendations to get a current weight on R #1, but the facility failed to do so. She stated that the nutritionist would typically go to the DON or the Administrator if recommendations were not followed but was not able to say if this happened. The DCO confirmed weight loss for R #1 was not planned. M. On 11/14/24 at 3:00 pm during an interview with the DON, she confirmed that the facility failed to follow the doctor's order and the nutritionist's recommendations of weighing R #1. The DON confirmed that the facility failed to act after all documentation showed R #1 not meeting her goal of consuming eighty precent of her meals. She stated that placing R #1 on a house supplement should have been done sooner than 09/12/24. The DON confirmed that the doctor and nutritionist were not notified of R #1's significant weight loss because it was not being monitored appropriately. She stated planned weight loss was not in R #1's plan of care. R #2 N. Record review of R #2's Face Sheet revealed she was admitted to the facility on [DATE] with multiple diagnoses including: 1. Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), unspecified. 2. Type 2 Diabetes without complications (a condition results from insufficient production of insulin, causing high blood sugar) 3. Unspecified severe protein-calorie malnutrition (a severe loss of weight or lack of weight gain). O. Record review of R #2's Weight Summary revealed the following: 1. On 05/01/24, the resident weighed 221.8 pounds. 2. On 06/03/24, the resident weighed 198.8 pounds. 3. On 07/03/24, the resident weighed 215.8 pounds. 4. On 08/01/24, the resident weighed 210.0 pounds. 5. On 09/01/24, the resident weighed 198.2 pounds. 6. On 10/01/24, the resident weighed 190.4 pounds. 7. On 11/05/24, the resident weighed 181.4 pounds. P. Record review of R #2's care plan revealed the following: 1. [Name of R #2] will consume [sign for greater than] 85% of meals through next review, dated 11/19/19 and revised on 07/17/24. 2. [Name of R #2] will not have any significant weight changes through next review, dated 03/01/24 and revised on 10/15/24. Q. Record review of R #2's Documentation Survey Report for the months of July 2024, August 2024, September 2024, and October 2024 revealed that R #2 ate no more than twenty-five percent of any meal. R. On 11/14/24 at 11:45 am during an interview with the Director of Clinical Operations (DCO) she confirmed that R #2's weight loss is significant and stated she was unsure if the nutritionist was notified. S. On 11/14/24 at 3:00 pm during an interview with the DON, she confirmed that the facility failed to act after all documentation showed R #2 not meeting her goal of consuming more than eighty-five percent of her meals. The DON is not sure if the doctor and nutritionist were notified of R #2's significant weight loss but confirmed they should have been. She stated that weight loss is not a goal in R #2's plan so the weight loss was not planned. R #3 T. Record review of R #3's Face Sheet revealed he was admitted to the facility on [DATE] with multiple diagnoses including: 1. Anemia (low red blood cell count), unspecified. 2. Nontoxic Single Thyroid Nodule (a lump that forms in the thyroid gland). 3. Type 2 Diabetes Mellitus (a condition results from insufficient production of insulin, causing high blood sugar) with Hyperglycemia (high blood sugar). 4. Inflammatory Disease of Prostate (male reproductive gland). U. Record review of R #3's MDS dated [DATE] revealed that he requires setup or cleanup assistance for dining. V. Record review of R #3's care plan revealed a goal of [Name of R #3] will consume [sign for more than] 85% of meals through next review dated 06/11/24 and revised on 10/31/24. W. Record review of R #3's Weight Summary revealed that R #3 weighed 207.8 pounds on 06/03/24 and 160.2 pounds on 11/11/24 (weight loss of 22.9% in six months). X. Record review of R #3's Documentation Survey Report for the months of June 2024, July 2024, and August 2024 revealed that R #3 ate no more than fifty percent of any meal. Y. On 11/14/24 at 11:45 am during an interview with the Director of Clinical Operations (DCO) she confirmed that R #3's weight loss is significant and stated she was unsure if the nutritionist was notified. The DCO confirmed R #3's weight loss was not planned. Z. On 11/14/24 at 3:00 pm during an interview with the DON, she confirmed that the facility failed to act after all documentation showed R #3 not meeting her goal of consuming more than eighty-five percent of her meals. She stated the weight of 207.8 pounds may have been an error but confirmed R #3 was not reweighed to rule this out. R #4 AA. Record review of R #4's Face Sheet revealed that she was admitted to the facility on [DATE] with multiple diagnoses including: 1. Cerebral Infarction, (an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), unspecified. 2. Cellulitis (deep inflammation of the tissues just under the skin; caused by infection) of left lower limb. 3. Hyperlipidemia, (a condition in which there are high levels of fat particles in the blood; high cholesterol) unspecified 4. Laceration (a wound produced by tearing) of Esophagus (part of the body that connects the throat to the stomach), subsequent encounter. BB. Record review of R #4's MDS revealed that she requires supervision or touching assistance for dining. CC. Record review of R #4's Weight Summary revealed that R #4 weighed 170.2 pounds on 09/24/24 and 150.2 pounds on 10/31/24 (loss of 20 pounds which equals 11.75% weight loss in 38 days). DD. Record review of R #4's care plan dated 08/14/24 revealed no goals or interventions related to significant weight loss. EE. Record review of R #4's medical orders revealed no order to address significant weight loss. FF. On 11/14/24 at 11:45 am during an interview with the Director of Clinical Operations (DCO) she confirmed that R #4's weight loss is significant and stated she was unsure if the nutritionist was notified. She stated weight loss was not planned for this resident. GG. On 11/14/24 at 3:00 pm during an interview with the DON, she confirmed that R #4's weight loss of 11.75% is considered significant weight loss and should be included in the care plan. 51657

Based on record review, observation, and interview, the facility failed to ensure comprehensive care plans were revised for 4 (R #21, 76, 81, and 99) of 4 (R #21, 76, 81, and 99) residents reviewed for revision of care plans. This deficient practice has the potential for new interventions not to be put in place when a resident has a fall which could likely result in serious injury. The findings are: Resident #21 A. Record review of the facility face sheet dated 03/27/18 for R #21 revealed an admission of 03/27/18 with the following Diagnoses: [REDACTED]. (loss of memory), [MEDICAL CONDITIONS], Takotsubo syndrome (weakening of the left ventricle, the heart's main pumping chamber), wedge compression fracture (collapse of a vertebra) of first lumbar vertebra (lower spine), repeated falls, difficulty in walking, and muscle weakness. B. Record review of the facility event summary report for R #21 revealed that from 02/06/19 through 03/30/19, the following incidents were noted: 1. 02/06/19 - Resident attempting to sit on dining room chair, missed chair and sat on floor, no injury, able to stand and bear weight, ambulates per norm (normal), denies pain, discomfort. 2. 02/08/19 - Resident was leaving dining area ambulating with her walker, when she appeared to lose her footing. She went backwards hitting her back against the window of the nurses station. Noted reddened area right thumb. Started neuro's (assessment of cognition, vital signs, pupils) as she did hit the back of her head. 3. 02/10/19 - Resident sat up on edge of bed and slid off onto floor. 4. 02/27/19 - Resident found on the floor. 5. 03/17/19 - At approximately 4:30 pm resident fell in the dining room. Staff rushed to her lying on the floor. She was transferred to wheelchair. This nurse tried to arouse resident but she was unresponsive. Certified Nurse Aides (CNA's) activated 911. Resident was nonresponsive for approximately 2-3 minutes. No apparent physical injuries noted. 6. 03/30/19 - When resident was being assisted to bed an unlicensed personnel noticed a bruise on resident left biceps.The bruise is black and blue and is 21.6 centimeters by 12. 7 centimeters. Resident sent to emergency room . C. Record review of the care plan dated 03/26/18 for R #21 revealed no update to the care plan for the falls on 02/06/19, 02/08/19, 02/10/19, and 03/17/19. D. Record review of the care plan dated 03/26/18 for R #21 revealed no update to the care plan for the bruise that was documented on 03/30/19. E. On 04/05/19 at 10:01 am, during an interview, the Minimum Data Set (Center for Medicare Medicaid Services assessment tool) Coordinator (MDSC) #1 stated the process is that the care plan should be updated at the time of the fall/incident by the nurse. If it isn't done, then in the morning meeting we should update the care plan. Resident #76 F. Record review of facility face sheet dated 02/17/17 revealed R #76 was admitted on this date. Admission [DIAGNOSES REDACTED]. functioning) without behavioral disturbances, diabetes (high blood sugar), hypertension (high blood pressure), [MEDICAL CONDITIONS] (plaque builds up inside your arteries), [MEDICAL CONDITION] (low [MEDICAL CONDITION]), muscle weakness, difficulty in walking, lack of coordination, dysphagia (difficulty in swallowing), displaced fracture of left radial styloid process (a [MEDICAL CONDITION] joint, though the most common type of wrist fracture occurs at the end of the radius bone of the forearm), and pain in joint. G. Record review of Progress Notes for R #76 dated 09/14/18 revealed, Note: Status of condition: no change Data: Alert and oriented to self at 1545 resident complaint of (c/o) pain to left hand. no redness or swelling noted is able to move hand at wrist with no increase in pain. refuses to go to hospital. 2130 (9:30 pm) assessed resident denies pain able to move wrist/ hand/ fingers of left hand denies pain at this time reviewed with her that she can go to emergency room (ER) to x-ray her hand and wrist again refuses stating its not hurt see again moving her wrist and hand and fingers with no c/o pain. Action: Comfort measures positioning. Resident states she will call for help to go to B.R. (bathroom) Response: States that this nurse has helped. and she has no pain. H. Record review of Progress Notes for R #76 dated 09/21/18 revealed, .Resident did c/o of pain on 9/14/18 at 3:45 pm on the 2-10 pm shift. She stated that her left hand and wrist were hurting. At 10:30 pm resident was given the option to send to ER for further evaluation she did refuse stating that its not hurt and then was able move her wrist with full ROM (range of motion) and move all of her digits with full ROM, so after assessment of resident she stated that she will let someone know if her pain starts back up again and if she changes her mind on going to the ER. I. Record review of Progress Notes for R #76 dated 09/28/18 revealed, Late Entry: Note: Late entry for 09/28/18 Certified Nurse Assistant (CNA) reported discoloration to left anterior forearm. 2 areas bruises related to fall on 09/14. J. Record review of Progress Notes for R #76 dated 09/28/18 revealed, .Change reported to Primary Care Clinician: (name of CNP) 09/28/2018 12:20 PM Orders obtained include: Send for . left forearm x ray X-ray . K. Record review of Progress Notes for R #76 dated 10/03/18 revealed, Physician Notified: (name of Nurse Practitioner (CNP)) confirmed she received. x-ray report. Results reviewed (describe): Left forearm x-ray 2 views: Impression: Distal radial fracture involving the articular surface (broken arm bone near the wrist). Physician Response/Other action taken: New order to refer to orthopedics. L. Record review of Progress Note for R #76 dated 10/11/18 revealed, Late Entry: Note: This is a follow-up note from the change in condition-medical that occurred on 09/28/2018 Status of condition: improved Data: Resident went to see (name of doctor)orthopedics for her non-displaced distal radius fracture left arm: (name of doctor) note states, No cast, No surgery Should be fine within 4 weeks if not follow up. Family aware as they were at the appointment M. On 04/03/19 at 3:30 pm during an interview the Minimum Data Set Coordinator (MDSC #1) stated for R #76 , The falls are not listed on the care plan and there is no specific care plan intervention for the dates of her falls. Resident #81 N. Record review of facility face sheet dated 02/22/2019 for R #81 revealed this to be the resident's admitted . Admission [DIAGNOSES REDACTED]. O. Record review of Facility Event Tracking Log dated 10/01/2018 to 04/02/2019 revealed the following incidents for R #81: 03/10/2019 at 9:30 pm - Fall 03/11/2019 at 5:15 pm - Fall 03/12/2019 at 3:40 pm - Fall 03/26/2019 at 6:45 am - Fall P. Record review of Facility Care Plans dated 01/25/2019 for Falls for R #81 revealed no documented evidence that the falls on 03/10/19, 03/11/19, 03/12/19, and 03/26/19 were addressed in the care plan or that interventions were reviewed/updated to reflect these falls. Q. On 04/05/2019 at 3:30 pm during an interview, the DON stated that the falls for 03/10/2019, 03/11/2019, 03/12/2019, 03/26/2019 were not revised on the Care Plans for Falls for R #81. He also stated that he is unsure why the care plan was not revised to address these falls. Resident #99 R. Record review of facility face sheet dated 12/06/18 for R #99 revealed this to be the residents admitted . Admission [DIAGNOSES REDACTED]. of the liver (a late stage of scarring of the liver caused by many forms of liver diseases and conditions), hypertension (high blood pressure), [MEDICAL CONDITION] (is a noncancerous increase in size of the prostate), dementia (a broad category of brain diseases that cause a long-term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning) without behavioral disturbances, [DIAGNOSES REDACTED] of the intestine (small, bulging pouches that can form in the lining of your digestive system), muscle weakness, cognitive communication deficit, need for assistance with personal care. S. Record review of Change in Condition Evaluation Form dated 12/15/18 for R #99 revealed, rsd (resident) found sitting in floor in front of w/c (wheelchair) in br. (bathroom) confused behavior is baseline. denies pain. able to assist with transfers. neuro checks begun and wnl (within normal limits). abrasion to right lower back. T. Record review of Change in Condition Evaluation Form dated 01/06/19 for R #99 revealed, rsd found on floor beside his bed. able to assist with transfer then ambulate with stand by assist. neuro checks wnl. contusion (bruise) to right temple. no other injuries or pain noted, moving all ext (extremities) normally. U. Record review of Change in Condition Evaluation Form dated 03/22/19 for R #99 revealed, rsd found sitting on floor beside his bed. denies pain, no s/s (signs and symptoms) of injury, able to assist with standing and transfer to bed. neuro checks started and wnl (within normal limits). will continue to monitor. V. On 04/03/19 at 3:30 pm during an interview the Minimum Data Set Coordinator (MDSC #1) when asked about the falls for R #99 and the interventions stated, The falls are not listed on the care plan and there is no specific care plan intervention for the dates of his falls.

Based on record review and interview the facility failed to adequately supervise residents to prevent injuries for 2 (R #21 and #81) of 4 (R #21, #76, #81 and #99) residents reviewed for accidents. Resident #21 was noted to have an injury of unknown origin (broken arm) and R #81 had repeated falls with one resulting in a head injury that required stitches. If residents are not adequately supervised residents have the potential to suffer further injuries. The findings are: Resident #21 A. Record review of the facility face sheet dated 03/27/18 for R #21 revealed an admission of 03/27/18 with the following Diagnoses: [REDACTED]. (loss of memory), [MEDICAL CONDITIONS], Takotsubo syndrome (weakening of the left ventricle, the heart's main pumping chamber), wedge compression fracture (collapse of a vertebra) of first lumbar vertebra (lower spine), repeated falls, difficulty in walking, and muscle weakness. B. On 04/01/19 at 2:45 pm, during an observation of R #21 revealed, R #21 had a sling to her left upper arm. C. Record review of the facility event summary report for R #21 revealed, from 02/06/19 through 03/30/19 the following incidents were noted: 1. 02/06/19 - Resident attempting to sit on dining room chair, missed chair and sat on floor, no injury, able to stand and bear weight, ambulates per norm, denies pain, discomfort. 2. 02/08/19 - Resident was leaving dining area ambulating with her walker, when she appeared to loose her footing. She went backwards hitting her back against the window of the nurses station. Noted reddened area right thumb. Started neuro's (assessment of cognition, vital signs, pupils) as she did hit the back of her head. 3. 02/10/19 - Resident sat up on edge of bed and slid off onto floor. 4. 02/27/19 - Resident found on the floor. 5. 03/17/19 - At approximately 4:30 pm resident fell in the dining room. Staff rushed to her lying on the floor. She was transferred to wheelchair. No apparent physical injuries noted. 6. 03/30/19 - When resident was being assisted to bed an unlicensed personnel noticed a bruise on resident left biceps. The bruise is black and blue and is 21.6 centimeters by 12. 7 centimeters. Resident sent to emergency room . D. Record review of a emergency department physician note dated 03/30/19 for R #21 revealed, . Patient brought to the emergency room via emergency medical service from nursing home with complaints of ecchymosis (a bruise) to the left upper arm.Disposition: 03/31/19 - discharged to Nursing Home. Impression: other displaced fracture of upper end of left humerus (long bone in the arm that runs from the shoulder to the elbow). She needs a follow up appointment with . Humerus treated with immobilization. E. Record review of a nursing note dated 3/31/2019 for R #21 revealed, Note: This nurse was told in report that residents left humerus is broken. She needs a follow up appointment with orthopedic (specializes in bone disorders) physician #2 in 1-2 days. Resident voices no complaints of (c/o) pain but APAP ([MEDICATION NAME] pain medication) 500 milligrams (mgs) was given. F. Record review of a radiologist report dated 03/31/19 for R #21 revealed, Indication: Deformity, Findings: There is a humeral head and neck fracture with angulation (distorted part of body to form an angle) and impaction (parts of the broken bone are driven toward or into each other by force) of the humeral neck fracture component. The humeral shaft is intact. G. On 04/05/19 at 12:10 pm, during an interview, the Administrator stated that she/he was unable to determine how R #21's left arm was broken. Resident #81 L. Record review of Facility Face Sheet dated 02/22/2019 for R #81 revealed this to be the resident's admitted . Admission [DIAGNOSES REDACTED]. M. Record review of Facility Event Tracking Log dated 10/01/2018 thru 04/02/2019 revealed the following falls for R #81: 02/28/2019 at 4:30 am, Fall 03/06/2019 at 5:30 pm, Fall 03/10/2019 at 9:30 pm, Fall 03/11/2019 at 5:15 pm, Fall 03/12/2019 at 3:40 pm, Fall 03/26/2019 at 6:45 am, Fall 03/30/2019 at 10:00 pm, Fall O. Record review of Facility Event Tracking Log dated 10/01/2018 thru 04/02/2019 revealed no documented evidence of the fall on 03/01/2019 Fall. (This fall is documented in two separate progress notes below.) P. Record review of Facility Progress Notes for R #81 revealed the following: 1) 03/02/2019 at 1:05 pm revealed, This is a follow-up note from the accident/incident/fall in past 72 hours that occurred on 03/01/2019 . S/P (status [REDACTED]. 2) 03/03/2019 at 12:57 revealed, This is a follow-up note from the accident/incident/fall in past 72 hours that occurred on 03/01/2019. Status of condition:no change. DATA: Resident s/p day 3 from witnessed fall . Q. Record review of Facility Progress Notes dated 03/12/2019 at 12:23 pm revealed, 3:40 pm CNA called nurse to rsd (resident) room. Nurse observed rsd on floor lying in prone position. No injury noted. Rsd denies hitting head . Rsd has been displaying behaviors the past few days. Rsd is ramming wheelchair into staff and other residents. Does not know own limitations for safety. Rsd is unable to walk or transfer without assistance however continues to do so without help. Rsd has also been verbally and physically aggressive, kicking the CNAs. Rsd has had recent med changes for mood and behavior but does not seem effective . R. Record review of Facility Progress Notes dated 03/30/2019 at 11:29 pm revealed, A change in condition has been noted. The symptoms include: Falls 03/30/2019 at night . S. Record review of Facility Progress Notes dated 03/31/2019 at 7:29 am revealed, .post fall of 10:00 on 03/30/2019 . Staples to forehead . bruising to forehead light purple in color measuring 6.0 cm (centimeters) x (by) 3.0 cm, 1.0 cm x 1.0 cm bruise pink in color on bridge of nose, 1.0 cm x 1.0 cm back of head . T. Record review of hospital discharge paperwork dated 03/31/2019 for R #81 revealed, Chief Complaint: Laceration (deep cut or skin tear). The patient is brought from (name of facility) by EMS (Emergency Medical Services) for a laceration to her forehead. She fell out of her wheel chair and struck her head on the tile floor . Physical Exam . There is a 3 cm vertical laceration upper forehead . the wound is stapled using seven staples . ED (Emergency Department) Course and MDM (Medical Decision Making): Facial laceration, initial encounter, minor closed head injury . CT (Computed tomography is a diagnostic medical test that produces multiple images or pictures of the inside of the body) head without contrast . Other: There is a small area of [MEDICAL CONDITION] (swelling) in the midline right frontal scalp . Conclusion . there is a new small area of [MEDICAL CONDITION] in the right frontal scalp suggestive of new scalp injury . U. On 04/05/2019 at 3:30 pm, during an interview, the DON stated that he was unsure as to why the falls for 03/10/19, 03/11/19, 03/12/19, and 03/26/19 had not been addressed. V. On 04/05/2019 at 4:15 pm, during an interview, R #81's daughter stated that she is concerned with the number of falls R #81 has had and that she did not used to have many falls.

The following deficiency was cited as a result of a Complaint survey that was initiated on 09/28/17. An immediate jeopardy was identified on 09/29/17 at 3:08 pm, and a Plan of Removal was accepted on 10/02/17 at 4:34 pm. Based on record review and interview the facility failed to immediately notify the physician of laboratory (lab) tests dated 08/02/17 indicating a need for the physician to assess and treat for 1 (R #3) of 1 (R#3) resident reviewed for neglect. Not reporting out of range labs to the physician resulted in R #3 being admitted to a hospital intensive care unit (ICU) on 08/12/17 (2 weeks after the 08/02/17 lab results) in [MEDICAL CONDITION] and required [MEDICAL TREATMENT] (treatment to remove excess fluid build up that the kidneys are unable to remove). The abnormal lab results were: 1. Creatinine 2.2 - high - range 0.7 to 1.2 (an indicator for renal function and helps determine need for [MEDICAL TREATMENT] treatment); 2. BUN 76 - high - range 6 to 20 (blood urea nitrogen (BUN) test is used to evaluate kidney function); 3. BUN: Creatinine Ratio 35 - high - for ages 21 - 70 range 10 to 27 (ratio may be used to determine the cause of acute kidney injury or dehydration); 4. Potassium (K+) 5.4 - high - range 3.5 to 5.3 (chemical (electrolyte) that is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells); 5. Red blood cells 2.6 - low - range 4.1 to 5.6 (means of delivering oxygen to the body tissues); 6. Hemoglobin 7.8 - low - range 12.5 to 17 (protein inside red blood cells that carries oxygen.) This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J, identified at the facility on 09/29/17 at 3:08 pm. The the Center Nurse Executive (CNE) (facility title for Director of Nursing) and the facility's Clinical Quality Specialist (CQS) was notified at this time. The facility provided an acceptable Plan of Removal on 10/02/17 at 4:34 pm. Based on the Plan of Removal, the interventions included: 1. Staff education on the facility's policy and procedure for diagnostic tests and physician notification, interventions and monitoring of lab results. 2. Training to occur for each staff member and contract staff before working the next shift/day, etc. 3. A laboratory tracking record was initiated and will be reviewed to identify out of range lab results and a record of physician notification. 4. The CNE will ensure lab results were conveyed to the physician and documented per facility policy. 5. An audit of ordered labs was conducted and those found missing or needing to be conveyed to the physician were acted on. Based on the Plan of Removal, the Immediate Jeopardy was lifted on 10/02/17 at 4:34 pm. This resulted in the scope and severity being reduced from a J to a scope and severity of G. Based on record review and interview the facility neglected to immediately notify R #3's physician of lab work indicating possible issue with R #3's kidney function and red blood cells. On 08/12/17 R #3 became lethargic, had dark yellow, thick milky urine, and was admitted to a hospital ICU [MEDICAL CONDITION] (a condition in which the body is fighting a severe infection that has spread via the bloodstream, they will likely have low blood pressure leading to poor blood circulation to vital tissues and organs). This failure caused R #3 to have an acute kidney injury, requiring the need for [MEDICAL TREATMENT]. If the facility fails to notify the physician for abnormal laboratory results the residents can suffer a potentially severe decline in health. The findings are: A. Record Review of R #3's admission record indicated an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. B. Record Review of R #3's lab results dated 08/02/17 revealed, 1. Creatinine 2.2 - high - range 0.7 to 1.2; 2. BUN 76 - high - range 6 to 20; 3. BUN: Creatinine Ratio 35 - high - for ages 21 - 70 range 10 to 27; 4. Potassium (K+) 5.4 - high - range 3.5 to 5.3; 5. Red blood cells 2.6 - low - range 4.1 to 5.6; 6. Hemoglobin 7.8 - low - range 12.5 to 17. C. On 09/29/17 at 9:49 am, during an interview, the CNE stated that there was no documentation that the lab results for R #3 dated 08/02/17 were reviewed by the physician or the Certified Nurse Practitioner (CNP). The CNE stated that the physician's monthly progress notes had no documentation that the physician was aware of the lab results. The CNE stated that if the lab results had been followed-up, the facility could have potentially prevented the worsening of (name of resident) kidney issues. D. On 09/29/17 at 11:56 am, during an interview, the CNP stated that she was not sure if the labs for R #3 for 08/02/17 were brought to her attention. When given the results, the CNP stated that if the resident appeared ill, orders would be given to send the resident to the ER. I would also look at the potassium level. When told the potassium was 5.4, the CNP stated I would have sent him/her to the ER. E. Record Review of a nursing note (NN) dated 08/12/17 at 1:00 pm for R #3 revealed, Resident appears sleepy. Answers questions appropriately but is slower at response. Foley catheter ( a tube into the bladder todrain urine) this morning with small amount of dark yellow urine. Urine also thick and milky. No urine output since this morning. New orders to send to emergency room (ER). F. Record Review of the (name of ambulance) transport document dated 08/12/17 at 3:18 pm revealed, Pt (patient) was laying in bed on arrival with nurse at bedside. Pt stated that he felt bad. Initially pt stated that he has been feeling ill since yesterday. Pt's nurse stated that pt has been feeling bad since yesterday, and that this morning she noticed pt blood sugar was dropping. Pt has history of diabetes. She states that pt has not eaten very much recently . During assessment pt became more unresponsive, . initially blood glucose (BG) - 104, 2nd BG 74, Pt becoming more lethargic and unresponsive. G. Record Review of R #3's ER lab results dated 08/12/17 revealed, 1. Creatinine 7.8 - high - range 0.7 to 1.2; 2. BUN 115 - high - range 6 to 20; 4. Potassium (K+) 7.2 - high - range 3.5 to 5.5. H. Record Review of ER NN documentation dated 08/12/17 revealed, 4:10 pm - B/P 63/40, P 93 and Lab/test results: were received at 6:20 pm. The critical value/test reported was potassium of 7.2 and 7.3 (normal range 3.5 to 5.4) when it was rerun. I. Record Review of the ER physician documentation dated 08/12/17 revealed, Diagnosis/assessment/plan: admitted to ICU . He was found to have [MEDICAL CONDITION] (elevated potassium), acute kidney injury, and to be in septic shock. Creatinine of 7.8, baseline runs around 2. He has no urine output. This is likely secondary to acute tubular necrosis (the death of renal tubes of the kidneys) from [MEDICAL CONDITION] (low blood pressure),[MEDICAL CONDITION], and urinary tract infection. He will need [MEDICAL TREATMENT] . Potassium of 7.2 . received intravenous (IV) calcium [MEDICATION NAME] (mineral supplement/ medication it is used by injection into a vein to treat low blood calcium, high blood potassium, and magnesium toxicity) times 2, 3 dosages of IV regular insulin (medication to lower blood sugar) and [MEDICATION NAME] 50 (type of sugar in water for injection for intravenous), and [MEDICATION NAME] (used to bring potassium levels down). we will get a Quinton catheter (vascular access for [MEDICAL TREATMENT]) placement and [MEDICAL TREATMENT] as his blood pressure is more stable. J. On 09/29/17 at 12:40 pm during an interview, R #3 stated My blood sugar was in the 40's. I don't remember going in the ambulance or going to the hospital. I woke up and I was in ICU.

Based on record review and interview, the facility failed to notify the physician for: 1) laboratory (lab) blood results that were abnormal for 1 (R #3) of 2 (#3 and #5) residents; 2) obtain blood work as ordered for 1 (R #5) of 2 (R #3 and #5) residents reviewed for physician notification. This deficient practice likely resulted in R #3 being admitted to the hospital Intensive Care Unit (ICU), for a urinary tract infection [MEDICAL CONDITIONS] (infection in the blood), and need for acute [MEDICAL TREATMENT] (a treatment that removes toxins from the body when the kidneys fail to function), and R #5 being admitted to the hospital with [REDACTED]. If the facility fails to notify the facility of abnormal lab results or fails to draw blood as ordered the residents could potentially suffer a decline in health conditions requiring a hospital admission. Findings for R #3: A. Record Review of R #3's admission record indicated an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. B. Record Review of a nursing note (NN) dated 08/12/17 at 1:00 pm for R #3 revealed, Resident appears sleepy. Answers questions appropriately but is slower at response. Foley catheter (a tube into the bladder to drain urine) this morning with small amount of dark yellow urine. Urine also thick and milky. Nurse Practitioner notified of decreased urine output and appearance of urine. New orders received to sent CBC (complete blood count) and CMP(complete metabolic profile) .New orders received to . No urine output since this morning. New orders to send to emergency room (ER). C. Record Review of ER (emergency room ) NN documentation dated 08/12/17 revealed, 4:10 pm - Blood Pressure (B/P) 63/40 - low, Pulse (P) 93 - high and Lab/test results: were received at 6:20 pm. The critical value/test reported was potassium of 7.2 and 7.3 (normal range 3.5 to 5.4) when it was rerun. (Potassium is needed for cells to function properly. The kidneys remove excess potassium through the urine to keep a proper balance of this mineral in the body. If your kidneys are not working well, they may not be able to remove the proper amount of potassium.) D. Record Review of R #3's lab results dated 08/02/17 revealed, 1. Creatinine 2.2 - high - range 0.7 to 1.2 (an indicator for renal function and helps determine need for [MEDICAL TREATMENT] treatment); 2. BUN 76 - high - range 6 to 20 (blood urea nitrogen (BUN) test is used to evaluate kidney function); 3. BUN: Creatinine Ratio 35 - high - for ages 21 - 70 range 10 to 27 (ratio may be used to determine the cause of acute kidney injury or dehydration); 4. Potassium (K+) 5.4 - high - range 3.5 to 5.3 (chemical (electrolyte) that is critical to the proper functioning of nerve and muscles cells, particularly heart muscle cells); 5. Red blood cells 2.6 - low - range 4.1 to 5.6 (means of delivering oxygen to the body tissues); 6. Hemoglobin 7.8 - low - range 12.5 to 17 (protein inside red blood cells that carries oxygen). E. On 09/29/17 at 12:40 pm during an interview, R #3 stated My blood sugar was in the 40's. I don't remember going in the ambulance or going to the hospital. I woke up and I was in ICU. F. On 09/29/17 at 9:49 am, during an interview, the Center Nurse Executive (CNE) (facility title for Director of Nursing) stated that there was no documentation that the lab results for R#3 dated 08/02/17 were reviewed by the physician or the Certified Nurse Practitioner (CNP). The CNE stated that the physician's monthly progress notes had no documentation that the physician was aware of the lab results. The CNE stated that if the lab results had been followed-up, the facility could have potentially prevented the worsening of (name of resident) kidney issues. G. On 09/29/17 at 11:56 am, during an interview, the CNP stated that she was not sure if the labs for R #3 dated 08/02/17 were brought to her attention. When given the results, the CNP stated that if the resident appeared ill, orders would be given to send the resident to the ER. I would also look at the potassium level. When told the potassium was 5.4, the CNP stated I would have sent (Name of R #3) to the ER. Findings for R #5: H. Record review of R #5's face sheet revealed, a current admission date of [DATE]. Admission [DIAGNOSES REDACTED].) I. Record review of a Physician order [REDACTED].These labs are to be completed on 9-25-17. J. Record review of a written statement dated 10/10/17 at 9:00 am from the facility phlebotomist (a nurse or other health worker trained in drawing venous blood for testing) revealed, I (name of phlebotomist) did try to draw labs on (name of resident #5) 09/25 and 09/27. Resident stated he had not been drinking enough fluids and said he knows he is tough to draw blood when he is dehydrated. On 09/27 (name of physicians group) called and asked why they did not have his results yet. I spoke with (name of person at physicians office) and told her he was dehydrated and would try him again. On 09/29 we finally were able to get enough blood to send to the hospital. K. Record review of facility Policy and Procedure: Peripheral Blood Effective date: 08/01/05 Revision date: 01/02/14 revealed, (section numbers are not readable) . Send specimens to lab with appropriate laboratory requisition. Notify physician/mid-level provider if unable to collect specimen. Document: time and type of specimen collection; Number of attempts; Patient response; Notification of physician/mid-level provider if applicable. L. Record review of facility eINTERACT transfer form dated 10/04/17 revealed, .Transfer/Discharge Details .Sent to: (name of hospital) Date: 10/03/17 2:30 pm . Reason(s) for Transfer: Abnormal Kidney Function . M. On 10/10/17 at 3:50 pm during an interview, the Center Nurse Executive (CNE) (facility title for Director of Nursing) stated that the labs were drawn on 09/29/17 and had been ordered for 09/25/17 with no explanation why the labs were drawn four days later than ordered. (Name of resident) was transported to the hospital and admitted for abnormal kidney function. N. On 11/03/17 at 11:30 am during an interview, the CNE stated the phlebotomist should have notified her and any other nurse on the first day, 09/25/17, that the phelomatimst was unable to draw blood from R #5. O. On 11/03/17 at 10:30 am during an interview, R #3 and R #5's medical doctor (MD) stated the facility did not contact him with R #3's lab results or during the time frame of 08/09/17-08/12/17 when the resident became increasingly ill, ultimately requiring emergency transport to the Emergency Department (ED) of the local hospital. The MD also stated he was not informed that the facility could not draw the blood necessary for laboratory tests for R #5. The MD stated, I always have my cell phone, they (facility) know they can contact me 24/7. I cannot explain why they did not in either of these cases.

Based on record review and interview the facility failed to monitor and provide appropriate care for: 1) a Foley catheter (tube in the bladder to drain urine) to prevent a severe infection and 2) prevent a urinary tract infection [MEDICAL CONDITION] (a severe infection) for 2 (R #3, and #5) of 2 (R #3, and #5) residents reviewed for urinary tract infections [MEDICAL CONDITION]. This deficient practice likely resulted in R #3 being admitted to the hospital Intensive Care Unit (ICU), for a UTI,[MEDICAL CONDITION] (infection in the blood), and need for acute [MEDICAL TREATMENT] (a treatment that removes toxins from the body when the kidneys fail to function), and R #5 being admitted to the hospital with [REDACTED]. If the facility fails to appropriately monitor and provide necessary care to prevent UTIs, residents can potentially acquire life threatening infections. The findings are: Findings for R #3: A. Record Review of R #3's admission record indicated an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. B. Record Review of a nursing note (NN) dated 08/12/17 at 1:00 pm for R #3 revealed, Resident appears sleepy. Answers questions appropriately but is slower at response. Foley catheter this morning with small amount of dark yellow urine. Urine also thick and milky. No urine output since this morning. New orders to send to emergency room (ER). C. Record Review of the (name of ambulance) transport document dated 08/12/17 at 3:18 pm revealed, Pt (patient) was laying in bed on arrival with nurse at bedside. Pt stated that he felt bad. Initially pt stated that he has been feeling ill since yesterday. Pt's nurse stated that pt has been feeling bad since yesterday, and that this morning she noticed pt blood sugar was dropping. Pt has history of diabetes. She states that pt has not eaten very much recently . During assessment pt became more unresponsive, . initially blood glucose (BG) level - 104, 2nd BG level -74, (normal blood glucose levels are 70 to 105) Pt becoming more lethargic and unresponsive. D. Record Review of the emergency room (ER) physician documentation dated 08/12/17 revealed, Diagnosis/assessment/plan: admitted to ICU . found to have [MEDICAL CONDITION] (elevated potassium), acute kidney injury, and to be in septic shock. has no urine output. This is likely secondary to acute tubular necrosis from [MEDICAL CONDITIONS], and urinary tract infection. He will need [MEDICAL TREATMENT] . E. Record review of a laboratory Urine Culture report dated 08/12/17 revealed, positive for bacteria strains; escherichia coli (bacteria normally live in the intestines of healthy people) greater than 100,000 (normal is 0) col/ml (colonies per milliliters) and Proteus mirabilis (a bacteria) greater than 100,000 col/ml. F. Record review of R #3's facility Treatment Administration Record (TAR) revealed an order to Irrigate bladder (irrigation of the bladder is to flush clots and debris out of bladder and to restore patency of the catheter) at bedtime every Wednesday for [MEDICAL CONDITION]. Irrigate bladder per catheter with 60 milliliters (Ml) of normal saline (NS) aspirating back with catheter-tip syringe over and over until irrigant is clear documentation of completion is as follows: 1. TAR for (MONTH) (YEAR) revealed the irrigation was completed once on 05/10/17. 2. TAR for (MONTH) (YEAR) revealed the irrigation was not done by evidence of blank documentation on 06/07/2017, 06/14/17, 06/21/17 and 06/28/17. 3. TAR for (MONTH) (YEAR) revealed the irrigation was not done by evidence of blank documentation on 07/04/2017, 07/12/17, 07/19/17 and 07/26/17. 4. TAR for (MONTH) (YEAR) revealed the irrigation was not done by evidence of blank documentation through 08/12/17 when R #3 was admitted to the hospital. G. On 10/11/17 at 10:18 am during interview, the Center Nurse Executive (CNE) (facility title for Director of Nursing) stated that R #3's UTI possibly could have been prevented if the irrigations were done. Findings for Resident #5: I. Record review of R #5 face sheet revealed, an original admitted d of 05/18/17 and a readmission date of [DATE]. Admission [DIAGNOSES REDACTED].) J. Record review of the Care Plan for Urinary Incontinence for R #5 dated 09/06/17 includes the following Goal and Interventions: .encourage resident to consume all fluids during meals. Offer/encourage fluids of choice, monitor for s&s (signs and symptoms) of infection and report to physician. K. Record review of a Physician Orders, for R #5 dated 08/28/17 revealed, CMP (complete metabolic profile) (lab tests that give the physician information on current health status) . UA (urinalysis) .These labs are to be completed on 9-25-17. L. Record review of Nurses Notes (NN) for R #5 dated 09/29/17 at 9:42 am revealed, . Urine sample obtained this am for pending MD (medical doctor) appointment next week . M. Record review of laboratory (lab) report R #5 dated 10/02/17 revealed the following abnormal lab results indicating potential UTI or kidney injury: 1. Hematology - (the study of blood) a. Hemoglobin (the molecule in red blood cells that carries oxygen) 7.1 low - normal range 14-18 2. Chemistry - (information about the function of the kidneys and other organs.) a BUN (test is used to evaluate kidney function) 149 high - normal range 8-21 b. Creatinine (a test that measures kidney function) 5.7 high - normal range 0.6 - 1.3 c. eGFR (a blood test for kidney function) 8 low - normal range 60 3. Urinalysis - (tests performed on a urine sample) a. Appearance - cloudy - normal clear b. Blood - 5+ high - normal negative c. pH (test measures the level of acid in urine)- 9 high - normal range 5-7 d. Protein - 3+ high - normal range none e. Leukocyte Esterase (a urine test for the presence of white blood cells and other abnormalities associated with infection) - 3+ high - normal range none N. Record review of NN R #5 dated 10/03/17 at 2:09 pm revealed, Note: New telephone order from (name of doctor) to transport resident to (name of hospital) for evaluation r/t (related to) increased BUN, decreased hemoglobin and dehydration . O. Record review of NN dated 10/03/17 at 5:16 pm revealed, Note: . (name of doctor) reported to nurse that resident's last labs were very concerning as many of his levels were too low and he was dehydrated. She gave telephone orders for him to be transported to (name of hospital) for IV (intravenous) fluids and observation. P. Record review of facility eINTERACT transfer form dated 10/04/17 revealed, .Transfer/Discharge Details .Sent to: (name of hospital) Date: 10/03/17 2:30 pm . Reason(s) for Transfer: Abnormal Kidney Function . Q. Record review of Discharge Summary from (name of hospital) dated 10/06/17 revealed, .Medical Problems: Acute [MEDICATION NAME] (infection of the bladder), Acute renal (kidney) failure, Acute kidney injury . Dehydration,[MEDICAL CONDITION] (a potentially life-threatening complication of an infection) due to organism with acute [MEDICAL CONDITION], UTI . R. On 10/10/17 at 3:50 pm during an interview the CNE stated that the labs were drawn on 09/29/17 and had been ordered for 09/25/17 with no explanation why the labs were drawn 4 days later than ordered.

The following deficiency was cited as a result of a complaint received during a recertification survey that was initiated on 05/09/17. An immediate jeopardy was identified on 05/15/17 and a plan of removal was accepted on 05/16/17. Based on record review and interview, the facility failed to provide the proper treatment for [REDACTED]. By allowing the resident to administer his own tube feeding without instruction and supervision, 2. failed to check the placement and residual (amount of food remaining) of the residents feeding tube, and 3. failed to follow physicians order, for 1 (R #5) of 1 (R #5) resident reviewed for the use of a feeding tube. This failure could likely result in complications including; aspiration (drawing fluid into the lungs) pneumonia, diarrhea, vomiting, and dehydration. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J identified at the facility on 05/15/17 at 6:15 pm. The facility administrator was notified at this time. The facility provided an acceptable Plan of removal on 05/16/17 at 4:30 pm. Based on the Plan of Removal, the interventions included: 1. R #5's physician, and family were notified of the event allowing R #5 to feed himself through the feeding tube. 2. A physical assessment was performed to include abdominal, respirator, and cardiac status by the physicians' nurse practitioner at 7:15 pm on 05/15/17. 3. Tube placement and residual were verified by Licensed Practical Nurse (LPN) #1 during the 10 pm-6 am shift on 05/15/17. 4. The facility determined there were 4 other residents receiving tube feedings. These residents were assessed for residual and proper tube placement was verified. 5. Training for licensed nurses was implemented on 05/15/17 for 3 facility licensed nurses with competency evaluation demonstrations performed, and will continue for all licensed staff before the start of their next shift. 6. The Licensed Practical Nurse #2 was suspended at 7:15 pm on 05/15/17 and will not return to the nursing position. 7. Facility policy for tube feeding management dated 11/28/16, was reviewed. It was determined to be current and meeting current standards of practice. The licensed nurses were educated on the policy. Based on the Plan of Removal, the Immediate Jeopardy was lifted on 05/16/17 at 4:30 pm. This resulted in the scope and severity being reduced from a scope and severity of J to a scope and severity of G. Based on record review and interview the facility failed to: 1. ensure that tube feedings were being administered by licensed nurses by allowing R #5 to administer the feeding without supervision or being instructed on the procedure, 2. obtain a physician order [REDACTED].>3. provide the correct amount of feeding, 4. not checking for residual or placement prior to the feeding, for 1 (R #5) of 1 (R #5) residents reviewed for feeding tubes. This failure could likely cause R #5 to develop aspiration pneumonia, diarrhea, nausea, vomiting, and dehydration. R #5 is severely comprised with [MEDICAL CONDITION] and is receiving [MEDICAL CONDITION] and [MEDICAL CONDITION]. The findings are: A. Record review of the facility face sheet for R #5 revealed an admitted d of 03/22/17. Admission [DIAGNOSES REDACTED]. The tube is used for feeding or drainage), [MEDICAL CONDITION] disorder (is a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), muscle weakness and lack of coordination. B. On 05/11/17 at 10:20, during an interview with R #5's Family Member (FM) #1, FM #1 stated that she felt (name of resident) was not receiving his tube feedings on the evening shift. Further stated that she did leave a message for the Administrator but had not received a response. FM #1 stated that (name of resident) [MEDICAL CONDITION] of the tongue and the feedings are to keep him from losing weight. C. On 05/15/17 at 7:40 am, during an interview with R #5's FM #1 stated that (name of resident) was very confused yesterday and was concerned. D. On 05/15/17 at 7:55 am, observation of R #5 revealed, R #5 was awake and oriented to name. During this observation R #5 stated to his sister I don't even know how I got here. E. On 05/15/17 at 5:00 pm, during an interview with Licensed Practical Nurse (LPN) #2, LPN #2 stated I just gave (name of resident) 2 cans of formula. I assumed (name of resident) would drink them or put them down the feeding tube. LPN #2 was asked why 2 cans, LPN #2 stated R #5 requested 2 cans. LPN #2 was asked what the resident did with the cans, LPN #2 stated I don't know what he did. LPN #2 then asked the resident what was done with the 2 cans, the resident (R #5) replied I put them down the tube. 1. On 05/15/17 at 5:05 pm, R #5 was asked about his knowledge to do the feeding, R #5 stated I have been watching them. 2. On 05/15/17 at 5:07 pm, LPN #2 was asked if R #5 had been in-serviced on the proper procedure for using the feeding tube. LPN #2 stated I have not given R #5 an in-service. 3. On 05/15/17 at 5:07 pm, LPN #2 was asked if R #5's tube placement or residual was checked, LPN #2 stated I did not. 4. On 05/15/17 at 5:08 pm, LPN #2 was asked about the current order for the tube feeding and if there was an order for [REDACTED].#2 stated, I gave too many cans, but the resident requested 2 cans, and there is no order for (name of resident) to do the feeding. F. Record review of Physician orders [REDACTED]. There was no order for R #5 to do the feeding. G. Record review of the facility's Medication Self-Administration Evaluation form dated 03/23/17 revealed: 22. Approval granted to self administer? No. 23. If approval not granted, explain. Resident has a new G tube (gastrostomy tube - tube in the stomach), continues NPO (nothing by mouth) and at this time unable to administer . H. Record review of Nurses' notes for R #5, from 03/22/17 through 05/15/17 revealed, no documentation that R #5 had been educated on the procedure for self-administration of tube feedings. I. Record review of physician orders [REDACTED]. 1. Tube Feed: check for residual every shift prior to feeding. If 250 milliliters (ml) or over, hold feeding for 1 hour and recheck. If residual 250 ml or over notify physician. Document amount of residual in ml. 2. Tube Feed: elevate head of bed 30-45 degrees during feeding and for 1 hour after. Check tube for proper placement prior to each feeding, flush or medication administration. every shift. J. Record review of Nurses' notes for R #5 from admission date of [DATE] through 05/15/17 revealed only one documentation of the amount of residual, 03/25/17. K. Record review of the Medication Administration Records (MAR) for March 2017, April 2017, and May 2017, revealed Tube Feed: Check for residual every shift prior to feeding, document amount of residual in ml. The MAR indicated [REDACTED]. L. On 05/15/17 at 6:05 pm, during an interview, the Center Nurse Executive (CNE) (same as the Director of Nursing) stated, The nurse should have checked the order before doing anything and a physician order [REDACTED]. The nurse (LPN #2) should have done the feeding. We don't let the residents do their own medication unless there is a physician order. We should check for placement and residual before feeding and document. The feeding could have gone to the wrong place, which could lead to aspiration pneumonia. M. On 05/15/17 at 6:15 pm, during an interview, the Corporate Nurse Manager (CNM) stated that the licensed nurse (LPN #2) admitted that the formula was given to the patient (R #5) and not administered by LPN #2.

Based on record review and interview, the facility failed to ensure that residents received adequate supervision and assistive devices to prevent falls with injuries for 2 (R #3 and R #4) of 4 (R # 1, 2, 3, and 4) residents reviewed for falls. This deficient practice aused R #3 to have a fall hitting the back of the head and for R #4 a fall resulting in a scalp contusion and fracture of the nose. The residents injuries required an emergency room visit. The findings are: Resident #3: A. Record review of the facesheet for R #3 revealed an admission date of [DATE], [DIAGNOSES REDACTED]. B. Record review of R #3's care plan dated 03/23/17 revealed, Focus, Resident is at risk for falls: No Goal or Interventions were listed on the care plan. C. Record review of nurses note for R #3 dated 03/30/17 at 5:46 pm, revealed, Resident found on floor in his room flat on his back with his head on the legs of the bedside table and his feet out in front of him. Red drainage noted to left temple and back of scalp. 3 assist to sitting in chair. V/S (vital signs) done. 126/108 (blood pressure), temperature 103.3 time 2 checks, 112 HR (heart rate), no loss of consciousness. Is alert, stated I just fell . Trembling noted. skin very warm and dry. D. Record review of the local Hospital Emergency Department (ED) Documentation dated 03/30/17 at 6:10 pm revealed, Presenting complaint: Emergency Medical Services (EMS) states: Fall today, fell backwards, hit head on foot of bedside table. No LOC (loss of consciousness) . ED Documentation (by physician) at 8:00 pm - This [AGE] year old male presents to ED via EMS ground with complaints of Fall Injury. The patient presents with confusion, decreased mental status. ED Documentation revealed R #3 was admitted to the hospital. E. On 05/25/17 at 8:56 am, during an interview the Center Nurse Executive (CNE), stated, We care planned for falls, but we did not put any interventions in place. Resident #4: F. Record review of the Admission Record dated 10/09/14 revealed that R #4 is [AGE] years old and was admitted to the facility with medical [DIAGNOSES REDACTED]. G. Record review of the facility Fall Log dated 11/01/16 to 05/09/17 revealed, a total of 15 reported falls for R #4 on the following dates: 1) 01/27/17 2) 01/28/17 3) 02/04/17 4) 02/06/17 5) 02/08/17 6) 02/11/17 7) 03/04/17 8) 03/10/17 9) 03/17/17 10) 03/21/17 (9:00 am) 11) 03/21/17 (10:45 am) 12) 03/27/17 13) 03/28/17 14) 04/02/17 15) 05/01/17 H. Record review of the care plan for R #4 dated 10/23/14 with latest revision dated 02/13/17 revealed that R # 4 had falls 03/04/17, 03/10/17, 03/17/17, 03/21/17 (9:00 am), 03/21/17 (10:45 am), 03/27/17, 03/28/17, 04/02/17, 05/01/17, without any evidence of new interventions. I. Record review of R #4 Progress Notes dated 02/04/17 revealed: Had an accident/fall in past 72 hours in hallway. Resident was standing next to wheel chair in hallway. A Certified Nursing Assistant (CNA) . witnessed resident hit her head on siderail (of the wheelchair) as R #4 fell to the ground. Resident was sent to the emergency room (ER) for evaluation and treatment related to hitting the head. J. Record review of R #4's emergency room (ER) Discharge Instruction dated 02/04/17 revealed, that the [DIAGNOSES REDACTED]. K. Record review of R #4's Progress Notes dated 02/08/17 at 10:30 am, revealed Sent out to ER to eval and treat S/P (status [REDACTED]. L. Record review of R #4's ER X-ray report dated 02/08/17 revealed: Impression: There are comminuted fractures (a break or splinter of the bone into more than two fragments) involving the near base of the nasal bones bilaterally (affecting both sides). With displacement (moving of something from its place or position) of fracture fragments particularly on the left . M. On 05/11/17 at 3:00 pm, during an interview, the Regional Nursing Director (RND) stated that all interventions had been tried to prevent R #4 from falling and the facility did not know what else to do. N. On 05/12/17 at 10:00 am, during an interview, the CNE stated that the resident had broken her nose in the facility during February and continues to fall because of not having any safety awareness related to advanced dementia. The CNE stated, We just don't know what else to do.

Based on record review, and interview, the facility failed to ensure that 2 (R #3 and 7) of 2 (R #3 and #7) residents reviewed for Urinary Tract Infections [MEDICAL CONDITION] were being assessed and monitored for signs and symptoms of UTI. This deficient practice likely resulted in fever for R #3 (103 degrees Fahrenheit) and R #7 (104 degrees Fahrenheit). Both residents required an emergency room visit. R #3 stayed in the hospital for one day and R #7 was hospitalized for [REDACTED]. Findings for Resident #3: A. Record review of the facesheet for R #3 revealed an admission date of [DATE], [DIAGNOSES REDACTED]. B. Record review of the facesheet for R #3 revealed a second admission date of [DATE], with a [DIAGNOSES REDACTED]. C. Record review of R#3 care plans revealed no evidence of a care plan for urinary issues. D. Record review of a nurses note for R #3 dated 03/30/17 at 5:46 pm, revealed, Resident found on floor in his room flat on his back with his head on the legs of the bedside table and his feet out in front of him. Red drainage noted to left temple and back of scalp. 3 assist to sitting in chair. V/S (vital signs) done. 126/108 (blood pressure), temperature 103.3 time 2 checks, 112 HR (heart rate), no loss of consciousness. Is alert, stated I just fell . Trembling noted. skin very warm and dry. E. Record review of the Emergency Department (ED) from (name of local hospital) for R #3 revealed, Physician documentation - 03/30/17 at 8:00 pm, The patient presents with confusion, decreased mental status. Pt (patient) has been brought in by Emergency Medical Services (EMS) from (Name of local Nursing home). Pt's (bvnm,patient) sister states she thinks he might have a UTI (urinary tract infection) or something. Pt also has a fever, per pt's sister pt has had a decrease in mental status and states he is confused. F. Record review of the ED nurse documentation For R #3 revealed, Outcome 03/31/17 at 12:54 am, Admit to inpatient status to ICU (intensive care unit in a hospital) accompanied by nurse, with oxygen, on monitor. G. Record review of the Hospital History and Physical dated 03/30/17 at 11:48 pm revealed, This morning the patient was confused as per the family. He was oriented to place, person, but he is talking tangentially (speech wanders and shows a lack of focus) as per the family. He was having fever with a temperature of 103 degrees Fahrenheit in the emergency room (ER). He also had a temperature of 104 degree Fahrenheit in the ER. The patient was also having visual hallucinations at the nursing home today prior to the fall as per the ER report.Denies fever by the patient, but the temperature is 104. The patient has some chills. Plan: 4. Based on clinical, diagnostic findings, and upon my best judgement, this patient is expected to stay in the hospital for at lease 2 days, which includes 2 midnights including tonight for the [DIAGNOSES REDACTED]. The patient is at high risk because [MEDICAL CONDITION]. H. On 05/11/17 at 11:07 am, during an interview the facility Infection Control Nurse (ICN), stated that Escherichia coli in the urine could be introduced when a resident cleans after elimination or how the staff clean the residents. I. On 05/17/17 at 4:15 pm, during an interview with R #3's FM #2, stated, The day (Name of Resident) fell , earlier in the day (03/30/17) I told the nurse he was not feeling well. J. On 05/25/17 at 8:56 am, during an interview with the Center Nurse Executive (CNE) (same as the Director of Nursing) stated that there is no nursing documentation of monitoring, from admission to discharge, signs or symptoms of a possible urinary tract infection including no documentation about the color, smell, or amount of any urine output for R #3. Findings for Resident #7: K. Record review of R #7's Admission Record indicated that the resident was originally admitted to the facility 02/12/10 and the latest re-admission was 03/31/17. The [AGE] year old was last admitted with a medical [DIAGNOSES REDACTED]. in the circulating blood), and acute [MEDICATION NAME] (a sudden inflammation of the bladder). L. Record review of R #7's Care Plan dated 07/02/15 with revision 09/13/16 and a target date of 06/30/17 revealed: R #7 was at risk for complications of infection related to history of UTI (urinary tract infection) and had the potential to recur. Inteventions include: Monitor for signs and symptoms of infections and report to physician as indicated, obtain labs/cultures as ordered and report results to physician as indicated, monitor vital signs (blood pressure, temperature, heart rate) and report to physician as indicated. M. Record Review of Resident #7 's facility progress notes revealed no documentation of the resident's condition to include montioring of signs and symptoms of infections from 03/23/17 to 03/28/17 when the resident became unreponsive and was sent to an acute care hospital. N. Record review of R #7's discharge [DIAGNOSES REDACTED]. tissues and organs), secondary to UTI. Urine culture grew E coli (bacteria normally found in intestines, that cause infection and severe symptoms like diarrhea and dehydration). O. On 05/16/17 at 11:20 during an interview the Center Nurse Executive (CNE) stated that R #7's temperature came out of nowhere. We had no idea he was sick until we found him unresponsive (3/28/17) with a temperature of 104 degrees Fahrenheit.

The following deficiency was a result of a QIS Recertification/Extended/Complaint survey that was initiated on 08/15/16. An immediate jeopardy was identified on 08/23/16 and a plan of removal was accepted on 08/29/16. The immediate jeopardy was continued on 09/08/16 and a plan of removal was accepted on 09/14/16. Based on record review, observation and interview, the facility failed to prevent accidents for 5 (R #10, 108, 46, 23, and 35) of 5 (R #10, 108, 46, 23, 35) residents reviewed for accidents. This failed practice likely resulted in: 1. Resident # 10 having 4 falls with the fall on 08/16/16 resulting in a fractured left hip and a fall on 08/19/16 that resulted in a laceration to the right side of her forehead requiring stitches. 2. Resident #108 having 8 falls. 3. Resident # 46 having 10 falls. 4. Resident #23 having an accident/incident on 07/21/16 that resulted in a large bruise of unknown origin, an unwitnessed fall on 07/23/16 that likely contributed to a sprained wrist and an unwitnessed fall on 07/28/16. 5. Resident #35 fell on [DATE], required a hospital visit and received stitches to his head, continued to have pain and it was discovered that R #35's neck was re-fractured. A second fall on 08/31/16 required a hospital visit, the facility then placed R #35 on 1:1 (1 resident to 1 staff) monitoring and it was discovered on 09/07/16 that R #35 was not receiving the 1:1 monitoring. These deficient practices resulted in an Immediate Jeopardy at a scope and severity of K, being identified at the facility on 08/23/16 at 1:50 pm. The facility Administrator was notified at this time. The facility provided an acceptable Plan of Removal on 08/29/16 at 3:02 pm. based on the Plan of Removal, interventions included: 1) Resident #10 was placed on 1:1 staffing, Resident was evaluated by Therapy and received a reclining wheelchair, 2) Resident # 23 was evaluated for fall interventions. A low bed and fall pad have been in place as interventions, a soft touch call light was implemented on 08/24/16. A Therapy assessment for a wheelchair was completed on 08/25/16. A Nursing Physical Assessment of was completed on 08/29/16. 3) Resident # 35's medications were reviewed by the Pharmacist on 08/24/16 to determine if current medication regimen contributed to his fall. The results were to discontinue Alfuzosin which can have side effects pertaining to falls and dizziness. It was ordered discontinued by the Medical Director (MD). Resident #35 had foot rests placed on his wheelchair on 08/26/16 and his care plan was up-dated on 08/26/16. 4) New fall risk assessments were completed for all residents. 5) Minimum Data Set (MDS) Coordinators and Unit Managers up-dated care plans based on current fall risk interventions. Staff were notified of new interventions on August 29 and August 30. 6) An audit of all residents MDS's for accuracy related to falls prior to admission and falls in the past 90 days was completed on 08/26/16. 7) The Admissions Director will review all medical information available on new residents for history or fall risk prior to admission. 8) the medical record of all new admissions will be reviewed at the Daily Clinical Meeting the first business day after admission 5 times a week, for completion of a fall risk assessment, accurate and complete nursing assessment, fall risk care plan and resident specific interventions. 9) MDS Coordinators were educated on reviewing the medical information on all new admissions regarding falls and risk for falls. 10) The Center Nurse Executive (CNE) (same as the Director of Nursing (DON)) and the Center Executive Director (CED) (Administrator) were educated on timeliness of reporting injuries of unknown origin to the Department of Health (State Agency). The floor nurses have been educated to call them (CNE & CED) with all injuries of known or unknown origin on weekends and holidays. The CNE will ensure an incident report is recorded in the Resident Management System (RMS). 11) All licensed staff were educated on accurately completing fall risk assessments upon admission, quarterly and with every fall beginning 08/27/16. 12) The Facility Medical Director will be educated on reviewing the medical record for accuracy of documentation by the Corporate Medical Director on 08/30/16. 13) The CNE & CED will complete a chart and summary of falls and will present this to the Quality Assurance Performance Improvement (QAPI) Committee monthly for discussion and further recommendations for identifying performance improvement. 14) An audit tool has been developed for identifying safety measures for residents on each unit. This will be up-dated Monday thru Friday at the Clinical Meeting for each unit's residents. Based on the Plan of Removal and observation, the IJ was lifted on 08/29/16 at 3:02 pm. This resulted in the scope and severity being reduced from a scope and severity of K to a scope and severity of H. SECOND IMMEDIATE JEOPARDY Based on record review and interview an Immediate Jeopardy was initiated on 09/08/16 at 2:32 pm when Resident # 82 was identified for a fall where the resident had his recent amputation incision reopen, bleed profusely, requiring the resident to be readmitted to the hospital and an additional surgery to re-close the wound, and Resident # 35 had a second fall on 08/31/16 that required a hospital visit, the facility then placed R #35 on 1:1 monitoring and it was discovered on 09/07/16 that R #35 was not receiving the 1:1 monitoring. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of K, being identified at the facility on 09/08/16 at 2:32 pm. The facility Administrator was notified at this time. The facility provided an acceptable Plan of Removal on 09/14/16 at 5:30 pm. based on the Plan of Removal, interventions included: 1) The CED & CNE were educated on the definition of a fall per regulation at F 323. 2) On 09/14/16 the ACED, CNE and the two unit managers were educated on the new process for maintaining a call log for the on call nurses. 3) The CNE, CNE and Center Nurse Educator were educated on reporting falls and those requiring medical attention, to the Department of Health (State Agency) as soon as possible but within 24 hours or if a life threatening injuries within 2 hours, beginning 09/09/16. 4) Beginning 09/09/16 Licensed staff and Certified Nursing Assistant's (CNA's) will be educated on the definition of a fall, including the requirement to report any falls to the charge nurse immediately. The charge nurse will complete an incident report and a nurse's note will be entered into the system. 5) Resident #35: An interdisciplinary team meeting was held on 09/09/16 to assess Resident #35's fall risk and the least restrictive safety measures. MD recommended continuing with 1:1 staffing which remains in effect. 6) A 1:1 staffing, 24 hours a day has been care planned and a schedule of 1:1 staffing (will be referred to as sitters for this plan) was developed by the CED. Licensed staff and CNA's were educated on the 1:1 staffing procedures beginning on 09/09/16. 7) A new Fall Risk Decision Tree Tool was developed to address conditions to be considered in addition to the Fall Risk Assessment Form. The licensed staff were educated on completing this new tool upon admission, quarterly and with a new fall beginning 09/09/16. 8) A new fall risk assessment for Resident #35 was completed on 09/11/16 by the CNE to include the new Fall Risk Decision Tree. 9) A fall risk Decision Tree will be completed on current residents to accurately assess fall risk by 09/12/16. 10) Care Plans will be up-dated after a fall during the Daily Clinical stand-up 5 times weekly by the CNE/Designee. 11) Investigation of the falls: When there is a fall the focus of the fall will be placed on the investigation. Included will be the 5 parts of an investigation: Who, What, When, Where and How. 12) Nurses will be educated on 09/15/15 at the All-Staff meeting on completing nurse's notes for their residents having a change of condition, fall or adverse event, in addition to a change of condition report. the nurses will also be educated on dating and signing any care plan up-dates/changes beginning on 09/14 until all nurses have received this education. 13) Resident #82: On 09/08/16 the CNE called Name of Medical Director to review recommendations to residents fall risk due to residents recent amputation. An Interdisciplinary Team Meeting was held on 09/09/16 to assess the residents fall risk. It is determined the safest method of transfers to and from the wheelchair will be provided by mechanical lift. It is further recommended that 2 staff persons assist Resident #82 with all weight bearing ADL's including repositioning, toileting, bed mobility and hygiene. His care plan has been up-dated, and staff are being educated on this change beginning 09/09/16. In services for licensed nurses and CNA's will begin 09/14/16 and will be completed prior to working next assigned shift on the mechanical lift to include return demonstration of proper usage with care to the stump during transfers. 14) licensed staff and CNA's will be educated on caring for Resident #82 relating to managing his stump during transfers. 15) Resident Care Cards for CNA's will be up-dated by 09/12/16 with any changes to ADL's and/or care the CNA's provides daily 5 time weekly at the Clinical Stand-up Meeting. The cards will be placed in binders at each nurses station. 16) the CED and CNE will track and trend falls including time of day, hallway or unit, mitigating factors as trends before bed or after meals. The tracking and trending of falls and accidents will be reviewed at the monthly QA committee meeting for further review and recommendations. The results will be reviewed with the new Medical Director monthly for further recommendations. 17) The Medical Director participated in the review of the survey results and the plan of removal regarding the accident and falls immediate jeopardy. Based on the Plan of Removal and observation, the IJ was lifted on 09/14/16 at 5:30 pm. This resulted in the scope and severity being reduced from a scope and severity of K to a scope and severity of H. Based on record review, observation and interview the facility failed to prevent accidents for two (#82 & #35) of 2 (#82 & # 35) reviewed for accident risks by: 1) a fall where the resident had his recent amputation incision reopen, bleed profusely, requiring the resident to be readmitted to the hospital and an additional surgery to re-close the wound. 2) Resident # 35 had a second fall on 08/31/16 that required a hospital visit, the facility then placed R #35 on 1:1 monitoring and it was discovered on 09/07/16 that R #35 was not receiving the 1:1 monitoring. 3) not developing a care plan for Resident #82 addressing the care of his new amputation including proper transfer of the resident. 4) Not revising the care plan after the fall. 5) Not reporting the fall to the State Agency. Findings for Resident #10 A. Record review of facility facesheet dated 06/17/15 revealed Resident # 10 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of Facility Incident reports (these are titled RMS - Event Summary Report) revealed, Resident # 10 has had 4 falls since admission on 06/17/16. These are on 07/07/16, 08/11/16, 08/16/16 and 08/19/16. The fall on 08/16/16 required transport to the emergency room (ER) with resulting in a left hip fracture with subsequent surgery for [REDACTED]. The fall on 08/19/16 resulted in a laceration to the right side of the forehead requiring transport to the ER and stitches. There is no evidence the facility reported the 08/19/16 incident to the State Agency. C. Care Plans dated 07/14/16 revealed the following with Problem, measurable Goals and Approaches include, Risk for mood symptoms, Wandering behavior, Physical and verbal aggression, Decline in cognitive function, Risk for falls, Risk for fractures related to (r/t) osteoporosis, Risk for bruising/skin tears, Risk for skin breakdown, Vision impairment. 1. Review of Care Plans revealed, Fall care plan with a revision date of 05/10/16 revealed under Focus - Fall 07/04/16 there is no evidence of a goal for this fall and no evidence of new approaches for this fall. 2. Record review of the Fall Care Plans revealed no evidence that the 08/11/16 fall is noted on care plans. 3. Record review of the Fall Care plan for the 08/16/16 fall revealed, 08/19/16 Focus - Readmission s/p (status [REDACTED]. Further Care Plan for the 08/19/16 readmission Focus - Fall s/p re-admission resident to stay in common area until bedtime, ER transfer r/t laceration to forehead. 4. Record review of Care Plan dated 08/20/16 revealed, Focus - laceration to forehead, Goal - will heal without signs and symptoms of infection, Interventions - remove sutures in 7-10 days, Monitor for signs and symptoms infection/pain. Further Care Plan also dated 08/20/16 revealed, Focus - ER visit s/p/ fall with [DIAGNOSES REDACTED]. D. Record review of facility Progress Notes dated 07/04/16 at 3:26 pm revealed, Resident #10 had a(n) accident/incident/fall in past 72 hours. dining room - res. was attempting to sit on her walker and she slid to the floor; did not hit head; denies pain/discomfort; able to move all extremities (MAE) .Resident #10 is not demonstrating symptoms of pain. 1. Record review of facility Progress Note dated 08/11/16 at 2:00 pm, revealed, Resident #10 had a(n) accident/incident/fall in past 72 hours. In room, attempting to sit on walker. Resident in her room trying to sit down on her rollator walker. Missed and sustained a fall. She does not appear to have injury. Redness to back and right outer abdomen was noted. Resident shows no evidence of pain or discomfort. Was assisted up and ambulated back to bed with staff to her side, showing no problems . Resident # 10 is not demonstrating symptoms of pain. 2. Record review of facility Progress Note dated, 08/16/16 at 4:22 am, revealed, Note: Resident found on floor, sustained a skin tear to left elbow, complaining of pain to both elbows and both hips. Contacted Power of Attorney (POA) and notified her that resident was to be sent out to ER, she stated that she preferred Name of Hospital. Non emergency transport notified. Fall was not witnessed, neuro checks started. 3. Record review of Progress Note dated 08/19/16 at 2:53 pm, revealed, Note: Resident admitted /readmitted to 160-B. Reason for readmission is post-surgery. A Braden score (a score used to predict pressure ulcer risk) of 17.0 and Fall Risk score of 20.0 were obtained as part of this assessment. Call bell placed within reach. Physician notified/orders verified: Yes . Comments: Resident readmitted this afternoon from Name of Hospital via facility van transport. She is s/p fracture. She is alert to self. A little drowsy. Denies pain. Able to answer some yes/no questions . Up on wheelchair for dinner. 4. Record review of Progress Note dated 08/20/16 at 1:15 am, revealed, Note: Resident #10 had a(n) accident/incident/fall in past 72 hours, not witnessed. Residents room. Resident was found on the floor at 1930 (5:30 pm)after being put to bed. She had a laceration to the right side of her forehead. She was sent to the emergency room due to the laceration and the fact that she had just had hip surgery . Resident # 10 is experiencing pain. Head .Sent to emergency room . E. Interviews were conducted as follows: 1. On 08/24/16 at 8:25 am, during an interview with the Alzheimer's Unit Charge Nurse LPN #1, the Charge Nurse stated, I was here for her 07/04/16 fall. She had a rollator walker and went to sit on it. It just rolled out from under her and she fell to the floor. She had no injuries from that fall. I was not here for any of her other falls. 2. On 08/24/16 at 8:30 am during an interview with the Night shift Charge Nurse LPN #3 the Charge Nurse stated, She had a fall on 08/16/19 and was having a problem bearing weight. We called the ambulance to come pick her up and take her to the ER. When asked about how she fell the Charge Nurse stated, It was an unwitnessed fall. She was in her room and I don't know how she fell . she was also having an increase in pain so between that and the problem with weight bearing is the reason we sent her out. I really don't remember anything else. 3. On 08/24/16 at 11:30 am, during an interview with the Minimum Data Set Coordinator (MDSC) the MDSC (who did the Change in Condition report regarding the fall) stated, She was trying to sit on her rollator missed the seat and had a fall. No injuries but redness to the back and right outer abdomen. She ambulated with assistance back to bed. No complaint of (c/o) pain. 4. On 08/24/16 at 1:50 pm, during an interview with Registered Nurse (RN) # 2 the RN stated, We had put her to bed and instructed the CNA's to check on her while working with other residents. Within 15 minutes she had gotten out of bed and fell . Bed was in low position, fall mat was in place. She had a laceration to the right side of her forehead, I cleansed it. I put a dressing in place just to keep the blood out of her eyes and called Emergency Medical Services (EMS). Findings for Resident #108 F. Record review of facility facesheet dated 05/09/14 revealed Resident #108 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. G. Record review of the Facility Event Tracking Log (facility name for Incident Report Log) revealed, Resident # 108 had falls on: 02/19/16, 03/28/16, 04/11/16, 04/14/16, 04/22/16, 04/27/16, 05/02/16, and 07/18/16. H. Record review of the Risk Management System (RMS)-Event Summary Report (facility name for Incident Report) revealed: Fall . 02/10/16 .Resident was found on the floor in the Dining Room. The fall was unwitnessed, she was helped onto a chair and was assessed. She denies pain and no bruise was found on head and other parts of the body. Neuro check was started. Fall .03/28/16 .Found sitting in floor beside bed. No signs and symptoms of distress noted. Denies pain. Laughing when CNA's entered room. Fall .04/11/6 .Found on the floor next to magazine rack, small scratch to left elbow area. denies pain. Fall .04/14/16 .resident seen putting herself closer to edge of wheelchair and falling onto the floor landing on her buttocks. Fall .04/22/16 .Resident attempting to get out of bed. Resident lowered onto floor. Fall .04/27/16 .Resident was attempting to ambulate and sat on floor; did not hit head; no injury noted; able to ambulate with staff assist. Fall .05/02/16 .resident found laying on the floor in front of the magazine rack; able to move all extremities and stand without difficulty; neuro checks started. Fall .07/18/16 .Resident found next to her bed. No signs and symptoms of injury or pain. I. Records review of Progress Notes revealed the following: 1. 02/19/16 at 5:33 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, not witnessed. Dining room, sitting trying to get up. Resident was sitting on a chair and fall (sic) on her buttocks as she was trying to stand up. There was no injury found on her and the fall was unwitnessed. Resident #108 is not demonstrating symptoms of pain. 2. Record review of Progress noted dated, 03/28/16 at 12:00 am, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, not witnessed. Residents room laying in bed ONSET AND DURATION: Found lying on floor beside bed. Laughing when CNAs entered room. No S/S of distress noted . Resident #108 is not demonstrating symptoms of pain. 3. Record review of Progress Notes dated 04/11/16 at 4:04 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, not witnessed. in dinning room ONSET AND DURATION: found resident on floor next to magazine rack, small scratch to left elbow noted, minimum bleeding noted only upon cleaning, covered and dry .Resident #108 is not demonstrating symptoms of pain. 4. Record review of Progress Notes dated, 04/14/16 at 10:15 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours. Dining room ONSET AND DURATION: Resident has long history of poor safety awareness Resident #108 is not demonstrating symptoms of pain. 5 Record review of Progress Note dated, 04/22/16 at 6:40 am, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, witnessed. Residents room, attempting to get out of bed. ONSET AND DURATION: Resident assisted back onto bed. No s/s of injury .Resident #108 is not demonstrating symptoms of pain. 6. Record review of Progress Note dated, 04/27/16 at 2:21 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, witnessed. getting up from w/c in dining room ONSET AND DURATION: res. was attempting to stand up from w/c; res. then sat on the floor with no injury noted; able to ambulate with staff assist .Resident #108 is not demonstrating symptoms of pain. 7. Record review of Progress Note dated, 05/02/16 at 2:30 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, not witnessed. dining room ONSET AND DURATION: res. was ambulating unattended and sat on floor .Resident #108 is not demonstrating symptoms of pain. 8. Record review of Progress Note dated, 07/18/16 at 8:15 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, not witnessed. Resident found next to her bed, getting out of bed ONSET AND DURATION: Resident found next to her bed. Residents bed was in the lowest position possible. No s/s of injury and resident is showing no s/s of pain .Resident #108 is not demonstrating symptoms of pain. J. Record review of Fall Care Plans with dates of, 06/04/15 with multiple revision dates, 04/11/16, 04/14/16, revisions on 04/22/16, 04/27/16, 04/29/16, 05/02/16 and new care plan for 07/18/16. There is no evidence of a care plan revision for the fall on 02/19/16 or the fall on 03/28/16. K. Observation of Resident #108 from 08/24/16 at 1:00 pm thru 2:35 pm revealed a pleasantly confused, clean, neat appropriately dressed resident. Resident was participating in activities to the level of her disease process. No odors were noted. L. On 08/25/16 at 9:40 am, during an interview with the Alzheimer's Care Unit Charge Nurse the Charge Nurse stated, Overall I feel it is just a lack of safety awareness r/t severe dementia. She just wants to get up out of anything wheelchair (w/c)/bed/chair etc., wants to walk. She doesn't understand she is not capable of doing these things without assistance. Safety measures we have put in place are, being sure the w/c brakes are locked, toilet her at least when she gets up, after meals and as needed. Low bed is in place with a scoop mattress and we do at least a one person assist with any movements to or from bed, w/c or chair etc. M. On 08/25/16 at 10:05 am during an interview with Alzheimer's Care Unit CNA the CNA stated that, we toilet her every 2 hours, Assist with all ADL's. She has a low bed with fall mat. We assist her in and out of bed and her w/c. Findings for Resident #46 N. Record review of the facility facesheet dated, 10/01/2010 revealed Resident #46 original admitted to the facility was 04/28/2010 with the current admission date of [DATE]. Admission [DIAGNOSES REDACTED]. O. Care Plans dated 07/21/16 with Focus, measurable Goals and Interventions include, Assistance with ADL's, Physical aggression, Social inappropriate behavior, Decline of cognitive function, Impaired communication,Risk of falls Distressed mood symptoms, Insomnia, Risk for alterations in functional mobility, Hx of dementia, Use of antidepressant medications, Risk for skin breakdown, Risk of bruising/skin tears, Incontinent of urine. P. Record review of Facility Event Tracking Log (facility name for Incident Report Log) revealed the following falls for Resident # 46: Fall .02/21/16 .Patient fall on bottom when getting off toilet. No injuries to report. Neuro's started. Will continue to monitor. Fall .03/19/16 .Found resident on floor on the left side of toilet under guard rails on bottom. Fall .03/27/16 .Resident was found on floor next to bed. States she was trying to transfers self to wheelchair and legs gave out. Able to move all extremities. Denies pain or discomfort. No bruising noted. Assisted resident up to chair. Fall .04/27/16 .Resident was attempting to transfer self to shower chair. fell on floor in shower room landing on right side of body. No redness or swelling noted. Fall .05/11/16 .Resident fell during toilet transfer on right side of toilet no injury or complaint of pain. Not witnessed so neuro's were started. Fall .05/18/16 .Resident attempted to transfer to toilet by self. Assessment of resident revealed ROM (range of motion) intact. No redness or bruising, no c/o pain or discomfort, no s/s of acute distress. Will toilet resident every 2 hours. Fall .05/29/16 .Resident was found sitting on the floor between her bed and her wheelchair. Resident states she was attempting to transfer self. A large knot was noted to the right side of her forehead. Neuro checks were done. Head to toe assessment within normal limits. V/S are stable. Fall 06/29/16 .Resident attempting to transfer self to w/c from bed. Found resident on right side on floor with w/c on top of her. Resident stated she transferred herself yesterday and thought she could do it again. Reminded resident to utilize call light for assistance and to lock tires on w/c fro transfers. Fall .08/06/16 .The resident found on floor in dining room. States she was pushing another residents wheelchair. Denies pain. No injury noted. Neuro checks started. Care plan up-dated. Daughter (POA) and MD notified. Will continue to monitor. Fall .08/08/16 .Summoned to bathroom of resident, found resident on floor up against wall. No redness or bruising noted, no s/s of pain or distress, did not verbalize any complaints of pain. Will monitor neuro status and vital signs. Q. Record review of Fall Care Plan: Fall dated 02/21/16 - there is no evidence of the fall on the care plan nor any up-date. Fall on 03/19/16 there is no indication of the fall in the care plan but a intervention with that date revealed, Monitor resident for un-met needs. Fall dated 03/27/16 - there is no evidence of the fall in the care plans and no evidence of new interventions. Fall dated 04/27/16 - there is no evidence of the fall in the care plan and no evidence of new interventions. Fall on 05/11/16 - Fall is noted on the care plan with a new goal of remain free from falls x 14 days. There is no evidence of a new intervention. Fall 05/18/16 - There is no evidence of the fall on the care plan and no evidence of any new intervention. Fall 05/29/16 - There is no evidence of the fall on the care plan and no evidence of any new intervention. Fall 06/29/16 - There is no evidence of the fall on the care plan and no evidence of any new intervention. Fall 008/06/16 - There is no evidence of the fall on the care plan. There is a new intervention dated 08/06/16 - Remind the resident to not push other resident wheelchair. Fall - 08/08/16 - There is no evidence of the fall on the care plan and no evidence of any new intervention. R. Record review of Physicians Orders revealed the following ordered medications, Cefpodoxime Proxetil - Antibiotic, Clonazepam - an anticonvulsant - a benzodiazepine, Docusate Sodium - a laxative, Milk of Magnesia - a laxative, Acetaminophen - non--narcotic analgesic, Cetirizine - a antihistamine, Trazodone - an antidepressant, Cholecalciferol - a vitamin, Sertraline - a antidepressant, Nitroglycerin tablet - a antianginal, Memantine - a psychotherapeutic and neurological medication, Mylanta - a antacid, Levothyroxine - a thyroid agent, Levocetirizine - a antihistamine, Ibuprofen - a analgesic/antinflammatory, Guaifenesin - a cough/cold/allergy medication, Aspirin - a non-narcotic analgesic. There is no evidence the resident receives any medications that contain an opiate. S. Record review of Progress Note dated, 02/21/16 at 9:40 am, revealed, Note: Patient had a(n) accident/incident/fall at 9 am not witnessed. In bathroom transferring to toilet Patient was found sitting on floor by toilet, she stated she fell while trying to sit on toilet. She denied hitting her head, and denied any pain. No injuries noted. Patient is not demonstrating symptoms of pain. 1. Record review of Progress Note dated 03/19/16 at 7:00 am, revealed, Late Entry: Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. Residents room ONSET AND DURATION: Resident was found on floor by CNA. Resident states she was trying to transfer self to toilet. No injuries noted .Resident #46 is not demonstrating symptoms of pain. 2. Record review of Progress Note revealed, There is no evidence of any Progress Note for the fall on 03/27/16. 3. Record review of Progress Note dated, 04/28/16 at 5:24 pm, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. shower room, attempting to transfer self ONSET AND DURATION: resident attempted to transfer self to shower chair, she fell on her right side. no injury. Resident #46 is not demonstrating symptoms of pain. 4. Record review of Progress Note dated, 05/11/16 at 2:59 pm, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. residents bathroom and transferring to toilet ONSET AND DURATION: toileting herself-fell on floor to the right of the toilet. up against the wall when she was found. ROM intact, no complaints of pain or discomfort. will continue to monitor for delayed injury .Resident #46 is not demonstrating symptoms of pain. 5. Record review of Progress Note dated 05/19/16 at 6:41 pm, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. residents bathroom, attempting toilet self ONSET AND DURATION: attempting to toilet self, no complaints of pain or discomfort. no s/s of acute distress. no redness or bruising present. will monitor for delayed symptoms Resident #46 is not demonstrating symptoms of pain. 6. Record review of Progress Note dated, 05/29/16 at 11:45 am, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours, not witnessed. Residents room ONSET AND DURATION: Resident was found on floor by CNA. States was transferring to w/c from bed. Bed was not in low position and was wearing plain socks .Resident #46 is not demonstrating symptoms of pain. 7. Record review of Progress Note dated, 06/29/16 at 2:46 pm, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. room and attempting to transfer to bed ONSET AND DURATION: resident attempting to transfer self to w/c from bed. found resident on right side on floor with w/c on top of her. resident stated she transferred herself yesterday and thought she could do it again. re

The following deficiency was a result of a QIS Recertification/Extended/Complaint survey that was initiated on 08/15/16. An immediate jeopardy was identified on 09/15/16 and a plan of removal was accepted on 09/19/16. Based on record review, and interview the facility failed to provide proper care for [DIAGNOSES REDACTED] (blood sugar below 70 as identified by the facility) for 1 (R #166) of 4 (R #34, 82, 125, and 166) residents reviewed for diabetes. This failed practice had the potential for R #166 to not recover from R #166's incident of unresponsiveness (not responding to verbal or touch stimuli), and being clammy with diaphoresis (excess perspiration) on 08/26/16 with low blood sugar results of 48 at 3:45 pm, 46 at 3:50 pm, 54 at 4:00 pm, and 60 at 4:05 pm. R #166 remained unresponsive until a sternal (breastbone) rub was done at 4:05 pm. The facility staff did not follow their protocol for [DIAGNOSES REDACTED] for R #166. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of K, being identified at the facility on 09/15/16 at 12:25 pm. The facility Administrator was notified at this time. The facility provided an acceptable Plan of Removal on 09/19/16 at 1:45 pm. based on the Plan of Removal, interventions included: 1) Resident #166 was currently in the hospital. 2) An audit was completed on 09/16/16 of current residents with orders for blood glucose monitoring, 3) Licensed staff were educated on diabetic care for both low and high blood sugar on 09/15/16 and will be completed on 09/23/16, 4) An audit of nourishment room will ensure orange juice is available. 5) Daily auditing of the 24 hour report, follow up to ensure intervention is effective, and ensure physician was notified. Based on the Plan of Removal and observation, the IJ was lifted on 09/19/16 at 1:45 pm. This resulted in the scope and severity being reduced from a scope and severity of K to a scope and severity of H. Based on record review, observations and interview the facility failed to provide necessary care and services to maintain or improve residents well-being for 3 (R #166, 82, and 162) of 3 (R #166, 82, and 162) residents reviewed for quality of care by not: 1) providing proper care for [DIAGNOSES REDACTED] for R #166 as evident by R #166 incident of unresponsiveness, clammy with diaphoresis, and with low blood sugar results of 48 at 3:45 pm, 46 at 3:50 pm, 54 at 4:00 pm, and 60 at 4:05 pm on 08/26/16. R #166 remained unresponsive until a sternal rub was done at 4:05 pm, 2) provide proper care of new amputation for R #82 and 3) failed to control pain for R #162. These failed practices had the potential for R #166 to not recover from unresponsiveness, R #82 had the potential for non healing of the amputation, and R #162 to experience extreme uncontrolled pain. The findings are: FINDINGS FOR R #166 Record review of the admission face sheet for R #166 revealed, admission date of [DATE] with the following Diagnoses: [REDACTED]., and end stage renal (kidney) disease. A. Record review of nurse's notes (NN) revealed: 1. NN dated 08/06/16 - . blood sugar during 4:00 pm was 49, resident was alert, gave resident a peanut butter sandwich and protein shake. There is no documentation that the physician was notified. 2. NN dated 08/18/16 at 9:06 pm - Observation: Resident observed with signs/symptoms (s/s) hypoglycemic episode. Alert, lethargic, ability to arouse with verbal/tactile stimuli, but remains to close eyes back immediately. Inability to keep eyes open to eat supper, Accucheck (blood sugar test) result 48. Mighty shake (protein shake) provided. Blood glucose recheck 66 .provided with another shake. No time was listed for either blood glucose check. There is no documentation that the physician was notified. 3. NN dated 08/26/16 at 5:50 pm - Resident was found by Physical Therapy (PT) unresponsive, clammy and with diuresis (sic). This nurse checked her Blood Sugar (BS) at 3:40 and it was 48. Registered Nurse (RN) administered [MEDICATION NAME] (medication to raise blood sugar) checked BS again at 3:45 pm, it was (BS) 43, resident still unresponsive at this point with pain stimulation. RN gave another [MEDICATION NAME] at 3:50 pm, BS checked 46 unresponsive at 4:00 pm, another [MEDICATION NAME] was given and her BS was 54. Licensed Practical Nurse (LPN) #7 do (sic) a sternum rub and the resident came too. BS checked at 4:05 it was 60. 4:10 pm, resident is now alert and oriented able to voice needs. This nurse assisted resident in drinking a protein shake and eating half a peanut butter sandwich. There is no documentation that the physician was notified or that emergency medical service was activated. B. Record review of a physician progress notes [REDACTED]. Later after visit day nurse advised that patient blood sugar was reading 40 and did not know what to do since patient does not have [MEDICATION NAME] (medication to raise the concentration of glucose/sugar in the bloodstream). Advised nursing staff to send patient out to emergency room (ER) immediately for further evaluation and treatment. This would explain patient behavior earlier during examination which was not just fatigue or because she had just taken a pain medication. There is no documentation for R #166 being sent to the ER (emergency room ). D. Record review of the physician orders [REDACTED].< (less than) 70 initiate hypoglycemic protocol, > (greater than) 401+ give 20 units and call medical doctor, subcutaneously before meals and at bedtime for diabetes E. Record review of the facility [DIAGNOSES REDACTED] Protocol dated 01/02/14 revealed: 1. Asymptomatic low blood glucose (less than 70 .) - Treatment: Hold all diabetic medications, including insulin and oral medications. Administer rapidly absorbed simple carbohydrate such as 4 ounces (oz) juice, or 5 or 6 oz regular soda pop or tube of glucose gel per patient's routine. If below 70, repeat juice and blood glucose measurement times 1. If no improvement, notify physician. 2. Symptomatic conscious able to swallow - Treatment: If less than 70 . immediately administer rapidly absorbed simple carbohydrate such as 4 oz. juice, or 5 or 6 oz regular soda pop or tube of glucose gel per patient's routine. Remain with resident and monitor vital signs. Put patient in safe environment such as bed or chair. Repeat blood glucose measurement in 10-15 minutes. If below 70, repeat juice and blood glucose measurement 10-15 minutes after juice administration. Hold Medications, . Notify physician. 3. Symptomatic unconscious - Treatment: Perform fingerstick blood glucose measurement. If less than 70 . immediately administer [MEDICATION NAME] 1 milligram (mg) intramuscularly (IM) or subcutaneously. Notify physician immediately. If no response to [MEDICATION NAME] in 15 minutes, repeat [MEDICATION NAME] 1 mg IM or subcutaneously and activate emergency medical service (EMS). Remain with patient and monitor vital signs. Hold diabetic medications. F. Record review of the Medication Administration Record (MAR) dated 08/05/16-08/31/15 revealed, low blood sugars with no documentation of any intervention to show the hypoglycemic protocol was followed and no documentation that the physician was notified, as follows: 1. 08/07/16 - 11:00 am result 64, 5:00 pm result 57. 2. 08/08/16 - 9:00 pm result 48. 3. 08/09/16 - 5:00 pm result 62. 4. 08/13/16 - 5:00 pm result 62. 5. 08/16/16 - 5:00 pm result 62. 6. 08/24/16 - 5:00 pm result 59. 7. 08/27/16 - 7:00 am result 44. G. Record review of R #166's care plan revealed, The resident has a [DIAGNOSES REDACTED]. Interventions - Monitor for signs and symptoms of hyper/[DIAGNOSES REDACTED] and report abnormal findings to physician 08/05/16. Notify Physician of glucose < (less than) 70 or > (greater than) 400. H. On 09/15/16 at 10:22 am, during an interview with LPN #7, about R #166's low blood sugar incident on 08/26/16, LPN #7 stated that on 08/26/16 she was not the nurse for R #166, they (LPN #8 and Registered Nurse (RN) #1) called me in there and the only thing I did was the sternum rub. LPN #7 further stated that she read the hyper/[MEDICAL CONDITION] protocol after this event, because she did not receive the protocol in orientation. LPN #7 stated that they did not know if EMS or the physician were contacted. I. On 09/15/16 at 11:10 am, during a interview with LPN #8, about R #166's low blood sugar incident on 08/26/16, LPN #8 stated I believe her BS was 43. I was training with RN #1 that day. I believe the therapist found her unresponsive. R #166 was given 3 doses of [MEDICATION NAME], but I know recommendation was 2. In front of the MAR there is a protocol, and I read it. I did not call physician and there was no discussion of calling EMS or family. Once she came to I fed her a peanut butter sandwich and it was hard to get her to eat it because she didn't like peanut butter. I charted the event even though I wasn't the nurse administering the [MEDICATION NAME], because I was told to by RN #1. I was also told to write a note on a sheet of paper to be put in a binder for the physician to see on Monday. J. On 09/15/16 at 11:22 am, during a interview with RN #1, about R #166's low blood sugar incident on 08/26/16, RN #1 stated I'm aware of the oral protocol. I have not read the one for the [MEDICATION NAME]. From prior readings it is my understanding that you can not harm person with 3 doses of [MEDICATION NAME]. If she didn't come to, we would have called EMS after the 3rd dose. I did not call him (R 166's physician). I did leave a note in his communication book. I did consider it an emergency, that's why [MEDICATION NAME] was given, but she came to so we didn't call EMS. We stabilized her, so no I didn't think it was emergent to call physician. The [MEDICATION NAME] should be charted in the MAR. I don't recall if it was done. Findings for Resident #82 L. Record review of facility facesheet dated 10/03/2011 revealed Resident #82 original admission was on 10/03/11 with current admission being on 09/05/16. M. Admission [DIAGNOSES REDACTED]. N. Record review of Care Plans revision dated 08/31/16 revealed, Focus: Risk for falls related to impaired mobility, weakness and recent left leg amputation. Goal: No falls with major injury x 90 days. Interventions: There is no evidence in the care plan of interventions for care of the stump or interventions for transfers or assist. 1) 08/31/16 Assistance with ADL's, measurable Goals and Interventions. 2) 01/11/16 Diabetes, with measurable Goals and Interventions. 3) 08/31/16 Potential for complications i.e. infection, non-healing related to knee disarticulation (amputation of the leg below the knee) and surgical wound stump. Goal: Incision site to stump will heal without complications x 30 days. Interventions: there is no evidence of interventions specific to the care of the stump. O. Record review of Progress Note dated, 06/18/16 at 6:39 pm, revealed, Note: Dressings to both legs were changed. foul odor noted to left dressing. P. Record review of Progress Notes dated, 06/26/16 at 3:37 pm, revealed, Note: Increased amount of yellow drainage from both legs was present, but more so from the left. Multiple open area were noted to left leg. Dressing changes completed and wrapped with [MEDICATION NAME] (a surgical dressing). Q. Record review of Progress Notes dated, 08/03/16 at 3:00 pm, revealed, Late Entry: Note: Resident seen by Name of Certified Nurse Practioner, Certified Wound Nurse. For new wound to left foot. Diabetic/pressure wound. Wound bed covered with necrotic tissue with odorous serosangruineous (fluid leaving a wound that is yellowish with small amounts of blood) drainage. Referral to be sent to see Name of Podiatrist for assessment. New treatment orders received for Santyl (an ointment to heal wounds), [MEDICATION NAME] (an absorbent wound dressing), [MEDICATION NAME], and ace wrap. Change daily and PRN (as needed). R. Record review of Progress Note (Social Services) dated 08/09/16 at 12:58 pm revealed, Note: Contacted residents mother at the request of admissions and CNE (Clinical Nurse Executive) regarding her decision to have him return back to Name of Facility or have him go elsewhere. Spoke with his/her Power of Attorney (person or persons making both medical and financial decisions for someone who cannot make those decisions for themselves) regarding what the hospital was telling us about him not returning to (Name of Facility). She said that she had not decided because Name of Resident was going to be needing more care now because he was in surgery, as we spoke, having his foot amputated below the knee. She blames the care that he received here and the neglect he was subjected to. She wants to come and meet with the nurses and the doctors who cared for him before to ensure that he receive the proper care that he is going to need if he returns. S. Record review of Progress Notes dated 08/30/16 at 5:56 pm revealed, Skilled Services: Skilled Nursing; Therapy; Teaching/Training; Management/Evaluation; Nrsg Observation: Continues to work with therapy to reach set goals. Observations: Resident appt with ortho, new orders received Action/nursing interventions : Removed staples, F/U with Name of MD r/t right leg circulation and stent placing Resident's response: Tolerated well Skilled Services: Skilled Nursing; Therapy; Teaching/Training; Management/Evaluation; Nrsg Observation: Continues to work with therapy to reach set goals. T. Review of Progress Note dated 08/31/16 at 5:10 pm revealed, Late Entry: Note: CNA notified this nurse that the resident's incision was bleeding while turning him to clean up a loose stool that the resident had in bed. pt does not display much strength to assist himself. The below the knee stump surgical incision was bleeding and needed direct pressure. the area is approximately. 9 cm long and the widest part in the middle is approximately. 1.5 cm. his bed linens were saturated in blood and dripping on the floor. 4 ABD's (Large surgical dressings) 5 gauze were used for pressure. bleeding would subside for approximately. 15-30 sec but with minimal movement the clot would break loose. stump [MEDICAL CONDITION] (abnormal accumulation of fluid below the skin) and has + 1 [MEDICAL CONDITION] (slight indentation, no perceptible swelling of the leg)noted. [MEDICATION NAME] and paper tape dressed around the circumference of the stump. Spontaneous bleeding would occur. direct pressure was again performed. This continued until the EMS arrived and they tried to reinforce the area with more gauze pads and re-tape it. condition reported to EMS and resident was transferred to Name of Hospital ER. patient attitude was in denial and abrupt, rude and accusing staff for his misfortune. Instructed resident that he/she could not safely be a 1:1 for transfers and that more staff was necessary to provide safer maneuvering. Resident agreed but argued. U. Record review of Progress Note - Change In Condition - Skin, dated 08/31/16 at 7:30 pm revealed, Note: Resident #82 has a new onset/change in skin integrity as evidenced by incision. Location: BKA ( [MEDICAL CONDITION]) dehiscence (wound rupture along a surgical incision) of surgical incision. experiencing pain. 5/10 when performing direct pressure to area, otherwise, no pain. Physician notified of change in condition Responsible party notified of change in condition. Interventions: New orders obtained Send to (Name of Hospital ER) to evaluate surgical incision. V. There was no evidence that this fall was investigated to determine cause nor was it reported to the State Agency. X. Record review of Progress Notes dated 08/31/16 at 10:50 am, revealed, Note: Resident #82 has a new onset/change in skin integrity as evidenced by skin tear. Location: Left Top Hand. not demonstrating symptoms of pain. NA There has been no medication change in the past week. Physician notified of change in condition Responsible party notified of change in condition. Interventions: New orders obtained cleanse, steri strips, monitor UTR (Until resolved). Y. Observation of Resident # 82 09/08/16 at 9:00 am, 09/09/16 at 1:00 pm and 09/13/16 at 11:00 am revealed a resident that is appropriately dressing, in a wheelchair, left stump covered by an ace wrap and the resident's pants. Z. On 09/09/16 at 9:18 am, during an interview with the Center Nurse Executive (CNE) the CNE when asked who did weekly skin checks the CNE stated, The nurses assigned to a hall do the skin checks. When asked about if there is a weekly skin check form the CNE stated, I believe so, yes. AA. On 09/09/16 at 12:17 pm, during an interview with RN #1 the RN stated, We are wrapping his legs from toes to knees. I look at everything when I'm doing their skin checks. I did not find anything on the left foot either a diabetic or a pressure ulcer. On his skin check on 07/31/16 I did not see anything on the left foot. I'm unaware of how the ulcer occurred. BB. On 09/09/16 at 1:35 pm during an interview with the Assistant Director of Nursing, (ADON) stated The ulcer was found by, (Name of RN no longer working at the facility), on the evening of 08/02/16. He/she called me at home and I advised he/she to cover it and keep it clean. CC. On 09/09/16 at 1:45 pm, during an interview with the Center Nurse Executive (CNE) stated, Only thing I can say is that when I did the skin check on 07/26/16 I did not see a ulcer on the residents left foot. DD. On 09/12/16 at 1:33 pm, during a phone interview with the Orthopedic Surgeon, the surgeon stated. The residents fractured toe could have been spontaneous with his diabetic Arthropathy (disease of the joint). As to the ulcer on his left foot that could not have occurred in 2-3 days. When the resident came into the office, even before I unwrapped the wound, I knew he had gangrene because I could smell it. The gangrene could have taken months to manifest itself. With the residents chronic conditions all these things may have taken months to years to present. His leg wounds could have contributed to his issues. All of these things lead to my decision to disarticulate (separation of two bones at their joint) the left leg. Findings for Resident #162 EE. Record review of the Admission Record dated 07/23/16 revealed that R#162 had a medical [DIAGNOSES REDACTED]. The resident has contractures (a permanent shortening of a muscle or joint) of both arms and legs, relies on nutrition being supplied via gastric tube (A tube inserted through a small incision into the stomach used to supply liquid nutrition and medications), a [MEDICAL CONDITION] (tube inserted into the trachea to gain control of the airway) is in place due to R#162's inability to open the airway in the throat, and chronic pain. FF. Record review of the physician's orders [REDACTED].#162 was prescribed a [MEDICATION NAME] Patch (A narcotic pain medication applied to the top of the skin for chronic pain) 50 MCG (microgram) per hour to be changed every 72 hours. GG. Record review of the MAR (Medication Administration Record), dated 08/17/16, revealed that the [MEDICATION NAME] (synthetic opioid pain medication in a patch applied to the skin) patch was replaced on 8/17/16. The patch was scheduled to be replaced on 08/20/16, and was not replaced on 8/20/16. The patch was not replaced until 08/23/16. HH. Record review of the Care Plans dated 07/23/16 and revised 08/04/16 revealed: Focus Resident exhibits alterations in comfort related to chronic pain. Interventions .Medicate resident as ordered for pain and monitor for effectiveness. Advise resident to request pain medication before pain becomes severe. II. On 08/23/16 at 4:00 pm, R#162 was observed in bed in his/her room. The [MEDICATION NAME]ed was observed and clearly marked 08/17/16. JJ. On 08/23/16 at 3:30 pm, during an interview family member #1 (FM#1) stated that (name of R#162) had been in great pain the night before on 08/22/16. FM#1 stated that the resident was awake crying and screaming in pain. FM#1 stated that staff reported six other residents were complaining that R#162 was keeping them awake. KK. On 08/23/16 at 4:15 pm, the CNE reviewed the MAR and stated that the [MEDICATION NAME] had been scheduled to be changed on 08/20/16 and that had not occurred.

Based on record review, and interview the facility failed to report and thoroughly investigate incidents of potential abuse/neglect/injuries of unknown origin to the State Survey Agency for 8 (R's #10, #23, #35, #50, #82, #149, #151, and #162) of 8 (R #10, #23, #35, #50, #82, #149, #151, and #162) residents reviewed for occurrences/incidents or events. This failure likely resulted in residents continuing to experience harm as the cause(s) of injuries and abuse were not identified and corrected by the facility. The findings are: A. Record review of the facility Abuse Prohibition Policy and Procedure dated 07/01/13 and revised 10/15/15 revealed: (Name of Facility) will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: 1) Screening of potential hires. 2) Training of employees (both new employees and ongoing training for all employees. 3) Prevention of occurrences. 4) Identification of possible incidents or allegations which need investigation. 5) Investigation of incidents and allegations. 6) Protection of patients during investigations. 7) Reporting of incidents, investigations, and Center response to the results of their investigations. Abuse is defined as the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services which are necessary to maintain physical or mental health including the following: 1) Verbal abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms. 2) Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. 3) Physical abuse includes hitting, slapping, pinching, kicking, as well as controlling behavior through corporal punishment. 4) Mental abuse includes but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Involuntary seclusion is defined as separation of a patient from other patients or from her/his room or confinement to her/his room against the patient's will, or the will of the patient's legal representative. Injuries of unknown origin are defined as an injury with both of the following conditions: 1) The source of the injury was not observed by any person or the source of the injury could not be explained by the patient. 2) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. Misappropriation of patient property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. The purpose of this policy is to ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all patients. Findings for Resident #10 B. Record review of the facility incident reports (these are titled Risk Management System (RMS) - Event Summary Report) revealed, R #10 has had 4 falls since admission on 06/17/16. The falls occurred on 07/07/16, 08/11/16, 08/16/16 and 08/19/16. C. Record review of a facility Progress Note for R #10 dated, 08/16/16 at 4:22 am, revealed, Note: Resident found on floor, sustained a skin tear to left elbow, complaining of pain to both elbows and both hips. Contacted Power of Attorney (POA) and notified her that resident was to be sent out to ER, she stated that she preferred Name of Hospital. Non emergency transport notified. Fall was not witnessed, neuro checks started. D. On 08/24/16 at 8:30 am, during an interview with LPN #3 about R #10, the Charge Nurse stated, She had a fall on 08/16/19 and was having a problem bearing weight. We called the ambulance to come pick her up and take her to the ER. When asked about how she fell , the Charge Nurse stated, It was an unwitnessed fall. She was in her room and I don't know how she fell . She was also having an increase in pain so between that and the problem with weight bearing is the reason we sent her out. I really don't remember anything else. E. Record review of a Progress Note for R #10 dated 08/19/16 at 1:15 am, revealed, Note: Resident #10 had a(n) accident/incident/fall in past 72 hours, not witnessed. Residents room. Onset and Duration: Resident was found on the floor at 1930 (7:30 pm) after being put to bed. She had a laceration to the right side of her forehead. She was sent to the emergency room due to the laceration and the fact that she had just had hip surgery . R #10 is experiencing pain. Head .Sent to emergency room . F. On 08/24/16 at 1:50 pm, during an interview with Registered Nurse (RN) # 2 about R #10's fall on 08/19/16, the RN stated, We had put her to bed and instructed the Certified Nurse Aide (CNA)'s to check on her while working with other residents. Within 15 minutes she had gotten out of bed and fell . Bed was in low position, fall mat was in place. She had a laceration to the right side of her forehead, I cleansed it. I put a dressing in place just to keep the blood out of her eyes and called Emergency Medical Services (EMS). G. On 08/24/16 at 2:00 pm, during an interview with the Center Nurse Executive (CNE) (same as the Director of Nursing (DON)), the CNE stated that, there was not an investigation of these incidents. H. There is no evidence that the injury of unknown origin on 08/16/16, which resulted in a [MEDICAL CONDITION], was thoroughly investigated and was not reported to the State Survey Agency until 2 days after the fall. There is no evidence that the injury of unknown origin on 08/19/16, which resulted in a laceration to the right side of the forehead was thoroughly investigated and reported to the State Survey Agency. Findings for Resident # 23 I. Record Review of the facility face sheet for R #23 dated 06/28/16 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. J. Record review of the facility Event Tracking Log dated July 2016 revealed R #23 had an incident on 07/22/16 - Injury of unknown origin. 1. Record review of the Nursing Progress Notes dated 07/22/16 at 4:27 pm revealed, R #23 had an accident/incident/fall in past 72 hours. Large bruise of unknown origin noted to left arm. 2. Record review of the Hospice Progress notes dated 07/22/16 revealed large bruise to left forearm and smaller one to left inner arm, purple/bluish color. (Name of CNE) notified of bruising and patients statement that facility aide grabbed arm when getting resident up yesterday morning. 3. On 08/22/16 at 1:20 pm, during an interview with the CNE, the CNE advised there are only 2 event reports in the system for R #23. The CNE stated there was an event report for 07/23/16 and 07/28/16, but not one for 07/22/16. The CNE advised that the event on 07/22/16 was reported by the charge nurse. The CNE stated The Hospice Registered Nurse (HRN) reported (Name of R #23) to have some bruises to the left forearm. 4. On 08/25/16 at 11:21 am, during an interview with the HRN, the HRN stated that on 07/22/16 the HRN noticed bruising to the R #23's left forearm. The HRN stated that R #23 reported that a facility aide had grabbed R #23's arm the day before when getting the resident out of bed. The HRN advised that the incident was reported to the charge nurse upon finding. 5. On 08/25/16 at 2:05 pm, during an interview with Registered Nurse (RN) #1, RN #1 stated that the HRN was in the facility the morning of 07/22/16 and reported to RN #1 that R #23 had a bruise on the left forearm. The HRN reported to RN #1 that R #23 stated the girl who got me up the day before was rough with me. RN #1 advised that when RN #1 got the information on 07/22/16, it was reported to the CNE and to R #23's Power of Attorney (POA). K. Record review of the facility 5-Day Follow Up dated 07/27/16 revealed: 1. The Hospice Registered Nurse (HRN) reported that R #23 told the HRN that the aide who got R #23 up the day before was rough. 2. RN #1 was notified of the bruise by the Hospice aide. The aide reported that R #23 stated a guy grabbed and squeezed R #23. 3. R #23 reported to the CNE, that the incident on 07/22/16, could possibly have happened during a shower. There is no evidence that there was an investigation conducted for this incident. L. Record review of the facility Event Tracking Log dated July 2016 revealed R #23 had an incident on 07/23/16 - Fall; documented as not reportable. 1. Record review of the facility Event Summary Report dated 07/23/16 for R #23 revealed, Resident was found on the bathroom floor after being heard calling out for help. M. Record review of the Nursing Progress Notes R #23 dated 07/26/16 at 2:40 am revealed, This is a follow up note from the accident/incident/fall that occurred on 07/23/16. Complains of pain to right wrist. Decreased range of motion, swelling to area. Sent to ER for x-rays of wrist. N. Record review of a complaint dated 07/27/16 revealed that on 07/26/16 Emergency Medical Services (EMS) arrived at (Name of facility) for a non-emergent transfer, in reference to a resident with an injured wrist. The complaint states that R #23 was in a great deal of pain with an obvious injury to the right wrist. R #23 had fallen on Saturday, however the injury went unnoticed for 3 days before EMS was contacted for an emergency room (ER) visit. Assessment of R #23 revealed a large contusion over the top of the wrist and hand with R #23 reporting extreme pain upon palpitation and manipulation. The complainant further stated, Leaving this resident alone to deal with the pain without so much as a wrap is morally and and professionally reprehensible. 1. Record review of the Nursing Progress Notes for R #23 dated 07/26/16 at 10:40 am. Status of condition: deteriorated. Resident returned from the ER with [DIAGNOSES REDACTED]. 2. On 08/25/16 at 1:42 pm, during an interview with the CNE, the CNE advised that R #23's fall on 07/23/16 was on the weekend and the only information to go by is the report that was provided by the charge nurse. The CNE stated, To my knowledge, the resident was found in the bathroom and was unattended. When asked if there was a state report made for this incident, the CNE replied, No. FINDINGS FOR R #35 O. Record review for R #35 revealed, admission date of [DATE], with the following Diagnoses: [REDACTED]. 1. Record review of Nurse's note for R #35 dated 07/25/16 at 3:45 am revealed, Certified Nurse Aide (CNA) stated that he was assisting resident to the restroom and that R #35 fell from his wheelchair as they were exiting the restroom. The CNA stated that he was unable to catch him before he hit the floor. R #35 sustained lacerations to his face (between his eyebrows and on the bridge of the nose near his left eye) and was transported to (name of hospital) . R #35 is experiencing pain. 07/25/16 4:55 am, new orders obtained, continued observation stitches received to bridge of nose. 2. Record review of R #35's physician progress notes [REDACTED]. CT reviewed and discussed at length with patient family. CT shows re-demonstrated (re-fractured) and fractures of C1 (cervical vertebrae) and C2. Fracture through C2 involving the odontoid (tooth like projection from the second cervical vertebra on which the first vertebra pivots) tip which appears more displaced than previous examination. P. Record review of the facility's Incident log from 02/2016 - 08/15/2016 revealed that R #35's fall on 07/25/16 that resulted in the re-fracturing of R #35's neck was not listed as a reportable fall. Q. On 08/19/16 at 1:25 pm, during an interview with the Center Nurse Executive (CNE) (facility's DON), the CNE stated that it was not reported because we knew how R #35 fell , so it did not need to be investigated. We reported it when we were called and told about (name of resident) neck being re-fracture. Findings for Resident #50 R. Record review of the facility face sheet for Resident #50, dated 08/19/16, revealed an admission date of [DATE] with a readmission of 08/19/2016. [DIAGNOSES REDACTED]. 1. Record Review of the facility's Investigative report dated 08/06/16 revealed LPN #5 reported to the CNE that (Name of R #50 was at the nurses station with several other residents stating the facility is a joke and R #50 is not happy here. LPN #5 reports that LPN #5 told resident if resident is unhappy here she had the option to leave. Resident was upset and would not talk to LPN after. 2. On 08/26/16 at 8:05 am, during an interview with R #50, R # 50 stated that around 08/08/16 LPN #5 yelled at R # 50. R #50 stated I told another resident that this place was a joke. That particular day there was a lot of admits and the staff was running around trying to get things done that were not possible. LPN #5 turned around and told me, in front of everyone, that this place is not a prison and I could have my walking papers. I did complain to the CNE. 3. On 08/31/16 at 10:25 am, during an interview with the CNE, the CNE stated that LPN #5 came and self reported the incident to the CNE. The CNE advised that the resident came in 2 days later to report what had happened. When asked if this was reported and investigated, the CNE replied I spoke with the resident and felt it did not need to be reported because the resident expressed that it was handled to R #50's satisfaction. 4. On 09/01/16 at 9:57 am, during an interview with R #50, R #50 stated I have not really seen an end result and no, I am not completely satisfied. I don't feel anything was really done. S. There is no evidence this incident was thoroughly investigated or reported to the State Survey Agency. Findings for Resident #82 T. Record review of facility facesheet for R #82, dated 10/03/2011, revealed Resident #82 original admission was on 10/03/11 with current admission being on 09/05/16. Admission [DIAGNOSES REDACTED]. 1. Record review of Hospital Discharge Summary dated 08/12/16 revealed, .Medical Problems .[MEDICAL CONDITION] (bacterial infection involving the inner layers of the skin) and abscess (a collection of pus that has built up within the tissue), gangrene (reduced blood supply to the tissue which results in cell death) of lower extremity, Osteomylitis (infection and inflammation of the bone and bone marrow) due to secondary diabetes, Osteomylitis of the ankle and foot . Left diabetic foot, chronic non-healing [MEDICAL CONDITION] .Orthopedic surgeon has disarticulated his knee surgically (amputation of the leg below the knee). 2. Record review of Care Plans revision for R #82 dated 08/31/16 revealed, Focus: Risk for falls related to impaired mobility, weakness and recent leg amputation. Goal: No falls with major injury x 90 days. Interventions: There is no evidence of interventions for care of the stump or interventions for transfers or assist. 3. Review of Progress Note for R #82 dated 08/31/16 at 5:10 pm revealed, Late Entry: Note: CNA notified this nurse that the resident's incision was bleeding while turning him to clean up a loose stool that the resident had in bed. pt does not display much strength to assist himself. BKS (below the knee stump)surgical incision was bleeding and needed direct pressure. the area is approximately. 9 cm long and the widest part in the middle is approximately. 1.5 cm. his bed linens were saturated in blood and dripping on the floor. 4 ABD's (Large surgical dressings) 5 gauze were used for pressure. bleeding would subside for approximately. 15-30 sec but with minimal movement the clot would break loose. stump [MEDICAL CONDITION] (abnormal accumulation of fluid below the skin) and has + 1 [MEDICAL CONDITION] (slight indentation, no perceptible swelling of the leg) noted. [MEDICATION NAME] (gauze bandage) and paper tape dressed around the circumference of the stump. Spontaneous bleeding would occur. direct pressure was again performed. This continued until the EMS arrived and they tried to reinforce the area with more gauze pads and re-tape it. condition reported to EMS and resident was transferred to Name of Hospital ER. patient attitude was in denial and abrupt, rude and accusing staff for his misfortune. Instructed resident that he could not safely be a 1:1 for transfers and that more staff was necessary to provide safer maneuvering. Resident agreed but argued. 4. On 09/09/16 at 9:18 am, during an interview with the Center Nurse Executive, (CNE) (facility title for DON) the CNE when asked if there was a investigation and report to the State Survey Agency regarding the injury to R #82's stump, the CNE stated, No. U. There is no evidence that the fall on 08/31/16 was thoroughly investigated and reported to the State Survey Agency. Findings for Resident #149 V. Record review of facility face sheet for Resident #149, dated 08/01/16 revealed, an admission date of [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. 1. Record review of a incident report dated 08/14/16 revealed that R #149 reported that the facility night nurse was withholding her medication and becomes angry when R #149 inquires about it. 2. Record review of Physician orders [REDACTED]. 3. Record review of Physician orders [REDACTED]. W. On 08/30/16 at 11:52 am, during an interview with R #149, R #149 stated that prior to her fall on 08/12/16, the night nurse was 3.5 hours late in giving the resident the nightly pain medication. R #149 advised that the nurse came in and told R #149 You do not need it right now. R #149 could not remember the name of the nurse. 1. On 08/30/16 at 1:25 pm, during an interview with the CNE, the CNE provided the name of the nurse involved. When asked if this incident was investigated, the CNE replied The nurse was not investigated for allegations of abuse and neglect, but the investigation was done based on allegations of medication not being given. 2. On 08/30/16 at 2:30 p.m., during an interview with CNA #7, CNA #7 stated This nurse is a don't play games with me and I won't play games with you type. CNA #7 stated This nurse is verbally aggressive and [MEDICATION NAME] and in 4 years of employment, this agency is one of the worst I have seen. 3. On 08/30/16 at 2:40 p.m., during an interview with CNA #4, CNA #4 stated this nurse is very demanding to the aides but slow in the nurse's own workload. CNA #4 stated (Name of Nurse) has the attitude of I will get to it when I get to it, whether it is medications or wound care. There have been times when this nurse has not completed things until 3:00 am. Things that should have been done early on the shift. CNA #4 also advised that this nurse is verbally aggressive toward the residents. X. There is no evidence this incident was thoroughly investigated or reported properly to the State Agency. Findings for R #151 Y. Record review of the admission face sheet for R #151 revealed, an admitted d of 06/01/16 with the following Diagnoses: [REDACTED]. 1. Record review for a note on the Activity of Daily Living (ADL) Correction Form revealed, 5/20/16 10 pm - 6 am, Resident saying CNA's told her it was too late to be on the bedpan and left her in BM (Bowel Movement) for an hour. 2. On 08/18/16 at 10:45 am, during an interview with the Manager of Clinical Operations (MCO) (corporation Director of Nursing DON) and the facility Center Nurse Executive (CNE) (DON) stated that they were not aware of the ADL documentation. 3. On 08/19/16 at 11:00 am, during an interview with the MCO, the MCO stated that the facility was not aware of the 05/20/16 incident for R #151 until the surveyor brought it to their attention, and that they were going to start an investigation. 4. On 8/23/16 at 10:00 am, during an interview with the CNE, the CNE was asked for the investigation of the ADL incident. The CNE stated that she was not finished with her investigation. 5. On 08/25/16 at 3:22 pm, during an interview with Certified Nurse Aide (CNA) #14, CNA #14 stated that she was the person that wrote the statement on the ADL Correction Form, and stated that she followed up with the Nurse. Findings for R #162 Z. Record review of the Admission Record dated 07/23/16 revealed, that R #162 had a medical [DIAGNOSES REDACTED]. The resident has contractures (chronic loss of joint motion due to structural changes in non-bony tissues) of both arms and legs and relies on nutrition being supplied via (by) gastric tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach), and a tracheotomy tube (tube inserted into the trachea to gain control of the airway) is in place due to R#162's inability to open his/her airway in the throat. 1. On 08/23/16 at 3:30 pm, during an interview, Family Member (FM) #1 stated that in the early morning hours of 08/18/16 R #162 was awake crying and in pain. The nurse on duty called name of resident a big baby and stated that FM #1 should take him home. FM #1 stated that R #162 said that the nurse slammed the door and R #162 had to sit in his/her poop for 2 hours. FM #1 stated that he/she reported it the Admissions Director (AD). 2. On 08/26/16 at 11:30 am, in an interview, the AD stated that on 08/22/16 (name of FM #1) reported that R #162 was screaming in pain during the early morning hours of 08/18/16 and had a bowel movement in his/her underwear. FM #1 stated that the nurse called him/her a big baby, slammed the room door and R #162 was left in fecal matter for two hours. The AD stated that the incident was verbally reported to the Assistant Director of Nursing (ADON). 3. On 08/26/16 at 12:00 pm, in an interview the ADON stated I was working the floor and training a new nurse the day that the AD told me about the incident. The ADON stated The incident was reported to me in passing and I assumed (name of AD) would report it to the higher powers. The ADON stated that he/she did not report it to anyone else. 4. On 08/26/16 at 1:00 pm, in an interview, the Center Nurse Executive (CNE) stated that this was a terrible incident and an incident/grievance report should have been reported at the time of occurrence. I would expect something this egregious to have been reported immediately to someone in administration. When asked if this incident had been reported the CNE stated, No.

Based on record review and interview, the facility failed to implement their policy and procedure regarding incident reporting for injuries of unknown origin by not completing investigations and not reporting the incidents to the State Survey Agency for 8 (#10, #23, #35, #50, #82, #149, #151 and #162) of 8 (#10, #23, #35, #50, #82, #149, #151 and #162) residents reviewed for incidents. This deficient practice has the potential to prevent staff from determining the cause of the incident, identifying the need for staff training and implementing needed changes. The findings are: A. Record review of the facility Abuse Prohibition Policy and Procedure dated 07/01/13 and revised 10/15/15 revealed: (Name of Facility) will prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients through the following: 1) Screening of potential hires. 2) Training of employees (both new employees and ongoing training for all employees. 3) Prevention of occurrences. 4) Identification of possible incidents or allegations which need investigation. 5) Investigation of incidents and allegations. 6) Protection of patients during investigations. 7) Reporting of incidents, investigations, and Center response to the results of their investigations. Abuse is defined as the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services which are necessary to maintain physical or mental health including the following: 1) Verbal abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms. 2) Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. 3) Physical abuse includes hitting, slapping, pinching, kicking, as well as controlling behavior through corporal punishment. 4) Mental abuse includes but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Involuntary seclusion is defined as separation of a patient from other patients or from her/his room or confinement to her/his room against the patient's will, or the will of the patient's legal representative. Injuries of unknown origin are defined as an injury with both of the following conditions: 1) The source of the injury was not observed by any person or the source of the injury could not be explained by the patient. 2) The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. Misappropriation of patient property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. The purpose of this policy is to ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all patients. Findings for Resident #10 B. Record review of the facility incident reports (these are titled Risk Management System (RMS) - Event Summary Report) revealed, R #10 has had 4 falls since admission on 06/17/16. The falls occurred on 07/07/16, 08/11/16, 08/16/16 and 08/19/16. C. Record review of a facility Progress Note for R #10 dated, 08/16/16 at 4:22 am, revealed, Note: Resident found on floor, sustained a skin tear to left elbow, complaining of pain to both elbows and both hips. Contacted Power of Attorney (POA) and notified her that resident was to be sent out to ER, she stated that she preferred Name of Hospital. Non emergency transport notified. Fall was not witnessed, neuro checks started. D. On 08/24/16 at 8:30 am, during an interview with LPN #3 about R #10, the Charge Nurse stated, She had a fall on 08/16/19 and was having a problem bearing weight. We called the ambulance to come pick her up and take her to the ER. When asked about how she fell , the Charge Nurse stated, It was an unwitnessed fall. She was in her room and I don't know how she fell . She was also having an increase in pain so between that and the problem with weight bearing is the reason we sent her out. I really don't remember anything else. E. Record review of a Progress Note for R #10 dated 08/19/16 at 1:15 am, revealed, Note: Resident #10 had a(n) accident/incident/fall in past 72 hours, not witnessed. Residents room. Onset and Duration: Resident was found on the floor at 1930 (7:30 pm) after being put to bed. She had a laceration to the right side of her forehead. She was sent to the emergency room due to the laceration and the fact that she had just had hip surgery . R #10 is experiencing pain. Head .Sent to emergency room . F. On 08/24/16 at 1:50 pm, during an interview with Registered Nurse (RN) # 2 about R #10's fall on 08/19/16, the RN stated, We had put her to bed and instructed the Certified Nurse Aide (CNA)'s to check on her while working with other residents. Within 15 minutes she had gotten out of bed and fell . Bed was in low position, fall mat was in place. She had a laceration to the right side of her forehead, I cleansed it. I put a dressing in place just to keep the blood out of her eyes and called Emergency Medical Services (EMS). G. On 08/24/16 at 2:00 pm, during an interview with the CNE, the CNE stated that, there was not an investigation of these incidents. H. There is no evidence that the injury of unknown origin on 08/16/16, which resulted in a [MEDICAL CONDITION], was thoroughly investigated and was not reported to the State Survey Agency until 2 days after the fall. There is no evidence that the injury of unknown origin on 08/19/16, which resulted in a laceration to the right side of the forehead was thoroughly investigated and reported to the State Survey Agency. Findings for Resident # 23 I. Record Review of the facility face sheet for R #23 dated 06/28/16 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. J. Record review of the facility Event Tracking Log dated July 2016 revealed R #23 had an incident on 07/22/16 - Injury of unknown origin. 1. Record review of the Nursing Progress Notes dated 07/22/16 at 4:27 pm revealed, R #23 had an accident/incident/fall in past 72 hours. Large bruise of unknown origin noted to left arm. 2. Record review of the Hospice Progress notes dated 07/22/16 revealed large bruise to left forearm and smaller one to left inner arm, purple/bluish color. (Name of CNE) notified of bruising and patients statement that facility aide grabbed arm when getting resident up yesterday morning. 3. On 08/22/16 at 1:20 pm, during an interview with the CNE, the CNE advised there are only 2 event reports in the system for R #23. The CNE stated there was an event report for 07/23/16 and 07/28/16, but not one for 07/22/16. The CNE advised that the event on 07/22/16 was reported by the charge nurse. The CNE stated The Hospice Registered Nurse (HRN) reported (Name of R #23) to have some bruises to the left forearm. 4. On 08/25/16 at 11:21 am, during an interview with the HRN, the HRN stated that on 07/22/16 the HRN noticed bruising to the R #23's left forearm. The HRN stated that R #23 reported that a facility aide had grabbed R #23's arm the day before when getting the resident out of bed. The HRN advised that the incident was reported to the charge nurse upon finding. 5. On 08/25/16 at 2:05 pm, during an interview with Registered Nurse (RN) #1, RN #1 stated that the HRN was in the facility the morning of 07/22/16 and reported to RN #1 that R #23 had a bruise on the left forearm. The HRN reported to RN #1 that R #23 stated the girl who got me up the day before was rough with me. RN #1 advised that when RN #1 got the information on 07/22/16, it was reported to the CNE and to R #23's Power of Attorney (POA). K. Record review of the facility 5-Day Follow Up dated 07/27/16 revealed: 1. The Hospice Registered Nurse (HRN) reported that R #23 told the HRN that the aide who got R #23 up the day before was rough. 2. RN #1 was notified of the bruise by the Hospice aide. The aide reported that R #23 stated a guy grabbed and squeezed R #23. 3. R #23 reported to the CNE, that the incident on 07/22/16, could possibly have happened during a shower. There is no evidence that there was an investigation conducted for this incident. L. Record review of the facility Event Tracking Log dated July 2016 revealed R #23 had an incident on 07/23/16 - Fall; documented as not reportable. 1. Record review of the facility Event Summary Report dated 07/23/16 for R #23 revealed, Resident was found on the bathroom floor after being heard calling out for help. M. Record review of the Nursing Progress Notes R #23 dated 07/26/16 at 2:40 am revealed, This is a follow up note from the accident/incident/fall that occurred on 07/23/16. Complains of pain to right wrist. Decreased range of motion, swelling to area. Sent to ER for x-rays of wrist. N. Record review of a complaint dated 07/27/16 revealed that on 07/26/16 Emergency Medical Services (EMS) arrived at (Name of facility) for a non-emergent transfer, in reference to a resident with an injured wrist. The complaint states that R #23 was in a great deal of pain with an obvious injury to the right wrist. R #23 had fallen on Saturday, however the injury went unnoticed for 3 days before EMS was contacted for an emergency room visit. Assessment of R #23 revealed a large contusion over the top of the wrist and hand with R #23 reporting extreme pain upon palpitation and manipulation. The complainant further stated, Leaving this resident alone to deal with the pain without so much as a wrap is morally and and professionally reprehensible. 1. Record review of the Nursing Progress Notes for R #23 dated 07/26/16 at 10:40 am. Status of condition: deteriorated. Resident returned from the ER with [DIAGNOSES REDACTED]. 2. On 08/25/16 at 1:42 pm, during an interview with the CNE, the CNE advised that R #23's fall on 07/23/16 was on the weekend and the only information to go by is the report that was provided by the charge nurse. The CNE stated, To my knowledge, the resident was found in the bathroom and was unattended. When asked if there was a state report made for this incident, the CNE replied, No. FINDINGS FOR R #35 O. Record review for R #35 revealed, admission date of [DATE], with the following Diagnoses: [REDACTED]. 1. Record review of Nurse's note for R #35 dated 07/25/16 at 3:45 am revealed, Certified Nurse Aide (CNA) stated that he was assisting resident to the restroom and that R #35 fell from his wheelchair as they were exiting the restroom. The CNA stated that he was unable to catch him before he hit the floor. R #35 sustained lacerations to his face (between his eyebrows and on the bridge of the nose near his left eye) and was transported to (name of hospital) . R #35 is experiencing pain. 07/25/16 4:55 am, new orders obtained, continued observation stitches received to bridge of nose. 2. Record review of R #35's physician progress notes [REDACTED]. CT reviewed and discussed at length with patient family. CT shows re-demonstrated (re-fractured) and fractures of C1 (cervical vertebrae) and C2. Fracture through C2 involving the odontoid (tooth like projection from the second cervical vertebra on which the first vertebra pivots) tip which appears more displaced than previous examination. P. Record review of the facility's Incident log from 02/2016 - 08/15/2016 revealed that R #35's fall on 07/25/16 that resulted in the re-fracturing of R #35's neck was not listed as a reportable fall. Q. On 08/19/16 at 1:25 pm, during an interview with the Center Nurse Executive (CNE) (facility's DON), the CNE stated that it was not reported because we knew how R #35 fell , so it did not need to be investigated. We reported it when we were called and told about (name of resident) neck being re-fracture. Findings for Resident #50 R. Record review of the facility face sheet for Resident #50, dated 08/19/16, revealed an admission date of [DATE] with a readmission of 08/19/2016. [DIAGNOSES REDACTED]. 1. Record Review of the facility's Investigative report dated 08/06/16 revealed LPN #5 reported to the CNE that (Name of R #50 was at the nurses station with several other residents stating the facility is a joke and R #50 is not happy here. LPN #5 reports that LPN #5 told resident if resident is unhappy here she had the option to leave. Resident was upset and would not talk to LPN after. 2. On 08/26/16 at 8:05 am, during an interview with R #50, R # 50 stated that around 08/08/16 LPN #5 yelled at R # 50. R #50 stated I told another resident that this place was a joke. That particular day there was a lot of admits and the staff was running around trying to get things done that were not possible. LPN #5 turned around and told me, in front of everyone, that this place is not a prison and I could have my walking papers. I did complain to the CNE. 3. On 08/31/16 at 10:25 am, during an interview with the CNE, the CNE stated that LPN #5 came and self reported the incident to the CNE. The CNE advised that the resident came in 2 days later to report what had happened. When asked if this was reported and investigated, the CNE replied I spoke with the resident and felt it did not need to be reported because the resident expressed that it was handled to R #50's satisfaction. 4. On 09/01/16 at 9:57 am, during an interview with R #50, R #50 stated I have not really seen an end result and no, I am not completely satisfied. I don't feel anything was really done. S. There is no evidence this incident was thoroughly investigated or reported to the State Survey Agency. Findings for Resident #82 T. Record review of facility facesheet for R #82 dated 10/03/2011 revealed Resident #82 original admission was on 10/03/11 with current admission being on 09/05/16. Admission [DIAGNOSES REDACTED]. Generalized muscle weakness, Type 2 diabetes, Obesity, [MEDICAL CONDITION]. 1. Record review of Hospital Discharge Summary dated 08/12/16 revealed, .Medical Problems .[MEDICAL CONDITION] (bacterial infection involving the inner layers of the skin) and abscess (a collection of pus that has built up within the tissue), gangrene (reduced blood supply to the tissue which results in cell death) of lower extremity, Osteomylitis (infection and inflammation of the bone and bone marrow) due to secondary diabetes, Osteomylitis of the ankle and foot . Left diabetic foot, chronic non-healing [MEDICAL CONDITION] .Orthopedic surgeon has disarticulated his knee surgically (amputation of the leg below the knee). 2. Record review of Care Plans revision for R #82 dated 08/31/16 revealed, Focus: Risk for falls related to impaired mobility, weakness and recent leg amputation. Goal: No falls with major injury x 90 days. Interventions: There is no evidence of interventions for care of the stump or interventions for transfers or assist. 3. Review of Progress Note for R #82 dated 08/31/16 at 5:10 pm revealed, Late Entry: Note: CNA notified this nurse that the resident's incision was bleeding while turning him to clean up a loose stool that the resident had in bed. pt does not display much strength to assist himself. BKS ( below the knee stump)surgical incision was bleeding and needed direct pressure. the area is approximately. 9 cm long and the widest part in the middle is approximately. 1.5 cm. his bed linens were saturated in blood and dripping on the floor. 4 ABD's (Large surgical dressings) 5 gauze were used for pressure. bleeding would subside for approximately. 15-30 sec but with minimal movement the clot would break loose. stump [MEDICAL CONDITION] (abnormal accumulation of fluid below the skin) and has + 1 [MEDICAL CONDITION] (slight indentation, no perceptible swelling of the leg) noted. [MEDICATION NAME] (gauze bandage) and paper tape dressed around the circumference of the stump. Spontaneous bleeding would occur. direct pressure was again performed. This continued until the EMS arrived and they tried to reinforce the area with more gauze pads and re-tape it. condition reported to EMS and resident was transferred to Name of Hospital ER. patient attitude was in denial and abrupt, rude and accusing staff for his misfortune. Instructed resident that he could not safely be a 1:1 for transfers and that more staff was necessary to provide safer maneuvering. Resident agreed but argued. 4. On 09/09/16 at 9:18 am, during an interview with the Center Nurse Executive, (CNE) (facility title for DON) the CNE when asked if there was a investigation and report to the State Survey Agency regarding the injury to R #82's stump the CNE stated, No. U. There is no evidence that the fall on 08/31/16 was thoroughly investigated and reported to the State Survey Agency. Findings for Resident #149 V. Record review of facility face sheet for Resident #149, dated 08/01/16 revealed, an admission date of [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. 1. Record review of a incident report dated 08/14/16 revealed that R #149 reported that the facility night nurse was withholding her medication and becomes angry when R #149 inquires about it. 2. Record review of Physician orders [REDACTED]. 3. Record review of Physician orders [REDACTED]. W. On 08/30/16 at 11:52 am, during an interview with R #149, R #149 stated that prior to her fall on 08/12/16, the night nurse was 3.5 hours late in giving the resident the nightly pain medication. R #149 advised that the nurse came in and told R #149 You do not need it right now. R #149 could not remember the name of the nurse. 1. On 08/30/16 at 1:25 pm, during an interview with the CNE, the CNE provided the name of the nurse involved. When asked if this incident was investigated, the CNE replied The nurse was not investigated for allegations of abuse and neglect, but the investigation was done based on allegations of medication not being given. 2. On 08/30/16 at 2:30 p.m., during an interview with CNA #7, CNA #7 stated This nurse is a don't play games with me and I won't play games with you type. CNA #7 stated This nurse is verbally aggressive and [MEDICATION NAME] and in 4 years of employment, this agency is one of the worst I have seen. 3. On 08/30/16 at 2:40 p.m., during an interview with CNA #4, CNA #4 stated this nurse is very demanding to the aides but slow in the nurse's own workload. CNA #4 stated (Name of Nurse) has the attitude of I will get to it when I get to it, whether it is medications or wound care. There have been times when this nurse has not completed things until 3:00 am. Things that should have been done early on the shift. CNA #4 also advised that this nurse is verbally aggressive toward the residents. X. There is no evidence this incident was thoroughly investigated or reported properly to the State Agency. Findings for R #151 Y. Record review of the admission face sheet for R #151 revealed, an admitted d of 06/01/16 with the following Diagnoses: [REDACTED]. 1. Record review for a note on the Activity of Daily Living (ADL) Correction Form revealed, 05/20/16 10 pm - 6 am, Resident saying CNA's told her it was too late to be on the bedpan and left her in BM (Bowel Movement) for an hour. 2. On 08/18/16 at 10:45 am, during an interview with the Manager of Clinical Operations (MCO) (corporation Director of Nursing DON) and the facility Center Nurse Executive (CNE) (DON) stated that they were not aware of the ADL documentation. 3. On 08/19/16 at 11:00 am, during an interview with the MCO, the MCO stated that the facility was not aware of the 05/20/16 incident for R #151 until the surveyor brought it to their attention, and that they were going to start an investigation. 4. On 8/23/16 at 10:00 am, during an interview with the CNE, the CNE was asked for the investigation of the ADL incident. The CNE stated that she was not finished with her investigation. 5. On 08/25/16 at 3:22 pm, during an interview with Certified Nurse Aide (CNA) #14, CNA #14 stated that she was the person that wrote the statement on the ADL Correction Form, and stated that she followed up with the Nurse. Findings for R #162 Z. Record review of the Admission Record dated 07/23/16 revealed, that R #162 had a medical [DIAGNOSES REDACTED]. The resident has contractures (chronic loss of joint motion due to structural changes in non-bony tissues) of both arms and legs and relies on nutrition being supplied via (by) gastric tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach), and a tracheotomy tube (tube inserted into the trachea to gain control of the airway) is in place due to R#162's inability to open his/her airway in the throat. 1. On 08/23/16 at 3:30 pm, during an interview, Family Member (FM) #1 stated that in the early morning hours of 08/18/16 R #162 was awake crying and in pain. The nurse on duty called name of resident a big baby and stated that FM #1 should take him home. FM #1 stated that R #162 said that the nurse slammed the door and R #162 had to sit in his/her poop for 2 hours. FM #1 stated that he/she reported it the Admissions Director (AD). 2. On 08/26/16 at 11:30 am, in an interview the AD stated that on 08/22/16 (name of FM #1) reported that R #162 was screaming in pain during the early morning hours of 08/18/16 and had a bowel movement in his/her underwear. FM #1 stated that the nurse called him/her a big baby, slammed the room door and R #162 was left in fecal matter for two hours. The AD stated that the incident was verbally reported to the Assistant Director of Nursing (ADON). 3. On 08/26/16 at 12:00 pm, in an interview the ADON stated I was working the floor and training a new nurse the day that the AD told me about the incident. The ADON stated The incident was reported to me in passing and I assumed (name of AD) would report it to the higher powers. The ADON stated that he/she did not report it to anyone else. 4. On 08/26/16 at 1:00 pm, in an interview the Center Nurse Executive (CNE) stated that this was a terrible incident and an incident/grievance report should have been reported at the time of occurrence. I would expect something this egregious to have been reported immediately to someone in administration. When asked if this incident had been reported the CNE stated, No.

Based on record review and interview, the facility failed to ensure that care plans were reviewed, revised and/or updated and implemented, for 8 (#24, #108, #46, #82, #23, #34, #35, #166) of 8 (#24, #108, #46, #82, #23, #34, #35, #166) residents reviewed for accidents. If residents' care plans are not being revised with the most recent information then residents are likely to not receive the care and services that they need. The findings are: Findings for Resident #24 A. Record review of facility facesheet dated 03/16/16 revealed Resident # 24 was admitted to the facility on [DATE]. B. Admission [DIAGNOSES REDACTED]. C. Record review of the Facility Incident Report dated 07/14/16 revealed, Fall -resident was in her room and she stated tripped over her roommates oxygen concentrator (machine that supplies oxygen) define; Resident did bump her head on dresser; Resident is able to stand and ambulate; states head is hurting does have a small raised area; Tylenol Extra Strength 2 given; D. Record review of Fall Care a plan dated 03/16/16 revealed, Fall on 07/14/16 bump to right side of head. There is no indication of a new Goal or new Interventions. E. On 08/24/16 at 1:40 pm, during an interview with the Alzheimer's Unit Charge Nurse the Charge Nurse stated, Heard the resident scream, she was on her roommates side of the room on the floor between the dresser and the bed. She had a bump to the right side of her head with no bruising. Stated it was a little sore. I gave her 2 Tylenol ES (extra strength) and that seemed to help. I observed no other injuries. Findings for Resident #108 F. Record review of facility facesheet for R#108 dated 05/09/14 revealed Resident #108 was admitted to the facility on [DATE]. G. Admission [DIAGNOSES REDACTED]. H. Assessments for R#108 include, Nursing assessment, Recreation Quarterly, Social services assessment, Nutritional assessment, Pain assessment, Staff assessment of Mental status and resident mood, Elopement evaluation. I. Care Plans for R#108 dated 06/02/16 revealed Problems, measurable Goals and Approaches include, Assistance with Activities of Daily Living (ADL's), Behaviors, Risk of elopement, Decline in cognitive function, Impaired communication, Risk of falls, Bowel incontinence, Exhibits mood symptoms, Use of anoxioltics (medication to reduce anxiety) and anti-depressants (medication to help with depression), Risk for bruising/skin tears, Risk of skin breakdown, Incontinent of urine. J. Record review of the Facility Event Tracking Log (facility name for Incident Report Log) revealed, Resident # 108 had falls on: 02/19/16, 03/28/16, 04/11/16, 04/14/16, 04/22/16, 04/27/16, 05/02/16, and 07/18/16. K. Record review of RMS-Event Summary Report (facility name for Incident Report) revealed: Fall . 02/10/16 .Resident was found on the floor in the Dining Room. The fall was unwitnessed, she was helped onto a chair and was assessed. She denies pain and no bruise was found on head and other parts of the body. Neuro check was started. Fall .03/28/16 .Found sitting in floor beside bed. No signs and symptoms of distress noted. Denies pain. Laughing when Certified Nurse Aide (CNA)'s entered room. Fall .04/11/6 .Found on the floor next to magazine rack, small scratch to left elbow area. denies pain. Fall .04/14/16 .resident seen putting herself closer to edge of wheelchair and falling onto the floor landing on her buttocks. Fall .04/22/16 .Resident attempting to get out of bed. Resident lowered onto floor. Fall .04/27/16 .Resident was attempting to ambulate and sat on floor; did not hit head; no injury noted; able to ambulate with staff assist. Fall .05/02/16 .resident found laying on the floor in front of the magazine rack; able to move all extremities and stand without difficulty; neuro checks started. Fall .07/18/16 .Resident found next to her bed. No signs and symptoms of injury or pain. L. Records review of Progress Notes for R#108 dated 02/19/16 at 5:33 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, not witnessed. DINNING ROOM ,SITTING TRYING TO GET UP ONSET AND DURATION: RESIDENT WAS SITTING ON A CHAIR AND FALL ON HER BUTTOCKS AS SHE WAS TRYING TO STAND UP. THERE WAS NO INJURY FOUND ON HER AND THE FALL WAS UNWITNESSED . Resident #108 is not demonstrating symptoms of pain. M. Record review of Progress noted for R#108 dated, 03/28/16 at 12:00 am, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, not witnessed. Residents room laying in bed ONSET AND DURATION: Found lying on floor beside bed. Laughing when CNAs entered room. No s/s (signs/symptoms) of distress noted . Resident #108 is not demonstrating symptoms of pain. N. Record review of Progress Notes for R#108 dated 04/11/16 at 4:04 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, not witnessed. in dinning room ONSET AND DURATION: found resident on floor next to magazine rack, small scratch to left elbow noted, minimum bleeding noted only upon cleaning, covered and dry .Resident #108 is not demonstrating symptoms of pain. O. Record review of Progress Notes for R#108 dated, 04/14/16 at 10:15 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours. Dining room ONSET AND DURATION: Resident has long history of poor safety awareness Resident #108 is not demonstrating symptoms of pain. P. Record review of Progress Note for R#108 dated, 04/22/16 at 6:40 am, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, witnessed. Residents room, attempting to get out of bed. ONSET AND DURATION: Resident assisted back onto bed. No s/s of injury .Resident #108 is not demonstrating symptoms of pain. Q. Record review of Progress Note for R#108 dated, 04/27/16 at 2:21 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, witnessed. getting up from w/c (wheelchair) in dining room ONSET AND DURATION: res. was attempting to stand up from w/c; res. then sat on the floor with no injury noted; able to ambulate with staff assist .Resident #108 is not demonstrating symptoms of pain. R. Record review of Progress Note for R#108 dated, 05/02/16 at 2:30 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, not witnessed. dining room ONSET AND DURATION: res. was ambulating unattended and sat on floor .Resident #108 is not demonstrating symptoms of pain. S. Record review of Progress Note for R#108 dated, 07/18/16 at 8:15 pm, revealed, Note: Resident #108 had a(n) accident/incident/fall in past 72 hours, not witnessed. Resident found next to her bed, getting out of bed ONSET AND DURATION: Resident found next to her bed. Residents bed was in the lowest position possible. No s/s of injury and resident is showing no s/s of pain .Resident #108 is not demonstrating symptoms of pain. T. Record review of Fall Care Plans for R#108 with dates of, 06/04/15 with multiple revision dates, 04/11/16, 04/14/16, revisions on 04/22/16, 04/27/16, 04/29/16, 05/02/16 and new care plan for 07/18/16. There is no evidence of a care plan revision for the fall on 02/19/16 or the fall on 03/28/16. U. Observation of Resident #108 from 08/24/16 at 1:00 pm thru 2:35 pm revealed a pleasantly confused, clean, neat appropriately dressed resident. Resident was participating in activities to the level of her disease process. No odors were noted. V. On 08/25/16 at 9:40 am, during an interview with the Alzheimer's Care Unit Charge Nurse, the Charge Nurse stated, Overall I feel it is just a lack of safety awareness r/t (related to) severe dementia. She just wants to get up out of anything wheelchair (w/c)/bed/chair etc., wants to walk. She doesn't understand she is not capable of doing these things without assistance. Safety measures we have put in place are, being sure the w/c brakes are locked, toilet her at least when she gets up, after meals and as needed. Low bed is in place with a scoop mattress and we do at least a one person assist with any movements to or from bed, w/c or chair etc. W. On 08/25/16 at 10:05 am during an interview with Alzheimer's Care Unit CNA the CNA stated that, we toilet her every 2 hours, Assist with all ADL's. She has a low bed with fall mat. We assist her in and out of bed and her w/c. Findings for Resident #46 X. Record review of the facility facesheet for R#46 dated, 10/01/2010 revealed Resident #46 original admitted to the facility was 04/28/2010, with the current admission date of [DATE]. Admission [DIAGNOSES REDACTED]. Y. Record review of Facility Event Tracking Log (facility name for Incident Report Log) revealed the following falls for Resident # 46: Fall .02/21/16 .Patient fall on bottom when getting off toilet. No injuries to report. Neuro's started. Will continue to monitor. Fall .03/19/16 .Found resident on floor on the left side of toilet under guard rails on bottom. Fall .03/27/16 .Resident was found on floor next to bed. States she was trying to transfers self to wheelchair and legs gave out. Able to move all extremities. Denies pain or discomfort. No bruising noted. Assisted resident up to chair. Fall .04/27/16 .Resident was attempting to transfer self to shower chair. fell on floor in shower room landing on right side of body. No redness or swelling noted. Fall .05/11/16 .Resident fell during toilet transfer on right side of toilet no injury or complaint of pain. Not witnessed so neuro's were started. Fall .05/18/16 .Resident attempted to transfer to toilet by self. Assessment of resident revealed ROM (range of motion) intact. No redness or bruising, no c/o pain or discomfort, no s/s (signs/symptoms) of acute distress. Will toilet resident every 2 hours. Fall .05/29/16 .Resident was found sitting on the floor between her bed and her wheelchair. Resident states she was attempting to transfer self. A large knot was noted to the right side of her forehead. Neuro checks were done. Head to toe assessment within normal limits. V/S are stable. Fall 06/29/16 .Resident attempting to transfer self to w/c from bed. Found resident on right side on floor with w/c on top of her. Resident stated she transferred herself yesterday and thought she could do it again. Reminded resident to utilize call light for assistance and to lock tires on w/c for transfers. Fall .08/06/16 .The resident found on floor in dining room. States she was pushing another residents wheelchair. Denies pain. No injury noted. Neuro checks started. Care plan up-dated. Daughter (POA) and MD notified. Will continue to monitor. Fall .08/08/16 .Summoned to bathroom of resident, found resident on floor up against wall. No redness or bruising noted, no s/s (signs/symptoms) of pain or distress, did not verbalize any complaints of pain. Will monitor neuro status and vital signs. Z. Record review of Fall Care Plan for R#46 : Fall dated 02/21/16 - there is no evidence of the fall on the care plan nor any up-date. Fall on 03/19/16 there is no indication of the fall in the care plan but a intervention with that date revealed, Monitor resident for un-met needs. Fall dated 03/27/16 - there is no evidence of the fall in the care plans and no evidence of new interventions. Fall dated 04/27/16 - there is no evidence of the fall in the care plan and no evidence of new interventions. Fall on 05/11/16 - Fall is noted on the care plan with a new goal of remain free from falls x 14 days. There is no evidence of a new intervention. Fall 05/18/16 - There is no evidence of the fall on the care plan and no evidence of any new intervention. Fall 05/29/16 - There is no evidence of the fall on the care plan and no evidence of any new intervention. Fall 06/29/16 - There is no evidence of the fall on the care plan and no evidence of any new intervention. Fall 008/06/16 - There is no evidence of the fall on the care plan. There is a new intervention dated 08/06/16 - Remind the resident to not push other resident wheelchair. Fall - 08/08/16 - There is no evidence of the fall on the care plan and no evidence of any new intervention. AA. Record review of Physicians Orders for R#46 revealed the following ordered medications, [MEDICATION NAME] Proxetil - Antibiotic, [MEDICATION NAME] - an anticonvulsant - a benzodiazepine, [MEDICATION NAME] Sodium - a laxative, Milk of Magnesia - a laxative, [MEDICATION NAME] - non--narcotic [MEDICATION NAME] - a [MEDICATION NAME] - a antidepressant, [MEDICATION NAME] - a vitamin, [MEDICATION NAME] - a antidepressant, [MEDICATION NAME] tablet - a [MEDICAL CONDITION], Memantine - a psychotherapeutic and neurological medication, [MEDICATION NAME] - a antacid, [MEDICATION NAME] - a [MEDICAL CONDITION] agent, [MEDICATION NAME] - a [MEDICATION NAME] - a [MEDICATION NAME]/[MEDICAL CONDITION], [MEDICATION NAME] - a cough/cold/allergy medication, Aspirin - a non-narcotic [MEDICATION NAME]. There is no evidence the resident receives any medications that contain an opiate. BB. Record review of Progress Note for R#46 dated, 02/21/16 at 9:40 am, revealed, Note: Patient had a(n) accident/incident/fall at 9 am not witnessed. In bathroom transferring to toilet Patient was found sitting on floor by toilet, she stated she fell while trying to sit on toilet. She denied hitting her head, and denied any pain. No injuries noted. Patient is not demonstrating symptoms of pain. CC. Record review of Progress Note for R#46 dated 03/19/16 at 7:00 am, revealed, Late Entry: Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. Residents room ONSET AND DURATION: Resident was found on floor by CNA. Resident states she was trying to transfer self to toilet. No injuries noted .Resident #46 is not demonstrating symptoms of pain. DD. Record review of Progress Note for R#46 revealed, There is no evidence of any Progress Note for the fall on 03/27/16. EE. Record review of Progress Note for R#46 dated, 04/28/16 at 5:24 pm, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. shower room, attempting to transfer self ONSET AND DURATION: resident attempted to transfer self to shower chair, she fell on her right side. no injury. Resident #46 is not demonstrating symptoms of pain. FF. Record review of Progress Note for R#46 dated, 05/11/16 at 2:59 pm, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. residents bathroom and transferring to toilet ONSET AND DURATION: toileting herself-fell on floor to the right of the toilet. up against the wall when she was found. Range of Motion (ROM) (range ones extremities can move) intact, no complaints of pain or discomfort. will continue to monitor for delayed injury .Resident #46 is not demonstrating symptoms of pain. GG. Record review of Progress Note for R#46 dated 05/19/16 at 6:41 pm, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. residents bathroom, attempting toilet self ONSET AND DURATION: attempting to toilet self, no complaints of pain or discomfort. no s/s of acute distress. no redness or bruising present. will monitor for delayed symptoms Resident #46 is not demonstrating symptoms of pain. HH. Record review of Progress Note for R#46 dated, 05/29/16 at 11:45 am, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours, not witnessed. Residents room ONSET AND DURATION: Resident was found on floor by CNA. States was transferring to w/c from bed. Bed was not in low position and was wearing plain socks .Resident #46 is not demonstrating symptoms of pain. II. Record review of Progress Note for R#46 dated, 06/29/16 at 2:46 pm, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. room and attempting to transfer to bed ONSET AND DURATION: resident attempting to transfer self to w/c from bed. found resident on right side on floor with w/c on top of her. resident stated she transferred herself yesterday and thought she could do it again. reminded resident to utilize call light for assistance and to lock tires on w/c for transfers . Resident #46 is not demonstrating symptoms of pain. JJ. Record review of Progress Note for R#46 dated, 08/06/16 at 7:00 am, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. The dining room ONSET AND DURATION: The resident Found on floor. She stated she was pushing another resident's wheelchair. The resident denies pain. NO change in LOC .Resident #46 is not demonstrating symptoms of pain. KK. Record review of Progress Note for R#46 dated, 08/09/16 at 4:23 pm, revealed, Note: Resident #46 had a(n) accident/incident/fall in past 72 hours. residents bathroom, toileting ONSET AND DURATION: summoned to bathroom of resident, found resident on floor up against wall. no redness or bruising noted, no s/s of pain or distress. did not verbalize any complaints of pain. will monitor neuro status and vital signs . Resident #46 is not demonstrating symptoms of pain. LL. Observation of Resident #46 on 08/26/16 at 8:00 am to 8:30 am and 08/29/16 from 8:15 am thru 8:45 am, revealed a moderately confused resident. The resident does self propel via w/c throughout the facility. Resident # 46 is clean, neat appropriately dressed and without odors. MM. On 08/29/16 at 9:00 am, during an interview with the South Hall Charge Nurse LPN #2 the Charge Nurse stated, I've only been on this side for a week and a half so I have not been aware she had had any falls. NN. On 08/26/16 at 9:05 am during an interview with South Hall CNA #1 stated, We go in as she is getting up to be sure she doesn't need the bathroom. Get her dressed and bring her out for the nurse and to breakfast. Sometime she does take herself back to her room to use the bathroom and transfers herself without assistance. This is when she has most of her falls. She is on a toileting plan so we are checking on her frequently. However she still self transfers without assistance. We do our best to prevent her from doing that but at times it's just not possible to keep up with her. OO. On 08/29/16 at 11:00 am, during an Interview with the Director of Nursing (DON) the DON stated, The CNA called and stated she had a change of mental status. Vital Signs (VS) were taken, her pupils were pinpoint so we called EMS to transport her to ER for evaluation. This was just before breakfast. She had had no medications that morning. Main reason we sent her was this was a complete change in mental status as to what she had been when the CNA's got her up and dressed about an hour before. We got a call from Name of Hospital the next day that she had tested positive for opiates. Our investigation revealed she was on no ordered medication that contained an opiate. We also investigated to see if she may have accidentally received her roommates [MEDICATION NAME]. We concluded that she did not receive her roommates [MEDICATION NAME]. Findings for Resident #82 PP. Record review of facility facesheet for R#82 dated 10/03/2011 revealed Resident #82 original admission was on 10/03/11 with current admission being on 09/05/16. QQ. Admission [DIAGNOSES REDACTED]. RR. Admission assessments for R#82 include, Admission nursing assessment, Pain assessment, Skin check, Medication self administration - evaluation, Braden (a scale used in the prediction of pressure ulcers) scale, AIMS (Abnormal Involuntary Muscle score) , Elopement risk. SS. Record review of Care Plans revision for R#82 dated 08/31/16 revealed, Focus: Risk for falls related to impaired mobility, weakness and recent leg amputation. Goal: No falls with major injury x 90 days. Interventions: There is no evidence in the care plan of interventions for care of the stump or interventions for transfers or assist. 08/31/16 Assistance with ADL's, measurable Goals and Interventions. 01/11/16 Diabetes, with measurable Goals and Interventions. 08/31/16 Potential for complications i.e. infection, non-healing related to knee disarticulation (amputation of the leg below the knee) and surgical wound stump. Goal: Incision site to stump will heal without complications x 30 days. Interventions: there is no evidence of interventions specific to the care of the stump. TT. Record review of Progress Note for R#82 dated, 06/18/16 at 6:39 pm, revealed, Note: Dressings to both legs were changed. foul odor noted to left dressing. UU. Record review of Progress Notes for R#82 dated, 06/26/16 at 3:37 pm, revealed, Note: Increased amount of yellow drainage from both legs was present, but more so from the left. Multiple open area were noted to leg. Dressing changes completed and wrapped with [MEDICATION NAME] (a surgical dressing). VV. Record review of Progress Notes for R#82 dated, 08/03/16 at 3:00 pm, revealed, Late Entry: Note: Resident seen by Name of Certified Nurse Practioner, Certified Wound Ostomy Nurse. For new wound to left foot. Diabetic/pressure wound. Wound bed covered with necrotic (premature death of cells) tissue with odorous serosangranous (fluid containing serum and blood) drainage. Referral to be sent to see Name of Podiatrist for assessment. New treatment orders received for Santyl (an ointment to heal wounds), [MEDICATION NAME] (an absorbent wound dressing), [MEDICATION NAME], and ace wrap. Change daily and PRN. WW. Record review of Progress Note (Social Services) for R#82 dated 08/09/16 at 12:58 pm revealed, Note: Contacted residents mother at the request of admissions and DON regarding her decision to have him return back to Name of Facility or have him go elsewhere. Spoke with his mother, Name of POA, regarding what the hospital was telling us about him not returning to Name of Facility. She said that she had not decided because Name of Resident was going to be needing more care now because he was in surgery, as we spoke, having his foot amputated below the knee. She blames the care that he received here and the neglect he was subjected to. She wants to come and meet with the nurses and the doctors who cared for him before to ensure that he receive the proper care that he is going to need if he returns. XX. Record review of Progress Notes for R#82 dated, 08/12/16 at 7:08 pm revealed, Note: Resident #82 admitted /readmitted to 111-B. Arrived by wheelchair van and wheelchair. Information upon admission obtained from patient chart . Reason for admission is post-surgery . A Braden (Scale for predicting pressure ulcer risk)score of 19.0 and Fall Risk score of 6.0 were obtained as part of this assessment. Call bell placed within reach. Physician notified/orders verified: Yes. YY. Record review of Progress Notes for R#82 dated 08/30/16 at 5:56 pm revealed, Skilled Services: Skilled Nursing; Therapy; Teaching/Training; Management/Evaluation; Nrsg Observation: Continues to work with therapy to reach set goals. Observations: Resident appt with ortho, new orders received Action/nursing interventions : Removed staples, follow up (F/U) with Name of Medical Doctor (MD) r/t right leg circulation and stent placing Resident's response: Tolerated well Skilled Services: Skilled Nursing; Therapy; Teaching/Training; Management/Evaluation; Nrsg Observation: Continues to work with therapy to reach set goals. ZZ. Review of Progress Note for R#82 dated 08/31/16 at 5:10 pm revealed, Late Entry: Note: CNA notified this nurse that the resident's incision was bleeding while turning him to clean up a loose stool that the resident had in bed. pt does not display much strength to assist himself. BKS (below the knee stump)surgical incision was bleeding and needed direct pressure. the area is approximately. 9 cm long and the widest part in the middle is approximately. 1.5 cm. his bed linens were saturated in blood and dripping on the floor. 4 ABD's (Large surgical dressings) 5 gauze were used for pressure. bleeding would subside for approximately. 15-30 sec but with minimal movement the clot would break loose. stump [MEDICAL CONDITION] (abnormal accumulation of fluid below the skin) and has + 1 [MEDICAL CONDITION] (slight indentation, no perceptible swelling of the leg) noted. [MEDICATION NAME] and paper tape dressed around the circumference of the stump. Spontaneous bleeding would occur. direct pressure was again performed. This continued until the EMS arrived and they tried to reinforce the area with more gauze pads and re-tape it. condition reported to EMS and resident was transferred to Name of Hospital ER. patient attitude was in denial and abrupt, rude and accusing staff for his misfortune. Instructed resident that he could not safely be a 1:1 for transfers and that more staff was necessary to provide safer maneuvering. Resident agreed but argued. 1. Record review of Progress Note - Change In Condition - Skin, for R#82 dated 08/31/16 at 7:30 pm revealed, Note: Resident #82 has a new onset/change in skin integrity as evidenced by incision. Location: BKA ([MEDICAL CONDITION]) dehiscence (wound rupture along a surgical incision) of surgical incision. experiencing pain. 5/10 when performing direct pressure to area, otherwise, no pain. Physician notified of change in condition Responsible party notified of change in condition. Interventions: New orders obtained Send to Name of Hospital ER to evaluate surgical incision. AAA. There was no evidence that this fall was investigated to determine cause nor was it reported to the State Agency. BBB. Record review of Progress Notes for R#82 dated 08/31/16 at 10:50 am, revealed, Note: Resident #82 has a new onset/change in skin integrity as evidenced by skin tear. Location: Left Top Hand. not demonstrating symptoms of pain. NA There has been no medication change in the past week. Physician notified of change in condition Responsible party notified of change in condition. Interventions: New orders obtained CLEANSE, STERI STRIPS, MONITOR UTR (Until resolved). CCC. Observation of Resident # 82 09/08/16 at 9:00 am, 09/09/16 at 1:00 pm and 09/13/16 at 11:00 am revealed a resident that is appropriately dressed, in a wheelchair, stump covered by an ace wrap and the residents pants. Resident is appropriate for age, clean neat and without odors. DDD. On 09/09/16 at 9:18 am, during an interview with the Director of Nursing (DON) the DON when asked who did weekly skin checks the DON stated, The nurses assigned to a hall do the skin checks. When asked about if there is a weekly skin check form the DON stated, I believe so, yes. EEE. On 09/09/16 at 12:17 pm, during an interview with RN #1 the RN stated that, We are wrapping his legs from toes to knees. I look at everything when I'm doing their skin checks. I did not find anything on the left foot either a diabetic or a pressure ulcer. On his skin check on 07/31/16 I did not see anything on the left foot. I'm unaware of how the ulcer occurred. FFF. On 09/09/16 at 1:35 pm during an interview with ADON the ADON stated that, the ulcer was found by, Name of RN no longer working at the facility, on the evening of 08/02/16. She called me at home and I advised her to cover it and keep it clean. GGG. On 09/09/16 at 1:45 pm, during an interview with the DON the DON stated that, Only thing I can say is that when I did the skin check on 07/26/16 I did not see a ulcer on the residents left foot. HHH. On 09/12/16 at 1:33 pm during a phone interview with the Orthopedic Surgeon, the surgeon stated. The residents fractured toe could have been spontaneous with his diabetic Arthropathy (disease of the joint). As to the ulcer on his left foot that could not have occurred in 2-3 days. When the resident came into the office, even before I unwrapped the wound, I knew he had gangrene (reduced blood supply to the affected tissue which results in cell death) because I could smell it. The gangrene (reduced blood supply to the tissue which results in cell death) could have taken months to manifest itself. With the residents chronic conditions all these things may have taken months to years to present. His leg wounds could have contributed to his issues. All of these things led to my decision to disarticulate (separation of two bones at their joint) the left leg. Findings for Resident # 23 III. Record review of facility face sheet for Resident #23, dated 06/28/16, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. JJJ. Record review of the Initial Nursing Assessment, effective date 06/14/16, revealed Did the resident have a fall at any time in the last month prior to admission/entry or reentry? This was answered No. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? This was answered Not assessed. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry reentry? This was answered Not assessed. KKK. Record Review of the Minimum Data Set ((MDS) dated [DATE] revealed Did the resident have a fall at any time in the last month prior to admission/entry or reentry? This was answered No. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? This was answered Not assessed. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry reentry? This was answered Not assessed. LLL. Record Review of the Functional Status section of the MDS dated [DATE] revealed R #23 was coded a 2 which interprets a one person physical assist. MMM. Record review of the Care Plan dated 06/15/16 with goals and interventions revealed R #23 is at risk for falls related to impaired mobility, cognitive impairment and decreased safety awareness and is at risk for decreased ability to perform Activities of Daily Living (ADL)s. There is no evidence that R #23 was care planned as a one person physical assist. NNN. Record review of the facility Event Summary Report dated 07/23/16 revealed Resident was found on the bathroom floor after being heard calling out for help. Resident stated was trying to get back into her wheelchair after using the bathroom but missed the chair. OOO. Record review of the facility Event Summary Report dated 07/28/16 revealed CNA reported resident was on floor in resident room. Upon assessment, resident was unable to state how resident ended up on the floor. PPP. Record review of the Nursing Progress notes dated 07/22/16 at 16:27 p.m. revealed R #23 had an accident/incident/fall in past 72 hours. Large bruise of unknown origin noted to left arm. Facial color is normal to ethnicity. Level of consciousness is confused. Oriented to person. Skin is cool, not demonstrating symptoms of pain. Physician notified of change of condition. 1. Record review of the Nursing progress notes dated 07/23/16 at 18:40 p.m. revealed a late entry created on 07/26/16 at 18:52 p.m. Note: (Name of R #23) had an accident/incident/fall in past 72 hours. Resident bathroom. 2. Record review of the Nursing Progress Notes dated 07/26/16 at 02:40 a.m. revealed a late entry created on 07/26/16 at 19:12 p.m. This is a follow up note from the accident/incident/fall in past 72 hours that occurred on 07/23/16

Based on record review, and interview, the facility failed to provide monitoring and treatment to promote healing and prevent worsening of pressure ulcers (PU), for 2 (R #60 and #166) of 4 (R #60, #23, #166, and #107) residents reviewed for pressure ulcers. R #60's Stage IV (very deep wound, reaching into muscle and bone and causing extensive damage to deeper tissues, tendons, and joints may occur) pressure ulcer increased in size and became infected. R #166 was admitted to the facility with 5, stage 2 (partial-thickness skin loss but no deeper than the dermis (second layer of the skin), pressure ulcers and did not receive treatment for [REDACTED]. R #166 was transferred to the local hospital and then transferred to another hospital for higher level of wound care [MEDICAL CONDITION] (life-threatening condition that arises when the body's response to infection injures its own tissues and organs). This deficient practice likely contributed to the residents acute illness, through infection, pain, and affected mental status. The findings are: FINDINGS FOR R#60 A. Record review of the admission [DIAGNOSES REDACTED].#60 was admitted with a medical [DIAGNOSES REDACTED]. B. physician progress notes [REDACTED]. lives in soil and water, dangerous to those who have weak immune systems), 3) Escherichia coli (a bacteria that is found in fecal matter that can cause serious disease outside of the human body). C. Record review of Wound Nurse Specialist (WNS) and the Center Nurse Executive (CNE) (same as a Director of Nursing DON), measurements for the stage 4 pressure ulcer are as follows: 1) 06/08/16 (admitted ); length 6.5 centimeters (cm); width 5.6 cm, depth 1.4 cm. 2) 07/14/16; Length: 6.5 centimeters (cm); width 4.5 cm; depth 2.5 cm. 3) 08/02/16; Length: 7.5 cm; width 5.0 cm; depth 3.0 cm. 4) 09/08/16; Length; 8.5 cm; width 7.0 cm; depth 3.0 cm. D. Record review of the Progress Notes dated 08/18/16 - 09/08/16 revealed, that on 08/21/16 the stage 4 wound to the coccyx had 30% slough (mass of dead tissue) and had a strong odor. E. Record review of the physician's orders [REDACTED]. F. On 09/15/16 at 3:47 pm, in an interview Licensed Practical Nurse (LPN) #7 stated that the wound had gotten worse and that the physician changed the treatment order. A culture was completed and 3 strains of organisms were discovered. G. On 09/15/16 at 4:00 pm, in an interview the CNE stated that the wound had gotten worse, had an odor and cultures were done. The CNE stated that he/she were the one who did the measurements when R #60 was first admitted to the facility on [DATE]. FINDINGS FOR R #166 H. Record review of the Preliminary Report dated 09/01/16 from the out of town hospital revealed, (Name of patient) presented to the local hospital on [DATE] for worsening pressure ulcers of her buttocks bilaterally (on both sides). (Name of patient) stated that she began to feel worsening pain of her buttocks over the last month. I. Record review of the admission face sheet for R #166 revealed, admission date of [DATE], with the following Diagnoses: [REDACTED]. J. Record review of the Nursing Admission Assessment dated 08/05/16, revealed, R #166 had a PU to right hip, right buttock, 2 PUs to the left buttock, and a PU to the left hip. R #166's record did not have any admission documentation for the size of the 5 PUs. K. Record review of R #166's care plan dated 08/05/16 revealed, no plan to address the care of the 5 PU's. L. Record review of the admission physician orders [REDACTED].#166 revealed, no order for the treatment of [REDACTED]. M. Record review of the Treatment Administration Record dated 08/05/16 - 08/31/16 for R #166 revealed, no indication of a treatment for [REDACTED]. This was 7 days after admission. 1. Record review revealed, a physician order [REDACTED]. An order dated 08/13/16 for the left lower buttocks, cleanse with wound cleanser, pat dry cover with Exuderm (dressing that creates a moist environment and is used in difficult body contours) - daily and PRN. 2. Record review of the treatment sheet for R #166 revealed no documentation to show the wound care was completed as follows: a. Right buttocks, and hip - No documentation for 08/15/16, 08/16/16, 08/17/16, 08/19/16, 08/20/16, and 08/21/16. b. Left hip, lower buttocks, and upper buttocks - No documentation for 08/15/16, 0816/15, 08/17/16, and 08/21/16. N. Record review for R #166 revealed, there was only one Skin Integrity Report dated 08/18/16, completed with measurements, during the 3 weeks and 4 days R #166 was in the facility. The PUs measurements were: left lower buttock - 1.8 centimeters (cm's) in length by 1.4 cm's wide, left hip - 3.6 cm's in length by 3.4 cm's wide, left buttock 11 cm's in length by 8.6 cm's wide, right hip - 4 cm's in length by 3.8 wide cm's, and right buttock 4 cm's in length by 2.6 cm's wide. The skin integrity report is to be completed weekly as noted on the form. O. Record review of the Preliminary Report from the out of town hospital revealed, (Name of patient) presented to the local hospital on [DATE] for [MEDICAL CONDITION] (syndrome of overall [MEDICAL CONDITION]) and worsening pressure ulcers of her buttocks bilaterally (on both sides). (Name of patient) stated that she began to feel worsening pain of her buttocks over the last month. P. On 09/13/16 at 2:22 pm, during an interview with the CNE, the CNE stated I do not know why the treatments were not signed out. The CNE concurred that there were no orders for the treatment of [REDACTED]. The CNE further stated that the facility has a wound care protocol and it should have been implemented for the stage 2 PUs on admission. Q. On 09/13/16 at 11:15 am, during an interview with the Assistant Director of Nursing (ADON), the ADON stated that she could not find the skin integrity reports for 08/11/16 and 08/25/16.

Based on record review, observation and interview, the facility failed to provide adequate supervision during activities when food is served for 1 (#1) of 4 (#1, 2, 3, 4) residents that were at risk for swallowing difficulties. This deficient practice likely resulted in Resident #1 choking, as evidenced by, crying, face turning red, gagging, drooling, coughing for several minutes and becoming very emotional, after receiving a strawberry(s), that was not pureed. The findings are: A. Record review of facility policy and procedure with a revision date of 07/01/14 titled, Recreation Services Policies and Procedures - 2.6 Supporting Dietary Compliance - (name of cooperation). Policy: Residents/patients will be able to participate in programs where food is served. Purpose: To ensure that Recreation staff are aware of resident/patient diets. Process: 1. Review resident's/patient's diet status to determine dietary restrictions. 2. The list of resident's/patient's, diet, and food behaviors must be available to staff serving food. 3. Recreation staff will request nursing support for programs where food is being served. 4. Recreation staff must receive training concerning: 4.1 Proper food handling at recreation programs, 4.2 Thickened liquids and diet consistency, 4.3 Emergency procedures, and 4.4 Proper methods of assisting or feeding resident's/patient's per state regulations. 5. All resident's/patient's are offered choices of food to eat during activities where food is being served and their rights are respected in making this choice. B. Record Review of the medical record for R #1 indicated a Speech Therapist diet order for R #1 dated, 01/22/16, Diet clarification order: downgrade to dysphasia (medical term for the symptom of difficulty in swallowing) puree solids with thin liquids . C. Record Review of a Physician's diet order for R #1 dated, 04/15/16, revealed, . Dysphasia puree texture. D. Record review of facility Change in Condition (Report) dated 05/11/16 at 5:38 pm, revealed, Note: (Name of resident #1) had a (n) .incident . in past 72 hours. Physical therapy room, eating strawberries. Onset and Duration: swallowing halved strawberries during an activity, in physical therapy room when choking began, speech therapist assisted resident to cough it out. Resident very emotional. Staff calmed resident . E. On 05/18/16 at 12:56 pm, during an interview with Speech Language Pathologist (SLP), the SLP stated, When I got to (Name of Resident #1), R#1 was drooling, gagging, very red faced and very emotional. I assessed her airway, she could speak and determined her airway was not blocked. I had her keep coughing for about 10 minutes to be sure there was nothing left to block her airway. F. On 05/18/16 at 1:05 pm, during an interview with Activities Aide #1 (AA #1) AA #1 stated, The strawberries were in a bucket on the dietary table toward the back of the dining/activities room and I don't know how Resident #1 got the strawberry. Prior to this incident we were not receiving a list of resident's diets so we had no way of knowing what their diets were. G. On 05/18/16 at 2:00 pm, during an interview with (Center Nurse Executive) (CNE) (facility title for the Director of Nursing) the CNE stated, We were having a Fiesta Day. During the afternoon activity we served non-alcoholic margaritas. I was notified of the choking incident due to a strawberry in the non-alcoholic margarita. H. On 05/20/16 at 9:05 am, during an interview with AA #1, when asked about training for resident diets specific to the Activities Department, AA #1 stated, We have not had any training of that type for at least 2 years, maybe longer. When asked how the activities staff ensures the safety of residents during activities AA #1 stated, Normally the only staff that is in activities, regardless of the number of residents present, is the activity aide. Usually it is just one aide. We do the best we can to keep an eye on everyone but it's hard. I. On 05/20/16 at 10:15 am, during an interview with the Dietary Manager (DM), when asked about the last training on diets for activity staff the DM stated, I have not done any training with the Activity staff on diets. J. On 05/20/16 at 10:42 am, during an interview with Cooperate Registered Dietician (CRD) the CRD stated, I have been unaware until this week that the Activities department required training on serving food during activities. So training has not been done. K. On 05/20/16 at 11:20 am, during an interview with (Certified Dietary Manager) (CDM) and (Registered Dietician) (RD), when asked if the Activities staff knew that the strawberries were to be pureed for Resident #,1 the CDM and RD stated, They should have known.

The survey team received a complaint on 12/09/15 concerning skin issues. Resident #3 was added to the sample based on the facility 802, which is a resident roster that includes current resident conditions. This resident roster indicated R #3 had pressure ulcers. Based on record review and interview the following was discovered. 1. R #3 developed a facility acquired pressure ulcer on the coccyx (tail bone), that was not discovered until the pressure ulcer was a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle). 2. The Stage IV pressure ulcer increased in size from 2.5 cm (length) by 1.5 cm (width) by 1.5 cm (depth) on 10/15/15 to 4 cm by 2 cm by 2 cm on 12/10/15. 3. R #3's physician documented the resident was having increased pain related to the pressure ulcer on the coccyx. 4. R#3 was not being bathed on a regular basis. 5. The facility was not administrating a pain medication to make moving and bathing of R #3 more comfortable. 6. R #3's right foot was pressing against the air pump of her mattress. 7. R #3 developed a Stage II (a pale pink wound bed and serous (fluid that is pale yellow and transparent) drainage and presents itself as an abrasion or blister) pressure ulcer to the lateral (outer) side of the right foot on 10/08/15. 8. Staff were not providing the proper care to R #3 because of her resistance. Staff were not trained on how to deal with R #3 and her behaviors. This resulted in an Immediate Jeopardy being called on 12/23/15 at 11:35 am. A plan of removal was received and approved on 12/23/15 at 5:20 pm. The Plan of Removal included: 1. Re-education of the nursing staff on the in house wound development, beginning 12/23/15 by the Director of Nursing Services (DNS). 2. Skin sweep to begin immediately 12/23/15, for residents in house by administrative nursing staff. This was completed 12/23/15. 3. The physician will be notified of any identified areas. Also, treatment orders will be obtained, if found, starting on 12/23/15. 4. The DNS, the Wound Nurse (WC) and Nurse Practitioner (NP) will complete wound rounds weekly to monitor progression of wounds and facilitate changing of the orders if wounds fail to progress. 5. The WN will enter all wound orders. 6. The Inter Disciplinary Team (IDT) will review all orders in the CARE meeting. 7. Care plans will be reviewed during the CARE meeting and updated as needed. 8. The WN will distribute a weekly wound report to member of the IDT. 9. The IDT will make walking rounds to assess if the residents require it following have: heels floated, boots, turned and repositioned, any pressure relieving device that is needed, completed by the WN on 12/23/15. As of 4:30 pm, on 12/23/15, all preventative measures are in place. 10. Subsequent checks will be performed on each hall on an un-announced/surprise schedule at least weekly. Based on the Plan of Removal, the scope and severity was decreased from a J to a H, Level 3. Based on record review, observation, and interview, the facility failed to 1) identify the presence of a pressure ulcer on the coccyx until the pressure ulcer was a Stage IV, 2) failed to provide routine bathing, 3) failed to appropriately clean after incontinence episodes, 4) failed to reposition R#3 off coccyx, 5) failed to position the resident so the right foot would not rub against the mattress air pump, resulting in a Stage II pressure ulcer to the lateral side of the right foot for 1 (R #3) of 2 (R #2 and #3) residents reviewed for pressure ulcers. This deficient practice likely caused R #3 to suffer avoidable pressure ulcers. The findings are: A. On 12/18/15 at 10:10 am, observation of wound care for R #3, was conducted with the facility Wound Nurse (WN). Observation revealed, a Stage IV pressure ulcer on R #3's coccyx, measured - length 4 centimeters (cm), width 2 cm, depth 2 cm, slough (dead tissue with a yellowish appearance) was noted to the upper third part of the wound on the the tail bone and a healing Stage II pressure ulcer to R #3's right lateral foot, with minimal serosanguineous (drainage consisting of both blood and serous (pale yellow and transparent) fluid) drainage, 50 % slough, and measured - length 2.2 cm, width 2.0 cm. During observation the wound measurements and description were stated by the WN. B. On 12/18/15 at 10:10 am, during an interview with the WN, the WN stated that R #3's Stage IV pressure ulcer on the coccyx was in house acquired and was not found until it was a Stage IV. The WN stated that R #3 was non-compliant and refused to be turned. The WN also stated the Stage II pressure on R #3's right foot was caused by the resident's foot rubbing against the air mattress pump. C. Record review of the October 2015 Wound Management Tracking Tool (WMTT), revealed the following for R #3's Stage IV coccyx pressure wound: 1. Week 10/15/2015 revealed, Wound onset date 10/09/15, wound location - coccyx, type of wound - pressure, measures 2.5 cm (length) by 1.5 cm (width) by 1.5 cm (depth), with moderate exudate (drainage), slough, in house acquired (INA), Stage IV. 2. Week 10/22/15 and 10/29/15 revealed, measures 2.5 cm by 1.5 cm by 2 cm. These measurements revealed an increase in depth of the pressure ulcer. 3. The WMTT for November 2015 revealed, the coccyx wound documentation was not dated but revealed, measurements of 3 cm by 1.5 cm by 3 cm. These measurements revealed an increase in the length and depth of the pressure ulcer. 4. The WMTT for December 2015 revealed, for the weeks of 12/03/15 and 12/10/15 measurements of 4 cm by 2 cm by 2 cm. These measurements revealed an increase in the length and width of the pressure ulcer. D. Record review for R #3's WMTT revealed, Right lateral foot Stage II pressure wound. 1. Week 10/08/2015 revealed, Wound onset date 10/05/15, wound location - right lateral foot, type of wound - pressure, measures 5 cm (length) by 3.5 cm (width), with light exudate, INA, Stage II. 2. Week 10/22/15 revealed, measurements of 4.5 cm by 3 cm by 0.1 cm with light exudate and tissue type slough, unstageable, progress - Decline: necrosis (dying tissue). 3. The WMTT for November 2015 revealed measurements of 2.5 cm by 2.5 cm by 0.7 cm. These measurements revealed an increase in the depth. 4. The WMTT for December 2015 revealed measurements of 2.7 cm by 2 by 0.6 cm. These measurements revealed an increase in the length. E. Record review of the Activities of daily living (ADL) care plan dated 01/20/15 and revised 05/04/15 revealed, Focus: dependent for care in bathing, grooming, bed mobility, transfer, and toileting due to chronic disease that compromises functional ability. Interventions: Administer [MEDICATION NAME] as ordered prior to moving/cleaning/bathing up to 3 times per week. Notify Nurse of refusals. F. Record review of the Activity of Daily Living Record (ADL) Records dated June 2015 through October 2015 revealed the following: l. June 2015 no documentation of any form of bathing. 2. July 2015 documentation show one shower on 07/27/15. 3. August 2015 documentation show one bed bath on 08/22/15. 4. September 2015 no documented of any form of bathing. 5. October 2015 no documentation of any form of bathing. G. Record Review of R #3's medication administration records (MAR) dated 06/01/15 - 10/15/15 indicated the following: 1. Order dated 05/29/15 [MEDICATION NAME] Solution 50 milligrams/milliliter (MG/ML) inject 1 ml intramuscularly as needed for pain; moderate pain, may give up to 3 times per week when needing to move or clean patient. 2. R #3's MAR indicated [REDACTED]. 3. R #3's MAR indicated [REDACTED]. 4. R #3's MAR, dated 08/01/15 to 08/31/15 revealed no evidence of [MEDICATION NAME] being administered during the month of August 2015. 5. R #3's MAR indicated [REDACTED]. 6. R #3's MAR, dated 10/01/15 to 10/30/15 revealed no evidence of [MEDICATION NAME] being administered between 10/01/15 to 10/15/15, prior to the order being discontinued. H. On 12/21/15 at 3:42 pm, during an interview with the Director of Nursing Services (DNS), the DNS stated that R #3 refuses care regularly and went months refusing to be turned, take showers or get out of bed. The DNS also stated the facility would call R #3's Power of Attorney (POA) to come to the facility and try to convince the resident to take a bath. I. On 12/21/15 at 2:35 pm, during an interview with R #3's (POA) stated she was aware that (R #3) refused care and states it was due to her mental status decline at the time. The POA stated she advised facility to bathe (R #3) regardless, but states(R #3) was not getting bathed regularly. R #3's POA stated she discovered the ones on her feet when she was painting resident's toenails. The POA stated (R #3) scoots down and feet hit the foot board and the air mattress pump rubs her feet. The POA stated that she feels this is the cause of the pressure sores on the feet. The POA further stated the coccyx pressure ulcer is between skin folds of buttocks and feels it was not found because they were not pulling the skin apart during baths. J. On 01/07/16 at 2:45 pm, during an interview with the Medical Director (MD), the MD stated that the CNAs did not open up the gluteal cleft (groove between the buttocks) when giving pericare or cleaning after incontinent episode. K. Record review of a physician order [REDACTED].#3) is on back, please make sure she is put on her sides more, pt beginning to get feeling and due to pressure ulcer experiencing more pain. L. On 12/22/15 at 10:39 am, during an interview with Registered Nurse (RN) #3, when asked about R #3's pressure ulcers, stated that the pressure ulcer on the resident's coccyx was not discovered until it opened up. She also stated when the pressure ulcer was discovered it was a Stage IV pressure ulcer.

The survey team received an onsite complaint from a family member of Resident #12 on [DATE] at 8:45 am. The family member was concerned that R #12 had recently returned to the facility and died shortly thereafter. Based on record review and interviews the following was discovered: 1. R #12 was being administered the medication, [MEDICATION NAME] ( blood thinning medication given to prevent clots). 2. R #12 had a physician order [REDACTED]. 3. R #12 did not have a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) (a laboratory test that measures the balance in the blood between preventing clots and causing excessive bleeding), for the month of [DATE]. 4. R #12 had a fall at the facility on [DATE] at 4:30 am. 5. R #12 did not receive treatment for [REDACTED]. 6. Hospital documentation indicated R #12 sustained a right subdural hematoma and PT/INR lab results were abnormal. R #12 was given fresh frozen plasma and Vitamin K. The resident then required transport to a higher level of care. This resulted in an Immediate Jeopardy being called on [DATE] at 9:45 am. A plan of removal was received and approved on [DATE] at 9:30 am. The Plan of Removal included: 1. Dates for draws of the [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) (a laboratory test that measures the balance in the blood between preventing clots and causing excessive bleeding), have been placed on the Medication Administration Record [REDACTED]. 2. The Physician is to be notified of the result of the PT/INR or the refusal to have the labs drawn with documentation. 3. All critical lab results will be called to the physician within one hour of receipt. 4. The laboratory book has been revised with directions on completing the required paperwork needed by the lab to process the lab draw. 5. This process will be monitored by the DNS/Designee for compliance 5 times a week to insure labs are being obtained and the Physician is notified. 6. The 24 hour report will be used by the off going nurse to give report to the oncoming nurse for changes and updates for the residents. Based on the plan of removal the scope and severity was decreased from a J to a G, Level 3. Based on record review and interview, the facility failed to monitor the effects of a blood thinning medication with laboratory monitoring from [DATE] to [DATE] for 1 (R#12) of 1 R(#12) residents reviewed for PT/INR (([MEDICATION NAME] Time and International Normalize Ratio to determine the clotting tendency of blood) . The PT/INR is used to monitor residents taking [MEDICATION NAME] (a blood thinning medication). This failure had the potential to cause abnormal bleeding and likely caused R # 12 to have to receive fresh frozen plasma (blood cells) as a result from an injury after a fall. The findings are: A. Record review for Resident #12 revealed the following: 1. physician's orders [REDACTED]. 2. Medication Administration Record [REDACTED]. [MEDICATION NAME] 6 mg. one time a day was given every Monday, Wednesday, and Friday, during the month of [DATE]. 3. physician's orders [REDACTED]. 4. Review of the laboratory section of the chart revealed no results related to the [MEDICATION NAME] for therapeutic monitoring. 5. Interdisciplinary Progress Note dated [DATE] revealed that the lab was not completed related to a lack of a physician's signature on the order. 6. There was no record that a PT/INR was completed for the month of [DATE]. B. Record review of the Emergency Department (ED) History and Physical Physician documentation dated [DATE] at 9:37 am, revealed that Resident #12 fell at (name of nursing home) and sustained a right-sided subdural hematoma (a collection of blood outside the brain usually caused by severe head injuries). Lab results obtained at that time revealed the resident had a PT of 76.8 (normal 9XXX,[DATE].90) and an INR of 6.36 (normal 1XXX,[DATE].30). Related to the injury and the abnormal PT/INR the resident was given fresh frozen plasma and Vitamin K. R #12 was transferred to another hospital for a higher level of care. C. Record review of a medical record Neurology Consultation dated [DATE] at a (name of local hospital) revealed that Resident received 4 units of of vitamin K (plays a key role in helping the blood clot preventing excessive bleeding), and 1 unit of Fresh Frozen Plasma (the fluid portion of one unit of human blood). D. On [DATE] at 12:30 pm, during an interview, the facility Nurse Practice Educator/Registered Nurse (NPE/RN) stated that the lab orders for the December PT/INR had been overlooked and not acted upon. The NPE/RN stated, They were just thrown in the basket with other lab orders and the PT/INR was not done for Resident #12. The NPE/RN stated that the nursing staff is responsible for notifying the physician that if lab results are not obtained or if they are abnormal.

The survey team received a complaint from the state survey central intake on 12/09/15. The complaint revealed that R #10 had wounds to both thighs that appeared to be burns. Investigation of the complaint also revealed that residents were not being assessed by the facility upon return from [MEDICAL TREATMENT]. Based on record review and interviews the following was discovered: 1. R #10 was transported to a local emergency department on 11/24/15 by EMS (Emergency Medical Service). EMS personnel documented both of R #10's legs in the groin area appeared to be scorch marks with blistering. EMS personnel also documented that R #10 was experiencing pain in his groin area from the wounds. 2. ER (emergency room ) physicians and nurses documented R #10 was found to have excoriated/eroded skin to both thighs. 3. ER personnel suspected R#10 had possibly been abused/neglected at the facility and reported the facility to Adult Protective Services and the State Survey Agency. 4. R #10 had a physician order [REDACTED]. 5. There was no documentation to indicate the facility followed the physician order [REDACTED]. 6. Documentation indicated the facility was not providing the treatment for the affected areas as ordered by the physician on 11/20/15. 7. The local [MEDICAL TREATMENT] center reported on 12/11/15 that R#10 had not received proper oral care, was agitated, and had feces on his hands. 8. Review of the facility [MEDICAL TREATMENT] communication form indicated the facility did not respond to the concerns of the [MEDICAL TREATMENT] center regarding R #10. 9. Review of the local [MEDICAL TREATMENT] center communication sheet to the facility indicated that on 12/04/15 R #1 arrived with a foul body odor. The [MEDICAL TREATMENT] center also documents that on 12/09/15 R #1's [DEVICE] ([DEVICE]) was crusted, red and the resident was complaining of pain. On 12/15/15 the [MEDICAL TREATMENT] center documented R #1 was constipated and gave the resident 30 millimeters of the medication [MEDICATION NAME]. 10. There was no documentation to indicate the facility responded to or acted upon the concerns from the [MEDICAL TREATMENT] center for R #1. This resulted in an Immediate Jeopardy being called on 12/23/15 at 11:35 am. A plan of removal was received and approved on 12/23/15 at 5:20 pm. The Plan of Removal included: 1. Re-education of the nursing staff on the in house wound development, beginning 12/23/15 by the Director of Nursing Services (DNS). 2. Skin sweep to begin immediately 12-23-15, for residents in house by administrative nursing staff. This was completed 12/23/15. 3. The physician will be notified of any identified areas. Also, treatment orders will be obtained, if found, starting on 12/23/15. 4. The DNS, the Wound Nurse (WN) and Nurse Practitioner (NP) will complete wound rounds weekly to monitor progression of wounds and facilitate changing of the orders if wounds fail to progress. 5. The WN will enter all wound orders. 6. The Inter disciplinary team (IDT) will review all orders in the CARE meeting. 7. Care plans will be reviewed during the CARE meeting and updated as needed. 8. The WN will distribute a weekly wound report to member of the IDT. 9. The IDT will make walking rounds to assess if the residents require it following have: heels floated, boots, turned and repositioned, any pressure relieving device that is needed, completed by the WN on 12/23/15. As of 4:30 pm on 12/23/15, all preventative measures are in place. 10. Subsequent checks will be performed on each hall on an un-announced/surprise schedule at least weekly. [MEDICAL TREATMENT] - 1) The licensed staff will be re-educated by the DNS/Assist Director of Nursing Service (ADNS) beginning 12/23/15 on pre/post [MEDICAL TREATMENT] assessments. 2) The pre-[MEDICAL TREATMENT] assessment shall include: Condition of the access site, complete set of vital signs, bruit, thrill, weight, medications administered, level of consciousness. 3) The post-[MEDICAL TREATMENT] assessments shall include: Residents level of consciousness upon returning to the facility, any complaints of pain or discomfort, bruit/thrill, condition of the access site, complete set of vital signs, weight upon return, any change of condition, level of consciousness. 4) The DNS/ADNS will validate the assessment has been completed after the resident returns from [MEDICAL TREATMENT] beginning 12/23/15. If anything was noted on the [MEDICAL TREATMENT] communication form from [MEDICAL TREATMENT], the IDT will ensure the charge nurse followed up with the concerns noted by [MEDICAL TREATMENT]. Based on the plan of removal the scope and severity was decreased from a J to a G, Level 3. Based on record review and interview, the facility failed to provide necessary care and services by: 1. Failing to follow a physician order [REDACTED].#10's thighs The physician had ordered foley catheter removal because of a possible allergic reaction to the plastic tubing. This deficient practice likely caused one (R #10) of one (R #10) residents reviewed for skin conditions to experience painful, excoriated, burn-like wounds to the groin/thigh area. 2. Failing to assess the [MEDICAL TREATMENT] catheter site and resident's physical condition and response to [MEDICAL TREATMENT] treatment for two (R #1 and R#10) of two (R#1 and R#10) reviewed for [MEDICAL TREATMENT]. The failure to assess R #1 and R #10 upon return from [MEDICAL TREATMENT] has the potential for the facility to be unaware of possible severe flucations in blood pressure or bleeding from the [MEDICAL TREATMENT]. The findings are: Findings for Resident #10 A. Record review of R #10's admission face sheet revealed, an admission date of [DATE] with a [DIAGNOSES REDACTED]. B. On 12/21/15 at 11:00 am, during an interview with R #10's Power of Attorney (POA) stated that R #10 had red areas on both thighs and when he was admitted to the (Name of Hospital) on 11/25/15 there were blisters. C. Record review of the emergency department (ED) Nurse Documentation from (Name of Hospital) dated 11/25/15 revealed, page 2 of 5, assessment - general: 11/25/15 at 01:48 am, Pt's spouse states pt was here approximately 11/20/15. No wounds to inner thighs at that time, per spouse. D. Record review of (Name of Hospital) General Information dated 11/25/15 revealed, On examination patient was found to have denuded (excoriated/eroded) skin in the medial aspect of both thighs. Questionable spilling of hot liquids and abuse at the nursing home is suspected and adult protective services contacted from the ED (emergency department). E. Record review of the (Name of Ambulance) transport documentation dated 11/24/15, no time noted, revealed, Upon arrival to scene we found a male patient (pt) in the supine position laying in bed. The pt bed sheets that he was laying on appeared to be stained with brown liquid and had the appearance of being dirty. Below the pt groin on both legs appeared to be scorch marks with blister. The wound was not bandaged and did not appear to have any ointment on it. Staff at (name of nursing home) stated that the last time the pt went to [MEDICAL TREATMENT] the wound was not present but when he returned the wound was present. The nursing staff further stated that they believed it was from his sweat pants being too tight and because of this the rubbing from the sweat pants caused the wound. The staff also stated that they had been wrapping the wound with ace (trade name for elastic wrap) bandages but they stopped because the task was difficult for them. The pt would respond to questions by shaking his head up and down for yes and side to side for no. The pt signaled using this method that he was experiencing pain in his groin area from his wound. G. Record review of the November 2015 treatment sheets for R #10 revealed, an order dated 11/20/15 for [MEDICATION NAME] cream to affected areas to both upper thighs bid (twice a day) for a rash that was not improving. There was no documentation to indicate treatment was provided as ordered on [DATE], 11/22/15 and 11/24/15. H. On 12/22/15 at 4:10 pm, during an interview with the Director of Nursing Services (DNS) stated that the order for [MEDICATION NAME] for R #10, was not charted as done on 11/21/15, 11/22/15, 11/24/15. I. Record review of a physician's orders [REDACTED]. J. Record review of nurse's notes for R #10 dated 11/23/15 until discharge to a local hospital on [DATE] revealed, no documentation that the physician order [REDACTED]. K. On 12/18/15 at 4:15 pm, during an interview with the DNS, stated that orders aren't always completed for several days and (R #10) was discharged to (Name of Hospital) before the order to remove the Foley catheter was carried through. The DNS further stated that the physician makes rounds and turns in all orders at the end of rounds, so there are just too many to complete on the day written. [MEDICAL TREATMENT] - The [MEDICAL TREATMENT] deficiency is a repeat deficiency from a survey conducted on 08/19/15. Findings for Resident #1 L. Record review of R #1's admission face sheet revealed, an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident is dependent on nutrition being provided via a [DEVICE] (a tube inserted through a small incision into the stomach and is used for long-term enteral nutrition), and is also dependent on [MEDICAL TREATMENT] (a process that uses a man-made membrane to remove wastes such as urea, from the blood). M. Record review of the Care Plan for R#1 dated 10/19/15 revealed: Focus- Resident #1 exhibits of is at risk for impaired renal function and is at risk for complications related to [MEDICAL CONDITION], [MEDICAL TREATMENT]. Interventions- Send communication form to [MEDICAL TREATMENT] and review upon return. Transfer to (name of [MEDICAL TREATMENT] center) on Monday, Wednesday, and Friday at scheduled time for treatment. N. [MEDICAL TREATMENT] Communication Records for the month of November 2015 were not available in the Medical Record. [MEDICAL TREATMENT] Communications Records for the month of December 2015 revealed the following: 1. [MEDICAL TREATMENT] treatments were completed 12/02/15, 12/04/15, 12/07/15, 12/09/15, 12/11/15, 12/16/15, 12/18/15, 12/21/15. 2. Recorded problems following [MEDICAL TREATMENT] and noted on the [MEDICAL TREATMENT] Communication Sheets were: 1) 12/04/15, Arrived with foul body odor. 2) 12/09/15, [DEVICE] contains crust reddened area, complained of hurting. 3) 12/11/15, Foot check, dry and cold, needs cream. 4) 12/15/15, Patient constipated, [MEDICATION NAME] 30 ml. today and continue Tums with each meal. O. Record review of the medical record revealed no evidence that these areas of concern were acted upon when R#1 returned to the facility following [MEDICAL TREATMENT] treatment. P. On 12/17/15 at 2:55 pm, during an interview Licensed Practical Nurse (LPN) #1 stated that they do vitals when R#1 leaves to go to [MEDICAL TREATMENT], however doesn't check anything when the resident returns to the facility. The LPN stated, Frankly I just hook her back up to her tube-feeding. The LPN was asked if the [MEDICAL TREATMENT] Communication Sheet was checked for any problems that occurred at [MEDICAL TREATMENT] the LPN stated, No I don't, I am usually slammed with admissions. Findings for Resident #10 Q. Record review of R #10's admission face sheet revealed, an admission date of [DATE] with a [DIAGNOSES REDACTED]. R. Record review of a physician order [REDACTED].#10 revealed, [MEDICAL TREATMENT] days: Monday, Wednesday, Friday; Pick up: 1315 (1:15). 1. An order dated 11/07/15 revealed, Monitor AV (arteriovenous) fistual/graft (artificial vessel used to join the artery and vein for [MEDICAL TREATMENT]) site for S/S (signs/symptoms) infection, [MEDICAL CONDITION], bleeding and upon return from [MEDICAL TREATMENT]. Notify primary care physician and [MEDICAL TREATMENT] unit if there are S/S of infection if AV fistual/graft site is bleeding apply pressure for 15 minutes and notify MD/Physician extender if bleeding does not stop. Ever shift. 2. Record review of R #10's Medication Administration Record [REDACTED]. The MAR for this order is not initialed as done by the nurse for the 10 pm-6 am shift for 11/9/15, 11/10/15, 11/11/15 and all shifts from 11/12/15 through 11/24/15. S. Record review of the facility [MEDICAL TREATMENT] communication record for R #10 revealed the following from the [MEDICAL TREATMENT] center: 1. 11/11/15 - BS (blood sugar) taken at 4:00 pm, 152. Blood Pressure (B/P) did increase as treatment (tx) continued, as high as 215/105. discharged stable. 2. 12/11/15 - Terrible oral care, needs it frequently, agitated pulling on Gastrostomy tube ([DEVICE] in the stomach for liquid feeding)/Catheter (tube in the bladder for draining urine)lines. Has feces on his hands needs to be cleaned. Access Condition: fair. T. Record review of the [MEDICAL TREATMENT] Communication Record revealed R #10 had [MEDICAL TREATMENT] treatments on 11/09/15, 11/11/15, 11/16/15, 11/18/15, 11/24/15 and 12/11/15. The Nurses Notes (NN) had no documentation for these dates for the return from [MEDICAL TREATMENT], or that a nursing assessment was completed for the access site for bleeding, vital signs, or general condition. NN's for the concerns the [MEDICAL TREATMENT] center noted on 11/11/15 and 12/11/15 show no documentation that the facility acted on the recommendation. U. On 12/21/15 at 10:50 am, during an interview with the DNS when asked about the charting for [MEDICAL TREATMENT] he stated that the facility had an in service (no date stated) but didn't have any [MEDICAL TREATMENT] patients until recently and had not done an audit on the charting. V. Record review of an education sheet, undated, revealed, If a resident is on [MEDICAL TREATMENT], we need to take special considerations. Please fill out and send with transportation the [MEDICAL TREATMENT] sheet. Upon the return of the resident, ensure the sheet made it back. If not, call the [MEDICAL TREATMENT] center and have them fax it over. Also, you must chart the resident back in with a short assessment summary. This goes for all residents coming back into the facility for whatever reason, with a set of vitals signs. Also, when assessing the resident, pay particular attention to the catheter site. Chart appearance, pain, and any dressing changes, etc. X. On 12/17/15 at 5:00 pm, during an interview with LPN #1, stated When they come back I don't usually reassess. LPN #1 further stated that they were told to be sure when they come back to put the [MEDICAL TREATMENT] sheet in the chart.

The survey team received a complaint on 12/09/15 concerning skin issues. Resident #3 was added to the sample based on the facility 802, which is a resident roster that includes current resident conditions. This resident roster indicated R #3 had pressure ulcers. Based on record review and interview the following was discovered. 1. R #3 developed a facility acquired pressure ulcer on the coccyx (tail bone), that was not discovered until the pressure ulcer was a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle). 2. The Stage IV pressure ulcer increased in size from 2.5 cm (length) by 1.5 cm (width) by 1.5 cm (depth) on 10/15/15 to 4 cm by 2 cm by 2 cm on 12/10/15. 3. R #3's physician documented the resident was having increased pain related to the pressure ulcer on the coccyx. 4. R#3 was not being bathed on a regular basis. 5. The facility was not administrating a pain medication to make moving and bathing of R #3 more comfortable. 6. R #3's right foot was pressing against the air pump of her mattress. 7. R #3 developed a Stage II (a pale pink wound bed and serous (fluid that is pale yellow and transparent) drainage and presents itself as an abrasion or blister) pressure ulcer to the lateral (outer) side of the right foot on 10/08/15. 8. Staff were not providing the proper care to R #3 because of her resistance. Staff were not trained on how to deal with R #3 and her behaviors. This resulted in an Immediate Jeopardy being called on 12/23/15 at 11:35 am. A plan of removal was received and approved on 12/23/15 at 5:20 pm. The Plan of Removal included: 1. Re-education of the nursing staff on the in house wound development, beginning 12/23/15 by the Director of Nursing Services (DNS). 2. Skin sweep to begin immediately 12/23/15, for residents in house by administrative nursing staff. This was completed 12/23/15. 3. The physician will be notified of any identified areas. Also, treatment orders will be obtained, if found, starting on 12/23/15. 4. The DNS, the Wound Nurse (WC) and Nurse Practitioner (NP) will complete wound rounds weekly to monitor progression of wounds and facilitate changing of the orders if wounds fail to progress. 5. The WN will enter all wound orders. 6. The Inter Disciplinary Team (IDT) will review all orders in the CARE meeting. 7. Care plans will be reviewed during the CARE meeting and updated as needed. 8. The WN will distribute a weekly wound report to member of the IDT. 9. The IDT will make walking rounds to assess if the residents require it following have: heels floated, boots, turned and repositioned, any pressure relieving device that is needed, completed by the WN on 12/23/15. As of 4:30 pm, on 12/23/15, all preventative measures are in place. 10. Subsequent checks will be performed on each hall on an un-announced/surprise schedule at least weekly. Based on the Plan of Removal, the scope and severity was decreased from a J to a H, Level 3. Based on record review and interview, the facility failed to implement the care plan for 1 (R #3) of 2 (R#2, and #3) residents reviewed for pressure ulcers (PU). This deficient practice is likely to cause residents who are identified and assessed at risk for pressure ulcers to develop pressure ulcers. The findings are: A. Record review of Resident #3's Admission Face Sheet revealed Resident #3 was admitted on [DATE] with a readmission of 01/12/15. [DIAGNOSES REDACTED]. B. Record review of Resident #3's care plan, with focus, goals, and interventions, dated 09/22/15 revealed Resident #3 is dependent for Activities of Daily Living (ADL) care in bathing, grooming, dressing, eating, bed mobility, transfer, locomotion, toileting due to chronic disease that compromises functional ability. Goals, initiated on 01/30/15, include Resident #3's ADL care needs will be anticipated and met in order to maintain the highest practicable level of functioning and well being. Interventions include: Will often refuse baths/showers or even allow staff to clean up after bowel movement. Administer [MEDICATION NAME] as ordered prior to moving/cleaning/bathing up to 3 times per week. Additional Focus revealed Resident #3 is at risk for skin breakdown (pressure ulcer) related to incontinence, friction and shear, and [MEDICAL CONDITION], refusing to turn and position, include, Resident will not show signs of skin breakdown. Interventions include: Evaluate for any localized skin problems, like dryness, redness, pustules, inflammation. Evaluate for skin risk factors per protocol. Monitor skin for signs/symptoms of skin breakdown, dryness, redness, cracking, blistering, decrease sensation and skin that does not blanche easily. Observe skin condition with ADL care daily and report abnormalities. C. Record Review of R #3's medication administration records (MAR) dated 06/01/15 - 10/15/15 indicated the following: 1. Order dated 05/29/15 [MEDICATION NAME] Solution 50 milligrams/milliliter (MG/ML) inject 1 ml intramuscularly as needed for pain; moderate pain, may give up to 3 times per week when needing to move or clean patient. 2. R #3's MAR indicated [REDACTED]. 3. R #3's MAR indicated [REDACTED]. 4. R #3's MAR, dated 08/01/15 to 08/31/15 revealed no evidence of [MEDICATION NAME] being administered during the month of August 2015. 5. R #3's MAR indicated [REDACTED]. 6. R #3's MAR, dated 10/01/15 to 10/30/15 revealed no evidence of [MEDICATION NAME] being administered between 10/01/15 to 10/15/15, prior to the order being discontinued. D. Record review of Resident #3's SBAR (Situation Background Assessment Recommendation/Request) form, dated 10/07/15 revealed at 9:20 pm, the Certified Nurse Assistant (CNA) informed the nurse of a pressure ulcer on Resident #3's coccyx (tail bone). Assessment revealed a stage 4 (full thickness tissue loss with exposed bone, tissue or muscle) pressure ulcer with tunneling (a wound progressing deeper into the body creating a sinkhole). E. On 01/14/16, at 12:10 p.m., during an interview with the Assistant Director of Nursing (ADON), the ADON stated that the MAR's do not show that Resident #3 was given [MEDICATION NAME] as an intervention, per the care plan. When asked about Resident #3's bathing/ADL record, the ADON stated I only see bed bath one time.

Based on record review and interview the facility failed to 1) maintain aseptic (free from contamination caused by harmful bacteria , viruses or other microorganisms) condition of a indwelling catheter by not changing catheter and bag when showing signs of crusting or having feces on tubing, 2) and failed to monitor for complications of Foley catheter use - signs and symptoms of Urinary tract infections (UTI'S) for 1 (R #10) of 3 (R #2, #10, and #5) residents reviewed for indwelling urinary catheters. This deficient practice likely resulted in R #10 developing a UTI with a strain of [DIAGNOSES REDACTED] (a bacteria which is resistant to several types of antibiotics). The findings are: A. Record review of the admission face sheet and nursing assessment dated [DATE] for R #10 revealed [DIAGNOSES REDACTED]. Further review of these records indicated R #10 had a indwelling urinary catheter because of immobility and skin breakdown. B. Record review of the facility Treatment Administration Record (TAR) dated 11/01/15 through 11/30/15 revealed an order dated 11/07/15 that indicated, Change Foley drainage bag when occluded (obstructed) or when Foley catheter is changed as needed. There was no documentation on the TAR to indicate the urinary catheter and bag had been changed. C. Record review of the facility's policies and procedures dated 06/01/1996 with revision date of 01/02/04 for Care of Indwelling Urinary catheter, revealed, 1) Perform catheter care twice a day and PRN, and 11.3) Change drainage bag with any catheter change or as needed. D. Record review of Nurse's Notes (NN) for R #10, from 11/07/15 through 11/24/15 revealed, no documentation about R #10's condition of the indwelling catheter, tubing or bag after 11/09/15. E. Record review from the (Name of Hospital) documentation revealed the following: 1. ED (Emergency Department) Nurse Documentation on 11/25/15 at 1:48 am, revealed, Emergency Medical Service (EMS) also reported facility requested ER (emergency room ) to look at patient's (pt) Foley catheter because pt was pulling at catheter. Feces noted on catheter, dark yellow thick crystallized appearance to urine in Foley tube. 2. Documentation dated 11/25/15 from the (Name of Hospital) titled History of Present Illness, on examination patient Foley was found to have dirty urine and urine bag was changed, signed by (Name of Physician). 3. A Urinalysis report from (Name of Hospital) dated 11/25/15 revealed the following results indicating a urinary tract infection: Blood 4+ High - normal is negative, Leukocyte esterase (enzyme produced by white blood cells) 3+ High - normal is N (none), Red Blood Cells 5-9 high - normal is 0, White Blood Cells 10-15 High - normal is 0, and Bacteria 1+ High - normal is none'. 4. Record review of the (Name of Hospital) ED Nurse Documentation on 11/25/15 at 1:34 am, revealed, Assessment for neglect: Signs of neglect: poor hygiene observed. 5. Record review of the (Name of Hospital) ED Nurse Documentation on 11/25/15 at 3:27 am, Notified Adult Protective services at 2:58 am (for signs of neglect). 6. Record review of the (Name of Hospital) Physician Discharge Summary dated 12/03/15 for the hospital admission of 11/25/15 revealed, Hospital Course: abuse at the nursing home is suspected and adult protective services contacted from the ED. F. On 01/14/15 at 3:00 pm, during an interview with the Assistant Director of Nursing Service (ADNS), stated A Foley bag should be changed if occluded or leaking. The ADON also stated if the tubing was crusty and the urine bag had sediment in the urine, it should be changed. The ADON stated Absolutely, the nurse should be assessing and use their nursing judgement to provide catheter care as needed.

Based on record review and interview, the facility failed to care plan for the care and monitoring of 1) [MEDICAL TREATMENT] complications: bleeding and infection of the [MEDICAL TREATMENT] (process of filtering blood to remove toxic materials in the blood when kidneys are not functioning) access site, weight gain and [MEDICAL CONDITION] (swelling caused by fluid retention) low or high blood pressure, fatigue or weakness, 2) failed to care plan for care and monitoring of a Foley catheter and 3) failed to care plan for the care of a Gastrostomy tube (tube in the stomach for nutrition ([DEVICE])) for 1 (R #10) of 4 (R #1, #2, #3, and #10) residents reviewed for care plans. This deficient practice has the potential for complications to be undetected and not acted on in a timely manner. The findings are: A. Record review of R #10's admission face sheet revealed, an admission date of [DATE] with a [DIAGNOSES REDACTED]. B. Record review of R #10's complete record revealed no initial care plan addressing care and monitoring for [MEDICAL TREATMENT], [DEVICE] or Foley catheter. C. On 01/07/15 at 2:00 pm, during an interview with Clinical Reimbursement Coordinator Nurse (CRCN) #1, stated that the care plan for R #10, did not have any initial interventions for [MEDICAL TREATMENT], [DEVICE] or Foley catheter care and monitoring. The CRCN #1 stated Yes ma'am, when asked if these issues should be on the initial care.

Based on record review and interview, the facility failed to complete a thorough investigation or to report injuries of unknown source to the State within 24 hours for 2 (#1, 3) of 2 (#1, 3) residents investigated for injuries of unknown origin. Resident #3 had sustained a bruise to the right outer hand and last 3 fingers that was later diagnosed as a fracture. Resident #1 had sustained a 6 cm (centimeter) abrasion to the right mid back and a 10 cm x (by) 6 cm bruise to the triceps area of the left arm. This deficient practice presents a risk of potential harm to resident safety. If injuries of unknown source are not investigated, the facility is unable to determine what happened in order to prevent it from re-occurring. If injuries of unknown source are not reported, the State Agency (SA) is not aware of the incident, therefore, the SA is not able to follow up with the facility to ensure resident safety. The findings are: A. Policy and Procedures, provided by the facility, for Prohibition of Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, dated January 2008/rev. 11/10, revealed; "4. Identification: Identify events, such as suspicious bruising of residents, injuries of unknown origin, occurrences, patterns, and trends that may constitute abuse; and to determine direction of the investigation. 5. Investigation: The center must have evidence that all alleged violations are thoroughly investigated. The center investigates different types of incidents; and identifies the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to proper authorities. ... 7. Reporting/Response: ... Immediate response is taken to ensure the safety of the resident. ... The center ensures that all alleged violations involving ... including injuries of unknown source, ...are reported immediately to the administration of the center and to other officials, in accordance with state law through established procedures... . An initial report will be completed and submitted to the Department of Health immediately upon notification of the allegation. ... Within 5 days ... of the incident final report is submitted in writing to appropriate state agencies ..." B. Record review of Interdisciplinary Progress Notes (IPN) for Resident #3 revealed the following: 1. On 03/13/12 at 1500 (3:00 pm), "Resident noted to have bruising to rt (right) outer hand and last 3 fingers. Deny pain able to squeeze hand bilat (bilaterally)." 2. On 03/13/12 at 2000 (8:00 pm), "Bruising remains fingers R (right) hand. CNA's (Certified Nursing Aides) report resident puts hand to wall during turning, maybe afraid of falling ..." 3. On 03/16/12 at 1300 (1:00 pm), " ... Some bruising noted to R (right) hand. Little finger blue." 4. On 03/17/12 at 1400 (2:00 pm), "... Bruising noted to R hand and little finger. Doesn't hurt as bad today." 5. On 03/21/12 at 1345 (1:45 pm), "POA (Power of Attorney) here- states, 'Mom's pinkie is hanging on by a thread. She says that it hurts.' No swelling noted to R hand. Does c/o (complain of) being a little sore. Called and left message for (name of physician) assistant." 6. On 03/21/12 at 1745 (5:45 pm), "VO (verbal order) Send to (name of hospital) in am for x-ray to R hand and appt (appointment) with (name of physician) at 1400 (2:00 pm) 7. On 03/22/12 at 1530 (3:30 pm), "(Name of physician) called. States finger is fx. (fractured) and would like res (resident) to see (name of orthopedic physician) ASAP (as soon as possible). States office would wrap hand." 8. On 03/23/12 at 1500 (3:00 pm), "...New order to buddy tape right 4th and 5th finger. Gentle care for finger. ... Have R hand x rayed before next visit... " C. Record review of the radiology report dated 03/22/12, revealed, "Indications: There is a nondisplaced minimally angulated fracture at the base of the proximal phalanx of the fifth digit...." D. The Progress Note, from the orthopedic specialist, dated 03/23/12 at 10:30 am, revealed that the distal joint of the right little finger was broken but not displaced. E. On 03/23/12, 10 days after the bruise was noted, the facility sent a report to the State Agency, after the Xray revealed a [MEDICAL CONDITION] finger. F. On 04/04/12 at 3:00 pm, the Director of Nurses (DON) was interviewed. When asked if there was an investigation into the cause of the bruise on the right hand of Resident #3, the DON stated, "Yes, I did investigate when it happened, it was not there at the beginning of the shift, and no one knew what could have happened to cause the bruise. I was not able to determine what happened." The DON was asked if that was an injury of unknown source. The DON stated, "Yes, it would be and our policies say we are to report those within 24 hours." When asked when it was reported to the State, the DON stated, "On 03/23/12, about 9 or 10 days after the bruise was noted." G. Record review of Interdisciplinary Progress Notes (IPN) for Resident #1 revealed the following: 1. On 03/19/12 at 0630 (6:30 am), "CNA's completing check and change found approximate 6 cm (centimeter) abrasion on residents right middle back. Resident states he doesn't know what happened. ..." 2. On 03/19/12 at 1430 (2:30 pm), "... did see abrasion to back and bruise to triceps area of left arm 10 cm x 6 cm and purple in color." 3. On 03/20/12 at 0150 (1:50 am), "Bruise/abrasion remains to upper back, bruise remains to left upper arm. Unexplained. ..." H. On 04/04/12 at 3:10 pm, the DON was interviewed. When the DON was asked if there was an investigation into the cause of the abrasion on the back of Resident #1, the DON stated, "Yes, I did investigate as to when it occurred and how it might have happened." When asked about the bruise on Resident #1's arm, the DON stated that he did not see the bruise and it was not reported to him. The DON stated, "After the investigation, I was not able to determine the cause of the injury." When asked if the abrasion on his back and the bruise on his arm were injuries of unknown source, the DON stated, "Yes, they were." When asked if the injuries of unknown origin were reported to the State Agency, the DON stated, "No, we did not report this at all."