Every finding on record at St Elizabeth Nursing Home

Based on interview and record review, the facility did not ensure that sufficient nursing staff were provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R) for 4 of 4 Residents (R14, R16, R30, & R34) and 1 of 1 anonymous resident reviewed for staffing. Surveyors entered the facility on the weekend due to the facility being triggered for low weekend staffing. R14 voiced concerns regarding call lights not answered in a timely manner and the facility does not have enough staff to care for residents. R16 voiced concerns with call light times not being answered for 45 minutes. An anonymous resident voiced concern that she had to wait two and a half hours for someone to get her up in the morning. R30's call light was on for 1 hour and 16 minutes on 4/26/26 before staff answered it. R34 voiced concerns about wait times being too long when using the call light. Evidenced by: The Facility assessment dated [DATE] includes the following: . Resident Level of Independence to Dependence: ADL ASSISTANCE: Dressing: 12.5% Independent, 42.5% Require assistance of 1-2, 45% are dependent Bathing: 0% Independent, 46.5% Require assistance of 1-2, 53.5% are dependent Transfer: 15% Independent, 45% Require assistance of 1-2, 40% are dependent Eating: 0% Independent, 40.7% Require assistance of 1-2, 18.6% are dependent Toileting: 15% Independent, 52.5% Require assistance of 1-2, 32.5% are dependent. The staffing plan detailed below describes how staffing decisions are made to ensure that there are sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care. *Staffing needs for facility, unit, and shift. The table below describes the number of staff available to meet residents' needs. Nursing, nutrition services and housekeeping staffing is evaluated at the beginning of each shift and adjusted as needed to meet the care needs and acuity of the resident population. Position: Licensed Nurses FTEs (Full Time Equivalent): 5.3 Certified Nursing Assistants (CNAS) FTEs: 10.8 Medication techs FTEs: 2.4. . The staffing ratios for the CNAs vary day to day depending on resident population and assessed need. When the care needs are higher, we assist the staff in finding ways to become more efficient, and adding more support if needed. Staffing adjustments based on changes to the resident population: Daily and throughout each shift, residents' individualized needs are assessed. The competencies and availability of staff are adjusted based on the results of such assessments. The data found within the Facility Assessment: Resident Population drives staffing decisions (staff assignments, systems for coordination, and continuity of care) . The monitoring of all discipline's staffing supports the resident specific needs on each unit Example 1: R14 was admitted to the facility on [DATE] and has diagnoses that include age-related osteoporosis (a condition where bones become weak and brittle due to aging), congestive heart failure (a chronic, progressive condition where the heart cannot pump blood efficiently, causing fluid buildup (congestion) in the lungs and body), and major depressive disorder. R14's Quarterly Minimum Data Set (MDS) Assessment, dated 1/29/26 shows R14 has a Brief Interview of Mental Status Score (BIMS) of 13 indicating R14 is cognitively intact. On 4/26/26, at 10:39 AM, Surveyor interviewed R14. R14 voiced concerns about the facility not having enough help to care for the residents. R14 indicated it takes the staff 45 minutes to answer her call light most times. R14 indicated there have been times she has had to wait on the toilet for staff for so long her legs fell asleep making it difficult to transfer off the toilet. R14 indicated that one time she fell while transferring up off the toilet due to her legs falling asleep from waiting so long. Example 2: R16 was admitted to the facility on [DATE] and has diagnoses that include anxiety disorder, and overactive bladder (condition characterized by a sudden, uncontrollable urge to urinate, often leading to frequent bathroom trips and incontinence). R16's Quarterly MDS (minimum data set) Assessment, dated 3/13/26 shows that R16 has a BIMS of 9, indicating R16 has moderate cognitive impairment. On 4/26/26 at 11:03 AM, Surveyor interviewed R16 and FM M (Family Member). R16 voiced concern that call light wait times are 45 minutes. FM M indicated it is hard getting staff to assist R16 to the bathroom most times. R16 and FM M returned from church at 10:15 AM and turned the call light on right away for R16 to use the bathroom. It is 11:05 AM and staff still have not answered the call light. Surveyor asked R16 and FM M what is the average wait time for staff to answer R16's call light. FM M indicated it depends on how much staff are working. As Surveyor was talking with R16 and FM M staff came into room and assisted R16 to the bathroom at 11:10 AM. On 4/26/26 at 11:15 AM, Surveyor interviewed an anonymous resident. Surveyor asked the resident if she receives the care she needs. The resident indicated no. The resident voiced concern about having to wait for staff this morning for over two hours. The resident indicated she put her call light on at 4:00AM and staff did not answer her call light until 6:30AM. The resident indicated the cna (certified nursing assistant) that was working informed the resident that she was the only cna working and there are four residents ahead of her. The resident indicated she was incontinent with urine and had to wait in a wet bed. The resident indicated she felt neglected, and the facility does not have the staff to properly care for the residents. Surveyor asked the resident if she had told anyone that she felt neglected. The resident indicated no and felt there would be retaliation from the staff. Example 3: R30 was admitted to the facility on [DATE] and has diagnoses that include difficulty in walking, need for assistance with personal care, repeated falls, and urinary incontinence. R30's Quarterly MDS (minimum data set) Assessment, dated 4/3/26 shows that R30's BIMS (Brief interview of mental status) is 14 indicating R30 is cognitively intact. Surveyor requested call light logs for the duration of Friday April 24, 2026- Sunday April 26, 2026. The call light log shows for R30: On 4/26/26, at 4:44AM, R30's call light was on for 1 hour and 16 minutes until it answered. The call light log shows for R14: On 4/25/26, at 7:46AM R14's call light was on for 25 minutes until answered. On 4/25/26, at 8:05AM, R14's call light was on for another 26 minutes until answered. On 4/26/26, at 4:19AM, R14's call light was on for 24 minutes until answered. On 4/26/26, at 7:09PM, R14's call light was on for 31 minutes until answered. The call light log shows for R16: On 4/24/26, at 3:13AM, R16's call light was on for 50 minutes until answered. On 4/24/26, at 6:39AM, R16's call light was on for 43 minutes until answered. On 4/26/26, at 10:30AM, R16's call light was on for 38 minutes until answered. On 4/26/26, at 8:06AM, R16's call light was on for 34 minutes until answered. The nursing schedule for Friday April 24, 2026, shows: Day Shift: 1 RN (registered nurse), 1 LPN (licensed practical nurse) and DON (director of nursing) PM Shift: 1 RN and 1 MT (Med Tech), 3 1/4 cnas Night Shift: 1 LPN and 1 cna. 1 cna called in. The nursing schedule for Saturday April 25. 2026, shows: Day Shift: 1 RN and 1 LPN, 2 1/2 cnas PM Shift: 1 MT and 1 RN. 3 cnas Night Shift: 1 RN and 1 cna. 1 cna called in. The nursing schedule for Sunday April 26, 2026, shows: Day Shift: 1 MT and 1 RN. 2 1/2 cnas PM Shift: 1 RN and 1 MT. 3 cnas Night Shift: 1 RN and 2 cnas Note: The nursing schedule for Friday April 24, 2026, and Saturday April 25, 2026, shows the night shift: one cna and one nurse worked. One cna had called in on both evenings. On 4/28/26 at 8:11 AM, Surveyor interviewed CNA N (certified nursing assistant) and asked if CNA N feels there are enough staff to care for the residents. CNA N indicated no. CNA N indicated there are times when daily assignments are not completed by cnas. CNA N indicated things get overlooked such as charting. CNA N indicated the facility expects the staff to stay after their shift to complete the charting. CNA N indicated cnas do not get toileting and repositioning completed on residents. CNA N indicated that the staff know what residents want things done at a particular time and those residents are the residents that the staff get to. As for the other residents they must wait. Surveyor asked CNA N how much time it should take for staff to answer a call light. CNA N indicated 3 minutes. Surveyor asked CNA N if answering a call light 20 minutes up to an hour addressing the residents' needs timely. CNA N indicated no, that is not acceptable. CNA N indicated residents do wait that long quite a bit. CNA N indicated the residents complain about the call light waiting times daily. On 4/28/26 at 9:39 AM, Surveyor interviewed CNA J. CNA J indicated there are times cnas do not get water passed to residents and residents do not get toileted, changed, and repositioned every two hours. CNA J indicated every three hours but not every two hours. Surveyor asked CNA J how much time should take before a call light is answered. CNA J indicated 2 minutes. Surveyor asked CNA J if answering a call light 20 minutes up to an hour after it is turned on is addressing the residents' needs timely. CNA J indicated no. On 4/28/26 at 9:48 AM, Surveyor interviewed CNA K and asked if CNA K feels there are enough staff to care for the residents properly. CNA K indicated not every day. Surveyor asked if there are times cnas do not get daily assignments completed. CNA K indicated cnas do not get showers completed at times and toileting/repositioning does not get done every two hours. CNA K indicated there are days cnas will get repositioning/toileting done twice. Surveyor asked CNA K how much time it should take before a call light is answered. CNA K indicated 5 to 10 minutes. Surveyor asked CNA K, answering a call light 20 minutes up to an hour after it is turned on, addressing the residents' needs timely. CNA K indicated no. On 4/28/26 at 10:48 AM, Surveyor interviewed NS D (nursing scheduler). NS D indicated the staffing pattern is determined by the administrator. NS D indicated the facility's staffing pattern is no less than 3 cnas on the day shift, 3 cnas on the pm shift and two cnas on the night shift. NS D indicated if the census is over 38, then 4 cnas on the day shift, 3 1/2 cnas on the pm shift, and two cnas on the night shift. NS D indicated there is a nurse on every shift and a med tech on the day and evening shifts. The night shift has one nurse. Surveyor asked NS D what the process is for a call in. NS D indicated if there is a call in Monday through Friday NS D tries to fill the position. If there is a call in on the weekends, the director of nursing tries to fill it. NS D indicated there is axillary staff to assist on the floor as needed. NS D indicated she is a cna and the dietary manager is a cna and both can assist when needed. On 4/28/26 at 10:53 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how much time should lapse between a call light being turned on until the call light is answered. DON B indicated the facility has no set goals. DON B indicated no more than 15 minutes should lapse before staff answer call lights. Surveyor reviewed the call light logs with DON B and asked if 20, 30, 45 minutes to over an hour before call lights are answered is addressing the residents' needs in a timely manner. DON B indicated no, there is no reason for those response times. DON B indicated there are enough staff on the floor. DON B indicated looking at the dates of the call light log she would say it is due to the staff that worked. Example 4: R34 admitted to the facility on [DATE] with diagnoses that include, in part: acute respiratory failure with hypoxia (severe shortness of breath with low blood oxygen), acute embolism and thrombosis of left popliteal vein and left tibial vein (blood clot in vein behind and below knee), and chronic diastolic (congestive) heart failure (heart condition with symptoms that may include shortness of breath, leg swelling, and fatigue). R34's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/4/26 indicates R34 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he is cognitively intact. On 4/26/26 at 9:48 AM, Surveyor spoke with R34. R34 indicated the facility is short-staffed and needs more help. R34 indicated it takes a long time to get help and said he has waited anywhere from 30 minutes to 2 or 3 hours to get staff to answer his call light. R34 indicated he occasionally needs help with going to the bathroom and wiping himself, and if staff doesn't come in to help him, he attempts to do it by himself. R34's most recent care plan includes the following, in part: Toileting: Toilet use: The resident requires (limited assistance) by (1) staff for toileting. Resident goes into the bathroom frequently on his own. Surveyor reviewed R34's call light wait times during the weekend of 4/4/26 to 4/26/26. On 4/26/26 at 5:27 AM, the report indicated R34 waited 1 hour and 9 minutes for his call light to be answered.

Based on interview and record review, the facility did not ensure that each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized, for 1 of 5 residents (R13) reviewed for immunizations. R13 was not offered the pneumococcal vaccination.This is evidenced by:Facility policy, titled Individual Immunizations, reviewed on 8/29/25, states in part: Policy: Prophylactic immunizations will be offered to individuals to promote the absence of Health Care Acquired Infections. Procedure: 1. Immunization: a. Upon admission, the organization will verify the individual's immunization status, update Primary Care Provider (PCP) as indicated, and administer immunizations as ordered. b. Individual will be offered immunizations based upon the Center for Disease Control (CDC). 3. Documentation: a. Immunization consent or refusal shall be documented within the Electronic Medical Record.According to CDC guidelines, routine pneumococcal vaccine recommendations for adults 50 years or older are as follows: Administer PCV15 (pneumococcal conjugate vaccine), PCV20, or PCV21 for .adults 50 years or older -Who have never received any pneumococcal conjugate vaccine / -Whose previous vaccination history is unknown (https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.htm).R13 admitted to the facility on [DATE] with an activated HCPOA (health care power of attorney). Surveyor reviewed R13's immunization documentation in her facility chart. There was no indication that she had ever received or been offered the pneumococcal vaccine. On 4/28/26 at 10:00 AM, Surveyor requested a vaccine consent or declination form for R13 from DON B (Director of Nursing).On 4/28/26 at 12:19 PM, DON B indicated they do not have vaccine consent or declination forms for residents to complete. Staff speaks with the resident or HCPOA and documents whether a vaccine was consented to and given or declined in the resident's chart under the immunizations tab. DON B indicated she spoke to R13's HCPOA that afternoon and she declined having R13 receive the pneumococcal vaccine. DON B documented the refusal in R13's chart.On 4/28/26 at 1:33 PM, Surveyor interviewed CNC C (Clinical Nurse Consultant). CNC C has been assisting the facility with infection prevention policy implementation. CNC C indicated vaccines should be reviewed, offered, and documented with the resident and/or HCPOA when the resident is admitted to the facility. CNC C reviewed R13's pneumococcal vaccine information and said it should have been offered or declined when she admitted to the facility. CNC C was unable to find documentation indicating it was offered prior to 4/28/26. CNC C indicated this is an area of opportunity for the facility to work on.

Based on observation, interview, and record review, the facility did not ensure that residents who need respiratory care are provided such care consistent with professional standards of practice for 2 of 3 residents (R34, R15) reviewed for oxygen.R34 did not have oxygen tubing dated or changed on a regular basis and did not have a sign on his door indicating oxygen was in use.R15 did not have oxygen tubing dated or changed on a regular basis.This is evidenced by:Facility policy, titled Safe Use of Oxygen, reviewed 2/11/26, states, in part: Policy: Entity will provide individuals who are in need of oxygen safe storage, use, and transportation in regulated health care settings. Procedure: A. Storage: .iv. Oxygen In Use signage will be posted in a prominent location.The facility did not provide any additional oxygen tubing/use policies.Example 1: R34 admitted to the facility on [DATE] with diagnoses that include, in part: acute respiratory failure with hypoxia (severe shortness of breath with low blood oxygen), chronic obstructive pulmonary disease (disease that causes obstructed airflow and breathing difficulties), and chronic diastolic (congestive) heart failure (heart condition with symptoms that may include shortness of breath, leg swelling, and fatigue). R34's physician orders include, in part: O2 (oxygen) (specify liter) per NC (nasal cannula)-continuously to keep sats > 88% (oxygen saturation level in the blood) Order date: 1/20/26 and O2 sat every shift, if <88%, start ) every shift for shortness of breath, low O2 sats Order date: 1/20/26. On 4/26/26 at 9:48 AM, Surveyor interviewed R34 and observed an oxygen concentrator in his room. There was no sign on the door of his room indicating oxygen was being used. The nasal cannula tubing connected to the oxygen concentrator was not dated. R34 indicated he uses oxygen frequently at night when he's feeling short of breath. On 4/26/26 at 3:57 PM, Surveyor asked RN E (Registered Nurse) about the facility's policy for changing oxygen tubing. RN E indicated the tubing should be changed every week. Surveyor asked RN E if R34's tubing was labeled with the date it was last changed and she said she didn't believe so. RN E indicated she wasn't sure how you would know when to change it again. Surveyor took RN E into R34's room to look at the oxygen tubing. RN E confirmed the tubing didn't have a date on it. RN E said she would change it and date the tubing.On 4/27/26 at 11:35 AM, Surveyor interviewed R34. R34 indicated he puts on oxygen overnight when he needs it; he doesn't use it every night. R34 indicated he doesn't have to ask the nurses for help and he takes it off when he gets up in the morning. Surveyor observed that R34's oxygen tubing was dated and there was an oxygen-in-use sign on his door.On 4/27/26 at 12:03 PM, Surveyor interviewed RN G about R34's oxygen use. RN G indicated his oxygen use is documented in the vitals tab in his chart when staff checks his oxygen saturation levels. RN G works day shift and said R34 does not use it when she's working. RN G reviewed the oxygen order in place for R34 and indicated no directions were specified, so it doesn't show up on his MAR (Medication Administration Record). RN G indicated the order was also not correct, as it specified R34 should be using oxygen continuously instead of as needed. RN G said she would reach out to the nurse practitioner to check on this.Surveyor reviewed R34's oxygen saturation values for April 2026. It was documented that R34 used oxygen five times. On 4/27/26 at 3:17 PM, Surveyor asked DON B (Director of Nursing) what her expectation is for a resident who is using oxygen. DON B said oxygen tubing should be changed every seven days and the filters should be cleaned. Every Wednesday night, staff should change it. DON B indicated she had missed the order for R34, but she corrected it. DON B indicated R34's tubing should be changed if it is being used. Surveyor asked if there should be a sign on the door indicating oxygen is being used. DON B said yes. Surveyor let DON B know there had not been a sign on R34's door on 4/26, but it was in place now.Surveyor reviewed R34's new orders: O2 @ (at) 1-2 L per NC to keep sats > 88% every 2 hours as needed for SOB (shortness of breath) or wheezing. Order date: 4/27/26., Change O2 tubing every 7 days and date. Every night shift every Wed (Wednesday) for equipment care. Change tubing when being used. Order date: 4/27/26., and Clean O2 filters every 7 day w/(with) soap and water, dry w/paper towel. Every night shift every 7 days for equipment care. Order date: 4/27/26.Example 2:R15 admitted to the facility on [DATE] with diagnoses that include, in part: cardiomyopathy (heart disease causing symptoms that may include fatigue, shortness of breath, and leg swelling), dependence on renal dialysis, end stage renal disease (kidney failure), and anemia in chronic kidney disease (reduced red blood cells causing fatigue, shortness of breath, and dizziness). On 4/26/26 at 2:34 PM, Surveyor observed nasal cannula tubing connected to the oxygen concentrator in R15's room without a date on it. On 4/26/26 at 4:31 PM, Surveyor took RN E (Registered Nurse) into R15's room to look at the oxygen tubing. RN E confirmed there was no date on the tubing. RN E indicated she would expect there to be a date on the tubing; without a date, she wouldn't know when to change it. Surveyor reviewed R15's new orders: O2 (Oxygen) 2 L (liters) per NC (nasal cannula) -continuously to keep sats > (greater than) 88% (percent) every shift for monitoring. Order date: 4/26/26., Change O2 tubing every 7 days and date. Every night shift every 7 days for equipment care. Order date: 4/26/26., and Clean O2 filters every 7 day w/(with) soap and water, dry w/paper towel. Every night shift every 7 days for equipment care. Order date: 4/26/26. Surveyor reviewed R15's physician orders for oxygen use. There were no orders in place specifying when tubing should be changed prior to 4/26/26. On 4/27/26 at 3:17 PM, Surveyor asked DON B (Director of Nursing) what her expectation is for a resident who is using oxygen. DON B said oxygen tubing should be changed every seven days and the filters should be cleaned. Every Wednesday night, staff should change it. DON B indicated she had missed the order for R15, but she corrected it.

Based on observation, interview, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services to prevent infections or complications for 2 of 2 residents (R5, R8) reviewed for catheters.Surveyors observed R5's indwelling urinary catheter to be resting in direct contact with the floor.Surveyors observed R8's indwelling urinary catheter to be resting in direct contact with the floor.This is evidenced by:Facility policy, titled Standard Indwelling Catheter Protocol, undated, states in part: Problem: Individual has indwelling catheter. Goal: Patency will be maintained and risk of infection will be minimized.CNA:.Keep drainage bag below level of bladder and off floor; tubing free of kinks, twists, or pressure.Example 1: R5 initially admitted to the facility on [DATE] with diagnoses that include, in part: neuromuscular dysfunction of bladder (nerve damage which interrupts signals between nervous system and bladder function), benign prosthetic hyperplasia with lower urinary tract symptoms (enlargement of the prostate gland causing urinary issues), and retention of urine (inability to fully empty the bladder).R5's physician orders include the following, in part: Indwelling foley catheter - order date: 5/30/25. R5's most recent care plan includes the following, in part: [R5] has an indwelling foley catheter due to neurogenic bladder.Hx (history) of MRSA (methicillin-resistant staphylococcus aureus / antibiotic-resistant bacteria) in urine, Has recurrent UTIs (urinary tract infections), enhanced barrier precautions.On 4/26/26 at 12:32 PM, Surveyor observed R5 in the dining room. R5's catheter bag was hooked onto the bottom of his wheelchair and had a front dignity flap on it to hide the urine from view. The catheter bag was in direct contact with the floor.On 4/26/26 at 12:47 PM, Surveyor pointed out R5's catheter bag touching the floor to NS D (Nursing Scheduler). NS D indicated it should not be on the floor and said she would ensure it was adjusted after R5 was finished in the dining room.On 4/26/26 at 3:46 PM, Surveyor observed R5 in his room. R5's was in his recliner chair and his catheter bag was hooked onto his recliner with the majority of the bag in direct contact with the floor.On 4/26/26 at 4:00 PM, Surveyor observed R5's catheter bag on the floor with RN E (Registered Nurse). RN E said the bag was hooked on the recliner. Surveyor asked if it should be lying on the floor even if it's hooked on the recliner. RN E said no and inserted the catheter bag into the pocket on the side of the recliner so it was no longer touching the floor.On 4/27/26 at 3:17 PM, Surveyor asked DON B (Director of Nursing) if urinary catheter bags should ever be touching the floor. DON B said no. Example 2:R8 admitted to the facility on [DATE] with diagnoses that include, in part: functional urinary incontinence (loss of bladder control due to an impairment) and neuromuscular dysfunction of bladder (nerve damage which interrupts signals between nervous system and bladder function). R8's physician orders include the following, in part: Indwelling foley catheter.for urinary retention diagnosis - order date: 4/17/26.On 4/26/26 at 12:32 PM, Surveyor observed R8 in the dining room. R8's catheter bag was hooked onto the bottom of her wheelchair and had a front dignity flap on it to hide the urine from view. The catheter bag was in direct contact with the floor.On 4/26/26 12:42 PM, Surveyor observed DM/CNA F (Dietary Manager & Certified Nursing Assistant) assist R8 back to her room in her wheelchair. Surveyor stopped DM/CNA F and asked if her catheter bag was dragging on the floor. DM/CNA F looked at R8's catheter bag and said yes, the front part was touching the floor. DM/CNA F attempted to adjust the catheter bag on the wheelchair frame, but it slid back down. DM/CNA F said she would tell someone.On 4/26/26 at 12:46 PM, DM/CNA F told Surveyor the catheter bag had been adjusted.On 4/27/26 at 3:17 PM, Surveyor asked DON B (Director of Nursing) if urinary catheter bags should ever be touching the floor. DON B said no.

Based on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 14 sampled Residents (R32).R32 was not assisted with toileting between 8:15 AM and 1:53 PM.This is evidenced by:The facility's policy Standard ADL (Activities of Daily Living) Protocol, undated, includes: ADLS: .toileting. Problem: Individual requires assistance with Activities of Daily Living (ADLs). CNA: Toileting every 2 or 3 hours or per individual preference. Provide incontinence care as needed.R32 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset and vascular dementia.R32's Significant change is status assessment MDS (Minimum Data Set), dated 2/20/26, has a BIMS (Brief Interview for Mental Status) score of 00, indicating R32 has severe cognitive impairment.R32's comprehensive care plan, printed 4/27/26, includes: Focus: R32 has an ADL self-care performance deficit r/t (Related To) Dementia.Interventions: Toilet Use: R32 is totally dependent on (2) staff for toilet use. Use two staff for incontinence cares. Transfer: R32 is totally dependent on (2) staff for transferring using a hoyer lift.Focus: R32 has urge and functional bowel/bladder incontinence r/t (Related To) need for assist with toileting.Interventions: offer toileting upon rising and after mealsOn 4/27/26 from 9:32 AM until 12:10 PM, Surveyor observed R32. During this time, R32 remained in her wheelchair. R32 spent much of that time in the dining room. R32 did propel herself around inside the building and sat in the lounge for a brief period of time. At 12:10 PM, R32 was sitting at the dining room table being served lunch.On 4/27/26 at 12:45 PM, Surveyor observed R32 sitting at the dining room table eating lunch.On 4/27/26 at 1:30 PM, Surveyor observed R32 sitting at the dining room table eating yogurt.On 4/27/26 at 1:32 PM, Surveyor interviewed CNA J (Certified Nursing Assistant). CNA J indicated she was assigned to R32 for the day. CNA J indicated she arrived to work around 8:30 AM, and R32 was already in the dining room for breakfast. CNA J indicated CNA K had assisted R32 for R32's morning cares. CNA J indicated she was not sure the last time R32 was provided incontinence care.On 4/27/26 at 1:34 PM, Surveyor interviewed CNA K regarding R32. CNA K indicated she is not assigned to R32's unit but did get R32 up. CNA K indicated she assisted R32 with incontinent care and getting R32 into her wheelchair for breakfast at 8:15 AM. CNA K indicated CNA J was assigned to R32 for the day. CNA K indicated toileting should be provided every 2 to 3 hours. CNA K indicated she had not assisted R32 after getting her up at 8:15 AM.On 4/27/26 at 1:53 PM, CNA J came to the dining room to assist R32 to her room. CNA J and CNA K assisted R32 into bed and provided incontinence care. Surveyor observed R32's brief to be saturated with urine and feces.On 4/27/26 at 2:10 PM, Surveyor interviewed CNA J. CNA J indicated toileting should be provided every 2 to 3 hours.On 4/27/26 at 2:11 PM, Surveyor interviewed RN L (Registered Nurse). RN L indicated toileting and repositioning for residents should occur every 2 hours.On 4/27/26 at 2:14 PM, Surveyor interviewed CNA H. CNA H indicated she had not assisted CNA J in providing incontinence care to R32. CNA H indicated toileting should be provided every 2 hours.On 4/27/26 at 3:00 PM, Surveyor interviewed DON B (Director of Nursing) regarding incontinence care. DON B indicated R32 should be assisted before and after meals with incontinence care. Surveyor informed DON B of the observation and interviews that staff had not provided incontinence care to R32 between 8:15 AM and 1:53 PM. DON B indicated R32 should have been toileted during that time.

Based on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASRR) process for 1 of 5 residents (R13) reviewed for PASRR screening. R13 did not have a PASRR Level 2 completed. This is evidenced by: Facility policy SNF Admissions, admission Criteria/Requirements revised 2/11/26, states, in part: .Policy: Uniform guidelines will be in place to promote clear expectations around the admission of individuals to the skilled nursing facility (SNF). Procedure: F. Residents diagnosed with serious mental illness or developmental disabilities will be screened prior to admission utilizing Preadmission Screen and Resident Review (PASRR). a. PASRR will contribute to individual's plan of care. b. PASRR level 2 screen may be utilized to determine the facilities' ability to manage the individual need. R13 was admitted to the facility on [DATE] with diagnoses of Neurocognitive disorder with Lewy Bodies (a progressive brain disease that disrupts thinking, movement, sleep and mood), Parkinson's (progressive brain disorder reducing the production of a chemical called dopamine, which causes movement related issues, such as tremors, muscle stiffness, slow movement, and balance problems), and dementia (a decline in brain function that interferes with daily life usually caused by irreversible brain damage). Surveyor requested PASRR II documentation for R13. On 4/28/26 at 12:10 PM, AD I (Admissions Director) indicated they were unable to locate a PASRR II on file for R13. On 4/28/2026 at 11:22 AM, Surveyor interviewed AD I. Surveyor asked AD I If you are looking at R13's PASSR Level 1, would you expect that she would need a level II. AD I stated Yes I would. It looks like the person that was doing this job before never turned it in but I'm submitting a new one right now. On 4/28/2026 at 11:36 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A Would you expect that R13 should have a PASRR level II completed, after looking at the level 1 screen. NHA A stated Yes, she should of had the level II done, our former Social Worker should have done one but didn't.

Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status and consult with the residents Physician on this for 1 of 3 residents (R3) reviewed for nutrition. R3 had a severe weight loss of 9.94% in 3 weeks. The facility did not notify the physician. The facility did not put interventions in place. Evidenced by:The facility policy entitled Nutrition at Risk, dated 11/30/06, states, in part: . Policy: Will provide services for nutritionally at-risk residents.Purpose: To ensure that these situations are addressed promptly and adequately.When a resident is determined to be at risk nutritionally, dining and nursing personnel will address the problem by assessment, diagnosis, care plan, implementation of action, and evaluation of the action in the respective discipline progress notes.1. Weight. C. 1. Abnormal fluctuation in weight would indicate nutritional risk. Interval Significant Loss 1 month 5% 3 months 7.5% 6 months 10% .3. Interventions A. Supplements/Fortified Foods/Scheduled Snacks B. Counseling by Registered Dietician/Dining Director. E. MD (Medical Director)- for diagnostic procedures. F. Recommend diet change. 2. Update resident care plan- quarterly and as needed.3. Re-evaluation process- at risk residents are charted on a minimum of one time per month by the Registered Dietician or Dining Director. R3 admitted to the facility on [DATE] and has diagnoses that include muscle weakness, repeated falls, and congestive heart failure (a chronic, progressive condition where the heart cannot pump blood efficiently, causing fluid buildup (congestion) in the lungs and body). R3's Care Plan, dated 4/06/26, states, in part: . Focus: Resident is at nutritional risk related to low BMI (Body Mass Index). Residents have increased needs for wound healing. Resident with RA (Rheumatoid arthritis), low back pain, COPD (Chronic Obstructive Pulmonary Disease), chronic respiratory failure and anemia which may affect meal intake and weight status. Allergy to banana and whole egg. Date Initiated: 4/06/26. Revision on: 4/06/26.Goal: The resident will safely consume foods/fluids to meet energy needs to maintain weight and meet fluid needs for hydration as health permits through review date. Date Initiated: 4/06/26. Revision on: 4/06/26. Target Date: 6/30/26.Interventions: .-Monitor and record weight as ordered. Notify MD (Medical Director)/responsible party of significant weight changes. Date Initiated: 4/06/26.-Monitor/record/report to MD PRN (as needed) s/sx (signs and symptoms) of malnutrition: Emaciation., muscle wasting, significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date Initiated: 4/06/26.-Provide and serve supplements as ordered: Med Pass 2.0- 60 mL (milliliters) TID (three times a day)-Mighty shakes TID. Date Initiated: 4/06/26. Revision on: 4/27/26.Note: There are no new interventions put into place 4/23/26 when weight loss triggered. R3's Nutritional Assessment, dated 4/06/26, states, in part: . C. Current Diet Order: General/RegularD. Current Supplements: None at present.I. Usual Body Weight: 100#J. Ideal Body Weight: 120# +/- 10% .L. Weight Goal: maintain/gain.AD. Diagnosis: Resident at nutritional risk related to low BMI. Resident has increased needs for wound healing. Resident with RA, low back pain, COPD, chronic respiratory failure and anemia which may affect meal intake and weight status. Allergy to banana and whole egg.AE. Interventions: Diet per MD order-General/Regular. Allergy to banana and whole egg. Med Pass 2.0- 60 mL TID. Monitor and record meal intake daily. Monitor weights per MD order for changes. Medications per MD order. Monitor labs as available. Offer alternates to meals disliked.AF. Monitoring: Intake, weight, labs and skin.AH. The resident will safely consume foods/fluids to meet energy needs to maintain weight and meet fluid needs for hydration as health permits. R3's weight record:4/01/26- 100.6 pounds4/02/26- 102 pounds4/16/26- 93 pounds4/23/26- 90.6 poundsNote: This shows R3 had a 9.94% severe weight loss in three weeks. R3's Physicians Orders, dated 4/27/26, states, in part: . General/Regular diet Regular texture, thin consistency. Start Date: 4/06/26.Med Pass 2.0 three times a day 60 mL TID. Start Date: 4/06/2026.Weekly weights every day shift every Thu for monitoring for 4 weeks. Start Date: 4/09/26. Of note: there is no MD notification that was found by Surveyor regarding weight loss in R3's progress notes. On 4/26/26 at 9:49 AM, Surveyor interviewed R3. R3 indicated the food in the facility is terrible. R3 indicated the food has no taste, no salt, and is very bland. R3 indicated her weight is down to 90 pounds from 100 pounds in just a few weeks. Surveyor asked if R3 receives a nutritional supplement. R3 indicated she receives Ensure once and awhile. R3 indicates she does not like it. Surveyor asked R3 if the facility has offered her other flavors or other supplemental choices. R3 indicated no.On 4/27/26 at 10:57 AM, Surveyor interviewed RD O (Registered Dietician) and reviewed R3's weights with RD O. On 4/1/26 admission, R3's weight was 100.6 pounds. On 4/23/26, R3's weight was 90.6 pounds indicating a 9.94% weight loss. Surveyor asked RD O if the 9.94% weight loss in three weeks is considered a severe weight loss. RD O indicated looking at R3's medical record, R3 is triggering for a severe weight loss. Surveyor asked RD O if R3 is at nutritional risk, and RD O indicated yes. Surveyor asked RD O what the process is for monitoring weights in the facility. RD O indicated the process for monitoring weights is the nurses take weights monthly or whatever is ordered. RD O then reviews the weights weekly and then sends a summary to the DON (Director of Nursing) and NHA (Nursing Home Administrator) to include weight discrepancy and what I recommend and what I feel is going on. The DON/NHA then notifies the nurse practitioner of the weight loss and recommendations. RD O indicates she puts interventions in place. Surveyor asked RD O, would she expect the physician to have been updated on R3's weight loss. RD O indicated yes as soon as the weight loss was identified. Surveyor asked RD O if she would expect interventions to be put into place for R3's weight loss. RD O indicated she would have expected a re-weigh when the weight dropped from 102 pounds to 93 pounds to verify the weight is accurate. After the re-weigh, I would expect interventions to be put into place and MD updated by the facility. Surveyor asked RD O if there have been any new interventions put into place with R3's weight loss. RD O indicated Med Pass 60 mLs TID (three times a day) was entered 4/06/26 into R3's medical chart and nothing since. Surveyor asked if RD O, with a severe weight loss such as R3s, would RD O expect a new intervention to be put into place and the care plan updated. RD O indicated yes.On 4/27/26, at 12:22 PM, Surveyor interviewed RN G (Registered Nurse) and asked what the process is for obtaining/monitoring weights. RN G indicated the cnas obtain the weights and report them to the nurse. The nurse enters the weight into the resident's medical record. If the weight flags +/- 5%, 7%, or 10% the nurse is responsible for notifying the MD. On 4/27/26, at 2:52PM, Surveyor interviewed DON B and reviewed R3's weights. Surveyor asked DON B if this 9.94% weight loss in three weeks is a severe weight loss. DON B indicated that 9.94% weight loss is significant. Surveyor asked if she would expect the physician to be notified of R3's weight loss of 9.94% and it be documented. DON B indicated yes. Surveyor asked if DON B would expect interventions to be put into place regarding R3's weight loss of 9.94%. DON B indicated yes.

Based on observation and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (R5) reviewed for hand hygiene while performing perineal (cleansing of the genital area) and catheter care (cleansing of the catheter tubing).CNA H (Certified Nursing Assistant) had a breach in infection control when performing perineal and catheter care.This is evidenced by:Facility policy, titled Hand Hygiene, reviewed on 5/8/25, states in part: Policy: The organization will promote clean hands as the single most important factor in preventing the spread of pathogens, antibiotic resistance, and incidence of infections. Procedure: A. Specific Indications for Hand Hygiene: 1. Immediately before touching a patient. 3. Before moving from work on a soiled body site to a clean body cite on the same patient. 4. After touching a patient or the patient's immediate environment. 5. After contact with blood, body fluids, or contaminated surfaces. 6. Immediately after glove removal.Surveyor requested a perineal or catheter care policy from facility. Facility provided a photocopy of perineal care instructions from a textbook. The title and publication date of the textbook were not provided. The instructions state, in part: .Completing the procedure: .Dispose of soiled articles in the appropriate receptacle. Remove and discard your gloves. Perform hand hygiene.On 4/28/26 at 7:45 AM, Surveyor observed CNA H perform perineal and catheter care for R5 while he was lying down in bed. CNA H applied a gown and gloves and then cleaned, rinsed, and dried R5's perineal area and catheter tubing. Without removing gloves and performing hand hygiene, CNA H proceeded to assist R5 with getting up, dressed, and into his wheelchair. CNA H also made R5's bed. On 4/28/26 at 8:02 AM, Surveyor asked CNA H if her hands were dirty after completing perineal and catheter cares for R5. CNA H said yes and indicated she should have washed her hands and changed her gloves after completing cares. On 4/28/26 at 10:00 AM, Surveyor interviewed DON B (Director of Nursing) and asked if hand hygiene and a glove change should be done after completing perineal and catheter care before going on to assist a resident with getting dressed and making his or her bed. DON B said yes.

Based on observation, interview and record review, the facility did not ensure each resident had a safe, clean, comfortable, and homelike environment or ensure housekeeping provided necessary services to maintain a sanitary, orderly, and comfortable area for 4 of 4 bathrooms affecting 7 residents (R4, R5, R6, R7, R8, R9, R10) reviewed for cleanly environment.R4 and R5's shared bathroom had a strong urine odor. There was dried urine and feces on the toilet chair (a device that sits over a toilet to provide extra support when using an existing toilet) and rim of the toilet. There was dried urine on the floor.R6's bathroom had feces on the toilet chair and rim of the toilet and the inside walls of the toilet.R7 and R8's shared bathroom had a strong urine odor. There was dried urine on the floor. There was feces on the back of the toilet chair. There was urine and toilet paper in the toilet.R9 and R10's shared bathroom had a strong urine odor. There was urine and toilet paper in the toilet. There was dried urine on the floor. The toilet paper on the floor was saturated with urine and dried.This is evidenced by:The facility does not have a policy and procedure for housekeeping.On 2/3/26 at 3:28 PM, NHA A (Nursing Home Administrator) indicated the facility does not have a policy and procedure for housekeeping.On 2/3/26 at 12:38 PM, Surveyor observed the following:R4 and R5's shared bathroom had a strong urine odor. There was dried urine and feces on the toilet chair and rim of the toilet. There was dried urine on the floor.R6's bathroom had feces on the toilet chair and rim of the toilet and the inside walls of the toilet.R7 and R8's shared bathroom had a strong urine odor. There was dried urine on the floor. There was feces on the back of the toilet chair. There was urine and toilet paper in the toilet.R9 and R10's shared bathroom had a strong urine odor. There was urine and toilet paper in the toilet. There was dried urine on the floor. The toilet paper on the floor was saturated with urine and dried.On 2/3/26 at 12:46 PM, Surveyor and CNA C (Certified Nursing Assistant) observed the residents' bathrooms. Surveyor interviewed CNA C regarding the bathrooms. Surveyor asked CNA C about R4 and R5's bathroom. CNA C indicated there was dried urine and feces on the toilet chair and rim of the toilet, dried urine on the floor, and the bathroom smelled of urine. Surveyor asked CNA C about R6's bathroom. CNA C indicated R6's bathroom had feces on the toilet chair, rim of the toilet, and the inside walls of the toilet. CNA C indicated R7 and R8's bathroom had a strong urine odor, dried urine on the floor, feces on the back of the toilet chair, and urine and toilet paper in the toilet. CNA C indicated R9 and R10's bathroom smelled of urine, there was urine and toilet paper in the toilet, there was dried urine on the floor, and the toilet paper on the floor was saturated with urine and dried. CNA C indicated these bathrooms are not clean. CNA C indicated housekeeping is responsible for the cleaning of the rooms. CNA C indicated HSK D (Housekeeper) is the only person for housekeeping and laundry.On 2/3/26 at 1:26 PM, Surveyor interviewed HSK D (Housekeeper). HSK D indicated she is the only person for housekeeping and laundry. HSK D indicated she is unable to get all the laundry done and clean the resident's rooms. HSK D indicated MNT E (Maintenance) oversees the housekeeping department. HSK D stated she has told MNT E that she is not able to complete both housekeeping and laundry by herself. HSK D indicated there is no checklist or schedule for resident rooms to be cleaned but each room should be cleaned daily. HSK D indicated the floors should be swept and mopped, high touch surfaces wiped down, trash taken out, and the bathrooms cleaned.On 2/3/26 at 1:43 PM, Surveyor interviewed MNT E (Maintenance). MNT E indicated he oversees the housekeeping department. MNT E stated he has talked with HSK D about her not being able to get both housekeeping and laundry completed. MNT E stated that HSK D mostly does laundry but helps with cleaning. MNT E stated he is responsible for cleaning the floors, like the lobby, hallways, etc. MNT E stated there are no hard schedules, check list or calendars on when the residents' rooms get cleaned. MNT E indicated resident rooms are cleaned twice a week. MNT E indicated resident rooms get touched every day as a rule, floors, high contact areas, doorknobs, toilets, and faucets. Surveyor and MNT E went to R4, R5, R6, R7, and R8's bathrooms. MNT E indicated these bathrooms are not clean. Surveyor and MNT E were unable to review R9 and R10's bathroom.On 2/3/26 at 3:13 PM, Surveyor interviewed DON B (Director of Nursing) regarding resident rooms. DON B indicated resident rooms should have their bathrooms cleaned and their floors swept and mopped every day. DON B indicated this should happen for every resident room daily. DON B indicated the CNAs are responsible for keeping the rooms tidy and picking up any bathroom messes and then housekeeping should be cleaning and sanitizing the bathrooms. DON B indicated she was made aware the bathrooms were not clean and she would expect them to be clean.

Based on interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect 33 of 33 residents residing in the facility. The facility's Water Management Plan team members were not aware of their role nor were control measures being executed and documented. The facility had no infection control rates calculated for the past year. The facilities COVID-19 and Pneumococcal vaccine protocol does not contain the newest Centers for Disease Control and Prevention (CDC) guidance. The facility has two policies and procedures that were not reviewed annually. This is evidenced by: The facility's Policy and Procedure titled Water Management Program (Legionella) dated 12/13/23 documents in part: .A. Water Management Team i. Entity's Water Management Program is overseen by the Water Management Team. ii. The team consists of, at a minimum, the Executive Director, Environmental Services Lead, and Infection Preventionist .C. Monitoring i. The Water Management Team will be responsible for monitoring risk and identifying potential cases or breaches of control measures of concern .vii. If rooms are closed due to low census or put out of use, a routine process will be implemented to run faucets, showers, and to flush toilets. viii. Documentation will be retained .D. Water Management Plan i. The Water Management Plan will be reviewed annually or more often as indicated . The facility's Risk Management Plan for Legionella Control dated 4/22/22 documents in part: .Operational and Verification Monitoring .Verification monitoring involves the taking of samples for analysis of a particular parameter. The results of the samples confirm that control measures are effective and water quality risk is being managed .System Component: Water Heaters, Risk: Water Temp (temperature) Fall Below 135, Frequency: Monitor temperature of all water heaters weekly .System Component: Circulation Pumps, Risk: Causing large dead leg areas in system, Frequency: Check operation of all pumps weekly . The facility's Policy and Procedure titled Individual Immunizations dated 12/5/24 documents, in part: .1. Immunization .b Individual will be offered immunization based upon the CDC recommendations and guidelines and as prescribed by their PCP (Primary Care Provider) . The facility's Policy and Procedure titled Infection Prevention and Control Program dated 12/5/24 documents in part: .4. Investigating i. Trends and patterns will be discussed with the Quality Assurance Performance Improvement (QAPI) committee. Process Improvement Projects will be charted and managed around identified opportunities for improvement, resulting in countermeasures . Example 1 DON/IP B (Director of Nursing/Infection Preventionist) and FSM H (Facility Service Manager) were not aware that they were part of the Water Management Team. The control measures to prevent Legionella were not being completed routinely or documented. On 2/13/25 at 8:10 AM, Surveyor interviewed FSM H. Surveyor asked FSM H what role you play in the Water Management Team? FSM H said we've not had a meeting about it, but recently I've found bits and pieces about it. Surveyor asked FSM H what control measures are being done on a routine basis to ensure that the facility doesn't develop Legionella? FSM H replied, empty rooms are being cleaned, flushing toilets, and in soiled utility room, dumping water in drain. Surveyor asked FSM H if there is documentation in place for this? FSM H replied they are working on putting that together. Surveyor asked FSM H if water heater temperatures are being monitored; FSM H stated not really. Surveyor asked FSM H if circulation pumps are being monitored; FSM H said the boiler room is my first stop in the morning. Surveyor asked FSM H if there was documentation of that, FSM H said no. On 2/13/25 at 9:44 AM, Surveyor interviewed DON/IP B. Surveyor asked DON/IP B what role you play in the Water Management Team? DON/IP B stated nothing yet. Surveyor asked DON/IP B, do you know what control measures should be being done on a routine basis to ensure that the facility doesn't develop Legionella; DON/IP B stated no. Example 2 The facility's Immunization Protocol information is not up to date with the most recent recommendations: The facility provided the following: The CDC's Recommendation Adult Immunization Schedule United States 2024 dated 11/16/23 documents, in part: .COVID-19 vaccination .2023-2024 formula not the most recent update .Pneumococcal vaccination: Age [AGE] years or older . It is important to note: CDC's Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States dated 10/31/24 documents, in part: .People ages [AGE] years and older, vaccinated under the routine schedule, are recommended to receive 2 doses of any 2024-2025 COVID-19 vaccine (i.e., Moderna, Novavax, or Pfizer-BioNTech) separated by 6 months (minimum interval 2 months) regardless of vaccination history, with one exception: Unvaccinated people who initiate vaccination with 2024-2025 Novavax COVID-19 Vaccine are recommended to receive 2 doses of Novavax followed by a third dose of any COVID-19 vaccine 6 months (minimum interval 2 months) later . The CDC's Pneumococcal Vaccine Recommendations dated 10/26/24 documents in part: CDC recommends pneumococcal vaccination for children younger than 5 years and adults [AGE] years or older. The facility policies did not have the newest information for COVID-19 and Pneumococcal vaccinations. On 2/13/25 at 9:44 AM, Surveyor interviewed DON/IP B. Surveyor asked DON/IP B if she was familiar with the most recent update to the CDC's COVID-19 and pneumococcal vaccine recommendations; DON/IP B replied, no. Surveyor asked DON/IP B, does your policy for vaccines reflect these updates; DON/IP B stated no. Example 3 Surveyor reviewed the facility's Risk Management Plan for Legionella Control dated 4/22/22 and the facility's Policy and Procedure titled Water Management Program (Legionella) dated 12/13/23. On 2/13/25 at 9:44 AM, Surveyor interviewed DON/IP B. Surveyor asked DON/IP B how often the facility's infection control policies are reviewed. DON/IP B looked to Regional Nurse Consultant and replied annually and upon any changes/updates. It should be noted these policies were not updated annually. Example 4 The facility did not have any infection control rates completed for the past year. Infection control rates are one way for a facility to track and trend the type of infections the facility has had month over month and year over year. Upon Surveyor's request, DON/IP B came to get the monthly infection control documentation that she had provided for review. On 2/13/25 at 9:44 AM, Surveyor interviewed DON/IP B. Surveyor asked DON/IP B when infection control rates are completed. DON/IP B said at the end of the month. Surveyor asked DON/IP B when these infection control rates were completed. DON/IP B stated when you asked for them.

Based on interview and record review, the facility failed to ensure that residents advance directive was signed by resident or resident representative for 1 of 3 (R18) reviewed for advanced directives. The code status preference form for R18 was not completed when she went from Do Not Resuscitate (DNR) to wanting Cardiopulmonary Resuscitation (CPR). Findings include The facility's code status policy states, in part: *If an individual wishes to be a full code, the individual's wishes will be maintained within the medical record *Staff will identify an individual's code status by documentation within the medical record *The individual's medical record will be the primary reference in case of an emergency to verify code status. The facility commonly uses a Resident CPR Preference Form to indicate the resident's choice between 1) No--I do NOT want cardiopulmonary resuscitation attempts or 2) YES--I want cardiopulmonary resuscitation attempts. This form is then signed by the resident or their representative. R18 was admitted to the facility on [DATE]. She was deemed incapacitated prior to her admission to the facility. The facility's records indicate R18's Power of Attorney (POA) signed a Resident CPR Preference Form indicating R18 Did NOT want cardiopulmonary resuscitation attempts. Additionally, R18's POA signed a state DNR form on behalf of R18 on [DATE]. R18 required a hospital stay, starting [DATE] and returning back to the facility on [DATE]. Hospital discharge paperwork, dated [DATE], indicated family had revoked R18's DNR. On [DATE] at 2:39 PM, Surveyor interviewed POA G (R18's Power of Attorney) who stated that shortly after R18 returned from the hospital, she (POA G) went to the nurse's station and told facility staff that they had revoked the DNR and wished R18 to be full code. The staff stated they would take care of it. POA G stated that she checked back in a few days later to make sure the facility had updated R18's status and facility staff had said it was done. POA G stated she was never asked to sign anything. On [DATE] at 4:35 PM, Surveyor interviewed ADON C (Assistant Director of Nursing) who stated that any resident that goes from a signed DNR to full code needs representative signed document. At this time, ADON C provided Surveyor an updated and POA-signed Resident CPR Preference Form indicating R18 wanted CPR. The form was dated [DATE]. ADON C indicated the form should have been given to R18's POA.

Based on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan included a sleep assessment and sleep monitoring/tracking to meet the resident's medical, nursing, and mental and psychosocial needs for 3 of 6 residents (R8, R15, and R30) reviewed for unnecessary medications. R8 is receiving Melatonin for sleep and did not have a sleep assessment or sleep tracking. R15 is receiving Melatonin for sleep and did not have a sleep assessment or sleep tracking. R30 is receiving Melatonin for sleep and did not have a sleep assessment or sleep tracking. This is evidenced by: Example 1 R8 was admitted to the facility on [DATE] with diagnoses that include, in part: depression, unspecified (medical condition characterized by low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning); insomnia, unspecified (a sleep disorder characterized by difficulty falling or staying asleep, resulting in poor sleep quality and daytime fatigue); other specified anxiety disorders (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life); and panic disorder (a disorder characterized by a sudden wave of fear or discomfort or a sense of losing control even when there is no clear danger). R8's Minimum Data Set (MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) of 15, indicating R8 is cognitively intact. R8's physician orders include, in part: Melatonin 3 mg by mouth at bedtime related to insomnia-order date 10/30/24. Surveyor requested a policy on sleep assessments/tracking and R8's sleep assessment and monitoring documentation. Documentation was not provided. Example 2 R15 was admitted to the facility on [DATE] with diagnoses that include, in part: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (when a person exhibits symptoms of dementia but the cause cannot be determined. Symptoms of dementia include memory loss, difficulty with thinking and problem solving, confusion and disorientation, changes in personality and behavior, and reduced ability to manage daily activities.), insomnia due to other mental disorder; and anxiety disorder. R15's MDS dated [DATE] indicates a BIMS of 0, indicating R15 has severe cognitive impairment. R15's physician orders include, in part: Melatonin 3 mg by mouth at bedtime related to insomnia due to other mental disease. Start date: 1/12/2025 Surveyor requested R15's sleep assessment and monitoring. Documentation was not provided. Example 3 R30 was admitted to the facility on [DATE] with diagnoses that include, in part: Alzheimer's Disease (a progressive brain disorder that causes memory loss, thinking problems, and behavioral changes) and dementia with behavioral disturbance. R30's MDS dated [DATE] indicates a BIMS of 10, indicating R30 has moderate cognitive impairment. R30's physician orders include, in part: melatonin 3 mg by mouth at bedtime for insomnia. Start date: 11/14/24 Surveyor requested R30's sleep assessment and monitoring. Documentation was not provided. On 2/13/25 at 8:04 AM, Surveyor interviewed DON B (Director of Nursing) and asked about protocol when sleep medications are ordered. DON B stated a sleep assessment is completed and targeted behaviors are added to the MAR (Medication Administration Record). Surveyor asked if R8, R15, and R30 had sleep assessments and sleep tracking. DON B stated no. Surveyor asked if the facility would expect that a sleep assessment and sleep tracking would be completed for residents with melatonin. DON B stated yes.

Based on observation, interview, and record review, the facility did not ensure that the resident environment remains as free of accident and hazards as possible for 1 of 1 sampled residents (R8). Surveyor observed R8's motorized wheelchair (Motorized Assistive Devices) being charged in her room. Staff state the wheelchair should be charged in the Beauty Shop. Evidenced by The facility policy, Motorized Assistive Device, reviewed 11/8/23, documents, in part, as follows: Policy: Individuals identified to use motorized assistive devices to reach the highest level of independent mobility will demonstrate safe and proper use of the equipment. Battery Storage: Batteries must be charged in a non-resident approved area. On 2/11/25 at 12:00 PM, Surveyor observed R8's motorized wheelchair battery plugged in and charging in her room next to R8's bed where R8 was sleeping. On 2/11/25 at 12:05 PM, Surveyor asked NHA A (Nursing Home Administrator) to come to R8's room. Surveyor asked NHA A, is it acceptable to charge R8's motorized wheelchair in her room. NHA A stated, no, all wheelchairs are to be charged in the Beauty Shop. On 2/11/25 at 12:07 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated, motorized wheelchairs are to be charged in the Beauty Shop. DON B stated, motorized wheelchairs are not to be charged in resident rooms. On 2/13/25 at 9:50 AM, Surveyor spoke with CNA I (Certified Nursing Assistant). Surveyor asked CNA I, where are motorized wheelchairs charged. CNA I stated, in the Beauty Shop. CNA I stated, we currently only have one (1) resident with an motorized wheelchair. R8 is the resident with an motorized wheelchair. On 2/13/25 at 9:55 AM, Surveyor observed NHA A (Nursing Home Administrator) walking down the hall by the Beauty Shop. Surveyor asked NHA A, should wheelchair batteries be charged behind a fire safe door. On 2/13/25 at 1:11 PM, Surveyor spoke with DON B (Director of Nursing). DON B shared the following education she started with staff: Education electric wheelchair charging: All power chairs, electric scooters or electric wheelchairs need to be charged in the Beauty shop ONLY. If staff notice that a resident is attempting to or has plugged in the electric device anywhere but the Beauty shop, it must immediately be unplugged and the charger removed from room. Remind the resident of the charging procedure. If the chair needs charging bring it to the Beauty shop for full charging.

Based on observation, interview, and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 2 residents (R6) reviewed for pain management. The facility failed to provide R6 with his scheduled pain patch and effectively manage his pain causing him to miss two physical therapy sessions. The facility also failed to assess the resident's pain goal and complete a comprehensive care plan to include his pain goal and non-pharmacological interventions. This is evidenced by: The facility policy entitled, Pain, dated 8/10/23, states, in part: Policy: Nursing staff will identify appropriate treatment and services for each individual's pain management .2. Care Planning a. Staff will manage an individual-centered interdisciplinary care plan and implement interventions/approaches to pain management including non-pharmacological interventions . 4. Notification. a. The medical provider will be consulted if pain interventions are not effective. b. The individual and/or individual representative will be updated on any changes. The facility policy entitled, Medication Administration-General Guidelines, dated 12/2019, states, in part, . B. Administration . 2) Medications are administered in accordance with written orders of the prescriber . D. Documentation (including electronic) . 6) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time . If electronic MAR (medication administration record) is used, documentation of the unadministered dose is done as instructed by the procedures for use of the eMAR system. An explanatory note is entered on the reverse side of the record . 7) If an electronic MAR system is sued, specific procedures required for . documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's use manual . On 2/11/25 at 12:20 PM, Surveyor interviewed R6. R6 indicated he was not getting his pain medication as prescribed, which was preventing him from participating in therapy. R6 states that staff frequently run out of his lidocaine patches, and sometimes cut them in half due to not having enough patches. R6 was admitted to the facility on [DATE], with diagnoses that include, in part: Adult failure to thrive, chronic obstructive pulmonary disease (lung disease causing difficulty breathing), muscle weakness, personal history of (healed) traumatic fracture, and other chronic pain. R6's Admission Minimum Data Set (MDS), with a target date of 11/27/24, indicates R6 has a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R6 is cognitively intact. Section J indicates R6 frequently has pain, the pain rarely effects his sleep, the pain frequently interferes with therapy activities, and the pain occasionally interferes with day-to-day activities. R6's Comprehensive Care Plan states, in part: Focus: resident has (chronic) pain r/t (related to) History of [sic] Fracture left lower extremity, pressure injury left buttock, non-pressure injury left calf. Goal: The resident will not have an interruption in normal activities due to pain through the review date. The resident will not have discomfort related to side effects of analgesia through the review date. The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Will verbalize adequate relief of pain using numeric pain scale through review date. Interventions: Administer analgesia as per orders. Give 1/2 hour before treatments or care. Administer medication per MD (medical doctor) order. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions (prn) Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Of note: There is no documented pain goal for R6 or effective non-pharmacological interventions. Physician Orders state, in part: Lidocaine External Patch. Directions: Apply to affected area topically one time a day for pain related to OTHER CHRONIC PAIN (G89.29) and remove per schedule. Start date: 12/31/24. Order status: Active. Record pain on scale of 0-10 every shift. Use number rating scale or Wong-Baker faces scale. Every shift. Start date: 11/20/24. Order status: Active. R6's Medication Administration Record states, in part: 1/15/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 which indicates the medication was not administered due to the medication not being available. 1/21/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 1/22/25: Lidocaine: Apply: 7:30 marked 16 1/23/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 1/24/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 2/6/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 2/7/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 2/10/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 R6's Pain Level documentation states, in part: 1/16/25 at 7:03 PM: 8 1/17/25 at 7:31 AM: 10 1/17/25 at 12:26 PM: 8 1/17/25 at 8:28 PM: 8 1/19/25 at 8:53 PM: 8 1/21/25 at 7:30 AM: 8 1/21/25 at 1:15 PM: 8 1/23/25 at 8:20 AM: 8 1/25/25 at 7:29 AM: 10 1/25/25 at 11:59 AM:8 1/27/25 at 7:37 AM: 10 1/30/25 at 12:19 AM: 9 1/31/25 at 7:32 AM: 9 2/1/25 at 7:19 AM: 9 2/2/25 at 8:07 AM: 9 2/5/25 at 8:28 AM: 9 2/6/25 at 9:18 AM: 9 2/7/25 at 7:52 AM: 8 2/10/25 at 3:55 PM: 8 On 2/11/25 at 2:50 PM, Surveyor interviewed PTA D (Physical Therapy Assistant). Surveyor asked PTA D if R6 has been compliant with his therapy. PTA D notes she only started working at the facility around 1 week ago, but states R6 has been compliant with her. Surveyor asked PTA D to check for notes regarding R6 missing therapy. PTA D searched her documentation and states on 1/20/25 there is a note written that states left lower extremity hurting too much not willing to do therapy. PTA D states on 2/5/25, there is a note written about R6 refusing therapy due to not being able to participate due to the pain in his leg. On 2/12/25 at 1:07 PM, Surveyor interviewed R6. R6 indicated he has a pain goal of 0 out of 10, however, he understands that he has chronic pain and just wants to participate in therapy, which he could do at a 6 or 7 out of 10. R6 emphasizes that he just wants to go home and needs to do therapy to go home. Surveyor asked R6 if there are any non-pharmacological interventions that help his pain. R6 reports heat helps the pain. Surveyor notes that during the interview, R6 was visibly wincing every time he attempted to reposition himself in his recliner. R6 reports his pain level is an 8 out of 10 at this time. Of note: R6's care plan does not have a goal pain level indicated and no non-pharmacological interventions are listed on the care plan or MAR (Medication Assessment Record) On 2/12/25 at 2:37 PM, Surveyor interviewed LPN E (Licensed Practical Nurse). Surveyor asked LPN E what the process is if a medication that is ordered for a resident is unavailable. LPN E states they try to pull it from contingency, if it is not available in contingency, they write a note and contact the pharmacy for resupply. Surveyor asked LPN E who has access to contingency stock. LPN E states only licensed nurses, so if med techs need a medication from contingency, they need to ask a licensed nurse. Surveyor asked LPN E if a provider should be contacted if a medication is missed. LPN E states, yes, because it is technically a medication error. On 2/13/25 at 8:49 AM, Surveyor interviewed LPN F. Surveyor asked LPN F what the process is if a medication that is ordered for a resident is unavailable. LPN F states if it's a normal medication they check contingency, if it's not in contingency, they contact the pharmacy to reorder the medication. Surveyor asked LPN F who has access to contingency stock. LPN F states all nurses have access. Surveyor asked LPN F if an ordered medication is not administered for any reason, should a progress note be written. LPN F states staff must write a progress note. Surveyor asked if any non-pharmacological interventions are effective for R6. LPN F states staff are frequently in his room repositioning him, but generally it's the pain medication that is effective. LPN F also states that PT (physical therapy) has been making R6 really sore. Surveyor asked LPN F what a 16 means on the MAR. LPN F states that it means the medication was not available. Surveyor advises LPN F that she marked R6's Lidocaine as 16 on the following dates: 1/15/25, 1/21/25, 1/24/25, and that no progress note was written. Surveyor asked LPN F if a progress note should have been written on those dates. LPN F states, yes, R6 should have had a progress note for those missed dates. On 2/13/25 at 10:35 AM, Surveyor interviewed DON B (Director of Nursing) B. Surveyor asked DON B what the expectation is if an ordered medication is not available. DON B indicates staff should let the doctor know so that they can hold the medication or change it to a different medication. DON B also indicates a progress note should be written. Surveyor asked DON B if there is a contingency stock. DON B states, that the licensed nurses have access. Surveyor asked DON B if a missed medication is considered a medication error. DON B states, yes, and it gets put into risk management, and the doctor, resident's power of attorney, and the resident are notified. Surveyor asked DON B what is R6's pain goal. DON B states we don't have a number goal for him, but that one should be listed as part of the pain assessment. Surveyor asked DON B if therapy should notify nursing staff if a resident is refusing therapy due to pain. DON B states, yes. Surveyor asked DON B if a pain goal should be part of R6's care plan. DON B states, yes. Surveyor asked DON B what non-pharmacological interventions are effective for R6. DON B indicates there are no non-pharmacological interventions on his care plan but there should be something documented. DON B also indicates there is nothing on the MAR regarding non-pharmacologic interventions. Surveyor asked DON B if she thinks R6's pain management is effective. DON B states, probably not, but he is going to a pain management clinic and has known addiction issues.

Based on interview and record review, the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident (R) for 1 of 1 residents (R6). R6 did not receive his ordered Lidocaine (Numbing medication used for pain control) on 1/21/25, 1/22/25, 1/23/25, 1/24/25, 2/6/25, 2/7/25, and 2/10/25 due to the medication not being available. This is evidenced by: The facility policy entitled, Medication Administration-General Guidelines, dated 12/2019, states, in part, . B. Administration . 2) Medications are administered in accordance with written orders of the prescriber . D. Documentation (including electronic) . 6) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time . If electronic MAR (medication administration record) is used, documentation of the unadministered dose is done as instructed by the procedures for use of the eMAR (electronic medication administration record) system. An explanatory note is entered on the reverse side of the record . 7) If an electronic MAR system is sued, specific procedures required for . documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's use manual . R6 was admitted to the facility on [DATE], with diagnoses that include, in part: Adult failure to thrive, chronic obstructive pulmonary disease (lung disease causing difficulty breathing), muscle weakness, personal history of (healed) traumatic fracture, and other chronic pain. R6's Admission Minimum Data Set (MDS), with a target date of 11/27/24, indicates R6 has a BIMS score of 13 out of 15, indicating R6 is cognitively intact. Section J indicates R6 frequently has pain, the pain rarely effects his sleep, the pain frequently interferes with therapy activities, and the pain occasionally interferes with day-to-day activities. Physician Orders state, in part: Lidocaine External Patch. Directions: Apply to affected area topically one time a day for pain related to OTHER CHRONIC PAIN (G89.29) and remove per schedule. Start date: 12/31/24. Order status: Active. R6's Medication Administration Record states, in part: 1/15/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 which indicates the medication was not administered due to the medication not being available. 1/21/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 1/22/25: Lidocaine: Apply: 7:30 marked 16 1/23/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 1/24/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 2/6/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 2/7/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 2/10/25: Lidocaine: Remove: 7:29, Apply: 7:30 both marked 16 On 2/11/25 at 12:20 PM, Surveyor interviewed R6. R6 indicated he was not getting his pain medication as prescribed, which was preventing him from participating in therapy. R6 states that staff frequently run out of his Lidocaine patches, and sometimes cut them in half due to not having enough patches. On 2/12/25 at 2:37 PM, Surveyor interviewed LPN (Licensed Practical Nurse) E. Surveyor asked LPN E what the process is if a medication that is ordered for a resident is unavailable. LPN E states they try to pull it from contingency, if it is not available in contingency, they write a note and contact the pharmacy for resupply. Surveyor asked LPN E who has access to contingency stock. LPN E states only licensed nurses, so if med techs need a medication from contingency, they need to ask a licensed nurse. Surveyor asked LPN E if a provider should be contacted if a medication is missed. LPN E states, yes, because it is technically a medication error. On 2/13/25 at 8:49 AM, Surveyor interviewed LPN F. Surveyor asked LPN F what the process is if a medication that is ordered for a resident is unavailable. LPN F states if it's a normal medication they check contingency, if it's not in contingency, they contact the pharmacy to reorder the medication. Surveyor asked LPN F who has access to contingency stock. LPN F states all nurses have access. Surveyor asked LPN F if an ordered medication is not administered for any reason, should a progress note be written. LPN F states staff must write a progress note. Surveyor asked LPN F what a 16 means on the MAR. LPN F states that it means the medication was not available. Surveyor advises LPN F that she marked R6's Lidocaine as 16 on the following dates: 1/15/25, 1/21/25, 1/24/25, and that no progress note was written. Surveyor asked LPN F if a progress note should have been written on those dates. LPN F states, yes, he should have had a progress note for those missed dates. On 2/13/25 at 10:35 AM, Surveyor interviewed DON (Director of Nursing) B. Surveyor asked DON B what the expectation is if an ordered medication is not available. DON B indicates staff should let the doctor know so that they can hold the medication or change it to a different medication. DON B also indicates a progress note should be written. Surveyor asked DON B if there is a contingency stock. DON B states, and that the licensed nurses have access. Surveyor asked DON B if a missed medication is considered a medication error. DON B states, yes, and it gets put into risk management, and the doctor, resident's power of attorney, and the resident are notified. R6 did not receive his lidocaine patch per physician orders on eight different occasions, resulting in medication errors.

Based on interview and record review, the facility did not ensure that residents (R) receiving psychotropic medication were free from unnecessary medications for 2 of 5 residents (R16 and R22) reviewed for unnecessary medications. R16 receives psychotropic medications. R16 does not have a care plan with targeted behaviors or behavior tracking for the anti-anxiety or antidepressant medications. R16 was receiving an as needed (PRN) anti-anxiety medication beyond 14 days without physician follow up. R22 receives psychotropic medication. R22 did not have an Abnormal Involuntary Movement Scale (AIMS; screening to identify abnormal movements which can develop as a side effect of antipsychotic medication use). Findings include: The facility's Standard Psychoactive Medications Protocol, undated, states, in part: .Goal: Individual will have minimized side effects of psychotropic drug use. MAA (medication assistant): .document target behaviors and report changes to licensed nurse.Nursing: .document target behaviors, interventions, and effectiveness . Complete AIMS per policy . The facility's Tardive Dyskinesia Monitoring policy, dated 7/22/22, states, in part: Policy: Individuals who receive antipsychotic medications will be monitored for signs and symptoms of Tardive Dyskinesia (TD) with the use of the Abnormal Involuntary Movement Scale (AIMS). Procedure: A. Individuals receiving antipsychotic medications will be monitored with an AIMS assessment every six months by a licensed nurse. B. Individuals who have a dose increase/decrease of antipsychotic medications should be monitored with an AIMS monthly times three months. C. Individuals who are placed on an antipsychotic medications should receive an AIMS assessment within seven days of initiation of the antipsychotic medication. D. Pharmacist/designee will monitor AIMS assessments monthly . Example 1 R16 admitted to the facility on [DATE] with diagnoses that include, in part: anxiety disorder (a mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life); depression (medical condition characterized by low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning); and insomnia (a sleep disorder characterized by difficulty falling or staying asleep, resulting in poor sleep quality and daytime fatigue). R16's Minimum Data Set (MDS) dated [DATE] indicates a Brief Interview for Mental Status (BIMS) score of 15, indicating R16 is cognitively intact. R16's physician orders include, in part: *Lorazepam 1mg (milligram) by mouth every 12 hours as needed for anxiety. Order date: 1/24/25. It is important to note: there is no stop date indicated for this medication. *Sertraline 25 mg by mouth in the morning for depression/anxiety. Order date: 2/9/25 R16's Medication Administration Record (MAR) indicates PRN lorazepam was administered on 2/9/25, 2/11/25, and 2/12/25. Important to note: these administrations are after the 14 day period allowed for PRN (as needed) psychotropic medication orders. On 2/13/25 at 7:26 AM, Surveyor interviewed LPN J (Licensed Practical Nurse) and asked about PRN psychotropic medications. LPN J stated the order is good for 14 days, then would need to be reordered. LPN J stated that when entering a PRN order into the resident's chart, a 14-day duration is added, so that the medication ends and a re-assessment is completed. On 2/13/25 at 8:04 AM, Surveyor interviewed DON B (Director of Nursing) and asked about psychotropic medication protocols. DON B stated that the resident needs to have behavior monitoring of targeted behaviors. Surveyor asked about PRN psychotropic medications. DON B stated they get a 14-day stop date and then the physician needs to do a face to face visit before reordering the medication. Surveyor asked if R16 has tracking of targeted behaviors. DON B stated no. Surveyor asked if facility would be expected to track targeted behaviors for R16. DON B stated yes. Surveyor asked if R16 should have received lorazepam on 2/9/25, 2/11/25, and 2/12/25. DON B indicated no, R16 should not have gotten this medication as there was not a 14-day physician review/assessment. Example 2 R22 admitted to the facility on [DATE] with diagnoses that include, in part: depression and unspecified dementia with psychotic disturbance (a condition where cognitive decline characteristic of dementia is accompanied by psychotic symptoms, such as hallucinations and delusions). R22's MDS, dated [DATE], indicates a BIMS was not completed due to the resident is rarely / never understood. R22's physician orders include, in part: Zyprexa 5 mg by mouth in the morning related to dementia with psychotic disturbance. On 2/12/25 at 2:53 PM, Surveyor interviewed LPN E and asked about protocols for an antipsychotic medication. LPN E stated that AIMS (Abnormal Involuntary Movement Scale) assessment is to be completed by the floor nurse at admission and quarterly. On 2/13/25 at 8:04 AM, Surveyor interviewed DON B (Director of Nursing) and asked about protocols for an antipsychotic medication. DON B indicated that AIMS is to be done on admission, with a new order/change in order, and quarterly. Surveyor asked if R22 had an AIMS assessment. DON B stated no. Surveyor asked if facility would expect R22 to have had an AIMS assessment. DON B stated yes.

Based on interview and record review, the facility did not ensure the COVID-19 Vaccine policy and procedure was up-to-date and implemented for 2 of 5 (R22 and R11) residents reviewed. R22 and R11 did not have, nor were they offered the 2024-2025 COVID-19 Vaccine. This is evidenced by: The facility's Policy and Procedure titled Individual Immunizations dated 12/5/24 documents in part: .1. Immunization a. Upon admission, the organization will verify the individual's immunization status, update Primary Care Provider (PCP) as indicated, and administer immunizations as ordered, b. Individual will be offered immunization based upon the Center for Disease Control (CDC) recommendations and guidelines and as prescribed by their PCP . The facility provided the following: The CDC's Recommendation Adult Immunization Schedule United States 2024 dated 11/16/23 documents, in part: .COVID-19 vaccination .2023-2024 Formula . It is important to note the facility's current recommendations are not up to date as they are for 2023-2024 formula. Of note: The CDC's Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States dated 10/31/24 documents, in part: .People ages [AGE] years and older, vaccinated under the routine schedule, are recommended to receive 2 doses of any 2024-2025 COVID-19 vaccine (i.e., Moderna, Novavax, or Pfizer-BioNTech) separated by 6 months (minimum interval 2 months) regardless of vaccination history, with one exception: Unvaccinated people who initiate vaccination with 2024-2025 Novavax COVID-19 Vaccine are recommended to receive 2 doses of Novavax followed by a third dose of any COVID-19 vaccine 6 months (minimum interval 2 months) later . Example 1 R22 is over the age of [AGE] years old and has the following diagnoses: essential hypertension (high blood pressure), senile degeneration of brain (dementia), history of transient ischemic attack (mini stroke) and cerebral infarction without residual deficits (stroke), and dementia with psychotic disturbance. R22 has documented COVID-19 vaccines on 2/2/21, 3/2/21, and 11/3/21. R22 does not have a documented vaccine for 2024-2025 season, nor does the facility has evidence R22 declined the vaccination. Example 2 R11 is over the age of [AGE] years old and has the following diagnoses: chronic diastolic (congestive) heart failure (heart becomes stiff and can't relax properly in-between beats), chronic obstructive pulmonary disease (lung condition), nonrheumatic mitral (valve) insufficiency (valve isn't closing properly), anemia (not enough healthy red blood cells), chronic kidney disease (kidneys are damaged, causing buildup of waste), obstructive sleep apnea (breathing repeatedly stops and starts during sleep), and pneumonia (lung infection). R11 has documented COVID-19 vaccines on 5/6/21, 6/2/21, 2/2/22, and 10/6/22. R11 does not have a documented vaccine for 2024-2025 season nor does the facility have evidence R22 declined the vaccination. On 2/13/25 at 9:44 AM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). Surveyor asked DON/IP B if R22 or R11 were offered the 2024-205 COVID-19 vaccine. DON/IP B said no, not that I know of. Surveyor asked DON/IP B should R22 and R11 have been offered the 2024-2025 COVID-19 vaccine; DON/IP B stated yes.

Based on interview and record review the facility did not ensure an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This affected 1 of 4 sampled residents (R2). On 10/15/24, R2 was seen in the Emergency Department (ED) where he was diagnosed with a Urinary Tract Infection (UTI) that grew greater than 100,000 colonies of Enterobacter cloacae complex and greater than 100,000 colonies of Methicillin Resistant Staphylococcus aureus (MRSA), a multi-drug resistant organism. The facility failed to obtain R2's Urinalysis Culture and Sensitivity (UA C/S) from the hospital to ensure R2 was receiving the appropriate antibiotic. R2 was not receiving the correct antibiotic to effectively treat MRSA. On 10/19/24, R2 began experiencing abdominal pain, exhibiting signs of distress including heaving breathing and groaning, was febrile (running a fever) with an elevated pulse, and experiencing general weakness when he was sent to the ED. Subsequently, R2 was hospitalized for sepsis due to the UTI and treated with Vancomycin, Cefepime and Levaquin via IV (intravenously) and required an intravenous fluid (IVF) bolus. This is evidenced by: The facility's Antibiotic Stewardship policy and reviewed 12/5/24, documents in part: The organization will implement an Antibiotic Stewardship Program (ASP) as outlined below. Procedure: Leadership i. The Infection Preventionist (IP) will be identified to support the facility's safe and appropriate use of antibiotics. ii. The IP will communicate the facility's expectations for antibiotic use to the medical director and collaborate in communicating these to prescribing clinicians. 2. Accountability i. The IP will collaborate with the Medical Director, Executive Director, Director of Nursing, pharmacy consultant, and laboratory representative as needed to: 1. Review infections and monitor antibiotic usage patterns through Quality Assurance Performance Improvement (QAPI) process. 2. Obtain and review antibiograms for institutional trends of resistance as available. 3. Monitor antibiotic resistance patterns and infections. ii. Laboratory will provide facility-specific antibiogram as available.4. Action i. Licensed nurse to complete evaluation at time of signs and symptoms or when antibiotic is ordered. ii. IP and/or designee will review completed Infection Screener Evaluation which follows McGeers Infection Criteria. iii. Appropriateness of use and duration of antibiotic(s) will be monitored and reviewed as needed. 5. Education i. educational opportunities as identified by the QAPI Team should be provided for clinical staff as well as residents and their Resident Representative on appropriate use of antibiotics R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to, the following: diabetes mellitus type 2 (a disease that occurs when your blood sugar is too high), chronic respiratory failure with hypercapnia (a condition where there is too much carbon dioxide in the blood over a prolonged period of time), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and dementia (a group of thinking and social symptoms that interferes with social functioning). R2 is his own decision maker. On 10/15/24 at 6:49 PM, the facility documented the following eInteract SBAR (Situation, Background, Assessment and Recommendations): Situation: The Change in Condition reported to the CIC (Change in Condition) Evaluation are/were: Abdominal pain. At the time of the evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: 111/74 (9/4/24 at 2:02 PM-not current); Pulse: 95 (9/4/24 at 2:04 PM-not current); R: 18 (9/4/24 at 2:04 PM-not current); Temp: 98.0 (9/4/24 at 2:04 PM-not current); Weight 337.6 (10/15/24 8:12 AM); Pulse Oximetry: 96% oxygen via Nasal Canula (9/4/24 at 2:04 PM-not current) Primary Diagnoses: Chronic Respiratory Failure with Hypercapnia Relevant medical history is CHF, COPD (Chronic Obstructive Pulmonary Disease-a lung disease that makes it difficult to breathe) or, Dementia, Diabetes Code Status: Full Code Resident/Patient had the following medication changes in the past week: N/A (not applicable) Resident/Patient is on Coumadin/warfarin: No Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: No changes observed. Functional Status Evaluation: No changes observed. Behavioral Status Evaluation: Blank Respiratory Status Evaluation: Blank Cardiovascular Status Evaluation: Blank Abdominal/GI (gastrointestinal): Abdominal pain GU/Urine Status Evaluation: Lower abdominal pain or tenderness Skin Status Evaluation: Blank pain Status Evaluation: Does the resident/patient have pain: Yes. Neurological Status Evaluation: Blank Nursing observation, evaluation, and recommendations are: Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: (Name and clinic) notified of resident transfer to hospital. New Testing Orders: Urinalysis or culture New Intervention Orders: Blank New or Change in Medications: Blank On 10/15/24 at 7:28 PM, R2's Progress Notes document as follows: Per family request, Resident sent to ER (emergency room ) at 3:30 PM for severe abd (abdominal)/groin pain. Resident stated his catheter is not releasing urine. The nurse did a flush of Resident catheter without experiencing any resistance. Call made to provider to notify them of the transfer to ER. Resident's family member with him for entire visit. Resident returned with a diagnosis of Acute cystitis with hematuria. Order for Cefdinir has been sent to pharmacy. On 10/15/24, R2's hospital emergency room report documents, in part, the following: Patient (Pt) presents to ED with concern that his Foley isn't draining. He has had this in for about a month now. They attempted to flush it at the facility, and it seemed to be working properly. Pt (patient) seems to have a little pain at the tip of his penis, no wound appreciated there. Pt reports he feels like he is having some bladder pain as well. Pt with no fevers/chills Medical Decision Making: Resident presents to ED with some urinary discomfort/bladder pain. Pt has a Foley in place. This is draining well. Bladder scan here is negative. I don't believe flushing or replacing is needed at this point. Will check UA (urinalysis), does feel like might have UTI (Urinary Tract Infection). Pt also notes some constipation as well. Pt with very benign abdominal exam. Low suspicion for obstruction or diverticulitis (doesn't have an appendix). I discussed possible labs/CT (Computed Tomography is an x-ray/imaging of the inside of the body) to further assess, but at this point we are in agreement with holding off. On 10/15/24 at 4:58 PM, the ED physician ordered a STAT (immediate) urinalysis with reflex culture if indicated. On 10/15/24 at 6:09 PM, R2's UA C/S indicate the following: >100,000 CFU/ml (colonies) Enterobacter cloacae complex >100,000 CFU/ml **Methicillin Resistant Staphylococcus aureus The physician documents the UA (urinalysis) does have some evidence of infection. After reviewing previous cultures, will start him on Omnicef Family member given strict return precautions. Pt to follow up with PCP (Primary Care Provider). Clinical Impression: Acute cystitis with hematuria New Prescriptions Cefdinir (Omnicef) 300 mg (milligrams) oral capsule - Take 1 capsule by mouth 2 (two) times daily for 7 days. It is important to note, Cefdinir is not an effective medication to treat MRSA. On 10/15/24, R2 returned to the facility (at an unknown time). The facility did not begin administered Cefdinir until the following morning as it is not available in contingency. It is important to note, the emergency department ran a urine culture and sensitivity (C&S) to identify the appropriate antibiotics for R2's urinary tract infection. This was collected on 10/15/24 and resulted on 10/18/24. The facility did not request these results or follow up on the urine culture and sensitivity, and thus did not recognize a cephalosporin such as Cefdinir was not indicated to treat the MRSA infection. If the facility would have called for the C&S and noted Cefdinir was not indicated for MRSA, they could have consulted with the physician to perhaps initiate another antibiotic or an additional antibiotic. R2's C&S dated 10/15/24 and resulted (lab results were ready) 10/18/24 state in part: >100,000 CFU/ml (colonies) Enterobacter cloacae complex >100,000 CFU/ml **Methicillin Resistant Staphylococcus aureus (MRSA) Under Enterobacter cloacae complex the following cephalosporins are sensitive (ok to use to treat this bacteria) Cefepime, Cefptaxime and Ceftazidine. It should be noted under MRSA these cephalosporins are blank indicating cephalosporins were not indicated for MRSA. On page 2 of the C&S report there are multiple other antibiotics which are sensitive to both Enterobacter and MRSA. On 10/18/24 at 7:35 PM, R2's Progress Notes document as follows: Resident has had several episodes of loose stool this evening. Placed call to on call to have resident's Loperamide order reinstated. Awaiting call back from on call. On 10/19/24 at 7:53 PM, R2's Progress Notes document as follows: Resident has fever that is not responding to Acetaminophen. Temp 100, BP 146/96, P 113, Resp 20, O2 95% at 3 liters. Provider contacted on call physician to receive order to send Resident to ER (emergency room ). Family member notified of Resident's condition and will meet him at the ER. On 10/19/24, R2's hospital notes document the following: Pt (Patient) was admitted on [DATE] for issues with genital discomfort and generalized body aches. He had associated SOB (shortness of breath). He was previously on a course of cefdinir for a UTI prior to this issue but had no improvement in symptoms. Initial work up revealed lactic acidosis along with urine clx (culture) positive gram-negative bacteria. He did initially receive Vancomycin and Cefepime (intravenous antibiotics) for abx (antibiotic) coverage but was later switched to Levaquin (a third intravenous antibiotic) as indicated by culture susceptibilities. He also received 1L (liter) IVF (intravenous fluid). The following day patient had resolution of his lactic acidosis. He did tolerate antibiotic change well and did have his foley catheter changed He is to finish his course Levaquin - last day of administration would be on 10/27/24. Admission Diagnosis: UTI Urinary tract infection associated with indwelling urethral catheter. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present Secondary Diagnoses: Sepsis secondary to UTI R2 was hospitalized on [DATE] and discharged back to the facility on [DATE]. On 10/19/24 at 9:53 PM, R2's progress notes document as follows: This nurse spoke to Registered Nurse at ER. Resident is to be admitted with unresolved UTI. Antibiotics will be given via IV (Intravenous). On 10/20/24 at 6:24 PM, the facility documented the following eINTERACT SBAR Summary for Providers (a late entry): Situation: The Change in Condition/s reported on this CIC (change in condition) Evaluation are/were: Abdominal pain, Abnormal vital signs (low/high) BP, heart rate, respiratory rate, weight change) At the time of evaluation resident/patient vital signs, weight and blood pressure were: Pulse: P 113 - 10/19/24 6:28 PM Type: Regular RR: R 20 10/19/24 at 6:28 PM Temp: T 100 10/19/24 at 6:29 PM Weight: 337.6 pounds 10/15/24 at 8:12 AM Pulse Oximetry: O2 96% 9/4/24 at 2:02 PM Oxygen via Nasal Canula Blood Glucose: BS 159 10/19/24 at 3:14 PM Resident/Patient is in the facility for Long Term Care Primary Diagnosis is: Chronic Respiratory Failure with hypercapnia. Relevant medical history is CHF, COPD, Dementia, Diabetes Code Status: Full Code Advance Directives: N/A (not applicable) Resident/patient had the following medication changes in the past week: Cefdinir. Resident/patient is not anticoagulant other than warfarin: Yes. Resident is on hypoglycemic medications: Insulin. Outcomes of physical assessment: Positive findings reported on the resident for this change in condition were: Mental Status Evaluation: No changes observed. Functional Status Evaluation: General weakness. Behavioral Status Evaluation: Blank. Respiratory Status Evaluation: Blank. Cardiovascular Status Evaluation: Resting pulse greater than 100 or less than 50. Abdominal/GI Status Evaluation: Diarrhea, Abdominal pain. GU/Urine Status Evaluation: Lower abdominal pain or tenderness. Skin Status Evaluation: Blank. Pain Status Evaluation: Does the resident/patient have pain: Yes. Neurological Status Evaluation: Blank. Nursing observations, evaluation, and recommendations: Resident exhibiting signs of distress with heavy breathing and groaning. Temp elevated as well as pulse. Primary Care provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: On call nurse contacted and order given to send Resident to ER for further assessment. New Testing orders: Urinalysis or culture. New Intervention Orders: Blank. Other: Resident admitted to hospital for IV (intravenous) antibiotic therapy. It is important to note, on 10/15/24 the facility failed to obtain R2's UA C/S (Urinalysis Culture and Sensitivity) from the hospital laboratory to ensure R2 was receiving the appropriate antibiotic. Note, R2 was not receiving the correct antibiotic to effectively treat MRSA (Methicillin-Resistant Staphylococcus Aureus). Subsequently, R2 was hospitalized for sepsis due to the UTI (Urinary Tract Infection) and treated with IV (intravenously) antibiotics and IVF (intravenous fluid) bolus. It is also important to note, the facility did not contact the physician about the culture results. On 1/8/25 at 3:10 PM, Surveyor spoke with DON B (Director of Nursing) and RN C (Registered Nurse - Corporate). Surveyor asked DON B and RN C, what is the process when a resident is diagnosed with a UTI in the ER and discharges back to the facility. RN C stated, there should be follow up regarding the culture and sensitivity to ensure the resident is receiving the correct antibiotic. RN C stated this process is considered antibiotic stewardship. RN C stated, the facility recognizes that there is an overall lack of follow up and stated they are working to be better. RN C stated, the previous DON (Director of Nursing) who was also the IP (Infection Preventionist) is no longer employed at the facility due to lack of follow up. RN C stated this was the previous DON's responsibility to follow up on culture and sensitivity reports to ensure residents are receiving the correct antibiotic. RN C stated, this was not done, and it should have been. RN C stated, we have to always track down the culture and sensitivity. RN C stated, the facility does not have access to EPIC Link (electronic charting used by the hospital), so they need to call the lab and request the results be faxed to them. Surveyor asked RN C, was the physician notified of the culture and sensitivity. RN C stated, no, the physician was not notified and he/she should have been notified.

Based on interview and record review, the facility failed to immediately consult with a physician when needing to alter treatment for 1 of 3 (R3) residents reviewed for physician notification. R3 had four instances of hypotension (low blood pressure) from November 2024 to January 2025. The facility did not call the on-call physician to report R3's hypotension to allow for an alteration of treatment if the physician deemed it necessary. This is evidenced by: The facility policy titled Change of Condition and Provider Notification with a review date of 8/10/23 states in part; a change of condition (COC) is a deviation from an individuals baseline .a licensed nurse is involved in the assessment process and contributes to the collection of the data base, the planning of interventions and evaluation of the individuals response to the COC .The primary care provider will be contacted for notification and to obtain further orders from the provider as necessary. According to American Medical Directors Acute Change of Condition in Long Term Care Setting indicates a blood pressure (BP) less than 90 requires immediate MD notification and a pulse greater than 100 requires immediate notification. Of note the facility uses INTERACT as their standard of practice. According to INTERACT II dated 2010 a blood pressure (BP) less than 90 requires immediate MD notification. R3 was admitted to the facility on [DATE] with diagnoses that include, in part: Chronic Obstructive Pulmonary Disease (Chronic lung disease that progressively obstructs the resident's ability to breathe), Congestive Heart Failure (Failure of the heart to adequately pump blood, causing fluid to back up into the lungs), chronic kidney disease (kidneys inadequately filtering blood), Atrial fibrillation (irregular heart rhythm), and obstructive sleep apnea (inadequate lung ventilation while sleeping). R3's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/18/24 states that R3 has a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating that R3 is cognitively intact. On 1/8/25, Surveyor reviewed R3's After Visit Summary and Discharge Transfer Orders documents from her hospital stay from 11/8/24-11/11/24. These documents indicate R3 had transfer orders that include, in part: to notify the physician of a systolic blood pressure under 90, a diastolic blood pressure under 60. R3's Vital Sign documentation states, in part: 11/3/24 at 10:29 AM: Blood Pressure (BP) 87/67. Warning: Systolic (Blood pressure when heart contracts) Low of 90 exceeded. 11/22/24 at 7:29 PM: BP 88/60. Warning: Systolic Low of 90 exceeded. 12/30/24 at 7:20 PM: BP 89/54. Warning: Diastolic (Blood pressure when heart relaxes) Low of 60 exceeded, Systolic Low of 90 exceeded. 1/1/25 at 9:11 PM: BP 81/46. Surveyor reviewed R3's progress notes. No progress notes were written indicating a physician was notified of these vital signs for the listed dates. Surveyor requested DON B (Director of Nursing), RN C (Registered Nurse) to review the facility's secure chat log and other facility documents for any evidence that a physician was notified for these dates. No documentation was able to be provided to Surveyor regarding physician notification. On 1/8/25 at 1:30 PM, Surveyor interviewed DON B (Director of Nursing) and RN C (Registered Nurse). Surveyor asked DON B and RN C if they consider discharge transfer orders to be physician orders. DON B and RN C indicate that these are orders and should have either been transcribed into the electronic medical record or provided to the facility physician for review. Surveyor asked DON B if a complete RN assessment, including a full set of vital signs, should have been conducted upon the discovery of R3's hypotension. DON B indicates a full RN assessment, including a full set of vital signs should have been conducted. Surveyor asked DON B and RN C if a physician should have been notified following identification of R3's hypotension and tachycardia. DON B and RN C indicate a physician should have been notified at that time.

Based on interview and record review, the facility failed to meet professional standards of quality for 1 of 3 Residents (R3) reviewed for weights. R3 has a history of Congestive Heart Failure (Failure of the heart to adequately pump blood, causing fluid to back up into the lungs) and had no physician order for weights, and was not weighed for months at a time. This is evidenced by: The facility policy, entitled, Weighing Individuals, dated 6/13/23, states, in part: Policy: Individuals are weighed according to orders. Procedure: A. Weights are obtained per order and reviewed: 1. On admission/readmission, 2. Weekly for the first four weeks, 3. Monthly. B. Weights are documented and reviewed with previous weights for any changes. C. The Provider is updated with weights as ordered or indicated . R3 was admitted to the facility on [DATE] with diagnoses that include, in part: Chronic Obstructive Pulmonary Disease (Chronic lung disease that progressively obstructs the resident's ability to breathe), Congestive Heart Failure, chronic kidney disease (kidneys inadequately filtering blood), Atrial fibrillation (irregular heart rhythm), and obstructive sleep apnea (inadequate lung ventilation while sleeping). R3's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/18/24 states that R3 has a Brief Interview of Mental Status (BIMS) of 14 out of 15, indicating that R3 is cognitively intact. Surveyor reviewed R3's physician orders. R3's physician orders do not include an order for weights. R3's Weight Summary from July 2024-December 2024 shows: 7/18/24: 143 lbs. (pounds) 9/12/24: 137 lbs. 11/11/24: 156 lbs. (Of note: The American Heart Association (AHA) recommends daily weights for people with heart failure because it can be an early indicator of worsening heart failure. This is due to the body retaining fluid due to the improper functioning of the heart. The AHA recommends having knowledge of the physician's recommended weight change parameters and notifying the physician if this weight change occurs). Source: https://www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failure/managing-heart-failure-symptoms On 1/3/25 at 7:57 AM, Surveyor reviewed NP D's (Nurse Practioner) progress note. This note states, in part: . Monitor weights/volume status-no recent weight . On 1/8/25, Surveyor reviewed R3's Discharge Transfer Orders documents from her hospital stay from 11/8/24-11/11/24. These documents indicate R3 had transfer orders that include, in part: to notify the physician of a weight gain or loss of 3 lbs. in a day or 3 lbs. in a week. On 1/8/25 at 1:30 PM, Surveyor interviewed DON B (Director of Nursing) and RN C (Registered Nurse). Surveyor asked DON B and RN C if they consider discharge transfer orders to be physician orders. DON B and RN C indicate that these are orders and should have either been transcribed into the electronic medical record or provided to the facility physician for review. Surveyor asked DON B and RN C if the facility has a standard for weighing residents, whether that be every resident gets weighed weekly, monthly, etc. RN C indicates there is no standard, and the facility follows physician orders. Surveyor asked DON B and RN C if R3 should have a physician order for weights due to her history of congestive heart failure. DON B and RN C indicate that R3 should have an order for weights. On 1/8/25 at 1:58 PM, Surveyor called NP D, to ask questions regarding their expectation for resident care. NP D did not answer, and a message was left with a request for a return call. NP D did not return Surveyor call regarding R3's care.

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when experiencing a change in condition for 2 of 4 sampled residents (R7 and R8). R7 had a change in condition on 6/22/24. R7 has diabetes mellitus type 2. The facility has not completed daily diabetic foot checks, assessed, nor measured R7's diabetic wound, described the wound bed or continuously monitored R7's wound. In addition, R7's provider was not updated. R7 was sent to the hospital on 6/27/24 for osteomyelitis of the right second toe. Subsequently, R7's right second toe was amputated on 6/28/24. R7 developed a new diabetic wound that worsened and became infected with MRSA (Methicillin-Resistant Staphylococcus Aureus), Corynebacterium Striatum, Pseudomonas aeruginosa, and Enterococcus Faecalis; MRSA and Corynebacterium Striatum are life-threatening Multidrug-Resistant Organisms (MDRO). Staff failed to measure and assess R7's wound weekly, failed to contact a Physician/NP (Nurse Practitioner) timely, failed to complete wound treatments and failed to implement aggressive preventative measures to prevent R7's wound from deteriorating/worsening. These failures created a finding of immediate jeopardy that began on 6/22/24. NHA A (Nursing Home Administrator) was notifed of the immediate jeopardy on 10/10/24 at 12:35 PM. The immediate jeopardy was removed on 10/10/24 and continues at a severity/scope level of G (actual harm/isolated) as evidenced by the following: R8 received a burn on his foot from Tea Tree Oil after a nurse completed the treatment incorrectly placing undiluted Tea Tree Oil directly on R8's foot. The facility did not complete weekly assessment per standards of practice. R8's wound became infected requiring antibiotics. As evidenced by: The facility policy, Standard Diabetes Mellitus Protocol, undated, indicates, in part, as follows: Problem: Patient has potential for fluctuating blood sugar and/or complications of diabetes mellitus. Goal: Patient will: 1) remain compliant with diet 2) blood sugars to be within parameters as determined by the physician orders 3) exhibit no hypo/hyperglycemia episodes. Complete daily foot checks; Update physician and responsible party as needed, check blood sugars/labs as ordered. The facility policy, Pressure Injury Prevention and Managing Skin Integrity, reviewed 8/10/23, indicates, in part, as follows: Weekly Wound Rounds: a. Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concern(s) will be added to weekly wound rounds. b. Registered Nurse (RN) or designee will: i. Conduct weekly skin evaluation, ii. Update the PCP (Primary Care Provider) with any decline in wound appearance, or as necessary. iii. Update the care plan with interventions as applicable. Administrative Review a. Interdisciplinary Team (IDT) reviews Pressure Ulcer/Abnormal Skin Findings through Quality Assurance Committee. R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, diabetes mellitus type 2, neuropathy, BKA (below the knee amputation) to LLE (left lower extremity) on 12/16/22, toe amputation to right foot (7/28/21), peripheral arterial disease, phantom limb pain, history of MRSA (Methicillin-Resistant Staphylococcus Aureus) (unclear source), and Chronic Kidney Disease Stage 3b. R7's Admission Minimum Data Set (MDS) dated [DATE] indicates R7 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. R1's MDS indicates he is at risk for skin impairment and was admitted with no skin impairment. R7's Certified Nursing Assistant (CNA) Kardex, dated 10/8/24, documents the following: Skin Integrity Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage. R7's Progress Notes: On 6/10/2 at 10:25 PM, LPN O (Licensed Practical Nurse) documents, in part, the following: Rt (right) leg/foot noted with redness and weeping to the top of R foot cleansed with NS and wrapped with kerlix. On 6/11/24 9:45 PM, LPN O documents the following: Resident in w/c (wheelchair) started on PO (oral)/ABT (antibiotic)/Cellulitis/Rt Foot (right) with CDI (clean, dry, intact) T97.6 no adverse reaction noted. On 6/11/24, R7 was started on Cedfinir oral capsule 300 mg Give 1 capsule 2x/d for cellulitis for 10 days for right foot cellulitis. Note, Cefdinir is an antibiotic used to treat bacterial infections. On 6/12/24 at 11:59 PM, LPN O documents the following: Resident A/O x4 (Alert and Oriented) remains on PO/ABT/Tx/Cellulitis Leg with CDI dressing. T98.9 no adverse reaction noted. On 6/15/24 at 1:37 PM, LPN O documents the following: Resident up in w/c A/O/4 remains on PO/ABT/Cellulitis Rt Foot Red and dry no wheeping [SIC] noted Tx applied per MD (Medical Doctor) order tolerated well T-97.9 On 6/15/24 at 8:53 PM, LPN O documents the following: Resident remains on PO/ABT/Rt Leg infection no adverse reaction noted T98.7 Tx done per MD order tolerated it well. T97.9 On 6/16/24 at 11:49 AM, Resident remains on PO/ABT/TX no adverse reaction noted T97.6 Rt Foot Tx done tolerated it well to Rt Foot. On 6/17/24 at 10:11 PM, LPN O documents the following: Resident remains on PO/ABT/Tx/Lft [SIC] Leg Cellulitis no adverse reaction noted T97.6 Rt Foot Tx applied after Shower Foot very Red and Moist tolerated Tx well. R7 has an order for Mupirocin oint (ointment) 2% (Used to treat bacterial skin infections or staph) apply followed by ABD (dressing) and wrap with kerlix. The facility did not complete a total of ten (10) treatments on the following dates: 6/10/24, 6/12/24, 6/17/24, 6/19-6/22/24, 6/24-6/26/24; note there are no measurements or indication why the facility is using this. On 6/17/24, R7's Weekly skin check is blank. On 6/22/24 at 5:22 AM, LPN O documents as follows: Tx done per MD order to Rt Foot and Buttock both draining very much with foul order [SIC] and large amount of [NAME] drainage advised to keep leg elevated and take a break from sitting up in the W/C (wheel chair) resident is very non-compliant was also told that on PM shift as well but didn't listen. T97.8 It is important to note, there is no update to the provider, no measurement, or wound assessment. On 10/9/24 at 11:45 AM, Surveyor called LPN O (Licensed Practical Nurse). LPN O did not return Surveyor's call. On 6/24/24 at 1:30 PM, NP Q (Nurse Practitioner) documents the following: Chief Complaint: seen for follow up diffuse rash x 3 days R7 was seen resting in bed. He is seen for diffuse rash to upper torso, arms, legs, groin. He has increased edema to bilateral thighs as well as redness to bilateral groin. He was treated with Diflucan as well as nystatin cream with little improvement for intertrigo (a rash that appears between the folds of skin). He does have a diagnosis of T2DM (Diabetes Mellitus Type 2), but unable to see blood glucose monitoring. Will add Bumex (a diuretic to decrease fluid), will update A1C (blood glucose monitoring over 3 months), update labs, will add prednisone, continue Benadryl. Facility staff made aware of plan of care. Continue wound care with [NAME] [SIC], encourage to shower three times weekly if possible, patient agrees with POC (Plan of Care). Skin - no masses, no rashes, no lesion on exposed skin, PVD (peripheral vascular disease) skin change to RLE (right lower extremity) . Of note, NP Q is no longer employed with clinic and instructed the facility to not contact her. On 10/9/24 at 1:35 PM, Surveyor contacted NP Q (Nurse Practitioner). NP Q did not return Surveyor's call. On 6/24/24, R7's Weekly skin check is blank. On 6/24/24 at 10:21 PM, LPN O documents, in part, the following: Skin Evaluation: Skin warm & dry, skin color WNL (within normal limits), mucous membranes moist, turgor normal. Resident has current skin issues. Skin tissue: Open lesion (other than ulcers, rashes and cuts). Skin issue location .Infection of the foot. Skin issue location: Rt Foot Wound bed: Granulation. Wound exudate: Purulent. Per wound condition: Maceration. Dressing saturation: Heavy (75%). Wound odor: Yes. Tissue: Cool. Note: .Cellulitis to Rt Foot Note: Provider not updated, no indication of what the wound looks like or being updated on the odor or drainage. On 6/25/24 at 10:30 PM, LPN O document the following: Resident in recliner with leg elevated on a pillow with CDI (Clean, dry and intact) dressing to Rt Foot. On 6/27/24 at 4:47 AM, Physician/Med Dir R (Physician/Medical Director) conducted a visit at the facility. Physician/Med Dir R documents the following: Reason: Physician Monthly Follow-up Visit Type: SNF (Skilled Nursing Facility) Monthly Compliance Subjective: Patient seen today for multiple chronic conditions. Laying in bed no fever, chills, nausea, vomit, chest pain or chest tightness. Has a diffuse rash for which he was started on prednisone. It has been pruritic (itchy skin) but it seems to be improving as well. He does have some flaky skin and thus was started on Aquaphor as well. Care discussed with nursing staff. Physical Exam - General-no acute distress, comfortable Extremities-left below the knee amputation, right lower extremity dressing Phantom limb syndrome Type 2 diabetes mellitus with foot ulcer. Continue with current plan of care, monitor blood sugars, avoid hypoglycemia. Followed by wound care as well. It is important to note, this MD (Medical Doctor) note is for monthly compliance. The note indicates, right lower extremity dressing and Type 2 diabetes mellitus with foot ulcer. MD/Med Dir R's note does not indicate if Physician/Med Dir assessed or looked at R7's wound, or if he was aware that there was purulent drainage or an odor. On 6/27/24 at 6:53 AM, Physician S, a traveling wound physician, documented the first assessment and measurements for R7's wound. Non-Pressure wound of the Right, second toe Full Thickness Etiology (quality): Undetermined/Unknown Further Etiology Detail unclear of how wound developed per patient Duration: >1 day Objective: Healing/Maintain Healing Wound Size (L x W x D): 1.3 x 1.3 x 0.1 cm (centimeter) Surface Area: 1.69 cm2 Exudate: Moderate Sero-sanguinous Granulation Tissue: 60% Other viable tissues: 40% (Bone, Cartilage) Additional Wound Detail: bone/joint exposed in appearing toe fracture with surrounding cellulitis, unclear etiology of wound and onset and whether surrounding cellulitis is indicative of superficial vs deep (bone) involvement. Expanded Evaluation Performed: .Patient requiring an increase in the level of care, recommend sending patient to ED (emergency department) given toe wound with bone exposed with surrounding cellulitis, unknown duration of wound given cellulitis and bone exposure reccomend ED (emergency department) eval for abx (antibiotics) and possible amp (amputation). On 6/27/24, R7 was immediately sent to the ED following Physician S's assessment. R7's second (2nd) toe on his right foot was amputated on 6/28/24. On 6/27/24 at 8:14 AM. The facility notified the clinic (name) regarding resident bone/joint exposed in appearing toe fracture with surrounding cellulitis, unclear etiology of wound and onset and whether surrounding cellulitis is indicative of superficial vs deep (bone) involvement. Resident sent to Hospital ED. R7's hospital report documents the following: Chief complaint exposed bone, R (right) foot exposed bone - cefepime and vanco (intravenous antibiotics) given in ER - (ended up with [NAME] syndrome from vanco) - No s/sx (sign/symptoms) systemic infection. HX MRSA (Methicillin-Resistant Staphylococcus Aureus) and CKD (Chronic Kidney Disease) stg (stage) 3. R7 was hospitalized ,d+[DATE] - 7/2/24. (5 days) R7's Hospital Report documents the following: Admission Dx (Diagnosis): Injury of toe on right foot, initial encounter. Reason for hospitalization : Development of new ulcer with exposed bone wound of second toe on right foot. Significant Findings: Osteomyelitis of the second right toe Patient Course & Care: .R7 was sent for admission due to wound of his second right toe which looked infected. He was admitted and started on IV (intravenous) antibiotics and podiatry was consulted. Decision was made to do the toe amputation which was done. Infectious diseases was consulted and made long-term antibiotic recommendations. He was able to discharge back to his SNF (Skilled Nursing Facility) and receive his IV antibiotics they are to follow-up with podiatry and infectious diseases. PRINCIPAL/FINAL DIAGNOSES: Osteomyelitis right second toe On 8/1/24, R7 was seen by Infectious Disease. The report documents the following: Reason for follow up right foot secondary to osteomyelitis. Surgical cx (culture) distal portion of amp (amputation) 6/28/24 - MRSA (Methicillin-Resistant Staphylococcus Aureus); Pseudomonas aeruginosa, Corynebacterium Striatum. It is important to note, MRSA and Corynebacterium Striatum are both life-threatening Multidrug-Resistant Organisms (MDROs). Surgical cx (culture) proximal amp/bone 6/28/24: E. Faecalis (Enterococcus Faecalis); Corynebacterium Striatum Visit Diagnosis: Acute osteomyelitis of Right Foot On 10/7/24 at 11:45 AM, Surveyor spoke with R7. Surveyor asked R7 regarding the right second toe that was amputated. Surveyor asked R7 how the wound occurred. R7 stated he is unsure how the wound occurred; however, he may have stubbed or bumped it on something. Surveyor asked R7, is there anything that staff did to cause the wound. R7 stated, No. On 10/9/24 at approximately 12:00 PM Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, do you expect medication to be administered per physician orders. DON B stated, Yes. Surveyor shared R7's order for Muprocin ointment: Muprocin oint (ointment) 2% (Used to treat bacterial skin infections or staph) apply followed by ABD and wrap with kerlix. Surveyor asked DON B, do you expect R7's Muprocin (an antibiotic)/treatment to be completed per physician orders. DON B stated, Yes. Surveyor shared with DON B that R7's Muprocin/treatment was not completed on the following dates: 6/10, 6/12, 6/17, 6/19-6/22 and 6/24-6/26. Surveyor asked DON B, should R7 have received Muprocin/treatment per physician orders. DON B stated, Yes. Surveyor asked DON B, did the facility identify that Cefdinir/treatment was not completed per physician orders. DON B stated, no. Surveyor shared LPN O's progress note on 6/22/24 that documents R7's toe was Draining very much with foul odor and Large amount of green drainage. Surveyor asked DON B if he sees documentation that the provider was notified. DON B reviewed R7's medical record for documentation. DON B stated, he does not see documentation that R7's provider was notified on this date (6/22/24) or any day prior to R7 being sent to the ED (emergency department). Surveyor asked DON B, should LPN O have notified the provider regarding Draining very much with foul odor and Large amount of green drainage. DON B stated, Yes. Surveyor asked DON B, how often should diabetic foot checks be done. DON B stated, Daily. Surveyor asked DON B, why is it important that this is completed daily. DON B stated, so we can catch things early so they don't become problematic later on. DON B added, We don't want a delay in care for our residents. Surveyor asked DON B, do you expect daily diabetic foot checks to be completed for diabetic residents. DON B stated, I would, yes. Surveyor stated, R7's weekly skin assessments are not completed on 6/17/24 and 6/24/24. Surveyor asked DON B, should staff have completed R7's weekly skin assessments on 6/17/24 and 6/24/24. DON B stated, Yes. Surveyor asked DON B, are any staff WCC (Wound Care Certified) staff. DON B stated, No, nobody has the credentials. Surveyor asked DON B, do you expect staff to assess and measure wounds. DON B stated, yes. DON B stated, A description of some sort should happen. DON B stated, he normally leaves wound measurements up to the wound care physician. Surveyor asked DON B, how often should wounds be measured. DON B stated, Weekly. On 10/9/24 at approximately 1:00 PM, Surveyor observed R7's amputation site is healed. On 10/9/24 at 4:05 PM, Surveyor spoke with PA P (Physician Assistant). Surveyor shared with PA P that the facility is not completing daily diabetic foot checks for R7. Surveyor asked PA P, would you expect the facility to be completing daily diabetic foot checks. PA P stated, Yes. Surveyor shared LPN O's (Licensed Practical Nurse) progress note from 6/22/24 documenting R7's toe wound as Draining very much with foul odor and Large amount of green drainage. Surveyor asked PA P, would you expect to be notified. PA P stated, Yes, absolutely in a situation like that. Surveyor asked PA P, how soon would you expect to be notified. PA P stated, Immediately upon finding this and Don't delay, even 1 hour. PA P checked the clinic records and stated on 6/22/24 there is no note that a provider was updated by the facility. PA P added, on 6/24/24 there was a follow up for a rash and no indication of the toe. Surveyor asked PA P, do you expect the facility to administer medications and treatments per provider orders. PA P stated, Yes, absolutely. The facility's failure to complete daily diabetic foot checks, assess, measure, and describe wound beds weekly, continuously monitor R7's wound, and notify R7's provider when the wound has deteriorated resulted in R7 being sent hospital on 6/27/24 for osteomyelitis of the right second toe. Subsequently, R7's right second toe was amputated on 6/28/24. This created a finding of immediate jeopardy which was removed on 10/10/24 when the facility completed the following: 1. Skin sweep of entire facility completed 10/10/2024 2. Sweep of all active treatment orders completed for accuracy done 10/10/2024. 3. All residents with DM have daily foot checks added to TAR. done 10/10/2024 4. Education will be mandatory for all nurses and CNA prior to next working shift including: DM foot care with completing daily diabetic foot checks; skin change observation expectations are that CNA report all skin changes immediately to the nurse; provider notification and change of conditions expectations are that nurses will report all diabetic foot ulcers, redness, purulence, drainage to physician; weekly wound assessments with measurements;and treatments completed as ordered. Starting 10/10/24 pm shift thru all staff completion. Monitoring, Audits, QAPI, and Facility Assessment 1. DON or designee will ensure DM foot checks done daily X 14, weekly x 4 and monthly x 2 bringing results to QAPI. 2. DON or designee will ensure weekly skin checks are completed daily x 14, weekly X 4 and monthly X 2 bringing results to QAPI. 3. DON or designee will ensure weekly skin documentation completed during wound rounds; weekly X 6 and monthly x 2 bringing results to QAPI. 4. DON or designee will audit wound care treatments two residents weekly X 6, monthly x 2 bringing results to QAPI. 5. Clinical Nurse Consultant will audit process of PCC documentation / 24 hour board follow up weekly x 6 and monthly X 2 to ensure changes of condition have needed follow up completed. Example 2 R8 was admitted to the facility 7/23/24 with diagnoses including, but not limited to, as follows: diabetes mellitus type 2, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, non-pressure chronic ulcer of the left foot, cellulitis of left lower limb, muscle weakness, lack of coordination, cramp and spasm. R8's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R8 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. R1's MDS indicates he does not have current venous or arterial ulcers. On 3/5/24 Physician/Med Dir R (Physician/Medical Director) ordered the following treatment: 3 drops of Tea Tree oil per ounce of water to soak left great toe three times a week. Every evening shift every Tue, Thu, Sat for fungal treatment of Left great toe. (It is important to note, Physician/Med Dir R (Physician/Medical Director) ordered the Tea Tree oil to be diluted and not applied directly to or under the the toenail.) On 4/4/24 R8's Weekly Skin Check indicates no areas of concern. On 4/24/24 R8's Weekly Skin Check indicates No skin issues. On 4/20 or 4/28/24, per interview with DON B (Director of Nursing) R8 reported to DON B (Director of Nursing) the second digit on his left foot was burning. DON B stated, he assessed the area and did not see anything. DON B stated, he thought this burning pain may be from neuropathy. DON B stated, R8's skin was intact with no redness. DON B did not document this encounter. DON B stated, this occurred when he was working the floor on a PM shift and completed R8's Tea Tree oil treatment. On 5/1/24, R8's Weekly Skin Check indicates the previous ADON (Assistant Director of Nursing; no longer employed at the facility) circled R8's feet and initiated; no additional information is provided. No areas of concern are documented on the Skin Check or Progress Notes. On 5/6/24 at 4:42 PM, updated by ADON (previous) on open area to Left foot/toe 2.0 cm x 0.4 cm x 0.3 cm. Great toe and next 2nd toe S/S (signs/symptoms) of infection, minimal drainage, redness and increased pain to area. New orders received: Culture wound prior to start of ABX (antibiotic) Start on Cefdinir 300 mg PO (by mouth) BID x 10 days Tx (Treatment): Cleanse Left foot with wound cleanser and apply non-adhesive dressing Daily x 10 days. Monitor S/S infection daily. On 5/6/24 at 5:52 PM, a Registered Nurse documented the following: Cx (culture) to Left toe obtained and sent to (hospital name) by Assistant Director of Nursing (prior), Tx (treatment) completed post cx (culture) by RN. Resident toes on left foot very sensitive. ABD applied to top of Telfa for protection. Physician S, a wound physician, completed the following wound assessments. 5/9/24 (Initial assessment) Exam - Peripheral Vascular: Examination of left lower extremities. Mild edema, foot warm, wound present. See Focused Wound Exam below. Examination of right lower extremities: Mild edema, foot warm Pedal pulses left .Dorsalis Pedis Monophasic Signal Detected by Portable Doppler Pedal pulses right .Dorsalis Pedis Monophasic Signal Detected by Portable Doppler Focused Wound Exam: Chief complaint: Patient present with a wound on his left foot. Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 7 days Objective: Healing/Maintain Healing Wound Size: 1.5 x 0.5 x Not measurable cm (centimeters) Depth is unmeasurable due to presence of nonviable tissue and necrosis. Surface Area: 0.75 cm2 Exudate: Light Sero-sanguinous Thick adherent devitalized necrotic tissue: 30% Granulation Tissue: 70% 5/16/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 14 days Objective: Healing/Maintain Healing Wound Size: 1.5 x 0.5 x 0.1 cm (centimeters) Surface Area: 0.75 cm2 Exudate: Light Sero-sanguineous Thick adherent devitalized necrotic tissue: 30% Granulation Tissue: 70% Wound Progress: Not at goal 5/23/24 .Peripheral Vascular Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 21 days Objective: Healing/Maintain Healing Wound Size: 1.3 x 0.5 x 0.1 cm (centimeters) Surface Area: 0.65 cm2 Exudate: Light Sero-sanguineous Granulation Tissue: 100% Expanded Evaluation Performed: .The patient's advancing peripheral arterial disease/gangrene significantly increases their susceptibility to complications and poor prognosis. Patient with L (left) SFA (Superficial femoral artery) occlusion with distal region to popiteal. PT (Physical Therapy and DP (Doctor of Podiatry) referral to vascular surgery for revascularize discussion with angio with PTA (angiogram with percutaneous transluminal angioplasty is a procedure that combines an angiogram with an interventional procedure to open a blocked or narrowed artery. PTA is a minimally invasive procedure that involves inserting a catheter with a balloon into an artery to widen it and improve blood flow.) vs operative planing for possible distal bypass target given delayed wound healing from his injury. Wound Progress: Improved evidence by decreased surface area 5/30/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 28 days Objective: Healing/Maintain Healing Wound Size: 1.4 x 0.7 x 0.1 cm (centimeters) Surface Area: 0.98 cm2 Exudate: Light Sero-sanguineous Granulation Tissue: 100% Wound progress: Not at goal 6/6/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 35 days Objective: Healing/Maintain Healing Wound Size: 1.2 x 0.6 x 0.1 cm (centimeters) Surface Area: 0.72 cm2 Exudate: Light Sero-sanguineous Granulation Tissue: 100% Wound Progress: Improved evidence by decreased surface area 6/13/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 42 days Objective: Healing/Maintain Healing Wound Size: 1.0 x 0.7 x 0.1 cm (centimeters) Surface Area: 0.70 cm2 Exudate: Light Sero-sanguineous Granulation Tissue: 100% Wound progress: Improved evidence by decreased surface area Dressing Treatment Plan: Primary Dressing(s): Silver sulfadiazine apply once [NAME] for 23 days. Secondary dressing(s): Telfa apply once daily for 23 days. Gauze roll (kerlix) 2.25 (inch) apply once daily for 23 days. 6/27/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness (*Note, the facility went 14 days in between wound assessments and measurements. The wound worsened and is now 50% slough. The facility did not notify Physician S that R8's wound worsened. Physician S assessed R8 for a routine wound care visit and noted R8's change in condition.) Etiology: Burn Duration: > (greater than) 56 days Objective: Healing/Maintain Healing Wound Size: 1.5 x 1.5 x 0.1 cm (centimeters) Surface Area: 2.25 cm2 Exudate: Light Sero-sanguineous Slough: 50% Granulation Tissue: 50% Wound progress: Not a goal Dressing Treatment Plan: Primary Dressing(s): Santyl apply once daily for 30 days; Alginate calcium with silver apply once daily for 30 days: silver will not inactivate santyl Secondary Dressing: Gauze island with bdr (border) apply once daily for 30 days Reason for no sharp debridement: Debridement not indicated secondary to severe peripheral arterial disease 7/4/23 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 63 days Objective: Healing/Maintain Healing Wound Size: 1.7 x 1.5 x 0.1 cm (centimeters) Surface Area: 2.55 cm2 Exudate: Light Sero-sanguineous Slough: 30% Granulation Tissue: 70% Wound progress: Not a goal Dressing Treatment Plan: Santyl apply once daily for 23 days; Alginate calcium with silver apply once daily for 23 days: silver will not inactivate santyl Secondary Dressing: Gauze island with bdr (border) apply once daily for 23 days Reason for no sharp Debridement: Debridement not indicated secondary to severe peripheral arterial disease Investigations: Recommended And/Or Reviewed: X-ray recommended on left D2 (digit 2/2nd toe) R/O (rule out) OM (osteomyelitis) on 7/4/24. On 7/4/24 Physician S wrote the following new order: Doxycycline 100 mg (milligrams) BID (two times a day)x 14 days stop 7/18/24. pre-medicate prior to dressing changes given patient's pain with change and following to minimize patient refusal of care due to pain. *7/11/24 .Focused Wound Exam: Burn Wound of The Left Foot Full Thickness Etiology: Burn Duration: > (greater than) 70 days Objective: Healing/Maintain Healing Wound Size: 1.7 x 1.5 x 0.1 cm (centimeters) Surface Area: 2.55 cm2 Exudate: Light Sero-sanguineous Slough: 30% Granulation Tissue: 70% Wound progress: Not a goal Expanded Evaluation Performed: .The patient's advancing peripheral arterial disease/gangrene significantly increases their susceptibility to complications and poor prognosis, patient with PAD (peripheral arterial disease), have previously recommended vasc (vascular) studies and PVS (an ultrasound for Peripheral Vascular Disease) given nonhealing wound in setting of PAD (Peripheral Arterial Disease). MRI (Magnetic Resonance Imaging) ordered for definitive eval of possible underlying OM (osteomyelitis), patient will require sedation to perform as prior attempt unsuccessful. On 7/11/24, Physician S documented the following Progress Note: Patient with erythema surrounding wound site despite ongoing Doxycycline therapy, patient scheduled to see pcp (primary care physician) for clearance or MRI however given this erythema despite abx (antibiotic) patient would likely require hosp (hospital) admission for broadspec (broadspectrum) abx (antibiotic) and expidited workup for OM and intervention (revasc if possible) +1 amp. R8 was hospitalized from 7/11-7/23/24. On 7/18/24, Physician S's documented the following Progress Note: The patient's visit has been rescheduled, patient remains in hospital s/p (status post) LE (left extremity) stent placement. IV abx (antibiotics) R8's hospitalization documents the following: Chief Complaint: Toe necrosis/cellulitis Patient with worsening necrosis of his foot and some spreading cellulitis appearance. He had been on Doxycycline and followed closely by wound care in the outpatient setting. he has since been put on Cefepime and vancomycin under the direction of the infectious disease team. With evaluation by local podiatry they did not feel like they could definitely amputate the involved toe without knowing more about his vasculature. Apparently there is inability to get CT angiogram for a number of days locally. He is being brought up to facilitate the workup here with vascular evaluation and CT angiogram imaging. At the time of my evaluation he describes just the discomfort in his left second digit as noted. No new areas of discomfort. Feels like the erythema in his leg is improving. Physical Exam: Extremities: Some degraded tissue on the left second digit with some other surrounding erythema, the erythema up his foot to his is receding. Circulation: Radial, pedal pulses are intact and symmetrical Assessment and Plan Infected diabetic left foot ulcer Possible Left 2nd toe OM (osteomyelitis) Cellulitis Culture from 7/11/24 growing pseudomonas/MRSA (Methicillin-Resistant Staphylococcus Aureus) ID (Infectious Disease) consulted, appreciate recs - vanco (vancomycin), cefepime, metronidazole (intravenous antibiotics), continue on discharge, ordered per ID. He will need a 6 week course of IV (intravenous) antibiotic therapy, day 0 of therapy is 7/12/24. Surveillance labs while on IV antibiotic therapy to include weekly CBC (Complete Blood Count) with differential, creatinine, ALT (Alanine aminotransferase), and vancomycin trough (tests level of vancomycin in the bloodstream), and every other week CRP (C-Reactive Protein). Podiatry consulted, recs appreciated - underwent soft debridement, patient unable to tolerate sharp debridement PAD (Peripheral Arterial Disease) CT angiogram (medical imaging) showing significant PAD (Peripheral Arterial Diease). Vascular surgery spoke with patient and will perform an angiogram on 7/15. PT/OT (Physical T [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 1 of 1 supplemental residents (R180) reviewed for elopement, 2 of 2 residents (R17 and R23) reviewed for motorized wheelchair charging, and 1 of 3 sampled residents (R24) and 1 of 1 supplemental residents (R180) reviewed for falls. R180 was a high risk for elopement. The facility failed to ensure R180 had adequate supervision to prevent elopement. In addition, the facility did not ensure R180 had an elopement device on his person when the resident returned from a hospitalization . R180 eloped and traveled over 1/2 mile from the facility. R180 was at risk for falls and had numerous falls with fractures while at the facility. The facility failed to complete comprehensive, contemporaneous evaluations of each fall, identify root cause of the falls, and implement robust care plan interventions to prevent further falls or prevent injury from falls. The facility's failure to provide adequate supervision for a resident known to wander with a history of elopement, failure to check Wander Guard and door alarms per manufacturer's recommendations, failure to reapply Wander Guard device after R180 returned from an appointment, and failure to ensure interventions were in place to prevent falls with injury created a finding of immediate jeopardy (IJ) that began on 02/07/22. On 10/27/22 at 12:00 PM, NHA A (Nursing Home Administer) and DON B (Director of Nursing) were notified of the IJ. The immediate jeopardy was removed on 10/27/22 and continues at a scope and severity of D (isolated/no actual harm) as the facility continues to implement their removal plan. R17's and R10's motorized wheelchairs were observed charging in their rooms and not in a contained area behind firesafe doors. R24 did not have a call light within reach. Evidenced by: The facility's Elopement Prevention policy, reviewed 7/22/22, includes, in part, Policy: interventions for wandering prone individuals will be individualized to maximize their independence, safety, and well-being. Procedure: at the time of admission, gather data regarding history of wandering or elopement. A licensed nurse will complete the elopement risk evaluation upon admission, quarterly and change of condition. An interim plan of care for minimizing the risk of elopement will be initiated upon high-risk determination. The interdisciplinary team will initiate a plan of care for an individual determined high risk for elopement. Interventions to decrease risk of wandering such as devices and monitoring will be initiated . and documented in the individual's plan of care. Revisions of the Elopement Risk Evaluation will be completed quarterly and or upon an individual's significant change in condition, as needed, determined by the interdisciplinary team. the plan of care for minimizing elopement risk will be reviewed each time the elopement risk evaluation is completed. Employees will be educated to elopement prevention. The facility's policy, entitled Standard Wander Protocol, undated, includes: . problem has a history of wandering and/or displays risk of elopement . goal: to ensure safety of the individual who wanders or is at risk for wandering. RN/LPN: initiate wander guard . check wonder guard placement every shift . check wander guard functionality daily . document wandering incidents, including actions taken . replace wander guard per manufacturer's guidelines . review need for wander guard placement and removal quarterly . All: provide diversional activity is as appropriate, respond to alarms, redirect from unsafe situations, maintain a calm approach to the individual, approach from the front, walk in step with individual first before redirecting when attempting to elope, involve individual and/or responsible party in care plan process. Wander Guard, manufacturer's recommendations, include: . test your departure alarm system regularly. Test monitors weekly on each shift with all surrounding power devices turned on. Test signaling devices daily as detailed in the signaling device instructions and your Wander Guard user manual. Record results on the resident's med chart. Failure to regularly test your Wander Guard departure alert system could result in an unauthorized departure and cause injury or death to a resident. Wander Guard's departure alert system is designed to assist staff, not replace them. Because the Wander Guard system is so effective when used properly, staff may become complacent, thinking the system will not fail. Anything electronic can fail. The responsibility for maintaining the security of wanderers remains with a conscientious, alert staff. Test your Wander Guard system regularly . Troubleshooting: The alarm doesn't always sound when it should . Is there a metal object, such as a table or cabinet within 5 inches of the top, front or sides of the door monitor? . Is a nearby electromagnetic device such as computer . interfering with the system? . Are signaling devices worn by the monitored resident working? . Facility policy, entitled Falls, reviewed 6/24/22, includes, in part: a licensed nurse will determine the individual's risk for falls and individualized care needs . if the individual is at risk for falls then create a falls care plan. An individual falls care plan will be created as indicated. Administrative review: upon review of the fall incident report the interdisciplinary team (IDT) using root cause analysis will gather information to investigate and gather relevant information. IDT reviews fall event through quality assurance committee. Example 1: R180 admitted to the facility 2/2/2022 with diagnoses including [CONDITION(S)], dementia without behavioral disturbance, anxiety disorder, and repeated falls. R180 was assessed as a high risk to wander. R180's Minimum Data Set (MDS), dated [DATE], indicated R180's cognition is severely impaired with a BIMS (Brief Interview for Mental Status) score of 3 out of 15. R180 required one person limited physical assist with walking, bed mobility, dressing, transfers, and toileting. R180 is incapacitated. R180's Wandering Risk Assessment, dated 2/2/22, indicates in part the following: R180 has a diagnoses of dementia . is independently mobile . paces, wanders, tries to get out doors, . perceives the need to be doing something other than what he is doing . does not exhibit sign of sundowners . does not have a history of elopement . family/responsible party has voiced concerns that would indicate resident may have wandering tendencies or try to leave . Resident has diagnosis of dementia. Resident is also a smoker. Was observed walking to door. Very forgetful, but easily redirected. Wander Guard was placed on ankle to alert staff. Score: 16 Category: High Risk R180's fall risk assessment, dated 2/2/22, indicates R180 is at risk for falls, with the following risk factors: intermittent confusion, 3 or more falls in last 3 months, incontinent, jerking, or unstable making turns, balance problems when walking, balance problems while standing, decreased muscular coordination, requires use of assistive devices (walker), takes 3 to 4 medications currently and has 1 to 2 predisposing diseases . R180's Care Plan includes, in part, the following: The resident is an elopement risk/wanderer related to History of attempts to leave facility unattended, Wander Guard in place Date Initiated: 2/14/22 The resident will not leave facility unattended through the review date. Date Initiated: 2/14/22 Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (blank) . Date Initiated: 2/14/22 Family brought in vending machine money for resident to use instead of going to gas station Date Initiated: 3/4/22 Red Stop Sign Velcro exit signs posted by frequently attempted doors Date Initiated: 3/4/22 Signs in room to call for assist Date Initiated: 3/4/22 WANDER ALERT: Wander Guard Date Initiated: 2/14/22 R180's Care Plan, includes: R180 is at risk for falls related to deconditioning/weakness post hospitalization . need for assist with mobility, impulsivity, anxiety/depression, and [CONDITION(S)] with [CONDITION(S)] medication, . abnormal labs, balance concerns, history of falls . Interventions: 2/3/22 Bed mobility - one assist . Transfer - one assist with wheeled walker . Encourage R180 to use bell to call for assistance . 2/14/22 distract R180 from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers: (blank) . Wander Guard applied. 2/25/22 R180 is to wear gripper socks 3/4/22 bedroom door alarm added. Family brought in vending machine money for resident to use instead of going to the gas station. Family provided scratch off tickets for use as needed. Signs in room to call for assist. 8/5/22 R180 to have a low-profile bed, mats next to bed, Dycem to chair 8/22/22 R180 is not to be left alone in dining room. R180 is to get up first in the morning unless he is sleeping, check often to see if he is awake. R180's Physician Orders, include: Start date: 2/3/22 End date: 7/28/22 check placement and function of Wander Guard every shift. Start date: 2/15/22 End date: 7/28/22 15-minute checks R180's Medical Record included the following: R180's Nurse's Note, dated 2/5/22 at 9:08 PM, includes Resident voiced wanting to go outside for a cigarette. Resident was easily re-directed. Medical Doctor (MD) was notified and request for nicotine patch was ordered for 21 mg 24-hour patch. Resident was given a shower. No skin breakdown. Resident's sister coming tomorrow morning to cut resident's hair. Will continue to monitor for smoking sensation and elopement. R180's Nurse's Note, dated 2/7/22 at 12:44 AM, includes Writer and CNA (Certified Nursing Assistant) were providing cares in room on short hall. Writer walked out of room to hear door alarm going off. Writer and CNA immediately began checking doors. While going to door by kitchen writer saw resident heading across parking lot. Writer opened door and directed resident back inside building. Resident offered no resistance but appeared a little shaky. When asked where he was planning on going resident stated he was headed to get coffee. Writer assisted resident back to his room and educated on risks of elopement to which resident stated Yes, I could freeze to death out there Resident was walking at fast pace and shuffling feet with walker not touching ground. Educated on need to use call light and wait for assistance as well for safety. decaf coffee made and given. Call placed with messages left for DON (Director of Nursing), NHA A (Administrator), and R180's first contact. Placed on 15-minute checks at this time. On 2/7/22 there was a high of 27 degrees and a low of 18 degrees in this area. R180's Nurse Note, dated 2/14/22 at 12:09 PM, includes: R180 has Wander Guard intact, and family is bringing in scratch off tickets as needed to keep his mind off going to gas station. R180's Nurse Note, dated 2/14/22 at 4:02 PM includes Nurse alerted by dietary that resident exited the building. Dietary aide seen the resident walk out the door. Resident's Wander Guard was in place but did not alert the alarm. The resident was found just outside exit door next to dietary. When the resident was asked where he was going the resident stated, I was trying to go to my mom's house. Resident was easily redirected back to his room. Family and DON notified of elopement. Implementing 15-minute checks and Wander Guard system check every shift. Will continue to monitor. On 2/14/22 there was a high of 27 degrees and a low of 12 degrees in this area. R180's Medical Record contained the following: Nurse's Note (NN) Fall report: 147 Witnessed Date: 2/24/22 Time: 8:05pm Location: Outside Injury: none Outcome: Root Cause: none Interventions in place at time of fall, noted in Report Notification: Yes Assessment: [NAME]: New Interventions: Yellow neon sign was placed on exit door near room to STOP do not exit Notes/Concerns: Med Tech Picked resident up off ground outside, R180's Fall Report, dated 2/24/22 at 8:05 PM, includes location - outside . Yellow neon sign was placed on exit door near room to stop and do not exit . Medication Technician picked resident up off of the ground outside. On 2/24/22 there was a high of 25 degrees and low of 10 degrees in this area. Fall report: 148 Unwitnessed Date: 2/25/22 Time: 6:15AM Location: Dining room Injury: none Outcome: Root Cause: not using walker regular socks on Interventions in place at time of fall, noted in Report Notification: Yes Assessment: [NAME]: Yes New Interventions: have gripper socks/or shoes on when ambulating Notes/Concerns: R180's NN 2/25/2022 06:51 AM Phone call to POA (Power of Attorney) to inform of resident's unwitnessed fall in the dining room. Spoke with POA who said, That's why I'm so relieved that he is going to stay longer than his therapy anticipated so he can be watched. R180's NN 2/25/2022 06:51 AM Resident up this am and walking down long hallway with walker looking for bathroom as his was clogged with cups and straws. Was assisted to bathroom in activity room. Writer getting report and was then called to dining room to resident on floor. He was not able to state why he fell . [NAME] was left in hallway and resident was only in regular socks. neuro checks, body check, and VS stable R180's Nurse's Note, dated 2/27/2022 at 3:15 AM Resident was not in his room. Staff had been doing rounds on other residents. Staff immediately went looking for him. Resident was found sitting in the employee break room eating a bag of potato chips he had purchased from the vending machine. Resident has his wallet and several dollars on the break room table. Resident was asked if he would like something to drink. Resident stated he wanted a Pepsi. Staff offered resident a 6oz can of cola from the kitchen, so he did not have to spend his money. Resident also had a pack of cookies to eat. Resident assisted to find his new room where he sat on the bed to watch TV. R180's Comprehensive Care Plan was updated with bedroom door alarm Date Initiated: 3/4/2022 NN dated 3/1/2022 8:03 AM Upon start of shift R180 displays erratic behavior with cognitive decline from baseline. Pt VS with [CONDITION(S)] and [CONDITION(S)] increasing R180 fall risk status. R180 observed wearing pants upside down, walking in the hall with a commode as a walker, R180 able to answer question only to name, unaware of place, time, and situation. R180 shows flat affect and slight agitation with interaction, R180 room displays manic behavior with magazines, candy, and clothes everywhere and items placed in the toilet. R180 suspected to be psychiatric episode, this facility unable to safely attend to R180 to ensure fall and elopement risks. ER NOTE 3/1/22: your CT scan showed a T11 endplate fracture (small fx of thoracic spine . Follow up with Personal Care Provider in one week . (It is important to note the facility did not report this injury of unknown origin to the state agency or conduct a thorough investigation regarding this injury.) NN 3/1/2022 9:22 PM Wander guard replaced to left arm would not allow this nurse to place it on his ankle. Nurse Practitioner Note, 3/9/22: Patient seen ambulating in facility with his TLSO brace on .denies pain . no elopement attempts . Neurosurgery Note, 3/16/22 - wear brace at all times when you are not lying flat in bed . Do not lift anything greater than 5 lbs. restrict bending twisting or turning of the mid back and lower back . return to Neurosurgery in one month NN 3/21/2022 10:44 AM: Resident has an MRI April 6th @ 11:30 (hospital name). Pick up between 11:00 AM and 11:15 AM. (social worker name) will take to appointment. Fall report: 155 unwitnessed Date: 3/22/22 Time: 7:00pm Location: Hallway Injury: Right Knee Outcome: Bruising on Right Knee (front) Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: Yes [NAME]: New Interventions: Notes/Concerns: 6/22/22 resident is impulsive and has no safety awareness. Staff will be present with him, and they turn their head for one second and he attempts to get up on his own. Will continue to monitor res. To keep from having major injuries. (It is important to note 3 months after the fall the IDT team met and discussed this fall.) NN 3/22/2022 7:47PM: Resident was heard by Med Tech but not physically seen as he was pushing his w/c and went down in hallway landing on his knees. Some bruising noted to right knee. Neuro checks initiated. Dr. and family notified. Resident with dx. of [CONDITION(S)] stated he was just going too fast, stated everything was just going too fast, offered [MEDICATION(S)] which he took, and a snack sat in dining room for a while. Assisted to bed. Fall report: 157 Date: 3/25/22 Time: 2:00pm Location: Resident bedroom, By bed unwitnessed Injury: None Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: [NAME]: New Interventions: Notes/Concerns: Fall report: 158 Unwitnessed Date: 3/26/22 Time: 2:00pm Location: resident's bedroom by Bathroom door Injury: Hit back of head Outcome: ER, Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: Yes [NAME]: New Interventions: Notes/Concerns: resident has had increase in tremor like movements, poor color with grayish hue. Constant reminders to call for assist. NN 3/25/2022 10:51 PM: At 2:00 PM R180 spilled his pop while attempting to pick it up slid down on floor next to his bed. No apparent injuries. Dr. and family notified. Neuro checks started. NN 3/31/2022 2:17 PM: R180 had unwitnessed fall during lunch, R180 was eating in dining room, staff unsure how as dining room is closed related to covid precautions. This RN was on break when another staff member alerted that R180 is on floor in dining room. R180's vitals obtained at the time and are within normal limits. No visible injury, R180 states a lot of pain all over. Non emergent paramedics called with no availability, 911 called and transported R180 to Hospital Emergency Department for evaluation. POA called without answer, message left to call hospice service for update. NN 3/31/2022 6:41PM: Resident returned from ER visit following a fall, No new orders. No apparent injuries. Had CT scan of head which was negative. NN 4/2/2022 12:37PM: Late Entry: Resident very weak this am, having a hard time standing and focusing. [NAME] skin tone. Stating he does not feel great. This writer was one on one with resident totally dependent on feeding. Was unable to hold cup d/t tremors. Oak medical was updated and will be in to evaluate. Spoke with POA [NAME] who stated just to monitor. Will speak to NP when she arrives. Will continue to monitor. 4/2/2022 17:03 Nurse's Note Late Entry: Note Text: Nurse completed AIMS assessment on resident related to increased uncontrollable body movements. Resident needs assistance with feeding due to uncontrollably shaking of the arms. Increase in shuffling gait. Increase in need of assistance with cares. POA and MD updated on change in condition. Neuro Note, 4/6/22: new acute fractures noted on MRI at T2, T5, and T11. (It is important to note the facility did not thoroughly investigate the new injuries of unknown origin and did not report them to the state agency.) NN 4/7/2022 8:49PM: This writer received call from R180's Nurse Practitioner (NP) from neuro. NP stated scan on 4/6/2022 revealed T2, T5, and T11 fracture. Not certain if this is old or new. Wanted R180 to come in tomorrow 4/8/22 to Ortho at 3:00 PM to receive new brace from neck to waist. Social Worker who usually transfers resident was unable. R180's family member will transport. Discussed with NP that resident has no complaints of pain and no facial grimacing noted. NP understands that R180 will probably not wear brace. Left message for POA to return call back. 2nd contact was updated on plan. NN 4/8/2022 5:01AM: Resident was walking down the hallway looking lost early this AM. Resident smelled strongly of bowel movement. Staff assisted resident into his bathroom to clean him up. He was incontinent of an extremely large bowel movement (BM) with formed stool balls (approx. 5 balls of BM that were approx. 3-4 in diameter) mixed with thick liquid stool. Perhaps this is what caused resident's nausea and emesis earlier. NN 4/8/2022 12:23PM: Sent to emergency room for change of condition, 2 falls, loose stools, leaning heavily to the right. Report called to emergency room nurse, family aware and will meet him there. Fall report: 162 Unwitnessed Date: 4/8/22 Time: 3:30pm Location: Bathroom Injury: Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Assessment: [NAME]: New Interventions: Notes/Concerns: med change [MEDICATION(S)] dose cut in half, possible change of plane Fall report: 163 Unwitnessed Date: 4/8/22 Time: 7:47pm Location: resident bedroom floor next to tv stand Injury: none Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: Yes [NAME]: New Interventions: Notes/Concerns: Resident restless all morning, color pale NN 4/8/2022 8:03PM: Resident had a fall in his rm., had been more restless with multiple self-transfers after redirection. More tremors noted. Incontinent of loose stool 3 times this morning. Dr. notified along with POA. NN 4/9/2022 2:32 AM: Phone call to Mercy Hospital to get update on resident. Resident was admitted to 4th floor ortho Rm 4131 with DX of [CONDITION(S)] (with MRI inflamed colon) and being treated with IV ABX. Resident also noted to have metabolic [CONDITION(S)]. Resident is reportedly on a video monitor in his room because he keeps getting up unassisted to walk around. This writer informed nurse on phone of resident passing of 5 huge round balls of hard formed stool (about the size of tennis ball or baseball) on the NOC shift 4/7/22 at approx. 0300. NN 4/9/2022 2:32 AM: Phone call to Hospital to get update on resident. R180 was admitted to 4th floor ortho Rm 4131 with diagnosis of [CONDITION(S)] (with MRI inflamed colon) and being treated with IV antibiotics. Resident also noted to have metabolic [CONDITION(S)]. NN 4/13/2022 readmitted from Hosp . Catheter placed for retention . Fall report: 165 Date: 4/13/22 Time: 6:30pm Location: Dining Room Injury: redness to area on shin Outcome: Root Cause: Interventions in place at time of fall, noted in Report: had back brace on Notification: Assessment: [NAME]: New Interventions: Notes/Concerns: Resident restless reminded frequently to call for assist does not. Makes sudden moves. Hx of frequent falls. Fall report:166 witnessed Date:4/14/22 Time: 7:08pm Location: dining room Injury: none Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: Yes [NAME]: New Interventions: Notes/Concerns: (noted that resident was 1:1, broda chair, back brace) Fall report: 167 Witnessed Date: 4/14/22 Time: 11:00pm Location: Nursing Station Injury: none Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: [NAME]: New Interventions: Notes/Concerns: 1:1 d/t constantly trying to get up to walk when his legs are too weak to support him, and his balance is way off. Res. Being 1:1 due to earlier fall on PM at supper in DR. has made several attempts to stand up from broda chair while 1:1 at nurses' station. Went to get out of broda to stand up and went off the left side of footrest. NN 4/14/2022 11:17 PM: This nurse was getting this resident a drink while getting ice witnessed resident attempt to stand and went down on buttocks. No apparent injuries did not hit head. Resident very restless redirected freq. has decreased cognition and will reattempt to self-transfers at times just mins. later. NN 4/15/2022 12:55 AM: Fax out to clinic to inform of resident's witnessed fall while trying to stand up from his broda chair this night shift. Resident's legs are weak, and his balance continues to be very off so that whenever he attempts to stand unassisted, his legs give out and he drops straight to the floor. Resident also had a fall around supper time on the PM shift when he tried standing up from his chair. That fall was also reported as being witnessed. Resident currently on neuro checks from the same type of fall that he had yesterday 4/13/22 on the PM shift. R180 was wearing his back brace for all the falls. Fall report: 169 Witnessed Date:4/18/22 Time: 7:02pm Location: dining room self-transferring Injury: none Outcome: Root Cause: none Interventions in place at time of fall, noted in Report Notification: Assessment: [NAME]: New Interventions: Notes/Concerns: instructed multiple times to call for assist attempted to stand again in front of nurse right after instruction. Difficult to redirect. R180's MDS, with ARD 4/20/22, indicates R180's cognition is severely impaired with a BIMS score of 3 out of 15. NN 4/23/2022 3:53 AM: Resident seems to be much more alert and brighter with better balance. He woke up around 1am and was out in hallway looking for staff in his wheelchair. Resident was not wearing his brace. Resident easily redirected back to his room, assisted to toilet and then back to his bed. Resident refused to wear his back brace in bed. Resident sat up and ate two McDonalds hamburgers and drank a 4oz root beer then went back to sleep. NN 4/26/2022 6:32 PM: Resident ambulating independently fell , hit his head as witnessed by another resident. Did not move . called 911 for transport to emergency room , transported at 6:30 PM, POA notified. NN 4/29/2022 12:20 MDS: Weekly Medicare review for April: 4/19: PT: Max assist for mobility, significant fall risk. Have not been able to progress ambulation. Standing tolerance of 20 seconds. OT: max assist for all cares. Very confused. No carryover to directions. ST: brace appears to contribute to swallow issues. Nsg-assisted with mobility/personal cares. 2 falls with leg weakness, refusing brace use at times. Fall report:173 Unwitnessed 5/1/22 8:49 AM checking for ants in dining room Date: 5/1/22 Time: 8:49am Location: dining room Injury: none Outcome: Root Cause: Interventions in place at time of fall, noted in Report Notification: Yes Assessment: [NAME]: New Interventions: Notes/Concerns: 5/2/22 - res has had multiple falls throughout stay. All previous interventions have been in place and remain in place. Resident has memory issues and can't recall discussions from 2 min. ago. Will continue with interventions. will continue with frequent checks. NN 5/1/22 9:03 AM: Writer found Resident lying on right side in the dining room, near his table, approximately 6-8 feet from his wheelchair. On assessment, he was alert and oriented as per usual x1. When asked what he was doing on the floor, he responded, I'm checking for ants! and began to laugh. He was not wearing his brace at the time of the fall but was applied after the fall. He had no complaints of pain and moved all extremities well. CMS intact x4. No external rotation or shortening noted hips. Resident lifted to wheelchair after assessment with mechanical lift. VSS. NN 5/1/2022 12:30PM: . Was approached by CNA to assess the resident due to him leaning to the right in his wheelchair. On assessment, I found him leaning 45 degrees in his wheelchair. Alert and Oriented x1 as per usual. Resident denies pain at this time. BP= 169/103; P=112; r=20 SpO2=94% RA and T=97.7. Writer decided to send Resident to Emergency Department 911. 1240 Call place to on call Oak Medical. No one was available to speak to and to receive order. 1245 Call to Rock County 911 Center. 1250 While talking to 911 dispatcher, writer heard a sound behind me, and I turned around and found that resident had fallen out of his wheelchair onto the floor hitting his head on the med cart. 1257 Janesville Paramedics here to assess and transport resident Fall report: 5/1/22 1:18 PM - change of condition, leaning to the right, fall at nurses stations. RN turned back and resident fell . - sent to ER. NN 5/1/2022 8:35 PM: Resident returned to facility from emergency room following a fall on a.m. shift. No injuries were sustained, or evidence of any injuries found in ED. NN 5/2/2022 10:04 AM: Pt had another unwitnessed fall this morning in dining room after breakfast. R180 stated standing to obtain chocolate milk. R180 multiple times daily reminded to ask for help with transfers, staff unable keep R180 within sight constantly although attempted. NP at facility during incident, assessment shows R180 cognitive baseline decreased with unwitnessed fall, resident stated might have hit head. No visible injury assessed R180 sent to emergency room via paramedics per NP orders. Call placed to POA, and message left to return call to hospice services. Fall report: 174 Date:5/2/22 Time: 1:18pm Location: nurses station Injury: hit head on med cart Outcome: ER Root Cause: Interventions in place at time of fall, noted in Report Notification: POA Not notified Assessment: [NAME]: yes New Interventions: Notes/Concerns: No follow up in report 5/2/22 elopement risk score 15 NN 5/5/2022 7:18 PM Resident removed indwelling foley catheter. Resident had foley catheter inER on [DATE] for urinary retention. Resident voided a total of 600 ml this p.m. shift. Resident showed no residual urine on bladder scan. MD notified. Order placed for bladder scan x3 days for residual urine monitoring. Resident has a urologist referral order placed. Will continue to monitor. NN 5/13/2022 4:49 AM: Resident was apparently seen by Neurosurgery on 5/12/22. After Visit summary scanned . Appointment for 5/24 was voided out. No new orders. Resident to be encouraged to wear brace at all times when not laying flat in his bed. NN 5/14/2022 3:45 PM: Nurse received a phone call at the nurses station from the lobby. The dietary aide on the call stated that a resident was in the lobby who needed assistance. Nurse went to the lobby with a wheelchair to assist the resident. The resident was in the lobby sitting in a lobby chair. Nurse transported resident to resident's room via wheelchair. Resident stated to a CNA on p.m. shift that he just returned from the library. CNA reported resident's statement to the nurse. Nurse asked resident if he had just gotten back from the library. Resident did not have a wander guard on his body. Nurse began to look for wheelchair and it was not located. Nurse placed a wander guard on R180's L ankle. When placed nurse noticed an open pack of cigarettes and a lighter tucked in his sock. Nurse could also smell cigarette smoke in the resident's room. Nurse then removed cigarettes and lighter from resident's possession. Nurse then asked the resident where the lighter and cigarettes had come from. Resident stated that he had gotten them from the gas station that he had went to today. Resident stated that his wheelchair was near the gas station. Staff located the wheelchair near a local gas station (location given in town 0.7 miles from facility). The wheelchair was returned to facility by a staff member. The wheelchair did not have the resident's Wander Guard. Nurse placed a Wander Guard on resident. Ensured the wander guard was worki [TRUNCATED]

Based on observation, interview and record review the facility did not ensure residents receive care, consistent with professional standards of practice, to prevent pressure ulcers for 3 of 3 residents ( R5, R14 and R25) with pressure injuries reviewed of a total sample of 18. R5 developed a DTI (Deep Tissue Injury) that worsened into an unstageable wound to her left heel. The facility did not measure or assess the Pressure Injury (PI) weekly and did not implement aggressive offloading when R5 refused heel boots. R14 developed two stage 2 pressure injuries to her bilateral buttocks that the Facility is not measuring or assessing weekly. R14's preference is to sleep in recliner not a bed; R14's recliner does not have a pressure reducing cushion in it. R25 developed three stage 2 pressure injuries to his bilateral buttocks and coccyx the Facility is not measuring or assessing weekly. This is evidenced by: The Facility's Policy and Procedure entitled Pressure Injury Prevention and Managing Skin Integrity dated 6/18/21, documents in part: I. Policy: Prevention measures are put in place to reduce the occurrence of pressure injuries .c. Based on the resident's Braden Scale Score, pressure reduction interventions will be implemented by nursing and documented in the resident's medical record .3. Skin Checks .ii. Weekly 1. While providing routine care, a licensed nurse is to monitor the skin condition of each resident weekly and document the Skin Check in the medical record .4. Weekly Wound Rounds a. Upon identification of abnormal skin findings, a licensed will complete a skin incident. Resident with abnormal skin concern (s) will be added to weekly wound rounds. b. Wound Care Certified (WCC) Nurse or designee will: i. Conduct weekly skin evaluation .iii. Update the Care Plan with any new interventions as applicable .c. The staff nurses will follow through with the skin care interventions implemented for prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Example 1 R5 is a short term rehab resident of the facility. R5 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's most recent MDS (Minimum Data Set) dated 6/16/21 documents R5 scored a 14 on her BIMS (Brief Interview of Mental Status), which indicates she is cognitively intact. R5's MDS also documents no pressure injuries, but R5 is at risk for developing pressure injuries, and has no unhealed pressure injuries. R5's Braden Scale Scores are documented as follows: 6/9/21= 16 (mild risk), 6/16/21= 15 (mild risk), 6/23/21= 15, 6/30/21= 15, 7/7/21= 15, 8/1/21= 15 R5's TAR (Treatment Administration Record) reviewed from admission in June through September (current): June- nothing regarding left heel July- nothing regarding left heel August- Start Date 08/02/2021- Wound Care: DTI left heel. Apply [MEDICATION(S)] to area BID. Every morning and at bedtime [SIC] -Start Date 08/02/2021- Left heel protector to be worn to decrease pressure to left heel area related to DTI. Every shift [SIC] September-Start Date 09/01/2021- Left heel DTI. Cleanse with wound cleanser, apply Gentell Collagen Particles, cover with Meplix every M-W-F (Mon-Wed-Fri) until healed. In the morning every Mon, Wed, Fri for treatment [SIC] -Start Date 08/02/2021- Left heel protector to be worn to decrease pressure to left heel area related to DTI. Every shift [SIC] R5's July TAR documents: 7/22/21- no new skin concerns under weekly skin check 7/29/21- is blank, indicating skin check was not done R5's Nurses' Notes document the following: 7/31/2021 at 21:12 (9:12 PM)- Skin/Wound Note: Patients right heel is boggy. Patient denies sensation in her BLE (bilateral lower extremities). The skin is intact. [MEDICATION(S)] applied for protection. Area measured is 5 cm (centimeters) by 2 cm. It is important to note this is documented incorrectly as right heel and should be left heel. 8/1/2021 at 20:05 (8:05 PM)- Nurse's Note: Pt (Patient) left heel assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Area measures 5.2 x 2.4 cm, no exudate, defined wound edges with peri-wound WDL (within defined limits). Call placed to physician to update with message left for on call physician to return call to facility with tx (treatment) applied and requested for iodine application covered with foam dressing. Soft boot applied while in bed, pt. already utilizes air mattress, wound added to wound binder tracking, will continue to monitor. 8/2/2021 at 11:57 AM- Nurse's Note: Physician updated on left heel DTI. Order received for [MEDICATION(S)] BID (twice a day) and heel protector to decrease pressure to area. Resident informed of new orders and verbalizes understanding. Denies pain or discomfort to area. 8/4/21 at 17:30 (5:30 PM)- Nurse's Note: Wound assessment this shift to left heel DTI, measuring 2 x 2.4 cm with skin intact, appears as deflated blood blister, 100% epithelial tissue, no exudate . 8/4/21 at 17:33 (5:33 PM)- Nurse's Note: Pt utilizes air mattress and soft boot to heel while in bed with elevation when possible. 8/6/2021 at 4:39 AM- Nurse's Note: Resident in bed this NOC shift w/o (without) left heel boot. Resident states that she believes the heel boot is causing the skin breakdown on her left heel. Resident allowed this writer to put the heel boot back on her left foot . 8/10/2021 at 3:23 AM- Nurse's Note: .Resident not wearing her heel protector on left heel. Was agreeable to having this writer put the heel protector on. Resident's left foot has slight foot drop and is turned in slightly. 8/11/2021 at 11:18 AM- Weight Change Note: .Resident noted to have DTI- it is 100% granulation and is re-absorbing .Current meal pattern remains appropriate. 8/13/2021 at 2:25 AM- Nurse's Note: Resident has been declining to wear her left boot/heel protector. Resident was willing to put it on this NOC shift though. 8/16/2021 at 21:46 (9:46 PM)- Nurse's Note: Tx (treatment) applied per order to left heel measuring 2 x 2 cm, no exudate noted, no s/sx (signs and symptoms) of infection, wound bed appears as reabsorption with 100% granulation tissue noted, well defined edges and surrounding skin WDL, pt. denies pain. Cleansed area with NS (normal saline), air dried and painted with [MEDICATION(S)], pt. use of air mattress and soft boot at HS (hour of sleep) effective with wound progression. Wound binder updated . 9/9/21 at 14:28 (2:28 PM)- Skin/Wound Note: Left heel has returned to 100% black eschar. Fax sent to MD as update and to request iodine order. R5's eMAR (electronic Medication Administration Record)- Administration Notes (for MAR and TAR) Left heel protector to be worn to decrease pressure to left heel area related to DTI. every shift: 8/13/21 at 23:56 (11:56 PM)- Resident refused boot this NOC shift saying that it was the cause or her having a blister on her left heel. Resident was agreeable to having both heels floated on a pillow through. 8/14/21 at 9:24 AM- Resident refused 8/15/21 at 4:25 AM- refusing to wear left heel boot, but willing to have her heels floated on a pillow. 8/17/21 at 5:37 AM- refusing to use heel boot to protect heel, but willing to float heels on pillow 8/18/21 at 1:32 AM- refusing to use heel protector but allowing to float heels on pillow 8/22/21 at 2:27 AM- refusing heel protector but willing to have pillow under legs to elevate heels 8/24/21 at 4:45 AM- refuses to wear heel protector, but will allow heels to float on pillow 8/25/21 at 9:35 AM- Resident refusing to put boot on stating that it is very hot and don't stay in place. Education provided on need. Continues to decline. Allowed writer to use pillows to off load bilateral heels. 8/26/21 at 5:14 AM- refusing to use left heel protector, but willing to elevate heels on pillow 8/27/21 at 5:04 AM- Resident continues to refuse heel boot, but acceptable to having heels floated on pillow 8/27/21 at 21:19 (9:19 PM)- Resident declined to use heel protector while in bed. She states it is too hot and she don't like it because it makes it hard for her to move around. Education provided about pressure and positioning. BLES (bilateral lower extremities) floated on pillows as resident would allow. [MEDICATION(S)] applied to L (left) heel 8/29/21 at 1:49 AM- refused heel protector. Left heel floated on pillow tolerated 8/30/21 at 23:43 (11:43 PM)- refusing heel protector, but agreeable to floating heel on pillow 9/1/21 at 3:52 AM- Refusing to use heel boot for protection, but willing to have heel floated on pillow. 9/2/21 at 4:51 AM- refuses left heel protector 9/4/21 at 5:24 AM- Refused to wear heal protectors 9/7/21 at 3:10 AM- Refusal of heel protector. Accepting of floating heel on pillow though 9/9/21 at 5:11 AM- Refusing to use heel protector but agreeable to floating heel on pillow R5's eMAR- Administration Notes Wound Care: DTI left heel. Apply [MEDICATION(S)] to area BID. every morning and at bedtime. 8/30/21 at 13:28 (1:28 PM)- Collagen applied as heel has opened. DON (Director of Nursing) obtaining new orders from PA (Physician Assistant) R5's Wound Evaluation Flowsheet documents the following: 8/1- 5.2 cm x (by) 2.4 cm, no exudate, 100% blood blister, wound margins well defined 8/4- 2 x 2.4 cm, no exudate, 100% epithelial tissue, wound margins well defined, current treatment: NS, [MEDICATION(S)] BID, current preventative interventions: air mattress/soft boot 8/16- 2 x 2 cm, no exudate, 100% epithelial tissue, wound margins: well defined, current treatment: NS, [MEDICATION(S)] BID, current preventative interventions: air mattress/ soft boot at HS It is important to note that there is no further documentation on R5's wounds. This is 3 weeks of no wound assessments during which time R5's wound deteriorated, opened up and is now unstageable. R5's Care Plan does not have anything on it about a pressure injury to left heel or preventative pressure relieving interventions. R5's anticoagulant Care Plan documents .Daily skin inspection . dated 6/10/21. R5's left medial tibia and #5 metatarsal fx (fracture) with knee fusion Care Plan documents .CMTS (circulation, motion, temperature, sensation) daily . dated 6/10/21. R5's Diabetes Care Plan documents .Check all of body for breaks in skin and treat promptly .Inspect feet daily for open areas, sores, pressure areas, blisters, [CONDITION(S)] or redness . dated 6/10/21. R5's ADL (activity of daily living) Care Plan documents .LLE (Left lower extremity): Positioning boot to be worn while in bed or up in recliner; keep anti rotation bar on to prevent foot rolling inward . dated 7/5/21. It is important to note there is no signed out documentation of preventative interventions for R5 from admission, both R5 and the CNA's attest R5 never had this boot and the CMTS checks for R5's left leg have not yet ended. R5's CNA (Certified Nursing Assistant) kardex documents- LLE: Positioning boot to be worn while in bed or up in recliner; keep anti rotation bar on to prevent foot rolling inward. It is important to note both R5 and the CNA's attest that R5 never had this boot. R5's Pressure Redistribution Mattress System documents Recommended for maximum therapeutic prevention treatment and management of pressure ulcers. The Manufacturer's Recommendations do not speak to what stage pressure injury this mattress is good for. On 9/8/21 at 11:53 AM, Surveyor noted R5 had a blue boot on her dresser in her room. It is important to note this type of boot is typically used for floating heels to prevent pressure injuries. On 9/8/21 at 2:42 PM, Surveyor observed RN D (Registered Nurse) perform R5's wound treatment to her left heel. RN D removed the old dressing, noting moderate amount of brown-ish/yellow-ish/green-ish drainage. Surveyor asked RN D if the wound had an odor, RN D said no. Surveyor noted wound bed to be circular in shape with defined wound edges, peri-wound pink, dry and intact, wound bed noted to be deep purple-ish/brown-ish/black-ish in color. Surveyor asked R5 if the wound caused her pain, R5 stated I can't feel it at all because of my Diabetes, there's no pain. On 9/8/21 at 2:59 PM, Surveyor interviewed R5. Surveyor asked R5 if she wears the blue boot that is on her dresser, R5 said I used to wear that boot in bed but I don't like it because it twirls around and is then uncomfortable. Surveyor asked R5 if the facility tried any other way of elevating her heels, R5 stated they put a pillow under my leg when they put me to bed sometimes but it doesn't stay. On 9/9/21 at 7:55 AM, Surveyor observed R5 in bed lying on right side, left heel resting on mattress (direct pressure of wound on mattress), pillow (1) behind legs on bed, not under legs to elevate heels, blue boot across room on dresser. It is important to note that 1 pillow would not be enough to float R5's heels off of bed. On 9/9/21 at 11:36 AM, Surveyor interviewed LPN E (Licensed Practical Nurse). Surveyor asked LPN E what interventions they have tried in relation to pressure injury prevention with R5, LPN E stated she has worked at the facility a month and R5's wound has been there the whole time. Surveyor asked LPN E what interventions they've used since she started, LPN E stated R5 is supposed to wear blue boot, but she doesn't like to so we try to float on pillows. On 9/9/21 at 11:45 AM, Surveyor interviewed CNA F. Surveyor asked CNA F what interventions they have tried in relation to pressure injury prevention with R5, CNA F said we started with floating her heels then I think the boots. Surveyor asked CNA F if either were effective, CNA F stated I get the feeling she kicks the pillow out and she refuses the boot. On 9/9/21 at 12:15 PM, Surveyor interviewed DON B. Surveyor asked DON B what her expectations for pressure injury prevention interventions would be for a R5 with her diagnoses, DON B replied air mattress, following whatever precautions put in place by physician, and turning and repositioning. Surveyor asked DON B if she would expect R5's heels to be floated, DON B stated yes unless restrictions won't allow. Surveyor asked DON B when the staff noted R5's heel to be boggy, what would she have expected to be implemented; DON B stated definitely elevate feet and apply skin prep to heel. Surveyor asked DON B if she would expect staff to identify a skin concern before it has reached the DTI state, DON B said yes. Surveyor asked DON B if they have a WCC nurse in the facility, DON B stated no. On 9/9/21 at 12:17 PM, Surveyor interviewed RN Consultant G (who was previously an Interim DON at this facility). Surveyor asked RN Consultant G what interventions to prevent pressure injuries were in place for R5 upon admission, RN Consultant G said she's had an air mattress since admit and she could move her legs independently. Surveyor asked RN Consultant G when are skin checks to be completed. RN Consultant G stated CNA's check with cares and report anything they see to the nurse; nurses do weekly skin check. When Surveyor asked RN Consultant G if wounds should be assessed and measured weekly, RN Consultant G stated yes, we used to do wound Wednesday, not sure what happened after I left. On 9/9/21 at 5:00 PM, Surveyor interviewed R5. Surveyor asked R5 if she ever used a boot that had bar on it to prevent her ankle from turning. R5 stated no. Surveyor asked R5 if the Facility ever used any other intervention to prevent pressure to her heels, R5 said they tried a pillow but it doesn't always stay and I have no feeling; that blue boot twists around and is uncomfortable. R5 went on to state sometimes I put my left leg on my right leg due to pain in my hip. Surveyor asked R5 what the staff talked to her about when they wanted to put boot back on or elevate legs on pillows, R5 stated They always said I should wear it so it doesn't cause pressure. Surveyor asked R5 did anyone ever talk to you about what could happen if there was continued pressure to the area, R5 said no they did not. On 9/9/21 at 5:05 PM, Surveyor interviewed CNA H. Surveyor asked CNA H what interventions have been used with R5 to prevent pressure injuries, CNA H said we have elevated her heels with pillows and used the blue boot. Surveyor asked CNA H how many pillows does R5 require to keep her heels floated, CNA H said two. Surveyor asked CNA H if R5 ever had a boot with a bar on it that prevented her ankle from turning inward, CNA H stated no. On 9/9/21 at 6:02 PM, Surveyor interviewed DON B. Surveyor asked DON B if the facility had completed a risk versus benefit with R5. DON B said no, there is none. Of note CNAs and R5 state R5 never had a boot with a bar on as the CNA kardex and Care Plan indicate. R5 did have an air mattress in place; however, did not have a turning/repositioning schedule or other preventative heel floating mechanism in place until after her heel pressure injury developed. The facility was aware back on 8/4/21 R5 was not agreeable to using the blue boot and there was not a risk versus benefit completed with her. R5 states sometimes a pillow is placed to elevate heels off of mattress, but not always. Surveyor observed R5's heel resting directly on mattress on 9/9/21. The facility did not attempt other interventions prior to R5 developing the heel pressure injury. The facility is not assessing or measuring R5's heel pressure injury weekly. The facility failed to follow NPIAP (National Pressure Injury Advisory Panel) standard of practice as their Policy and Procedure indicates. The facility did not complete weekly skin check on 7/29/21. The facility noted R5's left heel to be boggy on 7/31/21. On 8/1/21, the facility found a DTI- blood filled blister to R5's left heel. Facility obtained treatment order on 8/2/21 for R5's left heel. Starting on 8/4/21 the facility documents R5's dislike and unwillingness to use blue boot provided. There is no documentation until 8/13/21 the facility was utilizing pillows to float heels. The facility documented on 8/24/21 and 8/27/21 that education was provided to R5 but not the risks that coincide with pressure. R5's left heel pressure injury deteriorated on 8/30/21 to an open wound and on 9/9/21 it is documented as 100% eschar. Example 2 R25 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R25's BIMS is 15. R25's Braden Scale for predicting pressure ulcer risk was a 16 (scores of 15-18 indicate risk) on 8/16/21. Braden Scale on 9/6/21 was 17 for R25 with the following statement in part .requires moderate to maximum assistance in moving . requires frequent repositioning with maximum assistance. Per the facility's nurse's admission note for R25 on 8/16/21 at 12:45 PM, Skin assessment performed. Scattered MASD (moisture associated skin damage) to bilateral buttocks with epithelial layer removed measuring 6.5 x 7.0 x 0.1. 2 center areas will measure out as Stage 2 pressure injuries. Care plan dated 8/17/21, has a focus area that states in part, .R25 has three stage 2 pressure ulcers to coccyx and buttocks. Interventions of the care plan includes in part .weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate .administer treatments as ordered and monitor for effectiveness. Per the facility nutritional assessment dated [DATE], R25 had a prealbumin level of 5.8 with normal ranges 15-36 .due to skin status and low protein level, recommendation to provide ProSource (protein supplement drink) 1 ounce twice daily and multivitamin with minerals for extra nutritional support. R25's MDS, dated [DATE], indicates extensive assistance required with bed mobility and total dependence for transfers from bed to chair. R25's skin evaluation dated 8/23/21, includes wound measurements of the bilateral buttocks of 6.2 cm (centimeter) long x 6.8 cm wide x <0.1 cm deep. There were no further wound measurements in R25's record. On Thursday 9/9/21 at 3:03 PM, Surveyor observed RN D completing wound care for R25. Surveyor asked RN D, are you going to measure the wounds? RN D replied, Wounds are measured on Wednesday's. Surveyor replied, there are no measurements in R25's chart for yesterday. RN D did not measure the wounds. Example 3 R14 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's BIMS is 15. R14's minimum data set (MDS) assessment dated [DATE] includes diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/7/21 at 11:30 AM, Surveyor interviewed R14, do you ever rest in bed? R14 responded, No, I like it right here. R14's care plan dated 11/20/20, indicated focus areas of Potential for pressure ulcer development related to immobility with interventions in part .follow the facility's policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .teach family/resident the importance of changing positions .encourage small frequent position changes and self-care deficit related to limited mobility with interventions in part .resident requires skin inspection daily with cares, weekly with shower, observe for redness, open areas, scratches, cuts, bruises and report changes . Per the facility's nutritional assessment, dated 7/29/21, R14's skin is free of pressure sores. Per the facility documentation, R14's Braden Scale score was 18 on 8/26/21 which indicates R 14 was at risk for skin breakdown. The facility's progress notes of 8/27/21 state in part .Resident has had areas of callous like skin buildup on bilateral buttocks .that have now opened up .will consult therapy to see if there is some possibility of trialing a seat cushion in her recliner. Resident spends all her time sitting in her recliner with position changes only when she toilets and then adjusting the chair from reclining to sitting position throughout the day and night. Nursing progress notes for R14 dated 8/28/21 indicate .Upon assessment, 2 pressure injuries identified to bilateral buttocks. Both areas Stage 2 .resident uses recliner for seating and for sleep .refer to therapy for appropriate cushion to provide pressure relief when in recliner .Left buttock pressure ulcer, stage 2, partial thickness skin loss, Length 0.2 cm x width 0.2 cm x depth 0.1 cm, wound bed granulation present, no exudate .Right buttock pressure injury stage 2, partial thickness skin loss, length 0.3 cm x width 0.3 cm x depth 0.1 cm, wound bed granulation present, no exudate . The facility's documentation includes a nurse's note on 9/4/2021 which states in part .resident's [MEDICATION(S)] dressings removed from upper part of buttocks/left and right. Upon removal, skin was damaged which caused slight amount of bleeding. Areas cleansed, new dressings applied. Due to damage from [MEDICATION(S)], [MEDICATION(S)] placed on each area instead .will continue to monitor. Of note, per the facility policy the wound should have been measured by this date and was not. On 9/8/21 at 10:45 AM, Surveyor observed RN P completing R14's wound care on buttocks; there was no dressing in place or removed at the time of observation. Surveyor asked RN P, is there a pressure relieving device for R14's chair? RN P responded, I will have to ask therapy. Does R14 ever go to bed or change position? RN P answered, R14 refuses to go to bed as evidenced by the lack of bed in this room. R14 also doesn't like to reposition. Measurements of the wounds were not taken, the note documenting the intervention states in part .Wound bed observed with edges well defined, surrounding skin WDL (well defined limits), [MEDICATION(S)] dressing applied to right and left side. Pressure relieving options reviewed with pt. (patient) who still refuses air cushion to chair .as well as continued refusal to utilize bed to reposition. On 9/09/21 at 10:06 AM, Surveyor interviewed CNA H, how often does R14 receive a shower? CNA H responded, Twice a week. Surveyor asked, what is the routine for skin checks? CNA H stated, We tell the nurses if we see a change. Surveyor asked CNA H, does the RN come check each resident's skin on shower day? CNA H replied, No. Surveyor asked CNA H, have you noted skin concerns with R14? CNA H answered, Yes, on her buttocks and feet. On 9/09/21 at 10:12 AM, Surveyor interviewed LPN E, tell me the routine for assessment of skin? LPN E stated, It is done weekly on shower day. Surveyor asked LPN E, was it completed this week for R14? LPN E replied, It should have been. Surveyor asked LPN E, is this documented anywhere? LPN E stated, Not that I know of. On 9/9/21 at 11:00 AM, Surveyor asked DON B, are any staff wound care certified? DON B replied, no. Surveyor asked DON B, what would you expect for wound care for R14? DON B answered, Weekly assessment and documentation. I understand R14 refuses to reposition and a cushion for her chair. Surveyor asked DON B, is there any risk/benefit discussions or care plan information about these refusals? DON B stated, No.

Based on interview and record review, the facility did not ensure that a resident who enters the facility without pressure injuries does not develop pressure injuries and a resident having pressure injuries receives necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing for 3 of 6 residents (Residents 8, 3, and 7). R8 was admitted to the facility without a pressure injury (PI) and was identified to be at risk for PI development. R8 developed a facility acquired PI on her left heel. While treating R8's left heel PI, the facility was wrapping Supra Form around R8's left heel and foot to hold the foam in place on R8's heel. The Supra Form created an abrasion on the dorsum (top) of R8's left foot that progressed into an avoidable Stage IV (stage 4) PI with tendon exposed. The facility failed to update R8's plan of care once the PI developed and failed to notify the physician when the PI deteriorated. Subsequently, R8's PI of the top of her Left foot became infected and required IV (intravenous) and oral antibiotics. The facility failed to remove or change the medical device (Supra Form) that caused pressure, failed to immediately update plan of care once the PI was identified, and failed to consult the physician when the PI when deteriorating, creating a finding of Immediate Jeopardy. The Immediate Jeopardy began on 2/22/17 when the PI was noted to be a Stage IV with tendon exposure. The facility did not implement new interventions to prevent further skin breakdown or inform physician of the deterioration. The Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the Immediate Jeopardy on 6/13/17 at 5:15 PM. The immediacy was removed 6/13/17 and continues at a scope and severity of G as the facility continues to implement its removal plan and as evidenced below. R3 developed a Stage III pressure injury from a leg brace. There is no documented evidence the facility provided daily skin checks to R3's lower extremities as ordered by the physician. R7 currently has a Stage II pressure injury to her buttock area. The facility has not completed thorough and consistent wound assessments of this wound. Findings as follows: The facility's policy entitled Skin and Wound Management, undated, states in part: Pressure Ulcers (PIs) / Skin Breakdown - Clinical Protocol: 1. The nursing staff will assess and document an individual's significant risk factors for developing sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall assess and document/report the following: a. Vital signs b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. c. Pain assessment d. Resident's age and sex e. Resident's mobility status f. Current treatments, including support surfaces g. All active diagnoses 4. The wound care nurse will help the staff define the type (for example, arterial, or stasis ulcer) 5. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing (occlusive, absorptive, etc.) and application of topical agents. 6. The wound care nurse will notify the physician to help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. 7. During Resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated , extensive, or non-healing wounds. 8. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. a. Healing may be delayed or may not occur, or additional ulcers may occur because of other factors which cannot be modified. According to the Wound Care Education Institute's Skin and Wound Management Course, wound assessment should be done upon each dressing / patient visit and documented weekly at minimum. In addition, this course teaches the purpose of measuring wounds is to track and measure the progression of healing from week to week. For the measurements to be useful, consistency is the key. According to the NPUAP's (National Pressure Ulcer Advisory Panel's) Pressure Injury Staging, a Stage III pressure injury has full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer and the granulation tissue and epiboly (rolled edges) are often present. Slough and / or eschar may be visible. Example 1 R8 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Note that R8 does not have a [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/2/17 indicated a Brief Interview of Mental Status (BIMS) was unable to be completed. R8 is not able to communicate her needs. R8 has an Activated Health Care Power of Attorney (AHCPOA). Section M0150 of the MDS indicates Resident 10 was at risk for developing a PI. Section G0110, Activities of Daily Living (ADL's) indicates R8 requires extensive assist of two for bed mobility and transfers. A PI Care Area Assessment (CAA) worksheet, dated 9/19/16, states in part: Pressure Ulcer Assessment: no pressure ulcers (PIs) Pressure: Requires staff assistance to move sufficiently to relieve pressure over any one site, confined to bed or chair most of the time, requires pressure reducing mattress or seat cushion. [MEDICATION NAME] Risk Factors: Cognitive loss limits mobility, incontinence. R8 has dementia with progression of the disease and poor cognition with decreased ability to make needs know. Description of Problem: R8 has contractures with a palm protector for her Left hand and a blue terry cloth cone for her right hand. She has an APP mattress and cushion in her wheelchair. Her Braden is 15 putting her at risk for impaired skin integrity. She needs staff assist to reposition and meet her needs. Of note, subsequent MDSs completed for R8 indicate R8 is at risk for PI development. R8 has a comprehensive plan of care, dated 6/5/17, entitled Impaired Skin Integrity, top of Left foot, Right foot second toe. Related to: Urinary incontinence, limited mobility, cognitive impairment. Goal: Regain Skin Integrity. Nurse Aide: Provide pressure reducing w/c (wheelchair) cushion, inflatable heel protectors (added 12/12/17), App mattress (added 12/12/16) - ensure air mattress is plugged in inflated and pump is working - notify nurse if not functioning, keep brief unattached at night, float heels, keep skin clean and dry, use lift sheet when moving resident in bed, float heels when in bed, monitor skin with cares and notify nurse of changes, foot cradle when in bed to keep bed linens off feet to prevent pressure (added 1/4/17), keep socks loose around toes to prevent pressure (added 6/5/17), use pillows for support, use moisturizer with cares, barrier cream to peri area. On 12/15/16, the facility obtained a new order for the left heel blister: Apply skin prep to left heel blister twice a day AM PM first date: 12/15/16 (until resolved). Order d/c 2/17/17. On 12/20/16, RN G wrote the following fax request to MD (Medical Doctor). The MD signed the order on 12/28/16 and treatment was started 12/29/16. The fax read as follows: .May we have an order for [REDACTED]. We will continue skin prep order. According to Nurse Notes, the facility continued to wrap R8's leg foot with kerlix (the facility refers to this product as kerlix or kling but per interview with Registered Nurse (RN) G (below) they have consistently used Supra Form on R8's PIs since December 2016. The facility does not use kerlix or kling. RN G stated the facility was wrapping Supra Form over the treatment order since 12/28/16. Note: Kerlix is softer and has significantly more stretch which makes it more gentle and non-restrictive on wounds. On 2/8/17, Licensed Practical Nurse (LPN) T wrote the following fax request to MD. The MD signed the order 2/16/17 and treatment was started 2/17/17. Weekly wound check done today on left heel open. Total area 4.0cm x 5.0cm blanchable redness with mild maceration. Two open areas with red wound bed. Recommend following changes, d/c (discontinue) skin prep BID. May we have orders to change tx (treatment) to apply foam dressing to left heel (non-adherent foam) wrap with kling to hold in place. Change M-W-F and PRN (as needed). LPN T documented the following nursing note, dated 2/15/17, at 6:09 PM, in part: New area noted on top of left foot, at the base of leg, 5.5 cm x 1.5cm blanchable redness with a superficial opening 0.5cm x 1.5cm, this is likely d/t (due to) wrap that holds foam on heel in place, skin prep applied and covered with foam for protection, fax sent to MD for order, message left for POAHC to return call. 2/15/17, at 6:50 PM, fax sent to attending physician regarding new area on Left top of foot at base of leg, protective foam dressing applied, requesting order. Call placed to have APOAHC return call for update on new area. 2/15/17 - a fax was sent to attending physician that reads as follows: R8 noted with an abrasion like area 5.5 cm x 1.5 cm blanchable redness with an area at base 0.5 cm x 1.5 cm superficial opening. Likely this is d/t (due to) wrap that is being used to hold foam on heel (resolving blister) skin prep applied and covered with foam. May we have an order to keep foam in place for protection, change every 5 days and PRN? Top of Left foot red tendon area. Note: this order was not signed by the MD until 2/17/17. Treatment started 2/17/17, d/c 3/1/17. Note: the MD was not immediately contacted when the area first appeared on 2/15/17. The Telephone Order (TO) signed by MD, on 2/17/17, Treatment Administration Record (TAR) reads as follows: Apply foam dressing to Left Heel (non- adherent foam), wrap with kling to hold in place 3x/wk. Monday Wednesday Friday PM. First day: 2/17/17. Note, the order is to change the dressing every 5 days, not every 3 days. The order was entered incorrectly on the TAR and was being changed more often than ordered. This order was d/c 2/24/17. 2/22/17 - the Family Medicine attending MD documented L heel/dorsum foot bandaged although no open areas. Unsure of benefit of L (left) foot dressing - may D/C but keep pressure relieving boots. Note: the facility noted the PI was open after the MD had seen R8 on this day. Nursing notes, dated 2/22/17, at 4:11 PM, state in part: Top of Left foot tendon area that was red is now open. Wound bed is red. Areas measures 3.0 cm X 3.0 cm X less than 0.1 cm with small amount of bleeding. Skin very fragile and is peeling away. Has some dark purple areas to immediate periwound. There is some dark red discoloration that does not blanche to top of Left foot with slight [MEDICAL CONDITION]. The redness decreases and blanches as redness extends into Left lower leg about ankle level. The whole area of redness measures 15.0 cm X 7.0 cm. The facility notified the physician via phone. No new order for the left foot. Left heel blister has resolved. Gently removed peely skin to left heel. Has pink new skin to left heel that blanches well. Foam dressing is left off. Heel is firm. On 2/23/17, at 7:13 PM, R8's Telephone Order states: Send to ER (emergency room ) for evaluation of left foot wound, possible infection. The hospital History and Physical states as follows: Being admitted for [MEDICAL CONDITION] of left foot. Patient (R8) brought in by caretaker from nursing home for infection of dorsum of left foot. Per caretaker, R8 had abrasion on dorsum of foot for the past few days. However, noted breakage in skin with drainage of purulent material and development of progressively worsening [DIAGNOSES REDACTED] up her left leg yesterday, 2/22/17. Caretaker denies fever. Patient is demented at baseline and is currently at her baseline status. On 2/24/17, the hospital cultured the PI on R8's dorsum on her left foot. The PI culture results were positive for staphylococcus aureus. This isolate tested negative for inducible [MEDICATION NAME] resistance. Note: R8's PI on her right toe (2nd digit), also a facility acquired PI, tested positive staphylococcus aureus as well. The hospital Assessment and Plan states the following: [MEDICAL CONDITION] of dorsum of left foot s/p (status [REDACTED]. Stage 3. Rapidly progressing. [DIAGNOSES REDACTED]tous, warm, purulent drainage and progressing up to mid shin. Patient is afebrile, there is no leukocytosis. Patient was started on [MEDICATION NAME] in ED (Emergency Department). IV [MEDICATION NAME] in 600 mg BID initiated 2/24/17. R8 returned to the facility, on 2/24/17, with orders for [MEDICATION NAME] 250 mg tab, take 2 tabs by mouth today, then 1 tab daily for the next 4 days. R8 also received orders for Santyl - Apply nickel thick daily to entire wound, extending cream past edges. Note: TAR indicates the following order on 2/24/17: Cleanse left anterior foot @ (at) ankle wound with normal saline (Saf-clense deactivates Santyl Ointment), Apply Santyl Ointment nickel thick over slough within wound bed and beyond slough edges, place [MEDICATION NAME] over santyl, Cover with 4x4 fluffs x2 and wrap with kerlix and secure with tape, being sure to avoid the skin with tape. Apply waffle boots daily. D/C 3/1/17. Note: Surveyor requested MD order for this treatment and facility was unable to locate the order. 2/28/17: Wound measurement: 3.0 cm x 5.0 cm - 100% slough in wound bed A TO, dated 3/1/17, indicates the following order signed by the MD (signature undated). Changes to tx on left foot: d/c [MEDICATION NAME] use hydrogel impregnated gauze over wound on top of santyl, skin prep peri wound use foam dressing instead of fluff. Note: the TAR indicates the following order on 3/1/17: Cleanse left anterior foot @ ankle wound with normal saline (Saf-clense deactivates Santyl Ointment), Apply Santyl Ointment nickel thick over slough within wound bed and beyond slough edges, place hydrogel impregnated gauze over santyl, apply skin prep to peri wound, Cover with foam dressing and wrap with kerlix and secure with tape, being sure to avoid the skin with tape, Apply waffle boots daily. 3/7/17: Wound measurement. 4.5 x 3.0 - Thick yellow slough - 1.0cm x 0.5cm red tissue at 5:00 position (No physician notification) 3/9/17: Wound measurement. 4.0 cm x 3.0 cm (Podiatrist visit) 3/16/17: Wound measurement. 2.5 cm x 4.0 cm - Thick yellow slough 3/29/17 Wound measurement. 2.5 cm x 4.0 cm - 90% slough 4/5/17: Wound measurement. 4.0 x 3.0 - Depth unable to determine 4/5/17 - Primary MD writes physician progress notes [REDACTED]. Poor progress of wound on dorsum L foot. Will write order for Podiatry to see patient (pt) for further recommendations. R8 likely needs sharp debridement. Significant slough. 4/11/17: Wound measurement. 2.0 cm x 3.0 cm - Eschar/slough - greenish yellow to center 4/14/17: Wound measurement. 4.0 cm x 2.8 cm - Wide slough appearing tan yellow in color (2.0cm x 3.0cm) 4/19/17: Wound measurement. 3.6 cm x 2.5 cm 4/27/17: Wound measurement. 4.2 x 2.0 - Notes indicate: Teaching R8 how to reposition self and benefits of doing this and not doing this. Note: R8 is unable to reposition herself. 5/1/17: Wound measurement. 2.0 x 3.2 cm with tendon exposure (Podiatry) 5/1/17 Physician order [REDACTED]. 5/11/17 Physician Order: Change kerlix outer wrap daily. Leave the tape/[MEDICATION NAME] bandage in place. 5/11/17: Wound measurement. 3.5 cm x 2.0 cm with tendon exposure (Podiatry) No further measurements after 5/11, including Podiatry visits 5/25/17 physician's orders [REDACTED]. Do not remove [MEDICATION NAME]. On 5/11/17, R8 returned to the Podiatrist. The Podiatrist applied a Puraply graft 2 on the dorsum of R8's right (note, it is the left) foot. If carried out, the typical debridement of the biofilm and note that in 2 areas the extensor tendon is truly exposed in the wound. We placed the graft uneventfully and R8 tolerated the debridement adequately as well. This was covered by [MEDICATION NAME] and fixated using paper tape followed by a sterile gauze bandaging. Instructions have been written to leave the tape and [MEDICATION NAME] in place with daily changes of the gauze bandaging. On 6/13/17, at 11:00 AM, Surveyor observed RN U change the treatment to R8's dorsal left foot. Surveyor was not able to observe the PI on the dorsum of R8's left foot as the [MEDICATION NAME] is to stay in place until R8 goes back to Podiatry. The facility changes the kerlix. Surveyor observed RN U wrap R8's left foot with Supra Form. The facility has continued to use Supra Form since 12/28/16, despite the MD orders that kerlix is best and with the knowledge that the Supra Form caused the initial abrasion to R8's dorsal left foot that led to a Stage IV PI with tendon exposure. As noted earlier, Kerlix is softer and has significantly more stretch which makes it more gentle and non-restrictive on wounds. The tendon on R8's dorsal left foot is still exposed today. On 6/13/17, at 5:15 PM, Surveyor spoke with NHA A, DON B, and RN G. RN G stated that the facility only uses Supra Form and does not use kerlix or kling. RN G stated that Supra Form has been used consistently on R8's Left foot since December 2016. Surveyor asked DON B if the facility educated their nurses regarding not wrapping Supra Form too tightly. DON B stated, No. DON B agreed that the MD should be called for new PIs or worsening PIs. On 6/14/17, at 11:00 AM, Surveyor spoke with LPN T. LPN T stated R8 had a resolving blister on her left heel and as treatment for [REDACTED]. LPN T clarified were wrapping over the tendon on top of her foot. LPN T stated R8's heel needed protection. LPN T stated on 2/15/17, when she removed the Supra Form wrap from R8's left foot, the area on top of R8's foot looked abraised from the wrap (Supra Form). LPN T stated, Based on what I was observing, the wrap was the likely cause. Surveyor asked LPN T if she told anybody. LPN T stated she told RN G. LPN T stated at that time she had just taken over Infection Control and was transitioning into Wound Care. LPN T stated she and RN G communicate regarding all the wounds. Surveyor asked LPN T if she recalls if the Supra Form was wrapped tightly on R8's Left foot on 2/15/17 when she discovered the abraised area. LPN G stated she does not recall if it was wrapped tightly. LPN G stated there was no change to the treatment after that and the nurses were not educated regarding following orders and not wrapping Supra Form too tight. LPN G stated shortly after that R8's L heel PI healed. Systematically, the facility failed to remove the medical device (Supra Form) that caused pressure, failure to immediately update plan of care once the PI was identified, and failure to consult the physician when the PI was deteriorating created a finding of Immediate Jeopardy, which began 2/22/17. The facility removed the Immediate Jeopardy, on 6/13/17, by taking the following actions: The following measures and systemic changes have been put into place immediately to ensure that the deficient practice does not recur and will be completed tonight: -All residents will have head to toe skin assessments (in-house skin sweep) to identify skin issues that we may not be aware of. -Braden Risk Assessments completed on all residents. -Residents with medical devices will be put on BID skin checks to make sure no pressure is caused from that device. Nursing staff in-serviced immediately and prior to start of next shift in-serviced on: -How to identify PIs -PIs need to be appropriately staged -When interventions should be implemented to prevent pressure injuries -When a PI develops, re-evaluate the plan of care and implement something new to prevent PI from worsening and lower resident risk -Importance of weekly wound assessments including: type, location, stage, and measurement -Treatments will not be initiated without a Doctor's order -The facility plans to monitor its performance to make sure that solutions are sustained by: DON B or designee will monitor weekly wound notes x 4 weeks, weekly x 4 weeks, and, monthly x 4 months, and quarterly x 3. DON B or designee will complete daily audits x 14 days. Weekly x 4 weeks. Monthly x 3 months. Audit results will be reviewed at QUA for effectiveness. Started immediately on 6/13/17. Example 2 R3's [DIAGNOSES REDACTED]. R3's most current Braden Scale, dated 4/7/17, identifies R3 to be at risk for pressure injuries with a total score of 15 (at risk). R3's care plan, in place on 5/10/17, just before R3's pressure injury was identified on 5/10/17, shows a care plan problem, dated 3/10/17, which states: Problem: Impaired Skin integrity related to limited mobility, Dx (diagnosis) of MS manifested by skin breakdown. Interventions to this care plan problem included: weekly skin assessment . evaluate healing process and revise care plan as needed. treatment of [REDACTED]. keep skin clean and dry . frequent turning . use pressure - reducing support surfaces in bed and chair, elevate heels, foot cradle on end of bed with linens on top . R3 fell from her electric wheelchair, on 11/14/16, and sustained a right femur fracture and a left proximal tibia fracture. R3 was placed in a knee immobilizer with a physician order, dated 11/18/16, which states daily skin checks. R3's record contains the following information: 11/2016 TAR (Treatment Administration Record): Entry dated 11/18/16 stating Keep Knee Immobilize clean, dry, and in place. Daily skin checks to Bilateral Lower Extremities. This entry is noted to be done TID (three times a day) and staff will sign this entry out each shift to confirm it was done. 11/29/16 Orthopedic Physician orders: Maintain Knee Immobilize Daily skin Checks. 12/2016 TAR: Entry dated 11/18/16 stating: Keep Knee Immobilize clean, dry, and in place. Daily skin checks to Bilateral Lower Extremities noted and signed out TID. 1/12/17 Orthopedic Physician orders: . Frequent skin checks . 1/2017 TAR: Entry dated 11/18/16 stating: Keep Knee Immobilize clean, dry, and in place. Daily skin checks to Bilateral Lower Extremities noted and signed out TID. 2/2013 TAR: Entry dated 11/18/16 stating: Keep Knee Immobilize clean, dry, and in place. Daily skin checks to Bilateral Lower Extremities noted and signed out TID. 3/23/17 Orthopedic Physician orders: Bilateral Hinged Knee braces which can be unlocked at all times, May sit in wheelchair, PT (Physical Therapy) for knee ROM (Range of Motion), F/U (follow up) in 6 weeks (with) PA (Physician's Assistant). 3/2017 TAR: Entry dated 11/18/16 stating: Keep Knee Immobilize clean, dry, and in place. Daily skin checks to Bilateral Lower Extremities was discontinued on 3/23/17. A new entry dated 3/23/17 was added to this TAR and states: Supportive Device: Bilateral Hinged Knee Braces which can be unlocked at all times. May sit in wheelchair, continuous use. It is important to note with this new entry noted on the TAR, staff do not sign this entry out as being completed. The order for Daily Skin Checks was not carried over to the new TAR entry on 3/23/17 despite having no specific order to discontinue these daily skin checks. 4/2017 TAR: Entry dated 3/23/17 stating: Supportive Device: Bilateral Hinged Knee Braces which can be unlocked at all times. May sit in wheelchair, continuous use. 5/5/17 Orthopedic Physician Order's: . Hinged knee braces, unlocked. Frequent skin checks . 5/2017 TAR: Entry dated 3/23/17 stating: Supportive Device: Bilateral Hinged Knee Braces which can be unlocked at all times. May sit in wheelchair, continuous use. Frequent skin checks, as noted in the 5/5/17 orders, is not noted on the 5/2017 TAR. 5/10/17 Nurses Notes 11:03 AM: Spoke with (Nurse Practitioner) regarding new pressure area / indentation on resident's Right outer lower leg from brace. Requesting an order for [REDACTED]. Results: new order received and noted. 5/10/17 NP (Nurse Practitioner) Telephone order: Non - border foam pad to right outer lower leg pressure area. Change daily (for protection from brace). Recommend calling ortho regarding brace. 5/10/17 Nurses Notes 11:49 AM: Location: Right anterior lower leg - Writer called in to shower room this morning and observed a new pressure area from brace that measures 7.5 cm (centimeter) long x 1 cm wide x 0.2 cm depth. Resident did c/o (complain of) pain when lightly touched, area tender. Procedure done: Non - bordered foam pad placed over area. Action: Physician notified. Continue to observe. 5/10/17 Nurses Notes 2:20 PM: Spoke with (Name) Nurse with (Physician) office (Ortho) regarding: Informed nurse that it was recommended to call d/t (due to) new significant pressure area on right lower leg from braces. (Nurse) stated that braces are not custom made for resident, the braces can be unlocked if resident is sitting in wheelchair or laying in bed so they're not causing pressure. 5/17/17 Nurses Notes 12:10 PM: . Skin problems: Abraded area Right lateral lower leg from where leg brace pressed into leg about 3.5 cm x 0.5 cm. Area is red. No drainage. Covered with foam border dressing. Padded that area of her leg with non border foam dressing to help keep brace from pressing on her leg. 5/17/17 Nurses Notes 12:48: Call placed to (NP) regarding: Left voice message for (NP) to return writer's call . update (NP) on abraded area to Right lateral lower leg. That area was cleansed with wound cleanser and foam dressing applied. A non - bordered foam dressing was used to pad that area of Right leg, to help keep leg brace from pressing on leg. Await call back from (NP). 5/17/17 Nurses Note 1:35 PM: Spoke with (NP) who returned writer's call regarding abraded area to right lateral lower leg. Result: New orders received and noted 5/17/17. 5/17/17 NP telephone order: Cleanse RLE abraded area (with) wound cleanser, apply foam dressing every 3rd day. 5/20/17 Nurses Notes 11:01: Location 1: Right lower leg - There is moderate amount of slough on the lower portion of abraded area. Writer applied a small amount of Santyl (an enzymatic [MEDICATION NAME] ointment) to area and then covered with a bordered foam dressing per order. It is important to note at the time of this entry there is no evidence a physician was notified of this change of condition to this PI (now with slough - moderate amount) and no order for Santyl to be used on this PI. 5/23/17 Nurses Notes 1:38 PM: Location 1: RLL (Right lower leg) - Large amount of yellow slough noted on bottom portion of area. There was a large amount of drainage on old dressing. Treatment completed as ordered. New dressing applied. It is important to note there is still no evidence a physician was noted of this change of condition to this PI now with a large amount of yellow slough. 5/23/17 Nurses Notes 7:22 PM: . Right anterior lower leg 7.2 cm L (length) x .8 cm W (Width) at bottom, area wider at bottom and narrows going up. 75% base wound is slough with 25% granulation, edges arounf {sic} slough are granulated. Slough is a pale yellow white color, no noted odor. Peri wound is intact and clean. Wound exudate is serous. Padded the brace at the area of pressure and loosened brace straps while in bed. It is important to note there is still no evidence a physician was noted of this change of condition to this PI now with 75% slough to wound base. 5/24/17 11:22 AM: Spoke with: (NP) regarding: Requesting to change order of Right lower leg d/t slough being present. 5/24/17 NP telephone order: Cleanse RLE (Right lower extremity) abraded area with normal saline. Apply Santyl ointment and cover with bordered foam dressing daily until slough resolves. Then start previous treatment to leg until healed. This order for Santyl was received 4 days after slough was originally noted to this pressure injury. It is important to note that at no time does the facility identify the stage of this pressure ulcer. This wound has not been assessed and measured each week, going from 5/23/17 to 6/6/17 (14 days), without measurements and a full wound assessment. On 6/13/17, at 10:00 AM, Surveyor spoke with DON (Director of Nursing) B and RN (Registered Nurse) G who is familiar with R3 and her wounds. DON B stated their Wound Certified Nurse (WCN) had recently left employment at the facility and RN G is one of two nurses who have been doing wound care and measurements. Surveyor asked RN G to speak on the facility's wound care program. RN G stated wounds are measured weekly and should include size, what the bed of the wound looks like, what the peri wound looks like, what the edges look like, whether the wound is improving, if there is any drainage noted or if the resident is experiencing any pain. Surveyor asked if the type of wound and the stage should be noted. RN G stated yes, the type of wound, the stage, if it is a DTI (Deep Tissue Injury), MAD (Moisture Associated [MEDICAL CONDITION]), or if it is unstagable should always be documented. Surveyor asked DON B and RN G if R3 has had her skin checked daily or frequently since she has been wearing either a knee immobilize or brace. DON B stated she believes they have but states I don't believe we document that. RN G stated she recalls signing off on this, but when she and DON B reviewed R3's current TAR on the computer, they confirmed that it was not on the current TAR. RN G speculated that it may have fallen off from previous months. DON B stated she will continue to look for evidence staff were monitoring R3's skin to her lower extremities daily or frequently. Surveyor asked DON B if treatments such as Santyl are to be given without an order. DON B stated no. Surveyor shared concerns that on 5/20/17, nursing staff treated R3's Right lower leg wound with Santyl without an order. DON B confirmed this would not be the expectation. Surveyor asked if there may be a standing order for Santyl to be used when slough is present in a pressure wound. DON B stated, I don't think so. Example 3 R7's [DIAGNOSES REDACTED]. R7's most current Braden Scale notes R7 to have a total score of 21 (minimum risk). R7's care plan, in place at the time the 6/7/17 mid buttock pressure injury was discovered, states: 3/15/17 Problem: Potential for Impaired Skin Integrity related to: needs assist for cares, Disease process [MEDICAL CONDITION], dry skin Interventions to this care plan problem include: Skin assessment per policy, encourage fluids and meals . offer fluids with position changes, keep skin clean and dry . R7's record documents the following information: 6/8/17 6:08 AM Nurses Notes: Late entry for 6/7/17 Skin problems: open area that measures 0.5 cm (centimeters) x 0.5 cm. Location: Right mid buttock. Skin Treatment: Application of nonsurgical dressing (with or without to

Based on interview and record review the facility did not immediately consult with the resident's physician when there is need to alter treatment for 1 of 10 (R6) sampled residents reviewed. On 4/14/17, at 6:30 AM, R (Resident) 6 presented with a change of condition of new symptoms of swelling and pain to her Left leg; the facility did not have evidence of on-going assessments or thorough monitoring of R6's condition and did not notify the physician until 4/17/17. This resulted in R6 being urgently sent to the emergency roiagnom on the evening of 4/17/17 for treatment of [REDACTED]. This is evidenced by: The facility's Change of Condition policy, dated 6/24/14, states in part: . A resident experiencing an acute change of condition will receive prompt recognition, assessment, intervention and monitoring .Physicians will be notified of changes of condition . All residents in the facility are at risk for a change of condition. Staff will identify and report changes of condition . review recent hospital discharge summaries .communicate changes with shift change and 24 hour report . According to the American Medical Director's Association (AMDA) Acute Change of Condition in the Long-Term Care Setting, sudden onset of [MEDICAL CONDITION] with tenderness and redness warrants immediate physician notification. R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R6's comprehensive care plan, dated 6/5/17, includes in part Problem: Nutrient/drug interaction related to current anticoagulant, Goal: no signs/symptoms of interaction, Interventions: Administer medications as ordered, observe for adverse effects on food intake, Avoid offering vitamin K rich foods. R6 nurses notes include in part: - 4/14/17 at 6:36 AM: Skin Problems: Several area of deep/bright purple and red bruising to bilateral legs from mid-thigh to calves. Back of calves on bilateral legs is largely reddened/purple in color. Area is painful to touch per R6 report. 6:38 AM: Circulatory findings: left leg remains swollen from thigh to ankle, non-pitting, soft, warm to touch. Pedal pulses strong, equal, and regular . 11:09 PM: Current pain level 0. - 4/15/17 at 8:59 PM: . B/L LE (Bilateral lower extremities) discoloration including purple and red noted covering surface area from knee to ankle extending around both LE. L (Left) shin raised area purple in color blistered 3 x 2.5 CM (centimeter) L LE [MEDICAL CONDITION] 2+ pitting. Wound nurse notified. -4/16/17 at 11:13 AM: Circulatory findings: bruising B/L LE .[MEDICAL CONDITION] Left sided 1+ [MEDICAL CONDITION] . peripheral pulses: present strong. 3:04 PM Denies pain .8:40 PM: . B/L LE discoloration including purple and red noted covering surface area from knee to ankle extending around both LE. L shin raised area purple in color blistered 3 x 2.5 CM (centimeter) L LE [MEDICAL CONDITION] 2+ pitting. Wound nurse notified. - 4/17/17at 10:00 AM: Lower Left leg more [MEDICAL CONDITION] than Right. Skin to Left lower leg is tight, fragile. Has area of discoloration to BLE that are slowly resolving. Has a scattered area of red discoloration to Left anterior leg high above knee area. Left anterior lower left (shin area) where raised purple area was observed on 4-15-17 is flat. Total area measures 3 cm x 3cm with a darker center that measures 2 CM x 1.5 CM .R6 denies any pain or discomfort. Wearing arm and leg protectors continuously. Legs to be elevated during the day . Will update (name) NP (Nurse Practitioner) on above observations. On 4/17/17, after the facility notified the NP of R6 symptoms, orders were received to obtain a D Dimer (a blood test used to rule out blood clots). The D Dimer result was elevated at 17.7 (normal is less than 0.5). At 6:00 PM R6 was transferred to the emergency room for evaluation of [MEDICAL CONDITION]. Review of R6 Emergency Department notes, on 4/17/17, includes in part: -R6 with history of PE and [MEDICAL CONDITION]'s . noted increased Left lower extremity swelling over the weekend. (R6) was taken off [MEDICATION NAME] in December after she had Hemocult-positive test . Symptoms increasing in severity. -Review of systems . Cardiovascular: Positive for leg swelling . -Physical exam: . Marked Left lower extremity swelling and [MEDICAL CONDITION]. Mild tenderness to palpation. -Ultra Sound of lower extremities: Impression-examination is positive for bilateral [MEDICAL CONDITION] with partial [MEDICAL CONDITION] of bilateral common femoral and popliteal veins throughout. -Diagnostic Impressions: Lower leg [MEDICAL CONDITION], acute, bilateral -New discharge medication orders [REDACTED]. R6 returned to the facility at 11:20 PM on 4/17/17. It is important to note that R6's comprehensive care plan does not specifically address staff monitoring R6 for new bruising or bleeding related to anticoagulant therapy which was started 4/17/17. R6's physician orders [REDACTED]. Of note, a serious complication of a [MEDICAL CONDITION] is [MEDICAL CONDITION] embolism (a blood vessel in the lung becomes blocked by a blood clot that travels to your lungs from another part of your body), this can be a fatal. Immediate medical attention is needed when a [MEDICAL CONDITION] is suspected to prevent this potentially life threatening event. On 6/12/17, at 3:30 PM, Surveyor interviewed DON (Director of Nursing) B about what she would expect staff to do on 4/14/17, at 6:30 AM, when R6 was identified as having new onset of Left leg swelling, pain, and discoloration to her lower extremities. DON B stated that she would expect staff to report this change to the physician right away and to report it to other shifts so that thorough nursing assessments would be completed for R6. Notification to R6's physician was not done on 4/14/17 and should have been, resulting in a delay in R6 receiving necessary treatment for [REDACTED].

Based on interviews and record reviews, the facility did not ensure that 1 of 1 residents (Resident 10) reviewed for hydration was provided with sufficient fluids to meet assessed hydration needs. The recorded fluid intakes were not totaled from 3/22/16 (Resident 10's admission) through 6/9/16. When totaled during survey, Resident 10 took in less than 30% of her calculated fluid need. The facility does not have a hydration intake policy or system to ensure that residents whose intake does not meet the daily estimated needs and are at risk for dehydration are monitored for and provided with adequate hydration. There is no evidence that staff analyzed the daily fluid intakes, alerted the Registered Dietician (RD) to the low intakes and/or implemented approaches to assist Resident 10 in meeting her daily fluid needs. On 4/14/16, Resident 10 was transferred to the hospital due to decline in health status and was diagnosed with [REDACTED]. Despite the [DIAGNOSES REDACTED]. Resident 10 was again admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. Despite a readmission order on 6/3/16 to push fluids Resident 10 continued not to meet her fluid needs as indicated from 6/4/16 to 6/9/16 when Resident 10 was showing signs of dehydration without Physician or RD consultation. The facility failed to ensure that Resident 10 received sufficient fluids to ensure proper hydration - which subsequently led to two hospitalization s with a [DIAGNOSES REDACTED]. Failure to ensure adequate hydration created a finding of immediate jeopardy. Immediate jeopardy began on 4/19/16, the date that Resident 10 was readmitted to the facility and no plan of care was created or updated to increase fluid intake or to monitor fluid intakes daily to ensure fluid needs were being met. The NHA was notified on 6/21/16 that immediate jeopardy existed. The immediate jeopardy was removed on 6/21/16. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as all portions of the corrective action plan have not been fully implemented. This is evidenced by: According to Medscape (www.medscape.com/view article/ 8) Dehydration in Geriatrics from Geriatrics and Aging 2007:10(9) 590-596: Dehydration is a common and serious condition in older adults. Mortality of patients with dehydration is high if not treated adequately . In the older adult dehydration often causes atypical symptoms such as confusion, constipation, or falls Body weight proved to be the most responsive to changes in hydration Patients consuming less than 50% of meals are at high risk for dehydration. Caregivers should be aware of and anticipate this hazard. Diagnosing dehydration and monitoring fluid balance requires repeated measurement of weight, Creatinine, and physical signs such as tongue hydration. The facility policy titled Hydration Policy and Procedure including Dehydration risk factors and identification (Undated) states: Care shall be taken to provide each resident on a daily basis and throughout their stay with sufficient fluid intake through multi-disciplinary interventions in order to maintain proper hydration. Purpose: Upon admission and throughout the resident stay, facility staff (nurses, dietician, and dietary manager) shall access (sic) the resident for signs of adequate hydration and will be [MEDICAL CONDITION] of signs of dehydration or possible insufficient fluid intake. Staff shall also watch for abnormal laboratory (lab) values including elevated potassium, sodium, [MEDICATION NAME], blood urea nitrogen (BUN) and/or urine specific gravity. The facility recognizes that the resident may become at risk for dehydration due to various conditions, but not limited to: 1. Fluid loss. 2. Increased fluid need. 3. Functional impairments that make it difficult to obtain fluids independently. 4. Dementia. 5. Refusal of fluids. If the staff recognizes that a resident is at risk for possible dehydration a problem shall be immediately noted on the care plan and approaches designed and implemented to promote and ensure adequate hydration. Admission Hydration Assessment: 1. Average fluid intake goal for resident shall be established within 48 hours of resident admission. Fluid needs shall be established by Dietician or Dietary Manager according to residents' size and special diet needs. Formula for figuring fluid needs - weight of residents/2.2 X 30 cubic centimeters (cc) = total fluid cc per 24 hour (hr) period. 2. Fluid needs will be recorded on nutritional assessment, in dietary notes and on Resident care plan. 3. Fluid intake pattern shall be established and recorded according to residents' likes, dislikes, allergies [REDACTED]. 4. An interdisciplinary approach shall be implemented to assure adequate fluid intake. Fluids will be encouraged in room, at snack times, and during activity sessions. (Note the policy is not dated or signed by the Facility or the Medical Director to ensure a review and implementation of the policy occurred.) On 6/9/16 at 2:00 PM Surveyor interviewed Nursing Home Administrator (NHA) A regarding the Hydration policy and requested information on how fluids were totaled and monitored on a daily basis. NHA A stated the hydration policy was developed by the Former Director of Nursing (DON), the Former Registered Dietician (RD) and Dietary Manager (DM) O. NHA A stated she did not know when exactly the policy was developed. NHA A stated there is not a date or a signature of any facility staff members or the Medical Director on the form to ensure the form was reviewed and by all parties or when the policy was implemented in the facility. On 6/9/16 at 2:09 PM, NHA A informed Surveyor the facility did not have policy related to intakes or how intakes should be totaled or what the expectation is when a resident does not meet their fluid needs. NHA A stated they are working on a policy and have started a template of the process, but there is nothing current that the facility is following. On 6/9/16 at 2:27 PM PM, Surveyor interviewed Dietary Manager (DM) O regarding the Hydration policy. DM O stated the policy was developed by the former DON, former Registered Dietician (RD), and DM O. DM O stated the policy must have been developed prior to December because the former RD left in December. DM O stated she does not remember when it actually was developed. Surveyor asked DM O what the interdisciplinary approach was under #4 of the assessment part of the policy. DM O stated they were still talking about the policy when the RD left the facility. DM O stated the policy was never really implemented or followed after the RD and former DON left the facility. Resident 10 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Resident 10's current medication list in part includes; [MEDICATION NAME] 40 milligrams (mg) twice a day, [MEDICATION NAME] 10 mg daily, [MEDICATION NAME] 500 mg twice day, Potassium Chloride 10 Milliequivelent (meq) daily . Admission Nursing note in part dated 3/22/16, Blood Pressure (BP) on admission 142/64. Eating: Requires no help from staff. Usual Appetite: has fair appetite. Resident reports lack of appetite. Short and long term memory OK. Hydration assessment dated [DATE], Cognition: Decisions consistent/reasonable. Mobility: extensive assist with transfer. Hand Dexterity: Limited ability to grasp cup. Health condition: Diabetes and [MEDICAL CONDITION]. Skin Turgor: less than 3 seconds. Eating ability: Eats/drinks independently. medications: [REDACTED]= 5. Resident 10's Admission Minimum Data Set (MDS), completion date of 4/4/16, includes a brief interview for metal status (BIMS) score of 14, indicating Resident 10's memory is intact. Resident 10 is independent with meals after set up. Resident 10's weight is 200 lbs and receives a therapeutic diet. Resident 10's most current Medicare required 14 day MDS completed on 5/5/16 indicates Resident 10 remains a 14 on her BIMS and needs supervision with meals. Dietary note dated 4/5/16, Swallowing: Admitting weight: 211 pounds (lbs). Weight Loss: Resident has had significant weight loss, resident current weight is 187.5 lbs, and current weight is down 23.5 lbs from admission weight of 211 lbs. Weight loss in (sic) due to having [MEDICAL CONDITION]. Resident's intake is between 50% - 100%. Nutrition approaches: therapeutic diet Cardiac low salt, low cholesterol, low fat. Recommendations: continue to follow dietary plan of care (poc) EATING ASSISTANCE: Requires setup help only from staff. (Note: Resident 10's estimated fluid needs were not established or documented within the dietary note.) Resident 10's daily total fluid intake from 3/22/16 (admission) through 4/14/16 (Hospital admit) was documented as follows. Assessed fluid need during this time period, based on the admission weight 197 pounds, was 2,686 milliliters (ml) per day. 22 out of 22 days Resident 10 did not meet her fluid needs. 3/22/16 - No fluid record. 3/23/16 - 240 milliliters 3/24/16 = 900 ml 3/25/16 = 720 ml 3/26/16 = 720 ml 3/27/16 = 600 ml 3/28/16 = 720 ml 3/29/16 = 600 ml 3/30/16 = 600 ml 3/31/16 = 880 ml 4/1/16 = 3 ml 4/2/16 = 560 ml 4/3/16 = 960 ml 4/4/16 = 1060 ml 4/5/16 = 720 ml 4/6/16 = 1040 ml 4/7/16 = 480 ml 4/8/16 = 1 ml 4/9/16 = 360 ml 4/10/16 = 480 ml 4/11/16 = 830 ml 4/12/16 = 220 ml 4/13/16 = 630 ml *Nursing Note date 4/14/16 at 10:52 AM, At (Clinic name) accompanied by staff. Resident 10 went from the clinic to the emergency room . Resident 10's emergency room report in part dated 4/14/16, History is limited from the patient she does not recall the reason for being brought here. Per the Nurse Practitioner at the clinic she was noted to be sleepy and her blood pressure was 60 over 30s. They sent her over here for further evaluation. She states this has been ongoing for a while. Resident 10's Hospital history and Physical in part dated 4/14/16 at 11:04 AM, Chief complaint: Urinary Tract Infection [MEDICAL CONDITION], Dehydration, and [MEDICAL CONDITION]. History of present illness: Resident 10 is being admitted with worsened confusion and lethargy from subacute rehab. She now presents with ongoing lethargy and low blood pressure (BP) as low as 60 systolic blood pressures (SBP). She was admitted via the emergency room (ER) where she received 2 liters (L) intravenous (IV) fluid boluses with improvement in her blood pressure. Diagnostic studies: 4/14/16 ER lab results -BUN: 92 (Normal 9 - 19). Creatinine 3.01 (normal: 0.57 - 1.11). 4/16/16 lab results: BUN 53. Creatinine 1.67 4/17/16 lab results: BUN 38. Creatinine 1.35 4/18/16 lab results: BUN 29. Creatinine 1.30 Resident 10 was readmitted to facility after [DIAGNOSES REDACTED]. Daily fluid intake total from 4/19/16 through 4/26/16 when Resident 10's dietary assessment was completed. 4/19/16 = 0 ml 4/20/16 = 4 ml 4/21/16 = 440 ml 4/22/16 = 720 ml 4/23/16 = 720 ml 4/24/16 = 720 ml 4/25/16 = 720 ml 4/26/16 = 590 ml (Note: On 4/26/16 Dietary assessment completed indicating Resident 10 needs 3272 ml of fluids per day.) Note: Resident 10 did not have average fluid intake goal established within 48 hours of her admission. Resident 10's estimated fluid needs were assessed and documented on 4/26/16 34 days after her original admitted . Fluid intake from 4/19/16 to 4/26/16 was 3,914 ml, which was 15% of her assessed need of 3271 ml/day. On 6/14/16 at 4:00 PM NHA A spoke with Surveyor via the telephone. NHA A stated she wanted to clarify the large estimated fluid needs for Resident 10. NHA A stated she spoke with RD and she indicated Resident 10's fluid needs were estimated to be higher than required due to Resident 10's condition and need for extra fluids during that assessment period. NHA A stated Resident 10 was reassessed later and her fluid needs were then decreased. *Nursing note dated 4/24/16 at 1:26 AM, at 15:00 (3 PM) Resident had a medium emesis in her room. At 6:11 AM, Fax sent to Resident 10's Physician regarding emesis on 4/23/16. *Nursing note 4/25/16 at 6:51 AM, Spoke with Physician on call (Nurse Practitioner (NP)) regarding: Change in condition low blood pressure 82/48. New orders received and noted. Re-hydrate resident recheck BP in 3 hours. Resident 10's Physician order [REDACTED]. Pulse (P) 60. Orders to hydrate resident for 2 -3 hours and recheck BP. (It is important to note the medical record did not contain an ongoing hydration assessment or an updated plan of care to ensure Resident 10 was hydrated per Physician order.) Nursing dated 4/25/16 at 10:37 AM: Usual Appetite: has poor appetite. Dietary assessment dated [DATE] in part, Total fluids needs: 3272 ml. Resident has experienced a significant weight loss in 1 month. Current weight 180.4 is down 19.6 pounds (#s) from 200# one month ago. Nutrition intake fluid: High Risk: Consumes less than (<) 1,000 milliliters (ml) per day. Conditions/Diagnoses: [REDACTED]. Monitor and encourage fluid intake every (q) 2 hours (hrs), record intake. Nutrition care plan problem: Remain appropriate/current. Care plan dated 4/26/16 in part, Problem: (Dehydration/Fluid) Potential for fluid volume deficit. Related to: Inadequate fluid intake. Manifested by: Recent hospitalization with [DIAGNOSES REDACTED]. Vital signs stable. Interventions: Encourage fluids. Provide assistance with fluids as needed. Assess mental status changes. Monitor indicators of hydration. Every 2 hour fluid monitoring. To monitor and encourage fluid intake. Nursing to record intake on Medication Administration Record [REDACTED]. Assist with fluid intakes. Offer variety of fluids. Keep fluids in reach. Dietary note dated 5/20/16, 30 day note: Average daily fluid intake record is 1260 ml. (Note Resident 10's estimated fluid needs = 2,454 ml per day according to the calculated facility fluid intake formula.) Care plan titled Nutrition, dated 5/20/16: Strength: Eating 83% of meals. Goal Adequate fluid intake times three months. Interventions: Provide fluid between meals provide hour sleep (hs) supplement as ordered. Resident 10's daily fluid intakes from 4/27/16 through 6/1/16 were as follows. (Note: Estimated fluid needs = 3272 ml per RD assessment on 4/26/16 also calculated as 2,454 ml per day according to the calculated facility fluid intake formula.) 4/27/16 = 1220 ml 4/28/16 = 540 ml 4/29/16 = 1320 ml 4/30/16 = 1350 ml 5/1/16 = 780 ml 5/2/16 = 680 ml 5/3/16 = 870 ml 5/4/16 = 1320 ml 5/5/16 = 1350 ml 5/6/16 = 800 ml 5/7/16 = 970 ml 5/8/16 = 1090 ml 5/9/16 = 1560 ml 5/10/16 = 990 ml 5/11/16 = 985 ml 5/12/16 = 840 ml 5/13/16 = 740 ml 5/14/16 = 830 ml 5/15/16 = 1270 ml 5/16/16 = 510 ml 5/17/18 = 720 ml 5/18/16 = 1020 ml 5/19/16 = 481 ml 5/20/16 = 940 ml 5/21/16 = 1510 ml 5/22/16 = 1690 ml 5/23/16 = 920 ml 5/24/16 = 870 ml 5/25/16 = 720 ml 5/26/15 = 580 ml 5/27/16 = 990 ml 5/28/16 = 600 ml 5/29/16 = 920 ml 5/30/16 = 880 ml 5/30/16 = 5 ml 6/1/16 = 4 ml Fluid intake from 4/26/16 to 6/1/16 was 32,775 ml. Fluid need was 117,792 ml (based on 4/26/16 RD assessment) or 88,344 ml (based on facility fluid intake formula). Resident 10's intake was only 28-37% of assessed fluid need. *Nursing note dated 6/1/16 at 9:49 PM, Transferred to acute care hospital by ambulance. Reason: for admission for decreased kidney function and elevated labs. Resident 10's Hospital History and Physical dated 6/1/16, Assessment and Plan: Dehydration, Weakness, Acute on [MEDICAL CONDITION]. Gentle hydration overnight, and recheck labs in am. Chief complaint of Present Illness: She (Resident 10) presented here complaining of nausea, vomiting and generalized abdominal pain and weakness. Complains of bilateral lower quadrant pain times 48 hours with several episodes of vomiting. Decreased appetite. Her labs showed worsening Creatinine and elevated [MEDICATION NAME] secondary to dehydration. She was admitted for observation overnight. Recent labs: BUN 56. Creatinine 3.50. Impression Hospital problems: 1. Acute [MEDICAL CONDITION] with tubular necrosis: suspected secondary to dehydration and concurrent use of Sulfa (Bactrim). Plan: IV hydration. Place Foley catheter. Monitor renal function daily. *Nursing note dated 6/3/16 (re-admitted ) at 5:06 PM, Hydration: Mucous membranes: pink moist. Has indwelling catheter IV site: to left forearm. Needs 1800 ml of 0.9% sodium chloride (NACL) IV fluids at 75 ml per hour over next 24 hours. Resident 10 sent to Urgent care to have IV restarted at 3:00 PM today. Urgent care called back at 4:30 PM to report they were unable to insert new IV. Resident will return to with current IV at 5:00 PM Urgent care indicated IV leaking and will continue to try to put in new IV before Resident 10 returns. *Nursing note dated 6/3/16 at 5:38 PM, Returned from Urgent care. Resident 10's Physician here on rounds and wrote new orders regarding IV. Unable to place a new IV and discontinued old IV due to leaking. Will encourage fluids. *Nursing note dated 6/4/16 at 3:30 AM, Hydration findings: symptoms of dehydration poor skin turgor/tenting changed mental status. MUCOUS MEMBRANES dry APPEARANCE Sluggish SKIN TURGOR decreased. *Nursing note dated 6/3/16 at 6:42 AM, Nervous system findings: altered mental status, confused and hallucinating. Resident has signs of dehydration fluids encouraged. Will continue to push fluids. *Nursing note dated 6/3/16 at 1:25 PM, Hydration findings: dry skin. Skin turgor decreased. Urine decreased output. Hydration assessment dated [DATE], Cognition: Decisions consistent/reasonable. Mobility: extensive assist with transfer. Hand Dexterity: No problem with grasping. Health condition: Diabetes and History UTI. Skin Turgor: <3 seconds. Eating ability: Eats/drinks independently. medications: [REDACTED]= 3. (Note: score of 8 or higher indicates risk for dehydration. Resident 10's health condition does not indicate Resident 10 has the [DIAGNOSES REDACTED]. Nor does this score reflect that Resident 10 was not taking in adequate fluids and had recently been hospitalized with dehydration, which would add additional risk factors for dehydration for Resident 10.) Care plan dated 6/3/16 in part, Problem: (Dehydration/Fluid) Potential for fluid volume deficit. Related to: Inadequate fluid intake. Manifested by: Recent hospitalization with [DIAGNOSES REDACTED]. Vital signs stable. Interventions: Encourage fluids. Provide assistance with fluids as needed. Assess mental status changes. Monitor indicators of hydration. Every 2 hour fluid monitoring. To monitor and encourage fluid intake. Nursing to record intake on Medication Administration Record [REDACTED]. Assist with fluid intakes. Offer variety of fluids. Keep fluids in reach. (It is important to note Resident 10's care plan remains unchanged from 4/6/16. Resident 10 was hospitalized with a second incident of dehydration and no new intervention was added to the care plan to prevent future episodes of dehydration for Resident 10.) Medication Administration Record [REDACTED]. Despite Resident 10 exhibiting signs and symptoms of dehydration Resident 10 continued to receive [MEDICATION NAME] 40 mg twice a day at 8 AM and 12 noon. There is no evidence Resident 10's Physician was contacted with the symptoms of dehydration or to hold the diuretic medication. Subsequent to Resident 10's return to the nursing home, the facility did not update her care plan with respect to monitoring or increasing fluid intake even though she was diagnosed with [REDACTED]. No interventions were added upon her return to ensure adequate hydration. 6/3/16 Physician order [REDACTED]. Unable to maintain or restart IV. Push oral (P.O.) fluids. BMP on Monday. *Nursing note dated 6/5/16 at 1:34 AM, Hydration findings: symptoms of dehydration poor skin turgor tenting. *Nursing note dated 6/5/16 at 1:13 PM, Hydration findings: no problems noted dry skin poor skin turgor/tenting SKIN TURGOR poor Tenting CAP REFILL <2 *Nursing note dated 6/6/16 at 3:02 AM, Hydration findings: poor skin turgor/tenting. *Nursing Note dated 6/7/16 at 1:33 AM, Hydration findings: poor skin turgor/tenting. *Nursing note dated 6/7/16 at 1:34 PM, Hydration findings: poor skin turgor/tenting. *Nursing note dated 6/7/16 at 9:21 PM, Late entry for 6/6/16 Hydration findings: dry skin dry mouth, Mucous membranes pink, dry lips, Skin turgor decreased, Heart rate increased. *Nursing note dated 6/7/16 at 9/21 PM, Hydration findings: poor skin turgor/tenting dry skin. Mucous membranes pink dry lips Appearance sluggish. *Nursing notes dated 6/8/16 at 1:19 AM, Hydration findings: dry skin Mucous membranes pink dry Skin turgor decreased. *Nursing notes dated 6/9/16 at 4:46 AM, Hydration findings: poor skin turgor/tenting Mucous membranes pink dry lips. Skin turgor decreased. *Nursing notes dated 6/9/16 at 10:38 AM, Hydration findings: no problem noted Mucous membranes pink dry Skin turgor poor. Despite the order to push fluid on 6/3/16 there is no evidence the facility monitored or increased fluid for Resident 10 when she showed clinical signs of dehydration on 6/5/16 through 6/9/16. There is no evidence Resident 10's Physician was notified with the change in hydration condition from 6/5/16 when the nursing note indicates Resident 10 is showing signs of dehydration through 6/9/16. Resident 10 continues not to meet her fluid needs after readmission to the facility and the discontinuation of the IV fluids on 6/3/16. Dietary assessment dated [DATE] in part, Weight 189#. Total fluids 1800 - 2000 ml per day (Note current facility fluid formula: 2.2 (85) X 30 = 2,577 ml per day is Resident 10's fluid needs). Nutrition intake food: Moderate risk: Intake meets 26 - 75% of estimated needs average meal intake 52% and eats 1 - 2 snacks. Appetite fair. Resident reports appetite not the best. Nutrition fluid intake: High Risk: Consumes (<) 1,000 ml per day. Fluids are encouraged water at bedside; staff offers fluids at every contact. Medications related: High Risk: [MEDICATION NAME], and [MEDICATION NAME]. Current labs: Creatinine 3.5, after IV fluids Creatinine 2.89. Resident visit: Writer met with resident who reported her appetite isn't the best. Resident said she doesn't like what food is offered at meals but will ask fir substitute like soup. Resident states she is trying to drink sips water throughout day. Care plan problem: Remain appropriate. Resident 10's total daily fluid intake total from 6/3/16 through 6/9/16. Resident 10 was re-assessed by the Dietician to receive 1800 - 2000 ml per day (Note: current facility fluid formula: 2.2 (85) X 30 = 2,577 ml per day is Resident 10's fluid needs). 6/3/16 = 720 ml 6/4/16 = 480 ml 6/5/16 = no documentation occurred. 6/6/16 = 1280 ml 6/7/16 = 600 ml 6/8/16 = 1130 ml 6/9/16 = 540 ml Recorded fluid intake from 6/3/16 to 6/9/16 was 7750 ml, which was 43% of her assessed need of 2,577 ml/day. On 6/9/16 at 9:30 AM Surveyor requested Resident 10's lab results from 5/4/16 from Director of Nursing (DON) B. DON B at 10:32 AM presented Surveyor with a fax received on 6/9/16 at 9:53 AM. DON B stated the lab results were not in Resident 10's record and the facility just received the lab results today. DON B also stated Resident 10's Physician also requested a repeat BMP to be completed in 1 week from 5/4/16. DON B stated the repeat BMP was never completed for Resident 10. Resident 10's 5/4/16 BMP results, BUN 52, Creatinine 2.88, Sodium 134 (normal 136 - 145), Potassium 5.6 (normal 3.5 - 5.1). On 6/9/16 at 10:52 AM Surveyor interviewed Director of Nursing (DON) B regarding the facility process of monitoring lab values and ensuring results are placed in the medical record for review. DON B stated we missed this one (BMP on 5/4/16). The facility nurse should follow up with the lab to get the lab results of the current lab done. DON B stated the Physician wanted a repeat lab on 5/11/16, but the results and the order never were received at the facility. The BMP on 5/11/16 was never completed. DON B stated she would expect all labs to be followed up on. On 6/9/16 at 12:20 PM, Surveyor interviewed Licensed Practical Nurse (LPN) C regarding monitoring fluid intakes for resident at risk for dehydration. LPN C stated the fluids are calculated from the Nurses during med passes, Certified Nursing Assistants (CNAs) passing water and during meals. All fluids are calculated each shift and placed on the intake form. Surveyor asked LPN C who monitors the fluids or calculates them to ensure the resident is meeting their estimated fluid needs. LPN C stated no one totals the fluids or reports a resident is not meeting their fluid needs. Surveyor asked LPN C if the night shift had ever reviewed the totals and reports to you that a resident is not meeting their fluid needs so the physician could be updated. LPN C stated no one has ever reviewed the fluids or informed her if a resident is not meeting their fluid needs. LPN C stated the estimated fluid needs are also on the intake report sheet. Surveyor asked LPN C who reviews the totals to ensure fluids needs are met. LPN C stated she does not know who reviews the total fluid needs. LPN C stated she does not look at the form for meeting total fluid needs. On 6/9/16 at 1:30 PM Surveyor interview DM O regarding Resident intake monitoring for dehydration. DM O stated the fluids from all meals, nurses and certified nursing assistants (CNAs) are all placed in the computer. The fluids all go into a form called the intake record. The intake record breaks out the fluids by shift and then gives a daily total. DM O stated she does not review the fluid intakes for any residents. DM O stated the computer does not flag her to indicate a resident is not meeting their needs. DM O stated the nurses do a hydration assessment upon admission and if they find someone at risk they will let her know. DM O stated the nurses do not tell her who is not drinking fluids or if a resident is not drinking enough to meet their daily estimated needs. DM O stated she has never looked at the intake form for any resident to review fluid intakes. DM O stated the RD looks at the fluids when she is her. DM O stated the RD is contracted and only works twice a week. On 6/9/16 at 2:09 PM Surveyor interviewed with NHA A regarding her expectation of the facility monitoring of fluids when a resident returns to the facility with a dehydration diagnosis. NHA A stated she would expect the Dietician to be included in the process. The RD should develop a plan of how much fluid the resident should receive on a daily basis. The staff should offer the resident choice of items they are more likely to eat and drink. If the resident is still not meeting their needs then the Physician should be notified to see what the Physician would like done. The RD should lead this process. Surveyor asked NHA A what process is currently in place to ensure resident at risk are fluids are monitored daily to ensure they are meeting their fluid needs. NHA A stated there is not a process at present to monitor total fluid needs with total fluid intake in a 24 hour period. NHA A stated the computer program currently does not flag any resident who does not meet their needs or who does not meet 1,000 ml per day. On 6/9/16 at 2:17 PM Surveyor interviewed DON B regarding expectation of monitor intake for Resident at risk for dehydration. DON B stated she would expect a 3 day intake monitoring to be done upon admission, after the 3 days a review would be completed to assess how much fluid is taken in. DON B stated Nurses should be monitoring daily fluids versus estimated fluid needs to ensure those at risk are meeting their needs. DON B stated the Physician should be notified when the resident is not meeting their fluid needs. DON B stated she will review the policies and put into place a policy that ensure fluid needs are being met. (It is important to note DON B started at the facility the week prior to 5/24/16.) On 6/9/16 at 3:20 PM Surveyor spoke with Resident 10, Resident 10 was sitting in her room resting in a recliner. Glass of water with a straw was present at Resident 10 bedside table. Surveyor asked Resident 1 whom assisted her with her fluids during the day? Resident 10 stated no one helps her; ladies bring in the water and leave it at the bedside. Resident 10 also stated she is not asked to drink while in her room by anyone. Resident 10 continued to state I feed myself at meals; no one assists or comes to help me. Resident 10 stated no one asked me to drink more fluids when I am at the table. On 6/20/16 (11 days after the end of the survey.) Surveyor was contacted by NHA A. NHA A stated Resident 10 now has a Physician note from a recent Physician Visit. Resident 10's Physician note dated 6/20/16 at 11:40 AM, states: Chief complaint Nursing home visit. 2 recent admissions for Acute on [MEDICAL CONDITION] / dehydration. no clues or symptoms before recent admissions. Has been eating and enjoys soup most. Water drinking reviewed - always has a pitcher at her side - staff has been urging fluid intake. Examination (Exam) BP 102/60. Speech and mentation clear. Most probable cause of recent admission was Bactrim (sulfa) renal insult (tubular [MEDICAL CONDITION]) not poor oral (PO) intake or excessive dieretics (sic) for prominent lower extremity [MEDICAL CONDITION]. The facility did not have a sufficient system in place to monitor a resident's actual fluid needs on a daily basis. The facility did not have a sufficient assessment process to capture and monitor residents at risk for dehydration. The facility knew the resident recent [DIAGNOSES REDACTED]. The facility did not initiate a more rigorous assessment/care plan to prevent further episodes of dehydration for Resident 10. Systemically, the facility's failure to assess, evaluate and attempt aggressive nutritional and fluid interventions for Resident 10 created an immediate jeopardy situation which began 4/19/16. The facility removed the immediate jeopardy on 6/21/16 by taking the following actions: 1. Corrective action taken for Resident 10 allegedly affect by the deficient practice: Resident evaluated by Physician and registered dietician to ensure proper fluid intake is established. Resident placed on Intake/Output monitoring times (X) 7 days, and then reviewed by Interdisciplinary team (IDT) to determine further monitoring needs: Completion date: 6/21/16 2. The following measures and systemic changes have been put into place to ensure that the deficient practice does not recur: All residents have hydration risk assessments completed on 6/21/16. 3. Resident found at risk will be placed on Intake/Output monitoring X 7 days, and then reviewed by IDT to determine further mon

Based on record review and interview, in 6 of 9 total residents reviewed for abuse (Residents 1, 9, 8, 7, 2 and 3 ) the facility did not have an operable system that ensured all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures and that steps were taken to prevent further potential abuse while an investigation was in progress. This had the potential to affect all facility residents. Resident 1 was assessed to be cognitively intact. On 11/25/14, CNA F told Resident 1 she stunk and threatened to take Resident 1 to the shower even though Resident 1 had a life-long fear of water because of a near-drowning incident as a child. this caused Resident 1 to tremble, to cry, and to not be able to sleep because of her she would be taken out of erh mor The information had been relayed to the staff responsible for initiating an investigation into the incident. The facility did not immediately initiate an investigation and did not report the allegation to the state agency. The facility did not implement appropriate interventions to prevent reoccurrence. The facility did not conduct an analysis to determine the cause of facility system breakdown in reporting and did not provide education to staff regarding the initiating corrective action timely. The CNA continued to work with Resident 1 and other vulnerable residents 48 days after the alleged abuse occurred. The facility did not take steps to prevent further potential abuse when the abuse was first reported. Lack of immediate action to report, investigate and to prevent further potential abuse created an Immediate Jeopardy, which began on 11/25/14 and was discovered on 1/12/15. The Nursing Home Administrator was informed of this finding on 1/13/15 and the Immediate Jeopardy was removed on 1/13/15. The deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy/widespread) as all portions of the corrective actions have not been fully implemented and as evidenced below. The facility did not have evidence they fully investigated or document an allegation that Resident 9 was in the presence of a Certified Nursing Assistant (CNA) while the CNA was yelling and swearing at a co-worker. The facility did not have evidence they fully investigated an allegation that Resident 8 did not receive medications when requested. The facility did not have evidence they fully investigated an allegation that Resident 7 was not cleaned up fully after an incontinence episode. There is no documentation regarding an incident between Resident 2 and Resident 3 was investigated nor that interventions were put into place to prevent reoccurrence. This is evidenced by: On 1/12/15 at 9:15 AM, Surveyor spoke with Nursing Home Administrator (NHA) A regarding the investigation process in the facility. NHA A stated the the Compliance Officer (CO) used to investigate and complete all the allegations of abuse, misconduct, and misappropriation reports, but he was fired in October of 2014. The responsibility for investigating and reporting then went to the Director of Nurses (DON), who was fired 11/24/14. NHA A stated she now has been in charge of reporting and investigation any allegation until the new CO has been trained. NHA A stated she has filed only one self report since the firing of the CO in October. NHA A stated she is unable to find other investigation or reports since the firing of the DON on 11/24/14. NHA A stated currently the facility does not have any one except NHA A looking into allegations of abuse, misconduct or misappropriation. Example 1 Resident 1 was admitted to the facility on [DATE] with the following diagnoses; Depression, Asthma, Diabetes, [MEDICAL CONDITION], and History of falls. Resident 1's nursing note, dated 11/13/14, at 3:49 PM, states Short term memory - OK. Long term memory - OK. Resident 1 is able to recall she is in a nursing home, staff names and faces, location of room and current season. Resident 1's decisions are consistent and reasonable. Resident 1's nursing note dated 11/17/14 at 12:27 PM, AM bathing did not occur declined altogether, reason: scared of water, refused. Resident 1's care plan in part, dated 11/19/14, Strength: Activities. Goal: To return to her home in the community. Nurse Aide: it is very important to Resident 1 to take care of personal items. Prefers bed bath as Resident 1 is afraid of water. Resident 1's nursing note, dated 11/23/24 at 6:31 PM, It has been reported that staff (CNA) have attempted to assist resident to take shower, writer spoke with resident and resident states. "I never took one at home and not going to start now, I washed up in the sink. Will again attempt to persuade resident to allow staff to take shower and wash hair. Will continue to monitor. Resident 1's care plan entry was made on 11/24/14 at 11:04 AM, Other: Bed bath on shower day. Resident 1 is afraid of water. Resident 1's nursing note dated 11/24/14 at 1:34 PM, AM bathing: Did not occur declined altogether, reason: Resident refuses any kind of shower...washed her hair in beauty shop. Resident 1's nursing note, dated 11/24/14 at 1:58 PM, states: Refused approached on 3 occasions asking her to shower, resident declined due to fear of water. Resident 1's nursing note dated 11/25/14, at 4:12 PM, states Psychological: Appears psychologically stable. Reaction to stress: withdraws from others and worries. Personality: appears withdrawn. Resident 1's nursing note, dated 12/1/14 at 2:56 PM, Certified Nursing Assistant (CNA) reports she (Resident 1) is afraid of water and is refusing her bath and head wash. Resident 1's care plan titled Self care deficit: in part, dated 12/2/14: Other: All Staff- Bed bath on shower day. Resident is afraid of water. Encourage cap to shampoo hair... On 1/12/15 at 1:20 PM Surveyor spoke with Licensed Practical Nurse (LPN) C regarding Resident 1 taking a shower. LPN C stated it was reported to her by the CNAs that CNA F was going to force Resident 1 into the shower and Resident 1 became very upset. LPN C stated she did not know the date of the incident. LPN C stated CNA F had stated by the time clock she was "going to get stinky in the shower today you just watch." LPN C stated CNA G would have more information regarding the incident. LPN C stated the NHA and DON have not requested a written statement from her and they have not talked to her regarding the concern. LPN C stated she is aware the NHA was immediately informed of CNA F attempting to force Resident 1 and making Resident 1 cry. CNA F continues to work with residents right after NHA A was notified. On 1/12/15 at 2:30 PM, Surveyor spoke via the telephone with Safety Checker (SC) H, regarding CNA F threatening Resident 1 to shower. SC H stated she was the safety check person on duty that night from 5 PM to 10 PM. SC H stated she does not remember what night the incident occurred. SC H stated she was doing her safety rounds and was walking by to check on Resident 1. CNA F stated as she walked to Resident 1's room she saw CNA F in the room. CNA F motioned to SC H to get away from the door so SC H would go away SC H stated she went back to check on Resident 1. SC H stated CNA F is not assigned to Resident 1 so it seemed odd that she was in the room. SC H stated Resident 1 did not look right while CNA F was speaking to her. SC H heard CNA F was getting nasty with Resident 1. SC H entered Resident 1 room and CNA F exited the room. Resident 1 was crying and stated: CNA F told Resident 1 that she stunk and needed to bathe. Resident 1 also stated she was afraid of CNA F and was afraid she would come back in to the room and force her to take a shower. SC H stated Resident 1 was shaking and crying. SC H stated she left the room and went and informed RN D of Resident 1 condition and what she heard CNA F state to Resident 1. SC H stated the NHA did not interview her or ask her to write a statement of what she had seen and heard. SC H stated CNA F went back to her assigned hall and continued to care for the residents. On 1/12/15 at 1:25 PM Surveyor spoke with Certified Nursing Assistant (CNA) G regarding CNA F and Resident 1 taking a shower. CNA G stated she was working 3rd shift and answered Resident 1's call light. Resident 1 was scared and nervous when CNA G entered her room. CNA G stated Resident 1 told her that CNA F told her she had to take a shower because she stunk. Resident 1 also stated she was terrified of water because she almost drowned. CNA G informed Resident 1 she did not have to take a shower. CNA G stated Resident 1 told her CNA F stated the call light did not work so you cannot call for help and no one wants to be near you because you stink. Resident 1 was trembling and crying during the conversation. CNA G stated she reported it to Licensed Practical Nurse (LPN E) as soon as she left Resident 1's room. CNA G stated she was aware the allegation was reported to the NHA, that CNA F was trying to force Resident 1 to shower. CNA G stated CNA F informed the PM shift at the time clock that Resident 1 was going to take a shower because she was going to see to it. CNA G stated everyone knew Resident 1 was terrified of water. Resident 1 just kept crying and shaking and was afraid CNA F was going to come back and force her to shower. CNA G stated she has not been interviewed by the NHA or asked for a statement regarding Resident 1. CNA G stated it was reported the shift before. CNA G stated other residents have had concerns with CNA F. CNA G stated Resident 6 has reported CNA F for being mean and rude to the NHA in the past. CNA G stated CNA F intimidates residents and they are afraid of her. Resident 1 was afraid of her. On 1/12/15 at 1:42 PM, Surveyor spoke with CNA I regarding Resident 1 and taking a shower. CNA I stated she worked with Resident 1 and was aware of Resident 1 was afraid of the shower. CNA I stated she had asked Resident 1 to take a shower after she was first admitted . Resident 1 always refused the shower. Surveyor asked CNA I regarding any knowledge of CNA F attempting to force Resident 1 to take a shower and telling Resident 1 she stunk. CNA I stated she had heard that CNA F went in to Resident 1's room and told her she stunk and she had no choice she was going to take a shower. CNA I stated Resident 1 stated CNA F was very rude and mean when she came in her room and told her she demanded she had to take a shower. Resident 1 was scared of CNA F and of water. CNA I stated she had not been interviewed or asked to write a statement about CNA F demanding Resident 1 to take a shower. On 1/12/15 at 1:59 PM, Surveyor spoke with RN D regarding Resident 1 and her shower concerns. RN D stated she was Resident 1's nurse on the PM shift. RN D stated CNA H came to her and told her she needed to go see Resident 1 now. RN D stated she entered Resident 1's room and Resident 1 was crying and trembling from head to toe. RN D stated she knew Resident 1's background and that Resident 1 was afraid of water and had not showered since admission. Resident 1 verbalized she was afraid of CNA F. Resident 1 told RN D that CNA F was going to force her to take a shower. Resident 1 continued to state CNA F told her she stunk and all the other residents know she stinks and do not want her around them. Resident 1 stated CNA F stated I could not leave this room or go by anyone because I stunk and she was going to take me to the shower. Resident 1 stated she was afraid CNA F was going to come back into her room and force her to shower. RN D stated she reported the allegation of abuse to the NHA. RN D stated she called the NHA to Resident 1's room and informed her what Resident 1 had just stated that CNA F was going to force her to shower, told her she stunk and she is extremely afraid of showers. RN D also stated she informed the NHA Resident 1 was crying and shaking while talking about CNA F. RN D stated she asked NHA if she needed her to witness the interview and the NHA stated no she will speak to Resident 1. Surveyor asked RN D why she did not document the occurrence or write a statement related to Resident 1 allegation. RN D stated the NHA told her not to document the information that she would take care of the situation. RN D stated she was not asked to write a statement from the NHA. RN D stated she was new to this facility and did not know the policy of how to handle the situation after it was reported to the NHA. RN D stated she will from now on report the allegation and ensure the person is removed from the facility for any allegation of abuse. RN D stated CNA F was never removed from the facility or the resident areas after the allegation was reported to the NHA. RN D stated she did not talk to any other CNA or ask for statement because the NHA stated she would take care of the investigation. On 1/12/15 at 2:10 PM Surveyor spoke with RN D regarding how Resident 1 was after the incident. RN D stated Resident 1 would not sleep she kept watching to ensure CNA F did not enter. RN D stated Resident 1 did not sleep for several days after. RN D stated Resident 1 continued to state she was afraid CNA F was going to come back in her room and she was very afraid she would force her to the shower. RN D stated she heard from the CNAs that CNA F had been informed of the new plan of care for Resident 1 of not bathing and had stated while punching in at the time clock, we are going to "get stinky into the shower today mark my words." RN D stated she previously had written up CNA F for violation of safety issues and had presented them to CNA F. RN D stated she was then informed by the DON that the facility does not discipline or write up CNAs; instead, they are to re-educate them. RN D state re-education had been done several times prior to and changes did not occur. RN D stated she placed the write up under the DON's door. RN D stated she did not know the day the allegation occurred, although it was before Resident 1 was moved to room [ROOM NUMBER] on 12/2/14. Surveyor asked RN D how the CNAs know the resident's plan of care. RN D stated it was common knowledge to everyone in the facility that Resident 1 was afraid of water. RN D stated there is a care plan in the resident room to follow and also in the medical record which indicated Resident 1 is afraid of water. On 1/12/15 at 3:39 PM, Surveyor spoke with NHA A regarding the allegation of abuse from CNA F to Resident 1. NHA A stated she is aware of the incident. NHA A stated she does not remember what date the incident occurred. NHA A stated RN D did come to her and report the allegation of abuse. NHA A stated she did not collect statements or have any evidence she spoke with Resident 1 or any other staff about the allegation of abuse from RN D. NHA A stated only RN D came to her with the allegation and no other staff informed her of the allegation. NHA A stated she did not interview or ask any other staff about the allegation. NHA A stated RN D did inform her Resident 1 was in her room crying and afraid of CNA F due to the manner CNA F spoke to Resident 1. NHA A stated she entered Resident 1's room alone and Resident 1 stated she was not going to take a shower. NHA A stated Resident 1 kicked her out of her room. On 1/12/15 at 4:00 PM, Surveyor asked NHA A if she asked Resident 1 if CNA F was going to force her into the shower. NHA A stated she did not. Surveyor asked NHA A if she asked Resident if it was true CNA F stated she stunk and no one wanted to be by someone who is stinky. NHA A stated she did not. NHA A stated in her mind no one else had any information related to the allegation so she did not proceed with the investigation. NHA A stated she spoke to CNA F and CNA F stated she did go in and ask Resident 1 if she would take a shower and Resident 1 refused. NHA A stated CNA F stated she left the room. Surveyor asked NHA A if she has interviewed any other staff or residents related to the incident with Resident 1 and CNA F. NHA A stated in her mind no one else had any information related to the allegation. NHA A stated she sent CNA F back to her unit to continue to work. NHA A stated she did not remove CNA F from the resident area or the facility after she was notified of the allegation. On 1/12/15 at 4:35 PM, Surveyor spoke with Director of Nursing (DON) B regarding the care plan note on 11/19/14. DON B stated she was the Minimum Data Set nurse at the time the care plan was updated. DON B stated she does not remember who told her to add she is afraid of the water to the care plan. DON B continued to state she was informed Resident 1 should have a bed bathe because she does not like water. On 1/12/15 at 5:25 PM Surveyor spoke with RN D regarding Resident 1 after the CNA F left the room. RN D stated she checked on Resident 1 throughout the shift. Resident 1 continued to state she was afraid CNA F was going to come back into her room. RN D stated Resident 1 did not sleep. Surveyor asked RN D if she had asked CNA F to go into Resident 1's room to offer her a shower. RN D stated she did not ask CNA F to shower Resident 1 or to enter Resident 1's room. On 1/13/15 at 10:25 AM, Surveyor spoke with Licensed Practical Nurse (LPN) E regarding Resident 1 and CNA F's interaction. LPN E stated Resident 1 was very apprehensive about taking a shower. LPN E discussed with Resident 1 she thought the date was 11/24/14 to take a bed bathe due to her fear of water. LPN E stated I charted she was afraid of water and refused shower, so it was that night I believe. LPN E stated she knows people with Dementia also fear water so she used the same technique with Resident 1. LPN E stated Resident 1 was comfortable with the new plan of taking a bed bathe and not a shower. LPN E stated she informed all of the CNAs and passed the information on in report so the nurses also were aware of the new plan. LPN E stated she heard the following day from the staff that CNA F was going to force Resident 1 to take a shower and informed Resident 1 she stunk. LPN E stated she entered Resident 1's room and found Resident to be distraught. LPN E stated Resident 1 was crying and very upset, stated Resident 1 was afraid they were going to come in again and force her to take a shower. LPN E stated Resident 1 shrunk back into her shell. LPN E stated she talked 1:1 with Resident 1 and reassured Resident 1 she would not let anyone come into her room and force her to shower. LPN E stated she again informed Resident 1 a bed bath was the plan for her. LPN E stated it's all in the approach to residents and CNA F does not think before she does things to residents. LPN E continued to state she has never been interviewed by the NHA or anyone else in the facility related to CNA F threatening to take Resident 1 into the shower. LPN E stated the NHA called her to her office and asked her to be the nurse CNA F could come to if she has problems. LPN E stated any staff member can come to her with any issues and was informed CNA F would only be coming to LPN E for concerns. LPN E stated she has had performance issues in the past with CNA F and wanted to give her written warning and CNA F started to cry and put on airs in front of the NHA. Nurses then were informed the facility does not write up CNAs for performance the nurses could only re-educate the staff. Due to the history of CNA F and the NHA, LPN E did not feel comfortable going to the NHA about CNA F and what occurred with Resident 1. LPN E stated she passed on to all CNAs that Resident 1 is very frightened and will not be having a shower. LPN E stated she believe the incident occurred on 11/25/14. Resident 1 was abused by CNA F and when the abuse was witnessed it was not immediately stopped. The allegation was reported to the NHA. The NHA did begin an investigation but the investigation was not thorough and complete and no measures taken to prevent further potential abuse as CNA F continued to work with residents. The failure to fully investigate and to take actions to prevent further potential abuse created a situation of immediate jeopardy. The facility removed and corrected the Immediate Jeopardy on 1/13/15 when: 1. CNA F was terminated from the facility. 2. All staff is being immediately educated on need to report abusive situations and any signs potential abuse to the Compliance Officer, Social Services or NHA. 3. The NHA will confer immediately with the Compliance Officer and the Director of Nursing concerning all reported situations to ensure we are following their policy and procedures for all allegations of abuse. 4. All staff before returning to work will be educated on protecting residents from abuse and reporting immediately. 5. The reported situation will be investigated immediately by the Compliance officer, Social services and the NHA. All staff on duty will be interviewed as well as several interviewable residents. Cross reference F223 and F226 Example 2 On 1/12/15 at 9:20 AM Surveyor asked Nursing Home Administrator (NHA) if she had any current allegations of abuse in the facility. NHA A stated she has not had any current allegations of abuse that she has investigated. NHA A continued by stating there was an incident Sunday evening (1/11/15). Four Certified Nursing Assistants (CNAs) came to NHA A and stated that CNA F spoke in a harsh tone and swore in front of Resident 9. NHA A stated the 4 CNAs came to her around 9:30 PM last evening and talked with me for several minutes. The evening shift ends at 10:00 PM. Surveyor asked NHA A for her initial investigation and statement related to the incident. NHA A stated she did not perform an investigation into the allegation as yet. Surveyor asked NHA A what time the allegation occurred. NHA A stated the CNAs stated it occurred before 7:00 PM. The other CNAs were asking CNA F to assist them in taking vital signs due to the outbreak of an illness in the facility. The CNAs stated CNA F became upset and started swearing in front of residents. NHA A stated the CNAs did not immediately report the allegation or protect Resident 9 from further occurrence. NHA A indicated that she tried to go into Resident 9's room after the CNAs talked with her and Resident 9 was sound asleep and appeared to be resting very comfortable and I did not wake her. NHA A stated that she talked to CNA F; CNA F stated she did not do it. When NHA A spoke with CNA F she had already completed her shift and was getting ready to leave, approximately 10:00 PM. The surveyors entered the building before 8:00 on 1/12 so NHA A had not had a chance to speak with Resident 9. Additionally, CNA F was terminated on 1/12/15 and did not work another shift after this incident. Surveyor asked NHA A why an investigation or statements were not taken at the time of the allegation. NHA A stated CNA F stated she did not do it. NHA A stated she would begin an investigation now. There is no documentation of an investigation, or evidence Resident 9 or other vulnerable residents were protected at the time of the allegation. Example 3 In the facility concern book there was a document dated 10/29/14 regarding Resident 8. The document states: Resident 8 asked the nurse (nurse not identified) for her medication and Resident 8 was told she would have to wait because the nurse was still passing the 5 o'clock medication. Resident 8 was also concerned nurse on duty refusing to put cotton in her ears after ear drops; Resident 8 likes her medicine at 6:15 PM due to fatigue from [MEDICAL TREATMENT]. The nurse on duty told her she would have to wait because the nurse had to eat because she (the nurse) was diabetic. Resident 8 felt the nurse was upset with her when she did eventually come give her the medicine. The nurse gave Resident 8 a "dirty look" and Resident 8 said, "Don't be mad at me, I am the resident." Nurse stated, "I am upset with you." On 1/12/15, at 1:15 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated she was aware of the situation. NHA A stated she had another nurse give Resident 8 her medication and the nurse was fired. NHA A was not able to recall the nurse who was involved. There is no documentation of an investigation, who was involved or how it was resolved. Example 4 Per the facility's "Record of Concern," on 11/10/14 Resident 7's family member complained of an odor and a bag of soiled linen (brief) in the middle of the floor after Resident 7 had been walked back from lunch. The family stated the linen was there since before lunch. The family also stated Resident 7 was not fully cleaned up before going to lunch; she had an odor coming from her. This was reported on 11/11/14 to Social Services (SS) J. On 1/12/15, at 10:44 AM, Surveyor interviewed SS J regarding the allegation. SS J stated it was a nursing concern so she would have passed it on to the Director of Nursing (DON) to deal with. (Note: not the current DON.) SS J stated she did not have any additional information. On 1/12/15, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated that concern occurred when the previous DON was not doing her job. NHA A stated she felt there was education given and would look for it. No additional information was provided. Example 5 The State Agency received a complaint regarding altercations between Resident 2 and Resident 3 and there is no plan to prevent additional altercations or an investigation into the situation. On 1/12/14, Surveyor reviewed Resident 2 and Resident 3's records. Resident 2 was admitted on [DATE] and his Power of Attorney for Healthcare was activated on 6/19/13. Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Interventions are to ignore the behavior and try to redirect. There was no indication in either Resident 2 or 3's record of any altercation or behaviors toward other residents. Surveyor requested the facility's investigations for allegations of abuse and resident to resident altercations. There were no resident-to-resident altercation investigations or reports provided. On 1/12/14, at 10:44 AM, Surveyor interviewed Social Services (SS) J. SS J stated she recalled something occurring between Resident 2 and 3 as she heard bits and pieces of it the next day and they were moved into the cafe. SS J stated she did not do any follow up as it was reported as being handled. On 1/12/14, at 1:15 PM Surveyor interviewed Nursing Home Administrator (NHA) A about any incidents with Resident 2 and 3. NHA A stated there was an incident between the two. NHA A stated she was out of the area but got a call stating Resident 2 and 3 were eating at the same table in the dining room. Resident 2 asked Resident 3 for his dessert. Resident 3 said no and then Resident 2 took it. The two were getting loud. Two other residents were moved from the area as they were done but still loud with staff because they did not want to move. NHA A stated the plan was to have the residents sit at different tables but Resident 2 and 3 wanted to sit together and Resident 3's wife asked if they could sit in the cafe (small room next to the dining room). NHA A stated she did talk with 3-4 other resident the next morning regarding the incident. NHA A stated she would have expected the nurse or medication technician to a note of it and notify SS J. NHA A did not provide any documentation of the incident. On 1/12/14, at 1:41 PM, Surveyor interviewed Dietary Manager (DM) K. DM K stated she recalled she was in the building when Resident 2 and 3 were yelling at each other. DM K stated she could not recall when the incident occurred. DM K stated staff came to her and asked if they could move Resident 2 to a different table as he was trying to take other residents stuff and this was getting Resident 3 going. DM K said the residents were moved for the next meal and the following morning Resident 2 and 3 started eating in the cafe. There is no documentation of the incident including no investigation. The facility was not able to identify when the incident occurred. Neither Resident 2 nor 3's care plan was updated or a notation made in their record.

Based on interview and record review the facility did not ensure that it had a system whereby the policies and procedures that prohibit mistreatment, abuse and neglect of residents were implemented for 6 of 9 total residents reviewed (Resident 1, 9, 7, 8 2, and 3). This had the potential to affect all residents of the facility. On 11/24/14 it was brought to the attention of Nursing Home Administrator (NHA) A that Certified Nursing Assistant (CNA) F had been abusive to Resident 1. (CNA F had told Resident 1 that she stunk, that no one wanted to be around her, and threatened to take her to the shower even though Resident 1 had a life-long fear of water because of a near-drowning incident.) This abuse had been witnessed by Certified Nursing Assistants (CNAs) and reported to the Registered Nurse (RN). Resident 1 was trembling and crying and did not sleep. The RN did immediately report this abusive behavior to the Nursing Home Administrator (NHA). The NHA did not implement facility policies and procedures and did not fully investigate the incident, did not protect residents from further potential abuse and did not report the allegation to the state agency. The failure to have a system in place to implement the abuse policy and procedure led to the finding of Immediate Jeopardy. Immediate Jeopardy started on 11/25/14. The NHA and DON were notified of the Immediate Jeopardy on 1/13/15. The facility removed the immediate jeopardy on 1/13/15; however, the deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy /widespread) because not all staff has been retrained regarding abuse prevention, reporting, and the protection of residents and as evidenced by the following: Additional examples not at the IJ level include: The facility did not have evidence they fully investigated or document an allegation that Resident 9 was in the presence of a Certified Nursing Assistant (CNA) while she was yelling and swearing at a co-worker. Resident 8 made an allegation of a nurse refusing to give her medications. The facility did not implement their policy to investigate and to collect and retain information pertinent to the investigation. Resident 7's family voiced a concern of cares not completed, the facility did not implement their policy to investigate and retain pertinent information. Resident 2 and 3 were involved in an altercation. The facility did not implement their policy to investigate and retain pertinent information of the investigation. This is evidenced by: The facility policy titled Abuse prevention and reporting, in part, dated 3/27/14, Policy: If abuse is suspected or alleged, the facility will report this to the Nursing Home Administrator (NHA) or Compliance Officer (CO), initiate necessary reports, and investigate the incident per Centers for Medicare and Medicaid Services (CMS) and the state regulations. The facility will protect the resident to ensure they are safe at all times. Procedure: For all allegations of abuse, neglect, misappropriation property, and injuries of unknown origin, the following will occur. 1. Staff will first ensure the safety of the resident. 2. Report the allegation to the NHA or CO. 3. Determine if the allegation meets the definition of abuse reporting requirements. 4. Complete form per CMS memo. 5. Investigate the incident and send a complete investigation per above referred CMS memo. Prevention: 2. The facility will provide care plans to address the needs of the residents and assure the assigned staff have access to the information. 3. The facility will provide appropriate supervision of all staff, on all shifts to identify inappropriate staff behaviors and take immediate corrective action. 5. Residents, families and staff will be encouraged to report concerns, incident and grievances without fear of retribution, Feedback will be provided regarding expressed concern. 7. Conduct a review of incident reports to identify patterns trends of events that could constitute abuse and determine if an investigation is warranted. 8. The NHA and Director of Nursing (DON) and or the designee as needed will monitor and assess staff for signs of burnout, frustration, or stress. Investigation: Any allegation involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property will be immediately reported to the Nurse in Charge, who will then contact the NHA or CO. The NHA or CO will review the CMS memo to determine reporting needs, and if necessary, complete the online preliminary report. A designated staff member of the facility will conduct and complete an internal investigation. The NHA or CO will submit the completed form documenting the completed investigation to the appropriate state agency within 5 days of the incident. Protection: During the investigation, the facility will protect the resident/s as appropriate, including but not limited to the following: 1. Separation and redirection of residents. 2. An employee against whom there is a charge of abuse will be immediately suspended from duty until the NHA or CO has reviewed the findings of the investigation (which may exceed the 5 day time frame.) 5. The facility will collect, retain and safeguard all information and evidentiary material pertinent to the investigation of abuse or neglect. 6. Any retaliation will be considered a separate incident of abuse. Reporting of Allegations of Abuse or Mistreatment: The facility will report allegations immediately to the Division of Health Services (DHS) online reporting system. The internal investigation will be sent in no later than 5 working days from the date of the initial reporting. On 1/12/15 at 9:15 AM, Surveyor spoke with Nursing Home Administrator (NHA) A regarding the investigation process in the facility. NHA A stated the the Compliance Officer (CO) used to investigate and complete all the allegations of abuse, misconduct, and misappropriation reports, but he was fired in October of 2014. The responsibility for investigating and reporting then went to the Director of Nurses (DON), who was fired 11/24/14. NHA A stated she now has been in charge of reporting and investigation any allegation until the new CO has been trained. NHA A stated she has filed only one self report since the firing of the CO in October. NHA A stated she is unable to find other investigation or reports since the firing of the DON on 11/24/14. NHA A stated currently the facility does not have any one except NHA A looking into allegations of abuse, misconduct or misappropriation. Example 1 Resident 1 was admitted to the facility on [DATE] with the following diagnoses; Depression, Asthma, Diabetes, [MEDICAL CONDITION], and History of falls. Resident 1's nursing note, dated 11/13/14, at 3:49 PM, states Short term memory - OK. Long term memory - OK. Resident 1 is able to recall she is in a nursing home, staff names and faces, location of room and current season. Resident 1's decisions are consistent and reasonable. Resident 1's nursing note dated 11/17/14 at 12:27 PM, AM bathing did not occur declined altogether, reason: scared of water, refused. Resident 1's care plan in part, dated 11/19/14, Strength: Activities. Goal: To return to her home in the community. Nurse Aide: it is very important to Resident 1 to take care of personal items. Prefers bed bath as Resident 1 is afraid of water. Resident 1's nursing note, dated 11/23/24 at 6:31 PM, It has been reported that staff (CNA) have attempted to assist resident to take shower, writer spoke with resident and resident states. "I never took one at home and not going to start now, I washed up in the sink. Will again attempt to persuade resident to allow staff to take shower and wash hair. Will continue to monitor. Resident 1's care plan entry was made on 11/24/14 at 11:04 AM, Other: Bed bath on shower day. Resident 1 is afraid of water. Resident 1's nursing note dated 11/24/14 at 1:34 PM, AM bathing: Did not occur declined altogether, reason: Resident refuses any kind of shower...washed her hair in beauty shop. Resident 1's nursing note, dated 11/24/14 at 1:58 PM, states: Refused approached on 3 occasions asking her to shower, resident declined due to fear of water. Resident 1's nursing note dated 11/25/14, at 4:12 PM, states Psychological: Appears psychologically stable. Reaction to stress: withdraws from others and worries. Personality: appears withdrawn. Resident 1's nursing note, dated 12/1/14 at 2:56 PM, Certified Nursing Assistant (CNA) reports she (Resident 1) is afraid of water and is refusing her bath and head wash. Resident 1's care plan titled Self care deficit: in part, dated 12/2/14: Other: All Staff- Bed bath on shower day. Resident is afraid of water. Encourage cap to shampoo hair... On 1/12/15 at 1:20 PM Surveyor spoke with Licensed Practical Nurse (LPN) C regarding Resident 1 taking a shower. LPN C stated it was reported to her by the CNAs that CNA F was going to force Resident 1 into the shower and Resident 1 became very upset. LPN C stated she did not know the date of the incident. LPN C stated CNA F had stated by the time clock she was "going to get stinky in the shower today you just watch." LPN C stated CNA G would have more information regarding the incident. LPN C stated the NHA and DON have not requested a written statement from her and they have not talked to her regarding the concern. LPN C stated she is aware the NHA was immediately informed of CNA F attempting to force Resident 1 and making Resident 1 cry. CNA F continues to work with residents right after NHA A was notified. On 1/12/15 at 2:30 PM, Surveyor spoke via the telephone with Safety Checker (SC) H, regarding CNA F threatening Resident 1 to shower. SC H stated she was the safety check person on duty that night from 5 PM to 10 PM. SC H stated she does not remember what night the incident occurred. SC H stated she was doing her safety rounds and was walking by to check on Resident 1. SC H stated as she walked to Resident 1's room she saw CNA F in the room. CNA F motioned to SC H to get away from the door so SC H would go away SC H stated she went back to check on Resident 1. SC H stated CNA F is not assigned to Resident 1 so it seemed odd that she was in the room. SC H stated Resident 1 did not look right while CNA F was speaking to her. SC H heard CNA F was getting nasty with Resident 1. SC H entered Resident 1 room and CNA F exited the room. Resident 1 was crying and stated: CNA F told Resident 1 that she stunk and needed to bathe. Resident 1 also stated she was afraid of CNA F and was afraid she would come back in to the room and force her to take a shower. SC H stated Resident 1 was shaking and crying. SC H stated she left the room and went and informed RN D of Resident 1 condition and what she heard CNA F state to Resident 1. SC H stated the NHA did not interview her or ask her to write a statement of what she had seen and heard. SC H stated CNA F went back to her assigned hall and continued to care for the residents. On 1/12/15 at 1:25 PM Surveyor spoke with Certified Nursing Assistant (CNA) G regarding CNA F and Resident 1 taking a shower. CNA G stated she was working 3rd shift and answered Resident 1's call light. Resident 1 was scared and nervous when CNA G entered her room. CNA G stated Resident 1 told her that CNA F told her she had to take a shower because she stunk. Resident 1 also stated she was terrified of water because she almost drowned. CNA G informed Resident 1 she did not have to take a shower. CNA G stated Resident 1 told her CNA F stated the call light did not work so you cannot call for help and no one wants to be near you because you stink. Resident 1 was trembling and crying during the conversation. CNA G stated she reported it to Licensed Practical Nurse (LPN E) as soon as she left Resident 1's room. CNA G stated she was aware the allegation was reported to the NHA, that CNA F was trying to force Resident 1 to shower. CNA G stated CNA F informed the PM shift at the time clock that Resident 1 was going to take a shower because she was going to see to it. CNA G stated everyone knew Resident 1 was terrified of water. Resident 1 just kept crying and shaking and was afraid CNA F was going to come back and force her to shower. CNA G stated she has not been interviewed by the NHA or asked for a statement regarding Resident 1. CNA G stated it was reported the shift before. CNA G stated other residents have had concerns with CNA F. CNA G stated Resident 6 has reported CNA F for being mean and rude to the NHA in the past. CNA G stated CNA F intimidates residents and they are afraid of her. Resident 1 was afraid of her. On 1/12/15 at 1:42 PM, Surveyor spoke with CNA I regarding Resident 1 and taking a shower. CNA I stated she worked with Resident 1 and was aware of Resident 1 was afraid of the shower. CNA I stated she had asked Resident 1 to take a shower after she was first admitted . Resident 1 always refused the shower. Surveyor asked CNA I regarding any knowledge of CNA F attempting to force Resident 1 to take a shower and telling Resident 1 she stunk. CNA I stated she had heard that CNA F went in to Resident 1's room and told her she stunk and she had no choice she was going to take a shower. CNA I stated Resident 1 stated CNA F was very rude and mean when she came in her room and told her she demanded she had to take a shower. Resident 1 was scared of CNA F and of water. CNA I stated she had not been interviewed or asked to write a statement about CNA F demanding Resident 1 to take a shower. On 1/12/15 at 1:59 PM, Surveyor spoke with RN D regarding Resident 1 and her shower concerns. RN D stated she was Resident 1's nurse on the PM shift. RN D stated Safety Checker (SC) H came to her and told her she needed to go see Resident 1 now. RN D stated she entered Resident 1's room and Resident 1 was crying and trembling from head to toe. RN D stated she knew Resident 1's background and that Resident 1 was afraid of water and had not showered since admission. Resident 1 verbalized she was afraid of CNA F. Resident 1 told RN D that CNA F was going to force her to take a shower. Resident 1 continued to state CNA F told her she stunk and all the other residents know she stinks and do not want her around them. Resident 1 stated CNA F stated I could not leave this room or go by anyone because I stunk and she was going to take me to the shower. Resident 1 stated she was afraid CNA F was going to come back into her room and force her to shower. RN D stated she reported the allegation of abuse to the NHA. RN D stated she called the NHA to Resident 1's room and informed her what Resident 1 had just stated that CNA F was going to force her to shower, told her she stunk and she is extremely afraid of showers. RN D also stated she informed the NHA Resident 1 was crying and shaking while talking about CNA F. RN D stated she asked NHA if she needed her to witness the interview and the NHA stated no she will speak to Resident 1. Surveyor asked RN D why she did not document the occurrence or write a statement related to Resident 1 allegation. RN D stated the NHA told her not to document the information that she would take care of the situation. RN D stated she was not asked to write a statement from the NHA. RN D stated she was new to this facility and did not know the policy of how to handle the situation after it was reported to the NHA. RN D stated she will from now on report the allegation and ensure the person is removed from the facility for any allegation of abuse. RN D stated CNA F was never removed from the facility or the resident areas after the allegation was reported to the NHA. RN D stated she did not talk to any other CNA or ask for statement because the NHA stated she would take care of the investigation. On 1/12/15 at 2:10 PM Surveyor spoke with RN D regarding how Resident 1 was after the incident. RN D stated Resident 1 would not sleep she kept watching to ensure CNA F did not enter. RN D stated Resident 1 did not sleep for several days after. RN D stated Resident 1 continued to state she was afraid CNA F was going to come back in her room and she was very afraid she would force her to the shower. RN D stated she heard from the CNAs that CNA F had been informed of the new plan of care for Resident 1 of not bathing and had stated while punching in at the time clock, we are going to "get stinky into the shower today mark my words." RN D stated she previously had written up CNA F for violation of safety issues and had presented them to CNA F. RN D stated she was then informed by the DON that the facility does not discipline or write up CNAs; instead, they are to re-educate them. RN D state re-education had been done several times prior to and changes did not occur. RN D stated she placed the write up under the DON's door. RN D stated she did not know the day the allegation occurred, although it was before Resident 1 was moved to room [ROOM NUMBER] on 12/2/14. Surveyor asked RN D how the CNAs know the resident's plan of care. RN D stated it was common knowledge to everyone in the facility that Resident 1 was afraid of water. RN D stated there is a care plan in the resident room to follow and also in the medical record which indicated Resident 1 is afraid of water. On 1/12/15 at 3:39 PM, Surveyor spoke with NHA A regarding the allegation of abuse from CNA F to Resident 1. NHA A stated she is aware of the incident. NHA A stated she does not remember what date the incident occurred. NHA A stated RN D did come to her and report the allegation of abuse. NHA A stated she did not collect statements or have any evidence she spoke with Resident 1 or any other staff about the allegation of abuse from RN D. NHA A stated only RN D came to her with the allegation and no other staff informed her of the allegation. NHA A stated she did not interview or ask any other staff about the allegation. NHA A stated RN D did inform her Resident 1 was in her room crying and afraid of CNA F due to the manner CNA F spoke to Resident 1. NHA A stated she entered Resident 1's room alone and Resident 1 stated she was not going to take a shower. NHA A stated Resident 1 kicked her out of her room. On 1/12/15 at 4:00 PM, Surveyor asked NHA A if she asked Resident 1 if CNA F was going to force her into the shower. NHA A stated she did not. Surveyor asked NHA A if she asked Resident if it was true CNA F stated she stunk and no one wanted to be by someone who is stinky. NHA A stated she did not. NHA A stated in her mind no one else had any information related to the allegation so she did not proceed with the investigation. NHA A stated she spoke to CNA F and CNA F stated she did go in and ask Resident 1 if she would take a shower and Resident 1 refused. NHA A stated CNA F stated she left the room. Surveyor asked NHA A if she has interviewed any other staff or residents related to the incident with Resident 1 and CNA F. NHA A stated in her mind no one else had any information related to the allegation. NHA A stated she sent CNA F back to her unit to continue to work. NHA A stated she did not remove CNA F from the resident area or the facility after she was notified of the allegation. On 1/12/15 at 4:35 PM, Surveyor spoke with Director of Nursing (DON) B regarding the care plan note on 11/19/14. DON B stated she was the Minimum Data Set nurse at the time the care plan was updated. DON B stated she does not remember who told her to add she is afraid of the water to the care plan. DON B continued to state she was informed Resident 1 should have a bed bathe because she does not like water. On 1/12/15 at 5:25 PM Surveyor spoke with RN D regarding Resident 1 after the CNA F left the room. RN D stated she checked on Resident 1 throughout the shift. Resident 1 continued to state she was afraid CNA F was going to come back into her room. RN D stated Resident 1 did not sleep. Surveyor asked RN D if she had asked CNA F to go into Resident 1's room to offer her a shower. RN D stated she did not ask CNA F to shower Resident 1 or to enter Resident 1's room. On 1/13/15 at 10:25 AM, Surveyor spoke with Licensed Practical Nurse (LPN) E regarding Resident 1 and CNA F's interaction. LPN E stated Resident 1 was very apprehensive about taking a shower. LPN E discussed with Resident 1 she thought the date was 11/24/14 to take a bed bathe due to her fear of water. LPN E stated I charted she was afraid of water and refused shower, so it was that night I believe. LPN E stated she knows people with Dementia also fear water so she used the same technique with Resident 1. LPN E stated Resident 1 was comfortable with the new plan of taking a bed bathe and not a shower. LPN E stated she informed all of the CNAs and passed the information on in report so the nurses also were aware of the new plan. LPN E stated she heard the following day from the staff that CNA F was going to force Resident 1 to take a shower and informed Resident 1 she stunk. LPN E stated she entered Resident 1's room and found Resident to be distraught. LPN E stated Resident 1 was crying and very upset, stated Resident 1 was afraid they were going to come in again and force her to take a shower. LPN E stated Resident 1 shrunk back into her shell. LPN E stated she talked 1:1 with Resident 1 and reassured Resident 1 she would not let anyone come into her room and force her to shower. LPN E stated she again informed Resident 1 a bed bath was the plan for her. LPN E stated it's all in the approach to residents and CNA F does not think before she does things to residents. LPN E continued to state she has never been interviewed by the NHA or anyone else in the facility related to CNA F threatening to take Resident 1 into the shower. LPN E stated the NHA called her to her office and asked her to be the nurse CNA F could come to if she has problems. LPN E stated any staff member can come to her with any issues and was informed CNA F would only be coming to LPN E for concerns. LPN E stated she has had performance issues in the past with CNA F and wanted to give her written warning and CNA F started to cry and put on airs in front of the NHA. Nurses then were informed the facility does not write up CNAs for performance the nurses could only re-educate the staff. Due to the history of CNA F and the NHA, LPN E did not feel comfortable going to the NHA about CNA F and what occurred with Resident 1. LPN E stated she passed on to all CNAs that Resident 1 is very frightened and will not be having a shower. LPN E stated she believe the incident occurred on 11/25/14. The NHA was immediately notified and did not follow the facility policy to protect Resident 1 from further abuse. The person accused of abuse was not immediately removed from resident areas to protect other residents per the facility policy. The facility did not follow the facility policy and did not take steps to prevent further potential abuse when the abuse was first reported, to immediately protect residents when the CNA spoke derogatorily about the resident, to interview all staff who worked with the CNA, and to retrain all staff after the abuse was discovered. The facility did not self-report the abuse to the Office of Caregiver Quality according to their current policy. Resident 1 was abused by CNA F and when the abuse was witnessed it was not immediately stopped. The allegation was reported to the NHA. The NHA did do an investigation and no measures were taken to prevent further potential abuse as CNA F continued to work with residents. The failure to investigate and to take actions to prevent further potential abuse created a situation of immediate jeopardy. The facility removed and corrected the Immediate Jeopardy on 1/13/15 when: 1. CNA F was terminated from the facility. 2. All staff is being immediately educated on need to report abusive situations and any signs potential abuse to the Compliance Officer, Social Services or NHA. 3. The NHA will confer immediately with the Compliance Officer and the Director of Nursing concerning all reported situations to ensure we are following the policy and procedures for all allegations of abuse. 4. All staff before returning to work will be educated on protecting resident from abuse and reporting immediately. 5. The reported situation will be investigated immediately by the Compliance officer, Social services and the NHA. All staff on duty will be interviewed as well as several interviewable residents. Cross reference F 223 and F 225 Example 2 On 1/12/15 at 9:20 AM Surveyor asked Nursing Home Administrator (NHA) if she had any current allegations of abuse in the facility. NHA A stated she has not had any current allegations of abuse that she has investigated. NHA A continued by stating there was an incident Sunday evening (1/11/15). Four Certified Nursing Assistants (CNAs) came to NHA A and stated that CNA F spoke in a harsh tone and swore in front of Resident 9. NHA A stated the 4 CNAs came to her around 9:30 PM last evening and talked with me for several minutes. The evening shift ends at 10:00 PM. Surveyor asked NHA A for her initial investigation and statement related to the incident. NHA A stated she did not perform an investigation into the allegation as yet. Surveyor asked NHA A what time the allegation occurred. NHA A stated the CNAs stated it occurred before 7:00 PM. The other CNAs were asking CNA F to assist them in taking vital signs due to the outbreak of an illness in the facility. The CNAs stated CNA F became upset and started swearing in front of residents. NHA A stated the CNAs did not immediately report the allegation or protect Resident 9 from further occurrence. NHA A indicated that she tried to go into Resident 9's room after the CNAs talked with her and Resident 9 was sound asleep and appeared to be resting very comfortable and I did not wake her. NHA A stated that she talked to CNA F; CNA F stated she did not do it. When NHA A spoke with CNA F she had already completed her shift and was getting ready to leave, approximately 10:00 PM. The surveyors entered the building before 8:00 on 1/12 so NHA A had not had a chance to speak with Resident 9. Additionally, CNA F was terminated on 1/12/15 and did not work another shift after this incident. Surveyor asked NHA A why an investigation or statements were not taken at the time of the allegation. NHA A stated CNA F stated she did not do it. NHA A stated she would begin an investigation now. There is no documentation of an investigation, or evidence Resident 9 or other vulnerable residents were protected at the time of the allegation. Example 3 In the facility concern book there was a document dated 10/29/14 regarding Resident 8. The document states: Resident 8 asked the nurse (nurse not identified) for her medication and Resident 8 was told she would have to wait because the nurse was still passing the 5 o'clock medication. Resident 8 was also concerned nurse on duty refusing to put cotton in her ears after ear drops; Resident 8 likes her medicine at 6:15 PM due to fatigue from [MEDICAL TREATMENT]. The nurse on duty told her she would have to wait because the nurse had to eat because she (the nurse) was diabetic. Resident 8 felt the nurse was upset with her when she did eventually come give her the medicine. The nurse gave Resident 8 a "dirty look" and Resident 8 said, "Don't be mad at me, I am the resident." Nurse stated, "I am upset with you." On 1/12/15, at 1:15 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated she was aware of the situation. NHA A stated she had another nurse give Resident 8 her medication and the nurse was fired. NHA A was not able to recall the nurse who was involved. There is no documentation of an investigation, who was involved or how it was resolved. Example 4 Per the facility's "Record of Concern," on 11/10/14 Resident 7's family member complained of an odor and a bag of soiled linen (brief) in the middle of the floor after Resident 7 had been walked back from lunch. The family stated the linen was there since before lunch. The family also stated Resident 7 was not fully cleaned up before going to lunch; she had an odor coming from her. This was reported on 11/11/14 to Social Services (SS) J. On 1/12/15, at 10:44 AM, Surveyor interviewed SS J regarding the allegation. SS J stated it was a nursing concern so she would have passed it on to the Director of Nursing (DON) to deal with. (Note: not the current DON.) SS J stated she did not have any additional information. On 1/12/15, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated that concern occurred when the previous DON was not doing her job. NHA A stated she felt there was education given and would look for it. No additional information was provided. Example 5 The State Agency received a complaint regarding altercations between Resident 2 and Resident 3 and there is no plan to prevent additional altercations or an investigation into the situation. On 1/12/14, Surveyor reviewed Resident 2 and Resident 3's records. Resident 2 was admitted on [DATE] and his Power of Attorney for Healthcare was activated on 6/19/13. Resident 3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Interventions are to ignore the behavior and try to redirect. There was no indication in either Resident 2 or 3's record of any altercation or behaviors toward other residents. Surveyor requested the facility's investigations for allegations of abuse and resident to resident altercations. There were no resident-to-resident altercation investigations or reports provided. On 1/12/14, at 10:44 AM, Surveyor interviewed Social Services (SS) J. SS J stated she recalled something occurring between Resident 2 and 3 as she heard bits and pieces of it the next day and they were moved into the cafe. SS J stated she did not do any follow up as it was reported as being handled. On 1/12/14, at 1:15 PM Surveyor interviewed Nursing Home Administrator (NHA) A about any incidents with Resident 2 and 3. NHA A stated there was an incident between the two. NHA A stated she was out of the area but got a call stating Resident 2 and 3 were eating at the same table in the dining room. Resident 2 asked Resident 3 for his dessert. Resident 3 said no and then Resident 2 took it. The two were getting loud. Two other residents were moved from the area as they were done but still loud with staff because they did not want to move. NHA A stated the plan was to have the residents sit at different tables but Resident 2 and 3 wanted to sit together and Resident 3's wife asked if they could sit in the cafe (small room next to the dining room). NHA A stated she did talk with 3-4 other resident the next morning regarding the incident. NHA A stated she would have expected the nurse or medication technician to a note of it and notify SS J. NHA A did not provide any documentation of the incident. On 1/12/14, at 1:41 PM, Surveyor interviewed Dietary Manager (DM) K. DM K stated she recalled she was in the building when Resident 2 and 3 were yelling at each other. DM K stated she could not recall when the incident occurred. DM K stated staff came to her and asked if they could move Resident 2 to a different table as he was trying to take other residents stuff and this was getting Resident 3 going. DM K said the residents were moved for the next meal and the following morning Resident 2 and 3 started eating in the cafe. There is no documentation of the incident including no investigation. The facility was not able to identify when the incident occurred. Neither Resident 2 nor 3's care plan was updated or a notation made in their record. Reference F225

Based on medical record review, interview, and observation, the facility did not ensure that each resident was free from physical, verbal and mental abuse for 1 of 9 sampled residents. Resident 1 was verbally abused by a Certified Nursing Assistant (CNA). The CNA told Resident 1 she stunk and no one wanted to be around or sit near Resident 1. The CNA told Resident 1 she was going force her to take a shower, even though the resident had a life-long fear of water due to a near-drowning incident. This caused Resident 1 to become very upset, tremble, cry and become withdrawn. Resident 1 remained afraid the CNA would return to her room and could not sleep for fear that the CNA would come and take her from her room. This is evidenced by: Resident 1 was admitted to the facility on [DATE] with the following diagnoses; Depression, Asthma, Diabetes, [MEDICAL CONDITION], and History of falls. Resident 1's nursing note, dated 11/13/14, at 3:49 PM, states Short term memory - OK. Long term memory - OK. Resident 1 is able to recall she is in a nursing home, staff names and faces, location of room and current season. Resident 1's decisions are consistent and reasonable. Resident 1's nursing note dated 11/17/14 at 12:27 PM, AM bathing did not occur declined altogether, reason: scared of water, refused. Resident 1's care plan in part, dated 11/19/14, Strength: Activities. Goal: To return to her home in the community. Nurse Aide: it is very important to Resident 1 to take care of personal items. Prefers bed bath as Resident 1 is afraid of water. Resident 1's nursing note, dated 11/23/24 at 6:31 PM, It has been reported that staff (CNA) have attempted to assist resident to take shower, writer spoke with resident and resident states. "I never took one at home and not going to start now, I washed up in the sink. Will again attempt to persuade resident to allow staff to take shower and wash hair. Will continue to monitor. Resident 1's care plan entry was made on 11/24/14 at 11:04 AM, Other: Bed bath on shower day. Resident 1 is afraid of water. Resident 1's nursing note dated 11/24/14 at 1:34 PM, AM bathing: Did not occur declined altogether, reason: Resident refuses any kind of shower...washed her hair in beauty shop. Resident 1's nursing note, dated 11/24/14 at 1:58 PM, states: Refused approached on 3 occasions asking her to shower, resident declined due to fear of water. Resident 1's nursing note dated 11/25/14, at 4:12 PM, states Psychological: Appears psychologically stable. Reaction to stress: withdraws from others and worries. Personality: appears withdrawn. Resident 1's nursing note, dated 12/1/14 at 2:56 PM, Certified Nursing Assistant (CNA) reports she (Resident 1) is afraid of water and is refusing her bath and head wash. Resident 1's care plan titled Self care deficit: in part, dated 12/2/14: Other: All Staff- Bed bath on shower day. Resident is afraid of water. Encourage cap to shampoo hair... On 1/12/15 at 1:20 PM Surveyor spoke with Licensed Practical Nurse (LPN) C regarding Resident 1 taking a shower. LPN C stated it was reported to her by the CNAs that CNA F was going to force Resident 1 into the shower and Resident 1 became very upset. LPN C stated she did not know the date of the incident. LPN C stated CNA F had stated by the time clock she was "going to get stinky in the shower today you just watch." On 1/12/15 at 2:30 PM, Surveyor spoke via the telephone with Safety Checker (SC) H, regarding CNA F threatening Resident 1 to shower. SC H stated she was the safety check person on duty that night from 5 PM to 10 PM. SC H stated she does not remember what night the incident occurred. SC H stated she was doing her safety rounds and was walking by to check on Resident 1. SC H stated as she walked to Resident 1's room she saw CNA F in the room. CNA F motioned to SC H to get away from the door so SC H would go away SC H stated she went back to check on Resident 1. SC H stated CNA F is not assigned to Resident 1 so it seemed odd that she was in the room. SC H stated Resident 1 did not look right while CNA F was speaking to her. SC H heard CNA F was getting nasty with Resident 1. SC H entered Resident 1 room and CNA F exited the room. Resident 1 was crying and stated: CNA F told Resident 1 that she stunk and needed to bathe. Resident 1 also stated she was afraid of CNA F and was afraid she would come back in to the room and force her to take a shower. SC H stated Resident 1 was shaking and crying. SC H stated she left the room and went and informed RN D of Resident 1 condition and what she heard SC F state to Resident 1. On 1/12/15 at 1:25 PM Surveyor spoke with Certified Nursing Assistant (CNA) G regarding CNA F and Resident 1 taking a shower. CNA G stated she was working 3rd shift and answered Resident 1's call light. Resident 1 was scared and nervous when CNA G entered her room. CNA G stated Resident 1 told her that CNA F told her she had to take a shower because she stunk. Resident 1 also stated she was terrified of water because she almost drowned. CNA G informed Resident 1 she did not have to take a shower. CNA G stated Resident 1 told her CNA F stated the call light did not work so you cannot call for help and no one wants to be near you because you stink. Resident 1 was trembling and crying during the conversation. CNA G stated she reported it to Licensed Practical Nurse (LPN E) as soon as she left Resident 1's room. CNA G stated CNA F informed the PM shift at the time clock that Resident 1 was going to take a shower because she was going to see to it. CNA G stated everyone knew Resident 1 was terrified of water. Resident 1 just kept crying and shaking and was afraid CNA F was going to come back and force her to shower. CNA G stated CNA F intimidates residents and they are afraid of her. Resident 1 was afraid of her. On 1/12/15 at 1:42 PM, Surveyor spoke with CNA I regarding Resident 1 and taking a shower. CNA I stated she worked with Resident 1 and was aware of Resident 1 was afraid of the shower. CNA I stated she had asked Resident 1 to take a shower after she was first admitted . Resident 1 always refused the shower. Surveyor asked CNA I regarding any knowledge of CNA F attempting to force Resident 1 to take a shower and telling Resident 1 she stunk. CNA I stated she had heard that CNA F went in to Resident 1's room and told her she stunk and she had no choice she was going to take a shower. CNA I stated Resident 1 stated CNA F was very rude and mean when she came in her room and told her she demanded she had to take a shower. Resident 1 was scared of CNA F and of water. On 1/12/15 at 1:59 PM, Surveyor spoke with RN D regarding Resident 1 and her shower concerns. RN D stated she was Resident 1's nurse on the PM shift. RN D stated Safety Checker (SC) H came to her and told her she needed to go see Resident 1 now. RN D stated she entered Resident 1's room and Resident 1 was crying and trembling from head to toe. RN D stated she knew Resident 1's background and that Resident 1 was afraid of water and had not showered since admission. Resident 1 verbalized she was afraid of CNA F. Resident 1 told RN D that CNA F was going to force her to take a shower. Resident 1 continued to state CNA F told her she stunk and all the other residents know she stinks and do not want her around them. Resident 1 stated CNA F stated I could not leave this room or go by anyone because I stunk and she was going to take me to the shower. Resident 1 stated she was afraid CNA F was going to come back into her room and force her to shower. On 1/12/15 at 2:10 PM Surveyor spoke with RN D regarding how Resident 1 was after the incident. RN D stated Resident 1 would not sleep she kept watching to ensure CNA F did not enter. RN D stated Resident 1 did not sleep for several days after. RN D stated Resident 1 continued to state she was afraid CNA F was going to come back in her room and she was very afraid she would force her to the shower. RN D stated she heard from the CNAs that CNA F had been informed of the new plan of care for Resident 1 of not bathing and had stated while punching in at the time clock, we are going to "get stinky into the shower today mark my words." RN D stated she previously had written up CNA F for violation of safety issues and had presented them to CNA F. RN D stated she was then informed by the DON that the facility does not discipline or write up CNAs; instead, they are to re-educate them. RN D state re-education had been done several times prior to and changes did not occur. Surveyor asked RN D how the CNAs know the resident's plan of care. RN D stated it was common knowledge to everyone in the facility that Resident 1 was afraid of water. RN D stated there is a care plan in the resident room to follow and also in the medical record which indicated Resident 1 is afraid of water. On 1/12/15 at 4:35 PM, Surveyor spoke with Director of Nursing (DON) B regarding the care plan note on 11/19/14. DON B stated she was the Minimum Data Set nurse at the time the care plan was updated. DON B stated she does not remember who told her to add she is afraid of the water to the care plan. DON B continued to state she was informed Resident 1 should have a bed bathe because she does not like water. On 1/12/15 at 5:25 PM Surveyor spoke with RN D regarding Resident 1 after the CNA F left the room. RN D stated she checked on Resident 1 throughout the shift. Resident 1 continued to state she was afraid CNA F was going to come back into her room. RN D stated Resident 1 did not sleep. Surveyor asked RN D if she had asked CNA F to go into Resident 1's room to offer her a shower. RN D stated she did not ask CNA F to shower Resident 1 or to enter Resident 1's room. On 1/13/15 at 10:25 AM, Surveyor spoke with Licensed Practical Nurse (LPN) E regarding Resident 1 and CNA F's interaction. LPN E stated Resident 1 was very apprehensive about taking a shower. LPN E discussed with Resident 1 she thought the date was 11/24/14 to take a bed bathe due to her fear of water. LPN E stated I charted she was afraid of water and refused shower, so it was that night I believe. LPN E stated she knows people with Dementia also fear water so she used the same technique with Resident 1. LPN E stated Resident 1 was comfortable with the new plan of taking a bed bathe and not a shower. LPN E stated she informed all of the CNAs and passed the information on in report so the nurses also were aware of the new plan. LPN E stated she heard the following day from the staff that CNA F was going to force Resident 1 to take a shower and informed Resident 1 she stunk. LPN E stated she entered Resident 1's room and found Resident to be distraught. LPN E stated Resident 1 was crying and very upset, stated Resident 1 was afraid they were going to come in again and force her to take a shower. LPN E stated Resident 1 shrunk back into her shell. LPN E stated she talked 1:1 with Resident 1 and reassured Resident 1 she would not let anyone come into her room and force her to shower. LPN E stated she again informed Resident 1 a bed bath was the plan for her. LPN E stated it's all in the approach to residents and CNA F does not think before she does things to residents. LPN E stated she believe the incident occurred on 11/25/14. Cross reference F223 and F226

Based on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 4 residents reviewed (Residents 1 and 3). Resident 1 sustained a fall on March 19, the facility placed Resident 1 on every 15 minute checks. The facility did not complete the 15 minute checks and Resident 1 fell and fractured his hip, requiring surgical repair. The facility did not re-implement a care plan related to falls after his return from the hospital. The facility did not have a falls program that investigated falls and did not complete root-cause assessments related to resident falls. Resident 3 sustained a fall on 5/10/14. The facility did not implement a new fall intervention. The facility did not have a fall program that investigated the fall and did not determine the root cause related to Resident 3's fall. This is evidenced by: The facility's policy titled "Policy and Procedure for Fall Prevention" dated 7/16/12 states, " ...All residents will be observed and assessed for fall risks with a preventative intervention implemented (as applicable) upon admission, quarterly, and with a change in condition. Staff will reduce fall risks and risk of fall-related injuries while maximizing quality of life. All residents will be monitored for safety. Staff will identify and report all safety concerns ...Assessment: 3. Has the resident just fallen? Complete an incident report and new fall assessment ...Implement a new preventative intervention and add it to the care plan (when possible the new intervention should be related to reducing the risks and/or causative factors) ...4. Evaluate the factors associated with the fall. The nature of the falls refers to the characteristics and related circumstances, including time and location ...Cause refers to factors that are associated with or that directly result in a fall. It is critical identify underlying contributors to the fall to prevent it from happening again. A. Identify causes of the fall at the time of the fall ...Treatment: 6. Develop a Plan for Managing Falls and Fall Risks; A. Care plan goals to prevent falls, decrease falls and decrease risk and severity of injury. B. Determine, implement, and document multicomponent interventions to manage and prevent falling with individuals. C. Review individual risks with the interdisciplinary team to manage risks to reduce the number of falls and number of fallers. D. If a fall occurs (or reoccurs) despite the initial intervention, add additional or different interventions after a fall to minimize the risk of falling and fall-related injuries. Document rationale. Update plan of care..." Example 1 According to "Cumulative [DIAGNOSES REDACTED]. According to "Face Sheet", Resident 1 has an activated Power of Attorney for health care. The facility completed an initial Minimum Data Set (MDS) assessment on 3/5/14. This assessment notes that Resident 1 scored three points on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Section G "Functional Status" indicates that Resident 1 needs extensive, two-person physical assistance for bed mobility, transferring, and ambulation. Section V "Care Area Assessment (CAA) Summary" notes that the CAA for Falls triggered and a care plan was developed. Resident 1's Plan of Care dated 2/28/14 for "Falls" states, "Problem (Falls): potential for injury. Related to: mental status/gait/balance; Goal: no injury; Goal time: three months; Nurses- proactively promote comfort, Nurses-transfer with assistance, Nurses-Instruct to call for help, Nurses-Keep personal items in reach, Nurses-Corrective eyewear, Nurses-monitor for behavior changes, Nurse Aide-encourage to ask for assistance, Nurse Aide-call button in reach, Nurse Aide-assist with ambulating, transferring toileting, Nurse Aide-anticipate needs, Nurse Aide-report pain indicators, Nurse Aide-nonskid footwear, 3/3/14 All staff-do not leave in room while in wheelchair, Nurse Aide-blue boots off when in wheelchair ...3/21/14 All Staff-15 minute safety checks when in bed." It is important to note that the 15 minute safety checks while in bed was discontinued on 5/28/14 and states "Client discharged ." Resident 1's entire plan of care related to falls was discontinued after his transfer to a hospital on [DATE]. Resident 1 returned to the facility on [DATE] and then was discharged on [DATE]. Nurse's Notes dated 3/19/14 state, "Date of incident: 03/19/2014; Shift: AM; Day of Week: Wednesday; Location: resident's room; Mental State: normal for resident; Activity at time: in bed ...Injury: Scrape 0.1 X 0.2 cm (centimeters) right 2nd toe. Possible cause: found down; Staff involved: none ...New intervention: safety checks q (every) 15 minutes when in bed ..." Nurse's Notes dated 3/20/14 state, "Continues to self transfer out of bed. Found walking in hall, pushing chair ahead of him. Legs appeared to bear weight fully ..." On 6/16/14, Surveyor requested evidence that the facility completed the care planned 15 minute safety checks for Resident 1. The facility provided documentation that "Night Companion" checks were completed for Resident 1 from 2/21/14 to 5/28/14. The facility indicated that "Night Companion" checks are a standard, every 30 minute check completed for residents during the night. This documentation states, "5/20/14 ...0100 (1:00 AM) Awake he has tried getting out of bed to go the bathroom but when someone comes he doesn't have to go. 0130 (1:30 AM) Awake had to go to the bathroom then changed his mind ...0230 (2:30 AM) Awake got out of bed tried to move his walker I had to call for assistance. CNA (Certified Nursing Assistant) came and toileted him ...5/26/14 ...0230 (2:30 AM) awake got up 2 times in a half hour I got him back to bed ...2030 (8:30 PM) awake has been getting out of bed and wandering around his room looking for things to put togetherhe (SIC) thinks if I tell him I'm looking for the things he needs and if he goes to be I will let him know when I find them then he is OK with it. I find he relaxes more if I leave his door open a small crack so I can peek in on him ..." The facility completed a "Night Companion" check for Resident 1 on 5/28/14 at 4:58 AM and Resident 1 was noted to be asleep. The facility also provided "PM Safety Check" which was documented as completed every 30 minutes on 4/8/14, 4/11/14, 4/12/14, 4/13/14, 4/14/14, 4/15/14, 5/9/14, 5/10/14, 6/1/14 and 6/2/14, while Resident 1 was in bed. The facility did not have evidence that Resident 1 was checked on while in bed every 15 minutes, per resident 1's plan of care. Nurse's Notes dated 5/28/14 state the following: "06:43 (6:43 AM) Call placed to: ER nurse. Result: report to ER nurse. Incident type: observed on floor. Date of incident: 05/28/2014 05:35 (5:35 AM). Day of week: Wednesday. Location: Resident's room. Mental State: normal for resident. Activity at time of fall: in bed. Equipment involved: none. Injury: laceration c/o (complains of) pain right hip. First aide: immediately applied, transferred to emergency room . Possible cause: found down. Staff involved: none. Witnesses: none. Neuro Checks: pupils equal, round and react to light ..." Resident 1's notes from St. Mary's Hospital-Janesville, dated 5/28/14 state, "...The patient presents to the emergency department by EMS for evaluation of a fall. The patient reportedly rolled out of bed and hit his head. The patient is anticoagulated with Coumadin. He sustained a small abrasion to the right scalp. Patient mainly has right-sided hip pain. He is unable to straighten his right lower extremity. He has a skin tear over his right elbow. He denies loss of consciousness, head ache or neck pain ...Final diagnostic impressions: Fall, accidental, right hip pain, right scalp abrasion, anticoagulation with Coumadin, dementia, right lateral elbow skin abrasion, nondisplaced intertrochanteric fracture of the right hip ...Patient disposition: transfer to St. Mary's Hospital ..." Resident 1 returned to the facility on [DATE]. Review of Resident 1's plan of care indicates that the facility did not re-implement a care plan related to falls for Resident 1, upon his return to the facility. Nurse's Notes dated 5/31/14 state, "General skin condition: dry, bruising, surgical incision ...right anterior thigh: 2.5 cm incision with 6 staples, right anterior thigh: 1 cm incision with 3 staples. F/U (follow up) incident: continue to observe ..." On 6/16/14, Surveyor requested fall investigations for Resident 1, from Director of Nursing (DON) B. At 10:55 AM, DON B provided the following documentation, representing the facility's fall investigations: "5/29/14: Did the fall result in injury? Yes-major injury; Date of incident: 05/28/2014; Time of incident: 05:35 AM; Day of Week: Wednesday; Was fall observed? No; Was resident alone at time of fall? Yes; Location of Fall: still in bed from noc (night) shift; # Falls in the past 3 months (including this fall): 3; Were protective/safety devices in use at time of fall? No; Environmental cues? None; Health/Care status clues? None. Summary of Factors: resident self transferred, dx (diagnosis) of dementia and is impulsive. He did not remember why he was getting up, just that he lost his balance and tried to catch himself. Out to ER. Found to have hip fx (fracture). admitted to Madison for repair." The facility did not complete a thorough assessment of Resident 1's fall. The facility did not refer to Resident 1's plan of care and determine why the care planned every -15-minute safety checks were not completed. The facility did not identify that the every-30-minute safety check was due at 5:38 AM, as Resident 1 was last checked at 4:58 AM on 5/28/14. Surveyor spoke with Registered Nurse (RN) C on 6/16/14 at 1:25 PM. RN C indicated that she was in charge of care planning and fall assessments. Surveyor asked RN C if she looked in to (Resident 1's) fall on 5/28/14 that resulted in a fracture. RN C stated that she did not really do anything at that time because the resident was not there, he was in the hospital. RN C stated that she did not look at (Resident 1's) plan of care related to falls, to determine if it was implemented. RN C stated that she did put the intervention for the 15 minute checks on (Resident 1's) care plan. Surveyor asked where she could find evidence that the 15 minute checks were completed. RN C stated that she thought it was in the CNA charting, in the Night Companion. Surveyor asked how frequent the Night Companion staff checks on residents. RN C stated that the Night Companion checks on residents every 30 minutes. Surveyor asked RN C what the CNAs refer to, in order to provide care for residents. RN C stated that the CNAs refer to the main care plan in ECS (electronic medical record) so this would have instructed staff to complete every 15 minute checks on (Resident 1). Surveyor spoke with DON B on 6/16/14 at 12:58 PM. DON B stated that the Night Companion is for those residents who are at fall risk and is a 30 minute frequency check. Surveyor asked when Resident 1's 15 minute checks were to be initiated. DON B stated that this would have been on 3/19/14. DON B stated that she was only seeing that the 30 minute checks were completed. DON B stated that she would check into this. No additional information was located related to completion of the 15 minute checks. On 6/16/14 at 1:15 PM, Nursing Home Administrator (NHA) A stated that the facility had decided to do 30 minute checks on (Resident 1). Surveyor requested evidence of this assessment and change in care plan intervention. NHA A stated that the night of (Resident 1's) fall, on 5/28/14, the nurse needed the safety checker and (Resident 1) was asleep and that this scenario was charted. Surveyor requested this documentation. NHA A did not provide this information and it was not located in Resident 1's medical record. Surveyor spoke with DON B and RN C on 6/16/14 at 2:30 PM. DON B stated that the admitting nurse would re-initiate a care plan for a resident who returns to the facility. DON B stated that it was (RN C) who readmitted (Resident 1) to the facility on [DATE]. Surveyor asked RN C about the care plan. RN C stated that she knew there was a care plan in (Resident 1's) room after he was readmitted . Surveyor asked to see this document. RN C stated that these are not kept. Surveyor asked DON B and RN C who looked at the 5/28/14 fall after Resident 1 returned to the facility. RN C stated that she did not look into the fall. The facility determined that Resident 1 was in need of every-15-minute checks while in bed. The facility did not implement this intervention. Resident 1 fell from bed and sustained a fracture of the right hip, which required surgical repair. The facility did not complete an investigation into falls for Resident 1. The facility did not implement a fall care plan after Resident 1 was readmitted to the facility. Example 2 Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility completed an initial Minimum Data Set (MDS) assessment on 4/23/14. This assessment notes that Resident 3 scored four points on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Section G "Functional Status" indicates that Resident 3 needs extensive, one-person physical assistance for bed mobility, transfers, ambulation, and toileting. Section J1800 Number of Falls Since Admission/Entry or Reentry or Prior Assessment, whichever is more recent, notes that Resident 3 has had 2 falls with no injury. Review of Resident 3's room CNA Assignment Sheet, under falls, dated 6/10/14 reads, "Purple Star." On 6/16/14 at 8:45 AM during initial facility tour, Surveyor observed a magnet containing a purple star, on the door frame of Resident 3's room, and a large blue floor mat at the foot of Resident 3's bed. On 6/16/14 at 8:55 AM, Surveyor interviewed CNA (Certified Nursing Assistant) E as to the meaning of the "Purple Star" magnet on Resident 3's door frame. CNA E stated that the purple star magnet meant that Resident 3 was not to be left alone in her room due to fall risk. Review of Resident 3's nurses notes dated 5/10/14 indicate that Resident 3 was transferred to the hospital emergency room at 12:00 PM due to being found sitting on the floor with her back up against the dresser drawer with complaints of back pain. Review of Resident 3's nurses notes dated 5/10/14 indicates that Resident 3 returned to the facility at 14:30 (2:30 PM) with no new orders. A review of the incident report for Resident 3 indicates that the new intervention would be for Resident 3's bed to be in the lowest position. *This intervention was already in place.* On 6/16/14 at 12:20 PM, Surveyor requested the investigation for Resident 3's 5/10/14 fall from DON (Director of Nursing) B. DON B stated that DON B would look for the investigation. On 6/16/14 at 12:40 PM, Surveyor spoke with RN (Registered Nurse) C regarding the 5/10/14 investigation for Resident 3's fall. RN C stated, "I just went ahead and reviewed the fall care plan. No changes were made." Surveyor then asked RN C if other disciplines were involved in the review of Resident 3's falls, RN C stated, "No." Surveyor then asked RN C what the facility process was following a fall, RN C stated, "I review the incident report, talk to staff to see why the resident fell , check to see if the resident needs something new or if something is not working." Surveyor then asked RN C if RN C completed this process for Resident 3, RN C stated, "Yes, but I did not write anything down." Surveyor then asked RN C if a new Fall Risk Assessment was completed for Resident 3 following the 5/10/14 fall as per the facility policy/process, RN C stated, "No." On 6/16/14 at 1:30 PM, Surveyor interviewed DON B regarding the facility process following falls. DON B stated, "If there is no injury we do follow up charting for 3 days, we talk about the fall at the morning standup meetings Monday through Friday, but do not document the discussion anywhere. RN C does the follow-up after any fall. Something needs to be put in place immediately, and a follow-up up Fall Risk Assessment is completed." Surveyor then asked DON B if a new intervention was put into place after Resident 3's 5/10/14 fall, and if a fall risk assessment was completed, DON B stated, "No." The facility did not follow up on Resident 3's fall to determine root cause or place new interventions to maintain Resident 3's safety.

Based on observation, interview, and record review, the facility did not ensure that based on the comprehensive assessment of a resident, a resident who enters the facility without pressure ulcers does not develop pressures ulcers unless the individual's clinical condition demonstrates that they were unavoidable, and that a resident having pressure ulcers receives the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 2 of 7 residents reviewed for pressure ulcers (Residents 6 and 5). Resident 6 has an in house acquired stage 3 pressure ulcer on Resident 6's left hip. Resident 6 was placed on a specialty mattress which is intended for use only for a stage 1 pressure ulcer. As changes in the pressure ulcer occurred, the facility did not update the care plan, did not promptly inform the physician or the Wound Care Consultant, and did not initiate changes in treatment. Resident 6's plan of care indicated Resident 6 was to be out of bed for 1 and 1/2 hours only and Resident 6 was in his chair for greater then 4 hours on 2 days of a 3 day survey. The pressure ulcer has become larger and infected. Resident 5 acquired an stage 2 pressure ulcer to the right ischial area. Resident 5 was placed on a specialty mattress with specifications to use only for a stage 1 pressure ulcer. Resident 5 was observed with the incorrect physician ordered dressing to the right ischial ulcer on 1 day of the 3 day survey. This is evidenced by the following: A Quick Reference Guide entitled "Pressure Ulcer Prevention" published by the National Pressure Ulcer Advisory Panel in 2009 indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Using a pillow under the calves so the heels are elevated (i.e., "floating") will accomplish reduction of pressure on heels. The facility policy titled "Wound care admission policy, Pressure Ulcer Prevention and wound Care", no date indicated, indicates the following; Upon admission every patient will be assessed for pressure ulcer risk by an assigned Registered Nurse (RN).... 4. Patient Immobilized or at Risk If immobilized or at risk, the following shall be implemented and documented in the medical record: a. The patient shall be turned and repositioned frequent intervals as necessary. b. Pressure reduction devices shall be used as ordered. c. Positioning devices such as foam or pillows may be placed between bony prominence's to prevent direct contact, and off load heels (float heels). g. Staff shall initiate skin care as appropriate. The patient shall be turned and positioned at frequent intervals as necessary. 5. Hydration and Nutrition consult The patient's hydration will be maintained and a nutrition consult initiated as indicated. 6. Bed Linens Staff shall keep bed linens smooth, dry and clean... General pressure ulcer management guidelines policy 1. Nurse initiation of guidelines and WCC (Wound Care Certified) consult. The RN/LPN shall initiate pressure ulcer prevention protocols and consult WCC for at risk patients on admission and/or later if the patients condition warrants. 2. Specialty mattress/bed orders. The nurse shall consult the WCC for recommendations of alternations pressure air mattress overlay. On 10/15/11 at 1:05 PM Surveyor spoke with DON B regarding Resident 5 and 6's plan of care and current standard of practice for pressure wounds. DON B stated the residents' plan of care is to be followed by all staff. DON B also stated when the care plan indicated heels to be floated, heel protectors to be on and a Resident to be in a wheel chair for a certain length of time it is her expectation the care plan is followed. Example 1 Resident 6 was admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] stage 3, Peripheral [MEDICAL CONDITION], and Dementia. Resident 6's care plan titled "Risk for skin breakdown", dated 2/14/11, indicates the following; Problem: At Risk for skin breakdown due to impaired mobility, incontinent of bowel, use of oxygen, and Foley catheter. Goal: Resident 6 will have no skin breakdown with protective/preventive skin care Interventions 4. Assess nutritional status and make referral to dietician if indicated. 5. Float heels... 10. Pressure relieving mattress on Resident 6's bed. Cushion or sheep skin in his wheel chair. 11. Report any signs of reddened skin areas or other signs of skin breakdown to the nurse immediately. 12. Turn and reposition at frequent intervals as necessary. 15. Resident 6 is not to be up in wheel chair greater then one hour and thirty minutes. Resident 6's nursing notes, dated 3/14/11, at 10:15 AM indicate Resident 6 has a dark purple colored area of skin on left hip measuring 2.0 centimeters (cm) by 2.5 cm surrounded by firm, normal colored skin. Resident 6 denies pain. Resident 6's physician was notified for treatment to the left hip area. Subsequent to this change in condition, facility staff did not document an observation or treatment of [REDACTED]. Resident 6's nursing notes, dated 4/5/11, at 7:00 AM indicate Resident 6 ' s dressing was changed to his left hip. Resident 6 has a quarter sized black area when the dressing was removed from the left hip area. The Director of Nursing (DON) and the WCC were informed. Resident 6's physician was not notified and changes in Resident 6's care plan were not made until the following day. Resident 6's care plan titled "Stage 3 pressure ulcer", dated 4/6/11, indicates the following; Problem: Stage 3 pressure ulcer, left hip. Goal: Resident 6 Pressure ulcer will heal without complications by the next review Interventions: 3. Turn and reposition at frequent intervals as necessary. (Resident 6's care plan does not direct the staff of a time frame to turn or reposition Resident 6 after the stage 3 ulcer developed.). Resident 6 is not to be up in wheel chair greater then 1 1/2 hours... 6. Position Resident 6 off affected areas. 7. Pressure relieving cushion on wheel chair. Air mattress on Resident 6's bed... 13. Provide treatment per physician orders. See Treatment administration record (TAR). Monitor for effectiveness and or complications to healing... 14. Assess for pain, provide pain medication 30 minutes prior to dressing change if indicated. Resident 6's nursing notes, dated 4/6/11, at 4:00 PM (32 hours after the first change in Resident 6's pressure ulcer was identified) indicates Resident 6 ' s pressure ulcer on the left hip measured 2.0 cm by 2.6 cm unstageable at the time of the observation. Resident 6's pressure ulcer is 99% black eschar and the peri wound is bright red, and warm to touch. Resident 6 has generalized [MEDICAL CONDITION] of the left hip from the waist down. A fax sent to the physician for Resident 6's, dated 4/6/11, at 4:30 PM indicates the following: Resident 6 has the following wound which is unstageable. Pressure ulcer to the left trochanter measuring 2.0 cm by 2.6 cm. The pressure ulcer wound bed is firm black eschar. Resident 6's pressure ulcer is 99% black eschar. Provide pressure ulcer redistribution mattress and turn every 2 hours, and do not position on his left side. Resident 6's fax also indicates a Nutritional assessment by the Dietician to be completed. On 4/6/11, the facility placed a Paradise PARA3002 air mattress overlay on Resident 6 ' s bed. This was applied 23 days after the areas were first noted on 3/14/11 and was the wrong type of mattress. The facility provided the manufacturer recommendation form indicating that the air mattress overlay is to be used for a pressure ulcer at a stage 1 or less. On 10/5/11 at 10:30 AM Surveyor spoke with Director of Nursing (DON) B regarding Resident 6's air mattress manufacturer recommendations. DON B indicated the current air mattress Resident 6 is on is only indicated for use when a resident has a stage 1 pressure ulcer or less. DON B also indicated the manufacturer recommendations do not indicate it is effective for Resident 6's current stage 3 pressure ulcers. Resident 6's Physician order [REDACTED]. The nurses are to apply Santyl to the Black eschar at the left trochanter wound, cover the wound with a 4 by 4 gauze dressing, change the left trochanter wound twice a day, cleanse the wound with the facility wound cleanser, provide pressure redistributing mattress and turn Resident 6 every 2 hours. Resident 6's Physician order [REDACTED]. 2. Resident 6 to be started on [MEDICATION NAME] 100 milligrams (mg) one tablet twice a day for wound infection ([MEDICAL CONDITION])... 4. Avoid positioning Resident 6 on his left hip until healed. Resident 6's nursing notes, dated 4/7/11, at 9:00 PM indicates Resident 6 was started on an antibiotic for the wound (pressure ulcer) infection to the left hip. Resident 6's nursing notes, dated 7/19/11, at 1:45 PM document a pressure ulcer assessment completed to the left hip. Resident 6's left hip pressure ulcer had been debrided at the hospital during Resident 6's recent hospitalized from [DATE] thru 7/18/11. Resident 6's stage 3 left hip pressure ulcer currently measured 1.6 cm by 1.7 cm by 1.5 cm (deep) with 99% yellow slough. Resident 6's nursing notes, dated 7/29/11, at 10:00 AM indicate Resident 6 left hip pressure ulcer changed. Resident 6's pressure ulcer has tunneling noted approximately 0.3 cm around inner edge of the pressure ulcer. Resident 6's dressing was reapplied and the WCC was notified of the wound tunneling. Resident 6's physician was not notified of the change and there was not a change in Resident 6's care plan with the change in Resident 6's pressure ulcer. Resident 6's nursing notes, dated 7/30/11, at 9:25 PM indicate Resident 6 ' s left hip pressure ulcer has yellow slough on the bottom of the wound bed and eschar (a change in the pressure ulcer) on the top edge toward the top of the pressure ulcer. Resident 6's pressure ulcer looks bigger than a dime and 2.5 cm deep and the gauze dressing had bloody drainage. Resident 6's left hip pressure ulcer dressing was changed. Resident 6's physician was not notified of the change and there was not a change in Resident 6's care plan with the change in Resident 6's pressure ulcer. Resident 6's nursing notes, dated 7/30/11 (Saturday), at 10:00 PM indicate the top of the pressure ulcer appears to be black in color. Resident 6's nursing notes indicates Resident 6's nurse will have the WCC (A Registered Nurse working at the facility) look at the pressure ulcer on Monday morning. Resident 6's nursing notes, dated 7/31/11, at 3:45 PM indicate Resident 6 left hip pressure ulcer dressing was changed. Resident 6's pressure ulcer is approximately 2 cm by 2 cm deep with yellow slough on the bottom of the pressure ulcer and black eschar on the upper edges of the pressure ulcer (a decline in the pressure ulcer). Resident 6's skin around the pressure ulcer is darker in color. The Gauze packing removed from Resident 6's pressure ulcer was covered in blood as well as the 2 by 2 gauze covering the wound was covered in blood. There was no contact with the physician or the Wound Care Consultant and no change made in treatment. Resident 6's nursing notes, dated 8/1/11, at 10:30 AM indicates... Resident 6 left hip pressure ulcer wound bed is dark gray black in color with a small amount of yellow slough at the base of the pressure ulcer. Resident 6's left hip pressure ulcer outer area is black in color... The WCC (A Registered Nurse working at the facility) was notified of the change in status of the pressure ulcer but there is no documentation to indicate that the WCC saw and evaluated the resident on this day. Resident 6's physician was not notified of the change and there was no change in Resident 6's care plan with the change in Resident 6's pressure ulcer. Resident 6's nursing notes, dated 8/3/11, at 9:30 AM indicates. Resident 6 wound and skin assessment was completed by the facility WCC (4 days after the first documentation of the decline in the pressure ulcer). Resident 6's sacrum and left buttock with deep red area and non blanchable at the top and bottom of the red area... Resident 6's physician was informed and a request for treatment was made. Resident 6's resident care sheet (Certified Nursing Assistant (CNA) care guidelines kept in the residents' room), dated 8/4/11, indicates the following; 1. Special care section: a. Do not position on Resident 6's left hip or right hip bone. b. Reposition 15-30 degrees, and frequent changes in position when Resident 6 is in bed. c. Resident 6 is not to be up in wheel chair for over 1 1/2 hours. 2. Bed Mobility section: a. Air mattress b. Off load heels. c. frequent position changes of 30 degrees. 3. Bathing: a. high risk for skin breakdown. b. Whirl pool 2 times a week for wound healing. 4. Activities: Resident 6 is to have a pillow to the right side when in a wheel chair to prevent leaning as needed. Resident 6's nursing notes, dated 8/10/11, at 3:00 AM indicates. Resident 6 left hip pressure ulcer stage 3 area 2 by 2 dressing was removed. Resident 6's pressure ulcer had a moderate amount of yellow gray drainage accompanied by a foul smell. Resident 6's pressure ulcer measured approximately 4 cm in diameter. Resident 6's pressure ulcer bottom of the ulcer has yellowish gray slough. Resident 6's pressure ulcer lip (edges) are firm and slightly denuded. Resident 6's physician or the WCC was not notified of the change and there was not a change in Resident 6's care plan with the change in Resident 6's pressure ulcer. Resident 6's nursing notes, dated 8/12/11, at 9:00 PM indicates. Resident 6 left hip pressure ulcer old dressing was removed (now using a 3 by 3 dressing) with a large amount of foul smelling gray drainage from Resident 6's pressure ulcer. There was no contact with the MD or WCC and no change in treatment on this date. Resident 6's nursing notes, dated 8/14/11, at 7:20 PM indicates. Resident 6 left hip pressure ulcer has a large amount of foul smelling green drainage. Resident 6's physician or the WCC was not notified of the change and there was not a change in Resident 6's care plan with the change in Resident 6's pressure ulcer. Resident 6's nursing notes, dated 8/17/11, at 9:00 PM indicates. Resident 6 left hip pressure ulcer has a large amount of gray and greenish drainage. Resident 6's pressure ulcer base with a slight pink tissue. Resident 6's left hip pressure ulcer is mostly gray yellow in color, and the peri-wound is red in color. Resident 6's nursing notes, dated 8/18/11, at 3:00 PM indicates. Resident 6 left hip stage 3 pressure ulcer was assessed by the WCC (It is important to note Resident 6's change in pressure ulcer documentation was on 8/10/11. Resident 6 was seen by the WCC 8 days after the change in the pressure ulcer was documented.) Resident 6's left hip stage 3 pressure ulcer with 55% yellow slough, and slough also located in the undermining. Resident 6 left hip pressure ulcer identified the wound bed center to be teal in color. Physician notified of the change in color and to be assessed by the Nurse Practitioner. Resident 6's physician order, dated 8/19/11, indicates the following; Resident 6's left hip pressure ulcer treatment changed to apply Santyl with a Q-tip to the 9 O'clock and the 2 O'clock pressure ulcer area... Physical therapy evaluation for wheel chair to evaluate if the wheel chair width is too small and may be adding pressure to the left hip. The Physician order [REDACTED]. Resident 6's nursing notes, dated 8/20/11, at 3:00 AM indicates. Resident 6 started on [MEDICATION NAME] (antibiotic) for left hip pressure ulcer infection. Resident 6 was placed on an antibiotic 10 days after first signs of infection were documented. Resident 6's nursing notes, dated 8/26/11, at 9:00 PM indicates, Resident 6 continues on [MEDICATION NAME] (antibiotic) for left hip pressure ulcer infection. Resident 6's nursing notes, dated 9/2/11, at (no time indicated) indicates Resident 6 ' s left hip stage 3 pressure ulcer has whitish slough at the base of the wound bed. Resident 6's left hip pressure ulcer has a teal wire across the wound bed, 1.0 cm in length. Resident 6's dressing was noted to have moderate amount of tan drainage, and his left hip pressure ulcer periwound was firm at the 12:00 through the 3:00 position. Resident 6's Physician was notified of the changes. Resident 6's Physician order, dated 9/2/11 indicates the following; 1. [MEDICATION NAME] 250 mg orally twice a day for 10 days for left hip pressure ulcer infection. 2. Contact Orthopedic Surgeon regarding the teal wire located at the base of the left hip pressure ulcer (former hip repair hardware completed to the left hip) for course of treatment and directions. Resident 6's nursing notes, dated 9/2/11, at 2:55 PM indicates the following; Return call received from Resident 6's Power of attorney for Health Care (POAHC) regarding Resident 6's left hip surgeries and orthopedic Surgeons... follow up requested to Medical Records (MR) I. On 10/5/11 at 12:30 PM Surveyor spoke with MR I regarding Resident 6's Physician order [REDACTED]. MR I stated the physician did not see Resident 6 on 9/9/11, the physician visit had been on 9/13/11. In addition, MR I indicated she was instructed by WCC/MDS D that MR I no longer had to follow up on the physician order [REDACTED]. MR I removed the copy of the instruction to follow up with Resident 6's orthopedic Surgeon from the box of items to be shredded and provided the form to Surveyor . (It is important to note the Orthopedic Surgeon office was not notified of the teal wire for treatment and direction, and Resident 6's Physician order [REDACTED]. Resident 6's nursing notes, dated 9/2/11, at 9:00 PM indicates. Resident 6 is to restart on [MEDICATION NAME] for left hip pressure ulcer infection. Resident 6's Fax, dated 9/22/11, at 9:00 PM indicates the following; Resident 6's skin report has a stage 3 pressure ulcer to the left hip. Resident 6's left hip pressure ulcer is pale pink in color. Resident 6's current treatment is Santyl twice a day. WCC/MDS requested to discontinue the Santyl treatment and begin using wound cleanser spray and pack with 1/8 inch nu-gauze twice a day and cover with a 4 by 4 dressing until healed. A box was provided for an answer Yes or No. Resident 6's fax also indicated to stop the whirlpool treatment 2 times a week a box was also provided for the answer Yes or No. (It is important to note the fax was not signed by the Physician or returned to the facility until 9/27/11.) Resident 6's nursing notes, dated 9/28/11, at 2:30 PM indicate. Resident 6's left hip pressure ulcer skin and wound assessment was completed. Resident 6's left hip pressure ulcer wound bed has yellow and tan slough present and tanish drainage on the removed dressing. Resident 6's left hip pressure ulcer is deeper and the granulating tissue is now slough. Resident 6's left hip pressure ulcer periwound with indurating of 4 cm from 12:00 o'clock through 6:00 o'clock. Resident 6's Physician order, dated 9/28/11 indicates the following; 1. [MEDICATION NAME] 250 mg tablet twice a day for 10 days for left hip pressure ulcer infection. 2. Restart Santyl to left hip pressure ulcer. Cleanse with NS (normal saline) and apply Santyl and cover with a 4 by 4 dressing daily. Resident 6's nursing notes, dated 9/28/11, at 9:00 PM indicate. Resident 6 on [MEDICATION NAME] (antibiotic) for ongoing left hip pressure ulcer infection. On 10/4/11 at 8:30 AM Surveyor observed WCC/MDS D do a treatment to Resident 6's pressure ulcers. WCC/MDS D removed the covers from Resident 6. Resident 6's feet were lying directly on the bed with a pillow under Resident 6's knees (Resident 6's heels were not floated). Resident 6 had tan drainage from the left hip pressure ulcer area. WCC/MDS D cleansed the pressure ulcer with wound cleanse applied Santyl and covered the left hip pressure ulcer with a 4 by 4 dressing. Resident 6's Physician order, dated 9/28/11 indicates the following; Restart Santyl to left hip pressure ulcer and Cleanse with (normal saline) NS. Resident 6's physician order [REDACTED]. WCC/MDS D cleansed the wound with wound cleanse instead of normal saline. Resident 6's Treatment administration sheet dated [DATE], indicates the following; 9/28/11 hand written entry indicates Santyl left hip pressure ulcer daily cleanse with wound cleanser, apply Santyl cover with 4 by 4 dressing daily. (Resident 6's telephone Physician order, dated 9/28/11 indicates the following; Restart Santyl to left hip pressure ulcer and cleanse with (normal saline) NS.) On 10/4/11 at 8:50 AM Surveyor observed Resident 6 up in his high back wheelchair leaning to the right side. Resident 6 did not have a pillow on his right side of his wheel chair. At 10:00 AM Resident 6 remained up in his wheel chair in the dining room area. At 11:00 AM Resident 6 remained up in his wheel chair in the dining room area observing the Trivia activity. At 12:05 PM Resident 6 was up in his wheel chair eating lunch in the dining room. At 12:45 PM Resident 6 remained in the dining room area with a male family member. At 1:00 PM Resident 6 remained in his wheel chair in the front lobby area of the facility with the male family member. At 1:10 PM Resident 6 remained in his wheel chair in his room. Surveyor observed Resident 6 up in his wheel chair until 1:20 PM when Resident 6 was placed back in bed. Resident 6 was in his wheelchair for 4 hours and 10 minutes. Resident 6's care plan indicates Resident 6 is not to be in wheel chair for greater then 1 1/2 hours. On 10/4/11 at 4:30 PM Surveyor spoke with WCC/MDS D regarding Resident 6's current left hip pressure ulcer. WCC/MDS D indicated she first observed Resident 6's left hip pressure ulcer on 4/6/11. WCC/MDS D also indicated she does not know and did not look into if Resident 6's left hip pressure ulcers was in house acquired or what date Resident 6's left hip pressure ulcer developed. On 10/5/11 at 8:45 AM Surveyor observed Certified Nursing Assistant (CNA) E remove the covers from Resident 6. Resident 6's feet were lying directly on the bed and a pillow was placed under Resident 6's knees (Resident 6's heels were not floated). On 10/5/11 at 9:15 AM Surveyor observed Resident 6 up in his high back wheelchair in the dining room area. Resident 6 did not have a pillow on his right side of his wheel chair, and resident 6 was leaning to the right side of his wheel chair. At 10:00 AM Resident 6 remained up in his wheel chair in the dining room area. At 10:30 AM Resident 6 remained up in his wheel chair in the dining room area. At 11:00 AM Resident 6 remained up in his wheel chair in the dining room area. At 12:15 PM Resident 6 was up in his wheel chair eating lunch in the dining room. At 12:45 PM Resident 6 remained in the dining room area in his wheel chair. 1:00 PM Resident 6 remained in his wheel chair in the dining room area of the facility with the male family member. At 1:10 PM Resident 6 remained in his wheel chair. Surveyor observed Resident 6 up in his wheel chair until 1:35 PM when Resident 6 was placed back in bed. Resident 6 was in his wheelchair for 4 hours and 20 minutes. Resident 6's care plan indicates Resident 6 is not to be in wheel chair for greater then 1 1/2 hours. Example 2 Resident 5 was admitted to the facility on [DATE] with the following diagnoses; Tardive Dyskinesia, Spinal stenosis, and [MEDICAL CONDITION]. The resident did not have a pressure ulcer on admission. Resident 5's comprehensive Minimum Data Set (MDS), dated [DATE], indicates the following; Resident 5 needs total assist of 1 with bed mobility, and total assist of 2 with transfer. Resident 5 is at risk for developing a pressure ulcer. Resident 5's care plan titled "Risk for skin breakdown", dated 4/29/11, indicates the following; Problem: At Risk for skin breakdown due to immobility, paralysis from the waist down, weakness, and incontinent of bowel. Goal: Resident 5 will have no skin breakdown with protective/preventive skin care Interventions:... 1. Assist and teach Resident 5 to reposition self. Provide 1/2 side rails... 8. Turn and reposition at frequent intervals as necessary. (Resident 5's care plan does not direct the staff of a time frame to turn or reposition. 9. Float heels. 16. Assess nutritional status and make referral to dietician if indicated. 17. a hand written entry, dated, 9/7/11 Air Mattress for bed. Resident 5's Resident care sheet (Certified Nursing Assistant care guidelines kept in Resident 5's room), dated 8/11/11, indicates the following; 1. Special care section: a. Wear leg sleeves, put on before transfers. b. Elevate lower extremities on pillows when in bed. 2. Bed Mobility section: a. Wears heel protectors in bed. c. Turning schedule frequent as needed. A small note hand written in the right corner of the Resident care sheet indicates Resident 5 is turned from side to side and Resident 5 is to be up for meals only. Resident 5's pressure ulcer risk assessment indicates Resident 5 scored a 16 on the risk assessment. A score of 16-27 indicates Resident 5 is at high risk for skin breakdown. Resident 5's nursing note, dated 9/19/11, at 1:30 PM indicates Resident 5's skin report noted a 3.7 centimeter (cm) by 2.5 cm right ischial area dark pink and purple tissue with a blanchable outer border. Resident 5's Physician was notified and requested treatment orders. The physician notification and treatment orders were completed via the facsimile (Fax). On 9/19/11 a hand written facsimile (Fax) was sent to Resident 5's physician office indicating the following; Resident 5 skin report noted a 3.7 centimeter (cm) by 2.5 cm dark pink purple pressure ulcer to Resident 5's right ischial. Resident 5's right ischial blanches outer edges only. Resident 5 has a deep tissue injury due to non blanchable tissue to the center of Resident 5's pressure ulcer. Resident 5 is also noted to have wrinkled skin on the buttocks area... A request to the physician was made to cover the pressure ulcer with a [MEDICATION NAME] dressing 4 by 4 and change the [MEDICATION NAME] dressing every 3 days and as needed for 14 days and review. The physician approved this order on 9/21/11, 2 days after the fax request was sent to the physician. The facility form titled "Weekly Pressure Ulcer Report", dated 9/18/11 through 9/24/11 indicates Resident 5 has a deep tissue pressure ulcer to the right Ischial acquired here (at the facility) measuring 3.7 cm by 2.5 cm. The Weekly Pressure Ulcer Report also indicates Resident 5's is to be turned in bed on her right and left side, and Resident 5 is to be up for meals only. Resident 5's Dietary progress note, dated 9/22/11, indicates Resident 5's present weight is at 121# which has been stable throughout the month. A request has been made that Resident 5's diet order read general diet with ground meat as needed... (It is important to note this is the only dietary note written in the month of September and the last dietary note in Resident 5's medical record.) Resident 5's dietary note does not assess or evaluate the need for dietary changes in skin integrity. (Resident 5 also has a venous status ulcer to her right leg.) Resident 5's Treatment Administration Sheet (TAR), dated 9/28/11, indicates Resident 5's Right ischial pressure ulcer #1 measures 2.5 cm by 2.0 cm dark pink. Resident 5's right ischial pressure ulcer #2 measures 0.5 cm by 0.3 cm by 0.1 cm. Resident 5's #2 right ischial pressure ulcer documented as a Stage 2 half of pressure ulcer wound bed is granulating margins are even and the peri wound is dark pink in color. On 10/4/11 at 8:55 AM Surveyor observed WCC/MDS D remove the covers from Resident 5. Resident 5's feet were lying directly on the bed with a pillow under Resident 5's knees. Resident 5's heels were not floated. Resident 5 did not have heel protectors on her left or right foot. Resident 5's right hip ischial pressure ulcer area was covered with a dressing ([MEDICATION NAME]). WCC/MDS D removed the white dressing and cleansed with pressure area with facility wound cleanser. Resident 5 right ischial pressure ulcer was approximately 1.5 cm by 1.5 cm bright red in color. WCC/MDS D placed a tan colored dressing ([MEDICATION NAME]) over Resident 5's right ischial pressure ulcer. On 10/4/11 at 8:55 AM Surveyor during the pressure ulcer Observation with WCC/MDS D. WCC/MDS D stated to Surveyor Resident 5 needs heel protectors on and WCC/MDS would have to bring her some (heel protectors). WCC/MDS D also stated Resident 5 did not currently have heel protectors available in her room. On 10/4/11 at 2:00 PM Surveyor observed Resident 5 lying in bed on top of bed covered with a small blanket which did not cover Resident 5's feet. Resident 5 did not have heel protectors on her right or left foot. Resident 5's heels were lying directly on the mattress. Resident 5 was lying directly on her back even though the care plan said side-to-side. On 10/5/11 at 10:30 AM Surveyor spoke with Director of Nursing (DON) B and requested the manufacturer recommendations for Resident 5's current air mattress. DON B provided Surveyor a one page document for Resident 6's air mattress which indicated the following: Resident 5's air mattress is an Aero Pulse tier 1. Resident 5's air mattress is to be used on pressure ulcer through stage 1. DON B reviewed the manufacturer recommendation with Surveyor . DON B stated the mattress is to be used for a pressure ulcer stage 1 or less, thus inappropriate for Resident 5 as she currently has stage 2 pressure ulcers. On 10/5/11 at 7:30 PM Surveyor spoke with WCC/MDS D regarding Resident 5's treatment to the right ischial pressure ulcer. WCC/MDS D stated Resident 5 was to have a [MEDICATION NAME] on the right ischial area. WCC/MDS D also stated resident 5 did have the incorrect treatment on when she did the dressing change on 10/4/11 that Surveyor had observed.

Based on record reviews, review of a facility investigation, and interviews, the facility did not ensure that 1 of 11 residents (#8) was free of a significant medication error. On 7/9/10, Resident #8 was given [MEDICATION NAME] sulfate 200mg, instead of [MEDICATION NAME] sulfate 10mg, which had been ordered by the physician. This error occurred because the physician's orders [REDACTED]. Registered Nurse (RN)-C poured the [MEDICATION NAME] sulfate and gave the medication to Hospice RN-E to give to Resident #8. This was the first time Resident #8 had received [MEDICATION NAME] sulfate. Resident #8 was very drowsy, but arousable until approximately 6:00 p.m., when he became non-responsive. Resident #8 was found breathless and pulseless at 10:05 p.m. The administration of 20 times the ordered amount of [MEDICATION NAME] solution to Resident #8 created a situation of immediate jeopardy. The immediate jeopardy began on 7/9/10. The facility was notified of the immediate jeopardy on 8/13/10. It was determined the facility removed the immediate jeopardy on 8/13/10. The deficient practice continues at a scope/severity level of a D (potential for harm that is not immediate jeopardy/isolated) because the facility needs to complete staff training and evaluate the effectiveness of the training. Findings include: Surveyor # reviewed Resident #8's record on 8/11-8/13/10. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8 was receiving Hospice services when the following occurred. On 5/13/10, the facility received a Prescription Authorization form from the hospice agency, which contained a signed order for [MEDICATION NAME] sulfate. The order specified [MEDICATION NAME] sulfate (MS) oral concentrate 20 milligrams(mg)/milliliter(ml), with instructions to give 10mg p.o.(orally)/sl (sublingual - under the tongue) every 2 hours as needed. May repeat in 30 minutes if ineffective for dyspnea/pain. LPN-H correctly transcribed the order onto the May Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (10mg = 0.5ml.) The June 2010 physician's orders [REDACTED]. "[MEDICATION NAME] 20mg/ml, 1 tsp 10ml p.o. under tongue as needed, may repeat in 30 minutes if ineffective for pain/dyspnea. The June 2010, MAR indicated [REDACTED]. The July 2010, physician's orders [REDACTED]. A review of the May - July 2010 MAR's revealed the [MEDICATION NAME] sulfate was not used until 7/9/10. Surveyor # spoke with LPN-H on 8/12/10 at 2:15 p.m., regarding the transcription error, which occurred in May 2010. LPN-H stated the facility changed pharmacies in late May and when the new pharmacy sent the printed orders to verify, she noted the [MEDICATION NAME] sulfate was not on the printed order sheets. LPN-H stated when she wrote the order on the printed sheet, she somehow wrote it incorrectly. The pharmacy then printed the order as LPN-H had written it, on the June and July 2010 MARs. According to documentation in the nurses' notes, during the dayshift of 7/9/10, vital signs were obtained by LPN-H. Resident #8's Blood Pressure (BP) was 140/80, pulse was 96, and respirations were 22. Resident #8 was described as having rattling respirations and non-productive cough. He ate well for both meals. The note written by the dayshift nurse indicated the Hospice RN was going to come in the afternoon. According to Hospice progress notes dated 7/9/10, when Hospice RN-E came to the facility the resident was in his recliner sleeping. He aroused when approached by nurse. Hospice RN-E described Resident #8 as being warm, his face was flushed, and his skin was clammy. Resident #8's pulse was 105 and irregular, respirations 36, and 02 SAT 91% per oximyzer. Resident #8's breathing was labored and he was using accessory muscles and belly breathing. Hospice RN-E advised RN-C to give Resident #8 some Tylenol for fever and [MEDICATION NAME] oral solution for labored breathing. The Hospice progress note stated RN-C gave Resident #8 Tylenol 650 mg, and [MEDICATION NAME] 1 tsp per the facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On facility MAR, order is written as 10ml (1 tsp), and on the bottle states 10mg. The Hospice progress notes of 7/9/10, stated Hospice RN-E remained with the resident monitoring his status until 5:05 p.m. Resident #8 remained comfortable, sleeping in his recliner. At 3:50 p.m., his respirations were 30/min, pulse 72 and regular, pulse ox 93% on 10 liters/min. Respirations were less labored. At 4:20 p.m. and 4:45 p.m., respirations remained 30/min, and he was aroused easily to touch on his forearm. Responded appropriately to questions. Daughter is leaving at this time and will return later. Hospice RN-E updated her supervisor regarding medication error and visit and notified Hospice Nurse-F of the need to visit the facility around 6:30 p.m. to check on the resident's status. RN-C documented the following in the clinical record on 7/9/10. Due to a transcription error, Resident received 10ml of [MEDICATION NAME] concentrate orally at 3:30 p.m. Vital signs (VS) at this time were temperature-99.6, pulse 72, respirations 30, blood pressure (BP) 152/84, and 02 SAT 93% on 10 l/min. Breathing was shallow but rapid. At supper, Resident #8 was asleep, responsive, but returned to sleeping. Would not take pills or swallow liquids. Returned to his room. VS were temperature 98.9, pulse 80, respirations 28, BP 142/74, 02 SATs 96% on 10 l/min. Resident woke and helped RN-C and a Certified Nursing Assistant (CNA) get him get adjusted in his recliner. Surveyor # spoke with Family Member-I on 8/13/10, at 8:50 a.m. Family Member-I stated she was with Resident #8 from 3:40 p.m. until 4:45 p.m. Family Member-I stated that when she left the facility (on 7/9/10) at 4:45 p.m., Resident #8 told her "I'm just so tired, I can't stay awake." Family Member-I stated she returned to the facility at approximately 6:10 p.m., at which time she could not arouse Resident #8. Family Member-I stated Resident #8 remained non-responsive until his death around 10:00 p.m. Hospice RN-F documented in the facility record at 7:30 p.m., on 7/9/10. She wrote that Resident #8 was in the recliner, not able to be aroused. His heart rate was 88, respirations were 24/min. Hospice RN-F stated she had a lengthy discussion with Resident #8's daughter. The Hospice progress note from Hospice RN-F's visit on 7/9/10 was reviewed. The note stated Hospice RN-F had been informed that Resident #8 had received a larger dose of [MEDICATION NAME] than ordered. Hospice RN-F wrote that when she arrived at the facility Resident #8 was completely unresponsive, but had a regular heart rate of 88. Resident #8 was in no apparent discomfort. His breathing was comfortable and within normal limits. Hospice RN-F wrote that the resident's daughter was in the room and upset, asking how much [MEDICATION NAME] the patient received. Hospice RN-F stated that "this was unknown. However, patient is stable at this time..." On 7/9/10 at 8:30 p.m., Licensed Practical Nurse (LPN)-D documented in the nurses' notes that Resident #8 continues to be unresponsive due to sedation of MS ([MEDICATION NAME] sulfate) given earlier. Resident #8's heart rate was 88, respirations 24 and his blood pressure was 102/60. According to nurses' note documentation on 7/9/10, Resident #8 was noted breathless and pulseless at 10:05 p.m. The discharge summary listed the final [DIAGNOSES REDACTED]. The facility investigation revealed the error occurred when RN-C poured the [MEDICATION NAME] sulfate solution according to the instructions on the MAR, which resulted in a 10ml (200mg) dose instead of a 10mg dose. The facility investigation revealed that RN-C poured the [MEDICATION NAME], then gave it to Hospice RN-E, who gave the [MEDICATION NAME] to Resident #8. The facility questioned if RN-C had actually poured 10ml, but the remaining [MEDICATION NAME] in the bottle had been discarded after Resident #8 passed away. The facility had identified several concerns including RN-C pouring the medication and another nurse giving the medication, the error in transcription of the physician's orders [REDACTED]. The Director of Nursing told Surveyor # on 8/11/10, at approximately 3:20 p.m., that he had not done any in-servicing to correct the problems identified because he was waiting until after the state review of the self report, to make sure he had identified all the issues, and would conduct the in-servicing at that time. On 8/13/10 at 9:15 a.m., Surveyor # spoke with RN-C regarding the significant medication error. RN-C stated she was sure she had poured 10 ml of [MEDICATION NAME] sulfate because that was the instructions on the MAR. RN-C stated she was very busy and did not take the time to do the math (for the dosage) right away. The bottle of [MEDICATION NAME] came with a 1 ml dropper to measure the solution. RN-C stated since she needed 10ml, she measured the dosage in the med cup. After she had given the medication to Hospice RN-E, she went to check the original physician's orders [REDACTED]. RN-C stated that she knows that 10ml was not 1 tsp, so she should have known it wasn't right. (The MAR indicated [REDACTED]. RN-C stated she spoke with Physician-G about the incorrect [MEDICATION NAME] dosage. RN-C stated Physician-G suggested [MEDICATION NAME] (to counteract the effect of [MEDICATION NAME]), but the pharmacy was not able to locate any [MEDICATION NAME]. RN-C stated Physician-G had discussed the possibility of calling 911, but Resident #8 was not unresponsive. RN-C stated Resident #8 was never unresponsive to her. On 8/13/10 at 10:20 a.m., Surveyor # spoke with Hospice RN-E, who confirmed that RN-C had poured the [MEDICATION NAME] and gave it to Hospice RN-E, who gave the [MEDICATION NAME] to Resident #8. Hospice RN-E stated RN-C told her it was a teaspoon of [MEDICATION NAME]. Hospice RN-E stated she did not look closely at the amount of [MEDICATION NAME] in the med cup. On 8/13/10 at 9:35 a.m., Surveyor # spoke with LPN-D regarding Resident #8's condition the evening of 7/9/10. LPN-D states she had received report from RN-C that Resident #8 had received too much [MEDICATION NAME] and was being monitored. LPN-D states she checked Resident #8 frequently. LPN-D states Resident #8 was very sleepy, but arousable at suppertime, so she had him taken to the dining room but he was too sleepy to eat or drink. Shaking him did arouse him at that time. According to LPN-D, within about 1/2 hour (approximately 6:00 p.m.), she could no longer get Resident #8 to respond. LPN-D states she told RN-C that Resident #8 "should be shipped out" (sent to the hospital), but RN-C told her the hospital couldn't do any more than they were doing since [MEDICATION NAME] was not available. LPN-D states she left the facility at 8:30 p.m., at which time she again informed RN-C that Resident #8 was not arousable, even with a sternal rub. RN-C told LPN-D that Resident #8 responded to her. LPN-D told Surveyor # that she checked Resident #8 3-4 times between 6:00 p.m. - 8:30 p.m., and he never responded to her during that time. LPN-D stated she thought Resident #8 should have been sent to the hospital, but RN-C didn't agree, and LPN-D didn't know what else she should do. On 8/13/10 at 10:25 a.m., Surveyor # spoke with Hospice RN-F. Hospice RN-F had come to the facility to see Resident #8 the evening of 7/9/10. Hospice RN-F stated she did not know how much [MEDICATION NAME] had been given in error. Hospice RN-F stated that Resident #8 was basically incoherent, sound asleep, and a sternal rub did not awaken him. Hospice RN-F stated she left because there was nothing she could do for Resident #8. On 8/13/10 at 6:00 p.m., Surveyor # spoke with Physician-G. Physician-G states he was informed while he was in the facility making rounds on 7/9/10, that a medication error had occurred with Resident #8, and he had received "10 fold more" [MEDICATION NAME] than what was ordered. Hospice staff stayed with Resident #8 for a while, and Physician-G was informed that Resident #8 was stable. Physician-G stated he had discussed with RN-C what to do. They had discussed calling 911, but since Resident #8 was stable they decided not to call the paramedics. Physician-G stated he also discussed the possibility of giving [MEDICATION NAME], but the pharmacy could not locate any [MEDICATION NAME]. Physician-G stated Resident #8 was stable when he left the nursing home at 4:45 p.m., on 7/9/10. Physician-G states he was informed on Monday, 7/12/10, that Resident #8 had passed away. Administration of 20 times the ordered amount of [MEDICATION NAME] sulfate created a situation of immediate jeopardy. The facility removed the immediate jeopardy on 8/13/10, by which time the facility had: * A policy was written and implemented for action to be taken by nurse when the supervisor disagrees with him/her. An in-service was completed with staff present on 8/13/10, with all other staff members to be in-serviced at the beginning of their respective shifts. This will be monitored by the administrator through interviews with all members of the nursing staff individually prior to the Quality Assurance quarterly meeting. * A policy was written and implemented for auditing/reconciling the MAR indicated [REDACTED]. In-servicing was completed on 8/13/10, with 2 staff members unable to attend who will be in-serviced by 8/17/10. This will be monitored by the Director of Nursing, who will conduct the second audit review and will present findings, after corrections, to the Quality Assurance Committee at the quarterly meeting. *A policy was written and implemented on administering pain medication to a resident in a timely manner when needed, with in-servicing with the Director of Nursing. In-servicing was completed on 8/13/10, with 2 staff members unable to attend who will be in-serviced by 8/17/10. This will be monitored by the Director of Nursing through interviews with residents at the monthly Resident Council Meetings. Any complaints from residents or staff members will be addressed immediately with the nursing staff in general and the nurse involved in the complaint individually. It will be reviewed by the Quality Assurance Committee quarterly. * All nursing staff were in-serviced by the pharmacist on proper destruction and disposal of narcotics and all other medications. In-servicing completed on 8/13/10, with one remaining staff member to be in-serviced on 8/14/10. This will be monitored by the Director of Nursing and the pharmacist each time the destruction occurs by determining that proper destruction procedures were followed using the destruction form. * All nursing staff were in-serviced on the proper procedure for receiving orders for medications in writing, fax or by telephone. In house staff in-serviced on 8/13/10, with one remaining staff member to be in-serviced on 8/14/10. This will be monitored by the Medical Records Manager each month through the current audit protocol. * Memo posted for all nursing staff regarding proper administration of medication: no nurse is to measure, draw-up or otherwise prepare any medication and hand it to a second nurse to administer. Memo was posted 8/13/10. This will be audited by the Director of Nursing who will ensure that the memo is repeated quarterly to each nurse through the pay check memo.

Based on record review and interviews, the facility did not immediately consult with a physician when 1 of 11 residents reviewed (Resident #8) experienced a significant change of condition. On 7/9/10 at 3:30 p.m., Resident #8 received [MEDICATION NAME] sulfate 200mg instead of [MEDICATION NAME] sulfate 10mg. On 7/9/10, the physician was notified of the medication error when it was discovered around 3:40 p.m., however, facility nurses did not notify the physician when the resident became unresponsive at approximately 6:00 p.m. Resident #8 remained unresponsive throughout the evening on 7/9/10 and was found breathless and pulseless at approximately 10:05 p.m. Failure to keep the physician informed of Resident #8's condition created a situation of immediate jeopardy. The immediate jeopardy began on 7/9/10. The facility was notified of the immediate jeopardy on 8/13/10. It was determined the facility removed the immediate jeopardy on 8/13/10. The deficient practice continues at a scope/severity level of a D (potential for harm that is not immediate jeopardy/isolated) because the facility needs to complete staff training and evaluate the effectiveness of the training. Findings include: Surveyor # reviewed Resident #8's record on 8/11-8/13/10. Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #8 was receiving Hospice services when the following incident occurred. According to Hospice notes, on 7/9/10 at approximately 3:35 p.m., Resident #8 was given Tylenol 650mg and [MEDICATION NAME] oral solution 1 tsp. for fever and respiratory difficulty. Resident #8 was "belly breathing and working hard to breath." According to the facility investigation, due to a transcription error, an incorrect dosage of [MEDICATION NAME] sulfate had been written on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The concentration of the [MEDICATION NAME] sulfate was 20 milligrams (mg) in each ml. So instead of receiving [MEDICATION NAME] sulfate 10mg, Resident #8 was given [MEDICATION NAME] sulfate 200mg. This was the first time Resident #8 had received [MEDICATION NAME] sulfate. According to the facility investigation, Registered Nurse(RN)-C had discovered the error shortly after the medication was given, and informed Physician-G. When interviewed by Surveyor # , on 8/13/10 at 9:15 a.m., RN-C stated she had notified Physician-G, who was in the facility making rounds, as soon as she discovered the error. RN-C stated Physician-G wanted Resident #8 to receive [MEDICATION NAME] (a medication to counter the effect of the [MEDICATION NAME]), but the pharmacy was unable to locate any [MEDICATION NAME]. Resident #8 was drowsy but arousable at that time and the decision was made to monitor his status. According to documentation in the nurses' notes, on 7/9/10 at suppertime (approximately 5:30 p.m., Resident #8 was sleepy but responsive. His pulse was 80, respirations 28 and blood pressure (BP) was 142/74. According to an interview with Family Member-I, when she arrived at the facility shortly after 6:00 p.m., Resident #8 was unarousable. Hospice RN-F documented on 7/9/10 at 7:30 p.m., that Resident #8 was in his recliner and was "not able to be aroused." His heart rate was 88, his respirations were 24 per minute. Resident #8 was not observed to be in any distress, "but rather sleeping heavily." When interviewed on 8/13/10 at 10:25 a.m., Hospice RN-F stated when she arrived to see Resident #8 on 7/9/10, he was "basically incoherent, sound asleep, a sternal rub did not awaken him." Hospice RN-F told Surveyor # that she did not know how much [MEDICATION NAME] sulfate Resident #8 had received, but Family Member-I did tell Hospice RN-F that Resident #8 had received an overdose. Hospice RN-F stated she "left because there was nothing I could do." On 7/9/10 at 8:30 p.m., Licensed Practical Nurse (LPN)-D documented in the nurses' notes, that Resident #8 continues to be unresponsive due to sedation of MS ([MEDICATION NAME] sulfate) given earlier. Resident #8's heart rate was 88, respirations 24 and his blood pressure was 102/60. According to nurses' note documentation, Resident #8 was noted breathless and pulseless at 10:05 p.m.on 7/9/10. There was no evidence in the record that the physician had been notified that Resident #8 had become unresponsive and had remained unresponsive on 7/9/10 after 6:00 p.m. On 8/13/10 at 9:35 a.m., Surveyor # spoke with LPN-D regarding Resident #8's condition the evening of 7/9/10. LPN-D states she had received report from RN-C that Resident #8 had received too much [MEDICATION NAME] and was being monitored. LPN-D states she checked Resident #8 frequently. LPN-D states Resident #8 was very sleepy, but arousable at suppertime, so she had him taken to the dining room but he was too sleepy to eat or drink. Shaking him did arouse him at that time. According to LPN-D, within about 1/2 hour (approximately 6:00 p.m.), she could no longer get Resident #8 to respond. LPN-D states she told RN-C that Resident #8 "should be shipped out" (sent to the hospital), but RN-C told her the hospital couldn't do any more than they were doing since [MEDICATION NAME] was not available. LPN-D states she left the facility at 8:30 p.m., at which time she again informed RN-C that Resident #8 was not arousable, even with a sternal rub. RN-C told LPN-D that Resident #8 responded to her. LPN-D told Surveyor # that she checked Resident #8 3-4 times between 6:00 p.m. - 8:30 p.m., and he never responded to her during that time. LPN-D stated she thought Resident #8 should have been sent to the hospital, but RN-C didn't agree, and LPN-D didn't know what else she should do. On 8/13/10 at 6:00 p.m., Surveyor # spoke with Physician-G. Physician-G states he was informed while he was in the facility making rounds on 7/9/10, that a medication error had occurred with Resident #8, and he had received "10 fold more" [MEDICATION NAME] than what was ordered. Hospice staff stayed with Resident #8 for a while, and Physician-G was informed that Resident #8 was stable. Physician-G stated he had discussed with RN-C what to do. They had discussed calling 911, but since Resident #8 was stable they decided not to call the paramedics. Physician-G stated he also discussed the possibility of giving [MEDICATION NAME], but the pharmacy could not locate any [MEDICATION NAME]. Physician-G stated Resident #8 was stable when he left the nursing home at 4:45 p.m., on 7/9/10. Physician-G states he was informed on Monday, 7/12/10, that Resident #8 had passed away. Physician-G states he was not notified that Resident #8 had become unresponsive, and he would have expected nursing staff to notify him of that change in condition. Failure to immediately consult with a physician when a resident became unresponsive after having received 20 times the ordered amount of [MEDICATION NAME] sulfate created a situation of immediate jeopardy. The facility removed the jeopardy on 8/13/10, by which time the facility had: * A policy written and implemented for action to be taken by nurse when the supervisor disagrees with him/her. An in-service was completed with staff present on 8/13/10, with all other staff members to be in-serviced at the beginning of their respective shifts. This will be monitored by the administrator through interviews with all members of the nursing staff individually prior to the Quality Assurance quarterly meeting. * Nurses on duty were in-serviced on the significance of proper physician notification concerning change of condition of residents. All other staff members will be in-serviced at the beginning of their respective shifts. In-services will be completed by 8/14/10. This will be monitored by the Minimum Data Set (MDS) Coordinator/Assistant Director of Nursing at the daily morning meetings to insure physicians have been properly notified of every change of condition. During the monthly chart audit, the auditors will specifically note physician notification of change of condition. If this has not been done in a timely manner, the nurse(s) involved will be called in for review of the incident.

Based on record reviews and interviews, the facility did not have procedures to assure the accurate administration of all drugs and biologicals to meet the needs of 1 of 11 residents (#8) reviewed. On 7/9/10, Resident #8 was given morphine sulfate 200mg, instead of morphine sulfate 10mg, which had been ordered by the physician. This error occurred when the physician's orders [REDACTED].#8. This was the first time Resident #8 had received morphine sulfate. On 7/9/10, Resident #8 was very drowsy, but arousable until approximately 6:00 p.m., when he became non-responsive. On 7/9/10, Resident #8 was found breathless and pulseless at 10:05 p.m. Findings include: The facility had general policies and procedures for medication administration. The Procedure for Administering Medications In Cart (not dated), instructs nurses on the process of checking the medication for the correct resident, route and dosage. The policy includes instructions for taking the medication to the resident and initialing the medication on the med sheet. The procedure also addresses Storage in Medication Cart and Record Keeping. Nurses are instructed to review and update medication records monthly for all residents. Surveyor # reviewed Resident #8's record on 8/11-8/13/10. According to documentation in the clinical record, Resident #8 received an incorrect dosage of morphine sulfate on 7/9/10, at 3:30 p.m.. He became increasingly drowsy until around 6:00 p.m., after which he could no longer be aroused. Resident #8 was found pulseless/breathless at 10:05p.m. (see details at F333) On 5/13/10, the facility received a Prescription Authorization form from the hospice agency, which contained a signed order for morphine sulfate. The order specified morphine sulfate (MS) oral concentrate 20 milligrams(mg)/milliliter(ml), with instructions to give 10mg p.o.(orally)/sl (sublingual - under the tongue) every 2 hours as needed. May repeat in 30 minutes if ineffective for dyspnea/pain. LPN-H correctly transcribed the order onto the May Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. To deliver morphine sulfate 10mg, nurses would need to administer 0.5ml of the morphine sulfate oral concentrate 20mg/ml. A review of the June 2010 physician's orders [REDACTED]. "Morphine Sulfate 20mg/ml, 1 tsp 10ml p.o. under tongue as needed, may repeat in 30 minutes if ineffective for pain/dyspnea. The June 2010, MAR indicated [REDACTED]. The July 2010, physician's orders [REDACTED]. Surveyor # spoke with LPN-H on 8/12/10 at 2:15 p.m. Surveyor # spoke with LPN-H regarding the transcription error which occurred in May 2010. LPN-H stated the facility changed pharmacies in late May and when the new pharmacy sent the printed orders to verify, she noted the morphine sulfate was not on the printed order sheets. LPN-H stated when she wrote the order on the printed sheet, she somehow wrote it incorrectly. The pharmacy then printed the order as LPN-H had written it, on the June and July 2010, MARs. Surveyor # asked LPN-H what the facility protocol was for reconciling physician's orders [REDACTED].[REDACTED]. LPN-H stated that even after the morphine was written incorrectly on the June 2010 MAR, she should have caught the error when the July MAR's were verified. LPN-H stated that there were many changes to the MAR's and physician orders [REDACTED]. LPN-H also stated that she is often interrupted when trying to reconcile MARs. A review of the facility investigation revealed that on 7/9/10, a Hospice nurse asked RN-C to administer the morphine to Resident #8 for breathing difficulties. RN-C told the Hospice nurse that she did not have time to give the morphine right away. The Hospice nurse said she could give the morphine to Resident #8. The facility investigation indicated RN-C poured 10ml of the morphine solution according to the order as it was transcribed. RN-C gave the morphine to Hospice RN-E who gave the morphine to Resident #8. On 8/13/10 at 9:15 a.m., Surveyor # spoke with RN-C regarding the medication error. RN-C stated she was sure she had poured 10 ml of morphine sulfate because that was the instructions on the MAR. RN-C stated she was very busy and did not take the time to do the math (for the dosage) right away. The bottle of morphine came with a 1 ml dropper to measure the solution. RN-C stated since she needed 10ml, she measured the dosage in the med cup. She went to check the original physician's orders [REDACTED]. RN-C stated that she knows that 10ml was not 1 tsp, so she should have known it wasn't right. (The MAR indicated [REDACTED]= 1 tsp.). On 8/13/10 at 10:20 a.m., Surveyor # spoke with Hospice RN-E, who confirmed that RN-C had poured the morphine and gave it to Hospice RN-E, who gave the morphine to Resident #8. Hospice RN-E stated RN-C told her it was a teaspoon of morphine. Hospice RN-E stated she did not look closely at the amount of morphine in the med cup. On 8/11/10 at 3:30 p.m., the Director of Nursing indicated that nurses should not administer any medication they have not prepared.