Every finding on record at Taos Healthcare

Based on observations, record reviews, and interviews; the facility failed to ensure medication error rate did not exceed five percent for 3 (R #16, R#26, and R #61) of 3 (R #16, R#26, and R #61) residents. The medication error rate was 11.54% from staff administering 26 medications with 3 errors. This deficient practice is likely to result in medications continuing to be administered incorrectly, increasing the risk for adverse outcomes and potential harm.The findings are:A. On 01/12/26 at 4:03 PM, during observation of medication administration, observed RN Registered Nurse (RN) #1 crush divalproex sodium (Depakote; an anticonvulsant) 500 milligrams (mg) delayed release for R #26.B. Record review of R #26 divalproex sodium 500mg delayed release medication package label does not state do not crushC. On 01/12/26 at 4:03 PM, during an interview with RN #1, she stated there is no warning on divalproex sodium label, and no indication she is unable to crush this medication.D. Record review of R #26 medication order stated Depakote Oral Tablet Delayed Release 500 MG give 1 tablet by mouth two times a day for bipolar. No notation stating to not crush medicationE. Record review of R #26, provider order shows to crush oral medications if indicated and to mix with applesauce. No order present regarding medical need to crush divalproex sodium.F. On 01/12/26 at 4:18PM, during observation of medication administration, RN #1 administering medications for R #61, Symbicort aerosol 160-4.5 micrograms (mcg)/per actuation/puff (act) inhaler (budesonide [a bronchodilator]/formoterol [a steroid]; inhaled medication to expand lungs and airway) not administered.G. On 01/12/26 at 4:18PM, during an interview with RN #1, she stated the medication is not available, and is not present in Rx Now machine (a device for storing medications) as an emergency supply. RN #1 stated she spoke with pharmacy regarding inhaler for R #61, currently awaiting delivery of medication.H. Record review on 01/12/26 at 4:25 PM, R #61 medication administration shows a total of six missed doses of Symbicort Aerosol 160-4.5 mcg/act inhaler. Missing doses are as follows;01/10/26 evening dose missed01/11/26 and 01/12/26 missed doses for morning and evening01/13/26 missed morning doseI. On 01/13/26 at 8:54AM during an observation of medication administration, observed RN #2 administered medication for R #16. Observed RN #2 crush phenytoin sodium (anticonvulsant medication to control seizures) extended-release oral capsule for administration.J. Record review of R #16 physician order dated 08/15/24 stated May crush PO medication and/or open capsules if indicated and mix with applesauce. No order present stating medical need to crush phenytoin sodium.K. Record review of R #16 physician order dated 07/13/25 revealed phenytoin sodium extended oral capsule 100mg order does not indicate any information regarding acceptability of crushing medication.L. Record review on 01/13/26 at 9:00 AM of R #16 physician order dated 07/13/25 revealed phenytoin sodium medication package label states do not crush.M. On 01/13/26 at 1:37 PM, during an interview with the Director of Nursing (DON), she stated it is her expectation staff do not crush extended/delayed release or enteric (barrier on oral medications to prevent dissolving in the acidic environment of stomach, delaying release until reaching higher pH of small intestine) coated medications. DON further stated it is the policy to not crush extended release even if it is not listed on the medication label, unless there is an order stating it would be medically necessary to crush extended release medications, such as inability to swallow, if no order present medication should not be crushed. DON stated the expectation she has for staff regarding missed medications is to take as soon as possible. If multiple days are present without the medication she is to be notified. DON stated once notified she would call pharmacy and provider to have medication or alternate delivered. DON stated there is an emergency kit for one time usage, and if medication is not present there to call pharmacy immediately as there is an agreement between their supplier for local pharmacy to obtain medication if needed quickly. DON confirmed the process was not followed for R #61's missing Symbicort Aerosol 160-4.5 mcg/act inhaler and acknowledged missed doses of medication.

Based on observations, record reviews, and interviews, the facility failed to ensure a safe, clean, and homelike environment when staff failed to:- Ensure residents consistently had access to hot water.- Maintain the dining room in a homelike manner.- Maintain resident rooms and restrooms in good repair. These failures had the potential to affect all residents who utilize the dining room and all residents in eight sampled resident rooms. If the facility does not ensure resident rooms and common areas are clean, free from pests, and maintained in good repair, then residents are at risk of decreased quality of life, pest infestation, injury due to unsafe environmental conditions, and infections due to hot water not being available. The findings are:Water TemperaturesA. On 01/11/26 at 12:26 pm during an observation in the kitchen revealed the last date water temperatures were logged was 01/07/26.B. On 01/12/2026 at 1:14 pm during an interview R #60 resident stated he had been trying to get a shower done but there was no hot water. He was informed the hot water was turned on Stated been trying to get a shower all day and night and water was cold. R #60 stated the issues with not having hot water have been going on for about 7 months and there was no hot water during Christmas. He stated he was informed that staff are turning the hot water off at night and turning back on during the day. He further stated that some elderly residents are not being showered for weeks because their showers are scheduled to be done at night. He stated he likes to shower at night, but it has been too cold, and the water doesn't heat up. He stated the facility staff told him they were going to get a new boiler because the current one always trips and shuts off.C. On 01/13/26 at 1:39 pm during an interview, R #107 stated the issues with not having hot water available have been going on for about six months. She stated there is no hot water at night so residents who are scheduled for night showers are either not receiving showers or recieving cold showers. She stated staff has advised residents to request the kitchen to boil hot water for them to wash up with. D. On 01/13/2026 at 5:15 pm during an interview, the Administrator (ADM) stated he thinks the issues with the hot water started over the past weekend. He stated the hot water temperatures should be between 90 and 108 degrees. He stated he thinks the boiler keeps tripping. The ADM further stated it was not acceptable for items to be stored in resident showers.E. On 01/13/2026 at 5:20 pm during an observation of hot water temperature in resident room [ROOM NUMBER] was reading between 80-83 degrees.F. On 01/13/2026 at 5:22 pm during an observation of hot water temperature in resident room [ROOM NUMBER] was reading between 78-80 degrees; and the faucet leaks nonstop.G. On 01/13/2026 at 5:26 pm during an observation of hot water temperature in resident room [ROOM NUMBER] was reading between 72-73 degrees; and the toilet runs nonstop.H. On 01/13/2026 at 5:31 pm during an observation of hot water temperature in resident room [ROOM NUMBER] was reading between 74-75 degrees; there were items stored in the shower.I. On 01/13/2026 at 5:35 pm during an observation of hot water temperature in resident room [ROOM NUMBER] was reading between 80-82 degrees.J. On 01/13/2026 5:39 pm during an observation of hot water temperature in resident room [ROOM NUMBER] was reading at 94 degrees.K. On 01/13/2026 at 5:42 pm during an observation of hot water temperature in resident room [ROOM NUMBER] was reading at 94 degrees.L. On 01/13/2026 5:27 pm during an interview, the Corporate Maintenance Director stated he found out about the hot water issues yesterday when he arrived at the facility. M. On 01/13/26 at 5:56 pm during an observation and interview revealed the hot water temperature for the dishwashing machine was reading at 80 degrees. The Dietary Manager (DM) stated he thinks it should be heating up to 160 degrees. Observation also revealed significant hard water build up on the outer lower part of the machine. He stated he could not find the temperature logs for the dishwashing machine.N. On 01/14/26 at 4:00 pm during an interview the DM stated kitchen staff takes the dishwashing machine water temperatures and then turns them into him (DM), and he updates the log and he had fallen behind on updating the log. He stated the logs should always be current.O. On 01/15/2026 at 10:19 am during an interview, CNA #3 stated residents do complain about there being no hot water for showers. CNA #3 Stated the hot water was out temporarily about a month ago. She further stated; they have to wait for a good while for there to be hot water after the dishwasher has been running. P. On 01/15/2026 at 11:55 during an interview, LPN #1 stated the water system has been giving them issues for a while; she has been told that the boiler has to be reset often.Q. On 01/15/26 at 1:05 pm during an interview, the dietitian stated it was her expectation that all kitchen logs would be up to date. Dining RoomR. On 01/11/26 at 12:42 pm an observation of the main dining room revealed there was a ceiling tile missing above the entrance to the dining room and there was exposed wiring; two ceiling tiles next to the missing tile had brown water spots on them.S. On 01/12/26 at 11:50 am, observation of the main dining room revealed there is a television set mounted on the wall that is connected to a power surge bar; the television power cord and the power surge bar were both hanging unsecured against the wall next to a resident dining table. Residents were observed to be seated at this dining table. There was also a projector screen on the same wall and the power box to it was also hanging unsecured.T. On 01/13/26 at 3:04 pm an observation of the main dining room revealed two ceiling vents located immediately over resident tables were covered with dust build up.Resident Rooms and RestroomsU. On 01/12/2026 - 01/15/26 during observations of resident rooms revealed the following:- 01/12/26 at 11:21 am, room [ROOM NUMBER] the window blinds were broken and the sink in the restroom was slow to drain.- 01/12/26 at 11:28 am, room [ROOM NUMBER] there was a sit-to-stand mechanical lift and a bedside commode stored in the shower.- 01/12/2026 at 1:10 pm, room [ROOM NUMBER] revealed there was a blood-like smear on wall next to bed B; there were no outlet covers on the outlets near the head of beds A and B; and there was a bedside commode stored in the shower.- 01/13/2026 at 5:42 pm, room [ROOM NUMBER], there was an exposed light bulb on the bottom of the wall near the doorway, the housing for the light was missing; the light fixture in the restroom was filled with dead insects.- 01/14/26 at 9:22 am, room [ROOM NUMBER], there was a bedside commode and a wheelchair stored in the shower.- 01/14/26 at 9:30 am, room [ROOM NUMBER], there were random items, including a bedside commode stored in the shower.- 01/14/26 at 9:37 am, room [ROOM NUMBER], there were random items stored in the shower.- 01/14/26 at 9:42 am, room [ROOM NUMBER], there were random items stored in the shower; and there were dead insects in the light fixture.V. On 01/15/2026 at 3:22 pm during an interview, the ADM stated the light fixtures should not be full of dead insects, there should not be an exposed light bulbs and all light fixtures should have covers, there should not be any broken or missing outlet covers, the dirty vents in dining room over resident dining tables should be clean. His expectation is that these concerns would be taken care of by maintenance, and he expects them to respond to repair requests timely.

Based on record review and interview, the facility failed to meet professional standards for 2 (R #'s 9 and 104) of 2 (R #'s 9 and 104) residents by: Allowing R #9 to use and store respiratory medical equipment without physician orders. Not following R #104's care plan to complete weekly skin assessments/checks. If the facility is not adhering to professional standards for quality improvement, the resident is not likely to get the highest quality of care. The findings are:R #9: A. Refer to F0880 for related findings. B. On 01/15/26 at 3:21 pm during an interview with the Regional Nurse Consultant (RNC), she stated R #9's family will bring in outside medical equipment that is not ordered. The RNC confirmed staff should be aware of what medical equipment R #9 possess and ensure there are physician orders for those devices. R #104: C. Record review of R #104's face sheet revealed R #104 was admitted into the facility on [DATE]. D. Record review of R #104's care plan dated 08/25/25 revealed R #104 was at risk for pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) related to impaired mobility and fragile skin. Staff interventions included a licensed nurse to assess R #104's skin at least weekly and report any changes. E. Record review of R #104's weekly skin check page located in the electronic health record (EHR) dated 12/01/25 through 01/15/25 revealed the following: R #104 did not receive a weekly skin assessment from 12/22/25 until 01/11/26 (three consecutive weeks). F. On 01/15/26 at 11:32 am during an interview with Licensed Practical Nurse (LPN) #1, she stated nurses are supposed to complete head to toe assessments every week. G. On 01/15/26 1:06 pm during an interview with the Wound Care Nurse (WCN), she stated R #104's wound are treated weekly by her and the wound clinic. The WCN confirmed the facility nursing staff should be completing R #104's skin assessment weekly and that did not happen. H. On 01/15/26 at 3:25 pm during an interview with the RNC, she confirmed R #104's weekly skin checks should not have been missed.

Based on record review and interviews, the facility failed to complete an annual performance review of Certified Nursing Assistants (CNAs) for 3 (CNAs #4, #6, and #7) of 5 (CNAs #3, #4, #5, #6, and #7) CNAs randomly reviewed. If the facility is not completing a performance review of every CNA at least once every 12 months, then residents are likely to not receive the appropriate care and services, and the CNAs may not meet the needs of all residents. The findings are: A. Record review of the facility staffing list dated 01/12/26 revealed the following: CNA #4 was hired on 10/20/17 and was still working in the facility. CNA #6 was hired on 12/01/21 and was still working in the facility. CNA #7 was hired on 10/05/22 and was still working in the facility. B. Record review of the facility CNA annual performance reviews requested on 01/14/26 revealed CNAs #4, #6, and #7 did not have annual performance reviews completed and/or available for review. C. On 01/15/26 at 1:09 pm during an interview with Registered Nurse (RN) #3, he stated he recently was put in charge of facility CNA training and annual performance reviews. RN #3 also stated each CNA is required to complete an annual performance review. D. On 01/15/26 at 3:50 pm during an interview with the Regional Nurse Consultant (RNC), she confirmed CNAs #4, #6, and #7 did not have annual performance reviews completed and should have.

Based on observation and interviews the facility failed to properly store medical supplies located in the facility medication storage room. This deficient practice is likely to result in expired medical equipment being used for resident care leading to potential infection risk, as sterility is lost over time allowing introduction of bacteria.The findings are:A. On 01/13/26 at 12:36 PM, during an observation of the 400, 500, and 600 halls' medication storage room, observed box of ReliOn Ultra Thin Lancets (small single use needles used to puncture skin to draw blood for capillary blood sugar checks) in drawer related to blood glucose checking equipment, with an expiration date of 10/2023.B. On 01/13/26 at 12:38 PM, during an interview with RN #3, he verified ReliOn Ultra Thin Lancets expired in 2023. RN #3 stated he is unaware of the policy regarding medical supply expiration dates, but stated he thinks it should be thrown outC. On 01/13/26 at 1:37 PM, during an interview with the Director of Nursing (DON), she stated it is her expectation staff does not use any expired products, all expired medications should be disposed of. DON further stated lancets should be thrown away when they are expired, otherwise they can be used for care.

Based on observation, interviews, and record review, the facility failed to ensure residents were served meals consistent with posted menus and food preferences were followed for 5 (R #) of 5 (R #) residents reviewed for dining when: The facility did not change nor follow the posted menus. R #22 did not receive food according to her meal ticket. R #86 was not served food according to preference. This deficient practice is likely to result in residents being unable to make informed meal choices and not receiving meals consistent with their preferences.The findings are:R #22X. Record review of R # 22's face sheet revealed R #22 was admitted to the facility on [DATE] with the diagnosis of chronic respiratory failure with hypoxia (a long-term, progressive condition where the lungs cannot adequately transfer oxygen into the bloodstream, resulting in consistently low blood oxygen levels).X. Record review of R #22's Physician Orders revealed order, dated 12/31/25, for heart health diet (limited sodium, saturated fats, trans fats, and added sugars), regular diet texture.X. On 01/12/26 at 12:00pm, during an observation of lunch, R #22'd lunch ticket revealed request for a salad in the additional notes. Further observation revealed R #22 did not have a salad with her meal.X. On 01/12/26 at 12:02pm, during an interview, R #22 stated she did not receive a salad with her lunch. R #22 stated she asked kitchen staff about her missing salad and was told they did not have a salad available for her. R #22 confirmed sje wanted a salad with her lunch.X. On 01/12/26 at 12:23pm, during an interview, Dietary Aide #1 (DA #1) stated R #22 did not receive a salad because the kitchen did not have a salad readily prepared for her.X. On 01/12/26 at 12:35pm, during an interview, the Registered Dietician (RD) stated it was her expectation the kitchen staff would have prepared and given salad to R #22 when it was requested. X. On 01/12/26 at 1:10pm, during an interview, the Dietary Manager (DM) stated it was his expectation the kitchen staff would have had a salad prepared for R #22. R #86X. Record review of R #86's face sheet revealed R #86 was admitted to the facility on [DATE] with a diagnosis of muscle wasting and atrophy (the loss of muscle tissue, resulting in reduced size, strength, and function).X. Record review of R #86's Food and Nutrition Assessment, dated 12/30/25, revealed R #86 had no known food allergies and was on a regular diet.X. On 01/12/26 at 12:04pm, during an observation of lunch, R #86's lunch ticket revealed R #86 was to be served a pork sandwich on a bun, potato salad, coleslaw, and ice cream. Further observation revealed R #86 was served mashed potatoes in place of potato salad.X. On 01/12/26 at 12:05pm, during an interview, R #86 stated items listed on food menus were often inconsistent with what was served. R #86 stated she would have preferred the potato salad shown on the menu but received mashed potatoes instead. X. On 01/15/26 at 4:08pm, during an interview with the Regional Nurse Consultant (RNC), she confirmed menus should have been updated and residents should have been served what was on the menu.

Based on observation and interviews, the facility failed to ensure food was stored, handled, and monitored under sanitary conditions when they failed to:Ensure food items were properly stored and protected in a manner to prevent cross contamination and outdated use.Ensure required dish machine, refrigerator, and freezer temperature daily logs were up to date.Ensure staff responsible for food safety were knowledgeable of safe food temperatures.This deficient practice could likely affect all 94 residents identified on the resident census list provided by the Administrator on 01/11/26. If food was not stored, handled, and monitored under sanitary conditions then residents are at an increased risk of contracting food born illness. The findings are:Food Storage A. On 01/11/26 at 12:26pm, an observation of the facility's kitchen revealed the refrigerator contained the following:A gallon of [NAME] Golden Italian Dressing expired 11/11/25.Two gallons of Ready Set Serve Lime Juice expired 09/29/25.A 46 fluid ounce box of Readycare Thickened Apple Juice expired 12/06/25.B. On 01/11/26 at 12:28pm, an observation of the facility's kitchen revealed the large walk-in refrigerator contained the following:Four 34-ounce containers of Dannon Low Fat Plain Yogurt expired 01/10/26.An opened package of ground meat exposed to the air.10 broken and empty eggshells stored in the same container as unbroken, unused eggs.C. On 01/11/26 at 12:30pm, an observation of the facility's kitchen revealed dry storage room contained an opened package of Nilla Wafers exposed to the air.D. On 01/14/26 at 3:50pm, an observation of the facility's kitchen revealed the large walk-in refrigerator contained six gallons of Ready Set Serve Lime Juice expired 09/24/25.Temperature LogsE. On 01/11/26 at 12:35pm, an observation of the facility's kitchen revealed PPM (Parts Per Million) dish machine maintenance, kitchen refrigerator, kitchen walk-in refrigerator, and kitchen freezer daily logs were not up to date, with last entry entered on 01/07/26.F. On 01/14/26 at 3:55pm, during an interview, the Dietary Manager (DM) stated no foods in the kitchen should be expired. DM stated it was his expectation foods would be stored properly and not exposed to air. DM stated kitchen staff gave him entries to update kitchen temperature logs and he had fallen behind in updating logs. DM stated logs should be up to date. DM stated it is the responsibility of all kitchen staff to ensure foods are properly stored, not expired, and logs are up to date. DM stated possible hazard was residents could get sick.Staff Knowledge Related to Food SafetyG. On 01/14/26 at 4:00pm, during observation and interview, dietary manager took food temperatures of items prepared for resident service and demonstrated uncertainty regarding acceptable food temperatures. Dietary manager stated he was unsure whether the temperatures obtained were safe.H. On 01/15/26 at 1:05pm, during an interview, the Registered Dietician (RD) stated it was her expectation the DM would know what the safe food temperatures were. Dietician stated it was her expectation all kitchen logs would be up to date. RD stated this was overall the responsibility of the DM and herself.

Based on observation, and interviews the facility failed to maintain a safe and sanitary environment for 2 (R #'s 9 and 16) of 2 (R #'s 9 and 16) residents reviewed, when:R #9's respiratory spirometer (an instrument for measuring the air capacity of the lungs) and nebulizer (a medical device that delivers medication in the form of a fine mist directly into the lungs) was not stored appropriately to maintain cleanliness. The facility failed to administer a new medication for R #16 after a medication was removed from packaging which fell on top of medication cart and was placed back into medication cup by nurse. This deficient practice is likely to result in the transmission of infectious agents to the residents.The findings are: R #9: A. Record review of R #9's face sheet revealed R #9 was admitted into the facility on [DATE]. B. Record review of R #9's care plan dated 06/30/25 revealed R #9 requires oxygen (O2) use due to Chronic Obstructive Pulmonary Disease (COPD; lung disease). C. On 01/12/26 at 2:51 pm during an interview and observation of R #9, he stated he has two spirometers that he uses as well as a nebulizer for his COPD. One nebulizer and one spirometer were present on R #9's bed and not stored in a secure bag to maintain cleanliness. One other spirometer was observed to be stored on a windowsill and not stored in a secured bag to maintain cleanliness. D. On 01/12/26 at 2:53 pm during an interview with Registered Nurse (RN) #1, she confirmed R #9's two spirometers, and one nebulizer was not stored appropriately. RN #1 stated R #9's respiratory equipment should be stored in bags. E. On 01/15/26 at 1:56 pm during an interview with the Infection Preventionist (IP), she stated R #9's respiratory equipment should be labeled, dated, and stored in a bag to maintain cleanliness. R #16: F. On 01/13/26 at 8:54 AM during an observation of medication administration for R #16, observed Registered Nurse (RN) #2 preparing glucosamine (medication to assist in pain relief for osteoarthritis [chronic degeneration of the joint cartilage]) 500 mg (milligram) oral tablet for administration, removed pill from bubble packaging. Upon removal, pill missed medication cup and landed on top of medication cart. Observed RN #2 pick pill up without gloves and place medication into medication cup with other medications. G. On 01/13/26 at 8:55 AM during an interview with RN #2, she stated protocol would indicate that she should throw the pill that was on top of the medication cart away and remove a new one from the bubble package. RN #2 stated she was unsure if she had picked the medication up and placed it into the medication cup. H. On 01/13/26 at 1:37 PM during an interview with Director of Nursing (DON), DON stated regarding infection control, the expectation is for staff to perform hand hygiene between residents, and not to use same cups and supplies for multiple residents. DON also stated if a pill lands on top of the medication carts the expectation is the pill is not used. The pill is to be disposed of, and a new pill is to be removed for administration.

Based on record review and interview, the facility failed to maintain documentation related to staff COVID-19 (an acute respiratory infection caused by the SARS-CoV-2 virus) vaccinations that included staff were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine, staff were offered the COVID-19 vaccine or information on obtaining a COVID-19 vaccine, and the COVID-19 vaccine status of staff and related information was available for all staff that work in the facility. This deficient practice could likely lead to residents contracting respiratory infections and could result in the spread of infection to other residents.The findings are: A. Record review of the facility infection control documentation/vaccinations reviewed on 01/15/25 revealed facility staff vaccination lists were not available for review. B. On 01/15/26 at 1:47 pm during an interview with the Assistant Director of Nursing (ADON) #1/Infection Preventionist (IP), she stated she does not have the facility staff COVID-19 vaccinations status list, and she does not provide education to staff regarding the COVID-19 vaccine.

Based on the interview and record review, the facility failed to ensure that grievances were consistently tracked, resolved, and communicated back to residents. If the facility is not responding to resident concerns, then residents may feel unimportant and this may impact their mental health as well as their physical health if residents are not receiving the appropriate meals and receiving regular showers. The findings are: A. On 01/13/2026 at 1:39 pm during a resident council meeting, the following issues were discussed: - R #107 stated residents are not being notified of how or when a grievance they have filed has been resolved. She stated grievances get turned in and they are never followed up on. She stated some of the grievances that have been filed that are waiting to be resolved are:1. Communication with kitchen staff is an issue because all kitchen staff are Spanish speaking only and they are not following resident tickets. No one from dietary attends their resident council meetings even though they have invited the dietary manager. 2. Residents have not been getting to their appointments, not sure if it's because transport department is low staffed. 3. Laundry is not being returned.4. Consistently no hot water available to residents for at least the past six months. - R #62 stated she is not getting showers because there is no hot water.- R #107 stated there is no official grievance official and she believes this is why residents are not getting a response about any resolutions.B. On 01/15/2026 at 3:00 pm during an interview, the Regional Nurse Consultant (RNC) stated the Social Services Director (SSD) or the Administrator are responsible to follow up on grievances and their process is to notify residents of grievance outcomes in person. She stated the SSD is the grievance official and it is the facility's expectation that all grievances be addressed and resolved within five working days.

Based on record review and interviews, the facility failed to ensure psychotropic medication (medication used to treat mental health conditions) consent forms were signed by the resident or resident representative prior to medication administration for 3 (R #'s 3, 6, and 8) of 3 (R #'s 3, 6, and 8) residents reviewed for unnecessary psychotropic drugs. This deficient practice is likely to put residents at an increased risk for undesirable side effects (including but not limited to; increased thoughts of suicide, insomnia, fatigue, sexual dysfunction) associated with the use of these medications.The findings are:R #3: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's physician orders dated October and November 2025 revealed the following: 10/08/25: Buspirone HCL (anti-anxiety medication), give 10 mg (milligrams) by mouth three times a day for anxiety. Order was discontinued on 11/04/25. 11/04/25: Buspirone HCL, give 15 mg by mouth three times a day for anxiety. Order was discontinued on 11/11/25. 11/11/25: Buspirone HCL, give 10 mg by mouth three times a day for anxiety. Order was discontinued on 11/16/25. 11/16/25: Buspirone HCL, give 15 mg by mouth three times a day for anxiety. Order was discontinued on 11/24/25. 11/24/25: Buspirone HCL, give 10 mg by mouth three times a day for anxiety. Order was discontinued on 01/02/26. C. Record review of R #3's pharmacist recommendations dated 11/05/25 revealed R #3 was prescribed the psychotropic medication Buspirone for anxiety. Pharmacist recommendation stated, Informed consent should be obtained at admission, prior to initiation of a psychotropic, or prior to increasing a dose. A consent form could not be found in in this resident's [R #3] record. The Pharmacist recommendation indicated a psychotropic medication consent form should be present in R #3's electronic health record (EHR).D. Record review of R #3's psychotropic medication consent form dated 01/12/26 revealed the consent form was for Buspirone with the order date of 11/05/25. Date and time of consent was documented as being obtained on 11/05/25 at 12:00 am. This form was created and signed on 01/12/26 (after the initial medication start date). E. On 01/15/26 at 11:32 am during an interview with Licensed Practical Nurse (LPN) #1, she stated the facility nurses will obtain a psychotropic medication order from a provider, but the Assistant Director of Nursing (ADON) #1 is responsible for completing the psychotropic medication consent form prior to medication administration. F. On 01/15/26 at 1:54 pm during an interview with the ADON #1, she confirmed R #3's psychotropic consent form for Buspirone use was not completed prior to medication administration and should have been. G. On 01/15/26 at 3:06 pm during an interview with the Regional Nurse Consultant (RNC), she confirmed R #3's psychotropic consent form for Buspirone use was not completed prior to medication administration and should have been. R #6: H. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE]. I. Record review of R #6's physician orders dated June 2025 revealed the following: 06/03/25: Clonidine HCL (used for anti-anxiety) 0.1 mg, give one tablet by mouth two times a day for anxiety. Order was discontinued on 06/06/25. 06/05/25: Clonidine HCL 0.1 mg, give one tablet by mouth every 12 hours as needed for anxiety. Order was discontinued on 08/07/25. 06/25/25: Ativan (Lorazepam; anti-anxiety medication) 0.5 mg, give one tablet by mouth every six hours as needed for 14 days. J. Record review of R #6's physician orders dated August 2025 revealed the following: 08/07/25: Hydroxyzine HCL (used for anti-anxiety) 25 mg, give one tablet by mouth at bedtime for anxiety. K. Record review of R #6's pharmacist recommendations dated 08/14/25 revealed R #6 was prescribed the psychotropic medications Lorazepam, Hydroxyzine, and Clonidine for anxiety. Pharmacist recommendation stated, Informed consent should be obtained at admission, prior to initiation of a psychotropic, or prior to increasing a dose. A consent form could not be found in in this resident's [R #6] record. The Pharmacist recommendation indicated a psychotropic medication consent form should be present in R #6's EHR.L. Record review of R #6's psychotropic medication consent forms dated 09/10/25 revealed the following: Lorazepam consent form was for the order date of 06/03/25. Date a time consent was documented as being obtained on 06/05/25 at 12:00 am. This form was created and signed on 09/10/25 (after the initial medication start date). Clonidine consent form was for the order date of 06/03/25. Date a time consent was documented as being obtained on 06/09/25 at 12:00 am. This form was created and signed on 09/10/25 (after the initial medication start date). Hydroxyzine consent form was for the order date of 06/03/25. Date a time consent was documented as being obtained on 06/09/25 at 12:00 am. This form was created and signed on 09/10/25 (after the initial medication start date). M. On 01/15/26 at 1:55 pm during an interview with the ADON #1, she confirmed R #6's psychotropic consent form for Lorazepam, Clonidine, and Hydroxyzine use was not completed prior to medication administration and should have been. N. On 01/15/26 at 3:07 pm during an interview with the RNC, she confirmed R #6's psychotropic consent form for Lorazepam, Clonidine, and Hydroxyzine use was not completed prior to medication administration and should have been. R #8: O. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE]. P. Record review of R #8's physician orders dated 11/06/25 revealed R #8 was prescribed Seroquel (Quetiapine, anti-anxiety) 25 mg, give one tablet via PEG-Tube (percutaneous endoscopic gastrostomy tube; a feeding tube inserted directly into the stomach through the abdominal wall to provide nutrition when oral intake is insufficient) three times a day for anxiety. Q. Record review of R #8's pharmacist recommendations dated 12/04/25 revealed R #8 was prescribed the psychotropic medication Quetiapine for anxiety. Pharmacist recommendation stated, Informed consent should be obtained at admission, prior to initiation of a psychotropic, or prior to increasing a dose. A consent form could not be found in in this resident's [R #8] record. The Pharmacist recommendation indicated a psychotropic medication consent form should be present in R #8's EHR.R. Record review of R #8's psychotropic medication consent form dated 01/12/26 revealed the consent form was for Quetiapine with the order date of 11/07/25. Date and time of consent was documented as being obtained on 11/07/25 at 12:00 am. This form was created and signed on 01/12/26 (after the initial medication start date). S. On 01/15/26 at 1:56 pm during an interview with the ADON #1, she confirmed R #8's psychotropic consent form for Quetiapine use was not completed prior to medication administration and should have been. T. On 01/15/26 at 3:08 pm during an interview with the RNC, she confirmed R #8's psychotropic consent form for Quetiapine use was not completed prior to medication administration and should have been.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 (R #25) of 1 (R #25) resident reviewed, when:Facility nursing staff used threatening language via text messages to R #25 while on approved facility leave. A facility nurse inappropriately touched R #25's foot when he returned to the facility after approved facility leave. If the facility performs inappropriate use of text messaging and touching, then residents are at risk for physical injury and psychological harm, including fear or distress related to staff interactions. The findings are: A. Record review of R #25's face sheet revealed R #25 was admitted into the facility on [DATE]. B. Record review of R #25's nursing progress notes dated 12/28/25 revealed the following: 12/28/25 at 3:54 am: R #25 was not in his room, sign out log indicated R #25 signed out of the facility on 12/26/25 at 10:20 am to go home. R #25's cellphone was called, but R #25 did not answer. R #25's wife was called, and she stated she did not pick up R #25 and R #25 was not with her at home. The Administrator (ADM) and the Director of Nursing (DON) were both notified and the police were called. 12/28/25 at 7:31 pm: R #25 returned to the facility without complaints of pain or discomfort.C. On 01/11/26 at 2:56 pm during an interview with R #25, he stated there was a miscommunication regarding his overnight pass in December 2025. R #25 stated he was only out of the facility for one night and that was approved, but the facility though he was out of the facility longer than that. R #25 also stated while he was out of the facility, the DON sent him threatening messages stating he needed to pick up his belongings from the facility because he was being discharged . R #25 confirmed he was confused and he felt threatened by those messages. R #25 also stated when he returned (on 12/28/25), his nurse went into his room and hit his foot while using foul language towards him. R #25 confirmed he felt intimidated by the nurse and the DON, and he reported this to the Assistant Director of Nursing (ADON) #2. D. On 01/15/26 at 12:05 pm during an interview with Registered Nurse (RN #5) she stated R #25 went out on approved out of facility leave (on 12/27/25), but the night shift nurse (on 12/27/25 through 12/28/25) did not know R #25 had left the facility. RN #5 also stated R #25 told her when he returned to the facility, the night shift nurse went into his room and tapped him on the feet. RN #5 stated R #25 told her that he felt like a child after the night shift nurse tapped his feet, and he did not like that treatment from her. E. On 01/15/26 at 1:28 pm during an interview with the ADON #2, he stated R #25 reported to him that the night nurse tapped R #25's foot when he returned to the facility. The ADON #2 confirmed R #25 reported to him that R #25 did not like that treatment by the night shift nurse. The ADON stated he reported R #25's concerns to the DON and Administrator, and the night shift nurse was suspended. F. On 01/15/26 at 1:54 pm during an interview with the ADON #1, she stated she was aware of R #25 stating that when he returned to the facility on [DATE], the night shift nurse used foul language with him and hit his feet. The ADON #1 confirmed this incident was being investigated, but she was not aware of the outcome. G. On 01/15/26 at 3:06 pm during an interview with the Regional Nurse Consultant (RNC), she stated there was a miscommunication between the DON and R #25 when R #25 had approved out of facility leave. The RNC stated R #25 was with his daughter and the DON tried to contact R #25. The RNC also stated due to the DONs concerns regarding R #25 missing, the night shift nurse was relieved that R #25 was back in the facility and was only lecturing R #25 while tapping R #25's foot in a friendly manner. The RNC confirmed she was not made aware of the DONs text messages to R #25 regarding discharge until the survey. The RNC stated the night shift nurse should not have tapped R #25's feet especially since R #25 interpreted that act as abusive. The RNC also confirmed the DONs text messages to R #25 were inappropriate and that was going to be investigated. H. On 01/15/26 at 3:15 pm during an interview with the Regional Administrator (RA), she stated R #25 did not report this to ADON #2 until the beginning of this survey (01/12/26). The RA stated the DON was scared that R #25 was missing when she sent those text messages to him. The RA confirmed the DON did not intend to upset R #25, but R #25 did interpret those messages as a threat. The RA stated this incident is currently being investigated and the findings will be submitted to the State Agency.

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) Level 1 screening was completed accurately for 1 (R#6) of 1(R #6) resident reviewed, when the PASRR level 1 indicated no mental health diagnosis despite admission documentation identifying a diagnosis of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). This deficient practice could result in the facility failing to identify and address residents' mental health needs and ensure appropriate screening and services at admission.The findings are:A. Record review of R # 6's face sheet revealed R #6 was admitted to the facility on [DATE] with the following diagnoses:Unspecified dementia, moderate, with agitation (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).Bipolar disorder, unspecified.B. Record review of R #6's PASRR, completed on 06/03/25, indicated R #6 did not have a diagnosis of a mental illness.C. On 01/13/26, at 2:26 pm, during an interview, the Admissions Coordinator (AC) stated Admissions reviewed PASRRs for residents upon admission. AC stated she and the admissions liaisons were responsible for ensuring the PASRR forms were accurately completed. AC acknowledged R #6's PASRR at admission indicated R #6 had no mental health diagnosis. AC acknowledged R #6 was admitted to facility with a diagnosis of bipolar disorder. AC stated it was her expectation the inaccuracy on R #6's PASRR would have been identified and corrected upon admission.

Based on record review and interview, the facility failed to revise the care plan for 1 (R #11) of 1 (R #11) resident reviewed for oxygen (O2) use. If the facility is not updating the care plan to reflect the residents' current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the residents' needs. The findings are:A. Record review of R #11's face sheet revealed R #11 was admitted into the facility on [DATE]. B. Record review of R #11's physician orders dated 12/16/25 revealed R #11 was prescribed O2 at 2 liters per minute (LPM) via nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). C. Record review of R #11's care plan dated 12/23/25 revealed O2 use was not care planned for R #11. D. On 01/15/26 at 9:56 am during an interview with Certified Nursing Assistant (CNA) #2, he confirmed R #11 wears O2 every day. E. On 01/15/26 at 3:09 pm during an interview with the Regional Nurse Consultant (RNC), she confirmed R #11's care plan should include O2 use, but it does not.

Based on interview and record review, the facility failed to ensure pain management was provided in accordance with professional standards for 1 (R #25) of 3 (R #21, 25 and 60) when staff administered pain medication to a resident when the resident reported pain levels of 2 - 7, which did not meet the physician's ordered parameters of 8 or higher. If staff are not following physicians' orders then residents are at risk of being over medicated and may have inadequate pain control. The findings are:Based on interview and record review, the facility failed to ensure pain management was provided in accordance with professional standards for 1 (R #25) of 3 (R #25, #00 and 00) when staff administered pain medication to a resident when the resident reported pain levels of 00 - 00, which did not meet the physician's ordered parameters of 00 -00. If staff are not following physicians' orders then residents are at risk of being over medicated and may have inadequate pain control. The findings are:A. On 01/12/2026 at 3:09 pm during an interview, R #25 stated that sometimes the facility does not have his pain medication and they have to get it out of the emergency supply. He stated he regularly takes oxycontin (narcotic pain medication) for pain. B. Record review of R #25's physicians' orders revealed the following:- An order dated 12/16/25 for Oxycontin HCl Oral Tablet, 5 milligrams (mg). Give 5 mg by mouth every four hours as needed for pain. Use for severe pain, level 8 or above- An order dated 01/05/26 for Oxycontin HCl Oral Tablet, 5 milligrams (mg). Give 5 mg by mouth every four hours as needed for pain. Use for severe pain, level 8 or above. Pain level scale is as follows:* 0: No pain.* 1: Very mild pain, barely noticeable. * 2: Minor pain. * 3: Noticeable pain but manageable. * 4: Moderate pain. * 5: Moderately strong pain. * 6: Strong pain that interferes with daily activities.* 7: Severe pain, limits normal activities. * 8: Very strong pain. * 9: Intense pain, unable to converse.* 10: Worst pain possible. C. Record review of R #25's Medication Administration Records revealed the following:- 12/01/25 - 12/31/25. Oxycontin was administered on 12/16/25, 12/20/25, and 12/21/25 with the documented pain level of 5; on 12/23/25 with a documented pain level of 6; and on 12/23/25 and 12/30/25 with a documented pain level of 7. - 01/01/26 - 01/31/26. Oxycontin was administered on 01/09/26 with a documented pain level of 2, on 01/07/26 and 01/13/26 with a documented pain level of 3; on 12/05/25 (twice) 12/06/25, 12/08/25 and 12/14/25 with a documented pain level of 5; and on 12/07/25 with a documented pain level of 6. D. On 01/15/26 at 12:12 pm during an interview, RN #4 stated that she was not used the physicians' orders stating a specific pain level; she verified the orders for R #25 were specifically ordered for a pain level greater than 8. She verified the administrations in December and January were all administered with a pain level lower than 8. She stated she would consider the administrations as not following physicians' orders. E. On 01/15/2026 at 3:00 pm during an interview with the Regional Nurse Consultant (RNC) confirmed the physicians' orders had not been followed for oxycontin administration when it was administered for any pain level under 8.

Based on observation, record review, and interviews; the facility failed to acquire medications for 1 (R #61) of 9 (R 35, R #16, R #26, R #58, R #61, R #65, R #67, R #89, and R #103) residents. This deficient practice is likely to result in missed doses of medication continuing, and potentially lead to serious harm, exacerbation of disease process, or other adverse outcomes for residents.The findings are:A. On 01/12/26 at 4:18PM, during an observation of medication administration, Registered Nurse (RN) #1 administering medications for R #61, Symbicort aerosol 160-4.5 mcg (micrograms)/act (per actuation/puff) inhaler (budesonide [a bronchodilator]/formoterol [a steroid]; inhaled medication to expand lungs and airway) not administered.B. On 01/12/26 at 4:18PM during an interview with RN #1, she stated the medication is not available and is not present in Rx Now machine (a device for storing medications) as an emergency supply. RN #1 stated she spoke with pharmacy regarding inhaler for R #61, currently awaiting delivery of medication.C. Record review of R #61 medication administration shows missed doses of the Symbicort Aerosol 160-4.5 mcg/act inhaler as follows:01/10/26 evening dose missed01/11/26 and 01/12/2026 missed doses for morning and evening01/13/2026 missed morning doseD. On 01/13/26 at 1:37 PM during interview with Director of Nursing (DON), she stated the expectation she has for staff regarding missed medications is to take as soon as possible. If multiple days are present without the medication she is to be notified. DON stated once notified she would call pharmacy and provider to have medication or alternate delivered. DON stated there is an emergency kit for one time usage, and if medication is not present there to call pharmacy immediately as there is an agreement between their supplier for local pharmacy to obtain medication if needed quickly. DON confirmed the process was not followed for R #61's missing Symbicort Aerosol 160-4.5 mcg/act inhaler and acknowledged missed doses of medication.

Based on record review and interview, the facility failed to ensure the results of all investigations of allegations of abuse, neglect, and injuries of unknown source were submitted to the State Agency within 5 working days for 1(R #1) of 1(R #1) resident. If the facility is not submitting the five-day follow-up, residents are likely to be at risk of further abuse/neglect. The findings are:A. Record review of the facility's investigations revealed that a 5 day follow up had not been submitted to the state agency. B. On 09/29/25 at 5:21 pm during an interview with the facility's Administrator, he confirmed that a five day follow up had not been submitted to the state agency.

Based on record review and interview, the facility failed to thoroughly investigate allegation of abuse for 1 (R #1) of 1 (R #1) resident reviewed for abuse. If staff do not thoroughly investigate allegations of abuse, then the other residents are at risk of abuse which may cause physical, emotional, and psychological harm. The findings are: A. Record review of R #1's face sheet revealed he was admitted to the facility on [DATE] and discharged to acute care hospital on [DATE] with multiple diagnoses including, but not limited to: -Acute (sudden onset) kidney failure (sudden loss of kidney function) -Hydroureter (swelling of the ureter [duct by which urine passes from the kidney to the bladder] due to urine buildup) -Obstructive (blockage) and reflux (the flow of a fluid through a vessel or valve in the body in a direction opposite to normal) uropathy (blockage in the urinary tract), unspecified -Need for assistance with personal care -Personal history of malignant (tern to describe active cancer cells or tumors) neoplasm (abnormal growth of cell) of prostate (gland located below the bladder and in front of the rectum in males) -Other artificial opening of urinary tract status (an artificial outlet from the urinary tract is an additional opening from the kidneys, ureters or urethra [The urinary system includes your kidneys, ureters, bladder and urethra. This system filters your blood, removing waste and excess water. This waste becomes urine]). B. Record review of R #1's Minimum Data Set (MDS; a collection of assessments of a resident's abilities and care needs) Brief Interview of Mental Status (BIMS; a simple test of mental/memory abilities), dated 06/14/25, revealed a score of 11, moderate cognitive impairment. C. On 09/29/25 at 5:21 pm, interview with the administrator revealed the following: -She confirmed that she is the abuse coordinator for the facility. -She confirmed that she spoke with the grandson (Family Member/FM #1) on 06/14/25 who he reported R #1 had wet blankets and the male nurse who brought the dry blankets had tucked him roughly. The Administrator confirmed that this was the Certified Nursing Assistant (CNA) #1 who was identified by R #1 of rough handling. -She confirmed the identified male nurse was CNA #1 and obtained his written statement, as well as Licensed Practical Nurse (LPN) #1 and LPN #2's written statement since they all work together that shift and was involved in R #1's care. -She stated that she met with R #1 on 06/14/25 in the local acute care hospital and interviewed him about the allegation of abuse, she stated that R #1 thought the incident happened at another acute care hospital. -She stated that after interviewing CNA #1, LPN #1, and LPN #2 on 06/14/25 and concluded that R #1 was referring to the other acute care hospital. The Administrator did not proceed to investigate further. She confirmed that after she spoke with the grandson, stated that R #1 was referring to their facility, not the other acute care hospital. She confirmed that she did not think further investigation was needed. D. On 09/29/25 at 3:17 pm, during an interview, FM #1 stated the following: - R #1 told him about a male staff who came in with a bad attitude and delivered the blankets he requested. As this nurse was tucking R #1 in, the nurse was rough and pulled one of his tubes that made them send R #1 to the local acute care hospital. -He confirmed on 06/14/25 with R #1 that the incident happened at the facility he was staying at and brought it up to the administrator's attention. E. On 10/01/25 at 11:07 am, interview with CNA #1 stated the following: -He is familiar with R #1. -He stated that the first time he checked on R #1, during that shift, was around 7:00 PM and noticed that his chucks (or chux pads, disposable bed pads) was wet, as well as the gauze (a wound dressing) on his left side. He stated he notified LPN #1 and changed his chucks.

Based on record review, observation, and interview, the facility failed to store and serve food under sanitary conditions when staff failed to: 1. Ensure opened food items in the refrigerator, freezer, and dry storage room were dated and labeled. 2. Ensure staff utilized a sanitizing solution when cleaning various food related surfaces. 3. Ensure eggs and cheese were stored in a manner to prevent food borne pathogen growth when not in the refrigerator. 4. Ensure all storage areas are kept clean and free of debris. 5. Ensure kitchen staff wore their face mask appropriately. These deficient practices are likely to affect all 85 residents listed on the resident census list and are likely lead to foodborne illnesses if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 12/05/24 at 8:40 am, an observation of the facility kitchen revealed the following: - Eight eggs and a small package of sliced cheese sat on a cart next to the kitchen stove. The eggs and cheese sat for one hour and were not on ice. The eggs were warm to touch, and the cheese started to change color. - The Dietary Aide cleaned food service areas and counter tops with the same dish cloth. The Dietary Aide did not use a sanitizing solution between wiping the different surfaces. - A tray of glasses with an unidentified orange liquid sat on the top shelf of the refrigerator unlabled and undated. - A bag of cut red onions were in the refrigerator, losing their form, turning liquidy, and were unlabeled and undated. - A bag of round pastries were in the refrigerator and open to air, - A bag of unidentified items were in the refrigerator and open to air. - The dry storage room floor had dirt and debris under the food shelves. - The water wells on the steam table had calcium build-up and food particles. - A tray containing five salads were in the facility refrigerator unlabeled and undated. B. On 11/25/24 at 1:45 pm during interview, Dietary Aide (DA) #2 confirmed there was a bag of unidentified substance in the refrigerator, and it was not dated. He also confirmed there were five tossed salads not dated in kitchen refrigerator. C. On 11/25/24 at 4:40 pm during an interview with the DM, he confirmed all the above findings. He stated staff could not clean the wells in steam table any better. Facemasks D. On 11/25/24 at 1:40 pm during observation, DA #1 wore his mask below his nose on chin while helping prepare food in the facility kitchen, DA #1 stated it should be covering his nose and not on his chin. He confirmed that all staff are required to wear masks at all times while in the facility due to a respiratory virus outbreak in the building. E. On 11/25/24 at 4:40 pm during an interview with the DM, he stated staff should always were face masks appropriately and at all times while in the facility.

46064 Based on record review and interview, the facility failed to give written notice for a room change, including the reason for the change, before the residents were moved for 2 (R #1 and R #3) of 2 (R #1 and R #3) residents. This deficient practice is likely to result in frustration and confusion for residents. The findings are: Findings for R #1: A. Record review of R #1's face sheet, dated 11/25/24, revealed the following: - admitted [DATE]. - Other drug induced secondary Parkinsonism (symptoms that may occur due to the side effects of taking certain medications.) - Dementia, mild, with other behavioral disturbance (a disease that causes loss of memory, language, problem-solving and other thinking abilities.) - Disorganized schizophrenia (a mental disorder characterized by speech, emotional expressions, thoughts, and actions that are disorganized or not in tune with what is expected or appropriate.) - Cognitive communication deficit (difficulty understanding and speaking with other people.) - Other symptoms and signs involving cognitive functions and awareness. B. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 9/17/24, revealed R #1 had a Brief Interview for Mental Status (BIMS; a screening tool used to assess cognition) score of 6, severe cognitive impairment. C. Record review of R #1's electronic medical record (EMR) revealed R #1 was moved from the [NAME] Unit to the [NAME] Unit on 09/27/24. The record did not contain notes to show the facility notified the resident's family. D. On 12/04/24 at 10:16 am during an interview, R #1's daughter stated she was not made aware that R #1 was going to be moved to another unit. She stated she found out he moved when she went to visit him and was unable to locate him in his room. She stated his room on the [NAME] Unit was empty of all personal belongings, and staff told her that he was now residing on the [NAME] Unit. R #1's daughter stated she would have expected the facility to notify her of R #1's move. Findings for R #3: E. On 12/04/24 at 9:50 am during an interview with R #3, she stated she moved rooms, and she was not notified of the room change. R #3 stated she wondered why they moved her when she did not want to be moved. R #3 stated all her clothing and belongings were not move into her new room, and she did not know where her personal belongings were being kept. F. On 12/04/24 at 10:01 during an interview, Certified Nurse Aide (CNA) #3 confirmed R #3 was moved to the [NAME] Unit and prior to the move the resident was on the [NAME] Unit. CNA #3 stated R #3 was moved, because her room was being painted. The CNA stated she was not sure if staff notified R #3 that she was moving to a new room and why. CNA #3 stated R #3's belongings remained in her old room. G. On 12/04/24 at 12:15 pm during an interview with the Director of Nursing (DON), she stated the protocol was to notify housekeeping, dining services, and nurses station when moving residents from one room to another and to document the move in the resident's medical record. The DON stated staff should also notify the resident's family, and that should also be documented in the medical record. The DON was unable to provide any documentation for R #1's or R #3's room change. H. On 12/04/24 at 12:20 pm during an interview with the Administrator, she stated R #3's room change was temporary, because staff were painting her room. The Administrator stated the facility will let the families and the resident know a couple of days in advance that their loved one was going to be moved to another room. The Administrator was unable to provide any documentation as to when staff notified R #1 and R #3 of the room changes or that staff notified the residents' family members.

Based on record review and interview, the following was identified: 1. A resident was found unresponsive and [MEDICATION NAME] ([MEDICATION NAME] is a prescription medicine used for the treatment of [REDACTED]. 2. The facility failed to have readily available emergency/lifesaving medications, such as [MEDICATION NAME] and [MEDICATION NAME] (a hormone used to raised the level of glucose, a type of sugar, in the blood). 3. The facility failed to train nursing staff on how to access these lifesaving/emergency use medications. These deficient practices resulted in Immediate Jeopardy being called on [DATE] at 8:17 pm. The facility Administrator (ADM) and Director of Nursing (DON) were notified at this time. A first plan of removal was received on [DATE] at 7:50 am and was rejected. A second plan of removal was received and accepted on [DATE] at 9:25 am. Implementation of the Plan of Removal was validated onsite. The scope and severity was reduced from Level 4, K to Level 2, E. The Plan of Removal Included: 1. Nurses not having access to [MEDICATION NAME] and [MEDICATION NAME] has the potential to affect all 58 residents. 2. Facility has assessed the availability of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] and [MEDICATION NAME] available always in facility E-kit (RX now (automated medication dispensing system)). 3. The facility will ensure that all nurses will be educated on the proper protocol in obtaining emergency medicine from the E Kit (RX now ). Education began immediately and will be ongoing until all nurses have received education. 4. Facility Director of Nursing will ensure all Nurses demonstrate understanding of proper use of Rx machine . 5. Facility Director of Nursing will monitor and evaluate that all staff are educated semiannually and during new hire orientation to ensure understanding of operation of E-KIT (RX Now) . Based on observation, record review, and interview, the facility failed to have available emergency lifesaving medications for 25 (R #2, 5, 8, 9, 12, 14, 15, 16, 17, 23, 24, 27, 28, 29, 31, 35, 38, 40, 45, 46, 52, 153, 155, 256, and 257) of 25 (R #'s 2, 5, 8, 9, 12, 14, 15, 16, 17, 23, 24, 27, 28, 29, 31, 35, 38, 40, 45, 46, 52, 153, 155, 256, and 257) residents either [DIAGNOSES REDACTED]. 1. Not having [MEDICATION NAME] ordered and available for R #257 when found unconscious likely resulting in a delay of medication administration. 2. Not training nursing staff on how and where to access [MEDICATION NAME] and Glucogon in the event that a resident was to experience a narcotic overdose or Diabetic emergency (dangerously low blood sugar) and become unconscious/unresponsive. This deficient practice could likely result in residents not receiving life saving medication immediately during an emergency in which a delay in administration could likely result in death. The findings are: A. Record review of Physicians Orders for R #s 2, 5, 8, 9, 14, 23, 24, 28, 29, 31, 38, 40, 45, 153, 155, and 256 revealed that these residents have orders for [MEDICATION NAME] (medication used to treat certain medication overdoses). B. Record review of Face Sheets for R #s 12, 15, 16, 17, 24, 27, 28, 29, 31, 35, 40, 45, 46, and 52 revealed that these residents have a [DIAGNOSES REDACTED]. C. Record review of Face sheet for R #257 revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. in which a person has recurrent episodes of depressed mood) [DATE], ALCOHOLIC [MEDICAL CONDITION] (neurological disorder in which peripheral nerves throughout the body malfunction simultaneously as a result of high alcohol intake over a period of time) [DATE]. D. Record review of physician orders [REDACTED]. E. Record review of R #257's progress note dated [DATE] revealed, Incident Note Text: Resident found to be unresponsive by CNA (Certified Nursing Assistant), resident vital signs are T (temperature) 98.6, P (pulse) 53, R (respirations) 10 and labored, b/p (blood pressure) ,[DATE], spO2 (oxygen saturation) 77% (percent) on 6 L (liters), B/G (blood glucose) 81, resident is cyanotic (bluish or grayish discoloration of the skin due to deficient oxygen in the blood), cold and clammy, pupils are pinpoint and fixed, (Name of MD) with orders to transfer to (Name of Local hospital). (Name of local police department) officer in scene to administer one dose of [MEDICATION NAME]. Resident then woke up angry and was transferred to (name of local hospital) with all needed paperwork. F. Record review of physician orders [REDACTED]. Combine all parts provided in the kit. Insert mucosal atomizer tip into one nostril and administer ,[DATE] of the syringe (0.5 ml). If no response, repeat dose after ,[DATE] minutes in other nostril. G. On [DATE] at 6:31 pm during an interview with the DON, she stated, If they (residents) are found unresponsive, I expect the nurses to call a code (to begin CPR), go to the chart to see if they (unresponsive resident) are a DNR (Do Not Resuscitate- a legal order, written or oral depending on country, indicating that a person does not want to receive CPR if that person's heart stops beating) or full-code, do CPR if a full-code, call the physician, and take vitals. They (staff) should check the pulse, check to see if they're (unresponsive resident) breathing, check their (unresponsive resident) blood sugar and follow the [DIAGNOSES REDACTED] (low blood sugar) protocols, which is the Insta Glucose and [MEDICATION NAME]. That's (Insta Glucose and [MEDICATION NAME]) in the RX Now (Pyxis). If it's (resident's Blood Glucose Level) under 60, they (staff) can use the [MEDICATION NAME]. Everybody (residents) has [MEDICATION NAME] orders that is on a narcotic. We did it ([MEDICATION NAME] training) when they (Pharmacy) told us to put everyone on [MEDICATION NAME] after the incident that happened (incident with R #257 on [DATE]). We now have emergency [MEDICATION NAME] from the pharmacy in the RX Now. We're (nursing home) connected to the hospital and EMS (Emergency Medical Services) is almost always over there. PD (Police Department) is at the hospital too, and it will take them a few minutes to get here. DON confirmed the RX Now (Pyxis) is only available to staff at one station, but staff should get [MEDICATION NAME] or [MEDICATION NAME] immediately. DON regarding R #257 also stated, We called (911)because he (R #257) didn't have a [MEDICATION NAME] order. I don't remember how long it took them (local police department) to give him (R #257) [MEDICATION NAME]. Police gave it to him (R #257) because he (R #257) didn't have an order for [REDACTED].>H. On [DATE] at 2:39 pm during an interview with Registered Nurse (RN) #1, he stated if there was an unresponsive resident, he would initiate a danger response. He would also check the resident's ABC's (Airway, Breathing, and Circulation), he would call for assistance, if necessary call 911, and he would perform CPR (Cardiopulmonary Resuscitation). RN #1 also stated he would check the unresponsive residents blood glucose level (BGL). RN #1 stated if a resident is a Diabetic, a glucose order is available and if there is a resident on an Opiate medication, an order for [REDACTED].#1 stated if there is no order for emergency medications, he would review resident record, (name of local hospital), request the on-call physician for that resident, and call the on-call physician for that resident. I. On [DATE] at 2:53 pm during an interview Licensed Practical Nurse (LPN) #2, she stated if there was an unresponsive resident, she would get a Certified Nurse Aide (CNA) to help. LPN #2 stated she would also contact the physician, the 911 dispatch, and then the family. LPN #2 confirmed she would perform CPR on a full-code resident. LPN #2 also confirmed if the resident was Diabetic, she would obtain a BGL (Blood glucose level-) with vitals, and if the resident was on a narcotic, she would administer [MEDICATION NAME] due to the residents having an order for [REDACTED].#2 stated her next step to locate these medications would be to go to the emergency Pyxis, which she has a code to open, but she has never used it. LPN #2 confirmed she was unsure if [MEDICATION NAME] or [MEDICATION NAME] were available in the facility. She further stated that the ADON (Assistant Director of Nursing) has been present anytime there was need to get into the emergency Pyxis and had never accessed it on her own before. J. On [DATE] at 2:59 pm during an interview with Certified Medication Aide (CMA) #4, she confirmed there was no [MEDICATION NAME] or Glucose located in the med cart located on the 200 halls. CMA #4's do not administer emergency/lifesaving medications, a nurse would be the one to assess and administer those (emergency/lifesaving) medications. K. On [DATE] at 3:03 pm during an interview with RN #1, he stated that he did not know where [MEDICATION NAME] and [MEDICATION NAME] were stored. He confirmed that these medications are for emergencies and are probably in the emergency Pyxis. He stated that about a week ago he had informed the ADON that he did not have access to the emergency Pyxis and as of this date ([DATE]) he still did not have access. L. On [DATE] at 3:06 pm during an interview with CMA #3 and RN #1, both searched through the 400 and 500 hall med (medication) cart and could not find [MEDICATION NAME] or Glucose available in the cart. CMA #3 and RN #1 also confirmed [MEDICATION NAME] and Glucose were not present in the med (medication) storage room for that side of the facility. M. On [DATE] at 3:09 pm during an interview with CMA #5, she confirmed there was no [MEDICATION NAME] or Glucose present for the 600-hall med cart. She stated, she would call the nurse to assess the resident and the nurse would administer any needed medications. N. On [DATE] at 4:23 pm during an interview with the DON, she stated emergency medications are stored in the Rx Now by (Name of Pharmacy) (Pyxis) and all the nurses have access to it. O. During observation on [DATE], RN #1 and LPN #1 were the only nurses working the floor during the day shift. P. On [DATE] at 3:34 pm during interview with the Pharmacist #1, she confirmed that [MEDICATION NAME] and [MEDICATION NAME] Kit (glucose) is stored in the RxNow (machine used to dispense emergency and onetime ordered medication) for the facility. Pharmacist #1 stated the RxNow process allows for dispensing an emergency medication or a one time medication ordered by a physician. The process is for the nurse to enter a code specific to the nurse accessing the RxNow. The nurse would then enter the medication ordered to dispense from RxNow. Pharmacist #1 confirmed that she had offered the DON a list of medications available in the Pyxis but the DON replied It would be a waste of paper

Based on observation, record review, and interview, the facility failed to meet professional standards of quality for 4 (R#6, #9, #14 and #52) of 4 (R#6, #9, #14 and #52) residents by: 1. Not administering oxygen (O2) in accordance with the physician's orders [REDACTED]. 2. Not administering medication in accordance with the physician's orders [REDACTED]. If the facility is not administering oxygen and pain medications as ordered, the resident is likely to not receive the therapeutic benefits as needed, actual harm occurred when R#6 failed to receive their pain medication, resulting in unmanaged pain. The findings are: Findings for O2: A. Record review of R #52's physician orders [REDACTED]. May titrate to keep Sats (saturations- the fraction of oxygen-saturated hemoglobin relative to total hemoglobin in the blood) > (greater than) 88% (percent). DX (diagnosis) [MEDICAL CONDITION] ([MEDICAL CONDITION]- a group of lung diseases that block airflow and make it difficult to breathe/ Asthma. B. Record review of R #52's care plan dated 03/09/21 revealed, Focus: (Name of R #52) has episode of SOB (Shortness of Breath) and poor endurance. O2 ordered to keep O2 sats above 88% RA (Room Air) as evident. Goal: (Name of R #52) will be able to perform her daily routines without SOB. Interventions: Place resident on room concentrator (a device that concentrates the oxygen from a gas supply by selectively removing nitrogen to supply an oxygen-[MEDICATION NAME] product gas stream) when in room and portable (O2) when out of room. R #52's care plan indicates R #52 should be wearing O2 at all times. C. On 03/09/21 at 9:28 am during an interview with R #52, R #52 is observed not wearing O2 in her room. D. On 03/09/21 at 9:29 am during an interview with Certified Nursing Assistant (CNA) #1, she stated, She (R #52) uses oxygen in the night, but not in the day. CNA #1 confirmed R #52 was not wearing O2 in her room. E. On 03/10/21 at 11:46 am during an interview with CNA #2, he stated, If she (R #52) does need it (O2), she (R #52) will wear it at night. CNA #2 confirmed R #52 was not wearing O2 in assisted dining area. F. On 03/10/21 at 11:48 am during an interview with Certified Medication Aide (CMA) #1, she confirmed R #52 was not wearing O2 in assisted dining area. CMA #1 also stated R #52 should not be wearing O2. G. On 03/11/21 at 10:00 am during an interview with the Director of Nursing (DON), she stated, (Name of Facility Medical Director (FMD)) said she (R #52) needed O2 for her [MEDICAL CONDITION] and we put in a diagnosis. She (R #52) has been on O2, but she didn't have the order for it. I don't know how we missed her. She (R #52) should be wearing O2 at all times. Findings for Pain Medication: R #6 H. Record review of R#6 Face sheet printed on 03/11/21 reveals Central Pai[DIAGNOSES REDACTED], Muscle spasms. I. Record review of Physicians orders dated 03/03/21 reveals [MEDICATION NAME] Hcl 50 mg tablet give 50 mg by mouth three times a day for for Chronic Pain. J. On 03/11/21 at 3:17 pm during facility task of observation of medication carts the 100/200 cart was selected the following was observed. K. On 03/11/21 at 3:17 pm during interview with Licensed Practical Nurse (LPN) #1 and controlled Drug Record reconciliation of the 100/200 wing Medication cart. R #6 had been administered the medication [MEDICATION NAME] HCL (medication used to control pain) 50 mg (milligrams) at 12:45 pm and the remaining medications in the bubble pack (medication card packaging) should have been 33 remaining tablets in accordance with the Individual Patient's Narcotic Record. Review of the bubble pack reveals there were 34 remaining tablets in the bubble pack. When LPN #1 was asked about the discrepancy in the medication count, she stated. I was going to give it ([MEDICATION NAME] 50mg) to him, but I guess I did not give it to him. It is a prn (as needed) medication. L. On 03/11/21 at 3:30 pm during an observation of R #6 he was observed to be restless and thrashing about his bed and grimacing (an expression usually of pain). M. Record review of R #6's Medication Administration Record [REDACTED]. N. On 03/11/21 at 4:28 pm during an interview with the Director of Nursing (DON), she stated. The [MEDICATION NAME] is used for pain, I will report it as a medication error. I do not know why she (LPN #1) would not give it to the resident he is one that has bad spasms and he cannot tell you but you can see it on his face and his body movements. It would be cruel not to give it ([MEDICATION NAME]) to him. O. On 03/11/21 at 5:05 pm during an interview with LPN #1 regarding administration of [MEDICATION NAME] at 12:45 pm, she stated, I thought I gave it ([MEDICATION NAME]) to him (R #6), so I marked it (as given in R #6's MAR. He (R #6) raises his legs and makes sounds when he is in pain. He (R #6) was screaming and I'm not sure, but I thought he (R #6) maybe wanted to go the bathroom or something. LPN #1 confirmed R #6's [MEDICATION NAME] was not administered to him after she documented the medication as being given. LPN #1 also confirmed R #6 appeared to be in discomfort. R #9 P. On 03/11/21 at 3:20 pm during observation of medication cart R #9's Controlled Drug Record reveals [MEDICATION NAME]-Acetamin 5-325 (medication used for pain) take 1 tab by mouth every 4 hours as needed for pain, had 21 remaining tablets, record review of the bubble pack reveals there were 20 remaining tablets. Q. On 03/11/21 at 3:22 pm during an interview with LPN #1 regarding administration of [MEDICATION NAME]-Acetamin at 12:00 pm, she stated. I did put it in a cup and I could not find him so later on I found him and forgot to mark it down as given. I was giving it to him for pain. R. Record review of Physicians orders dated 03/03/21 reveals [MEDICATION NAME] 325 mg give 650 mg by mouth every 4 hours as needed for minor pain or fever. S. On 03/11/21 at 4:30 pm during an interview with the DON she stated the medication on the cards should match the Doctors orders first of all and then medication should always be documented when it is given. DON verified Physicians order did not match bubble pack and she further verified that the count on the bubble pack and the count on the Individual Patient's Narcotic record did not match. R #14 T. On 03/11/21 at 3:25 pm during observation of medication cart and R #14's Controlled Drug Record reveals [MEDICATION NAME] Hcl 5 mg tablet. Take 1 tab by mouth twice daily as needed. (Medication used for pain) reveals had been administered on 03/11/21 at 8:55 am medication Individual Patient's Narcotic Record reveals 10 remaining tablets. Medication bubble pack reveals medication was never given was still reaming in the bubble pack. Bubble pack reveals 11 tablets remaining. Record review of Individual Patient's Narcotic Record U. On 03/11/21 at 3:26 pm during an interview with LPN #1 regarding the administration of [MEDICATION NAME] at 8:55 AM, she stated. I was going to give it to him, I must have forgotten. V. On 03/11/21 at 3:45 pm during an interview with the DON she stated, all medications should be given as ordered and marked on the MAR (medication Administration Record) when they are given and they should not be marked as given and not given to the resident as given. I do not understand why something was signed out as given and it was not given. I will report as medication errors.

On 06/06/17 at 2:11 pm during observation, R #'s 11 and 52 were seated at a patio table outside of the Activity Room. R #52 was smoking a cigarette while R #11 who was not smoking, was seated next to her while wearing her oxygen which was on at 2 liters per nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows). No one, other than the 2 residents, was present in the smoking area at this time. R #11 stated Yes, it's (oxygen) on. Record review of R #52's Smoking Assessment revealed she requires supervision while smoking. Interview with Certified Nurse Aide (CNA) #6 confirmed she was scheduled to supervise smokers at this time, but was inside the facility supervising other residents at risk for falls. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at a scope and severity (S&S) level 4, J. The facility Administrator was notified of the IJ on 06/06/17 at 4:48 pm. On 06/06/17 at 5:46 pm, the first plan of removal (POR) was received and rejected, and on 06/06/17 at 6:26 pm, the second POR was received and approved. The S&S was lowered to D, level 2. Based on the POR the interventions included: Ensuring all residents who smoke in the facility are adequately monitored and supervised to maintain their safety and the safety of others: the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) will immediately supervise the resident smoking area this evening, will immediately acquire the smoking materials of all residents who smoke in the facility to be maintained by the charge nurses in the locked medication carts; and will immediately begin the retraining of certified and licensed nursing staff currently on shift and will plan to retrain this evening's oncoming nursing staff shifts on the need to maintain all resident smoking materials in the medication carts and consistently supervise all residents each and every time a resident requests to obtain their smoking materials and smoke in the designated resident smoking area. Other interventions which will be in effect are: 1. The DON and ADON will re-train all certified and licensed nursing staff on the need to maintain all resident smoking materials and resident smoking supervision. 2. A staffing schedule will be prepared assigning certified or licensed staff to consistently be available to supervise residents in the smoking area. 3. A mandatory nursing staff meeting will be scheduled for 06/09/17 to review the training program regarding resident smoking supervision. Based on observation, record review and interview, the facility failed to provide supervision of residents that require supervision while smoking to prevent an accident for 2 (R #11 and 52) of 2 (R #11 and 52) residents reviewed during random observation by: 1. Not providing supervision to R #52 who requires supervision when in designated smoking area 2. Not ensuring residents did not enter smoking area with oxygen. If the facility is not ensuring that residents at risk for smoking accidents are supervised and that oxygen is not being used in the smoking area, then residents are likely to be at risk of accidents, injury or death. The findings are: Findings for R #11: A. Record review of the Face Sheet dated 06/08/17 revealed R #11's current [DIAGNOSES REDACTED]. activity, resulting in convulsions). B. Record review of physician's orders [REDACTED]. [DIAGNOSES REDACTED]. C. Record review of Care Plan updated in May 2017 revealed Problem: Poor endurance due to shortness of breath as evident by O2 used.' Interventions and Approach: Administer oxygen therapy as ordered. Findings for R #52: D. Record review of the Face Sheet dated 06/06/17 revealed R #52's current [DIAGNOSES REDACTED]. E. Record review of Resident Smoking assessment dated [DATE] revealed resident is a supervised smoker based on the following questions which were answered in the negative: 1. Is resident able to extinguish a lit cigarette ash/cigarette which has fallen on his/her person and/or on others/ 2. Is resident able to move without assistance to designated smoking area? 3. Does resident have a past history of poor judgement regarding safety or himself/herself or others? F. Record review of the Care Plan updated 04/05/17 revealed 1. Problem: She chooses to visit with other residents and smoke outside. Goal: (Name of R #52) will continue to smoke in a safe environment without causing harm to self or others. Findings related to smoking: G. Record review of facility Smoking Policy revised 12/2007 revealed Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. H. On 06/06/17 at 2:11 pm, during observation, R #11 was sitting on a chair in the smoking area (outside patio) with her portable oxygen concentrator on her wheel chair in front of her; R #11 was speaking to R #52 who was smoking at the time, seated at the same table. I. On 06/06/17 at 2:19 pm, during observation and interview with R #11, she stated Yes, it's (oxygen) on. Observation of the meter on the concentrator indicated the unit was 3/4 full and the flow of oxygen could be heard as R #11 would inhale. J. On 06/06/17 at 2:21 pm, during an interview with LPN (Licensed Practical Nurse) #3 she stated (Name of R #11) was out visiting her friend and (Name of R #52) and still had her oxygen on. She's never done that before, she shouldn't have been out there with it on. K. On 06/06/17 at 3:18 pm, during an interview with RN #1 (Registered Nurse), she stated, (Name of R #52) smokes a couple of cigarettes per day, one of the CNA's (Certified Nurse Aide) is out there or keeping track of her when she wants to come back in, the CNA's don't sit out there they just walk by and check on her. L. On 06/06/17 at 3:23 pm, during an interview with DON, she stated, With her (R #52) someone should always be watching her. Smoking assessment are done and everyone on the list is on supervision. We have her on supervision. Light duty staff (Staff that cannot perform regular job duties) should be out there all the time. They know better than to just leave that area and they text one of us to go out there so they can go relieve (Go to the restroom) themselves. They should be out there all the time and are supposed to be all the time. When asked if R #52 could be outside by herself and has full control of her cigarettes she stated, We don't like them to have their own cigarettes, she can do her own devices and smoke on her own, sometimes she forgets to take off her oxygen and leave it inside but we can catch them when they are going and always takes it off; that is why the nurses have cigarettes, that way we know what is going on. She further stated, Yes, it is a concern that (Name of R #11) was outside with her oxygen on. Oxygen and cigarettes do not go together. M. On 06/06/17 at 3:36 pm, during an interview with CNA #5, she stated, I was out to lunch, one of the other CNA's was supposed to be out here watching them (the residents who smoke). (Name of R #52) is supposed to be supervised, when smoking, they shouldn't have been alone. N. On 06/06/17 at 3:41 pm during an interview with LPN #3, she stated, (Name of CNA #6) should have been observing the smoking situation with (Name of R #52). She doesn't go outside with the smokers, but she watches from the hallway across the courtyard. She should have intervened if someone who was on oxygen approached a smoker. When asked if being inside the building, and across the courtyard from a smoker was too great a distance to be able to intervene quickly enough if there was a fire, she stated, That's a good question. O. On 06/06/17 at 3:55 pm, during an interview with CNA #6 she stated, Yes, I was supposed to be outside with the smokers, but today they had me watching 2 other ladies, who were fall risks inside in the back where we get snacks. I kept peeking out there to make sure they were okay. They were about 20 feet away, that is when I saw the other lady, (Name of R #11) with her O2 (oxygen) go out and sit by (Name of R #52). They told me not to leave the lady I was watching inside and then when you (points at surveyor) went outside that is when I peeked out to see. I did not know if I should go outside or not. She further stated, I knew she (R #11) shouldn't be out there with the O2 on but I couldn't find anybody quickly to go outside. P. On 06/06/17 at 4:10 pm, during observation, the distance between the chair inside where the CNA was seated and the smoking area courtyard where the R #11 and 52 were seated, measured 60 feet. Q. On 06/06/17 at 4:50 pm, during an interview with the Administrator, he stated, I can give up to the fact that it happened. It could be a tag. It doesn't have to be an IJ. R. Record review of CDC (Centers for Disease Control): Fatal Fires Associated with Smoking During Long Term Oxyegn Therapy (LTOT) dated 08/08/08 revealed Fires associated with tobacco use are the leading cause of residential fire deaths in the United States. Medical oxygen can saturate clothing, fabric and hair. Oxygen will not explode but will act as an accelerant. A fire, such as a lit cigarette, will burn faster and hotter in an oxygen enriched environment.

The facility failed to prevent the development of a urinary tract infection [MEDICAL CONDITION] for R #28 which likely lead to the resident being hospitalized due [MEDICAL CONDITION] (a life-threatening wide-spread infection). The facility did not notify the physician when the resident continued to have signs of a UTI after a course of antibiotic treatment was completed, and did not notify the physican of abnormal changes in the resident's urine color/clarity. The Physician (PHYS) #1 did not thoughly investigate his own observation of the change in the resident's urine color. During the survey nursing staff did not implement proper urinary catheter bag infection control practices by allowing the resident's urinary catheter bag to contact the bare floor and did not have a system in place to ensure that residents at risk for dehydration received adequate fluid intake. This resulted in an Immediate Jeopardy (IJ) being called at the scope and severity level J on 02/05/15. On 02/05/15, an acceptable plan of removal was provided and the scope and severity was lowered to G. Based on record review and interview, the facility failed to ensure that 1 (R #28) of 3 (R #22, 28, and 92) residents reviewed for urinary catheter use received adequate services to prevent infection by not identifying symptoms of infection/dehydration and not notifying the physician of these urinary changes. This deficient practice likely resulted in R #28 [MEDICAL CONDITION] (wide-spread infection) related to a urinary tract infection requiring hospitalization . The findings are: A. Record review of Departmental Notes for R #28 dated 09/30/14 to 01/01/15 revealed the following with no indication that the physician was notified: 1. 09/30/14: "Urine purple in color this evening." 2. 10/06/14 at 2:53 am: "yellow, scant cloudy urine." 3. 10/06/14 at 3:38 am: "yellow, cloudy urine in cath (catheter) bag. Instilled 5cc (milliliters) sterile water in cath tubing." 4. 10/06/14 at 4:33 am: "yellow, cloudy urine in cath tubing." 5. 10/06/14 at 10:52 am: "unable to flush s/p (supra pubic-catheter inserted into bladder through abdomen) cath at this time." The catheter was noted to be flushed. "s/p cath draining clear yellow urine with small amounts of sediment." 6. 10/10/14: revealed a notation that indicated the resident had yellow urine with small amounts of sediment. 7. 10/12/14: "yellow urine with moderate amount of sediment noted in catheter tubing." 8. 10/16/14: "urine is yellow and cloudy." 9. 10/26/14: "clear yellow urine with large amount of white sediment." 10. 11/02/14 at 2:52 am: revealed a notation that indicated that the resident had a temperature of 100.3 and was given Tylenol to reduce fever. 11. 11/02/14 at 9:06 pm: "urine yellow with mucous." 12. 11/03/14 at 4:19 am: "yellow, cloudy urine in cath bag." 13. 11/11/14: the resident was ordered the antibiotic, Bactrim, for five days for a urinary tract infection. 14. 11/13/14: "urine is dark yellow in color with small amounts of sediment." 15. 11/15/14: "draining yellow urine with small amounts of mucous noted." 16. 11/16/14: "yellow scant cloudy urine in cath bag." 17. 11/18/14: "antibiotics are complete." 18. 11/23/14: "cloudy, yellow urine in cath bag." 19. 12/01/14: "Supra pubic catheter was flushed and is patent. Very little mucus (sic) present in urine bag. dark amber urine." 20. 12/07/14: "(Name of resident #28) presents with purple urine in catheter bag, tubing scant cloudy medium..." . 21. 12/08/14: "supra pubic cath was flushed and patent dark amber urine." 22. 12/21/14: "Catheter is patent draining dark amber urine." 23. 12/22/14: "amber, cloudy urine in cath bag." B. Record review of the Care Plan for R #28 dated 03/22/12 revealed a problem area of potential for urinary tract infection related to presence of supra public catheter. Approached for this problem area included, ...observe and record urine appearance at least montly assessment or as needed. Report any abnormalities to physician." C. Record review of Departmental Notes dated 01/04/15 at 9:33 pm revealed a notation that read "...draining clear yellow urine...resident had received IV (in vein) therapy and hydration until discharge." D. On 02/05/15 at 2:16 pm during an interview with RN (Registered Nurse) #1 when asked what type of abnormalities might you find when assessing a foley catheter? She responded "Color, clarity, if you have blood or mucous, strong odor." When asked if there are abnomalities, what do you do? She responded "Look to see if there are other complaints, are they lethargic, change in mental status, temp (temperature). Sometimes they have mucous, sometimes you monitor that. Hematuria (bloody urine), if it got tugged or something. If they show a temp, you would call the doctor. Sometimes you don't need to call the doctor right away, but if it is real obvious. Chart it in the nurses notes and pass it along in report. If they are afebrile (not feverish), but symptoms persists, then call the doctor." E. On 02/05/15 at 5:59 pm during an interview with the DON (Director of Nursing), when asked about R #28's general condition before being hosptalized on [DATE], she stated, "Typically his urine is really really dark. For him, that is normal. More than one occasion, we have sent a UA (Urine Analysis). There is a med that turns the urine a dark red." DON confirmed that the resident was not on a medication that would cause urine discoloration. When asked if the resident is chronically dehydrated, DON stated, "Not so much. He usually eats and drinks what we give him. When asked if the resident's urine appeared cloudy, DON stated "He has mucous. Some may say cloudy." When asked if she ever observed purple urine, DON stated "Yes, I have heard people call it that. It is not typical of him." When asked if purple urine would that be a concern, the DON stated "If the color changed dramatically, I would be worried." DON was asked if a UA had been ordered when (name of MD #1) assessed the resident on 12/09/14, she confirmed that no UA results were in the resident's medical record. During interview with the DON, she called (name of MD #1) and asked him, "On 12/9/14 does your progress note mean the catheter site or the urine is purple?" DON stated that MD #1 confirmed it was urine and MD #1 thought that the resident was on a urinary antiseptic. DON confirmed the resident was not on a urinary antiseptic at the time of MD #1's assessment on 12/09/14.

Immediate Jeopardy related to F323 The facility failed to ensure that residents were free from accidents by not providing the adequate feeding assistance and supervision to R #55 during meal time on 02/02/15 and not appropriately identifying R #55's signs of choking, such as coughing and watery eyes. During the dining observation, R #55 was served her breakfast without staff supervision and when she began coughing, staff did not intervene. CNA #2 was observed to walk away from the table, and another R #104 began to feed R #55 her breakfast. At this time, R #55 began to demonstrate signs of choking. These deficient practices resulted in an Immediate Jeopardy (IJ) at a scope and severity J, being identified at the facility on 02/02/15 at 11:12 am. The facility Administrator was notified at this time. The facility took corrective action by providing an acceptable Plan of Removal on 02/02/15 at 11:30 am. Based on the plan of removal, interventions included: 1. Supervision of the Total Assist Dining room and any resident room in which facility staff are assigned to feed the residents by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), starting on 02/02/15 until all staff can be re-trained. 2. The dietary manager will immediately provide a list of all residents requiring total assistance to the ADON and DON. 3. Staff being re-trained by the DON and ADON starting the lunch hour on 02/02/15 until all staff have been retrained. 4. The facility is assigning a Nurse Supervisor to the Total Assist Dining Room during mealtimes. At this time, the scope and severity was lowered to a G. Immediate Jeopardy related to F315 The facility failed to prevent the development of a urinary tract infection [MEDICAL CONDITION] for R #28 which likely lead to the resident being hospitalized due [MEDICAL CONDITION] (a life-threatening wide-spread infection). The facility did not notify the physician when the resident continued to have signs of a UTI after a course of antibiotic treatment was completed, and did not notify the physican of abnormal changes in the resident's urine color/clarity. The Physician (PHYS) #1 did not thoughly investigate his own observation of the change in the resident's urine color. During the survey nursing staff did not implement proper urinary catheter bag infection control practices by allowing the resident's urinary catheter bag to contact the bare floor and did not have a system in place to ensure that residents at risk for dehydration received adequate fluid intake. This resulted in an Immediate Jeopardy (IJ) being called at the scope and severity level J on 02/05/15. On 02/05/15, an acceptable plan of removal was provided and the scope and severity was lowered to G. Based on record review, observation and interview, the facility failed to implement the care plan and follow physician's orders [REDACTED].#22, 28, 55 & 63) of 20 (R #2, 10, 22, 28, 55, 57, 60, 63, 68, 72, 75, 80, 81, 90, 92, 98, 113, 121, 122 & 136) resident's reviewed for urinary catheter use, unnecessary medications and during dining observation by: 1. Not providing adequate assistance and supervision while R #55 was eating which likley resulted in the resident choking on food. 2. Not administering PRN (as needed) [MEDICAL CONDITION] medications as ordered by the physician for R #63. 3. Not implementing the care plan for R #63 by administering anti-anxiety/psychotic medications without identifying specific target behaviors to warrant their use. 4. Not providing catheter care as indicated in the care plan for R #22 and R #28. This deficient practice likely resulted in R#28 [MEDICAL CONDITION] related to a urinary tract infection requiring hospitalization on [DATE]. If the facility is not implementing care plans and following the physician's orders [REDACTED]. The findings are: Findings for R #55 A. Record review of R #55's Care Plan dated 08/27/14 revealed, "Potential for weight/diet issue as evident by the following risk factors: total assistance with feeding. Approaches: all resident considered aspiration risk follow aspiration risk protocal (sic). Allow resident ample time to consume food." B. Record review of "General Aspiration Precautions for Residents at (Name of facility)" undated includes the following: "Aspirations symptoms include: choking, coughing, wet gurgley voice quality after swallowing, leakage of food or saliva from mouth, and tearing up. If any of these symptoms are noticed by anyone please stop all eating and drinking and call patient's nurse. Any concerns or issues communicate to the Speech Therapist, DON (Director of Nursing), or DOR (Director of Rehab)." C. On 02/02/15 at 8:07 am during an observation breakfast service in the total assist dining room, Certified Nursing Assistant (CNA) #2 was feeding R #55. R #55 began to cough after receiving bites of food. Registered Nurse (RN) #3 brought R #55 her morning medications in a cup, administed them and R #55 continued to cough. At 8:17 am, CNA #2 fed R #55 another bite of food and R #55 continued to cough, R #55's eyes began to water. At 8:21 am, CNA #2 fed R #55 a bite of food; R #55 attempted to swallow and coughed up food in her mouth. While R #55 had food debris in and around her mouth, CNA #2 walked away from the table where the resident was sitting. At 8:22 am, R #104 began feeding R #55 three bites of pureed breakfast food, one bite immediately after the other. R #55 coughed on the food that she was given; R #55's eyes were reddened and began to water. D. On 02/02/15 at 10:38 am during an interview with RN # 3, she confirmed that residents who are dependent with eating are to be supervised by staff and staff should not leave the resident while they are eating. When asked what she would do if a resident had signs of aspiration, she responded, "Usually if they are choking they get evaluated from speech therapy. We notify the doctor and we make sure they dont have a temp (temperature) 1 hour afterwards. They either upgrade or down-grade the diet. We would need speech therapy for a diet change, and someone would notified." When asked what a CNA should do if they see signs of aspiration, she responded, "Notify the nurses." When asked if R #55 is at risk of aspiration, she responded "I would say. She is on a pureed diet. She has CP ([MEDICAL CONDITION]). Yeah, she is still on pureed, on thin liquids." When asked if R #55 has aspirated before, she responded, "She was coughing today, but I don't think that was from that. She has had a cold and a runny nose. She got some Tylenol and cough medicine. Her vitals were good. She doesn't have a temp. Everything looked fine." Findings for not following physician's orders [REDACTED]. E. Record review of the physician's orders [REDACTED]. 1. "[MEDICATION NAME] ([MEDICATION NAME]) (anti-anxiety medication) 0.5 mg (milligrams) tablet. Give one 0.5 mg tablet by mouth twice daily as needed. Dx: (diagnosis) agitation" 2. "[MEDICATION NAME] (anti-psychotic medication) 25 mg tablet. Give one-half tablet by mouth once daily as needed. Dx: agitation not responsive to [MEDICATION NAME]." F. Record review of the Medication Adminsitration Record (MAR) dated 01/30/15 revealed the resident was adminsitered the medication [MEDICATION NAME] 12.5 mg at 5:18 pm for agitation. The MAR indicated [REDACTED]. G. Record review of the departmental notes dated 01/29/15 to 01/31/15 revealed no indication that the medication [MEDICATION NAME] 0.5 mg was adminsitered on 01/30/15. H. On 02/05/15 at 10:08 am during an interview with RN #4, she confirmed that according to the physician's orders [REDACTED]. Findings for not implementing the care plan Findings for R #63 I. Record review of Care Plan dated 11/25/14 revealed R #63 was identified as being at risk for side effects related to the use of the anti-anxitey medication [MEDICATION NAME] and the anti-psychotic medication [MEDICATION NAME]. Approaches for these problem areas were noted as, "Monitor and record (Name of R #63)'s target behaviors." & "Monitor (Name of R #63)'s behavior." respectivley. J. Record review of the MAR indicated [REDACTED] 1. The PRN anti-psychotic medication [MEDICATION NAME] 12.5 mg on 01/30/15 at 5:18 pm for agitation. The MAR indicated [REDACTED]. 2. The PRN anti-anxiety medication [MEDICATION NAME] 0.5 mg on 02/03/15 at 2:09 pm. The MAR indicated [REDACTED]. K. Record review of the Departmental Notes dated 01/29/14 to 02/04/15 did not indicate what specific type of behavior the resident exhibited in order to warrant the use of the medication. L. On 02/05/15 at 10:08 am during an interview with Registered Nurse (RN) #4, she was asked about what types of behaviors staff should be monitoring for with regard to R #63's anxiety and [MEDICAL CONDITION]. RN #4 stated, "Typically she displays anxiety by saying that she is going home and/or the her son is coming to the facility to pick her up." RN #4 confirmed that while she has worked with the resident she has not exhibited signs of [MEDICAL CONDITION]. Findings for R #22 M. Record review of the care plan dated 06/05/13 revealed the resident was identified as having a problem area of, "(Name of R #22) uses a supra pubic Define the suprapubic. catheter." An apporach for this problem area was identified as, "Catheter care for (Name of R #22) every shift." N. Record review of the Hygiene and Bathing roster dated revealed the resident was documented as receiving catheter care on the following dates and instances: 1. 01/24/15: once 2. 01/25/15: once 3. 01/26/15: once 4. 01/27/15: once 5. 01/28/15: once 6. 01/29/15: once 7. 01/31/15: once 8. 02/02/15: none 9. 02/03/15: once 10. 02/04/15: once Findings for R #28 O. Record review of the Care Plan dated 03/22/12 revealed a problem area of potential for urinary tract infection related to presence of supra pubic catheter. Approached for this problem area included, performing catheter care "BID (twice a day), observe and record urine appearance at least montly assessment or as needed. Report any abnormalities to physician." P. Record review of Departmental Notes dated 09/30/14 to 01/01/15 revealed the following with no indication that the physician was notified: 1. 09/30/14: "Urine purple in color this evening." 2. 10/06/14 at 2:53 am: "yellow, scant cloudy urine." 3. 10/06/14 at 3:38 am: "yellow, cloudy urine in cath bag. Instilled 5cc (milliliters) sterile water in cath tubing." 4. 10/06/14 at 4:33 am: "yellow, cloudy urine in cath tubing." 5. 10/06/14 at 10:52 am: "unable to flush s/p cath at this time." The catheter was noted to be flushed. "s/p cath draining clear yellow urine with small amounts of sediment." 6. 10/10/14: revealed a notation that indicated the resident had yellow urine with small amounts of sediment. 7. 10/12/14: "yellow urine with moderate amount of sediement noted in catheter tubing." 8. 10/16/14: "urine is yellow and cloudy." 9. 10/26/14: "clear yellow urine with large amount of white sediment." 10. 11/02/14 at 2:52 am: revealed a notation that indicated that the resident had a tempurature of 100.3 and was given Tylenol to reduce fever. 11. 11/02/14 at 9:06 pm: "urine yellow with mucous." 12. 11/03/14 at 4:19 am: "yellow, cloudy urine in cath bag." 13. 11/11/14: the resident was ordered the antibiotic, Bactrim, for five days for a urinary tract infection. 14. 11/13/14: "urine is dark yellow in color with small amounts of sediment." 15. 11/15/14: "draining yellow urine with small amounts of mucous noted." 16. 11/16/14: "yellow scant cloudy urine in cath bag." 17. 11/18/14: "antibiotics are complete." 18. 11/23/14: "cloudy, yellow urine in cath bag." 19. 12/01/14: "Supra pubic catheter was flushed and is patent. Very little mucus present in urine bag. dark amber urine." 20. 12/07/14: " (Name of resident #28) presents with purple urine in catheter bag, tubing scant cloudy medium..." . 21. 12/08/14: "supra pubic cath was flushed and patent dark amber urine." 22. 12/21/14: "Catheter is patent draining dark amber urine." 23. 12/22/14: "amber, cloudy urine in cath bag." Q. On 02/05/2015 at 9:40 am during an interview with LPN (Licenced Practical Nurse) #1, when asked how often catheter care is done, she said daily. R. Record review of the Hygiene and Bathing Roster dated 12/21/14 to 01/01/15 revealed the resident was provided catheter care on the following instances: 12/22/14 none, 12/25/14 once, 12/26/14 once, 12/27/14 once, 12/29/14 once, 12/31/14 none. S. Record review of admission assessment by physician #2 (Name of Doctor of Osteopathic Medicine) dated 01/01/15 revealed, R #28 was admitted to the hospital for a primary [DIAGNOSES REDACTED]. Chronically ill elderly man with a supra pubic catheter, presenting [MEDICAL CONDITION]: fever, [MEDICAL CONDITION] and increased respiratory rate, borderline blood pressure. Urinary tract infection identified on urinalysis and by examination of his catheter. Prior UTI led to [MEDICAL CONDITION]." Another notation read "According the ER (emergency room ) nurse, his supra pubic catheter was very malodorous (strong odor) and covered with some growth. The catheter was changed in the ED (Emergency Department)." Resident's vital signs noted to be: Temperature 101.9, Pulse 119, and Respirations 22." The resident's white blood cell count (cells in the body indicating an immune system responce to infection) was high at 16.0 K (thousand)/mm3 (millimeters cubed), normal range is 4.0-10.0 K/mm3. T. Record review of the discharge summary by physician #3 (Name of medical Docotor) dated 01/04/15 revealed the resident's hospital course was noted as, "1.[MEDICAL CONDITION]. This is most likely secondary to urinary tract infection with Kiebsiella pneumoniae (a type of bacteria). His maximum temperature was on the evening of admission up to 102.6. He then defervesced (reduction in fever) and remained afebrile (with no fever). He was initially treated with [MEDICATION NAME] (an type of antibiotic) and switched [MEDICATION NAME](another type of antibiotic) as the Kiebsiella is pansensitive (sensitive to all types of antibiotics). His mental status has improved. Blood pressure stabilized. 2. Urinary tract infection. Kiebsiella pneumonia greater than 100,000 colonies sensitive to [MEDICATION NAME] and Cipro. Treated with 2 days of IV (in vein) [MEDICATION NAME] and switched to Cipro. 3. Chronic suprapubic catheter. Had significant growth and malodor when evaluated in the emergency department. Seems to have had a delay in being changed at the nursing home. Should be changed every 3-4 weeks." U. On 02/05/15 at 2:16 pm during an interview with RN #1 when asked what type of abnormalities might you find when assessing a foley catheter? "Color, clarity (if you have blood or mucous) strong odor." If there are abnomalities, what do you do? "Look to see if there are other complaints, are they lethargic, change in mental status, temp. Sometimes they have mucous, sometimes you monitor that. Hematuria, if it got tugged or something. If they show a temp, you would call the doctor. Sometimes you dont need to call the doctor right away, but if it is real obvious. Chart it in the nurses notes and pass it along in report. If they are afebrile, but symptoms persists, then call the doctor."

The facility failed to ensure that residents were free from accidents by not providing the adequate feeding assistance and supervision to R #55 during meal time on 02/02/15 and not appropriately identifying R #55's signs of choking, such as coughing and watery eyes. During the dining observation, R #55 was served her breakfast without staff supervision and when she began coughing, staff did not intervene. CNA #2 was observed to walk away from the table, and another Res #104 began to feed R #55 her breakfast. At this time, R #55 began to demonstrate signs of choking. These deficient practices resulted in an Immediate Jeopardy (IJ) at a scope and severity J, being identified at the facility on 02/02/15 at 11:12 am. The facility Administrator was notified at this time. The facility took corrective action by providing an acceptable Plan of Removal on 02/02/15 at 11:30 am. Based on the plan of removal, interventions included: 1. Supervision of the Total Assist Dining room and any resident room in which facility staff are assigned to feed the residents by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), starting on 02/02/15 until all staff can be re-trained. 2. The dietary manager will immediately providing a list of all residents requiring total assistance to the ADON and DON. 3. Staff being re-trained by the DON and ADON starting the lunch hour on 02/02/15 until all staff have been retrained. 4. The facility assigning a Nurse Supervisor to the Total Assist Dining Room during mealtimes. At this time, the scope and severity was lowered to a G. Based on observation, record review and interview, the facility failed to ensure that residents were free from accidents for 1 (R #55) of 1 (R #55) resident reviewed during dining room observation, by not providing adequate supervision during meals, not providing feeding assistance in accordance with her plan of care, and not immediately responding to R #55's signs of choking. The findings are: A. On 02/02/15 at 8:07 am during an observation breakfast service in the total assist dining room, Certified Nursing Assistant (CNA) #2 was feeding R #55. R #55 began to cough after receiving bites of food. Registered Nurse (RN) #3 brought R #55 her morning medications in a cup, administered them and R #55 continued to cough. At 8:17 am, CNA #2 fed R #55 another bite of food and R #55 continued to cough, R #55's eyes began to water. At 8:21 am, CNA #2 fed R #55 a bite of food; R #55 attempted to swallow and coughed up food in her mouth. While R #55 had food debris in and around her mouth, CNA #2 walked away from the table where the resident was sitting. At 8:22 am, R #104 began feeding R #55 three bites of pureed breakfast food, one bite immediately after the other. R #55 coughed on the food that she was given; R #55's eyes were reddened and began to water. R #55 continued to cough. B. On 02/02/15 at 10:38 am during an interview with RN # 3, she confirmed that residents who are dependent with eating are to be supervised by staff and staff should not leave the resident while they are eating. When asked what she would do if a resident had signs of aspiration, she responded "Usually if they are choking they get evaluated from speech therapy. We notify the doctor and we make sure they don't have a temp (temperature) 1 hour afterwards. They either upgrade or down-grade the diet. We would need speech therapy for a diet change, and someone would notified." When asked what a CNA should do if they see signs of aspiration, she responded "Notify the nurses." When asked if R #55 is at risk of aspiration, she responded "I would say. She is on a pureed diet. She has CP ([DIAGNOSES REDACTED]). Yeah, she is still on pureed, on thin liquids." When asked if R #55 has aspirated before, she responded "She was coughing today, but I don't think that was from that. She has had a cold and a runny nose. She got some Tylenol and cough medicine. Her vitals were good. She doesn't have a temp. Everything looked fine." C. Record review of the Nurses Information book dated 01/29/15 revealed R #55 was assigned to the "Total Assist 1" dining room. All residents who are served in the "Total Assist 1" dining room require total assistance/supervision while dining. D. Record review of Residents on Specific Aspiration Precautions dated 09/07/11 revealed "Specific aspiration precautions also includes: 3. Eat only with supervision." R #55 was identified on this form. E. Record review of (Name of Family Practice) Encounter Summary for R #55 dated 05/15/14 stated, "Nonverbal. At one point did seem to choke on her saliva and had several harsh coughs that she cleared. She did have a bout of coughing perhaps from aspiration (breathing in food particles) during the visit." F. Record review of Speech Therapy Clarification Order for R #55 dated 08/08/14 indicated, "treatment of [REDACTED]." G. Record review of R #55's Care Plan dated 08/27/14 revealed, "Potential for weight/diet issue as evident by the following risk factors: total assistance with feeding. Approaches: all resident considered aspiration risk follow aspiration risk protocal (sic). Allow resident ample time to consume food." H. Record review of, "General Aspiration Precautions for Residents at (Name of facility)" undated included the following: "Aspirations symptoms include: choking, coughing, wet gurgley voice quality after swallowing, leakage of food or saliva from mouth, and tearing up. If any of these symptoms are noticed by anyone please stop all eating and drinking and call patient's nurse. Any concerns or issues communicate to the Speech Therapist, DON (Director of Nursing), or DOR (Director of Rehab)."

The facility failed to prevent the development of a urinary tract infection [MEDICAL CONDITION] for R #28 which likely lead to the resident being hospitalized due [MEDICAL CONDITION] (a life-threatening wide-spread infection). The facility did not notify the physician when the resident continued to have signs of a UTI after a course of antibiotic treatment was completed, and did not notify the physican of abnormal changes in the resident's urine color/clarity. The Physician (PHYS) #1 did not thoughly investigate his own observation of the change in the resident's urine color. During the survey nursing staff did not implement proper urinary catheter bag infection control practices by allowing the resident's urinary catheter bag to contact the bare floor and did not have a system in place to ensure that residents at risk for dehydration received adequate fluid intake. This resulted in an Immediate Jeopardy (IJ) being called at the scope and severity level J on 02/05/15. On 02/05/15, an acceptable plan of removal was provided and the scope and severity was lowered to G. Based on record review, observation and interview, the facility failed to ensure that 1 (R #28) of 3 (R #22, 28, and 92) residents reviewed for urinary catheter use; received adequate services to prevent infection by not identifying symptoms of infection/dehydration, not notifying the physician of urinary changes, not providing adequate catheter/drainage bag care, and the physicians failure to act on urinary changes. This deficient practice likely resulted in R#28 [MEDICAL CONDITION] related to a urinary tract infection requiring hospitalization on [DATE]. The findings are: A. Record review of Long Term Care Admission/Transfer Orders for R #28 Page 1 of 4 dated 05/31/14 revealed that the resident was admitted to the facility with a recent history of "sepsis - urinary source/proteus (type of bacteria)." B. Record review of Departmental Notes for R #28 dated 9/30/14 to 01/01/15 revealed the following with no indication that the physician was notified: 1. 09/30/14: "Urine purple in color this evening." 2. 10/06/14 at 2:53 am: "yellow, scant cloudy urine." 3. 10/06/14 at 3:38 am: "yellow, cloudy urine in cath (catheter) bag. Instilled 5cc (milliliters) sterile water in cath tubing." 4. 10/06/14 at 4:33 am: "yellow, cloudy urine in cath tubing." 5. 10/06/14 at 10:52 am: "unable to flush s/p (supra pubic-catheter inserted into bladder through abdomen) cath at this time." The catheter was noted to be flushed. "s/p cath draining clear yellow urine with small amounts of sediment." 6. 10/10/14: revealed a notation that indicated the resident had yellow urine with small amounts of sediment. 7. 10/12/14: "yellow urine with moderate amount of sediment noted in catheter tubing." 8. 10/16/14: "urine is yellow and cloudy." 9. 10/26/14: "clear yellow urine with large amount of white sediment." 10. 11/02/14 at 2:52 am: revealed a notation that indicated that the resident had a tempurature of 100.3 and was given Tylenol to reduce fever. 11. 11/02/14 at 9:06 pm: "urine yellow with mucous." 12. 11/03/14 at 4:19 am: "yellow, cloudy urine in cath bag." 13. 11/11/14: the resident was ordered the antibiotic, Bactrim, for five days for a urinary tract infection. 14. 11/13/14: "urine is dark yellow in color with small amounts of sediment." 15. 11/15/14: "draining yellow urine with small amounts of mucous noted." 16. 11/16/14: "yellow scant cloudy urine in cath bag." 17. 11/18/14: "antibiotics are complete." 18. 11/23/14: "cloudy, yellow urine in cath bag." 19. 12/01/14: "Supra pubic catheter was flushed and is patent. Very little mucus (sic) present in urine bag. dark amber urine." 20. 12/07/14: " (Name of resident #28) presents with purple urine in catheter bag, tubing scant cloudy medium..." . 21. 12/08/14: "supra pubic cath was flushed and patent dark amber urine." 22. 12/21/14: "Catheter is patent draining dark amber urine." 23. 12/22/14: "amber, cloudy urine in cath bag." C. Record review of Physician's Progress Notes for R #28 by Medical Doctor (MD) #1 dated 12/09/14 revealed a notation that read, objective: "Indwelling catheter present, slightly purplelish discoloration." The assessment and plan for this problem area read "[MEDICAL CONDITION]. Supra pubic catheter. Recently changed. Not likely to be removed." D. On 02/05/2015 at 9:40 am during an interview with Licensed Practical Nurse (LPN) #1, when asked how often catheter care is done, she said "Daily." E. Record review of the Care Plan for R #28 dated 03/22/12 revealed a problem area of potential for urinary tract infection related to presence of supra public catheter. Approached for this problem area included, performing catheter care "BID (twice a day), observe and record urine appearance at least montly assessment or as needed. Report any abnormalities to physician." F. Record review of the Hygiene and Bathing Roster for R #28 dated 12/21/14 to 01/01/15 revealed the resident was provided catheter care once on the following dates: 12/25/14, 12/26/14, 12/27/14 & 12/29/14. On 12/22/14 & 12/31/14 no catheter care was documented as being provided. G. Record review of Departmental Notes for R #28 dated 01/01/15 at 2:48 pm revealed "1030 (am) vomited x2 (twice), small amts (amounts) of yellow emesis (vomit), mucus (sic) drainage from nose, resp (respirations) increased, T (temperature) 101.9, 119 (pulse), 22 (breaths), 121/70 (blood pressure), O2 Sat (oxygen saturation) 91% at 2.5L (liters), unable to swalow (sic) tylenol tablets d/t (due to) nausea, (name of MD #1) notified, condition update given, new orders-transfer to (name of hospital #1), 110 (pm) resident transferred to (name of hospital #1) via ambulance, contact person, (name of family member #1) notified." H. Record review of admission assessment by physician #2 (Name of Doctor of Osteopathic Medicine) dated 01/01/15 revealed, R #28 was admitted to the hospital for a primary [DIAGNOSES REDACTED]. Chronically ill elderly man with a supra pubic catheter, presenting [MEDICAL CONDITION]: fever, [MEDICAL CONDITION] and increased respiratory rate, borderline blood pressure. Urinary tract infection identified on urinalysis and by examination of his catheter. Prior UTI led to [MEDICAL CONDITION]." Another notation read "According the ER (emergency room ) nurse, his supra pubic catheter was very malodorous (strong odor) and covered with some growth. The catheter was changed in the ED (Emergency Department)." Resident's vital signs noted to be: Temperature 101.9, Pulse 119, and Respirations 22." The resident's white blood cell count (cells in the body indicating an immune system responce to infection) was high at 16.0 K (thousand)/mm3 (millimeters cubed), normal range is 4.0-10.0 K/mm3. I. Record review of the discharge summary by physician #3 (Name of medical Docotor) dated 01/04/15 revealed the resident's hospital course was noted as, "1.[MEDICAL CONDITION]. This is most likely secondary to urinary tract infection with Kiebsiella pneumoniae (a type of bacteria). His maximum temperature was on the evening of admission up to 102.6. He then defervesced (reduction in fever) and remained afebrile (with no fever). He was initially treated with [MEDICATION NAME] (an type of antibiotic) and switched [MEDICATION NAME](another type of antibiotic) as the Kiebsiella is pansensitive (sensitive to all types of antibiotics). His mental status has improved. Blood pressure stabilized. 2. Urinary tract infection. Kiebsiella pneumonia greater than 100,000 colonies sensitive to [MEDICATION NAME] and Cipro. Treated with 2 days of IV (in vein) [MEDICATION NAME] and switched to Cipro. 3. Chronic suprapubic catheter. Had significant growth and malodor when evaluated in the emergency department. Seems to have had a delay in being changed at the nursing home. Should be changed every 3-4 weeks." J. Record review of Departmental Notes dated 01/04/15 at 9:33 pm revealed "...draining clear yellow urine...resident had received IV therapy and hydration until discharge." K. On 02/05/15 at 2:16 pm during an interview with Registered Nurse (RN) #1 when asked what type of abnormalities might you find when assessing a foley catheter? She responded "Color, clarity, if you have blood or mucous, strong odor." When asked if there are abnomalities, what do you do? She responded "Look to see if there are other complaints, are they lethargic, change in mental status, temp (temperature). Sometimes they have mucous, sometimes you monitor that. Hematuria (bloody urine), if it got tugged or something. If they show a temp, you would call the doctor. Sometimes you don't need to call the doctor right away, but if it is real obvious. Chart it in the nurses notes and pass it along in report. If they are afebrile (not feverish), but symptoms persists, then call the doctor." L. On 02/05/15 at 5:59 pm during an interview with the Director of Nursing (DON), when asked about R #28's general condition before being hosptalized on [DATE], she stated "Typically his urine is really really dark. For him, that is normal. More than one occasion, we have sent a UA (Urine Analysis). There is a med that turns the urine a dark red." DON confirmed that the resident was not on a medication that would cause urine discoloration. When asked if the resident is chronically dehydrated, DON stated "Not so much. He usually eats and drinks what we give him. When asked if the resident's urine appeared cloudy, DON stated "He has mucous. Some may say cloudy." When asked if she ever observed purple urine, DON stated "Yes, I have heard people call it that. It is not typical of him." When asked if purple urine would that be a concern, the DON stated "If the color changed dramatically, I would be worried." DON was asked if a UA had been ordered when (name of MD #1) assessed the resident on 12/09/14, she confirmed that no UA results were in the resident's medical record. During interview with the DON, she called (name of MD #1) and asked him, "On 12/9/14 does your progress note mean the catheter site or the urine is purple?" DON stated that MD #1 confirmed it was urine and MD #1 thought that the resident was on a urinary antiseptic. DON confirmed the resident was not on a urinary antiseptic at the time of MD #1's assessment on 12/09/14. M. On 02/05/15 at 6:46 pm during an interview with RN #2, when asked if they document I&O's (Fluid intake and urinary output), she confirmed that they do not document I&O's. RN #2 stated "Not even for foleys. The CNA's (Certified Nurses Assistant) may do meals, but we rarely do I&O's for anyone." N. On 02/05/15 at 7:27 pm, R #28 was observed laying down in bed in his room with the bed in a low position. The resident's catheter bag was laying on the bare floor without a clean barrier underneath it. During the observation, RN #5, entered the resident's room and was interviewed. RN #5 confirmed that he was in the process of inspecting the resident's catheter system. At 7:40 pm, the resident's catheter bag was laying on the bare floor without a clean barrier underneath it.

Based on record review and interview, the facility failed to ensure that PHYS #1 monitored the changes in medical status for 1 (R #28) of 3 (R #22, 28, and 92) residents reviewed for urinary catheter use by not following up on the resident's urinary tract infection status after finishing antibiotics and not adequately investigating the source of the resident's urinary discoloration. This deficient practice likely resulted in R #28 [MEDICAL CONDITION] (wide-spread infection) related to a urinary tract infection requiring hospitalization . The findings are: A. Record review of Physician's Progress Notes for R #28 by PHYS #1 dated 11/04/14 revealed, "Recent problem. Low grade fever, Tmax (maximum temperature) about 100.3. Recent minor fall. Denies pain, difficulty urinating, cough or chest pain...urine is somewhat discolored. Assessment and Plan: low grade fever. Most likely urinary source. UA (Urine analysis) C&S (a test performed to determine the correct antibiotic to use on a bacteria), treat if symptoms suspected. Further workup if non diagnostic." B. Record review of Physician's Progress Notes for R #28 by PHYS #1 dated 12/09/14 revealed a notation that read, objective: "Indwelling catheter present, slightly purplelish discoloration." The assessment and plan for this problem area read "[MEDICAL CONDITION]. Supra pubic catheter. Recently changed. Not likely to be removed." C. Record review of Departmental Notes for R #28 dated 11/11/14 to 12/22/14 revealed notations that read: 1. 11/11/14: the resident was ordered the antibiotic, Bactrim, for five days for a urinary tract infection. 2. 11/13/14: "urine is dark yellow in color with small amounts of sediment." 3. 11/15/14: "draining yellow urine with small amounts of mucous noted." 4. 11/16/14: "yellow scant cloudy urine in cath (catheter) bag." 5. 11/18/14: "antibiotics are complete." 6. 11/23/14: "cloudy, yellow urine in cath bag." 7. 12/01/14: "Supra pubic catheter was flushed and is patent. Very little mucus (sic) present in urine bag. dark amber urine." 8. 12/07/14: "(Name of resident #28) presents with purple urine in catheter bag, tubing scant cloudy medium..." . 9. 12/08/14: "supra pubic cath was flushed and patent dark amber urine." 10. 12/21/14: "Catheter is patent draining dark amber urine." 11.12/22/14: "amber, cloudy urine in cath bag." 12. 01/01/15: "1030 (am) vomited x2 (twice), small amts (amounts) of yellow emesis (vomit), mucus (sic) drainage from nose, resp (respirations) increased, T (temperature) 101.9, 119 (pulse), 22 (breaths), 121/70 (blood pressure), O2 Sat (oxygen saturation) 91% at 2.5L (liters), unable to swalow (sic) tylenol tablets d/t (due to) nausea, (name of MD #1) notified, condition update given, new orders-transfer to (name of hospital #1), 110 (pm) resident transferred to (name of hospital #1) via ambulance, contact person, (name of family member #1) notified." D. On 02/05/15 at 5:59 pm during an interview with the DON (Director of Nursing), when asked about R #28's general condition before being hosptalized on [DATE], she stated "Typically his urine is really really dark. For him, that is normal. More than one occasion, we have sent a UA (Urine Analysis)." There is a med that turns the urine a dark red." DON confirmed that the resident was not on a medication that would cause urine discoloration. When asked if the resident is chronically dehydrated, DON stated "Not so much. He usually eats and drinks what we give him. When asked if the resident's urine appeared cloudy, DON stated "He has mucous. Some may say cloudy." When asked if she ever observed purple urine, DON stated, "Yes, I have heard people call it that. It is not typical of him." When asked if purple urine would that be a concern, the DON stated "If the color changed dramatically, I would be worried." DON was asked if a UA had been ordered when (name of MD) assessed the resident on 12/09/14, she confirmed that no UA results were in the resident's medical record. During interview with the DON, she called (name of MD) and asked him, "On 12/09/14 does your progress note mean the catheter site or the urine is purple?" DON stated that MD confirmed it was urine and MD thought that the resident was on a urinary antiseptic. DON confirmed the resident was not on a urinary antiseptic at the time of MD's assessment on 12/09/14. E. Record review of admission assessment by physician #2 (Name of Doctor of Osteopathic Medicine) dated 01/01/15 revealed, R #28 was admitted to the hospital for a primary [DIAGNOSES REDACTED]. Chronically ill elderly man with a supra pubic catheter, presenting [MEDICAL CONDITION]: fever, [MEDICAL CONDITION] and increased respiratory rate, borderline blood pressure. Urinary tract infection identified on urinalysis and by examination of his catheter. Prior UTI led to [MEDICAL CONDITION]." Another notation read "According the ER (emergency room ) nurse, his supra pubic catheter was very malodorous (strong odor) and covered with some growth. The catheter was changed in the ED (Emergency Department)." Resident's vital signs noted to be: Temperature 101.9, Pulse 119, and Respirations 22." The resident's white blood cell count (cells in the body indicating an immune system responce to infection) was high at 16.0 K (thousand)/mm3 (millimeters cubed), normal range is 4.0-10.0 K/mm3. F. Record review of the discharge summary by physician #3 (Name of medical Docotor) dated 01/04/15 revealed the resident's hospital course was noted as, "1.[MEDICAL CONDITION]. This is most likely secondary to urinary tract infection with Kiebsiella pneumoniae (a type of bacteria). His maximum temperature was on the evening of admission up to 102.6. He then defervesced (reduction in fever) and remained afebrile (with no fever). He was initially treated with [MEDICATION NAME] (an type of antibiotic) and switched [MEDICATION NAME](another type of antibiotic) as the Kiebsiella is pansensitive (sensitive to all types of antibiotics). His mental status has improved. Blood pressure stabilized. 2. Urinary tract infection. Kiebsiella pneumonia greater than 100,000 colonies sensitive to [MEDICATION NAME] and Cipro. Treated with 2 days of IV (in vein) [MEDICATION NAME] and switched to Cipro. 3. Chronic suprapubic catheter. Had significant growth and malodor when evaluated in the emergency department. Seems to have had a delay in being changed at the nursing home. Should be changed every 3-4 weeks."

The facility failed to ensure that 29 (1-29) out of 94 resident beds observed had safe, proper fitting mattresses and or side rails without gaps to promote safety and prevent injury. This deficient practice likely resulted in actual harm when Resident #3 got her feet caught in the bed frame and side rail and had to be transported to the Emergency Department (ED) for an evaluation. An Immediate Jeopardy (IJ) was identified on 03/07/12 at 1:30 pm. The administrator was notified of the findings for the IJ on 03/07/12 at 2:25 pm. The facility took corrective action by providing an acceptable Plan of Removal on 03/07/12 at 7:00 pm. The IJ was lifted on 03/08/12 at 5:34 pm and the scope and severity was lowered to an E. The Plan of Removal revealed the following: 1. The Director of Nursing (DON) and Director of Rehabilitation will compile a complete, updated list of side rails, half side rails and grab bars that are currently in place. The Assistant Director of Nursing (ADON) and the maintenance department will assess each and every one of the rails and grab bars to determine whether any spacing exists between the rail or bar and the bed and/or mattress or whether any rail or bar is loose or ill-fitting by 03/07/12. 2. The bars or rails determined to pose a risk to the resident's safety will either be removed or adjusted so that either no space exists or that they are not loose or ill-fitting. For those resident's determined to require the continued use of either a side rail, half rail or a grab bar, the facility staff will further assess the need within twenty-four hours (03/08/12), acquire orders and re-assess them on at least a quarterly basis from here on and will routinely check the bed rails or grab bars in use at least weekly as part of the weekly fall and restraint reduction meetings. 3. Following this initial bed rail and grab bar inspection and later today, the same facility staff will examine each and every mattress in the facility to determine whether any spacing exists between the mattresses and the bed frames. The list will be created tonight (03/07/12) and these mattresses will either be repositioned utilizing the mechanism in place on the bed frames to hold the mattresses in place and/or will be repositioned utilizing Velcro strips placed on the corners of the bed frames and on the bottoms of the mattresses to ensure there is no spacing between the mattresses and the head board or bed frame. 4. Any current mattresses that are ill-fitting will be replaced using the facility's medical equipment vendor, usually shipped in approximately 2-5 days. Based on observation, record review and interview the facility failed to develop and revise a care plan for 1 (Resident #3) of 15 (#1 through #15) residents. R #3 had two half side rails on the left side of her bed causing a large gap between the bed frame and side rails. R #3 was found on the floor with her feet caught up in the frame of the bed. This had the potential to harm 29 residents in the facility, listed on the CMS-802 provided by the Administrator on 03/07/12, identified as having improper fitting side rails or mattresses in which they could potentially get caught in between and sustain injury including death. The findings are: A. Record review of R #3's medical record revealed the following: 1. Review of the EMAR (Electronic Medication Administration Record) dated March 2012 for R #3 revealed a [DIAGNOSES REDACTED]. 2. The Initial Minimum Data Set ((MDS) dated [DATE] indicated the resident required extensive assist of one person for bed mobility and transfers. The care plan dated 03/07/12 did not indicate the resident used half rails for bed mobility. 3. The care plan dated 03/07/12, pg 1, approaches read, "Do not keep bedrails up unless necessary." 4. The Physical Therapy Progress Report dated 03/05/12-03/11/12 revealed the following, "Goal Topic: Bed Mobility, The patient rolls transfer supine (laying position) to sit from edge of bed in supine position without side rails with minimum assistance." B. On 03/07/12 at 11:00 am, observation of the resident's bed revealed two half rails on the left side of the bed. Both side rails were noted to be in the up position and were loose and collapsed into each other. A 8-10 inch gap was also noted between the bed frame and the side rails. The right side of the bed was up against the wall. C. On 03/07/12 at 11:08 am, during interview, Certified Nursing Assistant (CNA) #1 stated, "When I walked in, her (R #3's) feet were crossed at the head of the bed and caught in the side rail. Her toes were stuck in the side rail and her body was across the floor. It seemed like she fell on her head. She complained of her head hurting." D. On 03/07/12 at 12:20 pm, during interview, CNA #2 stated, "after lunch, R #16's son turned on the light and stated R #3 had fallen. Her (R #3's) feet where wrapped up in the side rail, her head towards the bottom (she hit the back of her head on the table) and she was very confused. The side rail was down but her feet were caught in the rails." E. On 03/07/12 at 1:00 pm, during interview, with the Director of Nursing (DON), she stated the staff tell her who needs side rails and she makes the decision to use them or not. Based on record review and interview, the facility failed to develop a Comprehensive Care Plan for 1 (R #4) of 3 (R #2, 3, 4) residents addressing fecal impaction and Urinary Tract Infection [MEDICAL CONDITION] for R #4. This deficient presents a risk that R #4 will not receive the care needed to address the fecal impaction and UTI and prevent them from re-occurring. The findings are: A. Review of R #4's admission History and Physical (H&P) dated 12/29/11, indicated constipation as a current diagnosis. The H&P indicated "the daughter tells me she (Name of R #4) will try to use the toilet, sometimes several times per hour, having very small somewhat hard stools. This can happen every few days and then stop for a month." B. Review of R #4's Care Plan for Drug Toxicity dated 01/11/12 indicated "the Certified Nurse Assistant (CNA) and Nursing are to monitor the resident's bowel elimination pattern and report any abnormalities to physician." C. Review of R #4's physician's orders [REDACTED]. D. Review of Physician's Progress Notes dated 02/28/12 indicated "Fecal impaction detected. Recently had UTI treated with Levoquin. Culture results have not arrived. Abdomen soft. Bowel sounds present. Enema: liquid with slight brownish discoloration." E. On 04/19/12 at 10:45 am, during interview, the Minimum Data Set (MDS) Coordinator stated "I did not know about the fecal impaction [DIAGNOSES REDACTED]. I did not know there were orders from the hospital and physician about a fecal impaction diagnosis. It (the UTI) was not specified in the Care Plan." F. Review of the facility's Policy and Procedure for Bowel Disorders revised October 2010 indicated "the nurse shall assess and document/report presence of fecal impaction. The physician will identify and order cause-specific and symptomatic interventions; e.g. institute a regimen to prevent constipation, etc. The staff and physician will monitor the individual's response to interventions and overall progress; for example ...frequency and consistency of bowel movements (BM)'s, and the frequency, severity and duration of abdominal pain."

Based on record review and interview, the facility failed to ensure that 1 (R#4) of 1 (R #4) resident was accurately assessed and monitored for constipation and incontinence. This deficient practice likely resulted in R #4 developing a urinary tract infection [MEDICAL CONDITION] and fecal impaction. The findings are: A. Review of R #4's admission History and Physical (H&P), dated 12/29/11, indicated constipation as a current diagnosis. The H&P indicated "(Name of R #4)'s daughter tells me she (R #4) will try to use the toilet, sometimes several times per hour having very small somewhat hard stools. This can happen every few days and then stop for a month." B. Review of R #4's Bowel and Bladder Roster Report, dated 01/01/12 through 02/22/12 indicated the Certified Nurse Assistants (CNA's) were documenting R #4's bowel movements (BM) every shift. C. Review of Physician's Progress Notes dated 02/28/12 indicated "Fecal impaction detected." D. Review of R #4's Electronic-Medication Assessment Record (E-MAR) Bowel and Bladder Report, dated 04/19/12 indicated "occasionally incontinent; bowel toileting program being used; constipation-yes." E. Review of R #4's physician's orders [REDACTED]. 1. "[MEDICATION NAME] powder, give with water 2 times/day Hold for diarrhea. Diagnosis: [REDACTED]. 2. "Two times daily enema soap suds. Give rectally 2 times daily until impaction clears. Auscultate (check for) bowel sounds and chart. Soap sud enema in medical room with detailed instructions attached. Diagnosis: [REDACTED]. 3. "[MEDICATION NAME] sodium 100 milligrams (mg) for constipation twice daily; [MEDICATION NAME] give 17 grams (gm) in 8 ounces (oz.) water Diagnosis: [REDACTED]. F. Review of the facility's Policy and Procedure for Bowel Disorders (revised October 2010) indicated "the nurse shall assess and document/report presence of fecal impaction. The physician will identify and order cause-specific and symptomatic interventions; e.g. institute a regimen to prevent constipation, etc. The staff and physician will monitor the individual's response to interventions and overall progress; for example ...frequency and consistency of bowel movements (BM)'s, and the frequency, severity and duration of abdominal pain." G. Review of R #4's physician's orders [REDACTED]. H. Review of R #4's Physician's Progress Notes dated 02/28/12 indicated "Recently had UTI treated with Levoquin. Culture results have not arrived." I. On 04/19/12 at 9:20 am, during interview, Licensed Practical Nurse (LPN) #1 stated "I don't understand why she (R #4) got fecal impaction or what caused it. Her feces are watery all the time." LPN #1 stated she does "not monitor (Name of R #4)'s BM's. The CNA's take care of checking her BM's. I did not observe anything regarding symptoms for (Name of R #4)'s UTI." J. On 04/19/12 at 10:30 am, during interview, the Director of Nursing (DON) stated "(Name of R #4) many times gives BM information to the CNA, without their witnessing it. (Name of R #4) was telling the CNA's what to document in the Bowel Movement Report, without eye witnesses to the size, consistency, frequency of R #4's BM's." When asked about the cause of R #4's fecal impaction, the DON stated "she (R #4) has small or medium formed bowel movements. We are teaching her to be independent with the bathroom. She (R #4) is going to the bathroom on her own and needs limited assistance with toileting." When asked if the CNA's or nursing actually see her BM's before they record the information on the Bowel and Bladder Report, the DON stated "she (R #4) might be flushing her own toilet and telling the CNA's the size, etc." K. On 04/19/12 at 10:45 am, during interview, the MDS Coordinator stated "I did not know about the fecal impaction [DIAGNOSES REDACTED]. I did not know there were orders from the hospital and physician about a fecal impaction diagnosis."

The facility failed to ensure that Resident #1 did not develop avoidable pressure sores, received the necessary treatment and care to promote healing, prevent infection and to prevent new sores from developing. Resident #1 developed 12 pressure ulcers within 26 days of admission to the facility, This resulted in an Immediate Jeopardy (IJ) being identified on 05/31/11 at 4:55 pm. The Administrator was notified of the findings for the IJ on 06/01/11 at 10:45 am. The scope and severity was lowered to a scope and severity of G after the facility submitted their Plan of Removal. The facility took corrective action by providing an acceptable Plan of Removal on 06/01/11 at 2:36 pm. The Plan of Removal indicated that the Director of Nursing (DON) would conduct performance reviews with the Certified Nurse Assistants (CNAs) to determine specific areas of care that would require additional training. The facility revised the resident skin check sheet for the use of licensed nurses as well as CNAs. The skin check list would be used for skin checks upon admission, during routine incontinent care, during bathing and during transfers within the facility or discharges from the facility. The licensed nurses would begin informational rounds with the CNAs at the end and beginning of every shift. The DON would write a protocol for incontinent care and skin care and re-train all licensed nurses and CNAs. Nurses were to begin weekly skin assessments on every resident. The assessments were to be monitored by the DON. The wound care specialist would document all open skin areas on the wound log and update the DON on a routine basis. Based on record review and interview the facility failed to ensure that 1 (#1) of 2 (#1 and #2) residents were provided with routine perineal care, preventative skin care and wound care. This deficient practice resulted in Resident #1 developing a rash, which lead to avoidable pressure ulcers. The facility also failed to maintain the skin integrity for Resident #1 and #2 and therefore both residents experienced a decline in skin integrity which was avoidable. The findings are: A. Record review of Resident #1's hospital discharge orders dated 03/24/11 revealed recurrent [MEDICAL CONDITION] (a bacterial skin infection) to the right leg, poorly controlled diabetes, [MEDICAL CONDITION], hypertension and [MEDICAL CONDITION]. There was no mention of the resident having pressure ulcers. Resident #1 was discharged to the facility to work on functional mobility and gait training before being discharged to home. B. Review of Resident #1's record revealed the following information: 1. Nursing Admission Form dated 03/24/11 revealed a notation of a reddened area to the posterior lower extremities but that the skin was intact. The admitting nurse Licensed Practical Nurse (LPN) #1 checked that Resident #1 was continent of bowel and bladder but wanted to use briefs at night. 2. The admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was compliant with care, was on a toileting program due to frequent urinary and bowel incontinence. The MDS also indicated that the resident was not at risk for pressure ulcers, and did not have any pressure ulcers although pressure ulcers were identified as a potential issue to be care planned. The discharge MDS dated [DATE] indicated Resident #1 was discharged with no pressure ulcers and without skin problems identified. 3. The initial nutrition assessment dated [DATE] documented poor skin integrity and increased protein needs due to "wounds." 4. The March 2011 monthly nursing summary was not signed by the nurse and did not include the date of the assessment. The nurse documented, "position every 2 hours by self, incontinent of bowel and bladder, assist to bathroom and briefs to be worn at all times. No skin breakdown." 5. The skin roster (a form the CNAs use to document skin concerns) dated 03/24/11 through 04/19/11 for Resident #1, revealed that CNA #1 charted skin issues on the following dates: 03/27/11, 04/11/11, 04/16/11 and 04/17/11. CNA #11 charted skin issues on 04/17/11 only. The report also indicated, "New skin concerns, nurse notified." 6. Review of the interim plan of care dated 03/26/11 revealed that Resident #1 was to be toileted "with assist (sic) of one person, self-control for bowel and bladder status." The section for skin integrity was left blank upon admission on 03/24/11. A notation indicate that the resident was at risk for skin breakdown and was to be repositioned every 2 hours while in bed. 7. A care plan conference was held on 04/06/11 to address the resident's needs. The resident was identified with the potential for skin breakdown, assistance was needed for bed mobility and he had frequent incontinence. Interventions included providing protective and preventative skin care after each shower or episodes of incontinence and total body checks after each shower or bath to be signed off by nursing. The resident was also to be repositioned every hour when up in the wheelchair and every 2 hours when in bed. The perineal area was to be cleansed with soap and water following each urination and bowel movement. 8. On 04/12/11 an update to the care plan included instructions for staff to apply [MEDICATION NAME] ointment to peri area, coccyx and inner thigh frequently. Resident #1 required "assistance to toilet by staff, not always aware of his own toileting needs, wears depends (an undergarment for incontinence) daily, staff assist with toileting schedule with goal to reduce the number of incontinent episodes to less than 6 per day." The approach also included instructions to "place resident on toileting schedule and to toilet in am, after meals, afternoon, before dinner and before bed, document continent episode on CNA smart charting. Evaluate resident's continence and establish a toileting schedule effective for resident to reduce number of incontinent episodes." C.Record Review of Resident #1's re-admission to the hospital on [DATE] revealed he was admitted to the emergency room (ER) at 2:18 pm. The facility sent the resident to the ER and documented a telephone order dated 04/19/11 at 1:30 pm to send to the ER. 1. The triage assessment at the hospital was completed on 04/19/11 at 2:18 pm by Physician Assistant (PA)# 1 documenting [DIAGNOSES REDACTED]. 2. An ER nursing note dated 04/19/11 at 4:50 pm by RN #7 stated, "(Name of Director of Day Medicine), from wound care came down in to consult and take measurements of decubitus ulcers observed by the PA (#1), the paramedic (PM #1) and myself." RN #7 also stated that the DDM documented this information in the official chart. 3. MD #3 completed and signed a multi-system evaluation of R#1 on 04/19/11 at 3:19 pm documenting 12 total decubiti ulcers (pressure ulcers), Candidiasis in groin, Acute [MEDICAL CONDITION], dehydration, [MEDICAL CONDITION] (higher than normal potassium levels in the blood) and Leukocytosis (abnormal amount of white blood cells in the blood indicating bacterial infection) signed by attending physician, MD #3. R #1 was transfered from the ED to the hospital's medical surgurical departmenton 04/19/11 at 8:00 pm. 4. The hospital's wound care report dated 04/20/11 and initial wound consultation revealed, "Bilateral necrotic (dead tissue cells) heel ulcers, multiple buttock wounds, groin wounds bilateral, sacral ulcers, right elbow eschar (scab or crust that forms on skin after a burn) and, left posterior upper thigh X2. Presented to ER with multiple wounds." The wound care specialist (DDM) documented a total of 18 open skin areas. The report also revealed that Resident #1 was incontinent of bowel and bladder. The hospital transfer/discharge summary dated 04/26/11, revealed the resident had to be transferred to another hospital for specialty wound care. D. Record Review of the wound care logs in the facility for the months of March and April 2011 did not indicate that Resident #1 was receiving wound care. E. On 05/11/11 at 2:40 pm, during an interview with Physical Therapist (PT) #1 confirmed that Resident #1 did not receive any type of wound care. F. On 05/11/11 at 4:00 pm, during an interview with Case Manager #1 from the hospital stated, "I received a phone call from the ER staff when (Name of Resident #1) was brought in because they were very upset." Case Manager #1 stated both he and the wound care specialist had to speak to the staff and calm them down since Resident #1 looked really bad. He also stated Resident #1 was "admitted with 18 documented wounds (12 were pressure ulcers) to the skin from the facility." G. On 05/12/11 at 9:15 am, during an interview with the Director of Day Medicine and the wound care specialist at the hospital they stated, "18 separate open areas were documented upon admission. One third of the wounds were necrotic, one old blister and about 50% slough and granulation (separation of dead tissue from normal or living tissue, growth of connective tissue that form on the surfaces of a wound during healing process). I made a report and took pictures. I understand that some of the areas (Name of Resident #1) could have picked but his heels and toes were not new wounds, they were old, necrotic and I was concerned about care issues for him. The wounds on his feet and heels were clearly pressure ulcers." H. Record review of the wound consultation report dated 04/20/11 by the Director of Day Medicine from the hospital recorded the following wound sites and measurements: " 1. Left elbow 1.0 X 0.4 cm 100% eschar 2. Right elbow 0.4 X 0.4 cm 100% eschar 3. Sacrum 1.2 X 0.3 X 0.1 cm 100% granulation 5. Left Heel 6.5 X 5.0 cm 100% necrotic 6. Right Heel 4.5 X 4.0 cm 100% necrotic 7. Right buttock 3.0 X 1.8 X 0.2 cm 90% eschar 8. Right buttock 4.2 X 3.8 X 0.2 cm 50% necrotic 9. Sacrum 1 X 0.5 X 0.1 cm slough 10. Scrotum 1.5 X 1.0 cm 100% necrotic 11. Left post. thigh 1.0 X 0.8 X 0.1 cm 90% necrotic left post. thigh 1.8 X 1.5 cm 100% necrotic 12. right post. thigh 5.8 X 4.0 cm 100% necrotic right post thigh 7.0 X 3.5 cm Old blister 13. right lateral foot 1.0 X 0.6 cm 14. left lateral foot 0.6 X 0.5 cm 15. Left 5th toe 1.0 X 1.0 cm necrotic 16. left buttock 4.2X3.8X0.2xm 50%necrotic " I. On 05/12/11 at 10:15 am, during an interview with PT #1 who was also the wound care specialist for the facility, stated the nursing staff gave her referral forms regarding Resident #1's skin condition but it was problems from his brief. PT #1 stated she had no knowledge of open areas on the resident's feet. PT#1 confirmed that CNA #1 had completed a skin care referral sheet. PT #1 stated CNA#1 knew about the heels and completed a referral. PT #1 stated she and the Compliance Officer were already working on a form for the CNAs to document skin issues using the anatomical figure. When asked if she knew about all the open areas on Resident #1's backside and why she did not include the resident on the wound log, she stated, "I knew the Medical Director (MD) #1 was coming in the next day and I wanted him to look at it first." During record review the following were the referral forms: 1. The referral form dated 04/11/11 revealed open areas to buttocks. 2. The referral form dated 04/15/11 revealed buttock area was excoriated. 3. The referral form dated 04/16/11 revealed red soft area on right outer knee from leg brace close to opening up. 4. The referral form dated 04/17/11 revealed 2 open areas, one to the left inner thigh and the other (deeper) on the right inner buttock near the scrotum. 5. The referral form dated 04/17/11 read, "Treatment needed, butte paste not helping." PT #1 wrote a note on the referral form dated 04/17/11 that areas were checked and all irritation were due to the briefs and that nursing was to change from briefs to pull ups and to encourage Resident #1 to spend less time in wheelchair with periods in bed. PT#1 wrote that MD #1 was to see the resident the next day. PT #1 confirmed she did not add the resident to the wound care report until 04/19/11 when the Resident #1 was seen by MD #1, 8 days after the first referral was made. J. On 05/12/11 at 10:30 am, during an interview with Registered Nurse (RN) #3, she confirmed she worked the night shift and that Resident #1 was compliant with care. She stated he did not refuse staff changing him when he was incontinent. She stated the staff reported his buttock was excoriated and that when she examined him she stated, "I saw it, his skin was open, oozing a lot of drainage, hard to tell exactly where it was coming from since his skin was so discolored." RN #3 stated she reported it to the day nurse on 04/18/11 in the morning and filled out a "Nursing-to-Therapy Referral form." RN #3 denied knowing Resident #1 had pressure ulcers or wounds to the feet or heels. K. On 05/12/11 at 11:00 am, during an interview with Minimum Data Set (MDS) coordinator she stated she checked Resident #1's skin on admission and there were no open areas. She confirmed that she got the information for the discharge MDS from PT #1. The MDS coordinator stated, "I didn't get to examine him so I documented what (Name of PT#1) told me. (Name of Resident #1) did not have open areas." The MDS coordinator confirmed there were no skin issues. The DON was present during the interview and confirmed the information in the "Kiosk smart charting system" from the CNAs was not accurate or reliable and stated, "There are communication issues between the CNAs and nurses and it needs to be fixed now." The DON confirmed there was no toileting schedule or follow-up on Resident #1's care plan related to urinary incontinence and skin care. The DON confirmed that the facility did not have a protocol for incontinence care or skin care for the CNAs to follow. L. On 05/12/11 at 11:50 pm, during an interview with CNA #1 he stated, "(Name of Resident #1) started to get ulcers on his bottom due to the briefs. (Name of Resident #1) came here with ulcers on his heels but weren't as bad as when he was sent out." CNA #1 confirmed that Licensed Practical Nurse (LPN) #2 knew about the ulcers because LPN #2 showered the resident. CNA #1 stated LPN #2 put cream on him. CNA #1 stated that "(Name of Resident #1) was very weak and needed a lot of assistance but was compliant with care and was very easy to get along with." CNA #1 stated that Resident #1 never refused incontinent care or showers and did require assistance from other CNAs for transfers. CNA #1 stated LPN #2 was notified of the resident's sores because they were so bad they were bleeding. CNA #1 denied knowledge of Resident #1's care plan. M. On 05/12/11 at 1:35 pm, during an interview with LPN #1, she confirmed she completed the admission paper work for Resident #1 and that his skin was intact and that he did not have any open areas on admission and nothing was reported to her by the CNAs on duty. N. On 05/12/11 at 2:00 pm, during an interview with CNA #2 she confirmed that Resident #1 was compliant with care. CNA #2 stated she reported to (LPN #2, #3, #4, and #5) that Resident #1 had a bad rash to his buttocks and his feet were red and leaking fluid. CNA #2 stated that the nurses and other CNAs (who she did not name) were aware of R #1's skin problems. When asked what directions the nurses (LPN #2, #3, #4 and #5) gave her, she stated, "We put cream on his rash to his groin and buttock, they never told us what to do about his feet, but they all knew." CNA #2 denied having knowledge of Resident #1's care plan needs. O. On 05/12/11 at 2:40 pm, during an interview CNA #3 stated she reported that R #1 had a bad rash on his inner legs. She stated "Very red and the size of enchiladas." She denied knowing about treatment to his feet and stated the CNAs put cream on his inner thighs and to the pressure ulcers on his buttocks but that the nurses were suppose to treat his feet. CNA #3 reported Resident #1's feet were bleeding a lot and the nurses (who she did not name) were aware. P. On 05/12/11 at 4:00 pm, during an interview, CNA #4 stated she reported that Resident #1 had "granitos" on his buttocks. An unidentified staff member translated "granitos" (a Spanish word) as "pimples." CNA #4 stated "His bottom and his feet would bleed and liquid came out of the pimples on his skin." CNA #4 stated the nurses gave her cream to apply to the pressure ulcers on his buttocks and denied treating his feet. CNA #4 stated "I usually work with RN #3 and she took care of him." CNA #4 stated his feet were not her responsibility, that it was the nurse's responsibility. Q. On 05/13/11 at 1:30 pm, during an interview, LPN #2 stated she usually worked weekends and no showers were given on the weekends so she did not have any reason to do a body check on Resident #1. LPN #2 stated a CNA (did not name the CNA) had informed her that Resident #1's bottom was bleeding and they put cream on him in accordance to PT #1's instructions. LPN #2 stated she filled out a Nursing-to-Therapy referral form on 04/17/11 due to the open areas on his buttocks and because there was no improvement. LPN #2 denied having any knowledge of the wounds to his feet or heels. R. On 05/13/11 at 8:30 am, during an interview with Medical Doctor #2 confirmed Resident #1 was his patient and "(Name of R #1) was pretty immobile and he was aware of early skin breakdown." When asked about Resident #1 having 18 open areas upon admission to the hospital he stated, "I can't answer any specific questions." MD #2 referred questions back to MD #1. S. On 05/16/11 at 3:30 pm, during an interview MD #1 stated "There was a note from staff to check his skin due to brief issues." MD #1 stated when Resident #1 went to his office he did not get to see his skin. MD #1 stated he was not aware of any open areas or pressure ulcers and there was no report about his feet. T. On 05/26/11 at 1:08 pm, during an interview with the DON confirmed that there was not a facility protocol for urinary incontinence care and skin care for the CNAs to refer to. U. On 05/31/11 at 3:15 pm, during an interview CNA #6 stated she was not aware of her residents incontinence care needs and was just going to use peri wash and wipes. V. On 05/31/11 at 4:18 pm, during an interview CNA #7 stated she used wipes for incontinence care, but stated "Not everybody does." When asked for clarification, she stated, "Some of the CNAs just change the briefs without cleaning their skin. We need to use the wipes mainly for the smell." W. On 06/01/11 at 9:45 am, during an interview, Unit Clerk (UC) #1 confirmed the dry wipes were to be placed in a Ziploc bag and the CNAs add water to moisten them. She pointed to the case of dry wipes and stated, "They do not contain any cleanser they are just dry wipes." X. Record review from the wound care hospital where Resident #1 was transferred to on 04/26/11 the following documentation was revealed: 1. History & Physical dated 04/26/11 read Chief Complaint: "Multiple necrotic ulcers... (Name of Resident #1) noted to have multiple buttock chemical burns, it looks like a stage III, a sacral ulcers, penile ulcerations, again from urine and a penile laceration... bilateral necrotic heel pressure ulcers. " 2. physician progress notes [REDACTED]. physician progress notes [REDACTED]. 3. Upon admission the nurses note dated 04/26/11 revealed 12 pressure ulcers, community acquired and perineal [MEDICAL CONDITION], anterior scrotum open, scrotal and penile ulcers. Pressure ulcers as listed below: a. Coccyx Stage II b. right medial thigh Stage III c. right posterior thigh Stage III d. posterior scrotum Stage III e. left medial thigh Stage III f. left posterior thigh Stage III g. left medial proximal thigh Stage III h. left medial distal thigh Stage III i. right lateral mid foot Unstageable j. right lateral heel Unstageable k. left 5th metatarsal head Unstageable l. left lateral heel Unstageable Y. Record review of the admission nursing assessment for Resident #2 dated 05/09/11 at 2:40 pm documented the resident's skin condition as "bruise left forearm and outer hand, several scratches, scabbed areas on lower legs, three bruises on abdomen, buttock, rectal area red, scar and bruises on right forearm." It was also documented that Resident #2 was incontinent of bowel and had a Foley Catheter (a tube inserted into the urethra for urination) in place. Z. Record review of Resident #2's interim plan of care dated March 2011 revealed, "Potential for skin breakdown R/T (related to) dx (diagnosis) decreased mobility/bedridden." The Approach read, "Assist with repositioning while in bed, keep skin clean and dry, assess skin daily for breakdown." AA. Record review of the initial wound consultation for R #2 at (name of hospital) dated 05/17/11 revealed the following: " 1. ...stage II pressure ulcer to sacrum with large area of non-blanchable [DIAGNOSES REDACTED] (indicative of a stage I pressure ulcer). 2. Sacral stage II pressure ulcer measurement of length 10 centimeters (cm) by width 5 cm." BB. Record review of wound care progress notes dated 05/19/11 documented Resident #2's sacral pressure ulcer measurement as length 4 cm by width 1.8 cm. CC. Record review of the hospital physician orders [REDACTED]." DD. On 05/26/11 at 8:10 am, during an interview with the Director of Family Medicine, Family Nurse Practitioner (FNP), and Wound Care Specialist at the hospital stated that Resident #2 had been admitted to the hospital from the facility with a Stage II pressure ulcer measuring 10 cm by 5 cm on his sacrum EE. On 05/26/11 at 9:00 am during an interview, CNA #1 stated, "Some nurses tell us if residents have UTIs, wounds and some don't." FF. On 05/26/11 at 10:15 am during an interview with PT #1, stated that she did all of the wound care in the facility. PT #1 stated that she was not aware that Resident #2 (who was in the facility 05/09/11-05/15/11) had any skin pressure areas. PT #1 confirmed that Resident #2 was not listed on the wound care log. GG. On 05/26/11 at 1:30 pm, during an interview LPN #2 stated that Resident #2 was admitted on [DATE] with a stage l pressure ulcer on his sacrum and a few small scabbed areas. HH. On 05/26/11 at 2:40 pm, during an interview with RN #4, he stated that he did not notice any skin problems for Resident #2. II. On 05/27/11 at 10:30 am, during a telephone interview with RN #1, he stated that he did not know of any skin problems with Resident #2.

The facility failed to ensure that Resident #2 was free from harm and aspiration due to improper feeding and positioning. This resulted in an Immediate Jeopardy (IJ) being identified on 05/31/11 at 4:00 pm. The administrator was notified of the findings for the IJ on 06/01/11 at 10:45 am. The facility took corrective action by providing an acceptable plan of removal on 06/01/11 at 2:00 pm. The plan of removal included immediate intervention to begin with the lunch time meal on 06/01/11 from 11:30 am to 1:00 pm. The Minimum Data Set (MDS) coordinator and the director of rehabilitation, with the assistance of the Speech Language Pathologist, the Dietary Manager and the four licensed charge nurses on duty, to supervise and monitor all residents, specifically those residents who were at risk for aspiration, were eating or being assisted with their feeding in the proper seating position in their wheelchairs or chairs or were properly positioned upright in their beds and were being supervised during their entire meal. Additionally, the Director of Nursing (DON) would complete performance reviews with the Certified Nurse Assistants (CNAs) to determine specific areas of care that will require additional training. The licensed nurses would begin informational rounds with the CNAs at the beginning and end of every shift starting on 06/01/11. The DON would write a protocol for aspiration risk prevention care and re-train all licensed nurses and CNAs. The plan of removal was accepted on 06/01/11 at 2:00 pm and the scope and severity of the deficiency was lowered to G. Based on record review and interview the facility failed to provide proper safety protocols while feeding and positioning one (#2) of four (#2 - #5) residents with who were at risk for aspiration. This deficient practice had the potential to cause harm to three other residents (#3 - #5) who were also at risk for aspiration. The findings are: A. Record review of Resident #2 physician admission orders increasingly difficult to care for by family; dementia, history of cerebral vascular accident, bedbound, indwelling Foley catheter, oxygen dependent, and Hypertension." On 05/09/11, therapy orders were received for physical therapy, occupational therapy, and speech therapy. Diet ordered on [DATE] was for "Mech (mechanical) soft NAS (no added salt)." Activity orders for transfers complete assist in accordance to Physical Therapy (PT) recommendations. "ST (Speech Therapy) eval (evaluation) plus swallow eval plus ST 5 x a week for orientation to facility and time concepts STM (Speech Therapy Management) and prob solv (problem solving) for safety and ADLs (Activities of Daily Living) assess diet texture and monitor po (by mouth) intake." B. Record review of the admission nursing assessment sheet dated 05/09/11 included an oral assessment that revealed, "No teeth, eats soft food, and needs assist." C. Record review of the initial nutrition assessment dated [DATE] revealed that the resident "Eats in bed, needs assist, difficulty chewing, Speech Therapy doing eval, diet order, regular/soft foods, no teeth." D. Record review of Speech Therapy plan of treatment dated 05/09/11 revealed primary [DIAGNOSES REDACTED]. The initial assessment dated [DATE] revealed that the resident was an "aspiration risk." The assessment section indicated, "Patient presents with dysphagia, decreased PO (by mouth) intake, decreased orientation to his room and to time concepts, difficulty with functional problem-solving for safety and ADL influencing ability to function and eat safely in his room and would benefit from skilled ST." E. Record review of physicians order dated 5/13/11 revealed "Diet clarification change to puree." F. Record review of interim plan of care dated, May 2011 revealed Resident #2's diet as "Regular" and also as "Pureed with regular fluids, mouth care by staff, no dentures and no teeth." G. Record review of Speech Therapy plan of treatment change log dated 05/15/11 revealed, "COG (cognitive)-Problem Solving-Patient demonstrates functional problem solving and safety awareness for daily living tasks verbal and visual cueing with marked ((frequent direction required in several situations) level of impairment." H. Record review of the daily skilled notes dated 05/15/11 revealed, "Resident up in wheelchair for two hours, taken to dining room for lunch, has been sleepy all shift and ate 25% of lunch meal, he was too sleepy to eat breakfast, and was physically unable to eat dinner. At 0600 (6:00 pm) resident was observed to be in respiratory distress, was lethargic (abnormal drowsiness or stupor), R (respirations) 44/min (normal range 16-20 per minute), BP (blood pressure) 100/58 (average 120/80), P (pulse) 100 (average 60 to 80 beats per minute), T (temperature) 98.8, O2 Sat (oxygen saturation) 86% (normal above 90%) on 3 L (liters) NC (per nasal canula), and is diaphoretic (profuse perspiration), increased O2 to 4 L, pulled resident up in bed, and elevated HOB. Called residents son to notify of fathers condition, he asked that I send out this resident to ER (emergency room ), notified PA (Physician Assistant #1) of resident's current condition and agreed to send resident to ER, transported via ambulance." I. Record review of the facility's policy on "Dysphagia-Clinical Protocol" dated 2005 revealed, "Treatment/Management, that the staff and physician would try to identify simple interventions to manage the situation for example, allowing the individual to eat more slowly, or addressing factors that make the individual less attentive or drowsier during meal times." J. Record review of History and Physical at the hospital dated 05/15/11 revealed an admitting [DIAGNOSES REDACTED]. "Aspiration pneumonia results from inhalation of foreign matter, such as vomitus or food particles, into the bronchi" (Springhouse Corporation - Diseases, second edition). K. Record review of the progress notes signed by the physician at the hospital dated 05/16/11 documented, "Aspiration Pneumonia - speech eval, thickened/puree diet. L. Record review of the physician's orders [REDACTED]." M. Record review of the physician's orders [REDACTED]." N. Record review of the ER triage assessment dated [DATE] at 7:49 pm revealed, "Pt (patient) brought in EMS (Emergency Medical Service) from the facility, Pt O2 sat 60 O2 (Patient's oxygen saturation 60 %), Pt aspirated, gastric contents on shirt observed." O. Record review of the physician's orders [REDACTED]." P. On 05/26/11 at 11:50 am, during an interview with Social Worker #2, she stated that she had been working with Resident #2 and was unaware of reason for his hospital transfer on 05/15/11. Q. On 05/26/11 at 1:15 pm, during an interview with the Dietary Manager, she stated that Resident #2 was admitted on [DATE] on a regular diet with soft foods by the physician. She stated that Resident #2 did not have any teeth but that people who do not have teeth can, "Gum it." She stated that dietary had not seen him yet because that was not required until the resident had been there "fourteen" days. R. On 05/26/11 at 1:30 pm, during an interview with Licensed Practical Nurse (LPN) #2, she stated that she did not know that Resident #2 had pneumonia while in the hospital just prior to his admission to the facility. She stated that the CNAs do the vital signs and told her that Resident #2's O2 saturation (sat) level was low at 84%. LPN #2 stated that she did not follow-up on the resident's O2 sat level even though it was low on admission. LPN #2 stated that she ordered a "Regular" diet for Resident #2 by mistake. She stated that the doctor ordered a "Soft" diet. S. On 05/27/11 at 10:30 am, during a telephone interview with Registered Nurse (RN) #1, who was responsible for Resident #2's care on 05/15/11 for the 7:00 am to 7:00 pm shift, stated, "I walked into (Name of Resident #2's) room where he was in bed at 6:00 pm, right after his supper meal and found him in respiratory distress." RN #1 stated, "(Name of Resident #2's) Head of Bed (HOB) was slightly elevated at 30 degrees when I walked into his room at 6:00 pm." RN #1 stated that the staff had gotten the resident up in a Wheelchair (w/c) at 10:00 am that day and that the resident had been too tired to eat breakfast. RN #1 stated that Resident #2 had been sleepy all shift and had only eaten a small portion of his lunch while sitting up in a w/c in the dining room. RN #1 stated that the resident had been fed in bed for the supper meal and that the resident had not eaten well. RN #1 stated that Resident #2's oxygen saturation was 85% to 87% (normal range 90%-100%) on 3 liters per minute and that "his lungs sounded moist with gurgles and rhonchi (low-pitched, snoring, rattling sounds that occur when fluid partially blocks the large airways.)" RN #1 stated that when he found Resident #2 in respiratory distress that he raised the head of the resident's bed and increased the oxygen from three to four liters per minute. RN #1 stated he first notified the resident's son and then Physician's Assistant (PA) #1 of Resident #2's condition. RN #1 stated that PA #1 told him to send the resident to theER on [DATE] in accordance to the son's request. T. On 06/01/11 at 10:30 am, during an interview with ST #2, she stated that "Residents are at greater risk for aspiration when fed in bed." She also stated that "The HOB should be elevated as close as possible to 90 degrees while the resident is eating in bed." ST #2 stated, "The HOB should remain at 90 degrees for at least 30 minutes after a meal consumption to help prevent aspiration." She stated "Residents should only be fed when they are alert." ST #2 stated she "worked with (Name of Resident #2) on 05/13/11 and 05/14/11 and that he was at risk for aspiration. She also stated that the resident "should be fed sitting upright in a chair in the dining room where he was visible to staff for safety precautions." ST #2 confirmed that Resident #2 was not safe to eat by himself.

Based on observation, record review and interview the facility failed to ensure 2 (#1 and #2) of 2 (#1 and #2) residents were provided care to promote their highest practicable physical well-being. The facility failed to ensure that 1 (#1) of 2 (#1 and #2) residents were provided with routine perineal care, preventative skin care and wound care. This deficient practice resulted in Resident #1 developing a rash, which lead to avoidable pressure ulcers. The facility also failed to maintain the skin integrity for Resident #1 and #2 and therefore both residents experienced a decline in skin integrity which was avoidable. The facility also failed to provide proper safety protocols while feeding and positioning Resident #2 who was at risk for aspiration. The findings are: A. Record review Resident #1's hospital discharge orders dated 03/24/11 revealed recurrent [MEDICAL CONDITION] (a bacterial skin infection) to the right leg, poorly controlled diabetes, [MEDICAL CONDITION], hypertension and [MEDICAL CONDITION]. There was no mention of the resident having pressure ulcers. Resident #1 was discharged to the facility to work on functional mobility and gait training before being discharged to home. B. Review of Resident #1's record revealed the following information: 1. Nursing Admission Form dated 03/24/11 revealed a reddened area to the posterior lower extremities but the skin was intact. The admitting nurse Licensed Practical Nurse (LPN ) #1 documented that Resident #1 was continent of bowel and bladder but the that the resident wanted to use briefs at night. 2. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was compliant with care, was on a toileting program due to frequent urinary and bowel incontinence. The MDS also indicated that the resident was not at risk for pressure ulcers, and did not have any pressure ulcers although pressure ulcers were identified as a potential issue to be care planned. The discharge MDS dated [DATE] indicated Resident #1 was discharged with no pressure ulcers and without skin problems identified. 3. The initial nutrition assessment dated [DATE] documented poor skin integrity and increased protein needs due to "wounds." 4. The March 2011 monthly nursing summary was not signed by the nurse and did not include the date of the assessment. The nurse documented, "position every 2 hours by self, incontinent of bowel and bladder, assist to bathroom and briefs to be worn at all times. No skin breakdown." 5. The skin roster (a form the Certified Nursing Assistants (CNAs) use to document skin concerns) dated 03/24/11 through 04/19/11 for Resident #1, revealed that CNAs #1 charted skin issues on the following dates: 03/27/11, 04/11/11, 04/16/11 and 04/17/11. CNAs #11 charted skin issues on 04/17/11 only. The report had a notation, "New skin concerns, nurse notified." 6. Review of the interim plan of care dated 03/26/11 revealed that Resident #1 was to be toileted "with assist (sic) of one person, self-control for bowel and bladder status." The section for skin integrity was left blank upon admission on 03/24/11. Documentation that the resident was at risk for skin breakdown was added on 03/26/11 and the approach was to reposition every 2 hours while in bed. 7. A care plan conference was held on 04/06/11 with the following needs addressed, "Potential for skin break down, assistance was needed for bed mobility, and frequent incontinence." Interventions included providing protective and preventative skin care after each shower or episodes of incontinence and total body checks after each shower or bath to be signed off by nursing. The resident was also to be repositioned every hour when up in the wheelchair and every 2 hours when in bed. The perineal area was to be cleansed with soap and water following each urination and bowel movement. 8. On 04/12/11 an update to the care plan included instructions for staff to apply [MEDICATION NAME] ointment to peri area, coccyx and inner thigh frequently. Resident #1 required "assistance to toilet by staff, not always aware of his own toileting needs, wears depends (an undergarment for incontinence) daily, staff assist with toileting schedule with goal to reduce the number of incontinent episodes to less than 6 per day." The approach also included to "place resident on a toileting schedule and to toilet in am, after meals, afternoon, before dinner and before bed, document continent episode on CNAs smart charting. Evaluate resident's continence and establish a toileting schedule effective for resident to reduce number of incontinent episodes." C. Record Review of Resident #1's re-admission to the hospital on [DATE] revealed he was admitted to the emergency room (ER) at 2:18 pm. The facility sent the resident to the ER and documented a telephone order dated 04/19/11 at 1:30 pm to send to the ER. 1. The triage assessment at the hospital was completed on 04/19/11 at 2:18 pm by Physician Assistant (PA)# 1 documenting [DIAGNOSES REDACTED]. The integumentary (skin) assessment noted 3 ulcers to penile area. Two 1cm (centimeter) ulcers noted to shaft of penile area and one 1cm ulcer noted to foreskin. 2. An ER nursing note dated 04/19/11 at 4:50 pm by RN #7 stated, "(Name of Director of Day Medicine), from wound care came down in to consult and take measurements of decubitus ulcers observed by the PA (#1), the paramedic (PM #1) and myself." RN #7 also stated that the DDM documented this information in the official chart. 3. MD #3 completed and signed a multi-system evaluation of Resident #1 on 04/19/11 at 3:19 pm documenting 12 total decubiti ulcers (pressure ulcers), Candidiasis in groin, Acute [MEDICAL CONDITION], dehydration, [MEDICAL CONDITION] (higher than normal potassium levels in the blood) and Leukocytosis (abnormal amount of white blood cells in the blood indicating bacterial infection) signed by attending physician, MD #3. Resident #1 was transferred from the ED to the hospital's medical surgical department 04/19/11 at 8:00 pm. 4. The hospital's wound care report dated 04/20/11 and initial wound consultation revealed, "Bilateral necrotic (dead tissue cells) heel ulcers, multiple buttock wounds, groin wounds bilateral, sacral ulcers, right elbow eschar (scab or crust that forms on skin after a burn) and, left posterior upper thigh X2. Presented to ER with multiple wounds." The wound care specialist (DDM) documented a total of 18 open skin areas. The report also revealed that Resident #1 was incontinent of bowel and bladder. The hospital transfer/discharge summary dated 04/26/11, revealed the resident had to be transferred to another hospital for specialty wound care. D. Record Review of the wound care logs in the facility for the months of March and April 2011 did not list Resident #1 as receiving wound care. E. On 05/11/11 at 4:00 pm, during an interview, Case Manager (CM) #1 from the hospital stated, "I received a phone call from the ER staff when (Name of Resident #1) was brought in because they were very upset." CM #1 stated that both he and the wound care specialist had to speak to the staff and calm them down since the resident looked really bad. He presented with 18 documented open wounds to the skin from the facility. F. On 05/12/11 at 9:15 am, during an interview with the Director of Day Medicine (DDM) and wound care specialist at the hospital stated, "18 separate open areas were documented upon admission. One third of the wounds were necrotic, one old blister and about 50% slough and granulation (separation of dead tissue from normal or living tissue, growth of connective tissue that form on the surfaces of a wound during healing process). I made a report and took pictures. I understand that some of the areas on (Name of Resident #1) could have been picked by him but his heels and toes were not new wounds, they were old, necrotic and I was concerned about care issues for him. The wounds on his feet and heels were clearly pressure wounds. (Name of Resident #1) had Candidiasis in the groin and penile area." G. Record Review of wound consultation report by the DDM from the hospital on [DATE] recorded the following wound sites and measurements: "1. Left elbow 1.0 X 0.4 cm 100% eschar 2. Right elbow 0.4 X 0.4 cm 100% eschar 3. Penis 0.8 X 0.4 cm 100% granulation 4. Sacrum 1.2 X 0.3 X 0.1 cm 100% granulation 5. Left Heel 6.5 X 5.0 cm 100% necrotic 6. Right Heel 4.5 X 4.0 cm 100% necrotic 7. Left groin 5.5 X 2.0 X 0.2 cm 10%necrotic,90%granulate 8. Right groin 3.2 X 0.6 X 0.2 cm Candidiasis 9 Right buttock 3.0 X 1.8 X 0.2 cm 90% eschar 10 Right buttock 4.2 X 3.8 X 0.2 cm 50% necrotic 11. Sacrum 1 X 0.5 X 0.1 cm slough 12. Scrotum 1.5 X 1.0 cm 100% necrotic 13. Left post. thigh 1.0 X 0.8 X 0.1 cm 90% necrotic left post. thigh 1.8 X 1.5 cm 100% necrotic 14. right post. thigh 5.8 X 4.0 cm 100% necrotic right post thigh 7.0 X 3.5 cm Old blister 15. right lateral foot 1.0 X 0.6 cm 16. left lateral foot 0.6 X 0.5 cm 17. Left 5th toe 1.0 X 1.0 cm necrotic 18. left buttock 4.2X3.8X0.2xm 50% necrotic " H. On 05/12/11 at 10:15 am, during an interview PT #1 stated the nursing staff did give her referral forms regarding Resident #1's skin but it was regarding to problems from his brief. PT #1 stated she had no knowledge of open areas on the resident's feet. PT #1 confirmed that CNAs #1 filled out a referral sheet and gave it to the nurse in charge . PT #1 stated CNAs#1 knew about the heels and filled out a referral form. When asked if she knew about all the open areas on the resident's backside and why the resident was not included on the wound log, she stated, "I knew the Medical Director ((MD) #1) was coming in the next day and I wanted him to look at it first." I. Record review of the nursing-to-therapy referral forms dated 04/11/11 documented open areas to buttocks and left front leg. The form dated 04/15/11 documented "bottom is excoriated, front groin has open area. The form dated 04/16/11 documented "red soft area on right outer knee from leg brace close to opening up." The form dated 04/17/11 documented "2 open areas, one to left inner thigh and the other (deeper) on right inner buttock near scrotum. Treatment needed, 'butte paste' not helping." PT #1 wrote a note on the nursing-to-therapy referral form dated 04/17/11 documenting that areas were checked and all irritation was due to briefs and nursing was to change from briefs to pull-ups and to encourage the resident to spend less time in wheelchair with rest periods in bed. PT #1 wrote that MD #1 to was going to see the resident the next day. PT #1 confirmed she did not add Resident #1 to the wound care report and it was not until 04/19/11 that MD #1 visited the resident at the facility, 8 days later. J. On 05/12/11 at 10:30 am, during an interview with Registered Nurse (RN) #3, she confirmed that Resident #1 was compliant with care, that he did not refuse staff changing him when incontinent and that the staff reported his bottom was excoriated. When RN#3 examined him she stated, "I saw it (referring to his bottom), his skin was open, oozing a lot of drainage, hard to tell exactly where it was coming from since his skin was so discolored." RN #3 stated she put barrier cream on it, reported off to the day nurse on 04/18/11 and filled out a "Nursing-to-Therapy Referral form." RN #3 denied ever having knowledge about ulcers or any wounds to resident's feet or heels. K. On 05/12/11 at 11:00 am, during an interview with MDS coordinator she stated she checked Resident #1's skin on admission and there were no open areas or areas of concern. She admitted getting information for the discharge MDS from PT #1. The MDS coordinator stated, "I didn't get to examine him so I documented what PT #1 told me. (Name Resident #1) did not have open areas." The MDS coordinator confirmed there were no skin issues documented on the admission or discharge MDS. The Director of Nursing (DON) confirmed the information in the Kiosk smart charting system from the CNAs was not accurate or reliable and stated, "There are communication issues between the CNAs and nurses and it needs to be fixed now." The DON confirmed there was no toileting schedule or follow-up on Resident #1's care plan related to urinary incontinence and skin care. The DON confirmed that the facility did not have a protocol for incontinent care or skin care for the CNAs to follow. L. On 05/12/11 at 11:50 am, during an interview CNAs #1 stated, "(Name of Resident #1) started to get sores on his bottom and his groin due to the briefs. He came here with sores on his heels but they weren't as bad as when he was sent out." CNAs #1 confirmed that Licensed Practical Nurse (LPN) #2 knew about the sores because he called her into the residents room and showed her. He stated LPN #2 put cream on the resident. CNAs #1 stated that Resident #1 "was very weak and needed a lot of assistance, was compliant with care and very easy to get along with." CNAs #1 denied that the resident refused incontinent care or showers. CNAs #1 stated he needed assistance from other CNAs to transfer the resident and LPN #2 was notified of the sores because "they were so bad they were bleeding." CNAs #1 denied knowing that Resident #1 had a Urinary Tract Infection [MEDICAL CONDITION]. He stated, "The nurses never told me." CNAs #1 denied knowledge of the resident's care plan which indicated establishing a toileting program and to re-evaluate Resident #1's voiding patterns. M. On 05/12/11 at 1:35 pm, during an interview LPN #1 confirmed she did the admission paper work on Resident #1 and his skin was intact. LPN #1 stated "(Name of Resident #1) did not have any open areas upon admission." She denied any recall of skin issues regarding Resident #1 and stated that CNAs #1 was really good about reporting to the nurses. LPN #1 stated she was concerned that staff did not report issues to the nurses because they barely spoke English and if they report a skin issue they must complete paperwork. LPN #1 stated she was not sure if some of the CNAs could read or write in English. N. On 05/12/11 at 2:00 pm, during an interview CNAs #2 confirmed that Resident #1 was compliant with care. CNAs #2 reported the resident had a bad rash on his buttocks and his feet were red and leaking fluid. CNAs #2 stated that nurses (LPN #2, #3 ,#4, and #5) and other CNAs (who she would not name) were aware of Resident #1's skin problems. When asked what directions the nurses gave her, she stated, "We put cream on his rash to his groin and buttocks. They never told us what to do about his feet, but they all knew." CNAs #2 denied having knowledge of Resident #1's care plan needs with regards to a toileting schedule and re-evaluation of voiding patterns. O. On 05/12/11 at 2:40 pm, during an interview, CNAs #3 reported that Resident #1 had a bad rash on his inner legs. She stated, "Very red and the size of enchiladas." She denied knowing about treatment to his feet and stated the CNAs put cream on his inner thighs and buttocks and the nurses did the feet. CNAs #3 reported that Resident #1's feet were bleeding a lot and that LPN #2 was aware. P. On 05/12/11 at 4:00 pm, during an interview CNAs #4 reported R #1 had "granitos" on his buttocks. Staff translated "granitos" (a Spanish word) to "pimples." CNAs #4 stated, "His bottom and his feet would bleed and liquid came out of the pimples on his skin." CNAs #4 confirmed the nurses gave them cream to apply to his rash on his buttocks and she denied treating his feet. CNAs #4 stated, "I usually worked with (Name of RN #3) and she took care of him." CNAs #4 stated that the resident's feet were not her job and that it was the nurses' responsibility. Q. On 05/13/11 at 1:30 pm, during an interview LPN #2 stated she usually works weekends and no showers were given on weekends so she did not have a reason to do a body check on Resident #1. LPN #2 stated that a CNAs (unable to recall name) called her because the resident's bottom was bleeding. She stated that she applied cream tot he resident's bottom in accordance to PT #1's instructions. LPN #2 also stated she filled out a nursing-to-therapy referral form due to the open areas on his backside and because there was no improvement. She stated she was concerned and felt like the wound care specialist should look at the resident again. LPN #2 denied having any knowledge of wounds to the resident's feet or heels. R. On 05/13/11 at 8:30 am, during an interview with Medical Doctor (MD) #2 stated he was involved with Resident #1's care and was familiar with the resident. MD #2 stated, "(Name of Resident #1) was pretty immobile and he was aware of early skin breakdown." When asked about the resident having 18 open areas upon admission to the hospital he stated, "I can't answer any specific questions." MD #2 referred questions to MD #1. MD #1 stated that Resident #1 went to his office but when he was there he did not see his skin. MD #1 stated, "There was a note from staff to check his skin due to brief issues." MD #1 stated there was no report about his feet and he was not made aware of any open or pressure areas. S. On 05/24/11 at 8:50 am, during an interview Case Manager (CM) #3 (from the wound specialty hospital) reported that Resident #1 told her that the facility did not treat him good and would leave him in his diapers and the urine burned his skin. CM #3 spoke to Resident #1's mother and brother who both agreed they did not want the resident to return to the facility. T. On 05/25/11 at 3:35 pm, during an interview CNAs #5 revealed the "Kiosk charting system" that CNAs use. When asked how a CNAs with little to no English was capable of charting and understanding this system, he stated, "I don't know, that's a good question." CNAs #5 proceeded to say, "I am bi-lingual but most of the staff here are Mexican and speak mainly Spanish." CNAs #5 explained his co-worker on the hall spoke only English so he would have to translate the Spanish for her. When asked how the residents communicated with Spanish speaking CNAs, he stated, "That's a good question." When CNAs #5 was asked how he knew what care his residents' needed, he stated there was not a care plan for him to follow just what the CNAs would pass on in report. U. On 05/25/11 at 4:00 pm, during an interview, the MDS Coordinator confirmed that the information the CNAs put into the Kiosk system was not accurate and the CNAs "information was not reliable and was inconsistent." V. On 05/26/11 at 9:15 am, during an interview CNAs #1 was asked how he knew what care to give his residents' he stated, "Difficult due to most staff are Mexican, never was like that before. We do the best we can. I speak only a little Spanish." When asked about resident details which need to be reported, he stated, "no, some of the nurses tell us what's going on and some don't." CNAs #1 confirmed a lot was lost due to communication barriers and it was a problem. W. On 05/26/11 at 1:08 pm, during an interview the Director of Nursing (DON) confirmed there was not a checklist or curriculum for training the CNAs. She also confirmed that there was not a facility protocol for urinary incontinence care and skin care for the CNAs to refer to. The DON acknowledged awareness of training issues and language barriers. X. On 05/31/11 at 3:15 pm, during an interview with CNAs #6 she stated she did not get a report on the hall she was working on and was new to the facility. CNAs #6 verbalized being "stressed" since she had no knowledge of who needed what. When asked about incontinent care, she stated she used peri wash and wipes and that the CNAs gathered their own supplies from the Unit Clerk (UC). Y. On 05/31/11 at 4:18 pm, during an interview CNAs #7 stated she used wipes for incontinent care. CNAs #7 stated, "Not everybody does." When asked for clarification, she responded, "Some of the CNAs just change the briefs without cleaning their skin." She stated, "We need to use the wipes mainly for the smell." CNAs #7 stated it was difficult to obtain report on the residents since most of the CNAs spoke mainly Spanish. When asked how she dealt with that she stated, "We get what we can and just figure it out from there." Z. On 06/01/11 at 9:45 am during an interview, UC #1 confirmed the dry wipes were to be placed in a Ziploc bag and the CNAs add water to moisten them. She pointed to the case of dry wipes and stated, "They do not contain any cleanse. They are just dry wipes." AA. Record Review from the wound care hospital where Resident #1 was transferred to on 04/26/11 (for specialty wound care) revealed the following documentation: 1. History & Physical dated 04/26/11 read Chief Complaint: "Multiple necrotic ulcers and [MEDICAL CONDITION] (infection of the kidney usually resulting from the spread of a bladder infection). (Name of Resident #1) noted to have multiple buttock chemical burns, it looks like a stage III, a sacral decubitus ulcer, penile ulcerations, again from urine and a penile laceration. Also has groin and penile Candidiasis. Bilateral necrotic heel pressure ulcers." 2. physician progress notes [REDACTED]." physician progress notes [REDACTED]." 3. Nurses notes upon admission 04/26/11 documented 12 pressure ulcers, (community acquired) and perineal [MEDICAL CONDITION], anterior scrotum open scrotal wounds and penile wounds. Pressure ulcers were documented as listed: a. Coccyx Stage II b. right medial thigh Stage III c. right posterior thigh Stage III d. posterior scrotum Stage III e. left medial thigh Stage III f. left posterior thigh Stage III g. left medial proximal thigh Stage III h. left medial distal thigh Stage III i. right lateral mid foot Unstageable j. right lateral heel Unstageable k. left 5th metatarsal head Unstageable l. left lateral heel Unstageable BB. Record review of the admission nursing assessment dated [DATE] at 2:40 pm for Resident #2 revealed the resident's skin condition as "bruise to left forearm and outer hand, several scratched, scabbed areas on lower legs, three bruises on his abdomen, buttocks, rectal area red, scar and bruises on his right forearm." Also documented was that Resident #2 was incontinent of bowel and had a Foley catheter in place. CC. Record review of the interim plan of care dated May 2011 for Resident #2 revealed, "Potential for skin breakdown R/T (related to) dx (diagnosis) decreased mobility/bedridden." The interventions included, "Assist with repositioning while in bed, keep skin clean and dry, assess skin daily for breakdown." DD. Record review of nurses notes dated 05/09/11 - 05/15/11 for Resident #2 revealed, "skin color as normal" and the check box for "services provided" prompt was blank and documented no pressure ulcer care given. EE. Record review of the CNAs Notes dated 05/09/11 - 05/15/11 for Resident #2 revealed, "No new skin concern." FF. Record review of physician orders [REDACTED]." GG. Record review of the wound care log dated 05/09/11 - 05/15/11 revealed that Resident #2's pressure ulcer on the sacrum was not documented on the log. HH. On 05/26/11 at 8:10 am, during an interview with Director of Family Medicine, Family Nurse Practitioner, and Wound Care Specialist at the hospital stated that Resident #2 had been admitted to the hospital from the facility with a Stage II pressure ulcer measuring 10 centimeters (cm) by 5 cm on his sacrum. She also stated that Resident #2 came in with a small, 4 cm by 1.8 cm, non-pressure open area with [MEDICAL CONDITION](fungus) on his perineum (the diamond-shaped region of the body between the pubic arch and the anus). II. Record review of initial wound consultation for Resident #2 at the hospital wound care center dated 05/17/11 revealed: 1. "Candidias in groin/scrotum region, red, raw, flakey, needs cream. Stage II pressure ulcer sacrum with large area of non-blanchable [DIAGNOSES REDACTED]. 2. Sacral stage II pressure ulcer measurement of length 10 cm by width by 5 cm." JJ. On 05/26/11 at 9:00 am, during an interview, CNAs #1 stated, "Some nurses tell us if residents have urinary tract infections (UTIs) or wounds and some don't." CNAs #1 stated that there were communication problems due to, "Most CNAs only speak Mexican Spanish, I speak English." CNAs #1 stated that routinely the CNAs only get report from CNAs, not the nurses. KK. On 05/26/11 at 10:15 am during an interview, Physical Therapist (PT) #1, who is also the Wound Care Specialist at the facility, stated that she did all of the wound care in the facility. PT #1 stated that she was unaware that Resident #2 (who was in the facility 05/09/11 - 05/15/11) had any skin pressure areas and stated she would have documented concerns or treatment on the facility "Wound Care Log." PT #1 confirmed that the resident was not listed on the wound care log. LL. On 05/26/11 at 1:30 pm, during an interview, LPN #2 stated that Resident #2 was admitted on [DATE] with a stage l pressure ulcer on his sacrum and a few small scabbed areas. MM. On 05/26/11 at 2:40 pm, during an interview, RN #4 stated that he was assigned to take care of Resident #2 and did not notice any skin problems. NN. On 05/27/11 at 10:30 am, during a telephone interview, RN #1, stated that he did not know of any skin problems while working with Resident #2. OO. Record review of the Physician admission orders increasingly difficult to care for by family; dementia, history of [MEDICAL CONDITION], bedbound, indwelling Foley catheter, oxygen dependent, and hypertension." Therapy orders included Physical Therapy, Occupational Therapy, and Speech Therapy. Diet order called for "Mech (mechanical) soft NAS (no added salt)." Activity orders for transfers called for complete assist in accordance to Physical Therapy recommendations. PP. Record review of physicians orders dated 05/09/11 revealed orders for "ST (Speech Therapy) Eval (Evaluation) plus Swallow Eval plus ST 5 x a week for orientation to facility and time concepts Speech Therapy Management (STM) and prob (problem) solv (solving) for safety and ADLs (Activities of Daily Living), assess diet texture and monitor po (by mouth) intake." QQ. Record review of Initial Nutrition assessment dated [DATE] revealed, "Eats in bed, needs assist. Difficulty chewing, ST doing eval. diet order: regular/soft foods, no teeth." RR. Record review of Daily Skilled Notes dated 05/15/11 documented by RN #1 revealed, "Resident up in wheel chair for two hours, taken to dining room for lunch, has been sleepy all shift and ate 25% of lunch meal, he was too sleepy to eat breakfast, and was physically unable to eat dinner. At 6:00 pm (Name of Resident #2) is observed to be in respiratory distress, is lethargic (abnormal drowsiness or stupor), R (respirations) 44/min (normal range 16 - 20 per minute), BP (blood pressure) 100/58 (average 120/80), P (pulse) 100 (average 60 to 80 beats per minute), T (temperature) 98.8, O2 Sat (oxygen saturation) 86% on 3 L (liters) NC (per nasal cannula), and is diaphoretic (profuse perspiration), increased O2 to 4 L, pulled resident up in bed, and elevated HOB (Head of Bed). Called resident's son to notify of father's condition, he asked that resident be sent to emergency room (ER), notified (Name of Physician Assistant (PA) #1) of residents current condition and agreed to send resident to ER, transported via ambulance." SS. Record review of completed care tasks dated 05/15/11 at 7:10 pm, CNAs #7 documented, "What % of Supper was eaten?" as "1%-25%-nurse notified." TT. On 05/27/11 at 10:30 am, during a telephone interview, RN #1, who was responsible for Resident #2's care on 05/15/11 for the 7:00 am to 7:00 pm shift, stated, "I walked into (Name of Resident #2's room where he was in bed at 6:00 pm, right after his supper meal and found him in respiratory distress." RN #1 stated, "(Name of Resident) #2 HOB was slightly elevated at 30 degrees when I walked into his room at 6:00 pm." RN #1 stated that the staff had gotten Resident #2 up in a wheel chair (w/c) at 10:00 am that day and that the resident had been too tired to eat breakfast. RN #1 stated that the resident had been sleepy all shift and had only eaten a small portion of his lunch while sitting up in a w/c in the dining room. He also reported that the resident had been fed in bed for the supper meal and that the resident had not eaten well. RN #1 stated that Resident #2's oxygen saturation was 85% to 87% (normal range 90%-100%) on 3 liters per minute and that "his lungs sounded moist with gurgles and rhonchi (low-pitched, snoring, rattling sounds that occur when fluid partially blocks the large airways (Lippincott Williams and Wilkins-Assessment)." RN #1 stated that when he found Resident #2 in respiratory distress he raised his HOB and increased the oxygen from three to four liters per minute. RN #1 stated he first notified Resident #2's son and then the PA #1 of Resident #2's condition. RN #1 stated that PA #1 told him to send Resident #2 to the ER in accordance to the sons request, which he did on 05/15/11.

Based on record review and interview the facility failed to provide appropriate treatment and care to prevent a Urinary Tract Infection [MEDICAL CONDITION] for one (#1) of two (#1 and #2) residents. This deficient practice caused actual harm to Resident #1 who contracted a UTI which led to [MEDICAL CONDITION] (kidney infection) and eventually acute [MEDICAL CONDITION]. The findings are: A. Record review of the nursing admission paper work dated 03/24/11 for Resident #1 revealed he was continent of bowel and bladder but the resident "wanted to use briefs at night." B. Record review of the admission Minimum Data Set (MDS) for Resident #1 dated 04/01/11 revealed the resident was on a toileting program due to frequent urinary and bowel incontinence. C. Record review of Resident #1's interim plan of care dated 03/26/11 addressed the following concerns, "Toilet with assist of one person, and self-control for bowel and bladder." D. Record review of Resident #1's interim plan of care dated 03/31/11 revealed, "frequent incontinence, cleanse perineal area with soap and water following each urination and bowel movement. E. An Update on 04/12/11 revealed, "Requires assistance for toileting by staff, not always aware of his own toileting needs, wears depends daily, staff assist with toileting schedule with goal to reduce the number of incontinent episodes to less than 6 per day." The approach was to "place resident on toileting schedule and toilet in am, after meals, afternoon, before dinner and before bed, document continent episodes on CNAs (Certified Nursing Assistant) smart charting. Evaluate resident's continence and establish a toileting schedule effective for resident to reduce number of incontinent episodes." F. An update added to care plan on 04/11/11 revealed that Resident #1 developed a UTI and the CNAs was to "monitor urine for color/consistency, document observations and nurse to report abnormalities to physician." G. Record review of the monthly nursing summary for March 2011 (not dated or signed) revealed Resident #1 was "Incontinent of bowel and bladder, assist to bathroom and briefs to be worn at all times, current UTI ." H. Review of the CNAs smart chart system for care tasks related to toileting and incontinent episodes contained the following documentation for each 24 hour period (Resident #1 required independent to extensive assistance.): 03/31/11 No toileting Voided (urinate) X3 04/01/11 No toileting Voided X1 04/02/11 Toileted X2 Voided X4 04/03/11 Toileted X1 Voided X4 04/04/11 No Toileting Voided X3 04/05/11 Toileted X1 Voided X4 04/06/11 No Toileting Voided X3 04/07/11 No Toileting Voided X3 04/08/11 Toileted X1 Voided X5 04/09/11 No Toileting Voided X2 04/10/11 No Toileting Voided X3 04/11/11 No Toileting Voided X1 04/12/11 No Toileting Voided X2 04/13/11 No Toileting Voided X3 04/14/11 No Toileting Voided X3 04/15/11 No Toileting Voided X3 04/16/11 Toileted X1 Voided X5 04/17/11 No Toileting Voided X4 04/18/11 No Toileting Voided X2 04/19/11 Toileted X1 Voided X3 I. Record Review of local hospital admission on 04/19/11 physician (MD#3) completed and signed a multi-system evaluation of R#1 documenting 12 total decubiti ulcers (pressure ulcers), Candidiasis (Yeast infection), in groin, Acute [MEDICAL CONDITION], Dehydration, [MEDICAL CONDITION] (higher than normal potassium levels in the blood) and Leukocytosis (abnormal amount of white blood cells in the blood indicating bacterial infection). I. Record Review of the History & Physical dated 04/26/11 (from the wound care hospital) revealed Resident #1 had [MEDICAL CONDITION] (infection of the kidney usually resulting from the spread of a bladder infection). The physician progress notes [REDACTED]. J. On 05/12/11 at 11:50 pm, during an interview CNAs #1 stated, Resident #1 was "compliant with care and very easy to get along with." CNAs #1 denied that the resident refused incontinent care or showers. CNAs #1 denied knowing that Resident #1 had a UTI. He stated, "The nurses never told me." CNAs #1 denied knowledge of Resident #1's care plan which indicated establishing a toileting program and to re-evaluate the resident's voiding patterns. K. On 05/12/11 at 2:00 pm, during an interview, CNAs #2 denied having knowledge of Resident #1's care plan needs with regards to a toileting schedule and re-evaluation of voiding patterns. L. On 05/26/11 at 1:08 pm, during an interview with the Director of Nursing (DON) she confirmed that there was not a facility protocol for urinary incontinent care and skin care for the CNAs to refer to. The DON confirmed that there was not documentation of a toileting program for Resident #1. M. On 05/31/11 at 4:18 pm, during an interview CNAs #7 stated she used wipes for incontinent care. CNAs #7 stated, "Not everybody does." When asked for clarification, she responded, "Some of the CNAs just change the briefs without cleaning their skin." She stated, "We need to use the wipes mainly for the smell." N. On 06/01/11 at 9:45 am, during an interview with Unit Clerk (UC) #1 she confirmed that dry wipes were to be placed in a Ziploc bag and the CNAs add water to moisten them. She pointed to the case of dry wipes and stated, "They do not contain any cleanser they are just dry wipes."

The facility failed to ensure that Resident #10 received the correct consistency of thickened liquids as ordered by the physician. This resulted in an Immediate Jeopardy (IJ) being identified on 03/28/11 at 1:00 pm. The Administrator was notified of the findings for the IJ on 03/28/11 at 6:50 pm. The facility took corrective action by providing an acceptable Plan of Removal on 03/28/11 at 7:35 pm. This resulted in the scope and severity of the deficiency being lowered to a Level 2, Scope D. The Plan of Removal included that for the remainder of the evening, all residents with physician orders [REDACTED]. The Plan of Removal also indicated that the Director of Nursing (DON), the Dietary Manager (DM) and the Director of Rehabilitation (DOR) along with the Speech Therapist (ST) will do the following: "Confirm that the current list of residents on thickened liquids is updated and accurate based on the current physicians orders. Begin re-training staff tonight (03/28/11) to include Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistant (CNAs), Restorative Nurse Aides and Activities staff on providing the appropriate liquid textures to those residents covering the 7:00 pm to 7:00 am licensed nursing shifts as well as the 2:00 pm to 10:00 pm and the 10:00 pm to 6:00 am CNA shifts. Ensure that thickened liquids are available to those residents who need them throughout the evening by providing pre-thickened liquids. All staff to be re-trained by 04/01/11 and prior to their next shift." Based on observation, interview and record review the facility failed to provide the correct consistency of thickened liquids necessary to maintain the highest practicable physical well-being for one (#10) of six (#1, #10, #25, #33, #49 and #101) residents who were at risk for aspiration. The findings are: A. On 03/28/11 at 12:45 pm, during observation, CNA #2 gave Resident #10 a large cup of water and added one and one half scoop of thickener. Resident #10 coughed occasionally throughout the meal. Record review of Resident #10's meal card noted that the resident required nectar thickened liquids. B. On 03/28/11 at 12:45 pm, during interview, CNA #2 was asked how she knew what amount of thickener to use. CNA #2 pointed to the back of the thickener can which read: "2-3 teaspoons per 4 ounces of fluid." CNA #2 verified that was not the measurement she used when serving Resident #10. CNA #2 also stated "(Name of R#10) doesn't like it too thick. I add it the way (Name of Resident #10) likes it." C. On 03/28/11 at 1:15 pm, during interview, RN #1 confirmed the cup used for Resident #10 was a 12 ounce cup. RN #1 stated, "The facility has several different sized cups and the CNA probably did not know the size." D. On 03/28/11 at 1:17 pm, during interview, the DM confirmed that the Speech Therapist trained CNAs on the use of thickener. The DM confirmed that the cup used for Resident #10 was a 12 ounce cup and stated that two large scoops should be used since the cup was not completely full. E. On 03/28/11 at 1:40 pm, during interview, Speech Therapist #1 confirmed that the cup served was 12 ounces and two large scoops was needed to obtain nectar consistency. Speech Therapist #1 confirmed that Resident #10's ability to swallow had decreased within the last year. Speech Therapist #1 also stated that she had just trained the CNA staff on using the thickener but would re-train them. F. On 03/28/11 at 5:05 pm, during observation, CNA #3 brought Resident #10 a cup of coffee which was not nectar consistency and gave the resident a sip. CNA #3 was asked if thickener was in the coffee and she stated she "put one scoop and a little bit more." G. On 03/28/11 at 5:14 pm, during interview, Speech Therapist #1 confirmed that the resident's cup of coffee was not nectar consistency. Speech Therapist #1 stated "No, it's too thin." H. On 03/29/11 at 9:45 am, during interview, the Primary Care Physician (PCP) for Resident #10 confirmed that the resident was on nectar thickened consistency due to a high risk for aspiration and stated that the resident had been hospitalized in the past for aspiration pneumonia. The PCP stated that he had seen Resident #10 choke on puree foods and the reason for the dysphagia (difficulty in swallowing) was due to his progressed [MEDICAL CONDITION]. I. Record review of Resident #10's medical record revealed the following information: 1. Nutritional Progress note dated 10/07/10 indicated that the resident's diet was mechanical soft with nectar thickened liquids. 2. Diet order and Communication form dated 10/08/10 with Resident #10's diet changed from puree to Mechanical soft with ground meat slippery and nectar thickened liquids. 3. Physician's telephone order dated 10/18/10 with diet change to Mechanical soft with ground meat slippery and nectar thickened liquids. 4. Monthly physician orders [REDACTED]. 5. Annual Nutrition Assessment which did not contain a signature or date and identified that Resident #10 as had chewing and swallowing problems. 6. Resident #10's tray ticket dated 03/29/11 indicated Nectar thick liquids.

The facility failed to ensure that Resident #10 received the correct consistency of thickened liquids as ordered by the physician. This resulted in an Immediate Jeopardy (IJ) being identified on 03/28/11 at 1:00 pm. The Administrator was notified of the findings for the IJ on 03/28/11 at 6:50 pm. The facility took corrective action by providing an acceptable Plan of Removal on 03/28/11 at 7:35 pm. This resulted in the scope and severity of the deficiency being lowered to a Level 2, Scope D. The Plan of Removal included that for the remainder of the evening, all residents with physician orders [REDACTED]. The Plan of Removal also indicated that the Director of Nursing (DON), the Dietary Manager (DM) and the Director of Rehabilitation (DOR) along with the Speech Therapist (ST) will do the following: "Confirm that the current list of residents on thickened liquids is updated and accurate based on the current physicians orders. Begin re-training staff tonight to include Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistant (CNAs), Restorative Nurse Aides and Activities staff on providing the appropriate liquid textures to those residents covering the 7:00 pm to 7:00 am licensed nursing shifts as well as the 2:00 pm to 10:00 pm and the 10:00 pm to 6:00 am CNA shifts. Ensure that thickened liquids are available to those residents who need them throughout the evening by providing pre-thickened liquids. All staff to be re-trained by 04/01/11 and prior to their next shift." Based on observation, interview and record review the facility failed to provide supervision to ensure that the correct consistency of thickened liquids was given for one (#10) of six (#1, #10, #25, #33, #49 and #101) residents who were at risk for aspiration. This deficient practice is likely to cause a resident to choke. The findings are: A. On 03/28/11 at 12:45 pm, during observation, CNA #2 gave Resident #10 a large cup of water and added one and one half scoop of thickener. Resident #10 coughed occasionally throughout the meal. Record review of Resident #10's meal card noted that the resident required nectar thickened liquids. B. On 03/28/11 at 12:45 pm, during interview, CNA #2 was asked how she knew what amount of thickener to use. CNA #2 pointed to the back of the thickener can which read: "2-3 teaspoons per 4 ounces of fluid." CNA #2 verified that was not the measurement she used when serving Resident #10. CNA #2 also stated "(Name of R#10) doesn't like it too thick. I add it the way (Name of Resident #10) likes it." C. On 03/28/11 at 1:15 pm, during interview, RN #1 confirmed the cup used for Resident #10 was a 12 ounce cup. RN #1 stated, "The facility has several different sized cups and the CNA probably did not know the size." D. On 03/28/11 at 1:17 pm, during interview, the DM confirmed that the Speech Therapist trained CNAs on the use of thickener. The DM confirmed that the cup used for Resident #10 was a 12 ounce cup and stated that two large scoops should be used since the cup was not completely full. E. On 03/28/11 at 1:40 pm, during interview, Speech Therapist #1 confirmed that the cup served was 12 ounces and two large scoops was needed to obtain nectar consistency. Speech Therapist #1 confirmed that Resident #10's ability to swallow has really decreased within the last year. Speech Therapist #1 also stated that she had just trained the CNA staff on using the thickener but would re-train them. F. On 03/28/11 at 5:05 pm, during observation, CNA #3 brought Resident #10 a cup of coffee which was not nectar consistency and gave the resident a sip. CNA #3 was asked if thickener was in the coffee and she stated she "put one scoop and a little bit more." G. On 03/28/11 at 5:14 pm, during interview, Speech Therapist #1 confirmed that the resident's cup of coffee was not nectar consistency. Speech Therapist #1 stated "No, it's too thin." H. On 03/29/11 at 9:45 am, during interview, the Primary Care Physician (PCP) for Resident #10 confirmed that the resident was on nectar thickened consistency due to a high risk for aspiration and stated that the resident had been hospitalized in the past for aspiration pneumonia. The PCP stated that he had seen Resident #10 choke on puree foods and the reason for the dysphagia (difficulty in swallowing) was due to his progressed Parkinson's disease. I. Record review of Resident #10's medical record revealed the following information: 1. Nutritional Progress note dated 10/07/10 indicated that the resident's diet was mechanical soft with nectar thickened liquids. 2. Diet order and Communication form dated 10/08/10 with Resident #10's diet changed from puree to Mechanical soft with ground meat slippery and nectar thickened liquids. 3. Physician's telephone order dated 10/18/10 with diet change to Mechanical soft with ground meat slippery and nectar thickened liquids. 4. Monthly physician orders [REDACTED]. 5. Annual Nutrition Assessment which did not contain a signature or date and identified that Resident #10 as had chewing and swallowing problems. 6. Resident #10's tray ticket dated 03/29/11 indicated Nectar thick liquids.

The facility failed to provide adequate supervision for 1 of 8 sampled resident's (Resident #5) who resided at the facility by leaving harmful chemicals unlocked and unsecured in resident areas with access. Resident #5 swallowed a toxic lemon cleaner left in the room unsecured on 07/02/10 which resulted in her having to be transported to the emergency room . During Administrative Review at the Health Facility Licensing and Certification Bureau and in conjunction with consultation with the Centers for Medicare and Medicaid Services, it was determined that an Immediate Jeopardy situation had occurred. The Administrator was notified of the Immediate Jeopardy on 09/21/10 at 7:50 pm. The facility took corrective action by providing an acceptable plan of removal on 09/21/10 at 10:30 pm. This resulted in the scope and severity of the deficiency being lowered to Level 3, Scope H. The plan of removal included the following items: 1. The Director of Maintenance and the Director of Nursing (DON) will ensure that each housekeeping cart is locked into their respective janitorial closets with bottles or containers of harmful products are locked. The Director of Maintenance along with available nursing staff will also perform rounds of the entire facility this evening to ensure that no extraneous bottles or containers of harmful products are located in any other accessible areas. 2. The Director of Maintenance and the DON will re-train current and future staff on the procedures for handling and storing harmful products to ensure that residents remain free from accidental ingestion. 3. The Director of maintenance will install self-locking door locks that lock when staff leave the storage areas. The director of maintenance will also ensure that the locking mechanisms of the housekeeping carts will be repaired. 4. Maintenance/life safety rounds will closely monitor all storage areas to ensure that they are consistently locked, the housekeeping carts when they are in use throughout the facility, the common areas listed including the main shower rooms on the 300 and 400 halls, the activity rooms, the soiled and clean utility rooms by each nurse's station, and the resident's rooms and bathrooms to ensure that harmful products are not left out and accessible to residents. Based on observation, record review and interview, the facility failed to keep harmful substance where residents did not have access to them for one of eight sampled residents (#5). This deficient practice had the potential for 94 residents to accidentally swallow, inhale or have skin contact with harmful, toxic substances. The findings are: A. During review of the medical record for Resident #5, a patient information sheet dated 07/02/10 indicated the resident was treated at a local emergency department for possible ingestion of a toxin. 1. Review of a facility incident report dated 07/02/10 indicated Resident #5's room mate notified facility staff after, "(Name of Resident #5) drank some of that cleaner and now she feels sick." The incident report also indicated there was a bottle of disinfectant in Resident #5's room and the lid was off. The report revealed that Resident #5 was complaining that her throat was burning. 2. During review of the file of facility incident reports a nurse's note page dated 08/07/10 was reviewed. The note indicated that at 6:30 am on 08/07/10 a bottle of a lemon chemical was found on the resident's night stand. The note indicated the nurse notified the Director of Nursing (DON). B. On 9/21/10 at 3:20 pm, observation of the shower room on the 300 hallway revealed that two spray bottles of Comet Cleaner with Bleach were hanging on the rail of the shower stall. The label on these bottles had a "caution -may cause eye irritation." 1. On 09/21/10 at 3:52 pm, the shower room on the 600 hall was noted to have a 32 ounce bottle of liquid comet cleaner with bleach. The container was one quarter full and located by the shower door. Another quarter full bottle of Comet Cleaner with Bleach was found on a top shelf of a cabinet in the shower room. 2. On 9/21/10 at 4:05 pm, during an observation of the biohazard room, off the 300 hallway indicated the door to the room was unlocked. In an unlocked cabinet in this room there was a bottle of Lemon-D-Fen, a surface disinfectant. The cautionary label on this bottle read: "Keep out of reach of children-harmful if absorbed through skin." C. On 9/21/10 at 4:55 pm, during observation and interview, the Director of Compliance was shown the spray bottles in the shower room. The Director stated, "This Clorox is not supposed to be here. It is supposed to be locked in the cabinet." When the Director was shown the lock on the cabinet, he stated, "This lock is broken and probably broken for too long." At this same time, the Director was shown the disinfectant in the bio hazard room. He stated, "This disinfectant should not be in here. It has a caution label on it." When asked where harmful chemicals should be kept, the Director stated, "In the paint room." D. On 09/21/10 at 5:00 pm, during observation of the paint room, an interview was conducted with the Director of Compliance. The paint room was located in hallway that accesses both the 300 and 600 halls which contain resident rooms. It was observed that the door to the "paint room" was unlocked. The Director stated, "This room is supposed to be locked." Upon initial inspection, the room contained numerous containers of paint, paint thinner, insect repellant, motor oil, antifreeze, and transmission fluid. E. On 9/21/10 at 8:20 pm, during observation, an inventory was taken of all the products found in the paint room. The following items found in the paint room were readily accessible to residents: 1. One gallon Acetone, 2. One gallon insect killer, 3. Two gallons Thompson water seal, 4. Two (11.5 ounces) mini-wax polyurethane, 5. Two (1/2 gallons) Envirotex hardener polymer coating, 6. 120 containers (located on 3 separate shelves) various types of paint interior and exterior, 7. One gallon windshield washer, 8. Two and ? quarts liquid Plummer, 9. Three cans (14 ounces) wasp and hornet killer, 10. Three cans spray text, 11. One can Elmer's glue, 12. Two (13 ounce pruning sealant, 13. Two (12 ounce) gap filler spray, 14. One (10 ounce) Scotch guard fabric, 15. One gallon descaler (liquid), 16. Two (1 gallon) anti-freeze, 17. Two gallons motor oil, 18. One (12.25 ounce) clear wood finisher, 19. One (17.6 ounce) hi strength spray adhesive, 2 20. Two (10 ounce) spray paint, 21. One can scotchgard, 22. Three (32 ounce) Turpentine, 23. Two (5.75 ounce) battery cleaner, 24. One (22 ounce) carpet stain lifter, 25. One (32 ounce) acetone, 26. One (12 ounce) paint thinner, 27. Four (5 gallon) latex zone marking paint Some of the items found in the paint room had the following warning labels: "toxic if swallowed or inhaled, keep out of reach of children, can cause skin irritation, may cause burn, respiratory tract irritant or eye irritant, harmful or fatal if swallowed, can be fatal."

Based on record review and interview, the facility failed to report and investigate all allegations of abuse, neglect, exploitation, and injuries of unknown origin to the state survey agency for two of eight sampled residents (#2 and 5). This deficient practice had the potential to affect 94 residents receiving care and services at the facility. The findings are: A. Review of the face sheet dated 09/15/10 for Resident #2 revealed a [DIAGNOSES REDACTED]. 1. Review of the Quarterly Minimum Dated Set (MDS) assessment dated [DATE] indicated in section B. Cognitive Decision Making was intact (no long term or short term memory loss and able to make decisions independently). Section G1b. Indicated the resident required limited assistance of one for transfers. 2. Review of the Nurses notes dated 07/17/10 at 9:10 pm read, "(Name of Resident's son) stated that his mother had told him that she had been assisted by male CNA (Certified Nursing Assistant) #8 to restroom and that he had been rude to resident and hurried her along, therefore causing her back to hurt." 3. Review of the History & Physical (H&P) dated 07/18/10 revealed Resident #2 went to the emergency room (ER) after complaining of back pain. On the H&P, revealed that Resident #2 stated the following, "The aide #8 that assisted her was extremely rough and was hurting her." Patient stated she requested him to stop and he did not, so she cried out at which point he just left her. Patient had to get in her wheelchair and go to the desk for help. After she was assisted she called her son who came to the (Name of facility) and requested to speak to the aide and was declined so he called police." B. Review of the facility's Incident Log from July 2010 through September 2010 revealed no incident report for Resident #2. Review of the medical record for Resident #2 revealed an H&P dated 07/18/10 that indicated the resident had complained of rough treatment by a male CNA #8 at the nursing home where she currently resided at. An incident report form was not completed and the incident was not reported by the facility to the appropriate authorities at the Department of Health/Division of Health Improvement (DOH/DHI). C. On 09/24/10 at 12:06 pm, during an interview, the Director of Nursing (DON) stated it was never reported to her. D. On 09/24/10 at 1:25 pm, during an interview, the Social Services Worker, stated she had never seen the H&P before 09/24/10 and "had not been told of it." E. On 09/24/10 at 2:30 pm, during an interview, the Administrator confirmed they had not completed an incident report or follow-up. F. Review of Resident #5's medical record indicated a patient visit information sheet from the local Emergency Department dated 07/02/10. The information sheet indicated Resident #5 was treated for [REDACTED]." During further review of Resident #5's entire medical record there was no documentation indicating what had happened to Resident #5. G. Review of the facility's incident reports indicated an incident report was completed on 07/02/10 for Resident #5. The incident report indicated Resident #5's room mate called for staff assistance after Resident #5 "drank some of that cleaner and now she feels sick." The report indicated a bottle of disinfectant was in Resident #5's room, the lid was off, and Resident #5 was complaining of a burning throat. The report also indicated the resident was sent by ambulance to the local Emergency Department for evaluation. H. On 9/21/10 at 2:30 pm, during an interview the Director of Nursing (DON) stated the nurse on duty should have made nursing notes and documented the follow-up to the incident of Resident #5 possibly drinking a disinfectant that was left in her room by housekeeping. The DON stated neither she nor the nurse on duty reported this incident to the state survey agency. I. On 9/21/10 at 3:00 pm, during an interview the Director of Social Services who according to facility policy was responsible for reporting and investigating allegations/incidents of abuse, neglect, exploitation, and injuries of unknown origin stated she was on leave from the facility when this incident occurred. She stated no one else from the facility told her the incident occurred and she did not report or investigate this incident. J. On 9/21/10 4:00 pm, during an interview the Administrator stated the incident was not reported or investigated. The Administrator stated the possible reason for this failure was "We did not see the incident as reportable, it was not neglect." K. A review of "Abuse, Neglect and Exploitation Policy and Procedures" dated 05/04/06 indicated the following information: "All reports of alleged resident abuse, neglect, exploitation, and injuries of an unknown source shall be reported by person with most knowledge of incident to SCI/DOH within 24 hours. A plan of action is developed to prevent further incidents. All incidents shall be thoroughly investigated. Investigation shall consist of Administrator appointing a staff to investigate the incident; appointed staff will interview resident, witnesses, or other parties that might have relevant information related to incident; a review of all circumstances surrounding incident; witness reports shall be in writing. Witnesses shall be required to sign and date."