Every finding on record at The Blossoms at Midtown Rehab & Nursing Center

Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to ensure residents were free from misappropriation of resident property for one (Resident #3) of three residents reviewed. The findings include:A review of an admission Record revealed the facility admitted Resident #3 on 06/11/2026 with diagnoses that included diabetes mellitus, vision loss in both eyes and depression. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) 06/18/2026, revealed Resident #3 had a Brief Interview for Mental Status (BMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #3's Care Plan initiated on 06/13/2026, revealed the resident was at risk for a psychosocial well-being problem related to major depressive disorder and suicidal ideation. Interventions included to allow the resident time to answer questions and to verbalize feelings perceptions, and fears. A review of Resident #3's admission Agreement dated 06/11/2026, revealed that the facility suggested the use of a safe or lockbox for Resident #3 to utilize for storage but there was no documentation to show whether the resident accepted or declined. During an interview on 08/26/2026 at 12:17 PM, Resident #3 stated they had cashed a check for $200 prior to admission to the facility. Resident #3 stated they were blind and asked the Mental Health Therapist (MHT) to assist in online purchases through Resident #3's phone. Resident #3 stated on 06/16/2026 they asked MHT to count the money in the resident's wallet, it was $200. Resident #3 stated they believed the MHT put the money back in the billfold. Resident #3 stated that a few days later Resident #3 asked Social Service (SS), take $20 out of the wallet for a pizza. Resident #3 placed $20 under their pillow. Resident #3 stated a week later MHT came and saw money out on the bed and asked to put it in the wallet. Resident #3 stated the MHT put the money in Resident #3's wallet and the MHT stated there was not any money in the wallet. Resident #3 stated they were upset and reported it. During an interview on 08/26/2026 at 9:35 AM, the SS stated Resident #3 asked him to get $20 out of the residents' wallet to order a pizza and there was money in the wallet at that time. SS stated he did not know how much. During an interview on 08/26/2026 at 10:18 AM, the MHT stated that on 06/18/2026 she went into Resident #3's room and the resident asked her to count the money in the residents' wallet. The MHT stated there was $180-$200 in the wallet at that time. The MHT stated that on 06/23/2026 the MHT visited the resident and saw $20 out, since the resident was blind and normally did not keep money out, she asked Resident #3 if she should put the money in the wallet which was kept in a drawer. The MHT stated there was no longer money in the wallet on 06/23/2026. The MHT stated she reported the missing money to the facility and was told to no longer involve herself with resident funds. The MHT stated she was in-serviced on the proper procedure for handling resident money. A review of an undated facility in-service with a topic of Financial Safeguards in Long Term Care revealed to Identify resident requests involving money, purchases, banking, or financial decisions. Understanding why financial matters must be directed to Social Services. Protect residents from financial exploitation and potential abuse. Follow facility procedures for handling resident financial requests. In-service was provided to staff including the MHT. During an interview on 08/26/2026 at 1:45 PM, the Administrator stated once the theft was reported to her, staff tried to locate it, the police were called, and investigation was started. The Administrator stated that herself, the Director of Nursing (DON), the SS and mostly everyone were responsible for investigating. The Administrator stated, SS was responsible for resident money. The Administrator stated that the facility had a lockbox in her office with keys if the resident requested to have one in their room for their personal items, but the facility could not make residents use it. The Administrator stated that Resident #3 declined the lock box. Review of a facility policy titled Abuse, Neglect, and Exploitation dated 07/2023, revealed Misappropriation of Property- the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on observations, interviews, record review and facility policy review, it was determined the facility failed to ensure incontinence care was provided to meet professional standards of practice for one (Resident #7) of three residents reviewed. The findings include: A review of the admission Record revealed the facility admitted Resident #7 on 08/21/2025, with diagnoses that included injury of cervical spinal cord, muscle wasting and atrophy, and muscle contractures of bilateral lower legs. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/27/2026, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS also revealed that Resident #7 was dependent on staff for toileting hygiene and to shower/bathe. A review of Resident #7's Care Plan Report initiated on 08/27/2025, revealed the resident had experienced serious trauma during [their] lifetime. Interventions included: to allow the resident to establish boundaries with staff when comfortable and staff to thoroughly communicate all care prior to performing. The Care Plan Report also indicated Resident #7 had an Activity of Daily Living (ADL) self-care performance deficit, bladder and bowel incontinence and was at risk for falls. Interventions included cleaning peri-area with each incontinence episode, and for staff to anticipate and meet the residents' needs with prompt response to all requests for assistance. A review of Resident #7's Task Sheet revealed on 08/04/2026, CNA #7 documented at 5:32 AM no care provided, and no behaviors or refusals. A review of Resident #7's Care Plan Conference Note dated 08/19/2026, revealed that Resident #7 voiced concerns of not receiving peri care and that CNAs were not answering call lights in a timely manner. This was signed by the Director of Nursing (DON), Social Services (SS) #2, and the MDS Coordinator. During an interview on 08/25/2026 at 3:35 PM, CNA #9 stated she worked the 08/04/2026 day shift and that Resident #7 complained about not being changed during the overnight shift. CNA #9 stated that Resident #7 had a wet brief and wet bed, and this was not normal for [Resident #7]. During an interview on 08/26/2026 at 10:42 AM, the DON stated the expectation was for staff to conduct purposeful rounding hourly. The DON stated rounding was completed to assess the resident's needs, check for safety hazards, check that call lights were within resident's reach, and to check for incontinence needs. The DON stated the facility did not have a policy regarding toileting schedules. The DON stated Resident #7's complaint was addressed immediately with responsible staff and then with all other employees. The DON stated there had been numerous CNAs and other residents who complained about being unable to find CNA #7 for hours at a time on his shift. A review of a facility in-service titled Recognizing and Responding to Clinical Alerts in long Term Care dated 05/21/2026, revealed an objective of implementing timely interventions, and documenting responses to ensure early recognition of changes in resident conditions. A review of a facility in-service with a topic of Abuse Policy dated 08/20/2026, revealed that each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. This surveyor attempted a phone interview with CNA #7 on 08/26/2026 at 12:03 PM, using the phone number listed on CNA #7's employee file; a male answered and informed this surveyor they had the wrong number. During an interview on 08/26/2026 at 1:10 PM, the Administrator stated that CNA #7 was terminated due to concerns about patient care and attendance issues during his first 90 days. A review of CNA #7's Disciplinary Action Report dated 08/05/2026, revealed a quality of work violation that resulted in termination. The Disciplinary Action Report indicated, Employee didn't provide care to several residents in a timely manner. The report was signed and dated by CNA #7 on 08/12/2026. A review of an undated online article for professional standards of care titled, World Health Organization's Quality of Care indicated that quality of care is the degree to which health services increase the likelihood of desired health outcomes with growing acknowledgment that quality health services should be, effective, safe, person-centered, and timely.

Based on observations, interviews, record review and facility policy review, it was determined that the facility failed to prevent avoidable accidents for one (Resident #2) of four residents reviewed. The findings include: A review of the admission Record revealed the facility admitted Resident #2 on 10/07/2026, with diagnoses that included lack of coordination, muscle wasting and atrophy, muscle weakness, recovery care following surgery on the abdomen and laceration of the liver. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/2025 , revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed Resident #2 was deaf and mute but was able to understand others and communicate their needs. The MDS also revealed Resident #2 required moderate assistance with all mobility and utilized a walker and a wheelchair. A review of Resident #2's Care Plan initiated on 10/08/2025 , revealed the resident was at risk for falls, used a bedside commode due to bladder incontinence, and had a communication deficit related to being deaf. Interventions included answering the call light, Anticipate and meet the resident's needs. Other interventions included that the resident preferred to communicate by sign language, a communication board, and a digital tablet. A review of an Order Summary revealed Resident #2 had multiple wound care orders for wounds on the right chest, right breast, right lateral flank, right upper flank and a surgical incision to the abdomen with a start date of 10/09/2025. A review of Resident #2's Medication Administration Record revealed Resident #2 had received a muscle relaxer at 12:00 PM on 10/14/2025. A review of a Progress Note dated 10/14/2026 at 3:48 PM, revealed a fall while transferring to the bathroom. A review of a facility Incident and Accident (I&A) report dated 10/14/2026, revealed Resident #2 had requested to use the bathroom and did not want to use the bedside commode. Two Certified Nursing Assistants (CNA) tried to transfer Resident #2 to a wheelchair to take them to the bathroom. The wheelchair was not completely under the resident when they sat down due to miscommunication [between resident and the CNAs assisting]. Resident #2 slid out of the wheelchair and fell to the floor. A Licensed Practical Nurse (LPN) was alerted, and Resident #2 was sent to the hospital via ambulance for an X-ray. During an interview on 08/25/2026 at 2:17 PM, LPN #1 stated they remembered submitting the I&A report about the incident with Resident #2. They confirmed communication was not an issue due to Resident #2 having a digital tablet and communication board to write on. LPN #1 stated that Resident #2 normally required a gait belt and either one or two people to transfer. LPN #1 confirmed that two CNAs were in the room when the fall was reported to them. During an interview on 08/25/2026 at 2:32 PM, CNA #2 stated that Resident #2 commonly used a bedside commode, and they would read lips when communicating. They stated Resident #2 would communicate by nodding their head yes or no if their hands were occupied. CNA #2 stated they did not remember Resident #2 requesting to use the bathroom instead of the bedside commode prior to this incident. They were unsure if a gait belt was used during the transfer to the wheelchair when the fall occurred. During an interview on 08/25/2026 at 2:52 PM, Resident #2 stated that they used the bedside commode during their stay at the facility. They also did not believe a gait belt was used during their transfer to the wheelchair on the day of the incident. Resident #2 confirmed they wanted to use the bathroom instead of the bedside commode. During an interview on 08/26/2026 at 12:47 PM, the Administrator stated the care plans were to help the CNAs by providing the best way to provide care to a resident. She stated the CNAs should have notified the nurse and or charge nurse first, before making decisions that deviate from the care plan such as deciding to take Resident #2 to the bathroom instead of transferring the resident to the bedside commode. The Administrator confirmed it is not within the CNAs scope of practice to decide whether to follow a care plan. During an interview on 08/26/2026 at 1:37 PM, the Director of Nursing (DON) confirmed CNAs must follow the care plan and if a resident was refusing, they should educate the resident on the importance of the care plan. The DON also stated the CNAs should report to a nurse or charge nurse if a resident was refusing to follow a care plan. On 08/26/2026 at 12:16 PM, the Director of Nursing (DON) stated the facility did not have a policy for falls. A review of a facility policy dated 01/2024 and titled Resident Rights, revealed a resident has the right to be informed of, and participate in, his or her care planning and treatment.

Based on observation, interview and record review the facility failed to accurately assess and complete the Minimum Data Set (MDS) for two (Resident #71 and Resident #48) of two residents reviewed. The findings include: Resident #71Review of an admission Record indicated Resident #71 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure, obstructive sleep apnea, and presence of a surgically created opening through the neck into the windpipe to allow air to fill the lungs. Review of Physician Orders for Resident #71 indicated to change tracheostomy collar and to perform tracheostomy care daily. The Physician Orders also included to check oxygen saturation daily and to give oxygen via trach cuff at 5 liters as needed. Review of the quarterly MDS with an Assessment Reference Date (ARD) of 08/05/2025 incorrectly indicated that Resident #71 did not require tracheostomy care, did not use oxygen and did not require suctioning, which are needed when a resident has a tracheostomy. On 08/27/2025 at 10:30 AM, the MDS Nurse stated she followed the RAI manual when completing the MDS. The MDS Nurse continued that it was important to accurately assess and correctly code the care required so residents receive the care they need. When questioned how the residents were assessed when the MDS was completed, she reported the nursing assessments in the electronic health records were reviewed and that a head-to-toe assessment was not completed by the coordinator when filling out the MDS. Resident #48 Review of a Medical Diagnosis report revealed Resident #48 had diagnoses which included schizophrenia, diabetes II, and hepatitis C. Review of the annual MDS with an ARD of 06/22/25, revealed a Brief Interview for Mental Status score of 12, which indicated Resident #48 had moderate cognitive impairment. The MDS also indicated that section A1500 showed 0, meaning no serious mental illness of intellectual disability, or PASRR II A review of a Care Plan dated 04/20/2024, revealed Resident #48 had a level II PASRR, and would follow the state PASRR program. On 08/28/2025 at 9:00 AM, the Administrator provided a letter from the State Designated Authority dated 06/12/2023, which indicated approval for 60 days of convalescent care, a letter dated 08/22/2023 which stated Resident #48 would need a level II PASRR screening, and an evaluation letter dated 08/29/2023 which indicated Resident #48 required specialized services at this time including pharmacological program, master treatment plan with periodic review and mental health evaluation. During an interview on 08/28/2025 at 9:22 AM, the MDS Nurse checked in electronic records and revealed Resident #48 did have a level II PASRR. On 08/28/2025 at 9:53 AM, the MDS Nurse stated Resident #48 had a PASRR II and section A1500 of the MDS should have reflected 1, which indicated Resident #48 had a mental disorder or intellectual disability to ensure proper assessments were completed and accurately reflected the resident's needs. The MDS Nurse revealed the Resident Assessment Instrument (RAI) manual was used as a guide for coding the MDS. This surveyor requested a copy from the RAI manual that addressed filling out section A1500. The MDS Nurse stated, There is not a MDS policy. On 08/28/2025 at 10:01 AM, the MDS nurse provided documentation from the RAI manual showing section A1500 should have been coded 1, to reflect a mental illness or intellectual disability. During an interview on 08/28/2025 at 4:04 PM, the Administrator was made aware of MDS concerns, and the Administrator stated that everything would be done to correct coding to accurately reflect the resident.

Based on observation, interview and facility policy review, the facility failed to ensure that the ice scoop holder was maintained in a sanitary manner; food items stored in the refrigerator, freezer, and dry storage area were covered or sealed; expired food items were promptly discarded on or before the expiration or use by-date; that dietary staff washed their hands between handling dirty and clean equipment; and hot food items were maintained at required temperature for one of one meal observed. The findings include: During an observation and interview on 08/26/2025 at 12:41 PM, this surveyor observed the ice scoop holder, on the wall by the ice machine, had an accumulation of wet black residue at the bottom of it, and the ice scoop was resting on the residue. The Dietary Manager (DM) confirmed the scoop holder was dirty and had mold-like residue at the bottom of it and should be cleaned daily. During an observation and interview on 08/26/2025 at 12:46 PM, this surveyor observed a box of alfredo sauce on a shelf in the refrigerator, the manufacturer's instructions specified that it must be kept frozen. The DM stated that she did not know who removed it from the freezer and placed it in the refrigerator and she would discard the sauce. During an observation and interview on 08/26/2025 at 12:52 PM, the following food items were improperly stored in the freezer: -One box of pizza opened was on a shelf, exposing it to freezer burn. The DM stated the pizza appeared dry and that the inner bag holding the pizza was not sealed -An opened box of cobbler dough, an open box of yeast roll, and an opened box of cheese omelets. The boxes were not covered or sealed, exposing the contents to freezer burn. -A box of chocolate ice cream, the container of ice cream was soft to touch. DM stated that it looked like it had been thawed and had been placed back in the freezer to re-freeze. During an observation and interview on 08/26/2025 at 1:10 PM, this surveyor observed a bag of breadcrumbs on a shelf in the storage room. The bag was opened, exposing the breadcrumbs to air, moisture, heat and potential pests. The DM stated that bugs could get into the bag and that the food content could become stale. During an observation and interview on 08/26/2025 at 4:09 PM, the following observations were made on a shelf in the kitchenette refrigerator on the third floor: -Seven bags of turkey sandwiches on a shelf. The bags were open, exposing the contents to air and cross contamination. -Two dated bowls of unidentified soup. The DM stated she had no idea what they were. -Seven bowls on a tray in the refrigerator. All bowls contained slices of honey dew melon. The slices of honey dew melon in one bowl had a greater than nine-millimeter circle of grayish, green material on it, the slices of honey dew melons in the remaining six bowls had spots of the same substance on either side of the top of the honey dew melon. The DM stated the melon were moldy. -Five bags of ham and cheese sandwiches on a shelf that had no date to allow for first in first out storage rotation. -Two bowls of salad with boiled eggs. The boiled eggs on top of the salad were discolored and there was no storage date on the bowls, the DM stated the salad was old. -A bag of grapes. The grapes had brown spots. The DM stated that the grapes had brown spots and a bit of fuzz, and she would throw them away. -A box that contained an egg, cheese and ham sandwich had no storage date on it. -A container of sour cream had an expiration date of 08/11/2025. -A plate that contained spaghetti leftovers, cut green beans, greens and cheese had a foul odor permeating from it. The DM stated it was spoiled. During an observation on 08/26/2025 at 4:33 PM, this surveyor observed a box of steak enchilada inside the freezer and had expiration date of 05/06/2025. During an observation on 08/26/2025 at 4:38 PM, this surveyor observed an open bag of bread on a shelf in the refrigerator. The bag was not sealed, exposing it to cross contamination. The Dietary Manager confirmed the bread would easily contaminate. A container of sour cream on a shelf in the refrigerator had an expiration date of 07/28/2025. During an observation and interview on 08/26/2025 at 5:00 PM, this surveyor observed Dietary [NAME] (DC) #4 use a rag to wipe off spilled leftover food items from the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents for supper. DC #4 stated she should have washed her hands after handling dirty objects and before handling clean equipment. During an observation and interview on 08/26/2025 at 5:53 PM, the temperatures of food on the steam tables in the kitchenette on the third floor were checked and read by DC #4 with the following results: Ground meat -115 degrees Fahrenheit. Mashed potatoes -130 degrees Fahrenheit. Hamburger patties- 103 degrees Fahrenheit. DC #4 stated she should have reheated the food items that were not hot enough to be served to the residents. During an observation and interview on 08/26/2025 at 6:00 PM, the temperatures of food on the steam tables in the kitchenette on the fourth floor were checked and read by the DM with the following results: Chicken noodle soup -130 degrees Fahrenheit. Mashed potatoes-120 degrees Fahrenheit. Hamburger patties -103 degrees Fahrenheit. Cut green beans - 120 degrees Fahrenheit. The DM stated she should have reheated the food items that were not hot enough to be served to the residents. During an interview on 08/27/25 at 4:10 PM, this surveyor asked Licensed Practical Nurse (LPN) #5 who was responsible for cleaning the refrigerators in the kitchen areas of each floor. LPN #5 responded that she thought dietary workers were responsible for cleaning the refrigerators in the kitchen areas of each floor, and moving forward from today it would be assigned to the nurses. During an interview on 08/27/2025 at 4:20 PM, ADON #6 stated the night shift nurses would be assigned to ensure the refrigerators on each floor are checked and cleaned nightly. A review of a facility policy titled, Food Safety: Ice indicated ice will not be handled with bare hands, but rather with a sanitized scoop and container for transport and distribution. A review of a facility policy titled, Hand Washing indicated hands should be washed when entering the kitchen at the start of the shift, as often as necessary during food preparation to remove soil or contamination and to prevent cross contamination when changing tasks, and after engaging in other activities that contaminate the hands. A review of a facility policy titled, Food temperatures indicated all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. A review of a facility policy titled Food Storage indicated all stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. All foods should be covered, labeled and dated.

Based on observations and interviews, it was determined that the facility failed to ensure a comfortable homelike environment for Rooms #430, #428, and #433 occupied by residents reviewed for a homelike environment. The findings include: During an observation on 08/25/2025 at 12:34 PM, the bathroom in room [ROOM NUMBER] was noted to have an unidentified brownish/black residue on the walls of the shower stall walls, floors, and shower curtain. This surveyor observed a basin with brownish/black residue noted sitting on the floor of the shower stall. The bathroom smelled of urine. A urinal was observed sitting on the nightstand with toothbrushes beside it. During an observation on 08/25/2025 at 12:46 PM, a shower chair in room [ROOM NUMBER] was noted to have a brownish residue on the bars of the shower chair and the mesh-like backing. This surveyor observed in the same bathroom missing and cracked tiles on the floor. The wall was noted to have scrape marks towards the bottom of the wall near the floor and there were basins noted under the sink, not bagged. During an observation on 08/25/2025 at 1:03 PM, a in room [ROOM NUMBER] was noted to have a fall mat on the floor beside the bed with spots of brownish/black unidentified substance. The pillow on the bed did not have a pillow case on it, the pillow case was noted to be flat and showed cracks in the plastic like material. On the wall behind the bed were noted large scrapes. This surveyor observed a chair sitting beside the bed, the seat was worn, and the material was peeling off. The flooring at the bottom of the wall was observed peeling off of the wall, with scrapes and brownish/black scuff marks. During a concurrent interview and observation on 08/28/2025 at 11:30 AM, the Housekeeping Supervisor indicated, We deep clean specific rooms daily. I have a list of rooms that I keep that are scheduled. When I do rounds, I look at all the curtains to see if any of them need to be cleaned. Resident #31's room gets cleaned daily and we use mold spray in the bathroom and scrub it. We used to only use the disinfectant, but the mold spray works better. I don't know how fast mold grows back. During a concurrent interview and observation in room [ROOM NUMBER] on 08/28/2025 at 11:50 AM, the Maintenance Director indicated, I have only been here a few weeks. The cleaning is maintained by housekeeping. I can get them whatever supplies they need to prevent this. This looks like mold. I don't think this is homelike. During an interview on 08/28/2025 at 12:35 PM, Resident #31 indicated I've been back at the facility going on two months, and my bathroom has been like this the whole time. The smell is awful. It's just nasty and I take showers in there. I have told them several times about the condition. Housekeeping goes in there, but it doesn't do any good. During a concurrent interview and observation on 08/28/2025 at 12:21 PM, the Assistant Director of Nursing (ADON) indicated, This bathroom is disgusting. That looks like mold. This could cause all kinds of infections, like respiratory or skin infections. This is not being cleaned daily. The residents are breathing this and walking on it. I'm going to go get housekeeping now, this is unacceptable. During an interview with the Administrator, on 08/28/2025 at 12:35 PM indicated, We are trying to work on updates for the facility. That looks like mold or rust. If the resident use that bathroom they could get sick. That is not sanitary. This is unacceptable and I will immediately get this corrected. Deep cleans are not being done appropriately. We do not have a housekeeping policy.

Based on observations, record review, and interviews the facility failed to ensure chemicals were properly stored away from residents to prevent accidents and injuries. Specifically, the storage room door, directly across the hall from the elevator door on 300 hall was left unlocked and unsecured. The room had chemicals, biohazard waste, a housekeeper's cart, and equipment stored inside. The Administrator provided a list of 55 ambulatory residents who could have been potentially affected. The facility failed to ensure razors were properly stored to prevent accidents and injury for one (Resident #57) of one resident reviewed for accidents. The findings include: Facility On 08/26/2025 at 11:06 AM, this surveyor observed a set of keys hanging from the doorknob of the soiled room directly across the hall from the elevator on 300-Hall. This surveyor turned the key and the door opened. This surveyor observed an unlocked housekeeping cart with a mop and water in a bucket on the cart, sitting just inside the door; a toilet/hopper bowl with water standing inside, chemicals sitting on shelves and on the counter, a red biohazard can, a cardboard bio-hazard box sitting directly on the floor, and a floor buffing machine. This surveyor was alone in the room approximately 40 minutes before surveyor left room and walked to the nurse's station to give the keys to the Unit Manager/Assistant Director of Nursing/Registered Nurse. The following were observed by this surveyor during the 40 minutes alone in the soiled room: A 32-ounce bottle of thermoplastic spray buff sitting in the open shelf of the cabinet in the room. The bottle was approximately 3/4 full without the lid on the bottle, leaving the chemical easily accessible. The Caution on the label documented may cause eye irritation. Contains ethylene glycol. Avoid contact with eyes. Wash thoroughly after handling. Do not ingest. First Aid: If splashed in eyes, flush with large quantities of water. Call physician if irritation persists. If swallowed, do not induce vomiting. Rinse out mouth with water. Call a physician or doctor for treatment advice. If in eyes: Hold eye open and rinse slowly and gently with water for 15-20 minutes. A tub of bleach disposable wipes. The caution on the label documented Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco, or using the toilet. First Aid: Call a poison control center or doctor for treatment advice. Physical or Chemical hazards: This product contains bleach. Do not use this product with other chemicals such as ammonia, toilet bowl cleaners, rust removers, or acid, as this releases hazardous gases. A gallon size container of Advanced Alcohol Gel Sanitizer, approximately half full was sitting on the counter. The label contained warnings for external use only, avoid contact with eyes. If contact occurs to rinse thoroughly with water. Flammable. This product contains ethyl alcohol. Keep away from sources of ignition. Discontinue use of redness develops. If irritation persists for more than 72 hours, consult a physician. Keep away from children. If swallowed, get medical help or contact a Poison Control Center right away. Active ingredient: Ethyl Alcohol 70%, purpose Antiseptic. Two-gallon size containers of concentrated glass cleaner were sitting in an open wire rack hanging on the wall. The gallon containers were not sealed; they contained a tube running from inside the container to the rack. The containers were approximately 3/4 full. The fluid inside the container was a blue liquid. A caution on the label documented: Eye Irritant, avoid eye and skin contact. First Aid - Eyes: flush thoroughly with plenty of water for at least 15 minutes. If irritation persists, seek medical attention. Skin - Wash thoroughly with plenty of water for at least 15 minutes. If irritation persists, seek medical attention. Internal - Drink plenty of water. Contact local poison control center or physician immediately. Contains: Isopropyl Alcohol. A gallon size container labeled concentrated glass cleaner was sitting in the open wire rack hanging on the wall. The container was approximately 1/8 full. The liquid inside was a pale yellow. A caution on the label documented: Eye Irritant, avoid eye and skin contact. First Aid - Eyes: flush thoroughly with plenty of water for at least 15 minutes. If irritation persists, seek medical attention. Skin - Wash thoroughly with plenty of water for at least 15 minutes. If irritation persists, seek medical attention. Internal - Drink plenty of water. Contact local poison control center or physician immediately. Contains: Isopropyl Alcohol. A gallon size container, labeled Glass Cleaner was sitting on the wire shelf hanging on the wall. The liquid inside the container was yellow in color. The label caution: Avoid contact with eyes and prolonged contact with skin. Avoid breathing vapors or spray mist. Do Not swallow this product. First Aid: Eyes - Flush eyes with plenty of water for at least 15 minutes. Get medical attention immediately. Skin - Wash skin with plenty of water, get medical attention if irritation develops. Inhalation - get to fresh air. If irritation persist get medical attention. Ingestion: Get medical attention immediately. A gallon size container, labeled Glass Cleaner was sitting on the wire shelf, hanging on the wall. The liquid inside the container was pink in color. The label gave a caution for eye irritant. Avoid eye and skin contact. First Aid - eyes: Flush thoroughly with plenty of water for at least 15 minutes. If irritation persists, seek medical attention. Skin: Wash thoroughly with plenty of water for at least 15 minutes. If irritation persists, seek medical attention Internal: Drink plenty of water. Contact local poison control center or physician immediately. Contains: Isopropyl Alcohol. A gallon size container of 3 in 1 carpet cleaner was sitting on an open shelf of a cabinet. The container was approximately 1/2 full. The label documented Warning - this product may cause irritation of exposed areas. Spilled materials is slippery. Avoid contact with eyes and skin. Us with adequate ventilation. Wash thoroughly after handling. Do not move to unmarked containers product residue. Do not reuse. Do not mix with anything but water, Use only in well-ventilated area. A clear spray bottle of 73 Disinfecting Acid Bathroom Cleaner, with a small amount of pink liquid inside was sitting on the open shelf of the cabinet. The label had a precautionary statement: Hazard to humans and domestic animals. Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco or using the toilet. First Aid: if in eyes hold eye open and rinse slowly and gently for 15 - 20 minutes. Call poison control or doctor for treatment advice. For emergency medical information, call toll-free [PHONE NUMBER]. An aerosol can of 2 in 1 odor eliminator/air freshener was sitting on the open shelf of the cabinet. If in eyes flush with water for 15 minutes, if irritation persist contact a doctor. If on skin, rinse with soap and water, contact a doctor if irritation develops or persists. If swallowed, call poison control or doctor immediately. A 24-ounce clear spray bottle of multi-surface degreaser was sitting on the shelf of the cabinet. The bottle contained a light blue colored liquid. It was approximately 1/3 full. The label contained a warning to keep away from children. Causes eye irritation. If in eyes rinse eyes cautiously with water for several minutes. If eye irritation persist get medical attention. Industrial use only. A clear spray bottle of all-purpose cleaner with a green liquid inside was sitting on the shelf of the cabinet. The container contained a small amount of green liquid. The label contained a cautious statement to avoid eye contact. A first aid treatment: in case of eye contact, flush well with water, if swallowed drink a glass of water and contact a physician. A clear spray bottle of rapid multi surface disinfectant cleaner was in the unlocked housekeeping cart. The bottle contained a blue liquid. The bottle was 32 ounces and was approximately 3/4 full. The label contained a precautionary statement: harmful to humans and domestic animals. Avoid contact with eyes or clothing. remove and wash contaminated clothing. Wash thoroughly with soap and water before handling and before eating, drinking, chewing, gum, using tobacco or using the toilet. First aid: if in eyes, hold eye open and rinse slowly and gently with water for 15-20 minutes. Call poison control center or doctor for treatment advice. For emergency medical information call toll-free [PHONE NUMBER]. A clear bottle of Bio-enzymatic odor eliminator. The label contained two sets of instructions. It was not clear which set the user would follow. The bottle was sitting inside the unlocked housekeeping cart. A clear spray bottle with a purple liquid inside was in the unlocked housekeeping cart. The bottle did not have any identifying label to identify the product, the use, or it's warnings. A clear spray bottle of 73 Disinfecting Acid Bathroom Cleaner, the bottle was approximately 3/4 full of pink liquid inside was sitting inside the unlocked door of the housekeeping cart. The label had a precautionary statement: Hazard to humans and domestic animals. Causes moderate eye irritation. Avoid contact with eyes or clothing. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco or using the toilet. First Aid: if in eyes hold eye open and rinse slowly and gently for 15 - 20 minutes. Call poison control or doctor for treatment advice. For emergency medical information, call toll-free [PHONE NUMBER]. A clear bottle of disinfectant cleaner was in the unlocked housekeeping cart. The bottle had a small amount of purple liquid inside. The front label said keep out of reach of children. The caution statement said see back panel. The back label was not on the bottle, thereby making it impossible for someone to know what precautions to follow for eyes, inhalation, swallowing, or skin contact. A cardboard biohazard box sitting directly on the floor contained a yellow biohazard bag with what appeared to be linens. A red biohazard can was sitting in the room with a red biohazard bag of what appeared biohazard trash. A trash bag full of trash on the housekeeping cart with trash inside. During an interview on 08/26/2025 at 11:40 AM, the Unit Manager/Assistant Director of Nursing/Registered Nurse (UM/ADON/RN) stated they did not know who the keys belonged to. The UM/ADON/RN stated the door should never be left unlocked because there were chemicals that were poisonous and hazardous in the room, and a resident could get in the room and drink the chemicals. The UM/ADON/RN stated if a resident were not alert or oriented, they could get stuck in the room. The UM/ADON/RN stated the biohazard box contained a yellow bag, which indicated it was biohazard linens possibly contained body fluids, urine, feces, sputum or worse. The UM/ADON/RN stated the red biohazard bin contained a red biohazard bag that looked like biohazard trash from a resident's room in isolation. The UM/ADON/RN identified the chemicals in the room to be spray buff, alcohol gel sanitizer, glass cleaner, all-purpose cleaners, air freshener, bleach wipes, carpet cleaner, acid bathroom cleaner, degreaser, disinfectant cleaner, odor eliminator, a clear bottle with purple liquid. UM/ADON/RN read the warnings on the chemical spray buff to cause eye irritation if splashed in the eyes. The UM/ADON/RN stated this chemical did not have a cap on it and it was pretty full. The UM/ADON/RN stated if swallowed do not induce vomiting, rinse out mouth with water and call physician. The UM/ADON/RN stated the alcohol gel indicated to avoid contact with eyes and rinse thoroughly with water, keep out of reach of children, it contained ethyl alcohol and if swallowed get medical help or poison control right away. The UM/ADON/RN stated the all-purpose cleaner indicated to keep out of reach of children, avoid eye contact, flush well with water, if swallowed drink water and contact physician. The UM/ADON/RN revealed that their concern with the biohazard box and red container would be if a resident got into the bags they would be exposed to whatever was on the linens or trash. The UM/ADON/RN said their concern with the commode/hopper toilet would be that it is full of water and if a resident put their hands in the water, it is just not safe or clean. The UM/ADON/RN said the equipment is not supposed to be in the room and their concern would be if a resident got in the room and plugged the machine in and turn it on, they could hurt themselves because they may not be able to control the machine. The UM/ADON/RN opened the door of the housekeeping cart and stated there was still water in the mop bucket, the gloves have been opened and were just laying here, the cart was in the middle of the room, and it was not locked. The UM/ADON/RN stated the disinfectant cleaner did not even have the back label so I would not know how to meet the resident's needs. I would not know if I should induce vomiting or not, which is important because you could cause damage to them if you induce and you shouldn't have. The UM/ADON/RN stated the keypad had not been working for a while now and they all had keys to the doorknob. During an interview on 08/26/2025 at 11:51 AM, Housekeeper (HK) #1 said they had left the keys in the door by mistake. HK #1 said their concern with leaving the keys in the door was someone could get their chemicals and stuff. HK #1 said someone could get sick or die if they got the chemicals and drank them because they could think it was a fruit drink. HK #1 said it would not be good if a resident got in the biohazard box or trash because you can't touch that stuff, they would be in trouble, they would get sick. HK #1 said they left their cart unlocked and left their keys in the door. HK #1 said they have to use keys because the keypad doesn't work and hasn't for a while now. On 08/26/2025 at 12:08 PM, the surveyor observed the back of the keypad, inside the soiled room did not have a cover on it and there were no batteries in the unit. The soiled room was across the hall from the elevator all resident's use to and from 300-hallway to other floors in the facility. On 08/26/2025 at 12:10 PM, the surveyor observed approximately 12 residents pass the door of the soiled room as they ambulated to and from the hallway and elevator. On 08/27/2025 at 2:46 PM, surveyor observed approximately 15 residents pass the door to the soiled room as they came off the elevator. There was a total of 50 ambulatory residents residing in the facility. On 08/27/2025 at 2:47 PM, during an interview Social Services Coordinator (SSC), stated the residents who reside on 300 and 400 halls go back and forth between halls to visit and go to the vending machine. On 08/27/2025 at 2:53 PM, during an interview LPN #2, stated the residents from 400 Hall came to 300 Hall for the vending machine, it was the only place in the building where a vending machine was located that the residents could access. On 08/27/2025 at 2:54 PM, this surveyor observed the vending machine was in the dining room of 300-Hall. On 08/28/2025 at 8:30 AM, the Administrator said they had concerns with the door to the soiled storage area being unlocked and unsecured because a resident could have gotten in the room and been hurt. A confused resident could have possibly gotten into the chemicals and been harmed. The door should be secured at all times, and everyone was responsible for ensuring the door was locked. The Administrator provided a list of 50 residents who were ambulatory and used the vending machine on the third floor where the unsecured soiled storage area was located. The list contained 50 names of residents residing in the facility. The Administrator stated the UM/ADON/RN, assigned to that hall monitored the doors to ensure they were locked. The Administrator stated the facility also had department managers who made rounds twice a day and monitor the doors. On 08/28/2025 at 8:45 AM, the Director of Nursing (DON) stated they had started an in-service on keeping the doors of storage and soiled rooms locked and secured at all times. The DON stated had a resident gotten in the room the resident could have been poisoned by the chemicals. The DON continued that it was important for them to know if a resident ever went in the room unattended so they could monitor the resident, notify the provider and start any treatment the doctor would want initiated. The DON stated the doors should be locked when not in use by an employee. The DON stated the staff that had gone into the room was responsible for ensuring the door was secured. The DON stated any resident roaming freely in their wheelchair or walking could have been harmed had they gone into the room. The DON stated they monitor the doors during walking rounds each day and made sure the doors are secured and locked. Resident #57 Review of Resident #57's Medical Diagnosis report revealed Resident #57 had diagnoses which included Schizophrenia, dementia and depression. The significant change Minimum Data Set (MDS) with an Assessment Reference date of 05/14/2025 indicated Resident #57 had a Brief Interview for Mental Status score of 10, which indicated moderate cognitive impairment. The MDS indicated 1-3 days a month resident had physical symptoms such as hitting, pacing, and scratching. The MDS also indicated Resident #57 was independent on toileting, bathing, dressing and personal care. Review of a Care Plan, dated 04/30/2025, revealed Resident #57 had a self-care deficit and required assistance of staff. The Care Plan also indicated to encourage Resident #57's participation in care and monitor and report changes. On 08/25/2025 at 11:50 AM, and 1:30 PM, a black razor was observed resting on the bathroom sink of the open bathroom door in Resident #57's room. Resident #57 was not in the room. This surveyor observed residents in wheelchairs going down 300 hall to the dining area. On 08/26/2025 at 9:00 AM, Resident #57 was observed in their room with a small red skin sheer on the chin. The razor was not observed in the bathroom. Resident #57 asked this surveyor, Can I have some shaving cream? Resident #57 did not indicate how the resident's chin was cut. Resident #57 was observed approaching the nurses station asking RN #8 for shaving cream. RN #8 stated, I will have to get the Certified Nursing Assistant (CNA) to help you because last time you nicked your chin. During an interview on 08/26/2025 at 3:00 PM, RN #8 said, CNAs assist residents with shaving on shower days and as needed residents are not allowed to keep razors in their room because they could harm themselves, and we have residents that wander on [Resident #57's] hall. RN #8 stated Resident #57 had schizophrenia and if the resident had an episode [pronoun] could harm [pronoun]self. RN #8 revealed she thought a razor was left out in Resident #57's room by someone that takes the resident shopping weekly and could have purchased razors for Resident #57. On 08/28/2025 at 1:00 PM, the Administrator revealed there was not a shaving or razor policy and provided an in-service binder. The Administrator confirmed that residents were not to shave themselves, the CNAs and nursing assist residents with razors, and razors are not to be left in resident rooms. The facility policy titled Accidents and Hazards indicated that the facility strives to ensure the resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistive devices to prevent accidents.

Based on observation, interview and record review the facility failed to ensure isolation practices were being followed by housekeeping staff to prevent the possible spread of infectious disease on one (Fourth) floor of the nursing facility. The findings include: On 08/25/2025, a contact isolation sign was observed on the door of room [ROOM NUMBER]. On 08/26/2025 at 11:00 AM, Housekeeper (HSK) #9 was observed on west 400 hall pushing the housekeeping cart with gloved hands. HSK #9, without changing gloves or performing hand hygiene, nor donning an isolation gown, was observed going into room [ROOM NUMBER] with a broom and dustpan. HSK #9 came out of the room and placed a small bag of trash in the trash compartment of the housekeeping cart. HSK #9 was observed, through the open room door, to move dirty linen and a trash container from room [ROOM NUMBER]'s bathroom to the room,. HSK #9 then came out of room [ROOM NUMBER] and picked up a bottle of spray and a toilet brush and went back into room [ROOM NUMBER]. A minute later, he replaced those two items on the housekeeping cart, got the mop and went back to mop the bathroom of room [ROOM NUMBER]. After mopping, HSK #9 returned the mop to the housekeeping cart and proceeded to push the housekeeping cart down the hall. HSK #9 did not change gloves or perform hand hygiene at any time during the cleaning of room [ROOM NUMBER], nor as he went to push the housekeeping cart down the hall. On 08/26/2025 at 11:13 AM, HSK #9, who had worked at this facility three years, confirmed he had been trained on what to do when cleaning a room where the resident was on isolation. He confirmed he knew what the contact isolation sign on the door of room [ROOM NUMBER] indicated, but that he was just trying to get it done quickly. On 08/28/2025 at 10:25 AM, the Administrator confirmed she expected housekeeping personnel to follow the same protocol as the nursing staff concerning isolation and to follow good infection control practices. Review of training for HSK #9 indicated HSK #9 had been in-serviced on infection control on 06/05/2025, and in-serviced on hand hygiene and personal protective equipment on 08/20/2025. The facility's policy on Infection Control and Prevention indicated infection prevention involved all disciplines, and staff would be monitored to ensure compliance with techniques and procedures to prevent the spread of infection. Based on observation, interview and record review the facility failed to ensure isolation practices were being followed by housekeeping staff to prevent the possible spread of infectious disease. On 08/25/2025 a contact isolation sign was observed on the door of room [ROOM NUMBER]. On 08/26/2025 at 11:00 AM housekeeper (HSK) #9 was observed on west 400 hall pushing the housekeeping cart with gloved hands. HSK #9, without changing gloves or performing hand hygiene nor donning an isolation gown, was observed going into room [ROOM NUMBER] with a broom and dustpan. HSK #9 came out of the room and placed a small trash bag of trash in the trash compartment of the housekeeping cart. HSK #9 was observed, through the open room door, to move a dirty linen and a trash container from room [ROOM NUMBER]'s bathroom to the room, at the resident's request. HSK #9 then came out of room [ROOM NUMBER] and picked up a bottle of spray and a toilet brush and went back into room [ROOM NUMBER]. A minute later he came back to the housekeeping cart and replaced those two items and got the mop and went back to mop the bathroom of room [ROOM NUMBER]. After mopping HSK #9 returned the mop to the housekeeping cart, he proceeded to push the housekeeping cart down the hall. HSK #9 did not change gloves or perform hand hygiene at any time during the cleaning of room [ROOM NUMBER] nor as he went to push is cart down the hall. On 08/26/2025 at 11:13 AM HSK #9, who had worked at this facility 3 years, confirmed he had been trained on what to do when cleaning a room where the resident is on isolation. He confirmed he knew what the contact isolation sign on the door of room [ROOM NUMBER] indicated, but that he was just trying to get it done quickly. On 08/28/2025 at 10:25 AM the Administrator confirmed she expected housekeeping personnel to follow the same protocol as the nursing staff concerning isolation and to follow good infection control practices. Review of a training indicated HSK #9 had been in-serviced on infection control on 06/05/2025 and in-serviced on hand hygiene and personal protective equipment on 08/20/2025. The facility's policy on Infection Control and Prevention indicated infection prevention involved all disciplines and staff would be monitored to ensure to ensure staff compliance with techniques and procedures to prevent the spread of infection.

Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure medications were administered as ordered by the physician for 2 (Residents #2 and #4) of 3 residents reviewed for correct medication administration as ordered by the physician. The findings include: A review of a facility policy titled, Policies and Procedures: Subject: Medication Administration, revised on 11/25/2022, indicated that medications were to be administered as ordered, including the required time frame. 1. A review of the Admission Record, indicated the facility admitted Resident #2 with diagnoses that included schizophrenia, bipolar disorder, major depressive disorder, and generalized anxiety disorder. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/10/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Resident #2 was marked as taking antipsychotic and antianxiety medications. A review of Resident #2's Care Plan, initiated on 07/12/2023, revealed the resident was at risk for behavior problems related to schizophrenia and bipolar disorder. Interventions included: administer medications as ordered, monitor and document for side effects and effectiveness and reward the resident for appropriate behavior. A review of the Order Summary Report, revealed Resident #2 had an order for [second generation atypical antipsychotic medication name] 100 milligrams (mg), give 1.5 tablets by mouth two times a day. According to December 2024 Medication Administration Record (MAR), Resident #2 had an order for [second generation atypical antipsychotic medication name] 100 mg give 2 tablets by mouth at bedtime from 12/01/2024 until 12/16/2024. A new order was written for [second generation atypical antipsychotic medication name] 100 mg give 3 tablets by mouth at bedtime to start 12/17/2024. [Antimanic agent medication name] 300 mg, give 2 tablets to equal 600 mg by mouth at bedtime. A review of December 2024, Medication Administration Record, revealed Resident #2 had not received [second generation atypical antipsychotic medication name] 100 mg, 2 tablets at bedtime for the dates of 12/08/2024, 12/09/2024, and 12/10/2024, and was marked hold/see nurses notes, 12/11/2024, 12/12/2024, 12/13/2024, 12/15/2024, and 12/16/2024 were marked other/see nurses notes. On 12/17/2024, Resident #2 refused the medication and on 12/18/2024 the resident was hospitalized . Resident #2 had not received [anti-manic agent medication name] 300 mg (2 tablets to equal 600 mg) on 12/07/2024 and was marked other/see nurses notes and 12/08/2024 was marked hold/see nurses notes. Resident #2 refused [antimanic agent medication name] on 12/17/2024 and was marked hospitalized for [DATE]. A review of Progress Notes, revealed Resident #2 had the following notes written: 12/07/2024: [antimanic medication name] 300 mg Give 2 tablets by mouth at bedtime . Out of medication at this time. This nurse will fax a refill form to the pharmacy. 12/08/2024: Clozapine 100 mg, Give 2 tablets by mouth at bedtime, pharmacy. 12/09/2024: Complete Blood Count (CBC) ordered per medical doctor this am to check levels before pharmacy can deliver meds. 12/09/2024: [second generation atypical antipsychotic medication name]100 mg, Give 2 tablets by mouth at bedtime, waiting on lab results. 12/10/2024: [second generation atypical antipsychotic medication name]100 mg, Give 2 tablets by mouth at bedtime, pharmacy. 12/11/2024: [second generation atypical antipsychotic medication name]100 mg, Give 2 tablets by mouth at bedtime, pharmacy. 12/12/2024: [second generation atypical antipsychotic medication name]100 mg, Give 2 tablets by mouth at bedtime, waiting on pharmacy. 12/13/2024: [second generation atypical antipsychotic medication name]100 mg, Give 2 tablets by mouth at bedtime, waiting on pharmacy. 12/15/2024: [second generation atypical antipsychotic medication name] 100 mg. Give 2 tablets by mouth at bedtime, pharmacy. 12/16/2024: [second generation atypical antipsychotic medication name] 100 mg, Give 2 tablets by mouth at bedtime, pharmacy. 12/17/2024: Pharmacy called for resident's [second generation atypical antipsychotic medication name] refill. Most recent CBC faxed to pharmacy. Awaiting call back. 12/17/2024: received resident's [second generation atypical antipsychotic medication name] from pharmacy. 12/17/2024: resident does not respond to verbal stimuli but has verbal response to physical stimuli. 12/17/2024: refused all meds and nourishment. 12/18/2024: resident was very confused and started yelling for help last evening, became combative, so disoriented, order to transfer. A review of the pharmacy manifest revealed Resident #2's [second generation atypical antipsychotic medication name] had been ordered from the facility on 12/10/2024 and was filled on 12/17/2024. A review of the Lab Results Report, revealed that Resident #2 had a CBC collected on 12/13/2024 at 7:30 AM and was reported on 12/14/2024 at 3:04 AM. A review of the hospital records, revealed that Resident #2 was admitted to the hospital on 12/18/2024 and the reason for admission stated, after speaking with a nurse at the [Facility Name] and indicated that Resident #2 had not received [second generation atypical antipsychotic medication name] for several days as their pharmacy would not release it due to the resident not having a current absolute neutrophil count and that Resident #2 had been stable for a long period of time on the combination of [second generation atypical antipsychotic medication name] and [antimanic medication name], but that since Resident #2 had not received the [second generation atypical antipsychotic medication name] in the last week, the resident had grown increasingly psychotic and disorganized. During an observation on 02/10/2025 at 11:38 AM, Resident #2 was lying in bed with the head of bed slightly elevated talking and laughing with the nursing staff. Resident #2 was singing a different version of Happy Birthday. 2. A review of the Admission Record, indicated the facility admitted Resident #4 with diagnoses that included discitis, cervical region, lumbago with sciatica, cord compression, acute respiratory failure and surgical aftercare following surgery on the nervous system. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/06/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #4 was marked as taking an antibiotic medication. A review of Resident #4's care plan, initiated on 01/14/2025 revealed the resident was on antibiotic therapy via peripherally inserted central catheter (PICC) to right upper extremity. Intervention included: administer antibiotic medications as ordered by physician and monitor/document side effects and effectiveness. A review of the Order Summary Report, revealed Resident #4 had an order for [glycopeptide antibiotic medication name] intravenous solution 1000 mg/200 milliliter (ml) intravenously twice a day. A review of Medication Administration Record, for February 2025 revealed Resident #4 had not received [glycopeptide antibiotic medication name] on 02/04/2025, 02/05/2025, 02/06/2025 and 02/10/2025. A review of Progress Notes, revealed Resident #4 had the following notes written: 02/04/2025 [glycopeptide antibiotic medication name] intravenous solution 1750 mg/350 ml, unavailable. Called pharmacy to stat over. 02/04/2025 resident did not receive afternoon antibiotic (ABT) due to being unavailable. Pharmacy notified and asked to stat over, pharmacy spoke with physician assistant and orders are to be sent over to lower the dose of antibiotic. 02/04/2025 waiting on delivery from pharmacy 02/05/2025 [glycopeptide antibiotic medication name] Intravenous Solution 1000mg/200ml no note written. 02/06/2025 [glycopeptide antibiotic medication name] Intravenous Solution 1000mg/200ml, has to have a new PICC line tomorrow. 02/10/2025 [glycopeptide antibiotic medication name] Intravenous Solution 1000mg/200ml, drug not available. During an interview on 02/10/2025 at 11:58 AM, Resident #4 stated, I was supposed to get my antibiotic at eight (8) this morning and I still haven't had it. Resident #4 confirmed that no one had spoken to him about why the medication had not been given. During an interview on 02/11/2025 at 11:50 AM, Licensed Practical Nurse (LPN) #1 confirmed that no intravenous (IV) antibiotic had been administered on 02/10/2025 due to not being able to locate the antibiotic and that the medication was searched for by LPN #1 and another LPN. During an interview on 02/11/2025 at 11:55 AM, LPN #2 confirmed that the medication had been searched for with LPN #1 and the antibiotic was unable to be located. During an interview on 02/11/2025 at 12:00 PM, the Administrator asked this surveyor to speak with the Regional Nurse Consultant, who was asked to review the documentation and confirmed per the MAR documentation and the progress notes that Resident #2 had not received [second generation atypical antipsychotic medication name] on 12/08/2024, 12/09/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/15/2024 and 12/16/2024 due to the medication not being available. The Regional Nurse Consultant agreed that [second generation atypical antipsychotic medication name] had been ordered on 12/10/2024 but was not delivered to the facility until 12/17/2024. During an interview on 02/11/2025 at 12:10 PM, the Regional Nurse Consultant explained that the antibiotic was not given to Resident #4 on 02/04/2025 due to the medication had been reduced and the facility was waiting for the medication to be delivered and on 02/05/2025 and 02/06/2025, Resident #4's PICC had malfunctioned, and a third-party vendor had to come in and re-insert a new PICC. He confirmed per the progress note and the MAR for 02/10/2025 that the antibiotic had not been administered due to the medication was unavailable. When asked what the importance of medications being administered as ordered, he stated, not getting their medications can lead to exacerbation of chronic medical conditions and we will have some things to look at concerning these issues.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure allegations of misappropriation of property were reported to the State Agency for 15 Resident, with 3 residents remaining on medications, (Resident #4, Resident #5, Resident #7) of 15 residents reviewed for abuse. Specifically, the facility failed to ensure alleged misappropriations of Resident #4, #5, #7 medications were reported. Findings include: A review of a facility policy titled, Abuse, Neglect, and Exploitation revised on 01/01/2024, indicated, Policy Statement: We are committed to the safety and well-being of all our residents. We believe that the resident has the right to be free from .misappropriation of property .The facility considers all the above to be abuse and uses the general term abuse to specify all .Reporting .3. The facility will report all alleged violations involving mistreatment, neglect, or abuse to the Office of Long-Term Care, Family, Police, and MD [medical doctor]. Suspicion or allegation of abuse shall be reported immediately, not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury . A review of a facility policy titled, Controlled Substances, revised on 01/31/2023, indicated, .Schedule II, III, IV, and V medications remaining in the facility after the resident has been discharged or the order discontinued, the charge nurse should surrender the narcotics to the DON/ADON [Director of Nursing/Assistant Director of Nursing]. Both the charge nurse and the DON/ADON should sign in the appropriate location in the narcotic book. The medications should be logged on the Arkansas Department of Health Report of Drugs Surrendered from and signed by both nurses. When possible, narcotic surrender should be completed when the pharmacy consultant is present to double check the medications. When narcotics are surrendered to DON/ADON, they should be taken to or mailed to the ADH Pharmacy Services division immediately. These logs should be stored in a binder and reconciled when the completed form is returned from pharmacy services. A review of the Arkansas Department of Health Report of Loss of Controlled Substances form indicated the facility, identified on 9/24/24 discontinued narcotics were not surrendered to Pharmacy Services and are unaccounted for .List of controlled substance lost. See attached . This form was signed by the Chief Nursing Officer [CNO] on 9/26/24. A review of the document attached to the Arkansas Department of Health Report of Loss of Controlled Substances form identified 15 residents affected and 693 drugs that were discontinued and unaccounted for. Further review revealed the faxed form failed to be transmitted to the Pharmacy Division of ADH. During an interview on 10/21/2024 at 11:4 a.m., the CNO confirmed that 693 drugs had been discontinued and had not been surrendered to the state. CNO confirmed the 693 missing narcotics had been reported to the Pharmacy Division of the Arkansas Department of Health [ADH] on 9/26/24. Upon review of listed missing narcotics, it was determined the fax failed to send to the Pharmacy Division of ADH. CNO verbalized the list would be faxed again today to ADH. The CNO provided successful fax confirmation on 10/21/24 at 1:32 p.m. During an interview with the CNO on 10/22/24 at 2:58 p.m., the CNO verbalized not reporting to the office of long-term care due to the medications had been discontinued and there were no negative outcomes for the residents. A review of the loss of controlled substance record submitted to ADH indicated Resident #4, R#5, R#7 still had current orders for the missing medications. A review of the admission record indicated the facility admitted Resident #4 with diagnoses that included acute and chronic respiratory failure, chronic lymphocytic leukemia of B-cell type not having achieved remission, chronic obstructive pulmonary disease with (acute) exacerbation, and osteoarthritis of hip and knee. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident was cognitively intact. A review of Resident #4's Care Plan initiated on 02/22/2023, revealed the resident was at risk for pain and had an order for opioids for pain. Interventions included give medications as ordered, observe/document for side effects, and monitor for effectiveness and adverse reactions. A review of physician orders and MAR revealed Resident #4 had Norco oral tablet 5-325 mg [milligram]give 1 tablet by mouth every 4 hours as needed for pain/wound care starting on 9/3/24. A review of the record of loss of controlled substance revealed Resident #4 had HCD/APAP [hydrocodone/acetaminophen] 5/325 mg quantity 42 missing. During an interview on 10/21/2024 at 1:02 p.m., Resident #4 confirmed taking opioid pain medication and denied any issues or concerns receiving the medication. A review of the Admission Record indicated the facility admitted Resident #5 with diagnoses that included type II diabetes mellitus with diabetic peripheral angiopathy with gangrene, bilateral above the knee amputation, and essential (primary) hypertension. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/30/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident cognitively intact. A review of Resident #5's Care Plan initiated on 11/30/2020, revealed the resident has chronic pain due to osteoarthritis and has and order for opioids for pain. Interventions included give medications as ordered, observed and document the frequency and intensity of the pain symptoms, and observe/document the effectiveness or ineffectiveness of medications. A review of physician orders and medication administration record [MAR]revealed Resident #5 had Norco oral tablet 5-325 mg (hydrocodone-acetaminophen) 1 tablet by mouth every 6 hours as needed for pain. A review of the record of loss of controlled substance revealed Resident #5 had HCD/APAP [hydrocodone/acetaminophen] 5/235 mg quantity 1 missing. A review of the narcotic book page 19 indicated Resident #5 had 32 tablets remaining of hydrocodone/acetaminophen 5/325 mg. The medication balance was transferred to page 29 of the narcotic book with a starting balance of 31 tablets indicating one tablet was unaccounted for. During an interview on 10/21/2024 at 1:20 p.m., Resident #5 confirmed taking opioid pain medication and denied any issues or concerns receiving the medication. A review of the admission record indicated the facility admitted Resident #7 with diagnoses that included acute and chronic respiratory failure, end stage renal disease, tracheostomy status [an opening in neck used for breathing], and dementia in other diseases. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/26/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. A review of Resident #7's care plan initiated on 01/04/2024, revealed the resident had anti-anxiety medications, at risk for a mood problem related to anxiety and risk for pain related to diagnosis. Interventions included administering medications as ordered, observe and documented the intensity and frequency of symptoms and monitor for safety.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure residents were free from misappropriation of property for 4 (Resident #3, #4, #5, #7) of 15 residents reviewed for misappropriation of property. Findings include: A review of a facility policy titled, Abuse, Neglect, and Exploitation revised on 01/01/2024, indicated, Policy Statement: We are committed to the safety and well-being of all our residents. We believe that the resident has the right to be free from .misappropriation of property .The facility considers all the above to be abuse and uses the general term abuse to specify all .Investigation: 3. In the event of misappropriation, a thorough search of the building is conducted to determine possible misallocation of missing items. A Missing Item Form is completed, and missing items are analyzed for patterns, location and care givers . A review of a facility policy titled, Controlled Substances, revised on 01/31/2023, indicated, .Schedule II, III, IV, and V medications remaining in the facility after the resident has been discharged or the order discontinued, the charge nurse should surrender the narcotics to the DON/ADON [Director of Nursing/Assistant Director of Nursing]. Both the charge nurse and the DON/ADON should sign in the appropriate location in the narcotic book. The medications should be logged on the Arkansas Department of Health Report of Drugs Surrendered from and signed by both nurses. When possible, narcotic surrender should be completed when the pharmacy consultant is present to double check the medications. When narcotics are surrendered to the DON/ADON, they should be taken to or mailed to the ADH Pharmacy Services division immediately. These logs should be stored in a binder and reconciled when the completed form is returned from pharmacy services. A review of the Arkansas Department of Health Report of Loss of Controlled Substances form, indicated the facility, identified on 9/24/24 discontinued narcotics were not surrendered to Pharmacy Services and are unaccounted for .List of controlled substance lost. See attached . This form was signed by the Chief Nursing Officer [CNO] on 9/26/24. A review of the Arkansas Department of Health Report of Loss of Controlled Substances form identified 15 residents affected and 693 drugs that were discontinued and unaccounted for. Further review revealed the faxed form failed to be transmitted to the Pharmacy Division of ADH. During an interview on 10/21/2024 at 11:45 a.m , the CNO confirmed 693 drugs had been discontinued and had not been surrendered to the state. CNO confirmed the 693 missing narcotics had been reported to the Pharmacy Division of the Arkansas Department of Health [ADH] on 9/26/24. Upon review of listed missing narcotics, it was determined the fax failed to send to the Pharmacy Division of ADH. CNO verbalized the list would be faxed again today to ADH. The CNO provided successful fax confirmation on 10/21/24 at 1:32 p.m A review of the Admission Record indicated the facility admitted Resident #3 with diagnoses that included Huntington's disease, protein calorie malnutrition, and adult failure to thrive. The significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/16/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to finish the assessment. A review of Resident #3's Care Plan initiated on 04/23/2024, revealed the resident was at risk for pain and has PRN [as needed] order for opioids. Interventions included give medications as ordered, observe and documented the frequency and intensity of the pain symptoms, and observed/documented for side effects of pain medication. A review of physician orders revealed Resident #3 had morphine sulfate oral solution 20 mg/5 ml [20 milligrams/5 milliliters] give 0.5 ml via G-tube [gastrostomy tube-flexible plastic tube used for delivering nutrition and medication into the stomach from outside the abdominal wall] every 4 hours as needed for pain. A review of record of loss of controlled substances revealed Resident #3 had oxycodone 5 mg [milligram] quantity 26 missing. A review of the Admission Record indicated the facility admitted Resident #5 with diagnoses that included type II diabetes mellitus with diabetic peripheral angiopathy [narrowing of the arteries restricting blood flow] with gangrene, bilateral above the knee amputation, and essential (primary) hypertension [high blood pressure] The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/30/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident cognitively intact. A review of Resident #5's Care Plan, initiated on 11/30/2020, revealed the resident has chronic pain due to osteoarthritis and has and order for opioids for pain. Interventions included give medications as ordered, observed and document the frequency and intensity of the pain symptoms, and observe/ document the effectiveness or ineffectiveness of medications. A review of physician orders and medication administration record [MAR] revealed Resident #5 had Norco oral tablet 5-325 mg (hydrocodone-acetaminophen) 1 tablet by mouth every 6 hours as needed for pain. A review of Arkansas Department of Health Report of Loss of Controlled Substances form revealed Resident #5 had Hcd/APAP [hydrocodone/acetaminophen] 5/325 mg quantity 1 missing. A review of the narcotic book page 19 indicated Resident #5 had 32 tablets remaining of hydrocodone/acetaminophen 5/325 mg. The medication balance was transferred to page 29 of the narcotic book with a starting balance of 31 tablets indicating one tablet was unaccounted for. During an interview on 10/21/2024 at 1:20 p.m., Resident #5 confirmed taking opioid pain medication and denied any issues or concerns receiving the medication. A review of the admission record indicated the facility admitted Resident #4 with diagnoses that included acute and chronic respiratory failure, chronic lymphocytic leukemia of B-cell type not having achieved remission, chronic obstructive pulmonary disease with (acute) exacerbation, and osteoarthritis of hip and knee. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2024, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident was cognitively intact. A review of Resident #4's Care Plan initiated on 02/22/2023, revealed the resident was at risk for pain and had an order for opioids for pain. Interventions included give medications as ordered, observe/document for side effects, and monitor for effectiveness and adverse reactions. A review of physician orders and MAR revealed Resident #4 had Norco oral tablet 5-325 mg give 1 tablet by mouth every 4 hours as needed for pain/wound care starting on 9/3/24. A review of the record of loss of controlled substance revealed Resident #4 had Hcd/APAP [hydrocodone/acetaminophen] 5/325 mg quantity 42 missing. During an interview on 10/21/2024 at 1:02 p.m , Resident #4 confirmed taking opioid pain medication and denied any issues or concerns receiving the medication. A review of the admission record indicated the facility admitted Resident #7 with diagnoses that included acute and chronic respiratory failure, end stage renal disease, tracheostomy status [an opening in neck used for breathing], and dementia in other diseases. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/26/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. A review of Resident #7's Care Plan initiated on 01/04/2024, revealed the resident had anti-anxiety medications, at risk for a mood problem related to anxiety and risk for pain related to diagnosis. Interventions included administering medications as ordered, observe and documented the intensity and frequency of symptoms and monitor for safety. A review of physician orders revealed Resident #7 had clonazepam oral tablet 1 mg give 1 tablet by mouth one time a day for anxiety and tramadol oral tablet 50 mg give 1 tablet by mouth every 6 hours as needed for pain moderate 4-6. A review of the record of loss of controlled substance revealed Resident #7 had clonazepam 1 mg quantity 14 missing and tramadol 50 mg quantity 4 missing. A review of the narcotic book page 37 indicated Resident #7 had 14 tablets remaining of clonazepam 1 mg. Page 37 indicated the medication had been discontinued and had been surrendered with a count of 14 tablets. A review of narcotic book page 46 indicated Resident #7 had 4 tablets remaining of tramadol 50 mg. During an interview on 10/21/2024 at 1:15 p.m., Resident #4 confirmed taking pain medication and denied any issues or concerns receiving the medication.

Based on observation, record review and interview, the facility to ensure foods stored in the refrigerator, freezer and storage room were covered, and sealed to maintain freshness and decrease the potential for cross contamination; the ice machine and ice scoop holder were maintained in clean condition to prevent potential contamination of residents' food and beverages; dietary employees washed their hands or changed gloves before handling clean equipment or food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 main kitchen. The failed practices had the potential to affect 20 residents who received meals from the kitchen on the 200 Hall; 30 residents who received meals from the kitchen on the 300 Hall; and 39 residents who received meals from the kitchen on the 400 Hall (total census of 97), as documented on a list provided by the Dietary Supervisor on 05/06/24 at 12:34 PM. The findings are: 1. On 05/05/2024 09:08 AM, the following observations were made in the kitchen area: a. There was water standing on the floor between the hand washing sink and the food preparation counter. b. An opened box of plain salt was on the shelf above the food preparation counter. The box was not covered. c. The ice machine panel and the area where the ice forms before dispensing into the ice collection area had wet black residue on them. The Surveyor asked the Dietary Supervisor to wipe out the wet black substances found on the panel and the area where ice forms. He wiped them off with tissue paper. The wet black substances easily transferred on the tissue papers. The Surveyor asked the Dietary Supervisor who uses ice from the ice machine and how often the ice machine is cleaned. He stated, We clean it once a month. That's the ice the Certified Nursing Assistants use to fill the water pitchers in residents rooms and the beverages served to the residents at mealtimes. 2. On 05/05/2024 at 09:17 AM, an opened resealable bag that contained shredded parmesan cheese was on a shelf in the refrigerator. The bag was not sealed. 3. On 05/05/2024 at 09:19 AM, the following observations were made in the walk-in freezer: a. Two of the two opened boxes of chocolate chip cookies were on a shelf. The boxes were not covered or sealed. There were no open dates on the boxes to identify when they were opened. b. An opened box of bread sticks. The box was not covered or sealed. c. An opened box of dough. The box was not covered or sealed. d. An opened box of hamburger patties. The box was not covered or sealed. 4. On 05/05/2024 at 09:40 AM, the following observations were made on a rack in the storage room: a. A dented can that contained mixed vegetables was on the rack to be used. b. A dented can of country season gravy was on the rack to be used. c. An opened bag of cornmeal was on a shelf in the storage room, exposing it to air or potential for pests. d. There was water leaking from the side of the ceiling light fixture to the floor. 5. On 05/05/2024 at 09:49 AM, the ice scoop holder located on the wall facing the ice machine had pink and wet brown residue at the bottom of it. The ice scoop was stored in the scoop holder, in direct contact with the residue. The Surveyor asked the Dietary Supervisor to wipe what was observed at the bottom of the scoop holder. He did so, and the pink and brown residue easily transferred to the tissue paper. He was asked how often they clean the ice scoop holder? He stated, We clean it once a week. 6. On 05/05/2024 at 09:52 AM, there was water standing on the floor in the dish washing machine. The area had a strong odor permeating from it. 7. On 05/05/2024 at 10:48 AM, Dietary Employee (DE) #1 picked up a can of soda from the counter and a bag from the floor and threw them away. Without washing her hands, she picked up clean eating utensils, by the end of the utensils that would go into the mouth and wrapped them in individual napkins for the residents to use at their lunch meal. The Surveyor asked DE #1 immediately what do the residents do with napkins? She stated, They use it to wipe their mouths when eating food. The Surveyor asked what should you have done after touching dirty objects or before handling clean equipment. DE #1 stated, I should have washed my hands. 8. On 05/05/2024 at 11:59 AM, there were dried food particles inside the blender bowl and on the blade to be used in pureeing the food items to be served to the residents who required pureed diets for lunch. DE #2 was about ready to scoop vegetables into the blender to be pureed. The Surveyor immediately asked DE #2 what was inside the blender bowl. DE #2 stated, That was yellow dried food particles. I will wash it. 9. On 05/05/2024 at 12:02 PM, DE #2 turned on the 3-compartment sinks hot water faucet and rinsed the blender bowl and blade. Afterwards he turned off the sink faucet with his bare hands, contaminating his hands. DE #2 did not use soap or sanitize the blender bowl and the blade. As DE #2 assembled the food preparation equipment and was about ready to use it in pureeing foods for the residents on pureed diets. The Surveyor asked DE#2 if he should sanitize the blender bowl and the blade before using them. He stated, Yes, I should have sanitized them. 10. On 05/05/24 at 01:27 PM, the ice scoop holder attached to the ice chest in the third-floor dining area had dark, crusty matter around two screws and dark specks of matter in the bottom of the scoop holder with the scoop lying in it. a. On 05/05/2024 at 01:29 PM, the Surveyor asked Licensed Practical Nurse (LPN) #4 to describe the area under the ice scoop. LPN # 4 stated, It looks to be dirty around the screws and needs to be wiped out. The Surveyor asked if this ice chest and scoop were being used. LPN #4 stated, Yes, it is being used. The Surveyor asked if the ice scoop was lying in a dirty scoop holder. LPN #4 stated, Yes, it is laying in a dirty holder. b. On 05/05/2024 at 01:31 PM, the Surveyor asked the Assistant Director of Nursing (ADON) who was responsible for cleaning the ice chests, scoops, and scoop holders. The ADON said the kitchen is responsible for cleaning the ice chests and confirmed the scoop holder had small black matter around the screws and on the bottom of the scoop holder where the scoop lays. c. On 05/05/2024 at 01:33 PM, the Director of Nursing (DON) confirmed the ice scoop holder was dirty. d. On 05/06/2024 at 04:00 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 how often the ice chests, scoops, and scoop holders were cleaned. CNA #1 stated, We clean them with an antibacterial wipe on the floor and as needed. e. On 05/06/2024 at 04:06 PM, the Surveyor asked CNA #2 who cleans the ice chests, scoops, and scoop holder. CNA #2 stated, I'm pretty sure the kitchen cleans them. I clean my own floor if it is needed. 11. A facility policy titled, Hand Washing provided by the Dietary Supervisor on 05/06/2024 at 11:37 AM included, .When to wash hands: a. When entering the kitchen at the start of a shift .After engaging in other activities that contaminate the hands .

Based on observation, record review and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to prevent respiratory complications for 2 (Residents #71 and #248) sampled residents. This failed practice had the potential to affect 57 residents that had physician orders for oxygen therapy. The findings are: 1. Resident #71 had diagnoses of stroke, end stage renal disease and coronary artery disease. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/12/2024 documented the resident scored 00 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS). a. A Physicians Order dated 05/01/2024 documented, .Oxygen at (3) L/Min (Liters per minute) per Nasal Cannula as needed for Shortness of Breath maintain O2 [oxygen] sats [Saturations] above ( ) . b. On 05/05/2024 at 12:01 PM, Resident #71 was lying in bed with oxygen in use at 2.5 liters via nasal cannula. c. On 05/06/2024 at 08:41 AM, Resident #71 was lying in bed with eyes closed. Oxygen was in use at 2.5 liters per nasal cannula. d. On 05/08/2024 at 08:34 AM, Resident #71 was lying in bed. Oxygen was in use at 1.5-2 liters via nasal cannula. e. On 05/08/2024 at 08:38 AM, the Surveyor spoke with Licensed Practical Nurse (LPN) #2 regarding Resident #71's oxygen settings. LPN #2 accompanied the Surveyor to Resident #71's room and LPN #2 said the oxygen was on 2 liters. The Surveyor asked LPN #2, who checks the oxygen setting? LPN #2 stated, Nurses round and check oxygen setting. f. On 05/08/2024 at 08:42 AM, the Surveyor spoke with LPN #3, and asked, what do the residents orders state that the oxygen should be set at. LPN #3 looked in Resident #71's electronic record and stated, There are oxygen orders that state oxygen at 3 liters prn, and here is an order for oxygen at two liters. 2. Resident #248 had diagnoses of Cerebral Infarction, Anoxic brain injury, and Type II diabetes mellitus. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/19/2024 documented a Brief Interview for Mental Status Score of 00 (0-7 suggest severe cognitive impairment). a. A Care Plan (dated 01/30/2024) documented, I require oxygen therapy at times. I manipulate O2 settings at times . For residents who should be ambulatory, provide extension tubing or portable oxygen apparatus . b. A Physician Orders (dated, 03/13/2023) documented, .O2 at 8 liters per minute via Tracheostomy every shift . c. On 05/05/2024 at 09:30 AM, the Surveyor observed Resident #248 on 5 liters of oxygen via nasal cannula to the tracheostomy, a Yankauer (a suction device) with undated tubing was resting in the right bedside table drawer not in a bag. d. On 05/05/2024 at 02:00 PM, Resident #248 moved to another room. The Surveyor observed Resident #248's oxygen concentrator was set on 5 liters. e. On 05/06/2024 at 09:54 AM, the Surveyor observed Resident #248 resting quietly on 10 liters of oxygen. f. On 05/07/2024 at 08:25 AM, the Surveyor observed Resident #248's oxygen concentrator was set on 10 liters. g. On 05/07/2024 at 11:16 AM, LPN #6 was asked to verify Resident #248's oxygen order. LPN #6 showed the Surveyor in the computer that Resident 248's oxygen order was for 8 liters of oxygen. LPN #6 accompanied the Surveyor to Resident 248's room and told the Surveyor that Resident #248 was on 10 liters of oxygen, and it should be on 8 liters. h. On 05/07/2024 at 12:25 PM, during an interview with the DON the Surveyor asked, what staff members are responsible for checking oxygen settings, and why? The DON confirmed that the DON and Management Team round daily to make sure oxygen is on the appropriate level. Too much oxygen or too little would be a concern because staff should follow the doctor's order. i. On 05/07/2024 at 02:50 PM, the DON provided a policy titled Oxygen Administration-Resident documenting, .The purpose of this procedure is to provide guidelines for safe oxygen administration . The DON also provided an In-service Education Report (dated, 04/18/2024) documenting, .Daily O2 Management. Attention department heads, please round daily to ensure routine and PRN O2 orders are set as prescribed, Thanks .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 74 residents who received regular diets and 13 residents who received mechanical soft diets from 1 of 1 kitchen. The findings are: 1. The menu for the lunch meal documented that the residents who received regular diets were to receive 4 ounces of oven fried chicken and the residents who received mechanical soft diets were to receive 4 ounces of ground oven fried chicken. b. On 05/05/2024 at 12:52 PM, the following observations were made during the noon meal service on the 200 Hall. The Dietary Supervisor served 12 residents one fried chicken leg each. c. On 05/05/2024 at 01:37 PM, the following observations were made during the noon meal service on the 400 Hall. The Dietary Supervisor served one fried chicken leg to 7 residents who were on regular diets on the 400 Hall kitchenette. d. On 05/05/2024 at 02:06 PM, the Surveyor asked Dietary Employee (DE) #2 to weigh one fried chicken leg and one fried chicken thigh. He did and stated, One fried chicken leg weighed two ounces and one fried chicken thigh weighed two point three ounces. At 02:08 PM, the Dietary Supervisor and DE #2 stated, We should have given two each, instead of one chicken. The Surveyor asked DE #2 how many servings of chicken did you ground for the residents who required mechanical soft diets on the 400 Hall. DE #2 stated, I did seven thighs. A total of 11 servings were prepared for all residents on mechanical soft diets, instead of total of 13 servings per the number of residents documented on the universe provided by the Dietary Supervisor on 05/06/2024 at 12:24 PM. 2. The menu for breakfast documented that all residents who received regular diets, mechanical soft diets were to receive 6 ounces of oatmeal, scrambled eggs, and cheese. a. On 05/06/2024 at 07:50 AM, the 200 Hall DE #3 used a 4 ounce ladle spoon, (1/2 cup), to serve a single portion of oatmeal to the residents who received their meal from the kitchenette on the 200 Hall, instead of a 6 ounce (3/4 cup). At 08:15 AM, the Surveyor asked DE #3 what size spoon she used to serve oatmeal and how many servings she gave to each resident. DE #3 stated, I used a 4 ounce spoon, and I gave one serving to each resident. The Surveyor asked did you look for the portion size on the written menu before serving the breakfast meal. DE #3 stated, No. b. All residents were served scrambled eggs with no cheese, instead of scrambled eggs with cheese. 3. On 05/06/2024 at 07:58 AM DE #4 used a 4 ounce (1/2) cup ladle spoon to serve a single portion of oatmeal to all the residents from the steam table in the kitchenette on the 300 Hall. At 08:21 AM, the Surveyor asked DE #4 what size of spoon he used to serve the oatmeal and how many servings he gave to each resident. DE #4 stated, I used a 4 ounce spoon, and I gave one serving to each resident. The Surveyor asked, Did you looked for the portion size on the written menu? DE #4 stated, No, I did not. I looked at their tray cards because it has portion size on it. b. All residents were served scrambled eggs with no cheese, instead of 6 ounces of oatmeal. 4. On 05/06/2024 at 08:05 AM, the following observations were made during the breakfast meal service from the kitchenette on the 400 Hall: a. DE #5 used a 4 ounce spoon to serve a single portion of oatmeal to all residents on the 400 Hall instead of a 6 ounce spoon. b. All residents were served regular scrambled eggs, instead of scrambled eggs with cheese. c. On 05/06/2024 at 08:19 AM, the Surveyor asked DE #5 what size spoon she used to serve oatmeal and how many servings she gave to each resident. DE #5 stated, I used a 4 ounce spoon, and I gave one serving to each resident. The Surveyor asked, Did you look for the portion size on the written menu? DE #5 stated, No. 5. On 05/06/2024 at 08:31 AM, the Surveyor asked DE #2 for the reason scrambled eggs and cheese was not served to the residents. DE #2 stated, Because we don't have cheese, and we are waiting on the truck.

Based on observation, record review and interview, the facility failed to ensure vegetables were not overcooked and were served in a method that maintained the appearance of food product and hot food items were served at temperatures that were acceptable to the residents to improve palatability and encouraged good nutritional intake during 1 of 2 meals observed. This failed practice had the potential to affect 20 residents who receive meal trays on the 200 Hall, 30 residents who receive meal trays on the 300 Hall, 39 residents who receive meal trays in their room on the 400 Hall. The findings are: 1. Review of Resident #41's Physicians Orders documented a diagnosis of Diabetes Mellitus Without Complications and an order for a general texture regular diet. a. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/05/2024 showed a Brief Interview for Mental Status (BIMS) of 13 (13 to 15 suggests cognitively intact). b. On 05/05/24 at 11:05 AM, the Surveyor asked Resident #41 how the food was. Resident #41 stated, Not good, same thing three or four times a week. It's always cold. 2. Review of Resident #89's Physicians Orders revealed the resident had a diagnosis of multiple fractures of the pelvis and received a general diet, regular texture, and thin liquids. a. On 05/05/2024 at 11:22 AM, the Surveyor asked Resident #89 how the food was. Resident #89 stated, The food is never hot. Sausage is always cold at breakfast. 3. On 05/05/24 at 11:32 AM, the Surveyor asked Resident #551 how the food was. Resident #551 stated the vegetables were mushy. 4. On 05/05/2024 at 01:32 PM, the vegetable blend served to the residents was mushy. At 02:06 PM, the Surveyor asked Dietary Employee (DE) #2 to describe the appearance of the vegetable blend served to the residents for lunch. DE #2 stated, It was over cooked and mushy. 5. On 05/06/2024 at 07:50 AM, the temperature of the food items on the steam table on the 200 Hall kitchenette when checked and read by DE #3 with the following results: a. Scrambled eggs - 120 degrees Fahrenheit. b. Sausage - 120 degrees Fahrenheit. c. Gravy - 100 degrees Fahrenheit. d. Hashbrowns - 100 degrees Fahrenheit. 6. At 08:15 AM, the Surveyor asked DE #3 what should have been done when hot food items were not hot enough on the steam table before serving them to the residents. DE #3 stated, I should have reheated them.

50580 Based on observation, interviews and policy review, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) between resident rooms to prevent cross contamination. This failed practice had the potential to affect all 99 residents in the facility. Findings Include: On 05/05/2024 at 9:22 AM, the Surveyor observed CNA #4 come out of room [ROOM NUMBER] with gloves on and go straight into room [ROOM NUMBER]. Both rooms #423 and #427 had a sign showing Enhanced Barrier Precautions (EBP). On 05/05/2024 at 9:40 AM, the Surveyor spoke with CNA #4. The Surveyor asked CNA #4 what proper hand hygiene is when you are entering and exiting a room with EBP. CNA #4 indicated you are supposed to leave your gloves on when you carry trash out of a room. The Surveyor asked if it was proper hand hygiene to go from one room to another room with gloves on. CNA #4 stated, No. The Surveyor asked how long she had worked in the facility. CNA #4 indicated about 2 months, prior to that she worked in the hospital setting. On 05/07/2024 at 03:46 PM, the Surveyor spoke with the Director of Nursing (DON) regarding what is proper hand hygiene for a CNA that is coming out of a room marked EBP. The DON indicated if a CNA is going out of a room, they are to sanitize their hands before leaving the room. The Surveyor asked if CNAs were supposed to wear gloves out of a room? The DON stated No. The Surveyor asked how CNAs were supposed to carry trash out of a resident's room. The DON explained that you take off your gloves and grab the inside of the glove and hold the trash with the glove while your fingers are touching the inside of the glove. On 05/07/2024 at 4:33 PM, received a policy titled Enhanced Barrier Precautions dated 03/21/2024 documented, .Effective implementation of EPB require staff training on proper use of PPE and the availability of PPE with hand hygiene products at the point of care.EBP is to be continued for the duration of a resident's admission. 2. Resident #33's Care Plan noted the resident had Unspecified protein-calorie malnutrition and Gastrostomy Status (a surgical opening into the stomach that provides nutritional support). a. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/02/2024 indicated Resident #33 has a PEG (Percutaneous Endoscopic Gastrostomy/feeding tube) tube. a. A Physicians Order dated 04/30/2024 documented, .Follow Enhanced Barrier Precautions (This is not isolation) . b. On 05/08/2024, a review of Resident #33's Care Plan with an initiated date of 04/02/2024 revealed the resident required Enhanced Barrier Precautions feeding tube and wound and gloves and gowns were required prior to high-contact care. High-contact resident care activities: - Dressing - Bathing/showering - Transferring - Providing hygiene - Changing linens - Changing briefs or assisting with toileting - Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator . c. On 05/07/2024 at 01:05 PM, during medication pass the Surveyor observed Licensed Practical Nurse (LPN) # 1 prepare three 30 mL of tap water and told Surveyor she was going to give a Baclofen 0.5 milligram tablet via the PEG tube to Resident #33. The Surveyor observed Enhanced Precautions Signs outside of Resident #33's door. d. On 05/07/2024 at 01:12 PM, the Surveyor observed LPN #1, without Personal Protective Equipment (PPE), mixing crushed Baclofen in warm water and then LPN #1 checked for tube placement. The Assistant Director of Nursing (ADON) presented to bedside without PPE applied and offered to assist with the administration of the Baclofen and flushes. Gloves were worn. e. On 05/07/2024 at 01:15 PM, after LPN #1 and the ADON completed administration of the Baclofen, LPN #1 was asked if Resident #33 was on enhanced barrier precautions and what procedure should have been followed when administering medication via a PEG tube. LPN #1 confirmed Resident #33 was on Enhanced precautions and confirmed an isolation gown should have been worn when administering medication to prevent giving the resident germs. Gloves were worn, but no isolation gown was worn. f. On 05/07/2024 at 01:17 PM, during an interview the ADON was asked if staff are to wear PPE (isolation gown) when entering enhanced precautions room and why. The ADON said nurses go from room to room and could bring germs to residents due to an open area in the body. The ADON stated, Yes, they [staff] are expected to wear PPE when providing care to enhanced barrier precautions residents. g. On 05/07/2024 at 4:33 PM, the Nurse Consultant provided a policy titled, Enhanced Barrier Precautions, which documented, This facility will follow CDC's [Centers of Disease Control] updated guidance on enhanced barrier precautions (EBP) for all health care settings, including nursing homes. Policy Interpretation and Implementation The EBP requires gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's [Multi Drug Resistant Organisms] staff hands and clothing . For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities .Device care or use: feeding tube .

Based on record review and interview, the facility failed to complete a discharge Minimum Data Set (MDS) assessment to accurately reflect the residents discharge status for 1 (Resident #95) sampled residents. This failed practice had the potential to affect 76 residents that were discharged in the last 90 days. The findings are: 1. Resident #95 had a diagnosis of fracture shaft of right tibia, arthritis, and seizure disorder. The Admission MDS with an Assessment Reference Date (ARD) of 02/09/2024 documented that the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 05/08/2024 at 11:20 AM, the Surveyor reviewed Resident #95's Discharge Return Not Anticipated MDS with an ARD of 02/23/2024 that documented, . A2105 Discharge Status .04 .Short Term General Hospital (acute Hospital .) . b. A Physician's Order dated 02/23/2024 documented, .Discharge home with home health services Prescriber . c. On 05/08/2024 12:35 PM, the Surveyor asked the MDS Coordinator when did Resident #95 discharge. The MDS Coordinator looked in the electronic record and stated, the resident discharged on [DATE] rd, 2023. The Surveyor asked where did Resident #95 discharge to when the resident left the faciity on n 02/23/2024. The MDS Coordinator looked in the electronic and stated, It documents that the resident discharged home. The Surveyor asked, Where does the Discharge Return Not Anticipated Minimum Data Set, dated dated dated [DATE] document that the resident discharged ? The MDS Coordinator looked in the electronic record and stated, To a short term acute hospital. The Surveyor asked if the MDS was accurate? The MDS Coordinator stated, Not according to the note. The Surveyor asked, why is it important that information on the MDS is accurate? The MDS Coordinator stated, The information is transmitted to the state. They need to know where the residents go, and it shows a safe discharge. d. On 05/8/2024 at 2:59 PM, the Administrator stated, We do not have a policy on Minimum Data Set Assessments we just follow the RAI (Resident Assessment Instrument) manual.

Based on observation, interview, and record review the facility failed to review and revise the care plan to include oxygen therapy was in use to ensure appropriate coordination of care for 1 (Resident #71) sampled resident that had physician's orders for oxygen therapy. This failed practice had the potential to affect 55 residents that had physician's orders for oxygen therapy. The findings are: 1. Resident #71 had diagnoses of stroke, end stage renal disease and coronary artery disease. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of 03/12/2024 documented that the resident scored 00 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS). a. A Physicians Order dated 05/01/2024 documented, .Oxygen at (3) L/Min (liters/minute) per Nasal Cannula as needed for Shortness of Breath maintain O2 sats [Saturations] above ( ) . b. On 05/05/2024 at 12:01 PM, Resident #71 was lying in bed with oxygen in use at 2.5 liters via nasal cannula. c. On 05/06/2024 at 08:41 AM, Resident #71 was lying in bed with eyes closed. Oxygen was in use at 2.5 liters per nasal cannula. d. On 05/08/2024 at 08:34 AM, Resident #71 was lying in bed. Oxygen was in use at 1.5 to 2 liters via nasal cannula. e. On 05/08/24 at 10:43 AM, the Surveyor reviewed the residents care plan with an initiation date of 03/13/2024 and it did not address that the resident was receiving oxygen therapy. f. On 05/08/2024 12:30 PM, the surveyor asked the MDS Coordinator, does (Resident #71) use oxygen therapy? The MDS Coordinator looked in the electronic record and stated, [Resident #71] does have an order for oxygen at three liters. The Surveyor asked, Does (Resident #71's) care plan address the use of oxygen? The MDS Coordinator stated, Let me see. After looking in the electronic record she stated, I do not see it on the care plan. The Surveyor asked, Should the care plan address the oxygen use by the resident? The MDS Coordinator stated, It should be if [Resident #71] is on it continuously. The nurses should let us know if the resident is using it continuously so we can update the care plan. The Surveyor asked, Why is it important that the care plan address the use of oxygen? The MDS Coordinator stated, So the nurses know what care the resident needs. There may be a new nurse who is unfamiliar with the resident. Nurses need to be able to look at the care plan and see exactly what care the resident needs. i. On 05/08/2024 at 2:59 PM, the Administrator stated, We do not have a policy on care plans we just follow the RAI (Resident Assessment Instrument) manual.

Based on observation and interview, the facility failed to ensure potentially hazardous items were stored in a secured manner for 1 (Resident #38) of 1 sampled resident. The findings are: A review of Policy titled Accidents and Hazards Policy effective date 08/2021 stated, .The facility strives to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents . A review of Resident #38's Care Plan shows the resident was admitted on [DATE] with diagnosis that included Unspecified Atrial Fibrillation (irregular and often very rapid heart rhythm), Type 2 Diabetes Mellitus without complications, Essential (Primary) Hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/16/2024 showed a Brief Interview for Mental Status (BIMS) of 12 (8 to 12 suggests moderate cognitive impairment). A review of Resident #38's Care Plan dated 05/01/2024 revealed the resident had a diagnosis of Dementia with Behavioral Disturbance. Interventions included staff will identify the immediate causes, and what triggers the risk factors related to Resident #38's Dementia disturbance. During an observation on 05/05/2024 at 11:16 AM, the Surveyor observed an 8.3 ounce aerosol can of citrus scent air freshener sitting on the nightstand in Resident #38's area of the room. Resident #38 indicated that staff on the night shift had bought it for him. During a concurrent observation and interview on 05/07/2024 at 11:36 AM, the Surveyor went into Resident #38's room and observed an 8.3 ounce aerosol can of citrus scent air freshener sitting on the night stand beside the residents bed. During an interview on 05/07/2024 at 11:54 AM, with the Social Service Director [SSD], regarding if she had knowledge of residents having aerosol air freshener in their rooms the SSD indicated that sometimes family members will bring items like that, that are not allowed, and that she did not know that a resident had any aerosol air freshener in their room. The Surveyor asked if it was okay for staff to bring aerosol air freshener to a resident. The SSD indicated that it was not okay, that residents are not supposed to have aerosol cans in their room. During an interview on 05/08/2024 at 12:28 PM, the Surveyor interviewed the Director of Nursing (DON) and showed him a picture of the aerosol air freshener sitting on the nightstand in Resident #38's room. The Surveyor asked if a resident was allowed to have an aerosol can in their room. The DON indicated that if they are care-planned they can have it. The Surveyor asked if it is safe sitting there on the nightstand? The DON stated, No, but if we try and take it away, he (resident) throws a fit.

Based on record review and interview, the facility failed to ensure 1 (Resident #199) received wound care as ordered by the physician to prevent wound infection and healing. This failed practice had the potential to affect 8 residents with pressure ulcer orders. The findings are: 1. Resident #199 had diagnoses of right lower amputated stump infection, type II diabetes mellitus, and acute kidney failure. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/15/2024 indicated a Brief Interview for Mental Status score of 12 (8-12 suggest moderate cognitive impairment). a. A Care Plan documented, .I have a pressure ulcer. Coccyx, Left heel .Date Initiated 01/11/2024 .Administer treatments as ordered and monitor for effectiveness . b. A Physicians Order dated 03/01/2024 documented, Apply [Povidone-iodine] to left heel and around left foot two times a day for wound care. c. On 05/08/2024 at 02:00 PM, the Surveyor observed the March Treatment Administration Record (TAR) and noted that there was no documentation that Resident #199 received the second application of Povidone-iodine to the left heel and around the left foot at 08:00 PM on March 15; March 17; March 19; and March 27th, 2024.

Based on observation, record review and interview, the facility failed to ensure a pressure ulcer to the left heel was identified so treatment could be promptly initiated to prevent further deterioration for 1 (Resident #2) and weekly skin assessments were completed and documented for 2 (Residents #2, and #5) of 4 (Residents #1, #2, #3, and #5) sampled residents who had pressure ulcers. This failed practice resulted in actual harm to Resident #2 who was not receiving weekly body audits and had an unstageable pressure ulcer to the left heel that had not been identified by staff and was not being treated. The facility failed to ensure the wound care dressings were applied as needed and the correct dressing was applied to 1 (Resident #5) of 4 (Residents #1, #2, #3, and #5) sampled residents who had orders for wound care and failed to ensure The findings are: 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/21 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview of Mental Stats (BIMS); required extensive one-person physical assistance with bed mobility, dressing, toilet use, and personal hygiene, total dependence with two plus person physical assistance with transfer and was always incontinent of bowel and bladder. a. The Care Plan with a completion date of 6/01/21 documented, .Monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . [etcetera] to MD [Medical Doctor] . weekly skin audit by licensed nurse . Observe my skin during routine care and notify my nurse as needed . Check all of body for breaks in skin and treat promptly as ordered by doctor . b. On 9/23/21 at 9:00 A.M., Resident #2 was in bed with a boot on his left foot. He was asked, How long have you had the wound to your left heel. He stated, I've had it since I've been here. I came in with it. He was asked, How often do they do a skin assessment on you? He stated, For a while they checked it every week and for the last 8 months or so they haven't checked it at all until the day you asked to see it. He was asked, How often does the treatment nurse check your heel to see if it's getting better or worse? He stated, They say it was healed and then they quit looking at it. I haven't seen the wound care nurse in three months. He was asked, Where did you get the boot from that you had on your left heel? He stated, I got it from therapy. c. On 9/23/21 at 4:00 P.M., the clinical records were reviewed. There was no documentation that indicated Resident #2 had a pressure ulcer to his left heel. d. A Wound Evaluation dated 9/24/21 documented, .Site: Left heel; Type: Pressure Injury (In House Acquired); Length: 3.0; Width: 1.5; Depth 0; Tender to touch . Necrotic 100% . Unstageable . Date identified 9/24/2021 . e. A September 2021 Treatment Administration record with a start date of 9/17/20 documented, .Weekly skin checks one time a day every Thursday . There were no initials for 9/09/21, 9/16/21, and 9/23/21 indicating the skin assessments were completed. f. On 9/24/21 at 12:35 P.M., Licensed Practical Nurse (LPN) #1 was asked, How long has [Resident #2] been wearing the boot on his left heel? She stated, He's been wearing it for a couple of months. She was asked, How often do you remove it? She stated, He'll ask the CNA's [Certified Nursing Assistants] to take it off. She was asked, Why is he wearing the boot? She stated, He has a wound on his left heel. I don't think it's open. She was asked, How long has he had the area to his left heel? She stated, Maybe it was a stage 1 non-blanchable probably over a month ago. She was asked, Who is responsible for doing the skin assessments? She stated, Treatment nurse. She was asked, Who ordered the boot? She stated, I think the PA [Physician Assistant]. The nurse got the PA to approve it probably. g. On 9/24/21 at 12:38 P.M., CNA #2 was asked, Do you work with [Resident #2]? She stated, I worked with him a couple of weeks ago. She was asked, Were you informed that [Resident #2] had a pressure ulcer to his left heel? She stated, No, the splint was on there when I got here. h. On 9/27/21 at 10:08 A.M., the Treatment Nurse removed the boot from Resident #2's left heel. There was a black area observed on his heel. The resident stated Ouch when the treatment nurse touched his heel. i. On 9/27/21 at 11:43 A.M., the Wound Care Nurse was asked, How long has [Resident #2] had the wounds on his left foot? He stated, I just found out when you asked me to assess him. j. On 9/27/21 at 11:55 A.M., CNA #1 was asked, How long had [Resident #2] had the wounds on his left foot? She stated, I don't know. k. On 9/27/21 at 1:27 P.M., CNA #3 was asked, How long had [Resident #2] had the wounds on his left foot? He stated, Far as I know he has had it a long time. He has a red area on his chest. I notified the nurse. l. On 9/27/21 at 2:55 P.M., the Director of Nursing (DON) was asked, Who's responsible wound assessments? She stated, Treatment nurses and nurses on the floor. She was asked, How long has [Resident #2] had the wounds on his left foot? She stated, Not positive. 2. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS with an ARD of 9/02/21 documented the resident was severely impaired in cognitive skills per a Staff Assessment for Mental Status; was at risk of developing pressure ulcers and/or injuries and had unhealed pressure ulcers/injuries. a. The Care Plan documented, .Skin: Resident is at risk for skin impairment due to her incontinence of bowel and bladder, and her need for total care assist with bed mobility .weekly skin check by licensed nurse .observe my skin during routine care and notify the nurse as needed .Date Initiated 03/07/2020 . b. The September 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse wound to right great toe with wound cleanser or NS, pat dry and silver alginate to wound bed cover with bordered foam QMWF and PRN Order Date 08/31/2021 . c. The last completed weekly skin assessment was documented on 7/01/21. d. A Weekly Wound Evaluation note dated 8/31/2021 at 6:29 P.M. documented, .Site: Right toe .Pressure Injury (In house Acquired) .Unstageable .Length 0.5 .Width: 0.7 .Depth UTD . When was wound identified 8/10/21 . e. On 9/24/21 at 2:15 P.M., Registered Nurse #1 removed the soft boots from both of the resident ' s feet. There was no open area to the left foot. There was an open area to the top of the second toe and the big toe on the right foot. There was one 2x (by) 2 covering both toes. The second toe was covered with the sticky part of the 2x2. The right toes did not have a bordered foam dressing. f. On 9/27/21 at 9:18 A.M., CNA #4 was asked to remove the boots from Resident #5's right foot. She removed the boot to the right foot, and there was no dressing to the pressure ulcers on her toes. g. On 9/27/21 at 11:43 A.M., the Treatment Nurse was asked, How often do [Resident #5] receive wound care? He stated, Monday, Wednesday, and Friday and whenever the bandage is off, we go in and re-enforce it. He was asked, When were the pressure ulcers on her toes identified? He stated, I don't know. h. On 9/27/21 at 12:08 P.M., CNA #5 was asked, How often does [Resident #5] receives wound care? She stated, Supposed to be every day. On days I have her and the bandage is off, I let the nurse know so somebody can come dress it. She was asked, When were the pressure ulcers on her toes identified? She stated, About 6 or 7 months. i. On 9/27/21 at 2:55 P.M., the DON was asked, How often does [Resident #5] receives wound care? She stated, Not sure. She was asked, When were the pressure ulcers on her toes identified? She stated, Don't know right off hand. 3. A Wound Care policy provided by the DON on 9/27/21 at 3:05 P.M. documented, .A system for pressure injury assessment and documentation with each dressing change or at least weekly is established .Completion of an in-house weekly report (submitted to the Director of Nursing) by the charge nurse or treatment nurse .Physician notification of pressure injury presence and responses to treatment .In-house notification of interdisciplinary team members of the presence of pressure injuries and stages .Education is provided to interdisciplinary team members, as indicated, upon orientation, and annually on: .Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Complaint # was substantiated (all or in part) with these findings: A. Based on record review and interview, the facility failed to ensure necessary care and services were provided after an unwitnessed fall, as evidenced by failure to ensure neurological assessments were initiated immediately after the fall occurred and conducted every 15 minutes thereafter for the first hour after the fall, to enable staff to promptly identify any neurological changes that might indicate possible [MEDICAL CONDITION], and failure to ensure the physician was immediately consulted upon the nurse's discovery of a change in neurological status to prevent a delay in evaluating the possible need for emergency treatment for 1 (Resident #6) of 4 (Residents #3 through #6) case mix residents who were at risk for falls. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #6, who experienced an unwitnessed fall with subsequent signs / symptoms of a possible change in neurological status, followed by the resident's death. The failed practice had the potential to cause more than minimal harm to 13 residents who experienced unwitnessed falls since 8/1/16, as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 10/13/16 at 2:50 p.m. The facility was informed of the Immediate Jeopardy condition on 10/13/16 at 3:31 p.m. The findings are: 1. The facility's policy titled, Falls Management, provided by the Registered Nurse Consultant on 10/14/16 at 2:37 p.m., documented, .In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present . Obtain vital signs: blood pressure, pulse and respirations . Obtain neurological checks (neuro-checks) per policy for any unwitnessed fall or any fall with evidence of injury to head. Note any differences in symmetrical hand grasp strength, leg movements; ask resident to smile looking for symmetry, check pupils for size, reactions and equal in size . 2. The facility's policy titled, Neurological Assessments, provided by the Registered Nurse Consultant on 10/13/16 at 3:17 p.m., documented, .Neurological assessments are performed to evaluate a resident's nervous system including brain function. Early detection of an injury or underlying condition provides the best chance of decreasing long term complications . Resident / patient with conditions resulting in changes, or potential changes, in their neurological status will be assessed for transfer to the acute care setting . To assess level of consciousness for a traumatic or potentially traumatic injury to the head .To assess neurological status after an unwitnessed fall . Neurological assessments will be completed as follows: .Every 15 minutes (for) first hour . Every 30 minutes (for) 2 hours . Every hour (for)2 hours . Every shift (for) 72 hours . Then as primary healthcare provider orders . The licensed nurse will complete the Neurological Assessment Flowsheet for data collection . Immediately report changes or concerns to the primary healthcare provider and family . 3. Resident #6 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/29/16 documented the resident scored 5 (0-7 indicates severely impaired cognitive skills) on a Brief Interview For Mental Status (BIMS), required extensive assistance of 2-plus persons for bed mobility and transfers, and had no falls since admission. a. A Resident Incident Report dated 8/6/16 at 11:00 a.m., and signed by Licensed Practical Nurse #2, documented, .Date 8/6/16 .Time 11:00 a.m.Location of Occurrence Day room . Narrative of incident and description of injuries . (Resident) sitting in dayroom during church and fell out of chair Nurse assess for injury and pain . follow up report 8/6/16 (local hospital) CT (computed tomography) . neuro-checks . A Neurological Assessment form dated 8/6/16 documented neuro-checks were performed at 11:00 a.m. and 11:15 a.m., which indicated both of the resident's upper extremities were strong. The form indicates the resident was sent to the hospital after the 11:15 a.m. neuro-check. The next neuro-check is documented at 1900 (7:00 p.m.). b. A Care Plan with a revised date of 8/6/16 documented, .Problem: (Resident) is at risk for fall related to history and immobility . Goal: .will be free from undetected fall related injuries thru next review . Approaches: .Frequent monitoring and anticipation of needs if resident is unable to or forgets to use call light . has mats at bedside . Report incidences of falls to physician and family/responsible party . ensure assistive equipment is used appropriately . 8/6/16 . UF (Unwitnessed Fall) . Out to ER (emergency room ) / MD (Medical Doctor) orders . c. A Resident Incident Report dated 8/11/6 at 4:40 p.m. and signed by Registered Nurse (RN) #2 documented, . Describe Injury: .Fall . Equipment in use: .wheelchair .Location of occurrence . Day area . Narrative of incident and description of injuries: Pt (patient) slid onto floor from wheelchair, no injuries observed . d. An Incident Documentation And Investigation Tool dated 8/11/16 and signed by RN #2 documented, .Investigation: date: 8/11/16 . time Occurred: 1640 (4:40 p.m.) . Location of Occurrence: Day Area . Causal relationships associated with the defined incident/problem: What condition/position was the resident in when accident occurred . lying on L (left) side on the floor . What was done immediately? Assessment, VS (vital signs) . There was no documentation to indicate neurological checks were initiated immediately for the unwitnessed fall. e. A Neurological Assessment form dated 8/11/16 documented the neurological checks were initiated at 5:15 p.m., 35 minutes after the fall occurred. The initial assessment documented, .Vital Signs . Blood Pressure 125/92, Temperature 97.8, Pulse 92, Respiration 16 . Upper Ext. (extremity) R/L (right/left) S/W (strong on right / weak on left) . lower extremities R/L S/S (strong on both sides) . Consciousness: Orient (oriented) x (times) 1 . Restless . Speech Garbled . Pain: Denies . No further neurological assessments were documented on the form. f. A Skilled Daily Nurses Note dated 8/11/16 and signed by RN #2 documented, . 1640 (4:40 p.m.) - Pt (patient) found lying on (left) side on the floor after sliding out of wheelchair. No injuries observed, VSS (vital signs stable). Pt taken to room and placed into bed. Will continue to monitor . 1650 (4:50 p.m.) (Physician) contacted, orders obtained for neuro (neurological) checks X (times) 12 hours . 1715 (5:15 p.m.) Neuro checks started . grips unequal . There was no documentation the physician was immediately consulted regarding the unequal grips in the resident's hands, which was a change in condition as compared with the neurological checks completed 5 days prior, on 8/6/16. According to the facility's policy and nursing standards of practice, the next neurological check would have been due 15 minutes later, at 5:30 p.m.; however, no further neurological checks were documented. The Skilled Daily Nurses Note dated 8/11/16 continued, .1810 (6:10 p.m.) - Pt found unresponsive, skin warm. Unable to obtain VS (vital signs) (at) this time . 1815 (6:15 p.m.) (emergency medical transport provider) responded . 1817 (5:17 p.m.) . AED (automated external defibrillator) applied, patient in asystole . 1820 (6:20 PM) Time of death pronounced . g. On 10/13/16 at 1:10 p.m., the Director of Nursing (DON) and Nurse Consultant were asked, When should neuro checks be started? Both stated, Immediately after a fall, if unwitnessed, or if a resident hits their head. They were asked if there should have been more frequent checks and monitoring after the unwitnessed fall for Resident #6. They both stated, Yes. h. On 10/14/16 at 9:56 a.m., RN #1 was asked if she remembered Resident #6 and the fall he experienced on 8/11/16. She stated, I was working when (Resident #6) fell . He fell in the evening. After the fall, I assisted the nurse and CNAs (Certified Nursing Assistants) get him to bed and assessed him. I assessed him on the floor before we got him out of the floor. I asked him if he was okay, and he stated, 'Yes.' I checked his head all around to see if any knots or discoloration. After I did that, we put him in the wheelchair and put him in bed. I told his nurse to check his neuro checks every 15 minutes for 1 hour. RN #1 was then asked to verify what the 'S' and 'W' indicated on the Neurological Assessment Forms, and she stated, The 'S' on the neuro check sheet means 'strong' and the 'W' means 'weak'. She was asked when the resident's neuro checks should have been initiated and stated, The neuro checks should have been done immediately after he fell , and then every 15 minutes. i. On 10/14/16 at 11:30 a.m., RN #2 was asked if she knew why the neuro checks were not initiated immediately, and continued every 15 minutes after the resident fell on [DATE]. She stated, I remember being in his room. He was found in the day area after he fell . Initially, when he fell , we were getting him in bed and paging the doctor. I had to recall the doctor for something else and spoke to his daughter a couple of times. That's why I didn't get neuro checks every 15 minutes. She was asked if she had notified the physician that the resident's grips were unequal upon discovery at 5:15 p.m. She stated, If I'm not mistaken, I think I paged the doctor after the neuro check and the left side was weak. I don't remember what the doctor said. 4. The Immediate Jeopardy was removed and the scope / severity reduced to H on 10/14/16 at 12:18 p.m., when the facility implemented the following Plan of Removal: a. (On 10/14/16) at 4:00 p.m., the Education Director/Department Heads began in-servicing all core nursing staff and agency nurses prior to reporting to their assigned unit. All core nursing staff will be educated no later than Tuesday, 10/18/16, and the agency staff will be in-serviced prior to reporting to their assigned unit. b. The DON/Unit Manager will monitor all incident and accidents, as well as follow-up and interventions, three times a week for two weeks, then weekly times 4 weeks, then monthly until compliance is met. c. Any unwitnessed falls will have implemented and follow the policy and procedures for neuro checks, and assessments with documentation, to include: the assessments for CNS (Central Nervous System) status of resident, to assess the LOC (Level of Consciousness), or change in condition, for resident, and to document neuro checks q (every) 15 minutes for first hour, then q (every) 30 minutes for two hours, then q (every) shift x (times) 72 hours, then as primary physician orders. d. Nursing documentation to be completed with a fall, or as change of condition occurs it will be monitored three times a week for two weeks, then weekly times four weeks, then monthly, to ensure compliance is met and monitored by the DON/Unit Managers. e. On 10/13/16 in-servicing began to educate all nurses and agency nurses regarding the deficient practice. All core nurses will be educated prior to reporting to their assigned unit no later than 10/18/16, and agency nurses will be in-serviced prior to reporting to their unit. f. All residents fall assessment were completed on 10/13/16 by the MDS Coordinators. The total number of residents at risk for this failed practice is 70 currently. g. Monitoring will be done by the DON/Unit Managers to ensure daily compliance is met and maintained. If at any time during the monitoring process there is deficient finding, staff will immediately be re-in-serviced. The Administrator will be notified immediately and a review of the current process will be conducted to assess the need for changes to be made to ensure compliance is met at all times. h. Any negative findings will be brought to the monthly QA (Quality Assurance) meetings, and then Quarterly QA meetings, to review compliance and ensure compliance is maintained. B. Based on observation, record review and interview, the facility failed to ensure necessary care and services were provided to manage pain, in order to attain or maintain the highest practical physical, mental and psychosocial well-being for Resident #4. The facility failed to ensure thorough pain assessments, to include severity and any contributing and / or alleviating factors, were consistently conducted and documented; and failed to ensure severe, unrelieved back pain after a fall was thoroughly evaluated to rule out injury as a cause of the pain and that necessary diagnostic studies (such as x-rays or computed tomography scanning) were promptly requested to determine if any fall-related injury was contributing to the resident's pain for 1 (Resident #4) of 1 case mix resident who complained of severe, unrelieved back pain after a fall. The failed practices resulted in a pattern of harm for Resident #4, who experienced a fall with subsequent severe, unrelieved back pain, which affected the residents' ability to participate in therapy and activities of daily living. The resident was diagnosed with [REDACTED]. The failed practices also had the potential to cause more than minimal harm for 31 residents who experienced falls since 8/1/16, as documented on a list provided by the Minimum Data Set (MDS) Coordinator on 10/13/16 at 2:50 p.m. The findings are: 1. Resident #4 was admitted to the facility on [DATE] after being hospitalized from [DATE] through 8/8/16 with Abdominal and Chest Pain and Weakness and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/3/16 documented the resident scored 11 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status, required extensive assistance of one person for transfers, dressing, personal hygiene, locomotion on and off of the unit and bathing; required extensive assistance of two-plus people for toilet use and bed mobility, had frequent pain rated as a severity of 6 on a numeric rating scale of 0 to 10 over the last 5 days and that had limited her day-to-day activities; received scheduled and as-needed pain medication; received non-medication intervention for pain; had no falls prior to or since admission; did not have any fracture related to a fall in the 6 months prior to admission; and received 5 days / 280 minutes Occupational Therapy and 6 days / 295 minutes Physical Therapy in the last 7 days. a. A hospital History and Physical (H&P) Final Report printed on 8/7/2016 documented the following findings during the resident's hospitalized from [DATE] through 8/8/16: .Primary Diagnosis . Chest Pain . Active Problem . Abdominal Pain . Active [DIAGNOSES REDACTED]. Unspecified Injury of Head, initial encounter . Weakness . Both patient and spouse have fallen several times and the fire department has come multiple times to help . History of . Chronic back pain . Addendum 8/3/16 - Patient is a [AGE] year old female with history of [MEDICAL CONDITION] . Evaluation, Physical Therapy (PT) Entered on: 8/4/16 . CT (computed tomography) Spine Lumbar . 23 July 2016 . Report: .Procedure: .CT (computed tomography) Cervical Spine without Contrast . CT (computed tomography) Lumbar Spine without Contrast . Comparison: .6/24/16 CT (computed tomography) lumbar spine . History: .Head and neck and back pain . Findings Lumbar Spine: .There is some [MEDICAL CONDITION] disc change upper lumbar spine and lower [MEDICATION NAME] spine with some osteophyte and [MEDICAL CONDITION] gas in the disc . No deformity or fracture . Some facet [MEDICAL CONDITION] change from L4 (Lumbar 4) to S1(sacral spine 1) is present . Conclusion: .[MEDICAL CONDITION] change lumbar spine .No acute finding . Findings CT (computed tomography) Cervical Spine: .No deformity or fracture . [MEDICAL CONDITION] change cervical spine . No cervical fracture . b. The facility's Admission Physician order [REDACTED].[MEDICATION NAME] 50 mg (milligrams) cap (capsule), i (one) cap PO (by mouth) TID (three times a day) . c. The Admission Data Collection Form dated 8/8/16 at 3:00 p.m. documented, .Diagnosis: [REDACTED]. Level of Consciousness: .alert . Cognitive skills for decision making: .severely impaired . Functional Status: .Transfers - able to transfer: two person assist . B .Ambulation - able to ambulate: .2 person assist; wheelchair only . Weight bearing - able to bear: .Full weight . Risk for Falls: .17 (Total score of 10 or above deems risk) . Pain Assessment: .Frequency of Pain: Pain Daily . Irritable .lack of concentration . emotional .Description of pain: .sharp .throbbing .Consolability poor (unable to reassure by voice or touch, unable to distract or reassure . Location . Back, legs . d. The Physician Admit Note dated 8/8/16 documented, .Past Medical History: .[MEDICAL CONDITION] . chronic back pain . medications: [REDACTED]. Assessment & Plan: .Debility with multiple falls - PT/OT . Adjust meds . Chronic back pain - Start Tylenol, [MEDICATION NAME], decrease [MEDICATION NAME] . e. A Physician's Telephone Order dated 8/8/16 and signed by LPN #4 at 6:30 p.m. documented, .Tylenol 650 mg PO TID .[MEDICATION NAME] 100 mg PO TID . Give 1 mg [MEDICATION NAME] injection IM (intramuscular) R/T (related to) anxiety from ER (emergency) Box . f. An Incident and Accident (I&A) Report dated 8/8/16 at 10:45 p.m. and signed by Licensed Practical Nurse (LPN) #2 documented, .category blank . note states 'fall' .Describe injury: .no injury .Activity: Behavioral . Location: Common Area .Immediate Actions Taken: .resident refused vital signs and pain assessment .MD (Medical Doctor) notified . first initial contact . 8/9/16 at (10:48 PM) . assessment .MD (Medical Doctor) notified . first initial contact . 8/9/16 at (10:48 PM) . Date/Time responded . 3:00 a.m., 8/9/16 . 24 Hour Follow-up . (blank) . additional follow-ups . (blank). A Witness Statement dated 8/8/16 and signed by Certified Nursing Assistant (CNA) #1 documented, .resident was lying on the couch and she slid to the floor . A Witness Statement dated 8/8/16 and signed by CNA #2 documented, .resident was lying on the couch and next thing you know she was on the floor. I did not see how she fell out of the couch . g. The Physician's Progress Note dated 8/9/16 and signed by Advanced Practice Nurse (APN) #1 documented, .8/9/16 at 10:00 a.m . Chief Complaint: .Confusion . HPI: (history of present illness) . seen for acute visit for confusion . (patient) refused all medications . will not talk to anyone . will not make eye contact . refuses all care . Physical Exam: .BP (blood pressure) 116/74 . HR (heart rate) 78 . Temp (temperature) 97.5 . RR (respiratory rate) 18 . skin/nails - bruises bilateral arms . There was no documentation regarding the fall on 8/8/16. h. An I & A dated 8/9/16 at 11:30 a.m. and signed by LPN #5 documented, .Describe injury: Resident fall .Equipment in use: .W/C (wheelchair) . Activity: . Ambulating . Location: 200 Hall Day Room .Property involved: .w/c (wheelchair), couch .Immediate Actions Taken: .First Aid given by: .DON (Director of Nursing) . Date: .8/9/16 . Time: .(11:30 a.m.) . Type of aid: .(blank) . Temperature .97.6 . Pulse .93 .Respirations . 24 . B/P (blood pressure) .210/98 . Pain Scale . (blank) . MD notified . 8/9/16 at 11:30 a.m . 8/9/16 at (1:00 p.m.) . Sent to Hospital: .(hospital name) . Transferred by (emergency transport provider . Date: 8/9/16 . Resident at time of Incident: .Mobility: .Ambulation: .Mental: .A & O (Alert and Oriented) (times) 1 (to Person) . Narrative: .(Resident) got up out of chair when she was sitting down and attempted to push her wheelchair and ambulate. Resident started losing balance, DON and I went to assist resident. She leaned forward, we lowered her to the couch, the couch slid so we lowered her to the floor . A Witness Statement dated 8/9/16 and signed by the DON documented, .Resident sitting in regular chair in common area. She stood and grabbed her wheelchair. I went to her to offer assist. She began to tremble and leaned forward. I held her and attempted to lower her to the couch in common area. The couch slid and resident was limp. I safely lowered her to the floor. Another LPN in area and assisted with a pillow to protect her head. No obvious injuries noted at this time . A Nurses Note dated 8/9/16 at 3:40 p.m. documented, .at 1:00 p.m. Resident sent out to (Hospital Name) emergency room related to increased blood pressure, irregular heart rhythm and shortness of breath . Resident exited facility via (emergency transport provider) at 7:00 p.m . A Nurses Note dated 8/9/16 on the 7:00 p.m. to 7:00 a.m. (7p-7a) shift documented, Resident returned to facility accompanied by (emergency transport provider) . Blood Pressure 177/82 . On 10/13/16 at 12:50 p.m., the DON was asked for any X-ray results related to the resident's fall on 8/9/16. She stated, There was not one done; she (resident) was sent to the hospital for the hypertension only. We felt that the fall was caused by her blood pressure. i. A Nurses Note dated 8/10/16 at 2:30 p.m. documented, .resident in bed alert, very confused, delusional, anxious, fidgety, disoriented. Did not know where she was. Reoriented to time and place with little effectiveness . There was no documentation of a pain assessment. A Nurses Note dated 8/10/16 at 8:30 p.m. documented, .resident is restless with noted movement of feet . There was no documentation of a pain assessment. j. A Nurses Note dated 8/11/16 at 8:30 p.m. documented, .Resident complained of back pain. There was no documentation of any assessment for injury or cause of pain or of any intervention to attempt to alleviate the pain. k. An Occupational Therapy (OT) Note dated 8/12/16 at 5:22 p.m. documented, .OT: Comments: . Patient reported 10/10 lower back pain at start of session, requested pain medication from the nurse and stated that her pain had gone down just a bit at the end of session . l. A Nurses Note dated 8/13/16 at 9:00 a.m. documented, .Complained of lower back pain (9/10). APAP (Tylenol) 325 mg (milligrams) ii (two tablets) po (by mouth) given for pain . m. An OT Note dated 8/13/16 at 9:09 a.m. documented, .OT: .Summary: .pt (patient) is experiencing back pain 10/10 with limited mobility, pt (patient) unable to tolerate getting up OOB (out of bed). Currently just receiving Tylenol for pain which is not managing pain .pt (patient) at max (maximum) assist with pain expressed, nursing aware, pt (patient) states she is going to change doctors if she does not get her pain meds (medications) or call 911 and go back to the hospital. Total assist for toileting in bed due to pain . n. Physician's Telephone Orders dated 8/13/16 documented, .[MEDICATION NAME] Patch 5%. Apply 1 patch to the lower back area and leave on for 12 hours and off 12 hours . [MEDICATION NAME] 5/325 mg (milligrams) i (one tablet) po now . o. A Nurses Note dated 8/14/16 (not timed) and signed by LPN #5 documented, .resident complained of back pain / back spasm and ask if she could have some pain meds. Explain med (medication) order per this nurse. [MEDICATION NAME] applied at (8:00 a.m.). Resident complained pain any time she is moved in the bed. Resident will not let the therapist or aide move her in the bed / out of bed. She screams loudly. Resident called the ambulance (911) complained back spasm. MD notified. N.O.(new order) given to (increase) [MEDICATION NAME] 0.5 mg (milligrams) to po q (every) 6 hrs (hours) prn (as needed) anxiety and give [MEDICATION NAME] 5/325 mg (one) po (times) 1 dose now. Both meds [MEDICATION NAME] and [MEDICATION NAME] given at (11:10 a.m.) . There was no documentation of a follow-up assessment to determine if these medications effectively controlled the resident's pain. p. Physician's Telephone Orders dated 8/14/16 at 11:20 a.m. documented, .1 . Increase [MEDICATION NAME] to 0.5 mg po Q (every) 6 hrly (hourly) prn (as needed) anxiety . 2 .Give [MEDICATION NAME] 5/325 (milligrams) i (one tablet) po (by mouth) (times) 1 dose now . q. A Physical Therapy (PT) Note dated 8/14/16 documented, .PT: .Pt (patient) refused therapy three times. Education training on the importance of participation in physical therapy. Patient was shaking stating, 'I need to have my pain meds medications). I'm in so much pain . I don't know why they won't just give me my [MEDICATION NAME] .' Patient performed rolling side to side but refused to attempt getting to the (edge of bed). Spoke to nursing staff coordinated pain meds (medications) and came back to attempt therapy. Patient continued to refuse therapy for the day . r. A Nurses Note dated 8/15/16 at 5:00 p.m. documented, .Resident in bed is alert with confusion, has had c/o (complaint of) pain generalized . Administered Tylenol 650 mg for pain was effective. Resident receives PT/OT has yet to finish a full session due to pain . There was no documentation of a pain scale assessment, an evaluation to determine if any non-pharmacological intervention would improve the resident's pain level or to determine the source of the pain. s. A OT Note dated 8/15/16 and signed at 4:12 p.m. documented, .OT: . Comments: .patient reported 10/10 pain in lower back, muscle spasms, and burning in BLEs (Bilateral Lower Extremities). Discussed with nursing who stated that patient has taken Tylenol for pain, muscle relaxers, and medication for restless leg syndrome. Patient did not get out of bed today . t. A Nurses Note dated 8/16/16 at 3:00 p.m. documented, .Resident is having a lot of pain which has been preventing resident from going to therapy, APN (Advanced Practice Nurse) is being notified of resident's condition. Received orders for [MEDICATION NAME] 5/325mg (milligrams) I (one tablet) po (by mouth) every 6 hours prn (as needed) for pain .d/c (discontinue) [MEDICATION NAME] . u. An OT Note dated 8/16/16 documented, .OT: .Comments: .Pt refused to sit at edge of bed. Pt c/o (complained of) pain in back while lying in supine in bed, nursing notified . v. The Physician's Progress Notes dated 8/16/16 at 12:15 p.m. and signed by APN #1 documented, .68 y/o seen for c/o back pain. Pt. (patient) presents in her room in bed. She is A&O x 3 (alert and oriented to person, place, and time) which is much different than when seen last. Pt c/o (complained of) back pain that is up and down her entire back, and down bil (bilateral) legs. Report long hx (history) this off and on through the years .C/O (complained of) SOB (shortness of breath) due to pain and C/O (complained of) difficulty with therapy due to pain. Assessment / Plan: .Back Pain, acute or chronic - Add [MEDICATION NAME] 5/325. Pt took 7.5 mg (milligrams) at home and multiple other meds (medications) from pain doctor. D/C (discontinue) [MEDICATION NAME] due to ineffective . 5 . Debility - therapy . There was no documentation to indicate that the APN was aware of the resident's recent fall or of consideration of the possibility of any new fall-related injury that might be contributing to the resident's ongoing complaints of severe, unrelieved pain. w. A Nurses Note dated 8/16/16 at 8:00 p.m. documented, .Resident unable to sit up to take meds because of pain in back . x. An OT Note dated 8/17/16 and signed at 12:10 p.m. documented, .OT: .Comments: . Pt demanded to go back to room while in gym due to severe back pain; nursing notified. Pt (patient) unable to tolerate complete tx (therapy) time. Pt very impulsive during tx (therapy) . y. A Nurses Note dated 8/17/16 on the 7p-7a shift documented, .PRN [MEDICATION NAME] given at 9:20 p.m. for 10/10 back pain . z. An OT Note dated 8/18/16 at 3:26 p.m. documented, .OT: Comments: .Pt c/o pain in back; nursing notified . aa. A Nurses Note dated 8/18/16 on the 7p-7a shift documented, .Resident alert and oriented (times) 3 (to person, place, time), resting in bed. C/O (complained of) back pain radiating down legs 9/10 per numeric scale. Resident states pain med (medication) [MEDICATION NAME] has not been effective. Request to get back on [MEDICATION NAME] . There was no documentation the physician was consulted regarding the resident's complaint of severe pain that was not relieved by the [MEDICATION NAME]. bb. A Physician's Telephone Order dated 8/19/16 at 11:15 p.m. documented, .Increase [MEDICATION NAME] 5 to Q 4 hrs (every 4 hours) PRN (as needed for) pain . [MEDICATION NAME] cream to back TID (three times per day) PRN Pain . cc. Nurses Notes dated 8/19/16 documented the following: At 3:30 p.m.: .Resident received new orders for [MEDICATION NAME] 5/325 q 4 hrs prn for pain, resident refused to participate in therapy today. Encouraged many times by nursing and therapy, still refused . At 9:00 p.m.: .Res. (Resident's) pain (not) being managed with [MEDICATION NAME] med (medication) not getting on top of resident's pain. Noted was screaming out when sleep but does not remember doing so . Late entry timed (No time): .N/O (New Order): .Increase [MEDICATION NAME] 5 to q 4 hrs prn pain . [MEDICATION NAME] cream to back TID prn pain . dd. Nurses Notes dated 8/20/16 documented, (3:30 p.m . Resident rec'd in bed, continues to (complain of) lots of pain in lower back, bilateral legs/feet, refuses therapy. Refused to get out of bed . 8:30 p.m. documented, .Resident asked for meds while c/o pain all over, unable to move in bed without facial grimacing and verbally tells staff she hurts . ee. Nurses Notes dated 8/21/16 documented, (12:00 p.m.) .Resident continues to have pain all over. Rec'd (received) [MEDICATION NAME] q 4 as ordered prn. According to resident pain med only works a little, is better than it has been. Resident continues to refuse to get out of bed or participate in therapy . (8:30 p.m.) .Resident c/o generalized pain that is not relieved by meds ordered at interval times ordered. Resident stated 'I was going to pain management and was on stronger meds and they were getting ready to burn some nerves in my back . ff. A Nurses Note dated 8/22/16 at 7:15 p.m. documented, .Medicated q 4 hours with [MEDICATION NAME] 5/325 mg po for lower back pain rated 10/10 .Pain management effective . A Nurses Note dated 8/22/16 on the 7p-7a shift documented, .res (resident) lying in bed A&O (times) 3 with c/o BLE (bilateral lower extremities) pain. PRN (as needed) pain RX (medication) given this shift .effective . gg. A physician progress notes [REDACTED].#1 documented, .Uncontrolled Pain .68 y/o WF seen due to uncontrolled pain .C/O (complained of) uncontrolled pain since being here. Pt tells me she saw a pain mgmt. (management) MD (physician) PTA (prior to admission), but she is unable to give me his name. Long hx (history) back pain but did have fall so will check x-ray to ensure no acute injury. C/O (complained of) low back pain radiating to bilateral legs. BLE (bilateral lower extremities) with burning pain . Assessment/Plan . Chronic pain . uncontrolled . Increase [MEDICATION NAME]. Add [MEDICATION NAME], increase [MEDICATION NAME], continue [MEDICATION NAME]. Check Xray . A Physician's Telephone

Based on observation, record review, and interview, the facility failed to ensure the call lights in resident rooms were functioning to allow for summoning for assistance to prevent potential accidents or in case of an emergency for 10 of 10 (Residents #19, #25-#30, #32, #33 and #35) case mix residents who resided on the 400 hall and failed to ensure the call light monitoring system at the nurses station on 1 of 4 halls was in working order. These failed practices resulted in Immediate Jeopardy, which caused or could have caused serious injury, harm, impairment or death for 10 residents who resided on the 400 hall and required staff assistance for Activities of Daily Living and 22 residents who resided on the 300 hall, and had the potential to affect 33 other residents who resided on the 400 hall. The Administrator was informed of the Immediate Jeopardy on 3/28/16 at 5:45 p.m. The findings are: 1. On 3/28/16 at 3:10 p.m., a Surveyor checked the call light in Resident Room #403 and it was not working. The Surveyor informed the Administrator of the non functioning call light. a. On 3/28/16 3:15 p.m., the Administrator stated the Assistant Maintenance man had fixed the call light and it was functioning. b. On 3/28/16 at 3:30 p.m. and at 4:45 p.m., the call light in Resident Room #403 was still not working. 2. On 3/28/16 between 4:45 and 5:20 p.m., all of the call lights in resident rooms on the 4th floor were checked for proper functioning. The following residents who required limited to extensive assistance with locomotion/transfers had call lights that were not working: a. Resident #19 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/8/16 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS); required extensive assistance of 2 for transfer, mobility dressing, toilet use, and personal hygiene; and had no functional limitations in the upper extremities. On 3/28/16 at 4:45 p.m., the resident's call light was activated by the Surveyor and it was not functioning. b. Resident #25 had [DIAGNOSES REDACTED]. The MDS with an ARD of 3/8/16 documented the resident scored 15 (13-15 indicates cognitively intact) on the BIMS; required extensive assistant with locomotion off the unit and limited assistance of staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; and had no impairment of the upper extremities. On 3/28/16 at 4:50 p.m., the resident stated, Sometimes does work (call light), sometimes don't, makes me so mad . sometimes I wait until the girls make their rounds to get help as no one knows I need help cause the darn light hasn't worked. c. Resident #30 had [DIAGNOSES REDACTED]. The MDS with an ARD of 1/20/16 documented the resident scored 0 (0-7 indicates severely impaired) on the BIMS; required extensive assistance of 1-2 staff for bed mobility and bathing, and totally dependent on staff for personal hygiene, and toileting; and had no functional limitations in the upper extremities. On 3/28/16 at 4:51 p.m., the call light was activated by the Surveyor and it was not functioning. d. Resident #26 had [DIAGNOSES REDACTED]. The MDS with an ARD of 3/6/16 documented the resident scored 3 (0-7 indicates severely impaired) on the BIMS; required extensive assistance of 1-2 staff for bed mobility, transfers, personal hygiene, bathing, and toileting; and had no functional limitation in the upper extremities. On 3/28/16 at 4:52 p.m., the call light was activated by the Surveyor and it was not functioning. e. Resident #35 had [DIAGNOSES REDACTED]. The MDS with an ARD of 3/4/16 documented the resident scored 0 (0-7 indicates severely impaired) on the BIMS; required extensive assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; and had no functional limitations in the upper extremities. On 3/28/16 at 4:55 p.m., the call light was activated by the Surveyor and it was not functioning. f. Resident #32 had [DIAGNOSES REDACTED]. The MDS with an ARD of 1/22/16 documented the resident scored 0 (0-7 indicates severely impaired) on the BIMS; required total assistance of 2 staff with transfers, bed mobility, toileting, personal hygiene, dressing and bathing; and had functional limitation in the upper extremities. On 3/28/16 at 5:05 p.m., the call light was activated by the Surveyor and it was not functioning. g. Resident #27 had [DIAGNOSES REDACTED]. The MDS with an ARD of 3/18/16 documented the resident scored a 13 (13-15 indicates cognitively intact) on the BIMS; required extensive assistance of 1 staff for dressing and bathing; and had no functional limitations in the upper extremities. On 3/28/15 at 5:08 p.m., the call light was activated by the Surveyor and it was not functioning. h. Resident #29 had [DIAGNOSES REDACTED]. The MDS with an ARD of 3/7/16 documented the resident scored 7 (0-7 indicates severely impaired) on the BIMS, independent in bed mobility and transfers and toileting, required limited assistance with dressing and personal hygiene and extensive assistance with bathing, and had no functional limitations in the upper extremities. On 3/28/16 at 5:07 p.m., the call light was activated by the Surveyor and it was not functioning. i. Resident #33 had [DIAGNOSES REDACTED]. The MDS with an ARD of 3/11/16 documented the resident scored 10 (8-12 indicates moderately impaired) on the BIMS, required limited assistance with bed mobility and personal hygiene, limited assistance with transfers and toilet used, and extensive assistance with bathing, and did not have any functional limitations in the upper extremities. On 3/28/16 at 5:15 p.m., the call light was activated by the Surveyor and it was not functioning. j. Resident #28 had [DIAGNOSES REDACTED]. The MDS with an ARD of 1/4/16 documented the resident the resident scored 15 (13-15 indicates cognitively intact) on the BIMS, was independent with supervision with all activities of daily living except for limited assistance with locomotion in room and on and off the unit, dressing and bathing, and had no functional limitations in the upper extremities. On 3/28/16 at 5:17 p.m., the call light was activated by the Surveyor and it was not functioning. 3. On 3/28/16 at 5:30 p.m., the call lights on the 300 Hall were checked and all were functioning. One of the Surveyors was standing at the 300 hall Nurses Station monitoring to ensure when the call lights were activated in a resident's room there was an audible alarm sounding at the nurses station. There was no audible signal. The nurse on duty stated that one of the computers that should have sounded and alerted staff was not operational at all. The nurse on duty was asked about the computer not working the nurses stated she did not know why the call system was not working at the nurses station and a new program was installed in May of 2015 and it had not worked at the 300 hall nurses station since then. 4. On 3/28/16 at 7:45 p.m., the Immediate Jeopardy was removed and the scope and severity lowered to an E when the facility implemented the following plan of removal: a. Upon notification of call lights not working properly, designated staff began a walk-thru every (Q) 15 minutes for each hall, on each floor to ensure safety. The Q 15 minute monitoring began at approximately 7:15 p.m. Staff members were provided a check off form for each resident to document such monitoring. b. Designated staff left the facility to purchase bells, or other devices that can alert staff members in the event the resident needs to alert the staff fro any assistance. Each resident was visually evaluated by the DON/RN Designee, to ensure appropriate device was issued to the appropriate resident. c. The bells and devices were purchased and put into place on 3/28/16; Administrator/designee ensured these were in place prior to leaving at 8:50 p.m. d. In-service began to all staff available at approximately 6:45 p.m. to ensure that each staff member is aware that a walk-thru for each hall on each floor, to ensure that residents are safe. Any negative issues will be reported addressed immediately. e. Staff members were instructed that any abnormal issues that are found during the monitoring will be reported to the Administrator and/or maintenance immediately, for further instructions. f. Staff member will continue to do monitoring for each floor and hall until the call light system is fully functioning. g. The company who installed the call light system was called at 6:26 p.m. regarding issues with the call light system. A service technician was at the facility at 11:00 a.m. for review and recommendation and repair of the system. h. DON/designee will monitor the call lights for proper functioning on a daily basis until compliance is achieved. A monitoring form to document the date, time, and room number will be used.

Complaints # (AR 672) and # (AR 753), were substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure the physician was immediately consulted regarding significant deterioration of a pressure ulcer for 1 of 1 (Resident # 7) case mix resident who had wounds that deteriorated since 11/1/14. The facility failed to ensure family members were notified of wound deterioration and changes in treatment for [REDACTED].# 7) case mix resident who had wounds that deteriorated since 11/1/14. This facility's failure to immediately consult with the physician regarding significant deterioration of a pressure sore resulted in a pattern of actual harm for Resident # 7 who had documented deterioration of a pressure ulcer for multiple days and had the potential to cause more that minimal harm for 3 residents in the facility who had wounds that deteriorated since 11/1/14 according to the listing received from Treatment Nurse # 2 on 12/19/14. The findings are: 1. The facility's policy titled "Skin Program" documented "... 6. Resident(s) with wounds will have appropriate treatment. If there is deterioration or no change in a wound within 2 weeks, the treatment will be changed ...". 2. Resident # 7 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/14 documented the resident scored a 1 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status, required extensive assistance with bed mobility and toilet use, was always incontinent of urine and bowel, was at risk for pressure ulcers, and had no unhealed pressure ulcers. a. The Admission-data Collection Form dated 11/14/14 at 2:00 p.m. documented, "... Skin: Mark the location of skin conditions/wounds on illustration below: ... redness (with line drawn to square around coccyx/sacral area) ... Skin Conditions: excoriation ... Skin Treatments: Application of ointments/meds ... Risk for Pressure Ulcers: ... Total Score: 14 ... 13-14 moderate risk ... Admission Nurses Notes: ... Redness to sacrum and gluteal areas. No open areas." This form was signed by Registered Nurse (RN) # 2. On 12/19/14 at 8:45 a.m. Registered Nurse (RN) # 2, the admitting nurse on 11/14/14, was asked "Do you recall (Resident # 7)?" RN # 2 stated, "Yes." RN # 2 was asked, "What did her bottom look like on admit?" RN # 2 stated, "Red.. RN # 2 was asked, "Did it look like a Stage I or a deep tissue injury?" RN # 2 stated, "No it was just reddish, it did not look a deep tissue injury from what I recall." b. The Pressure Ulcer Record documented "... Stage I: Redness not resolved within 30 minutes of pressure relief ... Date First Observed: 11/14/14. Site: Sacral. Stage: 1 by admission nurse. Size: (Blank) ... Date: 11/17/14. Stage: I. Length x (by) Width: 6 x 6 (centimeters). Depth: 0. Drainage: 0. Odor: 0 ... Progress and/or Remarks: Red and purple. Signature of Nurse: (Treatment Nurse # 1). Date: 11/24/14. Stage: UTD (Unable to Determine). Length x Width: 3 x 3 (centimeters). Depth: UTD. Drainage: (serosanguineous). Odor: 0 ... Progress and/or Remarks: Open area with slough. Signature of Nurse: (Treatment Nurse # 1). Date: 12/1/14. Stage: UTD. Length x Width: 4 x 4 (centimeters). Depth: UTD. Drainage: (serosanguineous). Odor: 0 ... Progress and/or Remarks: Slough, det (deteriorating). Signature of Nurse: (Treatment Nurse # 1). " c. A physician's telephone order dated 12/1/14 documented, "Cleanse sacral area with wound cleanser, apply foam border, change Monday, Wednesday, and Friday and prn (as needed)." This ordered was signed by Treatment Nurse # 1. A physician's telephone order dated 12/3/14 documented, "Multivitamin with minerals (per mouth) daily, Zinc 220 mg (milligrams) (per mouth) daily (times) 30 days, Prostat (30 milliliters) (per mouth) (twice a day), Vitamin C (500 mg) (per mouth) daily, Pre [MEDICATION NAME] next lab draw." This ordered was signed by Treatment Nurse # 1. d. The Pressure Ulcer Record documented, "... Date: 12/8/14. Stage: UTD. Length x Width: 6 x 6 (centimeters). Depth: UTD. Drainage: (serosanguineous). Odor: 0 ... Progress and/or Remarks: Slough, det (deteriorating). Signature of Nurse: (Treatment Nurse # 1)." The Pressure Ulcer Record documented, "... Date: 12/15/14. Stage: UTD. Length x Width: 5.5 x 5.5 (centimeters). Depth: UTD. Drainage: (serosanguineous). Odor: Yes ... Progress and/or Remarks: imp (improved) Slough. Signature of Nurse: (Treatment Nurse # 1)." e. On 12/17/14 at 2:10 p.m., Treatment Nurse # 1 set up supplies for wound care then entered the resident's room. After applying gloves, the nurse turned the resident to left side. A soiled foam bordered dressing dated 12/16/14 was noted. Approximately 1/3 of the dressing surface was covered with a greenish substance. The wound bed of the pressure ulcer was covered with green, yellow foul smelling drainage. After cleaning the wound, the wound bed was noted to be covered with white/yellow slough with some small pink areas. Treatment Nurse # 1 measured the open area of the wound as 5.5 centimeters by 5.5 centimeters. The Treatment Nurse stated the wound was "unstageable" and "can't get depth (measurement) due to slough". The wound bed was surrounded by an area of red colored skin that was approximately 1 centimeter wide. On completion of the dressing change, Treatment Nurse # 1 rolled the resident onto her back. The Treatment Nurse stated, "(Resident # 7) refuses to lay on her side." Treatment Nurse # 1 was asked, "Did you change the dressing yesterday?" Treatment Nurse # 1 stated, "Yes." Treatment Nurse # 1 was asked, "What did the wound look like?" Treatment Nurse # 1 stated, "Hard slough, not opened." Treatment Nurse # 1 was asked, "Any odor yesterday?" Treatment Nurse # 1 stated, "A little bit." f. On 12/18/14 at 2:12 p.m., Treatment Nurse # 1 was asked to review the resident's Pressure Ulcer Record. Treatment Nurse # 1 was asked, "Stage I was where?" Treatment Nurse # 1 stated, "Redness, no open areas on coccyx/sacrum that's on the care plan." Treatment Nurse # 1 was asked, "On 11/17/14 did you measure and stage the coccyx area?" Treatment Nurse # 1 stated, "Yes." Treatment Nurse # 1 was asked, "Was it a Stage I?" Treatment Nurse # 1 stated, "Yes it was red and purple." Treatment Nurse # 1 was asked, "You measured it on 11/24/14?" Treatment Nurse # 1 stated, "Yes but I only measured the open areas." Treatment Nurse # 1 was asked, "On 11/17/14 was the red a dark red?" Treatment Nurse # 1 stated, "No, reddish pink." Treatment Nurse # 1 was asked, "Purple area, what did you mean (11/17/14 red and purple)?" Treatment Nurse # 1 stated, "It looked like a purple red bruise." Treatment Nurse # 1 was asked, "If something is a purple red color is that a Stage I?" Treatment Nurse # 1 stated, "No, that's a suspected deep tissue injury." Treatment Nurse # 1 was asked to review the resident's chart. Treatment Nurse # 1 was asked, "When was the first wound care order written?" Treatment Nurse # 1 stated, "12/1/14 to clean with wound cleanser, foam dressing, and change Monday, Wednesday and Friday and as needed." Treatment Nurse # 1 was asked to get the Treatment Administration Records (TAR) for November and December 2014. At 2:55 p.m., Treatment Nurse # 1 returned to the conference room and stated, "There's no TAR for November." Treatment Nurse # 1 was asked, "So (Resident # 7) had an open area, that was staged as UTD (Unable to Determine) with slough on 11/24/14 and no treatments were started till 12/1/14?" Treatment Nurse # 1 stated, "Yes." Treatment Nurse # 1 was asked, "What treatment were you doing before 12/1/14?" Treatment Nurse # 1 stated, "Barrier cream." Treatment Nurse # 1 was asked, "The physician order [REDACTED].?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "On 12/8/14 you documented 6 x 6 and slough, det. Det means what?" Treatment Nurse # 1 stated "Deteriorating." Treatment Nurse # 1 was asked, "Did you get any new orders for wound care 12/8/14?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "On 12/15/14, you noted an odor?" Treatment Nurse # 1 stated, "Yes, but the size had improved some." Treatment Nurse # 1 was asked, "Did you let the doctor know about the odor on 12/15/14?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "Was there an increase in drainage noted?" Treatment Nurse # 1 stated, "Yes." Treatment Nurse # 1 was asked, "If there was a possible deep tissue injury on 11/17/14 ..." On 12/19/14 at 2:45 p.m., the Director of Nurses (DON) was asked, "When should the doctor and family have been notified regarding the pressure sore?" The DON stated "On 11/17/14, 11/24/14, 12/1/14 (as of 12/19/14, only documentation physician consulted regarding pressure sore), 12/8/14, and 12/15/14." g. On 12/19/14 at 8:40 a.m., Treatment Nurse # 1 was asked, "Did you talk with the resident's family about changes in the wound on 12/1/14 when you got new orders?" Treatment Nurse # 1 stated, "No. I left it with the nurses." Treatment Nurse # 1 was asked, "Did you call the family on 12/3/14 about the new orders you got?" Treatment Nurse # 1 stated, "No."

Complaint # (AR 672) and Complaint # (AR 720) were substantiated (all or in part) in these findings. Based on observation, record review, and interview, the facility failed to ensure there were no delays in providing Resident #7 the necessary care and services to prevent deterioration and promote healing of pressure sores. The facility failed to ensure residents were turned and positioned so that pressure was off loaded from the sacrum/coccyx; failed to ensure a low air loss speciality mattress was implemented in a timely manner to decrease pressure on the sacrum/coccyx and promote wound healing; failed to consult the physician in timely manner for continued pressure ulcer wound deterioration; failed to ensure appropriate treatments were implemented in a timely manner to promote pressure ulcer wound healing for 1 (Residents # 7) of 2 (Residents # 4 and 7) case mix residents who had pressure ulcers. These failed practices resulted in a pattern of actual harm for Resident # 7, who had documented deterioration in a pressure ulcer for multiple days without timely and appropriate interventions implemented to address the wound deterioration or promote healing and had the potential to cause more than minimal harm to 14 residents in the facility who had pressure ulcers with 10 of those residents having pressure ulcers of the sacrum/coccyx according to the listing received from Treatment Nurse # 2 on 12/19/14. The findings are: 1. The facility's policy titled "Pressure Ulcer Care" documented: "As the name implies, pressure ulcers result when pressure - applied with great force for a short period or with less force over a long period - impairs circulation, depriving tissues of oxygen and other life-sustaining nutrients. This process damages skin and underlying structures. Untreated, resulting in ischemic [MEDICAL CONDITION] and can lead to serious infections. Most pressure ulcers develop over bony prominences, when friction and shearing force combine with pressure to break down skin and underlying tissues. Persistent pressure on bony prominence obstructs capillary blood flow, leading to tissue necrosis. Common sites include the sacrum, coccyx ... Successful pressure ulcer treatment involves relieving pressure, restoring circulation ... Ideally, prevention is the key to avoiding extensive therapy. Preventive measures include off-loading pressure ... When a pressure ulcer develop despite preventive efforts, treatment includes methods to decrease pressure, such as frequent repositioning to shorten pressure duration and the use of special equipment to reduce pressure intensity. Treatment may also involve pressure-reducing devices, such as special beds, mattresses ... Staging pressure ulcers: ... Suspected deep tissue injury: Deep tissue injury is characterized by a purple or maroon localized area of intact skin or blood filled blister caused by damage of underlying soft tissue from pressure or shear. ... The depth of the deep tissue injury is unknown ... Stage I. Stage I ulcers are characterized by intact skin with nonblanchable redness of a localized area, usually over a bony prominence ... Implementation: ... turn and reposition the patient every 1 to 2 hours ... Use pillows to position the patient ..." 2. The facility's policy titled "Skin Program" documented: "1. Identify resident for Pressure Ulcer Risk - Braden Scale. 2. Implement Plan of Care interventions for residents' identified at risk for Pressure Ulcers ... 6. Resident (s) with wounds will have appropriate treatment. If there is deterioration or no change in a wound within 2 weeks, the treatment will be changed ... 9. All skin conditions will be assessed weekly with documentation of : a. Date b. Stage c. Length x (by) width x depth d. Drainage e. Odor f. Progress/Remarks g. Current Treatment Plan ...". 3. Resident # 7 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/14 documented the resident scored a 1 (0 - 7 indicates severe impairment) on the Brief Interview for Mental Status, required extensive assistance with bed mobility and toilet use, was always incontinent of urine and bowel, was at risk for pressure ulcers, and had no unhealed pressure ulcers. a. The Admission-data Collection Form dated 11/14/14 at 2:00 p.m. documented, "... Skin: Mark the location of skin conditions/wounds on illustration below: ... redness (with line drawn to square around coccyx/sacral area) ... Skin Conditions: excoriation ... Skin Treatments: Application of ointments/meds ... Risk for Pressure Ulcers: ... Total Score: 14 ... 13-14 moderate risk ... Admission Nurses Notes: ... Redness to sacrum and gluteal areas. No open areas." This form was signed by Registered Nurse (RN) # 2. On 12/19/14 at 8:45 a.m. Registered Nurse (RN) # 2, the admitting nurse on 11/14/14, was asked "Do you recall (Resident # 7)?" RN # 2 stated, "Yes." RN # 2 was asked, "What did her bottom look like on admit?" RN # 2stated, "Red.. RN # 2 was asked, "Did it look like a Stage I or a deep tissue injury?" RN # 2 stated, "No it was just reddish, it did not look a deep tissue injury from what I recall." b. The Admission Care Plan dated 11/14/14 documented, "Skin Care/Pressure Ulcers 11/14/14 ... (Treatment) ordered: per (physician) order. Weekly skin audit by licensed nurse. Stage I to coccyx area ... " The care plan documented a revision dated 11/21/14, "Resisting care, refusing to let staff turn (and) reposition or provide peri-care. Refuses to be repositioned ..." c. The Pressure Ulcer Record documented "... Stage I: Redness not resolved within 30 minutes of pressure relief ... Date First Observed: 11/14/14. Site: Sacral. Stage: 1 by admission nurse. Size: (Blank) ... Date: 11/17/14. Stage: I. Length x (by) Width: 6 x 6 (centimeters). Depth: 0. Drainage: 0. Odor: 0 ... Progress and/or Remarks: Red and purple. Signature of Nurse: (Treatment Nurse # 1). Date: 11/24/14. Stage: UTD (Unable to Determine). Length x Width: 3 x 3 (centimeters). Depth: UTD. Drainage: (serosanguineous). Odor: 0 ... Progress and/or Remarks: Open area with slough. Signature of Nurse: (Treatment Nurse # 1). Date: 12/1/14. Stage: UTD. Length x Width: 4 x 4 (centimeters). Depth: UTD. Drainage: (serosanguineous). Odor: 0 ... Progress and/or Remarks: Slough, det (deteriorating). Signature of Nurse: (Treatment Nurse # 1). " d. A physician's telephone order dated 12/1/14 documented, "Cleanse sacral area with wound cleanser, apply foam border, change Monday, Wednesday, and Friday and prn (as needed)." This ordered was signed by Treatment Nurse # 1. A physician's telephone order dated 12/3/14 documented, "Multivitamin with minerals (per mouth) daily, Zinc 220 mg (milligrams) (per mouth) daily (times) 30 days, Prostat (30 milliliters) (per mouth) (twice a day), Vitamin C (500 mg) (per mouth) daily, Pre [MEDICATION NAME] next lab draw." This ordered was signed by Treatment Nurse # 1. e. The Pressure Ulcer Record documented, "... Date: 12/8/14. Stage: UTD. Length x Width: 6 x 6 (centimeters). Depth: UTD. Drainage: (serosanguineous). Odor: 0 ... Progress and/or Remarks: Slough, det (deteriorating). Signature of Nurse: (Treatment Nurse # 1)." The Pressure Ulcer Record documented, "...Date: 12/15/14. Stage: UTD. Length x Width: 5.5 x 5.5 (centimeters). Depth: UTD. Drainage: (serosanguineous). Odor: Yes ... Progress and/or Remarks: imp (improved) Slough. Signature of Nurse: (Treatment Nurse # 1)." f. On 12/15/14 at 12:15 p.m., Resident # 7 was in bed on her back with the head of the bed elevated 30 degrees. There was no off loading of pressure to the sacral/coccyx area with the resident in this position. There was a foul odor noted that did not smell of urine or feces. A low air loss mattress was present on the bed. The only pillow on the bed was under the resident's head. On 12/16/14 at 8:19 a.m. and 3:47 p.m. and on 12/17/14 at 6:35 a.m., the resident was in bed on her back with the head of the bed elevated 30 degrees. There was no off loading of pressure to the sacral/coccyx area with the resident in this position. There was a foul odor noted that did not smell of urine or feces. A low air loss mattress was present on the bed. The only pillow on the bed was under the resident's head. g. On 12/17/14 at 2:10 p.m. Treatment Nurse # 1 set up supplies for wound care then entered the resident's room. After applying gloves, the nurse turned the resident to left side. A soiled foam bordered dressing dated 12/16/14 was noted. Approximately 1/3 of the dressing surface was covered with a greenish substance. The wound bed of the pressure ulcer was covered with green, yellow foul smelling drainage. After cleaning the wound, the wound bed was noted to be covered with white/yellow slough with some small pink areas. Treatment Nurse # 1 measured the open area of the wound as 5.5 centimeters by 5.5 centimeters. The Treatment Nurse stated the wound was "unstageable" and "can't get depth (measurement) due to slough". The wound bed was surrounded by an area of red colored skin that was approximately 1 centimeter wide. On completion of the dressing change, Treatment Nurse # 1 rolled the resident onto her back. The Treatment Nurse stated, "(Resident # 7) refuses to lay on her side." The resident had a pillow under her head and one partially under her right shoulder area. The resident's knees were raised to approximately 15 degrees and the head of the bed was elevated approximately 15 degrees. Treatment Nurse # 1 left the room after washing her hands and then returned to the room with a pillow. Treatment Nurse # 1 placed the pillow under the resident's knees and upper calves. This position did not off load pressure from the sacral/coccyx area. Treatment Nurse # 1 was asked, "Did you change the dressing yesterday?" Treatment Nurse # 1 stated, "Yes." Treatment Nurse # 1 was asked, "What did the wound look like?" Treatment Nurse # 1 stated, "Hard slough, not opened." Treatment Nurse # 1 was asked, "Any odor yesterday?" Treatment Nurse # 1 stated, "A little bit." h. On 12/18/14 at 1:20 p.m., CNA # 12 stated she worked 7:00 a.m. to 3:00 p.m. with Resident # 7. CNA # 12 was asked, "How long has she been on the air mattress?" CNA # 12 stated, "Since she's been here. I take that back, the first couple of weeks she was on a regular bed then went to an air mattress." CNA # 12 was asked, "Does she have a bed sore?" CNA # 12 stated, "Yes on her bottom, an open area." CNA # 12 was asked, "What do you do because of the bed sore?" CNA # 12 stated, "Turn her every two hours and reposition her, make sure there's a cushion in the wheelchair. She will turn herself back, she moves, she tries to get out of bed." CNA # 12 was asked ,"Have you tried a wedge to keep her turned?" CNA # 12 stated "No, only a pillow but it's not always there." On 12/18/14 at 1:45 p.m., Licensed Practical Nurse (LPN) # 10 stated he was the charge nurse from 7:00 a.m. to 7:00 p.m. for Resident # 7. LPN # 1 was asked, "How long has she been on the air mattress?" LPN # 10 stated, "They put that in place last week." LPN # 10 was asked, "Have you reported that she's not staying turned?" LPN # 10 stated, "No, I didn't know she wasn't. She's up most of the day." i. On 12/18/14 at 2:12 p.m., Treatment Nurse # 1 was asked to review the resident's Pressure Ulcer Record. Treatment Nurse # 1 was asked, "Stage I was where?" Treatment Nurse # 1 stated, "Redness, no open areas on coccyx/sacrum that's on the care plan." Treatment Nurse # 1 was asked, "On 11/17/14 did you measure and stage the coccyx area?" Treatment Nurse # 1 stated, "Yes." Treatment Nurse # 1 was asked, "Was it a Stage I?" Treatment Nurse # 1 stated, "Yes it was red and purple." Treatment Nurse # 1 was asked, "You measured it on 11/24/14?" Treatment Nurse # 1 stated, "Yes but I only measured the open areas." Treatment Nurse # 1 was asked, "On 11/17/14 was the red a dark red?" Treatment Nurse # 1 stated, "No, reddish pink." Treatment Nurse # 1 was asked, "Purple area, what did you mean (11/17/14 red and purple)?" Treatment Nurse # 1 stated, "It looked like a purple red bruise." Treatment Nurse # 1 was asked, "If something is a purple red color is that a Stage I?" Treatment Nurse # 1 stated, "No, that's a suspected deep tissue injury." Treatment Nurse # 1 was asked, "When did the resident get an air mattress?" Treatment Nurse # 1 stated, "12/9/14." Treatment Nurse # 1 was asked, "Why did it take so long to get the resident on the air mattress?" Treatment Nurse # 1 stated, "I don't know, she should have been placed on it the day she came in." Treatment Nurse # 1 was asked, "How do you know that the low air loss mattress was placed on 12/9/14?" Treatment Nurse # 1 stated, "That's when I went down stairs and found maintenance to get it on there." Treatment Nurse # 1 was asked to review the resident's chart. Treatment Nurse # 1 was asked, "When was the first wound care order written?" Treatment Nurse # 1 stated, "12/1/14 to clean with wound cleanser, foam dressing, and change Monday, Wednesday and Friday and as needed." Treatment Nurse # 1 was asked to get the Treatment Administration Records (TAR) for November and December 2014. At 2:55 p.m., Treatment Nurse # 1 returned to the conference room and stated, "There's no TAR for November." Treatment Nurse # 1 was asked, "So (Resident # 7) had an open area, that was staged as UTD (Unable to Determine) with slough on 11/24/14 and no treatments were started till 12/1/14?" Treatment Nurse # 1 stated, "Yes." Treatment Nurse # 1 was asked, "What treatment were you doing before 12/1/14?" Treatment Nurse # 1 stated, "Barrier cream." Treatment Nurse # 1 was asked, "The physician order [REDACTED].?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "On 12/8/14 you documented 6 x 6 and slough, det. Det means what?" Treatment Nurse # 1 stated "Deteriorating." Treatment Nurse # 1 was asked, "Did you get any new orders for wound care 12/8/14?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "On 12/15/14, you noted an odor?" Treatment Nurse # 1 stated, "Yes, but the size had improved some." Treatment Nurse # 1 was asked, "Did you let the doctor know about the odor on 12/15/14?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "Was there an increase in drainage noted?" Treatment Nurse # 1 stated, "Yes." Treatment Nurse # 1 was asked, "If there was a possible deep tissue injury on 11/17/14 ..." Treatment Nurse # 1 stated, "She should have been on an air mattress." Treatment Nurse # 1 was asked, "Do you recall where the pillows were when you finished her treatment today?" Treatment Nurse # 1 stated, "She had one under her head and one under her legs." Treatment Nurse # 1 was informed this surveyor noted a third pillow that was placed under the resident's right shoulder area. Treatment Nurse # 1 was asked, "When a pillow is placed under the shoulder area will that keep her off her back or off load pressure from the coccyx?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked "Do you check her for positioning during the day?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "If the resident is on her back while in bed is that going to help the pressure ulcer heal?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "Have you tried a wedge or other device to keep her off of her back?" Treatment Nurse # 1 stated, "No." j. The care plan dated 11/14/14 and revised on 12/18/14 documented, "... Focus: (Resident # 7) has an alteration in behaviors (due to) episodes of refusal of care and/or medications. (Diagnosis) of advanced dementia and demonstrates poor coping skills ... Focus: (Resident # 7) has a potential for alteration in her skin integrity (due to) decreased mobility ... incontinent of bowel and bladder. Advanced age of 89 with tissue thin and frail skin ... Intermittent refusal of care and participation (related to) her severe dementia and demonstration of decreased self awareness ... Intervention/Tasks: ... Therapeutic mattress ..." There was no documented plan to reposition or frequency to reposition specified. k. On 12/19/14 at 7:05 a.m., CNA # 13 stated she worked the 11:00 p.m. to 7:00 a.m. shift. CNA # 13 was asked, "Do you know (Resident # 7)?" CNA # 13 stated, "Yes." CNA # 13 was asked, "How often have you worked with her?" CNA # 13 stated, "Every night I'm here." CNA # 13 was asked, "How often is she turned?" CNA # 13 stated, "They just started turning her tonight." CNA # 13 was asked, "Did you ever turn her before this?' CNA # 13 stated, "No." CNA # 13 was asked, "How did she lie in bed prior to tonight?" CNA # 13 stated, "On her back." CNA # 13 was asked, "Did you know she had a dressing on her bottom?" CNA # 13 stated, "Yes." CNA # 13 was asked "You didn't keep her off her back prior to tonight?" CNA # 13 stated, "No. Tonight they told me she has a wedge and to keep her off her back." On 12/19/14 at 7:23 a.m., CNA # 14 stated she worked the 11:00 p.m. to 7:00 a.m. shift. CNA # 14 was asked, "Do you know or have you cared for (Resident # 7)?" CNA # 14 stated, "Yes." CNA # 14 was asked, "How often do you turn the resident?" CNA # 14 stated, "Every two hours, but she's a wiggler. She doesn't stay in the same position." CNA # 14 was asked, "Does she have a wound?" CNA # 14 stated, "Yes on her bottom." CNA # 14 was asked, "What do you do because of her wound?" CNA # 14 stated, "If there's no bandage we clean it good." CNA # 14 was asked, "Did she have any bandage on her bottom when she first came in?" CNA # 14 stated, "I don't think she did." CNA # 14 was asked, "What did you do when there was no dressing there and it was open?" CNA # 14 stated, "Barrier cream ... I put it on every time I cleaned her." l. On 12/19/14 at 9:35 a.m., the Administrator presented a copy of the barrier cream tube that the facility uses. The Sensi Care Protective Barrier cream tube documented, "... with 15% Zinc Oxide ... Uses: Temporarily protects and helps relieve chapped or cracked skin and lips. Helps treat and prevent diaper rash. Protects minor skin irritation associated with diaper rash and helps seal out wetness. Warnings: ... Do not use on deep or puncture wounds ... Stop use and ask doctor if condition worsens or symptoms last more that 7 days ..." m. On 12/19/14 at 7:35 a.m., LPN # 11 stated she worked the 7:00 p.m. to 7:00 a.m. shift. LPN # 11 was asked, "Do you know (Resident # 7)?" LPN # 11 stated "Yes". LPN # 11 was asked "Does she have a pressure ulcer?" LPN # 11 stated, "Yes on her bottom." LPN # 11 was asked, "Before yesterday what did you do for the pressure ulcer?" LPN # 11 stated, "Monitored for turning, she wiggles a lot. You can turn her then go back and she's on her back." LPN # 11 was asked, "Did you put a pillow or wedge to her back?" LPN # 11 stated, "No." LPN # 11 was asked ,"Which CNA usually works with the resident on 11:00 p.m. to 7:00 a.m. shift?" LPN # 11 stated, "Every night it's different." LPN # 11 was asked, "How long has she had a dressing?" LPN # 11 stated, "Not since she's been here, I'm not sure how long she's been her or when the dressing started." LPN # 11 was asked, "What was used on her bottom before the dressing?" LPN # 11 stated, "Barrier cream. But it wasn't open as much as it is now." LPN # 11 was asked, "Who put the cream on?" LPN # 11 stated, "We did every clean up." LPN # 11 was asked "You or the CNAs?" LPN # 11 stated, "Both." n. On 12/19/14 at 2:45 p.m., the Director of Nurses (DON) was asked, "For (Resident # 7) has a review of measurements of wounds been done?" The DON stated, "Yes, in weekly wound meetings." The DON was shown the pressure ulcer record for Resident # 7. The DON was asked, "Have you seen these measurements previously?" The DON stated, "Not until 12/9/14. I'm not included on that QA (Quality Assurance) meeting. It was led by a former wound care nurse and I was told not to attend by the Administrator." The DON was aske,d "When you saw the measurements what did you direct to be done?" The DON stated, "To put on a low air loss mattress. I wanted to know what the treatment was. I told them to call the doctor because the treatment wasn't working to see what they wanted to do." The DON was asked, "Did you follow up to see what was done?" The DON stated, "I talked with (Treatment Nurse # 1) and she said the mattress had been put on and she'd get the doctor to look at the wound on Friday (12/12/14)." The DON was asked, "Did the doctor see the wound?" The DON stated, "I don't know." The DON was asked, "When should staff have applied the low air loss mattress?" The DON stated, "On 11/17/14 when it looked like there was a deep tissue injury." The DON was asked, "On the measurements done 11/24/14. Your treatment nurse told me the 3 x 3 measurement was only the open area. Should she have measured all other area, including the surrounding red purple area?" The DON stated, "Yes, she could have done a better job with descriptions and measurements." The DON was asked, "Did you know that prior to the doctor order dated 12/1/14 that barrier cream was used when the wound opened on 11/24/14?" The DON stated, "No and it shouldn't have been."

Complaint # was substantiated (all or in part) with these findings: Based on record review and interview, the facility failed to ensure Resident #2 received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was initiated for a resident who was found unresponsive and failed to ensure advance directive code status was readily accessible and accurate for 1(Resident #2) of 2 (Residents #2 and #5) case mix residents who were a Full Code status. The failed practice resulted in Immediate Jeopardy, which likely caused or could have caused serious harm, injury or death, for Resident #2 who was found unresponsive, without breath sounds or heart rate and had the potential to cause more than minimal harm for 69 other residents who had a full code status according to a list provided by the Administrator on [DATE] at 9:20 a.m. The immediate jeopardy was removed by the facility on [DATE] prior to entrance date of the survey, however, the underlying deficient practices were not fully corrected. The facility was notified of the Immediate Jeopardy removed on [DATE] at 4:30 p.m. The findings are: 1. The facility's Cardiopulmonary Resuscitation (CPR) Policy and Procedure dated [DATE] documented, "CPR is initiated to support the ventilation and circulation function until: aid arrives and the resident is placed on advanced life support systems; he/she is stimulated to function on his/her own; and/or he/she is pronounced dead. CPR is initiated on all residents except those with a 'no code' order and appropriate documentation..." The Admission Data Collection Policy and Procedure dated [DATE] documented, "Upon admission and/or readmission to the facility, the nurse in charge shall complete a Data Collection Form to facilitate the beginning and/or revisions of the plan of care. The resident should be greeted upon arrival to the facility and the admissions procedures completed as soon as possible... If a 'no code' order is requested, be sure that you have all appropriate documentation. If not, notify Social Services or the DON." 2. Resident #2 had [DIAGNOSES REDACTED]. The 5 day Medicare Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 14 (,[DATE] indicates cognitively intact) on the Brief Interview for Mental Status and required extensive assistance with most activities of daily living. a. The resident ' s DNR/CPR (Do not Resuscitation/Cardiopulmonary Resuscitation) Instructions form dated [DATE] documented, "I want cardiopulmonary resuscitation to be provided in the event I have a cardiac or respiratory arrest." b. A Nurse's Note dated [DATE] at 10:00 a.m. documented, "Observed resting in bed with eyes opened. Respirations even, labored. SpO2 (Oxygen Saturation) 97%, pallor noted. Reports 'don't feel good.' RN (Registered Nurse) supervisor notified. B/P ,[DATE], T 97.2, R 24, P 57. RN supervisor assesses client. T/O (telephone order) received from (Advanced Practice Nurse), transfer to (hospital) for eval of resp distress..." c. The Hospital Transfer Report dated [DATE] documented, " Problem List as of [DATE] Resolved Pneumonia ...Resolved [MEDICAL CONDITION] ...Resolved Dehydration ...Pleural Effusion ...Date Reviewed [DATE] ...[DIAGNOSES REDACTED] ...Date Reviewed [DATE] ... " The Admission physician's orders [REDACTED]. The Sheet documented d. The Admission Care Plan dated [DATE] documented, "End of Life Care." This section was left blank. e. A Nurse's Note dated [DATE] at 5:40 a.m., and signed by Licensed Practical Nurse (LPN) #1 documented, "Summoned to room [ROOM NUMBER] by CNA (Certified Nurse Assistant). Entered room and found resident unresponsive without any vitals. No pulse, no respirations, no evidence of breathing for approximately one minute. No lung sounds for more than a minute. Resident was last by this nurse at 0230 (2:30 a.m.). Resident was responsive, alert, no distress. Noted O2 at 2L/min (liters per minute) per nasal cannula. This nurse changed tubing and water bottle at this time. Notified DON (Director of Nursing) at 0550 (5:50 a.m.)... Coroner notified at 0601 (6:01 a.m.)..." 1) The Division of Medical Services form 762, Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property & Exploitation of Residents in Long term Care Facilities dated [DATE] documented, "On [DATE] at approximately 5:40 a.m., CNA reported to charge nurse that female resident (Resident #2) was found unresponsive. The charge nurse immediately came and assessed (Resident #2) noting no vitals, no pulse and respiration was zero for one minute. The charge nurse notified the DON, physician and family. Charge nurse reported checking on (Resident #2) at approximately 2:30 a.m. that morning. Charge nurse did not call 911 or start CPR. (Resident #2) had a full code status. On [DATE] at approximately 9:30 a.m., the DON informed the Administrator the code status of (Resident #2). DON identified the charge nurse and was instructed to contact her and to return to the facility for interview. She arrived shortly thereafter and was interviewed... When asked by Administrator why she did not start CPR and call 911, she stated resident 'was gone'. When told that (Resident #2) was a Full Code, charge nurse stated 'I didn't know. It was not in the chart.' When asked about her nursing training according to the Nurse Practice Act, she stated she should have started a code and called 911. She provided a written statement and was informed by the Administrator of her suspension pending the outcome of this investigation... This investigation determined the charge nurse failed to initiate CPR on a non-responsive resident. The charge nurse was terminated on [DATE] by Administrator..." 2) A witness statement written by LPN #1 documented, "CNA summoned this nurse to room [ROOM NUMBER]. Upon entering room, resident unresponsive to verbal stimuli. O2 at 2L/min via nasal cannula, no pulse for 1 minute, no respirations for 1 minute, pupils fixed, skin warm, face cool. No vital signs present. No lung sounds present. MD (Medical Doctor) on call notified. DON notified. Coroner notified. Family notified." As of [DATE] at 2:45 p.m., LPN #1 could not be reached for interview. 3) On [DATE] at 8:33 a.m., CNA #1 was asked about the morning of [DATE]. He stated, "I was making my morning rounds and found the resident in bed unresponsive. I went out and told my nurse." He was asked when he last saw the resident before that. He stated, "We do rounds at 1 and 3 so I saw her on my last round... probably around 3:30 a.m. She was fine then. I told her if she needed anything to use her call light." He was asked about when he found her unresponsive and if he touched the resident. He stated, "I did touch her, but I don't remember any details on how she was. When I realized something was wrong, I went and got the nurse." f. On [DATE] at 11:35 a.m., the Administrator was asked during an interview about the incident on [DATE]. He stated, "The resident was initially on the 2nd floor when she came in. She went out to the hospital and when she came back she was on the 3rd floor. On readmission, the receiving nurse couldn't find the first chart so she started a second chart." The Administrator was asked where the first chart was located. He stated, "It was in the rack on the 2nd floor." The Administrator was asked if it would have been the responsibility of the admitting nurse to ensure the code status information was in the new chart. He stated, "Yes." The Administrator was asked if the admitting nurse contacted anyone about the code status of the resident on readmission. He stated, "I'm not sure." g. On [DATE] at 1:20 p.m., LPN #2 was asked what was involved with the admissions process. She stated, "We fill out a whole packet. Several pages. It has things like leave of absence form, vital signs form, nurse's notes, temporary care plan, progress notes..." She was asked about Advanced Directives and Code status forms. She stated, "The other admission people do that paperwork. That's not in the admission packet that I do. They do that paperwork with the family when the resident comes in." She was asked if the code status form was in Resident #2's chart on readmission. She stated, "I do so many admissions... I just can't remember. And I couldn't find her other chart. If there is no information in the chart to tell the nurse a resident's code status, then they are considered a full code. I do my part and then they may come after me and put their stuff in it." She was asked if she realized the resident's code status would not be in the chart over the weekend. She stated, "No. They are the ones who take care of that. If that information is not in the chart, I leave that section blank on the order sheet." She was asked what has changed since the incident with Resident #2 that would prevent this from happening again. She stated, "They are making sure the code status is in the chart on admission. Before it would be hit and miss on whether it would be in there or not. And I also know now that if the information isn't there, I will find out when I am doing the admission." h. On [DATE] at 1:53 p.m., the Admissions Director was asked about what was involved in the admissions process. He stated, "We make sure the admit packet is filled out... that includes the rights and obligations. I go over the policies and procedures and what's to be expected... The papers I fill out go into a file, but there are a few pieces that stay in the chart. The code status sheet is one of them. One of our steps in the admission process is to make sure code status is in there along with a face sheet." The Admissions Director was asked about the incident involving Resident #2 and why the code status was not in the readmission chart. He stated, "The admitting nurse needs to find out about that resident's code status if it's not there. It was in her other chart. The admitting nurse should never walk away from a chart until code status is in it. She could call somebody.... she could've called me. It was complacency on her part." He was asked what would happen if a resident is admitted on the weekends or after hours. He stated, "It happens a lot. If the admissions nurse isn't here, I come in and take care of it. I and another person take turns." 3. The Immediate Jeopardy was removed on [DATE] prior to the survey entrance date and the scope/severity was reduced to G when the facility implemented the following corrective actions: a. DMS-7734 and DMS-762 completed and sent to the Office of Long Term Care. b. The LPN involved was interviewed by the Administrator and RNC, a witness statement was obtained and one on one education was conducted. The nurse was immediately suspended pending the outcome of the investigation and was terminated on [DATE]. c. Inservicing for all nurses began on [DATE] on the code blue policy, with nurses being inserviced before providing care. d. All charts were audited for advanced directives and current code status orders. e. Care plans and CNA care cards were audited for code status and any discrepancies were corrected. 4. The survey team performed random chart audits to check for code status and no problems were noted. Nurses were interviewed and asked what they would do if they found a resident unresponsive, without vital signs and code status could not be located. They all stated they would initiate CPR. The admissions nurse verbalized the importance of having a resident's code status readily available. On [DATE] at 2:45 p.m., the facility's Regional Nurse Consultant (RNC) was asked what steps the facility had implemented to prevent recurrences. She provided documentation to indicate the facility had identified the failed practice and had initiated corrective action. The RNC was asked what system the facility had in place to ensure a resident's code status was readily available to staff. She stated, "Medical records does a daily audit on admissions and readmissions Monday through Friday to ensure the code status is there." She provided a check list that documented this. She was asked about the weekends and who was responsible for checking then, since the incident involving (Resident #2) happened early on a Monday morning. She did not respond.

Complaints # and # were substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure necessary treatment and services were provided to prevent deterioration and promote healing of pressure ulcers for Residents #1, #2 and #3. The facility failed to ensure clean technique was maintained during wound care to prevent potential infection 2 (Resident #s 1 and 3) of 4 (Resident #s 1, 2, 3, and 4) case mix residents who had physician orders for pressure ulcer treatments; The facility failed to ensure pressure ulcer treatments were provided as ordered by the physician to promote healing for 1 (Resident # 1) of 4 (Resident #s 1, 2, 3, and 4) case mix residents who had physician orders for pressure ulcer treatments; The facility failed to ensure dressings and positioning devices were applied properly to avoid causing increased pressure to the wound bed of an existing pressure ulcer, which could result in deterioration or delayed healing for 1 (Resident # 1) of 4 (Resident #s 1, 2, 3, and 4) case mix residents who had pressure ulcers. The facility failed to ensure specialty mattress coverings/sheets were used in accordance with the manufacturer's instructions to prevent unnecessary shearing/friction that could result in impaired skin integrity and increased risk for pressure ulcer development for 1 (Resident # 1) of 2 (Resident #s 1 and 3) case mix residents who had pressure ulcers and were on specialty beds. The facility failed to ensure the appropriate type of mattress was provided to decrease pressure for 1 (Residents # 2) of 3 (Resident #s 1, 2 and 3) case mix residents who had Stage III, Stage IV or unstageable pressure ulcers. The facility failed to ensure pressure ulcers were reassessed to include staging, measurements and wound description weekly and that the assessments were documented to assure prompt identification of any deterioration or failure to heal to prevent delays in changes to treatment for 3 (Resident #s 1, 2 and 3) of 4 (Resident #s 1, 2, 3, and 4) case mix residents who had pressure ulcers These failed practices resulted in a pattern of actual harm for Resident #1 who developed multiple pressure sores, Resident #2, whose pressure sore deteriorated, and Resident #3 who developed a Stage IV pressure sore. The failed practices also had the potential to cause more than minimal harm for 11 residents who had physician orders for pressure ulcer treatments, including 6 residents who had Stage III, Stage IV and/or unstageable pressure ulcers, according to lists received from the Administrator on 3/7/14. The findings are: 1. The facility's policy titled "Pressure Sore Prevention ABCs - Quick Look" documented, "...Pressure relieving... Evaluate for pressure relieving mattress... Use pressure redistribution device/positioning device... Manage urinary/fecal incontinence - clean and protect every 1 - 2 hours. Keep resident dry at all times..." 2. On 3/7/14 at 3:05 p.m., the Nurse Consultant provided the following, from Best Practices Evidence-Based Nursing Procedures. 2nd edition (ed.) Lippincott Williams & Wilkins, 2007, pages 527-529, as the facility policy on wound care for pressure ulcers: "Pressure ulcer care... Successful pressure ulcer treatment involves relieving pressure... Although many systems have been developed to help classify or 'stage' wounds, the system that the Agency for Healthcare Research and Quality the Wound, Ostomy and Continence Nurses Society (WOCN) recommend is a four-stage system based on the tissue layers involved ... Treatment includes methods to decrease pressure... Treatment may involve special pressure-reducing devices, such as beds, mattresses... Other therapeutic measures include decreasing risk factors and use of topical treatments, wound cleansing, debridement, and the use of dressings to support moist wound healing... The WOCN suggests using clean gloves for wound cleaning and routine dressing changes... Nurses usually perform or coordinate treatments, according to facility policy. The procedures detailed below address cleaning and dressing the pressure ulcer... Equipment: ...piston irrigating system... Implementation: ...Before a dressing change, wash your hands... Cleaning the pressure ulcer... Position the patient to increase his comfort, but make sure his position allows easy access to the pressure ulcer site... Open the normal saline solution container and the piston syringe. Carefully pour normal saline solution into an irrigation container to avoid splashing... Put on gloves to remove the old dressing and expose the pressure ulcer. Discard the soiled dressing... Inspect the wound... Measure the wound perimeter with the disposable wound-measuring device. Using the piston syringe, apply full force to irrigate the pressure ulcer to remove necrotic debris. Remove and discard your soiled gloves and put on fresh pair. Insert sterile cotton swab into the wound to assess wound tunneling or undermining ... Prepare to apply the appropriate topical dressing ... Assessing pressure ulcers (page 528) ... Keep in mind that if the wound contains necrotic tissue, you won't be able to determine the stage until you can see the wound base..." 3. Resident #1 had [DIAGNOSES REDACTED]. The Admission Data Collection Form dated 8/12/13 documented the resident had an open area above the left outer ankle and redness to the inner left foot at the great toe area. The Risk for Pressure Ulcer form documented a total score of 15, with a score of 13 to 14 indicating a moderate risk for pressure ulcer development. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/13 documented the resident scored 8 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status, was totally dependent for bed mobility and toilet use, was always incontinent of urine and bowel, was at risk for pressure ulcers, had one or more unhealed pressure ulcers, had 2 Stage 1 pressure ulcers, had 1 Stage 2 pressure ulcer, had 1 Stage 3 pressure ulcer that was 2.5 cm (centimeters) in length, 0.3 cm in width, and 0.2 cm deep, had 1 worsening Stage 2 and 1 worsening Stage 3 pressure ulcers, and no venous and arterial ulcers. a. The Care Plan dated as initiated on 8/12/13 and updated on 2/28/14 documented, "(Resident # 1) has an alteration in his skin integrity (due to) presence of a Stage 2 pressure ulcer to his (left) outer ankle on admit (post) [MEDICAL CONDITION] needs extensive to total assist with bed mobility, toileting... (incontinent) of bowel and bladder... (2/7/14) to wound clinic care for (evaluation and (prescription)/order. (2/11/14) Now cleaning all wounds (with) 1/4th (strength) Dakin's (solution) applying (nickel) size thickness (Santyl) (cover) (with) moist dressing (and) dry dressing/Kerlix. 2/14/13 Prostat... 2/28/14 (Resident) (with) Pressure sores - heels, feet, sacrum ... Interventions: 1. Turn (every) 2 (hours) side to side. (Note) family refuses back. 2. (Elevate) feet on pillows so no area that has (dressing) touches bed. Air mattress..." b. The February 2014 Physician Orders documented, " Start Date: 1/29/14 ...Glucerna 1.5 (cubic centimeters) per PEG (percutaneous endoscopic gastrostomy) via continuous pump at 60 ml/hr (milliliters per hour) ...Anorexia ... " c. Measurements of the pressure ulcer to the resident's coccyx and interventions were documented in various parts of the clinical record as follows: 1) Care Plan: "10/13/13: coccyx 3.0 x (by) 3.0 by 0.2... 10/17/13: Hospital. 10/21/13: coccyx: 4.5 x 3.0 x 0.3 (IV (Stage 4)) (deteriorated) while (at) (hospital)..." 2) The wound clinic Patient Wound Care Order Sheet and Wound Care Skin Integrity Evaluation sheets documented wound care from 11/8/13 thru 12/4/13. The Wound assessment dated [DATE] documented, " ...Coccyx ...Full Thickness ...Pressure Ulcer Stage III ... Length x (by) Width: 2.40 X 0.80 ... Depth: (less than) .020 ...100% granulation ... " The Pressure Ulcer Record documented weekly wound measurements from 12/2/13 through 12/23/13. The 12/23/13 measurements were documented as, "...Length x (by) Width: 4.5 x 2.8. Depth: UTD (unable to determine)..." 3) Care Plan: Measurements and stages were noted weekly on the care plan until 1/30/14. The 1/30/14 coccyx wound measurement was documented as "1.4 x 3.0 x (less than) 0.2" 4) Physician ' s orders dated 2/7/14 documented, " To wound clinic care for evaluation of wounds ... " On 3/6/14 at 2:30 p.m. the Administrator was asked to provide wound clinic documentation and measurements for Resident #1. As of 3/7/14 at 4:30 p.m. on exit, no additional wound clinic documentation other than records dated 11/18/13 and 12/4/13, which were located in the clinical record, were received. 5) Physician ' s Orders dated 2/11/14 documented, " ...Vitamin C 500 mg (milligrams) qd (every day) per tube. Zinc 220 mg qd x (times) 2 wks (weeks) per tube ... " Physician ' s Orders dated 2/14/14 documented, " Prostat (protein supplement) 30 cc (cubic centimeters) Bid (twice daily) per tube. Dx (diagnosis) [MEDICATION NAME]. " Physician ' s Orders dated 2/21/14 documented, " ...Foley cath (urinary catheter) to BSD (bedside drainage) ... " 6) The Pressure Ulcer Record dated 3/4/14 documented, "...Stage: Unstageable. Length x Width: 2.0 x 0.6. Depth: UTD... 90% slough, 10% granulation." 7) Physician Orders dated 3/6/14 increased the Glucerna 1.5 (cubic centimeters) per PEG from 60 cc to 65 cc. d. The following measurements were documented in various sections of the clinical record for the left 5th metatarsal: 1) Care Plan: "1/30/14: (left) 5th metatarsal 0.3 x 0.3 x (less than) 0.2". There was no stage specified. 2) The Pressure Ulcer Record documented wound measurements beginning 1/27/14 through 2/4/14. The 2/4/14 measurements were documented as, "Resolved." e. The following measurements were documented for the pressure ulcer proximal to the left 5th toe: 1) Care Plan: "1/30/14: Proximal (left) 5th toe 0.4 x 0.4 x (less than) 0.2". There was no stage specified. 2) The Pressure Ulcer Record documented wound measurements beginning 1/27/14 through 2/17/14. The 2/17/14 measurements were documented as, "...Length x Width: 0.3 x 0.3. Depth: (less than) 0.2..." 3) The Pressure Ulcer Record dated 3/6/14 documented, "...Stage: II. Length x Width: 0.4 x 0.2 Depth: 0." f. The following measurements were documented for the left foot: 1) Care Plan: "1/30/14: (Left) foot 2.0 x 2.0 x (less than) 0.2." There was no stage specified. 2) There were no other measurements available for review regarding this pressure ulcer. g. The following measurements were documented for the pressure ulcer on the right lateral edge of foot: 1) Care Plan: "1/30/14: Proximal (right) toe 0.6 x 0.4 x (less than) 0.2." There was no stage specified. 2) The Pressure Ulcer Record dated 3/4/14 documented, "...Stage: Unstageable. Length x Width: 1.0 x 1.0 Depth: UTD ... 100% slough ... Santyl." h. The following measurements were documented for the pressure ulcer on the right great toe: The Pressure Ulcer Record dated 3/4/14 documented, "...Stage: Unstageable. Length x Width: 0.7 x 0.8 Depth: UTD... Reabsorbed blood blister." i. The following measurements were documented for the pressure ulcer proximal to the right 5th toe: 1) Care Plan: "1/30/14: (Right) 5th (metatarsal) 0.4 x 0.4 x (less than) 0.2." There was no stage specified. 2) The Pressure Ulcer Record documented wound measurements beginning 12/9/13 through 2/17/14. The 2/17/14 measurements were documented as "...Length x Width: 0.4 x 0.8. Depth: UTD. SDTI (Suspect Deep Tissue Injury)..." j. The following measurements were documented for the pressure ulcer proximal to the right 5th toe: The Pressure Ulcer Record documented wound measurements beginning 1/27/14 through 2/17/14. The 2/17/14 measurements were documented as, "...Stage: SDTI. Length x Width: 2.0 x 2.0 . Depth: UTD." There were no further measurements available for review for this pressure ulcer, as of 3/7/14 at 4:30 p.m. During wound care observations on 3/5/14, there were two wounds to the right lateral foot; one was just below the small toe and the other was mid lateral foot. k. The following measurements were documented for the pressure ulcer on the right medial heel: The Pressure Ulcer Record dated 3/4/14 documented, "...Stage: Unstageable. Length x Width: 2.1 x 1.7 Depth: UTD... 100% re-absorbing blood blister." l. The following measurements were documented for the right inner ankle: 1) Care Plan: "1/30/14: (Right) ankle 0.6 x 1.0 x UTD." There was no stage specified. 2) The Pressure Ulcer Record documented wound measurements beginning 1/6/14 through 2/17/14. The 2/17/14 measurements were documented as, "...Length x Width: 0.8 x 0.7. Depth: UTD. SDTI. " 3) The Pressure Ulcer Record dated 3/4/14 documented, "...Stage: Unstageable. Length x Width: 0.5 x 1.0 Depth: UTD ... 100% Slough. Santyl." m. The clinical record (Physician Orders, Care Plan, Wound Clinic Evaluations, and Pressure Ulcer records) was reviewed on 3/5/14 and there were documented changes in wound care orders on 10/21/13, 10/23/13, 1/3/14, 1/27/14, 2/11/14, 2/25/14 and 3/4/14. n. On 3/5/14 at 9:05 a.m. Restorative Nurses Assistant (RNA) # 1, Certified Nurses Assistants (CNAs) # 7 and # 8 were present in the room. RNA # 1 was completing passive range of motion. The resident had dressings on his bilateral feet dated 3/4/14. The dressings were not covering the resident's bilateral inner ankle wounds. The wounds were covered with gauze wrapped in a figure 8 around the ankles and foot. The left inner ankle had gauze and 4 x (by) 4 dressings that were soiled with bright red serous drainage approximately 1/2 centimeter long and 3 centimeters wide. Serous red drainage was noted on the pillow case, which RNA # 1 removed from between the resident's legs. The wound on the inner left ankle was approximately the size of a quarter with slough/eschar covering part of the wound bed. A small amount of blood was noted in the wound bed. The right inner ankle wound was approximately the size of a dime with a scab/slough/eschar covering the wound bed. The peri wound area was red. There was a purple area approximately the size of a half dollar on the right inner heel area. RNA # 1 and CNAs # 7 and 8 positioned the resident using a foam wedge and 2 pillows between the posterior thighs and calves. The resident's heels were off the bed. RNA # 1 and CNAs # 7 and 8 put a pillow between the resident ' s legs that extended above the resident's knees and past the resident's ankles and heels. The resident was then turned onto the left side with his inner ankles at the same area, covered by and resting on the pillow that was between his legs. The resident was on a DermaFloat LAL (Low Air Loss) mattress. There was a flannel blanket folded into fourths noted under the resident from the mid back/flank area to the mid thigh area. The User-Service Manual for the DermaFloat LAL mattress documented, "...Recommended Linen: Special linens are not necessary for the DermaFloat LAL. There is no need for a bottom sheet as the therapy pad should be covering the therapy cells at all times... Based upon the resident specific needs, the following linens may be utilized: Draw or slide sheet to aid in positioning and to further minimize friction and shearing ... Keep the amount of padding between the resident and bed to a minimum for optimum performance..." o. On 3/5/14 at 11:15 a.m., CNAs # 2, #7 and # 8 went into the resident's room with incontinent supplies. The CNAs removed the top covers and the resident was lying on a flannel bath blanket folded into fourths. The resident was positioned on his back and CNA # 8 provided incontinent care after the resident's brief was lowered on the front. CNA # 8 left the room to get the resident's Charge Nurse. The Charge Nurse, Licensed Practical Nurse (LPN) # 6 entered the room and paused the tube feeding pump. The head of the bed was lowered. The resident was turned back onto his left side and the brief was opened on the back. The resident was incontinent of stool. CNA # 8 wiped the stool upward toward the dressing but stopped prior to the edge of the dressing on the coccyx. The lower edge of the dressing was loose and there was a brown substance noted on the outside and inside edges of the dressing. LPN # 6 stated "I need to get the Treatment Nurse in to change the dressing, it's coming off. " LPN # 6 sent CNA # 8 to get the Treatment Nurse. CNA # 8 removed the soiled dressing and completed incontinent care. A clean brief and draw sheet were placed under the resident. p. On 3/5/14 at 11:30 a.m., Treatment Nurses # 1 and # 3 entered the resident's room. Treatment Nurse # 1 cleaned the wound with a 4 x 4 sprayed with wound cleanser and repeatedly patted the coccyx wound with the same area of the 4 x 4. Treatment Nurse # 1 dried the wound with a dry 4 x 4 in the same manner as it was cleaned. Treatment Nurse # 1 noted the dressings on the resident's feet were not covering the wounds. Treatment Nurse # 1 stated, "I need to do wound care to his feet." After removing her gloves and picking up trash, Treatment Nurse # 1 washed her hands, picked up the tray used as a clean field and went to the treatment cart. At 12:11 p.m., Treatment Nurse # 1 placed a new paper towel on the tray used for a clean field. Treatment Nurse # 1 placed a medication cup with Santyl ointment, multiple dry 4 x 4's, multiple packets of q-tips, a cup with 4 x 4 over which Dakins 0.25% (1/4th) strength was poured. Treatment Nurse # 1 was wearing a spiral plastic bracelet with a key attached to the bracelet on her left wrist. As Treatment Nurse # 1 set up the supplies the key rubbed across the top of the TARs (Treatment Administration Record), the treatment cart, and against her uniform top. Treatment Nurse # 1 placed multiple packets of skin prep, 2 rolls of gauze and 1 packet of Duoderm Signal on the clean field. Treatment Nurse # 1 entered the resident's room and placed the tray on the resident's over bed table, then washed her hands. Treatment Nurse # 1 put gloves on and removed scissors from the right hand pocket on her uniform top. At 12:22 p.m., Treatment Nurse # 1 partially cut the dressing on the resident's right foot with the scissors. Treatment Nurse # 1 laid the scissors on the foot of the resident's bed and attempted to remove the dressing. Treatment Nurse # 1 partially cut the dressing 3 more times (total of 4 cuts), placing the scissors on the resident's bed after each partial cut and attempting to remove the dressing. After the fourth partial cut, Treatment Nurse # 1 was able to remove the dressing on the resident's right foot. At 12:25 p.m., Treatment Nurse # 1 cut the dressing on the left foot. As Treatment Nurse # 1 was cutting the dressing, the key on the spiral bracelet on her left wrist was rubbing against the resident's left shin area. Treatment Nurse # 1 removed the dressing from the left foot, laid the scissors on the paper on top of the bedside table and changed her gloves. At 12:30 p.m., Treatment Nurse # 1 measured all of the resident's wounds using a new measuring tape with each wound. The proximal wound on the lateral right foot was measured as 1.0 x 1.0 centimeters. Treatment Nurse # 1 stated this wound was "Unstageable." The distal wound of the lateral right foot by the toe was measured as 2.0 x 2.0 centimeters. Treatment Nurse # 1 stated this wound was "Unstageable." The wound by the great toe on the left foot was measured as 2.0 x 2.5 centimeters. The wound on the left inner ankle was measured as 2.0 x 2.0 centimeters. The wound on the inner right ankle was measured as 1.0 x 1.0 centimeters. The purple area on the inner right heel area was measured as 2.0 x 2.0 centimeters. Treatment Nurse # 1 changed gloves, held the Treatment Administration Records (TARs) in her hands and reviewed the ordered treatments. Treatment Nurse # 1 used a 4 x 4 with Dakin's solution on it to clean the distal wound on the right lateral foot wearing the same gloves she had on while holding the TARs. Treatment Nurse # 1 patted the wound repeatedly using the same area of the 4 x 4. Treatment Nurse # 1 cleaned the distal wound on the right lateral foot again with another 4 x 4 with Dakin's solution, again patting the wound bed repeatedly using the same area of the 4 x 4. Treatment Nurse # 1 patted the wounds dry with a different 4 x 4 for each wound in the same manner that she cleaned the wounds. Treatment Nurse # 1 used a q-tip to get Santyl from the medicine cup, then applied Santyl to the wound bed to the distal wound on the right lateral foot. Treatment Nurse # 1 used the same q-tip to get more Santyl from the medicine cup (possible cross contamination of Santyl) and applied Santyl to wound bed of the proximal wound on the right lateral foot. Treatment Nurse # 1 changed gloves, used a 4 x 4 with Dakin's solution to clean the right inner ankle wound. Treatment Nurse # 1 held the resident's right leg up off the mattress with her left hand and cleaned the wound on the inner right ankle. As Treatment Nurse # 1 was holding the leg up, the key on the spiral bracelet on her left wrist was touching the wound on the inner left ankle. Treatment Nurse # 1 patted the wound with the 4 x 4 with Dakin's solution repeatedly with the same area of the 4 x 4. Treatment Nurse # 1 laid the resident ' s right leg down and the area that was just cleaned was against the mattress. Treatment Nurse # 1 picked the right leg back up and patted the wound with a dry 4 x 4 repeatedly using the same area of the 4 x 4. Treatment Nurse # 1 laid the leg back down with the wound on the right inner ankle touching the mattress. Treatment Nurse # 1 used a clean q-tip to get Santyl from the contaminated medicine cup, lifted the right leg up and applied Santyl to the wound bed. Treatment Nurse # 1 laid the right leg down with the wound on the inner right ankle against the mattress. Treatment Nurse # 1 folded three 4 x 4's into fourths and placed a 4 x 4 on the wounds on the right lateral foot. Treatment Nurse # 2 then held the 4 x 4's in place as Treatment Nurse # 1 put a folded 4 x 4 on the right inner ankle wound and wrapped the foot with gauze. Using a folded 4 x 4, instead of a flat 4x4 over a larger surface area could potentially cause increased pressure to the wound bed. Both Treatment Nurses changed gloves. Treatment Nurse # 1 applied tape to the dressing on the right foot and dated the dressing. Treatment Nurse # 1 changed gloves and used 4 x 4 with Dakin's solution to clean the wound on the right foot by the great toe area. Treatment Nurse # 1 patted the wound repeatedly using the same area of the 4 x 4. Treatment Nurse # 1 used a dry 4 x 4 to dry the wound by repeatedly patting with the same area of the 4 x 4. Treatment Nurse # 1 opened a q-tip, removed Santyl from the contaminated medicine cup and applied the Santyl to the wound bed. Treatment Nurse # 1 used a 4 x 4 with Dakin's solution to clean the left inner ankle wound by repeatedly patting the wound bed with the same area of the 4 x 4. Treatment Nurse # 1 patted the inner left ankle wound dry with a 4 x 4, patting repeatedly with the same area of the 4 x 4. Treatment Nurse # 1 used a clean q-tip to get Santyl from the contaminated medicine cup and applied the Santyl to the wound bed on the inner left ankle. Treatment Nurse # 1 folded two 4 x 4s into fourths and put the folded 4 x 4 onto each wound on the right foot. Treatment Nurse # 1 wrapped the foot with gauze in a figure 8 wrap using multiple layers over the ankle area to hold the folded 4 x 4 onto the wound bed. Treatment Nurse # 1 applied 3 pieces of tape across the ankle area covering the gauze and extending onto the skin surrounding the ankle "to hold it in place." Treatment Nurse # 1 removed her gloves. Treatment Nurse # 1 wore the same gloves throughout the wound care of both wounds on the right foot. At 1:00 p.m., this surveyor left the room. Treatment Nurse # 1 did not use the Duoderm that was set up on the clean field. Treatment Nurse # 1 failed to follow the orders for wound care on the lateral left 5th toe area, the right heel, the top of the left foot, the inner left ankle, and the inner right ankle. 1) Physician orders dated 3/4/14 documented "(1). Cleanse wound to (right) foot (with) wound cleanser, pat dry. Apply Santyl to wounds. Cover (with) dry (dressing), secure (with) roll gauze (and) tape. (Change) daily. 2. Cleanse wound to (left) foot (with) (wound cleanser), pat dry. Apply Santyl to wounds. Cover (with) dry (dressing), secure (with) roll gauze (and) tape. Change daily. 3. Cleanse sacral wound (with) (wound cleanser). Apply [MEDICATION NAME] (dressings) to cover, (change) (every) 72 (hours)..." Physician Orders dated 2/25/14 documented, " ...(change) tx (treatment) order to L (left) inner ankle to cleanse L inner ankle (with) ? strength dakins apply Santyl (and) Calcium AG (silver) dsg (dressing) cover (with) dry dsg QOD (every other day) (and) prn (as necessary) ...NO (new order) Apply skin prep to blister lateral L 5th toe area (and) cover (with) duoderm for protection Q (every) 3 days (and) prn ... " The March TAR did not document the physician orders dated 3/4/14. The March TAR was copied on 3/5/14 at 4:20 p.m. Treatment Nurse # 1 had not initialed the treatments that were observed from 11:30 a.m. to 1:00 p.m. 2) On 3/7/14 at 11: 20 a.m. Treatment Nurse # 1 was asked, "Should open wounds touch the bedding?" Treatment Nurse # 1 stated "Never. The whole problem is with the aides not keeping him turned and his feet off the bed. He is not positioned like he should be, even after inservices." Treatment Nurse # 1 was asked, "What should happen if wounds touch the bedding, etc.?" Treatment Nurse # 1 stated, "It should be recleaned." Treatment Nurse # 1 was asked "Did anyone notify you the resident's wounds were exposed 3/5/14 at 8:40 a.m.?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "What if the wound with Santyl touches the bed?" Treatment Nurse # 1 stated, "Reclean and reapply." Treatment Nurse # 1 was asked, "If you fold a 4 x 4 into fourths, place it on the wound, and wrap it with gauze what would it cause to the wound bed?" Treatment Nurse # 1 stated, "Causes more pressure." Treatment Nurse # 1 was asked, "Why did you fold the 4 x 4s on (Resident # 1's) wounds?" Treatment Nurse # 1 stated, "That's what the other lady did." Treatment Nurse # 1 was asked, "Who?" Treatment Nurse # 1 stated "(Wound Care Specialist)." Treatment Nurse # 1 was asked, "Did you realize the inner right ankle touched the bed during wound care on 3/5/14?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "What do you think is going on with (Resident # 1's) feet?" Treatment Nurse # 1 stated, "I think he's never positioned like he should be because every time I go in there his feet aren't floated as ordered." Treatment Nurse # 1 was asked, "Have you seen the wound care orders dated 3/4/14 on (Resident # 1)?" Treatment Nurse # 1 stated, "Yes, I wrote it." Treatment Nurse # 1 was asked, "What happened to this on the TAR, it's not there?" Treatment Nurse # 1 stated, "I wrote it on the TAR, a blank one. I don't know what happened to that one." Treatment Nurse # 1 was asked, "Did you see the orders on the TAR for the blisters on his feet?" Treatment Nurse # 1 stated, "Yes, but (Wound Care Specialist) that comes here specifically told me not to do that." Treatment Nurse # 1 was asked, "Did you put Calcium Silver dressing on the inner ankle?" Treatment Nurse # 1 stated "No." Treatment Nurse # 1 was asked, "Whose responsibility is it to ensure the physician orders for wound care get transcribed to the TAR?" Treatment Nurse # 1 stated, "Mine, if I take it, but I'm sure I did it with (Wound Care Specialist) here and things are a mess, so I can hardly find the TAR books." Treatment Nurse # 1 was asked, "On the right foot of (Resident #1), he has multiple wounds, did you know you went from wound to wound with the same cleaning sponge?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "What happens when you go from one wound to the other wound like that?" Treatment Nurse # 1 stated, "It transfers microorganisms and increases the risk of infection." Treatment Nurse # 1 was asked, "When should you change gloves during wound care?" Treatment Nurse # 1 stated, "When entering, after removing dirty dressing, at each change of wound site and after care complete." Treatment Nurse # 1 was asked, "Did you realize you failed to change gloves at all during wound care to the right foot on (Resident # 1)?" Treatment Nurse # 1 stated, "No." Treatment Nurse # 1 was asked, "Tell me about the scissors you used." Treatment Nurse # 1 stated, "Should be cleaned before and after use." Treatment Nurse # 1 was asked, "Where should they be placed during use?" Treatment Nurse # 1 stated, "Somewhere away from other residents in a safe place." Treatment Nurse # 1 was asked, "When they were used in wound care on 3/5/14, you laid them in the bed. Where should they have been?" Treatment Nurse # 1 stated, "On a clean surface." Treatment Nurse # 1 was asked, "How much training have you had for wound care?" Treatment Nurse # 1 stated, "Not much; I've been here 6 weeks. (Wound Care Specialist) has spent some time with me; 3 or 4 times, and she stays maybe 4 hours at the most." 4. Resident # 2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/14 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status,was totally dependent for bed mobility, had no indwelling catheter, was always incontinent for urinary and bowel continence, was at risk for pressure ulcers, had one Stage 3 pressure ulcer with a length of 4.0 cm (centimeters), a width of 3.5 cm and a depth of 2.0 cm with the most severe tissue type of slough present in the ulcer bed. a. The care plan initiated on 1/23/14 documented "Focus: (Resident # 2) is at risk for skin breakdown and pressure ulcers (related to) incontinence, decrease mobility ... Interventions: ... Provide/monitor effectiveness of pressure relieving or reduction device(s): Pressure reduction mattress to bed ... Focus: (Resident # 2) is incontinent of bladder (related to) needed assistance with mobility, unsteady gait and transfers ... Interventions: ...Check her every two hours and provide incontinent care as needed..." b. The Pressure Ulcer Record dated 2/17/14 indicated a pressure ulcer on the coccyx ("x" drawn on coccyx area of the body diagram) and documented "Date First Observed: 2/17/14 on admission coccyx. Stage III. Size: 2.0 x (by) 1.5 x 2.8 (Length x Width x Depth) Date: 2/17/14. ... readmitted ." c. A physician order dated 3/4/14 documented, "1. (Discontinue previous border to sacral wound. 2. Cleanse sacral wound per protocol, pat dry, apply Santyl moistened (with) 4 x (by) 4's, cover (with) dry (dressing), (change) daily." d. The Pressure Ulcer Record dated 3/4/14 indicated a pressure ulcer on the coccyx ("x" drawn on coccyx area of the body diagram) and documented "Date: 3/4/14. Stage: Unstageable. Length x (by) Width: 3 x 2.5. Depth: UTD (Unable To Determine) ... 90% slough/10% hypogranulation." There were no other measurements documented other than the 2/17/14 measurements and the 3/4/14 measurements. e. On 3/4/14 at 4:15 p.m., the resident was not on a specialty mattress. On 3/5/14 at 8:35 a.m., 9:55 a.m., 10:30 a.m., 11:18 a.m., 1:00 p.m., 3:10 p.m. 4:45 p.m. and 6:05 p.m. and on 3/6/14 at 4:58 a.m., 7:25 a.m., 9:40 a.m., 12:05 p