Every finding on record at The Crossing at Riverside Health and Rehabilitatio

Based on observation and interview, the facility failed to ensure manufacturer instructions on food labels was followed; foods stored in the refrigerator was covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen; foods were dated the day received or opened to assure first in, first out usage to prevent potential for food bone illness; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 113 residents who received meals from the kitchen, (total census:115), as documented on a list provided by the Dietary Manager on [DATE] at 12:09 PM. The findings are: 1. On [DATE] at 10:01 AM, the following observations were made in the kitchen area: a. An opened bag of light brown sugar was on a shelf above the food preparation area. The bag was not sealed. There was no received or opened date on the bag. b. An opened bag of bread was on the counter. The bag was not sealed. 2. On [DATE] at 10:14 AM, Dietary Aide (DA) #1 picked up the water hose with his bare hand, used it to spray leftover food from inside of the dishes, contaminating his hands. He placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. DA #1 used a scraper to scrape off water on top of the utility cart. After the dishes stopped washing, he moved to the clean side of the dishwasher area and picked up clean dishes and placed them on the clean rack to be used in serving noon meal to the residents. The Surveyor asked DA #1 immediately what he should have done after touching dirty objects or before handling clean equipment. He stated, I should have washed my hands. 3. On [DATE] at10:21 AM, an opened bag of cocoa was on a rack in the storage room and was not sealed. 4. On [DATE] at10:27 AM, the following opened beverage containers were on top of the utility cart in the walk-in refrigerator. Their spouts were not covered, exposing them to cross contamination. a. Two pitchers of apple juice. b. A pitcher of cranberry juice. c. Two pitchers of orange juice. d. A pitcher of grape juice. 5. on [DATE] at 10:28 AM, the following observations were made in the walk-in freezer: a. An opened box of cookies. The box was not covered or sealed. b. An opened box of cheesy bread sticks. 6. On [DATE] at10:46 AM, an opened gallon of soy was on a shelf below the food preparation counter. The manufacturer specification on the gallon documented, Refrigerate after opening. 7. On [DATE] at 10:58 AM, an opened package of frozen waffles was on a shelf in the freezer in the dining room on the 300 Hall. The box was not covered, and the bag was not sealed. 8. On [DATE] at 11:08 AM, the following observations were made in the refrigerator on the 200 Hall: a. An opened resealable plastic bag that contained slices of lemon was on a shelf in the refrigerator. The bag was not sealed. b. A container of butter was on a shelf with an expiration date of [DATE]. c. A container of cottage cheese was on a shelf in the refrigerator with an expiration date of [DATE]. 9. On [DATE] at 12:11 PM, DA #2 wore gloves while untying the bread bag, then proceeded to place slices of bread on the pan without changing gloves and washing her hands. She added slices of cheese from the bag onto each slice of bread to prepare grilled cheese sandwiches for the residents who requested grill cheese sandwich with their noon meal. At 12:17 PM, the Surveyor asked DA #2, What should you have done after touching dirty objects and before handling food items and cleaning equipment? She stated, I should have changed gloves and washed my hands. 10. A facility policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices documented under employee must wash their hands.6. Employees must wash their hands: .c. Whenever entering or re-entering the kitchen. d. Before coming in contact with any food surfaces.h. After engaging in other activities that contaminate the hands .

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 8 residents who received meal trays in their rooms on the 100 Hall, 6 residents who received meal trays in their room on the 200 Hall, 13 residents who received meal trays on the 300 Hall, and 5 residents who received meal trays in their room on the 400 Hall, as documented on a list provided by Dietary Manager on 06/10/2024 at 12:09 PM. The findings are: 1. On 06/09/2024 at 10:40 AM, Resident #79 stated the food is never hot. 2. On 06/09/2024 at 1:27 PM, Resident #323 was sitting up in bed eating lunch. Family members were present. During an interview, Resident #323 said the resident had been here a week, and this was the first warm meal the resident had had, and that breakfast is always cold. Resident #323 also said, but this morning it was so cold the resident could not eat it at all. Resident #323 also said, the resident and the resident's family have complained about it to staff, and they (staff) informed them it's always cold when we get to the end of the hall. Resident #323 further said the resident's family member asked them if they could start at this end of the hall every other day and they stated no because then all the others will start complaining on the other end. 3. On 06/10/2024 at 7:52 AM, an unheated plate that contained a breakfast meal was on the counter by the steam table on the 400 hall dining room kitchenette. At 07:54 AM, as Nurse Aide #5 was about to deliver the tray to the room, the Surveyor asked Dietary Aide (DA) #3 to check the temperature of the food items. DA #3 did, and the temperatures were as follows: a. Scrambled eggs - 105 degrees Fahrenheit. b. Sausage links - 111.5 degrees Fahrenheit. 4. On 06/10/2024 at 12:43 AM, the Surveyor asked DA #3 to check the temperatures of food items on the last room tray on the counter by the steam table on the 300 hall dining room kitchenette. DA #3 did and the temperatures were as follows: a. Boneless chicken breast - 106.5 degrees Fahrenheit.

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 1 of 1 meal observed. This failed practice had the potential to affect 8 residents who received enhanced foods in the dining room on the 100 Hall, 6 residents who received meal trays in the dining room on the 200 Hall, 13 residents who received meal trays in the dining room on the 300 Hall, and 5 residents who received meal trays in the dining room on the 400 Hall, as documented on a list provided by the Dietary Manager 06/10/2024 at 12:08 PM. The findings are: 1. The menu for breakfast on 06/10/2024 documented the residents on enhanced food diets were to receive one cup of Super Cereal. 2. On 06/10/2024 at 07:40 AM, Dietary Aide (DA) #3 used a #8 scoop to serve a single portion of fortified oatmeal to the residents on fortified diets from the kitchenette on the 300 Hall. At 08:03 AM, the Surveyor asked DA #3 what scoop size she used to serve the fortified oatmeal and how many servings she gave to each resident. DA #3 stated, I used the gray scoop #8 (1/2 cup) and gave one serving each. 3. On 06/10/2024 at 07:46 AM, DA #4 used a #8 scoop to serve a single portion of fortified oatmeal to the residents on fortified diets from the kitchenette on the 400 Hall. At 08:00 AM, the Surveyor asked DA #4 what scoop size she used to serve the fortified oatmeal and how many servings she gave to each resident. DA #4 stated, I used the gray scoop #8 (1/2 cup) and gave one serving each. 4. On 06/10/2024 at 08:08 AM, DA #6 used a #8 scoop to serve a single portion of super cereal to the residents on enhanced food. At 08:09 AM, the Surveyor asked DA #6, who served the breakfast meal on the 200 Hall, what scoop size did she used to serve the fortified oatmeal and how many servings she gave to each resident. DA #6 stated, I used the gray scoop #8 (1/2 cup) and gave one serving each.

Based on observations, interviews, record reviews, and facility policy, the facility failed to provide appropriate treatment and services to prevent complications from enteral feedings for 1 (Resident #42) of 1 resident who was observed lying flat in bed when receiving a tube feeding. The findings are: On 06/10/2024 at 3:07 PM, the surveyor observed Resident #42 lying flat on their back in bed. The surveyor asked Licensed Practical Nurse (LPN) #8 to step into the room. LPN #8 stepped into the room and immediately gasped and immediately adjusted the head of bed (HOB) to 30 to 45 degrees. On 06/10/2024 at 3:08 PM, the surveyor conducted an interview with LPN #8. The surveyor asked LPN #8 what was the first thing you noticed about Resident #42 when you walked into the room. LPN 8 stated the head of the resident's bed was not elevated 30 to 40 degrees as it should be at all times. It was elevated earlier when I was in here, so the aides must have put [Resident #42] down to change them and did not elevate the HOB afterward. The surveyor asked why is that important. LPN #8 stated, so, she doesn't aspirate. She is on a continuous tube feeding. The surveyor asked, what is the tube feeding running at right now. LPN #8 stated, it is running at 35 milliliters per hour and 90 milliliter flush every 2 hours continuous. A review of Resident #42's Medication Administration Record (MAR) for 06/01/2024 to 06/30/2024 reflected Resident #42 was to receive an enteral feeding every day and night shift, with the HOB elevated 30 to 45 degrees at all times during feeding and for 1 Hour after feeding cessation. Order Date 09/25/2023. The surveyor reviewed the facility policy regarding Enteral Feedings-Safety Precautions, presented by the Administrator on 06/11/2024 at 9:30 AM. The policy stated, .Preventing Aspiration .Elevate the head of the bed (HOB) at least 30 [degrees] during tube feeding and at least 1 hour after feeding .

Based on observation, interview, and record review, the facility failed to ensure pureed food items were blended to a smooth and pudding-like texture to promote good nutritional intake and prevent potential choking for residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 4 (Residents #13, #15, #101 and #171) sampled residents who required pureed diets according to a list provided by the Administrator on 06/15/23 at 9:10 AM. The findings are: 1. On 06/12/23 at 12:30 PM, Resident #15 received a pureed meal tray. The pureed bread product remained in the shape of the scoop with ridges on the top. When the staff member inserted the spoon, the product remained whole and came away in a solid piece. 2. On 06/14/23 at 12:20 PM, Resident #3 received a pureed meal tray. Upon inserting his fork into the pureed bread, the resident lifted the entire bread product off the plate, brought it to his mouth and took a bite. 3. On 06/15/23 at 8:20 AM, the Surveyor asked the Registered Dietitian what the desired consistency of pureed bread should be. She stated, Like mashed potatoes or pudding. The Surveyor asked if a resident should be able to slice a pureed item or to insert their fork into the food item and raise the entire item off the plate. The Registered Dietitian stated, No, I will talk to them about that. She just needs to add some more warm milk. 4. A facility policy titled, Therapeutic Diets, provided by the Administrator on 06/15/23 at 9:10 AM documented, .4. A therapeutic diet is considered a diet ordered by a physician, practitioner or a dietitian as part of the treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: .c. Altered consistency diet. 5. If a mechanically altered diet is ordered, the provider will specify the texture modification .

Based on observation, record review, and interview, the facility failed to ensure posting of cautionary and safety signs for resident rooms indicating oxygen was in use for 2 (Residents #75 and #171) of 6 (Residents #40, #42, #75, #83, #171 and #174) sampled residents who used oxygen as documented on a list provided by the Administrator on 06/14/23 at 12:30 PM. The findings are: 1. Resident #75 had a diagnosis of Chronic Obstructive Pulmonary Disease. a. A Physicians Order dated 05/24/23 documented, Oxygen @ [at] 2L [liters] via NC [nasal Cannula] PRN [as needed] for SOB [Shortness of Breath]/Decreased Oxygen saturation. May remove for ADL's [Activities of Daily Living] and PRN per resident. Nursing to monitor oxygen flow rate every day and night shift Monitor for oxygen sign on door, if not present replace . b. The June 2023 Medication Administration Record (MAR) documented, Oxygen @ 2L via NC PRN for SOB/Decreased O2 SAT [saturation]. May remove for ADL'S and PRN per resident. Nursing to monitor oxygen flow rate every day and night shift Monitor for oxygen sign on door, if not present replace . 06/01/23 through 06/14/23 documented a nurse's initials indicating the residents use of oxygen daily. c. On 06/12/23 at 11:22 AM, Resident #75 was sitting in a wheelchair out in the hall with oxygen on via nasal cannula. The Surveyor was unable to locate an Oxygen in use sign on doorway to Resident #75's room. d. On 06/13/2023 at 8:00 AM, at the front entrance of nursing facility, the Surveyor was unable to locate signs indicating oxygen was in use in the Nursing Facility or a No Smoking Oxygen in use in the Nursing Facility posted at the front entrance of nursing facility. e. On 06/14/23 at 7:50 AM, Resident #75 was sitting in a wheelchair out in the hallway outside of the 400 Dining Room with oxygen on. No Oxygen in use signage was on doorway entrance to Resident #75's room. 2. Resident #171 had diagnoses of Chronic Respiratory Failure with Hypoxia and Dyspnea. a. A Physicians Order dated 05/12/23 documented, .Oxygen at 2L via NC PRN For SOB/Decreased O2 saturation. May remove for ADL's and PRN per Resident. Nursing to monitor oxygen flow rate every day and night shift Monitor for oxygen sign on door, if not present replace . b. On 06/12/23 at 11:32 AM, Resident #171 was in her room lying in bed wearing oxygen per nasal cannula. The Surveyor was unable to locate Oxygen in use signage on the doorway entrance to the room. c. On 06/13/23 at 9:15 AM, Resident #171 was moved to a new room on another hall and now shares a room with another resident. Resident #171 was receiving oxygen at 2 liters per minute via NC. The Surveyor was unable to locate oxygen in use signage on the door entrance to the room. d. On 06/14/23 at 8:09 AM, Resident #171 was in her room in bed with oxygen on at 2 liters per minute. No signage was on the door entrance to the room indicating oxygen was in use. 3. On 06/14/23 at 11:22 AM, the Surveyor asked Medication Tech #1 on the 400 Hall, Who is responsible for setting up the oxygen for the residents when it is ordered? She replied, That is the nurses, they do that. The Surveyor asked, Is it the nurse on all the halls that perform the setup of the oxygen in the resident's rooms when it is ordered? She replied, Yes, the nurse covering that hall is responsible for that. 4. On 06/14/23 at 11:35 AM, the Surveyor asked Assistant Director of Nursing (ADON) #2, Who is responsible for setting up the oxygen for the residents when it is ordered? She stated, The nurses are, they are responsible for setting up the concentrator, the tubing, the humidifier, dating the humidifier, the bag for storage and making sure the setting is correct per the orders. The Surveyor asked, Is there anything else that is needed for oxygen setup that should be done? She stated, Humidifier, administration device, concentrator, bag for storage and dating everything. The Surveyor asked, Who is responsible for the signage on the door to the resident's room when the resident is on oxygen? She stated, Oh yes, the nurse does that as well. I don't think it is on the check list for that, but I will get it added. The Surveyor asked, Is the oxygen sign stating, oxygen in use needed on the doorway to the resident's room when resident is on Oxygen? She stated, Yes, that should be done when it is set up. 5. A facility policy titled, Oxygen Administration, provided by the Administrator on 06/14/23 at 12:30 PM documented, .Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure: .4. No Smoking/Oxygen in Use signs . Steps in the Procedure .2. Place an Oxygen in Use sign on the outside of the room entrance door .

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained to rid the facility of pests. The failed practice had the potential to affect all 127 residents who resided in the facility, as documented on the Resident Census and Conditions of Residents provided by the Administrator on 06/13/23. The findings are: 1. On 06/12/23 at 10:30 AM, multiple flies were observed landing on the worktable, the can opener, and the top of the spice containers in the kitchen preparation area. 2. On 06/12/23 at 12:15 PM, during the lunch meal in the 300 Hall Dining Room, the Surveyor observed four flies in Dining Room area, landing on the first and second tables closest to the hallway. One resident was sitting at the first table and two residents were sitting at the second table. The Dining Room opened to the smoking area. There were no fans or any other preventative measures to keep flies from coming in when the doors were opened. 3. On 06/12/23 at 1:45 PM, Resident #1 was lying in bed, two flies were in the resident's room flying around the resident's bed and window area and landing on the bed. 4. On 06/13/23 at 9:43 AM, Resident #1 was in his room lying in bed, two flies were observed in the room landing on resident's bed and window seal. 5. On 06/14/23 at 7:45 AM, the Surveyor asked the Administrator, What specifically is the facility doing about the flies in the resident areas? She replied, We have [Pest Control Company] service that comes monthly, and they spray around the base boards. The Surveyor requested copies of the pest control visits. 6. On 06/14/23 at 8:00 AM, Resident #1 was lying in bed. The Surveyor observed one fly in his room. The Surveyor asked Resident #1, Does staff assist you with taking care of or getting rid of the flies when they are in your room? Resident #1 stated, Sometimes. The Surveyor asked, Does the staff come when you use your call light and need assistance? Resident #1 replied, Yes, most the time. 7. On 06/14/23 at 8:05 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1, What does the nursing facility do regarding the flies in the resident dining area and resident rooms? CNA #1 stated, Well, they spray for them, and we have the swatters, and a lot of the residents have their own swatters to use. The Surveyor asked, What is done for the residents that cannot prevent the flies from landing on their face or their person? CNA #1 stated, We have to assist them and try to prevent them from coming in, but when they go out to smoke on the Patio and the doors are open, the flies just come on in. The Surveyor asked, How often do you go into [Resident #1's] room and assist with the flies in the room? CNA #1 replied, Oh, we go in there all the time, in and out a lot during the day. 8. On 06/14/23 at 8:15 AM, The Surveyor asked Assistant Director of Nursing (ADON) #1, What does the nursing facility do regarding the flies in the resident dining area and resident rooms? ADON #1 stated, We are aware of them, and we do our best to get rid of them by using the swatters and the pest control is coming and spraying. The Surveyor asked, What is done for the residents that cannot prevent the flies from landing on their face or their person? ADON #1 replied, Oh, we go in [Resident #1's] room all the time, and I tell him I am the fly [NAME]. You know the doors going in and out to the Patio to smoke and the doors being open they just come in. The Surveyor asked, How often do you go into [Resident #1's] room and assist with the flies in the room? ADON #1 replied, I go in there usually every one to two hours and try to check on him and he has that fan that he uses to keep the flies out of his face. He uses it all the time. 9. The (Pest Control Company) Invoices from December 2022 through May 2023 were provided by the Administrator on 06/14/23 at 8:55 AM. The December 2022 through April 2023 Invoices documented treatments for rodents and roaches. The 05/22/23 Invoice documented, .Target Pests ants, beetles, crickets, spiders, wasp, flies, roaches, rodents . 10. On 06/14/23 at 12:10 PM, in the kitchen there were four flies on and about the center worktable. The Dietitian requested that the Dietary Manager obtain a fly swat and then sanitize the worktables. 11. On 06/14/23 at 12:30 PM, in the 100 Hall Dining Room there were two flies landing on and flying about a dining table where the residents who required assistance were seated. The flies landed on the trays and table. 12. A facility policy titled, Pest Control, provided by the Administrator on 06/14/23 at 3:27 PM stated, Policy Statement Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . 45065

Based on interview, and record review, the facility failed to ensure a resident was screened for a mental disorder or intellectual disability prior to admission and were evaluated to receive care and services appropriate to their needs for 1 (Resident #18) of 5 (Residents #18, #25, #61, #83 and #93) sampled residents with a severe mental illness diagnosis as documented on a list provided by Administrator on 06/15/23 at 9:07 AM. The findings are: 1. On 06/14/23 at 10:01 AM, the Surveyor asked the Administrator to provide a Preadmission Screening and Resident Review (PASARR) and a summary of active diagnoses for Resident #18. 2. Resident #18 had a diagnosis of Post Traumatic Stress Disorder (PTSD) active since 01/28/2008 and a Head Injury with Dementia active since 06/15/2007 as documented by on a Patient Chart Report provided by the Administrator on 06/14/23 at 10:50 AM. The Administrator stated, We don't have a PASARR on [Resident #18]. [Resident #18] received the Dementia diagnosis in 2007 and the PTSD in 08 [2008], from my understanding she wouldn't need one. I'll find you some information on it. a. The Care Plan with an initiated date of 07/17/20, last revised on 04/14/22 revealed Resident #18 exhibits behaviors related to unspecified mental development delays. b. The Care Plan with an initiated date of 04/20/23 revealed Resident #18 had impaired cognitive function related to unspecified lack of expected normal physiological development in childhood. 3. On 06/14/23 at 2:00 PM, the Surveyor asked the Nurse Educator if any information regarding the PASARR for Resident #18 had been obtained. She stated, No, we're sending her information in now to [State Designated Professional Associates]. The Administrator stated, I don't think she needs one. What will happen if [State Designated Professional Associates] says [Resident #18] is exempt? 4. A facility policy titled, Admission Criteria , with a revised date of March 2019, provided by the Administrator on 06/15/23 at 9:07 AM documented, .#9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process .

Based on observation, record review, and interview, the facility failed to ensure nails were trimmed and facial hair was removed regularly to maintain good grooming and hygiene for 1 (Resident #85) of 4 (Residents #85,#29, #209, and #211) sample mix residents who were dependent on staff for assist with personal hygiene. The failed practices had the potential to affect 12 residents who were dependent on staff for nail care, and 8 residents who were dependent on staff for shaving according to a list provided by the Administrator on 3/16/22 at 09:44 a.m The findings are: Resident #85 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/14/22 documented the resident scored 7 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS), required extensive assistance of 2 person for dressing and personal hygiene. a. The Plan of Care with a revised date 3/15/22 documented, .the resident has an ADL [activities of daily living] self-care performance deficit r/t [related to], critical illness [CONDITION(S)], dvt [[CONDITION(S)]] to lower extremities . The Plan of Care did not document nail care. b. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . c. On 03/14/22 at 12:17 PM, Resident #85 sitting was in his wheelchair in his room. The resident's nails on the left hand had a dark substance underneath them. Resident #85 was rubbing his face, reported he usually keeps a clean shave but it hasn't been done in a while. d. On 03/14/22 at 12:20 PM, Certified Nursing Assistant (CAN) #4 was in the room with the resident and reported that he had a shower Saturday, and he should have been shaved Saturday and it wasn't done. Resident #85 was asked if he wanted to be shaved and he said it would be nice and I wouldn't be itching like I am. e. On 03/14/22 at 12:21 PM, Registered Nurse (RN) #2 entered the resident's room and stated, I am fixing to clean his nails right now. The RN was asked, Should they have been cleaned before now? She stated, Yes ma'am.

Based on observation, interview and record review, the facility failed to ensure that a mechanical lift transfer was performed according to the manufacturer's guidelines to prevent potential injury for 1 (Resident #92) of 2 (Resident #92 and#93) sampled residents who were transferred with mechanical lifts. The facility failed to ensure the door to the shower room containing personal hygiene items was secured to provide a safe environment on 1 (200 hall) of 4 halls. This had the potential to affect 14 cognitively impaired residents residing on the 200 hall as provided by the list by the Nurse Consultant on 3/17/22 at 2:05 p.m. The findings are: 1. Resident #92 had diagnosis of Cognitive Communication Deficit, and Muscle Wasting and Atrophy not elsewhere classified. The Annual Minimum Data Set with an Assessment Reference Date of 02/09/22 documented the resident scored 2 (0-7 indicates severe impairment) on a Brief Interview for Mental Status and totally dependent for transfers the assistance of 2 persons. a. The care plan initiated 03/26/19 documented, transfer: [Resident #92] (brown sling) and assist x [times] 2 for transfers . b. On 03/15/22 at 7:59 a.m., Certified Nursing Assistant (CNA) #3 and CNA #2 use the mechanical lift to transfer the resident from the bed to the wheelchair (w/c). CNA #2 moved the lift under the bed with the legs together, the lift pad was attached to the lift. The resident was lifted and the lift was maneuvered to the w/c. The lift legs were not opened until reaching the w/c. c. On 03/15/22 at 8:03 a.m., CNA #2 was asked, When were you last trained on the use of the mechanical lift? She stated, A couple months ago. d. On 03/15/22 at 8:03 a.m., CNA #3 was asked, When were you last trained on the use of the mechanical lift? She stated, I just started in December [2021]. e. On 03/17/22 at 9:29 a.m., CNA#2 was asked, How were the legs of the lift positioned when you were transferring [R#92] to her w/c? She stated, When your under the bed they have to be closed otherwise it won't fit under the bed. She was asked, When were the left legs opened? She stated, When we got the lift from under the bed. Surveyor stated, I didn't observe the opening of the lift legs until you reached the w/c. She stated, OK. She was asked, When are the lift legs supposed to be opened? She stated, When we pull out from under the bed. f. On 03/17/22 a review of the Operating Manual documented, .Move the mechanical lift into position open the base to its widest position. 2. On 03/14/22 at 10:30 a.m. and at 11:57 a.m., and 03/15/22 at 8:06 a.m. and 12:41 p.m., the door to the shower room on 200 hall was open with shampoo, body wash, mouthwash, lotion, and shave cream on an overbed table. a. On 03/14/22 at 10:42 a.m., Housekeeper #1 came out of the shower room. She was asked, Was the door open when you walked in? She stated, Yes. She was asked, Is it supposed to be open? She stated, I guess. b. On 03/15/22 at 8:06 a.m. Registered Nurse (RN) #1 was asked, Is the door supposed to be open? She stated, no it's not supposed to be open. c. On 03/15/22 at 12:41 p.m., Certified Nursing Assistant (CNA) #2 was asked is that door [shower room] supposed to be open? The CNA stated, No. d. On 03/17/22 at 9:33 a.m., the Director of Nursing was asked, Should there be supplies out and accessible in an unlocked shower room? She stated, No ma'am. e. On 3/17/22 at 2:05 p.m. the Nurse Consultant provided a Receipt and Storage of Supplies and Equipment policy and procedure which documented, .All supplies and equipment must be stored in accordance with the manufacturer's recommendations. Hazardous/toxic materials must be stored and labeled in accordance with current regulations .

Based on record review and interview, the facility failed to ensure a recapitulation of the resident's stay that included, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results was completed at time of discharge for 1 of 1 (Resident #107) who was discharged in the past 90 days. This failed practice had the potential to affect 56 resident's discharged to private home in the last 90 days as identified on the list provided by the Administrator on 03/14/22. Resident #107 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Return Not Anticipated Minimum Data Set with an Assessment Reference Date of 02/07/22 documented the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status, and an admitted [DATE]. a. A progress note dated 2/7/22 documented, Resident discharge of own accord unplanned on this date. b. On 03/15/22 at 11:45 a.m., the discharge summary form under the section titled Give a recapitulation of resident's stay including course of treatment, pertinent labs, x-rays and consults documented, admitted r/t [related/to] above dx [diagnoses] for skilled care, wife choosing to take resident home at this time. c. On 03/15/22 at 12:40 p.m., a review of the Discharge Instructions did not identify a recapitulation of stay. d. On 03/17/22 09:39 a.m., the Director of Nursing (DON) was asked, Is what was documented as the recapitulation of stay was in fact a recapitulation of stay. The DON stated, No it's not. e. The Discharge Summary and Plan policy and procedure provided by the Director of Operations on 3/17/22 at 10:53 a.m. documented, .The discharge summary or post discharge instructions will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations.

Based on observation, record review and interview, the facility failed to ensure residents' fingernails were regularly trimmed and cleaned to promote good personal hygiene and grooming for 2 (Residents #1 and #2) of 3 (Residents #1, #2, and #3) sampled residents who were dependent for nail care and resided on the 100 Hall of 4 (100, 200, 300 and 400 Halls) Halls as documented on a list provided by the Administrator on 01/28/22 at 8:15 AM. The findings are: 1. Resident #1 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required extensive two-person physical assistance for bed mobility and personal hygiene; and required limited one-person physical assistance with bathing. a. The Care Plan with a revision date of 10/12/21 documented, [Resident #1] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] left side [CONDITION(S)] . Bathing/Showering: The resident is ext [extensive] x [times] 1 . b. The January 2022 ADL Bathing Log documented Resident #1 received a shower on Saturday, January 22, 2022, at 1:45 PM. c. On 1/24/22 at 11:59 AM, Resident #1 was lying in bed; the fingernails on both hands were long, extending approximately 1/3 inch beyond the fingertips. The fingernails on his left hand were stained, uneven and jagged. He had a scratch on his forehead. Resident #1 was uncertain as to when he might have scratched himself but attributed the scratch to his long nails. Resident #1 reported his ex-wife usually trimmed his nails, and he was unaware that the facility would actually trim them if needed. d. On 1/25/22 at 8:17 AM, Resident #1 was lying in bed; his fingernails remained as previously described. He was asked if staff filed and trimmed his nails. He stated They have never done them; my ex-wife does them when she visits. She was here yesterday, and I forgot to tell her to trim them. 2. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 1/10/22 documented the resident scored 5 (0-7 indicates severely cognitively impaired) on a BIMS; and required extensive one-person physical assistance for bed mobility, personal hygiene, and bathing. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Initial Care Plan dated 1/1/22 documented, The resident has an ADL self-care performance deficit . Bathing/Showering: Assist x 1, 3x/wk. [times/week] and PRN [as needed] . c. The January 2022 ADL Bathing Log documented Resident #2 received a shower on Saturday the 24th at 2:42 PM. d. On 1/24/22 at 12:15 PM and 1/25/22 at 8:30 am, Resident #2 was sitting in his wheelchair in the common area/dining room. The resident's fingernails extended approximately 1/8 inch beyond the fingertips with a brown substance under the nail tips. e. On 1/25/22 at 9:25 AM, Certified Nursing Assistant (CNA) #1 was asked, Who does the nail care on the residents? CNA #1 replied, The CNAs; if diabetic, the nurses. CNA #1 was asked, When is nail care performed on the residents? She replied, Every morning, during their shower and as needed. f. On 1/25/22 at 9:35 AM, CNA #2 was asked, Who does the nail care on the residents? CNA #2 replied, The CNAs; if diabetic, the nurses or treatment nurse. CNA #2 was asked, When is nail care performed on the residents? She replied, Every morning, during their shower and as needed. g. On 1/25/22 at 9:43 AM, Licensed Practical Nurse (LPN) #1 was asked, Who does the nail care on the residents? She replied, The CNAs; if diabetic, the nurses and treatment nurse. LPN #1 was asked, When is nail care performed on the residents? She replied, As needed and on their shower days. LPN #1 accompanied the surveyor to Resident #1's room and was asked, Who does the resident's nails? LPN #1 replied, The CNAs. LPN #1 was asked, When was the last time his nails were filed and trimmed? She replied, I'm not sure, but they need to be. h. On 1/25/22 at 1:43 PM, LPN #1 accompanied the surveyor to common/dining area where Resident #2 was and was asked, Who does [Resident #2's] nail care? She replied, The CNAs clean them but the nurses or the treatment nurse has to files and trim them. LPN #1 was asked, What is that brown substance under the resident's nail tips? She stated, I think its chicken; he had chicken for lunch. LPN #1 was asked, Should his fingernails be cleaned? She replied, Yes. 3. On 1/27/22 at 1:12 PM, the Assistant Director of Nursing (ADON) was asked, Who performs nail care on the residents? She replied, The CNAs; if they are diabetics, the CNAs clean their nails and the treatment or floor nurse trims and files their nails. The ADON was asked, When is nail care performed on the residents? She replied, Every morning, as needed and on shower days. The ADON was asked, Who is responsible to ensure the CNAs are performing nail care as needed? She replied, The nurses. 4. A facility policy titled, Fingernails/Toenails, Care of, provided by the Director of Nursing on 1/27/22 at 2:38 PM, documented, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . General Guidelines 1. Nail care includes daily cleaning and regular trimming . 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .

Based on observation, record review and interview, the facility failed to ensure all areas of the skin were cleansed and staff cleaned the urinary catheter from the insertion site outward to prevent potential urinary tract infection ([CONDITION(S)]) or other complications for 1 (Resident #3) of 2 (Residents #1 and #3) case mix residents who had an indwelling catheter and resided on the 100 Hall of 4 (100, 200, 300 and 400 Halls) Halls as documented on a list provided by the Administrator on 01/28/22 at 8:15 AM. The findings are: 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with an Assessment Reference Date of 01/01/22 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive one person physical assistance for bed mobility, toilet use and bathing, and required an indwelling catheter and was frequently incontinent of bowel. a. The January 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date 12/29/21 .[MEDICATION(S)] Solution Reconstituted 1 GM [Gram] Inject 1 gram intramuscularly one time a day related to Urinary Tract Infection . for 10 Days . Order Date 1/21/22 . [MEDICATION(S)] Tablet 1 GM Give 1 tablet by mouth two times a day related to Encounter for Attention to other Artificial Openings of Urinary Tract .Personal History of Urinary (Tract) Infections . Order Date12/29/21 . b. The Care Plan with a revision date of 12/29/21 documented, The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] [CONDITION(S)] . TOILET USE: The resident is EXT [Extensive] X [times] 1 assist [assistance] with supra pubic cath capped off/ vaginal foley, follow facility protocol for foley care TX [Treatment] as MD [Medical Doctor] ordered, cont [Continent] of bowel, may wear facility briefs . c. On 1/27/22 at 8:37 AM, Certified Nursing Assistants (CNA) #3 and #4 performed peri care and foley catheter care. CNA #3 wiped once down the labia to the catheter with a wipe. She then wiped the left and right groin, across the abdominal area and both legs and then wiped the catheter from the stat lock upwards toward the vaginal area. d. On 1/27/22 at 8:51 AM, CNA #3 was asked, How were you trained to cleanse the vaginal area during peri care? She replied, Down the middle of the vaginal area. CNA #3 was asked, Where you trained to separate the labia, wipe down the center then wipe down on the left and right side? She replied, Yes, I missed a few steps. CNA #3 was asked, How were you trained to perform catheter care? She replied, Grasp the tubing at the opening and wipe down the tubing 4 to 6 inches. CNA #3 was asked, Did you perform catheter care that way? The CNA replied, No, I wiped upwards from the stat lock. e. On 1/27/22 at 9:00 AM, the CNA Supervisor was asked, How are the staff trained to perform peri care? She replied, I use the check off sheet, spread the labia, down the center, left then right side of the labia . She was asked, How are staff trained to perform catheter care? She replied, Cleanse the labia as stated, grasp the tubing at the opening and wipe down, if not soiled x [times] 1, if soiled until clean. f. On 1/27/22 at 1:12 PM, the Assistant Director of Nursing (ADON) was asked, When performing peri care and cleansing the vaginal area, should the CNAs separate the labia and cleanse down the center and on each side of the labia? She replied, Yes. The ADON was asked, When performing catheter care, should the CNA secure the catheter at the urethra meatus and wipe downward? The ADON replied, Yes. The ADON was asked, Who is responsible to ensure the CNAs are performing catheter and peri care correctly? She replied, The hall ADONs, the Floor Nurse, the CNA Supervisor and the Infection Preventionist. g. A Perineal Care Skills Check Sheet provided by the Administrator on 1/27/22 at 11:05 AM documented, .FEMALE RESIDENT .2. Wipe vaginal area front to back, middle then sides . IF CATHETER PRESENT . 2. Secure catheter at insertion site, wipe away from body and down tubing 3-4 inches . h. A facility policy titled, Perineal Care Policy was provided by the Director of Nursing on 1/27/22 at 2:38 PM documented, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition . Steps in the Procedure . For a female resident: . b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches .)

Based on observation, record review, and interview, the facility failed to ensure incontinent care was promptly provided to minimize the potential for skin breakdown for 1 (Resident #2) of 3 (Residents #1, #2, #3) sampled residents who required assistance for perineal care. The findings are: Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data (MDS) with an Assessment Reference Date (ARD) of 05/10/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive two-person physical assistance with toilet use, personal hygiene, bed mobility and transfers. a. The Care Plan with a revision date of 05/11/21 documented, .has an ADL [activities of daily living] self-care performance deficit r/t [related to] WEAKNESS, LEFT SIDED WEAKNESS, HX [history] OF FALLS, COVID 19 .TOILET USE: The resident is EXT [extensive assistance]] X [times] 2, incontinent at times . b. On 08/04/21 at 1:24 PM, Resident #2 was resting in bed, leaning to the right, eating lunch. There was a draw sheet under him that had a large yellow wet spot with brownish-colored rings and spots. The room smelled of urine. The resident was unable to tell the surveyor how long he had been wet, when asked. c. On 08/04/21 at 1:25 PM, Licensed Practical Nurse (LPN) #1 was asked what was on the draw sheet. She replied, I'm not real sure, looks like maybe something might have been spilled. d. On 08/04/21 at 1:28 PM, Certified Nursing Assistant (CNA) #1 assisted LPN #1 to reposition Resident #2 in bed. The resident's incontinent brief was bunched up in the front and appeared to be completely saturated. The draw sheet had a large, wet, yellow stain with brownish-colored rings and spots, as though the urine had dried in areas before being rewet. CNA #1 was asked to describe what she saw on the draw sheet. She stated, It's wet. She was asked what the draw sheet was wet with. She replied, Urine. e. On 08/04/21 at 1:34 PM, CNA #2 was asked to look at the brief and the draw sheet and describe what she saw. She replied, His brief was swelled, and his sheet was soiled. She was asked when the last time Resident #2's brief was changed. She replied, Probably about 2 hours ago. f. On 08/05/21 at 3:23 PM, Registered Nurse (RN) #1 was asked how often perineal care should be provided. She replied, Whenever they need it. We try to check incontinent residents every two hours, but also as they need it. She was asked why it's important to change incontinent residents every two hours. She replied, To prevent skin breakdown and urinary tract infections. g. On 08/05/21 at 3:30 PM, the Administrator provided a policy that documented, Perineal Care, Purpose: .to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .

Complaint # (AR 181) and Complaint # (AR 182) was substantiated, all or in part, in these findings: Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #1) case mix resident who eloped from the facility. This failed practice resulted in immediate jeopardy, which caused or was likely to cause serious harm, injury or death to Resident #1, who flipped over in the wheelchair in the facility yard after eloping the facility, and had the potential to cause more than minimal harm to 13 residents who were an elopement risk as identified by the Administrator on 02/10/2021 at 9:53 A.M. The Administrator was informed of the past immediate jeopardy condition on 02/10/2021 at 2:12 P.M. The findings are: Resident # 1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 12/14/2020 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status and required limited assist of 1 person for bed mobility, transfer, personal hygiene, and dressing. Used a wheelchair for mobility and a wander/elopement alarm was used daily. a. Resident #1 did not have an elopement assessment prior to the elopement. b. The Care Plan documented, .resident is an elopement risk/wanderer r/t (related to) hx (history) of same. Date Initiated: 01/08/2019 . Goal The resident's safety will be maintained through the review date .Wander guard bracelet. Date Initiated: 01/08/2019. c. The February 2021 Nurses Progress Notes documented, . 2/6/2021 17:55 (5:55 P.M.) Note Text: Resident wandering throughout facility, on hall 200, attempted to exit dining room door to go outside, redirected, contacted DON (Director of Nursing) for placement of wander guard/watcher transmitter . 2/6/2021 22:30 (10:30 P.M.) Nsg-I&A (Nursing - Incident and Accident) Note Physician Contact 2/6/2021 AT 2358 (11:58 P.M.) Family Contact . 2/6/2021 AT 2258 (10:58 P.M.) Incident Description: I saw the resident .during my med (medication) pass between 2020-2030 (8:20 P.M. - 8:30 P.M.) then I gave her insulin .The resident is roaming around the hall and she entered another resident ' s room and saw the call light on and responded to the call. saw her and took her out of the room via W/C (wheelchair). The last I seen her on the hall around 9-9:30 (p.m.) . Immediate Intervention: The Police Officer who found her outside took her to emergency room . d. A History and Physical from the hospital documented, . 2/7/21 01:14 (1:14 A.M.) .patient was found in a ditch with wheelchair on top of her . She is currently not at her baseline, is confused . she was found to have a urinary tract infection . There were no physical injuries documented. e. A 762 (Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, Exploitation of Residents in Long Term Care Facilities) report submitted to the Office of Long-Term Care (OLTC) provided by the Administrator documented, . On 2/26/21 at 10:35 PM the Administrator was notified that (Resident #1) was found outside of the facility. The Administrator watched the recording of the elopement on facility cameras. (Resident #1) exited through the front door at 9:46 PM. Staff last reported seeing (Resident #1) on the hall at 9:36 PM. Resident was immediately taken to the hospital. Hospital reports she has no injuries, will be admitted for UTI (urinary tract infection) and observation r/t incident . Findings: . 2. (Resident #1) was last seen by facility staff at 9:36 PM. A passerby in a car saw (Resident #1) in front of the facility in the yard and called the police at 10:14 PM. Police had her transported . Police state (Resident #1) had flipped her wheelchair over in the yard and the chair was on top of her. 3. After investigating it was found that (Resident #1) did not have her wander guard on at the time she exited the facility. (Resident #1) was care planned to have a wander guard in place. Interviews with staff reflect that (Resident #1's) wander guard was attached to her wheelchair. 4. On 1/25/21 (Maintenance Assistant (MA) #1) was notified that the rubber piece on (Resident #1's) wheelchair had come off. He took the chair to repair it. (MA #1) stated he had a newer wheelchair that he gave (Resident #1) due to hers was older and not in the best shape. (MA #1) did not realize the wander guard was on (Resident #1's) wheelchair. (Resident #1's) original chair with the wander guard in place was found in maintenance area where (MA #1) had taken it repair. 5. Staff report that placing a wander guard on a resident's chair was something that was started per previous DON d/t (due to) concerns with skin and the bracelet cutting into the resident. (Resident #1's) has a history of [MEDICAL CONDITION] in her legs and staff would have concerns r/t the resident taking bracelet off of her wrist. (Resident #1's) wander guard was initially placed on 1/8/19. Wanderguard will be placed on the resident upon return, not on her chair. Actions Taken: 1. Administrator. Staff, MD and family notified. 2. Facility was immediately checked to ensure all residents were in the facility and accounted for-no negative findings. 3. All residents care planned for a wanderguard were immediately checked for placement, no negative findings. 4. Wanderguard system checked per maintenance director on every door in facility 5. Immediately a code was activated on second door in entry to ensure a lock on the entrance area at all times. 6. Staff interviews completed r/t (Resident #1 ' s) chair and wanderguard. 7. Action plan put into place regarding a system to prevent resident elopement from the facility. This plan includes Education on Policy and Procedures, Identifying residents at risk-all residents had new elopement assessments completed on 2/7/2021. Checking of wanderguard bracelets for function and placement, Interventions for residents who are found to have new behaviors of wandering/exit seeking, Care planning for those residents at risk and listing on the closet care plan of this risk for front line staff knowledge, Elopement book and where it is located. Training on Elopement upon hire, Procedures in case of an elopement and Elopement drills initiated. Staff inserviced r/t Wanderguard only being placed on the resident, not ever placed a resident's chair, walker etc. Wanderguard Company out to facility to ensure all systems are working properly. f. On 02/11/2021 at 3:45 P.M., Registered Nurse (RN) #1 was asked, Can you tell me about the night you called the DON prior to the actual elopement? She said, I'm the one that called that DON that night. I am the interim DON. I was on the 200 Hall and the resident came to my hall. I was standing outside on the patio. She tried to open the door. I told her you can't come out it is cold outside. She said, okay. I called the DON and told her the resident needed a wander guard, she keeps trying to get out. That was about 6:15 to 6:30 (p.m.). She said, she was coming up here she had to be at work at 7. I assumed she would put one on her when she got here. g. An Elopement Policy and Procedure documented, It is the policy of this facility to ensure that a system is in place that identifies residents as being at risk for elopement and that appropriate measure are implemented to prevent, detect and respond promptly to resident elopement . the following 4 criteria will be utilized in the elopement prevention system. 1. Assessment of residents 2. Precaution 3. Prevention 4. Training . h. On 02/11/2021 at 4:00 P.M., the Administrator was asked, Do you think the facility followed your policy prior to the elopement? She said, No.

Based on observation, record review and interview, the facility failed to ensure implementation of proper infection prevention and control practices to prevent the development and transmission of Covid -19 and other communicable diseases and infections by not changing the isolation gown from room to room on the quarantine hall for 1 (Residents #6) resident of 1 case mix resident on the quarantine hall and for 1 (Resident #3) resident of 1 case mix resident who was admitted to the facility in the past two months and tested positive for COVID-19 and failed to ensure staff wore a face mask to cover the mouth and nose while in the facility. These failed practices had the potential to affect 3 residents on the quarantine hall (300 Hall) according to the census by halls provided by the Administrator on 01/25/2021, 53 residents who were admitted to the facility and placed on the quarantine hall in the past two months according to a list provided by the Administrator on 01/29/2021 and 11 residents who were admitted to the quarantine hall for contact/droplet isolation with a negative Covid-19 test according to a list provided by the Nurse Consultant on 01/27/2021. The findings are: 1. Resident #6 was admitted to the facility on [DATE] and placed on quarantine contact/droplet isolation with [DIAGNOSES REDACTED]. The Admission assessment dated [DATE] documented a Brief Interview for Mental Status of 13 (13-15 indicates cognitively intact) and required substantial/maximal assistance with transfer, toilet use and personal hygiene. a. The January 2021 Physician order [REDACTED]. Order Date: 01/22/2021. b. The Comprehensive Care Plan documented, The resident has been exposed/has had probable exposure to Covid-19. Date Initiated: 01/24/2021.Use Contact and Droplet precautions. Date Initiated: 01/24/2021. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set with Assessment Reference Date of 01/11/2021 documented the resident scored 10 (8-12 indicates moderately impaired) per a Brief Interview for Mental Status and required extensive assistance of 2 persons for bed mobility, transfer, toilet use and personal hygiene. a. The (Hospital) SAR's -CoV 2 collected on 01/06/2021 documented on 01/07/2021 Negative. b. The January 2020 Physician order [REDACTED]. Order Date: 01/08/2021. c. The Comprehensive Care Plan documented, The resident has been exposed/has had probable exposure to Covid-19. Date Initiated: 01/11/2021.Approach Use Contact and Droplet precautions. Date Initiated: 01/11/2021 .The resident has the potential to develop a respiratory infection due to the Covid-19 pandemic. Date Initiated: 01/11/2021. The resident has tested positive for Covid-19. Date Initiated: 01/15/2021 . Use Contact and Droplet precautions. Date Initiated: 01/15/2021 . d. The Pathology Report for Resident #3 documented, Date collected 01/15/2021, Date reported 01/17/2021 .Respiratory: Covid 19 results. Severe Respiratory Syndrome Coronavirus 2 (SAR's CoV 2) Detected. 3. On 01/25/2021 at 9:42 a.m., the Administrator stated the back of the 300 Hall (Resident Rooms 309-317) were for the quarantine residents. The rooms were separated by a plastic sheeting that was secured on all 4 sides 4. On 01/25/2021 at 10:16 a.m., the Social Worker stated they wear the same gown on the hall (quarantine area) that they put on upon entrance to the facility. They can go on the resident's room on the quarantine contact/isolation with the same gown and change the gown before they leave the quarantine area. The Social Worker was asked, You wear the same isolation gown that you have been wearing in the facility to the quarantine area, going from room to room where residents are being monitored for possible Covid 19? The Social Worker stated, Yes, The Social Worker was asked, Isn't this an unknown if they have become infected by wearing the same isolation gown from resident to resident that are on quarantine contact/droplet isolation, doesn't this increase the potential to spread [MEDICAL CONDITION] from one resident to the next resident by wearing the same isolation gown in each residents room that are on quarantine contact/droplet isolation? The Social Worker stated. That is how they were told to do by the Nurse Consultant. 5. On 01/25/2021 at 10:22 a.m., Certified Nursing Assistant (CNA) #1 was wearing an isolation gown when she entered the back of the 300 Hall through the plastic sheeting that separated the front from the back of the hall. CNA #1 wearing the same isolation gown entered Resident #6's room. CNA #1 exited Resident #6's room with the same isolation gown on. CNA #1 stated they wear the same isolation gown on the quarantine hall they wear outside the quarantine residents rooms and they only change when they are leaving the area with the quarantine residents. 6. On 01/25/2021 at 3:28 p.m., Nurse Practitioner #1 was seated in the nurse's station on the right side of the Licensed Practical Nurse (LPN) #1 they were both looking at the computer screen. Nurse Practitioner #1 had her mask off of her mouth and nose within 2 feet of LPN #1. Nurse Practitioner #1 put on her mask when she saw the surveyor. 7. On 01/26/2021 at 8:57 a.m., the Administrator was asked if the staff were to wear a face mask at all times when in the facility. The Administrator stated. Yes. The Administrator was notified of the observation on the Covid Hall when the Nurse Practitioner was seated next to the Licensed Practical Nurse (LPN) #1 with her mask off the mouth and nose. 8. On 01/26/2021 at 10:46 a.m., the Surveyor spoke with the Administrator and the Nurse Consultants regarding the concern of infection control for the quarantine contact/droplet isolation residents that had been admitted from the hospital and on the back of the 300 hall. The Surveyor explained that during observation, The staff are wearing the same isolation gowns, that they had been wearing in other resident rooms in the facility and then entering the area with the quarantine contact/droplet isolation residents. The issue is that it is unknown what these residents may have. They have been placed on quarantine contact/droplet isolation to be monitored for potential Covid 19. The staff goes from one resident on quarantine contact/droplet isolation to the next resident on quarantine contact/droplet isolation with the same isolation gown that had been worn in other resident's rooms and then changing when they left the area. This is an infection control issue. I understand that the CDC stated that the same gown can be worn with the Covid positive residents due to them having the same organism. The residents on quarantine contact/droplet isolation it is unknown. The facility is in an outbreak, the risk of spreading infection from one quarantine resident to the next is greater with wearing the same isolation gown from one quarantine contact/droplet isolation resident to the next quarantine contact/droplet isolation resident. The Administrator stated, This has been the practice regarding the quarantine residents. The Surveyor explained, There is documentation from the CDC, wearing the same gown is for residents with like organisms. But when a resident is admitted from the hospital this is unknown. It is not known if the resident has Covid or not, so therefore you are wearing the same gown from one resident to the next with the potential of spreading the infection. For instant (Resident #3), the resident had been admitted on [DATE] with a negative Covid 19 according to documentation from the hospital prior to admission. The resident tested positive on 01/15/2021. Staff had been going from this resident's room to the next resident's room with the same gown and had the potential to spread the infection. 9. On 01/28/2021 at 11:58 a.m., Registered Nurse (RN) #1 was asked, In regard to the infection control practice being used for residents on quarantine contact/droplet isolation. These resident come in to be monitored for possible Covid 19. With staff coming from outside the quarantine areas to the residents on quarantine and going from one resident to the next resident with the same gown on. Is this not a chance to spread the infection? RN #1 stated, Yes. 10. On 01/28/2021 at 10:53 a.m., the Infection Control Preventionist was asked, In regard to the infection control practice being used for residents on quarantine contact/droplet isolation. These resident come in to be monitored for possible Covid 19. With staff coming from outside the quarantine areas to the residents on quarantine and going from one resident to the next resident with the same gown on. Is this not a chance to spread the infection? The Infection Control Preventionist stated, Yes. 11. On 01/28/2021 at 3:12 p.m., the Director of Nurses (DON) was asked, In regard to the infection control practice being used for residents on quarantine contact/droplet isolation. These resident come in to be monitored for possible Covid 19. With staff coming from outside the quarantine areas to the residents on quarantine and going from one resident to the next resident with the same gown on. Is this not a chance to spread the infection? The Director of Nurses (DON) stated, Yes. 12. A list received from the Nursing Consultant documented 11 residents had been admitted to the facility with a negative Covid 19 test and had tested positive after admission to the facility in the past 2 months. 13. COVID-19 Long-Term Care Facility Guidance April 2, 2020 The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) are issuing new recommendations to State and local governments and long-term care facilities (also known as nursing homes) to help mitigate the spread of the 2019 Novel Coronavirus (COVID-19) . The recommendation for a 14-day quarantine was based on estimates of the upper bounds of the COVID-19 incubation period. Quarantine's importance grew after it was evident that persons are able to transmit [DIAGNOSES REDACTED]-CoV-2 before symptoms develop, and that a substantial portion of infected persons (likely somewhere between 20% to 40%) never develop symptomatic illness but can still transmit [MEDICAL CONDITION]. In this context, quarantine is a critical measure to control transmission .CDC guidelines for isolation for residents with or suspected Covid 19. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic. The CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection . HCP (Health Care Personnel) should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers . Gowns, Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Reusable (i.e., washable or cloth) gowns should be laundered after each use. 14. The CDC Centers for Disease Control and Prevention. Coronavirus Disease 2019 (Covid 19) documented, Background Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens. Preparing for COVID-19 in Nursing Homes. Updated June 25, 2020 added guidance about new requirements for nursing homes to report to the National Healthcare Safety Network (NHSN). Implement Source Control Measures. HCP should wear a facemask at all times while they are in the facility. When available, face masks are generally preferred over cloth face coverings for HCP as face masks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Guidance on extended use and reuse of facemask's is available.

Based on observation, record review, and interview, the facility failed to ensure a cooling fan was clean; pans were air dried before storage, and the ice machine was maintained in a sanitary manner to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 100 residents who received meals and ice as documented on the list provided by the Dietary Manager on 12/17/2020. The findings are: 1. On 12/14/2020 at 11:00 a.m., a fan covered with gritty, grayish microscopic particles was sitting on a tilt skillet blowing toward the cook's worktable. The Dietary Manager was asked, Can you explain what you see? The Dietary Manager stated, It's dirty and blowing dust particles. 2. On 12/14/2020 at 11:05 a.m., six large pans on a storage rack stacked on top of one another were wet. The Dietary Manager was asked, Should the pans be stacked together wet? The Dietary Manager stated, No ma'am. They should air dry. 3. On 12/14/2020 at 11:09 a.m., a pinkish film was on the interior ceiling of the ice machine in the kitchen. The Dietary Manager took a white napkin and wiped the ceiling of the ice machine. The pinkish slimy film was on the napkin. (Photo taken.) The Dietary Manager was asked to describe what she observed on the interior ceiling of the ice machine, and the napkin. She replied, A pinkish substance. 4. A Handling Clean Equipment and Utensils Policy provided by the Dietary Manager on 12/16/2020 at 9:49 a.m. documented, a.Air dry pots, pans, and utensils before being stored 5. A Suggested Cleaning Procedures - Small Equipment Policy provided by the Dietary Manager on 12/16/2020 at 1:48 p.m. documented, .b. The ice machine should be cleaned as followed: Weekly: clean the outside of the machine with a clean cloth and detergent solution. Monthly: . Disconnect ice machine and discard all ice. Allow the machine to warm. Scrub all surfaces using clean cloth and detergent solution. After cleaning, rinse chest with water. Rinse again using a sanitizing solution at the appropriate strength. Allow chest to air dry. Return chest to services and plug in machine.

Based on observation, record review and interview, the facility failed to ensure toenails were clean and trimmed to promote good personal hygiene and grooming for 1 (Residents #205) sampled resident who needed assistance with nail care. This failed practice had the potential to affect all 102 residents according to a list provided by the Administrator on 12/16/2020 at 3:01 P.M. The findings are: 1. Resident #205 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set had not been completed. a. The Care Plan documented, . Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) recent hospitalization , weakness, dx (diagnosis) UTI (Urinary Tract Infection), Depression, Dementia .[MEDICAL CONDITION]. Date Initiated: 12/11/2020 . BATHING/SHOWERING: 3x/week (three times a week) and prn (as needed) . PERSONAL HYGIENE: Ext x 1 (extensive assist of 1 person) . b. On 12/14/2020 at 10:48 A.M., Resident #205 was sitting in a wheelchair. Her toenails were approximately 1/2 inch long and jagged. (Photo taken.) c. On 12/14/2020 at 12:28 P.M., Resident #205 was sitting in a wheelchair. Her toenails were approximately 1/2 inch long and jagged. d. On 12/15/2020 at 10:20 A.M., Resident #205 was sitting on the side of the bed. Her toenails were approximately 1/2 inch long and jagged. (Photos taken.) e. On 12/15/2020 at 10:23 A.M., Certified Nursing Assistant (CNA) #5 was asked, Does her toenails look long and jagged to you? The CNA said, Yes, she is a new admit. f. On 12/16/2020 at 12:54 P.M., the Director of Nursing (DON) was shown a photo of Resident #205's toenails. The DON was asked, Should her toenails be trimmed? She said, Yes. g. A Fingernails/Toenails, Care of Policy and Procedure provided by the Administrator on 12/16/2020 at 1:58 P.M. documented, . Purpose: The purposes of this procedure are to clean nail bed, to keep nails trimmed, and to prevent infection . General Guidelines; 1. Nail care include daily cleaning and regular trimming . 4. Trimmed and smooth nails prevent the resident from accidently scratching and injuring his/ her skin .

Based on observation, record review and interview, the facility failed to ensure fingernails were clean and trimmed for 5 (Residents #36, #38, #72, #92, #205) sampled residents who required assistance with nail care and facial shaving was provided to promote good personal hygiene and grooming for 2 (Residents #38 and #72) sampled residents who needed assistance with shaving. These failed practices had the potential to affect all 102 residents who required assistance with nail care according to a list provided by the Administrator on 12/16/2020 at 3:01 P.M. and the potential to affect 36 residents who required assistance with shaving according to a list provided by the Administrator on 12/16/2020 at 3:01 P.M. The findings are: 1. Resident #36 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/24/2020 documented the resident scored 1 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS) and required extensive assistance with two person for bed mobility, dressing, toilet use, and personal hygiene. a. The Care Plan documented, . has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) hx (history) of [MEDICAL CONDITION], LEFT SIDED WEAKNESS . BATHING/SHOWERING: The resident is ext (extensive) x (times) 1. Date Initiated: 04/11/2019. had a [MEDICAL CONDITION] (right side) affecting (left sided weakness, dominant right sided Date Initiated: 04/11/2019. Monitor/document residents' abilities for ADLs and assist resident as needed . b. On 12/14/2020 at 11:10 A.M., Resident #36 was sitting in a wheelchair at a table in the Dining Room. Resident #36's fingernails were approximately one-fourth (1/4) inch long and had brown substance under them. (Photo taken with Resident #36's permission.) c. On 12/16/2020 at 2:24 P.M., Certified Nursing Assistant (CNA) #3 was ask if the residents got their fingernails cut and cleaned with their showers. CNA #3 stated, If they need done, then they will get it done with their showers. She was asked, How often do they get showers? CNA #3 stated, Some residents get showers done on Monday, Wednesday and Fridays while others get showers on Tuesday, Thursday and Saturdays. d. On 12/16/2020 at 2:36 P.M., CNA #4 was asked if residents got their fingernails cut or cleaned with their showers. CNA #4 stated If they are diabetic then no. She was asked, What do the CNAs do if residents refuse to shower or get their fingernails trimmed? CNA #4 stated, Well we offer them a bed bath if they won't shower and ask several times if they refuse to get their nails cut. 2. Resident #38 had [DIAGNOSES REDACTED]. A Quarterly MDS with an ARD of 09/28/2020 documented the resident scored 14 (13-15 indicates cognitively intact) on a BIMS and required extensive assist of 2 persons for bed mobility, transfer, toileting use and personal hygiene. a. The Care Plan documented, . has an ADL self-care performance deficit r/t immobility, osteo[DIAGNOSES REDACTED] . BATHING: Assist x 1 for bathing/grooming/hygiene. Date Initiated: 06/22/2020 . b. On 12/14/2020 at 10:50 A.M., Resident #38 was lying in the bed. His fingernails were approximately one half (1/2) inch long and he had facial hair approximately 1/2 inch long. Resident #38 was asked, Do you need your fingernails cut and to be shaved? He said, Yes, I have been trying to get someone to do it. c. On 12/14/2020 at 12:56 P.M., Resident #38 was lying in bed. His fingernails were approximately 1/2 inch long and his facial hair was approximately 1/2 inch long. d. On 12/15/2020 at 10:02 A.M., Resident #38 was lying in bed. His fingernails were approximately 1/2 inch long (Photo taken.) and his facial hair was approximately 1/2 inch long. e. On 12/16/2020 at 12:54 P.M., the Director of Nursing (DON) was shown a photo of Resident #38's fingernails dated 12/15/2020 at 10:30 A.M. The DON was asked, Should a resident have a brown substance under their fingernails? She said, No. The DON was asked, Do they need trimmed? She said, Yes. f. A Shaving the Resident policy provided by the Administrator on 12/16/2020 at 1:45 P.M., documented, . Purpose The purpose of this procedure is to promote cleanliness and to provide skin care . 3. Resident #72 had [DIAGNOSES REDACTED]. The MDS with an ARD of 12/01/2020 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS and required extensive assist of 2 persons for bed mobility, transfer, toileting use and personal hygiene. a. The Care Plan documented, . Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 08/29/2020 . Personal Hygiene Routine: Ext x 1. Date Initiated: 11/12/2020 . b. On 12/14/2020 at 10:54 A.M., Resident #72 was lying in bed. His fingernails were approximately 1/2 inch long with a brown substance under them and his facial hair was approximately 1/2 inch long. c. On 12/14/2020 at 12:56 P.M., Resident #72 was lying in bed. His fingernails were approximately 1/2 inch long with a brown substance under them and his facial hair was approximately 1/2 inch long. d. On 12/15/2020 at 10:30 A.M., Resident #72 was lying in bed. His fingernails were approximately 1/2 inch long with a brown substance under them on both hands and his facial hair was approximately 1/2 inch long. (Photos taken.) e. On 12/16/2020 at 12:54 P.M., the DON was shown a photo of Resident #72's fingernails dated 12/15/2020 at 10:30 A.M. The DON was asked, Should a resident have a brown substance under their fingernails? She said, No. The DON was asked, Do they need trimmed? She said, Yes. 4. Resident #92 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 11/11/2020 documented the resident scored 15 (13-15 indicates cognitively intact) per a BIMS and required limited assistance with bed mobility, toileting, personal hygiene, and dressing. a. The Care Plan documented, . has an ADL self-care performance deficit r/t weakness, impaired mobility; .Date Initiated: 04/18/2018. assist with bed mobility, transfers, bathing, dressing, hygiene, toileting, locomotion, gait and with meals as needed. Date Initiated: 10/25/2017. PERSONAL HYGIENE: The resident requires assistance by (X) 1 staff with personal hygiene and oral care. Date Initiated: 10/25/2017 . b. On 12/14/2020 at 2:27 P.M., Resident #92 fingernails were approximately ½ inch long and jagged. She stated, We usually keep them cut and painted but everything has just been messed up since this Covid thing. (Photo taken.) c. On 12/15/2020 at 3:30 P.M., Resident #92 was not in her room. The staff reported Resident #92 was in the shower. d. On 12/17/2020 at 8:39 A.M., Resident #92 was sitting up in her wheelchair eating breakfast. Her fingernails were approximately ½ inch long and jagged. Resident #92 was asked, Is that how you like your nails? She replied, No, not at all. They need to be cut. They used to be pretty good about doing that, but it hasn't been done in a long time. (Photo taken.) e. On 12/17/2020 at 8:41 A.M., Certified Nursing Assistant (CNA) #7 was shown the photo of Resident #92's fingernails. CNA #7 was asked, When is nail care performed on the resident's? CNA #7 replied, Whenever they are showered. CNA #7 was asked, Do you think she needs nailcare? CNA #7 replied, Yes, I can do that as soon as she is finished eating. 5. Resident # 205 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set had not been completed. a. The Care Plan documented, . Focus: The resident has an ADL self-care performance deficit r/t recent hospitalization , weakness, dx (diagnosis) UTI (Urinary Tract Infection), Depression, Dementia . [MEDICAL CONDITION]. Date Initiated: 12/11/2020 . BATHING/SHOWERING: 3x/week (three times a week) and prn (as needed) . PERSONAL HYGIENE: Ext x 1 (extensive assist of 1 person) . b. On 12/14/2020 at 10:48 A.M., Resident #205 was sitting in a wheelchair. Her fingernails were approximately 1/2 inch long and jagged with a brown substance under them. The (Photo taken.) c. On 12/14/2020 at 12:28 P.M., Resident #205 was sitting in a wheelchair. Her fingernails were approximately 1/2 inch long and jagged with a brown substance under them. d. On 12/15/2020 at 10:18 A.M., Resident #205 was sitting in a wheelchair. Her fingernails were approximately 1/2 inch long and jagged with a brown substance under them. e. On 12/15/2020 at 10:23 A.M., CNA #5 was asked, Does her fingernails look long and jagged to you and have a brown substance under them? CNA #5 said, Yes, she is a new admit. f. On 12/16/2020 at 12:54 P.M., the DON was shown a photo of Resident #205's fingernails. The DON was asked, Should her fingernails be trimmed and clean? She said, Yes. 6. A Fingernails/Toenails, Care of Policy and Procedure provided by the Administrator on 12/16/2020 at 1:58 P.M. documented General Guidelines 1. Nail care includes daily cleaning and regular trimming.

Based on observation, record review and interview, the facility failed to ensure staff sat with a resident and did not stand over them while assisting them with eating to promote dignity for 2 (Residents #5 and #14) residents who were dependent on staff for eating This failed practice had the potential to affect 15 residents who were dependent on staff for eating according to the list provided by the Administrator on 12/17/20 at 3:25 P.M. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/18/2020 documented the resident scored 2 ( 0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS) and required limited assistance for eating, and extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. a. On 12/14/2020 at 12:55 P.M., Resident #5 was sitting at a table in the dining room. Certified Nursing Assistant (CNA) #1 was standing and feeding the resident. (Photo taken.) 2. Resident #14 had [DIAGNOSES REDACTED]. The Annual MDS with an ARD of 09/02/2020 documented the resident scored 1 (0-7 indicates severe impairment) on a BIMS and required extensive assistance for eating, bed mobility, transfers, dressing, toilet use, and personal hygiene. a. On 12/14/2020 at 12:56 P.M., Resident #14 was setting in a wheelchair at a dining room table. CNA #2 was standing and feeding the resident. (Photo taken.) 3. On 12/17/2020 at 12:33 P.M., CNA #9 was asked, When a resident requires feeding assistance, is it ok to stand up to feed them? CNA #9 stated, No ma'am. CNA #9 was asked, Is that a dignity issue? CNA #9 stated, Yes and you need to be eye level with them so they can see the food coming to them and who is giving it to them. 4. On 12/17/2020 at 12:48 P.M., Licensed Practical Nurse (LPN) #4 was asked, When a resident requires feeding assistance, is it ok to stand up to feed them? LPN #4 stated, No. LPN #4 was asked, Is that a dignity issue? LPN #4 stated, Yes. 5. On 12/17/2020 at 12:54 P.M., the Director of Nursing (DON) was asked, When a resident requires feeding assistance, is it ok to stand up to feed them? The DON stated, No ma'am. The DON was asked, Is that a dignity issue? The DON stated, Yes, it is. 6. On 12/17/20 at 1:01 P.M., the Administrator was asked, When a resident requires feeding assistance, is it ok to stand up to feed them? The Administrator stated, No. The Administrator was asked, Is that a dignity issue? The Administrator stated, Yes. 7. An Assistance with Meals policy provide by the Administrator on 12/17/2020 at 3:25 P.M. documented, .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity .Not standing over residents while assisting them with meals .

Based on observation, record review, and interview, the facility failed to ensure pressure ulcers were thoroughly assessed, measured and the condition of the wound was consistently monitored after discovery to ensure deterioration of the wound was promptly identified and addressed and failed to ensure physician ordered wound care was implemented to prevent further exacerbation of the pressure ulcer for 3 (Residents #1, #2, and #3) of 3 sampled residents who had pressure ulcers. These failed practices resulted in a pattern of noncompliance at harm level for Resident #1 who had a pressure ulcer to the sacrum due to the failure to change the dressing and monitor, measure or assess the wound on a consistent basis resulting in the worsening of the pressure ulcer and requiring a wound vac (vacuum) and had the potential to cause more than minimal harm for 19 residents who had pressure ulcers as documented on a list provided by the Administrator on 12/03/2020. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/28/2020 documented the resident scored 14 (13-15 cognitively intact) per a Brief Interview for Mental Status (BIMS), and required extensive assist of 2 persons for bed mobility, transfer, dressing, toilet use, and personal hygiene; had an indwelling foley catheter; was always incontinent of bowel; had 5 unstageable pressure ulcers due to coverage of wound bed by slough/or eschar with only 1 was present upon admission/entry or reentry; had 3 unstageable pressure injuries presenting as deep tissue injury and 3 were present upon admission/entry or reentry; and had no other ulcers, wounds, or skin problems. a. The Care Plan with a revision date of 10/07/2020 documented, .has 5 unstageable pressure wounds and 3 DTI (deep tissue injury) .Administer treatments as ordered and monitor for effectiveness . b. A weekly skin assessment dated [DATE] documented, .no new skin issues at this time . c. The December 2020 Physician order [REDACTED].every day and night shift .Monitor dressing to sacrum for signs/symptoms of infection, pain, and dressing intactness until resolved .every day and night shift . Order Date: 10/20/2020 d. A Wound Care wound evaluation dated 11/06/2020 documented, .sacrum .3.0 cm (centimeters) X (times) 6.0 cm .no area documented .right lateral hip .1.5 cm X 0.8 cm . e. The December 2020 Physician order [REDACTED].clean area with wound cleanser or sterile water, apply nickel sided layer of Santyl .place wound vac to wound at 125 intermediate pressure, white foam to be placed where wound is tunneling and black foam to fit wound bed .change dressing to wound vac every 72 hours .every Monday .Wednesday .Friday .for pressure wound . Order Date: 11/11/2020 f. The December 2020 Physician order [REDACTED].cleanse with wound cleanser or sterile water .pat dry with 4 x 4 gauze .apply nickel thick Santyl and pack wound with Iodiform packing strips, cover with 2 x 2 barrier island dressing on MWF (Monday, Wednesday, Friday) .and PRN (as needed) until resolved .for wound treatment . Order Date: 11/16/2020 g. The November 2020 Treatment Administration Record (TAR) and the progress notes documented, Wound dressings were changed on 11/16/2020 and were scheduled for Monday, Wednesday, Friday and PRN. Wound dressing changes were not documented as completed on 11/18/2020 and 11/20/2020. h. There was no documentation on the November 2020 TAR of monitoring and or accessing the dressing to the right trochanter for signs/symptoms of infection, pain, dressing intactness documented for 11/01/2020 for day or night shift .for day shift on 11/03/2020 .for night shift on 11/05/2020 .for night shift on 11/06/2020 .for day shift on 11/07/2020 .for day shift on 11/08/2020 .for day shift on 11/10/2020 .for day shift on 11/14/2020 .for day shift on 11/15/2020 .for day shift on 11/17/2020 .for day shift on 11/18/2020, 11/22/2020, 11/23/2020, 11/25/2020, 11/27/2020, 11/28/2020, and 11/29/2020 . i. There was no documentation on the November 2020 TAR for monitoring and accessing the sacrum for signs/symptoms of infection, pain, and dressing intactness documented on 11/01/2020 for day or night shift, 11/03/2020 for day shift on, 11/05/2020 for night shift, 11/06/2020 for night shift on, 11/07/2020 for day shift, 11/08/2020 for day shift, 11/10/2020 for day shift, 11/14/2020 for day shift, 11/15/2020 for day shift, 11/17/2020 for day shift, 11/18/2020 for day shift, 11/22/2020, 11/23/2020, 11/25/2020, 11/27/2020, 11/28/2020, and 11/29/2020 . j. A wound evaluation dated 12/02/2020 documented .sacrum .area 15.6 cm X 4.8 cm X 4.0 cm . k. On 12/02/2020 at 9:56 a.m., Resident #1 was in bed watching television. A wound vac was attached to the half bed rail, it was on and running. Resident #1 was asked, Do you have any pressure ulcers or sores? Resident #1 replied, Yes, I have a vac pump on my bottom, and I have a wound on my left hip and my heel and on my stump. Resident #1 was asked, Does the facility change the dressings on a regular basis? Resident #1 replied, No, I just want it changed three times a week. That's what they promised to do. Resident #1 stated, I have to wait days, and they are not going to heal if they are not properly handled. Resident #1 was asked, Does the facility have a wound treatment nurse? Resident #1 replied, The girl that used to do it all just walked out and quit. Then they had a guy doing it Monday, Wednesday, and Friday and he was good. Resident #1 was asked, What happened to him? Resident #1 replied, He walked out. Resident #1 stated, The agreement we had was for Monday, Wednesday, and Friday and there is no reason why they can't hold up their end. That's when they are supposed to change the dressings, all of them. Resident #1 was asked if this surveyor could look at his wounds. Resident #1 agreed to let this surveyor look at his wound dressings. (Photos taken.) l. On 12/02/2020 at 10:07 a.m., with the assistance of Certified Nursing Assistant (CNA) #3 and CNA #4. this surveyor observed Residents #1's dressings. Resident #1's buttocks / (and or) sacrum area was red and macerated. The drape dressing was brown and rolled on the edges. There was no date or initials on the dressing as to when the dressing/wound vac was changed. (Photo taken.) A dressing on Resident #1's left heel did not have a date or initials to note when the dressing was changed. CNA #3 and #4 were asked, Is there a date with initials on the dressing? CNA #3 and #4 replied, No. (A photo was taken with Resident #1's permission). A dressing to Resident #1's right knee below the amputation did not have a date or initials to note when the dressing was changed. CNA #3 and #4 were asked, Is there a date with initials on the dressing? Both CNA's replied, No. (Photo taken.) A pressure ulcer to the right hip was red/pink in color and there was no dressing in place. (Photo taken.) Resident #1's buttocks had a drape dressing with wound vac in place. Resident #1's buttocks/sacrum area was red and macerated. The drape dressing was brown and rolled on the edges. There was no date or initials on the dressing as to when the dressing/wound vac was changed. Both CNA #3 and #4 were asked, Is there a date with initials on the dressing? CNA #3 and #4 replied, No. (A photo was taken with Resident #1's permission). When the CNA's rolled Resident #1 over, Resident#1 stated, They are supposed to date it and initial it. Resident#1 was asked, How do you know they are supposed to date it and initial it? Resident#1 replied, Because that's what they used to do on the other hall. m. On 12/02/2020 at 11:37 a.m., the Assistant Director of Nursing (ADON) was asked, Who is the treatment nurse? The ADON replied, The treatment nurse quit without notice. The ADON was asked, Who is responsible for wound treatments? The ADON replied, We are all doing them, it's a team effort. The ADON was asked, Did the wound treatment nurse quit recently? The ADON replied, Yes, I don't know the exact date, maybe 2 weeks ago. The ADON was asked, Where are the wound treatments documented? The ADON replied, In the TAR (Treatment Administration Record). The ADON was asked, When are wound assessments performed? The ADON replied, Weekly by the treatment nurse. The ADON was asked, Who is responsible for wound assessments? The ADON replied, The wound care nurse was doing the wound assessments. The ADON was asked, What is the protocol for wound treatments? The ADON replied, They should have the date and initials. The ADON was asked, What does it mean if the wounds are not dated and it's not documented on the TAR? The ADON replied, Then we don't know when it was done. I would assume it's not been done. The ADON was asked, Are you aware of wound treatments and dressings not being changed for days? The ADON replied, We have a schedule, it's usually Mondays, Wednesdays, and Fridays. n. On 12/02/2020 at 11:47 a.m., Licensed Practical Nurse (LPN) #5 was asked, Who is the treatment nurse? LPN #5 replied, We had 2 treatment nurses, (Name) quit, and (Name) left. LPN #5 was asked, Who is responsible for wound treatments? LPN #5 replied, Whoever the floor nurse is. LPN #5 was asked, Did a wound treatment nurse quit recently? LPN #5 replied, Yes, November 18th or 19th I think. LPN #5 was asked, Where are wound treatments documented? LPN #5 replied, In the TAR. LPN #5 was asked, When are wound assessments performed? LPN #5 replied, Weekly. LPN #5 was asked, Who is responsible for wound assessments? LPN #5 replied, The treatment nurse. LPN #5 was asked, What is the protocol for wound treatments? LPN #5 replied, They should have the initials and date. LPN #5 was asked, What does it mean if the wounds are not dated and it's not documented on the TAR? LPN #5 replied, At that point, you go ahead and redo the treatment and click PRN. LPN #5 was asked, Are you aware of wound treatments and dressings not being changed for days? LPN #5 replied, I do know of one that treatment was not done, and a night shift nurse came in and done the treatments. LPN #5 was asked, Who would that be? LPN #5 replied, (Resident#1). o. On 12/03/2020 at 8:21 a.m., LPN #4 accessed Resident#1's electronic health record and documented on the TAR dressing changes with an effective date of 12/01/2020. p. On 12/03/2020 at 8:56 a.m., the Director of Nursing (DON) was shown a picture of Resident #1's wound on the hip and sacrum. The DON was asked to describe the dressing on the sacrum. The DON replied, There's a wound vac and the edges of the dressing are rolled and soiled with bowel movement. The DON was asked, Does this dressing look intact to you? The DON replied, It doesn't appear to be. The DON was asked, What would you do if you saw this on a resident? The DON replied, I would change it. q. On 12/03/2020 at 10:53 a.m., the DON was asked, Have the nurses been in-serviced on wound vac application and use, and when? The DON replied, I have not trained the nurses on a wound vac. I have no in-services. r. On 12/03/2020 at 10:54 a.m., Registered Nurse (RN) #1 was asked, Have you been trained on a wound vac application and use? RN #1 replied, No, I have not. s. On 12/03/2020 at 10:56 a.m., LPN #3 was asked, Have you been in-serviced on a wound vac since you've been here? LPN #3 replied, No. LPN #3 was asked, How long have you been here? LPN #3 replied, Since the beginning of November of this year. LPN #3 was asked, Have you ever changed (Resident #1's) wound vac? LPN #3 replied, Yes, but I have not been in-serviced here. t. On 12/03/2020 at 11:02 a.m., Resident#1 was asked, Have you ever refused for staff to change your dressings? Resident#1 replied, No. Resident#1 was asked, When was the last time staff changed your wound dressings? Resident#1 replied, Yesterday. Resident#1 was asked, Did they change them on Monday of this week? Resident#1 replied, No, they didn't change them on Monday. u. On 12/03/2020 at 11:10 a.m., LPN #2 was asked, Have you been trained or in-serviced on a wound vac? LPN #2 replied, Yes, a long time ago. LPN #2 was asked, Were you in-serviced since working here at the facility? LPN #2 replied, I've been here [AGE] years, but it's been years since I've used a wound vac here. We don't use them much and I'd have to brush up on it. v. A Witness Statement signed by LPN #3 dated 12/03/2020 was provided by the Administrator on 12/03/2020 at 1:00 p.m. documented, .I performed treatment on (Resident #1) 11/18/2020 and 11/25/2020 I forgot to sign my TAR but corrected it . LPN #3 stated in an earlier interview she had not been trained in a wound vac since being employed with the facility. w. A Witness Statement signed by LPN #4 dated 12/03/2020 was provided by the Administrator on 12/03/2020 at 1:00 p.m. documented, .I performed wound care on (Resident #1) on 12/01/2020 per physician's orders [REDACTED]. 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an Assessment Reference Date ARD of 11/05/2020 documented the resident scored 6 (0-7 indicate severe impairment) per a BIMS and required extensive assistance of two plus persons with bed mobility, toilet use, and personal hygiene. a. The Care Plan documented . The resident has potential/actual impairment to skin integrity of the head, neck, and abdomen - surgical incisions. Pressure Ulcer ST (stage) II to buttocks. Follow facility protocols for treatment of [REDACTED]. Date Initiated: 05/18/2020. b. The December 2020 Physician order [REDACTED]. Cleanse area with wound cleanser or sterile water, pat dry with 4x4, apply dime thick layer of collagen hydrogel, and cover with 4x4 barrier dressing on MWF (Monday, Wednesday, Friday) and PRN (as needed) until resolved. Every Mon, Wed, Fri for pressure area and as needed for soiling or removal. Order Date: 11/11/2020. c. The November 2020 Treatment Administration Record (TAR) documented, Tx to sacrum and right buttock SDTI. Cleanse area with wound cleanser or sterile water, pat dry with 4x4, apply dime thick layer or collagen hydrogel, and cover with 4x4 barrier dressing on MWF and PRN until resolved. Every Mon, Wed, Fri for pressure area. There was no documentation of a dressing change on Friday 11/13/2020 and Monday 11/30/2020. d. The Nursing Weekly Assessment/Note with Skin Audit dated 11/25/2020 documented .No new skin issues . e. On 12/02/2020 at 10:03 a.m., Registered Nurse (RN) #1 was asked how often wound dressings are to be changed. She stated, Three times a week and as needed is how they are normally ordered, but you just follow the order. RN #1 was asked, What do you do if you notice a dressing has not been changed on time? She stated I would take the bandage off to reassess the wound and change it. Then I would look at the TAR to see why it wasn't changed and if there is no reason why, I would report it to the Director of Nursing (DON). RN #1 was asked, Who is responsible for treatments? She stated The treatment nurse was, but then they quit. One of the department managers is filling in now. f. On 12/02/2020 at 10:17a.m., Licensed Practical Nurse (LPN) #1 was asked if (Resident #2) has any pressure ulcers currently. She stated, She has a healing one on her coccyx. LPN#1 was asked if (Resident #2) is receiving treatments for it. She stated, I'm not sure. I can look. LPN#1 was asked, Who is responsible for doing wound treatments? She stated, The treatment nurse. LPN#1 was asked, When the treatment nurse quit who was responsible? She stated Uh, I think another nurse came around and did them. g. On 12/02/2020 at 10:23a.m., Resident #2 was asked if it was okay to look at the dressing on her bottom. She stated Sure, but I don't think there is anything back there. Resident #2 was asked if she normally has a dressing to her bottom. She stated Sometimes. It was looking bad at one point, but it's a bit better now. They must've stopped treating it. Certified Nursing Assistant (CNA) #1 and CNA #2 assisted in rolling Resident #2 over on her left side. There was not a dressing in place. There was a red dime size spot on her right buttock. CNA #2 was asked if she saw a dressing in (Resident #2's) brief. CNA #2 stated, No. CNA #2 was asked if the reddened area to (Resident #2's) right buttock appeared to be scabbed over. She stated, I don't think so. It may be healing now. h. On 12/03/2020 at 11:10a.m., the Assistant Director of Nursing (ADON) was asked if a suspected deep tissue injury should be documented on the wound evaluations and weekly skin assessments. She stated Of course. The ADON was asked if there was a reason treatments were not done on 11/30/2020. She stated No. I was doing assessments that day to have a blank slate on what everyone's wound status was since I had just started taking over treatments. I let everyone know that the floor nurses were responsible to do their own treatments that day. i. On 12/03/2020 at 11:40 a.m., LPN #2 was asked, How familiar are you with (Resident #2)? She stated, Oh, very. LPN #2 was asked if she was aware of some of her skin issues. She stated, I think she had a pressure spot on like her sacrum up high, then a spot a bit lower on, I think her right butt cheek. LPN #2 was asked, What would you call the spot on her buttock? She stated, Well I'm not sure, but probably a DTI (Deep Tissue Injury). Because you can't really tell what it is cause it's a darker spot. LPN #2 was asked, Who is responsible for completing the weekly skin assessments? She stated We do the weekly assessments and the treatment nurse does the actual wound evaluation. When we do the assessment, we document if there are any issues with the skin, but we don't do measurements or staging, the treatment nurse does that on her evaluation. LPN#2 was asked if a Deep Tissue Injury should be documented on the Weekly Skin Assessment. She stated Yes. LPN #2 was asked, Who is responsible for wound treatments? She stated, I'm weekend option so we do our own cause we don't have a treatment nurse. 3. Resident #3 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 09/28/2020 documented the resident was moderately impaired in cognitive skills per a Staff Assessment for Mental Status and required extensive assistance of two plus persons with bed mobility, dressing, toilet use, and personal hygiene. a. The Care Plan documented . (Resident #3) has potential for pressure ulcer development r/t impaired mobility, weakness, incontinence of bowel & bladder; resident will not let you turn her, impaired cognition, refuses care at times, refuses to be changed at times, refuses repositioning at times, yells out when care is provided (dressing, peri care, incontinent care) Date Initiated: 02/16/2018 . Follow facility policies/protocols for the prevention/treatment of [REDACTED]. b. The December 2020 Physician order [REDACTED]. Every day and night shift. Order Date: 11/02/2020. c. The December 2020 Physician order [REDACTED]. Every Mon, Wed, Fri. Order Date 11/11/20. Treatment to left posterior inner thigh stage 2 pressure wound: Cleanse with wound cleanser or sterile water, pat dry wit 4x4 gauze, apply dime thick [MEDICATION NAME] and nickel thick Santyl, cover with 4x4 barrier dressing on MWF and PRN until resolved. Every Mon, Wed, Fri and as needed for soiling or removal. d. On 12/02/2020 at 10:10a.m., CNA #1 and CNA #2 rolled Resident #3 on her right side. There was no dressing to the coccyx or inner thighs. Resident #3 had slight redness to her bottom and what appeared to be a dark red open area on the back of her left upper thigh. CNA #1 began to provide incontinent care. When CNA #1 wiped between Resident #3's legs there was scant amounts of bright red liquid on the wipe. CNA #1 was asked if there were any wound dressings on (Resident #3) or in the brief. She stated, No there's nothing. CNA #2 then stated I know she had one on her bottom the other day, but I don't know what happened after 3 p.m. CNA #1 was asked what the red substance on the wipe was. She stated Blood, but it's just from one of her thighs. e. On 12/02/2020 at 10:17 a.m., LPN #1 was asked if (Resident #3) had any pressure ulcers. She stated, I think she has one to her right buttock and some excoriation to her thigh. LPN #1 was asked if any of the wounds were open. She stated, I'm not sure. I'd have to look. LPN #1 was asked if (Resident #3) was currently receiving treatments for it. She stated, Yes, she gets wound care. f. On 12/02/2020 at 12:11p.m., the DON was asked if she was aware of residents not receiving wound dressing changes. She stated No, I wasn't aware. The DON was asked who was responsible for treatments. She stated, The wound care nurse and if she's not here then the hall nurses. The DON was asked, Are the hall nurses made aware that they need to do wound care? She stated, I usually text them. The DON was asked if there was a reason for treatment orders to not be followed. She stated No. The DON was asked, What is done when a wound area is resolved? She stated, We resolve it by discontinuing the treatment. Sometimes we keep the treatment though. If it is an area that has reopened or if they are prone to skin issues in that area, we continue the treatment. The DON was asked if it is appropriate for healed wounds to still have treatment orders. She stated, Yes, they should. The DON was asked, Where are treatments documented at. She stated, On the TAR. The DON was asked what a blank space on the TAR indicates. She stated, Well it's one of two things either they didn't sign it, or it wasn't done. g. On 12/03/2020 at 11:10a.m., the Assistant Director of Nursing (ADON) was asked, Why on the TAR is (Resident #3's) excoriation not being monitored consistently? She stated, I don't know. The TAR is to be completed and the orders are to be followed. The ADON was asked, If a resident had an order for [REDACTED]. h. At 11:40a.m., LPN #2 was asked how familiar she was with (Resident #3). She stated, Pretty familiar. LPN #2 was asked if she could tell this surveyor about any skin issues that (Resident #3) may have. She stated Well, she has an abrasion to the left posterior thigh that is open. She also has a pressure area to her right buttock. Last Sunday when I worked, I think it was open too but I haven't had a chance to look at it today yet. LPN #2 was asked how she is made aware that a resident needs a treatment. She stated You go by the TAR. If they need it PRN, the CNAs are pretty good about letting us know if it comes off or is soiled. I like to go around and look at all of them myself too in the evenings. LPN #2 was asked if (Resident #3) should have a dressing on. She stated Yes. 4. A Wound Care policy documented, .Wound Care .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .The following information should be recorded in the resident's medical record: the date and time the dressing was changed .wound appearance, including wound bed, edges, presence of drainage .name and title of the individual changing the dressing .the type of dressing used and wound care given .all assessment data (i.e., (example) pain or discomfort) .if the resident refused the treatment and the reason why .notify the supervisor if the resident refuses the dressing change .report other information in accordance with facility policy and professional standards of practice .

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure the attending physician was immediately consulted regarding a significant change in condition for 1 (Resident #3) of 5 (Residents #1, #2, #3, #4 and #5) case mix residents who experienced a significant change of condition. This failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious injury, harm or death for Resident #3 who had a change of condition of the left lower extremity and had the potential to cause more than minimal harm for 7 residents who had a change of condition, as documented on a list provided by the Assistant Director of Nursing (ADON) on 5/3/11 at 3:00 p.m. The Administrator was notified of the Immediate Jeopardy on 5/4/11 at 4:30 p.m. The findings are: Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 2/25/11 documented the resident had a Brief Interview for Mental Status summary score of 3 (0-7 severe impairment), required extensive physical assistance of one person for bed mobility, transfer, dressing and bathing and had no functional limitation in range of motion of the upper or lower extremities. a. physician's orders [REDACTED]." physician's orders [REDACTED]." b. physician's orders [REDACTED]." The resident's April 2011 Medication Record documented [MEDICATION NAME] 75 mg and ASA 81 mg held 4/7/11, 4/8/11, 4/9/11, 4/10/11, 4/11/11 and 4/12/11 (date of eye surgery). c. A Body Audit dated 4/26/11 documented, "dry skin-lotion" with no other findings documented. d. The facility's Event Reporting dated 4/26/11 at 5:30 p.m., documented, "CNA (Certified Nursing Assistant) was transferring resident to w/c (wheelchair) from bed. Resident was on edge of w/c. CNA lowered resident to floor to avoid fall. Assist x (times) 2 staff to assist res (resident) to w/c. Complete body audit done. No injury noted." e. The 24-hour Report dated 4/26/11 documented on the section identified as the 6:00 p.m. to 6:00 a.m. section regarding Resident #3, "3 (plus) [MEDICAL CONDITION] noted to LLE (left lower extremity) - monitor." There was no documentation on the report that the physician was consulted. There was nothing documented in the Nurses Notes for 4/26/11. f. Nurse's Notes dated 4/27/11 at 1:50 a.m. documented, "3 (plus) [MEDICAL CONDITION] noted to LLE. No skin breakdown noted at this time. Res denies c/o (complaints) pain/discomfort to extremity. Res receives scheduled diuretics daily. Will cont (continue) to monitor. Legs elevated (with) pillows. Will inform day nurse at shift change to monitor also." There was no documentation in the Notes that the physician was consulted. On 5/4/11 at 3:30 p.m., Licensed Practical Nurse (LPN) #5 stated that she authored the Nurses Note dated 4/27/11 at 1:50 a.m. She stated, "The aide told me that the resident had a swollen leg. She had pulses, the leg was pale and cool to touch. There were no purple spots. I did not document my total assessment." g. On 5/4/11 at 2:15 p.m., LPN #4 stated, "Both the left and right legs were swollen on 4/26/11. They weren't much more swollen than usual. The family was here. On the 27th I worked 6:00 a.m. till 6:00 p.m. Both legs were swollen. The daughter brought it to my attention and I looked at them. Both legs had 2 plus [MEDICAL CONDITION]. I did not call the doctor. Her left leg was slightly more swollen, but not 3 plus. I did not call the doctor because she has had it since she has been here. Her left leg has been bigger than the right before. I asked her if she was having pain. She said no. The daughter was there at the time." There was nothing documented in the Nurses Notes for 4/27/11 after the 1:50 a.m. entry. h. On 5/4/11 at 5:40 p.m., LPN #6 stated, "I worked 6:00 p.m. till 6:00 a.m. on 4/27/11. The CNAs (Certified Nursing Assistant) came to me and said (Resident #3) was crying. I sat on the side of the bed with her. I asked her if she was hurting. She wasn't. When I left she was calmed down and I did not hear anything else about her that night." LPN #6 was asked if she was told in report that the left leg was swollen. She stated, "I don't remember the nurse reporting anything about it." The 24-Hour Report dated 4/27/11 did not document anything regarding Resident #3. There was nothing documented in the Nurses Notes for 4/27/11 after 1:50 a.m. i. On 5/4/11 at 11:10 a.m., LPN #7 stated, "On 4/28/11 (signed in on Daily Staffing Log as in at 5:21 a.m. and out at 2:00 p.m.), I saw (Resident #3's) legs. Her left leg was swollen. She had 3 plus [MEDICAL CONDITION]. The family was there. She had weak pulses in her foot. I did not notify the physician. I did not put the left leg [MEDICAL CONDITION] on the 24 hour report." j. A Body Audit dated 4/28/11 documented, relative to the left leg, "purple spots-swollen." On 5/4/11 at 10:10 a.m., CNA #1 stated that she documented the Body Audit on 4/28/11 (signed in on Daily Staffing Log as in at 5:59 a.m. and out at 2:00 p.m.) She stated, "I gave her a shower. One leg was shockingly big from the knee down. Both legs were swollen, but one much larger than the other. There was a big difference." She further stated that she did not report her findings to the charge nurse. "I don't know why." k. On 5/4/11 at 10:55 a.m., LPN #3 stated, "I worked the night of 4/28/11 (signed in on Daily Staffing Log as in at 5:42 p.m. and out at 10:00 p.m.). I didn't know anything about the leg." The 24-Hour Report dated 4/28/11 did not document anything regarding Resident #3. l. A Body Audit dated 4/29/11 related to the left leg documented, "Lt (left) leg 4 (plus) [MEDICAL CONDITION] to lower ext (extremity) (with) multiple small purple areas... Lt (left) foot 4 (plus) [MEDICAL CONDITION]." The Body Audit documented "reported to charge nurse. Res sent to ER (emergency room )." On 5/4/11 at 9:37 a.m., LPN #2 (Treatment Nurse) stated that she documented the Body Audit dated 4/29/11. She stated, "The Director of Nursing called and asked me to see her leg as the daughter was concerned with her legs. The daughter said she had blisters on the left leg. I went to look. There were no blisters. The left leg was very swollen and had purple spots, not bruises, like she bumped them. They were quarter size, round, multiple, four or five, I did not count. The left leg was probably twice the size of the right from the knee down. I did not measure. The skin was tight. I did not check the pulses. I told the charge nurse that the left leg was very swollen and that she needed to look at it. The daughter said the nurse that worked the day before was supposed to notify the doctor about the leg." m. Nurse's Notes dated 4/28/11 (actually 4/29/11 per physician order [REDACTED]. Pedal pulse faint, popliteal pulse faint. Bluish at ends of toes. VS (vital signs) 98/60 (blood pressure)-98.5 (temperature)-18 (respirations)-56 (pulse). Dgt (daughter) in room with resident. Resident sent to ER for evaluation. (Ambulance Transport Service) notified. Report called to ER." On 4/29/11 the physician's orders [REDACTED]." On 5/4/11 at 9:15 a.m., LPN #1 stated, "I took care of her on the 28th (4/28/11-actually 4/29/11 per physician order [REDACTED]. The treatment nurse asked me if I had seen her leg and I had not. I went to look at her leg. The pedal pulses were faint. I did vital signs. The daughter was in the room. I told her I felt like she needs to go to ER. She was lethargic, she would not respond but was a little bit out of it." Nurse's Notes dated 5/4/11 (at no time noted) documented, "(Resident #3) left facility on 4/29/11 to go to (Hospital's) ER." On 5/4/11 at 10:05 a.m., the Director of Nursing stated, "The Nurses Notes dated 4/28/11 where the resident was sent to the hospital... the LPN must have put the wrong date. It was 4/29/11 that she went to the hospital." n. The emergency room Physician documented an assessment of the resident's lower extremities dated 4/29/11 as, "[MEDICAL CONDITION], [DIAGNOSES REDACTED], calor (heat, as one of the 4 signs of inflammation) present to LLE." 1) The Lower Extremity Venous Report dated 4/29/11 documented an interpretation summary of, "Thrombus left common femoral, deep femoral, femoral and popliteal vein. A thrombus in the right superficial greater saphenous vein." 2) The Physician's History and Physical dated 4/29/11 documented the history of present illness as, "(Resident #3) is an [AGE] year old white female with end-stage Alzheimer's dementia, hypertension, [MEDICAL CONDITION], recurrent urinary tract infections and [MEDICAL CONDITION]. As per emergency room physician, patient has had worsening confusion over the past 2 to 3 days; thus, was sent to the emergency room . Daughter is currently here on the floor and reported that, since Monday, she has been getting more confused, her left lower extremity was getting more swollen, her urine looked darker and very foul-smelling. She has a history of recurrent urinary tract infection, according to her and she gets into confusion every time she had infection. In the emergency room , she was noted to have left lower extremity [MEDICAL CONDITION]." The impression was documented as, "[MEDICAL CONDITION] of the left lower extremity, Urinary Tract Infection, Dementia, Hypertension and [MEDICAL CONDITION]." o. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on 5/5/11 at 9:57 a.m., when the facility implemented the following Plan of Removal: "1. Inservices performed on 5/4/11: a.) DON (Director of Nursing) /ADON /and or Designee inserviced all nurses on duty of change of condition and notification of family and doctor immediately and follow up on 24-hour report with any changes. All nurses will be inserviced before working their next scheduled shift. b.) DON/ADON/and or Designee inserviced all nurses on duty on Event Report (Incident and Accident Report) follow up and reporting change of condition to doctor and family and doing a full assessment when monitoring every 8 hours at a minimum or more often if indicated by condition until condition resolved. All nurses will be inserviced before working their next scheduled shift. c.) DON/ADON/and or Designee inserviced all CNA's on duty on change of condition to notify charge nurse immediately. All CNA's will be inserviced before working their next scheduled shift. d.) DON/ADON/and or Designee inserviced all nurses and CNA's on duty regarding body audits. Body audits will be performed twice weekly by shower aides and they will give audit sheet to treatment nurse. RN and/or LPN will perform body audits on admission, readmission, change of condition and one time weekly. All nurses and CNA's will be inserviced before working their next scheduled shift. e.) DON/ADON/and or Designee inserviced all nurses on duty regarding checking orders to make sure that all follow up is complete. All nurses will be inserviced before working their next scheduled shift. f.) DON/ADON/and or Designee inserviced all nurses on duty regarding off going nurse must do a verbal report with oncoming nurse. Oncoming nurse must review 24 hour report and follow up on all noted issues. All nurses will be inserviced before working their next scheduled shift. 2. On 5/4/11 body audits were performed by RN (Registered Nurse) and LPN's on all residents. Any negative findings were reported to their respective attending physician and family immediately upon discovery. 3. All resident charts and daily 24-hour reports for the past 30 days were reviewed on 5/4/11 by DON, ADON, Medical Records and designees to identify any change of conditions to ensure appropriate follow up of the change. Any negative findings will be corrected immediately upon discovery. 4. Monitor the effectiveness of the inservice training: DON, ADON, Medical Records and designees will review 24-hour reports daily until compliance is achieved to identify change of condition and follow thru. Then review 5 (times) weekly. Negative findings will be corrected immediately upon discovery. DON, ADON, Medical Records and designees will review 5 medical records per nurses station (4 nurses stations) daily until compliance is achieved to identify change of condition and follow thru. Then we will review 20 charts weekly. Negative findings will be corrected immediately upon discovery. 5. DON, ADON, Medical Records and designees will monitor the effectiveness of the CNA inservice training by monitoring shower forms for change in skin condition 5 (times) weekly. 6. DON, ADON, Medical Records and designees will monitor and document body audits completed weekly thru daily start up process and will perform 20 random body audits weekly to compare accuracy until compliance is achieved. 7. ADON and designees used for monitoring will report negative findings to the DON and or administrator daily. 8. DON will report all negative findings to QA (Quality Assurance) subcommittee weekly. 9. Administrator will report all negative findings to the QA committee monthly for recommendations for corrective action."

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure necessary care and services were provided to attain or maintain the highest practicable physical well-being for Resident #3. The facility failed to thoroughly assess a significant change in the resident's condition, to immediately consult with the attending physician regarding the significant changes, to monitor the resident's condition at least every shift, and to report changes to the oncoming charge nurses to ensure the changes in condition could be monitored for 1 (Resident #3) of 5 (Residents #1, #2, #3, #4 and #5) case mix residents who experienced a significant change of condition. This failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious injury, harm or death for Resident #3 who had a significant change of condition of the left lower extremity and had the potential to cause more than minimal harm for 7 residents who had a change of condition, as documented on a list provided by the Assistant Director of Nursing (ADON) on 5/3/11 at 3:00 p.m. The Administrator was notified of the Immediate Jeopardy on 5/4/11 at 4:30 p.m. The findings are: Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 2/25/11 documented the resident had a Brief Interview for Mental Status summary score of 3 (0-7 severe impairment), required extensive physical assistance of one person for bed mobility, transfer, dressing and bathing and had no functional limitation in range of motion of the upper or lower extremities. a. physician's orders [REDACTED]." physician's orders [REDACTED]." b. physician's orders [REDACTED]." The resident's April 2011 Medication Record documented [MEDICATION NAME] 75 mg and ASA 81 mg held 4/7/11, 4/8/11, 4/9/11, 4/10/11, 4/11/11 and 4/12/11 (date of eye surgery). c. A Body Audit dated 4/26/11 documented, "dry skin-lotion" with no other findings documented. d. The facility's Event Reporting dated 4/26/11 at 5:30 p.m., documented, "CNA (Certified Nursing Assistant) was transferring resident to w/c (wheelchair) from bed. Resident was on edge of w/c. CNA lowered resident to floor to avoid fall. Assist x (times) 2 staff to assist res (resident) to w/c. Complete body audit done. No injury noted." e. The 24-hour Report dated 4/26/11 documented on the section identified as the 6:00 p.m. to 6:00 a.m. section regarding Resident #3, "3 (plus) [MEDICAL CONDITION] noted to LLE (left lower extremity) - monitor." There was no documentation on the report that the physician was consulted. There was nothing documented in the Nurses Notes for 4/26/11. f. Nurse's Notes dated 4/27/11 at 1:50 a.m. documented, "3 (plus) [MEDICAL CONDITION] noted to LLE. No skin breakdown noted at this time. Res denies c/o (complaints) pain/discomfort to extremity. Res receives scheduled diuretics daily. Will cont (continue) to monitor. Legs elevated (with) pillows. Will inform day nurse at shift change to monitor also." There was no documentation in the Notes that the physician was consulted. On 5/4/11 at 3:30 p.m., Licensed Practical Nurse (LPN) #5 stated that she authored the Nurses Note dated 4/27/11 at 1:50 a.m. She stated, "The aide told me that the resident had a swollen leg. She had pulses, the leg was pale and cool to touch. There were no purple spots. I did not document my total assessment." g. On 5/4/11 at 2:15 p.m., LPN #4 stated, "Both the left and right legs were swollen on 4/26/11. They weren't much more swollen than usual. The family was here. On the 27th I worked 6:00 a.m. till 6:00 p.m. Both legs were swollen. The daughter brought it to my attention and I looked at them. Both legs had 2 (plus) [MEDICAL CONDITION]. I did not call the doctor. Her left leg was slightly more swollen but not 3 (plus). I did not call the doctor because she has had it since she has been here. Her left leg has been bigger than the right before. I asked her if she was having pain. She said no. The daughter was there at the time." LPN #4 was asked if she had received a report regarding Resident #3 from the prior shift nurse. She stated that she did not remember. (Sign in sheets documented on duty 4/26/11 from 5:17 a.m. to 7:12 p.m. and 4/27/11 from 5:33 a.m. till 2:00 p.m.) h. On 5/4/11 at 5:40 p.m., LPN #6 stated, "I worked 6:00 p.m. till 6:00 a.m. on 4/27/11. The CNAs came to me and said (Resident #3) was crying. I sat on the side of the bed with her. I asked her if she was hurting. She wasn't. When I left she was calmed down and I did not hear anything else about her that night." LPN #6 was asked if she was told in report that the left leg was swollen. She stated, "I don't remember the nurse reporting anything about it." The 24-Hour Report dated 4/27/11 did not document anything regarding Resident #3. i. On 5/4/11 at 11:10 a.m., LPN #7 stated, "On 4/28/11 (signed in on Daily Staffing Log as in at 5:21 a.m. and out at 2:00 p.m.), I saw (Resident #3's) legs. Her left leg was swollen. She had 3 (plus) [MEDICAL CONDITION]. The family was there. She had weak pulses in her foot. I did not notify the physician. I did not put the left leg [MEDICAL CONDITION] on the 24 hour report." j. A Body Audit dated 4/28/11 documented, relative to the left leg, "purple spots-swollen." On 5/4/11 at 10:10 a.m., CNA #1 (Certified Nursing Assistant) stated that she documented the Body Audit on 4/28/11(signed in on Daily Staffing Log as in at 5:59 a.m. and out at 2:00 p.m.) She stated, "I gave her a shower. One leg was shockingly big from the knee down. Both legs were swollen but one much larger than the other. There was a big difference." She further stated that she did not report her findings to the charge nurse. "I don't know why." k. On 5/4/11 at 10:55 a.m., LPN #3 stated, "I worked the night of 4/28/11 (signed in on Daily Staffing Log as in at 5:42 p.m. and out at 10:00 p.m.). I didn't know anything about the leg." The 24-Hour Report dated 4/28/11 did not document anything regarding Resident #3. l. A Body Audit dated 4/29/11 related to the left leg documented, "Lt (left) leg 4 (plus) [MEDICAL CONDITION] to lower ext (extremity) (with) multiple small purple areas... Lt (left) foot 4 (plus) [MEDICAL CONDITION]." The Body Audit documented "reported to charge nurse. Res sent to ER (emergency room )." On 5/4/11 at 9:37 a.m., LPN #2 (Treatment Nurse) stated that she documented the Body Audit dated 4/29/11. She stated, "The Director of Nursing called and asked me to see her leg as the daughter was concerned with her legs. The daughter said she had blisters on the left leg. I went to look. There were no blisters. The left leg was very swollen and had purple spots, not bruises, like she bumped them. They were quarter size, round, multiple, four or five, I did not count. The left leg was probably twice the size of the right from the knee down. I did not measure. The skin was tight. I did not check the pulses. I told the charge nurse that the left leg was very swollen and that she needed to look at it. The daughter said the nurse that worked the day before was supposed to notify the doctor about the leg." m. Nurse's Notes dated 4/28/11 (actually 4/29/11 per physician order [REDACTED]. Pedal pulse faint, popliteal pulse faint. Bluish at ends of toes. VS (vital signs) 98/60 (blood pressure)-98.5 (temperature)-18 (respirations)-56 (pulse). Dgt (daughter) in room with resident. Resident sent to ER for evaluation. (Ambulance Transport Service) notified. Report called to ER." On 4/29/11 the physician's orders [REDACTED]." On 5/4/11 at 9:15 a.m., LPN #1 stated, "I took care of her on the 28th (4/28/11-actually 4/29/11 per physician order [REDACTED]. The treatment nurse asked me if I had seen her leg and I had not. I went to look at her leg. The pedal pulses were faint. I did vital signs. The daughter was in the room. I told her I felt like she needs to go to ER. She was lethargic, she would not respond, but was a little bit out of it." LPN #1 was asked if she read the Nurses Notes on 4/27/11. She stated, "Yes, after I sent her to the hospital." Nurse's Notes dated 5/4/11 (at no time noted) documented, "(Resident #3) left facility on 4/29/11 to go to (Hospital's) ER." On 5/4/11 at 10:05 a.m., the Director of Nursing (DON) stated, "The Nurses Notes dated 4/28/11 where the resident was sent to the hospital... the LPN must have put the wrong date. It was 4/29/11 that she went to the hospital." n. The emergency room Physician documented an assessment of the lower extremities dated 4/29/11 as, "[MEDICAL CONDITION], [DIAGNOSES REDACTED], calor (heat, as one of the 4 signs of inflammation) present to LLE." 1) The Lower Extremity Venous Report dated 4/29/11 documented an interpretation summary of, "Thrombus left common femoral, deep femoral, femoral and popliteal vein. A thrombus in the right superficial greater saphenous vein." 2) The Physician's History and Physical dated 4/29/11 documented the history of present illness as, "(Resident #3) is an [AGE] year old white female with end-stage Alzheimer's dementia, hypertension, [MEDICAL CONDITION], recurrent urinary tract infections and [MEDICAL CONDITION]. As per emergency room physician, patient has had worsening confusion over the past 2 to 3 days; thus, was sent to the emergency room . Daughter is currently here on the floor and reported that, since Monday, she has been getting more confused, her left lower extremity was getting more swollen, her urine looked darker and very foul-smelling. She has a history of recurrent urinary tract infection, according to her and she gets into confusion every time she had infection. In the emergency room , she was noted to have left lower extremity [MEDICAL CONDITION]." The impression was documented as, "[MEDICAL CONDITION] of the left lower extremity, Urinary Tract Infection, Dementia, Hypertension and [MEDICAL CONDITION]." o. The Immediate Jeopardy was removed and the scope/severity reduced to "H" on 5/5/11 at 9:57 a.m., when the facility implemented the following Plan of Removal: "1. Inservices performed on 5/4/11: a.) DON /ADON /and or Designee inserviced all nurses on duty of change of condition and notification of family and doctor immediately and follow up on 24-hour report with any changes. All nurses will be inserviced before working their next scheduled shift. b.) DON/ADON/and or Designee inserviced all nurses on duty on Event Report (Incident and Accident Report) follow up and reporting change of condition to doctor and family and doing a full assessment when monitoring every 8 hours at a minimum or more often if indicated by condition until condition resolved. All nurses will be inserviced before working their next scheduled shift. c.) DON/ADON/and or Designee inserviced all CNA's (Certified Nursing Assistants) on duty on change of condition to notify charge nurse immediately. All CNA's will be inserviced before working their next scheduled shift. d.) DON/ADON/and or Designee inserviced all nurses and CNA's on duty regarding body audits. Body audits will be performed twice weekly by shower aides and they will give audit sheet to treatment nurse. RN and/or LPN will perform body audits on admission, readmission, change of condition and one time weekly. All nurses and CNA's will be inserviced before working their next scheduled shift. e.) DON/ADON/and or Designee inserviced all nurses on duty regarding checking orders to make sure that all follow up is complete. All nurses will be inserviced before working their next scheduled shift. f.) DON/ADON/and or Designee inserviced all nurses on duty regarding off going nurse must do a verbal report with oncoming nurse. Oncoming nurse must review 24 hour report and follow up on all noted issues. All nurses will be inserviced before working their next scheduled shift. 2. On 5/4/11 body audits were performed by RN (Registered Nurse) and LPN's on all residents. Any negative findings were reported to their respective attending physician and family immediately upon discovery. 3. All resident charts and daily 24-hour reports for the past 30 days were reviewed on 5/4/11 by DON, ADON, Medical Records and designees to identify any change of conditions to ensure appropriate follow up of the change. Any negative findings will be corrected immediately upon discovery. 4. Monitor the effectiveness of the inservice training: DON, ADON, Medical Records and designees will review 24-hour reports daily until compliance is achieved to identify change of condition and follow thru. Then review 5 (times) weekly. Negative findings will be corrected immediately upon discovery. DON, ADON, Medical Records and designees will review 5 medical records per nurses station (4 nurses stations) daily until compliance is achieved to identify change of condition and follow thru. Then we will review 20 charts weekly. Negative findings will be corrected immediately upon discovery. 5. DON, ADON, Medical Records and designees will monitor the effectiveness of the CNA inservice training by monitoring shower forms for change in skin condition 5 (times) weekly. 6. DON, ADON, Medical Records and designees will monitor and document body audits completed weekly thru daily start up process and will perform 20 random body audits weekly to compare accuracy until compliance is achieved. 7. ADON and designees used for monitoring will report negative findings to the DON and or administrator daily. 8. DON will report all negative findings to QA (Quality Assurance) subcommittee weekly. 9. Administrator will report all negative findings to the QA committee monthly for recommendations for corrective action."