Every finding on record at The Springs of Hillcrest

Based on interviews, record review, facility policy review, and documents it was determined the facility failed to ensure written notification provided to the resident, and or the residents representative of transfer/discharge to the hospital included all the required information when a resident was transferred to the hospital for two (2) (Resident #86, # 81) of three (3) sampled residents, reviewed for hospitalization. Based on record review, interview, and facility policy review, it was determined the facility failed to ensure written notification was provided to the resident and/or the resident's representative of transfer or discharge to the hospital. The facility also failed to ensure that the notification included all the required information for two (Residents #86 and # 81) of three residents reviewed. Resident #86 A review of Resident #86's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/2025 indicated that Resident #86 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #86's MDS also revealed the resident had diagnoses which included bloodstream infection, paraplegia, and bone infection. A review of a Progress Note for Resident #86 with reference date of 08/06/2025 at 10:15 AM, indicated the Director Of Nursing (DON) spoke to an employee with [hospital name] infectious disease who stated due to the nature of the diagnosis that [medication name] (two drugs that fight bacteria) was the only medication to treat the diagnosis, and Resident #86 would need to transfer back to the hospital for treatment. During record review on 08/13/2025 at 3:30 PM, this surveyor noted there was no notice of bed hold or transfer in Resident #86's clinical records. During an interview on 08/13/2025 at 3:42 PM, this surveyor requested the notice of transfer and bed hold from the Administrator (AD). The AD did not provide a transfer form but provided a form titled Notification of Bed Hold Policy. The document the AD provided did not include the following information that was required for a Notice of Transfer: -The reason for transfer. -The effective date of transfer. -The location to where the resident was transferred. -Statement of the resident's appeal rights with required information. -The name, address (mail and email) and telephone number of the Office of Long-Term Care and the Ombudsman. During an interview on 08/13/2025 at 4:53 PM, the AD was asked to provide the Notification of Transfer to the family that included the information regarding the appeal process and the contact information of the Ombudsman and OLTC. No additional information was provided. During an interview on 08/14/2025 at 10:44 AM, Social Services revealed the letter notification of transfer and bed hold was sent to family in the mail. This surveyor asked Social Services why it was important that this information be given to the family. Social Services stated it was important for the appeal process to be given to the family in case they wanted to appeal, but she was not sure why the family would need the Ombudsman and the state contact information. During an interview on 08/14/2025 at 3:23 PM, the AD stated the Notice of Transfer and Bed Hold should be trigger after the nurse completed the quick Admission, Discharge, and Transfer (ADT) in the facility's electronic record system. The AD indicated that it was the resident representative's right to choose where the resident was transferred to. Resident #81 A review of a Discharge MDS with an ARD of 07/20/2025 revealed Resident #81 had a Staff Assessment for Mental Status that indicated the resident was cognitively intact. The MDS indicated the resident had diagnoses which included fracture to the right shoulder, cancer of the pancreas, cancer of the bone, and muscle shrinking and weakening. A review of Resident #81's Electronic Transfer Form indicated Resident #81 transferred to the hospital on [DATE]. During an interview with the AD on 08/13/2025 at 03:42 PM, this surveyor requested the documentation that was given to Resident #81 or Resident #81's representative at the time of transfer. The AD provided a document titled Notification of Bed Hold and indicated that was the written communication provided to the representative of Resident #81. The document did not contain the required information for a complete Notice of Transfer including the following: - The reason for transfer. - The effective date of transfer. - The location to where the resident transferred. - A statement of the residents' appeal rights with required information. - The name, address (mail and email) and telephone number of the OLTC and the Ombudsman. During an interview on 08/14/2025 at 10:44 AM, Social Services indicated the document titled Notification of Bed Hold was the only document provided to Resident #81 and Resident #81's representative at the time of transfer. Social Services also indicated there was not any additional written information provided to the representative of Resident #81 regarding the missing transfer information, appeal process, or the contact information for the Ombudsman. Social Services indicated that it was important that the family have the appeal process in case they wanted to file an appeal. During an interview on 08/14/2025 at 03:23 PM, the AD indicated that the document titled Notification of Bed Hold was the only document provided to the resident and representative upon transfer for Resident #81. The Administrator also indicated that no additional written information was provided to the representative of Resident #81, to contain the missing transfer information, appeal process, and the contact information for the Ombudsman. A review of a facility policy titled Transfer or Discharge Notice, revised March 2021, indicated that a resident and representative were to be notified of the specific reason for a transfer and the contact information of the Ombudsman, and the contact information of the state health department agency that had been designated to handle appeals of transfers and discharge notices.

Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure wound care supplies available for use were not expired in 2 of 2 medication rooms.Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure wound care supplies available for use were not expired in two (Station #1, Station #2) of two medication rooms observed. The findings include: During concurrent observation and interview on 08/14/2025 at 1:30 PM of Station #2 medication room with Licensed Practical Nurse (LPN) #1, the following medicated products for wound care were found to be expired. 1. Oil emulsion dressings with the following expiration dates and quantity 09/2021 – x1 and 02-2023 – x7 2. Silvasorb gel tube, expiration date 04/2025 3. DermaSyn/AG tube, expiration date 03/29/2025 LPN #1 indicated the wound care products identified were expired and stated that the products could be used because they were available. During concurrent observation and interview on 08/14/2025 at 1:45 PM of Station #1 medication room with LPN #1, the following medicated products for wound care were found to be expired. 1. Calcium alginate dressing expiration date 04-21-2024 2. Oil emulsion dressing with the following expiration dates and quantity 02-2023 – x3 and 09-2023 - x3 3. Providone Iodine bottle expiration date 02-2025 4. Dermasyn/AG gel tube expiration date 03-29-25 5. Hydrogel saturated gauze with the following expiration dates and quantity 10/27/24 – x4 and 02/2023 – x4 LPN #1 indicated the wound care products identified were expired and stated the products could be used because they are available. LPN #1 also indicated that the products should not be used since expired products can reduce the effectiveness of the medication. During an interview on 08/14/2025 at 2:10 PM, the Director of Nursing (DON) indicated the products identified were outdated. The DON stated it was important that expired products identified in Station #1 and Station #2 medication rooms not be used because expired medications can reduce the effectiveness of the medication. During an interview on 08/14/2025 at 3:05 PM, the Administrator indicated the expired products identified in Station #1 and Station #2 medication rooms should not be used because expired medications can reduce the effectiveness. On 08/14/2025 at 4:47 PM, the DON provided a policy titled Storage of Medications, with a revision date of November 2020. A review of the document indicated outdated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed.

Based on observation, record reviews and interviews, the facility failed to ensure serving items were properly covered; unused food items were kept away from used food items; the kitchen was free from buildup of unknown substances that had the potential to fall into food items to be served; equipment was in safe and useable condition; open food items were properly closed/sealed and had an open date; food items were not expired; food containers were put away without the contents being on the outside container; and the walls, floors, and door were in good repair without holes and or missing or chipped paint. The findings are as follows: 1. On [DATE] at 7:07 AM, the food domes (covers for transporting meals to residents eating in their rooms), were stored with the inside part that covers the food facing up. 2. On [DATE] at 7:21 AM, the used coffee filter holder containing a used coffee filter with coffee grounds, was on the counter between the coffee maker and the juice machine. An opened, unsealed package of coffee inside the filter was leaning against the used coffee filter holder. At 8:40 AM, the Surveyor asked about the unused coffee filter leaning against the used coffee filter holder. The Dietary Manager confirmed Dietary Employee #15 is not done with the coffee. 3. On [DATE] at 7:23 AM, 12 bowls, 13 desert bowls, 12 cups, and the plates in the plate warmer were not covered. There were black flies in the kitchen. The Dietary Manager confirmed that debris could fall on the items that were not properly covered. 4. On [DATE] at 7:36 AM, two air vents on the ceiling that face the food prep and cooking area had yellowish, brown, and black substances built up on the vent rails with various black and grey fuzzy objects. The wall below the air vents where the steam table is used for serving meals, had a black grimy build up with paint missing or chipping along the entire wall. The crease between the same wall and floor had a black sludgy looking substance built up in the crease. On [DATE] at 02:20 PM, the Dietary Manager confirmed Maintenance was responsible for cleaning the air vent. 5. On [DATE] at 7:43 AM, a spatula on the clean drying side of the sink had torn and missing pieces from all edges and various scratches on the flat side. The Dietary Manager confirmed the concern was food particles could still be in the torn and scratched areas of the spatula. 6. On [DATE] at 8:02 AM, the freezer in the Dry Goods Storage room contained the following: 2 one gallon bags of chicken breast with ice on the chicken breast; 1 bag with skinless fish filets with ice on the fish filets; 1 bag broccoli flowerets with a hole in the bag. The bottom shelf was held up with a coffee carafe due to the plastic on the right-side wall was cracked. The inside bottom shelf contained broken ice chunks and various black and brown specks. The outside bottom of the freezer was missing a vent cover with a brownish/yellow fuzzy build up; paint chips were missing and there was a brownish build up along the seam of the vent plate and freezer bottom; inside the hole where the vent cover should be had a buildup of black, grey, and brown fuzzy substance. The Dietary Manager confirmed that the ice chunks and black specks on the bottom of the freezer was from shifting things around. [DATE] at 02:11 PM, the Dietary Manager said, I think it is something that had a blind eye to. 7. On [DATE] at 8:08 AM, the deep freezer contained the following: 25 white meat chicken patties not sealed; 1 bag hash browns not seal; 1 box of white meat chicken patties without an open date; 1 box smoked sausage without an open date. 8. On [DATE] at 8:15 AM, the Dry Goods Storage contained the following: 1 flour bin with a scoop left inside laying on top of the flour; one 4 fluid ounce bottle of liquid smoke that expired on [DATE]; 1 outlet connected to the wall was covered in a black sticky substance with whitish-gray fuzz attached to the sticky substance. The Dietary Manager confirmed the scoop should not have been left in the flour container; the expired liquid smoke should not be on the dry goods shelving for use; the outlet could use a paint job. There is concern of debris with the food being stored in the room. 9. On [DATE] at 8:28 AM, the kitchen refrigerator contained one 1 gallon creamy Caesar salad dressing that had run down on the outside of the container. The Dietary Manager confirmed the dripping on the outside could get into other food items. The inside bottom of the refrigerator had a brownish-yellow buildup of an unknown substance. The Dietary Manager confirmed today is a scheduled cleaning day for this refrigerator. 10. On [DATE] at 8:40 AM, Dietary Employee #15 served food from the steamtable after the steamtable was placed against the wall underneath the air vents and against the wall that had a black grimy build up with paint missing or chipping along the entire wall. The Dietary Manager confirmed that food is not served from that area, so this is not a concern. At 8:42 AM, after informing the Dietary Manager about the food being served from that area the Dietary Manager confirmed the concern would be that debris could get into the food. 11. On [DATE] at 8:41 AM, food domes, 3 cups with lids and re-useable straws were lying directly on the shelf and 12 cups were stored on a cart that contained a buildup of white and brownish substances on all 3 shelving tiers. The Dietary Manager confirmed the cart and shelves needed to be cleaned. 12. On [DATE] at 8:44 AM, the shelving area above the food prep counter contained one 42 ounce rolled oats without an open date; one 5 pound container of smooth peanut butter that had peanut butter smears on the rim and sides; one 8.5 fluid ounces of extra virgin olive oil without an open date. The Dietary Manager confirmed there should be an open date on the food items and the peanut butter container should not have smears. 13. On [DATE] at 8:55 AM, the sand-up freezer contained the following: 1 box of 240 one ounce sugar cookies without an open date. The Dietary Manager confirmed there should have been an open date on the box. 14. On [DATE] at 9:00 AM, a piece of metal on the floor between the entrance into the kitchen work area and the uphill of the kitchen no longer had the black non-slip strip covering the metal strip that secured the metal strip to the floor. The Dietary Manager confirmed this was a safety hazard because it could cause someone to trip. The lower wall area across from the prep counter had a brownish unknown substance and the floorboard was missing, the crease between the floor and the wall had a black unknown substance build up. The Dietary Manager confirmed this is a concern mainly because of debris. It also needs a coating of paint. 15. On [DATE] at 2:55 PM, the Dietary Manager provided a policy titled, Clean and Sanitary shows .All food preparation areas, food service area, and dining area will be maintained in a clean and sanitary condition .; .1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation; 2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces . 16. On [DATE] at 2:55 PM, the Dietary Manager provided the policy for Cold Storage which shows, .All foods will be stored wrapped or in covered containers, labeled and dated, land arranged in a manner to prevent cross contamination. 17. On [DATE] at 2:55 PM, the Dietary Manager provided the policy for Safe Storage of Food shows, .All foods will be stored wrapped or uncovered containers, labeled, and dated, and arranged in a manner to prevent cross contamination . 18. On [DATE] at 9:30 AM, the Administrator provided City Termite and Pest Control service agreements and invoices. German cockroaches were contracted for [DATE], [DATE], [DATE], [DATE], and [DATE]. Flies were contracted for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].

Based on observation, record review and interview, the facility to ensure the dignity and privacy of 2 (Residents #187 and #438) residents. The findings are: 1. A review of the Medical Diagnosis indicated Resident #438 had diagnoses of: Urinary tract infection, heart failure, and Lymphedema (swelling in the body due to a buildup of fluid) . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/2024 indicated a Brief Interview for Mental Status Score (BIMS) of 7 (0-7 suggests severe cognitive impairment) and Resident #438 was admitted with an indwelling catheter. a. On 05/20/2024 at10:31 AM, an indwelling catheter bag was hanging from the bedside with no privacy bag. b. On 05/20/2024 at 02:00 PM, an indwelling catheter bag was hanging from the bedside with no privacy bag. c. On 05/21/2024 at 9:30 AM, an indwelling catheter bag was hanging from the bedside with no privacy bag. d. On 05/22/2024 at 9:20 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 if the indwelling catheter bag should always have a privacy bag. CNA #1 stated the catheter bag should have been in a privacy bag. e. On 05/22/2024 at 9:20 AM, the Surveyor asked the Infection Preventionist (IP) if an indwelling catheter bag should always have a privacy bag. The IP stated there should always be a privacy bag to protect the resident's dignity. f. On 05/22/2024 at 11:30 AM, the Director of Nursing (DON) was interviewed, and the Surveyor asked the DON if a privacy bag should be used to cover an indwelling catheter bag and if so, why would it be needed. The DON stated a privacy bag should remain in place to cover the catheter bag while maintaining a resident's dignity. 47916 2. Resident #187 had diagnoses of acute kidney failure, acute cystitis (an infection of the bladder), and urinary tract infection. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/14/2024 was in process. a. On 05/20/2024 at 01:30 PM, the Surveyor observed Resident 187's uncovered indwelling catheter bag draining yellow urine from the open doorway. b. On 05/20/2024 at 04:18 PM, the Surveyor observed Resident #187 resting quietly with the door open. The indwelling catheter was observed draining yellow urine facing the open doorway. c. On 05/22/2024 at 11:10 AM, a policy titled Dignity documented, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1.Residents are treated with dignity and respect at all times . d. On 05/21/2024 at 08:00 AM, the Surveyor observed Resident #187 resting quietly, with the indwelling catheter facing the wall. The Surveyor asked Registered Nurse (RN) #7 to observe Resident #187's indwelling catheter and asked what their procedure was for providing catheter care. RN #7 said that Resident #187 is new to the facility, and she (RN #7) places the catheter in a bag as soon as it is noticed. The Surveyor asked why the facilities policy was to put catheter bags in a privacy bag, and RN #7 said, It is a dignity issue. RN #7 confirmed Resident #187's indwelling catheter should be in a privacy bag. e. On 05/22/2024 at 11:30 AM, the Director of Nursing (DON) was asked what procedures were staff expected to follow when caring for a resident with a catheter. The DON told the Surveyor staff are expected to place catheters in a privacy bag to protect the dignity of the residents. f. On 05/22/2024 at 04:00 PM, the DON provided a policy titled, Catheter Care, Urinary, the policy did not address privacy bags.

Based on observation, record review and interview, the facility failed to ensure the rear casters/wheels were kept in the unlocked position when lifting and lowering residents when using a patient lift for 3 (Residents #11, #17, and #36) residents to prevent accidental falls and injury; failed to ensure damaged, or frayed lift pads were removed from service for 1 (Resident 17) resident who had an order for mechanical lift assistance; and failed to ensure chemicals were safely stored to prevent potential harm to 8 (Residents #5, #7, #8, #20, #26, #36, #56, #58) residents who ambulated or self-propelled in the facility. The findings are: 1. Resident #11 had diagnoses of Alzheimer's disease, bipolar disorder, and urinary tract infection. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/2024 indicated a Brief Interview for Mental Status (BIMS) score of 03 (0-7 suggest severe cognitive impairment). a. A Care Plan (Revised, 11/17/2022) documented, [Resident #11] has an ADL [activities of daily living] self-care performance deficit related to Alzheimer's . Total 2 (two) Person Assist by Mechanical Lift .with use of Blue lift pad . b. On 05/20/2024 at 10:52 AM, the Surveyor observed Nursing Assistant (NA) #11, and Certified Nursing Assistant (CNA) #2 placed a manual lift in the open leg position around Resident #11's chair. CNA #2 placed the rear casters/wheels in the locked position and lift pad was connected to the spread bar. Resident #11 was raised up in the air while the rear casters/wheels remained locked, then the rear wheels were unlocked, and Resident #11 was rolled over to the resident's bed to be changed. c. On 05/20/2024 at 11:14 AM, with the lift pad in place, and rear casters/wheels in the locked position the Surveyor observed Resident #11 placed back into the wheelchair. NA #11 and CNA #2 were asked to provide the purpose of locking the rear casters when lifting and lowering a resident in a mechanical lift. CNA #2 told the Surveyor that the wheels were locked for safety to keep the lift from moving while lifting a resident. NA #11 was asked if she had been in-serviced on the lift and the NA #11 told the Surveyor that she had been in-serviced on the lift. The Surveyor asked her to walk the Surveyor through the process of lifting and lowering a resident. NA #11 told the Surveyor that they roll the lift to the wheelchair with the legs open for stability. The wheels are locked, and the left pad is attached to the lift. The resident is lifted, then the tires are unlocked, and the resident is rolled to their bed, the tires are locked, and they are lowered. NA #11 confirmed that the rear casters or wheels are locked when lifting or lowering a resident to keep the lift from rolling for their safety. 2. Resident #17 had diagnoses of End stage renal disease, Legal blindness, and Atrial fibrillation. The Quarterly MDS with an ARD of 03/08/2024 indicated a BIMS score of 06 (0-7 suggest severe cognitive impairment). a. On 05/20/2024 at 02:55 PM, the Surveyor observed Resident #17 sitting on a blue, fraying lift pad when the resident returned from dialysis. b. On 05/20/2024 at 03:45 PM, the Surveyor observed CNA #12 and CNA #13 push Resident #17's wheelchair under the lift with legs in the open position and attach the lift pad to a mechanical lift. CNA #14 locked the rear casters and began to lift Resident #17 up. The Surveyor asked what the reasoning was behind locking the rear casters/wheels on the lift. CNA #14 told the Surveyor so they will not go anywhere while lifting or lowering the resident. All three CNA's (CNAs #12, #13, and #14) confirmed it was for safety. The Surveyor asked CNA #14 to stop while using the mechanical lift and describe Resident 17's lift pad. CNA #14 said, Damaged. The Surveyor asked what the process was for removing damaged lift pads from circulation. CNA #13 said she did not know for sure. The Surveyor asked if the lift pad should be replaced or was it safe to use. CNA #13 told the Surveyor that the person who put Resident #17 in the chair to go to dialysis should not have used the lift pad, and the resident was not able to be moved in a way to replace the lift pad so they would have to use it to put Resident #17 back to bed. c. On 05/21/2024 at 09:59 AM, while interviewing Laundry the Surveyor observed a lift pad resting in a stack of clean lift pads with obvious fraying. The Surveyor asked what the process was for removing damaged or frayed lift pads from service. Laundry told the Surveyor that if lift pads have a hole or something in them, the lift pads will be shown to a supervisor and the DON would have the final say. 3. Resident #36 had diagnoses of left below the knee amputation, cerebral infarction, and end stage renal disease. The Quarterly MDS with an ARD of 03/26/2024 suggested a BIMS score of 14 (13-15 suggest cognitively intact). a. A Care Plan (Revision, 12/30/2023) documented, Resident #36 has an ADL self-care performance deficit related to decline in independence in ADLs, transfers and mobility . Resident #36 requires Mechanical Lift with 2 staff assistance for transfers . b. On 05/20/2024 at 03:28 PM, CNA #12 placed the mechanical lift around Resident #36's specialty chair while CNA #13, and CNA #14 assisted in attaching the lift pad to the mechanical lift on the first and last hooks. CNA #12 locked the rear casters/wheels, and the resident was lifted off of the chair. CNA #12 unlocked the rear casters/wheels and Resident #36 was rolled over the bed. CNA #13 lowered Resident #36 to the bed without locking the rear casters/wheels. The Surveyor asked CNA #12 about the process for lifting and lowering resident with a lift. The three CNAs confirmed that the rear wheels are locked to keep the lift from moving all over the room. CNA #14 and CNA #13 told the Surveyor that locking the rear wheels was for the resident's safety. c. On 05/22/2024 at 03:35 PM, the Surveyor asked the Director of Nursing (DON) if staff had been in-serviced on mechanical lifts, and the DON responded, Yes. The DON was asked to explain the process staff are expected to use when lifting and lowering residents with a mechanical lift. The DON explained staff would get a blue lift pad, and with the legs of the mechanical lift in the open position staff would lock the wheels to attach the lift pad and lift or lower the resident. The Consultant asked to speak with the DON and explained that the wheels on a mechanical lift should remain unlocked so the machine will move with the resident if there is any sudden movement of a resident. The DON confirmed she was not aware the wheels should be unlocked when lifting and lowering residents with a mechanical lift. The DON was asked what the process was for removing damaged lift pads from service. The DON said nurses, CNAs, or any staff that see a damaged lift pad can remove the lift pad from service for resident safety. d. On 05/22/2024 at 04:00 PM, the DON provided the signature from an in-service (dated, 02/29/2024) with the following listed to the side: i. (Brand Name) Lift ii. Workman's Comp Procedures iii. Abuse Prevention and Reporting iv. OLTC (Office of Long Term Care) Survey tips v. Smoking Policy effective 03/01/2024 48977 4. Resident #38 had diagnoses of Alzheimer's disease and dementia. a. The Quarterly MDS with an ARD of 02/28/2024 documented Resident #38 scored 09 (8-12 indicates moderate impaired cognition) on a BIMS. b. A Care Plan for Resident #38 with a revision on 07/06/2023 documented Resident #38 had impaired cognitive function related to dementia and required cues, reorientation and supervision as needed. c. On 05/21/2024 at 09:56 AM, the Surveyor observed 2 bottles of air freshener on a shelf under the television in Resident #38's room. d. On 05/21/2024 at 12:59 PM, the Surveyor observed 2 bottles of air freshener on a shelf under the television in the Resident #38's room. e. On 05/23/2024 at 02:30 PM, the Surveyor observed 2 bottles of air freshener on a shelf under the television in the Resident #38's room with a warning noted on the bottles that indicated inhaling the contents can be harmful or fatal. f. On 05/23/2024 at 02:30 PM, Licensed Practical Nurse (LPN) #6 confirmed the air freshener should not be out and visible to wondering residents. g. On 05/23/2024 at 08:20 AM, the DON confirmed the air freshener should not be out in the opening and visible to wondering residents. h. On 05/23/2024 at 10:32 AM, a policy titled, Safety and Supervision of Residents documented, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .

Based on observation, interview, and facility policy review, the facility failed to ensure that staff displayed competency in caring for residents on Enhanced Barrier Precautions (EBP), and how to use hygiene supplies according to the manufacturer ' s directions for 1 (Resident #41) sampled resident. This failed practice had the potential to affect any resident on EBP and/or dependent on staff for baths. The findings include: 1. Resident #41 had diagnoses of Pressure ulcer of sacral region stage 4, Urinary tract infection, and Paraplegia. a. Resident #41 had the following Physician's Orders: (a) Supra pubic catheter to be changed by Urologist, (b) cleanse pressure ulcer to sacrum with wound cleanser pat dry, then apply an antibacterial wound dressing followed by a silicone dressing or abdominal dressing pad and secure with tape daily and as needed for soiled or dislodged dressing (c) Enhanced Barrier Precautions (EBP) related to sacrum wound, R heel wound and Supra pubic catheter. b. Review of the Quarterly MDS with an ARD of 03/06/2024 documented Resident #41 scored 15 (13-15 indicates cognitively intact) on a BIMS, and Resident #41 had an ostomy, indwelling catheter, and resident had one or more unhealed pressure ulcers/injuries. c. A review of Resident #41's Care Plan, (revision 05/23/2024), documented Resident #41 was on EBP related to indwelling medical devices, (suprapubic catheter), sacrum wound, and right heel wound. The Care Plan also documented staff should gown and glove during high-contact resident care activities. d. On 05/22/2024 at 09:20 AM, the Surveyor observed Licensed Practical Nurse (LPN) #3 at the bedside of a Resident #41, who was on Enhanced Barrier Precautions (EBP), providing care wearing only gloves. e. On 05/22/2024 at 09:50 AM, the Surveyor observed Certified Nursing Assistant (CNA) #4 and #5 assisting Resident #41, who was on Enhance Barrier Precautions, with a bed bath. CNA #4 applied soap to the resident body using a wet towel then CNA #5 patted the resident dry. Both CNA #4 and #5 wore only gloves while providing care. f. On 05/22/2024 at 10:05 AM, CNA #4 voiced that the soap was rinse free and that rinsing was not required. Both CNA #4 and #5 voiced that they did not know Resident #41 was on EBP and it was hard to tell if a Resident was on EBP, and the facility usually informs them or post a sign. g. On 05/22/2024 at 11:30 AM, LPN #3 stated, I know I messed up. LPN #3 voiced that when the Treatment Nurse entered the room, that is when he realized he had messed up and that it was hard to tell when a Resident is on EBP when you are in a rush. h. On 05/23/2024 at 12:16 PM, the Director of Nursing (DON) read the back of the soap used by the facility and stated what was written, apply, latter, rinse, and towel dry. The DON voiced that the residents could get skin irritation if the staff is applying soap and not rinsing the soap off the resident. i. On 05/23/2024 at 11:30 AM, the DON voiced that staff follow Enhanced Barrier Precautions when caring for a resident with an indwelling catheter and/or wound. The DON also voiced that staff had been in-serviced on EBP and were aware of the residents on EBP. j. On 05/22/2024 at 11:10 AM, a policy titled, Enhanced Barrier Precautions documented, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 2. Initiation of Enhanced Barrier Precautions: a. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO [Multidrug-Resistant Organisms] that is not currently targeted by CDC [Centers for Disease Control and Prevention]. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO .Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). PPE [Personal Protective Equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. 4. High-contact resident care activities include: a. dressing, b. bathing, c. transferring, d. providing hygiene, e. changing linens, f. changing briefs or assisting with toileting, g. device care or use: central lines, urinary catheter, feeding tubes, tracheostomy/ventilator tubes, h. wound care: any skin opening requiring a dressing . k. A policy titled, Bath, Bed documented, The purposes of this procedure are to promote cleanliness, provide comfort and to observe the condition of the resident's skin .

Based on observation, interview, and record review, the facility failed to ensure nebulizer treatments were not left at the bedside for the resident to self-administer for 2 (Resident #8 and #188) residents who were not assessed to be safe to self-administer nebulizer treatments; an unattended medication cart on the South Hall was locked on 1 of 1 observation to prevent misappropriation of resident medications; and a narcotic box containing controlled substances was kept and maintained securely behind two locks. The findings are: 1.a. A review of Resident #188's Physicians Orders (dated 05/17/2024) documented, .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 4 hours as needed for SOB related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED . b. On 05/20/2024 at 01:07 PM, Resident #188 was observed sitting on the side of the bed, and the Surveyor observed a nebulizer mouthpiece with the chamber resting in the crack in the arm of Resident #188's recliner. Resident #188 remarked that he put the nebulizer there, and he gives his own updrafts. c. On 05/20/2024 at 04:20 PM, the Surveyor observed Resident #188 sitting on the side of the bed self-administering an updraft, with vapor coming from the end of the tube. The Surveyor spoke with Licensed Practical Nurse (LPN) #9 and LPN #9 denied giving Resident #188 an updraft. LPN #9 looked at Resident #188's Medication Administration Record (MAR) and told the Surveyor that Resident #188 had an updraft at 12:00 PM given by someone else. LPN #9 stated, If they had stayed with him until it was complete he would not be able to give himself an updraft right now. The Surveyor asked what procedure is followed when administering updrafts. LPN #9 told the Surveyor the nurse should stay with the resident until the updraft is completed. d. On 05/22/2024 at 04:00 PM, the Director of Nursing (DON) provided a list of residents who self-administer their own medications, the showed no residents were assessed to self-administration medications. 2.a. On 05/22/2024 at 04:12 PM, the Surveyor observed LPN #10 go into Resident room [ROOM NUMBER] and leave the South 2 Hall medication cart unlocked. b. On 05/22/2024 04:14 PM, the Surveyor asked LPN #10 what the procedure was for leaving the cart while giving medications or checking blood sugars, and why. LPN #10 told the Surveyor that the cart should have been locked, and it was an oversite on her part. LPN #10 said the cart must be locked so residents or other staff cannot get into the cart. c. On 05/23/2024 at 12:45 PM, the Surveyor asked the Director of Nursing (DON) what procedure nursing staff were expected to use when leaving a medication cart in the hallway. The DON told the Surveyor the computer screen, and the cart should be locked to prevent someone from taking something from the cart. 48977 3. Resident #8 had the diagnoses of Acute and chronic respiratory failure with hypoxia, and Chronic obstructive pulmonary disease (COPD) with acute exacerbation. a. Resident #8 had a Physician's Order for Albuterol Sulfate Inhalation Nebulization Solution 1 applicator via mask every 4 hours as needed for shortness of breath (SOB). b. Review of the Admission Minimum Data Set with the Assessment Reference Date of 05/05/2024 documented Resident #8 scored 15 (13-15 indicates cognitively intact). c. The Care Plan did not address Resident #8 had been assessed to self-administer medications. d. On 05/22/2024 at 12:12 PM, the Surveyor observed Resident #8 receiving a nebulizer treatment inside the resident's room without staff in or around the resident's room. e. On 05/22/2024 at 12:12 PM, Licensed Practical Nurse #6 confirmed that the nurse is required to remain at the resident's side during the administration of a nebulizer treatment. f. On 05/22/2024 at 12:16 PM, the DON voiced the nurse should remain with the resident during a nebulizer treatment because anything could happen, the resident could go into distress. 50682 4. On 05/21/2024 at 1:00PM, the refrigerator at Nursing Station 2, was opened and contained a locked box. The Surveyor asked Registered Nurse (RN) #7 what was in the locked box. RN #7 said it contained narcotics. RN #7 unlocked the box, and it contained two 30 milliliter bottles of Ativan. The Surveyor asked RN #7 how many locks the narcotic box should be under. She said she didn't know. a. On 05/22/2024 at 11:30 AM, the DON was interviewed by the Surveyor. The DON was asked how many locks should controlled substances be behind. She said they should be behind two locks. b. On 05/22/2024 at 04:00 PM, the DON provided a policy titled Storage of Medications which documented, .The facility stores all drugs and biological in a safe, secure, and orderly manner .

Based on observation, record review and interview, the facility failed to ensure respiratory mask tubing/nasal cannula tubing was stored in a manner to prevent infection and cross contamination for 2 (Residents #50 and #17) resident; denture brush was stored in a secure and sanitary manner for 1 (Resident #438) resident to prevent infections and cross contamination; staff wore proper Personal Protective Equipment (PPE) prior to providing care for 1 (Resident #41) resident on Enhanced Barrier Precautions (EBP); hand hygiene was performed during perineal care for 2 (Residents #11 and #36) to prevent cross contamination, and the facility failed to ensure dirty laundry was bagged and returned to the laundry room in a manner to prevent the spread of germs to all 85 residents who resided in the facility. The findings are: 1. On 05/20/2024 at 09:22 AM, Resident #50 was observed resting in a recliner with a respiratory mask, not secured in a bag, and was resting on the floor between the bed and recliner. Registered Nurse (RN) #7 arrived at the bedside and told Resident #50 his mask was knocked off in the floor. RN #7 was observed picking the mask up off the floor and placing it in a blue mesh respiratory pouch dated 05/08/2024. a. On 05/21/2024 at 08:00 AM, the Surveyor interviewed RN #7 and asked how the blue pouches for storage work. RN #7 told the Surveyor the blue pouches are used to store respiratory tubing and mask, and it can be used for a month. The Surveyor asked RN #7 what process staff follow when a respiratory mask is found in the floor like Resident #50's mask was found on 05/20/2024. RN #7 told the Surveyor the respiratory mask should have been cleaned before being placed back in the bag due to risk of infection from being on the floor. RN #7 confirmed she returned the mask to the storage pouch without cleaning it first. b. On 05/22/2024 at 11:35 AM, the Surveyor asked the Director of Nursing (DON) what procedure or process staff was expected to follow if they find a respiratory mask resting on the floor. The DON told the Surveyor she would expect staff to throw away the mask and replace it with a new one to prevent infections. The DON confirmed the mesh blue respiratory pouches can store tubing and mask for 30 days. 2. Resident #17 had diagnoses of End Stage Renal Disease, Legal Blindness, and Atrial Fibrillation. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/08/2024 indicated a Brief Interview for Mental Status (BIMS) score of 06 (0-7 suggest cognitive impairment). a. A Care Plan (Revision 04/29/2024) documented, .The resident has oxygen therapy related to COPD .Oxygen via nasal cannula, as net 2 liters per minute as needed . b. On 05/20/2024 at 09:39 AM, the Surveyor entered Resident #17's room and noted the nasal tubing resting in a blue pouch dated 5/8/2024 with the cannula prongs resting outside the pouch. c. On 05/20/2024 at 02:52 PM, the Surveyor observed Resident 17's nasal cannula resting outside the blue storage bag. d. On 05/22/2024 at 08:30 AM, the Surveyor asked Registered Nurse (RN) #7 to look at the nasal cannula tubing and asked RN #7 what process was used to store oxygen tubing. RN #7 told the Surveyor that oxygen tubing should be completely placed into the blue mesh pouch. The Surveyor asked if the nasal canula hanging outside the bag was appropriate. RN #7 told the Surveyor leaving the nasal canula outside the mesh storage pouch would put the resident at risk of infection. e. On 05/22/2024 at 11:30 AM, the Surveyor asked the Director of Nursing (DON) what procedure staff are expected to follow when storing nasal canula tubing. The DON told the Surveyor that nasal canula tubing should be placed in a plastic bag or a blue mesh pouch. The DON confirmed the blue mesh pouches must be changed out every 30 days, and the plastic bags must be changed out every 7 days. The Surveyor asked if the nasal canula should be placed in the storage bag because it is the main part that goes in the resident's nose, or nares. The DON confirmed by not storing the nasal canula appropriately it would put a resident at risk of bacteria, or infection. f. On 05/22/2024 at 04:00 PM, the DON provided a policy titled, Oxygen Administration, which documented, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences . g. On 05/22/2024 at 04:00 PM, the DON provided documentation showing an Oxygen Settings in-service was done on 07/07/2023, and RN #7 was not on the list of in-serviced staff.If not in use, it is to be stored in the correct storage bag . 3. On 05/21/24 at 09:40 AM, the Surveyor observed a white laundry basket with unbagged dirty white rags and towels sitting outside the clean laundry room doors on the South Hall. The Surveyor was knocking on the laundry room door with no response when the Social Director walked up and said she had placed the dirty linens there. The Surveyor asked what the process was for bringing dirty linens to the laundry room, and should laundry be bagged when transferred to the laundry room. The Social Director told the Surveyor that she did not know what the process was, or why. She noticed there was a laundry basket of dirty linens left in the beauty shop from yesterday and she was trying to help by returning them to the laundry room. a. On 05/21/24 at 09:45 AM, the Surveyor interviewed Laundry and it was confirmed that dirty linens should be returned to the laundry room in bags to prevent the spread of germs. The halls have rolling barrels that bagged linens should be placed in. Laundry trades the barrels out with empty barrels throughout the day. b. On 05/22/2024 at 04:00 PM, while interviewing the DON the Surveyor asked about the process for returning laundry. The DON told the Surveyor that all laundry should be bagged, and there were barrels on each hall to place the bagged laundry in to prevent the spread of germs. c. The DON provided a policy titled, Infection Prevention and Control Program which documented, .12. Linens. a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection . f. Environmental services staff shall not handle soiled linens unless it is properly bagged . 4. Resident #11 with diagnoses of Alzheimer's disease, Bipolar disorder, and Urinary tract infection. The Quarterly MDS with an ARD of 04/19/2024 indicates a BIMS score of 03 (0-7 suggests severe cognitive impairment). a. A Care Plan (Revision, 06/26/2023) documented, Resident has an Activity of Daily Living (ADL) self-care performance deficit related to Alzheimer's . The resident is not toileted . b. On 05/20/24 at 11:07 AM, the Surveyor observed perineal care being performed by Nursing Assistant (NA) #11 and CNA #2 for Resident #11. NA #11 did not change gloves or perform hand hygiene during the procedure. CNA #2 assisted NA #11 in pulling Resident #11's pants up and shirt down. CNA #2 and NA #11 assisted in attaching Resident #11's lift pad and transferring Resident #11 to a specialty chair while NA #11 wore the same gloves used to provide perineal care. The Surveyor asked what the procedure was for providing peri care and using a clean verses dirty technique. NA #11 confirmed that she should have used the left hand to wipe Resident #11 instead of using the same hand to wipe with to avoid contamination, and there was a risk for infection. The Surveyor asked if NA #11 had received any in-services at the facility. NA #11 confirmed she was in-serviced on properly cleaning residents, resident rights, and lifting residents. NA #1 stated, They went over everything to make sure I could properly care for residents. The Surveyor asked NA #11 if gloves should have been changed after performing perineal care for Resident #11, and before touching clean clothes and objects in the room. NA #11 said, Yes, ma'am, I believe I should have changed my gloves. 5. Resident #36 had diagnoses of left below the knee amputation, cerebral infarction, and end stage renal disease. The Quarterly MDS with an ARD of 03/26/2024 suggested a BIMS score of 14 (13-15 suggests cognitively intact). a. On 05/20/24 at 03:34 PM, Certified Nursing Assistant (CNA) #12 and CNA #13 presented to Resident 36's bedside to assist with perineal care. Privacy curtains were in place. After the perineal care was performed, without changing gloves and/or performing hand hygiene CNA #12 covered up Resident #36. After covering Resident #36, CNA #12 removed her gloves and handed Resident #36 the call light. The Surveyor asked what the process was for providing perineal care and using good hand hygiene. CNA #12 and CNA #13 both confirmed that alcohol gel is outside the room, they can go to the bathroom and wash with soap and water, none of the CNA's had hand gel on their person, and they should have done hand hygiene before touching the resident's linens, call light, or environment. CNA #13 told the Surveyor they did not go to the bathroom and wash with soap and water during peri care. b. On 05/22/2024 at 11:45 AM, the Surveyor asked the Director of Nursing (DON) what procedure staff are expected to when follow going from dirty to clean, during perineal care. The DON told the Surveyor she would expect staff to perform hand hygiene with soap and water, or alcohol gel. The Surveyor asked if hand hygiene was important. The DON told the Surveyor hand washing prevents the spread of germs. 48977 6. Resident #41 had diagnoses of Pressure ulcer of sacral region stage 4, Urinary tract infection, and Paraplegia. a. Resident #41 had the following Physician's Orders: (a) Supra pubic catheter to be changed by Urologist, (b) cleanse pressure ulcer to sacrum with wound cleanser pat dry, then apply an antibacterial wound dressing followed by a silicone dressing or abdominal dressing pad and secure with tape daily and as needed for soiled or dislodged dressing (c) Enhanced Barrier Precautions (EBP) related to sacrum wound, R heel wound and Supra pubic catheter. b. Review of the Quarterly MDS with an ARD of 03/06/2024 documented Resident #41 scored 15 (13-15 indicates cognitively intact) on a BIMS, and Resident #41 had an ostomy, indwelling catheter, and resident had one or more unhealed pressure ulcers/injuries. c. A review of Resident #41's Care Plan, revision 05/23/2024, documented Resident #41 was on EBP related to indwelling medical devices, (suprapubic catheter), sacrum wound, and right heel wound. The Care Plan also documented staff should gown and glove during high-contact resident care activities. d. On 05/22/2024 at 09:20 AM, the Surveyor observed an Enhanced Barrier Precaution sign posted on the wall outside of Resident #41's door. Licensed Practical Nurse (LPN) #3 was at the bedside of Resident #41 providing care wearing only gloves. e. On 05/22/2024 at 09:50 AM, the Surveyor observed CNA #4 and CNA #5 assisting Resident #41 with a bed bath, both CNAs wore only gloves. f. On 05/22/2024 at 10:05 AM, both CNA #4 and CNA #5 voiced that they did not know Resident #41 was on EBP, and it was hard to tell if Resident #41 was on EBP that the facility usually informs them or post a sign. g. On 05/22/2024 at 11:30 AM, LPN #3 stated, I know I messed up. LPN #3 voiced that when the Treatment Nurse entered the room wearing a gown, was when he realized he had messed. h. On 05/23/2024 11:30 AM, the DON voiced staff should follow EBP when caring for a resident with an indwelling catheter and/or wound. The DON also voiced staff had been in-serviced on EBP and were aware of the residents on EBP. i. On 05/22/2024 at 11:10 AM, a policy titled, Enhanced Barrier Precautions documented, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 2. Initiation of Enhanced Barrier Precautions: a. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO [Multidrug-Resistant Organisms] that is not currently targeted by CDC [Centers for Disease Control and Prevention]. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO . 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned [applied] prior to entering the resident's room . 4. High-contact resident care activities include: a. dressing, b. bathing, c. transferring, d. providing hygiene, e. changing linens, f. changing briefs or assisting with toileting, g. device care or use: central lines, urinary catheter, feeding tubes, tracheostomy/ventilator tubes, h. wound care: any skin opening requiring a dressing . 50682 7. A review of the Medical Diagnosis indicated Resident #438 had diagnoses of: Urinary tract infection, Heart failure and Lymphedema (swelling in the body due to a buildup of fluid). The Admission MDS with an ARD of 03/28/2024 indicated a BIMS score (BIMS) of 7 (0-7 suggests severe cognitive impairment). a. On 05/20/2024 at 10:31 AM, the Surveyor observed Resident #438's denture brush in the bathroom resting on its side with the bristles touching the porcelain on the right side of the faucet. b. On 05/20/2024 at 02:00 PM, the Surveyor observed Resident #438's denture brush in the bathroom resting on its side with the bristles touching the porcelain on the right side of the faucet. c. On 05/21/2024 at 02:56 PM, the Surveyor observed Resident #438's denture brush in the bathroom resting on its side with the bristles touching the porcelain on the right side of the faucet. d. On 05/22/2024 at 9:20 AM, the Surveyor observed Resident #438's denture brush in the bathroom resting on its side with the bristles touching the porcelain on the right side of the faucet. The Surveyor asked CNA #1 how the denture brush should be stored. CNA #1 said the denture brush should be stored in a plastic baggy with the resident's name on it. The Surveyor asked the reason why it should be stored in the plastic bag. CNA #1 said it should be stored in a plastic bag because the sink is where staff wash their hands, and that the denture brush would be contaminated with germs by the hand washing. e. On 05/22/2024 at 11:30 AM, the Surveyor interviewed the DON. The surveyor asked the DON how the denture brush should be stored. The DON said it should be in a plastic bag with the resident's name on it to prevent bacteria.

Based on observation, interviews, and facility policy review, the facility failed to protect the privacy and dignity of 1 (Resident 41) sampled resident when providing wound care. The findings include: 1. Resident #60 had the diagnoses of Diabetes due to underlying condition with diabetic nephropathy (kidney damage caused by diabetes). a. Resident #60 had a Physicians Order for treatment to cleanse the left heel with wound cleanser, pat dry, apply wound gel to wound bed cover with a silicone dressing daily and as needed. b. The Quarterly Minimum Data Set with an Assessment Reference Date of 03/08/2024 documented Resident #60 scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. c. A Care Plan, revision on: 04/18/2024 noted Resident #60 had a deep tissue injury (DTI) to the left heel. d. On 05/20/2024 at 09:21 AM, the Surveyor observed staff at the Resident #60's bedside with the left foot raised up exposing the wound to the heel, the curtain was not pulled, and the door was open. e. On 05/20/2024 at 09:23 AM, the Treatment Nurse confirmed that the resident's privacy was not maintained. f. On 05/23/2024 at 08:20 AM, the Director of Nursing (DON) voiced that to maintain a resident's privacy the door should be closed and/or curtain pulled. g. On 05/22/24 at 11:10 AM, a policy titled, Dignity documented, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1.Residents are treated with dignity and respect at all times .

Based on observation, record review and interviews, the facility failed to ensure the care plan included oxygen therapy and Continuous Positive Airway Pressure (CPAP) as ordered by a physician. The findings are: On 04/19/2024, Resident #8 had a diagnosis of Acute and Chronic Respiratory Failure with Hypoxia, and Dependence on Supplemental Oxygen. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of 05/06/2024 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and received Oxygen therapy and a Non-invasive Mechanical Ventilator. a. Review of the Medication Administration Record for May 2024 showed, .Oxygen every 1 hours as needed for Shortness of Breath related to Dependence on Supplemental Oxygen @ 3 Liters . -Start Date- 04/19/2024 . b. Observations on 05/20/2024 at 1:02 PM; 05/21/2024 at 9:07 AM; and 05/22/2024 at 1:42 PM, noted Resident #8's oxygen concentrator was set at 3.0 liters per minute. At 1:44 PM, Licensed Practical Nurse (LPN) #6 confirmed Resident #8's oxygen concentrator was set at 3.0 liters per minute. At 3:00 PM, the MDS Coordinator LPN confirmed the care plan revision of 5/13/2024 did not contain either oxygen therapy or the use of a CPAP. c. On 05/23/2024 at 12:06 PM, the Director of Nursing (DON) provided a CPAP/BiPAP Support policy which showed, .To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen . To promote resident comfort and safety .Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask .Review the resident's medical record to determine his/her baseline oxygen saturation or arterial blood gases (ABGs), respiratory, circulatory, and gastrointestinal status .Review the physician's order to determine the oxygen concentration and flow, and the PEEP pressure (CPAP, IPAP, and EPAP) for the machine .Connect supplemental oxygen .and adjust flow rate as prescribed . d. On 05/23/2024 at 12:06 PM, the DON provided an Oxygen Administration policy which showed, .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences .Oxygen is administered under orders of a physician, except in the case of an emergency .The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: The type of oxygen delivery system .Equipment setting for the prescribed flow rates .Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen.

Based on observations, interviews, and record reviews, the facility failed to ensure a leg strap was in place to prevent trauma from an indwelling catheter for 1 (Resident #438) of 8 sampled residents who were dependent on staff for indwelling catheter care. Findings include: A review of the Medical Diagnosis indicated Resident #438 had diagnoses of: Urinary tract infection, heart failure, and lymphedema (swelling in the body due to a buildup of fluid) . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/2024 indicated a Brief Interview for Mental Status Score (BIMS) of 7 (0-7 suggests severe cognitive impairment) and Resident #438 was admitted with an indwelling catheter. a. A review of Physician Orders (dated 03/21/2024) documented, .[Name Brand] catheter .to aid in wound healing. Change monthly on the 15th . b. A review of Resident #438's care plan with a revision date of 4/18/2024 revealed, .The resident has .Indwelling Catheter: to aid in wound healing to unstageable Pressure Ulcer to Sacral area .Interventions include . CATHETER: The resident has . Indwelling Catheter. Position catheter bag and tubing below the level of the bladder, secure catheter tubing to leg with applicable device. c. On 05/21/2024 at 09:46 AM, Resident #438 told the Surveyor that there are times when staff are getting Resident #438 out of bed or repositioning, that the resident feels the catheter pulling. The Surveyor asked Resident #438 for permission to look at the tubing that was under the cover. The indwelling catheter was not secured to Resident #438's leg by using a leg strap or any other device. d. On 05/22/2024 at 09:20 AM, the Surveyor observed incontinent care being provided by Certified Nursing Assistant (CNA) #1, CNA #2, and the Infection Preventionist (IP). During care, the catheter tubing was unsecured to Resident #438's leg, the tubing became tight as the resident was turned. The Surveyor asked the IP if a resident was care planned to have a leg strap or something to secure the catheter tubing and should the leg strap be in place. The IP stated that the resident should have a leg strap in place to prevent the tubing from pulling, yanking, and to keep it stable. e. On 05/22/2024 11:30 AM, the Surveyor interviewed the Director of Nursing (DON). The Surveyor asked the DON to explain the process for staff to follow to make sure the catheter tubing is stable or secured. The DON stated that the catheter tubing should be held in place by placing a leg band on the resident. The Surveyor asked the DON who should be responsible for ensuring the leg strap was in place. The DON said that everyone should.

Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an altercation between two residents on the Secure Special Needs Unit. This failed practice resulted in actual harm for Resident #229 who received a laceration to her forehead requiring steri-strips and had the potential to cause more than minimal harm to 12 residents who resided on the Secure Special Needs Unit as documented on the Midnight Census Report provided by the Administrator on 07/03/23 at 9:31 AM. The findings are: 1. Resident #229 was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Suicidal Ideations, and Unspecified Psychosis. a. The Care Plan with a revision date of 07/03/23 documented, Focus: [Resident #229] is in the Special Needs Unit r/t [related to] cognitive status r/t dx [diagnosis] of Dementia with behavioral disturbance .Goal: I will be maintained in comfort, dignity and self esteem on an ongoing basis .Interventions: .Provide support and reassurance . b. A Physicians Order dated 07/04/23 documented, May clean skin tear to forehead with wound cleanser and apply steri strips. Keep clean and dry daily until healed. Cover if needed every shift for wound care . c. On 07/03/23 at 11:04 AM, Resident #229 was lying in bed. She had 5 steri-strips across her forehead with discolored areas around the laceration and down the left side of her face. The Surveyor asked what happened to her forehead. She stated, I was in here minding my own business when this woman came in here and whacked me good for no reason. The Surveyor asked what she was hit with. She stated, She hit me in the head with a baby doll. I placed my hands over my face so she wouldn't hit me again, and my hands got covered in blood, and my clothes had to be changed along with my bedding. d. On 07/05/23 at 9:11 AM, Resident #229 was sitting in a chair in her room. The steri-strips remained intact. Resident #229 stated, I know I look a sight. I still can't figure out why that lady hit me. I hope she don't come back cause I'll hit her back next time e. A Nursing Incident and Accident (I&A) Note dated 07/02/23 at 12:09 PM documented, .Incident Description: Resident received laceration to forehead r/t being struck by another resident. Immediate Intervention (to prevent reoccurrence): Redirected other resident out of this residents room. Immediate Intervention: cleansed residents' forehead and applied steri-strips . f. A Nursing Incident and Accident Follow Up Note dated 07/03/23 at 11:30 AM documented, .Date & Time of I&A: 7-2-23 1142 . I &A Description: Resident got hit by another resident with a baby-doll causing an injury . Long-term/Care Planned Intervention: Educated staff to try and keep these two residents separated . 2. Resident #54 had diagnoses of Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance and Anxiety Disorder. a. A Care Plan with an initiated and a revision date of 07/03/23, (Care Plan was initiated and revised during survey), documented, The resident is/has potential to be physically/verbally aggressive, hits at staff/other residents at times, swings walker at staff, cures staff r/t [related to] Dementia . Administer medications as ordered . Date initiated 05/12/2021 . Altercation with another resident using doll, instructed staff to keep these 2 residents separated. Baby doll therapy prn [as needed] . Date initiated: 07/03/2023 . Monitor/document/report PRN any s/sx [signs/symptoms] of resident posing danger to self and others. Date initiated: 05/12/2021 . b. A Care Plan with a revision date of 11/02/22 documented, The resident has a behavior problem. Will hit or kick caregivers or others if she doesn't want to be bothered r/t dx [diagnosis] of Unspecified Dementia with behavioral disturbance . Administer medications as ordered . Administer medications as ordered . Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation . c. The Nurses Notes dated 06/22/23, 06/28/23 and 06/30/23 by LPN #2 revealed Resident #54 had been hitting staff and residents and becoming very aggressive. 3. On 07/06/23 at 10:15 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1 to explain what had occurred with the Incident between Resident #229 and Resident #54. LPN #1 stated, I was on my other hall, off the unit and they paged me, then I was told by [Certified Nursing Assistant (CNA) #3] and [CNA#2] that [Resident #54] was wandering. They were in the shower room. When they came out [CNA #2] saw [Resident #54] was walking into [Resident #229's] room, then they heard [Resident #229] cry out. When they got to the room [Resident #229] was bleeding at the forehead and [Resident #54] was standing there with a doll in her hand. The area wasn't bruised, just cut. The Surveyor asked if Resident #54 had ever hit anyone else. He stated Yes. The Surveyor asked if Resident #54 had ever been sent out for this behavior. He stated, Don't know. I don't think so. 4. On 07/06/23 at 10:30 AM, CNA #3 was sitting beside Resident #54 in the Dayroom. The Surveyor asked CNA #3 if she was aware of the altercation between Residents #229 and Resident #54. She stated, Yes me and [CNA #2] were in the bathroom/shower room with another resident. When we came out, we heard [Resident #229] crying. When [CNA #2] and I got to the room, [Resident #54] was standing beside the bed with a doll in her hand and [Resident #229's] head was bleeding. The Surveyor asked why she thought that the doll was what she hit her with. She stated, It was the way she was holding it, like an object. She's always hitting on the residents and staff. The Surveyor asked what they did to prevent Resident #229 from hitting. She stated, We try to distract her, but she hits us. They try medicating her too. 5. On 07/06/23 at 10:55 AM, the Surveyor asked LPN #2 if she remembered what she charted on 06/22/23, 06/28/23 and 06/30/23 in Resident #54's chart about hitting staff and residents and becoming very aggressive. She stated, Yes. The Surveyor asked if the resident actually hit other residents and staff, or did she document the entries due to the resident was care planned to have the potential to be aggressive and hit. She stated Yes, she hits residents and staff. I wouldn't have put it in there if she hadn't of, so yes, she hit residents and staff on those days. The Surveyor asked if she had filled out any Incidents and Accidents forms from these behaviors. She stated, No, do I need to do them now. The Surveyor asked who she reported the hitting to. She stated, [Nurse Practitioner] and they changed her meds [medications]. The Surveyor asked if she told her supervisor or the Administrator. She stated, I told some, multiple times. The Surveyor asked why it was not documented. She stated, I thought I did. I get so busy. 6. On 07/06/23 at 11:20AM, the Surveyor asked the Nurse Practitioner if she was aware of or was notified of Resident #54 hitting other residents. She stated, Just the baby doll incident. The Surveyor asked if she had seen either Resident #229 or Resident #54 since the incident. She stated, No. 7. On 07/06/23 at 12:05 PM, the Surveyor asked the Director of Nursing (DON) if she was aware of Resident #54 hitting other residents. She stated, Only the baby doll incident. The Surveyor asked if she was aware of the documentation in Resident #54's record of incidents of hitting on 06/22/23, 06/28/23 and 06/30/23. She stated, No. The Surveyor asked what the facility's policy is regarding who and when to notify when an incident occurs. She stated, They need to be calling me. If there is an injury, they need to be putting an intervention in place. The Surveyor asked if the nurse should have notified her on 06/22/23, 06/28/23, and 06/30/23. She stated, Yes. The Surveyor asked why an I&A form was important regarding resident care. She stated, So I can look into it for an injury and educate them on seeing what the cause is and to make sure they are kept separated. I was not aware of all the hitting. The Surveyor asked what could have been done differently had she been aware of the hitting and aggression prior to the incident with Resident #229 and baby doll. She stated, There's a possibility that the incident on 07/02/23 might could have been prevented if we had known. The Surveyor asked prior to the incident, did Resident #54 have a history of hitting and aggression. She stated, I don't recall off the top of my head. The Surveyor asked what interventions had been put in place prior to the incident. The DON stated, I do not recall off the top of my head. Can I look in the electronic record? The DON looked in Resident #54's electronic record and stated, Baby doll therapy, take her outside, music, pleasant diversion (food, TV, conversation, books). The Surveyor asked if the resident was care planned for physical aggression. She stated, Yes. The Surveyor asked when the intervention with the baby doll was originally put in the Care Plan. She stated, 8/15/20. She has behaviors on and off but has been stable for a while. The Surveyor asked as far as the I&A on 07/02/23, who reported it to the Administrator. She stated, I did. She told me to do the report to State. The Surveyor asked during your investigation which staff did you talk to. She stated the Administrator, [CNA #3] and [LPN #1]. The Administrator told them the intervention to keep them separated. The Surveyor asked if she had talked to the residents. She stated, Yes, but they couldn't tell me anything. I talked to them on 07/03/23, and we took the doll then. 8. On 07/06/23 at 12:38 PM, the Administrator was asked if she was aware that Resident #54's electronic record provided entries for 06/22/23, 06/28/23 and 06/30/23, for hitting and aggression towards residents and staff. She stated, I saw them this morning while working on the reportable. I then told the DON, and she has contacted Geri-Psych [Geriatric Psychiatric Hospital] to get her admitted . The Surveyor asked when you send someone to Geri-Psych, is the physician notified. She stated, Yes. The Surveyor asked if she notified Resident #54's doctor about going to Geri-Psych. The Administrator stated, I told [DON] and she would do that part. The Surveyor asked once you read the electronic record and saw those entries about Resident #54 hitting other residents, did you or anyone else do anything else to provide safety for the residents. She stated No, I just told the DON and Nurse Consultant. The Surveyor asked if you had been aware prior to the incident on 07/02/23 would you have done anything differently. She stated, If we had known about it, we would have had interventions in place and the baby doll incident might not have occurred. 9. On 07/07/23 at 4:35PM, the Administrator provided a copy of the facility policy titled, Abuse Prevention and Investigation Protocol, which contained a document titled, Abuse and Neglect Definitions. The Surveyor asked, Do you have a policy specific to resident-to-resident altercations? The Administrator stated, I do not believe we have a policy specific to that. 10. The document titled, Abuse and Neglect Definitions, provided by the Administrator on 07/07/23 at 4:40 PM documented, Neglect: Is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs on an individual basis when a resident does not receive care in one or more areas . 11. The facility policy titled, Abuse Prevention and Investigation Protocol, provided by the Administrator on 07/04/23 at 4:40 PM documented, .Prevention: .7. The Care Plan Coordinator will screen all residents periodically for behavior problems which may lead to abuse towards others or others abused toward resident related to behavior problem. A care plan will be implemented with interventions directed toward preventing abuse by the Resident/abuse to the resident related to the behavior problem .

Based on observation and interview, the facility failed to ensure food was placed in the freezer per manufacturer instructions when received to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; kitchen vents were cleaned to provide a sanitary environment for food preparation, a storage shelf paint was peeling exposing the wood and the floor was chipped and dirty 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. The failed practices had the potential to affect 79 residents who received meals from the kitchen (total census: 79), as documented on a list provided by the Dietary Supervisor on 07/05/23 at 12:30 PM. The findings are. 1. On 07/04/23 at 2:45 PM, a box of hamburger buns and a box of hot dog buns were on a shelf in the storage room. The received date on both boxes documented, 06/28/23. The manufacturer instructions on the box documented, Keep frozen. The Surveyor asked the Dietary Supervisor when the box of hot buns and the box of hamburger buns were received. She stated, They both came in on 6/28/2023. The Surveyor asked, How long do you keep them out? She stated, Until use. 2. On 07/04/23 at 2:45 PM, the following observations were made in the kitchen area: a. The ceiling vent above the vent hood over the stove and close to the two-door refrigerator had dirt and lint particles stuck to the slats. b. The floor where the steam table was located, facing the coffee and juice maker was chipped and was covered with caked on greasy dark residue. c. On the wood shelves where canned goods were stored, the paint was peeling exposing the wood. 3. On 07/04/23 at 3:19 PM, Dietary Employee (DE) #1 turned on the sink faucet and washed her hands. After washing her hands, she turned off the faucet with her hands, contaminating them. She untied a bag of bread that was on the counter. Without washing her hands, she placed gloves on her hands, removed 8 slices of bread from the bag, placed them on foil paper on the counter. She unsealed packets of grape jelly and used a spoon to place and spread peanut butter and grape jelly on 4 slices of bread. She topped each slice of bread with another slice of bread and put them in individual bags to be served to the residents who requested a peanut butter and jelly sandwich with their supper meal. 4. On 07/04/23 at 3:28 PM, DE #2 picked up a recipe book and placed it on the counter. Without changing gloves and washing her hands, she picked up a clean edge beater and attached it to the head stand mixer of the blender to be used in mixing cake batter to be used in making apple crisp to be served to the residents for supper. At 3:30 PM, she opened a bag of cake mix and emptied it in the mixer bowl. She opened the refrigerator door and removed two boxes that contained butter sticks and placed them on the counter, contaminating her gloved hands. Without changing gloves and washing her hands, she unwrapped the sticks of butter with her gloved hand and placed them in a measuring cup. She placed the measuring cup with butter in the microwave and melted them. At 3:33 PM, she took the cup with melted butter out of the microwave to pour on the cake mix inside the mixer. The Surveyor immediately stopped her and asked her what she should have done after touching dirty objects and before handling clean equipment or handling food items. She stated, I should have removed the gloves and washed my hands, 5. On 07/04/23 at 4:44 PM, DE #2 was wearing gloves on her hands. She opened the oven door and checked on the pie in the oven. Without changing gloves and washing her hands, she picked up glasses by their rims and placed them on the counter to be used in serving beverages to the residents for supper meal. 6. On 07/04/23 at 4:45 PM, DE #1 turned off the faucet with her hands, contaminating them. Without washing her hands, she picked up a clean blade and attached the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. 7. On 07/04/23 at 5:09 PM, DE #3 used a marker to write dates on the lids of the glasses that contained beverages. Without washing her hands, she picked up the glasses by their rims and placed them on the tray on the counter to be served to the residents for supper. The Surveyor asked her what she should have done after touching dirty objects and before handling clean equipment. She stated, I should have washed my hands. 8. On 07/05/23 at 7:44 AM, DE #4 turned on the sink faucet and washed her hands. After washing her hands, she dried them with tissue paper, then turned off the faucet. She used the same tissue paper that she had used to dry her hands to wipe her face, contaminating her hands. Without washing her hands, she placed gloves on them, contaminating the gloves. When she was ready to remove cake from the bag. The Surveyor immediately stopped her and asked her what she should have done after using a tissue paper that she had used to dry her hands on to wipe her face. She stated, I should have removed the gloves and washed my hands. 9. The facility policy titled, Hand Washing, provided by the Dietary Supervisor on 07/05/23 at 12:30 PM documented, .4. When to wash your hands, wash your hands as often as possible. It is important to wash your hands: Before starting to work with food, utensils, or equipment. Before putting on gloves . After touching skin, face or hair . As often as needed during food preparation and when changing tasks.

Based on observation, record review and interview, the facility failed to ensure residents seated at the same dining table received their meals at the same time to allow the residents to eat together and promote dignity and respect for 1 (Resident #47) resident who shared a meal table during lunch on 07/03/24. The failed practice had the potential to affect 10 residents who received dietary trays in the Dining Room as documented on a list provided by the Director of Nursing (DON) on 07/07/23 at 11:02 AM. The findings are: 1. Resident #47 had diagnoses of Unspecified Dementia and Blindness. a. 07/03/23 at 1:47 PM, Resident #47 was sitting at a dining table with another resident. The other resident was served her lunch tray at 12:29 PM, she ate her lunch and left the table. All lunch trays were passed out in the Dining Room and food carts for the halls were being loaded. Resident #47's lunch tray was served at 12:56 PM. She ate her lunch alone at the table. b. On 07/03/23 at 12:58 PM, the Surveyor asked the Activity Director, Should a resident have to sit and watch her tablemate be served her meal, have time to eat it and leave the table before getting her food tray? She stated, No, the lady feeding the other resident should have made sure her tray was brought to her. c. On 07/03/23 at 1:00 PM, the Surveyor asked Certified Nursing Assistant (CNA) #2, Should a resident have to sit and watch her tablemate be served her meal, have time to eat it and leave the table before getting her food tray? She stated, No, I was waiting for her tray to come out. The Surveyor asked, Should you have gotten up and asked for her tray? She stated, Yes, I guess I should have. d. On 07/07/23 at 12:42 PM, the Surveyor asked the DON, Should a resident have to sit and watch her tablemate be served her meal, have time to eat it and leave the table before getting her food tray? She stated, No, all residents at the table should be served at the same time. The CNA should have gotten up and asked for the tray.

Based on observation, record review and interview, the facility failed to ensure oxygen was administered at the flow rate ordered by the physician to reduce the potential for respiratory complications for 3 (Residents #3, #11 and #21); oxygen tubing was changed and labeled for 2 (Residents #3 and #11) and humidifier bottles were monitored and changed as needed for 1 (Resident #3) of 8 (Residents #3, #7, #11, #,19, #21, #25, #44 and #72) sampled residents who had Physician Orders for oxygen therapy. These failed practices had the potential to affect 27 residents who had Physician Orders for oxygen therapy as documented on a list provided by the Director of Nursing (DON) on 07/07/23 at 11:02 AM. The findings are: 1. Resident #11 had diagnoses of Acute and Chronic Respiratory Failure with Hypoxia, Acute on Chronic Systolic (Congestive) Heart Failure and a Personal History of COVID-19. a. A Physicians Order dated 07/10/19 documented, Change oxygen tubing every Tuesday and label every night shift . b. The Care Plan with a revision date of 07/05/22 documented, The resident has oxygen therapy prn [as needed] r/t [related to] CHF [Congestive Heart Failure] . Oxygen Settings: oxygen (O2) via nasal prongs/mask @ [at] 2Lpm [liters per minute] PRN Humidified H2O [water]. Follow facility protocol for maintenance/cleaning of O2 machine and tubing . c. a Physicians Order dated 01/05/23 documented, Wear O2 at 2 lpm [liters per minute] via nc [nasal cannula] prn [as needed] as needed . d. On 07/03/23 at 10:00 AM, Resident #11 was sitting up in a chair watching TV with O2 at 1.5 lpm via nasal cannula. There was no date on the oxygen tubing. e. On 07/03/23 at 1:25 PM, Resident #11 was sitting up in a chair with the TV on with O2 at 1.5 lpm via nasal cannula. There was no date on the oxygen tubing. 2. Resident #3 had diagnoses of Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure and a Personal History of COVID-19. a. A Physicians Order dated 10/05/21 documented, O2 [oxygen] at 2 lpm via NC PRN . b. A Physicians Order dated 04/26/22 documented, Change oxygen tubing every Tuesday and label . c. The Care Plan with a revision date of 02/09/23 documented, I need oxygen therapy r/t dx [diagnosis] of Heart Failure .: increased SOB [shortness of breath] Oxygen Settings: O2 via nasal prongs @ 2 Lpm PRN Humidified H2O . d. On 07/03/23 at 10:15 AM, Resident #3 was sitting up in a chair watching TV with O2 at 2.5 LPM via nasal cannula. There was no date on the oxygen tubing. The humidifier bottle was empty. e. On 07/03/23 at 1:15 PM, Resident was sitting up in a chair with O2 at 2 LPM via nasal cannula. There was no date on the oxygen tubing. The humidifier bottle was empty. f. On 07/07/23 at 9:45 AM, the Surveyor asked Licensed Practical Nurse (LPN) #3 how often oxygen settings should be checked to make sure the setting is accurate. She stated, Every morning, we have to sign one time a day that we checked it. The Surveyor asked how often the humidifier bottles should be checked. She stated, Once a day, the night shift changes out tubing and humidifier bottles. The Surveyor asked if she worked on 07/03/23. She stated, Yes, I did. The Surveyor asked if she remembered checking Resident #3's humidifier bottle and O2 setting. She stated, Not really, but I'm sure I did. g. On 07/07/23 at 10:05 AM, the Surveyor asked LPN #4 how often oxygen settings should be checked to make sure the setting is accurate. She stated, Every morning, and several times throughout the day. The Surveyor asked how often the humidifier bottles should be checked. She stated, Once a day, the night shift usually changes out tubing and humidifier bottles, but we will if needed. h. On 07/07/23 at 10:20 AM, the Surveyor asked the DON how often oxygen settings should be checked to make sure the setting is accurate. She stated, Every morning, and each time the nurses go in the room. The Surveyor asked how often the humidifier bottles should be checked. She stated, At least once a day, the night shift usually changes out tubing and humidifier bottles and cleans the concentrators. The Surveyor asked should the bottles run empty. She stated, No they shouldn't. 42965 3. Resident #21 had a diagnosis of Alzheimer's Dementia, Stroke, and Ventricular Tachycardia. a. A Physicians Order dated 06/23/23 documented, May use O2 @ 2 LPM via n/c PRN every shift . b. The Care Plan with an initiation date of 06/26/23 documented, .Focus: The resident has oxygen therapy and Nebulizer Treatments per Orders r/t wheezing and shortness of breath with personal history of COVID-19 and Pneumonia .Goal: The resident will have no s/sx [signs and/or symptoms] of poor oxygen absorption . Intervention: .OXYGEN SETTINGS: O2 via nasal prongs/mask @ 2LPM PRN . c. On 07/03/23 at 10:46 AM, Resident #21 was sitting up in bed with oxygen in use at 3 liters per nasal cannula. The Surveyor asked the resident, Do you use your oxygen all the time? Resident #21 nodded his head up and down and smiled. d. On 07/05/23 at 7:43 AM, Resident #21 was sitting up in bed eating his breakfast. He had oxygen in use at 3 liters per nasal cannula. e. On 07/05/23 at 9:46 AM, Resident #21 was sitting up in bed watching television. He had Oxygen in use at 3 liters per nasal cannula. f. On 07/06/23 at 7:30 AM, Resident #21 was lying in bed with his eyes closed. He had oxygen in use at 3 liters per nasal cannula. g. On 07/07/23 at 8:15 AM, Resident #21 was sitting up in bed eating his breakfast. He had oxygen in use at 2 liters per nasal canula. h. On 07/07/23 at 9:25 AM, the Surveyor asked Registered Nurse (RN) #1, Are you the nurse for [Resident #21]? RN #1 stated, Yes. The Surveyor and the RN walked to Resident #21's room and once in the resident ' s room, the Surveyor asked RN #1, What is [Resident #1's] oxygen rate set at? RN #1 looked at the flow rate on Resident #21's oxygen concentrator and stated, It is set between 2.5 to just under 3. The Surveyor asked, What should [Resident #21's] oxygen rate be set at? RN #1 stated, I believe it should be set at 2 liters. I can double check as I am not completely sure since some resident's orders are for 2 to 4 liters. RN #1 looked at Resident #21's electronic medical record and stated, The order states oxygen at 2 liters per minute per nasal cannula as needed. The Surveyor asked, Who is responsible for checking the oxygen rate? RN #1 stated, All of the nurses are responsible for checking the oxygen rate. The Surveyor asked, How often should the oxygen rate be checked? RN #1 stated, At least every shift and as needed. The Surveyor asked, Is [Resident #21] able to adjust his own oxygen rate? RN #1 stated, No, he is not able to touch the machine. The Surveyor asked, Should doctor's orders for oxygen therapy be followed? RN #1 stated, Yes. Doctor's orders should be followed. I am going to correct the rate right now. 4. The facility policy titled, Oxygen Administration, provided by the DON on 07/07/23 at 11:02 AM documented, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration . Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . The policy did not address monitoring for correct flow rate or changing and labeling of the oxygen tubing or humidifier bottle.

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 7 residents who received pureed diets, 12 residents who received mechanical soft diets and 60 residents who received regular diets from 1 of 1 kitchen (total census: 79) according to a list provided by the Dietary Supervisor on 07/05/23 at 12:30 PM. The findings are: 1. On 07/04/23, the menu for the supper meal documented residents who received mechanical soft diets were to receive 4 ounce ladle spoon (1/2 cup) of chopped roasted zucchini, and 4 ounce spoon (1/2 cup) of chopped steam vegetables and a slice of bread each total of one cup of vegetable and residents on regular diets were to receive 4 ounce spoon (1/2 cup) of roasted zucchini, 8 ounces (1 cup) of Italian toss salad and 1 slice of bread each. 2. On 07/04/23 at 5:31 PM, the following observations were made during the serving of the supper meal: a. Dietary Employee (DE) #1 used a 3-ounce ladle spoon to serve a single portion of Italian tossed salad to the residents on regular diets. There was no bread served to them. The menu specified for each resident on regular diets to receive 8 ounces of Italian tossed salad (1 cup) and a slice of bread each. b. DE #1 used a 4 ounce ladle spoon to serve a single portion of zucchini and tomatoes to the residents on mechanical soft diets. There was no bread served to them. The menu specified for each resident on mechanical soft diets to receive 4 ounces of chopped roasted zucchini (1/2 cup), 4 ounces of chopped soft steamed vegetables (1/2 cup) total of 1 cup of vegetables and a slice of bread each. 3. On 07/06/23 at 7:42 AM, the Surveyor asked DE #1 what vegetables she gave to the residents on regular diets. She stated, I gave them zucchini with tomatoes and tossed salad. The Surveyor asked what spoon size she used to serve the zucchini with tomatoes and tossed salad and how many servings did she give. She stated, I used a 4 ounce spoon to serve a serving of zucchini with tomatoes and 3 ounce spoon to serve a serving of tossed salad. The Surveyor asked what vegetables she gave to the residents on mechanical soft diets and how many servings did she give. She stated, I used a 4 ounce spoon to serve a serving of zucchini with tomatoes. The Surveyor asked why the residents on regular diets and the residents on mechanical soft diets did not receive bread. She stated, I forgot.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 3 of 3 meals observed. The failed practice had the potential to affect 7 residents who received pureed diets as documented on a list provided by the Dietary Supervisor on 07/05/23. The findings are: 1. On 07/04/23 at 4:28 PM, Dietary Employee (DE) #1 used #8 scoop to place 8 servings of cheese ravioli with meat sauce into a blender, added 8 slices of bread and pureed. At 4:36 PM, DE #1 poured the pureed cheese ravioli into a pan and placed it in the oven. The consistency of pureed cheese ravioli was lumpy and not smooth with pieces of meat and bread visible in the mixture. At 5:40 PM, the Surveyor asked DE #2 to describe the consistency of the pureed cheese ravioli served to the residents who were on pureed diets. She stated, It was thick and lumpy. Puree is supposed to be free of lumps. 2. On 07/05/23 at 7:25 AM, the pureed sausage served to the residents on pureed diets was lumpy and was not smooth. At 7:36 AM, a pan of pureed sausage was on the steam table. The pureed sausage was lumpy and not smooth. The Surveyor asked DE #3 to describe the consistency of the pureed sausage served to the residents for breakfast. She stated, It is supposed to be smooth with no lumps. It has pieces of meat in it. 3. On 07/06/23 at 7:34 AM, the pureed sausage served to the residents on pureed diets was lumpy and not smooth. A Certified Nursing Assistant (CNA) who was assisting a resident in the Dining Room was asked to describe the consistency of the pureed sausage. She stated, It has lumps and was not smooth.

Based on observation, record review and interview, the facility failed to ensure food storage, preparation and service areas were free of pests. This failed practice had the potential to affect 79 residents who received a meal tray from the kitchen as documented on a list provided by the Dietary Supervisor on 07/05/23 at 12:30 PM. The findings are: 1. On 07/04/23 at 2:40 PM, upon entering the kitchen, there were three flies in a room leading to the kitchen where the ice-cream freezer was located and two flies crawling on the floor by the up-right freezer close to the food preparation counter. 2. On 07/04/23 at 3:14 PM, two flies were crawling on the floor close to the counter where food items were being prepared. One fly was outside a bowl on a tray in the opened cabinet above the food preparation counter. 3. On 07/04/23 at 3:20 PM, there were 3 flies on the cabinet above the food preparation counter. One fly was crawling on the floor in front of the deep fryer. The Surveyor showed the Dietary Supervisor the flies that were in the room leading to the kitchen where the ice cream freezer and dessert freezer were located and asked her to count the flies. She used a fly swatter and killed them. She stated, I killed nine flies. 4. On 07/04/23 at 5:00 PM, a fly was crawling on the floor in front of the two-door refrigerator. One was on the leg of a metal rack where tray covers were kept. One was crawling on the floor by the deep fryer. One was on the cabinet frame where 3 trays that contained clean bowls were stored. Three flies were crawling on the floor in the dish washing machine room. One fly was on the food preparation counter. 5. On 07/04/23 at 5:05 PM, there were 6 flies in a room leading to the kitchen where the ice cream freezer was located. The Dietary Supervisor used a fly swatter to kill them. She then killed three more flies. 6. On 07/05/23 at 7:40 AM, a fly was at a cabinet in the kitchen. The Surveyor asked Dietary Employee #5 to count the flies in the kitchen area. She did and stated, There are six flies. One was crawling on the floor in front of the food preparation counter. One was crawling on the counter around the microwave. One was crawling on the floor by the hand washing sink. One was crawling on the floor by the area leading to the dish washing machine room. One was on a metal rack where the tray covers were kept, and one was on the counter close to where glasses were kept on the counter. 7. On 07/05/23 at 12:49 PM, the Dietary Supervisor provided the following invoices: a. A (Pest Control Company) Invoice dated 05/16/23 documented, .Target Pest G [German] Roaches .Biweekly pest control service . Material Advion Ant Bait Gel Target Pest Fire Ant . Catchmaster Monitor Traps - not required. Order/Service Instructions Checked and signed logbook. Treated all needed rooms and replaced monitors. Inspected kitchen baited for German roaches and flies replaced monitors as needed . b. A (Pest Control Company) Invoice dated 06/06/23 documented, .Target Pest G Roaches .Biweekly pest control service Catchmaster Monitor Traps - not required. Order/Service Instructions, Inspected kitchen areas replaced monitors as needed. Treated exterior perimeter entry points for occasional pests and other invaders. Baited for flies. Checked and refilled bait stations as needed . c. A (Pest Control Company) Invoice dated 06/20/23 documented, .Target Pest G Roaches .Biweekly pest control service Catchmaster Monitor Traps Not Required . Order/Service Instructions Checked logbook no new entries. Inspected kitchen, replaced monitor as needed. Baited and treated for German roaches. Baited for flies. Treated rooms as needed for all occasional pests and other invaders. Baited for flies in needed areas . 8. On 07/06/23 at 11:00 AM, the Surveyor asked the Dietary Supervisor the reason there were so many flies in the kitchen. She stated, They were coming through the door. They are bad during the summertime.

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed to ensure a resident with mental health diagnoses received the necessary care and services in the most appropriate setting for 1 (Resident #75) of 2 (Residents #49 and #75) sampled residents who were screened for a Level II mental disorder or intellectual disability prior to admission. The findings are: 1. Resident #75 had diagnoses of Non Alzheimer's Dementia, Depression, Schizophrenia, and Personal History of other Mental and Behavior Disorders. a. A [State Designated Professional Associates] document provided by the Director of Nursing (DON) on 07/05/23 at 2:46 PM documented, .Date: Feb [February 16, 2023 . Re [Regarding]: [Resident #75] .The above-named client has been approved as an Exempted Hospital Discharge . If he/she is in a facility for 29 days, on the 30th day the nursing facility MUST call [State Designated Professional Associates] .Please contact [State Designated Professional Associates] when the client has admitted to your facility to complete the application process . b. On 07/05/23 at 3:36 PM, the Surveyor asked the DON who was responsible for completing the PASSARs. She stated, Me. The Surveyor asked if she had a Level II PASSAR on Resident #75. She stated, No. The Surveyor asked if Resident #75 had any mental diagnoses. She looked in the electronic record and stated, Unspecified Dementia, Schizophrenia, Mental Behavior Disorder and Depressive Episodes. The Surveyor asked should Resident #75 have had a Level II PASSAR. She said, Yes. c. On 07/05/23 at 3:11 PM, the Administrator stated, We have no policy on PASSARs.

Based on interview, and record review, the facility failed to ensure 1 (Resident #1) sampled resident was transported in the facility van to a doctor's appointment and did not cross a busy intersection in her electric wheelchair. The findings are: 1. Resident #1 had diagnoses of Hypertensive Heart Disease with Heart Failure, Depression, Unspecified, and Chronic Kidney Disease, Stage 4. A Quarterly Minimum Data Set (MDS) with a Reference Assessment Date of 12/26/22 documented a score of 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) .Mobility devices .wheelchair . a. The Care Plan with a Revision Date of 02/01/21 and a Completion Date of 4/03/23 documented, .The resident is High risk for falls r/t [related to] Deconditioning, Gait/balance problems .The resident needs a safe environment with even floors free from spills and/or clutter . b. On 04/10/23 at 10:30 AM., the Surveyor asked Resident #1, Did you have to go to an appointment without an assistant when you were supposed to go to the hospital? She stated, I made the appointment myself because I was hurting. When I got ready to go, they said the van was being used. I had to drive my electric wheelchair to the doctor's office. Look out the window, it's the building with the blue top. They know I had an appointment. My appointment was at 2:00 PM. I am sick and I told them that. I've been sick ever since last Wednesday. My head feels like it's about to bust. The Surveyor asked, Did you go to the Doctor's Office by yourself? She stated, No Certified Nursing Assistant (CNA) #1 went down there with me. c. On 04/10/23 at 2:50 PM., the Surveyor asked the Transportation Assistant, Did Resident #1 have an appointment last month? She stated, Yes she made it. The Surveyor asked, Did she go to her appointment? She stated, Yes, CNA #1 took her. The Surveyor asked, How did CNA #1 take her? She stated, She walked her over there. The Surveyor asked, Is there a reason she wasn't transported to the appointment? She stated, I had a transportation to go to [named city] that day and I'm the only driver. The Surveyor asked, When were you informed that she had an appointment? She stated, The day before. The Surveyor asked, Did you inform her that you couldn't take her? She stated, I was informed I had to take 2 other patients to [named city] at the very last minute. The Surveyor asked, Did anyone attempt to re-schedule her appointment? She stated, I told her that we would have to cancel, and she said whatever. She drove herself in her electric wheelchair and CNA #1 walked with her. The Surveyor asked, How did she get to her appointment without being in the road? She stated, I wasn't with her, CNA #1 was, and I can't say. d. On 04/10/23 at 3:45 PM., the Surveyor drove around to the Physician's Office. There were no sidewalks from the facility to the Physician's Office. There was a busy intersection that had to be crossed in order to get from the facility to the Physician's Office. e. On 04/11/23 at 8:45 AM., the Surveyor asked CNA #1, Did the facility let Resident #1 go to the doctor's office by herself, without an assistant when the staff was supposed to have taken her to the hospital? She stated, No, the Transportation Assistant, the lady over the van asked me if I can take her to the doctor. She told me to walk her over. That's when we went over there, but Resident #1 wasn't too happy about that. She told the Transportation Assistant that she wanted to reschedule her twice. Me I didn't understand why. If it was my [family member] I would be upset. I've never seen anything like that. It was windy that day. That was very disturbing to me. It was even cold to me. It's a busy intersection and I made sure it wasn't any cars coming. I made sure she was on the inside of me. She said twice that she wanted to cancel, and the Transportation Assistant ignored her. I made her feel like I was watching. The next day I came to work she had called her [family member]. I reported it and they said they would take care of it. We had 2 vans at the time that's why I really didn't understand why they couldn't take her over there. She really didn't want to go, but the Transportation Assistant didn't want to do that. They could have just dropped us off. She voiced her opinion way before we left. I told the Director of Nursing (DON) about it, and she said they did it in the past. f. On 04/11/23 at 9:01 AM., the Surveyor asked CNA #4,Did the facility let Resident #1 go to the doctor's office by herself, without an assistant when the staff was supposed to have taken her to the hospital? She stated, I do not know anything about it. The Surveyor asked, What could happen if a resident crosses the intersection in an electric wheelchair? She stated, Well they could get hit by a car. g. On 04/11/23 at 9:15 AM., the Surveyor asked CNA #2, Did the facility let Resident #1 go to the doctor's office by herself, without an assistant when the staff was supposed to have taken her to the hospital? She stated, I've heard it, but I don't know anything about it. The Surveyor asked, What could happen if a resident crosses the intersection in an electric wheelchair? She stated, Their wheelchair could go dead. A car might be going too fast to stop, and she could get hit. h. On 04/11/23 at 9:22 AM., the Surveyor asked the Registered Nurse, Did the facility let Resident #1 go to the doctor's office by herself, without an assistant when the staff was supposed to have taken her to the hospital? She stated, I didn't even know why she had that appointment that day. I didn't know she was going in her wheelchair. I assumed she was taken over there in the van. The next day I asked the Transport Driver were there any orders from that appointment, and she said no. The Surveyor asked, What could happen if a resident crosses the intersection in an electric wheelchair? She stated, She could get hurt, the electric wheelchair could stop. She could roll over a hump and fall out. I didn't know she went over there like that. It's shocking to me. i. On 04/11/23 at 9:35 AM., the Surveyor asked CNA #3, Did the facility let Resident #1 go to the doctor's office by herself, without an assistant when the staff was supposed to have taken her to the hospital? She stated, No, I normally work whirlpool. I've heard about it, but normally I work whirlpool, and I don't know details about it. The Surveyor asked, What could happen if a resident crosses the intersection in an electric wheelchair? She stated, It could stall on them. It's electric and something could malfunction. j. On 04/11/23 at 9:50 AM., the Surveyor asked the DON, Do you have a policy on accidents? She stated, We don't have an accident policy. The Surveyor asked, Did the facility let Resident #1 go to the doctor's office by herself, without an assistant when the staff was supposed to have taken her to the hospital? She stated, Yes, I was in the middle in the special needs unit. I did not know about Resident #1's appointment. I got those 2 approved to go to [named city] and it happen to be the same time as Resident #1's appointment. The Transport Assistant came to me and asked what I wanted to do about the appointment. I told her the only way for her to go is if someone supervises her in her wheelchair. The Surveyor asked, Does the facility allow residents to cross the intersection to attend appointments? She stated, Yes. The Surveyor asked, What could happen if a resident crosses the intersection in an electric wheelchair? She stated, Well it's no different than a vehicle. I guess anything could happen. k. On 04/11/23 at 10:00 AM., the Surveyor asked the Administrator, Did the facility let Resident #1 go to the doctor's office by herself, without an assistant when the staff was supposed to have taken her to the hospital? She stated, I was made aware of it upon my return from vacation. The Surveyor asked, Does the facility allow residents to cross the intersection to attend appointments? She stated, No. The Surveyor asked, What could happen if a resident crosses the intersection in an electric wheelchair? She stated, The battery could die.

Complaint # (AR 599) was substantiated, all or in part, with these findings: Based on observation, record review and interview, the facility failed to ensure adequate supervision was provided to prevent an accident with injury during transport in the facility van, which resulted in injury and that failed to ensure van transport staff were knowledgeable regarding protocols to follow in the event of a van accident with resident injury to prevent further potential injury for 1 (Resident #1) of 4 (Residents #1, #2, #3 and #4) case mix residents who were transported in wheelchairs via the facility van. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who sustained contusions to the sternum, a laceration on the top of her head, and multiple aches and when her wheelchair tipped over during transport, then was placed back in the wheelchair by transport staff and taken back to the facility before receiving treatment for [REDACTED]. 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an assessment reference date of [DATE] documented the resident scored 8 (,[DATE] -12 indicates moderately impaired) on a Brief Interview for Mental Status, required extensive assistance of one person for transfers, required extensive assistance of one person for locomotion off the unit and used a wheelchair for mobility. Verify bolded a. A Care Plan dated [DATE] documented, . Assisted with ADLs (Activities of Daily Living) decreased mobility, Dx (diagnosis) [MEDICAL CONDITION], hx (history) of fracture . Provide w/c (wheelchair) for mobility prn (as needed) . assist with transfers x (times) 1 assist . b. A Van Schedule for the month of (MONTH) (YEAR) (provided by the Administrator on [DATE] at 9:55 a.m.) documented, [DATE] . (Resident #1) - Wound Care - 9 a.m. c. A Nurses Note dated [DATE] at 8:45 a.m. documented, .R (Resident) being transported via NH (Nursing Home) van to MD (Medical Doctor) appt (appointment). Driver (Certified Nursing Assistant (CNA) #1) returned to NH (with) R stating R had taken seatbelt off and when driver stopped at stop sign and accelerated van again, R's w/c (wheelchair) turned over. R received a laceration to the top of her head approx (approximately) 3 cm (centimeters) in length. Phoned Dr. (Doctor) (with) orders to send to ER (emergency room ) for eval (evaluation) & (and) treat (treatment). (Ambulance Service) notified for transport . (8:50 a.m.) - (Ambulance Service) here to transport R to . ER . (8:55 a.m.) - Phoned dtr (daughter) to notify of incident, dtr stated R does not like seat belts & (and) will attempt to remove them when riding (with) her . d. An Incident /Accident report dated [DATE] at 8:45 a.m. documented, .Removed seat belt during transport in NH van & turned over received laceration to top of head approx 3 cm (centimeters) in length. R stated, 'I'm fine'. At this time transport by (Ambulance Service) . Maintenance to look (at) w/c & van. CNAs to be retrained in transporting Rs in van . e. An Office of Long Term Care (OLTC) Incident and Accident Report documented, . Date & Time of Discovery - [DATE] at (8:45 a.m.) . Summary of Incident - resident was being taken to MD (medical doctor) appt. (appointment) in NH van. NH van returned to facility and CNA/driver reported that resident had removed seatbelt while in transport. Driver stopped at stop sign and when she accelerated the resident's wheelchair turned over. Resident received a laceration to top of head. Resident was transported to (Hospital) emergency room via ambulance for treatment to laceration, receiving staples. NH van was sent to retrieve resident with two staff members aboard. On the return trip, resident began complaining of back and shoulder pain, so the driver turned around and went back to the hospital for x-rays of neck back and shoulders. Results of x-rays were received at approx 1930 (7:30 p.m.) hrs. Results show T11 ([MEDICATION NAME] vertebra #11) minimal superior endplate compression fractures that cannot be ruled out as acute. MD has ordered scheduling of MRI (magnetic resonance imaging) Monday to determine the age of fracture in question . Steps taken to prevent continued Abuse or Neglect during the investigation . All transport CNAs/drivers will be retrained in proper transport of residents in NH van. Driver in question has been suspended pending completion of investigation . A hospital Radiology Report dated [DATE] documented, .Cervical spine 3 views . Impression - Osteopenia without definite fracture or spondylolisthesis . Right Shoulder 2 views - Impression - [MEDICAL CONDITION] joint disease and chronic rotator cuff tear. No evidence of fracture . Left Shoulder 2 views - Impression - [MEDICAL CONDITION] joint disease without evidence of fracture . [MEDICATION NAME] spine - Impression - Osteopenia with L1 (lumbar vertebra #1) compression fracture and minimal T11 superior endplate compression fracture . The hospital emergency room documentation dated [DATE] at 9:26 a.m. documented, . Chief Complaint - Pt (patient) was being transferred in a nursing home van and her wheelchair tipped over and she hit the back of her head. She has an approx 1 in (inch) laceration with controlled bleeding . History of Present Illness . Patient came to the emergency room by ambulance after she fell out of the wheelchair and suffered a laceration to the occipital area of the scalp. no loss of consciousness. Denies any nausea vomiting. No chest pain. No shortness of breath. Bleeding under control . Procedure/Surgical History . Number of staples: 8 . The wound was cleansed with normal saline irrigation under pressure. Wound exploration reveals no muscle, tendon, nerve injury or foreign body. Wound was repaired under sterile technique with surgical skin staples. Patient tolerated the procedure well without complications . f. Nurses Notes dated [DATE] at 11:00 a.m. documented, .This nurse and (CNA #2) went in NH van to pick Res (resident) up from hospital. Res received staples to top of her head and no x-rays were done. On the way back from hospital res (resident) cont (continued) to c/o (complain) . hurting between her shoulder blades. This nurse phoned Dr who gave orders to take res back to hospital . This nurse took Res to outpatient and received x-rays then returned to NH. Res is not in any distress at this time. g. A Nurses Note dated [DATE] at 6:30 p.m. documented, .R c/o increased pain in bruised area on her chest from a recent fall. Dr was called and ordered R to be sent to hospital for a CXR (chest x-ray). Daughter notified . 2300 (11:00 p.m.) - returned from hospital. Will get results from radiology within 24 hrs (hours). Applied ice pack for 20 min (minutes) . emergency room documentation dated [DATE] at 19:57 (7:57 p.m.) documented, . History of Present Illness . Patient was involved in an accident 2 days ago in a wheelchair van that caused her to have injuries to her chest wall. Patient was in a wheelchair and it was not secured . Patient was seen in the emergency room initially for bilateral shoulder pain and back pain. X-rays of her shoulders and her spine were negative for any acute pathology. Patient now has a large contusion to her sternum which is very tender to palp (palpation) . Chest . Large hematoma to the sternal area . CT (Computed Tomography) chest w/o (without) contrast . Impression . Healing fractures left fifth through seventh ribs laterally. No definite acute rib fractures. Probable parasternal contusion . h. A Van Wheelchair Restraint In-Service which included a Step by Step return Demonstration Checklist of staff provided by the Administrator on [DATE] at 1:03 p.m. for the following Van Drivers (CNAs). Included with this package was a form entitled, Transportation Program - best Practice Recommendations for Van Safety, which included the previous training dates for each of the van drivers. CNA #3 signed and dated the [DATE] in-service sheet. The previous training for this CNA was dated and signed [DATE]. CNA #2 signed and dated the [DATE] in-service sheet. The previous training for this CNA was dated and signed on [DATE]. CNA #4 - signed and dated the [DATE] in-service sheet. The previous training for this CNA was dated and signed on [DATE]. The only training available for review for CNA #1 (the CNA driving the van at the time of the [DATE] incident) was signed and dated on [DATE]. i. The User Instructions for the facility's van restraints, received from the Administrator on [DATE] at 1:03 p.m., documented, . A. Secure Wheelchair . 1. Place wheelchair facing forward in securement area; apply wheel locks or turn power off. 2. Attach tie-downs into floor anchorages and ensure they are locked in. 3. Attach the four tie-down hooks to solid frame members or weldments, near sear level. Ensure tie-downs are fixed at approximately 45 degrees, and are within angles shown. Do not attach hooks to wheels, plastic or removable parts of wheelchair. 4. Ensure all tie-downs are locked and properly tensioned. if necessary, rock wheelchair back and forth or manually tension retractor knobs (If present) to take up additional webbing slack . B. 1. Attach Lap-Belts - use integrated stiffeners to feed belts through openings between seat backs and bottoms, and/or armrests to ensure proper belt fit around occupant. a. On the aisle, attach belt with female buckle to rear tie-down pin connector ensuring buckle rests on passengers hip. b. On the window side, attach belt with male tongue to rear tie-down pin connector; and insert into female buckle . 2. Attach Shoulder belt - extend shoulder belt over passengers shoulder and across upper torso and fasten pin connector onto lap belt. Note: Combination lap/shoulder belts serve as both window-side lap and shoulder belt. 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort . 1.) On [DATE] at 12:37 p.m., surveyors observed CNA #3 and CNA #2 load Resident #2 onto the white Dodge [MEDICATION NAME] via wheelchair. The CNAs properly secured all of the restraints and tested the tightness of the restraints by attempting to rock the wheelchair in all directions. The wheelchair remained securely in place. 2.) On [DATE] at 2:30 p.m., there was a sign dated [DATE] posted on the driver's side window of the silver van, which was the van where the [DATE] incident occurred. The sign documented, Out of order per Administrator.The surveyor observed as the Administrator secured a wheelchair on this van. The Administrator properly secured all restraints and tested the tension on the restraints by attempting to rock the wheelchair in all directions. The wheelchair remained firmly in place. j. On [DATE] at 1:17 p.m., the Administrator and the Director of Nursing (DON) were asked about the [DATE] van incident. The Administrator stated she was on vacation on the date of the incident, but the DON was here. The Administrator stated the DON met with the CNA #1 on Monday [DATE], but she did not have a written statement at this time. The Administrator stated the van driver told her she had locked the wheelchair, but the resident had released her seat belt. She (CNA) heard a bump and saw the resident lying backwards out of the wheelchair. The CNA stated she was less than one mile from the facility. The Administrator was asked what training had been done as to how staff should respond to emergency situations occurring on the van. The Administrator stated the CNA should do the same as if there was a fall in the facility, but there had not been any specific training. The Administrator stated CNA #3 did most of the training for the van, but there had been no training on emergencies in the van. The DON stated she spoke with the CNA, who said the resident had released her seat belt and flipped backwards out of the wheelchair. The CNA put the resident back into the wheelchair and pulled over into a gas station. When asked what the CNAs should do in the case of an emergency on the van, she stated it would be best for them to call 911 or the facility. k. On [DATE] at 1:49 p.m., Resident #1 was asked about the [DATE] incident on the van. The resident accurately described that she was on the van in her wheelchair on Friday ([DATE] was a Friday). She accurately stated she was going to (city) for her wound. She stated she did not know what happened, but that she came out of the wheelchair backwards. She stated, They say I undid the seat belt, but the belt came undone when I fell backwards. The resident stated her right leg, her chest, her back and the top of her head hurts. The resident pulled down the front of her shirt, revealing a yellow discoloration on her sternal area. The resident stated the driver brought her back here (to the facility), and then she went to the hospital. l. On [DATE] at 8:47 a.m., the Assistant Director of Nursing (ADON) was asked how long she had worked for the facility and about the [DATE] incident with Resident #1 on the facility's van. The ADON stated she had worked at the facility for [AGE] years and she worked on the day of the van incident with Resident #1. The ADON stated she was making rounds and a staff member came and told her that she was needed up front. When she arrived at the front nurses' station, Resident #1 was in a wheelchair at the nurses' station. CNA #1 was cleaning up blood from the resident's hair and Licensed Practical Nurse (LPN) #1 was on the phone calling the Doctor for an ambulance. The ADON stated she assessed the resident, checked her head and eyes and, within ,[DATE] minutes, the ambulance arrived. She assisted with putting the resident on the stretcher, then took CNA #1 out to the van with Resident #1's wheelchair and asked her to demonstrate how she had hooked up Resident #1's wheelchair. The ADON stated CNA #1 attached the hooks of the van's wheelchair restraint straps onto the wheels of the wheelchair instead of the frame. The ADON stated she did not think this was correct, so went back inside of the facility to look at the manual and realized this was not the correct way to secure the wheelchair; the hooks should have been placed on the frame of the wheelchair. The ADON stated she observed a fair amount of blood on the floor at the back of the van close to the door. She stated CNA #1 told her she had picked up the resident and placed her back into the wheelchair and then brought her back to the facility. She stated CNA #1 told her she was about one block from the nursing home when the incident occurred at the stop sign that the resident undid her seat belt and when the van accelerated from the stop sign, the resident fell back and the CNA pulled over at the old gas station. The ADON stated she went with CNA #2 to pick Resident #1 up from the hospital. She stated that before leaving the parking lot of the nursing home they she took the resident's wheelchair and the ADON retrained and observed the van driver (CNA #2) put and tie down the wheelchair onto the van. The silver van had been placed out of commission at this time and they used the white van. When the van driver had tied down the wheelchair she made sure that it was secure, she checked this again when the resident was in the wheelchair to make the wheelchair was secured correctly. m. On [DATE] at 9:40 a.m., CNA #2 stated she is the back-up transport person and had done this for the two years that she had been employed by the facility. She stated her last training for the van was 3 months ago, when they received the new van. When asked if she had received training on what to do in the event of an accident / injury on the van, she stated she is also an Emergency Medical Technician (EMT) and knew from her previous job to call 911, call the facility and not move the resident if there is an accident, but that she had not received any training on this since working for the facility. n. On [DATE] at 9:55 a.m., CNA #3 stated that she had worked at the facility for 4 years, that she was trained in a Cardiopulmonary Resuscitation (CPR) class to call 911 and not to move a resident if there was an emergency and that the previous DON also discussed this with her when she began to drive the van. o. On [DATE] at 10:06 a.m., CNA #4 stated she had worked at the facility for 3 years, was trained for both of the vans in (MONTH) (YEAR), and had a verbal check off 2 months ago. She stated she was also retrained this week and was checked off on how to tie down the wheelchair. The CNA stated that she knew to call 911 and call the facility if anything happened on the van, because she drives the van at another facility. The CNA stated she had not received training on what to do in the event of an emergency on the van at this facility. p. On [DATE] at 10:58 a.m., the Administrator was asked who trained the van drivers to secure the wheelchairs in the van and stated CNA #3 trained the van drivers. She stated she trained CNA #3, and they both went to the van supplier and received training for approximately one hour on the correct way to tie down and secure a wheelchair and resident in the van. The Administrator stated they had been using the silver van since (MONTH) (YEAR) and the white van since [DATE]. q. On [DATE] at 11:15 a.m., the maintenance man stated he had checked the silver van's restraints on [DATE] after the incident with no negative findings and that he checks the vans weekly. r. The Immediate Jeopardy was removed and the scope and severity was decreased to G on [DATE] at 4:39 p.m., when the facility implemented the following Plan of Removal: On [DATE], the DON and Administrator immediately suspended transport CNA (CNA #1) with incident occurring on [DATE] until further notice. On [DATE], 1 resident was identified by DON by chart review to have the potential to be affected by the deficient practice of moving a resident with a potential major injury without notifying a nurse first. Any negative findings were corrected immediately. The primary transportation driver was immediately in-serviced on [DATE] about the deficient practice of moving a resident with a potential major injury without notifying a nurse first and about what to do if an emergency situation occurs during transportation. The remaining transportation drivers will be is-serviced before their next transportation with a resident on the deficient practice of moving a resident with a potential major injury without notifying a nurse first and about what to do if an emergency situation occurs during a transportation. Any new transportation drivers will be trained by the designee on the practice of ensuring the proper protocols are used during an emergency situation during transportation and the deficient practice of moving a resident with a potential injury without notifying a nurse first upon hire. All transportation drivers will be in-serviced twice a year on the practice of following protocols during an emergency situation during transportation. The Administrator/designee will monitor to ensure all transportation drivers are following the proper protocols during an emergency situation during a transportation daily for 4 weeks or until compliance is verified by OLTC. Any negative findings will be corrected immediately and will be reported to daily QA&A (Quality Assessment and Assurance) for discussion.

Complaint # (AR 453) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure a mechanical lift was utilized in accordance with the manufacturer's instructions, to include selection and use of the correct lift sling, correct positioning of the sling during transfer and correct use of the color-coded sling straps, to prevent further potential accidents with injury for 1 (Resident #4) of 2 (Residents #4 and 6) case mix residents who required the use of a mechanical lift for transfers. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #4, who sustained bruising after being dropped and hit by a mechanical lift lever during a transfer, and had the potential to cause more than minimal harm to 11 residents who were transferred with a mechanical lift, as documented on a form dated 9/22/17. The Administrator was informed of the Immediate Jeopardy condition on 9/21/17 at 4:45 p.m. The findings are: Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of 8/9/17 documented the resident scored 12 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status, was totally dependent on 2-plus people for transfers and bed mobility, required the use of a wheelchair for mobility, and was only stable with assistance for surface-to-surface transfers. a. A Care Plan with an onset date of 8/14/17 documented, .Assist with transfers x (times) 2-4 (staff) assist / lift . The Care Plan did not specify a sling size or which color sling straps were to be utilized during transfers. b. A Nurse Aide Information Sheet (Closet Care Plan), not dated, documented, .Requires total assist for transfers, use lift and 2-4 person assist . The Closet Care Plan did not specify a sling size or which color sling straps were to be utilized during transfers. c. An Incident and Accident (I/A) Report dated 8/31/17 (not timed) documented, .Describe exactly what happened: .R stated that her legs was hurting and requested to get out of bed. As CNAs (Certified Nursing Assistants) #1, 7 and 8 & (and) myself (Licensed Practical Nurse (LPN) #5) try to lift her out of bed (with) the lift, it turned over, broke & hit her in the head .type of injury 5. Swelling . Steps to prevent recurrence: Maintenance to look at lift. Resident weight is within lift's parameters . Maintenance believes it was mechanical error. Lift serviced. We are using other lift on (Resident #4) . 9/4/17 - Conflicting stories r/t (related to) this incident are being talked on floor. Spoke (with) staff in room r/t specifics. (Resident #4) had requested to get up. They were using Hoyer lift, when they positioned (Resident #4) over her chair, the cylinder on arm of lift went down quickly instead of slowly, causing lift to tilt (and) hit resident. This was not human error but mechanical. I called (and) spoke at length (with) daughter, (daughter's name) and explained above. I told her if she or anyone ever had questions regarding any issue to please call me. I never had any reason to believe staff had done anything wrong. After speaking to them, I am sure they did not. Both lifts have been checked by maintenance. On 9/22/17 at 12:20 p.m., the Assistant Director of Nursing (ADON) was asked if the resident was injured during the mechanical lift incident on 8/31/17 and stated, The family called me and asked me why bruising was around her eyes, and I explained she was hit in the head with the lever, and the swelling moved to her eyes. LPN #4, who was also present for this interview, stated, I heard she had a fall and went down to her room to see her. That's when I noticed bruising around her eyes. I'm not sure about those dates. d. An In-service training report dated 9/8/17 documented staff were retrained on the facility's mechanical lifts. e. On 9/20/17 at 3:40 p.m., the ADON was asked if there had been any in-service training with staff regarding the use of the mechanical lift. At 4:20 p.m., Licensed Practical Nurse (LPN) #1 provided the team with Monthly Skills check-off sheets dated May 2016 and September 2017. The LPN was asked if there was any other training provided between these dates and stated, No, that's all we have. The Monthly Skills check-off list dated September 2017 documented, Hoyer Lift and had the signatures of 14 of the facility's 58 nursing staff as having been checked off on transfers. f. On 9/21/17 at 12:50 p.m., Resident #4 was asked to describe explain what happened when she fell from the lift on 8/31/17 and stated, A piece of it broke off the loop, and I hit the floor, and the lift fell on me. It took about 5 people to get me up. They need to give lessons on how to use it. I'm scared when they lift me. I know they use the green and black straps. The same thing happened the next day. They dropped me on the floor. It took all of them to get me up, and the nurse didn't check me. The surveyor immediately informed the Administrator of the resident's statement that she was dropped on the floor during a transfer on 9/1/17. The Administrator stated, (I'm) only aware of the fall on 8/31/17. g. On 9/21/17 at 2:35 p.m., the ADON was asked, Where are the mechanical lift and fall assessment kept? The ADON stated, They should be included in the Care Plan; let me ask (LPN #3). At 2:37 p.m., (LPN #3) stated, We don't have an assessment on paper, but I care plan if they're a 1 to 4-person mechanical lift transfer. h. The Invacare Reliant 450 or 600 User Manual documented, .Using the sling: Warning - Use an Invacare approved sling that is recommended by the individual's doctor, nurse or medical assistant for comfort and safety of the individual being lifted . When connecting slings equipped with color coded straps to the patient lift, the shortest of the straps must be at the back of patient for support. Using long section will leave little or no support for patient's back . The loops of the sling are color coded and can be used to place patient in various positions. The colors make it easy to connect both sides of the sling equally Make sure that there is sufficient head support when lifting a patient . On 9/21/17 at 2:50 p.m., Certified Nursing Assistants #1, #2 and #3 and Licensed Practical Nurse #1 transferred the resident from a wheelchair to bed, using a mechanical lift. Resident #4 was sitting in her wheelchair on a blue lift sling that had a color-coded strap (green, blue, purple) on each end of the sling pad. CNA #2 connected the green straps (near the resident's head) to the right and left metal hooks located on the backside of the hanger bar, and CNA #1 connected the purple straps (near the resident's buttocks) to the right and left metal hooks located on the front side of the hanger bar. CNA #3 operated the lift and lifted the resident from the wheelchair, while CNA #1 held the resident's legs and CNA #2 maneuvered the back of the sling. While the resident was being transferred, the top section of the sling was coming over her head and covered part of her face. The bottom section of the sling (near the buttocks) was only under her buttocks and provided no support to the upper thighs. The sling extended from the bottom of the resident's buttocks to above her head. Her legs and thighs were fully extended during the transfer. Her arms were covered and encased in the sling. During the transfer, CNA #1 stated, This lift sheet is too high. The resident appeared uncomfortable. The CNAs proceeded with the transfer and placed the resident in bed. CNA #1 stated, We got to take this lift pad off, because someone put it on her wrong. CNAs #1 and #2 turned and repositioned the resident so they could adjust the lift pad. They rolled the pad underneath the resident and turned it 180 degrees, so that the portion that was previously under her buttocks was now under her head. The staff then transferred the resident from the bed to the wheelchair. CNA #2 connected the purple straps, near the resident's head, to the metal hooks and CNA #1 connected the green straps, near the resident's thighs, to the metal hooks. CNAs #2 and #3's signatures were not included on the monthly check-off list for September 2017. i. On 9/21/17 staff members were asked, How do you know which sling pad and color strap to use for each resident and who trained you on the mechanical lift? Their responses were as follows: 1.) From 3:18 p.m.-3:23 p.m., CNAs #1, #2, #3 and Licensed Practical Nurse (LPN) #1 were interviewed. All 3 of the CNAs stated, We use the sling (strap) closest to her to sit her up and the bottom sling (strap) furthest from her body. (LPN #2) trained us on the sling. LPN #1 stated, I'm over the CNAs and I read the manual. 2.) At 3:30 p.m., LPN #2 was asked the above question via telephone and stated, I was trained over [AGE] years ago and I can't remember who trained me. I use the loop near the head that looks most comfortable and the second-to-the-last loop on the bottom one. 3.) At 3:50 p.m., CNA #5 was asked the above question via telephone and stated, (LPN #2) trained me on the lift . can't remember how long ago. 4.) At 3:50 p.m., CNA #4 stated, (LPN #2) trained me long ago. When asked how long ago, the CNA stated, Can't remember. 5.) At 4:05 p.m., CNA #6 stated, It's been so long ago since I was trained; we used to do it periodically throughout the year. I can't recall who trained me. 2. The immediate jeopardy was removed and the scope / severity reduced to E on 9/21/17 at 4:45 p.m., when the facility implemented the following plan of removal: a. On 9/21/17, the ADON immediately assessed (Resident #4) to ensure the proper lift sheet and the positioning of the lift sheet were correct during the use of the Vander lift during transfer. Any negative findings were corrected immediately. b. 11 residents were identified by MDS Coordinator by chart review to be affected by the failed practice of ensuring the proper lift sheet and the positioning of the lift sheet were correct during the use of the Vander lift during a transfer. The 11 residents were assessed by the interdisciplinary team to determine proper lift sheet is being used and is properly placed on resident during transfer with a Vander lift. Any negative findings were corrected immediately. c. South 2 CNAs were immediately counseled on 9/21/17 about the deficient practice of making sure the proper lift sheet and the positioning of the lift sheet are correct during the use of the Vander Lift during a transfer. All licensed staff working the evening shift on 9/21/17 and the night and day shift working 9/22/17 were immediately in serviced to ensure the proper size lift sheet is being used during a transfer using a Vander lift. All remaining licensed staff will be in serviced by their next scheduled shift to ensure the proper lift sheet and the positioning of the lift sheets are correct during the use of the Vander lift during a transfer. All new licensed hires will be trained by the designee on the practice of ensuring the proper lift sheet and is in the proper position of the lift is being used during a transfer with a Vander lift on a resident. d. The DON/designee will monitor to ensure the licensed staff is using the proper lift sheet and positioning the lift sheet correctly when using the Vander lift during a transfer 5 x (times) a week for 2 weeks, 3 x a week for 2 weeks, 1 x a week for 2 weeks or until compliance is verified by OLTC (Office of Long Term Care). Any negative finding will be corrected immediately and will be reported to daily QA&A (Quality Assessment and Assurance) for discussion.

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to immediately consult a physician after a nutritional assessment determined nutrition provided did not meet assessed needs for 1 (Resident #3) of 7 (Residents #1 through #7) case mix residents who were at risk for pressure ulcer development. The facility failed to immediately consult a physician and notify responsible parties after significant changes in condition of pressure ulcers for 2 (Residents #3 and #7) of 5 (Residents #3 through #7) case mix residents with pressure ulcers. The facility failed to consult with a physician about change in treatment of [REDACTED].#7) of 5 (Residents #3 through #7) case mix residents with pressure ulcers. The failed practices likely caused a pattern of harm for Resident #3 who received less than required nutritional support to prevent development of pressure ulcers over a period of approximately 5 months, one of which became unstageable and covered with eschar. This failed practice was likely to cause more than minimal harm for 20 residents at risk for development of pressure ulcers as documented on a listing provided by the Director of Nursing (DON) on 2/17/12 at 3:00 p.m. and 8 residents with pressure ulcers as documented on the Resident Census and Conditions of Residents dated 2/15/12. The findings are: 1. On 2/16/12 at 6:35 p.m., the DON provided a "Pressure Ulcer-Treatment" policy that documented, "Perform nutritional assessments per MD (medical doctor) order" and "Notify physician of change in status, when treatment is not effective, and alternate interventions should be considered or attempted." 2. On 2/17/12 at 8:38 a.m., the DON provided a "Changes in a Resident's Condition or Status" policy that documented, "It is the policy of this facility to report changes in the resident's condition or status. 1. Nursing Service shall be responsible for notifying the resident's attending physician when: b. There is a significant change in the resident's physical, mental or emotional status... 3. All notifications must be made as soon as practical, but in no case shall such notification exceed twenty-four hours." 3. On 2/14/12 at 5:52 p.m., the DON was asked about frequency of the Registered Dietician's (RD) facility visits and she stated, "RD comes quarterly." The DON was asked what they do in-between visits if a need arose, and she stated, "we call her." On 2/16/12 at 6:35 p.m., the DON provided a "Pressure Ulcer-Treatment" policy that documented, "Notify physician of change in status, when treatment is not effective, and alternate interventions should be considered or attempted." 4. Resident #3 had [DIAGNOSES REDACTED]. a. Nurse's Notes dated 12/22/10 through 3/30/11 documented the resident received a continuous tube feeding of Glucerna 1.2 at 60 cubic centimeters (cc) per hour. Nurse's Notes dated 4/12/11 documented the resident was transferred to a local hospital for observation due to a skin culture report of Pseudomonas organism growth. b. The Hospital Consultation Report dated 4/13/11 and signed by Physician #2 documented, "the patient developed abdominal distention here in the hospital. The patient has a long history of recurrent abdominal distention, especially when she gets her PEG (percutaneous endoscopic gastrostomy) feedings." In the "Vital Signs" section, the Report documented, "At the time of this examination the patient's weight is 161 pounds (lbs.)." The hospital Patient Transfer form dated 4/18/11 documented the resident was transferred back to the nursing facility with a physician's orders [REDACTED]. c. The "Nutritional Assessment of Tube Fed Resident" dated 5/2/11 and signed by the facility's Registered Dietitian (RD) documented under weight, "refuses to be weighed" and an Ideal Body Weight (IBW) of 135 lbs. +/- 10%. The Nutritional Assessment documented the resident's needed nutritional intake (with use of the IBW, not the resident's recent weight in the hospital, a difference of 26 lbs.) versus what was provided through the tube feeding as follows: total caloric needs = 1,447 calories (tube feeding provided less than required, 1,152 calories); total protein needs (without injury to skin) = 56 grams (g) protein/day (tube feeding provided less than required, 48 g/day) and total free water (with 200 cc flushes 4 times per day and 60 cc flush before and after medications 2 times per day) = 2,010 cc (tube feeding provided less than required, 1,846 cc/day). The RD's notes documented, "Tube feeding rate was decreased during hospitalization recently. Monitor tolerance to feeding; Increase as needed per MD (Medical Doctor)." d. Nurse's Notes dated between 5/2/11 and 8/2/11 were reviewed and there was no documentation of abdominal distention or intolerance of the tube feedings as ordered. The Nutritional Assessment RD notes dated 8/2/11 documented, "current wt. (none) (resident) refuses to be weighed . . . continues to receive Glucerna 1.2 at 40 cc/hour . . . is tolerating feeding (without) problems . . . MD aware of nutrition being received (and) will made adjustments as he sees necessary." A typed letter to Physician #1 dated 8/2/11 and signed by the Certified Dietary Manager (CDM) documented the resident's refusal of weights in the facility since January 2011 and the physician's initialed response documented, "ok." Nurse's Notes dated between 8/2/11 and 12/16/11 and Nutritional Progress Notes dated 8/5/11, 9/2/11, 10/12/11 and 10/19/11 (the most recent documented in the clinical record) did not document discussion or attempts to consult with Physician #1 about gradual increases in the resident's tube feedings in order to meet her assessed nutritional needs. e. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/18/11 documented the resident scored a 2 (0-7 indicates severe impairment) on the Brief Interview for Mental Status, had total dependence with two persons for bed mobility and toilet use, had a catheter, was always incontinent of bowel, no weight for the resident, received 51% or greater calories and 501 cc or greater fluids through a feeding tube, was at risk for development of pressure ulcers and did not have pressure ulcers. f. The Care Plan dated 10/19/11 documented a problem for potential skin breakdown with an approach, "Alert MD of any problems." Another problem for potential for impaired skin integrity documented an approach, "Treatment as ordered per MD." g. Treatment Administration Records (TARs), Weekly Skin Audit records, Weekly Pressure Ulcer Quality Improvement (QI) Logs and/or Nurse's Notes documented the development of pressure ulcers without physician consults and family notifications as follows: Buttocks/Coccyx: 1) Weekly Skin Audits dated 10/24/11 documented, "raw area buttocks," and Nurse's Notes dated 10/25/11 documented, "raw in creases (buttocks)." There was no documentation of the coccyx on the TARs for the weeks of 11/3/11, 11/10/11 and 11/23/11. There was no documentation in the above listed records the physician was consulted about the new skin breakdown and a request for treatment orders and the family was notified of the new skin break down. 2) The TAR weekly pressure ulcer (PU) documentation dated 11/16/11 documented, "Coccyx has multiple open areas in one large area. Wound gel applied." There was no documentation in the Nurse's Notes, Physician order [REDACTED]. The TAR dated November 2011 documented a treatment order dated 10/28/11, "Wound gel to coccyx bid (twice per day) (and) prn (as needed) until healed per protocol." On 2/16/12 at 3:35 p.m., the DON was asked about the use of wound gel without physician consult and she stated, "wound gel is on our wound protocol." The DON was asked if that meant she was stating it was okay to treat a new wound without calling the physician and she stated, "yes, (if) it's superficial." A request was made for that protocol. Other policies were provided on 2/16/12 and 2/17/12, but the facility had not provided a protocol for treatment of [REDACTED]. 3) TARs dated November 2011 documented a treatment order for the coccyx dated 11/23/11, "[MEDICATION NAME] to coccyx, (change) weekly (and) prn," 30 days after the initial documentation of skin breakdown at the coccyx. 4) TAR weekly PU documentation dated 11/29/11 documented, "(left) buttock has open areas (approximately) 1.5 cm and 1 cm diameter." Nurse's Notes dated 11/29/11 documented the initial notification to family of the resident's skin breakdown. 5) TAR weekly PU documentation dated 12/7/11 did not document an assessment of the resident's coccyx. TAR weekly PU documentation dated 12/15/11 documented the pressure ulcer had deteriorated in size, "(left) buttock open area measures 3 cm x 1 cm wound bed dark pink in color, (no) drainage noted." Nurse's Notes dated 12/15/11 documented the physician had been consulted about a critical level hemoglobin / hematocrit and orders received to admit the resident to a local hospital on [DATE] for a blood transfusion, but there was no documentation the physician was consulted about the pressure ulcer's deterioration or new orders at that time day. Left Heel: 1) Nurse's Notes dated 10/28/11 documented, "(resident) has open area (left) heel measures (1.5 x .75 cm), wound gel applied (and) covered per (Physician #1). Son (son's name) notified." 2) TAR weekly documentation dated 11/9/11 documented, "(left) heel open area 2 cm x 1. cm (no depth). Wound bed red (with) slough, (no) odor." There was no documentation in Nurse's Notes of the physician consultation or family notification of the deterioration in the left heel pressure ulcer. 3) TAR weekly documentation dated 11/16/11 documented further deterioration in size, "2 cm x 3 cm (no depth), wound bed (with) slough tissue present (and) small amount bleeding noted." There was no documentation in the nurses notes or TAR that the physician was consulted or family notified about the deterioration at that time. 4) TAR weekly documentation dated 11/23/11 documented, "(left) heel measures 6 cm x 4 cm dark eschar only small edge that is opened (with) small (amount) bleeding noted." Physician order [REDACTED]. Apply Santyl (a chemical debridement agent) to necrotic tissue. Cover (with) 4x4's and wrap (with) Kerlix." The treatment order change to include an agent for necrotic tissue was dated 14 days after the initial documentation of presence of necrotic tissue in the left heel pressure ulcer. 5) The local Hospital "Photographic Wound Documentation" forms dated 12/16/11 documented the pressure ulcer at the left heel, "2 cm (picture identifies wound size closer to facility measurements)." The second hospital's physician progress notes [REDACTED]. Right Heel: 1) TAR weekly pressure ulcer documentation dated 11/16/11 documented, "(right) heel has darkened area (approximately) (1.5) cm x 1 cm unopened." TAR weekly documentation dated 11/23/11 documented, "(right) heel has 2 cm diameter darkened area unopened." Nurse's Notes dated 11/29/11 documented, "(right) heel now open, (Physician #1) to come (and) look (at) wounds." That Nurse's Note was the initial documentation of a physician consult and family notification to inform of new breakdown at the resident's right heel, a period of 13 days. h. On 2/16/12 at 4:51 p.m., the facility's RD was asked what was done to ensure the resident received required nutrition to meet her needs prior to the development of pressure ulcers and she stated, "(Physician #1) reduced the rate and I documented as per (physician #1's) orders. We informed (physician #1) that she refused to be weighed, he signed that he knew and I thought that took care of it." 5. Resident #7 had [DIAGNOSES REDACTED]. The Significant Change in status MDS with an ARD of 1/17/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status, required total assistance of two persons for bed mobility, was incontinent of bowel, required total assistance of one person for toilet use, received 51% or greater calories and 501 cc or greater fluid through a feeding tube, was at risk for pressure ulcers and had a stage III pressure ulcer. The MDS documented the measurement of the pressure ulcer as no length, 0.5 cm width, and no depth with granulation tissue. a. The Care Plan dated 1/18/12 documented a problem for impaired skin integrity, stage III to coccyx with a goal, "see current ulcer to coccyx resolved this qtr. (quarter)," with an approach, "Alert MD of any problems." b. The TAR's dated 07/11 through 02/12 were reviewed. The resident had an initial treatment order dated 4/12/11 for dilute [MEDICATION NAME] wet to dry twice per day. The 7/11 TAR weekly pressure ulcer assessment dated [DATE] documented the pressure ulcer measured 1.5 cm round X 2 cm depth. c. The TAR dated 7/11 documented a treatment order change on 7/22/11 for the same treatment done one time per day with weekly wound measurements dated 7/20/11, 7/27/11, 8/10/11, 8/17/11 and 8/25/11 of 1.0 x 1.5 cm. TAR weekly pressure ulcer measurements dated 8/31/11 documented 1.0 x 2 cm, a deterioration for that wound, and there was no documentation on the TAR or in Nurse's Notes that the physician was consulted at that time. d. The TAR dated 10/11 documented a new treatment dated 10/27/11 for Normal Saline wet to dry dressing daily. e. The TAR weekly assessment dated [DATE] documented the pressure ulcer measured 0.75 x 0.5 cm. f. The resident was readmitted from the hospital on [DATE] with the same daily pressure ulcer treatment ordered since 10/27/11. The TAR's dated 12/11, 1/12 and 2/12 documented weekly assessments with measurements 0.5 x 1.0 cm (12/14/11), 1.0 x .25 cm (1/18/12), 1.0 x 5 cm (1/25/12) and 1.0 x .75 cm (2/8/12 and 2/15/12). There was no documentation on the TAR's or in the Nurse's notes that a physician was immediately consulted on 1/18/12, 1/25/12 or since 2/8/12 about the deterioration in the pressure ulcer size. g. On 2/16/12 at 9:42 a.m., Licensed Practical Nurse (LPN) #2 provided wound treatment as ordered with Certified Nursing Assistant (CNA) #3 in the room to assist. The resident's pressure ulcer at the coccyx was a stage III that measured approximately 1.0 x 1.0 cm with a pink wound bed. h. On 2/16/12 at 11:30 a.m., the DON was informed of the above information and asked to provide evidence that a physician had been consulted about the same wound treatment ordered since 10/27/11 without marked improvement to the pressure ulcer. As of 2/17/12 at 5:20 p.m., the facility had not provided that information.

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure Residents #1, #2, #3, #4, #5, #6, and #7 received the necessary treatment and services to promote healing of pressure ulcers or to prevent the development of pressure ulcers: The facility failed to ensure adequate nutrition was provided, which included protein supplements, for 1 (Resident #3) of 7 (Residents #1 through #7) case mix residents who were at risk for pressure ulcer development or had pressure ulcers. The facility failed to provide nutritional supplements as ordered for 1 (Resident #4) of 3 (Residents #3, #4 and #5) case mix residents who had pressure ulcers. The facility failed to ensure nutritional assessments were conducted with alternate methods in the absence of weights to ensure adequate nutrition to prevent the deterioration/development of pressure ulcers for 2 of 2 (Residents #1 and #3) case mix residents who refused weights and had pressure ulcers or was at risk to develop pressure ulcers. The facility failed to ensure treatment orders were obtained immediately after identification of a pressure ulcer and prior to the use of wound gel for 1 (Resident #3) of 7 (Residents #1 through #7) case mix residents who were at risk for pressure ulcer development or had pressure ulcers. The facility failed to ensure accurate and complete pressure ulcer assessments were completed on at least a weekly basis for 3 of 3 (Residents #3, #4 and #5) case mix residents who had pressure ulcers. The facility failed to conduct weekly Skin Audits as planned for 3 of 3 (Residents #3, #5 and #6) case mix residents who were at risk for and had pressure ulcers. The facility failed to ensure pressure relieving devices or methods were implemented to provide pressure relief for feet/heels for 6 of 6 (Residents #1, #2, #4, #5, #6 and #7) case mix residents who were at risk for pressure ulcer development; These failed practices likely caused a pattern of harm for Resident #3 who received less than the required nutritional support to prevent development of 3 pressure ulcers over a period of approximately 5 months, one of which became unstageable and covered with eschar. This failed practice was likely to cause more than minimal harm for 20 residents in the facility at risk for development of pressure ulcers and 1 resident who was not weighed or nutritional status assessed by another method as documented on a listing provided by the Director of Nursing (DON) on 2/17/12 at 3:00 p.m. and 8 residents with pressure ulcers as documented on the Resident Census and Conditions of Residents dated 2/15/12. The findings are: 1. On 2/14/12 at 5:52 p.m., the DON was asked about frequency of the Registered Dietician's (RD) facility visits and she stated "RD comes quarterly." The DON was asked what they do in-between visits if a need arose, and she stated, "we call her." a. On 2/16/12 at 6:35 p.m., the DON provided a "Pressure Ulcer-Treatment" policy that documented, "1. The nurse is responsible for carrying out the treatment of [REDACTED]. Nursing Care will consist of intensive application of the same measures as outlined in prevention of pressure ulcers... 3. Record Treatment in Medication Record and all pertinent observations, including depth and size in Decubitus sheet... Perform nutritional assessments per MD (medical doctor) order... Notify physician of change in status, when treatment is not effective, and alternate interventions should be considered or attempted." b. On 2/17/12 at 8:38 a.m., the DON provided a, "PUP (Pressure Ulcer Prevention)" Team in-service dated 2/6/12 that documented, "CNA's (Certified Nursing Assistants) were reminded of the proper procedures for reporting new skin issues . . . floating of reddened heels, and using positioning pillows for comfort and pressure relief." That in-service documentation did not document floating of heels as a preventative measure before redness occurred. The DON provided another policy, "Weekly Body Audits," that documented, "Procedures: Body audits are to be done by LPN's {licensed Practical Nurse) or RN's (Registered Nurse) on a weekly basis." On 2/17/12 at 8:38 a.m., the DON provided in-service training dated 6/6/11 that was titled, "Assessment and Documentation of Pressure Ulcers," and was presented by an outside source to all nurses who worked in the facility. The in-service handout documented, "Pressure Ulcer Wound Assessment - Location, Stage/partial or full thickness, Dimensions . . . Exudate, Wound Base Status, Surrounding tissue . . ." definitions of eschar and slough, "Outcomes - progression within 14-30 days or tweak treatment." 2. Resident #3 had [DIAGNOSES REDACTED]. a. Nurse's Notes dated 12/22/10 through 3/30/11 documented the resident received a continuous tube feeding of Glucerna 1.2 at 60 cubic centimeters (cc) per hour. Nurse's Notes dated 3/31/11 for day shift documented the resident had small amount of vomit noted and the tube feeding was turned off. Nurse's Notes dated 4/1/11 at 1:30 a.m. documented the tube feeding had been resumed at it's former rate. Nurse's Notes dated 4/12/11 documented the resident was transferred to a local hospital for observation due to a skin culture report of Pseudomonas organism growth. b. The Hospital Consultation Report dated 4/13/11 and signed by Physician #2 documented the resident was admitted on [DATE] due to a skin condition (on the resident's back) that was cultured and had identified Pseudomonas infection. The Consultation Report documented, "the patient developed abdominal distention here in the hospital. The patient has a long history of recurrent abdominal distention, especially when she gets her PEG (percutaneous endoscopic gastrostomy) feedings . . . there has been no history of nausea, vomiting, constipation, diarrhea." In the "Vital Signs" section, the Report documented, "At the time of this examination the patient's weight is 161 pounds (lbs.)." The hospital Patient Transfer form dated 4/18/11 documented the resident was transferred back to the nursing facility with a physician's orders [REDACTED]. c. The "Nutritional Assessment of Tube Fed Resident" dated 5/2/11 and signed by the facility's Registered Dietitian (RD) documented under weight, "refuses to be weighed" and an Ideal Body Weight (IBW) of 135 lbs. +/- 10%. The Nutritional Assessment documented the resident's needed nutritional intake (with use of the IBW, not the resident's recent weight in the hospital, a difference of 26 lbs.) versus what was provided through the tube feeding as follows: total caloric needs = 1,447 calories (tube feeding provided less than required, 1,152 calories); total protein needs (without injury to skin) = 56 grams (g) protein/day (tube feeding provided less than required, 48 g/day) and total free water (with 200 cc flushes 4 times per day and 60 cc flush before and after meds 2 times per day) = 2,010 cc (tube feeding provided less than required, 1,846 cc/day). The RD's notes documented, "Tube feeding rate was decreased during hospitalization recently. Monitor tolerance to feeding; Increase as needed per MD." On 2/16/12 at 4:55 p.m., the RD was informed of the resident's weight in the hospital on [DATE] (161 lbs.) and was asked why that weight was not used to do the nutritional assessment she documented 5/2/11 and she stated, "I do it (nutritional assessments) from what they (Certified Dietary Manager (CDM) and DON) have told me." d. Nurse's Notes dated between 5/2/11 and 8/2/11 were reviewed and there was no documentation of abdominal distention or intolerance of the tube feedings. The Nutritional Assessment RD notes dated 8/2/11 documented, "current wt. (none) (resident) refuses to be weighed . . . continues to receive Glucerna 1.2 at 40 cc/hour . . . is tolerating feeding (without) problems . . . MD aware of nutrition being received (and) will made adjustments as he sees necessary." A typed letter to Physician #1 dated 8/2/11 and signed by the Certified Dietary Manager (CDM) documented the resident's refusal of weights in the facility since January 2011 and the physician's initialed response documented, "ok." e. The Quarterly Dietary Consultant reports dated 5/11/11 and 8/2/11 did not document any nutritional recommendations by the RD for this resident. f. The 24 Hour Communication Records dated 8/10/11, 8/14/11 and 9/16/11 documented the resident vomited one time each day. Nurse's Notes for those dates did not document the isolated incidents of emesis for this resident. Nurse's Notes dated between 8/2/11 and 12/16/11 and Nutritional Progress Notes dated 8/5/11, 9/2/11, 10/12/11 and 10/19/11 (the most recent documented in the clinical record) did not document any discussions or attempts to consult with Physician #1 about gradual increases in the resident's tube feedings in order to meet her assessed nutritional needs. The failure to meet the resident's nutritional requirements for calories and protein placed the resident at higher risk for development of pressure ulcers. g. A written statement provided by the RD dated 2/16/12 documented, "Caliper measurement for body fat was not done on (resident) because the skin fold calipers would have increased risk of tearing her fragile skin and she had restricted ability to lift arm for accurate measurement. Using a tape measure for arm circumference is an inaccurate system at best so was not used. The facility does not have air bed weighing system and the 'lift' used for weighing bedfast residents was too great of risk for bone fracture. MD and family aware that weight was not done." h. Laboratory reports dated 9/20/11 documented the [MEDICATION NAME] level was low at 2.4 g (grams)/dL (deciliter) (normal=3.5-7.5). i. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/18/11 documented the resident scored a 2 (0-7 indicates severe impairment) on the Brief Interview for Mental Status, was totally dependent on two persons for bed mobility and toilet use, had a urinary catheter, was always incontinent of bowel, no weight documented, received 51% or greater calories and 501 cc or greater fluids through a feeding tube, was at risk for development of pressure ulcers and did not have pressure ulcers. j. The Braden Scale (for predicting Pressure Sore Risk) dated 10/19/11 documented a score of "15" with 15 - 18 representing mild risk for developing pressure ulcers. k. The Care Plan dated 10/19/11 documented a problem for potential skin breakdown with approaches, "Place resident in skin-breakdown-prevention program (PUP Team)... pressure relief mattress to bed... Alert MD of any problems... Use positioning pillows to provide pressure relief prn (as needed)." Another problem for potential for impaired skin integrity documented approaches, "Reassess pressure ulcers at least weekly... Treatment as ordered per MD." Another problem for inadequate oral intake related to failure to eat documented a goal, "resident will consume adequate nutrition to meet nutritional needs daily this quarter," with an approach, "Monitor weight." l. The October 2011 Physician order [REDACTED]." The TAR for 10/11 documented the resident's heels were floated as ordered 3 of 3 shifts per day. The same Physician order [REDACTED]. m. Treatment Administration Records (TAR's), Weekly Skin Audit records, Weekly Pressure Ulcer QI Logs and/or Nurse's Notes documented the resident's development of pressure ulcers as follows: Buttocks/Coccyx: 1) Weekly Skin Audits dated 10/24/11 documented, "raw area buttocks," and Nurse's Notes dated 10/25/11 documented, "raw in creases (buttocks)." There was no documentation on the TARs of the coccyx the weeks of 11/3/11, 11/10/11 and 11/23/11. There was no documentation in the above listed records of a physician consult concerning the new skin breakdown and treatment orders. 2) The TAR weekly pressure ulcer documentation dated 11/16/11 documented, "Coccyx has multiple open areas in one large area. Wound gel applied." There was no documentation in the Nurse's Notes, Physician order [REDACTED]. There was no documentation nurses notes, TAR or weekly skin audits of measurements of the "area" involved over the bony prominence of the coccyx. The Pressure Ulcer Log dated 11/17/11 documented the resident had a stage II pressure ulcer at the coccyx, but there were no measurements documented, and it also documented, "several small." 3) The November 2011 TAR documented a treatment order dated 10/28/11, "Wound gel to coccyx bid (twice per day) (and) prn until healed per protocol." On 2/16/12 at 3:35 p.m., the DON was asked about the use of wound gel without physician consult and she stated, "wound gel is on our wound protocol." The DON was asked if that meant she was stating it was okay to treat a new wound without calling the physician and she stated, "Yes, (if) it's superficial." A request was made for that protocol. Other policies were provided on 2/16/12 and 2/17/12, but the facility had not provided a protocol for treatment of [REDACTED]. 4) The November 2011 TARs documented a treatment order for the coccyx dated 11/23/11, "[MEDICATION NAME] to coccyx, (change) weekly (and) prn," This order was received 30 days after the initial documentation of skin breakdown of the coccyx. 5) The November 2011 AR weekly PU documentation dated 11/29/11 documented, "(left) buttock has open areas (approximately) 1.5 cm and 1 cm diameter." Nutritional Progress Notes dated 11/15/11 (the RD's scheduled quarterly visit) documented, "resident continues to receive Glucerna (at) 40 cc . . . MD aware that (resident) refuses to be weighed. (Resident) does have decubitus . . . recommend adding [MEDICATION NAME] Extra 4 ounces bid [MEDICATION NAME] via tube. (Resident) has increased healing needs (with) decubitus. [MEDICATION NAME] Extra will provide 250 cal (calories), 10.5 protein (per day) for healing." The addition of the [MEDICATION NAME] brought the resident's daily protein intake to 58.5 g, 12 g less than assessed for daily needs without skin breakdown on 5/2/11 by the RD. 5) TAR weekly PU documentation dated 12/7/11 did not document an assessment of the resident's coccyx. TAR weekly PU documentation dated 12/15/11 documented the pressure ulcer had deteriorated in size, "(left) buttock open area measures 3 cm x 1 cm wound bed dark pink in color, (no) drainage noted." Nurse's Notes dated 12/15/11 documented the physician was consulted about a critical level hemoglobin/hematocrit and orders received to admit the resident to a local hospital on [DATE], but there was no documentation the physician was consulted about the pressure ulcer's deterioration. There was no assessment of the pressure ulcer's stage documented in the TAR weekly PU documentation for this wound as of 12/15/11. 6) The local Hospital "Photographic Wound Documentation" forms dated 12/16/11 documented the pressure ulcer at the coccyx. The local hospital Nutritional Reassessment/Progress Note dated 12/21/11 documented the resident received [MEDICATION NAME] 1.5 calories at 45 cc/hour, since admitted on [DATE], which provided 68 grams of protein and a recommendation to increase the tube feeding to 50 cc/hour, "to provide a more protein sparing Kcal level." The local hospital's Discharge Summary dated 12/27/11 documented the resident was transferred to another hospital for vascular consultation. The second hospital's physician progress notes [REDACTED]. Left Heel: 1) Nurse's Notes dated 10/28/11 documented, "(resident) has open area (left) heel measures (1.5 x 0.75 cm), wound gel applied (and) covered per (Physician #1). Son (son's name) notified." TAR weekly PU documentation dated 10/28/11 documented measurements of 1.5 x 0.75 x less than 0.2 cm, but no staging was documented. 2) Nurse's Notes dated 11/7/11 documented, "(resident's) skin condition not better, some areas worse. phoned (Physician #1) (with) (new orders) received and noted." Physician order [REDACTED]. 3) The TAR weekly documentation dated 11/9/11 documented, "(left) heel open area 2 cm x 1 cm (no depth). Wound bed red (with) slough, (no) odor." There was no stage documented and slough was a form of necrotic tissue and the presence of it would have made that pressure ulcer unstageable. Corresponding documentation on the Pressure Ulcer QI Log dated 11/10/11 documented the same measurements and "stage II." 4) The TAR weekly documentation dated 11/16/11 documented further deterioration in size, "2 cm x 3 cm (no depth), wound bed (with) slough tissue present (and) small amount bleeding noted." There was no documentation the resident's physician was consulted about the deterioration at that time. 5) The TAR weekly documentation dated 11/23/11 documented, "(left) heel measures 6 cm x 4 cm dark eschar only small edge that is opened (with) small (amount) bleeding noted." The November 2011 Physician order [REDACTED]. Apply Santyl (a chemical debridement agent) to necrotic tissue. Cover (with) 4x4's and wrap (with) Kerlix." The treatment order change to include an agent for necrotic tissue was dated 14 days after the initial documentation of presence of necrotic tissue in the left heel pressure ulcer. 6) The TAR weekly documentation dated 11/30/11 documented further deterioration in the wound, "(left) heel ulcer measures 7 cm x 7 cm, 90% eschar tissue (and) 10% slough tissue, tissue is softening (and) now has odor noted, small (amount) yellowish drainage." Physician order [REDACTED]. Orders were also written to schedule an Arterial Doppler Study. 7) The TAR weekly documentation dated 12/14/11 documented the measurements of the left heel were 7.5 x 5 x 0.5 cm with slough tissue on small open edge and eschar approximately 95% of heel. There was no stage documented on the weekly pressure ulcer assessments. 8) The local Hospital "Photographic Wound Documentation" forms dated 12/16/11 documented the pressure ulcer at the left heel, "2 cm (picture identifies wound size closer to facility measurements)." The second hospital's physician progress notes [REDACTED]. Right Heel: 1) The TAR weekly pressure ulcer documentation dated 11/16/11 documented, "(right) heel has darkened area (approximately) (1.5) cm x 1 cm unopened." TAR weekly documentation dated 11/23/11 documented, "(right) heel has 2 cm diameter darkened area unopened." Nurse's Notes dated 11/29/11 documented, "(right) heel now open, (Physician #1) to come (and) look (at) wounds." This was the first documentation of the physician being notified after the initial documentation of the pressure ulcer 13 days earlier . 2) The November 2011 TAR documented a new treatment order dated 11/29/11, "Cleanse (right) heel (with) wound cleanser (and) 4x4's. Pat dry. Apply small (amount) of wound gel. Cover (with) Mepore." The TAR weekly documentation dated 11/30/11 documented the right heel pressure ulcer measured 1.5 x 1 cm with a "whitish," wound bed. The stage of the pressure ulcer was not documented. 3) The TAR weekly documentation dated 12/7/11 documented the right heel measurements were approximately 1.5 cm with pink wound bed and on 12/14/11 documented, "1 cm slit, pink in color, very small (amount) drainage." There was no further documentation of the wound and the local hospital did not document pictures or description of a pressure ulcer at the right heel for this resident. n. The November and December 2011 TARs documented a vascular ulcer on the top of the right foot on 11/15/11, which deteriorated as of 12/14/11 to an unstageable wound that measured 8.5 x 4.5 cm and was covered with eschar. o. A Diagnostic Arterial Doppler Study report dated 12/2/11 documented, "Bilateral trifurcation disease is probably present (decrease blood flow to the extremities)," but did not document that blood flow was totally obstructed. The Hospital (another other than the local hospital) History and Physical dated 12/28/11 documented, "pulses in either foot, they are bilateral." p. On 2/16/11 at 4:05 p.m., Physician #1 stated, "the heel and top of foot showed up simultaneously, it (left heel) was vascular." Physician #1 was informed of the 18 day period of time between the initial identification of the pressure ulcer at the left heel and the vascular ulcer on top of the left foot and he did not make any other statements. Physician #1 was asked why there was no gradual increase in the rate of the tube feeding to determine the resident's tolerance or additional protein prior to the resident's development of pressure ulcers. Physician #1 stated, "I know I kept up with the nutrition aspect of it... when we have skin issues we ramp up nutrition and we did that." q. On 2/16/12 at 4:51 p.m., the RD was asked what was done to ensure the resident received required nutrition to meet her needs prior to the development of pressure ulcers and she stated, "(Physician #1) reduced the rate and I documented as per (physician #1's)" orders. We informed (physician #1) that she refused to be weighed, he signed that he knew and I thought that took care of it." The RD was asked how often she routinely came to the facility and she stated, "quarterly." The RD was asked how the facility let her know between visits if a resident had a change that required new or additional nutritional assessment and she stated she was available by phone and "fax." The RD was asked if she remembered being called about reassessment for the resident's nutritional needs between 10/24/11 and her scheduled visit on 11/15/11 and she stated, "Not that I remember," and showed the surveyor the recommendations she documented on 11/15/11, when she initially was informed of the resident's pressure ulcers. 3. Resident #7 had [DIAGNOSES REDACTED]. The Significant Change in status MDS with an ARD of 1/17/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS), required total assistance of two persons for bed mobility, was incontinent of bowel, required total assistance of one person for toilet use, received 51% or greater calories and 501 cc or greater fluid through a feeding tube, was at risk for pressure ulcers and had a stage III pressure ulcer. The MDS documented the measurement of the pressure ulcer as no length, 0.5 cm width, and no depth with granulation tissue. a. The Care Plan dated 1/18/12 documented a problem for impaired skin integrity, stage III to coccyx with a goal, "see current ulcer to coccyx resolved this qtr. (quarter)," with approaches, "reassess pressure ulcers at least weekly," and "Alert MD of any problems." Another problem for "pressure ulcers stage 3 to coccyx," documented an approaches, "Normal Saline wet to dry dressing to center wound (stage 3) area daily and prn... May use positioning pillows for pressure relief prn." The Care Plan did not specifically document approaches to provide pressure relief to the resident's feet and heels or how to accomplish that approach. b. The TARs dated 7/11 through 2/12 were reviewed. The resident had an initial treatment order dated 4/12/11 for dilute [MEDICATION NAME] wet to dry twice per day. The 7/11 TAR weekly pressure ulcer assessment dated [DATE] documented the pressure ulcer measured 1.5 cm round X 2 cm depth. There was no stage or documentation of surrounding skin appearance. c. The July 2011 TAR documented a treatment order change on 7/22/11 for the same treatment done one time per day with weekly wound measurements dated 7/20/11, 7/27/11, 8/10/11, 8/17/11 and 8/25/11 of 1.0 x 1.5 cm. The TAR weekly PU measurements dated 8/31/11 documented 1.0 x 2 cm, a deterioration for that wound, and there was no documentation on the TAR or in Nurse's Notes that the physician was consulted at that time. There was no documentation of the stage of the pressure ulcer or surrounding skin appearance on the weekly pressure ulcer assessments documented on the August, September and October 2011 TAR's. d. The September and October 2011 TARs documented the pressure ulcer measurements ranged between 1.0 x 0.5 cm (9/27/11) and 1.0 x .75 cm (10/26/11). The October 2011 TAR documented a new treatment dated 10/27/11 for Normal Saline wet to dry dressing daily. e. The November 2011 TAR did not document weekly pressure ulcer assessments for the weeks of 11/2/11 and 11/9/11. The TAR weekly assessment dated [DATE] documented the pressure ulcer measured 0.75 x 0.5 cm. There was no documentation of stage or surrounding skin appearance in the assessments documented on the November 2011 TAR. f. The resident was readmitted from the hospital on [DATE] with the same daily pressure ulcer treatment ordered since 10/27/11. The December 2011 and January and February 2012 TAR's documented weekly assessments with measurements of 0.5 x 1.0 cm (12/14/11), 1.0 x .25 cm (1/18/12), 1.0 x 5 cm (1/25/12) and 1.0 x .75 cm (2/8/12 and 2/15/12). There was no documentation of stage or surrounding skin appearance in the assessments documented on the TARs dated as above, there was no weekly assessment documented the week of 1/13/12, and there was no documentation on the TAR or in the Nurse's Notes that a physician was immediately consulted on 1/18/12, 1/25/12 or since 2/8/12 about the deterioration in the pressure ulcer size. g. On 2/15/12 at 10:58 a.m., CNA #6 was in the room and the resident was in bed. CNA #6 was asked to assist in observation of the resident's lower extremities and she stated the resident's knees would not straighten and remained bent (flexed) at all times. The resident had pillows between her legs and under one foot, but there were no pressure relief devices or methods in place to relieve pressure to the resident's feet. h. On 2/16/12 at 9:42 a.m., LPN #2 provided wound treatment as ordered with CNA #3 in the room to assist. The resident's left inner foot was directly against the surface of the bed without pressure relief. The resident's pressure ulcer at the coccyx was a stage III that measured approximately 1.0 x 1.0 cm with a pink wound bed. After the treatment was completed, LPN #2 placed the resident's left foot on top of a bed pillow that was directly above the right foot, which did not provide pressure relief for the resident's feet. i. On 2/16/12 at 11:30 a.m., the DON was informed of the above information and asked to provide evidence that a physician had been consulted about the same wound treatment ordered since 10/27/11 without improvement. As of 2/17/12 at 5:20 p.m., the facility had not provided that information. j. On 2/17/12 at 5:30 p.m., the resident was positioned in bed to the right side, had a pillow between her knees and ankles. The resident's knees were both flexed and the resident's bare right foot was directly against the surface of the bed without off-loading of the right foot. 4. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 1/14/12 documented the resident scored 2 (0-7 indicates severe impairment) on the BIMS, required limited assistance of one person for bed mobility, was always incontinent of urine and bowel, and at risk of developing pressure ulcers. The MDS did not document a weight for this resident. a. The Care Plan dated 12/30/11 documented, "potential for weight loss related to inadequate nutrient intake at times," with an approach "monitor intake and weight." Care Plan Nurse's Notes dated 12/29/11 documented, "wt. (weight) stable." b. Nutritional Progress Notes dated 6/22/11 and signed by the CDM documented the resident weighed 182 pounds. Nutritional Progress Notes dated 7/8/11, 8/5/11, 9/2/11, 10/13/11, 11/8/11, 12/9/11 and 1/5/12 and signed by the CDM, documented the resident had refused to be weighed. The Nutritional Evaluation dated 12/29/11 and signed by the CDM documented, "resident has r/fused (refused) to be weighed." The CDM's Basal Energy Expenditures (BEE) formula for estimates of caloric needs for this resident used the resident's Ideal Body Weight, "IBW 130 (pounds) +/- 10%." As of 2/15/12 at 3:15 p.m., there were no Progress Notes or alternate method of assessment for the resident's caloric needs documented in the Dietary Section, Physician Orders, or Nurse's Notes by the facility's RD c. On 2/15/12 at 9:47 a.m., the CDM provided the RD's last 3 facility visit reports dated 5/11/11, 8/2/11 and and 11/15/11. This resident was not listed on the reports dated 8/2/11 or 11/15/11 as having been assessed for nutritional requirements by the RD as of that date and time, which potentially placed this resident at higher risk of pressure ulcer development. There was no documentation in the resident's Care Plan, physician progress notes [REDACTED]. d. On 2/14/12 at 5:33 p.m., the resident was in bed. The resident's bare feet were on a thin pillow against the bed surface and no heel-pads to prevent shearing/friction forces were present. On 2/15/12 at 12:41 p.m., LPN #2 was asked to assist in observation of the resident's lower extremities. The resident was in bed and both feet could be seen from the doorway, not covered and both heels pressed into a wooden footboard. LPN #2 pulled the covers back, the surveyor touched the footboard, and the LPN covered the resident's feet without repositioning them. The resident had no skin breakdown at that time. e. On 2/16/12 at 12:50 p.m., the DON was informed of the resident's lack of an accurate nutritional assessment and a request was made for any other information the facility could locate. As of 2/17/12 at 5:20 p.m., the facility had not provided further evidence for this resident. 5. Resident #2 had [DIAGNOSES REDACTED]. ulcers. a. The Care Plan dated 12/9/11 documented a problem for potential for skin breakdown with an approach, "place resident in skin-breakdown-prevention program (PUP Team)." The Care Plan did not document specific approaches for provision of pressure relief to feet and heels for this resident. b. On 2/14/12 at 5:22 p.m., LPN #1 was in the resident's room and the resident was in bed. Both of the resident's bare feet were flat against the bed surface without off-loading or heel-pads in place. c. On 2/15/12 at 12:28 p.m., CNA's #1 an

Based on observation, record review and interview, the facility failed to ensure dressing changes were provided as ordered to promote healing of pressure ulcers for 1 (Resident #2) of 3 case mix residents (Residents #1 through #3) who had pressure ulcers. This failed practice had the potential to affect 7 residents who had pressure ulcers (excluding Stage I) according to the Resident Census and Conditions of Residents form received from the facility on 4/4/12 at 10:45 a.m. The findings are: Resident #2 had [DIAGNOSES REDACTED]. The 14 Day Minimum Data Set with an Assessment Reference Date of 3/26/12 documented the resident had modified independence in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS), required limited assistance of one person physical assist for bed mobility, extensive assistance of two+ persons physical assist for transfers and toilet use, was incontinent, at risk for developing Pressure Ulcers and had 1 stage 2 pressure ulcer. a. A physician order [REDACTED]." b. The Care Plan dated 3/26/12 documented, "Stage 2 R buttocks/hip...Wound gel Bid and Prn..." c. The March 2012 TAR documented, "Apply wound gel and cover R buttock area Bid and prn, (order dated 3/23/12)." On 4/5/12 at 3:15 p.m., there were nurses initials on 9 out of 18 required shifts that were signed for changing the dressing. The back of the TAR documented the wound measured 2.5 by 2.5 centimeters on 3/22/12 and on 3/26/12 the measurement was 3.0 by 3.5 centimeters. d. The April 2012 Treatment Administration Record (TAR) documented, "Apply wound gel and cover R buttock area Bid and prn, (order dated 3/23/12)." On 4/5/12 at 12:40 p.m. there were nurses initials on 3 out of 9 required shifts that were signed for changing the dressing. There was no place on the TAR for the second shift to initial the BID treatment as having been administered. The back of the TAR documented the wound measured 2.5 by 1.5 centimeters on 4/2/12 (per Registered Nurse (RN) #1). e. On 4/5/12 at 2:35 p.m., License Practical Nurse (LPN) #1 was asked if she was administering the second treatment of [REDACTED]. She stated, I don't change the resident's dressing because it's every day on the 6-2 (6:00 a.m. - 2:00 p.m.) shift and prn as needed. It (the dressing) was changed this morning. I didn't do it yesterday." f. On 4/5/12 at 2:42 p.m. RN #1 stated, "The documentation for wound care is on the TAR and sometimes in the Nurse's Notes." The RN was asked to change the dressing and measure the resident's wound. g. On 4/5/12 at 2:44 p.m. the resident's wound was measured to be 2.5 by 2.0 centimeter by RN #1. The RN was asked how often was the dressing changed. RN #1 stated, "Daily and Prn, no wait, hers is Bid." Hearing this, Resident #2 stated, "They don't change it every day." h. On 4/5/12 at 2:50 p.m., RN #1 was shown the April, 2012 TAR. She stated, "They didn't put the 2-10 (2:00 p.m. - 10:00 p.m.) on the TAR." i. On 4/5/12 at 3:10 p.m., the Director of Nursing (DON) was told of the dressing changes for Resident #2 not being administered as ordered by the physician. She stated, "I need to have the MAR (Medication Administration Record) and TAR orders checked more often." She was asked how often were they checked now. She stated, "Once a month." j. On 4/5/12 at 3:20 p.m., LPN #1 was looking at the March 2012 TAR and the signature initials and stated, "That's me. I looked at the April TAR and saw the Bid and prn underlined. I am a new nurse so I thought Bid and prn were the same thing and that the order must have been changed. I know better now."

Complaint # was substantiated (all or in part) in these findings. Based on observation, record review and interview, the facility failed to ensure that complete information about pressure ulcer development and nutritional interventions was brought to Quality Assessment and Assurance (QA&A) committee meetings to allow identification of potential care concerns for 7 of 7 (Residents #1 through #7) case mix residents who were at risk for pressure ulcer development and/or had pressure ulcers. These failed practices likely caused a pattern of harm for Resident #3 who received less than required nutritional support to prevent development of 3 pressure ulcers over a period of approximately 5 months, one of which became unstageable and covered with eschar. This failed practice was likely to cause more than minimal harm for 20 residents at risk for development of pressure ulcers and 1 resident who was not weighed in the facility as documented on a listing provided by the Director of Nursing (DON) on 2/17/12 at 3:00 p.m. and 8 residents with pressure ulcers as documented on the Resident Census and Conditions of Residents form dated 2/15/12. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. a. Nurse's Notes dated 12/22/10 through 3/30/11 documented the resident received a continuous tube feeding of Glucerna 1.2 at 60 cubic centimeters (cc) per hour. Nurse's Notes dated 3/31/11 for day shift documented the resident had small amount of vomit noted and the tube feeding was turned off. Nurse's Notes dated 4/1/11 at 1:30 a.m. documented the tube feeding had been resumed at it's former rate. Nurse's Notes dated 4/12/11 documented the resident was transferred to a local hospital for observation due to a skin culture report of Pseudomonas organism growth. b. The Hospital Consultation Report dated 4/13/11 and signed by Physician #2 documented the resident was admitted on [DATE] due to a skin condition (on the resident's back) that was cultured and had identified Pseudomonas infection. The Consultation Report documented, "the patient developed abdominal distention here in the hospital. The patient has a long history of recurrent abdominal distention, especially when she gets her PEG (percutaneous endoscopic gastrostomy) feedings . . . there has been no history of nausea, vomiting, constipation, diarrhea." In the "Vital Signs" section, the Report documented, "At the time of this examination the patient's weight is 161 pounds (lbs.)." The hospital Patient Transfer form dated 4/18/11 documented the resident was transferred back to the nursing facility with a physician's orders [REDACTED]. c. The "Nutritional Assessment of Tube Fed Resident" dated 5/2/11 and signed by the facility's Registered Dietitian (RD) documented under weight, "refuses to be weighed" and an Ideal Body Weight (IBW) of 135 lbs. +/- 10%. The Nutritional Assessment documented the resident's needed nutritional intake (with use of the IBW, not the resident's recent weight in the hospital, a difference of 26 lbs.) versus what was provided through the tube feeding as follows: total caloric needs = 1,447 calories (tube feeding provided less than required, 1,152 calories); total protein needs (without injury to skin) = 56 grams (g) protein/day (tube feeding provided less than required, 48 g/day) and total free water (with 200 cc flushes 4 times per day and 60 cc flush before and after meds 2 times per day) = 2,010 cc (tube feeding provided less than required, 1,846 cc/day). The RD's notes documented, "Tube feeding rate was decreased during hospitalization recently. Monitor tolerance to feeding; Increase as needed per MD." On 2/16/12 at 4:55 p.m., the RD was informed of the resident's weight in the hospital on [DATE] (161 lbs.) and was asked why that weight was not used to do the nutritional assessment she documented 5/2/11 and she stated, "I do it (nutritional assessments) from what they (Certified Dietary Manager (CDM) and DON) have told me." d. Nurse's Notes dated between 5/2/11 and 8/2/11 were reviewed and there was no documentation of abdominal distention or intolerance of the tube feedings. The Nutritional Assessment RD notes dated 8/2/11 documented, "current wt. (none) (resident) refuses to be weighed . . . continues to receive Glucerna 1.2 at 40 cc/hour . . . is tolerating feeding (without) problems . . . MD aware of nutrition being received (and) will made adjustments as he sees necessary." A typed letter to Physician #1 dated 8/2/11 and signed by the Certified Dietary Manager (CDM) documented the resident's refusal of weights in the facility since January 2011 and the physician's initialed response documented, "ok." e. The Quarterly Dietary Consultant reports dated 5/11/11 and 8/2/11 did not document any nutritional recommendations by the RD for this resident. f. The 24 Hour Communication Records dated 8/10/11, 8/14/11 and 9/16/11 documented the resident vomited one time each day. Nurse's Notes for those dates did not document the isolated incidents of emesis for this resident. Nurse's Notes dated between 8/2/11 and 12/16/11 and Nutritional Progress Notes dated 8/5/11, 9/2/11, 10/12/11 and 10/19/11 (the most recent documented in the clinical record) did not document any discussions or attempts to consult with Physician #1 about gradual increases in the resident's tube feedings in order to meet her assessed nutritional needs. The failure to meet the resident's nutritional requirements for calories and protein placed the resident at higher risk for development of pressure ulcers. g. A written statement provided by the RD dated 2/16/12 documented, "Caliper measurement for body fat was not done on (resident) because the skin fold calipers would have increased risk of tearing her fragile skin and she had restricted ability to lift arm for accurate measurement. Using a tape measure for arm circumference is an inaccurate system at best so was not used. The facility does not have air bed weighing system and the 'lift' used for weighing bedfast residents was too great of risk for bone fracture. MD and family aware that weight was not done." h. Laboratory reports dated 9/20/11 documented the [MEDICATION NAME] level was low at 2.4 g (grams)/dL (deciliter) (normal=3.5-7.5). i. The Quarterly Minimum Data Set with an Assessment Reference Date of 10/18/11 documented the resident scored a 2 (0-7 indicates severe impairment) on the Brief Interview for Mental Status, was totally dependent on two persons for bed mobility and toilet use, had a urinary catheter, always incontinent of bowel, no weight documented, received 51% or greater calories and 501 cc or greater fluids through a feeding tube, was at risk for development of pressure ulcers and did not have pressure ulcers. j. The Braden Scale (for predicting Pressure Sore Risk) dated 10/19/11 documented a score of "15" with 15 - 18 representing mild risk for developing pressure ulcers. k. The Care Plan dated 10/19/11 documented a problem for potential skin breakdown with approaches, "Place resident in skin-breakdown-prevention program (PUP Team)... pressure relief mattress to bed... Alert MD of any problems... Use positioning pillows to provide pressure relief prn (as needed)." Another problem for potential for impaired skin integrity documented approaches, "Reassess pressure ulcers at least weekly... Treatment as ordered per MD." Another problem for inadequate oral intake related to failure to eat documented a goal, "resident will consume adequate nutrition to meet nutritional needs daily this quarter," with an approach, "Monitor weight." l. The October 2011 Physician order [REDACTED]." The TAR for 10/11 documented the resident's heels were floated as ordered 3 of 3 shifts per day. The same Physician order [REDACTED]. m. Treatment Administration Records (TAR's), Weekly Skin Audit records, Weekly Pressure Ulcer QI Logs and/or Nurse's Notes documented the resident's development of pressure ulcers as follows: Buttocks/Coccyx: 1) Weekly Skin Audits dated 10/24/11 documented, "raw area buttocks," and Nurse's Notes dated 10/25/11 documented, "raw in creases (buttocks)." There was no documentation on the TAR's of the coccyx the weeks of 11/3/11, 11/10/11 and 11/23/11. There was no documentation in the above listed records of a physician consult concerning the new skin breakdown and treatment orders. 2) The TAR weekly pressure ulcer documentation dated 11/16/11 documented, "Coccyx has multiple open areas in one large area. Wound gel applied." There was no documentation in the Nurse's Notes, Physician order [REDACTED]. There was no documentation nurses notes, TAR or weekly skin audits of measurements of the "area" involved over the bony prominence of the coccyx. The Pressure Ulcer Log dated 11/17/11 documented the resident had a stage II pressure ulcer at the coccyx, but there were no measurements documented, and it also documented, "several small." 3) The November 2011 TAR documented a treatment order dated 10/28/11, "Wound gel to coccyx bid (twice per day) (and) prn until healed per protocol." On 2/16/12 at 3:35 p.m., the DON was asked about the use of wound gel without physician consult and she stated, "wound gel is on our wound protocol." The DON was asked if that meant she was stating it was okay to treat a new wound without calling the physician and she stated, "Yes, (if) it's superficial." A request was made for that protocol. Other policies were provided on 2/16/12 and 2/17/12, but the facility had not provided a protocol for treatment of [REDACTED]. 4) The November 2011 TAR's documented a treatment order for the coccyx dated 11/23/11, "[MEDICATION NAME] to coccyx, (change) weekly (and) prn," This order was received 30 days after the initial documentation of skin breakdown of the coccyx. 5) The November 2011 AR weekly PU documentation dated 11/29/11 documented, "(left) buttock has open areas (approximately) 1.5 cm and 1 cm diameter." Nutritional Progress Notes dated 11/15/11 (the RD's scheduled quarterly visit) documented, "resident continues to receive Glucerna (at) 40 cc . . . MD aware that (resident) refuses to be weighed. (Resident) does have decubitus . . . recommend adding [MEDICATION NAME] Extra 4 ounces bid [MEDICATION NAME] via tube. (Resident) has increased healing needs (with) decubitus. [MEDICATION NAME] Extra will provide 250 cal (calories), 10.5 protein (per day) for healing." The addition of the [MEDICATION NAME] brought the resident's daily protein intake to 58.5 g, 12 g less than assessed for daily needs without skin breakdown on 5/2/11 by the RD. 5) TAR weekly PU documentation dated 12/7/11 did not document an assessment of the resident's coccyx. TAR weekly PU documentation dated 12/15/11 documented the pressure ulcer had deteriorated in size, "(left) buttock open area measures 3 cm x 1 cm wound bed dark pink in color, (no) drainage noted." Nurse's Notes dated 12/15/11 documented the physician was consulted about a critical level hemoglobin/hematocrit and orders received to admit the resident to a local hospital on [DATE], but there was no documentation the physician was consulted about the pressure ulcer's deterioration. There was no assessment of the pressure ulcer's stage documented in the TAR weekly PU documentation for this wound as of 12/15/11. 6) The local Hospital "Photographic Wound Documentation" forms dated 12/16/11 documented the pressure ulcer at the coccyx. The local hospital Nutritional Reassessment/Progress Note dated 12/21/11 documented the resident received [MEDICATION NAME] 1.5 calories at 45 cc/hour, since admitted on [DATE], which provided 68 grams of protein and a recommendation to increase the tube feeding to 50 cc/hour, "to provide a more protein sparing Kcal level." The local hospital's Discharge Summary dated 12/27/11 documented the resident was transferred to another hospital for vascular consultation. The second hospital's physician progress notes [REDACTED]. Left Heel: 1) Nurse's Notes dated 10/28/11 documented, "(resident) has open area (left) heel measures (1.5 x 0.75 cm), wound gel applied (and) covered per (Physician #1). Son (son's name) notified." TAR weekly PU documentation dated 10/28/11 documented measurements of 1.5 x 0.75 x less than 0.2 cm, but no staging was documented. 2) Nurse's Notes dated 11/7/11 documented, "(resident's) skin condition not better, some areas worse. phoned (Physician #1) (with) (new orders) received and noted." Physician order [REDACTED]. 3) The TAR weekly documentation dated 11/9/11 documented, "(left) heel open area 2 cm x 1 cm (no depth). Wound bed red (with) slough, (no) odor." There was no stage documented and slough was a form of necrotic tissue and the presence of it would have made that pressure ulcer unstageable. Corresponding documentation on the Pressure Ulcer QI Log dated 11/10/11 documented the same measurements and "stage II." 4) The TAR weekly documentation dated 11/16/11 documented further deterioration in size, "2 cm x 3 cm (no depth), wound bed (with) slough tissue present (and) small amount bleeding noted." There was no documentation the resident's physician was consulted about the deterioration at that time. 5) The TAR weekly documentation dated 11/23/11 documented, "(left) heel measures 6 cm x 4 cm dark eschar only small edge that is opened (with) small (amount) bleeding noted." The November 2011 Physician order [REDACTED]. Apply Santyl (a chemical debridement agent) to necrotic tissue. Cover (with) 4x4's and wrap (with) Kerlix." The treatment order change to include an agent for necrotic tissue was dated 14 days after the initial documentation of presence of necrotic tissue in the left heel pressure ulcer. 6) The TAR weekly documentation dated 11/30/11 documented further deterioration in the wound, "(left) heel ulcer measures 7 cm x 7 cm, 90% eschar tissue (and) 10% slough tissue, tissue is softening (and) now has odor noted, small (amount) yellowish drainage." Physician order [REDACTED]. Orders were also written to schedule an Arterial Doppler Study. 7) The TAR weekly documentation dated 12/14/11 documented the measurements of the left heel were 7.5 x 5 x 0.5 cm with slough tissue on small open edge and eschar approximately 95% of heel. There was no stage documented on the weekly pressure ulcer assessments. 8) The local Hospital "Photographic Wound Documentation" forms dated 12/16/11 documented the pressure ulcer at the left heel, "2 cm (picture identifies wound size closer to facility measurements)." The second hospital's physician progress notes [REDACTED]. Right Heel: 1) The TAR weekly pressure ulcer documentation dated 11/16/11 documented, "(right) heel has darkened area (approximately) (1.5) cm x 1 cm unopened." TAR weekly documentation dated 11/23/11 documented, "(right) heel has 2 cm diameter darkened area unopened." Nurse's Notes dated 11/29/11 documented, "(right) heel now open, (Physician #1) to come (and) look (at) wounds." This was the first documentation of the physician being notified after the initial documentation of the pressure ulcer 13 days earlier . 2) The November 2011 TAR documented a new treatment order dated 11/29/11, "Cleanse (right) heel (with) wound cleanser (and) 4x4's. Pat dry. Apply small (amount) of wound gel. Cover (with) Mepore." The TAR weekly documentation dated 11/30/11 documented the right heel pressure ulcer measured 1.5 x 1 cm with a "whitish," wound bed. The stage of the pressure ulcer was not documented. 3) The TAR weekly documentation dated 12/7/11 documented the right heel measurements were approximately 1.5 cm with pink wound bed and on 12/14/11 documented, "1 cm slit, pink in color, very small (amount) drainage." There was no further documentation of the wound and the local hospital did not document pictures or description of a pressure ulcer at the right heel for this resident. n. The November and December 2011 TAR's documented a vascular ulcer on the top of the right foot on 11/15/11, which deteriorated as of 12/14/11 to an unstageable wound that measured 8.5 x 4.5 cm and was covered with eschar. o. A Diagnostic Arterial Doppler Study report dated 12/2/11 documented, "Bilateral trifurcation disease is probably present (decrease blood flow to the extremities)," but did not document that blood flow was totally obstructed. The Hospital (another other than the local hospital) History and Physical dated 12/28/11 documented, "pulses in either foot, they are bilateral." p. On 2/16/11 at 4:05 p.m., Physician #1 stated, "the heel and top of foot showed up simultaneously, it (left heel) was vascular." Physician #1 was informed of the 18 day period of time between the initial identification of the pressure ulcer at the left heel and the vascular ulcer on top of the left foot and he did not make any other statements. Physician #1 was asked why there was no gradual increase in the rate of the tube feeding to determine the resident's tolerance or additional protein prior to the resident's development of pressure ulcers. Physician #1 stated, "I know I kept up with the nutrition aspect of it... when we have skin issues we ramp up nutrition and we did that." q. On 2/16/12 at 4:51 p.m., the RD was asked what was done to ensure the resident received required nutrition to meet her needs prior to the development of pressure ulcers and she stated, "(Physician #1) reduced the rate and I documented as per (physician #1's)" orders. We informed (physician #1) that she refused to be weighed, he signed that he knew and I thought that took care of it." The RD was asked how often she routinely came to the facility and she stated, "quarterly." The RD was asked how the facility let her know between visits if a resident had a change that required new or additional nutritional assessment and she stated she was available by phone and "fax." The RD was asked if she remembered being called about reassessment for the resident's nutritional needs between 10/24/11 and her scheduled visit on 11/15/11 and she stated, "Not that I remember," and showed the surveyor the recommendations she documented on 11/15/11, when she initially was informed of the resident's pressure ulcers. 2. Resident #7 had [DIAGNOSES REDACTED]. The Significant Change in status MDS with an ARD of 1/17/12 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment of Mental Status (SAMS), required total assistance of two persons for bed mobility, was incontinent of bowel, required total assistance of one person for toilet use, received 51% or greater calories and 501 cc or greater fluid through a feeding tube, was at risk for pressure ulcers and had a stage III pressure ulcer. The MDS documented the measurement of the pressure ulcer as no length, 0.5 cm width, and no depth with granulation tissue. a. The Care Plan dated 1/18/12 documented a problem for impaired skin integrity, stage III to coccyx with a goal, "see current ulcer to coccyx resolved this qtr. (quarter)," with approaches, "reassess pressure ulcers at least weekly," and "Alert MD of any problems." Another problem for "pressure ulcers stage 3 to coccyx," documented an approaches, "Normal Saline wet to dry dressing to center wound (stage 3) area daily and prn... May use positioning pillows for pressure relief prn." The Care Plan did not specifically document approaches to provide pressure relief to the resident's feet and heels or how to accomplish that approach. b. The TAR's dated 7/11 through 2/12 were reviewed. The resident had an initial treatment order dated 4/12/11 for dilute [MEDICATION NAME] wet to dry twice per day. The 7/11 TAR weekly pressure ulcer assessment dated [DATE] documented the pressure ulcer measured 1.5 cm round X 2 cm depth. There was no stage or documentation of surrounding skin appearance. c. The July 2011 TAR documented a treatment order change on 7/22/11 for the same treatment done one time per day with weekly wound measurements dated 7/20/11, 7/27/11, 8/10/11, 8/17/11 and 8/25/11 of 1.0 x 1.5 cm. The TAR weekly PU measurements dated 8/31/11 documented 1.0 x 2 cm, a deterioration for that wound, and there was no documentation on the TAR or in Nurse's Notes that the physician was consulted at that time. There was no documentation of the stage of the pressure ulcer or surrounding skin appearance on the weekly pressure ulcer assessments documented on the August, September and October 2011 TAR's. d. The September and October 2011 TAR's documented the pressure ulcer measurements ranged between 1.0 x 0.5 cm (9/27/11) and 1.0 x .75 cm (10/26/11). The October 2011 TAR documented a new treatment dated 10/27/11 for Normal Saline wet to dry dressing daily. e. The November 2011 TAR did not document weekly pressure ulcer assessments for the weeks of 11/2/11 and 11/9/11. The TAR weekly assessment dated [DATE] documented the pressure ulcer measured 0.75 x 0.5 cm. There was no documentation of stage or surrounding skin appearance in the assessments documented on the November 2011 TAR. f. The resident was readmitted from the hospital on [DATE] with the same daily pressure ulcer treatment ordered since 10/27/11. The December 2011 and January and February 2012 TAR's documented weekly assessments with measurements of 0.5 x 1.0 cm (12/14/11), 1.0 x .25 cm (1/18/12), 1.0 x 5 cm (1/25/12) and 1.0 x .75 cm (2/8/12 and 2/15/12). There was no documentation of stage or surrounding skin appearance in the assessments documented on the TAR's dated as above, there was no weekly assessment documented the week of 1/13/12, and there was no documentation on the TAR or in the Nurse's Notes that a physician was immediately consulted on 1/18/12, 1/25/12 or since 2/8/12 about the deterioration in the pressure ulcer size. g. On 2/15/12 at 10:58 a.m., CNA #6 was in the room and the resident was in bed. CNA #6 was asked to assist in observation of the resident's lower extremities and she stated the resident's knees would not straighten and remained bent (flexed) at all times. The resident had pillows between her legs and under one foot, but there were no pressure relief devices or methods in place to relieve pressure to the resident's feet. h. On 2/16/12 at 9:42 a.m., LPN #2 provided wound treatment as ordered with CNA #3 in the room to assist. The resident's left inner foot was directly against the surface of the bed without pressure relief. The resident's pressure ulcer at the coccyx was a stage III that measured approximately 1.0 x 1.0 cm with a pink wound bed. After the treatment was completed, LPN #2 placed the resident's left foot on top of a bed pillow that was directly above the right foot, which did not provide pressure relief for the resident's feet. i. On 2/16/12 at 11:30 a.m., the DON was informed of the above information and asked to provide evidence that a physician had been consulted about the same wound treatment ordered since 10/27/11 without improvement. As of 2/17/12 at 5:20 p.m., the facility had not provided that information. j. On 2/17/12 at 5:30 p.m., the resident was positioned in bed to the right side, had a pillow between her knees and ankles. The resident's knees were both flexed and the resident's bare right foot was directly against the surface of the bed without off-loading of the right foot. 3. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 1/14/12 documented the resident scored 2 (0-7 indicates severe impairment) on the BIMS, required limited assistance of one person for bed mobility, was always incontinent of urine and bowel, and at risk of developing pressure ulcers. The MDS did not document a weight for this resident. a. The Care Plan dated 12/30/11 documented, "potential for weight loss related to inadequate nutrient intake at times," with an approach "monitor intake and weight." Care Plan Nurse's Notes dated 12/29/11 documented, "wt. (weight) stable." b. Nutritional Progress Notes dated 6/22/11 and signed by the CDM documented the resident weighed 182 pounds. Nutritional Progress Notes dated 7/8/11, 8/5/11, 9/2/11, 10/13/11, 11/8/11, 12/9/11 and 1/5/12 and signed by the CDM, documented the resident had refused to be weighed. The Nutritional Evaluation dated 12/29/11 and signed by the CDM documented, "resident has r/fused (refused) to be weighed." The CDM's Basal Energy Expenditures (BEE) formula for estimates of caloric needs for this resident used the resident's Ideal Body Weight, "IBW 130 (pounds) +/- 10%." As of 2/15/12 at 3:15 p.m., there were no Progress Notes or alternate method of assessment for the resident's caloric needs documented in the Dietary Section, Physician Orders, or Nurse's Notes by the facility's RD c. On 2/15/12 at 9:47 a.m., the CDM provided the RD's last 3 facility visit reports dated 5/11/11, 8/2/11 and and 11/15/11. This resident was not listed on the reports dated 8/2/11 or 11/15/11 as having been assessed for nutritional requirements by the RD as of that date and time, which potentially placed this resident at higher risk of pressure ulcer development. There was no documentation in the resident's Care Plan, physician progress notes [REDACTED]. d. On 2/14/12 at 5:33 p.m., the resident was in bed. The resident's bare feet were on a thin pillow against the bed surface and no heel-pads to prevent shearing/friction forces were present. On 2/15/12 at 12:41 p.m., LPN #2 was asked to assist in observation of the resident's lower extremities. The resident was in bed and both feet could be seen from the doorway, not covered and both heels pressed into a wooden footboard. LPN #2 pulled the covers back, the surveyor touched the footboard, and the LPN covered the resident's feet without repositioning them. The resident had no skin breakdown at that time. e. On 2/16/12 at 12:50 p.m., the DON was informed of the resident's lack of an accurate nutritional assessment and a request was made for any other information the facility could locate. As of 2/17/12 at 5:20 p.m., the facility had not provided further evidence for this resident. 4. Resident #2 had [DIAGNOSES REDACTED]. ulcers. a. The Care Plan dated 12/9/11 documented a problem for potential for skin breakdown with an approach, "place resident in skin-breakdown-prevention program (PUP Team)." The Care Plan did not document specific approaches for provision of pressure relief to feet and heels for this resident. b. On 2/14/12 at 5:22 p.m., LPN #1 was in the resident's room and the resident was in bed. Both of the resident's bare feet were flat against the bed surface without off-loading or heel-pads in place. c. On 2/15/12 at 12:28 p.m., CNA's #1 and #2 were in the room to reposition the resident. The resident's feet were both directly against the bed surface. The CNA's repositioned the resident and did not off-load the resident's feet/heels to provide pressure relief. The CNA's both left the room with the resident's feet against the surface of the bed. 5. Resident #4 had [DIAGNOSES REDACTED]. An Annual MDS with an ARD of 11/24/11 documented the resident had short and long term memory problems, was severely impaired in cognitive skills for daily decision making per the SAMS, required extensive assistance of two persons with bed mobility, was always incontinent of bladder and bowel, had weight loss, and was at risk of developing pressure ulcers. a. The diet card dated 2/14/12 documented under notes "milk... Resource health shakes... spoon feed." On 2/14/12 at 5:55 p.m., the resident's evening meal tray did not have a health shake on it. CNA #4 was asked if she fed the resident. CNA #4 stated, "yes". CNA #4 was asked if the resident's meal tray had a health shake on it. CNA #4 stated, "He just had ice cream, milk, and food. No shake. He use to get them." b. The January and February 2012 TAR and Weekly Summary Report documented an order dated 11/11/08, "Keep LT (Left) heel padded. Heel protectors in bed...." 1) On 2/14/12 at 5:30 p.m., the resident was in bed with the head of the bed up. The resident's feet and ankles were on the surface of the bed mattress. There was no attempt to offload or float the feet off the bed mattress surface. The resident did not have heel protectors in place. 2) On 2/14/12 at 6:20 p.m., the resident was in bed, supine position with the head of the bed up. The resident's feet were on the surface of the bed mattress with no heel protectors on. 3) On 2/15/12, at 10:30 a.m., the resident was in bed in a supine position with the head of the bed up. CNA was asked to lift the resident's blanket so the feet could be observed. The resident's feet were on the surface of the bed mattress with no heel protectors on. A pillow was between the resident's ankles. There was no off-loading or floating of the resident's feet. The CNA recovered the resident's feet and left the room. 4) On 2/15/12 at 10:55 a.m., LPN #3 provided a dressing change on the resident's coccyx. When LPN #3 went to remove the old dressing from the resident's pressure sore, there was no dressing in place. CNA #5 was asked if the resident had been changed earlier. CNA #5 stated yes. The CNA was asked if the resident had a dressing in place at that time. CNA #5 stated, "No, (LPN #3) said she was going to do it later." The Stage II pressure ulcer at the coccyx measured approximately 0.5 cm round with superficial depth. At 11:15 a.m. CNA #5 positioned the resident on his back, put a pillow between his legs and covered the resident with a blanket. The resident's heels were on the bed mattress surface with no offloading, floating or heel protectors. 5) On 2/15/12 at 12:45 p.m., the resident was up in a reclined chair being fed by CNA #2. The foot rest of the chair was up with a pillow under the resident's lower legs. The resident's left heel was against the surface of the recliner foot rest. c. The January 2012 TAR documented "1/12/12 small area to coccyx open. measures 1/2 cm X 1/2 cm X (less than) 0.2 cm depth Tx (treatment) initiated." As of 2/19/12 at 10:50 a.m., the care plan dated as reviewed and last revised on 11/25/11, did not address the current pressure sore identif

Complaint # is substantiated all or in part in these findings. Based on record review and interview the facility failed to ensure that the physician was immediately consulted regarding a decreased level of consciousness that failed to improve and when the resident stopped eating and taking medications for 1 (Resident #5) of 1 case mix residents who had a change in condition. This failed practice resulted in actual harm to Resident #5, who required hospitalization for Dehydration, Urinary Tract Infection and Pneumonia, and had the potential to affect all 75 residents in the facility according to the Resident Census and Conditions of Residents form dated 1/11/11. The findings are: Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/10 documented the resident was severely impaired in cognitive skills, had short and long term memory problems and required limited assistance with eating. a. A Policy and Procedure documented "Changes in a Resident's Condition or Status; It is the policy of this facility to report changes in the resident's condition or status. 1. Nursing Service shall be responsible for notifying the resident's attending physician when: . . . b. There is a significant change in the resident's physical, mental or emotional status. c. the resident refuses treatment or medications. . ." b. Nurses Notes dated 11/23/10 at 10:00 a.m. documented, "Res (resident) to whirlpool per CNA's (Certified Nursing Assistant). State res unable to stand (and) is limp (and) leaned over. Held [MEDICATION NAME] this a.m. per nursing judgement d/t (due to) very drowsy acting. vs (vital signs) obtained temp (temperature) 99.6, P (Pulse) 112, R (Respiration) 18, O2 (oxygen) Sat (saturation) 94%, B/P (Blood Pressure) faint 100/60. Tylenol 650 mg. (milligrams), water taken well but (no) verbal response (and) res just stares ahead, call to (physician name). 12 p. (12:00 p.m.) N.O. (new order) received (and) noted. Call to (family name) and made her aware of situation (and) orders. 1530 (3:30 p.m.) MD (medical doctor) rounds (with) new order." c. A Doctor's Progress Note dated 11/23/10, no time noted documented, "Resting quietly in bed. She is a little [MEDICATION NAME] toxic and we are in the process of adjusting her doses. Her weight is down to 153 lb. (pounds) but I do not think anybody is interested in artificial nutrition." d. A Doctor's Progress Note dated 11/23/10, no time noted documented, "I talked to her nurse, (name of nurse) and patient is a little somnolent this morning. We are going to hold her [MEDICATION NAME] and get a serum [MEDICATION NAME]." e. A Doctor's Progress Note dated 11/23/10 documented, "Well, come to find out patient had a [MEDICATION NAME] level checked yesterday that was 20.3 which is outside the range of therapeutic and may be high enough to make her a little drowsy so we are going to drop her dose from 500 mg. to 400 mg. a day and repeat a level next Tuesday or Wednesday." f. A Nurse's Note dated 11/24/10, 2:00 p.m. - 10:00 p.m. shift documented, "...Skin warm, moist, intact. (resident) did not eat supper or take p.m. meds (medication). . ." There was no documentation the physician was notified of the resident not eating or taking her medication. g. A Nurses Note dated 11/25/10, 2:00 p.m. - 10:00 p.m. shift documented, "...(Resident) does not respond or make movement when being talked to. (Resident) did not take meds d/t not swallowing. (Resident) had no intake this shift..." There was no documentation the physician was notified of the resident not eating or taking her medication. h. A Nurses note dated 11/26/10, 10:00 p.m. - 6:00 a.m. documented ". . . no intake this shift. . . no changes in cond (condition) at this (time)." There was no documentation the physician was notified of the resident not drinking. i. A Nurses Note dated 11/26/10, 2:00 p.m. - 10:00 p.m. documented, "...(no) intake this shift. (no) distress noted at this (time)." There was no documentation the physician was notified of the resident not drinking. j. A Nurses Note dated 11/27/10 at 12:00 p.m. documented, "Father (name of father) here and refuses to let CNA feed res. States 'she is coughing and I want her sent to the hosp(hospital)'... Paged (physician)... 1300 (1:00 p.m.) Father upset and demanding res to be transferred... called (hospital) for on call- paged (physician). 1310 (1:10 p.m.) (Physician) phones and informed of above. order rec'd (received) and noted to send to (hospital) ER (emergency room ) for eval (evaluation)..." k. On 1/12/10 at 10:30 a.m. the Director of Nurses (DON) was asked why the facility did not notify the physician when the resident did not have an improvement in her condition. The DON stated "We were probably waiting on family to let us know what they wanted. In my mind, I was waiting on (family name) to let us know what they wanted to do." l. The hospital History and Physical dated 11/27/10 documented, "Chief Complaint; Decreased level of consciousness... Lab data: Sodium 167 (normal range 136 -145)... chloride 127 (normal range 98 - 109)... BUN 61 (normal range 7-25),... Chest x-ray possible infiltrate on the left side..Urine positive for [MEDICATION NAME], RBC's (red blood cells)... Assessment and Plan: 1. Dehydration with decreased level of consciousness... 4. Pneumonia...5. Urinary Tract Infection..."